RESUMEN
PURPOSE: The introduction of reimbursement for screening colonoscopy in Germany more than one year ago raised concerns that the consequent workload might lead to underuse of diagnostic colonoscopy for symptomatic patients. Available appropriateness criteria for diagnostic colonoscopy have been rarely tested in a realistic outpatient setting. This study was designed to test current appropriateness criteria for diagnostic colonoscopy to better select patients and potentially provide more capacity for screening cases. Secondary goals were yield and quality control in both the diagnostic and screening cases. METHODS: A prospective study was initiated in 39 private-practice offices to collect data on consecutive colonoscopies conducted during a 6-day study period. A detailed questionnaire was developed to define indications and symptoms, and all findings at colonoscopy were recorded. Colonoscopies were further analyzed and stratified into a screening and a diagnostic group. In the diagnostic group, indications were assessed according to the current guidelines for appropriateness (American Society for Gastrointestinal Endoscopy, European Panel for the Appropriateness of Gastrointestinal Endoscopy), and the results were correlated with the percentage of relevant findings (tumors, inflammatory conditions). RESULTS: During the study period, 1,397 colonoscopies (57 percent screening, 43 percent diagnostic) were analyzed (male/female ratio = 39/61 percent; mean age, 61 years). Fourteen percent and 37 percent, respectively, of the 605 diagnostic colonoscopies were regarded as inappropriate relative to the criteria of the American Society for Gastrointestinal Endoscopy and the European Panel for the Appropriateness of Gastrointestinal Endoscopy. However, the percentage of relevant inflammatory and neoplastic findings (polyps, cancer, inflammatory bowel disease, benign strictures) was only 5 to 10 percent higher in the appropriate group than in the inappropriate group. On the basis of these data, a hypothetical model for selecting appropriate indications was developed: if patients older than aged 50 years with pain, bleeding, and diarrhea, but not constipation, are regarded as having an appropriate indication, such an approach would save 20 percent of colonoscopies in these main indication groups (bleeding, pain, diarrhea, constipation), with a hypothetical miss rate for relevant findings (as defined above) of 5 percent. CONCLUSIONS: Currently used appropriateness criteria for diagnostic colonoscopy increase the yield of relevant findings but lead to a miss rate for relevant findings in the range of 10 to 15 percent. Simple selection criteria based on age and symptoms could be more suitable and should be tested in a larger group of patients.
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Colonoscopía/estadística & datos numéricos , Neoplasias Colorrectales/diagnóstico , Tamizaje Masivo/estadística & datos numéricos , Práctica Privada/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Alemania , Humanos , Masculino , Persona de Mediana Edad , Programas Nacionales de Salud , Selección de Paciente , Vigilancia de la Población , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Control de CalidadRESUMEN
BACKGROUND: Leukocytes transmitted in blood products exert a variety of immunological side-effects. Experience with bone marrow transplant recipients has shown that these can be induced even by very few cells. In liver transplant recipients, who usually receive large amounts of blood products, the effects of transfused leukocytes with regards to the rates of rejection and infection have not yet been investigated. MATERIAL/METHODS: Twenty liver transplant recipients were prospectively randomized to receive blood products (red blood cells, thrombocytes, fresh frozen plasma) through a leukocyte depletion filter, either irradiated with 40 Gy or not irradiated (10 patients, respectively). During the observation period of 90 days, the incidences of infections and rejections were analyzed. In addition, liver function tests, markers of infection (C reactive protein, lipopolysaccharide binding protein), and subpopulations of lymphocytes (total cell count, CD4/CD8 ratio, CD8CD45RO) were determined. RESULTS: Only one episode of mild rejection occurred (irradiated group). Rates of persistent graft dysfunction and severe infections were similar in both groups. The same applied to liver function tests, parameters of infection, and subpopulations of lymphocytes. CONCLUSIONS: These preliminary results suggest that irradiation of already leukocyte-depleted blood products may not be necessary and beneficial in liver transplant recipients.
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Transfusión Sanguínea , Trasplante de Hígado , Adulto , Femenino , Rayos gamma , Rechazo de Injerto/etiología , Humanos , Infecciones/etiología , Procedimientos de Reducción del Leucocitos , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/inmunología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Subgrupos de Linfocitos T/inmunologíaRESUMEN
INTRODUCTION: Postoperative infection is a major cause of morbidity and mortality. We investigated two serum markers for their ability to identify patients at risk for postoperative infection. Mannan-binding lectin (MBL) is a central molecule of the innate immune system and MBL deficiency is known to predispose to infection. Procalcitonin (PCT) is a sensitive marker for bacterial infection. METHODS: We investigated 162 patients undergoing elective surgery for cancer of the gastrointestinal tract. Patients were classified as having no complications (group A), having infection for unknown reason (group B) or having sepsis after events like aspiration or anastomotic leakage (group C). Analysis was done pre- and postoperatively for serum levels of MBL, PCT and C-reactive-protein. DNA was preoperatively sampled and stored and later analysed for genetic polymorphisms of MBL. RESULTS: The preoperative serum levels of MBL were significantly lower in group B patients than in group A patients (1332 +/- 466 ng/ml versus 2523 +/- 181 ng/ml). PCT measured on day one post-surgery was significantly higher in group B patients than in group A (3.33 +/- 1.08 ng/ml versus 1.38 +/- 0.17 ng/ml). Patients with an aberrant MBL genotype had a significantly higher risk of postoperative infections than wild-type carriers (p < 0.05). CONCLUSION: Preoperative MBL and early postoperative PCT measurement may help identify patients at risk for postoperative infection.
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Calcitonina/sangre , Infecciones/diagnóstico , Lectina de Unión a Manosa/sangre , Complicaciones Posoperatorias/diagnóstico , Precursores de Proteínas/sangre , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Proteína C-Reactiva , Péptido Relacionado con Gen de Calcitonina , Procedimientos Quirúrgicos del Sistema Digestivo , Femenino , Genotipo , Humanos , Masculino , Lectina de Unión a Manosa/genética , Persona de Mediana Edad , Fragmentos de Péptidos/sangre , Polimorfismo Genético/genética , Valor Predictivo de las Pruebas , Estadísticas no ParamétricasRESUMEN
BACKGROUND: Standardized methods to measure peritoneal cytokine production do not exist. This feasibility study examines the use of microdialysis to monitor perioperative peritoneal mediator production in patients following abdominal surgery for infective or non-infective conditions. MATERIALS AND METHODS: At the beginning of the operation, a microdialysis catheter was placed between the patient's parietal peritoneum and the muscular fascia of the abdominal wall in the connective tissue bed. The device was irrigated (18 microL/h, Ringer's solution/0.05% albumin) for up to 7 days. Samples of the dialysate were collected at least twice a day, and concentrations of interleukin (IL)-6 and monocyte chemoattractant protein (MCP)-1 were measured by an ELISA technique. Four of the nine patients included had proved intra-abdominal infections. RESULTS: In uninfected patients, IL-6 concentrations peaked 8 h after skin incision (mean +/- SEM): 1696 +/- 1292 pg/mL and dropped rapidly to significantly lower concentrations (less than 400 pg/mL) thereafter. MCP-1 concentrations also peaked at 8 h (12787 +/- 6893 pg/mL). In the following days, MCP-1 concentrations were variable between 1000 and 5000 pg/mL. In infected patients, early IL-6 production tended to be higher and that of MCP-1 tended to be lower than in uninfected patients. Catheters were removed between day four and day seven when the system failed or when the patients became mobile without any clinical symptoms of complications. CONCLUSION: The samples derived from microdialysis were suitable to measure sub-peritoneal mediator profiles during surgery and up to 7 days postoperatively. Microdialysis data should be validated for a potential correlation with the clinical course.
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Citocinas/metabolismo , Neoplasias Gastrointestinales/cirugía , Microdiálisis/métodos , Peritoneo/metabolismo , Abdomen/cirugía , Adulto , Anciano , Quimiocina CCL2/análisis , Quimiocina CCL2/metabolismo , Citocinas/análisis , Ensayo de Inmunoadsorción Enzimática , Estudios de Factibilidad , Femenino , Humanos , Interleucina-6/análisis , Interleucina-6/metabolismo , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/métodos , Atención Perioperativa , Proyectos Piloto , Complicaciones Posoperatorias/diagnóstico , Periodo Posoperatorio , Muestreo , Sensibilidad y EspecificidadRESUMEN
In injured patients, it has been shown that a polymorphism of the tumor necrosis factor-beta (TNFbeta) gene is related to the development of sepsis. We investigated the relation of TNFbeta gene polymorphism with the development of severe complications after elective major abdominal operations, and with production of TNFalpha perioperatively. In the present investigation, the Ncol polymorphism was studied in genomic DNA isolated from the blood of 172 patients. Preoperatively and postoperatively, lipopolysaccharide (LPS)-stimulated production of TNFalpha in the patients' whole blood was tested in vitro. Genotypes and TNFalpha production were related to the occurrence of severe complications. Postoperatively, 15% (n = 26) of the patients developed severe complications. The overall mortality was 2% (n = 3). The homozygous TNFB2 genotype was found in 54% of the patients, the homozygous TNFB1 genotype was found in 14% of the patients, and the heterozygous genotype was found in 32% of the patients. In patients with complications, the B2B2 genotype was much more frequent (21/26, 81%) than in those without complications (72/146, 49%; P < 0.003). The development of complications was associated with a lower capacity to produce TNFalpha 3 and 7 days after the operation. In patients without complications, the TNFbeta polymorphism was not related to different levels of TNFalpha production. These data indicate an association between TNFbeta polymorphism and postoperative complications and they suggest the B2/B2 genotype as a high risk factor for the development of sepsis after elective operative trauma.
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Predisposición Genética a la Enfermedad , Polimorfismo Genético , Complicaciones Posoperatorias/etiología , Factor de Crecimiento Transformador beta/genética , Adulto , Anciano , Anciano de 80 o más Años , Esófago/cirugía , Femenino , Genotipo , Homocigoto , Humanos , Intestinos/cirugía , Lipopolisacáridos/farmacología , Masculino , Persona de Mediana Edad , Páncreas/cirugía , Riesgo , Sepsis/prevención & control , Estómago/cirugía , Factores de TiempoRESUMEN
The aim of the study was to compare peritoneal and systemic production of interleukin 6 (IL-6) and monocyte chemoattractant protein-1 (MCP-1) in uninfected patients and in patients with peritonitis. Peritoneum was excised at laparotomy for acute peritonitis (n = 22) or noninfectious reasons (n = 61), and was incubated with or without lipopolysaccharide (LPS). Mediator concentrations in the culture-supernatants, in the patients' serum, and in plasmasupernatants of LPS-stimulated whole blood were related to outcome. Spontaneous production of IL-6 by the peritoneum was increased in infected patients compared with uninfected patients. In contrast to IL-6, LPS-stimulated production of MCP-1 was significantly less in infected patients. Serum concentrations of both mediators were higher in infected patients and the highest concentrations of MCP-1 were in patients who died. LPS-stimulated production of IL-6 in whole blood was least, whereas that of MCP-1 was greatest in infected patients who died. These contrasting results for local and systemic production of mediators illustrate the compartmentalized immune response to intra-abdominal infection.