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Update on the etiology, diagnosis and therapeutic management of sexual precocity
Brito, Vinicius Nahime;Latronico, Ana Claudia;Arnhold, Ivo J. P.;Mendon?a, Berenice Bilharinho;
Arquivos Brasileiros de Endocrinologia & Metabologia , 2008, DOI: 10.1590/S0004-27302008000100005
Abstract: precocious puberty is defined as the development of secondary sexual characteristics before the age of 8 years in girls and 9 years in boys. gonadotropin-dependent precocious puberty (gdpp) results from the premature activation of the hypothalamic-pituitary-gonadal axis and mimics the physiological pubertal development, although at an inadequate chronological age. hormonal evaluation, mainly through basal and gnrh-stimulated lh levels shows activation of the gonadotropic axis. gonadotropin-independent precocious puberty (gipp) is the result of the secretion of sex steroids, independently from the activation of the gonadotropic axis. several genetic causes, including constitutive activating mutations in the human lh-receptor gene and activating mutations in the gs protein a-subunit gene are described as the etiology of testotoxicosis and mccune-albright syndrome, respectively. the differential diagnosis between gdpp and gipp has direct implications on the therapeutic option. long-acting gonadotropin-releasing hormone (gnrh) analogs are the treatment of choice in gdpp. the treatment monitoring is carried out by clinical examination, hormonal evaluation measurements and image studies. for treatment of gipp, drugs that act by blocking the action of sex steroids on their specific receptors (cyproterone, tamoxifen) or through their synthesis (ketoconazole, medroxyprogesterone, aromatase inhibitors) are used. in addition, variants of the normal pubertal development include isolated forms of precocious thelarche, precocious pubarche and precocious menarche. here, we provide an update on the etiology, diagnosis and management of sexual precocity.
Warfarin in patients with cardioembolic stroke  [cached]
E.N. Dankovtseva,S.L. Arkhipov,D.A. Zateyshchikov
Rational Pharmacotherapy in Cardiology , 2012,
Abstract: Analysis of the current literature data on the use of warfarin in patients with cardioembolic stroke is presented. Cardioembolic stroke pathology and particularities of this condition therapy with antithrombotic medications are shown in details. Possibility to apply thrombolysis during warfarin treatment and the use of anticoagulants after cardioembolic stroke is discussed.
Cardioembolic Sources in Stroke Patients in South of Brazil  [PDF]
Luiz Carlos Porcello Marrone,Jo?o Pedro Farina Brunelli,Ricardo Lutzky Saute,Gustavo Henrique Tomasi,Bianca Cecchele Madeira,William Alves Martins,Robson Dupont Rohr,Ana Paula Heck,Luiz Ricardo Botton,Marilia Martins de Castro,Rodrigo Bodanese,Luiz Carlos Bodanese,Ant?nio Carlos Huf Marrone,Jaderson Costa da Costa
Thrombosis , 2014, DOI: 10.1155/2014/753780
Abstract: Background. Stroke is a leading cause of mortality and disability in Brazil and around the world. Cardioembolism is responsible for nearly 30% of the origins of ischemic stroke. Methods. We analyzed data of 256 patients with cardioembolic ischemic stroke (according to TOAST classification) who were admitted into the Hospital S?o Lucas-PUCRS from October 2011 to January 2014. The cardioembolic subtype was divided into six subgroups: arrhythmias, valvular heart disease, coronary artery disease, cardiomyopathy, septal abnormalities, and intracardiac injuries. The prevalence of the most important cardiovascular risk factors and medications in use for prevention of systemic embolism by the time of hospital admission was analyzed in each patient. Results. Among 256 patients aged 60.2 +/? 6.9 years, 132 males, arrhythmias were the most common cause of cardioembolism corresponding to 50.7%, followed by valvular heart disease (17.5%) and coronary artery disease (16%). Hypertension (61.7%) and dyslipidemia (43.7%) were the most common risk factors. Less than 50% of patients with arrhythmias were using oral anticoagulants. Conclusions. Identifying the prevalence of cardioembolic stroke sources subgroups has become an increasingly important role since the introduction of new oral anticoagulants. In this study, arrhythmias (especially atrial fibrillation) were the main cause of cardioembolism. 1. Introduction Stroke is the leading cause of mortality and disability in Brazil and South America. However, there is little knowledge about stroke epidemiology, stroke subtypes, and risk factors in Latin America [1–3]. Basically strokes can be divided into ischemic (85%) and hemorrhagic (15%). The clinical characteristics of stroke vary according to etiology and risk factors. To facilitate and standardize the classification of stroke subtypes, it was developed in 1993—the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification which divides the ischemic stroke into five subtypes: large-artery atherosclerosis, cardioembolism, small-vessel occlusion, stroke of other determined etiology, and stroke of undetermined etiology. Knowledge of the etiology of ischemic events is essential for correct treatment and secondary prevention to improve the best patient outcomes [4, 5]. In the south of Brazil, the most important source of ischemic stroke is large-artery atherosclerosis followed by cardioembolism and small-vessel disease. Cardioembolism is responsible for nearly 30% of the origins of ischemic stroke [2, 6, 7]. Cardioembolism can be subdivided into six subgroups:
Update on celiac disease – etiology, differential diagnosis, drug targets, and management advances
Scanlon SA, Murray JA
Clinical and Experimental Gastroenterology , 2011, DOI: http://dx.doi.org/10.2147/CEG.S8315
Abstract: ate on celiac disease – etiology, differential diagnosis, drug targets, and management advances Review (7531) Total Article Views Authors: Scanlon SA, Murray JA Published Date December 2011 Volume 2011:4 Pages 297 - 311 DOI: http://dx.doi.org/10.2147/CEG.S8315 Samantha A Scanlon1, Joseph A Murray1,2 1Department of Internal Medicine, 2Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA Abstract: Celiac disease (CD) is an immune-mediated enteropathy triggered by exposure to wheat gluten and similar proteins found in rye and barley that affects genetically susceptible persons. This immune-mediated enteropathy is characterized by villous atrophy, intraepithelial lymphocytosis, and crypt hyperplasia. Once thought a disease that largely presented with malnourished children, the wide spectrum of disease activity is now better recognized and this has resulted in a shift in the presenting symptoms of most patients with CD. New advances in testing, both serologic and endoscopic, have dramatically increased the detection and diagnosis of CD. While the gluten-free diet is still the only treatment for CD, recent investigations have explored alternative approaches, including the use of altered nonimmunogenic wheat variants, enzymatic degradation of gluten, tissue transglutaminase inhibitors, induction of tolerance, and peptides to restore integrity to intestinal tight junctions.
Racial Differences by Ischemic Stroke Subtype: A Comprehensive Diagnostic Approach  [PDF]
Sarah Song,Richard E. Burgess,Chelsea S. Kidwell
Stroke Research and Treatment , 2012, DOI: 10.1155/2012/735097
Abstract: Background. Previous studies have suggested that black populations have more small-vessel and fewer cardioembolic strokes. We sought to analyze racial differences in ischemic stroke subtype employing a comprehensive diagnostic workup with magnetic resonance-imaging-(MRI-) based evaluation including diffusion-weighted imaging (DWI). Methods. 350 acute ischemic stroke patients admitted to an urban hospital with standardized comprehensive diagnostic evaluations were retrospectively analyzed. Ischemic stroke subtype was determined by three Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification systems. Results. We found similar proportions of cardioembolic and lacunar strokes in the black and white cohort. The only subtype category with a significant difference by race was “stroke of other etiology,” more common in whites. Black stroke patients were more likely to have an incomplete evaluation, but this did not reach significance. Conclusions. We found similar proportions by race of cardioembolic and lacunar strokes when employing a full diagnostic evaluation including DWI MRI. The relatively high rate of cardioembolism may have been underappreciated in black stroke patients when employing a CT approach to stroke subtype diagnosis. Further research is required to better understand the racial differences in frequency of “stroke of other etiology” and explore disparities in the extent of diagnostic evaluations. 1. Introduction Prior studies have demonstrated a significantly higher incidence of both ischemic and hemorrhagic stroke in black patients compared to whites [1–3]. For ischemic stroke, population-based studies in North America have specifically reported an increased incidence of small vessel, large artery (intracranial), and undetermined stroke subtypes in the black population [1, 2, 4, 5]. In addition, several studies have examined differences in the proportion or distribution of ischemic stroke subtypes by race. Specifically, these studies have found a greater proportion of small vessel strokes [6–8] and a counterbalancing smaller proportion of cardioembolic strokes [1, 2] in blacks as compared to whites. These racial differences have been attributed, in part, to a higher prevalence of stroke risk factors in blacks, including smoking, hypertension, and diabetes [2]. However, there is the possibility that the incidence rates of certain subtypes of strokes, such as extracranial large artery, lacunar or cardioembolic subtypes, have been under- or overestimated in some studies due to incomplete diagnostic workup. In these previous studies,
Cardioembolic but Not Other Stroke Subtypes Predict Mortality Independent of Stroke Severity at Presentation  [PDF]
Latha Ganti Stead,Rachel M. Gilmore,M. Fernanda Bellolio,Anunaya Jain,Alejandro A. Rabinstein,Wyatt W. Decker,Dipti Agarwal,Robert D. Brown Jr.
Stroke Research and Treatment , 2011, DOI: 10.4061/2011/281496
Abstract: Introduction. Etiology of acute ischemic stroke (AIS) is known to significantly influence management, prognosis, and risk of recurrence. Objective. To determine if ischemic stroke subtype based on TOAST criteria influences mortality. Methods. We conducted an observational study of a consecutive cohort of patients presenting with AIS to a single tertiary academic center. Results. The study population consisted of 500 patients who resided in the local county or the surrounding nine-county area. No patients were lost to followup. Two hundred and sixty one (52.2%) were male, and the mean age at presentation was 73.7 years (standard deviation, SD = 14.3). Subtypes were as follows: large artery atherosclerosis 97 (19.4%), cardioembolic 144 (28.8%), small vessel disease 75 (15%), other causes 19 (3.8%), and unknown 165 (33%). One hundred and sixty patients died: 69 within the first 30 days, 27 within 31–90 days, 29 within 91–365 days, and 35 after 1 year. Low 90-, 180-, and 360-day survival was seen in cardioembolic strokes (67.1%, 65.5%, and 58.2%, resp.), followed for cryptogenic strokes (78.0%, 75.3%, and 71.1%). Interestingly, when looking into the cryptogenic category, those with insufficient information to assign a stroke subtype had the lowest survival estimate (57.7% at 90 days, 56.1% at 180 days, and 51.2% at 1 year). Conclusion. Cardioembolic ischemic stroke subtype determined by TOAST criteria predicts long-term mortality, even after adjusting for age and stroke severity. 1. Introduction Etiology of acute ischemic stroke (AIS) is known to significantly influence management, prognosis, and risk of recurrence. Certain stroke subtypes are associated with higher stroke severity at the time of presentation, which may account for the higher mortality seen. In 1993 the TOAST (Trail of ORG 10172 in Acute Stroke Treatment) investigators described a classification of AIS based on etiology, which is now the most commonly used etiological classification [1]. Comparison of clinical characteristics, functional outcomes, and mortality rates for specific ischemic stroke mechanisms may allow clinicians to identify those patients who are at higher risk and to evaluate treatment strategies more definitely. We conducted an observational study of all patients who presented to the emergency department (ED) with AIS and determined if ischemic stroke subtype (ISS) influences mortality even after correcting for stroke severity on initial presentation. 2. Methods This study was conducted at a tertiary care academic medical center, with an annual ED census of approximately
A cardioembolic stroke  [PDF]
N. Benyounes, R. Blanc, S. Welschbillig, M. Obadia, G. Chevalier, A. Cohen
World Journal of Cardiovascular Diseases (WJCD) , 2014, DOI: 10.4236/wjcd.2014.41003
Abstract:

A 76-year-old woman with unspecified congenital heart disease was admitted on April 25th for TIA. She had a possible history of atrial fibrillation. A slight fever was noted on admission. Her ECG was abnormal, as well as her transthoracic echocardiography (TTE). Troponin I was slightly increased. On May 11th, a stroke occurred, in relation with an occlusion of the basilar artery. The patient was transferred to our institution for an emergency desobstruction. A dramatic improvement allowed her to be discharged to a rehabilitation center on May 18th. However, she was re-hospitalized on June 5th, due to sepsis and neurological worsening. MRI showed new ischemic brain lesions. Several episodes of paroxysmal atrial fibrillation were documented, as well as pulmonary hypertension. Effective heparin therapy was initiated and transesophageal echocardiography (TEE) was requested this time. It revealed a congenital valvular heart disease (a subaortic membrane), complicated by infective endocarditis. Despite a monitoring of aPTT, a fatal hemorrhagic shock occurred. We report this unfortunately remarkable case to address the following important points: 1) In the setting of a neurological event, abnormal ECG and/or abnormal TTE and/or Troponin I elevation may indicate a cardioembolic mechanism and therefore seek a cardiac source of embolism. 2) When TTE fails to identify a cardiac source of embolism, TEE should be performed, especially when a preexisting heart disease is suspected or known. 3) The multiplicity in space (infarcts in both the anterior and posterior circulation, or bilateral) and/or the multiplicity in time (infarcts of different age) may indicate a cardioembolic stroke. 4) Congenital subaortic membrane predisposes to infective endocarditis. 5) When anticoagulant therapy is initiated on strong arguments in a septic patient (much discussed in infective endocarditis), aPTT monitoring alone may not be enough. An anti-Xa monitoring may be more appropriate.

Antithrombotic Medication for Cardioembolic Stroke Prevention  [PDF]
M. àngels Font,Jerzy Krupinski,Adrià Arboix
Stroke Research and Treatment , 2011, DOI: 10.4061/2011/607852
Abstract: Embolism of cardiac origin accounts for about 20% of ischemic strokes. Nonvalvular atrial fibrillation is the most frequent cause of cardioembolic stroke. Approximately 1% of population is affected by atrial fibrillation, and its prevalence is growing with ageing in the modern world. Strokes due to cardioembolism are in general severe and prone to early recurrence and have a higher long-term risk of recurrence and mortality. Despite its enormous preventive potential, continuous oral anticoagulation is prescribed for less than half of patients with atrial fibrillation who have risk factors for cardioembolism and no contraindications for anticoagulation. Available evidence does not support routine immediate anticoagulation of acute cardioembolic stroke. Anticoagulation therapy's associated risk of hemorrhage and monitoring requirements have encouraged the investigation of alternative therapies for individuals with atrial fibrillation. New anticoagulants being tested for prevention of stroke are low-molecular-weight heparins (LMWH), unfractionated heparin, factor Xa inhibitors, or direct thrombin inhibitors like dabigatran etexilate and rivaroxaban. The later exhibit stable pharmacokinetics obviating the need for coagulation monitoring or dose titration, and they lack clinically significant food or drug interaction. Moreover, they offer another potential that includes fixed dosing, oral administration, and rapid onset of action. There are several concerns regarding potential harm, including an increased risk for hepatotoxicity, clinically significant bleeding, and acute coronary events. Therefore, additional trials and postmarketing surveillance will be needed. 1. Introduction Embolism of cardiac origin accounts for about 20% of ischemic strokes. Several heart conditions enhance stroke risk. Atrial fibrillation is the most common condition of cardioembolic stroke, and anticoagulation is the treatment generally indicated for secondary prevention and in some cases for primary prevention. In this review, we analyse cardiac conditions prone to cardioembolic infarct and its management. We review atrial fibrillation, acute myocardial infarct, congestive heart failure and dilated cardiomyopathies, cardiac procedures, pacemakers, valve diseases, and endocarditis. We provide a table with AHA recommendations for patients with cardioembolic stroke types (Table 1) [1]. Transesophageal echocardiography has also provided evidence that the aortic arch is a common source of embolic material, but the risk of cerebral embolism appears to be directly related to the size of
Cardioembolic stroke on unaffected side during thrombolysis for acute ischemic stroke  [cached]
Garg Arun,Yaduvanshi Amitabh,Mohindra Kapil
Neurology India , 2010,
Abstract: Cardiac thrombus is not an established contraindication to thrombolysis with intravenous tissue plasminogen activator in acute ischemic stroke. Recurrent ischemic stroke involving an initially unaffected arterial territory during the course of thrombolysis in stroke has been reported, but remains exceptionally rare. We present a case that developed cardioembolic stroke on the previously unaffected side during thrombolysis for acute ischemic stroke.
Update on celiac disease – etiology, differential diagnosis, drug targets, and management advances  [cached]
Scanlon SA,Murray JA
Clinical and Experimental Gastroenterology , 2011,
Abstract: Samantha A Scanlon1, Joseph A Murray1,21Department of Internal Medicine, 2Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USAAbstract: Celiac disease (CD) is an immune-mediated enteropathy triggered by exposure to wheat gluten and similar proteins found in rye and barley that affects genetically susceptible persons. This immune-mediated enteropathy is characterized by villous atrophy, intraepithelial lymphocytosis, and crypt hyperplasia. Once thought a disease that largely presented with malnourished children, the wide spectrum of disease activity is now better recognized and this has resulted in a shift in the presenting symptoms of most patients with CD. New advances in testing, both serologic and endoscopic, have dramatically increased the detection and diagnosis of CD. While the gluten-free diet is still the only treatment for CD, recent investigations have explored alternative approaches, including the use of altered nonimmunogenic wheat variants, enzymatic degradation of gluten, tissue transglutaminase inhibitors, induction of tolerance, and peptides to restore integrity to intestinal tight junctions.Keywords: immune-mediated enteropathy, gliadin, gluten, epidemiology, CD diagnosis, therapy
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