Síndrome neuroléptico maligno: dificultades en el diagnóstico diferencial / Neuroleptic malignant syndrome: difficulties in the differential diagnosis

El síndrome neuroléptico maligno es una patología poco frecuente y, en ocasiones, difícil de diagnosticar debido a la variabilidad en cuanto a la forma de presentación y evolución. La importancia de su detección precoz está en la instauración de un tratamiento adecuado lo antes posible, ya que sus complicaciones son potencialmente letales en caso de no realizarse a tiempo. El caso clínico que presentamos sirve como ejemplo representativo de la heterogeneidad clínica de dicha entidad, ya que la sintomatología larvada del paciente, su forma de presentación oscilante unido a la lenta evolución del mismo plantearon dudas en cuanto al diagnóstico, lo que hizo necesario el estudio diferencial con diferentes patologías. Por otra parte, y aunque hay distintas medicaciones que pueden provocarlo, son los neurolépticos los principales en poder desencadenarlo. La combinación de estos y las fórmulas de liberación retardada favorecen la lentitud en la resolución del cuadro clínico (AU)

Neuroleptic malignant syndrome is a rare disease. It is sometimes difficult to diagnose because of its variability in presentation and evolution. The importance of early detection is the establishment of an appropriate treatment as soon as possible, as its complications are potentially lethal if not treated on time. The clinical case presented serves as a representative example of the clinical heterogeneity of the entity, as the overt symptoms of the patient, its form of oscillating presentation coupled with its slow evolution, raised doubts about the diagnosis. This required a differential study with different pathologies. On the other hand, and although there are various medications that can cause it, neuroleptics are the leading ones that can trigger it. The combination of these and time-release formulas favour the slow resolution of the clinical picture (AU)

Torsade de pointes / Torsades de pointes

Presentamos el caso de un varón tratado por convulsiones con diazepam en varias ocasiones. Finalmente se demuestra un síndrome de QT largo adquirido que le predisponía a torsades de pointes manifestándose con convulsiones y, por tanto, tratado erróneamente. Se repasa el síndrome del QT largo, describiendo las diferentes causas tanto congénitas como adquiridas, diagnóstico electrocardiográfico, la medición corregida del intervalo QT según la frecuencia cardiaca y tratamiento (AU)

The present is the case of a male treated on several occasions for seizures with diazepam. Eventually, an acquired long QT syndrome was demonstrated which predisposed him to torsades de pointes, manifesting as seizures and henceforth treated erroneously. The long QT syndrome is reviewed, describing the different causes of long QT interval, both congenital and acquired, electrocardiographic diagnosis, according to heart rate and treatment (AU)

Craniofacial skeletal pattern: is it really correlated with the degree of adenoid obstruction?

OBJECTIVE: The aim of this study was to compare the cephalometric pattern of children with and without adenoid obstruction.METHODS: The sample comprised 100 children aged between four and 14 years old, both males and females, subjected to cephalometric examination for sagittal and vertical skeletal analysis. The sample also underwent nasofiberendoscopic examination intended to objectively assess the degree of adenoid obstruction.RESULTS: The individuals presented tendencies towards vertical craniofacial growth, convex profile and mandibular retrusion. However, there were no differences between obstructive and non-obstructive patients concerning all cephalometric variables. Correlations between skeletal parameters and the percentage of adenoid obstruction were either low or not significant.CONCLUSIONS: Results suggest that specific craniofacial patterns, such as Class II and hyperdivergency, might not be associated with adenoid hypertrophy.

OBJETIVO: a presente pesquisa teve como objetivo comparar o padrão cefalométrico de crianças com e sem obstrução adenoidiana.MÉTODOS: a amostra consistiu de 100 crianças, com idades entre 4 e 14 anos, de ambos os sexos, submetidas a exames cefalométricos para a avaliação de variáveis cefalométricas horizontais e verticais. A amostra também foi submetida à nasofibroendoscopia, por meio da qual o grau de obstrução adenoidiana foi objetivamente aferido.RESULTADOS: os pacientes avaliados demonstraram tendência ao crescimento vertical acentuado, ao perfil convexo e à retrusão mandibular. No entanto, não houve diferenças entre pacientes portadores e não portadores de obstrução, em relação a todas as variáveis cefalométricas. As correlações estabelecidas entre os parâmetros esqueléticos e os percentuais de hipertrofia foram baixas ou não significativas.CONCLUSÕES: os resultados sugerem que padrões faciais específicos, tais como Classe II e hiperdivergência, parecem não estar associados à hipertrofia adenoideana.

Fluoxetine combined with clorazepate dipotassium and behaviour modification for treatment of anxiety-related disorders in dogs.

The effectiveness of clorazepate dipotassium combined with fluoxetine and a behaviour modification programme for the treatment of anxiety disorders in dogs was investigated. Forty dogs with anxiety disorders were initially enrolled and 36 dogs completed the trial. Dogs were classified into two behavioural categories (anxious dogs with aggression and anxious dogs without aggression) according to their presenting complaints, and were also subdivided into males, females, juveniles and adults. The dog owners were provided with a behaviour modification plan for their dogs to be commenced in the first week of therapy. Clorazepate dipotassium was administered PO at 1.0 mg/kg every 24 h for 4 weeks, and fluoxetine was administered PO at 1.0 mg/kg every 24 h for 10 weeks. Therapy with both drugs was initiated simultaneously. Improvement was reported in 25/36 dogs. Significant differences in treatment effects were observed between anxious dogs with aggression and anxious dogs without aggression (P<0.05). Positive correlations between owner compliance with the treatment plan and reported improvement achieved during three periods of study were also noted.

Generalized skin drug eruption to natalizumab in a patient with multiple sclerosis.

We report a generalized skin eruption in a young man being treated with natalizumab, a new drug used in patients with multiple sclerosis.

[Tolerance of prostate biopsy with use of local anesthesia and benzodiazepines: a randomized, prospective study]. / Tolerancia a la biopsia prostática con el uso de anestesia local y benzodiacepinas: estudio prospectivo aleatorizado.

INTRODUCTION: Prostate biopsy is an uncomfortable procedure, and attempts are therefore being constantly made to try and decrease biopsy-related pain. MATERIALS AND METHODS: A randomized, prospective study including 160 procedures was designed. Inclusion criteria were: first biopsy, PSA < 15 ng/mL, and age under 75 years. Patients were randomized into 4 groups. Group A was the control group, while group B received intracapsular anesthesia (8 mL of 2% lidocaine), group C 5 mg of oral clorazepate dipotassium one hour before biopsy, and group D both local anesthesia and clorazepate. Each patient completed a questionnaire including three 10-point visual analog scales for pain immediately after the procedure and 30 minutes later. RESULTS: Mean pain scores were 5.17 (group A), 1.72 (group B), 2.43 (group C), and 0.88 (group D) in the first questionnaire, and 1.71, 0.25, 0.75 and 0.35 respectively in the second questionnaire. Statistically significant differences were found in the ANOVA test. Group comparisons showed the following: 1. A vs B: statistically significant differences in both questionnaires (p = 0.006 and 0.011). 2. A vs C: a significant difference was found in the first questionnaire (0.051), but not in the second (0.012). 3. A vs D: significant differences in both questionnaires (0.001 and 0.010). No statistically significant differences were seen in both questionnaires (0.825 and 0.685) when benzodiazepines where added to local anesthesia (B vs D). CONCLUSION: Use of benzodiazepines as a single method to decrease biopsy-related pain is not warranted.

Tolerancia a la biopsia prostática con el uso de anestesia local y benzodiacepinas: estudio prospectivo aleatorizado / Tolerance of prostate biopsy with use of local anesthesia and benzodiazepines: a randomized, prospective study

Introducción: la biopsia prostática es un procedimiento molesto, lo que condiciona que constantemente intentemos disminuir el dolor durante su realización. Material y métodos: diseñamos un estudio prospectivo aleatorizado en el que incluimos 160 procedimientos. Criterios de inclusión: primera biopsia, antígeno prostático específico (PSA) < 15 ng/ml, edad menor de 75 años. Los pacientes fueron aleatorizados en 4 grupos. El primero (A) quedó como control, el B recibió anestesia intracapsular (8 ml de lidocaína 2%), el C 5 mg de clorazepato dipotásico vía oral una hora antes y en el D se aplicaron las dos medidas (anestesia local y clorazepato). Se entregó un cuestionario con tres medidas de dolor (valorándolo de 0 a 10) tras el procedimento y otro 30 minutos después. Resultados: las medias del dolor fueron 5,17 (A), 1,72 (B), 2,43 (C) y 0,88 (D) en el primer cuestionario. En el segundo fueron 1,71, 0,25, 0,75 y 0,35, respectivamente. La comparación de medias realizada mediante el test de ANOVA pone de manifiesto diferencias significativas. Al comparar los grupos entre sí encontramos: 1. A frente a B: diferencia significativa en ambos cuestionarios (p 0,006 y 0,011). 2. A frente a C: no significación en el primer cuestionario (0,051) y sí en el segundo (0,012). 3. A frente a D: diferencia en ambos cuestionarios (0,001 y 0,010). El uso de benzodiacepinas añadidas a la anestesia local (B frente a D) no mostró diferencias estadísticas en ambos cuestionarios (0,825 y 0,685). Conclusión: consideramos que el uso de benzodiacepinas no está justificado como método único de control del dolor para la realización de la biopsia prostática(AU)

Introduction: Prostate biopsy is an uncomfortable procedure, and attempts are therefore being constantly made to try and decrease biopsy-related pain. Materials and methods: A randomized, prospective study including 160 procedures was designed. Inclusion criteria were: first biopsy, PSA < 15 ng/mL, and age under 75 years. Patients were randomized into 4 groups. Group A was the control group, while group B received intracapsular anesthesia (8 mL of 2% lidocaine), group C 5 mg of oral clorazepate dipotassium one hour before biopsy, and group D both local anesthesia and clorazepate. Each patient completed a questionnaire including three 10-point visual analog scales for pain immediately after the procedure and 30 minutes later. Results: Mean pain scores were 5.17 (group A), 1.72 (group B), 2.43 (group C), and 0.88 (group D) in the first questionnaire, and 1.71, 0.25, 0.75 and 0.35 respectively in the second questionnaire. Statistically significant di fferences were found in the ANOVA test. Group comparisons showed the following: 1. A vs B: statistically significant di fferences in both questionnaires (p = 0.006 and 0.011). 2. A vs C: a significant di fference was found in the first questionnaire (0.051), but not in the second (0.012). 3. A vs D: significant di fferences in both questionnaires (0.001 and 0.010). No statistically significant differences were seen in both questionnaires (0.825 and 0.685) when benzodiazepines where added to local anesthesia (B vs D). Conclusion: Use of benzodiazepines as a single method to decrease biopsy-related pain is not warranted(AU)

[Electroconvulsive therapy in therapy-resistant mania. A case study]. / Elektroconvulsieve therapie bij therapieresistente manie.

A 25-year-old woman was separated for 6 weeks on account of her suicidal and chaotic behaviour occurring within the framework of a first manic episode. Her response to medication (olanzapine 20 mg, clorazepate 50 mg and lithium (serum level 0.9 mmol/l)) was inadequate. After only one ect treatment her condition had improved to such an extent that she no longer needed to be isolated. After about 4 weeks her mental condition was reasonably good; her medication consisted only of 10 mg of olanzapine and she could be transferred to out-patient care. ect can bring about rapid improvement in patients with therapy-resistant manic symptoms.

[Comparison of premedication regimes. A randomized, controlled trial]. / Prämedikationsregime im Vergleich. Eine prospektive, randomisierte, kontrollierte Studie.

BACKGROUND: The effect of two premedication regimes with different benzodiazepines on anxiety, hemodynamic data, sympatho-adrenal activity, and bispectral index (BIS) was evaluated during the variable time period prior to induction of anesthesia. PATIENTS AND METHODS: This prospective, double-blind study was performed with 50 ASA class I and II patients. Patients were randomized either to group I: evenings 22.00 hours 50 mg chlorazepate dipotassium (CD), mornings 07.00 hours 25 mg CD, placebo 30 min prior to anesthesia (on demand) or group II: evenings 50 mg CD, mornings placebo, 7.5 mg midazolam on demand. RESULTS: In group I the BIS dropped after administration of 25 mg CD and was significantly lower at 08.00, 09.00 and 10.00 hours compared to baseline (mean+/-SD; 90+/-5, 87+/-7 and 87+/-7, respectively vs. 95+/-4; p<0.05), whereas the BIS of group II did not decrease significantly. Both groups did not differ significantly with respect to all variables obtained throughout the study period. CONCLUSION: We conclude that 50 mg CD the evening before surgery prevented an increase of anxiety and sympatho-adrenal activity in both groups and might therefore be sufficient as premedication. Fixed time application of 25 mg CD at 07.00 hours or 7.5 mg midazolam 30 min prior to anesthesia did not further affect these variables preoperatively.

Psoriasis en relación con ansiedad, mejoría marcada tras tratamiento ansiolítico / Psoriasis and anxiety: marked improvement after anxiolytic therapy

No disponible

Repetitive transcranial magnetic stimulation (rTMS) in a patient suffering from comorbid depression and panic disorder following a myocardial infarction.

Application of repetitive transcranial magnetic stimulation was effective and safe in treating a 55-year-old man with comorbid depression and panic disorder, which occurred 6 months after a myocardial infarction.

Clobazam as a new antiepileptic drug and clorazepate dipotassium as an alternative antiepileptic drug in Japan.

PURPOSE: To confirm the efficacy and to clarify the problems of clobazam (CLB) as a new antiepileptic drug (AED) and clorazepate (CLP) as an alternative AED in Japan. METHODS: CLB and CLP were added on or replaced with conventional AEDs in 55 and 170 patients with refractory epilepsies, respectively. Short-term efficacy was studied after at least 2 months of CLB administration and at least 4 weeks of CLP administration. Long-term efficacy was examined in 31 cases with CLB for > or =6 months and in 86 cases with CLP for > or =6 months. CLB was initiated at 0.15-0.40 mg/kg and increased by 0.1-0.2 mg/kg every 1-2 weeks up to 0.28-1.25 mg/kg. CLP was started at 0.3-0.7 mg/kg and increased by 0.2-0.3 mg/kg every 1-2 weeks up to 2.5 mg/kg. Tolerance was examined in 42 cases with CLB for > or =3 months and 112 cases with CLP for > or =4 weeks. RESULTS: CLB was effective, defined as > or =50% reduction in seizure frequency, in 71% of the short-term subjects and 81% of the long-term subjects. Short-term efficacy was better in symptomatic localization-related epilepsies, but long-term efficacy did not differ according to seizure classification. Short-term efficacy was not different by seizure types or EEG findings. CLP was effective in 70% of the short-term subjects and 80% of the long-term subjects. CLP was more effective in patients with localization-related epilepsies or in patients with partial seizures or focal epileptiform discharges on EEG. Adverse effects developed in 47% of CLB cases and 31% of CLP cases, but the incidence was reduced by lower initial doses and slow dose titration. Tolerance occurred in 24% of CLB cases and 48% of CLP cases, half within 3-4 months after the initiation of CLB and half by 2 months after the start of CLP. Upon rechallenge, 70% of CLB-tolerant cases and 50% of CLP-tolerant cases responded to each drug again by increasing or maintaining the dosage. CONCLUSIONS: Excellent efficacy of CLB and excellent and prolonged efficacy of CLP for refractory epilepsies were confirmed. Frequent tolerance and adverse effects were major problems, but were manageable.

Clorazepate dipotassium versus midazolam for premedication in clear corneal cataract surgery.

PURPOSE: To evaluate and compare the efficacy of oral clorazepate dipotassium (Tranxilium) and intravenous midazolam (Dormicum) as premedication agents in retrobulbar anesthesia and clear corneal phacoemulsification with intraocular lens (IOL) implantation. SETTING: Department of Ophthalmology, University of Essen, Essen, Germany. METHODS: In a prospective clinical trial, 97 consecutive patients (97 eyes) having phacoemulsification with implantation of a foldable IOL were randomized to 2 groups. The first group received 10 mg oral clorazepate dipotassium and the second group, 1 mg intravenous midazolam. The surgeon's subjective experience of patients' cooperation during retrobulbar anesthesia and after surgery was measured on a 5-point Likert scale. The duration of surgery and rate of complications were documented. One day after surgery, the patients' subjective comfort during cataract surgery was evaluated using a 5-point Likert scale and the best corrected visual acuity was determined. RESULTS: The level of anterograde amnesia tended to be higher in the midazolam group than in the clorazepate dipotassium group (4% versus 0% for anesthesia administration; 14% versus 4% for surgery), but the difference between groups was not significant. There were no significant differences in patient cooperation or complications during surgery. Patient satisfaction scores were not significantly different between the groups (P<.14); however, patients in the midazolam group expected to have significantly less pain during surgery (P<.04). The rate of potential visual acuity recovery was similar between groups. CONCLUSIONS: Anterograde amnesia occurred more frequently and patients expected less pain before surgery with midazolam. Both anesthetic agents provided safe and effective premedication for retrobulbar anesthesia in clear corneal cataract surgery.

[Voluntary poisoning by ingestion of Datura stramonium. Another cause of hospitalization in youth seeking strong sensations]. / L'intoxication volontaire par ingestion de Datura stramonium. Une autre cause d'hospitalisation des jeunes en quête de sensations fortes.

Natural hallucinogenic substances have been used in numerous cultures throughout the world for millenniums, providing a sacred intermediary between men and gods. They were used during initiatory, divinatory rites and played an essential role in the myths of exorcism and charm where the initiated enters a sort of trance which separates the soul from the body before "revival". It resulted that a number of plants were given names reflecting their relationship with the divinities, bestowing upon them an aura of mystery and sacredness. With the development of free information superhighways via the net, recipes using these hallucinogenic substances can now travel anywhere on the planet, offering the non-initiated a means of experimenting their search for strong sensations. At the same time, the science of botany has undergone a major revolution. Patient observation of nature is no longer necessary since a well-conducted computer search can easily yield a large supply of plants offered for on-line purchase. Children and adolescents in primary and secondary schools are becoming a new target for the botanical market: young people exchange the latest recipes and Internet addresses, or more simply the objects of their new on-line purchase. This has led to an outbreak in the use of mushrooms and hallucinogenic plants where the cultural notion of initiation or sacred rites has metamorphosed into a phenomenon of communication between young people, notably during festive parties. Datura stramonium has become quite popular and the number of hospitalizations for acute datura poisoning has increased rapidly, as indicated by the statistics of the Bordeaux Poison Center (14 hospitalizations for voluntary poisonings with datura in 2002, compared with 5 in 2001). Besides the self-inflicted risk, one of the most important problems is the delay to diagnosis, simply because the primary care physician did not think of such an "exotic" cause. We report here the case of a 22-year-old young man hospitalized following ingestion Datura stramonium seeds. He presented confusions and dreamlike frenzy. The clinical course was favorable in 72 hours with symptomatic treatment, marked by amnesia of the episode.

PANDAS tras amigdalectomía / PANDAS following amygdalectomy

Se denomina PANDAS (Pediatric Autoinmune Neuropsychiatric Disorders Associated with Streptococcal Infections) al trastorno que se presenta en un subgrupo de pacientes con síntomas obsesivos y/o tics que aparecen relacionados con infecciones por estreptococo beta- hemolítico del grupo A.El caso clínico que se presenta corresponde a una niña de 5 años que desarrolla un trastorno obsesivocompulsivo en relación temporal con una amigdalectomía. Dicha paciente cumple los criterios diagnósticos y la evolución longitudinal correspondiente a este tipo de trastornos. (AU)