Rapid identification, capsular typing and molecular characterization of Streptococcus pneumoniae by using whole genome nanopore sequencing.

BACKGROUND: Whole genome sequencing has emerged as a useful tool for identification and molecular characterization of pathogens. MinION (Oxford Nanopore) is a real-time third generation sequencer whose portability, affordability and speed in data production make of it an attractive device for whole genome sequencing. The objective of this study is to evaluate MinION sequencer for pathogen identification and molecular characterization of Streptococcus pneumoniae isolated at a children's Hospital. Whole genome sequencing of 32 Streptococcus pneumoniae invasive isolates, previously characterized by standard methods (Quellung reaction, Multiplex PCR and Sanger-MLST), were performed. DNA was extracted using ZymoBIOMICS DNA Microprep kit. Quantification and purity of DNA was assessed by Qubit and Nanodrop, respectively. Library preparation was performed using the Rapid Barcoding Kit. Real-time workflow EPI2ME platform "What's it in my pot" was used for species identification. Fast5 sequences were converted into FASTQ by Albacore software. Reads were assembled using CANU software. PathogenWatch, genomic epidemiology and pubmlst online tools were used for capsular typing and/or whole genome-MLST profile. RESULTS: Rapid identification of Streptococcus pneumoniae was achieved by "What's in my pot". Capsular typing was correctly assigned with PathogenWatch in all 32 isolates at serogroup level and 24 at serotype level. Whole genome-MLST results obtained by genomic epidemiology and pubmlst were consistent with double locus variant clonal complex obtained by Sanger-MLST in 31 isolates. CONCLUSION: MinION sequencer provides a rapid, cost-effective and promising pathway for performing WGS by a pocked-sized device for epidemiological purposes but improving its sequencing accuracy will make it more appealing to be used in clinical microbiology laboratories.

Head trauma in the haemophilic child and management in a paediatric emergency department: Descriptive study.

INTRODUCTION: Haemophilia is one of the most common inherited bleeding disorders in the Emergency Department (ED). The most dangerous site of bleeding is the central nervous system. AIMS: To describe the characteristics of haemophiliacs arrived to our ED following a head trauma and to analyse the incidence of intracranial haemorrhage (ICH). MATERIALS AND METHODS: Retrospective, analytical, observational study, conducted in a Paediatric ED. We included haemophilic patients aged from birth to 16 years who consulted after a head trauma over a 6-year period. Data collected included age, type of haemophilia and head trauma, symptoms, prophylaxis status, CT imaging, treatment and number of visits to the ED. RESULTS: About 46 males and 85 episodes were analysed. The median age was 2.38 years. Severe haemophilia A was the most frequent type of disease (50%). All head injuries were mild, and the most frequent mechanism was a collision with an object (38.8%). In 62 episodes (72.9%) the patients were asymptomatic. The rest 23 events had symptomatology, being the most common headache (26%), emesis (21.7%) and drowsiness (17.4%). Head CT was obtained in 31 episodes, founding altered results in 10 (6 of them corresponding to ICH). All the patients with ICH had symptomatology. About 37 episodes required admission. CONCLUSION: Intracranial haemorrhage is one of the most dangerous events in haemophiliacs and it may occur after a head trauma. Our study suggests that, in case of head trauma, CT must be obtained in symptomatic patients and in those with additional risk factors. Asymptomatic patients must have prolonged observation.

A new method based on dispersive solid phase microextraction with commercial MOFs coupled to LC-MS/MS for the determination of isoflavones in soy drinks.

For the first time, a method based on dispersive solid phase microextraction (D-µSPE) using commercial metal-organic frameworks coupled to liquid chromatography-triple quadrupole tandem mass spectrometry (LC-MS/MS) has been proposed for the determination of isoflavones in soy drinks. The use of commercial sorbents simplifies the sample treatment procedure and allows their application to routine analysis. Optimization of the parameters involved in the microextraction process was carried out using a Box-Behnken experimental design. Under the optimized conditions, the limits of detection ranged between 2 and 7 µg L-1; the intra-day and inter-day precision were <10 and 20%, respectively, and the recoveries were in the range of 61-120%. No significant matrix effect was found, which allowed the use of external standard calibration method. The method was successfully applied to the determination of isoflavones in commercial soy milk samples.

[Childhood ischemic cerebrovascular disease in a paediatric emergency service: a descriptive study]. / Enfermedad cerebrovascular de tipo isquemico posnatal en urgencias pediatricas: estudio descriptivo.

AIM: To describe the clinical presentation, risk factors and complementary tests in patients of our paediatric emergency service with a final diagnosis of ischemic stroke. PATIENTS AND METHODS: Retrospective, analytical and observational study, performed in a Paediatric Emergency Service of a tertiary-level hospital. We included patients aged 1 month to 14 years during a 12-years period with a final diagnosis of ischemic cerebrovascular disease (CVD). We analyzed personal history, symptomatology and initial complementary tests. RESULTS: Twelve patients were included, 66% males, with a median age of 77 months. 42% had remarkable history. The most frequent clinical manifestation was motor disorder (75%). 42% were diagnosed in the first 24 hours, noticing an earlier diagnosis after the introduction of a multidisciplinary protocol about CVD. CT was performed in all patients, except in two cases in whom MRI was performed. 50% of the CTs were initially normal. In the etiological study developed lately, only 42% of the patients had risk factors. 91% had some kind of sequel. CONCLUSIONS: CVD is uncommon in pediatrics, but with a high morbimortality, so it is important to make an early diagnosis. Clinical and personal history are fundamental, nevertheless, we mainly deal with a previously healthy child without known risk factors at the time of the first evaluation. In case of clinical suspicion of stroke, a normal initial CT does not rule out a CVD, so other additional tests, such as MRI, are necessary.

TITLE: Enfermedad cerebrovascular de tipo isquemico posnatal en urgencias pediatricas: estudio descriptivo.Objetivo. Describir la presentacion clinica, los factores de riesgo y las pruebas complementarias realizadas en pacientes atendidos en urgencias con diagnostico de ictus isquemico. Pacientes y metodos. Estudio retrospectivo, analitico observacional, realizado en urgencias pediatricas de un hospital de tercer nivel. Se incluyeron pacientes entre 1 mes y 14 años durante 12 años, con diagnostico de enfermedad cerebrovascular (ECV) de tipo isquemico. Se analizaron los antecedentes personales, la sintomatologia y las pruebas complementarias iniciales. Resultados. Se recogieron 12 pacientes (66% varones), con una mediana de edad de 77 meses. El 42% presento algun antecedente reseñable. La manifestacion clinica mas frecuente fue la alteracion motora (75%). El 42% fueron diagnosticados en las primeras 24 horas, y se objetivo un diagnostico mas temprano tras la introduccion de un programa multidisciplinar sobre manejo de la ECV. En todos se realizo inicialmente una tomografia axial computarizada (TAC) craneal, salvo en dos casos en los que se hizo una resonancia magnetica. La mitad de las TAC fueron normales al inicio. En el estudio etiologico posterior se encontraron factores de riesgo solo en cinco pacientes (42%). El 91% presento algun tipo de secuela. Conclusiones. La ECV es poco frecuente en pediatria, con elevada morbimortalidad, y es importante realizar un adecuado diagnostico precoz. Son fundamentales la historia clinica y los antecedentes personales, aunque en la valoracion inicial es frecuente encontrarse ante niños sanos sin factores de riesgo conocidos en ese momento. Ante la sospecha clinica de ictus, una TAC craneal inicial normal no descarta una ECV y son necesarias otras pruebas, como la resonancia magnetica.

[Symptomatic secondary hyponatraemia due to combined treatment anticonvulsant and antidepressant: risk of sudden death in epilepsy?]. / Hiponatremia sintomática secundaria a tratamiento conjunto anticomicial y antidepresivo: ¿riesgo de muerte súbita en epilepsia?

The notable incidence of epilepsy in the general population, with the presence, more and more frequent of refractory therapeutic, it forces the anticonvulsant polytherapy. If we depart from the fact, that many of the epilepsies have a secondary cause, with affective disorders associate, we can understand the most habitual association of anticonvulsant and antidepressant. We present the clinical case of a 37-year-old-woman with refractory therapeutic epilepsy associated to exogenous depressive syndrome, in combined treatment with Carbamazepine, Lamotrigine and Venlafaxine, that suffers a episode of syncope secondary to symptomatic hyponatraemia, generated by syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The relevance of this case resides in the fact that the hyponatraemia generated by this pharmacological combination, up to now, it has not been described in the literature. This electrolytic anomaly can derive in secondary neurological and cardiovascular effects, in so outstanding occasions, as to produce the phenomenon denominated sudden death in the epileptic patient (SUDEP). We recommended a strict ionic control in those patients that require anti-epileptic and anti-depressant treatment combined, in order to avoiding paroxistic vascular episodes and to minimize the risk of SUDEP.

Primary Scarring Alopecia: Clinical-Pathological Review of 72 Cases and Review of the Literature.

PURPOSE OF THE STUDY: To analyze the epidemiologic, demographic, clinical, and histological characteristics of primary scarring alopecia (PSA) cases diagnosed over a 7-year period at the Department of Dermatology, Hospital Clinic, Barcelona, Spain. PROCEDURES: Seventy-two patients diagnosed with PSA between 2006 and 2012 were included. Age, sex, ethnic group, clinical pattern, predominant histological infiltrate, final clinical diagnosis, time of onset, treatments used, and clinical evolution were evaluated and correlated. RESULTS: The ethnic groups were distributed as follows: 93% European-Caucasian, 5% Mestizo-American, 1% oriental, and 1% Afro-American. Most cases were females (71%), and mean age was 51 ± 6 years. The follicular pattern was the most common, and the predominant inflammatory infiltrate was lymphocytic. Lichen planopilaris and frontal fibrosing alopecia were the main diagnoses. When correlating clinical aspects and histopathology, lymphocytic PSAs had a subacute onset and resulted in a nonchanging, more stable form, while neutrophilic PSAs had a more acute onset with an evolution of acute outbreaks. PSAs in a late stage with an absent/mild infiltrate had a subclinical onset and a slowly progressive or stable evolution. CONCLUSIONS: The PSAs are severe trichological conditions. Their high clinical and histopathological variability make them a diagnostic and therapeutic challenge. MESSAGE OF THE PAPER: Knowing the clinical and histopathological aspects of PSAs should be of crucial importance to the dermatologist.

[Utility of normality low limit of spirometry in diagnosed COPD patients]. / Utilidad del límite inferior de normalidad de la espirometría en pacientes diagnosticados de EPOC.

AIM: To evaluate the differences in COPD patients below the lower limit of normal (LLN) of the fixed ratio FEV1/FVC < 0.70 and those above this limit. PATIENTS AND METHODS: Cross-sectional study. COPD patients between 40 and 85 years old included in primary care clinical record database were randomly selected. Baseline and postbronchodilator spirometries were performed. Two groups of patients were established: FEV1/FVC<0.70 and ≤LIN (group1) and FEV/FVC<0.70 and >LIN (group 2). Sociodemographic, clinical, pulmonary obstruction, quality of life and attendance to health services variables were measured. The results of both groups were compared. RESULTS: 22.3% of the subjects were misdiagnosed FEV1/FVC < 0,70. Patients in group 2 (FEV1/FVC<0.70 y > LLN) are diagnosed at an older age, they have a lower exposure to tobacco and better pulmonary function (FEV1: 74.9% vs 54.6%). 35.5% of those patients belong to stage i of GOLD, vs 8.5%, this patients have an increased comorbidity. Patients in group 1 have more COPD exacerbations, worse quality of life, a higher BODEx index 2,3 (1.8) vs 1.1 (1.5); 55.1% of those patients were high risk patients (GoldC or Gold D). Diagnose before being 56 years old, an increased exposure to tobacco, the FEV>50%, and a lower comorbidity are associated with a greater chance of suffering COPD with LLN criteria. CONCLUSION: We obtain two groups of patients with differentiated clinical characteristics if we use LLN. Subjects with FEV1/FVC<0.7 and >LLN have less obstruction, less severity and more comorbidity, suggesting the possibility of overdiagnosis or misdiagnosis. On the other hand, younger age at the time of diagnosis, higher tobacco consumption and more severe obstruction are related with FEV1/FVC >0.70 and

[Inherited metabolic disorders in pediatric emergency services]. / Enfermedades metabólicas congénitas en un servicio de urgencias pediátricas.

INTRODUCTION: Advances in the early diagnosis and treatment have led to improved survival, and a better quality of life for patients with inherited metabolic disorders (IMD). They can go to the Pediatric Emergency Services (PES) for reasons unrelated to their disease. The purpose of this study was to review the characteristics of visitors to the PES of these patients in a tertiary hospital. MATERIAL AND METHODS: A retrospective observational study was conducted on all visits from patients with IMD to the PES of Hospital Infantil La Paz over the years 2011 and 2012. IMD type, complaint, duration of symptoms, need for hospitalization, and presence of metabolic decompensation was recorded. RESULTS: A total of 107 visits were analyzed, with the most frequent reason being for consultation of respiratory processes (30.8%). When the consultation was for vomiting, patients with protein-related disorders were those who delayed less in going to PES. One third of visitors were admitted, half of them due to metabolic decompensation of the underlying pathology. CONCLUSIONS: Patients with IMD came to PES for many different reasons, which in some cases were the cause or consequence of an acute metabolic decompensation that led to hospitalization. Being diseases with low prevalence, it would be useful to have diagnostic and therapeutic protocols in order to provide optimal care.

[Steroid treatment: risk factor for invasive pulmonary aspergillosis]. / Tratamiento esteroide: factor de riesgo para aspergilosis pulmonar invasiva.

To describe the association between invasive pulmonary aspergillosis and steroid treatment in patients with no immunodepression attributable to other causes. We reviewed the case histories of apparently non immunodepressed patients in our hospital with histological diagnoses of invasive pulmonary aspergillosis between 1992 through 1996. Seven patients were identified. Laboratory, clinical and radiological data were collected, as well as type and duration of steroid treatment. Four patients suffered underlying chronic obstructive pulmonary disease, 1 had temporal arteritis, 1 interstitial pulmonary fibrosis and 1 a neurological tumor. All had received steroid treatment for periods varying from several days to 16 months, at varying doses, although the majority of them were treated with 1mg/kg/day. All presented clinical profiles suggestive of pneumonia (5 community acquired and 2 nosocomial). Invasive pulmonary aspergillosis can appear in minimally immunocompromised patients, such as those undergoing steroid treatment and must be suspected whenever pneumonia is seen in patients receiving steroids who do not improve with widespectrum antibiotic treatment.

[Hepatocarcinoma: a rare form of presentation]. / Hepatocarcinoma: forma infrecuente de presentación.

A case of acute abdomen presenting with pain in the right upper abdomen, pyrexia and leukocytosis is presented. At laparotomy, hepatocarcinoma with necrosis and associated acute cholecystitis was found. This is apparently an unusual report of hepatocarcinoma presenting as acute cholecystitis.

[Management of colostomies with plug: clinical aspects and patient evaluation]. / Manejo de las colostomías mediante obturador: aspectos clínicos y evaluación de los pacientes.

AIM: To assess the effectiveness of the one-piece disposable plug device Conseal (Coloplast A/S, Espergaerd, Denmark) in colostomy patients, considering clinical and social aspects. PATIENTS AND METHODS: Twenty patients with definitive (perineal-abdominal amputation 17 cases) or transitory (Hartmann in 3 cases) colostomy were studied prospectively. No patient used self-irrigations. All of them completed the study. After obtaining the patient's consent, we analyzed for comfort, leaks, security, easy handling and skin conditions by means of personal interview and clinical examination. RESULTS: Sixteen patients (80%) had previously used conventional colostomy bags, 4 (20%) started to use the plug device during the postoperative period (average 8.7 days). Fifteen patients (75%) preferred to use the plug, whereas 5 (25%) considered the plug was insecure. CONCLUSIONS: Our study suggests that the one-piece disposable plug device improves the quality of life in patients with colostomy, although adequate selection of patients and previous training are mandatory.

[Three cases of mucolipidosis type III (author's transl)]. / Sialidosis tipo II o mucolipidosis III. A propósito de tres observaciones.

Three cases of mucolipidosis type III in three siblins ranging in age from 4 to 10 years are reported. One of them was severely involved; the other two in a lesser degree. The enzymatic studies performed are exposed, together with a discussion and interpretation of the findings. The concepts regarding the group of metabolic diseases among which mucolipidosis is nowadays included are reviewed. Some characteristics of the enzymatic disorder, origin of the disease, are finally commented.

[Respiratory function in pediatric survivors of malignant neoplasms]. / Función respiratoria en niños supervivientes de neoplasia maligna.

AIM: To evaluate post-treatment pulmonary function in patients with malignant extrapulmonary neoplasia and its relationship with age, type of neoplasty and treatment received. METHODS: Cohort study of 95 pediatric patients after chemotherapy with or without surgery or extrapulmonary thoracic radiotherapy. The patients were in remission without treatment and able to undergo pulmonary function testing. Personal history and exposure to risk factors or toxic habits were evaluated. Clinical examination, chest radiographs, pulmonary gammography, basal and stress pulmometry, forced spirometry, whole body phletismography and carbonmonoxide transfer test were performed. RESULTS: Mean age at diagnosis was 5 +/- 3.3 years. Treatment duration was 2.4 +/- 1.3 years and time without treatment 4.3 +/- 3. 3 years. Thirty-six patients were reviewed two and a half years after the first control. Thirty-nine patients had acute lymphoblastic leukemia and 57 had solid tumors. Sixty percent showed functional restriction due to chest deformity after undergoing chest surgery. The association between functional restriction and radiotherapy (6 patients) did not produce poorer functional results. Forty-three percent showed initial change in TLCO. Nineteen percent showed basal hemoglobin saturation under 93% which in 16% fell after physical exercise. These alterations improved with time. However, restrictive change initially present in 11.5% persisted at the second evaluation. Thoracic surgery was the main cause of thoracic deformity and therefore of restrictive change. The children under 8 years old and those who received longer treatments tended to show the worst TLCO values. The patients with neuroblastoma showed greater restrictive change while the change in TLCO was more frequent in patients with Burkitt s lymphoma and in those treated with cyclophosphamide. CONCLUSIONS: Neither personal or family history of respiratory disease nor the presence of symptoms such as cough served to identify risk of functional change. Restrictive change in pulmonary function was greater in patients who had undergone thoracic surgery. Functional values were worse in patients with neuroblastoma. Pulmonary function should be followed up in pediatric survivors of malignant neoplasia in order to prevent restrictive alterations.

[Medical pericarditis: study of 19 cases]. / Pericarditis médicas: estudio de 19 casos.

19 cases of medical pericarditis admitted to the PICU from 1978 to 1989 were reviewed, to asses the diagnostic and therapeutical approach. The overall incidence is low, 0.32% of the patients admitted to the PICU in that time period. We have found neither tuberculous nor purulent pericarditis, with a 42% of idiopatic forms. Echocardiography was the best method for syndromic diagnosis. The ethiological diagnosis of pericarditis was made, in most cases, by means of non invasive methods or in association with the underlying disease. The cualitative analysis of the pericardial fluid was not useful for the ethiological diagnosis, therefore, we suggest pericardiocentesis should be performed mainly as a therapeutical tool. There were no correlation between the amount of fluid obtained on the first pericardiocentesis and the later incidence of the pericardial effusion. Biopsy brought no ethiological specificity in the cases it was performed.

[Surgical treatment of congenital cardiopathies in the 1st year of life: experience in 893 treated cases]. / Tratamiento quirúrgico de las cardiopatías congénitas en el primer año de la vida: experiencia en 893 casos intervenidos.

We present a study of 893 infants treated surgically, of ages from 30 hours to 12 months old, with a global mortality rate of 23.1%. In 37.6% of the cases, a total correction of cardiopathy was reached, using closed techniques in 25.9% and open-heart surgery in 11.7%. Palliative techniques wer chosen in 62.3% of the patients. The highest mortality corresponds to those patients under one month old (40%), decreasing to 14% in the 7-12 month old group. Surgical indications and techniques used are commented in each group of cardiopathies, making special reference to post surgical care.

[Amino acid changes in blood of children with severe liver disease. The evaluation of differences according to distinct physiopathology]. / Alteraciones de los aminoácidos en sangre en niños con enfermedad hepática severa. Valoración de las diferencias en relación a la distinta fisiopatología.

OBJECTIVE: The aim of this study was to know the serum amino acid profiles in children with terminal hepatic diseases and to assess the differences between the two main physiopathological groups of hepatic damage: cholestasis and cellular necrosis. PATIENTS AND METHODS: We studied twenty-six pediatric patients with severe hepatic diseases admitted to the Pediatric Intensive Care Unit. Patients were divided into two groups according to the predominant hepatic lesion: cellular damage (fourteen children) and cholestasis damage (twelve cases). RESULTS: Overall, there is a significant increase in the aromatic amino acids (AAA) phenylalanine (p < 0.04) and tyrosine (p < 0.0003) and a decrease in the branched-chain amino acids (BCAA) leucine, isoleucine and valine (p < 0.00001), with a reduction in the BCAA/AAA ratio (p < 0.00001). However, we found a significant decrease in glutamine, cysteine, taurine, serine, threonine, tryptophan, total amino acids and essential amino acids, together with higher levels of glutamic acid, ornithine and citrulline, which reflects a more complex metabolic disturbance. The group with cholestatic damage shows very low taurine levels (p < 0.0003). Patients with predominantly cellular damage have higher increases in tyrosine (p < 0.01), phenylalanine and hydroxyproline (p < 0.01). CONCLUSIONS: These findings may help us to better understand the complex physiopathology of amino acid metabolism in different liver diseases. Moreover, the extremely low levels of taurine found prompted us to recommend additional dietary support particularly in children with cholestatic hepatopathy.