Etomidate in the treatment of Cushing syndrome.

Cushing syndrome is a metabolic disease caused by chronic exposure to high levels of glucocorticoids. It can present as an endocrine emergency due to a rapid increase in circulating cortisol leading to increased risk of cardiovascular disease and infection. Etomidate rapidly reduces plasma cortisol levels by inhibiting the action of 11ß-hidroxilase. We report the case of a patient with severe hypercortisolaemia accompanied by metabolic and psychiatric disorders in whom administration of etomidate reduced preoperative levels of cortisol.

EEG Interchannel Causality to Identify Source/Sink Phase Connectivity Patterns in Developmental Dyslexia.

While the brain connectivity network can inform the understanding and diagnosis of developmental dyslexia, its cause-effect relationships have not yet enough been examined. Employing electroencephalography signals and band-limited white noise stimulus at 4.8 Hz (prosodic-syllabic frequency), we measure the phase Granger causalities among channels to identify differences between dyslexic learners and controls, thereby proposing a method to calculate directional connectivity. As causal relationships run in both directions, we explore three scenarios, namely channels' activity as sources, as sinks, and in total. Our proposed method can be used for both classification and exploratory analysis. In all scenarios, we find confirmation of the established right-lateralized Theta sampling network anomaly, in line with the assumption of the temporal sampling framework of oscillatory differences in the Theta and Gamma bands. Further, we show that this anomaly primarily occurs in the causal relationships of channels acting as sinks, where it is significantly more pronounced than when only total activity is observed. In the sink scenario, our classifier obtains 0.84 and 0.88 accuracy and 0.87 and 0.93 AUC for the Theta and Gamma bands, respectively.

Risk factors for lymphedema after breast surgery: A prospective cohort study in the era of sentinel lymph node biopsy.

INTRODUCTION: The Objective was to investigate the incidence of lymphedema after breast cancer treatment and to analyze the risk factors involved in a tertiary level hospital. METHODS: Prospective longitudinal observational study over 3 years post-breast surgery. 232 patients undergoing surgery for breast cancer at our institution between September 2013 and February 2018. Sentinel lymph node biopsy (SLNB) or axillary lymphadenectomy (ALND) were mandatory in this cohort. In total, 201 patients met the inclusion criteria and had a median follow-up of 31 months (range, 1-54 months). Lymphedema was diagnosed by circumferential measurements and truncated cone calculations. Patients and tumor characteristics, shoulder range of motion limitation and local and systemic therapies were analyzed as possible risk factors for lymphedema. RESULTS: Most cases of lymphedema appeared in the first 2 years. 13.9% of patients developed lymphedema: 31% after ALND and 4.6% after SLNB (p < 0.01), and 46.7% after mastectomy and 11.3% after breast-conserving surgery (p < 0.01). The lymphedema rate increased when axillary radiotherapy (RT) was added to radical surgery: 4.3% for SLNB alone, 6.7% for SLNB + RT, 17.6% for ALND alone, and 35.2% for ALND + RT (p < 0.01). In the multivariate analysis, the only risk factors associated with the development of lymphedema were ALND and mastectomy, which had hazard ratios (95% confidence intervals) of 7.28 (2.92-18.16) and 3.9 (1.60-9.49) respectively. CONCLUSIONS: The main risk factors for lymphedema were the more radical surgeries (ALND and mastectomy). The risk associated with these procedures appeared to be worsened by the addition of axillary radiotherapy. A follow-up protocol in patients with ALND lasting at least two years, in which special attention is paid to these risk factors, is necessary to guarantee a comprehensive control of lymphedema that provides early detection and treatment.

Birth of a healthy infant after bone marrow-derived cell therapy.

Bone marrow-derived cell (BMDC) therapy has numerous applications as potential biological cells for use in regenerative medicine. Here, we present an original case of endometrial atrophy associated with genital tuberculosis in a woman who achieved a live birth with BMDC. This 27-year-old woman came to our center with endometrial atrophy and primary infertility. She had a past history of genital tuberculosis and amenorrhea. Her husband's semen quality was normal. The patient was counseled for hysteroscopy due to thin endometrium and advised in vitro fertilization (IVF) with donor eggs in lieu of poor ovarian reserve. Several attempts of IVF with hormone replacement therapy (HRT) were made, but the desired thickness of the endometrium was not achieved. Uterine artery injection of BMDC through interventional radiology was given, followed by HRT for three months, which resulted in improved endometrium. This was subsequently followed by IVF with donor egg. The treatment resulted in the conception and delivery of a 3.1-kg baby boy through lower segment caesarean section with no antenatal, intranatal or postnatal complications. Recently, there has been massive interest in stem cells as a novel treatment method for regenerative medicine, and more specifically for the regeneration of human endometrium disorders like Asherman syndrome and thin endometrium, which was the reason behind using this strategy for treatment.

Difteria: Experiencia en el servicio de enfermedades infecciosas del Hospital Universitario de Caracas

Difteria es una enfermedad infecciosa bacteriana producida por Corynebacterium diphtheriae, es altamente contagiosa, prevenible por vacunas, con importantes complicaciones agudas y alta mortalidad. Objetivo: Describir las características clínicoepidemiológicas y el manejo médico de los pacientes con diagnóstico de Difteria ingresados en el Servicio de Enfermedades Infecciosas del Adulto del Hospital Universitario de Caracas (HUC) en los años 2017 y 2018. Metodología: Estudio de casos, analítico, retrospectivo, de revisión de historias clínicas. Resultados: Ingresaron 27 pacientes de los cuales se encontraron 22 historias clínicas y se excluyeron 2. De los 20 pacientes 13 (65 %) ingresaron en el año 2017 y 7 (35 %) hasta mayo del 2018. Predominó el género masculino 11 (55 %). La mayoría eran procedentes del Distrito Capital 9 (45 %), seguido del estado Miranda 8 (40 %). El promedio de edad fue de 26 años. La mayoría 8 (40 %) no tenían reportes de datos epidemiológicos en la historia clínica, 7 (35 %) negaron viajes recientes, 3 (15 %) estaban vacunados. La mayoría de los pacientes consultaron por fiebre, odinia y odinofagia 13 (65 %), seguido de fiebre y odinia 6 (30 %), el 100 % tuvo membrana blanco grisácea como clínica primaria, seguido de edema de cuello 10 (50 %). La ubicación de las membranas fue más frecuente en amígdalas palatinas 15 (75 %), con 9 casos (45 %) de formas extensivas a úvula, paladar blando y paredes de orofaringe. Las complicaciones al ingreso fueron respiratorias 9 (45 %) y neurológicas 1 (5 %). El tratamiento fue penicilina cristalina en 12 casos (60 %) y antitoxina diftérica (ATD) en el 100 %, la mayoría administrada en las primeras 24 hrs 9 (45 %). Un paciente presentó polineuropatía y 1 falleció por insuficiencia respiratoria. Conclusiones: El HUC es un centro de referencia y es pertinente determinar las características clínico-epidemiológicas y el manejo médico de los pacientes hospitalizados con diagnóstico de difteria, en el contexto de la actual epidemia.

Diphtheria is a bacterial infectious disease caused by Corynebacterium diphtheriae, it is highly contagious, preventable by vaccines, with important acute complications and high mortality. Objective: To describe the clinical-epidemiological characteristics and medical management of patients diagnosed with Diphtheria admitted to the Adult Infectious Diseases Service of the Hospital Universitario de Caracas (HUC) in the years 2017 and 2018. Methodology: Case study, analytical , retrospective, review of medical records. Results: 27 patients were admitted, of which 22 clinical records were found and 2 were excluded. Of the 20 patients, 13 (65%) entered in 2017 and 7 (35%) up to May 2018. The male gender predominated 11 (55 %). Most were from Distrito Capital 9 (45%), followed by Miranda 8 (40%). The average age was 26 years. The majority 8 (40%) had no reports of epidemiological data in the clinical history, 7 (35%) denied recent trips, 3 (15%) were vaccinated. The majority of patients consulted for fever, odinia and odynophagia 13 (65%), followed by fever and odinia 6 (30%), 100% had grayish white membrane as primary clinic, followed by neck edema 10 (50%) . The location of the membranes was more frequent in palatine tonsils 15 (75%), with 9 cases (45%) of extensive forms to the uvula, soft palate and walls of the oropharynx. Complications at admission were respiratory 9 (45%) and neurological 1 (5%). The treatment was crystalline penicillin in 12 cases (60%) and diphtheria antitoxin (DAT) in 100%, the majority administered in the first 24 h 9 (45%). One patient presented polyneuropathy and 1 died due to respiratory failure. Conclusions: The HUC is a reference center and it is pertinent to determine the clinical-epidemiological characteristics and medical management of hospitalized patients diagnosed with diphtheria, in the context of the current epidemic.

Microdeletion 22q11.2 syndrome: Does thymus incidental surgical resection affect its immunological profile?

BACKGROUND: The del22q11 syndrome patients present immunological abnormalities associated to thymus alterations. Up to 75% of them present cardiopathies and thymus is frequently removed during surgery. The thymectomy per se has a deleterious effect concerning lymphocyte subpopulations, and T cell function. When compared to healthy controls, these patients have higher infections propensity of variable severity. The factors behind these variations are unknown. We compared immunological profiles of del22q11.2 Syndrome patients with and without thymectomy to establish its effect in the immune profile. METHODS: Forty-six del22q11.2 syndrome patients from 1 to 16 years old, 19 of them with partial or total thymectomy were included. Heart disease type, heart surgery, infections events and thymus resection were identified. Immunoglobulin levels, flow cytometry for lymphocytes subpopulations and TREC levels were determined, and statistical analyses were performed. RESULTS: The thymectomy group had a lower lymphocyte index, both regarding total cell count and when comparing age-adjusted Z scores. Also, CD3+, CD4+ and CD8+ lower levels were observed in this group, the lowest count in those patients who had undergone thymus resection during the first year of life. Their TREC level median was 23.6/µL vs 16.1µL in the non-thymus group (p=0.22). No differences were identified regarding immunoglobulin levels or infection events frequencies over the previous year. CONCLUSION: Patients with del22q11.2 syndrome subjected to thymus resection present lower lymphocyte and TREC indexes when compared to patients without thymectomy. This situation may be influenced by the age at the surgery and the time elapsed since the procedure.

Green tea polyphenols change the profile of inflammatory cytokine release from lymphocytes of obese and lean rats and protect against oxidative damage.

This study aimed to investigate whether green tea polyphenols (GT) modulate some functional parameters of lymphocytes from obese rats. Male Wistar rats were treated with GT by gavage (12 weeks/5 days/week; 500 mg/kg of body weight) and obesity was induced by cafeteria diet (8 weeks). Lymphocytes were obtained from mesenteric lymph nodes for analyses. In response to the cafeteria diet we observed an increase in activity of the metabolic enzyme hexokinase, ROS production, MnSOD, CuZnSOD and GR enzyme activities and proliferation capacity of the cells (baseline), whereas IL-10 production was decreased. Obese rats treated with GT decreased cell proliferation (under ConA stimulation). Hexokinase and G6PDH activity, ROS production and MnSOD, CuZnSOD, GPx and GR enzymes remained increased, accompanied by an increase in Nrf2 mRNA level. There was a decrease in pro-inflammatory IL-2, IL-6, IL-1ß, TNF-α cytokines that were accompanied by a decrease in the mRNA level of TRL4 while IL-10 production was increased in obese rats treated with GT. GT treatment of lean rats showed similar results to that of obese rats treated with GT, indicating that the effects of GT are independent of diet. Foxp3 and IRF4 mRNA levels were increased by GT. In conclusion, cafeteria diet modulated the function of lymphocytes from lymph nodes, increasing ROS production and decreasing anti-inflammatory IL-10, which could contribute to the inflammatory state in obesity. GT reduced ROS production, improving the redox status and reducing pro-inflammatory cytokine production by lymphocytes, suggesting that GT treatment may be driving lymphocytes to a more anti-inflammatory than pro-inflammatory microenvironment.

Use of a temporary inferior vena cava filter during pregnancy in patients with thromboembolic events.

There are circumstances in the management of thromboembolic events during pregnancy when anticoagulant therapy is either contraindicated or not advisable, such as when pulmonary embolism (PE) or deep venous thrombosis is diagnosed close to term, given the risk of bleeding during delivery. In these cases, the thromboembolic risk can be controlled using temporary inferior vena cava filters (T-IVCFs). We present the case of a pregnant woman with thrombophilia who remained at rest for eight weeks due to an amniotic prolapse and for whom the placement of a T-IVCF was decided at 32 weeks' gestation after anticoagulant therapy had failed. An emergency caesarean section was performed at 33 weeks' gestation due to placental abruption following the spontaneous onset of preterm labour. The risk of bleeding during delivery when high doses of heparin are used, and the risk of PE when the heparin dose is decreased, needs to be evaluated versus the risks related to T-IVCF placement procedure and, as such, a review of the published experience in this field is warranted. We have concluded that T-IVCFs can be a safe alternative treatment for pregnant women in whom anticoagulation therapy is either contraindicated or not advisable.

Fucoxanthin in association with vitamin C acts as modulators of human neutrophil function.

INTRODUCTION: Neutrophils provide the first line of defense of the innate immune system by phagocytosing, killing and digesting bacteria and fungi. During this process, neutrophils produce reactive oxygen species (ROS), which in excess, can damage the cells themselves and surrounding tissues. The carotenoid fucoxanthin (Fc) has been studied concerning its antioxidant and anti-inflammatory actions. Vitamin c (Vc) also demonstrates potent antioxidant action. This study aimed to evaluate the effect of Fc (2 µM) in association with Vc (100 µM) on functional parameters of human neutrophils in vitro. MATERIALS AND METHODS: We evaluated the migration and phagocytic capacity, intracellular calcium mobilization, ROS production (O2(·)⁻, H2O2, HOCl), myeloperoxidase activity, profile of antioxidant enzymes, phosphorylation of p38 MAPK and p65 NFκB subunit, GSH/GSSG ratio and release of pro-inflammatory cytokines (TNF-α and IL-6) in neutrophils under different stimuli. RESULTS: We verified an increase in phagocytic capacity for all treatments, together with an increase in intracellular calcium only in cells treated with Fc and Fc + Vc. ROS production was reduced by all treatments, although Vc was a better antioxidant than Fc. Phosphorylation of the p-65 subunit of NFκB was reduced in cells treated with Fc + Vc and release of TNF-α and IL-6 was reduced by all treatments. These findings indicate that the regulation of inflammatory cytokines by neutrophils is not exclusively under the control of the NFκB pathway. Fc reduced the activity of some antioxidant enzymes, whereas Vc increased GR activity and the GSH/GSSG ratio. CONCLUSION: In conclusion, the results presented in this study clearly show an immunomodulatory effect of the carotenoid fc alone or in combination with Vc on the function of human neutrophils.

Exploratory survey of image quality on CR digital mammography imaging systems in Mexico.

The purpose of this study was to assess the current status of image quality and dose in computed radiographic digital mammography (CRDM) systems. Studies included CRDM systems of various models and manufacturers which dose and image quality comparisons were performed. Due to the recent rise in the use of digital radiographic systems in Mexico, CRDM systems are rapidly replacing conventional film-screen systems without any regard to quality control or image quality standards. Study was conducted in 65 mammography facilities which use CRDM systems in the Mexico City and surrounding States. The systems were tested as used clinically. This means that the dose and beam qualities were selected using the automatic beam selection and photo-timed features. All systems surveyed generate laser film hardcopies for the radiologist to read on a scope or mammographic high luminance light box. It was found that 51 of CRDM systems presented a variety of image artefacts and non-uniformities arising from inadequate acquisition and processing, as well as from the laser printer itself. Undisciplined alteration of image processing settings by the technologist was found to be a serious prevalent problem in 42 facilities. Only four of them showed an image QC program which is periodically monitored by a medical physicist. The Average Glandular Dose (AGD) in the surveyed systems was estimated to have a mean value of 2.4 mGy. To improve image quality in mammography and make more efficient screening mammographic in early detection of breast cancer is required new legislation.

Radiation dose reduction in a neonatal intensive care unit in computed radiography.

The purpose of this study was to evaluate the dose received by chest x-rays in neonatal care with thermoluminescent dosimetry and to determine the level of exposure where the quantum noise level does not affect the diagnostic image quality in order to reduce the dose to neonates. In pediatric radiology, especially the prematurely born children are highly sensitive to the radiation because of the highly mitotic state of their cells; in general, the sensitivity of a tissue to radiation is directly proportional to its rate of proliferation. The sample consisted of 208 neonatal chest x-rays of 12 neonates admitted and treated in a Neonatal Intensive Care Unit (NICU). All the neonates were preterm in the range of 28-34 weeks, with a mean of 30.8 weeks. Entrance Surface Doses (ESD) values for chest x-rays are higher than the DRL of 50 µGy proposed by the National Radiological Protection Board (NRPB). In order to reduce the dose to neonates, the optimum image quality was achieved by determining the level of ESD where level noise does not affect the diagnostic image quality. The optimum ESD was estimated for additional 20 chest x-rays increasing kVp and reducing mAs until quantum noise affects image quality.

High prevalences of infection with Giardia intestinalis genotype B among children in urban and rural areas of Argentina.

The protozoan parasite most frequently associated with diarrhoea worldwide is Giardia intestinalis. In 2005, a study was initiated to identify the genotypes of this parasite infecting children in the Argentinian provinces of Buenos Aires, Mendoza and Chaco, and to explore the associations between the genotype detected in a child, the characteristics of the child's household and the child's clinical presentation. Overall, 998 children (504 boys and 494 girls) aged between 2-14 years, with or without symptoms, were enrolled. The G. intestinalis in 94 of the 117 stool samples found positive for the parasite by microscopy were successfully genotyped by PCR. Seventy-seven of the children were found to be infected with genotype B only and 14 with genotype AII only, three children being found to have mixed (AII and B) infections. Only genotype B was detected in children from rural areas (P<0·05) and most Giardia detected in children from households with a piped water supply were also of this genotype (P<0·05). The other household characteristics investigated (quality of building, history of flooding, type of sanitation, level of overcrowding, and presence/absence of pet dogs) had no significant effect on the genotype distribution. Children infected with genotype AII were significantly younger than those infected with genotype B (P<0·05) and there was a significant positive association between infection with genotype B and abdominal pain (P<0·05). Diarrhoea was not, however, found to be significantly associated with genotype-AII or genotype-B infection. This is the first published report on the Giardia genotypes circulating in the provinces of Mendoza and Chaco. The results indicate the importance of asymptomatic children in the transmission of Giardia among the young.

[Gelatinous nutritional supplements: a useful alternative in dysphagia]. / Suplementos nutricionales gelatinizados: una alternativa válida para la disfagia.

The oropharingeal dysphagia is a very prevalent syndrome among the elderly, and even more among institutionalized individuals. Dysphagia is frequently caused by neurodegenerative and cerebrovascular conditions, the dementia syndrome being the most common of them, where the latest stages of the process are often accompanied by frequent swallowing problems requiring to incorporate thick foodstuffs in the diet of the elderly, such as the pudding. Nutritional supplements with a puddinglike consistency are not financed by the National Health System. Therefore, when they are needed, patients must either pay their full price for them or thicken the liquid supplements financed by the National Health System. This is normally done in an individualized way, through the powder thickeners in the market. It is a very laborious and highly changeable process regarding the resulting consistency, with a poor homogeneous aspect; thus, it is complicated to implement this method in big community dwelling. We hereby present a different way to use these financed supplements, this is: mixing them up with commercial jelly resulting in a refined product with a homogeneous texture. These supplements will remain stable in their composition and safe to be used within 5 days.

[Comparison of Goldmann tonometry, pneumotonometry and the effect of the central corneal thickness]. / Comparación del tonómetro de Goldmann, neumotonómetro de contacto y el efecto del grosor corneal.

PURPOSE: To compare the intraocular pressure (IOP) measurements using the Goldmann applanation tonometer (GAT) and contact pneumotonometer (NTC), and to evaluate the effects of central corneal thickness (CCT) on the readings. METHODS: This was a prospective, observational clinical study, which included 96 eyes of 49 patients, 40 glaucomatous, 29 ocular hypertensive and 27 normal subjects. The IOP measurements were performed with each tonometer. The CCT was also measured. RESULTS: A strong correlation coefficient between GAT and the NTC was found (Pearson=0.922, p<0.001). The mean of paired differences between GAT and NTC was 0.72 ± 2.82 mmHg. The mean difference between GAT and NTC was low at lower levels of PIO and higher at higher levels of IOP. Readings with the GAT showed a mean increase in IOP of 0.47 mmHg for every 10 µm of CCT, and the NTC 0.34 mmHg for every 10 µm, the diference was not statistically significant. CONCLUSIONS: The contact pneumotonometer is a reliable method in diagnosis and follow up of our population. The effect of the central corneal thickness was more important for the Goldmann applanation tonometer.

[Purification and breaking techniques for cysts of Giardia spp]. / Técnicas de purificación y ruptura de quistes de Giardia spp.

The purpose of this study was to optimize and evaluate the purification techniques, isolation and breaking of cysts of Giardia spp from fecal samples to isolate DNA. Filtrated fecal samples were tested in 3 purification techniques: Telleman solution, sucrose and Telleman plus sucrose. The sucrose solution let us to isolate the cysts with less detritus. The cleaned cysts were splited in 3 techniques to test the breaking: osmotic shock and heat, chemistry degradation and thermic shock, enzymatic action and mechanic effect. Only the last method was successful and showed bands in agarose gel. The result of this study shows a routine and common method which could be used in the previous steps to the PCR technique for the genotypification of these parasites.

Técnicas de purificación y ruptura de quistes de Giardia spp / Purification and breaking techniques of cysts of Giardia spp

El objetivo de este trabajo fue optimizar y evaluar las técnicas de purificación, aislamiento y ruptura de quistes de Giardia spp a partir de heces formoladas para la obtención de ADN. La materia fecal filtrada fue sometida a 3 técnicas de purificación, utilizando soluciones de formol-éter, sacarosa y formol-éter más sacarosa. La solución de sacarosa permitió aislar los quistes con menos detritos. Los quistes purificados fueron tratados con 3 técnicas para la ruptura de los mismos: shock osmótico y calor, degradación química y shock térmico, acción enzimática y efecto mecánico. Solamente con la técnica de shock térmico, acción enzimática y efecto mecánico se observaron bandas fluorescentes en geles de agarosa. Los resultados de este trabajo permiten contar con una metodología de rutina, simple, que podría ser usada en los pasos previos a la técnica de PCR para la genotipificación de este parásito.

The purpose of this study was to optimize and evaluate the purification techniques, isolation and breaking of cysts of Giardia spp from fecal samples to isolate DNA. Filtrated fecal samples were tested in 3 purification techniques: Telleman solution, sucrose and Telleman plus sucrose. The sucrose solution let us to isolate the cysts with less detritus. The cleaned cysts were splited in 3 techniques to test the breaking: osmotic shock and heat, chemistry degradation and thermic shock, enzymatic action and mechanic effect. Only the last method was successful and showed bands in agarose gel. The result of this study shows a routine and common method which could be used in the previous steps to the PCR technique for the genotypification of these parasites.

[Prevalence and asthma risk factors in municipalities of the State of Guerrero, Mexico]. / Prevalencia y factores de riesgo de asma en municipios del estado de Guerrero, México.

OBJECTIVE: To determine the incidence and the principal risk factors cause of asthma in scholar children between 4 to 6 years old and in adolescents students between 13 to 14 years old in six municipalities in Guerrero State, Mexico. MATERIAL AND METHOD: A cross-sectional study was carried out with 6,136 students (both groups) in the Acapulco municipality on the second semester of 1999 and with 1,128 students in municipalities near to Acapulco in the first semester of year 2000. The procedure was to use the questionnaire ISAAC to interview the mothers of the children between 4 to 6 years old, and apply directly interviews to the 12 to 14 years old group. The study was carried out in public school with the more social recognition. RESULTS: Asthma prevalence in the Acapulco municipality was 33.55%. Detected in girls 34.8% and 32.0% in boys. In the rural municipalities near Acapulco the asthma prevalence was of 31.8%. Detected in girls 34.0% and 29.2% in boys. One of the principal risk factory cause of incidence in the urban area of Acapulco was the presence of the cement factory. In the rural area near Acapulco the principal risk factor was the common presence of cotton toys. A very high asthma incidence was identified in the studied municipalities. The principal group affected was the students between 13 to 14 years old without a remarkable difference between gender in the urban areas.