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Necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) are two of the most common emergencies of the gastrointestinal tract in preterm infants with very low birth weight (VLBW, birth weight < 1500 g). Identification of risk factors among these children is crucial for earlier diagnosis and prompt intervention. In this study, we investigated a relationship between ABO blood groups and the risk for surgical NEC/FIP. We genotyped the ABO locus (rs8176746 and rs8176719) in VLBW infants enrolled in a prospective, population-based cohort study of the German Neonatal Network (GNN). Of the 10,257 VLBW infants, 441 (4.3%) had surgical NEC/FIP. In univariate analyses, the blood group AB was more prevalent in VLBW infants with surgical NEC/FIP compared to non-AB blood groups (OR 1.51, 95% CI 1.07-2.13, p = 0.017; absolute risk difference 2.01%, 95% CI 0.06-3.96%). The association between blood group AB and surgical NEC/FIP was observed in a multivariable logistic regression model (OR of 1.58, 95% CI 1.10-2.26, p = 0.013) as well. In summary, our study suggests that the risk of surgical NEC and FIP is higher in patients with blood group AB and lower in those having non-AB blood groups.

Abstract: Appendicitis is a common intra-abdominal inflammatory disease, and morbidity increases with age when perforation occurs. Because, not all patients require emergency surgery, there have been numerous studies on factors for predicting perforated appendicitis. In this study, we aimed to confirm whether the delta neutrophil index (DNI) and the time from symptom onset to surgery are effective predictors for perforated appendicitis in different age groups.This was a retrospective study conducted on 542 appendicitis patients who underwent surgery at Kangdong Sacred Heart Hospital. The simple group consisted of 431 subjects, and the perforation group consisted of 111 subjects.Multiple logistic regression analyses demonstrated that age, neutrophil percentage, DNI, C-reactive protein (CRP), and symptomatic time were significant predictors of perforation. Analysis of the receiver-operating characteristic curve showed that the DNI was the most reliable predictive value. In the analyses according to age, the perforation rate was higher in the >65-year-age group; these patients also had a higher DNI, CRP, and symptomatic time. In the DNI analysis using receiver operating characteristic (ROC) analysis, the area under the curve was higher in the >65-year-age group than in other age groups. In addition, the cutoff values have been determined and perforation occurred significantly in the group with a DNI value of 2.1 or higher and a symptomatic time of 33 hours or longer.DNI is effective in predicting perforation in patients with appendicitis compared with other inflammatory factors. Furthermore, the simultaneous measurement of symptomatic time and DNI is helpful in predicting perforation and determining whether emergency surgery is necessary., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Trauma, hemorrhage, and peritonitis have widely varying impacts on endocrine response in the injured patient. We sought to examine cortisol response in established non-human primate models of traumatic hemorrhage and intra-abdominal contamination., Methods: Cynomologus Macaques were separated into two experimental groups, the polytrauma and hemorrhage model, involving a laparoscopic liver resection with uncontrolled hemorrhage, cecal perforation, and soft tissue excision; and the traumatic hemorrhage model, involving only liver resection and uncontrolled hemorrhage. Cortisol levels were measured pre-operatively, at the time of injury, and at regular intervals until post-operative day 1., Results: Cortisol levels increased 600% from the pre-operative value in the polytrauma and hemorrhage model, with minimal changes (20%) in the hemorrhage only model., Conclusion: Cortisol levels increase dramatically in response to polytrauma and intra-abdominal contamination as compared to hemorrhage only. The lack of response in the hemorrhage only group may be due to relative adrenal insufficiency caused by the shock state or lack of enticing stimuli from fecal peritonitis., (Published by Elsevier B.V.)

The present pandemic caused by the SARS COV-2 coronavirus is still ongoing, although it is registered a slowdown in the spread for new cases. The main environmental route of transmission of SARS-CoV-2 is through droplets and fomites or surfaces, but there is a potential risk of virus spread also in smaller aerosols during various medical procedures causing airborne transmission. To date, no information is available on the risk of contagion from the peritoneal fluid with which surgeons can come into contact during the abdominal surgery on COVID-19 patients. We have investigated the presence of SARS-CoV-2 RNA in the peritoneal cavity of patients affected by COVID-19, intraoperatively and postoperatively. KEY WORDS: Covid-19, Laparotomy, Surgery.

The recent advent of endoscopy has enabled the endoscopic submucosal dissection (ESD) of superficial nonampullary duodenal epithelial tumors. However, the substantially thin wall and presence of bile and pancreatic juice make it technically difficult to perform duodenal ESD without perforation, which leads to lethal complications. The present study evaluated the efficacy of autologous myoblast sheet transplantation for the prevention of late perforation after duodenal ESD in a porcine model. Two weeks before ESD, skeletal muscle was surgically excised from the femur of pigs, and myoblasts were isolated and seeded in temperature-responsive culture dishes to prepare sheets. Immediately after ESD, the autologous myoblast sheets were attached to the serosal surface at the ESD site with omentopexy. The pigs were divided into two groups: the autologous myoblast sheet group ( n = 5), where the myoblast cell sheet was attached to the ESD ulcer part from the duodenal serous side, and the Omentum group ( n = 5), where only the omentum was used. The pigs were sacrificed and analyzed macroscopically and histologically on postoperative day 3. The macroscopic examination of the abdominal cavity revealed perforation in the ESD ulcer area and leakage of bile in the Omentum group but no perforation in the Sheet group. A histopathological examination revealed that continuity of the duodenal wall at the ESD site was maintained with dense connective tissue in the Sheet group. In conclusion, autologous myoblast sheets were useful for preventing perforation after duodenal ESD.

Background and Objectives: The applications of laparoscopic surgery are expanding, but there is still controversy about its application in patients with peritonitis resulting from diverticulitis perforation. This study aimed to investigate the factors affecting the postoperative mortality rate in patients undergoing surgery for perforated diverticulitis. Further, we compared the recovery courses of patients between open and laparoscopic surgeries., Methods: We analyzed the medical records of adult patients with peritonitis caused by perforated diverticulitis from six hospitals of Hallym University Medical Center from January 2006 to December 2016., Results: A total of 166 patients were identified. In the univariate analysis, the statistically significant factors associated with postoperative mortality were age ≥ 60 years, body mass index ≥ 23 kg/m 2 , American Society of Anesthesiologists score ≥ 3, hypertension, serum blood urea nitrogen ≥ 23 mg/dL, creatinine ≥ 1.2 mg/dL, albumin < 3.0 g/dL, modified Hinchey score ≥ grade III, formation of stoma, and laparoscopic surgery. In multivariate analysis, serum albumin < 3.0 g/dL was the only factor associated with mortality. After case-control matching, we compared postoperative hospital course and prognosis between open and laparoscopic surgery groups. There was no significant difference in the clinical course between the groups. No significant difference was observed in the complication rate, reoperation rate, readmission rate, and mortality., Conclusion: Low preoperative serum albumin level (<3.0 g/dL) affects the mortality rate of patients after surgery. The hospital course and prognosis after laparoscopic surgery and conventional open surgery are comparable in patients with peritonitis caused by diverticulitis perforation., Competing Interests: Conflicts of Interest: All authors declare no conflict of interest regarding the publication of this article.

Previous studies have linked systemic glucocorticoid use with intestinal perforation. However, the association between intestinal perforation and endogenous hypercortisolism has not been well described, with only 14 previously published case reports. In this study, we investigated if intestinal perforation occurred more frequently in patients with ectopic ACTH syndrome and in those with a greater than 10-fold elevation of 24-hour urinary free cortisol level. Of 110 patients with ACTH-dependent Cushing's syndrome followed in two clinics in Canada, six cases with intestinal perforation were identified over 15 years. Age of patients ranged from 52 to 72, five females and one male, four with Cushing's disease and two with ectopic ACTH production, one from a pancreatic neuroendocrine tumor and one from medullary carcinoma of the thyroid. Five had diverticular perforation and one had intestinal perforation from a stercoral ulcer. All cases had their lower intestinal perforation when the cortisol production was high, and one patient had diverticular perforation 15 months prior to the diagnosis of Cushing's disease. As in previously reported cases, most had hypokalemia and abdominal pain with minimal or no peritoneal symptoms and this occurred during the active phase of Cushing's syndrome. Whereas all previously reported cases occurred in patients with 24-hour urinary free cortisol levels greater than 10-fold the upper limit of normal when measured and 11 of 14 patients had ectopic ACTH production, only one of our patients had this degree of hypercortisolism and four of our six patients had Cushing's disease. Similar to exogenous steroid use, patients with endogenous hypercortisolism also have a higher risk of intestinal, in particular diverticular, perforation and should be monitored closely for its occurrence with a low threshold for investigation and surgical intervention. Elective colonoscopy probably should be deferred until Cushing's syndrome is under control.

Aim: Information regarding the localization of the anatomic site of gastrointestinal (GI) tract perforation is essential for the following surgical procedure. The purpose of this study was to evaluate the significance of C-reactive protein (CRP) and other circulating markers for the prediction of the localization of intra-abdominal hollow organ perforation., Methods: Measurements of serum markers were analyzed in 423 patients with GI tract perforations, who were divided according to the intraoperative diagnosis into colorectal and upper GI tract perforation groups., Results: Levels of CRP were higher in patients with colorectal perforations than in upper GI tract perforations (p < 0.001). Moreover, high levels of CRP were associated with increased mortality of patients with hollow organ perforations (p = 0.009), which was largely driven by the subset of patients with perforations of the upper GI tract (p = 0.001)., Conclusion: Increased CRP levels predict worse clinical outcome in patients with intra-abdominal hollow organ perforations and are associated with perforations in the colorectal tract. Thus, CRP might be a useful marker for preoperative risk stratification and prediction of the localization of the perforation site., (© 2019 S. Karger AG, Basel.)

Aim: Acute appendicitis is one of the most common pathology requiring emergency operations, and if perforated, can cause morbidity and mortality. The serum bilirubin levels were studied to see whether an elevation predicted perforation., Material and Methods: In a retrospective cohort study the medical files of 221 patients who were operated for acute appendicitis were reviewed., Results: Total and indirect bilirubin levels were significantly higher in patients with a perforated appendicitis compared with patients with simple appendicitis. Elevated serum bilirubin had a sensitivity of 50.00 (95% CI 29.93 to 70.07) and a specificity of 80.73 (95% CI 74.43 to 86.05) when predicting a perforated appendicitis., Conclusions: Appendiceal perforation may be accompanied with elevated serum bilirubin level. Assessment of bilirubin levels must be a part of the initial evaluation of a suspected appendicitis in the emergency room., Key Words: Acute appendicitis, Gangrenous appendicitis, Perforated appendicitis, Serum bilirubin, Total Hyperbilirubinemia.

Background: Parenteral nutrition-associated cholestasis (PNAC) is a major cause of morbidity and mortality in premature infants. Early predictors of PNAC would have clinical value. We sought to evaluate risk factors and liver function testing as predictors of PNAC in premature infants with intestinal perforation., Methods: Medical records of infants with a gestational age <34 weeks, birth weight <2000 g, and intestinal perforation due to either necrotizing enterocolitis or spontaneous intestinal perforation were reviewed. We analyzed clinical data and the maximum values of the aspartate aminotransferase (AST) to platelet ratio index (APRI), alanine aminotransferase (ALT), AST to ALT ratio, and total bilirubin (TB)., Results: Sixty infants were identified, 17 infants with PNAC and 43 infants without PNAC. Sepsis, time to initiation of enteral feeds after perforation, and duration of PN were associated with PNAC. Within 2 weeks following intestinal perforation, APRI, ALT, and TB each differed significantly between infants who later developed PNAC and those that did not. The best APRI cut-point was 0.4775 within 2 weeks after perforation (area under the receiver operating characteristic curve, 0.90; positive predictive value, 85%; and negative predictive value, 87%); the cut-point for ALT was 13.5 (0.90, 85%, 84%), and the cut-point for TB was 3.55 (0.82, 69%, 83%), respectively, at 2 weeks after perforation. AST to ALT ratio did not differ between groups., Conclusions: APRI and ALT had reasonable predictive value for PNAC in premature infants with intestinal perforation, with the APRI the best predictor within 2 weeks after perforation., (© 2017 American Society for Parenteral and Enteral Nutrition.)

Aim: We aimed to study the effects of thymoquinone on erythrocyte deformability in an experimental model of sepsis given before or after the initiation of the sepsis model., Method: The animals were grouped as (n = 6) control, nigella sativa, sepsis, sepsis group with administration of nigella sativa before sepsis development and sepsis group with nigella sativa administration after sepsis development. Cecal ligation and puncture model (CLP) was used to induce sepsis in the animals. The thymoquinone was given 1 hour before or after the CLP in the study groups with a dose of 500 mg·kg(-1). Erythrocyte deformability and relative resistance was calculated., Result: Relative resistance was increased in the sepsis groups when compared to the control group (p < 0.0001). Deformability index was increased in the sepsis group when compared to the other groups (p < 0.0001 in all groups). Sepsis group with after nigella sativa groups deformability index was significantly different from the deformability index in control group (p = 0.002). The use of nigella sativa before the initiation of sepsis corrected the deformability index significantly and the results were comparable to the control group (p = 0.078)., Conclusion: Thymoquinone administration before induction of CLP was observed to have protective effects on these alterations in CLP sepsis (Tab. 1, Fig. 1, Ref. 26).

Aim: To assess the accuracy of serum procalcitionin (PCT) as a diagnostic marker in verifying upper and lower gastrointestinal perforation (GIP)., Methods: This retrospective study included 46 patients from the surgical intensive care unit (ICU) of the Second Affiliated Hospital of Harbin Medical University who were confirmed to have GIP between June 2013 and December 2016. Demographic and clinical patient data were recorded on admission to ICU. Patients were divided into upper ( n = 19) and lower ( n = 27) GIP groups according to the perforation site (above or below Treitz ligament). PCT and WBC count was obtained before laparotomy and then compared between groups. Meanwhile, the diagnostic accuracy of PCT was analyzed., Results: Patients with lower GIP exhibited significantly higher APACHE II score, SOFA score and serum PCT level than patients with upper GIP ( P = 0.017, 0.004, and 0.001, respectively). There was a significant positive correlation between serum PCT level and APACHE II score or SOFA score ( r = 0.715 and r = 0.611, respectively), while there was a significant negative correlation between serum PCT level and prognosis ( r = -0.414). WBC count was not significantly different between the two groups, and WBC count showed no significant correlation with serum PCT level, APACHE II score, SOFA score or prognosis. The area under the receiver operating characteristic curve of PCT level to distinguish upper or lower GIP was 0.778. Patients with a serum PCT level above 17.94 ng/dL had a high likelihood of lower GIP, with a sensitivity of 100% and a specificity of 42.1%., Conclusion: Serum PCT level is a reliable and accurate diagnostic marker in identifying upper or lower GIP before laparotomy., Competing Interests: Conflict-of-interest statement: All authors declare that they have no any conflicts of interest.

Background: Acute appendicitis is one of the most common emergency requiring operation. As the first discovered coagulation factor, plasma fibrinogen frequently increases with inflammation due to the activation of coagulation. The aim of this retrospective study was to investigate the diagnostic value of hyperfibrinogenemia as a preoperative laboratory marker for appendiceal perforation in patients with acute appendicitis., Materials and Methods: We identified 455 patients (202 females, 253 males; mean age, 31.7 years) with histologically confirmed acute appendicitis who underwent laparoscopic or open appendectomy. Results of preoperative laboratory values and post-operative histologic results were analysed retrospectively. A multivariate logistic regression model was performed to determine patient's age and laboratory tests associated with perforated appendicitis., Result: Mean plasma fibrinogen level of all patients was 3.99 g/L (1.41 SD; range, 1.73-10.6 g/L; median, 3.69 g/L). Patients with appendiceal perforation had a mean fibrinogen level of 5.72 g/L (1.52 SD; range, 3.38-10.04 g/L; median, 5.28 g/L), which was significantly higher than those with nonperforated groups (P = 0.001). Multivariate analysis showed fibrinogen and D-dimer were associated with perforation (P = 0.001, P = 0.014, respectively). Areas under the receiver operating characteristic curve of fibrinogen for discriminating acute perforated appendicitis from non-perforated groups were larger than white blood cell and D-dimer., Conclusions: Hyperfibrinogenemia was common in patients with acute appendicitis and fibrinogen may be useful as a predictive factor for appendiceal perforation., (© 2015 Royal Australasian College of Surgeons.)

Background: Duodenal ulcer perforation (DUP) is a severe acute abdominal disease. Mean platelet volume (MPV) and platelet distribution width (PDW) are two platelet parameters, participating in many inflammatory processes. This study aims to investigate the relation of MPV/PDW and DUP., Methods: A total of 165 patients were studied retrospectively, including 21 females and 144 males. The study included two groups: 87 normal patients (control group) and 78 duodenal ulcer perforation patients (DUP group). Routine blood parameters were collected for analysis including white blood cell count (WBC), neutrophil ratio (NR), platelet count (PLT), MPV and PDW. Receiver operating curve (ROC) analysis was applied to evaluate the parameters' sensitivity., Results: No significant differences were observed between the control group and DUP group in age and gender. WBC, NR and PDW were significantly increased in the DUP group ( P <0.001, respectively); PLT and MPV were significantly decreased in the DUP group ( P <0.001, respectively) compared to controls. MPV had the high sensitivity., Conclusions: Our results suggested a potential association between MPV/PDW and disease activity in DUP patients, and high sensitivity of MPV., (© 2017 by the Association of Clinical Scientists, Inc.)

Objective: To investigate the risk of developing lower intestinal perforations (LIPs) in patients with rheumatoid arthritis (RA) treated with tocilizumab (TCZ)., Methods: In 13 310 patients with RA observed in the German biologics register R heumatoid A rthritis: O b servation of Bi ologic T herapy, 141 serious gastrointestinal events possibly associated with perforations were reported until 31 October 2015. All events were validated independently by two physicians, blinded for treatment exposure., Results: 37 LIPs (32 in the colon/sigma) were observed in 53 972 patient years (PYs). Only two patients had a history of diverticulitis (one in TCZ). Age, current/cumulative glucocorticoids and non-steroidal anti-inflammatory drugs were significantly associated with the risk of LIP. The crude incidence rate of LIP was significantly increased in TCZ (2.7/1000 PYs) as compared with all other treatments (0.2-0.6/1000 PYs). The adjusted HR (ref: conventional synthetic (cs) disease-modifying anti-rheumatic drugs (DMARDs)) in TCZ was 4.48 (95% CI 2.0 to 10.0), in tumour necrosis factor-α inhibitor (TNFi) 1.04 (0.5 to 2.3) and in other biologic DMARDs 0.33 (0.1 to 1.4). 4/11 patients treated with TCZ presented without typical symptoms of LIP (acute abdomen, severe pain). Only one patient had highly elevated C reactive protein (CRP). One quarter of patients died within 30 days after LIP (9/37), 5/11 under TCZ, 2/13 under TNFi and 2/11 under csDMARD treatment., Conclusions: The incidence rates of LIP under TCZ found in this real world study are in line with those seen in randomised controlled trials of TCZ and higher than in all other DMARD treatments. To ensure safe use of TCZ in daily practice, physicians and patients should be aware that, under TCZ, LIP may occur with mild symptoms only and without CRP elevation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: To examine circulating levels of inter-alpha inhibitor protein (IaIp) in infants with necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP), and matched controls to assess the diagnostic accuracy of IaIp to differentiate NEC from SIP and to compare receiver operating characteristics of IaIp for NEC with C-reactive protein (CRP)., Study Design: A prospective, nested case-control study of infants with feeding intolerance was carried out. Blood and clinical data were collected from 27 infants diagnosed with NEC or SIP and from 26 matched controls admitted to our unit. Infants with modified Bell criteria stage 2 or greater were included as NEC. Clinical, radiologic, and/or surgical findings were used to identify infants with SIP. Controls were matched for gestational age, postnatal age, sex, and birth weight., Results: Mean ± SD IaIp blood levels were 147 ± 38 mg/L, 276 ± 67 mg/L, and 330 ± 100 mg/L in infants with NEC, SIP, and matched controls, respectively (P < .004 and P < .01). Receiver operating characteristics analysis to establish the predictive value of NEC demonstrated areas under curve of 0.98 and 0.63 for IaIp and CRP, respectively., Conclusions: IaIp levels were significantly decreased in infants with NEC compared with SIP and matched controls. The diagnostic accuracy of IaIp for NEC was superior to that of CRP., Competing Interests: The other authors declare no conflicts of interest., (Published by Elsevier Inc.)

Background: Acute appendicitis is one of the most common surgical emergencies. An early and accurate diagnosis of acute appendicitis is vital. Evidence for a link between platelets indices and inflammation disease comes from recent studies. We aimed to evaluate preoperative diagnostic values of platelet indices (Mean platelet volume-MPV, Platelet Distribution Width-PDW, Plateletcrit-PCT) and leukocyte count (WBC) in comparison with post-operative histopathology results in patients who underwent appendectomy., Methods: The 165 patients who underwent appendectomy, were evaluated retrospectively. Patients' demographic characteristics, imaging findings, preoperative laboratory markers and postoperative histopathology results were recorded. The patients were divided into three groups based on the histopathologic findings; perforated appendicitis, acute appendicitis without perforation and negative appendectomy group. The specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV) of the laboratory markers were measured. Additionally potential correlation among laboratory markers analysed., Results: The negative appendectomy rate was 15.1% in 165 patients. The leukocyte count was statistically higher in acute appendicitis (14.9×103/μL) group than negative appendectomy (6.9×103/μL) group. There was also statistically significant difference between groups according to the PCT levels. The leukocyte count achieved sensitivity, specificity, PPV, and NPV of 95.9, 24, 99.1, and 92.7% respectively. A significant positive correlation between WBC and PCT were obtained. Inflammatory markers were not directly related to the severity of the disease., Conclusions: Elevated leukocyte count and PCT levels support diagnosis of acute appendicitis in correlation with pathological findings. Thereby combination of the inflammatory markers, positive clinical and radiological findings would improve diagnostic accuracy in acute appendicitis., Key Words: Acute appendicitis, Inflammatory markers, Platelet indices.

Background: The early prediction of gangrenous/perforated appendicitis is of great importance for the surgical planning, further treatments, and predicting the course of disease. Ischemia-modified albumin (IMA) was previously reported as a biomarker of various ischemia-based diseases. Our aim is to determine the predictive value of serum IMA in the severity of acute appendicitis., Methods: Sixty-two patients who underwent urgent appendectomy were included in the study. Plasma level of IMA was measured after diagnosis and before treatment. All patients were classified as noncomplicated (acute) appendicitis and complicated (gangrenous/perforated) appendicitis according to histopathological findings, and comparisons were made between the groups., Results: The data of 62 patients with a mean age of 30.1 years were statistically evaluated. The pathological diagnoses were acute appendicitis in 33 (53.2%), and gangrenous/perforated appendicitis in 29 (46.8%) patients. There were significant differences in computed tomography (CT) findings (P = .031) and IMA (P = .012) levels between the groups. A strong positive correlation between IMA levels and CT findings was also found (Spearman ρ = +0.688, P = .003)., Conclusions: The IMA can be considered as a novel and useful marker to distinguish gangrenous/perforated appendicitis from noncomplicated appendicitis. The correlation of IMA with CT findings also enhances the predictive value of IMA., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: We examined the changes of mean platelet volume (MPV) and platelet distribution width (PDW) in subjects with appendicitis and whether MPV and PDW could be used to predict the development of complication due to appendicitis., Methods: The healthy control group, the cases of appendicitis with perforation, and the cases of appendicitis without perforation were compared with regard to MPV and PDW. We determined whether MPV and PDW were independent variables predictive of the development of complication in subjects with appendicitis., Results: This retrospective case-control study included a total of 362 patients (249 of which were male (68.8 %) and 113 were female (31.2 %); median age, 30 [range, 18-84 years]). One hundred and ninety-two subjects (53 %) presented with appendicitis and 170 (47 %) comprised the healthy control group. Sixty-six (18.2 %) of the subjects with appendicitis developed complication. MPVs were lower in subjects of appendicitis without complication compared to the subjects of appendicitis with complication and the control group (MPV, 9.78 ± 0.99 vs. 10.20 ± 1.21 and 10.14 ± 1.03, respectively [p = 0.005]). The PDW levels were not different between the three groups. Independent variables predictive of the presence of complication included increased MPV and time from onset of symptoms to hospital presentation (odds ratio[confidence interval], p-value: 1.507[1.064-2.133], 0.021 and 18.887[5.139-69.410], 0.0001, respectively)., Conclusions: Our findings suggested these, MPV values in cases of appendicitis without complication were lower than the cases with complication and healthy control and MPV is a predictor of the development of complication in subjects with appendicitis.

Results of treatment of 40 patients, suffering diffuse peritonitis in a terminal stage, were analyzed. In 20 patients (main group) the abdominal cavity sanation was done, using superoxyddysmutase solution. Concentration of uric acid, urea, creatinine, general bilirubin, C-reactive protein in the blood serum have had normalized more rapidly, than in a control group, witnessing satisfactory renal function present.

Sepsis is a life-threatening condition that arises when the body's response to infection causes systemic inflammation. High-mobility group box 1 (HMGB1), as a late mediator of sepsis, enhances hyperpermeability, and it is therefore a therapeutic target. Despite extensive research into the underlying mechanisms of sepsis, the target molecules controlling vascular leakage remain largely unknown. Moesin is a cytoskeletal protein involved in cytoskeletal changes and paracellular gap formation. The objectives of this study were to determine the roles of moesin in HMGB1-mediated vascular hyperpermeability and inflammatory responses and to investigate the mechanisms of action underlying these responses. Using siRNA knockdown of moesin expression in primary human umbilical vein endothelial cells (HUVECs), moesin was found to be required in HMGB1-induced F-actin rearrangement, hyperpermeability, and inflammatory responses. The mechanisms involved in moesin phosphorylation were analysed by blocking the binding of the HMGB1 receptor (RAGE) and inhibiting the Rho and MAPK pathways. HMGB1-treated HUVECs exhibited an increase in Thr558 phosphorylation of moesin. Circulating levels of moesin were measured in patients admitted to the intensive care unit with sepsis, severe sepsis, and septic shock; these patients showed significantly higher levels of moesin than healthy controls, which was strongly correlated with disease severity. High blood moesin levels were also observed in cecal ligation and puncture (CLP)-induced sepsis in mice. Administration of blocking moesin antibodies attenuated CLP-induced septic death. Collectively, our findings demonstrate that the HMGB1-RAGE-moesin axis can elicit severe inflammatory responses, suggesting it to be a potential target for the development of diagnostics and therapeutics for sepsis.

Objectives: The purpose of this study is to characterize the cytokine response of preterm newborns with surgical necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP) before surgical treatment and to relate these finding to intestinal disease (NEC vs. SIP)., Study Design: The study was a 14-month prospective, cohort study of neonates undergoing surgery or drainage for NEC or SIP or surgical ligation of patent ductus arteriosus (PDA). Multiplex cytokine detection technology was used to analyze six inflammatory markers: interleukin-2, interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-1 β (IL-1β), interferon-gamma, and tumor necrosis factor-α (TNF-α)., Results: Patients with NEC had much higher median preoperative levels of IL-6 (NEC: 8,381 pg/mL; SIP: 36 pg/mL; PDA: 25 pg/mL, p < 0.001), IL-8 (NEC: 18,438 pg/mL; SIP: 2,473 pg/mL; PDA: 1,110 pg/mL, p = 0.001), TNF-α (NEC: 161 pg/mL; SIP: 77 pg/mL; PDA: 71 pg/mL, p < 0.001), and IL-1β (NEC: 85 pg/mL; SIP: 31 pg/mL; PDA: 24 pg/mL, p = 0.001). Patients with NEC totalis (NEC-totalis had the highest levels of IL-8 and were significantly different from infants with limited NEC (28,141 vs. 11,429 pg/mL, p = 0.03)., Conclusion: Surgical NEC is a profoundly more proinflammatory disease than SIP. The cytokine profiles of patients with SIP are closer to those of a nonseptic surgical neonate., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

We describe a case in which a patient receiving parenteral nutrition (PN) developed hypophosphatemia. Due to lack of availability of parenteral phosphate supplements, we chose to restore phosphate using diluted hypertonic sodium phosphate enemas. Due to the recent shortages of parenteral minerals and vitamins, such an alternate means of repletion is of increasing importance. Diluted hypertonic sodium phosphate enemas are inexpensive, easy to administer, and effective since phosphate is readily absorbed across the rectal mucosa. We hope that through this type of repletion, life-threatening hypophosphatemia among patients receiving PN can be avoided.

Purpose: This study aims to assess the clinical relevance of postoperative arterial blood lactate (LAC) level as a prognostic factor in patients with colorectal perforation., Methods: Forty-two patients (22 males, 20 females; mean age, 70.8 years) underwent emergency surgery for colorectal perforation. The patients were divided into mortality and survivor groups. As a prognostic scoring system, Acute Physiological and Chronic Health Evaluation II (APACHE-II), Sequential Organ Failure Assessment (SOFA), and Systemic Inflammatory Response Syndrome criteria were calculated. These scores, postoperative LAC level, and other data, including site and etiology of perforation, elapsed time from onset to surgery (eTIME), preoperative white blood cell (WBC) and platelet counts, preoperative C-reactive protein (CRP), and preoperative arterial blood base excess were assessed between the groups., Results: The total mortality rate was 33.3 %. On univariate analysis, the APACHE-II and SOFA scores were significantly higher, and eTIME was significantly longer in the mortality group than in the survivor group. The postoperative LAC level was significantly higher in the mortality group (43.1 ± 14.1 mg/dl) than in the survivor group (23.8 ± 12.7 mg/dl; p < 0.001), and the preoperative WBC was significantly lower in the mortality group than in the survivor group. Multivariate logistic regression analysis using the mortality risk factors determined by univariate analysis (eTIME, APACHE-II score, SOFA score, preoperative WBC count, and postoperative LAC) demonstrated that postoperative LAC level was an independent risk factor for mortality., Conclusions: High postoperative LAC level was a useful factor for predicting high mortality rate in patients with colorectal perforation.

To define the role of systemic inflammation in infants with intestinal perforation (IP) and necrotizing enterocolitis (NEC), we measured 25 blood protein concentrations on days 1, 7 and 14 in 939 infants born before 28 weeks' gestation. On days 7 and 14, infants with NEC had elevated levels of C-reactive protein (CRP), serum amyloid A (SAA), IL-6 and IL-8. Infants with IP had elevated levels of CRP and insulin growth factor binding protein-1 on day 7 and elevated CRP, SAA, TNF-receptor-2 and matrix metalloproteinase-9 levels on day 14. A better understanding of systemic inflammation might help prevent and treat these disorders.

The clinical picture of classical homocystinuria is diverse. This is the first report of an adult homocystinuric patient with non-traumatic spontaneous small bowel perforation. A 47-year old man presented with abdominal rebound tenderness, hypotension and tachycardia, anemia, and elevated markers of inflammation. Other routine laboratory tests were normal. Abdominal x-ray showed no free air. An emergency laparotomy revealed jejunal perforation in the left upper quadrant. Histologic specimen showed full-thickness nonspecific inflammation of the intestinal wall with granulocytic infiltration, hemorrhage and necrosis. Tuberculosis, actinomycosis and typhus were histologically and clinically excluded. After excluding all known possible causes of perforation, we presumed a causative relationship between homocystinuria and small bowel perforation. It could be hypothesized that connective tissue weakness in homocystinuria is a result of homocysteine interference with recombinant human fibrillin-1 fragments or cross-linking of collagen through permanent degradation of disulfide bridges and lysine amino acid residues in proteins. DNA analysis showed three detectable mutations in the cystathionine beta-synthetase gene, 1278T:c.833T>C, and two new mutations, V372G:c.1133T > G, and D520G:c.1558A > G in the aternatively spliced exon 15.

Background: The importance of inflammation markers in predicting perforation in acute sigmoid diverticulitis is not well known. Predicting perforation by clinical examination alone may be hazardous. If perforation is suspected, then appropriate diagnostic tools such as computed tomography (CT) are indicated, and surgical intervention might be necessary., Methods: A cohort of consecutive patients with acute sigmoid diverticulitis diagnosed by CT and with complete laboratory findings (n = 247) were retrospectively divided into two groups, one with perforation (n = 86) and another without (n = 161). The latest values of C-reactive protein (CRP), white blood cell count (WBC), and serum bilirubin, as well as the activity of the alkaline phosphatase (AP) measured during the 48 h period before the CT scan, were assessed., Results: In the Wilcoxon rank sum test CRP and WBC correlate significantly (p < 0.05) with perforation in acute sigmoid diverticulitis, whereas the logistic regression model shows only CRP to correlate significantly (p = 0.001) with perforation. The sensitivities/specificities for perforation are 98%/5% for elevated CRP (>5 mg/l), 86%/27% for a CRP higher than 50 mg/l, 44%/81% for a CRP higher than 150 mg/l, 28%/93% for a CRP higher than 200 mg/l, 88%/44% for elevated WBC (>10 × 10(9)/l), 35%/90% for hyperbilirubinemia (>20 μmol/l), and 35%/91% for elevated AP (>110 U/l)., Conclusions: A CRP below 50 mg/l suggests a perforation to be unlikely in acute sigmoid diverticulitis, whereas a CRP higher than 200 mg/l is a strong indicator of perforation.

Blood-based monitoring of immunoinflammatory and organ function fluctuations is essential in models of critical illness. This is challenging in diseased mice as repetitive blood collection may be harmful and/or affect end points. We studied the influence of daily sampling in acutely septic (days 1-5) mice upon survival and selected hematologic and organ function parameters. In addition, we tested the reliabilty of complete blood cell (CBC) count using resuspended blood cells. Female OF-1 and CD-1 mice underwent cecal ligation and puncture (CLP) and were subdivided into Daily and Day 5 groups. Blood was collected daily for 5 days in the Daily group and only on day 5 post-CLP in the Day 5 group. We tested 20 μL (both strains) and 35 μL (OF-1 mice) sampling volumes. The 35-μL volume simultaneously served to test the CBC reliabilty in resuspended versus unprocessed blood. Daily sampling did not affect the 14-day CLP mortality. Compared with the Day 5 group, daily 35-μL sampling in OF-1 mice decreased the red blood cell count and hemoglobin concentration by 22% and 23% (P < 0.05). In neither strain did daily 20-μL sampling affect the red blood cell count, whereas there was a 9% hemoglobin decrease (P < 0.05) in OF-1 mice. Although alanine aminotransferase, lactate dehydrogenase, and glucose levels were comparable, urea significantly increased by 24% in the Daily group (20-μL volume, OF-1 mice). Interleukin 6, platelets, and white blood cell counts remained unaffected. There was an excellent correlation between regular and resuspended CBC for all cell types (r ≥ 0.9; slope, ≥0.9), except lymphocytes (r > 0.5; slope, >0.5). This method provides a feasible and safe translation of clinically relevant daily immunomonitoring to the mouse sepsis model.

In our study we investigated serum iron levels in the patients with localized or generalized peritonitis. These values were compared in group of 52 patients with acute peritonitis against group of 39 patients without inflammation within peritoneal cavity. The serum iron levels and Total Iron Binding Capacity (TIBC) was indicated in both group. Acute intraabdominal inflammation induced in all patients a state of hypoferremia. However, medium decline of iron level in patients with acute appendicitis or cholecystitis was smaller compare with that observed among the patients with generalized peritonitis caused by perforation of duodenal ulcer, perforation of large bowel diverticula or perforation of small bowel. It has been suggested that decline in iron serum level observed in those patients can be an element of metabolic response to trauma and represents a part of the innate immune system and thus constitutes the first line defence against infection. However, based on presently available knowledge we can not yet finally evaluate the clinical implication of serum iron monitoring in diagnosis and prognosis of the patients with peritonitis.

Background & Objective: Ileal perforation is a serious complication of typhoid fever. The exact reasons for the development of perforation in only a few of those infected with Salmonella Typhi is unknown, and it is likely that immunological factors are involved. Therefore we undertook this study to compare the antibody profile in patients with uncomplicated typhoid fever with those having ileal perforation by immunoblotting., Methods: Two groups of patients were included in the study. Group II comprised patients with uncomplicated typhoid fever (n=47), and group I with typhoid ileal perforation (n=33). The flagellar (H), lipopolysaccharide (LPS) and outer membrane protein (OMP) antigens of Salmonella Typhi were extracted and used to test patient sera for antibodies by immunoblotting, Results: Immunoblotting using S. Typhi antigens enabled the detection of S. Typhi antibodies in the two groups of patients. A significant difference was seen in the response of these two groups of patients with respect to antibodies to flagella, lipopolysaccharide and outer membrane proteins. Antibodies to flagella were more pronounced among patients with uncomplicated typhoid fever, while anti-OMP antibodies were significantly associated with typhoid ileal perforation., Interpretation & Conclusion: A comparison of antibodies in patients with uncomplicated typhoid fever and with ileal perforation revealed the differences in the antibody profiles of the two groups. Our study suggests that the difference in antibody response may in some way play a role in the pathogenesis of typhoid ileal perforation which can also potentially be exploited to develop suitable diagnostic tests.

Aim: E-selectin is an important mediator of leukocyte-endothelial adhesion. It is expressed on activated endothelium, and shed into the circulation in its soluble form. In babies with necrotising enterocolitis (NEC), increased intestinal expression of E-selectin has been associated with multiple organ failure and an adverse outcome. The aim of this study was to determine whether increased circulating soluble E-selectin (sE-selectin) was associated with a worse prognosis., Methods: With ethical approval, plasma samples from 20 infants with Bell stage II and III NEC were analysed. Both pre- and postoperative samples were available in 6 infants. The severity of illness was assessed using a sequential organ failure assessment score (SOFA) specifically designed for use in NEC. Plasma concentration of sE-selectin was determined by ELISA. Data, which were not normally distributed, were compared by Spearman's rank correlation coefficient and Wilcoxon signed rank test., Results: Plasma sE-selectin was strongly negatively correlated with corrected gestational age at the time of sampling (r = - 0.425, p = 0.006). There was no association between plasma sE-selectin and outcome (death or survival to discharge), severity of intestinal disease (focal, multifocal or pan-intestinal), or SOFA score. Surgery for suspected perforation, however, caused a significant elevation in sE-selectin levels (p = 0.031)., Conclusions: Plasma sE-selectin, a described marker of endothelial activation, is increased following surgery for NEC. However, prematurity appears to be the cause of an increase in sE-selectin level, confounding the potential use of sE-selectin levels as a predictor of severity of illness in NEC.

Purpose: Peritoneal drainage (PD) constitutes a definitive therapy for a subset of extremely low birth weight (ELBW) infants with spontaneous intestinal perforation (SIP). We investigated the factors which may differentiate these patients from those who require a laparotomy (LAP) after initial PD., Methods: A retrospective chart review of all ELBW infants (<1000 grams) who underwent PD at two tertiary neonatal intensive care units over a 42-month period was performed. Demographic, clinical, laboratory, and radiological data of the entire patient cohort were collected. Patients who underwent definitive PD were compared to those who required LAP following PD. Statistical comparisons were performed using independent samples T-tests for continuous variables, and Fisher's exact test for categorical variables., Results: Sixteen ELBW infants with SIP underwent PD. Five patients (31%) had definitive PD and 11 (69%) subsequently required LAP. Patients who had definitive PD had a lower percent band count at diagnosis (3.2+/-1.5 vs. 18.0+/-4.8; p=0.01), and were less likely to require vasopressor therapy at diagnosis and drain placement (40% vs. 91%, p=0.06), 24 hours later (40% vs. 100%, p=0.02), and 48 hours later (20% vs. 91%, p=0.01). There were no other statistically significant differences in any of the measured variables. Survival to discharge was 80% for PD and 82% for LAP (p=1.0)., Conclusion: Peritoneal drainage for spontaneous intestinal perforation in ELBW neonates is more likely to be definitive in the absence of bandemia and vasopressor requirement. These may be important factors in deciding whether to proceed to laparotomy.

Background/purpose: Few studies have addressed the predictive value of white blood cells (WBCs) and C-reactive protein (CRP) at different cutoff values in appendicitis. Our purpose was to determine the cutoff values for WBC and CRP at different periods during clinical evolution of appendicitis and to establish their use for the diagnosis of appendicitis and differentiation of simple from perforated appendicitis., Methods: We studied 198 patients operated on for appendicitis, which were further divided into 4 subgroups according to the time from the onset of symptoms to diagnosis. Receiver operating characteristic curves were constructed for CRP and WBC; the best cutoff points were used to calculate the sensitivity and specificity to discriminate patients with and without appendicitis and patients with simple and perforated appendicitis., Results: White blood cell and CRP individually and together had a high sensitivity to differentiate patients with and without appendicitis. The specificity of WBC and CRP taken individually and together to differentiate patients with simple and perforated appendicitis was high, but the sensitivity was low., Conclusions: White blood cell and CRP could be used to support the clinical diagnosis of appendicitis, and, depending on the time from the onset of symptoms to diagnosis, to differentiate patients with and without appendicitis and discriminate simple from perforated appendicitis.

Early diagnosis of perforated appendicitis is important for reducing morbidity rates. The aim of this study was to determine the value and utility of plasma D-lactic acid levels in identifying the type of appendicitis. In this clinical study, plasma D-lactic acid levels were assessed in 44 consecutive paediatric patients (23 with acute appendicitis, 21 with perforated appendicitis) before laparotomy. D-lactic acid levels were determined by an enzymatic spectrophotometric technique using a D-lactic acid dehydrogenase kit. Patients with perforated appendicitis had higher D-lactic acid levels (3.970 +/- 0.687 mg/dL) than patients in the control group (0.478 +/- 0.149 mg/dL) and patients with acute appendicitis (1.409 +/- 0.324 mg/dL; p < 0.05). For a plasma D-lactic acid level greater than 2.5 mg/dL, the sensitivity and specificity of the D-lactic acid assay were 96% and 87%, respectively. The positive predictive value was 87%, the negative predictive value was 96%, and the diagnostic value was 91%. These results suggest that the measurement of plasma D-lactic acid levels may be a useful adjunct to clinical and radiological findings in distinguishing perforated from acute non-perforated appendicitis in children.

Background/aims: Colorectal perforation remains a life-threatening condition associated with high mortality. Various factors and operative procedures have been discussed in regard to prediction of outcome, and several scoring systems have been proposed to predict the outcome of critically ill patients. The present study was undertaken to identify factors and determine predictive scoring systems for the postoperative outcome of patients with colorectal perforation., Methodology: Between January 1996 and December 2000, 45 consecutive patients underwent emergency operation for colorectal perforation. Twelve patients (26.7%) died in hospital. The correlation of outcome with various preoperative factors, APACHE II and SOFA scores were assessed retrospectively., Results: Univariate analysis showed that outcome was significantly related to maximum SOFA score (p=0.0069). Multivariate logistic regression analysis demonstrated that the maximum SOFA score was an independent predictor (p=0.016). Serum creatinine level (p=0.013) and platelet count (p=0.036) were associated with patient outcome in the SOFA score. Patients with a SOFA score higher than 7 had a greater risk of hospital death (p=0.0085)., Conclusions: The maximum postoperative SOFA score is a useful predictor of the outcome from surgery for colorectal perforation.

Background/purpose: The routine use of interval appendectomy for the treatment of perforated appendicitis, with or without abscess, remains controversial. The purpose of this study is to confirm the efficacy of this approach and to identify factors associated with failures and complications., Methods: All patients (n = 101) with their clinical diagnosis of perforated appendicitis confirmed with imaging were treated prospectively with fluids and intravenous antibiotics (clindamycin, ceftazidime) and were discharged home on oral fluids and analgesics regardless of fever. Intravenous antibiotics were continued at home until the patients were afebrile for 48 hours, and their white blood cell and differential counts were normal. Patients were readmitted at 8 to 12 weeks for an interval appendectomy. Failure to improve by 72 hours of antibiotic therapy mandated an early appendectomy. P values were determined by chi(2) analysis and Student's t test., Results: The 79 patients (78%) successfully treated with interval appendectomy had an overall 6.3% complication rate, and total hospitalization averaged 5.2 days. The treatment in 21 of 22 patients (22%) requiring early appendectomy failed because of a clinical picture suggesting small bowel obstruction. The patients with the failed procedures had a complication rate of 50% and were hospitalized an average of 12.8 days. The overall complication rate for the 101 patients was 15.8%, and the overall total hospitalization was 6.9 days. Patients requiring early appendectomy had a more frequent finding resembling a small bowel obstruction on their initial x-ray (50% v 13%, P = .004) and a higher percent band count on their initial differential blood cell count (22.6% v 7.6%, P<0.0001) than did those successfully treated with interval appendectomy. An initial band count <15% was predictive of an uncomplicated course (84% positive predictive value)., Conclusions: Interval appendectomy without complications is successful in the majority of patients with perforated appendicitis. An elevated initial band count > or =15% is associated with an increased likelihood of failure and complications.

Background: To assess the accuracy of procalcitonin as a measure of severity in patients with septic abdominal illnesses and the sepsis syndrome, to compare measurements with those of other inflammatory mediators, and to predict outcome., Methods: We carried out a prospective clinical study from 246 patients with infective or septic episodes confirmed at laparotomy and 66 patients undergoing elective operations who acted as controls. Specimens of blood for measurement of cytokine concentrations determination were obtained daily from septic patients. In the control group specimens were obtained before operation, at the end of operation, and on each of the following days until normal recovery (day 10). Every two weeks up to 3 months for patients with metastases, who were being followed up., Results: Compared with other cytokines such as tumor necrosis factor alphaa and interleukin 6 procalcitonin was closely related to the development of infective and septic complications. 59 of 246 patients (24%) with sepsis died. Procalcitonin concentrations preoperatively [median 2.05 compared with 4.2 ng/ml (p=0.08)] (Mann-Whitney U-test) did not differ, but those on the days 1,4 and at the end differed significantly [day 1: 4.9 compared with 13.8 ng/ml (p<0.01); day 4: 4.8 compared with 13.0 ng/ml (p<0.01) and 0.4 compared with 13.25 ng/ml (p<0.01) at the end of the study]. In the control group only 7 (1.6%) of all blood samples, were detected outside the normal range (up to 0.8 ng/ml)., Conclusions: Procalcitonin is a new indicator of infection and sepsis. TNF and IL-6 concentrations always rise after major operations and fall in the absence of infection, indicating operative trauma. Procalcitonin is sensitive in detecting infective complications. Under routine conditions the procalcitonin concentrations seems to be valid, reproducible and detectable.

Purpose: The aim of this study was to analyze the diagnostic accuracy of C-reactive protein and its possible advantage, if any, over leukocyte counts in acute appendicitis in children., Methods: We performed a retrospective study of 124 children (72 males) with a mean age of 9.3 (range, 2-14) years operated on under a clinical diagnosis of acute appendicitis. The diagnosis of acute appendicitis, confirmed by pathologic examination of the removed appendix, was then correlated with C-reactive protein, leukocyte count, and a combination of both C-reactive protein and leukocyte count, with a logistic regression model. C-reactive protein serum measurements were performed by an immunoturbidimetric test. The patients were divided into two groups according to the pathologic features of the removed appendix: Group A (n = 104), patients with acute appendicitis, and Group B (n = 20), patients without acute appendicitis. To assess the accuracy of C-reactive protein, leukocyte counts, and a combination of both parameters, receiver operating characteristic curves were used. The areas under the curve were compared using the maximum likelihood estimation method., Results: There were 95 cases (76.6 percent) of nonperforated appendicitis, 9 cases (7.3 percent) of perforated appendicitis and 20 cases (16.1 percent) of normal appendix. Mean C-reactive protein in Group A was 4.3 (standard deviation, 6.6) and in Group B was 1.2 (standard deviation, 1.7; P = 0.03). The C-reactive protein and leukocyte count values were correlated with the pathologic diagnosis of acute appendicitis. Mean C-reactive protein values increase as the pathologic inflammation type progresses (P = 0.007). The C-reactive protein receiver operating characteristic curve shows that the C-reactive protein value with highest accuracy was 1.7 mg/dl. The sensitivity, specificity, and accuracy rates calculated in the 1.7 cutoff were 58, 80, and 83.8 percent, respectively. A comparison of the respective receiver operating characteristic curves demonstrates that C-reactive protein, leukocyte count, and the combination of both tests all have a good diagnostic value but without any significant difference (P = 0.2)., Conclusions: In children, 1) serum C-reactive protein is increased in acute appendicitis; 2) such increase is related to the severity of the appendiceal inflammation; and 3) although serum C-reactive protein has an adequate diagnostic accuracy, neither individually nor in combination with the leukocyte count is it significantly better than the leukocyte count alone.

Authors studied the formation of endotoxic antibody level in healthy adults and in patients with appendicitis with a technique (indirect haemagglutination) not used till now. They found the antibody level against endotoxin to be increased in 91% of their patients in the postoperative period. Decrease in the antibody level against endotoxin was observed in two patients with gangrenous appendicitis and two patients with perforated appendicitis. Summarizing their results, authors consider mixed (aerobic, anaerobic) infection to be of decisive importance in the development of acute appendicitis, contributing to the weakened immune response of the host.

This study was undertaken to describe the metabolic O2 reserve of the coronary circulation in an awake sheep model of hyperdynamic sepsis. Forty-eight hours after sheep were randomized to either a SHAM group (n = 8) or a cecal ligation and perforation (CLP) group (n = 8), we measured hemodynamics, organ blood flows, and systemic and myocardial O2 metabolism variables at baseline and through four stages of progressive hypoxia. A significant elevation in arterial lactate levels occurred at a higher O2 delivery in the CLP group (527 +/- 55 ml/min/m2) than in the SHAM group (357 +/- 29 ml/min/m2, p < 0.05). The heart's metabolic O2 reserve (difference in circulatory determinants of O2 availability between baseline and where O2 uptake could not be sustained) was exhausted at an O2 content of 56.9 +/- 4.2 ml O2/L in SHAM sheep and 79.6 +/- 7.2 ml O2/L (p < 0.05) in CLP sheep. An increase in coronary blood flow was three times greater in SHAM than in CLP animals. Myocardial O2 extraction increased in hypoxia in SHAM sheep (0.78 +/- 0.03 to 0.88 +/- 0.02, p < 0.05), but not in CLP sheep (0.79 +/- 0.02 to 0.80 +/- 0.04). We conclude that the metabolic O2 reserve of the coronary circulation is depressed in this model of hyperdynamic sepsis as the ability to increase both coronary blood flows and myocardial O2 extraction was significantly limited.

Unlabelled: Diagnosis of acute appendicitis is established generally by the surgeon's clinical impression. Today, negative laparotomy rate because of clinical diagnosis is still 15 to 25 percent., Purpose: This study was designed to determine the accuracy of C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis and to compare it with the surgeon's clinical diagnosis., Methods: One hundred eight consecutive patients were studied prospectively. Depending on results of the examination by a surgeon, patients underwent surgery for acute appendicitis. Serum CRP measurements were performed before the operations but were not taken into account for the decision of laparotomy to compare it with the surgeon's clinical diagnosis., Results: Histopathologic findings confirmed acute appendicitis in 90 patients. Normal appendixes were removed in the remaining 18 patients. Mean serum CRP value was 5 (range, 0-12.6) mg/l in patients with normal appendix, 33.8 (range, 5-85.1) mg/l in patients with nonperforated appendicitis, and 128.5 (range, 79.2-230) mg/l in patients with perforated appendixes. These differences were highly significant (P < 10(-6)). Serum CRP levels were normal in three patients with acute appendicitis. Thus, the false-negative rate of CRP was 3 percent. Of 18 patients with normal appendectomy serum CRP levels were slightly elevated in two patients. We determined, therefore, a false-positive rate of CRP as 11 percent. CRP levels were false-negative in three patients and false-positive in two patients. Thus, CRP levels were true (positive or negative) in the remaining 103 patients. On the other hand, the diagnosis depending on surgeon's clinical impression was true in 90 patients and false in 18 patients. This difference was statistically significant (P = 0.0035). In the present study the sensitivity, specificity, and accuracy of serum CRP measurements were calculated as 93.5, 80, and 91 percent, respectively., Conclusion: We found that elevated serum CRP levels support surgeon's clinical diagnosis. We recommend CRP measurement as a routine laboratory test in patients with suspected diagnosis of acute appendicitis.

Purpose: To define patterns of care and outcome for pediatric appendectomy., Methods: A study was designed to evaluate all pediatric appendectomies performed in the 147 Department of Defense hospitals worldwide. Cases of nonincidental appendectomy were identified through discharge diagnoses and operative logs, and 98.6% of the charts were retrieved for review. All charts were abstracted, and data were entered into a 127-field database for analysis., Results: Over a 12-month period, ending January 1993, appendectomy was performed on 1,366 pediatric patients in the Department of Defense hospital system. The patients' median age was 12 years (range, 6 months to 18 years); 59% were male. The diagnosis was normal appendix for 157 patients (12%), acute nonperforated appendicitis for 930 (68%), and perforated appendicitis for 279 (20%). Age < or = 8 years was predictive (P < .001) of a higher rate of perforated appendicitis (33% v 18%) but was not predictive of normal pathology (13% v 11%). Female gender was associated with a significantly higher rate of normal pathology (17% v 8%; P < .001) but not of perforation (18% v 22%). Temperature elevation and right lower quadrant pain and tenderness did not clinically distinguish between diagnostic groups. Sixty-two percent of patients with a normal appendix had a white blood cell count of more than 10,000/mm3, as did 91% of patients with acute or perforated appendicitis. Those with perforated appendicitis received pre- and postoperative antibiotics, primarily ampicillin/gentamicin/clindamycin or Flagyl (41%), cefoxitin (34%), or Unasyn (15%). In 77% of this subgroup, intraoperative cultures were positive, with isolates for Escherichia coli (76%) Enterococcus (30%), Bacteroides (24%), and Pseudomonas (20%) predominating. There were no deaths. Major complications occurred in 1.2% of patients with acute appendicitis and in 6.4% of those with perforated appendicitis; there were no major complications in the group with normal appendectomies. The hospitalization period was more than 7 days for 1.6%, 40%, and 3.8%, respectively., Conclusion: This large series, from a large number of hospitals, with multiple practitioners, can serve as a community standard for pediatric appendectomy in the 1990s.

Objective: To evaluate the interleukin-6 (IL-6) concentration in the diagnosis of acute appendicitis, either as a single or four-hourly test., Design: Open study., Setting: Teaching hospital, Sweden., Subjects: 165 consecutive patients admitted with suspected acute appendicitis., Main Outcome Measures: Correlation of concentrations of IL-6 and C-reactive protein with white cell count, duration of symptoms, and histological appearance of the appendix., Results: Of 165 patients, 101 patients had their appendices removed, and of these 86 had histologically confirmed appendicitis. An IL-6 concentration of less than 15 ng/l was accepted as the reference. On admission IL-6 concentrations above 15 ng/l gave a sensitivity of 66% and a specificity of 31% for acute appendicitis. Repeated tests were of no value. When the patients operated on were divided in groups depending on the duration of symptoms, C-reactive protein was the most valuable test after 24 hours' abdominal pain. Total white cell count has the most sensitive in patients with abdominal pain of less than 24 hours' duration., Conclusions: Measurement of IL-6 concentrations does not increase the accuracy of the diagnosis of acute appendicitis. There was no significant correlation between IL-6 and C-reactive protein concentrations.

The condition of the cellular link of the immune system was studied in 30 patients with various forms of acute peritonitis. It was found that the reaction of the immune system in peritonitis is characterized by a phase property and is manifested by processes of redistribution and activation of the immunocompetent cells and normalization of reactivity. The ratio of these phases is determined by the severity of inflammation and intoxication. It is shown that inhibition of the immune system is most marked in diffuse peritonitis, which is due to the higher absorption capacity of the peritoneum in this stage of the pathological process. It was established that the response of the immune system to the operative trauma depends on the spread of peritonitis. The number of T-helpers, T-suppressors, and activated lymphocytes and the activity of the neutrophil alkaline phosphatase are most important in the prognosis of postoperative complications. These parameters may also be used in assessment of the efficacy of immunomodulation with levamisole.

Femoral arteriovenous differences and flux of amino acids across the leg were measured in seven septic patients and compared with those of six nonseptic patients on days 1 and 3 following major surgery. The septic patients were seriously ill and judged clinically to be catabolic. The postoperative patients, although not septic, were expected to have a maximal catabolic response to operation during the first 3 days after operation. Both groups had increased release of phenylalanine from the leg, an index of muscle proteolysis. Septic patients had decreased femoral arteriovenous differences (--20 vs --74 and --60 mumoles/liter) and decreased flux (34 vs 169 and 128 nm/100 gm of calf muscle) of the branched-chain amino acids as compared with the nonseptic postoperative patients on days 1 and 3. The arterial plasmal levels of the branched-chain amino acids and alanine were not different, but phenylalanine was elevated in the septic patients (88 vs 49 and 55 mumoles/liter). The insulin:glucagon molar ratio was lower in the septic patients (2.4 vs 4.4 and 5.5). These findings suggest that in the catabolism of sepsis there is greater oxidation of branched-chain amino acids in muscle than in the catabolism associated with uncomplicated surgery.

Plasma fibronectin (PFN) is a high molecular weight adhesive glycoprotein. Following trauma or sepsis PFN is acutely depleted, with rapid restoration of normal or supranormal levels after 24 to 48 hours. Cecal ligation with perforation provides an animal model of surgical trauma combined with polymicrobial sepsis. The present study examines whether this PFN level restoration 6 to 24 hours postoperatively is associated with de novo PFN synthesis and how this response is altered by pre-existing protein-calorie deprivation. Thirty-six adult male rats were divided into four groups: I--Controls, II--Prefasted Controls, III--Ligated, IV--Prefasted and Ligated. Control and experimental groups received intracardiac 35S-methionine 2 hours postoperatively. Plasma fibronectin (PFN) levels, PFN specific activity, plasma total protein, and total protein specific activity were determined at 0, 6, 24, and 48 hours postoperatively. Ligated rats (Groups III & IV) demonstrated significant PFN level increases 24 to 48 hours postoperatively (p less than 0.01-0.05). Despite a significant preoperative PFN level depression in prefasted rats (Groups II & IV), the 24-48 hours response to cecal ligation was not significantly altered. PFN specific activity was significantly increased among the operative groups 6 hours postoperatively, demonstrating de novo PFN synthesis following cecal ligation and perforation.

Twenty-four dogs were divided into five groups. Under pentothal sodium anesthesia, those in the control group received no further manipulation; another group underwent laparotomy only; and dogs in the last three groups had induced pancreatitis, intestinal ischemia and duodenal perforation, respectively. An analysis was made of serum and peritoneal lavage fluid in the dog of each group at 30 minute intervals for four and one-half hours. Parameters which were significantly elevated in dogs with pancreatitis compared with other groups included fluid amylase, lactate dehydrogenase, proteolytic activity and intestinal alkaline phosphatase and serum amylase. We judge that these biochemical differences in the lavage fluid, when taken with the physical characteristics of the fluid and the clinical symptoms, can significantly aid the clinician in arriving at the diagnosis of acute pancreatitis.