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Biomedical subjects

R S Gomes

Publications and source records attributed to R S Gomes.

18 recordsLinked to original sources
PubMed2005

Natural infection by Giardia sp. and Cryptosporidium sp. in dairy goats, associated with possible risk factors of the studied properties.

Visits were made to six farms raising dairy goats located in the mountain region of the state of Rio de Janeiro, Brazil, seeking to identify parasitism by Giardia sp. and Cryptosporidium sp. During the visits, fecal samples were collected from approximately 10% of the stock of each property. A questionnaire was given to the keepers on each property to obtain data for epidemiological analysis. A total of 105 fecal samples was collected, 56 from adult animals (over 12 months of age) and 49 from juvenile animals (less than 12 months). The fecal material was processed and subjected to the centrifuge-flotation technique and to staining with safranine-methylene blue. Protozoans of the genus Cryptosporidium were found at two properties, where the hygiene conditions of the installations were considered average and the stalls were made of wood slats raised from the ground. A total of five (4.8%) of the samples was found to be positive for the presence of this protozoan, all from juvenile animals. Cysts of the genus Giardia were found at two properties. Of the 105 samples analyzed, the protozoan was detected in 15 (14.3%), all in juvenile animals, and animals in the age range of 1-3 months had significantly more infections. Age, sanitary condition of the stalls and stalls made of wood slats and raised from the ground, can be pointed out as possible risk factors for infection by Giardia sp. and Cryptosporidium sp. The study reports for the first time the occurrence of Cryptosporidium sp. and Giardia sp. in goats in the state of Rio de Janeiro.

Animal Husbandry↗
PubMed2005

Comparison between natural infection by Cryptosporidium sp., Giardia sp. in dogs in two living situations in the West Zone of the municipality of Rio de Janeiro.

In order to compare natural infection by Cyptosporidium sp. and Giardia sp. in clinically healthy dogs living in two situations (animal shelter and household pets), we conducted 166 faecal exams using the technique of centrifugation-flotation in a sugar-saturated solution. Of the faecal samples, 94 came from shelter dogs and 72 from house pets. Eighty-two (49.4%) contained parasite eggs, cysts or oocysts. Of these, four (2.41%) contained Cryptosporidium sp. oocysts and 52 (31.33%) contained Giardia sp. cysts. There was no statistically significant difference between the origin of the dogs and Cryptosporidium sp. infection. Infection by Cryptosporidium sp. was not associated with the living conditions and sex. With respect to Giardia sp., we observed a statistically significant difference (p < 0.001) between the shelter dogs (45%) and the household pets 12.3%. There was no association of infection by Giardia sp. with age or sex.

Age Factors↗
PubMed1997

[Coronary angiography in the outpatient with angina pectoris].

Coronary angiography remains the only definitive diagnostic procedure to assess the severity and extension of coronary artery disease. We discuss some technical aspects and the place of angiography in the risk stratification of the coronary patient comparing conservative and invasive strategies. It is suggested that a progressively more important role will be played by the general practitioner regarding indication, interpretation and therapeutic decision, sharing responsibilities with the cardiologist and the patient. With increased facilities for coronary angiography and increased ad hoc angioplasties, observed at present, the GP should also be responsible for proper selection of the reference cardiologists and hospitals.

Ambulatory Care↗
PubMed1996

[Acute myocardial infarct in a young cocaine user].

In patients less than 40 years of age, acute myocardial infarction (AMI) has special clinical and pathophysiologic characteristics. Its prevalence varies between 5 and 10%. In such patients, AMI associated with chronic cocaine abuse has a non-negligible prevalence of 6%. The purpose of this report is to describe the case of a 24-year old male patient with smoking habits and chronic abuse of cocaine and hallucinogenic drugs. This patient developed clinical, enzymatic and electrocardiographic criteria of anterior AMI, two hours after the ingestion of an LSD-like hallucinogenic drug. The coronary angiography revealed a critical stenosis of the medium segment of the left anterior descendent artery, and a pre-stenotic aneurysmatic dilatation. In order to determine the etiology of the aneurysm, various laboratory and histologic tests were performed. The results of these were normal. We review the pathophysiology, clinical manifestations and prognosis of cocaine-associated AMI.

Adult↗
PubMed1993

[The determination of the mitral valve area after commissurotomy. A comparison of 2 echocardiographic methods].

OBJECTIVE: To compare the mitral valvular area obtained by two-dimensional echocardiography (2DMVA) to that obtained by Doppler through pressure half-time, (T1/2P) method (DMVA) in patients submitted to open or closed commissurotomy. POPULATION: Data were obtained from 53 patients, 44 females and 9 males who ranged in age from 19 to 63 years (mean = 40.4 +/- 8) submitted to open commissurotomy (group A) or closed procedure (group F). The time from surgery to Echo ranged from 10 to 100 months (mean = 63 +/- 26). Ther were twenty one patients, in group A and 32 in group F. METHODS: All the patients underwent two-dimensional echocardiography and continuous-wave doppler, guided by image and sound, so that the maximum velocity was located, using a Diasonics DRF 300 machine equipped with a combined echo-Doppler 3.5 mHz transducer. The mitral valve was visualized in short axis view the 2D mitral valve area was measured as the planimetered area along the inner border of the smallest orifice, while scanning through the short axis. Continuous-wave Doppler recordings were performed at 50 mm/s. The pressure half-time was measured as the interval between maximum velocity and maximum velocity/1.4. The valvular area (DMVA) was obtained by the expression 220/T1/2p. Maximum velocity (VMax) of mitral flux and the prevalence of significant mitral regurgitation (> = 2) were also compared in groups A and F. The relationship between 2DMVA and DMVA were compared by simple linear regression analysis and the other parameters by the t test and by chi-squared analysis. RESULTS: 2DMVA in the total patients was 2.26 +/- 0.59 and the DMVA 2.31 +/- 0.76 (NS). There were no significant difference between groups A e F concerning: VMax = 162.48 +/- 28.15 and 150.09 +/- 30.08, DMVA = 2.34 +/- 0.75 and 2.29 +/- 0.76 respectively, and mitral regurgitation = 2 patients in both groups. The correlation between the Doppler and the 2D obtained areas was good in group A r = 0.76 SEE there were no correlation between these values in group F r = 0.33. CONCLUSIONS: We can conclude that the mitral valvular area obtained by two-dimensional echocardiography, correlates to the Doppler mitral valvular area in patients with prior open commissurotomy proving the complementary role of the two methods.

Adult↗
PubMed1993

[Prognosis in unstable angina as a function of the clinical presentation].

OBJECTIVE: To assess the prognosis of Unstable Angina according to its clinical presentation using Braunwald's Classification. DESIGN: Retrospective study of hospital admissions from January 1982 to September 1990. SETTING: Coronary Care Unit and a Cardiology Department of a Central Hospital. PATIENTS: There were 132 patients, 109 men and 23 women, with a mean age of 56 +/- 9 years, all submitted to cardiac catheterization at least 90 days after hospital admission followed up during 34.2 +/- 24.2 months. MATERIAL AND METHODS: Patients were divided in three groups according to the clinical presentation of Unstable Angina: Group A--Aggravated Chronic Angina and/or "De Novo" Angina; Group B--Angina at Rest but not in the last 48 hours, and Group C--Angina at Rest in the last 48 hours. Group A was also sub-divided, and the patients with Unstable Angina after myocardial infarction were excluded. The previous clinical profile was evaluated as well as the circumstances in which Unstable Angina occurred, need of Coronary Care Unit, angiographic findings and follow-up. RESULTS: Within the 132 patients, 86 were in the group A, (59 with Aggravated Angina and 27 with "De Novo" Angina), 11 in group B, and 35 in group C. The group with Aggravated Angina had higher incidence of previous myocardial infarction and bypass surgery (p < 0.01 and p = 0.05), compared to group with "De Novo" Angina and B, and also three vessels disease associated to ventricular dysfunction. "Culprit Lesion" appeared more frequently as eccentric type I in group A, and as concentric in group C. Revascularization procedures were performed in 95 patients (CABG in 66 and PTCA in 29) being respectively: 21 and 6 were urgent, 19 and 18 were elective and 26 and 5 were late procedures. CABG were more frequent in group A. There were 73 major cardiac events in 44 patients (8 deaths, 12 myocardial infarction and 53 new episodes of Unstable Angina), which were more frequent in group with Aggravated Angina and group C. The chance of patients with major cardiac events was in a 78 months follow-up, about 25% for group with "De Novo" Angina, 50% for patients with Aggravated Chronic Angina, and was greater than 75% in patients with Angina at Rest and episodes in the last 48 hours (p < 0.05)--Log-rank Test. The worse prognosis was seen in patients with Aggravated Chronic Angina, when a gathering of clinic patterns of Braunwald's classification were present. CONCLUSIONS: In summary, the group with Aggravated Angina and group C had more severe disease, required more urgent CABG and PTCA, and had also a higher incidence of cardiac events. The group with better prognosis was the group with "De Novo" Angina, which should be distinguished of the group with Aggravated Angina who was the worst prognosis.

Aged↗
PubMed1992

[Ibopamine in the treatment of congestive heart failure. Multicenter follow-up study].

OBJECTIVE: To assess safety and efficacy of ibopamine, 200 mg TID, added to conventional treatment of congestive heart failure. DESIGN: A prospective, longterm, open study over two years (1986-88). A multicenter trial. SETTING: Outpatients of Departments of Internal Medicine of S. Francisco Xavier Hospital and Sta. Maria Hospital, and Departments of Cardiology of Sta. Cruz Hospital and Hospital Militar Principal, Lisbon. PATIENTS AND METHODOLOGY: 63 patients, 49 males from 34 to 80 years (m = 55.6 +/- 11.36) and 14 females from 41 to 80 years (m = 63 +/- 10.2), with congestive heart failure, NYHA class II in 52 patients (82.5%) and NYHA class III in 11 patients (17.5%) with a mean disease duration of 47.9 months entered into the study. Digoxin, diuretics, nitrates and antiarrhythmic drugs were allowed as concomitant therapy. Patients carried out clinical examination, ECG and laboratory tests monthly and X-Ray at the beginning and at the end of each year of the study. RESULTS: 42 patients completed one year of treatment and 20/42 continued for an additional year, 17 patients completed this second year of follow-up. From the 42 patients who completed the first year period, the NYHA class changed from II to I in 17/38 from II to III in 2/38 patients from III to II in 3/4 patients, and from III to IV in one patient. Twenty patients dropped during the first year of treatment. Six for non-compliance (less than 80% of the treatment). Two were submitted to cardiac valve surgery. Seven had cardiovascular clinical events: one ventricular tachycardia, one atrial fibrillation, one pulmonary edema, one patient had no therapeutic effect, two patients had anxiety and fatigue and one patient died suddenly. One diabetic patient had uncontrolled hyperglycemia. One patient had gastric ulcer. Two had nausea and vomiting. Dysrhythmia and nausea and vomiting were the only clinical events, considered, respectively, possibly related and related, to ibopamine. During the second year of treatment 9/11 patients were stabilized in NYHA class I and 6/9 in NYHA class II, one patient changed from class II to class I, and one patient changed from class I to class II of the NYHA. Three patients did not complete the second year of treatment; one due to abnormal creatininemia; one for probable pulmonary embolism with CHF worsening; the third died suddenly. None of these events was considered related to ibopamine. Heart rate, arterial pressure, laboratory values and cardiothoracic index did not vary over the two years of the study. CONCLUSIONS: This has been the first study with data from patients treated with 200 mg TID of ibopamine during two years. Ibopamine has been shown to be a safe and useful drug added to conventional treatment of cardiac heart failure. Clinical events were few and well controlled after ibopamine interruption.

Adult↗
PubMed1992

[Contribution of the electrocardiogram to the diagnosis of localization and extension of coronary lesions in patients with acute myocardial infarct].

UNLABELLED: With the purpose of evaluating the contribution of the ECG to the localization and extension of coronary artery lesions, 85 patients with the first acute myocardial infarction treated with thrombolysis, 79 males and 6 females (mean age 53.9 years), were studied, and the ECG changes at 3.5 and 24 hours correlated with the coronary angiographic findings before discharge. Patients were divided in two groups--Group A with anterior infarction (48 pts) and Group B with inferior infarction (37 pts). RESULTS: A) Returning of the ST downslope to baseline in inferior and anterior leads, respectively in anterior and inferior infarction at 24 h ECG, excluded associated LAD or RCA/CX lesions with a sensitivity (S) of 93% and 87% and aspecificity (E) of 60% and 58%, with a positive predictive value (PPV) of 62% and 77% and a negative predictive value of 86% and 85% respectively. All patients with anterior infarction had LAD stenosis. B) ST upslope bigger than 5 mm in V2-V3 or its presence in D-I or aVL associated to any precordial leads, diagnosed proximal LAD lesions with S of 82% and 73% and E of 75% and 73% respectively. The left axis deviation was present in 6 of 7 patients and pointed to proximal lesion. C) In Group B patients, RCA lesion was related to ST downslope in D-I, S = 77%, E = 37.5%, PVV = 80% and NPV = 33.5%, and the proximal localization (ratio between ST downslope in V2 and ST upslope in aVF) inferior to 0.5 mm with S and NPV = 80% and E and PPV = 100%. The presence of an isoelectrical ST in D-I in association with ST upslope in V5-V6 is related to CX with S and NPV = 100%, E = 85% and PPV = 25%. In conclusion, these results suggest that a careful analysis of ECG changes in patients with first acute myocardial infarction, can provide important information regarding the infarct related artery, localization of the stenosis and the presence of associated coronary artery disease, with implications in the risk stratification before hospital discharge.

Adult↗
PubMed1992

[Relationship between ventricular arrhythmia and clinical and echocardiographic parameters in hypertensive patients].

OBJECTIVE: Evaluation in arterial hypertension (HTA) patients, of the relationship between supraventricular and ventricular arrhythmias, stage of hypertension and echocardiographic parameters. DESIGN: Retrospective study based on the files of ambulatory electrocardiography (Holter). SETTING: Arrhythmology Outpatients Clinic from a Cardiac Department. PATIENTS: Adult patients with arterial hypertension, males and females, who underwent ambulatory electrocardiography (Holter) and echocardiography examinations. MATERIAL AND METHODS: Thirty patients, 15 males and females, 54 +/- 12 years old, were studied. Arterial hypertension was stratified in three stages according with the diastolic value. Symptoms, serum potassium, left ventricular hypertrophy (LVH) on the ECG, and echocardiographic parameters such as left ventricular dimensions, shortening fraction, septal wall and posterior wall thickness and left atrium dimensions were analysed. These parameters were correlated with the arrhythmic pattern concerning the number of premature supraventricular contractions and the number and complexity of premature ventricular contractions (PVC), evaluated by ambulatory electrocardiography (Holter). RESULTS: No relation was found between the arrhythmic pattern, stage of hypertension, symptoms and LVH on the ECG. Septal wall thickness was 14 +/- 3 mm in the group of patients with PVC greater than or equal to 10/hour and 12 +/- 3 mm in the population with PVC less than 10/hour (p less than 0.04). The shortening fraction was 27 +/- 8% in the group of repetitive PVC and 34 +/- 7% in the population without (p less than 0.003). A borderline relation was found between repetitive PVC and left atrium and left ventricular diastolic dimensions. CONCLUSIONS: In a population of arterial hypertension (HTA) who performed ambulatory electrocardiography (Holter), the prevalence of frequent or repetitive PVC was low. A positive correlation between frequent PVC and septal wall thickness and an inverse relation between repetitive PVC and LV shortening fraction, was found. These conclusions are according with the literature, relating the ectopic activity with LVH or deterioration of LV function. No relation was found between arrhythmias and stage of hypertension.

Aged↗
PubMed1991

[Non-invasive evaluation of a population with WPW syndrome].

OBJECTIVE: Evaluation of a WPW Syndrome population by non invasive methods; identification of the sudden death risk; results of treatment and patient selection for Electrophysiologic Studies (EPS). DESIGN: Retrospective study. SETTING: Arrhythmology Outpatients Clinic from a Cardiac Department. PATIENTS: Successive patients older than 12 years with a WPW pattern on the ECG and history of paroxysmal tachycardia followed-up for a period of 46 +/- 29 months. MATERIAL AND METHODS: The clinical, ECG, Holter, stress test and echocardiographic data from 32 patients, were analysed. A study evaluating clinical follow up and the results of treatment was done. RESULTS: The group of patients was very symptomatic. The main complaint was a feeling of tachycardia (84.4%). Orthodromic tachycardia was documented in 7 cases and atrial fibrillation with rapid ventricular rate in five. Intermittent delta wave pattern was found in 21 patients, with 11 cases identified by Holter and 4 by stress test. A predominant left accessory pathway was found (47%), but the anteroseptal location was frequent too (25%). The echocardiogram was not useful in any case. Eighty per cent of the patients became asymptomatic with medical treatment. Beta blockers and amiodarone (the last chance) were the most useful drugs. No mortality was found in the study group. EPS was considered for the 5 patients with paroxysmal atrial fibrillation and the 7 cases resistant to medical treatment. CONCLUSIONS: The difficulty to define the risk of a population with WPW Syndrome by non invasive methods was demonstrated. Eighteen one cases were included in a low risk group, due to the intermittent WPW pattern in the ECG. A high risk group was considered for the 5 patients with atrial fibrillation with fast ventricular rate. The risk was not established in 9 cases. Most of the patients became asymptomatic by medical treatment.

Adolescent↗
PubMed1991

[Echo-Doppler in patients undergoing mitral commissurotomy. Comparison of open and closed commissurotomy].

OBJECTIVE: 1. To evaluate with Echo-Doppler the medium/long term results of mitral commissurotomy. 2. To compare the results of open mitral commissurotomy to those of closed commissurotomy. PATIENTS AND METHODS: The Echo 2D-Doppler study has been performed in 117 patients (104 females and 13 males), randomly selected among patients previously submitted to open (62 d.) or closed (55 d.) mitral commissurotomy, with greater than or equal to 12 months follow-up. Pulsed and continuous Doppler recordings were obtained in all 117 patients, and the following parameters were evaluated: Maximum Mitral Gradient (MG); mitral valvular area calculated by half-pressure time (MVA); presence of mitral regurgitation greater than or equal to grade 2 (MR); evaluation of systolic Pulmonary Artery pressure (PAP) by the gradient RV/RA + 14mmHg, in the patients with tricuspid insufficiency; acceleration time (ACT), ejection time (EJT) and the relation ACT/EJT in pulmonary artery. To compare the results of open commissurotomy, to those of closed commissurotomy, and in order to minimize the pre-operative differences between the patients submitted to each of these interventions, only the patients in the same NYHA functional class before surgery (class III), and in sinus rhythm have been selected. In this way two groups were compared: group A-24 patients with open commissurotomy and group F-37 patients with closed commissurotomy. RESULTS: in the total of patients the results were: MG-9.8 +/- 4.2 mmHg; MVA-2.3 +/- 0.95 cm2; MR 16 pts. (13.7%); PAP obtained in 30 pts. (25.6%) -27.47 +/- 1.18 mmHg; the ACT, the EJT and the relation ACT/EJT in PA were respectively 115.63 +/- 34 ms, 309.9 +/- 38.5 ms, 0.37 +/- 0.1. The Doppler parameters obtained respectively in group A and in group F were: MG 8.96 +/- 4.5 mmHg and 10.38 +/- 3.82 mmHg (ns); MVA 2.62 +/- 1.01 cm2 and 2.08 +/- 0.84 cm2 (ns); MR 8.3% and 15.6% (ns) (Fig.3); the PAP have been calculated on 5(20.8%) patients in group A and on 10(27%) patients in group F and their respective values were 30.78 +/- 0.48 mmHg and 28.26 +/- 1.11 mmHg (ns); ACT 109.09 +/- 41.55 ms and 116.67 +/- 33.22 ms (ns); EJT 297.27 +/- 72.94 ms and 308.7 +/- 41.58 ms; ACT/EJT 0.35 +/- 0.12 and 0.38 +/- 0.10 (ns). CONCLUSION: Both open and closed commissurotomy revealed to be good therapeutic alternatives to mitral stenosis with identical long term results as evaluated by Echo-Doppler. The results of percutaneous mitral valvuloplasty should be compared with these in the future.

Adult↗
PubMed1989

[Percutaneous mitral valvotomy].

We report the first percutaneous mitral valvotomy performed in Portugal in October 19th 1987. The valvotomy was attempted successfully in a 34 year old man, with calcific mitral stenosis, in NYHA class III, with functional mitral valve area less then 1 cm2. The intervention was performed using the transseptal technique with two balloons (20 and 18 mm in diameter), placed in the mitral valve annulus through two long transseptal sheaths (14F). The procedure resulted in a marked decrease in the diastolic transmitral gradient, and an increase in mitral valve area superior to 100%. No immediate or late complications were observed, namely mitral regurgitation or left to right shunt through the atrial septum. One year later the patient is in NYHA class I, with a mitral valve area of 1.7 cm2.

Adult↗
PubMed1989

[Pulmonary valvotomy in adults. The double balloon technic--apropos of 2 cases].

Percutaneous double balloon valvotomy was performed in two adult patients with severe non dysplasic pulmonary valvular stenosis. The balloons were introduced through two 14F sheaths placed in the right and left femural veins, the intervention was well tolerated and succeeded with a marked decrease in right ventricular pressure and in pulmonary transvalvular gradient (113 and 147 mmHg to 10 and 12 mmHg respectively). The patients were discharged within 24 hours, without the need of Intensive Care admission. Indications for the procedure and technical aspects are presented, as well as the potential advantages of two balloons over one balloon and surgical valvotomy.

Catheterization↗
PubMed1989

[Diagnostic value of the submaximal treadmill exercise test in the subacute phase of myocardial infarct].

OBJECTIVES: To assess the diagnostic value of treadmill submaximal exercise testing (TSET), early after myocardial infarction (MI) under medical treatment, evaluating the ST changes predominantly. MATERIALS AND METHODS: 65 patients, 62 males and 3 females, mean age 52 years with demonstrated MI under clinical, electrocardiographic and enzymatic criteria were evaluated with TSET before hospital discharge. Thrombolytic therapy in acute phase of MI was done in 45 of the patients. All patients underwent angiographic studies with left ventriculography and selective coronariography. RESULTS: Of all TSET variables considered (Treadmill time, ST segment, presence of chest pain, systolic pressure, double product and presence of ventricular arrythmias) the single most important predictor for high-risk groups like left main disease and three vessels disease, was ST changes alone or associated with exercise precordial pain, with a sensitivity of 100% to left main and 83% to three vessels disease. In the thrombolytic group we did not find any differences related with reperfusion. IN CONCLUSION: TSET is a useful, noninvasive, and safe method for risk stratification after MI mainly when ST segment changes are considered alone or with stress precordial pain, predicting high risk groups, namely left main or three vessels disease patients.

Adult↗
PubMed1989

[From cardiac catheterization to the study of left ventricular function. Importance of relaxation and diastole in ischemic cardiopathy].

Some of the most recent developments on left ventricular function derived from Brutsaert's work on triple control of contraction and relaxation, and on the new division of the different phases of the cardiac cycle, are reviewed. This allows a re-assessment of the different hemodynamic parameters obtained from cardiac catheterization, which were then applied to relaxation and diastole and to coronary artery disease.

Cardiac Catheterization↗
PubMedDate not supplied

[Diagnosis of meningitis with reagent strips]

OBJECTIVE: To determine the usefulness of reagent strips in the evaluation of pleocytosis, cerebrospinal fluid glucose and protein levels for early and rapid diagnosis of meningitis in children. METHODS: We included cerebrospinal fluid samples of 164 children admitted to the outpatient clinic of Communicable Diseases of the General Pediatric Center (Fundação Hospitalar do Estado de Minas Gerais, CGP-FHEMIG) during the daytime hours from May of 1997 to May 1999, and who presented with clinical suspicion of meningitis. Patients ranged in age from one month to 12 years (median 12 months). Results from the cytological and biochemical assay (cellularity, cerebrospinal fluid glucose and protein levels) were obtained from 154 patients. These results were subsequently compared with the reaction of cerebrospinal fluid in reagent strips. RESULTS: The cytological and biochemical assay identified 43 cases of probable bacterial meningitis, 19 of probable viral meningitis, and 83 with no alterations. According to the reagent strips, there were 41 cases of probable bacterial meningitis, 2 of probable viral meningitis, and 71 with no alterations. By comparing the results of reagent strips and those of the cytological and biochemical assay, we obtained values for sensitivity, specificity, positive and negative predictive values, and accuracy (respectively 90.7; 98.1; 95.1; 96.4; and 96.1). Statistical analysis using McNemer test did not indicate significant differences between the two methods in the diagnosis of bacterial meningitis (P=0.68). Kappa statistics indicated a high level of agreement between the tests (P<0.0001). CONCLUSIONS: Our results suggest that reagent strips may be a useful additional resource in the diagnosis of bacterial meningitis, especially when it is difficult to collect a sufficient amount of cerebrospinal fluid or to indicate the initial treatment.

Journal Article↗