Isolated pulmonic valve infective endocarditis: a persistent challenge

Isolated pulmonic valve infective endocarditis is an uncommon clinical entity. We report our experience with three patients diagnosed with pulmonic valve endocarditis from our institution. Two cases were caused by Enterococcus faecalis (one was resistant to vancomycin) and one by coagulase-negative staphylococci (CNS). One of the cases of isolated pulmonic valve endocarditis due to the E. faecalis was nosocomially acquired; the case of CNS pulmonic valve endocarditis was dialysis catheter related. Each patient with isolated pulmonic valve endocarditis presented with hypotension and interstitial pulmonary infiltrates. Two patients were treated with linezolid. Both vancomycin-resistant enterococci (VRE) and CNS were eliminated from blood cultures on linezolid therapy. The challenges inherent in the management of pulmonic valve endocarditis mandate the development of individual patient-specific guidelines.

Factores asociados a la hospitalización por procesos sensibles a cuidados ambulatorios en los municipios

OBJECTIVES

To describe variability in admission rates for ambulatory care sensitive conditions (ASSC) in municipalities in the catchment area of a tertiary hospital and to determine the influence of primary care characteristics, socioeconomic factors, health of the population, and geographical accessibility to the hospital on this variability.

METHODS

An ecological study was carried out in 34 municipalities in the area served by the Hospital Virgen de las Nieves in Granada (Spain) including all admissions for ASSC from 1997 to 1999. The admission rates for men and women were calculated separately and were age-standardized by the indirect method. The following factors were analyzed as independent variables: characteristics of primary care (type of healthcare model and type of center), socioeconomic factors (unemployment rate, income per capita, number of business establishments, size of municipality), health (mortality rate), and accessibility (time in minutes from the municipality to the hospital). A multiple lineal regression model was estimated.

RESULTS

A total of 9.8% of all hospital admissions were due to ASSC. The mean annual admission rate was 10 admissions per 1.000 inhabitants. This rate was higher for men and for persons aged more than 74 years. The standardized admission ratios were not statistically different from 1 in 56% of the municipalities and were higher than 1 in 26% and lower than 1 in 18%. Sixty-two percent of the variability in rates for men was associated with time taken to reach the hospital, size of municipality, the interaction between both variables, and mortality. Eighteen percent of the variability in rates for women was associated with time taken to reach the hospital and the unemployment rate.

CONCLUSIONS

Variability in admission rates for ASSC was not associated with primary care characteristics in the geographical area analyzed. Accessibility (measured as time to the hospital) was the only variable associated with higher rates in both men and women. Admission rates for ASSC among women were higher when unemployment rates were higher, and rates among men were higher in larger municipalities and in those with higher mortality.

Gaucher's disease: morphological findings in a case studied with fine needle aspiration

Fine needle aspiration (FNA) is a diagnostic tool whose inexpensiveness, simplicity and innocuousness have led it to be increasingly accepted in daily medical practice. This method, which is useful for the study of lesions that are accessible by radiological exploration or palpation, provides information about the cytological aspects of punctured lesions. Sometimes, such information can be extended to the histological area through study of cell blocks, true microbiopsies, which are of great diagnostic use. This was the technique used in the case described in the present report.

Helicobacter pylori infection: a new cause of anorexia in peritoneal dialysis patients

OBJECTIVE

Helicobacter pylori (HP) infection has frequently been found in dialysis patients. Chronic infections induce overproduction of pro-inflammatory substances. Inflammation has been associated with cachexia and anorexia. We explored the relationship between HP infection, anorexia, and malnutrition in peritoneal dialysis (PD) patients.

PATIENTS AND METHODS

The study included 48 clinically stable PD patients divided into four groups: HP+ with anorexia (group I, n = 12); HP+ without anorexia (group II, n = 4); HP- with anorexia (group III, n = 5); and HP- without anorexia (group IV, n = 27). Infection with HP was diagnosed by breath test. Anorexia was evaluated using a personal interview and an eating motivation scale (VAS). The VAS included five questions that are answered before and after eating. The questions concern desire to eat, hunger, feeling of fullness, prospective consumption, and palatability. Biochemical markers of nutrition and inflammation were also determined.

RESULTS

At baseline, group I showed lower scores for desire to eat, hunger sensation, prospective consumption, and palatability. They also showed lower lymphocyte counts, prealbumin, transferrin, serum albumin, normalized equivalent of protein-nitrogen appearance (nPNA), and residual renal function (RRF). In addition, the same group showed higher levels of C-reactive protein (CRP) and more sensation of fullness than the remaining groups. In the entire series, we found significant linear correlations between the following markers of nutrition and certain questions on the VAS: albumin with before-lunch desire to eat (r = 0.38, p < 0.05), and prealbumin with before-lunch hunger (r = 0.41, p < 0.05) and after-lunch hunger (r = -0.35, p < 0.05). Negative linear correlations were found between albumin and fullness before lunch (r = -0.45, p < 0.01), and between prealbumin and before-lunch desire to eat (r = -0.39, p < 0.05). Negative linear correlations were also seen between CRP and albumin (r = -0.35, p < 0.05) and between CRP and prealbumin (r = -0.36, p < 0.05). Similarly, CRP showed a negative correlation with before-lunch desire to eat (r = -0.38, p < 0.05) and afterlunch desire to eat (r = -0.45, p < 0.01). After HP eradication, group I showed a significant increase in markers of nutrition and in VAS scores for almost all questions. Simultaneously, they showed a decrease in CRP level. Significant differences were also found in lymphocyte count (1105 +/- 259.4 cells/mm3 vs 1330.8 +/- 316 cells/mm3, p < 0.05), nPNA (0.9 +/- 0.16 g/kg/day vs 1.07 +/- 0.3 g/kg/day, p < 0.05), prealbumin (26.7 +/- 6.5 mg/dL vs 33.9 +/- 56.6 mg/dL, p < 0.01), albumin (3.48 +/- 0.3 g/dL vs 3.67 +/- 0.35 g/dL, p < 0.05), CRP (1.16 +/- 1.14 mg/dL vs 0.88 +/- 1.2 mg/dL, p < 0.054), before-lunch desire to eat (56.6 +/- 6.8 vs 72.2 +/- 4, p < 0.001), after-lunch desire to eat (5.4 +/- 2.6 vs 12.3 +/- 2, p < 0.01), hunger before lunch (55.4 +/- 5.4 vs 73.1 +/- 4.6, p < 0.001), hunger after lunch (5.8 +/- 2.9 vs 11 +/- 4, p < 0.01), fullness before lunch (36.6 +/- 10.3 vs 18.7 +/- 8.8, p < 0.001), consumption after lunch (5 +/- 4.7 vs 17.5 +/- 18, p < 0.05), and palatability (61 +/- 5.3 vs 74.1 +/- 4.1, p < 0.001).

CONCLUSION

Infection with HP is associated with anorexia, inflammation, and malnutrition in PD patients. Eradication of HP significantly improves this syndrome. Residual renal function seem to have a protective effect on appetite preservation. The present study supports the hypothesis of the involvement of inflammation in the pathogenesis of malnutrition in PD patients.

[Epidemiology of hip fractures in the elderly in Spain]

BACKGROUND

Ninety percent of hip fractures (HF) occur in people older than 64 years. We describe the epidemiological data (age, sex, date of admission and discharge and mortality) of elderly with hip fracture in the different regions of Spain.

METHOD

Data obtained from the Minimum Data Set of the Ministry of Health were used to analyse hip fracture incidence (Identified by codes 820.0 through 820.9 of the International Classification of Diseases) from 1996 through 1999. Demographic data of Spanish population were obtained from the National Institute of Statistics. HF rates were calculated using crude and age-and-sex adjusted density of incidence. Factors associated with in-hospital mortality were assessed by multivariate analyses.

RESULTS

89% (130.414) of 146.383 HF cases studied were in elderly patients with a mean age of 82 years old, being 78% females. The results showed a great variability through the different regions. Length of hospital stay was 16 days, and in-hospital mortality was 5%. Global HF rate was 517 cases per 100.000 elderly per year (270 cases/100.000 elderly males and 695/100.000 elderly females). In-hospital mortality was higher in males than females (8.1% vs 4.2%, respectively), increases progressively with age and it is higher during winter months. Factors associated with mortality were old age, male gender, fractured in winter, and living in Regions others than Mediterranean and Canary Islands.

CONCLUSIONS

Hip fracture is a condition that occurs more commonly in elderly people. It is more frequent in females and shows a great variation in incidence, mortality and length of hospital stay through different Spanish regions.

Abomasal and small intestinal nematodes from captive gazelles in Spain

The abomasal and small intestinal helminth fauna of three species of captive gazelles (Gazella dama mhorr, G. cuvieri and G. dorcas neglecta) kept in captivity in Almería (southeast Spain) have been studied, and the following species were identified: Nematodirus spathiger, N. filicollis, N. helvetianus, Camelostrongylus mentulatus, Trichostrongylus vitrinus, T. probolurus, T. colubriformis, Ostertagia ostertagi, O. harrisi, Teladorsagia (Ostertagia) circumcincta, and T. (Ostertagia) davtiani. Camelostrongylus mentulatus and N. spathiger were the most prevalent and abundant parasites. Ostertagia ostertagi, O. harrisi, N. helvetianus, and T. (Ostertagia) davtiani were identified for the first time in the genus Gazella. In addition, O. harrisi and Trichostrongylus probolurus are new records for Spain.

Endoscopic ligation compared with combined treatment with nadolol and isosorbide mononitrate to prevent recurrent variceal bleeding

BACKGROUND

After an episode of acute bleeding from esophageal varices, patients are at high risk for recurrent bleeding and death. We compared two treatments to prevent recurrent bleeding--endoscopic ligation and combined medical therapy with nadolol and isosorbide mononitrate.

METHODS

We randomly assigned 144 patients with cirrhosis who were hospitalized with esophageal variceal bleeding to receive treatment with endoscopic ligation (72 patients) or the combined medical therapy (72 patients). Sessions of ligation were repeated every two to three weeks until the varices were eradicated. The initial dose of nadolol was 80 mg orally once daily, with adjustment according to the resting heart rate; isosorbide mononitrate was given in increasing doses, beginning at 20 mg once a day at bed time and rising over the course of one week to 40 mg orally twice a day, unless side effects occurred. The primary end points were recurrent bleeding, complications, and death.

RESULTS

The median follow-up period was 21 months. A total of 35 patients in the ligation group and 24 in the medication group had recurrent bleeding. The probability of recurrence was lower in the medication group, both for all episodes related to portal hypertension (P=0.04) and for recurrent variceal bleeding (P=0.04). There were major complications in nine patients treated with ligation (seven had bleeding esophageal ulcers and two had aspiration pneumonia) and two treated with medication (both had bradycardia and dyspnea) (P=0.05). Thirty patients in the ligation group died, as did 23 patients in the medication group (P=0.52). The probability of recurrent bleeding was lower for patients with a hemodynamic response to therapy, defined as a decrease in the hepatic venous pressure gradient of more than 20 percent from the base-line value or to less than 12 mm Hg (18 percent, vs. 54 percent in patients with no hemodynamic response at one year; P<0.001), and the probability of survival was higher (94 percent vs. 78 percent at one year, P=0.02).

CONCLUSIONS

Combined therapy with nadolol and isosorbide mononitrate is more effective than endoscopic ligation for the prevention of recurrent bleeding and is associated with a lower rate of major complications. A hemodynamic response to treatment is associated with a better long-term prognosis.

Effect of different methods of administration of ivermectin on its efficacy against the shedding of gastrointestinal nematode eggs by gazelles

Seven different methods of administering ivermectin to gazelles were compared: subcutaneous injection, direct oral administration, administration in individual feeds, administration in a herd feed, direct oral administration of a second ivermectin formulation, administration in individual water supplies, and administration in the herd's water supply. The first five treatments were effective, as monitored by faecal egg count reduction tests, and administration in individual feeds or in a herd feed avoided the need to capture the animals, with the attendant risk of mortality. Of the factors associated with the recipients (species, sex, age and inbreeding coefficient) age was the only significant factor for the efficacy of the treatment. Oral or subcutaneous, individual or collective, and direct or indirect administrations were equally satisfactory for the treatment of all the parasite groups studied. Only when parasitic problems were due to Nematodirus species did direct administration to individual animals appear to be preferable.

Somatostatin treatment and risk stratification by continuous portal pressure monitoring during acute variceal bleeding

BACKGROUND AND AIMS

During acute variceal bleeding, several factors may lead to elevations of hepatic venous pressure gradient (HVPG), which may precipitate further hemorrhage. Whether somatostatin can suppress these increments is unknown. This study monitored somatostatin effects on HVPG during acute bleeding and assessed whether the changes affect outcome.

METHODS

In 40 patients with acute variceal bleeding treated with sclerotherapy, a catheter was placed into a main hepatic vein for 24-hour serial measurements of HVPG. After baseline measurements, patients received somatostatin (N = 25) or placebo (N = 15) under double blind conditions.

RESULTS

Somatostatin but not placebo produced a sustained decrease in HVPG (from 20.7 +/- 3.7 mm Hg to 17.7 +/- 2.7, P < 0.01). In patients receiving placebo, HVPG increased after a test meal (P = 0.018) and after blood transfusion (P = 0.034). Somatostatin completely prevented these increments. HVPG decreased significantly only in patients without further bleeding. One of 27 patients with HVPG <20 mm Hg at baseline or decreased >10% rebled vs. 9 of 13 who had neither of these 2 criteria (P < 0.0001). Both criteria had independent prognostic value for further bleeding.

CONCLUSIONS

During acute variceal bleeding, somatostatin produces a significant and sustained decrease in HVPG and prevents secondary elevations. Monitoring HVPG may stratify further bleeding risk and discriminate treatment response.

Oral administration of mebendazole failed to reduce nematode egg shedding in captive African gazelles

Idiosyncracies are observed in captive wild animals as regards the pharmacokinetics and efficacy of anthelmintics. This could be attributed to such factors as differences in host's metabolism, irregular distribution of anthelmintics due to the way they are administered and worm resistance to anthelmintics. Previously mebendazole was found to be poorly effective when administered in feed. An experiment was conducted to evaluate the efficacy of mebendazole when administered at the dosage rate of 15-20 mg/kg body weight to gastrointestinal nematodes in captive gazelles. Fifty-eight adult gazelles (Gazella cuvieri) were divided into four groups: T1 (animals dosed orally, directly into the mouth), T2 (treated orally, mixed in the water of a herd), T3 (treated orally, mixed in the water of one animal), and T4 (not treated). Individual faecal samples were taken before treatment, and 15 days thereafter. Mean percentages of reduction of egg shedding were calculated for Nematodirus spp., other trichostrongyles, total trichostrongylids, Trichuris spp. and total nematodes. No statistically significant differences were detected between the treatment groups and the control group or among the animals in the three treatment groups.

A prospective blinded evaluation of nerve conduction velocity versus Pressure-Specified Sensory Testing in carpal tunnel syndrome

The aim of this study was to compare the sensitivity, specificity, and pain associated with nerve conduction velocity testing and a new modality, the Pressure-Specified Sensory Device, in the diagnosis of carpal tunnel syndrome. The authors evaluated 79 patients, including 26 control subjects, and made the diagnosis of carpal tunnel syndrome based on the patient's history and physical examination. Both tests were then performed on each patient. The testers were blinded to the diagnosis and to any other test results. A 0 to 10-point visual analog pain scale was used to record the patient's reported testing discomfort. The sensitivity, specificity, and mean pain scale scores were calculated for each testing modality and compared. The nerve conduction velocity test had a sensitivity of 80% and a specificity of 77% whereas the sensitivity of the Pressure-Specified Sensory Device was 91% and the specificity was 82%. The difference between the tests was not significant. There was, however, a significant difference in the pain scores: nerve conduction velocity, 2.7 points; Pressure-Specified Sensory Device, 0.9 points (p < 0.001). This study shows that the Pressure-Specified Sensory Device is as sensitive and specific as nerve conduction velocity testing in the diagnosis of carpal tunnel syndrome, and is significantly less painful for the patient.