Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment.

OBJECTIVE: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. MATERIAL AND METHODS: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. RESULTS: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. CONCLUSIONS: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.

Odontogenic bacteria in periodontal disease and resistance patterns to common antibiotics used as treatment and prophylaxis in odontology in Spain.

Resistance in streptococci or Gram-negative bacteria is associated with antibiotic consumption. Scarce information exists on the antibiotic susceptibility of bacterial isolates from patients with periodontitis in countries with high antibiotic consumption, as this is an area in which microbiological testing is not performed in daily practice. The present study was undertaken to explore the susceptibility of bacterial isolates in periodontitis to antibiotics prescribed in odontology in Spain as treatment for local infections or prophylaxis for distant focal infections. Periodontal samples were prospectively collected in 48 patients classified by pocket depth of <4 mm and >or=4 mm. Species were identified by culture, selecting the five most frequent morphotypes per sample, and polymerase chain reaction (PCR). Susceptibility was determined by E-test. A total of 261 isolates were identified: 72.9% patients had Streptococcus oralis; 70.8% Streptococcus mitis; 60.4% Prevotella buccae; 39.6% Prevotella denticola; 37.5% Fusobacterium nucleatum; 35.4% Prevotella intermedia; 25% Capnocytophaga spp.; 23% Veillonella spp.; 22.9% Prevotella melaninogenica and Streptococcus sanguis; and <20% other species. Streptococcus viridans resistance rates were 0% for amoxicillin, approximately 10% for clindamycin, 9-22% for tetracycline, and for azithromycin ranged from 18.2% for S. sanguis to 47.7% for S. mitis. Prevotella isolates were susceptible to amoxicillin-clavulanic acid, with amoxicillin resistance ranging from 17.1% in P. buccae to 26.3% in P. denticola. Metronidazole resistance was <6% in all Prevotella species, while clindamycin resistance ranged from 0 to 21.1%. beta-Lactamase production was positive in 54.1% Prevotella spp., 38.9% F. nucleatum, 30% Capnocytophaga spp., and 10% Veillonella spp. In this study, amoxicillin-clavulanic acid was the most active antibiotic against all species tested, followed by metronidazole in the case of anaerobes.

Odontogenic bacteria in periodontal disease and resistance patterns to common antibiotics used as treatment and prophylaxis in odontology in Spain

La resistencia de los estreptococos o de las bacterias gramnegativas se asocia al consumo antibiótico, pero existe escasa información sobre la sensibilidad de los aislamientos de pacientes con periodontitis en los países con alto consumo de antibióticos, como es España; datos que pueden ser importantes cuando en la práctica diaria no se realizan determinaciones microbiológicas. En este estudio se analiza la sensibilidad de aislamientos de periodontitis a los antibióticos prescritos habitualmente en España en odontología para el tratamiento de infecciones locales o la profilaxis de infecciones a distancia. Se tomaron de forma prospectiva muestras periodontales de 48 pacientes clasificados, según la profundidad de la bolsa, en dos grupos: <4 mm y ≥ 4 mm. La identificación de las especies se realizó por PCR y por cultivo, seleccionando los cinco morfotipos más frecuentes en cada muestra. La sensibilidad antibiótica se determinó por E-test®. Se identificaron 261 cepas. El 72,9% de los pacientes presentaron Streptococcus oralis, el 70,8% Streptococcus mitis, el 60,4% Prevotella buccae, el 39,6% Prevotella denticola, el 37,5% Fusobacterium nucleatum, el 35,4% Prevotella intermedia, el 25% Capnocytophaga spp., el 23% Veillonella spp., el 22,9% Prevotella melaninogenica y Streptococcus sanguis, y <20% otras especies. Las tasas de resistencia de S. viridans fueron 0% a la amoxicilina, ≈10% a la clindamicina y 9% a 22% a la tetraciclina; se halló resistencia a la azitromicina entre el 18,2% de S. sanguis y el 47,7% de S. mitis. Los aislamientos de Prevotella fueron sensibles a la amoxicilina-ácido clavulánico. La resistencia a la amoxicilina osciló entre el 17,1% de P. buccae y el 26,3% de P. denticola. La resistencia al metronidazol fue <6% en las especies de Prevotella, mientras que a la clindamicina osciló entre un 0% y un 21,1%. El 54,1% de Prevotella spp., el 38,9% de F. nucleatum, el 30% de Capnocytophaga spp. y el 10% de Veillonella spp. eran productores de betalactamasas. Amoxicilina-ácido clavulánico fue el antibiótico más activo frente a todas las especies aisladas, seguido del metronidazol en el caso de los anaerobios

Resistance in streptococci or Gram-negative bacteria is associated with antibiotic consumption. Scarce information exists on the antibiotic susceptibility of bacterial isolates from patients with periodontitis in countries with high antibiotic consumption, as this is an area in which microbiological testing is not performed in daily practice. The present study was undertaken to explore the susceptibility of bacterial isolates in periodontitis to antibiotics prescribed in odontology in Spain as treatment for local infections or prophylaxis for distant focal infections. Periodontal samples were prospectively collected in 48 patients classified by pocket depth of <4 mm and ≥ 4 mm. Species were identified by culture, selecting the five most frequent morphotypes per sample, and polymerase chain reaction (PCR). Susceptibility was determined by E-test®. A total of 261 isolates were identified: 72.9% patients had Streptococcus oralis; 70.8% Streptococcus mitis; 60.4% Prevotella buccae; 39.6% Prevotella denticola; 37.5% Fusobacterium nucleatum; 35.4% Prevotella intermedia; 25% Capnocytophaga spp.; 23% Veillonella spp.; 22.9% Prevotella melaninogenica and Streptococcus sanguis; and <20% other species. Streptococcus viridans resistance rates were 0% for amoxicillin, ≈10% for clindamycin, 9-22% for tetracycline, and for azithromycin ranged from 18.2% for S. sanguis to 47.7% for S. mitis. Prevotella isolates were susceptible to amoxicillin-clavulanic acid, with amoxicillin resistance ranging from 17.1% in P. buccae to 26.3% in P. denticola. Metronidazole resistance was <6% in all Prevotella species, while clindamycin resistance ranged from 0 to 21.1%. β-Lactamase production was positive in 54.1% Prevotella spp., 38.9% F. nucleatum, 30% Capnocytophaga spp., and 10% Veillonella spp. In this study, amoxicillin-clavulanic acid was the most active antibiotic against all species tested, followed by metronidazole in the case of anaerobes

Enhancement of opiate analgesia by nimodipine in cancer patients chronically treated with morphine: a preliminary report.

The ability of nimodipine, a calcium-channel blocker, to enhance morphine analgesia and/or modify the development of tolerance was studied in patients with cancer pain who had needed successive increments of morphine for periods ranging from 21 to 780 days. Assessment of daily morphine consumption was the primary effect parameter. Nimodipine succeeded in reducing the daily dose of morphine in 16 of 23 patients (oral, n = 13; intrathecal, n = 3), and failed to modify it in 2 patients. Total oral daily dose was reduced by nimodipine (120 mg/day) from 282.6 +/- 47.7 mg to 158.7 +/- 26.2 mg (n = 15, P < 0.001). Intrathecal morphine was also reduced by 1-5 mg/day. Nimodipine was withdrawn in 5 patients during the first week of treatment due to intolerance (n = 3) or aggravation of the disease (n = 2). These preliminary results support experimental findings showing that pharmacological interference with Ca(2+)-related events may modify chronic opioid effects, including the expression of tolerance.