Giovani Gadonski

Gemcitabine Monotherapy Associated with Posterior Reversible Encephalopathy Syndrome

Posterior reversible encephalopathy syndrome is a clinicoradiologic entity that may present with headaches, altered mental status, seizures and visual loss as well as specific neuroimaging findings. We report a case of a 74-year-old woman receiving adjuvant gemcitabine chemotherapy as monotherapy for a stage IIa pancreatic adenocarcinoma, who developed posterior reversible encephalopathy syndrome.

Posterior Reversible Encephalopathy Syndrome Following a Scorpion Sting

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic entity not yet understood, that is present with transient neurologic symptoms and particular radiological findings. The most common imaging pattern in PRES is the presence of edema in the white matter of the posterior portions of both cerebral hemispheres. The cause of PRES is unclear. We report a case of 13‐year‐old male who was stung by a scorpion and developed a severe headche, visual disturbance, and seizures and had the diagnosis of PRES with a good outcome. Numerous factors can trigger this syndrome, most commonly: acute elevation of blood pressure, abnormal renal function, and immunosuppressive therapy. There are many cases described showing the relationship between PRES and eclampsia, transplantation, neoplasia and chemotherapy treatment, systemic infections, renal disease acute, or chronic. However, this is the first case of PRES following a scorpion sting.

Flow-mediated dilatation in the differential diagnosis of preeclampsia syndrome

BACKGROUND The preeclampsia syndrome is associated with endothelial dysfunction and the differential diagnosis between pure preeclampsia (PE) and superimposed preeclampsia (SPE) can be only be attained 12 weeks after delivery. OBJECTIVE To compare the assessment of endothelial function through flow-mediated dilatation in pregnant women with pure preeclampsia and superimposed preeclampsia. METHODS The flow-mediated dilatation of the brachial artery was carried out according to the recommendations of the International Brachial Artery Reactivity Task Force in pregnant women with preeclampsia syndrome. PE (n=14) and SPE (n=13) were diagnosed in the postpartum period according to the definitions of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. RESULTS The median of the flow-mediated dilatation (FMD) in SPE (6.0%; 1.9-10.3) was decreased in comparison with the PE (13.6%;4.4-17.1), an apparently relevant difference , but not statistically significant (p = 0.08). The FMD < 10% was detected in 30.8% of the PE cases and in 69.2% of the SPE cases (p = 0.057). Significant differences could not be detected in the morphology of the uterine arteries between the PE and SPE cases through the Doppler spectrum. CONCLUSION The FMD of the brachial artery of patients with preeclampsia syndrome was not capable of differentiating between PE and SPE. However, the data suggest that SPE is associated with worse endothelial function I comparison to PE.FUNDAMENTO: El sindrome de preeclampsia se asocia con la disfuncion endotelial y el diagnostico diferencial entre preeclampsia pura (PE) y sobreagregada (PES) solo puede realizarse 12 semanas despues del parto. OBJETIVO: Comparar la evaluacion de la funcion endotelial a traves de dilatacion mediada por flujo en gestantes con preeclampsia pura y sobreagregada. METODOS: La dilatacion mediada por flujo de la arteria braquial se realizo utilizando las recomendaciones de la International Brachial Artery Reactivity Task Force en gestantes con Sindrome de Preeclampsia. La Preeclampsia (n = 14) y preeclampsia sobreagregada (n = 13) fueron diagnosticadas en el posparto segun las definiciones del National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. RESULTADOS: El promedio de la dilatacion mediada por flujo (DMF) en la PES (6,0%; 1,9-10,3) fue reducido en comparacion con la PE (13,6%; 4,4-17,1), una disparidad aparentemente relevante, pero sin diferencia estadisticamente significativa (p = 0,08). Una DMF inferior al 10% se detecto en el 30,8% de las PE y en el 69,2% de las PES (p = 0,057). No aparecieron diferencias significativas en la comparacion entre la morfologia de las arterias uterinas de PE y PES a traves del espectro del Doppler. CONCLUSION: La DMF de la arteria braquial de pacientes con Sindrome de Preeclampsia no demostro ser un metodo capaz de diferenciar PE de PES. No obstante, los datos sugieren que la PES se asocia a una peor funcion endotelial en comparacion con la PE.

Blood–Brain Barrier Breakdown in Reduced Uterine Perfusion Pressure: A Possible Model of Posterior Reversible Encephalopathy Syndrome

BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a clinical entity characterized by headaches, altered mental status, seizures, and visual disturbances and is associated with white matter vasogenic edema. There are no experimental models to study PRES brain changes. METHODS Twenty-eight pregnant Wistar rats were divided into 4 groups of 7: (1) pregnant-control; (2) reduced uterine perfusion pressure (RUPP); (3) invasive blood pressure (IBP); and (4) reduced uterine perfusion pressure plus invasive blood pressure (RUPP-IBP). The RUPP and RUPP-IBP groups were submitted to a reduction of uterine perfusion pressure at pregnancy days 13 to 15. The invasive mean arterial pressure of the IBP and RUPP-IBP groups was measured on day 20. The blood-brain barriers (BBBs) of all groups were analyzed using 2% Evans Blue dye on day 21. RESULTS RUPP rats had higher blood pressures and increased BBB permeability to Evans Blue dye compared with the control animals. Brain staining occurred in 11 of 14 RUPP rats and in none of the control groups (P < .0001). CONCLUSIONS The physiopathology of PRES remains unclear. Here, we described the use of RUPP rats as a potential model to better comprehend this syndrome.

Posterior Reversible Encephalopathy Syndrome Associated with FOLFOX Chemotherapy

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic entity characterized by headaches, altered mental status, seizures, visual loss, and characteristic imaging pattern in brain MRI. The cause of PRES is not yet understood. We report a case of a 27-year-old woman that developed PRES after the use of FOLFOX 5 (oxaliplatin/5-Fluoracil/Leucovorin) chemotherapy for a colorectal cancer.

Síndrome da encefalopatia posterior reversível (PRES) e lúpus eritematoso sistêmico: relato de dois casos

The posterior reversible encephalopathy syndrome (PRES) is a novel entity clinically manifested by headache, changes of sensorium, seizures, and visual loss. PRES pathogenesis has not been fully clarified. The entity can be associated to a variety of clinical conditions, mainly hypertension, renal insufficiency and immunosuppressive therapy. A possible link of autoimmune disorders with PRES has been recently hypothesized. We herein describe two cases of systemic lupus erythematosus whereby PRES was triggered by different factors.

PP040. Expression of RANTES (CCL5) in maternal plasma, fetal plasma and placenta in pre-eclampsia and normotensive controls

INTRODUCTION Studies have shown pre-eclampsia (PE) as an exacerbation of gestational inflammatory process. RANTES (Regulated upon Activation, Normal T-cell Expressed, and Secreted)/CCL5 is a chemokine, which is involved in chronic inflammation by the recruitment of inflammatory cells. It is secreted by many cell types such as endothelial cells, smooth muscle cells, macrophages, platelets and activated T-cells. Thus we hypothesized that RANTES expression is altered in PE and may be different in gestational tissues (maternal plasma, fetal plasma and placenta). OBJECTIVES The purpose of the study is to analyze the expression of RANTES (CCL5) in three different tissues: maternal plasma, fetal plasma and placenta, in PE and normotensive controls (NC). METHODS PE was diagnosed by the National High Blood Pressure Education Program Working Group Report on High Blood Pressure in Pregnancy guidelines. The patients were assisted in the São Lucas Hospital from PUCRS, Porto Alegre, Brazil. Following ethical approval and informed written consent, maternal and umbilical plasma and placental biopsies were taken from 33 PE and 35 NC. Samples were centrifuged immediately after blood collection and plasma was stored at -80°C until assay. Placental Biopsies were taken midway between the cord and periphery, from the central region of cotyledons and were stored as well. RANTES expression was made by the ELISA test, in duplicates. They were also analyzed in each group: maternal age, maternal parity, gestational age on delivery, glucose, body mass index, proteinúria creatinuria ratio, systolic blood pressure (SBP), diastolic blood pressure (DBP), delivery method, birth weight, placental weight and Apgar index in 1st and 5th minute. RESULTS Maternal age at the time of blood collection was not significantly different between the two groups. The women with preeclampsia delivered earlier and had smaller babies compared with the controls. Significant associations between groups (p<0.001) were seen in SBP, DBP, birth weight and delivery method. RANTES was increased in maternal plasma and placenta in patients with PE and decreased in fetus plasma in the same group (p<0.001). CONCLUSION In this study, we have shown that RANTES expression in maternal plasma and placenta tissues, in women with established pre-eclampsia, is higher than in gestation-matched women with a healthy pregnancy. It confirms the hypotheses that physiology of PE is associated with an increase of normal gestational inflammatory process. However in fetus tissue, the inflammatory chemokine is decreased in PE women. FUNDING CAPES Foundation, Ministry of Education of Brazil, Brasília - DF 70040-020, Brazil.

Dilatação mediada por fluxo no diagnóstico diferencial da síndrome de pré-eclâmpsia

BACKGROUND The preeclampsia syndrome is associated with endothelial dysfunction and the differential diagnosis between pure preeclampsia (PE) and superimposed preeclampsia (SPE) can be only be attained 12 weeks after delivery. OBJECTIVE To compare the assessment of endothelial function through flow-mediated dilatation in pregnant women with pure preeclampsia and superimposed preeclampsia. METHODS The flow-mediated dilatation of the brachial artery was carried out according to the recommendations of the International Brachial Artery Reactivity Task Force in pregnant women with preeclampsia syndrome. PE (n=14) and SPE (n=13) were diagnosed in the postpartum period according to the definitions of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. RESULTS The median of the flow-mediated dilatation (FMD) in SPE (6.0%; 1.9-10.3) was decreased in comparison with the PE (13.6%;4.4-17.1), an apparently relevant difference , but not statistically significant (p = 0.08). The FMD < 10% was detected in 30.8% of the PE cases and in 69.2% of the SPE cases (p = 0.057). Significant differences could not be detected in the morphology of the uterine arteries between the PE and SPE cases through the Doppler spectrum. CONCLUSION The FMD of the brachial artery of patients with preeclampsia syndrome was not capable of differentiating between PE and SPE. However, the data suggest that SPE is associated with worse endothelial function I comparison to PE.FUNDAMENTO: El sindrome de preeclampsia se asocia con la disfuncion endotelial y el diagnostico diferencial entre preeclampsia pura (PE) y sobreagregada (PES) solo puede realizarse 12 semanas despues del parto. OBJETIVO: Comparar la evaluacion de la funcion endotelial a traves de dilatacion mediada por flujo en gestantes con preeclampsia pura y sobreagregada. METODOS: La dilatacion mediada por flujo de la arteria braquial se realizo utilizando las recomendaciones de la International Brachial Artery Reactivity Task Force en gestantes con Sindrome de Preeclampsia. La Preeclampsia (n = 14) y preeclampsia sobreagregada (n = 13) fueron diagnosticadas en el posparto segun las definiciones del National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. RESULTADOS: El promedio de la dilatacion mediada por flujo (DMF) en la PES (6,0%; 1,9-10,3) fue reducido en comparacion con la PE (13,6%; 4,4-17,1), una disparidad aparentemente relevante, pero sin diferencia estadisticamente significativa (p = 0,08). Una DMF inferior al 10% se detecto en el 30,8% de las PE y en el 69,2% de las PES (p = 0,057). No aparecieron diferencias significativas en la comparacion entre la morfologia de las arterias uterinas de PE y PES a traves del espectro del Doppler. CONCLUSION: La DMF de la arteria braquial de pacientes con Sindrome de Preeclampsia no demostro ser un metodo capaz de diferenciar PE de PES. No obstante, los datos sugieren que la PES se asocia a una peor funcion endotelial en comparacion con la PE.

Is there any relationship between ABO/Rh blood group and patients with pre-eclampsia?

OBJECTIVES The purpose of the present study was to evaluate the association between pre-eclampsia and blood groups in a group of pregnant women hospitalized in a University Hospital in Porto Alegre, Brazil - Hospital São Lucas (HSL)/PUCRS. STUDY DESIGN Our sample consisted of 10,040 pregnant women admitted to the maternity department of HSL between 2005 and 2010. The patients were reviewed retrospectively for inclusion. Medical records of 414 women were diagnosed as preeclampsia/eclampsia and 9611 women were identified to the control group. The patients were divided into two groups: the group with preeclampsia/eclampsia and the control group, and their blood groups were considered. Data were analyzed using SPSS for Windows version 17.0. Categorical data were summarized by counts and percentages, with the statistical significance evaluated by the Chi-square test. The null hypothesis was rejected when p<0.05. MAIN OUTCOME MEASURES Maternal parameters were compared between control group and pre-eclampsia, respectively, Systolic Blood Pressure (117±19.98 vs. 165±19.99); Diastolic Blood Pressure (73±14.23 vs. 106±14.24) and maternal weight at booking (73±33 vs. 83±33). For all data: mean+SD; p<0.05. In relation to blood groups, firstly they were stratified by Rh and ABO phenotypes, separately. After that the groups were put together. RESULTS No differences in blood group distribution were observed between controls and pre-eclampsia for any analysis. (p>0.05). CONCLUSIONS When we adopted stricter criteria for pre-eclampsia and a large sample from the same region we noted that the results did not show any association between blood groups and the development of pre-eclampsia.

Using the Reduced Uterine Perfusion Pressure model of preeclampsia to study the blood brain barrier permeability

AIMS: To use the Reduced Uterine Perfusion Pressure (RUPP) model for preeclampsia to describe and evaluate the blood brain barrier permeability in pregnant rats. METHODS: Forty-one pregnant Wistar rats were divided into different intervention groups between 13 to 15 days of gestation: Pregnant-Control (PC; n=12), Reduced Uterine Perfusion Pressure (RUPP; n=15), Invasive Blood Pressure-Control (IBP; n=7) and Reduced Uterine Perfusion Pressure and Invasive Blood Pressure (RUPP-IBP; n=7). The 14 rats of groups IBP and RUPP-IBP had their mean arterial pressure measured at day 21. All animals were then sacrificed, administered Evans Blue dye through the tail vein and perfused with paraformaldehyde 4%. Brains were removed and evaluated by a blinded pathologist. Results are presented as means and standard errors. Comparisons between the groups were performed using Students t-test for continuous variables and Fisher’s exact test for categorical variables. Statistical significance was set as a p value less than 0.05. RESULTS: Mean arterial pressure averaged 85.4±2.2 mmHg in the IPB group and 102.5±8.3 mmHg in the RUPP-IPB group (p=0.002). Among all the RUPP rats (RUPP and RUPP-IBP groups), 82% had a positive staining with Evans Blue dye for at least one of the brain hemispheres, while none of the pregnant control rats (PC and IBP groups) had brain staining (p<0.001). CONCLUSIONS: In this study, altered permeability of the blood brain barrier was successfully reproduced in pregnant rats exposed to the RUPP protocol. Therefore, we concluded that the RUPP model is a valid surrogate to study blood brain barrier abnormalities.