Biomarkers of thrombosis, fibrinolysis, and inflammation in patients with severe sepsis due to community-acquired pneumonia with and without Streptococcus pneumoniae

BACKGROUND

Severe Streptococcus pneumoniae (S. pneum) pneumonia has historically been associated with an acute presentation and increased mortality. Using data from patients with community-acquired pneumonia (CAP) and severe sepsis, we investigated: (1) the baseline patient characteristics and biomarkers of thrombosis, fibrinolysis, and inflammation in patients with CAP due to S. pneum infection (S. pneum CAP) or CAP due to infection with other or unidentified organisms (non-S. pneum CAP); (2) the behavior of these biomarkers over time and during treatment with drotrecogin alfa (activated) (DrotAA, recombinant activated protein C).

PATIENTS AND METHODS

Data from the PROWESS (Recombinant Human Activated Protein C Worldwide Evaluation on Severe Sepsis) trial were retrospectively analyzed by treatment (DrotAA or placebo) in patients with CAP.

RESULTS

Patients with S. pneum CAP (n = 157) tended to be younger and had fewer comorbid conditions than patients with non-S. pneum CAP (n = 445). Overall disease severity (median APACHE II scores) was not significantly different between the two groups at baseline. However, there were significant baseline differences in protein C and markers of coagulation, fibrinolysis, and inflammation. Although thrombosis markers were not different at baseline, D-dimer levels significantly increased from baseline to day 4 in placebo-treated patients with S. pneum compared to those with non-S. pneum. DrotAA treatment was associated with statistically significant improvements in protein C and markers of thrombosis in patients with S. pneum. In addition, the proportion of patients with severe protein C deficiency ( </= 40% activity) at baseline was significantly greater in patients with S. pneum than those with non-S. pneum. Among patients with S. pneum and severe protein C deficiency at baseline, a significantly greater proportion of patients were no longer severely protein C deficient after 4 days of DrotAA therapy.

CONCLUSION

In this population of patients with severe sepsis, patients with S. pneum CAP had a more severe dysregulation of coagulation, fibrinolysis, and inflammation than patients with non-S. pneum CAP; the former also developed significantly elevated levels of markers of thrombosis. Treatment with DrotAA was associated with significant improvements in protein C levels as well as markers of thrombosis. These characteristics may make patients with S. pneum CAP and severe sepsis particularly suited to derive a benefit from therapy with DrotAA.

Physician-ordered respiratory care vs physician-ordered use of a respiratory therapy consult service. Results of a prospective observational study

OBJECTIVE

To assess the impact of a respiratory therapy consult service (RTCS) on practices and appropriateness of ordering respiratory care services.

DESIGN

Nonrandomized prospective observational cohort study with concurrent controls.

SETTING

Adult non-ICU inpatient wards of an academic medical center.

PATIENTS

A convenience sample of 98 adult non-ICU inpatients at the Cleveland Clinic Hospital, representing 20 inpatient clinical services. Patients whose respiratory care plans were determined by respiratory care practitioners using sign and symptom-based algorithms to specify treatment comprised the treatment group (n = 51, respiratory therapy consult group). The nonconsult group (n = 47) were patients whose respiratory care plans were specified by their own physicians.

INTERVENTION

Specification of the respiratory care plan by the RTCS vs by the physicians themselves. Use of the RTCS was at the discretion of the managing physician.

OUTCOME MEASURES

Types and number of respiratory care treatments, length of hospital stay, costs of the respiratory therapy provided, appropriateness of respiratory care orders (based on comparison of the actual respiratory care orders with a reference respiratory care plan generated by a study investigator who was kept blind to the actual respiratory care plan), and adverse respiratory events.

RESULTS

Patients for whom the RTCS was requested by their physicians had a greater severity of respiratory illness based on having a lower triage score, but were otherwise similar at baseline. Fewer initial orders for respiratory care were discordant with the reference algorithms in RTCS patients (15% +/- 26% [SD]) than in nonconsult patients (43% +/- 36%; p < 0.001), and a smaller fraction of RTCS patients received at least one discordant initial respiratory care order (37% vs 72%; p < 0.001). Though provided to sicker patients with longer lengths of hospital stay, RTCS-directed care incurred similar respiratory care costs per patient ($335.63 +/- $272.69 [RTCS] vs $349.06 +/- $273.27; p = 0.72).

CONCLUSIONS

These results suggest that the RTCS can be an effective strategy to allocate respiratory care strategies appropriately while conserving the costs of providing respiratory care.

Therapist-driven protocols for adult non-intensive care unit patients. Availability and efficacy

As the growth of TDPs increases throughout the country, the need to evaluate the efficacy of TDPs becomes paramount. For TDPs to become a standard of practice they must respond adequately to their intended purpose. TDPs must reduce the amount of misallocation of respiratory services without compromising quality care. As the reduction of misallocation occurs, the results should show a reduction in department and patient costs. Protocols are not new to the medical community, but their need and use for respiratory care has increased. Preliminary studies thus far suggest that the use of TDPs can lessen misallocation of care without adverse events, and with the use of TDPs the number of respiratory modalities and the cost associated with these therapies have decreased. Further examinations of the efficacy of TDPs must be ongoing, however, in order to ensure that these preliminary studies truly reflect the outcomes of the use of TDPs.

Prediction of prostate cancer volume using prostate-specific antigen levels, transrectal ultrasound, and systematic sextant biopsies

OBJECTIVES

Prostate-specific antigen (PSA) levels, transrectal ultrasound, and systematic sextant biopsies have each shown limited ability to predict prostate cancer volume. In combination, these studies may allow more accurate estimation of volume and prognosis.

METHODS

One hundred twenty-four patients were evaluated prior to radical prostatectomy. Interactive stepwise multiple regression and separate logistic regression analysis were performed for prediction of prostate cancer volume and volume range.

RESULTS

The cancer volumes calculated correlated with the volumes in the radical prostatectomy specimens with R2 of 0.76. Cancers were predicted to be in the volume range associated with poor prognosis (more than 12 cc) or clinically insignificant cancer (less than 1.0 cc) with bias corrected error rates of 5.3% and 10%, respectively.

CONCLUSIONS

The formula for prediction of cancer volume correlates well with actual cancer volume in 92 patients but is not adequate to predict volume for an individual patient. The formulas for prediction of volume range show promising predictive ability and may be useful if the extent of disease is unclear.

Prostate specific antigen as a predictor of an abnormal digital rectal examination

OBJECTIVE

To assess the ability of serum prostate specific antigen (PSA) to predict and differentiate patients with normal and abnormal digital rectal findings.

SUBJECTS AND METHODS

A prospective analysis of 1374 participants in a prostate cancer screening programme was performed. After completion of a questionnaire including age and voiding symptoms as well as phlebotomy for PSA analysis, digital rectal examination was performed and the findings were categorized with respect to size, consistency, symmetry and nodularity.

RESULTS

In men less than 50 years of age the mean serum PSA level failed to discriminate any of the digital rectal examination categories. In men over 50 there was a statistically significant difference in mean PSA levels between symmetrical, normal sized prostates and symmetrically enlarged glands as well as between symmetrical, normal sized and abnormal prostates (P < 0.05). No statistically significant difference was found in mean serum PSA levels between symmetrically enlarged prostate glands and those with palpable nodules. PSA levels < or = 2.5 ng/ml (normal range for the Yang polyclonal assay) and < 7.4 ng/ml (corresponding to the normal range of < 4.0 ng/ml for the Hybritech monoclonal assay) demonstrated a probability of an abnormal digital rectal examination of 11% and 14% respectively. PSA levels > 18.4 ng/ml (corresponding to monoclonal levels of > 10 ng/ml) had a 67% probability of an abnormal digital rectal examination. However, moderate elevations in PSA could not be used to predict digital examination abnormalities due to the high incidence of moderate PSA elevations associated with symmetrical enlargement of the prostate.

CONCLUSIONS

Serial annual PSA measurements may provide an alternative means of screening men over 50 years of age. Contamination of results with PSA elevation due to benign prostatic hyperplasia remains, however, a problem.