Monitoring procalcitonin in febrile neutropenia: what is its utility for initial diagnosis of infection and reassessment in persistent Fever?

Background: Management of febrile neutropenic episodes (FE) is challenged by lacking microbiological and clinical documentation of infection. We aimed at evaluating the utility of monitoring blood procalcitonin (PCT) in FE for initial diagnosis of infection and reassessment in persistent fever.Methods: PCT kinetics was prospectively monitored in 194 consecutive FE (1771 blood samples): 65 microbiologically documented infections (MDI, 33.5%; 49 due to non-coagulase-negative staphylococci, non-CNS), 68 clinically documented infections (CDI, 35%; 39 deep-seated), and 61 fever of unexplained origin (FUO, 31.5%).Results: At fever onset median PCT was 190 pg/mL (range 30-26'800), without significant difference among MDI, CDI and FUO. PCT peak occurred on day 2 after onset of fever: non-CNS-MDI/deep-seated-CDI (656, 80-86350) vs. FUO (205, 33-771; p<0.001). PCT >500 pg/mL distinguished non-CNS-MDI/deep-seated-CDI from FUO with 56% sensitivity and 90% specificity. PCT was >500 pg/ml in only 10% of FUO (688, 570-771). A PCT peak >500 pg/mL (1196, 524-11950) occurred beyond 3 days of persistent fever in 17/21 (81%) invasive fungal diseases (IFD). This late PCT peak identified IFD with 81% sensitivity and 57% specificity and preceded diagnosis according to EORTC-MSG criteria in 41% of cases. In IFD responding to therapy, median days to PCT <500 pg/mL and defervescence were 5 (1-23) vs. 10 (3-22; p = 0.026), respectively.Conclusion: While procalcitonin is not useful for diagnosis of infection at onset of neutropenic fever, it may help to distinguish a minority of potentially severe infections among FUOs on day 2 after onset of fever. In persistent fever monitoring procalcitonin contributes to early diagnosis and follow-up of invasive mycoses

Aprender a investigar para argumentar sobre lengua: los registros lingüísticos orales en la ESO

Este artículo presenta una secuencia didáctica basada en el enfoque del proceso de enseñanza-aprendizaje de la lengua mediante la investigación y la interacción. El objetivo es proponer una manera de trabajar los contenidos lingüísticos en secundaria a través de un proceso que implique, por un lado, la creación de situaciones de reflexión compartida entre los alumnos y, por otro, un cambio de perspectiva en las tareas que habitualmente realizan los alumnos en el aula. Se trata de que los estudiantes pasen de desempeñar un papel básicamente receptivo (de las preguntas y las reflexiones del docente) a tener un papel claramente productivo, ya que para hacer una investigación se tienen que formular hipótesis, analizar resultados y extraer conclusiones. En concreto, a través de la secuencia didáctica que se propone se desarrollan las habilidades lingüísticas del alumnado mediante tres ejes: el concepto de registro lingüístico en relación con el contexto educativo, la reflexión a través de la argumentación y la investigación.

Anemia and brain oxygen after severe traumatic brain injury.

PURPOSE: To investigate the relationship between hemoglobin (Hgb) and brain tissue oxygen tension (PbtO(2)) after severe traumatic brain injury (TBI) and to examine its impact on outcome. METHODS: This was a retrospective analysis of a prospective cohort of severe TBI patients whose PbtO(2) was monitored. The relationship between Hgb-categorized into four quartiles (&#8804;9; 9-10; 10.1-11; >11 g/dl)-and PbtO(2) was analyzed using mixed-effects models. Anemia with compromised PbtO(2) was defined as episodes of Hgb &#8804; 9 g/dl with simultaneous PbtO(2) < 20 mmHg. Outcome was assessed at 30 days using the Glasgow outcome score (GOS), dichotomized as favorable (GOS 4-5) vs. unfavorable (GOS 1-3). RESULTS: We analyzed 474 simultaneous Hgb and PbtO(2) samples from 80 patients (mean age 44 ± 20 years, median GCS 4 (3-7)). Using Hgb > 11 g/dl as the reference level, and controlling for important physiologic covariates (CPP, PaO(2), PaCO(2)), Hgb &#8804; 9 g/dl was the only Hgb level that was associated with lower PbtO(2) (coefficient -6.53 (95 % CI -9.13; -3.94), p < 0.001). Anemia with simultaneous PbtO(2) < 20 mmHg, but not anemia alone, increased the risk of unfavorable outcome (odds ratio 6.24 (95 % CI 1.61; 24.22), p = 0.008), controlling for age, GCS, Marshall CT grade, and APACHE II score. CONCLUSIONS: In this cohort of severe TBI patients whose PbtO(2) was monitored, a Hgb level no greater than 9 g/dl was associated with compromised PbtO(2). Anemia with simultaneous compromised PbtO(2), but not anemia alone, was a risk factor for unfavorable outcome, irrespective of injury severity.

Eficiência da adubação orgânica com esterco bovino e com Egeria densa

Informações sobre a eficiência de uso dos nutrientes aplicados na adubação orgânica são ainda escassas. As recuperações aparentes dos nutrientes aplicados como esterco bovino e como restos de Egeria densa foram comparadas. Grande massa de egéria é retirada dos lagos do sistema hidrelétrico de Paulo Afonso e seu descarte tem sido problemático. Foram feitos cinco plantios consecutivos de milho, por 45 dias cada, em casa de vegetação, após aplicação única de doses equivalentes a 0, 10, 20, 30 e 40 Mg ha-1 de matéria seca. As adições de egéria e de esterco bovino aumentaram as quantidades de fitomassa seca e os conteúdos de N, P e K das plantas, de forma proporcional às doses aplicadas, porém o efeito da egéria foi 3 a 10 vezes maior que o do esterco, exceto quanto ao P, que foi semelhante. Os incrementos com a egéria começaram desde o primeiro plantio, e os do esterco, só no terceiro. No quinto plantio, ambos foram muito pequenos. A eficiência de recuperação dos nutrientes aplicados foi maior quando se utilizaram restos de egéria (N, 34-39 e 7-22 %; P, 47-103 e 9-11 %; e K, 55-76 e 26-34 %, respectivamente), mas, mesmo com a egéria, sobraram nutrientes no solo, que foram absorvidos em pequena proporção no quinto plantio. A liberação de nutrientes dos restos de egéria é mais rápida que no esterco bovino, e seu aproveitamento como adubo orgânico é recomendável.

Evaluation of an intravitreal fluocinolone acetonide implant versus standard systemic therapy in noninfectious posterior uveitis.

PURPOSE: To evaluate the safety and efficacy of an intravitreal fluocinolone acetonide (FA) implant compared with standard therapy in subjects with noninfectious posterior uveitis (NIPU). DESIGN: Randomized, controlled, phase 2b/3, open-label, multicenter superiority trial. PARTICIPANTS: Subjects with unilateral or bilateral NIPU. METHODS: One hundred forty subjects received either a 0.59-mg FA intravitreal implant (n = 66) or standard of care (SOC; n = 74) with either systemic prednisolone or equivalent corticosteroid as monotherapy (&gt; or =0.2 mg/kg daily) or, if judged necessary by the investigator, combination therapy with an immunosuppressive agent plus a lower dose of prednisolone or equivalent corticosteroid (&gt; or =0.1 mg/kg daily). MAIN OUTCOME MEASURES: Time to first recurrence of uveitis. RESULTS: Eyes that received the FA intravitreal implant experienced delayed onset of observed recurrence of uveitis (P&lt;0.01) and a lower rate of recurrence of uveitis (18.2% vs. 63.5%; P&lt; or =0.01) compared with SOC study eyes. Adverse events frequently observed in implanted eyes included elevated intraocular pressure (IOP) requiring IOP-lowering surgery (occurring in 21.2% of implanted eyes) and cataracts requiring extraction (occurring in 87.8% of phakic implanted eyes). No treatment-related nonocular adverse events were observed in the implant group, whereas such events occurred in 25.7% of subjects in the SOC group. CONCLUSIONS: The FA intravitreal implant provided better control of inflammation in patients with uveitis compared with systemic therapy. Intraocular pressure and lens clarity of implanted eyes need close monitoring in patients receiving the FA intravitreal implant.

Intrathecal analgesia and restrictive perioperative fluid management within enhanced recovery pathway: hemodynamic implications.

BACKGROUND: Intrathecal analgesia and avoidance of perioperative fluid overload are key items within enhanced recovery pathways. Potential side effects include hypotension and renal dysfunction. STUDY DESIGN: From January 2010 until May 2010, all patients undergoing colorectal surgery within enhanced recovery pathways were included in this retrospective cohort study and were analyzed by intrathecal analgesia (IT) vs none (noIT). Primary outcomes measures were systolic and diastolic blood pressure, mean arterial pressure, and heart rate for 48 hours after surgery. Renal function was assessed by urine output and creatinine values. RESULTS: One hundred and sixty-three consecutive colorectal patients (127 IT and 36 noIT) were included in the analysis. Both patient groups showed low blood pressure values within the first 4 to 12 hours and a steady increase thereafter before return to baseline values after about 24 hours. Systolic and diastolic blood pressure and mean arterial pressure were significantly lower until 16 hours after surgery in patients having IT compared with the noIT group. Low urine output (&lt;0.5 mL/kg/h) was reported in 11% vs 29% (IT vs noIT; p = 0.010) intraoperatively, 20% vs 11% (p = 0.387), 33% vs 22% (p = 0.304), and 31% vs 21% (p = 0.478) for postanesthesia care unit and postoperative days 1 and 2, respectively. Only 3 of 127 (2.4%) IT and 1 of 36 (2.8%) noIT patients had a transitory creatinine increase &gt;50%; no patients required dialysis. CONCLUSIONS: Postoperative hypotension affects approximately 10% of patients within an enhanced recovery pathway and is slightly more pronounced in patients with IT. Hemodynamic depression persists for &lt;20 hours after surgery; it has no measurable negative impact and therefore cannot justify detrimental postoperative fluid overload.