Cytomegalovirus reactivation enhances the virulence of Staphylococcus aureus pneumonia in a mouse model.

OBJECTIVES: Cytomegalovirus (CMV) reactivation in intensive care unit patients may increase mortality and favour bacterial pneumonia. We developed a murine model to compare the severity of staphylococcal pneumonia after CMV reactivation and in CMV-negative mice. METHODS: Balb/c mice were primo-infected with murine cytomegalovirus (MCMV n=90) or received saline (control n=90). After latency, all mice underwent caecal ligation and puncture to trigger MCMV reactivation in MCMV primary-infected mice. Surviving animals received an intra-nasal inoculation with methicillin-susceptible Staphylococcus aureus (MSSA) to induce pneumonia. Mortality, lung bacterial count, histology and interferon-alpha and gamma serum levels were compared in MCMV reactivated and control mice 2, 5 and 15 days after pneumonia. RESULTS: After MSSA pneumonia, MCMV mice showed a trend towards a higher mortality (9.4% versus 0%; p 0.09) and a higher weight loss (2.2 (0.6-4.1 g) versus 0.7 (-0.3 to 1.3 g); p 0.005). The lung bacterial count was higher in MCMV mice 2 days (5×103 (103 to 3×105) versus 102 (0 to 4×102) CFU/lung; p 0.007) and 5 days (2.5×104 (1.6×104 to 6.5×105) versus 15 (10-40) CFU/lung; p 0.005) after MSSA pneumonia. 8/40 (20%) MCMV mice developed lung abscesses compared to 0% in control (p 0.011). Interferon-alpha serum levels 2 days after staphylococcal pneumonia were higher in MCMV mice. CONCLUSIONS: MCMV reactivation decreased lung bacterial clearance and favoured the development of staphylococcal abscessing pneumonia. CMV reactivation may be responsible for a higher susceptibility to bacterial sepsis.

Prone positioning during veno-venous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome in adults.

BACKGROUND: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an effective rescue therapy for improving oxygenation in selected severe acute respiratory distress syndrome (ARDS). Prone position (PP) is usually considered before vvECMO and few data are available on the association of PP during VV-ECMO. Thus, we investigated the effect on oxygenation and the safety of PP during vvECMO. METHODS: During a two-year period, 15 patients with severe ARDS were turned into PP during VV-ECMO therapy for at least one of the three following conditions: severe hypoxemia (PaO2/FiO2 ratio below 70) despite maximal oxygenation, injurious ventilation parameters with plateau pressure exceeding 32 cmH2O or failure of attempt to wean ECMO after at least 10 days on ECMO support. RESULTS: PP was considered after a median of 9 days of ECMO and applied for a median of 12 hours and an average of 1.4 sessions per patient resulting in a total of 21 procedures. We found significant improvement in PaO2/FiO2 ratio at 6 hours (P=0.03) and 12 hours (P=0.007) after reversal. The improvement in oxygenation has still persisted 1hour (P=0.017) and 6 hours (P=0.013) after back to the supine position. No change in PaCO2, respiratory system (RS) compliance was observed. ECMO flow was maintained constant during the procedure. No complication related to PP was detected. CONCLUSION: PP may be considered in selected patients difficult to wean or remaining very hypoxemic despite VV-ECMO support.

P. aeruginosa bloodstream infections among hematological patients: an old or new question?

Pseudomonas aeruginosa is a well-known cause of severe and potentially life-threatening infections among hematological patients. A prospective epidemiological surveillance program ongoing at our Hematology Unit revealed an increase over time of P. aeruginosa bloodstream infections (BSI). Their impact on outcome and antibiotic susceptibility was analyzed. BSI which consecutively occurred at our institution during a 70-month period were evaluated and correlated with type of pathogen, status of underlying disease, neutropenia, previous antibiotic therapy, resistance to antibiotics, and outcome. During the observation period, 441 BSI were recorded. Frequency of Gram-negative BSI was higher than that of other pathogens (57.3%). Overall, 66 P. aeruginosa BSI were recorded; 22 out of 66 were multiresistant (MR P. aeruginosa). Thirty-day mortality for all BSI was 11.3%; it was 27.3% for P. aeruginosa BSI and 36.4% for MR P. aeruginosa. At multivariate analysis, only active hematological disease and P. aeruginosa BSI were associated to an increased risk of death. For MR P. aeruginosa, BSI mortality was 83.3% vs. 18.8% when empiric therapy included or not an antibiotic with in vitro activity against P. aeruginosa (p=0.011). Together with active disease, the emergence of P. aeruginosa BSI, particularly if multiresistant, was responsible for an increased risk of death among hematological patients at our institution. In this scenario, reconsidering the type of combination antibiotic therapy to be used as empiric treatment of neutropenic fever was worthwhile.

[Role of coagulation in acute pulmonary lesion physiopathology. Parallelism with sepsis]. / Papel de la coagulación en la fisiopatología de la lesión pulmonar aguda. Paralelismo con la sepsis.

Acute respiratory distress syndrome and acute lung injury for a part of a devastating syndrome characterized by acute onset, hypoxemia and bilateral infiltrates in the chest x-ray with absence of heart failure signs. Acute lung injury is the response of the lung to a local or systemic aggression, resulting in local inflammation and coagulation disorders, this leading to increased inflammatory pulmonary edema. Acute lung injury/acute respiratory distress syndrome are associated with increased procoagulant and reduced fibrinolytic activities mainly in alveoli and interstitial spaces in the lung. Fibrin deposits, which are the hallmark of early phase acute lung injury, stimulate fibroblast aggregation and collagen secretion, participating to the constitution of pulmonary fibrosis. The only clinical intervention found to have a significant impact on mortality in acute respiratory distress syndrome, despite the significant pro - gress in the understanding of the disease made over the past 10 years, is the use of low tidal volume ventilation. In severe sepsis, only recombinant human activated protein C administration has demonstrated a mortality reduction, together with faster improvement in respiratory dysfunction and shorter duration of mechanical ventilation. Future clinical trials should consider the potential benefit of anticoagulants administrated systemically or locally in the lungs to determine the role of anticoagulants in the treatment of acute pulmonary injury/acute respiratory distress syndrome.

Papel de la coagulación en la fisiopatología de la lesión pulmonar aguda. Paralelismo con la sepsis / Role of coagulation in acute pulmonary lesion physiopathology. Parallelism with sepsis

La lesión pulmonar aguda y, en su forma másgrave, el síndrome de distrés respiratorio agudo,tiene una alta morbimortalidad y se caracterizapor un inicio brusco, hipoxemia e infiltrados bilateralesen la radiografía de tórax con ausencia de signos de insuficiencia cardiaca. En la fisiopatología de la lesión pulmonar aguda participa, junto a la activación de la inflamación, una alteración del sistema de la coagulación.Las alteraciones del sistema de la coagulaciónpresentes en la lesión pulmonar aguda incluyen unaumento de la actividad procoagulante, así como un descenso de la actividad fibrinolítica, tanto en el espacio alveolar como en el intersticio pulmonar. Los depósitos de fibrina, que son el marcador inicial de la fase precoz de la lesión pulmonar aguda, estimulan la agregación de fibroblastos y la subsiguiente secreción de colágeno que conduce a la fibrosis pulmonar.El único tratamiento que ha demostrado tenerun impacto significativo sobre la mortalidad en lalesión pulmonar aguda/síndrome de distrés respiratorioagudo, a pesar de los avances sobre el conocimientode la enfermedad en los últimos 10 años, es el uso de ventilación protectora con volumen corriente bajo. En la sepsis grave donde también participa la coagulación, sólo el tratamiento con proteína C activada ha mostrado una reducción de la mortalidad junto con una mejoríade la disfunción respiratoria y descenso en losdías de ventilación mecánica.En el futuro, para determinar el papel de los anticoagulantes en el tratamiento de la lesión pulmonaraguda/síndrome de distrés respiratorio agudo, los próximos estudios deberían considerar el potencial beneficio de los anticoagulantes aplicados a nivel sistémico o local pulmonar

Acute respiratory distress syndrome and acutelung injury for a part of a devastating syndromecharacterized by acute onset, hypoxemia and bilateralinfiltrates in the chest x-ray with absenceof heart failure signs. Acute lung injury is the responseof the lung to a local or systemic aggression,resulting in local inflammation and coagulationdisorders, this leading to increased inflammatorypulmonary edema.Acute lung injury/acute respiratory distresssyndrome are associated with increased procoagulantand reduced fibrinolytic activities mainly in alveoli and interstitial spaces in the lung. Fibrindeposits, which are the hallmark of early phaseacute lung injury, stimulate fibroblast aggregationand collagen secretion, participating to the constitutionof pulmonary fibrosis.The only clinical intervention found to have asignificant impact on mortality in acute respiratorydistress syndrome, despite the significant progress in the understanding of the disease made over the past 10 years, is the use of low tidal volume ventilation. In severe sepsis, only recombinant human activated protein C administration has demonstrated a mortality reduction, together with faster improvement in respiratory dysfunction and shorter duration of mechanical ventilation.Future clinical trials should consider the potentialbenefit of anticoagulants administrated systemicallyor locally in the lungs to determine the role of anticoagulants in the treatment of acute pulmonary injury/acute respiratory distress syndrome

Prevalencia de hipertensión arterial en una población barrial de Santo Domingo / Arterial hypertension prevalence in a getto population of Santo Domingo

Con el objetivo de conocer la prevalencia de hipertensión arterial en el "Caliche de Cristo Rey", Santo Domingo, se realizó un estudio descriptivo en el período de Abril-Junio 1991. Nuestro Universo estuvo constituido por una población mayores de 15 años, determinamos que 86 casos (19.1//) eran hipertensos y 200 casos (45.0//) tenían hábitos tóxicos como cigarrillos, té, café, y alcohol. La mayor prevalencia de hipertensión arterial fue pacientes en edad comprendida entre 65 año o más (31.7//). En cuanto al sexo se determinó que el más frecuente fue el femenino con un 62.8//y en el masculino sólo un 70.0//tenía un nivel primario. El 90//de los pacientes encontrados con hipertensión arterial no reciben tratamiento. Hipertensión arterial, prevalencia, cardiología

Violación e intento de violación en una población de escolares femeninos / Rape and rape purpose in un scholar female population

Con el objetivo de determinar la frecuencia de la violación e intento de violación se realizó un estudio prospectivo y transversal en los estudiantes del cuarto año del bachillerato del liceo politécnico María de la Altagracia, Villa Duarte, Santo Domingo, en el período septiembre-noviembre 1990. De 347 estudiantes encuestadas 6(1.7 por ciento ) han sido violadas y 41(11.8 por ciento ) han sido victimas de intentos de violación. El 100 por ciento ocurrió sólo una vez, en tanto el intento de violación ocurrió dos veces en el 14.6 por ciento . De los 5 casos de violación (83.4 por ciento ), el vilador fue una sola persona, ocurriendo solo en horas de la noche, siendo este amigo, conocido, familiar enamorado en 66.* por ciento . Un 44.9 por ciento reportó sentimiento de verguenza y culpa y sólo el 33.3 por ciento comunicó la violación a alguien

[Infectious endocarditis in the neonatal period]. / Endocardite infectieuse en période néo-natale.

A case of bacterial endocarditis in a newborn without any congenital heart disease is reported. The clinical diagnosis was suspected on evolutive heart failure by mitral dysfunction with sepsis. T.M. mode echocardiography could detect only the valvular defects. Correlations between anatomic and echocardiographic findings allowed to discuss the limits of the method. Neonatal bacterial endocarditis is a rare event. Its diagnosis is difficult and its prognosis very poor. This affection must be prevented.