Evolution of Our Experience in Diagnosis and Therapy for Urinary Infections

The therapy for urinary infections is advised according to the antibiogram; the symptoms request an empirical therapy based on urinary infections knowledge and drugs spectrum activity. We considered the urinoculture performed on 3834 patients, 3012 male and 822 female, hospitalized in our Institute in the period between 01/01/2005 and 31/10/2006; 444 of these were positive (12.7 % - 451 bacterial strains). Table 1: bacterial strains isolaed. We reported some evaluations obtained by antibiogram. E. coli strains Ciprofloxacin sensitive resulted in 60% of cases. Enterococcus species and Enterococcus faecalis strains Ampicillin sensitive resulted in 96.4% and 100% of cases, respectively.

In this study there is a Gram negative prevalence, whereas we had previously observed an equivalence between Gram negative and Gram positive (p 0.001). These data are useful for empirical therapy.

Calcitonin assay in wash-out fluid after fine-needle aspiration biopsy in patients with a thyroid nodule and border-line value of the hormone

Assaying calcitonin (CT) in the wash-out fluid from fine-needle aspiration biopsies (CT-FNAB) could be useful in the diagnosis of medullary thyroid carcinoma (MTC). The aim of this study was to correlate serum CT with cytology and CT-FNAB. Twenty-seven subjects (age range 27-75 yr) were studied. FNAB was performed in a thyroid nodule (no.=16) or lymph-node (no.=1 previously operated on for MTC) or in the prevalent nodule of multinodular goiters (no.=10). CT-FNAB values obtained in 37 subjects with normal serum CT (<10 ng/l) who underwent FNAB for thyroid nodules served as a negative control. In these subjects, CTFNAB values were 8.2+/-6.4 ng/l (range 2-30 ng/l). In patients with a thyroid nodule under evaluation for MTC, serum CT and CT-FNAB values were 14.5+/-3.9 ng/l (range 10-24 ng/l) and 16.4+/-29.8 ng/l (range 2-144 ng/l), respectively. In 4 patients, CT-FNAB values were higher than the highest values found in our negative controls (30 ng/l), but cytology results were compatible with a benign thyroid lesion and pentagastrin testing was negative. In 3 cases with CT-FNAB <30 ng/l, cytology was indicative of an indeterminate or probably follicular malignant lesion and histology was negative for MTC. None of the other subjects in whom pentagastrin testing was conducted showed serum CT values >100 ng/l. Our data do not show any correlation between CT-FNAB and serum CT. In conclusion, borderline CT values in patients with thyroid nodules are not rare. Our experience suggests that CT-FNAB does not have the same importance as that reported in the literature for thyroglobulin and PTH assay in wash-out fluid after FNAB in malignant thyroid and hyperfunctioning parathyroid lesions.

Absence of thyrotropin-induced increase in leptin levels in patients with history of differentiated thyroid carcinoma undergoing recombinant human thyrotropin testing

BACKGROUND

Some extra-thyroid effects of TSH have been described in vitro and in vivo. TSH has recently been suggested to induce interleukin-6 secretion by adipocytes. Leptin is the main protein secreted by adipose tissue.

OBJECTIVE

The aim of our study was to evaluate the acute effect of the recombinant human TSH (rhTSH)-induced TSH surge on serum leptin levels in thyroidectomized patients undergoing levothyroxine (L-T4) suppressive therapy for differentiated thyroid carcinoma (DTC).

DESIGN

A cohort of 15 female DTC patients was evaluated. Standard rhTSH testing was performed. Leptin, TSH, thyroid hormones, and thyroglobulin were measured before and 3, 6, and 9 days after rhTSH testing. Some metabolic parameters were also evaluated at the baseline.

RESULTS

Baseline leptin levels were 12.2+/-3.2 microg/l. Only body mass index (BMI) correlated significantly (p<0.05) with leptin levels. After rhTSH administration, TSH levels increased significantly (p<0.001), while thyroid hormones remained unchanged. Twenty hours after the last rhTSH administration, leptin (11.8+/-3.0 microg/l) levels were unchanged. The maximal TSH level was negatively related with BMI (p<0.05), but no correlation between maximal TSH and leptin levels after rhTSH was noted.

CONCLUSIONS

Our in vivo experimental model suggests that an acute TSH increase after rhTSH testing is ineffective in changing circulating leptin levels.

New diagnostic tools for neonatal sepsis: the role of a real-time polymerase chain reaction for the early detection and identification of bacterial and fungal species in blood samples

Early diagnosis and treatment of neonatal sepsis are essential to prevent severe and life threatening complications. Consequently, rapid diagnostic tests capable to differentiate infected from non-infected newborns have the potential to make a significant impact on neonatal care. A new real-time polymerase chain reaction (PCR; LightCycler SeptiFast test M GRADE) has been proposed in the routine assessment of neonatal sepsis for the detection and identification of bacterial and fungal DNA from microorganisms which cause approximately 90% of all blood stream infections. The LightCycler SeptiFast test can detect and identify simultaneously the 25 most important bacterial and fungal species causing bloodstream infections within few hours by using a small volume of a single whole blood sample. Real-time PCR can be easily incorporated into the hospital setting for term or near-term infants admitted to the neonatal intensive care unit for sepsis evaluation.

Circulating levels of cytokines (IL-6 and IL-1beta) in patients with intermittent claudication, at rest, after maximal exercise treadmill test and during restore phase. Could they be progression markers of the disease?

AIM

Inflammation is considered to be one of the main mechanisms for the development and progression of peripheral arterial disease (PAD). Many studies have demonstrated that maximal exercise enhances the acute inflammatory response in claudicant patients, but no one has assessed the duration of this acute inflammatory activation. The aim of this study was to assess of the inflammatory pattern in claudicants and of the inflammatory response after maximal exercise and during the recovery from calf pain.

METHODS

Eleven patients with moderate claudication (MC) (age: 60.5+/-5.8 years; body mass index [BMI]: 27.5+/-4.6; absolute claudication distance [ACD]: 165.4+/-38), 10 patients with severe claudication (SC) (age: 60.3+/-5 years; BMI: 27+/-4.5; ACD: 91+/-11.3) and 8 healthy subjects (age: 59.4+/-6.8; BMI: 28.7+/-4.16) underwent to maximal treadmill test (speed 2.5 km/h, slope 15%). At rest, just after stop of the exercise (appearance of calf pain in patients, and 6 min of treadmill in controls) the circulating levels of interleukin (IL)-1beta and IL-6 have been measured.

STATISTICAL ANALYSIS

variance of mean values, Bonferroni t-test, split plot variance model, variance of d stop-before and stop-recovery have been utilized. P<0.05 has been considered the significant cut-off of the differences.

RESULTS

The maximal exercise excited significant (P<0.01) inflammatory activation in all patients: MC (rest IL-1beta: 1.55, 3.3 at stop; rest IL-6: 5.97, 8.38 at the stop); SC (rest IL-1beta: 2.97, 5.72 at stop; rest IL-6: 6.98, 9.99 at the stop). During recovery, MC showed a reduction of the inflammatory activation, whilst SC showed further increase (IL-1beta: 7.55; IL-6: 11.94).

CONCLUSION

The study confirms the higher inflammatory activation in claudicants and its enhancement after maximal exercise. During recovery, we found two kinds of response: type 1 (controls and MC), in which inflammation subsides, and type 2 (SC) characterized by further inflammatory increase. This trend is not univocal: 3 MC showed a type 2 response and 2 SC showed a type 1. In conclusion, inflammatory activation may depend not only on the degree of endothelial damage, but also on the individual inflammatory attitude, better assessed after maximal exercise than baseline values. This individual inflammatory responsiveness, considering the role of the rest measurement of markers of inflammation recently discussed, could be a useful marker for aggressive PAD.

Value of C reactive protein in the assessment of erosive osteoarthritis of the hand

OBJECTIVE

To investigate the value of serum C reactive protein (CRP) as a marker of erosive osteoarthritis (EOA) of the hand.

METHODS

Ninety eight patients, 67 with EOA and 31 with non-EOA of the hand, were included in the study and analysed for radiographic score (RS), number of erosions, and joint count (JC) at clinical observation and at bone scintigraphy. CRP was assayed in a serum sample by a highly sensitive immunonephelometric method.

RESULTS

The median (interquartile range) CRP level was 4.7 (2.4-6.9) mg/l in the EOA and 2.1 (0.5-4.9) mg/l in the non-EOA group (p = 0.001). In all patients, CRP correlated with RS (r(s) = 0.43, p<0.001), and mainly with JC at clinical observation (r(s) = 0.72, p<0.001) and at bone scintigraphy (r(s) = 0.47, p<0.001). The correlation of CRP with RS and JC was confirmed at clinical observation and at bone scintigraphy in the EOA subgroup, but only with JC at clinical observation in the non-EOA subgroup.

CONCLUSIONS

CRP levels are higher in EOA than in non-EOA patients. These levels probably reflect the disease activity of EOA, as suggested by correlations between CRP and JC at clinical observation and at bone scintigraphy.

Netilmicin effect on urinary retinol binding protein (RBP) and N-acetyl-beta-D-glucosaminidase (NAG) in preterm newborns with and without anoxia

The study aim was to evaluate urinary excretion of Retinol Binding Protein (RBP), compared with urinary excretion of N-acetyl-beta-D-glucosaminidase (NAG), in preterm infants with anoxia and netilmicin treatment. Urinary RBP and NAG were evaluated in 83 preterm newborns divided in 4 groups: 37 healthy preterm newborns (controls); 14 with neonatal anoxia; 16 treated with ampicillin + netilmicin; 16 with neonatal anoxia and treated with ampicillin + netilmicin. RBP was determined by an automated nephelometric technique and NAG by a colorimetric method on 5-h urine samples in the first week of life. Results showed that urinary excretion of RBP (average from first week values) was 1.06+/-0.67 g/mol creatinine (mean +/- SD) in controls, 1.99+/-1.41 in antibiotic-treated newborns, 3.99+/-4.57 in anoxic newborns and 3.75+/-3.48 in anoxic newborns under antibiotic treatment. When gestational age was not considered, a marked effect of anoxia (P<0.001) and a borderline effect of netilmicin (P<0.059) on RBP excretion were detected by ANOVA. However when gestational age was also considered by analysis of covariance, it appeared as the strongest predictor of RBP excretion (P<0.001), while the effect of netilmicin was no longer significant (P=0.181). The effect of anoxia persisted, although less remarkable (P=0.010). Conversely anoxia did not affect urinary NAG excretion, which was rather correlated with gestational age and netilmicin administration. The authors conclude that RBP and NAG urinary excretion may be used to discriminate between neonatal anoxia and netilmicin treatment, respectively as etiologic factors of renal tubular damage in the newborn.

Urinary epidermal growth factor in different renal conditions in children

Several studies have demonstrated the important role of growth factors, particularly epidermal growth factor (EGF) and transforming growth factor alpha (TGFalpha), in cellular growth after renal damage. EGF is mainly synthesized by the kidney. Many studies indicate that urinary EGF concentration significantly decreases in patients with acute and chronic renal failure. In this study we determined urinary EGF concentrations in children with renal and/or urological pathologies. We investigated 38 patients, 17 males and 21 females, of 3.34+/-2.96 years (mean +/- standard deviation), who were followed in the Nephrologic Unit of the Pediatric Department of the University of Verona for recurrent urinary tract infections: seven of these had vesicoureteric reflux and 4 had hypodysplasia. The results were compared with those from a healthy age-matched group of 44 children. In all patients, we assessed renal function including an examination of the urine with a microbiological evaluation. Moreover, a renal ultrasound and a voiding cystourethrogram were performed.

C-reactive protein and serum amyloid A protein in neonatal infections

In this study, we examine C-reactive protein (CRP) and serum amyloid protein A (SAA). Although the former is the best known and most commonly used indicator of inflammation, certain considerations underline the inadequacy of CRP determination alone for the early diagnosis of infection. In fact symptoms often precede the CRP elevation. SAA protein comprises a family of polymorphic apolipoproteins produced mainly by the liver, and several studies have stressed its importance in the diagnosis and monitoring of various diseases. Pathological SAA values are often detected in association with normal CRP concentrations. SAA rises earlier and more sharply than CRP. Finally, contrary to CRP, SAA presents the same trend in viral as well as bacterial infections. Although the data available on SAA in neonates are currently very limited, it is possible to postulate a role of primary importance for SAA in the management of neonatal infections.

Cystatin C in healthy women at term pregnancy and in their infant newborns: relationship between maternal and neonatal serum levels and reference values

Human cystatin C, a basic low molecular mass protein with 120 amino acid residues, is freely filtered by the glomerulus and almost completely reabsorbed and catabolized by the proximal tubular cells. Cystatin C has been recently proposed as a new sensitive endogenous serum marker for the early assessment of changes in the glomerular filtration rate. To define a reference basis for future clinical investigations in the perinatal period, we investigated the relationship between maternal and neonatal serum cystatin C in comparison with that of creatinine. We also defined reference values in healthy women at full-term pregnancy and in full-term newborns over the first 5 days of life. Seventy-eight women with uncomplicated pregnancy, aged between 19 and 40 years, and their infant newborns (43 males, 35 females) were enrolled in the study. The gestational age ranged from 37 to 43 weeks, and the birth weight from 2.50 to 4.15 kg. Blood samples were taken from all the women immediately before delivery and from their newborns at birth, 72 and 96 h after birth. Maternal and neonatal renal function was evaluated by standards parameters and by calculating creatinine clearance. In all serum samples, we measured cystatin C, creatinine, and urea. At term gestation, serum cystatin C ranged from 0.64 to 2.30 mg/L. At birth, serum cystatin C values ranged from 1.17 to 3.06 mg/L, significantly decreasing after 3 and 5 days of life. No correlation was found between maternal and neonatal serum cystatin C values (r = 0.09). As cystatin C serum levels in newborns are not significantly correlated with the respective maternal levels, neonatal serum cystatin C may originate almost exclusively in the neonate.

Markers of tubular damage in pre-eclampsia

BACKGROUND

The aaim of this study is to investigate the tubular damage markers in pre-eclampsia and in pregnancy induced hypertension (PIH).

METHODS

This transversal study involved 111 women admitted to the Department of Obstetric and Gynaecology, University Hospital, Padua (Italy) and was conducted from the 24th week until delivery: 23 had normal pregnancies, 54 manifest pre-eclampsia, and 34 manifested pregnancy-induced hypertension (PIH) without superimposed pre-eclampsia. The following laboratory tests were performed: U-alpha 1 microglobulin, U-NAG, uric acid and microalbuminuria. The four groups were compared using the Mann-Whitney test and the Kruskall-Wallis test for multiple comparisons. A value of p < 0.05 was considered as statistically significant.

RESULTS

As for the markers of tubular damage, the values for urinary NAG were significantly lower in the control group (0.97 U/mmol Creat) than in the pre-eclampsia group (2.89 U/mmol Creat), and the PIH group (2.12 U/mmol Creat) (p < 0.01). Values for urinary alpha 1-microglobulin were higher in the pre-eclampsia group (4.03 U/mmol Creat) than in the control (0.74 U/mmol Creat), and PIH groups (1.88 U/mmol Creat) (p < 0.01). As for the markers of glomerular damage, the values of microalbuminuria were higher in the pre-eclampsia group (134 micrograms/min) than in the control (9.4 micrograms/min), and PIH groups (10 micrograms/min), (p < 0.05). Uric acid, the marker of glomerular and tubular damage, was higher in the pre-eclampsia group (0.27 mmol/L) than in the control (0.20 mmol/L), and PIH groups (0.24 mmol/L), (p < 0.05).

CONCLUSIONS

In pre-eclampsia there is a tubular and glomerular damage to point out by an increased urinary excretion of NAG. In pre-eclampsia, an increase of urinary alpha 1-microglobulin excretion may be considered to be partly due to the overloading of the tubule and partly due to a mixed glomerular and tubular lesion.

Predictive markers of pre-eclampsia in hypertensive disorders of pregnancy

OBJECTIVE

The aim of this work is to assess the most widespread methods currently proposed and two new markers for predicting the development of pre-eclampsia in pregnant women with hypertension.

METHODS

The study involved 212 pregnant Caucasian women: 104 normotensive, 68 pregnancy-induced hypertensive and 40 chronic hypertensive. Blood and urine were sampled between 28 and 30 weeks gestation. All 108 hypertensive pregnant women, at the time of sampling, demonstrated proteinuria below 0.3 g/24 h. The following laboratory tests were performed: fibronectin, antithrombin-III, alpha-1-microglobulin, U-N-acetyl-beta-glucosaminidase, uric acid and albumin excretion rate. Student's t-test, discriminant analysis and chi2 (chi-square) test were used as statistical methods. A P value less than 0.05 was considered significant.

RESULTS

After discriminating analysis, only three of the six variables analyzed were able to discriminate patients who would develop pre-eclampsia from the remaining hypertensive pregnant women: microalbuminuria, uric acid and fibronectin (chi2 = 29.122, P < 0.01).

CONCLUSIONS

In agreement with previous studies, albumin excretion rate appeared to be the best predictive test for pre-eclampsia in hypertensive pregnant women, giving a higher positive predictive value and specificity (87.5 and 98.9%, respectively).

Cystatin C in paediatric nephrology. Present situation and prospects

Cystatin C is a small basic protein with a MW of 13,359 Daltons, consisting of a non-glycosylated polypeptide chain containing 120 amino-acid residues. Cystatin C is produced in all the nucleated cells of the human body and its output rate is constant. The kidney is the main catabolic site of cystatin C, since the protein, by virtue of its low MW and its positive charge at normal pH, is freely filtered by the glomerulus and almost completely reabsorbed, catabolised and broken down in the cells of the proximal convoluted tubule. It is practically entirely filtered via the glomerular membrane, without any significant tubular secretion. The constant production rate of cystatin C in all the tissues, its elimination via the glomerular filter and its non-dependence on many extrinsic factors, including sex, age, diet, inflammation, are potentially ideal conditions for an endogenous biochemical marker of glomerular filtration. A recent method for determining cystatin C, is based on an immune reaction, could increase its clinical application. Not many studies have been conducted to date on cystatin C in children. The cystatin C concentration was higher during the first few days of life (range: 1.64-2.59 mg/L) with a rapid reduction during the first 4 months. Beyond the first year of life, cystatin C concentration became constant, with a reference range of 0.7-1.38 mg/L. On the basis of the data currently available, neonatal serum cystatin C would appear to derive from the newborn itself. In fact no correlations were found between maternal and neonatal serum cystatin C values. Cystatin C determination appears to be at least equivalent to serum creatinine measurement for the assessment of glomerular filtration rate in children. Further extended studies are needed to investigate these aspects more thoroughly in neonates.

An immunological evaluation of type II diabetic patients with periodontal disease

Peridontal disease is a frequent complication of diabetes, and diabetic subjects often exhibit decreased immune response with increased susceptibility to infection. We evaluated the possible relationship between immune response and periodontal disease in 40 type II diabetic patients, mean (+/- SD) age 59 +/- 8 years and mean disease duration 17 +/- 4 years, with good metabolic control (mean fasting plasma glucose, 10.5 +/- 3.8 mM/L, mean HbA1c 8.1 +/- 1.66%), and in 40 age and gender-matched controls. Interproximal alveolar bone loss (ABL), as the percentage of bone loss from the cement enamel junction (CEJ) to the apex, was measured with a modified Schei ruler at the deepest point on the mesial/distal surface of the teeth, except third molars, on a panoramic radiograph. Immunological evaluation involved study of NADPH neutrophil superoxide production, neutrophil chemotaxis, lymphocyte subpopulations, immunoglobulins and complement. Diabetic patients showed significant differences compared with controls regarding ABL (30.6 +/- 14.7% versus 17.6 +/- 4.3%; p < 0.0001) and the T-helper/T-suppressor ratio (2.3 +/- 1.0% versus 1.8 +/- 0.8%; p < 0.05). Other parameters of cell-mediated immunity and humoral immune response did not show any significant variations. No correlation between immunological and radiographic analysis parameters were found. Further studies are needed to verify the exact role played by immunological factors in type II diabetic patients with periodontal disease.

Quantitative automated particle-enhanced immunonephelometric assay for the routinary measurement of human cystatin C

Human cystatin C is a low molecular mass protein of 13359 Dalton recently proposed as a new very sensitive marker of changes in glomerular filtration rate. Serum cystatin C concentration correlates negatively with glomerular filtration rate as well as or better than creatinine. We evaluated a recently introduced automated nephelometric immunoassay for cystatin C in serum or EDTA-plasma samples on the Behring Nephelometer System. The assay consists of incubating the 100-fold diluted sample for 6 minutes with latex particles covalently coated with anti-human cystatin C antibodies, and then quantifying the change of light-scatter produced. Method reproducibility is satisfactory, the intra- and inter-assay coefficients of variation ranging from 1.58% to 3.77% and from 5.6% to 11.47% respectively. Rheumatoid factor (< or = 1116 IU/ml), bilirubin (< or = 418 micrommol/l), triglycerides (10.47 mmol/), and haemoglobin (12 g/l) do not significantly interfere in the assay. No significant difference was found in cystatin C concentration between serum and EDTA-plasma samples. Cystatin C is stable in serum samples stored under different conditions up to one month. This method correlates well (mean difference=-0.536+/-0.307 mg/l) with another commercially available particle-enhanced turbidimetric immunoassay. Cystatin C offers better clinical sensitivity than creatinine for discriminating patients with normal renal function and those with mild-to-moderate reduction in renal function. This method is suitable for routine cystatin C measurement, including emergencies.

Renal tolerability of teicoplanin in a case of neonatal overdose

The literature does not contain reports regarding teicoplanin overdose in newborns. In a neonate with a history of recent postasphyctic acute renal failure which recovered within 7 days of life, antibiotic therapy with teicoplanin was started for sepsis due to Staphylococcus hominis. However, for 5 days the dosage was excessive (20 mg/kg twice daily instead of an initial dose of 16 mg/kg and then doses of 8 mg/kg once daily). Once this error had been noted, therapy was immediately suspended. Clinically the newborn had improved and blood culture at the end of the therapy was negative. Biohumoral tests revealed constantly normal levels of serum creatinine, serum cystatin C and blood nitrogen. Urinary parameters of tubulotoxicity were also within normal values. Urinary epidermal growth factor was increased. Teicoplanin was well tolerated at the renal level in the newborn even in this case of excessive dosage.

Is serum cystatin C a sensitive marker of glomerular filtration rate (GFR)? A preliminary study on renal transplant patients

Human cystatin C is a basic low molecular mass protein (13,359 Dalton) freely filtered through the glomerulus and almost completely re-absorbed and catabolized by proximal tubular cells. We measured serum cystatin C in 38 kidney transplant patients (23 males, 15 females) aged between 6 and 32 years. To assess renal function, serum and urinary creatinine were also determined in all patients, and creatinine clearance was finally calculated. Cystatin C was determined by a particle-enhanced turbidimetric assay, and creatinine was measured by gas chromatography-mass spectrometry. To compare the diagnostic efficiency of cystatin C with that of creatinine, inulin clearance was performed on 12 renal transplant patients, and receiver operating characteristic (ROC) analysis was applied. The results of this study demonstrate that serum cystatin C significantly increases in renal transplant patients with reduced creatinine clearance (< 70 mL/min per 1.73 m2) and that the diagnostic accuracy of serum cystatin C is better than of serum creatinine. Cystatin C may be utilized as a very marker of reduced GFR.