Oxacillinases and antimicrobial susceptibility of Ralstonia pickettii from pharmaceutical water systems in Croatia

This study evaluated antibiotic susceptibility and presence of bla_OXA22 and bla_OXA60 genes in 81 isolates of Ralstonia pickettii obtained from different purified and ultra-pure water systems in two different geographical areas of Croatia. E-test and disk diffusion test were performed to determine antibiotic susceptibility. Polymerase Chain Reaction was applied to detect genes encoding OXA-22 and OXA-60, oxacillinases previously identified in R. pickettii. The isolates were genotyped by pulsed-field gel electrophoresis. The results revealed variable susceptibility/resistance profiles. Our isolates exhibited high susceptibility rates to ceftriaxone, cefotaxime, piperacillin-tazobactam, ciprofloxacin, imipenem, cefepime and in lesser extent to ceftazidime. High rates of susceptibility were also observed for sulfamethoxazole-trimethoprim and piperacillin. High resistance rates were noticed for ticarcillin-clavulanate, aztreonam and meropenem, as well as for all aminoglycosides tested. Modified Hodge test was positive in 51,9% strains, indicating production of carbapenemases. bla_OXA22 and bla_OXA60 genes were detected in 37.0% and 80.3% strains, respectively. Pulsed-field gel electrophoresis identified three major clusters containing subclusters. R. pickettii should be taken seriously as a possible cause of nosocomial infections to ensure adequate therapy, to prevent the development of resistant strains and to try to reduce the possibility of R. pickettii surviving in clean and ultra clean water systems.

Warm red blood cell autoantibodies and clinical diagnoses in patients with or without autoimmune hemolysis

OBJECTIVES

Red blood cell autoantibodies (RBC autoAbs) of IgG class are found in the majority of patients with warm autoimmune hemolytic anemia (wAIHA) but sometimes also during the pretransfusion testing of patients with different diagnoses but without hemolysis. The aim of the study was to identify the main differences between these two groups of patients according to age, gender, subclass and titer of IgG RBC autoAbs and diagnosis.

MATERIAL AND METHODS

In the 9-year retrospective study, data were collected from records of 291 patients with IgG RBC autoAbs detected by gel technique, from which 111 with wAIHA.

RESULTS

More than 85% of patients in both groups were over 40 years old, with male to female ratio 1:1.9 in wAIHA vs 1:1.3 in patients without hemolysis (P=0.0916). The main characteristics of patients with wAIHA vs patients without hemolysis were: IgG only 38% vs 70%, IgG+Complement 62% vs 30%, total IgG1 79% vs 55%, IgG1+IgG3 35% vs 11%, titer of 100 for IgG1+IgG3 17% vs 3% (P<0.0001), respectively, while titer of 100 for IgG1 18% vs 9% (P=0.0241). The underlying diagnosis in wAIHA vs patients without hemolysis: hematologic disorders 41% vs 22% (P=0.0006), autoimmune disorders 12% vs 13% (P=0.8033), solid tumors 5% vs 14% (P=0.0154) and surgery procedures 6% vs 26% (P<0.0001).

CONCLUSION

We observed more wAIHA patients with high titer of IgG1 and high prevalence of IgG1+IgG3 and consider that patients without hemolysis having identical results might be interesting to find out how they are protected from damage by RBC autoAbs.

Lamotrigine in the treatment of pain syndromes and neuropathic pain

Anti-epileptic drugs are increasingly used in the treatment of pain syndromes and neuropathic pain. Sodium channel blockers can be effective in the treatment of pain. The object of our interest is the efficiency of lamotrigine in treating the pain. A MEDLINE search was conducted to identify pertinent studies, case reports, letters, and reviews in English published from 1986 to May 2007. The search has indicated efficiency in treating a number of painful syndromes and neuropathic pain; central pain, trigeminal neuralgia and trigeminal neuralgia in multiple sclerosis, pain in multiple sclerosis, SUNCT syndrome, cluster headache, glossopharyngeal neuralgia, neuropathic pain, allodynia, neuralgia after nerve section, postherpetic neuralgia, HIV-associated neuropathy. Further researches are required on the role of lamotrigine in treating the spinal cord injury pain, neuralgia after nerve section, postoperative analgesic requirement, and in migraine (Tab. 1, Ref. 46). Full Text (Free, PDF) www.bmj.sk.

Auditory evoked potentials (AEP)--an important help in early diagnosis of Schwannoma originating from vestibular nerve

Early diagnosis of expansive formations enables efficient therapy and maximal reduction of remaining neurological damage. Schwannoma situated entirely within the inner auditory canal with free pontocerebellar angle is a rather rare event. Of significant diagnostical help are auditory evoked potentials (AEP), computerised tomography (CT) of the temporal bone pyramid with measuring the inner auditory canal diameter, and magnetic resonance (MRI). In this paper we present a case of a 56-year-old woman with gradually advancing noise in the right ear, weakening of hearing and occasional instability while walking. AEP register no evoked response at the right side, whereas at the left side the latencies and amplitudes of evoked acoustic responses are adequate. CT of the temporal bone pyramid shows a difference in the inner auditory canal diameters of 0.04 cm. MRI shows a Schwannoma tumorous formation in the inner auditory canal, situated entirely within the canal with free pontocerebellar angle (Fig. 3, Ref. 16). Full Text (Free, PDF) www.bmj.sk.

Clinical manifestations of vertebrobasilar dolichoectasia

Vertebrobasilar dolichoectasia is defined as an increase in the length and diameter of the intracranial arteries. Clinical manifestations of dolichoectasiae result from compression of the cranial nerves and structures of the brain stem, turbulent flow causing tinnitus and vertigo, often with damages of small blood vessels of the brain. Dolichoectasia is an ishemic stroke risk factor. The role of dolichoectasia in occurrence of haemorrhagic stroke, aneurysm and arterial dissection and thrombosis is still not fully understood (Ref. 34).

An acute headache and hydrocephalus caused by the dermoid cyst

We present a case report of a 41-year-old man with an acute headache and hydrocephalus caused by the dermoid cyst. The dermoid cyst of the third brain ventricle caused an acute hydrocephalus and an increased intracranial pressure (with neurological signs such as nausea, vomiting, oedema papilae n. optici) and, consequently, an acute intensive headache. Computed tomography scans demonstrated a mass in the third ventricle extending into the prepontine cistern, whereas any initially established cerebrospinal fluid ventriculoperitoneal shunt required further revision (Fig. 2, Ref. 12). Full Text (Free, PDF) www.bmj.sk.

Vertigo associated with Chiari I malformation and syringomyelia

We report a rare case of a patient with late onset of Chiari I malformation with associated syringomyelia that was successfully treated with foramen magnum decompression. Our patient is presenting initially with vertigo and gradual weakening of the left-hand gross motor ability, gradual hypesthesia. Magnetic resonance imaging demonstrated a Chiari I malformation with syringomyelia. Posterior fossa decompression, C1 laminectomy and duroplasty were performed. After surgery, the vertigo completely resolved (Fig. 2, Ref. 13). Full Text (Free, PDF) www.bmj.sk.

Side effects of ropinirole in patients with idiopathic Parkinson's disease

OBJECTIVE

Results achieved in treating the Parkinson's disease (PD) by the dopamine receptor agonist, ropinirole, have been hampered by its side effects. According to the MEDLINE, the most common side effects of ropinirole are extreme sleepiness and/or sudden sleep attacks, nausea, dyspepsia, vertigo, orthostatic hypotension and leg oedema.

METHODS

The prospective research included PD patients who were administered non-ergoline dopamine agonist, ropinirole, over this period of time. The control group of patients were treated with levodopa.

RESULTS

The research included 50 patients: 31 women and 19 men, of the mean age of 61.4 +/- 4.3 years. One patient reported sleepiness and one of them sudden sleep attacks. Nausea was experienced by three patients, and vertigo by two. Depression, orthostatic hypotension, leg oedema, dyspepsia, dry cough and hypersalivation were registered in particular cases. The control group of PD patients, treated with levodopa, comprised 52 patients, 33 women and 19 men of the mean age of 63.2 +/- 4.1 years. In the control group, nausea was registered in two patients.

CONCLUSIONS

The non-ergoline dopamine agonist, ropinirole, most commonly causes nausea and sleepiness, less commonly uncontrollable sleep attacks, vertigo, dyspepsia, orthostatic hypotension, leg oedema. Dry cough and hypersalivation are recorded sporadically (Tab. 1, Ref. 22).

Cognitive impairment and epilepsy seizure caused by hypoparathyroidism

We report a 46-years-old man with idiopathic hypoparathyroidism who presented with gradually cognitive impairment and generalized tonic clonic epilepsy. Computed tomography (CT) and magnetic resonance imaging (MRI) of brain showed calcification in the basal ganglia, thalamus and cerebral white matter. Calcium level was low and phosphor was increased in serum, but parathormon level was low. Following introduction of replacement therapy, cognitive functions improved as well. After treatment with calcium and vitamin D supplementation he showed clinical, cognitive impariment and laboratory improvements (Fig. 2, Ref. 13).

Neurocysticercosis--non-specific clinical and neuroradiological presentation

Neurocysticercosis (cysticercosis cerebri) is a rare neurological diagnosis in Croatia. It is classically divided into four types: intraparenchymal, basilar cisternal, ventricular and diffuse. Computerized tomography (CT) and magnetic resonance imaging (MRI) established the diagnosis by demonstrating cysticercosis disseminated throughout the cerebral parenchyma. The authors emphasize the potential of the ELISA test to detect anticysticercosis antibodies in blood and cerebrospinal liquor (CSF). Diagnostics of neurocysticercosis is enabled jointly by clinical signs, neuroradiological, serum and liquor tests. We report the case of a 70-year old man with clinical and neuroradiological signs of cysticercosis cerebri. The neurological status is dominated by ataxia, corticospinal pathways damages and cognitive capacity impairments. CT of the brain shows calcificated and cystic lesions of various sizes. MRI of the brain enables the final diagnosis of the cysticercosis cerebri with multiple and multicentric lesions that indicate various stages of the cerebral cysticercosis (Fig. 2, Ref 20). Full Text (Free, PDF) www.bmj.sk.

Effects of APACHE II score on mechanical ventilation; prediction and outcome

AIM

To evaluate the influence of Acute Physiology and Chronic Health Evaluation (APACHE II) score on the choice of mechanical ventilation method and treatment outcome.

METHODS

A prospective, randomized trial was carried out at the multidisciplinary Intensive Care Unit over 22 months. Research sample consisted of 129 patients who required mechanical ventilation, divided in two groups: APACHE II < or = 20 and APACHE II > 20. Both groups were than randomized for either noninvasive or invasive mechanical ventilation. Comparison was made based on patient characteristics, objective parameters and influence of APACHE II score on treatment success and failure.

RESULTS

APACHE II scoring was shown to have statistical significance on outcome assessment. Statistical significance was in favour of patients with APACHE II score < or = 20 vs > 20 (ventilator associated pneumonia 0 vs. 10, tracheotomy 0 vs. 16, Intensive Care Unit mortality 0 vs 12). Furthermore, in the group with APACHE II score > 20, after randomization, there was a statistical significance in favour of noninvasive mechanical ventilation in need for tracheotomy 2 (4%) vs. 14 (28%) (p < 0.001).

CONCLUSION

Using good patient selection and applying strict protocols, in the group of patients with APACHE II < or = 20 all patients had successful mechanical ventilation, while in the group of patients with APACHE II > 20, noninvasive mechanical ventilation can be applied.

Tinnitus caused by vertebrobasilar dolichoectasia

A 73-year old man presented with the tinnitus in the left ear for 11 months. Computer tomography (CT) showed an enlarged dolichoectasia of the left vertebral artery. Magnetic resonance imaging (MRI) of the brain shows dolichoectasia of the left vertebral artery and the initial part of the basilar artery. Multi-slices computer tomographic (MSCT) angiography showed an enlarged vertebrobasilar dolichoectasia of the left vertebral artery, which compressed the vestibulocochlear nerve. This study supports a vascular compression of cranial vestibulocochlear nerve and the brainstem as a cause of tinnitus, and demonstrates a MSCT angiography value as an excellent, non-invasive technique to demonstrate the compression (Fig. 1, Ref. 20). Full Text (Free, PDF) www.bmj.sk.

Clinical importance of somatosensory evoked potentials in early diagnosis of syringomyelia

We report a rare case of syringomyelia, the development of which was monitored by somatosensory evoked potentials. The evoked potentials recorded over an eight months' period of time were correlated with the incidence of syringomyelia. Changes of the evoked response latency and amplitude were dtected. The evoked potential change and the sensation deficit indicated a pathological process. High-resolution MRI revealed syringomyelia in the cervical and the thoracic segments of the spinal cord. Somatosensory evoked potentials represent a sensitive diagnostic method recording changes in the biopotentials. Potential changes require localisation of a possible process and high-resolution MRI. Evoked potentials enable to monitor both, the disease development, but also the healing process (Fig. 3, Ref 11).

Somatosensory-evoked potentials and MRI in tuberculous spondylodiscitis

Early diagnosis of spondylodiscitis is a condition of efficient conservative treatment. Somatosensory-evoked potentials with clinical examination results are used in assessing the diagnosis, as well as in monitoring the course of disease and healing. MRI clearly shows the inflammatory process, healing and scars. We report a 46-year-old woman suffering from non-specific interscapular pains. The evoked somatosensory potentials of the tibial nerveshow potential conductivity being slowed down through the thoracic spine, which is clearly evident from the prolonged latency and the decreased amplitude of the evoked response. The performed thoracic spine MRI shows spondylodiscitis at the Thl0-11 level. The subject is a nurse administering BCG therapy at a urology clinic, due to the fact of which this was deemed to have been a case of tuberculous spondylodiscitis. Due to the possibility of scattering the causative agent by needle, the biopsy was given up and antituberculous therapy was administered ex juvantibus. The disease was followed up by clinical examinations, somatosensory-evoked potentials and MRI up to fully successful and final recovery from spondylodiscitis. The above examinations are of great help in diagnosing the tuberculous spondylodiscitis and monitoring the recovery (Fig. 6, Ref. 16).

Diagnostics of incomplete Brown-Sequard syndrome caused by meningococcal myelitis

We are reviewing a 20-year old girl with the history of acute meningococcal sepsa with meningitis and thoracic myelitis resulting from an early embolia into the spinal cord, which is a very rare complication of meningococcemia. The ipsilateral loss of sensation indicates lesion of the posterior ascendent fiber tracts in the spinal cord, witout contralateral motoricity deficite, this indicating the incomplete Brown-Sequard syndrome. Somatosensory-evoked potentials (SSEP) of the n. tibialis show milder impediments of conductivity by the thoracic segment at left. Magnetic resonance (MRI) of the thoracic spine shows lesion of the posterior ascendent fiber tracts (Fig. 2, Ref. 17).