Secondary Peritonitis and Intra-Abdominal Sepsis: An Increasingly Global Disease in Search of Better Systemic Therapies.

Secondary peritonitis and intra-abdominal sepsis are a global health problem. The life-threatening systemic insult that results from intra-abdominal sepsis has been extensively studied and remains somewhat poorly understood. While local surgical therapy for perforation of the abdominal viscera is an age-old therapy, systemic therapies to control the subsequent systemic inflammatory response are scarce. Advancements in critical care have led to improved outcomes in secondary peritonitis. The understanding of the effect of secondary peritonitis on the human microbiome is an evolving field and has yielded potential therapeutic targets. This review of secondary peritonitis discusses the history, classification, pathophysiology, diagnosis, treatment, and future directions of the management of secondary peritonitis. Ongoing clinical studies in the treatment of secondary peritonitis and the open abdomen are discussed.

Development of the spontaneous activity transients and ongoing cortical activity in human preterm babies.

Recent experimental studies have shown that developing cortex in several animals species, including humans, exhibits spontaneous intermittent activity that is believed to be crucial for the proper wiring of early brain networks. The present study examined the developmental changes in these spontaneous activity transients (SAT) and in other ongoing cortical activities in human preterm babies. Full-band electroencephalography (FbEEG) recordings were obtained from 16 babies at conceptional ages between 32.8 and 40 wk. We examined the SATs and the intervening ongoing cortical activities (inter-SAT; iSAT) with average waveforms, their variance and power, as well as with wavelet-based time-frequency analyses. Our results show, that the low frequency power and the variance of the average waveform of SAT decrease during development. There was a simultaneous increase in the activity at higher frequencies, with most pronounced increase at theta-alpha range (4-9 Hz). In addition to the overall increase, the activity at higher frequencies showed an increased grouping into bursts that are nested in the low frequency (0.5-1 Hz) waves. Analysis of the iSAT epochs showed a developmental increase in power at lower frequencies in quiet sleep. There was an increase in a wide range of higher frequencies (4-16 Hz), whereas the ratio of beta (16-30 Hz) and theta-alpha (4-9 Hz) range activity declined, indicating a preferential increase at theta-alpha range activity. Notably, SAT and iSAT activities remained distinct throughout the development in all measures used in our study. The present results are consistent with the idea that SAT and the other ongoing cortical activities are distinct functional entities. Recognition of these two basic mechanisms in the cortical activity in preterm human babies opens new rational approaches for an evaluation and monitoring of early human brain function.

Production of nisin with continuous adsorption to Amberlite XAD-4 resin using Lactococcus lactis N8 and L. lactis LAC48.

The production of nisin, biomass and lactic acid in pH-controlled and uncontrolled batch fermentation and batch fermentation (pH 5.5) with continuous removal of nisin was examined in the parent strain Lactococcus lactis N8 and LAC48. Strain LAC48 in batch fermentor (pH not controlled) gave a maximum nisin concentration of 2.5 x 10(6) IU g dcw(-1). The nisin concentration remained high (2.0 x 10(6) IU g dcw(-1)) after the logarithmic growth phase (10-22 h), whereas nisin production of strain N8 decreased after the logarithmic growth phase. The maximum nisin production of strain LAC48 was not directly related to the biomass formation and not associated with growth. In order to study end product inhibition in nisin production, a system was built for adsorption of nisin during fermentation. The adsorbent Amberlite XAD-4 was found to have an effective binding capacity for nisin. Cells of LAC48 and N8 compensated for the removal of nisin, indicating that nisin production also occurs in the stationary phase.

Anti-oxidant supplementation decreases TBA reactants in serum of elderly.

An "anti-oxidant cocktail" consisting of betacarotene, vitamins B6, C, E, zinc, and selenium or corresponding placebos were given for one y as daily dietary supplements to 45 elderly residents of a nursing home. Initially, the serum TBA reactant levels were higher (2.7 +/- 0.7 mumol/L) than those of an ad hoc control group of healthy younger adults (2.3 +/- 0.6 mumol/L), p less than 0.01. After three mo supplementation, the levels among the verum elderly had decreased to 2.2 +/- 0.6 mumol/L, and they remained at this lower level until the end of the study period, whereas the placebo group showed no change. A significant inverse correlation (r = -0.428, p less than 0.01) existed between the concentrations of serum TBA reactants and whole blood selenium (B-Se), but only B-Se levels above 200 micrograms/L were associated with a decrease in serum lipid peroxides. Serum alpha-tocopherol concentration also correlated inversely with serum TBA reactants but this correlation (r = -0.273, p less than 0.76) was not as strong as that of B-Se. Deficient vitamin B6 status, in biochemical terms, was observed in 25% of the elderly; a daily supplement of 2 mg B6 fully cured all cases of deficiency. The verum group improved slightly in several psychological tests, whereas subjects on placebo remained unchanged or deteriorated during the follow-up period. Clinical amelioration among the verum subjects was reported by the nurses; no toxic side effects were reported. In conclusion, the elderly benefited biochemically and clinically of dietary antioxidant supplements.

Vitamin B6 status of Finnish elderly. Comparison with Dutch younger adults and elderly. The effect of supplementation.

About 25% of Finnish and Dutch elderly appeared to be more or less deficient in vitamin B6 as compared to younger adults. Deficiency was observed at the cellular (PLP, EGOT and alpha-EGOT) as well as at the plasma level (PLP). The benefit of a one-year daily supplementation with 2 mg of pyridoxine-HCl was investigated at the biochemical and psychological level as compared to a placebo group. After one year, none of the supplemented elderly was deficient in biochemical terms. At the psychological level and at the level of general well-being, the elderly supplemented with vitamin B6 showed slight improvements. However, for the psychological variables significant correlations with the vitamin B6 parameters were not observed. Plasma fatty acids (e.g. gamma-linolenic acid) showed no correlation with the vitamin B6 status.

Vitamin E and selenium supplementation in geriatric patients : A double-blind preliminary clinical trial.

Sodium selenate (8 mg/d), organic selenium (50 µg/d) andd-alpha-tocopherol acetate (400 mg/d) were administered for 1 yr to 15 geriatric patients. Fifteen comparable controls received placebo. The mean age of both groups was 76 yr. The patients were assessed every 2 mo independently by two nurses using the Sandoz Clinical Assessment Geriatric-scale (SCAG). The propositae, showed significant improvement in the following SCAG parameters: depression, anxiety, self-care, mental alertness, emotional lability, motivation and initiative, hostility, interest in the environment, fatigue, anorexia, and general impression. A distinct improvement of the general condition was noticed after only 2 mo and the improvement continued up to the end of the 1-yr study period. The high selenium and vitamin E doses were well tolerated; there were no side effects whatsoever.

Selenium levels in whole blood of Finnish volunteers before and during organic and inorganic selenium supplementation.

High selenium barley biscuits containing 1 mumol (70 micrograms) organic Se were administered to healthy male volunteers for 5 weeks at doses of 2.1 mumol Se (group A) or 6.4 mumol (group B). In addition, 2 mg Na-selenate capsules (5.4 mumol Se) were given to two other groups at daily doses of 2 mg (group C) or 8 mg (group D). Groups A, B and C each comprised eight healthy men and group D eight healthy women and three men. The initial median concentration of whole blood selenium (B-Se for groups A, B and C were 1.0-1.1 mumol/l (range 0.7-1.7) and for group D 1.3 mumol/l (range 0.9-1.8). In 1-2 weeks time the B-Se concentrations rose to 1.6 mumol/l for groups A and C, to 1.8 mumol/l for group B, and to 2.2 mumol/l for group D. There was no decrease 1 week after the Se intake ceased. As expected, the level of B-Se increased more (in relation to dose) in those given organic Se than in those given inorganic Se. Groups A, B and C, however, had rather moderate increases. The daily dose required to raise the B-Se of Finns up to the North American level (2.2 mumol/l) was as high as 8 mg Na-selenate (21.5 mumol or 1700 micrograms Se), but the dose of organic Se which would be required to achieve this level is not yet known.

Serum gonadotropins and testosterone in men occupationally exposed to carbon disulfide.

Serum levels of gonadotropins and testosterone were determined for 69 men exposed to CS2 in viscose rayon production and for 22 nonexposed male controls. Mean ages of the two groups were 40 and 39 yr, respectively. The duration of exposure to CS2 ranged from 1 to 36 yr (mean, 12.5). Follicle stimulating hormone (FSH) levels were significantly higher among the exposed men than among the controls (13.6 versus 10.0 IU/l). The level of sex hormone binding globulin (SHBG) was significantly lower among the exposed men than among the controls (44 versus 53 nmol/l). Luteinizing hormone (LH) values were significantly higher among the 24-31 yr old exposed men than the controls of the same age. Levels of SHBG, of the free testosterone index, and of FSH and LH in men under 39 yr who had been exposed to CS2 for 1-9 yr differed significantly from those of their controls, whereas only FSH differed significantly among those exposed for 10 or more years in the same age group. In men aged 40 yr or more, after at least 10 yr of exposure, only FSH and LH were significantly higher than in the controls. Although the observed alterations do not seem to have any overt clinical implications for the study groups, they indicate that overall levels of CS2 that are well below the current Finnish threshold limit value (30 mg/m3) may affect the hormonal balance in the pituitary-gonadal axis, favoring the view that there may be an increased risk of latent primary gonadal insufficiency.

Quantitated effects of carbon disulfide exposure, elevated blood pressure and aging on coronary mortality.

Risk function analysis was performed in order to clarify the relationship between coronary heart disease death rate and occupational carbon disulfide exposure along with two other important risk factors, elevated diastolic blood pressure and older age, in a data set obtained from a 10-year prospective follow-up of coronary mortality in two cohorts of over 340 male industrial workers in Finland. The sole effect of carbon disulfide on the coronary mortality was statistically significant (relative risk = 2.3), and it was largely independent of the level of the other two risk factors. Log-linear models were fitted to predict coronary heart disease deaths. The analysis identified the dual role of raised blood pressure in the potential mechanism of coronary death. Relative risks ranging up to 48 were obtained for the joint non-synergistic effect of these three factors in the exposed group compared to a subgroup of nonexposed, 40-year-old normotensive men. The effect of carbon disulfide exposure on the risk of coronary death, while clearly distinguishable from the effect of hypertension and aging, stayed subordinate to them, but nevertheless remained an important risk element in the work environment.

Endocrinologic studies in men exposed occupationally to carbon disulfide.

The effect of long-term occupational exposure to CS2 on various endocrinologic parameters was studied in 15 exposed men and 16 age-matched controls. Duration of exposure varied between 10 and 36 yr. The CS2 concentrations in the viscose rayon plant have been below the Finnish threshold limit value of 30 mg/m3 (10 ppm) under normal operating conditions for the past 10 yr. Before this the exposure was considerably greater. Of the various endocrinologic parameters, serum follicle stimulating hormone (FSH) and luteinizing hormone (LH) were significantly increased in the exposed group, seven workers having values above the reference limit. This was taken as a sign of primary gonadal insufficiency, which was considered only latent as serum testosterone values were unaffected. No changes were seen in serum prolactin values before or after stimulation with thyrotropin releasing hormone (TRH). No disturbance was seen in thyroid function as evaluated by serum thyroxine (T4), free thyroxine index (FT1), triiodothyronine (T3), and the thyrotropin response to TRH. Serum cortisol was also unchanged. These results may reflect high exposure during past decades rather than exposure to the present low CS2 concentrations.

Impaired color discrimination among viscose rayon workers exposed to carbon disulfide.

A possible effect of chronic carbon disulfide exposure on the optic nerve was studied by giving the Farnsworth Munsell 100-Hue Test for color discrimination to 62 exposed and 40 nonexposed men. Carbon disulfide exposure did not relate to specific pattern defects in color discrimination, but impaired color discrimination occurred significantly more often in the exposed group than among the referents. The abnormal findings suggest an impairment in the receptiveness of the ganglion cells or demyelination of the optic nerve fibers.

Ten-year coronary mortality of workers exposed to carbon disulfide.

Two cohorts, one comprising 343 viscose rayon workers exposed for at least five years to carbon disulfide (CS2) and the other made up of 343 nonexposed men, were followed from 1967 to 1977 with respect to coronary heart disease (CHD) mortality. In the examination in 1967 known risk factors of CHD were controlled; only blood pressure was slightly higher in the exposed group. The difference was considered a result of exposure. Five exposed and eight nonexposed men had experienced a previous clinical myocardial infarction. The total mortality was 48 (14%) in the exposed group and 31 (9%) in the compeer group (p congruent to 0.05); 29 exposed and 11 nonexposed men had died from CHD (p less than 0.01), and 5 exposed and 1 nonexposed from other cardiovascular causes (p = 0.1). All coronary deaths occurred in the age interval 40 to 69 years. The estimated risk of death from CHD for this 30-year age span, assuming no competing risks of death, was 31.9% for the exposed cohort against 13.3% for the compeers. A multivariate analysis yielded age, raised blood pressure, and exposure to CS2 as prominent risk factors. The contributory risk caused by past occupational CS2 exposure seemed to increase the already notoriously high risk of CHD mortality among Finnish men.

Municipal occupational health services for small workplaces. Background and general methodology of the study.

This paper deals with the new Occupational Health Service Act of Finland, as well as the background, scope and general methodology of a walk-through survey. The study comprised 163 small places of work within two municipal health center areas, and the primary objective was to determine their need for actual occupational health services. The workplaces were surveyed for a comprehensive picture of their physical and chemical hazards, as well as for knowledge of first-aid preparedness, need for job-related health counseling, personnel facilities, personal protection, and the required ergonomic and safety activities at the workplaces within the community. This ad-hoc information was considered essential for the planning of a nationwide occupational health program, and, more specifically, an assessment could be made of the utility of health personnel in reducing and preventing occupational health and safety risks at small places of work. More specific details of the sample and methodology are reported in other communications.

First-aid preparedness in small workplaces with special reference to occupational health services.

First-aid preparedness was surveyed in 163 small firms employing 2,400 persons. Although 11% of the employees had received first-aid training, half of the firms lacked first-aiders. Only one-fourth of the first-aid kits were equipped according to instructions. Checking and maintenance of the equipment, as well as information about first aid at the place of work, were generally inadequate. Instructions were commonly lacking for the safe use of chemical substances. Only 9% of the firms fully complied with the requirements for optimum first-aid preparedness. Employers at small firms seem not to be sufficiently aware of their liabilities with regard to first aid. Yet, most of the faults and defects could be corrected by means of arrangements within the firms once the instructions were better known. During their visits to places of work occupational health personnel should inspect the first-aid preparedness and advise the employer on first-aid requirements. In addition the expertise of the insurance company, the local Red Cross or the regional institute of occupational health may be utilized.

Personnel facilities in small workplaces with special reference to occupational health services.

The personnel facilities of small workplaces generally complied with the requirements. Yet, defects were detected in 20% of the 163 firms surveyed. Most of the faults were insignificant from the point of view of health. The failures were due to the fact that the facilities had not originally been planned for their present purpose. The need for the inspection of sanitary installations such as toilets and washrooms and facilities for storing and drying clothes was noted in dirty jobs and in places of work with toxicologic hazards. The management of small firms rarely needs medical advice on sanitary, catering and welfare amenities.

Need for job-related health counseling in small workplaces.

Health counseling aimed at maintaining health and safety on the job is required in most small workplaces. From a labor protection point of view, the most important advice deals with environmental hazards such as protection against physical and chemical factors, ergonomic problems, and safety risks. Information provided by the employers was considered insufficient in three-fourths of the 163 firms surveyed in this study. The staff providing local occupational health services could perform two broad types of counseling. First, they could educate management as to its responsibilities for the health and safety of employees; health personnel can instruct management during their workplace visits. Second, during health examinations and other personal contacts, the worker can be advised about ways to improve or maintain his health. Moreover, such occasions also provide an opportunity for more extensive health counseling about personal, social emotional, and other problems although, in municipal health centers, these subjects belong within the scope of public health rather than occupational health.