[Treatment of severe liver trauma]

Two patients with severe liver trauma undergoing staged surgical treatment are reported in the article.

Drivers of year-to-year variation in exacerbation frequency of COPD: analysis of the AERIS cohort

The association between exacerbation aetiology and exacerbation frequency is poorly understood. We analysed 2-year follow-up data from a prospective observational study of patients with chronic obstructive pulmonary disease (COPD) (www.clinicaltrials.gov identifier number NCT01360398) to evaluate year-to-year variation in exacerbation frequency and related aetiology. A total of 127 patients underwent blood and sputum sampling monthly and at exacerbation to detect respiratory infections and eosinophilic inflammation; 103 continued into year 2 and 88 completed both years. The most common bacterial species at stable state and exacerbation was Haemophilus influenzae. Among infrequent exacerbators (one exacerbation per year), the incidence of viral infection at exacerbation was high (60.0% (95% CI 35.1-81.7%) in year 1 and 78.6% (53.4-94.2%) in year 2). Those with more frequent exacerbations tended to have higher relative incidence of bacterial than viral infection. Patients with at least two additional exacerbations in year 2 versus year 1 had a higher risk of H. influenzae colonisation at stable state than those with at least two fewer exacerbations, as detected by culture (OR 1.43 (95% CI 0.71-2.91) versus 0.63 (0.40-1.01), p=0.06) and PCR (1.76 (95% CI 0.88-3.51) versus 0.56 (0.37-0.86), p<0.01). This was not seen with other infection types or eosinophilic inflammation. Analysis of the same cohort over 2 years showed, for the first time, that changes in yearly COPD exacerbation rate may be associated with variations in H. influenzae colonisation.

Longitudinal profiling of the lung microbiome in the AERIS study demonstrates repeatability of bacterial and eosinophilic COPD exacerbations

Background

Alterations in the composition of the lung microbiome associated with adverse clinical outcomes, known as dysbiosis, have been implicated with disease severity and exacerbations in COPD.

Objective

To characterise longitudinal changes in the lung microbiome in the AERIS study (Acute Exacerbation and Respiratory InfectionS in COPD) and their relationship with associated COPD outcomes.

Methods

We surveyed 584 sputum samples from 101 patients with COPD to analyse the lung microbiome at both stable and exacerbation time points over 1 year using high-throughput sequencing of the 16S ribosomal RNA gene. We incorporated additional lung microbiology, blood markers and in-depth clinical assessments to classify COPD phenotypes.

Results

The stability of the lung microbiome over time was more likely to be decreased in exacerbations and within individuals with higher exacerbation frequencies. Analysis of exacerbation phenotypes using a Markov chain model revealed that bacterial and eosinophilic exacerbations were more likely to be repeated in subsequent exacerbations within a subject, whereas viral exacerbations were not more likely to be repeated. We also confirmed the association of bacterial genera, including Haemophilus and Moraxella, with disease severity, exacerbation events and bronchiectasis.

Conclusions

Subtypes of COPD have distinct bacterial compositions and stabilities over time. Some exacerbation subtypes have non-random probabilities of repeating those subtypes in the future. This study provides insights pertaining to the identification of bacterial targets in the lung and biomarkers to classify COPD subtypes and to determine appropriate treatments for the patient.

Trial registration number

Results, NCT01360398.

Impact and associations of eosinophilic inflammation in COPD: analysis of the AERIS cohort

Eosinophilic inflammation in chronic obstructive pulmonary disease (COPD) predicts response to treatment, especially corticosteroids. We studied the nature of eosinophilic inflammation in COPD prospectively to examine the stability of this phenotype and its dynamics across exacerbations, and its associations with clinical phenotype, exacerbations and infection.127 patients aged 40-85 years with moderate to very severe COPD underwent repeated blood and sputum sampling at stable visits and within 72 h of exacerbation for 1 year.Blood eosinophils ≥2% was prevalent at baseline, and predicted both predominantly raised stable-state eosinophils across the year (area under the curve 0.841, 95% CI 0.755-0.928) and increased risk of eosinophilic inflammation at exacerbation (OR 9.16; p<0.001). Eosinophils ≥2% at exacerbation and eosinophil predominance at stable visits were associated with a lower risk of bacterial presence at exacerbation (OR 0.49; p=0.049 and OR 0.25; p=0.065, respectively). Bacterial infection at exacerbation was highly seasonal (winter versus summer OR 4.74; p=0.011) in predominantly eosinophilic patients.Eosinophilic inflammation is a common and stable phenotype in COPD. Blood eosinophil counts in the stable state can predict the nature of inflammation at future exacerbations, which when combined with an understanding of seasonal variation provides the basis for the development of new treatment paradigms for this important condition.

[Laparoscopy in diagnosis and treatment of acute abdominal diseases in children]

2765 children with abdominal pains were observed in the clinic of pediatric surgery from 1995 to 1999. During the observation period the abdominal pains persisted in 85 children. As it was not possible to resect the acute abdominal diseases, these children underwent diagnostic laparoscopy. Destructive changes in the appendix were revealed in 12 patients, 73 patients have avoided unnecessary laparotomy and appendectomy. It is concluded that diagnostic potential of laparoscopy is not inferior to diagnostic laparotomy. Moreover laparoscopy has advantage as a method of final diagnosis.

[Minimally invasive surgery in cholelithiasis]

The results of minimally invasive surgical interventions (percutaneous transhepatic cholecystostomy, retrograde cholangiopancreatography with endoscopic papillosphincterotomy, percutaneous transhepatic cholangiostomy with endobiliary intervention, extracorporeal shock wave lithotripsy, laparoscopic cholecystectomy) in 1590 patients were analyzed, 2 methods and more were used in 74 of them. In 155 patients minimally invasive interventions were combined with open surgery. Rational combination of minimally invasive methods in cholelithiasis permits to cure majority of the patients, to avoid open operation and associated complications.

[Transcutaneous endobiliary interventions in mechanical jaundice]

The authors analyse experience in the treatment of 132 patients with obstructive jaundice which was caused by a neoplastic lesion in 61 and by a benign disease in 71 of them. Bearing in mind the serious condition of this category of patients and the high risk of the operative intervention, two-stage treatment is applied with preliminary decompression of the biliary system and restoration of the main hepatic functions in the first stage. Transcutaneous endo-biliary interventions are carried out when other sparing methods cannot be accomplished or are ineffective. The authors give an integral, finer evaluation of the functional condition of the liver, elimination of the biliary microflora, and in this manner develop the criteria of the indications for the second stage of the intervention (prolonged bile passage in the intestine). In view of the high risk of the operative intervention, the authors suggest wider use of the methods of transcutaneous endo-biliary interventions according to indications. Nine patients died (6.8% mortality) in increasing hepatorenal insufficiency with growth of the oncological process.

[Correction of disorders of the metabolic function of the liver in mechanical jaundice by transcutaneous transhepatic intrabiliary interventions]

The paper presents the analysis of the experience gained in the treatment of 132 patients with obstructive jaundice of varying etiology using transcutaneous transhepatic intrabiliary interventions. More accurate investigation of hepatic function and the process of its recovery is achieved by ueviridine test. In combination with other examinations the test is useful in the design of the treatment policy, promotes more efficient application of transcutaneous transhepatic intrabiliary interventions.

[Roentgenologically-guided biliary tract surgery in mechanical jaundice]

From experience in radiologically-guided endobiliary surgery in 96 patients the authors claim it to be an effective method in the treatment of obstructive jaundice of various etiology, especially when endoscopic methods proved to be poorly effective while surgical operations were linked with a high degree of risk. Analysis of the microflora of the bile is indicated. The expediency of two-stage treatment of patients with obstructive jaundice is pointed out. Thirty one patients were cured by radiologically-guided endobiliary surgery.