Predictive factors of mortality in severe community-acquired pneumonia: a model with data on the first 24h of ICU admission.

OBJECTIVE: To construct a model of factors predicting mortality in severe community-acquired pneumonia (SCAP) with data on the first 24h after admission to the intensive care unit (ICU). DESIGN: A prospective, observational study was carried out. SETTING: The ICU of a university hospital. PATIENTS: ICU-admitted patients with SCAP were studied prospectively. INTERVENTIONS: Admission pneumonia scores were calculated, and clinical variables were registered during the first 24h. Relationships between predictors of mortality at 28 days were assessed by means of a multivariate logistic regression model. RESULTS: A total number of 242 SCAP patients were evaluated. The SAPS II severity score was 37.2±15.5 points. Bivariate analysis showed high mortality to be more frequent in elderly patients, as well as in patients with high SAPS II scores, neoplastic disease or chronic renal failure. The other prognostic factors related to increased mortality included mechanical ventilation, acute respiratory distress syndrome (ARDS), acute renal failure, bacteremia, and septic shock. Mortality at 28 days was 23.1% (56 patients). Multivariate analysis of the risk factors generated a new predictive model of mortality applicable within the first 24h after ICU admission and comprising 5 main factors: age, CURB severity score 3-4, septic shock, ARDS, and acute renal failure. CONCLUSIONS: Age in years, CURB score 3-4, septic shock, ARDS, and acute renal failure during the first 24h of ICU admission were found to be independent predictors of mortality in SCAP patients.

Pain management at iliac donor sites after grafting of alveolar clefts.

The aim of this study was to answer the question: which analgesic protocol is most efficient and most effective in overcoming pain and promoting functional recovery after iliac bone grafting in cleft alveolus patients? A systematic review of the literature was performed. The population consisted of cleft lip and alveolus patients with or without cleft palate undergoing iliac crest bone grafting; the outcomes analysed were represented by the duration of hospital stay, subjective pain rating, and degree of impaired mobility. A total of 15 articles were selected for review. The following protocols were subject to comparison in this review: simple classic intravenous/per-oral analgesia, local anaesthetic infiltration in the donor site, anaesthetic-soaked sponge, neural blocks and continuous infusion at the donor site. The results of the included studies were individually reported identifying trends in the efficiency of the different pain-management techniques. Although hospital stay varied from same-day discharge to almost a week, other factors besides pain influenced this outcome. School was resumed after an average of 12.6 days and sport activities after maximum one month regardless of the used protocol. Even though the age of patients had a statistically significant influence on hospital stay durations, it did not determine the latter. The pain management protocols after iliac bone grafting of alveolar clefts selected for analysis have their advantages and drawbacks. All protocols seem effective meaning they reach adequacy in managing pain at the donor site. The efficiency of the protocols could not be assessed due to the lack of data and inconsistency in pain assessment scales. Further investigation through randomized controlled studies is required.

Multiphase whole-body CT angiography before multiorgan retrieval in clinically brain dead patients: Role and influence on clinical practice.

GOALS: To evaluate the contribution of multiphase whole-body CT angiography (CTA) for identifying the contra-indications to multiorgan retrieval (MOR) and improving the preoperative organ harvesting strategy. PATIENTS AND METHODS: One hundred and eleven consecutive patients who were clinically brain dead underwent multiphase whole-body CTA to confirm the diagnosis of brain death and for assessment of MOR. The CTA protocol included volumetric acquisitions of the brain and abdominopelvic cavity without IV administration of iodinated contrast material, then images of the thorax-abdomen-pelvis 25s after IV contrast administration, of the brain at 60s and finally an abdominopelvic CT acquisition at 90s. The diagnosis of brain death was based on well-established criteria. The assessment of thorax, abdomen and pelvis was based on a systematic checklist. Post-processing imaging techniques were used in all patients. RESULTS: No organs were retrieved from 21 patients due to patient refusal (19%). Twenty-two potential MOR were denied because of general contra-indications including 12/22 (54%) based on CTA criteria alone. Finally, 68 patients were eligible for MOR and 160 organs were harvested. The exclusion of specific organs was based on CTA alone for 2/16 livers, 4/70 kidneys and 5/55 lungs. Fifty hearts and 58 pancreases were not harvested, none based on CTA results alone. Hepatic abnormalities and vascular anatomical variants were identified in 10% of patients. At least one renal artery variant was found in 28% of patients, 13% presented with a double renal vein and 8% with a hepato-mesenteric artery. CONCLUSION: Multiphase whole-body CTA for MOR is based on the simultaneous association of cerebral CTA to determine brain death with CTA of the thorax, abdomen and pelvis. This rapid, standardized and easily accessible procedure has no harmful effects on harvested kidneys. It makes it possible to select the donors and the organs to be harvested and allows the retrieving surgeon to identify and anticipate technical difficulties.

Determinants of right ventricular pressure in mild hypertension.

OBJECTIVE: Doppler echocardiography was used to define reference values and determinants of tricuspid regurgitation peak velocity (TRV) in hypertensive patients. A TRV value > 2.5 m/s is the threshold usually defining abnormal right ventricular systolic pressure. DESIGN AND PATIENTS: Doppler echocardiography was performed in 320 consecutive uncomplicated hypertensive patients, without overt pulmonary or heart disease. Doppler echocardiography included LV mass measurement, LV inflow and pulmonary venous flow analysis, LV systolic function and TRV measurements. RESULTS: Among 320 patients, 255 had normal TRV < 2.5 m/s and 65 had elevated TRV > or = 2.5 m/s. Compared with the normal TRV group, the elevated TRV group was older (60 versus 50 years, P < 0.0001), systolic blood pressure was higher (156 versus 151 mmHg, P = 0.02) and antihypertensive therapy was more frequent (68 versus 51%, P = 0.02); indexed LV mass was higher (45.4 versus 40.6 g/m2.7, P = 0.001), pulmonary D wave peak velocity was higher (42 versus 38 cm/s, P = 0.03). In univariate analysis, age was the most predictive variable of TRV (r = 0.36). In multivariate analysis, three variables were independently related to TRV: age, LV mass, pulmonary D wave (multiple r = 0.47). CONCLUSION: In mild hypertension, TRV is independently related to age, and to a lesser extent, to LV morphology and LV filling pressure. In clinical practice, age should be taken into account to interpret TRV.

[Evaluation of the quality of filling out medical records in a hypertension consultation]. / Evaluation de la qualité du remplissage des dossiers d'une consultation d'hypertension artérielle.

The aim of the study was to evaluate the completion of medical records of a hypertension clinic and to compare standardized computerized records versus standard medical records. The medical records of 163 consecutive hypertensive patients attending at the Broussais hospital hypertension clinic between December 1995, 6th and January 1996, 21st were checked. At the last visit, the patients were attended by 16 physicians working in 4 different teams. The medical data were recorded by physicians in the computerized system called ARTEMIS in 120 patients and in standard structured forms in 43 patients. The patients notes were checked to see if 9 clinical items were recorded at the first visit (V1), at the visit before last (V2) and at the last visit (V3). The overall completion rate was high at V1 (92.2%) and significantly decreased at follow-up visits (82.6% at V2 and 83.2% at V3). The completion rate was significantly higher in the computerized records than in the standard notes: 95.8% vs 82.2% at V1, 91.9% vs 56.3% at V2 and 91.6% vs 59.7% at V3. During follow-up (V2 vs V1), a significant decrease in the completion rate of 6 items was observed in the standard notes (tobacco use, alcohol consumption, physical activity, compliance to treatment, body weight, manual blood pressure measurement). In the computerized records, only physical activity completion rate decreased. In conclusion, the computer may help to increase the quality of the medical records as reflected by the completion rate of items related to hypertension care.

[Audit of the treatment of arterial hypertension in specialized consultation]. / Audit du traitement de l'hypertension artérielle en consultation spécialisée.

The objective of the study was to estimate the control of elevated blood pressure (BP) among patients regularly followed-up and to analyse physicians attitudes in patients having uncontrolled BP. Two hundred and fifty-eight consecutive patients (mean age 56 years, 58% of males) with essential hypertension attending the outpatient department of a specialised hypertension clinic, having at least a 6-month follow-up at the clinic and at least 3 prior visits, were included in the study. Twelve different physicians were in charge of these patients. Data were collected [1] from the structured computerised record called ARTEMIS and [2] from a structured questionnaire filled up by the physician after each visit, where he/she explained the reasons for his/her decisions. BP was measured by a nurse using an automatic device (oscillometric method) and then by a physician using a mercury sphygmomanometer. During follow-up, mean physician's BP fell from 179/107 to 148/91 mmHg and mean nurse BP fell from 164/96 to 143/83 mmHg. Percentages of patients having a controlled hypertension (BP < 140/90 mmHg) were 27% (physician's BP) and 45% (nurse BP). Physicians did not modify treatment in 59% of patients among whom they measured a BP > or = 140/90 mmHg. The 3 main reasons given by physicians for not modifying treatment were: BP controlled when using other BP measurement methods (nurse, home or ambulatory BP), 44%; BP control considered as satisfactory, 29%; systolic hypertension in the elderly, 8%. The person (physician or nurse) who measures BP and the measurement method have dramatic consequences on BP control level. Reasons for not modifying treatment in uncontrolled patients (physician's BP > or = 140/90 mmHg) were based on opinions rather than evidence, for example when isolated systolic hypertension in the elderly is concerned.

[Management of thoracic aorta traumatism in 5 multiple traumatized patients]. / Manejo del traumatismo de aorta torácicaen cinco pacientes politraumatizados.

Thoracic aorta traumatism is a lesion associated to high morbidity-mortality at the site of the accident. In the 90's, treatment by placement of an endovascular stent was generalized with good results. In this work, we present a series of 5 clinical cases of patients admitted to the Intensive Care Unit of our hospital during the year 2006. Out of a total of 619 patients admitted in the same period, 121 (19.5%) were traumatic and 5 (4.13%) had thoracic aorta traumatisms. All of the patients were diagnosed by thoracic helical computed tomography on admission. Four patients had a pseudoaneurism of the aorta and underwent an operation. Three received endovascular treatment within the first 36 hours and the fourth on day 28 of admission. The fifth patient had a lesion of the intima and was not operated on. Posterior evolution was good in all the cases.

Unusually large adrenal adenoma excreting unusually large amounts of androgen metabolites in urine.

A 27-yr female patient was admitted to the hospital because of secondary amenorrhea and a severe and complex virilization syndrome. The urinary 17-Ks, 17 OHCS and testosterone glucuronide values were greatly increased. The plasma testosterone through very high, was within the normal limits in males (3.52 ng/ml). Urography, echography and CT scan revealed a large right adrenal tumor. Removal of the tumor brought about a considerable clinical improvement: reoccurrence of the menstrual cycle, a progressive decrease in the virilization syndrome and normalization of the urinary 17-Ks, 17-OHCS and of the plasma testosterone.

The excretion of noradrenergic metabolites, particularly MHPG, in obese children and adolescents.

Eighty obese children and adolescents (41 males) aged 4-18 were screened for urinary adrenergic derivatives (NA, A, AVM, MN, MHPG) and the results compared with age- and sex-matched controls. Significantly higher amounts of A (8.1 +/- 0.38 micrograms/24 h), MN (0.327 +/- 0.032 mg/24 h) and MHPG (2.74 +/- 0.192 mg/24 h) were found and significantly linear regression curves of MHPG were plotted against urinary creatinine and NA but not against age, weight and Quettelet index. A subgroup of 26 obese having urinary MHPG over 3 mg/24 h ("high MHPG excretors") revealed significantly greater means of weight Quettelet index, A and NA than the remaining 54--member subgroup ("low MHPG excretors"). It was concluded that in randomly selected obese children and adolescents there are obvious humoral signs of sympathetic nervous system overactivity and, possibly, of adrenomedullary increased tonus and that these manifestations may be due, at least in part, to increased central (encephalic) noradrenergic activity, especially in more overweight patients.

The level of urinary and plasma steroids after oral administration of cyclofenil to hirsute women with menstrual disorders and obesity.

Cyclofenil 600 mg/day was given to 10 women with excessive skin hair and marked excretion of urinary androgens. The urinary values of androgenic metabolites as well as the plasmatic values of radioimmunoassayable testosterone remained unaltered. A significant increase was noticed in the radioimmunoassayable plasma estradiol. Urinary total estrogens could not be assayed in the women under cyclofenil because of a non-specific color reaction. It was concluded that the estrogenic effects of cyclofenil are mediated, at least partly, by release of gonadotropins from the hypophysis.

Clinical assessment of cryptorchid boys by determination of urinary testosterone glucuronide following large doses of human chorionic gonadotropin (hCG).

Urinary TG and fractionated 17-ketosteroid (Drosdowsky) determinations were performed before and after the intramuscular administration of 15,000 IU of human chorionic gonadotropin (hCG) in 10 sexually immature healthy boys and in 12 bilaterally cryptorchid boys. The same basal determinations were made in 11 gonadless girls. Basal serum FSH and LH were determined (by radioimmunoassay) in controls and also in cryptorchid boys. If 15mug/24 h (three SD's of basal excretion in controls) is considered the smallest adequate response, the TG but not the fractionated 17-KS determination assessed fairly well either the presence or the functional capacity of the Leydig cell-containing tissue. Agonadic girls had significantly higher basal excretion of steroids and this is presumably due to their greater absolute body size and to their more advanced bone age.

Deviation of plasmatic aldosterone and significance of the stimulating (ACTH-cortrosyn) and inhibitory (propranolol) effects in hypertension and cardiovascular pathology.

Starting from the interference between the renin-angiotensin-aldosterone (RAA) system and cardiovascular pathology in arterial hypertension (AH) we have made a correlative study of the cardiovascular system and plasmatic aldosterone in normal and hypertensive subjects under conditions of stimulation (ACTH) and inhibition (propranolol). After administration of ACTH (one of the physiologic mediators of stress) increased values for plasmatic aldosterone were found. Negative cardiovascular effect: arrhthmia, angor, AH, cardiac asthma, under the condition of preexisting cardiovascular pathology or altered steroidogensis, were also noticed. Inhibition with propranolol does not have conclusive effects in AH with normal aldosterone. The best effect were noticed in that hypertension which implies the RAA pressor system in its pathogeny, irrespective of etiology, the reduction AT occurring in parallel with decline in plasmatic aldosterone values and total peripheral resistance (RPT). Administration of propranolol in AH with activated RAA system irrespective of etiology represents a pathogenic treatment able to prevent efficiently the major complications of AH.

Effect of a melatonin-free extract from bovine pineal on plasma and urinary steroids and on serum prolactin in hirsute amenorrheic adolescents.

Basal and post-suppressive dexamethasone (dxm) levels of some urinary androgen metabolites, plasma testosterone (T), 17 hydroxyprogesterone (17 OHP) and of basal serum prolactin were determined in 34 hirsute amenorrheic adolescents aged 13-17 in whom a five day course of bovine pineal extract (4 ml a day i.m.) was instituted. No convincing effect of pineal extract administration on plasma T and 17 OHP and on serum prolactin was detectable in most of pineal-treated patients. Suppressibility to dxm of plasma T and 17 OHP was not a relevant index of both the origin of androgens or the clinical course of the patients.

Assessment of the antimineralocorticoid effect of RU 28318 in healthy men with induced exogenous and endogenous hypermineralocorticism.

The antimineralocorticoid effect of a single dose of RU 28318, has been assessed in healthy men with exogenous or endogenous hypermineralocorticism. For exogenous hypermineralocorticism induced by ingestion of 9 alpha-fluorohydrocortisone (9 alpha-FHC) and aldosterone infusion, RU 28318 100 mg (9 alpha-FHC ingestion) or 200 mg (aldosterone infusion) was administered, and its effect compared with identical doses of spironolactone or a placebo. For endogenous hypermineralocorticism induced by ingestion of furosemide, RU 28318 100 and 300 mg was tested in comparison with 100 mg spironolactone or placebo. In all 3 studies, both RU 28318 and spironolactone significantly raised the urinary Na/K ratio when compared to placebo administration. No significant difference was apparent between RU 28318 and spironolactone. Thus, a single dose of RU 28318 in man has an antimineralocorticoid effect identical to those produced by the identical molar dose of spironolactone. In addition, the results show that furosemide-induced hyperaldosteronism constitutes a simple and reproducible test for assessing the antimineralocorticoid effect of a drug.

Studies of the reproduction function in hyper- and hypoadrenocorticism.

The investigation was carried out on 66 patients with hypo- or hyperfunctional syndromes of adrenocorticism, hospitalized and treated by our team. The patients were grouped into 5 lots according to their diseases. Lot one consisted of 34 female patients with Cushing's syndrome, lot two of 10 males with Cushing's syndrome, lot three of 10 males with Addison's disease and lot four, of 6 females with androgenic hypercorticism. The morphofunctional disorders of reproduction were followed up clinically and by complex hormone assays, before and after treatment. The incidence of these disorders is very high, and the results of clinical observations and of laboratory data demonstrate that both the excess of adrenocortical hormones and the decrease in their circulating level have a negative influence on the reproduction function or represent a risk factor in cases of pregnancy. By the curative treatment of the adrenal cortex a preventive treatment of abortion and/or sterility is achieved.

Plasma renin activity (PRA) and plasma aldosterone in the adrenal cortex hyperactivity. Studies on 50 hypertensive patients.

The authors have studied on 50 patients hospitalized in the Adrenal Pathology unit of the Institute of Endocrinology, the etiopathogeny of arterial hypertension (AH) in hypercorticism and the therapeutic implications, arriving at the conclusion that in 20% of the cases AH was probably due to an increased activity of renin-angiotensin and in 47% to elevated levels of aldosterone. The authors hypothesize that AH in the remaining 30% of the hypercorticism cases in this study is due to other mineralocorticoids in excess and suggest that the treatment should be pathogenic and strictly individualized.

The role of the renin-angiotensin system in arterial hypertension in hypercorticism.

The authors have studied on 25 cases of hypercorticism, one of the mechanisms of producing arterial hypertension, the renin-angiotensin system. The study showed that in only 20% of the cases plasma renin activity was high whereas in the remaining 80% other mechanisms were responsible for the hypertension. In the cases in which the plasma activity of renin was high, by studying the changes in the value of electrolytes we were able to derive some understanding of the mechanism of action of the RA2A system. Thus, the literature data show that sometimes the excess of glucocorticoids causes hypertension by activating directly the RA2A system and concomitently inhibiting the renin-kalikrein system (RKKS) and PgS; at other times, the excess of glucocorticoids is exerted on the same renin-angiotensin system, but via ACTH and ADH, the electrolytes values being those that demonstrate the borrowed mechanism.