Showing papers by "Hospital General Universitario Gregorio Marañón published in 1994"

Evolution of susceptibilities of Campylobacter spp. to quinolones and macrolides.

Abstract: Erythromycin, new macrolides, and quinolones are alternatives for the treatment of Campylobacter infections. Concerns related to the emergence of resistance to both groups of drugs have been raised. We studied the evolution of antimicrobial susceptibilities of 275 clinical isolates of microorganisms of the genus Campylobacter isolated in our institution during a 5-year period (1988 to 1992). The microorganisms studied were C. jejuni (n = 230), C. coli (n = 42), and C. fetus (n = 3). The overall resistance rates (determined by the agar dilution method and the recommendations of the National Committee for Clinical Laboratory Standards) were as follows: erythromycin, 2.3%; clarithromycin, 2.3%; azithromycin, 1.9%; ciprofloxacin, 28.5%; norfloxacin, 31%; ofloxacin, 26.3%; and nalidixic acid, 36.8%. The evolution of resistance (percent resistance in 1988 versus percent resistance in 1992) was as follows: erythromycin, 2.6 versus 3.1; clarithromycin, 2.6 versus 3.1; azithromycin, 2.6 versus 3.1; ciprofloxacin, 0 versus 49.5; norfloxacin, 2.6 versus 55.5; ofloxacin, 0 versus 45.6; nalidixic acid, 2.6 versus 56.8. Our data show stable macrolide activity against Campylobacter spp. and the rapid development of quinolone resistance over the last 5 years.

Failure of Cefotaxime in the Treatment of Meningitis Due to Relatively Resistant Streptococcus pneumoniae

Abstract: To our knowledge, we report the first failure of cefotaxime in the treatment of meningitis due to relatively resistant Streptococcus pneumoniae (MICs of penicillin and cefotaxime, 1 microgram/mL). Cure was achieved with a 14-day course of intravenous and intrathecal vancomycin. We recommend that in cases of meningitis caused by strains of S. pneumoniae for which MICs are > or = 1 microgram/mL, cefotaxime should be used with caution; however, if therapeutic failure is suspected therapy should be changed to intravenous and intrathecal vancomycin.

Waldeyer ring lymphomas. A clinicopathological study of 79 cases

Abstract: Waldeyer ring lymphomas belong to a category of tumours which has not yet been fully defined. Their relation to mucosa-associated lymphoid tissue (MALT) and other extranodal lymphomas remains largely unknown. We performed a clinicopathological retrospective study of 79 patients, and compared them with a series of MALT and nodal lymphomas. Tumours from the nasopharynx and palatine tonsil showed similar histological profiles, with a predominance of large B-cells. Centroblastic lymphomas constituted the largest group (n = 45), followed by those of centrocytic type (9) with smaller groups of centroblastic-centrocytic (5) and Hodgkin's lymphomas (2). Three monocytoid B-cell lymphomas were identified. Only one case could be classified as MALT lymphoma. The frequency of bcl-2 expression in large B-cell tumours of Waldeyer's ring has an intermediate range between large B-cell lymphomas occurring in mucosal and nodal locations. Epitheliotropism was present in all low-grade cases, and was therefore not a useful marker in the identification of potential MALT lymphomas in contrast with other mucosal sites. Comparative survival studies showed significant overall differences between Waldeyer ring lymphomas, MALT and nodal cases. These disappeared after taking stage and histological grade into account. We conclude that Waldeyer ring lymphomas show distinctive features, mainly in terms of histological distribution and immunophenotype. The key factor determining their behaviour could be their different spreading capability. These findings suggest that extranodal lymphomas are heterogeneous, and indicate the need for additional efforts to clarify this.

Primary renal lymphoma: report of 3 cases and review of the literature.

Abstract: Primary renal lymphoma is a controversial entity. Only 29 cases have been reported since 1980. Diagnostic criteria are not well established. We report here 3 new cases and review the literature. Primary renal lymphoma was considered on the basis of uni- or bilateral nonobstructive nephromegaly with or without renal failure. In all cases, the diagnosis was made after renal biopsy. Extrarenal abdominal involvement was excluded by imaging techniques. The role of staging laparotomy remains controversial. Chemotherapy is the treatment of choice, but the prognosis is poor. We propose a clinical definition of primary renal lymphoma in order to achieve a better management of the disease.

Impact of an educational program for the prevention of colonization of intravascular catheters.

Abstract: OBJECTIVE: To evaluate the efficacy of an educational program for the prevention of catheter colonization. DESIGN: Two cross-sectional studies were carried out in a 500-bed randomly selected area of the hospital, separated by an educational program on the care of intravenous lines based on the Centers for Disease Control and Prevention (CDC) recommendations for the control of catheter-related infections. SETTING: A 2,100-bed urban general hospital affiliated with the University of Madrid (Spain). METHODS: Characteristics of patients and catheters and appropriateness of catheter care were evaluated. Cultures were taken from the point of insertion of the vascular catheter, the hubs, and infusion fluids. When catheter-associated infection was suspected, the distal end of the catheter was sent for culture and two blood cultures were taken. We compared the clinical and microbiological data before and after carrying out an educational program based on CDC recommendations for the control of catheter-related infections. RESULTS: Characteristics of patients and catheters did not differ between the two cross-sectional studies. Compared with baseline data, after the educational program we observed a reduction of inappropriate catheter care, from 83% to 38% (45% difference, 95% confidence interval [CI95], 55% to 35%, P < 0.0000), and a reduction in the rate of skin colonization, from 34% to 18% (16% difference, CI95, 26% to 5%, P < 0.001). The frequency of phlebitis (15% versus 14%), hub colonizations (12% versus 11%), catheter colonizations (2% versus 1%), and catheter-related bacteremias (0% versus 0%) remained unchanged between the two cross-sectional studies. CONCLUSIONS: Our educational program improved catheter care and reduced significantly the proportion of skin colonization around the insertion point. However, the educational program did not modify the proportion of hub colonization; because hub colonization has been demonstrated to be a source of line sepsis, our data suggest the need for a specific program directed to the maintenance of catheter hubs.

Treatment of deep mycoses with liposomal amphotericin B

Abstract: Amphotericin B is the mainstay of therapy of many deep mycoses, but its use is seriously hampered by dose-limiting nephrotoxicity. In this study a liposomal formulation of amphotericin B was administered to ten patients with proven deep mycoses: invasive aspergillosis (n=4), deep candidiasis (n=4) and zygomycosis (n=2). The mean daily dosage of liposomal amphotericin B was 3.0 mg/kg (range 2.5 to 4 mg/kg), the mean total dosage of liposomal amphotericin B 2,781 mg (range 87 to 5,220 mg) and the mean duration of treatment 17 days (range 3 to 33 days). Treatment with liposomal amphotericin B was associated with little nephrotoxicity and an overall survival rate of 50 %. The median increase of serum creatinine from baseline levels was 0.38 mg/dl (−1.2 to 2.6 mg/dl).

Variceal hemorrhage: efficacy of transjugular intrahepatic portosystemic shunts created with Strecker stents.

Abstract: PURPOSE: To evaluate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) in treatment of variceal hemorrhage. MATERIALS AND METHODS: Forty-five patients with cirrhosis underwent TIPS placement for treatment of acute (n = 12) or recurrent (n = 33) variceal hemorrhage. Shunts were created with Strecker stents. RESULTS: Shunts were established by deployment of stents in 42 patients. The portosystemic pressure gradient decreased from an average of 20.4 mm Hg +/- 5.4 to 9.2 mm Hg +/- 4.1. Complications included hepatic failure (n = 1), acute shunt thrombosis (n = 2), right jugular vein thrombosis (n = 1), bacteremia (n = 1), and stent misplacement (n = 1). Acute bleeding was controlled in 12 patients. The 30-day mortality rate was 2%; four other patients have since died. During follow-up (mean, 8.9 months), variceal bleeding recurred in six patients. Hepatic encephalopathy developed in six patients. Shunt stenosis or occlusion requiring further intervention occurred in 20 patients. CONCLUSION...

Anticardiolipin antibodies in pediatric patients with human immunodeficiency virus.

Abstract: Objective To study the presence of IgG and IgM anticardiolipin antibodies (aCL) in children with human immunodeficiency virus (HIV) infection and to determine their prevalence and clinical significance. Methods We studied 34 children with HIV infection: 26 patients were classified P-2, and 8 were P-1 according to the Centers for Disease Control classification. HIV transmission was from mother to child in 33 cases. aCL were measured by ELISA: Results IgG aCL were found in 28 (82%) and IgM aCL in 7 (20%). No difference in frequency and levels was found between class P-2 (85%, mean 54.5 PL units) and class P-1 (75%, mean 50.3 PL units). aCL were not related to the duration of the infection, clinical stage of disease, or with events like opportunistic infections. Children from sexually infected or intravenous drug user mothers showed no differences. Conclusion As in adults, aCL are commonly found in children with HIV infection. The significance of this finding is still unclear.

Eyelid motor abnormalities in progressive supranuclear palsy

Abstract: Eyelid motor abnormalities found in progressive supranuclear palsy are reviewed. Electrophysiological correlates of blepharospasm, levator inhibition (blepharokolysis) and supranuclear paralysis of lid closure are presented.

Flutrimazole 1% dermal cream in the treatment of dermatomycoses: a randomized, multicentre, double‐blind, comparative clinical trial with 1% clotrimazole cream

Abstract: Summary. In a multicentre, double-blind, randomized, parallel group clinical trial, the efficacy and tolerability of flutrimazole 1% dermal cream were compared with those of a reference compound, clotrimazole 1% dermal cream, applied topically twice daily for 4 weeks in patients with clinically and mycologically diagnosed fungal infection of the skin. A total of 484 patients were included in the study (244 patients received flutrimazole cream and 240 clotrimazole cream). According to an intention to treat analysis of the data, there was no difference between the treatments in terms of the rate of mycological cure after 4 weeks: 79% of patients in the clotrimazole group and 80% of patients in the flutrimazole group were mycologically cured (P= 0.83). From a safety point of view, flutrimazole and clotrimazole were well tolerated and the overall incidence of adverse reactions (mainly mild local reactions such as irritation or burning sensation) was 7%. This study shows that, in the treatment of fungal infections of the skin, topically applied flutrimazole has good efficacy, similar to that of clotrimazole, and is well tolerated. Zusammenfassung. In einer multizentrischen, doppelblinden, randomisierten, in parallelen Gruppen durchgefuhrten klinischen Studie wurde eine 1-prozentige Flutrimazol-Creme hinsichtlich Wirksamkeit und Vertraglichkeit mit einer 1-prozentigen Clotrimazol-Creme als Referenzwirkstoff verglichen. Die Patienten mit klinisch und mykologisch diagnostizierter Pilzinfektion der Haut wurden uber 4 Wochen hinweg 2mal taglich lokal behandelt. Insgesamt 484 Patienten nahmen an der Studie teil; 244 erhielten Flutrimazol- und 240 Clotrimazol-Creme. Gemas einer ‘Intention-to-treat’- Analyse der Daten gab es zwischen den Behandlungen keinen Unterschied im Bezug auf die mykologische Heilungsrate: 79% der Patienten der Clotrimazol-Gruppe sowie 80% der Patienten der Flutrimazol-Gruppe waren mykologisch geheilt (P= 0,83). Unter dem Aspekt der Unbedenklichkeit wurden sowohl Flutrimazol als auch Clotrimazol gut toleriert bei einer Gesamtnebenwirkungsrate von 7% (hauptsachlich milde lokale Reaktionen wie Hautreizung oder Brennen). Die Studie zeigt, das Flutrimazol, lokal angewendet zur Behandlung von Hautpilzinfektionen, eine gute Wirksamkeit, vergleichbar derjenigen von Clotrimazol, aufweist and gut vertraglich ist.

Clinicopathologic and immunohistochemical studies on lichen amyloidosis and macular amyloidosis.

Abstract: Different authors have showed the epidermal origin of amiloyd in lichen amyloidosis (LA) and macular amyloidosis (MA). 1 We examined eight consecutive patients suffering from LA, MA, or biphasic amyloidosis (BA) in a clinicopathologic study characterizing amyloid deposits with several monoclonal antikeratin antibodies and establishing immunohistochemical differences among the three disorders. Patients, Materials, and Methods. Biopsy specimens were taken from all patients and divided into two portions. Half of the specimen was formalin-fixed, paraffin-embedded, and processed for hematoxylin-eosin, Congored, and thioflavine T staining. Samples were scored as positive or negative for the presence of amyloid deposits in the epidermis; papillar, middle, or deep dermis; and perivascular or periadnexial area. The other half was snap frozen in liquid nitrogen and processed for immunohistochemistry (avidin-biotin complex technique, Table ). Results. Patients 1 and 2 had MA, patients 2 through 6 had LA, and patients 7 and 8 had BA. Their mean age was

Autoimmune phenomena in children with human immunodeficiency virus infection and acquired immunodeficiency syndrome.

Abstract: We have studied sera from 44 children with Human Immunodeficiency Virus infection and Acquired Immunodeficiency Syndrome using immunoblotting, radioimmunoassay, enzymoimmunoassay and indirect immunofluorescence We have detected a low incidence of antinuclear (29%), anti-reticulin (29%) and anti-smooth muscle (147%) antibodies by indirect immunofluorescence By enzymoimmunoassay we have detected anti-dsDNA (205%) and anti-ENA [anti-nRNP (613%), anti-Sm (295%), anti-Ro (477%) and anti-La (181%)] antibodies Tests for anti-dsDNA by radioimmunoassay were negative, suggesting the presence of low-avidity anti-DNA antibodies By immunoblotting we have detected anti-C (nRNP) (333%), anti-BB' (Sm) (333%), anti-Ro (60 KD) (45%) and anti-La (113%) antibodies The presence of anti-Ro antibodies was associated with progressive neurological disease Long-term follow-up studies with larger numbers of patients are necessary to evaluate the clinical significance of the presence of anti-dsDNA and anti-ENA antibodies in children infected with Human Immunodeficiency Virus

Segmentary Splenectomy of the Lower Tip Because of Spontaneous Rupture of a Splenic Hemangioendothelioma in a New-Born Child - A Case Report

Abstract: We present the first exceptional case of splenic hemangioendothelioma, an infrequent and generally asymptomatic benign vascular tumor, here triggering hypovolemic shock through spontaneous rupture of the spleen without prior injury Conservative treatment of the spleen led us to perform a segmentary splenectomy of the lower tip with total extirpation of the vascular tumour and the acute splenic bleeding was controlled One year later, splenic functions are normal

Astrocytes in brain tumours. Differentiation or trapping

Abstract: Adult astrocytes have been described in several types of gliomas, being accepted as high differentiated cells. Their presence is specially important concerning the concept of undifferentiated neuroectodermal tumours (PNET). We have studied two series of brain tumors and compared and contrasted them with silver impregnation (89 cases) and GFAP (127 cases). These are our conclusions: these astrocytes show the same morphology not only in neuroectodermal tumours, but also in CNS parenchyma around meningiomas, metastasis and brain lymphomas; many of these astrocytes are mature, normal cells with involutive features, lying among tumoral cells without transitional stages; their presence is directly related to a prominent peritumoral gliosis, a high proliferation rate and an infiltrating growth. On this basis, it is suggested that most of them are astrocytes belonging to the invaded CNS tissue and not true tumoral cells.

[Charcot-Marie-Tooth disease, dilated myocardiopathy and cardiac conduction disorders]

Abstract: We describe the case of two brothers with Charcot-Marie-Tooth disease, dilated cardiomyopathy and disorders in the cardiac conduction. We review the literature in order to find physiological grounds for these associations. Despite the absence of consolidated data on this question, the genetic grounds could play some role here. In this sense, our cases contribute with the novelty that the disease affects two brothers. This has never been described before and could contribute, along with future observations, to clarify some etiopathogenic aspects of the disease.

Clinical and serologic course of patients with mixed connective tissue disease

Abstract: The so called mixed connective tissue disease (MCTD), continues to be a controversial entity, while some authors considered it a good characterized disease, others think that is an undifferentiated connective tissue disease. OBJECTIVE. To analyse the clinical and serological evolution of a group of patients diagnosed of MCTD, with particular consideration to the meaning of anti-nRNP and anti-Sm antibodies. METHOD. We have studied 20 patients diagnosed of MCTD and 112 with systemic lupus erythematosus (SLE). Anti-nRNP and anti-Sm antibodies were detected through counter immunoelectrophoresis, immunoblotting and ELISA. RESULTS. After an average time of evolution of 10 years, 70% (14/20) of the patients diagnosed of MCTD fulfill criteria for SLE (6 cases), scleroderma (6 cases) or polymyositis (2 cases). Anti-nRNP response is persistent, directed mainly against the 70 Kd and A-nRNP polypeptides and qualitatively higher in MCTD in SLE (absorbencies 2.64 vs 1.25. The immunoblotting test detected anti-Sm antibodies in 5 patients (25%) and ELISA test in 14 (70%). CONCLUSIONS. Clinical and serological evolution suggest that MCTD is an undifferentiated connective tissue disease. Anti-nRNP antibodies are characteristic, although anti-Sm antibodies can be detected with ELISA regardless whether on not patients fulfill SLE criteria.

[Value of transesophageal echocardiography in the assessment of blunt chest trauma: correlation with electrocardiogram, heart enzymes, and transthoracic echocardiogram].

Abstract: Objective To asses the feasibility, usefulness and clinical rentability of the transesophageal echocardiography (TEE) in the evaluation of patients suffering a severe blunt chest trauma as well as to correlate the TEE findings with those provided by the conventional electrocardiogram (ECG), cardiac isoenzymes assay and transthoracic echocardiography (TTE). Design Prospective study using ECG, blood cardiac enzymes assay, TTE and TEE. Setting Intensive care unit of a general hospital. Patients We studied 34 patients admitted with blunt chest trauma and suspected cardiac contusion in spite of the existence of other traumatic injuries in some of them. There were 23 (67.6%) males and 11 females, with a mean age of 37.1 +/- 19.4 years (range: 16-69 years). Material and methods Patients with a previous history of cardiovascular or chronic pulmonary disease, cardiac arrest upon admission or positive cocaine or amphetamine levels in the urine were excluded from the study. Suspected cardiac contusion was established by clinical data, electrocardiographic findings, enzymes blood values (CPK-total and MB-fraction) and TTE findings. Additionally, a TEE was performed in each patient. Patients were stratified into two groups according to the TEE findings: Group A patients had signs compatible with cardiac contusion and in Group B patients there was a lack of evidence to substantiate this diagnosis. Those tests were evaluated in respect to their accuracy in the diagnosis of cardiac contusion when compared to transesophageal echocardiography and TEE findings were compared, whenever possible, to surgical or necropsic findings. Results We found TEE signs of cardiac injury in 22 (64.7%) patients and a wide spectrum of traumatic cardiac abnormalities were identified. TEE signs of ventricular injury were found in 15 pts of Group A (68.2%) being the right ventricle the most frequent affected. There were also two cases of mitral leaflet rupture, one case of tricuspid valve prolapse (with severe tricuspid regurgitation and associated with right ventricle wall motion abnormalities) and seven cases of pericardial effusion as well as one case of thoracic aortic dissection. In every patient submitted to cardiothoracic surgery or necropsy the TEE findings were confirmed. TEE provided significant information, sometimes crucial, to the patient evaluation and management, it was performed without any difficulty and it doesn't carried out any related complication. TTE was technically suboptimal in 53% and fail to demonstrate many cases of cardiac contusion and the thoracic aorta lesion, being the number of cardiovascular injuries demonstrated by TEE significantly higher (p = 0.029). No statistically significant difference was found between the number of patients with either an abnormal ECG or high values of CPK-MB in each group. Neither clinical findings, cardiac enzymes values, serial ECG's nor TTE predicted all the patients who had traumatic cardiac injury and those would subsequently developed complications related to cardiac contusion. Conclusions A severe blunt chest trauma frequently results in cardiac injury. The ECG and the CPK-MB measurements appears both to be fairly sensitive and specific tests in the cardiac contusion diagnosis. TTE has shown to have important limitations in these patients, thus not allowing neither a complete echo evaluation nor a reliable one. TEE plays an important role in the evaluation and management of this type of patients providing rapid diagnostic information and being of high value in the rule out cardiac contusion as well as in the establishment of a specific diagnosis of cardiac and/or thoracic aorta injuries with a consequent better assessment and treatment strategy in these patients.

Total intravenous anesthesia in general surgery

Abstract: To evaluate unwanted side effects expressed in hemodynamic parameters, postanesthetic recovery and quality of intravenous total anesthesia (IVTA) with propofol, fentanyl and atracurium. A prospective study in 292 patients undergoing general surgery. Fifty-three percent of the patients were ASA I, 32.2% were ASA II and 14.8% were ASA II, representing a wide range of ages, weights and heights. Mean time of anesthesia was 108.25 +/- 56.96 min. Anesthesia was achieved with propofol 0.108 +/- 0.027 mg/kg/min, fentanyl 0.093 +/- 0.035 microgram/kg/min and atracurium 0.011 +/- 0.0034 mg/kg/min. Slight pain was evident at injection in 1.7% of the patients. Greater hemodynamic instability was recorded at induction, with mean decreases in systolic and diastolic arterial pressures of 16% and 10%, respectively, with scarcely any response to intubation and extubation. Anesthetic recovery was recorded at 5.95 +/- 4.97 min, with surgical amnesia in 100% of the patients. Nausea was seen in 3.42% and vomiting in 1.7%. Patient evaluation of anesthetic technique was "good" in 60.3% and "excellent" in 39.7%. Propofol dose was significantly (p < 0.05) correlated with age (r = -0.33) and time of anesthesia (r = -0.4). IVTA with propofol and fentanyl in general surgery provides adequate maintenance of anesthesia for surgery and recovery, with good hemodynamic stability. In older patients and longer times of anesthesia, the total dose of propofol administered decreases, with negative effect on time and quality of recovery. Total dose of propofol administered is not significantly correlated with either time or quality of recovery.

Hepatic angiosarcoma with splenic metastasis

Abstract: Angiosarcoma of the liver is an extremely rare tumor with a rapidly fatal course. This report describes the case of a 52-year-old male with an hepatic angiosarcoma not related to any known carcinogen. The hepatosplenic metastases and the brief clinical course, did not let us to complete diagnostic and therapeutic strategies.

[Ulcerative jejunitis: a complication of celiac disease].

Abstract: We report the case of a 57-year-old woman with celiac disease of long standing, who developed episodes of intestinal obstruction during two months. They were misdiagnosed as intestinal obstructions caused by adhesions. The barium meal and follow-through examination disclosed several jejunal stenoses. Therefore, the patient underwent early surgery where an intestinal resection was carried out. The histological examination showed the presence of benign ulcers at the stenoses. After surgery, the patient began to gain weight and her nutritional state improved remarkably.

[Primary coronary angioplasty in acute anterior myocardial infarction: immediate results].

Abstract: Background Some reports have indicated that primary angioplasty not contaminated by previous intravenous infusion of thrombolytic agents represents an efficient approach to the treatment of acute myocardial infarction. Patients and methods As a part of a more ambitious protocol aiming to compare primary angioplasty and intravenous recombinant tissue plasminogen activator, we performed direct coronary angioplasty in 33 patients (18 randomized to angioplasty and 15 because of contraindication to thrombolysis) that were admitted to our hospital with acute myocardial infarction with less than 5 hours elapsed from the onset of pain and with clear electrocardiographic criteria of anterior infarction. Results In 30 of the 33 patients (90.9%) the left anterior descending artery was recanalized and TIMI 2 flow in 17 and 3 in 13 was obtained. The average time elapsed from the onset of pain to the opening of the artery was 228 +/- 70 (120-390) minutes and from the time of admission to the coronary care unit to complete reperfusion 91 +/- 43 minutes (33-120). Thirty one patients (93.9%) were discharged from the hospital and two (6.1%) died. There was only one hemorrhagic complication without sequelae. Conclusions Primary coronary angioplasty in acute anterior myocardial infarction is an efficient, safe and not so difficult therapeutic strategy. Even though it requires a complex around the clock on call set up it is specially useful in specific subsets of patients.

[The prognostic factors of mortality in community-acquired pneumonia requiring hospitalization].

Abstract: The prognostic influence on mortality of parameters available in an emergency Unit is studied in patients with acquired community pneumonia (ACP) requiring hospitalization. Three hundred and thirty patients admitted consecutively from the emergency unit of a general hospital were evaluated. Radiological, analytical, clinical, and demographic data were recorded. The parameters associated with greater mortality were: age, absence of thoracic pain, obnubilation, hypotension, elevation in urea, GOT, GPT, LDH, decrease in prothrombin activity, pO2, pH, albumin, and the affectation of more than one lobe in a radiography of the thorax. Considering the parameters associated with a higher relative risk (age > 65 years, urea > 50 mg/dl, LDH > 460 U/l and prothrombin < 70%), the presence of three or four of these variables shaved a sensibility of 59 percent and a specificity of 93 percent in predicting mortality. In the multivariant analysis remained as significant: age, obnubilation, elevation in LDH, and decrease in the activity of prothrombin and pH. Appropriate knowledge of the prognostic factors in CAP allows for early determination of patients who require special attention in both diagnosis and in treatment upon hospitalization.

Discontinuation of prolonged bromocriptine therapy in Parkinson's disease patients with uncontrolled motor oscillations.

Abstract: The beneficial effect of bromocriptine in fluctuating Parkinson's disease (PD) under chronic levodopa therapy has been reported to be lost in the long term in most patients. We attempted slow bromocriptine discontinuation in nine PD patients to whom this drug have been added to levodopa because of fluctuating motor responses but who appeared to cease benefitting from this association after an average of 4.6 years (range, 1.3-8 years) of sustained bromocriptine therapy. Bromocriptine was discontinued by gradually tapering off the dosage (mean, 8.5 mg/week) while leaving levodopa medication unchanged. The percentage time spent "off" during waking hours increased in all patients (average, 30.2 +/- 18.5% versus 65.6 +/- 82.6%, p < 0.001) and in three patients the "on-off" pattern shifted from random fluctuations to disabling "off" periods 23-26 times longer than before discontinuation. Sustained bromocriptine therapy does not prevent the continuous deterioration of motor fluctuations. However, we believe that this drug remains partially effective over the long term and should not be discontinued in PD patients with uncontrolled fluctuations, even though their condition may actually appear to worsen as compared to when bromocriptine therapy was first started.