Alvise Martini

Procalcitonin levels in surgical patients at risk of candidemia

OBJECTIVE Although the majority of cases of sepsis in intensive care unit (ICU) patients are due to bacterial infection, fungal infections are common and their early identification is important so that appropriate treatment can be started. Biomarkers have been used to aid diagnosis of bacterial infections, but their role in fungal infections is less defined. In this study we assessed the value of procalcitonin (PCT) levels for the diagnosis of candidemia or bacteremia in septic patients. METHODS We prospectively recorded PCT levels in 48 critically ill surgical patients with signs of sepsis and at high risk for fungal infection, and compared levels in patients with candidemia and bacteremia. RESULTS Bacterial species were isolated from blood cultures in 16 patients, Candida species in 17, and mixed bacterial and Candida species in 2 patients. PCT levels were less elevated in patients with candidemia (median 0.71 [IQR 0.5-1.1]) than in those with bacteremia (12.9 [2.6-81.2]). A PCT value less than 2 ng/ml enabled bacteremia to be ruled out with a negative predictive value of 94%, and had a similar positive predictive value for candidemia. CONCLUSIONS Our data indicate that a low PCT value in a critically ill septic patient is more likely to be related to candidemia than to bacteremia.

A prospective evaluation of the Infection Probability Score (IPS) in the intensive care unit

OBJECTIVES Identification of infection remains a major challenge, particularly in acutely ill patients. The Infection Probability Score (IPS) was developed to help rule out infection in acutely ill patients. In the present study, we determined the IPS in acutely ill, intensive care unit (ICU) patients to assess its use in the diagnosis and treatment of infection. METHODS In this prospective, observational study, we enrolled 107 consecutive patients who were admitted to the ICU without antibiotic therapy. Patients were allocated to four groups according to the probability of infection determined from clinical and microbiological data and their IPS values were then evaluated daily throughout the ICU stay. RESULTS The IPS was higher in patients with the highest clinical probability of infection and decreased significantly in these patients after 5 days of effective antimicrobial therapy. The IPS remained below the cut-off value in non-infected patients. Patients in whom inadequate antimicrobial therapy was administered had a greater mortality than the other patients. CONCLUSIONS The IPS had a good predictive value for diagnosis of infection. In addition, dynamic evaluation of this score may help to assess the response to therapy.

A retrospective case series of ultrasound-guided suprascapular nerve pulsed radiofrequency treatment for hemiplegic shoulder pain in patients with chronic stroke

Purpose Hemiplegic shoulder pain (HSP) is the most common pain condition after stroke. Pulsed radiofrequency (PRF) treatment of the suprascapular nerve (SSN) effectively relieves shoulder pain conditions. To date, there is no study about the effects of PRF treatment for HSP. Thus, our aim was to report on a case series about its use in chronic stroke. Patients and methods Six chronic stroke patients with HSP (visual analog scale [VAS] score for pain ≥30 mm) underwent ultrasound-guided SSN PRF treatment. All were evaluated before treatment and at 4 and 16 weeks of follow-up. The main outcome was VAS score. Secondary outcomes were Modified Ashworth Scale, shoulder passive range of motion (PROM), Disability Assessment Scale (DAS), Fugl-Meyer Assessment, and EuroQol-5 dimension questionnaire (EuroQol-5D) scores. Results As compared with baseline, improvement was observed in the following parameters: VAS for pain (at 4 weeks, P=0.023; at 16 weeks, P=0.023); shoulder PROM for abduction (at 4 weeks, P=0.023; at 16 weeks, P=0.024), flexion (at 4 and 16 weeks, P=0.024), extension (at 4 and 16 weeks, P=0.02), and external rotation (4 and 16 weeks, P=0.02); DAS for hygiene (at 4 and 16 weeks, P=0.024), dressing (at 4 weeks, P=0.02; at 16 weeks, P=0.024), and pain (at 4 weeks, P=0.024; at 16 weeks, P=0.023); and EuroQol-5D (at 4 and 16 weeks, P=0.024). Conclusion Our observations support the use of ultrasound-guided SSN PRF treatment for HSP in chronic stroke patients.

Ultramicronized palmitoylethanolamide treatment in central neuropathic pain following longstanding spinal cord injury: try to extinguish the fire after everything was burned

note through consideration of multiple sources of relevant information. In addressing the multidimensional nature of the experience of pain, Dr Alcock does not object to the addition of the word “cognitive” to characterize the experience, but demurs on the use of the term “social,” suggesting it “may not be well suited to a definition of pain,” concluding that terms referring to sensation, thoughts, feelings, and behaviours are sufficient. Nevertheless, he observes that the biopsychosocial framework for pain argues for bidirectional relationships among “pain, biomedical, psychological, and social factors.” We note that increasing attention to the neurobiology of human interactions argues the ubiquity of social factors in human action and decisionmaking.We have an opportunity that should not be missed to explicitly acknowledge the importance of social factors as features of pain.

Acupuncture and auricular cryotherapy for chronic headache in a patient with type III von Willebrand disease

A 42-year-old women was referred to our pain therapy centre in April 2013 owing to a worsening migraine. She was known to have von Willebrand disease type III complicated by the development of alloantibodies to von Willebrand factor and previous anaphylactic shock during infusion of factor VIII/von Willebrand factor concentrates. The patient is being treated with a continuous infusion of recombinant factor VIII, when bleeding occurs. Since the age of 14, the patient has received combination oestrogen and progestogen treatment to prevent the risk of bleeding related to ovulation. She has no other relevant medical history. Migraine pain began at the start of 2007, and rapidly became severe (typically scoring 8–10 on the numerical rating scale (NRS) for a period of 72 h). The pain was treated with paracetamol, sumatriptan and rizatriptan in turn, without success. In view of her lifelong bleeding tendency, the use of non-steroidal anti-inflammatory drugs was avoided. Prophylactic therapy was started with propranolol and then with flunarizine, without benefit. The pain pattern was typical of migraine1 and …