[Unsuspected prolonged activated partial thromboplastin time in emergency surgery. Diagnostic and therapeutic guide]

Systematic complementary testing for asymptomatic patients before surgery yields an unexpectedly high percentage of anomalous results. Such results rarely affect perioperative management of the patient but may lead to unnecessary delays, which are potentially of great importance in emergency surgery. A 55-year-old woman with a clinical diagnosis of acute appendicitis was seen to have a prolonged activated partial thromboplastin time (APTT) of 1.94 before surgery. The patient's history did not suggest a coagulation disorder was likely, and when mixing normal and problem plasma failed to correct the APTT, we suspected an unspecified circulating anticoagulant was present. Surgery was delayed no further and no measures were taken. No excessive bleeding occurred during surgery or postoperative recovery. The main possible diagnoses for a women with unforeseen prolonged APTT are the presence of an unspecified circulating anticoagulant, factor XI or factor XII deficiency, or factor VIII deficiency associated with von Willebrand disease. Focusing on detecting a coagulation disorder while taking a patient's history and performing a simple laboratory test (mixing normal and problem plasma) can be useful for orienting management in emergency surgery.

[The effect of discontinuation of methylphenidate at adolescence onset on adult attention deficit hyperactivity disorder]

INTRODUCTION

The positive effect of methylphenidate on children and adults with ADHD is well known. However, the effect of discontinuation of methylphenidate at adolescence onset on adult s ADHD is unknown. Objective. To determine the effect of discontinuation of methylphenidate at adolescence onset on adult s attention deficit, hyperactivity, impulsivity and functional disabilities.

PATIENTS AND METHODS

Adults and their parents, spouses and/or friends were requested to fill out the same criteria diagnosis form filled out by their parents and teachers before (7 years of age), during (7.5 years of age) and at the end of treatment (12 years of age). They took methylphenidate (0.1 0.5 mg/kg/day) from age 7 to 12 years because ADHD. Inattention, hyperactivity, impulsivity and functional disability were statistically analyzed by the paired sample method before, during at the end of treatment and at age 27 years.

RESULTS

Methylphenidate used for 5 years (7.5 12 years of age) improved significantly (p< 0.001) the average score for inattention, hyperactivity, impulsivity and functional impairment compared to pre (7 year of age) and post (27 years of age) treatment. The discontinuation of methylphenidate for 15 years (12 27 year of age) deteriorate significantly the average score for inattention and functional impairment when pre adolescent and adult values were compared (p< 0.001).

CONCLUSIONS

The results strongly suggest that methylphenidate must be used throughout the adulthood to avoid the degree of inattention and functional disability found in this study.

[Myocardial Infarction in the population aged 25-74 in Navarra. Incidence, lethality and treatment in the period 1997-98. IBERICA study]

The principal aim of this study was to determine the incidence of Myocardial Infarction in the population aged 25-74 in Navarra, lethality after 28 days, and the characteristics of the treatment applied in the hospitals during the years 1997-1998. A search was conducted for possible cases of heart attack in the hospital services responsible for attending to them, by means of a review of clinical histories. The lethal cases that did not reach the hospitals were researched through the statistical bulletins of deaths, with the information on these deaths completed through the family doctors. 1,059 coronary events were registered, which corresponded to a crude rate of attack of 238 cases per 100,000 amongst men and 59 cases per 100,000 amongst women. Amongst the male patients who reached hospital alive, 50% were smokers, 41% showed hypercholesterolaemia, 35.9% were hypertense and 16% were diabetic. Amongst the women, who showed a higher average age, arterial hypertension was the most frequent risk factor, with 66%. During hospitalisation thrombolysis was carried out on 39.2% of the patients, primary or rescue angioplasty on 4.6%; aspirin or other anticoagulants were administered to 94.2%, beta-blockers to 60.6% and IECA to 37.4%. This study has shown that the frequency of Myocardial Infarction in Navarra is lower than that registered in many European and North American countries, and is concordant with the low rates of mortality due to this cause. Global analysis of the data shows that a high implementation of the care guidelines for this disease with respect to the use of efficient therapies could be observed in the years 1997 and 1998. Nonetheless, with the exception of the use of anticoagulants, hospital variability has been observed in the use of thrombolytic therapy and adjuvant therapies such as the beta-blockers or ACE Inhibitor, and in the use of diagnostic techniques such as arteriography.

Long-term response to interferon plus ribavirin in patients with chronic hepatitis C refractory to interferon

OBJECTIVE

A sustained response (SR) to interferon (IFN) is only observed in 15-20% of patients with chronic hepatitis C (CHC). The aim of this study was to determine the long-term effectiveness and safety of the treatment with IFN plus ribavirin (RIB) over two years in CHC patients without SR to IFN.

DESIGN

A prospective and open longitudinal follow-up study was conducted over 3 years.

PATIENTS AND METHODS

A total of 77 CHC patients were included: 63 non-responders (NR) and 14 relapsers (R) to IFN. Patients were treated with IFN (3 MU s.c. three times a week) and RIB (1,000-1,200 mg p.o. daily) for 12 months. Treatment tolerance and viral response (HCV-RNA in serum < 1,000 copies/ml) were assessed after 1, 3, 6 and 12 months of treatment. SR and relapsing rates were subsequently evaluated 6, 12 and 24 months after the end of the treatment, together with those variables capable of predicting SR.

RESULTS

At the end of the treatment, 19/77 patients responded (24.7%), 9/63 (14.3%) were non-responders and 10/14 (71.4%) relapsers, and these same patients exhibited SR after 6 months. The SR rate two years after treatment was 22.1% [8/63 (12.7%) NR and 9/14 (64.3%) R]. The relapse rate after 6 months and two years was respectively 0 and 10.5% (2/77). Independent variables capable of predicting SR were negative viremia conversion within the first month of treatment, maintenance of such negative viremia after 6 months, and R status to IFN. Side effects were recorded in 90.9% of cases (70/77), the most frequent being pseudoinfluenza syndrome. Treatment had to be discontinued in 33.8% of patients (26/77).

CONCLUSIONS

Combined IFN-RIB therapy for 12 months in CHC patients without SR to IFN obtains a long-term SR of 22.1%, this rate being higher in relapsers to prior IFN therapy (64.3% in R versus 12.7% in NR).

Expression of the HIV-1 co-receptors CCR5 and CXCR4 on placental macrophages and the effect of IL-10 on their expression

The chemokine receptors CCR5 and CXCR4 play a key role in HIV-1 infection as co-receptors for viral entry. In the placenta, an important natural barrier to HIV, the expression and regulation of these receptors has yet to be elucidated. In this study, we determined the expression of CCR5 and CXCR4 co-receptors on placental macrophages (PM) and the effect of interleukin-10 (IL-10) on co-receptor expression. PM were isolated from term placentae of HIV-uninfected mothers and cultured for up to 11 days. The cells were stimulated with IL-10 for 24 h and stained with specific antibodies to CCR5, CXCR4, CD4, CD3, CD11c and CD14 for flow cytometry. Unstimulated PM expressed significantly more CCR5 than CXCR4. Expression of both co-receptors was upregulated by stimulation with IL-10 at 24 h post-stimulation. In vivo expression of these co-receptors from frozen sections revealed a higher percentage of CCR5 positive cells. This is the first study in which expression of both co-receptors is detected on the PM membrane. These results are consistent with previous studies performed in our laboratory where PM were readily infected by CCR5-using HIV strains but could not be productively infected by HIV strains that exclusively use CXCR4 as a co-receptor.

Chemotaxis, viability, and labeling stability of leukocytes labeled with (99m)Tc-exametazime stabilized with methylene blue

The in vitro viability, chemotaxis, and labeling stability of leukocytes labeled using (99m)Tc-exametazime stabilized with methylene blue were evaluated and compared with those obtained using nonstabilized (99m)Tc-exametazime.

METHODS

Two identical leukocyte populations, from 30 healthy donors, were labeled simultaneously using freshly prepared and 2-h-old stabilized (99m)Tc-exametazime. The following quality control techniques were performed on each labeled leukocyte sample: eosin Y staining, chemotaxis radioassay, and labeling stability at 2 h after labeling.

RESULTS

Eosin Y staining showed a cell viability of at least 98% in all samples, without a significant statistical difference between the populations. Chemotactic indices obtained with leukocytes labeled with freshly prepared, unstabilized (99m)Tc-exametazime were statistically greater than those obtained using (99m)Tc-exametazime stabilized with methylene blue (z = 2.41; P<0.02). Labeling stability at 2 h after labeling was the same for both populations.

CONCLUSION

The use of (99m)Tc-exametazime stabilized with methylene blue for leukocyte radiolabeling does not affect either cell membrane integrity or labeling stability but can cause a decrease in the cell chemotactic capacity that discourages its clinical use.

CCR5 and beta-chemokines in HIV-1 infected children

The duration from initial infection with HIV-1 to CD4 lymphocyte depletion and progression to AIDS varies among infected individuals. Despite treatment with highly active antiretroviral therapy (HAART), patients still show different stages of disease progression. We examined the role of beta-chemokines and its receptor, CCR5 in HIV-1 infected children in order to define determinants of HIV progression among treated individuals. Population was divided in two groups: Group 1--Long Term Non Progressors (LTNP) includes 10 patients with B1-B2 CDC disease classification and with a less aggressive therapy (only 2 in HAART); Group 2--Rapid Progressors (RP) includes 9 patients with C3 disease classification. All the patients had a CCR5 wild type (wt) genotype indicating that they do not have the 32 base-pair deletion associated with slower progression. There was an increased production of MIP 1-beta in 8/10 LTNP but only in 4/9 Progressors (Paired t-test/Wilcoxon Sign test, p-value < 0.05). The change in the levels of MIP-1 beta after PHA stimulation was statistically significant in both groups. The levels of RANTES increased in LTNP and RP and the change of the levels after mitogen stimulation was statistically significant for both groups included. The production of RANTES and MIP-1 beta in response to stimulation between both groups was not statistically significant. The production of MIP-1 alpha was variable in both groups and the difference in the levels after mitogen stimulation between the groups was not statistically significant. These results suggest that beta-chemokines do not play an important role in HIV-1 progression in children undergoing HAART.

Interferon alfa-2b plus ribavirin for chronic hepatitis C patients who have not responded to interferon monotherapy

BACKGROUND

The role of combination therapy is poorly defined in chronic hepatitis C patients who are non-responders to interferon.

AIM

To assess the efficacy, safety and tolerance of interferon alfa-2b plus ribavirin in chronic hepatitis C patients who do not respond to interferon monotherapy.

METHODS

A total of 127 non-responder patients with chronic hepatitis C received 3 mU t.i.w. of interferon alfa-2b plus 1000-1200 mg ribavirin daily for 48 weeks. Effects of therapy were evaluated by serum aminotransferases and hepatitis C virus (HCV) RNA levels.

RESULTS

Twenty-nine (23%) patients had an end-of-treatment response. Six months after treatment, 20 (16%) patients were sustained responders. Early loss of HCV RNA was the strongest predictor of a sustained response (P < 0.0001). Remission was also more frequent in patients with genotype 1b (P < 0.02), elevated alanine aminotransferase (P < 0.03) and low gamma glutamiltranspeptidase (P < 0.002). Treatment was discontinued in 21 (17%) patients: in 14 for intolerance and in seven due to side-effects.

CONCLUSIONS

Combination therapy with interferon plus ribavirin produced a sustained response in 16% of chronic hepatitis C patients who were non-responders to interferon. This combination was safe and well tolerated.

[The main problems of occupational health in Navarra, 1994-1996]

In 1996 the Navarra Occupational Health Institute, an autonomous technical organization that integrates the functions and means related to occupational health matters, drew up the Occupational Health Diagnosis of Navarra, which is a region characterised by its important industrial sector and its high proportion of small and medium size companies. The results emphasise the high accident rate in the construction sector, the constant increase of professional diseases through "fatigue of tendon pods", as well as the importance of osteo-muscular processes as a cause of temporary and permanent disability. Forty sentinel occupational tumors, mainly mesothelioma, and 27 Obligatory Statement Diseases of occupational origin, mainly brucellosis, were identified in a period of seven years and three years, respectively. Verification was made of a lack of systematised information about population exposure to occupational risks, a scarce development of medical surveillance of exposed workers, and a lack of information about the incidence of occupational injuries in self-employed workers.

Analysis of risk factors associated with nosocomial bacteraemias

A prospective study of 2676 blood cultures was performed to identify the factors associated with clinically, significant nosocomial bacteraemia that occurred during a one year period in the Malaga University Clinical Hospital. Three hundred and fifty-five episodes of bacteraemia were considered clinically significant. The overall incidence of bacteraemia was 19.5/1000 admissions, of which 46% were hospital-acquired. A multivariate model showed that only six factors were significantly, and independently, responsible for nosocomial bacteraemias: intravascular catheterization (P < 0.0001, OR = 18.37), invasive procedures (P < 0.0001, OR = 10.38), malignancy (P = 0.035, OR = 3.11), indwelling devices (P = 0.005, OR = 3.05), stay in intensive care or surgical departments (P = 0.05, OR = 2.63) and length of hospital stay (P = 0.051, OR = 1.02). These results show that the factors which had most influence on the development of nosocomial bacteraemias were those factors associated with the treatment received by patients during their hospital stay.

M, García V, Santaballa JA. Solvent isotope effects in the oxidation of dipeptides by aqueous chlorine

A kinetic study of the mechanism of oxidation of Ala-Gly and Pro-Gly by aqueous chlorine has been carried out. Among other experimental facts, the deuterium solvent isotope effects were used to clarify the mechanisms involved. In a first stage, N-chlorination takes place, and then the (N-Cl)-dipeptide decomposes through two possible mechanisms, depending on the acidity of the medium. The initial chlorination step shows a small isotope effect. In alkaline medium, two consecutive processes take place: first, the general base-catalyzed formation of an azomethine (β ca. 0.27), which has an inverse deuterium solvent isotope effect (kOH-/kOD- ~ 0.8). In a second step, the hydrolysis of the azomethine intermediate takes place, which is also general base-catalyzed, without deuterium solvent isotope effect, the corresponding uncatalyzed process having a normal deuterium solvent isotope effect (kH2O/kD2O ~ 2). In acid medium, the (N-Cl)-dipeptide undergoes disproportionation to a (N,N)-di-Cl-dipeptide, the very fast decomposition of the latter in deuterium oxide preventing a reliable estimation of the solvent isotope effect.Key words: chlorination, deuterium isotope effects, fractionation factors, peptide oxidation, water treatment.

[Fungemia by Candida non albicans in patients with HIV infection]

OBJECTIVE

To analyse candidemia by Candida non albicans in adult HIV-infected patients from 1989 to August 1998.

PATIENTS AND METHODS

We retrospectively reviewed all HIV patients who presented at least one positive peripheral blood culture for Candida spp. Clinical, epidemiologic, immunologic and evolutive characteristics, and risk factors for candidemia were analysed.

RESULTS

During this period of time, 2,025 HIV-infected patients were diagnosed. Five of them developed candidemia by C. albicans and 6 by C. non albicans. These last ones were all men with mean age of 32.1 years old, and intravenous drug use was the risk factor for HIV in 5 of them; aids had previously been diagnosed in 4 patients and 3 had receipt imidazoles. None was neutropenic. Three cases were nosocomially acquired. Median CD4 cell count was 108.6 x 10(6)/l (3-366). Candida krusei was isolated in two intravenous drug users, Candida parapsilosis in two other patients and Candida glabrata and Candida tropicalis in one of the other two cases each. We treated 2 patients with amphotericin B and 2 with fluconazole. One patient died.

CONCLUSIONS

Candidemia is not frequent in HIV-infected patients. Candidemia by C. non albicans in HIV-infected patients presents similar characteristics as in other immunodepressed patients and it is fundamentally associated with previous use of imidazoles, nosocomial acquisition and late-stage aids. It is noteworthy that C. krusei was isolated in two intravenous drug users.

[A universal method to correct underreporting of communicable diseases. Real incidence of hydatidosis in Chile, 1985-1994]

BACKGROUND

There is evidence to postulate that undernotification is the reason for the great decrease in the reported incidence of hydatidosis in Chile.

AIM

To develop and propose a method to assess the notification of transmissible diseases, based on observed lethality and hospital discharges.

MATERIAL AND METHODS

Human hydatidosis in the period 1985-1994 was used as a model to develop the method. Official reports and mortality were analyzed first, determining the first lethality rate. A second lethality rate was calculated based on hospital discharges and a third, based on all Chilean surgical series published in the last two decades. Adjusting official notification of lethality to the true lethality according to surgical series, the number of unreported cases was calculated and the true incidence of hydatidosis was calculated, summing these cases to the official notification.

RESULTS

According to this method, the real rates of human hydatidosis in the period 1985-1994, would fluctuate between 6.5 and 11.4 per 100,000. This figure is four times higher than the official notification in the analysed period.

CONCLUSIONS

The correction of under notification based on hospital discharges, with or without correction for repeated hospital admissions, or real mortality of surgical series gave similar results, suggesting that both methods are correct.

[Patient preference and stereotype about the gender of the family physician]

OBJECTIVE

To study the preferences of patients on the gender of the physician when consulting for particular health problems; and to know the gender stereotypes that patients assign to physicians.

DESIGN

Cross-sectional study.

SETTING

Five teaching health centres in Granada (Spain).

PATIENTS

Randomised sample of patients that consulted 10 female and 20 female physicians during three months (17 patients per physician), for alfa = 5%, beta = 80%, to detect a difference of 12% between male and female physicians.

MEASUREMENTS AND MAIN RESULTS

We used a questionnaire adapted from Fennema (Family Medicine Dept., Wisconsin University, 1990) that was administered by interviewers after the consultancy, following a previous pilot study. Preference and stereotype scales comprised 10 items, with five reponses (neutral mid-point). Differences were analysed with chi 2 with correction for continuity. Non-reponders (33%) were replaced, and their age and sex did not bias the study results. Responders were 210 males (40.9%) and 304 women (59.1%). For "flux in penis/vagina" and "haemorrhoids" 50-60% of the patients preferred a physician of the same sex, with the remainder expressing no preference. The women preferred female physicians for family problems (23%) and depression (23%). The male physicians were more often perceived to be unorganised than were the females (24% vs. 5%, p < 0.0005), while the female physicians were more often described as humane (15% vs. 10%, p < 0.0005). Characteristics expressing technical competence were more often attributed to the male physicians than to the females, while those expressing empathy were more often attributed to the female physicians.

CONCLUSIONS

Patients prefer physicians of the same gender for some health problems and not for others. Patients assign gender stereotypes to physicians. These findings will permit a better interpretation of doctor-patient relationships.

[Focal nodular liver hyperplasia of atypical presentation]

Focal nodular hyperplasia is a benign hepatic tumor that usually appears in young women. Diagnosis of focal nodular hyperplasia is often incidental when an ultrasonography or computed tomography is performed by other reasons, because its course is generally asymptomatic; the presence of a central fibrous scar is characteristic. Management in focal nodular hyperplasia must be conservative, with ultrasonographic follow-up, and it only must be treated when patients are symptomatics or in case of tumoral enlargement. We report a case of FNH in which symptomatic presentation and the absence of central stellate scar in ultrasonography, computed tomography and magnetic resonance leads to a misdiagnostic of hepatic adenoma, that conditioned a surgical resection. The later examination was diagnostic of focal nodular hyperplasia.

[Nutritional risk factors for gallstones. Epidemiological analysis]

This article reviews the role of nutrition in the incidence of gallstones. The epidemiological situation of gallbladder disease has wide worldwide geographical variations, being Pima Indians and the Chileans the most affected populations. The main nutritional risk factor is obesity. Other risk are serum cholesterol and triglyceride levels, unbalanced and excessive caloric intake, fasting periods of more than eight hours, hypocaloric diets of less than 700 Kcal/day, specially in obese subjects and parenteral nutrition lasting more than two weeks. The main conclusion of this revision is that nutritional behaviors of the population must be improved through public health programs, to reduce the incidence of obesity and related nutritional imbalances.

[Fungemia in patients with HIV infection]

OBJECTIVE

To make an analysis of fungemia in HIV-infected patients in our hospital.

PATIENTS AND METHODS

We retrospectively (1989-1997) studied all HIV-infected patients with positive blood cultures for Candida sp., Cryptococcus neoformans or any other fungal infection.

RESULTS

C. neoformans was isolated in 11 patients (10 men and 1 woman): Six were treated with amphotericin B and 5 with fluconazole. 2 patients died during the acute phase and the infection relapsed in 3. Blood culture for Candida sp. were positive in 9 (8 men and 1 woman): only a case was nosocomial. Seven patients were intravenous drug users and the presenting manifestations were autolimited candidemia in 3, aortic and tricuspid endocarditis in 1 and 2 cases respectively and pneumonia in another one. Six C. albicans, 2 C. krusei and 1 C. glabrata were isolated. 3 patients received amphotericin B and 3 received fluconazole. 2 patients suffering from endocarditis died and so did the patient with C. glabrata infection. A patient, who denied having travelled to endemic areas, developed histoplasmosis; blood culture was positive for H. capsulatum. He initially had a good response to amphotericin B and itraconazole.

CONCLUSIONS

Fungemia is not frequent in HIV-infected patients. Cryptococcosis and histoplasmosis occur in advanced HIV-patients and candidemia is fundamentally associated with intravenous drug use.

[Effective renal plasma flow with I-131-hipuran: evaluation of a method with four extractions]

The aim of this work was to evaluate a method for the estimation of the effective renal plasma flow (ERPF) using sodium 131I-o-hippurate (OIH) by means the bicompartmental analysis of the radioactive concentration of 4 plasma samples, analyzing the error obtained respecting to the multi-sample method and comparing it with those obtained with other simplified methods. We calculated the ERPF from 62 patients using the multi-sample method as standard, the method based in a single sample at 44 minutes p.i., a method based in 2 samples from the first exponential, 4 methods based in 2 samples from the second exponential, one method based in 3 samples and 5 methods based in 4 samples (2 from the first exponential and 2 from the second exponential). Each simplified method was compared to the standard method and their absolute error (AE) and standard estimation error (SEE) were calculated. The method based in the 4 samples withdrawn at 4, 10, 30 and 60 minutes p.i. was the best of them with a correlation factor with the standard equal to 0.997, an EA that ranged from -63 ml/min to 49 ml/min (mean: -4 ml/min) and a SEE of 19.5 ml/min.

[Audit of deaths due to cervical cancer in a health service of Santiago. A preliminary analysis]

BACKGROUND

Despite the epidemiological importance and the surveillance programs to detect cervix uterine cancer in Chile, its mortality continues to be high.

AIM

To perform an audit of all deaths due to cervix uterine cancer, that occurred in a health service of Santiago during 1995.

MATERIAL AND METHODS

The clinical records and pathological studies of 46 women, whose death certificates indicated cervix uterine cancer as the cause of death, were audited.

RESULTS

In six women, the audit revealed that the cause of death was not a cervix uterine cancer, and they were discarded from further analyses. The higher mortality rate (36/100,000) occurred in women over 64 years old, those living in the poorest community and with less Papanicolaou vaginal smears coverage (La Pintana). The evolution prior to diagnosis was registered in only four women and was of less than one year. Most women consulted in advanced stages of the disease and only 48% were subjected to some sort of treatment (surgery, radiotherapy or chemotherapy). Mean survival was 3 years and mean age at death was 55.5 years old. There was a great lack of clinical and epidemiological information. In only 13 women information about previous Pap smears was registered.

CONCLUSIONS

Audit of deaths should be an important component of preventive programs for cervix uterine cancer, and the coverage of Pap smears should be improved.

[Prevalence of anti-hepatitis A in patients with chronic liver disease]

The recent availability of an effective vaccine for preventing hepatitis A has led to the performance of a prevalence study of antibodies versus the hepatitis A virus (HAV) in our patients with chronic liver disease by hepatitis B and C, as a step prior to vaccination. The sera of 425 patients with a mean age of 40 years was studied, with the global antibodies versus HAV being determined (Abbott). The prevalence was to 75.2% varying from 20% at 19 years to 93% in those over the age of 40. The prevalence was not related to sex, previous parenteral history, or drug addiction or infection by hepatitis B or C. Due to previous cost-benefit studies and the high prevalence found, the determination of anti-HAV in patients with chronic viral liver diseases prior to vaccination against HAV is recommended.

Serotypes of Escherichia coli isolated from septicaemic chickens in Galicia (northwest Spain)

The purpose of this study was to establish the serogroups of Escherichia coli that cause avian colibacillosis in Spain. The serogroups of 625 avian E. coli isolated between 1992 and 1993 were determined. The 458 E. coli from chickens with septicaemia belonged to 62 different O serogroups; however, 59% were of one of 18 serogroups (O1, O2, O5, O8, O12, O14, O15, O18, O20, O53, O78, O81, O83, O102, O103, O115, O116 and O132). These 18 serogroups were also determined as an important percentage (29%) of control isolates from faeces of healthy birds. Nevertheless, a significant difference (59% versus 29%; P < 0.001) was observed. Furthermore, the serogroups O12, O14, O18, O53, O78, O81, O102, O115, O116 and O132 were almost exclusively identified among septicaemic E. coli (31% versus 3%; P < 0.001). The high prevalence of O18, O81, O115, O116 and O132 isolates was not expected and may indicate the emergence of five new serogroups associated with avian colibacillosis not yet reported.

[Radionuclide scan with TC-99m-tin colloid in the evaluation of orthopedic implant infections]

We have studied 26 patients (32-77 years old, 16 females) with suspicion of joint arthroplasty infection: 11 total hip replacements, 12 total knee replacements and 3 osteosinthesys. A bone scintigraphy with MDP-99mTc, a scintigraphy with HMPAO-WBC and a scintigraphy with 99mTc-stannous colloid were made in all patients. The final diagnostic was based in joint cultures and clinic and radiologic evolution of the patients. The earliest phase of the bone scintigraphy was positive in 18 patients. The later phase was positive in all them. The WBC was positive in 20 out of 26 patients. The bone marrow scintigraphy showed a congruent pattern with WBC in 18 patients (17 infected and 1 without infection). The other ones (8 patients) showed an incongruent pattern (7 with infection and 1 without it). The results show that the bone marrow scintigraphy with 99mTc-stannous colloid improves the accuracy of the diagnostic of bone prosthesis infection and should be included into the diagnosis protocol of this disease.

[Splenic infarction]

A 53-year-old male suffered splenic infarction etiologically related to atrial fibrillation and non-obstructive hypertrophic cardiomyopathy. The main clinical manifestations were a one-month history of epigastric and left upper quadrant pain, with tenderness to palpation in the later zone. Laboratory tests revealed a slight leucocytosis (14.700) with left shift and a marked increase in LDH concentration (945 IU). Abdominal CAT and arteriography established the diagnosis, Echography proved normal. Patient evolution was satisfactory with conservative medical treatment. We conclude that splenic infarction should be considered in all cases of acute or chronic pain in the left hypochondrium. The diagnosis is established by CAT, arteriography and hepatosplenic gammagraphy. Medical management is initially advocated, surgery being reserved for those cases involving complications or in which diagnosis is not clear. Emphasis is placed on the main etiological, clinical, diagnostic and management characteristics of splenic infarction.

Intramammary immunization with live-attenuated Staphylococcus aureus: microbiological and immunological studies in a mouse mastitis model

Mammary infection was induced in lactating mice by intramammary injection of Staphylococcus aureus. Histopathological analysis revealed infiltration and lesions of varying magnitude that were still apparent 21 days after the challenge. Concomitantly, viable S. aureus was recovered from infected mammary glands. Mice were immunized by the intramammary route with 5 x 10(6) colony forming units of a temperature-sensitive mutant of S. aureus and subsequently received a boosting injection seven days later. On day 14 mice were challenged by the intramammary route with the wild-type strain. Intramammary immunization induced a significant increase in milk IgA (P < 0.05), serum IgG (P < 0.05) and serum IgA (P < 0.05) on the day of the challenge, when compared with non-immunized mice. Immunization decreased significantly (P < 0.01) the number of S. aureus colony forming units recovered 96 h after intramammary challenge. In conclusion, the feasibility of immunizing locally with temperature-sensitive S. aureus to induce immunity in the mouse mammary gland was demonstrated. The mouse model of mastitis is proposed as a useful system for screening temperature-sensitive S. aureus strains to be utilized in the development of a vaccine.

[Surgical risk assessment using multivariate analysis]

INTRODUCTION

Over and above the risk of a disease itself, surgical treatment implies additional risk involving possible temporary or permanent deterioration in a patient's health. Most studies of anesthetic-surgical risk are based on mortality or serious morbidity (severe, permanent deterioration). They may therefore be of limited applicability in hospitals where such outcomes are rare due to the types of patients treated. In order to compare and classify patients as well as improve outcome in such health care settings other parameters must be evaluated.

PATIENTS AND METHODS

Indicators presaging adverse situations related directly to surgery in our postoperative intensive care units involve blood transfusion and perioperative events. By applying multivariate (regression) analysis we can determine the factors that condition these unfavorable situations.

RESULTS

In the setting we studied, the main determinants of unfavorable events after surgery are patient health as shown by ASA classification, duration of operation and type of surgery.

CONCLUSIONS

1) Peripheral surgery in patients in good health is very safe. 2) Easily obtained parameters can be used to obtain a fairly efficient prediction of risk. 3) Single-setting risk studies are easy to carry out and useful for providing information about a specific hospital center.

[A case of Prune Belly Syndrome. Prenatal diagnosis]

Prune Belly Syndrome is a rare and complicated condition affecting the genitourinary organs and abdominal wall, it was named after the aspect of the abdomen after the bladder has been drained. In its fully developed form presents with the triad: megalocyst, abdominal muscle deficiency and cryptorchidism. We present a case of a patient with 22 weeks of gestation with ultrasonographic diagnosis of a large thoracoabdominal cyst. The delivery was by cesarean operation. We analyzed the literature.

[Obstetric analgesia using continuous epidural perfusion of bupivacaine, adrenaline, and fentanyl]

OBJECTIVES

To determine the efficacy and complications of continuous epidural perfusion of bupivacaine, adrenaline and fentanyl in the relief of pain during first and second stage labour during vaginal birth.

PATIENTS AND METHODS

Between January 1990 and March 1993 we used continuous epidural perfusion for control of pain during labor in 1307 women. The solution administered through an epidural catheter and maintained until expulsion was one 10 ml bolus of bupivacaine 0.25% with adrenaline 1:200,000 and fentanyl 25 micrograms followed by continuous perfusion of bupivacaine 0.0625% with adrenaline 1:200,000 and fentanyl 2 micrograms/ml at an infusion rate of 12 ml/h. When analgesia was insufficient, a bolus of local anesthetic was administered or a pudendal block was carried out.

RESULTS

Ninety-two percent of the birthing women reported good analgesic effect during the first stage; for 7% the effect was fair and for 0.55% it was poor. During the second stage 88% reported satisfactory analgesia, and 8% fair or poor. Assessment was not possible for the remaining women, who underwent cesarean sections. Complications were few and easily controllable.

CONCLUSIONS

Maintenance of epidural perfusion with 0.0625% bupivacaine with adrenaline 1:200,000 and fentanyl 2 micrograms/ml provides sufficient analgesia during all stages of childbirth.

[Asymptomatic bacteriuria and pyuria during pregnancy]

BACKGROUND

The presence of pyuria and the role of mixed culture in the diagnosis of asymptomatic bacteriuria in pregnant women have been evaluated

METHODS

One hundred and sixty four pregnant women without any symptomatology have been studied using two cultures of mid-stream urine samples and pyuria quantification. In addition culture of bladder urine has been carried out in 17 of these patients (12 with pure cultures and 5 with mixed cultures).

RESULTS

110 samples were culture negative without pyuria; 7 were pure cultures with pyuria; 19 pure culture without pyuria and the remaining 28 patients yielded mixed culture with or without pyuria in the first culture. Twenty of these 28 mixed cultures were negative in the second culture. A estimated frequency of asymptomatic bacteriuria in pregnancy was 16% and pyuria was only found in 27% of pregnant women with asymptomatic bacteriuria.

CONCLUSION

The pyuria is not a useful marker for the diagnosis of asymptomatic bacteriuria in pregnancy.

[Long-term results of endoscopic sphincterotomy]

A review is made of the results of long-term endoscopic sphincterotomy. We studied 81 endoscopic sphincterotomies performed between 1980 and 1985. The technique performed, its indications and immediate complications were evaluated, along with the follow-up carried out in these patients (minimum 6 years). In view of the results obtained, the patients were classified as asymptomatic or symptomatic. Thus, immediate complications (21.9%) were all minor, with the exception of one case (1.2%) of severe complication due to acute pancreatitis. One death was recorded three days after sphincterotomy, corresponding to an elderly patient with in situ gallbladder as a consequence of biliary sepsis. In turn, 91.4% of the patients followed-up at long term remained asymptomatic. The overall results show the method to be effective, with few either immediate or long-term complications.

[The accidents and complications of laparoscopy. A review of 8,915 cases]

Complications occurring in 8,915 laparoscopies done during 1957-1991 are analyzed. Complications were classified as major or minor, according to the need of surgical intervention for their management, and also in relation to pneumoperitoneum, introduction of the laparoscope, during the examination or after laparoscopy. The total number of major accidents was 54 (0.60%). Half of them as a consequence of the instrumentation or of liver biopsy. There were 442 minor complications (4.96%). Mortality included 10 patients (0.11%) as a sequel of uncontrolled haemorrhage, 5 of them after liver biopsy. The complications of laparoscopy cannot be ignored; as all invasive techniques it may have a risk, even in the most expert hands. Half of the major accidents and of the mortality were due to complications from liver biopsy.

[Syncope as presentation form of pulmonary thromboembolism. Study of 15 cases]

BACKGROUND

To evaluate the prevalence of syncope as a form of presentation of pulmonary thromboembolism (PTE) in the emergency department of a general hospital.

METHODS

All the cases of PTE having gone to the emergency department between May 1983 and July 1989 were collected. A radiography of the thorax, arterial gasometry, an electrocardiogram and a pulmonary perfusion scintigraphy were performed in each patient. Ventilation scintigraphy and/or pulmonary DIVAS were also carried out when necessary.

RESULTS

Of a total of 63 patients, 15 (24%) had a syncope as a primary manifestation. No significant differences were observed in regards to predisposing factors between the syncope group (S) and the non-syncope group (NS) with there being a predominance of women in the S group (p less than 0.05). Furthermore, the S group had a greater prevalence of tachycardia, hypotension, electrocardiographic changes, pleural effusion and perfusion defect greater than 50% in the pulmonary scintigraphy.

CONCLUSIONS

PTE should be discarded in any patient with a clinical picture of syncope with hypotension and tachycardia, especially if female. When PTE is presented as a syncope it is generally a massive embolism.

[Antimicrobial activity of ornidazole and 6 other antibiotics against anaerobic bacteria]

The antimicrobial susceptibility of 235 anaerobic bacterial strains to ornidazole, metronidazole, chloramphenicol, clindamycin, penicillin, cefoxitin and imipenem has been studied using agar-dilution technique. Ornidazole and metronidazole were active against 88.6% and 86% of gram-positive cocci. Overall, 99.1% of Bacteroides group fragilis, and 91.3% of non-fragilis Bacteroides were also sensitive to both drugs. We did not find any Clostridium perfringens resistant strain. Cefoxitin and penicillin showed good activity against all Clostridium perfringens strains, and also against 97.7% and 92.5% of gram-positive cocci. We found one single imipenem resistant strain among gram-positive bacteria. Bacteroides fragilis also showed sensitivity to penicillin (41.5%), cefoxitin (85.7%) and imipenem (97.1%). Clindamycin was active against Clostridium perfringens (90.9%), gram-positive cocci (86.7%) and imipenem (68.6%). Chloramphenicol showed good activity against Clostridium perfringens (100%), gram-positive cocci (95.5%) and Bacteroides spp. (99.4%). Our results showed an overall good activity of all the seven drugs tested against anaerobic gram-positive microorganisms. Of notice, we found a good activity of chloramphenicol, imipenem, metronidazole and ornidazole against Bacteroides spp.

The quality control of tuberculin PPD products from seven Latin American laboratories

The Pan American Health Organization, through its Pan American Zoonoses Center (CEPANZO), distributes the concentrated stock solution of PPD batch RT23 (1 mg ml-1 = 50,000 TU ml-1) to national central laboratories. In the laboratories the stock solution is diluted to 2 TU/0.1 ml and dispensed with the addition of Tween 80 and either chinosol or phenol as preservatives in rubber-stoppered vials for use in the Mantoux test. The expiry date is usually fixed at six months after filling. Samples of nine lots of PPD 2 TU from seven countries (Argentina, Brazil, Colombia, Dominican Republic, Ecuador, Paraguay and Uruguay) were received by CEPANZO for quality control. The biological activity and phenol concentrations of these samples were assayed periodically after storage at 4, 25 or 37 degrees C either unopened or opened and re-used in a manner simulating extreme field conditions of use and storage. The object of the study was to determine the stability of the biological activity as well as the maintenance of sterility of these conditions with a view to assessing the need for stricter requirements for the labelling of tuberculin. The results obtained showed that PPD 2 TU with 0.4-0.5% (w/v) phenol added, and dispensed in vials, was stable in its biological activity and maintained its sterility. Therefore, it seems unnecessary to issue stricter requirements than those currently applied.(ABSTRACT TRUNCATED AT 250 WORDS)