Intraoperative Hypertensive Crisis in a Patient with Normotensive Primary Aldosteronism. Lessons from a Clinical Case

Primary hyperaldosteronism is the most frequent cause of secondary hypertension. However, it can also be found in apparently normotensive patients, often associated with recurrent hypokalemia and isolated hypertensive episodes. We hereby present the case of a normotensive 50-year-old female patient with a surgical left kidney mass; however, after anaesthetic induction, surgery was aborted due to a severe hypertensive crisis. She was referred to our Hypertension Outpatient Clinic to rule out pheochromocytoma/ paraganglioma. The anamnesis revealed unexplained episodes of hypokalemia. Ambulatory blood pressure monitoring showed normal mean values of blood pressure and heart rate, with an isolated hypertensive peak. Plasma glucose, ions, creatinine, lipids, metanephrines and chromogranin A were normal, but plasma aldosterone was clearly elevated with suppressed plasma renin activity and high aldosterone/renin activity ratio. Primary aldosteronism was confirmed by the captopril test. Abdominal CT was compatible with left adrenal hyperplasia. Treatment with low-dose spironolactone was well tolerated and resulted in normal blood pressure, normokalemia and unsuppressed plasma renin activity. The patient underwent successful laparoscopic removal of a renal oncocytoma. We conclude that normotensive primary aldosteronism is not harmless; it can be associated with severe hypokalemia, anxiety, depression, hypertensive crisis and cardiovascular damage. Patients can also develop resistant hypertension. Adequate treatment can decisively improve the survival and quality of life of the patients with primary aldosteronism, but a correct diagnosis is needed first. Therefore, it must be considered as a diagnostic possibility in normotensive patients with unexplained hypokalemia or isolated hypertensive episodes.

Enfoques del ejercicio terapéutico sobre la espasticidad en miembro inferior post-Enfermedad Cerebro Vascular: revisión sistemática / Approaches of therapeutic exercise over lower limb spasticity after stroke: a systematic review

RESUMEN Introducción: En la enfermedad cerebro vascular uno de los principales problemas es la espasticidad, que compromete el control postural, la funcionalidad y la calidad de vida. Para lograr la mayor recuperación funcional, se han utilizado los enfoques neuromusculares del ejercicio terapéutico (Ej: Rood, Bobath, Brunnstrom y la Facilitación Neuromuscular Propioceptiva), sin embargo, existe controversia sobre la eficacia de estas intervenciones. Objetivo: Realizar un análisis crítico de la evidencia científica disponible sobre el efecto de los enfoques tradicionales en la espasticidad de los miembros inferiores en personas post-Enfermedad Cerebro Vascular. Métodos: Se incluyeron ensayos clínicos controlados de las bases de datos PUBMED, MEDLINE, PEDro, CINAHL, SCIENCEDIRECT y SCOPUS. La calidad metodológica de los artículos incluidos se evaluó por medio de la escala PeDro. Resultados: Once estudios cumplieron con los criterios de inclusión, obteniendo una calidad metodológica de intermedia a alta. Entre las limitaciones de los estudios revisados se destacan principalmente la ausencia del cálculo del tamaño de muestra, de enmascaramiento de los evaluadores, pérdida de participantes, muestras heterogéneas, carencia de protocolos estandarizados y diversidad de variables evaluadas. Conclusión: El tratamiento fisioterapéutico para disminuir la espasticidad puede ser efectivo aplicado entre tres y cinco días por semana, durante 40 minutos. Sin embargo, estos resultados están soportados en estudios con limitaciones metodológicas y dificultades en su comparación. Por ello, se requieren nuevos estudios para evaluar la eficacia de dichos enfoques, con el fin implementar intervenciones fisioterapéuticas basadas en la mejor evidencia, que contribuyan en una mejor calidad de vida de esta población.

ABSTRACT Introduction: Spasticity due to a stroke is one of the major changes that leads to sensorimotor deficits, causing postural control and functional capability deficits. In order to achieve the best possible functional recovery, several neuromuscular therapeutic exercise approaches have been employed (eg Rood, Bobath, Brunnstrom and proprioceptive neuromuscular facilitation), but still there are many doubts about the effectiveness of these interventions. Purpose: To perform a critical analysis of the available scientific evidence on the effect of the traditional approaches in spasticity recovery of the lower limbs in post-stroke individuals. Methods: Randomized controlled Trials available in PubMed, MEDLINE, PEDro, CINAHL, and Scopus data SCIENCEDIRECT bases were included in this study. The methodological quality of included articles was evaluated by the PEDro scale. Results: Eleven studies were included, obtaining a methodological quality of intermediate to high. The main observed limitations of the analyzed studies were: the absence of sample size estimation, the lack of blind evaluators, loss of participants, heterogeneous samples, lack of standardized protocols and diversity of employed variables. Conclusions: Based upon the results, it can be suggested that spasticity reduction can be effective applying from three to five days interventions per week, lasting 40 minutes. However, such suggestions are supported by studies with methodological limitations and employing different procedures that prevent a direct comparison among the studies. Therefore new studies are required to evaluate the effectiveness of such approaches, to implement physiotherapy interventions based on the scientific evidences that would further contribute to a better quality of life of post-stroke individuals.

Effect of walking and resting after three cryotherapy modalities on the recovery of sensory and motor nerve conduction velocity in healthy subjects / Efeito da marcha e do repouso após aplicação de três protocolos de crioterapia na recuperação da velocidade de condução sensorial e motora em sujeitos saudáveis

BACKGROUND: Different cryotherapy modalities have distinct effects on sensory and motor nerve conduction parameters. However, it is unclear how these parameters change during the post-cooling period and how the exercise carried out in this period would influence the recovery of nerve conduction velocity (NCV). OBJECTIVES: To compare the effects of three cryotherapy modalities on post-cooling NCV and to analyze the effect of walking on the recovery of sensory and motor NCV. METHODS: Thirty six healthy young subjects were randomly allocated into three groups: ice massage (n=12), ice pack (n=12) and cold water immersion (n=12). The modalities were applied to the right leg. The subjects of each modality group were again randomized to perform a post-cooling activity: a) 30min rest, b) walking 15 min followed by 15 min rest. The NCV of sural (sensory) and posterior tibial (motor) nerves was evaluated. Initial (pre-cooling) and final (30 min post-cooling) NCV were compared using a paired t-test. The effects of the modalities and the post-cooling activities on NCV were evaluated by an analysis of covariance. The significance level was α=0.05. RESULTS: There was a significant difference between immersion and ice massage on final sensory NCV (p=0.009). Ice pack and ice massage showed similar effects (p>0.05). Walking accelerated the recovery of sensory and motor NCV, regardless of the modality previously applied (p<0.0001). CONCLUSIONS: Cold water immersion was the most effective modality for maintaining reduced sensory nerve conduction after cooling. Walking after cooling, with any of the three modalities, enhances the recovery of sensory and motor NCV.

CONTEXTUALIZAÇÃO: Diferentes protocolos de crioterapia têm ação distinta nos parâmetros de condução neural sensorial e motora. No entanto, não se sabe como é o comportamento desses parâmetros no período pós-resfriamento e como o exercício físico realizado nesse período atuaria na recuperação da velocidade de condução nervosa (VCN). OBJETIVOS: Comparar o efeito de três protocolos de crioterapia na VCN pós-resfriamento e analisar o efeito da marcha pós-resfriamento na recuperação da VCN sensorial e motora. MÉTODOS: Trinta e seis sujeitos jovens e saudáveis foram alocados aleatoriamente em três grupos: criomassagem (n=12), pacote de gelo (n=12); imersão em água gelada (n=12). As modalidades foram aplicadas na perna direita. Os sujeitos de cada grupo foram novamente aleatorizados para realizar uma atividade pós-resfriamento: a) 30 min de repouso; b) 15 min de marcha seguidos de 15 min de repouso. Avaliou-se a VCN nos nervos sural (sensorial) e tibial posterior (motor). Comparações entre VCN inicial e final (30 min pós-resfriamento) foram realizadas com teste t de Student pareado. Os efeitos das modalidades e das atividades pós-resfriamento na VCN foram avaliados mediante análise de covariância. O nível de significância foi α=0,05. RESULTADOS: Houve efeito diferente entre imersão e criomassagem na VCN sensorial final (p=0,009). Pacote de gelo e criomassagem apresentaram efeitos similares (p>0,05). A marcha acelerou a recuperação da VCN sensorial e motora, independente da modalidade previamente aplicada (p<0,0001). CONCLUSÕES: Imersão em água gelada foi o procedimento mais eficaz para manter diminuída a condução nervosa sensorial após o resfriamento. A marcha pós-crioterapia, com qualquer um dos três protocolos, acelera a recuperação da VCN sensorial e motora.

Anastomosis Martin-Gruber: Aspectos anatómicos y electrofisiológicos / Martin-Gruber Anastomosis: Anatomical and electrophysiological issues

La anastomosis de Martin Gruber (AMG) es una de las variaciones anatómicas más frecuentes que consiste en la contribución de axones motores desde el nervio mediano hacia el ulnar en el antebrazo. Factores filogenéticos y genéticos se asocian con la aparición de la AMG. Entre tanto, otros factores como género, raza o lateralidad no parecen tener importancia en la aparición de la rama comunicante. Las clasificaciones de la AMG han sido establecidas según los hallazgos anatómicos, electrofisiológicos e histológicos y también según el lugar de origen y destino de la anastomosis. El objetivo de este artículo es revisar los factores asociados a la presencia de la AMG, así como las descripciones y clasificaciones anatómicas y electrofisiológicas. Esta revisión aporta información relevante para el reconocimiento de los patrones clásico y variante de inervación de la musculatura intrínseca de la mano. Dicho reconocimiento permite diagnosticar e intervenir apropiadamente las alteraciones de los nervios periféricos de la extremidad superior.

The Martin Gruber Anastomosis (MGA) is one of the most common anatomical variants of the upper limb, which consists of motor axons crossing through the forearm from the median nerve to the ulnar nerve. Phylogenetic and hereditary factors have been associated whit the MGA. However, gender, race, or laterality, do not seem to have importance in the appearance of the communicating branch. The MGA has been categorized according to findings in anatomy, electrophysiology and histology, in relation to the source and destination of the communicating branch. The aim of this article is to review the factors related to the presence of MGA, as well as the descriptions and classifications according to anatomy and electrophysiology. This revision contributes with important information relevant to the recognition of differences between the classic pattern and the variant pattern of the innervations of the intrinsic muscles of the hand. Such recognition allows a more appropriate diagnostic and intervention of disorders of the peripheral nerves in the upper limb.

Brain plasticity, signal transduction and epigenesis: a missing link revealed

It has been long thought that the brain reorganizes itself in response to environmental needs. Sensory experiences coded in action potentials are the mean by which information on the surroundings is introduced into neuronal networks. The information approaching the brain in the form of electrochemical codes must then be translated in biochemical, epigenetic and genetic ones. Only until recently we have begun understanding the underpinning of such informational transformations and how this process is expressed as neuronal plastic responses. Central for our comprehension of this matter is the finding that signals transduction cascades can modify gene expression by remodeling the chromatin through epigenetic mechanisms. Hence, chromatin remodeling seems to be the process by which experiences are “imprinted”.

Dolor de cuello/hombros y espalda en adolescentes: prevalencia y factores asociados / Neck pain/shoulder and back in adolescents: prevalence and factors associated

Objetivo: Determinar la prevalencia de dolor de cuello/hombros y espalda en adolescentes y explorar sus factores asociados. Materiales y métodos: Estudio de corte transversal con selección aleatoria de 30 instituciones. Se registraron género, edad, tener empleo, actividades sedentarias y deportivas, factores de carga (peso de la maleta y forma de cargarla) y postura en la silla escolar. Cuatro variables de salida fueron definidas: dolor agudo y crónico,localizado en cuello/hombros y espalda. Modelos de regresión log-binomial se aplicaron para estimar las razones de prevalencia (RP) e intervalos de confianza del 95%. Resultados: Se evaluaron 439 adolescentes, 231 mujeres (52,6%), edad 13,8 ± 1,8 años. Las prevalencias de dolor de cuello/hombros agudo y crónico fueron 25,6% IC95% (20.7 – 30,6) y 8,9% IC95% (6,0 – 11,8) respectivamente; para dolor de espalda agudo 22,9% IC95% (18,0 – 27,9)y crónico 10,5% IC95% (7,0 – 14,0). Los factores asociados con dolor de cuello/hombros agudo fueron empleo (RP 2,4), ver televisión (RP > 1,5), uso de computador (RP 1,5) y carga superior al 10% del peso corporal (RP 1,8);para el crónico la práctica de al menos una actividad deportiva (RP 0,5) y la postura inadecuada en la silla escolar (RP 7,1). Con dolor de espalda agudo se asoció el peso de carga (RP: 1,4), con el crónico edad (RP: 1,1) y más de 7 horas semanales de actividades deportivas (RP: 0,5). Cargar elementos adicionales en las manos se asoció con las cuatro variables de salida (RP>1,6). Conclusión: Los factores asociados son susceptibles de modificar mediante la implementación y evaluación de intervenciones en el ámbito escolar dirigidos a fomentar estilos de vida saludables.

Objective: To establish the prevalence of neck/shoulder pain (NSP) and back pain (BP) and explore associated factors in adolescents. Materials and mthods: Cross sectional study. Thirty schools were randomly selected from Bucaramanga. Sociodemographic variables, sedentary and sports activities, carrying load factors of scholar bag and postures in the school chair were registered. Four outcome variables were defined acute and chronic pain located in neck/shoulder and back pain. Log-binomial regression models were used to obtain the prevalence ratios (PR) and their 95% confidence intervals. Results: A total of 439 schoolchildren were evaluated, 231 (52.6%) female gender, age 13.8 ± 1.8 years old. Prevalence for neck/shoulder acute and chronic were 25.6% CI95% ( 20.7 – 30.6) and 8.9% CI95% ( 6.0 – 11.8) respectively; Acute back pain was 22.9% CI95 %( 18.0 – 27.9) and chronic 10.5% CI95% (7.0 – 14.0). Work (RP 2.4), watching TV (RP 1.5 – 2.0), computers use (RP 1.5) and carrying load>10% (RP1.8) were associated with acute neck/shoulder pain; the practice of at least one sport activity (RP 0.5) and bad posture in the sitting chair (RP 7.1) for chronic pain. Load carrying (RP 1.4) was associated with acute back pain; age (RP1.1) and > 7hours/week dedicated to sports activities (RP 0.5) for chronic pain. Additional elements load in hands was associated with the four outcome variables (RP>1.6). Conclusion: The prevalence found was very high. The associated factors may be modified by interventions directed to promote healthy styles of life in the scholar setting which must reduce pain.

Descripción anatómica del plexo braquial / Anatomical description of the brachial plexus

El plexo braquial tiene un papel importante en la función motora y sensorial del miembro superior. Está conformado por las raíces anteriores de C5 a T1, las cuales se agrupan en troncos y fascículos que originan cinco nervios terminales.El conocimiento detallado de este plexo permite identificar las variaciones y alteraciones más frecuentes. Aunque este tema ha sido objeto de publicaciones previas, la lectura y comparación bibliográfica resulta difícil, debido a la diversidad de las nomenclaturas utilizadas. El objetivo del artículo es presentar una descripción anatómica del plexo braquial con base en la nomenclatura anatómica internacional. Para su elaboración se consultaron textos clásicos y diversos recursos electrónicos (revistas y bases de datos), que se confrontaron y analizaron posteriormente. Esta revisión proporciona información útil a los estudiantes y profesionales del área de la salud, quienes participan en el diagnóstico y rehabilitación de las alteraciones del plexo.

The Brachial Plexus is responsible for cutaneous and muscular innervation of the entire upper limb. It is an arrangement of the anterior roots from above the fifth cervical vertebra to underneath the first thoracic vertebra (C5-T1) which gather in trunks and divisions to originated five main peripheral nerves. The deep anatomical knowledge of the plexus supports the identification of anatomical variation and alterations. Although this issue has been focus of some prior publications it is difficult to compare these because of the diversity of nomenclature used. Therefore, the objective of this revision article is to show the anatomical description of the Brachial Plexus based on international nomenclature. Classic text books and media sources (journal and databases) were contrasted and analyzed. This survey offers important information to students and health professionals who are interesting in diagnosis and rehabilitation of Brachial Plexus injuries.

Los canales TRP y su participación en la termotransducción / TRP channels and their participation in termotransduccion

El hombre tiene una fina capacidad para discriminar cambios de temperatura, lo cual sugiere la existencia de sensores con umbrales térmicos variables. Recientes investigaciones demuestran la participación de una familia de canales TRP (Transient Receptor Potential) en la termotransducción. En mamíferos se reconocen 20 canales TRP, con funciones sensoriales diversas: reconocimiento de la luz y de feromonas, dolor, mecano-sensación, gusto y termotransducción; además se describe su sobre-expresión en células cancerígenas. Estos canales poseen permeabilidad no selectiva a cationes monovalentes y al Ca2+. Se proponen seis canales TRP sensibles a temperatura, de los cuales los TRPV1,TRPV2, TRPV3 y TRPV4 se activan por calor y los TRPM8 y TRPA1 por frío. El objetivo del artículo es revisar la estructura, el funcionamiento y la participación de los canales TRP en la termotransducción. Este tema es clínicamente relevante, porque permite explicar efectos terapéuticos de algunas modalidades analgésicas, como la termoterapia.

The human being is able to discriminate few changes in environmental temperature. It suggests there are different types of sensors with variable thermal thresholds. Current researches have demonstrated the participation of a wide family of TRP channels (Transient Receptor Potential) in the thermotransduction. In mammals 20 TRP channels have been recognized, which perform diverse sensorial functions related with the recognition of the light, feromones,mechano-sensation, taste and temperature. Besides, has been described its role in the over-expression of cancerigenic cells. They have a non-selective permeability to monovalents cations and Ca2+. Six TRP channels sensitive to temperature have been proposed such as TRPV1, TRPV2, TRPV3 and TRPV4 that are activated by heat and TRPM8 and TRPA1 by cold. In this article we review the structure, functioning and participation of the TRP channels in the thermo transduction. This issue is clinical relevant, because it allows to explain therapeutic effects of some analgesic modalities, as the thermotherapy.

Clasificación, frecuencia y distribución de las lesiones linfoides oculares y orbitarias en la A.P.E.C. (revisión de 30 años: 1959-1990) / Study of ocular and orbital lymphoid lesions in a 30 year period at the A.P.E.C

Se presenta un estudio retrospectivo de revisión de lesiones linfoides oculares y orbitarias en un periodo de 30 años en el Hospital de la A.P.E.C. En total se evaluaron 60 casos, de los cuales, el 41.66 por ciento correspondió a lesiones malignas, el 31.66 por ciento a lesiones benignas y el 21.66 por ciento a lesiones limítrofres constituídas por todos aquellos casos con diagnóstico histopatológico dudoso entre linfoma e hiperplasia linfoide. De las lesiones malignas, el 76 por ciento correspondió a linfoma con predominio del tipo linfocítico y el 94.74 por ciento de la patología benigna se debió a hiperplasi linfoide. Los linfomas se presentaron entre la 7a. y 8a. decádas de la vida; por lo contrario la hiperplasia prevaleció en pacientes con edades entre 20 y 40 años. Se encontró una mayor frecuencia de las lesiones conjuntivales y no se demostraron diferencias clínicas significativas que distingan a los procesos benignos de los malignos. Se realiza una revisión de los factores inmunogenéticos involucrados en las nuevas clasificaciones de lesiones linfoides y se concluye que es necesaria la utilización de inmunohistoquímica para la clasificaicón definitiva de las lesiones limítrofes y se propone un protocolo clínico para la adecuada evaluación de los pacientes con tumores linfoides.