Effect of different therapeutic modalities on systemic, renal, and hepatic hemodynamics and short-term outcomes in cirrhotic patients with spontaneous bacterial peritonitis.

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is a major risk factor for hepatorenal syndrome. Albumin infusion has been shown to prevent renal impairment and reduce mortality in SBP. The study aimed to compare the effect of different therapeutic modalities on hemodynamics and short clinical outcomes in high-risk patients with SBP. METHODS: Two hundred cirrhotic patients with SBP and bilirubin greater than 4 mg[Fraction Slash]dl or creatinine more than 1 mg[Fraction Slash]dl were enrolled. Patients were randomized to receive albumin, terlipressin, low-dose albumin plus terlipressin, or midodrine. Systemic, renal, and hepatic hemodynamics were estimated at baseline, 3, and 10 days of treatment. Renal impairment was diagnosed when the blood urea nitrogen or serum creatinine levels increased by more than 50% of the pretreatment value. RESULTS: SBP resolved in most of patients in all groups (P>0.05). Cardiac output and portal flow decreased, whereas systemic vascular resistance increased significantly in terlipressin and albumin plus terlipressin groups compared with the albumin group after 3 and 10 days. After 10 days, plasma renin activity, renal, and hepatic arteries resistive index were significantly higher in the midodrine group compared with the albumin group. The midodrine group did not show any significant changes in the heart rate, mean arterial pressure, cardiac output, and portal blood flow compared with the albumin group after 3 or 10 days. There was no significant difference in renal impairment or mortality between any of the groups. CONCLUSION: Terlipressin and low-dose albumin plus terlipressin could be used as a therapeutic alternative to standard-dose albumin in high-risk SBP patients.

Portal and splanchnic hemodynamics after partial splenic embolization in cirrhotic patients with hypersplenism.

To assess the acute effects of partial splenic embolization (PSE) on portal and splanchnic hemodynamics in patients with cirrhosis. Ninety-five patients with hypersplenism were included in the study. Duplex examinations were performed before and 3 and 7 days after PSE. Portal and splanchnic hemodynamics including vessel cross-sectional area (CSA), mean flow velocities (cm/s), blood flows (mL/min), Doppler indices as portal congestion index (CI), liver vascular index, hepatic artery and superior mesenteric artery (SMA) pulsatility and resistive indices (PI and RI), were performed before and after PSE. In our study, 69 of 95 patients were males (72.6%) and 26 females (27.3%). Chronic hepatitis C virus infection was the main cause of cirrhosis (81.1%). PSE failed technically in six patients (6.3%). After PSE, both CSA and CI significantly decreased (p < 0.05 and <0.01). The portal vein velocity significantly increased (p < 0.01). The portal flow volume (892.4 ± 151 mL/min) did not show significant changes. The hepatic artery RI and PI showed a steady increase that became significant 7 days post-PSE (p < 0.05). The RI and PI of SMA increased significantly after 7 days of PSE (p < 0.05). PSE has an immediate portal decompression effect in patients with portal hypertension without reduction in portal flow. This effect on portal pressure should be investigated in future studies as a potential tool for management of acute variceal bleeding when other medical procedures fail.

Role of occult hepatitis B virus in chronic hepatitis C patients with flare of liver enzymes.

BACKGROUND: Occult HBV infection is defined by detection of HBV DNA in the serum or liver tissue of patients who test negative for HBsAg. The prevalence of occult HBV is higher in hepatitis C virus (HCV) positive patients than HCV negative patients and may have an impact on their clinical outcome. In this study, we evaluated the role of occult hepatitis B virus infection in chronic hepatitis C patients with ALT flare. METHODS: Sixty HBsAg negative patients with chronic hepatitis C virus infection were included. Patients were divided into 2 groups according to their ALT level: 30 patients with normal or slightly high ALT and 30 patients with ALT flare (≥ 5 times normal values). Patients in both groups were examined for the detection of anti-HBs, anti-HBc IgM, and anti-HBc IgG. HBV DNA was detected using semi-nested PCR technique. RESULTS: In patients with normal or slightly high ALT, HBV DNA was detected in 4 (13.3%) patients, while in those with ALT flare, HBV DNA was detected in 19 (63.3%) patients (p<0.001). No association was found between the presence of HBV DNA and various serology markers of HBV infection. CONCLUSION: Presence of occult hepatitis B, with its added deleterious effect, must always be considered in chronic hepatitis C patients especially those with flare in liver enzymes; HBsAg should not be used alone for the diagnosis of HBV infection.

Dynamical phenomena induced by bottleneck.

We study a microscopic follow-the-leader model on a circle of length L with a bottleneck. Allowing large bottleneck strengths we encounter very interesting traffic dynamics. Different types of waves--travelling and standing waves and combinations of both wave types--are observed. The way to find these phenomena requires a good understanding of the complex dynamics of the underlying (nonlinear) equations. Some of the phenomena, like the ponies-on-a-merry-go-round solutions, are mathematically well known from completely different applications. Mathematically speaking we use Poincaré maps, bifurcation analysis and continuation methods beside numerical simulations.

Study of adiponectin in chronic liver disease and cholestasis.

PURPOSE: Adiponectin is an adipocytokine suggested to have a hepatoprotective effect. To date, little information is available in the literature regarding changes in serum adiponectin levels in cirrhosis and cholestasis and the associated metabolic disturbances. In order to elucidate the role of adiponectin in chronic liver disease our aim was to determine serum adiponectin in patients with different grades of cirrhosis and cholestasis and to correlate it with markers of liver injury, inflammation and cholestasis. We also aimed to correlate adiponectin with markers of metabolic syndrome such as body mass index and insulin resistance. METHODS: Forty patients with cirrhosis; 30 patients with cirrhosis and cholestasis; and 20 matched controls were studied. They were subjected to clinical assessment, laboratory investigations: serum bilirubin, ALT, AST, alkaline phosphatase, GGT, albumin, C-reactive protein, prothrombin activity, fasting blood sugar, insulin. HOMA index was calculated. Abdominal ultrasonography and upper GI endoscopy were performed. RESULTS: Adiponectin was elevated in patients with cirrhosis and cirrhosis/cholestasis and was significantly higher in Child A and B. Adiponectin showed correlation with liver cell injury, marker of inflammation, synthetic liver function and markers of cholestasis. Adiponectin did not correlate with complications of cirrhosis as ascites and esophageal varices nor did it correlate with BMI or HOMA. CONCLUSIONS: Adiponectin is elevated in cirrhosis and shows correlation with degree of hepatocellular injury and cholestasis. Finally, adiponectin levels in cirrhosis do not correlate with parameters of body composition or metabolism but exclusively with reduced liver function.

[Tracheal infection following oncological surgery in larynx and pharynx]. / Colonización traqueal en cirugía oncológica de laringe y faringe.

Surgical wound infection is one of the most frequent complications in pharyngo-laryngeal external surgery. They are usually polimicro with gram-positive, negative both aerobial and anaerobial microrganisms. The trachea is usually sterile and contamination is due to the intoduction during intubation of germs from the oropharyngeal area. A retrospective study was performed including 40 patients with pharyngo-laryngeal carcinoma. When the tracheostomy was done a culture from the internal trachea wall was obtained for micro study. Only one patient had an sterile culture from the trachea. There were 3 patients with just one microorganism and all the rest had at least two, being mixed aerobial and anaerobial flora the most frequent.

Colonización traqueal en cirugía oncológica de laringe y faringe / Tracheal infection following oncological surgery in larynx and pharynx

La infección postoperatoria de la herida quirúrgica es una de las complicaciones más frecuentes de la cirugía faringolaríngea. Las infecciones son típicamente polimicrobianas, aislándose en ellas microorganismos gram-positivos, gram-negativos, aerobios y anaerobios. La contaminación de la tráquea, habitualmente estéril, se produce por la introducción directa de microorganismos desde la orofaringe a la tráquea, en el momento de la intubación. Se ha realizado un estudio prospectivo sobre 40 pacientes intervenidos quirúrgicamente por carcinoma faringolaríngeo. En el momento de realizar la traqueotomía a todos los pacientes se les tomó, con un escobillón estéril, una muestra de la pared interna de la tráquea para su estudio microbiológico. De los cultivos traqueales sólo uno de ellos fue estéril, en 3 se aisló un único microorganismo y en los 36 restantes se aislaron dos o más microorganismos, siendo lo más frecuente la flora mixta aerobia y anaerobia

Surgical wound infection is one of the most frequent complications in pharyngo-laryngeal external surgery. They are usually polimicro with gram-positive, negative both aerobial and anaerobial microrganisms. The trachea is usually sterile and contamination is due to the intoduction during intubation of germs from the oropharyngeal area. A retrospective study was performed including 40 patients with pharyngo-laryngeal carcinoma. When the tracheostomy was done a culture from the internal trachea wall was obtained for micro study. Only one patient had an sterile culture from the trachea. There were 3 patients with just one microorganism and all the rest had at least two, being mixed aerobial and anaerobial flora the most frequent

Peritonitis bacteriana espontánea por haemophilus influenzae / Spontaneous bacterial peritonitis due to Haemophilus influenzae

No disponible

Circulatory changes after prolonged ischemia in the epigastric flap.

The circulation system seems to have early encounters with pathophysiologic processes during ischemia and reperfusion, such as overproduction of oxygen radicals, nitric oxide depletion, and leukocyte plugging. The aim of this study was to determine the superficial perfusion and vessel distribution of the epigastric flap with a laser Doppler Imaging (LDI) system during ischemia/reperfusion, and to observe the clinical outcomes 7 days after reperfusion in a separate set of animals. An epigastric flap from male Sprague-Dawley rats (320 to 380 g) was used to assess perfusion in sham animals (n=6) or in 12 hr-ischemia animals (12 hr of ischemia and 3 hr of reperfusion, n = 10) with the LDI system. In a separate experiment, flap size, flap failure index, and histologic sections of the flap from sham animals (n=6) and 12-hr ischemia animals (n=6) were evaluated 7 days after reperfusion. Evaluation of the vessel distribution demonstrated a diffuse picture of flap perfusion after clamp release. Moreover, in the distal portion of the flap, circulation stopped immediately, resulting in a significantly decreased perfusion in the 12-hr ischemia animals during reperfusion, when compared with pre-surgical values (100 percent) or sham animals (77 +/- 26.5 vs. 108 +/- 9.6 percent PU). On day 7, the flaps of animals after ischemia and reperfusion showed significant shrinkage, an increase in flap failure index, as well as necrosis, edema, and leukocyte infiltration. Based on the findings, the authors propose that, after prolonged ischemia, the circulation becomes diffuse, and "no-reflow" occurs in the distal portions of the myocutaneous flap during reperfusion. Perfused areas, assessed with the LDI early during reperfusion, might still become necrotic after several days. In the authors' flap model, edema formation and leukocyte infiltration seem to be related more to ischemia reperfusion damage than to thrombus formation.

Valor de los parámetros clínicos en el diagnóstico de una infección amniótica en gestantes con amenaza de parto prematuro / Value of clinical signs in the diagnosis of amniotic infection in patients with preterm labor

Objetivo: Estudiar el valor de la leucocitosis, fiebre materna y la taquicardia fetal en el diagnóstico de una infección amniótica.Sujetos y métodos: Un total de 113 gestantes con amenaza de parto prematuro a las que se les practicaron una amniocentesis y un cultivo de líquido amniótico. Al ingreso se tomó la temperatura axilar, se realizó un hemograma y se realizó un registro cardiotocográfico. Se relacionó la presencia de un cultivo de líquido amniótico positivo con la fiebre ( 37,8 °C), la taquicardia fetal ( 160 lat/min) y la leucocitosis materna (> 15.000 leucocitos/ml).Resultados: Trece de las gestantes (11,5 por ciento) presentaron una infección amniótica; 26 mujeres (23 por ciento) tuvieron una leucocitosis, cinco de ellas tenían un cultivo de líquido amniótico positivo (p = 0,1); 5 gestantes tuvieron fiebre, dos de ellas con un cultivo de líquido amniótico positivo (p = 0,1); 26 gestantes presentaron una taquicardia fetal (23 por ciento), ocho de las cuales tuvieron un cultivo de líquido amniótico positivo (p = 0,001). La sensibilidad de la taquicardia fetal para detectar una infección amniótica fue del 61,5 por ciento y la especificidad del 82 por ciento.Conclusión: La taquicardia fetal fue el único parámetro clínico que se asoció significativamente a la infección amniótica, aunque su valor predictivo positivo fue bajo. (AU)

Valor de las interleuquinas en el liquido amniótico (LA) en el diagnóstico de la infección amniótica, prematuridad y morbimortalidad neonatal en gestantes con amenaza de parto prematuro (app) y membranas íntegras / Value of interleukins in amniotic fluid in the diagnosis of amniotic infection neonatal prematurity, morbidity in pregnant women at risk of preterm labor with intact membranas

Objetivo: Comparar el valor del factor de necrosis tumoral (TNF), interleuquina-1 (IL-1), interleuquina-6 (IL-6), interleuquina-8 (IL-8) en el diagnóstico de la infección amniótica, de la prematuridad y de la morbimortalidad neonatal. Sujeto y métodos: Se trata de un estudio prospectivo no aleatorio en el que se realizó una amniocentesis a 113 gestantes con APP y membranas integras. Se practicó un cultivo de LA y se determinaron los valores de TNF, IL-1, IL-6 y IL-8 en éste. Posteriormente se relacionaron los valores de las citoquinas con el resultado del cultivo del LA, la prematuridad, el cultivo de sangre neonatal y la mortalidad perinatal. Resultados: Hubo 13 gestantes con APP (11,5 por ciento) y cultivo de LA positivo; el parto fue pretérmino en 58 casos (51,3 por ciento). Los valores de las cuatro citoquinas se relacionaron de una manera estadísticamente significativa con la presencia de un cultivo de LA positivo, con una sensibilidad que osciló entre el 61,5 y 53,8 por ciento y una especificidad del 79,8 al 99 por ciento, y también con la mortalidad perinatal con una sensibilidad del 66,7 al 33,3 por ciento y una especificidad del 90,9 al 93,9 por ciento.La IL-6 y la IL-8 fueron las más sensibles (62,1 y 60,3 por ciento, respectivamente) en la detección de qué partos terminarían prematuramente, pero la más especifica fue la IL-1. La IL-8 fue la única que no se relacionó significativamente al resultado del hemocultivo neonatal.Conclusiones: Los valores de las cuatro citoquinas en LA tuvieron en general una correlación buena con el resultado del cultivo del LA, con la prematuridad, con la mortalidad perinatal y con el resultado del hemocultivo neonatal (AU)

Comparative in vitro antifungal activity of amphotericin B lipid complex, amphotericin B and fluconazole.

Amphotericin B (AMB) is considered the gold standard in the treatment of serious systemic mycoses in spite of its nephrotoxicity and adverse effects. Association with lipids enables larger doses of AMB to be given with a longer t((1/2)) and C(max), without the toxic effects at lower concentrations. Liposome-encapsulated AMB shows a lower affinity for mammalian cells and improves V(d), thus decreasing toxicity. Amphotericin B lipid complex (ABLC) is an AMB formulation associated with a biodegradable phospholipid matrix (5% molar) from which the drug is released by cell phospholipases. ABLC is recommended for serious mycoses refractory to conventional antifungal therapy or when AMB is contraindicated. We compared the in vitro antifungal activity of ABLC, AMB and fluconazole (FLZ) against 328 strains of clinically significant opportunistic fungi using a microdilution method (NCCLS, M-27A). 64.9% of the yeasts were inhibited by MIC of ABLC

Valor de la glucosa y el Gram de líquido amnióticoen el diagnóstico precoz de la infección amniótica en gestantes con amenaza de parto prematuro y membranas íntegras / Value of glucose and Gram stains of amniotic fluid for the early diagnosis of amniotic infection in pregnant women with threat of premature delivery and intact membranes

Objetivo: Comparar la sensibilidad, especificidad y valores predictivos de la glucosa y el GRAM en líquido amniótico en la detección precoz de una infección amniótica.Sujetos y métodos: Se trata de un estudio prospectivo no aleatorio en el que se realizó una amniocentesis a 113 gestantes con amenaza de parto prematuro y membranas íntegras. Se practicó un cultivo del líquido amniótico para determinar si había una infección amniótica. También se realizó una tinción de GRAM y se determinaron los valores de la glucosa en el líquido amniótico.Resultados: El cultivo de líquido amniótico fue positivo en 13 casos (11,5 por 100). En nueve gestantes se aislaron gérmenes anaerobios (69,2 por 100). Los valores de la glucosa < 16 mg/dl y la tinción de GRAM positiva se relacionaron de forma estadísticamente significativa con el resultado del cultivo de líquido amniótico. La glucosa tuvo una sensibilidad de 69,2 por 100 y una especificidad del 96 por 100 y la tinción de GRAM tuvo una sensibilidad del 38,5 por 100 y una especificidad del 100 por 100 en el diagnóstico de un cultivo de líquido amniótico positivo.Conclusión: el valor de la glucosa en líquido amniótico fue más sensible que la tinción de GRAM en el diagnóstico de un cultivo de líquido amniótico positivo (AU)

In vitro activities of 22 antimicrobial agents against Listeria monocytogenes strains isolated in Barcelona, Spain. The Collaborative Study Group of Listeriosis of Barcelona.

The in vitro activity of 22 antimicrobial agents against 82 human Listeria monocytogenes strains isolated in Barcelona from 1994 to 1998 was determined. Ampicillin and gentamicin showed good in vitro activity against all strains (MIC90: 1 and < or = 0.25 microg/ml, respectively). No resistance to rifampin or co-trimoxazole was detected and only one strain was resistant to tetracycline. Of the nine fluoroquinolones tested, clinafloxacin and gemifloxacin were the most active compounds (MIC90: 0.12 and 0.25 microg/ml, respectively). No increasing MICs values were observed during the five-year period.

[Determination of the in vitro antifungal susceptibility of clinically important yeasts using the Sensititre system]. / Determinación mediante el sistema Sensititre de la sensibilidad in vitro a los antifúngicos de levaduras de interés médico.

Using Sensititre (AccuMed, USA) we studied the in vitro antifungal activity of amphotericin B, fluconazole, itraconazole, ketoconazole and 5-fluorocytosine against 250 clinical yeast isolates taken from different hospitals, including Candida (151 C. albicans, 15 C. krusei, 14 C. parapsilosis, 11 C. tropicalis, 10 C. glabrata, 4 C. guilliermondii, 3 C. rugosa, 2 C. viswanathii, 2 C. famata and 2 C. kefyr), Cryptococcus (32 C. neoformans and 1 C. laurentii), Trichosporon (2 isolates) and Rhodotorula rubra (1 isolate). All the strains were susceptible to amphotericin B and showed an MIC <1 mg/l. The susceptibility of C. albicans (MIC(90) <256 mg/l), C. krusei (MIC(90) <64 mg/l), C. glabrata (MIC(90) <64 mg/l) and C. neoformans (MIC(90) 32 mg/l) to fluconazole was lower (14% isolates being resistant and 16.8% susceptible depending on the dose). The largest number of strains resistant to itraconazole was observed in C. albicans and C. glabrata (17.2% resistant and 24% susceptible and susceptible depending on the dose, respectively). Ketoconazole and 5-fluorocytosine were not effective in vitro against 12.8% and 2%, respectively, of all the isolates studied. Nine C. krusei and seven C. neoformans (12.9%) showed dose-dependent susceptibility to 5-fluorocytosine.

[Eikenella corrodens: five year experience in a general hospital]. / Eikenella corrodens: cinco años de experiencia en un hospital general.

BACKGROUND: Eikenella corrodens is a Gram negative bacillus that colonizes oropharyngeal and digestive mucous membranes. It is difficult to isolate in the laboratory. This might be the reason why its implication in different types of infection is not well known. We report a five year experience in a general hospital. METHODS: Charts of 125 infections have been retrospectively reviewed. No selective medium was employed for the isolation. RESULTS: Infections were related to oral cavity in 68 patients (54%) and to gastrointestinal tract in 45 (36%); in 12 no clear source could be found. The prevailing infections were: postsurgical 32, apendiceal 22, abscesses 22, and traumatic wounds 12. Seventy two percent of the patients were adults and 93% were hospitalized. Eighteen patients had a neoplasia, 6 were diabetic, and 3 had some kind of immunodeficiency. Etiology was polymicrobial in 91% of the cases, the prevailing association being with Streptococcus spp. (74%). Only 15 patients had a pure culture, 11 of which had received previous antibiotic treatment. The most serious infections were a subdural empyema secondary to sinusitis, a mediastinitis following a mouth floor abscess, and a peritonitis with pleural empyema preceded by an hepatic abscess. The three were polymicrobial. Outcome was always satisfactory with no associated death. CONCLUSIONS: The origin of these infections is almost always clearly related with its habitat, but their spectrum is wide. Polymicrobial condition of most of them makes diagnosis as well as interpretation of its clinical meaning difficult. Nevertheless, association of E. corrodens with serious or slow healing infections fully justifies the efforts towards its isolation and the choice of antibiotics to which it is susceptible.

Amniotic fluid glucose and cytokines values in the early diagnosis of amniotic infection in patients with preterm labor and intact membranes.

OBJECTIVE: Our goal was to compare sensitivity, specificity, and predictive values of glucose and cytokines [interleukin-1 (IL-1), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor (TNF)] in amniotic fluid (AF) to detect an AF-positive culture. METHODS: Amniocentesis was performed on 113 patients with preterm labour (PTL) and intact membranes. Fluid was cultured for aerobic and anaerobic bacteria, and for mycoplasmas. AF analysis included cytokines and glucose determinations. RESULTS: The prevalence of positive AF cultures was 11.5% (13/113). Anaerobic bacteria were isolated in 9 patients (69.2%). The glucose <16 mg/dl and cytokines values; IL-1 >640 pg/ml, IL-6 >55,000 pg/ml, IL-8 >1,000 pg/ml, TNF >672 pg/ml, were significantly correlated (P < 0.01) with AF culture result. Glucose had a sensitivity of 69.2% and a specificity of 96% for the prediction of positive AF culture. The sensitivity and specificity of the cytokines ranged from 61.5-53.4% and 79.8-8.99%, respectively. CONCLUSIONS: In the diagnosis of the AF-positive culture, glucose <16 mg/dl is more sensitive than cytokines.

[Enterobacter amnigenus. An unusual human pathogen]. / Enterobacter amnigenus. Un patógeno humano inusual.

BACKGROUND: Enterobacter amnigenus is a bacteria with doubtful pathogenicity. The observation of a patient with a well-documented E. amnigenus infection has prompted us to review the pathology caused by this microorganism. METHODS: Retrospective evaluation of the clinical charts of patients with any isolate positive for E. amnigenus over a period of 46 months. Based on the clinical data, presence or absence of other causal microorganisms and/or alternative diagnosis, E. amnigenus was classified as definitive, probable, or improbable cause of infection. RESULTS: We analyzed 15 E. amnigenus isolates, representing 0.97 of 10,000, the total bacterial isolates in our laboratory for this period, and 0.52% of those corresponding to Enterobacter sp. We were able to clinically evaluate E. amnigenus in 7 patients, in whom infection by this microorganism was classified as definitive in 4, probable in 1, and improbable in 2. Antibiotic susceptibility studies showed a resistance level of 83% to ampicillin, 75% to cefazoline and cefoxitine, and 33% to amoxicillin-clavulanic acid. All isolates were susceptible to third-generation cephalosporins, aztreonam, ciprofloxacin, cotrimoxazole and aminoglycosides. CONCLUSIONS: E. amnigenus cause well-documented bacterial infection in man. Thus, isolation of this microorganism should not be considered as a contaminant or simple colonizer. The clinical behavior and antimicrobial susceptibility of E. amnigenus is similar to that of E. cloacae, a taxonomically-related species.