Sensitivity analyses of probabilistic and deterministic DTI tractography methodologies for studying arm muscle architecture.

PURPOSE: To determine the sensitivity profiles of probabilistic and deterministic DTI tractography methods in estimating geometric properties in arm muscle anatomy. METHODS: Spin-echo diffusion-weighted MR images were acquired in the dominant arm of 10 participants. Both deterministic and probabilistic tractography were performed in two different muscle architectures of the parallel-structured biceps brachii (and the pennate-structured flexor carpi ulnaris. Muscle fascicle geometry estimates and number of fascicles were evaluated with respect to tractography turning angle, polynomial fitting order, and SNR. The DTI tractography estimated fascicle lengths were compared with measurements obtained from conventional cadaveric dissection and ultrasound modalities. RESULTS: The probabilistic method generally estimated fascicle lengths closer to ranges reported by conventional methods than the deterministic method, most evident in the biceps brachii (p > 0.05), consisting of longer, arc-like fascicles. For both methods, a wide turning angle (50º-90°) generated fascicle lengths that were in close agreement with conventional methods, most evident in the flexor carpi ulnaris (p > 0.05), consisting of shorter, feather-like fascicles. The probabilistic approach produced at least two times more fascicles than the deterministic approach. For both approaches, second-order fitting yielded about double the complete tracts as third-order fitting. In both muscles, as SNR decreased, deterministic tractography produced less fascicles but consistent geometry (p > 0.05), whereas probabilistic tractography produced a consistent number but altered geometry of fascicles (p < 0.001). CONCLUSION: Findings from this study provide best practice recommendations for implementing DTI tractography in skeletal muscle and will inform future in vivo studies of healthy and pathological muscle structure.

The Oral Microbiome and Cross-Kingdom Interactions during Pregnancy.

Pregnancy initiates a temporary transition in the maternal physiological state, with a shift in the oral microbiome and a potential increase in frequency of oral diseases. The risk of oral disease is higher among populations of Hispanic and Black women and those with lower socioeconomic status (low SES), demonstrating a need for intervention within these high-risk populations. To further our understanding of the oral microbiome of high-risk pregnant women, we characterized the oral microbiome in 28 nonpregnant and 179 pregnant low-SES women during their third trimester living in Rochester, New York. Unstimulated saliva and supragingival plaque samples were collected cross-sectionally, followed by assessment of the bacterial (16S ribosomal RNA) and fungal (18S ITS) microbiota communities. Trained and calibrated dentists performed oral examinations to determine the number of decayed teeth and plaque index. Initially, plaque from 28 nonpregnant women and 48 pregnant women were compared; these data showed significant differences in bacterial abundances based on pregnancy status. To further our understanding of the oral microbiome within the pregnant population, we next examined the oral microbiome within this population based on several variables. Streptococcus mutans, Streptococcus oralis, and Lactobacillus were associated with a greater number of decayed teeth. The composition of fungal communities differed between plaque and saliva, demonstrating 2 distinct "mycotypes" that were represented by a greater abundance of Candida in plaque and Malassezia in saliva. Veillonella rogosae, a common oral bacterium, was negatively associated with both plaque index and salivary Candida albicans colonization by culture data. This was further emphasized by in vitro inhibition of C. albicans by V. rogosae. Identification of interactions between the bacterial or fungal oral communities revealed that V. rogosae was positively associated with the oral commensal Streptococcus australis and negatively with the cariogenic Lactobacillus genus, suggesting V. rogosae as a potential biomarker of a noncariogenic oral microbiome.

Respiratory microbiome profiles are associated with distinct inflammatory phenotype and lung function in children with asthma.

BACKGROUND: Respiratory microbiome studies have fostered our understanding of various phenotypes and endotypes of heterogeneous asthma. However, the relationship between the respiratory microbiome and clinical phenotypes in children with asthma remains unclear. We aimed to identify microbiome-driven clusters reflecting the clinical features of asthma and their dominant microbiotas in children with asthma. METHODS: Induced sputum was collected from children with asthma, and microbiome profiles were generated via sequencing of the V3-V4 region of the 16S rRNA gene. Cluster analysis was performed using the partitioning around medoid clustering method. The dominant microbiota in each cluster was determined using the Linear Discriminant Effect Size analysis. Each cluster was analyzed for association among the dominant microbiota, clinical phenotype, and inflammatory cytokine. RESULTS: Eighty-three children diagnosed with asthma were evaluated. Among four clusters reflecting the clinical characteristics of asthma, cluster 1, dominated by Haemophilus and Neisseria, demonstrated lower post-bronchodilator (BD) forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) than that in the other clusters and more mixed granulocytic asthma. Neisseria negatively correlated with pre-BD and post-BD FEV1/FVC. Haemophilus and Neisseria positively correlated with programmed death-ligand (PD-L)1. CONCLUSION: To our knowledge, this study is the first to analyze the relationship between an unbiased microbiome-driven cluster and clinical phenotype in children with asthma. The cluster dominated by Haemophilus and Neisseria showed fixed airflow obstruction and mixed granulocytic asthma, which correlated with PD-L1 levels. Thus, microbiome-driven unbiased clustering can help identify new asthma phenotypes related to endotypes in childhood asthma.

Stretch reflex gain scaling at the shoulder varies with synergistic muscle activity.

The unique anatomy of the shoulder allows for expansive mobility but also sometimes precarious stability. It has long been suggested that stretch-sensitive reflexes contribute to maintaining joint stability through feedback control, but little is known about how stretch-sensitive reflexes are coordinated between the muscles of the shoulder. The purpose of this study was to investigate the coordination of stretch reflexes in shoulder muscles elicited by rotations of the glenohumeral joint. We hypothesized that stretch reflexes are sensitive to not only a given muscle's background activity but also the aggregate activity of all muscles crossing the shoulder based on the different groupings of muscles required to actuate the shoulder in three rotational degrees of freedom. We examined the relationship between a muscle's background activity and its reflex response in eight shoulder muscles by applying rotational perturbations while participants produced voluntary isometric torques. We found that this relationship, defined as gain scaling, differed at both short and long latencies based on the direction of voluntary torque generated by the participant. Therefore, gain scaling differed based on the aggregate of muscles that were active, not just the background activity in the muscle within which the reflex was measured. Across all muscles, the consideration of torque-dependent gain scaling improved model fits (ΔR2) by 0.17 ± 0.12. Modulation was most evident when volitional torques and perturbation directions were aligned along the same measurement axis, suggesting a functional role in resisting perturbations among synergists while maintaining task performance.NEW & NOTEWORTHY Careful coordination of muscles crossing the shoulder is needed to maintain the delicate balance between the joint's mobility and stability. We provide experimental evidence that stretch reflexes within shoulder muscles are modulated based on the aggregate activity of muscles crossing the joint, not just the activity of the muscle in which the reflex is elicited. Our results reflect coordination through neural coupling that may help maintain shoulder stability during encounters with environmental perturbations.

Experimentally quantifying the feasible torque space of the human shoulder.

Daily tasks rely on our ability to generate multi-dimensional shoulder torques. When function is limited, strength assessments are used to identify impairments and guide treatment. However, these assessments are often one-dimensional and limited in their sensitivity to diagnose shoulder pathology. To address these limitations, we have proposed novel metrics to quantify shoulder torque capacity in all directions. To quantify the feasible torque space of the shoulder, we measured maximal volitional shoulder torques in 32 unique directions and fit an ellipsoid model to these data. This ellipsoid model was used to quantify overall strength magnitude, strength balance, and the directions in which participants were strongest and weakest. We used these metrics to characterize three-dimensional shoulder strength in healthy adults and demonstrated their repeatability across days. Finally, using musculoskeletal simulations, we showed that our proposed metrics can distinguish between changes in muscle strength associated with aging or rotator cuff tears and quantified the influence of altered experimental conditions on this diagnostic capacity. Our results demonstrate that the proposed metrics can robustly quantify the feasible torque space of the shoulder and may provide a clinically useful description of the functional capacity of the shoulder in health and disease.

[Prosthetics after construction of the outer genitalia for transmen]. / Prothetik nach Genitalaufbau bei Transmännern.

BACKGROUND: Growing awareness of gender identity issues and a rising prevalence of female-to-male transsexualism is increasing demand for surgical solutions that deliver both aesthetically and functionally satisfying outer genitalia for transmen. OBJECTIVE: This article summarizes the available prosthetic options, describes different surgical approaches and reviews the outcome of prosthetics for transmen with a focus on penile prosthesis in phalloplasty. METHODS: Current international standards of care, reviews and original publications are critically reviewed and correlated with our own experience with more than 400 transmen at two interdisciplinary referral centres in Frankfurt, Germany and London, UK. RESULTS: Despite of a wide range of different phalloplasty techniques and prosthetic types, the currently most used technique is implantation of a three-piece, inflatable penile prosthesis in a radial-free-flap phalloplasty. There is still an ongoing debate about the number of implanted penile prosthesis cylinders, the use of customised corporoplasty-windsocks for the cylinder(s), and the location for the placement of the reservoir. At present there is only one penile prosthesis design for use in phalloplasties and long-term results are still pending. CONCLUSION: There is still no ideal implant available for the use in phalloplasties. The current literature does not provide evidence-based treatment algorithms, which is also due to a lack of prospective randomised studies and validated measurement tools for the postoperative outcome. Initial data for the first transmen-specific penile prosthesis as well as an increase of transgender studies might lead to an improvement of treatment and the quality-of-life of the affected transmen.

EcoSun Pass: A tool to evaluate the ecofriendliness of UV filters used in sunscreen products.

OBJECTIVE: Sunscreens play a major role in the EU sun protection strategy in order to prevent humans from UV light-induced skin damage. In recent years, the demand for high-quality sunscreen products including aspects of broad range and photostability of the UV protection, showing good spreadability onto human skin and excellent sensorial properties during and after application has increased. Environmental aspects are considered. Sunscreens are complex compositions, with UV filters being the key element in the formulations reaching up to about 30% in content in the final product. Some of these ingredients, however, may be regarded as hazardous for the aquatic environment. Nevertheless, the aquatic ecosystem represents only a single environmental compartment, which may be impacted by UV filters. Therefore, the EcoSun Pass (ESP) tool was developed in order to assess the overall environmental impact of UV filters in combination with its efficacy (Sun Protection Factor, SPF and UVA Protection Factor, UVA-PF). METHODS: For that purpose, at first 24 of the EU-approved UV filters for sunscreen applications were evaluated for their environmental hazard profiles. Nine example UV filter compositions representing both SPF 30 and 50 were evaluated for ecofriendliness using the ESP tool. RESULTS: The results revealed that two out of four SPF 30 compositions are considered as ecofriendly. Likewise, from the SPF 50 two out of five did meet the criteria for ecofriendliness. Furthermore, the results showed that most ecofriendly example formulations have also the lowest overall UV filter content in the product, based on the use of highly innovative and least hazardous UV filters. CONCLUSION: These results demonstrate that the tool is applicable to various formulations being present on the market and thus allows for a selection of most ecofriendly and efficient UV filters to be used in sunscreens.

OBJECTIF: les écrans solaires jouent un rôle majeur dans la stratégie de protection solaire de l'UE, afin de protéger les êtres humains contre les lésions cutanées causées par les rayons ultraviolets. Au cours des dernières années, la demande pour des écrans solaires de haute qualité a augmenté, notamment ceux ayant une bonne capacité d'étalement sur la peau humaine, d'excellentes propriétés sensorielles pendant et après l'application, une plage large et démontrant la photostabilité de la protection anti-UV. Les aspects environnementaux sont pris en compte. Les écrans solaires ont des compositions complexes, les filtres UV étant l'élément clé des formulations, avec une présence jusqu'à près de 30 % dans le contenu du produit final. Toutefois, certains de ces ingrédients peuvent être considérés comme dangereux pour l'environnement aquatique. Néanmoins, l'écosystème aquatique ne représente qu'un seul compartiment environnemental pouvant être affecté par les filtres UV. Par conséquent, l'outil EcoSun Pass (ESP) a été développé afin d'évaluer l'impact environnemental global des filtres UV, ainsi que leur efficacité (facteur de protection solaire, FPS et facteur de protection UV-A, UVAPF). MÉTHODES: dans ce but, les profils de risque environnemental de 24 des filtres UV approuvés dans l'UE, pour les applications d'écran solaire, ont d'abord été évalués. Le respect de l'environnement de neuf exemples de compositions de filtres UV, représentant les FPS 30 et 50, a été évalué à l'aide de l'outil ESP. RÉSULTATS: les résultats ont révélé que deux des quatre compositions de FPS 30 sont considérées comme écologiques. De même, deux écrans solaires sur cinq ayant un indice FPS 50 répondaient aux critères de respect de l'environnement. De plus, les résultats ont montré que la plupart des exemples de formulations écologiques contiennent également la plus faible teneur globale en filtres UV ; elles sont basées sur l'utilisation de filtres UV hautement innovants et les moins dangereux. CONCLUSION: ces résultats démontrent que l'outil est applicable à diverses formulations présentes sur le marché, et qu'il permet donc d'utiliser une sélection des filtres UV les plus écologiques et efficaces dans les écrans solaires.

[Gender reassignment surgery from male to female]. / Geschlechtsangleichung von Mann zu Frau.

For many trans*women, the surgical assignment of the male genital into a female is a fundamental part of the transition. Erogenous sensation of the neoclitoris is achieved by meticulous preparation of the penile glans with the neurovascular bundle. Several techniques are available for the formation of a neovagina, the penile inversion technique developed by Burou in the 1950s being the gold standard. With this technique, the inverted penile shaft skin is used as a pedicled flap to line the neovaginal canal. Alternatively, free skin grafts can be used, which serve primarily as a technique for redo procedures. Another technique is the use of intestinal segments to line the vaginal canal. This method is mostly used for redo procedures, but can also be performed primarily if penile skin is too small. Due to the numerous steps involved in the preparation, a wide variety of complications must be expected. Injury to the rectum during dissection of the neovaginal space, with an incidence of 4.5%, represents the greatest challenge. The most common complications are urethra-associated; hereby both a deviation of the urinary stream and strictures of the urethra are possible. The subjective satisfaction of trans*women with the surgical outcome is high and is reported in various studies to be 72-92%. On the basis of validated questionnaires it could also be shown that gender reassignment surgery leads to an increase in the trans*specific quality of life and promotes both subjectively perceived well-being and sexual satisfaction.

[Gender reassignment from female to male : Phalloplasty]. / Geschlechtsangleichung von Frau zu Mann : Phallusplastik.

BACKGROUND: The increasing prevalence of gender dysphoria necessitates an evaluation of the literature of phalloplasty techniques for female to male transgender individuals. OBJECTIVE: The following article provides an overview of the current surgical concepts and complications of phalloplasty, associated urethrogenitoplasty and the implantation of prostheses in phalloplasty. MATERIAL AND METHODS: Current international reviews and original publications from 2010 to 2020 were reviewed and correlated with our referral center experience with more than 350 female to male transgender patients over the last 25 years. RESULTS: Free radial forearm flap phalloplasty is the most widely used technique, followed by an anterolateral thigh flap (ALT flap) and pedicled or microsurgical transplantation. Hydraulic multicomponent prostheses are given preference and supplementary surgical techniques, such as scrotoplasty and glans sculpturing can make sense or be necessary. The complication rates after phalloplasty and after insertion of penile prostheses are substantial. Nevertheless, the overall patient reported satisfaction rate in the majority of studies is often over 80%. CONCLUSION: Due to the increasing prevalence of gender dysphoria there is currently a need for interdisciplinary referral centers for gender reassignment surgery. A certain standardization of surgical techniques and timing would be desirable but a review of the current literature shows a high heterogeneity so that this cannot be derived from the currently available literature. It is hoped that the recently founded S2K guideline committee on operative treatment of gender dysphoria under the auspices of the German Society for Urology and the Society for Plastic and Reconstructive Surgery can report an initial collection of experiences in 2021.

[Microsurgical penile reconstruction in case of intersexuality and after penis carcinoma]. / Mikrochirurgische Penisrekonstruktion bei Intersexualität und nach Peniskarzinom.

BACKGROUND: The goals of penile reconstruction and phalloplasty include aesthetics as natural as possible and the ability of patients to void while standing and to have sexual intercourse. This article presents two more rare indications and techniques, the phalloplasty using free radial forearm flapin case of intersexuality and after penectomy due to penis carcinoma. PATIENTS AND METHODS: In transsexual individuals numerous phalloplasties in Gottlieb and Levine`s technique, by means phalloplasty of free radial forearm-flap of the non-dominant forearm, were performed in our department over the last few years. However, this technique also has its significance for phalloplasty in non-transgender persons.Two patients are considered in detail with regard to indication and surgical technique and were followed up in a multimodal setting.Patient 1 is genetically male, thirty-five years old with a micropenis in the case of pseudohermaphroditism masculine and androgen resistance.Patient 2 is a fifty-one-year old genetically male and as a result of a penis carcinoma his penis had to be amputated at the level of penis root. After absence of recurrence for 1,5 years, the penile reconstruction took place after complete resection of the remaining residual penile stump and corpora cavernosa. Both patients underwent multimodal follow-up 15 months postoperatively with regard to phalloplasty sensors and donor-site restrictions. RESULTS: An aesthetic and functional acceptable result could be obtained for both patients. Both patients are able to void while standing. The multimodal follow-up 15 months postoperatively revealed relevant differences in the sensory findings of both patients, which are due to the different anatomy of reinnervation. CONCLUSION: In microsurgical experienced departments, the technique of A. radialis phalloplasty can also be used successfully in more rare indications, as shown here, a satisfying result can be achieved in terms of function and aesthetics. The complications shown here do not differ from those using phalloplasty in transgender persons.

Coprescription of opioid and naloxone in office-based practice and emergency department settings in the United States.

OBJECTIVES: The objective of the study was to estimate the national rates of naloxone coprescribing with opioids in office-based practice and emergency department (ED) settings in the United States (US). STUDY DESIGN: This study is a cross-sectional study. METHODS: We used the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets to estimate the national rates of naloxone coprescribing with opioids for the period 2014-2016. The analysis was stratified into office-based practice and ED settings. In ED settings, opioid and naloxone could be given to patients while they were in ED or as a prescription at discharge. Patients of all ages were considered for the analysis and sampling weights were applied to estimate national rates. RESULTS: In office-based settings, 7918 sample visits included one or more opioid prescriptions (10.67 per 100 office visits). Of those, one included naloxone as a coprescription. In ED settings, the opioid prescription was given at discharge in 6124 sample visits (9.68 per 100 ED visits). Of those, two included naloxone as a coprescription. On the other hand, opioid was given to patients in the ED in 8811 sample visits (13.57 per 100 ED visits). Of those, 30 included naloxone as a coprescription. CONCLUSIONS: The rates of naloxone coprescribing with opioids were extremely low in office-based and ED settings in the US. Expanding access to naloxone is a key component of the public health response to the opioid crisis. Based on our study findings, promoting the coprescription of naloxone with opioids may provide greater access to naloxone for those who are at risk of opioid overdose.

Effects of kinematic complexity and number of muscles on musculoskeletal model robustness to muscle dysfunction.

The robustness of motor outputs to muscle dysfunction has been investigated using musculoskeletal modeling, but with conflicting results owing to differences in model complexity and motor tasks. Our objective was to systematically study how the number of kinematic degrees of freedom, and the number of independent muscle actuators alter the robustness of motor output to muscle dysfunction. We took a detailed musculoskeletal model of the human leg and systematically varied the model complexity to create six models with either 3 or 7 kinematic degrees of freedom and either 14, 26, or 43 muscle actuators. We tested the redundancy of each model by quantifying the reduction in sagittal plane feasible force set area when a single muscle was removed. The robustness of feasible force set area to the loss of any single muscle, i.e. general single muscle loss increased with the number of independent muscles and decreased with the number of kinematic degrees of freedom, with the robust area varying from 1% and 52% of the intact feasible force set area. The maximum sensitivity of the feasible force set to the loss of any single muscle varied from 75% to 26% of the intact feasible force set area as the number of muscles increased. Additionally, the ranges of feasible muscle activation for maximum force production were largely unconstrained in many cases, indicating ample musculoskeletal redundancy even for maximal forces. We propose that ratio of muscles to kinematic degrees of freedom can be used as a rule of thumb for estimating musculoskeletal redundancy in both simulated and real biomechanical systems.

Patient perception and approval of faecal microbiota transplantation (FMT) as an alternative treatment option for obesity.

INTRODUCTION: Fecal microbiota transplantation (FMT) represents a treatment option for some diseases, e.g. recurring Clostridium difficile-associated colitis. However, there is also evidence that FMT can be effective in treating obesity. This pilot study established the approval and willingness of obese patients to undergo FMT. METHODS: We conducted a survey of adults with obesity using a questionnaire containing 21 both multiple choice and open questions was dispatched to a cohort of 101 persons with obesity. It included questions aiming at the process of FMT itself, donors as well as possible concerns. Additionally aspects of social background and disease activity were dealt with. RESULTS: The response rate amounted to 30.1% (n = 31). In our population, mean BMI was 40.5 kg/m2 while the vast majority already tried out treatment modalities to lose weight before. 25.8% of persons with obesity were aware of FMT. 62.1% were willing to undergo FMT if the donor was healthy and anonymous while only 6.9% clearly refused this option. Sixty preferred an anonymous donor or a person proposed by their doctor while colonoscopy was the preferred application by 76.7%. The absence of risks of the procedure (47.8%) formed the principal motivation while reduction of medication was considered as least important reason (in 26.1). Insufficient testing of the faeces concerning infections raised the most concerns (in 61.6%). CONCLUSION: For the majority of the persons with obesity surveyed FMT represents a treatment option. Approximately two thirds of the questionees would consider FMT as an alternative treatment option, even in spite of a satisfactory disease response to current standard therapies. Unsurprisingly there are concerns in regard to the transmission of possible infectious agents as well as to the hygieneic implementation of FMT itself.

[Reconstructive surgery in penile cancer]. / Rekonstruktive Operationen beim Peniskarzinom.

BACKGROUND: Due to the rising incidence of penile cancer and increasing life expectancy in western nations, the current international guidelines recommend a less aggressive surgical approach with reduced safety margins and preferably with organ preservation. OBJECTIVES: The goal of this review is to review the current data on stage-dependent reconstructive surgical techniques and their oncological and functional results. MATERIALS AND METHODS: Five recently published reviews and several single studies and publications on the topic of organ-sparing surgical techniques and penile reconstruction were evaluated to draw conclusions for surgery in penile cancer. RESULTS: Due to the rare incidence of penile cancer and the absence of comparative, prospective studies in the literature, evidence levels of the actual statements and conclusions are low. CONCLUSIONS: Organ-sparing techniques in penile cancer lead to slightly elevated local recurrence rates compared with traditional partial or total penile amputation. Thus, sufficient patient compliance is mandatory and an intensified follow-up for more than the usual 5 years postoperatively is required. On the other hand, these techniques enable the surgeon to offer improved functional and esthetic outcomes to the patient, maintaining erectile capacity and sensitivity. After extended partial or total penile amputation, penile reconstruction using free radial forearm flaps with later prosthetic implantation may be offered to younger and sexually active patients in cooperation with experienced plastic surgeons, even if the previously published case numbers do not permit standardization of these procedures.

Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome.

PURPOSE: Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery. METHODS: Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48 h later. Therein, decision for definite reconstruction (anastomosis or Hartmann's procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed. RESULTS: Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p = 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p = 0.001), and increased operation time (105 vs. 84 min., p = 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p < 0.001). Complication rate (44 vs. 24%, p = 0.092), mortality (12 vs. 0%, p = 0.061), overall number of surgeries (3.4 vs. 2.4, p = 0.017), enterostomy rate (76 vs. 36%, p = 0.001), and length of hospital stay (25 vs. 18.8 days, p = 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p = 0.005) and with fungal infection (100 vs. 49%, p = 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p < 0.001), enterostomy rate (81 vs. 48%, p = 0.017), and anastomotic leakage (29 vs. 6%, p = 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p = 0.014). CONCLUSION: Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.