Tuberculosis disease in immunocompromised children and adolescents: a pTBnet multi-centre case-control study

BACKGROUND

In high-resource settings the survival of immunocompromised (IC) children has increased and immunosuppressive therapies are increasingly being used. This study aimed to determine the clinical characteristics, performance of diagnostic tools and outcome of IC children with TB in Europe.

METHODS

Multicentre, matched case-control study within the Paediatric Tuberculosis Network European Trials Group (ptbnet), capturing TB cases <18 years diagnosed 2000-2020.

RESULTS

417 TB cases were included, comprising 139 children with IC (HIV, inborn errors of immunity, drug-induced immunosuppression and other immunocompromising conditions) and 278 non-IC children as controls. Non-respiratory TB was more frequent among cases than controls (32.4% vs. 21.2%; p = 0.013). IC patients had an increased likelihood of presenting with severe disease (57.6% vs. 38.5%; p < 0.001; OR [95% CI]: 2.073 [1.37-3.13]). Children with IC had higher rates of false-negative tuberculin skin test (31.9% vs. 6.0%; p < 0.001) and QuantiFERON-TB Gold assay (30.0% vs. 7.3%; p < 0.001) results at diagnosis. Overall, the microbiological confirmation rate was similar in IC and non-IC cases (58.3% vs. 49.3%; p = 0.083). Although the mortality in IC children was <1%, the rate of long-term sequelae was significantly higher than in non-IC cases (14.8% vs. 6.1%; p = 0.004).

CONCLUSIONS

IC children with TB disease in Europe have increased rates of non-respiratory TB, severe disease, and long-term sequelae. Immune-based TB tests have poor sensitivity in those children. Future research should focus on developing improved immunological TB tests that perform better in IC patients, and determining the reasons for the increased risk of long-term sequelae, with the aim to design preventive management strategies.

Radiological environmental monitoring of groundwater around NPP: A proposal for its assessment

Whether a nuclear installation has radiological impact and, in that case, its extension, are the questions behind any environmental analysis of the installation along its operational life. This analysis is based on the detailed establishment of the radiological background of the area. Accordingly, the dismantling and decommissioning process (D&D) of a nuclear power plant starts with a radiological monitoring plan, which includes the radiological characterization of the area and of its surroundings. At the completion of the D&D, unrestricted use for the site will be permitted strictly in accordance with results of the radiological survey within the limits established by the local authorities. Groundwater quality is typically included in any radiological analysis since, among other reasons, a significant part of it is highly likely to end up being extracted for domestic use and hence, human consumption. While there is no regulation containing maximum activity concentration or radionuclide guidance values for water that may be destined for uses other than public consumption, if groundwater is considered a "part" of the land, dose criteria for site release can be applied. Therefore, together with the guidance levels to be established for the different radionuclides expected in the groundwater, the detection limits to be employed when performing routine radio analytical characterization procedures in the laboratory should also be provided. In this paper, we first propose a relation of the potential radionuclides to be analyzed in groundwater, together with their detection limits to be achieved when the determinations are performed in a laboratory, and subsequently, we discuss the most suitable analytical methodologies and resources that would be necessary to undertake radiological characterization plans from a practical point of view.

[Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Guidelines on Cardiovascular Disease Prevention]

Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Guidelines on Cardiovascular Disease Prevention. We present the Spanish adaptation of the 2021 European Guidelines on Cardiovascular Disease (CVD) prevention in clinical practice. The current guidelines besides the individual approach greatly emphasize on the importance of population level approaches to the prevention of cardiovascular diseases. Systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor. Regarding LDL-Cholesterol, blood pressure, and glycemic control in patients with diabetes mellitus, goals and targets remain as recommended in previous guidelines. However, it is proposed a new, stepwise approach (Step 1 and 2) to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile. After Step 1, considering proceeding to the intensified goals of Step 2 is mandatory, and this intensification will be based on 10-year CVD risk, lifetime CVD risk and treatment benefit, comorbidities and patient preferences. The updated SCORE algorithm-SCORE2, SCORE-OP- is recommended in these guidelines, which estimates an individual's 10-year risk of fatal and non-fatal CVD events (myocardial infarction, stroke) in healthy men and women aged 40-89 years. Another new and important recommendation is the use of different categories of risk according different age groups (< 50, 50-69 ≥ 70 years). Different flow charts of CVD risk and risk factor treatment in apparently healthy persons, in patients with established atherosclerotic CVD, and in diabetic patients are recommended. Patients with chronic kidney disease are considered high risk or very high-risk patients according to the levels of glomerular filtration rate and albumin-to-creatinine ratio. New lifestyle recommendations adapted to the ones published by the Spanish Ministry of Health as well as recommendations focused on the management of lipids, blood pressure, diabetes and chronic renal failure are included.

Uncertainty and detection limits of 241Pu determination by liquid scintillation counting (LSC)

Determination of ²⁴¹Pu is an essential issue for radiation protection, as it is the precursor of some nuclides with high radiotoxicity. ²⁴¹Pu is a low energy beta emitter, which makes its measurement more challenging than that of Pu alpha emitters. The most widely used method for the measurement of ²⁴¹Pu is liquid scintillation counting (LSC). In this method, the assessment of Pu radiochemical yield is done by measuring the sample by alpha spectrometry before being lixiviated and measured by LSC. This double measurement affects uncertainty analysis, as well as decision threshold and detection limit, considering that both components of the total yield (radiochemical and lixiviation) should be contemplated. In this paper, and for quality assurance (QA) purposes, in-depth uncertainty and detection limit formulae for the proposed method, controlling correlations and considering all the parameters involved including chemical and lixiviation yields, have been developed. A sensitivity analysis of the uncertainty budget together with an assessment of ²⁴²Pu tracer quantity to be used, ensuring a total yield of at least 50% and a relative uncertainty of the leaching yield of at most 5%, have been carried out. In addition, an analysis of the impact of the real lixiviation yield value and its uncertainty on the results has been done. As a general conclusion, and considering the values of the parameters chosen for this work (samples of 1 g measured for 24 h by LSC), the ²⁴¹Pu uncertainties range from 5% to 30% depending on the activity concentration values and the detection limits range from 14 to 30 Bq kg^-1, depending on yield values. The main components of the uncertainty budget are the net ²⁴¹Pu and background counts obtained in the LSC measurement for low contaminated samples while this is the case for the alpha gross count rate in LSC measurement of the alpha calibration source for highly contaminated samples. In addition, an analysis of possible interference by Pu alpha emitters in the ²⁴¹Pu signal and a comparison of quench standard curves of ³H and ²⁴¹Pu are also performed.

Possibilities of the use of CeBr3 scintillation detectors for the measurement of the content of radionuclides in samples for environmental monitoring

The investigation of radioactivity in samples is an application of gamma-ray spectrometry dealing with low and very low level gamma-ray activities of different isotopes. Gamma-ray spectrometry performed in the framework of radiological environmental monitoring may be done after selective sampling processes or after a chemical purification of a sample. Both cases imply that only some specific radionuclides should contribute to the obtained spectrum. Gamma-ray spectrometry performed with medium energy resolution detectors may allow the possible distinction of their photopeaks. Therefore, a cerium bromide (CeBr₃) detector can be particularly attractive for routine tasks in radiological environmental monitoring as it has a high efficiency, medium energy resolution and it can work at room temperature. This study describes the conditions under which a CeBr₃ detector can serve for some routine analysis in radiological analysis of samples collected in the environment or collected by air-samplers in environmental radiological monitoring programmes.

Necrotizing pneumonia due to Mycoplasma in children: an uncommon presentation of a common disease

Mycoplasma pneumoniae is a common respiratory pathogen, especially in children, responsible for community-acquired pneumonia. Although, in most cases, infections caused by this bacterium follow a benign self-limited clinical course, cases of severe respiratory infections have been reported. We present two pediatric cases of necrotizing pneumonia due to Mycoplasma pneumoniae. Both patients initially presented with low-grade fever, cough and mild respiratory symptoms, however, imaging techniques showed necrotizing pneumonia. Initially, a typical bacterial pneumonia was suspected, so antibiotic empiric regimen did not included macrolides. When clinical evolution was not adequate, antibiotic treatment was modified in order to provide coverage to unusual pathogens. Both patients finally recovered once Mycoplasma was suspected, and oral macrolides were added to their treatment. Although M. pneumoniae is a rare cause of necrotizing pneumonia, it must be considered, when usual antibiotic empiric therapy is not being successful. Before thinking of uncommon germs, we must remember that: 'The unusual presentation of a common disease is generally more likely than the usual presentation of an uncommon disease'.

Quality of life in home-ventilated children and their families

HMV (home mechanical ventilation) in children has increased over the last years. The aim of the study was to assess perceived quality of life (QOL) of these children and their families as well as the problems they face in their daily life.We performed a multicentric cross-sectional study using a semi-structured interview about the impact of HMV on families and an evaluation questionnaire about perceived QOL by the patient and their families (pediatric quality of life questionnaire (PedsQL4.0)). We studied 41 subjects (mean age 8.2 years). Global scores in PedsQL questionnaire for subjects (median 61.4), and their parents (median 52.2) were below those of healthy children. 24.4% received medical follow-up at home and 71.8% attended school. Mothers were the main caregivers (75.6%), 48.8% of which were fully dedicated to the care of their child. 71.1% consider economic and healthcare resources insufficient. All families were satisfied with the care they provide to their children, even though it was considered emotionally overwhelming (65.9%). Marital conflict and neglect of siblings appeared in 42.1 and 36% of families, respectively.

CONCLUSIONS

Perceived QOL by children with HMV and their families is lower than that of healthy children. Parents are happy to care for their children at home, even though it negatively affects family life. What is Known: • The use of home mechanical ventilation (HMV) in children has increased over the last years. • Normal family functioning is usually disrupted by HMV. What is New: • The aim of HMV is to provide a lifestyle similar to that of healthy children, but perceived quality of life by these patients and their parents is low. • Most of the families caring for children on HMV agree that support and resources provided by national health institutions is insufficient.

Analysis of the use of the IAEA rapid method of 89Sr and 90Sr in milk for environmental monitoring

Rapid methods that are used during nuclear accidents or incident situations must first be implemented and validated in radioactivity measurement laboratories, so they can be ready to provide quick answers to governments, regulatory organizations and people in such situations. As these accident situations are rare and the methods are thus not frequently used, the best way to achieve this is to use the same methods for both routine environmental monitoring and rapid or emergency situations. Before this can be done, however, an analysis of the conditions under which a rapid method could be effectively used in routine situations should be carried out. This work analyses the performance of the rapid method for the simultaneous determination of ⁸⁹Sr and ⁹⁰Sr in milk, published by the IAEA, and compares it with another, more conventional method used for routine environmental purposes. Through numerical calculations and considering different ⁸⁹Sr and ⁹⁰Sr activities, we also conducted a study to obtain the optimum values for determination parameters - such as sample mass, counting times, time lapse between measurements and background counting times - that will allow the use of the IAEA rapid method as a routine environmental one.

Validating proposed migration equation and parameters' values as a tool to reproduce and predict 137Cs vertical migration activity in Spanish soils

This paper shows the procedure performed to validate the migration equation and the migration parameters' values presented in a previous paper (Legarda et al., 2011) regarding the migration of ¹³⁷Cs in Spanish mainland soils. In this paper, this model validation has been carried out checking experimentally obtained activity concentration values against those predicted by the model. This experimental data come from the measured vertical activity profiles of 8 new sampling points which are located in northern Spain. Before testing predicted values of the model, the uncertainty of those values has been assessed with the appropriate uncertainty analysis. Once establishing the uncertainty of the model, both activity concentration values, experimental versus model predicted ones, have been compared. Model validation has been performed analyzing its accuracy, studying it as a whole and also at different depth intervals. As a result, this model has been validated as a tool to predict ¹³⁷Cs behaviour in a Mediterranean environment.

INTERNATIONAL STANDARDS ON FOOD AND ENVIRONMENTAL RADIOACTIVITY MEASUREMENT FOR RADIOLOGICAL PROTECTION: STATUS AND PERSPECTIVES

Radiological protection is a matter of concern for members of the public and thus national authorities are more likely to trust the quality of radioactivity data provided by accredited laboratories using common standards. Normative approach based on international standards aims to ensure the accuracy or validity of the test result through calibrations and measurements traceable to the International System of Units. This approach guarantees that radioactivity test results on the same types of samples are comparable over time and space as well as between different testing laboratories. Today, testing laboratories involved in radioactivity measurement have a set of more than 150 international standards to help them perform their work. Most of them are published by the International Standardization Organization (ISO) and the International Electrotechnical Commission (IEC). This paper reviews the most essential ISO standards that give guidance to testing laboratories at different stages from sampling planning to the transmission of the test report to their customers, summarizes recent activities and achievements and present the perspectives on new standards under development by the ISO Working Groups dealing with radioactivity measurement in connection with radiological protection.

The BepiColombo Laser Altimeter (BeLA) power converter module (PCM): Concept and characterisation

This paper presents the principal considerations when designing DC-DC converters for space instruments, in particular for the power converter module as part of the first European space laser altimeter: "BepiColombo Laser Altimeter" on board the European Space Agency-Japan Aerospace Exploration Agency (JAXA) mission BepiColombo. The main factors which determine the design of the DC-DC modules in space applications are printed circuit board occupation, mass, DC-DC converter efficiency, and environmental-survivability constraints. Topics included in the appropriated DC-DC converter design flow are hereby described. The topology and technology for the primary and secondary stages, input filters, transformer design, and peripheral components are discussed. Component selection and design trade-offs are described. Grounding, load and line regulation, and secondary protection circuitry (under-voltage, over-voltage, and over-current) are then introduced. Lastly, test results and characterization of the final flight design are also presented. Testing of the inrush current, the regulated output start-up, and the switching function of the power supply indicate that these performances are fully compliant with the requirements.

A non-canonical mismatch repair pathway in prokaryotes

Mismatch repair (MMR) is a near ubiquitous pathway, essential for the maintenance of genome stability. Members of the MutS and MutL protein families perform key steps in mismatch correction. Despite the major importance of this repair pathway, MutS-MutL are absent in almost all Actinobacteria and many Archaea. However, these organisms exhibit rates and spectra of spontaneous mutations similar to MMR-bearing species, suggesting the existence of an alternative to the canonical MutS-MutL-based MMR. Here we report that Mycobacterium smegmatis NucS/EndoMS, a putative endonuclease with no structural homology to known MMR factors, is required for mutation avoidance and anti-recombination, hallmarks of the canonical MMR. Furthermore, phenotypic analysis of naturally occurring polymorphic NucS in a M. smegmatis surrogate model, suggests the existence of M. tuberculosis mutator strains. The phylogenetic analysis of NucS indicates a complex evolutionary process leading to a disperse distribution pattern in prokaryotes. Together, these findings indicate that distinct pathways for MMR have evolved at least twice in nature.

[Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice]

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

A novel strategy based on genomics and specific PCR reveals how a multidrug-resistant Mycobacterium tuberculosis strain became prevalent in Equatorial Guinea 15 years after its emergence

OBJECTIVE

Molecular epidemiology techniques in tuberculosis (TB) can identify high-risk strains that are actively transmitted. We aimed to implement a novel strategy to optimize the identification and control of multidrug-resistant (MDR) TB in a specific population.

METHODS

We developed a strain-specific PCR tailored from whole genome sequencing (WGS) data to track a specific MDR prevalent strain in Equatorial Guinea (EG-MDR).

RESULTS

The PCR was applied prospectively on remnants of GeneXpert reaction mixtures owing to the lack of culture facilities in Equatorial Guinea. In 147 (93%) of 158 cases, we were able to differentiate between infection by the EG-MDR strain or by any other strain and found that 44% of all rifampicin-resistant TB cases were infected by EG-MDR. We also analysed 93 isolates obtained from Equatorial Guinea 15 years ago, before MDR-TB had become the problem it is today. We found that two of the scarce historical MDR cases were infected by EG-MDR. WGS revealed low variability-six single nucleotide polymorphisms acquired by this strain over 15 years-likely because of the lack in the country of a specific program to treat MDR-TB.

CONCLUSIONS

Our novel strategy, which integrated WGS analysis and strain-specific PCRs, represents a low-cost, rapid and transferable strategy that allowed a prospective efficient survey and fast historical analysis of MDR-TB in a population.

Direct, indirect and total effects of 13-valent pneumococcal conjugate vaccination on invasive pneumococcal disease in children in Navarra, Spain, 2001 to 2014: cohort and case–control study

We estimated the direct, indirect and total effects of the 13-valent pneumococcal conjugate vaccine (PCV13) on invasive pneumococcal disease (IPD) in children. A population-based cohort study followed children aged between 2.5 and 59 months between 2001 and 2014 in Navarra, Spain. IPD incidence was compared by PCV status and period. All cases diagnosed from July 2010 to December 2014 and eight matched controls per case were analysed to estimate the adjusted direct effect of PCV13. A total of 120,980 children were followed and 206 IPD cases were detected. Compared with unvaccinated children in the baseline period (2001–2004), overall IPD incidence in 2011–2014 (76% average PCV coverage) declined equally in vaccinated (total effect: 76%; hazard ratio (HR): 0.24; 95% confidence interval (CI): 0.14–0.40) and unvaccinated children (indirect effect: 78%; HR: 0.22; 95% CI: 0.09–0.55). IPD incidence from non-PCV13 serotypes increased among vaccinated children (HR: 2.84; 95% CI: 1.02–7.88). The direct effect of one or more doses of PCV13 against vaccine serotypes was 95% (odds ratio: 0.05; 95% CI: 0.01–0.55). PCV13 was highly effective in preventing vaccine-serotype IPD. The results suggest substantial and similar population-level vaccine benefits in vaccinated and unvaccinated children through strong total and indirect effects.

[Invasive meningococcal disease in Navarra in the era of a meningococcal C vaccine]

INTRODUCTION

Systematic childhood vaccination against meningococcus C has had a considerable impact on meningococcal invasive disease (MID). The aim of this study is to perform an analysis on the epidemiology, the clinical features, and the factors associated with a worse prognosis of MID, in the era of a meningococcal C vaccine.

MATERIAL AND METHODS

The study included confirmed cases of MID in children less than 15 years of age in Navarra, Spain, between 2008 and 2014. The risk of death or permanent sequelae was evaluated according to the presence of clinical features and analytical parameters at diagnosis.

RESULTS

The average annual incidence was 7.9 cases per 100,000 children, with the highest attack rate in children < 1 year. Of 53 cases analysed, 87% were due to meningococcus B. Fever (100%), rash (91%), and elevation of procalcitonin (94%) were the most frequent findings at diagnosis. Some sign of shock was observed in 70% upon arrival at the hospital. The case-fatality rate was 3.8% and 10 % survived with permanent sequelae. Glasgow coma scale < 15 (odds ratio [OR]= 9.2), seizure (OR=8.3), sepsis without meningitis (OR=9.1), thrombocytopenia (OR=30.5), and disseminated intravascular coagulation (OR= 10.9) showed a greater association with a worse prognosis.

CONCLUSION

The MID continues to be a significant cause of morbidity and mortality in children. Therefore, new advances are needed in the prevention, early diagnosis, and detection of the factors associated with poor prognosis.

Radiological characterisation and radon equilibrium factor in the outdoor air of a post-industrial urban area

The radiological characterisation of outdoor air is always a complicated task due to the several radioactive emissions coming from the different radionuclides and also because of the very short half-lives of radionuclides in the natural radioactive series. In some places, this characterisation could result in unusual values because the natural presence of radionuclides with terrestrial origin can be modified by manmade activities. Nonetheless, this characterisation is useful not only for air quality control purposes but also because radon and its progeny in the outdoor air are the main contributors to human exposure from natural sources. In this study, we have carried out air particle sampling, followed by gamma-ray spectrometry, alpha spectrometry and beta counting determinations for this purpose. Subsequently, the outdoor air has been radiologically characterised through the obtained data and using a pre-existing analytical method to take into account the radioactive decays of short half-life radionuclides during sampling, sample preparation and measuring times. Bilbao was chosen to carry out this work. It is a medium-sized town located in northern Spain, close to the Atlantic Ocean and at sea level. This city has a recent industrial past as there were numerous steel mills and other heavy industries, including some quarries, and some open pit mines close to it, which concluded in a remediation program. So, it is a place where the air is potentially modified by manmade activities. The obtained results show that activity concentration values for long-lived radionuclides that precede radon and thoron are in the order of 10(-6) Bq m(-3) and long-lived ones after radon are around 10(-4) Bq m(-3). Thoron progeny are around 2 × 10(-2) Bq m(-3) and radon progeny are around 1.8 Bq m(-3). The mean radon equilibrium factor was 0.18. All of these values are close to the minimum UNSCEAR values, but show some variability, which highlights the importance of determining activity concentrations for each naturally occurring radionuclide and the equilibrium factor in the outdoor air.

Helicobacter pylori second-line rescue therapy with levofloxacin- and bismuth-containing quadruple therapy, after failure of standard triple or non-bismuth quadruple treatments

BACKGROUND

The most commonly used second-line Helicobacter pylori eradication regimens are bismuth-containing quadruple therapy and levofloxacin-containing triple therapy, both offering suboptimal results. Combining bismuth and levofloxacin may enhance the efficacy of rescue eradication regimens.

AIMS

To evaluate the efficacy and tolerability of a second-line quadruple regimen containing levofloxacin and bismuth in patients whose previous H. pylori eradication treatment failed.

METHODS

This was a prospective multicenter study including patients in whom a standard triple therapy (PPI-clarithromycin-amoxicillin) or a non-bismuth quadruple therapy (PPI-clarithromycin-amoxicillin-metronidazole, either sequential or concomitant) had failed. Esomeprazole (40 mg b.d.), amoxicillin (1 g b.d.), levofloxacin (500 mg o.d.) and bismuth (240 mg b.d.) was prescribed for 14 days. Eradication was confirmed by (13) C-urea breath test. Compliance was determined through questioning and recovery of empty medication envelopes. Incidence of adverse effects was evaluated by questionnaires.

RESULTS

200 patients were included consecutively (mean age 47 years, 67% women, 13% ulcer). Previous failed therapy included: standard clarithromycin triple therapy (131 patients), sequential (32) and concomitant (37). A total of 96% took all medications correctly. Per-protocol and intention-to-treat eradication rates were 91.1% (95%CI = 87-95%) and 90% (95%CI = 86-94%). Cure rates were similar regardless of previous (failed) treatment or country of origin. Adverse effects were reported in 46% of patients, most commonly nausea (17%) and diarrhoea (16%); 3% were intense but none was serious.

CONCLUSIONS

Fourteen-day bismuth- and levofloxacin-containing quadruple therapy is an effective (≥90% cure rate), simple and safe second-line strategy in patients whose previous standard triple or non-bismuth quadruple (sequential or concomitant) therapies have failed.

Revealing hidden clonal complexity in Mycobacterium tuberculosis infection by qualitative and quantitative improvement of sampling

The analysis of microevolution events, its functional relevance and impact on molecular epidemiology strategies, constitutes one of the most challenging aspects of the study of clonal complexity in infection by Mycobacterium tuberculosis. In this study, we retrospectively evaluated whether two improved sampling schemes could provide access to the clonal complexity that is undetected by the current standards (analysis of one isolate from one sputum). We evaluated in 48 patients the analysis by mycobacterial interspersed repetitive unit-variable number tandem repeat of M. tuberculosis isolates cultured from bronchial aspirate (BAS) or bronchoalveolar lavage (BAL) and, in another 16 cases, the analysis of a higher number of isolates from independent sputum samples. Analysis of the isolates from BAS/BAL specimens revealed clonal complexity in a very high proportion of cases (5/48); in most of these cases, complexity was not detected when the isolates from sputum samples were analysed. Systematic analysis of isolates from multiple sputum samples also improved the detection of clonal complexity. We found coexisting clonal variants in two of 16 cases that would have gone undetected in the analysis of the isolate from a single sputum specimen. Our results suggest that analysis of isolates from BAS/BAL specimens is highly efficient for recording the true clonal composition of M. tuberculosis in the lungs. When these samples are not available, we recommend increasing the number of isolates from independent sputum specimens, because they might not harbour the same pool of bacteria. Our data suggest that the degree of clonal complexity in tuberculosis has been underestimated because of the deficiencies inherent in a simplified procedure.

Effective dose in SMAW and FCAW welding processes using rutile consumables

The shielded metal arc welding (SMAW) and flux cored arc welding (FCAW) processes use covered electrodes and flux cored wire as consumables. Among these consumables, ones containing rutile are the most widely used, and since they have a considerable natural radioactive content, they can be considered as NORM (naturally occurring radioactive material). To calculate the effective dose on workers during their use in a conservative situation, samples of slag and aerosols and particles emitted or deposited during welding were taken and measured by gamma, alpha and beta spectrometry. An analytical method was also developed for estimating the activity concentration of radionuclides in the inhaled air. (222)Rn activity concentration was also assessed. With all these data, internal and external doses were calculated. The results show that external doses are negligible in comparison with internal ones, which do not exceed 1 mSv yr(-1), either in this conservative situation or in any other more favourable one. Radionuclides after Rn in the radioactive natural series are emitted at the same activity concentration to the atmosphere, this being around 17 times higher than that corresponding to radionuclides before Rn. Taking into account these conclusions and the analytical method developed, it can be concluded that one way to assess the activity concentration of natural radionuclides in inhaled air and hence effective doses could be the early gamma-ray spectrometry of aerosols and particles sampled during the welding process.

[Septic arthritis of the hip by Haemophilus Influenzae type F in childhood: a case report]

Septic arthritis of the hip is an acute infection, predominantly of bacterial etiology. Although Staphylococcus aureus is the primary pathogen in any age group, other potentially pathogenic microorganisms exist. We describe the case of an 18-month patient with septic arthritis of the hip with a rare causal agent (Haemophilus influenzae type F) and a good outcome. This case highlights the importance of considering other less common etiologic agents for septic arthritis in children, performing arthrocentesis with synovial fluid culture before starting antibiotic treatment, whenever this is possible. In addition, as in this case, it should be noted that a positive synovial fluid culture for Haemophilus influenzae forces typification of the bacteria in order to rule out or confirm a vaccine failure.

Effective dose in the manufacturing process of rutile covered welding electrodes

Shielded metal arc welding using covered electrodes is the most common welding process. Sometimes the covering contains naturally occurring radioactive materials (NORMs). In Spain the most used electrodes are those covered with rutile mixed with other materials. Rutile contains some detectable natural radionuclides, so it can be considered a NORM. This paper mainly focuses on the use of MCNP (Monte Carlo N-Particle Transport Code) as a predictive tool to obtain doses in a factory which produces this type of electrode and assess the radiological impact in a specific facility after estimating the internal dose.To do this, in the facility, areas of highest radiation and positions of workers were identified, radioactive content of rutile and rutile covered electrodes was measured, and, considering a worst possible scenario, external dose at working points has been calculated using MCNP. This procedure has been validated comparing the results obtained with those from a pressurised ionisation chamber and TLD dosimeters. The internal dose has been calculated using DCAL (dose and risk calculation). The doses range between 8.8 and 394 μSv yr(-1), always lower than the effective dose limit for the public, 1 mSv yr(-1). The highest dose corresponds to the mixing area.

Map on predicted deposition of Cs-137 in Spanish soils from geostatistical analyses

The knowledge of the distribution of (137)Cs deposition over Spanish mainland soils along with the geographical, physical and morphological terrain information enable us to know the (137)Cs background content in soil. This could be useful as a tool in a hypothetical situation of an accident involving a radioactive discharge or in soil erosion studies. A Geographic Information System (GIS) would allow the gathering of all the mentioned information. In this work, gamma measurements of (137)Cs on 34 Spanish mainland soils, rainfall data taken from 778 weather stations, soil types and geographical and physical terrain information were input into a GIS. Geostatistical techniques were applied to interpolate values of (137)Cs activity at unsampled places, obtaining prediction maps of (137)Cs deposition. Up to now, geostatistical methods have been used to model spatial continuity of data. Through semivariance and cross-covariance functions the spatial correlation of such data can be studied and described. Ordinary and simple kriging techniques were carried out to map spatial patterns of (137)Cs deposition, and ordinary and simple co-kriging were used to improve the prediction map obtained through a second related variable: namely the rainfall. To choose the best prediction map of (137)Cs deposition, the spatial dependence of the variable, the correlation coefficient and the prediction errors were evaluated using the different models previously mentioned. The best result for (137)Cs deposition map was obtained when applying the co-kriging techniques.

[Imported infectious diseases in fever of unknown origin in migrant children: 2 cases]

The increase in migratory movements has increased the incidence of infectious diseases that were infrequent in our setting. In the presence of fever in children from endemic areas, imported infectious diseases must be ruled out in the first place. We present two cases of typhoid fever in immigrant children, recently diagnosed in our centre. Both from countries with a high prevalence of the disease were admitted for study of fever of unknown origin. The two patients had been living in our country for less than one month. Isolation of the gram-negative bacillus in the blood cultures provided the key for reaching the etiological diagnosis. In both cases endovenous antibiotherapy was established and both the blood cultures and stools became negative before discharge. At present the two children are free of the disease.

Breast carcinomas with hyperprolactinemia at the time of diagnosis-clinico-biological association

AIM

To analyse association between preoperative hyperprolactinemia serum levels and clinical and biological features of breast tumors.

METHODS

Serum levels of prolactin were measured in 253 women with invasive breast cancer. Clinical and biological parameters analysed were age, size, lymph node involvement, distant metastasis and immunohistochemical expression of estrogen receptor, progesterone receptor, androgen receptor, bcl-2, p53 and Ki67.

RESULTS

In ductal carcinomas hyperprolactinemia were associated with high age (p = 0.017), and with bcl-2 + + + expression (p = 0.017). Furthermore, serum prolactin values were significantly higher in bcl-2 +++ cases vs negative (p = 0.029); the same happened when we considered the positivity threshold of 25 ng/mL (p = 0.015).

CONCLUSION

Is possible to detect in 6% of infiltrating ductal breast carcinomas hyperprolactinemia (>25 ng/mL), being associated only with increasing age, but not with other clinical or biological factors; and 2) the most surprising data was the association between prolactinemia (qualitative (>25 ng/mL) and quantitative) and intense bcl-2 tissue expression, which suggests that, probably, this (prolactinemia) is not a sign of worse prognosis and evolution.

Uncertainties in 63Ni and 55Fe determinations using liquid scintillation counting methods

The implementation of (63)Ni and (55)Fe determination methods in an environmental laboratory implies their validation. In this process, the uncertainties related to these methods should be analysed. In this work, the expression of the uncertainty of the results obtained using separation methods followed by liquid scintillation counting is presented. This analysis includes the consideration of uncertainties coming from the different alternatives which these methods use as well as those which are specific to the individual laboratory and the competency of its operators in applying the standard ORISE (Oak Ridge Institute for Science and Education) methods.

Differential findings regarding molecular epidemiology of tuberculosis between two consecutive periods in the context of steady increase of immigration

The demographic characteristics of the population of Madrid, with a steady increase in immigrants, from 4.7% in 1998 to 17.4% in 2007, provide an opportunity to study in depth the transmission of TB. Our aim was to compare two 3-year longitudinal molecular studies of TB to define transmission patterns and predictors of clustering. Two prospective population-based molecular and epidemiological studies (2002-2004 and 2005-2007) of TB patients were conducted in nine urban districts in Madrid using the same methodology. During the period 2002-2007, 2248 cases of TB were reported, and the incidence decreased from 23.5 per 100,000 in 2002 to 20.8 in 2007 (p <0.001). A total of 1269 isolates were molecularly characterized and included in the study. The comparison between the two periods showed that the percentage of foreign-born patients among TB cases increased from 36.2% to 45.7% (p <0.001). Furthermore, the percentage of clustered cases decreased (36.6% vs. 30.6%; p 0.028), and this decline was associated with a decrease of clustered cases among men and people under 35 years. We also observed a decrease in cases belonging to clusters containing ≥ 6 people (14.2% vs. 8.2%; p <0.001), and in cases belonging to mixed clusters containing Spanish-born and foreign-born patients (18.5% vs. 11.1%, p <0.001). Our molecular epidemiology study provides clues to interpret the decrease in the incidence of TB in a context of steady increase of immigration. In our region, the decrease in the incidence of TB can be explained predominantly as a result of a decline in recent transmission.

Inventory and vertical migration of 90Sr fallout and 137Cs/90Sr ratio in Spanish mainland soils

In this paper the inventory of (90)Sr in 34 points distributed along the Spanish peninsular territory is presented. Obtained values range between 173 Bq/m(2) and 2047 Bq/m(2). From these data set and those (137)Cs data obtained in a previous work the (137)Cs/(90)Sr activity ratio has been established, laying this value between 0.9 and 3.6. Also the migration depth of both radionuclides has been analysed obtaining for (137)Cs an average value 57% lower than that obtained for (90)Sr. Additionally, this paper presents the results obtained in 11 sampling points in which the activity vertical profile has been measured. These profiles have been analysed to state the behaviour of strontium in soils and after, by using a convective-diffusive model, the parameters of the model which governs the vertical migration of (90)Sr in the soil, v (apparent convection velocity) and D (apparent diffusion coefficient) have been evaluated. Mean values obtained are 0.20 cm/year and 3.67 cm(2)/year, respectively.

Inventory and vertical migration of ¹³⁷Cs in Spanish mainland soils

In this study the total activity of (137)Cs deposited per unit area over the Spanish peninsular territory was analysed using a 150 × 150 km(2) mesh grid, with samples taken from 29 points. The deposited activities ranged between 251 and 6074 Bq/m(2). A linear relationship was obtained between these values and the mean annual rainfall at each sampling point which allowed a map to be drawn, using GIS software, which shows the distribution of total deposited (137)Cs activity across the Spanish mainland. At twelve of these sampling points the vertical migration profile of (137)Cs was obtained. These profiles are separated into two groups with different behaviour, one of which includes clay and loam soils and the other containing sandy soils. For both groups of profiles the parameters of the convective-diffusive model, which describes the vertical migration of (137)Cs in the soil, v (apparent convection velocity) and D (apparent diffusion coefficient) were calculated.

International standardisation work on the measurement of radon in air and water

Radon is considered to be the main source of human exposure to natural radiation. As stated by the World Health Organization, the exposure due to the inhalation of indoor radon is much greater than the one via the ingestion of water as radon degasses from water during handling. In response to these concerns about the universal presence of radon, environmental assessment studies are regularly commissioned to assess the radon exposure of public and workers. The credibility of such studies relies on the quality and reliability of radon analysis as well as on the sample representativeness of the radiological situation. The standard-setting approach, based on consensus, seemed to lend itself to a settlement of technical aspects of potential comparison. At present, two Working Groups of the International Standardization Organization are focussing on drafting standards on radon and its decay products measurement in air and water. These standards, which aim for a set of rigorous metrology practices, will be useful for persons in charge of the initial characterisation of a site with respect to natural radioactivity as well as to those performing the routine surveillance of specific sites.

The disequilibrium between 210Po and 210Pb in raw and drinking waters

Many countries have to monitor and control the radioactivity in drinking waters in order to ensure compliance with the requirements of their respective regulations. Among radionuclides responsible for this radioactivity there are (210)Po and (210)Pb, which are usually not in radioactive equilibrium in waters. This paper deals with the analysis of this disequilibrium and the way that the water treatment plants affect it. To do this, (210)Po and (210)Pb activity concentrations were measured in raw and drinking water. The measurements were performed by alpha-particle spectrometry and gas flow proportional counting and the corresponding formulae for uncertainties and detection limits are presented. The values obtained show that the Po/Pb ratio is lower in surface than in ground waters. Regarding water treatment, this ratio adopts values lower in drinking water than in raw waters. In any case, for the waters analysed in this work the committed effective doses due to these radionuclides, are negligible.

Characterization of Mycobacterium tuberculosis Beijing isolates from the Mediterranean area

BACKGROUND

The Beijing lineage of Mycobacterium tuberculosis is causing concern due to its global distribution and its involvement in severe outbreaks. Studies focused on this lineage are mainly restricted to geographical settings where its prevalence is high, whereas those in other areas are scarce. In this study, we analyze Beijing isolates in the Mediterranean area, where this lineage is not prevalent and is mainly associated with immigrant cases.

RESULTS

Only 1% (N = 26) of the isolates from two population-based studies in Spain corresponded to Beijing strains, most of which were pan-susceptible and from Peruvian and Ecuadorian patients. Restriction fragment length polymorphism typing with the insertion sequence IS6110 identified three small clusters (2-3 cases). Mycobacterial interspersed repetitive unit-variable number tandem repeat typing (MIRU-15) offered low discriminatory power, requiring the introduction of five additional loci. A selection of the Beijing isolates identified in the Spanish sample, together with a sample of Beijing strains from Italy, to broaden the analysis context in the Mediterranean area, were assayed in an infection model with THP-1 cells. A wide range of intracellular growth rates was observed with only two isolates showing an increased intracellular replication, in both cases associated with contained production of TNF-alpha. No correlation was observed between virulence and the Beijing phylogenetic group, clustered/orphan status, or resistance. The Beijing strain responsible for extensive spread on Gran Canaria Island was also identified in Madrid, but did not lead to secondary cases and did not show high infectivity in the infection model.

CONCLUSIONS

The Beijing lineage in our area is a non-homogeneous family, with only certain highly virulent representatives. The specific characterization of Beijing isolates in different settings could help us to accurately identify the virulent representatives before making general assumptions about this lineage.

A single dose of intravenous esomeprazole decreases gastric secretion in healthy volunteers

BACKGROUND

Data suggest that esomeprazole decreases gastric secretion.

AIMS

To assess the effect of a single i.v. esomeprazole dose on gastric secretion volume 3 h after drug administration, as a primary endpoint, and to evaluate, as secondary endpoints, the reduction 1 and 5 h after dosing; time when the gastric pH was <2.5 and esomeprazole's safety.

METHODS

In all, 23 healthy Helicobacter pylori-negative volunteers (10 men, 13 women, mean age 28.2 +/- 6) participated in this single-centre, randomized, double-blind, placebo-controlled, 2-way, single-dose cross-over study. In different sessions, volunteers received i.v. either esomeprazole 40 mg or placebo. An inserted double-lumen nasogastric tube perfused and aspirated gastric liquid. Mechanical fractioned aspiration measured secretion volume; aliquot spectrophotometry assessed gastric secretion volume lost to the duodenum.

RESULTS

Three hours post-i.v. esomeprazole, average gastric secretion decreased by 77.6% (vs. baseline) compared to placebo. Values 1 and 5 h after dosing were 73.5% and 74.5%. Five hours after esomeprazole, the gastric pH was <2.5 3.9% of the time and 73.3% after placebo (P < 0.002). Esomeprazole was well-tolerated. No serious adverse events occurred.

CONCLUSIONS

Intravenous esomeprazole decreases gastric secretions. The potential clinical impact in averting bronchoaspiration during anaesthesia induction and in intensive care patients should be investigated in further studies.

Transmission permeability of tuberculosis involving immigrants, revealed by a multicentre analysis of clusters

In recent years, the number of cases of tuberculosis (TB) among immigrants in Spain has increased markedly, and led to this analysis of the recent transmission patterns of TB in the immigrant population in Madrid. The countries from which the highest number of immigrant cases have been reported were Ecuador (21%), Romania (16%), Morocco (12%), Peru (11%) and Bolivia (9%). Fifty-one per cent of the cases were from South America. In a multicentre study (2004-2006), IS6110 restriction fragment length polymorphism and spoligotyping were used to genotype the Mycobacterium tuberculosis isolates from 632 immigrant cases from 47 countries. A total of 183 cases (29%) were grouped into 59 clusters, which are markers of potential transmission events. Most of the clusters (81%) included patients living in different healthcare districts, and 54% of the clusters were multinational. When a sample of 478 autochthonous cases was included, 53% of the clusters involving immigrants also included autochthonous cases. This study revealed marked transmission permeability among nationalities and between the immigrant and the autochthonous populations.

Epidemiologic impact of blood culture practices and antibiotic consumption on pneumococcal bacteraemia in children

This study examined the roles of two different diagnostic approaches to children with fever of unknown origin in determining the patterns of pneumococcal bacteraemia in two Spanish regions by comparing their main epidemiologic characteristics. Whereas a blood culture is routinely obtained in this setting in Navarre, this is not generally the case in Majorca. Additionally, the potential role of antibiotic consumption in each region was also analysed. Cumulative incidences in children under the age of 14 years were 26.6 per 100,000 child-years in Navarre (121.1 in children <2 years of age) and 7.3 per 100,000 child-years in Majorca (33.3 in children <2 years of age). In contrast, the incidences per 1,000 blood cultures were similar in both regions. The relative risks of occult bacteraemia, bacteraemic pneumonia and meningitis among the children of Navarre compared to Majorcan children were 11.8, 2.6 and 0.8, respectively. The risk for less virulent (vaccine serotypes plus 6A, 19A and 23A) and for more virulent serotypes (1 and 7) was 4.9 and 3.1 times higher in Navarre, respectively. The number of 7-valent pneumococcal conjugate vaccine (PCV7) doses administered between 2003 and 2004 were also higher in Navarre. Conversely, antibiotic resistance and paediatric prescriptions for broad-spectrum antibiotics were greater in Majorca. Although the most salient differences between both regions, including the effectiveness of pneumococcal conjugate vaccine in Navarre, appeared to be confounded by the higher frequency of blood cultures taken there, certain differences in serotype composition may be explained by the higher antibiotic consumption in Majorca.