Delayed recovery from ataxic dementia following liposuction.

A 19-year-old student developed hypoventilation and cyanosis at the end of a cosmetic liposuction procedure. She was awake, but severely abulic, disoriented, and unable to stand and walk due to severe locomotor ataxia. Neuropsychological evaluation showed psychomotor slowness, and deficits in memory encoding and retrieval, and on executive, and visuospatial and visuoperceptual tests; oral comprehension and constructional praxis were spared. ¹H-MRS showed a reduction of NAA. A year later, her cognitive and neurological exam, and NAA returned to normal, and she resumed her normal life. The severity of the acute manifestations of hypoxic encephalopathy not always entail a poor prognosis.

Late-Life Presentation of Unsuspected G6PD Deficiency.

Deficiency of glucose-6-phosphate dehydrogenase (G6PD) is the commonest enzyme deficiency in humans with a wide range of possible clinical manifestations depending on the specific genetic variant in each case. Here we present the case of an 86-year-old male of African descent who acutely developed symptoms of G6PD deficiency immediately after he received methylene blue for treating methemoglobinemia. The contrast between a low SO2 on pulse oximetry and a normal arterial gas sampling raised the possibility of methemoglobinemia. The patient was treated with packed red blood cells and folic acid, and a rapid clinical improvement followed by normalization of the red blood cell count ensued. In view of the patient's advanced age, the lack of a history of similar episodes in the past, and the normal laboratory results during the hemolytic crisis, this case remained a diagnostic challenge for over three months, when a follow-up measure of G6DP activity eventually confirmed the diagnosis. A latent deficiency of G6PD may become clinically manifest under the appropriate triggering conditions even in elderly patients and in the absence of past or current clinical and laboratory evidence of G6PD deficiency.

HBV infection in HIV-infected subjects in the state of Piauí, Northeast Brazil.

In this study, the prevalence, genotype frequency, and risk factors for HBV infection in 768 HIV-infected subjects living in Piauí were determined. Forty-six (6.0 %) HIV-positive subjects were reactive for HBsAg and positive for HBV-DNA. Genotypes A (71.8 %), F (23.9 %) and D (4.3 %) were identified. Multivariate analysis revealed an association between HIV-HBV coinfection and male gender, older age groups, unprotected sex, reporting more than ten sexual partners throughout life, STD, and tattooing. This study shows the importance of monitoring sites and professionals who perform tattooing and practice safe sex to prevent the spread of HIV and HBV infections.

Diagnostic relevance of the carotid sinus massage during a head up tilt table test (HUTT).

BACKGROUND: Syncope due to carotid sinus hypersensitivity (CSH) may be underdiagnosed due to a low level of diagnostic suspicion and fear of complications caused by massage of the carotid sinus. OBJECTIVE: To investigate the relevance of carotid sinus massage in the diagnosis of non-convulsive faints and unexplained falls. METHODS: Two-hundred and fifty-nine patients with a mean age of 50+/-24 years referred for the investigation of non-convulsive faints or unexplained falls were evaluated with a head up tilt table test (HUTT) without ("passive") and with pharmacological stimulation. Clinical and laboratory work-up did not reveal an obvious cause for the complaints. Fifty-five volunteers with a mean age of 57+/-21 years with no history of seizures, faints or falls were used as controls. All participants underwent a HUTT preceded by digital stimulation of each carotid sinus both at zero and 60 masculine. RESULTS: Carotid sinus massage was positive in 4 controls. The relevance of CSH in the evaluation of syncope was supported by a positive response to carotid sinus massage at 60 masculine in 28 patients, most of whom were elderly men. Carotid sinus massage was positive at 0 masculine in only three of such patients. The results of the HUTT did not show statistical difference between patients with and without CSH. CONCLUSION: Carotid sinus massage at 60 masculine under controlled conditions should be included in the assessment of patients with non-convulsive faints or unexplained falls. Routine cardiovascular exams, including the HUTT, are not useful for the diagnosis in such cases. Further studies in normal individuals are needed to establish the significance of a positive response to carotid sinus massage in the absence of a history of fainting or falling.

Relevância diagnóstica da massagem do seio carotídeo durante teste de inclinação / Diagnostic relevance of the carotid sinus massage during a head up tilt table test (HUTT)

FUNDAMENTO: As síncopes por hipersensibilidade do seio carotídeo (HSC) podem ser pouco diagnosticadas por causa da baixa desconfiança diagnóstica ou do medo de complicações da própria massagem do seio carotídeo. OBJETIVO: Investigar o papel da hipersensibilidade do seio carotídeo (HSC) em desmaios não-convulsivos e quedas inexplicadas. MÉTODOS: Duzentos e cinqüenta e nove pacientes com idade média de 50±24 anos, encaminhados para investigação de desmaios não-convulsivos e quedas inexplicadas, foram submetidos ao Teste da Mesa Inclinada (TI) sem ("passivo") e com provocação farmacológica ("sensibilizado"). Exames clínicos e complementares não revelaram causa óbvia para as queixas. Cinqüenta e cinco voluntários com idade média de 57±21 anos sem história de epilepsia, desmaios e quedas serviram de controles. Todos os participantes foram submetidos ao TI precedido por estimulação digital dos seios carotídeos a zero e a 60º. RESULTADOS: A estimulação dos seios carotídeos foi positiva em 4 controles. O diagnóstico clínico de HSC foi endossado por resposta positiva à estimulação carotídea a 60º em 28 pacientes, em sua maioria homens idosos. A estimulação carotídea foi positiva a 0º em apenas três desses pacientes. Não houve diferença estatística no TI entre os pacientes com e sem HSC. CONCLUSÃO: A estimulação dos seios carotídeos a 60º deve ser incluída na avaliação rotineira de pacientes com desmaios não-convulsivos ou quedas inexplicadas, uma vez que os exames cardiovasculares de rotina, incluindo o TI, não foram úteis para estabelecer o diagnóstico nesses casos. Novos estudos em indivíduos normais são necessários para estabelecer o significado da resposta positiva à estimulação carotídea na ausência de história de desmaios ou quedas.

BACKGROUND: Syncope due to carotid sinus hypersensitivity (CSH) may be underdiagnosed due to a low level of diagnostic suspicion and fear of complications caused by massage of the carotid sinus. OBJECTIVE: To investigate the relevance of carotid sinus massage in the diagnosis of non-convulsive faints and unexplained falls. METHODS: Two-hundred and fifty-nine patients with a mean age of 50±24 years referred for the investigation of non-convulsive faints or unexplained falls were evaluated with a head up tilt table test (HUTT) without ("passive") and with pharmacological stimulation. Clinical and laboratory work-up did not reveal an obvious cause for the complaints. Fifty-five volunteers with a mean age of 57±21 years with no history of seizures, faints or falls were used as controls. All participants underwent a HUTT preceded by digital stimulation of each carotid sinus both at zero and 60º. RESULTS: Carotid sinus massage was positive in 4 controls. The relevance of CSH in the evaluation of syncope was supported by a positive response to carotid sinus massage at 60º in 28 patients, most of whom were elderly men. Carotid sinus massage was positive at 0º in only three of such patients. The results of the HUTT did not show statistical difference between patients with and without CSH. CONCLUSION: Carotid sinus massage at 60º under controlled conditions should be included in the assessment of patients with non-convulsive faints or unexplained falls. Routine cardiovascular exams, including the HUTT, are not useful for the diagnosis in such cases. Further studies in normal individuals are needed to establish the significance of a positive response to carotid sinus massage in the absence of a history of fainting or falling.

[Syncope in the elderly: diagnostic utility of carotid sinus massage in the head-up tilt test]. / Síncope no idoso: utilidade diagnóstica da massagem do seio carotídeo na posiçáo ortostática durante o "tilt test"

A 71-year-old man presented with a 6-month history of fainting. Consciousness was quickly regained without clouding or confusion. Ancillary investigations were inconclusive and he was treated with carbamazepine. The fainting spells did not cease and he was referred for a tilt-table test exam. In the head-up position (table tilted at 60 degrees), massage of the carotid sinus was immediately followed by asystole, unconsciousness, and a sharp drop in arterial pressure for 5 seconds. The same procedure in the lying position did not elicit clinical symptoms or haemodynamic imbalance. A diagnosis of carotid sinus hypersensitivity with a cardio-inhibitory response pattern was made. Carbamazepine was withdrawn and a double-chamber pacemaker was implanted in his right ventricle. He remained symptom-free for the ensuing 18 months. This case supports the diagnostic utility of carotid sinus massage during the head-up tilt test in patients with unexplained non-convulsive loss of consciousness.

Síncope no idoso. Utilidade diagnóstica da massagem do seio carotídeo na posiçäo ortostática durante o "tilt test" / Syncope in the elderly: diagnostic utility of carotid sinus massage in the head-up tilt test

Um senhor aposentado veio à consulta com história de desmaios há vários meses e uma série de exames cardiológicos e de neuroimagem inconclusivos. Medicado com carbamazepina, os desmaios persistiram, ocasionando ferimentos na face e nos braços. Durante o "tilt test" näo sensibilizado farmacologicamente, a massagem do seio carotídeo na posiçäo ortostática (mesa inclinada a 60º) produziu assistolia, perda da consciência e queda drástica da pressäo arterial por 5 segundos. A mesma manobra na posiçäo supina näo provocou sintomas ou alterações hemodinâmicas. Implantado marca-passo de dupla câmara e suspensa a carbamazepina, os desmaios näo se repetiram ao longo dos 18 meses de acompanhamento, confirmando o diagnóstico de hipersensibilidade do seio carotídeo com resposta cárdio-inibitória. Este caso ilustra e reafirma a utilidade do "tilt test" e da inclusäo da massagem dos seios carotídeos na posiçäo ortostática no protocolo de investigaçäo de todo paciente com síncope de causa inaparente

Use of the alr gene as a food-grade selection marker in lactic acid bacteria.

Both Lactococcus lactis and Lactobacillus plantarum contain a single alr gene, encoding an alanine racemase (EC 5.1.1.1), which catalyzes the interconversion of D-alanine and L-alanine. The alr genes of these lactic acid bacteria were investigated for their application as food-grade selection markers in a heterologous complementation approach. Since isogenic mutants of both species carrying an alr deletion (Deltaalr) showed auxotrophy for D-alanine, plasmids carrying a heterologous alr were constructed and could be selected, since they complemented D-alanine auxotrophy in the L. plantarum Deltaalr and L. lactis Deltaalr strains. Selection was found to be highly stringent, and plasmids were stably maintained over 200 generations of culturing. Moreover, the plasmids carrying the heterologous alr genes could be stably maintained in wild-type strains of L. plantarum and L. lactis by selection for resistance to D-cycloserine, a competitive inhibitor of Alr (600 and 200 micro g/ml, respectively). In addition, a plasmid carrying the L. plantarum alr gene under control of the regulated nisA promoter was constructed to demonstrate that D-cycloserine resistance of L. lactis is linearly correlated to the alr expression level. Finally, the L. lactis alr gene controlled by the nisA promoter, together with the nisin-regulatory genes nisRK, were integrated into the chromosome of L. plantarum Deltaalr. The resulting strain could grow in the absence of D-alanine only when expression of the alr gene was induced with nisin.

Insuficiência cardíaca congestiva. Correlaçäo entre a classe funcional e as funçöes sistólicas e diastólicas avaliadas pela ecocardiografia com doppler / Congestive heart failure. Correlation between functional class and systolic and diastolic functions assessed by Doppler echocardiography

OBJECTIVE: To evaluate the influence of systolic or diastolic dysfunction, or both on congestive heart failure functional class. METHODS: Thirty-six consecutive patients with a clinical diagnosis of congestive heart failure with sinus rhythm, who were seen between September and November of 1998 answered an adapted questionnaire about tolerance to physical activity for the determination of NYHA functional class. The patients were studied with transthoracic Doppler echocardiography. Two groups were compared: group 1 (19 patients in functional classes I and II) and group 2 (17 patients in functional classes III and IV). RESULTS: The average ejection fraction was significantly higher in group 1 (44.84 percent + or - 8.04 percent vs. 32.59 percent + or - 11.48 percent with p=0.0007). The mean ratio of the initial/final maximum diastolic filling velocity (E/A) of the left ventricle was significantly smaller in group 1 (1.07 + or - 0.72 vs. 1.98 + or - 1.49 with p=0.03). The average maximum systolic pulmonary venous velocity (S) was significantly higher in group 1 (53.53cm/s + or - 12.02cm/s vs. 43.41cm/s + or - 13.55cm/s with p=0.02). The mean ratio of maximum systolic/diastolic pulmonary venous velocity was significantly higher in group 1 (1.52 + or - 0.48 vs. 1.08 + or - 0.48 with p=0.01). A predominance of pseudo-normal and restrictive diastolic patterns existed in group 2 (58.83 percent in group 2 vs. 21.06 percent in group 1 with p=0.03). CONCLUSION: Both the systolic dysfunction index and the patterns of diastolic dysfunction evaluated by Doppler echocardiography worsened with the evolution of congestive heart failure

Correlação entre a classe funcional, a função sistólica e a função diastólica na insuficiência cardíaca / Correlation between functional class and systolic and diastolic functions in heart failure

Fundamento: Alguns estudos apontam o grau de disfunção sistólica como o principal determinante da capacidade de realizar atividades físicas na insuficiência cardíaca (IC), enquanto outros indicam uma maior participação da função diastólica. Objetivo: Identificar os principais determinantes da classe funcional (CF) na insuficiência cardíaca. Métodos: Trinta e seis pacientes consecutivos, do ambulatório de cardiologia, com diagnóstico clínico de IC, em ritmo sinusal, foram submetidos a questionário adaptado de tolerância a atividades físicas para a determinação da classe funcional (NYHA) e estudados através da ecocardiografia transtorácica com doppler. Dois grupos foram comparados: Grupo 1 (19 pacientes em CF I e II) e grupo 2 (17 pacientes em CF III e IV). Resultados: A média de fração de ejeção (FE) foi significativamente maior no grupo 1 (44,84por cento +/-8,04 versus 32,59por cento +/- 11,48 com p=0,0007). A média da relação velocidade de enchimento diastólico inicial/final (E/A) do ventrículo esquerdo foi significativamente menor no grupo 1 (1,07 +/-0,72 versus 1,98 +/-1,49 com peso=0,03). A média de velocidade sistólica em veia pulmonar foi significativamente maior no grupo 1 (53,53 cm/s +/-12,02 versus 43,41 +/-13,55 com p= 0,02). A média da relação velocidade sistólica/diastólica em veia pulmonar (S/D) foi significativamente maior no grupo 1 (1,52 +/-0,48 versus 1,08 +/-0,48 com p= 0,01). Houve predomínio de padrões diastólico pseudo-normais e restritivos no grupo 2 (58,83 por cento no grupo 2 versus 21,06por cento no grupo 1 com p= 0,03). Conclusão: Tanto o grau de disfunção sistólica assim como o padrão diastólico são determinantes da CF na IC. As funções sistólica e diastólica podem estar interrelacionadas e sofrem deterioração conforme avance a CF. Pacientes em CF III e IV apresentam FE menores, relações E/A maiores, velocidades sistólicas em veia pulmonar menores e relações de velocidades S/D em veia pulmonar menores, os quais podem ser utilizados como marcadores de uma maior morbidade

Coma e síndrome de herniaçäo transtentorial consequentes a lesäo hemisférica näo expansiva aguda / Coma and transtentorial herniation syndrome due to acute non-expansive hemispheral lesion

O presente trabalho retrata o caso de uma paciente que entrou em coma por infarto extenso do hemisfério cerebral direito e desenvolveu sinais clínicos característicos do estágio diencefálico da herniaçao transtentorial central. A TC, todavia, nao evidenciou os efeitos classicamente descritos de compressao ou distorçao da transiçao mesodiencefálica, mas duas imagens hipodensas, de idades diferentes, alojadas, respectivamente, nos territórios superficial e profundo das artérias cerebral média e anterior e no lobo frontal direito. Concordando com a piora clínica ao longo dos seis dias que antecederam a morte, a última TC revelou as imagens esperadas de deslocamentos do encéfalo. O caso se assemelha a outros da literatura, em testemunho de que os sinais clínicos de efeitos de massa no interior do crânio podem ser reproduzidos por comprometimento funcional agudo mono-hemisférico na ausência de deslocamentos físicos da massa encefálica. O papel desempenhado por distorçoes encefálicas na gênese e no prognóstico de curto-prazo do coma permanece em aberto.