Cost analysis of next-generation imaging in high-risk prostate cancer staging.

INTRODUCTION AND OBJECTIVE: Next-generation imaging (NGI) tests, such as choline PET/CT and PSMA PET, have shown to increase sensitivity in the detection of nodal and metastatic disease in prostate cancer. However, their use implies an increase in diagnostic costs compared to conventional imaging (CI) tests such as CT and bone scan. The aim of our study was to determine which diagnostic pathway is more cost-effective in high-risk prostate cancer. MATERIAL AND METHOD: Cost-effectiveness analysis of the available imaging tests (CI, Choline/PSMA PET) for the staging of high-risk prostate cancer. Sensitivity and specificity were estimated based on published evidence, and costs were collected from the Management Department. In order to carry out a cost-effectiveness analysis, five diagnostic pathways were proposed estimating the accurate diagnoses. RESULTS: PSMA PET was the most accurate diagnostic option. The CI diagnostic workup was the most economical and CI+PSMA the most expensive. Analyzing the diagnostic cost-effectiveness ratio, CI+PSMA proved to be the most expensive (€5627.30 per correct diagnosis) followed by PET PSMA (€4987.11), choline (€4599.84) and CI (€4444.22). CONCLUSIONS: PSMA PET is the most accurate strategy in staging distant disease in patients with high-risk prostate cancer. Radiotracer uptake tests such as CI have been shown to be the most cost-effective option, followed by choline and PSMA.

Determination of Corneal Power after Refractive Surgery with Excimer Laser: A Concise Review.

Refractive surgery with excimer laser has been a very common surgical procedure worldwide during the last decades. Currently, patients who underwent refractive surgery years ago are older, with a growing number of them now needing cataract surgery. To establish the power of the intraocular lens to be implanted in these patients, it is essential to define the true corneal power. However, since the refractive surgery modified the anterior, but not the posterior surface of the cornea, the determination of the corneal power in this group of patients is challenging. This article reviews the different sources of error in finding the true corneal power in these cases, and comments on several approaches, including the clinical history method as described originally by Holladay, and a modified version of it, as well as new alternatives based on corneal tomography, using devices that are able to measure the actual anterior and posterior corneal curvatures, which have emerged in recent years to address this issue.

VISUAL OUTCOMES, CONTRAST SENSITIVITY, AND SATISFACTION WITH MULTIFOCAL INTRAOCULAR LENS BLENDED TECHNIQUE: LATE MID-TERM RESULTS.

PURPOSE: To describe clinical visual outcomes, spectacle independence, and patient satisfaction after cataract surgery with blending implantation of ReSTOR (Alcon laboratories) multifocal intraocular lenses. MATERIAL AND METHODS: A single-arm, non-randomized prospective study assessed patients undergoing cataract surgery with ReSTOR® +2.50 intraocular lens in the dominant eye and +3.00 add in the fellow eye between January 2015 to January 2020. RESULTS: In total, 47 patients (94 eyes) were enrolled, 28 women and 19 men. The average age at surgery time was 64 ±8 years, average postoperative follow-up was 45.4 ±7.0 months, with a minimum of 18.9 months. Postoperative binocular uncorrected distance visual acuity (UDVA) was on average 0.07 logMar (Snellen 20/24), uncorrected binocular intermediate visual acuity at 65 cm was 0.07 logMar (20/24), uncorrected binocular near visual acuity at 40 cm was 0.06 logMar (20/23). Contrast sensitivity under photopic and scotopic conditions, with and without glare, remained at the upper limit of normality. 98% of patients were quite satisfied or very satisfied. 87% did not require glasses for any activities, either at distant vision, nor at near vision. CONCLUSIONS: Cataract surgery with ReSTOR® IOL blended vision showed medium-term satisfactory visual results, achieving spectacle independence and a high level of satisfaction.

SEVERE NEAR REFLEX SPASM IN A HEALTHY TEENAGER. A CASE REPORT.

INTRODUCTION: Spasm of the near reflex usually includes accommodative spasm, esophoria/tropia, and different degrees of miosis. Patients usually refer to distance blurred and fluctuating vision, ocular discomfort, and headaches. The diagnosis is established with refraction with and without cycloplegia; most of the cases have a functional etiology. However, some cases require neurological conditions to be ruled out; cycloplegics have an important diagnostic and therapeutic role. PURPOSE: To describe a case of bilateral severe accommodative spasm in a healthy 14-year-old teenager. CASE PRESENTATION: A 14-year-old boy with progressive diminished visual acuity attended for YSP consultation. The diagnosis of bilateral spasm of the near reflex was made, based on a gap refraction of 9.75 D between retinoscopy with and without cycloplegia and esophoria with normal keratometry and axial length. The spasm was eliminated with 2 drops of cycloplegic in each eye separated by 15 days; no clear etiology was found other than the start of school. CONCLUSION: Clinicians should be aware of pseudomyopia, especially in children with acute changes in visual acuity, who are usually exposed to myopigenic environmental factors that induce overstimulation of the parasympathetic third cranial nerve's innervation.

Variables predictoras de la duración de la amnesia postraumática tras un traumatismo craneoencefálico / Predictors of the duration of post-traumatic amnesia following traumatic brain injury

Introducción: La duración de la amnesia postraumática (APT) ayuda a estimar el nivel de recuperación tras un traumatismo craneoencefálico (TCE). Sin embargo, apenas se dispone de información sobre qué variables sociodemográficas y clínicas influyen en su duración. Este estudio pretende identificarlas y crear un modelo predictivo que permita estimar el tiempo que un paciente tarda en emerger de la APT. Pacientes y métodos: La muestra estaba formada por 40 pacientes adultos en APT ingresados en un centro neurorrehabilitador. El 89,7% había sufrido un TCE grave; el 10,3% restante, un TCE moderado. Su estado cognitivo se valoró mediante el Galveston Orientation and Amnesia Test (GOAT) –escala que permite determinar en qué momento se puede considerar que un paciente emerge de la APT–. Resultados: Se encontró una ecuación de regresión (F = 8,511; p < 0,001; R2 = 0,415), en la que las siguientes variables (clasificadas por su orden de importancia) explicaron el 41,5% de la variabilidad observada en la duración de la APT: a) GOAT administrado a la llegada al centro neurorrehabilitador; b) años de formación reglada del paciente; y c) días que estuvo en APT antes de ingresar en el centro neurorrehabilitador. La ecuación de regresión derivada fue la siguiente: 104,284 + (–0,708 × GOAT-inicial) + (–4,124 × años formación reglada) + (0,219 × APT-hospital agudos). Conclusiones: El tiempo que un paciente tarda en emerger de la APT está condicionado por la puntuación que obtiene en el primer GOAT administrado al ingresar en el centro neurorrehabilitador, el nivel de estudios, y los días que permanece en APT entre el momento del TCE y el ingreso en el centro neurorrehabilitador.(AU)

Introduction: The duration of post-traumatic amnesia (PTA) helps estimate the level of recovery following traumatic brain injury (TBI). Yet, little information is available about which sociodemographic and clinical variables influence its duration. This study aims to identify them and create a predictive model that makes it possible to estimate the time it takes for a patient to emerge from PTA. Patients and methods: The sample consisted of 40 adult patients with PTA admitted to a neurorehabilitation centre. A total of 89.7% had suffered a severe TBI, whereas the remaining 10.3% had had a moderate TBI. Cognitive status was assessed using the Galveston Orientation and Amnesia Test (GOAT) – a scale for determining at what point a patient can be considered to be emerging from PTA. Results: A regression equation was found (F = 8.511; p < 0.001; R2 = 0.415), in which the following variables (ranked in order of importance) explained 41.5% of the variability observed in the duration of PTA: a) GOAT administered on arrival at the neurorehabilitation centre; b) years of formal education of the patient; and c) days with PTA prior to admission to the neurorehabilitation centre. The equation derived was as follows: 104.284 + (–0.708 × GOAT-initial) + (–4.124 × years formal education) + (0.219 × hospital acute-APT). Conclusions: The time it takes for a patient to emerge from PTA is conditioned by the score obtained in the first GOAT administered on admission to the neurorehabilitation centre, their level of education, and the number of days elapsed with PTA between occurrence of the TBI and admission to the neurorehabilitation centre.(AU)

[Predictors of the duration of post-traumatic amnesia following traumatic brain injury]. / Variables predictoras de la duración de la amnesia postraumática tras un traumatismo craneoencefálico.

INTRODUCTION: The duration of post-traumatic amnesia (PTA) helps estimate the level of recovery following traumatic brain injury (TBI). Yet, little information is available about which sociodemographic and clinical variables influence its duration. This study aims to identify them and create a predictive model that makes it possible to estimate the time it takes for a patient to emerge from PTA. PATIENTS AND METHODS: The sample consisted of 40 adult patients with PTA admitted to a neurorehabilitation centre. A total of 89.7% had suffered a severe TBI, whereas the remaining 10.3% had had a moderate TBI. Cognitive status was assessed using the Galveston Orientation and Amnesia Test (GOAT) - a scale for determining at what point a patient can be considered to be emerging from PTA. RESULTS: A regression equation was found (F = 8.511; p < 0.001; R2 = 0.415), in which the following variables (ranked in order of importance) explained 41.5% of the variability observed in the duration of PTA: a) GOAT administered on arrival at the neurorehabilitation centre; b) years of formal education of the patient; and c) days with PTA prior to admission to the neurorehabilitation centre. The equation derived was as follows: 104.284 + (-0.708 x GOAT-initial) + (-4.124 x years formal education) + (0.219 x hospital acute-APT). CONCLUSIONS: The time it takes for a patient to emerge from PTA is conditioned by the score obtained in the first GOAT administered on admission to the neurorehabilitation centre, their level of education, and the number of days elapsed with PTA between occurrence of the TBI and admission to the neurorehabilitation centre.

TITLE: Variables predictoras de la duración de la amnesia postraumática tras un traumatismo craneoencefálico.Introducción. La duración de la amnesia postraumática (APT) ayuda a estimar el nivel de recuperación tras un traumatismo craneoencefálico (TCE). Sin embargo, apenas se dispone de información sobre qué variables sociodemográficas y clínicas influyen en su duración. Este estudio pretende identificarlas y crear un modelo predictivo que permita estimar el tiempo que un paciente tarda en emerger de la APT. Pacientes y métodos. La muestra estaba formada por 40 pacientes adultos en APT ingresados en un centro neurorrehabilitador. El 89,7% había sufrido un TCE grave; el 10,3% restante, un TCE moderado. Su estado cognitivo se valoró mediante el Galveston Orientation and Amnesia Test (GOAT) ­escala que permite determinar en qué momento se puede considerar que un paciente emerge de la APT­. Resultados. Se encontró una ecuación de regresión (F = 8,511; p menor de 0,001; R2 = 0,415), en la que las siguientes variables (clasificadas por su orden de importancia) explicaron el 41,5% de la variabilidad observada en la duración de la APT: a) GOAT administrado a la llegada al centro neurorrehabilitador; b) años de formación reglada del paciente; y c) días que estuvo en APT antes de ingresar en el centro neurorrehabilitador. La ecuación de regresión derivada fue la siguiente: 104,284 + (­0,708 × GOAT-inicial) + (­4,124 × años formación reglada) + (0,219 × APT-hospital agudos). Conclusiones. El tiempo que un paciente tarda en emerger de la APT está condicionado por la puntuación que obtiene en el primer GOAT administrado al ingresar en el centro neurorrehabilitador, el nivel de estudios, y los días que permanece en APT entre el momento del TCE y el ingreso en el centro neurorrehabilitador.

DETERMINATION OF FACTORS ASSOCIATED WITH LONG-TERM ENDOTHELIAL LOSS AND REFRACTIVE RESULT IN PATIENTS WITH ARTISAN PHAKIC LENS.

PURPOSE: To determine the changes in endothelial cell density, refractive results, and risk factors associated with endothelial loss in patients with irisclaw phakic intraocular lenses for myopia/myopic astigmatism (Artisan). METHODOLOGY: Data collection was obtained from an existing database with information on patients with a phakic Artisan lens implant between 1998 and 2011 at the Virgilio Galvis Ophthalmology Centre, with at least 5 years of follow-up. As a second stage, an analysis was carried out to identify the change in endothelial cell density and its potential associated factors. RESULTS: A total of 80 eyes with myopic errors were included with a follow-up of 11.9 + 3.48 years. The percentage of total loss of endothelial cells was greater than 25% of the preoperative density in 43.8% of the eyes. A postoperative annual loss > 1.6% was found in 47.0% of the eyes with that information available. 41 eyes (51%) had final endothelial density < 2000 cells/mm2, and 7 (8.8%) eyes had endothelial cell density < 1000 cells/mm2. Among the variables studied, no associated factors for long-term endothelial loss were found. During the course of the study, 8 (10%) phakic intraocular lenses were explanted, including 3 with accelerated endothelial loss, and another 2 with cataract associated and a significantly low endothelial density. The last mean spherical equivalent was -0.81 (±1.01 D), and the final uncorrected distance visual acuity was 0.45 logMar (Snellen 20/56). CONCLUSION: Artisan-type phakic lenses are a good alternative for the correction of high myopic defects, with predictable refractive results in the long term. However, there is an increased loss of endothelial cells in the long term in a high percentage of patients. Strict postoperative follow-up, including endothelial evaluation, is required, and further studies are warranted.

Cystoid Macular Edema after an uncomplicated Gonioscopy- Assisted Transluminal Trabeculotomy on a previously vitrec- tomized patient.

Purpose: The main purpose of this study was to report a case of cystoid macular edema (CME) after gonioscopy-assisted transluminal trabeculotomy (GATT). Methods: We describe the case of a 73-year-old woman with ocular hypertension and history of cataract surgery combined with posterior vitrectomy and epiretinal membrane peeling 2 years before, who developed CME after uncomplicated GATT procedure. Results: Uneventful GATT surgery was performed in an eye with ocular hypertension. A month after GATT surgery, the patient com-plained of blurry vision. Best corrected visual acuity had deteriorated from 20/20 on Snellen chart, to 20/70. The patient was diagnosed with CME. Treatment with topical non-steroidal anti-inflammatory drug (NSAID) and topical corticosteroids for one month, and oral carbonic anhydrase inhibitor for one week achieved a total CME regression with recovery of a normal macular and foveal architecture. Conclusions: Surgery-induced CME may occur following stand-alone microinvasive glaucoma surgery (MIGS) such as GATT. It would be worthwhile to conduct studies to explore whether the prophylactic use of NSAID and corticosteroids is justified.

Estimation of ocular axial length with optometric parameters is not accurate.

Myopia is a worldwide major public concern, aside from the visual disturbance needing optical correction, myopia may be associated with open angle glaucoma, retinal detachment and myopic maculopathy. The higher the myopia the higher the risk for retinal associated comorbidities, and the axial length is the more important measure to estimate risk of visual impairment. Recently a formula to predict axial length using spherical equivalent and keratometry was proposed, with the intention of categorizing the risk of visual impairment with Tideman et al. classification. PURPOSE: To evaluate the accuracy of an axial length prediction formula in a Colombian population 8-17 years old. METHODS: Children from MIOPUR study with optical biometer axial length measure (AL), manifest refraction and keratometry were included in the analysis. Predicted axial length (PAL) was calculated with the prediction formula. A Bland-Altman assessment was conducted, and the concordance correlation coefficient was measured. Proposed classification of AL to establish risk of visual loss was used with measured AL and with PAL. The percentage of eyes misclassified was then established. RESULTS: A total of 2129 eyes were included in the analysis. Mean difference of axial length (actual AL minus PAL) was -0.516 mm (-1.559 mm - 0.528 mm). Concordance correlation coefficient (CCC) of 0.656 (IC95 0.636-0.675) was found between the real AL and PAL. PAL differed from measured AL by 1 mm or more in 16.58 %, and by 2 mm or more, in 0.61 % of the eyes. In myopic eyes, PAL was in average 0.426 mm longer than the AL actually measured with CCC of 0.714 (IC95 0.666-0.761). PAL differed from measured AL by 1 mm or more in 21.92 %, and by 2 mm or more, in 0.45 % of the myopic eyes. The study revealed that 15.03 % of all eyes, and 29.81 % of myopic eyes, were misclassified when PAL was used. CONCLUSIONS: The proposed axial length prediction formula was not accurate, and it did not adequately classify risk of visual impairment in myopic eyes in a group of Colombian children. We consider that it is not possible to predict the axial length based only on optometric data, such as the corneal radius of curvature and the spherical equivalent. This is very possibly related to the variability of crystalline lens power within a population.

SPONTANEOUS REGRESSION OF A PRIMARY IRIS STROMAL CYST IN A PATIENT WITH KERATOCONUS. A CASE REPORT.

PURPOSE: To report the rare case of a 29-year-old male with a history of keratoconus, who presented with a primary iris stromal cyst which eventually showed spontaneous regression. METHODS: Description of the clinical findings in the case of a 29-year-old male with a prior history of keratoconus, but no eye surgery or trauma, who consulted for an iris cyst in the left eye, diagnosed 9 months earlier. CASE REPORT: Slit-lamp examination revealed mild dyscoria, and a large cyst in the inferior quadrant of the iris. Ultrasound biomicroscopy and anterior segment optical coherence tomography of the left eye confirmed the presence of a giant iris cyst with thin walls, in contact with the corneal endothelium. Corneal endothelial cell density in the inferior cornea (close to the cyst) was 1805 cells/mm2 and 2066 cells/mm2 in the central area. After considering the risk of anterior chamber epithelial downgrowth following any surgical procedure of the cyst, the patient received conservative management. In the following months, the patient presented with 3 episodes of anterior uveitis, managed with topical corticosteroids. Finally, at approx. 21 months after the initial diagnosis, the cyst presented spontaneous regression. Anterior segment optical coherence tomography confirmed the absence of fluid inside the cyst remnants and the final endothelial cell densities evidenced endothelial cell loss (inferior cornea 738 cells/mm2 and central cornea 1605 cells/mm2). CONCLUSION: Conservative management should be considered in patients with cysts that show slow progression and are distant from the visual axis, in order to minimise the risk of complications following any surgical procedure of the cyst. In addition, the present case is one of the few of primary stromal iris cysts with spontaneous regression reported in the literature.

PHOTOREFRACTIVE SURGERY WITH EXCIMER LASER AND ITS IMPACT ON THE DIAGNOSIS AND FOLLOW-UP OF GLAUCOMA. A REVIEW.

Excimer laser refractive surgery is a procedure performed worldwide to solve refractive errors and reduce dependence on glasses or contact lenses. There has been an increase in the number of procedures performed around the world. Myopia is the most common indication for corneal photorefractive surgery. Myopic patients have a higher risk of developing some type of glaucoma in their lifetime, such as primary open-angle glaucoma and others. Refractive surgery ablates central corneal stromal tissue, altering its thickness and biomechanics, which in turn makes it difficult to accurately measure intraocular pressure (IOP), since it underestimates it. This underestimation of IOP may delay the diagnosis of de novo glaucoma in patients with a history of refractive surgery. Each patient who wishes to undergo corneal refractive surgery should undergo a thorough glaucoma examination in order to monitor and detect the possible development and / or progression of glaucoma. A very useful practical approach is to perform a series of IOP measurements before and after surgery, when the eye is already stable, and the difference between the averages of the two sets of readings can then be used as a personalised correction factor for postoperative IOP monitoring in that eye. Also, if there is any suspicion of a possible glaucoma, paraclinical tests, such as coherent optical tomography of the retinal nerve fibre layer (RNFL), visual fields and photos of the optic nerve should be requested. All this data prior to refractive surgery should be provided to these patients, so that they can save it and give it to their treating ophthalmologists in the future.

Grado de conocimiento de insulinización por los médicos de atención primaria y su repercusión en el control de la diabetes / Level of knowledge about insulinization by Primary Care physicians and its impact on diabetes control

OBJETIVO: Analizar el grado de conocimiento y manejo actual de la insulinización por los médicos de atención primaria (AP), así como su impacto sobre el grado de control metabólico. MATERIALES Y MÉTODOS: Estudio secuencial exploratorio, principalmente cualitativo con un enfoque fenomenológico y posterior fase cuantitativa. Participaron 37 médicos de AP del Servicio Andaluz de Salud. Se realizó análisis univariado y bivariado de variables sociodemográficas y clínico-asistenciales. RESULTADOS: Existió una gran variabilidad entre los médicos de AP acerca del conocimiento sobre el tratamiento con insulinas (conocimiento bajo: 13,5%; medio: 59,5%; alto: 27,0%). Hubo una relación directa entre el conocimiento sobre insulinización y el grado de consecución de objetivos de HbA1c: a mayor grado de conocimiento, mejor control metabólico. Las insulinas basales más prescritas fueron la insulina glargina100 (56,8%), seguida de la insulina glargina300 (29,7%) y después la insulina NPH (8,1%). Hubo tendencia a presentar un diferente perfil de prescripción respecto a las insulinas basales, de tal forma que la prescripción de insulina NPH y de insulinas mixtas coincidía con el nivel más bajo de conocimiento. El 35,1% de los médicos de AP desconocían patrones de insulinización más complejos. CONCLUSIONES: Solo el 27% de los médicos de AP tienen un conocimiento elevado sobre el tratamiento con insulinas. Existe una relación directa entre el nivel de conocimiento sobre las insulinas y el grado de control glucémico. Es necesario mejorar el conocimiento sobre el tratamiento con insulinas para optimizar el control metabólico y disminuir el riesgo de complicaciones

OBJECTIVE: To determine the level of knowledge and current management of starting insulin treatment by Primary Care physicians, and its impact on metabolic control. MATERIALS AND METHODS: A mainly qualitative exploratory sequential study, with a phenomenological approach, followed by a quantitative phase. The study included 37 primary care physicians from the Andalusian Health Service. Socio-demographic and clinical care variables were analysed. Univariate and bivariate analyses were performed. RESULTS: There was a wide variability between Primary Care physicians in the level of knowledge of treatment with insulins (low knowledge: 13.5%; medium knowledge: 59.5%; high knowledge: 27.0%). There was a direct relationship between the level of knowledge and the attainment of HbA1c goals (as the level of knowledge increased, the metabolic control improved). The most common basal insulins prescribed were insulin glargine U-100 (56.8%), followed by insulin glargine U-300 (29.7%), and neutral protamine hagedorn (NPH) insulin (8.1%). There was a trend to show a different prescription pattern with basal insulins (as the level of knowledge decreased, the prescription of mixed and NPH insulins increased). More than one-third (35.1%) of primary care physicians did not know more complex patterns of treatment with insulins. CONCLUSIONS: Only 27% of Primary Care physicians had a high knowledge about treatment with insulins. There was a direct relationship between the level of knowledge about insulins and glycaemic control. It is necessary to improve the knowledge about insulin therapy in order to optimise metabolic control and reduce the risk of complications

Effervescence-assisted spiral hollow-fibre liquid-phase microextraction of trihalomethanes, halonitromethanes, haloacetonitriles, and haloketones in drinking water.

A new analytical method was optimized to determine 18 disinfection by-products (DBPs) in drinking water, including four different chemical groups. For this purpose, spiral-shaped hollow-fibre liquid phase microextraction with 1-octanol as the acceptor solvent assisted by effervescence was applied using a homemade supporting device that was specifically designed for this application. The device was printed in a 3D printer and allows for an increased fibre surface even with a low sample volume, which significantly facilitates the extraction. The samples were analysed by gas chromatography coupled to both an electron capture detector and a mass spectrometer for the quantification and unequivocal identification of the analytes, respectively. Effervescence was generated using citric acid and bicarbonate at a molar ratio 1:2, which significantly improves the extraction efficiency and reduces mechanical operations, since stirring and modifiers are not required. The results showed enrichment factors ranging from 13.1 to 140.1. Satisfactory recoveries (80-113 %) were obtained, with relative standard deviations from 3 to 15 % and good linearity. The detection limits (ng L-1) ranged from 10 to 35 (trihalomethanes), 12 to 220 (halonitromethanes), 17 to 79 (haloacetonitriles) and 10 to 16 (haloketones). The applicability of the method was assessed in 6 local water distribution systems.

Development of feed composition tables using a statistical screening procedure.

Millions of feed composition records generated annually by testing laboratories are valuable assets that can be used to benefit the animal nutrition community. However, it is challenging to manage, handle, and process feed composition data that originate from multiple sources, lack standardized feed names, and contain outliers. Efficient methods that consolidate and screen such data are needed to develop feed composition databases with accurate means and standard deviations (SD). Considering the interest of the animal science community in data management and the importance of feed composition tables for the animal industry, the objective was to develop a set of procedures to construct accurate feed composition tables from large data sets. A published statistical procedure, designed to screen feed composition data, was employed, modified, and programmed to operate using Python and SAS. The 2.76 million data received from 4 commercial feed testing laboratories were used to develop procedures and to construct tables summarizing feed composition. Briefly, feed names and nutrients across laboratories were standardized, and erroneous and duplicated records were removed. Histogram, univariate, and principal component analyses were used to identify and remove outliers having key nutrients outside of the mean ± 3.5 SD. Clustering procedures identified subgroups of feeds within a large data set. Aside from the clustering step that was programmed in Python to automatically execute in SAS, all steps were programmed and automatically conducted using Python followed by a manual evaluation of the resulting mean Pearson correlation matrices of clusters. The input data set contained 42, 94, 162, and 270 feeds from 4 laboratories and comprised 25 to 30 nutrients. The final database included 174 feeds and 1.48 million records. The developed procedures effectively classified by-products (e.g., distillers grains and solubles as low or high fat), forages (e.g., legume or grass-legume mixture by maturity), and oilseeds versus meal (e.g., soybeans as whole raw seeds vs. soybean meal expellers or solvent extracted) into distinct sub-populations. Results from these analyses suggest that the procedure can provide a robust tool to construct and update large feed data sets. This approach can also be used by commercial laboratories, feed manufacturers, animal producers, and other professionals to process feed composition data sets and update feed libraries.

[Level of knowledge about insulinization by Primary Care physicians and its impact on diabetes control]. / Grado de conocimiento de insulinización por los médicos de atención primaria y su repercusión en el control de la diabetes.

OBJECTIVE: To determine the level of knowledge and current management of starting insulin treatment by Primary Care physicians, and its impact on metabolic control. MATERIALS AND METHODS: A mainly qualitative exploratory sequential study, with a phenomenological approach, followed by a quantitative phase. The study included 37 primary care physicians from the Andalusian Health Service. Socio-demographic and clinical care variables were analysed. Univariate and bivariate analyses were performed. RESULTS: There was a wide variability between Primary Care physicians in the level of knowledge of treatment with insulins (low knowledge: 13.5%; medium knowledge: 59.5%; high knowledge: 27.0%). There was a direct relationship between the level of knowledge and the attainment of HbA1c goals (as the level of knowledge increased, the metabolic control improved). The most common basal insulins prescribed were insulin glargine U-100 (56.8%), followed by insulin glargine U-300 (29.7%), and neutral protamine hagedorn (NPH) insulin (8.1%). There was a trend to show a different prescription pattern with basal insulins (as the level of knowledge decreased, the prescription of mixed and NPH insulins increased). More than one-third (35.1%) of primary care physicians did not know more complex patterns of treatment with insulins. CONCLUSIONS: Only 27% of Primary Care physicians had a high knowledge about treatment with insulins. There was a direct relationship between the level of knowledge about insulins and glycaemic control. It is necessary to improve the knowledge about insulin therapy in order to optimise metabolic control and reduce the risk of complications.

Malignant transformation of a conjunctival keratoacanthoma requiring enucleation.

PURPOSE: We report a rare case of rapid transformation of a conjunctival keratoacanthoma (KA) into a highly aggressive squamous cell carcinoma requiring enucleation. To our knowledge, this is the second such case reported in the literature. METHODS: Case report. RESULTS: A 73-year-old man presented with a recurrent conjunctival lesion in the right eye. A slit lamp examination revealed a hyperkeratotic lesion in the limbar conjunctiva adhered to deep planes but with no ocular involvement. An incisional biopsy was performed because an area of scleromalacia was observed underlying the lesion. Histological findings were consistent with conjunctival KA. One week later, a raised lesion was observed invading the anterior chamber. Histological examination of another excisional biopsy specimen indicated conjunctival squamous cell carcinoma. The right eye was enucleated. Histological analysis confirmed intraocular tumor invasion. Complete clinical remission was observed over one year of follow up. CONCLUSIONS: Although conjunctival keratoacanthoma is normally benign, it is important to correctly differentiate between KA and squamous cell carcinoma, and closely monitor the eye after surgery because of the rare possibility of recurrence or conversion to squamous cell carcinoma. Immunohistochemistry could help in the diagnosis and management of dubious cases.

Synthesis of salt-stable fluorescent nanoparticles (quantum dots) by polyextremophile halophilic bacteria.

Here we report the biological synthesis of CdS fluorescent nanoparticles (Quantum Dots, QDs) by polyextremophile halophilic bacteria isolated from Atacama Salt Flat (Chile), Uyuni Salt Flat (Bolivia) and the Dead Sea (Israel). In particular, a Halobacillus sp. DS2, a strain presenting high resistance to NaCl (3-22%), acidic pH (1-4) and cadmium (CdCl2 MIC: 1,375 mM) was used for QDs biosynthesis studies. Halobacillus sp. synthesize CdS QDs in presence of high NaCl concentrations in a process related with their capacity to generate S2- in these conditions. Biosynthesized QDs were purified, characterized and their stability at different NaCl concentrations determined. Hexagonal nanoparticles with highly defined structures (hexagonal phase), monodisperse size distribution (2-5 nm) and composed by CdS, NaCl and cysteine were determined by TEM, EDX, HRXPS and FTIR. In addition, QDs biosynthesized by Halobacillus sp. DS2 displayed increased tolerance to NaCl when compared to QDs produced chemically or biosynthesized by non-halophilic bacteria. This is the first report of biological synthesis of salt-stable QDs and confirms the potential of using extremophile microorganisms to produce novel nanoparticles. Obtained results constitute a new alternative to improve QDs properties, and as consequence, to increase their industrial and biomedical applications.

Insulina tópica en queratopatía neurotrófica tras resección de neurinoma del acústico / Topical insulin in neurotrophic keratopathy after resection of acoustic neuroma

Caso clínico: Una paciente con antecedente de resección quirúrgica de un neurinoma del acústico presentó compromiso tanto del nervio facial como del nervio trigémino izquierdos. Inicialmente consultó por queratitis de exposición, pero 2 semanas después presentó una queratitis infecciosa. Tras la toma de la muestra corneal cursó con un defecto epitelial persistente, que no respondió al manejo médico. Se indicó insulina tópica con lo que se evidenció disminución del área de la lesión en los siguientes 5 días. Se colocó además, en ese momento, una lente de contacto terapéutica y, finalmente, 2 semanas después de haberse iniciado la insulina, el defecto epitelial cerró por completo. Discusión: Se trata de un caso complejo por la confluencia de parálisis facial, queratitis neurotrófica y queratitis infecciosa, que finalmente tuvo un resultado exitoso. La insulina tópica puede ser una terapia coadyuvante efectiva en casos de úlceras neurotróficas que no respondan a la terapia convencional

Case report: A patient with a history of surgical resection of an acoustic neuroma presented with involvement of both the left facial nerve and the left trigeminal nerve. She initially consulted for exposure keratitis, but two weeks later presented with an infectious keratitis. After taking the corneal sample, she presented with persistent epithelial defect, which did not respond to medical management. Topical insulin was indicated, and a decrease in the area of the lesion was seen in the following 5 days. A therapeutic contact lens was also placed at that time and finally, two weeks after the initiation of insulin, the epithelial defect completely closed. Discussion: This was a complex case due to the confluence of facial paralysis, neurotrophic keratitis, and infectious keratitis, which finally had a successful outcome. Topical insulin can be an effective adjuvant therapy in cases of neurotrophic ulcers that do not respond to standard therapy

Perfil de resistencia antibiótica en infecciones oculares en un centro de referencia en Floridablanca, Colombia / Antibiotic resistance profile in eye infections in a reference centre in Floridablanca, Colombia

Antecedentes y objetivo: Ante la creciente resistencia bacteriana a los antibióticos es necesario determinarla de manera local para servir de guía en el manejo clínico. El propósito de este estudio fue caracterizar el patrón de sensibilidad antibiótica en casos de infecciones oculares en una institución oftalmológica de tercer nivel en Floridablanca (Colombia). Materiales y métodos: Estudio observacional de corte transversal en el cual se analizaron los informes de cultivo y antibiograma de muestras tomadas de casos de conjuntivitis, queratitis infecciosas y endoftalmitis entre enero de 2013 y junio del 2016. Resultados: Ochocientas treinta y tres muestras fueron positivas para bacterias. Considerando microorganismos tanto grampositivos como gramnegativos, la gentamicina, la tobramicina y la ciprofloxacina mostraron tasas de resistencia altas (64,4; 40,3% y 29,1%). La moxifloxacina, la vancomicina, el imipenem y la gatifloxacina mostraron bajos porcentajes de resistencia: 2,6; 2,1; 0,6 y 0,4% respectivamente. Al comparar los resultados con estudios previos en nuestra institución se evidenció una disminución de la sensibilidad a las quinolonas de cuarta generación y al imipenem, especialmente dentro de los gramnegativos. Conclusión: Las quinolonas de cuarta generación, el imipenem y la vancomicina siguen teniendo in vitro una baja resistencia de las bacterias causantes de infecciones oculares. Sin embargo, se evidenció una tendencia al incremento de la resistencia de las bacterias gramnegativas. Se deben tomar medidas para intentar controlar este fenómeno, y pensar en posibles alternativas de terapia antimicrobiana ante infecciones causadas por estos microorganismos

Background and objective: In view of the increasing bacterial resistance to antibiotics, it is necessary to determine it locally in order to serve as a guide in clinical management. The purpose of this study was to characterise the pattern of antibiotic sensitivity in cases of eye infections in a third level ophthalmological institution in Floridablanca (Colombia). Materials and methods: An observational cross-sectional study in which an analysis was made of the culture and antibiogram reports of specimens taken from cases of conjunctivitis, infectious keratitis, and endophthalmitis between January 2013 and June 2016. Results: A total of 833 specimens were positive for bacteria. Considering both gram-positive and gram-negative microorganisms gentamicin, tobramycin, and ciprofloxacin showed high resistance rates (64.4%, 40.3%, and 29.1%, respectively). Moxifloxacin, vancomycin, imipenem, and gatifloxacin showed low percentages of resistance: 2.6%, 2.1%, 0.6%, and 0.4%, respectively. When comparing the results with previous studies in our institution, there was a decrease in sensitivity to the fourth-generation quinolones and imipenem, especially within the gram-negative ones. Conclusion: Fourth generation quinolones, imipenem and vancomycin continue to have a low in vitro resistance to bacteria that cause eye infections. However, there was a tendency to an increase in the resistance of gram-negative bacteria. Measures should be taken to try to control this phenomenon, and consider possible antimicrobial therapy alternatives to infections caused by these microorganisms

Topical insulin in neurotrophic keratopathy after resection of acoustic neuroma. / Insulina tópica en queratopatía neurotrófica tras resección de neurinoma del acústico.

CASE REPORT: A patient with a history of surgical resection of an acoustic neuroma presented with involvement of both the left facial nerve and the left trigeminal nerve. She initially consulted for exposure keratitis, but two weeks later presented with an infectious keratitis. After taking the corneal sample, she presented with persistent epithelial defect, which did not respond to medical management. Topical insulin was indicated, and a decrease in the area of the lesion was seen in the following 5 days. A therapeutic contact lens was also placed at that time and finally, two weeks after the initiation of insulin, the epithelial defect completely closed. DISCUSSION: This was a complex case due to the confluence of facial paralysis, neurotrophic keratitis, and infectious keratitis, which finally had a successful outcome. Topical insulin can be an effective adjuvant therapy in cases of neurotrophic ulcers that do not respond to standard therapy.