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.

A new mass spectrometry-based method for the quantification of histones in plasma from septic shock patients.

The aim of this study was to develop a novel method to detect circulating histones H3 and H2B in plasma based on multiple reaction monitoring targeted mass spectrometry and a multiple reaction monitoring approach (MRM-MS) for its clinical application in critical bacteriaemic septic shock patients. Plasma samples from 17 septic shock patients with confirmed bacteraemia and 10 healthy controls were analysed by an MRM-MS method, which specifically detects presence of histones H3 and H2B. By an internal standard, it was possible to quantify the concentration of circulating histones in plasma, which were significantly higher in patients, and thus confirmed their potential as biomarkers for diagnosing septic shock. After comparing surviving patients and non-survivors, a correlation was found between higher levels of circulating histones and unfavourable outcome. Indeed, histone H3 proved a more efficient and sensitive biomarker for septic shock prognosis. In conclusion, these findings suggest the accuracy of the MRM-MS technique and stable isotope labelled peptides to detect and quantify circulating plasma histones H2B and H3. This method may be used for early septic shock diagnoses and for the prognosis of fatal outcomes.

Antibiotic prescription for community-acquired pneumonia in the intensive care unit: impact of adherence to Infectious Diseases Society of America guidelines on survival.

BACKGROUND: The purpose of our study was to analyze prognostic factors associated with mortality for patients with severe community-acquired pneumonia (CAP). METHODS: We conducted a prospective multicenter study including all patients with CAP admitted to the intensive care unit during a 15-month period in 33 Spanish hospitals. Admission data and data on the evolution of the disease were recorded. Multivariate analysis was performed using the SPSS statistical package (SPSS). RESULTS: A total of 529 patients with severe CAP were enrolled; the mean age (+/-SD) was 59.9+/-16.1 years, and the mean Acute Physiology and Chronic Health Evaluation (APACHE) II score (+/-SD) was 18.9+/-7.4. Overall mortality among patients in the intensive case unit was 27.9% (148 patients). The rate of adherence to Infectious Diseases Society of America (IDSA) guidelines was 57.8%. Significantly higher mortality was documented among patients with nonadherence to treatment (33.2% vs. 24.2%). Multivariate analysis identified age (odds ratio [OR], 1.7), APACHE II score (OR, 4.1), nonadherence to IDSA guidelines (OR, 1.6), and immunocompromise (OR, 1.9) as the variables present at admission to the intensive care unit that were independently associated with death in the intensive care unit. In 15 (75%) of 20 cases of Pseudomonas aeruginosa infection, the antimicrobial treatment at admission was inadequate (including 8 of 15 cases involving patients with adherence to IDSA guidelines). Chronic obstructive pulmonary disease (OR, 17.9), malignancy (OR, 11.0), previous antibiotic exposure (OR, 6.2), and radiographic findings demonstrating rapid spread of disease (OR, 3.9) were associated with P. aeruginosa pneumonia. CONCLUSIONS: Better adherence to IDSA guidelines would help to improve survival among patients with severe CAP. Pseudomonas coverage should be considered for patients with chronic obstructive pulmonary disease, malignancy, or recent antibiotic exposure.

[Guidelines for the management of community pneumonia in adult who needs hospitalization]. / Guías para el manejo de la neumonía comunitaria del adulto que precisa ingreso en el hospital.

Community acquired pneumonia is still an important health problem. In Spain the year incidence is 162 cases per 100,000 inhabitants with 53,000 hospital admission costing 115 millions of euros per year. In the last years there have been significant advances in the knowledge of: aetiology, diagnostic tools, treatment alternatives and antibiotic resistance. The Spanish Societies of Intensive and Critical Care (SEMICYUC), Infectious Diseases and Clinical Microbiology (SEIMC) and Pulmonology and Thoracic Surgery (SEPAR) have produced these evidence-based Guidelines for the management of community acquired pneumonia in Adults. The main objective is to help physicians to make decisions about this disease. The different points that have been developed are: aetiology, diagnosis, treatment and prevention.

Sepsis and SOFA score: related outcome for critically ill renal patients.

AIMS: To evaluate the influence of sepsis in critically ill patients with acute renal failure (ARF), and to analyze the value of the sequential organ failure assessment (SOFA) score for assessing the morbidity and related mortality of these patients. MATERIAL AND METHODS: A prospective observational study developed in a medical intensive care unit (ICU) of a tertiary care university hospital. Data were collected from January 1, 2001 - July 31, 2002. The inclusion criterion was either a creatinine plasma level > or = 2 mg/dl on ICU admission or increases > or = 30% from its initial value. Sepsis was evaluated at the time of study inclusion, and patients were distributed into 2 groups (septic and nonseptic patients). RESULTS: Two hundred patients with ARF were prospectively enrolled in the study (91 (45.5%) septic and 109 (54.5%) nonseptic patients). Median age was 68 years in septic patients and 72 in nonseptic ones while the percentage of males in both groups was 66% vs 69%, respectively. Septic patients showed more organ failures and more respiratory, cardiovascular and coagulation failures at the time of study admission as well as a worse mean SOFA score during the first 4 days after inclusion (p < 0.01). Mortality rate at the ICU was significantly higher in the septic group when compared to the nonseptic one (55% vs 19.3%, OR = 2.21 (1.65 - 2.97)). Using stepwise logistic regression, acute tubular necrosis and oliguria in septic patients as well as cardiovascular failure (evaluated by SOFA score) in nonseptic patients were identified as independent risk factors for mortality. CONCLUSIONS: Septic and nonseptic ICU patients with ARF have an increased risk of ICU mortality depending on the type of organ failure. Although SOFA score does not predict outcome, it is a useful tool to categorize these patients and to describe a sequence of complications in critically ill patients.

[Extrinsic compression of the right atrium due to a mediastinal germ-cell tumor]. / Compresión extrínseca de la aurícula derecha por un tumor germinal mediastínico.

A patient with a mediastinal mass detected by plain chest roentgenogram is presented. The echocardiographic-Doppler examination and the computed tomography precise the gross nature and extent of the tumour and its anatomical location producing obstruction of the right atrium and modifying the blood flow pattern in this chamber. The serum tumour markers and the transthoracic biopsy confirm the diagnosis of primary mediastinal germ cell tumour.

[Obstructive sleep apnea syndrome in the Community of Valencia: current situation, study of needs and future prospects]. / Síndrome de la apnea obstructiva del sueño en la Comunidad Valenciana: situación actual, estudio de necesidades y perspectivas de futuro.

To analyze the infrastructure needs for diagnosing sleep apnea syndrome (SAS) in the Community of Valencia, we studied available resources and the diagnostic approaches to SAS in departments of pneumology and neurophysiology in 23 of the 25 public hospitals by means of a telephone interview. Only 52% of pneumology departments and 56% of neurophysiology departments studied SAS at any level. Level I study (conventional polysomnography) was performed by 42% of the pneumology departments and 100% of the neurophysiology departments. The remaining pneumology units used nighttime oximetry (a level IV technique). A special unit and trained personnel were available at 40% of hospitals. Home studies were performed by only 17%. Although 2,000 studies are performed annually, only 1,100 are level I and large interdepartmental differences were detected. The average waiting period was 16 months. Relations between pneumology and neurophysiology units were few and only one hospital took an interdisciplinary approach. The ratio of polysomnographs to inhabitants was 0.52/250,000 and the prevalence of nasal continuous positive airway pressure treatment was 36/100,000, lower than in other communities. We conclude that Valencia is understaffed and under-equipped, and that in some cases resources are under-used. Interdisciplinary approaches are scarcely used by the various specialists involved and the waiting lists for diagnostic tests required for prescribing empirical treatment are long. To attend the approximately 100,000 SAS patients estimated to reside in Valencia, it would be necessary to have 14 polysomnograph devices rather than the 8 available now, as well as to increase staff to meet demand and shorten waiting lists.

[Acute renal failure in critically ill patients. A prospective epidemiological study]. / Fracaso renal agudo en la unidad de cuidados intensivos. Estudio observacional prospectivo.

AIMS: To determine factors which may predict mortality in patients admitted to intensive care unit who present acute renal failure. METHODS: Prospective observational study of the patients admitted to a multidisciplinary intensive care unit over a year. The inclusion criteria were a creatinine plasmatic value > or = 2 mg/dl (177 micromol/l) or an increase (30% or higher) of its basal value on admittance. RESULTS: One hundred and twenty-seven patients (age = 65.83 +/- 15.06 years; 38% male) with acute renal failure, were prospectively enrolled in the study (13% of intensive care unit admissions). The univariate analysis showed that hospital origin, acute tubular necrosis, late ARF, oliguria, maintained hypotension, sedation or coma, oncological disease and need of mechanical ventilation were significantly associated with mortality (p < 0.05). This association was also found for sepsis (OR: 41.5), multiorganic failure (OR: 3.58) and respiratory, cardiovascular or haematological failure according to the SOFA score. The multivariate analysis found that four clinical variables had an independent predictive value for mortality risk: acute tubular necrosis [OR: 4.57 (2.32-9.00)], use of vasoactive drugs [OR: 2.32 (1.22-4.40)], oliguria [OR: 2.15 (1.12-4.13)] and the acute renal failure starting during admission [OR: 2.06 (1.09-3.88)]. CONCLUSION: Data related to renal failure have worse prognosis than other demographic or clinical data in critically ill patients with acute renal failure. Multicentric studies with unified criteria are needed to analyse the most important prognostic factors.

[Neuroleptic malignant syndrome, multiorgan failure and peripheral polyneuropathy]. / Síndrome neuroléptico maligno, fallo multiorgánico y polineuropatía periférica.

The Malignant Neuroleptic Syndrome (MNS) is characterised by the acute appearance of hyperthermia, muscular rigidity, loss of motor control, and alterations in the level of consciousness, which could prove fatal if not rapidly diagnosed and treated. It is held to be a serious idiosyncratic reaction which appears in patients being treated with neuroleptics, independently of the dosage and the length of time the drug has been prescribed. Relapses do not usually occur when the drug is re-prescribed, once the acute phase has been passed, which suggests the existence of predisposing factors. There are frequent complications (acute respiration difficulties, acute kidney failure, disseminated intravascular coagulation and multiorganic failure) which condition the prognosis. The treatment consists of the suppression of the neuroleptic, rehydration, and specific drugs (bromocryptine, sodium dantroline). We have analysed two new cases which reacted badly, one of them with a multiorganic failure and the other, who had a good initial therapeutical response but who went on to develop a peripheral neuropathy, an infrequent complication in international medical casebooks.

[Descriptive epidemiology of the vascular risk factors in Bañeres. Study group 'Bañeres Project']. / Epidemiología descriptiva de los factores de riesgo vascular en Bañeres. Grupo de Estudio 'Proyecto Bañeres'.

INTRODUCTION: Epidemiological studies of the risk factors of cerebrovascular disease are of great interest, particularly the identification of factors which may be modified. Previous studies carried out in the Alcoi region of Alicante province, showed a high prevalence of cerebrovascular disease. The town of Bañeres was therefore chosen for confirmation of this data and identification of the frequency of vascular risk factors. OBJECTIVE: To compare the group of patients with cerebrovascular disease with the remainder of the population interviewed. PATIENTS AND METHODS: In a door-to-door study in Bañeres 1,832 people were interviewed as part of the Bañeres Project. The population aged over 45 years was interviewed and filled in a questionnaire for diagnosis of transient ischemic accidents. RESULTS: Arterial hypertension: estimated prevalence 500/1,000 inhabitants, relative risk 3.24; diabetes mellitus: estimated prevalence 195/1,000, relative risk 2.18; coronary artery disease: estimated prevalence 58/1,000, relative risk 1.88; peptic ulcer: estimated prevalence 75/1,000, relative risk 1.23; smoking: estimated prevalence 110/1,000, relative risk 0.46; complete arrhythmia: prevalence 73/1,000, relative risk 5.23. Family histories of cerebrovascular accident, arterial hypertension, diabetes and coronary artery disease were not significant. CONCLUSIONS: Arterial hypertension, diabetes mellitus and arrhythmia were significantly more prevalent amongst patients with vascular disease in our setting. We found no association with the other risk factors analyzed.

[Spontaneous pneumothorax in pregnancy: description of a case and review of the literature]. / Neumotórax espontáneo en el embarazo: descripción de un caso y revisión de la literatura.

A case of pneumothorax during the 8th week of pregnancy is described. The literature is reviewed. We highlight the rareness of the case and discuss of possible relationship with protector hormonal factors.

[Primary spontaneous pneumothorax in 4 siblings]. / Neumotórax espontáneo primario en cuatro hermanos.

4 cases of spontaneous pneumothorax in 4 brothers, previously healthy with similar morphometric features and normal levels of alpha-1-antitrypsin, are presented. They all showed a tendency to relapse. The thoracoscopy carried out on one patient did show bullae and pleurodesis with tetracycline was non-effective. There were no functional alterations. We highlight the extremely rare occurrence of familial spontaneous pneumothorax. The literature is reviewed and genetic transmission mechanics is proposed, concluding that difficulties exist in identifying the non-symptomatic genetic carrier. We insist on the need to study family backgrounds in epidemiologic research.

[Adult respiratory distress produced by Pneumocystis carinii in a patient without AIDS]. / Distres respiratorio del adulto producido por Pneumocystis carinii en paciente no afecto de SIDA.

A case of a patient receiving chemotherapy because of breast cancer who developed adult respiratory distress caused by Pneumocystis carinii pneumonia is presented. The evolution was good after treatment with 20 mg/kg/day of trimethoprim and 100 mg/kg/day of sulfamethoxazole.

Macrolide-based regimens in absence of bacterial co-infection in critically ill H1N1 patients with primary viral pneumonia.

PURPOSE: To determine whether macrolide-based treatment is associated with mortality in critically ill H1N1 patients with primary viral pneumonia. METHODS: Secondary analysis of a prospective, observational, multicenter study conducted across 148 Intensive Care Units (ICU) in Spain. RESULTS: Primary viral pneumonia was present in 733 ICU patients with pandemic influenza A (H1N1) virus infection with severe respiratory failure. Macrolide-based treatment was administered to 190 (25.9 %) patients. Patients who received macrolides had chronic obstructive pulmonary disease more often, lower severity on admission (APACHE II score on ICU admission (13.1 ± 6.8 vs. 14.4 ± 7.4 points, p < 0.05), and multiple organ dysfunction syndrome less often (23.4 vs. 30.1 %, p < 0.05). Length of ICU stay in survivors was not significantly different in patients who received macrolides compared to patients who did not (10 (IQR 4-20) vs. 10 (IQR 5-20), p = 0.9). ICU mortality was 24.1 % (n = 177). Patients with macrolide-based treatment had lower ICU mortality in the univariate analysis (19.2 vs. 28.1 %, p = 0.02); however, a propensity score analysis showed no effect of macrolide-based treatment on ICU mortality (OR = 0.87; 95 % CI 0.55-1.37, p = 0.5). Moreover, the sensitivity analysis revealed very similar results (OR = 0.91; 95 % CI 0.58-1.44, p = 0.7). A separate analysis of patients under mechanical ventilation yielded similar results (OR = 0.77; 95 % CI 0.44-1.35, p = 0.4). CONCLUSION: Our results suggest that macrolide-based treatment was not associated with improved survival in critically ill H1N1 patients with primary viral pneumonia.

[Consensus document on vaccination against influenza in health care workers]. / Consenso sobre la vacunación frente a la gripe en el personal sanitario.

Health care workers (HCW) are included each year among risk groups for vaccination against influenza. However, vaccination coverage among this group in our country is very low, not exceeding 25%. Convinced that one of the best tools to increase this coverage among professionals in our country are the scientific evidence, 19 scientific societies and associations professionals bringing together health professionals more directly related to influenza as an health problem, and the General Nursing Council, met to discuss and develop this consensus document in order to inform HCW about the appropriateness of their vaccination against influenza and the benefits that flow from it for themselves, for their patients and for the rest of the population. This recommendation is based on 3 pillars: argument of necessity, ethics and exemplary.

[Community infections that require admission to the ICU]. / Infecciones comunitarias que requieren ingreso en UCI.

The clinical and diagnostic characteristics and treatment of the most severe and frequent community-acquired infections in the Intensive Care Units are analyzed. These are serious community-acquired pneumonias, meningitis, encephalitis and urinary tract infections. Regarding the pneumonias, emphasis is placed on the use of the severity scales to evaluate admission in the critical units, on evolutive monitoring using biological markers and on the importance of initiating adequate early antibiotic treatment. The importance of the Gram staining of the cerebral spinal fluid in the etiological diagnosis of meningitis, of the polymerase chain reaction amplification techniques in real time and of the magnetic resonance imaging in the etiological diagnosis of the encephalitis. Furthermore, concern is expressed regarding the increase of the percentage of the strains of extended spectrum betalactamase-producing Escherichia coli and Klebsiella pneumoniae in our country.