[Abdominal abscesses: their treatment and the study of prognostic factors]. / Ascessi addominali: trattamento e studio dei fattori prognostici.

The aim of this study is to define outcome predictors that might influence the prognosis and the mortality rate either of percutaneous drainage (DP) or open surgical drainage (DC) for abdominal abscesses. Seventy-one patients with 81 intra-abdominal abscesses were prospectively studied. They were 40 males and 31 females. Mean age was 47 +/- 15 years. Thirty-six (50.7%) patients had a simple abscess, while 35 (49.2%) had a complex abscess. Abscesses occurred most commonly in the sub-hepatic area, pelvic and para-colic space. Thirty-two (45%) patients had a percutaneous drainage, while 39 (54.9%) underwent an operative drainage management. Criteria for treatment selection were not randomized. However the two groups were statistically similar in respect to clinical features, cirrhosis, nutritional status, APACHE II scores), genesis and characteristics (simple, complex) of the abscesses. The treatment was considered successful when not requiring further drainage and the patient survived. Abdominal abscesses were cured in 53 (74.6) patients. In 13 cases (18.3%) a further drainage was necessary to obtain a complex resolution. Post drainage complications were significantly higher in the surgical drainage group (38.4% vs 12%, p < 0.05) because of the high incidence of wound infections. The overall mortality rate was 7%. Using an univariate analysis model, the only significant variable related to unsuccessful outcome in both the percutaneous and surgical group was abscess complexity (p < 0.005). Elderly (p < 0.005), malnutrition (p < 0.03), presence of cancer (p < 0.05), a high APACHE II score (p < 0.005) and the presence of a complex abscess (p < 0.02) were significantly identified as determinants of death.

[Operative risk in elderly patients with gastrointestinal hemorrhage]. / Il rischio operatorio nel paziente grande anziano con emorragia digestiva.

The risk of postoperative complications was evaluated in 16 patients aged 80 or more operated on for gastrointestinal bleeding (morbidity 43.7%, mortality 25%). For each patient was considered: ASA, APACHE II and SAPS scores, proteinemia, natremia and osmolarity (for the volume changes), Hb value and units of blood transfused, preoperative and operative length. APACHE II and SAPS scores resulted the only variables related to prognosis.

[Intestinal obstruction in the elderly. Causes, interventions, postop complications and risk factors]. / L'occlusione intestinale nel paziente grande anziano. Cause, interventi, complicanze postoperatorie e fattori di rischio.

Forty-eight patients aged 80 or more were operated on for intestinal obstruction mainly due to incarcerated hernias (39.6%) and colonic neoplasms (27.1%). The morbility rate was 27.1% and the mortality rate was 8.3%. The study of the variables frequently related to the risk of postoperative complications (cancer, intraoperative contamination, emergency and blood transfusion) showed statistical significance only for blood transfusion. The others (emergency included) did not have a prognostic significance in this series.

Control of CD4 effector fate: transforming growth factor beta 1 and interleukin 2 synergize to prevent apoptosis and promote effector expansion.

The signals that determine the size and duration of the primary T cell immune response are not well defined. We studied CD4 T cells at an important checkpoint in their development: when they have become effectors and are ready to rapidly mediate effector functions, both via direct interaction with antigen (Ag)-presenting cells and via cytokine production. We determined the effects of specific Ag and the cytokines interleukin (IL) 2 and transforming growth factor (TGF) beta 1 on T helper cell type 2 (Th2) effector apoptosis versus expansion. Th2-polarized effector cells were generated in vitro from naive CD4 T of T cell receptor transgenic mice, and then restimulated with or without peptide Ag plus Ag-presenting cells and cytokines. In the absence of added cytokines, effector cells cultured without Ag died of apoptosis after 4-7 d. Paradoxically, Ag both induced proliferation and high levels of cytokine synthesis and accelerated effector cell death. IL-2 directly induced proliferation of effectors, supported and prolonged Ag-induced proliferation, and partially blocked apoptosis. TGF-beta did not effect proliferation or influence cytokine secretion, but it also partially blocked apoptosis. Together, IL-2 and TGF-beta synergized to almost completely block apoptosis, resulting in prolonged effector expansion and leading to the accumulation of a large pool of specific effectors. When Ag and both cytokines were present, the effector population increased 10(4)-10(5) fold over 20 d of culture. The synergy of IL-2 and TGF-beta suggests that they interfere with programmed cell death by distinct mechanisms. Since Th2 effectors are specialized to help B cells develop into antibody-secreting plasma cells, these results suggest that the availability of Ag and of the cytokines IL-2 and TGF-beta is a key factor influencing the fate of Th2 effector cells and thus the size and duration of the primary antibody response.

Surgery in the very old patient: evaluation of factors linked to postoperative morbidity and mortality.

One hundred and sixty-seven patients over 79 years of age were studied prospectively in our Emergency Surgery Department in order to evaluate their outcome, and the possible existence of factors linked to morbidity and mortality. The most common indications for surgery were gallstones (22.1%), hernias (14.9%), colo-rectal cancer (13.7%), peptic ulcer (6.5%), gastric cancer (5.9%) and ischemic or hemorrhagic vascular diseases (13.1%). Emergency surgery was performed in 93 (55.6%) patients. Forty-nine patients (29.3%) developed 83 postoperative complications. The risk of morbidity was statistically higher in patients who had more than two associated diseases (p < 0.05) and received blood transfusions (p < 0.01). The mortality rate was 16.1%, and was significantly related to ASA scores > or = 4 (p < 0.001) and a high degree of intraoperative bacterial contamination (Classes III-IV) (p < 0.05). Compared to elective surgery emergency operations had a higher morbidity (33.3% vs 24.3%) and mortality (21.5% vs 9.4%), but the difference was not significant. Mortality/morbidity ratio was significantly higher in emergency, as compared to elective surgery (64.5% vs 38.8%, p < 0.001).