The use of delta neutrophil index and myeloperoxidase index as diagnostic predictors of strangulated mechanical bowel obstruction in the emergency department

Investigation of the clinical efficacy of thiol-disulfide homeostasis, delta neutrophil index, and ischemia-modified albumin in cases of incarcerated and strangulated hernia

BACKGROUND

The treatment of patients presenting with the diagnosis of incarcerated and/or strangulated inguinal hernia is mostly surgery. If strangulation and necrosis are present, the need for laparotomy arises, which may increase the risk of morbidity. Currently, it is not possible to clearly determine whether there is bowel ischemia and necrosis before surgery. In this study, we aimed to investigate the clinical efficacy of the thiol-disulfide homeostasis, delta neutrophil index (DNI), and ischemia-modified albumin (IMA) parameters in incarcerated and strangulated hernia cases.

METHODS

Patients that presented to the general surgery outpatient clinic due to inguinal hernia or to the emergency department of the hospital with a preliminary diagnosis of incarcerated and/or strangulated hernia in April 2021-November 2021 were included in the study. The patients were divided into the following four groups: patients that underwent elective repair for inguinal hernia (Group 1), those who were followed up without surgery due to incarcerated hernia (Group 2), those who underwent hernia repair without bowel resection due to incarceration (Group 3), and those who underwent bowel resection due to strangulation (Group 4). Group 1 was defined as the control group, while Groups 2, 3, and Group 4 were evaluated as the incarcerated/strangulated hernia group. The demographic data of the patients, length of hospital stay, body mass index, comorbidities, medical history and physical examina-tion findings, radiological examinations, treatments applied, white blood cell (WBC) count, lactate, and DNI, thiol-disulfide and IMA parameters were evaluated.

RESULTS

The WBC count, disulfide/native thiol, disulfide/total thiol, and IMA values were significantly higher in the incarcerated/strangulated hernia group than in the control group, while the native thiol and total thiol values were higher in the latter than in the former (P<0.05). There was no statistically significant difference between the groups in terms of lactate (P>0.05), but the mean WBC count was higher in Group 4 compared to Group 1, and the mean DNI was significantly higher among the patients who underwent bowel resection and anastomosis than in those that were followed up and discharged (P<0.05).

CONCLUSION

We consider that the preoperative evaluation of the thiol-disulfide homeostasis, IMA, and DNI parameters in incarcerated/strangulated hernia cases can be an effective and easily applicable method in predicting difficulties that may be encountered intraoperatively and the surgical procedure to be applied to the patient.

Assay variability and storage stability of the myeloperoxidase index of the ADVIA 2120i hematology analyzer in canine and equine whole blood samples

BACKGROUND

The myeloperoxidase index (MPXI), on ADVIA hematology analyzers, reflects the mean neutrophil myeloperoxidase staining. It is used as a marker of inflammation in animals and people, but assay variability and storage stability are unknown.

OBJECTIVE

We aimed to determine MPXI precision and stability with refrigerated storage of canine and equine EDTA-anticoagulated blood and compared MPXI results between two analyzers.

METHODS

Inter-assay coefficients of variations (CVs) were determined from three human-based controls assayed before and after a 20- or 21-day calibration. Blood from 14-16 dogs and 26 horses was assayed 4-10 times within 1 day for intra-assay CV measurements. Median control and single run results from 18 canine and 35 equine samples were compared between analyzers. Blood from 10-12 dogs and 10-11 horses was analyzed after collection, and 24, 48, and 72 hours of refrigerated storage.

RESULTS

Inter-assay CVs of controls were 10.7%-15.9% and 6.4%-9.6% before and 4.3%-7.7% and 2.8%-17.5% after calibration, for ADVIA 1 and 2, respectively. Calibration altered peroxidase gain settings and improved precision. Intra-assay CVs were 0.6%-64% and 3%-350% for canine and equine samples, respectively. Median MPXI results differed significantly between the analyzers, likely from calibration-associated changes in gains. MPXI decreased with storage, and with variable changes between animals and analyzers. Platelet clumps and lipid contributed to the variability in replicate MPXI measurements.

CONCLUSION

MPXI has a higher variability in equine samples than in canine samples. Equivalent results might not be obtained between analyzers. Results change unpredictably with repeated analyses over 72 hours. MPXI measurements might only be useful in controlled research settings.

A novel discriminant formula for the prompt diagnosis of strangulated bowel obstruction

PURPOSES

The diagnosis of strangulated bowel obstruction (SBO) is sometimes difficult. We attempted to create and verify a discriminant formula for use as a diagnostic aid for the early diagnosis of SBO.

METHODS

This retrospective study included 97 patients who underwent an operation for SBO from January 2007 to September 2018. First, a discriminant analysis was performed for 73 patients who underwent an operation from January 2007 to December 2015 in order to obtain a formula. Next, we analyzed 34 patients who underwent an operation from January 2016 to September 2018 to verify the formula.

RESULTS

The risk factors for SBO included ascites, signs of preperitoneal irritation, and lactate > 1.16 mmol/L. The discriminant formula is as follows: 1.954 × collection of ascites (1 or 0) + 1.239 × peritoneal irritation sign (1 or 0) + 0.378 × lactate - 2.331 (1: positive, 0: negative). The predictive value was as follows: sensitivity, 87.5%; specificity, 64.7%; and predictive accuracy, 73.5%. In patients who presented within 24 h of the onset, the sensitivity was 92.3%, the specificity was 75.0%, and the predictive accuracy was 85.7%.

CONCLUSION

Our discriminant formula seems useful for the rapid diagnosis of SBO.

The Diagnostic Value of ischemia-modified albumin (IMA) and signal peptide-CUB-EGF domain-containing protein-1 (SCUBE-1) in an Experimental Model of Strangulated Mechanical Bowel Obstruction

BACKGROUND

Mechanical bowel obstruction (MBO) is one of the principal pathologies requiring emergency surgery and a significant worldwide cause of morbidity. The identification of patients in whom bowel obstruction resolves spontaneously is important in terms of preventing unnecessary surgical interventions and future potential adhesions. The decision-making process is difficult in patients presenting without classic examination findings.

METHODS

36 female Sprague-Dawley rats randomly divided into six experimental groups. In Group 1, 3 and 5, laparotomy was performed, with blood and tissue specimens being collected after 1, 2 and 6 h, respectively. In Group 2, 4 and 6, the ileum segment was ligated following laparotomy, and blood and tissue specimens were collected after 1, 2 and 6 h, respectively. The ileum specimens were examined macroscopically, after which 1-cm sections were taken and examined in terms of histopathological changes. IMA and SCUBE-1 levels were determined for each group, and macro- and microscopic tissue examination findings were compared between the groups.

RESULTS

Comparison within the groups exposed to waiting times of 1 h (groups 1 and 2), 2 h (groups 3 and 4) and 6 h (groups 5 and 6) revealed higher mean IMA and SCUBE-1 levels in rats undergoing ligation together with incision (groups 2, 4, and 6) compared to those undergoing laparotomy only (groups 1, 3, and 5). Correlation analysis was applied to determine the relationship between total scores obtained from histopathological examination and IMA and SCUBE-1 values. The analysis revealed strong, significant and positive correlation between histopathological examination scores and IMA (r=0.643, p=0.000) and SCUBE-1 (r=0.509, p=0.002) values.

CONCLUSION

The study findings showed that both IMA and SCUBE-1 values increased in a strangulated MBO model in rats. We think that IMA and SCUBE-1 values can be used as a markers of damage in the early period in strangulated MBO, and that the patient's surgery requirement can thus be determined in the early period.

Delta Neutrophil Index for the Prediction of Prognosis in Acute Gastrointestinal Diseases; Diagnostic Test Accuracy Meta-Analysis

Delta neutrophil index (DNI) is a novel diagnostic and prognostic biomarker of various infectious or inflammatory conditions. However, data on optimal measurement time are scarce, and no studies have evaluated the potential role of the DNI as a prognostic biomarker of gastrointestinal diseases with diagnostic test accuracy meta-analysis. Core databases were searched. The inclusion criteria were as follows: patients who have gastrointestinal diseases and DNI measurements presenting diagnostic indices for predicting the prognosis, including severity, surgical outcomes, and mortality from gastrointestinal diseases. We identified twelve studies for the systematic review and ten studies for the quantitative analysis. Pooled area under the curve, sensitivity, specificity, and diagnostic odds ratio of DNI at the initial admission date were 0.82 (95% confidence interval: 0.78–0.85), 0.75 (0.52–0.89), 0.76 (0.63–0.86), and 10 (3–35), respectively. Meta-regression showed no reasons for heterogeneity and publication bias was not detected. Fagan’s nomogram indicated that the posterior probability of ‘poor prognosis’ was 76% if the test was positive, and ‘no poor prognosis’ was 25% if the test was negative. The DNI can be considered as a reliable initial measurement biomarker for predicting prognosis in patients with gastrointestinal diseases,

The delta neutrophil index is an early predictive marker of severe acute cholecystitis

BACKGROUND

Predicting severe acute cholecystitis (SAC) is important because the mortality rate is higher for patients with SAC than for non-SAC (NSAC) patients. We evaluated the predictive value of the delta neutrophil index (DNI), which is greater in patients with infectious and inflammatory conditions, for SAC among patients in the emergency department (ED).

METHODS

This retrospective observational study included 379 consecutive adult patients with AC admitted to the ED from January 2015 to December 2016. The included patients were classified into 2 groups (NSAC and SAC) according to the Tokyo Guidelines 2018. White blood cell (WBC) count, C-reactive protein (CRP) levels, and DNI values were assessed at ED admission.

RESULTS

The SAC group contained 28 patients (7.4%). DNI was among the early predictors of SAC and was an inflammatory marker with a significantly higher predictive value than WBC count or CRP level for detecting SAC. The predictive power of DNI was significantly higher than that of CRP when used in conjunction with WBC count, abdominal computed tomography, and clinical variables.

CONCLUSIONS

DNI measured at ED admission may serve as an early predictor of SAC.

Value of the Delta Neutrophil Index for Predicting 28-Day Mortality in Patients With Acute Pulmonary Embolism in the Emergency Department

PURPOSE

Acute pulmonary embolism (PE), frequently seen in the emergency department (ED), is a leading cause of cardiovascular morbidity and mortality. The delta neutrophil index (DNI) reflects the fraction of circulating immature granulocytes as a component of the systemic inflammatory response syndrome criteria. The pathogenesis of acute PE is significantly associated with inflammation. The aim of the study was to investigate the clinical usefulness of the DNI as a marker of severity in patients with acute PE admitted to the ED.

METHODS

We retrospectively analyzed the data of patients who were diagnosed with acute PE at a single ED, admitted from January 1, 2011 to June 30, 2017. The diagnosis of acute pulmonary embolism was confirmed using clinical, laboratory, and radiological findings. The DNI was determined at presentation. The clinical outcome was all-cause mortality within 28 days of emergency department admission.

RESULTS

We included 447 patients in this study. The multivariate Cox regression model demonstrated that higher DNI values on ED admission were significantly associated with short-term mortality (hazard ratio, 1.107; 95% confidence interval, 1.042-1.177). The optimal cut-off DNI value, measured on ED admission, was 3.0%; this value was associated with an increased hazard of 28-day mortality following PE (HR, 7.447; 95% CI, 4.183-13.366; P < 0.001) CONCLUSION:: The DNI value, obtained as part of the complete blood count analysis, can be easily determined without additional burdens of cost or time. A high DNI is useful as a marker to predict 28-day mortality in patients with acute PE.

Delta neutrophil index as a prognostic marker in emergent abdominal surgery

Background

Delta neutrophil index (DNI) is the fraction of circulating immature granulocytes provided by a routine, complete blood cell analyzer. It is known to be a useful prognostic marker of sepsis. The aim of this study was to evaluate the role of DNI in the diagnosis and prognosis of patients who had undergone emergent surgery for an acute abdomen.

Methods

A total of 694 patients who had visited the emergency room for acute abdominal pain and undergone emergent abdominal surgery from May 2015 to September 2016 were retrospectively reviewed. Clinical characteristics, laboratory findings on the day of hospital visit, hospital stay, postoperative complications, and 30‐day mortality were investigated.

Results

In the analysis of patients who had undergone an operation for acute peritonitis, the DNI was a good predictor for predicting 30‐day mortality rate (area under the curve [AUC]: 0.826). It was not inferior to other laboratory values, including activated partial thromboplastin time (AUC: 0.729), C‐reactive protein (AUC: 0.727), albumin (AUC: 0.834), prothrombin time (AUC: 0.816), and creatinine (AUC: 0.837) known to be associated with sepsis. Patients with high DNI displayed higher incidence of bacteremia and sepsis, longer hospital stay, higher postoperative complication rate, and higher 30‐day mortality rate than patients with low DNI. Among patients diagnosed with acute appendicitis, the DNI was a useful marker for differentiating appendiceal perforation.

Conclusion

The DNI was a practical and useful marker for predicting the prognosis of patients who needed emergent abdominal surgery.

Secondary peritonitis: principles of diagnosis and intervention

Secondary peritonitis accounts for 1% of urgent or emergent hospital admissions and is the second leading cause of sepsis in patients in intensive care units globally. Overall mortality is 6%, but mortality rises to 35% in patients who develop severe sepsis. Despite the dramatic growth in the availability and use of imaging and laboratory tests, the rapid diagnosis and early management of peritonitis remains a challenge for physicians in emergency medicine, surgery, and critical care. In this article, we review the pathophysiology of peritonitis and its potential progression to sepsis, discuss the utility and limitations of the physical examination and laboratory and radiographic tests, and present a paradigm for the management of secondary peritonitis.