Nonoperative management of blunt liver injury in hemodynamically stable versus unstable patients: a retrospective study.

PURPOSE: The success rate of nonoperative management (NOM) of traumatic liver injury is approximately 90%. Although NOM has become the standard treatment when patients' vital signs are stable, open surgical hemostasis is often selected when these signs are unstable. At our hospital, we extensively use NOM along with transcatheter arterial embolization (TAE) to treat patients with severe abdominal trauma, as per our original protocol. We also apply NOM for severe liver injury with unstable hemodynamics. This retrospective study aimed to investigate the efficacy of NOM for blunt liver injury in hemodynamically stable and unstable patients. METHODS: We retrospectively examined 23 patients with severe liver injuries who underwent NOM after visiting our emergency outpatient department between 2007 and 2017. Patients were assigned to either the stable group with stable hemodynamics or the unstable group with unstable hemodynamics. RESULTS: The stable group comprised 13 patients, and the unstable group comprised 10 patients. All patients underwent TAE. While all patients in the stable group were discharged alive, one patient in the unstable group died during the hospital stay. The response rate to NOM was 90%, and no patient switched from NOM to open surgery. A higher rate of complications with a significantly longer average stay in the intensive care unit was observed in the unstable group. CONCLUSIONS: Even in the unstable group, NOM with TAE performed under careful general management facilitated avoidance of open surgery and provided high survival rates.

Presepsin in the prognosis of infectious diseases and diagnosis of infectious disseminated intravascular coagulation: a prospective, multicentre, observational study.

BACKGROUND: Few prospective studies have described the prognostic accuracy of presepsin for 28-day mortality during days 0 to 7, or its role in the diagnosis of disseminated intravascular coagulation (DIC) in patients with infection. OBJECTIVE: We aimed to evaluate the clinical usefulness of presepsin levels by comparing infection markers such as procalcitonin, interleukin-6 and C-reactive protein, as well as markers of DIC such as fibrin degradation products (FDPs) and D-dimer, from days 0 to 7. DESIGN: A prospective, multicentre, observational study. SETTING: Four medical institutions between June 2010 and June 2011. PATIENTS: A total of 191 patients who fulfilled at least one of the systemic inflammatory response syndrome (SIRS) criteria were enrolled in the study. MAIN OUTCOME MEASURES: The presepsin levels were evaluated for their diagnostic accuracy in discriminating between SIRS and sepsis, the prognostic accuracy for 28-day mortality from days 0 to 7 and the diagnostic accuracy for DIC in patients with infection by comparison with other infection markers. RESULTS: The diagnostic accuracy for discriminating between SIRS and sepsis from combining the presepsin and procalcitonin measurements [area under the curve (AUC), 0.91; likelihood ratio, 4.96] was higher than that of presepsin (AUC, 0.89; likelihood ratio, 4.75) or procalcitonin (AUC, 0.85; likelihood ratio, 3.18) alone. Not only the correlation coefficient between the presepsin level and the sequential organ failure assessment (SOFA) score but also the prognostic accuracy of presepsin for 28-day mortality increased with the elapsed time, and both were highest at day 7. The diagnostic accuracy for DIC generated by combining presepsin and FDP (AUC, 0.84; likelihood ratio, 3.57) was higher than that of FDP (AUC, 0.82; likelihood ratio, 2.64) or presepsin (AUC, 0.80; likelihood ratio, 2.94) alone. CONCLUSION: The prognosis and severity of infection may be assessed more accurately by measuring the presepsin levels until day 7. Presepsin is a useful diagnostic tool for DIC with infection.

Presepsin as a powerful monitoring tool for the prognosis and treatment of sepsis: a multicenter prospective study.

Presepsin is a protein whose levels increase specifically in the blood of patients with sepsis. It is proposed as a diagnostic and prognostic marker for assessing the degree of sepsis severity. The present multicenter prospective study compared the clinical utility of presepsin with other conventional sepsis biomarkers including procalcitonin, interleukin-6, and C-reactive protein for evaluating the severity of sepsis during follow-up. Patients with sepsis (n = 103) admitted to the emergency room or intensive care unit were enrolled in this study and classified into 3 diagnostic groups: sepsis, severe sepsis, and septic shock. Blood samples were obtained from each patient on admission and after 1, 3, 5, and 7 days. The patients were further divided into the favorable and unfavorable prognosis groups on the basis of several indicators of sepsis severity (i.e., Sequential Organ Failure Assessment score, and Acute Physiology and Chronic Health Evaluation II score). The patients in the favorable prognosis group exhibited significant decreases in all biomarker levels on days 3 and 7 after admission. In the unfavorable prognosis group, only presepsin levels did not decrease significantly during follow-up. The period of antibiotics treatment in the unfavorable prognosis group was significantly longer than those in the favorable prognosis group (P < 0.05). The unfavorable prognosis group had significantly higher 28-day mortality than the favorable prognosis group (P < 0.05). Therefore, the results suggest that presepsin levels correlated with the severity of sepsis during follow-up in comparison with other conventional sepsis biomarkers.

Usefulness of presepsin in the diagnosis of sepsis in a multicenter prospective study.

The clinical usefulness of presepsin for discriminating between bacterial and nonbacterial infections (including systemic inflammatory response syndrome) was studied and compared with procalcitonin (PCT) and interleukin-6 (IL-6) in a multicenter prospective study. Suspected sepsis patients (n = 207) were enrolled into the study. Presepsin levels in patients with systemic bacterial infection and localized bacterial infection were significantly higher than in those with nonbacterial infections. In addition, presepsin, PCT, and IL-6 levels in patients with bacterial infectious disease were significantly higher than in those with nonbacterial infectious disease (P < 0.0001, P < 0.0001, and P < 0.0001, respectively). The area under the receiver operating characteristic curve was 0.908 for presepsin, 0.905 for PCT, and 0.825 for IL-6 in patients with bacterial infectious disease and those with nonbacterial infectious disease. The cutoff value of presepsin for discrimination of bacterial and nonbacterial infectious diseases was determined to be 600 pg/ml, of which the clinical sensitivity and specificity were 87.8 % and 81.4 %, respectively. Presepsin levels did not differ significantly between patients with gram-positive and gram-negative bacterial infections. The sensitivity of blood culture was 35.4 %; that for presepsin was 91.9 %. Also there were no significant differences in presepsin levels between the blood culture-positive and -negative groups. Consequently, presepsin is useful for the diagnosis of sepsis, and it is superior to conventional markers and blood culture.

Hepatic cyst infection complicated by a hepatobronchial fistula diagnosed with unique features.

A hepatobronchial fistula (HBF) is a rare condition, defined as an abnormal connection of the respiratory system with the liver parenchyma. Although imaging may be helpful for diagnosis, fistulae are often difficult to identify. An 81-year-old woman presented with mild fever and right upper quadrant abdominal pain. Computed tomography (CT) showed bilateral pneumonia and hepatic cyst infection with air-fluid levels. After mechanical ventilation, abdominal CT showed increased air in the hepatic cyst. The drainage bag for the hepatic cyst infection was also inflated by positive pressure ventilation, suggesting a possible HBF. The ventilator was adjusted to minimize pressure on the fistula and prevent retrograde infection. The fistula eventually closed spontaneously. Appropriate antibiotic treatment and continuous drainage resulted in improvement of the hepatic cyst infection; however, the patient died due to respiratory complications. HBF should be suspected when positive pressure ventilation results in increased air at the hepatic infection site.