Procalcitonin in the diagnosis of inflammation in intensive care units.

OBJECTIVES: To assess the effectiveness of different procalcitonin cutoff values to distinguish non-infected (negative+SIRS) from infected (sepsis+severe sepsis+septic shock) medical and surgical patients. DESIGN AND METHODS: PCT plasma concentration was measured using an automated chemiluminescence analyzer in 1013 samples collected in 103 patients within 24 h of admission in ICU and daily during the ICU stay. We compared PCT levels in medical and surgical patients. We also compared PCT plasma levels in non-infected versus infected patients and in SIRS versus infected patients both in medical and in surgical groups. RESULTS: Median values of PCT plasma concentrations were significantly higher in infected than in non-infected groups, both in medical (3.18 vs. 0.45 microg/L) (p<0.0001) and in surgical (10.45 vs. 3.89 microg/L; p<0.0001) patients. At the cutoff of 1 microg/L, the LR+ was 4.78, at the cutoff of 6 microg/L was 12.53, and at the cutoff of 10 microg/L was 18.4. CONCLUSIONS: This study highlights the need of different PCT cutoff values in medical and surgical critically ill patients, not only at the ICU admission but also in the entire ICU stay.

Emergence of linezolid resistance in the vancomycin-resistant Enterococcus faecium multilocus sequence typing C1 epidemic lineage.

A relatively high rate of vancomycin-resistant Enterococcus faecium not susceptible to linezolid was observed in intensive care unit patients. Linezolid-resistant isolates carried the G2576T mutation in the 23S rRNA gene, belonged to different clones, and shared the same allelic profile, which clusters in the C1 multilocus sequence typing epidemic lineage.

Comparison of procalcitonin and C-reactive protein as markers of sepsis.

OBJECTIVE: To compare the clinical informative value of procalcitonin (PCT) and C-reactive protein (CRP) plasma concentrations in the detection of infection and sepsis and in the assessment of severity of sepsis. DESIGN: Prospective study. SETTING: Medicosurgical intensive care unit. PATIENTS: Seventy consecutive adult patients who were admitted to the intensive care unit for an expected stay >24 hrs. INTERVENTIONS: None. MEASUREMENTS: PCT and CRP plasma concentrations were measured daily during the intensive care unit stay. Each patient was examined daily for signs and symptoms of infection and was classified daily in one of the following four categories according to the American College of Chest Physicians/Society of Critical Care Medicine criteria: negative, systemic inflammatory response syndrome, localized infection, and sepsis group (sepsis, severe sepsis, or septic shock). The severity of sepsis-related organ failure was assessed by the sepsis-related organ failure assessment score. MAIN RESULTS: A total of 800 patient days were classified into the four categories. The median plasma PCT concentrations in noninfected (systemic inflammatory response syndrome) and localized-infection patient days were 0.4 and 1.4 ng/mL (p <.0001), respectively; the median CRP plasma concentrations were 79.9 and 85.3 mg/L (p =.08), respectively. The area under the receiver operating characteristic curve was 0.756 for PCT (95% confidence interval [CI], 0.675-0.836), compared with 0.580 for CRP (95% CI, 0.488-0.672) (p <.01). The median plasma PCT concentrations in nonseptic (systemic inflammatory response syndrome) and septic (sepsis, severe sepsis, or septic shock) patient days were 0.4 and 3.65 ng/mL (p <.0001), respectively, whereas those for CRP were 79.9 and 115.6 mg/L (p <.0001), respectively. The area under the receiver operating characteristic curve was 0.925 for PCT (95% CI, 0.899-0.952), compared with 0.677 for CRP (95% CI, 0.622-0.733) (p <.0001). The linear correlation between PCT plasma concentrations and the four categories was much stronger than in the case of CRP (Spearman's rho, 0.73 vs. 0.41; p <.05). A rise in sepsis-related organ failure assessment score was related to a higher median value of PCT but not CRP. CONCLUSION: PCT is a better marker of sepsis than CRP. The course of PCT shows a closer correlation than that of CRP with the severity of infection and organ dysfunction.

Impact of oligon central venous catheters on catheter colonization and catheter-related bloodstream infection.

OBJECTIVE: To evaluate a new antimicrobial treatment for central venous catheters in comparison with a traditional treatment, by assessing the catheter colonization and catheter-related bloodstream infection rates in two groups of patients. DESIGN: Multiple-center, prospective randomized study. SETTING: The medical and surgical departments of ten institutions. PATIENTS: Patients requiring a central venous catheter for medical or surgical pathologies between June 2000 and November 2001. INTERVENTIONS: Patients in the control group received a conventional benzalkonium-treated double-lumen central venous catheter, while patients in the oligon group received an oligon-treated (polyurethane combined with silver, carbon, and platinum) catheter with the same characteristics. Data collection included demographics, preexisting clinical conditions, main pathology, catheter insertion, and management data. Catheter colonization was defined as the growth of > or = 15 colony-forming units in culture of catheter segments by the roll-plate method, or > or = 1000 colony-forming units for the sonication method, and catheter-related bloodstream infection was defined as isolation of the same organism from the colonized catheter and from the peripheral blood of a patient with clinical signs of bloodstream infection. MEASUREMENTS AND MAIN RESULTS: Data were obtained from 545 catheters. Of these, 132 catheters (24.2%) were positive for colonization. Patients in the oligon group demonstrated a lower risk for catheter colonization in the overall population (relative risk, 0.63; 95% confidence interval, 0.46-0.86; p = .003) and in the surgical subgroup (relative risk, 0.5; 95% confidence interval, 0.33-0.76;p = .001). Significant differences between groups were detected for coagulase-negative staphylococci and Gram-negative bacilli colonization rates. Twenty-one patients (3.8%) were positive for catheter-related bloodstream infection, without significant differences between control and oligon groups. CONCLUSIONS: Oligon treatment is effective in limiting the catheter colonization rate. Due to the limited amount of events, this study lacked the power to detect significant differences in terms of catheter-related bloodstream infection rate.

Reference fields in phantom tooth pain as a marker for remapping in the facial territory.

Six patients with chronic phantom tooth pain were studied for the presence of reference fields for their phantom sensation. In five of them, pain or dysesthesia in the affected oral structures was elicited by thermal or mechanical stimulation of areas that were well separate from these structures. However, a relation of topographical proximity between the stimulated areas and the areas of reference could be traced in the sensory maps. Therefore, denervation of small structures with coarse sensitivity can yield the plastic changes that have previously been described for larger deafferentations of areas endowed with finer discriminative capacity.

Results up to death in the treatment of persistent cervico-thoracic (Pancoast) and thoracic malignant pain by unilateral percutaneous cervical cordotomy.

The authors analyse the results up to death in 103 followed-up patients undergoing unilateral percutaneous cervical cordotomy for persistent cervico-thoracic malignant pain (45 cases of Pancoast syndrome and 58 cases of thoracic pain associated with lung cancer or metastases). On the basis of epidemiological data, relationships emerge between onset of pain, stage of cancer, patient survival and lasting efficacy of pain relief. Twenty (44%) of 45 patients with Pancoast syndrome were pain-free up to death as a result of cordotomy alone, while only 13/58 patients (22%) with thoracic pain were pain-free as a result of cordotomy alone owing to the very high incidence of mirror pain in this group of patients (42/58 patients, 72%) compared to those with Pancoast syndrome (14/45 patients, 31%). The type and intensity of mirror pain, however, were of such a nature in both groups as to be amenable to control with analgesic drugs. In both groups of patients, there was a low incidence of the causes of post-cordotomy pain recurrence contralateral to the lesion, i.e., deafferentation pain, fading of analgesia, and pain above the levels up to which deep pin-prick analgesia had been obtained. Cordotomy alone or, as necessary, in conjunction with analgesic drugs afforded complete pain control in 34/45 patients (75%) with Pancoast syndrome and in 50/58 patients (86%) with thoracic pain. These data provide evidence of the unique usefulness of the procedure in controlling otherwise intractable persistent cervicothoracic malignant pain, when the technique is correctly performed.

Subarachnoid neurolytic block (L5-S1) and unilateral percutaneous cervical cordotomy in the treatment of pain secondary to pelvic malignant disease.

The present study deals with the immediate and long-term results of subarachnoid neurolytic block (L5-S1) with 7.5%, 10% and 15% concentrations of phenol in glycerine and/or unilateral percutaneous cervical cordotomy in 73 patients (follow-up in 56 patients) suffering from perineal, perineopelvisacral or pelvisacral pain secondary to malignant diseases of the pelvic cavity. Subarachnoid neurolytic block (L5-S1) produced satisfactory, long-lasting relief of perineal pain when the higher concentrations of phenol (10 and 15%) were used. The only sequela reported was urinary retention. Percutaneous cervical cordotomy used for the treatment of pelvisacral or predominantly unilateral perineal pain gave complete pain relief until death in 76.7% of patients, either alone (36.7%) or in conjunction with pharmacological therapy (40%). Analysis of the data enabled us to establish the respective indications for the two procedures and to identify those cases in which their use may be complementary.

A new approach to the neurolytic block of the coeliac plexus: the transaortic technique.

The present study critically examines the coeliac plexus block techniques hitherto adopted, pointing out the complications involved and stressing the seriousness of the neurological complications due to spread of the neurolytic agent to the sympathetic chain and the lumbar plexus. Contrast enhanced CT scans demonstrate the difficulties involved in confining the neurolytic agent to the anterior, peri-aortic and precrural regions. The authors report their recent experience with coeliac plexus block by means of a single transaortic needle in 28 patients. In 12 of the patients, the CT scan revealed a spread was anterior to the medial crura of the diaphragm, sometimes extending laterally towards the costovertebral gutter along the ventral surface of the diaphragm.