Prognosis in epilepsy: initiating long-term drug therapy.

INTRODUCTION: Prognosis in epilepsy refers to the probability of either achieving seizure remission (SR), whether spontaneously or using antiepileptic drugs (AED), or failing to achieve control of epileptic seizures (ES) despite appropriate treatment. Use of AED is recommended after a second unprovoked ES. For a first episode, the decision of whether or not to start drug treatment depends on the risk of recurrence and the advantages or disadvantages of the antiepileptic drug. The main goal of treatment is achieving absence of ES without adverse effects (AE). AED is selected according to epilepsy type and the demographic and clinical characteristics of the patient. DEVELOPMENT: A PubMed search located articles and recommendations by the most relevant scientific societies and clinical practice guidelines concerning epilepsy prognosis and treatment. Evidence and recommendations are classified according to the prognostic criteria of the Oxford Centre for Evidence-Based Medicine (2001) and the European Federation of Neurological Societies (2004) for therapeutic actions. CONCLUSIONS: Most newly diagnosed epileptic patients achieve good control over their ES. The majority of the AEDs available at present provide effective control over all types of ES, and choice therefore depends on the patient's individual characteristics. Treatment should be initiated as monotherapy at the lowest effective dose, which in half of all patients provides ES control and is well tolerated. In cases in which the first AED is not effective, alternative therapy should be started, and monotherapy should be employed before combination therapy where possible. The probability of achieving good control over ES decreases with each successive treatment failure.

Actinotignum schaalii infection: Challenges in diagnosis and treatment.

Actinotignum schaalii affects elderly people and is associated with individuals with urological-related predispositions, but can be found in a variety of locations, such as cutaneous, intraabdominal, genitourinary and surgical infections. Disseminated infections occur less frequently and are by and large related to urinary tract colonisation. This pathogen is often neglected due to growth requirements, especially in urinary tract infections. We present 107 Actinotignum schaalii isolated from genitourinary samples (80.4%), from skin and soft tissue infections (13.1%), from bone and deep tissue infection (4.7%) and from blood cultures (1.9%). The automated system Alfred 60/AST was paramount for the isolation of 77.6% of the UTI. All the isolates tested were susceptible to penicillin, ampicillin, linezolid, vancomycin, teicoplanin, rifampicin and tetracycline. In conclusion, we present a large series of Actinotignum schaalii infections. This pathogen is hard to isolate, and is resistant to commonly used empirical antimicrobials.

[Intensive care services resources in Spain]. / Recursos estructurales de los Servicios de Medicina Intensiva en España.

OBJECTIVES: To identify the resources related to the care of critically ill patients in Spain, which are available in the units dependent of the Services of Intensive Care Medicine (ICM) or other services/specialties, analyzing their distribution according to characteristics of the hospitals and by autonomous communities. DESIGN: Prospective observational study. SETTING: Spanish hospitals. PARTICIPANTS: Heads of the Services of ICM. MAIN OUTCOME VARIABLES: Number of units and beds for critically ill patients and functional dependence. RESULTS: The total number of registries obtained with at least one Service of ICM was 237, with a total of 100,198 hospital beds. Level iii (43.5%) and level ii (35%) hospitals predominated. A total of 73% were public hospitals and 55.3% were non-university centers. The total number of beds for adult critically ill patients, was 4,738 (10.3/100,000 inhabitants). The services of ICM registered had available 258 intensive are units (ICUs), with 3,363 beds, mainly polyvalent ICUs (81%) and 43 intermediate care units. The number of patients attended in the Services of ICM in 2008 was 174,904, with a percentage of occupation of 79.5% A total of 228 units attending critically ill patients, which are dependent of other services with 2,233 beds, 772 for pediatric patients or neonates, were registered. When these last specialized units are excluded, there was a marked predominance of postsurgical units followed by coronary and cardiac units. CONCLUSIONS: Seventy one per cent of beds available in the Critical Care Units in Spain are characterized by attending severe adult patients, are dependent of the services of ICM, and most of them are polyvalent.

The future of intensive care medicine.

Intensive care medical training, whether as a primary specialty or as secondary add-on training, should include key competences to ensure a uniform standard of care, and the number of intensive care physicians needs to increase to keep pace with the growing and anticipated need. The organisation of intensive care in multiple specialty or central units is heterogeneous and evolving, but appropriate early treatment and access to a trained intensivist should be assured at all times, and intensivists should play a pivotal role in ensuring communication and high-quality care across hospital departments. Structures now exist to support clinical research in intensive care medicine, which should become part of routine patient management. However, more translational research is urgently needed to identify areas that show clinical promise and to apply research principles to the real-life clinical setting. Likewise, electronic networks can be used to share expertise and support research. Individuals, physicians and policy makers need to allow for individual choices and priorities in the management of critically ill patients while remaining within the limits of economic reality. Professional scientific societies play a pivotal role in supporting the establishment of a defined minimum level of intensive health care and in ensuring standardised levels of training and patient care by promoting interaction between physicians and policy makers. The perception of intensive care medicine among the general public could be improved by concerted efforts to increase awareness of the services provided and of the successes achieved.

[Current status of fibreoptic bronchoscopy in intensive care medicine]. / Situación actual de la realización de fibrobroncoscopias en los servicios de medicina intensiva.

Flexible bronchoscopy (FB) has been of great help in the management of critically ill patients. Its safety and usefulness in the hands of experienced professionals, with the required measures of caution, has resulted in the increasingly widespread use of the technique even in unstable critical patients subjected to mechanical ventilation and with high oxygen demands. The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), through its Acute Respiratory Failure (GT-IRA) and Infectious Diseases (GT-EI) Work Groups, aims to promote knowledge and standards of quality in the use of FB among all specialists in Intensive Care Medicine. Through an expert committee, the SEMICYUC has established the objective of accrediting such training, with the preparation of a curriculum and definition of those Units qualified for providing training in the different techniques and levels. The accreditation process seeks to stimulate good learning practice and quality in training. Both specialists in Intensive Care Medicine and other specialists, and the patients, will benefit from the commitment and control afforded by such accreditation, and from the learning and training which the mentioned process entails.

Man-portable laser-induced breakdown spectroscopy system for in situ characterization of karstic formations.

This paper reports the development and field testing of a man-portable instrument based on laser-induced breakdown spectrometry (LIBS) for inspection and analysis of speleothems. The 50 mJ of a Q-switched Nd:YAG laser operating at 1064 nm was used to generate a plasma on the sample. Plasma emission was then guided using a fiber-optic cable to a 1/10 m spectrometer equipped with a charge-coupled device (CCD) array detector. Plasma light was automatically processed in order to obtain surface and in-depth information from the speleothems. A field campaign in the interior of Nerja Cave (a large karstic formation in the South of Spain) has been carried out, aimed at evaluating the analytical performance of the instrument when operating in an unfriendly environment. Identification analysis of the speleothems' alteration layers and depth profiles of Sr and Ca is carried out and reported.

In situ analytical assessment and chemical imaging of historical buildings using a man-portable laser system.

In this work, the capability of laser-induced breakdown spectrometry for the in situ analytical assessment and chemical mapping of the façade of the cathedral of Malaga (Spain) has been demonstrated. The task required the use of a portable laser analyzer that allowed real-time spectral acquisitions in the field. A man-portable laser, based on a Q-switched Nd:YAG laser operating at its fundamental wavelength, has been utilized to generate a LIBS plasma of the sample surface. A chemical characterization of the different materials employed in the construction of this building has been performed. The purpose of this study was to use LIBS spectrochemical analysis to qualitatively discriminate between sandstone, limestone, marble, and cement mortar, which are the main components used in this class of historical monument. The field analysis was performed in two zones: the northern façade and the "girola"; the total areas of analysis of the two regions were 250 m(2) and 650 m(2), respectively. Chemical images of Si/Ca and Ca/Mg ratios from both parts of the building were generated. During the measurement campaign, a protocol of analysis was chosen so as to achieve an accurate description of the building materials with respectable spatial resolutions.

The neurologic effects of thiopental therapy after cardiac arrest.

We studied the effect of thiopental loading during resuscitation of 53 patients following cardiopulmonary arrest and compared the outcome with that found in 54 patients treated conventionally in the 30 previous months. Thiopental therapy (10 mg/kg i.v.) was begun within 30 min of the arrest once hemodynamic stability had been established. Thiopental infusion (20 mg/kg over 6 h) was followed by phenobarbital sodium (125 mg every 12 h), tolerance to the initial dose having been assessed. The in-hospital mortality rate for both groups was similar. In patients with ischemic heart disease, the mortality rate within the first 6 h was significantly higher in the thiopental group (p less than 0.05), although for the remaining patients there were more survivors among the thiopental treated patients (p less than 0.05). Excluding the patients who died within the first 6 h, 61% of the patients in the thiopental group survived cardiac arrest with normal cerebral performance, whereas only 37% in the standard treatment group showed normal functional outcome (p less than 0.03). These results suggest a favorable neurologic effect of thiopental loading during resuscitation of patients without ischemic heart disease. In patients with ischemic heart disease, an initial hemodynamic deterioration may contribute to minimising the beneficial effect of barbiturate therapy.

Variables discriminating individuals who seek orthodontic treatment.

Overall, these results support the view that dental-facial esthetics and self-perceptions of occlusal appearance, as well as attitudes toward malocclusion and orthodontic treatment, are important factors in the individual's decision to obtain orthodontic treatment. The data indicate that psychosocial variables not directly related to occlusal problems and treatment, do not add significantly to the description of differences between those who seek treatment and those who do not. While these analyses did not include a number of variables--such as socioeconomic factors or attitudes of significant others--which may also be important in predicting individual response to malocclusion, they do suggest strongly that psychosocial factors directly related to need for treatment are probably most productively assessed in terms of self-perceptions of occlusal appearance and attitudes regarding dental malrelations and their treatment.

CT evaluation of patients during treatment of advanced non-small cell lung carcinoma.

Twenty-one patients with Stage III non-small cell bronchogenic carcinoma were studied by chest radiograph and computed tomography (CT) before and after chemotherapy. In three patients (14%), the prechemotherapy CT showed measurable disease not seen on chest radiograph. Postchemotherapy CT scans showed additional measurable disease not seen on chest x-ray films in nine of 56 (16%) follow-up exams. This represented additional disease in seven of the 21 patients (33%). The CT findings resulted in a significant change in therapy in six of the 21 patients (29%).

Pelvic haematocele in ruptured ectopic pregnancy simulating uterine enlargement.

Rupture of an ectopic pregnancy may result in the formation of a pelvic haematocele. Four cases are presented in which the haematocele appeared as a solid or complex mass of coarse echoes on ultrasound examination and was indistinguishable from the uterus. Because of this, the sonographic examination suggested enlargement and inhomogeneity of the uterus. Differential diagnosis is discussed.

[Neuroleptic malignant syndrome, multiorgan failure and peripheral polyneuropathy]. / Síndrome neuroléptico maligno, fallo multiorgánico y polineuropatía periférica.

The Malignant Neuroleptic Syndrome (MNS) is characterised by the acute appearance of hyperthermia, muscular rigidity, loss of motor control, and alterations in the level of consciousness, which could prove fatal if not rapidly diagnosed and treated. It is held to be a serious idiosyncratic reaction which appears in patients being treated with neuroleptics, independently of the dosage and the length of time the drug has been prescribed. Relapses do not usually occur when the drug is re-prescribed, once the acute phase has been passed, which suggests the existence of predisposing factors. There are frequent complications (acute respiration difficulties, acute kidney failure, disseminated intravascular coagulation and multiorganic failure) which condition the prognosis. The treatment consists of the suppression of the neuroleptic, rehydration, and specific drugs (bromocryptine, sodium dantroline). We have analysed two new cases which reacted badly, one of them with a multiorganic failure and the other, who had a good initial therapeutical response but who went on to develop a peripheral neuropathy, an infrequent complication in international medical casebooks.

[Chloroquine-induced myopathy and neuropathy: progressive tetraparesis with areflexia that simulates a polyradiculoneuropathy. Two case reports]. / Miopatía y neuropatía inducida por cloroquina: tetraparesia progresiva con arreflexia que simula una polirradiculoneuropatía. A propósito de dos casos.

INTRODUCTION: Chloroquine is a drug that is widely used in rheumatology and occasionally prescribed in dermatology. From a neurotoxicological point of view, chloroquine can have effects on the peripheral nerves, muscles, neuromuscular junctions and the central nervous system. In this study we analyse the clinical, neurophysiological and anatomopathological findings in two patients with chloroquine induced neuromyopathy, which took the form of a polyradiculoneuropathy. CASE REPORTS: Case 1: a 75 year old female with rheumatoid arthritis treated with daily doses of 250 mg of chloroquine for four years. The patient visited because of several months history of predominantly proximal progressive tetraparesis with areflexia. Analytical tests and lumbar puncture were normal. Electromyogram (EMG): proximal myopathic and distal neuropathic patterns. Muscular biopsy: vacuolar myopathy with accumulations of phagolysosomes, lipids, lipofuscin, myelinic curvilinear bodies. Case 2: a 74 year old female with arthropathy treated with daily doses of 250 mg of chloroquine for nine months. The patient presented a progressive proximal paraparesis with generalised areflexia. Analytical tests and lumbar puncture were normal. EMG: mixed sensory motor polyneuropathy, myogenic pattern with high frequency discharges in the iliac psoas and a neurogenic pattern in the distal muscles. Muscular biopsy: vacuolar myopathy suggesting a myopathy due to chloroquine. After stopping treatment with this drug the patients progressed favourably. CONCLUSION: Chloroquine can induce a clinical pattern that suggests a polyradiculoneuropathy. It is important to establish a history of having taken this drug. If this is indeed the case, then an electromyographic study of the most proximal muscles should be performed in order to detect a myogenic pattern and the same exploration should be applied to the distal muscles to reveal a neurogenic pattern. The final diagnosis will be established by muscular biopsy.