Proposal to decrease the number of negative temporal artery biopsies.

OBJECTIVE: The percentage of negative temporal artery biopsies (TABs) remains very high in patients with suspected giant cell arteritis (GCA). The aim of our study was to identify the clinical predictors of TAB results to improve the effectiveness of this diagnostic procedure. METHODS: We performed a cross-sectional study of 125 consecutive patients who underwent TAB in the Department of Internal Medicine of a public tertiary hospital, from January 1997 to March 2002. We compared patients with a positive and a negative biopsy result. RESULTS: Forty-six of the 125 biopsies (36.8%) were positive for GCA and 79 (63.2%) negative. Temporal artery (TA) thickening (8.01), decreased pulse (5.58), jaw claudication (4.87), and scalp tenderness (4.29) presented the highest positive likelihood ratios (LR+). Erythrocyte sedimentation rate (ESR) (0.11), headache (0.39), TA thickening (0.42), and decreased pulse (0.48) had the lowest negative likelihood ratios (LR-). Only TA abnormalities [odds ratio (OR) 12.3] and scalp tenderness (OR 6) were independent predictors of biopsy results. By excluding patients with no evidence of TA abnormalities, scalp tenderness, or jaw claudication, only 48% of the 125 biopsies would have been performed; 59 negative biopsies would have been prevented, but six positive biopsies would have been missed. CONCLUSION: Careful assessment of patients with clinically suspected GCA to rule out artery abnormalities, scalp tenderness, and jaw claudication can lead to a dramatic decrease in the percentage of negative biopsies. This observation may contribute to improving the physician's decision-making process when contemplating TAB.

Exposure to extrinsic risk factors in prevalence surveys of hospital-acquired infections: a methodological approach.

The difficulties encountered in studying the presence of extrinsic risk factors in the framework of prevalence surveys of hospital-acquired infections (HAI) have led to the use of a variety of methodological approaches. This study examined the effect of retrospective approaches for obtaining data regarding exposure to extrinsic risk factors. The EPINE database for 1990 was used and a simulation model was created. All the evaluated approaches differed in their impact upon the association between risk factors and infections. Prevalence of exposure on the day of the survey, prevalence of exposure at any time before the survey was conducted, and total prevalence were found to be significantly associated with the probability of exposure and duration of exposure. For exposure periods of less than four days, the prevalence of exposure during the week prior to the survey was higher than that encountered on the day of the survey. In studying exposure to risk factors retrospectively, no evidence-based justification could be found to determine how many days prior to the day of actual exposure should be included in the study. However, the site of infection determined the proportion of devices removed due to HAI, and this proportion was not very high in this study. Limiting data to recording the presence of the risk factor on the day of the survey, without investigating past exposures, can provide an adequate estimate of the burden of extrinsic risk factors in one-day, point-prevalence surveys.

Evolution of closed urinary drainage systems use and associated factors in Spanish hospitals.

Although closed urinary drainage systems (CUDS) reduce the risk of catheter-associated urinary tract infection (CAUTI), open systems are still used in Spain. The object of this work was to describe the progress of CUDS use and factors associated with the drainage system type used in Spanish hospitals. The databases of the EPINE study (Study of Prevalence of Nosocomial Infections in Spain) from 1990 to 2000 were used. The EPINE study includes hospitalized patients of all ages in acute-care Spanish hospitals. Seventy-six thousand, seven hundred and eighty-eight catheterized patients were studied, and the whole database was used for the trend analysis of global hospital-acquired infection (HAI). The patient and the hospital were the two units of observation used in the analysis. Full implementation was defined as 90% CUDS use. A logistic regression model was applied to study factors influencing the use of CUDS and to determine prevalence trend. An odds ratio (OR) >1 indicates an incremental trend. The Pearson correlation coefficient between annual percentage of CUDS use and CAUTI prevalence was calculated. Variables for the year 2000 were compared using the Mann-Whitney U test between hospitals with and without full implementation. The prevalence of urinary catheterized patients in Spain increased from 12.4% in 1990 to 15.2% in 2000 (OR 1.019, 95% CI 1.016-1.021). The proportion of CUDS used increased from 50.6% in 1990 to 70% in 2000 (OR 1.1, 95% CI 1.095-1.104) and correlated with a significant decrease of UTIs (r = 0.65, P = 0.03). In 1990, 28.5% of hospitals had full implementation of CUDS and by 2000 this had risen to 40.3% (OR 1.093, 95% CI 1.06-1.127). Patients in medium (200-500 beds) and large (>500 beds) hospitals, as well as those with three of more diagnoses and two or more intrinsic risk factors had an increased probability of having a CUDS, whereas being hospitalized in areas other than intensive care, being male and less than 65 years old were associated with a lower probability of CUDS use. The median prevalence of catheterized patients in hospitals with full implementation, was significantly lower than in those without it (P = 0.049). Although CUDS use is increasing, there is still much work required to reach full implementation. Keeping CUDS for more severely ill patients may reflect a higher concern over the consequences of UTI in these patients. Nevertheless, it is necessary to change a practice that exposes patients to a known UTI risk factor and reach a consensus on indications for catheter insertion.

The importance of the day of the week and duration of data collection in prevalence surveys of nosocomial infections.

In a national prevalence survey setting, we studied whether the day of week selected for data collection, and the number of days needed to complete the survey, were associated with the prevalence of hospital-acquired infection (HAI). The EPINE (Estudio de Prevalencia de las Infecciones Nosocomiales en España) database (1990-2002) was analysed for the purposes of the study. Adjusting for the admission day in the week, the number of intrinsic risk factors, the number of extrinsic risk factors and the prevalence length of stay, a 'weekend effect' was confirmed in this study. The day of the week selected for data collection was related to the presence of infection in the surveyed patients, showing for the period of Saturday-Monday a higher prevalence of patients with HAI (adjusted OR 1.08, 95%CI 1.05-1.10). There was a crude positive trend between number of weeks and prevalence, but the number of days involved in data collection was finally not associated with the prevalence of HAI, once adjustment for hospital size was made. The percentage of repeated records increased linearly with hospital size, and the frequency of infections was higher within this group (OR 2.8, 95%CI 2.6-3.0). The results of this study highlight the need for encouraging hospitals to shorten the time spent in obtaining a prevalence survey. If it is impossible to carry out the survey within the limits of one day, data collection should then be limited to that period of the week, Tuesday to Friday.

Nosocomial infection surveillance and control activities in Spain under HELICS and NosoMed programs frame.

Since the 1980s, a number of multi-center studies for the surveillance of nosocomial infections have been developed in Spain. The first of them, EPINE (study on the prevalence of nosocomial infections in Spain), was followed by two incidence-based surveillance systems: ENVIN-UCI, for intensive care units, and PREVINE, applicable to a broader range of hospital areas. These surveillance systems have made it possible for Spain to participate in two European projects, namely HELICS and NosoMed. It is expected that the European countries participating in these projects will have substantial returns in terms of better prevention and control of health care-related infections.

Relevance of 99mTc-MIBI rest uptake, ejection fraction and location of contractile abnormality in predicting myocardial recovery after revascularization.

The aim of this study was to analyse the influence of rest technetium-99m-methoxy-isobutyl-isonitrile (99mTc-MIBI) uptake, left ventricular ejection fraction (EF) and dysfunctional location in the prediction of myocardial viability. Rest 99mTc-MIBI single photon emission computed tomography (SPECT) was analysed in 82 patients (59+/-9 years, 70 men, 12 women) with one or more segments showing severe hypokinesia, akinesia or dyskinesia who had undergone coronary revascularization. Before and within 3-6 months after the revascularization, gated blood pool scintigraphy was performed. In the post-revascularization control, contractile recovery was observed in 48.7% (155/318) of the segments with severe hypokinesia, akinesia or dyskinesia. Significant increases in sensitivity (53%, 72% and 91%, P<0.0001) and negative predictive value (62%, 68% and 79%, P = 0.01) were observed with decreasing rest uptake 99mTc-MIBI levels of 50%, 40% and 30%, respectively. The decrease in specificity was also significant (67%, 53% and 32%, P<0.0001). The negative predictive value was higher than the positive predictive value mainly in patients with EF < or = 0.35 and with anterior dysfunction. In logistic regression analysis, uptake levels and EF were independent variables that influenced sensitivity and specificity. The negative predictive value was influenced by EF and the positive predictive value only by dysfunctional location. This study suggests that the negative predictive value of 99mTc-MIBI SPECT is higher than the positive predictive value, mainly in patients with EF < or = 0.35, and that the rest uptake level, EF and dysfunctional location are factors that must be considered when results of 99mTc-MIBI SPECT are analysed.

[Efficacy of stress-rest myocardial SPET with 99mTc-MIBI in predicting recovery of postrevascularization contractile function. Results of the Spanish multicenter protocol. Working Group of Nuclear Cardiology]. / Eficacia del SPET miocárdico esfuerzo-reposo con 99mTc-MIBI en la predicción de la recuperabilidad de la función contráctil posrevascularización. Resultados del protocolo multicéntrico español. Grupo de Trabajo de Cardiología Nuclear.

BACKGROUND AND OBJECTIVES: The aim of this study was to evaluate the efficacy of stress-rest 99mTc-MIBI SPET to predict wall motion improvement after revascularization. MATERIAL AND METHODS: A prospective and consecutive series of 82 patients (59 +/- 9 years, 12 women), who had some segment with severe impairment of the contractility and underwent coronary revascularization by surgery (n = 64) or angioplasty (n = 18) were studied with rest 99mTc-MIBI SPET. All patients had a rest 99Tc-MIBI SPET, and an exercise test was also performed on 40 of these patients. Before and within 3-6 months after the revascularization a gated blood pool scintigraphy of three projections was performed. The segmentary contractile recovery after revascularization was assessed in relation to the quantification of the 99mTc-MIBI uptake and to the exercise-rest reversibility (exercise uptake < rest uptake). RESULTS: The mean value of the left ejection fraction did not change after the revascularization (41.1 +/- 14.5% vs 41.8 +/- 15.7%). In the post revascularization control a contractile recovery was observed in 40% (113/282) of the segments with severe hypokinesia, akinesia or dyskinesia. Exercise-rest reversibility and rest uptake > 30% were present in 62% (p = 0.002) and 89% (p < 0.0001) respectively of segments that improved contractility after revascularization. CONCLUSIONS: For the 99mTc-MIBI SPET an exercise-rest reversibility and > 30% uptake at rest are predictive criteria of contractile recovery after revascularization.

[The use and attitudes of adolescents toward addictive substances: a prevalence study]. / Consumo y actitudes de los adolescentes frente a sustancias adictivas: Encuesta de prevalencia.

OBJECTIVE: The purpose of this study was to know the use of addictive substances by adolescents of the city of Barcelona (Catalonia, Spain). PATIENTS AND METHODS: Data were obtained from an anonymous and self-administered questionnaire about tobacco use, alcohol use and non-institutionalized drug abuse. participants were students in 3 degrees BUP (16-17 years old) of twelve institutes that are representative of the different districts of the city. The survey was made during the 1991-1992 school year. RESULTS: Among the 426 individuals included, 32.2% reported use of tobacco, 59.2% alcohol, and 16.4% marijuana. Tobacco use was higher among females (p = 0.05), and that of alcohol (p < 0.0001) and other drugs (p = 0.02) higher among males. The parents' smoking behavior was significantly associated with the use of non-institutionalized drugs (p = 0.01). There was a positive and significant association among the use of all three kinds of addictive substances (p < 0.0001). CONCLUSIONS: The prevalence of tobacco, alcohol and non-institutionalized drug use by students in this age range is high. Compared with previous studies in this population we can appreciate a decreasing trend of use.

[Relationship between coffee and blood cholesterol in a sample of working women]. / Relación entre el café y el colesterol plasmático en una población laboral femenina.

BACKGROUND: Experimental studies have demonstrated that unfiltered coffee increases cholesterolemia. In Spain, filtered coffee is mainly consumed and its effect on cholesterolemia is controversial. METHODS: The relationship between coffee intake and the serum levels of total cholesterol was transversally studied in a population of 609 women between 18 to 65 years in age. The questionnaire and analyses were carried out in the context of periodic health examination. RESULTS: The consumption of coffee was positively associated with cholesterolemia in subjects under 30 years of age (p < 0.01) and in the group from 30 to 45 years in age (p < 0.05). This association was found to be statistically significant on multivariant analysis (multiple lineal regression) after adjusting for age, body mass index, cholesterol consumed in the diet, smoking, alcohol consumption and physical activity. CONCLUSIONS: Coffee was found to increase cholesterolemia in the female population and therefore a reduction in coffee intake would be recommendable in hypercholesterolemic subjects.

Time course of anti-SL-IV immunoglobulin G antibodies in patients with tuberculosis and tuberculosis-associated AIDS.

Immunoglobulin G (IgG) and IgM antibodies against the SL-IV antigen of Mycobacterium tuberculosis in the sera of patients with tuberculosis with negative serology for human immunodeficiency virus (HIV) infection (TB group; n = 97), patients with tuberculosis with positive serology for HIV infection (TB-HIV group; n = 59), and healthy controls (n = 289) were determined by enzyme-linked immunosorbent assay. All sera were obtained at the onset of tuberculosis, i.e., when clinical symptoms appeared. Clinical specimens were collected and cultured for the isolation of M. tuberculosis, and treatment with antituberculous drugs was started. Sera were also obtained from patients in the TB group at fixed intervals during treatment; sera were available from 13 patients in the TB-HIV group before the onset of tuberculosis. The best specificity and positive predictive values were obtained with the IgG assays. In the IgG assays at specificities above 96.0%, the sensitivities of the tests were 45.3 and 72.8% for the TB and TB-HIV groups, respectively, and the sensitivity was 51.9% when data from both groups were combined for analysis. For the TB group, results of this study indicated that the levels of IgG antibodies remain high during treatment. Thus, repetitive serological assays may not be useful for treatment follow-up. In the TB-HIV group, 12 of 13 patients had IgG-specific antibodies against the SL-IV antigen between 1 and 30 months before the onset of tuberculosis, so we suggest that the IgG antibody assay against SL-IV may be helpful for identifying tuberculosis in patients infected with HIV.

[Mycobacterial infections: yield of bacillary microscopy in different clinical samples (1975-1988)]. / Infecciones por micobacterias: rendimiento de la baciloscopia en diferentes muestras clínicas (1975-1988).

BACKGROUND: The yield of microscopy examination as a quick diagnostic test in several pulmonary and nonpulmonary samples referred to the mycobacterial laboratory of a general hospital is reviewed. METHODS: During a 14-year period (1975-1988), 113,836 biological products were investigated. In 9,972 a positive culture for mycobacteria was obtained. For the microscopy examination the auramin technique was used; if positive, acid-alcohol resistance was confirmed by overstaining with the Ziehl-Neelsen technique. The culture was used as the reference method. RESULTS: Microscopic examination was positive in 34% of samples with a positive culture, being 39% for Mycobacterium tuberculosis and 10% for environmental mycobacteria. The overall specificity was 99%, the positive predictive value was 91% and the negative predictive value was 94%. In pleuropulmonary samples the sensitivity ranged from 48% in sputum and 2% in pleural biopsy, with specificity higher than 99%. In nonpulmonary samples, sensitivity, specificity and positive and negative predictive values varied with the type of sample. The false positive rate (positive microscopy with negative culture) was 0.3, and it was shown that 80% of these patients had received previous therapy. In organic fluids (pleural, peritoneal, cerebrospinal), the sensitivity was not greater than 13%. CONCLUSIONS: Sputum, bronchoaspirate and bronchoalveolar lavage were better for the diagnosis of tuberculosis than gastric aspirate. Approximately 1 in each positive microscopy examinations corresponded to environmental mycobacteria. In some nonpulmonary samples with high sensitivity the positive predictive value was low. 80% of the false positive results corresponded to previously treated patients.