Co-infections and superinfections complicating COVID-19 in cancer patients: A multicentre, international study.

BACKGROUND: We aimed to describe the epidemiology, risk factors, and clinical outcomes of co-infections and superinfections in onco-hematological patients with COVID-19. METHODS: International, multicentre cohort study of cancer patients with COVID-19. All patients were included in the analysis of co-infections at diagnosis, while only patients admitted at least 48 h were included in the analysis of superinfections. RESULTS: 684 patients were included (384 with solid tumors and 300 with hematological malignancies). Co-infections and superinfections were documented in 7.8% (54/684) and 19.1% (113/590) of patients, respectively. Lower respiratory tract infections were the most frequent infectious complications, most often caused by Streptococcus pneumoniae and Pseudomonas aeruginosa. Only seven patients developed opportunistic infections. Compared to patients without infectious complications, those with infections had worse outcomes, with high rates of acute respiratory distress syndrome, intensive care unit (ICU) admission, and case-fatality rates. Neutropenia, ICU admission and high levels of C-reactive protein (CRP) were independent risk factors for infections. CONCLUSIONS: Infectious complications in cancer patients with COVID-19 were lower than expected, affecting mainly neutropenic patients with high levels of CRP and/or ICU admission. The rate of opportunistic infections was unexpectedly low. The use of empiric antimicrobials in cancer patients with COVID-19 needs to be optimized.

Hydrogen sulphide as a signalling molecule regulating physiopathological processes in gastrointestinal motility.

The biology of H2 S is a still developing area of research and several biological functions have been recently attributed to this gaseous molecule in many physiological systems, including the cardiovascular, urogenital, respiratory, digestive and central nervous system (CNS). H2 S exerts anti-inflammatory effects and can be considered an endogenous mediator with potential effects on gastrointestinal motility. During the last few years, we have investigated the role of H2 S as a regulator of gastrointestinal motility using both animal and human tissues. The aim of the present work is to review published data regarding the potential role of H2 S as a signalling molecule regulating physiopathological processes in gastrointestinal motor function. H2 S is endogenously produced by defined enzymic pathways in different cell types of the intestinal wall including neurons and smooth muscle. Inhibition of H2 S biosynthesis increases motility and H2 S donors cause smooth muscle relaxation and inhibition of propulsive motor patterns. Impaired H2 S production has been described in animal models with gastrointestinal motor dysfunction. The mechanism(s) of action underlying these effects may include several ion channels, although no specific receptor has been identified. At this time, even though there is much experimental evidence for H2 S as a modulator of gastrointestinal motility, we still do not have conclusive experimental evidence to definitively propose H2 S as an inhibitory neurotransmitter in the gastrointestinal tract, causing nerve-mediated relaxation.

Inverse gradient of nitrergic and purinergic inhibitory cotransmission in the mouse colon.

AIM: Gastrointestinal smooth muscle relaxation is accomplished by the neural corelease of ATP or a related purine and nitric oxide. Contractions are triggered by acetylcholine and tachykinins. The aim of this work was to study whether regional differences in neurotransmission could partially explain the varied physiological roles of each colonic area. METHODS: We used electrophysiological and myography techniques to evaluate purinergic (L-NNA 1 mm incubated tissue), nitrergic (MRS2500 0.3 µm incubated tissue) and cholinergic neurotransmission (L-NNA 1 mm and MRS2500 0.3 µm incubated tissue) in the proximal, mid and distal colon of CD1 mice (n = 42). RESULTS: Purinergic electrophysiological responses elicited by single pulses (28 V) were greater in the distal (IJPfMAX = -35.3 ± 2.2 mV), followed by the mid (IJPfMAX = -30.6 ± 1.0 mV) and proximal (IJPfMAX = -11.7 ± 1.1 mV) colon. In contrast, nitrergic responses decreased from the proximal colon (IJPsMAX = -11.4 ± 1.1 mV) to the mid (IJPsMAX = -9.1 ± 0.4 mV), followed by the distal colon (IJPsMAX = -1.8 ± 0.3 mV). A similar rank of order was observed in neural mediated inhibitory mechanical responses including electrical field stimulation-mediated responses and neural tone. ADPßs concentration-response curve was shifted to the left in the distal colon. In contrast, NaNP responses did not differ between regions. Cholinergic neurotransmission elicited contractions of a similar amplitude throughout the colon. CONCLUSION: An inverse gradient of purinergic and nitrergic neurotransmission exists through the mouse colon. The proximal and mid colon have a predominant nitrergic neurotransmission probably due to the fact that their storage function requires sustained relaxations. The distal colon, in contrast, has mainly purinergic neurotransmission responsible for the phasic relaxations needed to propel dehydrated faeces.

Potential role of the gaseous mediator hydrogen sulphide (H2S) in inhibition of human colonic contractility.

BACKGROUND: Hydrogen sulphide (H2S) is an endogenous signalling molecule that might play a physiologically relevant role in gastrointestinal motility. Cystathionine ß-synthase (CBS) and cystathionine γ-lyase (CSE) are two enzymes responsible for H2S production. d,l-Propargylglycine (PAG) is a CSE inhibitor whereas both aminooxyacetic acid (AOAA) and hydroxylamine (HA) are CBS inhibitors. The characterization of H2S responses and its mechanism of action are crucial to define H2S function. METHODS: Human colonic strips were used to investigate the role of H2S on contractility (muscle bath) and smooth muscle electrophysiology (microelectrodes). NaHS was used as a H2S donor. RESULTS: Combination of PAG and AOAA depolarized the smooth muscle (5-6mV, n=4) and elicited a transient increase in tone (260.5±92.8mg, n=12). No effect was observed on neural mediated inhibitory junction potential or relaxation. In the presence of tetrodotoxin 1µM, NaHS concentration-dependently inhibited spontaneous contractions (EC50=329.2µM, n=18). This effect was partially reduced by the guanylyl cyclase inhibitor ODQ 10µM (EC50=2.6µM, n=12) and by l-NNA 1mM (EC50=1.4mM, n=8). NaHS reversibly blocked neural mediated cholinergic (EC50=2mM) and tachykinergic (EC50=5.7mM) contractions. NaHS concentration-dependently reduced the increase in spontaneous mechanical activity (AUC) induced by carbachol (EC50=1.9mM) and NKA (EC50=1.7mM AUC). CONCLUSIONS: H2S might be an endogenous gasomediator regulating human colonic contractility. Its inhibitory effect is observed at high concentrations and could be mediated by a direct effect on smooth muscle with a possible synergistic effect with NO, as well as by an interaction with the cholinergic and tachykinergic neural mediated pathways.

EP2 and EP4 receptors mediate PGE2 induced relaxation in murine colonic circular muscle: pharmacological characterization.

BACKGROUND: Prostaglandin E2 (PGE2) is a regulator of gastrointestinal motility that might be involved in impaired motor function associated to gut inflammation. The aim of the present work is to pharmacologically characterize responses to exogenous and endogenous PGE2 in the mouse colon targeting EP2 and EP4 receptors. METHODS: Wild type (WT) and EP2 receptor knockout (EP2-KO) mice were used to characterize PGE2 and butaprost (EP2 receptor agonist) effects on smooth muscle resting membrane potential and myogenic contractility in circularly oriented colonic preparations. RESULTS: In WT animals, PGE2 and butaprost concentration-dependently inhibited spontaneous contractions and hyperpolarized smooth muscle cells. Combination of both EP2 (PF-04418948 0.1µM) and EP4 receptor antagonists (L-161,982 10µM) was needed to block both electrical and mechanical PGE2 responses. Butaprost inhibitory responses (both electrical and mechanical) were totally abolished by PF-04418948 0.1µM. In EP2-KO mice, PGE2 (but not butaprost) concentration-dependently inhibited spontaneous contractions and hyperpolarized smooth muscle cells. In EP2-KO mice, PGE2 inhibition of spontaneous contractility and hyperpolarization was fully antagonized by L-161,982 10µM. In WT animals, EP2 and EP4 receptor antagonists caused a smooth muscle depolarization and an increase in spontaneous mechanical activity. CONCLUSIONS: PGE2 responses in murine circular colonic layer are mediated by post-junctional EP2 and EP4 receptors. PF-04418948 and L-161,982 are selective EP2 and EP4 receptor antagonists that inhibit PGE2 responses. These antagonists might be useful pharmacological tools to limit prostaglandin effects associated to dismotility in gut inflammatory processes.

Differential functional role of purinergic and nitrergic inhibitory cotransmitters in human colonic relaxation.

AIM: ATP and nitric oxide (NO) are released from enteric inhibitory motor neurones and are responsible for colonic smooth muscle relaxation. However, how frequency of neural stimulation affects this cotransmission process and the post-junctional responses has not been systematically characterized in the human colon. METHODS: The dynamics of inhibitory cotransmission were studied using different protocols of electrical field stimulation (EFS) to characterize the inhibitory junction potentials (IJP) and the corresponding relaxation in colonic strips obtained from 36 patients. RESULTS: Single pulses elicited a fast IJP (IJPf(MAX) = -27.6 ± 1.6 mV), sensitive to the P2Y1 antagonist MRS2500 1 µm, that ran down with frequency increase leaving a residual hyperpolarization at high frequencies (IJPf∞ = -3.7 ± 0.6 mV). Accordingly, low frequencies of EFS caused purinergic transient relaxations that cannot be maintained at high frequencies. Addition of the P2Y1 agonist MRS2365 10 µm during the purinergic rundown did not cause any hyperpolarization. Protein kinase C (PKC), a putative P2Y1 desensitizator, was able to reduce the amplitude of the IJPf when activated, but the rundown was not modified by PKC inhibitors. Frequencies higher than 0.60 ± 0.15 Hz were needed to evoke a sustained nitrergic hyperpolarization that progressively increased reaching IJPs∞ = -13 ± 0.4 mV at high frequencies and leading to a sustained inhibition of spontaneous motility. CONCLUSION: Changes in frequency of stimulation possibly mimicking neuronal firing will post-junctionally determine purinergic vs. nitrergic responses underlying different functional roles. NO will be responsible for sustained relaxations needed in physiological processes such as storage, while purinergic neurotransmission evoking sharp transient relaxations will be dominant in processes such as propulsion.

Mechanisms of action of otilonium bromide (OB) in human cultured smooth muscle cells and rat colonic strips.

BACKGROUND: The pharmacological properties of otilonium bromide (OB) have been investigated using different experimental models, techniques, and conditions, and consequently, the results are not always easy to compare. The aim of the present work was to investigate the pharmacological properties of OB in human cultured colonic smooth muscle cells (HCSMCs), which is the main target of the drug 'in vivo'. Rat colonic strips were used to confirm the pharmacological properties. METHODS: Human cultured colonic smooth muscle cells were studied using the calcium imaging technique. Microelectrodes and muscle bath experiments were performed in rat colonic strips. KEY RESULTS: Otilonium bromide (OB) concentration dependently inhibited nifedipine-sensitive calcium transients induced by KCl (EC50  = 3.6 µM) and BayK8644 (EC50  = 4.0 µM). All the following experiments were performed in the presence of nifedipine. In HCSMC, carbachol-induced calcium transients were inhibited by OB (EC50  = 8.4 µM). Carbachol evoked 1-a smooth muscle depolarization (10 mV) that was antagonized by 100 µM OB; and 2-a contraction that was inhibited by OB (EC50  = 13.0 µM). 'Non-nitrergic (L-NNA 1 mM) non-purinergic (MRS2500 1 µM)' conditions were used to elicit endogenous excitatory responses. Electrical field stimulation caused 1-an atropine-sensitive excitatory junction potential that was inhibited by OB (EC50  = 8.9 µM) and 2-an atropine-sensitive contraction that was inhibited by OB (EC50  = 7.3 µM). In HCSMC, neurokinin A (NKA) and CaCl2 induced calcium transients that were inhibited by OB (NKA: EC50  = 11.7 µM; CaCl2 : EC50  = 17.5 µM). CONCLUSIONS & INFERENCES: Otilonium bromide causes inhibition of L-/T-type calcium channels, muscarinic, and tachykininergic responses that acting together explain the pharmacological properties of the compound.

P2Y(1) knockout mice lack purinergic neuromuscular transmission in the antrum and cecum.

BACKGROUND: Pharmacological studies using selective P2Y(1) antagonists, such as MRS2500, and studies with P2Y(1)(-/-) knockout mice have demonstrated that purinergic neuromuscular transmission is mediated by P2Y(1) receptors in the colon. The aim of the present study was to test whether P2Y(1) receptors are involved in purinergic neurotransmission in the antrum and cecum. METHODS: Microelectrode recordings were performed on strips from the antrum and cecum of wild type animals (WT) and P2Y(1)(-/-) mice. KEY RESULTS: In the antrum, no differences in resting membrane potential and slow wave activity were observed between groups. In WT animals, electrical field stimulation elicited a MRS2500-sensitive inhibitory junction potential (IJP). In P2Y(1)(-/-) mice, a nitrergic IJP (N(ω) -nitro-l-arginine-sensitive), but not a purinergic IJP was recorded. This IJP was equivalent to the response obtained in strips from WT animals previously incubated with MRS2500. Similar results were obtained in the cecum: 1- the purinergic IJP (MRS2500-sensitive) recorded in WT animals was absent in P2Y(1)(-/-) mice 2- nitrergic neurotransmission was preserved in both groups. Moreover, 1- spontaneous IJP (MRS2500-sensitive) could be recorded in WT, but not in P2Y(1)(-/-) mice 2- MRS2365 a P2Y(1) agonist caused smooth muscle hyperpolarization in WT, but not in P2Y(1) (-/-) animals, and 3- ß-NAD caused smooth muscle hyperpolarization both in WT and P2Y(1)(-/-) animals. CONCLUSIONS & INFERENCES: 1- P2Y(1) receptor is the general mechanism of purinergic inhibition in the gastrointestinal tract, 2- P2Y(1)(-/-) mouse is a useful animal model to study selective impairment of purinergic neurotransmission and 3- P2Y(1)(-/-) mouse might help in the identification of purinergic neurotransmitter(s).

Relative contribution of SKCa and TREK1 channels in purinergic and nitrergic neuromuscular transmission in the rat colon.

Purinergic and nitrergic neurotransmission predominantly mediate inhibitory neuromuscular transmission in the rat colon. We studied the sensitivity of both purinergic and nitrergic pathways to spadin, a TWIK-related potassium channel 1 (TREK1) inhibitor, apamin, a small-conductance calcium-activated potassium channel blocker and 1H-[1,2,4]oxadiazolo[4,3-α]quinoxalin-1-one (ODQ), a specific inhibitor of soluble guanylate cyclase. TREK1 expression was detected by RT-PCR in the rat colon. Patch-clamp experiments were performed on cells expressing hTREK1 channels. Spadin (1 µM) reduced currents 1) in basal conditions 2) activated by stretch, and 3) with arachidonic acid (AA; 10 µM). l-Methionine (1 mM) or l-cysteine (1 mM) did not modify currents activated by AA. Microelectrode and muscle bath studies were performed on rat colon samples. l-Methionine (2 mM), apamin (1 µM), ODQ (10 µM), and N(ω)-nitro-l-arginine (l-NNA; 1 mM) depolarized smooth muscle cells and increased motility. These effects were not observed with spadin (1 µM). Purinergic and nitrergic inhibitory junction potentials (IJP) were studied by incubating the tissue with l-NNA (1 mM) or MRS2500 (1 µM). Both purinergic and nitrergic IJP were unaffected by spadin. Apamin reduced both IJP with a different potency and maximal effect for each. ODQ concentration dependently abolished nitrergic IJP without affecting purinergic IJP. Similar effects were observed in hyperpolarizations induced by sodium nitroprusside (1 µM) and nitrergic relaxations induced by electrical stimulation. We propose a pharmacological approach to characterize the pathways and function of purinergic and nitrergic neurotransmission. Nitrergic neurotransmission, which is mediated by cyclic guanosine monophosphate, is insensitive to spadin, an effective TREK1 channel inhibitor. Both purinergic and nitrergic neurotransmission are inhibited by apamin but with different relative sensitivity.

Pharmacological characterization of purinergic inhibitory neuromuscular transmission in the human colon.

BACKGROUND: In the present study, we further characterize the purinergic receptors mediating the inhibitory junction potential (IJP) and smooth muscle relaxation in the human colon using a new, potent and selective agonist (MRS2365), and antagonists (MR2279 and MRS2500) of the P2Y(1) receptor. The P2Y(12) antagonist AR-C66096 was tested as well. Using this pharmacological approach, we tested whether ß-nicotinamide adenine dinucleotide (ß-NAD) fulfilled the criteria to be considered an inhibitory neurotransmitter in the human colon. METHODS: We carried out muscle bath and microelectrode experiments on circular strips from the human colon and calcium imaging recordings on HEK293 cells, which constitutively express the human P2Y(1) receptor. KEY RESULTS: Both the fast component of IJP and non-nitrergic relaxation was concentration-dependently inhibited by MRS2279 and MRS2500. This antagonism was confirmed in HEK293 cells. However, AR-C66096 did not modify either inhibitory response. Adenosine 5'-Ο-2-thiodiphosphate and MRS2365 caused a smooth muscle hyperpolarization and transient inhibition of spontaneous motility that was antagonized by MRS2279 and MRS2500. ß-Nicotinamide adenine dinucleotide inhibited the spontaneous motility (IC(50) = 3.3 mmol L(-1) ). Nevertheless, this effect was not antagonized by high concentrations of P2Y(1) antagonists. CONCLUSIONS & INFERENCES: Inhibitory purinergic neuromuscular transmission in the human colon was pharmacologically assessed by the use of new P2Y(1) receptor antagonists MRS2179, MRS2279, and MRS2500. The rank order of potency of the P2Y(1) antagonists is MRS2500 > MRS2279 > MRS2179. We found that ß-NAD partially fulfills the criteria to be considered an inhibitory neurotransmitter in the human colon, but the relative contribution of each purine (ATP/ADP vsß-NAD) requires further studies.

[Right primary iliac artery rupture during transurethral resection of bladder tumor]. / Rotura de la arteria ilíaca primitiva derecha durante la resección transuretral de un tumor vesical.

Injury to a large-caliber artery transurethral resection of a bladder tumor is a rare but serious complication. It is important that an anesthesiologist be able to detect such an injury, in order to include it among the many differential etiological diagnoses for shock. A 75-years-old man reported hematuria. An ultrasound image of the bladder showed many neoformations consistent with a diagnosis of multiple bladder neoplasms, and transurethral endoscopy was performed under subarachnoid anesthesia. Acute hypotension, bradycardia and shock developed 30 minutes into the procedure. The diagnosis was hypovolemic shock due to acute intraoperative hemorrhage, and exploratory laparotomy revealed an opening in the common iliac artery. The rupture was sutured. In spite of administration of crystalloids, colloids, blood products and vasoactive agents, a second operation was required due to hemodynamic instability. The patient died in the intensive care unit.

Tasas específicas de mortalidad por GRD y diagnóstico principal según la CIE-9-MC en un hospital de II nivel / Mortality rate by DRG and by the principal diagnosis according the ICD-9-CM in a II level Hospital of Insalud of Murcia during 1999

Introducción: La mortalidad hospitalaria es un indicador de la calidad asistencial, se puede evaluar según el diagnóstico principal al alta por éxitus o por los grupos relacionados con el diagnóstico (GRD).Objetivos: Conocer y analizar la mortalidad y tasa de mortalidad (TM) hospitalaria en los ingresados en el Hospital Morales Meseguer (Murcia) de nivel II del INSALUD en el año 1999.Metodología: Estudio del conjunto mínimo básico de datos al alta hospitalaria.Resultados: La TM fue de 3,8 por ciento, de los 508 fallecimientos analizados, el 56,7 por ciento correspondieron a varones. La TM fue similar en varones (3,6 por ciento) y en mujeres (3,9 por ciento). La mediana de edad de los fallecidos era de 77 años. El número de fallecimientos en menores de 80 años era mayor en varones (n=197; 65 por ciento) que en mujeres (n=102; 35 por ciento)(p=0,002). La suma de los éxitus de Medicina Interna y Cuidados Intensivos representa el 70 por ciento de casos ocurridos en el hospital. La TM fue mayor en la Unidad de Cuidados Intensivos (10,5 por ciento) seguido por Hematología (6,9 por ciento) y Medicina Interna (6,1 por ciento). Diez GRDs representa el 50 por ciento de las causas de muertes, todos ellos son de tipo médico. El GRD más frecuente fue el 541, Trastornos respiratorios con complicación (n=61, TM 12,8 por ciento), seguido por el GRD 533, Trastornos cerebrovasculares específicos excepto accidente isquémico transitorio (n=33; TM 34,7 por ciento), GRD123 Infarto agudo de miocardio (IAM) con éxitus (n=31; TM 100 por ciento), GRD 014 Otros trastornos del sistema nervioso (n= 27; TM: 10,3 por ciento) y GRD 552 Trastornos del aparato digestivo excepto esofagitis, gastroenteritis y úlcera no complicada (n=27; TM: 31,0). El diagnóstico principal más frecuente fue la enfermedad cerebrovascular (n=60, TM 12,2 por ciento), neumonía-bronconeumonía (n= 52, TM 10,9 por ciento), enfermedad pulmonar obstructiva crónica (n=36, TM 7,1 por ciento), IAM (n=33, TM 11,5 por ciento), y neoplasia del aparato digestivo (n=26; TM 8,5 por ciento). La TM en las mujeres con IAM (19,5 por ciento) fue superior a la los hombres (7,7 por ciento) (p=0,005), la TM en las mujeres con hernia abdominal (4,3 por ciento) fue superior a la de los hombres (0,6 por ciento) (p=0,01), y La TM de la pielonefritis e infección urinaria en los varones (4,9 por ciento) fue mayor a la de las mujeres (0 por ciento) (p=0,008).Conclusión: La mortalidad y TM por GRD y diagnóstico principal es un indicador que permite conocer y monitorizar la calidad de la asistencia sanitaria (AU)

[Splenectomy in a patient with beta thalassemia intermedia and severe hemolytic anemia]. / Esplenectomía en paciente con betatalasemia intermedia y anemia hemolítica grave.

A 36-year-old woman with beta thalassemia intermedia suffered a hemolytic crisis secondary to Epstein-Barr virus infection. She was given a transfusion of phenotypically compatible blood. However, severe hemolysis persisted (with hemoglobin levels around 4 g/dl) in spite of gamma globulin and corticosteroid administration. Emergency therapeutic splenectomy was performed. We discuss intraoperative management in situations of severe anemia, concluding that it is possible to survive significant decreases in hemoglobin concentration with cardiocirculatory reserve and respiration intact, maintaining normal volume.

[Specific mortality rates by DRG and main diagnosis according to CIE-9-MC at a level-II hospital]. / Tasas específicas de mortalidad por GRD y diagnóstico principal según la CIE-9-MC en un hospital de II nivel.

INTRODUCTION: The in hospital mortality is a marker of health care quality. It can be evaluated according by the principal diagnosis of disease or by Diagnosis Related Groups (DRG). OBJECTIVES: Know and to analyze the in hospital mortality and mortality rate (MR) in the patients admitted in the Hospital Morales Meseguer (Murcia) of II level of the INSALUD during 1999. METHODOLOGY: Study of the minimum basic group of data into the hospital. RESULTS: The MR was 3.8% of 508 deaths analyzes, 56.7% corresponded a male. The MR was equal in male (3.6%) and females (3.9%). The medium of age into deaths was 77 years. The numbers of deaths inpatients under 80 years was higher in males (n = 197; 65%) than in lower in female (n = 102; 35%)(p = 0.002). The addition of deaths of Internal Medicine and Intensive Care Unit represent a 70% of cases of deaths occurred in the hospital. The MR was higher in Intensive Care Unit (10.5%) followed by Hematology (6.9%) and Internal Medicine (6.1%). Ten DRG represents of 50% of the causes of deaths, and all of them were DRG of medical categories. The DRG more frequents was 541, Respiratory disorders with complication (n = 61, MR 12.8%), followed by DRG 533. Specific cerebrovascular disorders without Transit isquemic accident (n = 33; MR 34.7%), DRG 123 Acute myocardical infarction (AMI) with death (n = 31; MR 100%), DRG 014 Others disorders of nervous system (n = 27; TM: 10.3%) y DRG 552 Disorders of digestive tract without esophagitis, gastroenteritis and not complicated ulcer (n = 27; MR: 31.0). The main diagnostic more frequent was cerebrovascular diseases (n = 60, MR 12.2%), pneumonia-bronchopneumonia (n = 52, MR 10.9%), chronic obstructive lung disease (n = 36, MR 7.1%), AMI (n = 33, MR 11.5%), and neoplasia of digestive tract (n = 26; MR 8.5%). The MR of woman with AMI (19.5%) was higher than man (7.7%) (p = 0.005), the MR in woman with abdominal hernia (4.3%) was higher than man (0.6%) (p = 0.01), and MR of pyelonephritis and urinary infection in man (4.9%) was higher than woman (0%) (p = 0.008). CONCLUSIONS: The mortality and MR by DRG and main diagnostic is an indicator than permit to know and monitoring the quality of health care.

Epidemiology of elderly patients' burns in the South West of France.

A retrospective study of 716 patients aged 60 years and above (324 men, 392 women) was undertaken in order to determine quality control in burns management in the South West of France. The following epidemiological data was obtained: high hospitalization rate (7 per cent of the general admissions); monthly and seasonal periodicity; predominance of indoor accidents (86 per cent) with domestic accidents being more frequent in women (63 vs. 37 per cent). Outdoor accidents were mainly recreational and were five times more frequent in men than in women. The overall mortality was 39 per cent and was influenced by the burns extent, depth, predisposing factors and early management. More burns occurred in urban areas (53 per cent) but mortality was higher in patients from rural areas (62 vs. 38 per cent). It was observed that delay in management, especially fluid resuscitation of patients from the rural areas, was partly responsible for this outcome. Propositions were made to diffuse more information on the importance of early management of burns in rural areas.

Herpes simplex virus infection in burned patients: epidemiology of 11 cases.

Burned patients suffer significant immunosuppression during the first 3 or 4 weeks after hospitalization. Herpes simplex virus (HSV) infections are commonly seen in immunosuppressed patients and may account for considerable morbidity and some mortality. We studied retrospectively 11 patients with severe burn injury who became infected with HSV. We determined the prevalence of viral infection in this group of patients. Serological testing and viral culture was used to diagnose HSV infection. No general complications appeared in these 11 patients in association with HSV but two patients died of multiorgan failure. Locally, areas of active epidermal regeneration were most commonly affected. Acyclovir therapy was not used and the duration of hospitalization was normal in these 11 patients.

Assessment of vitamin and trace element supplementation in severely burned patients undergoing long-term parenteral and enteral nutrition.

The efficacy of an oral supplement of vitamins and trace elements during a longterm artificial parenteral and enteral nutrition was investigated for 3 months in patients with extensive burns. Thirty severely burned patients (22 male, 8 female, age 41 +/- 18 years, range 23-59 years, 33 +/- 12% total body surface area burn, 22% +/- 8 full thickness burn surface area) were included. Every 10 days, from day 10 until day 90, we determined serum levels of: *vitamins B1, B12, A, E, *folic acid, *copper, zinc, iron, *transferrin, albumin, prealbumin, total proteins, *fibronectin, retinol binding protein (RBP), *calcium, *phosphorus, *triglycerides, *total cholesterol, *C reactive protein (CRP), *erythrocyte folic acid. The mean daily nutritional support was 60 Kcals and 0.4 g N per kg of body weight, 70% enterally and 30% parenterally administered, with enteral vitamin and trace element supplementation. On day 10, there was a decrease of the serum level of 19/20 parameters. For 8 parameters (vitamin A, total cholesterol, iron, transferrin, fibronectin, phosphorus, RBP, total proteins), the level was lower than usual. Between day 10 and day 20, a significant normalization of 6 of them was noted, the average levels of transferrin and iron remaining below normal values until day 50. There was a significant decrease in C-reactive protein levels, however above normal limits. No deficiency in vitamins or trace elements was found. Cyclic variations of serum levels occurred which may be more related to volemic, hydroelectrolytic, endocrine and inflammatory disorders than to nutritional problems.

[Thyroid ophthalmopathy: clinical and tomographic study]. / Oftalmopatía tiroidea: estudio clínico y tomográfico.

BACKGROUND: To evaluate exophthalmos by Hertel exophthalmometer (HE) compared to computed tomography (CT), and extraocular muscle width on CT and its relation with the clinical course in patients with thyroidal ophthalmopathy. METHODS: On reviewed 118 orbits from 59 patients (50 women, mean age 40.6 y., range 12-84) who suffered a thyroidal ophthalmopathy (Graves' disease, n = 57; Hashimoto's thyroiditis, n = 2). Muscle width was evaluated using coronal and mid-axial scans in all cases. Medial rectus (MR) width was analysed by Hallin and Feldon technique. RESULTS: Exophthalmos by HE was 22.5 +/- 2.5 and 23.2 +/- 3.2 mm (right-RE/left eye-LE), and CT 20.8 +/- 3.2 and 20.9 +/- 2.9 mm (p < 0.00001, r = 0.72 and 0.65, respectively). MR width on mid-axial scan was 4.1 +/- 1.6 and 4.2 +/- 1.5 mm (RE/LE). On coronal scans, MR was the muscle more often enlarged followed by superior, inferior and lateral rectus. CONCLUSIONS: Exophthalmos measured by HE was greater than by CT-measured one, but with a good correlation. Muscle were not equally affected, being MR the most frequently enlarged. MR-width was not related to duration and severity of disease.