Resultados de urocultivos en adultos realizados por el laboratorio de microbiología del Hospital de Clínicas - San Lorenzo de enero del 2015 a agosto de 2016 y métodos de estudio de las infecciones urinarias disponibles en la institución / Results of urine culture in adults carried out by the microbiology laboratory of the Clinics Hospital - San Lorenzo from january 2015 to august 2016 and methods of study of urinary infections available in the institution

Introducción: Los objetivos de este trabajo son: presentar los métodos de estudio de las infecciones urinarias actualmente disponibles en el Laboratorio de Microbiología del Hospital de Clínicas y mostrar los datos de los urocultivos evaluados en forma retrospectiva. Materiales y Métodos: Para estudiar los métodos de estudio de los urocultivos disponibles en el Laboratorio hemos recurrido al archivo del Laboratorio cuyos datos fueron consecutivamente cargados en una planilla de procesamiento de datos Excel de Microsoft Office ®. Los resultados de los urocultivos fueron evaluados de enero de 2015 a agosto de 2016, en forma retrospectiva, observacional, en corte transverso, de los adultos de ambos sexos. Las muestras para urocultivo son recibidas y procesadas en el laboratorio, siguiendo pasos preestablecidos. Resultados: El microorganismo preponderante de los urocultivos fue Escherichia coli (60% de las mujeres y 32% de los varones) seguido por Klebsiella pneumoniae (19% de los varones, 14% de las mujeres). Otros microorganismos aislados fueron Candida sp., Enterococcus faecalis, Enterobacter cloacae, Pseudomona aeruginosa, Proteus mirabilis, Staphylococcus aureus, Acinetobacter baumanii. La resistencia de Escherichia Coli a nitrofurantoína fue del 6% en los varones y 1% en las mujeres. La resistencia de E.Coli a meropenen fue también escasa. En cuanto a Klebsiella pneumoniae en las mujeres, la resistencia fue del 3%. En los hombres, los antibióticos testados para Klebsiella pneumoniae mostraron una resistencia superior al 30%, con excepción del meropenem. Uropatógenos productores de betalactamas de espectro extentido (BLEE) y de carbapenemasas fueron detectados en el presente estudio. Discusión: La toma de la orina para el urocultivo se efectúa siguiendo pautas claras, emanadas del laboratorio. Con la utilización de medios actualmente disponibles en el laboratorio, es posible tipificar el género y la especie tanto de bacterias Gram negativas y positivas como de hongos. Conclusión: La estructura del Laboratorio de Microbiología ha tenido avances que permiten la identificación precisa de los gérmenes de los urocultivos, así como la prevalencia y la resistencia que presentan a ciertos antibióticos. Estos aportes son particularmente útiles para los casos de Escherichia coli y Klebsiella pneumoniae debido a su alta prevalencia. También fue factible constatar la emergencia de gérmenes productores de betalactamasas de espectro extendido (BLEE) y carbapenemasas.

Introduction: The objectives of this work are: to present the methods of study of urinary infections currently available in the Laboratory of Microbiology of the Hospital de Clínicas and to show the data of the urine cultures evaluated retrospectively. Material and method: in order to study the available methods in urine cultures in the Laboratory, we have used the laboratory file whose data were consecutively loaded in an Excel data processing form of Microsoft Office ®. The results of the urine cultures were evaluated from January 2015 to August 2016, in a retrospective, observational, cross-sectional study of adults of both sexes. Samples for urine culture are received and processed in the laboratory, following pre-established steps. Results: The predominant microorganisms were Escherichia coli in 60% of women and 32%of men, Klebsiella pneumonia 19% of men and 14% of women. Other isolated organisms were Candida sp., Enterococcus faecalis, Enterobacter cloacae, Pseudomonas aeruginosa, Proteus mirabilis, Staphylococcus aureus, and Acinetobacter baumanii. Escherichia coli resistance to nitrofurantoin was seen in 6% of men and 1% of women and meropenem resistance to E. coli was also low. As for Klebsiella pneumoniae in women, resistance to meropenem was seen in 3% of cases. In men, the antibiotics tested for Klebsiella pneumoniae showed resistance greater than 30% except for meropenem. Uropathogens producing Extended-Spectrum -lactamase (ESBL ) and Carbapenemase were found. Discussion: Urine collection for urine culture is done following clear guidelines emanating from the laboratory. With the use of media currently available in the laboratory, it is possible to typify the genus and species of both Gram negative and positive bacteria as well as fungi. Conclusion: The structure of the Laboratory of Microbiology has had advances that allow the precise identification of the germs of the urine cultures, as well as the prevalence and resistance to certain antibiotics. These contributions are particularly useful for the cases of Escherichia coli and Klebsiella pneumoniae due to their high prevalence. It was also possible to verify the emergence of spread spectrum beta-lactamases (ESBL) and carbapenemases.

Alemtuzumab in chronic lymphocytic leukemia: final results of a large observational multicenter study in mostly pretreated patients.

This retrospective study evaluated the benefit of alemtuzumab monotherapy in unselected patients with advanced B-cell chronic lymphocytic leukemia (CLL) and prolymphocytic leukemia (B-PLL) to definitely describe the impact of this antibody in clinical routine use. Data were collected from 208 consecutive, mainly pretreated, patients with CLL (n = 202), and B-PLL (n = 6) who had received alemtuzumab. Response, progression-free survival (PFS), and overall survival (OS) in various settings were assessed, and toxicities were documented. In these routine patients, a comparably low cumulative dose of alemtuzumab (median, 403 mg) was applied. In CLL, overall response rate was 32 %, and various pre-therapeutic parameters were predictive for inferior response, among them, the prior administration of ≥3 therapy lines (P < 0.001), refractoriness to fludarabine (P = 0.002), and bulky lymphadenopathy (P = 0.003). PFS and OS after start of alemtuzumab were 6.2 and 21.0 months, respectively. Bulky lymphadenopathy was the prominent risk factor for both inferior PFS (P < 0.001) and OS (P = 0.002). In B-PLL, four patients experienced a fatal outcome, whereas two patients had some benefit with alemtuzumab. The main adverse effects were CMV reactivation (20 %) and a broad spectrum of infections, which together were the main reasons for treatment interruption and/or premature termination. In conclusion, alemtuzumab administered even at low dose levels was effective but overall considerably toxic in routine CLL patients. We emphasize that alemtuzumab remains an important therapeutic option in subsets of CLL patients.

[Adverse effects of treatment with psychotropic drugs in the elderly - special risks, protective mechanisms, prognosis]. / Unerwünschte Wirkungen unter Therapie mit Psychopharmaka im Alter - Spezielle Risiken, Schutzmechanismen, Prognosen.

Due to their multimorbidity elderly patients take multiple medications, which increase the risks of adverse side effects. In this patient group, main aim of treatment is to achieve an optimal quality of live. Unwanted effects of drugs and of drug combinations (polypharmacy) have carefully to be checked.

[Delirious psychiatric nurse with abdominal pain - a medical chameleon]. / Deliranter Psychiatriepfleger mit Bauchschmerzen - Ein medizinisches Chamäleon.

Acute hepatic porphyrias stand for a group of rare genetic defects in the metabolism of heme biosynthesis, whereof acute intermittent porphyria is the most frequent one. Factors like drugs, infections, fasting, alcohol, or stress can provoke an acute crisis. The symptoms are very variable; however gastrointestinal and neuro-psychiatric symptoms are common. Furthermore darkening urine might be an important diagnostic sign. We describe the case of a 33-year-old psychiatric nurse presenting with stomach ache, hypertension, delirium and red spots in his underwear.

Role of vasopressin in the haemodynamic response to laparoscopic cholecystectomy.

We studied 10 patients undergoing laparoscopic cholecystectomy (group 1) and five control patients (group 2). We measured heart rate, arterial pressure, right atrial pressure (RAP), cardiac index (CI), systemic vascular resistance index (SVRI), intrathoracic pressure (ITP), plasma osmolality, adrenaline, noradrenaline and arginine vasopressin (aVP) concentrations, and serum renin activity (SRA), and calculated the atrial transmural pressure gradient (ATPG). We recorded significant decreases in mean arterial pressure (MAP), SVRI and CI in both groups (P < 0.05) after induction of anaesthesia. MAP and SVRI increased (P < 0.01) while CI decreased further in group 1 patients during the pneumoperitoneum. In group 1 plasma aVP concentration increased after insufflation of the pneumoperitoneum to a level sufficient to cause the recorded haemodynamic changes. ATPG decreased in group 1 patients during the pneumoperitoneum and this is a recognized trigger for aVP release.

The prevention of postoperative nausea and vomiting using a combination of ondansetron and droperidol.

We have studied the effect of combination antiemetic therapy (ondansetron and droperidol) with morphine delivered by patient-controlled analgesia following major gynaecological surgery. Sixty patients were randomly allocated to one of three treatment regimens; ondansetron alone (4 mg bolus and 0.13 mg.ml-1 in the morphine solution), droperidol alone (1.25 mg bolus and 0.05 mg.ml-1 in the morphine solution), or both drugs in combination. For the first 12 postoperative hours, patients receiving combination therapy experienced significantly less nausea than those receiving single antiemetic therapy (p < 0.001). There was no difference between the regimens from 12 to 18 h. We conclude that a combination of ondansetron and droperidol added to morphine in a patient-controlled analgesia system reduces postoperative nausea to a greater extent than treatment with either drug alone following major gynaecological surgery.

The abbreviated injury scale as a predictor of outcome of severe head injury.

OBJECTIVE: This study examined the correlation between the worst abbreviated injury scale 1990 (AIS) intracranial severity score and outcome following severe head injury. DESIGN: The initial CT scans of 109 severely head injury patients were examined by a neuroradiologist and classified according to the worst applicable intracranial severity code from the AIS. This score was then correlated with the glasgow outcome scale (GOS) at 6 months. For comparison, the GOS was also correlated with the diffuse injury scale (DIS) described by L.F. Marshall et al. [5], the worst post-resuscitation Glasgow coma score (GCS) in the first 24 h, and the head injury outcome prediction tree described by Choi et al. [1]. RESULTS: Our results show Spearman rank correlation coefficients of 0.58 (p < 0.001), 0.47 (p < 0.001), 0.45 (p < 0.001), and 0.31 (p < 0.01) for the correlation between the AIS, prediction tree, DIS, and GCS respectively and the GOS. Independent outcome (i.e. GOS good or moderate) was strongly predicted by an AIS of 3 or less (positive predictive value 95%, specificity 98%, sensitivity 40%, likelihood ratio 25:1). Death or vegetative survival was less strongly predicted in patients with an AIS of 5 (positive predictive value 71%, specificity 75%, sensitivity 67%, likelihood ratio 2.7:1). CONCLUSION: The AIS, based on initial CT scan, provides useful prognostic information in patients with severe head injury.

A comparison of droperidol and cyclizine in the prevention of postoperative nausea and vomiting associated with patient-controlled analgesia.

Fifty ASA 1 or 2 patients scheduled to undergo major gynaecological surgery were allocated randomly to one of two groups. All patients received a standard anaesthetic regimen. Patients in group 1 received droperidol 1.25 mg given intravenously 20 min prior to the end of surgery and a patient-controlled analgesia infusion containing morphine 1 mg.ml-1 and droperidol 0.05 mg.ml-1. Patients in group 2 received cyclizine 50 mg by slow intravenous injection 20 min prior to the end of surgery and a patient-controlled analgesia infusion containing morphine 1 mg.ml-1 and cyclizine 2 mg.ml-1. Fifteen of 25 patients (60%) in group 1 and 18 (72%) of 25 in group 2 suffered no nausea or vomiting postoperatively. Two patients (8%) in group 1 and three (12%) in group 2 suffered severe postoperative nausea or vomiting. We conclude that cyclizine is as effective as droperidol in the prevention of postoperative nausea and vomiting when included in a patient-controlled analgesia infusion using morphine.

Failure of anaesthesia with etomidate.

A case of failure of etomidate anaesthesia in a patient with chronic renal failure and multiple myeloma is described. Adequate serum levels of etomidate were confirmed. High levels of serum light chains were noted, and may be associated with the lack of action of etomidate.

Ethylene glycol antifreeze poisoning. Three case reports and a review of treatment.

We present three patients with ethylene glycol antifreeze poisoning whose management included the use of continuous veno-venous haemodiafiltration. Results from these cases demonstrate clearance of the ethylene glycol molecule.

Antiemetic efficacy of metoclopramide when included in a patient-controlled analgesia infusion.

A double-blind, randomised, controlled trial was performed to assess the antiemetic efficacy of metoclopramide when included in a morphine patient-controlled analgesia regimen. Fifty ASA grade 1 or 2 patients scheduled for elective intermediate or major gynaecological surgery were allocated into one of two groups. All patients received a standardised anaesthetic and metoclopramide 5 mg was given intravenously 10 min before the end of the procedure. Group 1 received a patient-controlled analgesia regimen using morphine 1 mg.ml-1 solution. Group 2 received a patient-controlled analgesia regimen using morphine 1mg.ml-1 with metoclopramide 0.5 mg.ml-1 solution. Postoperative antiemetic treatment was with metoclopramide 10 mg intramuscularly or cyclizine 50 mg intramuscularly if this was ineffective. Pain scores, sedation scores, and morphine requirement were not significantly different between the groups. There was no difference in nausea scores between the groups, but more patients suffered moderate or severe nausea in group 1 (10 patients) than group 2 (three patients, p < 0.026). We conclude that metoclopramide, when included in a patient-controlled analgesia regimen, reduces the incidence of moderate to severe nausea, but not the overall incidence of nausea.

Surgery and radiation therapy in the management of craniopharyngiomas.

Twenty-nine patients with histologically confirmed craniopharyngioma were treated from 1960 to 1978, inclusive. Twelve patients were below the age of 15 years, the remaining were adults. Seventy-five percent (9/12) of the patients below the age of 15 showed increased intracranial pressure at presentation and 58% (7/12) showed visual disturbances. In the adult group, 47% (8/17) presented with increased intracranial pressure and 88% (15/17) with visual disturbances. Hormonal, mental and behavior changes were almost equally distributed in both age groups. All patients underwent craniotomy, with subtotal resection of the tumor. Three adults died of postoperative complications (10%), of whom two died of pulmonary emboli and one of cerebral hemorrhage. Of the remaining 26 patients, 13 received immediate postoperative radiotherapy to a total dose of 50.0 to 56.0 Gy, in a target volume including the sellar and parasellar region during an overall treatment period of five to six weeks. All patients were evaluable with a minimum follow-up of four years since they finished their treatment or until death. The five-year recurrence-rate in the group that did not receive postoperative radiation therapy was 45% (5/11 patients) and the five-year rate of death of disease in this group was 27% (3/11 patients). For the group that received immediate postoperative radiation therapy the five-year recurrence-rate was 11% (1/9 patients) and no death of disease was observed in this group. This difference between the two groups was not significant. The corresponding 10-year rates were 71% (5/7 patients) for recurrence and 57% (4/7 patients) for death of disease in the group without, and in the group with immediate postoperative radiation therapy the rate was 25% (2/8 patients) for recurrence and 0 for death of disease. This difference turns out to be significant. Critical analysis of the morbidity in patients surviving after treatment showed no adverse effect on the visual or endocrine status of the group that received postoperative irradiation. It is concluded that in the management of patients with craniopharyngiomas, postoperative irradiation after subtotal resection improves the prognosis of the patient and does not add to visual or endocrine morbidity.

Ulcerative colitis complicated by autoimmune hemolytic anemia.

We have reported the rare association of severe autoimmune hemolytic anemia with active ulcerative colitis, and added to the sparse published recommendations concerning management. Although aggressive medical therapy resulted in only partial control of the inflammatory bowel disease and hemolysis, both disorders remitted rapidly after panproctocolectomy and splenectomy. Autologous red cells were safely transfused during surgery.