Understanding lactatemia in human sepsis potential impact for early management

Rationale: Hyperlactatemia in sepsis may derive from a prevalent impairment of oxygen supply/demand and/or oxygen use. Discriminating between these two mechanisms may be relevant for the early fluid resuscitation strategy. Objectives: To understand the relationship among central venous oxygen saturation (ScvO2), lactate, and base excess to better determine the origin of lactate. Methods: This was a post hoc analysis of baseline variables of 1,741 patients with sepsis enrolled in the multicenter trial ALBIOS (Albumin ItalianOutcome Sepsis). Variableswere analyzed as a function of sextiles of lactate concentration and sextiles of ScvO2.Wedefined the "alactic base excess," as the sum of lactate and standard base excess. Measurements and Main Results: Organ dysfunction severity scores, physiologic variables of hepatic, metabolic, cardiac, and renal function, and 90-day mortality were measured. ScvO2 was lower than 70% only in 35% of patients. Mortality, organ dysfunction scores, and lactate were highest in the first and sixth sextiles of ScvO2. Although lactate level related strongly to mortality, it was associated with acidemia only when kidney function was impaired (creatinine >2 mg/dl), as rapidly detected by a negative alactic base excess. In contrast, positive values of alactic base excess were associated with a relative reduction of fluid balance. Conclusions: Hyperlactatemia is powerfully correlated with severity of sepsis and, in established sepsis, is caused more frequently by impaired tissue oxygen use, rather than by impaired oxygen transport. Concomitant acidemia was only observed in the presence of renal dysfunction, as rapidly detected by alactic base excess. The current strategy of fluid resuscitation could be modified according to the origin of excess lactate

Predicting the occurrence of embolic events: an analysis of 1456 episodes of infective endocarditis from the Italian Study on Endocarditis (SEI)

Background: Embolic events are a major cause of morbidity and mortality in patients with infective endocarditis. We analyzed the database of the prospective cohort study SEI in order to identify factors associated with the occurrence of embolic events and to develop a scoring system for the assessment of the risk of embolism. Methods: We retrospectively analyzed 1456 episodes of infective endocarditis from the multicenter study SEI. Predictors of embolism were identified. Risk factors identified at multivariate analysis as predictive of embolism in left-sided endocarditis, were used for the development of a risk score: 1 point was assigned to each risk factor (total risk score range: minimum 0 points; maximum 2 points). Three categories were defined by the score: low (0 points), intermediate (1 point), or high risk (2 points); the probability of embolic events per risk category was calculated for each day on treatment (day 0 through day 30).Results: There were 499 episodes of infective endocarditis (34%) that were complicated by 65 1 embolic event. Most embolic events occurred early in the clinical course (first week of therapy: 15.5 episodes per 1000 patient days; second week: 3.7 episodes per 1000 patient days). In the total cohort, the factors associated with the occurrence of embolism at multivariate analysis were prosthetic valve localization (odds ratio, 1.84), right-sided endocarditis (odds ratio, 3.93), Staphylococcus aureus etiology (odds ratio, 2.23) and vegetation size 65 13 mm (odds ratio, 1.86). In left-sided endocarditis, Staphylococcus aureus etiology (odds ratio, 2.1) and vegetation size 65 13 mm (odds ratio, 2.1) were independently associated with embolic events; the 30-day cumulative incidence of embolism varied with risk score category (low risk, 12%; intermediate risk, 25%; high risk, 38%; p < 0.001).Conclusions: Staphylococcus aureus etiology and vegetation size are associated with an increased risk of embolism. In left-sided endocarditis, a simple scoring system, which combines etiology and vegetation size with time on antimicrobials, might contribute to a better assessment of the risk of embolism, and to a more individualized analysis of indications and contraindications for early surgery

Monitoring the quality of laboraties and the prevalence of resistance to antituberculosis drugs: Italy, 1998-2000

In 1998 a network of 20 regional tuberculosis (TB) laboratories (the Italian Multicentre Study on Resistance to Antituberculosis drugs (SMIRA) network) was established in Italy to implement proficiency testing and to monitor the prevalence of drug resistance nationwide. The network managed 30% of all TB cases reported in Italy each year. The aim of the present report is to describe: 1) the accuracy of drug-susceptibility testing in the network; 2) the prevalence of drug resistance for the period 1998-2000. Data were collected from the network laboratories. Sensitivity to streptomycin and ethambutol increased from the first survey (1998-1999) to the second survey (2000) from 87.7 to 91.9%. Specificity, predictive values for resistance and susceptibility, efficiency and reproducibility were consistent in both surveys. In previously untreated cases, the prevalence of multidrug-resistance was the same in both surveys (1.2%), while a slight decrease from the first to the second survey was observed for monoresistance to rifampicin (from 0.8 to 0.4%) and isoniazid (from 2.9 to 2%,). The significant association found between isoniazid resistance and immigration is a useful indicator for both clinicians managing individual tuberculosis cases and public health services planning control strategies

What to eat. the terapeutic and dietetic compliance of patients on peritoneal dialysis.

Nutrition education is important for patients on peritoneal dialysis. Yet, despite initial nutrition training and monthly reinforcements during follow-up visits, phosphorus control remains unsatisfactory. For this reason a meeting with an external renal dietician open to patients and their relatives was organized. Biographical data and average phosphorus levels for the 3 months prior to the meeting are shown in Table.1 Patients 11 (6 F - 5 M) Age (years) 63 (47-81) Time on Dialysis (months) 72 (6-348) Body Mass Index (kg/m2) 25.8 (22.3-32.4) Phosphorous mg/dl (average of 3 months) 5.95 (3.9-8.2)After a lecture delivered by the centre’s nephrologist, a questionnaire on phosphorus control was compiled by the participants. The renal dietician then explained how to: control dietary phosphorous intake, properly use chelating agents, reduce phosphorous in cooking and make smart food choices. A trained chef then demonstrated how to cook some regional recipes specifically reworked to reduce their phosphorous content without sacrificing taste. Participants then verified that the recipes were indeed appetizing. At this point, the same questionnaire given at the start of the meeting was re-given. From this, an improvement in the understanding of phosphorus control was seen. For example, in response to the question “Who is responsible for controlling phosphorus?” the percentage of patients correctly answering “the patient" rose from 55% before the meeting to 91% after the meeting. To successfully manage kidney disease patients and their relatives need to understand how to best control for phosphorous and this can only be done through continuous nutrition education. The Authors are waiting on the results of phosphorus levels for the next 3 months. The Authors would like to thank Baxter Healthcare for its organizational support

Susceptibility of gram positive cocci to teicoplanin. Three year survey (1984-1986) at Perugia University

From 1984 to 1986, 1038 Gram positive cocci (865 Staphylococci and 173 Enterococci) have been tested for sensitivity to teicoplanin by the agar diffusion method: only one strain (Staphylococcus haemolyticus) resulted to have no zone of inhibition around the teicoplanin disk. All Staphylococcus haemolyticus strains showed higher MIC: 2.79 mcg/ml after 24h of incubation and 20.50 mcg/ml after 48h. The reduced teicoplanin sensitivity of Staphylococcus haemolyticus was not detected by the agar diffusion test

Choroidal granuloma caused by atypical mycobacterium in a patient with AIDS: a case report

The case presented is a chorioretinal granuloma in a patient with AIDS. The neoformation appeared to be caused by atypical mycobacterium, although it was not possible to isolate the germ. The chorioretinal infection caused by atypical mycobacterium in patients with AIDS occurs very rarely and has so far been described only as a post-mortem finding