Needle caliber and design are associated with the risk of post-dural puncture headache after diagnostic lumbar puncture / O calibre e o design da agulha estão associados ao risco de cefaleia pós-punção dural após punção lombar diagnóstica

Introduction:Post-dural puncture headache (PDPH) is defined as an orthostatic headache that develops within the first few days after performing a spinal tap and it is related to extravasation of cerebrospinal fluid (CSF) into the epidural space, resulting in CSF hypovolemia and hypotension. The risk factors for PDPH are not yet fully understood. Objective:To evaluate the risk of spontaneously reported PDPH according to the size and type of spinal tap needle. Methods:A total of 4589 patients undergoing outpatient lumbar puncture (LP) were included. All CSF collections were performed at Senne Liquor Diagnostico, a laboratory specialized in CSF collection and analysis. Patients were instructed to report by telephone if they had orthostatic headache during the first 7 days after LP to the medical team of the laboratory. Patients with previous headache were instructed to report any change in the headache pattern during the same period. Needle gauge was classified into two groups: 1) 25 G or less and 2) greater than 25 G. Two types of needles were used and compared: 1) Pencil point and 2) Quincke. Comparisons of the percentages of spontaneous reports of PDPH were made using the chi-square test. Results:141 patients (3.07%) reported PDPH to the laboratory's medical team. Needles of 25G gauge or less were used in 31.8% of cases. The percentage of patients reporting PHD in the group of 25G or less needles was 1.9% versus 3.6% in the group of larger than 25G needles (p=0.003). Pencil point needles were used in 10.6% of cases. The percentage of PHD among pencil point group was 1.4% versus 3.2% in Quincke group (p=0.026). Conclusion:25 G or finer gauge needles as well as pencil point type needles significantly reduced the risk of spontaneously reported PHD.

Introdução: A cefaleia pós-punção dural (CPPD) é definida como uma cefaleia ortostática que se desenvolve nos primeiros dias após a realização de uma punção lombar e está relacionada ao extravasamento de líquido cefalorraquidiano (LCR) para o espaço peridural, resultando em hipovolemia do LCR e hipotensão. Os fatores de risco para CPPD ainda não são totalmente compreendidos. Objetivo:Avaliar o risco de CPPD relatada espontaneamente de acordo com o tamanho e tipo de agulha de punção lombar. Métodos: Foram incluídos 4.589 pacientes submetidos à punção lombar (PL) ambulatorial. Todas as coletas de LCR foram realizadas no Senne Liquor Diagnostico, laboratório especializado em coleta e análise de LCR. Os pacientes foram orientados a relatar por telefone à equipe médica do laboratório se apresentassem cefaleia ortostática nos primeiros 7 dias após a PL. Pacientes com cefaleia prévia foram orientados a relatar qualquer alteração no padrão de cefaleia durante o mesmo período. O calibre da agulha foi classificado em dois grupos: 1) 25 G ou menos e 2) maior que 25 G. Dois tipos de agulhas foram utilizados e comparados: 1) ponta de lápis e 2) Quincke. As comparações dos percentuais de notificações espontâneas de CPPD foram feitas por meio do teste do qui-quadrado. Resultados:141 pacientes (3,07%) relataram CPPD à equipe médica do laboratório. Agulhas de calibre 25G ou menos foram utilizadas em 31,8% dos casos. A porcentagem de pacientes que relataram HDP no grupo de agulhas 25G ou menos foi de 1,9% versus 3,6% no grupo de agulhas maiores que 25G (p=0,003). Agulhas com ponta de lápis foram utilizadas em 10,6% dos casos. O percentual de DPH no grupo ponta de lápis foi de 1,4% versus 3,2% no grupo Quincke (p=0,026). Conclusão: Agulhas de calibre 25 G ou mais fino, bem como agulhas tipo ponta de lápis reduziram significativamente o risco de HP relatado espontaneamente.

Neumoencéfalo recurrente post quirúrgico, a raíz de dos casos / Post-surgical late pneumoencephalus, based on two cases

El neumoencéfalo es una patología que comúnmente se presenta después de cirugía neuroquirúrgica y ocasionalmente endonasal. Estos se suelen manejar de manera conservadora, sin embargo, se pueden asociar a distintas etiologías las cuales los hacen recurrir. En este reporte presentamos dos casos de neumoencéfalo tardío post quirúrgico asociado a fístulas de LCR de bajo flujo, donde se discute su clínica, etiología y manejo posterior.

Pneumocephalus is a pathology that commonly occurs after endonasal surgery, these are usually managed conservatively, however they can be associated with different etiologies which make them recur. In this report we present two cases of post-surgical late pneumocephalus associated with low-flow CSF fistulae, where its symptoms, etiology, and subsequent management are discussed.

Assessment of Qualitative and Quantitative Changes in 5 days stored Platelet Concentrates in Bangabandhu Sheikh Mujib Medical University

Background: The fast-growing demand for platelet concentrates (PC) necessitates the storage of these blood products before transfusion. Platelets are prepared as concentrates from the whole blood or by plateletpheresis. Qualitative and quantitative assessment of these PCs is an important issue in transfusion medicine. To assess the qualitative, quantitative changes and bacteriological safety of 5 days of stored platelet concentrates (PC).Material & Methods:This prospective study was conducted at the department of Clinical Pathology in collaboration with the Department of Transfusion Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from April 2008 to April 2009. A total of 65 healthy donors were included in the study as per the inclusion and exclusion criteria. Therefore, 65 platelet concentrates (bags/units) were prepared from the donors. Purposive sampling of the units was done. pH and platelet indices (PLT, MPV, PDW and P-LCR) were measured and Gram staining of PCs was performed on days 0 and 5. Statistical significant tests were done at a 95% confidence interval using the statistical package for social science (SPSS).Results:The mean (±SD) pH was 7.18±0.07 ranging from 7.0 to 7.3 during day 0. On day 5 the mean (±SD) pH was 6.77±0.11 and their range was from 6.5 to 7. The mean pH difference was statistically significant (p<0.05) between day 0 and day 5. The mean (±SD) PLT/unit was 70.56±15.56 x109/unit and it ranged from 38.01 to 110.6 x109/unit during day 0. On day 5 the mean (±SD) PLT/unit level was 68.46±15.52 x109/unit and it ranged from 36.82 to 107.2 x109/unit. The mean PLT/unit difference was statistically significant (p<0.05) between day 0 and day 5. The mean (±SD) MPV was 9.34±0.92 fl and it ranged from 7.5 to 11.5 fl during day 0. During day 5 the mean (±SD) MPV was 9.27±0.99 fl ranging from 7.0 to 11.2 fl. The mean (±SD) PDW was 10.07±1.61 fl and which ranged from 7.4 to 14.4 fl during day 0. During day 5 the mean (±SD) PDW was 10.72±1.71 fl ranging from 7.0 to 15.4 fl. The mean (±SD) PLCR was 18.28±5.67 % and it ranged from 8.0 to 32.5 % during day 0. During day 5 the mean (±SD) PLCR was 21.18±5.91 % and it ranged from 10.0 to 36.3 %. The mean PLT, PDW and PLCR differences were statistically significant (p<0.05) between day 0 and day 5 in the unpaired t-test, however, the mean MPV difference was not statistically significant (p<0.05) between day 0 and day 5. Gram staining of platelet concentrates on day 0 and day 5 found no bacteria.Conclusions:Storage-induced lesions take place in PCs when stored for 5 days in second-generation storage containers under the currently recommended conditions, but how far these changes are clinically relevant needs to be investigated.

Optimización de una técnica de PCR convencional para la amplificación de la región LCR y el gen E6 del virus del papiloma humano tipo 16

El cáncer de cuello uterino es el cuarto cáncer más frecuente en mujeres en el mundo y a nivel mundial, el VPH 16 se encuentra presente en aproximadamente el 60% de los casos. A la fecha, las variantes de VPH 16 se clasifican en 4 linajes y 16 sublinajes asociándose algunas variantes con severidad de lesión. La secuenciación de la región LCR y del gen E6 es utilizada para la clasificación de variantes. Por ello, el objetivo fue optimizar 2 PCRs convencionales para detectar la región LCR y una PCR para el gen E6. Para ello, se utilizaron muestras positivas para VPH 16, cebadores específicos para la región LCR y el gen E6. Se probaron las reacciones a diferentes temperaturas de anillamientos. La concentración de MgCl2, dNTP y cebadores fueron determinadas siguiendo las recomendaciones del fabricante de la enzima ADN polimerasa utilizada. Para la amplificación de la región LCR y el gen E6 del VPH 16, se observaron mejores resultados a una temperatura de anillamiento de 57°C y 50°C, respectivamente. La concentración de MgCl2 utilizada en ambas reacciones fue de 1,5mM, la de dNTP 0,2mM y la de cebadores 0,2uM. La optimización de la reacción de PCR permitirá obtener amplicones aptos para secuenciación, a fin de determinar las variantes génicas y posteriormente evaluar funcionalidad y actividad transcripcional que puedan estar relacionadas con la patogénesis cervical.

Cervical cancer is the fourth most common cancer in women in the world and worldwide HPV 16 is present in approximately 60% of cases. To date, HPV 16 variants are classified into 4 lineages and 16 sublineages, with some variants being associated with lesion severity. Sequencing of the LCR region and the E6 gene is used for variant classification. Therefore, the objective was to optimize two conventional PCRs to detect the LCR region and one PCR for the E6 gene. For this purpose, HPV 16 positive samples, specific primers for the LCR region and the E6 gene were used. The reactions were tested at different alignment temperatures. The concentration of MgCl2, dNTP, and primers was determined following the recommendations of the manufacturer of the DNA polymerase enzyme used. For amplification of the LCR region and the HPV 16 E6 gene, the best results were observed at an annealing temperature of 57°C and 50°C, respectively. The concentration of MgCl2 used in both reactions was 1.5mM, dNTP 0.2mM and primers 0.2uM. The present optimization will be used to sequence the amplified products to determine the variants and subsequently evaluate the functionality and transcriptional activity in order to relate it to cervical pathogenesis.

Assessment of Qualitative and Quantitative Changes in 5 days stored Platelet Concentrates in a tertiary care Hospital of Bangladesh

Background: The fast growing demand for platelet concentrates (PC) necessitates the storage of these blood products prior to transfusion. Platelets are prepared as concentrates from the whole blood or by plateletpheresis. Qualitative and quantitative assessment of these PCs are an important issue in transfusion medicine. Aim of the study: To assess the qualitative, quantitative changes and bacteriological safety of 5 days stored platelet concentrates (PC).Material & Methods:This prospective study was conducted at the department of Clinical Pathology in collaboration with the department of Transfusion medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka during April 2008 to April 2009. A total of 65 healthy donors were included for the study as per the inclusion and exclusion criteria. Therefore, 65 platelet concentrates (bags/units) were prepared from the donors. Purposive sampling of the units was done. pH and platelet indices (PLT, MPV, PDW and P-LCR) were measured and Gram staining of PCs were performed on day 0 and 5. Statistical significant tests were done at 95% confidence interval using statistical package for social science (SPSS).Results:The mean (±SD) pH was 7.18±0.07 ranging from 7.0 to 7.3 during day 0. During day 5 the mean (±SD) pH was 6.77±0.11 and their range was from 6.5 to 7. The mean pH difference was statistically significant (p<0.05) between day 0 and day 5. The mean (±SD) PLT/unit was 70.56±15.56 x109/unit and it ranged from 38.01 to 110.6 x109/unit during day 0. During day 5 the mean (±SD) PLT/unit level was 68.46±15.52 x109/unit and it ranged from 36.82 to 107.2 x109/unit. The mean PLT/unit difference was statistically significant (p<0.05) between day 0 and day 5. The mean (±SD) MPV was 9.34±0.92 fl and it ranged from 7.5 to 11.5 fl during day 0. During day 5 the mean (±SD) MPV was 9.27±0.99 fl ranging from 7.0 to 11.2 fl. The mean (±SD) PDW was 10.07±1.61 fl and which ranged from 7.4 to 14.4 fl during day 0. During day 5 the mean (±SD) PDW was 10.72±1.71 fl ranging from 7.0 to 15.4 fl. The mean (±SD) PLCR was 18.28±5.67 % and it ranged from 8.0 to 32.5 % during day 0. During day 5 the mean (±SD) PLCR was 21.18±5.91 % and it ranged from 10.0 to 36.3 %. The mean PLT, PDW and PLCR difference were statistically significant (p<0.05) between day 0 and day 5 in unpaired t-test, however the mean MPV difference was not statistically significant (p<0.05) between day 0 and day 5. Gram staining of platelet concentrates on day 0 and day 5 found no bacteria.Conclusions:Storage-induced lesions take place in PCs, when stored for 5 days in second generation storage containers under the currently recommended conditions, but how far these change are clinically relevant need to be investigated

Blood-cerebrospinal fluid (CSF) barrier dysfunction means reduced CSF flow not barrier leakage - conclusions from CSF protein data / Disfunção da barreira hemato-liquórica significa redução do fluxo de líquido cefalorraquidiano, e não quebra de barreira - conclusões a partir de estudos sobre as proteínas do LCR

ABSTRACT Background: Increased concentrations of serum proteins in cerebrospinal fluid (CSF) are interpreted as blood-CSF barrier dysfunction. Frequently used interpretations such as barrier leakage, disruption or breakdown contradict CSF protein data, which suggest a reduced CSF flow rate as the cause. Results: Even the severest barrier dysfunctions do not change the molecular size-dependent selectivity or the interindividual variation of the protein transfer across barriers. Serum protein concentrations in lumbar CSF increase with hyperbolic functions, but the levels of proteins that do not pass the barrier remain constant (brain proteins) or increase linearly (leptomeningal proteins). All CSF protein dynamics above and below a lumbar blockade can also be explained, independent of their barrier passage, by a reduced caudally directed flow. Local accumulation of gadolinium in multiple sclerosis (MS) is now understood as due to reduced bulk flow elimination by interstitial fluid (ISF). Nonlinear change of the steady state in barrier dysfunction and along normal rostro-caudal gradients supports the diffusion/flow model and contradicts obstructions of diffusion pathways. Regardless of the cause of the disease, pathophysiological flow blockages are found in bacterial meningitis, leukemia, meningeal carcinomatosis, Guillain-Barré syndrome, MS and experimental allergic encephalomyelitis. In humans, the fortyfold higher albumin concentrations in early fetal development decrease later with maturation of the arachnoid villi, i.e., with beginning CSF outflow, which contradicts a relevant outflow to the lymphatic system. Respiration- and heartbeat-dependent oscillations do not disturb net direction of CSF flow. Conclusion: Blood-CSF and blood-brain barrier dysfunctions are an expression of reduced CSF or ISF flow rate.

RESUMO Introdução: Concentrações aumentadas de proteínas séricas no líquido cefalorraquidiano são interpretadas como disfunção da barreira (hemato-liquórica) sanguínea do LCR. Interpretações frequentemente usadas, como vazamento de barreira (quebra ou rompimento de barreira), rompimento ou quebra, contradiz os dados de proteína do LCR, que sugerem uma taxa de fluxo reduzida do LCR como a causa. Resultados: Mesmo as disfunções de barreira mais graves não alteram a seletividade dependente do tamanho molecular nem a variação interindividual da transferência de proteína através de barreiras. As concentrações de proteínas séricas no LCR lombar aumentam com as funções hiperbólicas, mas as proteínas que não passam a barreira permanecem constantes (proteínas do cérebro) ou aumentam linearmente (proteínas leptomeningeais). Toda a dinâmica das proteínas do LCR acima e abaixo de um bloqueio lombar também pode ser explicada, independente de sua passagem pela barreira, por um fluxo caudal reduzido. O acúmulo local de gadolínio na esclerose múltipla (EM) é agora entendido como decorrente da redução da eliminação do bulk flow pelo fluido intersticial (FIS). A mudança não linear do estado estacionário na disfunção da barreira e ao longo dos gradientes rostro-caudais normais apoia o modelo de difusão/fluxo e contradiz as obstruções das vias de difusão. Independentemente da causa da doença, os bloqueios fisiopatológicos do fluxo são encontrados na meningite bacteriana, leucemia, carcinomatose meníngea, síndrome de Guillain-Barré, EM e encefalomielite alérgica experimental. Em humanos, as concentrações de albumina quarenta vezes mais altas no desenvolvimento fetal inicial diminuem tarde com a maturação das vilosidades aracnoides, isto é, com o início do fluxo de LCR, o que contradiz um fluxo relevante para o sistema linfático. As oscilações dependentes da respiração e do batimento cardíaco não perturbam a direção do fluxo do LCR. Conclusão: As disfunções das barreiras hemato-liquórica e hemato-encefálica são uma expressão da redução da taxa de fluxo do LCR ou FIS.

El rol de la proteína beta trace en distintas áreas de la Medicina / The role of beta trace protein in different areas of Medicine / O papel da proteína beta trace em diferentes áreas da Medicina

La proteína beta trace (PBT), también llamada Prostaglandina D2 Sintasa de tipo lipocalina, es una glicoproteína de peso molecular entre 23 y 29 kDa que convierte la prostaglandina H2 en prostaglandina D2. La misma está asociada a diferentes entidades clínicas. Por sus características moleculares puede ser un indicador útil de la alteración precoz en la filtración glomerular; por el aumento de su síntesis y su concomitante elevación en suero, un predictor de riesgo cardiovascular; y por su alta concentración en líquido cefalorraquídeo (LCR), un biomarcador de fístula de LCR. Puede medirse en distintos líquidos biológicos, como suero, orina y LCR. El objetivo de esta revisión fue actualizar los conocimientos de esta proteína para evaluar su utilidad en distintas áreas de la Medicina. La trascendencia de PBT en el campo de la bioquímica como posible biomarcador dependerá de la patología de base del paciente.

The beta trace protein (BTP), also called Prostaglandin D2 Synthase lipocalin type PGDS, is a glycoprotein between 23 and 29 kDa of low molecular weight that converts prostaglandin H2 in prostaglandin D2. BTP is a protein that has multiple clinical associations. Due to the characteristics of the molecule, it may indicate an early alteration in glomerular filtration; by the serum increase of its synthesis, it is a predictor of cardiovascular risk, and for its high concentration in cerebrospinal fluid (CSF), it is a marker of leakage. This protein can be measured in different biological fluids such as serum, urine, and CSF. The objective of this review is to update the knowledge about this protein as a biomarker. The significance of BTP in the field of biochemistry as a possible biomarker will depend on the patient's underlying pathology.

A proteína beta trace (PBT), também chamada de Prostaglandina D2, sintase de lipocalina é uma glicoproteína de peso molecular entre 23 e 29 kDa, que converte prostaglandina H2 em prostaglandina D2. PBT é uma proteína que está associada a várias entidades clínicas. Devido às características moleculares, pode ser uma indicação útil da alteração precoce na filtração glomerular, devido ao aumento de sua síntese e sua concomitante elevação em soro, um preditor de risco cardiovascular e, devido à sua alta concentração no líquido cefalorraquidiano (LCR), é um biomarcador da fístula LCR. É uma proteína que pode ser medida em diferentes fluidos biológicos, como soro, urina e LCR, e o objetivo desta revisão foi atualizar os conhecimentos desta proteína para avaliar sua utilidade em diversas áreas da medicina. A importância de PBT no campo da bioquímica como possível biomarcador dependerá da patologia subjacente do paciente.

Cerebrospinal fluid lactate: a differential biomarker for bacterial and viral meningitis in children / Lactato no líquido cefalorraquidiano: um marcador diferencial para meningite bacteriana e meningite viral em crianças

Abstract Objective: To assess the performance of cerebrospinal fluid (CSF) lactate as a biomarker to differentiate bacterial meningitis from viral meningitis in children, and to define an optimal CSF lactate concentration that can be called significant for the differentiation. Methods: Children with clinical findings compatible with meningitis were studied. CSF lactate and other conventional CSF parameters were recorded. Results: At a cut-off value of 3 mmol/L, CSF lactate had a sensitivity of 0.90, specificity of 1.0, positive predictive value of 1.0, and negative predictive value of 0.963, with an accuracy of 0.972. The positive and negative likelihood ratios were 23.6 and 0.1, respectively. When comparing between bacterial and viral meningitis, the area under the curve for CSF lactate was 0.979. Conclusions: The authors concluded that CSF lactate has high sensitivity and specificity in differentiating bacterial from viral meningitis. While at a cut-off value of 3 mmol/L, CSF lactate has high diagnostic accuracy for bacterial meningitis, mean levels in viral meningitis remain essentially below 2 mmol/L.

Resumo Objetivo: Estudar o desempenho do lactato no líquido cefalorraquidiano como biomarcador para diferenciar a meningite bacteriana da meningite viral em crianças, e definir uma concentração de lactato ótima no líquido cefalorraquidiano que possa ser significativa para a diferenciação. Métodos: Foram estudadas crianças com achados clínicos compatíveis com meningite. O nível de lactato no líquido cefalorraquidiano e outros parâmetros convencionais do líquido cefalorraquidiano foram registrados. Resultados: Em um valor de corte de 3 mmol/L, o lactato no líquido cefalorraquidiano apresentou uma sensibilidade de 0,90, especificidade de 1,0, valor preditivo positivo de 1,0, valor preditivo negativo de 0,963, com uma precisão de 0,972. Os índices de probabilidade positivo e negativo foram 23,6 e 0,1, respectivamente. Para comparação entre a meningite bacteriana e viral, a área abaixo da curva do lactato no líquido cefalorraquidiano foi 0,979. Conclusões: Concluímos que o lactato no líquido cefalorraquidiano possui alta sensibilidade e especificidade na diferenciação da meningite bacteriana da meningite viral. Embora em um valor de corte de 3 mmol/L o lactato no líquido cefalorraquidiano possua alta precisão de diagnóstico da meningite bacteriana, os níveis médios na meningite viral permanecem basicamente abaixo de 2 mmol/L.

Diagnóstico de Cryptococcus neoformans mediante la PCR- RFLP en el líquido cefalorraquídeo (LCR) en pacientes hospitalizados en el sur de Brasil / Cryptococcus neoformans diagnosis using PCR-RFLP on cerebrospinal fluid (CSF) of hospitalized patients in southern Brazil

Introducción: Cryptococcus neoformans es un hongo levaduriforme encapsulado, de distribución mundial, principalmente en regiones tropicales, causando infecciones en individuos inmunocomprometidos, sobre todo en los infectados con el virus de la inmunodeficiencia humana (HIV). La capacidad de infección de este hongo es variable, pudiendo citar la facultativa patogenicidad, cápsula con actividad fagocitaria y producción de melanina como antioxidante. El objetivo de este trabajo fue evaluar el uso de la PCR/ RFLP para la detección e identificación de C. neoformans directamente del líquido cefalorraquídeo (LCR) de pacientes ingresados en un hospital público de la ciudad de Lages, Estado de Santa Catarina, sur de Brasil, comparando el resultado con la tinción específica para el hongo y el crecimiento en medio de cultivo. Métodos: Las muestras fueran directamente teñidas con tinta china para observar la cápsula, bien como después sembladas en medio de cultivo (agar dextrosa Sabouraud y agar de Níger) para crecimiento fúngico; también se hizo la extracción del ADN con fenol-cloroformo. La técnica fue utilizada para amplificación del gen URA5 mediante reacción en cadena de la polimerasa (PCR) y después con las enzimas de restricción HhaI y Sau96I para genotipaje mediante la PCR-RFLP. Resultados: En dos muestras fueran aislados C. neoformans con la tinción china y amplificados en la PCR, en las cuales fueran identificados como var. grubii. Conclusión: El serotipo A var. grubii es lo más aislado en la criptococosis humana, principalmente en pacientes HIV, pero se desconoce la preferencia de este serotipo por este grupo de enfermos. (AU)

Introduction: Cryptococcus neoformans is an encapsulated yeast with worldwide circulation, predominantly in tropical regions, causing infections in immunocompromised individuals, particularly those infected with human immunodeficiency virus (HIV). The virulence of this fungus is variable, and it should be mentioned the facultative pathogenicity, capsule with anti-phagocytic activity, and antioxidant melanin production. The aim of this study was to evaluate the use of polymerase chain reaction (PCR)/ restriction fragment length polymorphism (RFLP) for detection and identification of C. neoformans directly from the cerebrospinal fluid (CSF) of patients admitted to a public hospital with suspected meningitis and/or meningoencephalitis in the city of Lages, Santa Catarina, southern Brazil. Results were compared using Chinese ink and growth media. Methods: The samples were submitted to direct examination with Chinese ink for capsule observation, then to growth on culture media (Sabouraud Agar and Niger), with subsequent DNA extraction with phenol-chloroform. PCR was the technique used for amplification of URA5 gene, and then restriction enzymes HhaI and Sau96I were used for genotyping by PCR-RFLP. Results: In two samples, C. neoformans were isolated by Chinese ink and amplified by PCR. They were identified as serotype var. grubii. Conclusion: C. neoformans var. grubii is the most commonly isolated in human cryptococcosis, mainly in HIV patients. However, the preference of this serotype for this group of patients is unknown. (AU)

Validación de la escala de Valgado para el diagnóstico de meningitis en niños

Introducción: En los últimos años se han desarrollado múltiples escalas con el fin de establecer parámetros objetivos, basados en las características del líquido cefalorraquídeo que faciliten el diagnóstico diferencial entre meningitis bacteriana (MB) y aseptica (MA) y la consecuente decisión de iniciar o no antibióticos. Objetivos: Validar una escala predictiva para el diagnóstico de MA y MB en los pacientes pediátricos mayores de 30 días de vida y menores de 12 años. Métodos: Se revisaron de forma retrospectiva los estudios de líquido cefalorraquídeo de 69 historias de pacientes pediátricos, los cuales cumplieron con las definiciones establecidas, criterios de inclusión y ningún criterio de exclusión. Se asignó el puntaje según la Escala de Valgado, y se manejaron los datos usando EpiInfo SPSS y Epidat. Resultados: Los parámetros de la escala, mostraron una sensibilidad de 100 % (IC 95 %: 95,8-100 %); especificidad de 94,7 % (IC 95 %: 88,1-100 %). Se obtuvo un valor predictivo positivo de 80 % (IC 95 %: 56,4-100 %) y un valor predictivo negativo de 100 % (IC 95 %: 99,1-100 %). La razón de verosimilitud positiva fue de 19 (I.C 95 %: 6,3-57,2 %) y la negativa fue de 0; el test de KAPPA obtuvo un valor de 0,86. Conclusión: La escala clínica predictiva de Valgado resultó ser una herramienta válida, en vista de sus altos niveles de sensibilidad y especificidad; segura, por sus elevados valores de predictividad; eficiente, en vista de sus aceptables índices de eficiencia pronóstica; y reproducible en vista de los niveles de concordancia mostrados.

Introduction: In recent years, multiple scales have been developed in order to establish objective parameters, based on the characteristics of the cerebrospinal fluid that facilitate the differential diagnosis between bacterial meningitis (BM) and aseptic (AM) and the consequent decision to initiate or not antibiotics. Objectives: Validate a predictive scale for the diagnosis of am and bm in pediatric patients older than 30 days of age and younger than 12 years. Methods: The cerebrospinal fluid caractheristics of 69 pediatric patients were retrospectively reviewed by using their medical records. all of them, met the established definitions, inclusion criteria and no exclusion criteria. the score was assigned according to the valgado scale, and the data were handled using epiinfo spss and epidat. Results: Scale parameters showed a sensitivity of 100 % (95 % ci: 95.8-100 %); specificity of 94.7 % (95 % ci: 88.1-100 %). a positive predictive value of 80 % (95 % ci: 56.4-100 %) and a negative predictive value of 100 % (95 % ci: 99.1-100 %) were obtained. the positive likelihood ratio was 19 (95 % ci: 6.3-57.2 %) and negative was 0. kappa test obtained a value of 0.86. Conclusion: The predictive clinical valgado scale proved to be a valid tool in view of its high levels of sensitivity and specificity; safe, because of its high values of predictivity; efficient, in view of its acceptable predictive efficiency indices; and reproducible in view of the levels of concordance shown.

Escala diagnóstica de Thwaites: experiencia en el Hospital Carlos Andrade Marín (Quito-Ecuador) / Thwaites diagnostic scale: experience in the Carlos Andrade Marin Hospital (Quito-Ecuador)

Introducción: La tuberculosis es un problema de salud pública. La escala diagnóstica de Thwaites es una herramienta usada para diferenciar la meningitis tuberculosa de otros tipos de meningitis bacterianas. Materiales y métodos: Estudio retrospectivo en pacientes con sospecha de meningitis bacteriana realizado en el Hospital Carlos Anadrade Marín con la información de los registros médicos del sistema informático AS-400. Resultados: Estudiamos 41 casos de meningitis bacteriana no tuberculosa y 7 casos confirmados de tuberculosis. Los resultados del uso de la escala fueron: sensibilidad 88% y especificidad 88%. Razón de Verosimilitud positiva: 7.33 y Razón de Verosimilitud negativa: 0.14. Discusión: La escala de Thwaites podría ser útil para diferenciar la meningitis bacteriana piógena de la tuberculosa. Palabras clave: OMS-OPS; thwaites; LCR; Meningitis, Tuberculosis.

Introduction: tuberculous meningitis is one of the most common public health problems worldwide. Thwaites diagnostic scale is a tool used to differentiate tuberculous meningitis from other types of bacterial meningitis. Methods: This is a retrospective study carried out in patients diagnosed of bacterial meningitis developed at Carlos Andrade Marin Hospital. Information was taken from the medical records stored in the AS400 system. Results: Of 48 patients studied, 41 had bacterial meningitis and seven tuberculous meningitis. The sensitivity and the specificity of Thwaites' diagnostic score were 88%. The LR+ and LR- were 7.33 y 0.14 respectively. Discusion: Thwaites' diagnostic score was found to be a useful tool to differentiate bacterial from tuberculous meningitis.

Meningitis recurrente por Streptococcus pneumoniae en paciente con malformación congénita de oído derecho

La meningitis recurrente es una entidad rara que sugiere la presencia de una comunicación adquirida o congénita entre el liquido cefalorraquídeo y las áreas mucocutáneas adyacentes. Presentamos el caso de una paciente de 11 meses con historia de meningitis recurrente (4 episodios) asociadas a hipoacusia neurosensorial y otorrea intermitente en la que se diagnóstico fístula del LCR en oído interno así como una malformación secular cócleo-vestibular compatible con displasia de Mondini. Ante cuadros recurrentes de meningitis bacteriana en la edad pediátrica y más aún, si padece hipoacusia neurosensorial como en nuestro caso, es necesario agotar todas las posibilidades diagnósticas de forma precoz y oportuna en busca de malformaciones. En especial las fístulas congénitas que frecuentemente se les asocian y que con una temprana intervención quirúrgica puede evitar futuros episodios.

Recurrent meningitis is a rare but severe entity which suggests the presence of an acquired or congenital communication between of cerebrospinal fluid and adjacent mucocutaneous sites. We present the case of an 11 month patient with history of recurrent meningitis ( 4 episodes), associated to neurosensorial hipoacusia and intermittent otorrhea in which a diagnosis of cerebrospinal fluid fistula in the middle ear as well as a secular cochlea-vestibular malformation, compatible with Mondini dysplasia was made. In the presence of recurrent bacterial meningitis in the pediatric age, moreover if the patient suffers hearing impairment as in our case, it is necessary to exhaust all diagnostic possibilities early and timely in search of malformations, especially congenital fistulas, as they are associated and prompt surgical intervention may prevent futher episodes.

Cerebrospinal fluid examination may be useful in diagnosing neurosyphilis in asymptomatic HIV+ patients with syphilis / El examen del líquido céfalo raquídeo puede ser útil en el diagnóstico de neurosífilis en pacientes VIH + asintomáticos con sífilis

ABSTRACT Lumbar puncture in neurologically asymptomatic HIV+ patients is still under debate. There are different criteria for detecting neurosyphilis through cerebrospinal fluid (CSF), especially in cases that are negative through the Venereal Disease Research Laboratory (VDRL), regarding cellularity and protein content. However, a diagnosis of neurosyphilis can still exist despite negative VDRL. Treponema pallidum hemagglutination assay (TPHA) titers and application of the TPHA index in albumin and IgG improve the sensitivity, with a high degree of specificity. Thirty-two patients were selected for this study. VDRL was positive in five of them. The number of diagnoses reached 14 when the other techniques were added. It was not determined whether cellularity and increased protein levels were auxiliary tools in the diagnosis. According to our investigation, CSF analysis using the abovementioned techniques may be useful in diagnosing neurosyphilis in these patients.

RESUMO La punción lumbar (PL) en pacientes VIH+ neurológicamente asintomáticos es controversial. Existen diferentes criterios para detectar en el líquido cefalorraquídeo (LCR) neurosífilis (NS): el examen Venereal Disease Research Laboratory (VDRL) en primer lugar, en caso de negatividad: la celularidad y el tenor de proteinas. Sin embargo el diagnóstico de NS puede ser sostenido a pesar de la negatividad de las técnicas mencionadas. La titulación del Treponema pallidum hemagglutination assay (TPHA) y la aplicación del índice de TPHA en Albúmina e Ig G mejoran la sensibilidad asociando elevado grado de especificidad. 32 pacientes fueron seleccionados para este estudio, el VDRL fue positivo en 5. El diagnóstico se elevó a 14 cuando se sumaron el resto de las técnicas. No se evidenció que la celularidad y el aumento de proteínas fueran herramientas auxiliares para el diagnóstico. De acuerdo a nuestro trabajo el estudio del LCR con las técnicas señaladas puede ser de utilidad en el diagnóstico de NS en estos pacientes.

Ascitis por líquido cefalorraquideo secundario a derivación ventriculo-peritoneal / Cerebrospinal fluid ascites secondary to ventriculo - expert neal

La ascitis por Líquido cefalorraquídeo es una complicación relativamente rara que se ha reportado en la literatura prácticamente desde 1972. Junto con el pseudoquiste abdominal corresponde a un 2% de las complicaciones de las derivaciones ventriculoperitoneales. Múltiples teorías han intentado explicar la patogenia de esta patología. A continuación se presenta el caso de un paciente de 36 años del Hospital México quien luego de 11 años de colocada una DVP desarrolla un cuadro de ascitis por LCR cuyos estudios clínicos no mostraron causa desencadenante evidente del cuadro por lo que fue necesario realizar una derivación ventrículo-atrial. Se incluye además una revisión de la literatura vigente.

Ascites by cerebrospinal fluid (CSF) is a relatively rare complication that has been reported in the literature almost since 1972. Along with abdominal pseudocyst corresponds to 2% of the complications of ventriculoperitoneal shunts (VPS) . Multiple theories have attempted to explain the pathogenesis of this disease. Then the case of a patient of 36 years of the Hospital Mexico who after 11 years VPS placed one develops a picture of ascites CSF is presented whose clinical studies showed no obvious precipitating cause it was necessary to perform a ventriculo -atrial shunt. A review of the current literature is also included.

Fístula de líquido cefalorraquídeo postraumática: propuesta de algoritmo diagnóstico y terapéutico / Post-traumatic cerebrospinal fluid fistula: proposal of diagnostic and therapeutic algorithm

Introducción: la fístula de líquido céfalorraquídeo (LCR) se define como la salida anormal de líquido desde el cráneo al exterior a través de una brecha osteomeníngea, constituyendo una puerta de entrada de gérmenes al endocráneo y sus espacios con potencial riesgo infeccioso y en ocasiones vital. Es una patología relativamente frecuente, la cual clásicamente se divide en fístulas traumáticas y no traumáticas, siendo un gran desafío para el neurocirujano su resolución. Objetivo: presentar el primer caso de fístula de LCR postraumática en Uruguay, estudiado con cisterno-RNM, como método diagnostico. Caso clínico: se presenta el caso clínico de un paciente asistido en el Hospital de Clínicas. A través de este caso clínico ilustrativo, se busca realizar una puesta al día con respecto a los principales puntos de controversia, en vistas a plantear un algoritmo diagnostico y terapéutico. Discusión: encontramos como principales puntos de controversia: el comienzo de tratamiento (tto) antibiótico (ATB) profiláctico una vez realizado el diagnostico; que estudios paraclínicos imagenológicos son necesarios para el diagnostico, y, el tipo de tratamiento indicado. Conclusiones: de la bibliografía analizada, podemos concluir, que para un correcto diagnostico, se deben solicitar de rutina TC y RMN, y, si hay dudas: cisterno-RNM, endoscopía, o cisterno-TC. En cuanto al algoritmo terapéutico, concluimos que se debe realizar tratamiento conservador, con tratamiento medico por dos a cuatro semanas, y, si persiste fístula se debe indicar tratamiento quirúrgico. El tto. ATB es una opción y no una recomendación.

Introduction: the cerebrospinal fluid (CSF) fistula is defined as the abnormal leak of fluid from the skull to outside the body through an osteomeningeal gap, which allows the passage of organisms to the intra-cranial space, with the risk of infection, potentially life-threatening. Divided as traumatic and non-traumatic, the condition is relatively common, and poses great challenges to neurosurgeons. Objective: to present the first case of post-traumatic CSF fistula in Uruguay, assessed with cistern MRI with diagnostic purposes. Case report: the case described is that of a patient that received treatment at the University Hospital (Hospital de Clínicas). The case is used to illustrate the condition and review the latest controversial issues involved in the algorithms for the diagnosis and therapy of the condition. Discussion: the main controversial issues found included the following: when to start prophylactic antibiotic (ATB) therapy following diagnosis; imaging tests requested for diagnosis, and type of therapy prescribed. Conclusions: the review of literature leads us to conclude that a correct diagnosis requires the routine use of CT and MRI; if doubts persist, cistern MRI, endoscopy, or cistern CT are indicated. With regards the therapeutic algorithm, we conclude that therapy should be conservative, applying medical therapy for two to four weeks; surgery will be prescribed if the fistula persists after that. Antibiotic therapy is an option and not a recommendation.

Correlation analysis of large-platelet ratio (P-LCR) and stroke in patients with atrial fibrillation / 实用医学杂志

Objective To investigate the correlation between large platelet ratio (P-LCR) and stroke in patients with atrial fibrillation. Methods 152 consecutive patients with atrial fibrillation were selected and divided into two groups according to whether accompanying stoke or not. Clinical features of patients and blood test indicator P-LCR were analyzed by Logistic regression analysis. Results In total, 152 subjects, including 47 patients with stoke and 105 patients without stoke,were included in the study. Univariate analysis showed that the difference in age, diabetes, hypertension, lipid-lowering therapy and P-LCR between two groups was statistically significant (P < 0.05). Logistic regression analysis showed that age, diabetes and P-LCR were independent risk factors of stroke in patients with atrial fibrillation. Conclusions Age, diabetes and P-LCR are independent risk factors of stroke in patients with atrial fibrillation.

Biological markers of Alzheimers disease / Biomarcadores da doenca de Alzheimer

The challenges for establishing an early diagnosis of Alzheimer’s disease (AD) have created a need for biomarkers that reflect the core pathology of the disease. The cerebrospinal fluid (CSF) levels of total Tau (T-tau), phosphorylated Tau (P-Tau) and beta-amyloid peptide (Aβ42) reflect, respectively, neurofibrillary tangle and amyloid pathologies and are considered as surrogate markers of AD pathophysiology. The combination of low Aβ42 and high levels of T-tau and P-Tau can accurately identify patients with AD at early stages, even before the development of dementia. The combined analysis of the CSF biomarkers is also helpful for the differential diagnosis between AD and other degenerative dementias. The development of these CSF biomarkers has evolved to a novel diagnostic definition of the disease. The identification of a specific clinical phenotype combined with the in vivo evidence of pathophysiological markers offers the possibility to make a diagnosis of AD before the dementia stage with high specificity.

O desafio de se estabelecer o diagnóstico precoce de doença de Alzheimer (DA) levou ao desenvolvimento de biomarcadores que reflitam os aspectos patológicos centrais da doença. As dosagens no líquor da proteína Tau total (T-Tau), Tau fosforilada (P-Tau) e peptídeo beta-amiloide (Aβ42) no líquido cefalorraquidiano (LCR) refletem, respectivamente, as patologias Tau e amiloide, sendo consideradas como marcadores da fisiopatologia da DA. Os biomarcadores do LCR podem identificar acuradamente pacientes com DA em estágios precoces da doença, mesmo antes do desenvolvimento da demência. A análise combinada dos biomarcadores permite também fazer o diagnóstico diferencial entre DA e outras demências degenerativas. O desenvolvimento dos biomarcadores de DA conduziu a uma nova definição diagnóstica da doença. A identificação de um fenótipo clínico específico associado a uma evidência fisiopatológica in vivo provida por um biomarcador possibilita estabelecer, com alta especificidade, o diagnóstico de DA antes do estágio demencial.

Acelularidad del líquido cefalorraquídeo como factor pronóstico adverso en meningitis criptocóccica / Acellularity of cerebrospinal fluid as adverse prognostic factor in cryptococcal meningitis

Introducción: las enfermedades oportunistas, y dentro de ellas la meningitis criptocóccica en pacientes inmunodeprimidos, constituyen causa mayor de letalidad en países en vías de desarrollo. Objetivo: identificar factores de mal pronóstico como la acelularidad del líquido cefalorraquídeo (LCR) para individualizar medidas terapéuticas encaminadas al logro de una mayor supervivencia y calidad de vida de estos pacientes. Métodos: se estudió la celularidad de todos los LCR de los 170 casos de Bojanala, North West, ingresados en el Hospital Provincial de Rustenburg, South África por meningitis criptocóccica desde mayo de 2001 hasta abril de 2004. Se interrelacionó el número de células blancas del LCR con la letalidad intrahospitalaria, seropositividad al virus de inmunodeficiencia humana (VIH) y nivel de linfocitos T4. Resultados: se detectó una asociación altamente significativa entre acelularidad basal del LCR y riesgo a morir, y significativa con progresión lineal de mayor mortalidad en los casos con descenso evolutivo del número de células blancas en sucesivos LCR. Se constató un alto índice de letalidad (36,5 por ciento)por meningitis criptocóccica. No hubo diferencias significativas entre acelularidad y letalidad en pruebas de comparación de grupos acorde al nivel de linfocitos T4 y a la confirmación o no de la seropositividad al VIH. Conclusiones: tanto la acelularidad basal como la progresión descendente evolutiva del número de células blancas del LCR constituyen herramientas útiles para la predicción del riesgo a morir por meningitis criptocóccica

Introduction: opportunistic diseases, and among them, cryptococcal meningitis in immune-compromised patients, are a major cause of lethality in developing countries Objective: to identify mal prognostic factors such as acellularity of cerebrospinal fluid (CSF) to identify therapeutic measures aimed to achieve improved survival and quality of life of these patients. Methods: cellularity was studied in all CSF of the 170 cases in Bojanala, North West, who were admitted to the Rustenburg Provincial Hospital, South Africa for cryptococcal meningitis from May 2001 to April 2004. The number of CSF white cell with hospital mortality, seropositive human immunodeficiency virus (HIV) and level of T4 lymphocytes were interrelated. Results: a highly significant association was found between baseline CSF acellularity and risk of death, and significant linear progression of increased mortality in patients with developmental decline in the number of white cells in successive CSF. A high fatality rate (36.5 percent) for cryptococcal meningitis was also found. No significant differences was found between acellularity and lethality tests comparing groups according to the level of T4 lymphocytes and the confirmation or otherwise of HIV seropositivity. Conclusions: both basal acellularity and evolutionary downward progression of the number of CSF white cells are useful tools for predicting the risk of death for cryptococcal meningitis

The history of cerebrospinal fluid analysis in Brazil / Historia do estudo do liquido cefalorraquidiano no Brasil

Analysis on cerebrospinal fluid (CSF) in neurological diagnosis has always been considered to be a strong point among the main complementary examinations in Brazil. The present paper reviews the main events in the history of CSF in the neurological sciences, with emphasis on the founders of several CSF schools in our country from the beginning of the 20th century to the present time.

No Brasil o estudo do líquido cefalorraquidiano (LCR) como arsenal diagnóstico para a neurologia sempre foi considerado um ponto forte entre os principais exames complementares. Neste artigo são revisados os fatos principais da história do LCR dentro das ciências neurológicas, com ênfase aos fundadores das diversas escolas de LCR do nosso país desde as primeiras décadas do século XX até o momento atual.

Prevalencia de infección por citomegalovirus en pacientes pediátricos con afecciones neurológicas en el estado Zulia, Venezuela (2007-2008) / Prevalence of cytomegalovirus infection in pediatric patients with neurological disorders in Zulia state, Venezuela (2007-2008)

El objetivo de este estudio fue determinar la prevalencia de citomegalovirus en pacientes pediátricos con afecciones neurológicas, provenientes del Estado Zulia, Venezuela durante el período 2007-2008. Se recolectaron 186 muestras pareadas de líquido cefalorraquídeo (LCR) y suero, de pacientes entre 1 mes y 14 años de edad, que presentaron sintomatología clínica sugestiva de afectación del SNC y cuyo estudio bacteriológico convencional de LCR resultó negativo. Se determinó la relación albúmina LCR/suero a fin de descartar contaminación y a los pares óptimos se les determinó por la técnica de ELISA anticuerpos IgM e IgG en suero e IgG en LCR anti-CMV. Del total de muestras recolectadas 40,86% (76/186) resultaron óptimas para el análisis. De los 76 casos analizados, el 2,6% (2/76) de las muestras de suero resultaron positivas para IgM; 93,4% (71/76) fueron seropositivas a IgG mientras que el 31,6% (24/76) de las muestras de LCR presentaron anticuerpos IgG. En cuanto a los parámetros citoquímicos del LCR, se observaron valores de glucosa aumentados en el 58,3% (p<0,05) de los pacientes con CMV que presentaron meningoencefalitis. En los pacientes con meningitis que presentaron positividad de anticuerpos IgG anti-CMV en el LCR se observó un aumento significativo (p<0,01) en las proteínas del LCR. Se evidencia que una proporción de los pacientes pediátricos con afecciones neurológicas presentaron infección aguda por CMV, lo que demuestra una participación importante de este agente en pacientes del estado Zulia, Venezuela para el período en estudio.

The aim of this study was to determine the prevalence of cytomegalovirus (CMV) in pediatric patients with neurological disorders from Zulia State, Venezuela, during the period 2007-2008. Samples of cerebrospinal fluid (CSF) and serum were obtained from 186 patients with neurological symptoms and bacteriological negative CSF. The albumin CSF/serum content was determined to rule out contamination of CSF and optimal pairs were determined by ELISA of IgM and IgG anti-CMV antibodies in serum and IgG in CSF. Only 40.86% (76/186) of patients were optimal for this study. Serum samples positive for IgM antibodies (2/76; 2.6%) and IgG antibodies (71/76; 93.4%) were obtained. CSF IgG antibodies were observed in 24/76 patients (31.6%). Increased values of glucose in CSF (p<0.05) were observed in 58.3% of CMV patients with meningoencephalitis. In addition, increased CSF protein concentration (p<0.01) was observed in CSF anti-CMV antibodies positive patients with meningitis. This study shows high prevalence of acute CMV infection in pediatric patients with neurological affections suggesting an important role of this virus in this pathology during the studied period.