A 2020 review on the role of procalcitonin in different clinical settings: an update conducted with the tools of the Evidence Based Laboratory Medicine.

Biomarkers to guide antibiotic treatment decisions have been proposed as an effective way to enhancing a more appropriate use of antibiotics. As a biomarker, procalcitonin (PCT) has been found to have good specificity to distinguish bacterial from non-bacterial inflammations. Decisions regarding antibiotic use in an individual patient are complex and should be based on the pre-test probability for bacterial infection, the severity of presentation and the results of PCT serum concentration. In the context of a high pre-test probability for bacterial infections and/or a high-risk patient with sepsis, monitoring of PCT over time helps to track the resolution of infection and decisions regarding early stop of antibiotic treatment. As outlined by the Evidence Based Laboratory Medicine (EBLM), not only the pre-test probability but also the positive likelihood ratio influence the performance of a test do be really diagnostic. This aspect should be taken into account in the interpretation of the results of clinical trials evaluating the performance of PCT in guiding antibiotic therapy.

Nocardia infection over 5 years (2011-2015) in an Italian tertiary care hospital.

This study was conducted reviewing clinical records of 14 patients affected by nocardiosis over 5 years in a tertiary care hospital. Nocardia abscessus was responsible for one third of infections, deviating significantly from the results reported by other epidemiological investigations and highlighting the key role of molecular identification tests. Indeed, a precise identification of species is crucial for the determination of antibiotic sensitivity patterns and, consequently, for the choice of antibiotic treatment. Noteworthy, 40% of isolates of N. abscessus (formerly N. asteroides complex) showed resistance to carbapenems, which are usually recommended for empirical therapy.

Complex alpine extrication: case report of mountain and speleological rescue cooperation.

Mountain sporting activities are an increasingly popular practice that exposes mountaineers to a high risk of adverse events. This report describes a unique case of recovery in an austere environment that involved explosives. In June 2012, a 52-year-old man ascended a cliff tower in the Eastern Alps, Italy. A landslide occurred, and a boulder crushed the climber against a large stone located farther down the cliff, causing compression of the lower limbs and the pelvis with consequent severe musculoskeletal trauma. The National Alpine and Cave Rescue Unit (NACRU) arrived and proceeded with stabilization of the injured climber, which took 6 hours and involved a difficult extrication supported by the Cave Rescue division of NACRU. Unfortunately, during transport to the trauma center of Borgo Trento, Verona, the patient exhibited signs of progressive traumatic shock because of crush syndrome, hypovolemia, and acidosis, which led to cardiac arrest and death. Based on an extensive literature review, this report was determined to be the only one of a mountain rescue using explosives for the extrication of a victim in the Northeast Italian Alps. This case describes how a rescue in austere environments can represent a high-risk situation, and it shows how improvisation and cooperation between rescue teams are crucial for a successful recovery.

The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study.

PURPOSE: The aim of this multicenter study was to assess the feasibility, safety, and accuracy of the intracavitary ECG method for real-time positioning of the tip of different types of central venous catheters. METHODS: A total of 1444 catheter insertions in adult patients were studied in eight Italian centers (539 ports, 245 PICCs, 325 tunneled CVCs, 335 non-tunneled CVCs). Patients with no visible P wave at the standard baseline ECG were excluded. Depending on the type of catheter and its purpose, the target was to position the tip either (a) at the cavo-atrial junction, or (b) in the lower third of the superior vena cava, or (c) in the upper part of the atrium. The final position was verified by a post-procedural chest x-ray. RESULTS: The method was feasible in 99.3% of all cases. There were no complications potentially related to the method itself. At the final x-ray control, 83% of all tips were positioned exactly at the target; 12.4% were positioned within 1-2 cm from the target, but still in a correct central position; only 3.8% were malpositioned. The mismatch between intra-procedural ECG method and post-procedural x-ray was significantly lower when the x-ray was taken in supine position. CONCLUSIONS: Our multicenter study confirms that the intracavitary ECG method for real time verification of tip position is accurate, safe, feasible in all adult patients and applicable to any type of short-term or long-term central venous access device.

Vascular access: an historical perspective from Sir William Harvey to the 1956 Nobel prize to André F. Cournand, Werner Forssmann, and Dickinson W. Richards.

Sir William Harvey (1578-1657), who had many precursors, discovered blood circulation in 1628 after a significant number of anatomic dissection of cadavers; his studies were continued by Sir Christopher Wren and Daniel Johann Major. The first central vein catheterization was performed on a horse by Stephen Hales, an English Vicar. In 1844, a century later, the French biologist Claude Bernard attempted the first carotid artery cannulation and repeated the procedure in the jugular vein, again on a horse. He was first to report the complications now well known to be associated with this maneuver. In 1929 Werner Forssmann tried cardiac catheterization on himself, but could not investigate the procedure further since his findings were rejected and ridiculed by colleagues. His work was continued by André Frédéric Cournand and Dickinson Woodruff Richards Jr in the United States. In 1956 the three physicians shared the Nobel Prize for Medicine for their studies on vascular and cardiac systems. The genius and the perseverance of the three physicians paved the way towards peripheral and central catheter vein placement, one of the most frequently performed maneuvers in hospitals. Its history still remains unknown to most and deserves a short description.

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.