Foreign body in the appendix presenting as acute appendicitis: a case report

Background

Foreign bodies are a rare cause of appendicitis. In most instances, ingested foreign bodies pass through the alimentary tract asymptomatically. However, those that enter the lumen of the vermiform appendix may not be able to re-enter the colon and may initiate an inflammatory process. We report a case of acute appendicitis induced by an unusual foreign body.

Case presentation

A 26-year-old Sub-Saharan woman presented with right iliac fossa pain and tenderness. She underwent an open appendectomy which revealed a condom fragment within the appendiceal lumen. A detailed retrospective history confirmed accidental ingestion of the condom 2 weeks prior to onset of symptoms.

Conclusions

Although a rare finding, a variety of foreign bodies can be lodged in the appendix and may instigate an inflammatory process. There is a need to increase awareness of the potential dangers of ingested foreign bodies.

The utility of hyperthermic intra-abdominal chemotherapy with gemcitabine for the inhibition of tumor progression in an experimental model of pancreatic peritoneal carcinomatosis, in relation to their behavior with pancreatic cancer stem cells CD133+ CXCR4

OBJECTIVE

The origin of pancreatic cancer has been identified as a population of malignant pancreatic stem cells CD133+ CXCR4+ immunophenotype. These cells have high capacity for early locoregional invasion, being responsible for early recurrence and high mortality rates of pancreatic cancer. We propose a study for decreasing tumor progression of pancreatic cancer by reducing the volume and neoplastic subpopulation of pancreatic cancer stem cells CD133+ CXCR4+. Therefore, we develop a new therapeutic model, characterized by the application of HIPEC (Hyperthermic Intraperitoneal Chemotherapy) with gemcitabine.

DESIGN

Pancreatic tumor cell line: human cell line BxPC-3. The animal model involved 18 immunosuppressed rats 5 weeks weighing 150-200 gr. The implantation of 13 × 10(6) cells/mL was performed with homogeneous distribution in the 13 abdominopelvic quadrants according to the peritoneal carcinomatosis index (PCI) and were randomized into three treatment groups. Group I (4 rats) received intravenous saline. Group II (6 rats) received intravenous gemcitabine. Group III (8 rats) received HIPEC at 41 °C for 30 min with gemcitabine + gemcitabine IV. A histological study confirmed pancreatic cancer and immunohistochemical quantification of pancreatic cancer stem cells CD133+ CXCR4+ tumor cells.

RESULTS

There was a population decline of pancreatic cancer stem cells CD133+ CXCR4+ in the HIPEC group with respect to the other two groups (p < 0.001). There was a decrease in PCI between treatment groups (p < 0.05).

CONCLUSION

The initial results are encouraging since there is a declining population of cancer stem cells CD133+ CXCR4+ in the HIPEC group and decreased tumor volume compared to the other two treatment groups. All the conclusions are only valid for BxPC3 cell line, and the effects HIPEC on Kras-driven pancreatic tumors remain to be determined.

Identification of CD90 as Putative Cancer Stem Cell Marker and Therapeutic Target in Insulinomas

The long-term prognosis after surgical resection of malignant insulinoma (INS) is poor. Novel adjuvant therapies, specifically targeting cancer stem cells (CSCs), are warranted. Therefore, the goal of this study was to characterize and target putative INS CSCs. Using fluorescence-activated cell sorting, human INS cell line CM and pancreatic carcinoid cell line BON1 were screened for the presence of stem cell-associated markers. CD90, CD166, and GD2 were identified as potential CSC markers. Only CD90(+) INS cells had an increased tumor-initiating potential in athymic nude mice. Anti-CD90 monoclonal antibodies decreased the viability and metastatic potential of injected cells in a zebrafish embryo INS xenograft model. Primary INS stained positive for CD90 by immunohistochemistry, however also intratumoral fibroblasts and vascular endothelium showed positive staining. The results of this study suggest that anti-CD90 monoclonals form a potential novel adjuvant therapeutic modality by targeting either INS cells directly, or by targeting the INS microenvironment.

Diagnostic Value of White Blood Cell and C-Reactive Protein in Pediatric Appendicitis

Background. Acute appendicitis (AA) associated with acute phase reaction is the most prevalent disease which requires emergency surgery. Its delayed diagnosis and unnecessarily performed appendectomies lead to numerous complications. In our study, we aimed to detect the role of WBC and CRP in the exclusion of acute and complicated appendicitis and diagnostic accuracy in pediatric age group. Methods. Appendectomized patient groups were constructed based on the results of histological evaluation. The area under a receiver operating characteristic (ROC) curve (AUC) was performed to examine diagnostic accuracy. Results. When WBC and CRP were used in combination, based on cut-off values of ≥13.1 × 10³/μL for WBC counts and ≥1.17 mg/dL for CRP level, diagnostic parameters were as follows: sensitivity, 98.7%; specificity, 71.3%; PPV, 50.6%; NPV, 99.5%; diagnostic accuracy, 77.6%; LR(+), 3.44; LR(−), 0.017. AUC values were 0.845 (95% CI 0.800–0.891) for WBC and 0.887 (95% CI 0.841–0.932) for CRP. Conclusions. For complicated appendicitis, CRP has the highest degree of diagnostic accuracy. The diagnosis of appendicitis should be made primarily based on clinical examination, and obviously more specific and systemic inflammatory markers are needed. Combined use of cut-off values of WBC (≥13100/μL) and CRP (≥1.17 mg/L) yields a higher sensitivity and NPV for the diagnosis of complicated appendicitis.

Open versus laparoscopic approach in the treatment of abdominal emergencies in elderly population

AIM

To evaluate the role of laparoscopy in the treatment of surgical emergency in old population.

PATIENTS AND METHODS

Over-70 years-old patients submitted to emergency abdominal surgery from January 2013 to December 2014 were collected and grouped according to admission diagnoses. These accounted small bowel obstruction, colonic acute disease, appendicitis, ventral hernia, gastro-duodenal perforation, biliary disease. In each group it was analyzed the operation time (OT), the morbidity rate and the mortality rate comparing open and laparoscopic management using T-test and Chi-square test.

RESULTS

159 over 70-years-old patients underwent emergency surgery in the General and Emergency surgery Operative Unit (O.U.) of the Policlinic of Palermo. 75 patients were managed by a laparoscopic approach and 84 underwent traditional open emergency surgery. T-Test for OT and Chi-square test for morbidity rate and mortality rate showed no differences in small bowel emergencies (p=0,4; 0,250,9; p>0,95) and in gastro-duodenal perforation (p=0,9; p>0.9; p>0.95). In cholecystitis, laparoscopy group showed lower OT (T-Test: p= 0,0002) while Chi-square test for morbidity rate (0,1

CONCLUSIONS

The collected data showed the feasibility of laparoscopic management as an alternative to open surgery in surgical emergencies in elderly population.

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Key Words

• surgery
• laparoscopy
• elderly
• emergency

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MESH Headings

• Abdomen/surgery
• Aged
• Digestive System Diseases/surgery
• Emergency Treatment
• Hernia, Ventral/surgery
• Humans
• Laparoscopy

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Affiliation(s)

G. COCORULLO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
N. FALCO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
R. TUTINO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
T. FONTANA Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
G. SCERRINO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
G. SALAMONE Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
L. LICARI Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
G. GULOTTA Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy

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The Current Role of Radiologic and Endoscopic Imaging in the Diagnosis and Follow-Up of Colonic Diverticular Disease

OBJECTIVE

Colonic diverticular disease is among the most prevalent conditions in Western society and is a common cause for outpatient visits and hospitalizations. The role of imaging is in evolution, but it has proven useful in confirming clinically suspected disease, assessing severity and complications, and directing patient management.

CONCLUSION

This review focuses on the current role of radiologic and endoscopic imaging in distinct clinical scenarios of diverticular disease, with emphasis on diverticulitis and its follow-up.

Prognostic and Functional Significance of MAP4K5 in Pancreatic Cancer

Objectives

MAP4K5 plays an important role in regulating a range of cellular responses and is involved in Wnt signaling in hematopoietic cells. However, its functions in human malignancies have not been studied. The major objectives of this study are to examine the expression, functions and clinical significance of MAP4K5 in pancreatic ductal adenocarcinoma (PDAC).

Materials and Methods

The expression levels of MAP4K5, E-cadherin, vimentin, and carboxylesterase 2 (CES2) were examined by immunohistochemistry in 105 PDAC and matched non-neoplastic pancreas samples from our institution. The RNA sequencing data of 112 PDAC patients were downloaded from the TCGA data portal. Immunoblotting and RNA sequencing analysis were used to examine the expression of MAP4K5 and E-cadherin in pancreatic cancer cell lines. The effect of knockdown MAP4K5 using siRNA on the expression of CDH1 and vimentin were examined by Real-time RT-PCR in Panc-1 and AsPC-1 cells. Statistical analyses were performed using IBM SPSS Statistics.

Results

MAP4K5 protein is expressed at high levels specifically in the pancreatic ductal cells of 100% non-neoplastic pancreas samples, but is decreased or lost in 77.1% (81/105) of PDAC samples. MAP4K5-low correlated with the loss of E-cadherin (P = 0.001) and reduced CES2 expression (P = 0.002) in our patient populations. The expression levels of MAP4K5 mRNA directly correlated with the expression levels of CDH1 mRNA (R = 0.2490, P = 0.008) in the second cohort of 112 PDAC patients from The Cancer Genome Atlas (TCGA) RNA-seq dataset. Similar correlations between the expression of MAP4K5 and E-cadherin were observed both at protein and mRNA levels in multiple pancreatic cancer cell lines. Knockdown MAP4K5 led to decreased CDH1 mRNA expression in Panc-1 and AsPC-1 cells. MAP4K5-low correlated significantly with reduced overall survival and was an independent prognosticator in patients with stage II PDAC.

Conclusions

MAP4K5 expression is decreased or lost in majority of PDACs. The strong associations between low MAP4K5 expression and loss of E-cadherin, reduced CES2 expression and decreased overall survival may suggest an important role of MAP4K5 in epithelial-to-mesenchymal transition, chemotherapy resistance and tumor progression in pancreatic cancer. Targeting impaired MAP4K5 signaling may represent a new therapeutic strategy for pancreatic cancer.

New drugs for the treatment of complicated intra-abdominal infections in the era of increasing antimicrobial resistance

The continuing increase in multidrug-resistant organisms (MDROs) worldwide has created new challenges in treating complicated intra-abdominal infections (cIAIs). A number of novel antimicrobial agents have been developed against resistant pathogens. To target extended-spectrum β-lactamase (ESBL)-producing pathogens, novel β-lactam antibiotics, such as ceftolozane/tazobactam, ceftazidime/avibactam, aztreonam/avibactam, imipenem/relebactam and S-649266, are antimicrobial alternatives for cIAIs. Two new drugs, eravacycline and plazomicin, have activity against Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae, carbapenem-resistant Acinetobacter baumannii and ESBL-producers. New lipoglycopeptides and oxazolidinones provide feasible options against resistant Gram-positive pathogens. These novel antimicrobials may play a role in improving the clinical outcomes of cIAIs caused by MDROs.

Prognostic role of HER2 amplification based on fluorescence in situ hybridization (FISH) in pancreatic ductal adenocarcinoma (PDAC): a meta-analysis

Background

Previous studies have shown that human epidermal growth factor receptor 2 (HER2) may play an important role in the invasion and metastasis of pancreatic cancer, but the relationship between HER2 amplification level and prognosis of pancreatic cancer patients is still controversial. Therefore, we performed a meta-analysis to determine the prognostic significance of HER2 amplification based on fluorescence in situ hybridization (FISH) in patients with pancreatic cancer.

Methods

PubMed, EMBASE, and Web of Science (Jan 2001 to Jun 2015) were searched. Only articles that detect the HER2 amplification by FISH method were included. RevMan 5.3 and STATA version 12 were used to perform this meta-analysis. Pooled calculations were carried out on hazard ratio (HR) and 95 % confidence interval (CI) to assess the risk of disease.

Results

A total of six eligible studies were enrolled in meta-analysis. The univariate analysis results showed that HER2 amplification was not significantly associated with patients’ overall survival (pooled HR, 1.87, 95 % CI, 0.64–5.46, P = 0.25), which are maintained in one study of multivariate analysis (HR 0.51, 95 % CI, 0.12–2.14, P = 0.358). HER2 amplification also had no correlation with clinicopathological factors such as age, gender, lymph node metastasis, and tumor stage.

Conclusions

Our results showed that HER2 amplification based on FISH may not be a good prognostic factor for survival in patients with pancreatic cancer.

Relationship between epithelial to mesenchymal transition and prognosis in pancreatic cancer

AIM: To investigate the relationship between epithelial to mesenchymal transition (EMT) and patient's prognosis in pancreatic cancer.

METHODS: E-cadherin and Vimentin protein expression was detected by immunohistochemistry in 60 pancreatic cancer specimens. EMT was divided into three grades according to the expression of E-cadherin and Vimentin: Ⅰ [E-cadherin (+)/ Vimentin (-)], Ⅱ [E-cadherin (-)/Vimentin (-)], and Ⅲ [E-cadherin (-)/Vimentin (+)]. Kaplan-Meier survival analysis was used to evaluate the relationship between EMT and patient's prognosis.

RESULTS: The 1-, 2-, and 3-year overall survival rates in 60 patients with pancreatic cancer were 50%, 29% and 50%, respectively. High expression of E-cadherin was associated with a good prognosis (P = 0.006), while elevated expression of Vimentin related with a poor prognosis (P = 0.002). Median survival of patients with grades Ⅰ, Ⅱ and Ⅲ EMT was 24.07 mo ± 4.50 mo, 11.97 mo ± 0.92 mo and 6.30 mo ± 0.52 mo, respectively. A higher grade of EMT was associated with a worse prognosis (P = 0.001). Cox proportional hazards models suggested that EMT was one of independent risk factors for poor prognosis in pancreatic cancer (P = 0.025), with HR = 1.779 (95%CI: 1.077-2.939).

CONCLUSION: EMT is an independent predicable risk factor for poor prognosis in pancreatic cancer.

MIA PaCa-2 and PANC-1 - pancreas ductal adenocarcinoma cell lines with neuroendocrine differentiation and somatostatin receptors

Studies using cell lines should always characterize these cells to ensure that the results are not distorted by unexpected morphological or genetic changes possibly due to culture time or passage number. Thus, the aim of this study was to describe those MIA PaCa-2 and PANC-1 cell line phenotype and genotype characteristics that may play a crucial role in pancreatic cancer therapeutic assays, namely neuroendocrine chemotherapy and peptide receptor radionuclide therapy. Epithelial, mesenchymal, endocrine and stem cell marker characterization was performed by immunohistochemistry and flow cytometry, and genotyping by PCR, gene sequencing and capillary electrophoresis. MIA PaCa-2 (polymorphism) expresses CK5.6, AE1/AE3, E-cadherin, vimentin, chromogranin A, synaptophysin, SSTR2 and NTR1 but not CD56. PANC-1 (pleomorphism) expresses CK5.6, MNF-116, vimentin, chromogranin A, CD56 and SSTR2 but not E-cadherin, synaptophysin or NTR1. MIA PaCA-1 is CD24⁻, CD44^+/++, CD326^−/+ and CD133/1⁻, while PANC-1 is CD24^−/+, CD44⁺, CD326^−/+ and CD133/1⁻. Both cell lines have KRAS and TP53 mutations and homozygous deletions including the first 3 exons of CDKN2A/p16^INK4A, but no SMAD4/DPC4 mutations or microsatellite instability. Both have neuroendocrine differentiation and SSTR2 receptors, precisely the features making them suitable for the therapies we propose to assay in future studies.

Facing Terminal Ileitis: Going Beyond Crohn's Disease

Terminal ileitis (TI) is an inflammatory condition of the terminal portion of the ileum that may occur acutely with right lower quadrant pain followed or not by diarrhea, or exhibit chronic obstructive symptoms and bleeding and normally it is associated to Crohn's disease (CD) although it may be associated to other different conditions. This review intended to contribute to a better understanding of TI in order to help in the diagnosis, medical approach and patient care. This work was performed on a survey of articles collected in different databases and a retrospective search was carried out to identify relevant studies in the field. Pathological conditions such as ulcerative colitis, the intake of non-steroidal anti-inflammatory drugs, infectious diseases, eosinophilic enteritis, malignant diseases, spondyloarthropathies, vasculitides, ischemia, sarcoidosis, amyloidosis and others may be related to ileitis but it is commonly referred to CD. To a correct therapeutic approach, it is necessary to understand the causes of this inflammation process. The performance of a clinical, laboratory, endoscopic, and histopathological evaluation of the individuals is crucial to the correct diagnosis and treatment once the inflammation of the ileum may occur due to different pathological conditions besides CD, leading to difficulties in the diagnosis. Thus, an individual approach is necessary once the correct diagnosis is crucial for the immediate therapeutic approach and recovering of the patient.

Clinical characteristics and antimicrobial patterns in complicated intra-abdominal infections: a 6-year epidemiological study in southern China

Complicated intra-abdominal infection (cIAIs) are a common and important cause of morbidity worldwide. In this study, the clinical features, microbiological profiles, antimicrobial patterns and treatments of 3233 cIAI patients (mean age, 47.6 years; 54.7% male) with 3531 hospitalisations from 2008-2013 were retrospectively investigated. The most commonly isolated bacteria were Escherichia coli (47.6%), Klebsiella pneumoniae (16.9%), Enterococcus faecalis (10.4%) and Pseudomonas aeruginosa (8.8%). Ciprofloxacin, aminoglycoside (gentamicin), piperacillin/tazobactam and carbapenems exhibited activity against 53%, 76%, 88% and 100% of extended-spectrum β-lactamase (ESBL)-positive Enterobacteriaceae isolates, respectively. Pseudomonas aeruginosa isolates exhibited 100%, 95%, 88%, 71% and 76% susceptibility to aminoglycoside (gentamicin), ciprofloxacin, meropenem, imipenem and ceftazidime, respectively, and Enterococcus remained 100% susceptible to vancomycin and linezolid. β-Lactam antibacterials other than penicillin (specifically third-generation cephalosporins) and imidazole derivatives (ornidazole and metronidazole) were the most common first-line treatments. Patients subjected to regimen change after initial antibiotic treatment had predisposing conditions (e.g. older age, more severe co-morbidities) and a higher incidence of P. aeruginosa infection; in addition, these patients encountered a higher average cost of care and worse clinical outcomes compared with those without medication modification. Taken together, these findings indicate the importance of appropriate initial empirical therapy and suggest the use of combination therapy comprising cephalosporins and metronidazole.

Antibiotics alone for uncomplicated acute appendicitis in high operative risk adult patients: Analytical review of RCTs and proposal of evidence based treatment decision

BACKGROUND

Clinical trials have so far shown controversial results as regards the standard of care for treating uncomplicated acute appendicitis (uC-AA). High operational risk adult patients (HORAP) could represent selected patients where primary antibiotic conservative therapy (pACT or A) could be indicated.

METHODS

We carried a comprehensive search of the PubMed searching engine in the English language scientific literature from 1995 to 2015, using medical subject headings "antibiotics", "uncomplicated appendicitis", "appendicectomy", "conservative treatment", "surgery" and "randomized clinical trial". All RCTs comparing the outcomes of pACT versus primary surgical open or laparoscopic appendectomy (pSOLA or S) as primary treatment options for uC-AA were identified. Inclusion criteria for our analytical review were RCTs evaluating outcomes in terms of or related to all of the following four parameters: treatment efficacy, post therapeutic/operative complications, in hospital length of stay (LOS) and recurrence.

RESULTS

The conclusion of all five RCTs considered antibiotics alone in the treatment of AA as an efficient and non inferior therapeutic option respect to surgery. Primary ACT was characterised by a higher LOS, a higher rate of recurrence and a lower rate of postoperative complication than pSOLA.

CONCLUSIONS

Based on the current body of evidence, an appropriate pACT could be a rational tailored primary treatment option for CT proven uC-AA in HORAP. Accurate diagnoses and surgical risk stratification in patients with uC-AA could aid decision making for target therapy. However, results of large sample prospective multicenter RCTs are required to routinely recommend pACT for uC-AA in the clinical practice.

Translational research-the need of a new bioethics approach

Translational research tries to apply findings from basic science to enhance human health and well-being. Many phases of the translational research may include non-medical tasks (information technology, engineering, nanotechnology, biochemistry, animal research, economy, sociology, psychology, politics, and so on). Using common bioethics principles to these areas might sometimes be not feasible, or even impossible. However, the whole process must respect some fundamental, moral principles. The purpose of this paper is to argument the need for a different approach to the morality in translational bioethics, and to suggest some directions that might be followed when constructing such a bioethics. We will show that a new approach is needed and present a few ethical issues that are specific to the translational research.

Antibiotic resistance evaluation and clinical analysis of acute appendicitis; report of 1431 consecutive worldwide patients: A cohort study

BACKGROUND

Acute appendicitis (AA) is one of the most common diseases affecting especially young but also older people. A systematic evaluation of bacteriology of AA has been frequently conducted in children but is not well known and discussed in adult population.

STUDY DESIGN

The study has been obtained from two multicenter prospective observational studies (CIAO and CIAOW studies). The aim of the study is to analyze the intra-abdominal bacteriology in AA and its relation with clinical outcomes.

RESULTS

Patients included were 1431, 806 male (56.3%). The mean/median age was 38.9 (SD ± 18.4) and 35 (range 18-94). Clinical condition at the admission was sepsis in 623 patients (43.5%), severe sepsis and septic shock in 29 (2%) and 10 (0.7%). Peritonitis was localized in 1107 patients (77.4%) and generalized in 324 (22.6%). Adequate source-control and empirical antimicrobial therapy were reported in 95.2% and 88.7% of the patients. 47 isolated bacteria (6.8%) were resistant. Two (4.2%) were health-care-associated infections and 45 (95.7%) were community-acquired infections. Univariate analysis showed factor associated to resistant bacteria was the inadequacy of the empiric antimicrobial therapy (p = 0.013); at multivariated analysis factors associated with mortality were age>70 years (p = 0.003) and severe sepsis at the admission (p = 0.02); factors associated to ICU admission were: severe sepsis (p < 0.0001), generalized peritonitis (p < 0.0001), malignancy (p < 0.0001) and cardiovascular disease (p < 0.0001).

CONCLUSION

The evolution of antimicrobial resistance, in common community-acquired infections, combined with lack of new antibiotics development are strictly linked to clinical outcomes. Adequate empirical antimicrobial therapy is fundamental to counteract bacterial resistance.

Practice Guidelines for Primary Care of Acute Abdomen 2015

Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine, in collaboration with four other medical societies, launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines (all clinical questions and recommendations were shown in supplementary information). A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen. A total of 108 questions based on nine subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended. The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.

Long non-coding RNA LOC389641 promotes progression of pancreatic ductal adenocarcinoma and increases cell invasion by regulating E-cadherin in a TNFRSF10A-related manner

Long non-coding RNAs (lncRNAs) are important regulators in pathological processes, yet their potential roles in pancreatic ductal adenocarcinoma (PDAC) are poorly understood. Here, we found that a novel lncRNA, LOC389641, was upregulated in PDAC tissues and cell lines. The expression of LOC389641 was significantly correlated with staging, lymph node metastasis and overall survival. Knockdown of LOC389641 impaired cell proliferation and invasion and induced cell apoptosis in vitro, whereas overexpression of LOC389641 had the opposite effect. The growth promoting effect of LOC389641 was also demonstrated in vivo. Further, a significant negative correlation was observed between E-cadherin levels and LOC389641 levels in vivo. Knockdown of LOC389641 upregulated E-cadherin expression, but knockdown of E-cadherin had a limited influence on LOC389641. Importantly, after E-cadherin was inhibited, the enhancement of LOC389641 on cell invasion was hindered. Moreover, the expression of LOC389641 was closely associated with its genomic neighboring gene TNFRSF10A. Lastly, knockdown experiments showed that TNFRSF10A might be a connection between LOC389641and E-cadherin. We conclude that LOC389641 promotes PDAC progression and increases cell invasion by regulating E-cadherin with the possible involvement of TNFRSF10A.

Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study)

BACKGROUND

To validate a new practical Sepsis Severity Score for patients with complicated intra-abdominal infections (cIAIs) including the clinical conditions at the admission (severe sepsis/septic shock), the origin of the cIAIs, the delay in source control, the setting of acquisition and any risk factors such as age and immunosuppression.

METHODS

The WISS study (WSES cIAIs Score Study) is a multicenter observational study underwent in 132 medical institutions worldwide during a four-month study period (October 2014-February 2015). Four thousand five hundred thirty-three patients with a mean age of 51.2 years (range 18-99) were enrolled in the WISS study.

RESULTS

Univariate analysis has shown that all factors that were previously included in the WSES Sepsis Severity Score were highly statistically significant between those who died and those who survived (p < 0.0001). The multivariate logistic regression model was highly significant (p < 0.0001, R2 = 0.54) and showed that all these factors were independent in predicting mortality of sepsis. Receiver Operator Curve has shown that the WSES Severity Sepsis Score had an excellent prediction for mortality. A score above 5.5 was the best predictor of mortality having a sensitivity of 89.2 %, a specificity of 83.5 % and a positive likelihood ratio of 5.4.

CONCLUSIONS

WSES Sepsis Severity Score for patients with complicated Intra-abdominal infections can be used on global level. It has shown high sensitivity, specificity, and likelihood ratio that may help us in making clinical decisions.

Acute appendicitis: proposal of a new comprehensive grading system based on clinical, imaging and laparoscopic findings

Advances in the technology and improved access to imaging modalities such as Computed Tomography and laparoscopy have changed the contemporary diagnostic and management of acute appendicitis. Complicated appendicitis (phlegmon, abscess and/ or diffuse peritonitis), is now reliably distinguished from uncomplicated cases. Therefore, a new comprehensive grading system for acute appendicitis is necessary. The goal is review and update the laparoscopic grading system of acute appendicitis and to provide a new standardized classification system to allow more uniform patient stratification. During the last World Society of Emergency Surgery Congress in Israel (July, 2015), a panel involving Acute Appendicitis Experts and the author’s discussed many current aspects about the acute appendicitis between then, it will be submitted a new comprehensive disease grading system. It was idealized based on three aspect of the disease (clinical and imaging presentation and laparoscopic findings). The new grading system may provide a standardized system to allow more uniform patient stratification for appendicitis research. In addition, may aid in determining optimal management according to grade. Lastly, what we want is to draw a multicenter observational study within the World Society of Emergency Surgery (WSES) based on this design.

MicroRNA-200b inhibits the growth and metastasis of glioma cells via targeting ZEB2

MicroRNAs (miRs) have been found to play important roles in mediating a variety of biological processes in human cancers, including tumor cell proliferation, migration, invasion, and epithelial-mesenchymal transition (EMT). In the present study, we aimed to investigate the putative role of miR‑200b in the progression of glioma. Real-time RT-PCR data showed that the miR‑200b levels were frequently reduced in primary glioma tissues (n=88) and cell lines, when compared to normal brain tissues (n=25). Moreover, decreased miR‑200b level was tightly associated with the malignant progression of glioma. Overexpression of miR‑200b significantly suppressed cell proliferation, migration, invasion and EMT in glioma U251 and U87 cells. Luciferase reporter assay data further identified ZEB2 as a direct target of miR‑200b, and the protein expression of ZEB2 was markedly reduced after overexpression of miR‑200b in U251 and U87 cells. Furthermore, restoration of ZEB2 effectively reversed the reduced expression of ZEB2, as well as the suppressive effects of miR‑200b overexpression on the proliferation, migration, invasion and EMT in glioma U251 and U87 cells. Moreover, in vivo study showed that overexpression of miR‑200b significantly inhibited tumorigenesis as well as the tumor growth of glioma cells, and effectively protected nude mice from tumor-induced death. Taken together these findings suggest that miR‑200b has suppressive effects on the proliferation, migration, invasion and EMT of glioma cells, partly at least, via targeting ZEB2. Therefore, miR‑200b acts as a novel tumor suppressor in glioma, and thus may become a promising therapeutic candidate for glioma.

Ebstein Anomaly: An Overview for Nursing

Ebstein anomaly is a rare congenital heart defect. Many nurses have probably never encountered this anomaly, with very few able to accurately depict the pathological anatomy of the condition. As technology further develops, providers are better equipped to recognize and manage Ebstein anomaly. There are important considerations for nurses when caring for an individual with Ebstein anomaly. The aim of this article is to give an overview of the condition exploring the pathophysiology, how patients typically present, and how to effectively care for a patient with Ebstein anomaly regarding medical and surgical courses of treatment. It is important for nurses to have a resource to reference on Ebstein anomaly, and the majority of current literature is solely based for medical providers. Furthermore, Ebstein patients may be seen on a variety of units in the hospital beyond cardiology (i.e., pregnant patient with a diagnosis of Ebstein anomaly).

Morphology-Independent Virulence of Candida Species during Polymicrobial Intra-abdominal Infections with Staphylococcus aureus

Intra-abdominal polymicrobial infections cause significant morbidity and mortality. An experimental mouse model of Candida albicans-Staphylococcus aureus intra-abdominal infection (IAI) results in 100% mortality by 48 to 72 h postinoculation, while monomicrobial infections are avirulent. Mortality is associated with robust local and systemic inflammation without a requirement for C. albicans morphogenesis. However, the contribution of virulence factors coregulated during the yeast-to-hypha transition is unknown. This also raised the question of whether other Candida species that are unable to form hyphae are as virulent as C. albicans during polymicrobial IAI. Therefore, the purpose of this study was to evaluate the ability of non-albicans Candida (NAC) species with various morphologies and C. albicans transcription factor mutants (efg1/efg1 and cph1/cph1) to induce synergistic mortality and the accompanying inflammation. Results showed that S. aureus coinoculated with C. krusei or C. tropicalis was highly lethal, similar to C. albicans, while S. aureus-C. dubliniensis, S. aureus-C. parapsilosis, and S. aureus-C. glabrata coinoculations resulted in little to no mortality. Local and systemic interleukin-6 (IL-6) and prostaglandin E2 (PGE2) levels were significantly elevated during symptomatic and/or lethal coinfections, and hypothermia strongly correlated with mortality. Coinoculation with C. albicans strains deficient in the transcription factor Efg1 but not Cph1 reversed the lethal outcome. These results support previous findings and demonstrate that select Candida species, without reference to any morphological requirement, induce synergistic mortality, with IL-6 and PGE2 acting as key inflammatory factors. Mechanistically, signaling pathways controlled by Efg1 are critical for the ability of C. albicans to induce mortality from an intra-abdominal polymicrobial infection.

SLC39A6: a potential target for diagnosis and therapy of esophageal carcinoma

Background

Esophageal squamous cell carcinoma (ESCC) is a highly lethal cancer, and its underlying molecular mechanisms are poorly understood. Recent large-scale genome-wide association studies in Chinese Han populations have identified an ESCC susceptibility locus within the SLC39A6 gene. Here, we sought to explore the expression and biological function of SLC39A6 in ESCC.

Methods

Multiethnic validation of SLC39A6 protein expression was performed in different cohorts of patients from Chinese Han and Kazakh populations in the Xinjiang region by immunohistochemistry. The associations among SLC39A6 expression, clinicopathological parameters, and prognosis outcomes of ESCC were analyzed. And the effects of SLC39A6 silencing by siRNA on cell proliferation, apoptosis, and invasiveness, as well as the proteins involved in epithelial-to-mesenchymal transition (EMT) of esophageal cancer cells, were studied.

Results

SLC39A6 protein expression increased progressively from normal esophageal epithelium (NEE) to low-grade intraepithelial neoplasia to ESCC, and finally reached the highest in high-grade intraepithelial neoplasia from Han ethnic. Similarly, SLC39A6 protein was significantly overexpressed in Kazakh ethnic ESCC compared with that in NEE. Increased expression of SLC39A6 was found to be closely correlated with histological grade and early Tumor-Node-Metastasis stage I/II. High tumorous SLC39A6 expression was significantly correlated with shorter overall survival (OS). Cox regression analysis confirmed that SLC39A6 expression was an independent prognostic factor for poor OS in ESCC. Experimentally, the suppression of SLC39A6 expression promoted ESCC cell apoptosis but abrogated proliferation and invasion, and induced an EMT phenotype that included enhanced expression of E-cadherin, loss of vimentin, and morphological changes in ESCC cells in vitro.

Conclusions

Combined, our findings highlight a tumor-promoting role for SLC39A6 in ESCC, suggesting that SLC39A6 could serve as an early detector of high-risk subjects and prognostic biomarker. The targeting of SLC39A6 might be a potential therapeutic strategy for blocking ESCC.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-015-0681-z) contains supplementary material, which is available to authorized users.

The Challenge of Antimicrobial Resistance in Managing Intra-Abdominal Infections

BACKGROUND

In recent years, there has been a worldwide increase in infections caused by microorganisms resistant to multiple antimicrobial agents.

METHODS

In the past few decades, an increased prevalence of infections caused by antibiotic-resistant pathogens, including Enterococcus spp., carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter baumannii, extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella spp., carbapenemase-producing Klebsiella pneumoniae, and resistant Candida spp., also has been observed among intra-abdominal infections (IAIs).

RESULTS

The increasing prevalence of multi-drug resistance is responsible for a substantial increase in morbidity and mortality rates associated with IAIs.

CONCLUSIONS

It is necessary for every surgeon treating IAIs to understand the underlying epidemiology and clinical consequences of antimicrobial resistance. Emergence of drug resistance, combined with the lack of new agents in the drug development pipeline, indicates that judicious antimicrobial management will be necessary to preserve the utility of the drugs available currently.

Benefits of WSES guidelines application for the management of intra-abdominal infections

INTRODUCTION

The use of antibiotics is very high in the departments of Emergency and Trauma Surgery above all in the treatment of the intra-abdominal infections, to decrease morbidity and mortality rates; often the antimicrobial drugs are prescribed without a rationale and they are second-line antibiotics; this clinical practice increases costs without decreasing mortality. Aim of our study is to report the results in the application to the clinical practice of the World Society Emergency Surgeons (WSES) guidelines for the management of intra-abdominal infections, at the department of Emergency and Trauma Surgery of the University Hospital of Parma (Italy) in 2012.

METHODS

A retrospective observational analysis was carried out about patients admitted in the department of Emergency and Trauma Surgery of Parma (Italy), between January 2011 and December 2012. The data are expressed as percentages (%) and means (± SD). The results of the compared groups were analyzed using the Pearson's Chi-Square and Fisher's tests. For means involving continuous numerical data, the independent sample T test and the Mann-Whitney U-test were used for normally and abnormally distributed data, respectively (the data had been previously tested for normality using the Kolmogorov-Smirnov test). A p-value < 0.05 was considered statistically significant.

RESULTS

Between January 2011 and December 2012, 2121 (968 in 2011 and 1153 in 2012) patients were admitted in the department of Emergency and Trauma Surgery (Italy) of Parma University Hospital with a diagnosis of acute IAI. Morbidity in 2012 was 10,2% compared to 22.7% in 2011 and mortality in 2012 was 1,1% compared to 3,2% in 2011 (p < 0,05). Costs for antibiotics in 2012 was 51392 euro, with a reduction of 31% compared to 2011.

CONCLUSIONS

This study demonstrates that an inexpensive and easily application of guidelines based on medicine evidence in the use of antibiotics can lead to a significative reduction of hospital costs with outcomes improvement.

Ceftolozane/tazobactam for the treatment of complicated intra-abdominal infections

INTRODUCTION

Decisions regarding empirical antimicrobial therapy for complicated intra-abdominal infections (cIAIs) are increasingly difficult because of the threat of antimicrobial resistance. Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae are a particular challenge, as is multidrug-resistant (MDR) Pseudomonas aeruginosa, both of which are encountered in cIAI. Ceftolozane/tazobactam is a new antimicrobial that provides an effective solution for treating cIAI.

AREAS COVERED

Evidence concerning the mechanism of action of ceftolozane/tazobactam, its in vitro activity against common cIAI pathogens, and pharmacokinetic and pharmacodynamic properties are reviewed. The clinical efficacy and safety of ceftolozane/tazobactam plus metronidazole, as determined by the Phase II and III clinical trials in hospitalized adults with cIAI, are discussed.

EXPERT OPINION

Ceftolozane/tazobactam has demonstrated efficacy and safety in patients with cIAI, including those who are infected with ESBL-producing Enterobacteriaceae and P. aeruginosa. High rates of clinical cure by ceftolozane/tazobactam in Phase II and III trials suggest that this antimicrobial will be valuable for treating infections caused by MDR Gram-negative bacteria. In recent years, clinicians have become dependent on carbapenems for treating MDR infections. There is concern that this could lead to emergence of carbapenem-resistant strains, emphasizing the importance of antimicrobial stewardship. Ceftolozane/tazobactam appears to be an effective carbapenem-sparing alternative for treating cIAI.

Re-evaluation of Mannheim prognostic index in perforative peritonitis: prognostic role of advanced age. A prospective cohort study

BACKGROUND

Peritonitis from perforation of abdominal viscera is associated with high mortality. In western countries individuals older than 65 years constitute a significant proportion of the population and intra abdominal infections are more challenging to manage in these aged patients.

METHODS

This prospective cohort study included 143 consecutive patients operated on for primary perforative peritonitis. The aim of the study was to assess the prognostic efficacy of Mannheim Peritonitis Index (MPI) in a population with a significant proportion of older patients and to substantiate advanced age as an independent prognostic factor. Patients' informations were collected both on hospitalization and after surgical exploration; severity of peritonitis was evaluated using the MPI. The prognostic value of MPI was compared to older age and other clinical variables.

RESULTS

The intra-hospital mortality was 25.2%. According to the MPI score, the ROC curve identified 21 as cut-off value with a sensitivity of 86% and a specificity of 59% in predicting the risk of death. MPI score and age over 80 years old resulted independent predictors of mortality at multivariate analysis. In the subgroup of patients with MPI score≥21, the mortality rate was 46.4% for patients older than 80 years old and 38.3% for younger patients (p=0.07); in patients with MPI score<21, the mortality of those aged more than 80 years reached 33.3% compared to 3.4% for younger patients (p=0.001).

CONCLUSIONS

Age older than 80 years is strongly related to major increase in mortality rates and should be taken into account together with the MPI score in planning the surgical approach and the post-operative care.

Role of modern 3D echocardiography in valvular heart disease

Three-dimensional (3D) echocardiography has been conceived as one of the most promising methods for the diagnosis of valvular heart disease, and recently has become an integral clinical tool thanks to the development of high quality real-time transesophageal echocardiography (TEE). In particular, for mitral valve diseases, this new approach has proven to be the most unique, powerful, and convincing method for understanding the complicated anatomy of the mitral valve and its dynamism. The method has been useful for surgical management, including robotic mitral valve repair. Moreover, this method has become indispensable for nonsurgical mitral procedures such as edge to edge mitral repair and transcatheter closure of paravaluvular leaks. In addition, color Doppler 3D echo has been valuable to identify the location of the regurgitant orifice and the severity of the mitral regurgitation. For aortic and tricuspid valve diseases, this method may not be quite as valuable as for the mitral valve. However, the necessity of 3D echo is recognized for certain situations even for these valves, such as for evaluating the aortic annulus for transcatheter aortic valve implantation. It is now clear that this method, especially with the continued development of real-time 3D TEE technology, will enhance the diagnosis and management of patients with these valvular heart diseases.

Role of damage control surgery in the treatment of Hinchey III and IV sigmoid diverticulitis: a tailored strategy

Many of the treatment strategies for sigmoid diverticulitis are actually focusing on nonoperative and minimally invasive approaches. The aim of this systematic review was to evaluate the actual role of damage control surgery (DCS) in the treatment of generalized peritonitis caused by perforated sigmoid diverticulitis.A literature search was performed in PubMed and Google Scholar for articles published from 1960 to July 2013. Comparative and noncomparative studies that included patients who underwent DCS for complicated diverticulitis were considered.Acute Physiology and Chronic Health Evaluation score, duration of open abdomen, intensive care unit length of stay, reoperation, bowel resection performed at first operation, fecal diversion, method, and timing of closure of abdominal wall were the main outcomes of interest.According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses algorithm for the literature search and review, 10 studies were included in this systematic review. DCS was exclusively performed in diverticulitis patients with septic shock or requiring vasopressors intraoperatively. Two surgical different approaches were highlighted: limited resection of the diseased colonic segment with or without stoma or reconstruction in situ, and laparoscopic washing and drainage without colonic resection.Despite the heterogeneity of patient groups, clinical settings, and interventions included in this review, DCS appears to be a promising strategy for the treatment of Hinchey III and IV diverticulitis, complicated by septic shock. A tailored approach to each patient seems to be appropriate.

Cost of care and antibiotic prescribing attitudes for community-acquired complicated intra-abdominal infections in Italy: a retrospective study

INTRODUCTION

Complicated intra-abdominal infections (cIAIs) are a common cause of morbidity worldwide, and in spite of improvements in patient care, therapeutic failure still occurs, impacting in-hospital resource consumption. This study aimed to assess the costs associated with the treatment of community-acquired cIAIs, from the Italian National Health Service perspective.

METHODS

This retrospective study analyzed the charts of patients who were discharged from four Italian university hospitals between January 1 and December 31, 2009 with a primary diagnosis of community-acquired cIAIs. Patient characteristics, diagnosis, surgical procedure, antibiotic therapy, and length of hospital stay were all recorded and the cost of total hospital care was estimated. Costs were calculated in Euros at 2009 values.

RESULTS

The records of 260 patients (mean age 48.9 years; 57% males) were analyzed. The average cost of care for a patient hospitalized due to cIAI was €4385 (95% CI 3650-5120), with an average daily cost of €419 (95% CI 378-440). Antibiotic therapy represented just under half (44.3%) of hospitalization costs. The strongest predictor of the increase in hospital costs was clinical failure: patients who clinically failed received an average of 8.2 additional days of antibiotic therapy and spent 11 more days in hospital compared with patients who responded to first-line therapy (both p < 0.05 vs. patients who were successfully treated). Furthermore, they incurred €5592 in additional hospitalization costs (2.88 times the cost associated with clinical success) with 53% (€2973) of the additional costs attributable to antibiotic therapy. Overall, antibiotic appropriateness rate was 78.8% (n = 205), and was significantly higher in patients receiving combination therapy compared with those treated with monotherapy (97.3% vs. 64.6%).

CONCLUSION

The results of this study suggest that hospitals need to be aware of the clinical and economic consequences of antibiotic therapy of cIAIs and to reduce overall resource use and costs by improving the rate of success with appropriate initial empiric therapy.

Complicated intra-abdominal infections worldwide: the definitive data of the CIAOW Study

The CIAOW study (Complicated intra-abdominal infections worldwide observational study) is a multicenter observational study underwent in 68 medical institutions worldwide during a six-month study period (October 2012-March 2013). The study included patients older than 18 years undergoing surgery or interventional drainage to address complicated intra-abdominal infections (IAIs). 1898 patients with a mean age of 51.6 years (range 18-99) were enrolled in the study. 777 patients (41%) were women and 1,121 (59%) were men. Among these patients, 1,645 (86.7%) were affected by community-acquired IAIs while the remaining 253 (13.3%) suffered from healthcare-associated infections. Intraperitoneal specimens were collected from 1,190 (62.7%) of the enrolled patients. 827 patients (43.6%) were affected by generalized peritonitis while 1071 (56.4%) suffered from localized peritonitis or abscesses. The overall mortality rate was 10.5% (199/1898). According to stepwise multivariate analysis (PR = 0.005 and PE = 0.001), several criteria were found to be independent variables predictive of mortality, including patient age (OR = 1.1; 95%CI = 1.0-1.1; p < 0.0001), the presence of small bowel perforation (OR = 2.8; 95%CI = 1.5-5.3; p < 0.0001), a delayed initial intervention (a delay exceeding 24 hours) (OR = 1.8; 95%CI = 1.5-3.7; p < 0.0001), ICU admission (OR = 5.9; 95%CI = 3.6-9.5; p < 0.0001) and patient immunosuppression (OR = 3.8; 95%CI = 2.1-6.7; p < 0.0001).

The total right/left-volume index: a new and simplified cardiac magnetic resonance measure to evaluate the severity of Ebstein anomaly of the tricuspid valve: a comparison with heart failure markers from various modalities

BACKGROUND

The classification of clinical severity of Ebstein anomaly still remains a challenge. The aim of this study was to focus on the interaction of the pathologically altered right heart with the anatomically-supposedly-normal left heart and to derive from cardiac magnetic resonance (CMR) a simple imaging measure for the clinical severity of Ebstein anomaly.

METHODS AND RESULTS

Twenty-five patients at a mean age of 26±14 years with unrepaired Ebstein anomaly were examined in a prospective study. Disease severity was classified using CMR volumes and functional measurements in comparison with heart failure markers from clinical data, ECG, laboratory and cardiopulmonary exercise testing, and echocardiography. All examinations were completed within 24 hours. A total right/left-volume index was defined from end-diastolic volume measurements in CMR: total right/left-volume index=(RA+aRV+fRV)/(LA+LV). Mean total right/left-volume index was 2.6±1.7 (normal values: 1.1±0.1). This new total right/left-volume index correlated with almost all clinically used biomarkers of heart failure: brain natriuretic peptide (r=0.691; P=0.0003), QRS (r=0.432; P=0.039), peak oxygen consumption/kg (r=-0.479; P=0.024), ventilatory response to carbon dioxide production at anaerobic threshold (r=0.426; P=0.048), the severity of tricuspid regurgitation (r=0.692; P=0.009), tricuspid valve offset (r=0.583; P=0.004), and tricuspid annular plane systolic excursion (r=0.554; P=0.006). Previously described severity indices ([RA+aRV]/[fRV+LA+LV]) and fRV/LV end-diastolic volume corresponded only to some parameters.

CONCLUSIONS

In patients with Ebstein anomaly, the easily acquired index of right-sided to left-sided heart volumes from CMR correlated well with established heart failure markers. Our data suggest that the total right/left-volume index should be used as a new and simplified CMR measure, allowing more accurate assessment of disease severity than previously described scoring systems.

Current concept of abdominal sepsis: WSES position paper

Although sepsis is a systemic process, the pathophysiological cascade of events may vary from region to region.

Abdominal sepsis represents the host’s systemic inflammatory response to bacterial peritonitis.

It is associated with significant morbidity and mortality rates, and is the second most common cause of sepsis-related mortality in the intensive care unit.

The review focuses on sepsis in the specific setting of severe peritonitis.

Is laparoscopy a safe approach for diffuse appendicular peritonitis? Feasibility and determination of risk factors for post-operative intra-abdominal abscess

BACKGROUND

Several studies have assessed feasibility and early outcomes of the laparoscopic approach for complicated appendicitis (CA). However, these studies suffer from limitations due to the heterogeneous definitions used for CA. No studies have assessed feasibility and early post-operative outcomes of the laparoscopic approach in the specific management of diffuse appendicular peritonitis (DAP). Consequently, outcomes of the laparoscopic approach for the management of DAP are poorly documented.

METHODS

The laparoscopic approach is the first-line standardised procedure used by our team for the management of DAP. All patients (aged >16 years) who underwent laparoscopy for DAP (CA with the presence of purulent fluid with or without fibrin membranes in at least a hemi abdomen) between 2004 and 2012 were prospectively included. Post-operative outcomes were analysed according to the Clavien-Dindo classification.

RESULTS

Laparoscopy for DAP was performed for 141 patients. Mean age was 39.6 ± 20 (16-92) years. A total of 45 patients (31.9%) had pre-operative contracture. The mean pre-operative leukocyte count was 14,900 ± 4,380 mm(-3). The mean pre-operative C-reactive protein (CRP) serum concentration was 135 ± 112 (2-418) mg/dl. The conversion rate was 3.5%. The mean operative time was 80 ± 27 (20-180) min. There were no deaths. The rate of grade III morbidity was 6.5%. Ten patients (7.1%) experienced intra-abdominal abscess (IAA); seven of these cases were treated conservatively. The mean length of hospital stay was 6.9 ± 5 (2-36) days. A pre-operative leukocyte count >17,000 mm(-3), and CRP serum concentration >200 mg/dl were significant predictive factors for IAA in multivariate analyses [odds ratio (OR) 25.0, 95% confidence interval (CI) 2.4-250, p = 0.007 and OR 16.4, 95% CI 1.6-166, p = 0.02, respectively].

CONCLUSION

The laparoscopic approach for DAP is a safe and feasible procedure with a low conversion rate and an acceptable rate of IAA in view of the severity of the disease. Pre-operative leukocyte counts >17,000 mm(-3) and pre-operative CRP serum concentrations >200 mg/dl indicate a high risk of IAA.

Phase 2, randomized, double-blind study of the efficacy and safety of two dose regimens of eravacycline versus ertapenem for adult community-acquired complicated intra-abdominal infections

Eravacycline is a novel fluorocycline, highly active against Gram-positive and Gram-negative pathogens in vitro, including those with tetracycline and multidrug resistance. This phase 2, randomized, double-blind study was conducted to evaluate the efficacy and safety of two dose regimens of eravacycline compared with ertapenem in adult hospitalized patients with complicated intra-abdominal infections (cIAIs). Patients with confirmed cIAI requiring surgical or percutaneous intervention and antibacterial therapy were randomized (2:2:1) to receive eravacycline at 1.5 mg/kg of body weight every 24 h (q24h), eravacycline at 1.0 mg/kg every 12 h (q12h), or ertapenem at 1 g (q24h) for a minimum of 4 days and a maximum of 14 days. The primary efficacy endpoint was the clinical response in microbiologically evaluable (ME) patients at the test-of-cure (TOC) visit 10 to 14 days after the last dose of study drug therapy. Overall, 53 patients received eravacycline at 1.5 mg/kg q24h, 56 received eravacycline at 1.0 mg/kg q12h, and 30 received ertapenem. For the ME population, the clinical success rate at the TOC visit was 92.9% (39/42) in the group receiving eravacycline at 1.5 mg/kg q24h, 100% (41/41) in the group receiving eravacycline at 1.0 mg/kg q12h, and 92.3% (24/26) in the ertapenem group. The incidences of treatment-emergent adverse events were 35.8%, 28.6%, and 26.7%, respectively. Incidence rates of nausea and vomiting were low in both eravacycline groups. Both dose regimens of eravacycline were as efficacious as the comparator, ertapenem, in patients with cIAI and were well tolerated. These results support the continued development of eravacycline for the treatment of serious infections, including those caused by drug-resistant Gram-negative pathogens. (This study has been registered at ClinicalTrials.gov under registration no. NCT01265784.).

Prescription behaviours for tigecycline in real-life clinical practice from five European observational studies

OBJECTIVES

There is limited information on the use of tigecycline in real-life clinical practice. This analysis aims to identify and understand tigecycline prescribing patterns and associated patient outcomes for approved indications.

PATIENTS AND METHODS

A pooled analysis of patient-level data collected on the prescription of tigecycline in five European observational studies (July 2006 to October 2011) was conducted.

RESULTS

A total of 1782 patients who received tigecycline were included in the analysis. Of these patients, 61.6% were male, the mean age was 63.4 ± 14.7 years, 56.4% were in intensive care units, 80.2% received previous antibiotic treatment and 91% had one or more comorbid conditions. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores at the beginning of treatment were 17.7 ± 7.9 and 7.0 ± 4.0, respectively. The majority of patients (58.3%) received tigecycline for treatment of complicated skin and soft-tissue infections (cSSTIs; n = 254) or complicated intra-abdominal infections (cIAIs; n = 785). Tigecycline was given at the standard dose (100 mg plus 50 mg twice daily) to 89.3% of patients for a mean duration of 11.1 ± 6.4 days. The main reasons for prescribing tigecycline were failure of previous therapy (46.1%), broad-spectrum antibiotic coverage (41.4%) and suspicion of a resistant pathogen (39.3%). Tigecycline was prescribed first-line in 36.3% of patients and as monotherapy in 50.4%. Clinical response rates to treatment with tigecycline alone or in combination were 79.6% (183/230; cSSTIs) and 77.4% (567/733; cIAIs).

CONCLUSIONS

Although tigecycline prescription behaviour showed some heterogeneity across the study sites, these results confirm a role for tigecycline in real-life clinical practice for the treatment of complicated infections, including those in critically ill patients, across Europe.

2013 WSES guidelines for management of intra-abdominal infections

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.