Incidental findings on brain MRI in a cohort of diabetic patients.

OBJECTIVE: To study the frequency and management of incidental findings in nonenhanced brain MRI of a middle-aged population of type 2 diabetic patients. METHODS: We retrospectively analyzed the results of 289 brain MRI obtained from subjects between 40-75 years recruited from a previous study. Incidental findings were classified into three categories: (1) Vascular findings; (2) neoplastic findings; and (3) others. On the other side, we made a classification of referral findings. To compare our results, we reviewed the prevalence and evidence about management of both incidental and referral findings in other series. RESULTS: We found an overall prevalence of incidental findings of 10.4% (30/289). Incidental findings raised according to age. The most common incidental findings were: 7 vascular (2.4%), 6 calcifications (2.1%), 6 cystic (2.1%) and 5 neoplastic (1.7%) lesions. A percentage of 1.7% (5/289) were referral findings which required further clinical work-up. CONCLUSION: Incidental findings are relatively common in patients with type 2 diabetes. The most frequent are vascular findings, accordance with previous studies. Referral findings are uncommon. Clinical evidence about how to best manage the majority of incidental findings is lacking.

The determination of copeptin levels helps management decisions among transient ischaemic attack patients.

BACKGROUND: Most approaches to transient ischaemic attack (TIA) triage use clinical scores and vascular imaging; however, some biomarkers have been suggested to improve the prognosis of TIA patients. METHODS: Serum levels of copeptin, adiponectin, neopterin, neuron-specific enolase, high-sensitivity C-reactive protein, IL-6, N-terminal pro-B-type natriuretic peptide, S100ß, tumour necrosis factor-alpha and IL-1α as well as clinical characteristics were assessed on consecutive TIA patients during the first 24 h of the onset of symptoms. RESULTS: Among 237 consecutive TIA patients, 12 patients (5%) had a stroke within 7 days and 15 (6%) within 90 days. Among all candidate biomarkers analysed, only copeptin was significantly increased in patients with stroke recurrence (SR) within 7 days (P = 0.026) but not within 90 days. A cut-off point of 13.8 pmol/l was established with a great predictive negative value (97.4%). Large artery atherosclerosis (LAA) [hazard ratio (HR) 12.7, 95% CI 3.2-50.1, P < 0.001] and copeptin levels ≥13.8 pmol/l (HR 3.9, 95% CI 1.01-14.4, P = 0.039) were independent predictors of SR at the 7-day follow-up. LAA was the only predictor of 90-day SR (HR 7.4, 95% CI 2.5-21.6, P < 0.001). ABCD3I was associated with 7- and 90-day SRs (P = 0.025 and P = 0.034, respectively). The association between copeptin levels and LAA had a diagnostic accuracy of 90.3%. CONCLUSIONS: Serum copeptin could be an important prognostic biomarker to guide management decisions among TIA patients. Therefore, TIA patients with copeptin levels below 13.8 pmol/l and without LAA have an insignificant risk of 7-day SR and could be managed on an outpatient basis.

Prediction of myocardial infarction in patients with transient ischaemic attack.

BACKGROUND: Determinants of risk of myocardial infarction (MI) after transient ischaemic attack (TIA) are not well defined. The aim of our study was to determine the risk and risk factors for MI after TIA. METHODS: We prospectively recruited patients within 24 h of transient ischaemic cerebrovascular events between October 2006 and January 2013. A total of 628 TIA patients were followed for six months or more. MI and stroke recurrence (SR) were recorded. The duration and typology of clinical symptoms, vascular risk factors and aetiological work-ups were prospectively recorded and established prognostic scores (ABCD2, ABCD2I, ABCD3I, Essen Stroke Risk Score, California Risk Score and Stroke Prognosis Instrument) were calculated. RESULTS: Twenty-eight (4.5%) MI and 68 (11.0%) recurrent strokes occurred during a median follow-up period of 31.2 months (16.1-44.9). In Cox proportional hazards multivariate analyses, we identify previous coronary heart disease (CHD) (hazard ratio [HR] 5.65, 95% confidence interval [CI] 2.45-13.04, P < 0.001) and sex male (HR 2.72, 95% CI 1.02-7.30, P = 0.046) as independent predictors of MI. Discrimination for the prognostic scores only ranged from 0.60 to 0.71. The incidence of MI did not vary among the different aetiological subtypes. Positive diffusion weighted imaging (DWI) (7.5% vs 2.5%, P = 0.007), and ECG abnormalities (Q wave or ST-T wave changes) (13.6% vs 3.6%, P = 0.001) were associated to MI. CONCLUSION: According to our results, discrimination was poor for all previous risk prediction models evaluated. Variables such as previous CHD, male sex, DWI and ECG abnormalities should be considered in new prediction models.

N-terminal pro-brain natriuretic peptide level determined at different times identifies transient ischaemic attack patients with atrial fibrillation.

BACKGROUND AND PURPOSE: The etiological classification of patients with transient ischaemic attack (TIA) is a difficult endeavor and the use of serum biomarkers could improve the diagnostic accuracy. The aim of this study was to correlate atrial fibrillation, the main cardioembolic etiology (CE), with different serum biomarkers measured in consecutive TIA patients. METHODS: The concentrations of interleukin-6 (IL-6), tumor necrosis factor-alpha, neuron-specific enolase, high-sensitivity C-reactive protein, IL-1-α and the N-terminal pro-B type natriuretic peptide (NT-proBNP) were quantified in the serum of 140 patients with TIA and 44 non-stroke subjects. Measurements were performed at different times throughout evolution: within 24 h of symptoms onset and at days 7 and 90. RESULTS: With the exception of IL-6, all biomarkers were higher in TIA patients than in controls. NT-proBNP was significantly related to the presence or new diagnosis of AF at all time points analyzed. Furthermore, the baseline NT-proBNP level was significantly higher than values at the 7-day and 90-day follow-up. For this reason, different cut-off values were obtained at different times: 313 pg/ml at baseline [odds ratio (OR) = 18.99, P < 0.001], 181 pg/ml at 7 days (OR = 11.4, P = 0.001) and 174 pg/ml (OR = 8.46, P < 0.001) at 90 days. CONCLUSION: High levels of NT-proBNP determined during the first 3 months after a TIA were associated with AF. Consequently, this biomarker may be useful to reclassify undetermined TIA patients as having disease of CE.

The influence of organisational management on door-to-needle times for fibrinolytic treatment.

INTRODUCTION: Door-to-needle time (DNT) has been established as the main indicator in code stroke protocols. According to the 2018 guidelines of the American Heart Association/American Stroke Association, DNT should be less than 45minuts; therefore, effective and revised pre-admission and in-hospital protocols are required. METHOD: We analysed organisational changes made between 2011 and 2019 and their influence on DNT and the clinical progression of patients treated with fibrinolysis. We collected data from our centre, stored and monitored under the Master Plan for Cerebrovascular Disease of the regional government of Catalonia. Among other measures, we analysed the differences between years and differences derived from the implementation of the Helsinki model. RESULTS: The study included 447 patients, and we observed significant differences in DNT between different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%), reduced DNT by a median of 14minutes. However, the linear regression model only showed an inversely proportional relationship between the adoption of the Helsinki code stroke model and DNT (beta coefficient, -0.42; P<.001). The removal of vascular neurologists after the adoption of the Helsinki model increased DNT and the 90-day mortality rate. CONCLUSION: DNT is influenced by the organisational model. In our sample, the application of the Helsinki model, the role of the lead vascular neurologist, and notification of code stroke by pre-hospital emergency services are key factors for the reduction of DNT and the clinical improvement of the patient.

Patterns of diffusion-weighted magnetic resonance imaging associated with etiology improve the accuracy of prognosis after transient ischaemic attack.

OBJECTIVE: diffusion-weighted magnetic resonance imaging (DWI) is a sensitive diagnostic tool for detecting acute ischaemic lesions in patients with transient ischaemic attacks (TIAs). The additional predictive value of DWI lesion patterns is not well known. METHODS: two hundred and fifty-four consecutive patients with TIA underwent DWI within 7 days of symptom onset. The presence and pattern of acute ischaemic lesions were related to clinical features, etiology, and stroke recurrence at seven- and 90-day follow-up. RESULTS: diffusion-weighted images abnormalities were identified in 117 (46.1%) patients. The distribution of DWI lesions was cortical, 31; subcortical, 32; scattered lesions in one arterial territory (SPOT) 42; and in multiple areas, 12. SPOT were significantly associated with motor weakness, large-artery atherosclerosis (LAA), and the cardioembolic subtype of TIA. Single cortical lesions were also associated with cardioembolism, whereas subcortical acute lesions were associated with recurrent episodes, dysarthria, and motor weakness. During follow-up, seven patients had a stroke within 7 days (2.8%, 95% CI 2.9-6.4%), and 12 had a stroke within 3 months (4.7%%, 95% CI 2.9-6.4%). In the Cox logistic regression model, the combination of LAA and positive DWI remained as independent predictors of stroke recurrence at 90-day follow-up (HR 5.78, 95 CI 1.74-19.21, P = 0.004). CONCLUSION: according to our results, MRI, including DWI, should be considered a preferred diagnostic test when investigating patients with potential TIAs. The combination of neuroimaging and vascular information could improve prognostic accuracy in patients with TIA.

Predictive value of ankle brachial index in patients with acute ischaemic stroke.

BACKGROUND: The ankle brachial index (ABI) is a known measure of lower-limb peripheral artery disease (PAD), as well as a marker for other cardiovascular disease events. OBJECTIVE: Our goal was to compare the prevalence of abnormal ABI scores (ABI or=3 (33.8% vs. 7.1%, P = 0.001) and large-artery atherosclerosis (LAA) (43.5% vs. 19.4%, P = 0.015). Multivariate analyses (logistic regression) only identified VRF > 3 as independently associated with low ABI (OR: 6.46; 1.81-23.02; P = 0.004). Abnormal ABI was associated with stroke recurrence (32.1% vs. 13.6%, P = 0.027) and the appearance of any major vascular event (50.0% vs. 17.0%, P < 0.001). In the logistic regression analysis, adjusted for VRF, age, and LAA, ABI remained as an independent predictor of vascular events (HR 3.99; 1.90-8.41 P < 0.001). CONCLUSION: Abnormal ABI was associated with classical risk factors, especially hypertension. The measurement of ABI amongst patients with IS appeared to be useful to identify high-risk patients and plan adequate prevention therapies.

The influence of organisational management on door-to-needle times for fibrinolytic treatment. / La influencia de la gestión organizativa en el tiempo puerta-aguja del tratamiento fibrinolítico.

INTRODUCTION: Door-to-needle time (DNT) has been established as the main indicator in code stroke protocols. According to the 2018 guidelines of the American Heart Association/American Stroke Association, DNT should be less than 45minutes; therefore, effective and revised pre-admission and in-hospital protocols are required. METHOD: We analysed organisational changes made between 2011 and 2019 and their influence on DNT and the clinical progression of patients treated with fibrinolysis. We collected data from our centre, stored and monitored under the Master Plan for Cerebrovascular Disease of the regional government of Catalonia. Among other measures, we analysed the differences between years and differences derived from the implementation of the Helsinki model. RESULTS: The study included 447 patients, and we observed significant differences in DNT between different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%), reduced DNT by a median of 14minutes. However, the linear regression model only showed an inversely proportional relationship between the adoption of the Helsinki code stroke model and DNT (beta coefficient, -0.42; P<.001). The removal of vascular neurologists after the adoption of the Helsinki model increased DNT and the 90-day mortality rate. CONCLUSION: DNT is influenced by the organisational model. In our sample, the application of the Helsinki model, the role of the lead vascular neurologist, and notification of code stroke by pre-hospital emergency services are key factors for the reduction of DNT and the clinical improvement of the patient.

Effect of maternal dietary amino acid pattern on rat offspring.

The effect of lifetime feeding to gravid rats of diets containing different indispensable amino acid patterns on body and brain composition of the offspring was studied. Two groups of rats were fed, from weaning to delivery, either experimental diet B or diet I. Both diets contained the same amount of total nitrogen (3.14%), available lysine (0.4%) and "complete protein to total protein ratio" (22.5%), but whereas diet I provided an excess of indispensable amino acids over the amount of limiting amino acid, diet B supplied all of the indispensable amino acids in marginal amounts and in a rather well balanced pattern. The nitrogen content of diet B was matched to the nitrogen content of diet I by addition of a mixture of dispensable amino acids. A control group fed stock diet (C) was run simultaneously. Birth body weight, carcass nitrogen to water ratio, and brain weight of pups were significantly lower in B than in I. The figures for I were not significantly different from the controls. Brain DNA content in B was significantly lower than in C, but in I it was lower than for both B and C. Nitrogen to water ratio and brain DNA content of group B were low when compared to the standard curves for our colony; however, DNA content was normal for the degree of body development. On the other hand, in group I brain DNA was preferentially affected, as if body and brain maturity were dissociated.

Immunoglobulin A level in human milk from mothers delivering preterm.

Little information is available on immunoglobulin content of milk from mothers of preterm babies. In this study we have measured IgA levels in samples from preterm and term mothers during the 1st month postpartum. The concentration of IgA tended to be constant in the preterm group (about 251 mg/dl) while it showed a decreasing trend in the term group (from 212.8 +/- 19.9 to 171.6 +/- 12.8 mg/dl). From day 10 onward IgA levels in preterm milk were significantly higher than in term milk (p less than 0.002). These findings support the idea that premature infants fed their own mothers' milk would benefit from more stable levels of IgA, at a time when their mucosal immune system is poorly developed.

Clinical abdominal angiostrongylosis. A study of 116 children with intestinal eosinophilic granuloma caused by Angiostrongylus costaricensis.

A total of 116 cases of intestinal eosinophilic granuloma caused by Angiostrongylus costaricensis in children were studied during the 10-year period 1966-1975 at Costa Rica's National Children's Hospital. A similar prevalence of cases was observed each year. The disease was twice as frequent in males as in females, and occurred predominantly in children 6-13 years old (53% of cases). The clinical symptoms were those of "acute abdomen," with pain at the right iliac fossa, pain on palpation, a tumor-like mass, abdominal rigidity, and painful rectal examination. The picture was, nevertheless, mild to moderate. Fever was classified as mild. Leukocytosis with predominance of eosinophils was seen in most cases. Radiology revealed rigidity and spasticity of the intestinal wall with poor filling on medium contrast. Thiabendazole and diethylcarbamazine were given, but there was no evidence that they were effective. Surgery was performed in 90 cases--appendectomy, ileo-colonic resection, or hemicolectomy. The main localizations of the lesions were the cecum, ascending colon, appendix, and small intestine. The pathologic findings in tissues were edema and rigidity of the intestinal wall, yellow granulations in the subsera and, in the later years of the study, eggs, larvae, or the parasite itself. Two of the patients died; the remainder recovered.

Hypothesis on the time course of antigen dependent changes in lymphoid organs proved by experimental data of depleted growing rats' mesenteric lymph nodes.

The results described in this paper partially agree with the hypothesis that mesenteric lymph nodes (MLN) of depleted growing rats recover their antigen specific determinants after the oral administration of 20% casein for 5-9 days following the time course of antigen dependent changes observed in virgin lymph nodes. With respect to the 39 days old control group, depleted MLN showed a highly diminished number of mature T cells (W3/13+) as well as surface and intracellular alpha heavy chain (alpha s and alpha cit). The oral administration of a 20% casein diet during 5 days tends to restore the appearance of these determinants; however, normal values were not attained even if refeeding was continued for 9 days. The discrepancy between the proposed hypothesis and the observed results might be ascribed to: a) defective migration of T cells from thymus; b) the diminished number of TH cells involved in terminal differentiation; c) inability of B cells to respond to T cell-derived factors.

[Metachronous adenocarcinoma of the duodenum associated with previous colorectal carcinoma]. / Adenocarcinoma de duodeno metacrónico asociado a carcinoma colorrectal previo.

We present two patients who developed a carcinoma of the duodenum years after a colectomy was performed adenocarcinoma of the colon. Duodenal carcinoma has been reported in patients with villous tumor of the colon, familial adenomatous polyposis, Gardner's syndrome, celiac disease and Crohn's disease. A relationship between carcinoma of the Vater's ampulla and adenocarcinoma of the colon has also been reported. However, we have not found in the literature this association in patients without familial adenomatous polyposis or Gardner's syndrome.

[Nutritional evaluation of protein concentrates of beans (Phaseolus vulgaris) and lentils (Lens esculenta)]. / Evaluación nutricional de concentrados proteicos de porotos (Phaseolus vulgaris) y de lentejas (Lens esculenta).

The composition and nutritive value were determined in navy bean meal (Phaseolus vulgaris) and lentil meal (Lens esculenta), and in their respective protein concentrates obtained through extraction followed by isoelectric precipitation. Sulfur amino acids per gram of nitrogen were lower in the concentrates than in the meals, while there was no difference for lysine and threonine. The white bean protein concentrate had a lower biological value than the meal but better digestibility, although trypsin inhibitor concentration was unchanged. Digestibility greatly improved with heating but it did not increase beyond 81% even after autoclaving. Autoclaved samples supplemented with methionine reached a biological value of 83. The lentil protein concentrate also had a lower biological value than the meal but digestibility was high for both samples (91%) and remained unchanged after heating. Trypsin inhibitors were absent. After supplementing with methionine, a biological value of only 63 was obtained, due to the low level of tryptophan, the second limiting amino acid. In spite of the concentrates' lower biological value, it was proved that they equalled the meals' potential for complementing cereal, as their content in lysine and threonine is high. The concentrates have the additional advantage of allowing effective supplementation without increasing the legume-cereal ratio.

[Determination of folates in food. Comparative and critical study]. / La determinación de folatos en alimentos. Estudio crítico y comparativo

A study on the microbiologic method for folate determination in natural products was carried out. The variables that must be considered were analyzed previous to the application of this technique, that is: nature of combinations of the compounds with vitamin activity, function and distribution of the conjugases, capacity of absorption of the polyglutamates present in foods, natural inhibitors of the conjugases and the importance of the selection of the microorganism used. Based on the preliminary investigations a modified microbiological microtechnique is proposed and its importance for some nutricional aspects is discussed.

[Serum creatine phosphokinase activity: analysis of information provided by different ways of expressing the results]. / Actividad de creatin-fosfoquinasa en suero: análisis de la información suministrada por differentes formas de expresión de los resultados

An experimental model with undernourished rats fed experimental diets containing either imbalanced proteins or low amount of well balanced proteins was used to evaluate the utility of serum CPK activity determination in human malnutrition. Special attention was given on the information provided by four ways of expression of the enzymatic activity. CPK activity was expressed as: 1) Specific activity, 2) Activity per ml serum, 3) Total activity per rat and 4) Total activity per 100 g body weight. Statystical analysis showed: a) Activity expressed per mg serum protein or per ml serum did not agree with the known physiological phenomena induced on muscle by the experimental diets: CPK activity values expressed in these ways are not useful in malnutrition studies. b) Serum total activity of CPK per rat provides a similar information to the creatinin/height index, which is easier to perform. c) Total CPK activity per 100 g body weight demonstrated to be adequate to provide information about muscle mass in rats under controlled experimental conditions. However, it is not possible to use this form of expressing CPK activity in human malnutrition, because it would be also necessary to know: plasma volumen, age, actual body weight, clinical and the nutritional background, etc., of the patient for an accurate interpretation of results.

[Enrichment of wheat flour with sunflower and soya flour for bakery products]. / Enriquecimiento de la harina de trigo con harinas de soja y girasol para la obtencion de productos de panaderia

In order to improve the nutritive value of wheat protein, with a wheat flour, defated soybean flour and sunflower seed flour were mixed on the basis of their amino acid composition. The highest nutritive value, 86 expressed as CS, was obtained with 60% wheat flour + 28% defatted soybean flour + 12% defatted sunflower seed flour. The mixture was used to prepare: a) sea-biscuits, baked in a traditional bakery oven, and b) crackers, baked in an electric endless oven. Similar products, baked with wheat flour alone, were studied as controls. Chemical composition, total lysine, methionine, cystine, threonine and available lysine content were determine on the raw flours and mixture. Protein, fats and available lysine were determined on the bakery products. The nutritive value of the latter was assessed by their NPUop from which NPUst was calculated. The results showed an increase in the protein content of the enriched bakery products up to 60% over the controls. The nutritive value of the products was lower than the calculated figure for the raw mixture. Products b had the highest NPUst (56.4), surpassing the figures for the control (33.3) and also for product a (53.5). These values agreed with the figures for lysine availability which decreased with heat according to the cooking process. These data and the good acceptability of the crackers suggest that their enrichment with soybean and sunflowers seed concentrates asayed, could help to fulfill protein requirements in children.

[Relation between erythrocyte free protoporphyrins and usual iron intake in a group of University of Buenos Aires students]. / Relación entre protoporfirinas libres en glóbulo rojo e ingesta habitual de hierro en un grupo de estudiantes de la Universidad de Buenos. Aires.

In order to analyze the interrelationships between free erythrocyte protoporphyrins and the usual iron intake in adult students, biochemical, and hematological values, and dietary daily intake, obtained using the recall method during seven days, were studied. Hematocrit (Hto.), hemoglobin (Hb) and free erythrocyte protoporphyrins (FEP) were determined in a group of 145 female university students, healthy according to the standard parameters of the Buenos Aires University Health Department. Mean iron intake was 23.0 +/- 1.5 mg per day, about 44% being provided by animal sources; 74.5% of the population was within the recommended daily intake according to FAO/WHO; only 0.7% of the population did not cover protein requirements while 35% did not cover energy needs. Hto. and Hb were below normal levels in 7.8% of the population when compared with standards according to ICNND. To obtain information about normal values to FEP, expressed as microgram/100 ml red cells (FEP% r.c.) and FEP/Hb ratio, the group of students with adequate intake of energy and proteins who had normal values for Hb and Hto. was selected. This group, including 94 women, had a mean FEP% r.c. of 15.71 +/- 7.26 and a mean FEP/Hb ratio of 0.44 +/- 0.21. There was observed an inverse correlation between FEP% r.c. and FEP/Hb with total iron intake (r = 0.80 and r = 0.78, respectively) and between FEP% r.c. and Hb concentration (r = 0.81). These results confirm the usefulness of the free erythrocyte protoporphyrins determination as a good index of iron stores and usual intake of this population.