Evaluation of scoring systems in terms of early prediction of severe acute pancreatitis and mortality in patients over 65 years of age.

Selen Acehan; Salim Satar; Müge Gülen; Basak Toptas Firat; Deniz Aka Satar; Adnan Taş

doi:10.17826/cumj.1121730

Araştırma Makalesi

65 yaş üstü hastalarda puanlama sistemlerinin şiddetli akut pankreatiti ve mortaliteyi erken öngörme açısından değerlendirilmesi

Yıl 2022, Cilt: 47 Sayı: 3, 1327 - 1338, 30.09.2022

Selen Acehan Salim Satar Müge Gülen Basak Toptas Firat Deniz Aka Satar Adnan Taş

https://doi.org/10.17826/cumj.1121730

Öz

Amaç: Bu çalışmanın amacı, acil serviste akut pankreatit tanısı alan 65 yaş üstü hastalarda hastalık şiddeti skorlarının erken dönemde Şiddetli Akut Pankreatit (SAP) gelişimini ve mortaliteyi öngörme gücünü araştırmayı amaçladık.
Gereç ve Yöntem: Acil servise başvuru sırasında Yatak Başı Akut Pankreatit Şiddet İndeksi (BISAP) skoruna ek olarak RANSON (ilk başvuru) ve Bilgisayarlı Tomografi Şiddet İndeksi (CTSI) hesaplandı.
Bulgular: Çalışmaya yüz altmış hasta (%46,9'u 80 yaş üstü) dahil edildi. 80 yaş üstü hastalarda istatistiksel olarak daha yüksek hastanede yatış süresi, yoğun bakımda kalış süresi, SAP ve daha yüksek mortalite gözlemledik. ROC eğrisini incelediğimizde, BISAP puanının AUC değerlerinin hem SAP hem de mortalite tahmininde en yüksek olduğunu belirledik (AUC: 0.911, %95 CI 0.861-0.962; AUC: 0.918, %95 CI 0.864- 0.9722, sırasıyla). İkili lojistik analiz, BİSAP puan değerindeki her birim artış için SAP için 4,7 kat artan risk ve 12,3 kat artan ölüm oranı gösterdi.
Sonuç: BISAP, 65 yaş üstü akut pankreatitli hastalarda acil servise başvuruda SAP ve mortalite tahmini için iyi bir öngörücü olabilir.

Anahtar Kelimeler

BISAPS, CTSI, mortalite, RANSON, şiddetli akut pankreatit

Kaynakça

References 1. Quero G, Covino M, Ojetti V, et al. Acute pancreatitis in oldest old: a 10-year retrospective analysis of patients referred to the emergency department of a large tertiary hospital. Eur J Gastroenterol Hepatol. 2020, 32(2):159-165 https://doi.org/10.1097/MEG.0000000000001570.
2. Henden Çam P, Baydin A, Yürüker S, et al. Investigation of Geriatric Patients with Abdominal Pain Admitted to Emergency Department. Curr Gerontol Geriatr Res. 2018, 30; 2018:9109326. https://doi.org/10.1155/2018/9109326.
3. Roberts-Thomson, I.C. The Non-surgical Acute Abdomen. In: Wichmann, M., McCullough, T., Roberts-Thomson, I., Maddern, G. (eds) Gastroenterology For General Surgeons. Springer, Cham. 2019. https://doi.org/10.1007/978-3-319-92768-8_17
4. De Dombal FT. Acute abdominal pain in the elderly. J ClinGastroenterol. 1994, 19(4):331-5. https://doi.org/10.1097/00004836-199412000-00016 5. Laurell H, Hansson LE, Gunnarsson U. Acute Abdominal Pain among Elderly Patients. Gerontology. 2006, 52(6), 339–344. https://doi.org/doi:10.1159/000094982
6. Osterwalder I, Özkan M, Malinovska A, et al. Acute Abdominal Pain: Missed Diagnoses, Extra-Abdominal Conditions, and Outcomes. J Clin Med. 2020, 9(4):899. https://doi.org/10.3390/jcm9040899
7. Quero G, Covino M, Fiorillo C, et al. Acute pancreatitis in elderly patients: a single-center retrospective evaluation of clinical outcomes. Scandinavian Journal of Gastroenterology. 2019, 54:4,492-498. https://doi.org/10.1080/00365521.2019.1588369
8. Somasekar K, Foulkes R, Morris-Stiff G, et al. Acute pancreatitis in the elderly-can we perform better? Surgeon. 2011, 9:305–308. https://doi.org/10.1016/j.surge.2010.11.001
9. Rossetti B, Spizzirri A, Migliaccio C, et al. Acute pancreatitis in the elderly: Our experience. BMC Geriatrics. 2009, 9(47). https://doi.org/10.1186/1471-2318-9-S1-A47
10. Banks PA, Bollen TL, Dervenis C, et all. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013, 62(1):102–11. http://doi.org/10.1136/ gutjnl-2012-302779.
11. Chen L, Lu G, Zhou Q, et al. Evaluation of the BISAP score in predicting severity and prognosis of acute pancreatitis in Chineese patients. Int Surg. 2013, 98;6-12. http://doi.org/10.9738/0020- 8868-98.1.6.
12. Głuszek S, Kozieł D. Prevalence and progression of acute pancreatitis in the Świętokrzyskie Voivodeship population. Pol Przegl Chir. 2012, 84(12):618–625.
13. Roberts SE, Morrison-Rees S, John A, et al. The incidence and aetiology of acute pancreatitis across Europe. Pancreatology. 2017, 17(2):155–165.
14. Carvalho JR, Fernandes SR, Santos P, et al. Acute pancreatitis in the elderly: a cause for increased concern? Eur J Gastroenterol Hepatol. 2018, 30:337–341. https://doi.org/10.1097/MEG.0000000000001028
15. García-Alonso FJ, de Lucas Gallego M, Bonillo Cambrodón D, et al. Gallstone-Related Disease in the Elderly: Is There Room for Improvement? Dig Dis Sci. 2015, 60, 1770–1777. https://doi.org/10.1007/s10620-014-3497-4
16. Gardner TB, Vege SS, Chari ST, et al. The effect of age on hospital outcomes in severe acute pancreatitis. Pancreatology. 2008, 8:265–270. https://doi.org/10.1159/000134274
17. Papachristou GI, Whitcomb DC. Predictors of severity and necrosis in acute pancreatitis. Gastroenterol Clin North Am. 2004, 33:871–890.
18. Marshall JC, Cook DJ, Christou NV, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995, 23(10):1638–52.
19. Wu BU, Johannes RS, Sun X, et al. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008, 57(12):1645-46. https://doi.org/10.1136/gut.2008.158170
20. Ranson JH, Rifkind KM, Roses DF, et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974, 139:69–81.
21. Balthazar EJ (2002). Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002, 223 (3): 603-13. https://doi.org/10.1148/radiol.2233010680
22. https://www.un.org/development/desa/pdf/.
23. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health.
24. Márta K, Lazarescu AM, Farkas N, et al. Aging and Comorbidities in Acute Pancreatitis I: A Meta-Analysis and Systematic Review Based on 194,702 Patients. Front. Physiol. 2019, 10:328. https://doi.org/10.3389/fphys.2019.00328
25. Machado MCC, da Silva FP, Coelho AMM. Do Elderly Patients with Acute Pancreatitis Need a Special Treatment Strategy? In: Rodrigo L, editor. Acute and Chronic Pancreatitis [Internet]. London: IntechOpen; 2015, [cited 2022 Apr 11]. Available from: https://www.intechopen.com/chapters/47337. https://doi.org/10.5772/58916.
26. Okamura D, Starr ME, Lee EY, et al. Age-dependent vulnerability to experimental acute pancreatitis is associated with increased systemic inflammation and thrombosis. Aging Cell. 2012, 11(5):760-9. https://doi.org/10.1111/j.1474-9726.2012.00841.x.
27. McKay CJ, Evans S, Sinclair M, et al. High early mortality rate from acute pancreatitis in Scotland, 1984–1995. Br J Surg. 1999, 86:1302–1305.
28. Kozıel D, Ga-Osuch M, Sulıga E, et al. Elderly persons with acute pancreatitis- specifics of the clinical course of the disease. Clin Interv Aging. 2019, 14:33-41.
29. Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Critical Care Medicine. 2007, 35(6);1477-83. https://doi.org/10.1097/01.CCM.0000266585.74905.5A
30. Pereverzeva L, Uhel F, Peters Sengers, et al. Association between delay in intensive care unit admission and the host response in patients with community-acquired pneumonia. Ann Intensive Care. 2021, 11;142. https://doi.org/10.1186/s13613-021-00930-5.
31. Larvin M, McMahon MJ. APACHE-II score for assessment and monitoring of acute pancreatitis. Lancet. 1989, 2: 201–5.
32. Blamey S, Imrie C, O’neill J, et al. Prognostic factors in acute pancreatitis. Gut. 1984, 25: 1340-1346.
33. Lankisch PG, Weber–Dany B, Hebel K, et al. The harmless acute pancreatitis score: a clinical algorithm for rapid initial stratification of nonsevere disease. Clinical Gastroenterology and Hepatology. 2009, 7: 702-705.
34. Balthazar EJ, Freeny PC, van Sonnenberg E. İmaging and intervention in acute pancreatitis. Radiology. 1994, 193(2),297–306.
35. Williford ME, Foster Jr WL, Halvorsen RA, et al. Pancreatic pseudocyst: comparative evaluation by sonography and computed tomography. American Journal of Roentgenology. 1983, 140(1):53-57.
36. Khanna AK, Meher S, Prakash S, et al. Comparison of Ranson, Glasgow, MOSS, SIRS, BISAP, APACHE-II, CTSI scores, IL-6, CRP, and procalcitonin in predicting severity, organ failure, pancreatic necrosis, and mortality in acute pancreatitis. 2013, HPB Surg Article ID 367581. http://dx.doi.org/10.1155/2013/367581
37. Venkatesh N, Vijayakumar C, Balasubramaniyan G, et al. Comparison of different scoring Systems in Predicting the severity of acute Pancreatitis: A Prospective Observational Study. Cureus. 2020, 10;12(2): e6943. http://dx.doi.org/10.7759/cureus.6943.
38. Ryu JK. Evaluation of severity in acute pancreatitis. Korean J. Gastroenterol. 2009, 54, 205–211. http://dx.doi.org/10.4166/kjg.2009.54.4.205
39. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013, 13; e1–15. https://doi.org/10.1016/j.pan.2013.07.063
40. Hritz I, Czako L, Dubravcsik Z, et al. Acute pancreatitis. Evidence-based practice guidelines, prepared by the Hungarian Pancreatic Study Group. Orv. Hetil. 2015, 156, 244–261. https://doi.org/10.1556/OH.2015.30059
41. Ong Y, Shelat VG. Ranson score to stratify severity in Acute Pancreatitis remains valid – Old is gold. Expert Review of Gastroenterology & Hepatology. 2021, 15(8), 865–877. http://dx.doi.org/10.1080/17474124.2021.1924058
42. Di MY, Liu H, Yang ZY, et al. Prediction Models of Mortality in Acute Pancreatitis in Adults. Annals of Internal Medicine. 2016, 165(7);482. http://dx.doi.org/10.7326/m16-0650
43. Chandra S, Muralı A, Bansal R, et al. The Bedside Index for Severity in Acute Pancreatitis: a systematic review of prospective studies to determine predictive performance. J Community Hosp Intern Med Perspect. 2017, 7: 208-213
44. Arvanıtakıs M, Dumonceau JM, Albert J, et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy. 2018, 50: 524-546.

Evaluation of scoring systems in terms of early prediction of severe acute pancreatitis and mortality in patients over 65 years of age.

Yıl 2022, Cilt: 47 Sayı: 3, 1327 - 1338, 30.09.2022

Selen Acehan Salim Satar Müge Gülen Basak Toptas Firat Deniz Aka Satar Adnan Taş

https://doi.org/10.17826/cumj.1121730

Öz

Purpose: The aim of this study is to investigate the power of disease severity scores to predict the development of Severe Acute Pancreatitis (SAP) and mortality in the early period over 65 years old diagnosed with acute pancreatitis in the emergency department.
Materials and Methods: We calculated RANSON (on admission) and Computed Tomography Severity Index (CTSI) in addition to Bedside Index for Severity in Acute Pancreatitis (BISAP) score on admission to the emergency department.
Results: One hundred and sixty patients (46.9% over 80 years of age) were included in the study. We observed statistically higher length of hospitalization, longer duration of stay in the intensive care unit, SAP and higher mortality in patients over 80 years of age. When we examined the ROC curve, we determined that the AUC values of the BISAP score were highest in both SAP and mortality estimation (AUC: 0.911, 95% CI 0.861-0.962; AUC: 0.918, 95% CI 0.864-0.9722, respectively). Binary logistic analysis indicated a 4.7-fold increased risk for SAP and a 12.3-fold increased mortality for each unit increase in BISAP score value.
Conclusion: BISAP may be a good predictor for SAP and mortality estimation on admission to the emergency department in patients over 65 years of age with acute pancreatitis.

Anahtar Kelimeler

BISAPS, CTSI, mortality, RANSON, severe acute pancreatitis

Kaynakça

References 1. Quero G, Covino M, Ojetti V, et al. Acute pancreatitis in oldest old: a 10-year retrospective analysis of patients referred to the emergency department of a large tertiary hospital. Eur J Gastroenterol Hepatol. 2020, 32(2):159-165 https://doi.org/10.1097/MEG.0000000000001570.
2. Henden Çam P, Baydin A, Yürüker S, et al. Investigation of Geriatric Patients with Abdominal Pain Admitted to Emergency Department. Curr Gerontol Geriatr Res. 2018, 30; 2018:9109326. https://doi.org/10.1155/2018/9109326.
3. Roberts-Thomson, I.C. The Non-surgical Acute Abdomen. In: Wichmann, M., McCullough, T., Roberts-Thomson, I., Maddern, G. (eds) Gastroenterology For General Surgeons. Springer, Cham. 2019. https://doi.org/10.1007/978-3-319-92768-8_17
4. De Dombal FT. Acute abdominal pain in the elderly. J ClinGastroenterol. 1994, 19(4):331-5. https://doi.org/10.1097/00004836-199412000-00016 5. Laurell H, Hansson LE, Gunnarsson U. Acute Abdominal Pain among Elderly Patients. Gerontology. 2006, 52(6), 339–344. https://doi.org/doi:10.1159/000094982
6. Osterwalder I, Özkan M, Malinovska A, et al. Acute Abdominal Pain: Missed Diagnoses, Extra-Abdominal Conditions, and Outcomes. J Clin Med. 2020, 9(4):899. https://doi.org/10.3390/jcm9040899
7. Quero G, Covino M, Fiorillo C, et al. Acute pancreatitis in elderly patients: a single-center retrospective evaluation of clinical outcomes. Scandinavian Journal of Gastroenterology. 2019, 54:4,492-498. https://doi.org/10.1080/00365521.2019.1588369
8. Somasekar K, Foulkes R, Morris-Stiff G, et al. Acute pancreatitis in the elderly-can we perform better? Surgeon. 2011, 9:305–308. https://doi.org/10.1016/j.surge.2010.11.001
9. Rossetti B, Spizzirri A, Migliaccio C, et al. Acute pancreatitis in the elderly: Our experience. BMC Geriatrics. 2009, 9(47). https://doi.org/10.1186/1471-2318-9-S1-A47
10. Banks PA, Bollen TL, Dervenis C, et all. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013, 62(1):102–11. http://doi.org/10.1136/ gutjnl-2012-302779.
11. Chen L, Lu G, Zhou Q, et al. Evaluation of the BISAP score in predicting severity and prognosis of acute pancreatitis in Chineese patients. Int Surg. 2013, 98;6-12. http://doi.org/10.9738/0020- 8868-98.1.6.
12. Głuszek S, Kozieł D. Prevalence and progression of acute pancreatitis in the Świętokrzyskie Voivodeship population. Pol Przegl Chir. 2012, 84(12):618–625.
13. Roberts SE, Morrison-Rees S, John A, et al. The incidence and aetiology of acute pancreatitis across Europe. Pancreatology. 2017, 17(2):155–165.
14. Carvalho JR, Fernandes SR, Santos P, et al. Acute pancreatitis in the elderly: a cause for increased concern? Eur J Gastroenterol Hepatol. 2018, 30:337–341. https://doi.org/10.1097/MEG.0000000000001028
15. García-Alonso FJ, de Lucas Gallego M, Bonillo Cambrodón D, et al. Gallstone-Related Disease in the Elderly: Is There Room for Improvement? Dig Dis Sci. 2015, 60, 1770–1777. https://doi.org/10.1007/s10620-014-3497-4
16. Gardner TB, Vege SS, Chari ST, et al. The effect of age on hospital outcomes in severe acute pancreatitis. Pancreatology. 2008, 8:265–270. https://doi.org/10.1159/000134274
17. Papachristou GI, Whitcomb DC. Predictors of severity and necrosis in acute pancreatitis. Gastroenterol Clin North Am. 2004, 33:871–890.
18. Marshall JC, Cook DJ, Christou NV, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995, 23(10):1638–52.
19. Wu BU, Johannes RS, Sun X, et al. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008, 57(12):1645-46. https://doi.org/10.1136/gut.2008.158170
20. Ranson JH, Rifkind KM, Roses DF, et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974, 139:69–81.
21. Balthazar EJ (2002). Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002, 223 (3): 603-13. https://doi.org/10.1148/radiol.2233010680
22. https://www.un.org/development/desa/pdf/.
23. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health.
24. Márta K, Lazarescu AM, Farkas N, et al. Aging and Comorbidities in Acute Pancreatitis I: A Meta-Analysis and Systematic Review Based on 194,702 Patients. Front. Physiol. 2019, 10:328. https://doi.org/10.3389/fphys.2019.00328
25. Machado MCC, da Silva FP, Coelho AMM. Do Elderly Patients with Acute Pancreatitis Need a Special Treatment Strategy? In: Rodrigo L, editor. Acute and Chronic Pancreatitis [Internet]. London: IntechOpen; 2015, [cited 2022 Apr 11]. Available from: https://www.intechopen.com/chapters/47337. https://doi.org/10.5772/58916.
26. Okamura D, Starr ME, Lee EY, et al. Age-dependent vulnerability to experimental acute pancreatitis is associated with increased systemic inflammation and thrombosis. Aging Cell. 2012, 11(5):760-9. https://doi.org/10.1111/j.1474-9726.2012.00841.x.
27. McKay CJ, Evans S, Sinclair M, et al. High early mortality rate from acute pancreatitis in Scotland, 1984–1995. Br J Surg. 1999, 86:1302–1305.
28. Kozıel D, Ga-Osuch M, Sulıga E, et al. Elderly persons with acute pancreatitis- specifics of the clinical course of the disease. Clin Interv Aging. 2019, 14:33-41.
29. Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Critical Care Medicine. 2007, 35(6);1477-83. https://doi.org/10.1097/01.CCM.0000266585.74905.5A
30. Pereverzeva L, Uhel F, Peters Sengers, et al. Association between delay in intensive care unit admission and the host response in patients with community-acquired pneumonia. Ann Intensive Care. 2021, 11;142. https://doi.org/10.1186/s13613-021-00930-5.
31. Larvin M, McMahon MJ. APACHE-II score for assessment and monitoring of acute pancreatitis. Lancet. 1989, 2: 201–5.
32. Blamey S, Imrie C, O’neill J, et al. Prognostic factors in acute pancreatitis. Gut. 1984, 25: 1340-1346.
33. Lankisch PG, Weber–Dany B, Hebel K, et al. The harmless acute pancreatitis score: a clinical algorithm for rapid initial stratification of nonsevere disease. Clinical Gastroenterology and Hepatology. 2009, 7: 702-705.
34. Balthazar EJ, Freeny PC, van Sonnenberg E. İmaging and intervention in acute pancreatitis. Radiology. 1994, 193(2),297–306.
35. Williford ME, Foster Jr WL, Halvorsen RA, et al. Pancreatic pseudocyst: comparative evaluation by sonography and computed tomography. American Journal of Roentgenology. 1983, 140(1):53-57.
36. Khanna AK, Meher S, Prakash S, et al. Comparison of Ranson, Glasgow, MOSS, SIRS, BISAP, APACHE-II, CTSI scores, IL-6, CRP, and procalcitonin in predicting severity, organ failure, pancreatic necrosis, and mortality in acute pancreatitis. 2013, HPB Surg Article ID 367581. http://dx.doi.org/10.1155/2013/367581
37. Venkatesh N, Vijayakumar C, Balasubramaniyan G, et al. Comparison of different scoring Systems in Predicting the severity of acute Pancreatitis: A Prospective Observational Study. Cureus. 2020, 10;12(2): e6943. http://dx.doi.org/10.7759/cureus.6943.
38. Ryu JK. Evaluation of severity in acute pancreatitis. Korean J. Gastroenterol. 2009, 54, 205–211. http://dx.doi.org/10.4166/kjg.2009.54.4.205
39. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013, 13; e1–15. https://doi.org/10.1016/j.pan.2013.07.063
40. Hritz I, Czako L, Dubravcsik Z, et al. Acute pancreatitis. Evidence-based practice guidelines, prepared by the Hungarian Pancreatic Study Group. Orv. Hetil. 2015, 156, 244–261. https://doi.org/10.1556/OH.2015.30059
41. Ong Y, Shelat VG. Ranson score to stratify severity in Acute Pancreatitis remains valid – Old is gold. Expert Review of Gastroenterology & Hepatology. 2021, 15(8), 865–877. http://dx.doi.org/10.1080/17474124.2021.1924058
42. Di MY, Liu H, Yang ZY, et al. Prediction Models of Mortality in Acute Pancreatitis in Adults. Annals of Internal Medicine. 2016, 165(7);482. http://dx.doi.org/10.7326/m16-0650
43. Chandra S, Muralı A, Bansal R, et al. The Bedside Index for Severity in Acute Pancreatitis: a systematic review of prospective studies to determine predictive performance. J Community Hosp Intern Med Perspect. 2017, 7: 208-213
44. Arvanıtakıs M, Dumonceau JM, Albert J, et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy. 2018, 50: 524-546.

Toplam 43 adet kaynakça vardır.

Ayrıntılar

Birincil Dil	İngilizce
Konular	Klinik Tıp Bilimleri
Bölüm	Araştırma
Yazarlar	Selen Acehan 0000-0003-4390-6593 Salim Satar 0000-0001-6080-4287 Müge Gülen 0000-0002-5080-3501 Basak Toptas Firat 0000-0001-8327-8814 Deniz Aka Satar 0000-0002-7257-8683 Adnan Taş 0000-0002-5706-2136
Yayımlanma Tarihi	30 Eylül 2022
Kabul Tarihi	5 Eylül 2022
Yayımlandığı Sayı	Yıl 2022 Cilt: 47 Sayı: 3

Kaynak Göster

MLA	Acehan, Selen vd. “Evaluation of Scoring Systems in Terms of Early Prediction of Severe Acute Pancreatitis and Mortality in Patients over 65 Years of Age”. Cukurova Medical Journal, c. 47, sy. 3, 2022, ss. 1327-38, doi:10.17826/cumj.1121730.

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