Microbial Translocation Is Associated with Extensive Immune Activation in Dengue Virus Infected Patients with Severe Disease

Background:Severe dengue virus (DENV) disease is associated with extensive immune activation, characterized by a cytokine storm. Previously, elevated lipopolysaccharide (LPS) levels in dengue were found to correlate with clinical disease severity. In the present cross-sectional study we identified markers of microbial translocation and immune activation, which are associated with severe manifestations of DENV infection.Methods:Serum samples from DENV-infected patients were collected during the outbreak in 2010 in the State of São Paulo, Brazil. Levels of LPS, lipopolysaccharide binding protein (LBP), soluble CD14 (sCD14) and IgM and IgG endotoxin core antibodies were determined by ELISA. Thirty cytokines were quantified using a multiplex luminex system. Patients were classified according to the 2009 WHO classification and the occurrence of plasma leakage/shock and hemorrhage. Moreover, a (non-supervised) cluster analysis based on the expression of the quantified cytokines was applied to identify groups of patients with similar cytokine profiles. Markers of microbial translocation were linked to groups with similar clinical disease severity and clusters with similar cytokine profiles.Results:Cluster analysis indicated that LPS levels were significantly increased in patients with a profound pro-inflammatory cytokine profile. LBP and sCD14 showed significantly increased levels in patients with severe disease in the clinical classification and in patients with severe inflammation in the cluster analysis. With both the clinical classification and the cluster analysis, levels of IL-6, IL-8, sIL-2R, MCP-1, RANTES, HGF, G-CSF and EGF were associated with severe disease.Conclusions:The present study provides evidence that both microbial translocation and extensive immune activation occur during severe DENV infection and may play an important role in the pathogenesis

Changing strategies in diverticulitis

Contains fulltext : 140192.pdf (publisher's version ) (Open Access)Radboud Universiteit Nijmegen, 30 april 2015Promotores : Goor, H. van, Bleichrodt, R.P

[Diagnostic image (318). A man with a non-healing preauricular wound],Diagnose in beeld (318). Een man met een niet-genezend wondje voor het oor.

Contains fulltext : 53058.pdf (publisher's version ) (Closed access)A 23-year-old man presented with a left-sided non-healing small preauricular wound, which existed for several months after an operation for an infected suspected 'epidermal cyst'. At operation a preauricular sinus with fistula was excised

[Diagnostic image (318). A man with a non-healing preauricular wound]

A 23-year-old man presented with a left-sided non-healing small preauricular wound, which existed for several months after an operation for an infected suspected 'epidermal cyst'. At operation a preauricular sinus with fistula was excised

Reply to letter: "the role of abdominal imaging in cases with a high probability of acute left-sided colonic diverticulitis based on a clinical scoring system"

Item does not contain fulltex

[Damage control surgery in polytraumatized patients],'Damage control surgery' bij polytraumapatïenten.

Contains fulltext : 51228.pdf (publisher's version ) (Open Access)Care for the polytraumatized patient in the pre-hospital phase has improved rapidly in recent years. This has resulted in more patients being alive on arrival at the hospital. The treatment of polytraumatized patients requires a different approach to that of regular trauma patients because they are threatened not only by the injuries themselves but also by the metabolic disruptions that follow. Therefore, the concept of damage control surgery (DCS) has been developed with the primary aim of controlling the life-threatening situation without immediate definitive repair of the sustained injuries. DCS describes a triphasic approach for abdominal and thoracic injuries and for injuries of the pelvic and extremities. The first phase aims at surgical intervention to stop the bleeding and to prevent further contamination. The second phase consists of resuscitation on the Intensive Care Unit and the third phase aims at definitive repair of the sustained injuries. Despite the low level of evidence found in the literature, DCS seems to reduce mortality rates in polytraumatized patients. Therefore, when initiated correctly and at the right moment, it appears to be a promising technique

[Damage control surgery in polytraumatized patients]

Care for the polytraumatized patient in the pre-hospital phase has improved rapidly in recent years. This has resulted in more patients being alive on arrival at the hospital. The treatment of polytraumatized patients requires a different approach to that of regular trauma patients because they are threatened not only by the injuries themselves but also by the metabolic disruptions that follow. Therefore, the concept of damage control surgery (DCS) has been developed with the primary aim of controlling the life-threatening situation without immediate definitive repair of the sustained injuries. DCS describes a triphasic approach for abdominal and thoracic injuries and for injuries of the pelvic and extremities. The first phase aims at surgical intervention to stop the bleeding and to prevent further contamination. The second phase consists of resuscitation on the Intensive Care Unit and the third phase aims at definitive repair of the sustained injuries. Despite the low level of evidence found in the literature, DCS seems to reduce mortality rates in polytraumatized patients. Therefore, when initiated correctly and at the right moment, it appears to be a promising technique

How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system

Item does not contain fulltextOBJECTIVE: The aim of this study was to assess and compare the diagnostic value of elements of the disease history, physical examination, and routine laboratory tests in patients with suspected acute left-sided colonic diverticulitis (ALCD). BACKGROUND: Misdiagnosis rates for diverticulitis vary in literature between 34% and 68% which needs improvement. Because of the frequent misdiagnosis, liberal use of imaging has been recommended. Before making a plea for routine imaging, the diagnostic accuracy of different variables of disease history, physical examination, and routine laboratory tests needs to be specified. METHODS: All patients seen on the emergency department because of acute abdominal pain suspected of ALCD in whom an abdominal computed tomography was performed, between January 2002 and March 2006, were studied. Univariate logistic regression was used to study differences in patients' characteristics and symptoms, findings at physical examination and routine laboratory tests between patients with and without ALCD. Independent predictors to the risk of ALCD were identified using multivariate logistic regression and used to create a clinical scoring system. RESULTS: Of 1290 patients with acute abdominal pain, 287 patients were eligible for analysis. Acute left-sided colonic diverticulitis was the final diagnosis in 124 patients (43%). Age, 1 or more previous episodes, localization of symptoms in the lower left abdomen, aggravation of pain on movement, the absence of vomiting, localization of abdominal tenderness in the lower left abdomen, and C-reactive protein 50 or more were found to be independent predictors of ALCD. A nomogram was constructed based on these independent predictors with a diagnostic accuracy of 86%. CONCLUSIONS: This study showed that the clinical diagnosis of diverticulitis is difficult to make but can be improved using a clinical scoring system. In case of a high chance of ALCD based on the nomogram, additional imaging may not be needed

Patient-reported Outcomes After Conservative or Surgical Management of Recurrent and Chronic Complaints of Diverticulitis: Systematic Review and Meta-analysis

Item does not contain fulltextBACKGROUND & AIMS: Patients with diverticulitis develop recurrences and chronic abdominal symptoms. Recurrent diverticulitis is seldom complicated, which has led to a conservative treatment approach. However, some studies suggest that surgical intervention reduces recurrence and chronic abdominal problems. We conducted a systematic review and meta-analysis of quality of life (QOL) and other patient-reported outcomes (PROs) after conservative vs surgical treatment of uncomplicated diverticulitis. METHODS: We searched the CENTRAL, MEDLINE, EMBASE, and PsycInfo databases for randomized trials and cohort studies reporting on QOL or other PROs after conservative or operative treatment for uncomplicated diverticulitis from January 1990 through May 2014. Eight PROs were defined and graded according to their clinical relevance. Risk of bias was assessed by using the Cochrane Collaboration tool. Subgroup and sensitivity analyses were performed to test the robustness of the results. The review protocol was registered through PROSPERO (CRD42013005854). RESULTS: We analyzed data from 21 studies that comprised 1858 patients; all studies had a high risk of bias. There were no head-to-head comparisons of gastrointestinal symptoms or general QOL between elective surgical vs conservative treatment of recurrent diverticulitis. On the basis of Short-Form 36 scores, patients had higher QOL scores after elective laparoscopic resection (73.4; 95% confidence interval [CI], 65.7-81.1) than conservative treatment (58.1; 95% CI, 47.2-69.1). A lower proportion of patients had gastrointestinal symptoms after laparoscopic surgery (9%; 95% CI, 4%-14%) than conservative treatment (36%; 95% CI, 27%-45%) in all cohorts and in 1 trial comparing these treatments (odds ratio, 0.35; 95% CI, 0.16-0.7). The proportion of patients with chronic abdominal pain after elective laparoscopy was 11% (95% CI, 1%-21%) compared with 38% (95% CI, 19%-56%) after conservative treatment. CONCLUSIONS: On the basis of a systematic review and meta-analysis, patients have better QOL and fewer symptoms after laparoscopic surgery vs conservative treatment. However, studies of PROs for treatment of diverticulitis were of low quality