[Hemobilia as a sign of arterio-biliary fistula]. / Gemobiliya kak proyavlenie arteriobiliarnoi fistuly.

Hepatic artery aneurysms (HAA) are rare (20% of all visceral arteries). Most often, HAAs are asymptomatic and detected at autopsy. However, their ruptures and/or bleeding following pressure ulcers in visceral gastrointestinal organs are a significant clinical and diagnostic problem. We present 2 patients with obstructive jaundice and hemobilia. Diagnostics revealed aneurysm of the right hepatic artery with arterio-biliary fistula. Life-threatening hemobilia is a consequence of HAA rupture into biliary system. Endovascular approach is preferable for HAA without clinical manifestations. Awareness of this disease is important for early detection and active surgical intervention before possible complications.

[18F-fluorodeoxyglucose PET/CT in the diagnosis of vascular graft infection]. / Vozmozhnosti PET/KT S 18F-ftordezoksiglyukozoi v diagnostike infektsii sosudistykh protezov.

OBJECTIVE: To investigate diagnostic role of 18F-fluorodeoxyglucose PET/CT in patients with suspected vascular graft (VG) infection. MATERIAL AND METHODS: A prospective analysis included data of 30 PET/CT examinations for suspected infection of aortic VG (n=27) and bypass grafts (n=3) after surgical treatment (median 48 months). In 77% (23/30) of cases, the diagnosis was initially «possible¼ (n=11) or «rejected¼ (n=12) in accordance with common diagnostic criteria. All PET/CT results were verified by clinical, laboratory and intraoperative («=20) data. VG infection was confirmed in 18 patients and ruled out in 12 cases. RESULTS: PET/CT confirmed VG infection in 94% (17/18) and excluded in 50% (6/12) of cases. False PET/CT results were obtained in 23% (7/30) cases: false positive in 6 cases and false negative in 1 case. Thus, sensitivity, specificity and diagnostic accuracy of PET/CT were 94%, 50% and 77%, respectively; positive and negative predictive value - 74% and 86%. PET/CT results allowed correct reclassifying 33% (10/30) of cases. VG infection was confirmed in 73% (8/11) of patients with initially «possible¼ diagnosis and excluded in 17% (2/12) of patients with initially «rejected¼ infection. Moreover, whole body PET/CT revealed unknown inflammation foci outside VG in 73% (22/30) of cases. These data were applied to correct treatment approach in 80% (24/30) of cases. CONCLUSION: Our results showed high efficacy of 18F-fluorodeoxyglucose PET/CT in the diagnosis of VG infection. Despite low specificity, this technique has high sensitivity and accuracy that allowed reclassifying 33% of cases.

[THE NEW CONCEPT OF COMBINED USE OF EXTRACORPOREAL BLOOD CORRECTION IN COMPLEX INTENSIVE THERAPY OF SEVERE SEPSIS IN PATIENTS AFTER CARDIAC SURGERY].

OBJECTIVE: Clinical and laboratory evaluation of the safety and efficacy of combined application of LPS selective adsorption (using cartridges with immobilized polymyxin B on fibers) and plasma filtration and adsorption (CPFA) in patients with severe sepsis after surgery on the heart and blood vessels. MATERIAL AND METHODS: The study involved 40 adult patients with severe sepsis after cardiac surgery. Group I included 20 patients who received the combined therapy with LPS-selective adsorption and CPFA in a single circuit. The control group 2 consisted of 20 patients who received the standard complex intensive therapy of sepsis. Inclusion criteria were clinical and laboratory indices of sepsis (FAA endotoxin activity level above 0.6; procalcitonin 2 ng/ml). RESULTS: Patients in Group I had an increase in mean aerial pressure by 12% (p = 0.001), the oxygenation index of 36% (p = 0.004), leukocytosis reduction (p = 0.01) and a significant decrease in body temperature (p = 0.0001). We also registered declines of FAA endotoxin activity by 35% (p = 0.0003) and Procalcitonin by 55% (p = 0.005). Patients of the control group had no significant change in the level of white blood cells, procalcitonin, and temperature. 28-day survival rate was 65 and 35% in the 1st and 2nd groups, respectively (p = 0.11). CONCLUSION: Combination of LPS adsorption and CPFA in a single extracorporeal circuit in the complex intensive therapy is a safe and effective treatment of severe sepsis.

[Structural Polymorphism of Genome Islands Encoding Resistance to Beta-Lactams in Coagulase-Negative Staphylococci Isolated at Hospitals of the Russian Federation].

Coagulase-negative staphylococci (CoNS) are considered as a reservoir of mobile genetic elements and first of all of the staphylococcal cassette chromosome mec (SCCmec), defining staphylococci resistance to beta-lactams. Types II, IV, IVa, V, VII and VIII SCCmec were detected among 95 staphylococcal strains isolated in different regions of the Russian Federation. Subtypes C1a, C1b, C1c and C1 SCCmec were also identified (class B mec complex and two complexes of ccr1 and ccr2 genes recombinases). Some other cassette types carrying A, C1 and C2 classes of the mec complexes in combination with various recombinase genes were detected. The S.epidermidis isolates mainly formed cassettes carrying mec complex B, while the S. haemolyticus isolates had cassettes carrying classes C1 and C2 mec complex. Out of 9 isolates of S. hominis 5 isolates carried a new type cassette: class A mec complex in combination with the complex of the recombinase ccr1 genes. SCCmec was not identified in S. capitis and S. pasteuri. Their representatives carried either mec complex (1 isolate of S. pasteuri) or the recombinase complexes (2 isolates of S. capitis). The detected SCCmec variants in CoNS could be a source of emergence of new genetic lines of MRSA.

[EXPRESS IDENTIFICATION OF POSITIVE BLOOD CULTURES USING DIRECT MALDI-TOF MASS SPECTROMETRY].

OBJECTIVE: To evaluate the effectiveness of direct identification of pathogens of bacteremia by direct matrix assisted laser desorption ionization time-flight mass spectrometry (mALDI-TOF) compared to routine method. MATERIAL AND METHODS: A prospective study included 211 positive blood cultures obtained from 116 patients (106 adults and 10 children, aged from 2 weeks to 77 years old in the ICU after open heart surgery. Incubation was carried out under aerobic vials with a sorbent for antibiotics Analyzer BacT/ALERT 3D 120 (bioMerieux, France) in parallel with the primary sieving blood cultures on solid nutrient media with subsequent identification of pure cultures using MALDI-TOF mass spectrometry analyzer Vitek MS, bioMerieux, France routine method), after appropriate sample preparation we carried out a direct (without screening) MALDI-TOF mass spectrometric study of monocomponental blood cultures (n = 201). RESULTS: using a routine method in 211 positive blood cultures we identified 23 types of microorganisms (Staphylococcus (n = 87), Enterobacteria- ceae (n = 71), Enterococci (n = 20), non-fermentative Gram-negative bacteria (n = 18), others (n = 5). The average time of incubation of samples to obtain a signal of a blood culture growth was 16.2 ± 7.4 h (from 3.75 to 51 hours.) During the first 12 hours of incubation, growth was obtained in 32.4% of the samples, and on the first day in 92.2%. In the direct mass spectrometric analysis mnonocomponental blood cultures (n = 201) is well defined up to 153 species of the sample (76.1%), while the share of successful identification of Gram-negative bacteria was higher than that of Gram-positive (85.4 and 69, 1%, respectively p = 0.01). The high degree of consistency in the results of standard and direct method of identifying blood cultures using MALDI-TOF mass spectrometry (κ = 0.96, p < 0.001; the samples included in the calculation for which both option given result). Duration of the direct mass spectrometric analysis, including sample preparation, was no longer than 1 hour: CONCLUSION: The method of direct MALDI-TOF mass spectrometry allows to significantly speed up the identification of blood cultures that may contribute as much as possible early appointment effective regimes of starting antibiotic therapy.

[Experience of using endotoxin selective adsorption in patients with severe sepsis after open-heart surgery].

PURPOSE OF THE STUDY: To evaluate the safety and effectiveness of selective lipopolysaccharide (LPS)-adsorption therapy using polymyxin B immobilised fibre cartridges in adult patients complicated with severe sepsis after cardiac surgery. METHODS: 105 patients received extracorporeal LPS-adsorption procedures using Toraymyxin columns--PMX (Toray, Japan) in addition to the standard treatment according to the Surviving Sepsis Campaign guideline study group. For control group we selected 40 patients, comparable by PMX group in age, body weight, severity of illness, and the duration of cardiopulmonary bypass, received only standard therapy. All patients received significant doses of vasoactive drugs for hemodynamic support, mechanical ventilation and broad-spectrum antibiotics. Mean APACHE II and SOFA scores were comparable for both groups. Inclusion criteria were: clinical signs of severe sepsis, endotoxin activity assay (EAA) > or = 0.6, elevated blood plasma procalcitonin (PCT) > 2 ng ml(-1). The inclusion criteria were clinical signs of severe sepsis, endotoxin activity assay (EAA) > or = 0.6, and blood plasma procalcitonin (PCT) > 2 ng ml(-1). RESULTS: Extracorporeal treatment was administered within 24 h of a severe sepsis diagnosis. Each patient in PMX group received 2 LPS-adsorption procedures and each session of hemoperfusion lasted for 120 minutes. After the LPS-adsorption course, we noted any indices of haemodynamic improvements, including an increase in mean arterial pressure on 22% (p < 0.001), mean oxygenation index (on 24.5%, p < 0.001), normalisation of leukocytosis and a decrease in mean body temperature. After the procedures of LPS-adsorption we found the statistically significant decreasing of LPS concentrations according to LAL-test and EAA. In the control group, there were no significant changes in any of the studied parameters except body temperature. Moreover, the 28-day mortality was 42% in the study group and 65% in the control group (p = 0.032). The endotoxin adsorption procedures were not associated with any adverse reactions, and specifically no extracorporeal circuit thrombosis cases were noted. CONCLUSION: Selective LPS-adsorption is a safe and effective additional treatment method for severe sepsis patients.

[Procalcitonin as a predictor of bacteremia in postoperative cardiosurgery patients].

PURPOSE OF THE STUDY: To define diagnostics ability of procalcitonin (PCT) test for prediction of bacteremia of different etiology in cardio-surgical patients. MATERIALS AND METHODS: 10158 pairs of blood examples from cardio-surgical patients in early postoperative period were studied from 2007 to 2012. Results of PCT test were compared with blood cultures. The data is presented as absolute values and proportions. Furthermore a mean and standard error of the mean is presented. Differences in compared groups with p < 0.05 are considered statistically significant. RESULTS: In average a bacteremia occurred on a 6th day of postoperative period. Frequency of the positive blood cultures was 20.7%. 972 cases of bacteremia (46.2%) was caused by Gram-positive cocci, 702 cases (33.3%) by Gram-negative bacteria and 338 (16.1%) by yeast-like fungi. Mixt-cultures were defined in 93 cases (4.4%). Monocultural bacteremia was analyzed only (n = 2012). Average level of PCT was higher (statistically significant) in cases with blood cultures than in cases without it (14.35 +/- 0.91 ng per ml vs. 7.35 +/- 0.26 ng per ml, p = 0). The highest PCT was fixed in cases of bacteremia caused by Gram-negative bacteria (26.03 +/- 2.13 ng per ml). There was no significant difference between bacteremia due to enterobacteria and non-fermenting agents (30.56 +/- 4.05 ng per ml u 22.79 +/- 0.21 ng per ml, p = 0.07). Statistically significant differences according to the average PCT were defined between bacteremia caused by Gram-negative bacteria (26.03 +/- 2.13 ng per ml), Gram-positive cocci (7.24 +/- 0.88 ng per ml, p = 0), Candida species (9.02 +/- 1.84 ng per ml, p = 0), and cases of contamination (9.92 +/- 2.79 ng per ml, p = 0). Average PCT was not significantly different in cases of bacteremia due to coagulase-negative staphylococci (5.94 +/- 0.87 ng per ml), S. aureus (4.04 +/- 0.9 ng per ml), enterococci (15.72 +/- 3.52 ng per ml), Candida species (9.02 +/- 1.84 ng per ml), in cases of contamination (9.92 +/- 2.79 ng per ml) and in cases of the negative blood cultures (7.35 +/- 0.26 ng per ml). According to ROC-analysis the optimal cut-off point for PCT as a predictor of Gram-negative bacteremia was 2.47 ng per ml, AUC 0.7 (95% DI 0.68-0.72). Index of sensitivity was 64%. CONCLUSIONS: PCT level in blood plasma of patients with bacteremia higher (statistically significant) than in patients with negative blood cultures. Gram-negative infection is more likely in cases when PCT higher than 2.47 ng per ml.

[SCD14-ST (presepsin) level monitoring in cardiac surgical patients during perioperative period].

UNLABELLED: Purpose of the study was to define prognostic ability of presepsin (sCD14-ST) as a predictor of complications in cardiac surgical patients during perioperative period. METHODS: Patients operated for acquired heart valvular diseases with cardiopulmonary bypass were involved in the study (n = 51, age 58 +/- 11 years). Following parameters were studied; demographic data, duration of cardiopulmonary bypass, time of aorta clamping, severity-of-disease by APACHE II scale before surgery, on 1st, 2nd, 3rd and 6th day after surgery, routine clinical laboratory data and sCD14-ST. RESULTS: there were no clinical laboratory evidences of inflammation before surgery in all patients. There was no difference between biomarkers in patients who had normal condition during postoperative period and in patients who had complications and/or untoward outcomes during postoperative period. Presepsin level in 6 patients (11.8%) was 543 (519-602) ng/ml, maximal 1597 ng/ml. Infection complications accrued in 19 patients (37%). Hospital mortality was 13.7% (7 patients), all cases of death was in group of patients with infection complications. Statistically significant differences in the level of presepsin and severity-of-disease by APACHE II in groups of patients with infection complications and without accrued on 1st and 2nd days of postoperative period. Optimal split point were 702 ng/ml, 8.5 points and 3.3 ng/ml. Increased postoperative level of presepsin is associated with a risk of infection complications and untoward outcomes. CONCLUSION: sCD14-ST monitoring with the use of severity-of-disease scales and recent biomarkers allow to identify patients with high risk of infection complications and untoward outcomes.

[The express mode of identification of agents of bacteriemias using the technique of gas chromatography-mass spectrometry].

The comparative evaluation was carried out concerning the effectiveness of generic identification of hemocultures using the technique of gas chromatography-mass spectrometry by comparison with data of common cultural method. The content of vials with positive hemoculture was analyzed using both the common microbiologic methods and the technique of gas chromatography-mass spectrometry with detection of markers of the most widespread agents of nosocomial bacteriemias: microorganisms of genus Staphylococcus, Enterococcus, Klebsiella, Escherichia, Serratia, Pseudomonas, Acinetobacter, Stenotrophomonas, Candida. The possibility of applying the technique of gas chromatography-mass spectrometry for generic express-identification of agents of bacteriemias was established. The full concurrence of results obtained by gas chromatography-mass spectrometry with the results of common bacteriologic method was revealed. The time saving of analysis during generic identification of hemocultures using gas chromatography-mass spectrometry up to three and less hours against 1.5-2 days in case of common approach. The established information can input into earlier start of etiotropic therapy under severe infections.

[Etiopathogenetic extracorporeal treatment of severe sepsis in patients after cardiac surgery].

The study deals with assessment of LPS-adsorption and haemodialysis with EMiC2-filters use in the complex treatment in cardio-surgery patients with heavy sepsis. 64 adult patients included in the study were divided into two groups. 26 patients of the main group with heavy sepsis (EEA > 0.6; procalcitonin level higher than 2 ng/ml) received LPS-adsorption and haemodialysis with EMiC2-filters. 38 patients of control group with heavy sepsis developed after surgeries on heart and vessels did not receive extracorporeal methods of treatment. Positive effect of combined extracorporeal treatment on haemodynamics, oxygenation, endotoxin activity decreasing, procalcitonin level, inflammatory and antiphlogistic cytokines level was identified Trend of 28-day survival increasing was indentified in the main group.

[The first experience of application of PCR techniques in real-time mode to diagnose bacteriemia during postoperational period in cardiosurgery patients].

The results comparison is made between PCR polymerase chain reaction techniques in real-time mode and cultural techniques of analysis of blood samples in patients with suspicion of bacteriemia during early postoperational period. From September to December 2009 43 blood samples from 37 adult patients aged 59+9.2 years were analyzed on suspicion of bacteriemia. The blood samples for PCR analysis (SeptiFast technique Roche diagnostics, Switzerland) were taken parallel to the inoculation. Among 43 samples 20 (46.5%) were positive. The species structure of identified germs was as follows: Enteroccocus Faecalis - 2, Klebsiella pneumonia - 2, Enteroccocusfaecium - 1, Pseudomonas aeruginosa - 2, coagulase negative Staphilococcus - 11. All cases of seeding of coagulase negative Staphilococcus were interpreted using PCR techniques as negative or contamination. In four cases a full matching of results of compared techniques was obtained. In cases when hemoculture was negative (n = 23) the PCR techniques permitted to detect two positive results (Staphilococcus spp. and Stenotrophomonas maltophilia). In three cases of positive hemoculture the PCR techniques brought negative result and at that in two cases the causative agents (Pseudomonas fluorescens and Ralstonia mannitolilytica) were out of specter of pathogens detected by this method. The PCR techniques in real-time mode permit to reduce significantly time of pathogen investigation and to detect the false positive results conditioned by contamination. This techniques has to be applied in parallel with cultural technique because only this approach provide a possibility to get the clinically needed data related to the sensitivity of causative agent to antibacterial preparations.

[Estimation of species diversity of coagulase-negative staphylococci isolated in hospitals of Russian Federation in 2009-2010].

AIM: Comparative analysis of species diversity of sample of coagulase-negative staphylococci (CNS) isolated in hospitals of different specializations. MATERIALS AND METHODS: For identification of 102 CNS strains, biochemical systems manufactured by NPO "Diagnostic Systems", VITEK 2 Compact, and BBL Crystal as well as sequencing of fragments of tuf and gap genes were used. RESULTS: Greater differentiating capability of genotyping compared with phenotyping methods for species identification of staphylococci was demonstrated. Six CNS species were identified in the sample: S. epidermidis, S. haemolyticus, S. hominis, S. warneri, S. capitis, and S. pasteuri. The largest species diversity was noted for strains from maternity hospitals in Nizhny Novgorod and Kulakov Scientific Center for Obstetrics, Gynecology and Perinatology. Strains isolated from blood of patients in Bakulev Center for Cardiovascular Surgery were represented mostly by S. epidermidis and S. haemolyticus. Differences in species diversity of CNS--causative agents of neonatal conjunctivitis and omphalitis--were observed. CONCLUSION: Two species of CNS: S. epidermidis and S. haemolyticus pose special threat as nosocomial pathogens both in hospitals for adults and obstetrical facilities. Additionally, in neonatal units it is necessary to control such species as S. warneri, S. capitis, S. pasteuri.

[Selective hemoperfusion in gram-negative severe sepsis of patients after cardiac surgery: a prospective randomized study].

Early in the new millennium, sepsis remains one of the most urgent problems of modern reanimatology. Endotoxin, a component of the cell wall of gram-negative bacteria is of paramount importance in the pathogenesis of sepsis. Complex intensive care for severe sepsis involves selective endotoxin hemoperfusion with Polymyxin B and Alteco LPS adsorber, which has been performed in 2 patients. This study will enable specialists to formulate their opinion as to whether it is expedient to incorporate selective endotoxin hemoperfusion into complex intensive care for severe sepsis.

[Diagnosis and antimicrobial therapy of pneumonia caused by continuous mechanical ventilation after cardiosurgery].

The paper gives an update on the incidence and etiological structure of mechanical ventilation (MV)-associated pneumonias. The specific features of their pathogenesis are considered; clinical and laboratory diagnostic methods are reviewed. It is shown that it is necessary to make a microbiological monitoring. An algorithm is proposed to choose the tactics of antimicrobial treatment for MV-associated pneumonia; recommendations for the rational choice of antibiotics are given.

[The first experience in using selective sorbents in complex intensive care of patients with infectious and septic complications after cardiac surgery].

Early in the new millennium, sepsis remains one of the most urgent problems of modern medicine as before in view of a steady tendency for a rise of morbidity rates and for stably high mortality rates in patients (from 30 to 70%). The endotoxin lipopolysaccharide (LPS) of the cell wall of gram-negative bacteria plays the most important role in the pathogenesis of sepsis. This paper assesses the first experience in using endotoxin-selective sorption technologies within complex intensive care of critically ill patients with infectious and septic complications after cardiac surgery. Group 1 comprised 6 patients undergoing Alteco LPS adsorption procedures. Group 2 included 5 patients having hemoperfusion using Polymixin B-based Toraymyxin columns. The authors'first experience in clinically using LPS adsorption suggests that it is absolutely expedient to include extracorporeal selective hemoperfusion into the complex intensive care for infectious and septic complications in patients after operations on the heart and vessels.

[Surgical treatment of prosthetic endocarditic of cardiac valves].

Results of surgical treatment of patients with cardiac valves prosthetic endocarditis are discussed. General hospital lethality was 15.4%. Immediate results of operations using different type of prosthetic cardiac valves were analyzed. Biological grafts permits to decrease the rate of prosthetic endocarditic recurrence on hospital stage. Urgency of repeated surgery and also radical resection of infected focus with possible reconstruction of fibrous ring integrity influence hospital lethality.

[Systemic inflammation after operations on the open heart: significance of a microbial factor].

The given review of the literature discusses, from the present standpoints, the pathogenetic, clinical, and diagnostic aspects of a systemic inflammatory reaction developing during cardiac surgery under extracorporeal circulation. There is evidence that endogenous infection is of importance in developing systemic inflammation during cardiosurgical interventions. Current approaches to the early diagnosis of systemic bacterial inflammation, by applying the procalcitonin test and the chromatographic mass-chromatographic technique are proposed. The prevention of systemic inflammation and its sequels is considered.