Disseminated histoplasmosis and AIDS: a prospective and multicentre study to evaluate the performance of different diagnostic tests.

The burden of histoplasmosis has been poorly documented in most of the endemic areas for the disease, including Brazil. Also, modern non-culture-based diagnostic tests are often non-available in these regions. This was a prospective cohort study in HIV-infected patients with suspected disseminated disease evaluated with different diagnostic tests. Patients were enrolled in three referral medical centres in Porto Alegre, Brazil. Among 78 evaluated patients, disseminated histoplasmosis was confirmed in eight individuals (10.3%) by the means of classical (culture/histopathology) tests. Antigen detection in the urine was found to be more sensitive: IMMY® ALPHA ELISA detected 13 positive cases (16.7%) and the in-house ELISA test developed by the Centers for Disease Prevention and Control (CDC) detected 14 (17.9%). IMMY® and CDC tests provided concordant results in 96.2% of cases. This is the first study to compare the performance of the in-house CDC ELISA test with the IMMY® commercial test for the diagnosis of histoplasmosis, and a high degree of concordance was observed. The study revealed that H. capsulatum is an important agent of disseminated disease in AIDS patients in Brazil, reinforcing the importance of making available modern diagnostic tests as well as safer antifungal agents for the treatment of histoplasmosis.

Nosocomial bloodstream infections in a nationwide study: comparison between solid organ transplant patients and the general population.

BACKGROUND: The incidence of bloodstream infection (BSI) varies according to the transplanted organ. Mortality can be as high as 24%, with a significant impact on graft survival. Transplantation is a risk factor for multidrug-resistant (MDR) organisms, but comparison with a non-transplanted population in a single large cohort has not been described. METHODS: This is a prospective nationwide study (16 centers) reporting data on 2364 monomicrobial nosocomial BSIs, comparing 83 episodes in solid organ transplant patients with 2447 BSIs occurring in the general hospital population. RESULTS: The prevalence of groups of infecting organisms (gram-positive, gram-negative, and fungi) was similar between transplant patients and the general population and a similar crude mortality rate was observed (34.9% in transplant vs. 43.3% in non-transplant patients). Staphylococcus aureus was the single most frequently isolated organism in both groups, and Acinetobacter species was more frequently isolated in the general population. Regarding MDR organisms, Klebsiella species, and Enterobacter species resistant to cefepime, as well as Acinetobacter species resistant to meropenem, were significantly more frequent in transplant patients. CONCLUSION: Antimicrobial resistance is higher, particularly among gram-negative bacteria in the transplant population, although the overall mortality rate between transplant and non-transplant patients with nosocomial BSI is similar.

The effect of control group selection in the analysis of risk factors for extended spectrum beta-lactamase-producing Klebsiella pneumoniae infections. A prospective controlled study.

The aim was to evaluate the effect of control selection on risk factor analysis for extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-KP) infections. Four contemporaneous case-control studies were conducted prospectively with 372 patients: Study 1 (ESBL-KP-infected vs non-infected); Study 2 (ESBL-KP-infected vs non-ESBL-KP-infected); Study 3 (all KP-infected vs non-infected); Study 4 (non-ESBL-KP-infected vs non-infected). Time at risk (TAR, i.e. duration of hospital stay) was the most significant risk factor [Study 1: odds ratio (OR): 5.74 (95% CI: 2.26-14.59; P<0.001); Study 2: 3.52 (1.47-8.43; P=0.005); Study 3: 2.68 (1.57-4.58; P<0.001)]; central venous catheterisation (CVC) was a risk factor in Study 1: 5.31 (1.67-16.82; P=0.005) and Study 3: 2.10 (1.04-4.27; P=0.04). Prior use of cephalosporins (PUC) was a risk factor only in studies with non-infected patients as controls [Study 1: 5.64 (1.90-16.72; P=0.002) and Study 3: 4.60 (2.09-10.13; P<0.001)]. The ORs were uniformly lower with 'non-ESBL-KP-infected' (TAR: 3.52; CVC: 2.07; PUC: 1.97) compared with 'non-infected' patients (TAR: 5.74; CVC: 5.31; PUC: 5.64) as control groups. Selection of control patients has a crucial role in the evaluation of risk factors for ESBL-KP infections. A consistent underestimation of the magnitude of the risk factors is observed when the control group is defined by the non-ESBL-KP-infected patients.

Percutaneous transluminal balloon valvuloplasty of adult aortic stenosis: report of 92 cases.

Percutaneous transluminal balloon valvuloplasty was attempted in 92 adult patients with severe calcific aortic stenosis. The mean age was 75 +/- 11 years (range 38 to 91) and 35 patients were more than 80 years old. Most of the patients were severely disabled; 66 were in New York Heart Association functional class III or IV, 27 had syncopal attacks and 21 had severe angina pectoris. Because of unacceptably high surgical risk or contraindication to thoracic surgery, 42 patients could not be considered for valve replacement. Other patients either were in a category of high operative risk or refused the surgical intervention. Valvuloplasty was performed by way of the femoral route (82 patients) or the brachial route (10 patients). Catheters of size 15, 18 and 20 mm were successively placed across the aortic valve and three inflations were usually done with each of them, lasting 80 seconds on average, until a decrease in peak to peak systolic pressure gradient to 40 mm Hg or less was attained, a result considered satisfactory. The inflated balloons were not totally occlusive in most cases and clinical tolerance of inflation was good. Valvuloplasty resulted in a reduction of mean systolic gradient from 75 +/- 26 to 30 +/- 13 mm Hg (p less than 0.001); the final gradient was less than 40 mm Hg in 78 patients. Mean calculated aortic valve area increased from 0.49 +/- 0.17 to 0.93 +/- 0.36 cm2 (p less than 0.001). Immediately after the procedure, ejection fraction increased from 48 +/- 16 to 51 +/- 16% (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Paranasal sinus development and choanal atresia.

BACKGROUND: Although the determinates of paranasal sinus development and sinusitis are not well defined, a candidate factor is blockage of the choana. HYPOTHESIS: Maxillary sinuses ipsilateral to unilateral choanal atresia are comparatively small and have more evidence of sinusitis than do the contralateral sinuses. DESIGN: Retrospective. SETTING: Children's hospitals. PATIENTS: Sixteen nonsyndomic children with isolated unilateral congenital choanal atresia. MAIN OUTCOME MEASURES: Determination of maxillary sinus volumes and mucoperiosteal thickening on preoperative computed tomograms. RESULTS: Maxillary sinuses ipsilateral to unilateral choanal atresia have slightly larger volumes than, and mucoperiosteal thickening that is similar to, the contralateral sinuses. CONCLUSION: These data suggest that maxillary sinus development and sinusitis are independent of posterior nasal ventilation and drainage.

Heterotopic neuroglial tissue causing airway obstruction in the newborn.

BACKGROUND: Heterotopic neuroglial (brain) tissue is a rare cause of airway obstruction in newborns. Fewer than 30 cases have been reported in the English literature. Brain heterotopias can mimic more common congenital anomalies of the head and neck. OBJECTIVE: To review our experience in the diagnosis and treatment of children with heterotopic pharyngeal neuroglial tissue. DESIGN: Case series. SETTING: Tertiary care children's hospital. PATIENTS: Four newborns with airway obstruction caused by heterotopic neuroglial tissue. RESULTS: All patients were infants (3 full-term girls and a 32 weeks' gestation boy) who had airway obstruction in the newborn period. All patients underwent preoperative computed tomography and magnetic resonance imaging, which revealed a heterogeneous mass involving the pharynx, neck, and parapharyngeal space. Bony deformities of the skull base and mandible were present in all patients, although intracranial connection was absent. Multiple surgical procedures were performed in all 4 patients. Tracheotomy was performed in 2 patients, gastrostomy tube placement was required in 3, and a nasopharyngeal tube was used in 1. Combined cervicofacial and transoral approaches were used for resection, preserving vital structures. Histopathologic evaluation revealed mature glial tissue and choroid plexus-like structures. CONCLUSIONS: Heterotopic neuroglial tissue must be considered in the differential diagnosis of airway obstruction in the newborn. Management is surgical resection, with attention to vital structures and function-analogous to surgery for lymphangioma. Multiple surgical procedures might be necessary in the treatment of these patients.

Resuscitation of the newborn with airway compromise.

Respiratory problems in the newborn period are a diagnostic and therapeutic challenge. The goal of expeditious airway establishment may not be straightforward. Familiarity with features of the normal and abnormal infant airway anatomy, physiology, as well as intubation equipment and alternatives to intubation is essential. A systemic approach provides clues that are helpful in the successful management of the neonate in respiratory distress.

Gender and intra-observer agreement about laryngoscopy of papilloma.

BACKGROUND: The gender of the observer may bias data. OBJECTIVE: Compare the intra-observer agreements of male and female pediatric otolaryngologists about videotaped images of laryngeal papilloma. DESIGN: Five male and six female pediatric otolaryngologists independently viewed videotapes of ten children undergoing treatment for laryngeal papilloma. Each of 12 anatomic sites was categorized as disease present, absent, or indeterminate. Each observer estimated the percent overall airway obstruction. 5-24 weeks later, each observer repeated his/her assessments. RESULTS: The mean intra-observer agreements for both male and female pediatric otolaryngologists were good, and identical (kappa 0.63; proportion of positive agreement 0.82; proportion of negative agreement 0.72). Females more frequently categorized a site as indeterminate. Males more frequently categorized a site oppositely on repeat assessment. The males' indeterminate/opposite ratio was less than that of the females' (P = 0.03). Intra-observer estimates of overall airway obstruction have wide variability: for male pediatric otolaryngologists, differences exceeding 30% are significant; for females, 40%. CONCLUSION: Male and female pediatric otolaryngologists had equally good and identical intra-observer kappa scores and proportions of positive and negative agreement. However, males used the indeterminate category less than did the females, and males more often gave an opposite categorization at the second viewing session. Estimates of overall airway obstruction have much intra-observer variability.

Multicentric infantile myofibromatosis.

Infantile myofibromatosis (IM) is a rare tumor of infancy and childhood, typically presenting as a firm, nodular mass involving soft tissue, bone or viscera. Approximately one-third of cases involve the head and neck. These tumors can be solitary or multicentric. Biopsy reveals tumor cells that resemble myofibroblasts. Spontaneous regression may occur. A high degree of suspicion is necessary to differentiate this entity from other more aggressive processes histiocytosis, fibrosarcoma, rhabdomyosarcoma. We describe the case of a male infant with multicentric myofibromatosis, presenting with multiple thoraco-abdominal subcutaneous nodules and lytic mass lesions of the temporal bone and calvarium. The characteristic clinical, radiologic and histopathologic features of this process are reviewed along with diagnostic and therapeutic options.

Assessing the antimicrobial prescription request process in a teaching hospital in Brazil: regulations and training.

It is known that antimicrobials are often prescribed inappropriately. One method used to deal with this problem is to regulate antimicrobial use by monitoring prescriptions. We report a study of physician compliance with the request for antibiotic process which was prepared and reviewed by a special infection control committee in our hospital the Nosocomial Infection Prevention Service (SCIH). The objective of this study was to identify the profile of inappropriate requests for restricted therapeutic antimicrobials used at Nossa Senhora da Conceição Hospital (HNSC), in Porto Alegre, Brazil. All 3,389 requests for therapeutic antimicrobials made between May 20, and October 31, 1996, were assessed and classified as appropriate and inappropriate. We determined that 17. 8% of the requests were inappropriate (a total of 720 errors). These were categorized according to 12 reasons for inappropriateness. Of these, the 3 most frequent inappropriate requests were deviation from standard use (26.73%), inappropriate length of treatment (23. 19%), and unfounded justification (13.61%). The reasons for inappropriateness were also arranged in three categories considering the following aspects: I. technical (59%); II. compatibility with the institutional program (32.36%), and III. administrative (8.61%). The 720 requests that were initially rejected were evaluated to see how antibiotic use was affected. In approximately 400 (55%), the forms could be appropriately modified after discussion with the physician. We conclude from this study that most of the inappropriate requests for antimicrobials in our hospital can be remedied by educating the staff since the errors were largely technical in nature. Thus, the SCIH should focus more on its role as an educational rather than as a regulatory body. By expanding this educational role, we anticipate improved physician compliance with our guidelines, and more appropriate antimicrobial prescribing and usage.

[Variations in blood pressure at rest and during the day in 40 ambulatory hypertensive patients]. / Etude des variations de la tension artérielle de repos au cours de la journée chez 40 hypertendus ambulatoires.

Forty patients considered to be hypertensive on the basis of occasional blood pressure recordings obtained during three out-patient consultations (BP-C) underwent hourly blood pressure recordings throughout the day under standardized conditions at rest and lying down, but with normal daily activities between measurements. The average of the hourly measurements provides a basal blood pressure profile independent on non-standardizable factors of everyday life such as physical exercise and emotion without being artificially influenced by prolonged rest. The average ambulatory blood pressure (BP-A) is much lower than the BP-C. In particular, practically normal values (148-90) were observed in the group of patients with moderate but undiscutable hypertension (165/98) on the BP-C readings. During the same day, variations of 10 to more than 30% of systolic and diastolic pressures were observed in over 3/4 of the patients; the highest values were recorded between 8 and 12 o'clock in about 70% of cases, most commonly at the first reading at 8 or 9 o'clock in the morning. This study shows that large variations of blood pressure are observed during the daytime even when repeated recordings are made under standardised conditions. This method of determining the day time blood pressure profile is a different approach to the study of hypertension than that based on ambulatory measurements made with a portable blood pressure recorder.

[Anterior lead ST-segment depression in inferior wall infarction. Early angiographic study. Effect on the results of intracoronary thrombolysis]. / Sous-décalage antérieur du segment ST dans l'infarctus myocardique inférieur. Etude angiographique précoce. Incidence sur les résultats de la thrombolyse intracoronaire.

Of 32 patients with inferior myocardial infarction undergoing coronary angiography in the first 6 hours for intracoronary streptokinase thrombolysis, 19 (Group I) had ST depression of more than 1 mm in the anterior chest wall leads (VI-V4) whilst 13 (Group II) had no ST changes in these leads. Quantitative analysis of left ventricular angiograph showed a significantly lower ejection fraction in Group I (52 +/- 8.5%) compared to Group II (59 +/- 8%, p less than 0.05) and that this difference was due to a greater zone of inferior wall hypokinesia, irrespective of whether this was assessed by measuring its surface area (HKS cm2: Gr I: 11 +/- 6, Gr II: 4 +/- 3, p less than 0.01) or percentage ventricular perimeter (HK%: Group I 45 +/- 15, Group II 26 +/- 12, p less than 0.001). On the other hand, anterior wall motion was normal in both groups. Coronary angiography showed proximal obstruction of the right coronary artery in 84% of patients in Group I. In Group II, the coronary obstruction tended to be distal or incomplete. The prevalence and average severity of associated stenosis of the left anterior descending artery were the same in both populations. The success rate of thrombolysis was not significantly different between the two groups. In successful procedures with a patent artery on the 14th day, improved regional contractility was only observed in Group I (HKS cm2: 11.5 +/- 6 vs 8 less than 4.4, p less than 0.05; HK%: 47 +/- 14 vs 38 +/- 9, p less than 0.05): the hypokinetic zone was unchanged in Group II.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous transluminal aortic valvuloplasty using a balloon catheter. A new therapeutic option in aortic stenosis in the elderly]. / Valvuloplastie aortique percutanée transluminale par sonde à ballonnet. Une possibilité thérapeutique nouvelle dans le rétrécissement aortique du sujet âgé.

Aortic valvular dilatation with a balloon catheter was performed in 44 patients, 20 men and 24 women, most of whom were very elderly (average age 77 years). The indication for valvular replacement had not been retained in these cases because of surgical contra-indications or a very high operative risk and in 3 cases because of patient refusal. Twenty-nine patients were in functional classes III or IV of the NYHA classification; 12 had syncopal episodes and 18 had invalidating angina. The dilatation was performed by a femoral arterial approach in 34 cases, and by a brachial arterial approach in 10 cases. MEDI-TECH catheters with 15, 18 or 20 mm diameters when inflated were used in the majority of cases. Several inflations lasting 10 to 240 seconds were performed in each case with balloons of increasing size. This was well tolerated in all but one patients who had a sharp syncope. The immediate results confirmed valvular dilatation. The average transvalvular pressure gradient fell from 76 +/- 25 mmHg to 30 +/- 13 mmHg (p less than 0.001). The aortic valve surface area calculated by the Gorlin formula increased from 0.5 +/- 0.18 cm2 to 1 +/- 0.42 cm2 (p less than 0.01). After dilatation the gradient was less than or equal to 40 mmHg in 37 cases; aortic valve surface area was greater than or equal to 1 cm2 in 14 cases and less than or equal to 0.7 cm2 in only 5 cases. The left ventricular ejection fraction increased immediately after valvuloplasty from 44 +/- 16 p. 100 to 49 +/- 15 p. 100 (p less than 0.01). In the 18 cases in which it was less than 40 p. 100 before valvuloplasty, it increased from 30 +/- 6 p. 100 to 36 +/- 9 p. 100 (p less than 0.02). Residual aortic regurgitation was only observed in one case. Two patients died in the hospital period (4.6 p. 100). There were no other serious complications. During an average follow-up period of 60 days (3 weeks to 6 months) there was a big improvement in symptoms in the great majority of cases and, in particular, syncopal and anginal attacks disappeared. Only 4 patients remained in functional classes III or IV after valvuloplasty. Percutaneous aortic valvuloplasty is a new, relatively simple, low risk, economic and very effective therapeutic procedure in all cases in which aortic valve replacement is contra-indicated or refused by the patient.(ABSTRACT TRUNCATED AT 400 WORDS)

[Evaluation of functional myocardial recovery after emergency revascularization by intracoronary fibrinolysis in the acute infarct period]. / Evaluation de la recupération fonctionnelle du myocarde après revascularisation en urgence par fibrinolyse intracoronarienne à la période aiguë de l'infarctus.

An angiographic study was carried out to evaluate myocardial recovery in 50 patients who had undergone coronary angiography in the first six hours of myocardial infarction with the object of attempting emergency revascularisation by a selective intracoronary infusion of streptokinase. Left ventriculography performed before initial coronary arteriography and 2 to 10 weeks later was compared. The ejection fractions and two indices obtained by quantitative analysis of regional contractility, the surface (SHK) and extent (EHK) of the ischemic zones were calculated. The patients were divided into two groups according to results: Group I, 25 patients with patent arteries at the second control, and Group II, 25 patients not revascularised or with a reobstructed artery at the second angiographic control. In Group I, the ejection fraction remained stable (47 +/- 11 p. 100 to 48 = 10 p. 100 N.S.) but SHK (13 +/- 6 cm2 to 10 +/- 5 cm2, p less than 0,01) and EHK in percentage of ventricular circumference (48 +/- 12 p. 100 to 42 +/- 11 p. 100, p less than 0,05) fell significantly. In Group II, the ejection fraction fell (55 +/- 9 p. 100 to 44 +/- 11 p. 100, p less than 0,001) whilst SHK (7 +/- 4 cm2 to 11 +/- 5 cm2, p less than 0,001) and EHK (34 +/- 11 p. 100 to 43 +/- 14 p. 100, p less than 0,001) increased significantly. These results show that revascularisation may result in significant functional myocardial recovery and, consequently, that some ischemic myocardium can be salvaged in these patients.