Unmasking influenza virus infection in patients attended to in the emergency department.

BACKGROUND: Infection by the influenza virus may pass undetected in many adult patients attended to in the emergency department because its diagnosis usually relies on clinical manifestations, which can be distorted by symptoms of a preexisting disease, superposed complications or nontypical manifestations of influenza virus infection (confusing symptoms). PATIENTS AND METHODS: We performed this observational, prospective study with an antigen detection test by indirect immunofluorescence assay (IFA) to estimate the presence of influenza virus infection in such patients. No confirmatory test was performed to validate a positive or negative IFA result. Then we compared those who were antigen positive to those who were negative and also analyzed those who were positive classified by age, comorbidity and clinical presentation. We also evaluated the use of medical and hospital resources and vaccination status. Posterior pharynx swab specimens from 136 consecutive adult patients, 74 women and 62 men with a mean age of 68.7 +/- 17.9 (range: 18-97) years attended to in the emergency department of a university hospital in Barcelona during the 1999-2000 influenza epidemic were examined. Tested patients presented either a classical influenza syndrome, a deterioration of a previous condition or any abrupt onset of symptoms without an obvious cause. RESULTS: Influenza A virus antigen was detected in 99 (72.8%) of the 136 patients included in the study. Confusing symptoms were present in 86 patients with laboratory-confirmed influenza and 40 of them lacked influenza syndrome. Prostration, aching and fever out of proportion to catarrhal symptoms (disproportionate prostration) and cough were independent predictors for this diagnosis (OR = 5.14; 95% CI: 1.98-13.35, p = 0.001 and OR = 4.40, 95% CI, 1.65-11.75, p = 0.03, respectively). Among the 99 patients who tested positive, 72 were >or= 65 years of age. This older positive group compared to the 27 also positive < 65 (non-old) had a tendency to show symptoms mediated by cytokines less frequently: malaise was present in 76.4% of the older positive patients vs 92.6% in the non-old positive ones, p = 0.07. The equivalent percentages for muscle ache were: 56.9% vs 77.8%, p = 0.06; for dysthermia: 54.2% vs 70.4%, p = 0.08; for headache: 35.2% vs 66.7%, p = 0.005, and for disproportionate prostration: 47.2% vs 66.7%, p = 0.08. Cough was more frequent in the older positive group: 94.4% vs 77.8%, p = 0.02. Older positive patients were also hospitalized and received antibiotics more frequently than the non-old positive ones: 65.3% vs 40.7%, p = 0.03 and 81.9% vs 63.0%, p = 0.046, respectively. Hospitalization was independently correlated with the presence of complications (OR = 4.5, 95% IC 1.27-15.95, p = 0.02). Patients with the highest comorbidity, evaluated with the Charlson scale, were more inadequately vaccinated than those with moderate or low comorbidity. CONCLUSION: Influenza virus infection has a great and underestimated impact in the emergency department during influenza epidemics. High frequency of confusing symptoms, which overcome classical influenza syndrome in adult people with comorbidity, may explain this effect. Disproportionate prostration and cough are symptoms that independently predict its diagnosis in the global adult population, whereas in the elderly, fever and cough should arouse this suspicion whether or not they present classic symptoms. In our setting, individuals with high comorbidity are inadequately vaccinated.

[Varicella pneumonia in the adult. Study of 9 cases]. / Neumonía varicelosa en el adulto. Estudio de nueve casos.

BACKGROUND: In the adult, the primary infection by the varicella-zoster virus acquires an unusual severity due to several complications, the most frequent of them being pneumonia. We study the main characteristics of nine patients diagnosed of pneumonia varicellosa. METHODS: Clinical, therapeutic and evolutive features of 9 adult patients, both immunocompetents and immunodepressed, diagnosed of pneumonia varicellosa are retrospectively reviewed, in the last ten years, at Hospital de Sant Pau, Barcelona. Diagnosis of varicella was established on the basis of the typical rash in the context of a feverish illness. The antecedents of smoking habit, pregnancy and underlying disease, evaluating especially arterial blood and platelet count at entrance, are assessed. RESULTS: Nine patients (4 males and 5 women; mean age 38 years) were included in the study. Seventy-eight percent of patients were smokers of more than 20 cigarettes a day; one met criteria of simple chronic bronchitis, another suffered ankylosing spondylitis and three were known carriers of human immunodeficiency virus. None of the female patients was pregnant. Respiratory symptoms began from the third and fifth day after the skin rash, and the most common symptoms were cough (89%), dyspnea (67%) and hemoptysis (22%). Arterial blood gas determination showed hypoxemia in four patients (45%). Chest X-ray revealed an interstitial pattern predominantly at both bases, with a case of right pleural effusion. Intravenous acyclovir was started in 6 patients, foscarnet in one and symptomatic therapy in two patients. All patients had a favourable clinical course, none of them requiring entrance to the Intensive Care Unit. CONCLUSIONS: Adult patients with varicella pneumonia that suffer respiratory insufficiency, thrombocytopenia or are carriers of base illnesses must be early treated with intravenous acyclovir. However, despite clinical, biological and radiological recovery is earlier with such treatment, the evolution seems equally favourable if it is only conducted, for instance, symptomatic therapy with antithermic and antihistaminic compounds.

Graves' disease presenting as localized myxoedematous infiltration in a smallpox vaccination scar.

We describe a 54-year-old woman with diffuse myxoedematous infiltration at the site of a smallpox vaccination scar as the presenting symptom of Graves' disease. Associated features included acute ocular symptoms (vascular congestion of the sclera, epiphora and blurred vision) and transient erythema on both shins. However, there were no signs of pretibial myxoedema. A number of neoplastic, inflammatory and systemic diseases may localize to scar tissue in skin, including at smallpox vaccination sites, but this case demonstrates the unusual occurrence of myxoedematous infiltration at such a site and illustrates a most atypical cutaneous presentation of Graves'disease.

Group A streptococcal meningitis in the antibiotic era.

A case of group A streptococcal meningitis is reported and the 51 cases reported in the literature since 1966 reviewed. A total of 24 men and 24 women were included in the study; the mean age (+/-SD) was 20.9+/-25.5 years. Fifty-eight percent of the patients had comorbid conditions, 80% had a distant focus of infection, and 65.8% had blood cultures positive for group A streptococci. Seventy-five per cent of the patients were treated with penicillin. The overall case-fatality rate was 12% (6 patients). Sequelae were more prevalent among children (44%) than among adults (7.7%) (OR=9.43; 95% CI, 1.02-438.95; P=0.03). Group A streptococcus is a rare cause of pyogenic meningitis, affecting mainly children or adults with comorbidity. Although the case-fatality rate is relatively low, neurological sequelae are frequent among survivors, especially children.

[Quality of life in arterial hypertension]. / Calidad de vida en la hipertensión arterial.

BACKGROUND: Quality of life is a key issue for the consideration of hypertension therapy. However, reliable and sensitive evaluation methods are not available in Spain. To this end, a quality of life questionnaire has been elaborated, its yield has been evaluated, and the influence of hypertension and several associated variables on the quality of life has been assessed. METHODS: A questionnaire on quality of life consisting of 62 items was elaborated. Its final evaluation was divided in an overall value and in four subindexes related with anxiety, depression, side effects, and somatic complaints. It was applied to two groups of hypertensive patients, one from hospital care (n = 90) and another from primary care (n = 89), and to a control group (n = 76). RESULTS: Although both populations with hypertension were significantly different regarding age, sex, use of therapies, organic impact and blood pressure, they were overall similar in quality of life. However, quality of life was different from that in control group, which showed better indices. In the hypertensive population, sex, severity of hypertension, type of therapy or duration of the disease did not have any influence on quality of life. CONCLUSIONS: The overall similar quality of life in both hypertensive groups (in spite of the many significant differences in their descriptive features) and the different quality of life between hypertensive and normotensive individuals (in spite of the similitude of their demographic parameters) suggest that the diagnosis of hypertension has by itself a greater influence on the quality of life than several hypertension-associated variables. It has also been found that the method used was sensitive and valid. Therefore, the use of the quality of life questionnaire can be a useful instrument for the monitorization of hypertensive patients.

The impact of a patient education programme in the control of hypertension.

The value of patient education programmes in the control of hypertension is controversial. We have conducted a prospective study to investigate a patient education programme in our clinic. Every new patient was randomised into one of two different groups: a control group (CG, n = 149) and an intervention group (IG, n = 138); the latter group was invited to attend two educational talks and subsequently one tutorial meeting. Blood pressure, heart rate, Quetelet Index, attendance, knowledge level, analytical parameters and the prevalence of other risk factors were measured in both groups before and after 6 months follow-up. No significant differences were detected between the two groups initially. At 6 months, both groups significantly lowered their BP; the only differences observed between groups (IG vs. CG) were: the number of correct answers to the questionnaire (14.5 +/- 3.7 vs. 12.9 +/- 3.7, P less than 0.01), the rate of occasional therapeutic abandonment (10.3 vs. 25%, P less than 0.05), 24 h sodium excretion (97 +/- 45 vs. 127 +/- 68 mmol/l, P less than 0.01) and the number of withdrawals (39 vs. 25%, P less than 0.05). We conclude that in spite of increased knowledge, less frequent abandonment of drug treatment and better observance of a low salt diet, patients in the IG had an increase in the number of drop-outs. Our data suggest that education in hypertension clinics should play a supportive role rather than a primary one in the control of high blood pressure.

Effects of long-term treatment with metoprolol and hydrochlorothiazide on plasma lipids and lipoproteins.

In order to evaluate the effects of one-year antihypertensive treatment on plasma lipids and lipoproteins, 65 patients whose diastolic blood pressure was in the range 95-120 mmHg were randomly allocated to groups that received either hydrochlorothiazide or metoprolol, or both drugs when the response to one of them was insufficient to control blood pressure. Blood pressure was effectively reduced in all groups. Patients on hydrochlorothiazide showed a significant increase (P less than 0.01) in low-density lipoprotein cholesterol (LDL-C) after 3 months of treatment. A significant increase in triglycerides was observed after 6 and 12 months, together with a decrease in high-density lipoprotein cholesterol (HDL-C) after 12 months (P less than 0.05) of treatment in patients on metoprolol. In patients treated with both hydrochlorothiazide and metoprolol, total cholesterol increased after 3 (P less than 0.001) and 6 months (P less than 0.05), triglycerides increased after 6 (P less than 0.01) and 12 months (P less than 0.01), and LDL-C increased after 3 (P less than 0.05), 6 (P less than 0.001) and 12 months (P less than 0.01) of treatment, respectively. In 61% of the patients, three or more lipid parameters were affected during the study period. We conclude that long-term antihypertensive treatment with hydrochlorothiazide, metoprolol, and particularly with both drugs, can induce lipid effects that deserve recognition, because in some cases these might counteract the possible benefit of a reduction in blood pressure on the prevention of coronary heart disease.

[Effect of muscle relaxation in hypertensive patients]. / Efecto de la relajación muscular en pacientes hipertensos.

The efficacy of muscle relaxation in the treatment of hypertension has been described by several authors. Our experience with this type of technique is analyzed in this report. The clinical histories of 38 individuals who have taken part in the relaxation program since the end of 1984 (relaxation group: RG) with at least 6 months of follow up, have been reviewed. For each RG patient, two sex, age, and initial diastolic blood pressure (DBP) matched controls were found, obtaining thus a control group (CG) consisting of 70 hypertensive patients who were not participating in any relaxation program. The final efficacy of the program was evaluated recording the systolic blood pressure (SBP), the DBP, and heart rate (HR) 6 and 12 months after the initiation of the program also considering the drop outs and the need of drugs (evaluated with a therapeutic index: TI). There were no differences in the initial parameters between the two groups except for the TI (uncontrollable variable) which was higher in the RG. The final values in the RG showed a slightly lower blood pressure (RG = 135.2/86.9 mm Hg; CG = 139.4/90.4 mm Hg, p = 0.082 for the DBP) as well as a lower number of drop outs (RG = 18.4%); CG = 32.9%, p less than 0.1). 10 patients in the RG while none in the CG were medically discharged. (p = 0.000). The only significant difference found was the increase in TI in the CG (p = 0.000), while the increase observed in the RG was not statistically significant.

Nifedipine in the treatment of renal colic.

A double-blind randomized, clinical trial was conducted in 43 patients to evaluate the efficacy of sublingual nifedipine in the treatment of pain in renal colic. Comparison was made with a combination of dipyrone, pitofenone and fenpipramide, which is usually administered intravenously in Spain. With nifedipine, pain completely disappeared in 44% of the cases, and with the combination of drugs, in 89% (p less than 0.005). More adverse effects were noted with the combination than with nifedipine. Both treatments brought about a slight drop in arterial pressure without leading to hypotension in any case. There was no change in heart rate. The possible causes of the relatively low level of success with nifedipine were analyzed. The possibility of using nifedipine under certain circumstances in which other drugs are contraindicated or when their administration is unfeasible is suggested.