Filippo Pieralli

Short-Term Clinical Outcome of Patients With Acute Pulmonary Embolism, Normal Blood Pressure, and Echocardiographic Right Ventricular Dysfunction

BACKGROUND The role of echocardiographic right ventricular (RV) dysfunction in predicting clinical outcome in clinically stable patients with pulmonary embolism (PE) is undefined. In this study, we assessed the prevalence and clinical outcome of normotensive patients with RV dysfunction among a broad spectrum of PE patients. METHODS AND RESULTS This prospective clinical outcome study included cohort of 209 consecutive patients (age, 65+/-15 years) with documented PE. Acute RV dysfunction was diagnosed in the presence of >/=1 of the following: RV dilatation (without hypertrophy), paradox septal systolic motion, and Doppler evidence of pulmonary hypertension. Four groups were identified: 28 patients presenting with shock or cardiac arrest (13%), 19 hypotensive patients without shock (9%), 65 normotensive patients with echocardiographic RV dysfunction (31%), and 97 normotensive patients without RV dysfunction (47%). Among normotensive patients with RV dysfunction, 6 (10%) developed PE-related shock after admission: 3 of these patients died, and 3 were successfully treated with thrombolytic agents. In comparison, none of the 97 normotensive patients without RV dysfunction developed shock or died as a result of PE. CONCLUSIONS A significant proportion (31%) of normotensive patients with acute PE presents with RV dysfunction; these patients with latent hemodynamic impairment have a 10% rate of PE-related shock and 5% in-hospital mortality and may require aggressive therapeutic strategies. Conversely, normotensive patients without echocardiographic RV dysfunction have a benign short-term prognosis. Thus, early detection of echocardiographic RV dysfunction is of major importance in the risk stratification of normotensive patients with acute PE.

Utility of an integrated clinical, echocardiographic, and venous ultrasonographic approach for triage of patients with suspected pulmonary embolism

The potential role of ultrasound techniques in diagnosing acute pulmonary embolism (PE) has been investigated in severe cases with hemodynamic compromise, but is still unclear for the whole clinical spectrum of patients with suspected PE. The aim of this study was to assess the utility of an integrated bedside evaluation for PE based on the combination of a clinical score, 2-dimensional echocardiography, and color venous duplex scanning. A group of 117 consecutive patients with suspected PE was assessed using a clinical likelihood score, echocardiography, and venous duplex scanning in order to obtain a preliminary diagnosis of PE, which was subsequently compared with the final diagnosis obtained by lung perfusion scintigraphy and angiography. A preliminary diagnosis of PE was made in 70 patients; a final diagnosis of PE was made in 63 patients, of which 56 had and 7 did not have a preliminary diagnosis of PE. The preliminary diagnosis therefore showed 89% sensitivity and 74% specificity, with a total accuracy of 82%. In patients with massive PE, sensitivity and negative predictive values of the preliminary diagnosis were 97% and 98%, respectively. Echocardiography was poorly sensitive (51%) but highly specific (87%) for PE. Thus, the integration of clinical likelihood, echocardiography, and venous duplex scanning provides a practical approach to patients with suspected PE, allows the rapid implementation of appropriate management strategies, and may reduce or postpone the need for further instrumental evaluation of more limited access.

Cardiovascular Complications and Short-term Mortality Risk in Community-Acquired Pneumonia

Background. Previous reports suggest that community-acquired pneumonia (CAP) is associated with an enhanced risk of cardiovascular complications. However, a contemporary and comprehensive characterization of this association is lacking. Methods. In this multicenter study, 1182 patients hospitalized for CAP were prospectively followed for up to 30 days after their hospitalization for this infection. Study endpoints included myocardial infarction, new or worsening heart failure, atrial fibrillation, stroke, deep venous thrombosis, cardiovascular death, and total mortality. Results. Three hundred eighty (32.2%) patients experienced intrahospital cardiovascular events (CVEs) including 281 (23.8%) with heart failure, 109 (9.2%) with atrial fibrillation, 89 (8%) with myocardial infarction, 11 (0.9%) with ischemic stroke, and 1 (0.1%) with deep venous thrombosis; 28 patients (2.4%) died for cardiovascular causes. Multivariable Cox regression analysis showed that intrahospital Pneumonia Severity Index (PSI) class (hazard ratio [HR], 2.45, P = .027; HR, 4.23, P < .001; HR, 5.96, P < .001, for classes III, IV, and V vs II, respectively), age (HR, 1.02, P = .001), and preexisting heart failure (HR, 1.85, P < .001) independently predicted CVEs. One hundred three (8.7%) patients died by day 30 postadmission. Thirty-day mortality was significantly higher in patients who developed CVEs compared with those who did not (17.6% vs 4.5%, P < .001). Multivariable Cox regression analysis showed that intrahospital CVEs (HR, 5.49, P < .001) independently predicted 30-day mortality (after adjustment for age, PSI score, and preexisting comorbid conditions). Conclusions. CVEs, mainly those confined to the heart, complicate the course of almost one-third of patients hospitalized for CAP. More importantly, the occurrence of CVEs is associated with a 5-fold increase in CAP-associated 30-day mortality.

Yield of nuclear scan strategy in chest pain unit evaluation of special populations.

BackgroundPatients with chest pain (CP) and nondiagnostic ECG represent heterogeneous population in whom the evaluation of coronary risk factors including metabolic syndrome (MetS) and diabetes mellitus (DM) might improve risk stratification. MethodsWe enrolled 798 consecutive CP patients; 14% presented with MetS and 10% with DM; the remaining 76% presented with other coronary risk profiles (others). All patients underwent maximal exercise tolerance test (ETT) and myocardial perfusion imaging (exercise-MPI). Those with positive testing underwent angiography, whereas the remaining patients were discharged and later followed up. Primary end-point was a composite of coronary stenoses greater than or equal to 50% documented by angiography or coronary events at follow-up. ResultsPatients with MetS or DM had significantly lower survival free from end-point than those patients without (P<0.001). Exercise-MPI showed high negative predictive value in MetS, DM, and others (>96%); however, positive predictive value was 69, 74, and 52%, respectively (P<0.05). ETT alone showed negative predictive value (88%) which was significantly lower than exercise-MPI (98%), (MetS vs. others: P<0.001, and DM vs. others: P=0.05). The area under the receiver-operating characteristic curves obtained from the multivariate model includes clinical data alone, clinical data and ETT results, or clinical data and exercise-MPI results increase progressively. ConclusionA nuclear scan strategy in special populations, including CP patients with MetS or DM, is a valuable tool for risk stratification and adds incremental prognostic value over clinical and ETT values.

Draft Genome Sequence of the First Hypermucoviscous Klebsiella quasipneumoniae subsp. quasipneumoniae Isolate from a Bloodstream Infection

ABSTRACT Klebsiella quasipneumoniae is a recently described species, formerly identified as K. pneumoniae phylogroup KpII. Information on pathogenic and virulence potential of this species are lacking. We sequenced the genome of a hypermucoviscous K. quasipneumoniae clinical isolate showing a virulence genes content (allABCDRS, kfuABC, and mrkABCDFHIJ) peculiar to hypervirulent K. pneumoniae strains.

A case of Candida glabrata severe urinary sepsis successfully treated with micafungin

Candida glabrata is frequently resistant to fluconazole, and in advanced renal failure the safe use of this and other recommended drugs is limited. We report a case of a 56 years-old diabetic woman with renal failure and severe urinary sepsis from C. glabrata successfully treated with micafungin.

Procalcitonin Kinetics in the First 72 Hours Predicts 30-Day Mortality in Severely Ill Septic Patients Admitted to an Intermediate Care Unit

Background Severe sepsis and septic shock are leading causes of morbidity and mortality among critically ill patients, thus the identification of prognostic factors is crucial to determine their outcome. In this study, we explored the value of procalcitonin (PCT) variation in predicting 30-day mortality in patients with sepsis admitted to an intermediate care unit. Methods This prospective observational study enrolled 789 consecutive patients with severe sepsis and septic shock admitted to a medical intermediate care unit between November 2012 and February 2014. Kinetics of PCT expressed as percentage were defined by the variation between admission and 72 hours, and 24 and 72 hours; they were defined as Δ-PCT0-72h and Δ-PCT24-72h, respectively. Results The final study group of 144 patients featured a mean age of 73 ± 14 years, with a high prevalence of comorbidities (Charlson index greater than 6 in 39%). Overall, 30-day mortality was 28.5% (41/144 patients). A receiver-operating-characteristic (ROC) analysis identified a decrease of Δ-PCT0-72h less than 15% (area under the curve: 0.75; 95% confidence interval (CI): 0.67 - 0.82) and a decrease of Δ-PCT24-72h less than 20% (area under the curve: 0.83; 95% CI: 0.74 - 0.92) as the most accurate cut-offs in predicting mortality. Decreases of Δ-PCT0-72h less than 15% (HR: 3.9, 95% CI: 1.6 - 9.5; P < 0.0001) and Δ-PCT24-72h less than 20% (HR: 3.1, 95% CI: 1.2 - 7.9; P < 0.001) were independent predictors of 30-day mortality. Conclusions Evaluation of PCT kinetics over the first 72 hours is a useful tool for predicting 30-day mortality in patients with severe sepsis and septic shock admitted to an intermediate care unit.

Septic shock from community-onset pneumonia: is there a role for aspirin plus macrolides combination?

Dear Editor, Pneumonia occurring in patients living in the community is the most common infection leading to hospitalization in intensive care units and the first cause of death associated with infectious diseases. The mortality rate due to pneumonia has shown little improvement over time despite advances in antimicrobial therapy and improved intensive care medicine, and severe sepsis and septic shock are associated with a mortality rate as high as 50 % [1]. It has been suggested to use agents that interfere with the pathogenesis of sepsis by modulating inflammation and coagulation. From January 2013 to January 2014, we prospectively observed all patients with community-onset pneumonia needing hospitalization at two teaching hospitals in Italy (Policlinico Umberto I, Rome and University Hospital of Careggi, Florence). We performed a post hoc analysis on patients with pneumonia presenting to the emergency department (ED) with septic shock, to evaluate whether any clinical factor or therapeutic intervention is associated with improved survival in this setting of patients. Adult patients fulfilling criteria for community-acquired pneumonia and healthcare-associated pneumonia were included in the study. Septic shock was defined according to Surviving Sepsis Campaign criteria. The effect of clinical and therapeutics variables on the primary end-point was assessed by means of a logistic regression model. In order to correct for possible bias arising from the observational nature of the experiment, we corrected all relevant effect estimates and p values with the propensity score analysis. Overall, 188 patients with pneumonia and septic shock were included in the analysis. The 30-day mortality rate was 42.5 %. No difference in the term of median age was detected between survivors and non-survivors. Patients who died had a higher mean sequential organ failure assessment (SOFA) score, presented more frequently with delirium, had a more frequent PaO2/FiO2 ratio\300, needed more frequent mechanical ventilation, non-invasive ventilation, and continuous renal replacement therapy. Survivors were more likely to receive macrolide therapy and a combination of aspirin plus a macrolide (see supplementary material). All patients taking aspirin were on chronic aspirin therapy at a dosage of 100 mg/day. At Cox regression analysis SOFA score[3 [hazard ratio (HR) 1.13, 95 % confidence interval (CI) 1.06–1.20, p\ 0.001], delirium (HR 1.56, 95 %CI 1.14–3.23, p = 0.01), and PaO2/FiO2 ratio\300 (HR 2.42, 95 % CI 1.28–3.56, p\ 0.001) were independently associated with death, while receipt of aspirin plus a macrolide (HR 0.24, 95 % CI 0.08–0.79, p = 0.01) was associated with survival. This latter finding was confirmed by the propensity score adjusted estimates (see Table 1). The use of macrolides has been previously associated with lower mortality in patients with severe pneumonia, and the administration of clarithromycin has been associated with restoration of the balance between pro-inflammatory versus anti-inflammatory mediators in patients with Gram-negative sepsis and ventilator-associated pneumonia (VAP). A further double-blind, randomized, multicenter trial found that clarithromycin accelerates resolution of VAP, and favors weaning from mechanical ventilation [2]. As regards to aspirin, a propensity-adjusted analysis by Chen and coworkers revealed that the pre-hospital use of aspirin was associated with a decreased risk of developing an acute respiratory distress syndrome (ARDS) [3]. Furthermore, we recently reported a beneficial activity of aspirin in patients with community-onset pneumonia, with a

Chagas disease as a cause of heart failure and ventricular arrhythmias in patients long removed from endemic areas: an emerging problem in Europe.

Chagas disease is a parasitic disease caused by the protozoan Trypanosoma cruzi. In endemic areas (South and Central America), Chagas disease represents a relevant public health issue, and is the most frequent cause of cardiomyopathy. In nonendemic areas, such as Europe, Chagas disease represents an emerging problem following the establishment of sizeable communities from Brazil and Bolivia. Chagas cardiomyopathy represents the most frequent and serious complication of chronic Chagas disease, affecting about 20–30% of patients, potentially leading to heart failure, arrhythmias, thromboembolism, stroke and sudden death. Because late complications of Chagas disease may develop several years or even decades after the acute infection, it may be extremely challenging to reach the correct diagnosis in patients long removed from the countries of origin. We report two examples of Chagas cardiomyopathy in South American women permanently residing in Italy for more than 20 years, presenting with cardiac manifestations ranging from left ventricular dysfunction and heart failure to isolated ventricular arrhythmias. The present review emphasizes that Chagas disease should be considered as a potential diagnosis in patients from endemic areas presenting with ‘idiopathic’ cardiac manifestations, even when long removed from their country of origin, with potential implications for treatment and control of Chagas disease transmission.

Procalcitonin-guided antibiotic therapy: an expert consensus.

Abstract Background: Procalcitonin (PCT) is a useful biomarker of bacterial infection and its use is associated to reduced duration of antibiotic therapy in the setting of intensive care medicine. To address the need of practical guidance for the use of PCT in various clinical settings, a group of experts was invited to participate at a consensus process with the aims of defining the rationale for appropriate use of PCT and for improving the management of critically ill patients with sepsis. Methods: A group of 14 experts from anesthesiology and critical care, infectious diseases, internal medicine, pulmonology, clinical microbiology, laboratory medicine, clinical pharmacology and methodology provided expert opinion through a modified Delphi process, after a comprehensive literature review. Results: The appropriateness of use of PCT in terms of diagnosis, prognosis and antimicrobial stewardship was assessed for different scenarios or settings such us management of infection in the emergency department, regular wards, surgical wards or in the intensive care unit. Similarly, appropriateness and timing of PCT measurement were evaluated. All the process consisted in three Delphi rounds. Conclusions: PCT use is appropriate in algorithms for antibiotic de-escalation and discontinuation. In this case, reproducible, high sensitive assays should be used. However, initiation or escalation of antibiotic therapy in specific scenarios, including acute respiratory infections, should not be based solely on PCT serum levels. Clinical and radiological findings, evaluation of severity of illness and of patient’s characteristics should be taken into proper account in order to correctly interpret PCT results.