Continuous prolonged prone positioning in COVID-19-related ARDS: a multicenter cohort study from Chile

Background

Prone positioning is currently applied in time-limited daily sessions up to 24 h which determines that most patients require several sessions. Although longer prone sessions have been reported, there is scarce evidence about the feasibility and safety of such approach. We analyzed feasibility and safety of a continuous prolonged prone positioning strategy implemented nationwide, in a large cohort of COVID-19 patients in Chile.

Methods

Retrospective cohort study of mechanically ventilated COVID-19 patients with moderate-to-severe acute respiratory distress syndrome (ARDS), conducted in 15 Intensive Care Units, which adhered to a national protocol of continuous prone sessions  ≥ 48 h and until PaO2:FiO2 increased above 200 mm Hg. The number and extension of prone sessions were registered, along with relevant physiologic data and adverse events related to prone positioning. The cohort was stratified according to the first prone session duration: Group A, 2–3 days; Group B, 4–5 days; and Group C, > 5 days. Multivariable regression analyses were performed to assess whether the duration of prone sessions could impact safety.

Results

We included 417 patients who required a first prone session of 4 (3–5) days, of whom 318 (76.3%) received only one session. During the first prone session the main adverse event was grade 1–2 pressure sores in 97 (23.9%) patients; severe adverse events were infrequent with 17 non-scheduled extubations (4.2%). 90-day mortality was 36.2%. Ninety-eight patients (24%) were classified as group C; they exhibited a more severe ARDS at baseline, as reflected by lower PaO2:FiO2 ratio and higher ventilatory ratio, and had a higher rate of pressure sores (44%) and higher 90-day mortality (48%). However, after adjustment for severity and several relevant confounders, prone session duration was not associated with mortality or pressure sores.

Conclusions

Nationwide implementation of a continuous prolonged prone positioning strategy for COVID-19 ARDS patients was feasible. Minor pressure sores were frequent but within the ranges previously described, while severe adverse events were infrequent. The duration of prone session did not have an adverse effect on safety.

Outcomes of Sepsis and Septic Shock in Cancer Patients: Focus on Lactate

The number of oncological patients (OP) admitted to intensive care units (ICU) for sepsis/septic shock has dramatically increased in recent years. The definition of septic shock has been modified, adding hyperlactatemia as a severity biomarker for mortality. However, it remains poorly reported in septic OP. We performed a retrospective analysis from a prospective database of sepsis/septic shock patients admitted to our ICU between September 2017 and September 2019 and followed until day 90. We identified 251 patients and 31.9% had active oncological comorbidity, mainly solid tumor (81.3%). Septic shock criteria were met for 112 (44.6%). Hyperlactatemia was observed in 136 (54.2%) patients and this was associated with a lower survival rate. Overall 90-day mortality was 15.1%. In OP vs. non-OP, hyperlactatemia was more frequent (65% vs. 49.1%, p = 0.013) and associated with lower survival (65.4% vs. 85.7%, p = 0.046). In OP, poor performance status was also associated with lower survival (HR 7.029 [1.998-24.731], p = 0.002) In an adjusted analysis, cancer was associated with lower 90-day survival (HR 2.690 [1.402-5.160], p = 0.003). In conclusion, septic OP remains a high mortality risk group in whom lactate levels and performance status could help with better risk stratification.

General care in the management of severe traumatic brain injury: Latin American consensus

Severe traumatic brain injury (sTBI) remains prevalent in the young adult population. Indeed, far from descending, the incidence of sTBI remains high. One of the key bases of treatment is to avoid, detect and correct secondary injuries of systemic origin, which aggravate the primary lesion. Much of this can be achieved by maintaining an adequate physiological microenvironment allowing recovery of the damaged brain tissue. General care measures are nonspecific actions designed to meet that objective. The available guidelines on the management of sTBI have not included the topics contemplated in this consensus. In this regard, a group of members of the Latin American Brain Injury Consortium (LABIC), involved in the different aspects of the acute management of sTBI (neurosurgeons, intensivists, anesthesiologists, neurologists, nurses and physiotherapists) were gathered. An exhaustive literature search was made of selected topics in the LILACS, PubMed, Embase, Scopus, Cochrane Controlled Register of Trials and Web of Science databases. To establish recommendations or suggestions with their respective strength or weakness, the GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was applied. Additionally, certain recommendations (included in complementary material) were not assessed by GRADE, because they constitute a set of therapeutic actions of effective compliance, in which it was not possible to apply the said methodology. Thirty-two recommendations were established, 16 strong and 16 weak, with their respective levels of evidence. This consensus attempts to standardize and establish basic general care measures in this particular patient population.

[Deep brain stimulation in Parkinson's disease]

BACKGROUND

Deep brain stimulation is an essential therapeutic tool in Parkinson's disease.

AIM

To assess the results of a series of patients with Parkinson's disease treated with micro-electrode guided subthalamic nucleus stimulation.

MATERIAL AND METHODS

Twenty patients with idiopathic Parkinson's disease were studied (10 males). Three months after surgery, we analyzed the change in motor disturbances, medication need to control symptoms and quality of life.

RESULTS

We observed a significant improvement in all the assessed variables. Motor involvement determined as OFF hours and expressed as percentage of the day changed from 30 ± 15 to 10 ± 7% in the preoperative and postoperative periods, respectively. ON hours without dyskinesia changed from 17 ± 16 to 78 ± 21%. ON hours with dyskinesia changed from 53 ± 23 to 12 ± 15%. Medication need changed from 1,505 ± 499 to 1,214 ± 528 levodopa equivalents. Parkinson's Disease Questionnaire 39 score changed from 62.9 ± 22.7 to 34.3 ± 18.5. During the 5-year follow-up a continuous improvement of symptoms was observed.

CONCLUSIONS

Micro-electrode guided subthalamic nucleus functional surgery in patients with Parkinson's disease has good immediate and late results.

In Situ Synthesis of Al-Based MMCs Reinforced with AlN by Mechanical Alloying under NH₃ Gas

Aluminum matrix composites (AMCs) reinforced by aluminum nitride were prepared by mechanical alloying followed by a simple press and sintering method. Milling began under vacuum and after a period of between 1 and 4 h, NH₃ gas flow (1 cm³/s) was incorporated until the total milling time of 5 h was reached. Results show that in addition to the strain hardening taking place during mechanical alloying, NH₃ plays an additional role in powder hardening. Thereby, the properties of the sintered compacts are strongly influenced by the amount of N incorporated into the powders during milling and the subsequent formation of AlN during the consolidation process. The obtained AMC reaches tensile strengths as high as 459 MPa and hardness much higher than that of the as-received aluminum compact.

Uncovered secret of a Vasseur-Tramond wax model

The technique of anatomical wax modelling reached its heyday in Italy during the 18th century, through a fruitful collaboration between sculptors and anatomists. It soon spread to other countries, and prestigious schools were created in England, France, Spain and Austria. Paris subsequently replaced Italy as the major centre of manufacture, and anatomical waxes were created there from the mid-19th century in workshops such as that of Vasseur-Tramond. This workshop began to sell waxes to European Faculties of Medicine and Schools of Surgery around 1880. Little is known of the technique employed in the creation of such artefacts as this was deemed a professional secret. To gain some insight into the methods of construction, we have studied a Vasseur-Tramond wax model in the Valladolid University Anatomy Museum, Spain, by means of multi-slice computerised tomography and X-ray analysis by means of environmental scanning electron microscopy. Scanning electron microscopy was used to examine the hair. These results have revealed some of the methods used to make these anatomical models and the materials employed.

Risk factors for suicide in schizophrenia: systematic review and clinical recommendations

OBJECTIVE

To identify risk factors associated with suicide of patients with schizophrenia and provide clinical recommendations, which integrate research findings into a consensus based on clinical experience and evidence.

METHOD

A task force formed of experts and clinicians iteratively developed consensus through serial revisions using the Delphi method. Initial survey items were based on systematic literature review published up to June 2013.

RESULTS

Various risk factors were reported to be implicated in suicide in schizophrenia. Our findings indicate that suicide risk in schizophrenia is mainly related to affective symptoms, history of a suicide attempt and number of psychiatric admissions. Other risk factors identified are given by younger age, closeness to illness onset, older age at illness onset, male sex, substance abuse and period during or following psychiatric discharge. Integrating the evidence and the experience of the task force members, a consensus was reached on 14 clinical recommendations.

CONCLUSION

Identification of risk factors for suicide in individuals diagnosed with schizophrenia is imperative to improve clinical management and develop strategies to reduce the incidence of suicide in this population. This study provides the critical overview of available data and clinical recommendations on recognition and management of the above-mentioned risk factors.

Occupational disability in bipolar disorder: analysis of predictors of being on severe disablement benefit (PREBIS study data)

OBJECTIVE

Patients diagnosed with bipolar disorder (BD) are reported to have significant work impairment during interepisode intervals. This study was carried out to assess potential predictors of occupational disability in a longitudinal follow-up of euthymic patients.

METHOD

We included 327 euthymic patients diagnosed with BD type I or type II, 226 of whom were employed and 101 were receiving a severe disablement benefit (SDB). Sociodemographic data were studied and episode recurrence was assessed along a 1-year follow-up. Logistic regression analysis was applied to determine predictors of receiving SDB. Cox regression was built to study recurrences.

RESULTS

Predictors of receiving SDB were: axis II comorbidity [Odds Ratio (OR) = 2.94, CI: 1.26-6.86, P = 0.013], number of manic episodes (OR = 1.21, CI: 1.10-1.34, P < 0.001), being without stable partner (OR = 2.44, CI: 1.34-4.44, P = 0.004) and older age (OR = 1.08, CI: 1.05-1.12, P < 0.001). Bipolar patients receiving SDB presented more episodic recurrences regardless of polarity than employed bipolar patients (P = 0.002). The time until recurrence in 25% of the bipolar patients receiving SDB was 6.08 months (CI: 4.44-11.77) being 13.08 months (CI: 9.60 to -) in the employed group.

CONCLUSION

Occupational disability in bipolar patients is associated with axis II comorbidity, more previous manic episodes, not having a stable relationship, older age, and more recurrences at 1-year follow-up.

Social cognition and interaction training (SCIT) for outpatients with bipolar disorder

INTRODUCTION

Patients with bipolar disorder show social cognition deficits during both symptomatic and euthymic phases of the illness, partially independent of other cognitive dysfunctions and current mood. Previous studies in schizophrenia have revealed that social cognition is a modifiable domain. Social cognition and interaction training (SCIT) is an 18-week, manual-based, group treatment designed to improve social functioning by way of social cognition.

METHOD

37 outpatients with DSM-IV-TR bipolar and schizoaffective disorders were randomly assigned to treatment as usual (TAU)+SCIT (n=21) or TAU (n=16). Independent, blind evaluators assessed subjects before and after the intervention on Face Emotion Identification Task (FEIT), Face Emotion Discrimination (FEDT), Emotion Recognition (ER40), Theory of Mind (Hinting Task) and Hostility Bias (AIHQ).

RESULTS

Analysis of covariance revealed significant group effects for emotion perception, theory of mind, and depressive symptoms. The SCIT group showed a small within-group decrease on the AIHQ Blame subscale, a moderate decrease in AIHQ Hostility Bias, a small increase in scores on the Hinting Task, a moderate increase on the ER40, and large increases on the FEDT and FEIT. There was no evidence of effects on aggressive attributional biases or on global functioning.

LIMITATION

No follow up assessment was conducted, so it is unknown whether the effects of SCIT persist over time.

CONCLUSION

This trial provides preliminary evidence that SCIT is feasible and may improve social cognition for bipolar and schizoaffective outpatients.

DNA sperm damage correlates with nuclear ultrastructural sperm defects in teratozoospermic men

Sperm morphology has consistently been the best indicator of male fertility. Transmission electron microscopy currently provides the most information on the subcellular details of sperm structure. Recently, assessment of sperm DNA damage has been employed to assess fertility potential. The purpose of this work was to link sperm DNA damage, evaluated by an intercalated fluorescent dye, with the structural characteristics of sperm. Conventional semen analysis was performed on samples from men undergoing fertility evaluation. Thirty men were evaluated and assigned to three subgroups based on strict criteria for sperm morphology: normal morphology (>14% normal forms), intermediate morphology (5-14% normal forms), and poor morphology (<5% normal forms). By quantifying acridine orange-positive cells and ultrastructural sperm defects, we found that the poor morphology pattern group showed a positive association between sperm carrying damaged DNA and the percentage of sperm nucleus with vacuoles (P = 0.01). No statistically significant correlations were established in other ultrastructural characteristics of sperm, including immature chromatin, lytic changes, or abnormal sperm tails. These results suggest that zones without chromatin in the sperm nucleus reflect underlying chromosomal or DNA defects in severe teratozoospermic men. This association should be considered in the evaluation of male fertility.

[Ten myths about withdrawal of mechanical ventilation in terminal patients]

The most difficult of treatment limitation decisions, both for physicians and families, is the withdrawal of mechanical ventilation (MV). Many fears and uncertainties appear in this decision. They are described as ten myths whose falseness is argued in this article. The myths are: 1) Withdrawing MV causes the patients death; 2) Withdrawing MV is euthanasia; 3) Withholding and withdrawing MV are morally different; 4) MV can be withdrawn only when the patient has asked for it; 5) Chilean law only authorizes to withdraw VM when brain death has occurred; 6) Withdrawing MV cannot be done if the patient is not an organ donor; 7) Physicians who withdraw MV are in high risk of legal claims; 8) To withdraw MV the physician needs an authorization from the hospital ethics committee, lawyer or institutional authority; 9) There is only one way to withdraw MV; 10) Withdrawing MV produces great suffering to the patients family. Making clear that these myths are false facilitates appropriate decisions, therefore preventing therapeutic obstinacy and more suffering of terminally ill patients, which favors their peaceful death. For the physician this goal should be as rewarding as preventing the death of a curable patient.

[Validation of transcranial Doppler in the diagnosis of brain death]

BACKGROUND

The clinical diagnosis of brain death is complex.

AIM

To evaluate the diagnostic accuracy of transcranial Doppler (TCD) for brain death.

PATIENTS AND METHODS

Patients seen on the intensive care unit of a private hospital between January 2004 to December 2008, were included if they were in structural coma, had no craniectomy and had a blind evaluation by a neurologist and TCD done in less than three hours. The diagnosis of brain death was based on a clinical evaluation that considered the absence of sedative drugs, median blood pressure>60 mmHg, body temperature over 35 masculine Celsius and complete absence of brainstem reflexes. An expert neurosonologist, with a TCD-PMD-100, 2 Mhz transducer, used an institutional protocol that considers the examination as positive for brain circulatory arrest when there is presence of reverberating, small systolic peaks or the disappearance of a previous signal present on both middle cerebral arteries and intracranial vertebral arteries.

RESULTS

Fifty three patients were evaluated, 25 with clinical brain death. On 45 cases (84.9%), the interval between both evaluations was less than one hour. The sensitivity, specificity, positive and negative predictive values for the diagnosis of brain death with TCD were 100, 96, 96.1 and 100% respectively. Positive and negative likelihood ratios for brain death were 28 and 0, respectively.

CONCLUSIONS

TCD is a valid and useful technique for the diagnosis of brain death and can be used on complicated cases.

P300 event-related potential in euthymic patients with bipolar disorder

Auditory P300 event-related potential (ERP) and performance on Sustained Attention were evaluated in 24 euthymic bipolar patients and 38 healthy volunteers. There were no significant differences between groups, and performance in sustained attention had no significant influence in the P300 responses. P300 response might be driven by the presence of mood symptoms.

[Profile of bipolar disorder outpatients: a cross-sectional study in the Madrid Community]

INTRODUCTION

The purpose of this cross-sectional study is to obtain a sociodemographic, clinical, psychosocial functioning and therapeutic profile of bipolar outpatients in the Madrid Community.

METHODS

A total of 115 outpatients were consecutively recruited by 10 psychiatrists.

RESULTS

Mean time between initial symptoms and an accurate bipolar diagnosis was of 7.6 years. A depressive episode was the onset of the illness in most patients independently of clinical subtype. Syndromal or subsyndromal symptoms were present in 47% of the patient population, dominating the depressive polarity (33.1%). A subjectively reduced perception of quality of life was associated to the presence of depressive symptoms and a worse clinical outcome last year. More than half of the patients (58.2%) were overweight or obese. Lithium was the most frequently used mood stabilizer (71.3%), whereas 41% of the patients were taking at least three psychotropic drugs.

CONCLUSIONS

Results of this study widely confirm previous data on bipolar disorder. Reduction in quality of life of bipolar patients associated to depressive symptoms must be highlighted. It is necessary to optimize treatments in bipolar disorder in order to improve prognosis.

[Addition of an arterio-venous shunt during veno-arterial extracorporeal life support in a patient with Hantavirus pulmonary syndrome]

A subgroup of patients infected with the Hantavirus develops a pulmonary syndrome (HPS) characterized by severe acute respiratory failure and myocardial depression, that has a high mortality rate. Extracorporeal life support (ECLS) could be a valuable therapeutic tool in such patients. We report a 24 years old male with HPS that was successfully managed when an arterio-venous shunt was added to a conventional veno-arterial ECLS technique. Precise criteria have been developed to predict which patients should be considered for this treatment.

Process of adaptation to Spanish of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Scale. Self applied version (TEMPS-A)

INTRODUCTION

Investigation of the predisposing factors for affective disorders has shown that measures to assess affective temperament are necessary. The TEMPS-A is a self-evaluation measure to assess four affective temperaments (hyperthymic, depressive, cyclothymic and irritable) and anxious temperament.

METHOD

The TEMPS-A questionnaire version that includes 110 questions has been adapted following the translation-backtranslation methodology, including two translations to Spanish and the classification of equivalence to English by an independent author.

RESULTS

The study results indicated that a satisfactory translation was obtained, as indicated by the validation of equivalence by the bilingual consultant. All the items showed a perfect (A) or satisfactory equivalence (B).

CONCLUSIONS

The TEMPS-A, Spanish version, is an understandable questionnaire that is equivalent to the original version in English, that allows for the evaluation of affective temperaments.

[Intrathoracic blood volume versus pulmonary artery occlusion pressure as estimators of cardiac preload in critically ill patients]

BACKGROUND

Monitoring of cardiac preload by determination of pulmonary artery occlusion pressure (PAOP) has been traditionally used to guide fluid therapy to optimize cardiac output (CO). Since factors such as intrathoracic pressure and ventricular compliance may modify PAOP, volumetric estimators of preload have been developed. The PiCCO system is able to measure CO and intrathoracic blood volume (ITBV) by transpulmonary thermodilution.

AIM

To compare a volumetric (ITBV) versus a pressure (PAOP) determination to accurately estimate cardiac preload in severely ill patients.

PATIENTS AND METHODS

From June 2001 to October 2003, 22 mechanically ventilated patients with hemodynamic instability underwent hemodynamic monitoring with pulmonary artery catheter (PAC) and PiCCO system. ITBV index (ITBVI), PAOP and CI were measured simultaneously by both methods. One hundred thirty eight deltas (D) were obtained from the difference of ITBVI, PAOP, CI-PAC and CI-PiCCO between 6-12 am and 6-12 pm. Linear regression analysis of DITBVI versus Eth CI-PiCCO and Eth PAOP versus DCI-PAC were made.

RESULTS

Mean age of patients was 60.8 +/- 19.4 years. APACHE II was 23.9 +/- 7. Fifteen patients met criteria for acute respiratory distress syndrome (ARDS). Delta ITBVI significantly correlated with DCI-PiCCO (r=0.54; 95% confidence interval = 0.41-0.65; p <0.01). There was no correlation between DPAOP and DCI-PAC.

CONCLUSION

ITBVI correlated better with CI than PAOP, and therefore it seems to be a more accurate estimator of preload in unstable, mechanically ventilated patients.

Functional cerebral asymmetry in affective disorders: new facts contributed by transcranial magnetic stimulation

A growing body of experimental data usually finds a slightly lower activation in the left hemisphere than in the right in depressive syndromes, whereas the opposite occurs in mania. Transcranial magnetic stimulation (TMS) seems to have a distinctive lateralized effect with manic or depressed patients. These clinical findings provide new elements for discussion of the significance of unbalanced hemispherical activation as a biological substrate in affective disorders. Based on these data and on the theories of chaos and complexity, a hypothesis for the physiopathology of affective disorders and the functional mechanism of TMS is proposed. This hypothesis is in agreement with valence theory.

Stereotactic computed tomographic-guided aspiration and thrombolysis of intracerebral hematoma : protocol and preliminary experience

BACKGROUND AND PURPOSE

We review preliminary experience with patients harboring intracerebral hematoma (ICH) treated by stereotactic computed tomographic (CT) guided thrombolysis and aspiration and assess procedure feasibility and safety.

METHODS

Twelve patients with supratentorial ICH >/=25 mL without suspected underlying structural etiology or coagulopathy and an initial Glasgow Coma Scale (GCS) score of >/=5 were treated. A catheter was directed stereotactically or manually into the ICH through a burr hole under CT guidance. Hematoma aspiration was followed by instillation of urokinase (5 000 to 10 000 IU). This was repeated every 6 to 8 hours at bedside, with interval CT imaging, until the ICH volume diminished to <25 mL, less than half of its initial volume, or after a maximum of 10 aspirations/instillations.

RESULTS

Mean age was 69 years (range 55 to 82 years). Median initial GCS was 12 (range 5 to 14). There were 7 ganglionic and 5 lobar ICH, and baseline hematoma size ranged 29 to 70 mL (mean 46 mL). Final ICH volume ranged from 14 to 51 mL (mean 21 mL), with ICH volume reduction by an average of 57% (range 38% to 70%). One patient (8. 3%) suffered hematoma expansion during the procedure. At 6 months after the procedure, 3 patients (25%) had achieved a good recovery (Glasgow Outcome Scale [GOS] score of 5), 5 patients (42%) were dependent (GOS 3), and 1 (8.3%) remained vegetative (GOS 2). Three patients (25%) died in hospital (1 from cardiac arrhythmia and 2 from respiratory failure).

CONCLUSIONS

CT-guided thrombolysis and aspiration appears safe and effective in the reduction of ICH volume. Further studies are needed to assess optimal thrombolytic dosage and must include controlled comparisons of mortality, disability outcome, time until convalescence, and cost of care in treated and untreated patients.

Effects of corticotropin-releasing factor on circadian locomotor rhythm in the golden hamster

Stress produces a reduction in the amplitude of some circadian rhythms. The neurochemical mechanisms underlying stress-induced changes in circadian rhythms are not known. To investigate a possible role of corticotropin-releasing factor (CRF) in this phenomenon, three related experiments were carried out: activity rhythms of male golden hamsters (10/14 hours light/dark entrained, lights on at 0800 h) were measured 1) following the intracerebroventricular administration of CRF (0.5, 1.0, 2.0, or 4.0 microg) at two different times of day, 2) following social stress (30-min resident-intruder confrontation), 3) and following the administration of the CRF-antagonist alpha-helical CRF9-41 (2.0 microg) prior to a 15-min resident-intruder confrontation. CRF produced a significant, dose-related decrease in circadian rhythm amplitude following administration in the morning hours, but not in the afternoon. CRF also induced transient increases in activity post injection concomitant with an activation of the hypothalamic-pituitary-adrenocortical (HPA) system. Stress similarly reduced the amplitude of activity patterns and stimulated the HPA system. The stress-induced depression of circadian rhythm amplitude was significantly attenuated following alpha-helical CRF9-41. These data suggest a role for CRF in the stress-related modulation of circadian locomotor rhythm amplitude.

Tianeptine therapy for depression in the elderly

1. Depression is frequent in the elderly but difficult both to diagnose and treat due to a number of distinctive features. 2. Tianeptine is a novel antidepressant with a reverse mode of action to that of the selective serotonin reuptake inhibitors yet with proven efficacy and safety. 3. 63 elderly patients (mean age:68.8 years; range:65-80 years) with depressive symptoms (major depression:55.6%; dysthymia:44.4%) were included in a 3-month open multicenter study with tianeptine (25 mg daily). 4. 43 patients (68.2%) completed the study. There were no drop-outs due to side-effects. Total Montgomery and Asberg Depression Rating Scale scores were significantly decreased (p < 0.01) on day 14, with a response rate of 76.7%. 5. Improvements were also observed in anxiety and cognitive performance. Side-effects were seen in only 11.7% of patients, with no changes in laboratory or ancillary safety parameters. Tianeptine is thus effective and well tolerated in this category of patient.

[Treatment with tianeptine for depressive disorders in the elderly]

Depression is frequent in the elderly but difficult both to diagnose and treat due to a number of distinctive features. Tianeptine is a novel antidepressant with a reverse mode of action to that of the selective serotonin reuptake inhibitors yet with proven efficacy and safety. 63 elderly patients (mean age: 68.8 years; range: 65-80 years) with depressive symptoms (major depression: 55.6%; dysthymia: 44.4%) were included in a 3-month open multicenter study with tianeptine (25 mg daily). 43 patients (68.2%) completed the study. There were no drop-outs due to side-effects. Total Montgomery and Asberg depression rating scale scores were significantly decreased (p < 0.01) on day 14, with a response rate of 76.7%. Improvements were also observed in anxiety and cognitive performance. Side-effects were seen in only 11.7% of patients, with no changes in laboratory or ancillary safety parameters. Tianeptine is thus effective and well tolerated in this category o patient.

[Treatment of dysthymia with sertraline]

We studied 50 patients (40 females, 10 males) diagnosed of dysthymia according to 1CD-10 criteria (F34.1), retrospectively and prospectively. All were treated with Sertraline, with an initial dose of Sertraline 50-100 mg/day, allowing increases to a maximum of 200 mg/day during the follow up. The clinical and therapeutical evolution was measured by HDRS (Hamilton Depression Rating Scale) 21 items, HARS (Hamilton Anxiety Rating Scale), Clinical Global Impression (CGI), subjective patient impression, compliance, secondary effects, complementary treatments when needed, severity, evolution evaluated on days 15, 30, 60 and 90, from the patient and psychiatrist perspective. Seventy two percent of the sample completed the three months of treatment. We obtained a good clinical efficacy with sertraline observed by a statistical significant decrease (p < 0.01) in the scales in the second week of treatment, which continued in following weeks. The mean doses varted from 78 mg/day to 98.7 mg/day during the three months of follow up The tolerance to Sertraline in our sample was good and similar to other data in the literature. Fourteen patients withdrew, but only six (12%) were due to secondary effects In spite of the study's limitations due to the lack of a control group, we could affirm that sertraline was an effective treatment for dysthymic patients and it should be recommended as a first choice in the treatment of affective disorders, facilitating other psychotherapeutical approach due to its favourable tolerance profile.

[Systemic leptospirosis as a cause of multiple organ failure. Report of a case]

Leptospirosis is a world-spread zoonosis that is incidentally acquired by humans. It causes a diphasic febrile illness in which the Weil syndrome is its severest form, with renal, hepatic, clotting and central nervous system involvement. We report a 73 years old male, that was admitted to an intensive care unit with multiple organ failure due to leptospirosis. The clinical picture initially resembled a sepsis due to biliary tract obstruction and was operated, not finding a biliary tract obstruction. Considering the history of a fall to sewed waters, leptospirosis was suspected and treatment with penicillin was started, obtaining a full recovery of the patient.

[Extracorporeal respiratory assistance. Experience in the treatment of severe acute respiratory failure]

Acute respiratory distress syndrome (ARDS) secondary to systemic injury has a high mortality. Symptomatic treatment with mechanical ventilation, PEEP and high levels of inspired oxygen is effective for most of the patients. When ventilatory support fails in reversing hypoxemia, extracorporeal respiratory assistance has been advocated as a temporary treatment until lung repair occurs. We described our experience in eleven patients (9M, 2F, 41 +/- 16 yo) with severe ARDS refractory to conventional treatment and expected to die if not assisted with extracorporeal oxygenation. All patients required invasive monitoring; seven needed continuous renal therapy because of concurrent renal failure. Venous-venous percutaneous cannulation and systemic anticoagulation were performed and extracorporeal oxygenation and CO2 removal started with blood pump flows of 20 to 30% of patient cardiac output. Improved oxygenation and decreased CO2 levels were immediately observed in 10/11 patients. One patient failed to have reversal of hypoxemia because recirculation and died shortly after initiation of extracorporeal therapy. Plasma leak syndrome and bleeding were observed in 3 and 2 patients respectively. Extracorporeal assistance was maintained for 52 +/- 34 h (19-134). Five (45%) patients were weaned off the pump and two (18%) survived and were discharged. Despite the high cost, extracorporeal respiratory assistance, when applied to selected patients, can reverse hypoxia and may save some previously unsalvagable patients, allowing them to return to a normal life.

Syphilis in San Diego County 1983-1992: crack cocaine, prostitution, and the limitations of partner notification

BACKGROUND AND OBJECTIVES

Recent epidemics of syphilis have been associated with crack cocaine use and anonymous sex for drugs, suggesting a potential limitation of sex partner notification as a disease control strategy. To assess these factors in an inner city epidemic of syphilis in San Diego County, California, we performed a descriptive epidemiologic analysis.

STUDY DESIGN

Descriptive epidemiologic data were obtained from case investigation reports of primary and secondary syphilis.

RESULTS

In the middle and late phases of the epidemic (1990-1992), the incidence of syphilis in the inner city area was more than six times that in remainder of the county. Illegal drug use was reported by 30% of patients. Drug use, especially crack cocaine, was related to prostitution. The estimated total number of sex partners per patient ratio was 4.2, whereas the named sex partners per patient ratio was only 1.5. Twenty-two percent of patients did not report any named partners. Overall, only 26% of the estimated total number of sex partners received treatment.

CONCLUSIONS

Expanding partner notification to include more high-risk persons identified through social networks and increasing screening among high-risk populations may improve control of inner city drug/prostitution-related syphilis epidemics.

Direction of catheter insertion and incidence of paresthesias and failure rate in continuous epidural anesthesia: a comparison of cephalad and caudad catheter insertion

BACKGROUND AND OBJECTIVES

Paresthesias and unblocked segments during continuous epidural anesthesia--sometimes leading to higher doses of local anesthetics--can increase the risk of this technique. A cephalad insertion of the epidural catheter might decrease the incidence of these problems, but this has not been evaluated before in a controlled study.

METHODS

In a prospective, double-blind, randomized study, we compared the incidence of paresthesias during catheter insertion and the failure rate of continuous epidural anesthesia in two groups of obstetric patients. In group 1 (n = 52), the Tuohy needle bevel was directed cephalad during catheter insertion. In group 2 (n = 53), it was directed caudad. The catheter was introduced 4-5 cm into the epidural space, and bupivacaine 25 mg plus fentanyl 50 micrograms were administered through it.

RESULTS

Twenty percent of the patients in group 1 had paresthesias versus 40% in group 2 (p = 0.0249; 95% confidence interval of the difference 1-40%); intensity of paresthesias was greater in group 2. Pain relief was complete in 75% and 80% of the patients in groups 1 and 2, respectively (NS); three patients in group 1 and one in group 2 had unblocked segments (NS).

CONCLUSIONS

Our results support the contention that the catheter should be directed cephalad during insertion for continuous epidural anesthesia.

Integration of prevention efforts

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Penicillinase-producing Neisseria gonorrhoeae in California. Report of a major outbreak and control recommendations

A major outbreak of penicillinase-producing Neisseria gonorrhoeae occurred in California beginning in late 1986. After a state public health emergency was declared in April 1987, a statewide, cooperative federal-state-local treatment and control program was implemented. It was successful in reducing the reported incidence by 59%. Despite the success of this effort, penicillinase-producing N gonorrhoeae is not controlled in California, and, while not nearly the magnitude reported in Florida, an increasing number of cases are again being reported in California. We present recommendations for clinicians and local public health officials, including the epidemiologic and empiric treatment of suspected gonorrhea cases with ceftriaxone when the incidence of penicillinase-producing gonococcal cases in a community exceeds 1% of all reported gonorrhea cases.

Septicemic plague in New Mexico

Eighteen of the 71 cases of plague reported in New Mexico from 1980 to 1984 were septicemic. We reviewed these cases to better describe the clinical presentation of this disorder and to identify risk factors for developing septicemic plague. The symptoms (fever, chills, malaise, headache, and gastrointestinal symptoms) and signs (tachycardia, tachypnea, and hypotension) of septicemic plague are similar to those of other forms of gram-negative septicemia. Abdominal pain was reported in nearly half of the cases, and differential white blood cell counts revealed a marked shift to the left. The risk of developing septicemic plague was higher for persons greater than 40 years of age. Because of empirical antibiotic treatment of older persons, deaths from septicemic plague occurred primarily among persons less than 30 years old. Deaths from septicemic plague could be reduced by aggressive antibiotic therapy for patients with a clinical presentation suggesting gram-negative septicemia, especially patients less than 30 years old.

Plague masquerading as gastrointestinal illness

In clinical descriptions of human plague, fever and tender lymphadenitis are emphasized and gastrointestinal manifestations are rarely mentioned. A review of 71 human plague cases showed that gastrointestinal symptoms occurred commonly (57%). Vomiting (39%) was the most frequent symptom, with nausea (34%), diarrhea (28%) and abdominal pain (17%) occurring less often. Physicians treating patients who reside in or have recently visited plague-endemic areas should include plague in the differential diagnosis in the presence of gastrointestinal symptoms and fever.

Risk factors for measles vaccine failure among immunized students

An outbreak of measles occurred in a municipal school system which had reported 98% of students immunized against measles. A case-control study was conducted to determine reasons for vaccine failure. Vaccine failure was associated with immunizations that could not be documented in the provider's records. Among children with provider-documented immunization, vaccine failure was associated with vaccination at 12 to 14 months of age with an odds ratio of 4.73. Among children vaccinated at 15 months or older, vaccine failure was not associated with time elapsed since vaccination. Studies should be conducted to determine whether unreliable immunization records are a more widespread problem. Further consideration should be given to routine revaccination of children previously vaccinated at 12 to 14 months of age.

Animal bites as an occupational hazard among animal control officers

One hundred-and-two full-time animal control officers (ACOs) in New Mexico were surveyed to learn about animal bite risks in this little-studied occupational group. The overall bite rate was 2.57 per working-year (175-500 times population-based rate estimates). A "high risk" ACO subset (seven officers involved in 67 per cent of bite incidents) was discovered. Evaluation of animal bite data can contribute to prevention of occupational injuries among the estimated 10,000 full-time ACOs in this country.

Risk of pregnancy among adolescent schoolgirls participating in a measles mass immunization program

A large measles vaccination program in the Albuquerque, New Mexico public schools in 1981, conducted according to US Public Health Service guidelines, was studied to determine rates of pregnancy among adolescent vaccinees. Pre-vaccination counseling of 1,922 clinic attendees prevented seven pregnant girls from being vaccinated. Despite counseling, of 1,913 female vaccinees age 13-18 years old, two were pregnant at the time of vaccination (1.05 pregnancies per 1,000 vaccinees) and an additional four girls became pregnant in the three months after vaccination (2.1 pregnancies per 1,000 vaccinees). Data supporting low or absent fetal risks from measles and rubella vaccine, combined with the low pregnancy rate among vaccinees documented in this study, support the reasonableness of the recommended strategy for measles and rubella vaccination of secondary schoolgirls.

Significance of the transient bradycardic pattern in prepathological oxytocin stress test

The perinatal prognostic significance of a type of Prepathological Oxytocin Stress Test, namely Transient Bradycardia coincident with a period of hyperdynamia in otherwise normal test, is analyzed. The 43 studied cases are compared to a group of 492 patients responding normally. The significantly higher incidence of intrapartum meconium and fetal distress, low Apgar Score and neurologically affected newborns seems to demonstrate that the Prepathological Test is a real entity. The possible fetal risk and the usefulness of the Oxytocin Test are discussed.