Acute bacterial prostatitis: heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute prostatitis

BACKGROUND

There is currently a lack of consensus for the diagnosis, investigations and treatments of acute bacterial prostatitis (AP).

METHODS

The symptoms, investigations and treatments of 371 inpatients diagnosed with AP were analyzed through a retrospective study conducted in four departments - Urology (U), Infectious Diseases (ID), Internal Medicine (IM), Geriatrics (G) - of two French university hospitals.

RESULTS

The cause of admission, symptoms, investigations and treatments depended markedly on the department of admission but not on the hospital. In U, patients commonly presented with a bladder outlet obstruction, they had a large imaging and functional check-up, and received alpha-blockers and anti-inflammatory drugs. In ID, patients were febrile and received longer and more appropriate antibiotic treatments. In G, patients presented with cognitive disorders and commonly had post-void urine volume measurements. In IM, patients presented with a wide range of symptoms, and had very diverse investigations and antibiotic regimen.Overall, a 3:1 ratio of community-acquired AP (CA-AP) to nosocomial AP (N-AP) was observed. Urine culture isolated mainly E. coli (58% of AP, 68% of CA-AP), with venereal agents constituting less than 1%. The probabilistic antibiotic treatments were similar for N-AP and CA-AP (58% bi-therapy; 63% fluoroquinolone-based regimen). For N-AP, these treatments were more likely to be inadequate (42% vs. 8%, p < 0.001) and had a higher rate of bacteriological failure (48% vs. 19%, p < 0.001). Clinical failure at follow-up was more common than bacteriological failure (75% versus 24%, p < 0.001). Patients older than 49 had more underlying urinary tract disorders and a higher rate of clinical failure (30% versus 10%, p < 0.0001).

CONCLUSION

This study highlights the difficulties encountered on a daily basis by the physicians regarding the diagnosis and management of acute prostatitis.

Increase of CD4+ CD25+ regulatory T cells in the peripheral blood of patients with metastatic carcinoma: a Phase I clinical trial using cyclophosphamide and immunotherapy to eliminate CD4+ CD25+ T lymphocytes

We determined the number and functional status of CD4+ CD25(high) regulatory T cells (Treg) in blood samples from patients with metastatic carcinoma, and evaluated their sensitivity to a single intravenous infusion of cyclophosphamide. Treg numbers were significantly higher in 49 patients with metastatic cancer (9.2% of CD4+ T cells) compared to 24 healthy donors (7.1%). These cells expressed the transcription factor forkhead box P3 (FoxP3), glucocorticoid-induced tumour necrosis factor receptor family-related protein (GITR) and intracellular CD152, and demonstrated a suppressive activity in vitro against CD4+ CD25- autologous proliferation. At a single intravenous infusion, cyclophosphamide failed, in association with a non-specific immunotherapy by intratumoral bacille Calmette-Guérin (BCG), to modulate significantly Treg numbers or function. Metastatic cancer is associated with an expansion of peripheral blood CD4+ CD25(high) FoxP3+ GITR+ CD152+ Treg cells whose immunosuppressive properties do not differ from those of healthy subjects. Moreover, cyclophosphamide administration may not represent an optimal therapy to eliminate Treg, which further underlines the need to identify specific agents that would selectively deplete these cells.

[Case-control study evaluating the incidence of hyperhomocysteinemia in cancer patients in an internal medicine department]

PURPOSE

Cancer is a cause of venous thromboembolism. However, the physiopathology remains unknown. Hyperhomocysteinemia could be a promoting factor.

METHOD

We built a case-control study of 65 patients followed for 2 years to compare levels of homocystéinémie in cancer bearing patients with that in matched cancer free control patients.

RESULTS

Fifty per cent of cancer bearing patients had significantly increased blood serum levels of homocystéine (P=0.006). This increase did not correlate with any deficiency in blood serum levels of folate or vitamin B12.

CONCLUSION

High levels of homocystéinémie could be linked to tumor proliferation.

Les abcès pyogènes secondaires du psoas : à propos de six cas et revue de la littérature

PURPOSE

Psoas abscess is a rare disease in developed countries. Its diagnosis is difficult and any delay could lead to a worsen prognosis. The aim of this study is to determine the best diagnostic and therapeutic practices.

METHODS

A retrospective study of psoas abscess that occurred during six months was performed.

RESULTS

Six cases of secondary psoas abscess are reported. They were associated with spondylodiscitis in three cases, arthritis and gynaecologic infection in the three remaining cases. Anatomic diagnosis was performed by tomodensitometry. Microbiologic diagnosis was obtained by blood culture or direct puncture of the abscess. Antibiotics were associated with percutaneous drainage in two cases, with simple puncture in one case, and with surgery in one case. A local improvement w observed in all cases. The oldest patients presented the worst complications which were not directly caused by the abscess.

CONCLUSION

Physicians must be aware of psoas abscess because of their increasing incidence. Despite the fact that digestive pathologies are the main cause of secondary psoas abscess, bone infections, particularly spine infections, should be taken into consideration. Tomodensitometry guided puncture or percutaneous drainage are of diagnostic and therapeutic interest. Infectious samples must be taken before starting antibiotics, which have to be efficient against Gram negative bacillus, anaerobes and Staphylococcus aureus. Surgery must be quickly performed when the primary infection localisation need it, in case of voluminous abscess or when antibiotics and drainage are inefficient.

[Medication errors resulting from drug preparation and administration]

BACKGROUND

The risks associated with drug use are not confined to adverse reactions. Failures can occur in the process of drug prescribing, dispensing and administration. Such preventable events are termed 'medication errors'. Errors in preparation and administration, the last step in the medication process, constitute a good indicator of the quality of the medication process, and are irredeemable.

METHODS

A protocol for measuring errors in the preparation and administration of medication has been developed and used in an internal medicine department at the University Hospital of Dijon.

RESULTS

This protocol has enabled several different rates of medication errors to be determined depending on the calculation approach used: 15.1% with respect to interventions by nurses, 41% relating to the total number of opportunities for error, and 8.8% with respect to a methodological problem analysed in the study. The potential clinical significance, incidence and causes of errors during the medication process were also analysed.

DISCUSSION AND CONCLUSION

Medical errors are not detected in our health system and are thus not preventable. Their consequences are incompatible with a well organised treatment process. The rate of medication errors is therefore a good indicator of the quality of the medication system in a hospital that is following the current steps for risk reduction and accreditation.

Systemic mastocytosis: predictable factors of poor prognosis present at the onset of the disease

Systemic mastocytosis (SM) refers to a group of heterogeneous diseases that can be divided into indolent SM, for which prognosis is favorable, and malignant SM, which has a poor prognosis. While the diagnosis of SM is often a challenge since clinical and biological abnormalities are not specific, prognosis is even more difficult to predict. Thus, we aimed to highlight predictable factors in a cohort of 28 cases of SM. Among the 13 women and 15 men studied were 7 patients who had an aggressive form of SM that ultimately led to death in 3 of them. We found common characteristics among these seven patients. First, they were older when the first symptoms appeared and when the diagnosis was confirmed. Second, ascitis, lymphadenopathy, anemia, and thrombocytopenia were significantly more frequent, while cutaneous lesions and flush were less frequent. Moreover, general symptoms, gastrointestinal disorders, neutropenia, and coagulation abnormalities also seemed to characterize this group of patients. Understanding the factors that predict SM is essential in order to provide patients with the malignant form of the disease with specific treatments.

Variable expressivity of the clinical and biochemical phenotype associated with the apolipoprotein E p.Leu149del mutation

Splenomegaly with sea-blue histiocytes, thrombocytopenia and hypertriglyceridemia is a very rare association that has been described in only one report to date. The molecular defect in the two reported patients consists in a deletion of a leucine at position 149 in the receptor-binding region of the apoE molecule. Here, we report on another family in whom the proband and his brother were diagnosed with splenomegaly, thrombocytopenia and hypertriglyceridemia. An apoE p.Leu149del mutation was found in both subjects. A large beta band in the VLDL fraction and elevated VLDL cholesterol-to-plasma triglyceride ratio was observed in the proband only. Their mother, presenting with isolated hypertriglyceridemia, also carried the same p.Leu149del mutation. The coexistence of factors facilitating the development of hypertriglyceridemia and/or low HDL-cholesterol level could explain why the proband and his brother developed a splenomegaly with thrombocytopenia, whereas the mother did not. Moreover, the presence of an apoE2 allele in the proband likely explains the more severe phenotype we observed in this subject. In conclusion, the apoE p.Leu149del mutation results in a very striking phenotype including one or all symptoms among splenomegaly, thrombocytopenia and hypertriglyceridemia, and should be considered as a differential diagnosis of storage disorders in the causes of splenomegaly with sea-blue histiocytes.

Pancréatite aiguë non alcoolique non biliaire

INTRODUCTION

The possibility of nicotine toxicity, although rare, should be considered in cases of acute edematous pancreatitis.

CASE

A 30-year-old woman was hospitalized to identify the cause of an initial episode of acute edematous pancreatitis. The observation of native anti-DNA and antiphospholipid antibodies suggested lupus pancreatitis and/or an antiphospholipid syndrome, both subsequently ruled out. The final diagnosis was nicotine poisoning induced by the combination of a nicotine patch and tobacco smoking.

CONCLUSION

Although a nicotine patch has never been reported in connection with an episode of acute pancreatitis before, this case suggests that such an event might be a rare complication of an overdose of nicotine.

[The interest of a short-lived orientation unit in a department of internal medicine]

OBJECTIVE

To assess the activity of a short-lived orientation unit (SLO) with 9 beds that only receives patients from the emergency department in whom diagnosis and/or specific treatment must be set-up while awaiting a vacant bed in the appropriate medical department.

METHODS

During the 29 months after the creation of the SLO (Feb. 2001 to June 2003), we analysed the parameters supplied every month by the medical computer department: number of patients hospitalized in the SLO, age, gender, principle diagnosis according to the PMSI coded data, duration of hospitalisation, number of deaths, number of releases direct to home, number of transfers to a specialized unit and qualification of the referral units.

RESULTS

1840 patients (mean age: 73 years) were hospitalized in this unit. The most frequent diseases were bronchopneumonia (16%), syncope episode (14%), cerebral stroke (12%), thromboembolic diseases (11%) and heart failure (10%). The mean duration of hospitalization was 3.7 days (less than 48 hours in 46% of cases). In 40% of cases, patients were able to return directly to their homes. In 62% of cases, the patients were referred to a specialised unit within 48 hours. The functioning of the SLO has various specificities (repeated personalised telephone contacts, letters for rapid transfer, difficult co-operation with certain departments...).

CONCLUSION

The SLO is useful for patients since it accelerates their adapted management and allows quick transfer to the unit adapted to their pathology, permitting correct adequation between the pathologies of the patients and the competence of the specialised medical unit.

Intravascular malignant lymphomatosis diagnosed on a muscular biopsy: a case report

Intravascular malignant lymphomatosis (IML) is characterized by proliferation of malignant lymphoid B cells within the lumens of small vessels. Common symptoms include general weakness and central neurological and cutaneous signs. Only histopathological analysis can confirm the diagnosis. We report on a 69-year-old man hospitalized for general weakness, inflammatory syndrome, and hemophagocytic syndrome (HS). Our observation shows that histopathological signs may be observed on a muscular biopsy without clinical or biological signs of muscular involvement.

[Acute-phase reaction]

The systemic changes induced by inflammation have been referred as the acute-phase response. The changes in the concentrations of acute-phase proteins are due largely to changes in their production by hepatocytes induced by pro-inflammatory cytokines. Because of its specificity, sensibility and short half-life, C-reactive protein is the most useful indicator among all the acute-phase proteins. The clinical strategy to deal with an acute-phase response is to search the aetiology: infections, neoplasms, auto-immune and allergic diseases. The treatment of an acute-phase response is the treatment of its aetiology.

Comparison of low-molecular-weight heparin and warfarin for the secondary prevention of venous thromboembolism in patients with cancer: a randomized controlled study

BACKGROUND

The use of warfarin sodium for treating venous thromboembolism in patients with cancer is associated with a significant risk of recurrence and bleeding. The use of low-molecular-weight heparin sodium for secondary prevention of venous thromboembolism in cancer patients may reduce the complication rate.

OBJECTIVE

To determine whether a fixed dose of subcutaneous low-molecular-weight heparin is superior to oral warfarin for the secondary prophylaxis of venous thromboembolism in patients with cancer and venous thromboembolism.

METHODS

In a randomized, open-label multicenter trial performed between April 1995 and March 1999, we compared subcutaneous enoxaparin sodium (1.5 mg/kg once a day) with warfarin given for 3 months in 146 patients with venous thromboembolism and cancer.

MAIN OUTCOME MEASURE

A combined outcome event defined as major bleeding or recurrent venous thromboembolism within 3 months.

RESULTS

Of the 71 evaluable patients assigned to receive warfarin, 15 (21.1%; 95% confidence interval [CI], 12.3%-32.4%) experienced one major outcome event compared with 7 (10.5%) of the 67 evaluable patients assigned to receive enoxaparin (95% CI, 4.3%-20.3%; P =.09). There were 6 deaths owing to hemorrhage in the warfarin group compared with none in the enoxaparin group. In the warfarin group, 17 patients (22.7%) died (95% CI, 13.8%-33.8%) compared with 8 (11.3%) in the enoxaparin group (95% CI, 5.0%-21.0%; P =.07). No difference was observed regarding the progression of the underlying cancer or cancer-related death.

CONCLUSIONS

These results confirm that warfarin is associated with a high bleeding rate in patients with venous thromboembolism and cancer. Prolonged treatment with low-molecular-weight heparin may be as effective as oral anticoagulants and may be safer in these cancer patients.

Vasculitis in the very elderly

BACKGROUND

Whatever may be their clinical presentation, vasculitis syndromes (VS) have a bad prognosis in the very elderly.

OBJECTIVE

The aim of this work was to study VS particularities in very old people. Most published studies on VS in elderly people concern patients older than 60 years; studies concerning very old patients are unusual.

METHODS

We studied retrospectively subjects older than 75 years with a diagnosis of VS from the Departments of Geriatrics and Internal Medicine at Dijon University Hospital. These subjects were hospitalized between January 1995 and December 1999. Data were obtained from the medical files of these patients. Several aspects were considered: type of VS, associated diseases, treatment, complications, and outcome.

RESULTS

Twelve patients, 5 men and 7 women aged 79-91 (mean age 82.3) years, were included. Primary VS was observed in half of the patients and secondary VS in the others. The initial clinical presentation was often polymorphous and unspecific; 8 of the patients died, 2 developed progressive severe functional impairment, 1 was stabilized under therapy, and 1 patient with VS secondary to infection recovered. Most patients either died quickly or progressively deteriorated from infections, malnutrition, or functional impairment.

CONCLUSION

The health of the majority of patients (83%) deteriorated dramatically, leading to death or severe functional impairment.

[Elevation of serum lactate dehydrogenase. Diagnostic, prognostic and evolutive values]

OBJECTIVE

Determination of serum lactate dehydrogenase (LDH) levels is an usual practice. However, its place in the diagnosis process is not clear. We have collected serum LDH levels superior to 2-fold the normal rate and we tried to determine their diagnostics interest and, predictive and progressive values.

METHODS

Retrospective study during 3 months in hospitalized adults. LDH levels were measured by spectrophotometry (Normal rate: 313-618 UI/L).

RESULTS

196 cases with LDH level elevations higher than 1236 UI/L were analyzed. The etiology of LDH level elevations were was benign in 60% of cases, malignant in 36% and, undetermined in 5%. There was no difference in between average values of LDH level average values of benign and malignant etiology (2708 vs 2842 UI/l). LDH rates and high LDH level elevations were not helpful for in the diagnosis process (a variety of 43 etiology was able to elevate increased LDH rates). In 45% cases, LDH level was 2 to 3-fold the normal rate; in 47.5% cases, 3 to 10-fold normal rate, and in 7.5% cases, superior to 10-fold normal rate. LDH elevations superior to 10-fold the normal rate were caused by benign etiology in 11 cases and malignant disease in 4 cases. A level superior to 10-fold the normal rate was not helpful in determining to determine the benign or malignant characteristics of the initial disease. However, LDH rate superior to 10 normal rate was a pejorative predictive criteria (hospitalization in intensive careunity in 73% of cases and mortality rate of 53%). During follow up of a neoplasia or malignant hemopathy follow up, several LDH measurements LDH level determinations were determined in for a small number of patients. LDH level normalizations is are attributable to efficientan effective treatment; LDH level elevations are associated with a therapeutic failure echappment. Evolution in LDH levels evolution was influenced by progression in neoplasia and malignant hemopathy evolution and also by various several treatments such as like blood transfusions, growth factors, radiotherapy and chemotherapy.

CONCLUSION

LDH level elevation, however whatever its rate, don't seem to do not help in differentiating have interest to differentiate benign from malignant diseases. However, an elevation LDH elevation higher than 10-fold the normal rate is a pejorative predictive criteria, since because the mortality rate is superior toupper than 50%. During follow-up of in the neoplasia and malignant hemopathy follow up, so long as they are measured at distance from treatment, variations in LDH levels are a good marker of evolution, rate variations represent an evolutive marker conditionally the level determination would be realize remote several treatment.

Mazabraud syndrome in two patients: clinical overlap with McCune-Albright syndrome

Mazabraud syndrome is a rare sporadic disorder, mainly characterized by bone fibrous dysplasia and intramuscular myxomas. We report here two new cases of Mazabraud syndrome. One of our patients (Patient 1) also had café-au-lait spots and multinodular goiter suggestive of McCune-Albright syndrome. We review the 37 previously reported cases with Mazabraud syndrome and discuss the 6/37 patients with criteria of Mazabraud and McCune-Albright syndromes. Based on the clinical overlap between the two syndromes, we tested the GNAS1 gene in blood leukocytes and skin fibroblasts of Patient 1, but found no evidence of an activating mutation in the GNAS1 gene.