Incorporating abbreviated EEGs in the initial workup of patients who present to the emergency room with mental status changes of unknown etiology.

Patients frequently present to the emergency room (ER) with mental status changes without obvious cause. The EEG is underused in this population. The authors investigated whether an abbreviated EEG (AbEEG) can be incorporated in the early evaluation of these patients to provide useful information. A 5-minute AbEEG was performed using a preformed electrode placement system on 25 patients who presented to the ER with mental status changes of unknown cause. AbEEG findings were categorized as normal, showing diffuse abnormalities, focal abnormalities, electrographic seizures, or uninterpretable. Using retrospective chart review, the authors determined if the cause of mental status change was a diffuse encephalopathy or a nonneurologic event (DENNE), a focal brain abnormality, nonconvulsive status epilepticus (NCSE), psychogenic, or unknown, and if particular AbEEG findings were associated with specific causes of altered sensorium. The AbEEG identified NCSE in two patients who presented with new-onset seizures. The presence of diffuse slowing on the AbEEG was highly suggestive of mental status changes due to DENNE. AbEEGs can be successfully incorporated in the early evaluation of patients who present to the ER with mental status changes of unknown cause and provide useful information in this setting.     

Primary cerebral neuroblastoma (neurocytoma) in adults

Summary We report a case of a third ventricular neuroblastoma (neurocytoma) in a 66 year old man. A stereotactic needly biopsy was performed to obtain a tissue diagnosis and was followed by total resection. We elected not to give radiation or chemotherapy and to follow the patient closely with serial CT scans. Presently, 48 months postoperatively, the patient is free of tumor by head CT scan and able to live independently. We reviewed the literature of primary cerebral neuroblastomas/neurocytomas occurring in adults (15 years of age) and found 32 cases. Our patient is the oldest of this group with a mean age of 32 ± 14 years (S.D.). The location of the 33 neoplasms was intraventricular in 17 cases (52%) and intraparenchymal in 16 cases. The male to female ratio was 2: 1. Of the 17 patients having a minimal follow-up period of 5 months (mean 51 months), five developed recurrences after 5 to 144 months (mean 50 months) compared to 12 patients without recurrence after a 6- to 72-month follow-up period (mean 52 months). Recurrences occurred statistically significantly more often in parenchymal neuroblastomas/neurocytomas than in intraventricular tumor locations.     

<Emphasis Type="Italic">Taenia crassiceps</Emphasis> cysticercosis: immune response in susceptible and resistant BALB/c mouse substrains

Taenia crassiceps can naturally and experimentally infect rodents in which they reproduce by budding. Differences in the susceptibility to T. crassiceps cysticercosis were found between two BALB/c substrains: BALB/cAnN (susceptible) and BALB/cJ (resistant). In chimeric mice, resistance was transferred to susceptible mice with bone marrow cells from the resistant mice, which argues in favor of an immune mediation of the resistant phenotype. To further explore the immune response that could underlie these differences in susceptibility, the specific cellular immune response elicited by the parasite was explored in both substrains. An increased proliferative response and IL-2 levels were induced by cysticercal antigens only in splenocytes from resistant mice. A decrease in the percentage of CD4(+) (11.1%), CD8(+) (17.5%) was found in splenocytes from susceptible BALB/cAnN mice. A study of the TCRV beta repertoire revealed a significant decrease in V beta 2 in both CD4(+) and CD8(+) splenocytes only in the susceptible BALB/cAnN strain.     

Mixed malignant mesenchymoma metastatic to the central nervous system

A unique case of central nervous system metastases of mixed malignant mesenchymoma in an 84-year-old man is described. The tumor exhibited an osteogenic appearance in the cerebral lesion and a primitive mesenchymal appearance in lesions of the brain stem and cerebellum. The primary site was apparently the chest wall, and there were also metastases to the lung and liver.     

Impact of Cold Ischemia Time on the Function of Liver Grafts Preserved With Custodiol

ObjectiveThis study aimed to evaluate how cold ischemia time (CIT) interferes with liver graft function in the first 7 days after surgery for Custodiol (HTK) preserved organs.MethodsThis retrospective observational study analyzed the medical records of 38 transplantation patients at Hospital Leforte Liberdade, São Paulo, in 2018. The study population was divided into 2 groups (group A, CIT < 8 hours; group B, CIT > 8 hours). Postoperative parameters—such as international normalized ratio, total bilirubin, aspartate aminotransferase/alanine aminotransferase, alkaline phosphatase, gamma glutamyl transferase (GGT), lactate dehydrogenase, lactate, creatinine, red blood cell transfusion, need for hemodialysis, use of vasoactive drugs, endotracheal intubation time, length of stay in the intensive care unit (ICU), and length of hospital stay—were compared.ResultsGroup A (CIT < 8 hours) presented less need for red blood cell transfusions (odds ratio 0.29; confidence interval 0.06-0.98; P = .04), had a shorter hospital stay (P = .024), and had lower levels of total bilirubin (P = .05) and GGT (P = .05) in the first 7 postoperative days. The other variables showed no statistically significant difference.ConclusionIn livers preserved with Custodiol, CIT > 8 hours generated higher levels of total bilirubin and GGT in the postoperative period, in addition to higher hospital costs; greater need for red blood cell transfusions; and longer hospitalization, including longer stays in the ICU.     

Evaluation of Schistosomiasis Mansoni Morbidity by Hepatic and Splenic Elastography

In patients with Mansoni schistosomiasis, it is fundamental to evaluate the disease morbidity, which is reflected by the severity of periportal fibrosis (PPF) and parameters of portal hypertension, as analyzed by ultrasonography (US). This study aimed to evaluate the morbidity of schistosomiasis by hepatic and splenic point shear-wave elastography (pSWE) and relate this to US parameters. The PPF pattern, the diameter of the portal and splenic veins and the size of the spleen were evaluated by US. Then, liver and spleen pSWEs were assessed in 74 patients using the same equipment. As the PPF pattern progressed, the splenic pSWE values significantly increased. Significant correlations between splenic pSWE, the longitudinal and transverse lengths of the spleen and the diameters of the portal and splenic veins were observed. These findings, however, were not observed through hepatic pSWE. In conclusion, the splenic pSWE has the potential for assessing morbidity in schistosomiasis mansoni.     

Reference intervals of aortic pulse wave velocity assessed with an oscillometric device in healthy children and adolescents from Argentina

Age-related reference intervals (RIs) of aortic pulse wave velocity (Ao-PWV) obtained from a large healthy population are lacking in South America. The aims of this study were to determine Ao-PWV RIs in a cohort of healthy children and adolescents from Argentina and to generate year-to-year percentile curves.

Ao-PWV was measured in 1000 healthy subjects non-exposed to traditional cardiovascular risk factors (Age: 10–22 y. o., 56% males). First, we evaluated if RIs for males and females were necessaries (correlation and covariate analysis). Second, mean (M) and standard deviation (SD) age-related equations were obtained for cf-PWV, using parametric regression methods based on fractional polynomials. Third, age-specific (year to year) percentiles curves (for all, males and females children and adolescents) were generated using the standard normal distribution. They were, age-specific 1st, 2.5th, 5th, 10th, 25th, 50th, 75th, 90th, 95th, 97.5th and 99th percentile curves and values.

After covariate analysis (i.e., adjusting by age, jugulum-symphysis distance, body weight and height), specific RIs for males and females of children and adolescents were evidenced as necessaries. The equations were

For all subjects:

Ao-PWV_Mean = 4.98 + 12.86x10^?5 Age³.

Ao-PWV_SD = 0.47 + 21.00x10^?6Age³.

For girls:

Ao-PWV_Mean = 5.07 + 10.23x10^?5Age³.

Ao-PWV_SD = 0.50 + 10.00x10^?6Age³.

For boys:

Ao-PWV_Mean = 4.87 + 15.81x10^?5Age³.

Ao-PWV_SD = 0.46 + 22.34x10^?6Age³.

Our study provides the largest database to-date concerning Ao-PWV in healthy children and adolescents in Argentina. Age-related equations (M and SD values) for Ao-PWV are reported by the first time. Specific RIs and percentiles of Ao-PWV are now available according to age and sex for an Argentinian population.     

Comparison of an intravenous pulse of methylprednisolone versus oral corticosteroid in severe acute rheumatic carditis: a randomized clinical trial

OBJECTIVES: To compare the short-term prognosis of patients with severe acute rheumatic carditis when treated with an intravenous pulse of methylprednisolone in comparison with conventional treatment using oral prednisone. METHODS: We designed a randomized clinical trial in the setting of a university general hospital in Brazil. We randomly allocated 18 patients with the diagnosis of severe acute rheumatic carditis and congestive heart failure to receive an intravenous pulse as opposed to oral prednisolone. Methylprednisolone was administered in a dose of 1 g intravenously for 3 consecutive days in the first and second weeks, for two days in the third, and one day in the fourth week. Prednisone was administered in a dose of 1.5 mg/kg/day over the period of 4 weeks. RESULTS: The mean age of the patients was 11.1 +/- 3.7 years, with a median of 12 years. Patients on oral treatment showed a more pronounced decrease in the heart rate, sedimentation rate, and in the titres of C-reactive protein than those receiving intravenous therapy. At the end of treatment, a mild decrease in the left ventricular end-systolic dimension was found in those having oral treatment, compared to an increase in the group having intravenous treatment (p = 0.036). The ejection fraction showed a median increase of 5% in those undergoing oral treatment, and a median decrease of 6% in the group with intravenous therapy (p = 0.009). There were 5 therapeutic failures in those receiving intravenous therapy (56%), including 1 death. Therapeutic failures were not observed in those treated orally (p = 0.03). CONCLUSION: Intravenous treatment of methylprednisolone, as a single anti-inflammatory agent, was inferior to conventional treatment with oral prednisone in the control of severe rheumatic carditis.     

Evaluation of risk factors in superobese patients submitted to conventional Fobi-Capella surgery

BACKGROUND: Obesity is one of the worlds greatest health problems. The Roux-en-Y gastric bypass is the gold standard treatment for severe obesity. Surgery in obese patients has an acceptable level of morbidity and mortality. The superobese patient, a subcategory of severe obese patients with a high surgical risk has not yet been analyzed as a group. METHODS: A retrospective and prospective cohort study was conducted enrolling 135 patients submitted to Roux-en-Y gastric bypass for treatment of severe obesity at the " Hospital das Clínicas" , Federal University of Pernambuco, Recife, PE, Brazil, between November 1997 and September 2003. The independent variables were possible risk factors of adverse outcomes: age, gender, weight, body mass index, diabetes, hypertension, hypercholesterolemia, sleep apnea, cardiopathy/coronariopathy, pneumopathy or any other co-morbidity. The dependent variables were major complications, minor complications and death. RESULTS: Diabetes (RR = 1.6 and CI = 1.02-2.40) and sleep apnea (RR = 1.8 and CI = 1.18-2.64) were associated to minor complications. Cardiopathy/coronariopathy were associated with major complications (RR = 5.42 and CI = 1.22-2.40) and death (RR = 16.25 and CI = 3.00-87.95). BMI >or=55 kg/m2 was associated with minor complications (RR = 1.58 and CI = 1.04-2.40), major complications (RR = 3.17 and CI = 1.03-9.80) and death (P = 0.007). After logistic regression, the body mass index >55 kg/m2 remained as a strong risk factor of death (OR = 3.6 and CI = 1.05-12.32). CONCLUSIONS: The body mass index >or=55 kg/m2 was the main risk factor for severe complications and death. Other risk factors affecting the outcome were diabetes, obstructive sleep apnea and cardiopathy/coronariopathy.