[Impact of surgery on the mortality of infective endocarditis in a hospital without cardiac surgery]. / Impacto de la cirugía en la mortalidad de la endocarditis infecciosa en un hospital sin cirugía cardiaca.

OBJECTIVE: Infective endocarditis has a high morbidity and mortality and requires a coordinated medical-surgical management. The objective was to analyse the impact of surgery on mortality in a hospital without cardiac surgery. METHODS: Evaluation of a prospective cohort of patients with infective endocarditis diagnosed between August 2011 and January 2016 according to modified Duke's criteria. RESULTS: Sixty-four patients were included, of whom seventeen patients were operated (26.6%). Mortality was 32.8% and it was associated with chronic obstructive pulmonary disease history, staphylococci coagulase-negative and the appearance of complications, as valvular insufficiency and embolisms in the central nervous system; cardiac surgery was not associated with mortality. Four patients (6,6%) were not operated despite indication of cardiac surgery. The main reason for not been intervened was the poor presurgical prognosis (44.7%). CONCLUSIONS: Mortality due to infective endocarditis in a hospital without cardiac surgery is high. The need for interhospital teams is strengthened.

[Telemedicine, prison and illness associated with HIV]. / Telemedicina, centros penitenciarios y enfermedad por VIH.

OBJECTIVE: Communicate the activity of telemedicine, from its opening, between a hospital consultation of infectious diseases and a penitentiary center. METHODS: Descriptive study of the tele-consultation of infectious diseases of the Alcorcón Foundation University Hospital with the Navalcarnero penitentiary center from 2013 to 2017, which is carried out by videoconference. The reason and number of consultations, diagnosis of HIV, antiretroviral treatment (ART), immunovirological situation, diagnosis of hepatitis C virus (HCV= and intervention performed by the infectious expert were analyzed. RESULTS: A total of 75 patients were evaluated in a total of 168 consultations (in the first year 11 consultations and in the fifth year 62). The index of successive / new consultations was 1.24 and 85% of the patients required less than 1 year of follow-up. 84% of patients did not move to the hospital. 99% of patients accepted this modality. 96% were HIV positive, 94% of them took ART and 85% had undetectable viral load with 532 CD4/mL of medium. 90% had positive serology for HCV. 72% of the consultations were for the assessment of HCV treatment, which was sofosbuvir/ledipasvir by 63%. 40% changed their ART (70% to avoid interactions). CONCLUSIONS: Most of the evaluated patients have HIV infection. This type of consultation has a growing demand, is efficient (avoids transfers and is decisive) and has high acceptance. The most frequent reason for consultation was the treatment of HCV and more than a third of patients required ART change.

[Post-exposure prophylaxis against HIV, do we use our resources appropriately?] / Profilaxis post-exposición frente VIH, ¿utilizamos adecuadamente nuestros recursos?

OBJECTIVE: Post-exposure prophylaxis (PEP) against human immunodeficiency virus can be occupational, non-occupational or vertical transmission. The aim of our study was to analyse the indication and treatment carried out in a hospital. METHODS: Retrospective observational study that included all patients who received PEP between 2006 and 2014. The project was approved by the Committee for Ethics in Clinical Research. RESULTS: We evaluated 54 PEP, which were started at 11.8 hours' average. The antiretroviral drugs were adequately chosen, but the duration pattern did not adjusted to the recommendations published at that time. Tolerance was good, being gastrointestinal symptoms the most frequent adverse effects; only once was necessary to replace the pattern. There were usual losses during follow up, reaching in some subgroups 50%. CONCLUSIONS: Indication and choice of drugs were adequate in the three kinds of contact risks, but monitoring should improve.

Assessing clinical probability of organic disease in patients with involuntary weight loss: a simple score.

BACKGROUND: Involuntary weight loss (IWL) is a frequent complaint with a difficult diagnosis. Any one of a number of different diseases may be the source of the symptom. However, there is no universal clinical protocol that can help physicians study this complex syndrome. METHODS: In March 1998, we defined a diagnostic protocol for the study of IWL. IWL was defined as an involuntary and documented weight loss of at least 5% of the usual body weight in the previous 3 months. We analyzed 78 consecutive patients with IWL who came to our clinic between March 1998 and December 2000. RESULTS: An organic disease was found in 56% of cases; cancer, metabolic and digestive diseases were the most common entities. Psychiatric problems were found in 33% of cases. After extensive study, an idiopathic group of 11% was identified. The variables that were independently predictive of a final diagnosis of organic disease were: age>50 years (OR: 8.6, CI 95%: 1.7-43.6), psychiatric symptoms (OR: 0.2, CI 95%: 0.1-0.8), smoking (OR: 14.3, CI 95% 2.3-74), the presence of guide symptoms (OR: 8.0, CI 95%: 1.8-34.4), and anemia (OR: 3.1, CI 95%: 2.5-387). Sixteen percent of the patients died, more often those suffering from organic diseases. Based on multivariate regression coefficients, a clinical risk score was established. CONCLUSIONS: IWL is a complex and frequent syndrome with a 16% rate of mortality during the first year. A protocol based on clinical data can help in the management of IWL. Our clinical prediction rule may help physicians to identify those patients with IWL who are likely to have an underlying organic disease.

Evaluation of inflammatory cytokine secretion by human alveolar macrophages.

The alveolar macrophage (AM) secretes interleukin 1beta (IL-1beta), tumour necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and interleukin-8 (IL-8), all of them inflammatory cytokines involved in the pathogenesis of many lung diseases. The aim of the present work was to evaluate the basal and stimulated secretion of these cytokines by human AMs. Human AMs were collected by bronchoalveolar lavage (BAL) from four healthy controls and 13 patients with diffuse interstitial lung disease (five cases of sarcoidosis, three of hypersensitivity pneumonitis and five of idiopathic pulmonary fibrosis). AMs were cultured in the presence or absence of different concentrations of lipopolysaccharide (LPS), phorbolmyristate and gamma-interferon. IL-1beta, TNF-alpha, IL-6 and IL-8 levels were measured in BAL fluid and culture supernatant using specific enzyme-linked immunosorbent assays. The substance found to stimulate the secretion of inflammatory cytokines to the greatest extent was LPS at a concentration of 10 microg/ml. Regarding the secretion of IL-1beta, four observations were of interest: basal secretion was very low; LPS exerted a potent stimulatory effect; considerable within-group variability was observed; and there were no significant differences in the comparisons among groups. With respect to TNF-alpha secretion, the results were similar. The only striking finding was the higher basal secretion of this cytokine with respect to that of IL-1beta. Regarding the secretion of IL-6, the same pattern followed by TNF-alpha was found. However, it should be stressed that the increase induced by LPS was smaller than in the two previous cytokines. Regarding the secretion of IL-8, three findings were patent: the strong basal secretion of this cytokine; the moderate increase induced by LPS; and the existence of significant differences among the different groups with respect to the stimulated secretion of this cytokine, which reached maximum values in patients with idiopathic pulmonary fibrosis. Finally, it should be noted that the pattern of cytokines observed in the BAL fluid was similar to that found in cultured AM supernatants. The pattern of inflammatory cytokine secretion by AMs differs from that of other cells of the mononuclear phagocyte system (MPS). In this sense. AMs secrete low amounts of IL-1, moderate amounts of TNF-alpha and IL-6, and high quantities of IL-8. Adherence is an important stimulus in the secretion of these molecules and LPS elicits an increased secretion inverse to the basal secretion. There is considerable individual variability in the secretion of inflammatory cytokines by the AMs of patients with interstitial lung disease and the AMs of these patients are primed in vivo for the secretion of these cytokines. The results of our study, carried out in vitro, can be extrapolated to the in vivo setting.

Effect of cyclosporin A on inflammatory cytokine production by human alveolar macrophages.

Cyclosporin A (CsA) is an immunomodulator drug that has been used in the treatment of several types of advanced pulmonary interstitial disease. This beneficial effect occurs mainly in circumstances in which alveolitis due to CD4 lymphocytes is absent, suggesting that CsA acts on other types of cells. The present study was undertaken to determine the effect of CsA on inflammatory cytokine secretion by human alveolar macrophages (AMs). Human AMs were collected by bronchoalveolar lavage from four control subjects and 13 patients with interstitial lung disease. Purified human AMs were incubated with different concentrations of CsA (200, 20 and 2 ng ml-1) in the presence or absence of lipopolysaccharide (LPS). Interleukin-1 beta (IL-1 beta), tumour necrosis factor-alpha (TNF-alpha), IL-6 and IL-8 levels were measured in supernatants using specific enzyme-linked immunosorbent assays. It was found that CsA inhibits basal secretion of TNF-alpha and IL-8 at 20 and 200 ng ml-1. However, none of the different concentrations of CsA modified basal secretion of IL-1 beta nor IL-6. By contrast, a lower concentration of CsA (2 ng ml-1) inhibits LPS-stimulated secretion of all inflammatory cytokines. It is concluded that CsA exerts a modest effect on inflammatory cytokine production by human AMs.

[Acute eosinophilic pneumonia in a pregnant woman]. / Neumonía eosinófila aguda en gestante.

Acute eosinophilic pneumonia is a recently described pulmonary phenomenon involving rapidly progressing respiratory insufficiency. Although it can appear at any age, it has never been reported during pregnancy and its impact on gestation is therefore unknown. We describe the clinical signs and course of disease in this first report of acute eosinophilic pneumonia in a pregnant woman. We emphasize the diagnostic utility of bronchoalveolar lavage, the resolution of symptoms without corticoid treatment and, mainly, the absence of adverse repercussions of the disease on pregnancy.

Action of cyclosporin A on mononuclear phagocytes.

Classically, cyclosporin A has been reported to exert its immunomodulatory action through its effect on T lymphocytes by inhibiting the synthesis of interleukin 2. However, the inhibition of T-lymphocyte activation does not suitably account for all the effects observed following cyclosporin A administration. It is possible that some of them could be due to the action of cyclosporin A on other cells, among which are mononuclear phagocytes. This article offers a detailed review of the consequences of the interaction of cyclosporin A on the capacities (surface antigen expression and production of inflammatory mediators), functions (chemotaxis, phagocytosis, intracellular destruction and cytotoxicity) and actions (antimicrobial defense, antitumor defense and immune cooperation) of these cells. The general conclusion is that the capacities, functions and actions of the macrophages related to non-specific defense are more resistant to cyclosporin A than those related to immunoregulation.

Comparison of two techniques (flow cytometry and alkaline immunophosphatase) in the evaluation of alveolar macrophage immunophenotype.

The alveolar macrophage (AM) plays an essential role in the pathogenesis of interstitial lung diseases. The expression of specific membrane antigens is related to the functional or madurative status of the cells of mononuclear phagocyte system. The aim of this study was to analyze the expression of several markers (HLA-DR, CD11b, CD16, CD14) in AM obtained by bronchoalveolar lavage from control patients (n = 6), patients with sarcoidosis (n = 6), diffuse neoplastic infiltration of the lung (n = 7), pulmonary fibrosis (n = 4), and hypersensitivity pneumonitis (n = 3) by two evaluation techniques (flow cytometry and alkaline immunophosphatase). In the light of the results we can conclude that in the immunophenotypical study of the alveolar macrophage, flow cytometry (with semiquantitative evaluation to avoid the problem of autofluorescence) is a useful tool in the evaluation of those antigens that are only weakly or moderately expressed on AM (CD11b or CD14), whereas the alkaline immunophosphatase technique is of great interest in the evaluation of those that are strongly expressed (i.e., HLA DR). Additionally, the variable expression of the different antigens in the different alveolar-interstitial pathological states is patent in some diseases.