Novel hematologic inflammatory parameters to predict acute mesenteric ischemia

A novel nomogram integrating body composition and inflammatory-nutritional markers for predicting postoperative complications in patients with adhesive small bowel obstruction

Background

Postoperative complications in adhesive small bowel obstruction (ASBO) significantly escalate healthcare costs and prolong hospital stays. This study endeavors to construct a nomogram that synergizes computed tomography (CT) body composition data with inflammatory-nutritional markers to forecast postoperative complications in ASBO.

Methods

The study's internal cohort consisted of 190 ASBO patients recruited from October 2017 to November 2021, subsequently partitioned into training (n = 133) and internal validation (n = 57) groups at a 7:3 ratio. An additional external cohort comprised 52 patients. Body composition assessments were conducted at the third lumbar vertebral level utilizing CT images. Baseline characteristics alongside systemic inflammatory responses were meticulously documented. Through univariable and multivariable regression analyses, risk factors pertinent to postoperative complications were identified, culminating in the creation of a predictive nomogram. The nomogram's precision was appraised using the concordance index (C-index) and the area under the receiver operating characteristic (ROC) curve.

Results

Postoperative complications were observed in 65 (48.87%), 26 (45.61%), and 22 (42.31%) patients across the three cohorts, respectively. Multivariate analysis revealed that nutrition risk score (NRS), intestinal strangulation, skeletal muscle index (SMI), subcutaneous fat index (SFI), neutrophil-lymphocyte ratio (NLR), and lymphocyte-monocyte ratio (LMR) were independently predictive of postoperative complications. These preoperative indicators were integral to the nomogram's formulation. The model, amalgamating body composition and inflammatory-nutritional indices, demonstrated superior performance: the internal training set exhibited a 0.878 AUC (95% CI, 0.802-0.954), 0.755 accuracy, and 0.625 sensitivity; the internal validation set displayed a 0.831 AUC (95% CI, 0.675-0.986), 0.818 accuracy, and 0.812 sensitivity. In the external cohort, the model yielded an AUC of 0.886 (95% CI, 0.799-0.974), 0.808 accuracy, and 0.909 sensitivity. Calibration curves affirmed a strong concordance between predicted outcomes and actual events. Decision curve analysis substantiated that the model could confer benefits on patients with ASBO.

Conclusion

A rigorously developed and validated nomogram that incorporates body composition and inflammatory-nutritional indices proves to be a valuable tool for anticipating postoperative complications in ASBO patients, thus facilitating enhanced clinical decision-making.

The Diagnostic Value of Biomarkers in Acute Mesenteric Ischaemia Is Insufficiently Substantiated: A Systematic Review

OBJECTIVE

There is an urgent need for accurate biomarkers to support timely diagnosis of acute mesenteric ischaemia (AMI) and thereby improve clinical outcomes. With this systematic review, the aim was to substantiate the potential diagnostic value of biomarkers for arterial occlusive AMI.

DATA SOURCES

The Pubmed, Embase, and the Cochrane Library electronic databases were searched.

REVIEW METHODS

A systematic review of the literature has been conducted to define the potential diagnostic value of biomarkers for arterial occlusive AMI. All studies including ≥ 10 patients describing biomarkers for macrovascular occlusive AMI between 1950 and 17 February 2023 were identified within the Pubmed, Embase, and the Cochrane Library electronic databases. There were no restrictions to any particular study design, but letters and editorials were excluded. The QUADAS-2 tool was used for the critical appraisal of quality. The study protocol was registered on Prospero (CRD42021254970).

RESULTS

Fifty of 4334 studies were eligible for inclusion in this review. Ninety per cent of studies were of low quality. A total of 60 biomarkers were identified, with 24 in two or more studies and 15 in five or more studies. There was variation in reported units, normal range, and cut off values. Meta-analysis was not possible due to study heterogeneity. Biomarkers currently recommended by the European Journal of Vascular and Endovascular Surgery, European Society for Trauma and Emergency Surgery 2016, and World Society of Emergency Surgery 2017 guidelines also had heterogeneous low quality data for use in the diagnosis of AMI.

CONCLUSION

This systematic review demonstrates high heterogeneity and low quality of the available evidence on biomarkers for arterial occlusive AMI. No clinical conclusions can be drawn on a biomarker or combination of biomarkers for patients suspected of arterial occlusive AMI. Restraint is advised when rejecting or determining AMI solely based on biomarkers.

The Impact of Biomarkers on the Early Detection of Acute Mesenteric Ischemia

BACKGROUND

acute mesenteric ischemia (AMI) is a life-threatening condition that is caused by inadequate blood flow through the mesenteric vessel and is related to high mortality rates due to systemic complications. This study aims to systematically review the available literature concerning the major findings of possible biomarkers for early detection of acute mesenteric ischemia in the human population.

METHODS

studies that measured the performance of biomarkers during acute mesenteric ischemia were identified with the search of PubMed, Embase, Medline, and Cochrane library.

RESULTS

from a total of 654 articles, 46 articles examining 14 different biomarkers were filtered, falling within our inclusion criteria. Intestinal fatty acid-binding protein (I-FABP) was the most commonly researched biomarker regarding AMI, with sensitivity ranging from 61.5% to 100% and specificity ranging from 40% to 100%. The second most commonly researched biomarker was D-dimer, with a sensitivity of 60-100% and a specificity of 18-85.71%. L-lactate had a sensitivity of 36.6-90.91% and a specificity of 64.29-96%. Several parameters within the blood count were examined as potential markers for AMI, including NLR, PLR, MPV, RDW, DNI, and IG. Citrulline, interleukin 6 (IL-6), and procalcitonin (PCT) were the least-researched biomarkers.

CONCLUSION

different biomarkers showed different accuracies in detecting AMI. I-FABP and D-dimer have been the most researched and shown to be valuable in the diagnosis of AMI, whereas L-lactate could be used as an additional tool. Ischemia-modified albumin (IMA), alpha glutathione S-transferase (αGST), interleukin 6 (IL-6), and citrulline showed potential use in their respective studies. However, further research needs to be done on larger sample sizes and with controls to reduce bias. Several studies showed that neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), mean platelet volume (MPV), red-cell distribution width (RDW), delta neutrophil index (DNI), and immature granulocytes (IGs) might be useful, as well at the same time be widely distributed and affordable in combination with other markers presenting higher specificity and sensitivity.

Preoperative Neutrophil Lymphocyte Ratio in Prediction of Adnexal Mass Torsion

Aims

Adnexal torsion commonly affects reproductive age group females. Prompt diagnosis and early management help in the preservation of fertility. However, its diagnosis is challenging. Preoperative diagnosis can be suspected in only 23-66% of the cases and half of the patients operated for adnexal torsion have different diagnosis. This article thus aims to identify the diagnostic value of preoperative neutrophil lymphocyte ratio in adnexal torsion in comparison with other untwisted unruptured ovarian cysts.

Methods

This was a retrospective study conducted in the duration of five years from 1st January 2016 to 1st January 2020. The data about demographic parameters, hematological parameters, operative approach, operative technique, and histopathological reports were derived from an electronic database and documented on proforma. SPSS was used for statistical analysis. Logistic regression analysis and influence of each factor on preoperative diagnosis of Adnexal torsion was evaluated.

Results

A total of 125 patients were included in the article (adnexal torsion group n = 25, untwisted unruptured ovarian cyst group n = 100). There was no statistically significant difference in comparison to age, parity, and abortion between both groups. Most patients had undergone laparoscopic surgery which was based on surgeon's skill and preference. Nineteen (78%) patients in the adnexal torsion group underwent oophorectomy while infarcted ovary was seen in only 4 cases. Among the blood parameters, only neutrophil-lymphocyte ratio (NLR) >3 was found to be statistically significant under logistic regression analysis. Most common adnexal pathology to undergo torsion was serous cyst.

Conclusion

Preoperative neutrophil-lymphocyte ratio can be a predictive marker for diagnosis of adnexal torsion and can differentiate it from untwisted unruptured ovarian cysts.

Prediction factors for ischemia of closed-loop small intestinal obstruction

A closed-loop type of intestinal obstruction leads to ischemic necrosis. There have been indicators that may predict ischemia and its severity, such as biomarkers and computed tomography scans. In addition to the usual inflammation markers, such as white blood count-neutrophil count and c-reactive protein (CRP), the most accurate predictors that have been proposed are the CRP-to-albumin ratio, the neutrophil/lymphocyte ratio and the platelet/lymphocyte ratio. Endothelin 1 is another promising biomarker of ischemia that must be assessed in daily clinical practice. Advanced age and frailty status were assessed as predictors of mortality. A timely operative procedure without any delay ensures a better outcome.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

CCL26 regulates the proportion of CD4+CD25+FOXP3+ Tregs and the production of inflammatory factors in peripheral blood mononuclear cells following acute ischemic stroke via the STAT5 pathway

Acute ischemic stroke (AIS) is the most common type of stroke. Recent studies have found that AIS is closely involved in the immune regulation function of regulatory T cells (Tregs). C-C motif chemokine ligand 26 (CCL26) is a member of the chemokine family that plays an essential role in cell activation, cell differentiation, lymphocyte homing, and inflammatory and immune responses. The present study aimed to investigate the role of CCL26 in the regulation of Tregs in AIS. Peripheral blood mononuclear cells (PBMCs) were incubated with a CCL26-neutralizing antibody. The proportion of cluster of differentiation (CD)4⁺CD25⁺ forkhead box P3 (FOXP3)⁺ Tregs was increased, and the expression of FOXP3, phosphorylated signal transducer and activator of transcription 5 (p-STAT5), and that of the immunosuppressive factors, interleukin (IL)-10 and transforming growth factor (TGF)-β1, was upregulated. Conversely, the expression of immune-promoting factors, such as tumor necrosis factor (TNF)-α and IL-6 was significantly downregulated. Further experiments using CCL26 recombinant protein-treated PBMCs revealed a decreased proportion of CD4⁺CD25⁺FOXP3⁺ Tregs and the downregulated expression of FOXP3, p-STAT5, TGF-β1 and IL-10. Moreover, the expression of immunostimulatory factors, such as CX3C chemokine receptor 1, TNF-α and IL-6 was significantly upregulated. On the whole, these results demonstrate that CCL26 regulates the proportion of CD4⁺CD25⁺FOXP3⁺ Tregs and the production of inflammatory factors in PBMCs following AIS via the STAT5 pathway.

Platelet to lymphocyte ratio as a predictive factor of 30-day mortality in patients with acute mesenteric ischemia

Introduction

Acute mesenteric ischemia is associated with high rates of mortality. The aim of this study was to investigate the prognostic value of the neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR) on 30-day outcomes in patients with acute mesenteric ischemia.

Material and methods

Consecutive patients who were admitted for an acute mesenteric ischemia were retrospectively included. The full white blood count at the time of admission to the hospital was recorded. The population was divided into 4 subgroups according to the quartiles of the NLR and the PLR. The 30-day outcomes including the mortality and the complications were compared among the subgroups.

Results

In total, 106 patients were included. A surgical treatment including revascularization and/or digestive resection was performed for 56 patients (52.8%). The 30-day all-cause mortality was 72 patients (67.9%). Patients with higher PLR value (PLR >429.3) had significantly higher rate of mortality compared to the other groups (80.8% vs 46.2%, 66.7% and 77.8%, p = 0.03). No significant difference on 30-day outcome was observed among the subgroups divided according to the NLR.

Conclusion

The PLR, but not the NLR, is a predictive factor of 30-day mortality in patients with acute mesenteric ischemia.

Sensitivity and Specificity of the Platelet-Lymphocyte Ratio and the Neutrophil-Lymphocyte Ratio in Diagnosing Acute Mesenteric Ischemia in Patients Operated on for the Diagnosis of Mesenteric Ischemia: A Retrospective Case-Control Study

Aim: The present study aims to determine whether various hematological parameters and ratios of patients could be used to diagnose AMI. Materials and Methods: The subjects of the study are the patients who were hospitalized with an acute mesenteric ischemia (AMI) pre-diagnosis and underwent surgery as a consequence. The patients who were determined to have the diagnosis of AMI intraoperatively are categorized in the AMI Group. The patients whose operations do not reveal AMI (negative exploration) are categorized in the Control Group. These two groups are compared in terms of hematological parameters and rates. Results: In the study, the PLR (p = 0.017), NLR (p = 0.33), PDW (0.023), RDW (p = 0.025) values are significantly higher in the AMI group compared to the control group while the LYMP (p = 0.023) count is significantly lower. Conclusions: For the patients admitted to the emergency clinics with suspected AMI, the increased PLR, NLR, PDW, and RDW values together with the reduced lymphocyte count can be used to support the diagnosis.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio Are Effective Predictors of Prognosis in Patients with Acute Mesenteric Arterial Embolism and Thrombosis

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been shown to be valuable prognostic markers for a variety of pathological conditions including solid tumors, sepsis, and others. However, the prognostic values of the NLR and PLR in patients with acute mesenteric arterial embolism (AMAE) and acute mesenteric arterial thrombosis (AMAT) have not been elucidated. The aim of this study was to determine the predictive value of the NLR and PLR for poor prognosis in patients with AMAE and AMAT.

METHODS

A total of 137 patients with AMAE (n = 77) or AMAT (n = 60) were divided into a poor outcome group (cases of intestinal necrosis or death) and a better outcome group (cases without intestinal necrosis who survived successfully), according to prognosis. Neutrophil, platelet, and lymphocyte counts were recorded before pharmacotherapy or surgery. The NLR and PLR were calculated, and logistic regression analysis was performed to test their prognostic values.

RESULTS

The cutoff values for NLR and PLR were 11.05 and 156.26, respectively. The PLR was linearly associated with the NLR (R = 0.769, P < 0.001). NLR (odds ratio [OR] = 6.835, 95% confidence interval [CI] = 2.282-20.469, P = 0.001), PLR (OR = 4.871, 95% CI = 1.627-14.587, P = 0.005), and coronary heart disease (OR = 3.388, 95% CI = 1.156-9.929, P = 0.026) were found to be independent prognostic factors for the patients.

CONCLUSIONS

NLR ≥ 11.05, PLR ≥ 156.26, and coronary heart disease were shown to be risk factors for poor prognosis in patients with AMAE and AMAT. According to these factors, patients can be divided into 3 prognostic groups: good, NLR < 11.05 with PLR < 156.26; moderate, NLR < 11.05 with PLR ≥ 156.26 or NLR ≥ 11.05 with PLR < 156.26; and poor, NLR ≥ 11.05 with PLR ≥ 156.26.

Effect of platelet-lymphocyte ratio and lactate levels obtained on mortality with sepsis and septic shock

BACKGROUND

Sepsis is a potentially fatal condition with high treatment costs, and is especially common among the elderly population. The emergency management of septic patients has gained importance.

OBJECTIVE

Herein, we investigated the effect of admission lactate levels and the platelet-lymphocyte ratio (PLR) on the 30-day mortality among patients older than 65years who were diagnosed with sepsis and septic shock according to the qSOFA criteria at our hospital's emergency department.

METHODS

This observational study was conducted retrospectively. We obtained information regarding patients' demographic characteristics, comorbid conditions, hemodynamic parameters at admission, initial treatment needs at the emergency department.

RESULTS

131 patients received a diagnosis of sepsis and septic shock at our emergency department in two years. Among these, 45% (n=59) of the patients died within 30days of admission. Forty (30.5%) patients required mechanical ventilation. There was a significant difference between the survival and non-survival groups with regard to systolic and diastolic blood pressures (p=0.013 and 0.045, respectively). There were significant differences between the two groups with respect to the Glasgow Coma Scale score (p<0.001) and BUN levels (p<0.001). The mortality status according to qSOFA scores was revealed a significant difference between the two groups (p<0.001).

CONCLUSION

Our results showed that the patients who died within 30days of admission and those who did not had comparable PLR and lactate levels (p=0.821 and 0.120, respectively). We opine that serial lactate measurements would be more useful than a single admission lactate measurement for the prediction of mortality.

The use of platelet indices, plateletcrit, mean platelet volume and platelet distribution width in emergency non-traumatic abdominal surgery: a systematic review

Platelet indices (PI) -- plateletcrit, mean platelet volume (MPV) and platelet distribution width (PDW) -- are a group of derived platelet parameters obtained as a part of the automatic complete blood count. Emerging evidence suggests that PIs may have diagnostic and prognostic value in certain diseases. This study aimed to summarize the current scientific knowledge on the potential role of PIs as a diagnostic and prognostic marker in patients having emergency, non-traumatic abdominal surgery. In December 2015, we searched Medline/PubMed, Scopus and Google Scholar to identify all articles on PIs. Overall, considerable evidence suggests that PIs are altered with acute appendicitis. Although the role of PI in the differential diagnosis of acute abdomen remains uncertain, low MPV might be useful in acute appendicitis and acute mesenteric ischemia, with high MPV predicting poor prognosis in acute mesenteric ischemia. The current lack of consistency and technical standards in studies involving PIs should be regarded as a serious limitation to comparing these studies. Further large, multicentre prospective studies concurrently collecting data from different ethnicities and genders are needed before they can be used in routine clinical practice.