Interaction of DGAT1 polymorphism, parity, and acetate supplementation on feeding behavior, milk synthesis, and plasma metabolites.

Acetate supplementation increases milk fat production, but interactions with animal-related factors have not been investigated. The objective of this study was to characterize the interaction of acetate supplementation with parity and genetic potential for milk fat synthesis including the DGAT1 K232A polymorphism (AA and KA genotypes). In total, 47 primiparous and 49 multiparous lactating cows were used in 2 blocks in a crossover design. The basal diet was formulated to have a low risk of biohydrogenation-induced milk fat depression and had 32.8% and 32.0% neutral detergent fiber and 21.7% and 23.6% starch [all on a dry matter (DM) basis] in block 1 and 2, respectively. The control treatment received the basal diet, and the acetate supplementation treatment included anhydrous sodium acetate supplemented to the basal diet at 3.2% and 3.1% of DM of the diet for block 1 and 2, respectively (targeting 10 mol/d of acetate). The DGAT1 genotype frequency of the experimental cows was 45% AA and 51% KA, with 4% cows with either a KK or unimputable genotype. Acetate supplementation increased DM intake (DMI) in KA multiparous cows, but acetate did not change DMI in AA multiparous or primiparous cows of either genotype. Acetate supplementation increased the frequency of meals by 8% and decreased the length of each meal by ∼5 min compared with control. There was no effect of acetate on milk yield. Acetate supplementation increased milk fat yield and concentration by 117 g/d and 0.31 percentage units, respectively, regardless of DGAT1 polymorphism or parity. The increase in milk fat yield was mostly due to an increase in yield of 16C mixed-sourced fatty acids, suggesting that acetate supplementation drives mammary de novo synthesis toward completion. Response to acetate supplementation was not related to genomic predicted transmitting ability of milk fat concentration and yield or to pretrial milk fat percent and yield, suggesting that acetate increases milk fat production regardless of genetic potential for milk fat yield and level of milk fat synthesis. Interestingly, analyzing the temporal effect on the interaction between treatment and DGAT1 polymorphism on milk fat yield suggested that DGAT1 polymorphism may affect the short-term response to acetate supplementation during the first ≤7 d on treatment. Acetate supplementation also increased plasma ß-hydroxybutyrate concentration and decreased plasma glucose concentration. In conclusion, acetate supplementation consistently increased milk fat synthesis regardless of parity or genetic potential for milk fat synthesis.

Interaction of sodium acetate supplementation and dietary fiber level on feeding behavior, digestibility, milk synthesis, and plasma metabolites.

Acetate supplementation has been shown to increase milk fat yield in diets with low risk of biohydrogenation-induced milk fat depression. The interaction of acetate supplementation with specific dietary factors that modify rumen fermentation and short-chain fatty acid (FA) synthesis has not been investigated. The objective of this experiment was to determine the effect of acetate supplemented as sodium acetate at 2 dietary fiber levels. Our hypothesis was that acetate would increase milk fat production more in animals fed the low-fiber diet. Twelve lactating multiparous Holstein cows were arranged in a 4 × 4 Latin square design balanced for carryover effects with a 2 × 2 factorial arrangement of dietary fiber level and acetate supplementation with 21-d experimental periods. The high-fiber diet had 32% neutral detergent fiber and 21.8% starch, and the low-fiber diet had 29.5% neutral detergent fiber and 28.7% starch created by substitution of forages predominantly for ground corn grain. Acetate was supplemented in the diet at an average 2.8% of dry matter (DM) to provide approximately 10 mol/d of acetate as anhydrous sodium acetate. Acetate supplementation increased DM intake by 6%, with no effect on meal frequency or size. Furthermore, acetate supplementation slightly increased total-tract apparent DM digestibility and tended to increase organic matter digestibility. Acetate supplementation increased milk fat concentration and yield by 8.6 and 10.5%, respectively, but there was no interaction with dietary fiber. The increase in milk fat synthesis was associated with 46 and 85 g/d increases in the yield of de novo (<16C) and mixed source (16C) FA, respectively, with no changes in yield of preformed FA (>16C). There was a 9% increase in the concentration of milk mixed-source FA and a 7% decrease in milk preformed FA with acetate supplementation, regardless of dietary fiber level. Acetate supplementation also increased the concentrations of plasma acetate and ß-hydroxybutyrate, major metabolic substrates for mammary lipogenesis. Overall, acetate supplementation increased milk fat yield regardless of dietary fiber level through an increase mostly caused by an increase in longer-chain de novo FA, suggesting stimulation of mammary lipogenesis. The heightened mammary de novo lipogenesis was supported by an increase in the concentration of metabolic substrates in plasma.

Effect of the timing of sodium acetate infusion on the daily rhythms of milk synthesis and plasma metabolites and hormones in Holstein cows.

Dairy cows have a daily pattern of feed intake which influences ruminal fermentation and nutrient absorption. Milk synthesis also exhibits a daily rhythm and is altered by the timing of feed availability. Nutrients can regulate physiological rhythms, but it is unclear which specific nutrients affect the rhythms of milk synthesis in the cow. The objective of this study was to determine the effect of the timing of acetate infusion on the daily rhythms of feed intake, milk synthesis, milk fatty acids, plasma insulin and metabolites, and core body temperature. Ten lactating ruminally cannulated Holstein cows (127 ± 24.6 d in milk; mean ± standard deviation) were arranged in a 3 × 3 Latin square design. Treatments were ruminal infusions of 600 g/d of acetate either continuously throughout the day (CON) or over 8 h/d during the day (day treatment, DT; 0900 to 1700 h) or the night (night treatment, NT; 2100 to 0500 h). Experimental periods were 14 d with a 7-d washout between periods. Cows were milked every 6 h during the final 7 d of each experimental period to determine the daily pattern of milk synthesis. Blood samples were taken to represent every 4 h across the day and plasma glucose, insulin, ß-hydroxybutyrate, urea nitrogen, and acetate concentration were measured. An intravaginal temperature logger was used to measure core body temperature. Data were analyzed with cosinor-based rhythmometry to test the fit of a cosine function with a period of 24 h and to determine the acrophase (time at peak) and amplitude (peak to mean) of each rhythm. Milk yield fit a daily rhythm for all treatments and DT and NT phase-delayed the rhythm and DT increased the robustness of the rhythm. Milk protein concentration fit a daily rhythm for all treatments and DT increased robustness, whereas NT phase-delayed the rhythm. Plasma acetate concentration also fit a daily rhythm in all treatments. Plasma acetate peaked at ∼1600 h in CON and DT and at 0053 h in NT, reflecting the timing of treatment infusions. There was a daily rhythm in plasma ß-hydroxybutyrate that reflected the plasma acetate rhythm. Core body temperature fit a rhythm for all treatments, but the amplitude of the rhythm was smaller than previously observed. In conclusion, the timing of acetate infusion influences peripheral rhythms of milk synthesis and plasma metabolites.

Comparison of the effects of short-term feeding of sodium acetate and sodium bicarbonate on milk fat production.

Supplementation with sodium acetate (NaAcet) increases milk fat production through an apparent stimulation of de novo lipogenesis in the mammary gland. Sodium acetate increases acetate supply to the mammary gland, but it also increases dietary cation-anion difference, which can also increase milk fat yield. The objective of this study was to determine if the effect of NaAcet on milk fat production was due to an increase in acetate supply or an increase in dietary cation-anion difference. The study included 12 multiparous cows in a replicated 3 × 3 Latin square design balanced for carryover effects, with 14-d experimental periods. Treatments were a basal total mixed ration (31.8% neutral detergent fiber, 14.8% crude protein, 25.5% starch, and 4.4% fatty acids on a dry matter basis) as a no-supplement control, acetate supplemented at 3.25% of dry matter as NaAcet, and sodium bicarbonate (NaHCO3) providing an equal amount of sodium to the NaAcet treatment. The NaAcet and NaHCO3 were mixed into the basal diet before feeding. Milk samples were taken at each milking during the last 3 d of each period. Plasma samples were taken every 9 h during the last 3 d (a total of 8 times) to determine concentrations of plasma metabolites and hormones. Eating behavior was monitored during the last week of each period using an automated system. The NaAcet and NaHCO3 treatments increased milk fat concentration and yield compared to the no-supplement control. The NaAcet treatment increased milk fat production predominantly by increasing the yield of de novo and mixed-source fatty acids. The NaHCO3 treatment increased the yield of preformed and de novo fatty acids, suggesting different mechanisms for the 2 treatments. The NaAcet treatment increased plasma acetate concentration in a period of the day concurrent with the highest dry matter intake. The NaAcet treatment increased milk fat production by stimulating the production of de novo fatty acids, a mechanism consistent with previous reports, possibly by increasing acetate supply to the mammary gland. The NaHCO3 treatment increased milk fat production by increasing the production of all biological categories of fatty acids, except for odd and branched-chain fatty acids, possibly by increasing overall diet digestibility.

Meta-analysis of the relationship between milk trans-10 C18:1, milk fatty acids <16 C, and milk fat production.

The economic value of milk fat and its responsiveness to management strategies provides strong interest in maximizing milk fat production by minimizing occurrence of biohydrogenation-induced milk fat depression (BH-MFD) and maximizing de novo synthesized fatty acids (FA). Tools that allow a timely diagnosis of BH-MFD would improve nutritional management. Specific milk FA or FA categories correlate to milk fat concentration and are of interest for diagnosing the cause of changes in milk fat concentration. The objective of the current study was to characterize the relationship between milk fat concentration and trans-10 C18:1, a proxy for BH-MFD, and FA <16 carbons that originate solely from de novo lipogenesis using a meta-analysis approach that used data from the literature and unpublished Penn State experiments. Prior to the meta-analysis, the effect of FA methylation method on milk FA profile was tested to determine potential bias between papers. There was no difference between sodium methoxide, acid, and acid-base methylation methods on trans-10 C18:1 concentration, but acid methods resulted in loss of short-chain FA. The relationship between trans-10 C18:1 and milk fat percentage was investigated using a 2-component model, where one component described the fraction unresponsive to BH-MFD and the other described a responsive fraction that is exponentially related to trans-10 C18:1. The 2 fractions where characterized utilizing a Bayesian hierarchical model accounting for between-study variability. The model was defined by the function f(x, θ1, θ2, θ3) = θ1 + θ2exp(θ3), where the unresponsive θ1 fraction was 2.15 ± 0.09%, the responsive θ2 fraction was 1.55 ± 0.08%, and the exponential term θ3 was -0.503 ± 0.07 (posterior mean ± posterior standard deviation from the Bayesian hierarchical model). A Lin's concordance correlation coefficient of 0.67 suggested good agreement between observations and predictions from the Bayesian hierarchical model, computed only with the model's mean population parameters. There was a linear relationship between milk fat concentration and FA <16 C as a percentage of total FA (intercept = 2.68 ± 0.237 and slope = 0.043 ± 0.011; coefficient of determination = 0.31). The relationship between milk FA <16 C and milk fat concentration is weaker than what has been published, likely because multiple factors can reduce de novo FA without reducing milk fat and the broad range of diets present in the literature.

Síndrome de doble corteza en paciente masculino adulto sin lisencefalia / Double cortex syndrome in a male patient without lissencephaly

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Transcranial Doppler ultrasound measurements of cerebral hemodynamic parameters in healthy volunteers at 2850 meters altitude. / Parámetros hemodinámicos cerebrales, determinados mediante Doppler transcraneal, en un grupo de voluntarios sanos a 2.850 metros de altura.

BACKGROUND: Transcranial Doppler ultrasound (TDU) is useful in cerebrovascular patients. TDU findings are operator-dependent; they can also be influenced by anatomical and physiological variables as well as by the altitude at which the study is done. OBJECTIVE: To report the cerebral hemodynamic parameters measured by TDU in subjects who live in Quito, Ecuador (altitude 2850 meters). MATERIAL AND METHODS: We recruited 47 volunteers with no history or clinical evidence of stroke, hypertension, metabolic disorders, or hematologic disorders; 2 patients were excluded because they did not have a viable cranial window for TDU study. Thus, we recorded mean cerebral blood flow velocity, peak systolic flow velocity, end-diastolic flow velocity, and pulsatility indices in 45 patients (28 (62.2%) women; mean age, 35.9 years). We recorded patients' age, sex, and hematocrit. We analyzed cerebrovascular hemodynamic parameters by sex and age group. RESULTS: No significant differences between hemispheres were observed in mean flow velocities, except in the anterior cerebral arteries with right predominance. Flow velocities were higher in women and in the youngest age group. No significant differences in the pulsatility indices were found between sexes or between age groups. The flow velocities in this series are lower than those reported for other series. CONCLUSIONS: The hemodynamic parameters in this series are lower than in other series and are influenced by the altitude, age, and sex.

¿Por qué emplear el análisis estadístico implicativo en los estudios de causalidad en salud? / Why Use the Implicative Statistical Analysis in Studies of Health Causality?

El análisis estadístico implicativo es una técnica de minería de datos, surgida para resolver problemas de la didáctica de las matemáticas, se basa en la inteligencia artificial y el álgebra booleana, para modelar la casi implicación entre eventos y variables de un conjunto de datos. El objetivo de este ensayo es exponer las evidencias teóricas y prácticas que demuestran su utilidad para el estudio de la causalidad en la salud, para lo cual se realizó una revisión exhaustiva del tema en las bases de datos bibliográficas alojadas en Internet. Se presentan una serie de razones que justifican el uso de esta técnica en estudios de causalidad en medicina, en relación con el número de variables, el tamaño de la muestra, los supuestos requeridos para su aplicación y la naturaleza asimétrica de sus índices. También se identifican algunas ventajas con respecto a las técnicas estadísticas tradicionales, como la detección de eventos raros, que pasan inadvertidos a medidas como el apoyo y la confianza. Finalmente, se mencionan las investigaciones clínico-epidemiológicas donde se ha utilizado este análisis(AU)

Implicative statistical analysis is a technique of data mining, emerged to solve problems of the Didactic of mathematics, it is based on Artificial Intelligence and Boolean Algebra, to model the quasi-implication between events and variables of a data set. The objective of this essay is to expose the theoretical and practical evidences that demonstrate its utility for the study of causality in health, for which an exhaustive review of the subject was carried out in the bibliographic databases hosted on the internet. A series of reasons are presented that justify the use of this technique in causality studies in medicine, regarding the number of variables, the sample size, the assumptions required for its application and the asymmetric nature of its indices. Also some advantages are identified with respect to traditional statistical techniques such as detection of rare events, which would go unnoticed to measures such as support and trust. Finally, clinical-epidemiological investigations where this analysis has been used are mentioned(AU)

Effect of dietary supplementation of sodium acetate and calcium butyrate on milk fat synthesis in lactating dairy cows.

Acetate is a major source of energy and substrate for milk fat synthesis in the dairy cow. We recently reported a linear increase in milk fat yield and greater than a 30% net apparent transfer of acetate to milk fat with ruminal infusion of neutralized acetate. Additionally, ruminal acetate infusion linearly increases plasma ß-hydroxybutyrate. The objective of the current study was to investigate the ability of acetate and butyrate fed in a diet to increase milk fat synthesis. Twelve multiparous lactating Holstein cows were randomly assigned to treatments in a 3 × 3 Latin square design with 14-d periods that included a 7-d washout followed by 7 d of treatment. Cows were fed ad libitum a basal diet with a low risk for biohydrogenation-induced milk fat depression, and treatments were mixed into the basal diet. Treatments were 3.2% NaHCO3 (control), 2.9% sodium acetate, and 2.5% calcium butyrate (carbon equivalent to acetate treatment) as a percent of diet dry matter. Feeding sodium acetate increased dry matter intake by 2.7 kg, had no effect on milk yield, and increased milk fat yield by 90 g/d and concentration by 0.2 percentage units, compared with control. Calcium butyrate decreased dry matter intake by 2.6 kg/d, milk yield by 1.65 kg/d, and milk fat yield by 60 g/d, compared with control. Sodium acetate increased concentration and yield of 16 carbon mixed source fatty acids (FA) and myristic acid, while decreasing the concentration of preformed FA, compared with control. Calcium butyrate had no effect on concentration of milk FA by source, but increased concentration of trans-10 C18:1 in milk by 18%, indicating a shift in rumen biohydrogenation pathways. Our data demonstrate that milk fat yield and concentration can be increased by feeding sodium acetate at 2.9% of diet dry matter, but not by feeding calcium butyrate at an equivalent carbon mass.

Fitobezoar gástrico gigante secundario a estenosis pilórica tratado con Coca-Cola(R): a propósito de un caso / Giant gastric phytobezoar secondary to pyloric stenosis treated with Coca-Cola(R): A case report

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Factores asociados a una evolución desfavorable en la hemorragia subaracnoidea aneurismática. Serie de 334 pacientes / Factors associated with poor outcome for aneurysmal subarachnoid haemorrhage in a series of 334 patients

Objetivo: Evaluar los factores sociodemográficos, clínicos, imagenológicos y relacionados con la atención médica que influyen sobre el pronóstico de los pacientes con hemorragia subaracnoidea aneurismática al alta hospitalaria. Pacientes y método. Se realizó un estudio tipo cohorte, retrospectivo, con 334 pacientes atendidos en el Hospital Hermanos Ameijeiras en La Habana, Cuba, en el periodo comprendido entre octubre de 2005 y junio de 2014. Resultados: En el análisis multivariado se encontró que los factores asociados a una evolución desfavorable fueron la edad mayor a 65 años (OR 3,51, IC 95% 1,79-5,7, p = 0,031), el sexo femenino (OR 2,17, IC 95% 1,22-3,84, p = 0,0067), la HTA sistólica (OR 4,82, IC 95% 2,27-9,8, p = 0,0001), la hiperglucemia al ingreso (OR 3,93, IC 95% 2,10-7,53, p = 0,0003), las complicaciones como la sepsis respiratoria (OR 2,73, IC 95% 1,27-5,85, p = 0,0085), los trastornos hidroelectrolíticos (OR 3,33, IC 95% 1,33-8,28, p = 0,0073), la hidrocefalia (OR 2,21, IC 95% 1,05-4,63, p = 0,0039), el resangrado (OR 16,50, IC 95% 8,24-41,24, p = 0,0000), el vasoespasmo sintomático (OR 19,00, IC 95% 8,86-41,24, p = 0,0000), el infarto cerebral (OR 3,82, IC 95% 1,87-7,80, p = 0,0000), el resangrado múltiple (OR 6,69, IC 95% 1,35-36,39, p = 0,0019), así como los grados III y IV de las escalas de la Federación Mundial de Neurocirujanos (OR 2,09, IC 95% 1,12-3,91, p = 0,0021) y de Fisher (OR 5,18, IC 95% 2,65-10,29, p = 0,0008). Conclusiones: La evolución de la hemorragia subaracnoidea aneurismática está relacionada con la edad, el sexo, el estado clínico al arribo a la unidad de ictus, así como las características imagenológicas según la escala de Fisher, las cifras de tensión arterial y de glucemia, y las complicaciones como los trastornos hidroelectrolíticos, la hidrocefalia, el resangrado, el vasoespasmo y el resangrado múltiple

Objective: This study evaluates care-related sociodemographic, clinical, and imaging factors and influences associated with outcome at discharge in patients with aneurismal subarachnoid haemorrhage. Patients and method: Retrospective cohort study in 334 patients treated at Hospital Hermanos Ameijeiras in Havana, Cuba between October 2005 and June 2014. Results: Logistic regression analysis determined that the following factors were associated with higher risk of poor outcome: age older than 65 years (OR 3.51, 95% CI 1.79-5.7, P = .031), female sex (OR 2.17, 95% CI 1.22-3.84, P = .0067), systolic hypertension (OR 4.82, 95% CI 2.27-9.8, P=.0001), and hyperglycaemia at admission (OR 3.93, 95% CI 2.10-7.53, P = .0003). Certain complications were also associated with poor prognosis, including respiratory infection (OR 2.73, 95% CI 1.27-5.85, P = .0085), electrolyte disturbances (OR 3.33, 95% CI 1.33-8.28, P = .0073), hydrocephalus (OR 2.21, 95% CI 1.05-4.63, P = .0039), rebleeding (OR 16.50, 95% CI 8.24-41.24, P = .0000), symptomatic vasospasm (OR 19.00, 95% CI 8.86-41.24, P = .0000), cerebral ischaemia (OR 3.82, 95% CI 1.87-7.80, P = .000) and multiplex rebleeding (OR 6.69, 95% CI 1.35-36.39, P = .0019). Grades of III and IV on the World Federation of Neurological Surgeons (OR 2.09, 95% CI 1.12-3.91, P = .0021) and Fisher scales (OR 5.18, 95% CI 2.65-10.29, P = .0008) were also related to poor outcome. Conclusions: Outcome of aneurysmal subarachnoid haemorrhage was related to age, sex, clinical status at admission to the stroke unit, imaging findings according to the Fisher scale, blood pressure, glycaemia and such complications as electrolyte disturbances, hydrocephalus, rebleeding, and multiplex rebleeding

Factors associated with poor outcome for aneurysmal subarachnoid haemorrhage in a series of 334 patients. / Factores asociados a una evolución desfavorable en la hemorragia subaracnoidea aneurismática. Serie de 334 pacientes.

OBJECTIVE: This study evaluates care-related sociodemographic, clinical, and imaging factors and influences associated with outcome at discharge in patients with aneurismal subarachnoid haemorrhage. PATIENTS AND METHOD: Retrospective cohort study in 334 patients treated at Hospital Hermanos Ameijeiras in Havana, Cuba between October 2005 and June 2014. RESULTS: Logistic regression analysis determined that the following factors were associated with higher risk of poor outcome: age older than 65 years (OR 3.51, 95% CI 1.79-5.7, P=.031), female sex (OR 2.17, 95% CI 1.22-3.84, P=.0067), systolic hypertension (OR 4.82, 95% CI 2.27-9.8, P=.0001), and hyperglycaemia at admission (OR 3.93, 95% CI 2.10-7.53, P=.0003). Certain complications were also associated with poor prognosis, including respiratory infection (OR 2.73, 95% CI 1.27-5.85, P=.0085), electrolyte disturbances (OR 3.33, 95% CI 1.33-8.28, P=.0073), hydrocephalus (OR 2.21, 95% CI 1.05-4.63, P=.0039), rebleeding (OR 16.50, 95% CI 8.24-41.24, P=.0000), symptomatic vasospasm (OR 19.00, 95% CI 8.86-41.24, P=.0000), cerebral ischaemia (OR 3.82, 95% CI 1.87-7.80, P=.000) and multiplex rebleeding (OR 6.69, 95% CI 1.35-36.39, P=.0019). Grades of iii and iv on the World Federation of Neurological Surgeons (OR 2.09, 95% CI 1.12-3.91, P=.0021) and Fisher scales (OR 5.18, 95% CI 2.65-10.29, P=.0008) were also related to poor outcome. CONCLUSIONS: Outcome of aneurysmal subarachnoid haemorrhage was related to age, sex, clinical status at admission to the stroke unit, imaging findings according to the Fisher scale, blood pressure, glycaemia and such complications as electrolyte disturbances, hydrocephalus, rebleeding, and multiplex rebleeding.

[Symptomatic vasospasm. Clinical manifestations]. / Vasoepasmo sintomático. Caracterización clínica.

INTRODUCTION: Symptomatic vasospasm in the setting of a subarachnoid hemorrhage is a complication of difficult diagnosis in some clinical situations. Objectives. Describe the clinical characteristics of cerebral vasospasm demonstrated by neurovascular studies in patients with ruptured saccular aneurysm. PATIENTS AND METHODS: 19 consecutive patients with symptomatic vasospasm, evaluated with TCD and any variant of neurovascular study with contrast injection. All these cases were in degrees between 1 and 3 of the World Federation of Neurological Surgeons Scale. RESULTS: The cognitive and behavioral manifestations were the most frequent (53%), followed by neurological focal deficits (26%). Clinical vasospasm occurred most frequently between day 9 and 10. Vasospasm is predominant in the arteries of the anterior circulation. The high mortality (42%) and the antecedent of arterial hypertension characterized the group with symptomatic vasospasm. There was no statistical relationship between the result of the scale of Fisher and the symptomatic vasospasm. All the TCD parameters had statistical significance. CONCLUSIONS: The clinical manifestations more frequently associated with symptomatic vasospasm were cognitive and behavioral. This group of patients is characterized by a high mortality. The TCD is a test of great value to predict cerebral ischemia due to vasospasm.

Vasoespasmo sintomático. Caracterización clínica / Symptomatic Vasospasm. Clinical manifestations

Introducción. El vasoespasmo sintomático en la hemorragiasubaracnoidea es una complicación de difícildiagnóstico en algunas situaciones clínicas.Objetivos. Describir las características clínicas de ungrupo de pacientes con HSA aneurismática, que presentaronvasoespasmo sintomático demostrado en losestudios neurovasculares.Pacientes y métodos. Se estudiaron 19 enfermos convasoespasmo sintomático, evaluados con DTC y conalguna variante de estudio neurovascular con inyecciónde contraste. Todos los casos se encontraban en gradosentre I y III de la escala de la Federación Mundial deCirujanos Neurológicos.Resultados. Los síntomas y signos cognitivo conductualesfueron las manifestaciones más frecuentedel vasoespasmo (53%), seguido del déficit neurológicofocal (26%). Las manifestaciones clínicas ocurrieroncomo promedio entre el 9no y 10mo día de evolución. Elvasoespasmo predominó en las arterias de la circulaciónanterior. La mortalidad elevada (42%) y el antecedentede hipertensión arterial caracterizó el grupocon vasoespasmo sintomático. No se encontró relaciónestadística entre el resultado de la escala de Fishery la isquemia cerebral por vasoespasmo. Todos losparámetros del DTC evaluados tuvieron significaciónestadística.Conclusiones. Las manifestaciones clínicas más frecuentesen el vasoespasmo sintomático son de tipocognitivo conductuales. Este grupo de enfermos secaracteriza por una elevada mortalidad. El DTC esuna prueba de gran utilidad en el seguimiento de estospacientes (AU)

Introduction. Symptomatic vasospasm in the settingof a subarachnoid hemorrhage is a complication ofdifficult diagnosis in some clinical situations. Objectives.Describe the clinical characteristics of cerebralvasospasm demonstrated by neurovascular studies inpatients with ruptured saccular aneurysm.Patients and methods. 19 consecutive patients withsymptomatic vasospasm, evaluated with TCD and anyvariant of neurovascular study with contrast injection.All these cases were in degrees between 1 and 3 of theWorld Federation of Neurological Surgeons Scale.Results. The cognitive and behavioral manifestationswere the most frequent (53%), followed by neurologicalfocal deficits (26%). Clinical vasospasm occurred mostfrequently between day 9 and 10. Vasospasm is predominantin the arteries of the anterior circulation. Thehigh mortality (42%) and the antecedent of arterialhypertension characterized the group with symptomaticvasospasm. There was no statistical relationshipbetween the result of the scale of Fisher and the symptomaticvasospasm. All the TCD parameters had statisticalsignificance.Conclusions. The clinical manifestations more frequentlyassociated with symptomatic vasospasm werecognitive and behavioral. This group of patients ischaracterized by a high mortality. The TCD is a test ofgreat value to predict cerebral ischemia due to vasospasm (AU)

[Delays in the arrival of patients with subarachnoid haemorrhage at a tertiary hospital]. / Demora en la llegada de pacientes con hemorragia subaracnoidea a un hospital terciario.

INTRODUCTION: Patients with subarachnoid haemorrhage should be referred to a tertiary hospital as early as possible. The aim of this research was to study how long these patients take to reach a tertiary care centre in Havana. PATIENTS AND METHODS: We conducted a prospective study of patients with subarachnoid haemorrhage who were admitted to the Stroke Unit at the Hospital Hermanos Ameijeiras between January 2005 and December 2007. The time of arrival at the hospital was determined and a comparison was carried out between patients who arrived after 72 hours and those who reached the hospital sooner. RESULTS: The sample studied comprised 94 patients. Only 34 (36%) arrived during the first three days, whereas 13 (13.8%) reached the hospital within the first 24 hours. None of the sociodemographic and clinical variables that were studied was associated with early remission. The length of time spent in hospital by patients admitted during the first 72 hours was 14.9 days, while in the other cases it was 17.57 days (p = 0.248). The greatest impact on early remission to the tertiary centre was on the outcome at discharge on the Rankin scale, which was lower in those who arrived early compared to the rest of the cases (p = 0.05); the same was true of mortality, which was 5.9% in those who arrived within the first 72 hours versus 11.7% in the others (p = 0.04). CONCLUSIONS: Only a third of the cases reached hospital during the first 72 hours and this group had a more favourable course.

[Clinical usefulness of transcranial Doppler ultrasound imaging in the diagnosis of cerebral vasospasm in subarachnoid haemorrhage. A validation study]. / Utilidad clinica del Doppler transcraneal en el diagnostico del vasoespasmo cerebral en la hemorragia subaracnoidea. Estudio de validacion.

INTRODUCTION: During the clinical course of aneurysmal subarachnoid haemorrhage, cerebral vasospasm is one of the most dreaded medical complications. AIM. To determine the usefulness of transcranial Doppler (TCD) ultrasound imaging in diagnosing vasospasm in patients with subarachnoid haemorrhage (SAH) who were attended in a Stroke Unit. PATIENTS AND METHODS: The study included 89 patients with SAH of a non-traumatic origin; these patients had been admitted to a Stroke Unit and were submitted to a contrast-enhanced neurovascular study and daily monitoring with TCD. Values were determined for the sensitivity, specificity, predictive power and overall precision of the TCD ultrasound imaging, together with the differences in mean flow rate and the coefficient of correlation between the gold standard test and the results of monitoring with TCD. RESULTS: Female patients under 50 years of age with favourable initial clinical degrees were predominant. Aneurysmal SAH was prevalent and the frequency of angiographic vasospasm was 40%, in the majority of cases located in the middle cerebral arteries. Most of the patients had mean cerebral blood flow rates of or below 120 cm/s. The peaks of mean blood flow rate were obtained between the fourth and the tenth day. Overall precision, sensitivity and the predictive negative value of TCD were good. Specificity was excellent for flow rates below 130 cm/s, and the predictive positive value was low. CONCLUSIONS: Monitoring with TCD proved to be useful for diagnosing cerebral vasospasm in patients with a good initial clinical status.

Utilidad clínica del Doppler transcraneal en el diagnóstico del vasoespasmo cerebral en la hemorragia subaracnoidea. Estudio de validación / Clinical usefulness of transcranial doppler ultrasound imaging in the diagnosis of cerebral vasospasm in subarachnoid haemorrhage. A validation study

Introducción. Durante el curso clínico de hemorragia subaracnoidea aneurismática, el vasoespasmo cerebral esuna de las complicaciones médicas más temibles. Objetivo. Comprobar la utilidad de la ecografía Doppler transcraneal (DTC) para diagnosticar el vasoespasmo en pacientes con hemorragia subaracnoidea (HSA) atendidos en una Unidad de Ictus.Pacientes y métodos. Estudio de 89 pacientes con HSA no traumática, ingresados en una Unidad de Ictus, a los cuales se realizó un estudio neurovascular contrastado y monitorización diaria con DTC. Se determinaron los valores de sensibilidad, especificidad, predictivos y de precisión global de la ecografía DTC, las diferencias de velocidad de flujo media y el coeficiente de correlación entre la prueba estándar de referencia y los resultados de la monitorización con DTC. Resultados. Predominaron los pacientes menores de 50 años del sexo femenino con grados clínicos iniciales favorables. Prevaleció la HSA aneurismática y la frecuencia de vasoespasmo angiográfico fue del 40%, preferentemente localizado en las arterias cerebrales medias. La mayoría de los pacientes tenían velocidades medias del flujo sanguíneo cerebral iguales o inferiores a 120 cm/s. Los picos de velocidad de flujo media se obtuvieron entre el cuarto y el décimo día. La precisión global, la sensibilidad y el valor predictivo negativo del DTC fueron buenos. La especificidad fue excelente para velocidades de flujo inferiores a 130 cm/s, yel valor predictivo positivo, bajo. Conclusión. Se comprobó la utilidad de la monitorización con DTC para el diagnóstico del vasoespasmo cerebral en pacientes con buen estado clínico inicial

Introduction. During the clinical course of aneurysmal subarachnoid haemorrhage, cerebral vasospasm is one ofthe most dreaded medical complications. Aim. To determine the usefulness of transcranial Doppler (TCD) ultrasound imaging in diagnosing vasospasm in patients with subarachnoid haemorrhage (SAH) who were attended in a Stroke Unit. Patients and methods. The study included 89 patients with SAH of a non-traumatic origin; these patients had been admitted to a Stroke Unit and were submitted to a contrast-enhanced neurovascular study and daily monitoring with TCD. Values were determined forthe sensitivity, specificity, predictive power and overall precision of the TCD ultrasound imaging, together with the differences in mean flow rate and the coefficient of correlation between the gold standard test and the results of monitoring with TCD.Results. Female patients under 50 years of age with favourable initial clinical degrees were predominant. Aneurysmal SAH was prevalent and the frequency of angiographic vasospasm was 40%, in the majority of cases located in the middle cerebral arteries. Most of the patients had mean cerebral blood flow rates of or below 120 cm/s. The peaks of mean blood flow ratewere obtained between the fourth and the tenth day. Overall precision, sensitivity and the predictive negative value of TCD were good. Specificity was excellent for flow rates below 130 cm/s, and the predictive positive value was low. Conclusions. Monitoring with TCD proved to be useful for diagnosing cerebral vasospasm in patients with a good initial clinical status