Severe sepsis in the emergency department: an observational cohort study from the university hospital of the West Indies / Sepsis severa en la sala de emergencias: un estudio observacional de cohorte en el hospital universitario de West Indies

OBJECTIVE: To describe the incidence, treatment and outcomes of patients with severe sepsis and septic shock in a setting where early goal directed therapy (EGDT) is not routinely performed. METHOD: An observational study of all adult patients admitted from the emergency department (ED) of the University Hospital of the West Indies (UHWI) with a diagnosis of severe sepsis and septic shock from July 5, 2007 to September 1, 2008 was conducted. Baseline parameters, treatment patterns and inhospital outcomes were evaluated. RESULTS: A total of 58 011 patients were seen and 762 (1.3%) had sepsis, 117 (15.4%) of whom were classified as severe sepsis or septic shock. Mean (SD) age was 59.2 (23.3) years and 49% were female. Medical history included hypertension (29%), diabetes mellitus (26%), stroke (8%), heart failure (6%) and HIV (6%). The most common sources of sepsis were pneumonia (67%) and urinary tract infection (46%). Median, interquartile range (IQR) time from triage to antibiotic administration was 126 (88, 220) minutes and antibiotics were given to 65.7% within three hours. Overall, organisms were sensitive to empirical antibiotics in 69%. Median (IQR) lactate was 5.3 (4.5, 7.5) mmol/L. Most patients (95%) were admitted to the ward; 1% went to the intensive care unit (ICU) and 2% died in the ED. Mean (SD) length of hospital stay was 9.5 (10.3) days. Inhospital mortality was 25% and survival correlated inversely with age (r pb = 0.25; p = 0.006). CONCLUSION: Despite a lack of EGDT, sepsis treatment patterns were consistent with "bestpractice" and mortality was lower than international comparators.

OBJETIVO: Describir la incidencia, el tratamiento y los resultados para pacientes con sepsis severa y shock séptico en un entorno donde la terapia dirigida por metas tempranas (TDMT) no se realiza de modo rutinario. MÉTODO: Se realizó un estudio observacional de todos los pacientes adultos con diagnóstico de sepsis severa y shock séptico, ingresados en la Sala de Emergencias del Hospital Universitario de West Indies (HUWI) desde el 5 de julio de 2007 al 1ero. de septiembre de 2008. Se evaluaron los parámetros iniciales de referencia, los patrones de tratamiento, y la evolución intrahospitalaria. RESULTADOS: Un total de 58 011 pacientes fueron vistos, 762 (1.3%) de ellos con sepsis. De estos casos con sepsis, 117 (15.4%) fueron clasificados como sepsis severa o shock séptico. La edad media (SD) fue 59.2 (23.3) años y 49% eran mujeres. Historia clínica incluía hipertensión (29%), diabetes (26%), accidente cerebrovascular (8%), insuficiencia cardíaca (6%) y VIH (6%). Las fuentes más comunes de la sepsis fueron neumonía (67%) e infección del tracto urinario (46%). La mediana del tiempo (IQR) transcurrido desde la selección (triaje) hasta la administración de antibióticos fue 126 (88, 220) minutos, y los antibióticos fueron entregados al 65.7% dentro de las tres horas. En general, los organismos fueron sensibles a los antibióticos empíricos en 69%. La mediana del lactato (IQR) fue 5.3 (4.5, 7.5) mmol/L. La mayoría de los pacientes (95%) fueron ingresados a la sala; 1% se destinó a la unidad de cuidados intensivos (UCI), y el 2% murió en la Sala de Emergencias. El promedio (SD) de la estancia hospitalaria fue de 9.5 (10.3) días. La mortalidad intrahospitalaria fue de 25%, y la supervivencia se halló en correlación inversa con la edad (rpb = .25; p = 0.006). CONCLUSIÓN: A pesar de la falta de TDMT, los patrones del tratamiento de sepsis fueron consistentes con las "mejores prácticas", y la mortalidad fue menor comparada con los datos de comparación a nivel internacional.

Ileal perforation in typhoid: bacteriological and immunological findings.

In typhoid perforation patients, Salmonella typhi was isolated from blood in 4%, ileal contents in 23%, peritoneal pus in 13% and from mesenteric lymph nodes in 71%. While isolation of S. typhi was made from patients with less than 4 days of chloramphenicol therapy, cultures were negative from these sites after 5 days of therapy; however, S. typhi appeared to remain viable in the lymph nodes even after such therapy. All isolates of S. typhi were sensitive to chloramphenicol. Significant SAT titers (0 > or = 1/240) were obtained in only 7/21 (33%) of patients. The perforated group had lower geometric mean titers (0-1/138; H-1/46), when compared to matched patients with uncomplicated typhoid fever (0-1/476; H-1/148). This difference was significant (0- p < 0.005; H- p < 0.0025). The two groups (uncomplicated and perforated) showed no significant difference in total serum IgG, IgM and IgA or isohemagglutinin levels, indicating that the apparent hyporeactivity was not due to a generalized humoral immunodeficiency. Mesenteric lymph node histology showed hyporeactivity in both the T cell and B cell zones. These findings are discussed with the suggestion that S. typhi-specific host immunological hyporeactivity could be an explanation for these observations and a basis for the pathogenesis of perforation. Aerobic cultures of the peritoneal pus gave 39 isolates from 25 patients; the predominant isolates were Escherichia coli (24) and Klebsiella pneumoniae (12). On no occasion was S. typhi the predominant isolate. Gentamicin and kanamycin were the only two antibiotics which were consistently effective in vitro against the aerobic isolates from peritoneal pus.

Absorcion espontanea del cristalino.Presentacion de casos clinicos y analisis de los sindromes en que se observa el fenomeno. / Spontaneous absorption of the crystalline lens: report of clinical cases and analysis of syndromes where the phenomenon is observable

Se presentan cinco casos clinicos de absorcion espontanea del cristalino. Un caso era consecutivo a trauma sin evidencias de perforacion ocular, dos casos eran debidos a rubeola congenita, un caso se debia a persistencia de vitreo primario hiperplastico y un caso era un sindrome de Hallermann-Streiff. Los sindromes en que se presenta este fenomeno son analizados en profundidad haciendo referencia a otros elementos clinicos que lo acompanan en cada uno de ellos. Se hace una revision bastante exhaustiva de la literatura la que no tiene pretensiones de ser completa