Trombosis venosa cerebral en una paciente puérpera con preeclampsia con datos de severidad / Cerebral venous thrombosis in a post-partum patient with preeclampsia with signs of severity

Resumen ANTECEDENTES: la trombosis venosa cerebral es infrecuente, pero con mayor incidencia durante la gestación y el puerperio. OBJETIVO: revisar la bibliografía más reciente y proponer una opción de tratamiento de la paciente con trombosis venosa cerebral durante el puerperio. CASO CLÍNICO: paciente de 30 años de edad, con antecedente de dos embarazos y dos cesáreas. En el séptimo día de puerperio tuvo edema de miembros inferiores, cifras tensionales elevadas, cefalea y alteraciones visuales. Con el tratamiento antihipertensivo con nifedipino y neuroprotección con sulfato de magnesio se logró el control de la hipertensión, aunque persistieron la cefalea y los síntomas de visión borrosa y diplopía. La resonancia magnética reportó: trombosis venosa de seno transverso lateral izquierdo. Con el tratamiento anticoagulante hubo disminución importante de los síntomas neurológicos. CONCLUSIONES: puesto que la preeclampsia y la eclampsia pueden ocultar los síntomas de la trombosis venosa cerebral, es importante tener siempre en mente ambos padecimientos para el diagnóstico y tratamiento oportuno de uno y otro.

Abstract BACKGROUND: cerebral venous thrombosis is infrequent, but with the highest incidence during pregnancy and puerperium. OBJECTIVE: to review the most recent bibliography and propose a treatment option for the patient with cerebral venous thrombosis during puerperium. CLINICAL CASE: a 30 year old patient with a history of two pregnancies and two Cesarean sections. On the seventh day of puerperium she presented edema of the lower limbs, high blood pressure, headache and visual disorders. Antihypertensive treatment with nifedipine and neuroprotection with magnesium sulfate, hypertension was controlled although the headache and blurry vision and double vision symptoms persisted. The MRI results reported: venous thrombosis of the left lateral transverse sinus. With anticoagulant treatment there was significant decrease of neurological symptoms. CONCLUSIONS: since preeclampsia and eclampsia can hide symptoms of cerebral venous thrombosis, it is important to always consider both conditions for the timely diagnosis and treatment of both.

Abuso sexual en pediatría / Sexual abuse in children

El servicio de Emergentología del Hospital del Niño Jesús de Tucumán realizó un trabajo retrospectivo, que abarcó de Enero de 2005 hasta Abril de 2006, sobre menores de 14 años ingresados con diagnóstico de abuso sexual (AS). Se registraron 32 pacientes, de los cuales sólo 23 cumplieron con los criterios de inclusión. Las niñas fueron las más afectadas; los varones agredidos fueron en su mayoría menores de 5 años. El grupo más comprometido estuvo entre los 5 y 10 años. Casi el 80 por ciento de loa gredidos tenia menos de 10 años. Las familias de las victimas en 3/4 partes de los casos, eran disfuncionales, con necesidades básicas insatisfechas, y caracterizadas por alcoholismo en más de la mitad de los casos, violencia intrafamiiar y abandono paterno. Sin embargo, casi la cuarta parte de las agresiones se dio en hogares considerados bien constituidos. En casi todos los ataques el agresor era una persona conocida, la mayoría familiar directo, generalmente conviviente o vecino, que gozaba de la confianza de los niños y sus padres. Gran parte de las agresiones fueron reiteradas. La mayoría de los abusadores era mayor de edad ; el 41 por ciento tenía menos de 18 años y en dos casos, menos de 12 años. No hubo violencia o maltrato físico en más del 90 por ciento. Otro dato relevante fue la normalidad del examen físico en el 35 por ciento de los casos en los que el contacto se limitó a frotamientos, manoseos, estimulación oral o maniobras masturbatorias. Se deduce por lo tanto que un examen físico negativo no descarta AS. Se observó también alta incidencia de lesiones genitales y/o anales consideradas crónicas, como consecuencia de AS de larga data. El examen paricial sólo fue positivo en un 33 por ciento. Sin embargo, debe señalarse que las posibilidades de encontrar evidencia forense aumentan cuando la pericia se hace precozmente, antes de las 12 horas del hecho y cuando no se ha realizado antes del estudio el aseo genital.

Evidencia serológica de la presencia del virus herpes canino tipo 1 en la provincia de Lima / Serological evidence of the presence of canine herpes virus type 1 in Lima province

El Virus Herpes Canino tipo 1 (VHC-1) es responsable de la enfermedad hemorrágica canina en cachorros menores de cuatro semanas de vida y de algunos problemas reproductivos en perras adultas. En el Perú, la enfermedad no ha sido reportada, aunque existen hallazgos que sugieren su presencia. El objetivo del presente estudio fue demostrar la presencia de anticuerpos contra el VHC-1 entre la población canina con antecedentes asociados a problemas reproductivos. Se recolectaron muestras de sangre de 28 animales procedentes de siete distritos de la provincia de Lima que tuvieron algún antecedente relacionado a problemas reproductivos o mortalidad neonatal. Las muestras fueron analizadas con la prueba de inmunofluorescencia indirecta (IFI) donde nueve canes (32 ± 17 por ciento) resultaron positivos.

The canine Herpesvirus type 1 (CHV-1) is responsible for the canine hemorrhagic disease in puppies aged less than four weeks and for some reproductive problems in adult bitches. In Peru, the disease has been not reported, although there are findings suggesting its presence. Thus, the aim of this study was to show the presence of antibodies against CHV-1 among the canine population associated with history of reproductive problems. Blood samples from 28 animals belonging to seven districts of the province of Lima were collected. These dogs had a history of reproductive problems or neonatal mortality. Samples were submited to the indirect immunofluorescense test (IFAT), and nine of them (32 ± 17 por ciento) were positive to the test.

Increased pituitary vascular endothelial growth factor-a in dopaminergic D2 receptor knockout female mice.

Vascular endothelial growth factor (VEGF)-A is an important angiogenic cytokine in cancer and pathological angiogenesis and has been related to the antiangiogenic activity of dopamine in endothelial cells. We investigated VEGF expression, localization, and function in pituitary hyperplasia of dopamine D2 receptor (D2R)-knockout female mice. Pituitaries from knockout mice showed increased protein and mRNA VEGF-A expression when compared with wild-type mice. In wild-type mice, prolonged treatment with the D2R antagonist, haloperidol, enhanced pituitary VEGF expression and prolactin release, suggesting that dopamine inhibits pituitary VEGF expression. VEGF expression was also increased in pituitary cells from knockout mice, even though these cells proliferated less in vitro when compared with wild-type cells, as determined by 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium proliferation assay, proliferating cell nuclear antigen expression, and [(3)H]thymidine incorporation. In contrast to other animal models, estrogen did not increase pituitary VEGF protein and mRNA expression and lowered serum prolactin secretion in vivo and in vitro in both genotypes. VEGF (10 and 30 ng/ml) did not modify pituitary cell proliferation in either genotype and increased prolactin secretion in vitro in estrogen-pretreated cells of both genotypes. But conditioned media from D2R(-/-) cells enhanced human umbilical vein cell proliferation, and this effect could be partially inhibited by an anti-VEGF antiserum. Finally, using dual-labeling immunofluorescence and confocal laser microscopy, we found that in the hyperplastic pituitaries, VEGF-A was mostly present in follicle-stellate cells. In conclusion, pituitary VEGF expression is under dopaminergic control, and even though VEGF does not promote pituitary cellular proliferation in vitro, it may be critical for pituitary angiogenesis through paracrine actions in the D2R knockout female mice.

[Non-valvular atrial fibrillation and completed stroke: factors determining mortality, recurrence and prognosis after a first event in the Mexican population]. / Fibrilación auricular no valvular e infarto cerebral: determinantes de mortalidad, recurrencia y pronóstico después de un primer evento en población mexicana.

AIMS: Non-valvular atrial fibrillation (NVAF) accounts for 25% of completed strokes (CS) of a cardioembolic origin in patients over 60 years old. Our aim was to define the predictors of a good and poor prognosis after a CS secondary to an NVAF in our milieu. PATIENTS AND METHODS: We evaluated the risk factors (RF) and severity of CS in relation to death, functionality and recurrence at 5 years. 81 patients between the ages of 49 and 88 were followed up consecutively for 1 to 90 months; 38 (46.9%) of them were males. Multivariate analysis was performed with the following independent variables: age, gender, smoking, hypertension, heart disease, diabetes mellitus and characteristics of the stroke. The severity of the CS was assessed by means of the modified Rankin scale, which was dichotomised into a good prognosis (0-2) and a poor prognosis (> or = 3), both basal and at the end of the clinical control. We also evaluated the secondary preventive treatment used and its relation with recurrence, prognosis, death and complications. RESULTS: No RF was linked to a poor prognosis or recurrence; 88% had a poor prognosis. Antiplatelet drugs were used in 42% of cases and 39% received anticoagulants. A good final progression was observed in 9.5% of the patients treated with antiplatelet drugs versus 35% of those receiving anticoagulation therapy (p = 0.004). Severity of the CS on admission was worse in the aspirin group, with no differences in recurrence and mortality. A better prognosis was observed in patients from urban areas. CONCLUSIONS: Use of antiplatelet drugs, living in a rural area and a Rankin score of > or = 3 on admission are factors suggesting a poor prognosis in the clinical control at 5 years.

Fibrilación auricular no valvular e infarto cerebral: determinantes de mortalidad, recurrencia y pronóstico después de un primer evento en población mexicana / Non-valvular atrial fibrillation and completed stroke: factors determining mortality, recurrence and prognosis after a first event in the Mexican population

Objetivo. La fibrilación auricular no valvular (FANV) representa el 25% de los infartos cerebrales (IC) de origen cardioembólico en mayores de 60 años. Nuestro propósito fue definir los factores de buen y mal pronósticos después de un IC secundario a FANV en nuestro medio. Pacientes y métodos. Evaluamos los factores de riesgo (FR) y la gravedad del IC en relación con muerte, funcionalidad y recurrencia a cinco años. Se siguieron 81 pacientes consecutivos de entre 49 y 88 años, durante 1-90 meses; 38 (46,9%) fueron hombres. Se realizó un análisis multivariado con las siguientes variables independientes: edad, sexo, tabaquismo, hipertensión, cardiopatía, diabetes mellitus y características del infarto. La gravedad del IC se evaluó mediante la escala modificada de Rankin, dicotomizada en buen pronóstico (0-2) y mal pronóstico 3), basal y al final del control clínico. Evaluamos también el tratamiento de prevención secundaria utilizado y su relación con recurrencia, pronóstico, muerte y complicaciones. Resultados. Ningún FR se asoció con mal pronóstico o recurrencia; el 88% tuvo mal pronóstico. En el 42% se utilizaron antiagregantes, y en el 39% anticoagulantes. Se observó una buena evolución final en un 9,5% de los pacientes con antiagregantes frente a un 35% con anticoagulación (p 0,004). La gravedad del IC al ingreso fue peor en el grupo de aspirina, sin diferencias en recurrencia y mortalidad. Se observó mejor pronóstico en los pacientes provenientes de áreas urbanas. Conclusión. El uso de antiagregantes, vivir en área rural y un Rankin 3 al ingreso son factores de mal pronóstico en el control clínico a los cinco años

Aims. Non-valvular atrial fibrillation (NVAF) accounts for 25% of completed strokes (CS) of a cardioembolic origin in patients over 60 years old. Our aim was to define the predictors of a good and poor prognosis after a CS secondary to an NVAF in our milieu. Patients and methods. We evaluated the risk factors (RF) and severity of CS in relation to death, functionality and recurrence at 5 years. 81 patients between the ages of 49 and 88 were followed up consecutively for 1 to 90 months; 38 (46.9%) of them were males. Multivariate analysis was performed with the following independent variables: age, gender, smoking, hypertension, heart disease, diabetes mellitus and characteristics of the stroke. The severity of the CS was assessed by means of the modified Rankin scale, which was dichotomised into a good prognosis (0-2) and a poor prognosis 3), both basal and at the end of the clinical control. We also evaluated the secondary preventive treatment used and its relation with recurrence, prognosis, death and complications. Results. No RF was linked to a poor prognosis or recurrence; 88% had a poor prognosis. Antiplatelet drugs were used in 42% of cases and 39% received anticoagulants. A good final progression was observed in 9.5% of the patients treated with antiplatelet drugs versus 35% of those receiving anticoagulation therapy (p = 0.004). Severity of the CS on admission was worse in the aspirin group, with no differences in recurrence and mortality. A better prognosis was observed in patients from urban areas. Conclusions. Use of antiplatelet drugs, living in a rural area and a Rankin score of 3 on admission are factors suggesting a poor prognosis in the clinical control at 5 years

[Acute myocardial infarction: what is new?]. / Infarctus du myocarde et thrombolyse: actualités.

Current recommendations on the management of acute myocardial infarction and the use of thrombolysis are reviewed.

[Transesophageal echocardiographic findings in patients under 40 years of age with cerebrovascular event]. / Hallazgos ecocardiográficos transesofágicos en pacientes menores de 40 años con evento vascular cerebral.

UNLABELLED: The potential cardioembolic sources for ischemic stroke in patients younger than 40 years could be asymptomatic. The purpose of this study is to justify routine implementation of transesophageal echocardiography (TEE) in the study of young patients with ischemic stroke. MATERIAL AND METHODS: 34 patients younger than 40 years with ischemic stroke were studied with TEE complemented with contrast study, looking for potential cardioembolic sources or intracardiac shunts. RESULTS: 19 patients were male and 15 female with ages between 18-40 years (average 31 years). None had cardiac signs or symptoms. Eleven anomalies were detected in 20 patients (58.8%); of these, only 3 were considered as probably coursing with cardioembolic sources: patent foramen ovale (PFO), mitral valve prolapse, and ventricular enlargement, which were found in 12 patients (35.29%). In patients with cardiovascular anomalies, we found a hypercoagulable state, associated in eight patients with PFO (four patients), two with valvular thickening, and two with valvular nodules. CONCLUSIONS: In patients younger than 40 years with ischemic stroke, TEE is useful in detecting direct and indirect cardiac sources of embolism, even in those patients with unsuspected cardiac disease.

[The neurological complications of infectious endocarditis]. / Complicaciones neurológicas de la endocarditis infecciosa.

We review the neurologic complications of 131 episodes of infective endocarditis, and the influences of some factors that are considered risk factors at its presentation, like the presence of vegetations detected by echocardiography, type and location of involved valve, or bacterial culture. Neurologic complications occurred in 28 patients (21.4%), 4 of them were excluded because of the absence of neuroimaging studies. In 21 patients the underlying cardiac pathology was valve disease and in the remaining 3 patients was congenital heart disease. 11 patients had native valve endocarditis and 10 prosthetic valve endocarditis. The cultured bacteria were Streptococcus viridans in 8 cases and Staphylococcus aureus in 7. The most frequent complication was cerebrovascular with incidence of cerebral embolism, and intracerebral hemorrhage of 62.5% and 8.3% respectively. Echocardiographic evidence of vegetation was seen in 18 patients, and cerebral embolism were noted in 12. Death occurred in 29% of patients with neurologic complications and 27% without. Two of nine patients who underwent open-heat surgery died. We conclude that there is no difference in the incidence of neurologic complications between mitral and aortic valve groups, neither when comparing native and prosthetic valve groups. Open-heart surgery does not increase mortality in this group of patients.

[Sonographic patterns by transcranial Doppler in acute cerebral infarction]. / Patrones sonográficos por Doppler transcraneal en el infarto cerebral agudo.

AIM: To evaluate the correlations between the patterns of Transcranial Doppler (TCD) and the extent and pathophysiologic mechanism of the ischemia as well as the prognosis of patients with acute ischemic stroke. METHODS: 37 patients with ischemic stroke within the first 24 hours of evolution were examined using TCD, neuroimaging, and neurologic state at admission and disarcharge. The TCDs were grouped into four categories: normal, stenotic, hemispheric asymmetry and trunk occlusion of the middle cerebral artery (MCA); they were correlated with the extent of brain damage, pathophysiologic mechanism of the stroke and prognosis. RESULTS: Normal TCD was highly predictive of lacunar infarction secondary to small vassels disease (p = 0.01) and good recovery (p < 0.02). The stenotic and hemispheric asymmetry patterns correlated highly with a cortical infarctions (p < 0.05) and a cardioembolic mechanism. The occlusion of the MCA was highly correlated with a large infarction (p < 0.01) and with poor outcome and death (p = 0.004). CONCLUSIONS: Our data show that TCD has a value in predicting the prognosis and the severity, location and pathophysiologic mechanism of cerebral strokes.