Pathogenesis and prevention of catheter-related septicemia.

Intravascular catheters are contaminated by bacterial flora present on the patient's own skin or on the hands of the personnel manipulating the catheter-tubing junction. In the former case, contamination is more often extraluminal and often leads to CRS soon after catheter insertion. In the second circumstance, contamination preferentially involves the endoluminal route and results in bacteremia after the initial 10 to 14 days of catheter use. Effective prevention relies on thorough aseptic technique during insertion of the catheter or manipulation of its hub. Further studies are required to define the best means of achieving permanent sterilization of the insertion site. New hub designs should reduce the risk of hub contamination and CRS in prolonged intravascular catheterizations.

Psychotropic drug consumption and other factors associated with heroin overdose.

In clinical or forensic practice there are few studies assessing which risk factors are associated with heroin overdoses. A series of 76 consecutive non-fatal heroin overdoses were compared to 22 consecutive subjects who self-injected heroin within 1 h before admission to the emergency room. Whereas blood levels of alcohol and IgE and urinary cocaine metabolite levels were similar in both groups, higher benzodiazepine plasma levels were detected in the heroin overdose group. The assessment of methadone, dextropropoxyphene, amphetamines and cannabis in urine analysis did not show differences between both groups. The interview revealed that only 48% of subjects in the heroin overdose group self-administered the last dose of heroin before admission in the usual setting as compared to 100% of subjects in the non-overdose group. The application of a log-linear regression model identified self-injection of heroin in an unusual place and plasma concentrations of total morphine and benzodiazepines as risk factors for heroin overdose.

Prevention of catheter sepsis: the hub.

The prevention of catheter sepsis lies in a sound understanding of the routes through which catheters get contaminated. The catheter hub has been recognized as a portal for microorganisms causing catheter sepsis, particularly in central venous catheters inserted for > 1 wk. Bacteria and fungi may reach the internal surface of the catheter connector during manipulation by hospital staff and then colonize the entire lumen of the catheter. Endoluminal contamination has diagnostic, therapeutic, and preventive implications. Some traditional preventive approaches (site care, subcutaneous cuffs and tunnels, maximal aseptic barriers at the time of catheter insertion, and external antiseptic or antibiotic coating) may fail because they focus solely on the skin as a source of bacteria. Hub-related catheter sepsis can be prevented by aseptic hub manipulation, appropriate junction protection, and by reducing the number of catheter lumens, side ports, three-way stopcocks, and changes of the infusion sets. Needleless systems must be evaluated in terms of their safety in preventing endoluminal contamination. A new disinfecting catheter hub incorporating an antiseptic barrier has been developed and reduced hub-related catheter sepsis by more than 90%. The endoluminal route of intravascular catheter contamination must be taken into account when designing strategies for the diagnosis and prevention of catheter-related sepsis.

[Information on opiate and cocaine consumption in the emergency room clinical records: validity and reliability]. / Información sobre el consumo de opioides y cocaína en la anamnesis de urgencias: validez y fiabilidad.

BACKGROUND: Data on drug consumption obtained from emergency room clinical records have been used for various epidemiological purposes. However the validity and reliability of these data remain unknown. This paper assesses the reliability and validity of an Emergency Room Toxicological Register (HMR) which has collected information on drug misuse from emergency room clinical records since 1979, and examines the implications for epidemiological applications. SUBJECTS AND METHODS: An Emergency Room Survey (ERS) was carried out in a Barcelona Hospital including opiate or cocaine users identified by the physician and a systematic sample of other patients age 15 to 49 years old. Data on clinical records of interviewed patients were also reviewed. Episodes from identified drug users (686) and HMR (676) for the same study period were linked and validity and reliability were analyzed. RESULTS: Sensitivity ranged between 63 and 86%, and specificity was 98%, Kappa index higher than 0.72 and intraclass correlation coefficient was 0.99. CONCLUSIONS: Information about drug users included in emergency room clinical records proved to be valid as an information system for drug use surveillance. However data about patterns of less heavy users, as cocaine use, are underreported.

[Exhaustion syndromes in a popular marathon]. / Síndromes por agotamiento en una maratón popular.

The clinical characteristics of seven healthy subjects who required hospital care for an exhaustion syndrome due to extenuated physical exercise during participation in a public marathon are presented. All the patients were used to practising sports activities and in all the cases the symptoms of exhaustion appeared in the last few kilometers of the race. The most frequent symptom found in all the patients was lipothymia with falling to the ground followed by gastrointestinal manifestations, muscle cramping and fever. Upon analysis the signs of rhabdomyolysis and others suggestive of dehydration were observed in all the cases. Leukocytosis was observed in four and hypopotassemia in two. Evolution was good in all the cases with rest and hydroelectrolytic reposition. Finally, the preventive measures to avoid heat stroke and exhaustion syndromes in public marathons are reported.

[Neurosyphilis in patients infected with the human immunodeficiency virus]. / Neurosífilis en los pacientes infectados por el virus de la inmunodeficiencia humana.

Nervous central system involvement is observed in two out of three patients infected with human immunodeficiency virus and probably, the true prevalence is even higher than that clinically detected. The coexistence of neurosyphilis in this group of patients has been poorly studied and the possibility that some alterations in the natural history of syphilis related to its rapid course with respect to time in which neurologic involvement would occur would have reasonable immunologic basis. We report two patients aged 26 and 22 who presented antibodies against human immunodeficiency virus together with meningo-vascular syphilis with spinal involvement and secondary brain infarction, respectively. In both patients, neurosyphilis was the first manifestation of human immunodeficiency virus infection and none of them referred a history of previous primary or secondary syphilis.

[A unique medical experience: the 1992 Barcelona Olympic Games]. / Una experiencia médica única: los Juegos Olímpicos de Barcelona 1992.

BACKGROUND: The request for medical attention derived from Olympic Games is variable, with few previously published experiences and thus, the estimations made by the organizers are difficult. METHODS: The health care program established during the 1992 Olympic Games held in Barcelona is described and the clinical cases attended are reported. RESULTS: The number of persons accredited by the Barcelona Olympic Committee was 132,286. Health care attendance was provided in the sports installations, the olympic villages of the journalists and athletes, olympic family hotels, press centers and the International Youth Camp. A Polyclinic was in operation in the Olympic Village with a 24 hour Emergency Department. A total of 15,552 visits were made, 524 of which were sent to the Emergency Department of the Olympic Hospital (Hospital del Mar in Barcelona). Three hundred twenty visits were programed in the Out Patient Departments of the Hospital and a total of 81 patients were admitted to the hospital with a mean stay of 3.9 days. The most common medical problems encountered were those related with the locomotor system. CONCLUSIONS: The health care program designed for the Barcelona 1992 Olympic Games was adequate to attend the health care demand required.

[Acquired immunodeficiency syndrome: a descriptive study and analysis of survival in 73 cases]. / Síndrome de inmunodeficiencia adquirida: estudio descriptivo y análisis de la supervivencia en 73 casos.

The clinical features and prognostic factors influencing survival in 73 patients diagnosed of acquired immunodeficiency syndrome (AIDS) from June 1984 to November 1988 were evaluated. Mean age was 32 years. The predominant risk group were drug abusers (67%). The most common opportunistic infections were extrapulmonary tuberculosis and esophageal candidiasis. After 6 months, with 42 patients followed up, the probability of survival was 69% +/- 11 (95% confidence interval); after 12 months, with 28 patients, it was 65% +/- 12 (95% confidence interval); and after 18 months, with 11 patients, it was 54% +/- 15 (95% confidence interval). Patients younger than 30 years and those with extrapulmonary tuberculosis had a longer survival than the rest (p = 0.046 and p = 0.014, respectively). The remaining evaluated variables did not have any influence on survival.

[Incidence of nosocomial infections. Comparison of 2 surveillance systems: clinical vs microbiological follow-up]. / Incidencia de la infección nosocomial. Comparación de dos sistemas de vigilancia: seguimiento clínco frente a seguimiento microbiológico.

The effectiveness of a clinical and a microbiological follow-up systems for the detection of hospital-acquired infection (HI), both independently and simultaneously applied, were prospectively evaluated. The observed incidence rate was 11.4%. The clinical follow-up detected 81.3% of HI while microbiological follow-up detected 59.7%. This difference was statistically significant (p less than 0.001). It took 43 and 45 minutes to detect each instance of HI with the clinical and microbiological methods, respectively. Clinical methods are the most adequate to obtain maximal sensitivity in the overall surveillance of hospital-acquired infection, whereas microbiological follow-up may be useful for the detection of some types of HI such as bacteremia or urinary tract infection.

[Imported malaria: a clinical and epidemiological description of 49 cases]. / Paludismo importado: descripción clínica y epidemiológica de 49 casos.

Malaria is the most common protozoan infection in the world. In 1964, it was considered eradicated in our country, all the new cases being declared as imported, the present migratory and tourism factors obviously having increased the incidence. We analyzed 49 cases of imported malaria diagnosed at "Hospital de Mar" in Barcelona between 1976 and 1987. 14 patients were emigrants from endemic areas. Africa as the continent (73.4%), and equatorial Guinea as the country (44.8%) being the geographical areas most frequently found as sources of the cases. Only 40% of tourists took chemoprophylaxis measures and only half of them did it correctly. The most usual plasmodium found was the P. Falciparum (21 cases). The conclusion is evident, it is necessary to create a greater awareness in our area, improving the information for travellers to tropical countries applying sanitary controls to immigrants who come from endemic areas.