The prediction of surgical intervention in patients with tubo-ovarian abscess.

The aim of this study was to compare the clinical characteristics of patients with tubo-ovarian abscess (TOA) who responded to medical treatment and those who underwent surgical intervention due to medical treatment failure. Electronic medical records were evaluated retrospectively to identify patients who were diagnosed with TOA. Demographic, clinical, and laboratory data including white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were compared between the medical treatment group and the surgical intervention group. Patient age, TOA diameter, WBC count, CRP, and ESR were significantly different between the groups. On multiple regression analysis, significant correlations were identified between age (p = .001), ESR (p = .045), and failure of medical treatment. TOA diameter (p = .065) showed a borderline association with surgical intervention. The risk of needing surgical intervention in TOA patients can be predicted using ESR in addition to age and TOA size as risk factors.IMPACT STATEMENTWhat is already known on this subject? For patients diagnosed with a tubo-ovarian abscess (TOA), the size of TOA and the patient's age are helpful for early identification of patients who are likely to need surgical treatment. Inflammatory markers such as C-reactive protein and white blood cell are also associated with the risk of surgical intervention.What do the results of this study add? Erythrocyte sedimentation rate (ESR) in addition to the size of TOA and the patient's age is a useful marker in determining whether to undergo surgery in patients with TOA.What are the implications of these findings for clinical practice and/or further research? ESR combined with the patient's age and the size of TOA is clinically useful in predicting the need for early surgical intervention in patients with TOA. Large prospective controlled studies are required to establish relationship between inflammatory markers and the risk of surgical intervention.

Oral Antibiotics and Abscess Formation After Appendectomy for Perforated Appendicitis in Children.

BACKGROUND: There is little consensus regarding the use of postoperative antibiotics in the management of perforated appendicitis in children. Patients are commonly discharged with oral antibiotics after a course of intravenous antibiotics; however, recent literature suggests that patients can be safely discharged without any oral antibiotics. To further evaluate this protocol, we conducted a multicenter retrospective preimplementation/postimplementation study comparing rates of abscess formation and rehospitalization between patients discharged with and without oral antibiotics. MATERIALS AND METHODS: We reviewed the records of all pediatric patients who underwent appendectomies for perforated appendicitis at NYU Tisch Hospital, Bellevue Hospital, and Hackensack University Medical Center from January 2014 to June 2019. Data pertaining to patient demographics, hospital course, intraoperative appearance of the appendix, antibiotic treatment, abscess formation, and rehospitalization were collected. RESULTS: A total of 253 patients were included: 162 received oral antibiotics and 91 did not. The median length of antibiotic treatment (oral and intravenous) was 11 (10-14) d for patients on oral antibiotics and 5 (3-6) d for patients without oral antibiotics (P < 0.01). The median leukocyte count at discharge was 9.5 (7.4-10.9) and 8.1 (6.8-10.4) for these groups, respectively (P = 0.02). Postoperative abscesses occurred in 22% of patients receiving oral antibiotics and 15% of patients on no antibiotics (P = 0.25). Rates of rehospitalization for these groups were 10% and 11%, respectively (P = 0.99). CONCLUSIONS: Children who have undergone appendectomy for perforated appendicitis can be safely discharged without oral antibiotics on meeting clinical discharge criteria and white blood cell count normalization.

Can the Need for Invasive Intervention in Tubo-ovarian Abscess Be Predicted? The Implication of C-reactive Protein Measurements.

STUDY OBJECTIVE: To evaluate the clinical parameters of hospitalized patients with pelvic inflammatory disease (PID) for the presence of tubo-ovarian abscess (TOA) and predict the need for intervention. DESIGN: A prospective cohort study. SETTING: A tertiary care university medical center. PATIENTS: Ninety-four patients were diagnosed with complicated PID and hospitalized between 2015 and 2017. INTERVENTIONS: Patients with PID were treated with parenteral antibiotics according to Centers for Disease Control guidelines. Demographic, clinical, sonographic, and laboratory data for patients with PID were analyzed. Inflammatory markers including C-reactive protein (CRP), white blood cells (WBCs), erythrocyte sedimentation rate (ESR), and clinical parameters were collected at admission and during hospitalization. MEASUREMENTS AND MAIN RESULTS: Forty-eight of 94 patients (51.1%) hospitalized with complicated PID were diagnosed with TOA sonographically. CRP levels were the strongest predictor of TOA, followed by WBC count, ESR, and fever on admission. The areas under the receiver operating characteristic (ROC) curve for CRP, WBC, ESR, and fever were .92, .75, .73 and .62, respectively. CRP specificity was 93.4% and sensitivity was 85.4% for predicting TOA, with cutoff value of 49.3 mg/L. Twelve patients (25%) failed conservative management and underwent surgical intervention including laparoscopy (n = 7), computed tomography (CT)-guided drainage (n = 4), and laparotomy (n = 1). In this group, CRP levels significantly increased from admission to day 1 and day 2 during hospitalization (128.26, 173.75, and 214.66 mg/L, respectively; p < .05 for both). In the conservative management group, CRP levels showed a plateau from admission to day 1 and then a decrease until day 3 (110, 120.49, 97.52, and 78.45 mg/L, respectively). CONCLUSION: CRP is a sensitive, specific inflammatory marker for predicting TOA in patients with complicated PID, and levels >49.3 mg/L suggest the presence of TOA. In the TOA group, CRP level trends correlated well with success or failure of conservative management. Increasing CRP levels during treatment may be used as an indicator of the need for invasive intervention, and daily CRP measurements can help predict the need for invasive intervention.

Evaluation of white blood cell count at time of discharge is associated with limited oral antibiotic therapy in children with complicated appendicitis.

BACKGROUND: Variation exists for postoperative antibiotics in children with complicated appendicitis. We investigated the impact of white blood count (WBC) at discharge on oral antibiotic therapy, abscess rate, and readmission rate. MATERIAL/METHODS: We conducted a two year review of children with complicated appendicitis. In the pre-protocol group, total antibiotic therapy was ten days (IV and oral) and home oral antibiotics at discharge. In the post-protocol group, children with leukocytosis were prescribed oral antibiotics to complete seven days of total antibiotic therapy and children without leukocytosis were not prescribed oral home antibiotics. RESULTS: There was no difference between mean hospital days after operation (3.52 vs. 3.24, p = 0.5111), means days of inpatient intravenous antibiotics (3.13 vs. 2.58, p = 0.5438), post-operative abscess rates (20.7% vs. 19.6%, p = 0.9975), or readmission rate (13.4% vs. 12.4%, p = 1.000). The post-protocol group had a shorter average total antibiotic duration (4.24 vs. 9.52 days, p < 0.001) and were more likely to be discharged without oral antibiotics (71.1% vs 8.5%, p < 0.001). DISCUSSION: Limiting home antibiotics at discharge to children with leukocytosis significantly decreases home antibiotic use.

Impact of Bedside Tracheostomy on Procalcitonin Kinetics in Critically Ill Patients.

BACKGROUND: Critically ill patients are particularly vulnerable to invasive procedures and complications; however, tracheostomy is frequently performed in the intensive care unit (ICU). We analyzed the effects of tracheostomy on procalcitonin (PCT) kinetics and investigated whether PCT could reliably predict septic complications after tracheostomy. METHODS: We retrospectively identified 134 patients who underwent bedside tracheostomy during their ICU stay at a Japanese university hospital from October 2010 to December 2015. We extracted PCT data from the day of the procedure (day 0) to postoperative day 2 and defined alert PCT as a PCT level ≥0.5 ng/mL, which had not decreased from the previous day. We divided patients into the following groups: nonevent, aseptic complication, and septic complication. RESULTS: Twelve (9.2%) patients developed acute aseptic complications, and 12 (9.2%) patients developed septic complications. In the nonevent group, the PCT value decreased continuously in the initial PCT ≥ 0.5 ng/mL subgroup (P < .001, P <.001 for trend). In contrast, significant changes were not observed in the initial PCT < 0.5 ng/mL subgroup. Significant differences and an upward trend in alert PCT incidence rate existed between the groups (P < .001, P < .001 for trend): nonevent group, 5.5%; aseptic complication group, 41.7%; and septic complication group, 66.7%. In a multivariate linear regression model, septic complications were independently associated with PCT change at postoperative days 1 and 2 (adjusted ß = 3.58, P < .001; adjusted ß = 9.84, P < .001, respectively). Procalcitonin predicted septic complications more accurately than C-reactive protein, with the area under the receiver operating characteristic curves of 0.8 versus 0.63 (P = .058) and 0.91 versus 0.69 (P = .036) at postoperative days 1 and 2, respectively. CONCLUSION: Our results demonstrated that PCT was not elevated after uncomplicated surgical tracheostomy in critically ill patients.

Phlegmonous appendicitis in children is characterized by eosinophilia in white blood cell counts.

BACKGROUND: Phlegmonous and complicated appendicitis represent independent entities depending on hereditary immunological mechanisms. However, clinically there are no means to distinguish uncomplicated phlegmonous from complicated appendicitis. The ability to distinguish these two forms of appendicitis is relevant as current attempts are to treat both forms of the disease differently. The aim of the present study was to investigate differences in white blood cell counts (WBCs) in these conditions to identify areas of interest for future molecular studies. METHODS: White blood cell counts of patients aged between 7 and 14 years who underwent appendectomy from January 2008 to June 2016 were investigated with special reference to particular cellular subpopulations. RESULTS: A total of 647 children were included in the study. Within distinct inflammatory patterns, significant eosinophilia and basophilia were found in phlegmonous inflammation compared with complicated inflammation (0.11 ± 0.19 × 109/L vs. 0.046 ± 0.104 × 109/L, P < 0.0001, and 0.033 ± 0.031 × 109/L vs. 0.028 ± 0.024 × 109/L, P < 0.001). CONCLUSIONS: Compared with complicated disease, phlegmonous appendicitis seems to depend primarily on eosinophil inflammation. This observation is stable over time and indicates a direction for investigation of underlying genetic prerequisites.

Persistent methicillin-resistant Staphylococcus aureus bacteremia owing to placental abscess.

Staphylococcus aureus as a pathogen in human gestational membranes, a rather rare phenomenon, has recently been the focus of several researches. S. aureus forms biofilms on these membranes and potentially causes chorioamnionitis in pregnant women. We report a case of persistent methicillin-resistant S. aureus (MRSA) bacteremia owing to placental infection, causing chorioamnionitis and preterm birth. A 29-year-old Japanese woman at the 27th gestational week was diagnosed with acute promyelocytic leukemia and underwent all-trans retinoic acid therapy. Soon after hospitalization, the patient presented with persistent MRSA bacteremia of unknown origin. Despite various antimicrobial therapies, she experienced 12 MRSA bacteremia episodes over 6 weeks. However, after child birth, MRSA bacteremia disappeared without any complications. A pathologic examination of her placenta revealed placenta abscess, resulting in a diagnosis of MRSA-associated chorioamnionitis. Molecular analysis proved that a single MRSA strain (SCCmec Type IVa), which tested negative for Panton-Valentine leukocidin and toxic shock syndrome toxin-1, caused the obstinate infection. We should be aware that persistent MRSA bacteremia in pregnant women can originate from placental abscess.

C-Reactive Protein on Postoperative Day 1 Is a Reliable Predictor of Pancreas-Specific Complications After Pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula and pancreas-specific complications have a significant influence on patient management and outcomes after pancreatoduodenectomy. The aim of the study was to assess the value of serum C-reactive protein on the postoperative day 1 as early predictor of pancreatic fistula and pancreas-specific complications. METHODS: Between 2013 and 2016, 110 patients underwent pancreaticoduodenectomy. Clinical, biological, intraoperative, and pathological characteristics were prospectively recorded. Pancreatic fistula was graded according to the International Study Group on Pancreatic Fistula classification. A composite endpoint was defined as pancreas-specific complications including pancreatic fistula, intra-abdominal abscess, postoperative hemorrhage, and bile leak. The diagnostic accuracy of serum C-reactive protein on postoperative day 1 in predicting adverse postoperative outcomes was assessed by ROC curve analysis. RESULTS: Six patients (5%) died and 87 (79%) experienced postoperative complications (pancreatic-specific complications: n = 58 (53%); pancreatic fistula: n = 48 (44%)). A soft pancreatic gland texture, a main pancreatic duct diameter < 3 mm and serum C-reactive protein ≥ 100 mg/L on postoperative day 1 were independent predictors of pancreas-specific complications (p < 0.01) and pancreatic fistula (p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 100 mg/L on postoperative day 1 was a significant predictor of pancreatic fistula (AUC: 0.70; 95%CI: 0.60-0.79, p < 0.01) and pancreas-specific complications (AUC: 0.72; 95%CI: 0.62-0.82, p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 50 mg/L at discharge was a significant predictor of 90-day hospital readmission (AUC: 0.70; 95%CI: 0.60-0.79, p < 0.01). CONCLUSIONS: C-reactive protein levels reliably predict risks of pancreatic fistula, pancreas-specific complications, and hospital readmission, and should be inserted in risk-stratified management algorithms after pancreaticoduodenectomy.

A case of amebiasis with negative serologic markers that caused intra-abdominal abscess.

A 23-year-old Japanese woman presented with abdominal distention following fever, diarrhea, and abdominal pain during a stay in Taiwan. Serology for the detection of amebic-antibodies and stool microscopic examination were both negative. A computed tomography scan showed a 13 cm diameter abscess spreading from the lower abdominal wall to the pelvic retroperitoneal space. Needle aspiration of the abscess was done under computed tomography guidance, and microscopy of the aspirated fluid revealed trophozoites of Entamoeba. The patient was diagnosed as amebiasis with negative serologic markers that caused intra-abdominal abscess. Intravenous metronidazole treatment for two weeks did not result in any improvement of the abscess. After irrigation and drainage of the abscess, her symptoms resolved. This case report highlights that amebiasis should be considered when indicated by patient history, including travelers returning from endemic areas, and that further evaluation is necessary for diagnosis, even if the serology and stool test are negative.

Lack of utility of measuring serum bilirubin concentration in distinguishing perforation status of pediatric appendicitis.

BACKGROUND: Pediatric appendicitis is a common, potentially serious condition. Determining perforation status is crucial to planning effective management. PURPOSE: Determine the efficacy of serum total bilirubin concentration [STBC] in distinguishing perforation status in children with appendicitis. METHODS: Retrospective review of 257 cases of appendicitis who received abdominal CT scan and measurement of STBC. RESULTS: There were 109 with perforation vs 148 without perforation. Although elevated STBC was significantly more common in those with [36%] vs without perforation [22%], the mean difference in elevated values between groups [0.1mg/dL] was clinically insignificant. Higher degrees of hyperbilirubinemia [>2mg/dL] were rarely encountered [5%]. Predictive values for elevated STBC in distinguishing perforation outcome were imprecise [sensitivity 38.5%, specificity 78.4%, PPV 56.8%, NPV 63.4%]. ROC curve analysis of multiple clinical and other laboratory factors for predicting perforation status was unenhanced by adding the STBC variable. Specific analysis of those with perforated appendicitis and percutaneously-drained intra-abdominal abscess which was culture-positive for Escherichia coli showed an identical rate of STBC elevation compared to all with perforation. CONCLUSIONS: The routine measurement of STBC does not accurately distinguish perforation status in children with appendicitis, nor discern infecting organism in those with perforation and intra-abdominal abscess.

Procalcitonin in Crohn's disease with fever episodes, a variable to differentiate intra-abdominal abscess from disease flares.

BACKGROUND: Crohn's Disease (CD) is a chronic inflammatory disease accompanied by many complications, such as intra-abdominal abscess (IAA). A frequent problem in CD is the discrimination of fever caused by exacerbated bowel inflammation or IAA. METHODS: A total of 80 CD patients complaining with fever episodes were included prospectively. PCT, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count (WBC) were evaluated on admission. IAA was identified based on image studies and response to antibiotic therapy by physicians blind to the serum PCT level. At last, correlation between serum PCT level and patients' disease activity was also investigated. RESULTS: Sixteen patients were identified with IAA, which showed significantly higher serum PCT level when compared with those patients who have no IAA (0.505 ng/ml vs 0.112 ng/ml, p < 0.01). PCT is a better biomarker of IAA in CD patients compared with CRP, ESR and WBC (AUC = 0.954, 0.757, 0.771 and 0.554, respectively). And the cutoff value for PCT in differentiating patients with and without IAA was 0.35 ng/ml. Correlation between serum PCT level and CDAI score (r = 0.575) was weaker than that of CRP and ESR (r = 0.628 and 0.634 respectively), but stronger than that of WBC (r = 0.162). CONCLUSION: PCT can be an additional marker for detecting IAA in CD patients with fever episodes, and may serve as a new serological marker of disease activity.

Hyperbaric oxygen therapy improves colorectal anastomotic healing.

PURPOSE: Hyperbaric oxygen treatment (HBOT) has been found to improve the healing of poorly oxygenated tissues. This study aimed to investigate the influence of HBOT on the healing in ischemic colorectal anastomosis. METHODS: Forty Wistar rats were randomly divided into a treatment group that received HBOT for 10 consecutive days (7 days before and 3 days after surgery), or in a control group, which did not receive the therapy. Colectomy with an ischemic anastomosis was performed in all rats. In each group, the rats were followed for 3 or 7 days after surgery to determine the influence of HBOT on anastomotic healing. RESULTS: Five rats from each group died during follow-up. No anastomotic dehiscence was seen in the HBOT group, compared to 37.5 % and 28.6 % dehiscence in the control group on postoperative day (POD) 3 and 7, respectively. The HBOT group had a significantly higher bursting pressure (130.9 ± 17.0 mmHg) than the control group (88.4 ± 46.7 mmHg; p = 0.03) on POD 3. On POD 3 and POD 7, the adhesion severity was significantly higher in the control groups than in the HBOT groups (p < 0.005). Kidney function (creatinine level) of the HBOT group was significantly better than of the control group on POD 7 (p = 0.001). Interestingly, a significantly higher number of CD206+ cells (marker for type 2 macrophages) was observed in the HBOT group at the anastomotic area on POD 3. CONCLUSION: Hyperbaric oxygen enhanced the healing of ischemic anastomoses in rats and improved the postoperative kidney function.

Preprocedural Coagulation Studies in Pediatric Patients Undergoing Percutaneous Intervention for Appendiceal Abscesses.

The literature reports poor correlation between coagulation screening and prediction of bleeding risk in children. Our aim is to determine whether there is a role for coagulation studies in children undergoing percutaneous intervention for appendiceal abscesses. A retrospective review of 1805 patients presenting with a diagnosis of appendicitis from September 2008 to September 2013 was performed. Patients presenting with appendiceal abscess who underwent percutaneous intervention were selected for further review (n = 131). A total of 76 patients (58%) had normal coagulation studies, whereas 55 (42%) had elevated values. An international normalized ratio ≥ 1.3 was found in 26 patients. Patients with normal coagulation values had an incidence of bleeding of 1.3 per cent. In the abnormal coagulation group, 8 patients received fresh frozen plasma before intervention, whereas 47 did not. There was one hematoma noted in each group with an incidence of bleeding of 3.6 per cent. The overall incidence of hematoma was 2.3 per cent with no significant difference in bleeding risk between the normal and abnormal coagulation groups. In conclusion, although many patients are found to have elevated coagulation studies, most do not have bleeding complications after intervention. There is poor correlation between coagulation screening and postprocedural outcomes evidenced by the low risk of bleeding.

Clinical significance of serum triglyceride elevation at early stage of acute biliary pancreatitis.

BACKGROUND: Pancreatitis induced by hypertriglyceridemia (HTG) has gained much attention. However, very limited numbers of studies have focused on the clinical significance of TG elevation in non-HTG induced pancreatitis, such as acute biliary pancreatitis (ABP). This study aimed to study the clinical significances of triglyceride (TG) elevation in patients with ABP. METHODS: We retrospectively analyzed a total of 426 ABP cases in our research center. According to the highest TG level within 72 h of disease onset, the patients were divided into a normal TG group and an elevated TG group. We analyzed the differences between the two groups of patients in aspects such as general information, disease severity, APACHE II (acute physiology and chronic health evaluation II) and Ranson scores, inflammatory cytokines, complications and prognosis. RESULTS: Compared with the normal TG group, patients in the elevated TG group showed a significantly higher body mass index and were significantly younger. TG elevation at the early stage of ABP was associated with higher risk of severe pancreatitis and organ failures, especially respiratory failure. For patients with severe pancreatitis, those with elevated TG levels were more likely to have a larger area of necrosis, and higher incidence of pancreatic abscess as well as higher mortality (17.78% versus 9.80%, P < 0.05). CONCLUSIONS: In ABP patients, TG elevation might participate in the aggravation of pancreatitis and the occurrence of systemic or local complications. Thus, the TG level may serve as an important indicator to determine the prognosis of patients with ABP.

Postoperative intra-abdominal infection and colorectal cancer recurrence: a prospective matched cohort study of inflammatory and angiogenic responses as mechanisms involved in this association.

BACKGROUND: Anastomotic leakage is associated with higher rates of recurrence after surgery for colorectal cancer. However, the mechanisms responsible are unknown. The aim was to investigate the inflammatory and angiogenic responses in patients undergoing surgery for colorectal cancer who had postoperative intra-abdominal infection, and to compare the results with patients without complications. METHODS: Consecutive patients undergoing surgery for colorectal cancer with curative intent were included. Patients who had an anastomotic leak or intra-abdominal abscess were included in the infection group and matched with patients who had an uncomplicated postoperative course. IL-6 and VEGF were measured in serum and peritoneal fluid. RESULTS: Serum concentration of IL-6 was higher in the infection group (n = 30) compared with the control group (n = 30) on day 4 (infection: 42.3 [27.6-1473.2] versus control: 0.6 [0.6-17.1] pg/ml; p = 0.008). IL-6 in peritoneal fluid was higher in the infection group at 48 h and day 4 (infection: 1000.2 [995.4-1574.0] versus control: 90.3 [35.2.6-106.1] pg/ml; p = 0.001). Serum VEGF was higher in the infection group on day 4 (infection: 1128.6 [427.3-10000.0] versus control: 438.3 [214.1-677.6] pg/ml; p = 0.001). Peritoneal VEGF concentration was higher in the infection group at 48 h and day 4 (infection: 10000.0 [2563.0-10000.0] versus control: 477.8 [313.5-814.4] pg/ml; p = 0.001). Two-year recurrence rate was higher in patients with infection (infection: 30% versus control: 4%; p = 0.001). CONCLUSIONS: Intra-abdominal infection increases IL-6 and VEGF after surgery for colorectal cancer. Amplification of inflammation and angiogenesis might be one of the mechanisms responsible for the higher recurrence rate observed in patients with anastomotic leakage or intra-abdominal abscess.

Correlation of plasma osteopontin and neutrophil gelatinase-associated lipocalin levels with the severity and clinical outcome of pelvic inflammatory disease.

OBJECTIVE: To investigate the correlation of two important inflammatory biomarkers, plasma osteopontin and neutrophil gelatinase-associated lipocalin (NGAL), with the severity and outcome of pelvic inflammatory disease (PID). MATERIALS AND METHODS: Sixty-one patients with PID, including 25 patients with tubo-ovarian abscess (TOA), were consecutively recruited. Their blood samples were tested for the concentrations of plasma osteopontin and NGAL using enzyme-linked immunosorbent assay. The associations of these biomarkers with TOA, length of hospitalization, and incidence of surgery were also analyzed. RESULTS: Plasma osteopontin level was significantly increased in PID patients with TOA compared to PID patients without TOA (median 107.77 ng/mL vs. 72.39 ng/mL, p = 0.004). However, there was no significant difference for plasma NGAL. If the cutoff level of plasma osteopontin was set at 81.1 ng/mL, there was a 76.0% sensitivity and a 24.0% false negative rate in predicting TOA in PID patients. Plasma osteopontin significantly correlated with length of hospital stay (r = 0.467, p < 0.001), and this correlation was better than that of NGAL. However, neither biomarker was associated with incidence of surgery. CONCLUSION: Plasma osteopontin has a better correlation with TOA and length of hospitalization compared to NGAL. If plasma osteopontin level falls below 81.1 ng/mL, PID patients will have about a 20% chance of developing TOA. Incorporating plasma osteopontin, but not NGAL, will allow for an adjuvant diagnostic biomarker for TOA and predictor of length of hospital stay.

Increased apoptosis of peripheral blood neutrophils is associated with reduced incidence of infection in trauma patients with hemorrhagic shock.

OBJECTIVE: We aimed to describe the relationship between early peripheral leukocyte apoptosis and incidence of subsequent infection in trauma patients with hemorrhagic shock (T/HS). METHODS: T/HS patients requiring emergency surgery were prospectively enrolled. Nucleosome ELISA and TUNEL staining were performed on peripheral blood drawn pre-operatively, post-operatively and at 24 h. Subjects were followed for 30 days or until death or hospital discharge to record all episodes of infection. RESULTS: Forty-one subjects were enrolled. Six died within 24 h of surgery and were not included in the analysis. Nucleosome levels peaked post-operatively and dropped to baseline levels at 24 h (p = 0.03). TUNEL analysis revealed that polymorphonuclear neutrophils (PMNs) accounted for 72% of apoptotic leukocytes; the remaining apoptotic cells were mainly lymphocytes. Increased post-operative leukocyte apoptosis was associated with decreased systemic inflammatory response syndrome (SIRS) severity. Seventeen of the 35 survivors (48.6%) developed infections, while 18 (51.4%) did not. Pre-operative and post-operative nucleosome levels were 2.5 and 3 times higher, respectively, in T/HS patients who did not develop infection compared to those who did. Increased nucleosome levels were associated in particular with protection against sepsis (p=0.03) and multiple infections (p = 0.01). CONCLUSION: Peripheral blood PMN apoptosis in the early resuscitative period is associated with decreased incidence of subsequent infection in T/HS patients.

Cat scratch disease presenting with a retroperitoneal abscess in a patient without animal contacts.

Cat scratch disease (CSD) is usually diagnosed in patients presenting with regional lymphadenopathy and pyrexia that follow contacts with animals. We describe here a young adult male patient who presented with marked pyrexia and a retroperitoneal abscess without relevant medical histories, illustrating that CSD can be a diagnostic challenge on selected occasions.