Xie, Tian1; Wang, Shikai1; Zhang, Xiangda2; Ou, Sihua3; Mo, Xiaoqiao4 Author Information

OBJECTIVE:To establish a prognostic Nomogram model for predicting the risk of early death in polytrauma patients. METHODS:Data extracted from a polytrauma study on Dryad, an open access database, was selected for secondary analysis. Patients from 18 to 65 years old with polytrauma in the original data were included. All patients with missing variables, such as blood lactic acid (Lac), Glasgow coma score (GCS) and injury severity score (ISS) at admission, were excluded. The differences of gender, age, Lac, ISS and GCS scores between the patients who died within 72 hours and those who survived were analyzed. The risk factors for 72-hour death were analyzed by Logistic regression, and the Nomogram prediction model was established using R software. The receiver operating characteristic (ROC) curve was used to evaluate the predictive ability of the model, and the Bootstrap method was used for internal verification by repeating sample for 1 000 times. Decision curve (DCA) was applied to analyze the clinical practical value of the model. RESULTS:A total of 2 315 polytrauma patients were included. Logistic regression analysis showed that Lac, GCS score and age > 55 years old were the risk factors for early death in polytrauma patients [Lac: odds ratio (OR) = 1.36, 95% confidence interval (95%CI) was 1.29-1.42, P < 0.001; GCS score: OR = 0.76, 95%CI was 0.73-0.79, P < 0.001; age > 55 years old: OR = 1.92, 95%CI was 1.37-2.66, P < 0.001]. The prediction model was established by using the above risk factors and displayed by Nomogram. ROC curve analysis showed that the area under the ROC curve (AUC) of Nomogram model to predict the risk of death within 72 hours was 0.858, and the predictive ability of Nomogram model was significantly higher than that of Lac (AUC = 0.743), GCS score (AUC = 0.774) and ISS score (AUC = 0.699), all P < 0.05. The model calibration chart showed that the predicting probability was consistent with the actual occurrence probability, and the DCA showed that Nomogram model presented excellent clinical value in predicting the 72-hour death risk for polytrauma patients. CONCLUSIONS:The prognostic Nomogram model presents significantly predictive value for the risk of death within 72 hours in polytrauma patients. Prognostic Nomogram model could offer individualized, visualized and graphical prediction pattern, and provide physicians with practical diagnostic tool for triage system and management of polytrauma according to precision medicine.

Background: This retrospective study aims to investigate the effects of the endovascular and surgical strategy for treating patients with acute mesenteric venous thrombosis (AMVT). Methods: We retrospectively studied 68 patients with AMVT who underwent treatment in Jinling Hospital during the period from January 2009 to December 2014. The mean age was 45 +/- 12 years (range 20-72 years). All patients were treated by using the combined treatment that included endovascular treatment, damage control surgery, surgical intensive care, and intestinal rehabilitation treatment. Clinical outcomes and complications were compared during the follow-up period. Results: All the 68 cases received anticoagulant treatment. However, only 24 received the endovascular intervention, 19 received surgical resection, and 25 patients received endovascular treatment combined with bowel resection. The overall mortality rate was 2.94% (2 cases). Bowel resection range significantly decreased (92 +/- 14 cm vs. 162 +/- 27 cm, t = -2.377, P = 0.022) in the combination therapy group, when compared with the surgery group. During the 1-year follow-up period, 4 cases suffered from short bowel syndrome. Conclusions: Our study indicates that AMVT can be successfully treated with the early improvement of intestinal blood circulation. Further, our applied combined approach showed a favorable outcome in mesenteric thrombosis patients and reduced the mortality rate by improving the prognosis significantly.

Objective To explore the diagnosis and treatment of mesenteric venous thrombosis secondary to long-term ischemic enteropathy.Methods The retrospective cross-sectional study was conducted.The clinical data of 36 patients with mesenteric venous thrombosis secondary to long-term ischemic enteropathy who were admitted to the Nanjing General Hospital of Nanjing Military Command from January 2009 to June 2017 were collected.Diagnostic methods:history inquiry,physical examination,laboratory test and image finding.Treatment methods:parenteral nutrition support,selective stage 1 bowel resection with anastomosis or stage 1 bowel resection and colostomy,definitive stage 2 operation for recovering digestive tract.Anticoagulation therapy was performed.Observation indicators:(1) clinical characteristics;(2) treatment;(3) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications up to December 2017.Measurement data with skewed distribution were described as M (P25,P75) and M (range).Results (1) Clinical characteristics:① the main clinical manifestations:34,33,27,20,17 and 14 patients showed respectively discomfort after meal,abdominal pain,abdominal distension,nausea with vomiting,stop of analis exhaust and defecation and weight loss of different degree,and the worst patient lost 20 kg within 1 month.The clinical manifestations of 30 patients were more than 3.② The score of acute physiology and chronic health evaluation (APACHE)Ⅱ in 36 patients was 4 (2,6).③ Laboratory test:total protein (TP),albumin and prealbumin were 55.8 g/L (45.2 g/L,59.1 g/L),30.6 g/L (27.3 g/L,37.5 g/L) and 100.0 g/L (86.0 g/L,132.0 g/L),respectively,showing a decreased trend.④ Imaging finding:enhanced scans of abdominal CT showed the portal cavernous in 16 patients,the absence of main trunk of superior mesenteric vein with extensive collaterals in 12 patients,and dovelopment of portal vein and main trunk of superior mesenteric vein in 8 patients.One patients had intestinal edema and stenosis.X-ray contrast examination of digestive tract showed intestinal stenosis with mucosal erosion in 28 patients and complete intestinal obstruction in 8 patients.(2) Treatment:of 36 patients,24 underwent stage 1 bowel resection with anastomosis and other 12 received stage 1 bowel resection and colostomy (11 undergoing definitive stage 2 operation for recovering digestive tract and 1 refusing stage 2 operation due to advanced age).The length of resected bowel was 30 cm (15 cm,80 cm).One patient with stage 1 bowel resection with anastomosis was complicated with small bowel fistula,and was cured by conservative treatment.There was no complication in other patients.(3) Follow-up:all 36 patients were followed up for 3-10 months,with a median time of 6 months.During the follow-up,7 patients were complicated with secondary portal hypertension,5 of 7 were improved by symptomatic treatment,and 2 died of severe digestive tract bleeding;other patients had no related complications.Conclusions The discomfort after meal and bowel obstruction are the main clinical manifestations of mesenteric venous thrombosis secondary to long-term ischemic enteropathy.The abdominal CT with X-ray contrast examination benefits to diagnosis of patients with poor nutrition status and mild infection.The main strategy includes early surgical resection and postoperative anticoagulation therapy after bleeding risk evaluation.

A growing number of studies have recently revealed a potential role for neutrophil extracellular traps (NETs) in the development of inflammation, coagulation and cell death. Deleterious consequences of NETs have been identified in ischemia-reperfusion (I/R)-induced organ damage, thrombosis and sepsis. And exogenous DNase-I has been suggested as a therapeutic strategy to attenuate ischemia-reperfusion (I/R) injuries in the kidney, brain and myocardium. Herein, we designed a study to investigate whether NETs contribute to the pathogenesis of intestinal I/R injury and evaluated the therapeutic value of DNase-1 in a rat model of intestinal I/R injury. In this rat model of intestinal I/R injury, we found that extracellular DNA was readily detectable in rat serum after 1 h of ischemia and 2 h of reperfusion. Treatment with DNase-1 significantly reduced the inflammatory response, restored intestinal barrier integrity and increased the expression of tight junction proteins. Our results indicate the existence of NETs in I/R-challenged intestinal tissues and firstly provide more evidence that DNase-1 may be an effective treatment for attenuating intestinal I/R injury.

Objective To explore the value of serum circulating free DNA (cf-DNA) in predicting prognosis of patients with abdominal trauma combined with sepsis.Methods Sixty-two patients with abdominal trauma combined with sepsis were divided into two groups of A(survival,51 cases) and B(death,11 cases) according to the final result,in whom peripheral venous blood samples were collected within 6 hours of sepsis and serum cf-DNA level was measured by direct fluorescence assay.The scattergram and Spearman rank correlation analysis were used to evaluate the correlation between early serum level of cf-DNA and APACHE Ⅱ score,SOFA score and inflammatory markers.Results Serum levels of cf-DNA and CRP,APACHE Ⅱ score,SOFA score and neutrophilic granulocyte count were higher in group B than those in group A(P＜0.05 or P＜0.01).Serum level of cf-DNA was postivitely correlated with APACHE Ⅱ score(rs =0.352,P＜0.01),SOFA score (rs =0.300,P＜0.05),serum level of CRP(rs =0.377,P＜0.01) and neutrophilic granulocyte count (rs =0.342,P＜0.01) in early sepsis.Taking 0.876 μg/ml as the best cutoff threshold,the sensitivity and specificity of serum cf-DNA for predicting the survival were 90.8％ and 82.4％,respectively.The AUC of serum cf-DNA,SOFA score,APACHE Ⅱ score and CRP for predicting survival were 0.911 [95％CI(0.831-0.990)],0.775[95％CI(0.640-0.910)],0.840[95％CI(0.731-0.949)] and 0.743 [95％CI(0.562-0.925)].Conclusion In the patients with abdominal trauma combined with sepsis,early serum level of cf-DNA is significantly correlated with APACHE Ⅱ score,SOFA score and inflammatory markers.Compared with APACHE Ⅱ score and SOFA score,serum level of cf-DNA has a better value in predicting the prognosis.

Objective To investigate the influential factors of surgical treatment for ischemic enteropathy secondary to portal venous system thrombosis (PVST).Methods Clinical data of 27 patients with ischemic enteropathy secondary to PVST admitted in our department from January 2009 to Jun 2016 were analyzed retrospectively.These patients were divided into two groups according to different surgical procedures:ischemic bowel resection with primary anastomosis or ostomy.Results There were significant differences between the groups in albumin and prealbumin level (t =3.585,4.194,P ＜0.05).There were also significant differences for BMI and body fat (t =2.325,2.430,P ＜ 0.05).The average time from the onset PVST to ischemic enteropathy was 20 d.Conclusion There should be awareness of ischemic enteropathy.Intestinal resection and anticoagulation therapy is necessary.The choice of surgical procedures depends on the preoperative nutrition level (albumin,prealbumin).

机体处于某些病理状态,如严重创伤、感染、肿瘤、缺血再灌注以及自身免疫性疾病时,循环游离DNA(circulating cell-free DNA,ccfDNA)含量明显升高.最新研究发现,ccfDNA作为一种潜在致病因素,可能加快疾病进展[1].同时,对其含量及质量进行检测,发现ccfDNA可为疾病的早期诊断、预后评估提供重要的临床参考价值.脓毒症是外科ICU最常见和最复杂的问题之一,是导致全球患者死亡和危重病的最主要原因之一,也是研究学者最受关注的热点.随着研究的深入,大量研究表明异常增高的 ccfDNA 参与脓毒症的发生与发展,然而在ccfDNA的来源、致病机制、诊断应用、疾病预后等方面仍存有争议 [2-3].本文将结合国内外最新文献,对ccfDNA在脓毒症中的来源、致病机制以及其作为一种生物学标志物在脓毒症的应用等相关研究现状作一综述,报告如下.

Background: Damage control surgery and open abdomen (OA) have been extensively used in the severe traumatic patients. However, there was little information when extended to a nontrauma setting. The purpose of this study was to evaluate whether the liberal use of OA as a damage control surgery adjunct improved the clinical outcome in acute superior mesenteric artery occlusion patients.Study Design: A single-center, retrospective cohort review was performed in a national tertiary surgical referral center.Results: Forty-four patients received OA (OA group) and 65 patients had a primary fascial closure (non-OA group) after diagnosed as peritonitis secondary to acute superior mesenteric artery occlusion from January, 2005 to June, 2016. Revascularization was achieved through endovascular aspiration embolectomy, open embolectomy, or percutaneous stent. No difference of bowel resection length was found between groups in the first emergency surgery. However, more non-OA patients (35.4%) required a second-look enterectomy to remove the residual bowel ischemia than OA patients (13.6%, P < 0.05). OA was closed within a median of 7 days (4 to 15 d). There was a mean of 134 cm residual alive bowel in OA, whereas 96 cm in non-OA. More non-OA patients suffered from intra-abdominal sepsis (23.1% vs. 6.8%, P < 0.01), intra-abdominal hypertension (31% vs. 0, P < 0.01), and acute renal failure (53.8% vs. 31.8%, P < 0.05) than OA group after surgery. Short-bowel syndrome occurred infrequently in OA than non-OA patients (9.1% vs. 36.9%, P < 0.01). OA significantly decreased the 30-day (27.3% vs. 52.3%, P < 0.01) and 1-year mortality rate (31.8 % vs. 61.5%, P < 0.01) compared with non-OA group.Conclusions: Liberal use of OA, as a damage control adjunct avoided the development of intra-abdominal hypertension, reduced sepsis-related complication, and improved the clinical outcomes in peritonitis secondary to acute SMA occlusion.

Budd–Chiari syndrome (BCS) with hepatic vein (HV) occlusion is manifested by severe liver damage in acute cases and esophageal variceal bleeding or refractory ascites in chronic cases, which is difficult to differentiate from cirrhotic portal hypertension.