Clinical vasospasm after subarachnoid hemorrhage: response to hypervolemic hemodilution and arterial hypertension

Delayed neurologic deterioration from vasospasm remains the greatest cause of morbidity and mortality following subarachnoid hemorrhage. The authors assess the incidence and clinical course of symptomatic vasospasm following subarachnoid hemorrhage using a uniform management protocol over a 24-month period. One hundred eighteen consecutive patients were admitted to the neurovascular surgery service within 2 weeks of subarachnoid hemorrhage not attributed to trauma, tumor, or vascular malformation (113 patients had aneurysms). Early surgery was performed whenever possible, and hypertensive hypervolemic hemodilution therapy was instituted at the first sign of clinical vasospasm. Forty-two patients (35.6%) developed characteristic signs and symptoms of clinical vasospasm with angiographic verification of spasm in 39 cases. All patients with clinical vasospasm received hypervolemic hemodilution therapy aiming for a hematocrit of 33-38%, a central venous pressure of 10-12 mm Hg (or a pulmonary wedge pressure of 15-18 mm Hg), and a systolic arterial pressure of 160-200 mm Hg (120-150 mm Hg for unclipped aneurysms) for the duration of clinical vasospasm. Over the course of treatment, 60% of patients with clinical vasospasm had sustained improvement by at least 1 neurologic grade, 24% maintained a stable neurologic status, and 16% continued to worsen. At the end of hypervolemic hemodilution therapy, 47.6% had become neurologically normal, 33.3% had a minor neurologic deficit, and 19% had a major neurologic deficit or were dead. There were 3 instances of cardiopulmonary deterioration (7%), all of which were in patients without Swan-Ganz catheters, and all resolved with appropriate diuresis. One patient rebled and died while on hypervolemic hemodilution therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Normal ovarian function in a mild form of late-onset 3 beta-hydroxysteroid dehydrogenase deficiency

Late-onset 3 beta-hydroxysteroid dehydrogenase (HSD) deficiency was diagnosed in a 30-year-old woman with hirsutism and normal menstrual cycles. No genital abnormalities were present. Elevated basal serum levels of delta 5-3 beta-hydroxysteroids were demonstrated. Serum pregnenolone (P5) was 3.0 ng/ml, and dehydroepiandrosterone sulphate (DHEA-S) 3245 ng/ml. Basal serum levels of delta 4 steroids were low or within normal limits. Serum progesterone (P) was 0.5 ng/ml, 17 alpha-hydroxyprogesterone (17-OHP) 0.2 ng/ml, androstenedione (delta 4A) 0.4 ng/ml, and testosterone (T) 0.1 ng/ml. All delta 5/delta 4 steroid ratios were elevated. Dexamethasone (DEX) administration normalized the elevated levels of delta 5-3 beta-hydroxysteroids, whereas delta 4-3-ketometabolites exhibited only minor modifications. The DHEA-S/delta 4A ratio increased more than five times over the basal ratio, and P5/P and 17 alpha-hydroxypregnenolone (17-OHP5)/17-OHP ratios did not increase after adrenocorticotrophic hormone ACTH stimulation. Studies of basal ovarian function revealed 17 beta-estradiol (E2) and gonadotropins within normal limits according to the menstrual cycle. In the follicular phase, follicle-stimulating hormone (FSH) was 101.3 ng/ml, luteinizing hormone (LH) 46.0 ng/ml, and E2 49.7 pg/ml; in the luteal phase, FSH was 180.0 ng/ml, LH 69.3 ng/ml, and E2 50.1 pg/ml. The presence of ovulatory cycles was documented on the basis of the biphasic pattern of the basal body temperature cycles and the increment in P levels. This case demonstrates the existence of normal ovulatory function in a woman with late-onset of a mild form of HSD.

Differential diagnosis of CT-hypodense cranial lesions with indium-111-oxine-labeled leukocytes

Scintigraphy using indium-111-oxine-labeled white blood cells was used as a complementary diagnostic study in the differential diagnosis of 20 intracerebral cystic lesions for which computerized tomography scanning did not exclude abscess. To lower the rate of false-positive findings with scintiscanning, three criteria of positivity were tested in the 20 lesions. The most stringent criterion yielded 100% sensitivity, 94% specificity, and 96% diagnostic accuracy. The clinical and surgical implications of these results are discussed.

Cystic cavernous angiomas of the posterior fossa. Report of three cases

Three histologically verified cases of cystic cavernous angioma of the posterior fossa are reported. The clinical history of these patients is presented, and the diagnostic and surgical problems arising from the extreme rarity of the combination of cerebellar site and cystic nature of the lesion are discussed.

Endocrine and immunogenetic evaluation of an XX male infant with perineoscrotal hypospadias

To clarify the origin of the genital ambiguity occasionally associated with the XX male syndrome, a series of endocrinological studies were undertaken in an affected 6 months old infant with perineoscrotal hypospadias. The patient fulfilled all the diagnostic criteria of the syndrome: the testes were descended bilaterally, the Mullerian derivatives were absent, the 46,XX chromosome complement was ascertained in different cell lines, and male levels of H-Y antigen were detected in cultured skin fibroblasts. Circulating gonadotrophin levels and pituitary LRH responsiveness were within normal limits for the age group. Serum testosterone (T) levels were normal, and gonadal stimulation with hCG caused a significant rise on serum T. Incubations of [3H]T with fibroblasts from genital skin revealed normal activity of steroid 5 alpha-reductase. Moreover, normal concentrations of thermostable cytosol androgen receptors were revealed in cultured fibroblasts. Altogether the results indicated that ambiguity of the external genitalia in this patient was the result of neither abnormal T biosynthesis, peripheral A-ring T reduction, nor androgen intracellular specific binding, and suggested that the nature of the incomplete virilization could be a non-endocrine independent event associated to this disorder. The data are also consistent with the notion that testicular impairment observed in adult XX males develops later in life.

Omental evisceration through an abdominal stab wound: is exploratory laparotomy mandatory?

The authors reviewed and analysed the records of 75 patients with omental and bowel evisceration as a result of abdominal stab wounds to discover whether omental prolapse makes laparotomy mandatory. Major intraabdominal injuries were found in 82.7% of the total group, 82.9% in those with omental protrusion and 82.5% in patients with bowel prolapse. The nature of the injuries and the incidence of multiple organ trauma were similar in the two groups. Negative laparotomy did not cause important morbidity. The authors conclude that omental herniation after stab wounds of the abdomen should routinely prompt exploratory celiotomy.

[Hepatopathy associated with ulcerative colitis in childhood. Apropos of 2 cases]

Two patients of 3 and 5 years old presented ulcerative colitis associated with liver disease. In both cases, liver biopsy evidenced a severe pericholangitis. The authors have undertaken a comparative bibliographical study, emphasizing the low incidence of this association in our environment. They have also studied the relationship between the hepatic lesion and that of the colonic mucosa.

Right ventricular function in Chagas disease

To study right ventricular function, we performed cardiac catheterization, and right and left cineventriculograms in 60 chagasic patients and 15 non-chagasic, non-heart disease patients. Chagasic patients with normal electrocardiograms and left cineventriculograms also had normal right ventricular function. Nine of 14 chagasic patients with normal Ecg's and early left ventricular damage had right ventricular dilatation and/or segmental inferior-apical asynergy. Fourteen of 19 chagasic patients with abnormal Ecg's and advanced left ventricular damage, but without signs of congestive heart failure, and all chagasic patients with congestive heart failure, had marked right ventricular dilatation, severe right contractility depression and abnormal right apical or para-apical motion. These findings indicate that Chagas disease is a diffuse cardiomyopathy in which the left ventricle seems to be affected earlier and to a greater extent than the right ventricle. Since segmental abnormalities were predominantly observed in apical and para-apical areas of the ventricles, performance of right and left cineventriculograms is recommended before implantation of cardiac pacemakers.

46,XX gonadal absence: a variant of the XX pure gonadal dysgenesis?

Two unrelated 46,XX individuals with female phenotype and sexual infantilism were studied. Endocrine findings showed anoestrogenism and hypergonadotrophism with a normal pituitary response to LRH. Laparotomy disclosed ovarian absence with normal Mullerian derivatives and no gonadal streaks were found within the true pelvis or inguinal canals. This condition represents the 46,XX counterpart of the 46,XY gonadal absence syndrome. Whether the XX agonadism reported here is a different and distinctive entity or is a variant of the XX pure gonadal dysgenesis syndrome can not be ascertained at present.

Clinical and endocrine spectrum in patients with the 45,X/46,XY karyotype

Cytogenetic and endocrine studies were performed in five unrelated 45,X/46,XY individuals in an attempt to correlate them with their clinical expression and gonadal morphology. A lack of a consistent pattern between cytogenetic findings and phenotype was observed. Endocrine studies revealed a wide spectrum of hypothalamic, pituitary, and gonadal hormone production as assessed by the base line levels of LH, FSH, T, and delta 4-A and their responses to appropriate exogenous stimulation (LH-RH and HCG). An adequate correlation between endocrine findings with gonadal morphology and phenotype could be established; thus demonstrating that patients with this particular chromosome complement have a functional integrity of the gonadotropin hypothalamic pituitary activity modulated accordingly with the gonadal function of each particular case.

Hospital-based employees' opinions about adolescents of four racial-ethnic groups

We obtained opinions about adolescents' characteristics and behaviors from 290 employees of a medical school and its hospitals. Employees were asked for their opinions about 4 positive, 2 neutral, and 6 negative characteristics and about 5 sexual, 8 substance use, and 5 relationship behaviors. Most employees were willing to characterize adolescents in general, but fewer were willing to express opinions about white, black, Mexican-American or Oriental teens in particular. There was poor correspondence between the general adolescent ratings, the ratings of the racial-ethnic groups, and reports in the literature. The respondents, unable to accurately describe white and black teens, could not characterize Mexican-American teens and characterized Oriental teens predominantly in the category "least likely to behave this way." The data suggest that adults' stereotyping of adolescents' behaviors and characteristics is common and suggests the need for programs to better inform adults about adolescents.

Gonadotropin dynamics in XX males

Hypothalamic-pituitary gonadotropin function was evaluated in two postpubertal XX males. Serum levels of LH and FSH were moderately elevated, and the serum testosterone level was low. A subnormal response by testicular Leydig cells to hCG was observed. The LH and FSH responses to LRH were normal. A significant LH increase was observed after castration. Weekly administration of testosterone enanthate (250 mg) for 10 consecutive weeks caused a reduction (greater than 75%) in gonadotropins and abolishment of the LRH pituitary response. No differences were observed in terms of gonadotropin dynamics compared with other forms of hypergonadotropic hypogonadism. These results indicate that XX males exhibit hypergonadotropic hypogonadism secondary to testicular failure with a preserved androgen responsiveness of the hypothalamic-pituitary unit.

On the mechanism of action of progestins

The effect of two synthetic injectable progestins, norethisterone oenanthate3 (NET-e) and medroxyprogesterone acetate (MPA) upon the hypothalamic pituitary unit was evaluated in post-menopausal women (PMW) and in castrated individuals with androgen un-responsiveness in order to gain insight into their mechanism of gonadotrophin inhibition. Continuous administration of natural progesterone (P4) to PMW by medicated vaginal rings was used as the experimental control. Elevated base line levels of serum immunoreactive gonadotrophins and normal pituitary LRH responses were found in PMW and pseudohermaphrodites. Progesterone did not affect circulating gonadotrophin levels or the pituitary LRH response in PMW.

Administration of MPA 150 mg induced a clear decrease in serum gonadotrophins and a significant decrease in LRH pituitary responsiveness in a post-menopausal woman whereas no effect was observed on serum gonadotrophins and pituitary response to LRH in a patient with androgen unresponsiveness. Administration of NET-e 200 mg resulted in a significant decrease in circulating gonadotrophins in PMW and pseudohermaphrodites, while LRH pituitary sensitivity was diminished in all subjects except one post-menopausal woman.

These results demonstrated that two structurally different synthetic progestins (NET-e and MPA) had a potent gonadotrophin inhibitory activity in PMW while natural progesterone did not, thus indicating a different mode of action. Furthermore their differing effect on individuals with complete androgen unresponsiveness suggested that antigonadotrophic activity of NET-e is mediated by its oestrogenic-progestational effect, while MPA acts through its androgenic potency and therefore requires the presence of androgen receptors.

Induction of ovulation in a true hermaphrodite with male phenotype

Ovulation was induced in a 16-yr-old 46 XX/47 XXY true hermaphrodite with a male phenotype. The presence of testicular tissue was assessed by a normal androgen response to hCG. Administration of FSH and LH for 8 consecutive days, followed by a single dose of hCG, induced a biphasic serum profile of 17 beta-estradiol and progesterone similar to that observed in normal menstrual cycles. In addition, a significant rise in serum testosterone was noticed during the luteal phase. Laparotomy revealed the presence of a uterus, with evidence of endometrial bleeding and absence of a vagina. These results demonstrated that gonadotropins were able to induce follicular maturation, ovulation, and endometrial bleeding in a true hermaphrodite resembling a normal ovulatory cycle. Gonadotropin administration can be used as a diagnostic tool for establishing the presence of ovarian tissue in this gonadal development abnormality.

[Diagnosis by non-invasive methods of incipient left ventricular lesions in patients with Chagas' disease. Use of echocardiography and mechanocardiography]

In this study, ninety-seven patients with positive complement-fixation reaction for Chagas' disease were submitted to M-mode echocardiograms, fonomechanocardiograms, right and left heart catheterization and left cine-ventriculogram, in an attempt to establish the usefulness of these non-invasive methods for the diagnosis of myocardial damage in Chagasic patients. Only the left ventricular end-diastolic volume determination showed a significant echo-angiographic correlation, as well as a satisfactory sensitivity and specificity to detect early myocardial damage. Therefore, with this parameter it was possible to diagnose 33% of patients which had left ventricular cine-angiographic damage, without clinical, electrocardioangiographic or radiological abnormalities. All other non-invasive parameters measured in this study were useful only in patients with advanced myocardial damage, recognizable by abnormal ECG or clinical signs of congestive heart failure. We recommend to obtain good quality left ventricular ecocardiograms in every chagasic patient, particularly those with normal ECG. This will allow the diagnosis of incipient cardiomyopathy in almost one third of all chagasic patients with early left ventricular abnormalities, recognizable by cine-ventriculograms.

The role of oestrogens on gonadotrophin secretion in the testicular feminization syndrome

The role of oestrogens on gonadotrophin secretion was assessed in three related patients with the complete form of testicular feminization syndrome. Serum LH and FSH levels were measured before and after LRH stimulation as well as before, during and after chronic clomiphene citrate administration. Moderately elevated LH basal levels with a significant LH rise following LRH were observed. Normal or even low FSH level with poor response to LRH were found in all subjects. Administration of clomiphene citrate resulted in a significant serum LH increase without any change of FSH. Following castration both LH and FSH rose and a normal response to LRH was observed. These results were interpreted as demonstrating that, while endogenous oestrogens modulate LH secretion in patients with androgen unresponsiveness, it plays no role in regulating FSH secretion and suggested that a factor of testicular origin without androgenic or oestrogenic activity is responsible for FSH regulation.