Impact of carbapenem resistance on clinical and economic outcomes among patients with Acinetobacter baumannii infection in Colombia.

Acinetobacter baumannii is a major cause of healthcare-associated infection, often affecting critically ill patients. The purpose of the study was to examine the associations of carbapenem resistance with mortality, length of hospital stay and hospital costs among patients infected with A. baumannii in intensive-care units (ICUs) in Colombia. A prospective, multicentre cohort study was conducted among 165 patients with A. baumannii infection admitted to ICUs between April 2006 and April 2010. Patients with carbapenem-resistant A. baumannii had higher risk of 30-day mortality than patients with carbapenem-susceptible A. baumannii in the univariate analysis (unadjusted hazard ratio = 2.12; 95% CI 1.14-3.95; p 0.018). However, carbapenem resistance was not significantly associated with risk of mortality (adjusted hazard ratio = 1.45; 95% CI 0.74-2.87; p 0.28) after adjusting for APACHE II score and other confounding factors. We did not find a significant difference in length of stay in ICU after the onset of infection between the two groups in the multivariate analysis (adjusted mean = 13.1 days versus 10.5 days; p 0.14). The average total cost of hospitalization among patients with carbapenem-resistant A. baumannii was significantly higher than that among patients with carbapenem-susceptible A. baumannii in the multivariate analysis (adjusted cost; US$ 11 359 versus US$ 7049; p <0.001). Carbapenem resistance was not significantly associated with mortality, though we are unable to rule out an increased risk due to the limited sample size. Carbapenem resistance was associated with an additional cost of hospitalization.

Carbapenem resistance and mortality in patients with Acinetobacter baumannii infection: systematic review and meta-analysis.

Acinetobacter baumannii has emerged as a major cause of healthcare-associated infections. Controversy exists as to whether antimicrobial resistance increases the risk of mortality. We conducted a systematic review and meta-analysis to examine this association. We searched MEDLINE and EMBASE databases up to May 2013 to identify studies comparing mortality in patients with carbapenem-resistant A. baumannii (CRAB) vs. carbapenem-susceptible A. baumannii (CSAB). A random-effects model was used to pool Odds Ratios (OR). Heterogeneity was examined using I(2). We included 16 observational studies. There were 850 reported deaths (33%) among the 2546 patients. Patients with CRAB had a significantly higher risk of mortality than patients with CSAB in the pooled analysis of crude effect estimates (crude OR = 2.22; 95% CI = 1.66, 2.98), although substantial heterogeneity was evident (heterogeneity I(2) = 55%). The association remained significant in the pooled adjusted OR of 10 studies. Studies reported that patients with CRAB compared to patients with CSAB were more likely to have severe underlying illness and also to receive inappropriate empirical antimicrobial treatment, which increases the risk of mortality. Our study suggests that carbapenem resistance may increase the risk of mortality in patients with A. baumannii infection. However, cautious interpretation is required because of the residual confounding factors and inadequate sample size in most studies.

Un modelo para armar: Una propuesta metodológica para abordar el estudio comparativo de la historia de la salud pública, de las profesiones de la salud y de sus relaciones de doble vía con la sociedad / A Model to Assemble: A Methodological Proposal to Address the Comparative Study of the History of Public Health, Health Professions and their Two-Way Relationships with Society / Um modelo para armar: Uma proposta metodológica para abordar o estudo comparativo da história da saúde pública, das profissões da saúde e de suas relações de via dupla com a sociedade

Objetivo. El artículo presenta la propuesta teórico-metodológica que, a partir de elementos ya trabajados previamente, se construyó durante la primera fase de un proyecto de largo alcance que busca elaborar una historia comparada de la medicina y la salud pública en América Latina. Metodología. Para exponer dicha propuesta, en un primer momento se elabora un breve balance historiográfico de la literatura existente sobre la historia de la medicina y de la salud pública en América Latina; en un segundo momento, se plantea una reconfiguración del concepto de 'campo de la salud', basada en un análisis crítico del concepto, y que se va perfilando como el marco de referencia para un programa de investigación en estudios sociales de la salud de largo plazo, en la Universidad del Rosario, programa en el cual se enmarca este proyecto comparativo; y, en un tercer momento, se presentan los lineamientos generales de la propuesta sobre la que se sustentará el proyecto. Resultados: Como resultado final se presenta una matriz que se estructuró a partir de todos los elementos teórico-metodológicos articulados en este estudio historiográfico. Dicha matriz está compuesta de nueve atributos y sus correspondientes categorías, que se utilizarán para llevar a cabo la segunda fase del proyecto comparativo de la historia de la medicina y la salud pública. La matriz se usará tanto para guiar la búsqueda de la información histórica como para llevar a cabo el análisis y la comparación conclusión.

The article shows the theoretical and methodological proposal that, grounded in previous studies, was built during the first phase of a long-term project that seeks to develop a comparative history of medicine and public health in Latin America. For laying out purposes, this article initially develops a brief historiographical overview of the literature on the history of medicine and public health in Latin America. It then proposes a reconfiguration of the 'health field' concept, based on a critical analysis of the concept, that begins to appear as a framework for a long term program of Social Studies of Health Research in El Rosario University, in which this comparative proposal is articulated. In a third moment, the article presents the general outlines of the proposal. As a final result, it presents a matrix to be used in the second phase of the comparative project of the history of medicine and public health in Latin America. It was structured upon all the theoretical and methodological elements discussed in this historiography study. This matrix was composed by nine attributes and their corresponding categories, which will be used as a guide to gather the historical records and to do the respective analysis and comparison.

Objetivo. O artigo apresenta a proposta teórico-metodológica que, a partir de elementos já trabalhados previamente, se construiu durante a primeira fase de um projeto de longo alcance que busca elaborar uma história comparada da medicina e a saúde pública na América Latina. Metodologia. Para expor dita proposta, em um primeiro momento elabora-se um breve balanço historiográfico da literatura existente sobre a história da medicina e da saúde pública na América Latina;em um segundo momento expõe-se uma reconfiguração do conceito de "campo da saúde", baseada em uma análise crítica do conceito, e que vai-se perfilando como o marco de referência para um Programa de Pesquisa em Estudos Sociais da Saúde de longo prazo, na Universidad del Rosario, programa no qual moldura-se este Projeto Comparativo; e em um terceiro momento, se apresentam os lineamentos gerais da proposta sobre a que se sustentará o Projeto. Resultados. Como resultado final apresenta-se uma matriz que se estruturou a partir de todos os elementos teórico-metodológicos articulados neste estudo historiográfico. Dita matriz está composta de nove atributos e suas categorias correspondentes, que se utilizarão para levar a cabo a segunda fase do projeto comparativo da história da medicina e a saúde pública. A matriz se usará tanto para guiar a busca da informação histórica quanto para levar a cabo a análise e a comparação.

XV-2c/KM19 haplotypes analysis of cystic fibrosis patients from western Mexico.

The analysis of polymorphic markers within or closely linked to the cystic fibrosis transmembrane regulator (CFTR) gene is useful as a molecular tool for carrier detection of known and unknown mutations. To establish the association between mutations in the CFTR gene in western Mexican cystic fibrosis (CF) patients, the distribution of XV2c/KM19 haplotypes was analyzed by PCR and restriction enzyme digestion in 384 chromosomes from 74 CF patients, their unaffected parents, and normal subjects. The haplotype analysis revealed that haplotype B was present in 71.9% of CF chromosomes compared to 0% of non-CF chromosomes. The F508del and G542X mutations were strongly associated with haplotype B (96.7% and 100% of chromosomes, respectively). The haplotype distribution of the CF chromosomes carrying other CFTR mutations had a more heterogeneous background. Our results show that haplotype B is associated with CFTR mutations. Therefore, haplotype analysis is a suitable alternate strategy for screening CF patients with a heterogeneous clinical picture from populations with a high molecular heterogeneity where carrier detection programs are not available. In addition, it may be a helpful diagnostic tool for genetic counseling and carrier detection in the relatives of CF patients and in couples who are planning to have children.

[Ambiguous epileptic syndrome: from the point of view of adults]. / Sindromes epilépticos ambiguos: perspectivas desde el adulto.

AIM: To review a series of neurological problems that we frequently encounter in our day-to-day clinical practice and which are difficult to diagnose correctly because of the type of presenting symptoms and clinical features they have. DEVELOPMENT: In spite of the fact that a good patient record and detailed neurological examination are still essential, use of long-term (LT) video-EEG monitoring is sometimes indispensable given the ambiguity of the clinical signs and symptoms. Selected subjects were young adult patients of both sexes who had been referred to the Epilepsy Unit at our hospital for study, due to the existence of doubts about their diagnosis. A detailed patient record was drawn up for each patient, and they were also submitted to a neurological examination and LT video-EEG monitoring, which lasted between two and six days. In some of these patients, the diagnosis was modified following their admission and important changes were introduced in their treatment. CONCLUSIONS: LT video-EEG is an important test when it comes to establishing a correct neurological diagnosis in patients with mixed or poorly defined clinical symptoms.

Síndromes epilépticos ambiguos: perspectivas desde el adulto / Ambiguous epileptic syndrome: from the point of view of adults

Objetivo. Revisar una serie de problemas neurológicos,que vemos con frecuencia en nuestra clínica diaria y que por suforma de presentación y características clínicas suponen una dificultada la hora de su correcto diagnóstico. Desarrollo. A pesar de que una buena historia clínica y una exploración neurológica detalladasiguen siendo fundamentales, la monitorización de larga duración(MLD) vídeo-EEG representa un arma en ocasiones imprescindibledada la ambigüedad de los síntomas y signos clínicos. Sehan seleccionado pacientes adultos jóvenes, de ambos sexos, remitidosa la Unidad de Epilepsia de nuestro hospital para estudio,por dudas en el diagnóstico. A todos se les realizó historia clínicadetallada, exploración neurológica y MLD vídeo-EEG, de entredos a seis días de duración. En algunos de estos pacientes, el diagnósticose modificó tras el ingreso y se realizaron importantes cambiosen el tratamiento. Conclusión. La MLD vídeo-EEG es una exploraciónimportante a la hora de establecer un diagnóstico neurológicocorrecto en pacientes con sintomatología clínica abigarradao mal definida

Aim. To review a series of neurological problems that we frequently encounter in our day-to-day clinical practiceand which are difficult to diagnose correctly because of the type of presenting symptoms and clinical features they have.Development. In spite of the fact that a good patient record and detailed neurological examination are still essential, use oflong-term (LT) video-EEG monitoring is sometimes indispensable given the ambiguity of the clinical signs and symptoms.Selected subjects were young adult patients of both sexes who had been referred to the Epilepsy Unit at our hospital for study,due to the existence of doubts about their diagnosis. A detailed patient record was drawn up for each patient, and they werealso submitted to a neurological examination and LT video-EEG monitoring, which lasted between two and six days. In someof these patients, the diagnosis was modified following their admission and important changes were introduced in theirtreatment. Conclusions. LT video-EEG is an important test when it comes to establishing a correct neurological diagnosis inpatients with mixed or poorly defined clinical symptoms

Kingella kingae como causa de infección en dos niños menores de dos años / Kingella kingae infections in two children younger than two years old

Kingella kingae es un cocobacilo gramnegativo, aerobio, pertenenciente a la familia de las Neisseriaceae. Presentamos dos casos clínicos de infección por Kingella kingae: bacteriemia y artritis séptica, diagnosticados en nuestro centro en el intervalo de un mes. Kingella kingae forma parte de la flora orofaríngea habitual, pudiendo ser la puerta de entrada de las infecciones sistémicas. Desde la administración de la vacuna frente a Haemophilus influenzae tipo b, Kingella kingae está siendo la principal bacteria gramnegativa implicada en infecciones osteoarticulares en niños menores de tres años. Kingella kingae es muy sensible a los antibióticos que normalmente se utilizan de forma empírica. Las infecciones por Kingella kingae habitualmente siguen un curso clínico benigno, y se han descrito casos de resolución espontánea. Queremos hacer hincapié en el hecho de que este microorganismo no es sospechado o buscado en infecciones en pacientes pediátricos. Kingella kingae es un microorganismo de difícil aislamiento, poco resistente en condiciones adversas, por lo que es importante inocular la muestra de sangre o líquido articular en frasco de hemocultivo (AU)

Hipercalcemia tumoral / Hypercalcemia of malignancy

Las neoplasias y el hiperparatiroidismo primario son las causas más frecuentes de hipercalcemia y comprenden el 90 por ciento de éstas. Hace casi medio siglo que se describió el síndrome de la hipercalcemia humoral tumoral y 15 años que se identificó su agente etiológico, la proteína relacionada con la paratirina (PTHrP), y se introdujo su medida en la práctica clínica y de investigación. El desarrollo de la hipercalcemia humoral tumoral constituye un signo de mal pronóstico. Disponemos de nuevos y potentes fármacos hipocalcemiantes (fundamentalmente bifosfonatos) para el tratamiento de estas situaciones, lo que permite a los pacientes mejorar su calidad de vida en fases a menudo terminales de la enfermedad (AU)

Integración de No Conformidades y Acciones Correctoras en el Sistema de Calidad / Integration of non-compliance and corrective actions in quality assurance

Proponemos una gestión de No ConformidadesAcciones Correctoras según las directrices incluidas en la norma de certificación UNE-EN-ISO 9001:2000 y en la norma de acreditación ISO 17025 para los laboratorio de ensayos. Con el objetivo de establecer criterios para la mejora constante de la calidad, en el presente trabajó se engloban como No Conformidades la gestión de las Reclamaciones técnicas y el tratamiento del Producto No Conforme. Las acciones llevadas a cabo para rectificar las No Conformidades se tratan como Acciones Correctoras. Dicha integración queda plasmada en un formato tipo Procedimiento General de Calidad, del cual se derivan los documentos y registros pertinentes. La implantación, el seguimiento y la gestión propuestos se basan en la integración del Sistema de Calidad en un soporte informático que permita agilizar las actividades y simplificar la documentación. Dicho soporte será debidamente validado. La integración, a nuestro criterio, conlleva al cumplimiento y a alcanzar los objetivos definidos por el Sistema de Calidad del laboratorio (AU)

Identification of factors associated with poor peripheral blood progenitor cell mobilization in Hodgkin's disease.

BACKGROUND AND OBJECTIVES: Although the use of drugs which damage stem cells is common in patients with Hodgkin's disease (HD), factors affecting peripheral blood progenitor cell (PBPC) mobilization have not been clearly established in this group of patients. The aim of this study was to identify factors associated with poor PBPC mobilization in patients with HD. DESIGN AND METHODS: In order to address this issue we have evaluated in 54 patients with HD mobilized with G-CSF alone the following factors: sex, age, histologic subtype, B symptoms at diagnosis, status of remission, previous chemotherapy and radiotherapy, interval from diagnosis and last chemotherapy cycle to harvest, and dose of G-CSF. Univariate analysis was performed using Student's t-test, Pearson's correlation and Spearman's correlation. A stepwise regression model was used to determine which of the variables was the most predictive of PBPC mobilization. RESULTS: In univariate analysis poorer PBPC mobilization was observed in patients who had previously received at least two courses of mini-BEAM (p=0.006), a high number of different chemotherapy regimens (p=0.002), a chemotherapy score >30 (p=0.02) and more than 9 months of alkylating agents (p=0.07). We did not find radiotherapy to be a significant factor affecting progenitor cell yield (p=0.59). In the stepwise regression model, only the previous administration of two or more mini-BEAM cycles predicted a poor PBPC yield (p=0.006). INTERPRETATION AND CONCLUSIONS: Previous chemotherapy, principally exposure to a mini-BEAM regimen, seems to be the principal factor affecting collection of PBPC in patients with HD mobilized with G-CSF alone. Since mini-BEAM is an effective salvage regimen in relapsed or refractory HD, collection of PBPC should be planned when there has been no or only minimal exposure to a mini-BEAM regimen.

BMT: Serum Ferritin as Risk Factor for Veno-occlusive Disease of the Liver. Prospective Cohort Study.

Veno-occlusive disease of the liver (VOD) is an important complication in hematological transplantation. The aim of this study is to analyze the risk factors for VOD and other forms of liver toxicity in a cohort of 180 peripheral stem cell transplants performed in our Center. We find that elevated pretransplant levels of serum ferritin are the most important risk marker for VOD. We believe that ferritin reflects damage induced by oxygen radicals resulting from iron-mediated catalysis. We also discuss different risk factors for VOD and other forms of liver toxicity, suggesting diferent pathogenic mechanisms.

A prospective randomized trial of granulocyte colony-stimulating factor therapy after autologous blood stem cell transplantation in adults.

In order to assess the potential clinical benefit of filgrastim (G-CSF) after peripheral blood stem cell (PBSC) autotransplantation a randomized study was begun in our center in July 1997: 62 patients were involved (30 received filgrastim after PBSC infusion and 32, the control group, received no cytokines). All were adults (median 40 years, range 18-65). Patients with one of three different pathologies were recruited: 28 had advanced breast carcinoma, 23 had lymphomas (12 Hodgkin's disease and 11 non-Hodgkin's lymphoma) and 11 had de novo AML. All of them were transplanted using myeloablative chemotherapy conditioning regimens. G-CSF was administered subcutaneously from day +5 in the treated group at a dose of 5 microg/kg body weight/day. The numbers of CD34+ and mononuclear (MNC) cells infused were similar in each group. Only minor differences regarding the use of G-CSF could be inferred from the analysis of the data. Faster granulocyte engraftment was evident in the treated group (mean of 10 vs 12 days to achieve >0.5 x 109/l granulocytes, P = 0.0008), without differences in incidence and severity of infections, days of fever or duration of antibiotic treatment between groups. There was slightly slower platelet engraftment (mean of 15 days in the group with G-CSF vs 12 days in the other group to achieve >20 x 109/l platelets, P = NS) in this series, but there were no differences in incidence and severity of haemorrhage or platelet transfusion support. Considering the economical costs, the median expenditure per inpatient stay was Eur5961 (range Eur4386-Eur17186) in the G-CSF group compared with Eur5751 (range Eur3676-Eur15640) in the control group (P = 0.47). From our data it could be concluded that for adult patients transplanted with PBSC there is no clear beneficial impact of post-infusion G-CSF administration.

Dye rashes.

Physicians may administer intravenous dyes to patients, most commonly to delineate vascular or urinary anatomy, without an appreciation of the potential hazards associated with these compounds. We report two cases in which skin eruptions followed the intravenous administration of the dyes fluorescein and methylene blue; these eruptions were the same colors as the dyes. In our first patient, urticaria, which was yellowish in color and fluorescent under a Wood's lamp, occurred after the administration of fluorescein. In the second patient, painful blue macules appeared randomly on the forearm within 15 seconds after methylene blue was injected into a free-flowing intravenous cannula on the dorsal aspect of the hand.

Serum Ferritin as Risk Factor for Veno-occlusive Disease of the Liver. Prospective Cohort Study.

Veno-occlusive disease of the liver (VOD) is an important complication in hematological transplantation. The aim of this study is to analyze the risk factors for VOD and other forms of liver toxicity in a cohort of 180 peripheral stem cell transplants performed in our Center. We find that elevated pretransplant levels of serum ferritin are the most important risk marker for VOD. We believe that ferritin reflects damage induced by oxygen radicals resulting from iron-mediated catalysis. We also discuss different risk factors for VOD and other forms of liver toxicity, suggesting diferent pathogenic mechanisms.

[Primary epiploic appendicitis]. / Les appendicites épiploïques primitives.

Primary epiploic appendicitis include torsion and primary inflammation of appendices epiploicae. These uncommon pathologies have been until present exceptionally diagnosed before surgery. Clinical and biological features have a small specificity. However, US and CT findings suggest the diagnosis. Our study reports 6 cases.

Hematopoietic cell transplantation using plasma and DMSO without HES, with non-programmed freezing by immersion in a methanol bath: results in 213 cases.

A simplified cryopreservation method for bone marrow (BM) and peripheral blood progenitor cells (PBPC) was utilized in hematopoietic cell transplantation of 213 patients with hematological or solid neoplasms after ablative chemotherapy (187 with peripheral blood progenitor cells and 26 with bone marrow). Cells were cryopreserved, after addition of autologous fresh plasma with DMSO, without HES, by freezing to -80 degrees C in a methanol bath and non-programmed freezer. For the patients autotransplanted with PBPC, the median period necessary for recovery of more than 0.5 x 10(9)/l granulocytes was 11 days (range 6-44), and 15 (8-204) days were required to obtain more than 20 x 10(9)/l platelets. For the patients autotransplanted with BM, the median period necessary to recover >0.5 x 10(9)/l granulocytes was 12 days (range 9-33), and 24 (12-57) days to obtain more than 20 x 10(9)/l platelets. These results support this method as being very effective in achieving high-quality cryopreservation. The procedure, which uses a non-programmed freezer, simplifies and reduces enormously the cost of the technical measures currently in use, enabling its adoption in almost any clinical oncological institution.