Fiebre Q aguda: riesgo de desarrollo de endocarditis / Acute Q fever and the risk of developing endocarditis

Objetivo: Valorar los datos clínicos y serológicos como parámetros indicativos de posible evolución a endocarditis tras un episodio de fiebre Q aguda. Pacientes y métodos: Estudio de cohortes retrospectivo de la evolución a endocarditis tras un episodio de fiebre Q aguda, analizando evolución clínica, serológica y tratamiento antibiótico recibido. Resultados: Se reclutó a 80 pacientes, presentando el 20% niveles de anticuerpos IgG de fase I ≥ 1:1.024 en los primeros 3 meses. Solo el 44% recibió antibioterapia en la fase aguda; únicamente 2 enfermos recibieron antibioterapia prolongada. Se realizó ecocardiograma al 15%. Ningún paciente presentó síntomas indicativos de infección crónica ni evolucionó a endocarditis tras una mediana de seguimiento de 100 meses, independientemente de la elevación precoz de anticuerpos IgG de fase I. Conclusiones: La elevación precoz de anticuerpos IgG fase I no se asoció a evolución a endocarditis a pesar de no haberse realizado tratamiento antibiótico prolongado en pacientes asintomáticos (AU)

Objectives: Assess clinical and serological data as parameters indicative of a possible evolution to endocarditis after an episode of acute Q fever. Patients and methods: Retrospective cohort study of evolution to endocarditis after an acute Q fever episode, analyzing the clinical and serological evolution and the antibiotic treatment administered. Results: Eighty patients were recruited, 20% of whom had phase I IgG antibody levels ≥ 1:1024 in the first 3 months. Only 44% of the patients underwent antibiotherapy in the acute phase; only 2 patients underwent extended antibiotherapy. Fifteen percent of the patients underwent an echocardiogram. None of the patients had symptoms suggestive of chronic infection or progressed to endocarditis after a median follow-up of 100 months, regardless of the early increase in phase I IgG antibodies. Conclusions: The early increase in phase I IgG antibodies in asymptomatic patients is not associated with progression to endocarditis despite not undergoing prolonged antibiotic treatment (AU)

Acute Q fever and the risk of developing endocarditis. / Fiebre Q aguda: riesgo de desarrollo de endocarditis.

OBJECTIVES: Assess clinical and serological data as parameters indicative of a possible evolution to endocarditis after an episode of acute Q fever. PATIENTS AND METHODS: Retrospective cohort study of evolution to endocarditis after an acute Q fever episode, analyzing the clinical and serological evolution and the antibiotic treatment administered. RESULTS: Eighty patients were recruited, 20% of whom had phase i IgG antibody levels ≥ 1:1024 in the first 3 months. Only 44% of the patients underwent antibiotherapy in the acute phase; only 2 patients underwent extended antibiotherapy. Fifteen percent of the patients underwent an echocardiogram. None of the patients had symptoms suggestive of chronic infection or progressed to endocarditis after a median follow-up of 100 months, regardless of the early increase in phase i IgG antibodies. CONCLUSIONS: The early increase in phase i IgG antibodies in asymptomatic patients is not associated with progression to endocarditis despite not undergoing prolonged antibiotic treatment.

Epidemiology and clinical features of community-acquired, healthcare-associated and nosocomial bloodstream infections in tertiary-care and community hospitals.

Classification of bloodstream infections (BSIs) as community-acquired (CA), healthcare-associated (HCA) and hospital-acquired (HA) has been proposed. The epidemiology and clinical features of BSI according to that classification in tertiary-care (TH) and community (CH) hospitals were investigated in a prospective cohort of 821 BSI episodes from 15 hospitals (ten TH and five CH hospitals) in Andalucía, Spain. Eighteen percent were CA, 24% were HCA and 58% were HA. The incidence of CA and HCA BSI was higher in CH than in TH (CA: 3.9 episodes per 1000 admissions vs. 2.2, p <0.01; HCA: 5.0 vs. 2.9, p <0.01), whereas the incidence of HA BSI was lower (7.7 vs. 8.7, p <0.01). In CA and HCA BSI, the respiratory tract was more frequently the source in CH than in TH (CA: 30% vs. 15%; HCA: 20% vs. 9%, p ≤0.03). In HCA BSI, chronic renal insufficiency and tunnelled catheters were less frequent in CH than in TH (11% vs. 26% and 7% vs. 19%, p ≤0.03), although chronic ulcers were more frequent (22% vs. 8%, p 0.008). BSIs as a result of methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa were very rare in CA episodes, although extended-spectrum b-lactamase-producing Escherichia coli (ESBLEC) caused a similar proportion of all BSIs in CA, HCA and HA episodes. Multivariate analysis revealed no significant difference in mortality rates in CH and TH. HCA infections should be considered as a separate class of BSI in both TH and CH, although differences between hospitals must be considered. CA BSIs were not caused by multidrug-resistant pathogens, except for ESBLEC.

Modificaciones en los ingresos y mortalidad de los pacientes con infección por VIH durante el período 2001-2003 (réplica) / Modifications in admissions and mortality of patients with HIV infection during the period 2001-2003 (response)

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Structured intermittent interruption of chronic HIV infection treatment with highly active antiretroviral therapy: effects on leptin and TNF-alpha.

The changes in nutritional parameters and adipocytokines after structured intermittent interruption of highly active antiretroviral treatment of patients with chronic HIV infection are analyzed. Twenty-seven patients with chronic HIV infection (median CD4+ T cell count/microl: nadir, 394; at the beginning of structured interruptions, 1041; HIV viral load: nadir, 41,521 copies/ml; at the beginning of structured interruptions <50 copies/ml; median time of previous treatment: 60 months) were evaluated during three cycles of intermittent interruptions of therapy (8 weeks on/4 weeks off). CD4+ T cell count, HIV viral load, anthropometric measures, and serum concentrations of triglycerides, cholesterol, leptin, and tumor necrosis factor and its soluble receptors I and II were determined. After the three cycles of intermittent interruptions of therapy, no significant differences in CD4+ T cell count/microl, viral load, or serum concentrations of cholesterol or triglycerides with reference to baseline values were found. A near-significant higher fatty mass (skinfold thicknesses, at the end, 121 mm, at the beginning, 100 mm, p = 0.100), combined with a significant increase of concentration of leptin (1.5 vs. 4.7 ng/ml, p = 0,044), as well as a decrease in serum concentrations of soluble receptors of tumor necrosis factor (TNFRI, 104 vs. 73 pg/ml, p = 0.022; TNFRII 253 vs. 195 pg/ml, p = 0.098) were detected. Structured intermittent interruption of highly active antiretroviral treatment of patients with chronic HIV infection induces a valuable positive modification in markers of lipid turnover and adipose tissue mass.

Relación entre factores precipitantes y mortalidad en el delirio agitado en Cuidados Paliativos / Relation of precipitating factors and mortality in agitate delirum of Palliative Care patients

Objetivo: el delirio agitado aparece con frecuencia en los pacientes con enfermedad oncológica avanzada. El objetivo de este estudio es analizarla etiología del delirio agitado y su relación con la mortalidad observada. Método: estudio retrospectivo de 631 pacientes de Cuidados Paliativos. Los factores etiológicos se clasificaron en: opioides, infección, iones metabólico, insuficiencia respiratoria, lesión del sistema nervioso central, o desconocido. Analizamos su relación con la mortalidad y el momento de aparición del delirio. Se aplicó el test de Chi cuadrado para variables cualitativas y t de Student para variables cuantitativas. Resultados: el delirio agitado se diagnosticó en 53 pacientes (8,4%). Edad media 67 años (DE 12,9). La neoplasia primaria se localizaba en pulmón (39,6%), aparato genitourinario (24,5%), aparato digestivo (17,0%), mama (9,4%) y otros (9,4%). Los precipitantes fueron: opioides (26,4%), infección (26,4%), iones-metabólico (17,0%), insuficiencia respiratoria(15,1%), lesión en el sistema nervioso central (7,5%) y desconocido (7,5%). La presencia de estos factores fue distinta dependiendo de que el delirio fuese el motivo de ingreso (opioides 32,4%, infección 29,4%) o apareciese durante la hospitalización (insuficiencia respiratoria 36,8%, infección 21,1%); p = 0,019. Se observó mayor mortalidad durante la hospitalización en los pacientes que presentaron delirio respecto a los que no (67,9vs. 41,2%, OR 3,03, IC 95%: 1,7-5,7). No encontramos diferencia en el número acumulado de factores etiológicos en los pacientes con delirio que fallecieron y en los que no (2,56 vs. 2,59). La mortalidad fue inferior, casi significativo, cuando la infección fue el factor precipitante (50,0 vs. 75,0-78,6%); p = 0,23. Conclusión: la infección y el inicio o aumento de dosis de opioides, factores tratables, fueron los precipitantes más frecuentes de delirio. Ninguno de los factores estudiados, ni el número acumulado de los mismos, se relacionó de una manera significativa a menor mortalidad (AU)

Objective: agitated delirium is frequently detected in patients suffering from advanced cancer. The objective of this study was to analyze the etiology of agitated delirium and the relation to mortality. Method: retrospective study of 631 terminally ill cancer patients. Putative etiologic factors were: opioid therapy, infection, metabolic disorders, respiratory insufficiency, central nervous system lesion or unknown. We tried to find their relation to mortality and onset of delirium. It was used the Chi square test for qualitative variables and t Student for quantitative variables. Results: agitated delirium was diagnosed in 53 patients (8.4%). Mean age was 67 years (SD 12.9); male: female 2: 1. Primary neoplasms were located at lung (39.6%), genitourinary system (24.5%), digestive system (17.0%), breast (9.4%) and others (9.4%). Inducing factors were: opioid therapy (26.4%), infection (26.4%), metabolic disorders (17.0%), respiratory insufficiency (15.1%), central nervous system lesion (7.5%) and unknown (7.5%). Frequency of precipitating factors was different whether the delirium was the cause of admission (opioid therapy 32.4%, infection 29.4%) or was developed during hospitalization (respiratory insufficiency 36.8%, infection 21.1%); p = 0.019. Higher mortality during hospitalization was observed in patients with delirium contrasting with those without it (67.9 vs. 41.2%, OR 3.03, 95% CI: 1.7-5.7). There was no difference in the accumulated number of etiologic factors inpatients with delirium who died and those who did not: 2.56 vs. 2.59. Mortality was lower, near significantly, when infection was the precipitating factor (50.0 vs. 75.0-78.6%); p = 0.23. Conclusion: infection and onset or an increase in the doses of opioids, two treatable causes, were the most recurrent precipitating factors of delirium. None of studied factors neither the accumulated number of them was related to mortality with statistical difference (AU)

[Admissions and mortality changes in a third-level care Hospital Internal Medicine Department (1996-2000). Influence of the modifications in the HIV infection treatment]. / Evolución de los ingresos y la mortalidad en un Servicio de Medicina Interna de un hospital de tercer nivel (1996-2000). Influencia de las modificaciones en el tratamiento de la infección por el VIH.

OBJECTIVE: To analyze the impact of highly active anti-retroviral therapy (HAART) on the admissions and mortality of patients with human immunodeficiency virus (HIV) infection and of all patients cared in an Internal Medicine Department. METHODS: A retrospective study with analysis of admissions and deaths in the Internal Medicine Department of a third-level care hospital between January 1996 and December 2000. HAART was introduced starting in 1997. Age, gender, main diagnosis at discharge, diagnosis related group (DRG) weight, death cause, and hospital stay were assessed globally and annually. RESULTS: During the study period 7,580 admissions took place, of which 939 were secondary to HIV infection related diseases. The incidence of HIV-related admissions declined in 32.9% and the case-fatality rate in 67.8% between 1996 and 2000, with increase at the same time of the number of patients with noninfectious respiratory pathology and of overall number of patients with infections. Average hospital stay of patients cared in the Internal Medicine Department remained stable, with reduction of 31.5% of that of the group with HIV infection starting in 1997. DRG complexity in this group decreased 0.56 points. CONCLUSIONS: The introduction of HAART has been associated to a reduction in the incidence of admissions, in the complexity of the diagnoses, and in the mortality in the group of patients with HIV infection. At the same time there was an increased in the number of patients with respiratory and infectious pathology different from that related to HIV.

Evolución de los ingresos y la mortalidad en un Servicio de Medicina Interna de un hospital de tercer nivel (1996-2000). Influencia de las modificaciones en el tratamiento de la infección por el VIH / Admissions and mortality changes in a third-level care Hospital Internal Medicine Department (1996-2000). Influence of the modifications in the HIV infection treatment

Objetivo. Analizar la repercusión de la terapia antirretroviral de gran actividad (TARGA) sobre los ingresos y mortalidad de los pacientes con infección por el virus de la inmunodeficiencia humana (VIH) en particular y sobre un Servicio de Medicina Interna en general. Métodos. Estudio retrospectivo que analiza los ingresos y éxitus producidos en el Servicio de Medicina Interna de un hospital de especialidades entre enero de 1996 y diciembre de 2000. La TARGA se introdujo a partir de 1997. Se valoraron edad, género, diagnóstico principal al alta, peso del grupo relacionado con el diagnóstico (GDR), causa de la muerte y estancia hospitalaria de forma global y distribuidas anualmente. Resultados. Durante el período se produjeron 7.580 ingresos, de los cuales 939 estuvieron producidos por patologías relacionadas con la infección por el VIH. El número de ingresos por VIH disminuyó en un 32,9% y la tasa de letalidad en un 67,8% entre 1996 y 2000, aumentando el volumen de pacientes con patología respiratoria no infecciosa e infecciones en general. La estancia media de los pacientes ingresados en el servicio se mantuvo estable, disminuyendo la del grupo con infección por el VIH un 31,5% a partir de 1997. La complejidad de los GDR en este grupo disminuyó 0,56 puntos. Conclusiones. La introducción de la TARGA se ha relacionado con una disminución en el número de ingresos, complejidad de los diagnósticos y fallecimientos en el grupo de pacientes con infección por el VIH. Ese lugar ha sido ocupado por enfermos con patología respiratoria e infecciosa diferente a la relacionada con el VIH

Objective. To analyze the impact of highly active anti-retroviral therapy (HAART) on the admissions and mortality of patients with human immunodeficiency virus (HIV) infection and of all patients cared in an Internal Medicine Department. Methods. A retrospective study with analysis of admissions and deaths in the Internal Medicine Department of a third-level care hospital between January 1996 and December 2000. HAART was introduced starting in 1997. Age, gender, main diagnosis at discharge, diagnosis related group (DRG) weight, death cause, and hospital stay were assessed globally and annually. Results. During the study period 7,580 admissions took place, of which 939 were secondary to HIV infection related diseases. The incidence of HIV-related admissions declined in 32.9% and the case-fatality rate in 67.8% between 1996 and 2000, with increase at the same time of the number of patients with noninfectious respiratory pathology and of overall number of patients with infections. Average hospital stay of patients cared in the Internal Medicine Department remained stable, with reduction of 31.5% of that of the group with HIV infection starting in 1997. DRG complexity in this group decreased 0.56 points. Conclusions. The introduction of HAART has been associated to a reduction in the incidence of admissions, in the complexity of the diagnoses, and in the mortality in the group of patients with HIV infection. At the same time there was an increased in the number of patients with respiratory and infectious pathology different from that related to HIV

Absence of favourable changes in circulating levels of interleukin-16 or beta-chemokine concentration following structured intermittent interruption treatment of chronic human immunodeficiency virus infection.

Changes in virological and immunological parameters were analysed following structured intermittent interruption of highly active anti-retroviral therapy (HAART) of patients with chronic human immunodeficiency virus (HIV) infection. Parameters analysed were serum levels of the CD8+ T-cell-derived inhibitory molecules interleukin-16 (IL-16), monocyte inhibitory protein-1beta (MIP-1beta) and RANTES ('regulated upon activation, normal T-cell expressed and presumably secreted'), and the enhancer of HIV replication, monocyte chemotactic protein-1 (MCP-1). Twenty-five patients with chronic HIV infection were evaluated during three cycles of intermittent interruptions of therapy (8 weeks on/4 weeks off) in comparison with 20 healthy sex- and age-matched controls. At enrolment, HIV-infected patients showed significantly higher serum concentrations of IL-16 and RANTES, and significantly lower concentrations of MCP-1, than did healthy controls. Levels of MIP-1beta were similar in both groups. Only the serum levels of IL-16 increased significantly in HIV-infected patients after every treatment interruption. However, differences between the CD4+ or CD8+ T-cell counts/microL, HIV loads and serum concentrations of each cytokine at baseline and at the end of the three cycles of intermittent interruptions of therapy were not significant. It was concluded that structured intermittent interruption of HAART for patients with chronic HIV infection did not modify the immunological parameters, including serum levels of CD8+ T-cell-derived inhibitory molecules, or the virus parameters studied. Thus, the findings do not support the use of this treatment modality for the management of HIV-infected patients.