Vittorio Schweiger

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.

Hypoxia-reperfusion affects osteogenic lineage and promotes sickle cell bone disease

Sickle cell disease (SCD) is a worldwide distributed hereditary red cell disorder, characterized by severe organ complication. Sickle bone disease (SBD) affects a large part of the SCD patient population, and its pathogenesis has been only partially investigated. Here, we studied bone homeostasis in a humanized mouse model for SCD. Under normoxia, SCD mice display bone loss and bone impairment, with increased osteoclast and reduced osteoblast activity. Hypoxia/reperfusion (H/R) stress, mimicking acute vaso-occlusive crises (VOCs), increased bone turnover, osteoclast activity (RankL), and osteoclast recruitment (Rank) with upregulation of IL-6 as proresorptive cytokine. This was associated with further suppression of osteogenic lineage (Runx2, Sparc). To interfere with the development of SBD, zoledronic acid (Zol), a potent inhibitor of osteoclast activity/osteoclastogenesis and promoter of osteogenic lineage, was used in H/R-exposed mice. Zol markedly inhibited osteoclast activity and recruitment, promoting osteogenic lineage. The recurrent H/R stress further worsened bone structure, increased bone turnover, depressed osteoblastogenesis (Runx2, Sparc), and increased both osteoclast activity (RankL, Cathepsin k) and osteoclast recruitment (Rank) in SCD mice compared with either normoxic or single-H/R-episode SCD mice. Zol used before recurrent VOCs prevented bone impairment and promoted osteogenic lineage. Our findings support the view that SBD is related to osteoblast impairment, and increased osteoclast activity resulted from local hypoxia, oxidative stress, and the release of proresorptive cytokine such as IL-6. Zol might act on both the osteoclast and osteoblast compartments as multimodal therapy to prevent SBD.

Severe maternal morbidity in a tertiary care centre of northern Italy: a 5-year review.

Objective: To assess prevalence and causes of severe acute maternal morbidity cases and evaluate their impact on feto-maternal wellbeing and on facility resources. Study Design: Observational retrospective study adopting management-based criteria in a tertiary care public hospital during a 5-year period. Criteria adopted were: intensive care unit admission, blood transfusion ≥ 4 units, emergency peripartum hysterectomy and arterial embolization at any time during pregnancy. Results: A total of 80 cases were identified, most of them (97.5%) through a combination of two criteria, ICU admission and blood transfusion. Commonest severe obstetric morbidities were major obstetric haemorrhage (48.8%) and hypertensive disorders (27.5%). Immigrant status (OR 1.68, 95% CI 1.03–2.7), pre-term birth (OR 4.15, 95% CI 2.5–6.8), Caesarean section (OR 7.74,95% CI 4.2–14.3) were factors significantly associated with SAMM cases. Major abdominal surgery was necessary in 26 women (32.5%), with emergency peripartum hysterectomy in 11 (13.5%). These events led to an average blood consumption per woman of 6.5 ± 12.8 units and a mean hospital stay of 8.9 ± 5.0 days, significantly longer (p < 0.001) than the average duration of post-delivery care. Maternal mortality to morbility ratio was 1:80. Conclusions: An integrated intervention-based approach proved to be effective in finding severe acute maternal morbidity cases. Information on underlying causes and associated risk factors may improve prevention and treatment of obstetric morbidities, thus reducing feto-maternal adverse effects and hospital expenditures.

O001. The Italian Consensus Conference “Chronic Pain in Neurorehabilitation” - Group 29: headache and facial pain

Headaches and other cranio-oro-facial pains are widely distributed in the general population. Unfortunately, there is very little evidence regarding the impact of these conditions in patients admitted to rehabilitation units, regardless of the disease or syndrome requiring rehabilitation. The availability of diagnostic and therapeutic guidelines, as well as the increasing number of data coming from controlled clinical trials, should be implemented in these patients to reduce the burden of pain and improve their global outcome. The Italian Society for Neurorehabiltation, in collaboration with the Italian Society of Physical Medicine and Rehabilitation, has promoted the Consensus Conference on Pain with the aim to foster attention on pain also in the rehabilitative field (http://www.doloreinneuroriabilitazione.it/). The working group has proposed the following recommendations: - Standard methods or criteria exist to evaluate head and cranio-facial pain in terms of intensity (B); - Standard methods exist to evaluate migraine in terms of disability (A); - It is important to evaluate the impact of cephalic and cranio-facial pain in neurorehabilitation (D); - Standard methods or criteria exist to diagnose head and cranio-facial pain (GL); - It is important to identify predictive factors associated with the development of cephalic and cranio-facial pain in association with a condition requiring neurorehabilitation (D); - Effective pharmacological treatment exists for primary headaches and for trigeminal neuralgia (GL); - Manual therapy is indicated in the management of migraine and tension-type headache (GL); - Manual therapy may be effective in TMD-associated pain (D); - Botulinum toxin A is effective in the treatment of idiopathic trigeminal neuralgia (B); - Botulinum toxin A is effective in the treatment of hemifacial spasm (B); - Topical capsaicin is effective in chronic neuropathic pain (B); - Evidence is needed to evaluate the impact of treating cephalic and cranio-facial pain on the outcome of patients undergoing neurorehabilitation (D). The recommendations are presently under evaluation by the Consensus Conference panel.

Fentanyl Buccal Tablet: A New Breakthrough Pain Medication in Early Management of Severe Vaso-Occlusive Crisis in Sickle Cell Disease

Sickle cell disease (SCD) is a worldwide distributed hereditary red cell disorder. The principal clinical manifestations of SCD are the chronic hemolytic anemia and the acute vaso‐occlusive crisis (VOCs), which are mainly characterized by ischemic/reperfusion tissue injury. Pain is the main symptom of VOCs, and its management is still a challenge for hematologists, requiring a multidisciplinary approach.

Assessing and treating primary headaches and cranio-facial pain in patients undergoing rehabilitation for neurological diseases

BackgroundPain is a very common condition in patient undergoing rehabilitation for neurological disease; however the presence of primary headaches and other cranio-facial pains, particularly when they are actually or apparently independent from the disability for which patient is undergoing rehabilitation, is often neglected. Diagnostic and therapeutic international and national guidelines, as well as tools for the subjective measure of head pain are available and should also be applied in the neurorehabilitation setting. This calls for searching the presence of head pain, independently from the rehabilitation needs, since pain, either episodic or chronic, interferes with patient performance by affecting physical and emotional status. Pain may also interfere with sleep and therefore hamper recovery.MethodsIn our role of task force of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN), we have elaborated specific recommendations for diagnosing and treating head pains in patients undergoing rehabilitation for neurological diseases.Results and ConclusionIn this narrative review, we describe the available literature that has been evaluated in order to define the recommendations and outline the needs of epidemiological studies concerning headache and other cranio-facial pain in neurorehabilitation.

Intracranial Subdural Hematoma after Spinal Anesthesia for Cesarean Section

Intracranial subdural hematoma following spinal anesthesia is an infrequent occurrence in the obstetric population. Nevertheless, it is a potentially life-threatening complication. In the majority of the cases, the first clinical symptom associated with intracranial subdural bleeding is severe headache, but the clinical course may have different presentations. In this report, we describe the case of a 38-year-old woman with an acute intracranial subdural hematoma shortly after spinal anesthesia for cesarean section. Early recognition of symptoms of neurologic impairment led to an emergency craniotomy for hematoma evacuation with good recovery of neurologic functions. The possibility of subdural hematoma should be considered in any patient complaining of severe persistent headache following regional anesthesia, unrelieved by conservative measures. Only early diagnosis and an appropriate treatment may avoid death or irreversible neurologic damage.

Effect of 5% Lidocaine Medicated Plaster on Pain Intensity and Paroxysms in Classical Trigeminal Neuralgia

Objective: Trigeminal neuralgia (TN) is a neuropathic pain condition affecting one or more branches of the trigeminal nerve. It is characterized by unilateral, sudden, shock-like, and brief painful attacks, which follow the distribution of trigeminal nerve branches, and with no other accompanying sensorimotor or autonomic signs and symptoms. Current guidelines stipulate which therapies represent first-, second-, and third-line treatments for TN, but there is a consistent mismatch between the therapeutic guidelines and the patient’s preferences and expectations. Case Summary: We report on 2 patients with classical TN in whom conventional drugs for TN were not tolerated. In these patients, treatment with 5% lidocaine medicated plaster (LMP) resulted in reduction of pain intensity and the number of pain paroxysms. Discussion: LMP is known to block the sodium channels on peripheral nerves and may cause a selective and partial block of Aδ and C fibers. According to the TN ignition hypothesis, blockage of peripheral afferents by LMP may reduce pain paroxysms. The effect of LMP may outlast the pharmacokinetics of the drug by reducing pain amplification mechanisms in the central nervous system. LMP has limited or no systemic side effects. Conclusions: LMP may be an effective and well-tolerated treatment option for TN in those patients who do not tolerate or who refuse other therapies. Future randomized controlled studies should better address this issue.

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.