Genetic characteristics of VanA-type vancomycin-resistant Enterococcus faecalis and Enterococcus faecium in Cuba.

VanA-type vancomycin-resistant enterococci isolates from bloodstream infections in Cuba were genetically characterized. Enterococcus faecalis isolates were assigned to sequence type (ST) 28, closely related to Eastern Europe, while Enterococcus faecium belonged to ST262, ST656 and ST1349, and showed different genetic profiles.

High prevalence of bla OXA-23 in Acinetobacter spp. and detection of bla NDM-1 in A. soli in Cuba: report from National Surveillance Program (2010-2012).

As a first national surveillance of Acinetobacter in Cuba, a total of 500 Acinetobacter spp. isolates recovered from 30 hospitals between 2010 and 2012 were studied. Acinetobacter baumannii-calcoaceticus complex accounted for 96.4% of all the Acinetobacter isolates, while other species were detected at low frequency (A. junii 1.6%, A. lwoffii 1%, A. haemolyticus 0.8%, A. soli 0.2%). Resistance rates of isolates were 34-61% to third-generation cephalosporins, 49-50% to ß-lactams/inhibitor combinations, 42-47% to aminoglycosides, 42-44% to carbapenems and 55% to ciprofloxacin. However, resistance rates to colistin, doxycycline, tetracycline and rifampin were less than 5%. Among carbapenem-resistant isolates, 75% harboured different bla OXA genes (OXA-23, 73%; OXA-24, 18%; OXA-58, 3%). The bla NDM-1 gene was identified in an A. soli strain, of which the species was confirmed by sequence analysis of 16S rRNA gene, rpoB, rpoB-rpoC and rpoL-rpoB intergenic spacer regions and gyrB. The sequences of bla NDM-1 and its surrounding genes were identical to those reported for plasmids of A. baumannii and A. lwoffi strains. This is the first report of bla NDM-1 in A. soli, together with a high prevalence of OXA-23 carbapenemase for carbapenem resistance in Acinetobacter spp. in Cuba.

Emergence of Klebsiella pneumoniae clinical isolates producing KPC-2 carbapenemase in Cuba.

The emergence of Klebsiella pneumoniae producing carbapenemase (KPC) has now become a global concern. As a part of a nationwide multicentre surveillance study in Cuba, three K. pneumoniae clinical isolates resistant to carbapenems were detected for a 1-month period (September to October 2011). PCR and sequence analysis revealed that the three strains harboured bla KPC-2. They showed resistance or intermediate susceptibility to expanded-spectrum cephalosporins, other ß-lactams, a ß-lactam/ß-lactamase inhibitor combination, and gentamicin. Two strains were susceptible only to colistin, whereas the other strain showing colistin resistance was susceptible to fluoroquinolones. These bla KPC -2-positive K. pneumoniae strains were classified into ST1271 (CC29), a novel clone harbouring bla KPC -2, and were revealed to be genetically identical by PCR-based DNA fingerprinting. The three patients infected with the KPC-producing K. pneumoniae had common risk factors, and had no overseas travel experience outside Cuba, suggesting local acquisition of the resistant pathogen. This is the first report of a KPC-producing K. pneumoniae in Cuba. Although detection of KPC in Enterobacteriaceae is still rare in Cuba, our finding indicated that KPC-producing bacteria are a global concern and highlighted the need to identify these microorganisms in clinical laboratories.

Focal cortical dysplasia. Clinical-radiological-pathological associations.

INTRODUCTION: The term focal cortical dysplasia (FCD) describes a particular migration disorder with a symptomatology mainly characterised by drug-resistant epileptic seizures, typical neuroradiological images, and histological characteristics, as well as a very positive response to surgical treatment in the majority of cases. MATERIAL AND METHODS: A total of 7 patients were studied, comprising 6 children with a mean age of 34.3 months and one 25-year-old male with very persistent focal seizures and MRI images that showed FCD. RESULTS: Three of the patients (all girls) were operated on while very young, with extirpation of the FCD and the surrounding area; with the histopathology study showed agreement between the MRI images and the macroscopic study of the slices. The histology study showed findings typical of a Taylor-type FCD (poor differentiation between the cortical grey matter and the subcortical white matter, and balloon cells). Three years after the FCD extirpation, the same 3 patients remained seizure-free with no anti-epilepsy medication. Two others have seizure control with medication, another (the adult) is on the surgical waiting list, and the remaining patient refused the operation. CONCLUSION: Taylor-type FCD is associated with a high percentage of all drug-resistant focal seizures, and it needs to be identified and extirpated as soon as possible. Well planned and well-performed surgery that leaves no remains of dysplasia can cure the disease it in many cases.

Schizencephaly: a study of 16 patients.

OBJECTIVE: To present 16 patients with schizencephaly and neurological involvement, and analyse their characteristics and neuroimages. MATERIAL AND METHODS: The study included 16 patients, 8 males and 8 females, all of whom were diagnosed with schizencephaly at less than 3 years of age; 2 patients were diagnosed prenatally. Schizencephaly was identified by computerized tomography (CT) in 1 patient and by MR or three-dimensional MR (3DMR) with a 1.5tesla apparatus in the others. Most patients were referred for evaluation because of psychomotor delay, motor disabilities and/or seizures. RESULTS: Five patients had bilateral schizencephaly with open lips (2 of them had suffered intrauterine cytomegalovirus infections); 2 showed unilateral schizencephaly with separated lips, 8 presented unilateral schizencephaly with fused lips, and 1 had schizencephaly with open lips on one side and fused lips on the other. Prenatal cytomegalovirus infection was diagnosed in 2 patients. A cerebral malformation that affected the midline was diagnosed by routine ultrasound studies in 2 patients. Eight patients (50%) presented with seizures that were focal, except for one patient who showed secondary generalisation. The latter was the only patient whose disease was refractory to complete seizure control with antiepileptic medication. All patients had some degree of motor deficit, which was either unilateral (hemiparesis) or bilateral (tetraparesis). CONCLUSION: 3D MR imaging was very important in diagnosing of schizencephaly in our patients because it showed the polymicrogyria that covered the area of the cleft and permitted us to rule out porencephaly. Neuronal migration disorders such as heterotopias and, more frequently, cortical dysplasias, were observed in several patients. Half of the patients had epilepsy which was controlled with antiepileptic medication, except in 1 patient.

Abnormalities of the spinal dura mater: are multiple clinical syndromes with dural lesions associated with abnormal connective tissue?

We review several clinical and radiological entities that present with abnormalities of the spinal dura that may be related to each other. These include: the syndrome of spontaneous intracranial hypotension, neuroenteric cysts, spontaneous spinal cord herniation, degenerative disc disease associated with disc clefts or associated with intradural complications, and Hirayama disease. Our observations focus on common imaging findings of dural tears, abnormal peridural fluid and associated degenerative disc disease. We propose that T2 fat sat sequences should be routinely used in spinal imaging protocols to evaluate extradural fluid.

Dramatic dilatation of the upper airway secondary to a Valsalva manoeuvre in a lateral cephalometric teleradiograph of a child.

Radiographs are routinely used by orthodontists for the planning of treatment for their patients and they can, in some cases, play a decisive role in the early diagnosis of some unexpected medical or surgical disorders. This report presents the case of a substantial dilatation of the upper airway in a 10-year-old girl, which was attributed to a forced Valsalva manoeuvre. The diagnosis was confirmed upon repetition of the teleradiograph with the mouth open.

Congenital and evolving vascular disorders associated with cutaneous hemangiomas: case report.

Conventional arteriography in an 11-month-old boy with cardiopathy, aortic arch coarctation and haemangiomas showed the absence of the right internal carotid and vertebral arteries, hypertrophy of the right external carotid artery, with enlargement of the internal maxillary and ophthalmic arteries that supplied the right cerebral hemisphere. An MRI study showed an infarcted area in the posterior zone of the left cerebral hemisphere vascularised by the middle cerebral artery that was caused by a thrombosis during a severe bout of gastroenteritis. MRA studies performed at 16 and 23 years of age revealed progressive narrowing of the left carotid and vertebral arteries, persistence of the proatlantal and trigeminal arteries, and poor cerebral vascularisation that, at adult age, was entirely supplied through collateral arteries, branches of both external carotids, the presence of unilateral duplication of the vertebral arteries and ascending pharyngeal artery.

Formulation and characterization of nystatin gel

The main objective of this research is to develop and characterize a series of carbopol 934 (CP) hydroxypropyl methylcellulose (HPMC) and a combination of carbopol-HPMC as a gel base for topical delivery of nystatin. The drug level was held constant at 1.72% w/w and the level of propylene glycol which is used as a co-solvent and penetration enhancer was also kept constant at 2% w/w. The total level of the polymer was held constant at 1.5% w/w as a single polymer or combination of two polymers. The polymers combination selected were: carbopol 934 to HPMC at a ratio of 0:1, 1:0, 1:2, 2:1 and 1:1. The batch size was 500 g and triethanolamine was used to adjust the pH of the gel. The rheological study showed that formulation containing combination of 2 carbopol and 1 HPMC ratio gave the highest viscosity, and exhibited an apparent pseudoplastic thixotropic behavior. The diffusion study indicated that gel formulation containing carbopol-HPMC at a ratio of 2:1 gave the highest percent drug diffusion compared to formulation containing low carbopol to HPMC ratio, carbopol alone or HPMC alone. Both in-vitro release and rheological study indicated that carbopol-HPMC had the best gel strength, physical properties and ability to diffuse the drug than carbopol or HPMC alone. The results obtained in this study demonstrated that the combination of carbopol and hydroxypropyl methylcellulose can be used as a gel vehicle for nystatin topical application.

[Spinal subarachnoid hematoma after lumbar puncture in a patient with leukemia: report of a case and review of the literature]. / Hematoma subaracnoideo espinal tras punción lumbar en paciente con leucemia: presentación de un caso y revisión de la literatura.

Acute myeloradicular compression due to a spinal subarachnoid hematoma (SSAH) after lumbar puncture (LP) is an extremely rare complication. Several risk factors have been involved in the production of these hematomas, mainly the presence of hemostasis disorders in the patient. We report the case of a 20-year-old man with leukemia and thrombocytopenia (26,000 platelets/mm(3)) who, after undergoing a LP, developed paraparesis and became unable to stand. A magnetic resonance disclosed the presence of a ventral intradural hematoma from D12 to L4. An emergency decompressive laminectomy was performed and a hematoma located in the subarachnoid space was partially removed. On the fourth postoperative day, the patient was able to walk without assistance, but one month later, he died because of systemic complications of his disease. Only 26 cases of SSAH after LP have been found in the literature review we have performed. In most of them, the following common features have been observed: association with anticoagulant therapies, association with thrombocytopenia, delayed onset of compressive myeloradicular syndrome, need of surgical treatment, good functional outcome in half of patients, and short life expectancy for patients with previous serious illness. Risk for developing a SSAH after LP could be high in leukemia patients with a tendency to have severe thrombocytopenia (perhaps less than 25,000 platelets/mm(3)).

[Aphasias for verbal and sign languages are due to lesions of nearly localised but not identical brain regions of the left hemisphere]. / Las afasias para lenguaje oral y de signos se producen por lesión de estructuras cercanas pero no idénticas del hemisferio dominante.

OBJECTIVES: To study the characteristics of verbal and sign language aphasia in a patient fluent in both languages, who had had a recent left hemisphere stroke as well as to localise the site responsible for Spanish sign language aphasia. PATIENT AND METHODS: 56 years old male, with risk factors for stroke, who presented an episode of sudden onset aphasia and right hemiplegia that partially recovered in a few hours. The residual deficit of language was explored with a detailed protocol that included comprehension, denomination, oral and phonetic praxis, propositional and automatic spontaneous language, reading and writing tasks. The examination of verbal and sign language was video-recorded. The lesion was localised by magnetic resonance imaging 24 days after the stroke. RESULTS: The patient, whose infarction involved the superior temporal gyrus and sylvian operculum, presented similar abnormalities for comprehension of complex sentences, many phonemic paraphasias and no trouble to repeat single words. Oral language was not fluent, but sign language was quite fluent with a rich vocabulary, but with semantic paraphasias, agrammatism and without self-criticism for his own mistakes. CONCLUSIONS: The pattern of oral and sign language alterations is partially different, more for expressive than perceptive discourse, although both types of aphasias are caused by lesions of the left hemisphere. The regions responsible for these abnormalities of both symbolic languages are localised close to each other, but not in the same place.

Vertebroplasty in the treatment of vertebral tumors: postprocedural outcome and quality of life.

The results of percutaneous vertebroplasty with polymethylmethacrylate (PMMA) of vertebral metastases were evaluated by a retrospective review of a consecutive series of 21 patients, with special reference to functional outcome. Patients complained of vertebral pain in all cases. Walking was impossible for 13 patients. Ten patients presented neurological deficit. Treatment included percutaneous vertebroplasty in all patients, radiotherapy in 15 patients and neural decompression surgery in 3 patients. Mean duration of hospitalization was 14.1 days (range 2-60 days) and the mean follow-up was 5.6 months (range 1-18 months). Preprocedural pain, measured by the visual analog scale (VAS), was 9.1, decreasing to 3.2 after the procedure and 2.8 at the last follow-up visit. Morphinics were discontinued in 7 of 14 patients following discharge from hospital. Ten out of 13 (77%) patients recovered walking capacity. Neurological status improved in three out of five patients. No further vertebral compression occurred in the vertebrae treated. Overall, 81% of the patients in this study were satisfied or very satisfied with the procedure. One patient (5%) had transitory radicular neuritis after the procedure. No major complications were observed. In conclusion, percutaneous vertebroplasty with PMMA proved to be safe and beneficial, providing significant and early improvement in the functional status of patients with spinal metastasis.

Percutaneous vertebroplasty: long-term clinical and radiological outcome.

We assessed radiographic and functional outcome in 13 patients with a minimum of 5 years follow-up from a prospectively monitored series of 17 patients who underwent percutaneous vertebroplasty (PPV). A visual analogue scale (VAS) and the short McGill questionnaire (MPQ) were used to assess average symptoms. The VAS showed significant improvement after treatment: the initial score was 9.07+/-0.6 (mean+/-SD), falling to 2.07 (1.14) on the third day, 1.07 (1.07) by the third month and 2.15 (2.6) at 5 years. Pain reduction was statistically significant ( P<0.001). The MPQ showed a significant improvement after treatment ( P<0.001), but had worsened by the last follow-up. All patients were "very" or "somewhat satisfied" with the procedure. We saw no further collapse of the vertebrae injected or migration or changes in the shape of the cement. A new fracture was seen in three patients, affecting four vertebrae, only two of which were adjacent to the treated level. On CT following the procedure, there was cement in the epidural veins adjacent to the vertebra in 48% of cases, but only patient developed a transitory neuritis.

[Quality of clinical trials published in Spain on asthma in comparison to trials in English language journals]. / Calidad de los ensayos clínicos publicados en España sobre el asma: comparación con los ensayos clínicos publicados en revistas anglosajonas.

OBJECTIVES: To evaluate the quality of clinical trials on asthma published in Spanish journals in comparison with those published in European or North American English-language journals. METHOD: Clinical trials were identified by searching MEDLINE and the Spanish Medical Index (Indice Médico Español), and by manual searches for trials mentioned in the bibliographies of the previously identified trials. Quality was assessed by the method proposed by Detsky and colleagues in their 1992 article in Journal of Clinical Epidemiology. RESULTS: The articles published in Spanish journals had lower mean quality scores than those in European or North American English-language journals. Trials published in Spain were less likely to give certain details of methodology, including ethics committee approval, details of randomization or patient enrollment and blinding. Among trials published in Spain, those with non-Spanish authors had lower mean quality scores. CONCLUSION: Clinical trials published in Spain on asthma treatments are of poorer quality than those published in English-language journals. Editors should consider using clinical trial quality checklists during the peer review process to raise the standards for published articles.

[Nasal carriers of methicillin-resistant Staphylococcus aureus among cuban children attending day-care centers]. / Portadores nasales de Staphylococcus aureus resistente a la meticilina entre niños cubanos que asisten a círculos infantiles.

BACKGROUND: Recent but scarce reports of methicillin-resistant Staphylococcus aureus strains (MRSA) among children without risk factors associated with its acquisition prompted us to investigate its presence in the community. PATIENTS AND METHODS: During the September and October months in 1997, nasal and pharyngeal swabs were obtained from 358 children aged less than five years who attended three day-care centers in the Marianao Area, La Habana City, Cuba. The isolated S. aureus strains were characterized for antimicrobial sensitivity using the Kirby-Bauer method. Methicillin resistance was confirmed by te Oxacillin Salt-Agar Screening-Plate method recommended by the National Committee for Clinical Laboratory Standards. RESULTS: 18.7% of children were carriers of S. aureus in the upper respiratory tract; 2.2% of children carried MRSA strains. The highest resistance levels corresponded to erythromycin (50.74%) and tetracycline (29.9%). All tested strains were sensitive to ciprofloxacin. CONCLUSIONS: Our results provide evidence on the recovery of MRSA strains among healthy children attending day-care centers and are suggestive of a rapid colonization and spread of these microorganisms in the community.

[Arachnoiditis and intraspinal lesion. Complications of tuberculous meningitis in 2 patients with human immunodeficiency virus infection]. / Aracnoiditis y lesión intramedular. Complicaciones de la meningitis tuberculosa en dos pacientes con infección por el virus de la inmunodeficiencia humana.

Radiculomyelitis (arachnoiditis) (RMA) is a severe complication of tuberculous meningitis (TM). Two patients with HIV infection and TM are here reported. These patients developed RMA. In Spain only four cases of RMA have previously been reported (only one of them was HIV-positive). Clinical manifestations (subacute paraplegia, radicular pain, sensitive level and neurogenic bladder) are reported. Cerebrospinal fluid had inflammatory features, wit predominance of mononuclear cells and remarkable increase in protein content. Magnetic resonance imaging (MRI) is the most suitable diagnostic method. The therapeutic possibilities of this complication are discussed.

[Contact urticaria, rhinoconjunctivitis and bronchial asthma from occupational use of papain]. / Urticaria de contacto, rinoconjuntivis y asma bronquial ocupacional por papaína.

Papain is a plant protein with a wide pharmacological, domestic and industrial use. It leads a high sensitisation, being the most common rotue of entry the inhalation. The occupational allergy to papain in exposed workers was described some years ago, being presented with bronchial asthma, rhinitis or both. In most of the cases, the specific IgE was positive. We present a case contact urticaria, rhinoconjunctivitis and bronchial asthma per papain of occupational origin. Papain prick test, specific IgE and nasal challenge were positive. The peak flow record showed diary decreases during the working week and the basal spirometry showed obstruction to the airflow. The patient was moved away the place where papain was handled and this resolved the clinical symptoms and the spirometry returns to the normal values. We present a case of IgE-mediated allergy, vehicled by tow routes: contact and airborne. The latest produced clinical manifestations later. Papain was used as Cephalopoda softening, because of that it worth emphasising its seasonal use.