[Sudden paralysis of upward gaze in a 9-year-old girl]. / Parálisis súbita de la supraversión de la mirada en una niña de 9 años.

TITLE: Parálisis súbita de la supraversión de la mirada en una niña de 9 años.

Acidosis con hiperlactacidemia por metformina: frecuencia de su diagnóstico en la práctica clínica habitual y relación con la insuficiencia renal / Metformin-associated hyperlactacidaemia acidosis: Diagnosis rate in standard clinical practice and its relationship with renal failure

Antecedentes y objetivos: Estudio observacional sobre la diferencia entre el número de casos diagnosticados en situación clínica habitual de acidosis con hiperlactacidemia sospechosa de ser causada por metformina y su incidencia según la ficha técnica. Adicionalmente se exploró la relación con la función renal de la acidosis hiperlactacidémica por metformina. Pacientes: Se identificaron los casos de acidosis entre los años 2013 y 2014 mediante el análisis del CMBD y las peticiones al laboratorio. Se seleccionó a los pacientes que presentaban lactato venoso > 2,7 mmol/L en el momento de ser atendidos y para los que constaba el uso ambulatorio de metformina. La relación causal con la metformina fue evaluada independientemente por varios investigadores. Los casos incidentes se calcularon con base en el número de pacientes a los que se les había dispensado un medicamento que contuviera metformina durante el mismo periodo en el área estudiada. Resultados: Se identificaron 476 casos de acidosis, de los que en 20 se consideró que la metformina era sospechosa de causar el cuadro de acidosis con hiperlactacidemia, lo que supone una incidencia de 6,57/10.000 pacientes. El 85% de los casos presentaban insuficiencia renal aguda. Conclusiones: La incidencia aparente de acidosis con hiperlactacidemia en pacientes tratados con metformina es mayor que la establecida en la ficha técnica (inferior a 1/10.000). El desarrollo de acidosis con hiperlactacidemia por metformina está relacionado con el deterioro agudo de la función renal

Background and objectives: Observational study on the difference between the number of cases of acidosis with hyperlactacidaemia suspected of being caused by metformin diagnosed in standard clinical practice and the incidence of this condition according to the datasheet. The study also explored the relationship between renal function and metformin-associated hyperlactacidaemia acidosis. Patients: We identified cases of acidosis between 2013 and 2014 by analysing the minimum basic data set and laboratory requests. We selected patients who presented venous lactate levels >2.7 mmol/L at the time they were treated and for whom the use of outpatient metformin was confirmed. The causal relationship with metformin was independently evaluated by several researchers. The incident cases were calculated based on the number of patients who had been dispensed a drug containing metformin during the same period in the study area. Results: We identified 476 cases of acidosis. Metformin was suspected of causing the condition of acidosis with hyperlactacidaemia in 20 of these cases, which represents an incidence rate of 6.57/10,000 patients. Eighty-five percent of the cases presented acute renal failure. Conclusions: The apparent incidence of acidosis with hyperlactacidaemia in patients treated with metformin is greater than that established in the datasheet (<1/10,000). The onset of metformin-associated hyperlactacidaemia acidosis is related to acute renal impairment

Metformin-associated hyperlactacidaemia acidosis: Diagnosis rate in standard clinical practice and its relationship with renal failure. / Acidosis con hiperlactacidemia por metformina: frecuencia de su diagnóstico en la práctica clínica habitual y relación con la insuficiencia renal.

BACKGROUND AND OBJECTIVES: Observational study on the difference between the number of cases of acidosis with hyperlactacidaemia suspected of being caused by metformin diagnosed in standard clinical practice and the incidence of this condition according to the datasheet. The study also explored the relationship between renal function and metformin-associated hyperlactacidaemia acidosis. PATIENTS: We identified cases of acidosis between 2013 and 2014 by analysing the minimum basic data set and laboratory requests. We selected patients who presented venous lactate levels >2.7 mmol/L at the time they were treated and for whom the use of outpatient metformin was confirmed. The causal relationship with metformin was independently evaluated by several researchers. The incident cases were calculated based on the number of patients who had been dispensed a drug containing metformin during the same period in the study area. RESULTS: We identified 476 cases of acidosis. Metformin was suspected of causing the condition of acidosis with hyperlactacidaemia in 20 of these cases, which represents an incidence rate of 6.57/10,000 patients. Eighty-five percent of the cases presented acute renal failure. CONCLUSIONS: The apparent incidence of acidosis with hyperlactacidaemia in patients treated with metformin is greater than that established in the datasheet (<1/10,000). The onset of metformin-associated hyperlactacidaemia acidosis is related to acute renal impairment.

Enfermedad pulmonar intersticial difusa por metaplasia peribronquiolar / Diffuse interstitial lung disease related to peribronchiolar metaplasia

Introducción: Las enfermedades pulmonares intersticiales son un grupo de afecciones raras con una importante morbimortalidad. La metaplasia peribronquiolar, también conocida como lambertosis, es un hallazgo histológico inespecífico que puede encontrarse en estas patologías. Caso clínico: Se presenta el caso clínico de un niño con dificultad respiratoria y necesidad de oxigenoterapia suplementaria desde el periodo de lactancia. Se observó un infiltrado alvéolo-intersticial en la tomografía computarizada de tórax, por lo que ante la clínica y la imagen, la sospecha diagnóstica fue de neumopatía intersticial. La primera biopsia pulmonar no mostraba alteraciones. Al inicio recibió tratamiento con corticoides sistémicos y broncodilatadores de mantenimiento. Con una evolución clínica fluctuante y debido a la persistencia de las necesidades de oxígeno, se realizó una segunda biopsia pulmonar, cuyos hallazgos eran compatibles con una lambertosis. Finalmente el paciente inició tratamiento con hidroxicloroquina. En la actualidad realiza una vida prácticamente normal y sólo precisa oxígeno domiciliario en escasas ocasiones. Discusión: En este paciente, dada la clínica y la imagen compatibles, el resultado normal de la biopsia no descartó en un principio la patología intersticial. En los adultos la lambertosis se ha asociado con el tabaco y los agentes infecciosos, mientras que en los niños parece estar relacionada con causas genéticas. Se llevó a cabo un tratamiento con corticoides y, en segunda línea, con hidroxicloroquina. Conclusiones: Aunque el diagnóstico definitivo de la metaplasia peribronquiolar es histológico, un resultado normal en la biopsia no descarta una posible enfermedad intersticial. Son necesarios más ensayos clínicos que definan el tratamiento más apropiado en estos pacientes

Introduction: Interstitial lung diseases are a group of rare diseases related to important morbidity and mortality. Peribronchiolar metaplasia, also known as lambertosis, could be found in some of these illnesses. Clinical case: We present a child with respiratory symptoms and need of oxygen since he was an infant. An interstitial alveolar infiltrate was seen in the computarized tomography. According to the clinic and imaging, the first diagnostic approach was an interstitial lung disease. The first lung biopsy was normal. He initially received treatment with cortico-steroids and bronchodilators during years, with no clear improving. A second lung biopsy was performed in which we found changes compatible with lambertosis. Finally, he started treatment with hidroxychloroquine and currently he has a normal life and rarely needs oxygen at home. Discussion: In our patient, despite the normal result of lung biopsy, the diagnosis of interstitial lung disease was not discarded because of the suggestive symptoms, signs and imaging tests. Lambertosis in adults is related to tobacco and infectious agents, but in children genetics seem to be important. The initial treatment were corticosteroids and then hidroxychloroquine. Conclusions: Although the diagnosis is histopathological, a normal lung biopsy does not discard an interstitial lung dis-ease. There is need of more clinical trials to establish the appropriate treatment for these patients

[Emergent drugs (II): the Pharming phenomenon]. / Drogas emergentes (II): el pharming.

The use of medicines, with or without medical prescription, for recreational ends by the young population has received little attention from doctors. In the USA, one in five adolescents has used medicines for recreational purposes, and consultations in Emergency Departments for medicine abuse have exceeded those for illegal drugs. Although few data are available in Spain, such consumption is situated between 3.1 and 8.6% according to surveys. The medicines most used are dextromethorphan and methylphenidate. The former, on sale without prescription, presents a varied symptomatology, dosage and dependent metabolic action, ranging from euphoria to hallucinations. Methylphenidate, taken orally, nasally or intravenously, is used as a stimulant in substitution for cocaine and is one of the medicines most diverted onto the illicit market at the world level. In principle, other substances like modafinil and propofol present a limited incidence of non-medical use, but they have a probable abuse potential that should be borne in mind, above all in the health context. Finally, opiates like fentanyl, oxycodone and buprenorphine, with new pharmaceutical presentations, have recently become generalized in the therapeutic arsenal of many medical specialities; they are giving rise to phenomena of abuse, dependence and diversion towards the illicit market. Demands for detoxification treatment, their mixture with illegal substances, and cases of death should alert us to the abuse of these medicines.

Drogas emergentes (II): el pharming / Emergent drugs (II): the Pharming phenomenon

El uso por la población joven de fármacos con y sin receta médica con fines recreativos, ha tenido escasa atención por los médicos. En USA, uno de cada cinco adolescentes han usado fármacos con finalidad recreativa, y en el servicio de Urgencias, las consultas por abuso de fármacos han superado a las de drogas ilegales. Aunque es España existen pocos datos, este consumo se sitúa, según las encuestas, entre el 3,1 y el 8,6%.Los fármacos más utilizados son el dextrometorfán y el metilfenidato. El primero, de venta sin receta, presenta una sintomatología variable, dosis y acción metabólica dependiente, el cual varía desde la euforia a las alucinaciones. El metilfenidato se utiliza como estimulante sustituto de la cocaína, tanto por vía oral como nasal e intravenosa, siendo uno de los fármacos con más desvío hacia el mercado ilícito a nivel mundial. Otras sustancias como el modafinilo y el propofol presentan un uso no médico en principio de escasa incidencia, pero con un potencial de abuso a tener en cuenta, sobre todo en el ámbito sanitario. Finalmente, opiáceos como el fentanilo, la oxicodona y la buprenorfina, de reciente generalización en el arsenal terapéutico de muchas especialidades médicas y con nuevas presentaciones farmacéuticas, están produciendo fenómenos de abuso, dependencia y comercio ilícito. Las demandas de tratamiento de desintoxicación, la mezcla con sustancias ilegales y los casos de muerte, alertan sobre el abuso de estos fármacos (AU)

The use of medicines, with or without medical prescription, for recreational ends by the young population has received little attention from doctors. In the USA, one in five adolescents has used medicines for recreational purposes, and consultations in Emergency Departments for medicine abuse have exceeded those for illegal drugs. Although few data are available in Spain, such consumption is situated between 3.1 and 8.6% according to surveys. The medicines most used are dextromethorphan and methylphenidate. The former, on sale without prescription, presents a varied symptomatology, dosage and dependent metabolic action, ranging from euphoria to hallucinations. Methylphenidate, taken orally, nasally or intravenously, is used as a stimulant in substitution for cocaine and is one of the medicines most diverted onto the illicit market at the world level. In principle, other substances like modafinil and propofol present a limited incidence of non-medical use, but they have a probable abuse potential that should be borne in mind, above all in the health context. Finally, opiates like fentanyl, oxycodone and buprenorphine, with new pharmaceutical presentations, have recently become generalized in the therapeutic arsenal of many medical specialities; they are giving rise to phenomena of abuse, dependence and diversion towards the illicit market. Demands for detoxification treatment, their mixture with illegal substances, and cases of death should alert us to the abuse of these medicines (AU)