The value of the continuous genotyping of multi-drug resistant tuberculosis over 20 years in Spain.

Molecular epidemiology of circulating clinical isolates is crucial to improve prevention strategies. The Spanish Working Group on multidrug resistant tuberculosis (MDR-TB) is a network that monitors the MDR-TB isolates in Spain since 1998. The aim of this study was to present the study of the MDR-TB and extensively drug-resistant tuberculosis (XDR-TB) patterns in Spain using the different recommended genotyping methods over time by a national coordinated system. Based on the proposed genotyping methods in the European Union until 2018, the preservation of one method, MIRU-VNTR, applied to selected clustered strains permitted to maintain our study open for 20 years. The distribution of demographic, clinical and epidemiological characteristics of clustered and non-clustered cases of MDR/XDR tuberculosis with proportion differences as assessed by Pearson's chi-squared or Fisher's exact test was compared. The differences in the quantitative variables using the Student's-t test and the Mann-Whitney U test were evaluated. The results obtained showed a total of 48.4% of the cases grouped in 77 clusters. Younger age groups, having a known TB case contact (10.2% vs 4.7%) and XDR-TB (16.5% vs 1.8%) were significantly associated with clustering. The largest cluster corresponded to a Mycobacterium bovis strain mainly spread during the nineties. A total of 68.4% of the clusters detected were distributed among the different Spanish regions and six clusters involving 104 cases were grouped in 17 and 18 years. Comparison of the genotypes obtained with those European genotypes included in The European Surveillance System (TESSy) showed that 87 cases had become part of 20 European clusters. The continuity of MDR strain genotyping in time has offered a widespread picture of the situation that allows better management of this public health problem. It also shows the advantage of maintaining one genotyping method over time, which allowed the comparison between ancient, present and future samples.

Penfigoide ampolloso secundario a vildagliptina / Bullous pemphigoid secondary to vildagliptin

El penfigoide ampolloso es una enfermedad autoinmune caracterizada por presencia de lesiones urticariformes o eccematosas muy pruriginosas sobre las que posteriormente pueden aparecer ampollas tensas de contenido seroso o hemorrágico. Planteamos un caso clínico de un paciente con penfigoide ampolloso secundario a vildagliptina. Aunque el diagnóstico definitivo se realiza mediante dos biopsias cutáneas, en nuestro caso, dada la alta sospecha clínica, comenzamos con tratamiento con corticoides y suspendimos la vidagliptina con resolución del cuadro en pocas semanas. Nos parece interesante no solo por el diagnóstico en sí, sino también para destacar la importancia del papel del médico de familia en este tipo de enfermedades tanto a nivel del diagnóstico como del seguimiento de la evolución y del tratamiento. Y por otra parte para resaltar la utilidad de las nuevas tecnologías, como la teledermatología

Bullous pemphigoid is an autoimmune disease characterised by presence of very pruritic hives-like or eczema-like lesions on top of which serum- or blood-containing tense blisters can later appear. We present the clinical case of a patient with bullous pemphigoid secondary to vildagliptin. Although the definitive diagnosis is made by two skin biopsies, in this case, given high clinical suspicion, we began treatment with corticosteroids and discontinued vildagliptin, with complete resolution in a few weeks. This case is interesting not only for its diagnosis, but also to highlight the importance of the role of the family doctor in this type of diseases, in diagnosis and in the follow-up and treatment. And also to emphasise the usefulness of new technologies, like teledermatology

Pseudo-outbreak of Mycobacterium fortuitum in a hospital bronchoscopy unit.

BACKGROUND: Mycobacterium fortuitum survive in different environmental conditions, biofilm formation and resistance to chlorinated disinfectants makes its isolation frequent in hospital environments, even being involved in outbreaks by contamination of medical equipment such as bronchoscopes. We describe a pseudo-outbreak by M fortuitum isolated in samples from 9 patients who underwent bronchoscopy in the pneumology bronchoscopy unit of the University Hospital Complex of the Canary Islands from December 2016 to March 2017. METHODS: We proceeded to investigate the pseudo-outbreak with a combination of epidemiologic, environmental, and molecular typing data. RESULTS: The source/reservoir of pseudo-outbreak was the hospital water used by the bronchoscope automatic washing machine (without antibacterial filter), so control measures were taken. Molecular typing was performed on 7 strains from 7 patients, and a sample of water was collected from a tap in the pneumology bronchoscopy unit: all of which had the same pattern. CONCLUSIONS: Our study demonstrates the presence of nontuberculous mycobacteria in the hospital water supply, and thus the need to take measures against them because they compromise patients' health. We also suggest the need for hospital water quality guidelines in which methods to control and/or eliminate them are established.

Optimismo de los pacientes cardiológicos respecto a la reanimación cardiopulmonar. Posibles causas y consecuencias / Optimism regarding cardiopulmonary resuscitation among patients with heart disease. Possible causes and consequences

OBJETIVO: El pronóstico predicho por los cardiópatas españoles respecto a la reanimación cardiopulmonar se aleja significativamente de la realidad. Buscamos determinar si existen diferencias de percepción con respecto a otros pacientes y elaborar hipótesis que puedan justificarlo. MÉTODO: Estudio descriptivo mediante encuesta a una serie consecutiva de pacientes cardiológicos, no cardiológicos y a estudiantes de medicina. RESULTADOS: Tras una parada cardiorrespiratoria intrahospitalaria los pacientes cardiológicos refirieron una supervivencia media al alta total (76 vs.62%; p < 0,01) y libre de deterioro cognitivo (65 vs.55%; p = 0,02) significativamente superior a la de los pacientes no cardiológicos, a pesar de tener una edad media superior y haber presenciado en más ocasiones maniobras de reanimación. Los estudiantes de medicina refieren supervivencias (62 y 48% respectivamente) que también se encuentran muy alejadas de la realidad. Aunque ambos grupos de pacientes referían que el médico era su principal fuente de información sobre la salud (91 y 90%), el contacto principal con la reanimación había sido a través de series o películas de televisión. Ningún paciente rechazó la participación en el estudio. CONCLUSIONES: El paciente cardiológico tiene una visión de los resultados de la reanimación cardiopulmonar más optimista que el resto. Este hecho debe tenerse en cuenta, puesto que podría comprometer el desarrollo de las conversaciones sobre sus cuidados al final de la vida

OBJECTIVE: The outcomes regarding cardiopulmonary resuscitation predicted by Spanish cardiac patients are far from the reality. We sought to determine differences of perception with respect to other patients and develop hypotheses that might justify them. Method: Descriptive study using an interview-guided survey with a consecutive series of cardiac patients, non-cardiac patients, and medical students. RESULTS: Following in-hospital cardiac arrest, cardiac patients reported a significantly higher mean survival to discharge (76 vs.62%, p < 0.01) and free from neurological disability (65 vs.55%, p = 0.02) than non-cardiac patients, despite being older and having more frequently undergone resuscitation manoeuvres. Medical students also reported survivals (62 and 48%, respectively) that are also far from the reality. Although both groups of patients reported that physicians were their main source of health information (91 and 90%), their main contact with resuscitation had been through TV series and/or movies. No patient declined to participate in the study. CONCLUSIONS: Cardiac patients have a more optimistic vision of the results of cardiopulmonary resuscitation. This fact should be taken into account in planning conversations about end-of-life care

Mycobacterium tuberculosis genotypes and predominant clones among the multidrug-resistant isolates in Spain 1998-2005.

Although the incidence of tuberculosis (TB) is gradually decreasing in Spain, there is an increase in the proportion of foreign-born cases. This changing scenario is slowly shifting the local TB epidemiology from endemic to imported cases with an increased risk for multidrug-resistant (MDR) and extensively drug resistant (XDR) strains of Mycobacterium tuberculosis complex. MDR/XDR strains from Spain (n=366 MTBC isolates, 1 strain per patient) isolated between 1998 and 2005 were retained for this retrospective analysis. All strains were analyzed by spoligotyping, while 12-loci MIRU-VNTR data were available for 106 isolates from 2003 to 2005. Demographic, phylogenetic, and epidemiologic analyses using anonymized data were collected and analyzed using the SITVIT2 database. Our study provides with a first snapshot of genetic diversity of MDR/XDR-TB in several autonomous regions of Spain. It highlights significantly more of SIT1/Beijing and SIT66/BOV MDR isolates (5.7% and 7.38% respectively) and increasingly more foreign-born cases from Eastern Europe. Future studies should focus on shared genotypes between Spanish and foreign-born patients to decipher the modes of transmission and risk factors involved, and decipher the proportion of imported cases of active disease versus cases of reactivation of latent TB infection among foreign-born individuals.

Pediatric drug-resistant tuberculosis in Madrid: family matters.

BACKGROUND: The rates of isoniazid (INH) and multidrug-resistant (MDR) tuberculosis (TB) among European children vary between 10.4% and 3.5%. Spain is a low endemic country with reported rates of 4.9% of INH resistance and 1.3% of MDR in adults. However, data regarding patterns of TB resistance in children are scarce. Our aim is to determine the incidence and risk factors for pediatric-resistant TB in our setting to help developing age-targeted guidelines. METHODS: A multicenter, retrospective study including 22 hospitals from Madrid region (EREMITA study group) was performed from January 2005 to June 2010. Medical records from children diagnosed with TB were reviewed for demographic characteristics, clinical presentation and outcomes. Risk factors for INH and MDR TB were identified. RESULTS: Of 396 children diagnosed with TB, 72.4% were born to foreign parents. Microbiologic confirmation by culture (n = 200) or PCR (n = 8) was documented in 208 children (52.5%). Drug susceptibility results were available in 188 children: 9.6% (n = 18) were resistant to INH and 3.1% (n = 6) were MDR. INH resistance was more common in immigrants compared with native families (11.9% vs. 0%; P = 0.013), as was also MDR (4.5% vs. 0%; P = 0.34). Extrapulmonary TB and previous antituberculous treatment were significantly associated with INH and MDR, while immunosuppression was associated only with MDR. CONCLUSIONS: The rates of INH and MDR TB were different according to the parents' origin, with higher rates among children born to foreign parents. Local surveillance of drug-resistant TB is critical to develop appropriate guidelines for treatment.

Long-term molecular surveillance of multidrug-resistant tuberculosis in Spain.

The data presented here span 11 years (1998-2008) of monitoring of multidrug-resistant tuberculosis (MDR-TB) clustering through molecular typing techniques in Spain. The molecular and epidemiological data of 480 multidrug-resistant Mycobacterium tuberculosis complex isolates were analyzed. Thirty-one clusters involving 157 (32.7%) patients were identified. The proportion of immigrants increased substantially over the study period reaching 65% in 2008; however, the clustering rate remained stable indicating that local transmission was little influenced by imported MDR-TB. The three major clusters respond to the persistence of two autochthonous strains throughout the study period and an extensively drug-resistant (XDR) Mycobacterium bovis outbreak with only two cases was reported since 2002. Molecular and epidemiological evidence for the importation of new strains and their spread within the community was found. Immigrant-only clusters most often grouped patients infected abroad with strains belonging to rare spoligotypes. Conversely, widespread spoligotypes of the Latin-American and Mediterranean (LAM) and Haarlem families were responsible for the majority of the MDR-TB local transmission. The demonstration of clusters spanning several Spanish regions that have been ongoing throughout the study period makes it advisable to maintain a continuous molecular surveillance in order to monitor the spread of MDR-TB.

Alternative methods for sampling and preservation of photosynthetic pigments and tocopherols in plant material from remote locations.

Current methods for the study of pigments involve freezing in liquid nitrogen and storage at -80 degrees C or lyophilization until HPLC analysis. These requirements greatly restrict ecophysiological research in remote areas where such resources are hardly available. We aimed to overcome such limitations by developing several techniques not requiring freezing or lyophilization. Two species with contrasting foliar characteristics (Olea europaea and Taraxacum officinale) were chosen. Seven preservation methods were designed, optimized and tested in a field trial. These protocols were compared with a control immediately frozen after collection. Pigments and tocopherols were analysed by HPLC. Main artefacts were chlorophyll epimerization or phaeophytinization, carotenoid isomerization, altered de-epoxidation index and tocopherol degradation. Among all methods, sample desiccation in silica gel provides robust samples (pigment composition was unaffected by storage time or temperature) and almost unaltered pigment profiles, except for a shift in epoxidation state. Although liquid nitrogen freezing and subsequent lyophilization or freezer storage were preferred, when these facilities are either not available or not suitable for long-distance transport, desiccation with silica gel, passive extraction in acetone and/or storage of fresh samples in water vapour saturated atmospheres enable a complete pigment characterization. Silica gel is advisable for long-term sample conservation.

Respiratory fluxes in a Canary Islands pine forest.

We estimated component and whole-ecosystem CO(2) efflux (R(ECO)) in a Pinus canariensis Chr. Sm. ex DC stand in Tenerife, Canary Islands, an ecotone with strong seasonal changes in soil water availability. From November 2006 to February 2008, we measured foliage, stem and soil CO(2) efflux by chamber techniques. Site-specific CO(2) efflux models obtained from these chamber measurements were then combined with half-hourly measurements of canopy, stem and soil temperature as well as soil water potential, leaf and stem surface area data for scaling up component-specific CO(2) efflux to R(ECO). Integrated over an entire year, R(ECO) was 938 g of C m(-2) in 2007 and comprised the following component fluxes: 77% from soil, 11% from stems and 12% from foliage. Whole-ecosystem CO(2) efflux varied markedly throughout the year. During the cold and wet season, R(ECO) generally followed the seasonal trends in temperature, and during the warm and dry summer, however, R(ECO) was significantly reduced because of limited soil water availability in the main rooting horizon.

Orquiepididimitis por Mycobacterium africanum / No disponible

No disponible

Accumulating pollutants in conifer needles on an Atlantic island - a case study with Pinus canariensis on Tenerife, Canary Islands.

Concentrations of potential pollutant elements Na, Cl, and S were investigated in needles of Pinus canariensis grown at 55 field plots in Tenerife. Microelement concentrations (including heavy metals) were measured at a subset of 18 plots. Na and Cl concentrations were high at low elevations (up to 8 mg g(-1) Cl and 5.5 mg g(-1) Na). Na/Cl ratio close to standard seawater indicated sea spray influence up to 1200 m a.s.l. Only at few plots, sulphur concentrations indicated possible pollutant impact. Cluster and correlation analyses identified a related group of V, As, Cr, Fe, Mo, Ni, Cu, Pb, and Al, possibly related to traffic exhaust aggregated with soil particles. Mainly north-eastern, lower elevated plots were exposed to those immissions, but metal concentrations were generally low compared to data from other studies. In conclusion, seawater and soil particles explained most of the element distribution pattern in pine needles in Tenerife, but strong indications for some effect of local sources of air pollutants were detected.

New multiplex PCR for rapid detection of isoniazid-resistant Mycobacterium tuberculosis clinical isolates.

In this study, we describe a multiplex PCR to detect a AGC-->ACC (serine to threonine) mutation in the katG gene and a -15 C-to-T substitution (inhA(C-15T)) at the 5' end of a presumed ribosome binding site in the promoter of the mabA-inhA operon. These mutations have been reported in the majority of previous studies as the most frequent mutations involved in the resistance to isoniazid (INH) of Mycobacterium tuberculosis clinical strains with high levels of resistance. The method was optimized and validated after an analysis of 30 M. tuberculosis clinical isolates with known sequences of the relevant part of the katG gene and the regulatory region of the mabA-inhA operon. We analyzed 297 INH-resistant M. tuberculosis isolates collected in Spain from 1996 to 2003 by PCR-restriction fragment length polymorphism (using the katG gene), DNA sequencing, and the newly developed multiplex PCR. The results were concordant for all 297 isolates tested. The analysis revealed that 204 (68.7%) of the isolates carried one or both of the mutations. This finding suggests that with further development this multiplex PCR will be able to detect the majority of the INH-resistant M. tuberculosis clinical isolates from Spain and other countries where a high frequency of similar mutations occur.

Measuring antioxidants in tree species in the natural environment: from sampling to data evaluation.

Biochemical measurements of antioxidants and protective pigments have been successfully introduced as markers of environmental stress in field studies (mainly forest studies). A guideline for field sampling and analysis methods is required to allow better comparison of data from different studies. The present review paper recommends HPLC methods for the analysis of ascorbate and glutathione (in oxidized and reduced form), tocopherols, and chloroplast pigments. Methodological variations are substantially lower (coefficients of variance of repeated extractions typically 4-9%) than biological variations of field samples (typical variation coefficients 8-36%), hence special emphasis is put on considerations of sampling standardization in the field with respect to sample time (seasonal and diurnal) and representative sampling of individuals and tissues. Following the suggestions in this paper would enable researchers to produce results that could be compared with those of several forest studies on conifers published in recent years. A larger data-set available for multivariate statistical evaluations (e.g. principal component analysis and cluster analysis) will enhance the diagnostic value of such investigations.