Search

Retinoblastoma represents 3% of cancers in children under fifteen years of age. The standard paediatric treatment for saving the affected eye is supraselective intra-arterial chemotherapy performed in interventional rooms. In order to address the radiation toxicity due to the angiography, the aim of this study was to determine the typical dose value corresponding to the procedure, estimate the paediatric patients’ eye lens dose and study the relationship between dose indicators and dose to the lens. An automatic dose management software was installed in two interventional rooms to obtain the distribution of the dose indicators kerma-area product and reference-point air kerma, getting a typical value 16 Gy·cm2 and 130 mGy, respectively (n = 35). The eye lens dose estimates were obtained with photoluminescent dosimeters placed on the patient’s eyelids. In the left eye, the entrance surface air kerma was 44.23 ± 2.66 mGy, and 12.72 ± 0.89 mGy in the right eye (n = 10). There was a positive correlation between dose to the lens per procedure and dose indicators, with R2 > 0.65 for both eyes. Based on this information, the threshold for the onset of radiation-induce cataracts (500 mGy) will be exceeded if the treatment is performed for more than 8 sessions.

Background and purpose The present study was conducted with the objective of evaluating the safety of primary mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO) stroke and comorbidities that preclude treatment with IV thrombolysis (IVT), compared with patients who received standard IVT treatment followed by MT. Secondary objectives were to analyse the recanalization rate and outcomes. Methods A prospective observational multicenter study (FUN-TPA) that recruited patients treated within 4.5 hours of symptom onset was performed. Treatments were IVT followed by MT if occlusion persisted, or primary MT when IVT was contraindicated. Outcome measures were procedural complications, symptomatic intracranial hemorrhage (SICH), recanalization rate, National Institutes of Health Stroke Scale (NIHSS) score at 7 days, modified Rankin Scale (mRS) score and mortality at 90 days. Results Of 131 patients, 21 (16%) had medical contraindications for IVT and were treated primarily with MT whereas 110 (84%) underwent IVT, followed by MT in 53 cases (40%). The recanalization rate and procedural complications were similar in the two groups. There were no SICHs after primary MT vs 3 (6%) after IVT+MT. Nine patients (43%) in the primary MT group achieved independence (mRS 0–2) compared with 36 (68%) in the IVT+MT group (p=0.046). Mortality rates in the two groups were 14% (n=3) vs 4% (n=2) (p=0.13). Adjusted ORs for independence in patients receiving standard IVT+MT vs MT in patients with medical contraindications for IVT were 2.8 (95% CI 0.99 to 7.98) and 0.24 (95% CI 0.04 to 1.52) for mortality. Conclusions MT is safe in patients with potential comorbidity-derived risks that preclude IVT. MT should be offered, aiming for prompt recanalization, to patients with LVO stroke unsuitable for IVT. Trial registration number NCT02164357; Results.

Kaposi sarcoma (KS) is an angioproliferative tumour that develops as a result of an infection by human herpesvirus 8, which is considered a necessary cause but not sufficient. Other factors - genetic, immunological and environmental - might play a role in the development of the disease. We report a case of KS secondary to endogenous Cushing syndrome (ECS) due to a pituitary adenoma, an association that has been reported only once. We also conducted a search through the Medline and PubMed databases for cases involving KS and ECS, finding only three additional cases that shared common clinical and prognostic features with ours. ECS might favour the development of KS due to immunosuppression. Dermatologists and other clinicians should be aware of this association, as it might be an underdiagnosed condition. It also has an important impact on the management of KS, and based on this review it relies on a good prognosis when ECS is well controlled.

Background and purpose The complexity and expense of endovascular treatment (EVT) for acute ischaemic stroke (AIS) can present difficulties in bringing this approach closer to the patients. A collaborative node was implemented involving three stroke centres (SCs) within the Madrid Stroke Network to provide round-the-clock access to EVT for AIS. Methods A weekly schedule was established to ensure that at least one SC was ‘on-call’ to provide EVT for all those with moderate to severe AIS due to large vessel occlusion, >4.5 h from symptom onset, or within this time-window but with contraindication to, or failure of, systemic thrombolysis. The time-window for treatment was 8 h for anterior circulation stroke and

Resumen Objetivo Analizar el nivel de desgaste profesional o burnout que presentaban los medicos de atencion primaria de Avila y la influencia de factores sociales, laborales y de salud en la aparicion del mismo. Material y metodos Se realizo un estudio epidemiologico transversal y descriptivo dirigido a todo el personal medico de atencion primaria de Avila durante el primer semestre de 2011, mediante 2 cuestionarios: el Maslach Burnout Inventory y otro de variables sociodemograficas, laborales y de salud. Resultados Se obtuvo una tasa de respuesta del 51,8%. La edad media fue de 48,55 ± 8,16. El 52% eran varones, casados el 77%, con plaza en propiedad el 45%, trabajando en centros rurales el 78% y realizando guardias mas consulta el 82%. La prevalencia en nuestro estudio resulto ser baja, 16% en su grado grave. Constatamos una alta prevalencia de la enfermedad, 68%, en su grado grave o moderado/grave. Estar casado (p = 0,012), no hacer guardias (p burnout en grado grave o moderado/grave. Conclusiones Encontramos un nivel moderado de burnout . Al contrario de lo que pensaban muchos facultativos, la prevalencia de la enfermedad en su forma grave fue baja, pero si fue elevada al considerar en conjunto los grados grave y moderado/grave. Por tanto, se deberian extender medidas para reducir el estres laboral de los medicos con el fin de una mejor practica laboral y eficiencia profesional.

Objective: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. Materials and methods: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. Results: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100, 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. Conclusions: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes. Resumen: Objetivo: Actualización de la guía para el diagnóstico y tratamiento de la hemorragia subaracnoidea de la Sociedad Española de Neurología. Material y métodos: Revisión y análisis de la bibliografía existente. Se establecen recomendaciones en función del nivel de evidencia que ofrecen los estudios revisados. Resultados: La causa más frecuente de hemorragia subaracnoidea espontánea (HSA) es la rotura de un aneurisma cerebral. Su incidencia se sitúa en torno 9 casos por 100.000 habitantes/año y supone un 5% de todos los ictus. La hipertensión arterial y el tabaquismo son sus principales factores de riesgo. Se ha de realizar el tratamiento en centros especializados. Se debe considerar el ingreso en unidades de ictus de aquellos pacientes con HSA y buena situación clínica inicial (grados I y II en la escala de Hunt y Hess). Se recomienda la exclusión precoz de la circulación del aneurisma. El estudio diagnóstico de elección es la tomografía computarizada (TC) craneal sin contraste. Si esta es negativa y persiste la sospecha clínica se aconseja realizar una punción lumbar. Los estudios de elección para identificar la fuente de sangrado son la resonancia magnética (RM) y la angiografía. Los estudios ultrasonográficos son útiles para el diagnóstico y seguimiento del vasoespasmo. Se recomienda el nimodipino para la prevención de la isquemia cerebral diferida. La terapia hipertensiva y el intervencionismo neurovascular pueden plantearse para tratar el vasoespasmo establecido. Conclusiones: La HSA es una enfermedad grave y compleja que debe ser atendida en centros especializados, con suficiente experiencia para abordar el proceso diagnóstico y terapéutico. Keywords: Subarachnoid haemorrhage, Cerebral aneurysm, Diagnosis, Vasospasm, Delayed cerebral ischaemia, Rebleeding, Medical treatment, Palabras clave: Hemorragia subaracnoidea, Aneurisma cerebral, Diagnóstico, Vasoespasmo, Isquemia cerebral diferida, Resangrado, Tratamiento médico

This paper presents the manufacturing and characterization results of biomimetic shaped thin film batteries (TFB). The final structures presented a total mass of approximately 60mg per cm² of active area, with a mean overall thickness of 100µm. Experimental results of TFB cycling at different C rates showed almost no capacity fade for current densities between 0.5 and 10mA, leading to surface energy densities as high as 0.15 mWh.cm−2 and power densities up to 5mW.cm−2.The achieved electrochemical results are among the highest values reported in the literature for such miniaturized energy devices, which will contribute to bring new solutions for powering MEMS actuation based micro/nanorobotics.

Background and purposeThe benefits of mechanical thrombectomy (MT) in basilar artery occlusions (BAO) have not been explored in recent clinical trials. We compared outcomes and procedural complications of MT in BAO with anterior circulation occlusions.MethodsData from the Madrid Stroke Network multicenter prospective registry were analyzed, including baseline characteristics, procedure times, procedural complications, symptomatic intracranial hemorrhage (SICH), modified Rankin Scale (mRS), and mortality at 3 months.ResultsOf 479 patients treated with MT, 52 (11%) had BAO. The onset to reperfusion time lapse was longer in patients with BAO (median (IQR) 385 min (320–540) vs 315 min (240–415), pConclusionsMT is more laborious and shows more procedural complications in BAO than in anterior circulation strokes. The likelihood of futile recanalization is higher in BAO and is associated with greater age and longer procedure duration. A refinement of endovascular procedures for BAO might help optimize the results.

Las fístulas arteriovenosas en la cabeza y el cuello son entidades poco frecuentes. La mayoría es secundaria a heridas penetrantes por arma blanca. Se describe el tratamiento exitoso mediante cirugía endovascular de una fístula postraumática tras una herida penetrante entre la arteria maxilar interna izquierda y la vena yugular externa. A través de este caso clínico y la revisión de la literatura se ilustran las causas, manifestaciones, estudio radiológico y tratamiento de una fístula postraumática entre la arteria maxilar interna y la vena yugular externa. A través de este caso clínico se demuestra la utilidad de los procedimientos endovasculares en el tratamiento de estas complicaciones.Traumatic arteriovenous fistulas of the head and neck region are uncommon. The majority are due to penetration of blunt injury. We describe a successful endovascular treatment of a posttraumatic fistula between the left maxillary artery and the external jugular vein due to a penetration injury. This case and a review of the literature illustrate the causes, manifestations, image studies and treatment for a posttraumatic fistula between the maxillary artery and the external jugular vein. This case demonstrate the utility of endovascular treatment of head and neck injuries complications.

Resumen Introduccion El diagnostico definitivo de la hipofisitis autoinmune es histologico; sin embargo, puede sospecharse en base a criterios clinicos, bioquimicos y radiologicos. Objetivo El objetivo de nuestro estudio fue revisar la presencia de anticuerpos antihipofisis (AAH) y anticuerpos antitiroideos en pacientes con sospecha de hipofisitis autoinmune por si la presencia de los primeros pudiera ayudar en el diagnostico de la enfermedad. Material y metodos Estudiamos 36 pacientes divididos en 7 grupos por datos que hicieran sospechar una hipofisitis autoinmune (insuficiencia suprarrenal secundaria aislada, deficiencias hormonales sin causa justificada, hiperprolactinemia idiopatica, silla turca vacia, masa selar con engrosamiento del tallo, confirmacion histologica de hipofisitis) o por historia de autoinmunidad endocrina. Incluimos tambien 24 controles sin patologia endocrina conocida. En todos se determinaron AAH mediante inmunofluorescencia indirecta sobre sustrato de glandula pituitaria de primate y anticuerpos antitiroideos mediante tecnica de aglutinacion. Resultados Los AAH fueron positivos en 9 pacientes, todos ellos mujeres, y en ningun control, perteneciendo el 43% de los pacientes con AAH positivos al grupo de pacientes con insuficiencia suprarrenal aislada. En 8 pacientes se determinaron de nuevo AAH durante el seguimiento, en 6 se mantuvieron negativos, en una se positivizaron y en otra se hicieron negativos. Los anticuerpos antitiroideos fueron positivos en 12 pacientes, de los cuales el 22,2% tambien tenian AAH positivos y en un control. Conclusiones La prevalencia de AAH fue baja, siendo todos los casos mujeres y en su mayoria con insuficiencia suprarrenal secundaria aislada. Solo en el 22% de los pacientes estudiados coexistieron AAH y anticuerpos antitiroideos.

Background and purpose: Endovascular therapies in acute ischaemic stroke may offer benefits to patients that are not eligible for standard use of intravenous tissue activator plasminogen (iv t-PA) or when this is not effective. Our aim is to present the initial experience in with endovascular techniques in the Community of Madrid. Methods: We present data from our registry of acute ischaemic strokes treated with endovascular re-perfusion therapies in five University Hospitals in Madrid (Spain) during the period 2005–2009. We recorded demographic data, vascular risk factors, risk severity with the NIHSS (National Institute of Health Stroke Scale), endovascular techniques, complications and mortality rates. Functional outcome and neurological disability at 90 days was defined by the modified Rankin scale (mRs). Results: A total of 41 patients were treated with endovascular therapies. Mean age was 58.6 ± 19.9, and 56.1% were males. Of those 22 patients had an anterior circulation stroke and 19 had a posterior circulation stroke. Baseline NIHSS score was: median, 17 [range, 2–34]; 7 patients had previously received IV t-PA. The following endovascular techniques were performed: mechanical disruption (26 patients), intra-arterial infusion of t-PA (26 patients), angioplasty and stenting (5 patients), mechanical use of MERCI device (3 patients). Partial or total re-canalization was achieved in 32 patients (78%). Only one patient had a symptomatic cerebral haemorrhage. Three months after stroke, 53.6% of the patients were independent (mRs = 2) and overall mortality rate was 19.5%. Conclusions: Acute ischaemic stroke is a potentially treatable medical emergency within the first hours after the onset of symptoms. Stroke endovascular procedures constitute an alternative for patients with IV t-PA exclusion criteria or when this is not effective. Resumen: Introducción y objetivos: El intervencionismo neurovascular (INV) en la fase aguda del ictus isquémico es una alternativa válida en los casos en que la trombólisis intravenosa está contraindicada o cuando no ha sido efectiva. Nuestro objetivo es presentar la experiencia inicial del INV en la Comunidad de Madrid. Métodos: Registro prospectivo de ictus isquémicos tratados con INV en la Comunidad de Madrid (2005–2009). Se recogen variables epidemiológicas, factores de riesgo y gravedad del ictus mediante la NIHSS (National Institute of Health Stroke Scale). Registramos el tipo de técnica, la situación funcional a los 3 meses, mediante la escala de Rankin modificada (eRm), complicaciones hemorrágicas y mortalidad. Resultados: Se incluyó a 41 pacientes. La media±desviación estándar de edad fue 58,6 ± 19,9 años; el 56,1%, varones. Hubo 22 pacientes con ictus de circulación anterior y 19, de circulación posterior. La mediana de la puntuación NIHSS basal fue 17 [intervalo, 2–34]; 7 pacientes recibieron trombólisis intravenosa previa. Las técnicas utilizadas fueron: interrupción mecánica (26 pacientes), trombólisis intraarterial (26 pacientes), angioplastia/ stent (5 pacientes), extracción mecánica mediante dispositivo MERCI (Mechanical Embolus Removal in Cerebral Ischemia) (3 pacientes). Se consiguió una recanalización parcial o total en 32 pacientes (78%). Un paciente presentó una transformación hemorrágica sintomática (2,4%). Al cabo de 3 meses el 53,6% de los pacientes eran independientes (eRm = 2) y la mortalidad general fue del 19,5%. Conclusiones: El ictus isquémico es una emergencia médica tratable en las primeras horas. El INV es una alternativa terapéutica factible y útil en los casos de contraindicación o ineficacia de la trombólisis intravenosa. Keywords: Ischaemic stroke, Thrombolysis, Endovascular procedures, Cerebral infarction, Intra-arterial thrombolysis, Tissue plasminogen activator, Palabras clave: Ictus isquémico, Trombólisis, Intervencionismo neurovascular, Infarto cerebral, Trombólisis intraarterial, Activador del plasminógeno tisular

Background and Purpose— The complexity of endovascular revascularization treatment (ERT) in acute ischemic stroke and the small number of patients eligible for treatment justify the development of stroke center networks with interhospital patient transfers. However, this approach might result in futile transfers (ie, the transfer of patients who ultimately do not undergo ERT). Our aim was to analyze the frequency of these futile transfers and the reasons for discarding ERT and to identify the possible associated factors. Methods— We analyzed an observational prospective ERT registry from a stroke collaboration ERT network consisting of 3 hospitals. There were interhospital transfers from the first attending hospital to the on-call ERT center for the patients for whom this therapy was indicated, either primarily or after intravenous thrombolysis (drip and shift). Results— The ERT protocol was activated for 199 patients, 129 of whom underwent ERT (64.8%). A total of 120 (60.3%) patients required a hospital transfer, 50 of whom (41%) ultimately did not undergo ERT. There were no differences in their baseline characteristics, the times from stroke onset, or in the delays in interhospital transfers between the transferred patients who were treated and those who were not treated. The main reasons for rejecting ERT after the interhospital transfer were clinical improvement/arterial recanalization (48%) and neuroimaging criteria (32%). Conclusions— Forty-one percent of the ERT transfers were futile, but none of the baseline patient characteristics predicted this result. Futility could be reduced if repetition of unnecessary diagnostic tests was avoided.

To evaluate the long-term effectiveness of nasolacrimal stents for the treatment of obstructive epiphora, and the complications related to the procedure.This study is a non-randomized prospective clinical trial. Eighty-five patients underwent fluoroscopally-guided placement of polyurethane stent in 86 lacrimal systems for the treatment of severe idiopathic obstructive epiphora. The sites of obstruction were: sac-duct junction (n = 65), sac (n = 10), and nasolacrimal duct (n = 11). The procedure was performed in an outpatient basis under local anesthesia. Patients were followed for a mean of 24 months (1-84) with clinical examinations and/or dacryocystography. Clinical success was defined as symptoms resolution or improvement, and the patency of the lacrimal system to irrigation.Stent placement was technically successful in 76 (88.4%) eyes. Technical failures (11.6%) were caused by inability to pass the guide-wire through the lacrimal system. Immediate complications occurred in 19 (22%) eyes, were mild and included: self-limited epistaxis (7), mild palpebral hematoma (7), moderate pain (3), lacrimal puncta bleeding (1), palpebral emphysema (1), and false passage (1). Of the 76 inserted stents, 33 (43.4%) became occluded, and 43 (56.6%) remained patent after a mean of 24 months. Mean duration of stent patency was 38 months. Clinical success was achieved in 40 (52.6%) of the successfully implanted stents.The procedure is well tolerated and can be performed on an outpatient basis. Patency decreases with follow-up, and, in the long-term, the success rate is inferior to that achieved by external dacryocystorhynostomy. However, it many be considered as a valid alternative to surgery in selected patients.

The aim of the present work is to demonstrate the applicability of the MELCOR- and CONTAIN-computer programs, respectively, to determine the radiological source terms (RST) of a pressurized water reactor under conservative release conditions based on preliminary reactor data from the European Pressurized Water Reactor Conceptional Design Phase. The determination of the RST means the quantification of the possible release of radionuclides from the plant (mostly from the containment) into the environment in case of a severe accident. This contribution gives an outline of the procedures by which the RST can be estimated conservatively. Such procedures have to be known if the ‘harmful effects of ionizing radiation’ outside the reactor plant, as mentioned in legislation, are determined in a proper way. It is demonstrated that the computer codes available at Forschungszentrum Karlsruhe can be used for the complete analyses of the containment behaviour and the accident consequences, provided that the design data of the nuclear reactor and information on the initiating phase of the accident are available. The first 12 h of a postulated Large Break Loss-of-Coolant Accident are analysed and a time dependent RST to the environment is calculated, which can be used as input for the COSYMA code system for the assessment of the accident consequences.

Resumen Se presenta una serie de 38 pacientes diagnosticados de Malformacion arteriovenosa dural (MAVD) estudiados desde 1980 a 1996 Tiempo de seguimiento de 6 meses a 10 anos con media de 2,7 anos. 18 casos (47%) eran fistulas carotido-cavernosas (FCC) y 20 casos (53%) de otra localizacion, 10 en el seno transverso sigmoides (STS), 6 en el tentorio, 2 en la fosa anterior, y 2 en el seno sagital superior. En las FCC se siguio la clasificacion de Barrow y cols. (15 tipo D, 2 tipo B, y 1 tipo C) y en el resto de los casos se siguio la clasificacion de Cognard y cols. (2 casos tipo I, 3 tipo IIa, 1 tipo IIa+b, 9 tipo III, y 5 tipo IV). De los 18 casos de FCC, en 12 (67%) se siguio tratamiento endovascular y/o quirurgico, en 5 (27%) tratamiento con compresiones y en uno (6%) no se realizo tratamiento por rehusar el mismo. Se consiguio el cierre de la fistula en dos casos, mejoria clinica y angiografica en 11 casos, situacion estacionada en 4 casos y empeoramiento en uno. No hubo mortalidad y el seguimiento medio ha sido de 2,8 anos. De los 20 casos localizados fuera del seno cavernoso, 11 (55%) fueron sometidos a tratamiento endovascular y/o quirurgico, 2 (10%) se trataron con compresiones y en 7 (35%) no se realizo tratamiento. El resultado final fue excelente en 5 casos con cierre de la fistula, mejoria en 2 casos, estacionado en 11 casos y malo en 2 casos que fueron exitus (10%). El seguimiento medio de este grupo fue de 2,5 anos. Las MAVDs constituyen una entidad definida gracias a los estudios angiograficos superselectivos. Por su complejidad cada caso debe tratarse individualmente. Las FCC se consideran una entidad diferente por su menor agresividad y buena evolucion con el tratamiento conservador y cuando se opta por tratamiento activo la embolizacion por via arterial es la eleccion. En el resto de las MAVDs los tipos 111 y IV tienen indicacion de tratamiento activo, bien endovascular (arterial y/o venoso) o quirurgico con o sin embolizacion previa, por su mayor agresividad.

Resumen Los cavernomas representan del 5 al 13% de las anomalias vasculares del Sistema Nervioso Central. Su localizacion extra axial es rara y en el angulo pontocerebeloso lo es mas aun, habiendose publicado solamente seis casos en la literatura accesible. Presentamos un nuevo caso con historia larga de afectacion de los pares VII y VIII. En la Tomografia Computarizada (TAC) la lesion era ligeramente hiperdensa y no se realzaba con contraste. La Resonancia Magnetica (RM) localizo precisamente la lesion. En imagenes ponderadas en TI era iso hipointensa con areas moteadas hiperintensas y en imagenes ponderadas en T2 era heterogenea e hiperintensa con un ligero halo de hiposenal rodeando la lesion. La paciente fue operada y la masa extra axial adherida a los pares VII y VIII Yal tronco cerebral fue extirpada en su. totalidad. La evolucion fue sin complicaciones. La Resonancia Magnetica ha demostrado ser de gran utilidad para el diagnostico de esta lesion.

We report the clinical presentation (relapsing epistaxis after Le Fort I osteotomy), craniofacial digital subtraction angiography findings, and endovascular embolization through a microcatheter, in a 26-year-old patient with a pseudoaneurysm of the descending palatine artery.

To determine the level of burnout in general practitioners of Avila and the influence of social, occupational and health factors.A descriptive cross-sectional epidemiological study was conducted and aimed at all Primary Care medical staff of Avila during the first half of 2011, using two questionnaires: the Maslach Burnout Inventory and other sociodemographic, health and occupational variables.A response rate of 51.8% was obtained. The mean age was 48.55±8.16, and 52% were male, 77% married, 45% with tenure, 78% worked in rural centres, and, 82% performed out of hours home visits plus clinics. The prevalence of severe burn out was low (16%) in our study was low. A high prevalence (68%) of moderate/severe level of the condition was found. Being married (P=.012), do not guards (P.0001), working in rural areas (P=.008), and to be an area doctor (p=.03), predisposes to suffer burnout in severe or moderate/severe burnout.A moderate level of burnout was found. Contrary to what many doctors thought, the prevalence of the condition in its severe form was low, but was high when taking the severe and moderate/severe forms together. Therefore, measures should be extended to reduce occupational stress of doctors, in order to improve working practices and professional efficiency.

OBJECTIVES Several reports have shown an increase in serum gastrin levels in patients with Cushing’s syndrome (CS). However, the actual origin of this hypergastrinaemia is not known. Two hypotheses have been proposed: concomitant ACTH and gastrin secretion by corticotrophic pituitary adenomas or hypergastrinaemia induced by hypercortisolism. DESIGN AND PATIENTS We performed simultaneous, bilateral inferior petrosal sinus (IPS) sampling in nine patients with Cushing’s disease (CD), proven by histological studies. In all of them, blood samples were taken from both IPS and a peripheral vein to measure plasma ACTH and serum gastrin. In addition, we measured peripheral serum gastrin levels after an overnight fast in 10 patients with CS (seven with pituitary tumours and three with adrenal tumours) before and after surgical treatment. RESULTS Petrosal-peripheral and interpetrosal gradients of ACTH were higher than 2.0 and 1.4, respectively, confirming the pituitary origin of ACTH. Mean serum gastrin levels were 149.1 ± 53.6 ng/l in peripheral vein, 183.4 ± 71.7 ng/l in dominant IPS and 181.4 ± 68.9 ng/l in non-dominant IPS. No significant differences in gastrin concentrations in these locations were found. Mean preoperative gastrin level in patients with CD was 194.6 ± 47.9 ng/l, whereas in patients with adrenal tumours it was 247.3 ± 125.9 ng/l. After surgical treatment, the gastrin levels decreased to 62.1 ± 13.2 ng/l (P

Resumen Se presenta el caso de un paciente con lumbalgias y dificultad en la marcha, objetivandose con Resonancia Magnetica (RM) dos metastasis lumbosacras procedentes de un oligodendroglioma cerebral que fue intervenido 5 anos antes. El paciente fue intervenido de las metastasis lumbosacras, administrandose a continuacion radioterapia espinal. La evolucion fue favorable durante los siguientes dieciocho meses con mejoria del cuadro clinico. La evolucion posterior fue de crecimiento del tumor cerebral con afectacion del tronco, falleciendo al cabo de 6 meses.

An isolate of Bacillus thuringiensis subsp. israelensis (BTI) was obtained from field-collected larvae of the saturniid moth, Hylesia metabus. This isolate was shown to belong to serotype H 14, and to produce a spherical parasporal body identical to that of the type strain of BTI. With an LC50 of 0.764 μg cm−2, this isolate was more toxic to H. metabus than the HD-1 strain of B. thuringiensis subsp. kurstaki (HD-1). These results demonstrate that BTI can be active against lepidopterous insects, a wider spectrum of activity than previously realized.

ResumenLas fístulas arteriovenosas en la cabeza y el cuello son entidades poco frecuentes. La mayoría es secundaria a heridas penetrantes por arma blanca. Se describe el tratamiento exitoso mediante cirugía endovascular de una fístula postraumática tras una herida penetrante entre la arteria maxilar interna izquierda y la vena yugular externa. A través de este caso clínico y la revisión de la literatura se ilustran las causas, manifestaciones, estudio radiológico y tratamiento de una fístula postraumática entre la arteria maxilar interna y la vena yugular externa. A través de este caso clínico se demuestra la utilidad de los procedimientos endovasculares en el tratamiento de estas complicaciones.AbstractTraumatic arteriovenous fistulas of the head and neck region are uncommon. The majority are due to penetration of blunt injury. We describe a successful endovascular treatment of a posttraumatic fistula between the left maxillary artery and the external jugular vein due to a penetration injury. This case and a review of the literature illustrate the causes, manifestations, image studies and treatment for a posttraumatic fistula between the maxillary artery and the external jugular vein. This case demonstrate the utility of endovascular treatment of head and neck injuries complications.

Resumen Presentamos 11 pacientes con astrocitomas de ventriculo lateral de bajo grado de malignidad. La manifestacion clinica fue principalmente por sintomas de hipertension endocraneal, seguido de crisis comiciales. Cinco de los 6 pacientes con crisis comiciales presentaban Esclerosis Tuberosa (ET). La localizacion de estos tumores en el ventriculo lateral fue de predominio en su porcion anterior con 7 casos de los cuales 6 se originaron a nivel del foramen de Monro y 5 de estos 6 tumores en el estudio histologico fueron astrocitomas de tipo gigantocelular subependimario. Las caracteristicas de la tomografia axial computarizada (TAC) fueron en general hipo o hiperdensos con captacion de contraste a nivel de foramen de Monro y de densidad heterogenea en el resto de los tumores. La RM puso de manifiesto con mas precision la extension y localizacion del tumor junto con tuberomas en los casos de ET que pasaban desapercibidos con la TAC. Fueron intervenidos todos los casos y reintervenidos dos pacientes. Dos casos fallecieron por sangrado masivo al intentar una extirpacion total. Se comentaran las caracteristicas histologicas asi como la evolucion de estos procesos.

We present the case of a 69 year-old male without known antecedente who presented a clinical loss of distal force in his lower limbs during the last two months. Magnetic resonance imaging (MRI) showed an intramedullary spinal cord mass at the level of the medullaris cone. The patient was operated on; the histological diagnosis was clear cells carcinoma suggestive of metastasis from an unsuspected renal tumor that was later confirmed with an abdominal CT. When the patient's state is good, surgery can correct the neurological deficit produced by an intramedullary spinal cord lesion. The neurological state of our patient improved after the intervention, and 14 months after surgery, he has no neurological deficit in the lower limbs.

This paper proposes an optimization algorithm to reduce the distortion produced in the loop-filter of Continuous-Time Sigma-Delta Modulators. The aim of the algorithm is to find the loop-filter implementation that minimizes distortion at the output of the modulator, by modifying the output swing of every integrator. The algorithm is implemented in Matlab as an evolutive searching. During each step of the searching, the algorithm evaluates the harmonical distortion of a tone when it is applied to the modulator with a certain loop-filter implementation. The output of the algorithm is an optimum linear state-space representation of the loop-filter. This particular state-space representation leads to minimum distortion at the output of the modulator when the loop-filter is implemented with some specific circuitry previously defined. As long as the search is of evolutive type, the solution represents a local minimum only. The algorithm computes a random guess solution as the starting point for the optimization procedure, so that different local minimums may be found by running the algorithm itself several times. The algorithm has been applied to a 4th order 4-bit Continuous-Time Sigma-Delta Modulator as a simulation example.© (2005) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

Presentamos el caso de un varón de 69 años sin patología previa de interés que presentó clínica de pérdida de fuerza distal en miembros inferiores de dos meses de evolución. La resonancia magnética (RM) mostró la presencia de una masa intramedular a nivel del cono. El paciente fue intervenido practicándose resección de la tumoración, mostrando el estudio histológico la presencia de un carcinoma de células claras correspondiente a una sospecha de metástasis de un tumor renal, que posteriormente se confirmó con una tomografía axial computarizada (TAC) abdominal. Cuando el estado del paciente es bueno, la cirugía puede subsanar el déficit neurológico producido por la lesión intramedular. Nuestro paciente, tras la intervención, mejoró su estado neurológico; y actualmente, tras 14 meses, se mantiene sin déficit neurológico en miembros inferiores.

A large displacement electrostatic valve has been designed and realized for a realistic turbulent boundary layer control. This actuator consists of a pair of rigid electrodes and a flexible film having a S-shape providing local high electrostatic forces required for controling rather large pressure differences. The aim is the reattachment of the boundary layer near an aircraft flap trailing edge by transferring momentum energy via high speed pulsated micro air jets. The valve controls the frequency and the speed of the micro jets. An array of fifteen actuators has been manufactured and characterized by particles images velocimetry (PIV) and hot wire anemometry (HWA). The devices are able to control pressure differences up to 27 kPa with a supply voltage of 400 V. For this maximum pressure, the corresponding jet velocity downstream a 45 degree skew micro orifice (0.4 mm diameter) is close to 100 ms-1

[1] In November 2004, a regional climate change workshop was held in Guatemala with the goal of analyzing how climate extremes had changed in the region. Scientists from Central America and northern South America brought long-term daily temperature and precipitation time series from meteorological stations in their countries to the workshop. After undergoing careful quality control procedures and a homogeneity assessment, the data were used to calculate a suite of climate change indices over the 1961–2003 period. Analysis of these indices reveals a general warming trend in the region. The occurrence of extreme warm maximum and minimum temperatures has increased while extremely cold temperature events have decreased. Precipitation indices, despite the large and expected spatial variability, indicate that although no significant increases in the total amount are found, rainfall events are intensifying and the contribution of wet and very wet days are enlarging. Temperature and precipitation indices were correlated with northern and equatorial Atlantic and Pacific Ocean sea surface temperatures. However, those indices having the largest significant trends (percentage of warm days, precipitation intensity, and contribution from very wet days) have low correlations to El Nino–Southern Oscillation. Additionally, precipitation indices show a higher correlation with tropical Atlantic sea surface temperatures.

espanolEl sindrome de boca ardiente es un cuadro clinico complejo en el que el paciente manifiesta una sensacion de escozor o ardor intrabucal sin que aparezcan lesiones clinicas objetivables. Objetivo: Valorar la eficacia mediante la aplicacion de un gel de capsaicina a una concentracion de 0.025 mg., en pacientes con sindrome de boca ardiente. Pacientes y metodo: Se estudiaron a un grupo de 29 pacientes a los que se les realiza un protocolo de recogida de datos que incluye anamnesis, historia medica, exploracion bucal y pruebas complementarias. A 15 de dichos pacientes se les prescribe un gel de capsaicina y se les realiza un seguimiento durante varias semanas. Resultados: La eficacia de la capsaicina es relativamente baja, solo un 13% de los pacientes refiere una mejoria importante (con una disminucion de mas de 3 puntos en las escalas analogico-visuales) y un 6% mejoria parcial (disminucion menor de 3 puntos) con este tratamiento. Discusion: La estomatodinia es un cuadro clinico multifactorial que precisa de una mayor investigacion tanto de su etiologia como de su manejo terapeutico. Es de suma importancia realizar un correcto diagnostico y explicar este al paciente para poder mantener unas metas realistas sobre las posibilidades de exito. EnglishBurning mouth syndrome is a complex clinical condition, patients show a sensation of irritation or intraoral heat without objetivable clinical injuries. Objective: to value the effectiveness of a capsaicin 0,025% gel application in patients with burning mouth syndrome. Patients and methods: 29 patients with burning mouth syndrome was examined by means of anamnesis, medical history, oral explortation and complementary tests. 15 of these patients were administered a capsaicin gel and were examined for several weeks. Results: the effectiveness of capsaicin is relatively low, only 13% of patients refer an important improvement ( with a reduction more tha 3 points in the visual alalogical scales) and 6% partial improvement ( reduction under 3 points) with this treatment. Discussion: burning mouth syndrome is a multifactorial clinical problem that needs a carefuly of its etiology and therapeutic management. It is of extreme importance make a correct diagnosis and explain this condition to the patient to be able to maintain realistic objectives on the success possibilities.

Bacillus sphearicus C3-41, belonging to serotype H5a5b, is ahighly toxic strain isolated from a mosquito-breeding site in China. It has been shown that it had a higher toxicity against Culex spp. than the reference strain 2362 at the laboratory and field conditions. Using synthetic oligonucleotides designed on the basis of the binary toxin gene sequence of 2362, a 1.1 kb DNA fragment was produced and the genetic library was prepared from a HindIII digest of total DNA from C3-41. One colony containing the 3.5 kb HindIII fragment was selected for further studies. Sequence analysis revealed that this 3.5 kb Hind DNA fragment was composed of 3479 nucleic acids and the sequence of the binary toxin gene of C3-41 is completely identical to that of strain 2362. The toxin genes have been transferred into a nontoxic crystal-minus strain of Bacillus thuringiensis subsp. israelensis. The recombinant strains could express the binary toxin of B. sphaericus as crystaline structures during their sporulation. The expression products of the recombinants have a highly toxicity to susceptible Culex pipiens subsp. quinquefasciatus and no toxicity to resistant larvae(Culex pipiens subsp. pipiens) from France.

Muchos de los medicamentos que utilizamos en nuestras consultas, y a los que presuponemos inocuidad, pueden producir multitud de efectos secundarios que en ocasiones pueden llegar a ser letales. La agranulocitosis es una poco frecuente alteración sanguínea consistente en una neutropenia severa que asocia infecciones graves y una elevada mortalidad. Un gran número de medicamentos se han asociado con la producción de agranulocitosis antibióticos, antiinflamatorios , antidepresivos, etc... Dentro de estos medicamentos el metamizol ha sido uno de los fármacos que clásicamente se ha asociado a este trastorno sanguíneo. Ampliamente utilizado, el metamizol, goza de gran popularidad no sólo entre el ambiente médico sino entre los mismos pacientes que pueden conseguirlo sin receta médica en cualquier farmacia dentro de nuestro país. Aunque la asociación de agranulocitosis y metamizol es poco frecuente debemos tenerla presente por las graves consecuencias que puede traer. Tal fue el caso de la paciente que describimos, la cual tras haber recibido metamizol debió ser atendida urgentemente en su domicilio, siendo posteriormente remitida al hospital. La analítica en urgencias mostró una agranulocitosis. Posteriormente ingresaría en la unidad de cuidados intensivos donde, a pesar de las medidas de soporte y la antibioterapia, la paciente falleció a las pocas horas.