[Observational study of patients admitted to an Internal Medicine service]. / Estudio observacional de los pacientes ingresados en un Servicio de Medicina Interna.

OBJECTIVES: To analyse the entered more frequent disease in an Internal Medicine Department, the reasons for hospital admission diagnosis at discharge (according to entrance symptom's guide), the group of affected population and its correlation among them. PATIENTS AND METHODS: Over a total of 758 internal medicine admissions of the University Hospital of Valladolid during the year 1999 based on the information of discharge and clinical histories, a descriptive and observational epidemic study was made using the variables of sex, age, reason for admission (guide symptom) and diagnosis at discharge. The obtained results were represented by mean of diagrams of sectors and bars according to the analyzed variables. The data synthesis was made by measures of central tendency and dispersion. SPSS 10.0 version for windows program was used for the statistical study. The non parametric analysis for independent samples was made by the test of median and the U of Mann Whitney, and the parametric by chi-squired test and resistance of Kolmogorov-Smirnov. RESULTS: The median of age is 70 years. Rank 84 years. Interquartile rank 23, fashion in men 75 years and in women 86. The distribution in sex men 51%, women 49%. The more frequent reasons for entrance are dyspnea (35%) and neurological focus (11%). The more frequent diagnosis at discharge are dyspnea and chronic obstructive lung disease worsened by respiratory infection (11%), pneumonia (8%) and acute ischemic stroke (7%). CONCLUSIONS: In-patients in this service, are advanced in years (mainly women) (alpha = 0.05). The age does not get a normal distribution (alpha = 0.05). The frequency of the distribution in sex is similar. The most frequent reason for admission is dyspnea (35%). The most frequent diagnoses at discharge are chronic obstructive lung disease (11%), pneumonia (8%) and acute ischemic stroke (7%). The primary and secondary prevention and an improvement of the therapeutic measures of chronic cardiopulmonary disease would reduce significantly the welfare pressure in Internal Medicine Department and they would improve the population's life quality given that we are opposed to the diseases which are among the four first mortality causes in the world.

Estudio observacional de los pacientes ingresados en un Servicio de Medicina Interna / Observational study of in-patiens in an Internal Medicine Department

Objetivos: Analizar las patologías más frecuentes ingresadas en un servicio de Medicina Interna, los motivos de ingreso hospitalario, los diagnósticos al alta (según el síntoma guía de ingreso), el grupo de población afectada y su correlación entre ellos. Pacientes y métodos: Sobre un total de 758 ingresos en Medicina Interna del Hospital Universitario de Valladolid, durante el año 1999, en función de los informes de alta e historias clínicas, se realizó un estudio epidemiológico descriptivo observacional, utilizando las variables de sexo, edad, motivo de ingreso (síntoma guía) y diagnósticos al alta. Los resultados obtenidos fueron representados por medio de diagramas de sectores y de barras, en función de las variables analizadas. Para la síntesis de datos fueron utilizadas, medidas de tendencia central y de dispersión. El estudio estadístico empleado fue el programa SPSS versión 10.0 para Windows. El análisis no paramétrico para muestras independientes fue realizado con: la prueba de la mediana y U de Mann-Whitney, y el análisis paramétrico con el test 2 y contraste de Kolmogorov-Smirnov. Resultados: La mediana de edad es de 70 años, rango 84 años, rango intercuartílico de 23, con una moda en varones de 75 años y en mujeres de 86 años. La distribución por sexo: varones 51 por ciento, mujeres 49 por ciento. Los motivos de ingreso más frecuentes son: la disnea (35 por ciento) y la focalidad Neurológica (11 por ciento). Los diagnósticos al alta más frecuentes: EPOC reagudizado por infección respiratoria (11 por ciento), neumonía (8 por ciento) y ACVA isquémico (7 por ciento). Conclusiones: Los pacientes ingresados en este servicio son de edad avanzada (sobretodo en mujeres), ( = 0,05) significación estadística. La edad no sigue una distribución normal ( = 0,05) significación estadística. La frecuencia en la distribución por sexo es similar. El motivo de ingreso más frecuente es la disnea (35 por ciento). Los diagnósticos al alta más frecuentes son: La EPOC (11 por ciento), la neumonía (8 por ciento) y el ACVA isquémico (7 por ciento). La prevención 1ª y 2ª y una mejora de la medidas terapéuticas de las enfermedades crónicas cardiorrespiratorias, reduciría, significativamente la presión asistencial de los servicios de Medicina Interna y mejoraría la calidad de vida de la población, dado que estamos frente a enfermedades que están dentro de las cuatro primeras causas de mortalidad en el mundo (AU)

Disseminated microsporidiosis in a renal transplant recipient.

Disseminated microsporidiosis is diagnosed uncommonly in patients not infected with human immunodeficiency virus (HIV). We present a case of disseminated microsporidiosis in a renal transplant recipient who was seronegative for HIV. Chromotrope-based stains were positive for microsporidia in urine, stools, sputum, and conjunctival scrapings. Electron microscopy, immunofluorescence, polymerase chain reaction, and cultures of renal tissue identified the organism as Encephalitozoon cuniculi. The patient was treated with oral albendazole and topical fumagillin with clinical improvement. In addition, she underwent a transplant nephrectomy and immunosuppressive therapy was withdrawn. Follow-up samples were negative for microsporidia. However, the patient developed central nervous system manifestations and died. An autopsy brain tissue specimen demonstrated E. cuniculi by immunofluorescent staining. Disseminated microsporidiosis must be considered in the differential diagnosis of multiorgan involvement in renal allograft recipients.

Prevention of primary cytomegalovirus disease in organ transplant recipients with oral ganciclovir or oral acyclovir prophylaxis.

BACKGROUND: Optimal prophylaxis against cytomegalovirus (CMV) disease for organ transplant patients at risk for primary infection (donor seropositive, recipient seronegative, D+R-) remains to be determined. We hypothesized that prolonged oral ganciclovir therapy following intravenous therapy would provide increased protection. METHODS: A total of 155 evaluable D+R- organ transplant recipients from 13 transplant centers were entered into the study: all received intravenous ganciclovir (5 mg/kg/day) for 5-10 days and then either oral acyclovir (400 mg tid) or oral ganciclovir (1 g tid) for an additional 12 weeks. Patients were assigned to their treatment groups at a central randomization site, with a separate randomization scheme for each of the organs transplanted (kidney, heart, or liver). In the case of kidney transplants, the patients were stratified according to source of the kidney (living related vs. cadaveric donor). The primary endpoint was the incidence of CMV disease in the first six months post-transplant. RESULTS: Treatment with oral ganciclovir was associated with a significant decrease in the incidence of symptomatic disease or viremia when compared with the oral acyclovir group (32% vs. 50%, P<0.05). This difference was most marked in terms of tissue invasive disease: only 3 of 15 symptomatic patients in the ganciclovir group vs. 10 of 21 in the acyclovir group developed tissue-invasive infection (P<0.05). There was a significant difference in the time to CMV disease or viremia in the two groups: mean time 212+/-17 days post-transplant for the acyclovir group vs. 291+/-13 days for the ganciclovir group (P<0.001). The incidence of allograft rejection was 34% in the ganciclovir group and 46% in the acyclovir group (P=NS). Leukopenia was more common in the ganciclovir group (P<0.05), but in no case did it require drug discontinuation. Ganciclovir resistance did not develop in this study. CONCLUSION: Prophylaxis with oral ganciclovir following a brief course of intravenous ganciclovir provides useful protection against primary CMV disease.

Prospective evaluation of malignant neoplasms in cardiac transplant recipients uniformly treated with prophylactic antilymphocyte globulin.

Although there is convincing evidence that prophylactic administration of high doses of the monoclonal antibody OKT3 predisposes patients to an increased prevalence of early posttransplantation malignancy, particularly posttransplantation lymphoproliferative disease, it is indeterminate whether polyclonal antilymphocyte globulin poses a similar hazard. We reviewed the outcome of 112 consecutive cardiac transplant recipients who received uniform immunosuppression, including induction therapy with antilymphocyte globulin, and were prospectively followed-up for a median duration of 41.5 months (range 1 to 81 months). No patients had posttransplantation lymphoproliferative disease. Nine malignant neoplasms (8%) were detected from 6 to 70 months after transplantation. Four patients with cutaneous neoplasms were alive and well at the time this article was written. Three patients died of disseminated adenocarcinoma 6 months, 17 months, and 60 months after transplantation. One patient was undergoing treatment of Kaposi's sarcoma at the time this article was written, and another was undergoing treatment of transitional bladder cell carcinoma. Actuarial survival for all patients was 88% at 1 year and 79% at 5 years. Moderate doses of induction antilymphocyte globulin may facilitate rapid reduction of maintenance cyclosporine and steroid doses, thereby decreasing the duration of intense immunosuppression and lowering the risk of posttransplantation lymphoproliferative disease. Testing this hypothesis would require the development of reliable and reproducible in vivo assays to prospectively assess immune status.

Porcine bioprosthetic aortic valve endocarditis with ring abscess and aortic stenosis.

Porcine bioprosthetic valve endocarditis is an infrequent but serious complication of valve replacement surgery. Ring (or annular) abscess is a frequent finding in mechanical valve endocarditis. In contrast, porcine valve endocarditis most often involves the cusps, and annular infection is uncommon. Porcine valvular dysfunction secondary to endocarditis usually takes the form of incompetence, whereas stenosis is less frequent. We report a case of a 76-year-old female who developed endocarditis with Staphylococcus epidermidis nine months after placement of a Carpenter-Edwards porcine aortic valve. Her initial presentation included complete heart block and moderate aortic stenosis. Transesophageal echocardiography aided the diagnosis by demonstrating large vegetations, while transthoracic echocardiography showed only slight thickening of the valve leaflets. At operation, there was a circumferential abscess around the sewing ring causing valve dehiscence and virtual discontinuity of the aorta from left ventricle. Valve degeneration and organisms within the cusps were observed on microscopy. This case illustrates two infrequent complications of porcine aortic valve endocarditis, namely massive annular abscess with invasion of the conducting system and aortic stenosis. It also demonstrates the utility and limitations of transesophageal echocardiography in the diagnosis of this disorder.

Response of Weeksella virosa peritonitis to imipenem/cilastin.

CAPD peritonitis is most commonly due to gram positive infection. Gram negative bacillary infection is less frequent but is often seen in hospitalized patients or in those on antibiotics. Weeksella virosa (formerly known as Flavobacterium II F) has been isolated from the vaginal secretions and urine of normal women. As gram negative colonization typically proceeds from the perineal region, Weeksella virosa peritonitis might be expected in women at risk for gram negative peritonitis. A 33-year-old woman on CAPD developed multiply resistant Weeksella virosa peritonitis after prior hospitalization for pericarditis and antibiotic treatment for pneumonia. Cultures became negative and cell counts returned to normal during treatment with intravenous imipenem/cilastin. Curative treatment was completed with intraperitoneal imipenem/cilastin and oral ampicillin. Treatment was well tolerated despite theoretical concerns about the risk of seizures in patients with severe renal insufficiency not on hemodialysis.

Allogeneic whole pancreas transplantation in insulin-dependent diabetes mellitus.

A clinical whole organ pancreas transplantation program for patients with insulin-dependent diabetes mellitus complicated by end-stage renal disease was initiated at Henry Ford Hospital in 1987. Five patients have received pancreatic allografts after a previous kidney transplant (phase 1), and six patients had simultaneous pancreas-kidney transplants (phase 2). Ten patients had functioning pancreatic grafts after surgery, and all of them had normal carbohydrate tolerance with appropriate plasma free insulin responses to an oral glucose tolerance test three months after transplantation. As long as 28 months postsurgery six patients remained free of insulin requirements; however, one patient rejected the pancreatic allograft, and three patients died because of cytomegalovirus pneumonia. Two of the latter patients had functioning pancreatic allografts at the time of their demise. These results compare favorably with those of the International Pancreas Transplant Registry which reflects the world experience. Pancreas transplantation is a unique experimental treatment with the potential of restoring euglycemia and improving the prognosis of insulin-dependent diabetic patients.

Medical management of osteomyelitis: considerations for home antibiotic chemotherapy.

Osteomyelitis can result from hematogenous seeding or contiguous infection, especially in association with impaired vascularity. Appropriate antibiotic therapy requires identification of the pathogen or pathogens and confirmation that the pathogens are susceptible to the antibiotic selected. Because of the long duration of parenteral antibiotic therapy required, treatment of osteomyelitis is expensive when patients are kept in the hospital for this reason alone. The development of long-half-life antibiotics that can be administered intramuscularly once a day and that are well tolerated has made outpatient parenteral therapy possible for many such patients. Cefonicid is a long-acting second-generation cephalosporin with activity against many of the microorganisms involved in osteomyelitis. Clinical studies have shown that cefonicid is effective and safe when used in an outpatient treatment program. Such programs have realized considerable savings over the cost of inpatient therapy.

Isoniazid and ethambutol as a cause of optic neuropathy.

A well-recognized complication of ethambutol use is optic neuropathy, but the potential ocular toxicity of isoniazid is often overlooked. A patient developed optic neuropathy while being treated with isoniazid and ethambutol. The optic neuropathy subsided only when both drugs were discontinued, suggesting an additive toxic effect.

Imipenem-cilastatin in the treatment of methicillin-sensitive and methicillin-resistant Staphylococcus aureus infections.

Imipenem-cilastatin was evaluated for efficacy and toxicity as an antistaphylococcal agent in 23 patients; 11 of these patients were infected with methicillin-resistant Staphylococcus aureus (MRSA), and 12 were infected with methicillin-susceptible S. aureus (MSSA). There were 15 soft tissue, 5 endovascular, and 3 skeletal infections and a total of nine patients with bacteremia. As determined by in vitro susceptibility testing, the MICs for 90% of the MRSA and MSSA isolates tested were 6.25 and 0.39 micrograms/ml, respectively. Two MRSA isolates were resistant to a concentration of greater than 16 micrograms/ml. When 11 MRSA isolates and 7 MSSA isolates were incubated for 48 h the MICs for 90% of the isolates increased to greater than 50 micrograms/ml for the MRSA isolates and 6.25 micrograms/ml for the MSSA isolates. Three S. aureus isolates emerged resistant. Ten of 11 (91%) MRSA infections and 11 of 12 (92%) MSSA infections were clinically cured. Adverse reactions occurred in 25% of the imipenemcilastatin-treated patients. These reactions included gastrointestinal intolerance (7% of the patients), rash or pruritus (6%), eosinophilia (6%), thrombocytosis (4%), and a positive, direct Coomb test without hemolysis (3%). One of the two patients for whom therapy was discontinued because of gastrointestinal intolerance had antibiotic-associated colitis. Imipenem appears to be an effective antistaphylococcal agent against both MRSA and MSSA infections.

Osteomyelitis of the pubis. Report of seven cases.

Seven cases of osteomyelitis of the pubis are reported. Predisposing factors leading to osteomyelitis included parenteral drug abuse in six patients and pelvic surgery in one patient. The average duration of symptoms before diagnosis was three weeks. Needle aspiration of the symphysis pubis was performed in five patients, and culture results were positive in three of them. Two patients with negative cultures of needle aspirates had positive cultures from open biopsy specimens of the symphysis pubis. Blood cultures were done in all patients, and results were positive in two of them. Pseudomonas aeruginosa was the responsible pathogen in five patients, Escherichia coli in one, and Staphylococcus aureus in one. Most patients required several weeks of antibiotic therapy. None required surgical debridement.

Ceforanide: in vitro and clinical evaluation.

Ceforanide, a new cephalosporin antibiotic with a long half-life (3 h), can be administered twice daily. We evaluated its antimicrobial activity, pharmacology, and clinical efficacy. Twenty-seven patients with infections due to susceptible organisms received ceforanide, 0.5, 1, or 2 g, intramuscularly or intravenously every 12 h for 6 to 28 days. In vitro studies with the clinical isolates from 27 patients treated plus 263 additional isolates showed that ceforanide was active against cephalothin-susceptible gram-positive and gram-negative microorganisms. In addition, ceforanide inhibited 65% of cephalothin-resistant Escherichia coli and 65% of Enterobacter spp. at

In vitro and clinical studies of cefatrizine, a new semisynthetic cephalosporin.

Cefatrizine, a new oral semisynthetic cephalosporin, was evaluated in vitro and in the treatment of 18 patients with acute urinary tract infection, pneumonia, and soft tissue infection. In vitro, it was more active than cephalexin for gram-positive and gram-negative bacteria. It was also more active than cephalothin, cefazolin, and cephapirin against most of the gram-negative bacteria but less active against the gram-positive bacteria. Of the patients treated with cefatrizine, only one failed to respond. This patient had pneumococcal conjunctivitis and hypogammaglobulinemia and neutropenia. The mean peak serum level after multiple 6-hourly doses of 500 mg was 6.2 mug/ml. The serum levels of cefatrizine necessary for inhibition of most susceptible organisms were well within the achievable range. The drug was well tolerated, and no renal, hepatic, or hematological toxicity was detected.