Poor Collateral Circulation Assessed by Multiphase Computed Tomographic Angiography Predicts Malignant Middle Cerebral Artery Evolution After Reperfusion Therapies.

BACKGROUND AND PURPOSE: Collateral circulation (CC) has been associated with recanalization, infarct volume, and clinical outcome in patients undergoing acute reperfusion therapies. However, its relationship with the development to malignant middle cerebral artery infarction (mMCAi) has not been evaluated. Our aim was to determine the impact of CC using multiphase computed tomographic angiography (during the acute stroke phase in the prediction of mMCAi. METHODS: Patients with consecutive acute stroke with <4.5 hours who were evaluated for reperfusion therapies and presented with an M1-MCA or terminal internal carotid artery occlusion by CTA were included. CC was evaluated on 6 grades by multiphase CTA according to the University of Calgary CC Scale; CC status was defined as poor (grades, 0-3) or good (grades, 4-5). The mMCAi was defined according to clinical and radiological criteria. Recanalization was assessed with transcranial Doppler at 24 hours and final Thrombolysis in Brain Ischemia score≥2b in patients undergoing endovascular reperfusion treatment. RESULTS: Eighty-two patients were included. Mean age was 65.1±13.83 years, median baseline National Institutes of Health Stroke Scale score was 18 (interquartile range, 13-20), and 67.9% M1 and 32.1% terminal internal carotid artery occlusions. Fifty-three patients received endovascular reperfusion treatment. Fifteen patients developed mMCAi. In the univariate analysis, patients with mMCAi had lower CC scores (2.29 versus 3.71; P=0.001). Endovascular reperfusion treatment was associated with lower rate of mMCAi development than only intravenous reperfusion treatment (9.4% versus 29.6%; P=0.028). Patients with poor CC had higher risk of developing mMCAi (13% versus 2%; P=0.001). On the multivariate analysis adjusted by age, vessel occlusion, baseline National Institutes of Health Stroke Scale, and recanalization, the presence of poor CC by multiphase CTA was the only independent predictor of mMCAi (P=0.048; odds ratio, 9.72; 95% confidence interval, 1.387-92.53). CONCLUSIONS: CC assessment by multiphase CTA independently predicts malignant MCA infarction progression. In patients with persistent occlusion after reperfusion therapies, the presence of poor CC may improve the early mMCAi detection and management.

Maximal Admission Core Lesion Compatible With Favorable Outcome in Acute Stroke Patients Undergoing Endovascular Procedures.

BACKGROUND AND PURPOSE: Multiparametric imaging is meant to identify nonreversible lesions and predict on admission the minimum final infarct volume, a strong predictor of outcome. We aimed to confirm this hypothesis and define the maximal admission lesion volume compatible with favorable outcome (MALCOM). METHODS: We studied patients with internal carotid artery/middle cerebral artery occlusion selected with multiparametric computed tomography/magnetic resonance imaging, who underwent endovascular procedures. Admission infarct core was measured on initial cerebral blood volume-computed tomography perfusion or diffusion weighted imaging-magnetic resonance imaging. We defined percentage of lesion growth (final lesion admission core/admission core) and MALCOM: cutoff admission core volume above which probability of modified Rankin Scale 0 to 2 is <10%. RESULTS: Fifty-seven patients were studied (29 magnetic resonance imaging and 28 computed tomography perfusion). Mean core volume was 28±22 mL, and recanalization thrombolysis in cerebral ischemia 2b-3 was 77%. At 24 hours, mean infarct volume was 64±97 mL, and at 3 months modified Rankin Scale 0 to 2 was 45%. Median lesion growth was smaller in recanalizers (16.7% versus 198.3%; P<0.01). MALCOM was 39 mL. When recanalization was achieved, 64% of patients within MALCOM (<39 mL) achieved favorable outcome, whereas despite recanalization only 12% of patients beyond MALCOM (>39 mL) achieved modified Rankin Scale 0 to 2 (P=0.01). A regression model adjusted for age and recanalization showed that the only predictor of favorable outcome was having admission core lesion below MALCOM (OR: 9.3, 95% CI: 1.9-46.4; P<0.01). Analysis according to imaging modality showed that computed tomography-cerebral blood volume allowed larger MALCOM (42 mL) than magnetic resonance-diffusion weighted imaging (29 mL). In octogenarians, MALCOM (15 mL) was lower in younger patients (40 mL). CONCLUSIONS: Admission lesion core is associated with final infarct volume and is a strong predictor of favorable outcome. MALCOM according to imaging modality and patient age could be set and used on admission to select candidates for endovascular procedures.

Levetiracetam-induced drug reaction with eosinophilia and systemic symptoms syndrome.

OBJECTIVE: To describe a case of levetiracetam-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. CASE SUMMARY: A 31-year-old white male with a low-grade astrocytoma presenting with tonic-clonic seizures was treated with levetiracetam 1 g twice daily and dexamethasone (initial dosage 12 mg/day, tapered down to 2 mg/day). On day 45 after levetiracetam initiation, dexamethasone was discontinued and levetiracetam continued. The patient developed fever and dyspnea on day 46 and was admitted to the hospital on day 49. A chest X-ray showed bilateral pulmonary interstitial infiltrates, and laboratory tests showed elevated lactate dehydrogenase (LDH; 288 U/L [reference range <204]), ferritin (223 ng/mL [13-178]), and C-reactive protein (CRP; 3.1 mg/dL [<0.5]). Neurologic fever was suspected and the reinitiation of dexamethasone at 6 mg/day was followed by improvement of all symptoms; the patient was discharged on day 55 with dexamethasone 4 mg/day for 2 more days. On day 59, 2 days after the withdrawal of dexamethasone for the second time, the patient presented with a pruritic erythematous maculopapular rash along with recurrence of fever and dyspnea, and was admitted to the hospital. A chest X-ray showed reappearance of the bilateral pulmonary interstitial infiltrates, and laboratory tests showed impaired liver function (alanine aminotransferase 60 U/L [reference range <56], aspartate aminotransferase 53 U/L [<30], LDH 516 U/L, ferritin 419 ng/mL, and CRP 2.6). A diagnosis of DRESS syndrome was suspected and levetiracetam was discontinued. Upon levetiracetam withdrawal, the patient's symptoms resolved by day 66, and radiological images showed resolution of the interstitial infiltrate by day 68. The patient was discharged on day 68. Low-grade fever persisted until day 71, with no other symptoms. During a 2-month follow-up period, liver function test results returned to normal. DISCUSSION: DRESS is a hypersensitivity reaction to several drugs, mainly antiepileptic drugs (AEDs), characterized by cutaneous, hematologic, and visceral involvement. Levetiracetam is structurally and pharmacologically unrelated to other AEDs. Previously, only one case of levetiracetam-induced DRESS syndrome had been reported, which required corticosteroids to control symptoms. We describe a case of levetiracetam-induced DRESS syndrome presenting with pneumonitis and hepatitis that resolved with levetiracetam withdrawal. Our patient was classified as a definitive DRESS case according to the RegiSCAR scoring system, which grades DRESS cases. According to the Naranjo probability scale, the adverse drug reaction was considered probable. CONCLUSIONS: Although levetiracetam is usually well tolerated, clinicians should be aware of the potential for it to cause DRESS syndrome.

Endovascular treatment of intracraneal aneurysm with pipeline embolization device: experience in four centres in Barcelona.

UNLABELLED: Flow diverters represent a useful tool in the treatment of fusiform aneurysms and wide-neck saccular aneurysms which until the advent of this technology were problematic to treat. Pipeline™ Embolization Device (PED) has been described in several series showing high rates of occlusion and being relatively safe. OBJECTIVE: Shows the experience in four different neurointerventional centres in Barcelona with the PED (Covidien) between February 2010 and October 2013. METHODS: We reviewed retrospectively patients treated with PED in four neurointerventional centres in Barcelona between February 2010 and October 2013. RESULTS: Forty-two patients (89.4%) with non-ruptured aneurysms and five (10.6%) post-SAH were treated, with a mean age of 51 years (range 26-76). We treated 67 aneurysms with a mean of 1.4 1-3 PED per patient. We have no mortality and three post-procedural complications with clinical consequences, two of them severe with intracranial haemorrhage and the other with anterior choroidal artery thrombosis. Follow-up was in 45 patients (65 aneurysm) achieving complete occlusion in 90.8% at 12 months of follow-up. Two aneurysms which remained without any changes were distal and fusiform including main bifurcations (3.1%). CONCLUSION: Treatment by PED of fusiform or wide-neck saccular aneurysms is associated with high rates of occlusion after six and 12 months. Correct selection of the patients, aneurysms and also specific characteristics of the Pipeline device should be known in order to select the best therapeutic option. Our findings suggest that the indication must be judged case by case in the selection of suitable patients for PED therapy.

Metformin plus low-dose glimeperide significantly improves Homeostasis Model Assessment for insulin resistance (HOMA(IR)) and beta-cell function (HOMA(beta-cell)) without hyperinsulinemia in patients with type 2 diabetes mellitus.

OBJECTIVE: Type 2 diabetes mellitus is characterized by insulin resistance and defects in insulin secretion from pancreatic beta-cells, which have been studied by using euglycemic/hyperinsulinemic clamps. However, it is difficult to study insulin resistance and beta-cell failure by these techniques in humans. Therefore, the aim of this study was to evaluate the effect of three different antidiabetic therapeutic regimens on insulin resistance and beta-cell activity by using a mathematical model, Homeostasis Model Assessment for insulin resistance (HOMA(IR)) and beta-cell function (HOMA(beta-cell)). RESEARCH DESIGN AND METHODS: Seventy type 2 diabetic patients were randomly assigned to one of three therapeutic regimens: (A) metformin + American Diabetic Association (ADA)-recommended diet + physical activity; (B) metformin + low-dose glimepiride + ADA diet + physical activity; or (C) ADA diet + physical activity (no drugs). Blood samples were obtained before and after the treatment to determine serum levels of fasting and post-prandial blood glucose, fasting insulin, and glycosylated hemoglobin (HbA1c), and HOMA(IR) and HOMA(beta-cell) were calculated. RESULTS: Fasting and post-prandial levels of glucose, HbA1c, and fasting insulin and calculated HOMA(IR) and HOMA(beta-cell) values before treatment were significantly higher than the respective values after treatment for all groups of patients (P < 0.01). Significant differences were also found when comparing the treatment-induced reduction in fasting blood glucose (51.8%; P < 0.01), post-prandial blood glucose (55.0%; P < 0.05), and HOMA(IR) (65.3%; P < 0.01) in patients of Group B with that in patients receiving other therapeutic options (Groups A and C). CONCLUSIONS: Metformin plus low-dose glimepiride (plus ADA diet and physical activity) is a more effective treatment for type 2 diabetes than either metformin plus ADA diet and physical activity or ADA diet and physical activity alone. Determination of HOMA(IR) and HOMA(beta-cell) values is an inexpensive, reliable, less invasive, and less labor-intensive method than other tests to estimate insulin resistance and beta-cell function in patients with type 2 diabetes mellitus.

Homeostasis model assessment (HOMA) en pacientes diabéticos tipo 2 / Homeosatasis model assessment (HOMA) in patients diabetics type 2

En la actualidad, no existe discusión sobre el impacto de la insulino-resistencia en el inicio y desarrollo de la Diabetes tipo 2. Muchos han sido los métodos utilizados para valorar la insulino-resistencia, siendo el "Gold Standart" el Clamp Euglicémico-Hiperinsulinémico. Sin embargo, lo costoso y poco práctico de este método ha dado el impulso para el desarrollo de nuevas técnicas para la estimación de la sensibilidad insulínica a través de metodos matemáticos como el Homeostasis model assessment (HOMA). El propósito de este estudio fue evaluar la función pancreática y la resistencia a la insulina, mediante el HOMA, en dos grupos de individuos con edades equivalentes. El primer grupo estaba integrado por 25 individuos diabéticos tipo 2 con mal control glicémico, y el segundo grupo (grupo control) estaba constituido por individuos adultos sanos. Las concentraciones plasmáticas de glucosa para los diabéticos y los individuos sanos fueron de 11,4 ñ 0,9 mmol/ y 4,8 ñ 0,08 mmol/l respectivamente, (p<0,001), mientras las concentraciones plasmáticas de insulina en ambos grupos no fueron estadísticamente diferentes (16,8 ñ 0,7 y 15,9 ñ 1,7µUl/ml). Con relación a los valores de HOMA-IR se encontró diferencia significativa entre ambos grupos 8,6 ñ 1,3 en diabéticos y 3,6 ñ 0,2 en el grupo control (p<0,01), en tanto que la aplicación del HOMA ß-cell resultó igualmente en diferencias significativas entre ambos grupos: 269,6 ñ 10,9 en el grupo control, y 59,7 ñ 9,9 en diabéticos tipo 2 (p<0,001). Nuestros resultados muestran que el HOMA es una herramienta útil, rápida y precisa para la cuantificación de la función de la célula Beta y la sensibilidad insulínica de los tejidos periféricos en la práctica diabetológica diaria. Su bajo costo y sensibilidad apoyan su aplicación en estudios de grandes poblaciones

Comportamiento del perfil lipídico en una muestra de población adulta de la ciudad de Maracaibo / Behavior of the profile lipid in a specimen of population adult of the city of Maracaibo

Las enfermedades isquémicas representan un gran porcentaje de morbi-mortalidad en la población, Investigaciones han establecido la relación perfil lipídico alterado-mayor riesgo para enfermedades isquémicas. Estas cifras corresponden en su mayoría a poblaciones de adultos en otras regiones, por lo cual se considero necesario conocer el comportamiento para estos grupos etarios en nuestra región y el país. Se escogieron 186 individuos de ambos sexos (94 hombres y 92 mujeres) mayores de 40 años de la ciudad de Maracaibo. Fueron divididos en grupos etarios (40 a 49 a, 50 a 59a y 60a y más) y sexo (H y M). Se determinaron concentraciones de Colesterol Total (Ct), Triglicéridos (TG) y HDL colesterol (cHDL), a partir del suero; para el resto de las fracciones fue utilizada la formula de Friedewald. Las diferencias se consideraron como significativas cuando el valor de p<0,05. El Ct mostró diferencia significativa con relación al sexo en el grupo de 60a y más (176,9 ± 4,7 mg/dl-H Vs 200,1 ± 4,9 mg/dl-M). También entre hombres para cada grupo etario (193,5 ± 9,0 mg/dl Vs 192,2 ± 11,2 mg/dl Vs 176,9 ± 4,7 mg/dl). Niveles de TG mostraron significancia entre grupos etarios para hombres (221,15 ± 21,84 mg/dl Vs 170,96 ± 17,94 mg/dl Vs 131,45 ± 6,87 mg/dl), y comparando sexos en grupos de 40-49a (221,1 ± 21,8 mg/dl-H Vs 149,8 ± 9,7 mg/dl-M) y 60 años y más (131,4 ± 6,8 mg/dl-H Vs 157,7 ± 9,8 mg/dl-M. Niveles de cHDL mostraron diferencias entre sexos por cada grupo etario, 40-49a (39,3 ± 1,5 mg/dl-H Vs 48,3 1,7 mg/dl-M), 50-59a (37,3 ± 1,21 mg/dl-HVs 45,2 ± 1,7 mg/dl-M), 60a y más (41,4 ± 1,4 mg/dl-HVs 45,8 ± 1,21 mg/dl-M). Concentraciones de VLDL mostraron diferencia en los tres grupos etarios para hombres (44,2 ± 4,3 mg/dl Vs 34,1 ± 3,5 mg/dl Vs 26,3 ± 1,3 mg/dl), entre sexos para grupos 40-49a (44,2 ± 4,3 mg/dl-H Vs 29,9 ± 1,9 mg/dl-M) y 60a y más (26,2 ± 1,3 mg/dl-H Vs 31,5 ± 1,9 mg/dl-M). El estudio mostró descenso en niveles de Ct y TG en grupos etarios de 60a y más; al igual que diferencias significativas en los niveles de cHDL entre sexos para todos los grupos etarios estudiados

Enfermedad periodontal como factor de riesgo para la aterosclerosis / Periodontal disease with risk factor for the atherosclerosis

La asociación entre enfermedad periodontal y la aterosclerosis ha sido sustentada gracias a varios postulados en los cuales proceso inflamatorio característico de ambas entidades pudiera ser el nexo que explique por que es frecuente que estas patologías compartan rasgos patogénicos, clínicos, y fisiopatológicos. La asociación propuesta entre ambas está ligada a los efectos sistémicos de los lipopolisacáridos bacterianos liberados en el sitio de inflamación periodontal viajando por vía circulatoria para anclarse en el sub-endotelio de la íntima lo cual conduce a la sobre-expresión de moléculas de adherencia por parte de la célula endotelial, permitiendo la fijación y la entrada de monocitos al sub-endotelio. Esta interacción estimula la unión de los LPS a receptores específicos en la superficie de los monocitos y macrófagos desencadenando la liberación de citoquinas como el TNF-& e interleuquina-1 quienes amplifican la respuesta inflamatoria inicial. Además de ocasionar disfunción endotelial, infiltración laucocitaria y profileración de células musculares lisas, todos elementos característicos del fenómeno aterogénico. Los tóxicos bacterianos como los LPS, ácidos orgánicos de bajo peso molecular, aminas y leucotoxinas inician y perpetúan una serie de eventos inmunológicos en el hospedador que pueden ser divididos en fenómeno de tipo local como la enfermedad periodontal y distancia fenómeno aterogénico

Homeostasis model assessment (HOMA) en pacientes diabéticos tipo 2 / Homeostasis model assessment (HOMA) in patients diabetic tipe 2

En la actualidad, no existe discusión sobre el impacto de la insulina-resistencia sobre el inicio y desarrollo de la diabetes tipo 2. Muchos han sido los métodos utilizados para valorar la insulino-resistencia, siendo el "Gold Standard" el Clamp Euglicémico-Hiperinsulinémico. Sin embargo, lo costoso y poco práctico de este método ha dado el impulco para el desarrollo de nuevas técnicas para la estimación de la sensibilidad insulínica a través de modelos matemáticos como el HOMA, (siglas de "homeostasis model assessmenty"). El propósito de este estudio fue evaluar la función pancreática y la resistencia a la insulina mediante el HOMA en dos grupos de individuos con edades equivalentes. El primer grupo estaba integrado por 25 individuos diabéticos tipo 2 con mal control glicémico y el segundo grupo (grupo control) estaba constituido por individuos adultos sanos. Las concentraciones plasmáticas de glucosa para los diabétidos y los individuos sanos fueron de 11,44 ¤ 0,95 mmol/l y 4,80 ¤ 0,08 mmol/l respectivamente, (p<0,001), mientras las concentraciones plasmáticas de insulina en ambos grupos no fueron estadísticamente diferentes (16,83 ¤ 0,76 y 15,94 ¤ 1,71 µUl/ml). Con relación a los valores de HOMA-IR se encontró diferencia significativa entre ambos grupos 8,64 ¤ 1,39 en diabéticos y 3,65 ¤ 0,21 en el grupo control (p<0,01), en tanto que la aplicación del HOMA á-cell resultó igualmente en diferencias significativas entre ambos grupos 269,68 ¤ 10,98 en el grupo control y 59,73 ¤ 9,92 en diabéticos tipo 2 (p<0,001). Nuestros resultados muestran que el HOMA es una herramienta util, rápida y precisa para la cuantificación de la función de la célula Beta y la sensibilidad a la insulina de los tejidos periféricos en la práctica diabetológica diaria. Su bajo costo así como su sensibilidad apoyan su aplicabilidad en estudios en grandes poblaciones

Inicio de la cardiología en Venezuela / The beginning of cardiology in Venezuela

La cardiología, previamente establecidas sus bases entre los siglos XVI y XX, se inicia en 1920, cuando por primera vez aparece el vocablo "cardiología" como título de la revista Archivos de Cardiología y Hematología, fundada por Pitaluga y Galandre, en España. En venezuela la inicia, en 1925, el doctor Heberto Cuenca Carrujo, en Maracaibo, la cual continúa en Caracas, de 1931 a 1938. Cuenca regenta la cátedra de Medicina Interna (UCV), desde 1935, y fue Jefe del Servicio de Medicina (Hospital Vargas, 1936). Continuaron los doctores Gustavo Plaza Izquierdo como jefe de la cátedra de Cardiología (1936), y Bernardo Gómez desde 1937. Este, posteriormente, inicia la estructuración de las instituciones cardiológicas básicas del país, campaña a la cual se incorporó el doctor Carlos Gil Yepez. Cuenca público noventa trabajos de investigación clínica, treinta de ellos sobre la cardiología: isquemia, arritmias, electrocardiografía, radiología, congénitas, miocardiopatías y corazon en deportes, publicados en: 1. Revista de la Sociedad Médico-Quirúrgica del Zulia. 2. Gaceta Médica de Caracas. 3. Archivos Venezolanos de Cardiológía y Hematología, esta última, fundada y editada por él, en 1935, la cual constituyó la primera revista cardiológica venezolana. La primera investigación, en 1927, versó sobre electrocardiografía