Contributions to the management of intraabdominal infections

Artificial neural networks accurately predict intra-abdominal infection in moderately severe and severe acute pancreatitis

OBJECTIVE

The aim of this study was to evaluate the efficacy of artificial neural networks (ANN) in predicting intra-abdominal infection in moderately severe (MASP) and severe acute pancreatitis (SAP) compared with that of a logistic regression model (LRM).

METHODS

Patients suffering from MSAP or SAP from July 2014 to June 2017 in three affiliated hospitals of the Army Medical University in Chongqing, China, were enrolled in this study. A univariate analysis was used to determine the different parameters between patients with and without intra-abdominal infection. Subsequently, these parameters were used to build LRM and ANN.

RESULTS

Altogether 263 patients with MSAP or SAP were enrolled in this retrospective study. A total of 16 parameters that differed between patients with and without intra-abdominal infection were used to construct both models. The sensitivity of ANN and LRM was 80.99% (95% confidence interval [CI] 72.63-87.33) and 70.25% (95% CI 61.15-78.04), respectively (P > 0.05), whereas the specificity was 89.44% (95% CI 82.89-93.77) and 77.46% (95% CI 69.54-83.87), respectively (P < 0.05). ANN predicted the risk of intra-abdominal infection better than LRM (area under the receiver operating characteristic curve: 0.923 [0.883-0.952] vs 0.802 [0.749-0.849], P < 0.001).

CONCLUSIONS

ANN accurately predicted intra-abdominal infection in MSAP and SAP and is an ideal tool for predicting intra-abdominal infection in such patients. Coagulation parameters played an important role in such prediction.

Leptin and leptin receptor polymorphisms are associated with poor outcome (death) in patients with non-appendicular secondary peritonitis

Introduction

Leptin (LEP) and its receptor (LEPR) participate in the immunological response during infection. LEP serum levels rise during sepsis. In patients with peritonitis, an insufficient elevation in serum LEP is associated with an increased risk of death. As gene variants of LEP and LEPR have been associated with diverse pathologic conditions, we explored the association of genetic polymorphisms of LEP or LEPR with death in patients with secondary peritonitis.

Methods

A case control study was undertaken. LEP Gene -2548G > A and the LEPR Gene 223A > G polymorphism were determined in 74 patients. The odds ratio of genotype and allele distribution in survival (control) versus death (case) among patients was calculated. Serum LEP, interleukin (IL)-6, tumour necrosis factor alpha, C-reactive protein (C-RP), IL-10 and IL-13 levels were analyzed in 34 patients.

Results

There were significant differences in genotype and allele distribution between survivors and non-survivors for -2548G > A and 223A > G polymorphisms. The presence of the mutant allele A, in -2548, had an odds ratio of 4.64 (95% CI 1.22, 17.67) with significance (P = 0.017) in the risk of death. The presence of mutant allele G, in 223, had an odds ratio of 3.57 (95% CI 1.06, 12.01) with significance in the risk of death (P = 0.033). The presence of allele A in the -2548 polymorphism was associated with differences in serum LEP (P = 0.013), and IL-10 (P = 0.0001). The presence of allele G in 223 polymorphism was likewise correlated with differences in serum LEP (P < 0001), C-RP (P = 0.033), and IL-10 (P = 0.043).

Conclusions

The polymorphisms studied are associated with death in patients with peritonitis of non-appendicular origin. This association is stronger than many known risk-factors related to peritonitis severity, and is independent of body mass. The physiopathologic mechanism is possibly related to an insufficient increase in the elevation of serum LEP levels, and is unrelated to body mass.

Fatal anorectal trauma in the setting of sexual assault: case report and literature survey

Homicides exclusively due to genital trauma have not been widely reported, and anorectal trauma in sexual assaults is uncommon. We describe a case of a 45-year-old white woman who sustained devastating homicidal colorectal trauma that served as a primary cause of death in the setting of rape. Our patient sustained a 15-cm laceration of the anterior rectal wall and ultimately died of peritonitis and sepsis. Death from rectal perforation and sepsis in the setting of sexual assault is rare and has only been documented in 3 other cases, 2 pediatric patients and 1 elderly debilitated patient. Other representative and unique methods of perforation are reviewed along with a brief discussion of the development of peritonitis after perforating colorectal trauma.

Dual therapeutic action of antibiotic-loaded nanosheets for the treatment of gastrointestinal tissue defects

An ultra-thin polymer film (nanosheet) composed of polysaccharides (i.e., polysaccharide nanosheet) provides sufficient adhesiveness, flexibility and robustness to act as an effective wound dressing. We have recently demonstrated the sealing effect of a nanosheet on a murine cecal puncture. Nevertheless, a small percentage of bacteria penetrated the nanosheet because of its ultra-thin structure. Here, we have developed an antibiotic-loaded nanosheet to inhibit bacterial penetration and investigated its therapeutic efficacy using a model of a murine cecal puncture. Tetracycline (TC) was sandwiched between a poly(vinylacetate) (PVAc) layer and the polysaccharide nanosheet (named PVAc-TC-nanosheet). Under physiological conditions, TC was released from the nanosheet for 6 h. Microscopic observation between the interface of the PVAc-TC-nanosheet and bacteria demonstrated how its potent anti-microbial effect was achieved. In vivo studies show that overlapping therapy with the PVAc-TC-nanosheet (thickness: 177 nm) significantly increases mouse survival rate after cecal puncture as well as suppressing an increase in the intraperitoneal bacterial count and leukocyte count.

Relaparotomies: Why is Mortality Higher?

BACKGROUND

Relaparotomy is sometimes required for complications that develop after abdominal surgery, but it is associated with high mortality. We aimed to investigate the independent risk factors related to mortality in patients that undergo relaparotomies.

MATERIALS AND METHODS

One hundred and fourteen patients who had relaparatomies were evaluated. Risk factors studied were patient characteristics, cause of the first operation, condition of the first operation, systemic diseases, presence of peritonitis, relaparotomy interval, cause of relaparatomy, APACHE II score, transfused blood units, number of relaparatomies, length of hospital stay, and mortality. In order to determine the independent risk factors, we carried out multivariate logistic regression analysis.

RESULTS

There were 75 male and 39 female patients with a mean age of 46.06 ± 19.98 (15-84). The most common reasons for relaparotomy were leakage from intestinal primary repair or anastomosis (29.8%). Mortality developed in 55 (48.2%) patients undergoing relaparatomy. Intestinal necrosis (p = 0038) and intraabdominal sepsis (p = 0.027) were found to be risk factors in mortality. In multivariate logistic regression analysis, advanced age (OR 0.966, p = 0. 0.017) and APACHE II score ≥ 20 (OR 0.137, p < 0.0001) were found to be independent risk factors affecting mortality.

CONCLUSION

Advanced age and APACHE II score ≥ 20 were found to be independent risk factors affecting relaparotomy-related mortality.

Investigational treatments for postoperative surgical site infections

Surgical site infections rank third among nosocomial infections, representing a global threat, associated with the emergence of multi-drug-resistant bacteria. The pharmaceutical industry has recently curtailed developmental programmes; however, the need for new compounds is extremely important. This article reviews new antimicrobials and immunointerventional targets for their potential to treat surgical site infections in comparison with recently licensed compounds. Daptomycin, dalbavancin, oritavancin, telavancin, iclaprim and ranbezolid seem to be promising agents against infections caused by Gram-positive pathogens and effectively address the present problems of multi-resistance in Gram-positive infections. Peptide deformylase inhibitors and immunostimulating agents open new perspectives in this field; however, very few compounds targeting Gram-negative problematic pathogens are in the pipeline of the future. Tigecycline (recently marketed) ceftobiprole, ceftaroline and doripenem seem to possess an extended anti-Gram-positive and -negative spectrum. Among these compounds, only doripenem demonstrates activity against Pseudomonas aeruginosa, for which there is a clear unmet need for new compounds, focusing on new targets.

Management of peritonitis in the critically ill patient

Severe secondary peritonitis carries significant mortality, despite advancements in critical care support and other therapies. Surgical management requires a multidisciplinary approach to guide the timing and the number of interventions necessary to eradicate the septic foci and create optimal healing with the fewest complications. Research is needed regarding the best surgical strategy for very severe cases. The use of deferred primary anastomosis seems safe in patients presenting with hemodynamic instability and hypoperfusion. These patients have a high risk of anastomotic failure and fistula formation. Allowing for aggressive resuscitation and judicious assessment of the progression of local inflammation are safe strategies to achieve the highest success and minimize serious and protracted complications in patients who survive the initial septic insult.

Peritonitis - the Western experience

Peritonitis is a common surgical emergency. This manuscript will provide an overview of recent developments in the management of peritonitis in the Western world. Emphasis is placed on the emergence of new treatments and their impact of outcomes.