Trombosis seno sagital superior en el puerperio: reporte de un caso clinico / Upper sagittal sinus thrombosis in the puerperium: report of a clinical case

Gestante de 34 semanas de gestación, diagnosticada de preeclampsia con restricción del crecimiento fetal intrauterino. La paciente presentaba alteración en las cifras tensionales con proteinuria positiva en muestra aislada y un índice de proteínas/creatinina en orina de 3.07 mg/mg. Por estos motivos, previa maduración pulmonar, y una vez establecido el tratamiento hipotensor adecuado, se le realizó una cesárea con buena recuperación posterior y normalidad en las cifras tensionales por lo que la paciente fue dada de alta sin precisar tratamiento hipotensor de control. Una semana después del alta, la paciente acude de nuevo al centro hospitalario refiriendo cefalea holocraneal con pérdida de la sensibilidad en el miembro superior derecho. Tras los estudios pertinentes la paciente fue diagnosticada de trombosis del seno sagital superior, iniciándose tratamiento anticoagulante con buena tolerancia al mismo y una recuperación completa del cuadro sin secuelas.

Pregnant 34 weeks gestation diagnosed with preeclampsia with fetal intrauterine growth restriction. The patient had alteration blood presure with positive test of sample isolated proteinuria and an index of protein / creatinine ratio 3.07 mg / mg. For these reasons, previous lung maturation and the antihypertensive treatment was established, a cesárea was realized with good later recovery and normal blood presure. The patient went home without antihypertensive therapy. The patient came to the hospital again a week later, with intense holocraneal headache with loss of sensation in the right arm. After the relevant studies, the patient was diagnosed with thrombosis of the superior sagittal sinus starting anticoagulant therapy with good tolerance to it and a full recovery without sequelae. Pregnancy and specifically puerperium involves stages of risk for development of vascular disease in the brain especially in pathological processes such as preeclampsia. It is important to identify these patients to treat them, also to establish prevention protocols for future pregnancies to help reduce both maternal and fetal morbidity.

Endogenous interleukin (IL)-17A promotes pristane-induced systemic autoimmunity and lupus nephritis induced by pristane.

Interleukin (IL)-17A is increased both in serum and in kidney biopsies from patients with lupus nephritis, but direct evidence of pathogenicity is less well established. Administration of pristane to genetically intact mice results in the production of autoantibodies and proliferative glomerulonephritis, resembling human lupus nephritis. These studies sought to define the role of IL-17A in experimental lupus induced by pristane administration. Pristane was administered to wild-type (WT) and IL-17A(-/-) mice. Local and systemic immune responses were assessed after 6 days and 8 weeks, and autoimmunity, glomerular inflammation and renal injury were measured at 7 months. IL-17A production increased significantly 6 days after pristane injection, with innate immune cells, neutrophils (Ly6G(+)) and macrophages (F4/80(+)) being the predominant source of IL-17A. After 8 weeks, while systemic IL-17A was still readily detected in WT mice, the levels of proinflammatory cytokines, interferon (IFN)-γ and tumour necrosis factor (TNF) were diminished in the absence of endogenous IL-17A. Seven months after pristane treatment humoral autoimmunity was diminished in the absence of IL-17A, with decreased levels of immunoglobulin (Ig)G and anti-dsDNA antibodies. Renal inflammation and injury was less in the absence of IL-17A. Compared to WT mice, glomerular IgG, complement deposition, glomerular CD4(+) T cells and intrarenal expression of T helper type 1 (Th1)-associated proinflammatory mediators were decreased in IL-17A(-/-) mice. WT mice developed progressive proteinuria, but functional and histological renal injury was attenuated in the absence of IL-17A. Therefore, IL-17A is required for the full development of autoimmunity and lupus nephritis in experimental SLE, and early in the development of autoimmunity, innate immune cells produce IL-17A.

[Determination of target volume in pediatric radiotherapy: application to brain tumors]. / La détermination des volumes-cibles en radiothérapie pédiatrique: application aux tumeurs cérébrales.

Pediatric tumors have enjoyed considerable improvements for the past 30 years. This is mainly due to the extensive use of combined therapeutical modalities in which chemotherapy plays a prominent role. In many children, local treatment including radiotherapy, can nowadays be adapted in terms of target volume and dose to the "response" to an initial course of chemotherapy almost on a case by case basis. This makes precise recommendation on local therapy highly difficult in this age group. We will concentrate in this paper on brain tumors in which chemotherapy is of limited value and radiotherapy still plays a key-role.

Protection of coronary angioplasty-induced oxidative stress by Isovue used during angioplasty.

BACKGROUND: Oxygen free radicals (OFRs) have been implicated in ischemic-reperfusion cardiac injury. Use of percutaneous transluminal coronary angioplasty (PTCA) has created renewed interest in salvation of ischemic myocardium. The PTCA procedure is similar to the ischemia-reperfusion model. It is possible that OFRs are increased following PTCA. However, OFR-related cardiac complications are uncommon and the evidence for lipid peroxidation is conflicting. PATIENTS AND METHODS: In this study the levels of plasma malondialdehyde, OFR-producing activity of polymorphonuclear leukocytes (PMNL-CL) and blood antioxidant enzymes (superoxide dismutase, catalase and glutathione peroxidase) were measured in peripheral venous blood of 50 consecutive patients with stable angina undergoing elective PTCA. The ability of Isovue (used during PTCA) and of streptokinase (used during thrombolysis) to scavenge OH in the high performance liquid chromatography method and to reduce OH-induced lipid peroxidation were also assessed. Patients were divided into three groups: group 1, single vessel PTCA; group 2, two or more vessel PTCA; and group 3, combined single and multivessel PTCA. RESULTS: The results indicated that there was an increase in PMNL-CL (22% to 44%) and a decrease in plasma malondialdehyde (33% to 40%) at 60 mins following PTCA. The activity of antioxidant enzymes remained unaltered. Isovue scavenged OH in a concentration-dependent manner and was complete at a concentration below that used in patients. Streptokinase, on the other hand, was ineffective in scavenging OH. CONCLUSIONS: These results suggest that, in spite of increased production of OFR by polymorphonuclear leukocytes and unaltered activity of antioxidant enzymes, lipid peroxidation decreased. Lack of lipid peroxidation may have been due to the OH-scavenging property of Isovue. The observed differences in OFR-related complications between PTCA and thrombolytic therapy may have been due to the antioxidant activity of Isovue.

[Selected indications of embolization of vascular malformations of the face. Apropos of 2 cases]. / Indications raisonnées de l'embolisation dans les malformations vasculaires de la face. A propos de deux cas.

Interventional radiology has dramatically contributed to a better management of patients with a facial vascular malformation. Due to the extent of the lesion, these patients were formerly difficult to cure, but hyperselective embolisation can now overcome these problems with minimal risks. We present our therapeutic approach in 2 cases with favorable results and the choice of an embolization particle is discussed according to recent datas.

[District allocation and utilization of health care services in Pau da Lima, Salvador, Bahia, Brazil]. / O processo de distritalização e a utilização de serviços de saúde - avaliação do caso de Pau da Lima, Salvador, Bahia, Brasil.

This cross-sectional study is aimed at the identification of patterns in the utilization of health care services in Pau da Lima, a neighborhood in the city of Salvador, Bahia. In 1992, a household survey was carried out with 384 families selected through a random cluster sampling design. In each household, the family head or a surrogate informant was asked to answer a questionnaire about their use of any type of health care in the last month. From the total of 1,887 individuals, 236 reported at least one visit to health facilities during the referent period This means an estimated prevalence of health services utilization of 12.5%. With regard to the type of services, 25.9% of all visits were made to public sector facilities. Attendants were mainly women (73.7%) from 15 to 29 years of age. The main reason reported for the choice of the health facility was availability (63.7%), and the major reason for seeking health care was disease-related conditions (75.7%), rather than preventive procedures. These findings may result from the still unfinished process of distritalização(district allocation of services), which is evident in the lack of health services' infrastructure or coverage, as well as in persistent organizational problems. These issues may lead the population living in the respective district to seek health care outside the assigned catchment area. The authors discuss these findings in the context of the expansion of the private sector in the health area and the financial collapse of the public budget in Brazil.

Traumatismes cranio-maxillo-faciaux dans le service de stomatologie de l'Hopital de Kati (Mali) : a propos de 78 cas

Une etude retrospective des traumatismes cranio-maxillo-faciaux a ete entreprise au service de stomatologie de l'Hopital de Kati de janvier 1981 a decembre 1992. Celle-ci avait pour but de determiner la frequence des traumatismes cranio-encephalitiques en fonction de l'age; du sexe; du siege; de l'etiologie; de la residence; de l'ethnie et du statut social des patients. L'etude a porte sur un echantillon aleatoire de 78 malades dont 85;9 pour cent (67/78) etaient des hommes et 14;6 pour cent (11/78) des femmes. 60;8 pour cent des patients etaient ages de 19 a 43 ans. Les sieges les plus frequemment touches etaient l'etage inferieur 53;8 pour cent; et moyen 26;9 pour cent. Les accidents de circulation demeuraient les premieres causes de traumatisme cranio-maxillo-facial a l'Hopital de Kati (53;8 pour cent) contre 33;3 pour cent pour les coups et blessures et 12;8 pour cent pour les causes balistiques. Les ruraux des regions de Koulikoro (35;9 pour cent); Kayes (21;8 pour cent) et ceux du district de Bamako (20;5 pour cent) etaient les plus concernes et parmi eux; l'ethnie bamanan occupait 41;0 pour cent

Identification of Chiari's network with transesophageal echocardiography.

A prominent Chiari's network may be difficult to distinguish from pathologic right atrial masses on transthoracic echocardiography. We report a 38-year-old woman who had a cerebrovascular accident. Transthoracic echocardiogram revealed an atrial septal aneurysm and a mobile right atrial mass. This mass was correctly identified as Chiari's network on the basis of the transesophageal echocardiographic findings of a broad base of attachment in the right atrium and filamentous nature of the mass. These findings were confirmed at surgery.

Granulocytes in the inflammatory process of BALB/c mice infected by Leishmania amazonensis. A quantitative approach.

We used previously immunized (partially resistant) and naive (highly susceptible) BALB/c mice infected with Leishmania amazonensis for evaluating the role of granulocytes in the course of murine leishmaniasis. The animals were examined at different times post-infection and granulocytes counted in lesion tissues examined ultra-structurally. Polymorphonuclear granulocytes predominated during the early phase of infection and their number decreased with progression of infection; their number was similar in both groups during the early and intermediate phases of infection, though slightly higher in immunized animals during the late phase. Eosinophils represented approximately 10% of cells in the inflammatory infiltrate, being higher during the intermediate phase, and not differing between the groups. Another approach was the evaluation of granulocyte migration to the peritoneal cavity of susceptible BALB/c mice or resistant C57BL/6 mice under several stimuli. There was no statistically significant difference between resistant and susceptible animals in any of the treatments. Despite the influx of granulocytes to the lesion and its possible role in the initial destruction of injected Leishmania, this aspect does not seem to have an important effect on the outcome of the leishmanial infection.

Intact stones or fragments? Potential pitfalls in the imaging of patients after biliary extracorporeal shock wave lithotripsy.

Ultrasound is used after extracorporeal shock wave lithotripsy of gallbladder stones to assess fragmentation. In many patients with apparently successful fragmentation, the posttreatment studies show an intraluminal, echogenic focus within the gallbladder, with posterior acoustic shadowing characteristic of an intact stone. Cholesterol gallstones were fragmented in vitro by means of lithotripsy, and the sonographic appearance of the fragmented stones was followed up over time to study factors that might affect the process. After lithotripsy, fragments settled and produced an echogenic focus with posterior shadowing indistinguishable from the appearance of an intact stone. These experimental observations led to the development of a clinical maneuver to overcome the diagnostic pitfalls posed by the reaggregation of stone fragments in situ. This rollover maneuver helps distinguish between intact stones and fragments, and prevents both diagnostic errors in follow-up and unnecessary retreatment.

Detection and quantification of aortic regurgitation during aortic valvuloplasty.

The degree of aortic regurgitation, before and after balloon aortic valvuloplasty, was assessed in 32 patients, using double indicator dilution curves: a) the forward curve was obtained by dye injection into the left ventricle and sampling in the aorta; b) the regurgitant curve was obtained by dye injection in the aorta and sampling in the left ventricle. A regurgitant index (RI) was calculated by obtaining the ratio of the areas of the triangles from regurgitant and forward curves. Eight-five percent of the patients were 70 years or older. After valvuloplasty, aortic valve area increased from 0.5 +/- 0.3 cm2 to 0.7 +/- 0.3 cm2 (P = .0002) while left ventricular to aortic gradient decreased from 77 +/- 32 to 51 +/- 24 (P = .0001). RI did not significantly change in 58% of patients, increased in 25%, and decreased in 15.2%. We conclude that in most patients undergoing aortic valvuloplasty, regurgitation does not change after the procedure. In some patients it may increase significantly, and in a few it may even decrease. Indicator dilution curves technique seems to provide a sensitive, accurate, and reproducible method to detect and quantify aortic incompetence before and after valvuloplasty.

Fecal triglyceride excretion is not excessive in pancreatic insufficiency.

Steatorrhea can result from maldigestion or malabsorption. As the pathophysiology underlying impaired digestion differs from impaired absorption, it is important to differentiate these two disorders. It is generally accepted that patients with maldigestion excrete an excessive amount of triglyceride and patients with malabsorption excrete an excess of the lipolytic product of triglyceride, fatty acid. The two-step Sudan stain has been used as a simple test to differentiate these disorders. The validity of the test has not yet been established. In this study, fecal fatty acid and triglyceride were measured after extraction and thin-layer chromatographic separation. Our results indicate that in adult patients with pancreatic insufficiency, the fecal triglyceride content does not differ from the controls. However, a fivefold to sixfold increase in fecal fatty acid content in patients with pancreatic insufficiency was revealed. As patients with maldigestion do not excrete an excess of undigested triglyceride, it is not possible to differentiate maldigestion from malabsorption by quantifying fecal triglyceride and fatty acid.

Sudan stain of fecal fat: new insight into an old test.

The 72-h fecal fat determination is used as the gold standard to document the presence of steatorrhea. Although the Sudan stain for fecal fat is advocated as a sensitive screening test, a quantitative correlation between the 72-h fecal fat quantitation and the fecal Sudan stain is lacking. This study was designed to examine the staining properties of different classes of purified lipids in an experimentally defined artificial matrix, and to elucidate the reasons for the lack of quantitative correlation between these two tests. Our results indicate that the "neutral fat" stain without acidification or heating identifies triglyceride; and at an appropriate pH, the "neutral stain" also identifies fatty acid. The "split fat" stain with acidification and heating identifies both triglyceride and fatty acid. After acidification, fatty acid soaps are converted to the nonionized fatty acid. Thus, fatty acid soaps can be identified indirectly as fat droplets that are stained by the split fat stain. Although cholesterol is stained with Sudan stain after heating, upon cooling, cholesterol forms crystals of anhydrous cholesterol, making its staining pattern distinct. Neither the neutral fat nor the split fat stain can detect phospholipid or cholesteryl ester. The 72-h fecal fat determination is a measure of the total fatty acid content after a specimen is saponified. The resulting fatty acids are derived from a variety of endogenous and exogenous sources, including free fatty acids, soaps of fatty acids, triglycerides, cholesterol esters, and phospholipids. Therefore, the 72-h fecal fat quantitation does not differentiate between the primary sources of the measured fatty acid. It is concluded that the 72-h fecal fat determination is not specific for documenting triglyceride (fat) malabsorption. Until new methods are developed that specifically measure fecal triglyceride and fatty acid, the Sudan stain of fecal fat appears to be a more specific method for detecting the presence of triglyceride and fatty acid in a matrix.

Benign pneumoperitoneum in a patient with celiac sprue.

A patient with celiac sprue was found to have an asymptomatic pneumoperitoneum. Prompt recognition that the pneumoperitoneum was due to pneumatosis cystoides intestinalis prevented unnecessary surgical intervention. Severe mucosal disease of the small intestine can be associated with an asymptomatic pneumoperitoneum.

Aneurysmal dilatation of a patent umbilical vein masquerading as a pancreatic pseudocyst: CT characteristics.

A large cystic mass in a jaundiced patient had the appearance by sonography of a pancreatic pseudocyst. Computed tomography showed that the mass represented an aneurysmally dilated patent umbilical vein.

Bile salt binding properties of commonly used gastrointestinal drugs: maalox, carafate, and questran.

We have validated a method to measure bile salt binding by Maalox (aluminum hydroxide and magnesium hydroxide), Carafate (sucralfate), and Questran (cholestyramine) in vitro. The method used in this study involves a correction for adherent water volume and thus provides a correct measure of bile salt binding. With this approach, we described the binding properties of Maalox, Carafate, and Questran. The bile salt binding capacities of Carafate and Maalox are limited and do not have physiological or pharmacological significance. On the other hand, we found that Questran has substantial bile salt binding capacity. At the recommended dosage, Questran could deplete the total bile salt pool. We also found that Carafate, although not used as an antacid, has buffering capacity (maintaining a pH of solution in the range 4.2-4.8) which might contribute to its effectiveness as an ulcer treatment drug.

Regulation of the binding of sigma- and phencyclidine (PCP)-receptor ligands in rat brain membranes by guanine nucleotides and ions.

The effect of guanine nucleotides and ions on (+)-[3H]3-(3-hydroxyphenyl)-N-(1-propyl)piperidine [+ )-[3H]3-PPP), (+)-N-[3H]allylnormetazocine ((+)-[3H]SKF 10047) and [3H]1-[1-(3-hydroxyphenyl)-cyclohexyl]piperidine ([3H]PCP-3-OH) specific binding to rat brain membranes was examined. These 3 compounds are proposed as prototypical ligands for the labeling of the sigma- and phencyclidine (PCP)-receptor subtypes. Competition binding experiments of (+)-SKF 10047 with (+)-[3H]3-PPP yielded a biphasic inhibition curve which transformed to a monophasic curve when membranes were incubated in the presence of Gpp(NH)p (0.1 mM). The common (+)-[3H]3-PPP/(+)-SKF 10047 binding component is more susceptible to Gpp(NH)p than the high affinity [3H]PCP-3-OH/(+)-SKF 10047 common binding component. Low affinity [3H]PCP-3-OH binding, which may represent a PCP-selective site, is not affected by GTP and Gpp(NH)p. Mono- and divalent cations markedly inhibit high affinity [3H]PCP-3-OH binding but they had a differential inhibitory effect on the binding of the other radioligands tested. These findings suggest differences in the regulation of multiple psychotomimetic (sigma- and PCP) binding sites by guanine nucleotides and ions.

Hepatocanalicular injury associated with vitamin A derivative etretinate. An idiosyncratic hypersensitivity reaction.

A patient with pustular psoriasis developed jaundice, peripheral blood eosinophilia, and biochemical evidence of hepatocanalicular dysfunction four weeks after the initiation of etretinate therapy. A liver biopsy specimen showed bile duct damage, a periportal inflammatory infiltrate composed of neutrophils, eosinophils and lymphocytes, canalicular cholestasis, and focal hepatocyte necrosis. Clinical exclusion of other possible etiologic factors coupled with near resolution of the biochemical abnormalities within six weeks after complete discontinuation of the drug indicates that etretinate may induce an idiosyncratic hypersensitivity reaction. This is the first report to document etretinate associated bile duct injury.