Impact of one year of pandemic on Spanish Intensive Care Units

Objective

To measure the impact of the pandemic in Spanish ICUs.

Material and methods

On-line survey, conducted in April 2021, among SEMICYUC members. Participants were asked about number of patients admitted, increase in the number of beds and staff, structures created in the hospital and self-assessment of the work performed.

Results

We received 246 answers from 157 hospitals. 67.7% of the ICUs were expanded during the pandemic, overall increase in beds of 58.6%. The ICU medical staff increased by 6.1% and there has been a nursing shortage in 93.7% of units. Patients exceeded 200% the pre-pandemic ICU capacity. In 88% of the hospitals the collaboration of other specialists was necessary. The predominant collaboration model consisted of the intensive care medicine specialist being responsible for triage and coordinating patient management. Despite that 53.2% centres offered training for critical care, a deterioration in the quality of care was perceived. 84.2% hospitals drew up a Contingency Plan and in 77.8% of the hospitals a multidisciplinary committee was set up to agree on decision-making.

Self-evaluation of the work performed was outstanding and 91.9% felt proud of what they had achieved, however, up to 15% considered leaving their job.

Conclusions

The Spanish ICUs assumed an unprecedented increase in the number of patients. They achieved it without hardly increasing their staff and, while intensive care medicine training was carried out for other specialists who collaborated. The degree of job satisfaction was consistent with pre-pandemic levels.

Prospective study of urinary function and analysis of risk factors after rectal cancer surgery

BACKGROUND

Alterations in urinary function are complications of rectal cancer surgery. The aim of this study was to prospectively analyze the changes in urinary function in patients operated on for rectal cancer, and to identify risk factors that may have an impact on the deterioration of postoperative urinary function.

METHODS

A prospective study of urinary function in rectal cancer patients who had elective oncological resection with curative intention at the Arnau de Vilanova Hospital in Valencia, Spain, from January 2017 to March 2019. The evaluation of urinary function was performed using the International Prostate Symptom Score (IPSS) preoperatively, at 6 and 12 months after surgery. Predictive factors of urinary dysfunction were identified by univariate and multivariate analysis.

RESULTS

Ninety-four patients were enrolled in the study. Eighty-seven of them completed all the follow-up assessments (48 men and 39 women, mean age 65.74 ± 10.95 years,). The mean IPSS was 7.96 ± 7.59 preoperatively, 9.01 ± 6.81 at 6 months, and 8.63 ± 5.59 at 12 months, without statistically significant differences. There were no differences in IPSS between males and females. Preoperative urinary dysfunction was 39% and at 12 months, a deterioration occurred in 23 patients (26.4%). IPSS analysis of symptoms showed a statistically significant worsening of nocturia at 6 months (p = 0.002) and 1 year after surgery (p = 0.037) in women. American Society of Anesthesiologists (ASA) class (OR: 11, [95% CI2.4-53]; p = 0.010), surgical difficulty (OR: 4.5, [95% CI 1-19]; p = 0.027) and anastomotic leakage (OR: 14, [95% CI 1.6-117]; p = 0.010), were identified as independent risk factors for deterioration of urinary function after surgery.

CONCLUSIONS

Our study showed worsening urinary dysfunction after rectal cancer surgery in 26.4% of the patients. However, there were no statistically significant differences in mean IPSS scores at the three assessment times (preoperatively, 6 months, 12 months). ASA class, surgical difficulty, and anastomotic leakage may predict postoperative deterioration.

Long-term functional and clinical outcomes following transanal advancement flap for complex anal fistula repair: are there predictors of recurrence and incontinence?

AIM

Transanal flap is an attractive technique for complex fistulas. The aim of this study was to identify factors associated with poor outcome, recurrence and incontinence.

METHOD

All patients who underwent an advancement flap for the treatment of a complex anal fistula between 1995 and 2019 were prospectively enrolled. The patient data obtained included age, sex, body mass index, comorbid conditions and smoking history. The fistula characteristics analysed included previous anal surgery, anatomy of the fistula according to Park's classification, horseshoe or supralevator extension and preoperative seton drainage. The postoperative data registered included complications, postoperative stay, recurrence and incontinence. Predictive factors for recurrence and incontinence were identified using univariate and multivariate analysis.

RESULTS

One hundred and ninety patients were included; 134 (70.5%) were men and the mean patient age was 50 years. The median length of follow-up was 44.6 months. The fistula recurred in 14 patients (7.3%). Before surgery, 20 patients (10.5%) reported incontinence symptoms. In the continent patients a Wexner postoperative score of 0 was identified in 79.4%. Wexner scores between 1 and 3 were observed in 17% and scores of 4 or more in five patients (3%). Factors associated with recurrence included age < 50 years (OR = 4.8, P = 0.02, 95% CI 1.2-19), smoking (OR = 4.1, P = 0.03, 95% CI 1-16.5) and suprasphincteric fistula (OR = 0.5, P = 0.01, 95% CI 0.2-0.8) in multivariate log regression analysis. Major incontinence was influenced by female sex and previous anal surgery (OR = 7.5, P = 0.003, 95% CI 1.6-34 and OR = 0.1, P = 0.007, 95% CI 0.1-0.7, respectively).

CONCLUSION

Full-thickness transanal advancement flap is a good treatment for complex anal fistula repair. This study provides relevant information on risk factors for failure of therapy and incontinence, which can help in advising patients before surgery and planning a good treatment strategy.

Impact of the number of stapler firings on anastomotic leakage in laparoscopic rectal surgery: a systematic review and meta-analysis

BACKGROUND

Several univariate and multivariate studies have already identified the number of stapler firings for laparoscopic rectal transection for rectal cancer as an independent risk factor for anastomotic leakage. The aim of this study was to perform a systematic review and meta-analysis of the anastomotic leakage rate in laparoscopic rectal surgery according to the need of using one or two stapler firings for rectal transection.

METHODS

PubMed, Ovid, the Cochrane Library database and ClinicalTrials.gov were searched. All of the statistical analyses were performed using Revman software.

RESULTS

Five studies were included (1267 patients). The overall anastomotic leakage rate was 5.5% [0.7-8.4%]. Anastomotic leak occurred in 3.5% (17/491) of the cases where 1 stapler firing was used versus 6.7% (50/786) of the cases in which 2 firings were needed (50/786). Two stapler firings were significantly associated with an increased risk of anastomotic leakage (OR 2.44, 95% CI 1.34-4.42, p = 0.003, I² = 1%).

CONCLUSIONS

Our systematic review and meta-analysis suggest that two firings imply a higher rate of anastomotic leak than a single firing after laparoscopic rectal surgery with a double stapling technique. Coloproctologists should strive to reduce the number of linear stapler firings and try to transect the rectum with a single firing.

The Boltzmann project

The International Committee for Weights and Measures (CIPM), at its meeting in October 2017, followed the recommendation of the Consultative Committee for Units (CCU) on the redefinition of the kilogram, ampere, kelvin and mole. For the redefinition of the kelvin, the Boltzmann constant will be fixed with the numerical value 1.380 649 × 10-23 J K-1. The relative standard uncertainty to be transferred to the thermodynamic temperature value of the triple point of water will be 3.7 × 10-7, corresponding to an uncertainty in temperature of 0.10 mK, sufficiently low for all practical purposes. With the redefinition of the kelvin, the broad research activities of the temperature community on the determination of the Boltzmann constant have been very successfully completed. In the following, a review of the determinations of the Boltzmann constant k, important for the new definition of the kelvin and performed in the last decade, is given.

Real-time random safety audits: A transforming tool adapted to new times

Real-time random safety audits constitute a tool designed to transfer knowledge from the sources of scientific evidence to the patient bedside. It has proven useful in critically ill patients, improving safety in the process of critical patient care, turning unsafe situations into safe ones in daily practice, and ensuring adherence to scientific evidence. In parallel, the design and methodology involved affords process indicators that will make it possible to know how we provide care for our patients, evolution over time (with regular feedback for professionals), the impact of our interventions, and benchmarking.

Feasibility and utility of the use of real time random safety audits in adult ICU patients: a multicentre study

PURPOSE

The two aims of this study were first to analyse the feasibility and utility (to improve the care process) of implementing a new real time random safety tool and second to explore the efficacy of this tool in core hospitals (those participating in tool design) versus non-core hospitals.

METHODS

This was a prospective study conducted over a period of 4 months in six adult intensive care units (two of which were core hospitals). Safety audits were conducted 3 days per week during the entire study period to determine the efficacy of the 37 safety measures (grouped into ten blocks). In each audit, 50% of patients and 50% of measures were randomized. Feasibility was calculated as the proportion of audits completed over those scheduled and time spent, and utility was defined as the changes in the care process resulting from tool application.

RESULTS

A total of 1323 patient-days were analysed. In terms of feasibility, 87.6% of the scheduled audits were completed. The average time spent per audit was 34.5 ± 29 min. Globally, changes in the care process occurred in 5.4% of the measures analysed. In core hospitals, utility was significantly higher in 16 of the 37 measures, all of which were included in good clinical practice guidelines. Most of the clinical changes brought about by the tool occurred in the mechanical ventilation and haemodynamics blocks. Multivariate analyses demonstrated that changes in the care process in each block were associated with the core hospital variable, staffing ratios and severity of patient disease.

CONCLUSIONS

Real time safety audits improved the care process and adherence to the clinical practice guidelines and proved to be most useful in situations of high care load and in patients with more severe disease. The effect was greater in core hospitals.

[Intensive care services resources in Spain]

OBJECTIVES

To identify the resources related to the care of critically ill patients in Spain, which are available in the units dependent of the Services of Intensive Care Medicine (ICM) or other services/specialties, analyzing their distribution according to characteristics of the hospitals and by autonomous communities.

DESIGN

Prospective observational study.

SETTING

Spanish hospitals.

PARTICIPANTS

Heads of the Services of ICM.

MAIN OUTCOME VARIABLES

Number of units and beds for critically ill patients and functional dependence.

RESULTS

The total number of registries obtained with at least one Service of ICM was 237, with a total of 100,198 hospital beds. Level iii (43.5%) and level ii (35%) hospitals predominated. A total of 73% were public hospitals and 55.3% were non-university centers. The total number of beds for adult critically ill patients, was 4,738 (10.3/100,000 inhabitants). The services of ICM registered had available 258 intensive are units (ICUs), with 3,363 beds, mainly polyvalent ICUs (81%) and 43 intermediate care units. The number of patients attended in the Services of ICM in 2008 was 174,904, with a percentage of occupation of 79.5% A total of 228 units attending critically ill patients, which are dependent of other services with 2,233 beds, 772 for pediatric patients or neonates, were registered. When these last specialized units are excluded, there was a marked predominance of postsurgical units followed by coronary and cardiac units.

CONCLUSIONS

Seventy one per cent of beds available in the Critical Care Units in Spain are characterized by attending severe adult patients, are dependent of the services of ICM, and most of them are polyvalent.

[Medication errors in Spanish intensive care units]

OBJECTIVE

To estimate the incidence of medication errors in Spanish intensive care units.

DESIGN

Post hoc study of the SYREC trial. A longitudinal observational study carried out during 24 hours in patients admitted to the ICU.

SETTING

Spanish intensive care units.

PATIENTS

Patients admitted to the intensive care unit participating in the SYREC during the period of study.

MAIN VARIABLES OF INTEREST

Risk, individual risk, and rate of medication errors.

RESULTS

The final study sample consisted of 1017 patients from 79 intensive care units; 591 (58%) were affected by one or more incidents. Of these, 253 (43%) had at least one medication-related incident. The total number of incidents reported was 1424, of which 350 (25%) were medication errors. The risk of suffering at least one incident was 22% (IQR: 8-50%) while the individual risk was 21% (IQR: 8-42%). The medication error rate was 1.13 medication errors per 100 patient-days of stay. Most incidents occurred in the prescription (34%) and administration (28%) phases, 16% resulted in patient harm, and 82% were considered "totally avoidable".

CONCLUSIONS

Medication errors are among the most frequent types of incidents in critically ill patients, and are more common in the prescription and administration stages. Although most such incidents have no clinical consequences, a significant percentage prove harmful for the patient, and a large proportion are avoidable.

Management of giant anal condyloma by wide local excision and anoplasty

AIM

Treatment of giant condyloma acuminatum, is controversial, especially in human immunodeficiency virus (HIV)-positive patients, owing to concern over wound healing, complications, risk of progression to carcinoma and a high recurrence rate. The aim of this study was to evaluate the outcome after extensive local excision with V-Y anoplasty.

METHOD

Nine patients were identified from a prospective database, six of whom were HIV positive. All patients had a giant perianal condyloma acuminatum extending into the anal canal and perianal region, which required wide excision with V-Y reconstruction. Postoperative complications, recurrence and continence were all determined.

RESULTS

Nine patients were included (eight men, median age 40 years), six seropositive for HIV infection. A bilateral V-Y anoplasty was performed in six patients, and unilateral in two. There were no postoperative infections, graft failures or flap necrosis. The mean follow-up was 92 (2-137) months. One patient developed local recurrence treated with excision under local anaesthesia.

CONCLUSIONS

Extensive local surgery of giant perianal condyloma with anoplastic reconstruction gives good results even in HIV-positive patients.

Efficacy of a brief multifactorial adherence-based intervention on reducing the blood pressure of patients with poor adherence: protocol for a randomized clinical trial

Background

Lowering of blood pressure by antihypertensive drugs reduces the risks of cardiovascular events, stroke, and total mortality. However, poor adherence to antihypertensive medications reduces their effectiveness and increases the risk of adverse events. In terms of relative risk reduction, an improvement in medication adherence could be as effective as the development of a new drug.

Methods/Design

The proposed randomized controlled trial will include patients with a low adherence to medication and uncontrolled blood pressure. The intervention group will receive a multifactorial intervention during the first, third, and ninth months, to improve adherence. This intervention will include motivational interviews, pill reminders, family support, blood pressure self-recording, and simplification of the dosing regimen.

Measurement

The primary outcome is systolic blood pressure. The secondary outcomes are diastolic blood pressure, proportion of patients with adequately controlled blood pressure, and total cost.

Discussion

The trial will evaluate the impact of a multifactorial adherence intervention in routine clinical practice. Ethical approval was given by the Ethical Committee on Human Research of Balearic islands, Spain (approval number IB 969/08 PI).

Trial registration

Current controlled trials ISRCTN21229328

[Pilot Drug Utilization Study of systemic antifungal agents in the Hospital Clínico San Carlos. Proposal of a study method]

INTRODUCTION

The study aims to define a method for the evaluation of the usage of systemic antifungal agents, and test it, in order to be able to develop larger studies.

METHOD

Drug Use Study, pilot, observational, prescription- indication. We proposed a definition of antifungal type of treatment using as host factors the EORTC (European Organization for Research and Treatment of Cancer) criteria, the patient's clinical data as well as any evidence of fungal infection. Adequate use was evaluated by three standards of comparison: summary of product characteristics, hospital recommendations and an experts' committee.

RESULTS

60 antifungal prescriptions were recovered: fluconazole: 39; itraconazole: 6; liposomal amphotericin B: 5; caspofungin: 5; voriconazole: 5. Treatment was started as follows (N;%): microbiological (28;46.7), empirical (22;36.7) and prophylactic use (7;11.7). The indication for antifungal treatment was considered adequate in more than 90% of the cases for the three standards of comparison, whereas selection in 75-83% of the cases.

CONCLUSIONS

The method is considered satisfactory for the evaluation of antifungal treatments and is proposed for being used in larger studies. For all the antifungal agents evaluated, a high degree of appropriateness of use was found, though some conditions are considered improvable.

Clonal complexes and diversity of exotoxin gene profiles in methicillin-resistant and methicillin-susceptible Staphylococcus aureus isolates from patients in a Spanish hospital

Molecular epidemiology studies have allowed the identification of the methicillin (meticillin)-resistant (MRSA) and methicillin-susceptible (MSSA) clonal complexes (CCs) and clones of Staphylococcus aureus circulating in a Spanish hospital recently. Of 81 isolates tested, 32.1% were MRSA. Most of them carried staphylococcal cassette chromosome mec (SCCmec) IVc (88.5%) and belonged to CC5 (88.5%; multilocus sequence typing types ST125 [mainly associated with spa type t067], ST5, and ST228). A higher diversity was found among MSSA isolates (67.9%). Eighty percent shared the genetic background of major MRSA lineages (CC5 [38.2%; ST125 and ST5], CC30 [25.5%; ST30], CC45 [14.5%; ST45 and ST47], and CC8 [1.8%; ST8]), but CC12, CC15, CC51, and CC59 were also detected. Many exotoxin genes were present in each of the 81 isolates, independent of whether they were involved in sepsis (11 to 22) or other types of infections (13 to 21), and they appeared in 73 combinations. The relevant data are that (i) all isolates were positive for hemolysin and leukotoxin genes (98.8% for lukED and 25.9% for lukPV); (ii) all contained an enterotoxin gene cluster (egc with or without seu), frequently with one or more genes encoding classical enterotoxins; (iii) about half were positive for tst and 95% were positive for exfoliatin-encoding genes (eta, etb, and/or etd); and (iv) the four agr groups were detected, with agrII (55.6%) and agrIII (23.5%) being the most frequent. Taken together, results of the present study suggest a frequent acquisition and/or loss of exotoxin genes, which may be mediated by efficient intralineage transfer of mobile genetic elements and exotoxin genes therein and by eventual breakage of interlineage barriers.

[Indicators of quality in the critical patient]

The utility of using quality indicators as a tool to measure the common practice and evaluate efficacy of measures established to improve quality has been demonstrated, making it possible to identify and make known the improvements carried out. The project "Quality indicators in the critical patient" has been conducted by the Spanish Society of Intensive and Critical Medicine (SEMICYUC) under the methodological management of the Foundation Avedis Donabedian (FAD) of Barcelona. Its objective was to develop key indicators in the care of the critical patient, considering the following as added values: reaching an agreement on the quality criteria in these patients and providing the professionals with a potent and reliable instrument for clinical evaluation and management, introducing common evaluation methods that make it possible to unify the measure, making a comparative evaluation (benchmarking), having information that makes it possible to develop quality plans (quantitative, objective, reliable and valid data) and having a system that assures total quality of care to the critical patient.

Real-time polymerase chain reaction for quantitative detection of histamine-producing bacteria: use in cheese production

Biogenic amines are toxic substances that appear in foods and beverages as a result of AA decarboxylation. The enzyme histidine decarboxylase catalyzes the decarboxylation of histidine to histamine, the biogenic amine most frequently involved in food poisoning. The aim of the present work was to develop a real-time quantitative PCR assay for the direct detection and quantification of histamine-producing strains in milk and cheese. A set of primers was designed, based on the histidine decarboxylase gene sequence of different gram-positive bacteria. The results show the proposed procedure to be a rapid (total processing time < 2 h), specific and highly sensitive technique for detecting potential histamine-producing strains. Chromatographic methods (HPLC) verified the capacity of real-time quantitative PCR to correctly quantify histamine accumulation.

Heterologous expression of enterocin AS-48 in several strains of lactic acid bacteria

AIMS

Enterococcus faecalis produces a cationic and circular enterocin, AS-48, of 7149 Da, the genetic determinants of which are located within the pMB2 plasmid. We have compared enterocin AS-48 production by different enterococci species with that of other 'safe' lactic acid bacteris (LAB) (GRAS status) and looked into the subsequent application of this enterocin in food production.

METHODS AND RESULTS

In an effort to exploit this system for the heterologous expression of enterocin AS-48, a number of vectors containing the as-48 cluster were constructed and used to transform several LAB strains (genera Enterococcus, Lactococcus and Lactobacillus)

CONCLUSION

Heterologous production of enterocin AS-48 failed when bacteria other than those belonging to the genus Enterococcus were used as hosts, although expression of a partial level of resistance against AS-48 were always detected, ruling out the possibility of a lack of recognition of the enterococcal promoters.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our results reveal the special capacity of species from the genus Enterococcus to produce AS-48, an enterocin that requires a post-transcriptional modification to generate a circular peptide with a wide range of inhibitory activity against pathogenic and spoilage bacteria. Preliminary experiments in foodstuffs using nonvirulent enterococci with interesting functional properties reveal the possibility of a biotechnological application of these transformants.

Epistatic interaction between FCRL3 and MHC in Spanish patients with IBD

Inflammatory bowel disease (IBD), which comprises ulcerative colitis (UC) and Crohn's disease (CD), shows a multifactorial origin, with genetic and environmental factors involved. Although the genetic influence is clear for both diseases, the genetics involved is complex and epistatic interactions with other genes probably exist. The Fc receptor-like 3 gene (FCRL3) maps to the human chromosome 1q21-22 and certain single nucleotide polymorphisms (SNPs) in its promoter have been associated with some autoimmune diseases. Our aim was to study the role of two promoter SNPs of the FCRL3 gene (-169A>G, rs7528684 and -110C>T, rs11264799) in patients with IBD and their interaction with HLA-DRB1 and CARD15 in patients with UC and CD, respectively. A case-control study with 311 patients with CD, 324 patients with UC and 497 healthy controls was performed. All the individuals were White Spaniards. No significant associations were found between any FCRL3 SNP and CD or UC, but the stratification in patients with UC by human leukocyte antigen (HLA) showed a significant increase in heterozygosity at the FCRL3 locus, especially -169 AG (AG vs AA+GG, P= 0.0027, odds ratio = 3.6, 95% confidence interval 1.4-2.9), when HLA-DRB1*0103 carrier patients were compared with HLA-DRB1*0103 noncarriers. Our data suggest an epistatic interaction between genes in chromosomes 6p21 and 1q21-22, marked, respectively, by HLA-DRB1*0103 and FCRL3-169 AG.

Multiplex PCR for the detection and identification of dairy bacteriophages in milk

Bacteriophage infections of starter lactic acid bacteria are a serious risk in the dairy industry. Phage infection can lead to slow lactic acid production or even the total failure of fermentation. The associated economic losses can be substantial. Rapid and sensitive methods are therefore required to detect and identify phages at all stages of the manufacture of fermented dairy products. This study describes a simple and rapid multiplex PCR method that, in a single reaction, detects the presence of bacteriophages infecting Streptococcus thermophilus and Lactobacillus delbrueckii, plus three genetically distinct 'species' of Lactococcus lactis phages commonly found in dairy plants (P335, 936 and c2). Available bacteriophage genome sequences were examined and the conserved regions used to design five pairs of primers, one for each of the above bacteriophage species. These primers were designed to generate specific fragments of different size depending on the species. Since this method can detect the above phages in untreated milk and can be easily incorporated into dairy industry routines, it might be readily used to earmark contaminated milk for use in processes that do not involve susceptible starter organisms or for use in those that involve phage-deactivating conditions.

[Adverse events in Intensive Medicine. Managing risk]

Health care interventions entail a risk of adverse events (AE), that may cause lesions, incapacities and even death in the patients. Given the complexity of the care of the critical patient, the Critical Care Services are a high risk setting for the appearance of AE in these patients, many of them avoidable. Several studies show the influence of organizational factors focused on the system in the reduction of care risk and on the result of the critical patients. The voluntary and anonymous registry and reporting systems make it possible to identify a significant percentage of these incidents, analyze the factors related (that contribute or limit), establish preventive strategies, permitting management of risk, and potentially reduce the appearance and consequences of avoidable AE with all this. Initiatives such as the ICU Safety Reporting System (ICUSRS), that use a web database as registry system and includes contributions from different sites, favor the safety and risk culture, essential in the improvement of health quality of critical patients.

A randomized, placebo-controlled study of donepezil in poststroke aphasia

We studied 26 patients in a randomized, placebo-controlled, double-blind parallel trial to evaluate the efficacy and safety of donepezil in chronic poststroke aphasia. Donepezil (10 mg/day) improved aphasia severity at endpoint (week 16) relative to placebo (p = 0.037).

Multi-day radon signals with a radioactive decay limb—Occurrence and geophysical significance

Multi-day signals, generally with duration of 2-10 days, are a prominent temporal variation type of radon (Rn) in geogas in the unsaturated zone. Rare multi-day Rn signals have been found which are characterized by: (a) a declining limb lasting up to 10 days which conforms to the radioactive decay of Rn, (b) recurs at the same location and (c) is recorded in diverse situations-volcanic and seismogenic. It suggested that a Rn blob is injected at a lower level on a steady upward flow of geogas whereby the rise and final fall of the signal are attributed to the edges of the blob while the central Rn-decay segment records the passing of the decaying blob itself. Rn-decay signals are a small subset of multi-day Rn signals which are considered as highly irregular and unusable for the understanding of geophysical processes. In difference, it is concluded that multi-day Rn signals are probably proxies of subtle geodynamic processes at upper crustal levels and are therefore significant for studying such processes.

[Effects of parenteral glutamine in patients submitted to bone marrow transplantation]

Bone marrow transplantation (BMT) is a therapy used for hematologic malignancies and solid tumors. Associated chemotherapy and radiotherapy to which these patients are submitted induce secondary effects, with a high metabolic stress. Glutamine is considered a conditionally essential amino acid, and has been shown effective in severe catabolic states. The aim of the study was to assess the effect of parenteral nutrition (PN) therapy supplemented with glutamine on duration of nutritional support in a group of patients with BMT. We have also analyzed associated complications, the nutritional status, the clinical course at 6 months, differences as to type of transplantation, and oral ingestion capability. This is a phase IV, randomized, double blind, and parallel clinical trial, done at a single center. The study was performed on 49 patients, 29% male and 71% female patients, with ages between 21-63 years, distributed in 3 diagnostic groups (leukemia, lymphoma, and solid tumors), and admitted to the Hematology Department of our Hospital. Fifty percent of the patients in each group have received PN supplemented with glutamine (0.4 g/kg/day of L-alanine-L-glutamine), and the other 50% have received standard PN.

RESULTS

we have not found significant differences nor at the beginning nor at the end of the study between both groups with regards to studied variables.

CONCLUSIONS

PN is and effective therapy for maintenance of the nutritional status in patients submitted to a therapy with a, highly catabolic effect such as BMT. Although we have not been able to show the efficacy of glutamine supplementation in this study with the used dose, it does have been effective in other reports.

The functional genetic variation in the PTPN22 gene has a negligible effect on the susceptibility to develop inflammatory bowel disease

The aim of this study was to assess the possible association between the protein tyrosine phosphatase non-receptor 22 (PTPN22) gene 1858C-->T (rs2476601, encoding R620W) polymorphism and inflammatory bowel disease (IBD). Our study population consisted of 1113 IBD [544 ulcerative colitis (UC) and 569 Crohn's disease (CD)] patients and 812 healthy subjects. All the individuals were of Spanish white origin. Genotyping of the PTPN22 gene 1858C-->T polymorphism was performed by real time polymerase chain reaction technology, using TaqMan 5'-allelic discrimination assay. The frequency of the PTPN22 1858T allele in healthy subjects was 6.2% compared with 6.7% in the UC patients and 5.1% in Crohn's patients. No statistically significant differences were observed when the PTPN22 1858C-->T allele and genotype distribution among CD patients, UC patients and healthy controls were compared. These results indicate that the PTPN22 1858C-->T polymorphism does not appear to play a major role in IBD predisposition in our population.

Multicenter study of the multiple organ dysfunction syndrome in intensive care units: the usefulness of Sequential Organ Failure Assessment scores in decision making

OBJECTIVE

This study examined the incidence and mortality of multiple organ dysfunction syndrome (MODS) in intensive care units, evaluated the limitation of life support in these patients, and determined whether daily measurement of the Sequential Organ Failure Assessment (SOFA) is useful for decision making.

DESIGN AND SETTING

Prospective, observational study in 79 intensive care units.

PATIENTS AND PARTICIPANTS

Of the 7,615 patients admitted during a 2-month period we found 1,340 patients to have MODS.

MEASUREMENTS AND RESULTS

We recorded mortality and length of stay in the intensive care unit and the hospital and the maximum and minimum total SOFA scores during MODS. Limitation of life support in MODS patients was also evaluated. Stepwise logistic regression was used to determine the factors predicting mortality. The in-hospital mortality rate in patients with MODS was 44.6%, and some type of limitation of life support was applied in 70.6% of the patients who died. The predictive model maximizing specificity included the following variables: maximum SOFA score, minimum SOFA score, trend of the SOFA for 5 consecutive days, and age over 60 years. The model diagnostic yield was: specificity 100%, sensitivity 7.2%, positive predictive value 100%, and negative predictive value 57.3%; the area under the receiver operating characteristic curve was 0.807.

CONCLUSIONS

This model showed that in our population with MODS those older than 60 years and with SOFA score higher than 9 for at least 5 days were unlikely to survive.

Cytotoxin and pyrogenic toxin superantigen gene profiles of Staphylococcus aureus associated with subclinical mastitis in dairy cows and relationships with macrorestriction genomic profiles

A set of 84 Staphylococcus aureus isolates collected from the milk of cows with subclinical mastitis in Asturias (a cattle region of Spain) and six control strains were tested for sequences of genes encoding hemolysins (hla, hlb, hld, hlg, and hlg-2), leukotoxins (lukPV, lukM, and lukED), toxic shock syndrome toxin (tst), and enterotoxins (sea to see, seg to ser, and seu) by conventional and multiplex PCR. It was found that 84, 83, 11, and 39 isolates carried some type of hl, luk, tst, or se gene, respectively, which were arranged in 14 exotoxin genotypes. All of the isolates were negative for lukPV, hlg, sea, sed, see, sej, sek, sep, seq, and ser. Two gene groupings could be related with pathogenicity islands-[lukED, seg, sei, sem, sen, seo +/- seu] with Sabeta-1 and [tst, sec, sel] with SaPIbov, present in 45 and 13.1% of the isolates, respectively-while 11.9% of them carried both islands. Only one contained seb (together with upsilonSabeta-1), and another contained seh (together with lukED). The isolates were also analyzed by pulsed-field gel electrophoresis performed with SmaI. Thirty-nine SmaI profiles (similarity coefficient [S] = 0.94 to 0.21) were differentiated; 12, 1, and 10 of these, respectively, were generated by isolates presumptively carrying Sabeta-1, SaPIbov, or both. Five SmaI profiles (S > or = 0.8) formed a cluster, which contained 20 and 10 isolates carrying one (upsilonSabeta-1) or both islands. These data show the high frequency of genes encoding cytotoxins and pyrogenic toxin superantigens, their relationship with pathogenicity islands, and their distribution among a diversity of genetic types of S. aureus related to subclinical mastitis.

Genetic procedures for identification of enterotoxigenic strains of Staphylococcus aureus from three food poisoning outbreaks

Three food poisoning restaurant outbreaks due to Staphylococcus aureus, occurring during June-October 2002 in the Principality of Asturias (PA), Spain, provided the basis for investigating some aspects of the molecular epidemiology of this organism. The methods applied to identify strains and lineages included multiplex-polymerase chain reaction (PCR) to detect nine enterotoxin (se) genes, and three DNA fingerprinting procedures: pulsed-field gel electrophoresis (PFGE) with SmaI, randomly amplified polymorphic DNA (RAPD) with two selected primers, and plasmid restriction analysis with HindIII. Thirty-two isolates were differentiated into three non-se and 12 se strains, which were outbreak-specific, except for one that was represented in two of the outbreaks. In outbreak 1, the 16 food isolates analyzed had sec, seg and sei genes and generated a distinctive DNA fingerprint, being assigned to a single strain. This strain could be categorized as endemic in the PA and associated to manually handled dairy products and nasal carriers. In outbreak 2, the four food isolates analyzed fell into three strains, each one displaying a different se-gene profile (sea, sec and seg-seh-sei) and a distinctive DNA fingerprint. In outbreak 3, the five food isolates tested fell into four seg-sei strains generating identical RAPD but different PFGE and plasmid profiles, and one sea strain also collected from two nasal carriers. This last strain had also been found in manually handled vegetables in outbreak 2, and it belongs to a not very frequently found sea lineage in the PA. Multiplex-PCR to detect se genes together with the three applied DNA fingerprint typing procedures proved therefore to be useful tools in subclassifying S. aureus for epidemiological purposes.

Septicaemia due to Corynebacterium striatum: molecular confirmation of entry via the skin

Septicaemia due to Corynebacterium striatum occurs infrequently. A case of C. striatum septicaemia with a known skin focus is reported in a 69-year-old male with ischaemia, refractory anaemia and treated for thyroid cancer. The characterization and typing of blood and cutaneous isolates was carried out using biochemical and DNA molecular typing methods to analyse the isolates. This is the first reported case with a documented source.

Salmonella serotype Virchow causing salmonellosis in a Spanish region. Characterization and survey of clones by DNA fingerprinting, phage typing and antimicrobial resistance

The diversity of Salmonella serotype Virchow organisms causing human salmonellosis in a Spanish region over 1990-1996 was studied by genetic and phenotypic procedures. Isolates showing identical DNA fingerprintings (ribotypes, RAPD-, REP- and ERIC-types) were clustered into the same lineage. Eight lineages were defined, of which only one caused diseases throughout the studied period. Eleven phage types (PTs) were represented, the most frequent being PTs 8, 19, 31, throughout the study period, and PT4a only during 1994. Class I integrons with variable regions of 1000-, 1600-, and 2300-bp in size were respectively present in 24, 3 and 5 multiresistant isolates; 43.5% of isolates were susceptible to antimicrobials, the rest were grouped into 17 R-profiles, including from one up to eight resistances. Plasmids could be recovered from 71.5% of isolates and grouped into 25 plasmid profiles (with 1-7 plasmids each); a 3.6 kb cryptic-plasmid and a 60 kb virulence-plasmid were those most frequently found. Phage type, presence and size of integrons, and resistance profile were used to differentiate 39 clones. During the period studied 135 cases of Virchow salmonellosis were identified; 93 were apparently sporadic whereas the remainder were associated with four outbreaks. Infants under 1 year constituted the most frequent age group, with 30 gastroenteritis and two septicaemia episodes. In the four outbreaks, different clones falling into the prevalent lineage were implicated but each clone was involved in only one outbreak.

Enterotoxin production and DNA fingerprinting in Staphylococcus aureus isolated from human and food samples. Relations between genetic types and enterotoxins

A total of 224 Staphylococcus aureus strains from human carriers (110 strains) and manually handled foods (114 strains) collected in the Principality of Asturias, Spain over 1995-1999 were analysed for the production of enterotoxins (SEs) A, B, C, and D by a reversed passive latex agglutination test and by amplification of ent genes (A, B, C, D, E, and J) using PCR. Sixty-two strains were enterotoxigenic and a good relation between detection of SEs and their ent genes was found. No strain carried entE and all strains producing SED carried entD and entJ genes. Among the enterotoxigenic strains the percentages registered were 29, 8, 35, 18, 2, 2, and 6 for SEA, SEB, SEC, SEDJ, SEAC, SEADJ and SECDJ, respectively. DNA fingerprinting of 77 strains (the SE prototypes, 62 enterotoxigenic and 10 non-enterotoxigenic [NE]) was carried out by randomly amplified polymorphic DNA using two selected primers independently. Combining results from both primers, 10 genetic types were defined, which showed a different degree of relationship (similarity coefficient: 0.9-0.36) and were clustered into three lineages. One lineage clustered five genetic types and a wide diversity of strains, mainly SEA, SEB, SEDJ, and NE. Another lineage clustered only SEC, SECDJ and NE strains. These two lineages showed a low genetic relationship and appeared as endemic in healthy humans living in the Principality of Asturias. The third lineage included only the prototype strains for SEA and SEE.

[Lingual hamartoma. Report of a case]

The hamartomas that are located in the lingual region are very strange tumours. There are very few published in the world literature. A patient that presented a hamartoma was diagnosed and treated in our department.

Generation of food-grade recombinant lactic acid bacterium strains by site-specific recombination

The construction of a delivery and clearing system for the generation of food-grade recombinant lactic acid bacterium strains, based on the use of an integrase (Int) and a resolvo-invertase (beta-recombinase) and their respective target sites (attP-attB and six, respectively) is reported. The delivery system contains a heterologous replication origin and antibiotic resistance markers surrounded by two directly oriented six sites, a multiple cloning site where passenger DNA could be inserted (e.g., the cI gene of bacteriophage A2), the int gene, and the attP site of phage A2. The clearing system provides a plasmid-borne gene encoding beta-recombinase. The nonreplicative vector-borne delivery system was transformed into Lactobacillus casei ATCC 393 and, by site-specific recombination, integrated as a single copy in an orientation- and Int-dependent manner into the attB site present in the genome of the host strain. The transfer of the clearing system into this strain, with the subsequent expression of the beta-recombinase, led to site-specific DNA resolution of the non-food-grade DNA. These methods were validated by the construction of a stable food-grade L. casei ATCC 393-derived strain completely immune to phage A2 infection during milk fermentation.

Endarteritis and mycotic aortic aneurysm caused by an oral strain of Actinobacillus actinomycetemcomitans

Actinobacillus actinomycetemcomitans was isolated from blood cultures of a 33-year-old febrile patient with a previously undiagnosed coarctation of the aorta. Subgingival samples from diseased periodontal pockets revealed the presence of A. actinomycetemcomitans. An infected (mycotic) aortic aneurysm and endarteritis were diagnosed and surgically treated. The identity of blood and oral clinical isolates of A. actinomycetemcomitans was supported by genetic analysis, including fingerprinting by restriction fragment length polymorphism, ribotyping, and random amplified polymorphic DNA; biotyping; and antibiogram typing. These data strongly suggest that the periodontal pockets were the primary source of A. actinomycetemcomitans endarteritis in this case.

Genetic typing methods applied to the differentiation of clonal lines among Salmonella enterica serogroup G strains causing human salmonellosis

In Spain, in November 1995, an epidemiological alert recommended the surveillance of Salmonella serogroup G. The nine clinical isolates collected after and the four collected before the alert in Asturias were differentiated into six clonal lines by the combination of results from HincII ribotyping, PCR ribotyping, and RAPD typing using primers named A and S. The seven Gumpensis isolates showed identical DNA fingerprinting with the four typing procedures falling into a line. Six of these were collected during May-August from people living in a single health area suggesting that they could be associated with a community outbreak. The four Worthington isolates fell into three other lines, one Poona isolate into another line and one Havana isolate into another. 100% typeability was shown with all methods. The reproducibility of HincII ribotyping was better than that of PCR-based methods, although these were less time-consuming. The highest discriminatory power was obtained with HincII ribotyping and RAPD typing using primer A.

Usefulness of ribotyping in a molecular epidemiology study of shigellosis

Ribotyping performed with six restriction endonucleases was used to study the molecular epidemiology of shigellosis in Asturias, Spain. The series included Shigella sonnei from 34 sporadic cases, 3 outbreaks and 3 reference strains, and S. Flexneri from sporadic cases and 1 reference strain. The S. sonnei strains were grouped into 5 ribotypes with Sal I, 4 with Hind III and Pvu II, 3 with Bgl II and EcoR I and 2 with Hinc II (Discriminatory Index (DI) between 0.54 and 0.14); the S. flexneri into 5 ribotypes with Sal I, Hinc II and Hind III, and 4 with the other enzymes (DI = 0.71 - 0.63). The combination of results for 2 or more enzymes facilitated and additional discrimination, the highest values in S. sonnei were for the 6 enzymes (16 types, DI = 0.91) and in S. flexneri for some combinations of 3 or more enzymes (7 types, DI = 0.81). Ribotypes with the 6 enzymes defined 16 clonal lines in S. sonnei and 7 in S. flexneri, which showed a different degree of genetic heterogeneity, and all the lines of each species falling into a different cluster. No line appeared as clearly endemic in the bowels of Asturian people.

Comprehensive liposuction of lower limbs: basic concepts

The basic concepts of the aesthetics of proportioning the lower limb region by liposuction are discussed. The operative technique and some clinical cases are also discussed.

[Cytokines and nitric oxide in streptococcal toxic shock syndrome]

The plasma levels of endotoxin, tumor necrosis factor- alpha (TNF-alpha), interleukin -1 beta (IL-beta), IL-6, IL-8 and the nitrites and nitrates (NO2-/NO3-) as stable metabolites of nitric oxide (NO) were studied in the plasma of 2 patients with the streptococci toxic shock syndrome (STSS) associated to necrotizing fasciitis. A plasma profile of inflammatory mediators with high cytokine concentrations and NO2-/NO3- were observed with circulating endotoxin not being detected in plasma. The first patient died of fulminant refractory shock while the second survived following subacute evolution. The mediators profile, which was much higher in the first case, coincided with clinical severity. These data suggest that the cytokines and NO may have a role in the physiopathology of STSS and the severity of it is related to the levels of these mediators in the acute phase.

L-arginine: nitric oxide pathway in endotoxemia and human septic shock

OBJECTIVE

To investigate the relationship between nitric oxide production, endotoxemia, and hemodynamic alterations in human septic shock.

DESIGN

Prospective study.

SETTING

A 32-bed intensive care unit in a university referral hospital.

PATIENTS

Two groups of septic patients with shock (n = 13) or without shock (n = 16) and an additional group of nonseptic patients as control group (n = 25).

MEASUREMENTS

Plasma nitrite and nitrate concentrations were measured as an index of nitric oxide generation. Nitrite and nitrate concentrations were correlated with plasma endotoxin and hemodynamic variables.

MAIN RESULTS

Increased plasma nitrite and nitrate concentrations were found in patients with septic shock (p < .01). Nitrite and nitrate correlated directly with endotoxin concentration (r2 = .21, p < .05) and cardiac output (r2 = .49, p < .05), and inversely with systolic blood pressure (r2 = .24, p < .01).

CONCLUSIONS

This study demonstrated the activation of the L-arginine:nitric oxide pathway in human endotoxemic septic shock, suggesting that nitric oxide may be an important mediator of the hemodynamic disturbances in this pathophysiologic situation.

Interleukin-10 and the monocyte/macrophage-induced inflammatory response in septic shock

Interleukin (IL)-10 is a potent immunosuppressant of monocyte/macrophage function and may help control the inflammatory response induced by bacterial infection. To analyze whether IL-10 is detectable in plasma of patients with septic shock and to evaluate its relationship with endotoxin (lipopolysaccharide [LPS])-induced and monocyte/macrophage-induced inflammatory response, plasma IL-10, tumor necrosis factor (TNF)-alpha, IL-1 beta, IL-6, IL-8, LPS, and neopterin were studied in 24 patients with septic shock and in 12 critically ill patients. Eighty-three percent of patients with septic shock and 25% of critically ill patients had detectable levels of IL-10 (P < .001). There was a significant correlation between plasma IL-10, neopterin (r = .72), TNF-alpha (r = .76), IL-6 (r = .68), and IL-8 (r = .61) levels in patients with septic shock. Monocyte/macrophage activation leads to massive secretion of IL-10, which, however, seems to be unable to control the increased production of proinflammatory mediators during septic shock.

[The isolation of Schizophyllum commune in Panama]

The authors report the isolation of the basidiomycete Schizophyllum commune in two enclosed areas of healthy facilities in the city of Panama. The growth occurred in Sabouraud's agar as a white mycelium which gradually rose above the surface of the culture medium until it became a fan-shaped basidiocarp. This basidiomycete is found in environmental samples, but since there have been reports of its role in pathologic processes it should be included in the etiologic differential diagnosis in some patients and clinical laboratory must identify it and not discard it as a "contaminant".

[Surgical approach to the middle ear of the guinea pig]

A total of 40 guinea pigs have been used: in 5 a general anatomical dissection of the temporal bone was utilized; in another 5 guinea pigs a submandibular approach was performed; and in the remaining 30 a superior approach was employed. The submandibular approach begins with an incision of 30 mm inside of and parallel to the inferior border of the mandible , identifying the masseter muscle, the salivary gland, the thymus and posterior belly of the digastric muscle and, finally, the tympanic bulla. In the superior approach a horizontal supra-auricular incision of 15 mm is used which, after dissecting the temporal muscle, permits the access to the external wall of the epitympanum.