Experiencia en el tratamiento agudo con trombólisis de la enfermedad vascular cerebral en un hospital de Costa Rica / Experiences with the use of thrombolysis in the acute treatment of cerebrovascular disease in a hospital in Costa Rica

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Cefalea en racimos / Cluster headache

La cefalea en racimos (CR) o "neuralgia de Horton", es un tipo relativamente raro de cefalea que se presenta en forma de ataques y cuya severidad le ha dado el nombre de "dolor de cabeza suicida". Debido a que la CR es una patología bastante desconocida, el paciente puede tardar en ser diagnosticado, especialmente debido a que es raro que un médico lo atienda en el momento mismo del ataque. La CR suele ser confundida con sinusitis, migraña o patología dental. De ahí que los pacientes no reciban el tratamiento adecuado, o lo reciban demasiado tarde. Sin embargo, la CR es fácil de diagnosticar por lo típico del cuadro clínico, y en la mayoría de los casos, también es fácil de tratar. Por ello es importante que esta enfermedad sea reconocida lo antes posible. Los médicos de cabecera pueden jugar un importante papel en el proceso de diagnóstico. Descriptores: Cefalea en racimos, neuralgia de Horton, triptan.

Comparison between the antioxidant status of terrestrial and diving mammals.

Many diving mammals are known for their ability to deal with nitrogen supersaturation and to tolerate apnea for extended periods. They are all characterized by high oxygen-carrying capacity in blood together with high oxygen storage in their muscle mass due to large myoglobin concentrations. The above properties theoretically also imply a high tissue antioxidant defenses (AD) to counteract reactive oxygen species (ROS) generation associated with the rapid transition from apnea to reoxygenation. Different enzymatic (superoxide dismutase, catalase, glutathione reductase, glutathione peroxidase, and glutathione S-transferase), and non-enzymatic (levels of glutathione) AD as well as cellular damage (thiobarbituric acid-reactive substances contents, as a measure of lipoperoxidation) were measured in blood samples obtained from anesthetized animals, and also in blood obtained from recently dead diving mammals, and compared to some terrestrial mammals (n=5 in both groups). The results confirmed that diving mammals have, in general, higher antioxidant status compared to non-diving mammals. Apparently, to avoid exposure of tissues to changing high oxygen levels, and therefore to avoid an oxidative stress condition related to antioxidant consumption and increased ROS generation, diving mammals possess constitutive high levels of antioxidants in tissues. These data are in agreement with short-term AD adaptations related to torpor and to animals that experience large daily changes in oxygen consumption. These data are similar to the long-term adaptations of animals that undergo hibernation, estivation, freezing-thawing and dehydration-rehydration processes. In summary, animals that routinely face high changes in oxygen availability and/or consumption seem to show a general strategy to prevent oxidative damage by having either appropriate high constitutive AD and/or the ability to undergo arrested states, where depressed metabolic rates minimize the oxidative challenge.

[Profile of epilepsy in a neurology clinic in Costa Rica]. / Perfil de la epilepsia en un servicio de neurología en Costa Rica.

INTRODUCTION: Epilepsy is a worldwide medical problem it affects nearly 1% of the population. In Costa Rica it s no different. Although it is an important problem we don t have any statistical information concerning only epilepsy. PATIENTS AND METHODS: We took on the task of studying the cases of epilepsy in a Neurology clinic in a third level hospital, from January to August 2000. The clinical records of 127 patients with epilepsy were studied. We excluded patients with febrile seizures and those with only one isolated seizure not related to any neurological injury. RESULTS: There was a slight predominance of men (55.11%) over women (44,8%). A great majority of the patients did not have family history of epilepsy, and the average age of on set was 20.062 years. Idiopathic epilepsy was predominant with a 48,3%, 26,77% were cryptogenic and 25,19% symptomatic. Of this, the most frequent etiology was sclerosis and atrophy of the temporal lobe, followed by cerebrovascular disease. As to image studies 96,06% had CT, MRI or both; and 94,48% had an EEG. Of all the patients a great majority are receiving treatment with one antiepileptic drug (81,88%). Valproic acid and carbamazepine are the most commonly used. 51,98% of patients have not had a seizure in at least 8 months. CONCLUSIONS: It is clear, that our health system provides most of the basic needs required to control most of the epileptic patients. However there are important challenges in the present and pear future, such as developing video encephalography units for brain mapping and supporting new epilepsy surgery programs. It is our mission also to induce public health authorities to realize the impact of Epilepsy in social affairs and economics.

Perfil de la epilepsia en un servicio de neurología en Costa Rica / Profile of epilepsy in a neurology clinic in Costa Rica

Introducción. Nuestro país cuenta con uno de los sistemas de salud más desarrollados y de mayor cobertura en el continente americano. La epilepsia no se ha considerado todavía un problema prioritario en la salud pública, por lo que no contamos con estadísticas sobre su incidencia, prevalencia e impacto económico y social. Pacientes y métodos. Revisamos lo acontecido en la consulta de neurología de nuestro hospital entre los meses de enero y agosto del año 2000. Estudiamos los casos de 127 pacientes con epilepsia y excluimos los casos con convulsiones febriles o con convulsión única asociada a ausencia de trastorno neurológico subyacente. Resultados. Las características de esta población son de un ligero predominio de pacientes masculinos (55,11 por ciento) sobre los femeninos (44,8 por ciento). La mayoría de los pacientes no tenían antecedentes familiares de epilepsia, y la edad promedio de inicio fue de 20,062 años. La epilepsia idiopática predominó en un 48,3 por ciento: un 26,77 por ciento criptogénicas y un 25,19 por ciento sintomáticas. De éstas, la causa más frecuente fue la esclerosis y la atrofia del polo anterior del lóbulo temporal, seguida por la enfermedad cerebrovascular. En cuanto a los estudios imaginológicos, el 96,06 por ciento contaban con TAC, RM, o con ambas, y un 94,48 por ciento tenían EEG. Una gran mayoría de pacientes reciben tratamiento con un solo anticonvulsionante (81,88 por ciento), valproato y carbamacepina son los medicamentos más utilizados. El 51,96 por ciento de los pacientes no han sufrido crisis en un período mínimo de seis meses. Conclusiones. Nuestra evaluación determina que el país cuenta con los medios diagnósticos y terapéuticos necesarios para un correcto manejo de los pacientes epilépticos. Hay grandes retos por delante, como el de brindar un mayor impulso a las unidades de planificación y programas de cirugía. También se debe trabajar en el ámbito de las autoridades de salud, ya que la epilepsia no se enfoca aún como un problema prioritario de salud pública (AU)

Enteral nutrition prolongs delayed gastric emptying in patients after Whipple resection.

BACKGROUND: Delayed gastric emptying is one of the most frequent postoperative complications after Whipple resection. In the present study we evaluated the role of enteral nutrition in the development of delayed gastric emptying after Whipple resection. PATIENTS AND METHODS: Between January 1996 and June 1998, 64 patients (30 female, 34 male) underwent a classic (n = 27) or pylorus-preserving (n = 37) Whipple resection. Two patients were excluded; 30 patients received enteral and 32 patients received no-enteral nutrition. RESULTS: Delayed gastric emptying occurred significantly more in patients with enteral (17 of 30, 57%) than in patients with no-enteral nutrition (5 of 32, 16%) (P <0.01). Consequently, patients in the enteral nutrition group had a nasogastric tube for a significantly (P<0.01) longer period and had a significantly (P<0.01) longer hospital stay than patients in the no-enteral nutrition group. There were no differences in the frequency of occurrence of other postoperative complications between patients with enteral and no-enteral nutrition. CONCLUSION: In patients undergoing a Whipple resection, enteral nutrition is associated with a higher frequency of delayed gastric emptying with no advantages regarding other postoperative complications and should therefore be restricted to specific indications.

[Idiopathic dilatation of the large intestine (Ogilvie syndrome--acute pseudo-obstruction)]. / Idiopathische Dickdarmdilatation ("Ogilvie-Syndrom"--"Akute Pseudoobstruktion").

Acute colonic pseudo-obstruction (Ogilvie's syndrome) is characterized by abdominal distention and massive colonic dilatation without any mechanical cause of obstruction. We have reviewed the records of 57 patients, 36 men and 21 women (median age 65.4 y), from 1/1992 to 12/1996, with a colonic pseudo-obstruction, defined as dilatation of at least 10 cm on plain abdominal x-ray. 38 cases (66.5%) followed surgery or trauma and 19 (33.5%) developed symptoms during severe medical illness. 36 cases (63.2%) got i.v. narcotics prior to development of Ogilvie's syndrome. 4 patients underwent conservative treatment alone, 53 patients (93%) had endoscopic decompression with a decompression tube placed in 49 (86%). Due to 2 failures and 2 complications of endoscopic treatment (one ischemic lesion, one perforation; complication rate 3.8%) 4/53 patients had to be operated (7.5%). Clinical success of endoscopic treatment was 88.6% at first attempt and 92.5% at second attempt. General complications tended to be severe, according to the concomitant diseases (morbidity 35%); overall hospital mortality was 21% (12/57). In conclusion, we believe that endoscopic decompression and tube placement is effective and safe for acute colonic pseudo-obstruction not responding to 24 hour conservative treatment.

Epiteliopatia pigmentar placóide multifocal posterior aguda: relato de dois casos / Acute postorior multifocal pigment epitheliopathy: report of two cases

Os autores apresentam dois casos de epiteliopatia pigmentar placóide multifocal posterior aguda, doença idiopática e inflamatória, geralmente de evoluçäo benigna, caracterizada por múltiplas lesöes arredondadas, amarelo-esbranquiçadas ao nível do epitélio pigmentarretiniano. Sua patogênese é pouco entendida e a controvérsia persiste se ela representa primariamente uma disfunçäo do epitélio pigmentar retiniano ou uma doença vascular coroideana. Os autores discutem os achados oftalmológicos assim como apresentam uma revisäo bibliográfica dessa condiçäo.

Prophylactic Nd:YAG-laser iridotomy versus surgical iridectomy: a randomized, prospective study.

Both surgical iridectomy and YAG-laser iridotomy have been shown to prevent angle-closure glaucoma. However, it remains unknown as to which procedure is superior. We therefore conducted a prospective randomized study, which compared the effect of the two methods on visual acuity, intraocular pressure, endothelial cell density, depth of the anterior chamber, and iris configuration as well as acceptance by the patients. A total of 30 patients, who were treated for acute angle-closure glaucoma in one eye, were subjected to either surgical iridectomy or Nd:YAG-laser iridotomy in the other eye according to a randomized protocol. All patients were followed for 12 months by examination at the 1st, 6th, and 12th month post treatment. No significant difference between the two treatments was found regarding visual acuity or intraocular pressure. The peripheral anterior chamber increased in depth following both methods, whereas the central depth of the anterior chamber was unaffected. A better gonioscopic visibility of the trabecular meshwork resulted from the increased width of the chamber angle. Whereas the number of endothelial cells remained constant in the patients treated with laser iridotomy, a small decrease was observed in the group of patients who underwent iridectomy (-7.2% after 12 months; difference not significant). The subjective acceptance by the patients was better in the group treated with laser iridotomy. We conclude that the two methods are equivalent with regard to intraocular pressure and visual acuity. The constant number of endothelial cells and the better acceptance by the patients suggest Nd:YAG-laser iridotomy to be the preferable method for prophylaxis of acute angle-closure glaucoma.