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Query: UMLS:C0243026 (sepsis)
 52,417 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The cardiovascular response in sepsis is the result of subcellular dysfunction and impaired metabolism from the complex interaction of cytokine and mediator with cellular involvement. The typical cardiovascular abnormalities seen are tachycardia, hypotension (relative decrease in preload), increased cardiac index, decrease in left ventricular stroke work index, decrease in ejection fraction (which is load dependent), and an apparent decrease in contractility. After augmentation of preload, the ventricles dilate in a response similar to the Frank-Starling mechanism. By challenging these patients with the augmentation of preload and contractility to increase oxygen delivery would theoretically minimize microcirculatory dysfunction and lactic acid production. Survivors have an amplification of this biventricular response. This response would temporarily normalize within a week, while the nonsurvivors would still have increased hemodynamics (tachycardia) without the ventricular dilation as a compensatory response. Even though the survivor response is not predictable, therapeutic end-points have been proposed as a guide to therapy in these critically ill patients. Conflicting results have been reported regarding contractility and ventricular compliance measurements in septic models. The development of pressure-volume loops would be the ideal technique for the evaluation of ventricular diastolic compliance, true preload, and contractility (from the end-systolic pressure relationship, which is load independent) in sepsis. More research has to be done with this type of evaluation to further understand the dynamic cardiovascular response in sepsis. This question still persists. Why can't some patients be hemodynamically challenged to increase right and left ventricular end-diastolic volumes and oxygen delivery?
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PMID:Cardiovascular abnormalities in sepsis. 792 12

Between May 1989 and April 1993 we treated 108 patients, aged 44-82 years, for rectal cancer. Of them, 7 men and 2 women underwent anterior resection with colo-anal anastomosis. In this group the average distance of the tumor from the anal verge was 6 cm. Follow-up ranged from 12-48 months. There was no operative mortality. Perioperative morbidity included wound infection in 1 patient and pelvic sepsis in another; temporary disturbances in micturition occurred in 4; 1 developed an anastomotic stricture and another intestinal obstruction; 1 died of systemic spread; another was reoperated and salvaged, but had a local recurrence 3 years after the first operation. Continence was achieved in 6, while 3 had minor impairment of control. Frank incontinence did not occur. We believe that anterior resection with colo-anal anastomosis in low rectal cancer avoids a permanent colostomy, while meeting oncological and functional criteria. We advocate this procedure in selected patients with low rectal cancer.
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PMID:[Anterior resection with colo-anal anastomosis for low rectal cancer]. 803 62

There has been an increase in the indications for splenectomy for hematologic diseases. It is a consequence of expanding the list of disorders and liberalizing the indications for splenectomy for many diseases. Hereditary spherocytosis is the most frequently encountered congenital anemia for which splenectomy is curative. Splenectomy is generally advised for warm antibody acquired hemolytic anemia if conventional medical therapy fails. Idiopathic thrombocytopenic purpura (ITP) remains the most common hematologic disorder for which splenectomy is therapeutic. A variety of thrombocytopenias are improved by splenectomy. The myeloproliferative disorders constitute a spectrum of disease potentially improved by splenectomy, but preoperative management should be modified in this group. Splenectomy in patients with chronic leukemias and lymphomas are often palliative and facilitate chemotherapy. There are no specific requirements preoperatively other than the administration of pneumococcal and Hemophilus influenzae vaccines. Platelets are not administered to patients with ITP. An integral part of the procedure is the search for accessory spleens. The postoperative complication of overwhelming postsplenectomy sepsis must be considered; it occurs more frequently in association with specific basic diseases and can be obviated by appropriate treatment.
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PMID:Role of splenectomy in hematologic disorders. 886 75

P-selectin is a 140 kD protein found in the alpha-granules of platelets and the Weibel-Palade bodies of endothelial cells. On cell activation it is expressed on the cell surface and also secreted into plasma. Whether the circulating soluble P-selectin (sP-selectin) originates from platelets, endothelial cells, or both, is not known. We studied the level of sP-selectin in diseases with different platelet counts, with or without evidence of endothelial cell activation. Endothelial cell activation was confirmed by the detection of sE-selectin and ED1-fibronectin. A significant positive correlation between platelet count and sP-selectin concentration was observed in healthy controls, and in patients with thrombocytopenia due to bone marrow aplasia, or with thrombocytosis (r = 0.85; n = 47; p < 0.001). In patients with idiopathic thrombocytopenic purpura (ITP) the sP-selectin concentration was 110 +/- 39 ng/ml (n = 10), compared to 122 +/- 38 ng/ml in healthy controls (n = 26). However, their mean platelet count was lower (58 x 10(9)/l versus 241 x 10(9)/l in the control group). Accordingly, the levels of sP-selectin expressed per platelet increased to significantly higher levels (2.0 +/- 1.2 versus 0.6 +/- 0.2 fg/platelet in the control group; p < 0.0001). This suggests increased platelet turnover in patients with ITP. High levels of sP-selectin were found in patients with sepsis (398 +/- 203 ng/ml; n = 15) and with thrombotic thrombocytopenic purpura (TTP; 436 +/- 162 ng/ml; n = 12). Compared with patients with ITP, the concentration of sP-selectin per platelet was higher in patients with sepsis (4.8 +/- 4.3 fg/platelet; p < 0.005) or TTP (17.1 +/- 9.5 fg/platelet; p < 0.001). Endothelial cells are very likely to be the source in these patients and the presence of endothelial cell activation was confirmed by increased levels of circulating E-selectin and ED1-fibronectin. This study suggests that platelets are the major source of circulating sP-selectin in healthy individuals. Endothelial cell activation is associated with an increased sP-selectin concentration per platelet.
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PMID:The origin of P-selectin as a circulating plasma protein. 924 36

Idiopathic thrombocytopenic purpura (ITP) is an illness of primary acquired thrombocytopenia occurring in the absence of marrow failure. Splenectomy was first used as a treatment for ITP in 1913. However, with the realization that opsonin (critical for the optimal killing of invasive micro-organisms by white blood cells) is manufactured only in the spleen, spontaneous splenic removal was reevaluated and questioned. Splenectomy has a success rate that remains nearly identical (about 50% to 60%) whether it is performed soon after diagnosis or several months or years later. As yet, there is no consistently effective method to predict an individual ITP patient's response to splenectomy. As the time since splenectomy increases, however, the rate of excellent response decreases. Despite pneumococcal vaccination prior to splenectomy, fatal fulminant sepsis is an omnipresent possibility. Because a number of published studies, including the Johns Hopkins experience, have questioned the long-term outcome of splenectomy, splenectomy should not be the first treatment option for ITP patients. It should be performed only after all other therapeutic modalities have been exhausted, and the patient has a platelet count less than 25,000/microL and is hemorrhaging. Once patients have undergone splenectomy, they are Ineligible for potentially excellent treatment such as anti-D globulin or oral tolerance therapy.
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PMID:Long-term outcome of splenectomy for idiopathic thrombocytopenic purpura. 1067 20

Absence of the spleen or splenic function predisposes individuals to risk of overwhelming infection. These infections are most often due to encapsulated organisms, especially pneumococcus, Haemophilus influenzae type b, and meningococcus, but any bacterial agent may cause the rapid onset of septicemia, meningitis, pneumonia, and shock characteristic of the asplenic-hyposplenic condition. The risk is greatest in infants and young children, but asplenic-hyposplenic adults also have an increased risk of infection. Prophylactic antibiotics and immunization with polyvalent pneumococcal, H. influenzae type b, and meningococcal vaccines have reduced the incidence of infections in asplenic-hyposplenic individuals, but even these measures have not eliminated the risk. Surgeons have adopted techniques to save as much splenic tissue as possible and some splenic functions, such as pitting red cells, have been preserved, but conservative surgery has not provided total protection against overwhelming infection. Therapies designed to interrupt the cascade of overwhelming sepsis have not yet been successful. In those cases in which the spleen is surgically removed, the underlying disease or condition leading to splenectomy influences the risk of sepsis. Splenectomy incidental to other operations, such as gastrectomy, results in the lowest risk for overwhelming infection, but this is still some 35-fold greater than the risk for overwhelming infections in the general population. In increasing order of risk, the other main indications for surgical removal of the spleen are idiopathic thrombocytopenia purpura, trauma, transplantation procedures, hereditary spherocytosis, staging Hodgkin's disease, portal hypertension with hypersplenism, and thalassemia. Pathologists should comment on the risk of overwhelming sepsis when spleens are processed as surgical specimens, and should carefully weigh all splenic tissue, including accessory spleens and splenic implants (splenosis), in autopsy cases with and without overwhelming sepsis.
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PMID:Asplenic-hyposplenic overwhelming sepsis: postsplenectomy sepsis revisited. 1117 26

Idiopathic thrombocytopenic purpura is a condition that is characterized by persistently low platelet counts. Idiopathic thrombocytopenic purpura results from splenic sequestration and accelerated platelet destruction mediated by antiplatelet antibody. Most cases arise in previously healthy patients, mostly women ages 20 to 40. Clinical symptoms consist of bruising, petechiae, mucosal bleeding, menorrhagia, and intracranial bleeding. Platelet-associated immunoglobulin G can be detected in 90 per cent of patients. Therapy for adults and children is somewhat different. Splenectomy in adults should be considered in patients who fail to respond to steroids, develop thrombocytopenia after taper, or develop steroid toxicity. Ninety per cent of children will maintain normal platelet counts in 9 to 12 months. Some will recover spontaneously without medical therapy. Splenectomy in children is recommended if idiopathic thrombocytopenic purpura persists for more than one year or fails to respond to steroids. Our purpose was to determine whether management of idiopathic thrombocytopenic purpura in patients who undergo splenectomy at our institutions is appropriate and effective. We undertook a 5-year retrospective review of 27 patients with idiopathic thrombocytopenic purpura which have undergone splenectomy. All of the 27 patients were referred to surgeons after initial medical management. The patients were divided into two groups on the basis of length of therapy: longer than 6 months and less than 6 months. The longer than 6 months group contained 15 patients. This group had a postoperative complication rate of 40 per cent. Those in the group with <6 months therapy had a complication rate of 7 per cent. Average follow-up for all patients was 20 months. Eighty-eight per cent of the patients had complete response. Three per cent had a partial response with platelet counts >50,000. The partial response group did not respond well to preoperative steroid boluses with a great rise in platelet counts. Eighteen per cent of patients received platelet transfusions. Sixty per cent of the transfusions were given for inappropriate reasons. A large percentage of our patients had prolonged medical therapy before splenectomy. The inappropriate use of platelets was a common error in management. Patients treated for more than 6 months had more postoperative complications. An initial increase in platelets after steroid bolus is a good indicator for favorable response to splenectomy. We conclude that splenectomy is a safe and effective method of treatment for idiopathic thrombocytopenic purpura with no deaths or postsplenectomy sepsis to date.
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PMID:Splenectomy for idiopathic thrombocytopenic purpura: a five-year retrospective review. 1126 23

Idiopathic thrombocytopenic purpura (ITP) is a common acquired bleeding disorder in infancy and childhood. Most children rapidly improve, exhibiting a rise in platelet count to hemostatically normal levels within weeks to several months. Traditionally, chronic ITP is defined as persistence of thrombocytopenia (platelet count < 150 x 10(9)/L) for greater than 6 months. The Authors retrospectively evaluated 16 patients with chronic ITP, identified during a 12-year period of time in their Department of Pediatrics. The most important clinical and hematological parameters of patients were analyzed, including age at diagnosis, type and response to the initial treatment, number of multiple treatments, and duration of follow-up. At the last evaluation (december 1999) one patient was lost to the follow-up; one died of overwhelming postsplenectomy sepsis; four still require intermittent or chronic infusions of intravenous gamma-globulin; seven are in stable partial remission (PLT > 50 x 10(9)/L < 150 x 10(9)/L) and do not require any treatment; three are in complete remission (PLT > 150 x 10(9)/L). Finally, the Authors discuss of the natural history and management of this rare disease. Presently there are insufficient trial data to support evidence-based treatment guidelines in childhood chronic ITP and therefore it is reasonable to encourage future multicentre collaboration.
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PMID:[Long-term follow-up of chronic idiopathic thrombocytopenic purpura in children]. 1138 65

Idiopathic purpura fulminans produces rapidly progressive hemorrhagic necrosis of the skin with disseminated intravascular coagulation in individuals without known abnormalities of the protein C pathway or acute infections. The disease mainly affects children and in 90 % of cases is preceded by a benign infection. Its pathogenesis involves a temporary autoimmune protein S deficiency that provokes a state of hypercoagulability. We present the case of a previously healthy 2-year-old boy with hemorrhagic skin lesions characteristic of purpura fulminans and disseminated intravascular coagulation without sepsis. Severe, temporary protein S deficiency was confirmed. The patient received daily replacement therapy with fresh frozen plasma for 12 days and anticoagulation with heparin for 3 months. Evolution was favorable. Although the other parameters returned to normal, protein S remained low for 50 days despite treatment. The patient has made a complete recovery.
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PMID:[Idiopathic purpura fulminans with transient protein S deficiency]. 1157 47

Since idiopathic (immune) thrombocytopenic purpura (ITP) in adults is usually a chronic condition with few spontaneous remissions, the goal of treatment is not cure, but to maintain a hemostatically safe platelet level. The indication for treatment should be based not merely on platelet counts, but also clinical indices of bleeding. Although most patients show good initial response to prednisone, the side effects of steroids limit this treatment. Currently, long-term management usually involves splenectomy. Since splenectomy has surgical risks and may also predispose the patient to sepsis, a clinical trial using anti-D (WinRho-SDR) has been performed to determine whether this treatment can safely delay or avoid the need for surgery. The use of WinRho may also reveal the occurrence of spontaneous remissions, a previously unrecognized subgroup of adults with chronic ITP.
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PMID:Initial management of adults with idiopathic (immune) thrombocytopenic purpura. 1191 92


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