Search

Background. The purpose of our study was to analyze prognostic factors associated with mortality for patients with severe community-acquired pneumonia (CAP). Methods. We conducted a prospective multicenter study including all patients with CAP admitted to the intensive care unit during a 15-month period in 33 Spanish hospitals. Admission data and data on the evolution of the disease were recorded. Multivariate analysis was performed using the SPSS statistical package (SPSS). Results. A total of 529 patients with severe CAP were enrolled; the mean age (±SD) was 59.9 ± 16.1 years, and the mean Acute Physiology and Chronic Health Evaluation (APACHE) II score (±SD) was 18.9 ± 7.4. Overall mortality among patients in the intensive case unit was 27.9% (148 patients). The rate of adherence to Infectious Diseases Society of America (IDSA) guidelines was 5 7.8%. Significantly higher mortality was documented among patients with nonadherence to treatment (3 3.2% vs. 24.2%). Multivariate analysis identified age (odds ratio [OR], 1.7), APACHE II score (OR, 4.1), nonadherence to IDSA guidelines (OR, 1.6), and immunocompromise (OR, 1.9) as the variables present at admission to the intensive care unit that were independently associated with death in the intensive care unit. In 15 (75%) of 20 cases of Pseudomonas aeruginosa infection, the antimicrobial treatment at admission was inadequate (including 8 of 15 cases involving patients with adherence to IDSA guidelines). Chronic obstructive pulmonary disease (OR, 17.9), malignancy (OR, 11.0), previous antibiotic exposure (OR, 6.2), and radiographic findings demonstrating rapid spread of disease (OR, 3.9) were associated with P. aeruginosa pneumonia. Conclusions. Better adherence to IDSA guidelines would help to improve survival among patients with severe CAP. Pseudo monas coverage should be considered for patients with chronic obstructive pulmonary disease, malignancy, or recent antibiotic exposure. [ABSTRACT FROM AUTHOR]

The protein binding of itraconazole and fluconazole in the serum of patients with insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetes mellitus was investigated in vitro. The unbound percentage of itraconazole in patients with IDDM and NIDDM was significantly higher than that in healthy volunteers. In contrast, there were no significant differences in fluconazole protein binding. A negative correlation was established between itraconazole protein binding and albumin concentration, and a positive correlation with free fatty acid concentration. The existence of a larger percentage of unbound itraconazole in diabetes patients could imply a change in drug disposition and an alteration in the effect of the drug. This should be taken into consideration in long duration treatment, especially in view of the non-linear kinetics of itraconazole. [ABSTRACT FROM AUTHOR]

Background: Detecting Helicobacter pylori in fecal samples is easier and more comfortable than invasive techniques, especially in children. Thus, the objective of the present work was to detect H. pylori in feces from children by molecular methods as an alternative for diagnostic and epidemiological studies., Methods: Forty-five fecal samples were taken from pediatric patients who presented symptoms compatible with H. pylori infection. HpSA test, culture, real-time quantitative PCR (qPCR), fluorescence in situ hybridization (FISH), direct viable count associated with FISH (DVC-FISH), and Illumina-based deep-amplicon sequencing (DAS) were applied., Results: No H. pylori colonies were isolated from the samples. qPCR analysis detected H. pylori in the feces of 24.4% of the patients. In comparison, DVC-FISH analysis showed the presence of viable H. pylori cells in 53.3% of the samples, 37% of which carried 23S rRNA mutations that confer resistance to clarithromycin. After DAS, H. pylori -specific 16S rDNA sequences were detected in 26 samples. In addition, DNA from H. hepaticus was identified in 10 samples, and H. pullorum DNA was detected in one sample., Conclusion: The results of this study show the presence of H. pylori , H. hepaticus , and H. pullorum in children's stools, demonstrating the coexistence of more than one Helicobacter species in the same patient. The DVC-FISH method showed the presence of viable, potentially infective H. pylori cells in a high percentage of the children's stools. These results support the idea that fecal-oral transmission is probably a common route for H. pylori and suggest possible fecal-oral transmission of other pathogenic Helicobacter species.

Serum retinol-binding protein 4 (RBP4) has been proposed as a metabolic risk factor in obesity. We found that RBP4 levels also were associated with liver enzymes and cystatin C. Oxidant stress is a significant feature in obese children with greater values of RBP4 that can mediate the development of comorbidities., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: To examine vitamin D, parathyroid hormone, and serum calcium-phosphorus levels relationships to biomarkers of oxidative/nitrosative stress, inflammation, and endothelial activation, potential contributors for vascular complications in obese children., Study Design: Cross-sectional clinical study of 66 obese Caucasian children aged 7 to 14 years. Cardiovascular risk factors were assessed. Malondialdehyde and myeloperoxidase as measures of oxidative stress, and plasma nitrite+nitrate, urinary nitrate, and 3-nitrotyrosine as markers of nitrosative stress were measured. Adipocytokines, inflammatory molecules (high-sensitivity C-reactive protein, interleukin-6, and tumor necrosis factor-α), endothelial activation molecules (soluble intercellular adhesion molecule-1, soluble vascular cell adhesion molecule 1 [sVCAM-1]), E-selectin, and vascular endothelial growth factor were also investigated. Serum 25-hydroxy-cholecalciferol [25(OH)D], intact parathormone, and calcium-phosphorus levels were determined in these children and in a comparison group of 39 non-obese children., Results: Obese children had a significantly lower 25(OH)D level (P = .002) and a higher intact parathormone (P = .011) than non-obese children. Phosphorus and the calcium-phosphorus product were also significantly higher (P < .0001). Insufficient serum concentrations of 25(OH)D (<20 ng/mL) were detected in 5% of normal children and in 30% of the obese children. In the obese children with vitamin D insufficiency, malondialdehyde, myeloperoxidase, 3-nitrotyrosine, interleukin-6, and sVCAM-1 were substantially elevated. A partial correlation analysis showed an inverse relationship of 25(OH)D levels with 3-nitrotyrosine (r = -0.424, P = .001), and sVCAM-1 (r = -0.272, P = .032)., Conclusions: Insufficient 25(OH)D levels were detected in severely obese children with increased markers of oxidative/nitrosative stress, inflammation, and endothelial activation., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Objective: We evaluated the presence of oxidative stress in obese children without co-morbidities., Methods: The study population included 68 children (30 girls, 38 boys), between 6 and 14 years of age. The levels of markers of oxidative damage (malondialdehyde [MDA], and plasma carbonyl groups [CG]) and measures of antioxidant defense, such as the enzyme glutathione peroxidase (GPx) and low molecular scavengers (erythrocyte-reduced glutathione [GSH], alpha-tocopherol and beta-carotene) were determined. Children were categorized in groups by the standard deviation score of body mass index (SDS-BMI). Twenty children were non-obese (SDS-BMI< or =1.33), and the 48 obese children (SDS-BMI> or =2) were further divided into two groups: SDS-BMI> or =3 (22 children) and > or =2 SDS-BMI<3 (26 children)., Results: The levels of MDA and CG were significantly higher (p<0.05) in children with SDS-BMI> or =3. The GPx activity was increased, while the GSH concentration was lower in obese children compared with non-obese children (p<0.01). There were no differences in serum alpha-tocopherol and beta-carotene levels between groups. MDA was the sole marker of oxidative damage that was positively correlated with SDS-BMI, (r=0.35, p=0.015), and negatively with high-density lipoprotein cholesterol (HDL-C) (r=- 0.32, p=0.027). GPx was inversely related to total cholesterol (r=- 0.34, p=0.019). In multiple regression analysis, we confirmed that SDS-BMI and HDL-C were determinants of MDA., Conclusions: Severe childhood obesity is associated with oxidative stress. Thus, providing foods with high antioxidant capacity in addition to a hypocaloric diet is crucial for the treatment of obese children.

Community acquired pneumonia is still an important health problem. In Spain the year incidence is 162 cases per 100,000 inhabitants with 53,000 hospital admission costing 115 millions of euros per year. In the last years there have been significant advances in the knowledge of: aetiology, diagnostic tools, treatment alternatives and antibiotic resistance. The Spanish Societies of Intensive and Critical Care (SEMICYUC), Infectious Diseases and Clinical Microbiology (SEIMC) and Pulmonology and Thoracic Surgery (SEPAR) have produced these evidence-based Guidelines for the management of community acquired pneumonia in Adults. The main objective is to help physicians to make decisions about this disease. The different points that have been developed are: aetiology, diagnosis, treatment and prevention., (Copyright © 2005 Sociedad Española de Medicina Intensiva, Critica y Unidades Coronarias (SEMICYUC) and Elsevier España, S.L. All rights reserved.)

Background: The purpose of this study was to determine the incidence of candiduria in critically ill patients admitted to intensive care medical units (ICUs), to identify risk factors for candiduria and to assess the frequency distribution of different Candidaspp., Subjects and Methods: This was a prospective cohort observational and multicenter study. A total of 1,765 patients older than 18 years of age who were admitted for at least 7 days to 73 medical-surgical ICUs of 70 Spanish hospitals were included in the study. Urine cultures were performed once a week., Results: In 389 patients (22%), Candidaspp. in one or more urine samples were isolated. In the multivariate analysis, independent risk factors for candiduria included: age >65 years, female sex, length of hospital stay before ICU admission, diabetes mellitus, total parenteral nutrition, mechanical ventilation and previous use of antimicrobials. Candida albicanswas recovered in 266 cases (68.4%), followed by C. glabrata(32 cases, 8.2%) and C. tropicalis(14 cases, 36%). Previous use of antifungal agents was the only risk factor for the selection of Candidanon-albicans candiduria (OR 2.64, 95% CI 1.35-5.14, P=0.004). In-hospital mortality was 48.8% in patients with candiduria compared to 36.6% in those without candiduria ( P<0.001). Significant differences were also found for ICU mortality (38.% vs. 28.1%, P<0.001)., Conclusions: Twenty-two percent of critically ill patients admitted for more than 7 days in the ICU developed candiduria. C. albicanswas the most frequent causative pathogen. Previous use of antifungals was the only risk factor for the selection of Candidanon-albicans.

Background: Use of a large-bore nasogastric tube (NGT) and patient position are considered key factors in promoting gastroesophageal reflux (GER) and pulmonary aspiration in critically ill patients. The objective of this study was to determine the incidence of GER and pulmonary aspiration of gastric contents in mechanically ventilated (MV) patients using small-bore NGTs., Methods: We studied 30 patients on mechanical ventilation for acute respiratory failure who tolerated enteral nutrition through a small-bore NGT. Patients were randomly assigned to a group with (n = 16) or without (n = 14) a small-bore NGT and were maintained in a semirecumbent position during the study. GER and aspiration of gastric contents were assessed by a radioisotopic technique. Scans were done 24 hours after technetium-99m administration (n = 30). In 9 patients a dynamic scintigraphy was performed immediately after colloid administration, and samples of blood and tracheal and oropharyngeal secretions were obtained basally, 30 minutes, and 24 hours after technetium administration and analyzed for radioactivity using a gamma counter., Results: Both groups were similar in age, underlying diagnosis, number of days of mechanical ventilation at the day of study, and mortality. There were no GER reaching the oropharynx and aspiration of gastric contents in both groups., Conclusions: GER and aspiration of gastric contents were not detected in MV patients using small-bore NGTs and may be a simple measure to prevent ventilator-associated pneumonia.

A 44 year-old man with a type I Neurofibromatosis (NFI) and an intercostal mass is presented. By means of percutaneous fine needle aspiration punction under CT control, this tumor could be diagnosed of neurofibroma. It is important to remark not only the role of helical CT with anatomical reconstruction in the diagnosis of intercostal tumors, but also that intercostal location of neurofibromas has been rarely reported in the literature. Because of frequent association between NFI and neoplasms, it is always necessary to perform histological study of every new tumor that appears in the course of this entity.

We report on 9 patients where on a colon conduit has been constructed. Seven of them suffered from a bladder etrophy, one had a sacral teratoma and the remaining one a vesical rhabdomyoma. The latter two had undergone total cystectomy. This technique involves creation of a conduit with isolation of 10-15 cm of a loop of sigmoid colon. One of its ends is sutured and both ureters become reimplanted with an antireflux procedure. The other end is exteriorized through the skin. Thereafter, once any reflux or uretero-colonic stenosis has been ruled out, the cutaneous stoma is detached and anastomose to the sigmoid colon. Complete technique has been used on six patients. Three of them were operated on two stages with no complications. One patient received one uretero-ureteral anastomosis. Another one had an antireflux technique together with anastomosis between the colon conduit and the sigmoid colon in a one-stage procedure. This same patient had a continent reservoir created with a portion of stomach and the colon conduit. In three cases only the first stage of this operation has been performed and the skin stoma has not been closed because of persisting faecal incontinence. Currently 6 patients are continent (2 of them remain with occasional nocturnal incontinence). The remainder have still an open stoma. Renal function and acid-base balance are normal in all of these patients. Three of them are on bicarbonate support therapy.

Ureterocele is a congenital cystic dilatation of the intravesical segment of the ureter. As a consequence, the proximal ureter and renal pelvis become dilated and that results in renal-parenchymal pathological involvement. Management of this anomaly is still controversial. Among the therapeutical options there is a place for endoscopic punction. Our experience with 11 patients undergoing this treatment modality is reported. In all these cases endoscopic punction was the initial treatment. In 7 patients this technique was all that was needed. The technique of intravesical punction is described and its results are specified.

The serum protein binding of itraconazole and fluconazole, new azole antifungal agents, has been investigated in vitro, in serum from healthy volunteers and from patients with cancer. Protein binding was determined by ultrafiltration. Concentrations of both alpha 1-acid glycoprotein (AAG) and albumin (HSA) were measured in all serum samples. The serum protein binding of itraconazole was reduced in patients (96.02 +/- 1.41% vs 97.25 +/- 0.54%; p < 0.01) with respect to healthy volunteers. In contrast, fluconazole protein binding was increased in the same group of patients (22.96 +/- 3.60% vs 13.30 +/- 2.58%; p < 0.01). HSA levels in cancer patients were significantly decreased (p < 0.01) and AAG levels were found to be significantly elevated in patients with respect to control subjects (p < 0.05). A significant linear relationship between the bound/unbound concentration ratio of itraconazole and HSA (r2 = 0.3340; p < 0.01) was found. Similarly, a significant relation was established between the bound/unbound concentration ratio of fluconazole and AAG levels (r2 = 0.2235; p < 0.05). Thus, a weak association between the binding of these drugs and serum protein levels has been observed. It is concluded that both antifungal drugs show different protein binding behaviour in cancer patients.

Penbutolol is a beta-adrenoceptor antagonist that is extensively bound to alpha 1-acid glycoprotein (alpha 1-AGP), a protein that increases in inflammatory diseases thereby binding more drug in such conditions. Changes in serum binding can lead to modifications in the pharmacokinetics and pharmacodynamics of a drug, therefore, the central effect (as the anticonvulsant response) and brain uptake of penbutolol given intravenously to mice with experimental inflammation have been measured. A significant decrease of the central effect of penbutolol and its brain uptake was seen in diseased when compared with control animals (P less than 0.01). A parallel decrease in free fraction of penbutolol in diseased vs normal animals was detected. These results suggest that there is an increase in serum binding of basic drugs related to increments in alpha 1-AGP concentration, which reduces their central pharmacological effect.

The plasma protein binding of ketoconazole, an oral antifungal agent of a weak basic nature, was measured after the addition of the drug (10 micrograms.ml-1) to serum from 35 healthy individuals, ten patients with chronic renal disease and seven patients with hepatic cirrhosis. The percentage of free ketoconazole was markedly increased in patients with chronic renal disease and in patients with hepatic cirrhosis, when it was compared with the group of healthy volunteers (7.33 +/- 0.11 in renal patients; 6.12 +/- 1.43 in hepatic patients compared with 2.93 +/- 0.12 in healthy individuals). The binding ratio of ketoconazole in health and disease was significantly related to plasma albumin concentration, but not to plasma alpha 1-acid glycoprotein (AAG) concentration. Moreover, ketoconazole binds to isolated human serum albumin in a greater proportion but does not bind to isolated AAG indicating that human serum albumin is the major binding protein for this drug in plasma.

The incidence and clinical course of urinary tract infections in postmenopausal diabetic patients in comparison to non-diabetic women have been evaluated. All cases with former history of urinary instrumentation or underlying conditions favoring urinary infections were rejected. Urinary tract infection was present in 14.9 percent of postmenopausal diabetics versus 10.5 percent in the non-diabetics. The incidence of urinary tract infection in premenopausal women was 12.5 percent. Urinary pathogenes showed similar incidence rate in both groups: E. coli (41 versus 57 percent), P. mirabilis (20 versus 28 percent) and Klebsiella (11 versus 20 percent). Diabetic women showed a higher rate of sepsis and infection recurrence than non-diabetic (10.7 and 17.8 percent versus 2.6 and 2.6 percent, respectively). Severe impairment of renal function (plasma creatinine clearance > 2 mg/100 ml) was registered in 12.5 percent of postmenopausal patients with diabetes mellitus, but none of the non-diabetics suffered renal damage (p < 0.01).

A group of 50 children in the first year of life with vesicoureteric reflux (VUR) has been followed-up for a period of two-eleven years. VUR has been classified in four grades according to Hertz's criteria. Clinical evolution and renal scarring have been related to the degree of VUR. The absence of urinary tract infection (UTI) influences disappearance of the VUR grade 3 but does not influence the disappearance of VUR grade 2. There is a statistically significant correlation between renal scarring, the degree of VUR and renal growth. UTI influences renal growth in scarred kidneys with VUR grade 3. No scars have been seen in previously normal kidneys in the first radiological examination.