RESUMEN
BACKGROUND: Glycopeptides are often used for persistent fever in neutropenic patients. This study compares efficacy and toxicity of teicoplanin and vancomycin. PATIENTS AND METHODS: Hundred consecutive neutropenic patients with hematological malignancies and persistent fever after 72 h of first-line antibiotic therapy (91% piperacillin/tazobactam) were treated with teicoplanin (800 mg on day 1, then 400 mg/day)+piperacillin/tazobactam+gentamicin from 08/96 to 09/00 (group T) or with vancomycin (2 g/day)+meropenem+levofloxacin from 10/00 to 04/02 (group V). Success was defervescence (>or=7 days) in absence of any sign of continuing infection. Nephrotoxicity was monitored daily as increase in serum creatinine. RESULTS: Fifty patients were analyzed in each group. Efficacy was evaluated in patients with piperacillin/tazobactam as first-line therapy only. Treatment was successful in 76% in group T (n=42) and 59% in group V (n=49), p=0.118. Toxicity was evaluated in all patients. The median increase of creatinine was 11% (interquartile range 0%-30%) in group T and 17% (0%-74%) in group V, p=0.062. In patients who received concomitant amphotericin B (given for 7 days and 6 days, respectively, p=0.525), median creatinine increased from 0.9 mg/dl (0.8-1.1) to 1.2 mg/dl (0.9-1.5) in group T and from 0.9 mg/dl (0.8-1.08) to 1.55 mg/dl (1.33-2.23) in group V (p<0.001). This led to a doubling of creatinine in 2/23 (9%) patients of group T and in 9/16 (56%) patients of group V (p=0.003). A multivariate analysis revealed that concomitant use of amphotericin B (p<0.001) and treatment with vancomycin (p=0.002) were independently associated with nephrotoxicity. CONCLUSION: Teicoplanin and vancomycin were comparably effective in patients with neutropenia and persistent fever, but - if combined with amphotericin B - vancomycin was significantly more nephrotoxic than teicoplanin.
Asunto(s)
Antibacterianos/uso terapéutico , Infecciones/tratamiento farmacológico , Riñón/efectos de los fármacos , Neutropenia/etiología , Teicoplanina/uso terapéutico , Vancomicina/uso terapéutico , Antibacterianos/efectos adversos , Creatina/sangre , Quimioterapia Combinada , Femenino , Fiebre/etiología , Fiebre de Origen Desconocido/etiología , Humanos , Infecciones/etiología , Masculino , Persona de Mediana Edad , Análisis Multivariante , Teicoplanina/efectos adversos , Vancomicina/efectos adversosRESUMEN
Serious postoperative psycho-neurological dysfunction is at least partially attributed to the occurrence of gaseous microbubbles in the arterial line of extracorporeal circulation (ECC). Therefore, we investigated in a prospective randomized double blind study whether the usage of dynamic bubble trap (DBT) will reduce microbubble load of patients undergoing aortic valve replacement. Patients (n = 41) were divided into group I (GI, n = 22) with DBT introduced into the arterial line of ECC and group II (GII, n = 19) with placebo-DBT instead. Doppler ultrasonography was used for detection of microbubbles before and after DBT, and for detection of high intensity transient signals (HITS) within the middle cerebral artery. The recording time during ECC was divided into period 1 (P1, until aortic clamp removal) and period 2 (P2, clamp removal until the end of ECC). A significant reduction of microbubble load was found in GI only (p < 0.0001 for ECC; p < 0.0001 for P1; p < 0.0025 for P2). A significant difference in number of HITS between the groups was observed in P1 only (p < 0.002 left middle cerebral artery, p < 0.005 right middle cerebral artery), since in P2 the trapped air in left chamber can go to the supraaortal vessels without passing ECC. In conclusion the use of DBT cannot substitute careful venting after aortic declamping. Nevertheless, reduction of HITS in the cross-clamped period of ECC justifies the use of DBT in patients undergoing open chamber surgery.
Asunto(s)
Válvula Aórtica/patología , Prótesis Valvulares Cardíacas , Microburbujas , Aorta/patología , Método Doble Ciego , Embolia Aérea , Circulación Extracorporea , Femenino , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Masculino , Modelos Estadísticos , Estudios Prospectivos , Ultrasonografía Doppler Transcraneal/métodosRESUMEN
Air microbubbles mostly occur unnoticed during cardiopulmonary bypass and are predominantly responsible for serious postoperative psychoneurological dysfunction. A dynamic bubble trap (DBT), which removes air microbubbles from the arterial blood, was tested in a clinical study. The aim was to evaluate the efficiency of microbubble removal under clinical conditions. As blood passes through the DBT, which is placed in the arterial line between the arterial filter and arterial cannula, it is converted into a rotating stream. The bubbles are directed to the centre of the blood flow and are collected in the distal end of the DBT, from where they are returned to the cardiotomy reservoir. Doppler ultrasonography was used to detect the microbubbles before and after the DBT, and also the number of high-intensity transient signals (HITS) in the right and left middle cerebral artery during extracorporeal circulation. A significant reduction of microbubbles in the arterial line (3,990 before DBT, 537 after, p < 0.001) and HITS in the brain (51 in the DBT group, 77 in the placebo group, p = 0.04) was measured.
Asunto(s)
Daño Encefálico Crónico/prevención & control , Puente Cardiopulmonar/instrumentación , Embolia Aérea/prevención & control , Embolia Intracraneal/prevención & control , Complicaciones Intraoperatorias/prevención & control , Complicaciones Posoperatorias/prevención & control , Adulto , Anciano , Materiales Biocompatibles , Daño Encefálico Crónico/etiología , Catéteres de Permanencia , Arterias Cerebrales/diagnóstico por imagen , Activación de Complemento , Embolia Aérea/complicaciones , Diseño de Equipo , Femenino , Filtración , Hemostasis , Humanos , Embolia Intracraneal/etiología , Masculino , Ultrasonografía DopplerRESUMEN
The acute influence of therapeutic doses of theophylline on cerebral blood flow velocities during general anaesthesia induced either by halothane or isoflurane has not been elucidated previously. The aim of this study, was therefore to investigate these effects during steady state anaesthetic conditions in anaesthetized patients using transcranial Doppler sonography. Thirty-four Patients were investigated. Anaesthesia was maintained either with 1 MAC (minimum alveolar concentration) halothane (n = 16) or 1 MAC isoflurane (n = 18); FiO2: 40%; end-expiratory pCO2: normocapnia. Theophylline administration was performed before surgery by infusing 6 mg kg-1 over a period of 7.5 min. Measurements were recorded prior to theophylline administration, and immediately after 2 mg kg-1 (2.5 min), 4 mg kg-1 (5 min) and 6 mg kg-1 (7.5 min), as well as 5, 10, 15, 20, 30 and 45 min after theophylline administration. Recorded variables included blood pressure, heart rate, arterial oxygen saturation, end-expiratory pCO2, body temperatures, middle cerebral artery blood flow velocity and pulsatility index. Theophylline administration was well tolerated by all study subjects. Heart rate, blood pressure, body temperatures, arterial oxygen saturation and end-expiratory pCO2 remained constant during the whole examination period. Following theophylline, mean blood flow velocity decreased by 25% in the halothane and by 30% in the isoflurane group (P < 0.05). By the end of the examination period, mean blood flow velocity had not yet recovered to the initial values whereby in both groups the mean blood flow velocity was 26% below the initial values. In the isoflurane group, the pulsatility index increased by about 20% (P < 0.05) and remained high until the end of the examination. In the halothane group, however, there were no changes in the pulsatility index. Our results show a remarkable, significant and simultaneous decrease in blood flow velocity in the middle cerebral artery associated with theophylline administration during halothane and isoflurane anaesthesia in man.
Asunto(s)
Anestesia General , Anestésicos por Inhalación , Velocidad del Flujo Sanguíneo/efectos de los fármacos , Circulación Cerebrovascular/efectos de los fármacos , Halotano , Isoflurano , Teofilina/farmacología , Vasodilatadores/farmacología , Adulto , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Flujo Pulsátil , Ultrasonografía Doppler TranscranealRESUMEN
OBJECTIVE: Quantifying the influence of extreme isovolemic hemodilution (NH) with different colloids on cerebral blood flow velocities (transcranial Doppler sonography) and cutaneous microcirculatory blood flow (laser Doppler flowmetry) in healthy, non-premedicated volunteers was the aim of this study. METHODS: In seven volunteers (randomized cross-over design) 20 ml/kg blood was withdrawn within 30 min and simultaneously replaced with 6% hydroxyethyl starch (200,000/0.5, HES) or 3% gelatin (GEL). Thirty minutes later, the autologous blood was retransfused (RT) within 30 min. Due to a severe allergic reaction to gelatin in one volunteer, only 6 GEL-NH were evaluated. Recorded parameters were: mean blood flow velocities (Vm-MCA) as well as the pulsatility index (PI) and the resistance index (RI) over the middle cerebral artery. In addition laser Doppler flux (FLUX), cell velocity (SPEED), mean arterial pressure (MAP), heart rate (HR), hemoglobin (Hb) and hematocrit (Hc) were monitored. RESULTS: NH resulted in a withdrawal volume of 1498 +/- 85 ml (HES) and 1493 +/- 95 ml (GEL), (mean +/- SD) and induced a decrease in hemoglobin from 40.9 to 29.0% (HES) and from 39.8 to 30.0% (GEL). RT increased Hc to 34.2% (HES) and 34.5% (GEL). MAP and HR showed no significant alterations in both groups. Following NH, Vm-MCA rose almost the same way in either case (26% HES), 21% (GEL), but decreased continuously again during RT. After completing RT, only in the HES group Vm-MCA still remained higher than baseline values (14% HES, only 3% GEL). Similar inverse regression lines were found for the two groups between Hc and Vm-MCA: [Vm-MCAHES (cm/s) = -1.27 x Hc + 110.9; r = 0.98, P < 0.001 and Vm-MCAGEL (cm/s) = -1.32 x Hc + 110.9; r = 0.91, P < 0.001]. Furthermore, as a result of NH, FLUX and SPEED increased about 61% and 38% in the HES group and remained on higher values in comparison with starting positions (21% FLUX, 13% SPEED). However, the results in the GEL group were of a different kind: FLUX and SPEED increased stupendously to 291% and 114% combined with NH, but both were reduced by RT on a large scale (39 and 27% below baseline values). Whereas RI showed no group differences, there was a remarkable drop in PI during RT (17% HES, 12% GEL). CONCLUSION: The two plasma expanders studied show a close inverse correlation between the alterations of blood flow velocities in the middle cerebral artery and systemic hemoglobin and hematocrit values. In both groups the change in blood flow velocities is comparable. For the first time the results of relative changes in blood flow velocities following hemodilution and retransfusion in healthy volunteers are described that correspond closely by relative cerebral blood flow alterations found in animal studies as well. Moreover, a non-linear correlation of cutaneous microcirculation was shown by means of HES, but also by GEL. Obviously, there was the GEL group to be responsible for pronounced differences in cutaneous circulation.
Asunto(s)
Circulación Cerebrovascular/efectos de los fármacos , Gelatina/efectos adversos , Hemodilución/efectos adversos , Derivados de Hidroxietil Almidón/efectos adversos , Sustitutos del Plasma/efectos adversos , Piel/irrigación sanguínea , Adulto , Estudios Cruzados , Hematócrito , Hemodinámica/efectos de los fármacos , Hemoglobinas/metabolismo , Humanos , Masculino , Microcirculación/efectos de los fármacosRESUMEN
Sera of patients infected with Schistosoma japonicum, S. mansoni or S. haematobium were tested in an indirect haemagglutination assay (IHA) using soluble S. japonicum egg antigen (SjSEA) and soluble S. mansoni adult antigen prepared either from a Puerto Rican strain (SmAWA) or an Egyptian strain (SmBW; Cellognost-Schistosomiasis Kit). Reactions were best, in terms of titres and sensitivity, in homologous systems. Heterologous systems were less reliable, particularly those using sera from urinary schistosomiasis patients. It is suggested that IHA is a suitable test to detect Schistosoma infections, especially when homologous systems are used.
Asunto(s)
Antígenos Helmínticos/inmunología , Schistosoma japonicum/inmunología , Schistosoma mansoni/inmunología , Animales , Heces/parasitología , Pruebas de Hemaglutinación , Humanos , Recuento de Huevos de Parásitos , Orina/parasitologíaRESUMEN
The infestation by the larva of Echinococcus multilocularis, also known as alveolar echinococcosis, is the most dangerous parasitic disease of man in Middle Europe. This is due to the location in the liver but still more so because of the proliferative and infiltrating growth of the larval tissue. The basic infective cycle of the parasite is a zoonosis between foxes as final hosts and small rodents such as common voles as intermediate hosts. Man can be a false intermediate host and thus a carrier of the larval stage. The infection arises from oral ingestion of the tapeworm eggs either on wild berries or in dust. Dogs and cats are a further important source of infection. They can be facultative carriers of adult E. multilocularis and are thus able to excrete eggs or proglottids of the tapeworm. In west Germany, in particular the "Schwäbische Alb" must be regarded as an endemic region for E. multilocularis. According to the examinations of Zeyhle, the infection rate of foxes here is more than 15% on an average, in some local areas as for example in the district of Reutlingen it is over 25%. In order to estimate the danger of infection for man in hyperendemic areas the population of two villages of this district and also specially endangered occupational groups (hunters, foresters) of the whole "Schwäbische Alb" have been examined for echinococcosis by serological means. A stepless ELISA was used as screening test. Thus circa 2200 persons liable to E. multilocularis could be examined. Among the population of the district of Reutlingen nine highly suspective sera could be detected. Computer tomography of these nine persons showed only one case of Echinococcus which could be identified as E. multilocularis after operation. Presumably serological positive cases come up as a consequence of a real contact with E. multilocularis. But in most cases the larval cestode tissue might soon degenerate because man is a relatively poor intermediate host. It cannot be excluded, however, that the Echinococcus-larva could not yet be identified clinically because of its early stage. According to most cautious estimation the prevalence of E. multilocularis in this endemic area might be one per thousand, the contact frequency, however, up to one per cent.