Analyzing the training of PAs in ophthalmology.

OBJECTIVE: This study sought to determine the role of physician associates/assistants (PAs) in ophthalmology, the balance between barriers and facilitators in training, and optimal training for PAs in ophthalmology. METHODS: In this explanatory qualitative case study, 17 of the 94 PAs in ophthalmology in the United States participated in qualitative, semistructured interviews. Qualitative interviews were conducted using a validated interview guide. Interpretational data analysis methods helped in the development of various themes. RESULTS: Themes suggest that PAs play a unique role in assisting ophthalmologists in surgery, performing procedures autonomously, and evaluating and treating patients autonomously. PAs in ophthalmology reported current training programs as unfavorable, reported satisfaction in their careers, and identified formal postgraduate training programs as optimal training for PAs. CONCLUSIONS: Findings of this study suggest that formal postgraduate training programs can help PAs gain the necessary skills to successfully fulfill their roles in ophthalmology.

Impact of obesity on morbidity and oncologic outcomes after total mesorectal excision for mid and low rectal cancer.

BACKGROUND: A recent meta-analysis showed that obesity increased the conversion rate and postoperative morbidity of rectal cancer surgery, but did not influence pathological results. However, this meta-analysis included patients with cancer of the upper rectum and had many biases. The aim of the present retrospective study was to investigate the impact of obesity, defined as a body mass index (BMI) ≥ 30 kg/m2, on postoperative morbidity and short- and long-term oncologic outcomes of total mesorectal excision for mid and low rectal cancer in consecutive patients. METHODS: This study included all eligible patients who were operated on for mid and lower rectal cancer between 1999 and 2018 in our hospital. We compared 90-day postoperative morbidity and mortality, and short- and long-term oncologic outcomes between obese and non-obese patients. RESULTS: Three hundred and ninety patients [280 males, mean age 65.7 ± 11.3 years, 59 obese individuals (15.1%)] were included. There was no difference in the 90-day mortality rate between obese and non-obese groups (p = 0.068). There was a difference in the overall 90-day morbidity rate between the obese and non-obese groups that disappeared after propensity score matching of the patients. There was no difference in short-term oncological parameters, with a median follow-up of 43 (20-84) months, and there were no significant differences in disease-free and overall survival between obese and non-obese patients (p = 0.42 and p = 0.11, respectively). CONCLUSIONS: Obesity does not affect the 90-day morbidity rate, or short- and long-term oncologic results in patients operated on for mid and lower rectal cancer.

Breast cancer chemotherapy treatment monitoring based on serum sample Raman spectroscopy.

In this paper, breast cancer patients were monitored throughout their chemotherapy treatments (CHT), with blood serum sample Raman spectroscopy and multivariate analysis, approximately for a year. First of all, we discriminate between healthy and clinically diagnosed breast cancer patients. Breast cancer detection in terms of sensitivity and specificity were 87.14% and 90.55% respectively. Although no shifts of peaks in mean spectrum of samples from breast cancer patients were found with respect to the mean spectrum from control patients, some peaks did show clear differences in intensity, the greatest disparities found at 509, 545, 1063, 1103, 1338, 1556, 1083 and 1449 cm- 1 are associated with amino acids and phospholipid, 1246 and 1654 cm- 1, corresponding to amide III and I, respectively. Other peaks of interest encountered at 450, 661, 890, 917 and 1405 cm- 1 are associated to glutathione. Then, 6 breast cancer patients were monitored during their chemotherapy treatments, the results were in complete correspondence with their medical records, enabling a detailed study of the evolution of each patient's cancer. A special interest arose in the possible correlation between the intensity of Raman peak, 450 cm- 1, corresponding to glutathione and evolution of cancer throughout CHT, i.e., glutathione appears to be a good candidate as breast cancer biomarker. The results confirmed that Raman spectroscopy and PCA are, not only a good support to current breast cancer detection techniques, but could also be excellent techniques to monitor more efficiently breast cancer patients undergoing CHT, using blood serum samples which are a lot less invasive than other methods.

Using large-scale tropical dry forest restoration to test successional theory.

Microclimatic conditions change dramatically as forests age and impose strong filters on community assembly during succession. Light availability is the most limiting environmental factor in tropical wet forest succession; by contrast, water availability is predicted to strongly influence tropical dry forest (TDF) successional dynamics. While mechanisms underlying TDF successional trajectories are not well understood, observational studies have demonstrated that TDF communities transition from being dominated by species with conservative traits to species with acquisitive traits, the opposite of tropical wet forest. Determining how functional traits predict TDF tree species' responses to changing environmental conditions could elucidate mechanisms underlying tree performance during TDF succession. We implemented a 6-ha restoration experiment on a degraded Vertisol in Costa Rica to determine (1) how TDF tree species with different resource-use strategies performed along a successional gradient and (2) how ecophysiological functional traits correlated with tree performance in simulated successional stages. We used two management treatments to simulate distinct successional stages including: clearing all remnant vegetation (early-succession), or interplanting seedlings with no clearing (mid-succession). We crossed these two management treatments (cleared/interplanted) with two species mixes with different resource-use strategies (acquisitive/conservative) to examine their interaction. Overall seedling survival after 2 yr was low, 15.1-26.4% in the four resource-use-strategy × management-treatment combinations, and did not differ between the management treatments or resource-use-strategy groups. However, seedling growth rates were dramatically higher for all species in the cleared treatment (year 1, 69.1% higher; year 2, 143.3% higher) and defined resource-use strategies had some capacity to explain seedling performance. Overall, ecophysiological traits were better predictors of species' growth and survival than resource-use strategies defined by leaf and stem traits such as specific leaf area. Moreover, ecophysiological traits related to water use had a stronger influence on seedling performance in the cleared, early-successional treatment, indicating that the influence of microclimatic conditions on tree survival and growth shifts predictably during TDF succession. Our findings suggest that ecophysiological traits should be explicitly considered to understand shifts in TDF functional composition during succession and that using these traits to design species mixes could greatly improve TDF restoration outcomes.

Medical education from the point of view of medical students: Results from four participatory Delphi panels in Quito, Ecuador.

BACKGROUND: Medical curricula have historically been designed in a top-down approach, usually excluding students. While Delphi panels have been used as a tool for medical education curricula design, none have been conducted in Ecuador. In addition, no such approach has ever included students both as panelists and researchers. MATERIAL AND METHODS: Four Delphi panels were developed and conducted using a participatory approach that allowed medical students to take part both as expert panelists and researchers: specifically, students developed the questionnaire and conducted a qualitative synthesis. Questionnaire responses were anonymized and dispatched online to panelists. The information was organized and collected to develop the qualitative syntheses and prepare the final statements. RESULTS: Thirty-two medical students participated between February and May 2018. A total of 32 questions were developed, corresponding to five different categories. For some questions, consensus was reached; for other questions, general statements were obtained.Discussion and conclusion: Developing the questionnaire, responding to it and analyzing the answers allowed students to raise significant concerns regarding medical education topics proposing relevant policy and curricula change. Participatory Delphi panels can be an efficient tool to obtain organized feedback, improve student class involvement, and promote research skills.

Diet and lupus: what do the patients think?

OBJECTIVES: Cardiovascular disease is the leading cause of mortality in patients with systemic lupus erythematosus. Therefore, using diet to control blood lipid levels and modify cardiovascular disease risk could be a promising therapeutic strategy to control disease symptoms. The primary objective of this study was to learn about systemic lupus erythematosus patient experiences with diet, including their opinion on considering diet as a therapeutic option. The secondary objective was to obtain this information in a cost- and time-effective manner. METHODS: A lay summary and a 15-question diet-based online survey were publicly available for 3 weeks. Social media was used to promote the survey through relevant charities, hospitals and research groups. RESULTS: A total of 300 responses were received, 284 from patients with systemic lupus erythematosus. Patients reported that there was a lack of clinical counselling regarding diet, with only 24% stating their doctor had spoken to them about diet. Despite this, 100% of patients stated they would change their diet if they knew it would help their symptoms and 83% would take part in a future diet-based clinical trial. Text analysis of patient research suggestions identified a particular interest in using diet to treat fatigue and manage disease flares. CONCLUSIONS: This project successfully gathered patient information regarding diet and systemic lupus erythematosus over a short timeframe using an anonymous social media platform. The survey provided evidence that patients support further research and potential diet intervention studies investigating the effect of diet on the symptoms of systemic lupus erythematosus.

Decreased rotational flow and circumferential wall shear stress as early markers of descending aorta dilation in Marfan syndrome: a 4D flow CMR study.

BACKGROUND: Diseases of the descending aorta have emerged as a clinical issue in Marfan syndrome following improvements in proximal aorta surgical treatment and the consequent increase in life expectancy. Although a role for hemodynamic alterations in the etiology of descending aorta disease in Marfan patients has been suggested, whether flow characteristics may be useful as early markers remains to be determined. METHODS: Seventy-five Marfan patients and 48 healthy subjects were prospectively enrolled. In- and through-plane vortexes were computed by 4D flow cardiovascular magnetic resonance (CMR) in the thoracic aorta through the quantification of in-plane rotational flow and systolic flow reversal ratio, respectively. Regional pulse wave velocity and axial and circumferential wall shear stress maps were also computed. RESULTS: In-plane rotational flow and circumferential wall shear stress were reduced in Marfan patients in the distal ascending aorta and in proximal descending aorta, even in the 20 patients free of aortic dilation. Multivariate analysis showed reduced in-plane rotational flow to be independently related to descending aorta pulse wave velocity. Conversely, systolic flow reversal ratio and axial wall shear stress were altered in unselected Marfan patients but not in the subgroup without dilation. In multivariate regression analysis proximal descending aorta axial (p = 0.014) and circumferential (p = 0.034) wall shear stress were independently related to local diameter. CONCLUSIONS: Reduced rotational flow is present in the aorta of Marfan patients even in the absence of dilation, is related to aortic stiffness and drives abnormal circumferential wall shear stress. Axial and circumferential wall shear stress are independently related to proximal descending aorta dilation beyond clinical factors. In-plane rotational flow and circumferential wall shear stress may be considered as an early marker of descending aorta dilation in Marfan patients.

Evaluation of direct oral anticoagulants for the treatment of cancer-associated thrombosis: an update.

Cancer is associated with an increased risk of venous thromboembolism of four to sixfold. Cancer-related interventions such as chemotherapy, hormonal therapy and indwelling central venous catheters also increase the risk of venous thromboembolism. Low molecular weight heparin for at least 3-6 months is the current standard of care for the treatment of cancer associated venous thromboembolism. Anticoagulation should be continued as long as the cancer is active. Over the past few years, direct oral anticoagulants have emerged, including one direct thrombin inhibitor (dabigatran etexilate) and three factor Xa inhibitors (apixaban, edoxaban and rivaroxaban). In the randomized controlled trials comparing direct oral anticoagulants with vitamin K antagonists, the direct oral anticoagulants all provide non-inferior in prevention of thromboembolic events in patients with atrial fibrillation, for the prevention and treatment of venous thromboembolism and in acute coronary syndrome. In people with cancer, these drugs have emerged as attractive alternatives for the treatment of venous thromboembolism with the potential to overcome the limitations of low molecular weight heparin. Randomized controlled studies comparing direct oral anticoagulants to low molecular weight heparin in cancer patients are still limited and direct oral anticoagulants are not recommended for the treatment of cancer associated venous thromboembolism yet. However, new emerging data are supporting the use of direct oral anticoagulants in cancer-associated thrombosis. Here, we review recent data on the evidence related to the efficacy and safety of direct oral anticoagulants for the treatment of venous thromboembolism in patients with cancer.

Factors influencing the relationship between fluoride in drinking water and dental fluorosis: a ten-year systematic review and meta-analysis.

The relationship between naturally fluoridated groundwater and dental fluorosis has received large attention from researchers around the world. Despite recognition that several factors influence this relationship, there is a lack of systematic studies analyzing the heterogeneity of these results. To fill such a gap, this study performs a systematic review and meta-analysis to understand which factors influence this relationship and how. Selected studies were sampled between 2007 and 2017 from Web of Science, PubMed, Google Scholar and Scopus using keywords and Boolean operators. Results of the systematic review show that dental fluorosis affects individuals of all ages, with the highest prevalence below 11, while the impact of other factors (gender, environmental conditions, diet and dental caries) was inconclusive. Meta-regression analysis, based on information collected through systematic review, indicates that both fluoride in drinking water and temperature influence dental fluorosis significantly and that these studies might be affected by publication bias. Findings show that fluoride negatively affects people's health in less developed countries. The conclusions discuss policy tools and technological innovations that could reduce fluoride levels below that of the World Health Organization (WHO) (<1.5 mg/L).

Hexapartite Entanglement in an above-Threshold Optical Parametric Oscillator.

We demonstrate, theoretically and experimentally, the generation of hexapartite modal entanglement by the optical parametric oscillator (OPO) operating above the oscillation threshold. We show that the OPO generates a rich structure of entanglement among sets of six optical sideband modes interacting through the nonlinear crystal. The class of quantum states thus produced can be controlled by a single parameter, the power of the external laser that pumps the system. Our platform allows for the generation of massive entanglement among many optical modes with well defined but vastly different frequencies, potentially bridging nodes of a multicolor quantum network.

Experimental Fock-State Superradiance.

Superradiance in an ensemble of atoms leads to the collective enhancement of radiation in a particular mode shared by the atoms in their spontaneous decay from an excited state. The quantum aspects of this phenomenon are highlighted when such collective enhancement is observed in the emission of a single quantum of light. Here we report a further step in exploring experimentally the nonclassical features of superradiance by implementing the process not only with single excitations, but also in a two-excitation state. Particularly, we measure and theoretically model the wave packets corresponding to superradiance in both the single-photon and two-photon regimes. Such progress opens the way to the study and future control of the interaction of nonclassical light modes with collective quantum memories at higher photon numbers.

Ideal Cardiovascular Health in the southern cone of Latin America.

OBJECTIVE: The American Heart Association developed the concept of 'Ideal Cardiovascular Health', which is based on the presence of ideal levels across seven health factors. The goal of this study is to assess the prevalence of Ideal Cardiovascular Health in the Southern Cone of Latin America. STUDY DESIGN: We conducted a cross-sectional analysis as part of CESCAS I cohort. METHODS: This report included 5458 participants aged between 35 and 75 years who were selected using stratified multistage probability sampling in Argentina, Chile and Uruguay. Interviews included demographic information, the International Physical Activity Questionnaire, and a food frequency questionnaire on dietary habits. Participants were classified as current, former or non-smokers. Weight, height and blood pressure were measured by trained personnel, and fasting cholesterol and glucose plasma levels were measured. RESULTS: Only 0.1% (95% confidence interval [CI]: 0.0-0.2) met the seven criteria that define the Ideal Cardiovascular Health. The least prevalent healthy behaviour was having a healthy diet: 0.5% (95% CI: 0.3-0.7), while the least prevalent health factor was having blood pressure < 120/80 mmHg: 23.6% (95% CI: 22.1-25.0). CONCLUSIONS: The prevalence of Ideal Cardiovascular Health is very low in a representative sample of population from the Southern Cone of Latin America, and the levels of healthy lifestyle behaviours are even lower than ideal biochemical parameters. These results highlight the challenge of developing strategies to improve the levels of Ideal Cardiovascular Health at primary prevention levels.

Efficacy assessment of an intramammary treatment with a new recrystallized enrofloxacin vs ceftiofur and parenteral enrofloxacin in dairy cows with nonsevere clinical mastitis.

A recrystallized form of enrofloxacin as dehydrate-HCl (enro-C) was assessed for bacteriological and clinical cure efficacies in Holstein-Friesian cows affected of nonsevere clinical mastitis. Treatments were enro-Csusp (n = 81), treated with a pharmaceutical suspension of enro-C/quarter; group enro-Cpd (n = 80) treated as above, but using enro-C powder suspended in water; group CF (n = 65), treated with ceftiofur HCl/quarter; and group enroR (n = 66), treated with standard enrofloxacin solution (5 mg/kg, intramuscular). Cows had a mean milk production of 31 L/day and were 2-3 lactational periods old. Treatments were administered every 24 hr for 3 days. Groups treated with enro-C exhibited statistically significant (p > .05) better clinical cure as compared to groups treated with CF or enroR (95.06%, 96.25%, 67.79%, and 57.55%, for enro-Csusp , enro-Cpd , CF, and enroR , respectively). In contrast, probability of bacteriological cure was not statistically different among treatments. Yet, the outstanding clinical and bacteriological cure rates obtained for enro-C for nonsevere cases of mastitis is superior to previously reported data for parenteral enrofloxacin and other antibacterial-intramammary treatments. Impact of using enro-C on the rate and pattern of bacterial resistance, somatic cell counts and milk electric conductivity, must be studied. Also, the use of enro-C for complicated cases of mastitis should be studied and milk withdrawal times must be accurately established.

[Ability of French General Practitioners to detect common mental disorders identified using the Patient Health Questionnaire: Has this changed with the introduction of gatekeeping and registration with a chosen doctor?] / Détection par le médecin généraliste des troubles psychiatriques courants selon l'auto-questionnaire diagnostique le Patient Health Questionnaire : dix ans après, le dispositif du médecin traitant a-t-il modifié la donne ?

OBJECTIVES: The general practitioner (GP) is the most frequently consulted health professional by patients with common mental disorders (CMD). Yet approximately half of cases are not detected by the GP. Many factors linked to the patient, the doctor and the health care system influence detection. For example, detection rates are higher when patients are better known to their GP. On the other hand, patients visiting a different GP for reasons of dissatisfaction with previous care are more likely to be detected on the survey-day. In France, a form of gatekeeping was introduced in 2005 to encourage patients to register with a doctor (most often a GP) of their choice (known as the Preferred Doctor), responsible for care coordination and referral if necessary to secondary care. Visiting a different GP, other than for non-avoidable reasons (for e.g. GP unreachable, patient on holiday), is still possible but financially sanctioned with lower reimbursement rates. We aimed to compare GP detection rates before and after the introduction of this gatekeeping scheme. Patient service use behaviour such as doctor-shopping and GP referral to secondary care were also compared. METHODS: Two cross-sectional surveys using the same study methods were carried out 10 years apart. In 2003, 46 GPs and 1151 patients participated (approximately 25 patients per GP), with a 32.7% GP participation rate. In 2013, 38 GPs participated (of which 29 had participated in the previous study, with a 85.3% "recapture" rate) and 1133 patients (approximately 30 patients per GP). Patient participation rates were 89.8% and 67%, respectively. Patients completed self-report questionnaires in the waiting room of which the DSM-IV diagnostic criteria Patient Health Questionnaire (PHQ) and an adapted version of the Client Service Receipt Inventory (CSRI) on contacts with health care services in the previous six months. For each patient, the GP completed a questionnaire giving his rating of psychiatric illness on a five-point scale with his/her diagnosis for cases, and action undertaken. RESULTS: Of the patients, 27% and 25.4% had a CMD according to the PHQ (defined as a diagnosis of minor or major depression, panic attack, anxiety or somatoform disorder) in 2003 and 2013 respectively. Corresponding detection rates were 51% and 52.6%. Rates were highest for threshold disorders: panic disorder (69.4% and 79.9% in 2003 and 2013, respectively), major depression (75% and 63.3% in 2003 and 2013, respectively) and other anxiety disorders (69.1% and 78.8% in 2003 and 2013, respectively). In 2003, the GPs declared seeing 15.5% for the first time on the survey-day, compared to 9.6% in 2013 (P=0.006). Doctor-shopping declined between the two studies, from 18.4% to 12.1% for practical and mostly unavoidable reasons, and from 9.8% to 4.2% for dissatisfaction reasons (P<0.0001). Referral to specialist doctors increased from 9.7% in 2003 to 14.7% in 2013 (P=0.014). In 2013, on the survey-day, 94.8% of patients had registered with a Preferred Doctor and 81.2% were seeing this Preferred Doctor. In 2003, 93.5% of patients declared having a usual GP and 79.9% were visiting this GP on the survey-day. CONCLUSIONS: This is one of the first studies to report data from two repeated surveys carried out before and after a change in the health service organisation, with data collected from both the patient and the GP. We report relatively high GP detection rates for the two periods, with about 50% of CMDs, including subsyndromic conditions, detected by the GP. Rates are considerably higher for the threshold disorders. The overall detection rate did not increase as expected between the two studies. Detection is a complex topic, involving issues such as the suitability of applying categorical DSM-IV criteria diagnoses to primary care, the relevance of detecting subthreshold conditions and the ability of cross-sectional studies to correctly assess the ability of GPs to recognise cases. The introduction of gatekeeping with the choice of a Preferred Doctor has led to a decline in the frequency of doctor-shopping, whatever its reason, with patients no doubt being better known to the GP. Yet it appears most patients had already chosen a GP they were loyal to before the scheme, with a similar proportion of patients consulting their chosen GP or Preferred Doctor on both survey-days in 2003 and 2013, suggesting the scheme may to some extent only have officialised what already existed with respect to having a usual GP. The French reform still allows for doctor-shopping which can be considered as a positive aspect of the scheme: patients either dissatisfied with previous care or needing to change GP are thus able to "test" and choose the doctor that best suits their needs.

Short- and long-term outcomes of metformin compared with insulin alone in pregnancy: a systematic review and meta-analysis.

AIM: To assess the short- and long-term maternal and fetal impact of metformin in pregnancy compared with insulin. METHODS: We performed a comprehensive literature search of MEDLINE, EMBASE, BIOSIS, Cochrane Database of Systematic Reviews and ClinicalTrials.gov. Eligible studies were randomized control trials (RCTs) or follow-up of an RCT that: (1) compared metformin with insulin in pregnancy in women with gestational diabetes mellitus or Type 2 diabetes; and (2) reported maternal or fetal outcomes of interest. Two reviewers extracted the data, evaluated study quality and calculated pooled estimates. RESULTS: Sixteen studies (n = 2165 in quantitative analysis) were included. Metformin lowered the risk of neonatal hypoglycaemia [risk ratio (RR) = 0.63; 95% confidence interval (95% CI), 0.45 to 0.87], large for gestational age babies (RR = 0.80; 95% CI, 0.64 to 0.99), pregnancy-induced hypertension (RR = 0.56; 95% CI, 0.37 to 0.85) and total maternal pregnancy weight gain [mean difference (MD) -2.07; 95% CI -2.88 to -1.27]. Metformin did not increase preterm delivery (RR = 1.18; 95% CI 0.67 to 2.07), small for gestational age babies (RR = 1.20; 95% CI, 0.67 to 2.14), perinatal mortality (RR = 0.82; 95% CI, 0.17 to 3.92) or Caesarean section (RR = 0.97; 95% CI, 0.80 to 1.19). Long-term outcome information is limited. CONCLUSIONS: Our review found that metformin had no short-term adverse effects on pregnancy, potential benefits in the neonatal period, but limited long-term follow-up information. Prior to routine use, we recommend further follow-up studies of offspring exposed to metformin in utero.

Further understanding of doorway states in elastic systems.

In a previous work an elastic bar with a groove or notch that presents a doorway state was studied when the system was excited with 20 cycles of harmonic signals. The strength function had a Lorentzian width Γd = 1/πτd, where τd is the decay time of the prompt response. In the present paper, the doorway-state phenomenon is analyzed again for the same harmonic signals but for a very large number of cycles. The strength-function phenomenon is once more obtained, but now with a Lorentzian width Γ' which is larger than Γd. A qualitative and numerical explanation of this fact is given, leading therefore to further understanding of doorway states in elastic systems. The numerical results show a very good agreement with the values measured in the laboratory.

Factors associated with mixed dementia vs Alzheimer disease in elderly Mexican adults. / Factores asociados a la demencia mixta en comparación con demencia tipo Alzheimer en adultos mayores mexicanos.

INTRODUCTION: Mixed dementia (DMix) refers to dementia resulting from Alzheimer disease in addition to cerebrovascular disease. The study objectives were to determine the clinical and imaging factors associated with Dmix and compare them to those associated with Alzheimer disease. MATERIAL AND METHODS: Cross-sectional study including 225 subjects aged 65 years and over from a memory clinic in a tertiary hospital in Mexico City. All patients underwent clinical, neuropsychological, and brain imaging studies. We included patients diagnosed with DMix or Alzheimer disease (AD). A multivariate analysis was used to determine factors associated with DMix. RESULTS: We studied 137 subjects diagnosed with Dmix. Compared to patients with AD, Dmix patients were older and more likely to present diabetes, hypertension, dyslipidaemia, and history of cerebrovascular disease (P<.05). The multivariate analysis showed that hypertension (OR 1.92, CI 1.62-28.82; P=.009), white matter disease (OR 3.61, CI 8.55-159.80; P<.001), and lacunar infarcts (OR 3.35, CI 1.97-412.34; P=.014) were associated with Dmix, whereas a history of successfully treated depression showed an inverse association (OR 0.11, CI 0.02-0-47; P=.004) CONCLUSIONS: DMix may be more frequent than AD. Risk factors such as advanced age and other potentially modifiable factors were associated with this type of dementia. Clinicians should understand and be able to define Dmix.

Reactivation of coccidioidomycosis: a prosthetic joint infection in Spain.

A resident of Spain was found to have a prosthetic knee infection due to coccidioidomycosis. He had a history of having pneumonia which resolved while living in an area of California endemic for Coccidioides in 1957-1961. The patient left California in 1961 returned to Spain and never left Spain thereafter. In 2006, a total knee replacement was done. In 2013, a prosthetic knee infection was documented due to coccidioidomycosis. By molecular DNA analysis, Coccidioides immitis was identified from the knee tissue, a species most commonly found in California. This represents reactivation of a Coccidioides infection 56 years after leaving the endemic area.

"Low-field" intraoperative MRI: a new scenario, a new adaptation.

AIM: To describe the adaptation of Cruces University Hospital to the use of intraoperative magnetic resonance imaging (ioMRI), and how the acquisition and use of this technology would impact the day-to-day running of the neurosurgical suite. MATERIALS AND METHODS: With the approval of the ethics committee, an observational, prospective study was performed from June 2012 to April 2014, which included 109 neurosurgical procedures with the assistance of ioMRI. These were performed using the Polestar N-30 system (PSN30; Medtronic Navigation, Louisville, CO), which was integrated into the operating room. RESULTS: A total of 159 procedures were included: 109 cranial surgeries assisted with ioMRI and 50 control cases (no ioMRI use). There were no statistical significant differences when anaesthetic time (p=0.587) and surgical time (p=0.792) were compared; however, an important difference was shown in duration of patient positioning (p<0.0009) and total duration of the procedure (p<0.0009) between both groups. CONCLUSIONS: The introduction of ioMRI is necessary for most neurosurgical suites; however, a few things need to be taken into consideration when adapting to it. Increase procedure time, the use of specific MRI-safe devices, as well as a checklist for each patient to minimise risks, should be taken into consideration.