Bundles reduce anastomosis leak in patients undergoing elective colorectal surgery. A propensity score-matched study.

Background: anastomosis leak still being a handicap in colorectal surgery. Bowel mechanical preparation and oral antibiotics are not a practice recommended in many clinical practice guides. The aim is to analyse the decrease in frequency and severity of postoperative complications, mainly related to anastomotic leak, after the establishment of a bundle. Methods: Single-center, before-after study. A bundle was implemented to reduce anastomotic leaks and their consequences. The Bundle group were matched to Pre-bundle group by propensity score matching. Mechanical bowel preparation, oral and intravenous antibiotics, inflammatory markers measure and early diagnosis algorithm were included at the bundle. Results: The bundle group shown fewer complications, especially in Clavien Dindós Grade IV complications (2.3% vs. 6.2% p < 0.01), as well as a lower rate of anastomotic leakage (15.5% vs. 2.2% p < 0.01). A significant decrease in reinterventions, less intensive unit care admissions, a shorter hospital stay and fewer readmissions were also observed. In multivariate analysis, the application of a bundle was an anastomotic leakage protective factor (OR 0.121, p > 0.05). Conclusions: The implementation of our bundle in colorectal surgery which include oral antibiotics, mechanical bowel preparation and inflammatory markers, significantly reduces morbidity adjusted to severity of complications, the anastomotic leakage rate, hospital stay and readmissions. Register study: The study has been registered at clinicaltrials.gov Code: nct04632446.

Réplica: Código ictus. ¿Podríamos mejorar los tiempos? / Reply: Code stroke. Can we improve stroke times?

No disponible

Clinical and subclinical cardiovascular disease in female SLE patients: Interplay between body mass index and bone mineral density.

BACKGROUND AND AIMS: Since accelerated atherosclerosis has been reported in systemic lupus erythematosus (SLE), predictive biomarkers of cardiovascular disease (CVD) are needed. Among non-traditional risk factors, bone mineral density (BMD) has been related to CVD. However, its role in SLE remains controversial. This study aims to analyze the associations of subclinical atherosclerosis with traditional and non-traditional CV risk factors. METHODS AND RESULTS: In a cross-sectional study, atherosclerosis burden was compared between 112 female SLE patients and 31 controls. Plaque number and carotid intima-media wall thickness (cIMT) were assessed by ultrasonography. In a retrospective study, BMD determinations obtained 5-years before the ultrasonography assessment were analyzed in a subgroup of 62 patients. Plaque frequency was increased in SLE, even in patients without CV events or carotid wall thickening. cIMT was increased in patients with CVD, positively correlated with body mass index (BMI). Interestingly, a paradoxical effect of BMI on carotid parameters was observed. Whereas underweight patients (BMI < 20) showed increased prevalence of carotid plaques with low cIMT, those with BMI > 30 showed higher cIMT and plaque burden. Overweight patients (25 < BMI<30) exhibited both elevated cIMT and plaque number. BMI was an independent predictor of BMD. In our retrospective study, patients with either clinical or subclinical CVD exhibited lower BMD levels than their CV-free counterparts. A low lumbar spine BMD independently predicted CVD development after adjusting for confounders. CONCLUSION: SLE was associated with a higher subclinical atherosclerosis burden, a bimodal effect being observed for BMI. Decreased BMD can be a CV risk biomarker in SLE.

Análisis del primer año del nuevo protocolo de código ictus en Asturias. Experiencia de un único centro / Analysis of the new code stroke protocol in Asturias after one year. Experience at one hospital

Introducción: Los sistemas de código ictus prehospitalario han demostrado ser eficaces en la mejoría del acceso a una atención médica especializada en el ictus agudo y en condicionar un mejor pronóstico en la enfermedad, que es una de las principales causas de muerte y discapacidad en nuestro medio. El objetivo de este estudio es analizar los resultados del primer año de puesta en marcha del nuevo protocolo de código ictus (CI) en Asturias en un solo centro. Pacientes y métodos: Se incluye de forma prospectiva a los pacientes que acuden dentro del protocolo de código ictus a un centro de tercer nivel asistencial durante el periodo de un año. Resultados: Se analiza a 363 pacientes. La edad media fue de 69 años y en el 54% de los casos se trataba de varones. Para el mismo periodo del año previo las activaciones extrahospitalarias de CI fueron 236. Se llevaron a cabo 147 tratamientos recanalizadores (66 fibrinólisis y 81 trombectomías mecánicas o tratamientos combinados), lo que supuso un incremento del 25% con respecto al año previo. Conclusiones: Los recientes avances en la terapéutica del ictus agudo hacen necesaria la instauración de protocolos coordinados de CI que se adapten a las necesidades de cada región concreta, lo que puede resultar en un incremento del número de pacientes atendidos precozmente, así como de los tratamientos revascularizadores realizados (AU)

Introduction: Prehospital code stroke (CS) systems have been proved effective for improving access to specialised medical care in acute stroke cases. They also improve the prognosis of this disease, which is one of the leading causes of death and disability in our setting. The aim of this study is to analyse results one year after implementation of the new code stroke protocol at one hospital in Asturias. Patients and methods: We prospectively included patients who were admitted to our tertiary care centre as per the code stroke protocol for the period of one year. Results: We analysed 363 patients. Mean age was 69 years and 54% of the cases were men. During the same period in the previous year, there were 236 non-hospital CS activations. One hundred forty-seven recanalisation treatments were performed (66 fibrinolysis and 81 mechanical thrombectomies or combined treatments), representing a 25% increase with regard to the previous year. Conclusions: Recent advances in the management of acute stroke call for coordinated code stroke protocols that are adapted to the needs of each specific region. This may result in an increased number of patients receiving early care, as well as revascularisation treatments (AU)

Analysis of the new code stroke protocol in Asturias after one year. Experience at one hospital. / Análisis del primer año del nuevo protocolo de código ictus en Asturias. Experiencia de un único centro.

INTRODUCTION: Prehospital code stroke (CS) systems have been proved effective for improving access to specialised medical care in acute stroke cases. They also improve the prognosis of this disease, which is one of the leading causes of death and disability in our setting. The aim of this study is to analyse results one year after implementation of the new code stroke protocol at one hospital in Asturias. PATIENTS AND METHODS: We prospectively included patients who were admitted to our tertiary care centre as per the code stroke protocol for the period of one year. RESULTS: We analysed 363 patients. Mean age was 69 years and 54% of the cases were men. During the same period in the previous year, there were 236 non-hospital CS activations. One hundred forty-seven recanalisation treatments were performed (66 fibrinolysis and 81 mechanical thrombectomies or combined treatments), representing a 25% increase with regard to the previous year. CONCLUSIONS: Recent advances in the management of acute stroke call for coordinated code stroke protocols that are adapted to the needs of each specific region. This may result in an increased number of patients receiving early care, as well as revascularisation treatments.

El código ictus de Asturias / Code stroke in Asturias

Introducción: La trombólisis intravenosa con alteplasa es un tratamiento efectivo para el ictus isquémico si se aplica dentro de las primeras 4,5 horas, pero al que acceden <15% de los pacientes. La trombectomía mecánica recanaliza más obstrucciones proximales en las grandes arterias, pero necesita una infraestructura que la hace menos disponible. Métodos: Se detalla la evolución del código ictus en el Principado de Asturias y la adaptación del mismo a los sucesivos recursos para la atención urgente al ictus en la región. Teniendo en cuenta dichos recursos, las circunstancias poblacionales y geográficas de nuestra región, se plantea la reorganización del código ictus buscando la optimización del tiempo y la adecuación a cada paciente. Resultados: Reparto de las ocho áreas sanitarias de Asturias para derivar los pacientes candidatos a tratamientos de reperfusión hacia los dos hospitales donde se dispone de Unidad de Ictus y guardia de Neurología, con posibilidad de aplicar la fibrinólisis IV. Este reparto se realizó en función de la proximidad y la gravedad de los mismos, derivando todos los casos más graves directamente al hospital que dispone de guardia de Neurorradiología Intervencionista. El cribado del paciente se realizó por los Servicios de Emergencias Extrahospitalarias según la escala NIHSS. Conclusiones: Las modificaciones en el código ictus de Asturias permiten ofrecer tratamientos recanalizadores con buenos resultados, buscando la equidad y optimizando el manejo del binomio gravedad-tiempo para ofrecer a cada paciente el tratamiento óptimo en el menor plazo de tiempo posible y en condiciones de seguridad

Background: Intravenous thrombolysis with alteplase is an effective treatment for ischaemic stroke when applied during the first 4.5 hours, but less than 15% of patients have access to this technique. Mechanical thrombectomy is more frequently able to recanalise proximal occlusions in large vessels, but the infrastructure it requires makes it even less available. Methods: We describe the implementation of code stroke in Asturias, as well as the process of adapting various existing resources for urgent stroke care in the region. By considering these resources, and the demographic and geographic circumstances of our region, we examine ways of reorganising the code stroke protocol that would optimise treatment times and provide the most appropriate treatment for each patient. Results: We distributed the 8 health districts in Asturias so as to permit referral of candidates for reperfusion therapies to either of the 2 hospitals with 24-hour stroke units and on-call neurologists and providing IV fibrinolysis. Hospitals were assigned according to proximity and stroke severity; the most severe cases were immediately referred to the hospital with on-call interventional neurology care. Patient triage was provided by pre-hospital emergency services according to the NIHSS score. Conclusions: Modifications to code stroke in Asturias have allowed us to apply reperfusion therapies with good results, while emphasising equitable care and managing the severity-time ratio to offer the best and safest treatment for each patient as soon as possible

Code stroke in Asturias.

BACKGROUND: Intravenous thrombolysis with alteplase is an effective treatment for ischaemic stroke when applied during the first 4.5 hours, but less than 15% of patients have access to this technique. Mechanical thrombectomy is more frequently able to recanalise proximal occlusions in large vessels, but the infrastructure it requires makes it even less available. METHODS: We describe the implementation of code stroke in Asturias, as well as the process of adapting various existing resources for urgent stroke care in the region. By considering these resources, and the demographic and geographic circumstances of our region, we examine ways of reorganising the code stroke protocol that would optimise treatment times and provide the most appropriate treatment for each patient. RESULTS: We distributed the 8 health districts in Asturias so as to permit referral of candidates for reperfusion therapies to either of the 2 hospitals with 24-hour stroke units and on-call neurologists and providing IV fibrinolysis. Hospitals were assigned according to proximity and stroke severity; the most severe cases were immediately referred to the hospital with on-call interventional neurology care. Patient triage was provided by pre-hospital emergency services according to the NIHSS score. CONCLUSIONS: Modifications to code stroke in Asturias have allowed us to apply reperfusion therapies with good results, while emphasising equitable care and managing the severity-time ratio to offer the best and safest treatment for each patient as soon as possible.

Neurologic disorders associated with inflammatory bowel disease.

BACKGROUND AND PURPOSE: the study is aimed to report neurologic manifestations in a population of patients with inflammatory bowel disease in order to address its clinical characteristics. METHODS: we conducted a retrospective study based on a computer-guided search, of patients with Crohn's disease or ulcerative colitis diagnosed at three hospitals in Spain spanning from 2000 through 2008. Patients were classified into different clinical groups based on the type of neurologic involvement. Only patients without iatrogenic complications, vitamin deficiencies, or known cerebrovascular risk factors were included. RESULTS: we identified and reviewed the records of eighty-four inflammatory bowel disease patients with neurologic symptoms: thirteen patients with ulcerative colitis and twelve patients with Crohn's disease associated with neurologic complications were identified. Their ages ranged from 17 to 74 years. There was a slight predominance of women. Only four of them have another extra-intestinal manifestation. Most of the patients developed neurologic manifestations coincidental or after digestive symptoms appeared. Demyelinating disease was the most frequent manifestation observed (8 patients). Cerebrovascular, peripheral nerve, and epilepsy disorders were diagnosed in 6, 5, and 3 patients, respectively. One patient with myoclonus, one with amyotrophic lateral sclerosis, and one with sensorineural hearing loss were found. CONCLUSIONS: although an incidence could not be obtained, this population of patients with inflammatory bowel disease have a low frequency of severe neurologic disorders. Neurologic diseases, such as cerebrovascular disease, demyelinating disease, and peripheral neuropathy, could be associated with Crohn's disease and ulcerative colitis.

Tratamiento intravascular de la oclusión aguda carotídea con lesión en tándem intracraneal / Intravascular treatment for acute carotid occlusion with an intracranial tandem lesion

Se presenta el caso clínico de un paciente con una obstrucción aguda en el origen de la arteria carótida interna, a la que se asocia oclusión del segmento 1 de la arteria cerebral media homolateral con deterioro neurológico grave. Se describen las pruebas de neuroimagen (tomografía computarizada [TC] craneal sin contraste, angiografía por TC, perfusión por TC y arteriografía cerebral) y el tratamiento intravascular (fibrinólisis mecánica y farmacológica intraarteriales) con buen resultado morfológico y clínico. Se analiza el seguimiento del paciente (AU)

We present the case of a patient with an acute obstruction in the origin of the internal carotid artery that was associated with occlusion of segment one of the ipsilateral medial cerebral artery and severe neurologic deterioration. We describe the neuroimaging findings (unenhanced cranial computed tomography [CT], CT angiography, CT perfusion studies, and cerebral angiography) and the intravascular treatment (mechanical and pharmacological intra-arterial fibrinolysis). Treatment yielded good morphological and clinical results; we also analyze the follow-up of the patient (AU)

[Intravascular treatment for acute carotid occlusion with an intracranial tandem lesion]. / Tratamiento intravascular de la oclusión aguda carotídea con lesión en tándem intracraneal.

We present the case of a patient with an acute obstruction in the origin of the internal carotid artery that was associated with occlusion of segment one of the ipsilateral medial cerebral artery and severe neurologic deterioration. We describe the neuroimaging findings (unenhanced cranial computed tomography [CT], CT angiography, CT perfusion studies, and cerebral angiography) and the intravascular treatment (mechanical and pharmacological intra-arterial fibrinolysis). Treatment yielded good morphological and clinical results; we also analyze the follow-up of the patient.

Displasia fibromuscular, disección y oclusión asintomática de la arteria basilar / Fibromuscular dysplasia. Asymptomatic dissection and occlusion of the basilar artery

Introducción. Clásicamente, la oclusión de la arteriabasilar ha sido considerada una entidad de mal pronóstico ycon alta tasa de morbimortalidad. Estudios prospectivos másrecientes sugieren, sin embargo, un pronóstico más benigno.La arteria basilar se afecta sobre todo por la arteriosclerosis,pero también puede ser asiento de embolismos, disecciones,aneurismas y otras afecciones como la displasiafibromuscular.Caso clínico. Un hombre de 46 años fue ingresado por unepisodio transitorio de ataxia y disartria. El Doppler transcranealreveló un flujo estenótico en la arteria basilar conseñales microembólicas distales a la estenosis. La angiografíapor resonancia magnética (RM) demostró una displasiafibromuscular aislada en la arteria basilar que causaba unaestenosis mayor del 50 % sin lesiones parenquimatosas. Seinició tratamiento anticoagulante y 10 meses después, permaneciendoel paciente asintomático, una RM de controlmostraba una disección que evolucionó a oclusión completade la arteria basilar. Su porción distal se rellenaba por flujoinverso desde ambas arterias comunicantes posteriores. Laanticoagulación fue suspendida.Discusión. La displasia fibromuscular de la arteria basilares rara y habitualmente asintomática. Aunque puededesembocar en una disección, la presentación clínica másfrecuente es el ictus isquémico secundario a la estenosis. Lasdisecciones intracraneales se asocian con riesgo de hemorragiasubaracnoidea. Pese a ello, muchos autores recomiendanel tratamiento anticoagulante para la displasia fibromuscular.La oclusión de la arteria basilar, como muestraeste caso, no siempre conlleva un mal pronóstico. Éste estádeterminado, al menos en parte, por la presencia de una circulacióncolateral adecuada (AU)

Introduction. Historically, basilar artery occlusive disease has been considered to convey a poor prognosis and a high mortality rate. In contrast, recently prospective studies have shown a better prognosis. The basilar artery is most commonly affected by atherosclerosis, but may also be affected by embolisms, dissections, aneurysms, and other conditions like fibromuscular dysplasia. Case report. The case of a 46 year-old male who was admitted after suffering a transient episode of ataxic gait and dysarthria is reported. Transcranial Doppler showed a stenotic flow in the basilar artery with distal embolic signals. Magnetic resonance (MR) angiography demonstrated an isolated fibromuscular dysplasia of the basilar artery that caused a > 50% stenosis without parenchymal lesions. Oral anticoagulation treatment was initiated. The control MR angiography performed ten months later, and although the patient was asymptomatic, showed a dissection which evolved into a complete occlusion of the basilar artery. Its distal portion was filled via a reverse flow from both posterior communicating arteries.Anticoagulation treatment was discontinued. Discussion. Fibromuscular dysplasia of the basilar artery is a rare and usually asymptomatic disease. It may develop into a dissection, but the usual clinical presentation is stenosis-related ischemic stroke. Intracranial artery dissections may be further complicated by subarachnoid hemorrhage. Many authors have recommended anticoagulant therapy for fibromuscular dysplasia. Basilar artery occlusion, as this case shows, does not always convey a poor prognosis. This is determined, at least partially, by the presence of good collateral circulation (AU)

[Fibromuscular dysplasia. Asymptomatic dissection and occlusion of the basilar artery]. / Displasia fibromuscular, disección y oclusión asintomática de la arteria basilar.

INTRODUCTION: Historically, basilar artery occlusive disease has been considered to convey a poor prognosis and a high mortality rate. In contrast, recently prospective studies have shown a better prognosis. The basilar artery is most commonly affected by atherosclerosis, but may also be affected by embolisms, dissections, aneurysms, and other conditions like fibromuscular dysplasia. CASE REPORT: The case of a 46 year-old male who was admitted after suffering a transient episode of ataxic gait and dysarthria is reported. Transcranial Doppler showed a stenotic flow in the basilar artery with distal embolic signals. Magnetic resonance (MR) angiography demonstrated an isolated fibromuscular dysplasia of the basilar artery that caused a > 50% stenosis without parenchymal lesions. Oral anticoagulation treatment was initiated. The control MR angiography performed ten months later, and although the patient was asymptomatic, showed a dissection which evolved into a complete occlusion of the basilar artery. Its distal portion was filled via a reverse flow from both posterior communicating arteries. Anticoagulation treatment was discontinued. DISCUSSION: Fibromuscular dysplasia of the basilar artery is a rare and usually asymptomatic disease. It may develop into a dissection, but the usual clinical presentation is stenosis-related ischemic stroke. Intracranial artery dissections may be further complicated by subarachnoid hemorrhage. Many authors have recommended anticoagulant therapy for fibromuscular dysplasia. Basilar artery occlusion, as this case shows, does not always convey a poor prognosis. This is determined, at least partially, by the presence of good collateral circulation.

Estenosis arterial intracraneal de origen embólico persistente en el tiempo / Long lasting intracranial artery stenosis of embolic origin

Introducción. Se conoce como evanescentes a aquellas estenosis arteria les intracraneales consecutivas a la recanalización parcial de una oclusión de origen embólico. En general se considera que en un corto período de tiempo dichas estenosis se resuelven debido a la completa recanalización del vaso, diferenciándolas así de las estenosis de origen arteriosclerótico. Caso clínico. Presentamos el caso de un paciente de 61 años que sufrió un ictus en el territorio de la arteria cerebral media izquierda provocado por una fibrilación auricular previamente desconocida. En la fase aguda se constató la existencia de un flujo estenótico a nivel de la arteria cerebral media izquierda. A pesar de tratarse de una oclusión de origen embólico, pasó 1 año antes de que la estenosis se resolviese. Conclusiones. Casos como el presente cuestionan los protocolos en uso, que tienden a clasificar como arterioscleróticas a aquellas estenosis persistentes durante más de 3 meses y hacen necesarios estudios que aclaren la historia natural de las oclusiones arteria les intracraneales

Introduction. The term evanescent, or vanishing, has been used to describe those intracranial stenoses that are consecutive to fue partial recanalization of an embolic occ1usion. In general terms it has been admitted that fuose stenoses quickly disappear in parallel to the complete recanalization of the artery. This behaviour allows their differentiation from fue atherosc1erotic stenoses. Case reporto We present here a 61-year-old male who suffered a middle cerebral artery territory stroke secondary to an atrial fibrillation. In the acute phase, a stenotic flow was found in fue proximal portion of his left middle cerebral artery. Although it was an embolic occ1usion, one year passed before the stenosis disappeared. Discussion. Findings like this contradict the protocols in use (which consider a stenosis as atherosc1erotic if it remains for more than three months), and stress the need for new studies which clarify the natural history of the intracranial arterial occlusions

[Long lasting intracranial artery stenosis of embolic origin]. / Estenosis arterial intracraneal de origen embólico persistente en el tiempo.

INTRODUCTION: The term evanescent, or vanishing, has been used to describe those intracranial stenoses that are consecutive to the partial recanalization of an embolic occlusion. In general terms it has been admitted that those stenoses quickly disappear in parallel to the complete recanalization of the artery. This behaviour allows their differentiation from the atherosclerotic stenoses. CASE REPORT: We present here a 61-year-old male who suffered a middle cerebral artery territory stroke secondary to an atrial fibrillation. In the acute phase, a stenotic flow was found in the proximal portion of his left middle cerebral artery. Although it was an embolic occlusion, one year passed before the stenosis disappeared. DISCUSSION: Findings like this contradict the protocols in use (which consider a stenosis as atherosclerotic if it remains for more than three months), and stress the need for new studies which clarify the natural history of the intracranial arterial occlusions.

Seasonal change in nutritional status among young children in an urban shanty town in Peru.

Seasonal variation in nutritional status among young children has been described in rural populations, but in few urban settings. We examined seasonality in 7 years of nutritional surveillance data from an urban shanty town near Lima, Peru, where children 0-35 months old were measured at intervals of 4-5 months. We compared nutritional status by month, using generalized estimating equations to account for the intercorrelations among measurements of the same person at different times. The periodicity of the seasonal variation was found to fit a model in which the month of the year was sine-transformed, and this sine-transformed model was used to examine possible interactions with age, sex and year of examination. A total of 38,626 measurements was available from 11,333 children. In late winter, mean weight-for-height was an estimated 0.38 Z score higher than in late summer. The seasonal effect occurred at all ages, in both sexes, and in each year of surveillance. The amplitude was greatest for children 6-23 months old. The summer trough in weight-for-height was lower in 1989 than in other years; children who experienced this summer low had lower mean height-for-age in subsequent years. The seasonal variation in nutritional status may be related to differences in dietary intake, or to the higher prevalence of bacterial diarrhoea in summer than in winter. The more marked drop in weight-for-height in 1989 and subsequent trough in height-for-age may be related to political and economic changes than adversely affected food access in Peru.

[Interrelations among lactation, fertility, and infant mortality in Peruvian women not using contraceptives]. / Interrelacion entre lactancia, fecundidad y mortalidad infantil en mujeres peruanas no usuarias de anticonceptivos.

PIP: Results of two national surveys were used to study regional patterns of breast feeding and their relationship to birth spacing and infant mortality in Peru. Estimates of the duration of breast feeding were based on the 1984 National Survey of Nutrition and Health. The 1986 Demographic and Family Health Survey (DHS) was the basis for an analysis of factors associated with short durations of breast feeding and of the effect of breast feeding on birth spacing and infant mortality. Mothers who had ever used contraception were excluded from the segments based on the DHS data. Prevalence and life table methods were used to determine regional patterns of breast feeding. The study of risk factors for short duration of breast feeding used a retrospective cohort study comparing infants breast feeding for less than or more than 12 months using bivariate analysis. The effect on birth spacing was assessed using a life table methodology. The infant mortality rate was calculated for the 199 children born between 1980 and 1984 to mothers not using contraception. The duration of breast feeding was relatively short in Lima, perhaps because of the importance of the middle and upper socioeconomic strata. Breast feeding was prolonged in the sierra and of intermediate duration in the lowlands. The coastal area outside of Lima appeared to have an adequate duration of breast feeding. Birth order of 4 or under and urban residence were the only factors significantly related to breast feeding for less than one year. Prolonged lactation was associated with longer birth intervals in women who never used contraception. The median birth interval was increased by around five months according to the life table applied to children born between 1980 and 1984 to women interviewed in the DHS. Prolonged lactation was associated with lower mortality among infants of mothers not using contraception. Infants breast feeding for less than a year had a relative risk of mortality of 3.6 on the coast and 2.7 in the sierra or lowlands. Promotion of breast feeding, it would appear, offers a cost-effective response to the two serious problems of short birth intervals and high infant mortality.^ieng

Plasmids in Salmonella typhi in Lima, Peru, 1987-1988: epidemiology and lack of association with severity of illness or clinical complications.

A prospective study was conducted to better characterize the epidemiology of plasmid-bearing strains of Salmonella typhi in an endemic area of Lima, Peru, and to determine if plasmids were associated with specific manifestations of typhoid fever. Of 228 S. typhi isolated from patients at Cayetano Heredia University Hospital in Lima during 1987-1988, 76 (33%) contained plasmids. Ten different plasmid profiles were identified, with ten distinct plasmids present within these profiles. There was significant temporal clustering of isolates having common plasmid profiles. Two plasmids (both from the same isolate) carried antibiotic resistance genes. Two cryptic plasmids with approximate sizes of 55 and 65 kilobases (kb) appeared to be closely related, based on restriction endonuclease digestions and Southern blot analysis. An ampicillin resistance plasmid from a 1989 patient isolate differed by only a single restriction fragment from the cryptic 65-kb plasmid. No association was found between any plasmid or plasmid profile and severity or clinical manifestations of disease.

Detection of Salmonella typhi carriers in food handlers by Vi serology in Lima, Peru.

The work described here sought to assess the merits of using an indirect hemagglutination test employing highly purified Vi antigen to screen a high-risk population for chronic S. typhi carriers in Lima, Peru. A total of 1,931 female food handlers over 30 years old were enrolled in the study. Indirect hemagglutination tests performed on these subjects' sera, taking a titer of 1:40 or more as positive, yielded 29 positive results. Subsequent bacteriologic testing performed on 26 of these 29 subjects identified four (15%) as S. typhi carriers. The procedure had a sensitivity of 79%, indicating that the prevalence of S. typhi carriers among the population studied was on the order of 262 per 100,000. It appears that Vi serology employing highly purified Vi antigen offers a practical and cost-effective way of screening for S. typhi carriers in both endemic and nonendemic typhoid fever areas.

Use of norfloxacin to treat chronic typhoid carriers.

High relapse rates and low tolerability to ampicillin characterize present therapy for carriers of Salmonella typhi. Norfloxacin, a carboxyquinolone with a 90% minimum inhibitory concentration for S. typhi of less than or equal to 0.5 micrograms/mL, is a promising alternative. Carriers of S. typhi were treated in a double-blind trial with either norfloxacin (400 mg) or matching placebo given every 12 h for 28 d. Twelve assessable individuals were treated in each group. After therapy, 11 of 12 individuals treated with norfloxacin had negative stool and bile cultures for S. typhi. All placebo-treated carriers still had positive cultures immediately after therapy. Subsequently, 11 individuals were treated openly with norfloxacin. S. typhi was eradicated in seven of 11. Overall, the eradication rate for 23 individuals treated with norfloxacin was 78%. Eighteen individuals were followed up for one year, and their stool and/or bile cultures remained negative. From our results, norfloxacin is an effective and well-tolerated antimicrobial agent for eradicating the chronic typhoid carrier state.