The Role of Procalcitonin in Predicting Failure of Non-operative Management in Bowel Obstructions.

Procalcitonin has been investigated as a marker for bowel ischemia. This study examined the role of procalcitonin in predicting failure of non-operative management (NOM) in bowel obstructions. Patients with bowel obstructions at a single center from August 2022 to January 2023 were prospectively enrolled (n = 79). Lactic acid (LA) and procalcitonin were collected after surgical consultation. The primary outcome was success or failure of NOM. Univariate analysis, multivariable logistic regression, and performance measures of procalcitonin and LA in predicting bowel ischemia was performed. Of 79 patients included, 48 (61%) required operative intervention during index admission. There were no significant differences in demographics, comorbidities, procalcitonin, nor LA between groups. Time from last bowel movement was associated with failure of NOM (OR 1.03 [95% CI 1.01-1.06]; P = .008), though initial procalcitonin or LA was not. Procalcitonin >.3 ng/mL had acceptable sensitivity in screening for bowel ischemia.

Divergent Pathways of Ammonia and Urea Production and Excretion during the Life Cycle of the Sea Lamprey.

Little is known about nitrogenous waste (N waste) handling and excretion (JN waste) during the complex life cycle of the sea lamprey (Petromyzon marinus), an extant jawless fish that undergoes a complete metamorphosis from a filter-feeding larva (ammocoete) into a parasitic juvenile that feeds on the blood of larger, jawed fishes. Here, we investigate the ammonia- and urea-handling profiles of sea lampreys before, during, and after metamorphosis. The rates of ammonia excretion (Jamm) and urea excretion (Jurea) significantly decreased after the onset of metamorphosis, with the lowest rates observed during midmetamorphosis. Near the completion of metamorphosis, rates of JN waste (JN waste=Jamm+Jurea) significantly increased as sea lampreys entered the juvenile period. Feeding juvenile lampreys had greater than 10- to 15-fold higher Jamm and fivefold higher Jurea compared to nonfed juveniles, which corresponded to higher postprandial (postfeeding) concentrations of plasma ammonia and urea. The routes of Jamm and Jurea completely diverged following metamorphosis. In larvae, Jamm was equally split between branchial (gills) and extrabranchial (skin plus renal) pathways, but following metamorphosis, >80% of ammonia was excreted via the gills in nonfeeding juvenile lampreys, and >95% of ammonia was excreted via the gills in adult sea lampreys. Urea, on the other hand, was predominantly excreted via extrabranchial routes and, to a lesser extent, the gills in larvae and in nonfeeding juveniles. In adults, however, virtually all urea was excreted via urine. Reverse transcription polymerase chain reaction and in silico analyses also indicated that a urea transporter encoded by a slc4a2-like gene is present in lampreys. The branchial expression of this transporter is modulated throughout sea lamprey life history, as it is higher in the larvae and steadily decreases until the adult stage. We conclude that the divergent pathways of Jamm and Jurea during the sea lamprey life cycle reflect changes in their habitat, lifestyle, and diet. Further, the near-complete reliance on renal routes for Jurea in adult sea lampreys is unique among fishes and may reflect the ancestral condition of how this N waste product was handled and excreted by the earliest vertebrates.

A Retrospective Cohort Analysis of the Use of Enteral Nutrition Plus Pharmacologic Prophylaxis or Enteral Nutrition Alone.

Background: Due to the risk of development of stress ulcers in intensive care unit (ICU) patients, pharmacologic prophylaxis is often utilized. However, some literature describes the use of enteral nutrition instead as stress ulcer prophylaxis. Methods: The purpose of this study is to determine if enteral nutrition is similar to pharmacologic stress ulcer prophylaxis (SUP) with enteral nutrition for reduction of gastrointestinal (GI) bleeding, perforation, or ulceration in ICU patients. This was a retrospective, single-center cohort study that took place at an academic medical center. Adult ICU patients receiving enteral nutrition who had a risk factor for stress-related mucosal damage were included. The primary outcome was the incidence of GI bleeding, perforation, or ulcer formation. Results: Overall, 167 patients were included in the study, 147 in the pharmacologic prophylaxis plus EN group (PPEN) and 20 in the enteral therapy only (EN) group. Of 167 patients included, 22 patients (21 in the PPEN group and 1 in the EN group) developed a primary outcome of GI bleeding, perforation, or ulceration (14.3% vs 5%, P = .4781). Patients in the PPEN group had a higher incidence of pneumonia (42.2% vs 15%, P = .0194), but no difference was seen between groups when patients with pneumonia present on admission were excluded (20.6% vs 10.5%, P = .5254). Conclusion: In this small cohort of patients, enteral nutrition alone is as effective as pharmacologic therapy in addition to enteral nutrition for the reduction of stress-related GI bleeding, perforation, and ulceration.

Contrast-Induced Nephropathy in Ischemic Stroke Patients Undergoing Computed Tomography Angiography: CINISter Study.

GOAL: Computed tomography angiography (CTA) is a well-tolerated, noninvasive study of the intracranial vascular circulation; however, contrast-induced nephropathy (CIN) has been reported in 5%-7% of patients undergoing CTA. Limited studies have evaluated the risks of CIN in patients undergoing CTA. Our study was designed to evaluate the prevalence and risk factors for CIN in patients with ischemic stroke who receive a CTA. MATERIALS AND METHODS: Single-center, nested, case-control study of patients with ischemic stroke who received a CTA between June 18, 2012 and January 1, 2016. Patients were grouped based on development of CIN. FINDINGS: A total of 209 patients were included in the final analysis (178 controls, 31 cases). The prevalence of CIN during the time period studied was 14.8% (95% confidence interval [CI]: 10.2-20.2). A higher proportion of patients who developed CIN had a history of diabetes mellitus (37 [20.56%] versus 15 [48.39%]; P = .0009) and reported taking no medications prior to admission (35 [19.44%] versus 11 [35.48%]; P = .0458). However, a lower proportion of patients who developed CIN had a history of smoking (59 [32.78] versus 3 [9.68]; P = .0091). After statistical adjustment, only a history of diabetes (odds ratio [OR] 4.15 [95% CI: 1.765, 9.754), taking no medications prior to admission (OR 3.56 [95% CI: 1.417, 8.941]) and a self-reported history of smoking (OR 0.204 [95% CI: 0.057, 0.721]) remained associated with the development of CIN. CONCLUSIONS: Those patients with a history of diabetes mellitus or not taking medications prior to admission should be monitored closely for the development of contrast-induced nephropathy CIN.

Activated Prothrombin Complex Concentrate versus Plasma for Reversal of Warfarin-Associated Hemorrhage.

STUDY OBJECTIVE: To evaluate the efficacy and safety of an activated four-factor prothrombin complex concentrate (aPCC) versus plasma for the reversal of warfarin-associated hemorrhage. DESIGN: Single-center, retrospective cohort analysis of adult patients with warfarin-associated hemorrhage treated with either aPCC or plasma. PATIENTS: Patients received either aPCC or plasma as treatment for warfarin-associated hemorrhage between January 1, 2011, and July 1, 2013. Patients with missing data points were excluded from the final analysis. Of the 276 patients included in the final analysis, 128 received aPCC and 148 received plasma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Those patients who received aPCC achieved a lower posttreatment INR (1.1 [0.1] vs 1.6 [0.5]; p<0.05). In addition, patients who received aPCC had a 4.3 times higher odds of achieving an INR of less than 1.4 (97 [75.8%] vs 65 [43.9%]; p<0.05; odds ratio [OR] = 4.3 [95% confidence interval (CI) 2.6-7.3]). When controlling for vitamin K administration, history of diabetes mellitus, receipt of the recommended reversal agent dose, and pretreatment INR, aPCC administration remained an independent predictor for achieving an international normalized ratio (INR) of less than 1.4 in the first 24 hours after treatment (OR = 3.75 [95% CI 2.11-6.65]; p<0.001). In addition, there was no statistical difference between the groups with regard to occurrences of infusion reaction, pulmonary embolism, deep vein thrombosis, stroke, or myocardial infarction. CONCLUSIONS: Compared with patients who received plasma, patients who received aPCC achieved a lower posttreatment INR, had a larger INR change, and were more likely to achieve an INR less than the prespecified goal. Those patients who received aPCC did not have a higher incidence of thromboembolic events.