Terapia vestibular en vestibulopatía bilateral por gentamicina: reporte de un caso y revisión de la literatura / Vestibular therapy in a case of gentamicin-induced vestibulopathy: case report and literature revision

La vestibulopatía bilateral es poco frecuente, se caracteriza principalmente por inestabilidad al caminar o al estar de pie, visión borrosa inducida por el movimiento u oscilopsia al caminar o al realizar movimientos rápidos de la cabeza o del cuerpo, empeoramiento de la estabilidad en la oscuridad o terrenos irregulares, reducción de los síntomas al estar en condiciones estáticas, ganancia del reflejo vestíbulo-ocular angular reducida de forma bilateral, entre otros. Existen múltiples causas. Dentro de las causas identificables, se describen principalmente medicamentos ototóxicos, meningitis y enfermedad de Ménière. Se presenta el caso de una paciente de 64 años diagnosticada con vestibulopatía bilateral posterior a tratamiento intramuscular con gentamicina por sobreinfección bacteriana cutánea de las manos. La evaluación vestibular complementada con videonistagmografía y prueba de impulso cefálico asistida por video confirman el diagnóstico y se inicia tratamiento con rehabilitación vestibular enfocada en promover la compensación central a través de estrategias de sustitución principalmente; además de habituación y adaptación vestibular, favoreciendo la estabilización de la mirada, mantención del equilibrio, control postural, marcha y reducción de los síntomas.

Bilateral vestibulopathy is infrequent, and it is characterized mostly by unstable walking or when standing, blurred vision induced by movement, or oscillopsia when walking or performing fast movements; worsening of the stability in darkness or uneven ground, but with lack of symptoms in static conditions. Other symptoms may include bilateral reduction of the oculo-vestibular reflex. Among the identifiable causes, there is the use of ototoxic medication, meningitis, Ménière's disease, although it can be idiopathic or have a neurological cause. We hereby describe the case of a 64-year-old woman, diagnosed with bilateral vestibulopathy secondary to intramuscular treatment with gentamicin due to a bacterial hand infection. Vestibular assessment was complemented with video-nystagmography and video head impulse test which confirmed the diagnosis, and therapy was started with vestibular rehabilitation focused on promoting central compensation mainly, through substitution strategies. Also, habituation exercise and vestibular adaptation strategies were used, thus promoting sight stabilization, balance maintenance, postural control, walking, and reduction of the symptoms.

Manejo anestésico para la implantación de una prótesis aórtica por vía percutánea. Resultados de 100 casos / Anaesthetic management of percutaneous aortic valve implants: results of 100 cases

Introducción. La implantación de una prótesis aórtica por vía transfemoral representa una alternativa terapéutica en pacientes con estenosis aórtica severa desestimados para cirugía por elevado riesgo quirúrgico. Objetivo. Describir el manejo anestésico para prótesis aórtica por vía transfemoral y los resultados en 100 pacientes con estenosis aórtica severa. Material y métodos. Presentamos una serie de 100 casos consecutivos recogidos de forma prospectiva. El manejo anestésico se realiza con perfusión continua de remifentanilo y propofol, para sedación o anestesia general. Resultados. El 65% de los casos se culmina con sedación y el 35% con anestesia general (el 19% del total de forma electiva y el 16% del total por complicaciones ocurridas durante el procedimiento). Ocurren complicaciones en el 34% de los casos, siendo más frecuentes las de origen vascular y el bloqueo auriculoventricular completo. La mortalidad en las primeras 24h es del 5%. Conclusiones. La prótesis aórtica por vía transfemoral bajo sedación con remifentanilo-propofol puede considerarse una alternativa terapéutica válida para pacientes con estenosis aórtica severa sintomática, con elevado riesgo quirúrgico, desestimados para cirugía convencional (AU)

Introduction. Transfemoral transcatheter aortic-valve implantation represents a therapeutic alternative for patients with severe aortic stenosis who cannot undergo surgery due to high surgical risk. Objective. The aim of this study is to describe the anaesthetic procedure for transfemoral transcatheter aortic-valve implantation and the results on 100 patients with symptomatic severe aortic stenosis. Material and methods. A series of cases are presented with prospective data collected on 100 consecutive patients. The anaesthetic procedure consisted of continuous remifentanil and propofol infusions, for sedation or general anaesthetic. Results. Almost two-thirds (65%) of the cases ended on sedation, and 35% on general anaesthetic (19% out of this total were elective and 16% were due to complications during the procedure). Complications occurred in 34% of the cases, with both vascular and complete atrioventricular block being the most frequent. Mortality within the first 24h was 5%. Conclusions. Implantation of transfemoral aortic prosthesis under remifentanil-propofol sedation can be considered a valid therapeutic alternative for patients with severe symptomatic aortic stenosis, and with a high surgical risk, and therefore not considered for conventional surgery (AU)

The role of environmental land use conflicts in soil fertility: A study on the Uberaba River basin, Brazil.

In the Uberaba River basin (state of Minas Gerais, Brazil), pastures for livestock production have invaded areas of native vegetation (Cerrado biome), while already existing pastures were invaded by crop agriculture, with an expansion of sugar cane plantations in the most recent years. In some areas of the basin, these land use changes were classified as environmental land use conflicts because the new uses were not conforming to land capability, i.e. the soil's natural use. Where the areas in conflict became dense, some soil properties have changed significantly, namely the organic matter content and the exchangeable potassium concentration, which have decreased drastically (5kg/m(3) per 10% increase in the conflict area) threatening the fertility of soil. Besides, these changes may have triggered a cascade of other environmental damages, specifically the increase of soil erosion and the degradation of water quality with negative impacts on aquatic biodiversity, related to a disruption of soil organic matter structural functions. Because half the Uberaba catchment has been considered is a state of accentuated environmental degradation, not only caused by environmental land use conflicts, conservation measures have been proposed and requested for immediate implementation across the watershed.

Anaesthetic management of percutaneous aortic valve implants: Results of 100 cases. / Manejo anestésico para la implantación de una prótesis aórtica por vía percutánea. Resultados de 100 casos.

INTRODUCTION: Transfemoral transcatheter aortic-valve implantation represents a therapeutic alternative for patients with severe aortic stenosis who cannot undergo surgery due to high surgical risk. OBJECTIVE: The aim of this study is to describe the anaesthetic procedure for transfemoral transcatheter aortic-valve implantation and the results on 100 patients with symptomatic severe aortic stenosis. MATERIAL AND METHODS: A series of cases are presented with prospective data collected on 100 consecutive patients. The anaesthetic procedure consisted of continuous remifentanil and propofol infusions, for sedation or general anaesthetic. RESULTS: Almost two-thirds (65%) of the cases ended on sedation, and 35% on general anaesthetic (19% out of this total were elective and 16% were due to complications during the procedure). Complications occurred in 34% of the cases, with both vascular and complete atrioventricular block being the most frequent. Mortality within the first 24h was 5%. CONCLUSIONS: Implantation of transfemoral aortic prosthesis under remifentanil-propofol sedation can be considered a valid therapeutic alternative for patients with severe symptomatic aortic stenosis, and with a high surgical risk, and therefore not considered for conventional surgery.

Effects of uptake and efflux transporter inhibition on erythromycin breath test results.

The erythromycin breath test (EBT) is a standard test used to evaluate the extent of CYP3A4 activity. This study examines whether presumed changes in CYP3A4 activity are in fact related to inhibition of an uptake organic anion transporter using rifampin and inhibition of the efflux hepatic P-glycoprotein transporter using lansoprazole. Three EBT tests in healthy adults were conducted: EBT alone, with lansoprazole, and with rifampin. For all subjects, lansoprazole treatment increased respiratory (14)C excretion by +0.25+/-0.51 met/h (P=0.07) and rifampin decreased (14)C excretion by -0.44+/-0.40 met/h (P<0.001) compared with baseline. Comparing lansoprazole to rifampin, (14)C excretion increased by +0.69+/-0.50 met/h (P<0.001). Only women had significant changes after drug infusion: (14)C excretion after rifampin -0.40+/-0.36 met/h (P=0.018) and +0.47+/-0.44 met/h (P=0.018) after lansoprazole. Relying on EBT without considering transporter interactions can lead to errors in interpreting the degree of CYP3A4 metabolism.

Pulmonary tuberculosis in children in a developing country.

OBJECTIVE: We evaluated the clinical and epidemiologic characteristics of Peruvian children presenting with pulmonary tuberculosis (PTB) to determine whether features predictive of confirmed PTB could be identified. STUDY DESIGN: This was a cross-sectional study of 135 children (mean age: 6.8 years) presenting to the Hospital del Niño in Lima, Peru, with presumptive diagnosis of PTB. Clinical, epidemiologic, and laboratory findings were compared between 3 groups of pediatric patients with a presumptive diagnosis of PTB: those with positive Mycobacterium tuberculosis (MTB) cultures, those likely to have PTB based on clinical criteria but with negative cultures, and those who did not meet clinical diagnostic criteria or have positive cultures. RESULTS: A total of 50 (37%) patients were diagnosed with definitive PTB based on positive sputum culture. Another 55 (47%) patients were classified as having probable PTB based on meeting at least 2 of the following criteria: cough lasting for at least 2 weeks, typical chest radiograph changes, purified protein derivative (PPD) >/=10 mm, or history of tuberculosis family contact. Patients with definitive or probable PTB were significantly older than patients without clinical PTB, and those with symptomatic disease were significantly older than those with asymptomatic disease. Patients with PTB diagnosed by culture were significantly more likely than those diagnosed using clinical criteria to have cough lasting >/=2 weeks, fever, and a PPD >/=10 mm. CONCLUSIONS: The typical presentation of PTB in Peruvian children includes symptoms of active pulmonary disease similar to those seen in adults. This presentation differs significantly from that reported in developed countries, where many children have minimal or no symptoms at the time of presentation. The diagnostic criteria for pediatric PTB must be modified in hyperendemic developing country environments where features may differ from those described in the United States. The triad of cough lasting >/=2 weeks, fever, and a PPD >/=10 mm was highly predictive for culture-positive PTB among children in this low-income Peruvian population.

Development and qualification of a novel virus removal filter for cell culture applications.

Commercial bioreactors employing mammalian cell cultures to express biological or pharmaceutical products can become contaminated with adventitious viruses. The high expense of such a contamination can be reduced by passing all gases and fluids feeding the bioreactor through virus inactivation or removal steps, which act as viral barriers around the bioreactor. A novel virus barrier filter has been developed for removing viruses from serum-free cell culture media. This filter removes the 20 nm minute virus of mice by >3 log reduction value (LRV), the 28 nm bacteriophage PhiX174 by >4.5 LRV, the mycoplasma Acholeplasma laidlawii by > or =8.8 LRV, and the bacteria Brevundimonas diminuta by > or =9.2 LRV. Robust removal occurs primarily by size exclusion as demonstrated over a wide range of feedstocks and operating conditions. The filtered media are indistinguishable from unfiltered media in growth of cells to high densities, maintenance of cell viability, and productivity in expressing protein product. Insulin and transferrin show high passage through the filter. The virus barrier filter can be autoclaved. The relatively high membrane permeability enables the use of a moderate filtration area.

[The association of hematocrit with blood pressure and left ventricular mass in subjects over 55]. / Asociación del hematocrito con la presión arterial y la masa ventricular izquierda en sujetos mayores de 55 años.

OBJECTIVE: To establish the association between hematocrit, blood pressure (BP), and left ventricular mass (LVM) in persons older than 55 years. PATIENTS AND METHODS: One hundred patients older than 55 years (46 males and 54 females) with a wide range in BP were studied on an ambulatory basis. The following parameters were determined: hematocrit, casual BP (CBP), 24-h ambulatory blood pressure monitoring (ABPM), left ventricular mass index (LVMI) determined by echocardiography (according to the Devereux's formula), cardiac output (CO) (determined by cardiac echocardiography), peripheral vascular resistances (PVR) (determined according to mean blood pressure and cardiac output), and levels of creatinine in plasma and sodium in 24-hour urine. RESULTS: Mean age of patients was 65 years (range 55 to 83 years). Twenty-two percent of patients were smokers (17 males and 5 females) with a mean of 13 +/- 6 cigarettes/day. Mean hematocrit value was 41.4 +/- 3.6% (43.3 +/- 3.5 for males and 39.7 +/- 2.7% for females) (p < 0.001). Thirty-five percent of males and 26% of females had mild-moderate hypertension with an hematocrit of 42.3 +/- 3.5% versus 40.8 +/- 3.6% (p < 0.05). The LVMI was 132 +/- 37 g/m2 (139 +/- 38 g/m2 for males and 127 +/- 36 g/m2 for females). A significant linear association was observed between hematocrit value and diastolic BP: casual (r = 0.25; p < 0.05, 24 h mean (r = 0.34; p < 0.001), mean from 7 to 23 hours (r = 0.32; p < 0.001), mean from 23 to 7 hours (r = 0.37; p < 0.001). For females, these relationships were: r = 0.41, 0.36; 0.34 and 0.41, respectively (p < 0.01). No significant association was observed between these parameters among males. Among hypertensive patients this association was observed 24-h mean diastolic BP and mean from 23 and 7 hours (r = 0.39; p < 0.05). Among normotensive patients the values for this association were: r = 0.25; p < 0.05 and r = 0.26; p < 0.05, respectively. No significant association was observed between hematocrit value and LVMI for the total group and for the established subgroups. CONCLUSIONS: Among patients older than 55 years a weak significant association was found between hematocrit value and diastolic BP (both casual and in that obtained with ambulatory monitoring), but not with the left ventricular mass. The mean hematocrit value was significantly higher for hypertensive than for normotensive patients.

Preliminary studies on the response of Plasmodium falciparum to chloroquine in the Philippines, with the in vitro technique.

Previous investigations had shown that resistance to standard regimens of chloroquine occurred in some cases of falciparum infection in the Philippines. More extensive investigations into this phenomenon were planned by the Malaria Eradication Service, by means of the in vitro technique developed by Rieckmann, in order to determine both the distribution of resistant strains throughout the country and their local incidence. Before these studies were undertaken, a series of observations were made on cases of falciparum malaria encountered in Manila and its environs, to assess the reaction of local strains of the parasite to the in vitro test. These cases were also treated with standard doses of chloroquine and some were followed up for 4 weeks to compare the predictions made as a result of the in vitro tests with the in vivo observations. Of the 34 in vitro tests carried out, 18 were followed up in vivo. In 8 cases, no recrudescence occurred, but in the other 10 recrudescences were detected during the 4-week observation period, thus indicating parasite resistance to the drug. In each of the 18 cases, the in vivo response followed the in vitro prediction.