Preoperative prognostic factors for severe diffuse secondary peritonitis : a retrospective study

The aim of this study was to analyse preoperative risk factors for mortality or intensive care unit admission to describe severe peritonitis. This was a single academic centre retrospective study of consecutive adult patients operated for diffuse secondary peritonitis between 2012 and 2013. Patients with appendicitis or cholecystitis were excluded. Independent risk factors were identified using binary and ordinal logistic regression. A total of 223 patients were analysed. Overall 30-day mortality was 14.5 %. Postoperatively, 32.3 % of patients were admitted into the intensive care unit (ICU). Independent risk factors for severe peritonitis were septic shock (odds ratio (OR) 37.94, 95 % confidence interval (CI) 14.52-99.13), chronic kidney insufficiency (OR 5.98 (95 % CI 1.56-22.86), severe sepsis (OR 4.80, 95 % CI 2.10-10.65) and cardiovascular disease (OR 2.58, 95 % CI 1.22-5.47). Patients lacking these factors had no mortality. ICU admission was refused in 24 (10.8 %) patients with 70.8 % mortality. In a subgroup of patients without treatment limitations (n = 190), independent risk factors for weighted outcome of ICU admission or mortality were septic shock (OR 11.89, 95 % CI 4.98-28.40), severe sepsis (OR 5.56, 95 % CI 2.39-12.89), metastatic malignant disease or lymphoma (OR 3.11, 95 % CI 1.34-7.20) and corticosteroid use (OR 2.98, 95 % CI 1.18-7.51). When receiving full level of care, patients with preoperative organ dysfunctions in this subgroup had 8.2 % 30-day mortality. Preoperative organ dysfunctions, chronic kidney insufficiency and cardiovascular disease are the most important risk factors for severe peritonitis. Without these risk factors, patients had no mortality.Peer reviewe

Sekundaarinen vatsakalvotulehdus - yleisin kirurgisen sepsiksen syy : Riskipotilaiden tunnistaminen, laadukkaan hoidon kulmakivet ja avomahahoidon rooli

Vertaisarvioitu. English abstract.Sekundaarinen vatsakalvotulehdus on yleisin kirurgisesti hoidettava sepsiksen syy. Siihen liittyy merkittävä kuolemanriski, erityisesti jos potilaalle kehittyy elinhäiriöitä. Sekundaarisella vatsakalvotulehduksella tarkoitetaan maha-suolikanavan puhkeaman seurauksena syntynyttä vatsakalvotulehdusta. Riskipotilaiden varhainen tunnistaminen, viiveettä aloitettu laajakirjoinen empiirinen mikrobilääkehoito, elintoimintojen tukeminen, ripeä diagnostinen polku ja varhainen laadukas kirurgia ovat tehokkaan hoidon kulmakivet. Kroonisesti sairailla potilailla on suuri riski vaikeaan taudinkuvaan, ja hoitopäätökset tulee tehdä epäröimättä. Riskipotilaat tulee hoitaa ympärivuorokautisen päivystys-, kuvantamis-, leikkaus- ja tehohoitovalmiuden sairaaloissa. Alipainesidoksella toteutettu avomahahoito on potentiaalinen uusi hoitomuoto, mutta sen riski-hyötysuhde vaikeimmin sairaiden potilaiden hoidossa on osoittamatta. Hiljattain aloitettu kansainvälinen monikeskustutkimus on suunniteltu vastaamaan tähän kysymykseen.Peer reviewe

The role of the intra-abdominal view in complicated intra-abdominal infections

BackgroundThe prognostic role of what a surgeon observes in the abdomen of patients with complicated intra-abdominal infection (cIAI) is largely unknown. The aim of this prospective study was to systemically analyze components of the intra-abdominal view (IAV) and their association to severe complicated intra-abdominal sepsis (SCIAS) or mortality.MethodsThe study cohort consisted of adult patients with cIAI. The operating surgeon filled a paper form describing the intra-abdominal view. Demographics, operative details, and preoperative physiological status were collected. Descriptive, univariate, and multivariate statistical analyses were performed, and a new score was developed based on regression coefficients. The primary outcome was a composite outcome of SCIAS or 30-day mortality, in which SCIAS was defined as organ dysfunctions requiring intensive care unit admission.ResultsA total of 283 patients were analyzed. The primary outcome was encountered in 71 (25%) patients. In the IAV, independent risk factors for the primary outcome were fecal or bile as exudate (odds ratio (OR) 1.98, 95% confidence interval 1.05-3.73), diffuse peritonitis (OR 2.15, 1.02-4.55), diffuse substantial redness of the peritoneum (OR 5.73, 2.12-15.44), and a non-appendiceal source of cIAI (OR 11.20, 4.11-30.54). Based on these factors, an IAV score was developed and its performance analyzed. The area under the receiver operating characteristic for the IAV score was 0.81. The IAV score also correlated significantly with several outcomes and organ dysfunctions.ConclusionsThe extent of peritonitis, diffuse substantial redness of the peritoneum, type of exudate, and source of infection associate independently with SCIAS or mortality. A high IAV score associates with mortality and organ dysfunctions, yet it needs further external validation. Combining components of IAV into comprehensive scoring systems for cIAI patients may provide additional value compared to the current scoring systems.Trial registrationThe study protocol was retrospectively registered on April 4, 2016, right after the first enrolled patient at Clinicaltrials.gov database (NCT02726932).Peer reviewe

Ensimmäisen päivystyspisteen erikoisala vaikuttaa potilaan hoitotuloksiin akuutissa mesenteriaali-iskemiassa : lähetekäytäntöjen ja triagen tärkeys

Tutkimuksen tarkoitus: Äkillinen suoliston verenkiertovajaus (akuutti mesenteriaali-iskemia (AMI)) on edelleen, kehittyneistä hoitomuodoista huolimatta, korkean kuolleisuuden tauti. Yksi olennainen hoidon tuloksiin vaikuttava tekijä on viive ensimmäisestä terveydenhuollon pisteestä leikkaukseen (leikkausviive), mutta tämän viiveen syyt ovat huonosti tunnettuja. Tämän tutkimuksen tarkoitus oli etsiä viiveeseen vaikuttavia tekijöitä, erityisesti hoitoketjun osalta. Aineisto ja menetelmät: Kyseessä on retrospektiivinen tutkimus, jossa tutkittiin 2006- 2015 Meilahden sairaalassa leikattuja AMI-potilaita. Poissuljimme tutkimuksesta potilaat, joilla oli pitkäaikainen, puoliäkillinen, paksusuoleen rajoittunut, laskimoperäinen tai verisuonia tukkimaton mesenteriaali-iskemia. Potilaat jaettiin kahteen alaryhmään sen mukaan, oliko ensimmäinen terveydenhuollon piste, jonka he kohtasivat kirurginen päivystys (KP) vai ei-kirurginen päivystys (ei-KP). Ensisijainen päätemuuttuja oli leikkausviive ja toissijaiset päätemuuttujat olivat sairaalahoidon kesto ja 90-päivän kuolleisuus. Tulokset: Lopullisessa tutkimuspotilasjoukossa oli 81 potilasta. Ei-KP ensimmäisenä hoitokontaktina oli itsenäisesti yhteydessä yli 12 tunnin leikkausviiveeseen (OR 3.7 (95% luottamusväli 1.3-10.2), mediaani viive 15.2 tuntia (IQR 10.9-21.2) vs. 10.1 tuntia (IQR 6.9-18.5), p = 0.025). Sairaalahoidon kesto oli lyhyempi (mediaani 6.5 päivää (4.0-10.3) vs. 10.8 päivää (7.0-22.3), p = 0.045) ja 90-päivän kuolleisuus matalampi KP-ryhmässä (50.0% vs. 74.5%, p = 0.025). Johtopäätökset: Ensimmäinen erikoisala johon potilas lähetetään, vaikuttaa oleellisesti AMI-potilaan leikkausviiveeseen ja kuolleisuuteen. Hoitoketjun sujuvoittaminen niin, että potilas pääsee mahdollisimman nopeasti hoitoon vatsaelin- ja verisuonikirurgiseen yksikköön, voi parantaa AMI:n hoidon tuloksia. (200 sanaa

Editor's Choice – Epidemiology, Diagnostics, and Outcomes of Acute Occlusive Arterial Mesenteric Ischaemia : A Population Based Study

Publisher Copyright: © 2022 The Author(s)Objective: The exact incidence and outcomes of acute occlusive arterial mesenteric ischaemia (AMI) are unclear as most studies include only patients diagnosed correctly while alive. The aim of this study was to assess the incidence, mortality, and diagnostics of AMI by also including patients diagnosed post-mortem. Methods: This retrospective study comprised patients diagnosed with AMI either alive or post-mortem between 2006 and 2015 within a healthcare district serving 1.6 million inhabitants. Key exclusion criteria were venous or non-obstructive ischaemia. Results: A total of 470 patients were included in the study of which 137 (29%) were diagnosed post-mortem. The most common misdiagnoses on those not diagnosed alive were unspecified infection (n = 19, 17%), gastrointestinal bleeding (n = 13, 11%), and ileus (n = 13, 11%). Of those diagnosed alive (n = 333), 187 (56%) underwent active surgical or endovascular treatment. During the 2006 – 2015 period, the overall incidence of AMI was 3.05 (95% CI 2.78 – 3.34)/100 000 person years and 26.66 (95% CI 24.07 – 29.45) for those aged 70 years or more. The mean autopsy rate during the study period was 29% for the overall population (32% during 2006 – 2010 and 25% during 2011 – 2015) and 18% for those aged 70 years or more. Overall, the 90-day mortality was 83% in all patients. The ninety day mortality decreased, being 87% during the first period (2006 – 2010) and 79% during the second period (2011 – 2015) (p = .029), while at the same time the proportion of patients diagnosed alive rose from 71% to 80% (p = .030) and the number of endovascular revascularisations rose from 1% to 5% (p = .022). Conclusion: A significant proportion of patients with AMI are not diagnosed alive, which is reflected in the mortality rates. Post-mortem examinations and autopsy rate data continue to be key factors in epidemiological studies on AMI.Peer reviewe

IN VITRO INHIBITORY ACTIVITIES OF THE EXTRACT OF HIBISCUS SABDARIFFA L. (FAMILY MALVACEAE) ON SELECTED CYTOCHROME P450 ISOFORMS.

Literature is scanty on the interaction potential of Hibiscus sabdariffa L., plant extract with other drugs and the affected targets. This study was conducted to investigate the cytochrome P450 (CYP) isoforms that are inhibited by the extract of Hibiscus sabdariffa L. in vitro. The inhibition towards the major drug metabolizing CYP isoforms by the plant extract were estimated in human liver microsomal incubations, by monitoring the CYP-specific model reactions through previously validated N-in-one assay method. The ethanolic extract of Hibiscus sabdariffa showed inhibitory activities against nine selected CYP isoforms: CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1 and CYP3A4. The concentrations of the extract which produced 50% inhibition of the CYP isoforms ranged from 306 µg/ml to 1660 µg/ml, and the degree of inhibition based on the IC50 values for each CYP isoform was in the following order: CYP1A2 > CYP2C8 > CYP2D6 > CYP2B6 > CYP2E1 > CYP2C19 > CYP3A4 >> CYP2C9 >> CYP2A6. Ethanolic extract of Hibiscus sabdariffa caused inhibition of CYP isoforms in vitro. These observed inhibitions may not cause clinically significant herb-drug interactions; however, caution may need to be taken in co-administering the water extract of Hibiscus sabdariffa with other drugs until clinical studies are available to further clarify these findings

Aptitud del suelo para cultivo de mango vallenato en guacoche, departamento del cesar

The ability of the "La Estancia" farm soil in Guacoche, Cesar state, for growing Vallenato mango (Mangifera indica L.) was evaluated. One hectare of soil was sampled with 16 pits to define the modal soil profile and describe its properties. Physicochemical analysis were carried out to disturbed and not disturbed samples from each horizon under the methodology reported in the Manual No. 47 del Instituto Colombiano Agropecuario and the methodology established by the Agustín Codazzi Geographical Institute (ACGI). According to the properties and the guide of Keys to Soil Taxonomy de los Estados Unidos, the soil was classified as a Typic Dystrustepts, sandy loam mixed isohyperthermic, of medium fertility., The soil does not have limitation for salts, sodium, or aluminum; locally the soil has high water tables that can cause root rot and facilitate the loss of fertilizer with edaphic application.Se evaluó la aptitud del suelo de la Finca “La Estancia” ubicada en Guacoche, departamento del Cesar, para el cultivo de mango (Mangifera indica L.) variedad Vallenato. Se muestreó una hectárea de suelo con 16 calicatas para definir el perfil modal del suelo y describir sus propiedades. Se tomaron muestras disturbadas y no disturbadas de cada horizonte para análisis fisicoquímico según Manual No. 47 del Instituto Colombiano Agropecuario y la metodología establecida por el Instituto Geográfico Agustín Codazzi (IGAC). El suelo fue clasificado como un Typic Dystrustepts, arenoso franco mixto isohipertérmico, de mediana fertilidad, según Claves de Taxonomía de Suelos de los Estados Unidos. El suelo no tiene limitaciones por sales, sodio o aluminio; localmente presentan niveles freáticos altos que pueden ocasionar pudrición de la raíz y facilitar la pérdida de fertilizantes con aplicación edáfica

Carboxylesterase Activities and Protein Expression in Rabbit and Pig Ocular Tissues

Hydrolytic reactions constitute an important pathway of drug metabolism and a significant route of prodrug activation. Many ophthalmic drugs and prodrugs contain ester groups that greatly enhance their permeation across several hydrophobic barriers in the eye before the drugs are either metabolized or released, respectively, via hydrolysis. Thus, the development of ophthalmic drug therapy requires the thorough profiling of substrate specificities, activities, and expression levels of ocular esterases. However, such information is scant in the literature, especially for preclinical species often used in ophthalmology such as rabbits and pigs. Therefore, our aim was to generate systematic information on the activity and expression of carboxylesterases (CESs) and arylacetamide deacetylase (AADAC) in seven ocular tissue homogenates from these two species. The hydrolytic activities were measured using a generic esterase substrate (4-nitrophenyl acetate) and, in the absence of validated substrates for rabbit and pig enzymes, with selective substrates established for human CES1, CES2, and AADAC (D-luciferin methyl ester, fluorescein diacetate, procaine, and phenacetin). Kinetics and inhibition studies were conducted using these substrates and, again due to a lack of validated rabbit and pig CES inhibitors, with known inhibitors for the human enzymes. Protein expression levels were measured using quantitative targeted proteomics. Rabbit ocular tissues showed significant variability in the expression of CES1 (higher in cornea, lower in conjunctiva) and CES2 (higher in conjunctiva, lower in cornea) and a poor correlation of CES expression with hydrolytic activities. In contrast, pig tissues appear to express only CES1, and CES3 and AADAC seem to be either low or absent, respectively, in both species. The current study revealed remarkable species and tissue differences in ocular hydrolytic enzymes that can be taken into account in the design of esterase-dependent prodrugs and drug conjugates, the evaluation of ocular effects of systemic drugs, and in translational and toxicity studies.Peer reviewe

Prophylactic retrorectus mesh versus no mesh in midline emergency laparotomy closure for prevention of incisional hernia (PREEMER) : study protocol for a multicentre, double-blinded, randomized controlled trial

Background: Despite the fact that emergency midline laparotomy is a risk factor for an incisional hernia, active research on hernia prevention in emergency settings is lacking. Different kinds of meshes and mesh positions have been studied in elective abdominal surgery, but no randomized controlled trials in emergency settings have been published thus far. Method: The PREEMER trial (registration number NCT04311788) is a multicentre, patient- and assessor-blinded, randomized controlled trial to be conducted in six hospitals in Finland. A total of 244 patients will be randomized at a 1 : 1 ratio to either the retrorectus mesh group, featuring a self-gripping prophylactic mesh, or to the no mesh (control) group, both closed by small-stitch 4 : 1 closure with continuous slowly absorbable monofilament suturing. The primary outcome of the PREEMER trial is the incidence of incisional hernia 2 years after surgery, which will be detected clinically and/or radiologically. Secondary outcomes are the Comprehensive Complication Index score, incidence of surgical-site infections and fascial dehiscence within 30 days of surgery; the incisional hernia repair rate and mesh- or hernia-related reoperations within the 2- and 5-year follow-ups; the incidence of incisional hernia within the 5-year follow-up; and quality of life measured by RAND-36, the Activities Assessment Scale and the PROMIS questionnaire within 30 days and 2 and 5 years from surgery. Additionally, health-economic explorative measures will be explored. Conclusion: The PREEMER trial will provide level 1 evidence on incisional hernia prevention in an emergency setting.Peer reviewe