Role of host and bacterial virulence factors in Escherichia coli spontaneous bacterial peritonitis

OBJECTIVES: Host factors and bacterial virulence determinants may play a role in Escherichia coli (E. coli) spontaneous bacterial peritonitis. We evaluated the importance of these factors in the emergence of fluoroquinolone-resistant strains and outcome in cirrhotic patients with E. coli spontaneous bacterial peritonitis. METHODS: E. coli spontaneous bacterial peritonitis was detected in a 2-year period in three tertiary hospitals. Clinical and bacteriological data were obtained. Phylogenetic group and 15 virulence genes of E. coli strains were analyzed by polymerase gene reaction and compared with 50 isolates from pyelonephritis patients. RESULTS: Forty-seven E. coli spontaneous bacterial peritonitis patients were identified, 18 (38%) were fluoroquinolone-resistant, a 12% increase compared with our earlier series from 1997 to 2002. Fluoroquinolone resistance was associated with norfloxacin prophylaxis, increased resistance to trimethoprim-sulfamethoxazole and cefotaxime, and less bacterial virulence, as demonstrated by a higher prevalence of 'nonpathogenic' phylogenetic groups A+B1 (56 vs. 28%; P=0.04) and lower virulence scores in fluoroquinolone-resistant E. coli compared with fluoroquinolone-susceptible E. coli. E. coli strains from cirrhotic patients belonged more frequently to 'nonpathogenic' phylogenetic groups A+B1, had fewer virulence factors and higher rates of fluoroquinolone resistance than isolates from pyelonephytis patients. Immunosuppression was independently associated with in-hospital and 3-month mortality. Bacterial virulence factors were unrelated to mortality. CONCLUSION: Fluoroquinolone-resistant E. coli spontaneous bacterial peritonitis prevalence is increasing because of norfloxacin prophylaxis. Strains from peritonitis are less virulent than strains from pyelonephritis because of a higher prevalence of A+B1 phylogeny and quinolone resistance. Mortality is related to immunosuppression, but not to bacterial virulence factors.     

Use of Ambulatory Blood Pressure Monitoring for the Screening of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a frequent and underdiagnosed disease in hypertensive individuals who experience cardiovascular events. The aim of this study was to define the best model that combined the ambulatory blood pressure (BP) monitoring (ABPM), anthropometric, sociodemographic, and biological variables to identify moderate to severe OSA. A total of 105 ABPM‐confirmed hypertensive patients were evaluated using their clinical histories, blood analyses, ABPM, and home respiratory polygraphic results. A multivariate logistic regression analysis was performed to identify the significant variables. The best model included sex, presence of obesity (body mass index ≥30 kg/m² and abdominal obesity), mean daytime BP, mean nocturnal heart rate, and minimal diastolic nighttime BP to achieve an area under the curve of 0.804. Based on this model, a validated scoring system was developed to identify the patients with an apnea‐hypopnea index ≥15. Therefore, in untreated hypertensive patients who snored, ABPM variables might be used to identify patients at risk for OSA.     

Phase II study of irinotecan (CPT-11) administered every 2 weeks as treatment for patients with colorectal cancer resistant to previous treatment with 5-fluorouracil-based therapies: comparison of two different dose schedules (250 and 200 mg/m2) according to toxicity prognostic factors

Our objective was to assess the antitumoral activity and toxicity of irinotecan (CPT-11) 60-min i.v. infusion every 2 weeks as second-line monotherapy of advanced colorectal cancer. Two doses were studied (250 and 200 mg/m) according to the risk of developing toxicity. Two groups of patients were studied: high-risk group (HR, 200 mg/m, n = 45; Karnofsky score 60-80% and/or the record of prior pelvic irradiation) and low-risk-group (LR, 250 mg/m, n = 51; Karnofsky score >80% and without prior pelvic irradiation). The mean number of cycles per patient was 7: 6.6 (HR group) and 8.3 (LR group). Median RDI was 0.96. The overall response rate was 8.9% [95% confidence interval (CI) 2.5-21.2%; HR group] and 15.7% (95% CI 7.0-28.5%; LR group), respectively. The LR group showed two complete responses and a higher percentage of stable disease (56.9 versus 33.3% in HR group). The median survival was 7.1 months (95% CI 5.2-8.9 months, HR group) and 11.7 months (95% CI 8.4-15.1 months, LR group). The median time to disease progression was 3.2 months (95% CI 1.0-5.4 months, HR group) and 5.3 months (95% CI 3.8-6.7 months, LR group). Both CPT-11 treatments were well tolerated. Grade 3/4 toxicity incidence was low, e.g. granulocytopenia (7% of patients in HR group and 9% in LR group) and delayed diarrhea (18% of patients in HR group and 14% in LR group). We conclude that the treatment of patients with the adjusted dose of CPT-11 according to prognostic factors for toxicity resulted in the improved toxicity profile, but showed poorer efficacy outcome. Therefore, the dose reduction in patients with low performance and treated with radiotherapy needs further investigation to provide some new insights on the benefit:risk ratio of such treatment.     

Mortality in healthy elderly patients after ICU admission

Purpose  The aim of this study was to assess mortality in healthy elderly patients after non-elective medical ICU admission and to identify predictive factors of mortality in these patients. Methods  Patients ≥65 years living at home and with full-autonomy (Barthel index, BI > 60), without cognitive impairment, and non-electively admitted to a medical ICU were prospectively recruited. A full comprehensive geriatric assessment was made with validated scales. Results  A total of 230 patients were included, 110 (48%) between 65 and 74 years and 120 (52%) ≥75 years. No significant differences were observed between the two groups in premorbid functional and cognitive status, main diagnosis at ICU admission, APACHE II and SOFA scores, use of mechanical ventilation or haemodialysis or length of ICU stay. Over a mean follow-up of 522 days (range 20–1,170 days) the cumulative mortality of the whole group was 55%, being significantly higher in older subjects (62 vs. 47%; P = 0.024). On multivariate analysis, only parameters related to quality of life (QOL) and functional status were independent predictors of cumulated mortality (P < 0.01, both). Thus, in patients with EQ-5D_vas (<70) or baseline Lawton index (LI) (<5) the hazard ratio for cumulated mortality was 2.45 (95% CI: 1.15–5.25; P = 0.03) and 4.10 (95% CI: 1.53–10.99; P = 0.006), respectively, compared to those with better scores. Conclusions  Healthy elderly non-elective medical patients admitted to the ICU have a high mortality rate related to premorbid QOL. The LI and/or EQ-5D_vas may be useful tools to identify patients with the best chance of survival.     

Renal oncocytoma: a true clinical entity?

Seven cases of renal oncocytoma, representing 4.10% of nephrectomies for tumors of the renal parenchyma between May 1978 and May 1985, are presented. From a thorough analysis of the literature and a comparison of these cases with well-differentiated, noninvasive clear-cell carcinomas, it can be concluded that renal oncocytoma is a variant of the wide spectrum of renal carcinomas. Hence, its clinical and therapeutical approach must not differ from that of the rest of the parenchymatous renal tumors.