Clinical Utility of Procalcitonin in the Diagnosis of Pneumonia

BACKGROUND

The clinical utility of procalcitonin in the diagnosis and management of pneumonia remains controversial.

METHODS

We assessed the clinical utility of procalcitonin in 2 prospective studies: first, a multicenter diagnostic study in patients presenting to the emergency department with acute dyspnea to directly compare the diagnostic accuracy of procalcitonin with that of interleukin 6 and C-reactive protein (CRP) in the diagnosis of pneumonia; second, a randomized management study of procalcitonin guidance in patients with acute heart failure and suspected pneumonia. Diagnostic accuracy for pneumonia as centrally adjudicated by 2 independent experts was quantified with the area under the ROC curve (AUC).

RESULTS

Among 690 patients in the diagnostic study, 178 (25.8%) had an adjudicated final diagnosis of pneumonia. Procalcitonin, interleukin 6, and CRP were significantly higher in patients with pneumonia than in those without. When compared to procalcitonin (AUC = 0.75; 95% CI, 0.71-0.78), interleukin 6 (AUC = 0.80; 95% CI, 0.77-0.83) and CRP (AUC = 0.82; 95% CI, 0.79-0.85) had significantly higher diagnostic accuracy (P = 0.010 and P < 0.001, respectively). The management study was stopped early owing to the unexpectedly low AUC of procalcitonin in the diagnostic study. Among 45 randomized patients, the number of days on antibiotic therapy and the length of hospital stay were similar (both P = 0.39) in patients randomized to the procalcitonin-guided group (n = 25) and usual-care group (n = 20).

CONCLUSIONS

In patients presenting with dyspnea, diagnostic accuracy of procalcitonin for pneumonia is only moderate and lower than that of interleukin 6 and CRP. The clinical utility of procalcitonin was lower than expected.

SUMMARY

Pneumonia has diverse and often unspecific symptoms. As the role of biomarkers in the diagnosis of pneumonia remains controversial, it is often difficult to distinguish pneumonia from other illnesses causing shortness of breath. The current study prospectively enrolled unselected patients presenting with acute dyspnea and directly compared the diagnostic accuracy of procalcitonin, interleukin 6, and CRP for the diagnosis of pneumonia. In this setting, diagnostic accuracy of procalcitonin for pneumonia was lower as compared to interleukin 6 and CRP. The clinical utility of procalcitonin was lower than expected.

CLINICALTRIALSGOV IDENTIFIER

NCT01831115.

P4553Clinical and prognostic value of right ventricular dysfunction in patients with chagas heart disease during acute decompensated heart failure

Introduction

The occurrence of right ventricular disfunction (RVD) is common in heart failure (HF) patients due to Chagas' disease (ChD). However, its clinical and prognostic value has not been studied during episodes of acute decompensated heart failure (ADHF).

Purpose

Evaluate the prognostic value of RVD in ADHF patients with ChD during hospitalization and after 180 days of discharge compared to other etiologies.

Methods

We analysed a prospective cohort of consecutive 768 patients admitted for ADHF between March 2013 and October 2018; 490 (63.7%) patients were male and the median age was 58 (48.3–66.8) years and left ventricular ejection fraction was 26% (median) (IQR 22–35%). We compared the clinical characteristics and the prognosis of ChD patients according to the presence of RVD in the echocardiogram to other etiologies.

Results

RVD was presented in 289 (37.6%) patients. Among patients with non-chagasic etiologies, those with RVD were younger [53 (41–62) vs 61 (52–70) years, p<0.0001], had high levels of BNP in the moment of hospitalization [1195 (606–2209) vs 886 (366– 555) pg/mL], p<0,0001], received more inotropes (79.2% vs 57.9%, p<0,0001), had longer hospitalization [35 (17–51) vs 21 (10–37) days, p<0.001] and more clinical signs of congestion as hepatomegaly (49% vs 28.6%, p<0.0001); jugular venous distension (68.3% vs 41.2%, p<0.0001) and leg edema (65.4% vs 49.2%, p=0.001). Among patients with ChD, those with RVD were older [61 (48- 66) vs 58 (48 - 67) years, p=0.017], and had more frequently signs of hypoperfusion (56.8% vs 36.5%, p=0.029), jugular venous distension (72.8% vs 52.8%, p=0.01) and hepatomegaly (56.8% vs 31.1%, p=0.011), higher BNP levels [1288 (567–2180) vs 1066 (472–2007) pg/mL, p=0.006] and more frequent use of intravenous inotropes (88.9% vs 67.1%, p=0.003); additionally ChD patients with RVD had a higher rate of death and transplant during hospitalization (51.2% vs 38.3%, p=0.001). When all groups were compared together, ChD patients with RVD had the highest rate of death, transplant and readmissions at 180-days of follow-up (Figure).

Figure 1

Conclusion

Patients with RVD demonstrated a distinct clinical presentation, biomarkers and worse prognosis in all etiologies. ChD patients with RVD in ADHF had the worst prognosis with the highest rate of death, heart transplant e rehospitalization in follow-up.

Prognosis and risk stratification in patients with decompensated heart failure receiving inotropic therapy

Objectives

The prognostic significance of transient use of inotropes has been sufficiently studied in recent heart failure (HF) populations. We hypothesised that risk stratification in these patients could contribute to patient selection for advanced therapies.

Methods

We analysed a prospective cohort of adult patients admitted with decompensated HF and ejection fraction (left ventricular ejection fraction (LVEF)) less than 50%. We explored the outcomes of patients requiring inotropic therapy during hospital admission and after discharge.

Results

The study included 737 patients, (64.0% male), with a median age of 58 years (IQR 48-66 years). Main aetiologies were dilated cardiomyopathy in 273 (37.0%) patients, ischaemic heart disease in 195 (26.5%) patients and Chagas disease in 163 (22.1%) patients. Median LVEF was 26 % (IQR 22%-35%). Inotropes were used in 518 (70.3%) patients. In 431 (83.2%) patients, a single inotrope was administered. Inotropic therapy was associated with higher risk of in-hospital death/urgent heart transplant (OR=10.628, 95% CI 5.055 to 22.344, p<0.001). At 180-day follow-up, of the 431 patients discharged home, 39 (9.0%) died, 21 (4.9%) underwent transplantation and 183 (42.4%) were readmitted. Inotropes were not associated with outcome (death, transplant and rehospitalisation) after discharge.

Conclusions

Inotropic drugs are still widely used in patients with advanced decompensated HF and are associated with a worse in-hospital prognosis. In contrast with previous results, intermittent use of inotropes during hospitalisation did not determine a worse prognosis at 180-day follow-up. These data may add to prognostic evaluation in patients with advanced HF in centres where mechanical circulatory support is not broadly available.

Clinical findings and prognosis of patients hospitalized for acute decompensated heart failure: Analysis of the influence of Chagas etiology and ventricular function

Aims

Explore the association between clinical findings and prognosis in patients with acute decompensated heart failure (ADHF) and analyze the influence of etiology on clinical presentation and prognosis.

Methods and results

Prospective cohort of 500 patients admitted with ADHF from Aug/2013-Feb/2016; patients were predominantly male (61.8%), median age was 58 (IQ_25-75% 47–66 years); etiology was dilated cardiomyopathy in 141 (28.2%), ischemic heart disease in 137 (27.4%), and Chagas heart disease in 113 (22.6%). Patients who died (154 [30.8%]) or underwent heart transplantation (53[10.6%]) were younger (56 years [IQ_25-75% 45–64 vs 60 years, IQ_25-75% 49–67], P = 0.032), more frequently admitted for cardiogenic shock (20.3% vs 6.8%, P<0.001), had longer duration of symptoms (14 days [IQ_25-75% 4–32.8 vs 7.5 days, IQ_25-75% 2–31], P = 0.004), had signs of congestion (90.8% vs 76.5%, P<0.001) and inadequate perfusion more frequently (45.9% vs 28%, P<0.001), and had lower blood pressure (90 [IQ_25-75% 80–100 vs 100, IQ_25-75% 90–120], P<0.001). In a logistic regression model analysis, systolic blood pressure (P<0.001, OR 0.97 [95%CI 0.96–0.98] per mmHg) and jugular distention (P = 0.004, OR 1.923 [95%CI 1.232–3.001]) were significant. Chagas patients were more frequently admitted for cardiogenic shock (15%) and syncope/arrhythmia (20.4%). Pulmonary congestion was rare among Chagas patients and blood pressure was lower. The rate of in-hospital death or heart transplant was higher among patients with Chagas (50.5%).

Conclusions

A physical exam may identify patients at higher risk in a contemporaneous population. Our findings support specific therapies targeted at Chagas patients in the setting of ADHF.

It is recognized that the clinical evaluation of patients remains the basis for the characterization of diseases, data interpretation, and patient care. However, incorporation of technological methods into clinical practice has challenged the way cardiologists’ value of history and clinical examination. The present study sought to analyze the importance of clinical findings in a contemporaneous cohort of patients admitted with decompensated heart failure. Our results indicate that the physical exam may identify patients at higher risk in a contemporaneous patient population, and that clinical presentation varies according to etiology—especially Chagas disease—and ventricular function. Our findings support the need of development of specific therapeutic approaches targeted at Chagas patients in the setting of acute decompensated heart failure, as they represent a more vulnerable population.

Animal Mitochondrial DNA Replication

Recent advances in the field of mitochondrial DNA (mtDNA) replication highlight the diversity of both the mechanisms utilized and the structural and functional organization of the proteins at mtDNA replication fork, despite the relative simplicity of the animal mtDNA genome. DNA polymerase γ, mtDNA helicase and mitochondrial single-stranded DNA-binding protein-the key replisome proteins, have evolved distinct structural features and biochemical properties. These appear to be correlated with mtDNA genomic features in different metazoan taxa and with their modes of DNA replication, although substantial integrative research is warranted to establish firmly these links. To date, several modes of mtDNA replication have been described for animals: rolling circle, theta, strand-displacement, and RITOLS/bootlace. Resolution of a continuing controversy relevant to mtDNA replication in mammals/vertebrates will have a direct impact on the mechanistic interpretation of mtDNA-related human diseases. Here we review these subjects, integrating earlier and recent data to provide a perspective on the major challenges for future research.

Effects of nemorosone, isolated from the plant Clusia rosea, on the cell cycle and gene expression in MCF-7 BUS breast cancer cell lines

BACKGROUND

Breast cancer is the cause of considerable morbidity and mortality in women. While estrogen receptor antagonists have been widely used in breast cancer treatment, patients have increasingly shown resistance to these agents and the identification of novel targeted therapies is therefore required. Nemorosone is the major constituent of the floral resin from Clusia rosea and belongs to the class of polycyclic polyisoprenylated benzophenones of the acylphloroglucinol group. The cytotoxicity of nemorosone in human cancer cell lines has been reported in recent years and has been related to estrogen receptors in breast cancer cells.

METHODS

Changes induced by nemorosone in the cell cycle and gene expression of the MCF-7 BUS (estrogen-dependent) breast cancer cell line were analyzed using flow cytometry and the RT(2) Profiler PCR array, respectively.

RESULTS

In comparison to breast cancer cells without treatment, nemorosone induced discrete cell cycle arrest in the G1 phase and significant depletion in the G2 phase. Moreover, the compound altered the expression of 19 genes related to different pathways, especially the cell cycle, apoptosis and hormone receptors.

CONCLUSION

These promising results justify further studies to clarify mechanisms of action of nemorosone, in view of evaluate the possible use of this benzophenone as adjuvant in the treatment of breast cancer.

Detection of bovine herpesvirus 2 and bovine herpesvirus 4 DNA in trigeminal ganglia of naturally infected cattle by polymerase chain reaction

Establishment of latent infection within specific tissues in the host is a common biological feature of the herpesviruses. In the case of bovine herpesvirus 2 (BoHV-2), latency is established in neuronal tissues, while bovine herpesvirus 4 (BoHV-4) and ovine herpesvirus 2 (OvHV-2) latent virus targets on cells of the monocytic lineage. This study was conducted in quest of BoHV-2, BoHV-4 and OvHV-2 DNA in two hundred trigeminal ganglia (TG) specimens, derived from one hundred clinically healthy cattle, majority of them naturally infected with bovine herpesvirus 1 (BoHV-1) and bovine herpesvirus 5 (BoHV-5). Total DNA extracted from ganglia was analyzed by polymerase chain reaction (PCR) designed to amplify part of the genes coding for BoHV-2, and BoHV-4 glycoprotein B and, for OvHV-2, the gene coding for phosphoribosylformylglycinamidine synthase-like protein. BoHV-2 DNA was detected in TG samples of two (2%) and BoHV-4 DNA in nine (9%) of the animals, whereas OvHV-2 DNA could not be detected in any of the TG DNA. The two animals in which BoHV-2 DNA was identified were also co-infected with BoHV-1 and BoHV-5. Within the nine animals in which BoHV-4 DNA was detected, six were also co-infected with BoHV-1 and BoHV-5. This report provides for the first time evidence that viral DNA from BoHV-2 and BoHV-4 can be occasionally detected in TG of naturally infected cattle. Likewise, in this report we provided for the first time evidence that the co-infection of cattle with three distinct bovine herpesviruses might be a naturally occurring phenomenon.

Haemolytic and proteinase activities in clinical isolates of Candida parapsilosis and Candida tropicalis with reference to the isolation anatomic site

The aim of this study was to determine in vitro haemolytic and protease activities of Candida parapsilosis and Candida tropicalis isolates, obtained from anatomically distinct sites. Analysis of haemolytic activity of C. parapsilosis and C. tropicalis isolates obtained from the same anatomic site revealed that C. tropicalis isolates from blood had statistically higher activity (P < 0.05) than C. parapsilosis. On comparison of haemolytic activities of Candida isolates obtained from different anatomic sites, C. parapsilosis isolates from tracheal secretion were found to have higher activity than blood isolates. Protease activity was detected in the majority of the isolates analysed. Analysis of proteinase activity of C. parapsilosis and C. tropicalis isolates obtained from the same anatomic site revealed that C. parapsilosis isolates from tracheal secretion had statistically higher activity than C. tropicalis isolates. On comparison of proteinase activities of Candida isolates obtained from different anatomic sites, C. parapsilosis isolates from tracheal secretion were found to have higher activity than blood and superficial lesions isolates. Furthermore, C. tropicalis isolates from superficial lesions had higher activity than tracheal secretion isolates. Our results show the potential of C. parapsilosis and C. tropicalis isolates, obtained from distinct anatomic sites, to produce haemolytic factor and proteinases. Anatomic sites of isolation seem to be correlated with these activities, particularly for C. parapsilosis isolates.

Neutralizing antibodies to bovine herpesvirus types 1 (BoHV-1) and 5 (BoHV-5) and its subtypes

This study was carried out to determine whether the sensitivity of serum neutralization (SN) tests would be affected by the use of distinct subtypes of bovine herpesvirus 1 (BoHV-1) and 5 (BoHV-5) as test challenge viruses. Bovine sera collected from a randomized sample (n=287) were tested in a 24h incubation SN against three type 1 viruses (BoHV-1.1 strains "Los Angeles" (LA) and "EVI 123"; BoHV-1.2a strain "SV 265") and three type 5 viruses (BoHV-5a strain "EVI 88"; BoHV-5b strain "A 663" and BoHV-5c "ISO 97"). SN sensitivity varied greatly depending on the test challenge virus used in the test, particularly when results against each virus were considered individually, where it ranged from 77% (detecting 80 out of 104 antibody-positive sera) with ISO 97 to 91% (95/104) with BoHV-1.1 strain LA. All tests to single viruses revealed a significantly low sensitivity (McNemar's; p<0.05). Maximum sensitivity (104/104) was achieved when positive results to a particular combination of four of the challenge viruses (LA+EVI 123+SV 265+A 663) or some combinations of five viruses (or all six viruses) were added cumulatively. These results provide evidence for no association between any particular virus type/subtype and higher SN sensitivity. In addition, it was clearly shown that when SN is performed with single test challenge viruses, sensitivity can vary so significantly that might compromise control or eradication efforts. Performing SN against a number of different viruses demonstrated to improve significantly the test's sensitivity.

Improving access to the control region and tRNA gene clusters of dipteran mitochondrial DNA

Despite the successful use of universal primers for amplifying insect mtDNA, specific regions remain difficult to recover and demand the use of taxon-specific primers. In this work, we describe a new set of primers for efficiently amplifying and sequencing the mtDNA control region and three tRNA gene clusters of dipterans of medical and veterinary importance, including Muscidae, Calliphoridae, and Oestridae species. These new primers were useful for investigating the nucleotide information and the structural organization of dipteran mtDNA.

Drugs of Abuse Induce Apoptotic Features in PC12 Cells

Drugs of abuse induce the release of dopamine in the central nervous system, particularly in the mesolimbic-mesocortical pathway. As dopamine may act as a neurotoxin, in this study, we analyzed the effects of the drugs of abuse, cocaine, heroin, and amphetamine, on the neurodegeneration of PC12 cells, a dopaminergic cell line, by evaluating the activity of caspase-3 and mitochondrial cytochrome c release. All the drugs were shown to induce caspase-3 activation, similarly to staurosporine, a classical inducer of apoptotic cell death. Furthermore, like staurosporine, the drugs of abuse induced a decrease in mitochondrial cytochrome c content, suggesting the involvement of the mitochondrial apoptotic pathway.

Análise de custos do tratamento de episódios de descompensação aguda de insuficiência cardíaca: levosimendan versus dobutamina

OBJECTIVE

To assess whether the treatment with levosimendan is more expensive than the usual one with dobutamine, since price of medications does not usually represent the greatest expense in the treatment of cardiac decompensation.

METHODS

The cost of treatment of 18 inpatients with cardiac decompensation, 9 of which treated with dobutamine (dobuta group) and 9 with levosimendan (levo group), was compared. Groups were similar concerning age, sex, functional class and cardiac function.

RESULTS

Treatment costs were similar for both groups. In the levo group, the costs with the drug were higher than in the dobuta group, but those related to the length of stay in intensive care unit and to the material used during admission were lower. Levo-drug: R$ 5,414.00; material: R$ 399.90; hospital daily rates: R$ 5,061.20; professional honorarium: R$ 3,241.80; total costs: R$ 14,117.00. Dobuta-drug: R$ 2,320.10; materials: R$ 1,665.70; hospital daily rates: R$ 6,261.90; professional honorarium: R$ 3,894.30; total costs: R$ 14,142.00.

CONCLUSION

Despite the higher price of levosimendan, the global cost of the treatment was similar for patients who were treated either with dobutamine or levosimendan. Patients who were treated with levosimendan had a shorter length of stay in intensive care unit.

Toxic effects of opioid and stimulant drugs on undifferentiated PC12 cells

Cell death and reactive oxygen species production have been suggested to be involved in neurodegeneration induced by the drugs of abuse. In this study we analyze the toxicity of the following drugs of abuse: heroin, morphine, d-amphetamine, and cocaine in undifferentiated PC12 cells, used as dopaminergic neuronal models. Our data show that opioid drugs (heroin and morphine) are more toxic than stimulant drugs (d-amphetamine and cocaine). Toxic effects induced by heroin are associated with a decrease in intracellular dopamine, an increase in DOPAC levels, and the formation of ROS, whereas toxic effects induced by amphetamine are associated with a decrease in intracellular dopamine and in ATP/ADP levels. In contrast with cocaine, both amphetamine and heroin induced features of apoptosis. The data suggest that the death of cultured PC12 cells induced by the drugs of abuse is correlated with a decrease in intracellular dopamine levels, which can be associated with an increased dopamine turnover and oxidative cell injury.

Inheritance pattern of RAPD markers in Melipona quadrifasciata (Hymenoptera: Apidae, Meliponinae)

Melipona quadrifasciata is an important pollinator agent in several regions of Brazil. Data concerning the genetics of this species are scarce in the literature. In this work we used the random amplified polymorphic DNA (RAPD) technique to determine the degree of polymorphism and the inheritance pattern of these molecular markers in this species. Our ultimate goal is to establish tools to be used in the study of the genomic organization of M. quadrifasciata. Genomic DNA from progenies F(1) and BC(1) were assayed with 79 different primers, yielding an average of 6.67 bands and 1.68 polymorphisms per primer. Three types of polymorphisms were detected: band presence/absence, band intensity, and fragment-length polymorphisms. Most of the observed polymorphisms were band presence/absence, typical of RAPD-dominant markers. The number of observed polymorphisms and their segregation in accordance with a Mendelian proportion confirm the importance of this technique for genome analysis of species like M. quadrifasciata that are poorly studied at the genetic level.

Endoscopic harvesting of the sural nerve graft: a cadaveric investigation

This study investigated an endoscopic technique of harvesting the sural nerve graft. Using endoscopic instrumentation, the sural nerve was harvested from six cadaveric legs. A 2-cm longitudinal incision was made immediately posterior to the lateral malleolus, and a 5-mm endoscope was introduced. The path of the nerve was followed to the popliteal space, and nerve dissection was performed from proximal to distal. Air inflation of a balloon was used to enlarge the endoscopic cavity. The cavity created around the nerve was insufflated with carbon dioxide gas, allowing complete nerve isolation. Using a 0.5-cm transverse incision, the nerve was cut and removed. This endoscopic sural nerve grafting approach offers potential advantages such as less injury to soft tissues, decreased pain, nerve integrity preservation, and good aesthetic results.

[Resurgence of the measles epidemic: situation in Minas Gerais, Brazil]

This study aims to describe the measles vaccination campaigns that have been carried out in the state of Minas Gerais, Brazil, since 1988; to highlight their importance in the control of the disease, and to pinpoint the age groups at risk during the recent epidemic, which began in 1996, spread all over the country, and declined in 1998. However, the analysis includes only data up to September 1997. The methodology used was based on the birth cohort analysis design. Data compared by cohorts included target population and vaccination coverage for each campaign, and measles incidence rates during the present epidemic. Results show that the more opportunities for exposure to vaccination campaigns, the lesser the risk for having measles in any birth cohort. In 1997, the relative risk for getting measles was 15.38 (IC 95%: 9.89 to 23.93) for the cohort under 2 years of age, which had not had the opportunity to be exposed to any vaccination campaigns, as compared to cohorts between 3 and 19 years of age with two or more opportunities of exposure to vaccination campaigns. On the basis of the experiences analyzed, catch-up measles vaccination campaigns as well as follow-up campaigns--particularly when routine vaccination did not achieve sufficient coverage--have had an outstanding role in controlling the measles epidemic in the state of Minas Gerais. We therefore suggest making the measles vaccine immediately available to all birth cohorts that did not have the opportunity for exposure to past vaccination campaigns and intensifying epidemiological surveillance. Moreover, it is necessary to find ways to improve routine vaccination coverage in order to achieve the 95% goal set by the National Plan to Eliminate Measles by the Year 2000.