Kinking of Bilateral Internal Carotid Arteries as Cause of Cognitive Dysfunction.

INTRODUCTION: Dolichoarteriopathies of the internal carotid artery (DICAs) is divided into three forms: tortuous, coiling and kinking. In case of kinking, internal carotid artery forms a sharp angle of <90 degrees, while in the background there is metaplasia of a tunica media with unknown etiology. The association with stroke is still questionable, but it is believed that it can be associated with cerebral ischemia and with clinical symptomatology that accompanies cerebral ischemia. AIM: Aim of article was to present diagnostic and therapeutic modality of patient with verified internal carotid artery kinking. CASE REPORT: The 55-year-old male patient was admitted to the Department of Neurology, General Hospital «Prim.dr. Abdulah Nakas¼, due to dizziness and instability while walking, forgetfulness, memory loss and low mood. He has previously been reported to be hypertensive and with diagnosis of diabetes mellitus and dyslipidemia. Doppler sonography also suspects on distal subocclusion of the internal carotid artery (low flow rates were observed). Diagnostic transcranial Doppler (TCD) of vertebrobasilar artery showed decreased blood flow velocities in both vertebral and basilar artery and indicated atherosclerotic altered blood vessels of the brain. CTA findings indicate bilateral kinking of internal carotid artery with right duplex Kinking. SPECT with 15 mCi 99mTc-hexamethylpropyleneamineoxime (99mTc-HMPAO) verified global cortex hypoperfusion, indicating chronic vascular failure. The patient was treated with acetylsalic acid, clopidogrel, atorvastatin, donepezil, memantine, escitalopram, bromazepam, along with antihypertensive and antidiabetic therapy (per os). CONCLUSION: A severe degree of kinking can cause neurological symptomatology, especially if it is bilateral. Symptoms of cerebrovascular disease are more pronounced when autoregulation of cerebral hemodynamics is impaired. Bilateral severe degree of kinking possibly can cause cognitive impairment. Diagnosis, analysis of the existence of possible risk factors for the onset, and the existence of genetic predisposition are a prerequisite for better understanding of the disease and optimal treatment.

Enfermedades infecciosas tropicales e importadas. Un reto para atención primaria / Tropical and imported infectious diseases. A challenge for primary care

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Pharmacological and psychosomatic treatments for an elderly patient with severe nausea and vomiting in reaction to postoperative stress.

Here we present a case of successful treatment employing a mixed approach including pharmacological and psychosomatic treatments for a 72-year-old woman who experienced severe nausea and vomiting in reaction to postoperative stress from gastric cancer surgery. This case demonstrates that appropriate provision of psychosomatic treatments, including a psychotherapeutic session and autogenic training, enhances the efficacy of pharmacotherapy.

Amitriptyline and bromazepam in the treatment of vibratory angioedema: which role for neuroinflammation?

Vibratory angioedema is a rare form of physical urticaria, hereditary or acquired, which occurs at body sites exposed to vibrations. Pathogenic mechanisms of disease are not completely clear and, consequently, current pharmacological treatment is sometimes unsatisfactory. We report the case of a horn player affected by acquired vibratory angioedema, relapsing after prolonged use of the instrument and resistant to systemic antihistamines and corticosteroids, which successfully responded to therapy with low doses of amitriptyline and bromazepam. A neuroinflammatory mechanism can be likely implicated in the pathogenesis of vibratory angioedema, in line with many different cutaneous/mucosal diseases involving a complex interplay of homeostatic/allostatic systems. Furthermore, in mucosal diseases, such as vibratory angioedema, physical/psychological stressors have a relevant role. In such cases, because of the complex interplay between nervous and immune system, the pharmacological activity of benzodiazepines and typical antidepressants may downregulate neuroinflammation.

Concurrent Presentation of Burning Mouth Syndrome and Globus Pharyngis in Enugu, Nigeria: A Ten-year Clinical Evaluation.

PURPOSE: To review 22 patients with globus pharyngis among a group of 39 patients who presented with burning mouth syndrome and to highlight the clinical presentation and treatment outcome of these oropharyngeal symptoms, often ignored by practicing oral surgeons. PATIENTS AND METHODS: We carried out a retrospective review of 39 patients with burning mouth syndrome seen at oral surgery units of three specialist hospitals in Enugu, Nigeria between 2001 and 2010. The focus was on the 22 of these patients with burning mouth syndrome and globus pharyngis (the persistent sensation of having phlegm, a pill or some other sort of obstruction in the throat when there is none). Relevant information included patients' oral habits and dental status, past medical history, sociodemographic data, onset of symptoms and treatment outcome. RESULTS: Amongst the 22 patients, 8 (36.4%) were males while 14 (63.6%) were females, giving a male to female ratio of 1:1.8. Of the 8 male patients, 3 (37.5%) were retrenched workers, 2 (25%) were drug addicts, 2 (25%) had a history of psychiatric problems and 1 (12.5%) had post-radiation therapy due to diagnosis of adenocystic carcinoma. Amongst the 14 female patients, 6 (42.8%) were divorcees, 3 (21.4%) were unemployed and unmarried, 2 (14.3%) had menopausal problems, 2 (14.3%) had dental prostheses and 1 (7.2%) had a history of mental disorder. CONCLUSION: Globus pharyngis can present at the same time in some individuals with burning mouth syndrome. The emotional aetiological factor in this unusual ailment calls for proper examinations and a multidisciplinary approach in the management of patients who presented with burning mouth syndrome, especially with a history of depression.

[Six-month follow-up study of drug treatment for cannabis addiction: comparison study of four drugs].

OBJECTIVES: Marijuana addiction is one of the most common forms of addiction worldwide. A variety of reasons for use exist, however, there are only a few tested treatments with frequent relapses. In this study, we examined the efficacy of four pharmacotherapy agents for the treatment of marijuana addiction: naltrexone, bupropion, escitalopram and bromazepam. MATERIALS AND METHODS: A total of 59 patients were randomly assigned into four groups. Each group received one of the pharmacological agents for 120 days. Four types of questionnaires were employed: The Hamilton Rating Scale for Depression--21 items, the Hamilton Rating Scale for Anxiety, the Global Assessment of Functioning and a Visual Analogue Scale for perceived need of the drug. In addition, random urine tests were performed to detect tetrahydrocannabinol [THC). RESULTS: Naltrexone proved to be the most efficacious of the four agents, with only four dropouts. Other agents proved less efficacious with six, seven and eights dropouts for bupropion, bromazepam and escitalopram, respectively. In addition, naltrexone was most efficacious in reducing anxiety and depression rates, and increasing functioning and perceived need for drug use. CONCLUSION: Out of four pharmacological agents, naltrexone proved to be most efficacious in treating marijuana addiction and related disorders. Further studies are needed to confirm our results.

Pharmacoepidemiological characterization of psychotropic drugs consumption using a latent class analysis.

France has one of the highest recorded rates of psychotropic use of drugs compared with other European countries, especially for anxiolytics, hypnotics and antidepressants. The aim of this study was to characterize the use of three psychotropic drugs among the most prescribed in France (bromazepam, paroxetine, zolpidem) using reimbursement databases in real-life conditions. Individuals from a region affiliated to the French General Health Insurance Scheme, who had received at least two dispensings of bromazepam, paroxetine or zolpidem reimbursed between 1 January and 30 June 2008, were included. We used a latent class analysis to identify different subgroups of users for these three psychotropic drugs. A total of 40,644 patients were included for bromazepam, 36,264 for zolpidem and 31,235 for paroxetine. Using latent class analysis, four clinical subtypes of users of bromazepam and zolpidem were identified: nonproblematic users, at-risk users, users with a probable mental disorder and compulsive users. Three subgroups were identified for paroxetine that differed rather by the prescription patterns. Users of anxiolytics and hypnotics with at-risk behaviours represented a significant proportion in the studied population. This original method could be extended to other prescription databases to identify populations at risk of abuse or dependence to psychotropic drugs.

La coordinación de esfuerzos en casos clínicos complejos: un valor añadido de cuidados paliativos en un hospital universitario / Coordinating efforts in complex clinical cases: added value of palliative care at a university teaching hospitalpcuth

Los cuidados paliativos se entienden generalmente en el contexto de la atención a pacientes terminales ingresados en hospitales o en unidades de hospitales de larga estancia. Sin embargo, cada vez son más frecuentes estas unidades en hospitales de alto nivel de desarrollo. Presentamos el caso de una paciente de especial complejidad, diagnosticada de carcinoma de recto en la que confluían cuatro problemas de difícil abordaje: dolor neuropático descontrolado a pesar de opioides, infección con repercusión sistémica, herida quirúrgica abierta y desánimo completo. Mostramos las medidas que se adoptaron y cómo una excelente colaboración inter-departamental, bajo la coordinación del equipo de medicina paliativa, sirvió para solucionar una situación que en un punto llegó aparecer insostenible (AU)

Palliative care is generally understood on caring for terminal patients in chronic settings but more recently these units are developing also in acute caresettings or university hospitals as consultants teams. We report the case of a complex patient with rectal adenocarcinoma and four problems of difficult approach: uncontrolled neuropathic pain despite opioids treatment, systemic infection, depression with intense demoralisation and open surgery wound. We show the measures adopted and how an excellent inter-departmental collaboration under the co-ordination of palliative medicine consultant team helped to resolve the untenable situation (AU)

Chemical gastritis after chronic bromazepam intake: a case report.

BACKGROUND: We describe a rare case of diffuse macroscopic discoloration and chemical gastritis due to chronic bromazepam intake. The chemical composition of pharmaceuticals has to be considered at endoscopy and it is evident that some chemical substances damage the epithelial tissue and lead to clinical symptoms. CASE PRESENTATION: Endoscopy was performed in an 82-year-old patient due to gastroesophageal reflux symptoms and epigastric pain. Gastroscopy showed a hiatal hernia and a scarred duodenal bulb. More striking was the yellow-brownish discoloration of the gastric and the duodenal mucosa. The gastric antrum and the duodenal bulb showed local discoloration that could not be rinsed off. The medical history indicated that bromazepam (6 mg) had been used daily as a sleeping aid in the previous two years. The histopathological findings showed appearances of chemical gastritis. Within the lamina propria and on the epithelial surface there were granules. There was no foreign body reaction to these granules. Corpus mucosa showed a mild chronic gastritis. CONCLUSIONS: If discoloration of the mucosa at endoscopy is seen, a careful drug history must be sought. This is the first case in literature that shows a chemical gastritis after bromazepam intake.

Enfermedad de Whipple: una infrecuente causa bacteriana de demencia / Whipple’s Disease: an uncommon cause of dementia

Presentamos un caso de demencia diagnosticada como Alzheimer, cuya evolución condujo al diagnóstico final de una enfermedad de Whipple cerebral (AU)

We present a dementia case, diagnosed as Alzheimer type. Nevertheless, the final diagnosis of Whipple’s disease was delayed (AU)

Efectos del bromacepam en el desarrollo de una actividad sensoriomotora: un estudio electroencefalográfico / The effects of bromazepan on the performance of a sensory-motor activity: an electroencephalographic study

Objetivos. Investigar los efectos del uso del bromacepam en la potencia relativa en alfa durante la realización de unatarea de mecanografía. Teniendo en cuenta las particularidades de cada hemisferio cerebral, nuestra hipótesis era que a travésde la medida de la potencia relativa sería posible investigar el efecto del bromacepam sobre áreas corticales específicas. Concretamente,se esperaba observar diferentes patrones de potencias en los procesos de atención, activación e integración sensoriomotora.Sujetos y métodos. La muestra estaba formada por 39 sujetos (15 hombres y 24 mujeres) con una media de edad de30 ± 10 años. Los grupos control (placebo) y experimental (bromacepam de 3 mg y 6 mg) fueron entrenados en la tarea de mecanografíacon un modelo doble ciego aleatorizado. Resultados. Mediante el ANOVA de tres vías y el test de Scheffé se comprobaroninteracciones entre los factores condición y momento y entre condición y sector. Conclusión. Las dosis empleadas en esteestudio facilitaron el desarrollo motor de la tarea de mecanografía. En este estudio, el uso del fármaco no impidió el aprendizajede la tarea, pero parece ser que concentró el esfuerzo mental sobre aspectos más restringidos y específicos de la mecanografía.Tuvo lugar una influencia sobre el ritmo y la eficacia de las operaciones ejecutadas durante mecanismos de codificacióny almacenamiento de nuevas informaciones. Asimismo, se comprobó un predominio de actividad en el área frontal izquierda(dominante) en el grupo bromacepam 3 mg, lo cual indica que esta dosis del fármaco permite al sujeto un mayor direccionamientode la actividad cortical para la planificación y la ejecución de la tarea(AU)

Aims. To investigate the effects of using bromazepam on the relative power in alpha while performing a typing task.Bearing in mind the particularities of each brain hemisphere, our hypothesis was that measuring the relative power wouldallow us to investigate the effects of bromazepam on specific areas of the cortex. More specifically, we expected to observedifferent patterns of powers in sensory-motor integration, attention and activation processes. Subjects and methods. The samplewas made up of 39 subjects (15 males and 24 females) with a mean age of 30 ± 10 years. The control (placebo) and experimental(3 mg and 6 mg of bromazepam) groups were trained in the typing task with a randomised double-blind model. Results. A threewayANOVA and Scheffé test were used to analyse interactions between the factors condition and moment, and betweencondition and sector. Conclusions. The doses used in this study facilitated motor performance of the typing task. In this study,the use of the drug did not prevent learning of the task, but it did appear to concentrate mental effort on more restricted andspecific aspects of typing. It also seemed to influence the rhythm and effectiveness of the operations performed duringmechanisms related to the encoding and storage of new information. Likewise, a predominance of activity was observed in theleft (dominant) frontal area in the 3 mg bromazepam group, which indicates that this dose of the drug affords the subject agreater degree of directionality of cortical activity for planning and performing the task(AU)

[Anxiety level and addiction to first-time prescriptions of anxiolytics: a psychometric study]. / Niveau d'anxiété et de dépendance des primoconsommants d'anxiolytiques: une étude de psychométrie.

CONTEXT: The anxiety epidemic and its corollary, the widespread prescription of anxiolytics, present a public health problem in view of the risk of addiction to these drugs. OBJECTIVE: To assess the level of anxiety and addiction in the borderline population at risk of addiction. DESIGN: The study analyzed a series of patients in the third month of their first prescription for anxiolytics. It used two validated scales: the Hospital Anxiety and Depression scale (HAD), and a French scale measuring addiction (the "Echelle Cognitive d'Attachement aux Benzodiazepines" or ECAB). RESULT: 83% of patients were still anxious at the third month of treatment. 23% had become addicted. DISCUSSION: There is a contradiction between the prolonged prescription and use of anxiolytics, which are associated with a risk of addiction, and professional guidelines that recommend short treatment for outpatients using these drugs for the first time.

Hyponatremia-induced seizure during carbamazepine treatment.

We report the case of a 54-year-old woman who was admitted for benzodiazepine withdrawal. After 6 weeks of carbamazepine treatment (600, then 200 mg) the patient suddenly suffered from a grand mal seizure. Laboratory findings revealed a clinical significant hyponatremia of Na 125 mmol/l (baseline: 143 mmol/l). CCT and ECG were normal. To our knowledge, this is the first description of a seizure related to hyponatremia in an adult carbamazepine-treated patient.

Benzodiazepines prescription in Dakar: a study about prescribing habits and knowledge in general practitioners, neurologists and psychiatrists.

Benzodiazepines are relatively well-tolerated medicines but can induce serious problems of addiction and that is why their use is regulated. However, in developing countries like Senegal, these products are used without clear indications on their prescription, their dispensation or their use. This work focuses on the prescription of these medicines with a view to make recommendations for their rational use. Benzodiazepine prescription was studied with psychiatrists or neurologists and generalists in 2003. Specialist doctors work in two Dakar university hospitals and generalists in the 11 health centres in Dakar. We did a survey by direct interview with 29 of 35 specialists and 23 of 25 generalists. All doctors were interviewed in their office. The questionnaire focused on benzodiazepine indications, their pharmacological properties, benzodiazepines prescribed in first intention against a given disease and the level of training in benzodiazepines by doctors. Comparisons between specialists and generalists were made by chi-square test. Benzodiazepines were essentially used for anxiety, insomnia and epilepsy. With these diseases, the most benzodiazepines prescribed are prazepam against anxiety and insomnia and diazepam against epilepsy. About 10% of doctors do not know that there is a limitation for the period of benzodiazepine use. The principal reasons of drugs choice are knowledge of the drugs, habit and low side effects of drugs. All generalists (100%) said that their training on benzodiazepines is poor vs. 62.1% of specialists, and doctors suggest seminars, journals adhesions and conferences to complete their training in this field. There are not many differences between specialists and generalists except the fact that specialists prefer prazepam in first intention in the insomnia treatment where generalists choose bromazepam. In addition, our survey showed that specialists' training in benzodiazepines is better than that of generalists. Overall, benzodiazepine prescription poses problems particularly in training, and national authorities must take urgent measures for rational use of these drugs.

Double-blind, comparative study of cyamemazine vs. bromazepam in the benzodiazepine withdrawal syndrome.

Cyamemazine is an anxiolytic antipsychotic, which reduces ethanol withdrawal symptoms. Here, we investigated if cyamemazine can be also effective as substitute drug to facilitate benzodiazepine withdrawal. A total of 168 patients treated with benzodiazepines for at least 3 months and with a <18 score in the Hamilton Anxiety Rating Scale (HARS) were included in the study. Previous benzodiazepine treatment was withdrawn, and patients were randomized to a 4-week treatment with cyamemazine (25-50 mg q.d.) or bromazepam (3-6 mg q.d.), followed by 2 weeks of placebo. The primary efficacy variable was the maximal anxiety rebound as measured with the HARS during the 42 days of treatment. No statistically significant differences between treatment groups were found for the extent or incidence of rebound anxiety. Considering all dropout patients as withdrawal failures, after 6 months of follow-up, 56/84 patients in the cyamemazine group (66.7%) and 55/84 patients in the bromazepam group (65.5%) were successfully withdrawn. 28 patients in the cyamemazine group and 18 in the bromazepam group had an adverse event, including anxiety, insomnia, dry mouth and somnolence. No extra-pyramidal symptoms were reported. In conclusion, cyamemazine was comparable to bromazepam in ensuring successful benzodiazepine withdrawal and in controlling the acute benzodiazepine withdrawal syndrome. Cyamemazine may be useful to facilitate benzodiazepine withdrawal in those patients where bromazepam substitution is not appropriate.