Marion Hemmersbach-Miller

Identification of Risk Factors for Perioperative Mortality in Acute Mesenteric Ischemia

IntroductionAcute intestinal ischemia is in most cases a lethal condition with a low survival rate. Risk factors of perioperative mortality are poorly defined. The aim of this study was to define risk factors that predict an adverse outcome of acute mesenteric ischemia (AMI).MethodsA total of 132 consecutive patients (73 men, 59 women), mean ± SD age 71.96 ± 13.64 years, who underwent surgery because of AMI in a university tertiary care center were evaluated over a period of 10 years. Clinical features, laboratory findings, etiologic factors, and surgical procedures were recorded and assessed as possible risk factors for perioperative mortality.ResultsOf 132 patients, 86 (65.2%) died during the perioperative period as a direct result of AMI. Significant univariate predictors of perioperative mortality were age (P = 0.01), cardiopathy (P = 0.002), digoxin intake (P = 0.015), shock (P = 0.01), urea plasma level (P < 0.001), creatinine (P < 0.001), potassium (P = 0.042), low pH (P = 0.015) and bicarbonate (P = 0.035); hemoglobin ≥ 2.48 mmol/L (P = 0.035); time delay to surgery (P = 0.023); colonic involvement (P < 0.001); small and large bowel involvement (P < 0.001); arterial versus venous ischemia (P = 0.007); and intestinal resection (P < 0.001). In the multivariate analysis, the variables previous cardiac illness (P = 0.045), urea plasma levels (P < 0.001), and small and large bowel involvement were identified as independent risk factors of perioperative mortality. Intestinal resection (P < 0.001) was a favorable predictor.ConclusionsAge, time delay to surgery, shock, and acidosis significantly increase the risk of mortality due to AMI, whereas intestinal resection has a protective effect. However, only previous cardiac illness, acute renal failure, and large bowel ischemia have a negative effect as independent risk factors of mortality of AMI.

Pyogenic liver abscesses: mortality-related factors.

Goal To analyse the characteristics and mortality-related factors in a series of patients hospitalized for pyogenic liver abscess (PLA). Background Pyogenic liver abscesses are infrequent but potentially life threatening. Factors related to mortality have been less studied. Study The medical records of 84 patients, 56 men and 28 women, mean age of 64.4 years (SD: 14) who were hospitalized between 1992 and 2005 owing to a PLA were reviewed. The past medical history, clinical signs and symptoms, laboratory values, imaging studies, microbiological features, treatment, complications and mortality were recorded. Factors related to complications and mortality were analysed. Results One or more bacteria were isolated in 65 patients (77.4%), being Streptococcus spp. (40.5%), Escherichia coli (27.4%), Klebsiella spp. (14.3%) and anaerobics (17.9%) the most frequent isolates. Complications developed in 60.7% of the cases, the most common one being a right pleural effusion (34.5%). Mortality rate was 19% (95% confidence interval: 10–28%). Mortality was associated with age (P=0.005), a previous history of coronary heart disease (P=0.016), absence of fever (P=0.001), development of sepsis and/or septic shock (P<0.001), raise of bilirubin levels (P=0.004), a biliary (P=0.035), or cryptogenetic origin (P=0.039), infection owing to E. coli (P=0.01) or to Candida (P=0.009) and development of pneumonia (P<0.001). Logistic regression revealed sepsis and/or septic shock as an independent risk factor for mortality. Conclusions Mortality associated with PLA is high. The main risk factor for mortality is the development of sepsis and/or septic shock.

Human Rickettsia felis Infection, Canary Islands, Spain

We report the first cases of human infection by Rickettsia felis in the Canary Islands. Antibodies against R. felis were found in 5 adsorbed serum samples from 44 patients with clinically suspected rickettsiosis by Western blot serology. Fleas from 1 patients dog were positive for R. felis by polymerase chain reaction.

Five-year survival and prognostic factors in a cohort of hospitalized nonagenarians

BACKGROUND The number of hospitalized nonagenarians is increasing. Only a few studies have evaluated long-term predictors of survival in these patients. The aim of this study was to determine the 5-year outcome of a cohort of hospitalized nonagenarians, and to identify predictors of long-term survival. METHODS In 124 consecutive medical hospitalized patients older than 89 years, and followed up during 5 years, the following variables were prospectively recorded: sociodemographic characteristics, main diagnoses, Charlson comorbidity index, Barthel index, Lawton-Brody test, Mini-Mental State Examination, Short Portable Mental Status Questionnaire of Pfeiffer, Mini Nutritional Assessment, albumin levels, and the 5-year survival. RESULTS Out of the 124 patients, 109 died (87.9%) during the follow-up. The probability of being alive at 1, 3 and 5 years was 45%, 22% and 12%, respectively. A worse 5-year survival was significantly related to the diagnoses of pneumonia (p=0.037), heart failure (p=0.045), higher Charlson index (p=0.026), poorer functional status measured by the Barthel index (p=0.003), and the Lawton-Brody test (p=0.007), cognitive impairment measured by the Pfeiffer test (p=0.011), and lower levels of albumin (p=0.028). In the multivariate analysis, the Charlson index (p<0.001), and the Barthel index (p=0.003) were independently related to 5-year survival. These two variables were also 5-year survival prognostic factors in the subgroup of discharged patients. A prognostic index using these two variables was created: PI=(0.2 × Charlson index + 0.6 × Barthel index) × 0.92. CONCLUSIONS In hospitalized nonagenarian patients, poor scores in the Barthel Index and a higher comorbidity evaluated by the Charlson index are independently related to 5-year survival.

The Age-Adjusted Charlson Comorbidity Index as an Outcome Predictor of Patients with Acute Mesenteric Ischemia

Acute mesenteric ischemia (AMI) is a catastrophic surgical condition, especially in older patients with multiple comorbidities. The aim of this study was to evaluate the impact of comorbidity on perioperative mortality and overall survival in patients surgically treated for AMI. A series of 186 consecutive patients (106 men and 80 women) who underwent surgery because of AMI in a university tertiary care center between 1990 and 2006 were retrospectively studied. The Charlson Comorbidity Index (CCI) score, unadjusted and adjusted by age, was preoperatively calculated in each patient. Perioperative mortality and overall survival were also recorded. The association between unadjusted and adjusted by age CCI and perioperative mortality and overall survival were analyzed. The mean age of the studied population was 72.1 years (SE +/-13.7 years). Hospital mortality was 64.5%. One-year, 3-year, and 5-year overall estimated survival by the Kaplan-Meier method after surgery for AMI was 26%, 23% and 21%, respectively. Perioperative mortality was not related to the unadjusted preoperative CCI (p = 0.093). Nevertheless, a statistically significant association was found between mortality and preoperative adjusted CCI (p = 0.007). Likewise, CCI unadjusted was almost related to overall survival (p = 0.055), but the values of the categorized CCI adjusted by age showed a statistically significant difference in overall survival (p = 0.012). In multivariate analysis, CCI adjusted by age remained independent prognostic factor of mortality. Comorbidity adjusted by age may play a role as a predictive factor for perioperative mortality and long-term survival in patients operated on for AMI.

VITAMIN B12 AS A PREDICTOR OF MORTALITY IN ELDERLY PATIENTS

ACKNOWLEDGMENT Financial Disclosure(s): Atsushi Tashiro had financial support from the foundation for the cost of statistical software and personal computer. Satoshi Tsukioka and Naoshi Tanaka had no financial support from the foundation. Author Contributions: Atsushi Tashiro was responsible for acquisition of subjects, data analysis, interpretation of the data, and preparation of the manuscript. Satoshi Tsukioka provided advice on design of the research and interpretation of the data. Naoshi Tanaka designed and coordinated the research. Sponsor’s Role: This work was supported by the Daiwa Securities Health Foundation. Financial support (donation) was provided only for the cost of statistical software and personal computer. The sponsors had no role in the design, methods, subject recruitment, data collections, analysis, or preparation of manuscript.

Cardiac Device Infections due to Mycobacterium fortuitum

Two cases of cardiac device infection due to Mycobacterium fortuitum are reported along with a discussion of their clinical management. Long-term therapy and removal of the infected device is needed. The slow progression and absence of systemic signs and symptoms suggest a low pathogenicity of M fortuitum.

Brain Abscess due to Nocardia otitidiscaviarum: Report of a Case and Review

We present a case of brain abscess caused by Nocardia otitidiscaviarum in an immunocompromized 44-y-old male. Only 7 other cases of N. otitidiscaviarum brain abscess or involvement were found in the literature. The mortality was 75% despite treatment among cases reviewed. There is a lack of therapeutic guidelines regarding brain abscesses due to Nocardia.

Red blood cell disorders in recently arrived African immigrants to Gran Canaria, Spain

BACKGROUND In the last decade immigration to Europe has increased, with Africa being the source of a large number of immigrants. In addition to infections, this group has other less known health problems, such as erythrocyte abnormalities. METHODS The objectives of this study were: the systematic evaluation of red cell abnormalities in 200 newly arrived asymptomatic African immigrants on the Canaries; the systematic evaluation of haemoglobinopathies and their characterization in this population; and the relationship of red blood cell disorders and parasitic infections. RESULTS Of the studied immigrants 53 (26.5%) had red cell disorders according to their CBC parameters (Hb and/or MCV). In 48 people (24.0%) one or more etiologic diagnoses were made. Specifically, in order of frequency, a total of 26 structural haemoglobinopathies, 14 α-thalassemias, 2 β-thalassemias and 14 iron deficiencies were diagnosed. There was a statistically significant association between the presence of anemia, microcytosis, structural haemoglobinopathies or α thalassemia and sub-Saharan origin. However, no statistically significant association between the abovementioned parameters and eosinophilia or helminthic infection was observed. CONCLUSIONS These results suggest that, even in the presence of normal Hb and MCV values, including haemoglobinopathies in the initial screening of newly arrived sub-Saharan immigrants would be very useful.

Human Oestrus sp. Infection, Canary Islands

To the Editor: Myiasis due to Oestrus ovis is a well known zoonosis that affects a variety of animals. Human myiasis has also been described and affects mainly persons in rural areas such as shepherds (1) and farmers (2). Although this disease has been reported in both humans and mammals in Spain (3,4), no human case has been described on the Canary Islands. We describe what we believe is the first confirmed case on the islands and discuss the potential utility of serologic diagnosis for this disease. A 55-year-old farmer from the island of El Hierro, with a medical history of hypercholesterolemia, Q fever, and murine typhus, but currently not being treated, consulted a physician in August 2005 concerning a wormlike sensation in his nose and sinuses that had lasted 2 days. Three days before noticing this sensation, he had been working in his neighbor’s barn, when he noticed that a passing fly “dropped” something in his nose. He also reported sneezing and watery rhinorrhea. These symptoms were self-treated with nasal anticongestants, which provided temporary relief. He finally sought medical attention when a severe cough developed and the wormlike sensation extended to his throat. On physical examination, the patient’s vital signs were normal, although a turbinate hypertrophy and mild redness of the throat were noted. No foreign objects or insects were seen on otorhinolaryngologic examination. The patient’s blood count showed 8,480 leukocytes/μL with 6.1% (520/μL) eosinophils. Because of his stated symptoms, myiasis was suspected, and symptomatic treatment was started, consisting of antihistamines, nasal anticongestants, cough suppressants, and asphyxiant methods, i.e., swallowed olive oil. The patient was monitored closely and had complete remission of his symptoms after 6 days. No relapse has occurred. In the meantime, we discovered that a serologic test for O. ovis was available (5). We requested and obtained a convalescent-phase serum sample from the patient on day 14 of his illness. Blood was also obtained from different “healthy” animals in the patient’s neighborhood, including 2 dogs, 4 sheep, and 5 goats. This serologic assay had not previously been used in testing humans. Excretory and secretory antigens from O. ovis L2 (OL2ES) were obtained as previously described (6), and samples were analyzed by an immune enzymatic assay technique (7). Appropriate testing with different dilutions of the antigens, sera, and immunoconjugates was conducted. Immunoglobulin G (IgG) was detected in the patient, sheep, goats, and dogs following a similar protocol. OL2ES concentrations were 1, 1, 3, and 5 μg/mL, respectively. Serum samples were diluted 1:100 for the patient and the dogs and 1:50 for the goats; immunoconjugates were diluted 1:1,500 for all species. O. ovis IgG was found in the patient’s sera, as well as in sera of the 2 dogs, 2 of 4 sheep, and all 5 goats (Table). Table Results and interpretation, Oestrus sp. infection, Canary Islands*† Human infection by O. ovis is generally considered to be an accidental occurrence (8). This case confirms, however, that myiasis caused by O. ovis must be considered in the differential diagnosis of a patient with typical symptoms and eosinophilia. Most farmers in this area have reported similar symptoms. Most, however, do not seek medical attention because they prefer to use homemade remedies, such as topical oil. The diagnosis of oestrosis is usually made by direct visualization of the larvae, since the most frequent symptoms are pharyngeal myiasis and ophthalmomyiasis. Immunodiagnostic methods, however, could be a viable alternative to the clinical examination when no larvae are directly seen but a high degree of suspicion exists. The ELISA was noted to have a sensitivity of 96.1% and a specificity of 55.8% (positive predictive value of 86.7% and negative predictive value of 82.8%) in various investigations made with sheep and goats (6). Although allergic symptoms are frequent in animals, the pathophysiologic process seems to be different in humans (8). Nevertheless, other authors have also described coughing and sneezing (1), probably attributable to irritation of the mucosa. In animals, a primary peak in eosinophil numbers has been noted 4 days after infection with a primary increase 48 hours after infection (9). In humans this pattern has not been described, but we did note a mild eosinophilia that disappeared after the patient recovered from his symptoms. Outcome of the disease in humans is generally benign. Treatment includes removal of the larvae and, in some cases, prevention of local infections. Ivermectin has also been found useful in animal and human infections (10). To our knowledge, this is the first case of human oestrosis on the Canary Islands, as well as the first human case described with eosinophilia. Physicians should be aware of the possibility of this disease in our region and of the fact that a serologic test is available for its diagnosis.