Marcos Martins da Silva

Neurological examination: pioneering authors and their books

The objective of this article is to highlight some of the most important pioneering books specifically focused on the neurological examination and their authors. During the XIX Century, Alexander Hammond, William Gowers and Charles Mills pioneered the neurological literature, followed in the XX Century by Aloysio de Castro, Monrad-Krohn, Derek Denny-Brown, Robert Wartenberg, Gordon Holmes, and Russel DeJong. With determination and a marked sense of observation and research, they competently developed and spread the technique and art of the neurological exam.

Fatores determinantes da letalidade após cirurgia para endocardite infecciosa

The factors leading to high postoperative mortality in active infectious endocarditis (IE) are poorly defined. We studied patients operated at an University Hospital between March 1978 and April 1992. We hipothesized that the summation of potential adverse factors would strongly increase mortality after surgery. We studied 39 patients (28 men), age range 13-70 years (mean±SD =32±16) operated during active IE (time from onset 52+48 days). Predisposing factor: rheumatic valvar disease in 14 cases, intravenous drug use in 5. Affected valves: aortic in 14, mitral in 10, tricuspid in 8, multiple structures in 7. In most cases, S aureus (12) or Streptoccocus sp (10) was isolated in blood cultures. Surgery was indicated in most patients because of heart failure (30), multiple embolic complications (17) or treatment failure (14). The possible adverse influence of specific demographic characteristics, clinical features and surgical variables was assessed by the Student t test or the %2 test. Also, multple regression analysis was performed in order to identify independent adverse factors for increased mortality. Positive correlations were further investigated with the X2 test to assess whether an increasing number of adverse factors could identify a special subset of patients with markedly elevated death risk. Fourteen patients (36%) died after surgery. Emergency surgery (p = 0.001), the presence of coma 6 hours after surgery (p = 0.0015) and S. aureus infection (p = 0.023) were all associated with increased mortality. The presence of neurological complications was correlated with a high mortality (54% vs. 27%). However this increase was of dubious statistical significance (p = 0.097). Multiple regression analysis confirmed S. aureus and emergency surgery as independent adverse factors for increased mortality. When put together, an increasing number of adverse factors was highly predictive of a fatal outcome, even after exclusion of that evaluated after surgery (level of consciousness). Patients with two or three adverse factors had a very high mortality rate (>76.9%). Mortality following surgery for active IE is increased in patients operated on an emergency basis especially if the infection is caused by S. aureus. The presence of neurological complications may also be associated with worse outcome. Early consideration of surgery should reduce the high mortality in patients with active IE.

How long does it take for putting on sneakers? An obsessive-compulsive ritual

A 24-year-old man with an 11-year history of obsessivecompulsive disorder with good insight presented with an otherwise unremarkable neurologic examination. Besides tic-like compulsions and obsessional thoughts about harming himself, he takes 1 minute and 25 seconds to put on each foot sneaker, a task usually expected to be accomplished in less than 5 seconds. The ritual (Figure) includes fingers repetitive movements (A to F), the need to hear the pounding of feet on the ground (G, H), and marching in the same place for sixteen steps (I to L). Obsessive-compulsive disorder is a distressing, time-consuming disease to which the neuropsychiatric science owes an adequate etiopathogenesis and treatment.

Delayed hemichorea syndrome associated with nonketotic hyperglycemia

A 69-year-old woman was admitted for investigation of an acute-onset right hemichorea1. T1-weighted brain magnetic resonance imaging (MRI) showed hyperintensity in the left basal ganglia (Figs 1A and B). Although diabetic, she had no hyperglycemia. Interestingly, two weeks earlier, the patient was admitted due to nonketotic hyperglycemia. Brain computed tomography, previously reported as normal (Fig 1C), showed subtle Delayed hemichorea syndrome associated with nonketotic hyperglycemia Sindrome de hemicoreia tardia associada ao estado hiperglicemico nao cetotico Tiago Aguiar, Renata Nogueira, Rafael Vidon, Marcos Martins da Silva, Pericles Maranhao-Filho