Risk factors for nosocomial pneumonia in critically ill trauma patients.

OBJECTIVE: To determine risk factors for nosocomial pneumonia in critically ill trauma patients. DESIGN: Prospective cohort study. SETTING: The trauma intensive care unit (ICU) of a 1500-bed tertiary-care hospital. PATIENTS: All critically ill trauma patients (n = 103) admitted consecutively between November 1995 and October 1996. INTERVENTIONS: A comparison of data recorded at the time of ICU admission and during the clinical evolution in patients with (n = 23) and without (n = 80) nosocomial pneumonia was made. Data referred mainly to possible risk factors were recorded; they also included factors related to pneumonia etiology and evolutive factors. Predictors of nosocomial pneumonia were assessed by logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: The presence of significant growth on quantitative cultures of the protected specimen brush (> or = 103 colony forming units/mL) was required to accept pneumonia as microbiologically proven, as well as the concurrence of a cohort of clinical and radiologic signs. Twenty-three (22.3%) patients developed nosocomial pneumonia. The mean age of these patients was 41.7 yrs; 18 of them (78.3%) were men. The microorganisms isolated in significant concentrations were Acinetobacter baumanii (ten cases), Staphylococcus aureus (11 cases), Pseudomonas aeruginosa (five cases), Haemophilus influenzae (two cases), and Klebsiella pneumoniae, Citrobacter freundii, Serratia marcescens, Enterococcus spp., Enterobacter spp., coagulase-negative Staphylococcus, and Streptococcus intermedius (one case each one). Risk factors for pneumonia by univariate analysis included nasogastric tube; continuous enteral feeding; prolonged mechanical ventilation (>1 day); use of H2-receptor antagonist, sucralfate, muscle relaxants, corticosteroids, barbiturates, and inotropic agents; positive end-expiratory pressure; intense sedation; re-intubation; tracheotomy; urgent brain computed tomography (CT) scan; craniotomy; iatrogenic event; and hyperventilation. The mortality rate was 43.5% (10 of 23) in the nosocomial pneumonia group and 18.8% in patients without nosocomial pneumonia (p =.02). Also, the mean stay in the ICU, the therapeutic charge (measured with total and mean punctuation of the Therapeutic Intervention Scoring System) and the complications, infectious and noninfectious, of the clinical evolution were significantly more frequent in patients with nosocomial pneumonia than in those without pneumonia (p <.05). In the multivariate analysis, continuous enteral feeding, craniotomy, prolonged mechanical ventilation (>24 hrs), use of positive end-expiratory pressure, and corticotherapy were independent predictors of nosocomial pneumonia. CONCLUSIONS: It seems that factors related to the patient's clinical course, rather than variables registered on the first days of ICU admission, are those that would exert an influence on the development of nosocomial pneumonia in critically ill trauma patients. In this way, from our point of view, in our study the main risk factors are the use of prolonged mechanical ventilation (>4 hrs) and positive end-expiratory pressure. At the same time, we can conclude that the reduction of this infection incidence could decrease the mean stay in the ICU, the therapeutic charge, and the prognosis in terms of mortality and morbidity.

Piel y menopausia: efectos de la edad, estado hormonal y tratamientos / Skin and menopause: age effects, hormone state and treatment

El deterioro de la piel con la edad está influido por factores endógenos como el componente genéticos o la situación hormonal; y por exógenos como el tabaco o las radiaciones ultravioletas de la luz solar. Una piel deteriorada impacta fuertemente en la calidad de vida de una mujer, por lo que es relevante tener posibilidades de mejorarla. Los estrógenos actúan en la piel aumentando el ácido hialurónico, lo que produce una mayor hidratación de la dermis; esta edematización, asociada al aumento de la polimerización del colágeno que provocan los estrógenos, aumentan el grosor cutáneo; también estas hormonas inducen mayor formación de vasos en la piel, lo que se traduce en mayor actividad metebólica de la epidermis. Estos efectos explican que la terapia de reemplazo hormonal mejore la calidad de la piel, disminuyendo las arrugas y mejorando las características biomecánicas de la piel. Otras alternativas para atenuar el envejecimiento cutáneo pueden ser algunas terapias no endocrina como los ácidos alfa-hidroxilados y los ácidos retinoicos. La protección de las radiaciones solares y los cambios de hábitos nocivos para la piel, como el consumo de cigarrillo son medidas que deben aconsejarse a todas las pacientes

[Chronic polyneuropathy due to vitamin E deficiency]. / Polineuropatía crónica secundaria a deficiencia de vitamina E.

Vitamin E deficiency has been implicated as a causal factor in neurological disease for some time. Nevertheless, only in the last 10 years have we begun to understand the role this vitamin plays in the normal functioning and structure of the nervous system. Chronic fat malabsorption syndromes are the most common causes of low levels of this highly fat-soluble vitamin. We present a case of chronic polyneuropathy due to vitamin E deficiency caused by malabsorption in which a biliary-cholonic fistula was present. Plasma tocopherol levels were normalized by parenteral substitution, leading to substantial clinical improvement. We suggest that vitamin E levels be determined in cases of digestive disorders involving malabsorption of fats and in chronic neurological diseases, particularly spinal-cerebral degenerative and polyneuropathic diseases that are mainly sensory or motor-sensory in nature, given the potential reversibility of these disorders when caused by vitamin E deficiency.