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This study aimed to identify factors that influence the selection of different approaches to prescribing levofloxacin (e.g., monotherapy vs. combined therapy, 12-h vs. 24-h interval) and the effect on mortality in the ICU. An observational, prospective, multicenter study was conducted. A logistic regression analysis was performed to identify factors associated with the prescription of levofloxacin in combined therapy and at a dose of 500 mg every 12 hours. In addition, a logistic regression analysis was conducted to determine the impact of the different prescribing methods on mortality in the ICU. The most frequently administered initial dose was 500 mg/24 h (48.5%) and 500 mg/12 h (48.3%). No factors were found to influence the choice of daily dose. A total of 49.7% of levofloxacin prescriptions were in combined therapy. Factors influencing the decision to prescribe a combined regimen included diagnosis of extra-ICU nosocomial infection (OR: 1.97; 95% CI: 1.13-3.42); severe sepsis (OR: 2.56; 95% CI: 1.66-3.94); septic shock (OR: 6.22; 95% CI: 3.54-10.9); and identification of the causative pathogen (OR: 1.99: 95% CI: 1.34-2.95). The mortality rate was 21.4% and the related factors were septic shock (OR: 3.09; 95% CI: 1.38-6.91); treatment failure (OR: 23.4; 95% CI: 12.3-44.6); and combined therapy (OR: 2.36; 95% CI: 1.21-4.59). The selection of the initial dose of levofloxacin was not influenced by any factor, as long as the antibiotic was given in combined therapy in patients in whom the cause of the infection had been identified, in patients with greater systemic response, and in nosocomial infection outside the ICU. The selection of combined therapy was associated with a worse prognosis.

The aim of this study was to assess the efficacy of a disinfectable needle-free connector in reducing the pass of micro-organisms to the lumen of the catheter. A prospective, controlled, experimental trial was performed in which a laboratory model simulated the insertion of a peripheral venous catheter. Catheters inserted in sterile conditions in a hemoculture bottle were closed with the disinfectable needle-free connector (study group) or with a cap (control group). After 9 days of contamination and manipulation of the connector and cap external surfaces, 100% of bottles in the control group were contaminated whereas 60% remained sterile in the study group. The disinfectable needle-free connector showed more resistance to the pass of microorganisms than the conventional cap according to our experimental model.

Background and Objective: To determine the frequency of infections caused by Enterococcus spp. in critically ill patients admitted to ICUs in Spain and to describe the clinical features and outcome of those patients in whom this pathogen was isolated., Patients and Method: Prospective, observational, multicenter study. Patients admitted to the ICUs who participated in the National Surveillance Study of Nosocomial Infections (ENVIN) from 1997 to 2001 were included. Patients were classified as infected by Enterococcus spp., infected by other pathogens, and without nosocomial infection (non-infected)., Results: Of 21,972 patients, 2,177 (9.9%) had acquired 3,490 nosocomial infections during their stay in the ICU. In 223 patients (10.2%), 239 episodes of infections in which one of the causative pathogen was Enterococcus spp. were identified (cumulative incidence 1.1 episodes of Enterococcus spp. infection per 100 patients). Enterococcus spp. accounted for urinary infection in 14.3% of cases and secondary bacteremia in 12.2% especially those related with abdominal infection (20%) and soft tissue infection (21.4%). Predominant species was E. faecalis in 197 isolates (82.4%). After multivariate analysis, variables significantly associated with infection caused by Enterococcus spp. included: age (odds ratio [OR]=1.13; 95% confidence interval [CI], 1.01-1.25); APACHE II score (OR=1.19; CI 95%, 1.07-1.32); and length of ICU stay (OR=1.02; CI 95%, 1.01-1.03). There were no differences in the overall ICU mortality rate between patients with Enterococcus spp. infection (31.8%) and those with infection caused by other pathogens (31.8%), although in both cases the mortality rate was significantly higher than in non-infected patients (11.1%)., Conclusions: Enterococcus spp. was present in 10.2% patients with ICU-acquired infection. Infection by Enterococcus spp. mainly occurred in the form of urinary tract infection and secondary bacteremia, mainly related to abdominal and soft tissue infections. E. faecalis predominated in all foci. There were no differences in mortality between patients with Enterococcus spp. infection and patients with infection caused by other pathogens.

Background and Objective: Our objective was to assess the frequency of fungal colonization and/or infection in critically ill patients admitted to intensive care units (ICUs) and to describe the characteristics and risk factors of those patients in whom fungi had been isolated., Patients and Method: Observational, multicenter study of patients admitted to 64 ICUs on March 23, June 22, and November 16, 1999. In these patients, the presence of fungi was investigated in some biological sample from the day of ICU admission to the day of assessment of fungal infection. Patients were classified as colonized or infected by fungi., Results: A total of 1,562 patients were included: 686 in the first period, 567 in the second, and 309 in the third, with a mean of 24.4 patients per ICU (range, 9-62). Fungi were isolated in 456 biological samples from 248 patients (15.9 patients per each series of 100 controlled patients): lung in 183 (40.1%) cases, urine in 90 (19.7%) cases, and oropharynx in 46 (10.1%) cases. Fungi were isolated in blood cultures in 17 (3.7%) patients. Candida albicans was the most frequently isolated fungal species in all sites (68.9%). Isolation of fungi allowed a diagnosis of fungal infection in 121 patients (fungal infection rate, 7.7 episodes per 100 patients admitted to the ICU). Individual risk factors for fungal infection were as follows: previous use of antimicrobials (OR=5.01; 95% CI, 1.77-14.2); mechanical ventilation (OR=3.45; 95% CI, 1.61-7.40); urgent surgical procedures (OR = 2.44; 95% CI, 1.59-3.74); solid neoplasm (OR=2.32; 95% CI, 1.29-4.19); use of corticosteroids (OR = 1.88; 95% CI, 1.18-2.99); and APACHE II score (OR=1.05; 95% CI, 1.02-1.07)., Conclusions: Fungi were isolated in 15.9% patients admitted to ICUs and they were the causative agents of infection in 7.7% of cases. Candida albicans predominated in all sites. Risk factors for fungal infection included previous use of antibiotics, mechanical ventilation, urgent surgery, solid tumor, use of corticosteroids, and intermediate severity of illness according to the APACHE II score.

Background: The purpose of this study was to determine the incidence of candiduria in critically ill patients admitted to intensive care medical units (ICUs), to identify risk factors for candiduria and to assess the frequency distribution of different Candidaspp., Subjects and Methods: This was a prospective cohort observational and multicenter study. A total of 1,765 patients older than 18 years of age who were admitted for at least 7 days to 73 medical-surgical ICUs of 70 Spanish hospitals were included in the study. Urine cultures were performed once a week., Results: In 389 patients (22%), Candidaspp. in one or more urine samples were isolated. In the multivariate analysis, independent risk factors for candiduria included: age >65 years, female sex, length of hospital stay before ICU admission, diabetes mellitus, total parenteral nutrition, mechanical ventilation and previous use of antimicrobials. Candida albicanswas recovered in 266 cases (68.4%), followed by C. glabrata(32 cases, 8.2%) and C. tropicalis(14 cases, 36%). Previous use of antifungal agents was the only risk factor for the selection of Candidanon-albicans candiduria (OR 2.64, 95% CI 1.35-5.14, P=0.004). In-hospital mortality was 48.8% in patients with candiduria compared to 36.6% in those without candiduria ( P<0.001). Significant differences were also found for ICU mortality (38.% vs. 28.1%, P<0.001)., Conclusions: Twenty-two percent of critically ill patients admitted for more than 7 days in the ICU developed candiduria. C. albicanswas the most frequent causative pathogen. Previous use of antifungals was the only risk factor for the selection of Candidanon-albicans.

Objectives: To assess the influence of nosocomial infection on length of stay in the intensive care unit (ICU) and to determine the relative effect of other factors on extra length of hospitalization associated with nosocomial infection., Design: Prospective cohort multicenter study in the context of the ENVIN-UCI project., Setting: Medical or surgical ICUs of 49 different hospitals in Spain., Methods: All consecutive patients (N = 6,593) admitted to ICUs of the participating hospitals who stayed for more than 24 hours during a 3-month period (from January 15 to April 15, 1996) were included. Length of ICU stay was compared between patients with and without nosocomial infections. RESULTS Uninfected patients (N = 5,868) had a median stay in the ICU of 3 days, whereas the median for infected patients (N = 725) was 17 days (P < .001). The median for infected patients with one episode of nosocomial infection was 13 days. The greatest length of stay (40 days) was among patients admitted to the ICU because of medical diseases, with an infection acquired before admission to the ICU, and with the largest number of nosocomial infection episodes. In extended stays, nosocomial infection was significantly associated with length of hospitalization (day 21; odds ratio, 22.38; 95% confidence interval 16.6 to 30.4), whereas an effect of variables related to severity of illness on admission (Acute Physiology and Chronic Health Evaluation II score, urgent surgery, and infection prior to ICU admission) was not found., Conclusions: The presence of nosocomial infection and the number of infection episodes were the variables with the strongest association with prolonged hospital stay among ICU patients.

Introduction: Two consensus conferences taking place in the United States and Spain were organized to optimize diagnosis and treatment of Candida spp. infections. Among other results, clinical scenarios in which early prescription of antifungal agents is indicated were identified., Objective: To determine the criteria followed by physicians for prescribing antifungal agents in critically ill patients in our country and to investigate adherence to the guidelines proposed by the consensus conferences., Methods: A questionnaire was designed and directed to 4th- and 5th-year residents in intensive care medicine and to specialists in intensive care with training in infectious diseases or other medical areas. Four case reports for which expert consensus indicates early antifungal treatment were included in the questionnaire; 1) recurrent peritonitis secondary to perforation of the digestive tract, with mixed flora including fungi; 2) persistent febrile syndrome in a patient with multiple mucosal fungal colonizations treated with broad-spectrum antibiotics; 3) candiduria and pyuria in a febrile patient; and 4) candidemia., Results: A total of 135 questionnaires from 45 different ICUs were returned (60% response rate). In the candidemia and fungal peritonitis examples, early treatment with antifungal agents was indicated in 100% and 85.9% of responses, respectively, whereas for sepsis with multifocal candidiasis and candiduria associated with pyuria and fever, early treatment was prescribed in only 41.5% and 55.6% of responses, respectively. There were no significant differences in response with regard to degree of training of the physicians surveyed. Fluconazole prescription predominated, mainly at doses of 400 mg/day, in mixed peritonitis, disseminated candidiasis and candiduria, whereas amphotericin B lipid formulations were preferentially indicated in cases of candidemia. Antifungal treatment (early or late) was prescribed in all responses for candidemia, in 95.5% for mixed peritonitis (fungi and bacteria), in 79.5% for multifocal candidiasis in patients with persistent sepsis, and in 77.9% for candiduria with fever and pyuria., Conclusions: Adherence to recommendations from the consensus conferences was high among intensive medicine specialists, with no differences according to level of training in infectious diseases.

Background: To determine risk and prognostic factors in patients admitted to the intensive care unit (ICU) in which an episode of bacteremia caused by Pseudomonas aeruginosa has been diagnosed., Patients and Method: Cohort, observational, prospective, multicenter study. Patients admitted to 30 ICUs in Spain in whom one or more pathogens were isolated from blood cultures were included., Results: In a total of 16,216 patients admitted to the participating ICUs during the study period, 949 episodes of bacteremia were diagnosed In 77 cases (8.11%), P. aeruginosa was the causative pathogen, with an infection rate of 4.7 episodes per 1000 patients. Independent risk factors associated with P. aeruginosa bacteremia were as follows: respiratory infection focus (OR 3.92; 95% IC 2.33-6.59; p

Objective: To review some anatomofunctional aspects of the pyramidal tract which are relevant in clinical practice, especially the newer concepts., Development: a) Although the motor function is best known, the pyramidal tract also has sensory functions, modulating the transmission of impulses in the spinal cord. In fact, motor function is a recent acquisition on the evolutionary scale. b) Other descending pathways, such as the cortico reticulospinal path, participate in voluntary movements. However, the pyramidal pathway is necessary for fine movements of the hand. c) Most of the pyramidal fibres control movements of the contralateral side of the body, but there are a few fibres which do not cross to the other side and play a part in ipsilateral body movements. These fibres seem to contribute to motor recovery following a brain lesion. d) Classically it is recognized that the motor cortex and pyramidal fibres follow a somatotopical distribution. Nevertheless territories corresponding to different parts of the body are superimposed to a considerable extent and may be modified on very diverse occasions. e) Experimentally it has been proved that a circumscribed lesion of the pyramidal pathway does not cause hyper reflexia or spasticity. The hyper reflexia and spasticity habitually seen in patients with pyramidal syndrome is due to lesions of other descending pathways., Conclusion: The pyramidal tract is anatomically and functionally related to other nerve structures and its activity is therefore integrated within the nervous system.

Objective: Afer twenty years of commercial availability of cefotaxime, the objective of this study was to know the reasons and modes of use, administration dosage as well as its effectiveness and tolerance in critically ill patients admitted to Intensive Care Units (ICU) in our country., Design: Open, prospective, observational, multicenter study., Subjects: All patients who had cefotaxime administered in monotherapy or in combination with other antibiotics were included as cases in this study., Results: A total of 624 patients were included in 44 ICUs (average 14 cases). Cefotaxime was indicated for therapy of 274 community-acquired infections (43.9%), 194 prophylaxis (31.1%), and 156 nosocomial infections (25.0%). Both community-acquired pneumonia (149, 34.7%) and mechanical ventilation associated pneumonia (62, 14.4%) predominated, followed by trachebronchitis (60, 13.9%) and central nervous system infections (42, 9.8%). Over half of infections (222, 51.6%) presented as systemic inflammatory response syndrome (SIRS), 133 (30.9%) as severe sepsis, and 75 (17.4%) as septic shock. In 374 (87.0%) out of the 430 cases of infection treatment, cefotaxime wan prescribed on an empirical basis and in 150 of them (40.1%) a further confirmation of the causative agent was obtained. In 120 (27.9%) cases, cefotaxime was administered as monotherapy and in the remaining cases in association with one or more antibiotics.The use of cefotaxime as prophylaxis was evaluated as failure in 31 (16.0%) of the cases, whereas in treatment it was considered as failure in 98 (22.8%) of the 430 cases, 51 community-acquired infections, 27 (27.3%) of ICU-acquired infections, and 20 (35.1%) nosocomial infections acquired outside the ICU. In 127 (29.5%) of the 430 infection treatments the initial treatment was changed. The reasons for the change included clinical failure (36, 28.3%), recovery of an uncovered pathogen with the antibiotic (40, 31.5%), emergence of multi-resistant pathogens (28, 22.0%), to decrease the therapeutic spectrum (7, 5.5%), and other reasons (16). Cefotoxime was also changed in 21 (6.0%) of the 194 cases in which it was used as prophylaxis. In 32 (5.1%) patients 37 adverse effects were noted which were associated with a possible or likely use of cefotaxime. Most notably, diarrhoea in 15 (2.4%) occasions and skin rash in 6 cases (1.0%)., Conclusions: Cefotaxime is still one of the therapies of choice for community-acquired and nosocomial infections as well as in different prophylactic modes. It is mostly used on an empirical basis and associated with other antibiotics. Clinical and microbiological efficiency is high whereas adverse effects related to its use have been scarce.

Objective: To compare clinical and bacteriological efficacy as well as tolerability of two regimens of broad-spectrum antibiotics (ceftazidime versus piperacillin/tazobactam) combined with amikacin in the treatment of nosocomial pneumonia in intensive care patients., Design: Open label, prospective, multicenter, and randomized phase III clinical trial., Setting: Medical or surgical intensive care units (ICUs) of nine acute-care teaching hospitals in Spain., Patients and Participants: One hundred and twenty-four ICU patients with nosocomial pneumonia and requiring mechanical ventilation were included. They were randomized to receive amikacin (15 mg/day divided into two doses) combined with either piperacillin (4 g every 6 h) and tazobactam (0.5 g every 6 h) (n = 88) or ceftazidime (2 g every 8 h) (n = 36)., Measurements and Results: The causative pathogen was determined in 60.2% of patients in the group of amikacin plus piperacillin/tazobactam and in 76.9% in the group of amikacin plus ceftazidime. A total of 94 bacterial organisms were isolated among which gram-negative bacilli predominated, Pseudomonas aeruginosa being the most frequent. Clinical response at the end of antibiotic therapy was considered satisfactory (cure and/or improvement) in 63.9% of patients in the amikacin plus piperacillin/tazobactam group and in 61.5% in the amikacin plus ceftazidime (odds ratio 1.1; 95% confidence interval 0.44-2.75). Eradication or presumptive eradication rates for each pathogen and for either gram-negative or gram-positive bacteria were similar in both antibiotic combinations (odds ratio 1.2; 95% confidence interval 0.39-3.66). A total of 21 adverse effects (23.9%) occurred in the amikacin plus piperacillin and tazobactam group and six (16.7%) in the amikacin plus ceftazidime group, thrombocytosis, renal dysfunction, and hepatic cytolysis being the most common. The efficacy and tolerability of the two therapeutic regimens were similar not only in the whole study population, but also in the subset of P. aeruginosa-related pneumonia (odds ratio 1; 95% confidence interval 0.08-13.37)., Conclusions: Amikacin associated with either ceftazidime or piperacillin and tazobactam has shown comparable efficacy and tolerability in the treatment of ICU patients with nosocomial pneumonia.

Background: A prospective multicentre study was undertaken to compare the efficacy of intravenous ciprofloxacin or imipenem in the treatment of severe nosocomial pneumonia requiring mechanical ventilation., Methods: Patients with a clinical suspicion of pneumonia were randomised to receive either ciprofloxacin (800-1200 mg/day) or imipenem (2-4 g/day) in doses adjusted for renal function and specimens of the lower respiratory tract were taken. Patients were included in the study when specimens showed significant growth for potentially pathogenic microorganisms in quantitative bacterial cultures (n = 75, ciprofloxacin 41/75 (55%); imipenem 34/75 (45%)). The clinical and bacteriological success rates were the primary and secondary efficacy variables. An intent-to-treat analysis was performed for all randomised patients who received at least one dose of the study medication (n = 149, ciprofloxacin 72/149 (48%), imipenem 77/149 (52%))., Results: The success rates were generally good, but neither the clinical success rates (ciprofloxacin, 29/41 (71%), imipenem, 27/34 (79%); 95% CI -10.8 to 28.1; p = 0.435) nor the bacteriological response rate (ciprofloxacin, 20/41 (49%), imipenem, 17/34 (50%); 95% CI -21.5 to 23.9; p = 1.0) were significantly different between the study arms. Pseudomonas aeruginosa was recovered in 26/75 patients (35%) and clinical (ciprofloxacin, 10/14 (71%), imipenem, 8/12 (67%); 95% CI -40.4 to 30.9; p = 1.0) and bacteriological response rates (ciprofloxacin, 7/14 (50%), imipenem, 3/12 (25%), 95% CI -60.9 to 10.9, p = 0.247) were not significantly different in this subgroup of patients. Resistance of Pseudomonas aeruginosa developed in 5/26 cases (19%), 1/14 (7%) to ciprofloxacin and 4/12 (33%) to imipenem (p = 0.147), and the mortality was 12/75 (16%) with no difference between treatment groups (ciprofloxacin, 8/41(24%), imipenem 4/34 (17%); p = 0.362). The clinical response was evaluable in 109/149 patients (73%) in the intent-to-treat analysis and was successful in 74/109 patients (68%). The clinical response rates were also not significantly different in the intent-to-treat analysis (ciprofloxacin, 34/52 (65%), imipenem, 40/57 (70%); 95% CI -12.8 to 22.3; p = 0.746)., Conclusions: Treatment with either ciprofloxacin or imipenem was effective in a selected group of patients with microbiologically confirmed, severe nosocomial pneumonia requiring mechanical ventilation. Although no differences between the study medication could be documented in this trial, smaller differences between treatment arms may have been missed because of sample size limitations.

We describe a case of vasculitis with colonic involvement/alterations associated with hepatitis C virus infection. Both the association of hepatitis C with vasculitis type periarteritis nodosa and the prominent involvement of the colon are infrequent. The presentation of this case--fever of unknown origin--as well as the difficulties of treating a patient who is a hepatitis C virus carrier are discussed.

The usefulness of double-phase parathyroid technetium-99m-MIBI scintigraphy for the detection of hyperplastic parathyroid tissue has been described. The aim of the present study was to establish the effectiveness of this new technique in the morphological and functional assessment of parathyroid glands in patients with different types of hyperparathyroidism. We performed 99mTc-MIBI scintigraphy (MIBI) and neck ultrasonography in 38 patients with primary (n=16) or secondary (n=22) hyperparathyroidism. All patients underwent surgical neck exploration, removing a total of 84 parathyroid glands. Before and after surgery, blood intact parathyroid hormone (iPTH) was measured peripherally and in both the right and left internal jugular veins. In patients with primary hyperparathyroidism, ultrasonography showed one enlarged gland in 11 cases (69%), while MIBI was positive in 15 (94%) (including two ectopic glands). The sensitivity of MIBI (93%) was greater than that of ultrasonography (68%), with a similar specificity (100 and 97%, respectively). In patients with secondary hyperparathyroidism, there was a discrepancy between both imaging modalities in 29 glands (33%). The sensitivity of both techniques was similar (41 and 54%, respectively), with the same specificity (89%). There were more difficulties in detecting the upper than the lower pathological glands. MIBI reflected more accurately the functionality of the glands, and ultrasonography has a better correlation with the volume and weight. In conclusion, Tc-99m-MIBI scintigraphy is a good technique to identify parathyroid hyperfunctioning tissue in cases of primary hyperparathyroidism and to detect ectopic glands, but it does not give significantly better results than conventional ultrasonography in patients with secondary hyperparathyroidism.

The management of status epilepticus (SE) is very complex due to the variability of its clinical features. This paper aims to achieve an schematic basis for a consensus in the treatment of these patients. Thus we need the clinical forms of SE grouped according to the differences in treatment. We also need to divided the development of every type of SE into stages in order to adjust the correct application of general measures and antiepileptic drugs. In patients prone to suffering recurrent seizures it is important to prevent risk factors. We can sometimes identify a premonitory phase during which the clinical deterioration presages SE; in these cases immediate treatment at home can prevent the evolution into true SE. Once SE has developed up to stage of early SE or stablished SE, the treatment must be carried out in emergency department. If seizures have not responded, the stage of refractory SE is reached and Intensive Care Unit facilities are mandatory. We devote special attention to conic-clonic SE but the other clinical forms of SE are categorized according to the differences in treatment.

Patients subjected to surgery often develop nosocomial infections, among which the intra-abdominal ones stand out as being a common cause of septicemia, multi-organ failure, and death of the critical patients. Advances have been made in the study of the physiopathology by studying the mediators which are responsible for the systemic inflammatory response, the microbiology (changes in the pathogen type and in the antimicrobial sensitivity), and for the clinical picture (cholecystitis, tertiary peritonitis). Abdominal ultra-sound and computerized axial tomography have contributed greatly to the diagnosis of these infections. The new treatment techniques are discussed, both of the drainage of the septic focus (percutaneous or surgical), as of the antimicrobial treatment and the supportive measures. The diagnostic and therapeutic advances have modified the prognosis of these patients, although this continues to be poor when there is development of the multi-organ failure syndrome.

Despite improvements in tube design and materials, the longer survival rates of critically ill patients make laryngeal and tracheal lesions still common following prolonged translaryngeal intubation. The time of intubation is almost the only factor employed in deciding whether or not tracheotomy has to be performed. Some patients will not develop laryngeal lesions afer long intubation periods, whereas some already have clinical symptoms after short periods of time. If the conditions of the larynx and trachea could be assessed before irreversible complications take place, then timing of tracheotomy could be individualized to avoid laryngeal stenosis as well as unnecessary tracheostomies. We present the preliminary results of an endoscopic study of the early laryngeal changes that take place during translaryngeal intubation. The method of exploration is explained and tissue changes seen and their evolution after extubation are described, emphasizing those that could have a predictive value.

When faced with the frequent use of parenteral nutrition (TPN) and the multiple problems which the maintenance of venous pathways presents, we initiated this study to try and show that the use of TPN catheters for the perfusion of drugs in "Y", does ot increase the incidence of infection. 70 patients subjected to TPN were studied, divided into 3 groups: I: TPN with exclusive use catheter (23 patients). II: TPN with a catheter through which antibiotic medication is administered in "Y" (22 patients). III: TPN with a catheter through which non-antibiotic medication is administered in "Y" (25 patients). Despite there being no extra manipulation in group I, when applying Cramer's "Y" we did not find any significant differences between the three groups as to incidence of infection. When relating the variables of infection and number of manipulations by means of chi-squared, we did not find significant differences either. There is no increase in the incidence of infection with the increase of manipulation. When we relate the variables of infection and number of days of treatment with TPN by chi-squared, we did not find significant differences either. There were no more infections of the catheters with more days of treatment. Neither did we find significant differences with respect to the number of manipulations, according to the calculation done by the Student T-rest, between groups II and III. Therefore, we have reached the conclusion that although the use of TPN for the administration of other drugs should not be used indiscriminately, it is absolutely valid for concrete cases, with a difficulty of multiple venolysis, as long as the drugs that shall be administered are stable with TPN and as a long as the norms form the correct administration and the aseptic techniques are observed.

The relationship between gastric (GC) and tracheal (TC) colonization and the development of ventilator-associated pneumonia (VAP) remains controversial. TC, GC, and pharyngeal (PC) colonization were studied serially in 80 patients with mechanical ventilation (MV) to ascertain the routes and onset of TC. Simultaneous sample from pharynx, stomach, and trachea were obtained throughout the MV period. Quantitative cultures were performed. Seventy-two patients (90%) had TC at some time during MV. Only 19 patients presented TC after PC or GC by the same microorganisms. Indigenous gram-negative and gram-positive microorganisms colonized mainly the trachea from the start of or during MV without previous PC or GC (p < 0.05). Pseudomonas were the microorganisms causing TC principally during MV without previous PC or GC (p < 0.005). Enterobacteria produced TC without a preferential route. Of the 12 patients who developed VAP, the microorganisms responsible had already colonized the trachea in 10 patients. Only 10 of the 21 microorganisms isolated in VAP had previously colonized the pharynx or stomach. In summary, although some microorganisms have preferential routes for producing TC, the microorganisms isolated frequently change during MV. TC precedes VAP in most patients, but only a minority develop a VAP; therefore, together with TC other factors must be involved in VAP development.

We describe three cases of acute intoxication by hydrogen sulphide which were produced after remaining between 50 and 60 minutes inside a cellulose tank. The three patients had loss of conscience. One of the patients developed a persistent vegetative state; another patient recovered although with neurological post-anoxic sequelas and the third case completely recovered one week after his hospitalization. The patients underwent symptomatic treatment and the environmental concentrations of hydrogen sulphide were measured at the site of the accident. Finally, the application of preventive measures is stressed.

A prospective study was performed to assess the value of differential quantitative blood cultures in the diagnosis of catheter-related sepsis when this condition is suspected on clinical grounds and to establish a reliable discriminative value for application without removal of the inserted catheter. A total of 107 central venous catheters from 64 patients were used for the study. Blood was obtained simultaneously through the suspected infected device and from a peripheral venipuncture. The catheter was removed and its tip cultured semiquantitatively. Catheter-related sepsis occurred in 17 patients. Using as cut-off value a colony count fourfold higher in blood drawn through the catheter than in simultaneously drawn peripheral blood, a sensitivity of 94%, specificity of 100% and positive predictive value of 100% were obtained. A single bacterial count greater than 100 cfu/ml in the quantitative culture of the catheter blood specimen in the presence of a positive qualitative peripheral blood culture of the same organism was also highly suggestive of catheter-related sepsis. Differential quantitative blood culture is a reliable method for the diagnosis of catheter-associated sepsis without catheter removal.

A child with palsy of the right facial nerve and bilateral palsy of the VIth, IXth and XIIth cranial nerves, dysfunction of the VIIIth cranial nerve, facial malformations and bilateral equinovarus was diagnosed on the basis of these features as having Moebius syndrome. Ocular studies disclosed congenital cataract and chorioretinal coloboma in both eyes. These ocular abnormalities have not previously been described in Moebius syndrome. This paper discusses whether the coexistence of these two types of anomalies may be due to occurrence of a break in the primitive internal carotid and trigeminal arteries between the fourth and fifth postconceptional weeks, causing maldevelopment of the choriocapillary and impairing neuron differentiation in cranial nerve nuclei.

The clinical picture, treatment and evolution of seven patients presenting snake bites are analyzed. Local symptoms were constant, with a spontaneous favorable evolution in 7 to 10 days. The most relevant systemic manifestations were coagulation anomalies which appeared in two patients. Treatment always included local wound care, antitetanicum antibiotic and anticoagulant prophylaxis with specific antiophidic serum in five patients.

3 cases of suicide due to ingestion of 150, 200 and 4 gr. of paraquat, respectively, are presented. Two of them were brothers and agricultural industrialists, the other one was a farmer. The first two cases died 16 and 10 hours after intake. The farmer died 21 days after ingestion. All of them had progressive hypoxemia and renal failure the two brothers had heart conduction system glycemia (23 mg/dl) a few hours after ingestion. The postmortem study showed edema, hemorrhage and congestion of the lungs, alveolitis, fibrosis and lobar atelectasia; renal tubular necrosis adrenal necrosis; colestasia; hepatic steatosis focal miocarditis. The clinical evolution, particularly short in the first two patients, is commented on, as well as the post-mortem findings, comparing them with those described in the literature. Finally, due to the high toxicity of this herbicide, we insist in prompt transport to herbicide, we insist in prompt transport to the hospital in order to apply early treatment.