Shunt Devices for Neurointensivists: Complications and Management.

Cerebrospinal fluid diversion has become the mainstay treatment in hydrocephalus for over 50 years. As the number of patients with ventricular shunt systems increases, neurointensivists are becoming the first-line physicians for many of these patients. When symptoms of a shunt malfunction are suspected and access to a neurosurgeon is limited or delayed, workup and temporizing measures must be initiated. The article highlights the functional nuances, complications, and management of current programmable shunt valves and their MRI sensitivity.

Self-adaptive MOEA feature selection for classification of bankruptcy prediction data.

Bankruptcy prediction is a vast area of finance and accounting whose importance lies in the relevance for creditors and investors in evaluating the likelihood of getting into bankrupt. As companies become complex, they develop sophisticated schemes to hide their real situation. In turn, making an estimation of the credit risks associated with counterparts or predicting bankruptcy becomes harder. Evolutionary algorithms have shown to be an excellent tool to deal with complex problems in finances and economics where a large number of irrelevant features are involved. This paper provides a methodology for feature selection in classification of bankruptcy data sets using an evolutionary multiobjective approach that simultaneously minimise the number of features and maximise the classifier quality measure (e.g., accuracy). The proposed methodology makes use of self-adaptation by applying the feature selection algorithm while simultaneously optimising the parameters of the classifier used. The methodology was applied to four different sets of data. The obtained results showed the utility of using the self-adaptation of the classifier.

[Dialysis and transplant. Spain in 2005]. / Informe de Situación de Diálisis y Trasplante en España, 2005.

In 2005, renal replace treatment (dialysis and transplant) was necessary for about 40,000 people, without being known the number accurate and either their basic characteristics, such as: time in treatment, modality or treatment changes. The presented data cover the 76% of the Spanish population and are the result of the cooperation among technicians of registries, nephrologists and transplant coordinations. 4,125 people started RRT in 2005, the total estimated acceptance rate for renal replacement therapy in adults in Spain was 126 pmp and regarding other European countries it locates us in an intermediate area. The incidence rate seems to keep stable in the last years although there were some differences among communities (from 104 pmp in Castile and Leon to 186 pmp in Canary Islands). Diabetes Mellitus is the most diagnosed cause of renal failure in 2005, more than 20% of patients, followed by vascular diseases. The estimated prevalence of renal replacement therapy in Spain at the end of 2005 was 903 pmp, with important variations among communities (from 806 pmp in Cantabria to 1056 pmp in Valencia Region). The 47% of prevalent RRT patients had a functioning transplant. Mortality on haemodialysis and peritoneal dialysis was 13.7% and 10.8% respectively. Mortality on transplant was 1.3%, one of the lowest values registered so far. Mortality on renal replacement therapy was around 5% among patients from 45 to 64 years, 11% between 65 and 74 years and 19% among the patients older than 75 years.

Symptomatic hypophosphataemic osteomalacia secondary to the treatment with iron carboxymaltose detected in bone scintigraphy. / Osteomalacia hipofosfatémica sintomática secundaria a tratamiento con hierro carboximaltosa objetivada con gammagrafía ósea.

The development of hypophosphataemic osteomalacia has been linked with several treatments, mainly antiretroviral and intravenous iron administration. The frequency of the hypophosphataemia requires monitoring the phosphate after the administration of iron carboxymaltose. We describe a case of a woman with no calcium-phosphorous metabolism disorder, to whom this treatment was prescribed for anaemia due to menorrhagia and intolerance to oral iron. She started with oligoarticular pain, which was spreading with a significant functional loss. The relationship with the administration of intravenous iron was discovered when scintigraphic findings together with laboratory results led to a diagnosis of hypophosphataemic osteomalacia. The patient responded satisfactorily to treatment with phosphate both clinically and in the follow-up bone scintigraphy.

[Antiretroviral pharmaceutical expenditure and possibilities for optimization]. / Gasto farmacéutico en medicación antirretroviral y posibilidades de optimización.

INTRODUCTION: A lack of treatment compliance, resistances and non-advanced stages of the disease are the reasons why not all HIV-infected patients benefit from the demonstrated efficacy of antiretroviral drug combinations--with the consequent important increase in costs. A prospective cohort follow-up study is conducted to analyze the distribution of antiretroviral pharmaceutical expenditure in a district hospital, and the possibilities for improving its efficiency. MATERIAL AND METHODS: The study comprised 128 HIV-infected patients seen for 12 consecutive weeks (September to November, 2004). The characteristics of previous follow-up were analyzed, and the patients were divided into groups according to the course over the following weeks and the results of prescribed treatment: group 1 (effective treatment), group 2 (ineffective treatment), and group 3 (treatment dropout). Based on the prescription history, corroborated with drug retrieval and the acquisition costs (FARMASYS software), the cost of antiretroviral medication was calculated for each of the 108 patients receiving highly active antiretroviral therapy (HAART). The statistical analysis was carried out with the SPSS version 11.5 statistical package, and considering statistical significance for p < 0.05. RESULTS: The cost generated by the 108 patients included during the study period who received HAART was 232,366 euros, with an average of 2,151 euros per patient and 19,363 euros per day of consultation. The distribution of patients and of the costs generated by the above defined groups was as follows: group 1: 79 patients (80.6%); group 2: 11 patients (10.6%); group 3: 18 patients (8.8%). In the group 1 patients, 15.2% of the antiretroviral expenditure corresponded to patients who had started therapy with a CD4+ count of > 350 cells/ml, while 45% had > 350 cells/ml at the present time, and 25.9% had > 500 cells/ml. Previous medication dropout was identified as a predictor of new dropouts and treatment failures. COMMENT: While the cost generated by antiretroviral medication is high, 19.4% is administered to patients who do not benefit from such treatment due to a lack of efficacy or dropouts, and in another 40-60% of cases the need for such treatment could be subject to consideration in view of the good immune status of the patients.

High prevalence of Strongyloides stercoralis among farm workers on the Mediterranean coast of Spain: analysis of the predictive factors of infection in developed countries.

Strongyloidiasis is a parasitosis characterized by persistent infection before dissemination and the development of potentially fatal disease. Since diagnosis is difficult, knowledge of the prevalence and geographic distribution of the disease is of practical importance. A study was made of Strongyloides stercoralis infection in a random and representative sample of farm workers in a tourist region in Spain based on the detection of larvae of triple stool samples. The prevalence of infection was 12.4% (95% confidence interval [CI] = 8.4-16.4). None of the 26 clinical or epidemiologic variables analyzed were found to be predictive of infection. Only eosinophilia (> 400 eosinophils/mm3) was significantly greater among the infected individuals (odds ratio = 73.4, 95% CI = 16.3-327.0), with a sensitivity of 93.5% and a specificity of 93.1%. A screening program is proposed to detect eosinophilia, to provide treatment without stool examinations, and thus afford a cost-effective policy for preventing the development of severe forms of the disease among specific risk groups where the prevalence of other parasitoses is low.

[Acute interstitial nephritis caused by clozapine]. / Nefritis intersticial aguda inducida por clozapina.

We are reporting a case of a 69 years old man developed acute renal failure due to interstitial nephritis during treatment with the drug clozapine, and that improve after to discontinuation of this drug. The clozapine is a new antipsychotic drug that may produce severes adverses reactions, like medullary toxicity. Recently 10 cases of clozapine-induced AIN have been reported. We want to associate to the cases publicated with a new case because it is a severe adverse reaction.

[Minimal-change disease with mesangial IgA deposits associated with Sjogren syndrome]. / Enfermedad de cambios mínimos con depósitos mesangiales de IgA asociada a síndrome de Sjögren.

Sjögren's syndrome may be accompanied by a dysregulation of IgA system implying the presence of increased serum polymeric IgA or circulating immune complexes and their consequent deposition within the kidney. In this context IgA nephropathy may only represent one of the complications brought by IgA deposition. Glomerular involvement and primary Sjögren's syndrome has been described previously only in isolated case reports, membranous nephropathy and membranoproliferative glomerulonephritis have been reported. We have not found any case of minimal change disease and glomerular IgA deposition associated with Sjögren's syndrome. In this patient nephrotic syndrome was related to serum increase of CA 19-9; this association has been reported in only three previous cases.

[Binswanger disease: a common type of vascular dementia]. / Enfermedad de Binswanger: un tipo frecuente de demencia vascular.

OBJECTIVE: This document intends to review the main features of Binswanger's disease and its differential diagnosis with other vascular pathologies of the white matter. DEVELOPMENT: Nowadays, the raise of the elderly group of population has led to a remarkable increase in dementia's prevalence, therefore it becomes necessary to study deeply vascular dementias, the second most common kind of dementia behind Alzheimer's disease. The detection of Binswanger's disease has increased due to the progress of neuroimaging techniques, that allow to identify ischemic lesions situated in the cerebral white matter and the existence of multiple lacunar infarcts. This clinical entity represents the most frequent type of subcortical dementia, although controversy still remains about its pathogeny, ethiology, and nosologic limits. CONCLUSIONS: The search for unified criteria is the first step in the microangiopathic subcortical dementia's field to achieve valuable treatment strategies.

[Alcohol and stroke: a controversial association]. / Alcohol e ictus isquémico: asociación controvertida.

OBJECTIVE: Although an increasing quantity of information concerning risk factors for stroke have been developed lately, the relationship between alcohol consumption and cerebral ischemic infarction, unlike at coronary sites, remains unclear. This review highlights the main pathogenic mechanisms of alcohol in the development of ischemic stroke, as it intends to be an update of this possible association. DEVELOPMENT: A critical literature review has been performed regarding this association to study its pathogenic mechanisms and the possible confounding factors present in the current design of epidemiological reports. CONCLUSIONS: There is an increasing evidence about the effect of light to moderate alcohol consumption and prevention of ischemic stroke. On the other hand it seems that heavy drinking, and particularly binge drinkers, are exposed to a higher risk for cardioembolic stroke. The growing incidence of acute heavy alcohol consumption highlights the necessity of considering a cardioembolic source when managing ischemic stroke, specially in young adults.

[Generic drugs in a district hospital. Intervention strategies]. / Especialidades farmacéuticas genéricas en un hospital comarcal. Impacto de dos estrategias de intervención.

OBJECTIVE: To know the prescription of generic drugs in specialized attention and the impact of two different intervention strategies: MATERIAL AND METHODS: Intervention trial with evaluation and later comparison. The data on the use of generic drugs are obtained from the medical reports. After an informative note of general character we repeated the taking of data one month later. In the service of Medicine we also analysed each doctor's profile prescriptions and a personalized informative note was edited and accompanied by a brief verbal explication of the campaign. Then repeated the collection of data to the week and the month. RESULTS: 1545 reports were revised (3460 prescribed drugs). 42% of the medication could be prescribed as generic but it was only made in 10% (21% in Internal Medicine). After the informative note no significant variations were observed. Only in Internal Medicine an initial increment was obtained (21 to 56%, RR 0.38, IC 0.26-0.55) that it disappeared at month. COMMENTS: The utility of the intervention to generic promotion is limited and transitory. Besides improve the information, seems necessary the implication of the physician in the promotion campaigns.

[Cost distribution of highly active antiretroviral therapy]. / Distribución del gasto farmacéutico en medicación antirretroviral.

UNLABELLED: The efficacy of highly active antiretroviral therapy (HAART) implies a high pharmaceutical cost. Deficient patient adhesion to therapy means that not all individuals benefit from treatment, while some patients are in non-advanced stages of the disease where such management may not be necessary. A study is made of the cost distribution of HAART. MATERIAL AND METHODS: An analysis was made of 199 HIV-infected adults subjected to HAART at least once during 2001. The medication history was used to calculate the cost of HAART in the global group, in the patients who abandoned treatment (group A), in the group in which viral load was not controlled (group B), and in the patients starting with or reaching a CD4+ count > 500 cells/mm3 (groups C1 and C2, respectively). RESULTS: The global annual cost of HAART (discounting returned medication) was 961,720 Euro (21.3% of the global hospital pharmacological expenditure), group A accounting for 6.3%, group B 14.26%, and subgroups C1 and C2 for 12.1 and 8.1, respectively. COMMENTS: In our center, almost 40% of antiretroviral drug expenditure may be considered of little use.

[Evaluation of the efficacy of sentinel node detection in breast cancer: chronological course and influence of the incorporation of an intra-operative portable gamma camera]. / Evaluación de la eficacia en la detección del ganglio centinela en el cáncer de mama: evolución cronológica e influencia de la incorporación de una gammacámara portátil intraoperatoria.

AIM: To define the sentinel node identification rate in breast cancer, the chronological evolution of this parameter and the influence of the introduction of a portable gamma camera. MATERIAL AND METHODS: A retrospective study was conducted using a prospective database of 754 patients who had undergone a sentinel lymph node biopsy between January 2003 and December 2011. The technique was mixed in the starting period and subsequently was performed with radiotracer intra-peritumorally administered the day before of the surgery. Until October 2009, excision of the sentinel node was guided by a probe. After that date, a portable gamma camera was introduced for intrasurgical detection. RESULTS: The SN was biopsied in 725 out of the 754 patients studied. The resulting technique global effectiveness was 96.2%. In accordance with the year of the surgical intervention, the identification percentage was 93.5% in 2003, 88.7% in 2004, 94.3% in 2005, 95.7% in 2006, 93.3% in 2007, 98.8% in 2008, 97.1% in 2009 and 99.1% in 2010 and 2011. There was a significant difference in the proportion of identification before and after the incorporation of the portable gamma camera of 4.6% (95% CI of the difference 2-7.2%, P = 0.0037). CONCLUSIONS: The percentage of global identification exceeds the recommended level following the current guidelines. Chronologically, the improvement for this parameter during the study period has been observed. These data suggest that the incorporation of a portable gamma camera had an important role.

[Assessment of the patient satisfaction with a Nuclear Medicine Service]. / Evaluación del grado de satisfacción de los pacientes atendidos en un servicio de Medicina Nuclear.

GOAL: To know the perceived quality and the levels of patient satisfaction with the Nuclear Medicine Service (MN). METHODS: A cross-sectional descriptive study was performed. The authors designed a self-applied questionnaire based on a questionnaire from a survey created by the National Health Service of the UK. The answers of 32 items were analyzed, including 4 social-demographic questions and one open question. The authors recoded the variables related to service quality and recorded them as "in accordance" and "not in accordance." The validity of the questionnaire was measured using Cronbach's alpha and determination (R(2)) indexes. The authors used the χ(2), Student's T, ANOVA and linear regression analysis statistical tests. RESULTS: A total of 179 questionnaires were analyzed (response rate: 36.6%, sampling error: 5.8%). Evaluation of general satisfaction and the recommendation of the NM Service obtained a mean score of 8.96 and 9.20 (1-10 scale) points, respectively. The most influential variable regarding general satisfaction was the general impression of the organization of the service. The strong points of the service were courtesy, general organizational image and cleanliness. The main areas for improvement were appointment change process and waiting list. There were no significant differences regarding satisfaction due to the social-demographic variables except for age. CONCLUSION: This satisfaction survey has shown that patients are satisfied with the Nuclear Medicine Service and that it is a useful tool to detect the strong points and areas for improvement of the Service from the user's perspective.