Degree of adherence to recommended antiviral treatment during the pandemic and post-pandemic periods of influenza A(H1N1)pdm09 in 148 intensive care units in Spain.

OBJECTIVE: To determine the degree of antiviral treatment recommendations adherence and its impact to critical ill patients affected by influenza A(H1N1)pdm09 mortality. DESIGN: Secondary analysis of prospective study. SETTING: Intensive care (UCI). PATIENTS: Patients with influenza A(H1N1)pdm09 in the 2009 pandemic and 2010-11 post-Pandemic periods. VARIABLES: Adherence to recommendations was classified as: Total (AT); partial in doses (PD); partial in time (PT), and non-adherence (NA). Viral pneumonia, obesity and mechanical ventilation were considered severity criteria for the administration of high antiviral dose. The analysis was performed using t-test or «chi¼ square. Survival analysis was performed and adjusted by Cox regression analysis. RESULTS: A total of 1,058 patients, 661 (62.5%) included in the pandemic and 397 (37.5%) in post-pandemic period respectively. Global adherence was achieved in 41.6% (43.9% and 38.0%; P=.07 respectively). Severity criteria were similar in both periods (68.5% vs. 62.8%; P=.06). The AT was 54.7% in pandemic and 36.4% in post-pandemic period respectively (P<.01). The NA (19.7% vs. 11.3%; P<.05) and PT (20.8% vs. 9.9%, P<.01) was more frequent in the post-pandemic period. The mortality rate was higher in the post-pandemic period (30% vs. 21.8%, P<.001). APACHE II (HR=1.09) and hematologic disease (HR=2.2) were associated with a higher mortality and adherence (HR=0.47) was a protective factor. CONCLUSIONS: A low degree of adherence to the antiviral treatment was observed in both periods. Adherence to antiviral treatment recommendations was associated with lower mortality rates and should be recommended in critically ill patients with suspected influenza A(H1N1)pdm09.

Epidemiological study of Clostridium difficile infection in critical patients admitted to the Intensive Care Unit.

UNLABELLED: Data on the epidemiology of infections caused by Clostridium difficile (CDI) in critically ill patients are scarce and center on studies with a limited time framework and/or epidemic outbreaks. OBJECTIVE: To describe the characteristics and risk factors of critically ill patients admitted to the ICU with CDI, as well as the treatments used for the control of such infections. MATERIAL AND METHODS: A retrospective study was made of patients included in the ENVIN-ICU registry with CDI in 2012. Patients were followed up to 72 h after discharge from the ICU. A case report form was used to record the following data: demographic variables, risk factors related to CDI, treatment and outcome. Infections were classified as community-acquired, nosocomial out-ICU and nosocomial in-ICU, according to the day on which Clostridium difficile isolates were obtained. Infection rates as episodes per 10,000 days of ICU stay are presented. The global in-ICU and hospital mortality rates were calculated. RESULTS: Sixty-eight episodes of CDI in 33 out of a total of 173 ICUs participating in the registry were recorded (19.1%) (2.1 episodes per 10,000 days of ICU stay). Forty-five patients were men (66.2%), with a mean (SD) age of 63.4 (16.4) years, a mean APACHE II score on ICU admission of 19.9 (7.4), and an underlying medical condition in 44 (64.7%). Sixty-two patients (91.2%) presented more than 3 liquid depositions/day, 40 (58.8%) in association with severe sepsis or septic shock. Community-acquired infection occurred in 13 patients (19.1%), nosocomial out-ICU infection in 13 (19.1%), and in-ICU infection in 42 (61.8%). Risk factors included age>64 years in 39 cases (57.4%), previous hospital admission (3 months) in 32 (45.6%), use of antimicrobials (previous 7 days) in 57 (83.8%), enteral nutrition in 23 (33.8%), and the use of H2 inhibitors in 39 (57.4%). Initial combined treatment was administered to 18 patients (26.5%). Metronidazole was used in 60 (88.2%) and vancomycin in 31 (45.6%). The in-ICU mortality rate was 25.0% (n=17), with a hospital mortality 27.9% (n=19). CONCLUSIONS: The rate of ICD in ICU patients is low, the infection affects severely ill patients, and is associated with high mortality. The presence of CDI is a marker of poor prognosis.

Early non-invasive ventilation treatment for severe influenza pneumonia.

The role of non-invasive ventilation (NIV) in acute respiratory failure caused by viral pneumonia remains controversial. Our objective was to evaluate the use of NIV in a cohort of (H1N1)v pneumonia. Usefulness and success of NIV were assessed in a prospective, observational registry of patients with influenza A (H1N1) virus pneumonia in 148 Spanish intensive care units (ICUs) in 2009-10. Significant variables for NIV success were included in a multivariate analysis. In all, 685 patients with confirmed influenza A (H1N1)v viral pneumonia were admitted to participating ICUs; 489 were ventilated, 177 with NIV. The NIV was successful in 72 patients (40.7%), the rest required intubation. Low Acute Physiology and Chronic Health Evaluation (APACHE) II, low Sequential Organ Failure Assessment (SOFA) and absence of renal failure were associated with NIV success. Success of NIV was independently associated with fewer than two chest X-ray quadrant opacities (OR 3.5) and no vasopressor requirement (OR 8.1). However, among patients with two or more quadrant opacities, a SOFA score ≤7 presented a higher success rate than those with SOFA score >7 (OR 10.7). Patients in whom NIV was successful required shorter ventilation time, shorter ICU stay and hospital stay than NIV failure. In patients in whom NIV failed, the delay in intubation did not increase mortality (26.5% versus 24.2%). Clinicians used NIV in 25.8% of influenza A (H1N1)v viral pneumonia admitted to ICU, and treatment was effective in 40.6% of them. NIV success was associated with shorter hospital stay and mortality similar to non-ventilated patients. NIV failure was associated with a mortality similar to those who were intubated from the start.

Clinical usefulness of lanthanum carbonate for serum phosphate control in difficult patients.

BACKGROUND: The adequate control of phosphataemia is of major importance in end-stage renal disease patients on maintenance dialysis. Recently, lanthanum carbonate (LC) has been added to the phosphate binder armamentarium. To our knowledge, no studies have yet evaluated the usefulness of this drug in uncontrolled hyperphosphataemic patients. METHODS: This was a 6-month prospective observational study. Patients on chronic hemodialysis who had previously failed to achieve serum phosphate control were enrolled. Thirty-four patients (i.e. 11% out of 305 from three dialysis units) met the inclusion criteria. Lanthanum carbonate was introduced and titrated to achieve serum phosphate control, according to the KDOQI guidelines. Clinical targets, gastrointestinal symptoms, and patients' satisfaction with therapy were assessed at baseline and after 6 months. RESULTS: Eight patients (23.5%) were withdrawn from the study due to side effects. In the remaining patients, serum phosphate level significantly decreased from 5.8 to 4.4 mg/dl and calcium-phosphate product also decreased significantly from 55.6 to 41.8 mg(2)/dl(2). The average number of all phosphate binder tablets taken per day was reduced from 6.7 to 4.7. Evaluation scores of dyspeptic symptoms and of patient's satisfaction with therapy also improved: from 7.5 to 5.3 and from 6.6 to 8.1, respectively. CONCLUSIONS: The introduction of LC improved serum phosphate control in over 70% of these "difficult patients". A lower pill burden was also obtained, which might help to simplify treatment and increase patients' compliance. Dyspeptic symptoms and overall satisfaction with treatment also improved.

Antibiotic prescribing for discoloured sputum in acute cough/lower respiratory tract infection.

We investigated whether discoloured sputum and feeling unwell were associated with antibiotic prescription and benefit from antibiotic treatment for acute cough/lower respiratory tract infection (LTRI) in a prospective study of 3,402 adults in 13 countries. A two-level model investigated the association between producing discoloured sputum or feeling generally unwell and an antibiotic prescription. A three-level model investigated the association between an antibiotic prescription and symptom resolution. Patients producing discoloured sputum were prescribed antibiotics more frequently than those not producing sputum (OR 3.2, 95% CI 2.1-5.0), unlike those producing clear/white sputum (OR 0.95, 95% CI 0.61-1.48). Antibiotic prescription was not associated with a greater rate or magnitude of symptom score resolution (as measured by a 13-item questionnaire completed by patients each day) among those who: produced yellow (coefficient 0.00; p = 0.68) or green (coefficient -0.01; p = 0.11) sputum; reported any of three categories of feeling unwell; or produced discoloured sputum and felt generally unwell (coefficient -0.01; p = 0.19). Adults with acute cough/LRTI presenting in primary care settings with discoloured sputum were prescribed antibiotics more often compared to those not producing sputum. Sputum colour, alone or together with feeling generally unwell, was not associated with recovery or benefit from antibiotic treatment.

[Study on the clinicopathological correlation in the secondary acute respiratory distress syndrome]. / Estudio sobre la correlación clínico-patológica en el síndrome de distrés respiratorio agudo secundario.

OBJECTIVE: This study has aimed to study the clinicopathological correlation of patients with secondary acute respiratory distress syndrome (ARDS), specifically having extrapulmonary causes. SETTING: A 22 beds intensive care unit. DESIGN: An observational study of case series. PATIENTS: Seventeen patients whose death was caused by acute respiratory distress syndrome were included. INTERVENTION: A systematic histopathological study was made of all the pulmonary lobes of patients who died in our ICU with the clinical diagnosis of secondary ARDS, who had undergone an autopsy between 1999 and 2009. The Kappa analysis was used to analyze the grade of correlation between the clinical and the pathological diagnosis. RESULTS: The autopsy confirmed to cases of false positive in 17 patients with ARDS (11%). The kappa value was 0.77, so that the concordance analysis was considered to be satisfactory. CONCLUSIONS: The clinical criteria for ARDS correlate well with acute alveolar damage (AAD) in the autopsy study in patients with secondary ARDS, although some false positive cases can be observed.

Pathophysiology of oropharyngeal dysphagia in the frail elderly.

BACKGROUND: Oropharyngeal dysphagia is a major complaint among the elderly. Our aim was to assess the pathophysiology of oropharyngeal dysphagia in frail elderly patients (FEP). METHODS: A total of 45 FEP (81.5 +/- 1.1 years) with oropharyngeal dysphagia and 12 healthy volunteers (HV, 40 +/- 2.4 years) were studied using videofluoroscopy. Each subject's clinical records, signs of safety and efficacy of swallow, timing of swallow response, hyoid motion and tongue bolus propulsion forces were assessed. KEY RESULTS: Healthy volunteers presented a safe and efficacious swallow, faster laryngeal closure (0.157 +/- 0.013 s) upper esophageal sphincter opening (0.200 +/- 0.011 s), and maximal vertical hyoid motion (0.310 +/- 0.048 s), and stronger tongue propulsion forces (22.16 +/- 2.54 mN) than FEP. By contrast, 63.63% of FEP presented oropharyngeal residue, 57.10%, laryngeal penetration and 17.14%, tracheobronchial aspiration. Frail elderly patients with impaired swallow safety showed delayed laryngeal vestibule (LV) closure (0.476 +/- 0.047 s), similar bolus propulsion forces, poor functional capacity and higher 1-year mortality rates (51.7%vs 13.3%, P = 0.021) than FEP with safe swallow. Frail elderly patients with oropharyngeal residue showed impaired tongue propulsion (9.00 +/- 0.10 mN), delayed maximal vertical hyoid motion (0.612 +/- 0.071 s) and higher (56.0%vs 15.8%, P = 0.012) 1-year mortality rates than those with efficient swallow. CONCLUSION & INFERENCES: Frail elderly patients with oropharyngeal dysphagia presented poor outcome and high mortality rates. Impaired safety of deglutition and aspirations are mainly caused by delayed LV closure. Impaired efficacy and residue are mainly related to weak tongue bolus propulsion forces and slow hyoid motion. Treatment of dysphagia in FEP should be targeted to improve these critical events.

Inhaled drugs as risk factors for community-acquired pneumonia.

The effect of inhaled drugs in community-acquired pneumonia (CAP) is unclear. This case-control study was designed to determine whether inhaled drugs were risk factors for CAP. All incident cases of confirmed CAP that occurred over 1 yr in patients with chronic bronchitis (CB), chronic obstructive pulmonary disease (COPD) or asthma were included, as well as CB, COPD and asthma controls. Risk factors for CAP and inhaled treatment were recorded during a personal interview. An effect of inhaled drugs on the risk of CAP was observed in COPD and asthma patients after adjusting for the effect of other respiratory diseases and their concomitant treatments. In COPD patients, inhaled steroids had a risk OR of 3.26 (95% CI 1.07-9.98) and in asthma patients inhaled anticholinergics had a risk OR of 8.80 (95% CI 1.02-75.7). In CB patients, no association with CAP was observed for any inhaler. These effects were independent of adjusting variables related to severity and other respiratory and non-respiratory risk factors for CAP, including vaccines. Inhaled ß(2)-adrenergic agonists did not show a significant effect on the risk of CAP in any of the respiratory diseases. Inhaled steroids may favour CAP in COPD patients, whereas anticholinergics may favour CAP in asthma patients. It is difficult to differentiate the effect of inhaled therapy from the effect of COPD or asthma severity on the risk of CAP, and these relationships may not be causal, but could call attention to inhaled therapy in COPD and asthma patients.

Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries.

OBJECTIVE: To describe variation in antibiotic prescribing for acute cough in contrasting European settings and the impact on recovery. DESIGN: Cross sectional observational study with clinicians from 14 primary care research networks in 13 European countries who recorded symptoms on presentation and management. Patients followed up for 28 days with patient diaries. SETTING: Primary care. PARTICIPANTS: Adults with a new or worsening cough or clinical presentation suggestive of lower respiratory tract infection. MAIN OUTCOME MEASURES: Prescribing of antibiotics by clinicians and total symptom severity scores over time. RESULTS: 3402 patients were recruited (clinicians completed a case report form for 99% (3368) of participants and 80% (2714) returned a symptom diary). Mean symptom severity scores at presentation ranged from 19 (scale range 0 to 100) in networks based in Spain and Italy to 38 in the network based in Sweden. Antibiotic prescribing by networks ranged from 20% to nearly 90% (53% overall), with wide variation in classes of antibiotics prescribed. Amoxicillin was overall the most common antibiotic prescribed, but this ranged from 3% of antibiotics prescribed in the Norwegian network to 83% in the English network. While fluoroquinolones were not prescribed at all in three networks, they were prescribed for 18% in the Milan network. After adjustment for clinical presentation and demographics, considerable differences remained in antibiotic prescribing, ranging from Norway (odds ratio 0.18, 95% confidence interval 0.11 to 0.30) to Slovakia (11.2, 6.20 to 20.27) compared with the overall mean (proportion prescribed: 0.53). The rate of recovery was similar for patients who were and were not prescribed antibiotics (coefficient -0.01, P<0.01) once clinical presentation was taken into account. CONCLUSIONS: Variation in clinical presentation does not explain the considerable variation in antibiotic prescribing for acute cough in Europe. Variation in antibiotic prescribing is not associated with clinically important differences in recovery. TRIAL REGISTRATION: Clinicaltrials.gov NCT00353951.

Laser induced breakdown spectroscopy as a tool for discrimination of glass for forensic applications.

Materials analysis and characterization can provide important information as evidence in legal proceedings. The potential of laser induced breakdown spectroscopy (LIBS) for the discrimination of glass fragments for forensic applications is presented here. The proposed method is based on the fact that glass materials can be characterized by their unique spectral fingerprint. Taking advantage of the multielement detection capability and minimal to no sample preparation of LIBS, we compared glass spectra from car windows using linear and rank correlation methods. Linear correlation combined with the use of a spectral mask, which eliminates some high-intensity emission lines from the major elements present in glass, provides effective identification and discrimination at a 95% confidence level.

New evidence of risk factors for community-acquired pneumonia: a population-based study.

The aim of the present study was to identify risk factors for community-acquired pneumonia (CAP), with special emphasis on modifiable risk factors and those applicable to the general population. A population-based, case-control study was conducted, with a target population of 859,033 inhabitants aged >14 yrs. A total of 1,336 patients with confirmed CAP were matched to control subjects by age, sex and primary centre over 1 yr. In the univariate analysis, outstanding risk factors were passive smoking in never-smokers aged >65 yrs, heavy alcohol intake, contact with pets, households with >10 people, contact with children, interventions on the upper airways and poor dental health. Risky treatments included amiodarone, N-acetylcysteine and oral steroids. Influenza and pneumococcal vaccine, and visiting the dentist were protective factors. Multivariable analysis confirmed cigarette smoking, usual contact with children, sudden changes of temperature at work, inhalation therapy (particularly containing steroids and using plastic pear-spacers), oxygen therapy, asthma and chronic bronchitis as independent risk factors. Interventions for reducing community-acquired pneumonia should integrate health habits and lifestyle factors related to household, work and community, together with individual clinical conditions, comorbidities and oral or inhaled regular treatments. Prevention would include vaccination, dental hygiene and avoidance of upper respiratory colonisation.

[Choosing not to dialysis in chronic renal failure in stage V (Renal Failure). Evolution of the characteristics of patients between 1992-1995 and 2000-2003]. / Elección de no diálisis en insuficiencia renal crónica en estadio V (fallo renal). Evolución de las características de los pacientes entre 1992-1995 y 2000-2003.

BACKGROUND: The incidence of chronic renal failure increase with the age. The selection of patient to dialysis has been increasing in spite of the high comorbidity. Moreover, in our clinical practice the aged patient is not contraindicated to dialysis. However, in the nephrology clinical practice not all the patients start the treatment with dialysis. OBJECTIVE The aim of our study has been to compare the characteristics of the patients who had not been dialyzed between the periods 1992-1995 and 2000-2003 to analyze the trend of the nephrology clinical practice. MATERIAL AND METHODS: Comparative study of the characteristics and the evolution of patients with chronic renal failure in stage V, (renal failure) not incorporated to dialysis in one hospital during four years between the periods the 1992-1995 ( period A) and 2000-2003 (period B). RESULTS: Start dialysis (period A versus period B): 116 patients, age 59.9+15.5 years vs. 229 patients, age 64.0+15.8 years (p<0.05). Non-dialysis (period A versus period B): 38 patients, age 77.5+9.3 years vs. 37 patients, age 81.7+6.2 years (p<0.01). Renal function: serum creatinina 7.4+2.4 mg/dl vs. 5.3+1.2 mg/dl (p<0.001), MDRD estimate glomerular filtration 6.9+2.4 mg/dl ml/min/1.73 m2 vs. 10.0+2.3 ml/min/1.73 m2 (p<0.001). Primary renal disease: unknown etiology 31.5 % vs. 24.3 %, nephroangiosclerosis 23.6 % vs. 32.4 %, diabetes 28.9 % vs. 21.6 %. Functional status: dependent patients 34.2 % vs 83.8 % (p<0.001). The principal reason for non-dialysis were: personal decision: 26.3 % vs. 35.1 %, dementia 15.8 % vs. 29.7 %, brief life expectancy because of serious co-existing diseases 13.1 % vs. 21.7 % and serious chronic illness with inability for themselves care 44.7 % vs. 13.1 %. Comorbid conditions: 2.3+1.0 vs. 3.0+1.5 (p<0.05). Survival: 55+168 days vs. 168+236 days (p<0.001). CONCLUSION: Most of the patients that don't begin dialysis are elderly together with a poor functional capacity and with more autonomy in their decisions. The identification of patients with renal failure (stage V) was detected early in the last period than in the following one. The conservative management of non-dialyzed uremic patients is a significative nephrology clinical practice due to more survival of those persons.

[Calcific uraemic arteriolopathy (calciphylaxis): incidence, clinical features and long term outcomes]. / Arteriolopatía urémica calcificante (calcifilaxis): incidencia, formas de presentación y evolución.

UNLABELLED: Calcific uraemic arteriolopathy, also named calciphylaxis, is a rare but serious disorder characterized by medial mural calcification of small vessel leading to tissue ischaemia. It most commonly occurs in end stage renal disease patients on dialysis or recently received renal transplant with chronic nephropathy allograft. The pathogenesis of calciphylaxis is poorly understood. Abnormalities in mineral metabolism are clearly involved, but the specific factors that induces this disorder are not completely known. OBJECTIVES: Describe the main clinical features, outcomes and follow up of all calciphylaxis cases recorded in our dialysis unit in order to analyse the incidence, the main biologic parameters and the therapeutic background in which calciphylaxis appeared. MATERIAL AND METHODS: We performed a descriptive study about all the calciphylaxis cases diagnosed at our dialysis unit between the years 1991 and 2005. RESULTS: 8 cases, 6 women. Mean age: 65.3 years. All the patients were on haemodialysis treatment (one previous renal transplant). Mean time on dialysis was 76.6 months. Cumulative incidence was 1.17%. The principal end stage renal disease aethiology was neprhoangioeslerosis in four patients. Secondary hiperparatyrhoidism was present in 4 patients and 2 of them had been paratyrhoidectomized previously. A second cutaneous biopsy was needed for correct diagnosis in 3 patients. Calciphylaxis distal lesions were present in 7 patients. Two cases required urgent paratyrhoidectomy in order to control calciphylaxis. Only in 2 cases a Ca x P product > 60 mg/dL was present and 3 cases had PTHi values higher than 300 pg/mL. Calcium phosphate binders and vitamin D were present in 2 and 4 cases, respectively. One patient with proximal calciphylaxis died due to skin injury infection. CONCLUSIONS: Calciphylaxis is a rare disorder but not exceptional, related to end stage renal disease patients. The diagnosis requires a high clinical suspicion, being sometimes difficult to distinguish from other entities in spite of pathological study. Proximal distribution of calciphylaxis had worst prognostic. Metabolic disorders and therapeutics background were not different from other patients included in dialysis treatment.

[Secondary amyloidosis (AA-type) due to localized cutaneous vasculitis]. / Amiloidosis secundaria asociada a vasculitis cutánea localizada.

We report a case of a 49 year old man, diagnosed soon after the outcome of casual proteinuria, of AA-type amyloidosis in relation to small and medium vessel cutaneous vasculitis without systemic involvement. This combination is a rare entity and only two cases of cutaneous hypersensibility vasculitis complicated with AA-type amyloidosis had been reported. We describe the results of the use of several immunosuppressive drugs during four years follow up with temporally total remission of the disease.

[Tetanus treated with continuous baclofen intrathecal perfusion]. / Tétanos tratado con perfusión continua de baclofeno intratecal.

After making a bibliographic search in our country and demonstrating the lack of original articles or communications on treatment with intrathecal baclofen for the generalized forms of tetanus, our objective is to present this treatment based on the successful experience of one clinical case. In relationship to the case, we review baclofen pharmacokinetic and pharmacodynamic effects and its possible utility in the treatment of tetanus.

[Renal involvement in amyloidosis. Clinical outcomes, evolution and survival]. / Afectación renal en la amiloidosis. Características clínicas, evolución y supervivencia.

BACKGROUND: Systemic amyloidosis is a disease resulting from extracellular deposition of fibrillar protein in various organs. Main systemic amyloidosis are: primary (AL) and Secondary (AA). The kidney is usually involved, conferring and adverse prognosis. In the last decade there has been a change in the aetiology of AA amyloidosis. OBJECTIVES: To analyse the incidence of AL and AA amyloidosis in our current population as well as the aetiology of AA amyloidosis. To describe clinical outcomes, renal involvement and survival. PATIENTS AND METHODS: We performed a descriptive analysis of all cases of amyloidosis diagnosed from 1992 to 2004 in our hospital. Diagnosis was assessed on histological criteria: positivity Congo Red stain. Clinical data, renal involvement, dialysis treatment and survival were analysed. RESULTS: 76 cases, 44 women, mean age 70.7 +/- 12. Types: 55 AA (72%), 21 AL (28%) systemic amyloidosis. AA aetiology was: 66% rheumatic disorders, 28% infectious disease, 6% others. Incidence for AL was 4.6 and for AA 12.2 cases/million. Renal involvement was present in 75% at diagnosis (69% Creatinine clearance < 60 ml/min, 37% urinary protein > 3 g/24 hours). 21 cases (28%) progressed to renal disease stage V in the 8.1 +/- 9.8 months follow up period, and 14 cases started dialysis treatment (10 HD, 4 CAPD). In 7 cases (33%) dialysis was not indicated due to their poor clinical condition, short life expectancy and bad quality of life. Mean global survival at diagnosis was 55% and 40% at 12 and 24 months (AL 58% and 19%; AA 55% and 44%). Mean survival from the start of dialysis was 30% and 5% at 12 and 24 months. CONCLUSIONS: Although amyloidosis has a low incidence in our population, the kidney is usually involved. Rheumatological disorders are the principal aetiology of AA amyloidosis. Long term survival is poor, specially for AL.