Pitfalls in pituitary diagnosis: peculiarities of three cases.

Due to the increasing availability and sensitivity of diagnostic methods, biochemical and imaging abnormalities of pituitary function and anatomy are becoming more frequent. Hyperprolactinaemia was found in three women without any prolactin (PRL) related clinical features. All three patients had normal libido, regular menses with evidence of ovulation, no galactorrhoea, and normal FSH, LH, TSH and free T4 serum levels. Magnetic resonance imaging (MRI) of the sellar region showed images that were compatible with pituitary microadenomas in all three cases. Due to the discordance between laboratory and clinical features, we searched for the presence of PRL aggregates with high molecular weight and low biological activity (macroprolactinaemia). Initially, we screened with a polyethylene glycol precipitation method, and then confirmed the presence of macroprolactinaemia by chromatography. All three cases screened positive for the presence of macroprolactinaemia. MRI alterations, compatible with pituitary microadenomas, may be due to true microincidentalomas, normal anatomical variations or imaging artefacts. In conclusion, we have described the presence of double diagnostic pitfalls that might lead to unnecessary medical or surgical intervention.

[Congenital mitral stenosis. Experience in 1991-2001]. / Estenosis mitral congénita. Experiencia 1991-2001.

OBJECTIVE: To describe ten years of experience with congenital mitral stenosis. METHOD: All cases with congenital mitral stenosis from January 1991 to 2001 were analized. RESULTS: 16 patients with congenital mitral stenosis were found, mean age 3 +/- 3.08 years. TYPES OF OBSTRUCTIONS: Mitral commisures combined with tendinous cords fusion (45%), parachute mitral valve 37%, supravalvar mitral ring in one, fusion between papillary muscle and leaflets in one, and double mitral orifice in one. Hemodynamic (in mmHg) findings: wedge pressure 18.4 +/- 4, pulmonary artery systolic 61 +/- 21, diastolic 34 +/- 15, mean 47 +/- 18 mmHg, mean transvalvar gradient (MTG) 12.9 +/- 7.3, PRU 5.5 +/- 3.8. Four patients received medical treatment. Surgical results: Six patients underwent mitral repair, and four were subjected to mitral valve replacement (two with previous mitral repair). Global mortality was 2 (12.5%). Follow-up was 3.5 +/- 3 years. There was a significant difference when the initial MTG 22.6 +/- 11.5 mmHg before surgical repair was compared with the final MTG 4.75 +/- 1.5 (P < 0.05), also when initial MTG 12 +/- 2.3 before mitral valve replacement was compared with the final MTG 6 +/- 1.15 mmHg (P < 0.05). CONCLUSION: Most patients are candidates for mitral surgical repair, however at mid term one third will require mitral valve replacement.

Direct communication between right pulmonary artery and left atrium.

A case of direct communication between right pulmonary artery and left atrium is reported. The diagnosis was made before surgical correction. A surgical ligation of the fistula resolved the cyanosis of the patient. Selective angiocardiogram of the right pulmonary artery 4 months after surgery revealed no residual shunt. This very rare malformation should be considered in the clinical setting of unexplained cyanosis. This is the number 50 case reported in the literature.

[Atrioventricular discordance. Clinico-surgical experience 1990-2000]. / Discordancia atrioventricular. Experiencia clínico-quirúrgica 1990-2000.

OBJECTIVE: To know the incidence of ventriculoarterial connections combined with atrioventricular discordance, associated lesions and surgical results, including the first case with anatomical correction. METHOD: All patients with atrioventricular discordance by echocardiography from 1990 to March 2000 were analyzed. RESULTS: Thirty six patients with atrioventricular discordance were found. Ages ranged from 0.1 to 46 years, with a mean 9.2 years (SD 5.9 years). Atrial chambers were situs solitus in 88.9%, inversus in 11.2%. The ventriculoarterial connections were discordant in 28 (77.7%), double outlet right ventricle in 4 (11.1%) (one of them was a "criss cross" heart), single outlet (pulmonary atresia) in 4 (11.1%), and double outlet left ventricle in 1 (2.7%). Associated lesions: Ventricular septal defect with pulmonary stenosis or atresia was present in 21 (58%), ventricular septal defect with no pulmonary obstruction was observed in 10 (28%). Five had tricuspid regurgitation with right ventricular disfunction, (two adults). Surgical results: 22 (61%) required 28 surgical procedures: 8 (36%) were palliative and 19 (86%) were corrective, one of them was our first anatomical correction. Operative mortality in all was 40.1%, postoperative atrioventricular block was observed in 9 (40.1%). CONCLUSION: Right ventricular dysfunction is not uncommon. Surgical results revealed high mortality and high pacemaker requirement for atrioventricular block.

The nature of the obstructive muscular bundles in double-chambered right ventricle.

OBJECTIVE: Our goal was to establish the morphologic nature of the obstructive muscular lesions in double-chambered right ventricle. METHODS: We based our morphologic observations on 10 normal hearts and on the surgical findings in 26 patients, aged 0.5 to 24 years, with a mean of 6.9 years (SD 5.8 years). In the normal hearts, we measured the distance from the pulmonary valve to the apex of the right ventricle and from the takeoff of the moderator band to the ventricular apex. From angiograms available in 20 patients, using the frontal view, we then measured the distance from the pulmonary valve to the apex of the right ventricle and from the midpoint of the obstructive lesion to the apex of the right ventricle. This permitted calculations of multiple ratios. RESULTS: In the 10 normal hearts, the moderator band took origin at a mean ratio of 0.48 (SD 0.16) of the ventricular length. On the basis of the angiographic findings, we identified 2 basic forms of double-chambered right ventricle. In 9 patients, the obstructive muscular shelf was positioned low and diagonally across the apical component, with a mean ratio of 0.38 relative to the ventricular length (SD 0.02). In the other 11 patients, the obstructive shelf was high and horizontal, with a mean ratio of 0.27 (SD 0.02). The difference was statistically significant (P =.001). Surgical repair was performed successfully in all 26 patients through a right ventriculotomy. CONCLUSIONS: Double-chambered right ventricle is the consequence of a high or low muscular division of the apical component of the right ventricle. The abnormal muscular bundle probably represents accentuated septoparietal trabeculations, rather than always being an abnormal moderator band.

Aneurysm of the pulmonary trunk with patent arterial duct.

We present a 14-year-old female with a massive aneurysm of the pulmonary trunk occurring secondary to bacterial endocarditis of the patent arterial duct. Echo Doppler imaging, magnetic resonance and angiography confirmed the diagnosis. On intermediate follow-up after surgical correction, the echo studies and cardiac catheterization disclosed no residual lesions. The patient is now asymptomatic.

The feasibility of complete anatomical correction in the setting of discordant atrioventricular connections.

OBJECTIVE: To evaluate the feasibility of anatomical correction based on morphological and echocardiographic findings in patients and preserved hearts with discordant atrioventricular connections. DESIGN: A retrospective study with clinicomorphological correlations to assess potential contraindications for anatomical correction in the setting of discordant atrioventricular connections. SETTING: A tertiary referral centre for congenital heart disease. MATERIAL: 25 specimens and 53 patients unified by presence of discordant atrioventricular connections. METHODS: The potential contraindications for anatomical correction were first evaluated on the basis of morphological findings in all 25 specimens with discordant atrioventricular connections collected in the department museum, including study of the major coronary arterial patterns in 20. These contraindications were then sought in a population of 53 patients examined echocardiographically between January 1992 and October 1997. RESULTS: At least one lesion was discovered that might have contraindicated anatomical correction in 14 of the specimens and in 16 of the patients. The most common lesions that might militate against the anatomical approach were severe Ebstein's malformation or straddling and overriding of the tricuspid valve, each when combined with hypoplasia of the morphologically right ventricle. Other potential contraindications were atrioventricular septal defect with common atrioventricular junction, and obstruction of the left ventricular outlet combined with a restrictive ventricular septal defect, although these may be overcome with increasing experience and expertise. CONCLUSIONS: According to the morphological and echocardiographic findings, at least 10 hearts and 37 patients would have produced no anatomical problems for the type of surgical correction in which the morphologically left ventricle is restored its rightful role as the systemic pumping chamber.

Trimethylolpropane phosphate (TMPP) perfusion into the nucleus accumbens of the rat: electroencephalographic, behavioral and neurochemical correlates.

The infusion (0.13 mumol/infusion) of the convulsant trimethylolpropane phosphate (TMPP) into the nucleus accumbens (NA) of adults Sprague-Dawley rats reliably induced subclinical seizures, hyperlocomotor activity, and integrated stereotypies. Observation of these behaviors was temporally correlated with the appearance of EEG paroxysms, as well as with significant decreases in extracellular concentrations of both dopamine (DA) and norepinephrine (NE) in the NA. Repeated perfusion of TMPP revealed significant increases in stereotypic behavior during subsequent pre-drug baseline testing.

Asymmetric syntheses, opioid receptor affinities, and antinociceptive effects of 8-amino-5,9-methanobenzocyclooctenes, a new class of structural analogues of the morphine alkaloids.

Several 8-amino-5,9-methanobenzocyclooctenes have been prepared by asymmetric organic synthesis techniques. Opioid receptor affinity studies have revealed the virtual absence of enantioselectivity for receptor binding, particularly at the mu-receptor, for the (+)-3a-f and the (-)-3a-f series. It is noteworthy that inversion of configuration at the nitrogen-bearing carbon atom [5S,8S,9S)-8-amino-3-hydroxy-5, 9-methano-9-(methoxymethyl)-5-methylbenzocyclooctene, (+)-3a vs (5S,8S,9R)-8-amino-3-hydroxy-5, 9-methano-9-(methoxymethyl)-5-methylbenzocyclooctene, (dl)-22] resulted in a > 10-fold increase in kappa-receptor affinity. Antinociceptive studies demonstrated that (dl)-22 was a full kappa-agonist while (+)-3a and (-)-3a did not possess kappa-activity. Although both (dl)-22 and (+)-3a/(-)-3a had high affinity for the mu-receptor, these compounds did not act as high-affinity agonists or antagonists at this receptor.

Prevalence of malnutrition in Mexican CAPD diabetic and nondiabetic patients.

Malnutrition is often present on continuous ambulatory peritoneal dialysis (CAPD), and contributes to morbidity and mortality. Diabetics (DM) have an increased risk for developing malnutrition. Our purpose was to assess the nutritional status (NS) of our CAPD population, to define NS differences between DM and nondiabetics (NoDM), and to identify NS-related factors. Patients were subjected to a nutritional assessment, which included a 24-hour dietary recall and a nutritional scoring system including anthropometric, biochemical, and subjective evaluation, and that classifies patients as: normal, and mildly, moderately, and severely malnourished. We studied 90 patients: 35 DM and 55 NoDM. In our whole population we observed a high frequency of malnutrition: NS was normal in 18%, and 20% had mild, 24% had moderate, and 38% had severe malnutrition. Ninety-one percent of DM and 76% of NoDM showed some degree of malnutrition. DM patients had significantly higher levels of malnutrition (p = 0.02), were significantly older, had more body fat, and spent less time on dialysis. There were 37 males and 53 females. Sex distribution was similar between DM and NoDM. Seventy-six percent of males and 86% of females had malnutrition. Moderate and severe malnourishment were more frequent in females. DM and female sex were the strongest predictors for moderate and severe malnutrition.

Operación de Fontan exitosa en atresia tricuspidea con transposición: reporte de un caso con cateterismo postoperatorio y revisión de la literatura / Succesful Fontan operation in tricuspid atresia with transposition: a case report with postoperative hemodynamic data and literature reviewed

Se reporta el primer caso de atresia tricuspídea (AT) con transposición de los grandes vasos operado con éxito y se revisa la literatura. Masculino de 8 años de edad estudiado en 1988 por cianosis y clase III NYHA. Con el ECO y el cateterismo cardíaco se diagnosticó situs solitus, conexión atrioventricular concordante, conexión ventriculoarterial discordante, AT y estenosis pulmonar severa. El enfermo fué sometido a operación de Fontan-Kreutzer el 24 de octubre de 1988. El cateterismo postoperatorio realizado 9 meses después mostró presión en aurícula derecha de 4 mmHg, arteria pulmonar media de 4, ventrículo izquierdo 112/4, la saturación de O2 en aorta mostró 90% y el angio en aurículaderecha demostró progresión normal del flujo hacia la arteria pulmonar. A 2 años de la operación se encuentra en clase I y sin cianosis. Después de revisar la literatura se concluye que la operación de Fontan constituye una paliación fisiológica aceptable en enfermos que hasta hace no muchos años se consideraban irreparables.

Conducto arterioso en el prematuro.Conceptos actuales. / Ductus arteriosus in the premature infant. Current concepts

Se sabe que el oxigeno es un factor importante en el proceso de cierre del conducto arterioso en el recien nacido; por el contrario la hipoxemia, cualquiera que sea su origen, impide dicho proceso. En el nino prematuro esta situacion es mas notoria cuanto mayor es el grado de prematurez y en consecuencia de inmadurez a la reaccion al estimulo del oxigeno. Otro factor importante es la insuficiencia respiratoria frecuente en estos ninos, lo cual propicia la hipoxemia; y, a su vez, la persistencia del conducto arterioso. Las medidas terapeuticas de asistencia ventilatoria en estos ninos han incrementado los casos de supervivencia; y con ellos, los casos de persistencia del conducto arterioso y los informes de tratamiento quirurgico a estas edades. En este trabajo se hacen consideraciones acerca de los metodos y procedimientos que confirman el diagnostico y respecto a las bases en que se funda el tratamiento quirurgico. Finalmente se comentan los beneficios y demostraciones del uso de prostaglandinas en el tratamiento farmacologico del conducto arterioso