An ideal laboratory test in the evaluation of a patient with acute pancreatitis (AP) should, in addition to accurately establishing the diagnosis of AP, provide early assessment of its severity and identify the etiology. None of the tests available today meet all these criteria, and presently there is no biochemical test that can be considered the "gold standard" for the diagnosis and assessment of severity of AP. In the diagnosis of AP, serum amylase and lipase remain important tests. Advantages of amylase estimation are its technical simplicity, easy availability, and high sensitivity. However, its greatest disadvantage is its low specificity. A normal amylase would usually exclude the diagnosis of AP, with the exception of AP secondary to hyperlipidemia, acute exacerbation of chronic pancreatitis, and when the estimation of amylase is delayed in the course of the disease. The major advantage of lipase is an increased sensitivity in acute alcoholic pancreatitis and in patients who initially present to the emergency room days after the onset of the disease, as lipase remains elevated longer than amylase. Although once considered to be specific for AP, nonspecific elevations of lipase have been reported in almost as many disorders as amylase, thus decreasing its specificity. Simultaneous estimation of amylase and lipase does not improve the accuracy. Other enzymes for the diagnosis of AP--pancreatic isoamylase, immunoreactive trypsin, and elastase--are more cumbersome and expensive and have no clear role in the diagnosis of AP. No enzyme assay has a predictive role in determining the severity or etiology of AP. Once the diagnosis of AP is established, daily measurements of enzymes have no value in assessing the clinical progress of the patient or ultimate prognosis and should be discouraged. A host of new serological and urinary markers have been investigated in the last few years. Their main use is in predicting the severity of AP. At present, serum C-reactive protein at 48 h is the best available laboratory marker of severity. Urinary trypsinogen activation peptides within 12-24 h of onset of AP are able to predict the severity but are not widely available. Serum interleukins 6 and 8 seem promising but remain experimental.

Nutritional indices (percentage ideal body weight [IBW], serum albumin, serum transferrin, total lymphocyte count [TLC] and delayed cutaneous hypersensitivity [DH] response) were assessed in 80 consecutive patients (aged 85-100 y) within 24 h of admission to determine their predictive value for mortality. Nine patients died. Pearson correlation analysis demonstrated that death was significantly (p less than 0.05 to less than 0.01) associated with sepsis, serum albumin less than 30 g/L, TLC less than or equal to 1500 cells/mm3, and percentage IBW less than or equal to 90%. However, when serum albumin was controlled for, logit regression analyses demonstrated that the impact of other nutritional indices on death was insignificant. The effect of serum albumin remained significant (p less than 0.05 to less than 0.01) even when age and physician's diagnosis were held constant. With the logit model, serum albumin greater than or equal to 30 g/L had a sensitivity of 0.33, specificity of 0.99, and overall predictive power of 0.91. Serum albumin is thus the simplest and best single predictor of mortality and can provide early identification of elderly people at increased risk of death.

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Rabies is a deadly disease with no cure which is mainly caused by dog bites. Data on dog bites and knowledge, attitude and practices (KAP) related to dog bites are not generally available to rural communities. We made a cross-sectional study of a rural community of ten villages served by a primary health centre selected by random sampling. Ten per cent of households selected by systematic random sampling were interviewed for KAP regarding dog bites. The dog bite rate was 25.7/1000 population per year. The rate for males was higher than for females; half of the bites were in summer; 40% did not go for any prophylaxis; half of the victims treated their wounds with chilli powder. Eighty per cent of the bites were class II or III and leg bites were most common. The majority of the community knew dog bites can cause death but they did not know the correct incubation period. Most knew that injections were available to prevent rabies. Only half said they would visit a hospital for treatment. Around 50% received tetanus toxoid.

To determine whether blood transfusion influences infection after trauma, we analyzed data on 5366 consecutive patients hospitalized for more than 2 days at eight hospitals over a 2-year period. The incidence of infection was significantly related to the mechanism of injury: penetrating injuries, 8.9%; blunt injuries, 12.9%; and low falls, 21.4%. Stepwise logistic regression analyses of infection using the variables age, sex, respiration rate in the emergency department, Glasgow Coma Scale in the emergency department, Injury Severity Score, shock (systolic blood pressure < 90 mm Hg on admission to the emergency department), and log of total amount of blood transfused during hospitalization showed that amount of blood received and Injury Severity Score were the only two variables that were significant predictors of infection across groups. Even when patients were stratified by Injury Severity Score, the infection rate increased significantly with increases in numbers of units of blood. Blood transfusion in the injured patients is an important independent statistical predictor of infection. Its contribution cannot be attributed to age, sex, or the underlying mechanism of severity of injury.

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

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