Defining core patient descriptors for perforated peptic ulcer research: international Delphi

BACKGROUND

Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research.

METHODS

Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings.

RESULTS

Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history.

CONCLUSION

This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.

The "pouch" of the Douglas's pouch

Hernia is described as the protrusion of an organ into the wall of its normal containing cavity. Internal hernia (IH) involves protrusion of viscera through: a peritoneal or mesentery defect, a normal or abnormal compartment of the peritoneal cavity. Hernias occurring in the pelvis cavity are usually classified according to the fascial margins breached and include sciatic, obturator and those through the rectouterin pouch: elytrocele and enterocele. Those hernias are defined by the protrusion of a viscus through the wall of the pelvis due to weakness of the pelvic fascia and/or muscles. Pelvic hernia through the pouch of Douglas (PD) involves the genital tract in female (elytrocele and enterocele). Sometimes described in the literature as Douglas hernia, this type of hernia must be distinguished from the conventional IH. As defined before, the borders to be considered for IH is the peritoneal membrane, which is not a real solid wall but delimitates the peritoneal cavity; and there is no peritoneal defect in elytrocele or enterocele. A PubMed search for IH through a defect in the peritoneal PD revealed only five female cases, making this an extremely rare condition. To our knowledge, we have presented here the only published case in a male. This probably congenital and morphologic anomaly (defect) of pouch of Sir Douglas must be distinguished as the real "Douglas IH". Authors discuss the concept of a new and more detailed classification of IH.

Mesenteric myofibroblastic tumor: NSAID therapy after incomplete resection

Myofibroblastic tumors are inflammatory tumors that arise in viscera and soft tissue; their etiopathology is poorly understood. They are capable of infiltration of adjacent organs, local recurrence after surgical resection, and even of distant metastasis. These characteristics result in persistent debate as to the nature of these lesions - whether they are inflammatory or neoplastic, benign or malignant lesions? Diagnosis is almost always made based on histopathological findings. Traditional management is complete surgical excision, but this may be difficult or impossible when the lesion develops in proximity to vital structures. We report the case of a 59-year-old man who was treated in our institution for mesenteric myofibroblastic tumor. Complete resection was not possible due to local infiltration of the mesentery. Recurrence was noted 3 months after surgery; treatment with steroidal and then non-steroidal anti-inflammatory medications (NSAIDs) resulted in clinical and radiologic regression of the tumor.

Delayed repair for traumatic abdominal wall hernia: is it safe?

Abdominal wall hernias after trauma have been recognized for more than a century, with the first case reported as occurring after a fall. Traumatic abdominal wall hernias (TAWHs) after blunt trauma are uncommon. The timing of definitive repair, early or delayed, is not clear. We report a case on TAWH and mesenteric avulsion, highlighting the reasons for immediate or delayed repair. A single case study can hardly be considered as a basis for profound changes in the management of post traumatic hernias. However, damage to all layers of the abdominal wall indicates high-energy trauma. In such cases, the damage is not, in all probability, limited to the integumentary system. For the moment, the timing of surgery in any TAWH should be considered differently according to the trauma, the wall defect, clinical and radiological findings, associated injuries, and the clinical status of the patient.

[Interference of hemolysis on haptoglobin determined by kinetic immunonephelometry and comparison between phenotypes]

The aim of the study was to check if a slight and non visible hemolysis to naked eye such as that induced by blood coagulation could interfere in the immunonephelometric measurement of haptoglobin, and if this interference was dependent on the protein phenotype. Results confirmed that blood coagulation induced a non visible hemolysis whose intensity markedly varied from one specimen to another. Under our conditions (kinetic measurement with a Beckman Coulter immunonephelometer), we observed with the sera a negative interference linked to the hemolysis induced by blood coagulation when compared to corresponding plasmas obtained with lithium heparinate (p < 0,005). It was checked also that this anticoagulant did not induce a positive interference. Hemolysis interference was not found phenotype dependent. These results lead us to recommend to perform haptoglobin measurements on heparinised plasmas.

A new continuous automated assay for the determination of intestinal lactase

BACKGROUND

A reliable, sensitive and practicable method for the measurement of intestinal lactase activity is needed.

METHOD

The assay is based on the continuous measurement of released glucose by a coupled hexokinase/glucose-6-phosphate dehydrogenase (HK/G6PDH) reagent.

RESULTS

The procedure was first optimized for lactase from rat intestinal mucosa. The optimum pH is 6.5 and apparent Km was 17 mmol/l for lactose. The procedure was also adapted on a Cobas Mira automated analyzer; progress curves of the reaction rate can be continuously monitored. The automated assay correlated strongly with the conventional method of Dahlqvist (r(2) = 0.996). The described method has also been applied to human intestinal mucosa biopsies after determination of the catalytic properties of human enzyme (optimum pH 6.0 and apparent Km 34 mmol/l).

CONCLUSION

The HK/G6PDH method is reliable, rapid, sensitive and easy to perform both manually as well as in the automated version. It is optimized for human and rat intestinal lactase.

A continuous automated method for the determination of intestinal disaccharidase activities

A reliable method for the measurement of various disaccharidase activities such as maltase, isomaltase and sucrase is introduced. It is based on the continuous measurement of liberated glucose by a commercially available glucose dehydrogenase reagent. The procedures were first optimized for enzymes from rat intestinal mucosa. The pH optima were similar (6.3-6.7) for the three enzymes tested, and the apparent Kms were estimated to be 18, 12 and 19 mmol/l for maltase, isomaltase and sucrase, respectively. The procedures were adapted on a Cobas Mira automated analyzer. The assays correlated strongly with the conventional method of Dahlqvist. They were reliable, rapid, easy to perform and validate because the progress curve of each reaction rate can be continuously monitored. The method described has also been applied to human intestinal mucosa (Caco-2 cells).

Effect of sodium deoxycholate on intestinal glucose absorption and (Na+-K+)-atpase in the rat

The effects of deoxycholate on glucose transport and intestinal (Na+-K+)-ATPase activity have been investigated in the rat jejunum in vivo using a perfusion technique.

Studies on intestinal adenosine triphosphatases. II. Stabilitiies in different rat subcellular fractions

Subcellular fraction (brush border, mitochondria, microsomes and plasma membranes) are isolated from the rat intestinal epithelial cells. A comparison was made between the effect of cold storage, freeze-thawing, heating and of some chemicals (DMSO, DTT, glycerol, sucrose) on the stability of Mg2+ and (Na+-K+) dependent ATPases in these fractions in order to determine possible difference linked to the localization in the enterocyte. Enzymatic activities were found more stable at -20 degrees C than at +4 degrees C. Microsomal (Na+-K+)-ATPase increased in activity until the 8th day, then declined. Brush border (Na+-K+)-ATPase was the least resistant of all fractions. For Mg2+-ATPase, that from mitochondria was that had lost much more activity (84%) in 15 days at +4 degrees C. With freeze-thawing there was a comparable decrease in all activities (20-35%). by heating between 35 and 60 degrees C, Mg2+-ATPase was shown to be more heat resistant than (Na+-K+)-ATPase. The addition of some stabilizing chemicals (DMSO, glycerol, sucrose) improved the heat stability of the two enzymes: better results were obtained with glycerol for Mg2+-ATPase and sucrose for (Na+-K+)-ATPase. These differences might be due to the compositon in membraine lipids or to the nature of the enzymes studied.