Analgesia epidural en paciente con déficit de factor XI / Epidural analgesia in a patient with factor XI deficit

El déficit de factorXI es una enfermedad hemorrágica rara que se caracteriza por presentar disminución del nivel o de la actividad del factor. Las mujeres embarazadas con esta patología presentan mayor riesgo de sangrado uterino durante el parto. El uso de analgesia neuroaxial en estas pacientes puede aumentar el riesgo de producir hematoma epidural. Es necesario realizar un seguimiento multidisciplinar en el que participen activamente anestesiólogos, hematólogos y ginecólogos. Actualmente disponemos de escasa bibliografía sobre el manejo anestésico de este tipo de patología. Presentamos el caso clínico de una mujer de 36años con antecedentes personales de déficit de factorXI, embarazada de 38 semanas de gestación que es programada para realización de inducción del parto. Previamente a la inducción se midieron los niveles del factor, y al ser inferiores al 40% se decidió transfundir 20ml/kg de plasma fresco congelado. Tras la transfusión presentó niveles superiores al 40%, por lo que se realizó analgesia epidural sin incidencias. La paciente no presentó complicaciones secundarias a la analgesia epidural ni a la transfusión de un volumen elevado de plasma.(AU)

Factor XI deficiency is a rare bleeding disorder characterized by a decreased level or activity of factor. Pregnant women are at increased risk of uterine bleeding during childbirth. Neuroaxial analgesia may increase the risk of epidural hematoma in these patients. However, there is no consensus on the anesthetic management. We present the clinical case of a 36-year-old woman with a personal history of factorXI deficiency, pregnant with 38weeks gestation who is scheduled to perform birth induction. Pre-induction factor levels were measured. They were less than 40%, so it was decided to transfuse 20mL/kg of fresh frozen plasma. After the transfusion it had levels greater than 40%, so epidural analgesia was performed without incident. The patient had no complications secondary to epidural analgesia or transfusion of a high volume of plasma.(AU)

Epidural analgesia in a patient with factor XI deficit.

FXI deficiency is a rare bleeding disorder characterised by a decreased level or activity of factor. Pregnant women are at increased risk of uterine bleeding during childbirth. Neuroaxial analgesia may increase the risk of epidural hematoma in these patients. However, there is no consensus on the anaesthetic management. We present the clinical case of a 36-year-old woman with a personal history of factor XI deficiency, pregnant with 38 weeks gestation who is scheduled to perform birth induction. Pre-induction factor levels were measured. They were less than 40%, so it was decided to transfuse 20 ml/kg of fresh frozen plasma. After the transfusion it had levels greater than 40%, so epidural analgesia was performed without incident. The patient had no complications secondary to epidural analgesia or transfusion of a high volume of plasma.

Anaesthetic management of a dopamine-secreting phaeochromocytoma.

Pheochromocytomas are rare neuroendocrine tumors that arise from chromaffin cells of the adrenal medulla. Most adrenal pheochromocytomas secrete norepinephrine and epinephrine. Dopamine secreting pheochromocytomas are extremely rare and differs from classic pheochromocytomas in clinical features, posing a significant diagnostic challenge. A 41-year-old women presented to our emergency department because of acute flank colic pain and normotension. The screening abdominal computed tomography scan revealed a left adrenal mass. The laboratory test showed significantly increase in plasma dopamine and 24-h urine dopamine. During surgical removal the patient remained hypotensive requiring doses of norepinephrine. The patient presented significant hypertensive responde during direct laryngoscopy and intubation.

Manejo anestésico de feocromocitoma productor de dopamina / Anaesthetic management of a dopamine-secreting phaeochromocytoma

El feocromocitoma es un tumor neuroendocrino raro que se origina en las células cromafines de la cresta neural del sistema nervioso autónomo. La mayoría de las feocromocitomas se caracterizan por secretar adrenalina y noradrenalina. Los productores de dopamina son infrecuentes y no presentan la sintomatología clínica típica, por lo que el diagnóstico puede ser complicado. Actualmente disponemos de escasa bibliografía sobre el manejo anestésico de este tipo de tumores.Presentamos el caso clínico de una mujer de 41 años que acudió a nuestro centro por dolor lumbar de tipo cólico de un mes de evolución y normotensión. Se realizó una tomografía axial computarizada abdominal que reveló masa hipercaptante en glándula suprarrenal izquierda. Los niveles de dopamina en orina y en plasma estaban elevados, los niveles de adrenalina y noradrenalina eran normales. Durante la intervención quirúrgica la paciente se mantuvo hipotensa precisando dosis de noradrenalina. Solo presentó un único pico hipertensivo durante la laringoscopia y la intubación orotraqueal.(AU)

Pheochromocytomas are rare neuroendocrine tumors that arise from chromaffin cells of the adrenal medulla. Most adrenal pheochromocytomas secrete norepinephrine and epinephrine. Dopamine secreting pheochromocytomas are extremely rare and differs from classic pheochromocytomas in clinical features, posing a significant diagnostic challenge.A 41-year-old women presented to our emergency department because of acute flank colic pain and normotension. The screening abdominal computed tomography scan revealed a left adrenal mass. The laboratory test showed significantly increase in plasma dopamine and 24-hour urine dopamine. During surgical removal the patient remained hypotensive requiring doses of norepinephrine. The patient presented significant hypertensive responde during direct laryngoscopy and intubation.(AU)

A longitudinal study of gene expression in first-episode schizophrenia; exploring relapse mechanisms by co-expression analysis in peripheral blood.

Little is known about the pathophysiological mechanisms of relapse in first-episode schizophrenia, which limits the study of potential biomarkers. To explore relapse mechanisms and identify potential biomarkers for relapse prediction, we analyzed gene expression in peripheral blood in a cohort of first-episode schizophrenia patients with less than 5 years of evolution who had been evaluated over a 3-year follow-up period. A total of 91 participants of the 2EPs project formed the sample for baseline gene expression analysis. Of these, 67 provided biological samples at follow-up (36 after 3 years and 31 at relapse). Gene expression was assessed using the Clariom S Human Array. Weighted gene co-expression network analysis was applied to identify modules of co-expressed genes and to analyze their preservation after 3 years of follow-up or at relapse. Among the 25 modules identified, one module was semi-conserved at relapse (DarkTurquoise) and was enriched with risk genes for schizophrenia, showing a dysregulation of the TCF4 gene network in the module. Two modules were semi-conserved both at relapse and after 3 years of follow-up (DarkRed and DarkGrey) and were found to be biologically associated with protein modification and protein location processes. Higher expression of DarkRed genes was associated with higher risk of suffering a relapse and early appearance of relapse (p = 0.045). Our findings suggest that a dysregulation of the TCF4 network could be an important step in the biological process that leads to relapse and suggest that genes related to the ubiquitin proteosome system could be potential biomarkers of relapse.

Social Cognition and Interaction Training (SCIT) versus Training in Affect Recognition (TAR) in patients with schizophrenia: A randomized controlled trial.

INTRODUCTION: Training in Affect Recognition (TAR) is a "targeted" and computer-aided program that has been shown to effectively attenuate facial affect recognition deficits and improve social functioning in patients with schizophrenia. Social Cognition and Interaction Training (SCIT) is a group "broad-based" intervention, that has also been shown to improve emotion recognition, theory of mind (ToM), and social functioning. To date, no study has compared the efficacy of two different social cognitive interventions. OBJECTIVES: We aim to compare the efficacy of TAR and SCIT on schizophrenia patients' performance on facial affect recognition, theory of mind, attributional style and social functioning before, after treatment, and three months thereafter. METHODS: One hundred outpatients with a diagnosis of schizophrenia were randomly assigned to the TAR or SCIT condition and completed pre- (T0) and posttreatment (T1) assessments and a 3-month follow up (T2) of emotion recognition (ER-40), theory of mind (Hinting Task), attributional style (AIHQ) and social functioning (PSP). RESULTS: The entire sample, receiving TAR or SCIT, showed improvements in theory of mind, attributional style, clinical symptoms and social functioning. This effect was maintained at three-months. The TAR intervention was more efficacious than the SCIT program in improving the recognition of facial emotions (ER-40). The TAR intervention also demonstrated a lower drop-out rate than the SCIT intervention. CONCLUSIONS: There were improvements in social cognition, symptomatology and functioning of patients in the entire sample, receiving SCIT or TAR. Both TAR and SCIT appear as valuable treatments for people with schizophrenia and social cognitive deficits.

Anaesthetic management of a dopamine-secreting phaeochromocytoma. / Manejo anestésico de feocromocitoma productor de dopamina.

Pheochromocytomas are rare neuroendocrine tumors that arise from chromaffin cells of the adrenal medulla. Most adrenal pheochromocytomas secrete norepinephrine and epinephrine. Dopamine secreting pheochromocytomas are extremely rare and differs from classic pheochromocytomas in clinical features, posing a significant diagnostic challenge. A 41-year-old women presented to our emergency department because of acute flank colic pain and normotension. The screening abdominal computed tomography scan revealed a left adrenal mass. The laboratory test showed significantly increase in plasma dopamine and 24-hour urine dopamine. During surgical removal the patient remained hypotensive requiring doses of norepinephrine. The patient presented significant hypertensive responde during direct laryngoscopy and intubation.

Impact of outbreak COVID-19 pandemic on psychiatry emergencies in Spain.

The SARS-CoV-2 pandemic has caused an unprecedented clinical situation. A retrospective cross-sectional study was designed with the aim to evaluate psychiatric emergencies from March 14 to May 1, 2020, coinciding with the start of the emergency state and the lockdown until the attenuation of the confinement. Data obtained during this period were compared with the emergencies attended in the same period of 2019. A total of 213 psychiatric emergencies were attended in 2020 compared with 367 in 2019. The mean number of emergencies per day was significantly lower during the COVID-19 outbreak in 2020 (M=4.35, SD= 2.04) vs. the same period in 2019 (M=7.50, SD= 3.18). A higher percentage of patients with schizo/psychotic disorders (34.3% in 2020, vs. 24.3% in 2019), as well as a lower percentage of patients with anxiety/adaptive disorders (25.4% in 2020 vs. 35.4% in 2019) was observed during the outbreak. A significant lower mean discharge/emergency ratio (M=42.17, SD= 26.94 in 2020 vs. M=63.43, SD= 17.64 in 2019) and a higher referral to Internal Medicine/emergency ratio (M=20.55, SD= 22.16 in 2020 vs. M=3.32, SD= 6.63 in 2019) was observed. The results suggest important changes in psychiatric emergencies during the most critical period of the COVID-19 outbreak in Spain.

Influence of social cognition as a mediator between cognitive reserve and psychosocial functioning in patients with first episode psychosis.

BACKGROUND: Social cognition has been associated with functional outcome in patients with first episode psychosis (FEP). Social cognition has also been associated with neurocognition and cognitive reserve. Although cognitive reserve, neurocognitive functioning, social cognition, and functional outcome are related, the direction of their associations is not clear. Therefore, the main aim of this study was to analyze the influence of social cognition as a mediator between cognitive reserve and cognitive domains on functioning in FEP both at baseline and at 2 years. METHODS: The sample of the study was composed of 282 FEP patients followed up for 2 years. To analyze whether social cognition mediates the influence of cognitive reserve and cognitive domains on functioning, a path analysis was performed. The statistical significance of any mediation effects was evaluated by bootstrap analysis. RESULTS: At baseline, as neither cognitive reserve nor the cognitive domains studied were related to functioning, the conditions for mediation were not satisfied. Nevertheless, at 2 years of follow-up, social cognition acted as a mediator between cognitive reserve and functioning. Likewise, social cognition was a mediator between verbal memory and functional outcome. The results of the bootstrap analysis confirmed these significant mediations (95% bootstrapped CI (-10.215 to -0.337) and (-4.731 to -0.605) respectively). CONCLUSIONS: Cognitive reserve and neurocognition are related to functioning, and social cognition mediates in this relationship.

MCCB cognitive profile in Spanish first episode schizophrenia patients.

The objective of the study was to examine the cognitive profile of Spanish patients with a first episode of schizophrenia (FESz) and to compare that to the profile of patients with a chronic schizophrenia (CSz) and non-psychiatric (NP) control subjects. The study included 106 FESz, 293 CSz, and 210 NP, assessed with the Spanish version of the MATRICS Consensus Cognitive Battery (MCCB). The MCCB cognitive profile in a Spanish sample of FESz was similar to the cognitive profile of CSz with some discrepancies in select domains. The scores of both patient samples were about 1-2 SD below the scores of non-psychiatric control subjects.

Differences in the regulation of inflammatory pathways in adolescent- and adult-onset first-episode psychosis.

A precise description of the inflammatory response in first-episode psychosis (FEP) by age of onset does not exist. We explored baseline and 6-month follow-up differences in the pro/anti-inflammatory balance in plasma and peripheral blood mononuclear cells in adolescent-onset FEP (≤ 18 y.o., N = 27) and adult-onset FEP (≥ 25 y.o., N = 43) using non-parametric 1-category ANCOVA, with age group as an independent variable and values of pro- and anti-inflammatory markers at baseline and at follow-up as dependent variables. We used a non-parametric repeated-measures mixed-effects model to explore the baseline/6-month change in pro- and anti-inflammatory markers within adolescent- and adult-onset groups, exploring differential trajectories of change by means of the interaction of time by age-of-onset group. Levels of the nuclear transcription factor (NFκB), a master regulator of the inflammatory and oxido/nitrosative status of cells, were higher in adolescent-onset FEP both at baseline and after 6 months. During follow-up, we found further increases in levels of soluble inflammatory markers (PGE2 and NO2-) only in adolescent-onset FEP. In contrast, in adult-onset FEP, the expression of inducible NO synthase (iNOS), which is also pro-inflammatory, tended to decrease, with no further increase in other pro-inflammatory markers. Significant differences in the direction of change by age-of-onset cohort exist only for NFκB (F = 4.165, df = 2, 70.95, p = 0.019). Our results support the existence of changes in the pro/anti-inflammatory balance in FEP depending on the neurodevelopmental stage at illness onset. These results also suggest that inflammation may be a potential therapeutic target in adolescent-onset FEP.

Emotion processing and psychosocial functioning in euthymic bipolar disorder.

OBJECTIVE: To examine emotion processing in euthymic bipolar patients (EBP) compared to healthy controls. In addition, to determine whether or not there is an association between emotion processing and psychosocial functioning. MATERIAL AND METHODS: A sample of 60 EBP and 60 healthy controls matched for age, gender, education level, and premorbid intelligence were studied. All subjects were assessed using the MATRICS Consensus Cognitive Battery (MCCB) and two additional executive function measures: the Trail Making Test-Part B and the Stroop Test. Emotion processing was examined using the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT). Psychosocial functioning was assessed using the Functional Assessment Short Test (FAST). RESULTS: Euthymic bipolar patients obtained lower scores than controls in all MSCEIT measures except for the using emotions branch. Likewise, EBP obtained a worse performance than healthy controls in all neurocognitive domains. Correlation between MSCEIT strategic area measures and FAST total score was found (r = -0.311; P < 0.016). Regression analysis showed that residual depressive symptomatology explains a 9.1% of the variance in functional outcome. MSCEIT strategic area score explained an additional 8.6%. Neurocognition did not increase the percentage of the variance explained by emotion processing. CONCLUSIONS: Euthymic bipolar patients exhibit deficits in emotion processing. Emotion processing is associated with social functioning in these patients.

BDNF and NGF Signalling in Early Phases of Psychosis: Relationship With Inflammation and Response to Antipsychotics After 1 Year.

Previous studies have indicated systemic deregulation of the proinflammatory or anti-inflammatory balance in individuals with first-episode psychosis (FEP) that persists 12 months later. To identify potential risk/protective factors and associations with symptom severity, we assessed possible changes in plasma levels of neurotrophins (brain-derived neurotrophic factor [BDNF] and nerve growth factor [NGF]) and their receptors in peripheral blood mononuclear cells (PBMCs). Expression of the 2 forms of BDNF receptors (active TrkB-FL and inactiveTrkB-T1) in PBMCs of FEP patients changed over time, TrkB-FL expression increasing by 1 year after diagnosis, while TrkB-T1 expression decreased. The TrkB-FL/TrkB-T1 ratio (hereafter FL/T1 ratio) increased during follow-up in the nonaffective psychosis group only, suggesting different underlying pathophysiological mechanisms in subgroups of FEP patients. Further, the expression of the main NGF receptor, TrkA, generally increased in patients at follow-up. After adjusting for potential confounders, baseline levels of inducible isoforms of nitric oxide synthase, cyclooxygenase, and nuclear transcription factor were significantly associated with the FL/T1 ratio, suggesting that more inflammation is associated with higher values of this ratio. Interestingly, the FL/T1 ratio might have a role as a predictor of functioning, a regression model of functioning at 1 year suggesting that the effect of the FL/T1 ratio at baseline on functioning at 1 year depended on whether patients were treated with antipsychotics. These findings may have translational relevance; specifically, it might be useful to assess the expression of TrkB receptor isoforms before initiating antipsychotic treatment in FEPs.

The MCCB impairment profile in a Spanish sample of patients with schizophrenia: Effects of diagnosis, age, and gender on cognitive functioning.

The MATRICS Consensus Cognitive Battery (MCCB) was administered to 293 schizophrenia outpatients and 210 community residents in Spain. Our first objective was to identify the age- and gender-corrected MCCB cognitive profile of patients with schizophrenia. The profile of schizophrenia patients showed deficits when compared to controls across the seven MCCB domains. Reasoning and Problem Solving and Social Cognition were the least impaired, while Visual Learning and Verbal Learning showed the greatest deficits. Our second objective was to study the effects on cognitive functioning of age and gender, in addition to diagnosis. Diagnosis was found to have the greatest effect on cognition (Cohen's d>0.8 for all MCCB domains); age and gender also had effects on cognitive functioning, although to a lesser degree (with age usually having slightly larger effects than gender). The effects of age were apparent in all domains (with better performance in younger subjects), except for Social Cognition. Gender had effects on Attention/Vigilance, Working Memory, Reasoning and Problem Solving (better performance in males), and Social Cognition (better performance in females). No interaction effects were found between diagnosis and age, or between diagnosis and gender. This lack of interactions suggests that age and gender effects are not different in patients and controls.

Differential relationships between set-shifting abilities and dimensions of insight in schizophrenia.

BACKGROUND: To assess insight in a large sample of patients with schizophrenia and to study its relationship with set shifting as an executive function. METHODS: The insight of a sample of 161 clinically stable, community-dwelling patients with schizophrenia was evaluated by means of the Scale to Assess Unawareness of Mental Disorder (SUMD). Set shifting was measured using the Trail-Making Test time required to complete part B minus the time required to complete part A (TMT B-A). Linear regression analyses were performed to investigate the relationships of TMT B-A with different dimensions of general insight. RESULTS: Regression analyses revealed a significant association between TMT B-A and two of the SUMD general components: 'awareness of mental disorder' and 'awareness of the efficacy of treatment'. The 'awareness of social consequences' component was not significantly associated with set shifting. CONCLUSIONS: Our results show a significant relation between set shifting and insight, but not in the same manner for the different components of the SUMD general score.

The MATRICS consensus cognitive battery (MCCB): co-norming and standardization in Spain.

The MATRICS Consensus Cognitive Battery (MCCB), developed by the National Institute of Mental Health (NIMH) Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative, has been recommended as the standard battery for clinical trials of cognition-enhancing interventions for schizophrenia. Normative data for the MCCB has been previously obtained in the U.S. Extrapolation of these normative data to different countries may be problematic due to the translation of the different tests, as well as potential cultural influences. We present the process of obtaining normative data for the MCCB in Spain with administration of the battery to a general community standardization sample. In addition, we examine the influence of age, gender, and educational level on test performance. The MCCB was administered to a total sample of 210 healthy volunteers, at three Spanish sites. For each site, recruitment of the sample was stratified according to age, gender, and educational level. Our findings indicate significant age, gender, and education effects on the normative data for the MCCB in Spain, which are comparable to those effects described for the original standardized English version in the U.S. The fact that the normative data are comparable, and that the variables age, gender, and education have a similar influence on performance, supports the robustness of the MCCB for use in different countries.

Incidence and lifetime risk of dementia and Alzheimer's disease in a Southern European population.

OBJECTIVE: To calculate both the incidence rates and the lifetime risk (LTR) of dementia and Alzheimer's disease (AD). METHODS: A two-phase case-finding procedure was implemented in a cohort of 4057 cognitively intact individuals 55+ years of age living in Zaragoza, Spain, and followed-up at 2.5 and 4.5 years. Age- and sex-specific incidence rates were calculated. A mortality-adjusted, multivariate model was used to document LTRs. RESULTS: The incidence rate of dementia continued to rise after the age of 90 years, but was slightly lower than in North and West European studies. Only a tendency for an increased LTR with age was observed. Thus, LTR was 19.7% for a 65-year-old woman and 20.4% at the age of 85 years, the corresponding figures for AD being 16.7% and 17.6%. The LTR of AD was higher in women and was about twice as high among illiterate individuals when compared with individuals with higher educational levels. CONCLUSIONS: The incidence rate of dementia in this Southern European city was slightly lower than in previous studies in North-West Europe. LTR of dementia and AD seems to be slightly increased with age. The association of illiteracy with higher LTR of AD is intriguing.

High frequency of childhood ADHD history in women with fibromyalgia.

Fibromyalgia and ADHD share some clinical features, and a reduced dopamine function has been proposed for both disorders. Here we found, in a large sample of fibromyalgia female patients, a higher frequency of childhood ADHD antecedent when compared with healthy women. Our data suggest that Fibromyalgia and ADHD have some common etiopathological mechanism.

DRD2 and ANKK1 genotype in alcohol-dependent patients with psychopathic traits: association and interaction study.

BACKGROUND: The TaqI-A polymorphism of the ANKK1 gene, adjacent to the DRD2 gene, has been associated with alcoholism and other psychiatric conditions, although other DRD2 gene variants, such as the C957T polymorphism, could be related to these phenotypic traits. AIMS: To investigate the contribution of the TaqI-A and the C957T polymorphisms to the presence of psychopathic traits in patients with alcoholism. METHOD: We performed association and interaction analyses of the polymorphisms in 150 controls and 176 male alcohol-dependent patients assessed for the presence of dissocial personal disorder, using the Psychopathy Checklist-Revised (PCL-R). RESULTS: There was a significant association of the TaqI-A and C957T polymorphisms when both genotypes were present, with PCL-R scores of F(1-171=0.13) (P=0.01) and a frequency of dissocial personal disorder OR=10.52, P<0.001. CONCLUSIONS: The TaqI-A of the ANKK1 gene and the C957T of the DRD2 gene are epistatically associated with psychopathic traits in alcohol-dependent patients.

Uso de antiepilépticos en adicciones / Use of antiepileptics in addictions

Las propiedades farmacológicas de los antiepilépticos como moduladores de los sistemas glutamatérgico y gabérgico indican su potencial utilidad en el tratamiento de los trastornos adictivos. Su eficacia clínica ha sido ampliamente estudiada en el tratamiento de desintoxicación de alcohol y benzodiazepinas y diferentes estudios avalan su utilidad en la prevención de recaídas en el consumo de alcohol. Con respecto a otras adicciones, hasta el momento se han realizado estudios sólo con muestras pequeñas y metodología diversa, por lo que los datos son menos consistentes, sin que pueda descartarse que estos fármacos puedan también aportar beneficios como tratamiento coadyuvante en otros trastornos adictivos. Además, los nuevos antiepilépticos ofrecen ventajas relevantes, especialmente respecto a su tolerabilidad. Los fármacos disponibles en la actualidad abarcan un amplio espectro de acciones fármaco dinámicas, de forma que el avance en el conocimiento de los mecanismos fisiopatológicos subyacentes a la adicción ayudará a diseñar estrategias más selectivas en la utilización de los antiepilépticos en función de sus mecanismos de acción específicos (AU)

The drug properties of antiepileptics as glutamatergic and gabaergic system modulators indicate their potential utility in the treatment of addictive disorders. Their clinical efficacy has been widely studied in the treatment of detoxication of alcohol and benzodiazepine. Furthermore, different studies support their utility in the prevention of relapses in alcohol consumption. In regards to other addictions, up to now studies have only been conducted with small samples and different methodologies. Thus, the data are less consistent and do not make it possible to rule out the fact that these drugs may also contribute benefits as coadjuvant treatment in other addictive disorders. In addition, the new antiepileptics offer relevant advantages, especially in regards to their tolerability. The drugs that are currently available include a wide spectrum of pharmacodynamic actions. Therefore, advance in the knowledge of the pathophysiological mechanisms underlying the addiction will help to design more selective strategies in the use of antiepileptics based on their specific action mechanisms (AU)