Comportamiento de la hemorragia digestiva alta en el quinquenio 2009 a 2013 / Behavior of the high digestive bleeding in the five-year period 2009-2013

Introducción: la hemorragia digestiva alta constituye un problema frecuente de salud en el mundo; así se comporta en Cuba, en la provincia Matanzas y en el hospital de estudio. Actualmente es considerada como causa mayor de morbimortalidad. Objetivo: determinar el comportamiento de la hemorragia digestiva alta en el Hospital Militar de Matanzas. Materiales y Métodos: se realizó una investigación descriptiva, en un periodo de cinco años que incluyó a todos los pacientes ingresados con ese diagnóstico, y los que durante su ingreso por otra causa presentaron episodios de hemorragia. El índice de Rockall permitió evaluar la necesidad de cirugía, recidiva y mortalidad. Resultados: la mayoría de los pacientes pertenecieron al grupo de riesgo intermedio. Los hombres fueron los más afectados, el grupo de tercera edad presentó mayor incidencia. La gastritis hemorrágica fue la primera causa de sangrado. La hipertensión arterial resultó ser el factor de riesgo relevante y el tabaquismo el hábito tóxico más frecuente. Conclusiones: como beneficio relevante se demostró la importancia de la endoscopia precoz para el diagnóstico de la causa, tratamiento y pronóstico de la hemorragia. Se observó una buena correlación entre el pronóstico del paciente al ingreso y su estado al final del tratamiento (AU).

Introduction: the high digestive hemorrhage is a frequent health problem in the world; it behaves the same in Cuba, in the province of Matanzas and in the hospital where the study was carried out. Currently it is considered a major cause of morbi-mortality. Objective: to determine the behavior of the high digestive bleeding in the Military Hospital of Matanzas. Materials and Methods: a descriptive research was carried out in a five-year period. It included all the patients admitted with that diagnosis and those who presented episodes of hemorrhage even if they were admitted by any other cause. The Rockall index allowed to assess the necessity of surgery, the recidivism and mortality. Results: most of the patients belonged to the intermediate risk group. Male patients were the most affected one; the group of elder people showed higher incidence. Hemorrhagic gastritis was the first cause of bleeding. Arterial hypertension was the relevant risk factor and smoking the most frequent toxic habit. Conclusions: as a relevant benefit it was showed the importance of precocious endoscopy for the diagnosis of the hemorrhage cause, treatment and prognosis. It was observed a good correlation between the patient´s prognosis at the admission and his status at the end of the treatment (AU).

Caracterização das leptospiras isoladas dos pacientes atendidos no Hospital Couto Maia / Characterization of isolated leptospires of patients seen in the hospital Couto Maia

A leptospirose é uma zoonose de distribuição mundial, com 1,2 milhões de casos registrados a cada ano. De 1996 a 2013, o grupo de pesquisa de leptospirose do CPqGM, realiza uma vigilância ativa no Hospital Couto Maia em Salvador-Ba, onde foi recrutado 4612 casos suspeitos para leptospirose. Destes 4612 foi confirmado o diagnóstico de 1853 (40%) utilizando pelo menos um dos três métodos de diagnóstico (MAT, Hemocultura, qPCR). Dentre os casos confirmados, 1759 (95%) foram confirmados pelo MAT. A sensibilidade do MAT foi diferente entre as amostras aguda e convalescente, sendo 60% na fase aguda e 97% na fase convalescente. O sorogrupo Icterohaemorrhagiae foi o mais prevalente (90%) dos casos confirmados para MAT. Durante o período do estudo foram coletadas 1133 hemoculturas e destas 203 (18%) foram positivas, sendo possível isolar leptospiras de 93/203 (45%) das hemoculturas, as quais foram soro-agrupadas com soros heterológos de coelho. A concordância entre o sorogrupo encontrado no MAT e na soro-agrupagem foi de 80%. Os achados mostram que existe uma concordância significante entre o sorogrupo encontrado pelos dois métodos, o que indica que o painel de cepas utilizado no MAT apresenta uma ótima cobertura para os sorogrupos prevalentes na região. A predominância de um sorogrupo facilitou quanto a tomadas de decisões para prevenção e controle, assim como facilita para o desenvolvimento de novos testes de diagnóstico e vacinas mais direcionados.

Leptospirosis is a re-emerging zoonotic disease of global importance, with 1,2 million cases reported each year. Diagnosis of leptospirosis is often difficult given the nonspecific disease presentation. In order to compare the performance of the two gold standard diagnostic tests for leptospirosis, the group enrolled 4612 patients with suspected leptospirosis during active surveillance at the state infectious disease reference hospital, Hospital Couto Maia, in Salvador, Bahia between 1996 and 2013. Of these, was confirmed Leptospira infection in 1853 (40%) using at least one of three diagnostic methods (microagglutination (MAT), blood culture, and qPCR). Was confirmed 1759 (95%) cases using only the MAT assay, and identified the serogroup Icterohaemorrhagiae as the infective agent in 90% of MAT positive samples. It was determined the sensitivity of the MAT was 60% for acute phase samples and increased to 97% for convalescent samples. Within this study period, it was possible to collect 1133 blood cultures and was isolated leptospires from 93 of 203 (45%) of blood cultures, and determined the serotype using heterologous rabbit sera. The concordance between the infective serogroup identified using hemoculture and MAT techniques was 80%. This result indicates that the panel of 11 strains used in the MAT represents a majority of the infective serogroups causing disease in our study population. The predominance of a single serogroup in symptomatic cases informs the development of new diagnostic tests and novel vaccines to prevent leptospirosis in Brazil.

Segurança da ablação de fibrilação atrial com RNI terapêutico: comparação com a transição com heparina de baixo peso / Safety of ablation for atrial fibrillation with therapeutic INR: comparison with transition to low-molecular-weight heparin

FUNDAMENTO: O manejo ideal da anticoagulação oral (ACO) no período pré- e pós-ablação de fibrilação atrial (FA) ainda é motivo de controvérsia. OBJETIVO: Comparar duas estratégias de anticoagulação: suspensão da warfarina com a utilização de heparina de baixo peso molecular (HBPM) e a realização da ablação sem a suspensão da warfarina, mantendo o RNI terapêutico (entre 2,0 e 3,0). MÉTODOS: 140 pacientes (pt) portadores de FA persistente/ permanente submetidos à ablação por cateter de FA foram divididos em dois grupos: no grupo I (70 pt), a warfarina foi suspensa cinco dias antes do procedimento e utilizada terapia de transição com HBPM (enoxaparina 1 mg/kg 2x/dia pré-ablação e 0,5 mg/kg 2x/dia após o procedimento); no grupo II (70 pt), a warfarina não foi suspensa e o procedimento foi realizado com RNI terapêutico. Ambos os grupos receberam heparina intravenosa (TCA > 350 seg) durante o procedimento. RESULTADOS: No Grupo I, observou-se complicação hemorrágica maior (1,4 por cento) e 4 pt (5,7 por cento) com complicações hemorrágicas menores. No Grupo II, 2 pt (2,8 por cento) apresentaram complicações hemorrágicas menores e 1 pt apresentou sangramento maior; porém, este ocorreu após uso de HBPM por RNI < 2,0. Não houve complicação tromboembólica ou morte cardiovascular nos dois grupos após 16 ± 8 meses. CONCLUSÃO: A realização de ablação por cateter de FA sem a suspensão de ACO e RNI terapêutico é uma estratégia semelhante em segurança e eficácia quando comparada à tradicional transição com HBPM, evitando um período inicial pós-ablação de anticoagulação potencialmente inadequada.

BACKGROUND: The ideal management of oral anticoagulation (OAC) before and after catheter ablation for atrial fibrillation (AF) is still controversial. OBJECTIVE: To compare two anticoagulation strategies for catheter ablation for AF: warfarin withholding and use of low-molecular-weight heparin (LMWH); and maintenance of warfarin and therapeutic INR (between 2.0 and 3.0). METHODS: 140 patients (pt) with persistent/permanent AF undergoing catheter ablation for AF were divided into two groups: Group I (70 pt), in which warfarin was withheld five days prior to the procedure and transition to LMWH was used (enoxaparin: 1 mg/kg 2x/day before ablation, and 0.5 mg/kg 2x/day after ablation); Group II (70 pt), in which warfarin was not withheld and the procedure was performed with therapeutic INR. Both groups received intravenous heparin (ACT > 350 seconds) during ablation. RESULTS: In Group I, one pt (1.4 percent) had a major hemorrhagic complication and four pts (5.7 percent) had minor hemorrhagic complications. In Group II, two pts (2.8 percent) had minor hemorrhagic complications and one pt had a major bleeding, which occurred after using LMWH due to INR < 2.0. None of the groups had thromboembolic complications or cardiovascular death over a period of 16 ± 8 months. CONCLUSION: Catheter ablation for AF without withholding OAC and with therapeutic INR is a strategy that has similar safety and efficacy when compared with the traditional transition to LMWH, avoiding the potentially inadequate anticoagulation of the initial post-ablation period.

Hemorragia Digestiva alta / Upper gastrointestinal tract hemorrhage

La Hemorragia Digestiva Alta (HDA) continua siendo un tema de constante revisión, no solo por los diferentes enfoques terapéuticos actuales, sino por una serie de circuntancias particulares y específicas propias de la patologías que la producen. La HDA es una de las complicaciones agudas de la enfermedad Cloridro-Péptica o de las Varices Esofágicas, que exige un tratamiento de regimen intensivo, para detener el sangramiento .

Homeostatic disorders in habitual nose bleeders

Two hundred and fifty [250] patients with repeated epistaxis were studied: 21.6% of them were found to have general cause for epistaxis not associated with defects in the haemostasis mechanism, 60.4% had local cause including those with blow-out haemorrhage from the lateral nasal wall and the rest had a defect in the primary haemostasis mechanism; 14.8% of them with a platelet dysaggregation, 0.4% had a defect in the capillary resistance, 1.6% were suffering from Von Willebrand disease and 1.21% from a deficiency of factor IX activity

Platelet dysfunction in malaria.

Platelet function tests including platelet aggregation, PF3, bleeding time and clot retraction were studied in 48 malarial patients. The suppression of platelet aggregation was demonstrated in both P. vivax and P. falciparum infection. However, this abnormality was more prominent in malarial patients who had systemic complications and bleeding. The recovery of the impaired platelet aggregation was observed at period of 7 and 14 days after parasitemia in malarial patients without and with systemic complications. The correlation between the suppression of platelet aggregation and thrombocytopenia was observed. From this study, bleeding in malaria are operated by two mechanisms: thrombocytopenia and severely depressed platelet aggregation.

Tratamento da esquistossomose hepatoesplênica com praziquantel: aspectos evolutivos / Ultrasonography in the diagnosis of hepatosplenic form of schistosomiasis portal hypertension and its

Foram tratados, com um novo medicamento antiesquistossomótico, derivado isoquinolinopirazino, Praziquantel, 42 pacientes com a forma hepatoes~lênica da esquistossomose mansônica, com o objetivo de se verificar a eficácia da droga e os efeitos do tratamento, a longo Drazo, sobre a evolução clínica, particularmente da hepatoesplenomegalia e dos testes de função hepática. Os exames parasitológicos de fezes e os testes bioquímicos (aspartato aminotransferase, alanina aminotransferase, gamaglutamiltranferase,fosfatase alcalina, bromosulfaleína, bilirrubinas total e direta e eletroforese das proteínas séricas) foram realizados antes do tratamento, e no 19 mês, 39, 69 e 129 meses apos o tratamento. O exame clínico e as medidas do fígado e do baço, além destas ocasiões, foram efetuados anualmente, até o 59 ano póstratamento. Foram calculadas as médias e os desvios padrões e aplicados os testes estatísticos adequados. Obteve-se, como principais conclusões, aos 12 meses: um percentual de cura de 83,33%; importante redução do número de ovos por grama de fezes, nos casos nao curados, com menor diminuição nos pacientes mais jovens; redução significante dos valores médios de aspartato aminotransferase, alanina aminotransferase, fosfatase alcalina e gamaglobulina sérica; elevação do valor médio da albumina sérica; não alteração dos valores médios de gamaglutamiltransferase, bromosulfaleína e bilirrubina total e direta; redução do fígado, en 80,95% dos pacientes, e não alteração, em 19,05%; redução do baço, em 78,79% dos indivíduos, e não alteração, em 21,21%; reversão da forma hepatoesplênica para a hepatointestinal, em 15,15% dos pacientes. Ao final do 59 ano, a diminuição do tamanho do fígado e do baço foi semelhante à observada após um ano de tratamento.

Haemorrhage in neonatal hepatic necrosis due to herpes infection.

A case of early neonatal severe bleeding and persistent hypoglycemia with a fatal outcome is reported. The autopsy examination revealed the features of neonatal hepatic necrosis. Further study by the electron microscopy indicated the presence of herpes type particles in the nucleus and cytoplasm of the remaining liver cells. Serological study of the maternal blood, post partum, revelaed positive reaction to Herpes simplex virus type 2 at low titer. It is believed that intrauterine herpes infection was responsible for the severe hepatic damage manifesting in complex clinical findings.

Bleeding manifestations in snake bite.

Bleeding following bites by the Malayan Pit Viper can either be local or systemic. Bleeding at the site of the bite is due to the local action of the venom as a vasculotoxin. Systemic bleeding occurs with severe poisoning and appears to be mainly dependent on platelet deficiency and the co-existing defibrination syndrome appears to play a minor role in the initiation of bleeding. Thus in the clinical situation non-clotting blood with no overt bleeding can continue up to weeks when specific antivenene is not given. Assessment of the severity of poisoning can easily be made at the bedside. Specific viper antivenene rapidly corrects the spontaneous bleeding and clotting defect of severe systemic poisoning but has no effect on local poisoning.