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The characteristics of magnetic resonance imaging (mri) of the brains and spinal cords of 11 dogs with histologically confirmed granulomatous meningoencephalomyelitis (gme) were determined. The lesions were in the brain of eight of the dogs, in the brain and spinal cord of two, and in the spinal cord alone in one dog. A single lesion was present in four of the dogs and multiple lesions were found in six. In one dog with intracranial signs, no visible lesions could be detected on mri. No meningeal enhancement was detected in T1-weighted images post-contrast, or in fluid attenuation inversion recovery (flair) images, but there were histological lesions in the meninges in nine of the dogs. The T2-weighted images and flair sequences were characterised in all cases by hyperintensity, whereas the signal intensity of the lesions on T1-weighted images was variable. After the administration of paramagnetic contrast, some of the lesions showed no enhancement, but others showed marked patterns of enhancement. The lesions in 10 of the dogs were easily identifiable by mri and the images had several unifying characteristics, but they could not be considered disease-specific.

✓ Magnetic resonance (MR) image—based computerized segmentation was used to measure various intracranial compartments in 49 normal volunteers ranging in age from 24 to 80 years to determine age-related changes in brain, ventricular, and extraventricular cerebrospinal fluid (CSF) volumes. The total intracranial volume (sum of brain, ventricular, and extraventricular CSF) averaged 1469 ± 102 cm3 in men and 1289 ± 111 cm3 in women. The difference was attributable primarily to brain volume, which accounted for 88.6% of the respective intracranial volumes in both sexes, but was significantly larger in men (1302 ± 112 cm3) than in women (1143 ± 105 cm3). In both, the cranial CSF volume averaged 11.4%. Total intracranial volume did not change with age, although the normalized brain volume of both men and women began to decrease after the age of 40 years. This decrease was best reflected by expansion of the extraventricular CSF volume which, after the age of 50 years, was more marked in men than in women. The volume of the cranial CSF, as determined by MR image-based computerized segmentation, is considerably larger than traditionally accepted and resides mostly extraventricularly. Expansion of CSF volume with age provides a good index of brain shrinkage although evolving changes and growth of the head with age tend to confound the results.

✓ Magnetic resonance image—based computerized segmentation was used to measure the volumes of the brain, gray and white matter components, and to identify regions with prolonged enhancement on T2-weighted imaging, such as periventricular or deep white matter hyperintensities. The authors also determined the volumes of the ventricles and subarachnoid space in control subjects and in patients with: 1) aqueductal stenosis (AS); 2) other causes of obstructive hydrocephalus (OH); 3) Alzheimer's disease (AD); and 4) normal-pressure hydrocephalus (NPH). In AS the volume of the brain was smaller, whereas that of ventricles and subarachnoid cerebrospinal fluid space was larger than that of controls. The decrease in brain volume was due primarily to white matter loss. Although in OH the ventricles were larger, the subarachnoid space was smaller than in controls, presumably due to encroachment by the brain, in which the volume remained unchanged. In AD, loss of both gray and white matter resulted in a smaller brain volume, whereas that of ventricles and subarachnoid space was larger than in controls. In NPH patients, only ventricular volume was greater, whereas all other compartments were similar to controls. The brain normally occupies 87% to 92% of the intracranial volume and consequently, as observed in our patients, relatively small decrements in brain size lead to large increments in ventricular and/or extraventricular volumes. The magnitude of such changes differed markedly among our patient groups, and whether such changes prove useful in clinical assessment and differentiation needs to be determined.

Important differences in patient survival exist between peritoneal dialysis (PD) and haemodialysis (HD). Several different studies have shown that PD yields a better survival rate than HD in the first and second years of treatment, especially in younger patients and non-diabetic patients with low comorbidity, whereas HD produces better results in diabetic patients, elderly patients, and in patients with greater comorbidity. In recent years, interesting changes have occurred in PD units in the Canary Islands, such as the introduction of peritoneal dialysis solutions with bicarbonate dialysate and low content of glucose degradation products, extended use of automated dialysis, and continuity of physicians and nurses in PD units, in addition to enhancing visits for advanced chronic kidney disease (ACKD).This situation led us to perform our study with the primary objective of comparing medium-term survival among incident dialysis patients on HD versus PD in recent years in the Canary Islands, and as a secondary objective, to compare survival between these two types of dialysis by subgroups as defined by age, sex and diabetes.This was a retrospective cohort study comparing survival between HD and PD patients starting dialysis in the Canary Islands between 01/01/2006 and 31/12/2009, with adjustment based on the propensity score analysis. We analysed data from the RERCAN database, which collects data on demographic variables, changes in type of dialysis, province and hospital of the patient, and mortality and its causes. We calculated Kaplan-Meier estimates of survival based on the overall population and stratified by age, sex and diabetes. We applied a Cox proportional hazards model for survival to estimate the relative mortality risk of PD compared with HD, using as independent variables: age, sex, quartiles of propensity score, the province of the patient, and diabetes. Finally, we applied a Cox model with time-dependent effects, using as a fixed risk factor the initial type of dialysis in order to assess the effect of PD versus HD on short and medium-term survival.The cohort included 1469 patients (173 PD and 1296 HD), with a mean age of 62.5 years, 65% male. Mean follow-up was 16.2±12.4 months. Factors associated with greater probability of choosing PD were younger age and living in the province of Las Palmas. The cumulative mortality in the intention to treat (ITT) analysis was 27.1% in the HD group and 8.7% in the PD group, P.0001. The cumulative probability of survival by ITT using PD vs HD was 96.6% versus 89% at 6 months (P.001), 96% versus 80% at 12 months (P.001), 90% versus 65% at 24 months (P.001), 82% versus 58% at 36 months (P.001) and 73% versus 45% at 46 months (P.001). In the subgroup analysis, survival was also higher in PD patients compared to HD patients both over and under 65 years old, in both diabetic and non-diabetic patients, and in both genders. The same analysis from the 90th day onward produced similar results. In the ITT analysis, the Cox-adjusted mortality risk for PD was 61% lower than for HD (RR: 0.398, 95% CI 0.237-0.669, P=.001), adjusted for age, diabetes, sex, patient's province and propensity score. Broken down by years of survival on the technique used, the relative risk of death for PD compared with HD in the first year was also significantly lower (RR 0.509, 95% CI: 0.259-0.999, P=.049). From year 2 onwards, only age was a risk factor for mortality (RR: 2.785, 95% CI: 1.525-5.086, P=.001) and no differences were shown between the two dialysis techniques.In the Canary Islands, PD has demonstrated survival advantages over HD in the short and medium term. It is remarkable that this benefit was found in young and old patients, men and women, and diabetic and non-diabetic patients, and that this advantage was maintained even after years of being on dialysis.

This study analysed trends in polypoid colorectal cancer (PCRC) diagnosed by colonoscopy during the period 1995-2008 and compared the patterns observed in the years 2005-2008 with 1995-1998.In the period 1995-2008, 24,245 colonoscopies were performed and 1041 patients with PCRC were diagnosed: pediculated (n = 220) or sessile (n = 821).The mean age at diagnosis was 68.3 ± 11.6 years. Males were more likely to have PCRC (males 62.6%vs females 37.4%; P0.0001). Significantly more pediculated PCRCs were located in the distal colon (P0.001). In the 2005-2008 period the prevalence of PCRC among patients undergoing colonoscopy decreased, the number of polypectomies increased significantly (P0.0001) and the pediculated PCRC location changed, with a significant increase in right-sided lesions.The prevalence of PCRC in patients undergoing colonoscopy decreased, with a significant increase in the number of polypectomies in the last decade. Pediculated PCRCs were more often located in the left colon and sessile PCRCs in the right colon. From the period 1995-1998 to 2005-2008 the location of pediculated PCRCs changed, with an increase in right-sided lesions.

Hemodialysis (HD) cost analysis provides information about the economic impact of the disease on the community. Its knowledge is crucial to adequate and optimize health resources. Our aim was to study sanitary and non-sanitary direct costs of HD, based on patients individual data. Furthermore, the effect of sociocultural factors and comorbidity on costs was evaluated.Retrospective and observational study of prevalence costs produced during one year of HD therapy. All patients from North Health District of Tenerife province (Canary Islands, Spain) included for at least 3 months on HD were considered for the study. Sociodemographic parameters and comorbidity data were collected from a generic individual survey and reviewing database records. Direct sanitary and non-sanitary costs were organized in 6 categories: HD sessions, medication costs, hospitalization costs (evaluated by Diagnosis-Related Groups classification system), outpatient care (including consultation and complementary studies); healthcare material and patient transportation.Finally, 161 patients were included (63 +/- 16 years, 63% males, 38% diabetics). Of note, the proportions of sociocultural deprivation was high among this population (75-85% did not complete first school and had non-qualified jobs). Mean cost of global therapy was 43,070 +/- 13,932 euro. Proportional allocation of costs was as follow: HD sesion 51%, pharmacy 27%, hospitalization 17%, transportation 3% and ambulatory care 2%. There was no association between sociocultural profile, comorbidity and therapy cost.This is the first study of HD costs, itemized by components of expenses, based in individual data and introducing GRD model for hospitalization cost. The highest expenses corresponded to HD sessions and medication (79%), both very homogeneous to this patient population. The saving in economic terms should be, fundamentally, the prevention of CKD.

Cardiovascular disease and other complications of atherosclerosis are the most common cause of death in patients with chronic renal failure in maintenance hemodialysis (MHD). Carotid ultrasonography is a simple non-invasive tool to investigate the vascular system, by means of intima media thickness (IMT) measurement and carotid wall calcifications.To determine IMT and the presence of plaques, and their possible clinical relationships; finally we tried to investigate whether they would predict cardiovascular morbidity and mortality in patients in MHD.We studied 60 MHD patients (age 68 +/- 13 years, 48% male, 50% diabetics, time on MHD 32 +/- 11 months) and a control group of 274 people matched for age and sex. Follow-up period was 66 +/- 13 months.Demographic and clinical data, serum levels of homocysteine (tHcy), folic acid (FA) and B6 and B12 vitamins. IMT was measured by high-resolution B-mode ultrasonography.IMT was higher in MHD patients than in those in the control group (0.947 +/- 0.308 vs 0.619 +/- 0.176 mm; P0.001). IMT was related with age (r = 0.268; P = 0.038), diabetic (r = 0.650; P0.001) and hypertensive condition (r = 0.333; P = 0.012), but not wih lipids, tHcy or FA. Patients who suffered from coronary artery disease, peripheral artery disease or stroke had higher IMT than those without those events (1.156 +/- 0.371 vs 0.875 +/- 0.285 mm; P0.001; 1.205 +/- 0.374 vs 0.911 +/- 0.231 mm; P = 0.007; 1.195 +/- 0.264 vs 0.844 +/- 0.251; P0.001 respectively). Something similar occurred with the presence of plaques. During the follow-up period 36 patients died (60%), 67% of them due to cardiovascular causes. IMT was higher in patients who died than those who survived (1.020 +/- 0.264 vs 0.858 +/- 0.334 mm; P = 0.044). The survival rate during the observation period was significantly lower in the final IMT fourth (20%) than in the first (72%) (P = 0.014). The presence of carotid plaques was an independent predictor of cardiovascular mortality.These findings suggests that measurement of carotid IMT and the presence of wall plaques are useful tools to predict cardiovascular events and mortality in patients in MHD.

We aimed to determine the incidence of colonic perforation (CP) following colonoscopy and postpolypectomy bleeding (PPB) in a teaching hospital, assessing the influence of endoscopist experience as a risk factor.All colonoscopies performed between 1995 and 2008 were reviewed. Demographic data, endoscopic procedure information, incidence of CP and PPB, and endoscopist experience were recorded.In the 14-year period, 25,214 endoscopic colonic procedures were performed, and 3991 patients underwent polypectomy. The overall CP risk was 0.51/1000 procedures; and PPB 14.7/1000. The relative risk (RR) ratio of complications was 2.8/1000 procedures. The RR rate was highest for endoscopists performing less than 591 procedures per year (4.0/1000 [95% CI, 3.7-4.3] vs 2.9/1000 [95% CI, 2.6-3.2]), P0.001).The complication rate after colonoscopy was comparable to that previously reported. Colonoscopy carried out by a low-volume endoscopist was independently associated with bleeding and perforation.

A pathological Oral Glucose Tolerance test (OGTT) is early marker of peripheral insulin resistance. Nevertheless, its utility in nondiabetic patients with CRF stage IV-V is undetermined.We wanted to detect, in a population of non diabetic patients with CRF, the presence of carbohydrates metabolism anomalies, by means of the OGTT and to relate it with metabolic, anthropometric, cardiovascular parameters and renal function. We studied 45 non diabetic patients with advanced CRF (stage IV-V), 26 men, mean age 66.5 years, with average Cockroft-Gault of 23.6 ml/min. We measured weight, height, waist and BMI. BIOCHEMICAL: glucose, insulin, OGTT, C peptide, lipid profile, HbA1C and Hto. Cardiovascular comorbidity, mean proteinuria and systolic and diastolic blood pressure (6 months pre and post analytical measure) were measured. Pulse pressure was also calculated.47% of the patients presented normal fasting glucose, whereas 53% had isolated impaired fasting glucose (IFG). After the OGTT, 36% of the patients presented impaired glucose tolerance (IGT) and 14% diabetes (200 mg/dl). Of the patients with normal fasting glucose, 38% had IGT after OGTT and 5% diabetes. Patients with abnormal OGTT were older (71+/-13.6 versus 60+/- 18.8 years, p=0.03), had greater HbA1C (5.6+/-0.5 versus 5.2+/-0.3%, p=0.02), total cholesterol (193+/-37.7 versus 169.8+/-44.9 mg/dl, p=0.03), pulse pressure (63.4+/- 14.5 versus 52.3+/-9.7 mmHg, p=0.0001) and greater prevalence of ischemic heart disease (28% versus 5%, p=0.05). Creatinine Clerance negatively correlated with the OGTT (r=-0.39, p=0.01) and plasma creatinine positively with fasting insulin (r=0.33, p=0.02) and C-peptide (r=0.42, p=0.006). Urinary Proteins were correlated with fasting glucose (r=0.30, p=0.04), C-peptide (r=0.52, p=0.001), triglycerides (r=0.36, p=0.01) and with the HOMA-IR index (r=0.30, p=0.05).Fasting Glucose did not predict OGTT results in patients with CRF. For this reason, we think that the OGTT can be very usefull tool to identify states of "prediabetes" and diabetes in patients with CRF, specially in those whose present an elevated Pulse Pressure, age greater than 65 years, hyperlipidaemia and HbA1C above 5.2%. The early detection of these metabolic anomalies, may lead to intensify dietetic and pharmacological measures directed to delay or to attenuate the appearance of diabetes and its serious complications in a population in which the cardiovascular risks factors are very elevated.

To study the characteristics of the entered patients in an Internal Medicine department.Descriptive and observational study with admissions elder than 65 years old in an Internal Medicine Department during the year 2002. The variables analyzed were: age, sex, intake date, discharge date, days of hospital stay, chronic disease previous, reason for admission (guide symptom), deceased and diagnosis at discharge. The statistical analysis was performed with measures of central tendency and of standard deviation, Chi-squared Mann-Whitney-Wilcoxon.770 patients were accepted for the study. The distribution in sex is similar, although the women show greater median age. The most frequent chronic disease was ischemic hypertensive heart disease (25.7%) and the 64.9% of the patients have some cardiovascular risk factor. The men show more cardiovascular risk factor and more chronic disease (p0.01). The most frequent was dyspnea (42.7%). The most frequent diagnosis was cardiac failure (20.6%). 16.6% of the patients died in the hospital, and the most frequent diagnosis was respiratory tract infection (49.5%).The most frequent pathologies are the cardiopulmonary chronic disease of developed countries. The primary and secondary prevention and an improvement of chronic cardiopulmonary disease would be an effective way of cost control in these disease.

To investigate hypertension control in elderly patients. To identify the cardiovascular risk factors and cardiovascular diseases associated with poor control of hypertension. To evaluate the pharmacologic treatment needed for the good control of hypertension. To analyse the existence of date in the medical history to evaluate the cardiovascular risk.A cross-sectional study of elderly hypertensive patients intaked between 1 to January 2002 to 31 December 2002 in a Internal Medicine Service. Blood pressure was measured in the standard manner. Blood pressure control was regarded as optimum if pressure averaged less than 140/90 mmHg or, in diabetics, less than 130/80 mmHg.The study included 484 hypertensive patients. In the hypertensive patients, both systolic and diastolic blood pressures were well controlled in 53.9% of patients, systolic blood pressure alone in 2,1% and diastolic blood pressure alone in 30.8%. The isolated systolic arterial hypertension prevalence is bigger in the group with poor control, p0.001. The 77% of hypertensive patients associated other cardiovascular risk factor, and the 69% associated any cardiovascular disease. The 64% of hypertensive patients needed pharmacologic treatment.Arterial blood pressure control was optimum in only one out of two hypertensive patients. Diabetes is the most influential variable in poor control. The diuretics are the active ingredients more used in the hypertension therapeutic.

Patients with alcoholism and alcohol withdrawal syndrome (AWS) have a worse prognostic.We have performed a retrospective analysis of the hospital discharges in with diagnosis include AWS from 1 of January of 1997 to the 31 of December of 2002.We identified 924 hospital stays with 2.4% of mortality (1.6% in Internal Medicine). Mortality is associated with greater age (57 years +/-15 vs. 49+/- 13, p0.005), with the diagnostic of hepatic cirrhosis (6.2 vs. 1.8%, p0.005), bacteraemia (10 vs. 1.8%, p0.001) and respiratory infection (9.6 vs. 1.8%, p0,001), with a lower mortality when AWS was secondary diagnosis (1.2 vs. 4.2%, p0.005). In multivariant analysis were associated with more mortality age (OR 1.03), hepatic cirrhosis (OR 3.4), bacteriemia (OR 4.5) and respiratory infection (OR 3.6).Alcohol withdrawal syndrome mortality could to benefit from treatment in an Internal Medicine Service.

Eosinophilia sometimes occurs in acute myeloid leukemia (AML), especially in core binding factor (CBF) leukemia. However, the pathogenesis of the differentiation from leukemic progenitors to eosinophils is not well understood in this type of leukemia. Recent reports showed that a novel fusion tyrosine kinase, Fip1-like1 (FIP1L1) platelet-derived growth factor receptor alpha (PDGFRalpha), is found in idiopathic hypereosinophilic syndrome. The involvement of another chimeric gene, PDGFRbeta, was also reported in myeloproliferative disorder with eosinophilia. These chimeric genes cause constitutive activation of PDGFR tyrosine kinases. On the other hand, a two-hit model for the pathogenesis of AML, which seems to be caused by inactivating mutations in transcription factors and genetic lesions in tyrosine kinase resulting in constitutive activation, has been proposed. On the basis of these findings, we screened for the expression of the FIP1L1-PDGFRalpha fusion gene and for mutations in the juxtamembrane and tyrosine kinase domains of PDGFRalpha/beta genes in 22 cases of CBF leukemia with eosinophilia. Among these cases, no FIP1L1-PDGFRalpha fusion gene was found. Although cDNA sequencing also detected three types of single-nucleotide alterations at kinase domains in PDGFRalpha/beta genes, all of them were silent changes and polymorphisms. Therefore, PDGFRalpha/beta genes do not appear to play a significant pathogenetic role in eosinophilia or leukemogenesis of CBF leukemia.

High levels of homocysteine (tHcy) are frecuent in MHD patients, and recognized as a risk factor for cardiovascular events. Vitamin supplements have been shown to lower serum Hcys, although optimal dose and efficacy is not well defined. Moreover, methylenetetrahydrofolate reductase (MTHFR) gene polymorphism can modulate its prevalence and response to treatment.To evaluate efficacy and safety of two vitamin supplement regimens on Hcys serum levels over a 12 month period.We conducted a prospective, randomised, double-blind trial in 60 stable MHD patients (68 +/- 13 years, 48% male, 50% diabetics). Patients were randomly assigned to one of two treatment regimens: 1) daily renal multivitamin containing folate (FA), vitamin B6 and B12 (5 mg, 10 mg and 0.4 mg respectively) (N = 27); and 2) supraphysiological daily doses (15 mg, 100 mg and 1 mg) (N = 33). These regimens were continued throughout the study period. Hcys levels were compared with a control group from the general population (N = 276) matched for age and gender.demographic and clinical data, serum levels of Hcys, FA, B6, B12 at baseline and after 1, 3, 6 and 12 months of treatment; MTHFR gene polymorphism (PCRRT).At baseline, global prevalence of hyperhomocysteinemia (tHcyor = 15 micromol/L) was 100% in patients and 22% en controls. Hcys levels were significantly higher in patients versus controls (32.4 +/- 8.9 vs 12.9 +/- 6.8; P0.0001). Both regimens were equally effective in reducing Hcys levels. As a whole, Hcys levels were reduced by 23.6% (P0.001) after one month of treatment. The highest reduction was observed at the sixth month (28.3%, 32.4 +/- 8.9 vs 22.7 +/- 6.4, P0.001) and remained stable thereafter. However, only 12% of patients normalised their plasma levels after 12 months of therapy. The effect of treatment was not influenced by age, gender, diabetes, body weight or time on MHD. Reduction rate of tHcy levels was related to baseline tHcy level (r = 0.500, P0.001) and baseline FA levels (r = -0.332, P = 0.009). The MTHFR polimorfism did not significantly modified the effect of the treatment. No side effects were associated with either regimen.Hyperhomocysteinemia is common in patients with conventional HD schedules and this is not related to vitamin deficiencies. Vitamin supplements significantly reduce Hcys levels in a sustained but suboptimal way. Supraphysiological doses did not improve the results. Further studies are requiered to demonstrate that this effect is associated with an improval in morbidity and mortality.

Gas exchange alterations have been described in cirrhotic patients; but by the moment, a few prospective studies have focused in them. The aim of this study was to describe the frequency and severity of gasometric alterations in hospitalized cirrhotic patients, a their correlation with hepatocellular disfunction.50 consecutive cirrhotic patients (41 males) admitted for liver decompensation (ascites, liver encephalopathy, alcoholic hepatitis and upper gastrointestinal bleeding) without acute or chronic cardiopulmonary disfunction were included in the study. Patients were classified according with Child-Pugh score (A, n = 13; B, n = 21; C, n = 16). Severe alcoholic hepatitis (SAH) was confirmed in 7 patients. Arterial gasometry was performed in all patients before discharge. Contrast echocardiography was performed in any case of suspicion of hepatopulmonary syndrome (HPS).Light hypoxemia was observed (80.9 mmHg), without differences with Child-Pugh. Hypocapnia was significantly more evident in Child C than in A and B (31.2 +/- 3.1 vs. 38.1 +/- 4.3 y 36.3 +/- 5 mmHg; p0,05), respectively. Cirrhotic patients with SAH showed a significantly higher hypocapnia by comparison with others (31.2 +/- 3.1 vs. a 36.3+/-5 mmHg; p0.05). In multivariate analysis, independent prognostic variables for hypocapnica were plasmatic levels of protrombin time, albumin and sodium. HPS was confirmed in 8 patients (16%).The most prevalent gas exchange abnormality in cirrhosis was the alteration of alveolar-arterial oxygen tension gradient, directly correlated with hepatocellur disfunction. Hypocapnia could be a compensatory mechanism or the result of the activation of central respiratory centres by non-depurated substances by the liver.

Background Transplantectomy has been the conventional therapy for symptomatic failed grafts left in situ (FGLIS). Graft intolerance syndrome (GIS) is a common complication after withdrawal of inmmunosuppresion. Our group first reported transvascular ethanol embolization (TVEE) as an alternative for the management of GIS. Objective Our goal was to evaluate the efficacy and safety of TVEE in a large series of patients with symptomatic FGLIS. Patients and methods From January 1989 to December 2001, 944 patients received cadaveric renal transplants in our center. During this period, 59 patients with FGLIS underwent TVEE (50 ± 7 years, 71% men, 15% diabetics). TVEE was performed using a transfemoral approach. A balloon occlusion catheter was inflated in the renal artery before ethanol injection (10–12 cc). The position of coils completed the procedure. No systematic prophylatic antibiotic or steroid treatment was administered. Results The main indication for TVEE was GIS (51 patients, 86%). TVEE was initially successful in 39 patients (66%). A second TVEE, which was performed in 9 of 20 unresolved cases, was successful in six. After a second TVEE, the efficacy increased to 76%. The most frequent complication was postembolization syndrome (62%), which was manifested by fever, local pain, and inflammation that generally resolved in 48–72 hours. No major complications or deaths were observed. One of four patients underwent transplantectomy. Histologic examination of the removed graft showed renal tissue necrosis (10 cases) and pyonephrosis (4 cases). Conclusions TVEE, a safe and effective technique, may be considered as the treatment of choice for symptomatic FGLIS.

Early after renal transplantation (RT) a rapid decrease in bone mineral density at the lumbar spine, femoral neck, and femoral shaft has been documented. In addition, an appreciable proportion of patients still remain losing bone late after RT. As a consequence, RT patients are at a high risk of bone fractures as compared to general population. Most fractures involve appendicular skeleton, particularly the feet and ankles, and the diabetic patient is at increased risk of fractures. Thus, early institution of preventive measures and treatment of established osteoporosis are central. The major cause of post-transplantation bone loss is corticosteroid treatment, and this should be used at the lower dose compatible with graft survival. Preexisting hyperparathyroidism also affects the early cancellous bone loss at the spine, and post-transplantation bone loss reflects variable individual susceptibility, resembling the polygenic determination of bone mineral density in general. Clinical trials have demonstrated that bisphosphonates or vitamin D plus calcium supplementation, prevent post-transplantation bone loss during the first 6-12 months. However, their role in preventing bone fractures has not been proven. Finally, recommendations for management, prevention and treatment, are summarized.

We present the case of a 16-year old woman with Alagille's syndrome, who had upper gastrointestinal bleeding due to rupture of esophageal varices secondary to presinusoidal portal hypertension without liver fibrosis. Portal thrombosis is a manifestation previously unreported in association to this syndrome.

To know the frequency of resistances of Mycobacterium tuberculosis and the associated factors.Prospective study of the sensitivity of Mycobacterium tuberculosis by means of the method of the proportions of Canetti in the Hospital Arquitecto Marcide-Profesor Novoa Santos (Ferrol, Spain) among 1991 and 1998. A descriptive and multiple regression analyses were performed.Were studied 355 strains. Primary resistance: Isoniazid 1.1%, Streptomycin 1.1%. Secondary resistance: Isoniazid 11.6%, in the 5.2% existed multidrug-resistance. The risk factors for drug-resistant tuberculosis were previous treatment (odds ratio [OR] = 10.9; 95% CI, 2.9-39.4) and age higher than 40 years (OR = 3.9; 95% CI, 1.1-14.5).A low frequency of resistance was observed. The factors associated with the resistances were previous treatment and age.

To ascertain the condition of the oral hygiene of school children 6 and 12 years of age in Galicia and to assess the degree to which said condition meets the World Health Organization (WHO) oral hygiene objectives for the year 2000.Observational cross-sectional study conducted in 1995 on a group of school children 6 and 12 years of age in Galicia selected by means of a multi-stage sampling by conglomerates, stratified by provinces and type of habitat.This study was conducted on 1,288 school age children, 643 in the 6-year-old group and 645 in the 12-year-old group. 46.7% of the 6 year-old children and 64.2% of the 12 year-olds were found to have cavities, which means an oc index of 1.84 and a AOC index of 1.60, respectively.A trend toward improvement in the oral hygiene of school-age children in Galicia has been found. The oral hygiene-related objectives recommended by the WHO for the year 2000 in the region of Europe have been accomplished, as a result of which further objectives are recommended.

A case of a dog with a long-standing history of seizures is reported. Neurological examination suggested an intracranial focal lesion, while magnetic resonance imaging disclosed a right cerebral mass with ventricular involvement. Pathological analysis of the resected specimen revealed characteristics of meningioangiomatosis.

We determined the extent to which opportunities for prevention were missed among patients with tuberculosis and the costs derived from the lack of prevention.Descriptive study of patients with active tuberculosis were studied in the hospital ward of tuberculosis at the A. Marcide-Novoa Santos Centre (Ferrol, Spain), from September of 1991 to August of 1995. Risk factors to develop tuberculosis, vaccination with BCG, previous tuberculin skin test and previous history of drug prophylaxis or tuberculosis therapy were determined. Then, we determined whether they had undergone prevention procedures in accordance with current recommendations of the American Thoracic Society. An evaluation of the direct and indirect derived costs was carried out in patients with any missed opportunity for tuberculosis prevention.Out of 433 studied patients, 167 (38.6%) got missed any opportunity for prevention. Out of 167, 29 patients (6.7%) did not complete a previous treatment; 9 (2.1%) did not complete drug prophylaxis; 12 (2.8%) with known previous positive tuberculin skin test and an indication for drug prophylaxis never received it, and 117 (27%) with known indications for screening never received a skin test. 62 patients (53%) with known exposure to active pulmonary tuberculosis, and 65 (55.6%) with predisposing medical conditions. From the missed opportunities for prevention we calculated some direct costs of 116,909,911 pesetas and some indirect costs derived from the absence to work (141.9 +/- 114.3 days) and from the death of 6 patients for tuberculosis.A large percentage of missed opportunities to prevent the disease was found among patients with tuberculosis. This means a considerable expense that could have been avoided.

Although subclavian vein stenosis is a well-known complication of haemodialysis subclavian catheters, little is known about its causes. Catheter-related infection is the most common complication of this technique, but its role in the genesis of late subclavian stenosis has not been established. We retrospectively analysed 80 subclavian catheterizations in a total of 54 chronic haemodialysis patients from a single center. Sixteen catheters had to be removed because of a well documented catheter-related infection: three catheter-related sepsis (2 with ipsilateral phlebitis), seven isolated fever with catheter tip colonization which disappeared after catheter removal, and six exit-site discharge with positive culture. For comparison we matched 14 contemporaneous catheters which were electively removed without evidence of infection and with a negative culture of the catheter tip. A venogram of the ipsilateral arm was performed in all the cases after more than 6 months of catheter removal. Both groups were remarkably similar with respect to age, sex, side of insertion, number of inserted catheters, time of indwelling, and time elapsed from removal to venography. Definite subclavian stenosis was three times more common among patients with previous catheter-related infection (75% versus 28%; P0.01). Interestingly, both patients with ipsilateral phlebitis showed total occlusion of the subclavian vein. Although all diabetic patients of the study (n = 6) suffered a catheter-related infection, the incidence of late subclavian stenosis was not more common than in non-diabetic infected patients. In summary, subclavian haemodialysis catheter-related infection is a major risk factor for the development of late subclavian vein stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

CAPD is considered a risk factor for low turnover bone disease. This was previously attributed to aluminum accumulation. We evaluated by biochemical and histomorphometric parameters (including double tetracycline labelling), 26 patients maintained on CAPD for 12-14 months. Three (11.5%) showed mild hyperparathyroidism, 5 (19.2%) osteitis fibrosa, 3 (11.5%) mixed forms, 4 (15%) osteomalacia and 11 (42.3%) adynamic bone disease. Only one patient with diabetes mellitus showed an aluminum stained bone surface10%. Intact PTH serum levels were lower in LTBD (133.2 +/- 128 vs 468.2 +/- 451 pg/ml; p0.05). We also evaluated prospectively 11 patients who underwent a bone biopsy at start of dialysis and after 12 months of CAPD treatment. Bone biopsies pre CAPD demonstrated normal-high bone turnover disease in 8/11 (72.7%) and low turnover bone disease in 3/11 (27%). In the follow-up biopsies, 2 patients showed osteitis fibrosa and other two mild forms. Low turnover bone disease was found in 7 patients (3 osteomalacia and 4 adynamic bone disease). We conclude that the predominant bone lesion in our CAPD patients is low turnover bone disease, predominantly adynamic forms, and aluminum does not seem to play a role on its genesis. Low intact PTH serum levels may be a predictor of low turnover bone disease.

It is suggested that asphyxia on newborns increases the susceptibility to epileptic syndromes. The effect of perinatal and postnatal anoxia on subsequent seizure susceptibility was assessed by amygdaloid kindling in adult rabbits. Rabbits from 1 day pre-term to 53 days were exposed to 100% N 2 for an average of 7 min or until the heart rate was reduced by 70%. Non-anoxic littermates served as controls. At 2 months of age, animals were implanted with bilateral amygdalae electrodes. after a postsurgical recovery period, afterdischarge (AD) thresholds were determined for the electrodes sites and a kindling paradigm was performed. There were no significant differences in the rate of kindling in all groups studied (control, anoxic at 1 day pre-term or at term, anoxic at 44 and 53 days). These results demonstrate that perinatal anoxia did not alter the seizure susceptibility in the adult rabbit kindling model.

The effects of pentylenetetrazole-induced convulsions on cerebrovascular permeability for horseradish peroxidase were studied in locally anesthetized, artificially respired, paralyzed cats. Horseradish peroxidase circulated for 1, 2.5, 5, 10, 30, and 60 min and accumulated in medium-size, i.e., arterial or venous, blood vessel walls. Cerebral neuropil was permeated earliest in thalamic nuclei including medial and lateral geniculate nuclei. No tight junctions containing horseradish peroxidase were found. With 1.0 and 2.5 min circulation of horseradish peroxidase, arterial adventitia and basement membranes contained more peroxidase than surrounding interstitial space in contrast to veins and capillaries. Convulsions increased the number of endothelial vesicles containing horseradish peroxidase in arteries, veins, and capillaries but total number (stained plus unstained) of endothelial vesicles was increased slightly only in capillaries. We conclude that increased permeability is initially at the arterial level, although veins may also become permeable. The role of the endothelial vesicles in transit or protein in and out of the nervous system is not clear.

An animal model for asymptomatic and overt lead toxicity is presented in which rabbit pups, 1 to 30 days of age, were fed a milk supplement containing Pb(NO3)2. Reduced body growth, increased mortality, hematologic abnormalities, kidney and liver histopathology, as well as encephalopathy, were observed in rabbits 2 to 30 days of age ingesting more than 2.8 mg of Pb/day. At the highest dose, brain lesions were widespread, involving the frontal and occipital cortex, striatum, hippocampus, and cerebellum. At moderate doses, the region most affected was the cerebellum. At the lowest dose no alteration in body, brain growth, mortality, or tissue histology was evident; however, basophilic stippling was observed. As a group, these asymptomatic rabbits generally exhibited higher activity than non-lead-fed littermates. The rabbit model presented here should provide many advantages in the study of lead toxicity on the developing nervous system, since (a) maximum brain development in the rabbit, like that in rhesus monkey and man, occurs perinatally, and (b) the effects of lead toxicity in the rabbit closely parallel those in man.

Brain serotoninergic neurons are known to participate in cardiovascular regulation. Administration of the serotonin precursor 5-l-hydroxytryptophan in conjunction with the monamine oxidase inhibitor phenelzine and the selective peripheral l-amino acid decarboxylase inhibitor carbidopa has been shown to raise the repetitive extrasystole threshold in the canine heart. The present investigation demonstrates that this drug regimen increases the cerebrospinal fluid concentration of serotonin and its major metabolite, 5-hydroxyindoleacetic acid, by 330 and 830%, respectively. By contrast, cerebrospinal fluid concentrations of norepinephrine and its major brain metabolite, 3-methoxy-4-hydroxyphenylethyleneglycol sulfate, and of dopamine's metabolite, 3, 4-dihydroxyphenylacetic acid, were not significantly altered. Concomitantly, the ventricular fibrillation threshold was elevated by 42% and the effective refractory period prolonged by 7%. Efferent sympathetic neural activity was suppressed in the normal heart (from 7.9 +/- 1.3 to 3.9 +/- 1.1 impulses/s). The surge in sympathetic activity associated with acute myocardial ischemia was markedly attenuated. These results indicate that enhancement of central serotoninergic neurotransmission can reduce the susceptibility to ventricular fibrillation mediated through a decline in sympathetic neural traffic to the heart.

Five adults with signs of normal pressure hydrocephalus underwent ventriculolumbar perfusions. Average cerebrospinal fluid (CSF) formation rate, 0.313 ± 0.020 ml/min, was comparable with that for nonhydrocephalics, but due to the larger CSF compartment, turnover rate was approximately one third. Slow turnover was further aggravated by a CSF absorption deficiency. Normally, absorption begins at approximately 68 mm CSF pressure and increases linearly at a rate of 7.6μl/ min/mm CSF pressure. In four patients the rate was reduced to 2.5μl/min/mm CSF once a critical mean CSF pressure was reached. This absorption deficit, accompanied by elevated pressure plateaus and heightened pulse pressures may lead to ventricular enlargement and, secondarily, to symptoms associated with normal pressure hydrocephalus. Only two of these four patients showed good response to shunting. In two nonresponding patients, follow-up revealed evidence of complicating intrinsic brain disease.

— The clearance of [14C]leucine from the ventricular and cranial subarachnoid space was studied in cats subjected to ventriculo-cisternal and ventriculo-craniosubarachnoidal perfusions. Clearance from both the ventricles and the subarachnoid space was mediated by transport mechanisms with nonsaturable and saturable components. Net clearance from the subarachnoid space was considerably greater than from the ventricles. Analysis of the transport kinetics revealed the affinity constants (Kt) to be comparable for both compartments but transport sites appeared to be more numerous in the subarachnoid space (greater Vmax). Proportionally, the amount of [14C]leucine retained by brain declined as the concentration of leucine in the perfusate was increased. Since at high concentrations the CSF transport systems and presumably cellular uptake were inhibited (self-saturated) it was assumed that the lower brain levels of [14C]leucine reflected a proportionately greater loss of [14C]-leucine from the brain interstitial space to blood.

The evolution of Lupus Nephritis to end-stage chronic renal failure is a frequent event. We report the case of a 28 years old patient with diffuse proliferative lupus nephritis with crescents formation and rapid decline of renal function without response to steroids, immunosuppressors and plasmapheresis. After 10 weeks of continued hemodialysis, during which the patient received 30 mg of prednisone in alternate days, renal function recovered spontaneously, and after 1 year of follow-up plasma creatinine is maintained in 2.5 mg/dl.

The fetal rabbit delivered by caesarean section 0 to 5 days before term (32 days) can serve as a reliable animal model to study the short- and long-term consequences of premature birth. More than 80% of the fetal rabbits delivered at day 28 of gestation will survive 24 h if anesthetics are avoided during delivery and measures designed to meet the metabolic demands of extrauterine life are met. Sixty percent will survive up to and beyond the 7th day postpartum if the preterm pups are kept in a temperature and humidity controlled environment and are fed rabbit milk. Theoretical and practical advantages of this animal model are discussed.

Tissue dehydration, including that of the brain, is a natural part of maturation. In the newborn it is accompanied by an acute salt water diuresis which is particularly pronounced in the premature infant. The decrease in cranial volume and fall in intracranial pressure to subatmospheric levels observed in premature infants after birth suggests that the brain shares in this process. Since fluid homeostasis is normally under hormonal control, the inordinate loss of fluid in the prematurely born may be attributable to a hormonal imbalance. The possibility that prolactin, a proven osmoregulatory hormone in submammalian species but not in mammals and primates, may have an important role in this process is suggested by recent evidence that prolactin regulates tissue water in fetal and newborn animals. If this hormone assists in the regulation of water and electrolyte content of the brain during the perinatal period then prolactin receptors might be expected at blood-brain and blood-CSF barriers. Our study with preterm, term and adult rabbits indicates that prolactin receptors are present and in much higher concentrations in the choroid plexus than in other tissues examined. Specific binding of prolactin to receptors on tissues normally is observed to increase with age. Since binding to the choroid plexus decreased with age it would suggest that the effect of prolactin on choroid plexus function may be more important during the perinatal than later stages of development.

SUMMARY Macrocephaly is one of the signs most commonly used in the diagnosis of hydrocephalus. Two children are reported who presented with macrocephaly. The results of neurological examination were normal apart from delay in mental development. Head circumferences were above the 98th percentile. Air studies showed mildly dilated ventricles with no obstruction, and ventriculolumbar perfusions indicated normal rates of cerebrospinal fluid formation and absorption. At seven years of age the children were mildly mentally retarded, with head circumferences above the 98th percentile. In the girl the ventricles were still mildly dilated but in the boy they were normal. It is concluded that the macrocephaly in these two children was the result of progressive megalencephaly and not of abnormal ventricular enlargement (hydrocephalus). RESUME Dynamique du liquide cephalo-rachidien dans la megalencephalie La macrocephalie est l'un des signes les plus communement utilises dans le diagnostic d'hydrocephalie. Les auteurs rapportent le cas de deux enfants (une fille de dix mois et un garcon de neuf mois) qui presentaient une macrocephalie. Les resultats de l'examen neurologique etaient normaux en dehors d'un retard de developpement mental. Les tours de tete etaient superieurs au 98eme percentile. Les etudes pneumographiques revelaient des ventricules legerement dilates sans obstruction et les perfusions ventriculo-lombaires montraient des taux normaux de formation et d'absorption du liquide cephalo-rachidien. A l'âge de sept ans, les enfants presentaient un retard mental modere et un tour de tete superieur au 98eme percentile. Chez la fille, les ventricules etaient encore legerement dilates, mais normaux chez le garcon. Les auteurs concluent que la macrocephalie de ces deux enfants etait le resultat d'une megalencephalie progressive et non d'un elargissement ventriculaire anormal (hydrocephalic). ZUSAMMENFASSUNG Liquordynamik bei Megalencephalie Makrocephalie ist eines der gebrauchlichsten Kriterien fur die Diagnose Hydrocephalus. Es wird uber zwei Kinder (ein zehn Monate altes Madchen und ein neun Monate alter Junge) mit Makrocephalus berichtet. Die neurologische Untersuchung zeigte keinen pathologischen Befund auser einer Verzogerung der geistigen Entwicklung. Die Werte fur den Kopfumfang lagen oberhalb der 98igsten Perzentile. Bei der Luftfullung zeigten sich geringgradig erweiterte Ventrikel ohne Obstruktion und die ventrikulo-lumbale Perfusion ergab normale Befunde fur die Liquorbildung und -absorption. Mit sieben Jahren zeigten die Kinder eine geringe Retardierung und ihr Kopfumfang lag oberhalb der 98igsten Perzentile. Bei dem Madchen waren die Ventrikel noch immer etwas erweitert, bei dem Jungen waren sie normal. Es wird daraus der Schlus gezogen, das die Makrocephalie bei diesen beiden Kindern durch eine progressive Megalencephalie bedingt war und nicht dureh abnorme Ventrikelerweilerung (Hydrocephalus). RESUMEN Dinamica del liquido cefalorraquideo en la megaloencefalia Macrocefalia es uno de los signos mas corrientemente usados en el diagnostico de la hidrocefalia. Se aportan dos ninos (una hembra de 10 meses y un varon de nueve meses) que presentaban macrocefalia. Los resultados del examen neurologico eran normales aparte de un retraso en el desarrollo mental. La circunferencia craneana estaba por encima del percentil 98. Los estudios con aire mostraron unos ventriculos ligeramente dilatados sin obstrucciones y las perfusiones ventriculolumbares indicaron unos niveles normales en la absorcion y formacion del liquido cefalorraquideo. A los siete anos de edad los ninos tenian un ligero retraso mental con una cirunferencia craneana por encima del percentil 98. En la nina los ventriculos eran todavia ligeramente dilatados pero en el nino eran normales. Se concluye que la macrocefalia en estos dos ninos era resultado de una megaloencefalia progresiva y no de un aumento anormal de los ventriculos (hidrocefalia).

A low molecular weight compound (about 600 daltons) extracted from human cerebrospinal fluid, and sensitive to proteolytic enzymes, has been shown to mimic the specific inhibitory effects of cardiac glycosides on the Na+/K+ pump of erythrocytes. The compound, which was labelled CSF-inhibitor (CSF-I) and reconstituted in artificial rabbit CSF, was used to study its effects on the rate of CSF formation in rabbits. Three groups of adult New Zealand white rabbits of either sex, anesthetized with ketamine and xylazine, and artificially respired were subjected to ventriculocisternal perfusions. Baseline rates of CSF formation were obtained during the first 2 hours of perfusion when plain rabbit CSF was used as the perfusate. Thereafter, the animals were perfused for an additional 2 to 3 hours with either plain rabbits CSF (controls), rabbit CSF containing 10(-6) M ouabain (group 2) or CSF-I (group 3). The rate of CSF formation in control animals was observed to gradually decline with time (about 7.5% in 4 hours). The addition of ouabain to the perfusate caused an abrupt and marked 43% decline in the rate of formation while the addition of CSF-I resulted in a 57% decline. These results suggest that the peptide CSF-I which is present in human CSF may act as an endogenous regulator of CSF production.

In recent years, use of the ventriculocisternal perfusion technique for the study of cerebrospinal fluid transport of substances has become prevalent. This report compares the effect of three anesthetic agents, commonly used in the laboratory, on the clearance of 35S-sulfate and 125I-iodide out of the CSF. When compared with chloralose, pentobarbital and (to a lesser extent) urethane inhibit the CSF clearance of these anions. In studies with isolated choroid plexus incubated in vitro, the accumulation of 125I-iodide was found to be significantly less in the choroid plexus obtained from the anesthetized than from the unanesthetized animal. These results suggest that the reduced CSF clearance observed in vivo was a result, at least in part, of inhibition of choroid plexus transport.

— Nerve ending and mitochondrial fractions were prepared from cat cerebral cortex by differential and sucrose density gradient centrifugation. The isolated fractions were characterized morphologically and enzymatically and the nerve-ending fraction was shown to be particularly rich in glutamate decarboxylase activity. The uptake of [3H] γ-aminobutyric acid (GABA) was studied by trapping the particles on a Millipore filter. GABA uptake was not saturable over the concentration range studied (0.018 to 8000 μM. Tissue/medium ratios were consistently greater than 2·5, and uptake was significantly reduced by ouabain and iodoacetate, or by replacing sodium with lithium or choline chloride. GABA uptake was significantly inhibited by desmethylimipramine (DMI) with an IC50 of approx. 10–20 μM. GABA uptake was reduced by structurally similar amino acids lacking an α-amino group, and also by methionine and phenylalanine, but not by short chain neutral amino acids.