Multifractal characterization of nystagmus eye movements.

In this work, we investigate the multifractal properties of eye movement dynamics of children with infantile nystagmus, particularly the fluctuations of its velocity. The eye movements of three children and one adult with infantile nystagmus were evaluated in a simple task in comparison with 28 children with no ocular pathologies. Four indices emerge from the analysis: the classical Hurst exponent, the singularity strength corresponding to the maximum of the singularity spectrum, the asymmetry of the singularity spectrum, and the multifractal strength, each of which characterizes a particular aspect of eye movement dynamics. Our findings indicate that, when compared to children with no ocular pathologies, patients with infantile nystagmus present lower values of all indices. Except for the multifractal strength, the difference in the remaining indices is statistically significant. To test whether the characterization of patients with infantile nystagmus in terms of multifractality indices allows them to be distinguished from children without ocular pathologies, we performed an unsupervised clustering analysis and classified the subjects using supervised clustering techniques. The results indicate that these indices do, indeed, distinctively characterize the eye movements of patients with infantile nystagmus.

Detección precoz de la ambliopía en Atención Primaria / Early detection of amblyopia in Primary Care

Introducción: la detección precoz de alteraciones visuales en la infancia tiene importancia ya que pueden causar problemas en el desarrollo visual, el rendimiento escolar o, incluso, suponer un riesgo vital como el retinoblastoma. El objetivo de este estudio es realizar una revisión bibliográfica sobre las actividades diagnósticas que puede realizar el pediatra de Atención Primaria (PAP) para mejorar el cribaje de la ambliopía, e identificar la edad más adecuada para este cribado. Material y métodos: se ha realizado una búsqueda bibliográfica de textos científicos en inglés y español publicados en los últimos 20 años en bases de datos como PubMed y Google Académico. Algunas de las palabras clave fueron: “amblyopia”, “vision screening”, “pediatric”, “retinoscopy” y “photoscreener”. Resultados: se encontraron 376 resultados, seleccionándose 29 artículos y dos libros que incluían métodos diagnósticos de ambliopía realizados por el PAP (Bruckner, Hirschberg, Cover test, estereopsis y agudeza visual) y otros más avanzados (retinoscopia, autorrefractómetros, fotorrefractómetros y potenciales evocados). Los programas de cribado y derivación al oftalmólogo realizados por el PAP están basados en métodos tradicionales, siendo en general poco objetivos y heterogéneos. Conclusiones: los resultados encontrados no definen la edad óptima para el cribado, ni la prueba o combinación de pruebas más adecuadas para evitar derivaciones innecesarias o que una alteración pase inadvertida. Sin embargo, este cribado puede realizarse sencilla y rápidamente a partir de los 6 meses de vida mediante métodos avanzados como fotorrefractometría. Aumentar los recursos disponibles del PAP y conocer su aplicabilidad real y sus beneficios clínicos puede precisar posteriores investigaciones (AU)

Introduction: early detection of visual alterations in childhood has special relevance since it can cause problems in visual development, school performance, or even pose a vital risk such as retinoblastoma. The aim of this study was to conduct a traditional review about the diagnostic procedures that can be performed by the Primary Care Pediatrician (PCP) to improve the screening of amblyopia and to identify the most appropriate age for this screening.Material and methods: a bibliographic search of scientific texts in English and Spanish published in the last 20 years in databases such as PubMed and Google Scholar has been carried out. Some of the key words were: “amblyopia”, “vision screening”, “pediatric”, “retinoscopy” and “photoscreener”.Results: 376 results were found. 29 articles and 2 books were selected covering diagnostic methods of amblyopia performed by the PCP (Bruckner, Hirschberg, Cover test, stereopsis and visual acuity assessment) and others more advanced (retinoscopy, autorefractometry, photorefractometry and evoked potentials). The screening and ophthalmologist referral programs performed by the PCP are based on traditional methods and are generally not very objective and heterogeneous.Conclusions: the evidence does not allow to define the optimal age to amblyopia screening or which test or combination of tests could be the most appropriate to avoid unnecessary referrals or unnoticed alterations. However, this screening can be performed easily and quickly from the age of 6 months using diagnostic methods such as photorefractometry. Increasing the available resources in PCP clinic and knowing its applicability and clinical benefits may require further research. (AU)

Clinical effectiveness of exenatide in diabetic patients waiting for bariatric surgery.

BACKGROUND: Bariatric surgery constitutes the most effective treatment for severely obese type 2 diabetic patients. Exenatide is a glucagon-like peptide 1 receptor agonist that can improve glycemic control and cause weight loss in patients with type 2 diabetes. Clinical experience with exenatide in obese patients with type 2 diabetes waiting for bariatric surgery has not been reported. The aim of the study was to evaluate, in clinical practice, weight and metabolic effects of exenatide (after 3 and 6 months) in patients with type 2 diabetes and obesity waiting for bariatric surgery. METHODS: A total of 100 diabetic adult subjects with a BMI ≥ 35 kg/m(2) were included. Primary endpoints were changes in weight and HbA1c after 6 months of treatment. Secondary endpoints were changes from baseline of a variety of clinical measures (triglycerides levels, blood pressure, and waist circumference). Data were analyzed at 3 and 6 months of follow-up. RESULTS: Treatment for 6 months with exenatide decreased significantly body weight (-12.5 kg) and waist circumference (-13 cm). Twenty percent of patients reduced their BMI under 35 kg/m(2) and significantly improved their metabolic profile (HbA1c <7 %). Significant and maintained decreases in HbA1c of 1 % were observed in the 3 and 6 months cohorts. Triglycerides levels and blood pressure also decreased from baseline to the end of the study. Treatment was discontinued in 19 % of patients mainly due to drug inefficacy (6 %) or adverse events (4 %). CONCLUSIONS: Exenatide twice daily (BID) leads to early, robust, and significant weight loss in a subset of patients with diabetes and severe obesity before bariatric surgery. Clinical trials are needed to confirm the benefits of GLP-1 agonists in type 2 diabetic obese patients or high-risk super-obese patients waiting for bariatric surgery.

Síndrome de Cushing y necrosis avascular de cadera: presentación de 2 enfermos / Cushing's syndrome and avascular hip necrosis: presentation of two patients

No disponible

Pegvisomant and cabergoline combination therapy in acromegaly.

Combination with cabergoline may offer additional benefits to acromegalic patients on pegvisomant monotherapy. We evaluated the safety and efficacy profile of this combination and investigated the determinants of response. An observational, retrospective, cross-sectional study. Fourteen acromegalic patients (9 females), who were partially resistant to somatostatin analogs and on pegvisomant monotherapy. Cabergoline was added because of the presence of persistent mildly increased IGF-I. The mean follow-up time was 18.3 ± 10.4 months. The efficacy and safety profile was assessed. The influence of clinical and biochemical characteristics on treatment efficacy was studied. IGF-I levels returned to normal in 4 patients (28%) at the end of the study. In addition, some decline in IGF-I levels was observed in a further 5 patients. The % IGF-I decreased from 158 ± 64% to 124 ± 44% (p = 0.001). The average change in IGF-I was -18 ± 27% (range -67 to +24%). Lower baseline IGF-I (p = 0.007), female gender (p = 0.013), lower body weight (p = 0.031), and higher prolactin (PRL) levels (p = 0.007) were associated with a better response to combination therapy. There were no significant severe adverse events. Significant tumour shrinkage was observed in 1 patient. Combination therapy with pegvisomant and cabergoline could provide better control of IGF-I in some patients with acromegaly. Baseline IGF-I levels, female gender, body weight, and PRL levels affect the response to this combination therapy.

Assessment of noise exposure during commuting in the Madrid subway.

Because noise-induced hearing impairment is the result not only of occupational noise exposure but also of total daily noise exposure, it is important to take the non-occupational exposure of individuals (during commuting to and from their jobs, at home, and during recreational activities) into account. Mass transit is one of the main contributors to non-occupational noise exposure. We developed a new methodology to estimate a representative commuting noise exposure. The methodology was put into practice for the Madrid subway because of all Spanish subway systems it covers the highest percentage of worker journeys (22.6%). The results of the application highlight that, for Madrid subway passengers, noise exposure level normalized to a nominal 8 hr (L(Ex,8h-cj) ) depends strongly on the type of train, the presence of squealing noise, and the public address audio system, ranging from 68.6 dBA to 72.8 dBA. These values play an important role in a more complete evaluation of a relationship between noise dose and worker health response.

Alucinaciones visuales en ancianos sin deterioro cognitivo: síndrome de Charles Bonnet / Visual hallucinations in the elderly with no cognitive impairment: Charles Bonnet syndrome

Presentamos el caso de una paciente de 90 años atendida en nuestro centro de salud cuyo síntoma principal es la aparición aislada de alucinaciones visuales complejas. La sintomatología produce una inquietud intensa a la paciente y a su entorno. La valoración por parte del equipo de atención primaria descartó enfermedades agudas subsidiarias de tratamiento urgente. Finalmente fue derivada a la unidad de demencias de zona para descartar deterioro cognitivo con inicio de síndrome de demencia como diagnóstico más probable. Allí, tras el estudio neuropsicológico se excluyó la demencia y se orientó como síndrome de Charles Bonnet, consistente en la aparición de alucinaciones visuales secundarias a déficit visual severo. Tras 5 años de seguimiento, la sintomatología ha desaparecido casi en su totalidad sin aparición de signos de deterioro cognitivo, lo cual hace patente la necesidad de incluir esta entidad en el diagnóstico diferencial de las alucinaciones visuales de los pacientes ancianos en atención primaria (AU)

We report the case of a 90 year-old female patient treated at our health centre whose main symptom was the presence of isolated visual hallucinations. The symptoms produced a state of intense concern to the patient and her family. The initial assessment by the primary care unit showed that no acute pathology was affecting the patient. So, the first option that was considered was cognitive impairment and the patient was referred to the Area Dementia Unit to exclude this pathology. However, after a neuropsychological examination, dementia syndrome was ruled out, and Charles Bonnet Syndrome, consisting of the appearance of visual hallucinations secondary to severe visual impairment, was considered instead. After five years, symptoms have almost completely disappeared and there are no signs of cognitive impairment. This shows the need to consider Charles Bonnet Syndrome in the differential diagnosis of visual hallucinations in elderly patients in primary health care (AU)

Feocromocitoma adrenal y neurofibromatosis tipo 1 / Adrenal pheochromocytoma and neurofibromatosis type 1

Bajo el término genérico de neurofibromatosis (NF) se incluyen diversos trastornos genéticamente determinados del sistema nervioso, que afectan al desarrollo y al crecimiento de las células y los tejidos que recubren y protegen las fibras nerviosas. Estos trastornos determinan el desarrollo de tumores (llamados neurofibromas) que pueden crecer en cualquier lugar del cuerpo, así como a la existencia de anormalidades en tejidos no pertenecientes al sistema nervioso, como la piel y los huesos. Se distinguen 2 tipos: neurofibromatosis tipo 1(NF-1) (85% de los casos) y neurofibromatosis tipo 2 (NF2). La neurofibromatosis tipo 1 se asocia a distintas enfermedades endocrinológicas, siendo una de ellas el feocromocitoma. Presentamos el caso de un varón de 56 años, diagnosticado en la juventud de neurofibromatosis tipo 1, que desarrolló un feocromocitoma adrenal derecho (AU)

Several genetically determined disorders of the nervous system that affect the development and growth of cells and tissues that cover and protect nerve fibers are included under the generic term of neurofibromatosis (NF). These disorders determine the development of tumors (called neurofibromas) that may grow anywhere in the body as well as the existence of abnormalities in tissues outside the nervous system, such as the skin and bones. Two types are distinguished: neurofibromatosis type 1 (85% of the cases) and neurofibromatosis type 2 (NF2). NF-1 is associated with various endocrine diseases, one of these being pheochromocytoma. We present the case of a 56-year old man, diagnosed in his youth of NF1, who developed a right adrenal pheochromocytoma (AU)

Myoepithelioma of a minor salivary gland of the cheek: case report.

Myoepithelioma is a rare neoplasm of the salivary glands, generally occurring in the parotid gland and less often in the minor accessory salivary gland of the oral cavity. The histological appearance includes solid, myxoid and reticular growth patterns. Vimentin and S-100 protein are very sensitive but non-specific immunohistochemical markers of neoplastic myoepithelium. Conservative surgery is the treatment of choice. A case of myoepithelioma of the minor salivary gland of the cheek with low grade malignancy is described, focusing on clinical behaviour, histopathological and immunohistochemical features and differential diagnosis.

Evaluación de la función hipofisaria tras episodio neurológico grave / Evaluation of pituitary function after a severe neurological event

Objetivo: Estudiar la relación entre episodios neurológicos graves (traumatismo craneoencefálico, hemorragia subaracnoidea o accidente cerebrovascular) y déficit en la función hipofisaria, así como establecer parámetros en el momento agudo del episodio neurológico que permitan predecir la función hipofisaria posteriormente. Material y métodos: Estudio descriptivo y transversal, realizado en pacientes de la Unidad de Cuidados Intensivos del Hospital Universitario de Getafe (Madrid), durante los años 2001 y 2002, que habían sufrido traumatismo craneoencefálico grave, hemorragia subaracnoidea o accidente cerebrovascular. De 65 pacientes ingresados, se reclutó solamente a 11. Se contactó con ellos transcurridos de 3 a 24 meses del episodio neurológico para realización de historia clínica endocrinológica, exploración física y determinaciones hormonales. A 8 pacientes estudiados se les tomaron muestras basales de hormonas hipofisarias y se les realizaron pruebas de estimulación. En los 3 restantes se realizaron pruebas de estimulación cuando las basales extraídas hacían sospechar déficit. Retrospectivamente, se revisaron las historias para obtener parámetros del momento del ingreso que pudiesen predecir el déficit. Resultados: En los pacientes que sufrieron un episodio neurológico grave que precisó cuidados intensivos inicialmente, existe una prevalencia de déficit de un 36,4%. Se encuentra un 18,2% de déficit en los ejes gonadal y somatotropo. La presencia de hipertensión intracraneal en el momento agudo se relaciona con la aparición de déficit mediante una relación estadísticamente significativa. Conclusión: En este estudio preliminar aparece un alto porcentaje de afección hipofisaria en la evolución de pacientes que sufren un episodio neurológico grave. La hipertensión intracraneal se asocia a la aparición del déficit (AU)

Objective: To determine the relationship between severe neurological events [traumatic brain injury (TBI), subarachnoid hemorrhage (SAH) or stroke] and pituitary dysfunction, as well as to establish parameters at the acute moment of the neurological event that could help to predict subsequent pituitary function. Material and methods: We performed a descriptive, cross-sectional study in patients with a severe TBI, SAH or stroke in the Intensive Care Unit of the Getafe University Hospital in Madrid (Spain) between 2001 and 2002. Of the 65 patients who were admitted, only 11 were recruited. Contact was made with these patients between 3 and 24 months after the neurological event to take a medical history and perform a physical examination and hormone determinations. Basal samples of pituitary hormones and stimulation tests were performed in eight patients. In the remaining three patients, the stimulation tests were only performed when the basal samples were suspicious for pituitary deficiency. Medical records were retrospectively reviewed to obtain admission parameters that could predict deficiency. Results: In patients who experienced a severe neurological event that initially required intensive care, the prevalence of hormone deficiency was 36.4%; gonadal and somatotropic deficiency was found in 18.2%. The presence of intracranial hypertension in the acute phase was statistically significantly related to the development of hormone deficiency. Conclusion: In this preliminary study a high percentage of pituitary involvement was found in the follow-up of patients who experienced a severe neurological event. Intracranial hypertension was associated with the development of hormone deficiency (AU)

La calidad percibida por el usuario, su relación con la información y la presencia de acompañante en una unidad de paritorios

Objetivo. Conocer la calidad percibida por el usuario en relación con la cantidad y calidad de información que recibían durante el proceso del parto y con la presencia de acompañante. Método. Se realizó un estudio observacional, descriptivo y transversal en la Unidad de Paritorios del Area Hospitalaria de Valme (Sevilla). Los individuos de estudio fueron 915 mujeres que acudieron al Servicio de Paritorio del hospital. Se utilizó un cuestionario autocumplimentado en el que se recogió la opinión sobre la calidad y cantidad de información recibida en el ingreso, la dilatación y en el proceso global del parto. Se relacionó la atención recibida por el usuario con la presencia de acompañante. Resultados y conclusiones. La identificación de los profesionales que reciben a los usuarios al ingreso alcanza el 90 por ciento de los casos. La cantidad y calidad de información aportada en las distintas fases es considerada buena o muy buena en casi la totalidad de las mujeres estudiadas. Por to que respecta a la presencia de acompañante en los procesos de dilatación, parto y posparto, se obtuvieron porcentajes elevados (88,5, 86,8 y 97,4 por ciento, respectivamente) (AU)

[Congenital bronchogenic subcutaneous cyst of the back. A case report and review of the literature]. / Cisti broncogena sottocutanea congenita del dorso. Segnalazione di un raro caso e revisione della letteratura.

The Authors describe a very rare congenital case of bronchogenic subcutaneous cyst of the scapular region occurring in a 8-year-old girl. Only 8 other cases have been published so far. The cyst was asymptomatic and was surgically removed. It measured 2.3 cm. in diameter. Histologically, the cyst was lined by ciliated columnar pseudostratified epithelium devoid of goblet cells and mucus secreting cells. The epithelium lacked immunoreactivity for estrogen and progesterone receptors. The cyst wall contained smooth muscle bundles, but cartilage was absent. Differential diagnosis with emphasis on cutaneous ciliated cyst (Mullerian cyst) is discussed. It appears conceivable that cutaneous ciliated bronchogenic cysts may show partial or fully developed features indicating their bronchial origin.

[Application of a geriatric evaluation protocol in primary care: comparison with data from the clinical history]. / Aplicación de un protocolo de valoración geriátrica en atención primaria: comparación con los datos de la historia clínica.

OBJECTIVES: To determine the prevalence of the health problems included in a multidimensional geriatric assessment (MGA) protocol and to compare them with the problems detected in the clinical histories (CH) of the population consulting at a primary care centre (PCC). DESIGN: Cross-sectional observational. SETTING: Urban PCC (metropolitan area of Barcelona). PATIENTS: Users > or = 65 of a PCC between 01/11/97 and 31/01/98. MEASUREMENTS AND MAIN RESULTS: A random sample of 114 people was chosen. The MGA protocol was used to screen disorders in: hearing, vision, mobility, affective state, cognitive state, social support, functionalism of the instrumental activities of daily life. The clinical histories provided age, sex and information previously recorded on these disorders. 102 people were surveyed (participation: 89.5%). The MGA enabled more problems to be detected, with the difference very marked in some cases such as visual disorders: 55.9% (46.2-65.5) with MGA and 23.5% (15.3-31.8) with CH. There was poor concordance between MGA and CH. For example, neither the 73.3% (54.1-87.7) of the hearing disorders detected with the MGA, nor 94.1% (71.3-99.8) of the cognitive deterioration detected with the MGA had been previously recorded in the CH. CONCLUSIONS: MGA detects more health problems than are normally recorded in primary care clinical histories, which makes this technique relevant to PC consultations with the elderly. However, it would be advisable to identify the population for whom there was better diagnostic performance.

Aplicación de un protocolo de valoración geriátrica en atención primaria: comparación con los datos de la historia clínica / Application of a protocol of geriatric assessment in primary care: comparison with the data in the clinical history

Objetivo. Determinar la prevalencia de los problemas de salud incluidos en un protocolo de valoración geriátrica multidimensional (VGM) y compararlos con los detectados en la historia clínica (HCAP) en población consultante de un centro de atención primaria (CAP). Diseño. Observacional transversal. Emplazamiento: CAP urbano (área metropolitana de Barcelona). Pacientes. Usuarios >= 65 años de un CAP entre 01-XI-1997 y el 31-I-1998. Mediciones y resultados principales. Se seleccionó una muestra aleatoria de 114 individuos. Se cribó con el protocolo VGM las alteraciones en: audición; visión; movilidad; estado afectivo; estado cognitivo; soporte social; funcionalismo de las actividades instrumentales de la vida diaria (AIVD). De la HCAP se recogió: edad, sexo e información previamente registrada sobre estas alteraciones. Se encuestaron 102 sujetos (participación, 89,5 por ciento). La VGM aporta más capacidad de detección de problemas, siendo la diferencia muy acentuada en algún caso, como en las alteraciones visuales, 55,9 por ciento (46,2-65,5) con VGM y 23,5 por ciento (15,3-31,8) con HCAP. La concordancia entre la VGM y la HCAP es baja. Así, por ejemplo, ni el 73,3 por ciento (54,1-87,7) de las alteraciones auditivas detectadas con la VGM ni el 94,1 por ciento (71,3-99,8) de los deterioros cognitivos habían sido registrados previamente en la HCAP. Conclusiones. La VGM detecta prevalencias de problemas de salud superiores al registro habitual de la HCAP, por lo que parece interesante utilizar esta técnica en las consultas de atención primaria a la población anciana. Sin embargo, sería recomendable identificar la población en la que el rendimiento diagnóstico fuera superior (AU)

Optimization of a dry powder inhaler formulation of nacystelyn, a new mucoactive agent.

The aim of this study was to optimize a dry powder inhaler formulation containing a new mucoactive drug, nacystelyn. Formulations were made using three types of lactose, crystalline alpha-lactose, spray-dried lactose and a roller-dried anhydrous beta-lactose. The roller-dried anhydrous beta-lactose possessed the most adequate surface properties, resulting in a significantly higher (P < 0.05) in-vitro lung deposition of nacystelyn than the conventional crystalline alpha-lactose and spray-dried lactose. The particle size distribution of roller-dried beta-lactose was optimized also. Within the size ranges tested (63-100, 90-125 and 100-160 microm), the coarser the lactose, the higher the in-vitro deposition of the drug (up to 40%). In contrast, the in-vitro lung deposition of 100-160 microm roller-dried beta-lactose was very low (< 0.5%), so limiting the potential risk of lung irritation due to the carrier. The influence of the ratio of active ingredient/excipient (w/w) was also investigated. No difference was observed for mixtures from 1:2 to 1:4 while higher dilutions (1:5 and 1:6) showed significantly (P < 0.005) lower deposition results. Finally, the influence of the airflow rate was assessed. No dependence of the fine particle dose was observed between 40 and 80 L min(-1) while significantly higher results were obtained at 100 L min(-1). The dry powder inhaler formulation of nacystelyn using the unusual roller-dried anhydrous beta-lactose resulted in very high and reproducible in-vitro deposition results. However, the latter needs to be confirmed by in-vivo studies.

[Double tachyarrhythmia: left anterior fascicular ventricular tachycardia associated with atrial flutter and fibrillation. Report of a case]. / Doble taquiarritmia: taquicardia ventricular fascicular anterior izquierda asociada a fibrilación y flutter auriculares. Reporte de un caso.

A patient with episodes of palpitation in whom the electrocardiogram showed a right bundle branch (RBBB) configuration and right axis deviation underwent electrophysiologic study and radiofrequency ablation. Left ventricular endocardial mapping during ventricular tachycardia (VT) identified the earliest ventricular activation in the anterolateral wall of the left ventricle. The fused Purkinje potential was recorded at that site, and preceded the QRS complex by 47 mseg, with pace mapping showing an optimal match between the paced rhythm and the clinical VT. The stimulus to QRS time was equal to the Purkinje potential-QRS time. Several radiofrequency lesions were applied in this region, one of them resulted with termination of the tachycardia. Following delivery of this lesion the ventricular tachycardia couldn't be induced either at baseline or during isoproterenol infusion. During VT, atrial fibrillation and atrial flutter were observed, cardioversion was performed reverting to sinus rhythm.

[Evaluation of simple and complex carbohydrate intake by diabetics]. / Evaluación de la ingesta de hidratos de carbono simples y complejos entre los diabéticos.

OBJECTIVE: To determine the percentages of total, simple and complex carbohydrates (CH) in the diet of a group of type II diabetics and to compare them with the recommended standards. DESIGN: Crossover study. SETTING: Primary Care Centre at Ciutat Badia. TARGET POPULATION: 436. SAMPLE: 205. Exclusions and drop-outs: 63. MEASUREMENTS AND RESULTS: Habitual intake was calculated by means of three dietary recordings over 24 hours. Average daily kilocalories were 1,757 kcal. 86.3% of the sample consumed a percentage of total CH below that recommended. Only 3.1% of the sample consumed a percentage of complex CH above the recommended minimum, while 70.2% of the sample consumed a percentage of simple CH above the recommended. CONCLUSIONS: The diabetic patients attended at our centre do not follow present dietary recommendations regarding the distribution of CH. New educational strategies adapted to the characteristics of this population must be worked out.