The vibrant and expressive organ music of Gordon Young remains a staple of the church organist's repertoire. In the first collection of Young material since his passing, Douglas Wagner has arranged ten organ compositions from some of Young's choral works. These short pieces, all displaying Young's signature style, combine to make a welcome volume of music from this beloved and much-missed composer. Titles include: Prelude; Psalm 23; Spiritual, Gigue and Orision and five more.
Homicide - is defined as a death due to the acts of another. Natural - is defined as a death solely by organic disease. If natural death is hastened by injury (such as a fall), the manner of death will not be considered natural. Pending - is a temporary designation for cause and/or manner when additional investigation, information and/or test results are required for certification. Pending is amended once all information and test results are received.
Severe acute pancreatitis is associated with persistent organ failure (cardiovascular, respiratory, and/or renal), and high mortality. Both new classification systems, Revised Atlanta Classification and Determinant-based Classification of Acute Pancreatitis Severity, are similar in establishing the diagnosis and severity of acute pancreatitis (1C).
Important insights on the management of AP, better understanding of the pathophysiology of organ failure and necrotizing pancreatitis, improved diagnostic imaging, minimally invasive techniques, and studies showing that patients in the severe group of the 1992 Atlanta Classification comprise subgroups with very different outcomes, were indications that a more accurate classification is warranted.
In a review in 2004, Johnson et al. reported that persistent organ failure (POF) for more than 48 h in the first week is strongly associated with the risk of death or local complications . They used a previous database of 290 patients with predicted SAP recruited from 78 hospitals through 18 centers in the UK, and also cited that resolution of organ failure within 48 h suggests a good prognosis.
The RAC was generated by an iterative, web-based consultation process incorporating responses from the members of 11 national and international pancreatic societies. Revisions were made in response to comments, and the web-based consultation was repeated three times. The final consensus was reviewed, and only statements based on published evidence were retained . The RAC is a broader overview than DBC: in addition to severity classification, it provides a clear definition of diagnosing AP, highlights the onset of pain as an important reference point, and defines individual local complications as well as interstitial and necrotizing pancreatitis [2, 14]. The RAC has three categories: mild, moderately severe, and severe, according to organ failure and local or systemic complications. The DBC added a fourth category: critical, based on two main determinants of mortality: (peri)pancreatic necrosis and organ failure (Table 2).
In general, patients with organ failure (accurately defined utilizing one of the established criteria or scoring systems) need an urgent transfer to an ICU. Accordingly, it may be unnecessary to transfer patients with transient organ failure to either a tertiary medical center or an ICU. Nevertheless, to confirm persistent organ failure, it needs to be documented for over 48 h.
MRI is preferable to CECT in patients with allergy to iodinated contrast, in patients with renal impairment/insufficiency (unenhanced MRI), in young or pregnant patients to minimize radiation exposure in order to identify nonliquefied material (e.g., debris or necrotic tissue), but is less sensitive than CT for detecting gas in fluid collections [24, 26]. CT without contrast is an alternative for the first two patient groups, if MRI is not available.
The predictors (or potential predictors) present in almost all of the scoring systems mentioned above include age, organ failure or immunocompromise, previous history of chronic disease, temperature, blood pressure, pulse rate, respiratory rate, body mass index, consciousness level, presence of peritonitis, presence of acute renal failure, blood white cell count, blood hematocrit, blood platelet count, blood glucose, blood urea nitrogen, serum creatinine, serum aspartate transaminase, serum lactate dehydrogenase, serum calcium, serum electrolytes, serum bilirubin, plasma albumin, oxygen saturation, pH, and base deficit, and multiple imaging modalities principally CT.
The BISAP score was derived using data from a population of 17,992 patients and validated on a population of 18,256 patients in the USA . It has similar accuracy to the APACHE-II score for predicting death and is a very simplified scoring system that can be easily applied in the earliest phases. One of the key points of this study is that it was able to identify patients at increased risk of mortality prior to the onset of organ failure . A retrospective analysis of 303 patients revealed that BISAP predicts severity, death, and especially organ failure (OF) in AP as well as APACHE-II does, and better than Ranson criteria, CT-severity index, CRP, hematocrit, and BMI. A BISAP score of two was a statistically significant cutoff value for the diagnosis of severe acute pancreatitis, organ failure, and mortality  (Table 4).
In patients with infected necrosis, the spectrum of empirical antibiotic regimen should include both aerobic and anaerobic Gram-negative and Gram-positive microorganisms. Routine prophylactic administration of antifungal is not recommended in patients with infected acute pancreatitis, although Candida spp. are common in patients with infected pancreatic necrosis and indicate patients with a higher risk of mortality (1B).
Acylureidopenicillins and third-generation cephalosporins have an intermediate penetration into pancreas tissue and are effective against gram-negative microorganisms and can cover the MIC for most gram-negative organisms found in pancreatic infections . Among these antibiotics, only piperacillin/tazobactam is effective against gram-positive bacteria and anaerobes.
Most pathogens in pancreatic infection are gastrointestinal Gram-negative bacteria (Escherichia coli, Proteus, Klebsiella pneumonia), which occur via disruption of the intestinal flora and damage to the bowel mucosa. Impaired body defenses predispose to translocation of the gastrointestinal organisms and toxins with subsequent secondary pancreatic infection. However, Gram-positive bacteria (Staphylococcus aureus, Streptococcus faecalis, Enterococcus), anaerobes, and, occasionally, fungi have also been found .
Fungal infection is a serious complication of acute pancreatitis with an associated increase in morbidity and mortality . Candida albicans is the most frequent organism encountered, followed by Candida tropicalis and Candida krusei. Although fungal infections complicating acute pancreatitis generally arise proportionately to the extent of pancreatic necrosis, there is not enough data to support the prevention of fungal infections and therefore is not recommended.
Continuous vital signs monitoring in high dependency care unit is needed if organ dysfunction occurs. Persistent organ dysfunction or organ failure occurrence despite adequate fluid resuscitation is an indication for ICU admission (1C).
Extensive fluid administration, adequate pain management with potentially harmful strategies, and organ function evaluation during initial treatment are the reason why continuous vital signs monitoring is crucial, whatever the setting is. Persistent organ dysfunction despite adequate fluid resuscitation needing specific organ support is usually delivered only in ICUs [11, 80].
Enteral feeding maintains the gut mucosal barrier, prevents disruption, and prevents the translocation of bacteria that seed pancreatic necrosis. In most institutions, continuous infusion is preferred over cyclic or bolus administration. Enteral nutrition as compared with total parenteral nutrition decreases infectious complications, organ failure, and mortality . In a multicenter, randomized study comparing early nasoenteric tube feeding within 24 h after randomization to an oral diet initiated 72 h after presentation to the emergency department with necrotizing pancreatitis, early nasoenteric feeding did not reduce the rate of infection or death. In the oral diet group, 69% of the patients tolerated an oral diet and did not require tube feeding .
A majority of patients with sterile necrotizing pancreatitis can be managed without interventions . However, it should be noted that nearly half of patients operated due to on-going organ failure without signs of infected necrosis have a positive bacterial culture in the operative specimen . Therefore, interventions should be considered when organ dysfunctions persist for more than 4 weeks.
Minimally invasive surgical strategies, such as transgastric endoscopic necrosectomy or video-assisted retroperitoneal debridement (VARD), result in less postoperative new-onset organ failure but require more interventions (1B).
An important question is what the preferred strategy is when percutaneous drainage does not result in resolution of the infection. The management options include open surgery, mini-invasive surgery, endoscopic surgery, and a combination of these. It is generally assumed that open surgery causes a more severe inflammatory response. There are various RCTs and a review comparing different strategies [104,105,106]. In summary, minimally invasive strategies (e.g., minimally invasive step-up approach, video-assisted retroper