Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye

PURPOSE

To describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with LR myopexy.

METHODS

A retrospective study of 9 cases between 2017-2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered Successful if the diplopia was improved or eliminated and a final vertical deviation (VD) ≤5 prism diopters (PD).

RESULTS

The mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33 PD (SD 3.16), and the mean final VD 3.44 PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another three. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation ≤5 PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (three with macular pathology).

CONCLUSION

Supra-equatorial displacement with LR myopexy for treatment of myopic sagging/heavy eye, is a therapeutic option if hypotropia is less than 12 PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent.

Convergence insufficiency with diplopia: Surgical treatment in adults

OBJECTIVE

To study the outcomes of treatment with central mini-plication of the medial rectus (MR) muscles in adult convergence insufficiency with diplopia.

METHODS

The study sample comprised 9 cases (7 women). The length of MR plication was collected. Other variables reported were postsurgical deviation, overcorrections in the early postoperative period and at the end of follow-up, final horizontal deviation at near and at distance vision, diplopia, and mean follow-up from surgery. Surgical outcome was considered to be favorable when diplopia and symptoms were resolved and final exotropia at near was ≤8 pd at the end of follow-up.

RESULTS

A central mini-plication of the MR was performed in 9 patients (8 unilateral). Mean (± SD) age was 58.66 (21.39) years. Mean near preoperative deviation: 16.22 (± 2.9) pd and distance preoperative deviation: 6.88 (± 4) pd Overcorrection at distance vision was recorded in 5 cases; this resolved by 3 months postoperatively. There was not overcorrection at near vision except one case. None of the cases operated on had overcorrection at the end of follow-up The final horizontal deviation was ≤8 pd at near vision, except for 3 cases (mean: 6.22). Symptoms and diplopia resolved in 8 cases. The mean follow-up was 10.33 months.

CONCLUSION

Central mini-plication of 1 or 2 medial rectus muscles can improve the symptoms and signs of exotropia associated with convergence insufficiency when exercises and the prisms are rejected by the patients and when these approaches have not solved the problem.

Transposition of the inferior oblique muscle belly without disinsertion for overshoot in adduction treatment

PURPOSE

To evaluate the efficacy and safety of inferior oblique muscle transposition and myopexy in patients with mild/moderate inferior oblique muscle overaction, with or without diplopia.

METHOD

We retrospectively analysed data for the 12 patients who underwent the technique. Data were collected from October 2018 to September 2021. Surgery was performed by suturing the inferior oblique belly to the sclera at 5 mm posterior to the temporal end of the inferior rectus. All 12 patients had mild hypertropia (≤6 prism diopters [pd]) in primary position and mild/moderate inferior oblique overaction. Mean preoperative hypertropia was 4.42 pd ± 1.62. Diplopia was recorded in 10 cases. The diagnoses were fourth nerve paresis (9), unilateral primary inferior oblique overaction (2) and dissociated vertical deviation (1). Torticollis was observed in 7 cases, 2 had subjective torsion and 2 objective torsion.

RESULTS

Mean age was 46.86 ± 25.1 years (50%: men). Diplopia resolved in 9 of the 10 cases. The mean final vertical deviation was 1.5 ± 2.93 (p = 0.001) pd in straight gaze. Of 7 mild overshoot in adduction, it disappeared in 3 and 4 remained the same. Of 5 moderate overshoot in adduction, 2 improved to mild and 3 disappeared. Torticollis was eliminated in 5 patients and improved in another 2. Mean time from surgery was 14.08 ± 8.05 months. There were no overcorrections.

CONCLUSIONS

Inferior oblique muscle transposition with myopexy is a safe and effective procedure in patients with mild-to-moderate inferior oblique muscle overaction and small-angle hypertropia, with or without diplopia.

Surgical outcomes of acquired acute comitant esotropia. Causes and classification

PURPOSE

To study the results of surgical treatment of acquired concomitant esotropia and its posible causes.

METHODS

Retrospective study of the patients with acute acquired esotropia that were operated on since 2017. Distance and near horizontal deviation, spherical equivalent and the excessive use of the tablets and smartphones were analyzed. A good sensorial outcome was considered when stereopsis was recovered and good motor outcome if horizontal deviation was ≤10 prism diopters at the end of the follow-up.

RESULTS

A total of 15 cases were included (60% women), mean age: 29.07 years (86.66% ≥16 years). Mean time since the beginning of the symptoms to the surgery was 23.3 months. Mean horizontal preoperative deviation was 19.73 ± 7.2 pd at near and 22.93 ± 7.3 dp at distance decreasing to 3.33 ± 3.8 pd at near and 3.86 ± 3.9 pd at distance (P < .001). The 66.6% had diplopía. The 46.66% had decompensated esophoria or microesotropia, 86,66 % myopia and the 33.33% referred excesive use of the tablets and smartphones. The medial rectus recession were done in 10 cases. A good motor outcome was obtained in the 93.33% of the cases and sensorial outcome in the 53.3% without diplopía.

CONCLUSION

Surgery was an excellent treatment to resolve the deviation and diplopia. The esophorias and microesotropias represented near the half of the cases and the excesive use of the tablets and smartphones were the third part of the sample. Most of the patients had myopia.

Strategies to mitigate ammonia and nitrous oxide losses across the manure management chain for intensive laying hen farms

Circular economy principle aims to achieve sustainable production systems, focusing on the waste valorisation and the reduction of gaseous losses to the atmosphere. Nitrogen (N) compounds in terms of ammonia (NH₃) and nitrous oxide (N₂O) represent the major losses to the atmosphere of laying hen manure management chain. We present a study aimed to evaluate NH₃ and N₂O emission and mitigation strategies at housing, storage and land spreading stages. The whole manure management chain was evaluated under different scenarios which combined mitigation strategies of each stage. Two intensive laying hen facilities were involved in the study. Evaluated mitigation strategies were: (i) frequency of manure removal from housing facility, (ii) dried manure storage after passing throughout a manure drying tunnel (MDT) compared to fresh manure storage and (iii) fresh or dried manure incorporation versus surface land application. Increasing the frequency of manure removal from 4 days to 1/3 daily, reduced N losses around 68%. Dried manure storage achieved around 75% reduction in N losses compared to fresh manure storage. Spreading dried manure on grassland surface reduced ≈77% NH₃ losses in relation to the emission level reached by fresh manure. The reduction was similar when dried manure was incorporated compared to surface application of fresh manure (≈79%). A 40% reduction in N losses was achieved using the MDT compared to no drying strategy. In the whole manure management chain, the combination of strategies that most reduced N losses was: removal frequency of 1/3 daily, dry storage after passing through the MDT and incorporated land application. These strategies reduced N losses between 40 and 60% compared to the 4 days of removal frequency, fresh storage and surface application of fresh manure.

Early Stepdown From Echinocandin to Fluconazole Treatment in Candidemia: A Post Hoc Analysis of Three Cohort Studies

Background

There are no clear criteria for antifungal de-escalation after initial empirical treatments. We hypothesized that early de-escalation (ED) (within 5 days) to fluconazole is safe in fluconazole-susceptible candidemia with controlled source of infection.

Methods

This is a multicenter post hoc study that included consecutive patients from 3 prospective candidemia cohorts (2007–2016). The impact of ED and factors associated with mortality were assessed.

Results

Of 1023 candidemia episodes, 235 met inclusion criteria. Of these, 54 (23%) were classified as the ED group and 181 (77%) were classified as the non-ED group. ED was more common in catheter-related candidemia (51.9% vs 31.5%; P = .006) and episodes caused by Candida parapsilosis, yet it was less frequent in patients in the intensive care unit (24.1% vs 39.2%; P = .043), infections caused by Nakaseomyces glabrata (0% vs 9.9%; P = .016), and candidemia from an unknown source (24.1% vs 47%; P = .003). In the ED and non-ED groups, 30-day mortality was 11.1% and 29.8% (P = .006), respectively. Chronic obstructive pulmonary disease (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.48–10.61), Pitt score > 2 (OR, 4.39; 95% CI, 1.94–9.20), unknown source of candidemia (OR, 2.59; 95% CI, 1.14–5.86), candidemia caused by Candida albicans (OR, 3.92; 95% CI, 1.48–10.61), and prior surgery (OR, 0.29; 95% CI, 0.08–0.97) were independent predictors of mortality. Similar results were found when a propensity score for receiving ED was incorporated into the model. ED had no significant impact on mortality (OR, 0.50; 95% CI, 0.16–1.53).

Conclusions

Early de-escalation is a safe strategy in patients with candidemia caused by fluconazole-susceptible strains with controlled source of bloodstream infection and hemodynamic stability. These results are important to apply antifungal stewardship strategies.

Gold Chain Formation via Local Lifting of Surface Reconstruction by Hot Electron Injection on H2(D2)/Au(111)

The hexagonal close packed surface of gold shows a 22 × 3 "herringbone" surface reconstruction which makes it unique among the (111) surfaces of all metals. This long-range energetically favored dislocation pattern appears in response to the strong tensile stress that would be present on the unreconstructed surface. Adsorption of molecular and atomic species can be used to tune this surface stress and lift the herringbone reconstruction. Here we show that herringbone reconstruction can be controllably lifted in ultrahigh vacuum at cryogenic temperatures by precise hot electron injection in the presence of hydrogen molecules. We use the sharp tip of a scanning tunneling microscope (STM) for charge carrier injection and characterization of the resulting chain nanostructures. By comparing STM images, rotational spectromicroscopy and ab initio calculations, we show that formation of gold atomic chains is associated with release of gold atoms from the surface, lifting of the reconstruction, dissociation of H₂ molecules, and formation of surface hydrides. Gold hydrides grow in a zipper-like mechanism forming chains along the [11̅0] directions of the Au(111) surface and can be manipulated by further electron injection. Finally, we demonstrate that Au(111) terraces can be transformed with nearly perfect terrace selectivity over distances of hundreds of nanometers.

Changes in ocular motility in Kabuki syndrome

Kabuki syndrome is a rare genetic disorder, caused by mutation in the KMT2D or KDM6A genes, which affects several organs in the majority of patients, among which are the eyes. The most typical clinical characteristics are mental retardation, postnatal growth retardation, skeletal anomalies, and characteristic facial features. As the eyes are affected in most of the cases, ophthalmological examination is recommended for the early detection of ocular anomalies, in order to prevent visual impairment. The most frequent ocular signs are strabismus, ptosis, and refractive anomalies. A series of cases of Kabuki syndrome is described in five children, four of whom exhibited strabismus with esotropia, over action of inferior oblique muscles, and under action of superior oblique muscles associated with a V pattern. Most published papers do not report or might underestimate the ocular problems. It may be appropriate to perform orbital magnetic resonances in order to detect changes in the muscle paths that are related to the pathology of the eye movements found.

Assessing ventilation rate measurements in a mechanically ventilated laying hen facility

Gaseous emission in laying hen facilities affects animal production performance and the environment. Emission is ruled by gas concentration and ventilation rate (VR), which are the key parameters to estimate precise emission factors. In this work, VR were assessed in a mechanical ventilated laying hen facility under Mediterranean climate conditions. The study was performed during a complete production cycle from July 2015 to October 2016. Direct hot wire anemometer (HWA) and fan rotational speed methods, and indirect CO2 mass balance method were used to assess the VR. Mean VR was 5.3 ± 2.9 m3 h-1 hen-1 for the HWA method. The mean uncertainty of VR based on the HWA method was 8.5%, and it varied among ventilation stages from 2.3 to 12.8%. Uncertainty was higher in warm season (9.6%) than in cold season (5.4%). In relation to fan rotational speed method, mean VR was 5.9 ± 3.3 m3 h-1 hen-1, which accounts for 8.3% more than the HWA method. According to the results, the fan rotational speed method would be less sensitive than the HWA method for assessing VR. VR was 6.3 ± 2.1 m3 h-1 hen-1 for the CO2 balance method, which estimated lower VR values in warm season compared to the laser tachometer (LT) method (-5%) but higher values compared to the HWA method (+5%). In contrast, it estimated higher values in cold season compared to the HWA method (+23%) and LT method (+17%). Correlation analysis showed a strong correlation between the CO2 balance method and both direct methods (R = 0.85 and 0.86 for HWA and LT, respectively).

A Single Hydrogen Molecule as an Intensity Chopper in an Electrically Driven Plasmonic Nanocavity

Photon statistics is a powerful tool for characterizing the emission dynamics of nanoscopic systems and their photophysics. Recent advances that combine correlation spectroscopy with scanning tunneling microscopy induced luminescence (STML) have allowed the measurement of the emission dynamics from individual molecules and defects, demonstrating their nature as single-photon emitters. The application of correlation spectroscopy to the analysis of the dynamics of a well-characterized adsorbate system in an ultrahigh vacuum remained to be demonstrated. Here, we combine single-photon time correlations with STML to measure the dynamics of individual H₂ molecules between a gold tip and an Au(111) surface. An adsorbed H₂ molecule performs recurrent excursions below the tip apex. We use the fact that the presence of the H₂ molecule in the junction modifies plasmon emission to study the adsorbate dynamics. Using the H₂ molecule as a chopper for STM-induced optical emission intensity, we demonstrate bunching in the plasmonic photon train in a single measurement over 6 orders of magnitude in the time domain (from microseconds to seconds) that takes only a few seconds. Our findings illustrate the power of using photon statistics to measure the diffusion dynamics of adsorbates with STML.

Can nonalcoholic beer, silicon and hops reduce the brain damage and behavioral changes induced by aluminum nitrate in young male Wistar rats?

Aluminum consumption has been associated with various neurodegenerative diseases. Previous studies suggest that regular beer intake reverses the pro-oxidant and inflammatory statuses induced by aluminum nitrate intoxication. This paper aims to evaluate the in vitro antioxidant capacity and acetylcholinesterase inhibitory activity of non-alcoholic beer (NABeer), silicon or hops, as well as their effect on animal behavior (e.g. curiosity, immobilization, rearing, grooming, swimming) and brain antioxidant enzyme (activity and gene expression) and anti-inflammatory status in aluminum nitrate intoxicated rats. Male Wistar rats were divided into five groups: 1) Control, 2) Aluminum nitrate (450 μg/kg/day), 3) Aluminum nitrate plus NABeer, 4) Aluminum nitrate plus hops, and 5) Aluminum nitrate plus silicon. Hops showed the highest in vitro antioxidant capacity and silicon the highest anticholinesterase activity. In the Aluminum group the brain aluminum/silicon ratio increased with impairment of brain antioxidant and inflammatory statuses. NABeer, silicon and hops block the negative effect on the in vivo antioxidant and inflammatory statuses induced by Aluminum nitrate and improve swimming and rearing behavioral tests. The various positive results suggest that NABeer is useful as a functional multi-target drink in the prevention of some neurodegenerative events caused by aluminum intoxication. More studies are required to conclude present results.

Binocular diplopia in a tertiary hospital: Aetiology, diagnosis and treatment

OBJECTIVE

To study the causes, diagnosis and treatment in a case series of binocular diplopia.

MATERIAL AND METHOD

A retrospective chart review was performed on patients seen in the Diplopia Unit of a tertiary centre during a one-year period. Diplopia was classified as: acute≤1 month since onset; subacute (1-6 months); and chronic (>6 months). Resolution of diplopia was classified as: spontaneous if it disappeared without treatment, partial if the course was intermittent, and non-spontaneous if treatment was required. It was considered a good outcome when diplopia disappeared completely (with or without treatment), or when diplopia was intermittent without significantly affecting the quality of life.

RESULTS

A total of 60 cases were included. The mean age was 58.65 years (60% female). An acute or subacute presentation was observed in 60% of the patients. The mean onset of diplopia was 82.97 weeks. The most frequent aetiology was ischaemic (45%). The most frequent diagnosis was sixth nerve palsy (38.3%), followed by decompensated strabismus (30%). Neuroimaging showed structural lesions in 17.7% of the patients. There was a spontaneous resolution in 28.3% of the cases, and there was a good outcome with disappearance of the diplopia in 53.3% at the end of the study.

CONCLUSIONS

The most frequent causes of binocular diplopia were cranial nerve palsies, especially the sixth cranial nerve, followed by decompensated strabismus. Structural lesions in imaging tests were more than expected. Only one third of patients had a spontaneous resolution, and half of them did not have a good outcome despite of treatment.

Complications of augmented superior rectus transposition in Duane syndrome

CLINICAL CASE

A patient diagnosed with Duane syndrome underwent an augmented superior rectus transposition (SRT) to lateral rectus (LR) and medial rectus (MR) recession. Vertical, torsional deviation and diplopia were observed post-operatively. Removal of the Foster suture and superior rectus recession resolved the symptoms.

DISCUSSION

SRT to LR is proposed in Duane syndrome with a favorable outcome. The benefit of SRT is open to debate. It could be an alternative for the vertical rectus transposition when MR recession has to be operated on in the same procedure, or in the immediate post-operative period, in order to decrease the risk of anterior segment ischaemia.

Outcomes of minimally invasive strabismus surgery for horizontal deviation

OBJECTIVE

To study the outcomes of minimally invasive strabismus surgery (MISS) for treating horizontal deviation

METHOD

Case Series of the first 26 consecutive patients operated on using the MISS technique in our hospital from February 2010 to March 2014.

RESULTS

A total of 40 eyes were included: 26 patients (mean age: 7.7 years old ± 4.9); 34.61%: male. A total of 43 muscles were operated on: 20 medial, and 23 lateral recti; 28 recessions (range: 3-7.5mm), 6 resections (6-7 mm), and 9 plications (6.5-7.5 mm) were performed. No significant difference was found (P>0.05) for visual acuity at postoperative day 1, and 6 months after surgery. A mild hyperaemia was observed in 29.27%, moderate in 48.78%, and severe in 21.95% at postoperative day 1 and in 63.41%, 31.70% and 4.87%, respectively, at 4 days after surgery. The complications observed were 4 intraoperative conjunctival haemorrhages, 1 scleral perforation, and 2 Tenon's prolapses. A conversion from MISS to a fornix approach was necessary in 1 patient because of bad visualization. The operating time range decreased from 30 to 15 minutes.

CONCLUSIONS

The MISS technique has obtained good results in horizontal strabismus surgery. The conjunctival inflammation was mild in most of the cases at postoperative day 4. The visual acuity was stable during follow-up, and operating time decreased after a 4-year learning curve.

Exciton dynamics of C60-based single-photon emitters explored by Hanbury Brown-Twiss scanning tunnelling microscopy

Exciton creation and annihilation by charges are crucial processes for technologies relying on charge-exciton-photon conversion. Improvement of organic light sources or dye-sensitized solar cells requires methods to address exciton dynamics at the molecular scale. Near-field techniques have been instrumental for this purpose; however, characterizing exciton recombination with molecular resolution remained a challenge. Here, we study exciton dynamics by using scanning tunnelling microscopy to inject current with sub-molecular precision and Hanbury Brown–Twiss interferometry to measure photon correlations in the far-field electroluminescence. Controlled injection allows us to generate excitons in solid C₆₀ and let them interact with charges during their lifetime. We demonstrate electrically driven single-photon emission from localized structural defects and determine exciton lifetimes in the picosecond range. Monitoring lifetime shortening and luminescence saturation for increasing carrier injection rates provides access to charge-exciton annihilation dynamics. Our approach introduces a unique way to study single quasi-particle dynamics on the ultimate molecular scale.

Electrons and holes trapped in a molecular crystal couple to form excitons. Here, the authors use scanning tunnelling microscopy to inject current with submolecular precision into structural defects in solid C₆₀ and demonstrate single photon emission from the excitons trapped there.

Acortamiento cubital. Contribución del sistema guiado para osteotomía y síntesis

Objetivos: El acortamiento cubital es la técnica quirúrgica empleada más habitualmente para casos de impactación y dolor cubitocarpiano. Tradicionalmente el cúbito ha sido cortado sin guía y la osteosíntesis realizada con una placa no diseñada para esta intervención, pero han surgido sistemas que pretenden facilitar el trabajo al cirujano utilizando guías para la osteotomía y placas de compresión específicas, e intentar mejorar la evolución de los pacientes. El propósito de este estudio es determinar si con el uso de los sistemas guiados se consiguen mejorar los resultados de la técnica previa.

Material y método: Entre 2004 y 2008 el acortamiento cubital se realizó en nuestro Centro sin utilizar una técnica guiada, a partir del 2008 se utilizó un sistema guiado. Se ha realizado un estudio descriptivo en 37 casos, 19 no guiados, 18 guiados, revisando el tiempo de duración de la cirugía, el rango de movimiento, el tiempo de consolidación y la retirada del material de osteosíntesis.

Resultados: Tras realizar un análisis estadístico de los datos, se ha visto que hay una diferencia estadísticamente significativa en relación con la variable duración de la cirugía, siendo la cirugía guiada veinte minutos más corta que la no guiada. No se han visto diferencias estadísticamente significativas en los otros parámetros.

Conclusión: En el acortamiento cubital el uso de los sistemas guiados para corte y osteosíntesis, consigue reducir el tiempo de la cirugía, sin ocasionar detrimento en los resultados en comparación con la técnica sin guía.

Graphene etching on SiC grains as a path to interstellar polycyclic aromatic hydrocarbons formation

Polycyclic aromatic hydrocarbons as well as other organic molecules appear among the most abundant observed species in interstellar space and are key molecules to understanding the prebiotic roots of life. However, their existence and abundance in space remain a puzzle. Here we present a new top-down route to form polycyclic aromatic hydrocarbons in large quantities in space. We show that aromatic species can be efficiently formed on the graphitized surface of the abundant silicon carbide stardust on exposure to atomic hydrogen under pressure and temperature conditions analogous to those of the interstellar medium. To this aim, we mimic the circumstellar environment using ultra-high vacuum chambers and investigate the SiC surface by in situ advanced characterization techniques combined with first-principles molecular dynamics calculations. These results suggest that top-down routes are crucial to astrochemistry to explain the abundance of organic species and to uncover the origin of unidentified infrared emission features from advanced observations.

Epidemiology and outcome of candidaemia in patients with oncological and haematological malignancies: results from a population-based surveillance in Spain

A prospective, population-based surveillance on candidaemia was implemented in five metropolitan areas of Spain from May 2010 to April 2011. We aimed to describe the distribution and susceptibility pattern of Candida species, and to evaluate risk factors for mortality in patients with oncological (solid tumours) and haematological malignancies. Adults (≥ 16 years) with cancer were included in the present report. Impact of therapeutic strategies on 7- and 30-day mortality were analysed by logistic regression, adjusting for propensity score by inverse weighting probability of receiving early antifungal treatment and catheter removal. We included 238 (32.6%) patients (195 oncological, 43 haematological). Compared with oncological patients, haematological patients were more likely to have received chemotherapy (53.5% versus 17.4%, p < 0.001) or corticosteroids (41.9% versus 21%, p < 0.001), and have neutropenia (44.2% versus 1.5%, p < 0.001). Overall, 14.8% of patients developed breakthrough candidaemia. Non-albicans Candida species (71.1% versus 55.6%, p 0.056) and Candida tropicalis (22.2% versus 7.6%, p 0.011) were more frequent in haematological patients. Based on EUCAST breakpoints, 27.6% of Candida isolates were non-susceptible to fluconazole. Resistance to echinocandins was negligible. Mortality at 7 and 30 days was 12.2% and 31.5%, respectively, and did not differ significantly between the patient groups. Prompt antifungal therapy together with catheter removal (≤ 48 hours) was associated with lower mortality at 7 days (adjusted OR 0.05; 95% CI 0.01-0.42) and 30 days (adjusted OR 0.27; 95% CI 0.16-0.46). In conclusion, non-albicans species are emerging as the predominant isolates, particularly in haematological patients. Prompt, adequate antifungal treatment plus catheter removal may lead to a reduction in mortality.

Ortho and para hydrogen dimers on G/SiC(0001): combined STM and DFT study

The hydrogen (H) dimer structures formed upon room-temperature H adsorption on single layer graphene (SLG) grown on SiC(0001) are addressed using a combined theoretical-experimental approach. Our study includes density functional theory (DFT) calculations for the full (6√3 × 6√3)R30° unit cell of the SLG/SiC(0001) substrate and atomically resolved scanning tunneling microscopy images determining simultaneously the graphene lattice and the internal structure of the H adsorbates. We show that H atoms normally group in chemisorbed coupled structures of different sizes and orientations. We make an atomic scale determination of the most stable experimental geometries, the small dimers and ellipsoid-shaped features, and we assign them to hydrogen adsorbed in para dimers and ortho dimers configuration, respectively, through comparison with the theory.

[Spasm of the near reflex. Treatment with botulinum toxin]

CLINICAL CASE

A 38-year old female with diplopia and esotropia, with limitation of ocular abduction in both eyes, with full abduction after doll's head rotation also being observed. She was diagnosed with spasm of the near reflex. Treatment with injections of botulinum toxin in both medial rectus has temporally resolved the convergence spasm.

DISCUSSION

Near reflex spasm is characterized as miosis, pseudomyopia, and convergent strabismus that lead to diplopia, blurred vision, headache, and variable, progressive, and intermittent esotropia. As the spasm worsens there will be limited ocular versions and ductions simulating a sixth nerve palsy. Botulinum toxin may be effective in some cases.

Immunoglobulins IgG1, IgM and IgA: a synergistic team influencing survival in sepsis

OBJECTIVE

The impact of endogenous immunoglobulin isotypes on the prognosis of patients with severe sepsis has not been sufficiently explored. The aim of this study was to evaluate the association between immunoglobulin levels in plasma and survival in patients with this condition.

DESIGN AND PATIENTS

A prospective multicentre cohort study was conducted. A total of 172 adult patients admitted to the intensive care unit (ICU) with severe sepsis or septic shock were recruited. Patients were classified based on deciles of immunoglobulin concentrations at diagnosis of sepsis. Categorical variables were created and tested for their association with survival during hospitalization in the ICU.

RESULTS

Overall, 42 patients died in the ICU during the study. Kaplan-Meier analysis showed that immunoglobulin concentrations below 300 mg dL(-1) for IgG1, 35 mg dL(-1) for IgM and 150 mg dL(-1) for IgA were associated with shorter survival times. Multivariate regression analysis showed that IgG1 < 300 mg dL(-1) was a risk factor for mortality [odds ratio (OR) 2.50, 95% confidence interval (CI) 1.04-6.03; P = 0.042]. The combined presence of IgG1, IgM and IgA levels below the described thresholds had a synergistic impact on mortality risk (OR 5.27, 95% CI 1.41-19.69; P = 0.013). A similar effect was observed for combined low levels of IgG1 and IgA (OR 4.10, 95% CI 1.28-13.12; P = 0.018) and also of IgG1 and IgM (OR 3.10. 95% CI 1.13-8.49; P = 0.028).

CONCLUSIONS

The combined presence of low levels of the endogenous immunoglobulins IgG1, IgM and IgA in plasma is associated with reduced survival in patients with severe sepsis or septic shock. Assessment of the concentrations of these immunoglobulins could improve the results of treatment with exogenous immunoglobulins in patients with sepsis.

Patient safety certification in a Department of Intensive Care Medicine: our experience with standard UNE 179003:2013

Systematic and structured methods must be used to ensure that healthcare risks are effectively managed. Spanish standard UNE 179003:2013 provides healthcare organizations with a framework and a systematic protocol for managing patient safety from a clinical and organizational perspective. Furthermore, it is useful in securing an efficient balance among health risk, health outcomes and costs. The UNE 179003:2013 certifies that a clinical service complies with rules and operating procedures aimed at reducing the incidence of adverse events. It also requires mandatory continuous improvement, given that the standard entails frequent monitoring of the risk management system through periodic audits. The aims of this paper are to describe the UNE 179003:2013 certification process in an Intensive Care Unit, propose a risk management program for critical patients, and offer some recommendations regarding its implementation.

[Duane vertical surgical treatment]

CASE REPORT

We report 3 cases with a vertical incomitance in upgaze, narrowing of palpebral fissure, and pseudo-overaction of both inferior oblique muscles. Surgery consisted of an elevation of both lateral rectus muscles with an asymmetrical weakening. A satisfactory result was achieved in 2 cases, whereas a Lambda syndrome appeared in the other case.

DISCUSSION

The surgical technique of upper-insertion with a recession of both lateral rectus muscles improved vertical incomitance in 2 of the 3 patients; however, a residual deviation remains in the majority of cases.

[Medication errors in Spanish intensive care units]

OBJECTIVE

To estimate the incidence of medication errors in Spanish intensive care units.

DESIGN

Post hoc study of the SYREC trial. A longitudinal observational study carried out during 24 hours in patients admitted to the ICU.

SETTING

Spanish intensive care units.

PATIENTS

Patients admitted to the intensive care unit participating in the SYREC during the period of study.

MAIN VARIABLES OF INTEREST

Risk, individual risk, and rate of medication errors.

RESULTS

The final study sample consisted of 1017 patients from 79 intensive care units; 591 (58%) were affected by one or more incidents. Of these, 253 (43%) had at least one medication-related incident. The total number of incidents reported was 1424, of which 350 (25%) were medication errors. The risk of suffering at least one incident was 22% (IQR: 8-50%) while the individual risk was 21% (IQR: 8-42%). The medication error rate was 1.13 medication errors per 100 patient-days of stay. Most incidents occurred in the prescription (34%) and administration (28%) phases, 16% resulted in patient harm, and 82% were considered "totally avoidable".

CONCLUSIONS

Medication errors are among the most frequent types of incidents in critically ill patients, and are more common in the prescription and administration stages. Although most such incidents have no clinical consequences, a significant percentage prove harmful for the patient, and a large proportion are avoidable.

[Horizontal sensory strabismus: characteristics and treatment results]

PURPOSE

To study the types of horizontal sensory strabismus, their causes, and treatment outcomes.

METHODS

A retrospective analysis of 44 patients with horizontal sensory strabismus who were treated from 2002 to 2007. Patients whose worse eye vision was inferior or equal to 0.2 were included. The deviation angle in primary position, causes, type of treatment, and pre-operative or post-operative diplopia were studied. A good result was considered if the final deviation was less than 10 prism diopters (pd).

RESULTS

Of the patients studied, 63.6% had exotropia and the 36.4% had esotropia. The visual acuity was between 0.1 and no light perception in 75% of patients. The causes responsible for low vision were congenital in 28, and acquired in 16 cases. The mean deviation was 46.7 pd. Diplopia was present in 5 cases, which were resolved with surgical treatment in 3 of them. The eye with reduced vision was operated on in 37 patients, both eyes in 6 cases, and botulinum toxin was injected in 1 case. The final outcome was successful in 90.6% of the cases which were surgically treated. The mean follow up was 31.84 months.

CONCLUSIONS

There were twice as many exotropias as esotropias. Strabismus surgery of the amblyopic eye shows excellent results without the need of new operations. There were no new diplopia cases.

Klebsiella pneumoniae: development of a mixed population of carbapenem and tigecycline resistance during antimicrobial therapy in a kidney transplant patient

Nine isolates of Klebsiella pneumoniae were isolated from a renal transplant patient suffering from recurrent urosepsis over a period of 4 months. Imipenem resistance was detected after imipenem-ertapenem therapy. When treatment was switched to tigecycline the K. pneumoniae developed resistance to tigecycline (MIC = 8 mg/L). The nine isolates were tested by determination of agar dilution MICs, phenotypic carbapenemase, extended-spectrum beta-lactamases and metallo-beta-lactamase (MBL) testing and pulsed-field gel electrophoresis. Polymerase chain reaction and sequencing analysis were employed for identification of bla genes and mapping of the integron carrying the MBL gene. The nine isolates were clonally related and all produced the SHV-12 enzyme. Five MBL-producing isolates showed imipenem MICs ranging from 2 to 64 mg/L and all were detected by testing with imipenem and EDTA. The five isolates harboured the bla(VIM-1) gene. Three isolates showed increased tigecycline MICs (4-8 mg/L). Serial blood cultures obtained on the same day resulted in a VIM-positive/tigecycline-susceptible and a VIM-negative/tigecycline-resistant K. pneumoniae isolate. No isolate developed concurrent imipenem and tigecycline resistance. The patient had a persistent urinary tract infection and recurrent bacteraemia caused by a mixed population of Klebesiella pneumoniae isolates adapting to the selective pressure of antimicrobial therapy at the time. The present study is a worrisome example of what could happen when an immunocompromised host is subjected to the pressures of antimicrobial therapy. In addition, we report the first treatment-emergent MIC increase of tigecycline from 0.5 to 8 mg/L in K. pneumoniae.

[Superior oblique sharpening surgery in the treatment of Brown syndrome plus]

PURPOSE

To describe superior oblique sharpening in congenital Brown syndrome plus.

MATERIAL AND METHODS

A retrospective study of 17 Brown syndrome cases that were treated with oblique superior sharpening from 1997 to 2007. Vertical deviation in primary position was classified as + to +++, head tilt as: mild (< 10°), moderate (10-20°) and severe (≥ 20°); elevation in adduction from -1 to -4. A good postoperative result was considered if last elevation limitation in adduction was zero or -1, without head tilt and vertical deviation in primary position.

RESULTS

Mean age was 4.9 years. Limitation elevation in adduction which was -3 in 8 cases (47.1%) and -4 in 9 (52.9%), which improved completely after surgery in 6, -1 in 9 and -3 in 2 patients. Preoperative hypotropia in 15 cases (13 mild, 1 moderate and one severe) was resolved in 13 after surgery. Of 14 patients with torticollis (3 mild, 10 moderate and one severe) it was surgically corrected in 11. Success was achieved in 14 (82.4%), 2 were under corrected (11.8%) and one was overcorrected (5.88%). Mean follow-up was 60.71 months.

CONCLUSIONS

Oblique superior sharpening as treatment for Brown syndrome plus is an effective procedure. The incidence of secondary oblique palsies has been very low.

Ordered vacancy network induced by the growth of epitaxial graphene on Pt(111)

We have studied large areas of (√3×√3)R30° graphene commensurate with a Pt(111) substrate. A combination of experimental techniques with ab initio density functional theory indicates that this structure is related to a reconstruction at the Pt surface, consisting of an ordered vacancy network formed in the outermost Pt layer and a graphene layer covalently bound to the Pt substrate. The formation of this reconstruction is enhanced if low temperatures and polycyclic aromatic hydrocarbons are used as molecular precursors for epitaxial growth of the graphene layers.

Utility of real-time PCR for the detection of Paracoccidioides brasiliensis DNA in the diagnosis of imported paracoccidioidomycosis

An increase in immigration from endemic regions has resulted in a number of cases of paracoccidioidomycosis (PCM) being imported into Spain. A molecular diagnostic technique based on real-time PCR was developed for the detection of Paracoccidioides brasiliensis DNA in both culture and patients' clinical samples. A Molecular Beacon probe was used, labelled with FAM and directed at the ITS1 region of ribosomic DNA. The detection limit of the technique developed was 1 fg of fungal DNA per microl of sample. This procedure proved to be very reproducible and specific. The technique was tested with cultures of 12 clinical strains and on samples from two patients with proven PCM. Real-time PCR was positive for all the culture strains, as well as those from both patients. By samples, the technique was positive in sputum and tissue biopsies but less useful on blood samples. Samples were analyzed several months after patient treatment, detecting a small amount of fungal DNA in one respiratory sample. This technique of real-time PCR is a sensitive method for rapid diagnosis of paracoccidioidomycosis and could serve to monitor patients after treatment has begun.