Enhanced attenuation of meningeal inflammation and brain edema by concomitant administration of anti-CD18 monoclonal antibodies and dexamethasone in experimental Haemophilus meningitis.

Antiinflammatory therapy has been shown to reduce the adverse pathophysiological consequences that occur in bacterial meningitis and to improve outcome from disease. In the present study, modulation of two principal steps of the meningeal inflammatory cascade was accomplished by concomitant administration of dexamethasone to diminish overproduction of cytokines in response to a bacterial stimulus and of a monoclonal antibody directed against adhesion-promoting receptors on leukocytes to inhibit recruitment of white blood cells into the subarachnoid space. Dexamethasone and antibody therapy produced a marked attenuation of all indices of meningeal inflammation and reduction of brain water accumulation after H. influenzae-induced meningitis in rabbits compared with results of each agent given alone and of untreated animals. In addition, the enhanced host's meningeal inflammatory reaction that follows antibiotic-induced bacterial lysis was profoundly ameliorated when dual therapy was administered without affecting clearance rates of bacteria from cerebrospinal fluid and vascular compartments. The combination of both therapeutic approaches may offer a promising mode of treatment to improve further the outcome from bacterial meningitis.

[Gastrointestinal bleeding caused by small bowel leiomyosarcoma]. / Hemorragia digestiva por leiomiosarcoma de intestino delgado.

The small bowel leiomyosarcoma is a infrequent tumour in the clinical practice. We report the case of a 50 year old male admitted to the hospital on two occasions for gastrointestinal bleeding. On the second occasion a push enteroscopy located in jejunum a tumour. The pathologic diagnosis was a low grade jejunal leiomyosarcoma. The patient required a surgical intervention with resection of the affected portion of the jejunum.

[Evaluation and improvement in the information of the patients who carry out a digestive endoscopy]. / Evaluación y mejora en la información de los pacientes que se realizan una endoscopia.

INTRODUCTION: The information is an important part of the attendance process though in occasions it can be inadequate or deficient. AIM: We detect an opportunity of improvement in the inadequate information of the patients who carry out an endoscopia. The aim is to evaluate and to improve the quality of the information. METHOD: We realize the first evaluation with 100 patients proceeding from consultations, detecting ignorance of the technology. Actions of improvement are applied, for 4 months, to realize the second evaluation, with the same number of patients and to evaluate improvement with regard to the situation of item. RESULTS: A deficit of information has been detected in the moment to indicate the endoscopia (little information contributed by the doctor prescriptor and in an important number of cases informed assent was not contributed) and after realizing the test, not contributing recommendations. We prioritize our action to this level with measures of improvement and after a new evaluation, a significant improvement decides in these situations. CONCLUSIONS: The studies of qualit level allow us to detect deficit situations and to improve situations in the services of health.

Lessons from the history of the human immunodeficiency virus/acquired immunodeficiency syndrome epidemic among Spanish drug injectors.

In Spain, approximately 10 years passed between the time when human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) harm-reduction programs should have been developed with sufficient coverage to have an optimum impact on public health (before the HIV/AIDS epidemic's explosion in 1984) and the date of their actual implementation. This delay yielded an enormous cost for the country. The introduction of the virus in drug injector networks during a period of widespread diffusion of heroin injection and the lack of political awareness of the growing problem were 2 important factors that contributed to the important diffusion of the HIV infection among Spanish injection drug users. Lessons can be learned that may be of great interest in countries or territories facing similar challenges now and in the future.

Impact of an educational program for the prevention of colonization of intravascular catheters.

OBJECTIVE: To evaluate the efficacy of an educational program for the prevention of catheter colonization. DESIGN: Two cross-sectional studies were carried out in a 500-bed randomly selected area of the hospital, separated by an educational program on the care of intravenous lines based on the Centers for Disease Control and Prevention (CDC) recommendations for the control of catheter-related infections. SETTING: A 2,100-bed urban general hospital affiliated with the University of Madrid (Spain). METHODS: Characteristics of patients and catheters and appropriateness of catheter care were evaluated. Cultures were taken from the point of insertion of the vascular catheter, the hubs, and infusion fluids. When catheter-associated infection was suspected, the distal end of the catheter was sent for culture and two blood cultures were taken. We compared the clinical and microbiological data before and after carrying out an educational program based on CDC recommendations for the control of catheter-related infections. RESULTS: Characteristics of patients and catheters did not differ between the two cross-sectional studies. Compared with baseline data, after the educational program we observed a reduction of inappropriate catheter care, from 83% to 38% (45% difference, 95% confidence interval [CI95], 55% to 35%, P < 0.0000), and a reduction in the rate of skin colonization, from 34% to 18% (16% difference, CI95, 26% to 5%, P < 0.001). The frequency of phlebitis (15% versus 14%), hub colonizations (12% versus 11%), catheter colonizations (2% versus 1%), and catheter-related bacteremias (0% versus 0%) remained unchanged between the two cross-sectional studies. CONCLUSIONS: Our educational program improved catheter care and reduced significantly the proportion of skin colonization around the insertion point. However, the educational program did not modify the proportion of hub colonization; because hub colonization has been demonstrated to be a source of line sepsis, our data suggest the need for a specific program directed to the maintenance of catheter hubs.

Serological diagnosis of neurobrucellosis.

The presence of antibodies was determined in the serum and cerebrospinal fluid in six patients with neurobrucellosis using the Rose Bengal test, the microdilution agglutination test, and the Coombs' test. Four of the patients were followed up for more than three months. The Rose Bengal test and the microagglutination test were positive in cerebrospinal fluid in five of the six cases at some stage. The Coombs' test was positive in cerebrospinal fluid in every patient and in one was the only positive serological test. Cerebrospinal fluid positivity is not excluded by low titres or negative results of antibodies in the serum for any of the three methods. A Coombs' test or some equivalent must always be made on the cerebrospinal fluid to diagnose neurobrucellosis.

Diagnosis of nosocomial pneumonia in mechanically ventilated patients by the blind protected telescoping catheter.

OBJECTIVES: To demonstrate that blind insertion of the protected telescoping catheter (PTC-NB) through the orotracheal tube can provide reliable pulmonary samples for the diagnosis of nosocomial pneumonia (NP) in ventilated patients. DESIGN: We performed a random comparison between the protected telescoping catheter introduced through a bronchofiberscope (PTC-B) and the PTC-NB to diagnose NP. SETTING: A general intensive care unit of a University Hospital. PATIENTS: 40 consecutive patients on mechanical ventilation and with suspicion of NP. The diagnosis of NP was suspected by clinical and chest X-ray findings. MEASUREMENTS AND RESULTS: NP was confirmed microbiologically in 26 (65%) patients and maintained in 8 patients by clinical and radiological criteria. PTC-NB confirmed the microbiological diagnosis of PN in 21 (80%) patients. The use of antibiotics prior taking respiratory samples reduced the sensitivity of PTC-NB and PTC-B from 100-74% and from 94-70% (p = 0.001). Both techniques agreed in 24 of 33 (73%) patients but such agreement was better when PN was on the right lung. Two patients developed a self-limiting hemoptysis after the PTC-B procedure. CONCLUSIONS: PTC-NB is as sensitive as specific as PTC-B for diagnosing PN in mechanically ventilated patients, being a much easier technique to use.

Blistering distal dactylitis in an adult.

Streptococci are responsible for a diverse spectrum of cutaneous infections like erysipelas, impetigo, and cellulitis. Blistering distal dactylitis is an infrequent, superficial infection of the anterior fat pad of the distal portion of the finger described classically in children. We report a case of blistering distal dactylitis in an adult caused by group A beta-hemolytic streptococci that was cured with oral phenoxymethyl penicillin. Familiarity with blistering distal dactylitis should permit the dermatologist and internist to diagnose this new entity in adults.

[Mucormycosis. The disease spectrum in 13 patients]. / Mucormicosis. El espectro de la enfermedad en 13 pacientes.

Mucormycosis is an uncommon infection caused by fungi of the order Mucorales. During an 8-year period, mucormycosis was diagnosed in 13 patients from three Madrid hospitals. There were 8 males and 5 females, with ages ranging from 21 to 75 years (mean 45 years). There were several underlying diseases, and 4 patients had more than one. Five had diabetes mellitus, 4 chronic renal failure, 2 acute myeloblastic leukemia, 2 were narcotic abusers and were infected by the human immunodeficiency virus (HIV), 1 had non-Hodgkin's lymphoma, 1 was a carrier of a renal allograft and 1 had systemic necrotizing vasculitis. There were different clinical presentations: rhino-orbital in 3, paranasal in 2, cutaneous in 2, pulmonary in 2, primary cerebral in 2, rhinocerebral in 1, and peritoneal in 1. The diagnosis was made during the first week in 6 patients, in the second week in 4, and it was delayed for more than one month in 2. Fresh examination of clinical samples was carried out in 3 patients and hyphae were visualized in all 3. Cultures were taken in 10 patients and they were positive in 7. All isolates were identified as Rhizopus sp. One patient died within 24 hours without being treated, 12 were treated with amphotericin B and 9 received surgical therapy. Six patients (46%) died. The involvement of central nervous system and the absence of surgical therapy were associated with a poor outcome. These results indicate that mucormycosis can develop in several clinical contexts and has a varying clinical presentation. It is a potentially curable infections when early diagnosed and appropriately treated.

[Chronic fatigue syndrome associated with Epstein-Barr virus infection]. / Síndrome de fatiga crónica asociado a infección por el virus de Epstein-Barr.

Epstein-Barr virus (EBV) infection is ubiquitous and may result in multiple and widely different clinical features; the most common of these is infectious mononucleosis (IM). Recently, a group of patients has been included in the chronic EBV infection syndrome (EBVIS), with a sustained nonspecific syndrome consisting of asthenia, anorexia, low grade fever and changes in mood, associated with a viral infection not necessarily caused by EBV; this has been called chronic fatigue syndrome (CFS). We report a patient who fulfilled the criteria for CFS associated with EBV after an acute, well documented EBV infection. We discuss its etiological and pathophysiological implications, emphasizing the need for extreme caution in the diagnosis of CFS. A merely clinical diagnosis may hide severe mistakes.

[Infection caused by the human immunodeficiency virus, hepatitis B virus and delta virus in homosexual males]. / Infección por el virus de la immunodeficiencia humana, el virus de la hepatitis B y el virus delta en varones homosexuales.

Serological markers of hepatitis B (HBV) and human immunodeficiency (HVI) viruses were investigated in the sera of 90 homosexual males. In addition, in HBsAg positive individuals antibodies against delta virus (DV) were also investigated. Forty sera (44.4%) were positive for HBV and HIV, 61 (67.7%) for HBV and 52 (57.7%) for HIV. HBsAg was detected in 8 cases (8.8%), 7 of which had positive anti-HIV sera. In no case infection by DV was detected. These data show the high prevalence of HBV and HIV infection in the study population. They also suggest that the HBsAg carrier status is more common among HIV positive homosexual males and that the investigated homosexual population has not yet been infected by DV.

[Ultrasonographic diagnosis of intestinal fistulae associated with Crohn disease]. / Diagnóstico ultrasonográfico de fístulas intestinales asociadas a enfermedad de Crohn.

In two patients with Crohn's disease, abdominal mass and fever, abdominal ultrasound disclosed enteroenteric fistula in one, and intestinal fistula associated to subcutaneous abscess in the second. We emphasize the role of ultrasound in the diagnosis of active Crohn's disease, especially as a complementary method for the detection of intraabdominal complications.

[Splenic rupture in acute pancreatitis]. / Rotura esplénica en una pancreatitis aguda.

The case of a 42-years-old male with acute pancreatitis of ethanol origin and formation of pseudocysts in the tail of the pancreas is presented. The patient suddenly presented a picture of hypovolemic shock caused by rupture of the spleen. Emergency splenectomy with resection of necrotic tissue was performed and thrombosis of the splenic vein was observed. The patient evolved satisfactorily following surgery.