Intracranial perianeurysmal cyst: still a dilemma. A case report with endovascular management.

Intracranial perianeurysmal cysts constitute an extremely rare entity with very few cases reported in the literature. These cysts present an unknown mechanism of formation and clinical significance. Several theories based on isolated cases have been proposed, without drawing a clear conclusion. It is also unknown if follow-up with imaging techniques is required or which is the most appropriate treatment. We describe an atypical case handled with a satisfactory outcome after endovascular treatment, suggesting the importance of hydrodynamic forces as the key factors in the mechanism of formation. We believe that this case can help in future analysis of this rare entity.

[Suppurative thrombophlebitis central venous catheterization]. / Tromboflebitis supurada laterocervical tras cateterización venosa central.

Suppurative thrombophlebitisis a very infrequent complication of the central venous catheterization. The majority of the cases are produced by species of staphylococci. A 22-year-old colombian-woman, student, without toxic habits was admitted because of temporary left astrocytoma (grade II). Nine days after implementing a catheter in the right subclavian vein she presented high fever (39.5 degrees C), shivers, progressive right side neck swelling and odinofagia. She had leukocytosis (26,300 cells/microl) and normal cerebrospinal fluid. After withdrawing the catheter, Staphylococcus aureus was isolated in the tip of the catheter and in four bottles of blood cultures. A neck CT demonstrated expansion and absence of contrast in the right internal jugular vein. The patient evolved satisfactorily with cloxacillin, gentamycin and low molecular weight heparin.

Peripheral blood stem cell collection after intermediate-dose cytarabine in adult patients with acute myeloblastic leukemia undergoing autologous blood stem cell transplantation in first complete remission.

Different strategies for collecting peripheral blood stem cells (PBSC) for autologous blood stem cell transplantation (ABSCT) have been reported for patients with acute myeloblastic leukemia (AML). We compared the clinical results of 2 consecutive protocols in 75 adult patients with AML in first complete remission who underwent ABSCT. In the first 56 patients (group A), PBSC were collected after induction and/or consolidation chemotherapy courses. In the subsequent 19 patients (group B), PBSC collection was done after a further intensification course with intermediate-dose cytarabine and mitoxantrone. Hematopoietic engraftment was similar in the 2 groups, with the median times to reach 0.5 x 10(9) neutrophils/L and 20 x 10(9) platelets/L being 13 days each in group A, and 12 days and 24 days, respectively, in group B. There were 3 graft failures (all in group A) and 5 transplantation-related deaths (6.6%, 4 in group A and 1 in group B). Although not statistically significant, the 3-year probabilities of both relapse (31% versus 66%; P = .12) and disease-free survival (60% versus 36%; P = .1) compared favorably for group B. Our study suggests that collection of PBSC after additional intensification can result in a better outcome for AML patients who undergo ABSCT.

[Descriptive study of patients diagnosed with asthma in a regional respiratory medicine practice]. / Estudio descriptivo de los pacientes diagnosticados de asma en una consulta neumológica de ámbito comarcal.

OBJECTIVE: To describe the characteristics of patients diagnosed of bronchial asthma (BA) in a regional respiratory medicine practice. METHODS: Over a period of two years, 88 adult patients followed a prospective-diagnostic protocol for BA that included taking of patient history to determine the probability of initial diagnosis (PID) of asthma, assessment of atopy and a lung function test that included spirometry with a bronchodilator test, recording of forced expiratory volume, and a methacholine challenge test. BA was diagnosed when symptoms denoting high or moderate PID were present and there was a positive reversibility and/or bronchial hyperreactivity test. The severity of disease was evaluated using the consensus criteria of the Global Initiative for Asthma (GINA). A student-t test and a chi 2 test were performed to compare data. RESULTS: BA was diagnosed in 24 men (30%) and 56 women (70%) with a mean age of 43.0 +/- 17.6 years (range 16 to 68). Significant differences between men and women were detected only for function parameters and cigarette consumption (p < 0.05). Fifty-three patients (66%) were referred by general practitioners, 22 (27%) were referred by hospital, and 5 came from other sources. The first group had a shorter history of disease course (p = 0.05) upon first evaluation. Sixty-one patients (76%) had mild asthma; these patients were younger and had had symptoms for a shorter period of time than those with more serious degrees of disease (16 with moderate asthma and 3 with severe asthma) (p < 0.05). Symptoms indicated a high PID in 57 cases (71%), and this figure increased significantly to 89.5% for those with more severe asthma (p < 0.05). Asthma was intrinsic for 39 patients and extrinsic for 41, with significant differences in age and total IgE between the two groups (p < 0.01). CONCLUSIONS: 1. BA is more than twice as common among women as among men. 2. Two thirds of patients are referred by general practitioners. 3. Mild asthma clearly predominates. 4. Clinical symptoms point to asthma, the PID in most cases being high.

Effects of quinidine, verapamil, nifedipine and ouabain on hysteresis in atrial refractoriness in the conscious dog: an approach to ionic mechanisms.

1. This work determines the effects of quinidine, verapamil, nifedipine and ouabain on the hysteresis of the atrial effective refractory period (AERP) in the conscious dog. 2. AERP was always longer in the increasing phase than in the decreasing phase of the extrastimulus method, thus demonstrating the existence of AERP hysteresis. Calculated as the difference between the two values, hysteresis was between 8+/-0.8 and 11+/-1.0 msec. 3. Quinidine increased hysteresis from 9+/-0.7 to 13+/-0.7 msec, whereas verapamil decreased it from 10+/-0.9 to 5+/-0.5 msec and nifedipine did not affect it. Ouabain also lengthened hysteresis from 8+/-0.8 to 11+/-1.2 msec. 4. Thus, these results confirm the existence of a hysteresis phenomenon in the AERP in the conscious dog and are evidence that the fast sodium and slow calcium specific membrane currents participate in this phenomenon.

Extracellular K+ dependence of inward rectification kinetics in human left ventricular cardiomyocytes.

BACKGROUND: In human ventricular cells, the inwardly rectifying K+ current (IK1) is very similar to that of other mammalian species, but detailed knowledge about the K+-dependent distribution of open and blocked states during rectification and about the K+-dependent modulation of inactivation on hyperpolarization is currently lacking. METHODS AND RESULTS: We used the whole-cell patch-clamp technique to record IK1 in myocytes isolated from subendocardial layers of left ventricular septum from patients with nonfailing hearts with aortic stenosis and cardiac hypertrophy who were undergoing open-heart surgery. Outward currents were very small at voltages positive to the reversal potential but increased at high external [K+]. Chord conductance measurements and kinetic analyses allowed us to estimate the proportion of channels in the open state and of those showing either slow unblock or instantaneous unblock (the so-called slow or instantaneous "activation") on hyperpolarization: the distribution in the individual states was dependent on external [K+]. The proportion of channels unblocking slowly was greater than that of channels unblocking instantaneously on hyperpolarization from the plateau voltage range. Hence, because of the previously reported link between the presence of highly protonated blocking molecules and slow unblock kinetics, it is suggested that high cellular concentrations of spermine may account for the low outward current density recorded in these cells. The current decrease observed on extended hyperpolarization was significantly relieved by an increase in external [K+]. CONCLUSIONS: The pattern of IK1 current alterations observed in the present model of human ventricular hypertrophy might favor enhanced excitability and underlie ventricular arrhythmias, possibly via increased intracellular polyamine levels.

Slow inward current in single cells isolated from adult human ventricles.

Characteristics of the slow inward current (Isi) in human ventricular myocytes isolated from septal specimens obtained in patients undergoing corrective cardiac surgery were studied using the whole-cell clamp method. A first series of experiments was performed under normal standard superfusion. Clamping from -60 mV evoked an inward current with a threshold at about -35 mV, a maximum around +10 mV and an apparent reversal potential at about +55 mV. No overlapping transient or background outward currents were detected in the -60 to +30 mV potential range, but time-dependent and steady-state outward currents were elicited at potentials above +30 mV. An overlap of steady-state activation and inactivation curves was present between -30 and +10 mV and a slight relief from inactivation was observed for voltages positive to +10 mV. The time course of inactivation consisted of fast and slow phases with time constants differing by a factor of eight. Slow time constants of inactivation were shorter at potentials that elicited larger Isi, and longer at potentials inducing smaller Isi. Recovery from inactivation evolved slowly with 100% reactivation occurring in about 4000 ms. Switching the holding potential from -60 to -40 mV led to a reversible decline of Isi without any change of the decay time constants. Isi was significantly increased by 0.1 microM isoproterenol. Total or partial inhibition by inorganic (2 mM Mn2+, 3 mM Co2+, 1 mM Cd2+) and organic (1 microM methoxyverapamil, 5 microM diltiazem) calcium antagonists did not unmask any transient outward current. However, a consistent increase of Isi was reversibly observed with 3 mM 4-aminopyridine while using standard solutions. A second series of experiments carried out with K(+)- and Na(+)-free solutions did not demonstrate any significant change from data observed with standard solutions except a reduction of outward currents at steps above +30 mV and alteration of inactivation kinetics. In this experimental setting, 4-aminopyridine also increased Isi but to a lesser degree. We conclude that Isi, as compared to the outward currents, is dominant in the diseased human ventricular cells we have studied.

[The effect of moderate surgical aggression on the immune system. The usefulness of the Multitest as a method for studying immune activity]. / Efecto de la agresión quirúrgica moderada sobre el sistema inmunitario. Utilidad del Multitest como método de estudio de la actividad inmune.

With the aim of studying the effect of moderate surgical aggression on the immunity system, a group of 22 patients was selected, who were not affected by immuno-depressive factors apart from the surgery itself. Changes in the nutritional state of these patients were analyzed using anthropometric, biochemical and immunity procedures, with regard to levels of immunoglobulin, complement and lymphocytic populations at different times during the first 30 postoperative days. Alterations were observed both in humoral and cellular immunity in the sense of temporary immunodepression. These changes were not reflected in the skin reaction tests to antigens in the Multitest (R). The origin and significance of postsurgical immunodepression was discussed, as well as the need for developing investigation models, both clinical and in the laboratory, in order to shed some light on the dilemma of the physiopathology of the immunity system in surgical patients.

Deferoxamine reduces neutrophil-mediated free radical production during cardiopulmonary bypass in man.

We assessed the effects of the iron chelator deferoxamine in 24 adult patients (12 controls, 12 treated) undergoing cardiopulmonary bypass for various cardiac operations. Deferoxamine was given both intravenously (30 mg/kg of body weight, starting 30 minutes before and ending 30 minutes after bypass) and as an additive to the cardioplegic solution (250 mg/L). Right atrial blood samples were taken before, during, and after bypass, and isolated polymorphonuclear neutrophils were evaluated for their capacity to generate superoxide radicals after stimulation with N-formyl-methionyl-leucyl-phenylalanine (FLMP, 10(-7) mol) and phorbol myristate acetate (100 ng/ml). At the same sampling times, measurement of the plasma levels of 6-keto-prostaglandin F1 alpha, the stable derivative of prostacyclin, was used as an index of membrane phospholipid breakdown. The two groups were not significantly different with regard to age, duration of bypass, and quantitative changes in polymorphonuclear neutrophil counts during the operation. Before bypass, the superoxide production of FMLP-stimulated polymorphonuclear neutrophils was comparable in the two groups. Conversely, after bypass, polymorphonuclear neutrophils harvested from deferoxamine-treated patients produced significantly fewer superoxide radicals than those of control patients (1.9 +/- 0.3 versus 3.7 +/- 0.2 nmol/10(6) polymorphonuclear neutrophils per minute, p less than 0.05). Stimulation of polymorphonuclear neutrophils by phorbol myristate acetate yielded similar changes, as the postbypass superoxide production was 12.6 +/- 2.5 nmol/10(6)/min in control patients and 7.1 +/- 0.9 nmol/10(6)/min in those receiving deferoxamine (p less than 0.05). In contrast, plasma levels of 6-keto-prostaglandin F1 alpha were not significantly different between the two groups. We conclude that deferoxamine-exposed polymorphonuclear neutrophils have a decreased oxidative responsiveness, compatible with the fact that they may have been less "primed" by secretagogues released during bypass, as compared with cells of untreated patients. Our results are consistent with the hypothesis that deferoxamine, by inhibiting iron-catalyzed free radical production, may limit the free radical-mediated amplification of the inflammatory response to bypass and as such could be effective in reducing the harmful effects of extracorporeal circulation.

[Comparative assessment of cardiac and psychologic results of aortocoronary bypass]. / Evaluation comparative des résultats cardiaques et psychiques du pontage aorto-coronaire.

Two categories of criteria are used to evaluate the cardiological and psychological results of aortocoronary bypass (ACB): objective criteria, which support the clinician's judgement, and subjective criteria, which contribute to the patient's comfort. Numerous studies have revealed major discrepancies between these two modes of evaluation. A prospective study was undertaken to compare the cardiological and psychological results of ACB at 1 year. The study was based on 24 parameters collected in an ordinary cardiology consultation and from an open discussion between the patient and his (or her) partner and a psychiatrist. In the first phase of the study the results observed in 51 patients were classified as "good" in 40 and "poor" in 11 by the cardiologist, as against "good" in 32 and "poor" in 19 by the psychiatrist. The psychiatrist's assessment differed from that of the cardiologist on 22 patients, being better in 7 and not as good in 15. The second phase of the study has been devised to validate the results obtained in the first phase and to evaluate the contribution of ergonometric test to the cardiological classification of 37 new patients. This study makes it possible to analyze the reasons for the difference in assessment of the cardiological and psychological benefits of ACB, and to develop a method for measuring the impact on these results of new therapeutic measures, such as rehabilitation.

Alpha-myosin heavy chain isoform and atrial size in patients with various types of mitral valve dysfunction: a quantitative study.

The cardiac myosin phenotype, an important determinant of myocardial contractility, is modified by chronic increases in hemodynamic load. To quantify the proportion of atrial alpha-myosin heavy chain in various types of left atrial overload and to assess the possible relation between this proportion and atrial size, 34 patients were studied, 4 with Wolff-Parkinson-White syndrome, 29 with various types of mitral valve dysfunction and 1 with an atrial septal defect. Four normal autopsy hearts were also studied. The proportion of alpha-myosin heavy chain among total (alpha plus beta) myosin heavy chains was determined in each atrial sample, using an enzyme-linked immunosorbent assay. The size of the left atrium was assessed by one- and two-dimensional echocardiography. Alpha-myosin heavy chain was the main isoform present in the normal atria (85.5 +/- 9% of total myosin heavy chains). Patients with pure tight mitral stenosis (n = 9), mitral stenosis plus mild regurgitation (n = 8) and severe mitral regurgitation (n = 8), who had a higher indexed left atrial transverse diameter than those with Wolff-Parkinson-White syndrome (33 +/- 6, 39 +/- 10 and 46 +/- 5 versus 19.5 +/- 2 mm/m2, p less than 0.01, p less than 0.001 and p less than 0.001, respectively), also demonstrated a much smaller percent of alpha-myosin heavy chain content (28 +/- 20, 23.5 +/- 13 and 12 +/- 10 versus 58 +/- 18%, p less than 0.01, p less than 0.01 and p less than 0.001, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Decreased incidence of supraventricular arrhythmias achieved by selective atrial cooling during aortic valve replacement.

Inadequate atrial hypothermia and subsequent ischemic injury have been recognized as the major causes of supraventricular arrhythmias (SVAs) and conduction defects following cold chemical cardioplegia. This study was designed to assess the effects of right atrial cooling (15 degrees-20 degrees C) during cardioplegic arrest upon the incidence of postoperative SVAs and conduction defects in 40 consecutive patients undergoing isolated aortic valve replacement. Atrial preservation was ensured by combining systemic (24 degrees C) and topical hypothermia with snared double caval cannulation during arrest. Myocardial temperatures in the right atrial septum and anterior wall of the right ventricle were recorded before and after each cardioplegic infusion and upon release of caval tapes. Postoperatively, the incidence of SVAs and conduction defects was assessed by continuous rhythm monitoring, bipolar atrial electrograms and, in ten patients, 24-h Holter recordings during the first postoperative day. With the venae cavae snared, temperatures in the right atrial septum were not significantly different from those measured simultaneously in the right ventricle. Release of caval tapes resulted in right atrial temperatures increasing to systemic temperature (from 17.1 +/- 2.9 degrees C to 25.9 +/- 5.6 degrees C [m +/- SD]; P less than 0.01). Atrial rewarming between cardioplegic infusions did not exceed 2.9 degrees +/- 3.2 degrees C. Postoperatively, four patients (10%) developed sustained atrial fibrillation. One additional patient had a single episode of paroxysmal atrial fibrillation and two patients experienced asymptomatic episodes of junctional rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)

Prolonged responsiveness to ouabain in hypertrophied rat heart: physiological and biochemical evidence.

The inotropic effect of ouabain on cardiac hypertrophy was evaluated on an isolated Langendorff rat heart preparation with performances registrated by means of an intraventricular balloon. These effects were compared with the drug action on the sarcolemma-bound Na+-K+-ATPase activity. On both normal and pressure-overload induced hypertrophied rat hearts (ventricular wt-to-body wt ratios of 2.1 and 3.3, respectively) the inotropic effect of ouabain (10(-9)-10(-4) M) was evaluated at 0.25 mM external Ca2+. Compared with normal hearts, the recovery of a normal contractile function after the inotropic response was significantly slower in hypertrophied hearts. This was valid with the two protocols applied. During a 30-min washout period, the inotropic response remained nearly unchanged in hypertrophied hearts, whereas it was almost completely reversed in control groups. Sarcolemmal vesicles from both heart groups exhibited high Na+-K+-ATPase activities (sp. act.: 105 +/- 16 mumol X h-1 X mg-1). In both normal and hypertrophied cardiac sarcolemmal preparations, the Na+-K+-ATPase was heterogeneous, with high- and low-sensitivity forms. Their relative proportion was two-to-one. In both heart groups, their respective apparent affinities for ouabain were similar (inhibitory concentration of 50% = 10(-8) and 10(-6) M, respectively). The release of ouabain from these two sites was measured, in washout experiments, by the rates of enzyme relief from inhibition. High- and low-sensitivity forms in hypertrophied heart preparations released ouabain at seven- and threefold lower rates, respectively, than the corresponding forms present in normal cardiac sarcolemmal vesicles.(ABSTRACT TRUNCATED AT 250 WORDS)

An asanguineous reperfusion solution. An effective adjunct to cardioplegic protection in high-risk valve operations.

The protection afforded by cardioplegia during elective ischemic arrest can be partly compromised by a reperfusion injury, which may impede the recovery of cardiac function. We previously showed experimentally that this postischemic damage could be largely avoided by an appropriate crystalloid reperfusate. The present study was thus undertaken to assess the effects of this "reperfusion solution" clinically. One hundred twelve patients undergoing valve replacement with the aid of hypothermic cardioplegia (K+ 12 mEq, Mg2+ 26 mEq) were prospectively divided in two groups: Group I (n = 49) received an unmodified blood reperfusate. In Group II (n = 63), 1 L of the reperfusion solution was delivered just prior to removal of the aortic clamp. The formulation of the reperfusion solution adhered to the following principles: (1) maintenance of cardioplegia (K+ = 15 mEq), (2) replenishment of Ca2+ stores (Ca2+ = 2.5 mEq), (3) substrate provision (glutamate = 2,942 gm), (4) buffering (pH = 7.70 at 28 degrees C), and (5) hyperosmolarity (370 mOsm). The two groups were matched for preoperative data except for a higher incidence of isolated aortic valve replacement (p = 0.01) in Group II. Also, the cross-clamp time (mean +/- standard error of the mean) was longer in Group II (94 +/- 4 minutes versus 63 +/- 4 minutes, p less than 10(-6]. The reperfusion solution was found to increase both the rate and extent of postischemic functional recovery, as evidenced by (1) a lower proportion of catecholamine-supported patients 48 hours after operation (9/63 [14.28%] versus 16/49 [32.6%] in the control group [p less than 0.03]) and (2) a lower amount (gamma/kg/min) of dobutamine required to achieve stable hemodynamics (11 +/- 1 versus 26 +/- 6 in the control group [p less than 0.03]). A similar recovery pattern was noted in the high-risk subgroup of patients with mitral valve disease. Further, serial postoperative hemodynamic measurements were performed in 31 randomly selected patients (10 control and 21 reperfused). Although the reperfused patients were found to be at higher risk because of lower preoperative cardiac indices and longer cross-clamp times, they consistently achieved better postoperative hemodynamics with a lower incidence of catecholamine support. This hemodynamic improvement was particularly reflected by a higher left ventricular stroke work index throughout the postoperative course, the difference being significant 6 hours and 12 hours postoperatively.(ABSTRACT TRUNCATED AT 400 WORDS)