Ampicillin Plus Ceftriaxone Combined Therapy for Enterococcus faecalis Infective Endocarditis in OPAT.

Ampicillin plus ceftriaxone (AC) is a well-recognized inpatient regimen for Enterococcus faecalis infective endocarditis (IE). In this regimen, ceftriaxone is usually administered 2 g every 2 h (AC12). The administration of AC in outpatient parenteral antibiotic treatment (OPAT) programs is challenging because multiple daily doses are required. AC regimens useful for OPAT programs include once-daily high-dose administration of ceftriaxone (AC24) or AC co-diluted and jointly administered in bolus every 4 h (ACjoined). In this retrospective analysis of prospectively collected cases, we aimed to assess the clinical effectivity and safety of three AC regimens for the treatment of E. faecalis IE. Fifty-nine patients were treated with AC combinations (AC12 n = 32, AC24 n = 17, and ACjoined n = 10). Six relapses occurred in the whole cohort: five (29.4%) treated with AC24 regimen and one (10.0%) with ACjoined. Patients were cured in 30 (93.3%), 16 (94.1%), and eight (80.0%) cases in the AC12, AC24 and ACjoined groups, respectively. Unplanned readmission occurred in eight (25.0%), six (35.3%), and two (20.0%) patients in the AC12, AC24 and ACjoined groups, respectively. The outcome of patients with E. faecalis IE treated with AC in OPAT programs relies on an optimization of the delivery of the combination. AC24 exhibit an unexpected rate of failures, however, ACjoined might be an effective alternative which clinical results should corroborate in further studies.

Influence of long-standing pulmonary arterial hypertension and its severity on pulmonary artery aneurysm development.

Pulmonary artery aneurysm (PAA) is a common finding in patients with long-term pulmonary arterial hypertension (PAH). The influence of PAH severity in the development of PAA remains unclear. We sought to determine whether PAA development is related to PAH severity and whether treatment optimization based on risk profile estimation is effective to stop pulmonary artery (PA) enlargement. This is a retrospective study of 125 PAH patients who underwent an imaging test (computed tomography or magnetic resonance) combined with a right heart catheterization within a six-month period. A multivariate analysis was performed to identify independent risk factors for PAA. Patients who underwent an additional imaging-test and RHC during follow-up were analyzed to evaluate changes on PA dimensions. PAA was diagnosed in 42 (34%) patients. PAA was more frequent in patients with congenital heart disease and toxic oil syndrome. PAH time-course showed to be an independent risk factor for PAA (HR 1.051, 95% CI 1.013-1.091, p = 0.008) whereas PAH severity did not. Twenty-six patients underwent a follow-up imaging-test and catheterization. After treatment optimization, a non-significant reduction of mean PA pressure was observed (58.5 mmHg [43.5-70.8] vs. 55.5 mmHg [47.5-66.3], p = 0.115) and a higher proportion of patients achieved a low-risk profile (19% vs. 35%, p = 0.157). However, the PA diameter significantly increased (40.4 ± 10.1 mm vs. 42.1 ± 9.6 mm; p = 0.003). PAA is a common condition in long-standing PAH but its development is not necessarily related to PAH severity. Despite stabilization after treatment optimization, a progressive PA dilatation was observed.

Frequency, Predictors, and Prognostic Impact of Pulmonary Artery Aneurysms in Patients With Pulmonary Arterial Hypertension.

Detection of pulmonary artery aneurysms (PAA) in pulmonary arterial hypertension (PAH) is increasing. We sought to determine the frequency of PAA in a PAH cohort, variables related to its development and its prognostic impact. We conducted a retrospective analysis of PAH patients who underwent a computed tomography or magnetic resonance. PAA was defined as a pulmonary artery >40 mm. Baseline, echocardiographic, and hemodynamic findings at PAH diagnosis were compared. Freedom from death or lung transplant was estimated by Kaplan-Meier method and compared by log-rank test. Predictors of PAA development were analyzed with multivariate models. Two-hundred patients underwent a computed tomography and/or magnetic resonance. In 77 (38%), a PAA (48.3 ± 7.2 mm) was detected. Time-course (months) of PAH was an independent risk factor for PAA (hazard ratio 1.01; 95% confidence interval 1.002 to 1.019; p = 0.016) whilst connective tissue disease was associated with a lower risk (hazard ratio 0.236; 95% confidence interval 0.060 to 0.920; p = 0.037). PAA patients showed lower rates of death and lung transplant from PAH diagnosis (p = 0.005), but no differences appeared when survival analysis was performed from first imaging test (p = 0.269). PAA patients presented a nonsignificant higher rate of sudden death (5% PAA vs 1% no-PAA; p = 0.073). In conclusion, the frequency of PAA was 38%. PAH time-course was an independent risk factor for PAA development whereas connective tissue disease -related PAH patients showed a lower risk. PAA patients showed lower rates of death or lung transplant from PAH diagnosis but no differences were found from imaging test. PAA patients had a nonsignificant higher rate of sudden death.

Management of incidentally diagnosed pulmonary artery dissection in patients with pulmonary arterial hypertension.

Pulmonary artery dissection is a rare entity, usually discovered post-mortem. In recent years, reported cases of living patients with a pulmonary artery dissection are growing and represent a challenging situation for clinicians.

Infecciones en dispositivos de estimulación cardiaca: diagnóstico y tratamiento en un centro de referencia / Infections in cardiac implantable electronic devices: diagnosis and management in a referral center

Introducción y objetivos: Las infecciones en dispositivos de electroestimulación cardiaca son cada vez más frecuentes debido a las indicaciones cada vez más amplias de estos sistemas. Algunos aspectos sobre su tratamiento son controvertidos y aportamos aquí nuestra amplia experiencia. Métodos: Se atendieron 325 infecciones (196 locales y 129 sistémicas) durante los años 1985 a 2015, el 28,5% de ellas procedentes de otros centros: 229 marcapasos, 69 desfibriladores automáticos implantables y 27 pacientes con terapia de resincronización cardiaca, con un seguimiento mínimo de 1 año tras el alta hospitalaria. Resultados: La tracción percutánea (TPC) fue la técnica utilizada más frecuentemente (n = 280), en infecciones tanto locales (n = 166) como sistémicas (n = 114), con una tasas de extracción completa del sistema del 82,5% del total y de curación, del 89%; las complicaciones fueron escasas (2 muertes achacables a la técnica). La mortalidad total fue del 1% en infecciones locales y el 8% en las sistémicas. Tras 212 TPC completas, se reimplantó un nuevo sistema contralateral en 209: en 152 de ellas en el mismo acto (73%) y en 57 en un segundo tiempo; no se apreciaron diferencias en el número de recidivas en el nuevo sistema (2 en 1 tiempo y 1 en 2 tiempos). Conclusiones: La TPC en manos expertas arroja buenos resultados en términos de eficacia, con escasas complicaciones. Se puede realizar el reimplante de dispositivos en un solo tiempo sin que ello conlleve un mayor riesgo de recidiva (AU)

Introduction and objectives: Infections in cardiac implantable electronic devices are increasing due to the expansion of the indications of these devices. The management of some aspects is controversial. Here, we report our broad experience. Methods: Between 1985 and 2015, 325 infections (196 local and 129 systemic) were registered; 28.5% of them were referred from other centers: 229 pacemakers, 69 implantable cardioverter-defibrillators, and 27 patients with cardiac resynchronization therapy. The follow-up was at least 1 year after hospital discharge. Results: Percutaneous traction (PCT) was the most frequent procedure (n = 280) in local (n = 166) and systemic infections (n = 114), with complete extraction of the system in 82.5% of the patients, clinical success in 89%, and few complications (2 deaths attributable to the technique). Overall mortality was 1% in local infections and 8% in systemic infections. After 212 complete PCT, a new device was placed in 209: of these, a contralateral system was implanted in the same procedure in 152 (73%) and in a second procedure in 57, with no differences in relapses (2 in the 1-stage procedure, and 1 in the 2-stage procedure). Conclusions: Percutaneous traction in experienced hands has good results with very few complications. It is possible to perform contralateral implantation of the new device on the same day without increasing the risk of relapse (AU)

Infections in Cardiac Implantable Electronic Devices: Diagnosis and Management in a Referral Center.

INTRODUCTION AND OBJECTIVES: Infections in cardiac implantable electronic devices are increasing due to the expansion of the indications of these devices. The management of some aspects is controversial. Here, we report our broad experience. METHODS: Between 1985 and 2015, 325 infections (196 local and 129 systemic) were registered; 28.5% of them were referred from other centers: 229 pacemakers, 69 implantable cardioverter-defibrillators, and 27 patients with cardiac resynchronization therapy. The follow-up was at least 1 year after hospital discharge. RESULTS: Percutaneous traction (PCT) was the most frequent procedure (n=280) in local (n=166) and systemic infections (n=114), with complete extraction of the system in 82.5% of the patients, clinical success in 89%, and few complications (2 deaths attributable to the technique). Overall mortality was 1% in local infections and 8% in systemic infections. After 212 complete PCT, a new device was placed in 209: of these, a contralateral system was implanted in the same procedure in 152 (73%) and in a second procedure in 57, with no differences in relapses (2 in the 1-stage procedure, and 1 in the 2-stage procedure). CONCLUSIONS: Percutaneous traction in experienced hands has good results with very few complications. It is possible to perform contralateral implantation of the new device on the same day without increasing the risk of relapse.

[Splenic artery aneurysm. Report of a case]. / Aneurisma de arteria esplénica. A propósito de un caso.

BACKGROUND: The incidence of splenic artery aneurysm is not well known because they are often asymptomatic. CLINICAL CASE: The case is presented of a 40 year-old woman diagnosed with a splenic artery aneurysm. She was clinically asymptomatic. A three-dimensional angiographic study was performed. The artery embolisation was rejected, according to the results of the study; thus it was decided to perform a laparoscopic splenic-aneurysmectomy. CONCLUSIONS: Splenic artery aneurysms may present with non-specific symptoms, such as abdominal pain or anorexia. However 2-10% of aneurysms debut as spontaneous rupture. For this reason treatment is indicated in symptomatic aneurysms or those with rupture risk factors. In these cases there are different possibilities, such as therapeutic embolisation, endovascular stenting or surgery. Surgical approach varies depending on the location of the aneurysm in the splenic artery, enabling aneurysmectomy, splenic-aneurysmectomy, or aneurysm exclusion to be performed.

Factores predictores de resolución de la resistencia a la insulina con la cirugía de banda gástrica ajustable / Predictive factors of insulin resistance resolution with adjustable gastric band surgery

INTRODUCCIÓN: El objetivo del estudio ha sido evaluar factores preoperatorios relacionados con remisión de la diabetes y pérdida de peso tras cirugía de banda gástrica ajustable por vía laparoscópica. MATERIAL Y MÉTODOS: Se incluye una cohorte retrospectiva de 95 pacientes a los que se colocó banda gástrica ajustable. Se realizó un estudio preliminar descriptivo de factores pronósticos mediante el modelo de regresión logística con SPSS 17.0. Las variables independientes fueron edad, sexo, índice de masa corporal (IMC), estado de diabetes y grado de obesidad; las variables dependientes fueron proporción de peso perdido, variación del diabetes status score y porcentajes de variación en la glucemia basal y en la hemoglobina glucosilada. RESULTADOS: Las variables que presentaron relación estadísticamente significativa con los porcentajes de variación en la glucemia basal y en la hemoglobina glucosilada fueron: el grado de obesidad durante el primer año y el estado preoperatorio de diabetes respectivamente. El análisis de las necesidades de tratamiento antidiabético mediante el diabetes status score modificado señala al IMC preoperatorio, la edad y el sexo como factores predictores significativos. CONCLUSIONES: En pacientes intervenidos de cirugía con banda gástrica la pérdida de peso contribuye a mejorar la sensibilidad a insulina. Esta mejoría del metabolismo glucídico se ve influida por factores tales como el sexo, la edad, el tratamiento insulínico, el tiempo de evolución de la diabetes y el grado de obesidad preoperatorio

INTRODUCTION: The aim of the study was to evaluate preoperative factors associated with remission of diabetes and weight loss after laparoscopic gastric band surgery. MATERIAL AND METHODS: A retrospective cohort of 95 patients who had an adjustable gastric band placed were included. A preliminary descriptive study of prognostic factors was performed using the logistic regression model with SPSS 17.0. The independent variables were age, sex, body mass index (BMI), diabetes status and degree of obesity; dependent variables were the proportion of weight loss, change in diabetes status score and percent changes in fasting sugar and glycosylated hemoglobin. RESULTS: The variables that were significantly associated with the percentage of changes in fasting blood sugar and glycated hemoglobin were: the degree of obesity in the first year; preoperative and diabetes status respectively. The analysis of the need for antidiabetic treatment using the modified diabetes status score showed preoperative BMI, age and gender as significant predictors. CONCLUSIONS: In patients undergoing gastric band surgery, weight loss is the fundamental mechanism by which insulin sensitivity increases. This improvement in glucose metabolism is influenced by factors such as sex, age, insulin treatment, duration of diabetes and degree of preoperative obesity

Predictive factors of insulin resistance resolution with adjustable gastric band surgery.

INTRODUCTION: The aim of the study was to evaluate preoperative factors associated with remission of diabetes and weight loss after laparoscopic gastric band surgery. MATERIAL AND METHODS: A retrospective cohort of 95 patients who had an adjustable gastric band placed were included. A preliminary descriptive study of prognostic factors was performed using the logistic regression model with SPSS 17.0. The independent variables were age, sex, body mass index (BMI), diabetes status and degree of obesity; dependent variables were the proportion of weight loss, change in diabetes status score and percent changes in fasting sugar and glycosylated hemoglobin. RESULTS: The variables that were significantly associated with the percentage of changes in fasting blood sugar and glycated hemoglobin were: the degree of obesity in the first year; preoperative and diabetes status respectively. The analysis of the need for antidiabetic treatment using the modified diabetes status score showed preoperative BMI, age and gender as significant predictors. CONCLUSIONS: In patients undergoing gastric band surgery, weight loss is the fundamental mechanism by which insulin sensitivity increases. This improvement in glucose metabolism is influenced by factors such as sex, age, insulin treatment, duration of diabetes and degree of preoperative obesity.

New surgical approach of retrorectal cystic hamartoma using transanal minimally invasive surgery (TAMIS) / Nova abordagem cirúrgica do hamartoma cístico retrorretal usando cirurgia transanal minimamente invasiva (TAMIS)

Introduction: Tailgut cysts or cystic hamartomas are rare developmental tumors of the pre-sacral space. Their true incidence is not well known but we must think on it when we have a patient with a multicystic uncapsulated tumor at presacral space. Tailgut cysts are often asymptomatic, and in other cases present with chronic perineal pain, constipation or rectal tenesmus. They must be treated to avoid complications such as infections (perianal fistula or abscess) and malignant degenerations (usually adenocarcinoma). Case report: One patient with anal pain was diagnosed with a perianal abscess. He was operated but at the second month review a MRI revealed a multilocular lesion in the presacral suggesting the presence of a retrorectal cystic hamartoma. An elective operation was performed by endoanal surgical approach using TAMIS. En bloc resection of the cyst was achieved with safe margins. The pathology result reported retrorectal cystic hamartoma. The patient was asymptomatic with no signs of recurrence in subsequent controls. Our experience, despite being based on one case, is evidence that TAMIS (Transanal Minimally Invasive Surgery) allows a minimally invasive dissection with similar benefits as the use of TEM/TEO devices. (AU)

Introdução: Tail gut cysts ou hamartomas císticos são tumores raros de desenvolvimento do espaço pré-sacral. Sua verdadeira incidência não é bem conhecida, mas devemos pensarnele quando temos um paciente com um tumor uncapsulated multicística no espaço présacral. Hamartomas císticos são muitas vezes assintomáticas, em outros casos, apresentase com dor perineal crônica, constipação ou tenesmo retal. Eles devem ser tratados para evitar complicações, como infecções (fístula perianal ou abscesso) e degenerações malignas (geralmente adenocarcinoma). Relato de Caso: Um paciente com dor anal foi diagnosticado com um abscesso perianal. Ele foi operado, mas na revisão do segundo mês uma ressonância magnética revelou uma lesão multilocular no pré-sacral, sugerindo a presença de um hamartoma cístico retrorretal. Uma operação eletiva foi realizada por abordagem cirúrgica endoanal usando TAMIS. A resseção em bloco do cisto foi conseguido com margens seguras. O resultado do exame patológico relatou hamartoma cístico retrorretal. O paciente encontrava-se assintomático, sem sinais de recidiva em controles posteriores. A nossa experiência, apesar de ser baseado em um dos casos, as provas que TAMIS (cirurgia transanal minimamente invasiva) permite um esvaziamento minimamente invasivo com benefícios similares como o uso de dispositivos de MET/TEO. (AU)

Tumores neuroendocrinos / No disponible

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Evaluación del entrenamiento de residentes en cirugía laparoscópica en el laboratorio basado en un modelo de anastomosis digestivas / Assessment of resident training in laparoscopic surgery based on a digestive system anastomosis model in the laboratory

IntroducciónLa complejidad de la cirugía laparoscópica hace necesario un entrenamiento específico fuera del quirófano para acortar la curva de aprendizaje y reducir la morbilidad. El objetivo del estudio es analizar la progresión en habilidades laparoscópicas tras un programa de entrenamiento en laboratorio.Material y métodosEstudio prospectivo de un programa de entrenamiento de residentes de 4 semanas anuales (20 h semanales) basado en anastomosis en endotrainer, realizado entre 2004 y 2007. Los parámetros principales fueron tiempo y número de anastomosis necesarias hasta llegar a una correcta ejecución. Una vez completada, la anastomosis se revisó conjuntamente mediante un residente y un monitor. Se registraron tiempo de ejecución y fallos anastomóticos (sutura floja, eversión de bordes y fuga).ResultadosDoce residentes realizaron 189 anastomosis yeyunoyeyunales (AYY) (media: 15,8) y 197 anastomosis gastroyeyunales (AGY) (media: 16,4). El tiempo medio de las AYY fue de 72,7min y el de las AGY fue de 87,2min. Se observó una gran reducción en el tiempo de ejecución desde el comienzo al final del programa. El porcentaje de anastomosis incorrectas disminuyó en función del tiempo de entrenamiento: el 26,6; el 21,8; el 17,1; el 17; el 16,1 y el 10,5% después de 20; 40; 60; 80; 100 y 120h, respectivamente. Considerando la reducción, tanto en tiempo de ejecución como en el índice de anastomosis incorrectas, después de 70h de entrenamiento la curva de aprendizaje alcanzaba una meseta.ConclusionesEl entrenamiento en endotrainer basado en anastomosis intestinales (tanto AYY o AGY) constituye un método útil de entrenamiento laparoscópico. Después de un entrenamiento de 70h se aprecia poca progresión (AU)

BackgroundThe complexity of laparoscopic surgery makes specific training out of the operating rooms necessary to shorten learning curves and to minimise morbidity rates. Our aim was to analyse the increase in laparoscopic skills after completion of a laboratory training program.Material and methodsProspective study of surgical resident training based on anastomosis performance on an “endotrainer”. The program consisted of 4 weeks per year (20h per week) between 2004 and 2007. The outcome measures were the time and number of anastomosis necessary to perform a proper anastomosis. Upon completion, the anastomosis was checked by both trainee and evaluator and quality was assessed. Time and technical failures (loose suture, edge eversion, leakage) were recorded.ResultsTwelve surgical residents were trained. They performed 189 jejuno-jejunal anastomoses (JJA), mean 15.8 per resident and 197 gastro-jejunal anastomoses (GJA), mean 16.4 per resident. The performance mean time was 72.7min for JJA and 87.2 for GJA. There was a marked reduction in time from the beginning to completion of training. The percentage of flawed anastomosis decreased with training: 26.6%, 21.8%, 17.1%, 17%, 16.1% and 10.5% after 20, 40, 60, 80, 100 and 120h, respectively. Bearing in mind reduction in both performance time and flawed anastomosis rate, it appears that after 70h of training the learning curve reaches a plateau zone.ConclusionsIntestinal anastomosis (either JJA or GJA) performed in “endotrainer” is a suitable model for laparoscopic training, without the need of live animals. After a training period of 70 hours, the improvement seems of little benefit (AU)

[Assessment of resident training in laparoscopic surgery based on a digestive system anastomosis model in the laboratory]. / Evaluación del entrenamiento de residentes en cirugía laparoscópica en el laboratorio basado en un modelo de anastomosis digestivas.

BACKGROUND: The complexity of laparoscopic surgery makes specific training out of the operating rooms necessary to shorten learning curves and to minimise morbidity rates. Our aim was to analyse the increase in laparoscopic skills after completion of a laboratory training program. MATERIAL AND METHODS: Prospective study of surgical resident training based on anastomosis performance on an "endotrainer". The program consisted of 4 weeks per year (20h per week) between 2004 and 2007. The outcome measures were the time and number of anastomosis necessary to perform a proper anastomosis. Upon completion, the anastomosis was checked by both trainee and evaluator and quality was assessed. Time and technical failures (loose suture, edge eversion, leakage) were recorded. RESULTS: Twelve surgical residents were trained. They performed 189 jejuno-jejunal anastomoses (JJA), mean 15.8 per resident and 197 gastro-jejunal anastomoses (GJA), mean 16.4 per resident. The performance mean time was 72.7 min for JJA and 87.2 for GJA. There was a marked reduction in time from the beginning to completion of training. The percentage of flawed anastomosis decreased with training: 26.6%, 21.8%, 17.1%, 17%, 16.1% and 10.5% after 20, 40, 60, 80, 100 and 120 h, respectively. Bearing in mind reduction in both performance time and flawed anastomosis rate, it appears that after 70 h of training the learning curve reaches a plateau zone. CONCLUSIONS: Intestinal anastomosis (either JJA or GJA) performed in "endotrainer" is a suitable model for laparoscopic training, without the need of live animals. After a training period of 70 hours, the improvement seems of little benefit.

Endocarditis por enterococo: análisis multicéntrico de 76 casos / Enterococcal endocarditis: A multicenter study of 76 cases

Aunque los enterococos ocupan el tercer lugar entre los microorganismos que más frecuentemente provocan endocarditis infecciosa (EI), tras los estreptococos y Staphylococcus aureus, hay pocos estudios multicéntricos que proporcionen un análisis en profundidad de la EI enterocócica. Métodos Descripción de las características de los 76 casos de endocarditis infecciosa izquierda (EII) enterocócica (59 nativas y 17 protésicas) de la base de datos del Grupo para el Estudio de las Infecciones Cardiovasculares de la Sociedad Andaluza de Enfermedades Infecciosas. Además, se hace hincapié en la comparación con la EII no enterocócica. Resultados El enterococo fue el causante de 76 de 696 episodios de EII (11%). Comparada con la EII no enterocócica, la EII enterocócica fue más frecuentemente observada en pacientes mayores de 65 años (el 47,4 frente al 27,6%; p<0,0005), con enfermedades crónicas (el 75 frente al 54,6%; p<0,001), válvulas calcificadas (el 18,6 frente al 10%; p<0,05), foco infeccioso previo urinario (el 30,3 frente al 2,1%; p<0,00001) o abdominal (el 10,5 frente al 3,1%; p<0,01) y produjo una mayor tasa de recidivas (el 6,6 frente al 2,3%; p<0,05). La EII enterocócica produjo menos manifestaciones cutáneas o vasculares periféricas (el 14,5 frente al 27,1%; p<0,05) y menos fenómenos inmunológicos (el 10,5 frente al 24%; p<0,01). Un 36,8% de los pacientes con EII enterocócica fueron sometidos a cirugía valvular durante el ingreso. La mortalidad durante el ingreso hospitalario de los pacientes con EII enterocócica fue del 32,9%, de los pacientes con EII por estreptococos del grupo viridans (EGV) fue del 9,3% y de los pacientes con S. aureus fue del 48,6% (enterococo frente a EGV: p<0,0001; enterococo frente a S. aureus: p=0,02). Los pacientes con EII enterocócica tratados con la combinación de una penicilina (..) (AU)

Although enterococci occupy the third position among microorganisms producing infectious endocarditis (IE) following streptococci and Staphylococcus aureus, few multicenter studies have provided an in-depth analysis of enterococcal IE. Methods Description of the characteristics of 76 cases of enterococcal left-sided infectious endocarditis (LSIE) (native: 59, prosthetic: 17) retrieved from the database of the Cardiovascular Infections Study Group of the Andalusian Society of Infectious Diseases, with emphasis on the comparison with non-enterococcal LSIE. Results Enterococci were the causal agent in 76 of the 696 episodes of LSIE (11%). Compared with non-enterococcal LSIE, enterococcal LSIE was more commonly seen in patients older than 65 (47.4% vs. 27.6%, P<0.0005), and those with chronic diseases (75% vs. 54.6%, P<0.001), calcified valves (18.6% vs. 10%, P<0.05), and previous urinary (30.3% vs. 2.1%, P<0.00001) or abdominal (10.5% vs. 3.1%, P<0.01) infections, and produced a higher rate of relapses (6.6% vs. 2.3%, P<0.05). Enterococcal LSIE was associated with fewer peripheral vascular or skin manifestations (14.5% vs. 27.1%, P<0.05) and fewer immunological phenomena (10.5% vs. 24%, P<0.01). Among the total of patients with enterococcal LSIE, 36.8% underwent valve surgery during hospitalization. In-hospital mortality was 32.9% for enterococcal LSIE, 9.3% for viridans group streptococci (VGS) LSIE and 48.6% for S. aureus LSIE (enterococci vs VGS: P<0.0001; enterococci (..) (AU)

[Enterococcal endocarditis: a multicenter study of 76 cases]. / Endocarditis por enterococo: análisis multicéntrico de 76 casos.

BACKGROUND: Although enterococci occupy the third position among microorganisms producing infectious endocarditis (IE) following streptococci and Staphylococcus aureus, few multicenter studies have provided an in-depth analysis of enterococcal IE. METHODS: Description of the characteristics of 76 cases of enterococcal left-sided infectious endocarditis (LSIE) (native: 59, prosthetic: 17) retrieved from the database of the Cardiovascular Infections Study Group of the Andalusian Society of Infectious Diseases, with emphasis on the comparison with non-enterococcal LSIE. RESULTS: Enterococci were the causal agent in 76 of the 696 episodes of LSIE (11%). Compared with non-enterococcal LSIE, enterococcal LSIE was more commonly seen in patients older than 65 (47.4% vs. 27.6%, P<0.0005), and those with chronic diseases (75% vs. 54.6%, P<0.001), calcified valves (18.6% vs. 10%, P<0.05), and previous urinary (30.3% vs. 2.1%, P<0.00001) or abdominal (10.5% vs. 3.1%, P<0.01) infections, and produced a higher rate of relapses (6.6% vs. 2.3%, P<0.05). Enterococcal LSIE was associated with fewer peripheral vascular or skin manifestations (14.5% vs. 27.1%, P<0.05) and fewer immunological phenomena (10.5% vs. 24%, P<0.01). Among the total of patients with enterococcal LSIE, 36.8% underwent valve surgery during hospitalization. In-hospital mortality was 32.9% for enterococcal LSIE, 9.3% for viridans group streptococci (VGS) LSIE and 48.6% for S. aureus LSIE (enterococci vs VGS: P<0.0001; enterococci vs S. aureus: P=0.02). Enterococcal LSIE patients treated with the combination of a penicillin or vancomycin plus an aminoglycoside (n=60) and those treated with ampicillin plus ceftriaxone (n=6) showed similar in-hospital mortality (26.7% vs 33.3%, P=0.66). High-level resistance to gentamicin was detected in 5 of 38 episodes of enterococcal LSIE (13.1%). CONCLUSIONS: Enterococcal LSIE appears in patients with well-defined clinical characteristics, and causes few peripheral vascular or skin manifestations and few immunological phenomena. The relapse rate is higher than in non-enterococcal LSIE. Mortality due to enterococcal LSIE is lower than that of S. aureus LSIE, and much higher than that of VGS LSIE. Mortality due to enterococcal LSIE is similar in patients treated with ampicillin plus ceftriaxone or with a combination of penicillin or vancomycin plus an aminoglycoside. High-level resistance to gentamicin remains uncommon in enterococci causing LSIE.

[Surgical resident training program in minimally invasive surgery experimental laboratory (CENDOS)]. / Programa de formación del residente de cirugía en un laboratorio experimental de cirugía minimamente invasiva (CENDOS).

INTRODUCTION: The rapid development of laparoscopic surgery makes resident training programmes necessary. OBJECTIVE: To analyse the results of a structured programme of laparoscopic training in an experimental laboratory. MATERIAL AND METHOD: From 2003 until 2007, we trained 11 general surgery residents for 20 h every 3 months, for three years. The practice consisted of suture and anastomosis in Endo-Trainer with animal organs, as well as laparoscopic techniques in live animals. In the Endo-Trainer practice we evaluated the time and quality of anastomosis performance. In laparoscopic techniques (cholecystectomy and anti-reflux surgery) a task table was evaluated, from 0 (no errors) to 100 (severe lesion). RESULTS: In total, 314 anastomosis were performed by the 11 residents, with a median of 28.5 per resident (24-42). The mean time for the first gastro-jejunal anastomosis was 135 min (100-140) and 65 min (57.5-105) for the first jejunal-jejunal anastomosis. Maximum learning was achieved after 45 training hours. There were no appreciable differences between both types of anastomosis. There was inadequate anastomosis quality due to leakage in 17.1% during the learning period and 13.7% during the consolidation period. In the animal, 172 procedures were performed. In cholecystectomy and anti-reflux surgery the mean scores were 2.4 and 5.6 points, respectively. In the remaining procedures, subjectively evaluated by the monitors, the quality was adequate in 65%, deficient in 22% and highly deficient in 13%. CONCLUSIONS: This structured programme of laparoscopic skills based on intestinal anastomosis allows for quicker resident training.