[Clinical characteristics and prognosis of Staphylococcus aureus bacteremia]. / Características clínicas, pronóstico y factores asociados de la bacteriemia por Staphylococcus aureus en la actualidad.

OBJECTIVE: Staphylococcus aureus bacteremia patients characteristics at a tertiary hospital are described, and complications, mortality and associated factors are analyzed. METHODS: Data from patients with S. aureus bacteremia admitted between March 2020 and February2021 at Miguel Servet university hospital in Zaragoza were retrospectively analyzed. RESULTS: Results showed a 14 days mortality of 24.2% and an 30 days mortality of 40%. Overall survival decreased with complications appearance [HR 3.1 (1.2-8.05)] and age over 65 years [HR 3.1 (1.4-6.6)]. The adjusted analysis showed correlation between a higher mortality at 14 and 30 days with age over 65 years [OR 6.3 (1.7-23.1)], sepsis presence [OR 19.3 (5.4-68.7)] and number of positive (+) blood cultures ≥3 [OR 5.4 (0.8-34.1)]. Mortality at 14 days was associated with sepsis presence [OR 58.2 (5.7-592.9)], number of positive (+) blood cultures ≥3 [OR 14.1 (1.1-173.7)] and an older age [OR 1.1 (1.03-1.1)]. Analyzing time to positive blood cultures ≤12 hours and number of positive blood cultures ≥ 3 at the same time, frequency of sepsis increased [30 patients (66.6%) vs 15 patients (33.3%); OR 3.4 (IC95% 1.5-8)]. CONCLUSIONS: High 14- and 30-days mortality were found, as well as a worse evolution in older age patients, with sepsis presence, and with greater number of positive blood cultures and times to positive blood cultures ≤12 h.

[Impact of Staphylococcus aureus bacteremia in COVID-19 patients]. / Impacto de la bacteriemia por Staphylococcus aureus en pacientes con COVID-19.

OBJECTIVE: The disease caused by SARS-CoV-2 (COVID-19) has been a challenge for healthcare professionals since its appearance. Staphylococcus aureus has been described as one of the main pathogens causing bacterial infections in viral pandemics. However, co- infection with S. aureus causing bacteremia in patients with COVID-19 has yet to be well studied. METHODS: We performed a e study of S. aureus bacteremia (SAB) at Hospital Miguel Servet (Zaragoza) from March 2020 to February 2021. The clinical characteristics, mortality and risk factors of adults hospitalized patients with BSA associated COVID-19 compared to patients without COVID-19. RESULTS: A total of 95 patients with SAB were identified. 27.3% were positive for SARS-CoV-2. SAB represented 9.9% of bacteremia, being the second agent in frequency after E. coli. Nosocomial bacteremia was more frequent in the group of COVID-19 patients. The most frequent source of BSA in these patients was the respiratory source (26.9% vs 0%; P<0.001) followed by the skin (15.5% vs 15.9%; P=1). The development of sepsis was more frequent in COVID-19 patients (61,5% vs 7,8%; P=0,336) and among them, who received dexamethasone at doses > 6 mg/day (62.5% vs. 37.5%, P<0.05). CONCLUSIONS: Our data suggest that BSA has a negative impact on the evolution of patients with COVID-19. However, further and preferably prospective studies are required to obtain solid data on the impact of BSA on coronavirus patients.

Age, Gleason Score, and PSA are important prognostic factors for survival in metastatic castration-resistant prostate cancer. Results of The Uroncor Group (Uro-Oncological Tumors) of the Spanish Society of Radiation Oncology (SEOR).

INTRODUCTION: The treatment of metastatic castration-resistant prostate cancer (mCRPC) has changed significantly in recent years. Inhibitors of androgen receptors have shown especially significant benefits in overall (OS) and progression-free survival (PFS), with a good toxicity profile. Treatment selection depends on the patient's individual clinical, radiological, and biological characteristics. OBJECTIVE: To describe treatment outcomes (efficacy, toxicity) in a cohort of patients with mCRPC in Spain. MATERIALS AND METHODS: Multicenter, retrospective study of patients with mCRPC included in a database of the Urological Tumour Working Group (URONCOR) of the Spanish Society of Radiation Oncology (SEOR). Metastatic CRPC was defined according to the prostate cancer working group 3 (PCWG3) criteria. The Kaplan-Meier technique was used to evaluate OS and the Common Terminology Criteria for Adverse Events (CTCAE, v.4.0) were used to assess toxicity. Univariate and multivariate Cox regression analyses were performed to identify the factors significantly associated with OS. RESULTS: A total of 314 patients from 17 hospitals in Spain diagnosed with mCRPC between June 2010 and September 2017 were included in this study. Mean age at diagnosis was 68 years (range 45-89). At a median follow-up of 35 months, OS at 1, 3, and 5 years were 92%, 38%, and 28%, respectively. Grades 1-2 and grade 3 toxicity rates were, respectively, 68% and 19%. No grade 4 toxicities were observed. On the multivariate analysis, the following factors were significantly associated with OS: age (hazard ratio [HR] 0.42, p = 0.010), PSA value at diagnosis of mCRPC (HR 0.55, p = 0.008), and Gleason score (HR 0.61, p = 0.009). CONCLUSIONS: Age, Gleason score, and PSA at diagnosis of mCRPC are independently associated with overall survival in patients with mCRPC. The efficacy and toxicity outcomes in this patient cohort treated in radiation oncology departments in Spain are consistent with previous reports.

Percutaneous transluminal renal angioplasty. A potentially effective treatment for preservation of renal function.

Percutaneous transluminal renal angioplasty (PTRA) was performed in a group of 12 patients with marked renal functional impairment, severe hypertension, and critical renovascular stenoses in a solitary functioning kidney (ten patients) or bilaterally (two patients). The procedure led to least partial dilation in 11 of the 13 stenoses acted on and stabilization or modest improvement in renal function in seven of the 11 patients in whom some technical success had been achieved. Moreover, the severity of the patients' hypertension appeared to be favorably affected following PTRA. Complications that were encountered included three episodes of nonoliguric acute renal failure, a thrombotic occlusion of a renal artery, a tear of the balloon segment of the catheter requiring femoral arteriotomy, and an episode of gastrointestinal tract bleeding. Percutaneous transluminal renal angioplasty may be an effective modality in the treatment of patients with severe renovascular stenosis, renal functional impairment, and hypertension.

Percutaneous transluminal renal angioplasty in nonatherosclerotic renovascular hypertension. Long-term results.

Nineteen stenotic arteries in 16 patients with severe renovascular hypertension of nonatherosclerotic nature (fibromuscular dysplasia in 13, neurofibromatosis in 3) were treated with percutaneous transluminal renal angioplasty. The procedure was technically successful in 12 of 14 (86%) stenoses in the fibromuscular dysplasia subgroup but in only one of five (20%) lesions in the neurofibromatosis subgroup. Hypertension was abated (3 patients) or disappeared (8 patients) in 11 of the 12 (92%) patients with fibromuscular dysplasia who had a technically successful angioplasty, an effect that was sustained at latest follow-up (avg, 37 mo; range, 10-73 mo). The only complication encountered was a retroperitoneal hematoma that resolved uneventfully. Coupled with those from other centers, the results of the present study indicate that angioplasty offers a strong potential for curability in patients with renovascular hypertension caused by fibromuscular dysplasia and that percutaneous transluminal renal angioplasty should be considered the treatment of choice for the initial management of all patients with fibromuscular renovascular hypertension.

Percutaneous transluminal renal angioplasty in management of atherosclerotic renovascular hypertension: results in 100 patients.

The long-term effect of percutaneous transluminal renal angioplasty (PTRA) on blood pressure and renal function was assessed in 100 consecutive patients with atherosclerotic renovascular hypertension. Technical success rates (complete plus partial) of a first PTRA averaged 76.2%, 74.1%, and 67.7% for the unilateral (n = 42), bilateral (n = 27), and solitary (n = 31) groups, respectively. Of the technical successes, 59% (43/73) experienced sustained blood pressure benefit (mostly amelioration) during a mean follow-up period of 29 months. Rates of blood pressure benefit were similar in the three groups. Ostial lesions comprised the majority of blood pressure benefit failures. Repeat angioplasty in 14 patients resulted in a 71% technical success rate and a 50% blood pressure benefit rate during a mean follow-up period of 22 months. Long-term stability of mean serum creatinine level was observed after technically successful angioplasty in all three groups. Acute renal insufficiency, which was reversible in all but one patient, complicated 26% of the procedures. Mechanical complications occurred in 14% (20/145) of the arteries acted on; surgical intervention was required in five patients. The mortality rate was 2%. These results suggest that angioplasty is effective in both the long-term management of renovascular hypertension and the preservation of renal function in a large fraction of patients with atherosclerotic renovascular hypertension.

Percutaneous transluminal renal angioplasty in the treatment of unilateral atherosclerotic renovascular hypertension.

Thirteen patients with severe, unilateral, atherosclerotic renovascular hypertension were treated with percutaneous transluminal renal angioplasty. The procedure produced wide patency of the stenosed vessel in 10 patients and partial dilatation in the remaining three. All patients exhibited a beneficial response in their hypertension; at latest follow-up, ranging from two to eighteen months, all patients were normotensive, four in the complete absence of any antihypertensive medication and the remaining nine while taking substantially less medication than before. Suppression of the differential renal-vein renin ratio was also documented. In one patient follow-up angiography, performed after seven months because of deterioration in renal function, revealed an occluded renal artery. Complications that were encountered included two small, segmental renal infarcts, three episodes of nonoliguric, presumably radiocontrast-induced, acute renal insufficiency and a soft-tissue hematoma that occurred one month after the procedure and was due to excessive anticoagulation. Percutaneous transluminal renal angioplasty may be an effective modality in the management of unilateral, atherosclerotic renovascular hypertension.

A prospective study of Doppler pressures and segmental plethysmography before and following aortofemoral bypass. Implications for predicting success and for adopting a uniform method of classifying arterial disease.

To determine the clinical and hemodynamic changes associated with aortofemoral bypass, 44 limbs of 31 patients underwent segmental plethysmography (PVR) and Doppler pressures (DSP) before operation, immediately after operation, and again at 6 months. Prior to operation patients were separated by angiographic criteria into two groups: aortoiliac segment disease alone (AI) (n = 22), and aortoiliac and femoropopliteal segment disease (AIFP) (n = 22). At 6 months the two groups were subdivided into four groups based on relief (oSx) or lack of relief (+Sx) of symptoms. Before operation the only significant difference between the four groups was a higher thigh PVR and calf DSP in the AI + Sx group. Six month PVR values in AIoSx were improved nearly twofold over preoperative measurements at the thigh and calf, but at the thigh level only for AIFPxSx. DSP was increased at all three levels in both AI and AIFPoSx groups. No hemodynamic improvement occurred in either the AI or the AIFP + Sx groups. A derivative index of PVR (thigh-ankle/15 mm) or the FPomega was significantly lower in AIFOsSx before operation. There was a significant disparity between classification by hemodynamics and by symptoms prior to operation which lessened somewhat after operation. These studies suggest that success or failure can be predicted before operation in AIFP by FPomega, and arterial disease should be classified by a combination of symptoms, angiography, and hemodynamics.

Lipoid cell tumor of the ovary.

An androgen-secreting tumor of the left ovary was preoperatively localized in a 55-year-old virilized woman by radioimmunoassay of blood androgens. The blood sample was obtained by bilateral catheterization of the ovarian and adrenal veins using a percutaneous retrograde femoral approach. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed, and revealed a lipoid cell tumor of the left ovary and right ovarian stromal hyperplasia. Despite early postoperative return of plasma adrogens to the normal range, virilizing signs persisted almost unchanged 1 year after surgery.

Chylous metrorrhea.

Chylous is an extremely unusual cause of leukorrhea. The diagnosis is established by verification of the chylous nature of the discharge, documentation of its uterine origin, and lymphangiographic demonstration of dilated pelvic lymphatics with uterine reflux. Surgical excision of the incompetent lymphatic channels is the treatment of choice.

Asymmetric hyperthecosis ovarii.

Testosterone and delta4-androstenedione concentrations, in venous blood obtained by percutaneous retrograde femoral catheterization of the ovarian and adrenal veins bilaterally, demonstrated the left ovary to be the predominant secretory source of androgens in an 18-year-old virilized female. Histologic examination of the excised ovarian tissue revealed asymmetric hyperthecosis ovarii and confirmed the biochemical data. This study demonstrates the accuracy of the venous catheterization method in locating preoperatively the hypersecretory source of androgens in virilized women. The favorable postoperative clinical result emphasizes the importance of an accurate preoperative diagnosis in virilized women even in the absence of ovarian neoplasia.

Management of biliary obstruction. A comparison of percutaneous, endoscopic, and operative techniques.

Surgery for obstructive jaundice is being challenged by endoscopic and percutaneous techniques. To compare their safety and efficacy, the courses of 157 patients treated for biliary obstruction were examined. Outcome was judged by mortality, complications, and need for further intervention. Forty-eight patients underwent endoscopic papillotomy (43 [90%] had stone disease) with two deaths and 11 cases of (23% incidence) of cholangitis. Pancreatitis developed in 9 (19%). Twenty-seven patients (56%) required further endoscopic, percutaneous, or surgical intervention. Sixty-five patients underwent transhepatic drainage (58 [89%] had malignant neoplasms) with a 28% (n = 18) mortality rate. Cholangitis developed in 26 (40%), and 50 (77%) required further transhepatic or surgical intervention. Forty-four patients underwent surgery (22 [50%] had stone disease and 12 [27%] had malignant neoplasms) with a 4.5% (n = 2) mortality rate. Cholangitis developed in 3 (7%), pancreatitis developed in 2 (4.5%), and bleeding developed in 1 (2%). Eight (18%) required further intervention. While endoscopic papillotomy provides efficacious treatment for stone disease, surgery provides a more expeditious, less morbid relief for malignant obstruction.

Transcatheter thromboembolectomy of acute renal artery occlusion.

Direct surgery of the renal artery has been performed for the relief of acute thrombotic or embolic occlusion of the renal artery to restore adequate renal perfusion and prevent irreversible renal failure. Occasionally, severe medical disease may increase surgical risk to a prohibitive level. An angiographic technique has been devised to provide an alternative approach and has been successfully used on five occluded renal arteries in four patients, with measurable benefit.

Management of variceal hemorrhage: results of a standardized protocol using vasopressin and transhepatic embolization.

We reviewed the courses of 40 patients with variceal bleeding treated with a standardized protocol, including intravenous (IV) vasopressin (Pitressin) and transhepatic embolization. Twelve of the 32 patients with acute episodes of massive variceal bleeding responded to the administration of IV vasopressin alone. Of the 20 patients who did not respond to vasopressin therapy, emergency transhepatic portography with embolization produced cessation of bleeding in ten (50%). The remaining ten patients who failed to respond to either IV vasopressin therapy or transhepatic embolization died, regardless of whether they were treated with aggressive medical therapy or emergency portosystemic shunt. Transhepatic embolization in both the emergent and elective situation demonstrated a thrombotic complication rate of 20%, which limited or precluded eventual therapy with elective portosystemic shunt. Because of this relatively high incidence of occult portal thromboses after transhepatic embolization, transhepatic portography should be obtained routinely prior to elective portosystemic shunts in those patients who have a history of transhepatic embolization.

Diagnostic evaluation of hirsutism in women by selective bilateral adrenal and ovarian venous catheterization.

To determine the most significant secretory source of their androgens, 13 hirsute nonvirilized women underwent selective bilateral adrenal and ovarian venous catheterization to obtain effluent blood for the assay of testosterone and delta4-androstenedione. In three patients the testosterone and delta4-androstenedione gradients were significantly greater in the adrenal venous effluents. Testosterone and delta4-androstenedione gradients were significantly greater in the ovarian venous effluents in four patients. In six patients there were no significant differences in the testosterone gradients between the adrenal and ovarian venous effluents. The delta4-androstenedione gradients were greater in the adrenal venous effluents in three of these patients, greater in the ovarian venous effluents in one, and not significantly different in two of these patients. The fact that the measurement of urinary 17-ketosteroid excretion, the suppressibility of peripheral plasma androgens with dexamethasone, and the stimulation of peripheral plasma androgens with human chorionic gonadotropin correlated poorly with the selective catheterization data suggests that the former modalities are imprecise in the diagnostic evaluation of hirsutism in women.

Infrarenal aortic occlusion: a reassessment of surgical indications.

Citing a high incidence of proximal propagation of aortic thrombosis, several authors have advocated aortic reconstruction for all patients with infrarenal aortic occlusion irrespective of their preoperative symptoms and potential operative risks. To test this thesis, the records and follow-up data of 38 patients seen at our institution between 1965 and 1982 with infrarenal aortic occlusion were analyzed. Twenty-four of the 38 patients were treated surgically (Group I); 16 (42 percent) had an aortobifemoral graft and 8 (21 percent) had an axillofemoral bypass graft. When the 14 patients who did not have surgery (Group II) and the 8 patients who had an axillofemoral graft were combined, 22 patients (58 percent) did not have aortic reconstruction (Group III), thus the aortic thrombus was left in situ. There was no significant difference in cumulative survival between the three groups at 4 year follow-up. Of 13 patients in Group III who were followed for more than 6 months (mean 48 months), none died from proximal propagation of aortic thrombosis. The decision for surgical intervention in patients with distal aortic occlusion should be arrived at, as in other patients with aortoiliac occlusive disease, by weighing preoperative symptoms and operative risks and not primarily by the level of risk of proximal propagation of thrombosis.

Retrieval of intravascular foreign bodies using a modified bronchoscopic forceps.

The author describes a specially designed, versatile forceps which allows rapid percutaneous retrieval of intravascular foreign bodies when used with a steerable catheter. The technique has been successful in 6 cases, and there have been no complications.

Percutaneous transluminal angioplasty for severe renovascular hypertension due to renal-artery medial fibroplasia.

Percutaneous transluminal renal angioplasty (P.T.R.A.) was performed in a 43-year-old woman with medial fibroplasia of the right main renal artery that was causing high-grade stenoses and severe hypertension. The procedure led to a virtually complete dilatation of the stenosing lesions and a prompt and lasting fall in blood-pressure to normal. Hypersecretion of renin from the right kidney was also promptly suppressed. The procedure was well tolerated by the patient and no complications were discerned. P.T.R.A. deserves further investigation to assess its role in the management of renovascular hypertension.

Translumbar carotid arteriography.

In seven patients, carotid arteriography and arch aortography were performed using a translumbar catheter exchange sheath which facilitated selective catheterization. No significant complications occurred. The translumbar approach is easier than the axillary approach, will result in fewer complications, and should be considered whenever a femoral arterial access is unavailable.