Showing papers by "Hospital General Universitario Gregorio Marañón published in 2003"

Prevalence of sleep-disordered breathing in children with Down syndrome: polygraphic findings in 108 children.

Abstract: Study Objectives: To assess the prevalence of sleep-disordered breathing in a nonselected group of children with Down syndrome and to determine significant predisposing factors for this condition. Design: Prospective study. Setting: Tertiary care university hospital in Madrid, Spain. Patients: The study population included 108 consecutive children with Down syndrome (mean [SD] age, 7.9 [4.5] years; range, 1-18 years) independently of whether or not suggestive clinical features of sleep-disordered breathing were present. Interventions: In addition to history, physical examination, and lateral radiographs of the nasopharynx, all participants underwent an overnight cardiorespiratory polygraphy at the hospital using a portable ambulatory device (Apnoescreen II plus). An apnea-hypopnea index of at least 3 was required for defining the presence of sleep-disordered breathing. Results: The prevalence of sleep-disordered breathing was 54.6%, with a significantly higher prevalence in boys (64.7%) than in girls (38.5%) (P <.05), The group with sleep-disordered breathing was significantly younger (6.4 [3.9] years) than those with normal polysomnographic recordings (9.6 [4.6] years) (P <.001). In the multivariate analysis, age (less than 8 years old) (odds ratio [OR], 3.36; 95% confidence interval [Cl], 1.40, 8.06); male sex (OR, 3.32; 95% Cl, 1.32, 8.12); and tonsillar hyperplasia (OR, 5.24; 95% Cl, 152, 19.03) were significantly associated with sleep-disordered breathing. Body mass index, adenoid hyperplasia, previous tonsillectomy or adenoidectomy, congenital heart disease, malocclusion, and macroglossia did not affect the prevalence of sleep-disordered breathing. Conclusions: The prevalence of sleep-disordered breathing in children with Down syndrome is very high, particularly in boys. Tonsillar hyperplasia may play a role in the pathophysiology of sleep-disordered breathing in these patients. Adenoid hyperplasia, obesity, and congenital heart disease were not important risk factors for sleep-disordered breathing.

Validación española del cuestionario Brief Pain Inventory en pacientes con dolor de causa neoplásica

Abstract: Fundamento y objetivo Validar la version espanola del cuestionario Brief Pain Inventory (BPI)para medir la intensidad del dolor de causa neoplasica y su impacto en las actividades de lavida diaria en pacientes con cancer. Pacientes y metodo Se incluyo consecutivamente a pacientes con dolor de origen neoplasico. Lospacientes cumplimentaron los cuestionarios BPI (Cuestionario Breve del Dolor o CBD en espanol)y el Rotterdam Symptom Checklist (RSCL) en la visita de inclusion. El CBD se repitio a los3-5 dias en los pacientes clinicamente estables de su dolor de origen neoplasico y ambos cuestionariosse repitieron al mes en los pacientes no estables de su dolor. Resultados Se evaluo a 126 pacientes, el 85,1% habia sufrido algun episodio de dolor irruptivoen las 24 h previas al inicio del estudio. El 86,5% de los pacientes completo el CBD en sutotalidad. Las puntuaciones del CBD se correlacionaron con la percepcion del paciente de laintensidad maxima del dolor y con la presencia de tumor diseminado. La dimension «sintomaspsicologicos» del RSCL fue la que presento mayor correlacion con las dimensiones del CBD(«intensidad del dolor» e «interferencia en las actividades»). La consistencia interna de las dimensionesfue buena (0,87 y 0,89), y la fiabilidad test-retest entre baja y moderada (0,53 y0,77). El CBD ha demostrado ser un instrumento capaz de detectar cambios en el nivel de dolor.Los cambios observados en las dos dimensiones del CBD entre las dos visitas de estudio reflejanlos cambios percibidos por el propio paciente en la intensidad del dolor. Conclusiones La version espanola del CBD se mostro valida para medir la intensidad del dolorde causa neoplasica y su impacto en las actividades de la vida diaria, en condiciones de practicaclinica habitual.

Ventilator-associated pneumonia after heart surgery: a prospective analysis and the value of surveillance.

Abstract: Objective To determine the frequency, etiology, and risk factors of ventilator-associated pneumonia (VAP) and purulent tracheobronchitis (TBX) in patients who have undergone heart surgery. To study the predictive role of systematic surveillance cultures. Design Prospective study. Setting Heart surgery intensive care unit. Patients Intubated heart surgical patients. Interventions Systematic tracheal aspirate and protected brush catheter cultures of all intubated patients. Measurements and Main Results Studied were the frequency of lower respiratory tract infection in ventilated patients and the role of surveillance cultures. The frequency of VAP was 7.87% (34.5 per 1,000 days of mechanical ventilation), and the criteria for purulent tracheobronchitis was fulfilled by 8.15% of patients (31.13 per 1,000 days of mechanical ventilation). After multivariate analysis, the variables independently associated with the development of respiratory tract infection were central nervous system disorder (relative risk [RR] = 4.7), ulcer disease (RR = 3.6), New York Heart Association score ≥3 (RR = 4), need for mechanical circulatory support (RR = 6.8), duration of mechanical ventilation >96 hrs (RR = 12.3), and reintubation (RR = 63.7). Mortality in our study was as follows: VAP patients, 57.1%; purulent tracheobronchitis patients, 20.7%; colonized patients, 11.5%; and noncolonized patients, 1.6%. Regular surveillance cultures were taken from all ventilated patients to assess the anticipative value of the cultures in predicting respiratory tract infection. A total of 1,626 respiratory surveillance samples were obtained. Surveillance cultures effectively predicted only one episode of VAP and one of tracheobronchitis. Conclusions Patients undergoing heart surgery have a high frequency of VAP. VAP is associated with a poor prognosis. In this study, surveillance cultures failed as an anticipative diagnostic method.

In Vitro Activities of Linezolid against Clinical Isolates of Mycobacterium tuberculosis That Are Susceptible or Resistant to First-Line Antituberculous Drugs

Abstract: We evaluated 117 isolates of Mycobacterium tuberculosis for susceptibility to linezolid by the proportion and E-test methods. Linezolid showed high in vitro activity, with all the strains inhibited by ≤1 μg of the drug per ml. E-test MICs were at least 4 dilutions lower than their equivalents by the standard proportion method.

Results after treatment of traumatic knee dislocations: a report of 26 cases.

Abstract: Background A retrospective study was carried out with all the cases of traumatic dislocation of the knee joint treated in our institution between 1988 and 1998. Methods In most cases (81%), the dislocation was reduced under general anesthesia and early surgical repair of damaged structures was performed as each case required. In five cases, the treatment was conservative because of associated skeletal and visceral injuries that made immediate surgery inadvisable. Results Peroneal nerve palsy (23%) and popliteal artery disruption (7.5%) were the most frequent early complications. The most common sequelae were instability (85%) and limp (50%). Early operative repair of all damaged structures was associated with the best functional result (55%). Nonoperative treatment was associated with 100% unsatisfactory results, and these patients are waiting for a second operation to treat the sequelae. Conclusion Operative treatment makes possible the recovery of structures that provide enough stability to perform day-to-day activities in the majority of cases.

Clinical Course and Prognostic Factors of Progressive Multifocal Leukoencephalopathy in Patients Treated With Highly Active Antiretroviral Therapy

Abstract: We analyzed survival rates, neurologic function, and prognostic factors for 118 consecutive patients with acquired immunodeficiency syndrome-associated progressive multifocal leukoencephalopathy (PML) treated with highly active antiretroviral therapy (HAART) in 11 hospitals throughout Spain. Seventy-five patients (63.6%) remained alive for a median of 114 weeks (2.2 years) after diagnosis of PML. Neurologic function of the survivors was categorized as cure or improvement in 33, stabilization or worsening in 40, and unknown in 2. The baseline CD4+ cell count was the only variable found with prognostic significance. The odds ratio of death was 2.71 (95% confidence interval, 1.19-6.15) for patients with CD4+ cell counts of or =100 cells/microL. One-third of patients with PML died despite receipt of HAART; neurologic function improved in approximately one-half of the survivors. A CD4+ cell count of <100 cells/microL was associated with higher mortality.

Migration of human blood dendritic cells across endothelial cell monolayers: adhesion molecules and chemokines involved in subset-specific transmigration

Abstract: Distinct subsets of dendritic cells (DCs) are present in blood, probably "en route" to different tissues. We have investigated the chemokines and adhesion molecules involved in the migration of myeloid (CD11c(+)) and plasmacytoid (CD123(+)) human peripheral blood DCs across vascular endothelium. Among blood DCs, the CD11c(+) subset vigorously migrated across endothelium in the absence of any chemotactic stimuli, whereas spontaneous migration of CD123(+) DCs was limited. In bare cell migration assays, myeloid DCs responded with great potency to several inflammatory and homeostatic chemokines, whereas plasmacytoid DCs responded poorly to all chemokines tested. In contrast, the presence of endothelium greatly favored transmigration of plasmacytoid DCs in response to CXCL12 (stromal cell-derived factor-1) and CCL5 (regulated on activation, normal T expressed and secreted). Myeloid DCs exhibited a very potent transendothelial migration in response to CXCL12, CCL5, and CCL2 (monocyte chemoattractant protein-1). Furthermore, we explored whether blood DCs acutely switch their pattern of migration to the lymph node-derived chemokine CCL21 (secondary lymphoid-tissue chemokine) in response to microbial stimuli [viral double-stranded (ds)RNA or bacterial CpG-DNA]. A synthetic dsRNA rapidly enhanced the response of CD11c(+) DCs to CCL21, whereas a longer stimulation with CpG-DNA was needed to trigger CD123(+) DCs responsive to CCL21. Use of blocking monoclonal antibodies to adhesion molecules revealed that both DC subsets used platelet endothelial cell adhesion molecule-1 to move across activated endothelium. CD123(+) DCs required beta(2) and beta(1) integrins to transmigrate, whereas CD11c(+) DCs may use integrin-independent mechanisms to migrate across activated endothelium.

PRE‐dialysis survey on anaemia management

Abstract: BACKGROUND The PRE-dialysis survey on anaemia management (PRESAM) was designed to assess the care given to pre-dialysis patients in the 12 months before haemodialysis or peritoneal dialysis, with emphasis on anaemia management. METHODS For this epidemiological study, a retrospective chart review was conducted for patients who started haemodialysis or peritoneal dialysis between 1 August, 1999 and 6 April, 2000. All adult patients who entered one of the 779 participating centres in 21 European countries, Israel or South Africa were included, except for patients who underwent dialysis only during an acute episode. In addition to demographic characteristics, the study examined the prevalence of anaemia, anaemia management including the use of iron supplementation and epoetin, source of referral to the dialysis centre, comorbidities and major clinical events. RESULTS A total of 4333 new dialysis patients were included in the survey. At the first visit to the dialysis centre, 68% of the patients had a haemoglobin (Hb) concentration < or = 11.0 g/dl; Hb concentration was positively correlated with creatinine clearance rate (r = 0.43, P < 0.01). Patients who received epoetin had a mean Hb concentration of 8.8 g/dl at the start of epoetin treatment, and 96% of these patients had an Hb concentration < or = 11.0 g/dl. Only 26.5% of the patients received epoetin before dialysis. The length of time under the care of a nephrologist was associated with meeting the European Best Practice Guidelines (EBPG) target Hb concentration, as well as receiving epoetin. CONCLUSIONS Few pre-dialysis patients met the EBPG target for Hb concentration, despite regular nephrology care.

Training improves muscle oxidative capacity and oxygenation recovery kinetics in patients with chronic obstructive pulmonary disease.

Abstract: We studied 21 patients with chronic obstructive pulmonary disease aged [mean (SD)] 63 (10) years, with a mean forced expiratory volume in 1 s of 40 (6)% and a peak oxygen uptake of 67 (11)% of predicted values. Patients trained for 6 weeks on a cycle ergometer at high work-rates (WR). Near-infrared spectroscopy was used to obtain the time-constant of the deoxygenation recovery signal (τHbO2) during three constant WR exercise tests, one below and two above the lactic acidosis threshold (θL). Glycolytic and oxidative enzymes and lactate concentrations were assessed in muscle biopsies. The τHbO2 decreased significantly in all three constant WR tests: –18 (24)s, –20 (23) s and –13 (22) s, respectively. Endurance time increased in the higher WR tests, by 5.7 (4.8) min and 3.6 (2.7) min, respectively. The activity of citrate-synthase (CS) and creatine-kinase changed significantly from 20 (10) to 30 (13) µmol·min–1·g–1 and from 3.825 (950) to 3.402 (526) µmol·min–1·g–1, respectively. Training also improved significantly the mean response time of the on-transient of oxygen uptake (τ'V˙O2) of the below-θL test. We found significant correlations between changes in CS and changes in τHbO2, τ'V˙O2 and endurance time. We conclude that leg training accelerates the speed of re-oxygenation of the vastus lateralis muscle after exercise. This improvement is correlated to changes in the oxidative enzymes.

Clinical applicability of the new EORTC/MSG classification for invasive pulmonary aspergillosis in patients with hematological malignancies and autopsy-confirmed invasive aspergillosis.

Abstract: Diagnosis of invasive pulmonary aspergillosis (IPA) is often difficult Recently, the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) has proposed new criteria for the classification of invasive fungal infections We have studied the clinical applicability of this classification in 22 patients with hematological malignancies who had IPA at autopsy While alive, according to the EORTC/MSG criteria, only 2 patients were classified as having proven IPA, 6 as probable, 13 as possible, and 1 was unclassifiable Of the patients, 64% had no microbiological or major clinical criteria before death Although the EORTC/MSG criteria are an important step forward in the standardization of definitions used for IPA in clinical research studies, most patients who die with extensive lung disease only reach a level of possible or probable IPA during life, further highlighting that these guidelines should not be used for clinical decision-making

Systolic dysfunction is a predictor of long term mortality in men but not in women with heart failure.

Abstract: Aims To evaluate possible gender differences in clinical profile and outcome of patients hospitalised with heart failure. Methods and results During 1996 a total of 1065 hospital in-patients had confirmed heart failure, with follow-up data through 2002. Women (58%) were significantly older, had higher prevalence of hypertension and diabetes, and lower prevalence of ischaemic heart disease, chronic pulmonary disease and alcoholism. The proportion of patients with normal left ventricular ejection fraction (LVEF) increased with age, but in all age groups women had normal LVEF more frequently than men. Echocardiography was performed less frequently in females: 62% vs. 71% in men, P 0.3 but women with LVEF ≤0.3 had a better prognosis than their male counterparts. Conclusions Survival is similar in women irrespective of LVEF and in men with LVEF >0.3 while men with severely depressed LVEF have a worse prognosis.

Hepatic and systemic haemodynamic changes after MARS in patients with acute on chronic liver failure.

Abstract: Hyperdynamic circulation and portal hypertension characterize acute on chronic liver failure (AoCLF), partially because of circulating mediators. Molecular Absorbents Recirculating System (MARS) may remove some of these substances. The objective of this study was to evaluate the effect of MARS on portal pressure, systemic haemodynamic and endogenous vasoactive systems. MARS treatment was performed in four patients with AoCLF (mean age 36.2 ′ 3.1 years; Child-Pugh C 11 ′ 1.8 points; three AAH and one NASH). Systemic and splanchnic haemodynamic measurements were performed before and after each session. Plasmatic renin activity (PRA) and NE were measured at baseline, at the end of the sessions and 10 days after MARS. All patients had severe portal hypertension (HVPG = 23 ′ 7 mmHg) and pronounced hyperdynamic circulation (MAP 77.8 ′ 11.7 mmHg; CO 11.2 ′ 1.6 L/min; SVRI 478.5 ′ 105 dyne s/cm 5 ). HVPG decreased at the end of the first session in all patients (23 ′ 7 mmHg vs 17.3 ′ 9.9 mmHg; P = 0.05; mean decrease 32 ′ 24%) because of a decrease in WHVP (40.7 ′ 5.6 mmHg vs 34 ′ 9.6 mmHg; P = 0.025; mean decrease 18 ′ 19%). MARS significantly attenuated hyperdynamic circulation as shown by a decrease in CO (11.2 ′ 1.6 L/min vs 9.4 ′ 2.1 L/min; mean decrease 12.3%), with an increase in MAP (77.8 ′ 11.7 mmHg vs 84.2 ′ 8 mmHg; mean increase 9.2%) and in SVRI (478.5 ′ 105 dyne s/ cm 5 vs 622 ′ 198 dyne s/cm 5 ; mean increase 41%). PRA and NE decreased significantly (14.2 ′ 17.2 ng/mL/h vs 3.7 ′ 3.4 ng/mL/h; 1319 ′ 1002 pg/mL vs 617 ′ 260 pg/mL, respectively). The NE decrease was correlated to HVPG decrease (r = 1, P = 0.01). MARS decreases portal hypertension and ameliorates hyperdynamic circulation in patients with AoCLF, probably mediated by clearance of vasoactive substances. Further studies are necessary to confirm these results.

Transanal self-expanding metal stents as an alternative to palliative colostomy in selected patients with malignant obstruction of the left colon.

Abstract: Background Palliative colostomy is still unavoidable in many patients with malignant obstruction of the left colon. This report describes an initial experience and follow-up in a small series of patients with left-sided colon obstruction in whom transanal self-expanding metal stent (SEMS) placement was attempted for palliative purposes. Methods Palliative transanal SEMS placement was attempted in 11 patients with malignant obstruction of the rectosigmoid region. The selection criteria included patients with advanced pelvic disease, peritoneal carcinomatosis and/or multiple parenchymatous metastatic disease. Wallstent oesophageal endoprostheses were used, and the technique was carried out by interventional radiologists. Results The technique succeeded in relieving the obstruction in seven patients, and surgical intervention was prevented in six. Five of these six patients died with an unobstructed colon from 26 days to 7 months after SEMS placement. The technique failed in four patients, three of whom underwent emergency colostomy. Conclusion Transanal SEMS placement is an appealing method for the relief of obstruction in selected patients, obviating the need for palliative colostomy. © 1998 British Journal of Surgery Society Ltd

Anatomical and functional brain variables associated with clozapine response in treatment-resistant schizophrenia.

Abstract: Clozapine alleviates the symptoms of a significant proportion of treatment-resistant schizophrenic patients. Previous studies suggest that the response to clozapine may be associated with prefrontal and temporal anatomy as well as with prefrontal, basal ganglia and thalamic metabolism. A sample of 25 treatment-resistant (TR) schizophrenic patients underwent magnetic resonance imaging (MRI) and 18F-deoxyglucose positron emission tomography (PET) before and after treatment with clozapine. We investigated the association between changes in positive, disorganized, and negative schizophrenic syndromes with clozapine treatment and a set of cerebral variables that included total intracranial volume (ICV); hippocampal, dorsolateral prefrontal (DLPF) and temporal gray-matter volume and metabolism; and metabolic activity of the thalamus, pallidum/putamen, and caudate head. Improvement in positive symptoms with clozapine was directly related to temporal gray-matter volume, whereas improvement of disorganization symptoms was inversely related to ICV and hippocampal volume. Patients with high baseline DLPF cortical volume and metabolic activity were more likely to experience improvement in their negative symptoms. We conclude that clinical improvement with clozapine may be related with the anatomy and metabolic activity of specific brain areas, with the structural integrity of the DLPF and temporal regions showing the maximum predictive capacity.

Fiabilidad del diagnóstico de la EPOC en atención primaria y neumología en España. Factores predictivos

Abstract: Objetivos: Los objetivos de este estudio fueron evaluar la metodologia empleada para el diagnostico de la enfermedad pulmonar obstructiva cronica (EPOC) en atencion primaria y en neumologia en Espana, y analizar los factores que determinan la realizacion de un diagnostico correcto de esta enfermedad Material y metodo: Se llevo a cabo un estudio observacional, descriptivo, transversal y multicentrico La seleccion de participantes se realizo mediante muestreo aleatorio estratificado por poblacion regional entre medicos de familia y neumologos Resultados: De los 898 sujetos reclutados, 568 (63,2%) tenian obstruccion al flujo aereo, 92 (10,3%) no cumplian los criterios funcionales de EPOC y 238 (26,5%) carecian de una espirometria que permitiera confirmar el diagnostico y establecer la gravedad del proceso Por niveles de actuacion, solo el 29,3% de los pacientes en atencion primaria fueron clasificados de forma correcta, frente al 84,8% en neumologia Del total de sujetos diagnosticados correctamente de EPOC, el 38,6% en atencion primaria y el 10,2% en neumologia fueron diagnosticados inicialmente por criterios clinicos radiologicos La disponibilidad de la espirometria en atencion primaria fue del 49,1% frente al 97,8% en el ambito de la neumologia (p < 0,001) Ademas, solo el 29,9% de los centros en el primer nivel asistencial contaban con un tecnico encargado de la realizacion del estudio, comparado con el 97,8% en atencion especializada de neumologia (p < 0,001) Los factores que determinaron el uso de la espirometria para realizar el diagnostico de EPOC fueron el nivel de asistencia, la disponibilidad de la prueba en atencion primaria, el lugar de residencia y la situacion de incapacidad laboral temporal por la EPOC Conclusiones: Hay un elevado porcentaje de pacientes con EPOC erroneamente diagnosticados, sobre todo en el ambito de la atencion primaria Existen diferencias en la metodologia diagnostica segun el nivel de asistencia de los pacientes La disponibilidad de la espirometria es un factor importante a la hora de realizar un diagnostico correcto de EPOC

Long‐term follow‐up of bone mineral density in Addison's disease

Abstract: BACKGROUND AND AIMS There is conflicting evidence regarding the long-term effects of long-term glucocorticoid replacement therapy (GRT) on bone mineral density (BMD) in patients with chronic adrenal insufficiency. Our aim was to evaluate bone turnover and changes in BMD in patients on GRT. PATIENTS AND METHODS We have studied 25 subjects (six men, 19 women; aged 62.4 +/- 11.3 years, duration of disease 21.7 +/- 11.7 years, fasting cortisol 63 +/- 36 nmol/l) on GRT (hydrocortisone 30 mg/day or prednisone 7.5 mg/day). BMD was assessed at the lumbar spine (LS; L2-L4), proximal femur (PF) and ultra distal radius (UR) by dual energy X-ray absorptiometry (DXA). The rates of bone loss were calculated using previous DXA measurements at the LS (48 and 60 months earlier). Serum calcium, phosphate alkaline phosphatase (ALP), bone ALP, serum osteocalcin (BGP), intact parathyroid hormone (PTH) and 25(OH) vitamin D were also measured. RESULTS BMD [Z-score; 95% confidence interval (95% CI)] was normal at the LS: (-1.15-+0.07); PF: (-0.90-+0.22) and UDR (-0.77-+0.36). No significant differences were found according to the type of replacement therapy or sex. No significant bone loss (g/cm2; 95% CI) was detected at the LS: (-0.021-+0.023). Fifty-six per cent of patients met osteoporotic criteria; a greater proportion of patients treated with prednisone had osteoporosis compared with those an hydrocortisone. All bone markers were in their normal ranges. CONCLUSIONS Patients on long-term therapy do not show accelerated bone loss at the lumbar spine. Nevertheless, a considerable proportion of patients, mainly those treated with prednisone, showed densitometric osteoporosis.

Low Blood CD8+ T-Lymphocytes and High Circulating Monocytes Are Predictors of HIV-1-Associated Progressive Encephalopathy in Children

Abstract: Objective. Human immunodeficiency virus type 1 (HIV-1)-associated progressive encephalopathy (PE) is a common and devastating complication of HIV-1 infection in children, whose risk factors have not yet been clearly defined. Regardless of the age of presentation, PE shortens life expectancy. Paradoxically, as survival of patients has been prolonged as a result of the use of antiretroviral therapy, the prevalence of PE has increased. Therefore, a predictive marker of PE emergence is critical. The objective of this study was to determine in an observational study whether any immunologic (CD4 + and CD8 + T-lymphocyte counts, monocyte counts) or virologic (viral load [VL], biological characteristics of viral isolates) marker might be predictive of PE and whether any particular marker may be involved in the timing of clinical onset of PE. Methods. A total of 189 children who were vertically infected with HIV-1 were studied retrospectively, 58 of whom fulfilled criteria of the American Academy of Neurology for PE. T-lymphocyte subsets and monocytes in peripheral blood were quantified by flow cytometry. HIV-1 RNA was measured in plasma using a quantitative reverse transcriptase polymerase chain reaction assay. Demographic, clinical, and viro-immunologic characteristics in infants were compared with control groups using logistic regression. Proportions were compared using the χ 2 test or Fisher exact test. For each child, immunologic and virologic markers were analyzed in parallel closely before clinical onset of PE and closely after PE onset and compared by using the Student t test for paired samples. Results. Overall, mortality of 58 HIV-1-infected children who developed PE was significantly higher than of children who did not develop this complication. Blood CD8 + T-lymphocytes + >25% (95% confidence interval: 1.2–13.9) and remained statistically significant after adjustment for treatment. When we compared the PE-positive group with the acquired immunodeficiency syndrome (AIDS)/PE-negative group (children who developed clinical category C and without neurologic manifestations) in a cross-sectional study within 12 months before PE or AIDS diagnosis, respectively, the %CD8 + T-lymphocytes were significantly lower in the PE-positive group. Normalized absolute counts of CD8 + T-lymphocytes with respect to seroreverting children were significantly lower in the group of children with encephalopathy with respect to the AIDS/PE-negative group (data not shown). It is interesting that a statistically significant increase was observed in circulating monocyte percentages and absolute counts shortly before the first neurologic symptoms compared with values after PE was established and with those from HIV-1-infected controls. With respect to AIDS-related events, PE was strongly associated with anemia and lymphoid interstitial pneumonitis in the PE-positive group with respect to a group of children with AIDS but without PE. Conclusion. HIV-1 infection of the central nervous system (CNS) remains an important clinical concern. The first step toward PE prevention in HIV-1-infected children should be directed at predicting risk of PE and thus the prompt and reliable identification of infants who are at risk for CNS disease progression. Low blood CD8 + T-lymphocytes is a strong early predictive marker of PE emergence in vertical HIV-1 infection. Indeed, among all of the immunologic and virologic variables assessed in this observational study, the only significant difference during the first months of life are the CD8 + T-lymphocytes. A peak of significantly higher peripheral monocytes before the onset of PE with respect to established PE has not been previously described, and strengthens the growing evidence that an increased traffic of monocytes to the brain may be a key factor in triggering neurologic symptoms. The suppression of HIV-1 replication is dependent on the presence of a relatively small number of HIV-1-specific CD8 + T-lymphocytes, and it is possible that the duration of the neurologically asymptomatic phase for any given child may depend mostly on the magnitude of specific CD8 + T-lymphocyte responses. Thus, a decrease of CD8 + T-lymphocytes would diminish the host capacity to control viral infection, as reported in animal models, enabling infected macrophages to cross the blood-brain barrier. Our results advocate the use of CD8 + T-lymphocyte and monocyte counts to follow-up HIV-1-infected children. We suggest that CD8 + T-lymphocytes may be the nexus for many different aspects of the disease, namely loss of control of HIV-1 replication determining higher VL, increased traffic of activated and/or infected monocytes, spread of infection to immune sanctuaries, and finally clinical neurologic emergence of PE. Moreover, we suggest that CD8 + T-lymphocytes or/and monocytes may be used as putative biological markers of neuropathogenicity. This might suggest their use in decision making of when to start more effective antiretroviral regimens for HIV-1 infection of the CNS and the need of new therapies either to preserve or to augment an adequate CD8 + T-lymphocyte immune response. Early detection of children who are at risk for developing PE is particularly important because aggressive highly active antiretroviral therapy improves neurologic symptoms, allows possible use of neuroprotective treatment to prevent further development of encephalopathy, and emphasizes the relevance of developing therapies aimed to enhance CD8 + T-lymphocyte function. In conclusion, the surrogate markers routinely used in clinical practice for HIV-1 infection (ie, CD4 + T-lymphocyte counts and VL) seem to be insufficient to evaluate the clinical involvement of the CNS. Other systemic markers, as the recent proposed markers for PE evolution (cerebrospinal fluid VL by lumbar puncture and brain atrophy by cerebral magnetic resonance imaging) are undoubtedly more invasive than measuring CD8 + T-lymphocyte and monocyte counts, when the neurologic manifestations of PE are still preventable.

The isolation of Aspergillus fumigatus from respiratory tract specimens in heart transplant recipients is highly predictive of invasive aspergillosis.

Abstract: Background. Prompt recognition of invasive pulmonary aspergillosis (IPA) after heart transplantation is essential for achieving a successful outcome. However, the significance of the isolation of Aspergillus from respiratory specimens in heart transplant recipients is not established. Methods. From 1990 to 1999, we analyzed first respiratory specimens with Aspergillus spp. growth from heart transplant patients in our institution. All specimens were cultured in both fungal and conventional media. Diagnosis of proven and probable IPA or colonization was made according to criteria of the Mycoses Study Group. Results. During the 10-year study period, Aspergillus spp. was recovered from 30 episodes from 27 heart transplant recipients (incidence: 10.5%). Three episodes were classified as indeterminate and were included in the analysis in a double way, first considering them as true positives and afterward as true negatives, so ranges were obtained. After applying diagnostic criteria, 18 of 30 episodes were proven or probable IPA, and 9 episodes were colonizations. Accordingly, 7 to 8% of heart transplant recipients suffered an IPA, and the overall positive predictive value (PPV) was 60% to 70%. When analyzed by species, the PPV of recovering Aspergillus fumigatus was 78% to 91%, whereas it was 0% for other species. The PPV increased to 88% to 100% when A. fumigatus was recovered from a respiratory specimen other than sputum and decreased to 50% to 67% when it was recovered from sputum. The sensitivities of fungal and conventional media for the recovery of Aspergillus spp. were 95% to 100% and 33% to 38%, respectively. Conclusion. The isolation of A. fumigatus from the respiratory tract of a heart transplant recipient is highly predictive of invasive aspergillosis.

Polyclonal and Compartmentalized Infection by Mycobacterium tuberculosis in Patients with Both Respiratory and Extrarespiratory Involvement

Abstract: Infection by Mycobacterium tuberculosis (MTB) is assumed to be caused by a single strain, and several MTB strains within the same patient are rarely considered. The present study analyzes the phenomenon of mixed infections by MTB in a group of 50 patients with both respiratory and extrarespiratory tuberculosis. First, the proportion of patients with infection by >1 strain was defined, and second, the clonal composition of the MTB populations at different infected sites was studied. In 3 (6%) of 50 patients, >1 strain was cultured, which indicates that mixed infections are not anecdotal. The coinfecting strains were not equally distributed at the respiratory and extrarespiratory site, which reflects a compartmentalization of the infection. In 1 patient, although 2 strains were found at the respiratory site, only 1 of these strains was involved in the extrarespiratory infection, which suggests that clonal selection can occur in the dissemination of the infection.