Defectos paradójicos en regiones con necrosis miocárdica. análisis mediante gated-spect de perfusión miocárdica.

Objectius: Valorar el significat dels defectes paradoxals (DP) segmentaris (captació en esforç més gran que en repòs) a la gated-SPECT (Single Photon Emission Computer Tomography) de perfusió miocàrdica amb compostos tecneciats en regions amb necrosi miocàrdica. Material i mètodes: Es van revisar 1764 SPECT de perfusió miocàrdica estrès-repòs consecutives de pacients amb infart (IM) previ i es van identificar 117 pacients (6,6%) en els quals els DPs corresponien a una regió amb necrosi miocàrdica. Es van valorar els criteris gammagràfics de viabilitat (intensitat del defecte, valor d'aquesta intensitat ponderat pel nombre de segments compromesos-VIP-, la motilitat i l'engrossiment miocàrdic sistòlic) en els segments d'aquestes regions i les característiques de l'artèria responsable en els 96 pacients en els quals s'havia practicat una coronariografia. Resultats: Es van analitzar 160 necrosis, 125 (75%) paradoxals (67 (54%) en regió AnteroSeptoApical i 58 (46%) en regió InferoLateral) i 35 (25%) no paradoxals (19 (54%) ASA i 16 ( 46%) IL). Els valors de severitat de la necrosi i del VIP van ser inferiors en l'estudi d'estrès respecte al repòs i la diferència d'aquests va ser sempre negativa, evidenciant un comportament gammagràfic paradoxal. Per contra, aquests valors van ser inferiors al repòs respecte a l'estrès en les necrosi no paradoxals posant de manifest un comportament gammagràfic de mínima o nul reversibilitat. Així mateix, es van trobar alteracions lleus en la motilitat i engrossiment de les necrosi paradoxals i moderats en les necrosi no paradoxals. Es van trobar 102 necrosis amb DP i coronariografia dels quals, 84 (88%) tenien permeabilitat a l'artèria responsable de la necrosi i 12 pacients (12%) tenien circulació colateral per compensar l'oclusió de l'artèria responsable. Conclusions: Tots els segments amb DP en regions amb necrosi complien criteris gammagràfics de viabilitat en les imatges d'estrès, considerant aquestes imatges millors per a l'avaluació d'aquest tipus de lesions. El vas responsable de la regió amb DP es trobava permeable o bé presentava circulació colateral evident en els casos en què la coronària es trobava closa.

Renal tubular NEDD4-2 deficiency causes NCC-mediated salt-dependent hypertension.

The E3 ubiquitin ligase NEDD4-2 (encoded by the Nedd4L gene) regulates the amiloride-sensitive epithelial Na+ channel (ENaC/SCNN1) to mediate Na+ homeostasis. Mutations in the human β/γENaC subunits that block NEDD4-2 binding or constitutive ablation of exons 6-8 of Nedd4L in mice both result in salt-sensitive hypertension and elevated ENaC activity (Liddle syndrome). To determine the role of renal tubular NEDD4-2 in adult mice, we generated tetracycline-inducible, nephron-specific Nedd4L KO mice. Under standard and high-Na+ diets, conditional KO mice displayed decreased plasma aldosterone but normal Na+/K+ balance. Under a high-Na+ diet, KO mice exhibited hypercalciuria and increased blood pressure, which were reversed by thiazide treatment. Protein expression of βENaC, γENaC, the renal outer medullary K+ channel (ROMK), and total and phosphorylated thiazide-sensitive Na+Cl- cotransporter (NCC) levels were increased in KO kidneys. Unexpectedly, Scnn1a mRNA, which encodes the αENaC subunit, was reduced and proteolytic cleavage of αENaC decreased. Taken together, these results demonstrate that loss of NEDD4-2 in adult renal tubules causes a new form of mild, salt-sensitive hypertension without hyperkalemia that is characterized by upregulation of NCC, elevation of β/γENaC, but not αENaC, and a normal Na+/K+ balance maintained by downregulation of ENaC activity and upregulation of ROMK.

Delayed otogenic hydrocephalus after acute otitis media in pediatric patients: the changing presentation of a serious otologic complication.

CONCLUSIONS: The clinical presentation of otogenic dural sinus thrombosis (DST) as a complication of acute otitis media (AOM) can be masked by antibiotic treatment. Morning episodes of vomiting and/or headache, visual impairment and a history of AOM seem to be indicative of otogenic hydrocephalus. We therefore advocate that the MRI scans of patients with similar symptoms should be carefully studied to facilitate the early diagnosis of a potentially life-threatening complication. OBJECTIVE: To describe the frequency, pathognomonic signs, clinical course and outcome of otogenic hydrocephalus and DST as complications of AOM in pediatric patients. MATERIAL AND METHODS: We undertook a retrospective chart review of all pediatric patients (age 1-14 years) treated for otitis media and its complications at an academic medical center between 1999 and 2003. The main outcome measures were otologic and ophthalmologic findings and CT and MRI scans at the beginning of treatment and 3 months later. RESULTS: We report on five cases with otogenic DST following AOM. All but one of them presented initially with diplopia caused by otogenic hydrocephalus. In four cases the otologic complaints had already disappeared by the time of MRI confirmation of the diagnosis. Only one child was referred with severe otologic symptoms. Management included systemic antibiotics, short-term heparin anticoagulation and surgical decompression. In our cases, even after intensive i.v. antibiotic treatment, only surgery led to a significant improvement in the clinical condition.

Frequency of specific anti-Toxoplasma gondii IgM, IgA and IgE in Colombian patients with acute and chronic ocular toxoplasmosis

We studied the frequency of specific anti-Toxoplasma IgM, IgA and IgE antibodies in serum of 28 immunocompetent Colombian patients, selected by ophthalmologists and with lesions that were compatible with ocular toxoplasmosis. Patients were classified in three groups: (i) group 1 consisted of ten patients with a first episode; (ii) group 2, with seven patients with a recurrence and (iii) group 3, consisted of eleven patients with chronic chorioretinal lesion without uveitis. We found that 10/28 (35%) of Colombian patients with ocular toxoplasmosis possessed at least one serological marker for Toxoplasma infection different from IgG. In group 1 (first episode), we found simultaneous presence of specific IgM plus IgA plus IgE in 1/10 (10%). In group 2 (recurrences) in 1/7 (14%) we found IgM and IgA test positives and in 1/7 (14%) we found IgM and IgE tests positives. In group 3 (toxoplasmic chorioretinal scar) the IgA serological test was positive in 2/11 (18%). These results show that serum IgM or IgA or IgE can be present during recurrences.

Ultraschalldiagnostik des nichttraumatischen akuten Abdomens: die Ursachen ausserhalb des Gastro-Intestinaltraktes [Ultrasound of non traumatic acute abdomen: extra-digestive causes]

In recent years, management of abdominal pain in emergency care units (ECU) has undergone a radical change. Chronic work overload of ECU and increase in severity and complexity of cases required an optimal medical imaging method, such as ultrasound, to establish an accurate diagnosis as quickly as possible. A great variety of causes may cause acute abdominal pain and the role of sonography is to accurately distinguish between these aetiologies. For the application of sonography, perhaps more so than with other imaging methods, a perfect knowledge of sonographical characteristics and technical possibilities is essential to achieve an optimal answer. The purpose of this review is to present and discuss the sonographic characteristics of extra-digestive causes of acute abdominal pain such as splenic infarction, thoracic pathologies, urinary and gynaecologic diseases or retroperitoneal pathologies.

Isolation and identification of Adenovirus in hospitalized children, under five years, with acute respiratory disease, in Havana, Cuba

Nine Adenovirus (Ad) strains isolated in Cuba, from 128 nasopharingeal swab specimens of children below five years old, with acute respiratory diseases, during 1996 and 1997, were studied by restriction enzyme analysis of genomic DNA with two endonucleases BamH I and Sma I. All different fragment patterns were compared with the respective prototypes. The identified adenoviruses were Ad 1 (n=4), Ad 2 (n=1) and Ad 6 (n=4). Males were more frequently infected than females. The analysis of the occurrence of these Adenovirus strains of subgenus C revealed that Ad 1 and Ad 6 were the predominant serotypes in 1996 and in 1997, respectively.

Outcome of patients with acute coronary syndrome in hospitals of different sizes. A report from the AMIS Plus Registry.

To assess the impact of admission to different hospital types on early and 1-year outcomes in patients with acute coronary syndrome (ACS). Between 1997 and 2009, 31 010 ACS patients from 76 Swiss hospitals were enrolled in the AMIS Plus registry. Large tertiary institutions with continuous (24 hour/7 day) cardiac catheterisation facilities were classified as type A hospitals, and all others as type B. For 1-year outcomes, a subgroup of patients admitted after 2005 were studied. Eleven type A hospitals admitted 15987 (52%) patients and 65 type B hospitals 15023 (48%) patients. Patients admitted into B hospitals were older, more frequently female, diabetic, hypertensive, had more severe comorbidities and more frequent non-ST segment elevation (NSTE)-ACS/unstable angina (UA). STE-ACS patients admitted into B hospitals received more thrombolysis, but less percutaneous coronary intervention (PCI). Crude in-hospital mortality and major adverse cardiac events (MACE) were higher in patients from B hospitals. Crude 1-year mortality of 3747 ACS patients followed up was higher in patients admitted into B hospitals, but no differences were found for MACE. After adjustment for age, risk factors, type of ACS and comorbidities, hospital type was not an independent predictor of in-hospital mortality, in-hospital MACE, 1-year MACE or mortality. Admission indicated a crude outcome in favour of hospitalisation during duty-hours while 1-year outcome could not document a significant effect. ACS patients admitted to smaller regional Swiss hospitals were older, had more severe comorbidities, more NSTE-ACS and received less intensive treatment compared with the patients initially admitted to large tertiary institutions. However, hospital type was not an independent predictor of early and mid-term outcomes in these patients. Furthermore, our data suggest that Swiss hospitals have been functioning as an efficient network for the past 12 years.

Audit of Acute Maternity Services (PDF 4894 KB)

Audit of Acute Maternity Services Final Report - October 2006

Acute Hospital Portfolio Year 3 Regional Summary (PDF 1153 KB)

February 2006 - report providing an overview of the performance of the Northern Ireland Trusts

Acute Hospital Portfolio - Catering Services in Northern Ireland Regional Summary (PDF 105 KB)

March 2003 - sets out the main findings from the study and key conclusions

Acute Hospital Portfolio - Accicent & Emergency in Northern Ireland Regional Summary (PDF 80 KB)

October 2003 - main findings arising from the study and the key conclusions

Acute Hospital Portfolio - Day Surgery in Northern Ireland Regional Summary (PDF 80 KB)

October 2003 - main findings arising from the study and the key conclusions

Asthme aigu sévère [Severe acute asthma]

Acute severe asthma is defined by the occurrence of an acute exacerbation resistant to the initial medical treatment, complicated by life-threatening respiratory distress due to severe lung hyperinflation. The conventional therapeutic approach is based on oxygen therapy and on the combined treatment of inhaled beta2-agonists at repeated doses and systemic corticosteroids. Inhaled or systemic magnesium sulfate is also recommended. The unresponsiveness to the initial bronchodilating therapy and the development of respiratory distress requiring intubation significantly increases mortality, due to the complications induced by mechanical ventilation. In these situations, a ventilatory strategy, including controlled hypoventilation with permissive hypercapnia, aiming at preventing lung hyperinflation, is indicated. Non-invasive ventilation may be successful in certain patients and represents an effective alternative to intubation. In ventilated patients, helium-oxygen mixtures can be considered as adjunctive therapies. After having reviewed the basic pathophysiological principles, this article will focus on the current medical treatment and of the modalities of mechanical ventilation in acute severe asthma.

Detection of circulant tumor necrosis factor-alpha , soluble tumor necrosis factor p75 and interferon-gamma in Brazilian patients with dengue fever and dengue hemorrhagic fever

Pro-inflammatory cytokines are believed to play an important role in the pathogenesis of dengue infection. This study reports cytokine levels in a total of 54 patients examined in Recife, State of Pernambuco, Brazil. Five out of eight patients who had hemorrhagic manifestations presented tumor necrosis factor-alpha (TNF-alpha) levels in sera which were statistically higher than those recorded for controls. In contrast, only one out of 16 patients with mild manifestations had elevated TNF-alpha levels. The levels of interleukin-6 (IL), IL-1beta tested in 24 samples and IL-12 in 30 samples were not significantly increased. Interferon-g was present in 10 out of 30 patients with dengue. The data support the concept that the increased level of TNF-alpha is related to the severity of the disease. Soluble TNF receptor p75 was found in most patients but it is unlikely to be related to severity since it was found with an equivalent frequency and levels in 15 patients with dengue fever and another 15 with dengue hemorrhagic fever.

Does history of falling predict length of stay in post-acute geriatric rehabilitation?

Objectives:To investigate the associations between falls before hospital¦admission, falls during hospitalization, and length of stay in elderly¦people admitted to post-acute geriatric rehabilitation. Method: History¦of falling in the previous 12 months before admission was recorded¦among 249 older persons (mean age 82.3±7.4 years, 69.1% women)¦consecutively admitted to post-acute rehabilitation. Data on medical,¦functional and cognitive status were collected upon admission. Falls¦during hospitalization and length of stay were recorded at discharge.¦Results: Overall, 92 (40.4%) patients reported no fall in the 12 months¦before admission; 63(27.6%) reported 1 fall, and 73(32.0%) reported¦multiple falls. Previous falls occurrence (one or more falls) was significantly¦associated with in-stay falls (19.9% of previous fallers fell¦during the stay vs 7.6% in patients without history of falling, P=.01),¦and with a longer length of stay (22.4 ± 10.1 days vs 27.1 ± 14.3 days,¦P=.01). In multivariate robust regression controlling for gender, age,¦functional and cognitive status, history of falling remained significantly¦associated with longer rehabilitation stay (2.8 days more in single fallers,¦p=.05, and 3.3 days more in multiple fallers, p=.0.1, compared to¦non-fallers). Conclusion: History of falling in the 12 months prior to¦post acute geriatric rehabilitation is independently associated with a¦longer rehabilitation length of stay. Previous fallers have also an¦increased risk of falling during rehabilitation stay. This suggests that¦hospital fall prevention measures should particularly target these high¦riskpatients.