Neumonía nosocomial y mutirresistencias en una unidad de cuidados intensivos de adultos de un hospital de tercer nivel / Pneumonia nosocomial and multiresistances in adult in a tertiary referral hospital

OBJETIVO: Determinar la incidencia y etiología de la Neumonía Nosocomial (NN) en la Unidad de Cuidados Intensivos (UCI) de adultos del Hospital Universitario Reina Sofía (HURS) de Córdoba. METODOLOGÍA: El Servicio de Medicina Preventiva del HURS elaboró un estudio epidemiológico observacional de cohortes prospectivo de los pacientes ingresados en la UCI de adultos entre 2006 y 2009. Se calcularon las siguientes medidas de incidencia: Incidencia Acumulada (IA) de pacientes infectados con NN, IA de neumonías y densidad de incidencia de neumonías asociadas a ventilación mecánica. Se procedió a realizar una estadística descriptiva con cálculos de frecuencias. RESULTADOS: Hubo 233 pacientes con NN (IA de pacientes con NN=5,3/100 pacientes ingresados). El 96,6% de los pacientes con NN habían estado sometidos a ventilación mecánica (VM)previa. La tasa de incidencia de NN asociada VM fue de 15,7/1000 días de ventilación. Se solicitaron cultivos en todas las NN. El microorganismo más frecuente causante de NN fue Acinetobacter spp. (41,7% de los aislamientos), seguido de P.aeruginosa (8%), S. aureus y C. albicans, ambos aislados en un 7,1% de los cultivos. El 40% de las NN fueron provocadas por microorganismos multirresistentes, destacando el A. baumannii (82,6%) seguido de S. aureus meticilin resistente (9,7%). Destaca la emergencia de Stenothropomonas maltophilia (3,9%). CONCLUSIÓN: Las cifras de incidencia de NN en la UCI han disminuido en la última década, pero siguen siendo superiores a las de otros estudios. Los microorganismos más frecuentemente involucrados en la neumonía han sido los gramnegativos, y de ellos en primer lugar A. baumannii. Prácticamente la totalidad de los aislamientos de este microorganismo fueron multirresistentes

OBJECTIVE: To determine the incidence and etiology of Nosocomial pneumonia (NP) in adult ICU of Reina Sofia University Hospital (RSUH) of Córdoba. METHODOLOGY: The Department of Preventive Medicine of RSUH conducted a prospective cohort study for admitted patients at adults’ ICU from 2006 to 2009. The following incidence rates were calculated: accumulated incidence (AI) rate of patients with NP and incidence density of pneumonia associated with mechanical ventilation. We conducted a descriptive statistical analysis with calculation of the frequencies. RESULTS: There were registered 233 patients with NP (AI of NP of admitted patients 5.3/100). About 96.6% of patients with NP were previously subjected to mechanical ventilation (MV). The incidence rate of NP associated MV was 15.7/1000 days of ventilation. Culture was requested to all cases with NP. The most frequent microorganism of NP was Acinetobacter spp. (41.7% of cultures) followed by P.aeruginosa (8%). S.aureus and C.albicans were isolated in 7% of cultures. About 40% of NP were caused by multidrug-resistant microorganisms, like A.baumannii (82.6%) followed by methicillin resistant S. aureus (9.7%). Also we noted the emergence of Stenothropomonas maltophilia (3.9%). CONCLUSION: Incidence rates of NP in the ICU have declined in the last decade, although our rates are still higher than the reported in other studies. The microorganisms most frequently involved in NP were gram negative, of which the most frequent was A.baumannii. Nearly all isolated microorganisms were multidrug-resistant

Underlying illness severity and outcome of nosocomial pneumonia: prospective cohort study in intensive care unit.

BACKGROUND: Previous studies have suggested that the final outcome of a patient with nosocomial pneumonia (NP) may depend on the patient's illness severity upon admission to the intensive care unit (ICU). AIM: To investigate the relationship between developing NP during hospitalization in an adult ICU and the risk of death with special focus on illness severity at admission in the unit. METHODS: A prospective cohort study was performed among all patients admitted for at least 24h to the ICU of a university reference hospital in Spain from 2006 to 2009. A stratified univariate study was performed according to the patients' illness severity at admission, estimated using the Acute Physiology And Chronic Health Evaluation (APACHE) II index. To determine whether the NP was independently associated with increased mortality in ICU, a multivariate logistic regression analysis was carried out, adjusting for potential confounders. RESULTS: In all, 4427 patients were studied, of whom 233 acquired NP while admitted. Patients who developed NP had a 2.6 higher risk (95% confidence interval: 2.1-3.0) of dying compared with those who did not develop NP. When stratified by the APACHE II index, the significant association remained at each stratum, although the strength of the association decreased as the value of the index increased. In the multivariate analysis, NP was independently associated with death in the ICU. The interaction between NP and the APACHE II index, with a negative coefficient, was also significant. CONCLUSIONS: Developing NP while admitted to the ICU was independently associated with increased mortality. However, the strength of the association decreased as the severity of patient illness upon admission to the ICU increased, not influencing death of patients with severe APACHE II values.

[Risk factors for Alzheimer's disease]. / Factores de riesgo de la enfermedad de Alzheimer.

AIM: In this review we present and discuss the main risk factors for Alzheimer's disease (AD) reported by epidemiological, genetic and biochemical studies. DEVELOPMENT: The most frequently mentioned factors are: 1. Age. It is the principal marker for the disease risk; 2. Sex. It is estimated that the prevalence of AD is higher in women than in men; 3. Genetics. Although the genetic role has been demonstrated, there is an important genetic heterogeneity; 4. Tobacco. Various studies have found a protective effect, however this effect could be attributed to survival bias; 5. Alcohol. The regular consumption of alcohol was associated with reduced incidence of AD, especially with wine consumption; 6. Family history of dementia. Nearly 40% of persons with AD have family history of dementia; 7. Non steroidal antiinflammatories (NSAIDs). The use of NSAIDS could help in reducing the symptoms of the disease or even avoid them; 8. Craneoencephalic trauma. The role of the craneoencephalic trauma is controversial; 9. Education. The increase of AD in low education persons was published; 10. Diet. The consumption of antioxidants in diet o in supplementary forms appears to be neuroprotector. CONCLUSIONS: The grand variety of published epidemiological studies with different methodology makes it difficult to find homogeneous results. This leaves us controversial impressions about how to prevent the disease.

[Meta-analysis: the science of review in Neurology]. / Metaanálisis: la ciencia de la revisión en Neurología.

INTRODUCTION: The review and continuous analysis of the present knowledge have always been necessary for scientific and clinical practice advance. This study presents the difference between narrative and systematic reviews, the most important points of meta-analysis, and finishes with detailed description of its phases. Our objective was to explain, in simple terms, the technique of meta-analysis and this could permit its application and use in the clinical practice and neurological investigations. DEVELOPMENT: The term meta-analysis was described for the first time by the psychologist Glass in 1967. Since then, the meta-analysis was utilized by many investigators as a technique to combine the results of different studies. The steps of a meta-analysis are: 1. Hypothesis of the study; 2. Localization of the studies of investigation; 3. Selection of the localized studies; 4. Qualitative meta-analysis; 5. Quantitative meta-analysis. Basically, It refers to the numeric combination of data, which were extracted by the reviewers. The mathematical method which will be used to evaluate the effect size should be chosen, also homogeneity and sensibility tests should be done. CONCLUSIONS: Well-designed meta-analysis is accepted as the optimum form to present the results of different studies. The meta-analysis could be of great importance for clinical practice and neurological research.

[Young onset Parkinson's disease and smoking: meta-analysis]. / Enfermedad de Parkinson temprana y tabaco: metanálisis.

INTRODUCTION: Previous systemic reviews have reported a protective effect of smoking against Parkinson's disease (PD). However, the protective effect has not been examined before by any systemic review in patients with young onset PD. OBJECTIVE: Examine the association between young onset PD and tobacco smoking. MATERIAL AND METHODS: We conducted a meta-analysis including all published observational studies that investigated this association before January 2003. All languages were included with no restriction for year of publication. Risk estimate and its 95% confidence interval (95% CI) were extracted or calculated for all localized studies in patients with young onset PD. RESULTS: Five case-control studies investigated the association between young onset PD risk and ever smoking. The fixed-effect pooled analysis was 0.55 (95% CI: 0.38 0.81), with insignificant homogeneity test. CONCLUSIONS: This meta-analysis shows a protective effect of tobacco smoking against young onset PD. Our results coincide with the other reviews which did not consider the age of diagnosis of PD. However, it is highly recommended prospective studies for the association between young onset PD risk and ever smoking

[Parkinson s disease risk factors]. / Factores de riesgo en la enfermedad de Parkinson.

AIMS: In this review we present and discuss the main risk factors (RF) for Parkinson s disease (PD) reported by epidemiological and biochemical research. METHODS: The most frequently mentioned RF are: 1. Age: PD is not a pathological condition that is restricted to the elderly, although most people who suffer from it are over 60 years of age; 2. Sex: in most epidemiological studies there are no differences to be found in prevalence of PD according to sex; 3. Genetic: no gene has been identified as being responsible for idiopathic PD. Nevertheless, family antecedents of PD have been identified as RF; 4. Craneoencephalic trauma: this factor can have a systematic bias, since patients seek an explanation for their illness and remember any head injury as its possible cause; 5. Neurotoxins: a great deal of research was focused on the relation between PD and direct or indirect exposition to compounds such as MPTP, used in pesticides; 6. Antioxidants: it is thought that if ingested in sufficiently high quantities, either as part of the diet or in the form of supplements, they might reduce the risk of PD or slow down its progress; 7. Smoking: several studies have shown a negative relation, while other studies found no significant relation. CONCLUSIONS: There are several RF for PD, although no single decisive triggering factor has been found to date. Future research must consider the hypothesis of a multifactor aetiology and take into account the interaction between genetic and environmental factors.

[Parkinson's disease, tobacco and age: meta analysis]. / Enfermedad de Parkinson, tabaco y edad: metanálisis.

INTRODUCTION: Epidemiological studies have demonstrated contradictory results about the association between smoking and the risk of Parkinson s disease (PD). OBJECTIVE: Examine the hypothesis of the EUROPARKINSON group that smoking protects against PD only in patients below 75 years of age. MATERIAL AND METHODS: We conducted a meta analysis including all observational studies that were published about this association before January 2001. All languages were included with no restriction for year of publication. Risk estimate and its 95% confidence interval (95% CI) were extracted or calculated for all localized studies in patients below or above 75 years of age. RESULTS: Seventeen studies investigated the association between PD risk and smoking in patients below 75 years of age. Meanwhile, only seven studies investigated the association in patients above 75 years of age. The fixed effect pooled analysis in patients below 75 years of age was 0.59 (95% CI: 0.52 0.67), with insignificant homogeneity test. Patients above 75 years of age had fixed effect pooled analysis of 0.76 (95% CI: 0.59 0.99), with insignificant homogeneity test. CONCLUSIONS: The pooled analysis in patients below 75 years of age clearly demonstrates that smoking is inversely associated with PD risk. The 95% CI of the pooled analysis in patients above 75 years of age is nearly overlapping unity. This result is not in favor for the negative association in old patients, and confirms the hypothesis of the EUROPARKINSON group.

Parkinson's disease, smoking and family history: meta-analysis.

To estimate the pooled risk of tobacco smoking for Parkinson's disease (PD) in patients with and without PD family history. We conducted systematic searches of Medline, PsycLIT, Embase, Current contents, Best Evidence, Nisc Mexico Biblioline, previous reviews, examination of cited reference sources and personal contact and discussion with several investigators expert in the field. Studies in all languages were considered. Published observational studies on PD and cigarette smoking stratified by PD family history were reviewed. When two or more papers were based on an identical study, the paper that principally investigated the relationship between PD, smoking stratified by PD family history or the paper that was published last was used. Three case-control studies were carried out between 1996 and 2000, of which one reported risk estimates. The risk of ever smoker in patients with positive PD family history was 0.82 (95% confidence interval 0.44-1.53). There was an obvious protective effect in the pooled estimate in patients with negative PD family history [odds ratio 0.77 (95% confidence interval 0.59-1.01)]. Although our pooled estimates show that smoking is inversely associated with the risk of PD only in patients with negative PD family history, further studies evaluating the interaction between smoking and PD family history are strongly needed.

[Parkinson's disease and smoking: coherence and plausibility]. / La enfermedad de Parkinson y el tabaco: coherencia y plausibilidad.

INTRODUCTION: Many studies have shown that smoking is lower in patients with Parkinson s disease. However, in other investigations this was not observed. The various studies involved showed wide variation with regard to methodology, criteria for diagnosis and periods of observation and hence it is difficult to compare them. DEVELOPMENT: The first studies published were designed to examine the effects of smoking in general and information was obtained regarding the possible disorders related to tobacco smoking according to the records of mortality, which may contain errors due to selective mortality and mistaken diagnosis. Most of the studies of cases and controls included prevalent cases which accepted the study, mainly hospital cases. Also it is probable that the prevalent cases of Parkinson s disease do not smoke because of their disorders of movement. CONCLUSIONS: Many researchers have found important information about the pathophysiology of Parkinson s disease and its association with smoking. However, the hypothesis regarding the association between smoking and low risk of Parkinson s disease are various and independent, apart from the hypothesis of a truly biological mechanisms. Since the subject is still controversial, systematic reviews together with epidemiological and experimental studies are necessary.

Factors associated with the condoning of female genital mutilation among university students.

Female genital mutilation (FGM) is practiced in Egypt, despite its recent ban, generally in rural and uneducated communities, under unsanitary conditions and by non-medical personnel. Immediate and long-term complications are frequent. The aim of this study was to gain insight into what beliefs or knowledge are conducive to supporting FGM. One thousand and seventy university students in Cairo, Egypt were randomly selected. A 32-item questionnaire was used to interview students regarding their knowledge and attitudes toward FGM. Multivariable analyses were performed to find factors associated with being against the abolishment of FGM.The response rate was 95% (n=1020). Twenty-eight percent of the students support FGM. The most significant factors associated with the condoning of FGM were believing FGM has a religious basis (OR=2.53), disagreeing that FGM is a custom with no other basis (OR=2.59), not believing it is harmful (OR=4.11), and ignoring that it is usually followed by complications (OR=5.14). Even in an educated population, a considerable amount of ignorance concerning FGM exists. Widespread education about FGM is important to dispel the myths that surround its practice and to bring the practice to an end.

Comparison of different methodological approaches to identify risk factors of nosocomial infection in intensive care units.

OBJECTIVE: Comparison of statistical methods and measurement scales to identify nosocomial infection risk factors in intensive care units (ICU). DESIGN: Prospective study in 558 patients admitted to the ICU of a referral hospital between February and November 1994. METHODS: Analysis using three logistic regression models, three standard Cox regression models, and two Cox regression models with time-dependent extrinsic factors. Different scales were used to measure exposures to risk factors (dichotomous, ordinal, quantitative, and time-dependent variables). RESULTS: The most appropriate models were those that measured exposure using dichotomous variables. Models using ordinal or quantitative variables estimated biased coefficients and/or failed to comply with the statistical assumptions underlying the analyses. The Cox regression model with quantitative time-dependent variables met all the statistical assumptions, obtained a precise assessment of risk by exposure time, and estimated unbiased coefficients. CONCLUSIONS: The Cox regression analysis with quantitative time-dependent variables is the most valid alternative for assessing the risk of nosocomial infection per day of exposure to an extrinsic risk factor in the ICU.

Breast cancer risk factors: PCB congeners.

The chronic effects of polychlorinated biphenyls (PCBs) are a public health concern, and a potential relationship with breast cancer has been postulated. The purpose of this study was to examine the possible relationship between PCBs and breast cancer. All women (134) treated by excision biopsy because of breast lump at Reina Sofia University Hospital, Cordoba, Spain over a period of 10 months were included in our study. They were all administered a questionnaire by interview, calculation of body mass index, histopathological examination of excised mass and chemical estimation of PCB congener levels in breast fat. The collected samples were from 65 (48.5%) women with benign lesions and 69 (51.5%) with malignant lesions. The variables associated with malignant lesions on univariate analysis were age, lactation period, overweight, PCB n-28 and PCB n-52. On the multivariate analysis PCB n-28 was found to be the most important risk factor (OR 9.6, 95% CI 3.8-24.4). Other risk factors were identified as age, drinking alcohol, low parity and overweight. If these findings can be confirmed in a large study population, however, they may have important implications for breast cancer risk.

In vitro culture, ultrastructure, antigenic, and molecular characterization of Encephalitozoon cuniculi isolated from urine and sputum samples from a Spanish patient with AIDS.

In this report we describe the cultivation of two isolates of microsporidia, one from urine and the other from sputum samples from a Spanish AIDS patient. We identified them as Encephalitozoon cuniculi, type strain III (the dog genotype), based on ultrastructure, antigenic characteristics, PCR, and the sequence of the ribosomal DNA internal transcribed spacer region.

[Study of 13 cases of anisakiasis in the province of Cordoba]. / Estudio de 13 casos de anisakiasis en la provincia de Córdoba.

Anisakiasis, or anisakidosis, is a parasitic zoonosis due to the infestation by nematodes of the Anisakidae family, mainly by Anisakis simplex. Notwithstanding its world wide distribution, in our country its appearance is quite recent (1991) with only 19 cases previously reported. We refer 13 cases diagnosed in different hospitals in the province of Córdoba, Spain, from September 1994 to July 1998 which represents the biggest series described in Spain so far. All the patients had a clinical onset as acute abdomen, so that they required early surgery in which a narrowing and inflammatory intestinal segment was observed and subsequently resected. Pathology revealed in such segments an intense eosinophilic infiltrate in the mucosa. Only in one of the cases parasitic fragments were detected in the intestinal mucosa and in the 12 remaining cases the diagnosis was immunological by IgE specific for Anisakis simplex determination and antigens detection of the nematode with monoclonal antibodies. As interesting epidemiologic antecedent we shall mention the fact that all patients referred a usual raw fish consumption (mainly anchovy with vinegar) which is host of third-stage larval of the parasite.

Comparison of various reversed-phase columns for the simultaneous determination of ephedrines in urine by high-performance liquid chromatography.

Different reversed-phase columns for basic analytes were compared for the simultaneous determination of ephedrines in urine, such as LiChrospher 60 RP-Select B, LiChrospher 100 RP18, Hypersil BDS-C18, Inertsil ODS-2, Spherisorb ODS-B and Symmetry Shield RP8. Symmetry Shield was the only column which did not require the use of high concentrations of buffer and triethylamine. With this column, a good separation of the six ephedrines and the internal standard was achieved using 50 mM phosphate buffer-25 mM triethylamine as a mobile phase. Linearity, precision and accuracy were satisfactory for the levels usually found in urine. Due to these all parameters the developed analytical method was found to be suitable for the application in the doping field.

Microsporidiosis in travelers with diarrhea from the tropics.

BACKGROUND: Microsporidia are protozoa which mainly affect severely immunodepressed AIDS patients in developed countries as well as those in developing ones. Traveler's diarrhea affects approximately 40% of people traveling from industrialized countries to developing ones, and no pathogens are identified in many of those patients on their returning, suggesting that known enteropathogens escape detection or entirely new ones could be responsible. Very few reports of travel-related microsporidiosis have been described. METHODS: Between January, 1996 and January, 1998, a total of 40 European travelers from the tropics with a clinical picture of protected diarrhea (three or more loose stools per day lasting for more than 3 weeks) were evaluated. Weber's trichrome modified by Kokoskin stain for microsporidial spores were performed in stool samples of every patient. Microsporidial DNA extraction and PCR amplification were attempted in every stool sample where microsporidial spores were observed. RESULTS: Four cases of imported Enterocytozoon bieneusi were detected: one HIV-infected short term traveler, a pregnant long term traveler, and two immunocompetent short term travelers. Diarrhea was self-limited, and the spores cleared from the stools in all HIV-non infected travelers, but showed a chronic course in the HIV-infected one. CONCLUSIONS: Available data is too limited to affirm that residence or travel in tropical countries increases the risk for microsporidial infection, but the cases presented here suggest that E. bieneusi could be a cause of self-limited diarrhea in immunocompetent travelers returning from the tropics or could chronically affect immunocompromised HIV-infected travelers.