Adding a chapter to the literature: A rare encounter of unilateral Moyamoya disease with ipsilateral persistent trigeminal artery.

Background: The coexistence of persistent trigeminal artery (PTA) and Moyamoya disease (MMD) has been reported. If their pathogenesis is related and if PTA is protective or harmful in MMD remains unknown as these are rare cerebrovascular anomalies. Case presentation: A 35-year-old woman with sudden global aphasia whose CT head and CT angiography of head and neck showed a hypodensity in the left posterior middle cerebral artery (MCA), a possible left proximal internal carotid artery occlusion, and a left PTA with hypoplasia of vertebral and basilar arteries. Digital subtraction angiography showed chronic MMD in the left MCA with extensive pial collateralization from anterior cerebral artery (ACA). The patient was initiated on single antiplatelet therapy and later she underwent direct bypass surgical intervention and rehabilitation. Discussion: Our case report brings attention to the infrequent coexistence of ipsilateral MMD and PTA suggesting a potential congenital pathogenesis based on embryologic development and hemodynamics. Also, we propose a protective role of PTA in MMD in case of large anterior vessel occlusion. This case contributes to the scarce literature on the intriguing relationship between MMD and PTA.

Factores asociados a la anticoagulación oral óptima en el adulto mayor con fibrilación auricular / Factors associated with optimal oral anticoagulation in elder patients with atrial fibrillation

Objetivos: Determinar la calidad del control de la anticoagulación oral y los posibles factores asociados al tiempo de rango terapéutico. Material y métodos: Estudio retrospectivo con grupo control y exploración de posibles variables, realizado en pacientes =65 años con fibrilación no valvular e indicación de anticoagulación del Hospital Cayetano Heredia entre el 2011-2013. Se determinó el tiempo de rango terapéutico (TRT) por el método de Rosendaal y se consideró control óptimo (TRT =60%) y subóptimo (TRT <60%). Se realizó análisis univariado para los factores. Resultados: La mediana de la edad fue 82,23 años, 74 (51,75%) fueron mujeres. Ciento cuarenta pacientes tuvieron indicación de anticoagulación, 94 (67,14%) iniciaron warfarina, 28 (19,72%) tuvo control óptimo y 66 (46,48%) subóptimo. La edad =75 años (OR 25,5; IC: 7,39-155,8), no bajo grado de instrucción (OR 8; IC 3,61-20,61), =3 comorbilidades (OR 4,5; IC 2,33-9,39), discontinuidad terapéutica (OR 2,75; IC 1,44-5,52) y polifarmacia (OR 4,2; IC 2,16-8,80) se asociaron con control subóptimo, mientras que independencia funcional (OR 4,3; IC 2,16-9,47), no deterioro cognitivo (OR 7,8; IC 3,53-20,19) y género femenino (OR 3; IC 1,62-5,81) al control óptimo. Conclusiones: Un gran porcentaje de pacientes con indicación de ACO y con bajo riesgo de sangrado no inició terapia anticoagulante; y el 50% de quienes la iniciaron, tuvo un control subóptimo. Los pacientes de mayor edad, con mayor comorbilidad y el uso de múltiples medicamentos se asociaron con control subóptimo; mientras que el género femenino y la independencia funcional se asociaron con control óptimo. (AU)

Objective: To determine the quality of oral anticoagulation control and the possible factors associated with time to reach therapeutic range. Methods: Retrospective study with a control group in patients =65 years old with nonvalvular atrial fibrillation who had indication for oral anticoagulation at Hospital Cayetano Heredia from 2011 to 2013. Time to therapeutic range (TTR) was determined by the Rosendal´s method, an optimal control was defined as TTR =60%. A multivariate analysis was performed. Results: Median age was 82.23 years; 74 (51.75%) were females; 140 patients had indication for anticoagulation; 94 (67.14%) started warfarin; 28 (19.72%) had optimal control and 66 did not (46.48%). Age = 75 years (OR 25.5; CI: 7.39-155.8) and no low degree of instruction (OR 25.5; CI: 7.39-155.8) were associated with sub optimal control, while functional independence (OR 4.3; CI: 2.16-9.47), no cognitive deterioration (OR 7.8; CI: 3.53-20.19) and female gender (OR 3; CI: 1.62-5.81) were associated with optimal control. Conclusions: A great percentage of patients with indications for oral anticoagulation and at low risk of bleeding did not start it, and 50% of those who started it had suboptimal control. Older patients with comorbidities who used multiple medications had sub optimal control, while females and functional independence were associated with optimal control. (AU)

Kissing abscess de la valva anterior mitral y pseudoaneurisma por endocarditis infecciosa de la válvula aórtica / Kissing-abscess of the anterior mitral valve and pseudo aneurism due to infective endocarditis of the aortic valve

Un mecanismo inusual de complicación de endocarditis infecciosa (EI) aórtica es llamado ôkissing abscessõ, producido por el impacto del flujo de la regurgitación aórtica y contacto de las vegetaciones sobre la valva anterior mitral. Los abscesos de la válvula mitral pueden complicarse con pseudoaneurismas. Se presenta el caso de un varón de 36 años con fiebre y sudoración de tres meses de evolución. Además, soplo diastólico aórtico y hepatomegalia. La ecocardiografía transesofágica (ETE) mostró válvula aórtica bicúspide con insuficiencia severa y perforación del seno no coronariano con múltiples vegetaciones de tamaño promedio de 4 mm, válvula mitral anterior con imagen anecogénica de 14 mm que corresponde a absceso con flujo Doppler en su interior y otra imagen anecogénica de pseudoaneurisma y múltiples vegetaciones subvalvulares. La extensión de la infección de la EI aórtica a la válvula mitral es una complicación con alta tasa de mortalidad, por ello es necesario el diagnóstico temprano.

An unusual complication of infective endocarditis (IE) of the aortic valve is called kissing-abscess, caused by the impact of the flow of aortic regurgitation and subsequent contact of vegetations over the anterior mitral valve. The resulting abscesses on the mitral valve can further complicate forming pseud aneurisms. We present the case of a 36-year-old male patient with a 3-month history of fever. A diastolic murmur on the aortic chest wall area was listened and hepatomegaly was also found on the physical examination. A trans-esophageal echocardiography revealed severe aortic insufficiency and perforation of the non-coronary sinus with multiple vegetations, mean size of 4 mm. In addition, the anterior mitral valve had a hypo-echogenic image of 14mm in size consistent with an abscess with Doppler flow in its interior and a pseudo aneurism with multiple sub-valvular vegetations. The extension of IE from the aortic to the mitral valve is associated with high mortality rate needing a prompt diagnosis.

Medical Student Knowledge of Neglected Tropical Diseases in Peru: A Cross-Sectional Study.

In developing countries, education to health-care professionals is a cornerstone in the battle against neglected tropical diseases (NTD). Studies evaluating the level of knowledge of medical students in clinical and socio-demographic aspects of NTD are lacking. Therefore, a cross-sectional study was conducted among students from a 7 year-curriculum medical school in Peru to assess their knowledge of NTD by using a pilot survey comprised by two blocks of 10 short questions. Block I consisted of socio-demographic and epidemiological questions whereas block II included clinical vignettes. Each correct answer had the value of 1 point. Out of 597 responders (response rate: 68.4%), 583 were considered to have valid surveys (male:female ratio: 1:1.01; mean age 21 years, SD ± 2.42). Total knowledge showed a raising trend through the 7-year curriculum. Clinical knowledge seemed to improve towards the end of medical school whereas socio-demographic and epidemiological concepts only showed progress the first 4 years of medical school, remaining static for the rest of the curricular years (p = 0.66). Higher mean scores in socio-demographic and epidemiological knowledge compared to clinical knowledge were seen in the first two years (p<0.001) whereas the last three years showed higher scores in clinical knowledge (p<0.001). In conclusion, students from this private medical school gained substantial knowledge in NTD throughout the career which seems to be related to improvement in clinical knowledge rather than to socio-demographic and epidemiological concepts. This study assures the feasibility of measuring the level of knowledge of NTD in medical students and stresses the importance of evaluating education on NTD as it may need more emphasis in epidemiological concepts, especially at developing countries such as Peru where many people are affected by these preventable and treatable diseases.