Septic Arthritis: Diagnosis and Treatment.

Septic arthritis must be considered and promptly diagnosed in any patient presenting with acute atraumatic joint pain, swelling, and fever. Risk factors for septic arthritis include age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, hip or knee prosthesis, skin infection, and immunosuppressive medication use. A delay in diagnosis and treatment can result in permanent morbidity and mortality. Physical examination findings and serum markers, including erythrocyte sedimentation rate and C-reactive protein, are helpful in the diagnosis but are nonspecific. Synovial fluid studies are required to confirm the diagnosis. History and Gram stain aid in determining initial antibiotic selection. Staphylococcus aureus is the most common pathogen isolated in septic arthritis; however, other bacteria, viruses, fungi, and mycobacterium can cause the disease. After synovial fluid has been obtained, empiric antibiotic therapy should be initiated if there is clinical concern for septic arthritis. Oral antibiotics can be given in most cases because they are not inferior to intravenous therapy. Total duration of therapy ranges from two to six weeks; however, certain infections require longer courses. Consideration for microorganisms such as Neisseria gonorrhoeae, Borrelia burgdorferi, and fungal infections should be based on history findings and laboratory results.

Evaluation of the Diesse Cube 30 touch erythrocyte sedimentation method in comparison with Alifax test 1 and the manual Westergren gold standard method.

The erythrocyte sedimentation rate (ESR) is a traditional nonspecific laboratory test used for the assessment of inflammation. Even if its usefulness is nowadays being largely debated, it is still considered a valuable laboratory test in selected clinical conditions, such as rheumatoid diseases, orthopedic infections and Hodgkin's lymphoma, and it can be used for the infectious, inflammatory, malignancies, and autoimmune diseases follow-up. The introduction of new methodologies on semi-automated and automated analyzers started about four decades ago and opened a new era of ESR analysis characterized by shorter assay time, use of (EDTA) undiluted blood, that increases sample stability and allows using a single sample for also other hematologic tests, and greater safety for laboratory personnel. In this context, the aim of this study was to evaluate the performances of new device Diesse Cube 30 touch, comparing it with Alifax Test 1 and with the gold standard Westergren method. The new Diesse Cube 30 touch for determination of the ESR shows a good correlation with the manual Westergren gold standard method in a shorter time, and in a standardized way, since all the phases of the test are automatized. The Diesse Cube 30 touch respect the manual gold standard method, displayed a small bias to confirm that the new automated test system tended to have a small bias for ESR values (mean positive bias +0.2 mm/h). The findings of the present study show that the Diesse Cube 30 touch Westergren-based method can be a valid alternative in laboratory analysis for the determination of ESR.

La velocidad de sedimentación globular en la práctica médica / The globular sedimentation velocity in the clinical practice

La velocidad de sedimentación globular es una de las pruebas de laboratorio más usadas en la práctica clínica. La VSG varía en diferentes situaciones, tanto fisiológicas como en enfermedad. Sin embargo, sus variaciones son de poco valor para el diagnóstico de enfermedades infecciosas, neoplásicas e inmunológicas, pero es de utilidad para el seguimiento y tratamiento de algunas enfermedades. Una VSG normal tiene valor, pero una VSG anormal debe ser ponderada

Does erythrocytic sedimentation rate have a circadian rythn?

El aumento de la velocidade de sedimentación globular (VSG) es la expresión sumaria de los cambios en la composición protéica del suero inducidos por la interleucina-1 (IL-1) como parte de la llamada "respuesta de fase aguda". Dado que la principal manifestación clínica de esta "fase aguda", la fiebre, suele ser mayor en las tardes y en las noches que en las mañanas, se investigó la posibilidad de que también los cambios en la VSG pudieron variar en forma circadiana. En 30 individuos normales y en 30 pacientes con fiebre se midió la VSG a las 7:00, a las 16:00 y a las 22:00 hrs. del mismo día. En los individuos normales los valores de VSG fueron de 6.8 ñ 3.1,7.4 ñ 2.5 y 7.8 ñ 2.5 mm/hora respectivamente (X ñ desviación estándar); las diferencias entre los tres horarios no fueron significativas. Los pacientes con fiebre tuvieron VSG a las 7:00 hrs. de 49.9 ñ 7.8 mm/hora, a las 15:00hrs. de 52.4 ñ 6.5 mm/hora y a las 22:00 de 55.7 ñ 7.2 mm/hora. La diferencia entre los valores obtenidos por el grupo de pacientes entre la mañana y la tarde no fue significativa; en cambio la VSG de la mañana fue significativamente menor que la de la noche (p<0.001> y ésta, significativamente mayor que la de la tarde (p<0.05). Puesto que todos los valores obtenidos en el grupo de enfermos con fiebre fueron anormales y todos los de los sujetos sanos fueron normales, el hallazgo no tiene ninguna implicación clínica, pero ilustra la posibilidad de que la producción de IL-1 en la fiebre o sus efectos sobre la síntesis de proteínas de fase aguda, no sean uniformes durante el día sino que sufran variaciones probablemente por influencia de otros ritmos circadianos fisiológicos

Flow cytometric measurement of rat lymphocyte subpopulations after burn injury and burn injury with infection.

Increased infection rates in burned patients may result from a disproportionate increase in the suppressor subpopulations. Measurement of lymphocyte subpopulations is difficult in burned patients because gradient-purified cells are contaminated by nonlymphoid cells. The accuracy of flow cytometric subpopulation analysis was improved by restricting (gating) the analysis to cells with light-scatter intensity typical of lymphocytes. Blood was obtained 48 hours after burn from rats receiving no burns, 30% scald burns, or burns seeded with Pseudomonas aeruginosa to induce infection. Subpopulations were identified by monoclonal antibodies to T-lymphocyte antigens. Gating increased the values obtained for most subpopulations, but the relative differences between groups were unchanged. Burned and infected animals, but not animals burned only, had a decreased ratio of helper to suppressor lymphocytes (HSR) relative to control. A decreased HSR correlated with sepsis, but not with infection susceptibility. This suggests that a decrease in HSR may be a result of infection rather than a cause of susceptibility to infection.

Erythrocyte sedimentation rate/zeta sedimentation rate.

Sedimentation rates are a vital laboratory adjunct to the clinical skills of the emergency physician. A patient with an elevated rate in the emergency department needs further evaluation and appropriate referral. If the test is markedly elevated, there is a 95 per cent chance of an infectious, inflammatory, or neoplastic process as the underlying cause.

[The sigma sedimentation rate in rheumatoid arthritis: comparative study of the erythrocyte sedimentation rate]. / La sigma-vs nell'artrite reumatoide: studio comparativo con la velocità di eritrosedimentazione (VES).

The authors studied 54 patients suffering from rheumatoid arthritis by sigma SR method. The sigma SR, unlike the ESR, often reveals inflammatory activity in patients suffering from possible or probable rheumatoid arthritis and is very useful to diagnose the disease. The sigma SR constantly increases when the disease is in active period, unlike the ESR, in patients affected by classic or definite rheumatoid arthritis. The authors conclude the sigma SR determination is useful in every case of rheumatoid arthritis, especially when the disease is at beginning and is difficult to be diagnosed, i.e. cases of possible and probable rheumatoid arthritis, and when clinical and biohumoral picture disagree.

Controversies regarding giant cell (temporal, cranial) arteritis.

It is important to establish the diagnosis of temporal arteritis because the disease is treatable; treatment may prevent blindness and even death. Temporal arteritis usually occurs in people older than 51 years of age, although very rarely, histologically documented disease occurs in younger people. The onset may be occult, so that there are few findings. A multitude of signs and symptoms may occur such as fever, headaches, malaise, weight loss, anemia, stroke, cranial nerve palsies, polymyalgia rheumatica, aortitis and other large vessel involvement. The eye may suffer from ischemic optic neuropathy (anterior or posterior), central or cilio-retinal arterial occlusion, ophthalmic artery ischemia, or extraocular muscle palsies. An arterial biopsy showing giant cell arteritis establishes the diagnosis. However, a negative biopsy does not rule out the disease because of the occasional presence of skip areas. Arteriography has only rarely yielded a positive temporal artery biopsy when the initial biopsy done elsewhere was negative. As a diagnostic parameter, the erythrocyte sedimentation rate is nonspecific, being elevated in diseases other than temporal arteritis and sometimes being falsely lowered by technical factors. Furthermore, the temporal artery biopsy is occasionally positive despite a normal erythrocyte sedimentation rate. Treatment is aimed at relieving the patient's symptoms and normalizing the erythrocyte sedimentation rate. Because of the wide spectrum of clinical and laboratory finding in temporal arteritis, no one specific treatment regimen with systemic corticosteroids works for all patients. Temporal arteritis is a well known disease of the elderly which ir rarely fatal but results in significant visual morbidity (Hinzpeter & Naumann, 1976; Spencer & Hoyt, 1960). Since Hutchinson's (1890) description, more than a thousand articles have been written on the subject (Cohen & Smith, 1974). Despite this, many unanswered questions and controversies remain concerning the diagnosis, prognosis and treatment of temporal arteritis. My goal is to review these questions and areas of controversy.

Sigma SR, a new method of measuring erythrocyte sedimentation rate. Its value in studying the action and interactions of non-steroidal anti-inflammatory agents.

Sigma SR is a new method of measuring erythrocyte sedimentation rate (ESR) and is characterized by an unvarying haematocrit, routinely corrected to 35%, and the sum of 4 sedimentation levels at 20, 30, 40, and 50 minutes. Two studies were carried out in patients with inflammatory arthritic disorders; the first in 25 patients treated with 1800 mg ibuprofen daily for 7 days, and the second in 31 patients treated either with indomethacin alone (150 mg/day) or combined with aspirin (1500 mg/day) for 5 days. In addition to the assessment of clinical parameters, the ESR was measured using the classical Westergren and the sigma SR methods. The results showed that there were little or no changes from baseline values in the ESR using the Westergren method. With the sigma SR method, however, statistically significant changes were recorded after treatment and these correlated with the clinical findings which demonstrated the anti-inflammatory action of ibuprofen and the reduction in activity of indomethacin by aspirin.

Erythrocyte-sedimentation rate before and after in-vitro defibrination: A rapid and simple method for increasing its specificity.

The erythrocyte-sedimentation rate (E.S.R.) was measured before and after in-vitro defibrination in 107 patients with high E.S.R.S. The reduction in E.S.R. on defibrination correlates with the fibrinogen level while the post-defibrination E.S.R. correlates with the globulin level. The ratio between the post-defibrination E.S.R. and the pre-defibrination, or standard, E.S.R. varies with different diseases; it is highest when an excess of globulins is the cause of the high E.S.R. and lowest when there is an excess of fibrinogen. Measurement of the post-fibrination E.S.R. is quick and easy and may help in the initial investigation of a high E.S.R.

The erythrocyte sedimentation rate in the newborn period.

Determination of the erythrocyte sedimentation rate in capillary blood can be of value in identifying neonates with infection. The normal values for the method described here range from 1 mm/l hour at 12 hours of age to 17 mm/l hour at 14 days of age. Most noninfected neonates with moderate to severe RDS or with other serious illness had values well within the normal range. Infected patients had marked elevations, and the majority of values returned to normal with clinical improvement. Coombs-positive ABO hemolytic disease was also responsible for elevated values. In about half of the infected patients the rise was not seen until 24 to 48 hours after clinical symptoms first appeared. The ESR can be useful in the nursery as a preliminary step in the laboratory evaluation of the sick neonate. Serial determinations may be of aid in identifying the infected infant when the results of bacteriologic cultures are obscured by antibiotic therapy.