[Second consensus report on the use of antimicrobial agents in exacerbations of chronic obstructive pulmonary disease]. / Segundo documento de consenso sobre uso de antimicrobianos en la exacerbación de la enfermedad pulmonar obstructiva crónica.

Aware of the importance of chronic obstructive pulmonary disease (COPD), a panel of experts belonging to the Spanish Society of Respiratory Medicine and Thoracic Surgery (SEPAR), the Spanish Society of Chemotherapy (SEQ) and the Spanish Society of Family and Community Medicine (SEMFyC) issued a statement of consensus in 2000 to serve as the basis for adequate antibiotic control of the disease. Three years later, in accordance with significant scientific progress made in this area, the statement has been thoroughly revised. The new paper in fact constitutes a second consensus statement on the use of antibiotics in COPD exacerbations. When several scientific associations expressed interest in joining the project and contributing to it the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of General Medicine (SEMG) and the Spanish Society of Rural and General Medicine (SEMERGEN) their incorporation led SEPAR and SEMFyC to change the structure of the statement and certain aspects of its content. Additionally, a new group of antibiotics, the ketolides, has joined the therapeutic arsenal. Telithromycin, the single representative of the group for the moment, can be considered not only an alternative treatment but even the drug of choice in certain clinical settings that are analyzed in the new statement. Those developments, along with others, such as the increasingly recognized action of levofloxacin against Pseudomonas aeruginosa and the steady action of amoxicillin with clavulanic acid when administered at recommended doses every 8 hours, provide new antimicrobial therapeutic protocols for COPD. Finally, the statement includes a scientific analysis of other groups of antimicrobial agents (macrolides, oral cephalosporins, etc.) and guidelines for both primary care physicians and specialists to follow when prescribing them.

[Giant cell arteritis: diagnostic value of a second biopsy of the temporal artery (author's transl)]. / Arteritis de células gigantes. Valor diagnóstico de una sequnda biopsia de la arteria temporal.

A 79-year old female patient with antecedents of headache and fever, was admitted because of fatigue, anorexia, anemia and elevated ESR. After admission she presented with rheumatic polymyalgia and synovial effusion in the knee. A first biopsy of the temporal artery was normal. After dismissing other possible causes a second biopsy of the contralateral temporal artery was bone and confirmed giant cell arteritis. Diagnostic value of a second temporal artery biopsy is discussed and justified by: a) a confirmed diagnosis is necessary for prolonged treatment with corticosteroids, b) if it is decided to treat the rheumatic polymyalgia with lower doses of corticosteroids than for temporal arteritis the certainty that no temporal arteritis is present and c) shortening the hospital stay and lowering the cost and number of diagnostic procedures. The frequency of arthritis and synovial effusion in temporal arteritis are also discussed.

[Hyporeninemic hypoaldosteronism. Case report and attempt at pathophysiological classification (author's transl)]. / Hipoaldosteronismo hiporreninémico. Presentación de un caso e intento de clasificación fisiopatológica.

A 75 year-old male presented with hyperkalemia unexplained by a moderate renal insufficiency, low basal levels of aldosterone and renin with a subnormal response to walking and saline depletion, and normal glucocorticoid function. The hyperkalemia was corrected by fluorocortisone administration. The concept of hypoaldosteronism is reviewed, defining it as an isolated aldosterone deficiency and thus excluding the combined deficiency of cortisol and aldosterone and the suprarenal enzyme deficits that simultaneously involve mineralocorticoid and glucocorticoid synthesis. Depending on the presence or absence of alterations of the renin-angiotensin axis, this infrequent syndrome can be pathophysiologically classified as low, normal or high renin hypoaldosteronism. The characteristic features of each type are described, and emphasis is made on the need for a high index of suspicion when unexplained hyperkalemia is present in order to perform the appropriate tests to confirm or rule out hypoaldosteronism.

[Bacteremia and sepsis due to Streptococcus agalactiae. Study of eight cases (author's transl)]. / Bacteriemia y sepsis por Streptococcus agalactiae. Presentación de ocho casos.

During a period of 29 months positive hemocultures to Streptococcus agalactiae corresponding to eight adult patients have been observed. These bacteria were apparently responsible for the clinical picture in five patients. In other two patients S. agalactiae appeared in the course of a sepsis caused by other germ. The remaining patient had a transient bacteremia and no treatment was required. Septic shock and bacterial endocarditis were the cause of death in two patients. Six patients cured. Literature on this subject is reviewed and the better prognosis of sepsis due to S. agalactiae in adults than in neonates is stressed. Endocarditis and meningitis occur as severe complications with poor prognosis. In patients with endocarditis the administration of penicillin and gentamicin as well as the consideration of early surgical replacement of the affected heart valve is recommended. Intravenous penicillin and gentamicin associated with intrathecal gentamicin are indicated in meningeal infections. Vancomycin is a good substitutive antibiotic in patients with penicillin hypersensibility.

[Spontaneous peritonitis due to Clostridium perfringens in three patients with cirrhosis (author's transl)]. / Peritonitis espontánea por Clostridium perfringens en tres enfermos cirróticos.

Three cases of spontaneous peritonitis due to Clostridium perfringens in cirrhotic patients with a fatal outcome are reported. The diagnosis was made clinically in two patients and by post-mortem examination in the third. One patient had elevated values of serum alpha-fetoprotein. These cases are compared with three other reported cases in the literature. Blood cultures were negative in the three patients, a fact that lends support to the theory of transmural migration of bacteria. In the authors' experience C. perfringens is the third most frequent agent responsible for spontaneous peritonitis in cirrhosis, preceded by E. coli and Streptococcus and followed by Klebsiella, a surprising fact given the scarce number of reported cases. Routine abdominal paracentesis is recommended in any cirrhotic patient with ascites, followed by appropriate antibiotic treatment whenever positive cultures are obtained. The efficacy of treatment is probably doubtful. The literature on antibiotic treatment of spontaneous peritonitis in cirrhosis is reviewed.

[Acute bacterial meningitis in adults: a clinical and developmental analysis of 100 cases]. / Meningitis aguda bacteriana en adultos: análisis clínico y evolutivo de 100 casos.

BACKGROUND: Characterize clinical findings and outcome of acute bacterial meningitis (ABM) in adults, with special emphasis on nosocomial meningitis and meningitis in the elderly. METHODS: We reviewed the charts of all persons 14 years of age or older in whom ABM was diagnosed in our hospital during a 12 and a half-year period. RESULTS: Ninety-seven patients were treated for 100 episodes of ABM, of which 23 percent were nosocomial and 27 percent occurred in elderly persons. Predisposing factors were present in 59 percent of the episodes. Fifty-four percent had the classic triad of fever, nuchal rigidity, and change in mental status. Cerebrospinal fluid pleocytosis with a neutrophilic predominance, hypoglycorrhachia, and elevated protein levels were present in 62 percent of the episodes. A pathogen was identified in 62 percent of the cases, in a higher frequency in elderly persons (p < 0.05) and in patients who had not received antibiotics before the lumbar puncture (p < 0.05). Causal agents more frequently identified were: Streptococcus pneumoniae (27 percent) in community-acquired meningitis, coagulase-negative Staphylococci (35 percent) in nosocomial meningitis, and Strep. pneumoniae (33 percent) in elderly persons. Central nervous system (CNS) complications occurred in 18 percent of episodes, and 15 percent developed systemic complications. The overall mortality rate was 9 percent, higher among patients in whom CNS complications began within 24 hours of admission (p < 0.05). CONCLUSIONS: A high proportion of cases of ABM in adults are nosocomial, or affect elderly persons. The fatality rate is high, particularly among those who develop CNS complications at the onset of the disease.

[Superior vena cava syndrome: a study based on 81 cases]. / Síndrome de vena cava superior: análisis de una serie de 81 casos.

BACKGROUND: Characterize the etiology, clinical picture, radiographic findings, usefulness of several diagnostic studies in establishing an etiologic diagnosis, and outcome after treatment of superior vena cava syndrome (SVCS). METHODS: We reviewed the charts of all patients diagnosed of SVCS in our hospital between the years 1983 and 1996. RESULTS: Eighty-one patients (70 male, 11 female) with an average age of 61 years were included in the study. In 77 (95%) patients a neoplastic cause was diagnosed, mainly lung cancer (76%). The most common clinical findings were: feeling of fullness in the head (81%), edema of the face and arms (78%), jugular venous distention (75%), prominent venous pattern over the chest wall (73%), dyspnea (59%), and cough (37%). The average length of time from the onset of symptoms to the date of diagnosis was 28 days. The chest x-ray was abnormal in 78 (96%) cases: mediastinal widening (51%) and right hilar mass (48%) were the most common findings. The diagnosis of SVCS was evident (from clinical picture and chest roentgenogram) in 76 (94%) patients. In SVCS due to malignancy, the most productive investigations in establishing a pathologic diagnosis were bronchoscopy (54%) and biopsy of a superficial lymph node (18%). Partial or complete clinical response to treatment was achieved in seventy percent of the cases. CONCLUSIONS: SVCS is an uncommon entity and his most frequent cause is bronchogenic carcinoma. The characteristic clinical and radiographic findings allow to do a reliable diagnosis of the syndrome. Initially, clinical response (partial or complete) to treatment is achieved in most patients.

[Characteristics and epidemiological changes for patients with community-acquired pneumonia in hospital emergency departments]. / Características y cambios epidemiológicos de los pacientes con neumonía adquirida en la comunidad en los servicios de urgencias hospitalarios.

BACKGROUND: The aim of this paper is to determine both the prevalence of community-acquired pneumonia (CAP) in the A & E Department and the most relevant epidemiological changes in the last decade, as well as the profile and management of these patients. METHODS: Descriptive cross-sectional analysis at 49 Spanish A & E Departments during 12 months. All patients with infections, respiratory infection or CAP diagnosis were included. All patients attended to in A & E during the study were recorded as well. RESULTS: CAP has increased its prevalence among patients in the A & E Departments in the past decade (0.85% to 1.35%, p <0.001). Fifty-one per cent were over 70 years old. Sixty-nine point eight per cent had some underlying disease and 17.8% had risk factors. Eleven point seven per cent met sepsis criteria, 4.6% severe sepsis and 3% septic shock. Thirty-seven per cent of patients were directly discharged from the A & E Departments. CONCLUSIONS: The impact and prevalence of CAP in A & E Departments has increased in the last decade. It is the most common cause of sepsis, severe sepsis and septic shock, admission to intensive care units and death due to infectious disease.