Comparación clínica y laboratorial de la fiebre amarilla severa versus dengue grave en Perú / Clinical and laboratory differences between severe yellow fever and severe dengue in emergency patients

En los centros de Emergencia con poco apoyo de laboratorio, es difícil diferenciar a los pacientes con dengue grave y fiebre amarilla severa. El objetivo fue comparar el perfil clínico y de laboratorio de los pacientes con dengue grave y fiebre amarilla severa en Urgencias. Se realizó un estudio observacional retrospectivo de pacientes con diagnóstico confirmado de dengue y fiebre amarilla en el período 2018 a 2020 atendidos en la Unidad de Emergencia del Hospital Carrión, Huancayo-Perú. Se evaluaron un total de 35 pacientes, 11 pacientes (31,4%) fueron diagnosticados con fiebre amarilla severa y 24 pacientes (68,5%) con dengue grave. La media de los resultados de laboratorio con fiebre amarilla severa fueron bilirrubina indirecta 4,7 ml/dL, aspartato transaminasa 4463 UI/L, transaminasa aminotransferasa 4329 UI/L, creatinina 4,9 mg/dl. En pacientes con dengue grave el hematocrito promedio fue 51,8, hemoglobina 17,6 g/dl, plaquetas 24 × 103/mm. En pacientes con síndrome ictérico-febril la presencia de bradicardia, bilirrubina indirecta elevada y transaminasas muy elevadas debe hacer sospechar de fiebre amarilla; mientras que los pacientes que acuden por ascitis, derrame pleural, aumento de hematocrito y deficiencia de plaquetas, se debe tratar como dengue grave sobre todo en Unidades de Emergencia con poco apoyo de laboratorio(AU)

In Emergency centers with little laboratory support, differentiating patients with dengue and yellow fever is difficult. The Aim was to compare the clinical and laboratory profile of patients with severe dengue and severe yellow fever in the Emergency unit. We conducted a retrospective observational study of patients with a confirmed diagnosis of dengue and yellow fever in the period 2018 to 2020 treated in the Emergency Unit of the Carrión hospital, Huancayo-Peru. A total of 35 patients were evaluated, 11 patients (31.4%) were diagnosed with severe yellow fever and 24 patients (68.5%) with severe dengue. The mean laboratory results in patients with severe yellow fever were indirect bilirubin 4.7 ml/dL, aspartate transaminase 4463 IU/L, transaminase aminotransferase 4329 IU/L, creatinine 4.9 mg / dl. In patients with severe dengue were hematocrit 51.8, hemoglobin 17.6 g / dl, platelets 24 × 103 / mm. In patients with syndrome jaundice and fever the presence of bradycardia, elevated indirect bilirubin, and very elevated transaminases should be suspicious for yellow fever; while in patients who come for ascites, pleural effusion, increased hematocrit and platelet deficiency, it should be treated as severe dengue especially in Emergency Units with little laboratory support(AU)

3T magnetic resonance spectroscopy as a powerful diagnostic modality for assessment of thyroid nodules

ABSTRACT Objective: Magnetic resonance spectroscopy (MRS) is a powerful tool for structural studies of chemical compounds and biomolecules and also documented promising findings as a potential imaging technology in thyroid oncology. This prospective study was to ascertain the clinical significance of 3 Tesla MRS in the evaluation of patients with thyroid nodules (TNs) as an ancillary diagnostic technique for thyroid carcinoma. Materials and methods: Magnetic resonance spectroscopy at 3T at echo- times (TEs) 136 and 270 ms was carried out on 15 patients with total number of 32 TNs larger than 1 cm3, which all were surgically resected. Choline (Chol) to creatine (Cr) ratio was assessed at 136 and 270 TEs on each nodule and a receiver operating characteristic (ROC) curve was used to determine optimal cut-off point. The findings were compared with histopathology of thyroid specimens. Results: There were 23 benign and 9 malignant lesions (7 papillary and 2 follicular thyroid carcinomas). The mean values of Chol/Cr at 136 and 270 TEs was 2.28 ± 3.65 and 1.52 ± 1.67 respectively and the difference between benign and malignant nodules was only significant at 136 TEs. The study revealed that Chol/ Cr ratio cut-off point of 2.5 best correlates with histopathology results (sensitivity = 75%; specificity = 100%; PPV = 100%; NPV= 92%). Conclusion: This preliminary study showed that 3T magnetic resonance spectroscopy might be a specific modality for the evaluation of thyroid nodules in differentiation of benign from malignant thyroid tissue. However, a larger series would give much greater confidence that this state-of-the-art technology will worth pursuing in clinical practice.

Analysis of Salivary Flow, pH, Buffer Capacity, and Creatinine in Individuals Undergoing Hemodialysis

Objective: To quantify salivary creatinine levels patients with end-stage renal disease (ESRD) before, during, and after hemodialysis sessions. Material and Methods: Sixty-eight individuals, aged between 4 and 25 years, were selected, and among these, 34 were diagnosed with ESRD and were undergoing hemodialysis (Group 1) and 34 were clinically healthy patients (Group 2). Saliva samples were collected before, during, and after hemodialysis sessions for Group 1 and compared with those of Group 2. Stimulated saliva flow rate (SSFR), buffer capacity (BC), pH, and salivary creatinine levels were determined. Shapiro-Wilk test, followed by the Friedman, Mann-Whitney and ANOVA tests were used to analyze the variables. Results: Mean SSFR values of Group 1 at the three stages of hemodialysis sessions did not differ from those of Group 2. Furthermore, BC and pH values were within their normal limits, and no difference was detected between the two groups. Mean salivary creatinine levels at baseline and during hemodialysis were significantly higher in Group 1 that in Group 2, but these values were not different between Groups at the end of hemodialysis. Conclusion: Salivary creatinine levels reduce significantly after hemodialysis sessions suggesting that saliva may be used to monitor the efficiency of hemodialysis or even indicate the moment at which it should start.

Study of renal and hepatic toxicity in rats supplemented with creatine

PURPOSE: To evaluate the renal and hepatic function, through biochemical analysis after 14 days of creatine supplementation in physically inactive rats. METHODS: Twenty four male, adult, Wistar rats were used which were kept in individual metabolic cages and were distributed into four groups, and received the following treatments by gavage:1) Control: distilled water; 2)Creatine 0.5g/Kg/day; 3) Creatine 1g/Kg/day; 4) Creatine 2g/Kg/day. Their urinary outputs as well as food and water intake were daily measured. At the end of the experiment, the animals were euthanized and serum samples were stored for biochemical analysis. RESULTS: Creatine supplementation at the doses given produced no significant changes in plasma levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total protein, albumin, total cholesterol, HDL cholesterol, LDL cholesterol, VLDL cholesterol, triglycerides, glucose, creatinine, urea, and creatinine clearance, compared to control group (p> 0.05) Similarly, water and food intake, as well as urinary output, did not show significant changes among the four groups studied. CONCLUSION: At the doses used, oral creatine supplementation did not result in renal and/or hepatic toxicity. .

Proton magnetic spectroscopy agreed better with magnetic resonance image to lateralization of epileptogenic zone than with surface electroencephalography / Espectroscopia de protons de hidrogenio na investigacao ambulatorial das epilepsias extra-temporais

Objective To analyze the agreement rate of proton magnetic spectroscopy with magnetic resonance image (MRI) and surface electroence-phalography (EEG) in extratemporal neocortical epilepsies. Methods A cross-sectional study, type series of cases included 33 patients, age range 13–59 years old, of both gender, presenting structural alteration identified by MRI (75.8%) or by neurophysiologic techniques (72.7%). The variables were alterations of N-acetyl-aspartate/choline, N-acetyl-aspartate/creatine, choline/creatine, and N-acetyl-aspartate/cho-line+creatine coefficient of asymmetry. Results Agreement rates of lateralization by coefficient of asymmetry of NAA/Cho, NAA/Cr, Co/Cr, and NAA/Cho+Cr with MRI, independent of alteration of surface EEG, were equal to 93.3, 57.9, 15.4, and 93.3%, respectively, modifying to 100, 33.3, 0, and 100%, in 16 patients, with lateralization agreement of MRI and surface EEG. Conclusion Proton magnetic spectroscopy agreed better with MRI to lateralization of epileptogenic zone than with surface EEG. .

Objetivo Analisar a taxa de concordância da espectroscopia de prótons de hidrogênio com imagem de ressonância magnética (IRM) e o eletrencefalograma (EEG) de superfície nas epilepsias neocorticais extratemporais. Métodos Estudo transversal, série de casos, incluiu 33 pacientes, com idade de 13 a 59 anos, de ambos os gêneros, apresentando alteração estrutural à IRM (75,8%) ou neurofisiológica à (72,7%). As variáveis estudadas foram as alterações dos coeficientes de assimetria de N-acetil-aspartato/colina, N-acetil-aspartato/crea-tina, Colina/Creatina e N-acetil-aspartato/colina+creatina. Resultados As taxas de concordância de lateralização dos coeficientes de assimetria de NAA/Co, NAA/Cr, Co/Cr e NAA/Co+Cr com a IRM, independentemente de alterações do EGG de superfície, passaram de 93,3, 57,9, 15,4, 93,3%, respectivamente, para 100, 33,3, zero, 100%, em 16 pacientes, mostrando concordância de lateralização entre IRM e EEG de superfície. Conclusão A espectroscopia de prótons de hidrogênio concordou melhor com a lateralização da zona epileptogênica pela IRM do que com o EEG de superfície. .

Thalamic metabolic abnormalities in patients with Huntington's disease measured by magnetic resonance spectroscopy

Huntington's disease (HD) is a neurologic disorder that is not completely understood; its fundamental physiological mechanisms and chemical effects remain somewhat unclear. Among these uncertainties, we can highlight information about the concentrations of brain metabolites, which have been widely discussed. Concentration differences in affected, compared to healthy, individuals could lead to the development of useful tools for evaluating the progression of disease, or to the advance of investigations of different/alternative treatments. The aim of this study was to compare the thalamic concentration of metabolites in HD patients and healthy individuals using magnetic resonance spectroscopy. We used a 2.0-Tesla magnetic field, repetition time of 1500 ms, and echo time of 135 ms. Spectra from 40 adult HD patients and 26 control subjects were compared. Quantitative analysis was performed using the LCModel method. There were statistically significant differences between HD patients and controls in the concentrations of N-acetylaspartate+N-acetylaspartylglutamate (NAA+NAAG; t-test, P<0.001), and glycerophosphocholine+phosphocholine (GPC+PCh; t-test, P=0.001) relative to creatine+phosphocreatine (Cr+PCr). The NAA+NAAG/Cr+PCr ratio was decreased by 9% and GPC+PCh/Cr+PCr increased by 17% in patients compared with controls. There were no correlations between the concentration ratios and clinical features. Although these results could be caused by T1 and T2 changes, rather than variations in metabolite concentrations given the short repetition time and long echo time values used, our findings point to thalamic dysfunction, corroborating prior evidence.

Protective Effect of Hypoxic Preconditioning on Hypoxic-Ischemic Injured Newborn Rats

Brief episodes of cerebral hypoxia-ischemia cause transient ischemic tolerance to subsequent ischemic events that are otherwise lethal. This study was conducted to evaluate the protective effect of hypoxic preconditioning on hypoxic-ischemic injury in the neonatal rat and the persistence of a protective window after hypoxic preconditioning. The rats were preconditioned with hypoxia (8% oxygen, 92% nitrogen) for three hours, subjected to ischemia using ligation of the right common carotid artery, and then exposed to another three hours of hypoxia. Using proton magnetic resonance spectroscopy, terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) staining, and morphologic scores, this study shows that hypoxic preconditioning 6-hr to 1-day before hypoxic-ischemic injury increases survival rates and has neuroprotective effects against subsequent hypoxic-ischemic injury. The mechanism of the protective effects of hypoxic preconditioning in the newborn rat brain may involve downregulation of apoptotic cell death.

Determinaciones de niveles de creatina y lípidos mediante espectroscopia por resonancia magnética en miocardio de pacientes con insuficiencia cardiaca no isquémica / Myocardial lipids and creatine measured by magnetic resonance spectroscopy among patients with heart failure

Background: Heart failure (HF) is characterized, among other features, by the development of alterations in myocardial energy metabolism, involving a decrease in glucose utilization and increased free fatty acid uptake by cardiomyocytes, associated with decreased deposits of high-energy phosphates (creatine phosphate/ creatine transporter). Magnetic resonance (MR) imaging allows a direct and noninvasive assessment of myocardial metabolites. Aim: To measure myocardial creatine and lipids by MR spectroscopy among patients with HF. Material and Methods: Cardiac MR spectroscopy (1.5 Tesla) with Hydrogen antenna and single voxel acquisition was performed in fve patients with non-ischemic heart failure, aged 58 ± 9.7 years, (60 percent males) and 5 healthy volunteers matched for age and sex. We analyzed the signals of creatine (Cr), lipids (L) and water (W) in the interventricular septum, establishing the water/lipid (W/L) and water/creatine (W/Cr) index to normalize the values obtained. Results: Among patients, left ventricular ejection fraction was 32 ± 6.9 percent, 60 percent were in functional capacity II, 60 percent had hypertension and one was diabetic. Spectroscopic curves showed a depletion of total Cr, evidenced by the W/ Cr index, among patients with heart failure, when compared with healthy controls (1.46 ± 1.21 and 5.96 ± 2.25 respectively, p < 0,05). Differences in myocardial lipid content, measured as the W/L index, were not significant (5.06 ± 2.66 and 1.80 ± 1.62 respectively, p = 0.08). Conclusions: Among patients with heart failure of non-ischemic etiology, there is a depletion of creatine levels measured by MR spectroscopy.

Evaluation of Severity in Acute Pancreatitis / 대한소화기학회지

Acute pancreatitis has a variable etiology and natural history, and some patients have severe complications with a significant risk of death. The prediction of severe disease should be achieved by careful ongoing clinical assessment coupled with the use of a multiple factor scoring system and imaging studies. Over the past 30 years several scoring systems have been developed to predict the severity of acute pancreatitis. However, there are no complete scoring index with high sensitivity and specificity till now. The interest in new biological markers and predictive models for identifying severe acute pancreatitis testifies to the continued clinical importance of early severity prediction. Among them, IL-6, IL-10, procalcitonin, and trypsinogen activation peptide are most likely to be used in clinical practice as predictors of severity. Even if contrast-enhanced CT has been considered the gold standard for diagnosing pancreatic necrosis, early scanning for the prediction of severity is limited because the full extent of pancreatic necrosis may not develop within the first 48 hour of presentation.

Espectroscopia cerebral em candidatos a transplante hepático / Cerebral magnetic resonance spectroscopy in patients with hepatic encephalopathy: analysis before and after liver transplantation

OBJETIVOS: Determinar os níveis dos metabólitos (mio-inositol [MI], colina [Cho], glutamina [Glx], creatina [Cr] e N-acetilaspartato [NAA]) por meio da espectroscopia por ressonância magnética em portadores de hepatopatia crônica, antes e após o transplante hepático, correlacionando com a avaliação clínica. MÉTODOS: Foram estudados prospectivamente 25 pacientes portadores de hepatopatia crônica do Serviço de Transplante Hepático da Universidade Federal do Paraná por meio de avaliação clínica e espectroscópica. Trinta voluntários sadios formaram o grupo controle, sendo submetidos às mesmas avaliações. Dezesseis dos 25 pacientes também foram avaliados após o transplante. RESULTADOS: Antes do transplante hepático reduções significativas nos índices de MI/Cr e Cho/Cr e aumento significativo no índice de Glx/Cr foram observadas nos pacientes portadores de encefalopatia hepática comparados ao grupo controle. Os critérios quantitativos de Ross para diagnóstico espectroscópico da encefalopatia hepática (MI/Cr e Cho/Cr < média + 2 desvios padrão do grupo controle) demonstraram uma sensibilidade de 61,54 por cento, especificidade de 91,67 por cento e precisão de 76 por cento, sendo que a Cho/Cr foi o melhor parâmetro isolado. A espectroscopia após o transplante mostrou mudanças nos índices metabólicos comparados com o status pré-transplante. CONCLUSÃO: A espectroscopia permite um diagnóstico preciso da encefalopatia hepática. A melhora dos níveis metabólicos após o transplante hepático sugere um importante papel do MI e da Cho no desenvolvimento da encefalopatia hepática.

OBJECTIVES: To determine the metabolite levels (myo-inositol [MI], choline [Cho], glutamate [Glx], creatine [Cr] and N-acetylaspartate [NAA]) visible on magnetic resonance spectroscopy in patients with chronic hepatic failure, before and after liver transplantation and to correlate these data with results of neuropsychiatric tests and clinical findings. METHODS: Twenty five patients with chronic hepatic failure from the Liver Transplantation Unit of the Federal University of Parana were prospectively studied. Patients were submitted to clinical evaluation and magnetic resonance spectroscopy. Thirty healthy volunteers also submitted to the same evaluations. Sixteen of the 25 patients were evaluated after liver transplantation. RESULTS: Before liver transplantation, significant reductions in MI/Cr and Cho/Cr and a significant increase in Glx/Cr were observed in patients with hepatic encephalopathy compared with healthy subjects. The Ross's criteria for spectroscopic diagnosis of the hepatic encephalopathy (MI/Cr and Cho/Cr lower than 2 SD of controls) demonstrated a sensitivity of 61.54 percent, specificity of 91.67 percent and accuracy of 76 percent, further Cho/Cr was the best parameter. Spectroscopy after liver transplantation showed changes in the metabolite ratios compared with the pretransplantation status. CONCLUSION: Magnetic resonance spectroscopy permits an accurate diagnosis of hepatic encephalopathy. Improvement of metabolic ratios after liver transplantation suggests an important role of MI and Cho in the development of hepatic encephalopathy.

Proton magnetic resonance spectroscopy of the frontal, cingulate and perirolandic cortices and its relationship to skin conductance in patients with schizophrenia

The aim of the present study was to determine whether specific subgroups of schizophrenic patients, grouped according to electrodermal characteristics, show differences in the N-acetylaspartate/creatine plus choline (NAA / (Cr + Cho)) ratios in the frontal, cingulate and perirolandic cortices. Skin conductance levels (SCL) and skin conductance responses to auditory stimulation were measured in 38 patients with schizophrenia and in the same number of matched healthy volunteers (control). All subjects were submitted to multivoxel proton magnetic resonance spectroscopic imaging. When compared to the control group, patients presented significantly lower NAA / (Cr + Cho) ratios in the right dorsolateral prefrontal cortex (schizophrenia = 0.95 ± 0.03; control = 1.12 ± 0.04) and in the right (schizophrenia = 0.88 ± 0.02; control = 0.94 ± 0.03) and left (schizophrenia = 0.84 ± 0.03; control = 0.94 ± 0.03) cingulates. These ratios did not differ between electrodermally responsive and non-responsive patients. When patients were divided into two groups: lower SCL (less than the mean SCL of the control group minus two standard deviations) and normal SCL (similar to the control group), the subgroup with a lower level of SCL showed a lower NAA / (Cr + Cho) ratio in the left cingulate (0.78 ± 0.05) than the controls (0.95 ± 0.02, P < 0.05) and the subgroup with normal SCL (0.88 ± 0.03, P < 0.05). There was a negative correlation between the NAA / (Cr + Cho) ratio in the left cingulate of patients with schizophrenia and the duration of the disease and years under medication. These data suggest the existence of a schizophrenic subgroup characterized by low SCL that could be a consequence of the lower neuronal viability observed in the left cingulate of these patients.

Proton MR spectroscopy of the foramen of Monro region in patients with tuberous sclerosis complex / Espectroscopia de prótons por RM da região do forame de Monro em pacientes com complexo esclerose tuberosa

PURPOSE: To evaluate with 1H-magnetic resonance spectroscopy (MRS) the metabolites rations of the foramen of Monro's region in patients with tuberous sclerosis complex (TSC). METHOD: Twelve patients with TSC and an age and gender-matched control group underwent MR imaging at a 1.5T scanner, and 1H-MRS at the foramen of Monro level with a multivoxel acquisition. Similar volumes of interest were selected in each side of the foramen of Monro and in the basal ganglia (lentiform nuclei). The obtained N-acetylaspartate (NAA), creatine (Cr) and choline (Cho) peak amplitude values and ratios were studied. The statistical analysis was performed and p<0.05 was considered statically significant. RESULTS: There was no significant difference between the NAA/Cr and Cho/Cr ratios near to the foramen of Monro and basal ganglia of the TSC patients compared with the controls (p>0.05). CONCLUSION: The NAA/Cr and Cho/Cr ratios near to the foramen of Monro and basal ganglia of TSC patients are similar to the rations obtained in the control group.

OBJETIVO: Avaliar através de espectroscopia de prótons as relações dos metabólitos da região do forame de Monro em pacientes com complexo esclerose tuberosa (CET). MÉTODO: Doze pacientes com CET e um grupo controle pareado por sexo e idade realizaram RM em aparelho de 1,5T, e a espectroscopia de prótons foi obtida ao nível do forame de Monro com aquisição multi-voxel. Volumes de interesse similares foram posicionados em cada lado do forame de Monro e nos gânglios da base (núcleos lentiformes). Os valores das relações e amplitudes de pico do N-acetilaspartato (NAA), creatina (Cr) e colina (Cho) foram estudados. A análise estatística foi realizada e valores de p<0,05 foram considerados estatisticamente significativos. RESULTADOS: Não houve diferença significativa entre as relações NAA/Cr e Cho/Cr na região do forame de Monro e nos gânglios da base dos pacientes com CeT comparados com os controles (p>0,05). CONCLUSÃO: As relações NAA/Cr e Cho/Cr na região do forame de Monro e nos gânglios da base de pacientes com CET são semelhantes àquelas obtidas no grupo controle.

Estimation of postmortem interval with single-voxel proton 1H-MR spectroscopy at different temperature / 法医学杂志

OBJECTIVE@#To find an objective method for estimation of postmortem interval (PMI) with single-voxel proton MR spectroscopy at different temperature.@*METHODS@#Changes of metabolite peak area and peak area ratio of the N-acetylaspartate (Naa), choline (Cho) and total creatine (Cr) in the brain of 24 rabbit models were measured by 1H-MR spectroscopy (1H-MRS) at 0.5, 1, 2, 4, 6, 8, 12, 16 and 24 h, respectively after death.@*RESULTS@#Naa and Cr decreased continuously with the extension of PMI, and the ratios of Naa/Cr and Cho/Cr also decreased continuously with the extension of PMI within 24 h. The quadratic polynomial regression equation is y=0.0019x2-0.803x+1.4498 (R2=0.962) (Equation 1) with the Naa/Cr used as an independent variable, while the quadratic polynomial regression equation is y=-0.0024x2+0.926x+1.1777 (R2=0.986) (Equation 2) with the Cho/Cr used as an independent variable. The average deviations were about 2.10-37.90 min and 1.69-40.87 min, respectively if the PMI was estimated by Equation 1 and Equation 2, respectively.@*CONCLUSION@#Our study indicates that there is a strong correlation between Naa/Cr, Cho/Cr and PMI, which may be used for estimation of PMI at different temperature.

Merosin-positive congenital muscular dystrophy: neuroimaging findings

Congenital muscle dystrophy (CMD) is a heterogeneous group of autosomal recessive myopathies. It is known that CMD may affect the central nervous system (CNS). Some authors have shown that merosin-negative CMD patients may have encephalic metabolic disturbances. In order to study metabolic changes within the brain, the authors performed a magnetic resonance spectroscopy (MRS) study in a 1-year-old girl with merosin-positive CMD (MP-CMD). MRS of brain demonstrated that NAA/Cr ratio was decreased (1.52), while Cho/Cr ratio was increased (1.78). These findings suggest that metabolic changes in CNS can also be found in patients with MP-CMD.

A distrofia muscular congênita (DMC) é um grupo heterogêneo de miopatias autossômicas recessivas que também podem afetar o sistema nervoso central (SNC). Alguns autores mostraram previamente que pacientes com DMC por deficiência da merosina podem apresentar alterações metabólicas no encéfalo. Com o objetivo de estudar as possíveis alterações metabólicas no SNC, os autores realizaram um estudo por ressonância magnética com espectroscopia em uma paciente de 1 ano com DMC sem deficiência da merosina. A razão NAA/Cr estava reduzida (1,52), enquanto que a razão Cho/Cr estava aumentada (1,78). Estes achados sugerem que alterações metabólicas no SNC também podem ser encontradas em pacientes com DMC merosina-positiva.

Subependymal giant cell astrocytoma with high choline/creatine ratio on proton MR spectroscopy / Astrocitoma subependimário de células gigantes com alta relação colina/creatina à espectroscopia de prótons por ressonância magnética

OBJECTIVE: To report a case of subependymal giant cell astrocytoma (SEGA) in a patient with tuberous sclerosis, emphasizing the proton MR spectroscopy (MRS) findings. CASE: A three year-old boy with tuberous sclerosis presented with a 3-month history of mild headache. The physical examination showed discrete mental retardation and multiple hypomelanic macules in the legs and back. MRI showed many cortical tubers and subependymal nodules. At the left foramen of Monro, there was a 15 mm nodule, with heterogeneous signal on T1 and T2-weighted images, and strong enhancement after contrast administration. MRS study (multi-voxel PRESS, TE=144ms) showed the following ratios: a) left foramen of Monro nodule N-acetylaspartate (NAA)/creatine (Cr)=0.93 and Choline (Cho)/Cr=1.6 and b) at the right Monro foramen NAA/Cr=1.56 and Cho/Cr=1.29. CONCLUSION: The MRS performed at the SEGA may show high Cho/Cr and low NAA/Cr ratios, similar to the other brain neoplasms. As a consequence, MRS may be a valuable tool for the early detection of neoplastic transformation of subependymal nodules near the foramina of Monro in patients with tuberous sclerosis.

OBJETIVO: Relatar caso de astrocitoma subependimário de células gigantes (ASCG) em paciente com esclerose tuberosa, enfatizando os achados de espectroscopia de prótons por ressonância magnética (EPRM). CASO: Um menino de três anos de idade apresentou-se com cefaléia por três meses. O exame físico demonstrou retardo mental discreto e múltiplas máculas hipomelanóticas no dorso e pernas. A ressonância magnética (RM) evidenciou múltiplos túberes corticais e nódulos subependimários. No forame de Monro esquerdo foi observado um nódulo de 15 mm, com sinal heterogêneo nas imagens ponderadas em T1 e T2, e realce intenso após a administração de contraste. A EPRM (multi-voxel PRESS, TE=144ms) demonstrou as seguintes relações: a) no nódulo no forame de Monro esquerdo N-acetilaspartato (NAA)/creatina (Cr)=0,93 e colina (Cho)/Cr=1,6 e b) no forame de Monro direito NAA/Cr=1,56 and Cho/Cr=1,29. CONCLUSÃO: A EPRM pode demonstrar relações altas de Cho/Cr e baixas de NAA/Cr em pacientes com ASCG, semelhante a outros tumores cerebrais. Sendo assim, a EPRM pode representar importante ferramenta diagnóstica na detecção precoce de transformação neoplásica de nódulos subependimários próximos ao forame de Monro em pacientes portadores de esclerose tuberosa.

Espectroscopia de prótons na doença de Alzheimer e no comprometimento cognitivo sem demência: estudo de uma amostra comunitária / Proton spectroscopy in Alzheimer's disease and cognitive impairment not dementia: a community study

OBJETIVO: Descrever os achados da espectroscopia de prótons (¹H-ERM) na doença de Alzheimer (DA) e no comprometimento cognitivo sem demência (CIND) em uma amostra da comunidade. MÉTODO: Foram avaliados seis pacientes com DA, sete com CIND e sete controles normais, originários da comunidade. ¹H-ERM foi realizada com voxel de 8 cm³ nas regiões temporal direita, parietal esquerda e occipital medial e estudados os metabólitos: N-acetilaspartato (NAA), creatina (Cr), colina (Cho) e mio-inositol (mI). RESULTADOS: O NAA foi maior nos indivíduos controles do que nos DA e intermediário no CIND. Análise de função discriminante mostrou que as associações Cr parietal-Cr occipital e Cr parietal-Cho occipital identificaram corretamente 92,3 por cento da amostra comparando Controle vs DA. Na comparação Controle vs CIND O mI temporal identificou corretamente 78,6 por cento dos indivíduos. CONCLUSÃO: A espectroscopia pode contribuir para o diagnóstico e seguimento de indivíduos com comprometimento cognitivo; avaliações de pacientes da comunidade podem revelar achados diferentes quanto à distribuição dos metabólitos cerebrais.

Trasplante renopancratico. Experiencia inicial en un centro de trasplante en Argentina / Kidney and pancreas tranplantation. Initial experience at a single transplant center in Argentina

Luego de más de 10 000 casos comunicados en todo el mundo hasta 1998, el trasplante simultáneo de páncreas y riñon se ha estabelecido como una práctica clínica segura y probablemente constituya el mejor tratamento existente para la diabetes mellitus con nefropatía terminal. Presentamos nuestros resultados de 12 trasplantes pancreáticos (8 vascularizados y 4 de islotes), realizados en pacientes diabéticos insulino-dependientes. Once de ellos recibieron simultáneamente un riñon. Uno requiró un retrasplante renal. Todos los páncreas vascularizados se implantaron en forma intraperitoneal, con anastomosis a los vasos ilíacos y drenaje exócrino a la vejiga. La sobrevida a un año para paciente, páncreas vascularizado y riñon fue de 86 por ciento, 86 por ciento y 71 por ciento respectivamente. Todo están libres de insulina y diálisis; el receptor de mayor sobrevida lleva 37 meses. Los islotes se obtuvieron de donantes cadavéricos únicos y se transplantaron en el peritoneo, por vía laparoscópica, sin procesos previos de cultivo ni purificación (islotes equivalentes por paciente: 3x10(5), 4x10(5), 1x10(6) y 5x10(5). Ninguno de los receptores de islotes quedó libre de insulina pero redujeron sus requerimentos en aproximadamente 40 por ciento, con mejor control metabólico (promedio HbA1c pretrasplante 9.4 + 1.8 vs 7.9 + 1.6 postrasplante). Un injerto renal se perdió en este grupo por trombosis venosa. El transplante renopancreático ofrece al paciente diabético en insuficiencia renal terminal la doble posibilidad de independizarse de la diálisis y del uso de insulina exógena. Los resultados funcionales con el páncreas entero son mejores que con islotes. Sin embargo, para aquellos pacientes diabéticos que no son aptos para recibir un páncreas vascularizado, el trasplante celular puede mejorar el metabolismo de los carbohidratos exponiendo al paciente a riesgo quirúrgicos mínimos.

Avaliaçäo da necessidade da dosagem rotineira de hematócrito, hemoglobina, uréia e creatinina séricos durante a avaliaçäo pré-anestésica / Assessment of the need for routine dosage of hematocrits, hemoglobin, blood urea nitrogen and serum creatinine during preoperative evaluation

Justificativa e objetivos - Muitas dúvidas e opiniöes existem quanto à realizaçäo de exames pré-operatórios de maneira rotineira, como parte integrante da avaliaçäo pré-anestésica. As tendências atuais apontam para a realizaçäo desses exames fundamentada em avaliaçäo clínica e exame físico detalhados, que säo as bases da avaliaçäo pré-anestésica. Como esses testes laboratoriais continuam sendo realizados indiscriminadamente e as dúvidas quanto a seu real valor também persistem, idealizamos este trabalho com o objetivo de avaliar os resultados de hematócrito, de hemoglobina, de uréia e de creatinina séricos, testes solicitados rotineiramente na avaliaçäo pré-operatória de pacientes candidatos a cirurgias eletivas, determinando sua necessidade e possivelmente esclarecer essas dúvidas. Método - foram estudados 1065 pacientes com idade a partir de 12 anos, estado físico ASA I, II e III, internados para realizaçäo de procedimento cirúrgico eletivo, divididos em sete grupos de diferentes faixas etárias, com distribuiçäo aleatória em relaçäo ao sexo. Foram observados e analisados os resultados dos exames laboratoriais de hematócrito, hemoglobina, uréia e creatinina séricos, que fazem parte da rotina de avaliaçäo pré-operatória da maioria das clínicas cirúrgicas de nosso hospital. A análise estatística realizada para cada variável estudada foi a Análise de Variância e, para a comparaçäo grupo a grupo, o Teste de Comparaçäo Múltipla de Benferroni. As diferenças foram consideradas significativas quando p < 0,05 ou 5 por cento. Resultados - Para os 1065 pacientes estudados, obtivemos um total de 4025 exames laboratoriais solicitados, sendo semelhante o número de exames realizados em cada grupo. Para os resultados de hematócrito e hemoglobina näo houve diferença entre os grupos e os valores situaram-se dentro de limites da normalidade. Considerando-se a uréia e a creatinina séricas, houve diferença entre os grupos de pacientes mais novos e aqueles de pacientes mais idosos e os resultados näo mostraram anormalidades significativas em todos os grupos. Conclusöes - concluímos que os valores médios obtidos, tanto de hematócrito e hemoglobina, quanto de uréia e creatinina séricos, em todos os grupos etários, säo aceitáveis para pacientes cirúrgicos, de uma maneira geral. Todavia, sua utilidade é mínima se realizados independentemente da avaliaçäo clínica. Assim, esses exames pré-operatórios de rotina devem ser abandonados e a boa prática clínica e o bom senso é que...

Creatina intraeritrocítica como valoración de la edad celular / Erythrocyte creatine as appraisal of cellular age

El índice de reticulocitos es el parámetro más utilizado para medir la producción eritrocitaria medular. Sin embargo, como éste ha sido asociado con cierto grado de error estadístico, se ha buscado un método objetivo y de fácil realización, la determinación de creatina intraeritrocítica, para obtener una mayor información acerca de la edad eritrocitaria en determinados procesos hemolíticos. La misma se determinó por el método del diacetil alfa-naftol, observándose una linealidad hasta 400 mg/l. Los valores de creatina obtenidos en el grupo control (n=100)fueron de 24 a 69 mg/l, y se utilizó el logaritmo de estos valores para normalizar la distribución de los datos. Se analizó un grupo de muestras de 216 pacientes con diferentes diagnósticos, obteniéndose valores aumentados del conteo de reticulocitos en un 75 por ciento de los casos de creatina intraeritrocítica en un 63 por ciento. Sin embargo, en un 13 por ciento de las muestras se obtuvieron valores aumentados de creatina intraeritrocítica con un conteo de reticulocitos normal o disminuido. Sin restarle su debida importancia a la determinación de reticulocitos, se recomienda realizar el análisis de creatina como dato complementario en el estudio de aquellos síndromes hemolíticos idioáticos que cursen con conteos normales o subnormales de reticulocitos