Ultrabrief (0.3 ms) or brief (0.5 ms) pulses for right unilateral electroconvulsive therapy: is there a difference in seizure thresholds?

OBJECTIVES: To compare the minimum charge to elicit a seizure using 2 different pulse widths, the brief pulse (0.5 milliseconds [ms]) and the ultrabrief pulse (0.3 ms). METHODS: We compared retrospectively the last 30 patients in our ECT unit whose seizure thresholds were titrated using a pulse width of 0.5 ms to the last 30 patients whose seizure thresholds were titrated using a pulse width of 0.3 ms. The former were regular clinical patients, and the latter were participating in a clinical trial on the use of ultrabrief pulse treatment. All titrations were performed with right unilateral electrode positioning. Most patients continued to use psychotropic medications. RESULTS: Initial seizure threshold (as measured in millicoulombs [mC]) for the brief pulse group (0.5 ms) was 16 (n = 1); 32 (n = 21), and 64 (n = 8); whereas for the ultrabrief pulse group (0.3 ms), it was 9.2 (n = 3), 38.4 (n = 21), 19.2 (n = 3), 76.8 (n = 2), and 307.2 (n = 1). Excluding the outlier, there was no statistical difference between mean seizure thresholds. CONCLUSIONS: If we exclude the outlier from the ultrabrief group (seizure threshold [ST], 307 mC), we can observe that most of the patients in both groups had an ST between 30 and 40 mC. No patient in the brief pulse group showed a lower ST than 16 mC, probably because this was the first step of titration for this group. The data suggest that the difference between 0.3 and 0.5 ms may not be big, although randomized prospective studies with a more precise and similar steps used for titration are needed. Clinical efficacy was not compared in the present study.

Recovery after ECT: comparison of propofol, etomidate and thiopental / Recuperação pós-eletroconvulsoterapia: comparação entre propofol, etomidato e tiopental

OBJECTIVES: To compare post anesthetic time for patient recovery after electroconvulsive therapy, as measured by the post anesthetic Recovery Score of Aldrete and Kroulik, using three different types of hypnotic drugs (propofol, etomidate and thiopental). METHOD: Thirty patients were randomized to receive one of the three drugs (n = 10 in each group), during a course of electroconvulsive therapy treatment. Patients and raters were blinded to which drug was received. Main treatment characteristics were recorded (as total electric charge received seizure threshold, number of treatments, and the mean time for recovery) along the whole treatment. RESULTS: Thiopental and propofol were associated with a significance increase in charge needed to induce a seizure (p < 0.0001) when compared to etomidate, as well as a significant decrease of time for recovery (p = 0.042). CONCLUSIONS: These findings suggest that, although there seems to be no difference in the clinical outcome across these three drugs, propofol offers the best recovery profile. However, it makes a higher mean electric charge necessary.

OBJETIVOS: Comparar o tempo de recuperação dos pacientes após eletroconvulsoterapia avaliada com a escala de recuperação pós-anestésica de Aldrete e Kroulik, utilizando três tipos de medicações anestésicas (propofol, etomidato and tiopental). MÉTODO: Trinta pacientes foram randomizados para receber uma das medicações (n = 10 em cada grupo) durante uma série de tratamentos com eletroconvulsoterapia. Os pacientes e o examinador ficaram cegos para o tipo de anestésico utilizado. As principais características do tratamento foram avaliadas (como carga total de eletricidade recebida, limiar convulsivo, número de sessões e o tempo médio para recuperação) ao longo de toda a série de tratamentos. RESULTADOS: Tiopental e propofol se associaram a um aumento significativo na carga elétrica total utilizada (p < 0,0001) quando comparados com etomidato, bem como uma diminuição significativa no tempo de recuperação pós-anestésica (p = 0,042). CONCLUSÕES: Estes achados sugerem que, apesar de não haver diferença na evolução clínica entre os três grupos estudados, a droga propofol oferece o melhor perfil de recuperação apesar de requerer uma carga elétrica média maior.

Recovery after ECT: comparison of propofol, etomidate and thiopental.

OBJECTIVES: To compare post anesthetic time for patient recovery after electroconvulsive therapy, as measured by the post anesthetic Recovery Score of Aldrete and Kroulik, using three different types of hypnotic drugs (propofol, etomidate and thiopental). METHOD: Thirty patients were randomized to receive one of the three drugs (n = 10 in each group), during a course of electroconvulsive therapy treatment. Patients and raters were blinded to which drug was received. Main treatment characteristics were recorded (as total electric charge received seizure threshold, number of treatments, and the mean time for recovery) along the whole treatment. RESULTS: Thiopental and propofol were associated with a significance increase in charge needed to induce a seizure (p < 0.0001) when compared to etomidate, as well as a significant decrease of time for recovery (p = 0.042). CONCLUSIONS: These findings suggest that, although there seems to be no difference in the clinical outcome across these three drugs, propofol offers the best recovery profile. However, it makes a higher mean electric charge necessary.

Significant improvement in extensive lichen sclerosus with tacrolimus ointment and PUVA.

Lichen sclerosus is an uncommon, chronic inflammatory skin disorder of unknown origin. It is clinically characterized by sclerotic, whitish, atrophic-type lesions. The most frequent site of the lesions is generally the genital region, with about 15-20% having additional extragenital involvement. We present the case of a 62-year-old woman with a very extensive extragenital lichen sclerosus who showed great clinical and subjective improvement with 0.1% tacrolimus ointment and psoralen plus UVA (PUVA), without any topical or systemic adverse effects. Combined treatment of 0.1% tacrolimus ointment and PUVA may be a good option in extensive cases of lichen sclerosus or when other treatment options have failed, and has a good tolerability and safety profile.

Histiocitosis de células de Langerhans / Langerhans cell histiocytosis

Las histiocitosis se originan por la proliferación de células del sistema fagocítico mononuclear en diferentes tejidos. Estas entidades conforman un grupo heterogéneo, y principalmente se clasifican en histiocitosis de células de Langerhans e histiocitosis de células no Langerhans. Las histiocitosis de células de Langerhans tienen en común la proliferación de células dendríticas presentadoras de antígeno con características fenotípicas y ultraestructurales de células de Langerhans. La infiltración puede limitarse a un órgano, o ser diseminada. El pronóstico y el tratamiento dependen sobre todo de la edad del paciente y del número y disfunción de los órganos afectados. La etiopatogenia es desconocida, aunque en la actualidad la mayor parte de los investigadores cree que se produce una alteración en la regulación del sistema inmunológico en estos pacientes

Histiocytoses originate from the proliferation of mononuclear phagocytes in different tissues. These entities make up a heterogeneous group, and are mainly classified as Langerhans cell histiocytoses and non-Langerhans cell histiocytoses. Langerhans cell histiocytoses have as a common characteristic the proliferation of dendritic antigen-presenting cells with phenotypical and ultrastructural characteristics of Langerhans cells. Infiltration may be limited to one organ, or may be disseminated. The prognosis and the treatment especially depend on the age of the patient and the number and dysfunction of the organs involved. Its etiopathogenesis is unknown, although most researchers currently believe that an alteration in the regulation of the immunological system occurs in these patients

Lupus eritematoso sistémico de presentación cutánea subaguda. Presentación de dos casos clínicos / Subacute cutaneous systemic lupus erythematosus. Presentation of two clinical cases

Se presentan 2 casos de lupus eritematoso sistémico (LES) que se manifestaron con síntomas cutáneos subagudos. Tanto el lupus cutáneo como el lupus sistémico son el resultado de interacciones entre genes de susceptibilidad y factores del medio, como la radiación ultravioleta, que provoca una respuesta inmunitaria anómala con una hiperreactividad de linfocitos T y B. Más del 50 % de los lupus cutáneos subagudos tienen o tendrán un LES, mientras que sólo del 16 al 61 % de los LES tienen lesiones de lupus cutáneo agudo

We present two cases of systemic lupus erythematosus (SLE) which began with subacute clinical manifestations. Both cutaneous and systemic lupus are the result of interactions between susceptibility genes and environmental factors such as ultraviolet radiation, giving rise to an anomalous response with hyperreactivity of T and B lymphocytes. Over 50 % of subacute cutaneous lupus cases have or will have SLE, while only 16 to 61 % of SLE cases have acute cutaneous lupus lesions

[Subacute cutaneous systemic lupus erythematosus. Presentation of two clinical cases]. / Lupus eritematoso sistémico de presentación cutánea subaguda. Presentación de dos casos clínicos.

We present two cases of systemic lupus erythematosus (SLE) which began with subacute clinical manifestations. Both cutaneous and systemic lupus are the result of interactions between susceptibility genes and environmental factors such as ultraviolet radiation, giving rise to an anomalous response with hyperreactivity of T and B lymphocytes. Over 50 % of subacute cutaneous lupus cases have or will have SLE, while only 16 to 61 % of SLE cases have acute cutaneous lupus lesions.

[Langerhans cell histiocytosis]. / Histiocitosis de células de Langerhans.

Histiocytoses originate from the proliferation of mononuclear phagocytes in different tissues. These entities make up a heterogeneous group, and are mainly classified as Langerhans cell histiocytoses and non-Langerhans cell histiocytoses. Langerhans cell histiocytoses have as a common characteristic the proliferation of dendritic antigen-presenting cells with phenotypical and ultrastructural characteristics of Langerhans cells. Infiltration may be limited to one organ, or may be disseminated. The prognosis and the treatment especially depend on the age of the patient and the number and dysfunction of the organs involved. Its etiopathogenesis is unknown, although most researchers currently believe that an alteration in the regulation of the immunological system occurs in these patients.

Placas eritematosas erosivas en caras laterales del cuello, axilas e ingles / Erythematous-erosive plaques on the sides of the neck, axillae and groins

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Fluorodeoxyglucose-positron emission tomography imaging versus sentinel node biopsy in the primary staging of melanoma patients.

BACKGROUND: Positron emission tomography (PET) imaging is superior to conventional techniques for the evaluation of patients with stage III and stage IV cutaneous melanoma. Several studies have highlighted the advantages of this noninvasive technique for the assessment of lymph node involvement. OBJECTIVE: To compare PET imaging with sentinel node biopsy for primary staging of cutaneous melanoma and to discuss the technical limitations of PET scanning. METHODS: Twenty-five consecutive patients with a histologic diagnosis of melanoma with a Breslow thickness equal or greater to 1 mm underwent a preoperative PET to assess lymph node involvement. RESULTS: Sentinel node biopsy and PET showed a sensitivity of 100% and 22%, respectively, in the identification of lymph node metastases. CONCLUSION: PET is not a sensitive technique for the primary staging of cutaneous melanoma.