Imágenes del depósito de gadolinio en el sistema nervioso central / Images of gadolinio deposit in the central nervous system Abstract

Magnetic resonance imaging has been shown to be very useful in the diagnosis and monitoring of multiple diseases affecting the central nervous system. Gadolinium has been used extensively worldwide. It has been estimated that since its introduction more than two hundred million doses of GBCA have been administered globally. Gadolinium-based contrast agents (GBCAs) were long considered medicines with a high safety profile, the literature reports incidences of immediate adverse effects such as headache, dizziness, and altered sense of taste. Studies performed a few years after the introduction of GBCA showed that there were gadolinium deposits in the tissues but their clinical significance was not known. It wasn’t until 2006 when the first reports were published that associated the gadolinium ion tissue deposits from GBCA with a systemic inflammatory entity of the connective tissue similar to scleroderma known as Nephrogenic Systemic Fibrosis (NSF), in patients with chronic renal failure. In 2013, the association between the use of GBCAs and the progressive increase in the signal intensity of the dentate nucleus and the globus pallidus in T1-weighted MRI images without contrast medium, was described for the first time. This review describes the most relevant aspects of the pathophysiology of these findings taking into account their differential diagnosis.

Las imágenes por resonancia magnética han mostrado ser de gran utilidad en el diagnóstico y seguimiento de múltiples enfermedades que afectan el sistema nervioso central. El gadolinio se ha utilizado ampliamente a nivel mundial. Se estima que desde su introducción se han administrado más de doscientos millones de dosis de MCBG en el mundo. Los medios de contraste basados en Gadolinio (MCBG) fueron considerados por mucho tiempo medicamentos con un alto perfil de seguridad, la literatura reporta incidencia de efectos adversos inmediatos como cefalea, mareo y alteración del sentido del gusto. Estudios realizados pocos años después de la introducción de los MCBG mostraron que había depósitos de gadolinio en los tejidos, pero no se conocía su significancia clínica Fue hasta 2006 cuando se publicaron los primeros reportes que asociaban el depósito tisular del ion gadolinio proveniente de los MCBG con una entidad inflamatoria sistémica del tejido conectivo similar a la escleroderma conocida como Fibrosis Sistémica Nefrogénica (FSN) en pacientes con falla renal crónica. En 2013 se describió por primera vez la asociación entre el uso de los MCBG y el aumento progresivo de la intensidad de señal del núcleo dentado y los globos pálidos en las imágenes de RM ponderadas en T1 sin medio de contraste. En esta revisión se describen los aspectos más relevantes de la fisiopatología de estos hallazgos considerando su diagnóstico diferencial.

[Early clinical and radiological basic detection of congenital hip dysplasia at primary health care units]. / Detección temprana clínica y radiológica básica de la displasia congénita de cadera en unidades médicas del primer nivel de atención.

DISCUSSION: The number of cases of late congenital hip dysplasia has increased, together with its sequelae, disability and absence of early diagnosis. The problem is that there is a difference between the sensitivity and the clinical exam, and the physicians knowledge of this topic is poor. We evaluated the quality of the training provided to the primary health care staff on congenital hip dysplasia. A prospective cohort study was undertaken to study 228 physicians for 3 years. A workshop was delivered and the physicians took a pre-workshop and a post-workshop exam. Then pelvic X-rays of infants under 6 months of age were taken and the X-ray references and measurements were assessed. The statistical analysis assesses the change in the pre-workshop and post-workshop grades in both the group that participated in the workshop and the group that did not. The statistical variables used included means, standard deviation, minimum and maximum grades, and the score differences. Students t test was used to prove the statistical significance of the differences, with n-1 degrees of freedom. Thirty-one pathological hips were detected in infants under 6 months of age in the group that took the workshop. The group that received the training shows that the latter may have a positive impact since an improvement in the grades (p 0.0001) was seen after the theoretical and practical course and after the X-ray measurements. A low knowledge level was observed. The training raised the awareness of the health care staff and a progressive increase was seen in the number of infants under 6 months of age who received a timely detection.

Hay un aumento en el número de casos de displasia de cadera congénita tardía, secuelas, discapacidad y falta de diagnóstico temprano. La problemática observada es que difieren la sensibilidad y exploración clínica y los conocimientos del tema en médicos son deficientes. Se evaluó la calidad de la capacitación en displasia congénita de cadera al personal del primer nivel de la atención médica. Se realizó un estudio de cohorte prospectiva estudiando a 228 médicos por tres años; se les aplicó un examen pre- y postcurso, se dio un taller. Posteriormente, se inició la toma de radiografías de pelvis en menores de seis meses, se evaluó la referencia y la medición radiográfica. El análisis estadístico valoró el cambio de calificación obtenida en las mediciones antes y después del taller, tanto en el grupo que lo recibió como en el que no lo llevó. Se utilizaron promedios, desviación estándar, mínimo y máximo para describir las calificaciones, así como para las diferencias de puntajes. Para probar la significancia en las diferencias, se utilizó «t¼ de Student, con n-1 grados de libertad. Se detectaron 31 caderas patológicas en menores de seis meses de vida con el taller. El grupo capacitado reflejó que el curso podría tener impacto positivo al mejorar significativamente la calificación (p 0.0001) posterior al curso tanto teórico como práctico y la medición radiográfica. Se evidenció un bajo conocimiento. La capacitación con el taller sensibilizó al personal médico y se observó un número progresivo de pacientes menores de seis meses con una detección oportuna.

Detección temprana clínica y radiológica básica de la displasia congénita de cadera en unidades médicas del primer nivel de atención / Early clinical and radiological basic detection of congenital hip dysplasia at primary health care units

Resumen: Hay un aumento en el número de casos de displasia de cadera congénita tardía, secuelas, discapacidad y falta de diagnóstico temprano. La problemática observada es que difieren la sensibilidad y exploración clínica y los conocimientos del tema en médicos son deficientes. Se evaluó la calidad de la capacitación en displasia congénita de cadera al personal del primer nivel de la atención médica. Se realizó un estudio de cohorte prospectiva estudiando a 228 médicos por tres años; se les aplicó un examen pre- y postcurso, se dio un taller. Posteriormente, se inició la toma de radiografías de pelvis en menores de seis meses, se evaluó la referencia y la medición radiográfica. El análisis estadístico valoró el cambio de calificación obtenida en las mediciones antes y después del taller, tanto en el grupo que lo recibió como en el que no lo llevó. Se utilizaron promedios, desviación estándar, mínimo y máximo para describir las calificaciones, así como para las diferencias de puntajes. Para probar la significancia en las diferencias, se utilizó "t" de Student, con n-1 grados de libertad. Se detectaron 31 caderas patológicas en menores de seis meses de vida con el taller. Discusión: El grupo capacitado reflejó que el curso podría tener impacto positivo al mejorar significativamente la calificación (p < 0.0001) posterior al curso tanto teórico como práctico y la medición radiográfica. Se evidenció un bajo conocimiento. La capacitación con el taller sensibilizó al personal médico y se observó un número progresivo de pacientes menores de seis meses con una detección oportuna.

Abstract: The number of cases of late congenital hip dysplasia has increased, together with its sequelae, disability and absence of early diagnosis. The problem is that there is a difference between the sensitivity and the clinical exam, and the physicians' knowledge of this topic is poor. We evaluated the quality of the training provided to the primary health care staff on congenital hip dysplasia. A prospective cohort study was undertaken to study 228 physicians for 3 years. A workshop was delivered and the physicians took a pre-workshop and a post-workshop exam. Then pelvic X-rays of infants under 6 months of age were taken and the X-ray references and measurements were assessed. The statistical analysis assesses the change in the pre-workshop and post-workshop grades in both the group that participated in the workshop and the group that did not. The statistical variables used included means, standard deviation, minimum and maximum grades, and the score differences. Student's t test was used to prove the statistical significance of the differences, with n-1 degrees of freedom. Thirty-one pathological hips were detected in infants under 6 months of age in the group that took the workshop. Discussion: The group that received the training shows that the latter may have a positive impact since an improvement in the grades (p < 0.0001) was seen after the theoretical and practical course and after the X-ray measurements. A low knowledge level was observed. The training raised the awareness of the health care staff and a progressive increase was seen in the number of infants under 6 months of age who received a timely detection.

Coagulación y síndrome metabólico en habitantes de gran altitud (3600 a 4100 MSNM), La Paz - Bolivia / Bleedingand metabolic syndrome residents high altitud, La Paz - Bolivia

OOBJETIVO: El objetivo del estudio fue determinar si es factor de riesgo el síndrome metabólico para fenómenos trombóticos y/o alteraciones en el recuento de plaquetas, volumen plaquetario medio (VPM), plaquetocrito (PCT), amplitud de distribución plaquetaria (ADP), tiempo de sangría y tiempo de coagulación en población habitante de gran altura 3600 m.s.n.m. a 4100 m.s.n.m. MATERIAL Y MÉTODOS: Se trata de un estudio observacional analítico de cohorte prospectiva.La población de estudio se constituyó por sujetos diagnosticados con y sin síndrome metabólico en población residente de la ciudad de El Alto y La Paz, Bolivia, cumpliendo criterios de selección para el diseño de cohorte prospectiva. El cálculo de muestra para estudios de Cohorte Prospectiva, fue de 291 pacientes de los cuales 97 son expuestos y 194 no expuestos. Expuestos adultos, residentes de La Paz o El Alto y cumplan con 3 criterios de síndrome metabólico según la NCEP-ATPIII actualizada. No expuestos a personas con 0 a 2 criterios de síndrome metabólico según la NCEP-ATPIII actualizada. Se excluyeron a personas con incapacidad física o mental, mujeres embarazadas, personas con diagnóstico ya definido de cáncer y personas en tratamiento con anticoagulantes. Se utilizaron instrumentos validados para la recolección de datos, la Historia clínica, así como procedimientos pre-analíticos, analíticos y pos-analíticos en hematología y bioquímica sanguínea, para este fin se tomó una muestra de sangre de 15 ml. RESULTADOS: La distribución de variables demográficas y físicas, en varones y mujeres expuestas (Sd. Metabólico) y no expuestas (Sin Sd. Metabólico), muestra diferencia estadística significativa. Las variables hematológicas y bioquímicas, presentan valores p de no significancia en promedio de plaquetas, valor medio plaquetario y amplitud de distribución de plaquetas.

OBJETIVE: The aim of the study was to determine if it is a factor of risk the metabolic syndrome for trombóticos and/or alterations in the of platelets, volume (VPM), plaquetocrito (PCT), wide's platelets distribution (ADP), time ofbleeding and time of coagulation in population inhabitant of high altitude 3600 m.s.n.m. to 4100 m.s.n.m. METHODS: It is analytical study prospective cohort. The population of study was composed by subjects diagnosed with and without metabolic syndrome in resident population of the high altitude city of La Paz and El Alto (Bolivia) with selection criteria. The calculation ofsample forstudies of prospective Cohort, belonged 291 patients of which 97 are exposed and 194 not exposed ones. Exposed adults, residents of La Paz or El Alto and expire with 3 criteria of metabolic syndrome according to the updated NCEP-ATPIII. They were excluded to persons by physical or mental disability, pregnant women, with diagnosis already defined of cancer and present in treatment with anticoagulants. There were in use instruments validated for the compilation of information, the clinical History, as well as pre-analytical, analytical and pos-analytical procedures in hematology and blood biochemistry, for this end there took a sample of blood of 15 ml. RESULTS: The distribution of demographic and physical variables, in males and exposed women (Sd. Metabolic) and not exposed (without Sd. Metabolic), sample differentiaes significant statics. The hematologic and biochemical variables, they present values p not significant, in mean platelets volume (VHP), plaquetocrito (PCT), wides platelets distribution (ADP).

Delving into cornerstones of hypersensitivity to antineoplastic and biological agents: value of diagnostic tools prior to desensitization.

BACKGROUND: Evidence regarding drug provocation test (DPT) with antineoplastic and biological agents is scarce. Our aim was to assess the usefulness of including DPT as a paramount gold standard diagnostic tool (prior to desensitization). METHODS: Prospective, observational, longitudinal study with patients who, during a 3-year period, were referred to the Desensitization Program at Ramon y Cajal University Hospital. Patients underwent a structured diagnostic protocol by means of anamnesis, skin tests (ST), risk assessment, and DPT. Oxaliplatin-specific IgE was determined in oxaliplatin-reactive patients (who underwent DPT regardless of oxaliplatin-specific IgE results). Univariate analysis and multivariate analysis were used to identify predictors of the final diagnosis among several variables. RESULTS: A total of 186 patients were assessed. A total of 104 (56%) patients underwent DPT. Sixty-four percent of all DPTs were negative (i.e., hypersensitivity was excluded). Sensitivity for oxaliplatin-specific IgE (0.35 UI/l cutoff point) was 34%, specificity 90.3%, negative predictive value 45.9%, positive predictive value 85%, negative likelihood ratio 0.7, and positive likelihood ratio 3.5. CONCLUSIONS: These are the first reported data based on more than 100 DPTs with antineoplastic and biological agents (paclitaxel, oxaliplatin, rituximab, infliximab, irinotecan, and other drugs). Implementation of DPT in diagnostic protocols helps exclude hypersensitivity (in 36% of all referred patients), and avoids unnecessary desensitizations in nonhypersensitive patients (30-56% of patients, depending on culprit-drug). Drug provocation test is vital to validate diagnostic tools; consequently, quality data are shown on oxaliplatin-specific IgE and oxaliplatin-ST in the largest series of oxaliplatin-reactive patients reported to date (74 oxaliplatin-reactive patients). Identifying phenotypes and predictors of a diagnosis of hypersensitivity may be helpful for tailored plans.

[Evaluation of the functional results in the treatment of pelvic limbs with multiple level surgery in spastic ICP patients]. / Evaluación de resultados funcionales en el tratamiento de miembros pélvicos con cirugía multinivel en pacientes espásticos con parálisis cerebral infantil.

UNLABELLED: The purpose of this study is to assess the effects of multiple level surgery of the pelvic limbs in patients with spastic infantile cerebral palsy seen at the National Rehabilitation Institute and show that their clinical improvement is comparable to the reports in the national and international literature. MATERIAL AND METHODS: This is a longitudinal, prospective, descriptive, self-controlled, before-and-after clinical trial that included patients with spastic infantile cerebral palsy who underwent multiple-level single-stage surgery from January 2007 to August 2008. The inclusion criteria were as follows: both genders, ages 4 to 16 years, with a complete clinical file, with preoperative and 8-12 month postoperative rehabilitation. Elimination criterion: any event not related with multiple-level surgery. Exclusion criterion: any surgeries prior to admission. A descriptive statistical analysis was used, together with the Student t-test and the chi-square test. RESULTS: 81 patients with a mean age of 7 +/- 3.2, an age range of 4-16 years; 60.5% males and 39.5% females. The subtypes of spastic infantile cerebral palsy were as follows: biparesis 64.2%, quadriparesis 22.2%, hemiparesis 8.6%, double hemiparesis 4.9%. The clinical-surgical classification (14) changed as a result of improvement and according to the number of surgical procedures: 6 patients (7.4%) had significant improvement (p = 0.13) with one procedure; 44 patients (54.3%) had significant improvement (p = 0.002) with two procedures; 28 patients (34.6%) had significant improvement (p = 0.04) with three procedures, and 3 patients (3.7%) had significant improvement (p = 0.19) with four procedures. On the other hand, when the number of surgical procedures was related with the diagnostic subtype of spastic infantile cerebral palsy, in those undergoing one procedure the clinical-surgical classification did not change in the cases of biparesis (p = 0.26), hemiparesis (p = 0.18), and double hemiparesis (p = 0.50). In those undergoing two surgical procedures the significant changes occurred for the cases of biparesis (p = 0.20), quadriparesis (p = 0.007), and double hemiparesis (p = 0.16). In those undergoing four procedures no changes occurred in the cases of biparesis (p = 0.26) and hemiparesis (p = 0.50). DISCUSSION: An improvement in the clinical-surgical classification was observed (p = 0.0001) based on the results of Gazi Zorer, as well as a significant improvement (p < 0.001) and an improvement reported by the gait analysis by the following authors: Ugur Sayli, Gouth, MA Khan.

Complexation of biologically active aromatic compounds with DNA in the presence of theophylline.

(1)H NMR measurements (500 MHz) have been used to determine the equilibrium hetero-association constants of theophylline (THP) with various biologically active aromatic compounds (daunomycin, novantrone, ethidium bromide, proflavine, norfloxacin) and the complexation constants of THP with both single- and double-stranded oligonucleotides in solution. The results provide a quantitative estimation of the effect of THP on the binding of aromatic ligands with DNA, and a determination of the fraction of aromatic ligand removed from DNA on addition of THP.

Colecistectomía laparoscópica ambulatoria en una unidad quirúrgica no hospitalaria / Ambulatory laparoscopic cholecystectomies in a surgical units

Se presentan 100 casos de Colecistectomia laparoscopica ambulatoria realizados por los autores en la Unidad de Cirugia Ambulatoria del Dispensario Central del Ejercito en Santa Fe de Bogota, D.C., entre enero de 1998 y agosto de 1999. Los resultados resaltan las ventajas de la Colecistectomia laparoscopica realizada de manera ambulatoria en una unidad quirurgica independiente del hospital, con estancia promedio de 7,6 horas en pacientes de todas las edades (18 a 93 años) y aun con riesgo quirurgico moderado (ASA I, II y III). Las cifras de morbimortalidad de la serie son comparables con otras de la literatura mundial y se logro una considerable reduccion de costos respecto a promedios extranjeros, y altos niveles de satisfaccion en los pacientes. Se demuestra que la Colecistectomia laparoscopica ambulatoria es segura y ventajosa en terminos economicos, realizada en unidades de cirugia por fuera del hospital.

Salt intake and renal outcome in patients with progressive renal disease.

Experimental studies suggest that salt intake plays a critical role in the progressive glomerular filtration rate (GFR) loss of established renal disease; however, this issue has never been addressed in humans. To this aim, we have retrospectively analyzed the clinical data of patients with chronic renal failure (CRF), in whom a low-protein diet was prescribed, over a period of about 3 years. On the basis of the daily urinary sodium output, the patients were divided into two groups: a group of patients constantly ingesting > 200 mEq NaCl/day (high sodium intake, HSD, n = 30) and a group in which salt intake was < 100 mEq/day (low sodium intake, LSD, n = 27). Patients taking diuretics or ACE inhibitors were excluded. At baseline, the LSD group, as compared to the HSD group, was characterized by significantly lower creatinine clearance (24 +/- 2 vs. 28 +/- 2 ml/min) and higher proteinuria (2.9 +/- 0.3 vs. 1.5 +/- 0.2 g/day). Despite the presence of these risk factors for progression, and a similar control of blood pressure (the average of the mean arterial pressure during follow-up was 111 +/- 2 mm Hg in LSD and 107 +/- 2 mm Hg in HSD), the LSD patients showed a better renal outcome: in this group, as compared to HSD, the GFR decline was lower (0.25 +/- 0.07 vs. 0.51 +/- 0.09 ml/min/month, p < 0.05), and proteinuria did not change while it markedly increased in HSD. During follow-up, LSD patients also ingested a significantly lower amount of protein. This study therefore suggests that efficacious salt restriction in CRF patients improves the outcome of renal disease independent from its antihypertensive effects.

Electroeyaculacion en pacientes con lesion de medula espinal / Electroejaculation in Spinal cord injury patients

Debido a la situación actual de orden público en nuestro país, la población de pacientes con lesión médula espinal en el Hospital Militar Central se ha incrementado en los últimos años. Ya que en nuestra institución no se disponía de programa de obtención de semen, se desarrolló la colaboración de ingenieros electrónicos de la Universidad Antonio Nariño, un equipo de electroeyaculación. Con la asesoría del Departamento de Investigaciones del Ministerio de Salud Pública, la aprobación el Comité de Etica del Hospital Militar Central y- colaboración de la Universidad de La Salle, se llevaron a cabo pruebas de seguridad en animales. Una vez comprobada la seguridad del equipo, se procedió a la etapa de experimentación en pacientes con lesión de médula espinal. Se utilizó un esquema de preparación de los pacientes que se describe en el trabajo, realizando las electroeyaculaciones con un voltaje inicial de 2 voltios y aumentos progresivos hasta un máximo de 20 voltios, con estímulos intermitentes de 3 segundos de duración y máximo un minuto en cada voltaje. Una vez obtenido el máximo de voltaje y estimulación, se recolectaba la solución "buffer' que se había colocado intravesical previa al procedimiento y se procesaba en forma inmediata para su estudio. Durante los procedimientos no se encontraron efectos adversos o complicaciones como la disreflexia autonómica o quemaduras, descritos ya en la literatura. El análisis de las muestras obtenidas reportó la presencia de espermatozoides en los 8 pacientes incluidos en el protocolo hasta el momento; con patrones de semen que muestran marcada oligoastenospermia. En algunos pacientes se obtuvo muestra mixta de eyaculación anterógrada y retrógrada. Actualmente se están empezando los estudios encaminados a lograr fertilización, usando métodos que dependen del patrón espermático obtenido, cuyos resultados serán reportados posteriormente

[Acute mesenteric infarct. I. Identification of predisposing factors and definition of the criteria of "cautious clinical monitoring" of the main groups of patients at risk]. / Infarto mesenterico acuto. Nota I. Identificazione dei fattori predisponenti e definizione dei criteri di "monitorizzazione clinica cautelativa" dei principali gruppi di pazienti "a rischio".

On the basis of experience acquired through 11 cases of acute mesenteric infarction personally observed over a 10-year period (1-1-1978-31-12-1987) and on the basis of a review on the literature, the usefulness for the purposes of early diagnosis and consequent early treatment of monitoring the essential, typical biological and clinical parameters of patients at risk of acute mesenteric infarction are reported.

[Effect of naloxone on somatosensory evoked potentials in congenital insensitivity to pain]. / Efecto de naloxona sobre los potenciales evocados somatosensoriales en la insensibilidad congénita al dolor.

The somatosensory evoked potentials were recorded (SEP) in a child 11 years old with congenital insensitivity to pain. The records were made before and after naloxone administration (160 mg i.m.) and they were compared with the SEPs from normal children. The place where records were taken was the somatosensory area of the scalp and the site of the stimulation was the contralateral medial nerve of the wrist. The results show that naloxone provokes higher waves of the patient's SEP that before administration of naloxone. On the other hand lower SEPs were observed in the patient with congenital insensitivity to pain than in those from normal children. The results suggest that congenital insensitivity to pain could be related to abnormal activities of morphine-like substances of endogenous production.

[Malabsorption of vitamin B 12 after gastrectomy for cancer]. / Il malassorbimento di vitamina B12 nelle gastrectomie per cancro.

The authors, after a short introduction of physiopathology, report on 17 patients who underwent a total (10 cases) or a subtotal (7 cases) gastrectomy for cancer at various times and then submitted to hemochromocytometric test and Schilling test modified by Katz and Bell. On the bases of information given by the tests, some clinical and therapeutic considerations are made.

Efecto de naloxona sobre los potenciales evocados somatosensoriales en la insensibilidad congenita al dolor. / Effect of naxolone on the somatosensory evoked potentials in congenital insensibility to pain

Se hizo registro de los potenciales evocados somatosensoriales(PES) en un nino de 11 anos con insensibilidad congenita al dolor antes y despues de la administracion de naloxona (160 mg.i.m.) y se compararon con los PES de ninos aparentemente sanos.Los resultados parecen indicar que la naloxona produce un aumento en la amplitud de los componentes de los PES registrados en el area somatosensorial del cuero cabelludo, contralateral al sitio de estimulacion en el nervio mediano a nivel de la muneca, por otra parte, hay una clara disminucion en la amplitud de los componentes de los PES registrados en el paciente con insensibilidad congenita al dolor con respecto a los obtenidos en un nino normal.Los resultados apoyan la suposicion de que los pacientes con insensibilidad congenita al dolor existe un aumento en las sustancias de produccion endogena parecidas a la morfina (endorfinas)

[Congenital pain insensitivity]. / Insensibilidad congénita al dolor.

A case showing multiple lesions that make it very illustrative is reported. Differential diagnosis is made with some other diseases that are similar in some isolated facts. Mention is also made on the pathophysiology of the disease as well as on the necessity of the intercourse of several medicosurgical specialties in the management of these patients. A brief review of the literature is made.