Microbial quality of commercial 'Golden Delicious' apples throughout production and shelf-life in Lleida (Catalonia, Spain)

'Golden Delicious' apples taken from different points throughout the production chain and shelf-life were analysed for Enterobacteriaceae, thermotolerant coliforms, E. coli, E. coli O157:H7 and Salmonella spp. A total of 36 samples picked up in the orchard, 36 after storage and handling in the packinghouses and 144 from different retail stores were analysed using standardised techniques. Enterobacteriaceae counts were very variable. Pantoea spp. was the main genera isolated. The percentage of samples with thermotolerant coliforms was 16.6%, 22.2% and 10.4% after harvest, after handling in the packinghouse and in the stores, respectively. Strains belonging to Citrobacter, Enterobacter, Klebsiella and Escherichia were isolated. Three samples coming from orchards, five from the packinghouse and two from retailers harboured E. coli. However, none of the E. coli strains isolated had the virulence genes that are pathogenic for humans. None of the samples was Salmonella positive. This is the first study regarding microbial safety of fresh apples in the European Union (EU).

Factores pronósticos de mortalidad relacionados con el estado nutricional en ancianos hospitalizados

BACKGROUND AND OBJECTIVE

The proportion of elderly patients hospitalized in acute care wards has progressively increased. Patients with a decreased functional status are prone to have malnutrition which negatively affects their prognosis and increases mortality. However, it is unclear whether functional and nutritional status are independent risk factors of mortality.

PATIENTS AND METHOD

We investigated the relation between functional status (Katz index) and nutritional parameters and the incidence of mortality in a prospective, observational study of a cohort of elderly patients who were admitted to an internal medicine ward. Prevalence of malnutrition upon admission and cumulative incidence rate of in-hospital mortality were computed. Also, potential nutritional and functional prognostic factors for in-hospital mortality were identified by multiple logistic regression.

RESULTS

The prevalence of malnutrition in 105 patients included in the cohort was 57.1% (95 percent confidence interval, 47.1% to 66.8%). The incidence of in-hospital mortality was 14.3% (95 percent confidence interval, 8.2% to 22.5%). After adjustment, independent prognostic factors for in-hospital mortality were: a high level of functional dependence (F and G categories of Katz index, OR 6.1; 95 percent confidence interval, 1.4 to 26.3), diminished levels of serum transferrin (each decrement of 1g/L, OR 8.3; 95 percent confidence interval, 3.4 to 20.0) and lymphocyte cell counts (each decrement of 0.5 x 10(9) cells/L, OR 2.3; 95 percent confidence interval, 1.5 to 3.5).

CONCLUSIONS

The prevalence of malnutrition and the incidence of mortality are very high in the hospitalized elderly. In our cohort, decreased serum transferrin and lymphocyte cell count, and an increased level of functional status were associated with an increased risk of in-hospital mortality. Given the high prevalence of geriatric patients in acute care hospitals, strategies to promote an adequate nutrition may reduce the risk of death.

[Prognostic factors associated with community-acquired aspiration pneumonia]

BACKGROUND

Aspiration pneumonia (AP) represents about 5-24% of community-acquired pneumonias. This condition mainly affects elderly patients and causes a high mortality. Our objective was to quantify the AP mortality rate and to identify prognostic factors upon patients admission.

PATIENTS AND METHOD

We underwent a retrospective observational study of a cohort of AP patients admitted to a tertiary care hospital during a 29 months period. The in-hospital mortality rate was calculated. To identify prognostic factors, basal characteristics of patients as well as their clinical presentation and complementary tests performed on admission were studied and analyzed by univariate and multivariate techniques. Odds ratios and 95% confidence intervals were estimated.

RESULTS

Thirty six out of 105 admitted patients with AP died (cumulative mortality incidence rate 34%, 95% CI 25-44%). In the univariate analysis, demographic, clinical and complementary test variables were associated with mortality. Final logistic model revealed the following independent variables: living in a nursing home (OR = 3.4; 95% CI 1.1-10.9), high degree of dependence (OR = 0.3; 95% CI, 0.1-0.9), body temperature (OR = 0.5 per Celsius degree; 95% CI, 0.3-1.0), serum creatinine levels (OR = 2.2 per mg/100 ml; 95% CI, 1.2-4.1) and LDH serum concentrations (OR = 1.5 per 100 IU/L; 95% CI, 1.1-2.0).

CONCLUSIONS

The mortality of community-acquired AP is very high. In addition to clinical and biological parameters on admission such as body temperature and LDH and creatinine serum concentrations, living in a nursing home and having a high degree of dependence for the basic daily activities were identified as independent prognostic factors. An in-depth knowledge of prognostic factors related to pre-admission care and assistance is needed to decrease the mortality in these patients.

[Effectiveness of a group therapy intervention to quit smoking. Randomized clinical trial]

BACKGROUND

Group therapy is a widely used technique for the treatment of tobacco, alcohol and other toxic addictions. Nevertheless, its effectiveness for smoking cessation remains to be established. Our objective was to evaluate the relative effectiveness of a group intervention versus an individual intervention for smoking cessation.

METHOD

Randomized clinical trial of 106 smokers wishing to quit their addiction, who were assigned to two types of intervention: Short Individual Intervention (SII) and Group Intervention (GI). Nicotine patches were administered as supplemental therapy when needed in both instances. Results were assessed by intention to treat analysis.

RESULTS

Although smoking cessation rates decreased in parallel with longer follow-up periods in each intervention group (from 39.6 to 26.4% and from 22.6 to 15.1% for GI and SII groups, respectively, at 3 and 6-months), the relative effectiveness was similar during both periods and there was no better response to any intervention at 3-months (relative risk [RR] = 1.75; CI95%, 0.96-3.18) and at 6-months (RR = 1.75; CI95%, 0.80-3.82). Compliance with GI was low and less than 60% of smokers attended to 5 out of 7 GI sessions.

CONCLUSIONS

Group intervention (GI) is not more effective than short individual intervention to quit smoking. However, this fact could be due to the low compliance observed with regard to smokers' attendance to GI sessions.

[Antimicrobial use in Spanish hospitals (EPINE, 1990-1999)]

BACKGROUND

Monitoring of antimicrobial use and knowledge of prescription habits are some of the strategies recommended to contain the resistance to antimicrobials in hospitals.

METHOD

We analyzed a series of 10 annual studies of prevalence during the period 1990-1999 (EPINE project) in Spanish hospitals. Estimates of antimicrobial use were calculated as the percent distribution of every antimicrobial related to the overall antimicrobials prescribed.

RESULTS

Among 484,013 hospitalized patients, 34 to 36% were receiving antimicrobials (antibiotics > 90%). Amoxicillin-clavulanate use increased from 3.8% in 1990 up to 14.8% in 1999 (P < 0.01). Significant increases were also observed in the use of carbapenems (0.9 to 2.7%; P < 0.01), glycopeptides (1.7 to 3.7%; P < 0.01) and quinolones (8.5 to 11.3%; P < 0.01) though to a lesser degree. Conversely, the use of aminoglycosides decreased over the decade studied (15.8 to 9.4%; P < 0.01).

CONCLUSIONS

Even though the use of antimicrobials has increased over the last decade, current figures are within the ranges observed in other countries. The pattern of antibiotics use has changed during this period: while the use of aminoglycosides decreased, that of -lactams plus -lactamase inhibitors, quinolones and carbapenems increased.

[Etiology of hospital-acquired infections in Spanish hospitals (EPINE, 1990-1999)]

BACKGROUND

Clinical and demographic characteristics of patients, their interaction with pathogens and antimicrobial therapies are prompting changes in the epidemiology of hospital-acquired infections (HI). The knowledge of the etiology of hospital-acquired infections is valuable for the treatment of infected patients and for the prevention of HI.

PATIENTS AND METHOD

We analyzed a series of 10 annual prevalence studies during the period 1990-1999 (EPINE project) in Spanish hospitals. Estimate of prevalence of infection was calculated by means of the percent distribution of every organism regarding overall identified organisms and infections.

RESULTS

40,550 HI were identified among 484,013 patients (HI prevalence = 8.4%; 95% CI, 8.3-8.5%). Gram-positive organism predominated steadily in bloodstream and surgical wound infections, while gram-negative bacilli predominated in respiratory and urinary tract infections. There was an increase in HI infections by Acinetobacter baumannii (from 1.9% in 1990 to 3.6% in 1999; P < 0.001) and Candida albicans (from 2.4 to 3.2%; P < 0.001), as well as an increase in both HI and community-acquired infections by methicillin-resistant Staphylococcus aureus [HI: from 4.7 to 40.2% (P < 0.001); community-acquired: from 2.7 to 15.6% (P < 0.001)].

CONCLUSIONS

We observed some changes in the etiology of infections over the last decade: rates of methicillin-resistant S. aureus hospital-acquired and community-acquired infections increased steadily and their initial rates multiplied by 8 and 6, respectively. Rates of HI caused by yeasts and A. baumannii increased also.

[Diagnosis and epidemiological investigation of an outbreak of Clostridium perfringens food poisoning]

OBJECTIVE

Clostridium perfringens is a classical agent of food-borne disease but because of the mildness and self-limiting nature of the illness, many cases are undiagnosed. This study describes the investigation of an outbreak of diarrhea due to C. perfringens in a public restaurant.

METHODS

An epidemiological survey was performed and the restaurant was inspected. The specific attack rates for the items on the menu were calculated. Odds ratios were calculated to investigate the independent association between each item and the disease using a logistic regression model. Investigation of C. perfringens toxin in the feces of four symptomatic subjects and one exposed but asymptomatic subject was performed by the reverse passive latex agglutination test.

RESULTS

The overall attack rate was 70.8%. The main symptoms were diarrhea (100%) and abdominal pain (94%). Significant differences were found in specific attack rates for consumption of different menu items. However, the independent contribution of each item was significant only for consumption of "ravioli with cheese sauce". Fecal detection of C. perfringens enterotoxin was positive in the four symptomatic subjects and negative in the exposed but asymptomatic subject.

CONCLUSIONS

The overall attack rate in this outbreak was high. The clinical symptomatology was similar to previously published data. The epidemiological analysis revealed "ravioli with cheese sauce" to be responsible for transmission of the disease and clinical investigation together with the fecal enterotoxin detection established C. perfringens as the etiological agent.

Predicting tuberculosis among HIV-infected patients admitted to hospital: comparison of a model with clinical judgment of infectious disease specialists

The aim of this prospective study was to compare a model based on clinical variables with the clinical judgment of infectious disease specialists to identify HIV-infected patients requiring isolation at admission in order to prevent the nosocomial transmission of tuberculosis. Clinical, epidemiological and radiological variables available at admission were recorded for 362 admissions of 274 HIV-infected patients. Using multiple logistic regression analysis, a model to identify patients with tuberculosis was developed based on four clinical variables (node enlargement, constitutional symptoms, intravenous drug use, history of previous correct therapy for tuberculosis) and a positive auramine sputum stain. This model was applied to each of the 362 admissions studied. The decision made by the infectious disease specialist at admission was also recorded. The results indicate that application of the model would have allowed physicians to correctly identify and isolate 24 of 27 patients with tuberculosis, while 5.4 patients without tuberculosis would have been unnecessarily isolated for every patient with tuberculosis. The results for the infectious disease specialists were slightly better, with 26 of 27 patients with tuberculosis being identified and isolated correctly and only 3.2 patients being isolated unnecessarily for every patient with tuberculosis. Thus, a simple model based on clinical variables may be useful in helping physicians identify tuberculosis carriers among HIV-infected patients, but infectious disease specialists are able to identify them more efficiently.

Phenyl-bridging in the 2-phenylethyl radical. A molecular orbital study

Density functional theory at the UB3PW91/6-31G(d.p) level on the open and bridged forms of the 2-phenylethyl radical are reported here together with activation energies and calculated rate constants for rearrangement of the bridged to the open radical. In addition, the effect of substituents on the aryl ring upon the relative energies, activation energies, and rate constants for rearrangement from the bridged to open forms are presented. Para-substituents include CH3, CF3.CN, CHO.OH, SH, O-, S-, and NO. The parent bridged radical is found to be 10.1 kcal/mol higher in enthalpy than the open form. The activation energy for conversion of the bridged to open radical is 3.96 kcal/mol. Para-substitution by CN or CHO significantly lowers the difference in energy between the species, while substitution by NO renders the bridged form more stable. Para-substitution by CN or CHO coupled with substitution with CN in the ortho-positions makes the open and bridged radical approximately equivalent in energy.

Enantioselective synthesis of fluorinated alpha-amino acids and derivatives in combination with ring-closing metathesis: intramolecular pi-stacking interactions as a source of stereocontrol

[reaction: see text]. Hydride reduction of C=N bonds stereocontrolled by intramolecular pi-stacking interactions of 1-naphthylsulfinyl and N-aryl groups, nonoxidative Pummerer rearrangement, and ring-closing metathesis are efficiently combined in a highly stereoselective entry to enantiomerically pure cyclic and acyclic fluorinated beta-amino alcohols and alpha-amino acid derivatives, respectively.

Risk factors for nosocomial transmission of multidrug-resistant tuberculosis due to Mycobacterium bovis among HIV-infected patients

OBJECTIVE

To identify risk factors for transmission of multidrug-resistant tuberculosis (MDR-TB) among hospitalized human immunodeficiency virus (HIV) infected patients exposed during a nosocomial outbreak.

DESIGN

Case control study. Cases were HIV-infected patients with MDR-TB due to Mycobacterium bovis (MDR-TBMb) who acquired the disease after exposure to an MDR-TBMb patient in an hospital ward. Controls were HIV-infected patients exposed to a case of MDR-TBMb in an hospital ward but who did not develop MDR-TBMb during the follow-up.

RESULTS

Nineteen cases and 31 controls were included. CD4 cell counts were significantly lower among cases. Exposure in the infectious diseases ward or exposure to the index patient were associated with development of MDR-TBMb, while exposure during a single-room hospital stay and exposure in the respiratory isolation ward were associated with non-development of MDR-TBMb. A multiple regression logistic model showed that only a CD4 cell count below 50/microL and exposure to the index patient increased the risk of developing MDR-TBMb (P < 0.05). Hospitalization in a single room seemed to protect HIV-infected patients from developing nosocomial MDR-TBMb (P = 0.052).

CONCLUSIONS

Over classic risk factors, such as length of exposure or sharing a room with a case, severe immunosuppression independently increases the risk of MDR-TB transmission in the context of a nosocomial MDR-TB outbreak among HIV-infected patients. This information must be considered in the management of tuberculosis outbreaks. Patients with CD4 cell counts below 50/microL should be the principal group targeted for prevention strategies in nosocomial outbreaks.

Cytogenetic and fluorescence in situ hybridization studies in four cases of plasma cell leukemia

We present a cytogenetic and fluorescence in situ hybridization (FISH) study, using centromeric probes for chromosomes 3, 7, 11, and 18, TP53 gene (17p13), and RB-1 locus (13q14) DNA probes, in four cases of plasma cell leukemia (PCL). Among the four cases, three presented monosomy of the RB-1 locus and one monoallelic deletion of the TP53 gene. The present report shows the usefulness of the FISH technique to detect abnormalities not previously observed by conventional cytogenetics.

Semiquantitative culture of subcutaneous segment for conservative diagnosis of intravascular catheter-related infection

BACKGROUND

Sensitivity and negative predictive values of combined surface cultures (skin and hub) are high in the presumptive diagnosis of catheter-related infection, but specificity and PPVs are poor. The purpose of the study was to evaluate the yield of the semiquantitative culture of the subcutaneous segment in the diagnosis of colonization of the catheter tip without removal of the catheter.

METHODS

A prospective study was performed in 124 nontunneled central venous catheters that were removed because of suspected infection or the end of therapy. Catheter colonization was considered if >15 colony-forming units (CFU) in the roll procedure or > 1,000 CFU in the quantitative Cleri procedure were recovered from the tip cultures ("gold standard"). Before removing the catheter, a semiquantitative culture of skin surrounding the point of insertion, a semiquantitative culture of the subcutaneous segment (after removing the catheter only 2 cm), a semiquantitative cultures of the hub, and a pareated quantitative blood culture were performed. Receiver operating characteristic curves were calculated to estimate the cutoff points, and a culture was considered positive when CFUs were > or =15, > or =15, and > or =5 for skin, hub, and subcutaneous segment cultures, respectively.

RESULTS

Catheter colonization was detected in 51 catheters. The mean duration of catheterization was 14 +/- 8 days, and the rates of incidence of tip colonization and bacteremia were 2.9 per 100 catheter days and 1.2 per 100 catheter days, respectively. Sensitivity of skin, subcutaneous, and hub cultures analyzed individually were < or =61%; however, specificity and positive predictive values (PPVs) of subcutaneous segment cultures were significantly higher than skin cultures (94% and 88.5% vs 71.6% (p = .001) and 62% (p = .014), respectively). Sensitivity of the combined skin and hub cultures and of the combined subcutaneous segment and hub cultures were similar: 86.2% and 84.3%, respectively; however, specificity and PPVs of this latter combination were significantly higher than former: 82% and 78.1% vs 59.7% (p = .008) and 61.9% (p = .07), respectively. The likelihood ratio of a positive test for the combined subcutaneous segment and hub culture was 4.68, and only 2.13 for the combined skin and hub culture.

CONCLUSIONS

These results indicate that the combined subcutaneous segment and hub culture constitutes an easy, effective procedure for the conservative diagnosis of catheter colonization.

Antimicrobial susceptibility profiles of oropharyngeal viridans group streptococci isolates from cystic fibrosis and non-cystic fibrosis patients

The antimicrobial susceptibility profile of 77 oropharyngeal viridans streptococci isolates from 34 cystic fibrosis (CF) patients and 58 isolates from 43 healthy non-CF patients were studied by the E-test and the standard disk diffusion methods. Overall penicillin and cefotaxime resistances (intermediate plus resistant isolates) were significantly higher (p < 0.05) among CF isolates (72.7% and 45.5%, respectively) than among non-CF isolates (51.7% and 15.5%, respectively). No significant difference was observed in overall (intermediate plus resistant) erythromycin resistance rates, although high-level erythromycin resistance (> or =32 microg/mL) was more frequently found in CF isolates (24.6%) than in non-CF isolates (12.1%). An unexpected high percentage of isolates showed low level erythromycin resistance (MIC range, 0.5-15 microg/mL): 41.5% in cystic fibrosis and 46.5% in non-CF isolates. No significant differences were observed regarding the percentage of colonized patients with at least one penicillin-resistant isolate. On the contrary, colonization with cefotaxime (p < 0.001) or erythromycin (p = 0.014) resistant isolates were significantly more prevalent in CF patients. Similar tetracycline and chloramphenicol resistance rates were observed for both groups. Viridans isolates resistant to a single antibiotic were more prevalent among non-CF patients and multiple resistance was higher among CF patients. Prior antibiotic exposure could result in differences in beta-lactam resistance and colonization rates with resistant isolates between both groups. None of the non-CF patients was previously treated with antimicrobials for a period of three months before sampling. In contrast, 94.1% of CF patients were treated with antimicrobials within the same period; 65.6% with beta-lactam antibiotics. Patients with CF disease, frequently exposed to antimicrobials, may be a reservoir of viridans streptococci isolates with resistance determinants, particularly to beta-lactam antibiotics.

Intraepithelial lymphocytes and coeliac disease: permanent changes in CD3-/CD7+ and T cell receptor gammadelta subsets studied by flow cytometry

Permanent changes in intestinal intraepithelial lymphocytes have been observed in coeliac patients. The aim of this investigation was to study small intestinal intraepithelial lymphocytes by using flow cytometry and to evaluate its diagnostic value in coeliac disease. Three-colour flow cytometry analyses were performed on isolated epithelial cells of 117 intestinal biopsies obtained from 113 children (54 coeliac disease, 4 other enteropathies, 18 Helicobacter pylori associated gastritis and 37 normal controls). A multiple logistic regression model was developed to select the best intraepithelial lymphocytes subset predictor of coeliac disease. Coeliac patients had significant higher levels of T cell receptor gammadelta intraepithelial lymphocytes than control patients (p < 0.01), H. pylori patients (p < 0.01) and other enteropathies (p < 0.05). The density of CD3-/CD7+ intraepithelial lymphocytes, a intraepithelial lymphocyte subset poorly characterized by immunohistochemical methods, was significantly lower in coeliac patients than in the control group (p < 0.01). H. pylori group (p < 0.01) and other enteropathies (p < 0.01). Both changes remained altered independent of the coeliac patient's diet. The data were used on a logistic regression analysis in order to calculate sensitivity [94.4%; 95% confidence interval (CI) 83.7-98.6%], specificity (94.9%; 95% CI 84.9-98.7%) and likelihood ratio for a positive test 18.5 (95% CI 6.1-55.8) in the diagnosis of coeliac disease.

CONCLUSION

Changes in T cell receptor gammadelta and CD3-/CD7+ intraepithelial lymphocytes subsets are permanently observed in paediatric coeliac disease. Their assessment, by three-colour flow cytometry on routine diagnostic biopsies, permits a better characterization of coeliac enteropathy and represents a valuable procedure to identify coeliac patients with different clinical presentations.

Outbreak of a multiresistant Klebsiella pneumoniae strain in an intensive care unit: antibiotic use as risk factor for colonization and infection

An observational study was undertaken to describe a nosocomial outbreak caused by multiresistant Klebsiella pneumoniae (MRKP). Ten patients in the pediatric intensive care unit (ICU) at a hospital in Madrid were colonized by or infected with MRKP from October 1997 to April 1998. Thirty-two patients with MRKP-negative surveillance cultures who were admitted to the ICU during the outbreak period were selected as control patients. Random amplified polymorphic DNA analysis of MRKP isolates revealed patterns that were indistinguishable from each other. After identification of colonized patients by surveillance cultures and implementation of standard and contact precautions, the outbreak was controlled. An age <12 weeks (odds ratio [OR], 13.1) and previous treatment with third-generation cephalosporins and aminoglycosides (OR, 31.2) were independently associated with MRKP colonization and/or infection. Individual exposure to antibiotics, irrespective of other clinical determinants, is a risk factor for MRKP acquisition. Screening high-risk patients during outbreaks and reducing the use of third-generation cephalosporins and aminoglycosides contribute to the control of these epidemics.

Quantifying excess length of postoperative stay attributable to infections: a comparison of methods

To quantify the net effect of deep surgical site infection (DSSI) on postoperative stay (POS) among patients who had undergone open heart surgery, and to assess the comparability of two methods, two observational studies were conducted: one on a retrospective cohort of 701 operated patients, and the other on a cohort of 31 infected patients versus a cohort of uninfected patients, with 1:1 matching. In addition to DSSI, a further three factors were identified by multivariate analysis as independent POS-related predictor variables. After internal validation of the multivariate model, excess POS attributable to DSSI amounted to 20.7 days (95% confidence interval [CI] 16.7-24.9). In contrast, excess length of stay attributable to DSSI among the matched pairs who survived infection (22) totaled 14.3 days (95% CI 3.2-25.4) and 26.5 days (mean and median differences). Multivariate techniques may prove a more appropriate and reliable analysis than matched-pair comparisons for the purpose of evaluating the extra stay and cost attributable to the nosocomial infections.

Nosocomial transmission of Mycobacterium bovis resistant to 11 drugs in people with advanced HIV-1 infection

BACKGROUND

Since 1990, several nosocomial outbreaks of multidrug-resistant (MDR) tuberculosis have occurred, none of which have involved Mycobacterium bovis. We describe an epidemic of nosocomial and primary MDR M bovis tuberculosis from December, 1993, to February, 1995, among HIV-1-infected patients in a district of Madrid.

METHODS

We undertook genetic characterisation of the M bovis strain and investigated its presence in a tuberculosis epidemic in a Madrid hospital in a case-controlled study. We assessed 19 cases diagnosed with MDR tuberculosis due to M bovis during the study period. For the control group, we randomly selected 33 patients with HIV-1 infection and isolation of a strain of M tuberculosis susceptible to isoniazid, rifampicin, or both, who were treated in Ramón y Cajal Hospital. Infection-control policies and practices were implemented.

FINDINGS

We detected 19 cases in HIV-1-infected patients of primary MDR tuberculosis produced by M bovis resistant to 11 antituberculosis drugs. We found phenotypic and genotypic similarities in the strains of M bovis. In the case group, the index case and two other cases had had previous contact with another hospital that had had an MDR tuberculosis outbreak. All patients died after a mean of 44 days (range 2-116), despite multidrug treatment with first-line and second-line antituberculosis drugs. The cases with M bovis MDR tuberculosis were significantly more likely than controls to have been admitted to a hospital ward at the same time as patients already infected with MDR tuberculosis during the 10 months before their diagnosis (adjusted odds ratio 94.6 [95% CI 9.4-956.3], p < 0.0001). Advanced HIV-1 immunosuppression was associated with the development of MDR tuberculosis. Implementation of control measures stopped the epidemic.

INTERPRETATION

An M bovis primary MDR tuberculosis epidemic that cannot be treated effectively and with high mortality has emerged in Europe and has been transmitted between hospitals.

Cytogenetic studies in seventy-six cases of B-chronic lymphoproliferative disorders

The results of cytogenetic studies are reported in 76 patients with B-chronic lymphoproliferative disorders (B-CLPD): 60 patients with chronic lymphocytic leukemia (CLL), six with follicular lymphoma in leukemic phase (FLLP), five with splenic B-cell lymphoma with villous lymphocytes (SLVL), two with chronic prolymphocytic leukemia (CPL), two with hairy cell leukemia (HCL), and one with plasma cell leukemia (PCL). PHA (phytohemagglutinin), PWM (pokeweed mitogen), LPS (lipopolysaccharide from Escherichia Coli), TPA (phorbol 12-myristate acetate), IL6 (interleukin 6), and DxS (dextran sulfate) were used as mitogens. Mitoses were obtained in 75 cases. Clonal aberrations could be demonstrated in 34 cases (44%). In CLL, classical type, chromosomes 6, 11, and 13 were more frequently involved, whereas trisomy 12 was frequently found in CLL mixed-cell type, in FLLP, and CPL. In SLVL the deletion del(7)(q32) is noteworthy and miscellaneous chromosome abnormalities in the remaining patients were observed. Regarding the efficiency of mitogens, PHA turned to be the most effective in obtaining metaphases and in detecting clonal chromosomal aberrations.

[Organizational models for the hematology areas of the district hospitals of Catalonia]

PURPOSE

The haematological assistance in Catalonia is based upon the district hospitals, in the first step, and the stage III hospitals located usually in higher population nuclei, in the second step. The purpose of this work was to analyse the resources of the "primary haematological assistance" network provided by the district hospitals, to evaluate them and to propose a model for their organisation.

MATERIAL AND METHODS

An enquiry was carried out to all members of the Grup de Treball d'Hospitals Comarcals de Catalunya (Catalonia's District Hospitals Task Force). The evaluable data included demographic figures of the population assisted, personnel of each haematological area, organising structure, clinical activity, cytomorphology, blood banks, laboratories and continuous formation activities.

RESULTS

The enquiry was answered by 15 of the 21 district hospitals (71.4%) with haematologists in Catalonia. The population assisted in those hospitals is 2,100,000 (ranging between 55,000 an 450,000). All centres are integrated in the National Health network. Eleven of the hospitals analysed have only one haematologist (73.3%). If his dedication is 100% of the time, this would represent a doctor for 105,000 people. The time devoted to work is 690 hours a week for all the population, with a mean of 3,043. Four patients assisted per hour. The total number of hospital beds is 3,353 (50-450), with a mean number of 1 haematologist for every 167.6 beds. The number of patients hospitalized due to blood diseases ranges between 3 and 13 per month. Six of the 15 centres are adjunct to the outpatient clinic. Two centres have a blood bank and 7 have developed an autotransfusion programme. All the centres but one perform oral anticoagulant treatment follow-up, the number of patients assisted ranging from 20 to 210 per week. None of the hospitals has a separate Haematology Service; in most of them haematology is structurally and functionally dependent from Laboratories and in some there is a mixed Laboratory/Internal Medicine functional organisation, depending of the Medical Direction. No haematologist is ever on call specifically for his specialty. Continuous formation activities are carried out in 9 of the 15 centres (60%).

COMMENT

Several measures are proposed to improve the haematological assistance, acting on different levels: continuous formation, patient flows and circuits, resident doctors training, anticoagulant treatment network, organisation models, credit cards from the Spanish Association of Haematology.

Proportion of mortality caused by severe hospital-acquired infection in open-heart surgery

OBJECTIVE

To investigate severe hospital-acquired infection as an independent risk factor for in-hospital mortality and the proportion of mortality caused by severe hospital-acquired infections in patients under going open-heart surgery.

SETTING

A 1,300-bed teaching hospital in Spain.

METHODS

A retrospective cohort study of 702 patients who underwent open-heart surgery procedures between January 1989 and December 1991. The mean age was 57 years, and 68% of the subjects were men. Of the 702 patients, 42% underwent a valve operation, 41% had coronary artery bypass grafting, 4% had both a valve operation and coronary artery bypass grafting, 5% underwent repair of congenital heart disease, and 8% had other surgical procedures.

RESULTS

The cumulative incidence of severe hospital infection was 16.8%. The overall mortality rate was 5.4%. The mortality risk was 5.15 times higher in nosocomially infected patients than in uninfected patients. In addition, univariate analysis revealed up to 18 perioperative variables associated with in-hospital mortality. By multiple logistic regression, we identified four factors that independently predicted increased risk of mortality: preoperative New York Heart Association functional class level IV; long duration of cardiopulmonary bypass; low cardiac output syndrome; and severe hospital-acquired infection. The proportion of mortality caused by severe hospital-acquired infection in the cohort was 31.1%.

CONCLUSIONS

Severe hospital-acquired infection is a principal factor in in-hospital mortality. One third of all deaths are caused by infection. Major efforts should be devoted to the prevention and control of severe nosocomial infections in open-heart surgery patients to prevent mortality.

Prevalence of agglutinating antibodies to Toxoplasma gondii in small ruminants of the Madrid region, Spain, and identification of factors influencing seropositivity by multivariate analysis

A seroepidemiological survey of Toxoplasma gondii infection in sheep and goats was conducted in the Madrid region of Spain. Sera were collected from 60 herds, for which farming management information and other relevant data for their characterization were also obtained through a questionnaire. The seroprevalence was 11.8% (64 out of 541), using the modified (2-mercaptoethanol) direct agglutination technique with a 1:64 cut-off titre. The relationship between seropositivity and the variables in the questionnaire was assessed by multivariate analysis. Four variables were found to be significantly associated with seroprevalence. Two of them, the presence of cats and a previous history of abortion outbreaks in the farm, were factors known to be linked with toxoplasmosis, indicating the validity of the serological data. Seropositivity was also related to a lack of replacements in the preceding year. Proximity to other farms appeared to be a protective factor negatively associated with seropositivity, probably because it was an indicator of proximity to an urban area and the availability of local sanitary facilities.

Colonization and infection with methicillin-resistant Staphylococcus aureus: associated factors and eradication

OBJECTIVES

To identify characteristics associated with methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection, and to evaluate the efficacy of systemic and topical antimicrobials in the eradication of MRSA carriage among hospitalized patients.

DESIGN

A case-control study was done to identify associations. Odds ratios were estimated by unconditional multiple logistic regression. Cohort study was done to evaluate MRSA decolonization efficacy by an oral regimen. Patients infected or colonized with MRSA received a 5-day course of oral (160 mg/800 mg) trimethoprim-sulfametroxazole twice daily and 600 mg of rifampin once daily as decolonization treatment. The proportion of MRSA-free patients after decolonization treatment was determined. Persistence of clearing was estimated by the Kaplan-Meier method.

SETTING

Ramón y Cajal Hospital, a 1,249-bed, tertiary-care teaching hospital in Madrid, Spain.

PATIENTS

One hundred ninety-two patients with hospital-acquired MRSA infection/colonization and 195 MRSA-free random controls.

RESULTS

Six factors were associated independently with MRSA infection/colonization: age (every 10 years of age, odds ratio [OR] = 1.3); ward (surgical, OR = 1; medical, OR = 3.1; intensive care unit, OR = 60); previous hospitalization (OR = 6.9); coma (OR = 25.3); invasive procedures (each, OR = 1.7); 3 or more weeks of hospitalization (OR = 3.8). We failed to show antibiotic therapy to be an independent risk factor for MRSA hospital infection/colonization. Overall, MRSA eradication was 64.2% by day 2 to 9 after completion of treatment. Kaplan-Meier product limit survival analysis showed that the probability of remaining MRSA-free was 65.3% (SE = 0.09) at 32 days after completion of treatment.

CONCLUSIONS

The results offer a rationale for reduction of MRSA infection/colonization in the hospital by interventions aimed at early identification of patients at higher risk, at prompt discharge of patients, and at preventing dissemination while performing invasive procedures. They also provide estimates of antibiotic treatment efficacy to reduce the reservoir of MRSA in the hospital.

[Predictive factors of surgical infection in heart surgery]

BACKGROUND

Deep infection of the surgical site in cardiac surgery may lead to very severe complications. There is controversy as to the importance which different factors may have in the incidence of this complication. The aim of this study was to determine the importance of determined factors on the risk of deep infection of the surgical site.

METHODS

A retrospective study of 1,127 patients submitted to cardiac surgery from 1989 to 1991 was performed. The factors associated to the development of deep surgical infection were determined by univariant analysis. A multiple logistic regression model was designed to identify the factors independently associated to the risk of infection. The morbidity of surgical infection attributable to prolonged preoperative stay was calculated.

RESULTS

Of the numerous factors associated to risk of surgical site infection on univariant analysis, only five were independently associated to risk of infection on multivariant analysis: prolonged preoperative stay (OR = 2.4 [1.1-5.5]), dirty surgery (OR = 3.2 [1.0-9.9]), length of the intervention (OR [every hour] = 1.5 [1.2-2.0]), diabetes mellitus or chronic obstructive pulmonary disease (OR = 2.6 [1.2-5.6]) and functional grade according to the New York Heart Association (OR = 3.4 [1.5-7.7]). The proportion of deep infection attributable to prolonged preoperative stay was 41.8% (4.0-58.2).

CONCLUSIONS

The incidence of deep surgical infection may be decreased with a reduction, whenever possible, of the length of surgical intervention and preoperative stay.

Expression of lymphocyte function-associated antigen (LFA)-1 in B-cell chronic lymphocytic leukemia

We investigated the expression of the lymphocyte function associated (LFA)-1 adhesion molecule, recognized by the CD11a and CD18 monoclonal antibodies, in 53 patients with B-cell chronic lymphocytic leukemia (B-CLL) and in 37 controls. The mean percentage of control lymphocytes expressing CD11a and CD18 positivity was 92 +/- 5.5 and 90 +/- 8.7, respectively and, in patients with B-CLL, 14.2 +/- 10.3 and 14.8 +/- 10.3 respectively (p < 0.001). No statistical difference was found between CD11a and CD18 expression and the Rai clinical stages. In our experience a decrease of LFA-1 is a constant finding in B-CLL, in the early stages of the disease. It may, therefore, be useful to differentiate between slight increases of neoplastic cells and reactive blood lymphocytosis.

[Alloimmune neonatal neutropenia: flow cytometry study of the 1st patient described in Spain with identification of an anti-NA1]

A strong antibody was found in a mother (first pregnancy) who had a severe neutropenic baby. The father's granulocytes were typed by flow cytometry as NA1+, NA2+, NB1+, ND1+ and the mother as NA1-, NA2+, NB1+ and ND1+. The antibody was identified as anti-NA1 by us, and confirmed later by a reference laboratory. The serum reacted with 54.8% of the 31 donors tested. The same antibody was found in the child's serum 35 days after birth, and the reactivity was stronger than in the mother's serum. The HLA-DR, DQ from the mother was DR3, DR7; DR52, DR53; DQ2. The baby's granulocytes were recovered slowly over a four-month period, but the course was benign without any specific treatment. Five months after birth, with recovery, the child's serum became negative and his granulocytes were confirmed as NA1+. Due to the difficulties in fully diagnosing and working with granulocytes we suspect that there are undetected cases; only one case has been recorded in Spain before.

A new chromosomal anomaly associated with mature B-cell chronic lymphoproliferative disorders: del(7)(q32)

Among 63 patients with chronic lymphoproliferative disorders (CLPD) studied cytogenetically in our laboratory, four showed a del(7)(q32); in two it was the sole cytogenetic anomaly and in two it was part of a complex karyotype. We suggest that despite the rarity of this anomaly, it could be related to CLPD.

[Duodenal ulcer and duodenocholedochal fistula]

A new case of choledocoduodenal fistula secondary to duodenal ulcer is reported, which manifested as an ulcer complicated by haemorrhage, duodenal stenosis and cholangitis. We recommend endoendoscopy as the main diagnostic tool. Surgical treatment should consist of avoidance of the fistulous tract, cholecystectomy, cholangiography, truncal vagotomy and gastroduodenal drainage by pyloroplasty or gastroduodenostomy.

Inhibitory effect of peak 2-4 of uremic middle molecules on platelet aggregation

It is well-known that uremic patients present prolonged bleeding times as a common complication. Factors responsible for this disorder have been extensively investigated. In order to elucidate the possible role of uremic middle molecules as responsible for the bleeding tendency observed in uremia, we have studied the effect on platelet aggregation of middle molecules obtained from uremic plasma by Sephadex and ion-exchange chromatography. Our results show that some purified middle molecular fractions have a specific inhibitory activity on platelet aggregation and suggest an important role for these compounds in the pathogenesis of uremic bleeding.

[Morphology of Sarcoptes Scabiei (variety hominis) under scanning electron microscopy]

Some morphologic aspects of S. S. by SEM in twelve parasites (female) extracted from the lesions with a pin are studied. We think that the extraction method and the posterior colocation of the parasite has contributed to its better understanding. We describe the dorsal cleft, a characteristic formation of the sarcoptidos, tapered on both sides with thorns in the form of shark's teeth. We analyze the details of the Ambulacro, constituted by the cut or the strait Pedicelo, with a distal extremity in the form of Condyl in which the suction cups are articulated. We can see, in the anogenital portion, two independent anal and genital orificius and, in the ventral area, the tocostoma, or cleft, where the eggs are deposited. Finally we analyze the bucal organs, the Pedipulpos, the morphology and disposition of the hipostoma and the queliceros.