Neutrophil CD64 as a marker of infection in patients admitted to the emergency department with acute respiratory failure

Introduction

Cluster of differentiation 64 (CD64) is expressed on neutrophils during bacterial infections and sepsis. The aim of our study was to assess the CD64 expression in patients admitted to the emergency department (ED) with a triage diagnosis of acute respiratory failure (ARF) and/or dyspnea and to verify a relationship between its value and the presence of infection.

Methods

We assessed neutrophil CD64 expression in peripheral blood of patients admitted to the ED with a diagnosis of ARF and/or dyspnea from September 2012 to April 2013. We measured CD64 index by flow cytometry (Leuko64™ kit) and classified patients as infected within 12 hours from admission, without an infection within 12 hours but infected within 72 hours from admission, and not infected. The primary outcome was differentiating CD64 values of patients with a diagnosis of infection within 12 hours and 72 hours from admission, from those of patients without a diagnosis of infection. The secondary outcome was verifying a relationship between CD64 values and patients’ characteristics, Sequential Organ Failure Assessment score, and intensive care unit admission.

Results

Of 212 patients included in the study, 40.1% were classified as infected within 12 hours from admission, 20.3% were without an infection 12 hours after admission but were infected within 72 hours, and 39.6% were not infected. The median CD64 index was higher in patients with an infection on admission (CD64 index: 3.58) than in those not considered infected (CD64 index: 1.37), P<0.0001. Among patients not infected at admission, the CD64 index was higher in those with an infection detected during the following hours of observation (CD64 index: 2.75) than in patients without a diagnosis of infection (CD64 index: 1.28), P<0.0001. A CD64 index >3.65 showed a sensitivity of 94.6%, a specificity of 86.8%, and an area under the receiver-operating characteristic curve of 0.952 for prediction of intensive care unit admission.

Conclusion

CD64 index could represent a useful diagnostic tool for differential diagnosis of ARF in the ED.

Procalcitonin as a marker of Candida species detection by blood culture and polymerase chain reaction in septic patients

Background

The aim of our study is to test procalcitonin (PCT) as surrogate marker of identification of Candida spp. by blood culture (BC) and real-time-polymerase chain reaction (PCR), whether alone or in association with bacteria, in septic patients.

Methods

We performed a single-centre retrospective study. We reviewed the clinical charts of patients with a diagnosis of severe sepsis or septic shock treated at our general intensive care unit from March 2009 to March 2013. We analysed all diagnostic episodes consisting of BC, real-time PCR assay and dosage of PCT. We registered age, sex, white blood count, sequential organ failure assessment score and type of admission between medical or surgical. When inclusion criteria were met more than once, we registered the new diagnostic episode as subsequent diagnostic episode. The diagnostic performance of PCT to predict Candida spp. identification alone or in mixed infections by either BC or PCR was tested using the receiver-operative characteristic curve. Logistic regression was constructed using presence of Candida spp. as the dependent variable.

Results

A total of 260 diagnostic episodes met the inclusion criteria. According to BC results classification, a significantly lower value of PCT was observed in Candida spp. BSI (0.99 ng/ml, 0.86 - 1.34) than in BSI caused by bacteria (16.7 ng/ml, 7.65 - 50.2) or in mixed infections (4.76 ng/ml, 2.98 - 6.08). Similar findings were observed considering PCR results. A cut-off of ≤ 6.08 ng/ml for PCT yielded a sensitivity of 86.8%, a specificity of 87.4%, a positive predictive value of 63.9%, a negative predictive value (NPV) of 96.3% and an area under the curve of 0.93 for Candida spp. identification by BC. A similar high NPV for a cut-off ≤ 6.78 ng/ml was observed considering the classification of diagnostic episodes according to PCR results, with an AUC of 0.85. A subsequent diagnostic episode was independently associated with Candida spp. detection either by BC or PCR.

Conclusion

PCT could represent a useful diagnostic tool to exclude the detection of Candida spp. by BC and PCR in septic patients.

A perioperative uncontrollable bleeding in an elderly patient with acquired hemophilia A: a case report

Key Clinical Message

Acquired hemophilia A should be taken into account in the differential diagnosis of perioperative bleeding in patients without any apparent reason for activated partial thromboplastin time prolongation.

Update on perioperative management of the child with asthma

Asthma represents the leading cause of morbidity from a chronic disease among children. Dealing with this disease during the perioperative period of pediatric surgical procedures is, therefore, quite common for the anesthesiologist and other professionalities involved. Preoperative assessment has a key role in detecting children at increased risk of perioperative respiratory complications. For children without an optimal control of symptoms or with a recent respiratory tract infection elective surgery should be postponed, if possible, after the optimization of therapy. According to clinical setting, loco-regional anesthesia represents the desirable option since it allows to avoid airway instrumentation. Airway management goals are preventing the increase of airflow resistance during general anesthesia along with avoiding triggers of bronchospasm. When their use is possible, face mask ventilation and laringeal mask are considered more reliable than tracheal intubation for children with asthma. Sevoflurane is the most commonly used anesthetic for induction and manteinance. Salbutamol seems to be useful in preventing airflow resistance rise after endotracheal intubation. Mechanical ventilation should be tailored according to pathophysiology of asthma: an adequate expiratory time should be setted in order to avoid a positive end-expiratory pressure due to expiratory airflow obstruction. Pain should be prevented and promptly controlled with a loco-regional anesthesia technique when it is possible. Potential allergic reactions to drugs or latex should always be considered during the whole perioperative period. Creating a serene atmosphere should be adopted as an important component of interventions in order to guarantee the best care to the asthmatic child.

[Treatment of local recurrences of rectal cancer]

In this work we report the results of 27 patients who underwent a second surgical operation for local disease recurrence after colorectal surgery for cancer. We describe the different intervention we performed and for everyone of them we analyze intraoperative mortality and morbidity, long term survival and quality of life related.

[Functional outcomes and quality of life in patients with anterior resection for rectal cancer. Does preoperative manometry predict the feasibility of a J-pouch?]

INTRODUCTION

The goal in the treatment of rectal cancer is the recovery of the disease with the best fecal continence and quality of life. The Authors compared quality of life and manometric results in patients treated with neo-adjuvant chemotherapy and rectal low anterior resection (LRA).

METHODS

From January 1998 to March 2002 50 patients with advanced (T3-T4) rectal cancer underwent neo-adjuvant chemotherapy. Subsequently 41 of them underwent LRA with colon pouch (19) or without the pouch (22). After few months the quality of life was evaluated through a questionnaire. Later they underwent manometric evaluation measuring resting, squeeze and rectal compliance.

RESULTS

The manometric results and the questionnaire scores agreed in 75% of patients. In detail, patients with hypotonic sphincter had a better (one could say good) quality of life if a LAR with pouch had been performed respect to the patients without pouch.

CONCLUSION

Performing LAR with colon pouch after neoadjuvant chemotherapy in patients with hypotonic sphincter improves quality of life. Preoperative anorectal manometry could select patient who would benefit from pouch construction.

[Complications of the anterior resection of the rectum]

The Authors report their experience, referred to the last 10 years (1980-1989), concerning 169 cases of anterior resection of the rectum. Manual and mechanical anastomoses were performed in 83 and 86 cases, respectively. Immediate and long-term complications are evaluated considering the type of anastomosis used, while results are correlated to the stage of the tumor.