Delta neutrophil index as a promising prognostic marker of emergent surgical intervention for acute diverticulitis in the emergency department

Delta neutrophil index levels can be a good indicator to predict patients with chronic rhinosinusitis who need surgery

OBJECTIVES

Predicting the need for surgical treatment among patients with chronic rhinosinusitis (CRS) is challenging. The delta neutrophil index (DNI) has been proposed as a useful laboratory marker of immature granulocytes, which indicates infection or severe inflammation in several diseases. This study evaluated DNI as an early predictor of the need for surgery in patients with CRS.

METHODS

A total of 117 patients diagnosed with CRS were enrolled in this retrospective and observational study. Medical records, including symptoms data, WBC count, ESR level, LUC count, Lund-Mackay scores, and DNI, were reviewed. The receiver operating characteristic (ROC) curves were analyzed to determine the optimal cut-off values for predicting surgery.

RESULTS

Among 117 patients, 49 patients (41.9%) needed surgical intervention. The areas under the WBC, ESR, LUC, and DNI ROC curves were .571, .600, .592, and .782, respectively. The optimal cut-off value of DNI to predict surgery was .9%. The prognostic precision of DNI showed that the sensitivity was 59.2% and the specificity was 98.5%. In the analysis of risk factors, DNI levels were significantly associated with surgical intervention (odds ratio, 2.22; 95% confidence interval, 1.48-3.34; P < .01).

CONCLUSIONS

The level of DNI, which reflects the severity of the disease, may be a useful predictor for determining the need for surgical intervention in patients with CRS. This is the first literature to verify the role of DNI in upper airway disease.

Neutrophil- and Platelet-Lymphocyte Ratio as Biomarkers of Severity in Complicated Diverticular Disease

INTRODUCTION

Diverticulitis is a prevalent gastrointestinal disease that may require surgical intervention. The aim of the study was to investigate the involvement of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) as biomarkers of severity in complicated diverticular disease (CDD) in Mexican patients and their correlation with the need for surgical intervention, the length of hospital stay, and mortality.

MATERIAL AND METHODS

An observational, longitudinal, and retrospective study performed from 2017 to 2021 was considered in patients over 18 years of age, with a diagnosis of CDD by using computed tomography and with a hemogram taken in the first 24 hours upon admission to the emergency department to describe the sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) of NLR and PLR in the CDD.  Results: A total of 102 Mexican patients suffering from CDD, 54% women and 46% men with a mean of 59 years, were analyzed. According to Hinchey's classification, 79 (77.5%) patients showed type I, 12 (12.8%) type II, 5 (4.9%) type III, and 6 (5.9%) type IV. The mean hospital stay was 8.8 days, with a mortality rate of 3.9%. The cut-off value was established at 5.1 for NLR according to the results of the receiver operating characteristic (ROC) curve with an area under the curve (AUC) of 0.633, a sensitivity of 90%, a specificity of 43%, PPV of 21.8%, and NPV of 96% for the prediction of CDD. A cut-off value for PLR at 72 was established according to the results of the ROC curve with an AUC of 0.482, a sensitivity of 78%, a specificity of 40%, PPV of 96%, and NPV of 9% for the prediction of CDD.

CONCLUSION

The NLR and PLR are easily calculable and accessible biomarkers that can be part of the decision-making for the diagnosis and treatment of CDD in Mexican people as has been observed in other populations. However, more prospective, multicenter comparative studies are needed to assess the efficacy and safety of these biomarkers in relation to those already described.

Can delta neutrophil index values predict the success of periodontal treatment in patients with periodontitis?

OBJECTIVES

The aim of this study was to evaluate the effect of delta neutrophil index (DNI) on non-surgical periodontal therapy (NSPT), whose role has been documented in the pathogenesis and follow-up of periodontal disease.

METHODS AND MATERIALS

The study included 35 patients with stage 3, grade A periodontitis (test group) and 35 patients without periodontal disease (control group). Initially, periodontal parameters were recorded and blood samples were taken from all patients. For patients with periodontitis, periodontal parameter measurements and blood sample analyses were repeated 3 months after NSPT.

RESULTS

After NSPT, DNI, CRP (C-reactive protein), neutrophil count, WBC (white blood cell), and neutrophil-lymphocyte ratio (NLR) values decreased in the test group, but did not reach a statistically significant level (p > 0.05). When the inflammatory variables were examined, significantly higher CRP, IG (immature granulocytes), DNI, neutrophil count, and WBC were observed in the test group compared to the control group (p < 0.05). In the test group, periodontal parameters were lower 3 months after NSPT than at baseline (p < 0.05).

CONCLUSION

Consistent with previous findings in the literature, the patients with periodontitis were determined to have higher levels of DNI, CRP, neutrophils, and WBC, compared to the individuals without periodontitis. Although a decrease was seen in DNI after NSPT, this was not at a significant level.

CLINICAL RELEVANCE

DNI is a guide in the evaluation of inflammation at the onset of periodontal disease, but studies with a larger number of cases are needed to use these parameters in the evaluation of treatment success.

TRIAL REGISTRATION

This study was retrospectively registered on December 27, 2022, with the number NCT05666622 at http://www.

CLINICALTRIALS

gov .

Platelet to lymphocyte ratio is a risk factor for failure of non-operative treatment of colonic diverticulitis

Non-operative treatment is the mainstay of colonic diverticulitis, but some patients require surgery due to non-operative treatment failure. This study aims to identify risk factors for the failure of non-operative treatment of colonic diverticulitis. From January 2011 to December 2020, we retrospectively reviewed 2362 patients with non-operative treatment for first-attack acute diverticulitis. Patients were categorized into non-operative treatment success or failure groups. Clinical characteristics and serum inflammatory markers were analyzed by multivariable logistic regression to determine risk factors for non-operative treatment failure of colonic diverticulitis. Overall, 2.2% (n = 50) of patients underwent delayed surgery within 30 days (median 4.0 [3.0; 8.0]) due to non-operative treatment failure. Multivariable logistic regression identified that platelet to lymphocyte ratio (odds ratio [OR], 4.2; 95% confidence interval [CI], 0.05-0.13; p < 0.001), diabetes mellitus (OR, 2.2; 95% CI, 0.01-0.09; p = 0.025), left-sided colonic diverticulitis (OR, 4.1; 95% CI, 0.04-0.13; p < 0.001), and modified Hinchey classification (OR, 6.2; 95% CI, 0.09-0.17; p < 0.001) were risk factors for non-operative treatment failure. Platelet to lymphocyte ratio (PLR) is a potential risk factor for the non-operative treatment failure of acute first-attack colonic diverticulitis. Therefore, patients with higher PLR during non-operative treatment should be monitored with special caution.

Indicative factors for surgical or angiographic intervention in hemodynamically stable patients with blunt abdominal trauma: A retrospective cohort study

INTRODUCTION

The standard of care for intraperitoneal injury in hemodynamically stable patients after blunt abdominal trauma has been replaced by non-operative management (NOM). However, selective NOM, depending on the situation, seems necessary in determining the treatment plan. In this study, we attempted to identify risk factors for surgical or angiographic intervention (SAI) in hemodynamically stable blunt abdominal trauma patients.

METHODS

This retrospective study which included adult patients who were brought to a regional trauma center was conducted from March 2015 to October 2019. We evaluated the characteristics of blunt abdominal trauma patients and analyzed factors that were related to the requirement of SAI in these patients. Patients were divided into SAI and conservative management (CM) groups.

RESULTS

We reviewed 1,176 patients, and after exclusions, of whom 248 blunt abdominal trauma and free fluid observed on CT were identified. The mean pulse rate was higher in the SAI than in the CM (P=0.025). Laboratory findings showed that lactate and delta neutrophil index (DNI) levels were higher in the SAI than in the CM (P=0.002 and 0.026 respectively). Additionally, the mean free fluid size in the SAI (85.69mm) was significantly larger than that in the CM (68.12mm; P=0.001), and blush was more frequently observed in the SAI (P<0.001). In multivariate analysis, only blush was an independent prognostic factor for SAI (OR 11.7, 95% CI, 5.1-30.8, P<0.001).

CONCLUSION

In hemodynamically stable patients with blunt abdominal trauma, blush but also high lactate and DNI are associated with the requirement of interventional radiology and/or surgery.

The Accuracy of Neutrophil-to-Lymphocyte Ratio and Abdominal Computed Tomography to Predict the Severity of Acute Cholecystitis

Background In this study, we evaluated neutrophil-to-lymphocyte ratio (NLR) values and abdominal computed tomography (CT) scans in preoperative patients of acute cholecystitis (AC) and their significance in differentiating between severe and non-severe conditions. This study will help further in-depth investigation on both of these diagnostic modalities and timely assess severe AC to avoid the worst prognosis. Methodology This single-center, cross-sectional study was conducted at Government Villupuram Medical College from July 2021 to January 2022. We enrolled patients aged >18 years diagnosed with AC. The demographic variables and clinical features of the enrolled patients were collected. All enrolled patients were divided into two categories (severe or non-severe AC) based on the pathological and clinical findings. The data were collected and entered in SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). The variation between the severe and non-severe AC groups was compared using Student's t-test to analyze continuous variables. The chi-square test was used to evaluate the association between the categorical variables. A p-value of <0.05 was considered significant. Results Among patients with severe AC, 29 (72.5%) were female, 29 (72.5%) were aged >50 years, 34 (85%) were alcoholics, and 26 (65%) were smokers. In patients with severe AC, the mean for NLR was 18.6500 ± 2.32655. On CT scans, 29 (72.5%) patients showed gallbladder distension, 31 (77.5%) showed increased pericholecystic fat stranding, and 18 (45%) showed pericholecystic fluid collection. CT scan findings and NLR values were significantly associated. Conclusions Gallbladder distension, increased pericholecystic fat stranding, and pericholecystic fluid collection on abdominal CT scan along with raised NLR are significant findings associated with assessing the severity of AC. Therefore, both testing modalities (CT scan and NLR) should be utilized together in hospitals to achieve better outcomes for AC and avoid complications.

Usefulness of the delta neutrophil index in predicting surgery in patients with foot and ankle infection

Background

In foot and ankle infections, cases with apparent soft-tissue necrosis or purulent fluid collections definitely require surgical treatments. However, clinicians often have difficulty in determining whether to perform surgery in ambiguous cases without these findings. This study aimed to investigate the impact of the delta neutrophil index as a predictor of surgical treatment in patients with foot and ankle infections.

Methods

In total, 66 patients diagnosed with foot and ankle infections who underwent the delta neutrophil index test were retrospectively investigated. Medical records, including data on diabetes mellitus status, delta neutrophil index values, white blood cell count, polymorphonuclear leukocyte count, erythrocyte sedimentation rate, and C-reactive protein level, were retrospectively investigated. Logistic regression models were analyzed for the correlation between biomarkers, such as the delta neutrophil index and surgical treatment. The area under the curve was investigated to evaluate the cut-off value of the logistic model in predicting surgery.

Results

The relationship between the delta neutrophil index and surgical treatment was analyzed. The delta neutrophil index, adjusted for diabetes mellitus, was the best predictor of future surgical intervention. Based on the Youden index, the cutoff point (the equation’s adjusted by diabetes mellitus) for the prediction of surgical treatment was defined as a probability of 0.3, with sensitivity and specificity of 82.4% and 77.6%, respectively.

Conclusions

Based on the present study, the delta neutrophil index can help clinicians decide the appropriate surgical treatment for foot and ankle infections at the right time.

Usefulness of delta neutrophil index as a biomarker to predict postoperative complication in patients who underwent esophagectomy: A case-control study

Esophagectomy demonstrates a high incidence of complications owing to its complexity and invasiveness; hence, early detection of complications is important. We aimed to evaluate the predictive value of the delta neutrophil index (DNI) for complications after esophagectomy.We retrospectively analyzed patients who underwent esophagectomy in the department of general surgery at a single institution between January 2011 and October 2020. Patient characteristics, laboratory findings, and clinical outcomes were assessed.Fifty-seven patients were enrolled in this study, of whom 31 (54.4%) had complications. The complication group had significantly longer mean mechanical ventilation, hospital stay and intensive care unit stay periods, and higher acute physiology, age, chronic health evaluation score and mortality rate than the noncomplication group. DNI on postoperative day (POD) 2 was also significantly higher in the complication group. Logistic regression analysis showed that DNI on POD 2 was an independent risk factor associated with the complications. Receiver operating characteristic curve analysis showed that the area under curve of DNI on POD 2 was 0.712 (cutoff value: 2.15%, sensitivity 61.5%, and specificity 70.8%).Our study indicated that postoperative DNI can be useful as an early predictive biomarker of the complications after esophagectomy.

Increased serum delta neutrophil index levels are associated with intrahepatic cholestasis of pregnancy

OBJECTIVE

This study aims to compare the maternal serum delta neutrophil index (DNI) levels in intrahepatic cholestasis of pregnancy (ICP) and healthy pregnancies.

METHODS

This study consisted of a group of patients (n = 40) diagnosed with isolated ICP who gave birth in our hospital and a control group (n = 60) between December 1, 2015, and June 30, 2018. The diagnosis of ICP was made based on pruritus and elevated fasting serum bile acids and liver enzymes. Laboratory tests of both groups in the hospitalization process were retrospectively examined. Maternal and neonatal characteristics, pregnancy outcomes, and DNI values of the two groups were compared. Statistical analyses were performed using SPSS version 20.

RESULTS

Mean maternal serum DNI levels were significantly higher in women with ICP than in the control group (0.49 ± 4.8 vs -3.99 ± 3.02, p = <0.01). Receiver operating characteristic (ROC) curve analysis was used to define the DNI value where ICP can be best predicted.

CONCLUSION

DNI, a new inflammatory marker, was found to be higher in women with ICP than in normal pregnancies.

Predictive factors for conservative treatment failure of right colonic diverticulitis

Purpose

Conservative treatment is the first-line therapy for acute colonic diverticulitis without severe complications, but treatment failure may increase hospitalization duration, medical costs, and morbidities. Usage of the modified Hinchey classification is insufficient to predict the outcome of conservative management. We aimed to investigate the clinical efficacy of the modified Hinchey classification and to evaluate predictive factors such as inflammatory markers for the failure of conservative management.

Methods

Patients diagnosed with right colonic diverticulitis undergoing conservative treatment at 3 hospitals between 2017 and 2019 were included. Patients were categorized into conservative treatment success (n = 494) or failure (n = 46) groups. Clinical characteristics and blood inflammatory markers were assessed.

Results

The conservative treatment failure group presented with more elderly patients (>50 years, P = 0.002), more recurrent episodes (P < 0.001), a higher lymphocyte count (P = 0.021), higher C-reactive protein (CRP) levels (P = 0.044), and higher modified Glasgow prognostic scores (P = 0.021). Multivariate analysis revealed that age of >50 years (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.27–5.08; P = 0.008), recurrent episodes (OR, 4.78; 95% CI, 2.38–9.61; P < 0.001), and higher CRP levels (OR, 1.08; 95% CI, 1.03–1.12; P = 0.001) were predictive factors for conservative treatment failure, but not the modified Hinchey grade (P = 0.159).

Conclusion

Age of >50 years, recurrent episodes, and CRP levels are potential predictors for conservative management failure of patients with right-sided colonic diverticulitis. Further studies are warranted to identify candidates requiring early surgical intervention.

Neutrophil-to-lymphocyte ratio as a predictor of complicated acute diverticulitis: A retrospective cohort study

Introduction

Currently, the debate on the usefulness of Neutrophil to Lymphocyte Ratio (NLR) as a predictor of complications in acute diverticulitis (AD) remains open, especially, the relation to the severity of the disease, the clinical impact, and the necessity of minimally invasive or emergency surgical procedures. On the other hand, its diagnostic efficacy has not been studied even in our field. The objective of the present study was to determine the utility and diagnostic precision of NLR in complicated acute diverticulitis (cAD).

Methods

Descriptive, retrospective cohort and analytical study. Patients older than 18 years with a diagnosis of AD were included, from 2013 to 2018. Demographic variables, days of hospitalization, leukocyte count, neutrophils, lymphocytes, ESR, CRP, and NLR were analyzed. The sensitivity and specificity for the diagnosis of cAD were determined using ROC curves.

Results

325 patients were included. Of these 196 (60%) were men. The median age was 52 years. A total of 30 (9%) were categorized as cAD. The patients with cAD presented mean values in the leukocyte count (14.02 ± 4.49 × 10⁹/l; p < 0.01), CRP (119.60 ± 87.67; p < 0.01) and NLR (7.61 ± 4.03; p < 0.01). An NLR cutoff value ≥ 4.2 was identified as the most appropriate to distinguish cAD, with a sensitivity of 80%, a specificity of 64%, NPV of 96%, and PPV of 18%.

Conclusion

NLR is a predictive marker of cAD, with a cut-off point of 4.2 being the best diagnostic approach.

•

About 10–15% of patients with acute diverticulitis (AD) can develop complications.

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The neutrophil-lymphocyte ratio (NLR) is a useful biomarker in predicting of severity of AD.

•

The purpose was to determine the usefulness and diagnostic accuracy of NLR in complicated acute diverticulitis (cAD).

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An NLR cutoff value ≥ 4.2 was identified as the most appropriate to distinguish cAD.

Delta Neutrophil Index for the Prediction of Prognosis in Acute Gastrointestinal Diseases; Diagnostic Test Accuracy Meta-Analysis

Delta neutrophil index (DNI) is a novel diagnostic and prognostic biomarker of various infectious or inflammatory conditions. However, data on optimal measurement time are scarce, and no studies have evaluated the potential role of the DNI as a prognostic biomarker of gastrointestinal diseases with diagnostic test accuracy meta-analysis. Core databases were searched. The inclusion criteria were as follows: patients who have gastrointestinal diseases and DNI measurements presenting diagnostic indices for predicting the prognosis, including severity, surgical outcomes, and mortality from gastrointestinal diseases. We identified twelve studies for the systematic review and ten studies for the quantitative analysis. Pooled area under the curve, sensitivity, specificity, and diagnostic odds ratio of DNI at the initial admission date were 0.82 (95% confidence interval: 0.78–0.85), 0.75 (0.52–0.89), 0.76 (0.63–0.86), and 10 (3–35), respectively. Meta-regression showed no reasons for heterogeneity and publication bias was not detected. Fagan’s nomogram indicated that the posterior probability of ‘poor prognosis’ was 76% if the test was positive, and ‘no poor prognosis’ was 25% if the test was negative. The DNI can be considered as a reliable initial measurement biomarker for predicting prognosis in patients with gastrointestinal diseases,

Delta neutrophil index for predicting mortality in trauma patients who underwent emergent abdominal surgery: A case controlled study

Background

Delta neutrophil index (DNI) can be used as a biomarker for infection to predict patient outcomes. We aimed to investigate the relationship between DNI and clinical outcomes in trauma patients who underwent abdominal surgery.

Materials and methods

We retrospectively analyzed injured patients who underwent emergent abdominal surgery in the regional trauma center of Wonju Severance Christian Hospital between March 2016 and May 2018. Patient characteristics, operation type, preoperative and postoperative laboratory findings, and clinical outcomes were evaluated. Logistic regression analysis was performed for risk factors associated with mortality.

Results

Overall, 169 patients (mean age, 53.8 years; 66.3% male) were enrolled in this study, of which 19 (11.2%) died. The median injury severity score (ISS) was 12. The non-survivors had a significantly higher ISS [25(9–50) vs. 10(1–50), p<0.001] and serum lactate level (9.00±4.10 vs. 3.04±2.23, p<0.001) and more frequent shock (63.2% vs 23.3%, p<0.001) and solid organ injury (52.6% vs. 25.3%, p = 0.013) than the survivors. There were significant differences in postoperative DNI between the two groups (p<0.009 immediate post-operation, p = 0.001 on postoperative day 1 [POD1], and p = 0.013 on POD2). Logistic regression analysis showed that the independent factors associated with mortality were postoperative lactate level (odds ratio [OR] 1.926, 95% confidence interval [CI] 1.101–3.089, p = 0.007), postoperative sequential organ failure assessment score (OR 1.593, 95% CI 1.160–2.187, p = 0.004), and DNI on POD1 (OR 1.118, 95% CI 1.028–1.215, p = 0.009). The receiver operating characteristics curve demonstrated that the area under the curve of DNI on POD1 was 0.887 (cut-off level: 7.1%, sensitivity 85.7%, and specificity 84.4%).

Conclusions

Postoperative DNI may be a useful biomarker to predict mortality in trauma patients who underwent emergent abdominal surgery.

The delta neutrophil index is an early predictive marker of severe acute cholecystitis

BACKGROUND

Predicting severe acute cholecystitis (SAC) is important because the mortality rate is higher for patients with SAC than for non-SAC (NSAC) patients. We evaluated the predictive value of the delta neutrophil index (DNI), which is greater in patients with infectious and inflammatory conditions, for SAC among patients in the emergency department (ED).

METHODS

This retrospective observational study included 379 consecutive adult patients with AC admitted to the ED from January 2015 to December 2016. The included patients were classified into 2 groups (NSAC and SAC) according to the Tokyo Guidelines 2018. White blood cell (WBC) count, C-reactive protein (CRP) levels, and DNI values were assessed at ED admission.

RESULTS

The SAC group contained 28 patients (7.4%). DNI was among the early predictors of SAC and was an inflammatory marker with a significantly higher predictive value than WBC count or CRP level for detecting SAC. The predictive power of DNI was significantly higher than that of CRP when used in conjunction with WBC count, abdominal computed tomography, and clinical variables.

CONCLUSIONS

DNI measured at ED admission may serve as an early predictor of SAC.

Neutrophil-to-lymphocyte ratio is independently associated with inflammatory activity and fibrosis grade in nonalcoholic fatty liver disease

BACKGROUND AND AIM

The progression of nonalcoholic fatty liver disease (NAFLD) to nonalcoholic steatohepatitis (NASH) is believed to be the driver for future development of fibrosis and cirrhosis. Nevertheless, there remains a lack of noninvasive methods for the diagnosis of NASH. The aim of the present study was to determine the role of neutrophil-to-lymphocyte ratio (NLR) in predicting histological severity in NAFLD.

PATIENTS AND METHODS

We performed a single-center retrospective study in EMMS Nazareth Hospital from July 2014 to May 2017. Liver biopsies were evaluated using the steatosis, activity, and fibrosis scoring system, which includes three components: (i) steatosis (0-3), (ii) activity grade (0-4), and (iii) fibrosis (0-4). Patients were divided into two groups. The first group was considered to have NAFLD when fibrosis grade was 0-1 and inflammatory activity was 0-1, whereas the second group included patients with fibrosis grade of 2-4 and inflammatory activity grade of 2-3, considered to have NASH.

RESULTS

Ninety-one (91) patients with biopsy-proven fatty liver were included. The average age was 42.13 ± 11.5 (18-74) years. Fifty-seven (62.6%) patients were male. Univariate analysis revealed several factors to be associated with advanced fibrosis and inflammatory activity, including NLR, C-reactive protein, and HOMA-IR, which correlated with fibrosis [odds ratio (OR): 1.405, 95% confidence interval (CI): 1.21-1.63, P < 0.0001; OR: 1.329, 95% CI: 1.05-1.68, P = 0.016; and OR: 1.922, 95% CI: 1.18-3.11, P = 0.007, respectively], and NLR, triglycerides, and HOMA-IR, which correlated with hepatocyte inflammation (OR: 1.210, 95% CI: 1.08-1.35, P = 0.0009; OR: 0.984, 95% CI: 0.97-0.99, P = 0.01; and OR: 2.069, 95% CI: 1.28-3.34, P = 0.003, respectively). On multivariate logistic regression analysis, NLR remains independently associated with advanced fibrosis grade and inflammatory activity (OR: 0.734, 95% CI: 0.631-0.854, P < 0.0001, area under the curve: 0.8622 and OR: 0.836, 95% CI: 0.74-0.95, P = 0.006, area under the curve: 0.7845, respectively). Our second major finding was defining an NLR cut-off point that was associated with inflammatory activity and fibrosis grade using receiver operating characteristic analysis based on the Youden index (J), which is defined by the maximal sensitivity and specificity.

CONCLUSION

NLR showed significant independent correlation with advanced inflammation and fibrosis in patients with NAFLD. This simple available laboratory tool may be incorporated into future diagnostic scores.

Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios Are Correlated with Complicated Diverticulitis and Hinchey Classification: A Simple Tool to Assess Disease Severity in the Emergency Department

Background and Aim

Rapid identification of patients with complications related to acute diverticulitis who require urgent intervention in the emergency department (ED) is essential. The aim of our study was to determine the role of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting severity of diverticulitis as assessed by Hinchey classification.

Patients and Methods

We performed a single retrospective study in EMMS Nazareth Hospital from 4/2014 to 4/2018. Patients were categorized into two groups: group A with mild to moderate complicated diverticulitis (Hinchey 1-2) and group B with severe complicated diverticulitis (Hinchey 3-4).

Results

Two hundred twenty-five patients were included. Two hundred seven patients were in group A, and 18 patients were in group B. On univariate analysis, age, NLR, and PLR correlated with advanced Hinchey classification and disease severity (stages 3-4) (OR 1.038, 95% CI 1.001–1.076, P=0.0416; OR 1.192, 95% CI 1.093–1.300, P < 0.0001; and OR 1.011, 95% CI 1.005–1.017, P=0.0005, respectively). On multivariate logistic regression analysis, the NLR and PLR remain significantly correlated with Hinchey 3-4 (OR 1.174, 95% CI 1.071–1.286, P=0.0006, and OR 1.008, 95% CI 1.001–1.015, P=0.0209, respectively). The area under the curve (AUC) for the NLR and PLR on univariate analysis was 0.7526 and 0.6748, respectively, and 0.7760 and 0.7391 on multivariate logistic regression analysis, respectively, and receiver-operating characteristic (ROC) curves were drawn.

Conclusion

The NLR and PLR independently associated with diverticulitis severity and positively correlated with advanced Hinchey classification. This simple available laboratory tool can be implemented into clinical practice to optimize patient management.

Diagnostic effectiveness of preoperative water-soluble contrast enema in colorectal perforation

OBJECTIVE

To evaluate the diagnostic usefulness of performing a preoperative water-soluble contrast enema (WSCE) before emergency surgery for colorectal perforation.

METHODS

We retrospectively reviewed 68 consecutive patients who underwent a preoperative WSCE before emergency surgery for colorectal perforation during the period from January 2011 to December 2017. Clinical characteristics and inflammatory biomarkers were compared between patients with Hinchey I-II versus those with Hinchey III-IV.

RESULTS

WSCE leakage occurred in 27 of 68 patients (39.7%). Univariate analysis showed that the two groups (Hinchey I-II and Hinchey III-IV) significantly differed regarding age, perforation site, cause of perforation, American Society of Anesthesiologists grade, presence or absence of WSCE leakage, and white blood cell count. Multivariable analysis revealed that WSCE leakage was a predictor of Hinchey III-IV, with an odds ratio of greater than 24 (P = 0.002). The sensitivity and specificity of WSCE leakage for differentiating those with Hinchey III-IV from those with Hinchey I-II were 76.5% and 97.1%, respectively.

CONCLUSIONS

This retrospective study indicates that preoperative WSCE before emergency surgery is a useful tool for predicting the presence of Hinchey III-IV in patients with colorectal perforation.

Delta neutrophil index as an early predictive marker of severe acute pancreatitis in the emergency department

Background

Predicting severe acute pancreatitis (AP) in the early clinical stage is important for low morbidity and mortality. Delta neutrophil index (DNI) is used to detect infection and inflammation, but no previous studies have evaluated the usefulness of DNI as an early predictor of progression to severe AP (SAP).

Methods

The medical records of patients who were diagnosed with AP at the emergency department (ED) of Wonju Severance Christian Hospital from January 2012 to August 2016 were retrospectively reviewed. The initial DNI obtained in the ED was compared with other inflammatory markers to predict SAP. Multivariate logistic regression was used for statistical analysis.

Results

Of the 209 cases included in the analysis, 13 were classified as SAP. Compared to the DNI of the mild to moderately SAP group, that in the SAP group was considerably higher. The DNI showed a positive correlation with the Atlanta classification and bedside index of severity in AP. Using multivariate logistic regression analysis, DNI was an independent predictor of early SAP detection (odds ratio 1.122, 95% CI 1.045-1.205, p = 0.001). Among the biomarkers, DNI had the highest predictive value for SAP.

Conclusions

The DNI measured in the ED at presentation is a potentially useful adjunctive marker to predict SAP.

Comparing the effectiveness of three scoring systems in predicting adult patient outcomes in the emergency department

This study aimed to evaluate the performance of the rapid acute physiology score (RAPS), the rapid emergency medicine score (REMS), and the modified early warning score (MEWS) in predicting the outcomes of adult patients presenting to the emergency department (ED).A retrospective review was undertaken between February 2014 and February 2018 in an adult ED of a 3300-bed university hospital. The RAPS, REMS, and MEWS were calculated to assess their capability to predict hospital admission, length of hospital stay, and in-hospital mortality, using area under receiver operating characteristic analysis. Multivariate analysis was used to identify variables that were independent predictors of the outcomes.We included 39,977 patients who had presented to the ED during 48 consecutive months, of whom 4857 were admitted and 213 died in hospital. The predictabilities of REMS, RAPS, and MEWS for hospital admission were 0.76, 0.59, and 0.55, respectively; the predictability of REMS, RAPS, and MEWS for hospital mortality were 0.88, 0.72, and 0.73, respectively; and the predictability of REMS, RAPS, and MEWS for length of hospital stay were 0.76, 0.67, and 0.65, respectively. Multivariate analysis showed that the Glasgow coma scale (GCS) (odds ratio (OR), 1.61; P < .001), age (OR, 1.50; P < .001), and MAP (OR, 1.27; P < .001) were independent predictors for hospital admission; GCS (OR, 2.92; P < .001), respiratory rate (RR) (OR, 2.69; P < .001), peripheral oxygen saturation (OR, 2.67; P < .001), MAP (OR, 2.11; P < .001), age (OR, 1.75; P < .001), and pulse rate (PR) (OR, 1.73; P < .001) were independent predictors for in-hospital mortality; and RR (OR, 1.41; P < .001), temperature (OR, 1.05; P = .01), and PR (OR, 0.96; P = .04) were independent predictors for length of hospital stay.Our study evaluated and confirmed the REMS as a powerful predictor of ED adult patient outcomes, including hospital admission, length of hospital stay, and in-hospital mortality compared to RAPS and MEWS.

Prognostic Value of Preoperative Neutrophil-to-lymphocyte Ratio for Prediction of Severe Cholecystitis

BACKGROUND

The predictive value of preoperative neutrophil-to-lymphocyte ratio (NLR) in patients with cholecystitis has not been established. The aim of this study was to investigate preoperative NLR in patients with cholecystitis and to identify a relevant NLR value that discriminates between simple and severe cholecystitis.

METHODS

This study included 136 patients who under went laparoscopic cholecystectomy due to cholecystitis. The Receiver Operating Characteristic (ROC) analysis was performed to identify the most useful NLR cut-off value in relation to the severity of cholecystitis. The patients were di vided into two groups according to the cut-off NLR value: high NLR group (≥4.18, n=23) and low NLR group (<4.18, n=113). Severe cholecystitis was defined as a state which includes inflammation, empyema, gangrene, perforation of gallbladder, adhesions or difficulty in dissecting Calot's triangle.

RESULTS

In the high NLR group, severe cholecystitis (p<0.0001) and higher C-reactive protein level (CRP) and white blood cells count (WBC) (p<0.0001) were significantly more frequent. There was no difference in homeostatic model assessment-insulin resistance index (HOMA-IR) between both groups before the operation (p<0.634). The incidence of severe cholecystitis was 16.9%. The NLR of 4.18 could predict severe cholecystitis with 78.3% sensitivity and 74.3% specificity. Spearman's correlation revealed significant association between the preoperative NLR and HOMA-IR on day 1, (r=0.254, p=0.030) and between preoperative NLR and CRP on day 1 (ρ=0.355; p<0.0001).

CONCLUSIONS

NLR ≥4.18 was significantly associated with severe cholecystitis. The preoperative NLR in patients under going cholecystectomy due to cholecystitis could be a useful surrogate marker of severe cholecystitis.