Shunt Devices for Neurointensivists: Complications and Management.

Cerebrospinal fluid diversion has become the mainstay treatment in hydrocephalus for over 50 years. As the number of patients with ventricular shunt systems increases, neurointensivists are becoming the first-line physicians for many of these patients. When symptoms of a shunt malfunction are suspected and access to a neurosurgeon is limited or delayed, workup and temporizing measures must be initiated. The article highlights the functional nuances, complications, and management of current programmable shunt valves and their MRI sensitivity.

Osteomalacia hipofosfatémica sintomática secundaria a tratamiento con hierro carboximaltosa objetivada con gammagrafía ósea / Symptomatic hypophosphataemic osteomalacia secondary to the treatment with iron carboxymaltose detected in bone scintigraphy

El desarrollo de osteomalacia hipofosfatémica se ha relacionado con diversos tratamientos, fundamentalmente antirretrovirales y administración de hierro por vía intravenosa. La frecuencia de la hipofosfatemia hace necesario vigilar el fosfato tras la administración de hierro carboximaltosa. Presentamos el caso de una mujer sin antecedentes de alteración del metabolismo fosfo-cálcico a la que se pautó este tratamiento por anemia debida a hipermenorrea e intolerancia al hierro por vía oral. Comenzó con dolor oligoarticular que se generalizó más tarde, con importante impotencia funcional y cuya relación con la administración por vía intravenosa de hierro fue descubierta cuando los hallazgos gammagráficos junto con la analítica orientaron hacia una osteomalacia hipofosfatémica. Respondió de forma satisfactoria al tratamiento con fosfato como se objetivó clínicamente y en la gammagrafía ósea de control (AU)

The development of hypophosphataemic osteomalacia has been linked with several treatments, mainly antiretroviral and intravenous iron administration. The frequency of the hypophosphataemia requires monitoring the phosphate after the administration of iron carboxymaltose. We describe a case of a woman with no calcium-phosphorous metabolism disorder, to whom this treatment was prescribed for anaemia due to menorrhagia and intolerance to oral iron. She started with oligoarticular pain, which was spreading with a significant functional loss. The relationship with the administration of intravenous iron was discovered when scintigraphic findings together with laboratory results led to a diagnosis of hypophosphataemic osteomalacia. The patient responded satisfactorily to treatment with phosphate both clinically and in the follow-up bone scintigraphy (AU)

Symptomatic hypophosphataemic osteomalacia secondary to the treatment with iron carboxymaltose detected in bone scintigraphy. / Osteomalacia hipofosfatémica sintomática secundaria a tratamiento con hierro carboximaltosa objetivada con gammagrafía ósea.

The development of hypophosphataemic osteomalacia has been linked with several treatments, mainly antiretroviral and intravenous iron administration. The frequency of the hypophosphataemia requires monitoring the phosphate after the administration of iron carboxymaltose. We describe a case of a woman with no calcium-phosphorous metabolism disorder, to whom this treatment was prescribed for anaemia due to menorrhagia and intolerance to oral iron. She started with oligoarticular pain, which was spreading with a significant functional loss. The relationship with the administration of intravenous iron was discovered when scintigraphic findings together with laboratory results led to a diagnosis of hypophosphataemic osteomalacia. The patient responded satisfactorily to treatment with phosphate both clinically and in the follow-up bone scintigraphy.

Determinación de antígeno carcinoembrionario en los exámenes rutinarios de salud realizados desde Atención Primaria / Carcinoembryonic antigen as a cancer screening marker by primary care physicians

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Self-adaptive MOEA feature selection for classification of bankruptcy prediction data.

Bankruptcy prediction is a vast area of finance and accounting whose importance lies in the relevance for creditors and investors in evaluating the likelihood of getting into bankrupt. As companies become complex, they develop sophisticated schemes to hide their real situation. In turn, making an estimation of the credit risks associated with counterparts or predicting bankruptcy becomes harder. Evolutionary algorithms have shown to be an excellent tool to deal with complex problems in finances and economics where a large number of irrelevant features are involved. This paper provides a methodology for feature selection in classification of bankruptcy data sets using an evolutionary multiobjective approach that simultaneously minimise the number of features and maximise the classifier quality measure (e.g., accuracy). The proposed methodology makes use of self-adaptation by applying the feature selection algorithm while simultaneously optimising the parameters of the classifier used. The methodology was applied to four different sets of data. The obtained results showed the utility of using the self-adaptation of the classifier.

Evaluación de la eficacia en la detección del ganglio centinela en el cáncer de mama: evolución cronológica e influencia de la incorporación de una gammacámara portátil intraoperatoria / Evaluation of the efficacy of sentinel node detection in breast cancer: chronological course and influence of the incorporation of an intra-operative portable gamma camera

Objetivo. Determinar el porcentaje de identificación global del ganglio centinela (GC) en el cáncer de mama, la evolución cronológica de este parámetro y la influencia de la introducción de una gammacámara portátil. Material y métodos. Estudio retrospectivo a partir de una base de datos prospectiva de 754 pacientes a las que se realizó biopsia selectiva del GC de forma consecutiva entre enero de 2003 y diciembre de 2011. La técnica fue mixta en periodo inicial y posteriormente con radiotrazador administrado intra-peritumoralmente. Hasta octubre de 2009 la exéresis del GC fue guiada por sonda y a partir de esta fecha se introdujo una gammacámara portátil para la detección intraoperatoria. Resultados. Se ha biopsiado el GC en 725 de 754 pacientes, siendo por tanto la eficacia global del 96,2%. Según el año de intervención quirúrgica los porcentajes de identificación han sido del 93,5% en 2003, del 88,7% en 2004, del 94,3% en 2005, del 95,7% en 2006, del 93,3% en 2007, del 98,8% en 2008, del 97,1% en 2009 y del 99,1% en 2010 y 2011. Existe una diferencia de proporciones entre el porcentaje de identificación antes y después de la incorporación de la gammacámara portátil del 4,6% que es estadísticamente significativa (IC 95% de la diferencia 2-7,2% con una p asociada de 0,0037). Conclusiones. El porcentaje de identificación global se halla por encima del nivel recomendado por las directrices actuales. Cronológicamente se constata elevación de este parámetro a lo largo del periodo estudiado. Los datos apuntan a que la incorporación de una gammacámara portátil ha tenido un papel en ello (AU)

Aim. To define the sentinel node identification rate in breast cancer, the chronological evolution of this parameter and the influence of the introduction of a portable gamma camera. Material and methods. A retrospective study was conducted using a prospective database of 754 patients who had undergone a sentinel lymph node biopsy between January 2003 and December 2011. The technique was mixed in the starting period and subsequently was performed with radiotracer intra-peritumorally administered the day before of the surgery. Until October 2009, excision of the sentinel node was guided by a probe. After that date, a portable gamma camera was introduced for intrasurgical detection. Results. The SN was biopsied in 725 out of the 754 patients studied. The resulting technique global effectiveness was 96.2%. In accordance with the year of the surgical intervention, the identification percentage was 93.5% in 2003, 88.7% in 2004, 94.3% in 2005, 95.7% in 2006, 93.3% in 2007, 98.8% in 2008, 97.1% in 2009 and 99.1% in 2010 and 2011. There was a significant difference in the proportion of identification before and after the incorporation of the portable gamma camera of 4.6% (95% CI of the difference 2–7.2%, P = 0.0037). Conclusions. The percentage of global identification exceeds the recommended level following the current guidelines. Chronologically, the improvement for this parameter during the study period has been observed. These data suggest that the incorporation of a portable gamma camera had an important role (AU)

[Evaluation of the efficacy of sentinel node detection in breast cancer: chronological course and influence of the incorporation of an intra-operative portable gamma camera]. / Evaluación de la eficacia en la detección del ganglio centinela en el cáncer de mama: evolución cronológica e influencia de la incorporación de una gammacámara portátil intraoperatoria.

AIM: To define the sentinel node identification rate in breast cancer, the chronological evolution of this parameter and the influence of the introduction of a portable gamma camera. MATERIAL AND METHODS: A retrospective study was conducted using a prospective database of 754 patients who had undergone a sentinel lymph node biopsy between January 2003 and December 2011. The technique was mixed in the starting period and subsequently was performed with radiotracer intra-peritumorally administered the day before of the surgery. Until October 2009, excision of the sentinel node was guided by a probe. After that date, a portable gamma camera was introduced for intrasurgical detection. RESULTS: The SN was biopsied in 725 out of the 754 patients studied. The resulting technique global effectiveness was 96.2%. In accordance with the year of the surgical intervention, the identification percentage was 93.5% in 2003, 88.7% in 2004, 94.3% in 2005, 95.7% in 2006, 93.3% in 2007, 98.8% in 2008, 97.1% in 2009 and 99.1% in 2010 and 2011. There was a significant difference in the proportion of identification before and after the incorporation of the portable gamma camera of 4.6% (95% CI of the difference 2-7.2%, P = 0.0037). CONCLUSIONS: The percentage of global identification exceeds the recommended level following the current guidelines. Chronologically, the improvement for this parameter during the study period has been observed. These data suggest that the incorporation of a portable gamma camera had an important role.

[Assessment of the patient satisfaction with a Nuclear Medicine Service]. / Evaluación del grado de satisfacción de los pacientes atendidos en un servicio de Medicina Nuclear.

GOAL: To know the perceived quality and the levels of patient satisfaction with the Nuclear Medicine Service (MN). METHODS: A cross-sectional descriptive study was performed. The authors designed a self-applied questionnaire based on a questionnaire from a survey created by the National Health Service of the UK. The answers of 32 items were analyzed, including 4 social-demographic questions and one open question. The authors recoded the variables related to service quality and recorded them as "in accordance" and "not in accordance." The validity of the questionnaire was measured using Cronbach's alpha and determination (R(2)) indexes. The authors used the χ(2), Student's T, ANOVA and linear regression analysis statistical tests. RESULTS: A total of 179 questionnaires were analyzed (response rate: 36.6%, sampling error: 5.8%). Evaluation of general satisfaction and the recommendation of the NM Service obtained a mean score of 8.96 and 9.20 (1-10 scale) points, respectively. The most influential variable regarding general satisfaction was the general impression of the organization of the service. The strong points of the service were courtesy, general organizational image and cleanliness. The main areas for improvement were appointment change process and waiting list. There were no significant differences regarding satisfaction due to the social-demographic variables except for age. CONCLUSION: This satisfaction survey has shown that patients are satisfied with the Nuclear Medicine Service and that it is a useful tool to detect the strong points and areas for improvement of the Service from the user's perspective.

Evaluación del grado de satisfacción de los pacientes atendidos en un servicio de Medicina Nuclear / Assessment of the Patient Satisfaction with a Nuclear Medicine Service

Objetivo. Conocer la calidad percibida y el grado de satisfacción de los pacientes con el servicio de Medicina Nuclear (MN). Metodología. Estudio descriptivo transversal. Se diseñó un cuestionario, adaptando un cuestionario elaborado por el National Health Service. Se analizaron las respuestas de 32 ítems, incluyendo 4 preguntas socio-demográficas y una abierta. Las variables relacionadas con la calidad de servicio se recodificaron en conformidad y no conformidad. Se midió la validez del cuestionario a través de los coeficientes alfa de Cronbach y de determinación (R2). Se utilizaron los test estadísticos χ2, t de Student, ANOVA y análisis de regresión lineal. Resultados. Fueron analizados 179 cuestionarios (tasa de respuesta: 36,6%, error muestral: 5,8%). La valoración de la satisfacción general y la recomendación del servicio de MN obtuvieron una puntuación media de 8,96 y 9,20 puntos respectivamente (escala 1-10). La variable que más influyó en la satisfacción general fue la impresión de la organización del servicio. Los principales puntos fuertes del servicio fueron la cortesía, la impresión de la organización del servicio y la limpieza; y las principales áreas de mejora, el cambio de cita y la lista de espera. No hubo diferencias significativas en la satisfacción en función de las variables sociodemográficas excepto para la edad. Conclusiones. La encuesta de satisfacción realizada nos ha permitido conocer que los pacientes están satisfechos con el Servicio de MN y, al mismo tiempo, constituye un instrumento útil para poder detectar los puntos fuertes y áreas de mejora del servicio desde la óptica del usuario(AU)

Goal. To know the perceived quality and the levels of patient satisfaction with the Nuclear Medicine Service (MN). Methods. A cross-sectional descriptive study was performed. The authors designed a self-applied questionnaire based on a questionnaire from a survey created by the National Health Service of the UK. The answers of 32 items were analyzed, including 4 social-demographic questions and one open question. The authors recoded the variables related to service quality and recorded them as "in accordance" and "not in accordance". The validity of the questionnaire was measured using Cronbach's alpha and determination (R2) indexes. The authors used the χ2, Student's T, ANOVA and linear regression analysis statistical tests. Results. A total of 179 questionnaires were analyzed (response rate: 36.6%, sampling error: 5.8%). Evaluation of general satisfaction and the recommendation of the NM Service obtained a mean score of 8.96 and 9.20 (1-10 scale) points, respectively. The most influential variable regarding general satisfaction was the general impression of the organization of the service. The strong points of the service were courtesy, general organizational image and cleanliness. The main areas for improvement were appointment change process and waiting list. There were no significant differences regarding satisfaction due to the social-demographic variables except for age. Conclusion. This satisfaction survey has shown that patients are satisfied with the Nuclear Medicine Service and that it is a useful tool to detect the strong points and areas for improvement of the Service from the user‘s perspective(AU)

Ganglio centinela en cáncer de mama: biopsia selectiva comparada con linfadenectomía axilar. Seguimiento a largo plazo / Sentinel ganglion in breast cancer: selective biopsy compared with axillary lymphadectomy

Fundamento. La biopsia selectiva del ganglio centinela(BSGC) ha reemplazado a la linfadenectomía axilar (LA),como procedimiento de elección, en el estadiaje del cáncerde mama en estadios iniciales y axila clínicamente negativa.El objetivo de este trabajo es comparar la supervivenciaglobal y libre de eventos de aquellas pacientes a lasque se realizó, en el periodo de validación de la técnica,BSGC seguida de LA respecto a las que se practicó BSGCy LA si el ganglio centinela (GC) presentaba metástasis.Material y métodos. Se han incluido 148 pacientes, 81pertenecientes al periodo de validación y 67 al grupo deaplicación clínica. El radiocoloide se administró intraperitumoralmente,obteniéndose imágenes hasta la visualizacióndel GC, posteriormente en la intervenciónquirúrgica se procedió a su identificación y extirpación.Resultados. En el grupo de validación, la eficacia de latécnica ha sido del 92,5%, la sensibilidad del 95,6% y latasa de falsos negativos del 4%. De las 81 pacientes, 75se encuentran libres de enfermedad (92,6%). De las 67pacientes pertenecientes al grupo de aplicación clínica,63 (94%) viven libres de enfermedad. Ninguna pacienteha presentado recurrencia ganglionar axilar.Conclusiones. En la validación de la técnica hemos obtenidounos valores que se hallan dentro de las exigenciasde calidad generalmente aceptadas. Con una mediade seguimiento de 6 años no hemos observado recurrenciaaxilar en ninguno de los dos grupos. No existediferencia estadísticamente significativa en la supervivenciaglobal y libre de eventos entre ambos grupos(AU)

Background. Selective biopsy of the sentinel ganglion(SBSG) has replaced axillary lymphadectomy (AL) asthe procedure of choice in staging breast cancer in itsinitial stages and in clinically negative axilla. The aimof this study is to compare global event-free survival ofthose patients subjected to SBSG followed by AL, duringthe period of validation of the technique, with respectto those subjected to SBSG and AL if the sentinelganglion (SG) showed metastasis.Methods. One hundred and forty-eight patients wereincluded, 81 belonging to the period of validation and67 to the clinical application group. Radiocoloid wasadministered intraperitumorally, obtaining images upuntil the visualisation of the SG; its identification andextirpation were carried out subsequently in the surgicalintervention.Results. The efficacy of the technique in the validationgroup was 92.5%, sensitivity was 95.6% and the rate offalse negatives was 4%. Of the 81 patients, 75 are freeof disease (92.6%). Of the 67 patients belonging to theclinical application group, 63 (94%) are free of disease.No patient has presented axillary ganglion recurrence.Conclusion. In the validation of the technique we obtainedvalues that fall within the demands of generallyaccepted quality. With an average follow up of 6 yearswe did not observe axillary ganglion recurrence in anyof the two groups. There is no statistically significantdifference in global and event free survival between thetwo groups(AU)

[Sentinel ganglion in breast cancer: selective biopsy compared with axillary lymphadectomy]. / Ganglio centinela en cáncer de mama: biopsia selectiva comparada con linfadenectomía axilar. Seguimiento a largo plazo.

BACKGROUND: Selective biopsy of the sentinel ganglion (SBSG) has replaced axillary lymphadectomy (AL) as the procedure of choice in staging breast cancer in its initial stages and in clinically negative axilla. The aim of this study is to compare global event-free survival of those patients subjected to SBSG followed by AL, during the period of validation of the technique, with respect to those subjected to SBSG and AL if the sentinel ganglion (SG) showed metastasis. METHODS: One hundred and forty-eight patients were included, 81 belonging to the period of validation and 67 to the clinical application group. Radiocoloid was administered intraperitumorally, obtaining images up until the visualisation of the SG; its identification and extirpation were carried out subsequently in the surgical intervention. RESULTS: The efficacy of the technique in the validation group was 92.5%, sensitivity was 95.6% and the rate of false negatives was 4%. Of the 81 patients, 75 are free of disease (92.6%). Of the 67 patients belonging to the clinical application group, 63 (94%) are free of disease. No patient has presented axillary ganglion recurrence. CONCLUSION: In the validation of the technique we obtained values that fall within the demands of generally accepted quality. With an average follow up of 6 years we did not observe axillary ganglion recurrence in any of the two groups. There is no statistically significant difference in global and event free survival between the two groups.

[Dialysis and transplant. Spain in 2005]. / Informe de Situación de Diálisis y Trasplante en España, 2005.

In 2005, renal replace treatment (dialysis and transplant) was necessary for about 40,000 people, without being known the number accurate and either their basic characteristics, such as: time in treatment, modality or treatment changes. The presented data cover the 76% of the Spanish population and are the result of the cooperation among technicians of registries, nephrologists and transplant coordinations. 4,125 people started RRT in 2005, the total estimated acceptance rate for renal replacement therapy in adults in Spain was 126 pmp and regarding other European countries it locates us in an intermediate area. The incidence rate seems to keep stable in the last years although there were some differences among communities (from 104 pmp in Castile and Leon to 186 pmp in Canary Islands). Diabetes Mellitus is the most diagnosed cause of renal failure in 2005, more than 20% of patients, followed by vascular diseases. The estimated prevalence of renal replacement therapy in Spain at the end of 2005 was 903 pmp, with important variations among communities (from 806 pmp in Cantabria to 1056 pmp in Valencia Region). The 47% of prevalent RRT patients had a functioning transplant. Mortality on haemodialysis and peritoneal dialysis was 13.7% and 10.8% respectively. Mortality on transplant was 1.3%, one of the lowest values registered so far. Mortality on renal replacement therapy was around 5% among patients from 45 to 64 years, 11% between 65 and 74 years and 19% among the patients older than 75 years.

Experiencia inicial en el diagnóstico y tratamiento del tumor vesical superficial con Hexvix® / Initial experience in the diagnosis and treatment of superficial bladder tumors with Hexvix®

Objetivo: El actual standar en el diagnóstico y seguimiento del tumor vesical es la cistoscopia con luz blanca. Recientes estudios sugieren que la cistoscopia con fluorescencia a través de derivados de las porfirinas puede mejorar la detección de lesiones vesicales. Hemos analizado los resultados en el diagnóstico y tratamiento de lesiones vesicales utilizando la cistoscopia de fluorescencia con hexaminolevulinato (Hexvix®) en nuestro centro. Métodos: Entre septiembre 2006 y septiembre 2007, a 39 pacientes consecutivos con sospecha ó confirmación de tumor vesical se les administró una instilación endovesical de Hexvix® una hora antes de la cirugía. Se realizó en primer lugar una cistoscopia con luz blanca (CLB) y posteriormente con luz azul (CLA). Se resecaron todas las lesiones papilares y las sospechosas para análisis histológico. La edad media fue de 70.1 años (50-86). 30 hombres (76.9%) y 9 mujeres (23.1%). Las características de los tumores fueron: 18% tumores primarios, 51% recurrencias y 30% controles cistoscópicos. 24 pacientes habían recibido con anterioridad algún tratamiento (9 mitomicina C y 15 BCG). 7 pacientes demostraron citologías urinarias positivas previas. Resultados: Todas las lesiones papilares visualizadas con luz blanca se confirmaron con luz azul (18 pacientes). De éstos, 17 tuvieron biopsias positivas (6 pTaG1, 9 pT1G1-3, 1 pT2, 1 CIS). En 15 pacientes (38.4%) se objetivó al menos 1 lesión más solo visualizada con la luz azul. En este grupo, 8 pacientes (20.5%) tuvieron un diagnóstico histológico positivo (3 pTaG1, 2 pT1G3, 3 CIS). En 5 de estos casos (13%) el manejo terapéutico posterior cambió al introducir la luz azul (BCG vs MMC). Todos los casos de CIS (4) fueron diagnosticados mediante luz azul. En el postoperatorio no se demostraron efectos secundarios (locales ó sistémicos) debidos a la administración de Hexvix® Conclusiones: Nuestros resultados sugieren un incremento en el diagnóstico de lesiones tumorales vesicales, papilares y planas, con el uso de la cistoscopia bajo fluorescencia. Esto ha determinado un cambio de actitud terapéutica relevante en un 13% de los pacientes. Obviamente, se necesita mayor experiencia para consolidar estos resultados y un seguimiento a largo plazo para valorar el impacto a nivel de recurrencia y progresión tumoral (AU)

Objectives: White light cystoscopy is the current standard for the diagnosis of bladder cancer and monitorization for recurrence. Recent studies suggest that porphyrin based fluorescence cystoscopy may improve endoscopic detection of bladder tumors. We aimed to evaluate the improvement that hexaminolevulinate fluorescence cystoscopy could lead in bladder cancer detection and treatment at one single centre. Methods: Between September 2006 and September 2007 a total of 39 patients with known or suspected bladder cancer underwent bladder instillation with 50 ml 8 mM hexaminolevulinate (HAL) for 1 hour. The bladder was inspected using white light cystoscopy (WLC), followed by blue light (fluorescence) cystoscopy (BLC). Papillary and suspicious lesions were resected for histological examination. Mean age was 70.1 years (50-86). Thirty patients were male (76.9%) and 9 female (23.1%). The tumor characteristics were: 18% primary tumors, 51% recurrences and 30% control cystoscopies. 24 patients had previously received some treatment (9 MMC and 15 BCG). Only 7 patients had previous positive urine cytology. Results: All papillary lesions visualized with WLC were confirmed by BLC (18 patients). From these, 17 have positive biopsies (6 pTaG1, 9 pT1G1-3, 1 pT2, 1 CIS). In 15 patients (38.4%) we found at least 1 lesion more with BLC. In this group 8 cases (20.5%) had positive histological diagnosis (3 pTaG1, 2 pT1G3, 3 CIS). In five patients (13%) post-TUR therapeutic management has changed by using BLC (BCG vs MMC). All four patients with CIS were diagnosed by BLC. There was no evidence of local or systemic side effects due to HAL in the postoperative time. Conclusions: Our results suggest there is an improvement in the diagnosis of papillary and flat lesions in bladder cancer by using HAL fluorescence cystoscopy. This has changed the management in the postoperative period (MMC vs BCG) in 13% of the patients. Obviously, we need more patients to assess our data and long term follow-up to analyze the impact in terms of tumor recurrence and progression (AU)

Informe de situación de diálisis y trasplante en España, 2004 / Dialysis and transplant situation, Spain 2004

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