Perampanel-Induced Psychosis in a Young Woman: A Case Report.

OBJECTIVES: A case of perampanel-induced psychosis in a young woman is reported, a side effect that has only rarely been reported in the literature. METHODS: We describe a case of a young woman with epilepsy and no psychiatric history with perampanel-associated altered behavior and psychotic symptoms, requiring hospitalization in an acute psychiatry ward. We also provide a literature review on the possible neurobiological pathways implicated. RESULTS: Perampanel is believed to block a small proportion of the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor current, retarding epileptiform discharges while sparing most normal synaptic transmission. Most common adverse events are related to central nervous system (including dizziness, drowsiness, blurred vision and imbalance) and psychiatric symptoms have been reported. CONCLUSIONS: The biological vulnerability to psychiatric and behavioral adverse reactions of antiepileptic drugs is multifactorial and different mechanisms and clinical predisposing factors may interact. For this reason, patients starting these antiseizure drugs need long-term and comprehensive clinical monitoring.

Higher Cerebral Small Vessel Disease Burden in Patients with White Matter Recent Small Subcortical Infarcts.

INTRODUCTION: Recent small subcortical infarcts (RSSI) are considered an acute manifestation of cerebral small vessel disease (CSVD). We assessed whether the topography of RSSI was related to CSVD markers on magnetic resonance imaging (MRI). MATERIAL AND METHODS: We screened the local registries of two independent stroke centers in Catalonia and selected patients with a symptomatic RSSI on MRI performed during admission. RSSI location was classified into brainstem, supratentorial subcortical structures (SSS), and centrum semiovale (CSO) regions. Clinical variables, including vascular risk factors, were collected. Radiological markers of CSVD on MRI were evaluated individually and by means of the global CSVD burden score. The associations between each RSSI location and CSVD markers were studied in uni- and multivariate logistic regression analysis. RESULTS: Among 475 patients with RSSI, 152 (32%) had an infarct in the brainstem, 227 (48%) in SSS, and 96 (20%) in CSO region. The median CSVD burden score was 2 (IQR, 1-3). After adjusting for confounding factors, a RSSI in CSO was associated with higher periventricular and deep white matter hyperintensity scores [OR 1.64 (95% CI, 1.16-2.33), and OR 1.44 (95% CI, 1.07-1.93), respectively]. Higher CSVD burden score was positively associated with CSO [OR 1.48 (95% CI, 1.22-1.81)] and inversely associated with SSS [0.85 (95% CI, 0.72-0.99)] location after adjusting for relevant confounders. CONCLUSIONS: CSO RSSI were related to a higher burden of CSVD, particularly to white matter hyperintensities, compared to other RSSI locations. The pathophysiological significance of such findings should be investigated in the future with advanced neuroimaging techniques.

Susceptibility Vessel Sign in Deep Perforating Arteries in Patients with Recent Small Subcortical Infarcts.

OBJECTIVES: Recent small subcortical infarcts (RSSI) are considered an acute manifestation of cerebral small vessel disease. Paramagnetic signals in perforating arteries supplying RSSI may be detected on T2*-relaxation derived sequences on MRI and is defined as susceptibility vessel sign (SVS). We aimed to study the prevalence of SVS in patients with RSSI, and explore whether its identification is related to cerebral small vessel disease markers. MATERIALS AND METHODS: We selected patients with RSSI identified on MRI during admission from a single-center stroke registry. The main demographic and clinical features, including vascular risk factors, were collected. Radiological features of RSSI and cerebral small vessel disease [white matter hyperintensities in deep and periventricular regions, enlarged perivascular spaces, lacunae, microbleeds, and brain atrophy] were described using validated qualitative scores. The presence of SVS was assessed on T2*gradient-echo or other susceptibility-weighted imaging. We compared the clinical and radiological features of patients with or without SVS in uni- and multivariate models. RESULTS: Out of 210 patients with an RSSI on an MRI, 35 (17%) showed SVS. The proportion of SVS+ patients was similar in different susceptibility imaging modalities (p=.64). Risk factor profiles and clinical course were similar in SVS+ and SVS- patients. SVS+ patients had a higher grade of deep white matter hyperintensities and brain atrophy, more lacunae (p=.001, p=.034, p=.022, respectively), and a similar degree of the rest of radiological variables, compared to SVS- patients. In the multivariate analysis, the grade of deep white matter hyperintensities was the only independent factor associated with SVS [OR 3.1 (95% CI, 1.5-6.4)]. CONCLUSIONS: SVS in patients with RSSI is uncommon and related to a higher grade of deep white matter hyperintensities. Pathophysiological mechanisms underlying the deposition of hemosiderin in the path of occluded perforating arteries are uncertain and might include endothelial dysfunction or embolic mechanisms.

Cross-sectional study of 13 Leptospira serovars in cows in a Colombian dairy region / Estudio transversal de 13 serovares de Leptospira en vacas en una región lechera colombiana / Estudo transversal de 13 sorotipos de Leptospira em vacas em uma região leitera colombiana

Abstract Background: Leptospirosis in cattle is recognized as a major cause of reproductive loses due to abortions, early embryonic death, and infertility. The type of Leptospira serovars that are currently circulating in Colombian herds is largely unknown due to the lack of national reports. Objective: The prevalence of antibodies specific to 13 Leptospira spp serovars was investigated in unvaccinated cows from 26 herds in San Pedro de los Milagros (Province of Antioquia) dairy region. Methods: Microscopic agglutination test was used on serum samples, following WHO recommendations. Results: A total of 112/900 (12.4%) of the animals had antibody titers of 1:100 or greater to at least one Leptospira serovar. Of those positive, 34/900 (3,8%) animals seroconverted to two or more serovars. In order of decreasing prevalence, the serovars detected were: hardjo prajitno, pomona, grippotyphosa, tarassovi, copenhageni, canicola, cellodeni and bratislava. There were 28 animals seropositive to serovar hardjo. Conclusion: Our results indicate that leptospirosis should be included as a differential diagnosis for various reproductive problems in this region.

Resumen Antecedentes: La leptospirosis es la mayor causal de pérdidas reproductivas debidas a abortos, muerte embrionaria temprana e infertilidad. Se desconocen los serovares de Leptospira que actualmente se encuentran circulando en el rebaño colombiano debido a la falta de reportes nacionales. Objetivo: Se investigó la prevalencia de anticuerpos específicos para 13 serovares de Leptospira spp en vacas no vacunadas de 26 rebaños en la región lechera de San Pedro de los Milagros (Provincia de Antioquia). Métodos: La prueba de aglutinación microscópica fue empleada en muestras de suero de acuerdo a las recomendaciones de la OMS. Resultados: Un total de 112/900 (12,4%) de los animales presentaron títulos de anticuerpos de 1:100 o superiores para al menos un serovar de Leptospira. Entre los positivos, el 34/900 (3,8%) de los animales presentaron seroconversión para dos o más serovares. En orden decreciente de prevalencia, los serovares detectados fueron: hardjo prajitno, pomona, grippotyphosa, tarassovi, copenhageni, canicola, cellodeni y Bratislava. En total, 28 animales fueron seropositivos al serovar hardjo. Conclusión: La leptospirosis debería ser incluida como diagnóstico diferencial en problemas reproductivos en esta región.

Resumo Antecedentes: Aleptospirose em bovinos é reconhecida como uma das principais causas de perdas reprodutivas devido a abortos, morte embrionária precoce e infertidade. Os sorotipos de Leptospira que estão atualmente em circulação no rebanho colombiano não se conhecem devido à falta de reportes nacionais. Objetivo: Neste estúdio foi investigada a prevalência de anticorpos específicos para 13 sorovares de Leptospira spp em vacas não vacinadas de 26 rebanhos leiteiros da região de San Pedro, Antioquia. Métodos: Foi empregado o teste de aglutinação microscópica (MAT) em amostras de soro de acordo com as recomendações da OMS. Resultados: Um total de 112/900 (12,4%) animais apresentaram títulos de anticorpos de 1:100 ou superiores para pelo menos um sorotipo de Leptospira. Dos animais positivos, 34/900 (3,8%) soroconverteram para dois ou mais sorotipos. A fim de diminuir a prevalência, foram detectados os sorotipos: hardjo, prajitno, pomona, grippotyphosa, tarassovi, copenhageni, canicola, cellodeni e Bratislava. Um total de28 animais foram soropositivos para o sorotipo hardjo. Conclusão: Os resultados indicam que a leptospirose deveria ser incluída nos diagnósticos diferenciais para o diagnóstico diferencial de problemas em doenças reprodutivas nos bovinos de Antioquia.

Anestesia para cirugía correctiva de escoliosis / Anesthesia for corrective surgery of scoliosis / Anestesia para a cirurgia corretiva de escoliose

La Unidad Docente Asistencial de Anestesiología Pediátrica del Centro Hospitalario Pereira Rossell integra el equipo multidisciplinario de tratamiento de las enfermedades de la columna vertebral desde hace cinco años. La escoliosis es una de las deformidades del raquis que puede requerir cirugía correctiva con implicancias anestesiológicas relevantes. Realizamos un estudio retrospectivo y descriptivo de 95 procedimientos anestesiológicos realizados a los pacientes que fueron sometidos a cirugía correctiva de escoliosis en el período comprendido entre marzo de 2.011 a marzo de 2.016. Los objetivos de este trabajo son comunicar nuestra experiencia junto con una revisión no sistematizada de la evidencia científica disponible en las bases de datos: Pubmed, Medline y SciELO. Concluimos que un manejo óptimo de los pacientes con escoliosis se logra realizando una adecuada evaluación perioperatoria.

The teaching care unit of pediatric anesthesiology of the Pereira Rossell Hospital has taken part for 5 years, in a multidisciplinary team which treats spinal disorders. Scoliosis is a deformity of the rachis that may require corrective surgery with relevant anesthesiological implications. We made a retrospective and descriptive study of 95 anesthesiological procedures realized to patients who had a scoliosis corrective surgery between March 2011 and March 2016. The objectives of this work is to communicate our experience together with a no systematic revision of the scientific evidence available on databases like: Pubmed, Medline and SciElo. The conclusions we have reach is that a better management of patients with scoliosis is achieved by making an adequate preoperative evaluation.

A Unidade Docente Assistencial de Anestesia Pediátrica de o Centro Hospitalar Pereira Rossell, faz cinco anos integra a equipe multidisciplinar de tratamento das doenças da coluna vertebral. A escoliose é uma das deformidades da raque que pode requerer cirurgia corretiva com implicações anestésicas relevantes. Realizamos um estudo retrospectivo e descritivo de 95 procedimentos anestésicos realizados aos pacientes que foram a cirurgia corretiva de escolioses no período compreendido entre março de 2011 a março de 2016. Os objetivos deste trabalho é comunicar nossa experiência e fazer uma revisão não sistematizada da evidencia cientifica disponível nas bases de dados: Pubmed, Medline e Scielo. Concluímos que um manejo ótimo dos pacientes com escolioses se obtém realizando uma apropriada avaliação perioperatoria.

Síndrome de takotsubo durante la inducción de una anestesia general

RESUMEN La cardiomiocardiomiopatía de takotsubo o síndrome de disfunción apical transitoria del ventrículo izquierdo, es una falla cardíaca aguda reversible descrita por primera vez en la población japonesa en 1990, siendo cada vez más frecuentes los reportes vinculados al período perioperatorio. La forma del ventrículo izquierdo en la ventriculografía se asemeja a una vasija japonesa clásica usada para atrapar pulpos llamada “takotsubo”, de donde surge el nombre de este cuadro. Reportamos el caso de una paciente de 57 años, sexo femenino, coordinada para artrodesis de columna lumbar. Post inducción anestésica, imposibilidad de intubación orotraqueal (IOT) lográndose ventilación dificultosa mediante máscara laríngea (ML). Se presenta hipoxemia, taquicardia e hipertensión arterial. Se agrega regurgitación con noción de aspiración a través de la ML. Evoluciona con inestabilidad hemodinámica con tendencia a la hipotensión arterial y edema agudo de pulmón, por lo que se suspende cirugía comenzando las medidas de apoyo cardiovascular. En tratamiento intensivo (CTI) presenta: electrocardiograma (ECG) sin elementos claros de isquemia, troponinas positivas, Ecocardiograma: aquinesia extensa anteroseptal y apicolateral del ventrículo izquierdo con severa disminución de la fracción de eyección del ventrículo izquierdo (FEVI) de 38%. Al tercer día, repite angor solicitando coronariografía (CACG) de urgencia que no muestra lesiones coronarias significativas. Ecocardiograma revela aquinesia apical tipo Takotsubo sin gradientes interventriculares, con FEVI de 26%. Buena evolución posterior con alta al décimo día.

SUMMARY Transient left ventricular apical ballooning syndrome , also known as takotsubo cardiomyopathy is a reversible acute cardiac failure described for the first time for Japanese population at 1990, being reports linked to perioperative period each time more frequent. The left ventricle’s shape at ventriculography resembles a classic Japanese vessel used to catch octopuses called “takotsubo”, from which the name of this picture comes from. We report a case of a female 57 years old patient ,scheduled for a lumbar spinal fusion. After anesthesia induction endotraqueal intubation was impossible and ventilation was difficult under laryngeal mask. Hipoxemia, tachycardia and arterial hypertension were observed. Regurgitation of gastric contents and aspiration were confirmed. The patient installed an hemodynamic instability with arterial hipotension and then acute pulmonary edema. Surgery was stopped and cardiovascular resuscitation was started. In the intensive care unit electrocardiogram didn´t show definite signs of ischemia, troponin levels were positive and echocardiogram showed extensive left ventricular anteroseptal and apicolateral akinesia with severe decrease of LVEF to 38%. On the third day the patient had an episode of angina pectoris. The coronary angiography dismissed significant coronary artery lesions. Another echocardiogram showed apical akinesia type Takotsubo without interventricular gradients and LVEF 26%. The patient improved and she was discharged on the tenth day.

RESUMO A cardiomiopatia de takotsubo ou síndrome de disfunção apical transitória do ventrículo esquerdo é uma falha cardíaca aguda reversível descrita pela primeira vez na população Japonesa em 1990, sendo cada vez mais freqüentes os relatos vinculados ao perioperatorio. A forma do ventrículo esquerdo na ventriculografia se assemelha a uma vasilha japonesa clássica usada para pegar polvos chamada "tako-tsubo", o que dá origem ao nome deste quadro. Relatamos o caso de uma paciente de 57 anos, sexo feminino, marcada para cirurgia eletiva de artrodeses de coluna lombar. Logo após induzir a anestesia não se conseguiu a intubação orotraqueal (IOT), conseguindo ventilação com mascara laríngea (ML). Apresenta hipoxemia, taquicardia e hipertensão arterial. Acrescenta-se regurgitação com possibilidade de aspiração através da ML. Evoluiu com instabilidade hemodinâmica e tendência a hipotensão arterial e edema agudo de pulmão, pelo qual se suspende a cirurgia começando com medidas de apoio Cardiovascular. Na Unidade de Cuidados Intensivos (UCI) apresenta: Electrocardiograma (ECG) sem elementos claros de isquemia, troponinas positivas, ECG: aquinesia extensa anteroseptal e apicolateral do ventrículo esquerdo com severa diminuição da fração de ejeção do ventrículo esquerdo (FEVI) 38 %. Ao 3º dia, repete angina solicitando-lhe cinecoronariografia (CACG) de emergência que não apresenta lesões coronárias significativas. Ecocardiograma mostra aquinesia apical tipo Takotsubo sem gradientes interventriculares, com FEVI de 26%. Boa evolução posterior com alta aos 10 º dia.

Plasma and brain cholinesterase in methomyl-intoxicated free-ranging pigeons (Columba livia f. domestica).

A mortality event caused by exposure to the carbamate insecticide methomyl was diagnosed in several hundred pigeons fed treated corn kernels in a city park. A cholinesterase inhibitor insecticide was initially suspected based on clinical signs and a significant inhibition (P < 0.05) of brain cholinesterase (ChE) activity compared with normal values for the species. However, brain ChE activity was within the normal range in birds subsequently submitted in an advanced stage of autolysis. Two groups of 10 healthy pigeons were allocated into a control group and an experimental group, which was offered corn samples retrieved from the incident site. Within minutes of ingesting the contaminated corn, the birds became immobile, had transient wing fluttering, and developed profuse salivation immediately followed by death. Plasma ChE activity at death had declined by more than 95% of preexposure levels (0.04 +/- 0.02 vs. 1.56 +/- 0.23 micromol/min per milliliter). Brain activity in the sagittal brain sections that were immediately frozen after death was inhibited by > or =50% of control birds (13.5 +/- 2.2 vs. 27.5 +/- 1.8 micromol/min per gram). However, the sagittal sections left for 1.5 days at ambient temperature of 25 degrees C had normal or higher activity, an effect that was attributed to a combination of spontaneous reactivation and dehydration. After incubation of both plasma and brain homogenates for 1 hr at 37 degrees C, ChE activity recovered by 2- and 1.46-fold, respectively. An organophosphorus and carbamate screen conducted by 2 independent laboratories identified and quantified methomyl in treated kernels at 400 ppm. These results indicate that spontaneous reactivation and dehydration can mask previous reductions in ChE activity.

Manejo hemodinámico intraoperatorio del quemado con falla multiorgánica

In order to evaluate the hemodynamic management during escharectomy and grafting in severely burned patients, 1.978 (1.635-2.201) intraoperative records of 56 patients were reviewed. Mean age was 39 years (21-59). Mean burned surface area was 32% (11-75). All patients had a multiorganic failure syndrome (MOF). During the procedure, all vaso and cardioactive drugs infusions were maintained (epinephrine, norepinephrine, dopamine either alone or in combination). The aim of therapy was to maintain a normal mean arterial pressure (MAP), modifying the dosages of vasoactive drugs and/or volume replacement according to the results. Hemodynamic monitoring was performed with an intraoesophagic Eco Doppler device, measuring aortic output (AO) and integrating the values of MAP and ECG for the calculation of the systemic vascular resistances (TSVR) and the systolic time intervals (STI) as estimation of myocardial performance. The results, compared with normal values showed: maintained tachycardia, MAP of 94 ± 22 mmHg, increased AO and diminished TSVR. The STI showed values of myocardial depression in spite of the inotropic infusions: PePi 148±26 mseg (p<0,05), PePi/LVETi 0,40±0,1 (p<0,05) The comparison of the cases between those with MAP > 90 mm Hg and those with MAP <90 mmHg, showed higher TSVR and values suggestive of myocardial depression in the former ones. MAP>90 mmHg :TSVR 1232±568 dyn.s-1.cm-5.m-2, PePi/LVETi 0,42±0,1. MAP<90 mmHg TSVR 802±389, PePi/LVETi 0,39±0,1 (p<0,05 for both). The measured hemodynamic pattern matches with an hyperdinamic one, with a sustained beta stimulus and diminished TSVR, although enough to maintain a normal MAP. In spite of the infusion of vaso and cardioactive drugs and the fall of the TSVR, myocardial depression was almost constantly detected. This one increased when the postcharge raised, even though TSVR were in lower values than the normal mean. This intraanesthetic hemodynamic management, trying to modulate the TSVR the minimun necessary to obtain a MAP within normal limits, seems to be acceptable for this special group of sick patients.