Imported Human West Nile Virus Lineage 2 Infection in Spain: Neurological and Gastrointestinal Complications.

We report the first human case of West Nile virus (WNV) lineage 2 infection imported to Spain by a traveler returning from Romania. Serum, cerebrospinal fluid and urine samples were analyzed and West Nile virus infection was identified by PCR and serological tests. The patient developed fever, diarrhea and neurological symptoms, accompanied by mild pancreatitis, described previously in very few cases as a complication of WNV infection and by alithiasic cholecystitis. Viral RNA was detected in urine until 30 days after the onset of symptoms and neutralizing antibodies were detected at very low titers. The phylogenetic analysis in a fragment of the NS5 gene of the virus showed a homology with sequences from WNV lineage 2 belonging to the monophyletic Central/Southern European group.

Longitudinally extensive transverse myelitis with neuro-lymphatic protein expressionin systemic lupus erithematosus patient. An autopsy case report / Mielitis transversa longitudinal extensa con expresión proteica neurolinfática en un paciente con lupus eritematoso sistémico. Reporte de una autopsia

Acute transverse myelitis (inflammation across one or more segments of spinal cord) is a rare complication of systemic lupus erythematosus (SLE) although its frequency is greater than in the general population. Even less common is longitudinal extensive transverse myelitis (LETM), (inflammation affects three or more vertebral segments). The pathogenesis of LETM is unclear and the management uncertain. We present a case of a 34-year-old woman with SLE and LETM of the whole spine, with rapid progression despite intensive treatment. Autopsy revealed a spine with liquefactive necrosis; some vessels showed fibrinoid necrosis and there were thrombi and an infiltration of lymphocytes and neutrophils in both the grey and white matter. Histological examination of brain revealed necrosis and oedema in the cortex and around the lateral ventricles. The immunohistochemistry showed CD3-positive T-lymphocytes in the wall of the spinal blood vessels, and a prominent D2-40 immunostaining, mainly localized at perivascular inflammatory regions (AU)

La mielitis aguda transversa (inflamación en uno o más segmentos de la médula espinal) es una complicación muy rara, con mayor prevalencia en los pacientes con lupus eritematoso sistémico que en la población general. Mucho menos frecuente es que esta inflamación afecte a 3 o más segmentos espinales. Su patogénesis no está bien definida y el tratamiento es incierto. Presentamos un caso de autopsia de una mujer de 34 años de edad con lupus eritematoso sistémico y mielitis transversa longitudinal extensa con un evolución clínica rápidamente desfavorable. Se encontró una médula espinal con necrosis licuefactiva, necrosis fibrinoide de la pared de los vasos, trombos en los mismos y una infiltrado inflamatorio de linfocitos y neutrófilos en la sustancia gris y blanca. En el cerebro había necrosis y edema de la corteza y alrededor de los ventrículos laterales. El estudio inmunohistoquímico mostró linfocitos T CD3 positivos en la pared de los vasos, con una fuerte expresión de D2-40 perivascular (AU)

Clinical risk conditions for acute lung injury in the intensive care unit and hospital ward: a prospective observational study.

BACKGROUND: Little is known about the development of acute lung injury outside the intensive care unit. We set out to document the following: the association between predefined clinical conditions and the development of acute lung injury by using the American-European consensus definition; the frequency of lung injury development outside the intensive care unit; and the temporal relationship between antecedent clinical risk conditions, intensive care admission, and diagnosis of lung injury. METHODS: We conducted a 4-month prospective observational study in three Spanish teaching hospitals, enrolling consecutive patients who developed clinical conditions previously linked to lung injury, both inside and outside the intensive care unit. Patients were followed prospectively for outcomes, including the diagnosis of acute lung injury or acute respiratory distress syndrome. RESULTS: A total 815 patients were identified with at least one clinical insult; the most common were sepsis, pneumonia, and pancreatitis. Pulmonary risk conditions were observed in 30% of cases. Fifty-three patients (6.5%) developed acute lung injury; 33 of these (4.0%) met criteria for acute respiratory distress syndrome. Lung injury occurred most commonly in the setting of sepsis (46/53; 86.7%), but shock (21/59; 36%) and pneumonia (20/211; 9.5%) portended the highest proportional risk; this risk was higher in patients with increasing numbers of clinical risk conditions (2.2%, 14%, and 21% (P < 0.001) in patients with one, two, and three conditions, respectively). Median days (interquartile range) from risk condition to diagnosis of lung injury was shorter with pulmonary (0 (0 to 2)) versus extrapulmonary (3 (1 to 5)) (P = 0.029) risk conditions. Admission to the intensive care unit was provided to 9/20 (45%) patients with acute lung injury and to 29/33 (88%) of those with acute respiratory distress syndrome. Lung injury patients had higher mortality than others (acute lung injury 25.0%; acute respiratory distress syndrome 45.5%; others 10.3%; P < 0.001). CONCLUSION: The time course from clinical insult to diagnosis of lung injury was rapid, but may be longer for extrapulmonary cases. Some patients with lung injury receive care and die outside the intensive care unit; this observation needs further study.

Sepsis incidence and outcome: contrasting the intensive care unit with the hospital ward.

OBJECTIVE: To describe the outcome of patients with sepsis according to location on a ward or in an intensive care unit. DESIGN: Prospective multicentered observational study. SETTING: Three academic hospitals in Madrid, Spain. PATIENTS: Consecutive patients with sepsis admitted to participating hospitals from March 1 to June 30, 2003. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the study period, 15,852 patients >18 yrs of age were admitted. Sepsis was identified in 702 patients, giving an estimated cumulative incidence rate of 367 cases per 100,000 adult area residents per year and a cumulative incidence rate among patients admitted to the hospital of 4.4%. Most septic patients had a community-acquired infection (71%). Severe sepsis developed in 199 patients (incidence rate, 104 cases per 100,000 adult area residents per year), and 59 patients developed septic shock (incidence rate, 31 cases per 100,000 adult area residents per year). Most of the patients met the criteria for severe sepsis or septic shock on the same day that they would have qualified for the septic status one step down the scale. In the other patients, the median time between sepsis and severe sepsis was 2 days (interquartile range, 2-5) and between severe sepsis and septic shock was 3 days (interquartile range, 1-4). Only 32% of severe sepsis patients received intensive care. The hospital mortality for all septic patients was 12.8%; for severe sepsis, 20.7%; and for septic shock, 45.7%. CONCLUSIONS: This study shows the high incidence of sepsis in a general population of patients admitted to hospital. A significant proportion of patients with severe sepsis are not transferred to the intensive care unit.

Noninvasive vs conventional mechanical ventilation in acute respiratory failure: a multicenter, randomized controlled trial.

STUDY OBJECTIVE: Noninvasive mechanical ventilation (NIMV) is beneficial for patients with acute respiratory failure (ARF) when added to medical treatment. However, its role as an alternative to conventional mechanical ventilation (CMV) remains controversial. Our aim was to compare the efficacy and resource consumption of NIMV against CMV in patients with ARF. DESIGN: A randomized, multicenter, controlled trial. SETTING: Seven multipurpose ICUs. PATIENTS: Sixty-four patients with ARF from various causes who fulfilled criteria for mechanical ventilation. INTERVENTION: The noninvasive group received ventilation through a face mask in pressure-support mode plus positive end-expiratory pressure; the conventional group received ventilation through a tracheal tube. MEASUREMENTS AND RESULTS: Avoidance of intubation, mortality, and consumption of resources were the outcome variables. Thirty-one patients were assigned to the noninvasive group, and 33 were assigned to the conventional group. In the noninvasive group, 58% patients were intubated, vs 100% in the conventional group (relative risk reduction, 43%; p < 0.001). Stratification by type of ARF gave similar results. In the ICU, death occurred in 23% and 39% (p = 0.09) and complications occurred in 52% and 70% (p = 0.07) in the noninvasive and conventional groups, respectively. There were no differences in length of stay. The Therapeutic Intervention Score System-28, but not the direct nursing activity time, was lower in the noninvasive group during the first 3 days. CONCLUSIONS: NIMV reduces the need for intubation and therapeutic intervention in patients with ARF from different causes. There is a nonsignificant trend of reduction in ICUs and hospital mortality together with fewer complications during ICU stay.

[Intrahospital mortality after discharge from the ICU (hidden mortality) in patients who required mechanical ventilation]. / Mortalidad intrahospitalaria tras el alta de una unidad de cuidados intensivos en pacientes que han precisado ventilación mecánica.

BACKGROUND AND OBJECTIVE: Our goal was to determine the hidden mortality (HM) in patients who underwent an episode of mechanical ventilation (MV). We also analyzed the factors associated with an increase in the risk of hidden mortality. PATIENTS AND METHOD: Prospective cohort study. Patients admitted to an ICU who required MV and who were monitored until their discharge from hospital. We performed a multivariate study with a logistic regression model including all the variables that were present in a univariate analysis p < 0.20. RESULTS: Forty-one of the 215 patients who were discharged from the ICU died when they were admitted to hospital, which represents a hidden mortality rate of 19% (CI 95% 11%-27%). A mean period of 9 days elapsed between discharge from the ICU and patient's death, with 25% of patients dying within the first two days. Commonest cause of death was respiratory failure (37%). Factors independently associated with an increase in the risk of hidden mortality were (values expressed as adjusted odds ratio (CI 95%): age > 74 years 1.15 (1.01 to 1.26) (p = 0.02); APACHE II > 29 1.14 (1.01 to 1.27) (p = 0.04); reason for MV being coma 1.21 (1.07 to 1.37) (p = 0.002); reason for MV being cardiopulmonary arrest 1.28 (1.18 to 1.68) (p < 0.001); tracheotomy in ICU 1.31 (1.19 to 1.68) (p < 0.001) and stay in the ICU longer than 16 days 1.35 (1.01 to1.70) (p = 0.04). CONCLUSIONS: An important number of patients discharged from the ICU after an episode of MV die in hospital. Risk factors associated with an increased risk of death in hospital identify a group of patients who, after excluding those with non-cardiopulmonary resuscitation orders, would possibly benefit from high surveillance or intermediate care units.

Mortalidad intrahospitalaria tras el alta de una unidad de cuidados intensivos en pacientes que han precisado ventilación mecánica / Intrahospital mortality after discharge from the ICU (hidden mortality) in patients who required mechanical ventilation

FUNDAMENTO Y OBJETIVO: Establecer la mortalidad oculta (MO) de los pacientes tras un episodio de ventilación mecánica (VM) y analizar los factores asociados a incremento de riesgo de MO. PACIENTES Y MÉTODO: Estudio prospectivo de cohortes que incluyó a pacientes ingresados en una unidad de cuidados intensivos (UCI) polivalente que requirieron VM, seguidos hasta el alta hospitalaria. Se realizó un estudio multivariable mediante modelo de regresión logística que incluyó todas las variables que presentaron en el análisis univariable un valor de p < 0,20. RESULTADOS: De los 215 pacientes dados de alta de la UCI, 41 fallecieron en el hospital, siendo la MO del 19 por ciento (IC del 95 por ciento, 11-27 por ciento) El tiempo transcurrido desde el alta de la UCI hasta el fallecimiento fue de 9 días de mediana, y el 25 por ciento de los pacientes falleció en los dos primeros días. La causa más frecuente de fallecimiento fue la insuficiencia respiratoria (37 por ciento). Los factores asociados de forma independiente al incremento de riesgo de MO fueron (valores expresados como odds ratio ajustada [IC del 95 por ciento]), la edad superior a 74 años (1,15 [1,01-1,26]) (p = 0,02), un índice APACHE II mayor de 29 (1,14 [1,01-1,27]) (p = 0,04), coma como motivo de VM (1,21 [1,07-1,37]) (p = 0,02), parada cardíaca como motivo de VM (PCR) (1,28 [1,181,68]) (p < 0,001), traqueotomía en UCI (1,31 [1,19-1,68]) (p < 0,001) y estancia en UCI superior a 16 días (1,35 [1,01-1,70]) (p = 0,04). CONCLUSIONES: Un porcentaje importante de pacientes dados de alta de la UCI tras un episodio de VM fallecen en el hospital. Los factores de riesgo asociados con un incremento de riesgo de muerte en el hospital identifican a un grupo de pacientes, excluyendo a aquellos en los que hay una orden de no practicar maniobras de resucitación cardiopulmonar, que posiblemente se beneficiarían de unidades de alta vigilancia o de cuidados intermedios. (AU)