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.

Norovirus as the cause of medically attended gastroenteritis: a hospital-based experience.

Gastroenteritis remains an important cause of morbidity and mortality worldwide. With the introduction of vaccines against rotavirus, interest has shifted to understanding the epidemiology of norovirus (NoV). While the importance of NoV in gastroenteritis outbreaks is well established, its role in sporadic gastroenteritis is less known. To better define the role of NoV as a cause of sporadic gastroenteritis we investigated its prevalence in the patients seen in our paediatric hospital with special emphasis on its seasonal and age distribution. Over a 12-month period discarded stool specimens submitted to our paediatric hospital for testing of an infectious aetiology were retrieved and additionally tested for NoV by real-time reverse transcriptase-polymerase chain reaction; demographical and clinical information were also obtained. Overall, NoV was the single most commonly identified pathogen and found in 68/892 (7·6%) total specimens or 68/258 (26%) of pathogen-positive specimens. The highest rates of NoV were detected in children aged 6 months to 4 years (50/332, 15·1%) and presenting between October and January (46/314, 14·7%). NoV has become the main cause of gastroenteritis in our paediatric population.

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.

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.

[Brainstem injury diagnosed by MRI. An epidemiologic and prognostic reappraisal]. / Lesión traumática del tronco cerebral diagnosticada por resonancia magnética. Reconsideración epidemiológica y pronóstica.

INTRODUCTION AND OBJECTIVES: CT-scan allows emergency surgical evaluation of head injury lesions, but does not offer a comprehensive diagnosis of the resulting brain injuries. Magnetic Resonance Imaging (MRI) can complete the evaluation of head injury, particularly in the brain stem. We attempted to estimate the frequency of traumatic primary brain stem injuries MATERIAL AND METHODS: Thirty patients with moderate or severe head injury (GCS < or = 13) underwent a MRI study during the first two weeks after trauma. In order to exclude old patients with previous ischemic lesions unrelated to the head trauma, only young patients (16-40 years-old) were included. Patients with cranial surgery were also eliminated from the study. Based on previous studies, the FLAIR (8000/120/T. Inversion 2200mseg) sequence was selected. RESULTS: Brain stem injuries were detected in 26.6% of the patients; this was confirmed by two independent radiologists. Six patients had hyperintense lesions compatible with diffuse axonal damage, and two others showed hemorrhagic lesions. These findings were directly related to a specific neurological deficit in four patients; while in the remaining, unspecific consciousness disturbances were noted. CONCLUSIONS: We believe that the FLAIR sequence demonstrate a type of traumatic brain stem injury (probably corresponding to diffuse axonal injury) that is more frequent and less severe in terms of prognosis than those classically described in previous CT scan studies.

The effect of granulocyte-macrophage colony-stimulating factor (GM-CSF) on primitive hematopoietic stem cell (PHSC) function and numbers, after chemotherapy.

OBJECTIVE: Primitive hematopoietic stem cell function was assessed after cyclophosphamide with granulocyte-macrophage colony-stimulating factor (GM-CSF), with or without preadministration of interleukin-1, using competitive repopulation. METHODS: C57B6/J mice injected with one or four biweekly intravenous injections of cyclophosphamide, 200 mg/kg, received granulocyte-macrophage colony-stimulating factor, 1 microg, subcutaneously for 5 days, beginning 24 hours after cyclophosphamide. Alternatively, mice were injected with interleukin-1, 1 microg, 20 hours before administration of drug or drug and cytokine. Marrow obtained from mice sacrificed 4 weeks after the last dose of drug or drug and cytokine was used in competitive repopulation. RESULTS: Significant reductions in marrow repopulating ability occurred after a single dose of cyclophosphamide or multiple injections. Repopulating units (RU) were calculated, and both binomial and Poisson models for estimation of primitive hematopoietic stem cell (PHSC) numbers were used. RU were significantly diminished for all treatment groups when compared to controls. PHSC numbers were not significantly affected by either regimen of cyclophosphamide given alone. Addition of GM-CSF to cyclophosphamide, whether the latter was given in single or multiple doses, led to further, although insignificant, declines in repopulating ability, as well as PHSC and RU numbers. Interleukin-1 usage exacerbated the observed repopulating defect. There was evidence of replicative failure in individual cells, indicating a qualitative defect also. SUMMARY: Additive stem cell depletion and qualitative replicative defect occur after chemotherapy-cytokine usage. However, the replicative defect of PHSC seen after addition of GM-CSF is not significantly worse than that seen with cytotoxic drug use alone.

Compliance issues related to the selection of antibiotic suspensions for children.

OBJECTIVE: To evaluate the palatability, cost and other compliance issues as variables in the selection of antibiotic suspensions for children. METHODS: Eighty-six physicians and health care personnel randomly sampled amoxicillin (used as a standard for comparison) and 11 other antibiotics, evaluating them in categories of appearance, smell, texture, taste and aftertaste. Overall scoring was then adjusted for cost, duration of therapy and dosing intervals. RESULTS: Overall taste (palatability) ranking of antibiotics, highest to lowest, was as follows: loracarbef, cefdinir, cefixime, azithromycin, ciprofloxacin, trimethoprim-sulfamethoxazole, clarithromycin, trimethoprim, amoxicillin/clavulanate, cefpodoxime and cefuroxime. Overall rating of antibiotics was greatly influenced by other compliance variables, in order of their impact: cost; duration of therapy (5 vs. 10 days); and dosing intervals. Cost was not judged to be a major factor by most participants unless antibiotic expense was >$50.00 for treatment of otitis media in our hypothetical 2-year-old, 13-kg child. Taking all variables into consideration, final ranking from highest to lowest was azithromycin, cefdinir, loracarbef, cefixime, amoxicillin, trimethoprim-sulfamethoxazole, cefpodoxime, trimethoprim, clarithromycin, ciprofloxacin, cefuroxime and amoxicillin/clavulanate. CONCLUSIONS: Variables related to compliance for families filling antibiotic prescriptions and children taking these products are important in the selection of antimicrobial therapy. Because final assessment is likely to vary considerably among health care personnel, decisions must be made on an individual basis.

Treatment of cutaneous sporotrichosis with one daily dose of potassium iodide.

BACKGROUND: Recommended treatment for cutaneous sporotrichosis consists of a saturated solution of potassium iodide (SSKI) administered in three daily doses (tid). Because compliance with this regimen has been a problem in our previous experience, we evaluated the use of one daily (qd) full dose of SSKI. METHODS: Patients with culture-confirmed cutaneous sporotrichosis were entered in a randomized, nonblinded study to compare the safety and efficacy of qd vs. tid dosage of SSKI. RESULTS: Fifty-seven patients were enrolled to receive either qd (29) or tid (28) SSKI. Three (1 in the qd and 2 in the tid group) were not compliant with the assigned regimen. Side effects were common but mild in both treatment groups (61% in the qd and 42% in the tid group, P = 0.17); treatment had to be discontinued because of side effects in 3 cases (2 in the qd and 1 in the tid group). Overall 26 (89.6%) and 25 (89.2%) of the individuals initially assigned to the qd and tid dosing schedule, respectively, were cured by the treatment. No relapse was detected after 45 days of follow-up. CONCLUSION: These findings suggest that a single daily full dose of SSKI appears to be appropriate therapy for cutaneous sporotrichosis; further studies with larger numbers of patients are required.

Epidemiology of sharp object injuries in a children's hospital.

BACKGROUND: Limited data exist on the frequency, circumstances and management of sharp object injuries (SOIs) in pediatric facilities. METHOD: SOIs reported at a large children's hospital during a 2-year period were reviewed. RESULTS: One hundred thirteen SOIs were reported for an average of 6 injuries per 100 employees per year. The greatest number of injuries occurred among nurses (46%) and physicians (23%), but phlebotomists experienced the highest rate (25.5 injuries per 100 full time equivalent employees per year). Most common locations were the patient room (27%), operating room (25%) and intensive care units (17%). Needles accounted for 71% of injuries and procedural devices accounted for 22%. Forty-eight percent of injuries occurred during use of the item, 42% after use or during disposal and 7% after disposal. Twenty percent were associated with loose sharps and 15% with inadvertent patient movement. Only 2 injuries were associated with recapping. Eighty-eight percent of the objects were contaminated with blood or body fluid. Of 88 known source patients 1 tested positive for hepatitis B surface antigen, 2 for hepatitis C virus and none for HIV. One hundred four employees sought treatment: 36 received tetanus vaccine; 14 received hepatitis B vaccine; 9 received hepatitis B immunoglobulin; and 12 received zidovudine. No employee subsequently tested positive for HIV, hepatitis B virus, or hepatitis C virus. CONCLUSIONS: SOIs represent a frequent occurrence among pediatric health care workers. Minimizing the use of sharps, appropriately restraining patients during procedures and promptly disposing of sharp items after use might decrease the frequency of SOIs.

Urinary steroids from a newborn human infant. Identification of 2 alpha-hydroxy-4-pregnene-3,20-dione, 3 beta,15 beta-dihydroxy-5-pregnen-20-one and 3 beta,15 alpha-dihydroxy-5-pregnen-20-one.

Urinary steroids from healthy newborn human infants were analyzed by gas-liquid chromatography and gas-liquid chromatography-mass spectrometry. The identification of 2 alpha-hydroxy-4-pregnene-3,20-dione and the characterization of its 2 beta-isomer is recorded here for the first time. Mass spectrometric evidence supporting the identification of 3 beta,15 beta-dihydroxy-5-pregnen-20-one and 3 beta,15 alpha-dihydroxy-5-pregnen-20-one is also presented. Furthermore, the following 15-hydroxylated steroids were also found and identified: 3 beta,15 epsilon,16 epsilon-trihydroxy-5-androsten-17-one, 5-androstene-3 beta,15 alpha,16 alpha,17 beta-tetrol, 3 beta,15 beta,17-trihydroxy-5-pregnen-20-one and 5-pregnene-3 beta,15 epsilon,17,20 epsilon-tetrol. The origin of these 2- and 15-hydroxylated urinary steroids is discussed in relation to current knowledge of 4-pregnene-3,20-dione and 3 beta-hydroxy-5-pregnen-20-one metabolism during the human perinatal period.

Identification of 2 alpha-hydroxy-4-pregnene-3,20-dione in human pregnancy urine.

2 alpha-Hydroxyprogesterone (2 alpha-hydroxy-4-pregnene-3,20-dione) was identified in human late pregnancy urine by liquid-gel chromatography, GLC and GC-MS. In addition, the following 2-hydroxylated C21 steroids were found and identified as 2 zeta-hydroxy-5 zeta-pregnane-3,20-dione, 2 zeta,20 zeta-dihydroxy-4-pregnen-3-one, 2 alpha,3 alpha-dihydroxy-5 alpha- (and 5 beta)-pregnan-20-one, two isomers of pregnane-2,3,20-triol and 2 zeta,3 zeta,16 zeta-trihydroxy-5 zeta-pregnan-20-one.

Nutritional status of Helicobacter pylori-infected children in Guatemala as compared with uninfected peers.

The effect of Helicobacter pylori infection on the nutritional status of children in a developing country was studied using a cross-sectional design. Children attending an all-girl public school in inner Guatemala City, Guatemala were evaluated to acquire sociodemographic information and anthropometric nutritional parameters (weight-for-height [WFH] and height-for-age [HFA]), and detect H. pylori-specific serum IgG antibodies. Of 211 children 5-10 years of age, 107 (51%) were infected. The WFH values were not different between infected and uninfected subjects, and were not affected by the sociodemographic variables. The HFA values decreased significantly with age (P = 0.008), lower income (P = 0.04), and H. pylori infection (P = 0.05). When controlled for age and income level, the effect of infection on HFA became nonsignificant (P = 0.30). Helicobacter pylori appeared to have no effect on the nutritional status of the studied children; the differences detected were small and likely due to sociodemographic factors.

Dietary risk factors associated with the transmission of Helicobacter pylori in Lima, Peru.

The factors influencing the risk of acquisition of Helicobacter pylori infection are not well established. One hundred four children (0-17 years of age) requiring an endoscopy for the evaluation of gastrointestinal symptoms had demographic and dietary data collected and biopsy specimens of the gastric antrum stained for the identification of H. pylori. The 52 (50%) infected subjects were significantly older than the uninfected ones with no difference in gender, crowding, source of drinking water, or exposure to domestic animals. Increased prevalence of infection was associated with increased consumption of food from street vendors, and decreased consumption of fruits in the subgroup that denied consuming food from street vendors. No association was found with consumption of fish, chicken, beef, beans, vegetables, rice, cheese, milk, and unboiled water. These findings support the role of food prepared under unhygienic conditions as a probable mechanism of transmission of H. pylori in developing countries.

Diarrheal disease in Peru after the introduction of cholera.

Surveillance was conducted one day each week from December 1992 through May 1993 to determine the clinical features and etiology of diarrhea among a population in a suburban community of Lima, Peru. Patients who had had three or more loose stools during the previous 24 hr were enrolled at a clinic located in the community or at a nearby regional hospital. A total of 143 cases of diarrhea were detected for an overall rate of 7.1 cases per 1,000 population. The enteropathogens isolated were Vibrio cholerae 01 (31%), enterotoxigenic Escherichia coli (22%), and Salmonella, Shigella, Campylobacter, and Aeromonas species (10%). Specimens from the remaining cases were negative for enteropathogens. All isolates of V. cholerae were susceptible to tetracycline, doxycycline, nalidixic acid, norfloxacin, trimethoprim-sulfamethoxazole, trimethoprim, gentamicin, chloramphenicol, and cephalothin. Cases of diarrhea associated with V. cholerae were more common among adults, and more likely to experience severe dehydration and require hospitalization than the non-cholera cases. Data indicated that among the cases diagnosed, V. cholerae and enterotoxigenic E. coli were the more common causes of diarrhea in a suburban community of Lima during the summer season.

Helicobacter pylori infection in children with abdominal ailments in a developing country.

Helicobacter pylori commonly infects children in developing countries. To determine the frequency of this infection and its potential role in specific gastrointestinal entities, all patients requiring upper gastrointestinal endoscopy for the evaluation of abdominal ailments in a gastroenterology practice in Lima, Peru, were evaluated during a 1-year period. Gastric biopsies were obtained for each child and were stained with hematoxylin-eosin and Warthin-Starry stains. Of the 107 evaluable patients (mean age 7.4 years, 58% boys), 52 (49%) were infected. The infection rate increased with older patients (P = 0.004). Children with recurrent abdominal pain (P = 0.04), an endoscopic finding of nodular gastritis (P = 0.007), and a histologic finding of chronic active gastritis (P < 0.0001) were infected more commonly.

Effects of 16 weeks of training prior to a major competition on hormonal and biochemical parameters in young elite gymnasts.

The aim of this study was to investigate the response to 16 weeks of training on selected hormonal and biological parameters in seven international competition level female artistic gymnasts (14.5 +/- 1.2 years). Data were collected at the beginning of the first training week (W1) and in the 16th week (W16). Assessments also included anthropometric measurements, dietary intake for 7 days and Tanner staging. No gymnast had reached menarche and the puberty stages corresponded to Tanner's pubertal stage 2. The gymnasts were smaller than average for their age group, with a height:weight ratio above the 50th percentile. Energy intake was about 31% lower than recommendations. Significant decreases in IGF-I, IGFBP3, IGF-I:C ratio and triglyceride values and increases in uric acid and creatinine levels were noted. Cortisol values were high regardless of the period. This training provided evidence for alterations in resting somatotropic and adrenocorticotropic parameters.

Acute gastroenteritis.

Acute gastroenteritis represents a frequent cause of morbidity and mortality among children in the developing world as well as morbidity in the developed world. Despite the large number of potential etiologic agents, management of gastroenteritis is uniform and aimed to prevent the two major complications, dehydration and malnutrition. Current guidelines emphasize the use of oral rehydration and the early reintroduction of age-appropriate foods. These guidelines are reviewed here, the underlying principles discussed, and practical points provided.