Supraglottic airway device to improve ventilation success and reduce pulmonary aspiration during cardio-pulmonary resuscitation by basic life support rescuers: a randomised cross-over human cadaver study

Objectives: Early airway management during cardiopulmonary resuscitation (CPR) prevents aspiration of gastric contents. Endotracheal intubation is the gold standard to protect airways, but supraglottic airway devices (SGA) may provide some protection with less training. Bag-mask ventilation (BMV) is the most common method used by rescuers. We hypothesized that SGA use by first rescuers during CPR could increase ventilation success rate and also decrease intragastric pressure and pulmonary aspiration.Methods: We performed a randomized cross-over experimental trial on human cadavers. Protocol A: we assessed the rate of successful ventilation (chest rise), intragastric pressure, and CPR key time metrics. Protocol B: cadaver stomachs were randomized to be filled with 300 mL of either blue or green serum saline solution through a Foley catheter. Each rescuer was randomly assigned to use SGA or BMV during a 5-minute standard CPR period. Then, in a crossover design, the stomach was filled with the second colour solution and another 5-minute CPR period was performed using the other airway method. Pulmonary aspiration, defined as the presence of coloured solution below the vocal cords, was assessed by a blinded operator using bronchoscopy. A generalized linear mixed model was used for statistical analysis.Results: Protocol A: Forty-eight rescuers performed CPR on 11 cadavers. Median ventilation success was higher with SGA than BMV: 75.0% (IQR: 59.8-87.3) vs. 34.7% (IQR: 25.0-50.0), (p = 0.003). Gastric pressure and differential (maximum minus minimum) gastric pressure were lower in the SGA group: 2.21 mmHg (IQR: 1.66; 2.68) vs. 3.02 mmHg (IQR: 2.02; 4.22) (p = 0.02) and 5.70 mmHg (IQR: 4.10; 7.60) vs. 8.05 mmHg (IQR: 5.40; 11.60) (p = 0.05). CPR key times were not different between groups. Protocol B: Ten cadavers were included with 20 CPR periods. Aspiration occurred in 2 (20%) SGA procedures and 5 (50%) BMV procedures (p = 0.44).Conclusion: Use of SGA by rescuers improved the ventilation success rate, decreased intragastric pressure, and did not affect key CPR metrics. SGA use by basic life support rescuers appears feasible and efficient.

Electrical response of La2/3-xLi3xTiO3 ceramics obtained by spark plasma sintering

The ceramic system La2/3-xLi3xTiO3 presents as an interesting candidate to be used as an electrolyte in solid-state Li-ion batteries. In this paper the electrical response of the ceramic, La2/3-xLi3xTiO3 with x = 0.11 is reported. La2/3-xLi3xTiO3 nanoparticles were synthesized by high energy milling and sintered by Spark Plasma Sintering from an amorphous phase. After sintering, the samples were structurally characterized by XRD and Raman techniques. Measurements of complex impedance varying frequency from 1 Hz to 10 MHz and temperature from 25 °C to 270 °C were performed. The study of DC conductivity allowed us to find the contributions to the total conductivity, grain, and grain boundary of the samples. From the activation energy values, it was possible to determine the conductive mechanism corresponding to the mobility of Li+ ions.

Clinical trial on the effect of tranexamic acid on bleeding and fibrinolysis in primary hip and knee replacement

BACKGROUND

Tourniquet-induced ischaemia could increase fibrinolysis and enhance tranexamic acid (TXA) efficacy in total knee arthroplasty (TKA) compared to total hip arthroplasty (THA). The aims of this study are to compare the effect of TXA on bleeding and fibrinolysis in both types of surgery, and to record thromboembolic complications.

METHODS

A prospective double-blind study was conducted on patients scheduled for TKA or THA who received TXA (2 bolus of 10mg/kg) or placebo. Bleeding and fibrinolysis were evaluated. Doppler-ultrasound and computed tomography were performed in order to assess any thromboembolic complications.

RESULTS

A total of 44 patients were included (11 THA and 11 TKA treated with TXA; 11 THA and 11 TKA as controls). Blood losses were significantly lower in the TXA group (mean 921mL vs 1,383mL in THA and 969mL vs 1,223mL in TKA), and no transfusions were needed with TXA, whereas 5 blood units were transfused in controls. TXA was equally effecting in reducing bleeding in both surgeries (33% in THA and 21% in TKA). The significant mean increase in D-dimers from baseline to 6 hours after surgery (1,004 ug/L to 10,284 ug/L in THA and 571 ug/L to 6,480 ug/L in TKA) was attenuated by TXA (1,077 ug/L to 2,590 ug/L in THA and 655 ug/L to 2,535 ug/L in TKA). There were no differences in thromboembolic episodes.

CONCLUSIONS

Prophylactic use of tranexamic acid is equally effective in reducing bleeding in TKA and THA. Both surgeries have a similar effect on fibrinolysis.

Anti-NMDA (a-NMDAR) receptor encephalitis related to acute consumption of metamphetamine: Relevance of differential diagnosis

A 19-year-old male came to the Emergency Room of our hospital due to an episode of dystonic movements and disorientation 4 days after consuming methamphetamine, which evolved to a catatonic frank syndrome and eventually to status epilepticus. Definitive diagnosis was anti-NMDA receptor encephalitis, an acute inflammation of the limbic area of autoimmune origin in which early diagnosis and treatment are key elements for the final outcome. In this case, initial normal tests and previous methamphetamine poisoning delayed diagnosis, because inhaled-methamphetamine poisoning causes similar clinical symptoms to anti-NMDA receptor encephalitis. Methamphetamine poisoning may have caused an immune response in the patient, bringing on the progress of the pathology.

[Health-care workload and instructional capacity of Spanish hospitals accredited to train residents in anesthesiology]

OBJECTIVES

To describe the health-care workload and instructional capacity of Spanish hospitals accredited to train anesthesiology residents.

METHODS

Survey of supervisors of anesthesiology residents in 2008 to determine caseloads in surgery and obstetrics as well as in pain clinics and critical care units. The results are presented for different Spanish autonomous communities. The maximum theoretical capacity for instruction in accordance with European guidelines is calculated.

RESULTS

The 100 hospitals surveyed train 325 residents per year and could theoretically increase the training opportunities they offer, within certain limits. Given optimal distribution of resources, the system could train 397 residents per year in pediatric surgery in 3-month rotations, 442 residents in neurosurgery in 2-month rotations, and 479 residents in thoracic surgery in 1-month rotations. Some Spanish communities presently have problems giving training in the settings of pediatric, thoracic, and major outpatient surgery. Furthermore, even though anesthesiologists are presently responsible for 41.6% of available critical care beds, 46 hospitals do not have a sufficient number of beds to give training in this setting. This shortage may have negative repercussions on the accreditation of training programs.

CONCLUSIONS

Although certain limitations were found, the survey showed that the training capacity of the system is greater than accreditation suggests. It would therefore be possible to increase the number of residents.

[Acute intermittent porphyria and inappropriate ADH syndrome]

A 44-year-old woman complained of abdominal pain of 4 days' duration accompanied by vomiting and painful urination. The admitting physician noted neurologic signs consistent with axonal polyneuropathy and hyponatremia. In the absence of other explanations for the syndrome, SIADH was diagnosed. Because of the nonspecific nature of the observations, the patient was assessed by various specialists and admitted to the anesthetic recovery unit due to worsening of neurologic signs and suspicion of acute intermittent porphyria. The diagnosis was confirmed by laboratory findings of elevated d-aminolevulinic acid and porphobilinogen levels and normal stool porphyrins. The patient improved with intravenous hematin infused over 4 days.

Subtype-specific changes in 5-HT receptor-mediated modulation of C fibre-evoked spinal field potentials are triggered by peripheral nerve injury

Neurotransmitter serotonin (5-HT) released from descending pain modulation pathways to the dorsal horn is crucial to spinal nociception processing. This study sought to gain insight into the modulatory roles of specific serotonin receptor subtypes in experimentally induced neuropathic pain. In rats subjected to spinal nerve ligation (SNL) surgery, we recorded field potentials evoked in the spinal dorsal horn by C fibre-input, during spinal superfusion with subtype-selective drugs. In neuropathic rats, subtype 5-HT1A agonist 8-OH-DPAT (100 nM) was found to potently depress evoked field potentials, as opposed to 5-HT2A or 5-HT2B subtype agonists TCB-2 (100 nM) or BW 723C86 (1 microM), respectively, which consistently enhanced evoked potentials. All three failed to alter spinal field potentials in sham operated rats. CP 94253 (1 microM), WAY 161503 (1 mM) or SR 57227 (at 1 microM in SNL rats, and 100 microM in sham rats), selective agonists for 5-HT1B, 5-HT2C and 5-HT3 receptors, respectively, significantly depressed evoked field potentials in both animal groups. The 5-HT4 agonist RS 67333 (1 microM) was depressant only in sham operated animals. Only after SNL, spinal superfusion with 5-HT1A- or 5-HT1B receptor-antagonists (S)-WAY 100135 (100 microM) or SB 224289 (100 microM), respectively, disinhibited C fibre-evoked potentials, whereas 5-HT2A or 5-HT2B receptor-antagonists 4F 4PP (100 microM) or SB 204741 (100 microM) depressed evoked potentials, suggesting tonic activity of all four subtypes as a consequence of experimental nerve injury. The present findings reveal profound subtype-specific changes in the functional modulatory activities of spinal serotonin receptors following peripheral nerve injury. In particular, spinal hyperexcitation promoted by receptors 5-HT2A and 5-HT2B is suggested as a novel pathogenic pathway contributing to neuropathic pain.

[Acute respiratory failure after treatment with cyclophosphamide in a patient with proliferative glomerulonephritis]

Cyclophosphamide is an alkylating immunosuppressant drug that is used mainly in neoplastic and immunologic diseases. Lung toxicity due to treatment with cyclophosphamide, though rare, often has a poor prognosis. Diagnosis of the lung lesion is difficult because these patients have associated immunosuppression and a consequent risk of opportunistic lung infections. We report the case of a man with acute respiratory distress syndrome after treatment with cyclophosphamide for proliferative crescentic glomerulonephritis. The diagnosis of lung lesion due to cyclophosphamide was based on ruling out other possible causes. The principal diagnostic tool used was bronchoalveolar lavage. The patient progressed satisfactorily, responding adequately to corticosteroids and then maintenance therapy, without the need for mechanical ventilation.

Improving the electrical performance of a conductive atomic force microscope with a logarithmic current-to-voltage converter

A new configuration of conductive atomic force microscope (CAFM) is presented, which is based in a standard CAFM where the typical I-V converter has been replaced by a log I-V amplifier. This substitution extends the current dynamic range from 1-100 pA to 1 pA-1 mA. With the broadening of the current dynamic range, the CAFM can access new applications, such as the reliability evaluation of metal-oxide-semiconductor gate dielectrics. As an example, the setup has been tested by analyzing breakdown spots induced in SiO2 layers.

[Meningococcal purpura fulminans: treatment with recombinant protein C activator in 3 cases]

Purpura fulminans is a serious disease associated with high rates of morbidity and mortality. It usually leads to disseminated intravascular coagulation and septic shock related to reduced levels of protein C. Recombinant protein C (rPC) activator has been used successfully to inhibit this process. Intracranial hemorrhages are the most important, life-threatening adverse effects of treatment with rPC activator. We report 3 cases of patients with meningococcal purpura fulminans who developed septic shock and multiorgan dysfunction. They were treated with the protocol for septic shock, antibiotics and rPC activator from the time of admission, and improvement in hemodynamic dysfunction was observed within hours in all patients. All received platelet replacement transfusions. Subarachnoid bleeding complications occurred in 2 patients. One patient died 5 days after admission and 2 were discharged from the intensive recovery care unit 28 days after admission.

Role of secreted glyceraldehyde-3-phosphate dehydrogenase in the infection mechanism of enterohemorrhagic and enteropathogenic Escherichia coli: Interaction of the extracellular enzyme with human plasminogen and fibrinogen

Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) (EC 1.2.1.12) is an anchorless, multifunctional protein displayed on the surface of several fungi and Gram-positive pathogens, which contributes to their adhesion and virulence. To date a role for extracellular GAPDH in the pathogenesis of Gram-negative bacteria has not been described. The aim of this study was to analyze the extracellular localization of GAPDH in enterohemorrhagic (EHEC) and enteropathogenic (EPEC) Escherichia coli strains and to examine its interaction with host components that could be related to the infection mechanism. Recombinant E. coli GAPDH was purified and polyclonal antibodies were obtained. Western blotting and immunoelectron microscopy showed that GAPDH is located on the bacterial surface and released to the culture medium of EHEC and EPEC strains. GAPDH export in these Gram-negative pathogens depends on the external medium, is not mediated by vesicles and leads to an extracellular active enzyme. Non-pathogenic E. coli strains do not secrete GAPDH. Two-dimensional electrophoresis analysis showed that in E. coli GAPDH is present at least in two major forms with different isoelectric points. Of these forms, the more basic is secreted. Purified GAPDH was found to bind human plasminogen and fibrinogen in Far-Western blot and ELISA-based assays. In addition, GAPDH remained associated with colonic Caco-2 epithelial cells after adhesion of EHEC or EPEC. These observations indicate that exported GAPDH may act as a virulence factor which could contribute to EHEC and EPEC pathogenesis. This is the first description of an extracellular localization for this enzyme, with a function other than its glycolytic role in Gram-negative pathogens.

[Myocarditis in the differential diagnosis of acute coronary syndrome]

A 69-year-old man with no remarkable medical history was admitted to the intensive care unit in septic shock due to severe community-acquired pneumonia. Twelve hours later he developed electrocardiographic abnormalities with ST elevation in leads II, III, aVF, V5, and V6 in the absence of chest pain and the presence of dyspnea, agitation, and hypertension. Serial measurements of cardiac enzymes were also elevated. Acute coronary syndrome was suspected. A cardiac ultrasound revealed left ventricular dilation with akinesia and systolic dysfunction (ejection fraction, 40%). Emergency catheterization revealed normal coronary arteries, suggesting a probable diagnosis of acute myocarditis. From the fourth day, the patient was progressing favorably. Findings in a follow-up ultrasound were consistent with the onset of dilated myocardiopathy, and angiotensin converting enzyme inhibitors were prescribed. All serology and microbiological studies were negative. Fifteen days after admission the patient was discharged to home after clinical, radiologic and analytic recovery.

Influence of formulation on propofol pharmacokinetics and pharmacodynamics in anesthetized patients

BACKGROUND

In anesthesia with propofol, variability persists besides sophisticated effect targeting. Drug formulation may be another factor. We have analyzed, retrospectively, the pharmacokinetics (PK) and pharmacodynamics (PD) in monitored surgery patients anesthetized with one each of five formulations of propofol.

METHODS

Propofol 1% ('form' 1: Diprivan(Zeneca Limited, Macclesfield, UK), 2: Recofol(Schering Espana, Madrid, Spain), 3: Ivofol(Juste, Madrid, Spain), 4: Propofol Abbott (Abbott Laboratories, Madrid, Spain), 5: Fresenius (Fresenius Kabi Espana, Barcelona, Spain)) was administered to 77 ASA I-II patients of age [mean (range) 44 (18-65) years]. Induction of anesthesia was with varying propofol doses up to endpoints of either 60 on the Bispectral Index system (BIS) in group I (n = 48, model development) or standard clinical signs in group II (n = 29, validation). Maintenance was with three 10-min infusions of 10, 8 and 6 mg kg(-1) h(-1). Three blood samples were obtained from each subject, immediately after induction, and at 15 and 30 min on maintenance, with BIS and hemodynamic variables recorded at these times also. Total and free blood concentrations (Cb) of propofol were determined with HPLC. Pharmacokinetic and PD models with link equilibration rate ke0, were studied with a mixed-effects procedure (NONMEM).

RESULTS

The induction dose (group I) showed large interindividual variability [mean (range) 163 (90-290 mg)] that correlated significantly with age, basal systolic blood pressure and formulation. The PK of propofol (basic model) was described by a one-compartment model with (typical value [interindividual coefficient of variation percent (CV%)]) CL=2.30 l min(-1) (27%) and V=8.40 l (80%). Weight (WT) and formulation, within NONMEM, were found to be significant covariates for CL and V, reducing their CV% to 25% and 74%, respectively. The final PK/PD model, which includes formulation, showed a 50% reduction in the CV% for both the ke0 and the residual error. This PK/PD model was validated in group II with 33% precision and no bias.

CONCLUSION

The PK and PD are not equal for all formulations, which contributes to an increase in variability of the observed effect.

[Biologic effect of diflubenzuron on Blattella germanica (Dictyoptera: Blattellidae)]

The Amejeiras strain of Blatella germanica (Dictyoptera: Blattellidae) kept in lab conditions since 1994 and susceptible to arpocarb, malathion and cipermethrin insecticides, was studied. This strain was treated with 4 diflubenzuron (Dimilin OMS 1804) concentrations supplied by feeding nymphs at their first stage of development, with the purpose of determining their effect on the survival, phenotype and period of nynmphal development of this species. The dosage-mortality line of regression was determined and the values of CE50 = 0.042% and CE95 = 0.357% were obtained. Sublethal effects were observed in the nymphs treated with the 4 tested concentrations whereas the morphogenetic effects in adult insects only occurred when they were exposed to higher concentrations (0.25% and 0.4%). The nymph development stage showed a highly significant increase when the diflubenzuron concentration was raised. (F = 11.64; p < 0.001).

[Preoperative thrombocytopenia with a postoperative diagnosis of thrombotic thrombocytopenic purpura]

A 64-year-old woman came to the emergency room complaining of vomiting and abdominal pain; appendicitis was suspected and surgery ordered. A blood work up showed a significantly low platelet count (39,000/microliter) and 6 units were transfused before surgery. The only observations during surgery were ileitis and Meckel's diverticulum. Thrombocytopenia persisted over the first 48 hours after surgery in spite of another transfusion of platelets, with worsening awareness and acute renal failure. After diagnosis of thrombotic thrombocytopenic purpura (TTP), the patient was admitted to the intensive care unit and treatment with fresh plasma and corticoids was started. Two weeks later, after complex evolution and ten sessions of plasmapheresis, the patient was transferred to the hematology ward. TTP must be considered a medical emergency. Platelet transfusions are contraindicated, as they can cause serious clinical deterioration. A low platelet count before surgery should lead to differential diagnosis to determine the cause, with the aim of judging whether platelet transfusion is warranted or not. In some etiological processes, such as in the case we report, platelet transfusion may be life-threatening; corrective measures must be taken early in the process and such transfusion avoided.

[Typing habitats of Aedes albopictus in Cuba and their association with other species of Culicidae, 1995-1998]

A typing of the habitats of Aedes albopictus in Cuba was made after its detection in 1995. It was observed in suburban areas of the Boyeros Municipality, in Havana City, where a study was conducted from October, 1995, to July, 1998. Most of the positive repositories were found outside the houses. Tins, tires, trees and plants were the places preferred for its breeding. It was found in the breeding places associated with Aedes mediovittatus and Culex quinquefasciatus, dominant species in these places. It was also observed a trend towards an increase of the number of repositories colonized only by the species under study. Reference was made to the phenomenon of competence between this species and the indigenous species present in such places.

[Incidence of Aedes (S) aegypti and other Culicidae in the municipality of Playa, La Habana City]

An analysis was made on the incidence of Culicidae present in Playa Municipality, Havana City, during the intensive stage of the anti-aegypti campaign from June to July, 1997, according to its requirements. Culex quinquefasciatus was the predominant species with a total of 269 focuses. It was collected in all the People's Councils and in every type of repository, excepting clay repositories. The second most abundant species was the Aedes aegypti with 199 focuses, followed by Aedes mediovittatus with 67. The Almendares-Sierra, Ampliación-Almendares and Miramar People's Councils showed the highest values of Culicidae infestation in the municipality. The Aedes aegypti prevailed in the first and Cx. quiquefasciatus in the second. The artificial repositories, low tanks and other repositories had the highest number of mosquito focuses in the municipality. The Cx quinquefasciatus preferred the artificial depositories, whereas the A. aegypti preferred the low tanks. Most of the positive depositories were colonized by only one species (92.7% of the total). 7.3% corresponded to mixed focuses. It was found that Cx. quinqufasciatus and A. aegypti were the most associated species.

[The ecological succession of mosquito species in the town of Boyeros, Ciudad de la Habana 1994-1996]

An analysis was made on the incidence of Culicidae in Boyeros municipality, City of Havana from 1994 to 1996 based on the requirements of the national program for eradication of Aedes aegypti. A total of 13 species was detected in which Aedes mediovittatus predominated during 3 years of study, followed by Culex quinquefasciatus whereas for the first time Aedes albopictus species was found in the territory. People's Councils Wajay, Santiago de las Vegas and Armada exhibited the highest values of infestation by Culicidae in the municipality, therefore, they required that anti-Aedes program, operators paid more attention to this situation. It was found that depots preferred by Culicidae for breeding were larval traps followed by low tanks in 1994 and 1995 and by other reservoirs in 1996. A mediovittatus preferred larval traps whereas Cx. quinquefasciatus preferred low tanks except in 1996 when this species was mostly found in other tanks. 93% of all test-positive reservoirs found were colonized by only one species, whereas 7% presented larvae from 2 species or more. A. mediovittatus and C. quinquefasciatus were the most related, above all in low tanks.

[Entomological surveillance over Aedes (S) aegypti and other culicids in Ciudad de La Habana, Cuba 1991-1996]

The results of the entomologic surveillance carried out from 1991 to 1996 in Boyeros municipality, City of Havana within the Program for Eradication of Aedes aegypti were analyzed. Data on mosquitoes fauna collected in the municipality by various sampling methods, larval survey, human bait, capture at rest and larval traps. Culex quinquefasciatus, Aedes mediovittatus and Aedes aegypti species were the most found by the different methods. It was proved that water tanks, man-made deposits, other kinds of tanks and low tanks were the most exploited resources by mosquitoes for their breeding in this municipality whereas larval surveys were the most sensitive method for detecting species since it contributed a greater variety of species. Reference is made to the search for a mechanism that help estimate adult populations from larval indices provided by surveys and the method of capture at rest is stressed as the most sensitive method for adult mosquitoes, particularly for dengue vector within the surveillance system aimed at this species.

[Proportional abundance of culicidae in the urban ecosystem of Havana City]

Proportional abundance of the four most common mosquito species was determined in six types of breeding places located in Plaza de la Revolución municipality, City of Havana from 1993-1996. Culex quinquifasciatus exhibited values over 0.60 except in tyres and larval traps in 1993 and 1994 whereas Aedes mediovittatus showed similar values in low tanks and artificial reservoirs in 1994 (0.43 and 0.56 respectively). It was also observed that this species prefers larval traps. Aedes aegypti and Culex migripaplpus had the lowest abundance values (0.01). These results allowed us to state that there is a sort of shared use by these species of those reservoirs where they breed and that Culex quinquefasciatus is the predominant one.

[The effect of 2 diets on the biological aspects of Blattella germanica (Dictyoptera: Blattellidae) under laboratory conditions]

It was conducted a study of 2 colonies of Blattella germanica (Dictyoptera: Blattellidae) kept since 1994 in the laboratory at 29 +/- 1 degrees C, 70-75% of relative humidity and with different foods: one on a diet without proteins, consisting in portions of potatoes (Solanum tuberosum, L.), ripe banana (Musa paradisiaca, L.) and a sugary solution 10%, and the other with a protein content of 20.45% composed of pulverized and dry laboratory food for rats and a source of water. 6 nymphal stages were found with both types of food. There were determined the times of interchanges and the time of nymphal development, which were much shorter among the nymphs fed with proteins. The longevity of each sex showed no significant differences in connection with the type of food used. The times of appearance and eclosion of the oothecae of each oothecal cycle were determined with both foods. It was found that the females deposited up to 5 oothecae during their lives with the 2 types of diet. The average of nymphs per ootheca among the females fed with proteins was much greater (t = 5.33; p < 0.001). The results of this study show that when the food for B. germanica contains proteins, its nymphal development is faster and its reproductive capacity increases, which means that protein is a necessary nutrient for the diet of this species.

[The incidence of Culicidae in an urban area of Ciudad de La Habana during 1995]

In the present paper it is made an analysis of the incidence of culicides in the municipality of Marianao, Havana City, during 1995, after following the requirements of the National Program for the Eradication of Aedes aegypti. 6 species of mosquitoes were found in the municipality, with a predominance of the Culex quinquefasciatus and Aedes mediovittatus species. 4 focuses of Aedes aegypti were detected during this period. It was found that the groups of deposits preferred by the culicides for their breeding in this municipality were other deposits, low tanks, artificial deposits and larva traps. The People's Councils 4 and 5 (Libertad and Pogolotti) had the highest number of focuses (967 and 1,240, respectively, and therefore, they need more attention. It is analyzed the influence of the deficiencies of the public services, such as the collection of solid, wastes (garbage) and the existence of leakages and sewing overflows, on the proliferation of mosquitoes in the municipality.

[Adult onset subacute sclerosing panencephalitis. Report of two cases with atypical presentation]

Subacute sclerosing panencephalitis is an infrequent central nervous system viral disease and is a late manifestation of persistent infection by a mutant form of measles virus. Since it affects mainly children and teenagers, the diagnosis in older ages is difficult. Its main clinical symptoms are cognitive impairment, behavioral disturbances and myoclonia. We report two males, aged 21 and 22 years old, presenting with the disease with atypical manifestations. One had a catatonic syndrome and the other, amaurosis. The recognition of the different presentation forms of the disease, endemic in developing countries, allows an earlier diagnosis and a more efficient treatment, when available.

[Ecologic indexes in the surveillance system of Aedes aegypti (Diptera: Culicidae) in Cuba]

The ecological indexes called diversity (H') and equitability (J') of the mosquito species were determined in six of the most common reservoirs of the urban ecosystem in the Plaza de la Revolución municipality, City of Havana. Data analysis showed that according to the values of these indexes, the most dangerous reservoirs were tyres, larvitraps and artificial reservoirs in general. Reference is also made on the use of larvitraps in the surveillance system of Aedes aegypti and the detection and stabilization of mosquitoes such as Aedes mediovittatus and Culex migripalpus in the urban ecosystem. The variety of species ranged from 2 to 7 in the studied reservoirs which showed differences in the patterns of use of the resources in the urban ecosystem.