[Stroke as the first manifestation of a concealed pancreatic neoplasia]. / Ictus como primera manifestación de una neoplasia pancreática oculta.

INTRODUCTION: Stroke is very seldom seen as the first manifestation of a neoplasia. The mechanisms that are most frequently involved in its pathogenesis are Trousseau's syndrome, haematological disorders such as disseminated intravascular coagulation or thrombocytosis, and the release of mucin by the tumour. Secondarily, non bacterial thrombotic endocarditis, septic or neoplastic cell embolism, venous sinus thrombosis and atherosclerosis secondary to radiotherapy have been reported. CASE REPORTS: Case 1: a 27-year-old male who presented a stroke in the right thalamus with a torpid progression and digestive complications; neuroimaging studies revealed unknown neoplasia of the head of the pancreas. Case 2: a 53-year-old male with repeated stroke (left sylvian and right occipitotemporal) and progressive neurological deterioration secondary to disseminated neoplastic disease, which had its origins in the body and tail of the pancreas. In both cases all the diagnostic explorations carried out in an attempt to determine the aetiopathogenesis of the stroke were negative. The post mortem study in the second patient revealed the existence of a non bacterial thrombotic endocarditis, which was taken as being one of the mechanisms involved. CONCLUSIONS: The pathogenic mechanisms of cerebral ischemia associated to neoplasia are discussed and the primary and secondary forms are differentiated. We highlight the idea that when dealing with a stroke with an unknown aetiology and a torpid progression, the neurologist must consider the existence of a concealed neoplasia with stroke as its first manifestation.

Ictus como primera manifestación de una neoplasia pancreática oculta / Stroke as the first manifestation of a concealed pancreatic neoplasia

Introducción. El ictus como primera manifestación de una neoplasia es excepcional. Los mecanismos patogénicos más frecuentemente implicados son el síndrome de Trousseau, trastornos hematológicos, como la coagulación intravascular diseminada o la trombocitosis, y la liberación de mucina por parte del tumor. Secundariamente, se han apuntado, entre otros, la endocarditis trombótica no bacteriana, el embolismo séptico o de células neoplásicas, las trombosis de senos venosos y la aterosclerosis secundaria a radioterapia. Casos clínicos. Caso 1: varón de 27 años de edad que presenta ictus talámico derecho de evolución tórpida, con complicaciones digestivas; en los estudios de neuroimagen se halla eoplasia de la cabeza del páncreas no conocida. Caso 2: varón de 53 años con ictus de repetición (silviano izquierdo y temporooccipital derecho), con deterioro neurológico progresivo secundario a una enfermedad neoplásica diseminada con origen en el cuerpo y la cola del páncreas. En ambos casos, todas las exploraciones diagnósticas realizadas dirigidas a conocer la etiopatogenia del ictus fueron negativas. El estudio necrópsico en el segundo paciente reveló la existencia de una endocarditis trombótica no bacteriana, que se apuntó como uno de los mecanismos implicados. Conclusiones. Se discuten los mecanismos patogénicos de isquemia cerebral asociados a neoplasia, y se distingue entre primarios y secundarios. Se destaca la idea de que, ante un ictus de etiología no filiada y evolución tórpida, el neurólogo debe plantearse la existencia de una neoplasia oculta con un ictus como primera manifestación (AU)

Introduction. Stroke is very seldom seen as the first manifestation of a neoplasia. The mechanisms that are most frequently involved in its pathogenesis are Trousseau’s syndrome, haematological disorders such as disseminated intravascular coagulation or thrombocytosis, and the release of mucin by the tumour. Secondarily, non-bacterial thrombotic endocarditis, septic or neoplastic cell embolism, venous sinus thrombosis and atherosclerosis secondary to radiotherapy have been reported. Case reports. Case 1: a 27-year-old male who presented a stroke in the right thalamus with a torpid progression and digestive complications; neuroimaging studies revealed unknown neoplasia of the head of the pancreas. Case 2: a 53-year-old male with repeated stroke (left sylvian and right occipitotemporal) and progressive neurological deterioration secondary to disseminated neoplastic disease, which had its origins in the body and tail of the pancreas. In both cases all the diagnostic explorations carried out in an attempt to determine the aetiopathogenesis of the stroke were negative. The postmortem study in the second patient revealed the existence of a non-bacterial thrombotic endocarditis, which was taken as being one of the mechanisms involved. Conclusions. The pathogenic mechanisms of cerebral ischemia associated to neoplasia are discussed and the primary and secondary forms are differentiated. We highlight the idea that when dealing with a stroke with an unknown aetiology and a torpid progression, the neurologist must consider the existence of a concealed neoplasia with stroke as its first manifestation (AU)

D-penicillamine and plasmapheresis in acute liver failure secondary to Wilson's disease.

We report a case of a 19-year-old woman with acute liver failure, Coombs negative hemolytic anemia, and renal failure as initial manifestations of Wilson disease with recovery following medical treatment. The clinical picture and low serum transaminase and alkaline phosphatase levels gave us a clue to suspect Wilson disease and to initiate plasmapheresis and D-penicillamine soon after admission. The serum and urinary copper levels were elevated with low serum ceruloplasmin. We proceeded to ambulatory follow-up with medical treatment with D-penicillamine. A few months later, during the course of a laparoscopic cholecystectomy because of symptomatic gallstone disease, a liver biopsy sample was obtained that showed histological liver fibrosis and strongly elevated levels of liver tissue copper.

Análisis de la fiabilidad de cuatro ventiladores empleados en pacientes críticos / Reliability assessment of four ventilators used in critically-ill patients

OBJETIVOS: Comprobar la fiabilidad de cuatro ventiladores empleados en la práctica diaria habitual con enfermos críticos con insuficiencia respiratoria aguda. MÉTODOS: Estudio experimental, realizado con 4 ventiladores y un comprobador de respiradores Bio-Tek® VT.2, ajustado con distintos valores de resistencia y compliancia. Se recogieron las diferencias entre los datos obtenidos por los respiradores y el comprobador, en los volúmenes entregados y la presión teleespiratoria. Se comprobó si las diferencias existentes entre los respiradores y el comprobador podrían ser significativas, y el coeficiente de variación para estudiar la posible desviación de los parámetros programados a lo largo del tiempo. Se calcularon y aplicaron los márgenes de error de los respiradores. RESULTADOS: En situaciones de compliancia y resistencia, parecidas a las que presentan los enfermos con enfermedad pulmonar obstructiva crónica y síndrome de distrés respiratorio agudo, hay diferencias entre los volúmenes corrientes medidos por la monitorización de los respiradores y los entregados al final de sus circuitos respiratorios, aunque apenas se superan los márgenes de error. El coeficiente de variación no fue significativo en ninguna de las situaciones de compliancia y resistencia aplicadas. CONCLUSIONES: Existen diferencias, frente a situaciones de baja compliancia y/o elevada resistencia, entre los volúmenes corrientes monitorizados y los entregados en algunos ventiladores, aunque dichas diferencias sean pequeñas y apenas superen los márgenes de error admitidos para los ventiladores. Los resultados del coeficiente de variación indican una alta capacidad de mantener constantes los parámetros programados a lo largo del tiempo (AU)

OBJECTIVES: Mechanical ventilators are often used in critically-iII patients with acute respiratory insufficiency. We aimed to assess the reliability of four commonly used ventilators. METHODS: This experimental study assessed four Bio-Tek® VT-2 ventilators set for different levels of impedance and compliance in comparison with a tester. We gathered data on differences between the ventilators and the tester for volumes supplied and end-expiratory pressures. Statistical significance was determined using a Student-t test (95% confidence interval) and a coefficient of variation was calculated to study variation over time in parameters programed. Error margins were calculated and applied for each ventilator. RESULTS: For situations in which compliance and impedance are similar to those of patients with chronic obstructive pulmonary disease and acute respiratory distress syndrome, there were differences in tidal volumes measured by the ventilators monitors and those actually supplied at the end or the breathing circuits, although the differences are only slightly greater than the error margins. The coefficients of variation were not significant at any or the compliance and impedance levels studied. CONCLUSIONS: In situations of low compliance and/or high impedance, tidal volumes supplied by ventilators and volumes shown on the monitors are different, although the differences are small and hardly exceed the ventilators acceptable error margins. The coefficient of variation indicated that the parameters set remain highly stable over time (AU)

[Analysis of the reliability of 4 ventilators used in critically ill patients]. / Análisis de la fiabilidad de cuatro ventiladores empleados en pacientes críticos.

OBJECTIVES: Mechanical ventilators are often used in critically-ill patients with acute respiratory insufficiency. We aimed to assess the reliability of four commonly used ventilators. METHODS: This experimental study assessed four Bio-Tek VT-2 ventilators set for different levels of impedance and compliance in comparison with a tester. We gathered data on differences between the ventilators and the tester for volumes supplied and end-expiratory pressures. Statistical significance was determined using a Student-t test (95% confidence interval) and a coefficient of variation was calculated to study variation over time in parameters programmed. Error margins were calculated and applied for each ventilator. RESULTS: For situations in which compliance and impedance are similar to those of patients with chronic obstructive pulmonary disease and acute respiratory distress syndrome, there were differences in tidal volumes measured by the ventilators monitors and those actually supplied at the end of the breathing circuits, although the differences are only slightly greater than the error margins. The coefficients of variation were not significant at any of the compliance and impedance levels studied. CONCLUSIONS: In situations of low compliance and/or high impedance, tidal volumes supplied by ventilators and volumes shown on the monitors are different, although the differences are small and hardly exceed the ventilators acceptable error margins. The coefficient of variation indicated that the parameters set remain highly stable over time.

[Morbi-mortality of medical and surgical treatments in the intracranial bleeding like complication of therapy with drugs that modifies normal coagulation]. / Morbimortalidad del tratamiento médico conservador y del tratamiento neuroquirúrgico en los casos de hemorragia intracraneal como complicación del empleo de fármacos que modifican la hemostasia.

INTRODUCTION: Antiaggregant and anticoagulant therapy has possible sever secondary effects, being the most serious intracranial bleeding. OBJECTIVES: Compare morbi-mortality between surgical and medical treatments in anticoagulated and/or antiaggregated patients with any kind of intracranial bleeding. Also risk factors and main indications of those treatments are studied. PATIENTS AND METHODS: Descriptive and retrospective study including 105 patients admitted in our Critical Care Unit, with intracranial bleeding, under anticoagulant or antiaggregant treatment. We study the type of bleeding (subarachnoid, epidural, subdural and intraparenchimal bleeding) and the relation between morbi-mortality and treatment applicated using relative risk like analytic tool. RESULTS: Major bleeding risk appears after the six first months from the beginning of the treatment. Thirty-four patients died with a relative risk of 1.55 in the surgical patients from the medical treatment patients. Relative risk between anticoagulated patients and antiaggregated ones was 1.16. Serious consequences happened on eight of the 49 patients under surgical treatment, and on 13 of the 52 patients under medical treatment. CONCLUSIONS: Surgical treatment has more morbi-mortality. Oral anticoagulation has only a little more relative risk than treatment with antiaggregants. Both groups had serious consequences.

Morbimortalidad del tratamiento médico conservador y del tratamiento neuroquirúrgico en los casos de hemorragia intracraneal como complicación del empleo de fármacos que modifican la hemostasia / Morbi-mortality of medical and surgical treatments in the intracranial bleeding like complication of therapy with drugs that modifies normal coagulation

Introducción. Los antiagregantes y los anticoagulantes son fármacos con posibles efectos secundarios graves, siendo uno de los más graves la aparición de hemorragias intracraneales. Objetivos. Comparar la morbimortalidad del tratamiento neuroquirúrgico (TNQ) frente al tratamiento médico conservador (TMC) en pacientes bajo tratamiento anticoagulante (AC) y/o antiagregante (AA), que presentan algún tipo de complicación hemorrágica intracraneal, y describir tanto las indicaciones más frecuentes de dichos tratamientos como los distintos factores de riesgo vascular presentes en los enfermos. Pacientes y métodos. Análisis descriptivo y retrospectivo sobre un total de 105 pacientes, en tratamiento con anticoagulantes y/o antiagregantes, que ingresaron en la Unidad de Cuidados Intensivos de nuestro hospital con hemorragias intracraneales. Se analiza el tipo predominante de sangrado y su morbimortalidad, tanto en relación con el tratamiento de base (AC frente a AA) como con el tratamiento realizado (TNQ frente a TMC), y para ello se calcula el riesgo relativo. Resultados. El riesgo hemorrágico mayor se establece a partir de los seis primeros meses tras el inicio del tratamiento. Se produjeron un total de 34 fallecimientos, con un riesgo relativo de los pacientes sometidos a TNQ del 1,55 respecto al TMC. El riesgo relativo de los pacientes que fallecieron y tomaban sólo anticoagulantes fue del 1,16 respecto a los que recibían antiagregantes. Las secuelas graves ocurrieron en 18 de los pacientes sometidos a TNQ y en 24 de los que estuvieron bajo TMC. Conclusiones. En nuestra serie, el TNQ se relaciona con mayor morbimortalidad y se objetiva que la toma de anticoagulantes orales apenas supone un mayor riesgo relativo que la toma aislada de antiagregantes. Tanto en los enfermos sometidos a TNQ como en los de TMC hay graves secuelas (AU)