C-reactive protein but not procalcitonin may predict antibiotic response and outcome in infections following major abdominal surgery

We aimed to evaluate the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) as markers of infection, sepsis and as predictors of antibiotic response after non-emergency major abdominal surgery. We enrolled, from June 2015 to June 2019, all patients who underwent surgery due to abdominal infection (peritoneal abscess, peritonitis) or having sepsis episode after surgical procedures (i.e. hepatectomy, bowel perforation, pancreaticoduodenectomy (PD), segmental resection of the duodenum (SRD) or biliary reconstruction in a Tertiary Care Hospital. Serum CRP (cut-off value < 5 mg/L) and PCT (cut-off value < 0.1mcg/L) were measured in the day when fever was present or within 24 h after abdominal surgery. Both markers were assessed every 48 h to follow-up antibiotic response and disease evolution up to disease resolution. We enrolled a total of 260 patients underwent non-emergency major abdominal surgery and being infected or developing infection after surgical procedure with one or more microbes (55% mixed Gram-negative infection including Klebsiella KPC, 35% Gram-positive infection, 10% with Candida infection), 58% of patients had ICU admission for at least 96 h, 42% of patients had fast track ICU (48 h). In our group of patients, we found that PCT had a trend to increase after surgical procedure; particularly, those undergoing liver surgery had higher PCT than those underwent different abdominal surgery (U Mann–Whitney p < 0.05). CRP rapidly increase after surgery in those developing infection and showed a statistical significant decrease within 48 h in those subject being responsive to antibiotic treatment and having a clinical response within 10 days independently form the pathogens (bacterial or fungal). Further we found that those having CRP higher than 250 mg/L had a reduced percentage of success treatment at 10 days compared to those < 250 mg/mL (U Mann–Whitney p < 0.05). PCT did not show any variation according to treatment response. CRP in our cohort seems to be a useful marker to predict antibiotic response in those undergoing non-emergency abdominal surgery, while PCT seem to be increased in those having major liver surgery, probably due to hepatic production of cytokines.

The Management of Viral Hepatitis in CKD Patients: An Unresolved Problem

Chronic kidney disease (CKD) patients in dialysis (HD) show peculiar, atypical features of clinical presentation and diseases (cardiovascular, metabolic, hematologic). This is also true for viral hepatitis infections, for which CKD patients represent an important risk group. In the past, hepatitis B virus (HBV) was the major cause of viral hepatitis in end-stage renal disease (ESRD). However, the introduction of a rigorous infection-control strategy, routine screening of patients and staff for hepatitis B serologic markers, vaccination of susceptible patients and staff, use of separate rooms and dedicated machines for HD of HbsAg-positive patients have all led to a decline in the spread of HBV infection in dialysis. Despite the prevalence of the antibody-hepatitis C virus (HCV), there has been a marked decrease in HD patients; after the introduction of routine screening for HCV and the use of erythropoietin, its occurrence ranges from 5% to 25% in the United States, with a prevalence of 6.8% in Europe. In CKD and in HD patients, the presence of HBV and HCV is an independent and significant risk factor for death and this risk may be at least partially attributed to chronic liver disease with its attendant complications. Liver disease can progress with modest hepatic inflammation and prominent fibrosis; the natural history of viral hepatitis in these patients is dependent on the immune dysfunction typical of kidney disease. Despite recent advances in antiviral therapy, there are still many uncertainties in regards to the efficacy and long-term outcomes of treatment with antiviral agents.

Comparison between patients with depressive disorders and healthy controls in resilience and coping skills

Introduction

Resilience in the psychiatric field, it is defined as the ability to recover from perceived adverse or changing situations through a dynamic process of adaptation. This process is influenced by personal characteristics, family and social resources and is expressed by positive coping skills. It is well known that resilience has an inverse relation with depression, however, the specific role of resilience in disorders like depression, personality disorders and psychosis is not fully understood.

Objectives

Compare differences in resilience and coping skills in a sample of patients with depressive disorder in acute phase versus healthy controls.

Methods

We are conducting a cohort study to the date we recruited 82 inpatients admitted in our psychiatric ward. The data have been gathered from the 1st December 2014 and they will continue to be collected until the 1st December 2016, the healthy controls are represented by 67 subjects with similar socio-demographic features.

Inclusion criteria are: diagnosis of depressive disorders or dysthymia according to DSM-IV-TR diagnostic criteria, age > 18 years, proper understanding of Italian language, willingness to give written informed consent. We compared them with healthy controls with similar socio-demographic features.

Patients’ assessment includes the following tests:

– Resilience Scale for Adults (RSA);

– Brief-COPE Scale (Brief-COPE);

– Statistical analysis will be performed using SPSS for Windows, 21.0 (Armonk, NY: IBM Corporation).

Results

Data collection is still ongoing.

Conclusions

From a preliminary analysis of data, we assume that the levels of resilience and coping of our patients is reduced compared with controls, however the recruitment during the acute phase could significantly influence final results.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The Psycho-geriatric Patient in the Emergency Room (ER) of the Maggiore della Carità Hospital in Novara

Introduction

Due to population aging, the health system will face increasing challenges in the next years. Concerning mental disorders, they are major public health issues in late life, with mood and anxiety disorders being some of the most common mental disorder among the elderly. For this reason, increasing attention has to be paid to the evaluation of the elderly in psychiatry emergency settings.

Objectives

To evaluate the socio-demographic and clinical features of over 65 patients referred to psychiatric consultations in the ER of “Maggiore della Carità” Hospital in Novara, in a 7 years period.

Aims

The analysis of the characteristics of the study sample could be potentially useful in resource planning in order to better serve this important segment of the general population.

Methods

Determinants of ER visits for over 65 patients referred to psychiatric evaluation were studied retrospectively from 2008 to 2015.

Results

Elderly patients made up 14,7% (n = 458) of all psychiatric evaluation in the ER (n = 3124). About two thirds (65,9%) were females and one third were males (34,1%). The mean age of patients recruited was 75.11 years. The majority of subjects (68.6%) presented without a diagnosis of Axis I according to DSM-IV. The other most frequent diagnosis was “cognitive disorders” (11.4%) and “mood disorders” (10.9%).

Conclusions

The large proportion of patients without a diagnosis of Axis I, could be related to the misunderstanding of the psychosocial aspects of aging. Preliminary results highlight the importance of research on this topic, considering population aging and the impact of mental disorders in late-life.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Left kidney: an unusual site of cocaine-related renal infarction. A case report

Acute renal infarction is a well known, although relatively unfrequent, cause of flank pain resistant to administration of spasmolytic and nonsteroidal anti-inflammatory drugs. We present an original case of a 41-year-old man, complaining of acute severe left flank pain, resistant to common analgesic therapy, who was diagnosed of segmental renal infarction of a branch of left renal artery. Pathophysiology of renal damage in cocaine users is multifactorial, and it has been postulated that the right kidney was more prone to ischaemia. Left kidney represents an extremely unusual site of cocaine-related renal infarction.

Clinical features of cardio-renal syndrome in a cohort of consecutive patients admitted to an internal medicine ward

Introduction:

Cardiorenal syndrome (CRS) is a disorder of the heart and kidney whereby interactions between the 2 organs can occur. We recorded the clinical features of CRS in patients consecutively admitted to an Internal Medicine ward.

Patients and Methods:

We retrospectively analyzed the anthropometric, history, clinical, biochemical and treatment characteristics in 438 out of 2,998 subjects (14.6%) admitted to our unit (from June 2007 to December 2009), diagnosed with CRS, according to Acute Dialysis Quality Initiative (ADQI) recommendations. Estimated glomerular filtration (eGFR) was calculated using several equations: MDRD (Modification of Diet in Renal Disease; 2 variations GFR_MDRD186, GFR_MDRD175), Mayo, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Cockroft-Gault.

Results:

Mean age was 80±8 years, 222 (50.6%) were males, 321 (73.2%) were smokers, 229 (52.2%) were diabetic, 207 (47.2%) had a history of acute myocardial infarction, 167 (38.1%) had angina, 135 (30.8%) were affected by cerebrovascular disease, 339 (77.3%) had peripheral arterial disease. CRS was type 1 in 211 cases (48.2%), type 2 in 96 (21.9%), type 3 in 88 (20.1%), type 4 in 29 (6.6%) and type 5 in 14 (3.2%). eGFR, calculated by different formulae, ranged between 31 and 36 ml/min/1.73 m². GFR was lower in CRS type 3 than in the other types, and the values ranged between 24 and 27 ml/min/1.73 m². Mean hospital length-of-stay (LOS) was 9.8±6.3 days. Diuretics were the most prescribed medication (78.7%); only 5 patients underwent haemodialysis.

Conclusions:

CRS is common, especially in the elderly. CRS Type 1 was the prevalent subset and patients had stage 3-4 renal insufficiency. Results obtained from the GFR equations were similar although the Mayo equation tended to overestimate the eGFR.

The dilemma of diagnosing fever of unknown origin: large arteries vasculitis revealed by 18F-FDG PET/CT imaging. A case report

Fever of unknown origin (FUO) is an uncommon disease, and its underlying etiology may include a number causes, i.e., infections, malignancies, autoimmune conditions. Diagnosis is often a difficult task, and usually physician spend time and money in order to define the etiology of FUO. We report a case of patient who presented with FUO and headache, and positron emission tomography (PET) with 2-deoxy-2-[fluorine-18] fluoro-D-glucose (18F-FDG) allowed to reveal the presence of a large vessel vasculitis. 18F-FDG PET may represent an useful tool in patients with FUO, since it can early depict an hypermetabolic activity due to inflammation and so help to achieve a final diagnosis in some cases of FUO.

Neuroendocrine tumors diagnosed at the Antonio Cardarelli hospital (Naples, Italy) between 2006-2009: a single-institution analysis

Neuroendocrine tumors (NETs) are rare, with an incidence of about 5 per 100,000 inhabitants. As no study on NETs has ever been specifically conducted on the population of Campania, we performed a retrospective analysis of all newly diagnosed NETs at the Antonio Cardarelli hospital between 2006-2009. A search of the registry of the Pathology Department of the Antonio Cardarelli hospital was carried out to retrieve available data on all newly diagnosed NET cases. Two hundred and ninety-nine NET tumors were diagnosed at our Institution from January, 2006 to December, 2009. Globally, 121 patients (40% of the population) had a lung NET, while 92 patients (30% of the population) presented a GEP-NET. The most common primary tumor site varied by sex, with female patients being more likely to have a primary NET in the lung, breast or colon, and male patients being more likely to have a primary tumor in the lung. Also, twenty-three cases of breast NETs were identified, and clinical information regarding therapy and response was available for 22 patients. Our study represents a pioneering effort to provide the medical community in Campania with basic information on a large number of patients with different types of NETs. The Antonio Cardarelli hospital could greatly benefit from cooperation with other hospitals in order to become a highly specialized center for NETs in the region and Southern Italy.

Detection of urinary abnormalities in a community from northern Italy based on the World Kidney Day screening program

BACKGROUND

Chronic kidney disease (CKD) is a worldwide health problem, and promotion of the World Kidney Day has improved general population education and awareness of renal illnesses aimed at ameliorating disease prevention. The Kidney Day was also an opportunity for us to investigate risk factors for CKD in an Italian population.

PATIENTS AND METHODS

A total of 1,341 subjects from the general population living in the area of Ferrara, a town in the northeast of Italy, aged 50-70 years, were investigated. From each participant age, sex, smoking status, current antihypertensive medications, hypercholesterolemic and diabetic status, body mass index (BMI), waist circumference and blood pressure (BP) were obtained. All subjects underwent dipstick urinalysis for the evaluation of proteinuria, hematuria and leukocyturia.

RESULTS

Fifteen percent of patients were diabetics, and 20% were smokers. Mean BMI was 26.9 ± 4.3 kg/m(2), mean systolic BP was 133.7 ± 18.7 mmHg and mean diastolic BP 78.1 ± 9.9 mmHg. A total of 828 participants were not taking any antihypertensive drugs. In 24% of subjects, we found proteinuria, in 18% hematuria and in 16% leukocyturia. Proteinuria was significantly associated with age and diabetes, hematuria was associated with age, female sex and smoking status, and leukocyturia was associated with age and female sex.

CONCLUSIONS

Urinary abnormalities are common in general population, and in many cases, various abnormalities overlap. These abnormalities could be associated with cardiovascular risk factors. We believe that our initiative, based on the experience of the World Kidney Day, could increase the awareness of general practitioners and general population of the risks of renal conditions.

Severe spontaneous properitoneal hemorrhage following ventral hernia repair caused by viral infection: report of a case

The authors report a case of severe spontaneous hemorrhage in a patient who underwent surgical repair of an upper umbilical ventral hernia with placement of a polypropylene mesh. On the third postoperative day the patient experienced bleeding in the properitoneal space (above and below the mesh), which spread up to and along the retroperitoneal area, causing severe hypovolemic shock. Postoperative investigations finally identified a virus as the cause of the complication.

Clinical approach to lupus nephritis: recent advances

Kidney involvement is common in systemic lupus erythematosus (SLE). Its clinical presentations are highly variable, ranging from mild asymptomatic proteinuria and/or hematuria to rapidly progressive uremia. Histological evidence of lupus nephritis is present in most patients with SLE, even when they do not yet have clinical manifestations. Current classification ISN/RPS 2003 (International Society of Nephrology/Renal Pathology Society) of lupus nephritis was promoted by a widely perceived need to re-examine existing classification, provide clearer distinctions between the histological classes, and improve diagnostic reproducibility and interobserver agreement. Lupus nephritis is a serious disease whose prognosis can usually be improved dramatically by treatment, but treatment is potentially toxic, prolonged, and complex. Current treatment regimens combine corticosteroids with cyclophosphamide, azathioprine or ciclosporin; mycophenolate mofetil has received much recent attention as a potentially immune suppressive agent and less aggressive immunosuppressive regimens can be prescribed. SLE patients should be regular followed to detect early kidney involvement.

Role of B-type natriuretic peptide in cardiovascular state monitoring in a hemodialysis patient with primary amyloidosis

BACKGROUND

Cardiac involvement occurs in up to 50% of patients with primary or A amyloidosis (ALA) and is associated with very poor prognosis. B-type natriuretic peptide (BNP) has been proposed as a guide for treatment of heart failure patients and as an index of myocardial dysfunction in patients with ALA. Data about BNP dosage for cardiovascular monitoring of patients with ALA on renal replacement therapy are lacking.

CASE

A 64 year old Caucasian man was admitted because of nephrotic syndrome in July 2003. Renal diagnosis was ALA. Melphalan and prednisolone were given but renal function worsened and in April 2004 standard bicarbonate hemodialysis was started. In March 2004 thalidomide was added to his therapy. During the follow-up ejection fraction was stable and was 65% on the contrary E/A ratio gradually increased and overtook 1. BNP plasma levels were increased and the values recorded during the follow-up were: 2505 pg/mL in October 2003 (normal reference values<100), 1827 in April 2004, 4006 in June 2004, 5000 in September 2004, 3750 in January 2005 and 1920 in April 2005. In September 2005 BNP was 3380 pg/mL. The patient was still alive after a follow-up longer than two years.

CONCLUSION

In ALA patients a powerful prognostic role of BNP has been reported whose expression is increased in ventricular myocytes of patients with cardiac involvement. BNP level monitoring does not appear to be superior to standard echocardiography in evaluating cardiovascular status of uremic patients with ALA.

[MEN type 1 and chronic renal failure: a rarely reported association]

BACKGROUND

Multiple endocrine neoplasia type 1 (MEN 1), or Wermer's syndrome, is a rare autosomal dominant genetic syndrome characterized by tumors or hyperplasia involving the pituitary, parathyroid, and pancreatic islet cells. Association between MEN 1 and nephrocalcinosis is well known, though data published in medical literature regarding Wermer's syndrome and chronic renal failure relation are still rare.

CASE

A 70-year-old Caucasian female patient had a history of primitive hyperparathyroidism, prolactinoma, glucagonoma, adrenal adenoma and pulmonary neuroendocrine neoplasia. She presented at our clinic first when she was 62 years old because of hypertension, nephrolithiasis (calcium oxalate) and diabetes mellitus treated with oral agents. During the eight-year follow-up she developed chronic renal failure (serum creatinine 1.8 mg/dL, glomerular clearance 35 mL/min) and partial thrombosis of abdominal aortic wall.

CONCLUSIONS

Although the association between renal failure and MEN 1 is rarely reported, patients affected by Wermer's syndrome have several risk factors of decreasing renal function such as hypertension, nephrolithiasis and diabetes mellitus. Moreover, hyperparathyroidism in MEN 1 is clinically similar to the kidney failure condition; indeed, diffuse hyper-plasia of more than one gland is common. Vitamin D should not be administered to these patients. Nephrologists should be involved in MEN 1 follow-up, with the aim to prevent kidney failure development by correcting risk factors.

Possibilities at present for the application of lumbar sympathectomy in chronic occlusive arterial disease of the lower limbs

BACKGROUND

Research on the limitations of the validity of lumbar sympathectomy in surgical treatment of lower limb occlusive arterial disease is still of great interest today.

METHODS

Our study deals with 385 patients who underwent the surgical removal of a segment which includes the 2nd and the 3rd ganglion of the lumbar sympathetic chain in the period between the month of January 1989 and the month of December 1998.

RESULTS

Results were good in 63.6% of patients and stationary in 10.53% of cases; in 26% of cases lumbar sympathectomy was not valid.

CONCLUSIONS

Satisfactory results were recorded, as will be shown in this text, on patients experiencing a period of rest pain, patients with ischaemic dystrophic lesions and those with very advanced intermittent claudication equally favourable results were seen in diabetic patients.

Technetium-99m-HMPAO-labeled leukocyte imaging in patients with seronegative spondyloarthropathies

OBJECTIVE

Gut inflammation is frequent among patients with seronegative spondyloarthropathies (SSp). The purpose of this study was to evaluate the presence of positive abdominal findings in patients with SSp who did not have clinical symptoms or signs of inflammatory bowel disease (IBD). This represents a new indication for abdominal 99mTc-HMPAO-labeled leukocyte scintigraphy.

METHODS

Eighty-six patients (59 with SSp and 27 controls) were prospectively imaged with 99mTc-HMPAO-labeled leukocytes.

RESULTS

Leukocyte imaging was positive in 33 patients with SSp (56%), 27 of these patients scored between 2+ and 4+ (51%). Four (15%) control patients also had positive findings.

CONCLUSION

These findings provide evidence linking SSp with intestinal inflammation. SSp may be an important new indication for 99mTc-HMPAO-labeled autologous leukocyte scintigraphy.

Breast cancer detection with sestamibi-Tc-99m and Tl-201 radionuclides in patients with non conclusive mammography

Early diagnosis of breast cancer using breast examination, mammography and ultrasonography is highly accurate, but radiologically dense breast represent a challenge for the mammographic detection of early stage tumors. The aim of this study is to determine the clinical value of scintigraphic techniques in the early diagnosis of breast cancer when other methods give non-conclusive results. The study includes 160 women with clinical suspicion of breast cancer and non-conclusive findings in mammography, randomized either to scintigraphic scans with Sestamibi Tc 99m or Tl 201. Up to date, 64 women have been enrolled, 46 in Tl-201 and 18 in Sestamibi Tc 99m. Results obtained show 73% sensitivity and 94% specificity with Tl 201 and 77% sensitivity and 100% specificity with Sestamibi Tc 99m. In this group, diagnostic accuracy improves when the tumors are bigger than two centimetres in diameter or when they are palpable. These preliminary results show that scintigraphic breast examination seems useful when other diagnostic methods provide non-conclusive results.

[Computerized bone mineral measurement. Radiation protection and legal aspects]

We begin by defining the standard units utilized in dosimetry and we illustrate the risks related to the interaction of ionizing radiation with living matter. Next we summarize the basic elements of radioprotection such as the physical and medical control of the employees and the inspection by the official authorities. Finally we consider the specific aspects of radioprotection in bone mineral measurement, in relation both with dosimetry and with the existing legislation on the matter.

Congenital dilatation of the intrahepatic bile ducts (Caroli's disease)

Caroli's disease (congenital dilatation of the intrahepatic bile ducts) was diagnosed in an 11-year-old girl with the aid of intravenous cholangiography. Recurrent abdominal pain, fever, and intermittent obstructive jaundice are the most common symptoms and usually develop during childhood or young adulthood. Operative cholangiography has been the most valuable method of diagnosing the condition and determining the location and extent of the disease process.