Incidental Discovery of a Presacral Extradural Myxopapillary Ependymoma.

Ependymoma is a malignant central nervous system tumor arising from the lining of the ventricles or central canal of the spinal cord. Extradural spinal ependymomas arise from heterotopic ependymal cells or the coccygeal medullary vestige and are extremely infrequent. We present a rare case of presacral extradural ependymoma. Extradural ependymomas typically demonstrate an extraneural spread and, thus, surveillance of the entire central nervous system is not typically recommended. A radiograph of the chest, liver profile, and attention to palpable lymphadenopathy (especially inguinal) on physical examination are vital for surveillance. Obtaining an R0 resection is the most important prognostic factor in survival and local recurrence.

Oral chondroitin sulfate and prebiotics for the treatment of canine Inflammatory Bowel Disease: a randomized, controlled clinical trial.

BACKGROUND: Canine inflammatory bowel disease (IBD) is a chronic enteropathy of unknown etiology, although microbiome dysbiosis, genetic susceptibility, and dietary and/or environmental factors are hypothesized to be involved in its pathogenesis. Since some of the current therapies are associated with severe side effects, novel therapeutic modalities are needed. A new oral supplement for long-term management of canine IBD containing chondroitin sulfate (CS) and prebiotics (resistant starch, ß-glucans and mannaoligosaccharides) was developed to target intestinal inflammation and oxidative stress, and restore normobiosis, without exhibiting any side effects. This double-blinded, randomized, placebo-controlled trial in dogs with IBD aims to evaluate the effects of 180 days administration of this supplement together with a hydrolyzed diet on clinical signs, intestinal histology, gut microbiota, and serum biomarkers of inflammation and oxidative stress. RESULTS: Twenty-seven client-owned biopsy-confirmed IBD dogs were included in the study, switched to the same hydrolyzed diet and classified into one of two groups: supplement and placebo. Initially, there were no significant differences between groups (p > 0.05) for any of the studied parameters. Final data analysis (supplement: n = 9; placebo: n = 10) showed a significant decrease in canine IBD activity index (CIBDAI) score in both groups after treatment (p < 0.001). After treatment, a significant decrease (1.53-fold; p < 0.01) in histologic score was seen only in the supplement group. When groups were compared, the supplement group showed significantly higher serum cholesterol (p < 0.05) and paraoxonase-1 (PON1) levels after 60 days of treatment (p < 0.01), and the placebo group showed significantly reduced serum total antioxidant capacity (TAC) levels after 120 days (p < 0.05). No significant differences were found between groups at any time point for CIBDAI, WSAVA histologic score and fecal microbiota evaluated by PCR-restriction fragment length polymorphism (PCR-RFLP). No side effects were reported in any group. CONCLUSIONS: The combined administration of the supplement with hydrolyzed diet over 180 days was safe and induced improvements in selected serum biomarkers, possibly suggesting a reduction in disease activity. This study was likely underpowered, therefore larger studies are warranted in order to demonstrate a supplemental effect to dietary treatment of this supplement on intestinal histology and CIBDAI.

Trends in the consumption of attention deficit hyperactivity disorder medications in Castilla y León (Spain): changes in the consumption pattern following the introduction of extended release methylphenidate.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is the most diagnosed behavioural disorder in children and adolescents; prevalence has been estimated around 5%. Studies have shown an increase in the use of ADHD medications during the last years. The aim of the present study was to learn the pattern and the evolution of ADHD medication consumption in Castilla y León (Spain). METHOD: Consumption data for the period 1992-2009 were obtained from databases containing information upon consumption and cost of medications dispensed by pharmacies at the expense of the Spanish National Health System. The data were expressed in defined daily doses (DDDs) per 1000 inhabitants per day (DDD/1000 inhabitants/day). A model to forecast consumption was built. RESULTS: Attention deficit hyperactivity disorder medication consumption increased in Castilla y León from 0.1 DDD/1000 inhabitants/day in 1992 to 1.5 DDD/1000 inhabitants/day in 2009; expected consumption will reach 2.5 DDD/1000 inhabitants/day by 2013. The drugs accounting for this increase were mainly made up of methylphenidate preparations (1.4 DDD/1000 inhabitants/day in 2009). From 1992 to 1999, there was a slight reduction in methylphenidate use; following amphetamine withdrawal, the consumption of stimulants began to increase, and figures showed a sharp rise after marketing of extended-release formulations in 2003. CONCLUSIONS: There has been an enormous increase in ADHD medication consumption in Castilla y León in the last few years; increase rocketed when extended-release methylphenidate was marketed. A rapid increase in the consumption is a warning on possible overdiagnosis and inappropriate prescription.

Effect of postextubation noninvasive ventilation with active humidification vs high-flow nasal cannula on reintubation in patients at very high risk for extubation failure: a randomized trial.

PURPOSE: High-flow nasal cannula (HFNC) oxygen therapy was noninferior to noninvasive ventilation (NIV) for preventing reintubation in a heterogeneous population at high-risk for extubation failure. However, outcomes might differ in certain subgroups of patients. Thus, we aimed to determine whether NIV with active humidification is superior to HFNC in preventing reintubation in patients with ≥ 4 risk factors (very high risk for extubation failure). METHODS: Randomized controlled trial in two intensive care units in Spain (June 2020‒June 2021). Patients ready for planned extubation with ≥ 4 of the following risk factors for reintubation were included: age > 65 years, Acute Physiology and Chronic Health Evaluation II score > 12 on extubation day, body mass index > 30, inadequate secretions management, difficult or prolonged weaning, ≥ 2 comorbidities, acute heart failure indicating mechanical ventilation, moderate-to-severe chronic obstructive pulmonary disease, airway patency problems, prolonged mechanical ventilation, or hypercapnia on finishing the spontaneous breathing trial. Patients were randomized to undergo NIV with active humidification or HFNC for 48 h after extubation. The primary outcome was reintubation rate within 7 days after extubation. Secondary outcomes included postextubation respiratory failure, respiratory infection, sepsis, multiorgan failure, length of stay, mortality, adverse events, and time to reintubation. RESULTS: Of 182 patients (mean age, 60 [standard deviation (SD), 15] years; 117 [64%] men), 92 received NIV and 90 HFNC. Reintubation was required in 21 (23.3%) patients receiving NIV vs 35 (38.8%) of those receiving HFNC (difference -15.5%; 95% confidence interval (CI) -28.3 to -1%). Hospital length of stay was lower in those patients treated with NIV (20 [12‒36.7] days vs 26.5 [15‒45] days, difference 6.5 [95%CI 0.5-21.1]). No additional differences in the other secondary outcomes were observed. CONCLUSIONS: Among adult critically ill patients at very high-risk for extubation failure, NIV with active humidification was superior to HFNC for preventing reintubation.

Trends in the consumption of antidepressants in Castilla y León (Spain). Association between suicide rates and antidepressant drug consumption.

OBJECTIVE: To learn the evolution of antidepressant and lithium use in Castilla y León (Central Spain) and its relationship with suicide rates. METHODS: A search in the ECOM (Especialidades Consumo de Medicamentos) database of the Spanish Ministry of Health for antidepressants and lithium was carried out for the period 1992-2005. Defined daily doses (DDD) per 1000 inhabitants per day were obtained as consumption data. Population and suicide rates data come from the Spanish National Statistics Institute. RESULTS: Antidepressant consumption increased 7-fold, from 6.9 DDD per 1000 inhabitants per day in 1992 to 47.3 in 2005; the corresponding increase in cost was more than 10-fold. Selective serotonin reuptake inhibitors (SSRIs) comprised 77% of the total consumption. Venlafaxine consumption multiplied by 2.2. The consumption of monoamine oxidase inhibitors (MAOIs) decreased after venlafaxine and mirtazapine were marketed. Lithium consumption increased by 76% during the period studied, but it plateaued in 2000. CONCLUSIONS: The consumption of antidepressants in Castilla y León has increased remarkably and the pattern has changed; there is an increase in the consumption of the new and more expensive antidepressants such as venlafaxine and escitalopram. No association was observed between suicide rates and antidepressant consumption.

Gynaecomastia associated with proton pump inhibitors: a case series from the Spanish Pharmacovigilance System.

OBJECTIVE: Proton pump inhibitors (PPIs) are widely used in the management of peptic ulcer and related symptoms. They have been linked to certain endocrine adverse reactions, including gynaecomastia. The aim of the present study is to investigate the association between the use of PPIs and the development of gynaecomastia. METHODS: Reports of cases of gynaecomastia that had putatively been induced by PPIs and that had been collected by the Spanish Pharmacovigilance System via the 'yellow card' scheme, were analysed. Reporting odds ratios (RORs) were calculated as a measure of disproportionality. RESULTS: Twenty-four cases of gynaecomastia associated with PPIs were identified in the database of the Spanish Pharmacovigilance System. Overall, there was a clear temporal sequence of events in all cases and the adverse effect disappeared after drug withdrawal in most of the cases; 14 patients were also receiving other drugs at the time of the adverse effect. The ROR for omeprazole exposure versus no exposure, but not that for other PPIs, showed a statistically significant elevation (ROR adjusted for age 5.23; 95% CI 3.32, 8.26). CONCLUSION: Considering the widespread use of PPIs, gynaecomastia may affect a large number of patients. In most cases, the condition seems to be reversible with drug withdrawal. Doctors should be aware of this potential adverse reaction when prescribing PPIs to their patients over long periods of time.

HMG CoA reductase inhibitors and impotence: two case series from the Spanish and French drug monitoring systems.

OBJECTIVE: HMG CoA Reductase inhibitors, more commonly called statins, are used in the pharmacological management of hyperlipidaemia. At present, the use of these drugs is increasing worldwide. They have been linked to certain adverse drug reactions, including impotence. The aim of the present study is to explore the basis of the association between statin use and impotence using data from spontaneous reports. METHOD: We analysed the cases of impotence associated with statins that were collected by the Spanish and French pharmacovigilance systems. We used cases of impotence as a numerator and consumption data as a denominator to estimate the cumulative reported incidence of impotence. RESULTS: Thirty-eight cases of impotence associated with statins have been identified in the database of the Spanish pharmacovigilance system; overall, there was a temporal sequence of events in all cases and the adverse reaction disappeared after drug withdrawal in 93% of the cases. Sixteen patients had also been treated with other drugs. In France, 37 cases were collected. In 85% of these cases recovery from the adverse reaction was observed after drug withdrawal; there was a positive rechallenge in five cases, and 15 patients were receiving other drugs at the same time. No significant differences among reported incidences with different statins were found. CONCLUSION: Considering the widespread use of this drug class and the under-reporting of this particular reaction it could affect a large number of patients. The reaction seems to be reversible in most of the cases after drug withdrawal. Doctors should be aware of this potential adverse reaction when prescribing statins to their patients.

A genetic predictive model for canine hip dysplasia: integration of Genome Wide Association Study (GWAS) and candidate gene approaches.

Canine hip dysplasia is one of the most prevalent developmental orthopedic diseases in dogs worldwide. Unfortunately, the success of eradication programs against this disease based on radiographic diagnosis is low. Adding the use of diagnostic genetic tools to the current phenotype-based approach might be beneficial. The aim of this study was to develop a genetic prognostic test for early diagnosis of hip dysplasia in Labrador Retrievers. To develop our DNA test, 775 Labrador Retrievers were recruited. For each dog, a blood sample and a ventrodorsal hip radiograph were taken. Dogs were divided into two groups according to their FCI hip score: control (A/B) and case (D/E). C dogs were not included in the sample. Genetic characterization combining a GWAS and a candidate gene strategy using SNPs allowed a case-control population association study. A mathematical model which included 7 SNPs was developed using logistic regression. The model showed a good accuracy (Area under the ROC curve = 0.85) and was validated in an independent population of 114 dogs. This prognostic genetic test represents a useful tool for choosing the most appropriate therapeutic approach once genetic predisposition to hip dysplasia is known. Therefore, it allows a more individualized management of the disease. It is also applicable during genetic selection processes, since breeders can benefit from the information given by this test as soon as a blood sample can be collected, and act accordingly. In the authors' opinion, a shift towards genomic screening might importantly contribute to reducing canine hip dysplasia in the future. In conclusion, based on genetic and radiographic information from Labrador Retrievers with hip dysplasia, we developed an accurate predictive genetic test for early diagnosis of hip dysplasia in Labrador Retrievers. However, further research is warranted in order to evaluate the validity of this genetic test in other dog breeds.

Antidepressant-induced hepatotoxicity.

Depression is a chronic, severe and increasingly prevalent illness associated with substantial morbidity, mortality and healthcare costs. Antidepressant drugs, the cornerstone of depression treatment, are not devoid of adverse effects, including hepatotoxicity. To review the risk of liver toxicity related to major antidepressants, the authors have followed structural criteria focusing on the underlying mechanism presumably involved and the role of particular chemical structures. The clinicopathological expression goes from transient increases in liver enzymes to fulminant liver failure. Classical antidepressants such as monoamine oxidase inhibitors (MAOIs) or tricyclic antidepressants (TCAs) seem to have the highest potential to induce liver damage compared with the newer drugs such as selective serotonin re-uptake inhibitors (SSRIs). The potential for severe hepatotoxicity associated with nefazodone is stressed. Guidelines for therapy and prevention of antidepressant-induced hepatotoxicity are also discussed.

A new suction instrument for spinal surgery.

OBJECTIVE: Spinal surgical procedures share the technical difficulty of having to preserve the integrity of the dura mater in a surgical field with different degrees of hemorrhage. This difficulty is particularly evident in the surgery of degenerative diseases. METHODS: We have developed a new surgical sucker that allows an easy dissection of the dural sac from adjacent structures and improves the overall surgical manipulation during degenerative lumbar spinal procedures. The present technical note describes this newly developed suction device that comprises a slightly oval spatula positioned at an angle of 30° to the bore of the suction tube. RESULTS AND CONCLUSION: Attending to the combination of a spatula and a suction device, it offers several advantages when compared to the instruments that are currently available. Namely, it facilitates the dissection of the ligamentum flavum from the subjacent dura mater, separating and holding this ligamentum from the dura mater; it also allows a slight retraction of the dural sac without direct suction and a better illumination of the surgical field through light reflected from the spatula.

Pilonidal disease and hidradenitis.

Pilonidal disease and hidradenitis suppurativa are common problems that affect young adults. The surgical management of pilonidal disease should be tailored to the individual clinical presentation and its goal is the resolution of pilonidal disease with low recurrence and low morbidity. The clinical course of hidradenitis suppurativa is characterized by chronicity with frequent flare-ups followed by quiescent periods. Treatment for both conditions needs to be individualized to the clinical presentation.

Complicaciones mecánicas del infarto: rotura de pared libre ventricular. Presentación de un caso / Mechanical complications of myocardial infarction: ventricular free wall rupture. Report of a case

En los pacientes con síndrome coronario agudo, dos terceras partes de los casos fallece sin alcanzar a recibir atención hospitalaria (principalmente en las primeras dos horas) debido a la muerte súbita. Del tercio restante, el 50% lo hará en las 24 horas siguientes a su ingreso hospitalario, principalmente debido a las complicaciones mecánicas del infarto. Actualmente, la identificación y estratificación inmediata del paciente con síndrome coronario agudo, el papel de las unidades coronarias y la reperfusión temprana (farmacológica o mecánica) en los casos indicados, han demostrado disminuir la morbimortalidad por cardiopatía isquémica. Dentro de las complicaciones mecánicas del infarto, la ruptura de pared libre ventricular se presenta en el 5-10% de los pacientes hospitalizados que fallecen por infarto agudo del miocardio con elevación del segmento ST. Se presenta un caso clínico con estas características.

In patients with acute coronary ischemic syndrome, two-thirds of cases die without reaching hospital care (mainly in the first two hours) due to sudden death. Of the remaining third, 50% will do so within 24 hours of hospital admission, mainly due to mechanical complications of infarction. Currently, the identification and early stratification, the role of coronary care units and early reperfusion (pharmacologic or mechanical) where indicated, have been shown to decrease morbidity and mortality from ischemic heart disease. Within the mechanical complications of infarction, ventricular free wall rupture occurs in 5-10% of hospitalized patients dying of acute myocardial infarction with ST segment elevation. We report a case with these features.

Trends in the consumption of opioid analgesics in Spain. Higher increases as fentanyl replaces morphine.

OBJECTIVE: During the past few years there have been changes in the availability of opioids in Spain, and new policies on palliative care have been implemented. The aim of this study was to describe the new pattern of opioid consumption in Spain and the associated economic impact. METHODS: A search in the ECOM (Especialidades Consumo de Medicamentos) database of the Ministry of Health and Consumer Affairs for the 1992-2006 period was carried out. This database contains information on prescriptions of primary care medicines that are covered by the National Health System in Spain. RESULTS: Since 1992, overall opioid consumption has increased 14-fold, from 0.3 DDD/1000 inhabitants per day to 4.4 DDD/1000 inhabitants per day. For the six drugs that require a special prescription form--morphine, methadone, oxycodone pethidine, tilidine and fentanyl--consumption increased from 0.1 DDD/1000 inhabitants per day in 1992 to 1.2 in 2006. During this same period, the total costs of these prescriptions increased by 36.8-fold, and the cost per day and per patient doubled. CONCLUSION: A huge increase in opioid consumption has occurred during the time period covered by this study, with fentanyl consumption accounting for most of that increase. Although oral morphine is the first-choice drug among strong opioids, fentanyl is currently the most consumed.

Management of diverticulitis in younger patients.

PURPOSE: This study was designed to evaluate the clinical course of sigmoid diverticulitis patients younger than aged 50 years examined by abdominal CT during the first episode of disease to elucidate whether the criteria used for older patients can safely be followed in their younger counterparts. METHODS: Retrospective review of patients with sigmoid diverticulitis treated from 1990 to 2003 was performed. INCLUSION CRITERIA: patients younger than aged 50 years with sigmoid diverticulitis documented by CT scan. Severity of disease was classified according to radiographic findings. Age, gender, treatment, recurrent disease, and need for colostomy were documented. RESULTS: A total of 5,499 patients were identified with sigmoid diverticulitis: 962 patients were younger than aged 50 years, and 411 had a CT scan on their first episode of disease. Of the 411 patients, 335 were classified as uncomplicated and 76 were complicated. Of the uncomplicated patients, 101 underwent an elective operation and 234 were followed nonoperatively. Of those followed, 67 had a recurrent uncomplicated episode, 10 had a recurrent complicated episode, of whom 5 required emergent operation and colostomy. Of the 76 patients with complicated disease, 23 had an emergent operation with colostomy, and 38 had an elective operation. Fifteen patients were followed without an operation and seven had a recurrent uncomplicated episode. None required emergent operation or colostomy. CONCLUSIONS: Younger patients with uncomplicated diverticulitis by CT criteria respond well to medical management and seldom required an emergent operation and colostomy. Young patients with diverticulitis should be treated according to the same criteria used for older patients.

Astrocitoma anaplásico do cerebelo: relato de caso / Anaplasic cerebellar astrocytoma: case report

Astrocitomas de alto grau são tumores de apresentação rara na fossa posterior, especialmente na idade adulta. A sobrevida média descrita na literatura é de cerca de 14 a 32 meses. A apresentação clínica mais frequente é na forma de síndrome de hipertensão intracraniana. Tende a evoluir com disseminação leptomeníngea e também pode estender-se ao tronco cerebral e à medula. Apresentamos um caso de astrocitoma anaplásico (grau III) da fossa posterior numa mulher de 62 anos, o único observado num adulto no nosso hospital num período de 10 anos. O diagnóstico foi confirmado com biópsia estereotáxica da lesão. A apresentação clínica está de acordo com o descrito na literatura, contudo a sobrevida observada foi significativamente mais curta.

High grade astrocytomas are rare tumors in posterior fossa, especially in adulthood. The median survival reported in literature is around 14 to 32 months. The most frequent clinical presentation is intracranial hypertension syndrome. It tends to present leptomeningeal dissemination and may also extend to the brainstem and spinal cord. We present a case of anaplastic astrocytoma (grade III) in the posterior fossa in a 62 year-old female, the only adult presentation of this tumor observed in our hospital over a period of 10 years. The diagnosis was confirmed by stereotactic biopsy of the lesion. The clinical presentation is consistent with that described in the literature, however the survival time was significantly shorter.