Pain Intensity, coping and maternal satisfaction in Low-Risk labouring Women: A prospective descriptive correlational study.

OBJECTIVES: The primary aim of the study was to explore pain intensity (PI) and pain coping (PC) scores and the relationship between them. The secondary aim was to explore the correlation between PI and PC scores with labour progress, parity, labour acceleration, labour augmentation and maternal satisfaction. METHODS: A prospective descriptive correlational study was conducted in a maternity hospital in Northern Italy. The sample included 54 low-risk women in active labour at term of pregnancy. A data record sheet was used to collect the relevant variables and the Italian Birth Satisfaction Scale Revised (I-BSS-R) was administered to participants at least 24 h after birth. RESULTS: In the first labour stage, the average PI score was 6.99 (SD = 1.95) and the average PC score was 6.5 (SD = 2.22). During the second labour stage, the average PI score was 7.75 (SD = 1.74) and the average PC score was 4.97 (SD = 2.76). The average PI score trend increased with labour progress. The average PC score improved between 4 and 7 cm of cervical dilatation. A significant positive correlation between PI scores and oxytocin augmentation (p < 0.001) and labour progression (p < 0.001) was noted. A significant positive correlation between PC scores and oxytocin augmentation (p = 0.02) was also observed. No significant differences were found for maternal satisfaction in regard to PI and PC scores. CONCLUSION: coping in labour do not solely depend on PI but also on labour progress and oxytocin augmentation. Additional support to empower women to cope with pain may be required in case of labour augmentation.

Midwifery students' perspectives of physical and virtual mobility activities including preferences for e-learning: A cross-sectional survey.

BACKGROUND: Contemporary higher education requires that all midwifery students have insight and understanding of global health practice and demonstrate intercultural sensitivity. However, the mobility models currently offered do not often fit the lives of large numbers of midwifery students. OBJECTIVES: To investigate midwifery students' international physical mobility activities and factors that affect mobility; to determine midwifery students' learning needs and preferences for related e-learning packages. DESIGN: Multi-centre, descriptive quantitative survey. SETTINGS: Four European Higher Education Institutions based in the United Kingdom, Estonia, Italy and the Netherlands offering an undergraduate midwifery programme. PARTICIPANTS: The sample included 205 midwifery students from Italy (n = 93), the Netherlands (n = 51); United Kingdom (n = 35) and Estonia (n = 26). METHODS: Data were collected in June-July 2020 through an online cross-sectional, bespoke questionnaire and analysed using summary statistical analysis. RESULTS: There is a high level of interest across a range of mobility opportunities, especially those of shorter duration. Barriers to mobility comprised finance, caring responsibilities, concerns about fitting mobility activities into the midwifery programme, negative impact on studies and language barriers. The most frequently identified facilitators of mobility included professional perspectives such as interest in other cultures and midwifery in other settings and an endorsement that mobility would add value to their development as a midwife. When engaging in virtual learning, the most preferred resources mentioned by the students were videos, video calls with peers, choice quiz and discussion forum. CONCLUSIONS: The barriers identified require new approaches to enable all midwifery students to benefit from transnational learning. The survey findings provide insights into midwifery students' perspectives from which a new mobility model can be developed.

Timing of hospital admission in labour: latent versus active phase, mode of birth and intrapartum interventions. A correlational study.

BACKGROUND: Hospitalization of women in latent labour often leads to a cascade of unnecessary intrapartum interventions, to avoid potential disadvantages the recommendation should be to stay at home to improve women's experience and perinatal outcomes. AIM: The primary aim of this study was to investigate the association between hospital admission diagnosis (latent vs active phase) and mode of birth. The secondary aim was to explore the relationship between hospital admission diagnosis, intrapartum intervention rates and maternal/neonatal outcomes. METHODS: A correlational study was conducted in a large Italian maternity hospital. Data from January 2013 to December 2014 were collected from the hospital electronic records. 1.446 records of low risk women were selected. These were dichotomized into two groups based on admission diagnosis: 'latent phase' or 'active phase' of labour. FINDINGS: 52.7% of women were admitted in active labour and 47.3% in the latent phase. Women in the latent phase group were more likely to experience a caesarean section or an instrumental birth, artificial rupture of membranes, oxytocin augmentation and epidural analgesia. Admission in the latent phase was associated with higher intrapartum interventions, which were statistically correlated to the mode of birth. CONCLUSIONS: Women admitted in the latent phase were more likely to experience intrapartum interventions, which increase the probability of caesarean section. Maternity services should be organized around women and families needs, providing early labour support, to enable women to feel reassured facilitating their admission in labour to avoid the cascade of intrapartum interventions which increases the risk of caesarean section.

Resolvin D1 enhances the resolution of lung inflammation caused by long-term Pseudomonas aeruginosa infection.

Pseudomonas aeruginosa lung infection is a main cause of disability and mortality worldwide. Acute inflammation and its timely resolution are crucial for ensuring bacterial clearance and limiting tissue damage. Here, we investigated protective actions of resolvin (Rv) D1 in lung infection induced by the RP73 clinical strain of P. aeruginosa. RvD1 significantly diminished bacterial growth and neutrophil infiltration during acute pneumonia caused by RP73. Inoculum of RP73, immobilized in agar beads, resulted in persistent lung infection up to 21 days, leading to a non resolving inflammation reminiscent of human pathology. RvD1 significantly reduced bacterial titer, leukocyte infiltration, and lung tissue damage. In murine lung macrophages sorted during P. aeruginosa chronic infection, RvD1 regulated the expression of Toll-like receptors, downstream genes, and microRNA (miR)-21 and 155, resulting in reduced inflammatory signaling. In vitro, RvD1 enhanced phagocytosis of P. aeruginosa by neutrophils and macrophages, recapitulating its in vivo actions. These results unveil protective functions and mechanisms of action of RvD1 in acute and chronic P. aeruginosa pneumonia, providing evidence for its potent pro-resolution and tissue protective properties on airway mucosal tissue during infection.

Prognostic factors in Merkel cell carcinoma patients undergoing sentinel node biopsy.

INTRODUCTION: Debate remains about prognostic factors in primary Merkel cell carcinoma (MCC). We investigated clinicopathological factors as determinants of survival in patients with MCC submitted to sentinel node biopsy. METHODS: Sixty-four consecutive patients treated for a primary MCC were identified from a prospectively maintained database at Fondazione IRCCS Istituto Nazionale dei Tumori, Milan. Time to events outcome were described by product limit estimators and proportional hazards model was used to investigate the association between outcome and potential predictors. RESULTS: The most common site of primary tumor was lower limbs (56.3%). The size of primary lesion was ≤2 cm in 67.2% of cases. Presence of residual disease after the diagnostic surgical excision was observed in 28% of cases. All patients received sentinel node biopsy (SNB) and a SN positivity was detected in 26.6%. The median follow up was 78 months. Disease recurrence occurred in 17 patients (26.6%). In the SN negative group 10 recurrences occurred (21.3%), whereas 7 (41.2%) were found in SN positive one. Nine patients SN negative (19.1%) died of disease and 3 (17.6%) among SN positive. SN status was not associated with survival (p = 0.78). Neither age, gender, size and site of primary tumor resulted predictors of patients' outcome. The presence of residual tumor in the specimen of the wide local excision, after the diagnostic surgical excision, was the only variable associated with survival (p = 0.03). CONCLUSIONS: Presence of residual tumor in the specimen of the wide local excision is the main prognostic factor in MCC patients.

Assessment of postpartum perineal pain after vaginal delivery: prevalence, severity and determinants. A prospective observational study.

AIM: Perineal pain is present, after birth, in almost all (95-100%) women who have experienced perineal trauma. It has been shown that women with spontaneous vaginal delivery and minimal or absent perineal trauma will have better recoveries: less pain, more tonic perineal muscles, improved sexual function and lower rates of depression. The purpose of the present study was to prospectively assess the prevalence of perineal pain in a population of women with vaginal birth at term and physiological single newborn. METHODS: Pain assessment was performed using two subjective scales: the Verbal Numeric Scale (VNS) of 11 points and the Verbal Rating Score (VRS) of 4 points. Data collection period ran from the first postnatal day until 6 months after delivery, with two intermediate measurements at 1 and 7 weeks after birth. RESULTS: The study enrolled 451 women: 239 primiparous and 212 multiparous, with a response rate of 92% at 6 months. The prevalence of pain was found 88.2% in the first day postpartum, 62.3% one week after birth, 8.0% at seven weeks and 0.7% at six months. With regard to the resumption of sexual activity at 6 months postpartum, a dyspareunia rate of 27% was observed in the Episiotomy group (OR 5.72, P<0.001). CONCLUSION: The study found that an increase in the extent of trauma is associated with the highest scores in the self-assessment of perceived pain, with long term persistent symptoms. Furthermore, the presence of an episiotomy is a conditioning factor for the sexual function after childbirth (OR 0.43, P<0.001).

Phenotype and function of dendritic cells and T-lymphocyte polarization in the human colonic mucosa and adenocarcinoma.

AIM: To evaluate the status of activation of the intestinal dendritic cells (DCs) and T lymphocytes (T cells) from surgical specimens of human colon and adenocarcinoma, and the potential effect of administration of interleukin 2 (IL-2). METHODS: Patients undergoing colectomy for cancer were randomized to receive subcutaneous IL-2 (12million UI/day) (treated group; n=10) for 3days before operation or no treatment (control group, n=10). DCs and T cells were isolated and purified from the lamina propria (LP) of segments of normal colon and adenocarcinoma of both groups. Cell phenotype was determined by expression of membrane receptors. Interaction between DC and T cells was assesses by a mixed leukocyte reaction using naïve T cells co-cultured with DCs. CD4+ T-cell polarization was studied by intracellular staining with monoclonal antibodies for interleukin-4 and interferon-gamma. RESULTS: CD4+ T cells were significantly less in tumour than in LP (p<0.05) in both treated and control groups. IL-2 did not modify the number of any of the T-cell subsets analysed. In contrast, T cells isolated from LP and neoplasm of treated patients produced more interferon-gamma and less interleukin-4 (p<0.05 vs. controls). IL-2 administration significantly increased (p<0.05) the number of mature, myeloid and plasmocytoid DCs compared to controls. Allogeneic naïve T cells were polarized toward a Th1 type of response which appeared to be mediated by IL-2 activated DCs. CONCLUSIONS: systemic IL-2 treatment may have immunomodulatory properties on intestinal DC maturation and drive a Th1 mediated anti-neoplastic response.

[Clinical role of interleukin-2 in the surgical treatment of liver metastasis due to colon adenocarcinoma]. / Ruolo clinico dell'interleuchina-2 nel trattamento chirurgico delle metastasi epatiche da adenocarcinoma del colon.

The surgical treatment of liver metastasis due to colorectal cancer can substantially modify the natural history of the disease, mainly when it is associated with effective medical treatment. Chemotherapy, via systemic or locoregional (intrahepatic) administration, has 2 possible objectives: as adjuvant treatment, to prevent or delay disease recurrence; as neo-adjuvant treatment, mainly interesting for the surgeon, to allow resective surgery in responding patients previously considered not-operable. Unfortunately, the severe immune deficiency associated with the advanced cancer negative impact on long-term outcome after any treatment (surgery, chemotherapy) is a limit for the clinical application of multidisciplinary treatments. Aim of this study is to review the possible different approaches to improve the clinical results, either as tumour response or overall survival, using an association of IL-2 with different chemotherapy procedures, in order to recover the locoregional and/or systemic immunodeficency. Several literature studies are worth of consideration not only for the biological activity reported, but also for the preliminary clinical results. At our Department, we have started a clinical experience in order to verify and confirm the results reported in these studies. The preliminary results seem to confirm an increase of chemotherapy activity obtained with an association of IL-2 immunotherapy with systemic therapy procedures and mainly with locoregional therapeutic programs.

[Nutritional therapy in surgical patients: an update]. / Terapia nutrizionale nei pazienti chirurgici. Un aggiornamento.

Patients undergoing major gastrointestinal surgery, often require an adequate artificial nutritional (AN) support for a pre-existing state of malnutrition and/or to overcome forced periods of postoperative starvation and/or for complications that alter the host metabolic response. When an indication to AN is given, enteral feeding should be preferred to parenteral nutrition because more physiological and less expensive. Moreover, recent data showed that patients fed enterally, rather than parenterally, in the postoperative period, have a significant better outcome with a reduction of morbidity and hospitalisation. The supplementation of standard feeds with key nutrients having immunomodulatory properties, such as arginine, omega-3 fatty acids and glutamine (pharmaconutrients), allows to control effectively the surgery-induced immunosuppression and hyperinflammation. An analysis on the principles of evidence-based medicine, supports the hypothesis that the pre-perioperative use of formulas enriched with pharmaconutrients, significantly reduces the rate of infectious complications and saves health care resources.

Surgery-induced decline in circulating dendritic cells in operable cancer patients: a possible explanation of postoperative immunosuppression.

BACKGROUND/AIMS: The recent advances in the immunobiology of tumor have demonstrated the essential role of dendritic cells in anticancer immunity. Dendritic cells activate anticancer immunity by secreting interleukin-12 and by activating T helper lymphocytes, with the following production of interleukin-2. Since surgery-induced immunosuppression has been proven to be associated with a decline in the blood levels of both interleukin-2 and interleukin-12, it could depend at least in part on a transient deficiency of dendritic cells system. Unfortunately, at present there are no data about changes in circulating dendritic cell number during the postoperative period. This preliminary study was performed to evaluate the influence of surgery on dendritic cell number in the peripheral blood. METHODOLOGY: The study included 14 consecutive operable gastrointestinal tract cancer patients, who were evaluated before and at day 7 of the postoperative period. The control group consisted of 50 healthy subjects. Immature (CD 123+) and mature (CD 11+) dendritic cell subsets were measured by FACS and monoclonal antibodies. RESULTS: Cancer patients showed a significantly lower mean number of immature dendritic cells with respect to that found in controls. The mean number of mature dendritic cells was also lower in patients than in controls, without, however, significant differences. Finally, surgery induced a statistically significant decline in the mean number of both immature and mature dendritic cells, and the decrease was particularly pronounced for immature dendritic cells. CONCLUSIONS: In addition to the well-demonstrated surgery-induced lymphocytopenia, this preliminary study shows that the surgical treatment may determine a significant decrease in circulating immature and mature dendritic cells. Because of the fundamental role of dendritic cells in regulating the immune responses, surgery-induced decline in circulating dendritic cells number could play a role in determining the immunosuppressive status, which characterizes the postoperative period.

Abrogation of surgery-induced decline in circulating dendritic cells by subcutaneous preoperative administration of IL-2 in operable cancer patients.

Surgery-induced immunosuppression is characterized by a decline in lymphocyte count, particularly T lymphocyte number. In addition, preliminary studies have shown that the postoperative period is also characterized by a decline in the number of circulating dendritic cells (DC), whose fundamental anticancer role has been recently demonstrated. Previous studies had already shown that the preoperative injection of IL-2 may completely abrogate surgery-induced lymphocytopenia, whereas its eventual influence on DC system during the perioperative period is still unknown. The present study was performed to evaluate the influence of IL-2 preoperative immunotherapy on the perioperative changes in circulating DC number in patients affected by colorectal cancer. The study included 14 consecutive patients, who were randomized to be treated with or without IL-2 presurgical immunotherapy (12 million IU/day for 3 days subcutaneously). Circulating immature and mature cells were evaluated before surgery and at days 3 and 7 of the postoperative period. The detection was made by FACS using monoclonal antibodies against CD123 and CD11c to recognize immature and mature DC, respectively. Surgery induced a significant decline in the mean number of both immature and mature DC. The pre-surgical administration of IL-2 completely abrogated surgery-induced decline in immature DC cell amount. Moreover, mature DC mean number was diminished only at day 3 of the postoperative period, since the value observed at day 7 was not significantly lower than that found before surgery. This preliminary study shows that surgery-induced immunosuppression is characterized also by a significant decline in the mean number of both immature and mature DC. Moreover, this study would suggest that the preoperative immunotherapy with IL-2 may counteract surgery-induced failure of DC system. Because of the fundamental antitumor role of DC, this evidence could have a prognostic impact on the clinical course of the neoplastic disease.

Pre-operative IL-2 immunoprophylaxis of cancer recurrence: long-term clinical results of a phase II study in radically operable colorectal cancer.

This study evaluates retrospectively the outcome of 20 colorectal cancer patients radically operated (M/F 13/7; primary/recurrent 15/5; Dukes B=11; C=6; D=3) who received pre-operative IL-2 (18,000, 000 IU/daily s.c. for 3 days) and the outcome of 40 colorectal cancer (primary/recurrent 40/0) patients age, sex and stage-matched radically operated, as control group. After a median follow-up of 72 months, in the IL-2 pre-operative group we observed 6/20 recurrences (30%) vs. 19/40 (47.5%) in controls. Mean and median disease-free period in patients who relapsed were respectively 21 months and 20.5 months (range 6-36) in IL-2 group vs. 14.1 and 12 months in the control group (range 3-34). After a 5-year follow-up, 4/20 (20%) IL-2 treated patients were dead vs. 19/40 control patients (47.5%) (log-rank chi2=3.7, p=0.05). Pre-operative IL-2 administration is safe, active in preventing post-operative lymphocytopenia and seems to improve the clinical outcome in radically operated colorectal cancer patients.

Predictive value of a pathophysiological score in the surgical treatment of perforated diverticular disease.

Resection is the preferred method of perforated diverticular disease treatment compared to conservative treatment. However, the immediate or deferred timing of bowel continuity restoration for advanced degrees of peritoneal contamination is debatable. This is a retrospective study designed to identify operative mortality predictors and guidelines for safe primary anastomosis. A pathophysiological score (acute physiology and chronic health evaluation, APACHE II) was applied to 135 consecutive patients who had undergone surgery for acute inflammatory complication of diverticular disease. A multivariate analysis was used to identify prognostic factors such as age, chronic diseases, neoplastic cancer, Acute Physiology Score (APS), Hinchey's classification and APACHE II scores. Seventy patients underwent primary resection and anastomosis, 35 underwent Hartmann's procedure and 15 conservative treatment. There was a significant correlation between operative mortality and increasing disease severity based on Hinchey's classification, APS and APACHE II scores. The multivariate analysis proved APACHE II scores to be the only prognostic factor of operative mortality. Both single and multivariate analysis of variance failed to identify a factor significantly associated with surgical and/or medical postoperative complications. APACHE II scores were the best predictor for operative mortality in patients with diverticular disease complications, but none of the classification criteria used was effective in predicting postoperative complication. Patients with phlegmonous sigmoiditis can be safely treated with primary resection and anastomosis. Conservative treatment should not be considered an effective method for diverticular disease. A prospective trial comparing resection with and without colostomy should be done for local and diffuse purulent peritonitis treatment. Hartmann's procedure is seen to be the only indicator for faecal peritonitis.

The management of shock and local injury in traumatic rhabdomyolysis.

Rhabdomyolysis (literally "striped muscle dissolution") is a biological and clinical condition that takes to plasmatic release of myoglobin, muscle enzymes and electrolytes, relates to the lysis of stripped muscle fibers. Rhabdomyolysis presents the clinician with two distinct problems: local injury and the systemic effects directly related to that injury. Locally, muscle, vessel and nerve compression are the primary issues. Systemic concerns relate to depleted intravascular volume, electrolyte imbalances and renal injury from myoglobin. Preventing the systemic and renal complications of the crush syndrome requires very early and vigorous treatment to sustain the circulation, preferably started at the site of the catastrophe. During the extrication of an injured person from a collapsed building, wrecked automobile, or other site, isotonic saline solution should be infused at the rate of 1.5 liters per hour as soon one of the trapped person's limbs has been freed. Some authors suggest to do a preventive fasciotomy in any suspicious case of compartmental syndrome, when the patient has severe muscular pain of the muscular cavity, tense swelling, hypoesthesia or anesthesia of the muscular cavity, pain at the passive mobilization of the limb. On the other hand other surgeons suggest doing a fasciotomy only in selected group of patients. Therefore, the traumatic rhabdomyolysis has few diagnostically problems. On the other hand, their treatment is complex and must have a multidisciplinary approach. So the rhabdomyolysis actually remain a severe disease with high mortality caused principally by visceral lesions related to sepsis.

Changes in cesarean delivery in an Italian university hospital, 1982-1996: a comparison with the national trend.

BACKGROUND: The cesarean delivery rate in Italy rose dramatically from the mid-1970s to 1996, accounting for 22.4 percent of all deliveries in the last national survey. The aim of this study was to analyze the results of the clinical practice of a new staff in the Department of Obstetrics and Gynecology of a university hospital, with particular focus on the application of common protocols. The rates of cesarean sections and perinatal mortality were chosen as parameters for good clinical practice and were compared with national data. METHODS: A new staff assumed the obstetric management at the hospital in 1982. Standardized protocols were implemented for all major indications for cesarean delivery (repeat cesarean section, dystocia, breech presentation, fetal distress). RESULTS: The rate of cesarean deliveries decreased from 26.4 to 12 percent and remained stable during the past decade. Other operative modalities were used for approximately 1.5 percent of deliveries. The perinatal mortality decreased to 0.5 percent in 1994. To confirm whether or not staff followed common protocols, a review of three years (1994-1996) showed a fairly stable frequency of cesarean sections on different days and nights during the week, confirming the homogeneity of obstetric management. CONCLUSIONS: Our data showed that, irrespective of the local situation and of the risks of litigation, a significant reduction of cesarean sections can be achieved in a tertiary care center without detrimental effects on newborns, especially in a teaching hospital where residents are trained. Despite national trends suggesting the contrary, some women may choose to deliver in an obstetrics department with better care and fewer operative procedures than in hospitals with higher cesarean delivery rates.

[Variations in interleukin-2 and interleukin-6 due to surgical trauma in cancer patients]. / Variazioni di interleuchina-2 e interleuchina-6 da trauma chirurgico in pazienti oncologici.

Inflammatory response after surgical trauma, which is necessary for infection control and tissue repairing, can actually produce some cytokines suppressive of the antitumoral immunity response. In this study the authors evaluate pre- and post-operative IL-2 (antitumor response activator) and IL-6 (lymphocytic response inhibitor and tumor growth factor) levels in 26 cancer patients undergoing resective surgery. Analysis of the results showed a significative IL-6 increase and a tendency to IL-2 decrease in the post-operative period. It is thus confirmed, even on the basis of the cytokines, the meaningful immunosuppressive effect of the surgical trauma on neoplastic growth control.

[Acute cholecystitis and gallbladder neoplasms: the experience of 2215 cases]. / Colecistite acuta e neoplasia della colecisti: esperienza su 2215 casi.

The authors have retrospectively analysed 2215 surgical procedures for gallbladder stones. The global incidence of gallbladder neoplasm has been 5%. This rate rises to 11% considering female patients over 60 years old. In this group, a gallbladder carcinoma was contemporary present in 17.4% of acute cholecystitis. Cholecystectomy may be suggested in every patients with gallstones, even asymptomatic, particularly if some risk factors are present.

[Open treatment in acute severe pancreatitis]. / Trattamento aperto nella pancreatite acuta severa.

Technical procedures normally used for open packing in our Institute (ICU) are described. Results of this procedure, utilized in thirteen patients suffering from infected pancreatic necrosis and multiple organ failure are reported. The grade of pancreatitis severity has been studied in detail. At admission patients presented a mean Ranson score of 6 and the morphological alteration sec. Balthazar was D in six patients and E in seven. At least two organs were insufficient at the beginning of our observation and the mean number of insufficient organs was 4. The mean APACHE II score was 20. Necrosis was documented in all patients. They were all admitted to ICU and the mean time of treatment was 50 days. Daily debridement was performed and continuous lavage was later added to daily open review. Three patients died, one from local bleeding and two from respiratory insufficiency. No patient died of sepsis and no mortality was observed in the last six cases. According to the severity of Ranson score, APACHE II, the number of insufficient organs and TAC morphological alteration predicted mortality rate should have been 70-80%; on the contrary, it was 25%. In conclusion open packing seems to be the correct treatment for infected pancreatic necrosis, particularly when it is complicated by multiple organ dysfunction.

The choice of surgical procedure for peritonitis due to colonic perforation.

OBJECTIVE: Because the choice of surgical procedure for colonic perforation is still matter of debate, we retrospectively studied peritonitis caused by spontaneous colonic perforation to assess predictors of mortality and the safety of primary resection and anastomosis. DESIGN: Case series. PATIENTS: We investigated one hundred thirty-six consecutive patients with peritonitis due to colonic perforation who were surgically treated in an emergency surgery department. Eighty-one patients underwent primary resection and anastomosis, thirty-three underwent the Hartmann procedure, and twenty-two had simple colostomy. The seriousness of peritonitis was assessed in terms of Hinchey stage, the Mannheim Peritonitis Index (MPI), and the acute physiology and chronic health evaluation (APACHE) II score. RESULTS: The overall mortality rate was 20%. The APACHE II scores and MPIs were lower for survivors than for nonsurvivors. The mortality rate was 6% for primary resection and anastomosis, 30% for the Hartmann procedure, and 59% for simple colostomy, but the severity scores were significantly lower in patients who underwent primary resection than those of patients who had the Hartmann procedure and colostomy, respectively. CONCLUSIONS: Since primary resection and anastomosis has been shown to be safe, we suggest that is is proper, even in the presence of peritonitis. In spite of this, we conclude that the surgical procedure does not influence outcome but that the mortality rate is related to the severity of peritonitis, accurately measured by APACHE II score and MPI.

Complement activation and polymorphonuclear neutrophil leukocyte elastase in sepsis. Correlation with severity of disease.

Complement activation is necessary for an adequate immune and inflammatory response to infections. Activation releases anaphylatoxins that cause vasodilation, increase vascular permeability, and trigger release of polymorphonuclear neutrophil leukocyte (PMN) lysosomal enzyme and oxygen radicals. Under normal circumstances, an orderly progression of such events has a beneficial antimicrobial effect. The same mechanism, however, when uncontrolled, may damage host tissues. To provide information about the clinical importance of such events in sepsis, different complement parameters (C3, C4, and the desarginated forms of C3a [C3a(des)-Arg] and C5a [C5a(des)-Arg]), PMN elastase, and malondialdehyde (a by-product of membrane peroxidation by oxygen radicals) were measured daily in 26 septic patients and correlated with two objectively assessed and previously validated severity scores (acute physiology and chronic health evaluation [APACHE II] and Sepsis Severity Score [SSS]). Nonsurvivors (n = 12) had significantly greater and longer lasting complement activation than that in survivors, as reflected by higher levels of catabolic peptides (C3a(des)-Arg) and lower levels of native proteins (C3 and C4). C3a(des)-Arg, C3, C4, and the C3a(des)-Arg-C3 ratio were correlated with Sepsis Severity Scores. Polymorphonuclear neutrophil leukocyte elastase levels were higher in nonsurvivors and were correlated with C3a(des)-Arg and the C3a(des)-Arg-C3 ratio. Malondialdehyde levels were significantly higher in all patients than in controls, without, however, any relationship to severity of disease or clinical outcome. Since the higher and more persistent the complement activation and polymorphonuclear neutrophil leukocyte stimulation, the worse the patient's prognosis, we conclude that these mechanisms may be important in the clinical development of sepsis.