Short-Course Antimicrobial Therapy Does Not Increase Treatment Failure Rate in Patients with Intra-Abdominal Infection Involving Fungal Organisms.

BACKGROUND: Fungi frequently are isolated in intra-abdominal infections (IAI). The Study to Optimize Peritoneal Infection Therapy (STOP-IT) recently suggested short-course treatment for patients with IAI. It remains unclear whether the presence of fungi in IAI affects the optimal duration of Antimicrobial therapy. We hypothesized that a shorter treatment course in IAI with fungal organisms would be associated with a higher rate of treatment failure. METHODS: Patients enrolled in the STOP-IT trial were stratified according to the presence or absence of a fungal isolate. They were analyzed as a subgroup based on original randomization to either the control group or an experimental group that received a four-day course of Antimicrobial therapy and by comparison with those without a fungal component to their infection. Descriptive comparisons were performed using a χ2, Fisher exact, or Kruskal-Wallis test as appropriate. The primary outcome was a composite of recurrent IAI, surgical site infection, and death. RESULTS: A total of 411 patients in the study (79%) had available culture data, of which 58 (14%) had positive fungal cultures. The most common organisms were Candida albicans and C. glabrata. The treatment failure rate was equivalent in the experimental and control arms (29.6% vs. 22.6%; p = 0.54). Patients with fungal isolates were more likely to have malignant disease (25.9% vs. 9.6%; p = 0.0004) and coronary artery disease (22% vs. 12%; p = 0.04), but were otherwise similar to those without fungal isolates. Patients with fungal isolates had more hospital days (median 10 vs. 7; p < 0.0001) and more days to resumption of enteral intake (median 5 vs. 3; p = 0.0006), but there was no difference in the composite outcome. CONCLUSIONS: Patients with IAI involving fungal organisms randomized to a shorter course of Antimicrobial therapy had no difference in the rate of treatment failure. These results suggest that the presence of fungi in IAI may not indicate independently the need for a longer course of Antimicrobial therapy.

Closed therapy of thoracic and lumbar vertebral body fractures in trauma patients.

BACKGROUND: The failure rate for the closed/non-surgical treatment of thoracic and lumbar vertebral body fractures (TLVBF) in trauma patients has not been adequately evaluated utilizing computed tomography (CT) studies. METHODS: From 2007 to 2008, consecutive trauma patients, who met inclusion criteria, with a CT diagnosis of acute TLVBF undergoing closed treatment were assessed. The failure rates for closed therapy, at 3 months post-trauma, were defined by progressive deformity, vertebral body collapse, or symptomatic/asymptomatic pseudarthrosis. The Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification was utilized to classify the fractures (groups A1 and non-A1 fractures) and were successively followed with CT studies. RESULTS: There were 54 patients with 91 fractures included in the study; 66 were A1 fractures, and 25 were non-A1 fractures. All had rigid bracing applied with flat and upright X-ray films performed to rule out instability. None had sustained spinal cord injuries. Thirteen patients (24%) failed closed therapy [e.g. 13 failed fractures (14%) out of 91 total fractures]. Five failed radiographically only (asymptomatic), and eight failed radiographically and clinically (symptomatic). A1 fractures had a 4.5% failure rate, while non-A1 fractures failed at a rate of 40%. CONCLUSION: Failure of closed therapy for TLVBF in the trauma population is not insignificant. Non-A1 fractures had a much higher failure rate when compared to A1 fractures. We recommend close follow-up particularly of non-A1 fractures treated in closed fashion using successive CT studies.

Novel Method Suggests Global Superiority of Short-Duration Antibiotics for Intra-abdominal Infections.

Desirability of outcome ranking and response adjusted for duration of antibiotic risk (DOOR/RADAR) are novel and innovative methods of evaluating data in antibiotic trials. We analyzed data from a noninferiority trial of short-course antimicrobial therapy for intra-abdominal infection (STOP-IT), and results suggest global superiority of short-duration therapy for intra-abdominal infections.

Longer-Duration Antimicrobial Therapy Does Not Prevent Treatment Failure in High-Risk Patients with Complicated Intra-Abdominal Infections.

BACKGROUND: Recent studies have suggested the length of treatment of intra-abdominal infections (IAIs) can be shortened without detrimental effects on patient outcomes. However, data from high-risk patient populations are lacking. We hypothesized that patients at high risk for treatment failure will benefit from a longer course of antimicrobial therapy. METHODS: Patients enrolled in the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated retrospectively to identify risk factors associated with treatment failure, which was defined as the composite outcome of recurrent IAI, surgical site infection, or death. Variables were considered risk factors if there was a positive statistical association with treatment failure. Patients were then stratified according to the presence and number of these risk factors. Univariable analyses were performed using the Kruskal-Wallis, χ2, and Fisher exact tests. Logistic regression controlling for risk factors and original randomization group, either a fixed four-day antimicrobial regimen (experimental) or a longer course based on clinical response (control), also was performed. RESULTS: We identified corticosteroid use, Acute Physiology and Chronic Health Evaluation II score ≥5, hospital-acquired infection, or a colonic source of IAI as risk factors associated with treatment failure. Of the 517 patients enrolled, 263 (50.9%) had one or two risk factors and 16 (3.1%) had three or four risk factors. The rate of treatment failure rose as the number of risk factors increased. When controlling for randomization group, the presence and number of risk factors were independently associated with treatment failure, but the duration of antimicrobial therapy was not. CONCLUSIONS: We were able to identify patients at high risk for treatment failure in the STOP-IT trial. Such patients did not benefit from a longer course of antibiotic administration. Further study is needed to determine the optimum duration of antimicrobial therapy in high-risk patients.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection.

BACKGROUND: Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS: Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS: This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY: The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

Surgical Infection Society Curriculum Development Symposium: An Overview.

Hospital-acquired infections, sepsis, and critically ill patients cost the healthcare system billions of dollars every year. Many factors contribute to these problems, and the remedies are multifactorial. Education is an important component in resolving many of the issues related to better combating the economic, social, and personal costs associated with surgical infections. The Surgical Infection Society (SIS) convened a symposium to begin a dialogue on how the SIS can facilitate a better understanding of how to educate the surgical infection professionals and trainees. The following report summarizes the presentations and commentary presented at the 2013 Annual Meeting.

Patients with Risk Factors for Complications Do Not Require Longer Antimicrobial Therapy for Complicated Intra-Abdominal Infection.

A prospective, multicenter, randomized controlled trial found that four days of antibiotics for source-controlled complicated intra-abdominal infection resulted in similar outcomes when compared with a longer duration. We hypothesized that patients with specific risk factors for complications also had similar outcomes. Short-course patients with obesity, diabetes, or Acute Physiology and Chronic Health Evaluation II ≥15 from the STOP-IT trial were compared with longer duration patients. Outcomes included incidence of and days to infectious complications, mortality, and length of stay. Obese and diabetic patients had similar incidences of and days to surgical site infection, recurrent intra-abdominal infection, extra-abdominal infection, and Clostridium difficile infection. Short- and long-course patients had similar incidences of complications among patients with Acute Physiology and Chronic Health Evaluation II ≥15. However, there were fewer days to the diagnosis of surgical site infection (9.5 ± 3.4 vs 21.6 ± 6.2, P = 0.010) and extra-abdominal infection (12.4 ± 6.9 vs 21.8 ± 6.1, P = 0.029) in the short-course group. Mortality and length of stay was similar for all groups. A short course of antibiotics in complicated intra-abdominal infection with source control seems to have similar outcomes to a longer course in patients with diabetes, obesity, or increased severity of illness.

Inclusion of Vancomycin as Part of Broad-Spectrum Coverage Does Not Improve Outcomes in Patients with Intra-Abdominal Infections: A Post Hoc Analysis.

BACKGROUND: Management of complicated intra-abdominal infections (cIAIs) includes broad-spectrum antimicrobial coverage and commonly includes vancomycin for the empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA). Ideally, culture-guided de-escalation follows to promote robust antimicrobial stewardship. This study assessed the impact and necessity of vancomycin in cIAI treatment regimens. PATIENTS AND METHODS: A post hoc analysis of the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial was performed. Patients receiving piperacillin-tazobactam (P/T) and/or a carbapenem were included with categorization based on use of vancomycin. Univariate and multivariable analyses evaluated effects of including vancomycin on individual and the composite of undesirable outcomes (recurrent IAI, surgical site infection [SSI], or death). RESULTS: The study cohort included 344 patients with 110 (32%) patients receiving vancomycin. Isolation of MRSA occurred in only eight (2.3%) patients. Vancomycin use was associated with a similar composite outcome, 29.1%, vs. no vancomycin, 22.2% (p = 0.17). Patients receiving vancomycin had (mean [standard deviation]) higher Acute Physiology and Chronic Health Evaluation II scores (13.1 [6.6] vs. 9.4 [5.7], p < 0.0001), extended length of stay (12.6 [10.2] vs. 8.6 [8.0] d, p < 0.001), and prolonged antibiotic courses (9.1 [8.0] vs. 7.1 [4.9] d, p = 0.02). After risk adjustment in a multivariate model, no significant difference existed for the measured outcomes. CONCLUSIONS: This post hoc analysis reveals that addition of vancomycin occurred in nearly one third of patients and more often in sicker patients. Despite this selection bias, no appreciable differences in undesired outcomes were demonstrated, suggesting limited utility for adding vancomycin to cIAI treatment regimens.

Does Self-Assessment Improve the Effectiveness of Grand Rounds Lectures in a Community-Based Teaching Hospital?

OBJECTIVE: To determine whether use of self-assessment (SA) questions affects the effectiveness of weekly didactic grand rounds presentations. DESIGN: From 26 consecutive grand rounds presentations from August 2013 to April 2014, a 52-question multiple-choice test was administered based on 2 questions from each presentation. SETTING: Community teaching institution. PARTICIPANTS: General surgery residents, students, and attending physicians. RESULTS: The test was administered to 66 participants. The mean score was 41.8%. There was no difference in test score based on experience with similar scores for junior residents, senior residents, and attending surgeons (43%, 46%, and 44%; p = 0.13). Most participants felt they would be most interested in presentations directly related to their surgical specialty. Participants, however, did not score differently on topics which were the focus of the program (40% vs. 42%; p = 0.85). Journal club presentations (39% vs. others 42%; p = 0.33) also did not affect the score. The Pearson correlation coefficient for attendance was 0.49 (p < 0.0001) demonstrated that attendance was very important. Participation in the weekly SA was significantly associated with improved score as those who participated in SA scored over 20% higher than those who did not (59% vs. 38%; p < 0.0001). Based on multiple linear regression for mean score, SA explained the variation in score more than attendance. CONCLUSIONS: The current study found that without preparation approximately 40% of material presented is retained after 10 months. Participation in weekly SA significantly improved retention of information from grand rounds presentations.

Obesity Is Not Associated with Antimicrobial Treatment Failure for Intra-Abdominal Infection.

BACKGROUND: Obesity and commonly associated comorbidities are known risk factors for the development of infections. However, the intensity and duration of antimicrobial treatment are rarely conditioned on body mass index (BMI). In particular, the influence of obesity on failure of antimicrobial treatment for intra-abdominal infection (IAI) remains unknown. We hypothesized that obesity is associated with recurrent infectious complications in patients treated for IAI. METHODS: Five hundred eighteen patients randomized to treatment in the Surgical Infection Society Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated. Patients were stratified by obese (BMI ≥30) versus non-obese (BMI≥30) status. Descriptive comparisons were performed using Chi-square test, Fisher exact test, or Wilcoxon rank-sum tests as appropriate. Multivariable logistic regression using a priori selected variables was performed to assess the independent association between obesity and treatment failure in patients with IAI. RESULTS: Overall, 198 (38.3%) of patients were obese (BMI ≥30) versus 319 (61.7%) who were non-obese. Mean antibiotic d and total hospital d were similar between both groups. Unadjusted outcomes of surgical site infection (9.1% vs. 6.9%, p = 0.36), recurrent intra-abdominal infection (16.2% vs. 13.8, p = 0.46), death (1.0% vs. 0.9%, p = 1.0), and a composite of all complications (25.3% vs. 19.8%, p = 0.14) were also similar between both groups. After controlling for appropriate demographics, comorbidities, severity of illness, treatment group, and duration of antimicrobial therapy, obesity was not independently associated with treatment failure (c-statistic: 0.64). CONCLUSIONS: Obesity is not associated with antimicrobial treatment failure among patients with IAI. These results suggest that obesity may not independently influence the need for longer duration of antimicrobial therapy in treatment of IAI versus non-obese patients.

Patients with Complicated Intra-Abdominal Infection Presenting with Sepsis Do Not Require Longer Duration of Antimicrobial Therapy.

BACKGROUND: A recent prospective, multicenter, randomized controlled trial found that 4 days of antibiotics after source control of complicated intra-abdominal infections resulted in similar outcomes when compared with longer duration. We hypothesized that the subset of patients presenting with sepsis have similar outcomes when treated with the shorter course of antibiotics. STUDY DESIGN: Patients from the STOP-IT (Study to Optimize Peritoneal Infection Therapy) trial database meeting criteria for sepsis (ie, temperature <36°C or >38°C and a WBC count <4000 cells/mm(3) or >12,000 cells/mm(3)) were analyzed. Patients had been randomized to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 calendar days of therapy (n = 45), or to receive a fixed short-course of antibiotics for 4 ± 1 calendar days (n = 67). Outcomes included incidence of and time to surgical site infection, recurrent intra-abdominal infection, Clostridium difficile infection, and extra-abdominal infections, as well as hospital days and mortality. RESULTS: One hundred and twelve of the 588 patients in the STOP-IT database met criteria for sepsis and were adherent to the protocol. With regard to short- vs long-course therapy, surgical site infection (11.9% vs 8.9%; p = 0.759), recurrent intra-abdominal infection (11.9% vs 13.3%; p = 1.00), extra-abdominal infection (11.9% vs 8.9%; p = 0.759), hospital days (7.4 ± 5.5 days vs 9.0 ± 7.5 days; p = 0.188), days to recurrent intra-abdominal infection (12.5 ± 6.6 days vs 18.0 ± 8.1 days; p = 0.185), days to extra-abdominal infection (12.6 ± 5.8 days vs 17.3 ± 3.9 days; p = 0.194), and mortality (1.5% vs 0%; p = 1.00) were similar. There were no cases of C difficile infection. Days to surgical site infection (6.9 ± 3.5 days vs 21.3 ± 6.1 days; p < 0.001) were fewer in the 4-day therapy group. CONCLUSIONS: There was no difference in outcomes between short and long-course antimicrobial therapy in patients with complicated intra-abdominal infection presenting with sepsis. Our findings suggest that the presence of systemic illness does not mandate a longer antimicrobial course if source control of complicated intra-abdominal infection is obtained.

Do Polymicrobial Intra-Abdominal Infections Have Worse Outcomes than Monomicrobial Intra-Abdominal Infections?

BACKGROUND: Numerous studies have demonstrated microorganism interaction through signaling molecules, some of which are recognized by other bacterial species. This interspecies synergy can prove detrimental to the human host in polymicrobial infections. We hypothesized that polymicrobial intra-abdominal infections (IAI) have worse outcomes than monomicrobial infections. METHODS: Data from the Study to Optimize Peritoneal Infection Therapy (STOP-IT), a prospective, multicenter, randomized controlled trial, were reviewed for all occurrences of IAI having culture results available. Patients in STOP-IT had been randomized to receive four days of antibiotics vs. antibiotics until two days after clinical symptom resolution. Patients with polymicrobial and monomicrobial infections were compared by univariable analysis using the Wilcoxon rank sum, χ(2), and Fisher exact tests. RESULTS: Culture results were available for 336 of 518 patients (65%). The durations of antibiotic therapy in polymicrobial (n = 225) and monomicrobial IAI (n = 111) were equal (p = 0.78). Univariable analysis demonstrated similar demographics in the two populations. The 37 patients (11%) with inflammatory bowel disease were more likely to have polymicrobial IAI (p = 0.05). Polymicrobial infections were not associated with a higher risk of surgical site infection, recurrent IAI, or death. CONCLUSION: Contrary to our hypothesis, polymicrobial IAI do not have worse outcomes than monomicrobial infections. These results suggest polymicrobial IAI can be treated the same as monomicrobial IAI.

Trial of short-course antimicrobial therapy for intraabdominal infection.

BACKGROUND: The successful treatment of intraabdominal infection requires a combination of anatomical source control and antibiotics. The appropriate duration of antimicrobial therapy remains unclear. METHODS: We randomly assigned 518 patients with complicated intraabdominal infection and adequate source control to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 days of therapy (control group), or to receive a fixed course of antibiotics (experimental group) for 4±1 calendar days. The primary outcome was a composite of surgical-site infection, recurrent intraabdominal infection, or death within 30 days after the index source-control procedure, according to treatment group. Secondary outcomes included the duration of therapy and rates of subsequent infections. RESULTS: Surgical-site infection, recurrent intraabdominal infection, or death occurred in 56 of 257 patients in the experimental group (21.8%), as compared with 58 of 260 patients in the control group (22.3%) (absolute difference, -0.5 percentage point; 95% confidence interval [CI], -7.0 to 8.0; P=0.92). The median duration of antibiotic therapy was 4.0 days (interquartile range, 4.0 to 5.0) in the experimental group, as compared with 8.0 days (interquartile range, 5.0 to 10.0) in the control group (absolute difference, -4.0 days; 95% CI, -4.7 to -3.3; P<0.001). No significant between-group differences were found in the individual rates of the components of the primary outcome or in other secondary outcomes. CONCLUSIONS: In patients with intraabdominal infections who had undergone an adequate source-control procedure, the outcomes after fixed-duration antibiotic therapy (approximately 4 days) were similar to those after a longer course of antibiotics (approximately 8 days) that extended until after the resolution of physiological abnormalities. (Funded by the National Institutes of Health; STOP-IT ClinicalTrials.gov number, NCT00657566.).

Management of idiopathic granulomatous mastitis with observation.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is becoming more commonly recognized and reported more often. Currently, many recommend corticosteroids in its management. METHODS: A retrospective chart review was conducted from January 2002 to June 2013. Data were collected regarding sociodemographic information, clinical history, treatment, and outcomes. RESULTS: Thirty-seven patients were found with IGM. Thirty-five patients were Hispanic born outside the United States. Early in the time period reviewed, 5 patients had masses excised and 5 patients were lost to follow-up. Twenty-seven cases of IGM resolved with observation. Corticosteroids were not used in the management. The average time to resolution was 7.4 months. Three patients (11%) had recurrent episodes after resolution. CONCLUSIONS: IGM is a self-limited benign condition that will resolve spontaneously without treatment. Patience with the natural history of IGM is important, as the process often includes periods of exacerbation before resolution.

Temporal resolution of idiopathic granulomatous mastitis with resumption of bromocriptine therapy for prolactinoma.

INTRODUCTION: Idiopathic granulomatous mastitis (IGM) is becoming more commonly recognized and reported more often. Currently, many recommend corticosteroids in its management. PRESENTATION OF CASE: A 34-year-old G3P2 Hispanic female, 28 weeks pregnant, presented with a 19cm right breast mass. She had a known prolactinoma treated with bromocriptine which was discontinued during her pregnancy. Ultrasound guided core biopsy procedure revealed granulomatous mastitis. The patient was told that the mass would resolve with observation. The patient seen at another institution by an infectious disease specialist who started treatment with amphotericin for presumptive disseminated coccidioidomycosis. Repeated titers were negative for coccidioides antibody. Repeat cultures were negative as well. Due to the persistence of the infectious disease specialist, tissue cultures were performed on fresh tissue specimens, which did not grow bacterial, fungal, nor acid fast organisms. The amphotericin regimen resulted in no improvement of her breast mass after 10 weeks. Within two weeks of stopping the antifungal therapy, however, the mass diminished to 6cm. The patient delivered at 39 weeks. Bromocriptine was restarted, and within 4 weeks, the lesion was no longer palpable. She had not shown signs of recurrence for 32 months. DISCUSSION: Treatment recommendations for IGM vary widely but antibiotics and antifungal medications are not recommended. Corticosteroid treatment is most commonly recommended, however, outcomes may not be different from management with observation. Prolactin may be involved in the pathophysiology of the process. CONCLUSION: IGM is becoming recognized more frequently. Observation and patience with natural history can be an effective management.

The effect of an evidence-based medicine curriculum on breast cancer knowledge and satisfaction of surgical residents.

OBJECTIVE: The current study was performed to determine if evidence-based medicine (EBM) curriculum would affect education of surgical residents. DESIGN: A 5-year prospective study was designed to determine if EBM curriculum could improve residents' satisfaction and understanding of breast cancer management during a breast surgical oncology rotation. During the first 2 years, 45 journal articles were used. During the subsequent 3 years, journal articles were not used. The proportion of patients seen in clinic was collected as an objective measure of the "effort" made by the resident. The final assessment was a 120-question examination. SETTING: Maricopa Medical Center, Phoenix, AZ. Safety net institution with General Surgery residency program. PARTICIPANTS: Postgraduate year 2 general surgery residents. RESULTS: Over 5 years, 30 postgraduate year 2 residents were involved. Univariate analysis showed that female sex (p = 0.04), residents with peer-reviewed publications (p = 0.03), younger age (p = 0.04), American Board of Surgery in-service training examination score (p = 0.01), and clinical effort (p < 0.01) were associated with higher scores. Although residents taught using the journal articles scored 7 points higher on the final examination, this was not significant (p = 0.10). Multivariate analysis showed that American Board of Surgery in-service training examination score and clinic efficiency remained statistically significant. Residents who were taught using the EBM curriculum had significantly higher satisfaction (4.4 vs 3.5, p = 0.001) compared with those who did not go through the EBM curriculum. CONCLUSIONS: The current study demonstrates that an EBM curriculum significantly improved resident satisfaction with the rotation. The EBM curriculum may improve residents' breast cancer knowledge. The most important predictor of resident performance was the effort of resident.

Predictive Value of Nutritional Markers for Wound Healing Complications in Bariatric Patients Undergoing Panniculectomy.

BACKGROUND: Hypoproteinemia and nutritional deficiencies are common after bariatric surgery, and although massive weight loss (MWL) patients experience increased wound complication rates, the association has not been causatively determined. OBJECTIVES: This study investigated preoperative nutritional parameters and wound complications in MWL patients (postbariatric and diet-controlled) undergoing panniculectomy at 2 academic institutions. METHODS: One hundred sixty-one consecutive patients undergoing elective panniculectomy after bariatric surgery or diet-controlled weight loss were identified. Patient demographics and nutritional indices (serum protein, albumin, and micronutrient levels) were analyzed. Complications including wound separation, infection, and operative debridements were compared. Post hoc comparisons tested for correlation between complications and nutritional markers. RESULTS: Postbariatric patients lost an average of 151 lb and presented at an average of 32 months after gastric bypass. Diet-controlled weight loss patients lost an average of 124 lb. Despite MWL, albumin levels were higher in the bariatric group (3.8 vs 3.4 g/dL, P < 0.05). Conversely, bariatric patients experienced increased wound complications (27% vs 14%; P < 0.05). Factors which were found to correlate to increased risk of wound dehiscence and infection were elevated body mass index at time of panniculectomy and amount of tissue removed. Multivariate analysis did not show serum albumin or percent weight loss to independently predict complications. CONCLUSIONS: Bariatric patients presenting for elective operations are at risk for protein and micronutrient deficiency. Despite aggressive replacement and normalization of nutritional markers, bariatric patients experience increased wound complications when compared to nonbariatric patients and traditional measures of nutritional evaluation for surgery may be insufficient in bariatric patients.

Intra-abdominal Infections.

Intra-abdominal infections are multifactorial, but all require prompt identification, diagnosis, and treatment. Resuscitation, early antibiotic administration, and source control are crucial. Antibiotic administration should initially be broad spectrum and target the most likely pathogens. When cultures are available, antibiotics should be narrowed and limited in duration. The method of source control depends on the anatomic site, site accessibility, and the patient's clinical condition. Patient-specific factors (advanced age and chronic medical conditions) as well as disease-specific factors (health care-associated infections and inability to obtain source control) combine to affect patient morbidity and mortality.

Local BLyS production by T follicular cells mediates retention of high affinity B cells during affinity maturation.

We have assessed the role of B lymphocyte stimulator (BLyS) and its receptors in the germinal center (GC) reaction and affinity maturation. Despite ample BLyS retention on B cells in follicular (FO) regions, the GC microenvironment lacks substantial BLyS. This reflects IL-21-mediated down-regulation of the BLyS receptor TACI (transmembrane activator and calcium modulator and cyclophilin ligand interactor) on GC B cells, thus limiting their capacity for BLyS binding and retention. Within the GC, FO helper T cells (TFH cells) provide a local source of BLyS. Whereas T cell-derived BLyS is dispensable for normal GC cellularity and somatic hypermutation, it is required for the efficient selection of high affinity GC B cell clones. These findings suggest that during affinity maturation, high affinity clones rely on TFH-derived BLyS for their persistence.