Performing Gram stain directly on catheter tips: assessment of the quality of the observation process.

A previous study performed in our institution showed that catheter tip (CT) staining by combining acridine orange and Gram stain (GS) before culture anticipated catheter colonization with exhaustive and careful observation by a highly trained technician. Our objective was to assess the validity values of GS without acridine orange on an external smear of CT for predicting catheter colonization and catheter-related bloodstream infection (C-RBSI). We compared different periods of observation and the results of two technicians with different levels of professional experience. Over a 5-month period, the roll-plate technique was preceded by direct GS of all CTs sent to the microbiology laboratory. The reading was taken at ×100 by two observers with different skill levels. Each observer performed a routine examination (3 min along three longitudinal lines) and an exhaustive examination (5 min along five longitudinal lines). The presence of at least one cell was considered positive. All slides were read before culture results were known. We included a total of 271 CTs from 209 patients. The prevalence of catheter colonization and C-RBSI was 16.2 % and 5.1 %, respectively. Routine and exhaustive examinations revealed only 29.5 % and 40.9 % of colonized catheters, respectively (p < 0.001). In contrast, they revealed high negative predictive values for C-RBSI (96.5 % and 96.3 %, respectively). Our study shows that the yield of GS performed directly on CTs is greater when staining is performed exhaustively. However, the decision to implement this approach in daily routine will depend on the prevalence rate of catheter colonization at each institution.

Effect of Quercetin Rich Onion Extracts on Bacterial Quorum Sensing.

Quorum sensing (QS) regulates bacterial gene expression and studies suggest quercetin, a flavonol found in onion, as a QS inhibitor. There are no studies showing the anti-QS activity of plants containing quercetin in its native glycosylated forms. This study aimed to evaluate the antimicrobial and anti-QS potential of organic extracts of onion varieties and its representative phenolic compounds quercetin aglycone and quercetin 3-ß-D-glucoside in the QS model bacteria Chromobacterium violaceum ATCC 12472, Pseudomonas aeruginosa PAO1, and Serratia marcescens MG1. Three phenolic extracts were obtained: red onion extract in methanol acidified with 2.5% acetic acid (RO-1), white onion extract in methanol (WO-1) and white onion extract in methanol ammonium (WO-2). Quercetin 4-O-glucoside and quercetin 3,4-O-diglucoside were identified as the predominant compounds in both onion varieties using HPLC-DAD and LC-ESI-MS/MS. However, quercetin aglycone, cyanidin 3-O-glucoside and quercetin glycoside were identified only in RO-1. The three extracts showed minimum inhibitory concentration (MIC) values equal to or above 125 µg/ml of dried extract. Violacein production was significantly reduced by RO-1 and quercetin aglycone, but not by quercetin 3-ß-D-glucoside. Motility in P. aeruginosa PAO1 was inhibited by RO-1, while WO-2 inhibited S. marcescens MG1 motility only in high concentration. Quercetin aglycone and quercetin 3-ß-D-glucoside were effective at inhibiting motility in P. aeruginosa PAO1 and S. marcescens MG1. Surprisingly, biofilm formation was not affected by any extracts or the quercetins tested at sub-MIC concentrations. In silico studies suggested a better interaction and placement of quercetin aglycone in the structures of the CviR protein of C. violaceum ATCC 12472 than the glycosylated compound which corroborates the better inhibitory effect of the former over violacein production. On the other hand, the two quercetins were well placed in the AHLs binding pockets of the LasR protein of P. aeruginosa PAO1. Overall onion extracts and quercetin presented antimicrobial activity, and interference on QS regulated production of violacein and swarming motility.

Vascular trauma induces rapid but transient mobilization of VEGFR2(+)AC133(+) endothelial precursor cells.

Bone marrow (BM)-derived circulating endothelial precursor cells (CEPs) are thought to play a role in postnatal angiogenesis. Emerging evidence suggests that angiogenic stress of vascular trauma may induce mobilization of CEPs to the peripheral circulation. In this regard, we studied the kinetics of CEP mobilization in two groups of patients who experienced acute vascular insult secondary to burns or coronary artery bypass grafting (CABG). In both burn and CABG patients, there was a consistent, rapid increase in the number of CEPs, determined by their surface expression pattern of vascular endothelial growth factor receptor 2 (VEGFR2), vascular endothelial cadherin (VE-cadherin), and AC133. Within the first 6 to 12 hours after injury, the percentage of CEPs in the peripheral blood of burn or CABG patients increased almost 50-fold, returning to basal levels within 48 to 72 hours. Mobilized cells also formed late-outgrowth endothelial colonies (CFU-ECs) in culture, indicating that a small, but significant, number of circulating endothelial cells were BM-derived CEPs. In parallel to the mobilization of CEPs, there was also a rapid elevation of VEGF plasma levels. Maximum VEGF levels were detected within 6 to 12 hours of vascular trauma and decreased to baseline levels after 48 to 72 hours. Acute elevation of VEGF in the mice plasma resulted in a similar kinetics of mobilization of VEGFR2(+) cells. On the basis of these results, we propose that vascular trauma may induce release of chemokines, such as VEGF, that promotes rapid mobilization of CEPs to the peripheral circulation. Strategies to improve the mobilization and incorporation of CEPs may contribute to the acceleration of vascularization of the injured vascular tissue.

Visceral leishmaniasis in human immunodeficiency virus (HIV)-infected and non-HIV-infected patients. A comparative study.

Visceral leishmaniasis is an endemic infection in Mediterranean countries, where it has become a frequent complication of acquired immunodeficiency syndrome (AIDS). The incidence of visceral leishmaniasis is increasing in Spain due to human immunodeficiency virus (HIV)-related cases, but some aspects of its epidemiology, clinical features, and management remain unknown. In addition, no comparative clinical studies about the disease in HIV-infected and non-HIV-infected patients have been reported. During a 24-year period, 120 cases of visceral leishmaniasis were diagnosed at our institution and 80 (66%) were associated with HIV infection. The mean age at diagnosis was higher in HIV-infected that in non-HIV-infected patients (33.2 versus 23.2 yr; p = 0.002), but the male/female ratio was similar in both groups. The main risk factor for HIV infection was intravenous drug abuse (78.7%). The clinical presentation of leishmaniasis was similar in both groups, but HIV-infected patients had a lower frequency of splenomegaly than HIV-negative individuals (80.8% versus 97.4%; p = 0.02). HIV-infected patients had a greater frequency and degree of leukopenia, lymphocytopenia, and thrombocytopenia. Most of them were profoundly immunosuppressed (mean CD4+ lymphocyte count, 90 cells/mm3) at the time of diagnosis of leishmaniasis, and 53.7% had AIDS. The sensitivity of serologic studies for Leishmania was significantly lower in HIV-infected than in non-HIV-infected patients (50% versus 80%; p < 0.001), but the diagnostic yield of bone marrow aspirate (67.1% versus 79.4%) and bone marrow culture (62.9% versus 66.6%) was similar in both groups. After initial treatment, the response rate was significantly lower in HIV-infected than in non-HIV-infected individuals (54.8% versus 89.7%; p = 0.001). The relapse rate was 46.2% and 7.5%, respectively (p < 0.001). Secondary prophylaxis with antimonial compounds or amphotericin B seems to be useful in preventing relapses in HIV-infected patients. The mortality rate was higher (53.7% versus 7.5%; p < 0.001) and the median survival time shorter (25 versus > 160 mo; p < 0.001) in AIDS patients than in HIV-negative individuals. Although leishmaniasis could contribute to death in a significant number of HIV-infected patients, it was the main cause of death in only a few of them. The CD4+ lymphocyte count and the use of highly active antiretroviral therapy and secondary prophylaxis for leishmaniasis were the most significant prognostic factors for survival in AIDS patients. Visceral leishmaniasis behaves as an opportunistic infection in HIV-infected individuals and should be considered as an AIDS-defining disease.

[Profile of a pneumology regional health service]. / Perfil de una consulta de neumología de ámbito comarcal.

This study analyzes patient demand in a regional public health pulmonology practice. The following data were recorded for all first-visit patients for a period of two years: age, sex, referral source, initial diagnosis by the referring physician, final diagnosis by the pulmonologist, and destination. The service studied 1,486 patients (men/women: 1.5). Most (71%) were between 40 and 80 years old. Referrals were from the family doctor (60%), health center (9%), emergency service (10%), hospital (12%), other specialists (6%), and others (3%). The most frequent reasons for remission were upper airway disease (UAD) (36%), specifically chronic obstructive pulmonary disease (COPD) and asthma, and the presentation of symptoms (28%) such as dyspnea, cough, hemoptysis and chest pain. Analysis of the final diagnoses for the patients presenting with symptoms showed that no disease could be detected in one third of those with dyspnea and hemoptysis or in half of those who complained of chest pain; acute respiratory infection was diagnosed in 45% of those complaining of persistent cough. UAD was the most frequent cause of symptoms. The index of doctor's visit/inhabitant was 0.97% for patients referred by family doctors and 0.38% for those from health centers, but the initial and final diagnosis profiles of these patients were not statistically different. Patients referred by emergency services had significantly more (p < 0.001) in number of radiological findings and hemoptysis. Those sent from hospitals more often suffered pneumonia. In conclusion, this profile of a regional public health pulmonology practice shows that: 1) UAD and clinical symptoms are the most frequent reasons for patient remission; 2) family doctors generate three times mor demand for services than do health centers, and 3) 14% of patients can be considered normal.

[The patterns of use and factors associated with the patient admission of hospital emergencies for asthma and chronic obstructive pulmonary disease]. / Patrones de frecuentación y factores asociados al ingreso en el hospital de las urgencias hospitalarias por asma y por enfermedad pulmonar obstructiva crónica.

The aim of this study was to describe the epidemiological characteristics of emergencies caused by asthma and chronic obstructive pulmonary disease (COPD) at the Hospital Clínico Universitario of Valencia (Spain) and to analyze factors related to hospital admissions for the same causes. Emergency room medical records for 1993 to 1995 of patients older than 14 years of age were examined to identify those due to asthma or COPD, according to established protocol. Demographic variables were described, followed by Poisson regression analysis of time and seasonal factors affecting emergencies. Factors related to hospital admission were analyzed by logistic regression, taking into account age group, sex, place of residence, and the year, month, day and hour of emergency room arrival. Asthma patients amounted to 1% of emergencies, while COPD patients accounted for 2%. The admission rate for women with asthma was higher than for men (F/M ratio = 0.78), whereas the rate for men with COPD was higher than for women (F/M ratio = 3.14). The largest age groups with asthma emergencies included young people aged 15 to 24 years old and those over 60. Hospital admissions or transfers to other hospitals were ordered for 17.4% of asthma patients and 38.8% of COPD patients. Nearly a third of COPD patients and a fifth of asthma patients were readmitted within the ten days following the first emergency. Clear temporal patterns of COPD emergency were observed for month (most occurring in winter), day of the week (most on Monday) and hour of the day (most during daytime hours, with fewer at midday). The time patterns were less evident for asthma emergencies, although the likelihood of admission because of asthma varied by month and day of the week. Emergency room records may be useful for studying the patterns of respiratory disease presentation. Other possible uses are epidemiologic monitoring and evaluation of health care quality.

[Hepatic veno-occlusive disease: report of a case]. / Doença veno-oclusiva hepática: relato de um caso.

OBJECTIVE: To alert the pediatricians about a disease caused by herbal teas considered harmless. METHODS: Report of a case of Hepatic Veno-Occlusive Disease in a child and review of the literature (MEDLINE and LILACS). RESULTS: Description of a case of a sudden beginning portal hypertension, secondary to Hepatic Veno-Occlusive Disease in a 2 year and 5 month-old-patient, coming from Cruz Alta-RS-Brazil, after a chronic consumption of herbal tea called "maria-mole" (Senecio brasiliensis), which contains pyrrolizidine alkaloids, known as hepatotoxic. After an adequate treatment, the patient presented a complete clinical and laboratorial recovery, and nowadays he doesnt show any symptoms anymore. CONCLUSIONS: Prevention of this disease depends on its divulgation among physicians and the general population, and the knowledge of toxic effects of many "innocuous" teas.

Scalp replantation after traumatic injury.

A 30-year-old female patient lost her scalp in an industrial accident. Surgeons used a microscope to reconnect the arteries and veins in her scalp and to reattach the scalp to the patient's cranium. The patient tolerated the procedure without complications, although she developed venous congestion in her right ear while she was in the neuroscience intensive care unit. After several days of leech therapy, the patient experienced an uneventful postoperative course. One month after discharge from the hospital, the patient's hair was growing back in and her incision lines were fading.

[Gastric neuroendocrine tumor]. / Tumor neuroendocrino gástrico.

Gastric carcinoid tumors arise from enterochromaffin-like (ECL) cells, these tumors represent 2-41% of all neuroendocrine tumors and 0.3% of malignant gastric neoplasias, being more common in men than in women, and commonly affecting people over 60 years old. These tumors arise from accelerated proliferation of the ECL cells as a consequence of the hypersecretion of gastrin, situation that can be present in atrophic gastritis and the Zollinger-Ellison syndrome. We report the case of a 51 year old hispanic female who presented with a 3 month history of abdominal pain, meteorism and constipation; she was treated with ranitidine and metoclopramide without clinical improvement, thus she underwent upper gastrointestinal endoscopy which showed an atrophic gastritis and gastric polyps. Histopathologic examination revealed a neuroendocrine gastric tumor which was positive to serotonine and gastrin stainings. Hormonal screening showed normal serum levels of LH, FSH, estradiol, ACTH, progesterone, calcitonin and cortisol. The serum level of gastrin was elevated with 500 pg/mL. Gammagraphic scanning with octreotide was negative for metastasis.

[Female pseudohermaphroditism. Mixed germ cell tumor of the ovary. A case report]. / Pseudohermafroditismo femenino. Tumor de células germinales de ovario, mixto. Presentación de un caso.

It is known as Pseudohermaphroditism or intersexual state, those entities in which external genitalia are ambiguous or are not according with gonadal o genetic chromosomic sex. They can have diverse etiology. Continual exposition to estrogens or androgens may induce female or male dysmorphism, and also development of benign or malignant tumors at target organs. We present a case of a young woman, 15 years old, with virilization, who attend medical consultation for progressive abdominal growing. The presence of ambiguous, genitalia since birth, was not a previous reason of concern. Diagnostic, findings, management and follow up for about 4 months are described and also a topic review. Genitalia develop during first trimester of intrauterine life, under influence of sexual steroids, and changes of sexual development can emerge as consequence of endocrine or morphologic disorders and the later ones, related to karyotypic abnormalities. Sexual steroid and their metabolites can demonstrate individually, different biological effects, suggesting the presence of individual receptors. The presence of cooperative effects between each steroid produce even more complexity to the evaluation of each steroid. Various mutations principally at gene receptors of sexual steroids, cause resistance to them. At female pseudohermaphroditism in difference from male P. there is no errancy at genetic gonadal transmission. These women are intrauterine exposed to excessive quantities of androgens, and they have normal internal genitalia but external ambiguous genitalia. The involved androgen comes from external factors, a it occurs at mother who receives progesterone to avoid abortion, but it is due frequently to androgen storage, caused by enzymatic blockade at steroidogenesis (adrenogenital syndrome).

Pelviscopy: broadening the scope of laparoscopy.

1. Two important aspects of pelviscopy that differ from laparoscopy are the use of an endocoagulator and intra-abdominal suturing capabilities. 2. Scrubbing and circulating roles were exchanged so each group could learn the technique, and new instruments were introduced to the entire staff as they were received. 3. A pelvic trainer helps inexperienced surgeons to develop their technique and practice suturing procedures. 4. Although acquiring the necessary skills is challenging, pelviscopy accomplishes the same therapeutic treatment as a laparotomy in a minor procedure.

Association between hospital emergency visits for asthma and air pollution in Valencia, Spain.

OBJECTIVE: To assess the short term effect of concentrations of black smoke, sulphur dioxide (SO2), nitrogen dioxide (NO2) and ozone (O3) in ambient air on emergency room visits for asthma in the city of Valencia, Spain during the period 1994-5. METHODS: Ecological study with time series data and application of Poisson regression. Associations between number of daily emergency visits in a city's hospital and concentrations of air pollutants were analysed taking into account potential confounding factors by the standardised protocol of the air pollution and health: a European approach (APHEA) project. RESULTS: Mean (range) daily number of emergency room visits for asthma was 1 (0-5). Concentrations of all pollutants studied remained within current air quality standards. The association between an increase of 10 micrograms/m3 in ambient air pollution and asthma, measured as a relative risk (RR) of emergency visits, was significant for NO2 24 hour mean (lag 0, RR 1.076, 95% confidence interval (95% CI) 1.020 to 1.134), NO2 hour maximum (lag 0, RR 1.037, 95% CI 1.008 to 1.066), and O3 hour maximum (lag 1, RR 1.063, CI 95% 1.014 to 1.114). The association was not significant for SO2 or for black smoke during the period analysed. The effects were not significantly different for the time of year, cold months (November to April), or warm months (May to October). CONCLUSIONS: Current concentrations of ambient air pollution in Valencia are significantly associated with emergency room visits for asthma. This association is high and more consistent for NO2 and O3 than for particulate matter and SO2 (classic pollutants).

Length of stay in a hospital emergency room due to asthma and chronic obstructive pulmonary disease: implications for air pollution studies.

The aim of this paper is to model the length of stay following hospital emergency due to asthma and chronic obstructive pulmonary disease (COPD) as well as those factors relating to its duration. Clinical records of all those hospital emergencies for asthma and COPD in people aged over 14 at the Hospital Clinico Universitario of Valencia (HCUV) during years 1993-1995 were reviewed. Data were analysed by entry and discharge time, sex, age and destination. Parametric survival models (exponential, Weibull and log-normal) were used for each diagnostic. Percentiles and relative percentiles were calculated; 1369 asthma emergencies and 2734 cases COPD were observed. The mean length of stay was 5.21 hours for asthma and 6.32 for COPD log-normal model was the best parametric model. Lengths of stay are greater for those hospital admitted. Stays, in cases of asthma, were shorter during months of August and November, with no differences for other variables. Also a shorter duration of stay for the month of August was found. Women are seen to stay for longer periods than men. Time modelling of emergency admission for asthma and COPD permits its use in the determining of the dates of incidence for episodes of asthma and COPD based on hospital admissions data, as seeing a median of delay in emergency rooms greater than 6 hours. For studies on air pollution impact these results imply that all those admissions during the early hours of the morning should be categorised as events of the previous day.

Plasma melatonin concentrations in hibernating marmots: absence of a plasma melatonin rhythm.

Plasma melatonin concentrations were measured throughout bouts of hibernation in marmots maintained in a short photoperiod (light-dark 8:16) and ambient temperature of 5 or 15 degrees C. Melatonin concentration was also measured in two animals maintained in constant darkness. As an animal entered hibernation, plasma melatonin concentrations dropped to basal levels when body temperature reached 25 degrees C, and they remained low until arousal. During deep hibernation plasma melatonin values did not vary significantly (P greater than 0.05) with respect to time of day or different ambient temperatures. With nocturnal arousal plasma melatonin levels were similar to euthermic night values. Lack of a plasma melatonin rhythm during hibernation suggests that the pineal gland is not temperature compensated during hibernation, and due to the low tissue temperature of the pineal the circadian pacemaker driving melatonin secretion is incapable of stimulating a rhythm.

Asthma visits to emergency rooms and soybean unloading in the harbors of Valencia and A Coruña, Spain.

Soybean unloading in the harbor of Barcelona, Spain, has been associated with large increases in the numbers of asthma patients treated in emergency departments between 1981 and 1987. In this study, the association between asthma and soybean unloading in two other Spanish cities, Valencia and A Coruña, was assessed. Asthma admissions were retrospectively identified for the period 1993-1995, and harbor activities were investigated in each location. Two approaches were used to assess the association between asthma and soybean unloading: One used unusual asthma days (days with an unusually high number of emergency room asthma visits) as an effect measure, and the other estimated the relative increase in the daily number of emergency room visits by autoregressive Poisson regression, adjusted for meteorologic variables, seasonality, and influenza incidence. No association between unusual asthma days and soya unloading was observed in either Valencia or A Coruña, except for one particular dock in Valencia. When the association between unloaded products and the daily number of emergency asthma visits was studied, a statistically significant association was observed for unloading of soya husk (relative risk = 1.50, 95% confidence interval 1.16-1.94) and soybeans (relative risk = 1.31, 95% confidence interval 1.08-1.59) in A Coruña. In Valencia, a statistical association was found only for the unloading of soybeans at two particular docks. Although these findings support the notion that asthma outbreaks are not a common hidden condition in most harbors where soybeans are unloaded, the weak associations reported are likely to be causal. Therefore, appropriate control measures should be implemented to avoid soybean dust emissions, particularly in harbors with populations living in the vicinity.