Lung recruitment maneuvers: opening the door to a hidden enemy. / Maniobras de reclutamiento pulmonar: abriendo la puerta a un enemigo oculto.

Recruitment manoeuvres (RM) are common practice in anaesthesiology; however, they can have adverse effects. We present an unforeseen complication in a patient undergoing surgical resection of a bronchial tumour who presented cardiac arrest due to pulseless electrical activity immediately after RMs. A transoesophageal echocardiogram performed after return of spontaneous circulation showed a patent foramen ovale (PFO), left ventricular dysfunction with segmental changes, and air in the left ventricle, leading to suspicion of paradoxical air embolism. The contractility changes normalised spontaneously, and postoperative evolution was uneventful. RMs cause changes in intracavitary pressures that can lead to opening of a PFO (present in up to 30% of the population) and reversal of the physiological left-right shunt. Transoesophageal echocardiography facilitated immediate diagnosis and follow-up.

Efecto del Medio Condicionado de la Línea Celular H9C2 Tratada con Dehidroepiandrosterona y Expuesta a Daño sobre la Motilidad de Células Troncales Mesenquimales / Effect of the Conditioned Medium from H9C2 Cell Line Treated with Dehydroepiandrosterone and Exposed to Damage on the Motility of Mesenchymal Stem Cells

RESUMEN: Las enfermedades cardiovasculares (ECV) son la principal causa de muerte a nivel mundial, donde la terapia con Células Troncales Mesenquimales (CTM) representa una alternativa para los pacientes que no logran recuperarse con los tratamientos actuales. El lograr que las CTM residentes se movilicen al órgano afectado representaría una ventaja para el manejo terapéutico de las ECV. La dehidroepiandrosterona (DHEA) es un precursor hormonal cuyos niveles disminuyen a lo largo de la vida, lo que se ha asociado al desarrollo de ECV. Diversos estudios han demostrado que el consumo de DHEA previene y mejora la condición cardiaca, aunque no se sabe si esto ocurre porque se ejerce un efecto en los cardiomiocitos y estos, a su vez, hacia las CTM. El objetivo del presente estudio fue determinar el efecto del medio condicionado procedente de la línea H9C2 pretratada con DHEA y sometida a daño, sobre la motilidad de CTM, llevando a cabo un ensayo de cierre de herida. El pretratamiento con DHEA y el daño en la línea H9C2, promueve la motilidad de CTM. El estímulo de la motilidad de CTM por un efecto indirecto de DHEA podría ser una estrategia terapéutica para el daño cardiaco.

ABSTRACT: Cardiovascular diseases (CVD) are the leading cause of death worldwide. Mesenchymal Stem Cell (MSC) therapy is an alternative for patients who cannot recover with current treatments. Ensure movilization of MSC to the affected organs would represent an advantage for therapeutic management of CVD. Dehydroepiandrosterone (DHEA) is a hormone precursor whose levels decrease throughout life, which has been associated with the onset of CVD. Several studies have shown that DHEA consumption, prevents and improves heart condition, although it is not known if this is because an effect on cardiomyocytes is exercised on these cells and this, in turn, to CTM. The aim of this study was to determine the effect of conditioned medium from H9C2 cell line pretreated with DHEA and subjected to damage, on the motility of CTM, performing a wound healing assay. Pretreatment with DHEA and damage to H9C2 cell line, promotes motility of CTM. Stimulation of CTM motility by an indirect effect of DHEA could be a therapeutic strategy for heart damage.

[Geriatric syndromes in patients with a non-recent hip fracture seen at a primary health care unit]. / Síndromes geriátricos en pacientes con fractura de cadera no reciente en una unidad de primer nivel de atención médica.

OBJECTIVE: To identify the frequency of geriatric syndromes in patients with a non- recent hip fracture seen at a primary health care unit in the state of Puebla, Mexico. MATERIAL AND METHODS: Cross-sectional study conducted in 376 patients with a non-recent hip fracture screened for geriatric syndromes. We included demographic variables, urinary incontinence, polypharmacy, sleep disorder, nutritional status, depression and autonomy. The two latter were assessed using the Yesavage geriatric depression scale and the Katz index. We used descriptive statistics. RESULTS: The total number of patients was 376; 219 (58%) were females and 157 (42%) were males; mean age was 72.57 years (65-95 +/- 7.08), and 98.7% had at least one geriatric syndrome. Depression was detected in 303 (80.9%), 282 (75%) were on polypharmacy, 262 (69.7%) had sleep disorders, 63 (16.8%) had experienced falls, 19 (5.1%) had urinary incontinence, 15 (4%) were obese, and 3 (0.8%) had loss of autonomy. CONCLUSION: 98.7% of the patients had at least one geriatric syndrome; females were the most affected sex; depression was the most frequent syndrome, followed by polypharmacy, sleep disorders, falls, urinary incontinence, obesity and loss of autonomy.

Prevalence of obesity and its relationship to clinical lipodystrophy in HIV-infected adults on anti-retroviral therapy.

BACKGROUND: Combination antiretroviral therapy (cART) is associated with lipodystrophy (lipoatrophy and lipoaccumulation) and several metabolic abnormalities that together can contribute to an increased cardiovascular risk. The aim of this study was to evaluate the prevalence of obesity in patients on cART according to the presence of clinical lipodystrophy (CL) and to analyze factors associated with obesity. METHODS: We evaluated 368 HIV-infected adults on cART. RESULTS: CL was present in 59.0%. Independently of gender, patients with CL were more frequently underweight [5.7% (21/368)] and of normal weight [47.3% (174/368)], and less frequently overweight [33.2% (122/368)] or obese [13.9% (51/368)]. Mean body mass index was higher in patients with abdominal prominence regardless of the presence of clinical lipoatrophy. Patients with CL had lower waist circumference, higher waist/hip and fat mass ratio and lower total and subcutaneous fat, without significant difference in visceral fat but with a higher visceral/subcutaneous fat ratio, as evaluated by CT at abdominal level. CL was significantly less frequent in overweight [odds ratio (OR)=0.21, 95% confidence interval (CI): 0.05-0.92] and obese (OR=0.05, 95%CI: 0.01-0.26) patients, when compared to underweight ones, independent of age, gender, duration of infection, cART regimen, virological suppression, and HIV-infection risk factor. CONCLUSIONS: Being overweight or obese is highly prevalent in HIV-infected patients on cART. Patients with CL were more frequently under- or normal weight, and less frequently overweight or obese. Obesity is a condition that should be considered in HIV patients on cART.

Assessment of body fat composition disturbances by bioimpedance analysis in HIV-infected adults.

HIV-lipodystrophy syndrome is characterized by different patterns of body fat distribution (BFD) which are identified by clinical and body composition (BC) assessment, including bioimpedance analysis (BIA). Our aim was to compare BC in HIV-infected patients on combination antiretroviral therapy (cART) according to 4 distinct phenotypes of BFD (G1-no lipodystrophy, G2-isolated central fat accumulation, G3-lipoatrophy, G4-mixed forms of lipodystrophy) and assessed factors associated with them. Anthropometry and BIA were performed in 344 HIV-1 patients. G2 and G4 phenotype patients had significantly higher fat mass (FM) but no differences were observed in fat-free mass (FFM) and total body water among the 4 phenotypes. Significant negative associations were found between the presence of lipoatrophy and female gender, body mass index (BMI), waist (WC), hip (HC) and thigh circumferences, and total body FM estimated by BIA. After adjustment for gender, cART duration and BMI, G3 had significant lower WC [odds ratio (OR)=0.84; 0.78- 0.90] and HC (OR=0.88; 0.81-0.96) mean. Independently of gender, cART duration and BMI, G2 remained significantly associated with higher WC (OR=1.11; 1.05-1.18) and HC (OR=1.15; 1.07-1.23) mean, and with FM estimated by BIA [FM as %, OR=1.17 (1.09-1.26); and FM as kg, OR=1.15 (1.06- 1.25)]. There was a significant positive association between G4 and female gender (OR=1.66; 1.01-2.75), BMI (OR=1.10; 1.04-1.17) and WC (OR=1.15; 1.09-1.21). The similar FFM along the BFD spectrum describes the actual BC of these patients without sarcopenia. In a clinical setting, BIA is an easy and useful tool to evaluate fat mass and FFM and gives us a picture of BC that was not possible with anthropometry.

Composite anatomical-clinical-molecular prognostic model in non-small cell lung cancer.

The objective of the present study was to elaborate a survival model that integrates anatomic factors, according to the 2010 seventh edition of the tumour, node and metastasis (TNM) staging system, with clinical and molecular factors. Pathologic TNM descriptors (group A), clinical variables (group B), laboratory parameters (group C) and molecular markers (tissue microarrays; group D) were collected from 512 early-stage nonsmall cell lung cancer (NSCLC) patients with complete resection. A multivariate analysis stepped supervised learning classification algorithm was used. The prognostic performance by groups was: areas under the receiver operating characteristic curve (C-index): 0.67 (group A), 0.65 (Group B), 0.57 (group C) and 0.65 (group D). Considering all variables together selected for each of the four groups (integrated group) the C-index was 0.74 (95% CI 0.70-0.79), with statistically significant differences compared with each isolated group (from p = 0.006 to p < 0.001). Variables with the greatest prognostic discrimination were the presence of another ipsilobar nodule and tumour size > 3 cm, followed by other anatomical and clinical factors, and molecular expressions of phosphorylated mammalian target of rapamycin (phospho-mTOR), Ki67cell proliferation index and phosphorylated acetyl-coenzyme A carboxylase. This study on early-stage NSCLC shows the benefit from integrating pathological TNM, clinical and molecular factors into a composite prognostic model. The model of the integrated group classified patients with significantly higher accuracy compared to the TNM 2010 staging.

El desaprendizaje: propuesta para profesionales de la salud críticos / Unlearning: proposal for critic health professionals

El desaprendizaje como método reflexivo de cuestionamiento crítico de la realidad, ayuda a examinar las estructuras teóricas que cada sujeto ha asimilado, frecuentemente de manera acrítica, durante su trayectoria formativa y profesional. Este examen crítico de las formas habituales de pensar y actuar en el mundo no pretende erigirse como guía del proceso de transición hacia formas de conciencia más verdaderas y fundamentadas. Lo que se busca, por el contrario, es realizar un ejercicio constante de interrogación de lo evidente y de aceptar los límites del pensamiento y las incertidumbres del presente (AU)

Unlearning as a reflexive method of critical questioning of reality helps us examine the theoretical structures that each individual has mastered, more often than not in an "acritical" manner, during his or her professional and formative trajectory. This critical examination of the habitual ways of thinking and behaving in today’s world is not intended, however, to serve as a guide for this transition process towards more authentic and fundamental forms of awareness. On the contrary, what we are looking for is to Performa continuous questioning exercise of what is evident and to accept the limits of our thinking patterns and the uncertainties of our time

A randomized trial comparing two corticosteroid regimens combined with mycophenolate mofetil and cyclosporine for prevention of acute renal allograft rejection.

INTRODUCTION: The launching of mycophenolate mofetil (MMF) has reduced the incidence of acute rejection episodes. We sought to evaluate the efficacy of decreasing the steroid dose. MATERIALS AND METHODS: This was a quasiexperimental, randomized, prospective trial. We enrolled 150 patients who received de novo renal transplantations from living or cadaveric donors, fulfilling the screening criteria. Patients were randomized to one of the following two arms: (A) MMF at a 2 g/d dose, cyclosporine (CsA) at a dose necessary to achieve target levels, and corticosteroids at the usual doses; (B) MMF at a 2 g/d dose, CsA at a dose necessary to achieve target levels, and corticosteroids at doses 50% lower than those of group A. RESULTS: Group A included 72 (48%) and group B, 78 patients (52%). There were no differences among the variables: leukopenia occurred in 11 patients in group A, and five patients in group B. Complications occurred in 67.4% (56) of group A, but only 32.6% (27) were related to infections. One case of urinary infection occurred in group B, while six occurred in group A. There was one case of acute rejection in group A, and none in group B. One graft loss occurred in group A. There were no differences in the remaining variables under study. DISCUSSION: The results showed an increased complication rate related to receiving usual steroid doses. There was no increase in acute rejection episodes among patients receiving 50% of the usual steroid dose.

Normativa sobre valoración del riesgo quirúrgico en el carcinoma broncogénico / Guidelines for the Evaluation of Surgical Risk in Bronchogenic Carcinoma

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Valoración del riesgo quirúrgico. Presentación / No disponible

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Genotype-phenotype relationships in Berardinelli-Seip congenital lipodystrophy.

Generalised lipodystrophy of the Berardinelli-Seip type (BSCL) is a rare autosomal recessive human disorder with severe adverse metabolic consequences. A gene on chromosome 9 (BSCL1) has recently been identified, predominantly in African-American families. More recently, mutations in a previously undescribed gene of unknown function (BSCL2) on chromosome 11, termed seipin, have been found to be responsible for this disorder in a number of European and Middle Eastern families. We have studied the genotype/phenotype relationships in 70 affected subjects from 44 apparently unrelated pedigrees of diverse ethnic origin. In all subjects, hepatic dysfunction, hyperlipidaemia, diabetes mellitus, and hypertrophic cardiomyopathy were significant contributors to morbidity with no clear differences in their prevalence between subjects with BSCL1 or BSCL2 and those with evidence against cosegregation with either chromosome 9 or 11 (designated BSCLX). BSCL2 appears to be a more severe disorder than BSCL1 with a higher incidence of premature death and a lower prevalence of partial and/or delayed onset of lipodystrophy. Notably, subjects with BSCL2 had a significantly higher prevalence of intellectual impairment than those with BSCL1 or BSCLX (p<0.0001, OR 17.0, CI 3.6 to 79.0). The higher prevalence of intellectual impairment and the increased risk of premature death in BSCL2 compared to BSCL1 emphasise the importance of molecular diagnosis of this syndrome and have clear implications for genetic counselling.

[Craniopharyngiomas. Clinicopathological aspects in different age groups]. / Craniofaringeomas. Aspectos clinicopatológicos em diferentes grupos etáirios.

Craniopharyngiomas are rare brain tumors of the hypothalamo-pituitary region, developing from embryonic remnants of Rathke's pouch and sac. Their overall incidence is 0.13 per 100,000 person years. Most frequently, they are suprasellar, start growing in childhood and originate neurological and hormonal symptoms. We retrospectively studied patients treated in our institution for craniopharyngioma in the last 10 years, in order to evaluate their clinical, imaging and pathological characteristics. Of the 32 patients analysed, 18 were females and 14 males with ages ranging between 6 and 81 years (early onset group--EOG aged 5-14 years: 7 patients; middle age onset group--MAOG aged 15-49 years: 15 patients; late age onset group--LOG aged > or = 50 years: 10 patients). Visual impairment was the most frequent presenting clinical feature in EOG (71.4%) and MAOG (86.6%), while in the LOG personality and cognitive changes including memory loss predominated (60%). Headaches were very frequent in all groups (EOG 42.8%, MAOG 60%, LOG 40%). Meningitis and seizures were presenting features, each in one patient. Regarding endocrine symptoms and signs, growth failure was present in 57.2% of the EOG. Amenorrhea was present in 5 of 10 female patients of the MAOG. Preoperatively, TSH was deficient in 25%, ACTH in 15.6% and gonadotropin in 25% of the patients. There were no cases of diabetes insipidus. Preoperative CT and MR revealed a calcified mass in 12 (37.5%), a partially cystic mass in 20 (62.5%) and a lesion involving or extending into the third ventricle in 7 (21.9%) patients. Twenty seven (84.4%) patients were treated primarily by surgery. In 4 (12.5%) cases the tumour was considered inoperable and 1 (3.1%) patient refused surgery; all were in the LOG. Surgical approach was transsphenoidal in 2/27 (7.4%) (all of them in the LAOG) and by craniotomy in the others. The tumour removable was considered complete in 10 (37%--EOG 2/7, MAOG 6/15, LOG 2/5) and subtotal in 17 (62.9%) patients. Eight (29.6%) patients were reoperated for recurrent tumour. Postoperative radiotherapy was administered in 12 cases with residual tumor, and 3 inoperable tumors were treated primarily by conventional external radiotherapy. Pathological study revealed the adamantinomatous type in 25 (92.6%) and the papillary type in 2 (7.4%--all men in the MAOG) tumors. The average follow-up was longer in the EOG (82.6 +/- 40.7 months) than in MAOG (57.2 +/- 48.5 months) and in LOG (48 +/- 92 months). Four (12.5%) patients died, 1 during the follow-up period due to a radiation-induced astrocytoma and 3 in the postoperative period because of cerebral hemorrhage and hydrocephalus (1 in the EOG and 2 in the LOG). In summary, we found the clinical presentation to be different in the 3 age groups, with a large number of patients in the MAOG. In this group were the only examples of the papillary form. Better prognosis was associated with a total resection at initial surgery.

Prevalence and risk factors of clinical diabetic polyneuropathy in a Portuguese primary health care population.

OBJECTIVE: Distal symmetrical polyneuropathy in diabetics (DPN) has a variable prevalence around 30% and increases the risk for foot ulcers and amputations. We aimed at evaluating the prevalence of clinical DPN and associated risk factors in patients followed in primary care centers. MATERIAL AND METHODS: 101 type 2 diabetics were evaluated and 8 were excluded due to the presence of other causes of neuropathy. The remaining 93 had a mean age of 65.4 +/- 10.1 years and a mean diabetes duration of 10.1 +/- 11.1 years, 60.2% were women and 39.8% men. DPN was defined as the presence of both altered sensitivities and reflexes, regardless of symptoms. RESULTS: Seventy-two (80%) patients had symptoms of polyneuropathy, but DPN was present only in 29 (32.2%). Calluses (37.8%) and trophic skin (74.4%) and nail (75.6%) changes were found in both feet. There was a significant positive association of DPN with age (69.0 +/- 9.1 vs 63.3 +/- 9.9 years, p=0.01), disease duration (15.7 +/- 13.5 vs 7.2 +/- 8.8 years, p=0.001), feet skin changes (38.8 vs 13.0%, p=0.04) and myocardial infarction/ischemia (14.8 vs 1.7%, p=0.03). CONCLUSIONS: This sample of diabetic patients cared by family doctors presented a high prevalence of DPN. Aging, disease duration, the presence of feet skin changes and myocardial infarction/ischemia are factors that increase the prevalence of the disease. Primary care doctors awareness of the problem might help to decrease the associated morbidity.

Identification of the gene altered in Berardinelli-Seip congenital lipodystrophy on chromosome 11q13.

Congenital generalized lipodystrophy, or Berardinelli-Seip syndrome (BSCL), is a rare autosomal recessive disease characterized by a near-absence of adipose tissue from birth or early infancy and severe insulin resistance. Other clinical and biological features include acanthosis nigricans, hyperandrogenism, muscular hypertrophy, hepatomegaly, altered glucose tolerance or diabetes mellitus, and hypertriglyceridemia. A locus (BSCL1) has been mapped to 9q34 with evidence of heterogeneity. Here, we report a genome screen of nine BSCL families from two geographical clusters (in Lebanon and Norway). We identified a new disease locus, designated BSCL2, within the 2.5-Mb interval flanked by markers D11S4076 and D11S480 on chromosome 11q13. Analysis of 20 additional families of various ethnic origins led to the identification of 11 families in which the disease cosegregates with the 11q13 locus; the remaining families provide confirmation of linkage to 9q34. Sequence analysis of genes located in the 11q13 interval disclosed mutations in a gene homologous to the murine guanine nucleotide-binding protein (G protein), gamma3-linked gene (Gng3lg) in all BSCL2-linked families. BSCL2 is most highly expressed in brain and testis and encodes a protein (which we have called seipin) of unknown function. Most of the variants are null mutations and probably result in a severe disruption of the protein. These findings are of general importance for understanding the molecular mechanisms underlying regulation of body fat distribution and insulin resistance.

[Assessment of mediastinal tumor involvement (T factor) in lung cancer with transesophageal ultrasonography]. / Evaluación de la afectación mediastínica tumoral (factor T) en el cáncer de pulmón mediante ecografía transesofágica.

UNLABELLED: Transesophageal sonography was originally used to assess esophageal-gastric neoplasm. The technique may also be useful in the evaluation of pulmonary neoplasms for possible mediastinal involvement, with regard to both T and N factors. OBJECTIVE: To consider the validity of this minimally-invasive technique for assessing possible mediastinal involvement by direct tumoral invasion (T4) and to help obtain the most accurate staging of lung cancer. PATIENTS AND METHODS: Sixteen patients with confirmed histopathological diagnoses of pulmonary neoplasm were examined by transesophageal sonography in order to evaluate possible mediastinal involvement. They had previously been classified by computed tomography as T4 (12 patients) or possible T4 (4 patients). Mediastinal involvement was also assessed by mediastinotomy or thoracotomy in 15 of the 16 patients. RESULTS: Transesophageal sonography revealed mediastinal involvement in eight of the 16 patients; the rest had no such involvement. Surgical exploration of the mediastinum confirmed involvement in seven of those who had been so classified by sonography (with the remaining patient not having been assessed surgically). Among the eight patients who were considered free of mediastinal involvement, there was in fact none, although we found previously undetected infiltration of the posterior surface of the right pulmonary artery in one patient. Sensitivity was 87.5%, specificity 100% and accuracy 93.3%. CONCLUSION: Transesophageal ultrasound is a diagnostic tool that can provide additional information to complement other diagnostic strategies.

Evaluación de la afectación mediastínica tumoral (factor T) en el cáncer de pulmón mediante ecografía transesofágica / Transesophageal ultrasound assessment of mediastinal tumor involvement (T factor) in lung cancer

La ecografía transesofágica es una técnica inicialmente empleada en la valoración de las neoplasias esofagogástricas. Su utilización en la evaluación de las neoplasias pulmonares puede ser una ayuda valiosa a la hora de considerar la posible afectación mediastínica tanto en el factor T como en el N. Objetivo: Considerar la validez de esta exploración incruenta para determinar la posible afectación mediastínica por invasión directa del tumor (T4) como medio para conseguir una más correcta estadificación del cáncer de pulmón. Pacientes y métodos: Dieciséis pacientes con neoplasia de pulmón confirmada histopatológicamente han sido explorados mediante ecografía transesofágica para evaluar una posible afectación mediastínica. Previamente habían sido etiquetados por tomografía computarizada como T4 (12) o dudosos T4 (4). En 15 de los 16 pacientes se evaluó la afectación del mediastino con mediastinotomía o toractomía. Resultados: De los 16 pacientes, ocho presentaban afectación mediastínica mediante ecografía transesofágica y en el resto no. La evaluación quirúrgica del mediastino confirmó la afectación de éste en siete de los detectados por la ecografía (uno no se evaluó quirúrgicamente). De los 8 pacientes considerados como sin afectación mediastínica en siete no existía y en uno no se detectó una infiltración de la cara posterior de la arteria pulmonar derecha. La sensibilidad fue del 87,5 por ciento, la especificidad, del 100 por ciento y la exactitud del 93,3 por ciento. Conclusión: La ecografía transesofágica es un método diagnóstico que puede aportar información adicional y complementaria a otros métodos diagnósticos. (AU)

[Quality of health care]. / Qualidade nos cuidados de saúde.

Quality assurance is a relatively recent concern but already plays a major role in health care management and provision. Quality involves the definition of a comprehensive programme tailored by realistic and effective objectives and norms that include the structured review of procedures (namely clinical audits) and the use of up-to-date protocols. The involvement and motivation of health professionals, together with an adequate internal and external communication strategy, play a key role in the planning and application of these programmes. The use of programmed assessment, based on a solid knowledge of current practice, should have practical implications, optimising procedures in order to improve the quality of care. This commitment towards quality in health care should go far beyond governmental policy and should have clear support from health professionals.

Inefficiency of the anticoagulant therapy in the regression of the radiation-induced optic neuropathy in Cushing's disease.

Radiation-induced optic neuropathy is a rare complication (prevalence less than 1%) following radiotherapy of the sellar region. However, the vasculopathy in Cushing's disease predisposes to radiation-induced injury. We report the case of a 24-year-old man with Cushing's disease since he was 16. The hormonal study including bilateral inferior petrosal sinus catheterization diagnosed a pituitary right lesion, but imagiology was always negative. He underwent a transsphenoidal microadenomectomy and the pathological study showed the presence of corticotrophic hyperplasia but no adenoma. Secondary hypothyroidism and hypogonadism as well as permanent diabetes insipidus were diagnosed and because the patient was not cured he underwent a second transsphenoidal total hypophysectomy. After that and because he was still hypercortisolemic, pituitary external irradiation was given in a total dose of 6000 rad. Six months later he developed progressive bilateral visual loss. Cerebral MR revealed focal enhancement of the enlarged optic nerves and chiasm, associated with demyelination areas of the posterior visual pathways. Treatment was tried first with high doses of corticosteroids and later with anticoagulants-heparin EV. 1000 U/h during 7 days followed by warfarin, but unsuccessfully, probably because the patient was already amaurotic at the beginning of the last treatment.