Method for prediction of developing suppurative complications of acute pancreatitis

FIELD: medicine.

SUBSTANCE: invention describes a method for prediction of developing suppurative complications of acute pancreatitis involving laboratory blood analysis wherein the patients are examined for the kinetics of leukocyte chemiluminescence with using an activated suspension of clinical strains Acinetobacter baumannii or Pseudomonas aeruginosa or methicillin-resistant Staphylococcus aureus - MRSA and combining maximisation time - T max more than 1400.0 sec., maximum intensity - 1 max less than 5131.5 standard units, light sum - S less than 144000.0 standard units for the reaction initiated by Acinetobacter baumannii, and combining the values T max>1435.0 sec., I max<4708.0 standard units, S<118000.0 standard units for the reaction initiated by Pseudomonas aeruginosa, or combining the values T max>3520.0 sec., I max<4257.0 standard units, S<169000.0 standard units for the reaction initiated by MRSA enables predicting developing suppurative complications.

EFFECT: higher sensitivity and reduced time of prediction of suppurative complications of acute pancreatitis ensured by enabled assessment of the specific properties of patient's phagocytic response to etiologically significant activators.

1 ex, 4 tbl

 

The invention relates to medicine, can be used in surgery, intensive care.

There is a method of forecasting of purulent complications of pancreatic necrosis (RF Patent No. 2187117, G01N 33/53, 10.08.2002 g)providing for the determination of blood concentrations of lactoferrin and Il-8. The method is distinguished by the complexity associated with the methodology enzyme immunoassay, the need for specially trained personnel and equipment, lack of specificity and, as a consequence, late informative (only in the second phase after 10-12 days of onset).

Known methods for predicting complications of acute destructive pancreatitis, based on the methodology of neural network modeling (Pofahl W.E., Walczak S.M., Bhone E., Izenberg S.D. Use of an artificial neural network to predict length of stay in acute pancreatitis // Am. Surg. - 1998. - Vol.64, N9. - p.868-872; Litvin A.A., Chekhov A.L., Gorbachev G.K. Artificial neural network in predicting septic complications of acute pancreatitis // minimally Invasive surgery in the Republic of Belarus: materials resp. nauch.-practical use. proc. with international. the participation. Gomel, 2002). the proposed methods require analysis from 8 to 12 clinical, laboratory and instrumental criteria, including the definition of infiltrate in the abdomen on palpation, the data of ultrasound and computed tomography (CT). The main disadvantages of the method is to represent the duration and the inability of early prediction (before the appearance of the infiltrate in packing bag, Ultrasound and CT signs of destruction of the gland).

There is a method of forecasting the rehabilitation of necrotic foci in infected pancreatic necrosis (Akhmetov Russia, having got Prognostic criteria of the flow of pancreatic necrosis and the choice of medical tactics: author. Diss. on saisc. academic step. Kida. the honey. Sciences. - Perm, 2007) depending on the concentration in the blood plasma hydroxyproline. The method is distinguished by the simplicity of technical execution, but informative only when developed common infected pancreatic necrosis.

Closest to the present invention is a method for the diagnosis of infected pancreatic necrosis (RF Patent No. 2319150, G01N 33/48, 10.03.2008,), which consists in determining the parameters Lomonosovskiy gelatination chemiluminescence of blood plasma. The method does not take into account the main etiological links of the infectious process: the nature of the microorganism and the immune resistance of the organism, registering only the investigation developed complications.

The objective of the proposed method is to increase the sensitivity and reduce the time of forecasting the development of suppurative complications of acute pancreatitis.

The task to solve due to the fact that patients appreciate the parameters of the kinetics of the chemiluminescence of leukocytes, activated suspension of clinical strains of Acinetobacter baumannii or Pseudomonas aeruginsa or methicillinresistant Staphylococcus aureus - MRSA and the combination of the values of time of a maximum - TM more 1400,0 sec, the maximum intensity Imax is less 5131,5$, sutasoma - S less 144000,0 USD for reactions initiated by Acinetobacter baumannii., or when the combined values of TM > 1435,0 sec, I max < 4708,0 USD, S < 118000,0 $ - for the reaction initiated by Pseudomonas aeruginosa, or a combination of values TM > 3520,0 sec, Imax < 4257,0 USD, S < 169000,0 $ - for the reaction initiated by MRSA, predict the development of purulent complications.

The method is as follows: in patients with acute pancreatitis from the cubital vein taken 2 ml of blood into centrifuge tubes, mixed well with 80 UNITS of heparin and 1 ml poliglyukina, incubated the mixture for 25 minutes at 37°C and 30 minutes at room temperature, then transferred leukocyte supernatant into a clean centrifuge tubes and washed three times in Hanks solution without phenol red for 5 minutes at 1500 rpm after the third centrifugation, the supernatant was removed and the remaining cells diluted in 2 ml of Hanks solution. The count produced in the chamber Goryaeva: to 20 ml of leukocyte suspension add 200 ál of 10% solution of acetic acid with 0.25% solution Trypanosoma blue. After counting the cells bring with Hanks solution to a concentration of 2*106/ml.

In the measuring cuvette of chemiluminometer make a reaction mixture consisting of 50 MK is lyuminola, 200 μl of Hanks solution, 200 μl of the suspension of leukocytes and 40 µl of the suspended inductor.

As inducers of respiratory burst using a suspension of clinical strains of microorganisms in isotonic sodium chloride. For the preparation of suspensions of microorganisms 24-hour culture of clinical strains of Acinetobacter baumannii or Pseudomonas aeruginosa or methicillinresistant Staphylococcus aureus diluted in isotonic sodium chloride to a concentration of 108CFU/ml optical density, which is controlled using the photocolorimeter FEC-56M at a wavelength of 540 nm.

Time recording is 90 minutes. In patients with acute pancreatitis estimate the parameters of the kinetics of the chemiluminescence of leukocytes, activated suspension of clinical strains of Acinetobacter baumannii or Pseudomonas aeruginosa or methicillinresistant Staphylococcus aureus - MRSA and the combination of the values of time of a maximum - TM more 1400,0 sec, the maximum intensity Imax is less 5131,5 c.u., sutasoma - S less 144000,0 USD for reactions initiated by Acinetobacter baumannii, or a combination of values TM > 1435,0 sec, Imax < 4708,0 y.e., S < 118000,0 $ - for the reaction initiated by Pseudomonas aeruginosa, or a combination of values of T max > 3520,0 sec, Imax < 4257,0 y.e., S < 169000,0 y.e. for reactions initiated by MRSA, predict the development of purulent complications.

Among surveyed were 19 patients with aseptic the Russian form of pancreatic necrosis (first group) and 16 patients with infected pancreatic necrosis (second group) aged 20 to 75 years (table 1). To determine the normal settings of the parameters of the kinetics of leukocyte chemiluminescence additionally surveyed 55 conditionally healthy individuals-donors (comparison group).

Table 1
The distribution of patients by age, sex and etiology of acute pancreatitis
The average age, years46,86±3,3 (20-75)
Gender (male/female), abs.(%)21 (60,0%)/14 (40,0%)
Alcoholic16 (45.7 per cent)
Biliary13 (37.1 per cent)
Posttraumatic6 (17,1%)

The reasons for the development of pancreatic necrosis was alcohol (45,7%), diseases of the biliary system (37,1%), trauma to the pancreas - 17.1% of cases.

The diagnosis was established on the basis of the anamnesis, the clinical picture of the disease, laboratory tests, ultrasound examination of abdominal cavity and retroperitoneal space, esophagogastroduodenoscopy.

The Department conducted a comprehensive intensive infusion therapy with the use of antispasmodics, anal is feasible, drugs octreotide, antimetabolites, H2-receptor blockers, blood detoxification and hemodynamic series aimed at suppressing the exocrine functions of the pancreas and the decline of pancreatic taxinomie.

All patients were evaluated by the parameters of the kinetics of chemiluminescence, spontaneous and induced a nonspecific activator - simhasanam and suspension of clinical strains of Acinetobacter baumannii or Pseudomonas aeruginosa or methicillinresistant Staphylococcus aureus.

Table 2 presents the parameters of spontaneous and induced chemiluminescence of blood leukocytes apparently healthy individuals-donors and patients with pancreatic necrosis. Patients showed reliable compared with donors shortening the time of reaching the peak of spontaneous chemiluminescence in the absence of significant differences in intensity and sutasoma.

Table 2
The parameters of leukocyte chemiluminescence apparently healthy donors and patients with sterile pancreatic necrosis
IndexDonorsPatients of the first groupPU
Me (Q1-Q )Me (Q1-Q2)
1234
T max sp1399,0 (749,0-2118,0)309,0 (196,0-1832)*0,001350
T max zim1262,0 (1071,0-1596,0)1260,0 (770,0-1699,0)0,930143
T max Ps.aer1163,0 (771,0-1435,0)1907,0 (744,0-3367,0)*0,007658
Tmax Ac.bau1111,5 (860,0-1400,01382,0 (191,0-4126,0)0,932158
Tmax MRSA3081,0 (2287,0-3520,0)951,0 (438,0-2265,0)*0,000078
I max sp2483,0 (766,0-8976,0)2129,0 (694,0-6762)0,324022
I max zim17470,0 (8400,031162,0)20827,0 (11344,0-44444,0)0,230178
I max Ps.aer11877,0 (4708,0-29706,0)/td> 5638,0 (2576,0-11677)0,169971
I max Ac.bau12546,0 (5131,5-24998,5)4086,0 (1340,0-10520)*0,008318
I max MRSA6005,0 (4257,0-9516,0)4358,0 (1522,0-20014)0,601509
's max sp111000,0 (27700,0-267000,0)69700,0 (14100,0-111000)0,104844
S max zim516000,0 (282000,0-869000,0)687000,0 (220000,0-1560000)0,225941
S max Ps.aer311000,0 (118000,0-581000,0)183000,0 (73400,0-383000)0,340176
Smax Ac.bau321000,0 (144000,0-640000,0)95200,0 (53100,0-211000)*0,004349
Smax MRSA234000,0 (169000,0-362000,0)207000,0 (45900,0-738000)0,510224

Note: average values are represented by the median, lower and upper quartile [Me(Q1-Q2)]; T max sp is the time to reach the peak of spontaneous chemiluminescent the AI, T max zim - time to reach the peak induced simhasanam chemiluminescence, T max Ps.aer - time to reach the peak induced Pseudomonas aeruginosa chemiluminescence, T max Ac.bau - time to reach the peak induced Acinetobacter baumaimii chemiluminescence, T max MRSA - time to reach the peak induced methicillinresistant Staphylococcus aureus chemiluminescence, I max sp - maximum intensity of the spontaneous chemiluminescence, I max zim - maximum intensity of the induced simhasanam chemiluminescence, I max Ps.aer - maximum intensity of the induced Pseudomonas aeruginosa chemiluminescence, I max Ac.bau - maximum intensity of the induced Acinetobacter baumannii chemiluminescence, I max MRSA - maximum intensity of the induced meticillin-resistant Staphylococcus aureus chemiluminescence, S max sp - sutasoma spontaneous chemiluminescence, S max zim - sutasoma induced simhasanam chemiluminescence, S max Ps.aer - sutasoma induced Pseudomonas aeruginosa chemiluminescence, S max Ac.bau - sutasoma induced Acinetobacter baumannii chemiluminescence, S max MRSA - sutasoma induced meticillin-resistant Staphylococcus aureus chemiluminescence, PU- significance of differences between the donor and patients with edematous pancreatitis according to the criterion of Mann-Whitney (U-test), * - significance of differences at PU<0,05.

Analysis of reaction-induced nonspecific what ctivation - simhasanam, revealed no significant differences from the donor. The response of phagocytes of patients with sterile pancreatic necrosis on the activation of Pseudomonas aeruginosa was reflected in the increase of time of reaching the peak in the background close to the normal values of the intensity and sutasoma.

After induction of leukocyte suspension culture of Acinetobacter baumanni the observed decrease in the intensity of the glow and setosum in combination with the normal value of the time of reaching the peak chemiluminescence. Activation of phagocytes MRSA was accompanied by a decrease in time of the output curve at the maximum normal level of bactericidal activity (intensity and sutasoma). Thus, changes in the functional state of phagocytes revealed during activation of specific bacterial agents in patients with sterile pancreatic necrosis wore compensated character.

In 16 patients of the second group, submitted to the Department with the clinical picture of severe acute pancreatitis, later operated on for infected pancreatic necrosis, lengthening the time of reaching the peak chemiluminescence combined with low intensity and sitesmay when activated by various microbial cultures.

The calculation of operating characteristics of the proposed method for the diagnosis of infected pancreatitis was performed in accordance with the requirements of CONSRD (CONSORD GROUP, 1996). Diagnostic sensitivity of the proposed method of forecasting in the first week of inpatient treatment was 81,3%, in the second week - 93,8%, while when using the known method (Patent RF №2319150, G01N 33/48, 10.03.2008,) within a specified time sensitivity was 62.5% and 75.0%, respectively (table 3).

Thus, the parameters of chemiluminescence, activated by various microbial agents confirms the importance of phagocytic dysfunction of phagocytes in the pathogenesis of septic complications and allows these complications to predict. The advantage of this method is higher sensitivity, reduced time forecasting of infectious complications due to the possibility of evaluating the individual characteristics of the phagocytic response of the patient to significant etiological agents.

Table 3
Comparison of results of prediction and early diagnosis of suppurative complications of acute pancreatitis
Way checkIndicator, abs.
FEIOPL LO
Known, 17 days101546
Known 8-14 days121544
Offer, 1-7 days131723
Offer, 8-14 days151811
Note: FE - true positive, IO - true negative, PL - false positive, LO - false negative results of the research; diagnostic sensitivity (QH)=FE/(FE+FN).

Statement of the case history No. 2141

Patient C., 55 years, has arrived in Krasnoyarsk city centre surgical pancreatology 30.06.2009 in serious condition with a diagnosis of pancreatic necrosis after alcohol abuse. At admission were noted marbling of the skin, pulse 90 beats./min, BP 110/70 mmHg, body temperature 36,9°C. the dry Language, lined with whitish bloom. Belly swollen, tense and diseases is Yong in all departments, symptoms of peritoneal irritation negative. In the analysis of peripheral blood: hemoglobin - 162 g/l, leucocytes - 12,6×109/l (basophils - 1%, stab neutrophils - 1%, segmented - 67%, lymphocytes - 22%, monocytes - 9%), amylase - 118 mg*s/l, sugar - 6.2 mmol/l, total bilirubin - 30.4 μmol/l (direct - 2,3, indirect - 28,1), urea is 11.9 mmol/L. According to the ultrasound pancreas is not clearly visualized.

When the measurement of chemiluminescence leukocytes obtained the following results (table 4). Spontaneous chemiluminescence of phagocytes were characterized by a rapid exit of the curve at a maximum at low intensity values and sutasoma. Activation simhasanam was accompanied by some increase in time to achieve the maximum reaction at elevated values of kislotoproduktsii (setosum and intensity of chemiluminescence). Incubation of cells with clinical strains of microorganisms allowed to register failure phagocytic response in the highest degree to Acinetobacter baumannii and Pseudomonas aeruginosa (simultaneous increase in reaction time and decrease in intensity, setosum). These changes testified to the presence of a predisposition of the patient to the development of septic complications of acute pancreatitis.

Table 4
The study of leukocyte chemiluminescence patient S.
IndexNormal valuesThe values of the patient
123
The time to reach the peak of spontaneous chemiluminescence (CHL), s749,0-2118,0338
The time to reach the peak of CHL-induced simhasanam, s1071,0-1596,02545
The time to reach the peak of CHL-induced Pseudomonas aeruginosa, s771,0-1435,02394
The time to reach the peak of CHL-induced Acinetobacter baumannii, s860,0-1400,05147
The time to reach the peak of CHL-induced MRSA, sec2287,0-3520,04054
The maximum intensity of spontaneous chemiluminescence, $766,0-8976,0175
The maximum intensity of the chemiluminescence induced ZIM is Sanom, $ 8400,0-31162,041136
The maximum intensity of the chemiluminescence induced
Pseudomonas aeruginosa, y.e.
4708,0-29706,02566
The maximum intensity of the chemiluminescence induced Acinetobacter baumannii, y.e.5131,5-24998,54086
The maximum intensity of the chemiluminescence induced MRSA, y.e.4257,0-9516,04358
Sutasoma spontaneous chemiluminescence, y.e.27700,0-267000,07720
Sutasoma CHL induced simhasanam, y.e.282000,0-869000,01820000
Sutasoma CHL induced Pseudomonas aeruginosa, y.e.118000,0-581000,073400
Sutasoma CHL induced Acinetobacter baumannii, y.e144000,0-640000,0105000
Sutasoma CHL induced MRSA, y.e.169000,0-362000,0207000

In conditions of intensive therapy and reanimation of the beginning is rather conservative therapy. Based on identified predisposition of the patient to the development of septic complications and sensitivity potentially "threatening" microorganisms for antimicrobial prophylaxis patient prescribed group of carbapenems (imipenem). Despite ongoing therapy, 8.07.09, the patient's condition deteriorated, there are signs of infection foci of necrosis, ultrasound indicated the centers of pressure in the infiltration stuffing bags. Conducted besubstantially laparotomy through a mini-approach, abdominal pancreas, omentoplasty, retroperitoneoscopy. Revealed a Subtotal lesion of the pancreas, peripancreatic and parabolically fiber on the left. Bacteriological examination of the contents of the stuffing bags selected Enterococcus durans (106CFU/ml) and Acinetobacter baumannii (104CFU/ml). In the complex treatment of the patient used antibacterial drugs groups fluoroquinolones, cephalosporins III and IV generations, metronidazole. Carried out the immunotherapy drug Imunofan (1 ml daily for 10 days). For intra - and postoperative local rehabilitation stuffing bags used ozonated physiological solution.

In a subsequent double-spent stage of rehabilitation of relaparotomy marked the gradual purification of the sequestrum and the last relaparotomy the imp is NENO partial closure of postoperative wounds with drainage of the residual cavity stuffing bags. The patient was discharged 4.08.2009 outpatient aftercare.

Thus, the parameters of chemiluminescence leukocytes activated by clinical strains of microorganisms, allows to predict the development of purulent complications of pancreatic necrosis, which is crucial in the choice of treatment, the scheme antibacterial prophylaxis and immune disorders.

A method for predicting the development of suppurative complications of acute pancreatitis, including laboratory analysis of blood, characterized in that the patients to estimate the parameters of the kinetics of the chemiluminescence of leukocytes, activated suspension of clinical strains of Acinetobacter baumannii or Pseudomonas aeruginosa or methicillinresistant Staphylococcus aureus - MRSA and the combination of the values of time of maximum T max more 1400,0 with the maximum intensity I max less 5131,5$, sutasoma - S less 144000,0 USD for reactions initiated by Acinetobacter baumannii, or when the combined values of T max > 1435,0 with, I max < 4708,0 USD, S < 118000,0 $ - for the reaction initiated by Pseudomonas aeruginosa, or a combination of values of T max > 3520,0 with, I max < 4257,0 USD, S < 169000,0 $ - for the reaction initiated by MRSA, predict the development of purulent complications.



 

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2 ex

FIELD: medicine.

SUBSTANCE: method involves measuring forced exhalation volume per 1 s (FEV1) in l, full right ventricle evacuation time (RVE) in ms and angiotensin II value (AII) in ng/l. Discriminant relationship is built as D=0.504·RVE+3.038·FEV1 - 2.0·AII. D being less than 83.88, pulmonary hypertension occurrence is predicted within 1 year. D being equal to or greater than 83.88, no pulmonary hypertension is predicted to occur.

EFFECT: enhanced accuracy of prediction.

FIELD: medicine, medicinal immunology.

SUBSTANCE: method involves determination of heterophilic antibodies in human serum blood by the Paul-Bunnel's method relatively the level of circulating immune complexes, complement-activating properties of heterophilic antibodies by incubation of standardized ram erythrocytes with 0.8% serum for 30 ± 5 min and the following measurement of the erythrocytes lysis degree. The measurement of the effector function coefficient of heterophilic antibodies is carried out by the complement system Keff.f.h.a.-c.s. by the formula: Keff.f.h.a.-c.s. = Y/Tg.a. wherein Y means a lysis degree, %; Tg.a. means a reverse titer of heterophilic antibodies to ram erythrocytes. The damage assay is carried out by comparison of the immune status with the relative level of circulating immune complexes in serum. Method provides detection of preclinic from of immunodeficiency and autoimmune diseases that opens the possibility for their prophylaxis at most early stages of development. Invention can be used for assay of damage in the immune status in human serum blood.

EFFECT: improved method for assay.

5 tbl, 1 ex

FIELD: medicine.

SUBSTANCE: method involves concurrently examining anti-inflammatory IL-4 level in blood serum and lacrimal fluid. The value being within the limits of 60-70 pg/l in blood serum and 5-15 pg/l in lacrimal fluid, disease prognosis is considered to be unfavorable. The IL-4 concentration being within the limits of 90-100 pg/l in blood serum and 20-30 pg/l in lacrimal fluid, disease prognosis is considered to be favorable.

EFFECT: high accuracy of diagnosis.

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