Serum biomarkers to differentiate Gram-negative, Gram-positive and fungal infection in febrile patients.

Introduction. Contamination of specimens and overuse of broad spectrum antibiotics contribute to false positives and false negatives, respectively. Therefore, useful and applicable biomarkers of bacteremia are still required.Hypothesis/Gap Statement. IL-6 can be used as a serum biomarker to discriminate among bacterial infections and fungal infections in febrile patients with a bloodstream infection.Aim. We aimed to evaluate the diagnostic efficiency of neutrophil/lymphocyte ratio (NLR), procalcitonin (PCT) and interleukin-6 (IL-6) in discriminating Gram-negative (G-) bacteria from Gram-positive (G+) bacteria and fungi in febrile patients.Methodology. A total of 567 patients with fever were evaluated. Serum levels of IL-6, PCT, NLR and CRP were compared among a G- group (n=188), a G+ group (n=168), a fungal group (n=38) and a culture negative group (n=173). Sensitivity, specificity, Yuden's index and area under the Receiver operating characteristic (ROC) curve (AUC) were obtained to analyse the diagnostic abilities of these biomarkers in discriminating bloodstream infection caused by different pathogens.Results. Serum IL-6 and PCT in the G- group increased significantly when compared with both the G+ group and fungal group (P <0.05). AUC of IL-6 (0.767, 95 % CI:0.725-0.805) is higher than AUC of PCT (0.751, 95 % CI:0.708-0.796) in discriminating the G- group from G+ group. When discriminating the G- group from fungal group, the AUC of IL-6 (0.695, 95 % CI:0.651-0.747) with a cut-off value of 464.3 pg ml-1 was also higher than the AUC of PCT (0.630, 95 % CI:0.585-0.688) with a cut-off value of 0.68 ng ml-1. Additionally, AUC of NLR (0.685, 95 % CI:0.646-0.727) in discriminating the fungal group from G+ group at the cut-off value of 9.03, was higher than AUC of IL-6, PCT and CRP.Conclusion. This study suggests that IL-6 could be used as a serum biomarker to discriminate among bacterial infections and fungal infections in febrile patients with a bloodstream infection. In addition, NLR is valuable to discriminate fungal infections from Gram-positive infections in febrile patients with a bloodstream infection.

Open necrosectomy combined with continuous positive drainage and prophylactic diverting loop ileostomy for late infected pancreatic necrosis: a retrospective cohort study.

BACKGROUND: To evaluate an innovative open necrosectomy strategy with continuous positive drainage and prophylactic diverting loop ileostomy for the management of late infected pancreatic necrosis (LIPN). METHODS: Consecutive patients were divided into open necrosectomy (ON) group (n = 23), open necrosectomy with colonic segment resection (ON+CSR) group (n = 8) and open necrosectomy with prophylactic diverting loop ileostomy (ON+PDLI) group (n = 11). Continuous positive drainage (CPD) via double-lumen irrigation-suction tube (DLIST) was performed in ON+PDLI group. The primary endpoints were duration of organ failure after surgery, postoperative complication, the rate of re-surgery and mortality. The secondary endpoints were duration of hospitalization, cost, time interval between open surgery and total enteral nutrition (TEN). RESULTS: The recovery time of organ function in ON+PDLI group was shorter than that in other two groups. Colonic complications occurred in 13 patients (56.5%) in the ON group and 3 patients (27.3%) in the ON+PDLI group (p = 0.11). The length of stay in the ON+PDLI group was shorter than the ON group (p = 0.001). The hospitalization cost in the ON+PDLI group was less than the ON group (p = 0.0052). CONCLUSION: ON+PDLI can avoid the intestinal dysfunction, re-ileostomy, the resection of innocent colon and reduce the intraoperative trauma. Despite being of colonic complications before or during operation, CPD + PDLI may show superior effectiveness, safety, and convenience in LIPN.

Method for Establishing Continuous Reinfusion of Succus Entericus in Complex High-output Fistula.

To establish a continuous reinfusion of succus entericus and enteral nutrition (EN) in complex high-output fistula (HOF). Percutaneous puncture and catheterization technique was used to establish continuous reinfusion of succus entericus and EN in complex HOF. From May 2010 to June 2018, 21 patients with complex HOF used continuous reinfusion of succus entericus and EN. Six of them were completely cured, and 15 cases were cured after definitive surgery. Percutaneous puncture and catheterization technique was shown to be a useful and effective method for establishing continuous reinfusion of succus entericus and EN in patients with complex HOF. This method can prevent succus entericus loss and remove the barrier to implementing EN in HOF.

A technique to establish fistuloclysis for high-output jejunocutaneous fistula through percutaneous enterostomy: A case report.

RATIONALE: Currently, fistucolysis helps to establish intestinal nutrition and succus entericus reinfusion in the case of controllable mature high-output enterocutaneous fistula. However, if the tube cannot reach the distal limb of a fistula, fistuloclysis is not achieved. We proposed a strategy to establish succus entericus reinfusion for intractable intestinal fistula through percutaneous enterostomy. PATIENT CONCERNS: A 43-year-old man was transferred to our facility for postoperative enterocutaneous fistulae, sepsis, malnutrition, and electrolyte and fluid imbalance. The contrast X-ray demonstrated the breakdown of the primary anastomosis, with fistula output ranging from 1500 to 2000 mL/d, despite the administration of medications to reduce gastrointestinal secretions. DIAGNOSES: The patient was diagnosed with high-output anastomosis fistula by gastrointestinal radiography. INTERVENTIONS: We used percutaneous enterostomy to establish fistuloclysis. OUTCOMES: Fistuloclysis was established by percutaneous enterostomy successfully. No complications were found during the past 4-month follow-up after percutaneous enterostomy. He is waiting for reconstruction surgery after 6 months' enteral nutrition (EN). LESSONS: Fistuloclysis-assisted EN, if used appropriately, avoids the complications of long-term parenteral nutrition (PN) and may promote faster fistula healing.

Benefits of a circular approach to mobilize the thyroid during an endoscopic thyroidectomy.

BACKGROUND: Mobilization of the thyroid during an endoscopic thyroidectomy (ET) via a breast approach was originally carried out from the lower pole to the upper pole (upward approach). Here, we applied a modified circular approach to achieve better exposure of the surgical field, in which the path of thyroid mobilization started from the isthmus and resembled a circle. The purpose of this study is to evaluate the safety and feasibility of the circular approach compared with the upward approach. PATIENTS AND METHODS: From December 2008 to June 2013, 144 patients who underwent attempted ET via a breast approach were enrolled in this study, and their clinical outcomes were evaluated. RESULTS: In total, 141 of 144 procedures were successfully performed under endoscopy, including 60 (42.6%) via the upward approach and 81 (57.4%) via the circular approach. The mean operating time was significantly shorter in the circular approach group than in the upward approach group (90.6 minutes versus 112.5 minutes for hemithyroidectomy; 109.5 minutes versus 133.2 minutes for subtotal thyroidectomy; P<.05). Furthermore, the incidence of the transient recurrent laryngeal nerve palsy decreased in the circular approach group compared with the upward approach group (2.5% versus 13.3%; P<.05). CONCLUSIONS: These results seem to indicate that the circular approach is a better method of mobilizing the thyroid, especially for large nodules located in the lower pole of the thyroid. This approach may provide a better view of the surgical field, reduced operating times, and fewer postoperative complications.

Modified physiological and operative score for the enumeration of mortality and morbidity risk assessment model in general surgery.

AIM: To establish a scoring system for predicting the incidence of postoperative complications and mortality in general surgery based on the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM), and to evaluate its efficacy. METHODS: Eighty-four patients with postoperative complications or death and 172 patients without postoperative complications, who underwent surgery in our department during the previous 2 years, were retrospectively analyzed by logistic regression. Fifteen indexes were investigated including age, cardiovascular function, respiratory function, blood test results, endocrine function, central nervous system function, hepatic function, renal function, nutritional status, extent of operative trauma, and course of anesthesia. Modified POSSUM (M-POSSUM) was developed using significant risk factors with its efficacy evaluated. RESULTS: The significant risk factors were found to be age, cardiovascular function, respiratory function, hepatic function, renal function, blood test results, endocrine function, nutritional status, duration of operation, intraoperative blood loss, and course of anesthesia. These factors were all included in the scoring system. There were significant differences in the scores between the patients with and without postoperative complications, between the patients died and survived with complications, and between the patients died and survived without complications. The receiver operating characteristic curves showed that the M-POSSUM could accurately predict postoperative complications and mortality. CONCLUSION: M-POSSUM correlates well with postoperative complications and mortality, and is more accurate than POSSUM.

Intestinal barrier damage caused by trauma and lipopolysaccharide.

AIM: To investigate the intestinal barrier function damage induced by trauma and infection in rats. METHODS: Experimental models of surgical trauma and infection were established in rats. Adult Sprague-Dawley rats were divided into 4 groups: control group (n = 8), EN group (n = 10), PN group (n = 9) and Sep group (n = 8). The rats in PN and Sep groups were made into PN models that received isonitrogenous, isocaloric and isovolumic TPN solution during the 7-d period. Rats in EN and Sep groups received laparotomy and cervical catheterization on day 1 and received lipopolysaccharide injection intraperitoneally on d 7. On the 7(th) day all the animals were gavaged with lactulose and mannitol to test the intestinal permeability. Twenty-four hours later samples were collected and examined. RESULTS: The inflammatory responses became gradually aggravated from EN group to Sep group. The mucosal structure of small intestine was markedly impaired in PN and Sep groups. There was a low response in IgA level in Sep group when compared with that of EN group. Lipopolysaccharide injection also increased the nitric oxide levels in the plasma of the rats. The intestinal permeability and bacterial translocation increased significantly in Sep group compared with that of control group. CONCLUSION: One wk of parenteral nutrition causes an atrophy of the intestinal mucosa and results in a moderate inflammatory reaction in the rats. Endotoxemia aggravates the inflammatory responses that caused by laparotomy plus TPN, increases the production of nitric oxide in the body, and damages the intestinal barrier function.

Intestinal failure: pathophysiological elements and clinical diseases.

There are two main functions of gastrointestinal tract, digestion and absorption, and barrier function. The latter has an important defensive effect, which keeps the body away from the invading and damaging of bacteria and endotoxin. It maintains the systemic homeostasis. Intestinal dysfunction would happen when body suffers from diseases or harmful stimulations. The lesser dysfunction of GI tract manifests only disorder of digestion and absorption, whereas the more serious intestinal disorders would harm the intestinal protective mechanism, or intestinal barrier function, and bacterial/endotoxin translocation, of intestinal failure (IF) would ensue. This review discussed the theory of the intestinal failure, aiming at attracting recognition and valuable comments by clinicians.

Prophylactic treatment with growth hormone improves intestinal barrier function and alleviates bacterial translocation in stressed rats.

BACKGROUND: Damage to the gut barrier often occurs during critical illnesses. In such cases, it is very important to alleviate impairment of the intestinal barrier and protect intestinal barrier function. This study investigated the protective effect of growth hormone on intestinal barrier function in rats under stress. METHODS: This study consisted of prospective, randomized, and controlled animal experiments. Twenty-five Sprague-Dawley rats served as total parenteral nutrition (TPN) models and were divided into three groups: TPN group, sepsis (Sep) group, and growth hormone (GH) group. Another 8 rats served as normal controls. Each group received different stress stimuli. Rats were fed for 7 days, and samples were taken for examination 24 hours after gavaging with dual saccharides. RESULTS: The architecture of the small intestinal mucosa in the Sep group showed the most severe damage among all groups. Nitric oxide levels in blood plasma and immunoglobulin A levels in the intestinal mucosa of the GH group were significantly lower than in the Sep group (P < 0.02). There were no significant changes in CD3 counts and in the CD4/CD8 ratio between the four groups. Dual sugar tests and bacteriological examinations revealed that intestinal permeability and rate of bacterial translocation in the GH group were lower than in the Sep group (P < 0.01, respectively). CONCLUSION: Prophylactic treatment with growth hormone can alleviate damage to intestinal barrier function caused by trauma and endotoxemia in rats under stress.

Gut in diseases: physiological elements and their clinical significance.

The intestinal barrier function of GI tract is very important in the body except for the function of digestion and absorption. The functional status of gut barrier basically reflects the stress severity when body suffers from trauma and various stimulations. Many harmful factors such as drugs, illnesses, trauma and burns can damage the gut barrier, which can lead to the barrier dysfunction and bacterial/endotoxin translocation. The paper discusses and reviews the concepts, anatomy, pathophysiology of gut barrier and its clinical relations.

Effects of glutamine on intestinal permeability and bacterial translocation in TPN-rats with endotoxemia.

AIM: To evaluate the protective effect and mechanism of glutamine on the intestinal barrier function in total parenteral nutrition (TPN) rats with trauma or endotoxemia. METHODS: To perform prospective, randomized and controlled animal experimentation of rats with surgical trauma, TPN and endotoxemia, thirty-four male, adult Sprague Dawley rats were divided into four groups: control group (n=8), TPN group (n=9), trauma and endotoxemia group (LPS, n=8) and trauma plus endotoxemia supplemented with glutamine in TPN solution group (Gln.group, n=9). All groups except the control group were given TPN solutions in 7-day experimental period. For Gln group, 1 000 mg/kg/d of glutamine was added to TPN solution during day 1-6. On the 7(th) day all the animals were gavaged with lactulose (66 mg) and mannitol (50 mg) in 2 ml of normal saline. Then 24 h urine with preservative was collected and kept at -20 degrees. On day 8, under intra-peritoneal anesthesia using 100 mg/kg ketamin, the intestine, liver, mesenteric lymph nodes and blood were taken for examination. RESULTS: The body weight of LPS group decreased most among the four groups. The structure of small intestinal mucosa in TPN group, LPS group and Gln group showed impairments of different degrees, and the damage of small intestinal mucosa in Gln group was remarkably alleviated. The concentrations of interleukins in small intestine mucosa were lower (for IL-4 and IL-6) or the lowest (IL-10) in Gln group. The IgA level in the blood plasma and the mucosa of Gln group was the highest among all of the groups. The urine lactulose/mannitol test showed that the intestinal permeability in LPS group was lower than that in TPN group (P<0.001), but there was no difference between LPS group and Gln group. The rate of bacterial translocation in Gln group was lower than that in LPS group (P<0.02). CONCLUSION: Prophylactic treatment with glutamine could minimize the increments of intestinal permeability and bacterial translocation caused by trauma and endotoxemia in rats treated with TPN.