Analysis of bovine postmortem condemnation data in France: Contributions from a comprehensive and standardised information system at the slaughterhouse.

BACKGROUND: The condemnation of carcases and offal unfit for human consumption is a regulatory requirement at the slaughterhouse. Condemnation data, if comprehensive and standardised, can be a valuable source of information for risk-based inspection and decision making. METHODS: The aim of this study was to analyse postmortem condemnation data that were recorded in all bovine slaughterhouses in mainland France from 1 January 2016 to 31 December 2020 in a comprehensive and standardised information system. The rates of and reasons for condemnation, as well as factors influencing rate variation, were investigated through descriptive analysis and multivariable logistic regression models. RESULTS: The global, total and partial condemnation rates were 4.5%, 0.7% and 3.8% for adult cattle and 1.4%, 0.3% and 1.1% for calves, respectively. Reasons for condemnation varied with the animal category; for example, the three main reasons for total condemnation in adult cattle were serous infiltration of connective tissue (49% of condemned animals), congestive peritonitis (12.2%) and fibrinous peritonitis (10.9%), whereas the top three reasons for partial condemnation were unique abscess (21.9%), haemorrhagic infiltration (20.6%) and muscular sclerosis (17.4%). Condemnation rates were influenced by animal-related factors (sex, age, type of breed) and slaughterhouse-related factors (status, type, slaughter volume). CONCLUSION: Our findings could usefully contribute to the continuous improvement of the harmonisation of inspection decisions and support the risk manager's strategy in the modernisation of official controls at the slaughterhouse.

The Bucharest ESTES consensus statement on peritonitis.

INTRODUCTION: Peritonitis is still an important health problem associated with high morbidity and mortality. A multidisciplinary approach to the management of patients with peritonitis may be an important factor to reduce the risks for patients and improve efficiency, outcome, and the cost of care. METHODS: Expert panel discussion on Peritonitis was held in Bucharest on May 2017, during the 17th ECTES Congress, involving surgeons, infectious disease specialists, radiologists and intensivists with the goal of defining recommendations for the optimal management of peritonitis. CONCLUSION: This document is an updated presentation of management of peritonitis and represents the summary of the final recommendations approved by a panel of experts.

[Pathogenesis and classification of advanced peritonitis]. / Patogenez i klassifikatsiia rasprostranennogo peritonita.

The concept of pathogenesis of peritonitis and abdominal sepsis are discussed in the article. Significant scientific findings devoted to this issue occurred in recent years. Nevertheless, there is still no unity in understanding the pathogenesis of peritonitis. Accordingly, the question of its classification is still open. Literature review demonstrates diverse opinions regarding classification of peritonitis. The authors analyze the arguments for and against some classification categories taken on the basis of pathophysiological aspects of this serious complication of abdominal diseases.

Exit-Site Infection: A Comparison of Classification Systems.

In general, in peritoneal dialysis (PD) practice in hospitals, Twardowski and Prowant's exit-site classification system is used, while the International Society for Peritoneal Dialysis (ISPD) exit-site scoring system is practical to use in community visits with less experienced healthcare personnel. Nevertheless, when exit-site scoring is 3 points under the ISPD exit-site score system and it falls in the category of equivocal under the Twardowski and Prowant's exit-site classification, the physician should be vigilant about the possibility of developing peritonitis, and hence, patients need to be kept under periodic monitoring.

Getting the invite list right: a discussion of sepsis severity scoring systems in severe complicated intra-abdominal sepsis and randomized trial inclusion criteria.

Background: Severe complicated intra-abdominal sepsis (SCIAS) is a worldwide challenge with increasing incidence. Open abdomen management with enhanced clearance of fluid and biomediators from the peritoneum is a potential therapy requiring prospective evaluation. Given the complexity of powering multi-center trials, it is essential to recruit an inception cohort sick enough to benefit from the intervention; otherwise, no effect of a potentially beneficial therapy may be apparent. An evaluation of abilities of recognized predictive systems to recognize SCIAS patients was conducted using an existing intra-abdominal sepsis (IAS) database. Methods: All consecutive adult patients with a diffuse secondary peritonitis between 2012 and 2013 were collected from a quaternary care hospital in Finland, excluding appendicitis/cholecystitis. From this retrospectively collected database, a target population (93) of those with either ICU admission or mortality were selected. The performance metrics of the Third Consensus Definitions for Sepsis and Septic Shock based on both SOFA and quick SOFA, the World Society of Emergency Surgery Sepsis Severity Score (WSESSSS), the APACHE II score, Manheim Peritonitis Index (MPI), and the Calgary Predisposition, Infection, Response, and Organ dysfunction (CPIRO) score were all tested for their discriminant ability to identify this subgroup with SCIAS and to predict mortality. Results: Predictive systems with an area under-the-receiving-operating characteristic (AUC) curve > 0.8 included SOFA, Sepsis-3 definitions, APACHE II, WSESSSS, and CPIRO scores with the overall best for CPIRO. The highest identification rates were SOFA score ≥ 2 (78.4%), followed by the WSESSSS score ≥ 8 (73.1%), SOFA ≥ 3 (75.2%), and APACHE II ≥ 14 (68.8%) identification. Combining the Sepsis-3 septic-shock definition and WSESSS ≥ 8 increased detection to 80%. Including CPIRO score ≥ 3 increased this to 82.8% (Sensitivity-SN; 83% Specificity-SP; 74%. Comparatively, SOFA ≥ 4 and WSESSSS ≥ 8 with or without septic-shock had 83.9% detection (SN; 84%, SP; 75%, 25% mortality). Conclusions: No one scoring system behaves perfectly, and all are largely dominated by organ dysfunction. Utilizing combinations of SOFA, CPIRO, and WSESSSS scores in addition to the Sepsis-3 septic shock definition appears to offer the widest "inclusion-criteria" to recognize patients with a high chance of mortality and ICU admission. Trial registration: https://clinicaltrials.gov/ct2/show/NCT03163095; Registered on May 22, 2017.

[Treatment of acute purulent diverticulitis is still not clarified]. / Valg af behandling af akut, purulent divertikulitis er uafklaret.

Inflammation in colonic diverticula can develop into acute diverticulitis. Treatment varies depending on illness severity. Perforated diverticulitis with faecal peritonitis is treated surgically and Hartmann's procedure is the preferred operation. Peritoneal lavage might be an alternative to resection for purulent peritonitis. However, ongoing randomized trials are awaited to clarify this.

[Treatment of acute purulent diverticulitis is still not clarified].

Inflammation in colonic diverticula can develop into acute diverticulitis. Treatment varies depending on illness severity. Perforated diverticulitis with faecal peritonitis is treated surgically and Hartmann's procedure is the preferred operation. Peritoneal lavage might be an alternative to resection for purulent peritonitis. However, ongoing randomized trials are awaited to clarify this.

[TERTIARY PERITONITIS]. / PERITONITIS TERCIARIA.

Tertiary peritonitis is an intraabdominal infection that arises in some patients with secondary peritonitis, despite receiving appropriate treatment. Recently described, it is a syndrome of late peritonitis and we are still lacking a precise and widely adopted definition. Diagnosis is difficult and treatment is complex. Among other therapeutic efforts, this entity requires early and repeated surgical treatment, either on demand or scheduled laparotomy, or even laparostomy. Prognosis is poor, and mortality can reach up to 60% of patients. We present the most interesting aspects of this disease.

Role of K1 capsule antigen in cirrhotic patients with Escherichia coli spontaneous bacterial peritonitis in southern Taiwan.

Spontaneous bacterial peritonitis (SBP) is one of the most serious complications in patients with cirrhosis. This study aimed to investigate the prevalence of SBP caused by Escherichia coli isolates with or without the K1 capsule antigen in cirrhotic patients and the outcome. From January 2004 to January 2012, a total of 54 and 41 E. coli strains derived from patients with SBP and intestinal perforation (IP), respectively, were included for comparison in this study. Bacterial characteristics including phylogenetic groups, K1 capsule antigen, and 14 virulence factor genetic determinants, as well as data regarding patient characteristics, clinical manifestations, and in-hospital deaths, were collected and analyzed. The prevalence of the K1 capsule antigen gene neuA was more common in SBP isolates compared to IP isolates (28 % vs. 10 %, p = 0.0385). Phylogenetic groups B2 and group D were dominant in E. coli isolates with and without the K1 capsule antigen, respectively. The prevalence of virulence factors genes papG II, ompT, and usp was higher in E. coli K1 strains. There were 26 deaths (48 %) during hospitalization. Presence of the K1 capsule antigen in E. coli isolates was significantly associated with in-hospital death in cirrhotic patients with SBP (42 % vs. 14 %, p = 0.0331). This study demonstrates a higher prevalence of the K1 capsule antigen in E. coli SBP compared to E. coli peritonitis caused by IP. There were significant associations between the K1 capsule antigen and in-hospital mortality and bacterial virulence in cirrhotic patients with E. coli SBP.

[Peritonitis and catheter-related infections in peritoneal dialysis]. / La peritonite e le infezioni del catetere in dialisi peritoneale.

The incidence of peritoneal dialysis-related infections has decreased markedly over the past 20 years. This is commonly believed to be the result of improvements in connection technology and eradication of nasal and exit-site Staphylococcus aureus. However, peritonitis is still the most important cause of technique failure. The good results of single centers with a long experience of peritoneal dialysis and the excellent randomized trial results have proved to be incomparable with those of nonselected populations. The analysis of organism-specific infections joined to the identification of the entry pathway into the peritoneum could allow individual centers to focus on the weaknesses of the used protocols and procedures.

[Tertiary peritonitis: as difficult to define as it is to treat]. / Peritonitis terciaria: tan difícil de definir como de tratar.

Tertiary peritonitis is the most delayed and severe outcome of patients with complicated intra-abdominal infections. The major difficulty lies in giving a common, precise and consensus definition in order to know when to make its diagnosis and how it can be avoided and/or treated. This condition requires early and repeated surgery, wide spectrum antibiotic therapy against multi-resistant bacteria and intensive systemic support measures. Despite all this, the prognosis is extremely poor since it has a mortality which can reach up to 60%, with preventions being the most important measure to avoid it developing. In this article, we have made a specific review of tertiary peritonitis, of the accepted definitions, the risk factors, its pathophysiology, the microbiological flora involved, and its treatment.

APACHE II scoring system is superior in the prediction of the outcome in critically ill patients with perforative peritonitis.

BACKGROUND: There are several scoring systems used in the prediction of outcome in critically ill patients. This study was undertaken to evaluate APACHE II, SAPS I, Sepsis score, MOF, TISS-28 and MPI scoring systems in prediction of the outcome in patients with perforative peritonitis. PATIENTS AND METHODS: The prospective study of 145 patients of both sexes with perforative peritonitis was performed. The main outcome of study was peritonitis-related death. Variables necessary for calculation of the scoring systems were recorded at the initial admission to the hospital and the third and seventh day of hospitalization, except Mannheim Peritonitis Index, which was calculated during the first 24 hours after hospitalization. Cut-off points were specified and all values greater than cut-off points were taken to predict death. Sensitivity and specificity are graphically shown for the different values of cut-off points and represented with the receiver-operating characteristic curve. The difference in the area below the curve between scoring systems was statistically compared. RESULTS: The area under the curve for the first postoperative day was 0.87 for TISS-28 score, 0.86 for APACHE II score, 0.83 for MOF and SAPS I, 0.72 for MPI and 0.70 for Sepsis score. This demonstrated that TISS-28 and APACHE II are significantly better than other systems (p < 0.01). In addition, this discriminatory ability remained on the third and seventh postoperative day as well. The highest rate of correlation between the observed and the expected mortality rate for the first (Kendall's tau correlation 0.964) and the third day (Kendall's scorrelation 0.810) was in APACHE II system. CONCLUSION: APACHE II is superior in prediction of the outcome to other tested scoring systems.

[What should and should not be covered in intraabdominal infection]. / Lo que hay que cubrir y lo que no hay que cubrir en la infección intraabdominal.

Despite improvements in our knowledge of the physiopathology of severe infection, diagnostic methods, antibiotic therapy, postoperative care and surgical techniques, a substantial number of patients with intraabdominal infection (IAI) will develop advanced stages of septic insult requiring admission to the intensive care unit. The success of treatment of IAI is multifactorial and the best antibiotic protocol may be insufficient unless adequate control of the focus of infection has been achieved. The present article discusses the appropriacy of empirical antibiotic therapy and the main pathogens associated with treatment failure. We also analyze the patients at risk of infection with microorganisms requiring broad-spectrum antimicrobial coverage. However, excessive antibiotic treatment, in terms of either spectrum or duration, could jeopardize future patients in an environment already threatened by the scarcity of research and development into new molecules required for the emergence of pathogens resistant to current antibiotics.

Lo que hay que cubrir y lo que no hay que cubrir en la infección intraabdominal / What should and should not be covered in intraabdominal infection

A pesar de la mejora en el conocimiento de la fisiopatología de la infección grave, de las técnicas diagnósticas, del tratamiento antibiótico, de los cuidados perioperatorios y de la técnica quirúrgica, todavía un porcentaje relevante de pacientes afectados de infección intrabdominal (IAB) desarrolla estadios avanzados de infección y precisa el ingreso en las unidades de cuidados intensivos. El éxito del tratamiento de la IAB es multifactorial y es necesario saber que la mejor pauta antibiótica puede fracasar si el control del foco de la infección es deficiente o difícil de conseguir. El presente capítulo discute la adecuación del tratamiento antibiótico empírico y los principales patógenos que se han asociado con el fracaso terapéutico. Además, se analizan las situaciones y pacientes de riesgo en los que es precisa una cobertura antibiótica más amplia. El uso excesivo de antibióticos en espectro, cantidad y duración, sin tener en cuenta estos preceptos, puede conducirnos a un modelo de atención poco sostenible en un entorno amenazado por la escasez en la investigación y desarrollo de nuevas moléculas necesarias para atender la aparición de patógenos resistentes a los antibióticos actuales

Despite improvements in our knowledge of the physiopathology of severe infection, diagnostic methods, antibiotic therapy, postoperative care and surgical techniques, a substantial number of patients with intraabdominal infection (IAI) will develop advanced stages of septic insult requiring admission to the intensive care unit. The success of treatment of IAI is multifactorial and the best antibiotic protocol may be insufficient unless adequate control of the focus of infection has been achieved. The present article discusses the appropriacy of empirical antibiotic therapy and the main pathogens associated with treatment failure. We also analyze the patients at risk of infection with microorganisms requiring broad-spectrum antimicrobial coverage. However, excessive antibiotic treatment, in terms of either spectrum or duration, could jeopardize future patients in an environment already threatened by the scarcity of research and development into new molecules required for the emergence of pathogens resistant to current antibiotics

Preoperative CT staging in sigmoid diverticulitis--does it correlate with intraoperative and histological findings?

PURPOSE: This study was designed to evaluate whether the computed tomography (CT) reflects the extent of the inflammation in sigmoid diverticulitis (SD) in order to draw conclusions for selecting the appropriate treatment. METHODS: Two hundred four patients who underwent resection for SD from January 2003 to December 2008 were included. The preoperative CT stage was compared with intraoperative and histological findings. Patients were classified into phlegmonous (Hansen-Stock IIa), abscess-forming (HS IIb), and free perforated (HS IIc) forms of SD. Patients with a recurrent type of diverticulitis were excluded. RESULTS: In the phlegmonous type (HS IIa; n = 75), we found a correlation with the preoperative stage in 52% (intraoperative) and 56% (histological), an understaging in 12% (intraoperative) and 11% (histological), and an overstaging in 36% (intraoperative) and 33% (histological). In the abscess-forming type (HS IIb, Hinchey I/II; n = 87), we found conformity in 92% (intraoperative) and 90% (histological), understaging in 3% (intraoperative) and 0% (histological), and overstaging in 5% (intraoperative) and 10% (histological). In the presence of a free perforation (HS IIc, Hinchey III/IV; n = 42), we saw conformity in 100% (intraoperative and histological). The positive predictive value for correctly diagnosing of phlegmonous type (HS IIa), abscess-forming type (HS IIb), and free perforation (HS IIc) by CT was intraoperatively (histologically) 52% (56), 92% (90), and 100% (100), respectively. CONCLUSIONS: The CT is one of the most accurate methods for staging in SD. However, in the phlegmonous type (HS IIa), it leads to an overestimation of the findings in every third patient. It must be clarified whether this pronounced low inflammation should really be regarded as a complicated form of SD. In contrast, the abscess-forming (HS IIb) and free perforated (HS IIc) type of complicated SD is very well reflected by CT.

Mannheim Peritonitis Index and APACHE II--prediction of outcome in patients with peritonitis.

BACKGROUND: Early prognostic evaluation of patients with peritonitis is desirable to select high-risk patients for intensive management and also to provide a reliable objective classification of severity and operative risk. This study attempts to evaluate the use of scoring systems such as Acute Physiological and Chronic Health Evaluation score (APACHE II) and Mannheim Peritonitis Index (MPI) in patients with peritonitis. METHODS: A prospective study was conducted using 101 consecutive patients (69 male, 32 female) having generalized peritonitis over a two-year period. Both scoring systems were applied to patients before laparotomy. Based upon the scores, patients were arranged into three groups. The outcome of patients was noted and the accuracy of the two systems was evaluated. RESULTS: In the MPI system, mortality was 0 in the group of patients with a score of less than 15, while it was 4% in the patients scoring 16-25 and 82.3% in those with scores of more than 25. Similarly, in the APACHE II system, no mortality was noted in patients with scores less than 10. Mortality was 35.29% and 91.7% in the groups scoring 10-20 and more than 20, respectively. CONCLUSION: Both scoring systems are accurate in predicting mortality; however, the APACHE II has definitive advantages and is therefore more useful.

Possibility of simplification of APACHE II scoring system in the prediction of the outcome in critically ill patients with perforative peritonitis.

BACKGROUND: Simplification of APACHE II scoring system in the prediction of the outcome in critically ill patients with perforative peritonitis can be a useful and a cheaper model than the standard APACHE II system. We tested APACHE II and SAPS I scoring systems and variables of arterial pH, pO2, pCO2 and HCO3, cholesterol and albumin in the prediction of the outcome in these patients. PATIENTS AND METHODS: The prospective study involved 145 patients of both sexes with perforative peritonitis. The main outcome of this study was peritonitis-related death. APACHE II and SAPS I scoring systems were calculated on the admission (during the first 24 hours). Cutoff points were specified and all values greater than the cut-off points were taken to predict death. Sensitivity and specificity are graphically shown for the different values of cut-off points. They are presented with the ROC curve. Variables of arterial pH, pO2, pCO2 and HCO3 were tested with Feed-Forward Artificial Neural Network which had 4 hidden layers with 8 neurons in the layer. We used Levenberg-Marquardt method for training, and 16 variables for the entrance in the network. We tested correlation between cholesterol and albumin levels with the patient outcome. RESULTS: APACHE II ROC curve demonstrated that its discriminatory ability was better than the SAPS ROC curve. The area under the curve was 0.86 for APACHE II score in comparison to 0.83 for SAPS score. This illustrated that APACHE II is significantly better (P < 0.01) at determining of outcome. Use of FeedForward Artificial Neural Network (ANN) for analysis of variables such as arterial pH, pO2, pCO2 and HCO3, showed that withdrawal of these variables lead to the decreased power of prediction of APACHE II scoring system. Measurement of the correlation between the cholesterol and albumin levels and the patient outcome revealed that there was no significance between these parameters, as the level of correlation for cholesterol and albumin was -, 1, and -, 14, respectively. CONCLUSION: APACHE II has better prognostic power than SAPS scoring system. Withdrawal of variables such as arterial pH, pO2, pCO2 and HCO3, reduces the prognostic power of APACHE II system.

[Intra-abdominal infections: definitions and classification]. / Infezioni intraddominali: ambiti e definizioni.

Intraabdominal infections (IAIs) represent a wide variety of pathological conditions that involve lesions of all the intra-abdominal organs. They include both inflammation of single organs and any sort of peritonitis (primary, secondary, tertiary), where the severity of the disease often depends from the extension of the inflammation ((local or diffuse peritonitis). They include also the intra-peritoneal, retroperitoneal and parenchymal abscesses. The aim of current review is that of analyse the current definitions and classifications of intraabdominal infections.