Procalcitonin biomarker kinetics fails to predict treatment response in perioperative abdominal infection with septic shock

Introduction

Procalcitonin (PCT) biomarker is suggested to tailor antibiotic therapy in the medical intensive care unit (ICU) but studies in perioperative medicine are scarce. The aim of this study was to determine whether PCT reported thresholds are associated with the initial treatment response in perioperative septic shock secondary to intra-abdominal infection.

Methods

This single ICU, observational study included patients with perioperative septic shocks secondary to intra-abdominal infection. Demographics, PCT at days 0, 1, 3, 5, treatment response and outcome were collected. Treatment failure included death related to the initial infection, second source control treatment or a new onset intra-abdominal infection. The primary endpoint was to assess whether PCT thresholds (0.5 ng/ml or a drop from the peak of at least 80%) predict the initial treatment response.

Results

We included 101 consecutive cases. Initial treatment failed in 36 patients with a subsequent mortality of 75%. Upon admission, PCT was doubled when treatment ultimately failed (21.7 ng/ml ± 38.7 vs. 41.7 ng/ml ± 75.7; P = 0.04). Although 95% of the patients in whom PCT dropped down below 0.5 ng/ml responded to treatment, 50% of the patients in whom PCT remained above 0.5 ng/ml also responded successfully to treatment. Moreover, despite a PCT drop of at least 80%, 40% of patients had treatment failure.

Conclusions

In perioperative intra-abdominal infections with shock, PCT decrease to 0.5 ng/ml lacked sensitivity to predict treatment response and its decrease of at least 80% from its peak failed to accurately predict treatment response. Studies in perioperative severe infections are needed before using PCT to tailor antibiotic use in this population.     

Giant aneurysmal bone cyst of the scapula: A case report

Aneurysmal bone cyst (ABC) is a benign bone tumor affecting mainly children and young adults. It occurs in the metaphysis of the long bones. The scapula is a very rare location. Imaging may be highly suggestive of ABC in cases of an osteolytic, expansive, and hemorrhagic lesion with fluid-fluid levels and thin septa. The diagnosis must systematically be confirmed by performing a biopsy, in order to adopt the best therapeutic strategy. There are several therapeutic means, but wide resection remains the gold standard. The evolution is very variable and can go from spontaneous healing to recurrence with the destruction of the bone. We report a rare case of aneurysmal bone cyst of the scapula in a young patient.     

Complete common mesentery revealed by acute perforated appendicitis: case report and review of the literature

Intestinal malrotation in children is a rare aberration, due to a halt in the rotation and attachment of the primitive gut, it can be asymptomatic if the rotation terminates at 90 degrees, which manifests itself in unusual forms of appendicitis as in our observation, or dangerous in cases of inadequate common mesentery and worsened by small intestine volvulus. This 12-year-old boy experienced abdominal discomfort in the hypogastrium and left iliac fossa 4 days before admission. The pain had been developing in a feverish setting, and the clinical examination had revealed abdominal sensitivity. A biological inflammatory syndrome was detected throughout the biological workup, the CT scan allowed the diagnosis of acute appendicitis on a complete common mesentery, and the patient underwent a laparotomy appendectomy. Even though children frequently experience acute appendicitis in its conventional form, it is nevertheless highly challenging to identify in its atypical forms when intestinal malrotation is involved. An abdominopelvic CT scan is used to make the diagnosis, and appendectomy, preferably with laparoscopy, is the recommended course of action.     

A 2-year study of neonatal mortality in a large Malaysian hospital

A 2-year study was carried out in the Maternity Hospital, Kuala Lumpur to determine the neonatal mortality rates. This Hospital functions both as the local service centre as well as the national referral centre in Malaysia. Its neonatal services, however, were equipped and manned at those below Level III perinatal centre. During the study period 52, 877 livebirths took place in the Hospital. In 1987 and 1988 respectively, the low birthweight (less than 2500 gm) rates were: 112.8 and 101.9 per 1000 livebirths, very low birthweight (less than 1500 gm) rates: 11.1 and 8.8 per 1000 livebirths, neonatal mortality rates: 12.5 and 10.7 per 1000 livebirths and neonatal mortality risk ratio: 1.15 and 1.27. There was significant difference in mortality rates among the Malay, Chinese and Indian babies born in this hospital: the Indians had the highest and the Chinese the lowest rates. Babies delivered by breech or lower segment Caesarean section (LSCS) also had significantly higher mortality than those delivered by other modes of delivery. Low birthweight neonates constituted less than 45% of the total special care nursery admission but contributed to more than 70% of the total neonatal deaths. The common causes of neonatal deaths were problems of prematurity, infection, asphyxia and congenital malformations. Preterm and low birthweight neonates died primarily from problems of prematurity or infection. Term and larger neonates died mainly from asphyxia. More than 75% of the neonatal deaths occurred before 7 days of life. Improvement of antenatal care in the community and upgrading of perinatal services in this Hospital could help to lower the morbidity and mortality due to preventable causes.     

Anti-HCV-Positive Cirrhosis Associated with Schistosomiasis

Hepatosplenic schistosomiasis is occasionally associated with cirrhosis and progressive hepatic decompensation. The aim of the present study was to determine the prevalence of antibody to hepatitis C virus in patients with schistosomiasis and cirrhosis. The prevalence of anti-HCV was studied in 12 consecutive cases of schistosomiasis associated with biopsy proven cirrhosis. All patients had a past history of schistosomiasis and high liters of schistosomal antibodies in serum (1:32 to 1:4096). Five of the 12 patients had hepatic catheterization and were found to have sinusoidal involvement with corrected sinusoidal pressures ranging from 19 to 23 mm Hg. Four had ascites, six had pedal edema, and eight had peripheral signs of chronic liver disease in the form of palmar erythema, spider nevi, and/or gynecomastia. Ten of the 12 cases (83%) were repeatedly positive for anti-HCV/ELISA. These results suggest that when patients with schistosomiasis develop cirrhosis, associated hepatitis C virus infection should be suspected.     

Effect of pentoxifylline on hepatic injury caused in the rat by the administration of carbon tetrachloride or acetaminophen

The effect of pentoxifylline (PTX) on acute liver injury caused by CCl4 or acetaminophen was studied in the rat. PTX was given twice daily (18, 36 or 72 mg/kg), intraperitoneally (ip) for 5 days prior to CCl4 or acetaminophen. In addition, the effect of PTX administered simultaneously with CCl4 or acetaminophen was evaluated. Rats were killed 72 h or 48 h after CCl4 or acetaminophen administration, respectively. The administration of PTX at 72 mg/kg, conferred significant protection against the hepatotoxic actions of CCl4, reducing serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) levels to 31%, 59.2% and 63%, respectively. Histological examination showed a decrease in centrilobular necrotic areas in rats pretreated with PTX. Histochemical investigation revealed a decrease in glycogen and protein contents caused by CCl4 and these were prevented by PTX pretreatment. When administered with CCl4, PTX did not reduce CCl4-induced hepatic injury. In contrast, hepatic injury induced by acetaminophen was prevented by prior or co-treatment with PTX. Accordingly, with 72 mg/kg of PTX, the elevation of AST, ALT and ALP levels was lower by 45%, 80.6%, 54.3% for the former and by 32.4%, 77.2%, 52.4% for the latter, respectively. Stained sections were subjected to morphometric evaluation using computerized image analyzer. Quantitative analysis of the acetaminophen area of damage showed a reduction by 34.8, 65.5 and 89.2% by 18, 36 or 72 mg/kg for PTX, respectively. Rats treated with PTX revealed more or less normal hepatocyte architecture as well as marked improvement in protein and glycogen content. The study demonstrates that prior but not co-toxicant administration of PTX in a model of CCl4-induced liver injury results in less liver damage. In contrast, PTX is equally protective, when given either as a pretreatment or with acetaminophen exposure.     

Severe mitral regurgitation and heart failure due to caseous calcification of the mitral annulus

Caseous calcification is a rare form of mitral annular calcification. Echocardiography reveals an echodense mass in the inferior mitral annulus with smooth borders and an echolucent inner core. We present a case where caseous calcification of the mitral annulus caused severe mitral regurgitation, atrial fibrillation and heart failure. Transthoracic echocardiography, transesophageal echocardiography, cardiac magnetic resonance and computed tomography were performed and ensured the diagnosis. The mass was surgically removed and a prosthetic valve was implanted. We conclude that caseous calcification of the mitral annulus should be considered not only in the differential diagnosis of cardiac masses but also in the background of mitral regurgitation, atrial fibrillation and heart failure. This case also represents the usefulness of multimodal imaging in identifying cardiac masses.     

Evidence of clinical and genetic heterogeneity in autosomal dominant congenital cerulean cataracts

Autosomal dominant cerulean cataracts (ADCC) have previously been mapped to two loci: one on chromosome 17q24 and the other on chromosome 22q11.2–q12.2, which includes the ß-B2 crystallin (CRYBB2) candidate gene. Using polymorphic markers in these regions (D17S802, D17S836, D17S1806 and CRYBB2, D22S258) for linkage analysis, we excluded these loci in a large Moroccan family presenting with an unusual form of ADCC with early onset of lens opacities and rapid evolution. This finding confirms the clinical and genetic heterogeneity of autosomal dominant congenital cerulean cataracts.     

Effects of levosimendan in normodynamic endotoxaemia: a controlled experimental study

OBJECTIVES: Levosimendan is an inotropic and vasodilator drug that has proved to be useful in cardiogenic shock. Pretreatment with levosimendan in experimental hypodynamic septic shock in pigs has shown valuable effects in oxygen transport. Our goal was to assess the effects of levosimendan in a normodynamic model of endotoxaemia. METHODS: Twelve sheep were anaesthetized and mechanically ventilated. After taking basal haemodynamic and oxygen transport measurements, sheep were assigned to two groups during 120 min: (1) endotoxin (5 microg/kg endotoxin); (2) levosimendan (5 microg/kg endotoxin plus levosimendan 200 microg/kg followed by 200 microg/kg/h). Both groups received hydration of 20 ml/kg/h of saline solution. RESULTS: In the endotoxin group, cardiac output, intestinal blood flow and systemic and intestinal oxygen transports and consumptions (DO(2) and VO(2)) remained unchanged. In the levosimendan group, systemic and intestinal DO(2) were significantly higher than in the endotoxin group. Because stroke volume did not change (basal versus 120': 0.9+/-0.1 ml/kg versus 0.9+/-0.2 ml/kg, p=0.3749), the elevation in cardiac output by levosimendan (145+/-17 ml/min/kg versus 198+/-16 ml/min/kg, p=0.0096) was related to an increased heart rate (159+/-32 beats l/min versus 216+/-19 beats l/min, p=0.0037). Levosimendan precluded the development of gut intramucosal acidosis at 120' (endotoxin versus levosimendan, ileal intramucosal-arterial PCO(2) difference: 19+/-4 Torr versus 10+/-4 Torr, p=0.0025). However, levosimendan decreased mean arterial blood pressure (99+/-20 Torr versus 63+/-13 Torr, p=0.0235) and increased blood lactate levels (2.4+/-0.9 mmol/l versus 4.8+/-1.5 mmol/l, p=0.0479). All p-values are differences in specific points (paired or unpaired t-test with Bonferroni correction) after two-way repeated measures ANOVA. A p-value<0.05 was considered significant. CONCLUSIONS: Levosimendan improved oxygen transport and prevented the development of intramucosal acidosis in this experimental model of endotoxaemia. However, systemic hypotension and lactic acidosis occurred. Additional studies are needed to show if different doses and timing of levosimendan administration in septic shock might improve gut perfusion without adverse effects.     

Antihypercholesterolaemic effect of ginger rhizome (<Emphasis Type="Italic">Zingiber officinale</Emphasis>) in rats

Introduction  

Many herbal medicinal products have potential hypocholesterolaemic activity and encouraging safety profiles. However, only a limited amount of clinical research exists to support their efficacy.