Edilberto Nuñez

d-dimer is a significant prognostic factor in patients with suspected infection and sepsis☆

PURPOSE The aim of the study was to determine whether C-reactive protein (CRP), procalcitonin (PCT), and d-dimer (DD) are markers of mortality in patients admitted to the emergency department (ED) with suspected infection and sepsis. BASIC PROCEDURES We conducted a prospective cohort in a university hospital in Medellín, Colombia. Patients were admitted between August 1, 2007, and January 30, 2009. Clinical and demographic data and Acute Physiology and Chronic Health Evaluation II and Sepsis Organ Failure Assessment scores as well as blood samples for CRP, PCT, and DD were collected within the first 24 hours of admission. Survival was determined on day 28 to establish its association with the proposed biomarkers using logistic regression and receiver operating characteristic curves. MAIN FINDINGS We analyzed 684 patients. The median Acute Physiology and Chronic Health Evaluation II and Sepsis Organ Failure Assessment scores were 10 (interquartile range [IQR], 6-15) and 2 (IQR, 1-4), respectively. The median CRP was 9.6 mg/dL (IQR, 3.5-20.4 mg/dL); PCT, 0.36 ng/mL (IQR, 0.1-3.7 ng/mL); and DD, 1612 ng/mL (IQR, 986-2801 ng/mL). The median DD in survivors was 1475 ng/mL (IQR, 955-2627 ng/mL) vs 2489 ng/mL (IQR, 1698-4573 ng/mL) in nonsurvivors (P=.0001). The discriminatory ability showed area under the curve-receiver operating characteristic for DD, 0.68; CRP, 0.55; and PCT, 0.59. After multivariate analysis, the only biomarker with a linear relation with mortality was DD, with an odds ratio of 2.07 (95% confidence interval, 0.93-4.62) for values more than 1180 and less than 2409 ng/mL and an odds ratio of 3.03 (95% confidence interval, 1.38-6.62) for values more than 2409 ng/mL. PRINCIPAL CONCLUSIONS Our results suggest that high levels of DD are associated with 28-day mortality in patients with infection or sepsis identified in the emergency department.

Argon Plasma Coagulation Versus Aplication of 4 Percent Formalin for the Treatment of Radiation Induced Hemorrhagic Proctitis

RESUMEN Antecedentes: la proctitis actinica es una complicacion frecuente de la radioterapia para neoplasias pelvicas. En su forma mas severa puede llevar a hemorragias masivas con necesidad de atencion hospitalaria repetida y transfu-siones de sangre. La terapia medica de la proctitis actinica es frecuentemente inefectiva, mientras que la cirugia cur-sa con una alta morbimortalidad.Objetivos: se pretende comparar los resultados terapeuti-cos con el argon plasma (AP) (ERBE USA, Inc., Marietta, GA, USA) en pacientes con hemorragia inducida por la proctitis actinica versus una cohorte historica manejada con la ins-tilacion endoscopica de formol al 4%.Materiales y metodos: el AP se aplico atendiendo a la tec-nica de “no tocar” con una potencia de 50-60 Watt y a un flujo de argon de 2 l/min. Se predetermino una duracion de los pulsos inferiores a 1 segundo. El tratamiento se hizo a intervalos de cada 2 a 4 semanas cuando se requirio. La terapia con formol al 4% se hizo por un operador usando 20 ml e instilandolo directamente al recto por 5 minutos mediante un endoscopio flexible. Se pretende con la tecni-ca un contacto no muy prolongado con el formol. Resultados: los dos grupos son comparables en terminos de edad, genero y diagnostico. En 26 pacientes (24 mu-jeres) con hemorragia por proctitis actinica se aplico formol al 4% y 21 se trataron con AP (18 mujeres). Los pacientes que recibieron formol tuvieron la radioterapia en promedio 14 meses atras (rango 7-28) y los trata-dos con AP de 9 meses (rango 6-18). El tiempo promedio de sangrado antes de la terapia fue de 7 meses (rango de 4-14) para el tratamiento con formol y de 5,5 meses (rango 3-11) para el grupo con AP. El promedio de ad-ministracion de unidades de sangre fue de 2,6 unidades (rango 0-6) para el grupo con formol y de 1,8 (rango de 0-4) para los tratados con AP. En el grupo con formol tres pacientes requirieron mas de una terapia y en el grupo con AP cuatro pacientes. No hubo necesidad de mas transfusiones ni hubo resangrados importantes en el seguimiento de los dos grupos que fue en promedio de 20 meses (rango 6-35).Conclusiones: la terapia endoscopica con formol al 4% es simple, barata y efectiva para el tratamiento del san-grado por proctitis actinica y sus resultados son compa-rables al tratamiento con AP.Background: Radiation proctitis is a common complication of radiotherapy for pelvic malignancy. In more severe form, it leads to intractable or massive hemorrhage, which may require repeated hospital admissions and blood transfusions. Medical therapy in patients with radiation proctitis is usually ineffective, whereas surgery is associated with a high morbidity and mortality. Objectives: to compare the therapeutic results of the Argon Plasma Coagulator (AP) (ERBE USA, Inc., Marietta, GA, USA) application in patients with radiation proctitis-induced haemorrhage versus a historic cohort treated with 4% formalin irrigation. Material and Methods: AP was performed, applying the no-touch spotting technique at an electrical power of 50-60 Watt and an argon gas flow of 2 l/min. Pulse duration was less than 1 second. Treatment sessions were carried out at intervals of 2-4 weeks when was required. Patients with formalin were treated by a single operator using 20 mL of a 4% solution of formalin instilled into the rectum via a flexible colonoscope for 5 minutes. The technique used ensured minimal contact with formalin Results: The two groups were comparable in terms of age, sex, and diagnosis. Twenty six patients (24 females) with hemorrhagic radiation proctitis were treated with endoluminal formalin and 21 with AP (18 females). Patients with formalin were treated with radiotherapy at a median time of 14 months (range, 7-28 months) previously and 9 months (range, 6-18) in AP therapy. The median duration of time of symptomatic rectal haemorrhage before formalin therapy was 7 months (range, 4-14 months) and 5,5 months (range, 3-11 months). The median number of units of blood transfused previously per patient was 2,6 (range, 0-6) and 1,8. Three patients required repeat formalin application and four in AP group. There was not severe bleeding with any of the groups of treatment, nor was any blood transfusion needed, at follow-up mean of 20 months (range, 6-35 months). Conclusions: Formalin 4% therapy is a simple, inexpensive, and effective treatment for hemorrhagic radiation proctitis and could be compared with argon plasma treatment.