Degree of adherence to recommended antiviral treatment during the pandemic and post-pandemic periods of influenza A(H1N1)pdm09 in 148 intensive care units in Spain.

OBJECTIVE: To determine the degree of antiviral treatment recommendations adherence and its impact to critical ill patients affected by influenza A(H1N1)pdm09 mortality. DESIGN: Secondary analysis of prospective study. SETTING: Intensive care (UCI). PATIENTS: Patients with influenza A(H1N1)pdm09 in the 2009 pandemic and 2010-11 post-Pandemic periods. VARIABLES: Adherence to recommendations was classified as: Total (AT); partial in doses (PD); partial in time (PT), and non-adherence (NA). Viral pneumonia, obesity and mechanical ventilation were considered severity criteria for the administration of high antiviral dose. The analysis was performed using t-test or «chi¼ square. Survival analysis was performed and adjusted by Cox regression analysis. RESULTS: A total of 1,058 patients, 661 (62.5%) included in the pandemic and 397 (37.5%) in post-pandemic period respectively. Global adherence was achieved in 41.6% (43.9% and 38.0%; P=.07 respectively). Severity criteria were similar in both periods (68.5% vs. 62.8%; P=.06). The AT was 54.7% in pandemic and 36.4% in post-pandemic period respectively (P<.01). The NA (19.7% vs. 11.3%; P<.05) and PT (20.8% vs. 9.9%, P<.01) was more frequent in the post-pandemic period. The mortality rate was higher in the post-pandemic period (30% vs. 21.8%, P<.001). APACHE II (HR=1.09) and hematologic disease (HR=2.2) were associated with a higher mortality and adherence (HR=0.47) was a protective factor. CONCLUSIONS: A low degree of adherence to the antiviral treatment was observed in both periods. Adherence to antiviral treatment recommendations was associated with lower mortality rates and should be recommended in critically ill patients with suspected influenza A(H1N1)pdm09.

Epidemiological study of Clostridium difficile infection in critical patients admitted to the Intensive Care Unit.

UNLABELLED: Data on the epidemiology of infections caused by Clostridium difficile (CDI) in critically ill patients are scarce and center on studies with a limited time framework and/or epidemic outbreaks. OBJECTIVE: To describe the characteristics and risk factors of critically ill patients admitted to the ICU with CDI, as well as the treatments used for the control of such infections. MATERIAL AND METHODS: A retrospective study was made of patients included in the ENVIN-ICU registry with CDI in 2012. Patients were followed up to 72 h after discharge from the ICU. A case report form was used to record the following data: demographic variables, risk factors related to CDI, treatment and outcome. Infections were classified as community-acquired, nosocomial out-ICU and nosocomial in-ICU, according to the day on which Clostridium difficile isolates were obtained. Infection rates as episodes per 10,000 days of ICU stay are presented. The global in-ICU and hospital mortality rates were calculated. RESULTS: Sixty-eight episodes of CDI in 33 out of a total of 173 ICUs participating in the registry were recorded (19.1%) (2.1 episodes per 10,000 days of ICU stay). Forty-five patients were men (66.2%), with a mean (SD) age of 63.4 (16.4) years, a mean APACHE II score on ICU admission of 19.9 (7.4), and an underlying medical condition in 44 (64.7%). Sixty-two patients (91.2%) presented more than 3 liquid depositions/day, 40 (58.8%) in association with severe sepsis or septic shock. Community-acquired infection occurred in 13 patients (19.1%), nosocomial out-ICU infection in 13 (19.1%), and in-ICU infection in 42 (61.8%). Risk factors included age>64 years in 39 cases (57.4%), previous hospital admission (3 months) in 32 (45.6%), use of antimicrobials (previous 7 days) in 57 (83.8%), enteral nutrition in 23 (33.8%), and the use of H2 inhibitors in 39 (57.4%). Initial combined treatment was administered to 18 patients (26.5%). Metronidazole was used in 60 (88.2%) and vancomycin in 31 (45.6%). The in-ICU mortality rate was 25.0% (n=17), with a hospital mortality 27.9% (n=19). CONCLUSIONS: The rate of ICD in ICU patients is low, the infection affects severely ill patients, and is associated with high mortality. The presence of CDI is a marker of poor prognosis.

Antibiotic prescribing for discoloured sputum in acute cough/lower respiratory tract infection.

We investigated whether discoloured sputum and feeling unwell were associated with antibiotic prescription and benefit from antibiotic treatment for acute cough/lower respiratory tract infection (LTRI) in a prospective study of 3,402 adults in 13 countries. A two-level model investigated the association between producing discoloured sputum or feeling generally unwell and an antibiotic prescription. A three-level model investigated the association between an antibiotic prescription and symptom resolution. Patients producing discoloured sputum were prescribed antibiotics more frequently than those not producing sputum (OR 3.2, 95% CI 2.1-5.0), unlike those producing clear/white sputum (OR 0.95, 95% CI 0.61-1.48). Antibiotic prescription was not associated with a greater rate or magnitude of symptom score resolution (as measured by a 13-item questionnaire completed by patients each day) among those who: produced yellow (coefficient 0.00; p = 0.68) or green (coefficient -0.01; p = 0.11) sputum; reported any of three categories of feeling unwell; or produced discoloured sputum and felt generally unwell (coefficient -0.01; p = 0.19). Adults with acute cough/LRTI presenting in primary care settings with discoloured sputum were prescribed antibiotics more often compared to those not producing sputum. Sputum colour, alone or together with feeling generally unwell, was not associated with recovery or benefit from antibiotic treatment.

[Study on the clinicopathological correlation in the secondary acute respiratory distress syndrome]. / Estudio sobre la correlación clínico-patológica en el síndrome de distrés respiratorio agudo secundario.

OBJECTIVE: This study has aimed to study the clinicopathological correlation of patients with secondary acute respiratory distress syndrome (ARDS), specifically having extrapulmonary causes. SETTING: A 22 beds intensive care unit. DESIGN: An observational study of case series. PATIENTS: Seventeen patients whose death was caused by acute respiratory distress syndrome were included. INTERVENTION: A systematic histopathological study was made of all the pulmonary lobes of patients who died in our ICU with the clinical diagnosis of secondary ARDS, who had undergone an autopsy between 1999 and 2009. The Kappa analysis was used to analyze the grade of correlation between the clinical and the pathological diagnosis. RESULTS: The autopsy confirmed to cases of false positive in 17 patients with ARDS (11%). The kappa value was 0.77, so that the concordance analysis was considered to be satisfactory. CONCLUSIONS: The clinical criteria for ARDS correlate well with acute alveolar damage (AAD) in the autopsy study in patients with secondary ARDS, although some false positive cases can be observed.

Inhaled drugs as risk factors for community-acquired pneumonia.

The effect of inhaled drugs in community-acquired pneumonia (CAP) is unclear. This case-control study was designed to determine whether inhaled drugs were risk factors for CAP. All incident cases of confirmed CAP that occurred over 1 yr in patients with chronic bronchitis (CB), chronic obstructive pulmonary disease (COPD) or asthma were included, as well as CB, COPD and asthma controls. Risk factors for CAP and inhaled treatment were recorded during a personal interview. An effect of inhaled drugs on the risk of CAP was observed in COPD and asthma patients after adjusting for the effect of other respiratory diseases and their concomitant treatments. In COPD patients, inhaled steroids had a risk OR of 3.26 (95% CI 1.07-9.98) and in asthma patients inhaled anticholinergics had a risk OR of 8.80 (95% CI 1.02-75.7). In CB patients, no association with CAP was observed for any inhaler. These effects were independent of adjusting variables related to severity and other respiratory and non-respiratory risk factors for CAP, including vaccines. Inhaled ß(2)-adrenergic agonists did not show a significant effect on the risk of CAP in any of the respiratory diseases. Inhaled steroids may favour CAP in COPD patients, whereas anticholinergics may favour CAP in asthma patients. It is difficult to differentiate the effect of inhaled therapy from the effect of COPD or asthma severity on the risk of CAP, and these relationships may not be causal, but could call attention to inhaled therapy in COPD and asthma patients.

New evidence of risk factors for community-acquired pneumonia: a population-based study.

The aim of the present study was to identify risk factors for community-acquired pneumonia (CAP), with special emphasis on modifiable risk factors and those applicable to the general population. A population-based, case-control study was conducted, with a target population of 859,033 inhabitants aged >14 yrs. A total of 1,336 patients with confirmed CAP were matched to control subjects by age, sex and primary centre over 1 yr. In the univariate analysis, outstanding risk factors were passive smoking in never-smokers aged >65 yrs, heavy alcohol intake, contact with pets, households with >10 people, contact with children, interventions on the upper airways and poor dental health. Risky treatments included amiodarone, N-acetylcysteine and oral steroids. Influenza and pneumococcal vaccine, and visiting the dentist were protective factors. Multivariable analysis confirmed cigarette smoking, usual contact with children, sudden changes of temperature at work, inhalation therapy (particularly containing steroids and using plastic pear-spacers), oxygen therapy, asthma and chronic bronchitis as independent risk factors. Interventions for reducing community-acquired pneumonia should integrate health habits and lifestyle factors related to household, work and community, together with individual clinical conditions, comorbidities and oral or inhaled regular treatments. Prevention would include vaccination, dental hygiene and avoidance of upper respiratory colonisation.

Laser induced breakdown spectroscopy as a tool for discrimination of glass for forensic applications.

Materials analysis and characterization can provide important information as evidence in legal proceedings. The potential of laser induced breakdown spectroscopy (LIBS) for the discrimination of glass fragments for forensic applications is presented here. The proposed method is based on the fact that glass materials can be characterized by their unique spectral fingerprint. Taking advantage of the multielement detection capability and minimal to no sample preparation of LIBS, we compared glass spectra from car windows using linear and rank correlation methods. Linear correlation combined with the use of a spectral mask, which eliminates some high-intensity emission lines from the major elements present in glass, provides effective identification and discrimination at a 95% confidence level.

[Calcific uraemic arteriolopathy (calciphylaxis): incidence, clinical features and long term outcomes]. / Arteriolopatía urémica calcificante (calcifilaxis): incidencia, formas de presentación y evolución.

UNLABELLED: Calcific uraemic arteriolopathy, also named calciphylaxis, is a rare but serious disorder characterized by medial mural calcification of small vessel leading to tissue ischaemia. It most commonly occurs in end stage renal disease patients on dialysis or recently received renal transplant with chronic nephropathy allograft. The pathogenesis of calciphylaxis is poorly understood. Abnormalities in mineral metabolism are clearly involved, but the specific factors that induces this disorder are not completely known. OBJECTIVES: Describe the main clinical features, outcomes and follow up of all calciphylaxis cases recorded in our dialysis unit in order to analyse the incidence, the main biologic parameters and the therapeutic background in which calciphylaxis appeared. MATERIAL AND METHODS: We performed a descriptive study about all the calciphylaxis cases diagnosed at our dialysis unit between the years 1991 and 2005. RESULTS: 8 cases, 6 women. Mean age: 65.3 years. All the patients were on haemodialysis treatment (one previous renal transplant). Mean time on dialysis was 76.6 months. Cumulative incidence was 1.17%. The principal end stage renal disease aethiology was neprhoangioeslerosis in four patients. Secondary hiperparatyrhoidism was present in 4 patients and 2 of them had been paratyrhoidectomized previously. A second cutaneous biopsy was needed for correct diagnosis in 3 patients. Calciphylaxis distal lesions were present in 7 patients. Two cases required urgent paratyrhoidectomy in order to control calciphylaxis. Only in 2 cases a Ca x P product > 60 mg/dL was present and 3 cases had PTHi values higher than 300 pg/mL. Calcium phosphate binders and vitamin D were present in 2 and 4 cases, respectively. One patient with proximal calciphylaxis died due to skin injury infection. CONCLUSIONS: Calciphylaxis is a rare disorder but not exceptional, related to end stage renal disease patients. The diagnosis requires a high clinical suspicion, being sometimes difficult to distinguish from other entities in spite of pathological study. Proximal distribution of calciphylaxis had worst prognostic. Metabolic disorders and therapeutics background were not different from other patients included in dialysis treatment.

[Choosing not to dialysis in chronic renal failure in stage V (Renal Failure). Evolution of the characteristics of patients between 1992-1995 and 2000-2003]. / Elección de no diálisis en insuficiencia renal crónica en estadio V (fallo renal). Evolución de las características de los pacientes entre 1992-1995 y 2000-2003.

BACKGROUND: The incidence of chronic renal failure increase with the age. The selection of patient to dialysis has been increasing in spite of the high comorbidity. Moreover, in our clinical practice the aged patient is not contraindicated to dialysis. However, in the nephrology clinical practice not all the patients start the treatment with dialysis. OBJECTIVE The aim of our study has been to compare the characteristics of the patients who had not been dialyzed between the periods 1992-1995 and 2000-2003 to analyze the trend of the nephrology clinical practice. MATERIAL AND METHODS: Comparative study of the characteristics and the evolution of patients with chronic renal failure in stage V, (renal failure) not incorporated to dialysis in one hospital during four years between the periods the 1992-1995 ( period A) and 2000-2003 (period B). RESULTS: Start dialysis (period A versus period B): 116 patients, age 59.9+15.5 years vs. 229 patients, age 64.0+15.8 years (p<0.05). Non-dialysis (period A versus period B): 38 patients, age 77.5+9.3 years vs. 37 patients, age 81.7+6.2 years (p<0.01). Renal function: serum creatinina 7.4+2.4 mg/dl vs. 5.3+1.2 mg/dl (p<0.001), MDRD estimate glomerular filtration 6.9+2.4 mg/dl ml/min/1.73 m2 vs. 10.0+2.3 ml/min/1.73 m2 (p<0.001). Primary renal disease: unknown etiology 31.5 % vs. 24.3 %, nephroangiosclerosis 23.6 % vs. 32.4 %, diabetes 28.9 % vs. 21.6 %. Functional status: dependent patients 34.2 % vs 83.8 % (p<0.001). The principal reason for non-dialysis were: personal decision: 26.3 % vs. 35.1 %, dementia 15.8 % vs. 29.7 %, brief life expectancy because of serious co-existing diseases 13.1 % vs. 21.7 % and serious chronic illness with inability for themselves care 44.7 % vs. 13.1 %. Comorbid conditions: 2.3+1.0 vs. 3.0+1.5 (p<0.05). Survival: 55+168 days vs. 168+236 days (p<0.001). CONCLUSION: Most of the patients that don't begin dialysis are elderly together with a poor functional capacity and with more autonomy in their decisions. The identification of patients with renal failure (stage V) was detected early in the last period than in the following one. The conservative management of non-dialyzed uremic patients is a significative nephrology clinical practice due to more survival of those persons.

[Secondary amyloidosis (AA-type) due to localized cutaneous vasculitis]. / Amiloidosis secundaria asociada a vasculitis cutánea localizada.

We report a case of a 49 year old man, diagnosed soon after the outcome of casual proteinuria, of AA-type amyloidosis in relation to small and medium vessel cutaneous vasculitis without systemic involvement. This combination is a rare entity and only two cases of cutaneous hypersensibility vasculitis complicated with AA-type amyloidosis had been reported. We describe the results of the use of several immunosuppressive drugs during four years follow up with temporally total remission of the disease.

[Allopurinol-induced chronic granulomatous interstitial nephritis]. / Nefritis intersticial granulomatosa cronica por alopurinol.

Although drug induced interstitial nephritis is a relatively common cause of renal failure,granulomatous forms remain a rare condition. The development of a chronic granulomatous interstitial nephritis due to allopurinol is exceptional, only three cases have been described previously. We report on a patient who presented a granulomatous interstitial nephritis after 10 years of allopurinol administration (300 mg/day). At diagnosis, he had end stage renal disease and dialysis treatment was needed. Two months after drug withdrawal and on corticoid treatment a slow recovery of renal function was observed, allowing the interruption of dialysis. Two years after, the creatinine clearance is 23 ml/min,being dialysis free. We discuss the differential diagnosis of granulomatous interstitial nephritis and its rare association with allopurinol treatment.

[Helicobacter pylori does not contribute to iron deficiency in hemodialysis patients]. / Helicobacter pylori no contribuye al déficit de hierro de los pacientes en hemodiálisis.

BACKGROUND: Many studies in the general population have shown a link between Helicobacter pylori infection and iron-deficiency, often resulting in iron-deficient anaemia. Despite the high prevalence of iron deficiency in hemodialysis patients, no studies have been performed in this population. OBJECTIVE: To evaluate the role of Helicobacter pylori infection in the appearance of anemia and the iron requirements in our hemodialysis population. MATERIAL AND METHODS: After excluding patients with severe pathology and short life expectancy and those with blood losses secondary to other causes, 79 patients were included.Iron requirements and anaemia were determined by iron serum, ferritin, and hematocrit values; and by transfusion, eritropoietin and iron requirements. The diagnosis of Helicobacter pylori status was established by the concordance of at least two of the three non invasive diagnostic methods performed (breath test, serology and fecal antigen of Helicobacter pylori). RESULTS: Prevalence of Helicobacter pylori infection was 43%. No significant differences between patients infected or not by Helicobacter pylori were found in any of the variables analysed: hematocrit (33.5% versus 34.1%), serum iron (58.9 versus 63.7 pg/dl), ferritin(340.3 versus 264.2 ng/ml), transferrin saturation index (22.5% versus 25.2%), dose of eritropoietin administered (96.6 versus 93.5 U/kg/weekly), and parenteral iron (1,389 versus 1,538 mg/year). A noteworthy finding was that patients with Helicobacter pylori infection had been on hemodialysis for a shorter period than those without (37.4 versus 63.7 months,p = 0.04). CONCLUSION: Helicobacter pylori infection has no effect on anaemia (hematocrit, Eritropoietin dose or iron needs) in our hemodialysis patients. Prevalence of Helicobacter pylori is lower in patients with longer time on dialysis. We consider that the diagnosis of Helicobacter pylori infection must be reserved for clinical peptic ulcer suspicion or patients on transplant waiting list.

[Renal involvement in amyloidosis. Clinical outcomes, evolution and survival]. / Afectación renal en la amiloidosis. Características clínicas, evolución y supervivencia.

BACKGROUND: Systemic amyloidosis is a disease resulting from extracellular deposition of fibrillar protein in various organs. Main systemic amyloidosis are: primary (AL) and Secondary (AA). The kidney is usually involved, conferring and adverse prognosis. In the last decade there has been a change in the aetiology of AA amyloidosis. OBJECTIVES: To analyse the incidence of AL and AA amyloidosis in our current population as well as the aetiology of AA amyloidosis. To describe clinical outcomes, renal involvement and survival. PATIENTS AND METHODS: We performed a descriptive analysis of all cases of amyloidosis diagnosed from 1992 to 2004 in our hospital. Diagnosis was assessed on histological criteria: positivity Congo Red stain. Clinical data, renal involvement, dialysis treatment and survival were analysed. RESULTS: 76 cases, 44 women, mean age 70.7 +/- 12. Types: 55 AA (72%), 21 AL (28%) systemic amyloidosis. AA aetiology was: 66% rheumatic disorders, 28% infectious disease, 6% others. Incidence for AL was 4.6 and for AA 12.2 cases/million. Renal involvement was present in 75% at diagnosis (69% Creatinine clearance < 60 ml/min, 37% urinary protein > 3 g/24 hours). 21 cases (28%) progressed to renal disease stage V in the 8.1 +/- 9.8 months follow up period, and 14 cases started dialysis treatment (10 HD, 4 CAPD). In 7 cases (33%) dialysis was not indicated due to their poor clinical condition, short life expectancy and bad quality of life. Mean global survival at diagnosis was 55% and 40% at 12 and 24 months (AL 58% and 19%; AA 55% and 44%). Mean survival from the start of dialysis was 30% and 5% at 12 and 24 months. CONCLUSIONS: Although amyloidosis has a low incidence in our population, the kidney is usually involved. Rheumatological disorders are the principal aetiology of AA amyloidosis. Long term survival is poor, specially for AL.

Antibiotic prescription for community-acquired pneumonia in the intensive care unit: impact of adherence to Infectious Diseases Society of America guidelines on survival.

BACKGROUND: The purpose of our study was to analyze prognostic factors associated with mortality for patients with severe community-acquired pneumonia (CAP). METHODS: We conducted a prospective multicenter study including all patients with CAP admitted to the intensive care unit during a 15-month period in 33 Spanish hospitals. Admission data and data on the evolution of the disease were recorded. Multivariate analysis was performed using the SPSS statistical package (SPSS). RESULTS: A total of 529 patients with severe CAP were enrolled; the mean age (+/-SD) was 59.9+/-16.1 years, and the mean Acute Physiology and Chronic Health Evaluation (APACHE) II score (+/-SD) was 18.9+/-7.4. Overall mortality among patients in the intensive case unit was 27.9% (148 patients). The rate of adherence to Infectious Diseases Society of America (IDSA) guidelines was 57.8%. Significantly higher mortality was documented among patients with nonadherence to treatment (33.2% vs. 24.2%). Multivariate analysis identified age (odds ratio [OR], 1.7), APACHE II score (OR, 4.1), nonadherence to IDSA guidelines (OR, 1.6), and immunocompromise (OR, 1.9) as the variables present at admission to the intensive care unit that were independently associated with death in the intensive care unit. In 15 (75%) of 20 cases of Pseudomonas aeruginosa infection, the antimicrobial treatment at admission was inadequate (including 8 of 15 cases involving patients with adherence to IDSA guidelines). Chronic obstructive pulmonary disease (OR, 17.9), malignancy (OR, 11.0), previous antibiotic exposure (OR, 6.2), and radiographic findings demonstrating rapid spread of disease (OR, 3.9) were associated with P. aeruginosa pneumonia. CONCLUSIONS: Better adherence to IDSA guidelines would help to improve survival among patients with severe CAP. Pseudomonas coverage should be considered for patients with chronic obstructive pulmonary disease, malignancy, or recent antibiotic exposure.

[Prevalence of chronic kidney disease in community-dwelling elderly and associated cardiovascular risk factors]. / Prevalencia de la insuficiencia renal en la población general mayor de 64 años y episodios cardio-vasculares asociados.

BACKGROUND: Chronic kidney disease is a major public health problem in developed countries. The incidence of patients on dialysis is increasing progressively in the last years. The ageing population and increasing incidence of diabetes and hypertension are the main causes. Moreover, the level of kidney function is now recognised as a major risk factor for cardiovascular disease, even in mild cases. There is a great unaware about the prevalence of mild to moderate chronic kidney disease in the general population. The aim of the present study was to know the kidney function level in our general population over 64 years old, and the associated cardiovascular risk. METHODS: This is an epidemiological descriptive cross-sectional study, obtained by a representative random sampling of the population over 64 years living in the reference area of our Hospital. The glomerular filtration rate was estimated by the Cockroft-Gault formula and the MDRD equations. Kidney function has been classified by the K/DOQI stages. We examined the univariate and multivariate association between the estimated glomerular filtration rate and the presence of cardiovascular events. RESULTS: We analysed 253 subjects aged 65 to 93 years (mean 72 +/- 5.4). Present comorbidities were: HTA 64%, dislipemia 29%, diabetes 14%, active smokers: 10% of men, 1,5% of women. A previous cardiovascular event was present in 11% of patients (15% of men; 6,8% of women). A serum creatinin level over 1,3 and 1,5 mg/dl was present in 3,8% of women and 8% of men respectively. Nevertheless, chronic kidney insufficiency (estimated clreatinie clearance less than 60 mix') was present in 31-49% relying on the utilised formula. In addition to age, sex, and diabetes, an independent graded association was observed between reduced glomerular filtration rate and the existence of cardiovascular events. CONCLUSIONS: We have confirmed a high prevalence of renal insufficiency among elderly people, usually not detected by the isolated plasma creatinin concentration This aspect is important for cardiovascular stratification risk and medical decisions (diagnostic and/or therapeutic). The level of glomerular filtration rate is independently associated with cardiovascular events.

The usefulness of 111In-labeled platelet scintigraphy in the diagnosis of patients with febrile syndrome and a nonfunctioning renal graft.

111In-labeled platelet scintigraphy was used to confirm immunological intolerance as the cause of prolonged febrile syndrome in hemodialyzed patients with a nonfunctioning renal allograft. Thirty-six patients with febrile syndrome (> 38 degrees C) and a nonfunctioning renal graft were studied. Thirteen patients were under minimal steroids (5-10 mg/day) and 23 were free of immunosuppressive therapy. A control group of 6 patients without fever and with a nonfunctioning renal graft was also included. The labeling of autologous platelets with 111In-mercaptopyridine was performed following a modified technique of Thakur. Scans were obtained at 24 and 48 hr after injection of 100-200 microCi of 111In-labeled platelets. A platelet uptake index (PUI) was calculated to evaluate the results of the scintigraphy. A PUI > 1.5 at 24 or 48 hr was considered positive and suggestive of immunological activity in the nonfunctioning renal allograft. In the study group the PUI was considered positive in 26 patients and negative in 10. In 3 patients with positive PUI, fever disappeared after steroid treatment, and transplantectomy was performed in the remaining 23. In 8 of the 10 patients with a negative PUI, fever disappeared with antimicrobial therapy. In the control group, a negative PUI was obtained in all cases. The sensitivity of PUI in demonstrating immunological intolerance of the nonfunctioning renal allograft was 93% with a specificity of 100%. Our results suggest that this new approach with 111In-labeled platelet scintigraphy may constitute a good marker for discriminating the origin of the febrile syndrome in patients with a nonfunctioning renal allograft. A positive PUI (> 1.5) strongly suggested immunological intolerance of the nonfunctioning allograft.

Prognostic factors of pneumonia requiring admission to the intensive care unit.

All patients with severe pneumonias (community-acquired and nosocomial) who required treatment in the intensive care unit (ICU) were included in a 3-year prospective study. Predictive factors for a fatal outcome were analyzed in 127 patients. An etiologic diagnosis was made in 70 (55.1%) patients. Culture of sputum or tracheobronchial secretions were used only as criteria for microbiologic diagnosis of Legionella pneumophila. The pathogens most frequently identified were L pneumophila, Streptococcus pneumoniae, and Pseudomonas aeruginosa. Viruses were not detected as causative agents. A total of 54 patients died (mortality rate, 42.5%). The univariate analysis showed the following factors associated with mortality: advanced age (> or = 70 years); presence of septic shock, requirement of mechanical ventilation, and Simplified Acute Physiology Score [SAPS] index > 12 at the time of admission to the ICU or when symptoms appeared in patients already admitted to the ICU; development of any complication during ICU hospitalization; and P aeruginosa as the etiologic agent of the pneumonia. When all variables were introduced by a stepwise method, the final model included advanced age (> or = 70 years), SAPS index > 12, presence of septic shock, requirement of mechanical ventilation, bilateral pulmonary involvement, and P aeruginosa as the etiologic agent of pneumonia as prognostic factors associated with a fatal outcome.

Proportion of community-acquired pneumonia cases attributable to tobacco smoking.

STUDY OBJECTIVES: To assess the population-attributable risk (PAR) of smoking and the effect of tobacco smoking on the development of community-acquired pneumonia (CAP) in adults. DESIGN: A population-based case-control study. Information on history of smoking and other risk factors was obtained by a questionnaire administered by interview. SETTING: Mixed residential-industrial area having 74,610 adult inhabitants in Barcelona, Spain. PARTICIPANTS: Two hundred five male and female patients (age, 15 to 74 years old) with CAP diagnosed between 1993 and 1995. They were matched to 475 control subjects randomly selected from the municipal census. RESULTS: Smoking any type of tobacco had an odds ratio (OR) of CAP of 2.0 for ever smokers (95% confidence interval [CI], 1.24 to 3.24); 1.88 for current smokers (95% CI, 1.11 to 3.19); and 2.14 for ex-smokers (95% CI, 1.26 to 3.65). A positive trend for increased risk of CAP was observed for an increase in the duration of the habit, the average number of cigarettes smoked daily, and cumulative cigarette consumption. Former smokers had a 50% reduction in the OR 5 years after the cessation of smoking. The risk of CAP attributable to the consumption of any type of tobacco in this population was 32.4% of cases (95% CI, 14.8 to 50.1%). In subjects without a history of COPD, the PAR of tobacco was 23.0% (95% CI, 3.3 to 42.7%). CONCLUSION: This study gives better quantitative and qualitative evidence about the effects of tobacco smoking on the occurrence of pneumonia in the adult community.