Chronic hypoperfusion due to intracranial large artery stenosis is not associated with cerebral β-amyloid deposition and brain atrophy / 中华医学杂志(英文版)

BACKGROUND@#Insufficient cerebral perfusion is suggested to play a role in the development of Alzheimer disease (AD). However, there is a lack of direct evidence indicating whether hypoperfusion causes or aggravates AD pathology. We investigated the effect of chronic cerebral hypoperfusion on AD-related pathology in humans.@*METHODS@#We enrolled a group of cognitively normal patients (median age: 64 years) with unilateral chronic cerebral hypoperfusion. Regions of interest with the most pronounced hypoperfusion changes were chosen in the hypoperfused region and were then mirrored in the contralateral hemisphere to create a control region with normal perfusion. 11C-Pittsburgh compound-positron emission tomography standard uptake ratios and brain atrophy indices were calculated from the computed tomography images of each patient.@*RESULTS@#The median age of the 10 participants, consisting of 4 males and 6 females, was 64 years (47-76 years). We found that there were no differences in standard uptake ratios of the cortex (volume of interest [VOI]: P = 0.721, region of interest [ROI]: P = 0.241) and grey/white ratio (VOI: P = 0.333, ROI: P = 0.445) and brain atrophy indices (Bicaudate, Bifrontal, Evans, Cella, Cella media, and Ventricular index, P > 0.05) between the hypoperfused regions and contralateral normally perfused regions in patients with unilateral chronic cerebral hypoperfusion.@*CONCLUSION@#Our findings suggest that chronic hypoperfusion due to large vessel stenosis may not directly induce cerebral β-amyloid deposition and neurodegeneration in humans.

A abordagem metabolômica na indicação do tratamento de estenose de junção ureteropélvica em crianças / Metabolomics approach in the treatment of ureteropelvic junction stenosis in children

Estenose de Junção Ureteropélvica (JUP) é uma doença caracterizada pelo bloqueio do fluxo de urina da pelve renal (porção proximal do ureter no rim) ao ureter, tubo que liga o rim à bexiga. Essa formação congênita é uma das maiores causas de dilatação do rim (hidronefrose) em recém-nascidos e, em alguns casos, pode causar danos mais severos ao órgão. A hidronefrose causada pela estenose de JUP pode desaparecer espontaneamente sem perda da função renal, entretanto, é preciso um acompanhamento clínico. Por outro lado, em casos mais severos, onde a dilatação pode causar danos maiores ao rim, um tratamento cirúrgico se faz necessário. Embora existam métodos para o diagnóstico da estenose de JUP, como ultrassonografia, tomografia computadorizada, ressonância e cintilografia, é um grande desafio diferenciar os pacientes que requerem um tratamento cirúrgico e os que necessitam apenas de um acompanhamento convencional. A metabolômica global, que investiga de modo comparativo o conjunto de metabólitos de baixa massa molecular expressos em indivíduos em condições pré-selecionadas, tem o potencial de servir como ferramenta diagnóstica para os pacientes com estenose de JUP e, consequentemente, auxiliar na tomada de decisão entre um acompanhamento clínico ou tratamento cirúrgico. Assim sendo, no presente trabalho, três grupos de pacientes com estenose de JUP, pré-diagnosticados por métodos convencionais, foram investigados sob a perspectiva da metabolômica global, por meio de análises de urina, utilizando cromatografia gasosa e cromatografia líquida, ambas acoplada à espectrometria de massas (GC-MS e RPLC10 MS, respectivamente): pacientes que requerem tratamento cirúrgico (CIR), pacientes que requerem acompanhamento clínico (CLI), e indivíduos sãos (CON). Os resultados mostram que é possível encontrar metabólitos discriminantes entre todas as comparações (CON x CLI, CON x CIR e CLI x CIR); os metabólitos encontrados nas análises multivariada e univariada foram utilizados para construção da curva ROC, para confirmar a possibilidade de utilização desses compostos como biomarcadores. Foram observadas alterações em rotas metabólicas importantes para o bom funcionamento das funções renais, principalmente entre a comparação mais desafiadora (CLI x CIR), como o metabolismo da fenilalanina, da tirosina, da beta-alanina, dos aminoaçúcares e dos nucleotídeos. Há indícios de que o ciclo de Krebs também sofre alteração. Os resultados obtidos podem servir como ponto de partida para uma futura análise alvo e validação biológica

Ureteropelvic junction (UPJ) stenosis is a disease characterized by the interruption of the flow of urine from the renal pelvis (proximal part of ureter in the kidney) to the ureter, tube that links the kidney to bladder. That congenital formation is one of the main causes of kidney dilation (hydronephrosis) in newborns and, sometimes, can cause more serious damage to the organ. The hydronephrosis caused by UPJ stenosis can disappear spontaneously without compromising renal function, although a clinical follow-up is required. On the other hand, in more serious cases, when dilation can induce larger damage to the kidney, surgery intervention is necessary. Although there are methods to diagnose UPJ stenosis, such as ultrasound, computed tomography, resonance and scintigraphy, it is still a great challenge to distinguish patients that require surgery from those whose a clinical follow-up suffices. Global metabolomics, a method that investigates in a comparative manner the set of low molecular mass metabolites expressed by an individual in pre-selected conditions, has the potential to function as a diagnostic tool for patients with UPJ stenosis to support decisions about patient treatment, i.e., surgery versus clinical follow-up. In this work, three groups of UPJ stenosis patients were investigated with the aid of global metabolomics using urine analysis by gas chromatography and liquid chromatography coupled to mass spectrometry (GC-MS and RPLC-MS, respectively): one group consisted of UPJ stenosis patients requiring clinical follow-up (CLI), other group UPJ stenosis patients requiring surgery intervention (CIR) and a third group comprising healthy individuals, the control group (CON).12 The results show that it was possible to find discriminant metabolites among all pairwise comparisons (CON versus CLI, CON versus CIR and CLI versus CIR). The metabolites found by multivariate and univariate analyses were used to build ROC curves, to confirm whether it is possible to use them as biomarkers. Alterations in metabolic pathways that are important for the good maintenance of kidney functions were found, especially in the most challenged comparison (CLI versus CIR), such as the metabolism of phenylalanine, tyrosine, beta-alanine, amino acids and nucleotides. There are evidences that Krebs cycle was also impacted. The results obtained here can serve as a starting point to future targeted analysis and biological validation

Sclerosing mediastinitis causing unilateral pulmonary edema due to left atrial and pulmonary venous compression. a case report and literature review

Abstract Sclerosing mediastinitis (SM), previously named chronic fibrosing mediastinitis, is an inflammatory process that in its end-stage results to sclerosis around the mediastinal structures. SM is quite rare and has been correlated with inflammatory and autoimmune diseases, as well as malignancy. SM may either present in a mild form, with minor symptoms and a benign course or in a more aggressive form with severe pulmonary hypertension and subsequent higher morbidity and mortality. The diagnosis of SM may be difficult and quite challenging, as symptoms depend on the mediastinal structure that is mainly involved; quite often the superior vena cava. However, practically any mediastinal structure may be involved by the fibrotic process, such as the central airways, as well as the pulmonary arteries and veins, leading to obstruction or total occlusion. The latter may be impossible to undergo proper surgical excision of the lesion, and is considered to be a real challenge to the surgeon. We herein report a case of SM that presented with arterial and venous compression. The imaging appearance was that of unilateral pulmonary edema, associated with lung collapse. The case is supplemented by a non-systematic review of the relevant literature.

Lenticulostriate Artery Involvement is Predictive of Poor Outcomes in Superficial Middle Cerebral Artery Territory Infarction

PURPOSE: Patients with superficial middle cerebral artery (MCA) territory infarction may have concomitant lenticulostriate artery (LSA) territory infarction. We investigated the mechanisms thereof and the outcomes of patients with superficial MCA territory infarction according to the presence or absence of LSA involvement. MATERIALS AND METHODS: Consecutive patients with first-ever infarction in the unilateral superficial MCA territory were included in this study. They were divided into the superficial MCA only (SM) group and the superficial MCA plus LSA (SM+L) group. RESULTS: Of the 398 patients, 84 patients (21.1%) had LSA involvement (SM+L group). The SM+L group more frequently had significant stenosis of the proximal MCA or carotid artery and high-risk cardioembolic sources. Stroke severity and outcomes were remarkably different between the groups. The SM+L group showed more severe neurologic deficits (National Institute of Health Stroke Scale score 10.8±7.1 vs. 4.0±5.0, p2) at 3 months was more common in the SM+L group (64.3% vs. 15.9%, p<0.001). During a mean follow-up of 26 months, 67 patients died. All-cause (hazard ratio, 2.246) and stroke (hazard ratio, 9.193) mortalities were higher in the SM+L group than the SM group. In multivariate analyses, LSA involvement was an independent predictor of poor functional outcomes and stroke mortality. CONCLUSION: LSA territory involvement is predictive of poor long-term outcomes in patients with superficial MCA territory infarction.

Sinusoidal Constriction and Vascular Hypertrophy in the Diabetes-Induced Rabbit Penis

Objective To assess the morphological changes of penile vascular structures and the corpus cavernosum area in alloxan-induced diabetic rabbits. Materials and Methods Twenty male rabbits (2 months old) were divided into two groups with 10 rabbits each, the control group (CG) and the diabetic group (DG). The animals from DG received an intravenous injection of alloxan (100mg/kg) to induce the diabetes. Ten weeks after the induction of diabetes, all animals were euthanized. Two fragments of the penile shaft were harvested and samples were processed and paraffin embedded. Sections (5µm) were cut and stained for histological and immunohistochemical markers. Results Nuclear protrusion toward the lumen, and cytoplasmic vacuolization were observed in the tunica intima of the dorsal artery of the penis in DG. The thicknesses of the tunica media increased significantly in DG (p = 0.0350). It was also observed a significant increase in the area of the tunica media (p = 0.0179). There was no significant change in smooth muscle cell density in the tunica media of the dorsal artery of the penis (p = 0.0855). The collagen fiber pattern of the tunica adventitia of the dorsal artery of the penis was different between the control and diabetic groups. There was a significant decrease in the area occupied by the cavernous sinuses in DG (p = 0.0013). Conclusion Alloxan-induced diabetes mellitus in rabbits promotes important changes in penile vascular structures, thereby decreasing blood supply and affecting penile hemodynamics, leading to erectile dysfunction. .

Resultados obtenidos en el manejo de enfermedades cerebrales mediante terapia endovascular / Results obtained in the management of brain disorders with endovascular therapy

Antecedentes: La terapia endovascular neurológica ha evolucionado rápidamente en un período de tiempo relativamente corto. Esta técnica ha pasado de sus propósitos iniciales, enfocados a pacientes en los que la cirugía abierta no representaba una buena opción, a convertirse en una corriente de la práctica cotidiana. Objetivo: Exponer los resultados obtenidos en pacientes con diversas patologías cerebrales abordados por terapia endovascular, durante un período de 24 meses, con la finalidad de analizar los beneficios de este método terapéutico. Metodología: Estudio observacional, retrospectivo, analítico, que incluye como población todos los pacientes con patología cerebral intervenidos mediante terapia endovascular, en el Grupo Hospitalario Kennedy, Centro de Intervencionismo Angio Manabí, Hospital Luis Vernaza y Clínica Guayaquil; durante el período comprendido entre junio de 2010 a mayo de 2012. Resultados: Las patologías más diagnosticadas fueron aneurismas cerebrales con 75 por ciento (n = 175) de los casos, seguido por malformaciones arteriovenosas con 14 por ciento (n = 33). Las complicaciones observadas fueron migración de coil y ruptura de un aneurisma durante su embolización. Se observó una mortalidad total de 2,82 por ciento, relacionada con mal estado clínico y alto grado imagenológico de pacientes con aneurismas cerebrales. Posterior a la intervención, 96,23 por ciento (n = 204) de los pacientes permanecen en grado Rankin 1. Conclusiones: La terapia endovascular neurológica ha obtenido resultados altamente satisfactorios en diversas patologías del sistema nervioso, con bajo índice de complicaciones y morbimortalidad; constituyendo así una excelente elección en el manejo de estas patologías.

Background: Endovascular therapy has evolved rapidly over a relatively short period of time. This technique has evolved from its initial purposes, to treat patients for whom no good open surgical option existed, to become a mainstream of everyday practice. Objective: To present obtained results in patients with brain diseases approach by endovascular therapy, for a period of 24 months, in order to analyze the benefits of this therapeutic method. Methodology: Observational, retrospective, analytical study, of all patients with brain diseases treated by endovascular therapy at Grupo Hospitalario Kennedy, Centro de Intervencionismo AngioManabí, Hospital Luis Vernaza and Clínica Guayaquil, from June 2010 to May 2012. Results: Conditions most commonly diagnosed were brain aneurysms with 75 percent (n = 175) of cases, followed by arteriovenous malformations with 14 percent (n = 33). Complications observed were coil migration in two cases, and aneurysms rupture during the embolization. There was a total mortality of 2,82 percent, related to poor clinical condition and high imaging grade in patients with intracranial aneurysms. After intervention, 96,23 percent (n = 204) of the patients are in Rankin grade 1. Conclusions: Endovascular therapy has achieved highly satisfactory results in several diseases of the nervous system, with low rate of complications and morbid-mortality, making it an excellent choice in the management of these pathologies.

Estenosis biliares benignas: experiencia 77 casos / Benign biliary strictures: experience 77 cases

Se presenta la experiencia de los autores con 77 casos de estenosis biliares benignas tratadas en Unidad de Cirugía Hepática, Biliar y trasplante de hígado del Hospital Universitario de Maracaibo. Desde agosto de 1989 hasta diciembre de 2009, fueron registrados 77 casos de estenosis biliares benignas. Se tipificaron según la clasificación de Bismuth. 83,12% (64) de los pacientes habían sido colecistectomizados (estenosis post-iatrogenia durante este procedimiento): 41 (53,25%) abiertas y 23 (29,87%) laparoscópicas. 89,61 (69) de los pacientes consultaron por ictericia, 62,34% fiebre y 58,44% dolor abdominal. 9% (7) presentó estenosis Bismuth I, 22% (17) tipo II, 44,16% (34) tipo III y 24,68% (19) tipo IV. A todos se les realizó exploración biliar quirúrgica y anastomosis mucosa-mucosa con Y-Roux, tipo Hepp-Couinaud en 70 (87,5%) de los pacientes. La mortalidad fue 2,6% (2) paciente en el transoperatorio. Se presentaron en el peri-operatorio 19 (24,39%) complicaciones en 17 (22%) pacientes: 12 (15,6%) mayores y 7 (8,79%) menores. En un seguimiento promedio de 49 meses, 7-79% (6) pacientes presentaron re-estenosis de la derivación bilioentérica. El mayor porcentaje de estenosis biliares benignas son posteriores a procedimientos quirúrgicos, principalmente colecistectomia. La anastomosis bilioentérica tipo Hepp-Couinaud se realizó en el mayor número de pacientes con excelentes resultados.

Present experience of the authors with 77 cases of bening biliary strictures. From August of 1989 to December of 2009, 77 patients were recorded. Classification of Bismuth was used to classificate the strictures 64 (83,12%) patients were cholecistectomizated (stricture by iatrogenia during this procedure): 41 (53,25%) open and 23 (29,87%) laparoscopic. 89,61% (69) consulted by jaundice, 62,34 by fever and 58,44% by abdominal pain. 9%(7) had stricture Bismuth 1,22% (17) type II, 44,16% (34) type III and 24,68% (19) type IV. All patients were summated to surgical biliary exploration and mucous-mucous biliary anastomosis with Y-Roux. Hepp-Couinaud type in 70 (87,7%) of the patients. Perioperative mortality was 2,6% (2). Perioperative complications were 19 (24,39%) in 17 (22%) patients: 12 (15,6%) mayor and 7(8,79%) minors. In medial following of 49 months, 7,79% (6) presented re-stricture of bilio-enteric anastonosis. The majority of the strictures were due to surgical procedures. Hepp-Couinaud anastomosis was performed in almost all the patients with excellent outcome.

Isquemia artrial crónica de miembro superior con resolución quirúrgica: relato de un caso poco frecuente / Chronic arterial ischemia of the upper extremity with surgical resolution: report of an uncommon patient

The arterial reconstruction as a treatment for chronic ischemia of the upper extremities is common during the current surgical practice. It represents only the 4% of the total vascular surgical operations, by which only few reports have been published in the worldwide literature. Ischemic pathology of the upper extremities differs from the lower extremities, because it is more frequent the observation of a history of embolia, trauma, collagen vascular disease and thromboanguiitis obliterans. The surgical resolution is not frequent and the loss of the extremity even less, due to the abundantly colateral circulation of the vascular tree. A patient with this pathology is reported and the surgical management is discussed.

Atrapamiento de la arteria poplítea: Comunicación de un caso / Popliteal artery entrampment: Report of one case

Popliteal artery entrampment is a rare condition, occurring in young subjects, that causes ischemia of the extremity. The anatomical background is the compression or occlussion of the popliteal artery caused by forced plantar or dorsal flexion. We report a 32 year-old sportsman who presented with gangrene of the right first toe and a history of three months of progressive claudication. The Ankle-Brachial index and pulse volume curve registries showed a severe ischemia below the knee. Angiography showed a medial deviation of the popliteal artery associated to stenosis and aneurysm formation. A CT scan of the contralateral artery was normal. The patient was operated using a posterior approach, performing a reverse saphenous vein bypass graft and excising the popliteal artery. The postoperative period was uneventful.

Estudio morfológico-informático de las estenosis de las arterias femorales humanas para su aplicación como complemento diagnóstico / Morphological and informatical study of human femoral arteries stenoses for its application as diagnostic complement

El presente trabajo estudia el comportamiento del flujo sanguíneo a partir de arterias femorales humanas estenóticas con distintos grados de obstrucción, extraídas de autopsias y de amputaciones quirúrgicas y de simulaciones producidas por un programa computacional simulador original basado en el método de los elementos finitos para líquidos newtonianos, homogéneos e incompresibles. Su empleo produjo numerosas curvas de máxima resumidas en un único gráfico de aplicación sencilla para el profesional. Más allá de la evaluación del origen y del impacto de los remolinos analizando las distintas variables intervinientes (esto es: presión, velocidad y tensiones), los resultados aquí reportados pueden constituir un útil complemento diagnóstico junto a los demás métodos usados actualmente, a los que no contraviene ni invalida.

Hepatic venous outflow obstruction in Nepal.

Intra hepatic inferior venacaval (IVC) obstruction at the site or just above hepatic vein opening in the IVC, is a common hepatic problem in Nepal. These patients either present as a chronic IVC obstruction with insidious onset or may present with rapid onset disease (acute/subacute disease). The former type may be asymptomatic (20%) or may have features of chronic liver dysfunction. The latter presents with rapid onset ascites. Presence of hepatomegaly with flank/back veins are characteristic clinical features of the disease. The disease is invariably encountered amongst rural poor, alcoholic and in the peripartum period. Ultrasonography, IVC graphy hepatogram and liver biopsies are the usual diagnostic modalities. Twenty four percent of the 126 chronic hepatic IVC disease had associated liver cell cancer at our centre. The aetiology of the disease is unclear. Presently it is believed that local thrombophlebitis in IVC causes such obstruction. Despite, surgical and radiological intervention, the ideal management in such patients is yet to be established. We believe conservative therapy, particularly prevention and early therapy of sepsis in such patients prolongs survival.

Tetralogy of Fallot in adults--107 cases.

Clinical and haemodynamic profile of 107 adult patients above the age of 15 years with TOF was analysed. Cardiac catherization and selective cine-angiography were performed in all cases. Infundibular pulmonary stenosis, mal-alignment type of ventricular septal defect, mitral-aortic fibrous continuity and equal systolic pressures in both the ventricles and aorta were considered mandatory for the diagnosis of Tetralogy of Fallot. Aortic regurgitation was seen in 26 cases (24%), tricuspid regurgitation in 22 cases (21%), absent pulmonary valve in 3 cases (3%), branch pulmonary artery stenosis in 9 case (8.4%), major aortopulmonary collaterals in 15 cases (14%), right atrial pressure was more than 10 mmHg in 10 cases (11%) and right ventricular end diastolic pressure more than 9 mmHg in 73 cases (68%). The left ventricular end diastolic pressure was above 13 mmHg in 58 cases (54%).

Estenose bronquica de etiologia tuberculosa: patogenia e tratamento / Bronchial stenosis of tuberculous etiology: pathogenesis and treatment

Descrevemos quatro casos de estenose bronquica, uma complicacao rara de tuberculose pulmonar. No primeiro caso, uma mulher de 18 anos, sem tratamento previo para tuberculose, apresentou estenose bronquica como resultado da cicatrizacao de complexo primario. Nao havia lesao de parenquima ao raio X. Nos outros tres pacientes a estenose bronquica foi atribuida a tuberculose ativa com pesquisa positiva para bacilo alcool-acido resistente em escarro. Estes receberam tratamento para tuberculose. Em um deles isto foi suficiente para a resolucao da estenose, mas nos outros dois pacientes ocorreu estenose bronquica devido a fibrose.

Percutaneous transluminal coronary angioplasty of distal lesions: comparison of results with proximal lesions.

The results of percutaneous transluminal coronary angioplasty (PTCA) of 57 distal lesions were compared with 55 proximal lesions in 42 patients, aged 31 to 66 years (mean +/- SD: 51 +/- 9 yrs). Twenty nine (69%) had multivessel and 13 (31%) single vessel disease. The lesions classified as distal were located in left anterior descending (LAD) artery beyond the origin of second diagonal (D2), left circumflex (LCx) after the main obtuse marginal (OM) and right coronary artery (RCA) after the origin of acute marginal branch. Also included in this category were lesions in the second diagonal and obtuse marginal branches, two centimeters from their origin and stenosis in the posterior descending and posterolateral left ventricular branches of RCA. Out of 57 distal lesions 18 were 'complex' because of tandem location (5 patients), ulceration (6 lesions) and intraluminal thrombi (2 lesions). There was no significant difference in the mean luminal diameter stenosis between distal and proximal lesions, before and after PTCA. The primary success rate of angioplasty was 89.5% for the distal and 94.5% for the proximal lesions (P = NS). Inability to position the balloon across the lesion accounted for more failures in distal (3) compared to proximal (1) location. There were no major complications. Our results show that PTCA of distal lesions can be performed with a high rate of success, which is comparable to those with classical proximal lesions in the same patients.