Intraventricular hemorrhage treated with intraventricular fibrinolysis. A 10-year experience.

PURPOSE: We evaluate the results and complications of our intraventricular fibrinolysis protocol. MATERIAL AND METHODS: A retrospective analysis was made of the cases of intraventricular hemorrhage with 13-bed Intensive Care Unit. Graeb score 6 or above subjected to intraventricular fibrinolysis. We gathered demographic parameters, clinical risk scores, tomography data and case histories showing neurological status and complications related to intraventricular treatment. The results between those who died and the survivors were compared. RESULTS: Intraventricular fibrinolysis was performed in 42 patients (69% males) with intraventricular hemorrhage. The average age was 58.36 years (SD 16.67), with a median APACHE II score of 17.5 (r 3-29). A total of 16.7% were receiving acenocoumarol, and 7.1% were on antiplatelet drugs. The median Glasgow Coma Score at the start of treatment was 8 (r 3-13). The median Graeb score was 9 (r 6-12), and was severe (Graeb 9-12) in almost 62%. In turn, 26.2% of the patients developed ventriculitis, and there was further bleeding in 7.1%. Death occurred in 50% of the cases. None of the analyzed variables were significantly related to increased mortality. In the 21 survivors, the Glasgow Outcome Score at 3 months was 2 in 23.8% of the cases, 3 in 28.57%, 4 in 23.8% and 5 in 28.57% of the patients. CONCLUSIONS: Intraventricular fibrinolysis does not appear to involve a high rate of complications, and may result in lesser mortality, with a better functional outcome after three months than that estimated and published in the literature in reference to intraventricular hemorrhage.

Metronidazole resistance in Clostridium difficile is heterogeneous.

At our institution, the prevalence of clinical isolates of Clostridium difficile with resistance to metronidazole is 6.3%. We observed that initial metronidazole MICs of 16 to 64 mg/liter against toxigenic, primary fresh C. difficile isolates, as determined by agar dilution, decreased to 0.125 mg/liter after the isolates were thawed. In this study, we examined the possibility of heterogeneous or inducible resistance. Totals of 14 metronidazole-resistant and 10 metronidazole-susceptible clinical isolates of toxigenic C. difficile were studied. The isolates were investigated for the presence of nim genes by PCR. After the isolates were thawed, susceptibility testing was done by agar dilution, by disc diffusion using a 5-mug metronidazole disc, and by the Etest method. An experiment for determining the effect of prolonged exposure to metronidazole was applied to all resistant isolates and to susceptible control strains. None of the isolates presented the nim genes. All initially metronidazole-resistant C. difficile isolates became susceptible after thawing; however, they presented slow-growing subpopulations within the inhibition zones of both the disk and the Etest strip. All metronidazole-susceptible isolates remained homogeneously susceptible by both methods. After prolonged exposure in vitro to metronidazole, no zone of inhibition was found around the 5-microg disk in any of the metronidazole-resistant isolates, and the MICs as determined by the Etest method ranged from 0.125 to >256 mg/liter, with colonies growing inside the inhibition zone. Our results indicate that (i) resistance to metronidazole was not due to the presence of nim genes, (ii) resistance to metronidazole in toxigenic C. difficile isolates is heterogeneous, and (iii) prolonged exposure to metronidazole can select for in vitro resistance. We recommend routine performance of the disk diffusion method (5-microg metronidazole disk) with primary fresh C. difficile isolates in order to ensure that metronidazole-heteroresistant populations do not go undetected.

In vitro activity of ramoplanin against Clostridium difficile, including strains with reduced susceptibility to vancomycin or with resistance to metronidazole.

We evaluated the in vitro activity of ramoplanin, an antimicrobial compound that inhibits cell wall synthesis by acting at the level of lipid intermediate formation, against Clostridium difficile. We included strains with reduced susceptibilities to vancomycin (vancomycin-intermediate [Van(i)] strains) or with resistance to metronidazole (Mtz(r)), in order to assess the potential utility of ramoplanin for the treatment of C. difficile-associated diarrhea. We tested the activity of ramoplanin against a total of 105 nonduplicate clinical isolates of toxigenic C. difficile, including 8 Van(i) isolates and 6 Mtz(r) isolates, obtained from our laboratory. Ramoplanin was active against all strains tested at concentrations ranging from 0.03 to 0.5 microg/ml (MICs at which 50 and 90% of isolates were inhibited, 0.25 microg/ml; geometric mean MIC, 0.22 microg/ml). All isolates, independently of their levels of susceptibility to vancomycin or metronidazole, were considered susceptible to ramoplanin (MICs, < or =0.5 microg/ml).

[Immunoelectrophoretic and functional evidence in various infants of a transient variant of the fibrinogen (fetal fibrinogen?)]. / Evidencia inmunoelectroforética y funcional, en algunos recién nacidos, de una variante transitoria del fibrinógeno (fibrinógeno fetal?).

In 21 out of 466 full term newborn babies (4.5%) and in 5 out of 50 prematures (10%) a transient fibrinogen electrophoretic abnormality, anodic and cathodic, was found. The observation that the thrombin time in full term newborn babies is prolonged, compared with the adult levels, was confirmed (p less than 0.0005). The difference between the thrombin time in full term newborn babies without fibrinogen electrophoretic abnormalities and those who had them, was statistically significant (p = 0.005) suggesting that the abnormality is associated with the protein function. The normal electrophoretic component could be the "adult" equivalent of the protein and the cathodic variant, the "fetal" type of fibrinogen. This hypothesis could explained why the thrombin time of plasma in newborn normal babies is enriched with the "fetal" fibrinogen in variable proportion, and is delayed compared with that of the adults.

[Spontaneous retroperitoneal hemorrhage]. / Hemorragia retroperitoneal espontánea.

OBJECTIVE: The etiology of spontaneous retroperitoneal hemorrhage is analyzed and the clinical, diagnostic and therapeutic aspects are discussed. METHODS/RESULTS: Two cases of spontaneous retroperitoneal hemorrhage from a ruptured adenocarcinoma of the kidney are reported. Both patients presented the characteristic Lenk's triad. Definitive diagnosis was made on the CT findings and treatment was by nephrectomy. CONCLUSIONS: The most common cause of retroperitoneal hemorrhage arising from the kidney is a tumor. Treatment is based on the underlying cause of the underlying cause of the hemorrhage and the patient's hemodynamic status.

[Retroperitoneal tumors. Retroperitoneal myxoid liposarcoma. Report of a new case]. / Tumores retroperitoneales. Liposarcoma mixoide retroperitoneal. Presentación de un nuevo caso.

OBJECTIVE: To describe an additional case of a large retroperitoneal liposarcoma. METHODS/RESULTS: A case of a large retroperitoneal liposarcoma in a young male is presented. Treatment was by surgery. The clinical and pathological features, diagnosis, course and treatment of this lesion are discussed. CONCLUSIONS: Retroperitoneal tumors constitute a heterogeneous group of uncommon neoplasms of unknown etiology. Liposarcoma is the most frequent lesion in this group. It is usually asymptomatic and is often identified by the presence of a large abdominal mass. It is considered to be a peculiar lesion because of its biological and morphological features and course.

[Ongoing improvement in the quality of chronic prescriptions at a primary care center: a 5-year follow-up]. / Mejora continua de la calidad de la prescripción crónica en un centro de atención primaria: seguimiento de 5 años.

OBJECTIVE: To find how the indicators for prescriptions for the chronically ill during the 1988-1992 period evolved, based on the analysis of the repeat prescription archive; and to assess the persistence of the effect of the 1989 corrective intervention. DESIGN: A retrospective and longitudinal evaluation study. SETTING: Primary Care Centre. PATIENTS AND OTHER PARTICIPANTS: Four representative samples of patients with an ongoing prescription card for 1988 (n = 549), 1989 (n = 211), 1990 (n = 193) and 1992 (n = 126). MEASUREMENTS AND RESULTS: Indicators used were: percentage of patients in treatment with some medication of low intrinsic value (LIV), benzodiazepines, peripheric vasodilators (PV), oral non-steroidal anti-inflammatories (NSAID), external NSAID and the percentage of each one of these out of the prescription total. A progressive decrease in the percentage of LIV medication in the 1988-1992 period was detected. There were significant differences, both for oral anti-diabetes drugs of high intrinsic value (HIV) (24.4 and 12.7%), and of LIV (26.6 and 16.9%) (p < 0.001 in both cases). Benzodiazepines went down from 5.4 to 1.2% (p = 0.0006), PVs from 4.4 to 1.2% (p = 0.003) and oral NSAID from 4.7 to 2.4% (p = 0.049). The percentage of patients treated with LIV medication went down from 46.1 to 29.4% (p < 0.001) and from 52.4 to 38.1% (p = 0.004), for HIV and LIV oral anti-diabetes drugs, respectively. Patients treated with benzodiazepines went down from 14.7 to 4.0% (p = 0.0017), with PV from 12.0 to 3.2% (p = 0.005) and with oral NSAID from 12.7 to 7.9% (ns). CONCLUSION: A continuous improvement in the quality of prescription for the chronically ill has been observed over the last 5 years and can be attributed to the primary care team.

La proteina C reactiva como elemento diagnostico etiologico de las infecciones respitatorias en el nino. / C-reactive protein as etiologic element for diagnosis of respiratory infections in the child

En todo servicio de enfermedad respiratoria se plantea con frecuencia la interrogante del uso o el no uso del tratamiento antibiotico. Se estudiaron 424 ninos con una edad comprendida entre 29 dias y 14 anos ingresados en la sala 2 del hospital pediatrico docente "A. A. Aballi" en el periodo de un ano con infeccion respiratoria aguda. A todos los pacientes se les tomo muestra de sangre venosa para realizarles leucograma, eritrosedimentacion y Proteina C Reactiva. A todos los ninos se les realizo rayos X de torax. Se llego a la conclusion de que a pesar de que la Proteina C Reactiva positiva es mas definitiva que la leucocitosis, la eritrosedimentacion o la fiebre, para identificar el origen bacteriano, pueden ocurrir resultados falsos positivos o negativos. La Proteina C Reactiva debe ser usada conjuntamente con la clinica y la radiologia en la discusion del tratamiento