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Peripheral nerve blocks are common and effective means for anesthesia for limb surgery. The evaluation of the success of a peripheral blockade is based on the loss of sensation, with no objective means of detecting a successful block. The autonomic innervation to the upper extremity, which controls both the vascular tone and the activity of sweat glands, is supplied by nerve fibers accompanying the somatic nerve fibers. Previous studies have shown changes in both skin temperature and electrical resistance of the skin following brachial plexus block. We studied 20 patients undergoing hand surgery under infraclavicular brachial plexus block. The electrical resistance of the skin on the palmar aspect of the forearm was continuously recorded on the block arm and on the contralateral arm using a commercial skin resistance monitor. No statistically significant change in the electrical resistance of the skin was observed during 20 minutes after placement of the block. These results strongly suggest that the electrical resistance of the skin cannot be used to predict a successful infraclavicular block.

Our purpose was to evaluate the outcome of patients aged 70 years or older with a first-ever acute ischemic stroke and to identify the factors which determine poor outcome. Data from 115 patients, non-disabled prior to stroke, consecutively admitted to a medical department of a teaching hospital over a 30-month period, were prospectively collected at stroke onset and 6-month follow-up. Clinical and brain imaging findings and functional status were recorded. Predictors of unfavorable outcome at 6 months, defined as a modified Rankin Scale score >2, were analyzed by multiple logistic regression. The mean age of this cohort was 78.6 years (SD, 5.7) and 66.1% were women, 73.9% had hypertension, 25.2% diabetes, 36.0% atrial fibrillation (AF), 33.9% heart failure (HF), 15.8% previous transient ischemic attack (TIA), 47.8% a Charlson comorbidity index (CCI) score >1 and 52.2% a baseline National Institute of Health stroke scale (NIHSS) score ≥ 6. At 6 months, 54 patients (47%) had unfavorable outcome and the independent predictors of poor outcome were the initial systolic blood pressure and the NIHSS score on admission. In conclusion, near 50% of these old patients were dependent or dead 6 months after stroke onset and the main predictor of poor outcome was the neurological severity of stroke., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Primary systemic amyloidosis or AL amyloidosis is a rare condition characterized by extracellular deposits of fibrils composed of fragments of immunoglobulin light chains. Widespread deposition of this amyloid in tissues interferes with their normal function and leads to multiple organ failure. Clinical manifestations are highly variable due to the wide range of organs involved. The heart is affected in 90% of cases; in 30% of these, cardiac dysfunction is the form of presentation and in 50% it is the cause of death. The commonest form of cardiovascular manifestation is congestive heart failure due to restrictive cardiomyopathy caused by extensive interstitial infiltration of amyloid into the myocardium. Occasionally, it can present as angina, due to infiltration of amyloid into the walls of small vessels. The authors describe the case of a patient in whom the disease presented simultaneously with heart failure and effort angina, as well as intermittent claudication.

Hyperreactive malarial splenomegaly is thought to represent an immunological dysfunction due to recurrent episodes of malaria. The authors present a case of hyperreactive malarial splenomegaly in a patient from São Tomé e Príncipe and discuss aspects of its differential diagnosis and treatment. A revision is made of recent concepts related to its pathogenesis and relationship with lymphoproliferative disorders. Malarial DNA was found in the absence of parasite forms in the peripheral blood. This may indicate that latent infection plays a role in its pathogenesis.

This article presents the results of a prospective multivariable study of elderly patients aged over 70 years, hospitalized in an Internal Medicine Department of a Central Lisbon Hospital. The study aimed to identify, at the beginning of hospital admission (HA), predictive factors of hospital mortality (HM) and mortality at 6 months, of duration of HA, of admission to a nursing home at the time of discharge and during a period of 6 months thereafter and of hospital readmission during the 6 months following discharge. The study included 158 patients with a mean hospital stay of 15 days and a hospital mortality of 12%. The main pathologies responsible for hospital admission were cerebrovascular accident (22%), heart failure (20%) and pneumonia (16%). Mortality at 6 months was 29% and hospital readmission in the 6 months thereafter was 24%. When the patient was cared for by the spouse there was a statistically significant correlation with a shorter duration of admission (p = 0.006). Mean hospital stay was not significantly associated with any other variable. A subjective medical evaluation (SME) at the start of HA (p = 0.001), a low Barthel score prior to and at the time of HA, low serum albumin (p = 0.001) and a high leucocyte count (p = 0.005) were correlated with a higher HM. Nursing home admission was only positively correlated with cerebrovascular pathology. Mortality at 6 months was significantly correlated with the SME (p = 0.001), a low Barthel score prior to admission (p < 0.008) and at the time of HA (p < 0.001), nursing home residency (p < 0.005) and a low mental test score (p < 0.01). Hospital readmission at 6 months was influenced by the SME (p < 0.04) and by the reduction in the Barthel score caused by the illness and HA (p = 0.004). These correlations enabled the development of mathematical models that predict HM and mortality at 6 months and admission to a nursing home at the time of discharge and during a period of 6 months thereafter. They could be important in identifying elderly patients' needs early in the hospital admission and in the improvement of the strategy necessary for a successful and dignified hospital discharge.

Stroke is the third leading cause of death in most industrialised countries, among adults aged 65 years or more. In Portugal, however, it is the leading cause of death. Intracerebral hemorrhages comprise approximately 10 to 15% of all strokes. This particular type of stroke is associated with a worse prognosis. There is little published data concerning stroke in the Portuguese population, especially on the hemorrhagic type of the disease. The aim of the present study was to improve our knowledge on the epidemiology of hemorrhagic strokes in our community. The hospital charts of 60 patients with intracerebral hemorrhage who were admitted to our wards during the years of 1997 and 1998 were retrospectively reviewed. There was a predominance of male patients aged over 65. In most cases (78.3%), no causal factor was identified (spontaneous or "primary" hemorrhagic stroke). Hypertension was present in 80% of cases and was the most common risk factor. The percentage of putaminal and thalamic hemorrhages (48.3%) was similar to the percentage of lobar hemorrhages (46.7%). This differs from other studies. The prognosis of our patients was fairly good, with 38% of all cases being independent at thirty days. The 30-day case fatality rate was 10%. As in other studies, advancing age, a low Glasgow Coma Scale score, a large hemorrhage size and the intraventricular extension of blood were associated with a worse outcome.

The authors studied the immunological response before and after beginning anti-tuberculous therapy, of a previously health, HIV negative, 22 year old black male, from the Republic of Cape Verde. The patient had multiple vertebral bony lesions associated to subcutaneous abscesses. As immunological markers of antigen recognition, we measured blastogenic and cytotoxic responses and gamma-IFN secretion towards 30 kD, 65 kD, filtrate proteins of M. tuberculosis, M. tuberculosis (H37Rv) and PPD cultures. To characterise the role of cytokines during infection, expression of mRNA for gamma-IFN, IL-4 and IL-10 was also analysed. A slight increase of lymphocyte proliferation and gamma-IFN production was seen in response to purified protein derivative (PPD) and short term culture filtrate proteins (ST-CFP), after one month of therapy. More significant, was the increase in M. tuberculosis and PPD-specific cytolytic T lymphocyte response after one one month of treatment. After 6 months of treatment, blastogenic and cytotoxic responses and gamma-IFN production were considerably higher toward the antigen panel. The CD4/CD8 ratio increased from 0.7 to 1.4 after treatment. We observed that ST-CFP and MT-CFP induced increasingly higher lymphoproliferation and gamma-IFN production, confirming their role in the protective immune responses to M. tuberculosis. The reduced immune responses in the peripheral blood of this patient probably reflect a high activity in the local sites of infection. This case of disseminated tuberculosis infection maybe related to nutritional or social factors or may represent an example of reduced in ate resistance against tuberculosis infection.

Through a prospective controlled study of 81 non-selected patients with acute cerebral ischemia, admitted to the hospital over the period of one year, anticardiolipin antibodies (IgG and IgM) were compared to a control group with the objective of evaluating their place as independent risk factors for stroke. Stroke patients' anticardiolipin antibodies (ACA) were again measured at 6 months and compared to the initial values. At the time of the acute ischemic event, the patients' mean ACA IgM was significantly higher than that of the controls and, at 6 months, the patients' mean ACA IgG and IgM were significantly lower than at the time of stroke. Furthermore, through logistic regression analysis and taking into account all other stroke risk factors present in the patient population, ACA IgM's association with stroke was statistically significant. We conclude that ACA may have a role in the pathogenesis of acute cerebral ischemia. Their cross-reactivity with anti-oxidised LDL antibodies may constitute a link between atherosclerosis and thrombosis.

Hepatopulmonary Syndrome is an uncommon clinical situation of unknown cause. It remains the focus of intense investigation and ongoing debate. The authors present a case of a 77 year old man with chronic liver disease known for 5 years, who developed central cyanoses, digital clubbing and hypoxemia. On searching for the cause of these clinical features, the diagnosis of Hepatopulmonary Syndrome was admitted and confirmed by contrast enhanced echocardiography using agitated saline, and also by technetium 99m-labelled macroaggregated albumin scanning.

This is a case report of a 29-year-old white female patient with Kikuchi's disease, presenting fever, polyarthritis, lymph gland enlargement, anemia, leucopenia with a relative lymphocytosis, altered liver function tests and circulating immune complexes. A literature review is made with emphasis on the etiology, clinical course and pathogenesis of this illness.

A clinical case of a patient with pernicious anaemia and a carcinoid tumor of the gastric fundus is described. In the context of the case the relationship between pernicious anaemia, achlorhydria, atrophic gastritis and gastric carcinoid is discussed. The gastric neuroendocrine tumours and their structural and functional characteristics were reviewed in an attempt to clarify the nomenclature and the diagnostic and therapeutic approach in these situations.

Tetanus continues to be a frequent illness with a high rate of mortality which mainly affects the elderly. In view of this, 54 cases treated in the ICU between 1983 and 1991 were studied. The clinical support with mechanical ventilation and the use of new drugs, which allowed for a more satisfactory sedation and muscular relaxation, and which permitted the control of the autonomic overactivity, were the most determinant factors in the reduction of mortality verified in the late years of our practice.