RESUMO
BACKGROUND: There are no data on Mexican population referring to frequency and prognosis of transient ischemic attacks (TIA). The purpose of the present study was to: (1) estimate the prevalence, vascular risk factors and short-term outcome in patients with TIA included in the first Mexican registry of cerebrovascular disease, and (2) analyze the acute care provided in these patients. PATIENTS AND METHODS: This national registry of cerebrovascular diseases is a multicenter, observational, and hospital-based registry that was conducted from November 2002 to October 2004. The registry was developed to improve our knowledge in Mexico regarding risk factors profile, outcome, current diagnostic and treatment strategies, and short-term follow-up in patients with acute cerebral ischemia. Standardized data assessment was used by all centers which included information on demographics, pre-hospital events (including stroke onset and arrival to hospital), emergency department triage and workup. Short-term outcome was evaluated at day 30. Of this registry, TIA cases were selected and associated risk factors, clinical characteristics, diagnosis and treatment were analyzed. RESULTS: During the study time period, 2,000 patients were enrolled; 97 (5%) with diagnosis of TIA; 51 women and 46 men, mean age 69.3 +/- 11.4 years. Among these 97 patients; 51 (52.6%) were admitted to the hospital for evaluation. The main risk factors were; age > or = 65 years in 74%, hypertension in 64%, diabetes in 45%, and dislipidemia in 36% and obesity in 31%. The affected arterial territory was carotid TIA in 74% and vertebrobasilar in 26%. TIA was attributed to atherosclerosis in 63% of the patients, cardioembolism in 17%, and small vessels disease in 5%. At 30 days follow-up; three patients died during the initial evaluation (two secondary to cardiac arrhythmia, and one secondary to pneumonia). Among 14 of the 94 survivors (14.9%) we documented an early stroke recurrence, including cerebral infarction in nine patients (9.6%) and new TIA in five cases (5.3%). Considering death and cerebral infarction, the frequency of unfavorable major events was 12.4%. There were only three cases treated with carotid endarterectomy. CONCLUSIONS: The short-term risk of ischemic stroke, death or recurrent in TIA patients is high. These findings emphasize that all patients with TIA should undergo rapid investigation and management to prevent a major stroke and other vascular events.
Assuntos
Ataque Isquêmico Transitório , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/terapia , Masculino , México , Pessoa de Meia-Idade , Prognóstico , Sistema de Registros , Fatores de TempoRESUMO
BACKGROUND: Atherothrombosis, a generalized and progressive process, is currently a major healthcare problem in Mexico. METHODS: The worldwide Reduction of Atherothrombosis for Continued Health (REACH) registry aimed to evaluate risk factors for atherosclerosis, long-term cardiovascular (CV) event rates, and current management of either patients with established symptomatic atherosclerotic disease or asymptomatic subjects with multiple risk factors for atherothrombotic disease. One-year follow-up of the global REACH database was available for 64 977 outpatients. This report includes the Mexican subregistry wherein 62 internists, cardiologists, and neurologists evaluated baseline patient characteristics, risk factors, medications, and CV event rates as primary outcomes at 1-year follow-up. RESULTS: Complete 1-year follow-up data were available for 837 Mexicans. We observed a high prevalence of diabetes (47.1%), hypertension (74.7%), and hypercholesterolemia (57.8%). Antiplatelet, antihypertensive and/or glucose-lowering agents, and lipid-lowering drugs were used in 87.6%, 84.1%, and 61% of patients, respectively. The all-cause mortality rate was 3.3%. The composite outcome CV death/myocardial infarction/stroke/hospitalization for atherothrombotic events was higher in the symptomatic group (14.6%) than in asymptomatic subjects with multiple risk factors (5.1%; P = 0.01), similar to Latin American results of the global REACH report. The highest CV event rate occurred among symptomatic atherothrombotic patients with 3 vascular disease locations (30.2%), followed by those with 2 (21.9%) and 1 location (13.4%; P = 0.0006). CONCLUSIONS: Prevalence of risk factors and CV event rates including hospitalization in Mexican atherothrombotic patients was high despite the current medication use, which suggests it is necessary to have more aggressive risk-factor management.
Assuntos
Aterosclerose/epidemiologia , Doenças Cardiovasculares/epidemiologia , Trombose/epidemiologia , Idoso , Aterosclerose/diagnóstico , Aterosclerose/mortalidade , Aterosclerose/terapia , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/prevenção & controle , Feminino , Humanos , Masculino , México/epidemiologia , Pessoa de Meia-Idade , Prevalência , Modelos de Riscos Proporcionais , Sistema de Registros , Medição de Risco , Fatores de Risco , Trombose/diagnóstico , Trombose/mortalidade , Trombose/terapia , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Information on acute care and outcome of Mexican patients with ischaemic stroke is lacking. The aim of this report is to provide results of a first step stroke surveillance system and outcome at one year of follow-up. PATIENTS AND METHODS: In the PREMIER study 1,376 patients from 59 Mexican hospitals were included from January 2005 to June 2006. Of these, 1,040 (52% women, mean age 67.5 years) with first-ever cerebral infarction are here analyzed. Five visits were completed during the one year follow-up. RESULTS: Main risk factors were hypertension (64%), obesity (51%) and diabetes (35%). Total anterior circulation stroke syndrome occurred in 19% of patients, partial anterior in 38%, lacunar in 26% and posterior stroke syndrome in 17% cases. In 8% the stroke mechanism was large-artery atherosclerosis, in 18% cardioembolism, in 20% lacunar, in 6% miscellaneous mechanisms and in 42% the mechanism was undetermined, mainly due to a low use of diagnostic resources. Although 17% of patients arrived in < 3 h from stroke onset, only 0.5% had IV thrombolysis. Only 1% received endarterectomy or stenting. The 30-day case fatality rate was 15%. At one-year of follow-up, 47% had a modified Rankin score 0-2 (independent), 23% had 2-5 (dependent) and 29% died. One-year acute ischaemic stroke recurrence rate was 8%. CONCLUSION: In Mexico a significant proportion of patients arrive on time for thrombolysis, but very few receive this therapy. There is a low use of diagnostic resources to assign aetiology. Thirty-day case fatality rate doubles at 1-year after acute ischaemic stroke.
Assuntos
Acidente Vascular Cerebral/terapia , Resultado do Tratamento , Idoso , Feminino , Fibrinolíticos/uso terapêutico , Seguimentos , Humanos , Masculino , México , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Terapia TrombolíticaRESUMO
INTRODUCTION: The 'obesity paradox' is the decreasing risk of death after cardiovascular disease, with a high body mass index (BMI), even when BMI is a risk factor for vasculopathy, in the first place. Our aim was to analyze the influence of obesity on the functional recovery after ischemic stroke. PATIENTS AND METHODS: We studied 510 patients who survived a first-ever acute ischemic stroke, without cerebrovascular disease history, and without recurrence or death after 12 months of follow-up. We also studied 501 healthy subjects who received tetrapolar bioimpedance analysis to compare the waist-to-height ratio (WHtR), abdominal circumference and BMI, as adiposity indices, in order to apply them in stroke patients. RESULTS: In healthy individuals, WHtR performed better than BMI or abdominal circumference in predicting body fat. In a Cox proportional hazards model adjusted for multiple covariables, age (hazard ratio, HR = 1.11; 95% confidence interval, 95% CI = 1.08-1.14), NIHSS score (HR = 1.03; 95% CI = 1.01-1.05) and WHtR > 70 (HR = 2.44; 95% CI = 1.33-4.48) were associated with a high risk of attaining a modified Rankin scale more or equal than 3 at 12 months after stroke; whereas BMI > 35 (HR = 0.33; 95% CI = 0.11-0.98) was protector. CONCLUSION: As reflected by WHtR, the excess of adiposity increases the chance of severe disability after ischemic stroke. Since BMI reflects also total lean mass, it is risky to conclude that there is a protective effect of obesity alone in the functional recovery after stroke; nevertheless, it is possible that a certain magnitude of body mass is necessary to prevent severe disability in stroke survivors.
Assuntos
Isquemia Encefálica/complicações , Isquemia Encefálica/reabilitação , Obesidade/complicações , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recuperação de Função Fisiológica , Adulto JovemRESUMO
Early- and late-onset Parkinson's disease (EOPD and LOPD) have been associated with mutations in the PARKIN gene. Several studies have reported association of Parkinson's disease (PD) with different polymorphisms in different ethnic populations. To study the role of PARKIN polymorphisms as risk factors for PD in a genetically homogeneous northeastern Mexican population, four previously described coding polymorphisms (Ser167Asn, Val380Leu, Arg366Trp, and Asp394Asn) were analyzed by using the PCR-RFLP technique. This case-control study comprised 117 unrelated patients (mean age 59+/-12 years, range 25-83 years) and 122 healthy unrelated control subjects (mean age 50+/-15 years, range 25-85 years). The homozygous Trp366 and Asn394 genotypes were not present in our study. The Ser167Asn and Val380Leu polymorphisms were not associated with this disease. For the control group, Ser167Asn and Val380Leu were in Hardy-Weinberg disequilibrium. Given that the main causes of Hardy-Weinberg disequilibrium in controls are selection bias or genotyping error, a competing risk of death associated with the mutant gene could be an explanation of this disequilibrium and lack of association.
Assuntos
Doença de Parkinson/genética , Ubiquitina-Proteína Ligases/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Frequência do Gene , Estudos de Associação Genética , Predisposição Genética para Doença , Humanos , Desequilíbrio de Ligação , Masculino , México , Pessoa de Meia-Idade , Polimorfismo GenéticoRESUMO
Introduction Acute porphyrias are rare genetic disorders of incomplete penetrance (10%). This means that only 10% of the individuals with the genotype known to cause the disease will show any signs or symptoms of such disease. They consist of a deficiency of any enzyme of the heme biosynthesis and are considered as exceptional inborn errors of metabolism with an autosomal dominant inheritance. The incidence is 1 in 100 000. The symptoms are variable and unspecific, consisting mainly of severe abdominal pain, tachycardia, and hypertension. Other frequent manifestations are psychiatric symptoms like depression, psychosis, and hallucinations. In addition to these unspecific symptoms, patients may also present peripheral neuropathy and loss of sensation, which can become permanent. In severe cases, liver damage and chronic renal disease can occur. The objective of this study is to highlight the importance of the difficult diagnosis of acute porphyria, the implications of a misdiagnosis, and the importance of adequate treatment. Case We present a 47 year-old male with a history of abdominal pain for seven years. The pain was diffuse, progressive, and incapacitating. He was diagnosed and treated for chronic gastritis and cholecystitis without improvement. An elective cholecystectomy was performed but he continued with intense abdominal pain. Three years later he developed hallucinations, paresthesias, muscular weakness, depression, and irritability. He was managed as a psychiatric patient with psychotic tendencies. After a complete and thorough history of all his symptoms throughout the years and a re-examination of the patient, acute porphyria was considered as a possible diagnosis. Specific laboratory studies were indicated revealing elevated levels of porphyrines, elevated levels of PBGD, PBG in urine within normal levels, elevated presence of coproporphyrines by chromatography, and a normal PBGD enzymatic activity. The diagnosis of acute porphyria was established. Appropriate treatment was initiated starting with adequate pain management. A high carbohydrate diet was also recommended with appropriate nutritional requirements and caloric intake. Another important aspect of the management was the elimination of risk factors, like alcohol, cigarette smoking, and certain specific medications. Follow-up showed significant improvement of his symptoms and less frequent acute attacks with identification and elimination of risk factors. He was able to return to a stable work schedule. The patient presents residual permanent renal damage. Adequate doctor-patient education was maintained. Discussion This case is an important example of a not-so-rare genetic disease that any physician should have in mind when confronted with a patient with unspecific paroxysmal clinical manifestations. The possibility of acute porphyria should always be excluded before establishing a diagnosis of a psychiatric illness. Prompt diagnosis and management are crucial to reduce the risk of recurrences and permanent damage. Patient education is a very important aspect of the management of the disease since there is no cure. There is a specific treatment for the management of acute attacks (Hemin) but, unfortunately, it is still unavailable in our country. This is a problem that turns the management and prevention of risk factors into the most important tools we have to improve our patients' quality of life.
Introducción Las porfirias agudas son un conjunto de enfermedades genéticas de penetrancia incompleta (10%). Es decir, sólo 10% de los individuos con el genotipo determinado que causa la enfermedad presentan algún signo o síntoma de ella. Las porfirias agudas son causadas por una deficiencia de alguna de las enzimas de la biosíntesis del heme. Son unos de los pocos errores innatos del metabolismo que presentan herencia autosómica dominante. La incidencia es de 1 en 100 000, y es más común en mujeres de entre 30-40 años. Los síntomas son variables e inespecíficos; los más comunes son: dolor abdominal difuso e incapacitante, taquicardia e hipertensión. También se acompaña de síntomas psiquiátricos como depresión, intento de suicidio, paranoia y alucinaciones. Otros síntomas relacionados son neuropatía periférica y pérdidas sensitivas, daño hepático e insuficiencia renal crónica. El objetivo de este estudio es establecer la importancia de realizar un diagnóstico oportuno de porfiria aguda, ya que un diagnóstico erróneo puede generar tratamientos y gastos innecesarios al paciente. El diagnóstico de porfiria permite llevar a cabo un manejo y tratamiento adecuados que favorecen un buen pronóstico. Caso Se trata de un paciente masculino de 47 años de edad, sin antecedentes familiares relacionados, que presenta dolor abdominal intenso, difuso e incapacitante con siete años de evolución. Fue tratado como gastritis aguda y colecistitis. Se realizó colecistectomía sin lograr mejoría de los síntomas. Tres años después, se agregaron a los síntomas originales los siguientes: alucinaciones auditivas, parestesias, debilidad muscular, depresión e irritabilidad, por lo que se catalogó como paciente con trastorno psiquiátrico con tendencia psicótica. Se realizó historia clínica de todos los síntomas y una exploración física completa, por lo que se sospechó porfiria aguda. Se realizaron estudios de laboratorio específicos con los que se confirmó el diagnóstico de porfiria aguda por la presencia de niveles elevados de porfirinas en orina, niveles elevados de PBGD, niveles normales de PBG en orina, niveles significativamente elevados de coproporfirinas por cromatografía y actividad enzimática de PBGD en rangos normales. Se inició un tratamiento para el manejo adecuado del dolor. También, una dieta alta en carbohidratos, con aporte calórico adecuado. Se recomendó la eliminación de factores de riesgo como alcohol, cigarro y medicamentos específicos. Dos meses después se observó una mejoría significativa de los síntomas, control de crisis e identificación y eliminación de factores precipitantes. Los síntomas psiquiátricos desaparecieron y el paciente pudo reestablecer sus actividades laborales y sociales. El paciente presenta hasta el momento datos de insuficiencia renal crónica. Se continúa el seguimiento del paciente. Discusión El caso presentado representa un ejemplo de una enfermedad genética que todo médico debe tener en mente cuando se presenta un paciente con síntomas inespecíficos. El diagnóstico de porfiria aguda es un diagnóstico de exclusión, pero sigue siendo importante en el análisis del diagnóstico diferencial. Es de gran importancia descartar o confirmar un caso de porfiria aguda antes de establecer el diagnóstico de un trastorno psiquiátrico. Establecer un diagnóstico temprano y un tratamiento específico mejora el pronóstico y limita el daño, particularmente neurológico y hepático. La educación del paciente es de extrema importancia, ya que no existe cura para la porfiria aguda. Una prevención que evite los factores precipitantes conocidos es uno de los tratamientos principales de esta enfermedad, ya que el medicamento específico para el control de la crisis aguda (Hematina) no se distribuye en nuestro país. Aunado a un subdiagnóstico de la enfermedad, lo anterior vuelve aún más difícil el manejo de los pacientes.
Assuntos
Cefaleia/etiologia , Isquemia Miocárdica/complicações , Idoso , Feminino , Humanos , Fatores de RiscoRESUMO
El diagnóstico de la estenosis del acueducto de Silvio en el adulto se ha facilitado con el advenimiento de la tomografía axial computada (TAC). Los datos tomográficos son la dilatación de los ventrículos laterales y del tercer ventrículo con un IV ventrículo normal. En el presente trabajo se reporta la experiencia obtenida en el Servicio de Neurología del Hospital Universitario en Monterrey, con diez casos inicialmente diagnosticados por clínica y TAC como estenosis del acueducto. El diagnóstico definitivo se estableció en seis (concordando con el diagnóstico de ingreso), y en cuatro se demostraron otras etiologías como causa de este síndrome. Es importante la realización de TAC asociada a ventriculografía (VG) mediante microtrepano frontal lo cual nos permite definir otras posibles causas de obstrucción del acueducto. Algunas etiologías son: Cisticero en la porción distal del tercer ventrículo (caso 7) neoplásica periacueductal (caso 8) y cisticercos múltiples intraventriculares (caso 10), todos éstos sólo pudieron ser establecidos mediante la V.G. Se revisan los patrones de presentación clínica, enfatizándose la utilidad que la VG asociada a TAC proporcionan para la realización del diagnóstico definitivo de este síndrome, lo cual es importante en el manejo y pronóstico de estos pacientes
Assuntos
Adolescente , Adulto , Pessoa de Meia-Idade , Humanos , Masculino , Feminino , Encefalopatias/diagnóstico , Aqueduto do Mesencéfalo/patologia , Aqueduto do Mesencéfalo , Ventriculografia Cerebral , Diagnóstico DiferencialRESUMO
Durante los últimos nueve años estudiamos cincuenta casos de intoxicación por talio. Veintiocho casos fueron mujeres y vientidos fueron hombres. Uno de los casos fue un recién nacido, cuya madre sufrió este tipo de intoxicación durante el tercer trimestre de su embarazo. Las edades variaron de un día hasta 84 años de edad y en todos los casos la fuente de talio fue una solución raticida administrada oralmente, excepto en el recién nacido en quien la vía de acceso fue a través de la placenta y en una paciente en que fue transdérmica. En veintitrés casos la intoxicación fue accidental, con fines suicidas en veintiuno y con fines homicidas en cinco. En un caso la fuente de intoxicación fue desconocida. En todos los casos los niveles de talio se midieron en la orina, en algunos en la sangre y en el líquido cefalorraquídeo. Las principales manifestaciones clínicas fueron las de una neuropatía periférica severa de tipo mixto, con dolor abdominal, náusea, vómito y alopecia y en algunos casos manifestaciones psiquíatricas. En varios casos se practicaron estudios electrofisológicos, biopsia de nervio con examen de microscopía electrónica en tres pacientes, resonancia nuclear magnética y tomografía axial computarizada de abdomen y de cráneo en dos pacientes. Sólo uno de los pacientes murió y el resto se recuperó prácticamente en forma completa. Se revisan la patofisiología y las bases farmacológicas del manejo de este tipo de neurointoxicación
Assuntos
Humanos , Recém-Nascido , Adolescente , Adulto , Pessoa de Meia-Idade , Masculino , Feminino , Penicilamina/administração & dosagem , Penicilamina/farmacocinética , Penicilamina/uso terapêutico , Intoxicação/diagnóstico , Intoxicação/fisiopatologia , Intoxicação/terapia , Reação do Azul da Prússia , Tálio/farmacocinética , Tálio/intoxicação , Tálio/toxicidadeRESUMO
Se informa la evolución clínica de nueve pacientes con encefalitis secundaria a enfermedades exantemáticas atendidos en el hospital universitario de la Universidad Autónoma de Nuevo León de marzo a junio de 1990. Dos casos fueron secundarios a sarampión, tres a rubeóla y cuatro a varicela. Cuatro fueron niños y cinco más de dos a 14 años de edad. Los datos clínicos predominantes fueron: hemiparesia, cráneo hipertensivo, meningismo, y anormalidades del estado de conciencia. En el líquido cefalorraquídeo se observó pleocitosis linfocítica (promedio 295 células) con hiperproteinorraquia (promedio 118 mg/dL) y glucosa normal. Lo anterior, en presencia de enfermedad exantemática, sugirió invasión encefálica del virus. La imagen por resonancia magnética mostró zonas de alta señal principalmente en lóbulos frontales y temporales. Un paciente con varicela falleció: la autopsia demostró meningoencefalitis primordialmente en lóbulos temporal, occipital y tallo cerebral. En este informe se compara la frecuencia relativa de enfermedades exantemáticas y encefalitis secundarias en nuestro medio durante los últimos cuatro años.
Assuntos
Humanos , Masculino , Feminino , Pré-Escolar , Adolescente , Varicela/complicações , Surtos de Doenças , Encefalite/epidemiologia , Líquido Cefalorraquidiano/citologia , Rubéola (Sarampo Alemão)/complicações , Sarampo/complicaçõesRESUMO
El síndrome de Reye está claramente definido como una entidad clínico-patológica cuya frecuencia ha ido aumentando progresivamente. Ocurre casi exclusivamente en niños pero existen reportes de presentanción en adolescentes y adultos. Clínicamente se caracteriza por el antecedente de una enfermedad viral seguida algunos días después de vómitos, delirio y convulsiones. Las características anatomo-patológicas son: Infiltración grasa del hígado y otras vísceras con distorsión y edema de las mitocondrias y con edema cerebral. Se presentan 5 casos de síndrome de Reye estudiados en nuestro Hospital, uno de ellos con sobrevida y se revisan sus características clínicas, su evolución, diagnóstico y tratamiento
Assuntos
Lactente , Pré-Escolar , Masculino , Feminino , Síndrome de Reye , Síndrome de Reye/patologia , Síndrome de Reye/terapiaRESUMO
El hipertiroidismo en la infancia ocurre con una frecuencia relativa del 5 por ciento. La presencia de epilepsia y tirotoxicosis es poco frecuente. De acuerdo a la revisión de la literatura no existen reportes de esta asociación en niños. Descubrimos un paciente de cuatro años de edad con enfermedad de Graves que desarrolló crisis convulsiva tónico-clónica generalizada seguida de estado epiléptico parcial motor en hemicuerpo izquierdo. El EEG mostró actividad epileptiforme y la TC e IRM de cráneo resultaron normales. El EEG se normalizó al controlar el hipertiroidismo. De acuerdo a la revisión de la literatura, este es el primer caso reportado de epilepsia y tirotoxicosis en nuestro país. Se comentan los posibles mecanismos fisiopatológicos de las convulsiones en nuestro paciente con tirotoxicosis