Nestor Wainsztein

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive L...

Fungal endocarditis, in particular due to Candida species, requires medical and surgical treatment and amphotericin B is the drug of choice. Caspofungin is an echinocandin very effective against Candida and Aspergillus. We present a patient with Candida tropicalis endocarditis, fluconazol resistant, treated with caspofungin, on a compassional basis as a result of adverse effects with amphotericin B. The patient had a microbiological response.

Background Urine output is widely used as one of the criteria for the diagnosis and staging of acute renal failure, but few studies have specifically assessed the role of oliguria as a marker of acute renal failure or outcomes in general intensive care unit (ICU) patients. Using a large multinational database, we therefore evaluated the occurrence of oliguria (defined as a urine output  16 years) patients in the ICON audit who had a urine output measurement on the day of admission were included. To investigate the association between oliguria and mortality, we used a multilevel analysis. Results Of the 8292 patients included, 2050 (24.7%) were oliguric during the first 24 h of admission. Patients with oliguria on admission who had at least one additional 24-h urine output recorded during their ICU stay (n = 1349) were divided into three groups: transient—oliguria resolved within 48 h after the admission day (n = 390 [28.9%]), prolonged—oliguria resolved > 48 h after the admission...

Symptomatic pleural collection of cerebrospinal fluid is a rare but accepted complication in hydrocephalic paediatric patients treated with ventriculopleural shunts. Few cases have been described in adults, usually as complication of trauma, tumours or spinal surgery, particularly post-laminectomy. It should be considered in the differential diagnosis of pleural effusion after neurosurgical procedures involving the spine. We describe two patients with large cerebrospinal fluid collections in the pleural cavity caused by postoperative duropleural fistula, who presented with neurological symptoms, cerebrospinal fluid pressure headache and meningitis.

Fungal endocarditis, in particular due to Candida species, requires medical and surgical treatment and amphotericin B is the drug of choice. Caspofungin is an echinocandin very effective against Candida and Aspergillus. We present a patient with Candida tropicalis endocarditis, fluconazol resistant, treated with caspofungin, on a compassional basis as a result of adverse effects with amphotericin B. The patient had a microbiological response.

For many years, the evolution of Argentina's healthcare system has been influenced by political and economic instability. Inflation and hyperinflation have led to anarchic development of both health administration systems and hospitals. Critical care grew in a similar manner, resulting in a mix of > 500 critical care units with very different levels of technology and trained personnel. Cost-containment policies have been implemented mainly by health administration systems. Public institutions (university and large provincial and county hospitals) have suffered hard budget cuts that have resulted in a decrease in the quality of care and the loss of trained human resources. Union organizations, which cover the healthcare costs of > 60% of the population, implemented a low reimbursement policy that resulted in low standards of care for critically ill patients. The country's private hospital system is extremely heterogenous, ranging from little, simple institutions with a ...

Overall mortality due to stroke has decreased in the last three decades probable due to a better control of vascular risk factors. In-hospital mortality of stroke patients has been estimated to be between 6 and 14% in most of the series reported. However, data from recent clinical trials suggest that these figures may be substantially lower. Data from FLENI Stroke Data Bank and institutional mortality records between 2000 and 2010 were reviewed. Ischemic stroke subtypes were classified according to TOAST criteria and hemorrhagic stroke subtypes were classified as intraparenchymal hematoma, aneurismatic subarachnoid hemorrhage, arterio-venous malformation, and other intraparenchymal hematomas. A total of 1514 patients were studied. Of these, 1079 (71%) were ischemic strokes,39% large vessels, 27% cardioembolic, 9% lacunar, 14% unknown etiology, and 11% others etiologies. There were 435 (29%) hemorrhagic strokes, 27% intraparenchymal hematomas, 30% aneurismatic subarachnoid hemorrhage...

Julieta Arena, Patricio Brand, Hernan Chaves, Angel Cammarota y Néstor Wainsztein c a Servicio de Neurología, Instituto de Investigaciones Neurológicas Raúl Carrea, FLENI, Buenos Aires, Argentina b Servicio de Diagnóstico por Imágenes, Instituto de Investigaciones Neurológicas Raúl Carrea, FLENI, Buenos Aires, Argentina c Servicio de Medicina Interna, Instituto de Investigaciones Neurológicas Raúl Carrea, FLENI, Buenos Aires, Argentina

Hyperglycemia following an ischemic stroke has been associated with poor clinical outcome. We retrospectively assessed the effect of moderately controlled plasma glucose (correction from 135mg/dl) compared to conservative treatment (correction from 200 mg/dl), as regards neurological evolution, duration of hospitalization, at discharge and at 30 days post-discharge, also complications associated with the treatment in patients admitted to the intensive care unit. We studied 208 patients, 103 (24% diabetics) with moderate therapy and 105 (23% diabetics) with conservative treatment. The average blood glucose during hospitalization tended to be lower with the moderate treatment with no statistic significance (129 ± 30 vs. 138 ± 31 mg/dl; p = 0.06). The difference was significant in non-diabetics (119 ± 24 vs. 128 ± 24 mg/dl; p < 0.05), being even more pronounced in those non-diabetics with moderate to severe neurological deficit on admission (116 ± 23 vs. 130 ± 23 mg/dl; p < 0.01)...

The so-called stunned myocardium, defined as transitory myocardial contractile dysfunction, has been clearly demonstrated in diverse clinical situations. However, stunned myocardium related to ischemic stroke has been poorly identified. We describe two patients with diagnosis of acute ischemic stroke who developed eletrocardiographic changes, cardiac enzyme increasing levels and myocardial dysfunction secondary to abnormal cardiac wall motion. At the same time the patients developed acute lung injury with rapid resolution, perhaps as a consequence of neurocardiogenic components.

I read with interest the article by Capparelli et al.1 reporting the case of an elderly patient with normal renal function presenting with recurrent episodes of cephalosporin-induced encephalopathy. EEG showed a diffuse slowing without evidence of ongoing epileptiform activity. These authors hypothesized that this neurologic adverse effect could be secondary to the modification that these drugs may produce on the cerebral concentrations of gamma-aminobutyric acid (GABA). The existence of acute confusional states associated with the use of cephalosporins in subjects with variable degrees of renal failure …

Abnormalities observed in the electrocardiogram (ECG) after acute central nervous system (CNS) events have been reported. Our objective was to assess the incidence of heart rate-corrected QT interval (QTc) prolongation in patients admitted to the intensive care unit (ICU) after brain surgery. Admission standard 12-lead ECGs were analyzed blinded to patient data. The QT interval was measured and Bazzett's formula was used to obtain QTc. Prolonged QTc was defined as ≧450 ms. We included 114 patients in the study. The mean age was 49±17 years. Brain neoplasm was the surgical indication in 90% of the patients. The mean QTc was 470±42 ms. Prolonged QTc was found in 71% patients. The heart rate-corrected QT interval was between 450 ms and 500 ms in 52% and >500 ms in 19% of the patients. The heart rate and concentration of serum glucose were higher in the prolonged QTc group. Only 7·5% of all patients had hypokalemia (≤3 mEq/l). In the prolonged QTc group 9·2% had hypokalemia compared to 3·2% in normal QTc patients (P = 0·406). There were no significant associations between categories of QTc and the serum levels of creatinine, magnesium, calcium, sodium, or pH. Phenytoin and metoclopramide were not frequently used in patients with prolonged QTc. This study supports our hypothesis that prolonged QTc is frequently observed after a brain surgery. Hypokalemia, hypocalcaemia, and drugs such as metoclopramide or phenytoin could not explain the high incidence of prolonged QTc. Brain injury during a surgical procedure may be one of the primary causes of QTc prolongation after neurosurgery.

To present a model of decision analysis that allows assessing the trade-off between the short-term risks of performing a carotid endarterectomy and the rate of preventable future events. We used data from a systematic review to define values for a base case and perform a sensitivity analysis. The primary endpoint was a comparison of the fatal and disabling stroke-free survival during a 5-year period in a cohort of hypothetical patients who presented asymptomatic severe carotid stenosis and were treated with either immediate prophylactic carotid endarterectomy or medical treatment alone. The difference in estimated fatal and disabling stroke-free survival favoring endarterectomy in patients with asymptomatic severe carotid stenosis is less than 4 days over the course of 5 years. One-way sensitivity analysis demonstrated that if the perioperative rate of death or disabling stroke is greater than 2.1%, then medical treatment is better. A non-surgical strategy is also better if the risk of fatal and disabling stroke with medical treatment is less than 1.09% per year, or if the rate of fatal and disabling stroke beyond 30 days following endarterectomy is greater than 0.51% per year. In this model, immediate prophylactic carotid endarterectomy seems to offer a minimum net benefit in terms of fatal or disabling stroke-free survival over a 5-year period, when compared to medical treatment alone.

Base de dados : LILACS. Pesquisa : 310099 [Identificador único]. Referências encontradas : 1 [refinar]. Mostrando: 1 .. 1 no formato [Detalhado]. página 1 de 1, 1 / 1, LILACS, seleciona. para imprimir. Fotocópia. experimental, Documentos relacionados. Id: 310099. ...

A 53-year-old male presented with a 3-week history of back pain, anorexia, asthenia, and vomiting. At initial evaluation at the hospital reveled elevated serum calcium (17.5 mg%–4.37 mmol/l) and abnormal renal function. Magnetic resonance imaging (MRI) of his spine reveled an expansive lesion at T11-T12, with abnormal bone marrow signal intensity (low on T1-weighted images, high on T2weighted images) in the body and anterior archs. A diagnosis of multiple myeloma was made. (Spine biopsy showed bone plasmacytoma-monoclonal type-Ig G that involved paravertebral soft tissue.) He developed septic shock and multiorgan dysfunction, with severe upper-gastrointestinal bleeding. A gastrointestinal endoscopy was performed revealing multiple polypoid masses in the stomach and duodenum (Figs. 1 and 2), that were biopsied. Histologic studies of biopsy specimens showed atypical plasmacytotic cell infiltration in the antral mucosa, between glandular cells. Immunohistochemically, these atypical cells were shown to be monoclonal type-Ig G (Fig. 3). Multiple myeloma is a neoplasic proliferation of monoclonal plasma cells, that can result in osteolitic bone lesions, renal impairment, hypercalcemia, bone marrow failure, and the production of monoclonal gammapathy. Although usually restricted to the bone marrow, extramedullary involvement can occur in the form of plasmocytomas in up to 20% of cases. The most common site of extramedullary is the upper respiratory tract, including the oropharynx, nasopharynx, nasal cavities, sinuses, and larynx. Those in the gastrointestinal tract constitute approximately 10% of all extramedullary plasmocytomas (EMPs). All segments of the gastrointestinal tract may be involved by plasma cell infiltration. The small bowel is the most common site of involvement, follow by stomach, colon, and esophagus. Gastric plasmocytoma is an extremely rare form of EMPs, that was first described in 1928 by Vasiliu and Popa. It accounts for approximately 2% to 5% of EMPs, and tend to

SummaryBackground: Previously we observed in some but not all septic patients a low plasma concentration of plasminogen. Objectives: To investigate prospectively whether plasma levels of plasminogen or the ratio of plasminogen to alpha-2-antiplasmin have a prognostic value for survival from sepsis and to study the variation of other hemostatic parameters during septicemia. Patients: The study population consisted of 45 consecutive patients with septicemia, 15 non-septic patients from the same intensive care unit and 30 healthy volunteers. Measurements and Main Results: Plasminogen concentrations were significantly lower (p <0.001) in plasma of septic patients (median 0,62 IU/ml range: 15-1,06) than in plasma of healthy controls (median 1.00 IU/ml, range: 0.75-1.10) or of non-septic intensive care patients (median 00 IU/ml, range: 0.82-1.08). Among the other parameters tested, plasminogen activator inhibitor (PAI-1) antigen concentration and PAI activity were similar in septic and...