Immune regulation of procalcitonin: a biomarker and mediator of infection.

Procalcitonin (PCT) has recently emerged as a powerful biomarker for an early and accurate diagnosis of bacterial infection. Here we summarize our current understanding of the expression pathways of PCT, its potential cellular sources including immune cells, and factors inducing its secretion. Also addressed is the significance of increased blood PCT concentration, which may allow this molecule not only to act as a clinical biomarker but also as an active participant in the development and progression of infectious processes. Experimental approaches to delineate a better understanding of PCT functions, molecular pathways that modulate its expression and therapeutic opportunities to curtail its biological actions are discussed, as well.

Spontaneous regression of a giant pulmonary bulla.

Gradual expansion of a lung bulla is common and may be associated with debilitating pulmonary symptoms. The aetiology of bulla expansion is unclear. Spontaneous regression, on the other hand, is rarely observed. The case is presented of a man in whom near complete spontaneous resolution of a giant pulmonary bulla occurred. This event was associated with dramatic improvement in the radiographic picture and pulmonary function.

The problem central venous catheter.

Central venous catheter complications are an important nosocomial problem. This report outlines three complications of central line placement and provides some insights that may help physicians and surgeons avoid consequential problems with invasive line placement.

Analysis of 3,294 cases of upper gastrointestinal bleeding in military medical facilities.

OBJECTIVES: Upper gastrointestinal bleeding (UGIB) remains a commonly encountered medical emergency with significant morbidity and mortality. Most large studies detailing the specific incidence, demographic, and mortality data were performed more than a decade ago. This study analyzes 3,294 cases of UGIB from 139 military medical treatment facilities over a 12-month period. METHODS: A retrospective chart review of Department of Defense military medical treatment facilities for UGIB was performed from October 1990 through September 1991. Core data such as demographic information were analyzed, as well as specific data relating to UGIB. RESULTS: The incidence of UGIB was 36 per 100,000 population with a male-to-female ratio of 2.18 and a mean age of 52 +/- 19.65 yr. The number of cases increased with age; 44.5% of all patients were > or = 60 yr old. The overall mortality was 7.0% (231 of 3294), and death rates were similar among males and females (7.1% vs. 6.8%) with an odds ratio of 1.03 (CI: 0.77-1.402). Mortality increased with age in both genders; 73.2% of deaths occurred in patients more than 60 yr old. Comorbid illness was noted in 50.9% (1675 of 3294) of patients, with similar occurrence in males (48.7%) and females (55.4%). One or more comorbid illnesses were noted in 98.3% of the patients who died, and in 72.3% of cases, they were the primary cause of death. Bleeding was the primary cause of death in 18.6% of patients. Upper endoscopy was performed in 68.8% of cases, therapeutic endoscopy in 12.6%, repeat endoscopy in 10.7%, and surgery in 4.4%. Blood transfusions were administered in 47.3% of cases, with most patients receiving < 5 units of blood. Rebleeding after initial hemostasis was noted in 7.1% of cases. Factors related to increased mortality include age > 60 (p < 0.001), transfusion requirement > 5 U (p < 0.001), presence of comorbid illness (p < 0.001), rebleeding after initial hemostasis (p < 0.005), surgery (p < 0.001), and UGIB occurring during hospitalization (p = 0.027). CONCLUSIONS: We conclude: 1) The incidence of UGIB is 2-fold greater in males than in females, in all age groups; however, the death rate is similar in both sexes. 2) The mortality rate in this study is slightly lower than in most previous studies and may be more reflective of the average mortality in the community at large. 3) In UGIB patients, comorbid illness and not actual bleeding is the major cause of death. 4) Upper endoscopy was performed less often in this study than in other studies, and there were fewer blood transfusions; however, rebleeding and mortality rates remained similar.

Complications of suicidal hanging: a case report and brief review.

Suicide remains a significant societal dilemma commonly presenting as an acute medical emergency. Presented is a report of a near-hanging suicidal attempt by a 30-year-old, active duty Navy man. This case documents local injuries and neurologic and cardiopulmonary complications of near-fatal suicidal hanging, which is a common method of suicide in the United States.

Pneumonia in military recruits.

Lower respiratory disease is a major source of morbidity in military recruits, with hospitalization rates for pneumonia more than 30 times that of the non-recruit population. The etiologic agent remains unknown in over 75% of cases. This study prospectively examined the etiology of pneumonia among recruits at Naval Training Center, San Diego, California. Recruits presenting with cough, fever, or shortness of breath and pulmonary infiltrates on chest X-ray were eligible for enrollment. A standardized scoring form and focused physical exam were completed on each subject. Sputum specimens were obtained for Gram's stain and culture, DNA probing for Legionella and Mycoplasma species, and direct fluorescent antibody staining for Legionella. Acute and convalescent serologies were performed for adenovirus, influenza A and B, Mycoplasma pneumoniae, Chlamydia group, and respiratory syncytial virus. Of 110 eligible patients, 100 consented to enrollment and 75 patients completed the study. Etiologic diagnoses were obtained in 40 of the patients (53%). M. pneumoniae, Haemophilus influenzae, and viruses accounted for the majority of infections. Mixed infections were seen in six patients. Forty-seven percent of patients had no diagnosis established. Pneumonia in this series of military recruits was frequently caused by M. pneumoniae and H. influenzae. Fifty percent of cases were undiagnosed with routinely available laboratory methods. Further studies are warranted to more clearly define the etiologic agents of recruit pneumonia and the utility of prophylactic measures.

Pneumonia hospitalizations in the US Navy and Marine Corps: rates and risk factors for 6,522 admissions, 1981-1991.

The authors identified hospitalizations for pneumonia (n = 6,522) in active-duty Navy and Marine Corps personnel during 1981-1991 from computerized inpatient records. The crude mean annual rate of pneumonia hospitalization was 77.6 per 100,000 active-duty personnel; 65% of pneumonia hospitalizations had no etiologic agent identified. The most commonly reported agents to cause pneumonia hospitalization were Streptococcus pneumoniae (12.3%), Mycoplasma pneumoniae (10.8%), other streptococcal species (2.1%), and Haemophilus influenzae (1.9%). The median age at hospitalization was 22 years. The median duration of hospital stay was 4 days and the case fatality rate was 0.4%. The authors used a 2% sample of the entire population and by means of stepwise unconditional multivariate logistic regression modeling for pneumonia found that, independent of age, the most junior Navy and Marine Corps personnel were at highest risk. Whites were at higher risk than blacks, Hispanics, or Filipinos. These results indicate that among this generally healthy US young adult military population, pneumonia hospitalization is common, often brief, and frequently without specifically identified pathogens.

Severe metabolic alkalosis.

Our patient's acid-base disturbance may be among the highest recorded in nonfatal cases of metabolic alkalosis. This case also shows that life-threatening alkalemia can be safely and effectively treated by defining and removing the causes of alkalosis and applying aggressive supportive therapy with fluid repletion and potassium and electrolyte replacement. The need for potentially dangerous therapy such as exogenous acid administration, dialysis, or forced mechanical depression of respiration should not routinely be used on the basis of blood pH alone, and it should never replace thoughtful, organized supportive care.

Traumatic hemipelvectomy: a survivable injury.

Traumatic injury remains an unfortunate and all-too-common event in the United States military population. Traumatic hemipelvectomy is a rare but devastating injury with few survivors recorded in the medical literature. We report a surviving case of traumatic hemipelvectomy and review an approach to management.

Lack of agreement between measurement of ejection fraction by impedance cardiography versus radionuclide ventriculography.

OBJECTIVE: To determine the limits of agreement between left ventricular ejection fraction estimated using systolic time intervals from impedance cardiography and left ventricular ejection fraction estimated by radionuclide ventriculography. DESIGN: A prospective study for diagnostic tests using radionuclide ventriculography as the criterion standard. SETTING: A large military teaching hospital. PATIENTS: Twenty ambulatory adults scheduled for radionuclide ventriculography. MEASUREMENTS AND MAIN RESULTS: A regression equation to estimate ejection fraction from systolic time intervals is available in a widely used impedance-based cardiac monitoring device. The estimated ejection fraction is then used in an equation with stroke volume estimated by the same device to calculate an end-diastolic volume. We studied the agreement of the ejection fraction as estimated by this device with the ejection fraction estimated by radionuclide ventriculography by obtaining simultaneous estimates of ejection fraction over a broad range of adult patients. Twenty ejection fraction pairs were analyzed. The correlation of ejection fraction by impedance cardiography to ejection fraction by radionuclide ventriculography was significant (r2 = .55; p < .002). However, the mean difference between the technologies was -8.85%, with a standard deviation of the differences of 7.15%, resulting in a 95% confidence range for agreement of -23.2% to +5.5%. CONCLUSIONS: The 95% confidence range defining the limits of agreement between ejection fraction by impedance cardiography and ejection fraction by radionuclide ventriculography is not clinically acceptable. In the opinion of the authors impedance cardiography should not be used in place of radionuclide ventriculography for the assessment of ejection fraction at this time.

Thoracic electrical bioimpedance measurement of cardiac output in postaortocoronary bypass patients.

OBJECTIVE: To assess the degree of correlation and agreement between cardiac output by thermodilution and bioimpedance using the BoMed NCCOM3-R7 monitor in postaortocoronary bypass patients. DESIGN: Prospective, randomized sampling. SETTING: Military teaching hospital intensive care unit. PATIENTS: Fifty patients undergoing coronary artery bypass surgery with thermodilution pulmonary artery catheters in place. Simultaneous determination of cardiac output by thermodilution and thoracic bioimpedance was performed. Readings were taken between 8 and 24 hrs after surgery. Forty patients were intubated; 19 patients had left-sided tube thoracotomy in addition to two mediastinal tubes, and 19 patients were obese. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The overall degree of correlation between the two measures was fair (r2 = .24). The bias and precision measurements were inaccurate as well (-0.33 +/- 3.14). Patients with normal body habitus or who were not receiving mechanical ventilation showed the best correlation (r2 = .40 and r2 = .45, respectively). Only 62% (31/50) of all patients had simultaneous measurements fall within 20% of each other, and there were no clinical features that made identification of those patients possible. CONCLUSIONS: Use of the BoMed NCCOM3-R7 bioimpedance monitor as a replacement for thermodilution-derived cardiac output cannot be recommended in postaortocoronary bypass patients. The distortions of patients' normal anatomy and physiology, coupled with the presence of endotracheal tubes and mechanical ventilation, mediastinal tubes and chest tubes, result in only fair correlation, significant bias, and poor precision between the two measures of cardiac output.

Perplexing pericarditis caused by coccidioidomycosis.

In the patient I have described, evaluation of chronic progressive pulmonary coccidioidomycosis presenting itself as cryptogenic pericarditis revealed an unsuspected large endobronchial coccidioidoma. At follow-up after 2 years of fluconazole therapy, the patient was asymptomatic, with a dramatic decrease in infiltrate but no change in CF titers. In endemic areas, coccidioidomycosis should be included in the differential diagnosis of idiopathic pericarditis, especially in high-risk patient populations. Additionally, airway obstruction or compromise might be an early finding in chronic coccidial disease.

A review of sternal wound complications in a military hospital.

A retrospective review of sternal wound complications was conducted during a recent 13-month period at the Naval Hospital, San Diego. These complications developed in 5 (3.0%) of 168 patients after they underwent coronary artery bypass with saphenous vein grafts. Three or more of these patients were male, obese, and hypertensive, with a significant smoking history. All these factors have been previously reported to be associated with an increase in the incidence of sternal wound complications. All patients had prolonged postoperative intensive care treatment, and ultimately all patients recovered and were discharged from the hospital. Interestingly, as opposed to other reviews, we were unable to show an association of sternal wound complications with the use of internal mammary artery harvesting.