Software Suite Training Tool for MSK Exploration and Botulinum Toxin Infiltration Based on Ultrasound Imaging for the Spasticity Treatment.

Nowadays, one of the choice techniques for the spasticity treatment is the ultrasound-guided infiltration of Botulinum Toxin, because it is safe and effective. In order to medical professionals can carry out this technique, they need training and education. One of the safest and most time-free ways to facilitate the acquisition of practical medical skills is through simulators. In this paper we present an innovative technological environment, which includes an ultrasound simulator for training in muscle exploration and infiltration. The simulation platform will guide health professionals, with great realism and high degree of interactivity, in the autonomous training of all the tasks involved in the spasticity treatment procedure by infiltration of Botulinum Toxin, without the need for a real patient or costly phantoms.

Real needle for minimal invasive procedures training using motion sensors and optical flow.

Minimally invasive percutaneous insertion procedures are widely used techniques in medicine. Their success is highly dependent on the skills of the practitioner. This paper presents a haptic simulator for training in these procedures, whose key component is a real percutaneous insertion needle with a sensory system incorporated to track its 3D location at every instant. By means of the proposed embedded vision system, the attitude (spatial orientation) and depth of insertion of a real needle are estimated. The proposal is founded on a novel depth estimation procedure based on optical flow techniques, complemented by sensory fusion techniques with the attitude calculated with data from an Inertial Measurement Unit (IMU) sensor. This procedure allows estimating the needle attitude with an accuracy of tenths of a degree and the displacement with an accuracy of millimeters. The computational algorithm runs on an embedded computer with real-time constraints for tracking the movement of a real needle. This haptic needle location data is used to reproduce the movement of a virtual needle within a simulation app. As a fundamental result, an ergonomic and realistic training simulator has been successfully constructed for healthcare professionals to acquire the mental model and motor skills necessary to practice percutaneous procedures successfully.

Saccular aneurysms of the extracranial internal carotid artery. Experience and review of the literature.

The aim of this study was to describe the surgical technique employed and our results in the treatment of saccular aneurysms of the internal carotid artery at the extracranial level. We describe 3 cases of patients with saccular aneurysms of the extracranial internal carotid who underwent surgery at our unit within the last 3 years. We report on indications for treatment, surgical technique and results in terms of morbidity-mortality and also review the pertinent literature. Surgical treatment was indicated on the grounds of the patients being symptomatic: 2 had a history of cerebral ischemia, and 1 showed local compression symptoms. The surgical approach was presternocleidomastoid cervicotomy extended distally, and in 2 patients was accompanied by nasotracheal intubation to achieve adequate exposure. In 2 cases, we performed an aneurysmectomy with end-to-end anastomosis. In the third patient, the aneurysm neck was ligated from within the sac followed by aneurysmectomy. There was no mortality or neurological morbidity (local or general). The patients remain free from neurological symptoms with a patent carotid axis. Our clinical experience suggests that, despite the anatomically unfavorable location of this type of aneurysm and the greater complexity of the surgical technique, this patient group can be effectively treated. The frequent presence of an elongated carotid axis and an aneurysmal neck means the surgeon can easily restore arterial continuity by direct procedures.

[Iodine nutritional status in the school-aged population in Alicante (Spain)]. / Situación nutricional de yodo en la población escolar de Alicante.

BACKGROUND: According to the World Health Organization (WHO), goiter is endemic in Spain. The main cause of endemic goiter is iodine deficiency, which is also the principal cause of mental retardation and avoidable cerebral palsy throughout the world. MATERIAL AND METHODS: We conducted an observational study to determine the prevalence of endemic goiter and nutritional iodine status in the province of Alicante. Urinary iodine excretion was measured in a morning urine sample, and thyroid volume was measured by means of a thyroid ultrasound scan. A case of goiter was diagnosed if thyroid volume was above the 97th percentile adjusted by age, as published by the WHO. RESULTS: No cases of goiter were found. In addition, the median urinary iodine excretion levels adjusted by age were within the normal range, as defined by the WHO's criteria. CONCLUSIONS: Endemic goiter was not found in the province of Alicante and urinary iodine excretion values demonstrated adequate iodine intake. Further ultrasound studies are needed to establish reference thyroid volumes for our population.

Monophasic synovial sarcoma of the greater omentum: case report and review of literature.

Synovial sarcoma is a malignant spindle cell neoplasm normally arising from tissues around joints, bursa and tendon sheaths. Several reports involving the gastrointestinal tract, mainly the oesophagus and stomach, have been documented; however, the omentum remains an extremely unusual location. Monophasic type is composed exclusively of spindle cells arranged in fascicles. Establishing the correct diagnosis of these tumours could be challenging because of the similarities with gastrointestinal stromal tumours and other mesenchymal tumours with similar histology.

[Antimicrobial susceptibility of Pseudomonas aeruginosa clinical isolates in Castellón, Spain]. / Sensibilidad de aislamientos clínicos de Pseudomonas aeruginosa en Castellón.

A retrospective study of the susceptibility to antimicrobials (amikacin, tobramycin, gentamicin, ceftazidime, cefepime, piperacillin, piperacil-lin-tazobactam, imipenem, meropenem and ciprofloxacin) of 5,811 Pseudomonas aeruginosa isolates was performed in a general hospital over a period of 12 years. The majority of isolates was from respiratory samples (31.99%), followed by urine samples (26.36%) and ear samples (10.51%). There was a predominance of hospital strains (69.66%); 50.30% of those from medical services, 31.74% from critical care services (mainly ICU) and the remaining from surgical services. No antimicrobial included in our study showed an activity over all isolated strains. In health centers the majority of antimicrobials showed good activity, with a percentage of resistance less than 10%. However, hospital strains showed that only amikacin, piperacillin-tazobactam and meropenem had a percentage of resistance near or lower than 10%. In both environments, gentamicin presented with the highest percentage of resistance. Strains from patients hospitalized in critical care services showed an elevated resistance to tobramycin, imipenem and ceftazidime, while strains from patients in medical services showed resistance to ciprofloxacin. Similar studies published in Spain confirm the importance of conducting local studies in order to understand the antimicrobial susceptibility of P. aeruginosa in each region, and especially to carry out empirically based treatments.

Detection of Zoonotic Protozoa Toxoplasma gondii and Sarcocystis suihominis in Wild Boars from Spain.

Food safety regulations require the control of the presence of protozoa in meats destined for human consumption. Wild boar (Sus scrofa) meat may constitute a source of zoonoses. A 23.8% (688/2881) seroprevalence of anti-Toxoplasma gondii antibodies and 72.2% (662/910) Sarcocystis sarcocysts prevalence were detected among wild boars hunted in Southwestern areas of Spain. Identity of Sarcocystis spp. was performed by RFLP-PCR and sequencing, detecting S. miescheriana (7/8) and the zoonotic S. suihominis (1/8). Risk assessment studies of these coccidian in meats destined to human consumption are needed.

Detection of Leishmania DNA and blood meal sources in phlebotomine sand flies (Diptera: Psychodidae) in western of Spain: Update on distribution and risk factors associated.

Leishmaniosis caused by Leishmania infantum is present in Mediterranean countries, with high prevalence in areas of the center and south of Spain. However, in some regions such as Extremadura (in southwest of Spain), data has not been updated since 1997. The aim of this work was (i) to provide information about the distribution of phlebotomine sand fly species in western of Spain (Extremadura region), (ii) to determine risk factors for the presence of sand fly vectors and (iii) to detect Leishmania DNA and identify blood meal sources in wild caught females. During 2012-2013, sand flies were surveyed using CDC miniature light-traps in 13 of 20 counties in Extremadura. Specimens were identified morphologically and females were used for molecular detection of Leishmania DNA by kDNA, ITS-1 and cyt-B. In addition, blood meals origins were analyzed by a PCR based in vertebrate cyt b gene. A total of 1083 sand flies of both gender were captured and identified. Five species were collected, Phlebotomus perniciosus (60.76%), Sergentomyia minuta (29.92%), P. ariasi (7.11%), P. papatasi (1.48%) and P. sergenti (0.74%). The last three species constitute the first report in Badajoz, the most southern province of Extremadura region. Leishmania DNA was detected in three out of 435 females (one P. pernicious and two S. minuta). Characterization of obtained DNA sequences by phylogenetic analyses revealed close relatedness with Leishmania tarentolae in S. minuta and L. infantum in P. perniciosus. Haematic preferences showed a wide range of hosts, namely: swine, humans, sheep, rabbits, horses, donkeys and turkeys. The simultaneous presence of P. perniciosus and P. ariasi vectors, the analysis of blood meals, together with the detection of L. infantum and in S. minuta of L. tarentolae, confirms the ideal conditions for the transmission of this parasitosis in the western of Spain. These results improve the epidemiological knowledge of leishmaniosis and its vectors in this part of Spain, highlighting the need for ongoing entomological and parasitological surveillance.

DRB1-TNF-alpha-TNF-beta haplotype is strongly associated with severe aortoiliac occlusive disease, a clinical form of atherosclerosis.

Severe aortoiliac occlusive disease (AOD) is a clinical manifestation of peripheral arteriosclerosis. Atherosclerosis has been associated with some human leukocyte antigen (HLA)-DRB1 alleles, stressing its relationship with autoimmune or inflammatory disorders. Additionally, in rheumatoid arthritis patients, the DRB1*0404 allele is specifically associated with endothelial dysfunction. Our objective was to assess the role of class II HLA alleles in the susceptibility to AOD; a combined study of the nearby tumor necrosis factor (TNF) locus was also performed. We included 104 AOD patients and 504 healthy controls from Madrid. DRB1 typing and DRB1*04 subtyping was done by polymerase chain reaction amplification followed by hybridization with specific oligonucleotides. TNF-alpha and TNF-beta microsatellites were studied by polymerase chain reaction and capillary electrophoresis. None of the markers was associated with AOD, although a trend was observed for DRB1*0404 (OR = 2.18; p = 0.05). However, among DRB1*0404 individuals, the TNFa11-b4 pair was present more frequently in patients than in controls (OR = 16.0; p = 0.007). The combined appearance of TNFa11-b4 and DRB1*0404 was much more frequent in patients than in controls (OR = 5.92; p = 0.0013), a result enhanced by haplotypic estimates (OR = 10.0; p = 0.00017). Our results show that the HLA region modulates the predisposition to AOD. More specifically, they suggest that an extended haplotype encompassing DRB1*0404 and TNFa11-b4 carries a genetic factor conferring susceptibility to AOD.

Experimental studies in pigs on Trichinella detection in different diagnostic matrices.

A total of 72 specific pathogen-free (SPF) and Iberian pigs (three animals per group) were inoculated with 200, 1000 or 20,000 muscle larvae of T. spiralis, T. nativa, T. britovi and T. pseudospiralis. For each animal, the muscle larva burden was evaluated in nine muscle samples by digestion. The anti-Trichinella IgG kinetics in blood samples, taken twice prior and at days 5, 10, 15, 20, 25, 30, 40, 50 and 60 post-inoculation, and in muscle juice, obtained at necropsy, was evaluated by an ELISA using an excretory/secretory antigen. The mean larval recovery rate in SPF/Iberian pigs corresponded with the level of inoculum dose, and tongue, diaphragm and masseter were identified as predilection muscles. In SPF and Iberian pigs receiving 20,000 larvae of T. spiralis, an earlier seroconversion was detected from day 25 post-inoculation. At a 10-fold dilution, the muscle juice showed a good test agreement with blood serum.

Nontraumatic lower extremity amputations in diabetic and non-diabetic subjects in Madrid, Spain.

The purpose of this study was to determine the incidence of non-traumatic lower extremity amputations (LEAs) in diabetic and non-diabetic subjects in Madrid, Spain, and their direct cost. All patients who underwent LEAs between the 1st of January 1994 and the 31st of December 1996, and who had lived in area 7 of the city (569,307 inhabitants) for at least the last 6 months, were identified through operating theatre records cross-checked with Vascular Surgery Department discharge records. In addition, the direct cost of LEAs per year was estimated, taking into account the length of the hospital stay, the period of rehabilitation in the outpatient clinic after discharge, and the use of artificial limbs and their maintenance. The incidence of LEAs was 1.6 (95% CI: 1.1-2.2) per 10(5) non-diabetic subjects and 46.1 (95% CI: 34.5-57.6) per 10(5) diabetic patients. Relative risk was 28. Total direct costs associated with LEAs per year were US$ 56,131 in the diabetic population and US$ 30,765 in the non-diabetic population. Thus, potential cost savings associated with excess amputations in the diabetic population was estimated at US$ 541,353 per year of US$ 94,736 per 10(5) inhabitants. It is concluded that the incidence of LEAs in both diabetic and non-diabetic populations in area 7 is the lowest reported in European countries. The potential cost savings per 10(5) inhabitants and per year is estimated at US$ 94,736.

Comparison of peripheral arterial reconstruction in diabetic and non-diabetic patients: a prospective clinic-based study.

UNLABELLED: To assess the efficacy and safety of lower extremity arterial reconstruction in diabetic and non-diabetic subjects during a 3-year period. A prospective clinic-based study between 1994-1999 in Area 7, Madrid, with a population of 569307 and an estimated diabetic population of 37932 (15505 men and 22427 women). The level of arterial reconstruction and associated risk factors were ascertained. RESULTS: A total of 588 peripheral revascularization surgical procedures were performed in 481 patients. The diabetic patients (n=174, 36.2%) underwent 222 surgical procedures (including 48 follow-on operations, 21.6%), and 307 non-diabetic subjects underwent 366 surgical procedures (59 follow-on operations, 16.1%). The numbers of surgical procedures per 100000 people at risk and year were 18.8 and 1.8 for non-diabetic men and women, respectively, and 145.1 and 29.0 for men and women with diabetes mellitus (7.7- and 16.2-fold, respectively). Age at reconstruction surgery was 2 and 5 years earlier in non-diabetic than in diabetic men and women, respectively. Diabetic patients had a higher neuropathy score (P<0.05) and were less frequently smokers (P<0.05) than non-diabetic subjects. Diabetic subjects more frequently had distal reconstruction while proximal arterial reconstruction was more often performed in non-diabetic subjects. Between 64.6 and 80.4% of people with diabetes and 82.3 and 88.9% of non-diabetic subjects had no complications during their in-hospital stay. Distal amputation simultaneous to arterial reconstruction was the most frequent morbidity of people with diabetes during the study (P<0.05). Despite a graft occlusion rate after femoropopliteal revascularization significantly higher than in non-diabetic people (P<0.05), diabetic people more often required lower extremity amputations (LEAs) for the same level of bypass (P<0.01). Cumulative limb salvage rates were lower in diabetic patients than in non-diabetic subjects at femoropopliteal (49.2 vs. 89.7%; P<0.001), femorodistal (73.5 vs. 95.2%; P<0.01), and distal reverse (77.9 vs. 87.3%; P<0.05) arterial reconstruction, at the end of the third year, but similar after aorto-iliac reconstruction (93.1 vs. 97.5%). A higher neuropathy score and the presence of foot ulcers were associated to significantly lower limb salvage in diabetic patients (P<0.05), but not in non-diabetic people. Survival rates after 3 years were similar between diabetic and non-diabetic populations after aorto-iliac (93.1 vs. 97.5%), femoropopliteal (97.2 vs. 90.3%), and distal reverse (93.2 vs. 98.1%) revascularization, and slightly lower in diabetic compared to non-diabetic patients after femorodistal revascularization (82.1 vs. 96.3%; P<0.05). CONCLUSION: Although limb salvage after arterial reconstruction is lower in diabetic than in non-diabetic subjects, particularly in those with a higher neuropathy score, this surgical approach can be applied in both diabetic and non-diabetic subjects with otherwise similar outcome.

Presence of immunoglobulins and antigens in serum, lung and small intestine in Ascaris suum infected and immunised pigs.

The immunodetection of local Ascaris suum antigens and local and systemic antibodies were analysed in pigs reinfected with eggs or immunized with the 14, 42 and 97 kilodalton (kDa) fractions from A. suum. Twenty-one Iberian pigs were divided in 7 groups of 3 pigs. Groups 1 and 2 were uninfected and challenge control groups, respectively. Groups 3 and 4 were infected weekly with increasing doses of A. suum eggs and Group 4 was additionally treated with pyrantel pamoate. Groups 5, 6 and 7 were immunised with the 14, 42 or 97 kDa fractions from adult worms, respectively. Groups 2-7 were challenged with 10,000 infective eggs. Animals of Groups 3 and 4 showed a pulmonary granulomatous reaction with moderate number of eosinophils and leukocytes, while Groups 5-7 presented higher number of cells, especially in animals immunized with the 42 kDa fraction. These immunized groups presented abundant deposition of Ascaris body fluid (BF) and body wall (BW) antigens as well as the 14 and 42 kDa fractions in the pulmonary and intestinal tissues, while lower deposition of antigens was observed in animals of Groups 3 and 4. The immunized pigs of Groups 5 and 6 showed the highest systemic IgG titres in serum and these antibodies were negatively correlated with the number of larvae recovered in the lungs, suggesting that the IgG response may have a protective function against the ascariosis. The highest concentrations of IgA-bearing cells were observed in animals of Groups 3 and 4 compared to the immunised pigs (Groups 5-7), suggesting that local IgA production may be involved in the protection against migrating larvae. The main localisations of IgA-bearing cells were the bronchial and peribronchial areas of lungs and the lamina propia of duodenum. Low numbers of local IgG-bearing cells were observed in all animals and no IgM-bearing cells were detected in the local tissues.

Immunohistochemical distribution of antigens in liver of infected and immunized pigs with Ascaris suum.

In the present work, we carry out an immunopathological study of the swine ascariosis, under different conditions (control, infection and immunization). Twenty-one Iberian pigs were used and divided in seven groups. Groups 1 and 2 were the uninfected and challenged controls, respectively. Groups 3 and 4 were weakly infected with increasing doses of Ascaris suum eggs and treated with pyrantel (Group 4). Groups 5-7 were immunized with 14, 42 and 97 kDa proteins from the parasite, respectively. Groups 2-7 were challenged with 10,000 infective eggs 7 days before the sacrifice. The focal parasitic granulomata with eosinophils and lymphocytes were the main histopathological lesions in the liver of reinfected pigs, while more marked cellular infiltrate and abundant connective tissue were seen in the livers of immunized animals. There were important deposits of antigens in the livers of immunized and infected pigs. Antigens were mainly located in the connective tissue, with positive staining detection of the somatic larvae antigen, the body wall from the adult worms and the 14-, 42- and 97-kDa proteins. However, cholangiols, biliary ducts and macrophages presented an immunohistochemical positive stain against excretory-secretory and somatic antigens from the larvae and the body fluid antigen from the adult parasite. The detection of A. suum antigens in the liver of infected pigs improves the diagnosis of swine ascariosis. It may be possible to apply these procedures for diagnosis of human ascariosis in liver biopsies since A. suum from swine have been previously used as a substitute for the study of the human parasite Ascaris lumbricoides.

Generalizing CMAC architecture and training.

The cerebellar model articulation controller (CMAC) is a simple and fast neural-network based on local approximations. However, its rigid structure reduces its accuracy of approximation and speed of convergence with heterogeneous inputs. In this paper, we propose a generalized CMAC (GCMAC) network that considers different degrees of generalization for each input. Its representation abilities are analyzed, and a set of local relationships that the output function must satisfy are derived. An adaptive growing method of the network is also presented. The validity of our approach and methods are shown by some simulated examples.

Evidence of potential gene flow in Trichinella spiralis and in Trichinella britovi in nature.

During a study on the epidemiology of trichinellosis in Spain, 91 animals and 9 samples of sausages homemade with pork were found positive for Trichinella. Parasite identification at the species level was carried out by the polymerase chain reaction with a random primer on single muscle larvae. Seventy-one animals harbored Trichinella spiralis (17 domestic pigs, 53 wild boars, 1 fox), and 17 were infected with Trichinella britovi (1 domestic pig, 13 wild boars, 3 foxes). Sausages were infected with T. spiralis. Three wild boars (3.3% of infected animals) harbored both species. The presence of both T. spiralis and T. britovi in the same host suggests that infections with 2 isolates of the same species can also occur, permitting the gene flow within the species.

[Epidemiological aspects of ciprofloxacin-resistant Escherichia coli at a general hospital]. / Aspectos epidemiológicos de la resistenciade Escherichia coli a ciprofloxacino en un hospital general.

The susceptibility to ciprofloxacin of 7288 Escherichia coli clinical isolates from 5667 patients was determined over a 4-year period (1995-1998). Information about the patients' age, sex, specimen type, date, origin and susceptibility to Escherichia coli isolates was studied, and the c2 test was used for statistical comparison. Overall, 1003 (17.70%) patients out of the 5667 included in the study presented ciprofloxacin resistance. The annual resistance observed over this 4-year period was not considered statistically significant. The resistant isolates were more frequent among men, in urine specimens and in outpatients, and increased with different age groups. The average age of patients with resistant isolates was 61.29 years (SD 21.56) and that of patients with susceptible isolates was 39.76 years (SD 27.41). A similar rate of resistance was observed among outpatients from health centers and those from hospital outpatient services. The higher resistance rates were found in outpatients from the urology department. The resistance to other fluoroquinolones remained the same and was not significant for norfloxacin; it increased starting from 1997 for pefloxacin at the expense of ciprofloxacin-sensitive isolates.

Sylvatic trichinellosis in southwestern Spain.

The epidemiology of Trichinella spp. in their main sylvatic hosts, wild boar (Sus scrofa ferus and red fox (Vulpes vulpes), in Extremadura (southwestern Spain) was studied. We examined 88 Trichinella spp.-positive wild boar muscle-tissue samples from a total of 29,333 killed animals, referred to the Veterinary Parasitology Department (University of Extremadura, Spain) by the Extremadura Veterinary Service. Additionally, 227 red foxes killed during the hunting season and thus not subject to veterinary controls were examined for trichinellosis. Trichinella spp. larvae were found in six (3%) of the red foxes. All samples were examined using direct diagnostic techniques, including trichinoscopy and artificial digestion. The mean intensity of infection was 74.8 larvae/g (LPG) of muscle tissue in wild boars, compared to 30.6 LPG in foxes. Trichinella spiralis (sensu stricto) predominated over T. britovi in wild boars. Random amplified polymorphic DNA (RAPD) and alloenzyme typing showed that 74% of infected wild boars had only T. spiralis, 21% had only T. britovi, and 5% showed mixed infections. In contrast, 33% of infected foxes were infected only with T. spiralis, while 67% had T. britovi, suggesting a clear predominance of the latter in foxes. We suspect the existence of a paranthropic or sylvatic cycle in large areas of this region; given the ease of transfer between sylvatic and domestic or semi-domestic animals, this implies a high epidemiological risk.

Comparison of IgM, IgG1 and IgG2 responses to Trichinella spiralis and Trichinella britovi in swine.

Pigs infected with T. spiralis and T. britovi were followed by double (IgG) and triple antibody ELISA (IgG1, IgG2 and IgM) during a 12-week-period. Specific IgG and IgG1 responses were similar and showed a significant relation with the infecting doses and intensity of infection. Response to T. britovi was slightly lower than in groups infected with the same dose of T. spiralis. IgG2 response was weak and almost undetectable in the lowest infected pigs, but relationship with the intensity of infection was unclear. IgM antibodies showed rapid but transient increases, generally simultaneous to peaks of IgG response.

[Intravenous 3-day Helicobacter pylori eradication therapy is highly effective in patients with bleeding peptic ulcer]. / Alta eficacia erradicadora de la infección por Helicobacter pylori de una pauta terapéutica intravenosa de 3 días de duración en pacientes con úlcera péptica sangrante.

AIMS: To evaluate the efficacy of 3-day intravenous Helicobacter pylori eradication therapy in patients with bleeding peptic ulcer associated with H. pylori infection. MATERIAL AND METHOD: We studied 53 patients admitted to hospital with bleeding of the upper gastrointestinal tract due to peptic ulcer and positive urease test over a 12-month period. After endoscopic diagnosis, intravenous pantoprazole (40 mg/12 hours), metronidazole (500 mg/8 hours) and amoxicillin-clavulanic acid (1,000 mg/200 mg/8 hours) was administered for 72 hours. The efficacy of eradication therapy was evaluated by 13C-urea breath test at least 2 months after the end of treatment. RESULTS: Fifty-one patients were included. Of these, 40 had duodenal ulcer and 11 had gastric ulcer. H. pylori eradication was achieved in 87.5% of those with duodenal ulcers and in 63.6% of those with gastric ulcers (p = 0.066). No adverse reactions or episodes of bleeding recurrence were found and none of the patients withdrew from treatment. CONCLUSIONS: The ultra-short course eradication therapy used in this study is highly effective. Its efficacy is similar to that of oral treatment and it avoids certain problems such as adverse effects and adherence to treatment.