Survey of Carbapenemase-Producing Enterobacteriaceae in Companion Dogs in Madrid,Spain

We found a low prevalence (0.6%) of carbapenemase-producing Enterobacteriaceae (CPE) in fecal microbiota of companion dogs. A single VIM-1-producing Klebsiella pneumoniae isolate belonging to sequence type (ST) 2090 was detected. bla_VIM-1 was carried on a class 1 integron and an untypeable ∼48-kb plasmid. Emergence and spread of CPE in this group of animals may be a threat to public health in human and veterinary medicine. This finding supports the need for active surveillance studies in companion animals that live close to humans, as interspecies transmission may occur within the same household.     

Clonal spread of levofloxacin-resistant streptococcus pneumoniae invasive isolates in Madrid, Spain, 2007 to 2009

Among 1,349 Streptococcus pneumoniae invasive isolates, 45 (3.3%) were levofloxacin resistant. Serotype distribution was as follows: 8 (n=32 isolates), 19A (n=4 isolates), 7F (n=3 isolates), 9V (n=2 isolates), 10A (n=1 isolate), 19F (n=1 isolate), 6B (n=1 isolate), and nontypeable (n=1 isolate). Levofloxacin-resistant isolates had dual mutations in the gyrA and parC genes. Serotype 8 strains corresponded to a capsular switching of the Sweden(15A)-25 clone. Levofloxacin resistance was also detected among multiresistant (ST276(19A), Spain9V-ST156, ST88(19F), and ST1542(6B)) and among usually antibiotic-susceptible (Netherlands7F-ST191, ST1201(19A), and ST2639(10A)) clones.     

Respiratory responses to simultaneous static and rhythmic exercises in humans.

1. Six male subjects performed simulataneous static (hand-grip) and rhythmic (bicycle ergometer) exercises while their respiratory responses were measured. 2. Oxygen consumption increased with the intensity of rhythmic work load, with a modest additional oxygen consumption accompanying the addition of static effort during the rhythmic exercise. 3. Minute ventilation (VE) increased directly with rhythmic exercise, but increased disproportionately to the metabolic need when static effort was added. The mean increment of VE elicited by the static exercise influence was nearly constant at 20 l/min, regardless of the rhythmic load present. 4. Possible reflex mechanisms which result in disruption of the normally well-matched ventilation and metabolic oxygen demands whenever static effort is present are discussed.     

Resistance trends of the Bacteroides fragilis group over a 10-year period, 1997 to 2006, in Madrid, Spain

The changes in susceptibilities of Bacteroides fragilis group strains isolated in our hospital from 1997 to 2006 were studied. A total of 1,343 clinical strains were included. The study showed differences in the resistance rates in the different species of the group. Increasing resistance to clindamycin and moxifloxacin was observed. Susceptibility to imipenem, piperacillin-tazobactam, and metronidazole remained unchanged.     

11 March 2004: The terrorist bomb explosions in Madrid, Spain--an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital

At 07:39 on 11 March 2004, 10 terrorist bomb explosions occurred almost simultaneously in four commuter trains in Madrid, Spain, killing 177 people instantly and injuring more than 2000. There were 14 subsequent in-hospital deaths, bringing the ultimate death toll to 191. This report describes the organization of clinical management and patterns of injuries in casualties who were taken to the closest hospital, with an emphasis on the critically ill. A total of 312 patients were taken to the hospital and 91 patients were hospitalized, of whom 89 (28.5%) remained in hospital for longer than 24 hours. Sixty-two patients had only superficial bruises or emotional shock, but the remaining 250 patients had more severe injuries. Data on 243 of these 250 patients form the basis of this report. Tympanic perforation occurred in 41% of 243 victims with moderate-to-severe trauma, chest injuries in 40%, shrapnel wounds in 36%, fractures in 18%, first-degree or second-degree burns in 18%, eye lesions in 18%, head trauma in 12% and abdominal injuries in 5%. Between 08:00 and 17:00, 34 surgical interventions were performed in 32 patients. Twenty-nine casualties (12% of the total, or 32.5% of those hospitalized) were deemed to be in a critical condition, and two of these died within minutes of arrival. The other 27 survived to admission to intensive care units, and three of them died, bringing the critical mortality rate to 17.2% (5/29). The mean Injury Severity Score and Acute Physiology and Chronic Health Evaluation II scores for critically ill patients were 34 and 23, respectively. Among these critically ill patients, soft tissue and musculoskeletal injuries predominated in 85% of cases, ear blast injury was identified in 67% and blast lung injury was present in 63%. Fifty-two per cent suffered head trauma. Over-triage to the closest hospital probably occurred, and the time of the blasts proved to be crucial to the the adequacy of the medical and surgical response. The number of blast lung injuries seen is probably the largest reported by a single institution, and the critical mortality rate was reasonably low.     

Community-acquired methicillin-resistant Staphylococcus aureus in Madrid, Spain: transcontinental importation and polyclonal emergence of Panton-Valentine leukocidin-positive isolates

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) isolates producing the Panton-Valentine leukocidin (PVL) have been reported worldwide. We describe the molecular characteristics of PVL-positive CA-MRSA strains isolated in Madrid, Spain, and analyze the clinical features of patients infected with these isolates. From 2004 to 2007, we collected 13 PVL-positive MRSA isolates from patients attending to the emergency department. The isolates were genotyped by pulsed-field gel electrophoresis, SCCmec typing, agr polymorphism, and multilocus sequence typing. Susceptibility to 29 antimicrobials was determined by the broth microdilution and by the E-test methods. The isolates belonged to 3 genotypes: ST8-SCCmec IVc (n = 11), ST5-SCCmec IVa (n = 1), and ST80-SCCmec IVc (n = 1). The corresponding agr types were I, II, and III, respectively. Five isolates were resistant to tetracycline and doxycycline, and 1 was resistant to fusidic acid (ST80). The isolates were from children (n = 9) and adults (n = 4), and were associated with skin and soft tissue infections (n = 9), otitis (n = 1), and bacteremia (n = 1). Nine patients were from South America. Our results indicate the transcontinental importation and recent emergence in Spain of PVL-positive CA-MRSA strains belonging to 3 distinct lineages, including 1 predominant (ST8-SCCmec IVc).     

Antimicrobial resistance of Streptococcus pneumoniae isolates in 1999 and 2000 in Madrid, Spain: a multicentre surveillance study

Resistance to first-line antimicrobial agents in Streptococcus pneumoniae is increasing worldwide and the new fluoroquinolones may provide a good alternative. The antimicrobial susceptibility to levofloxacin and 13 other antibiotics of 300 isolates of S. pneumoniae, isolated in the Madrid community in 1999 and 2000, was determined. A total of 65.6% of isolates were penicillin intermediate or resistant strains. A high percentage of resistance to macrolides, clindamycin, tetracycline and chloramphenicol was also observed, mainly in penicillin-resistant strains. All but one strain was susceptible to levofloxacin.     

Integron content of extended-spectrum-beta-lactamase-producing Escherichia coli strains over 12 years in a single hospital in Madrid, Spain

The contribution of integrons to the dissemination of extended-spectrum beta-lactamases (ESBL) was analyzed on all ESBL-producing Escherichia coli isolates from 1988 to 2000 at Ramon y Cajal Hospital. We studied 133 E. coli pulsed-field gel electrophoresis types: (i) 52 ESBL-producing clinical strains (C-ESBL) (16 TEM, 9 SHV, 21 CTX-M-9, 1 CTX-M-14, and 5 CTX-M-10); (ii) 43 non-ESBL blood clinical strains (C-nESBL); and (iii) 38 non-ESBL fecal isolates from healthy volunteers (V-nESBL). Class 1 integrons were more common among C-ESBL (67%) than among C-nESBL (40%) or V-nESBL (26%) (P < 0.001) due to the high number of strains with bla(CTX-M-9), which is linked to an In6-like class 1 integron. Without this bias, class 1 integron occurrence would be similar in C-ESBL and C-nESBL groups (47% versus 40%). Occurrence of class 2 integrons was similar among clinical and community isolates (13 to 18%). No isolates contained class 3 integrons. The relatively low rate of class 1 integrons within transferable elements carrying bla(TEM) (23%) or bla(SHV) (33%) and the absence of class 2 integrons in all ESBL transconjugants mirror the assembly of translocative pieces containing bla(TEM) or bla(SHV) on local available transferable elements lacking integrons. The low diversity of class 1 integrons (seven types recovered in all groups) might indicate a wide dissemination of specific genetic elements in which they are located. In our environment, the spread of genetic elements encoding ESBL has no major impact on the dispersion of integrons, nor do integrons have a major impact on the spread of ESBL, except when bla(ESBL) genes are within an integron platform such as bla(CTX-M-9).     

A Utstein-style analysis of prognostic factors related to survival in out-of-hospital cardiac arrests in Akita-City, Japan

To analyze the epidemiology of out-of-hospital cardiac arrests and to elucidate modifiable factors affecting survival, we conducted a prospective cohort study in a middle-sized urban city served by a single emergency medical service (EMS) system in which emergency medical technicians use an automated external defibrillator. Data were collected from out-of-hospital cardiac arrests occurring between 1 January, 1994 and 31 December, 1998 by applying the Utstein style. The main outcome measure was survival at 1 year after hospital discharge. The overall incidence of out-of-hospital cardiac arrest was 71.7/100 000 inhabitants/year. Resuscitations were attempted in 762 of 1118 patients with confirmed cardiac arrest. Of the 762 patients, 37 (4.86%) survived. The cause of cardiac arrest was presumed to be cardiac in 340 (44.6%). Of the 340 cardiac arrests, 180 (52.9%) were witnessed by bystanders. Ventricular fibrillation (VF) was recorded as an initial rhythm in 56 (31.1%) of the 180 patients, and cardiopulmonary resuscitation (CPR) was performed by bystanders in 89 (49.4%). The survival rate was 39.2% (22/56) when cardiac arrest was bystander-witnessed and of cardiac origin with VF as an initial rhythm. VF as an initial rhythm, age of the patients and intervals of call-to-first CPR attempt and collapse-to-arrival at patient's side were major factors relating to survival in the witnessed cardiac arrests of cardiac origin. The age, and gender of the patients, place of collapse and intervals of collapse-to-first CPR and collapse-to-arrival at patient's side were representative factors affecting the incidence of VF as an initial rhythm. The survival rate in Akita-City from bystander-witnessed cardiac arrests of cardiac origin with VF as an initial rhythm was comparable to those in other regions with advanced EMS systems. However, the incidence of VF as an initial rhythm is extremely low. Reduction of intervals of call (collapse)-to-first CPR attempt and collapse-to-arrival at patient's side or authorization of use of automated external defibrillator in basic life support may increase the incidence of VF as an initial rhythm and improve the survival from witnessed cardiac arrests with cardiac origin.     

Spirituality in nursing and health-related literature: a concept analysis.

Spirituality has become an increasingly popular concept among the nursing and health-related literature. The purpose for conducting this concept analysis, guided by Walker and Avant's methodology, was to (a) examine how spirituality has been used within the current body of nursing and health-related literature, (b) clarify the meaning of spirituality by discovering what this concept's current critical attributes/characteristics are, and (c) propose a definition of spirituality based on the concept analysis findings. A total of 90 references were reviewed, including 73 nursing and health-related references. Concept analysis findings revealed that spirituality was defined within four main themes in the nursing and health-related literature: (a) spirituality as religious systems of beliefs and values (spirituality = religion); (b) spirituality as life meaning, purpose, and connection with others; (c) spirituality as nonreligious systems of beliefs and values; and (d) spirituality as metaphysical or transcendental phenomena.     

Management of an extremely premature infant in the out-of-hospital environment

The rate of premature infant mortality has decreased over the last several decades, with an accompanying decrease in the gestational age of premature infants who survive to hospital discharge. Emergency medical services (EMS) providers are sometimes called to provide prehospital care for infants born at the edge of viability. Such extremely premature infants (EPIs) present medical and ethical challenges. In this case report, we describe an infant born at 24 weeks into a toilet by a mother who thought she had miscarried. The EMS providers evaluated the infant as nonviable and placed him in a plastic bag for transport to a local emergency department (ED). The ED staff found the infant to have a bradycardic rhythm, initiated resuscitation, and admitted him to the neonatal intensive care unit. The infant died seven days later. We review the literature for recommendations in resuscitation of EPIs and discuss the ethics regarding their management in the prehospital setting.