INTRODUCTIONThe course of acute pancreatitis ranges from a mild transitory edematous to a severe necrotizing form. Necrotizing pancreatitis occurs in about 20% of all patients suffering from acute pancreatitis [1] . If infection of the necrotic tissue occurs mortality rates of up to 50% are reported with sepsis and multiorgan failure as most frequent causes [2][3][4][5] . It is generally accepted that in infected necrotizing pancreatitis the infected non-vital solid tissue has to be removed in order to control the sepsis. The standard treatment has traditionally been surgery [5,6] . By using modern surgical techniques like open packing, repeated laparatomies, closed packing or closed continuous lavage mortality rates could be decreased to 20%-40% [7][8][9][10][11][12] . However, these techniques are associated with a considerable surgical trauma which often causes escalation of multiorgan failure and sepsis [7,13] . Moreover, total anaesthesia is mandatory. Thus, in the last decade minimal invasive treatment regimes and in particular percutaneous drainage therapy were included in the management of infected necrotizing pancreatitis. Ultrasound (US) or computed tomography (CT) guided placement of drainages is reported to be effective in up to 90% for drainage of fluid collections or abscesses with purely liquid content [14] . However, the success rates Abstract AIM: To assess the outcome of patients with acute necrotizing pancreatitis treated by percutaneous drainage with special focus on the influence of drainage size and number.

The objective of this retrospective study was to evaluate the outcome of patients with acute necrotizing pancreatitis treated by active percutaneous necrosectomy. By searching the radiological, surgical and internal medicine databases, all patients with acute necrotizing pancreatitis treated by active percutaneous necrosectomy between 1992 and 2004 were identified. Demographic, laboratory, and clinical data, and details about invasive procedures were collected by reviewing patient charts, radiological and surgical reports. The computed tomography severity index (CTSI) scores were determined by reviewing CT images. Eighteen patients were identified. Median Ranson score on admission was 2. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was median 22. Median CTSI score was 7. Initially all patients were treated with CT-guided drainage placement. Because passive drainage proved not to be effective, subsequent minimally invasive, percutaneous necrosectomy was performed. Eight out of 18 patients recovered fully without the need for surgery. Ten of 18 patients required additional surgical necrosectomy. For one of ten patients, percutaneous necrosectomy allowed postponing surgery by 39 days. Four of ten surgically treated patients died: three from septic multiorgan failure, one from pulmonary embolism. Percutaneous minimally invasive necrosectomy can be regarded as a safe and effective complementary treatment modality in patients with necrotizing pancreatitis. It is suitable for a subset of patients to avoid or delay surgery.

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The immune system and the hypothalamic-pituitary-adrenal axis are linked by several mechanisms. Intracellular glucocorticoid receptors represent one important connection. The aim of this study was to examine the coherence between the number of glucocorticoid receptors, activation of the hypothalamic-pituitary-adrenal axis, inflammatory cytokine levels and the severity of illness in critically ill patients. In a prospective study, blood was collected from 20 healthy members of the hospital staff (control group) and 50 ventilated patients (sample group) within the first 24 hours after intubation and within three days of extubation. 5H-dexamethasone-binding assay was used to assess cytoplasmatic free glucocorticoid receptors levels. ACTH, cortisol, IL-6 and TNFα. levels were measured by ELISA. In the sample group, specific binding of 5H-dexamethasone was significantly decreased compared to the control group. Glucocorticoid receptor levels tended to be lower in more severely ill patients. Plasma cortisol and ACTH levels were significantly different from the control group after extubation but not at intubation. Severe illness is associated with rapid down-regulation of 5H-dexamethasone binding. This decrease occurs before elevation of plasma cortisol. Therefore, down-regulation of cortisol binding may be directly associated with the stress response and not due to feedback regulation following increase in plasma cortisol levels.

Monitoring of physiologic parameters in critically ill patients is associated with an enormous number of alarms, leading to reduced clinical value with high sensitivity but low specificity. To evaluate opinions of intensive care unit (ICU) staff on current monitoring we conducted a survey of German ICUs. Furthermore, the survey aimed to assess requirements and requests for future alarm systems. The survey was conducted between May 2006 and June 2007 on a randomised sample of German ICUs. Questionnaires with 24 partly closed-ended partly open-ended questions were posted. Of 915 letters, 274 (30%) from 185 contacted ICUs were returned and evaluated. One hundred and sixty physicians, the majority (52%) working in a department of anaesthesiology, and 114 nurses returned the survey. Most responders (87%) estimated that less than 50% of current alarms result in clinical consequences (52% estimated less than 25%). We suggested trend alarms, smoothing of signals to reduce artefacts, generation of new combined alarms and integrative monitoring of different alarm systems as improvements of current ICU alarm systems, all of which were agreed to by the majority. Free text commentaries focused on the need for reducing alarms caused by artefacts and called for improvement of the monitor-user interfaces. Our survey demonstrates the dissatisfaction of clinical staff with the current alarm systems regarding alarm frequency and specificity in German ICUs, thereby confirming data raised in single institutions. ICU staff's acceptance for new alarm algorithms like signal extraction or detection of trends as a basis for smart monitoring appealed to the majority of users.