Granulocytic sarcoma of the stomach: relapse after hematopoietic stem-cell transplantation for chronic myeloid leukemia.

An 18-year-old male underwent an allogeneic hematopoietic stem cell transplantation (allo-HSCT) for chronic myeloid leukemia (CML) in the first late chronic phase. On day 132, he was readmitted to the hospital with nausea, vomiting and nodular lesions on endoscopy. A diagnosis of granulocytic sarcoma of the stomach was made. Bone marrow cytogenetic analysis for the Philadelphia chromosome and nested polymerase chain reaction for BCR-ABL1 were both negative. Immunosuppression was abruptly discontinued, and by day 180, all gastric lesions had completely disappeared. However, there were histological signs of graft-versus-host disease. The patient developed progressive anorexia and elevated hepatic enzymes, which prompted the reintroduction of cyclosporine. Considering the risk of another relapse, imatinib mesylate (IM) 600 mg/day was started. The patient Is condition improved, and there was no evidence of disease recurrence at 36 months after relapse. Relapse of CML is the commonest cause of treatment failure after allo-HSCT. On rare occasions, a localized extramedullary presentation is seen. Unless properly treated, other extramedullary relapse sites and/or marrow infiltration usually occur. Withdrawal of immunosuppression, along with IM therapy seems to be an acceptable approach in this setting.

Estimulación eléctrica invasiva de C2-C3 en el tratamiento del dolor cefálico y facial: Neuralgia occipital. Migraña transformada. Cefalea en racimos. Algias faciales / C2-C3 Invasive electrical stimulation for the treatment of cephalic and facial pain: occipital neuralgia. Transformed migraine. Cluster headache. Facial algias

Introducción: La estimulación eléctrica extraespinal periférica cervico-occipital, llevada a cabo con un sistema implantado, es una técnica quirúrgica poco cruenta que puede proporcionar buenos resultados en pacientes con dolor neuropático refractario localizado en región cefálica y facial. Presentamos treinta y cuatro pacientes con dolor cervico-facial de larga evolución, persitente, severo, no controlado, de diferentes etiologías, en los que se habían agotado otras posibilidades terapéuticas, tratados en la Unidad del Dolor del Hospital Clínico, con estimulación eléctrica y electrodo cervico-occipital uni o bilateral. Material y método: Se trata de 34 pacientes tratados en el período de Junio 2002 a Febrero de 2008. Catorce de estos pacientes cumplían criterios diagnósticos de Migraña Transformada; otros dos casos se trataba de cefalea en racimos y en 18 corresponden a Neuralgia occipital y/o del trigémino. Antes del implante del sistema de estimulación se realizó bloqueo nervioso occipital con anestésico local con el fín dedeterminar el componente cervicogénico del cuadro álgico. El procedimiento quirúrgico se ha realizado en dos tiempos. La valoración de la eficacia está basada en la variación, antes y después del implante del sistema, de los siguientes parámetros: dolor continuo, dolor en las crisis y número de crisis, descanso nocturno, funcionalidad, actividad social y laboral, satisfacción del paciente, reducción del tratamiento farmacológico y estado emocional. Resultados: Los pacientes corresponden a 25 mujeres y 9 hombres, de 51,2 años de edad media (R. 29-80). Presentaban dolor continuo y en 27, además, se manifestaban crisis con agudización sintomática de gran severidad. Todos los pacientes necesitaban tratamiento farmacológico analgésico (media de 4,4fármacos por paciente). En todos los pacientes habían fracasado otras alternativas terapéuticas. El tiempo medio de evolución del dolor era de 98,9 meses (R. 5-360) (...)(AU)

Introduction: The peripheral cervical-occipital extraspinal electrical stimulation with an implanted system, is a little aggressive technique that can achieve good results in patients with refractory neurophatic pain localized in the cephalic and facial region. Thirty four patients with long-evolving, persistent, severe, uncontrolled pain of different ethiologies, localized in the cervical facial region, for whom other therapy options were exhausted, were treated with unilateral or bilateral cervical occipital electrical stimulation in the pain unit of the Zaragoza Clinic Hospital. Material and Method: Thirty four patients were treated from June 2002 to February 2008, fourteen of which were diagnosed with transformed migraine; two suffered from cluster headache and eighteen had occipital and/or trigeminal neuralgia. Before the neurostimulation system was implanted, an occipital nerve block was performed with local anesthetic to establish the cervicogenic component in the pain. The surgical procedure was performed in two stages. The treatment effectiveness assessment was made on the basis of the variation of the following parameters before and after the implant: ongoing pain, pain during the crisis, number of crisis events, overnight rest, functioning, social and laboral activity, patient satisfaction, drug therapy reduction and emotional status. Results: The participants were 25 female patients and 9 male patients with an average age of 51,2 (R. 29-80). They suffered from ongoing pain, and 27 of them also experienced crisis events with a very severe agudization of symptoms. All the patients needed pharmacological treatment with analgesics (average of 4,4 drugs per patient). Other treatment options had failed in all these patients. The mean time of pain evolution was 98,9 months (R. 5-360)...(AU)

Estimulación occipital. Experiencia de la unidad del dolor del Hospital Clínico de Zaragoza / Occipital stimulation. Experience of the main unit of the Zaragoza University Hospital

Los últimos avances en neuromodulación analgésica, con sistema implantado, han permitido ampliar sus posibilidades terapéuticas con la colocación de electrodos extraespinales sobre nervios periféricos (occipital, supraorbitario, mediano, cubital, radial, genitofemoral, peroneo, safeno y tibial posterior). La estimulación occipital está indicada en pacientes con dolor cefálico y facial, en la forma de migraña transformada(MT) o neuralgia occipital (NO), refractario al tratamiento. Diagnóstico confirmado por la remisión o mejoría temporal de la sintomatología con el bloqueo anestésico suboccipital. En condiciones psicológico-mentales dentro de la normalidad y sin contraindicación a la cirugía (AU)

The last advances in analgesic neuromodulation, with implanted system, have allowed to extend their therapeutic possibilities with the positioning of extraspinal electrodes on peripheral nerves. The occipital stimulation is indicated in patients with cranial and facial pain, in the form of headache transformed (MT) or occipital neuralgia (NOT), refractory to the treatment. Diagnosis is confirmed by the remission or temporary improvement of the symptoms with the anesthetic suboccipital blockade. In psychological-mental conditions within normality and without contraindication to the surgery (AU)

Tolerabilidad local de bruprenorfina T.D.S. tras la administración profiláctica de antihistamínicos antagonistas H1 / Buprenorphine local tolerability after the prophylactic administration of antihistamine H1 antagonists

Introducción: Uno de los efectos secundarios de la buprenorfina T.D.S, en un porcentaje importante de pacientes, es su mala tolerabilidad local. Objetivos: Evaluar la tolerabilidad local de buprenorfina T.D.S., tras la administración profiláctica de antihistamínicos antagonistas H1 por vía oral durante el primer mes de tratamiento y posteriormente por vía tópica, si persistía la irritación local. Así como su efectividad en el tiempo. Material y Método: Se ha realizado un estudio observacional prospectivo de 80 pacientes (60 mujeres y 20 varones), edad media 65,08 +/- 13,5 años (R 34 - 87), que presentaban dolor crónico osteoarticular de intensidad moderada. Seguimiento: 6 meses. Controles: visita basal, 1, 2, 3 y 6 meses. Dosis: buprenorfina T.D.S. entre 17,5 y 70 μg/h cada 3 días. Dosis media 37,84 +/- 16,34 μg/h. Todos los pacientes comenzaron tratamiento simultáneo con cetirizina vía oral 10 mg/día en dosis única nocturna durante un mes. A partir del mes, dimetindeno gel en aquellos pacientes con persistencia de exantema, eritema o prurito, al suspender la vía oral. Se valoró como: 1. Tolerabilidad local buena sólo con vía oral: aquellos pacientes que no presentaron ninguna reacción adversa local tras el mes de tratamiento oral y siguen igual a los 6 meses. 2. Tolerabilidad local buena con vía oral + vía tópica: aquellos pacientes que tras suspender la vía oral al mes, persistía reacción adversa local y tras la administración vía tópica no presentaron reacciones adversas locales y siguen igual a los 6 meses. 3. Tolerabilidad local regular con vía oral + vía tópica: aquellos pacientes que tras suspender la vía oral al mes, persistía reacción adversa local y tras la administración vía tópica han seguido con eritema y prurito leve y tolerable a los 6 meses. 4. Tolerabilidad local mala sólo con vía oral: aquellos pacientes que tras el mes de tratamiento oral presentaron eritema y prurito severo y tuvieron que suspender el tratamiento con buprenorfina T.D.S. 5. Tolerabilidad local mala con vía oral + vía tópica: aquellos pacientes que tras suspender la vía oral al mes, persistía eritema y prurito y tras la administración vía tópica no remitió la reacción adversa, suspendiendo buprenorfina T.D.S. Resultados: BUENO: 56 pacientes (70%) vía oral sólo y vía oral + tópica. REGULAR: 7 pacientes (8,75%) vía oral + tópica. MALO: 17 pacientes (21,25%) vía oral y vía oral + tópica, se suspende tratamiento. Conclusiones: Los resultados han sido buenos sin reacción adversa local y persistiendo en el tiempo en un alto porcentaje de los pacientes al seguir con la vía tópica tras el primer mes de la vía oral. No ha presentado ningún paciente tumefacción local ni reacción alérgica. Con la utilización de dimentideno no se ha observado alteración en la liberación del fármaco ni disminución en su efecto analgésico (AU)

Introduction: One of the side effects of buprenorphine T.D.S, in an important percentage of patients, with bad local tolerability. Objetives: To evalúate the local tolerability of buprenorphine T.D.S., after the prophylactic administration of antihistamine Hl antagonists orally during the first month of treatment and after using topical therapy if the local irritation persisted. As well as its effectiveness along the time. Material and Method: A prospective observational study of 80 patients have been made (60 women and 20 men), age mediates 65.08 ±13.5 years (R 34-87), with osteoarticular chronic pain of modérate intensity. We checked the following 6 months. Controls: basal, 1, 2, 3 and 6 months. Dose: buprenorphine T.D.S between 17.5 and 70 µg/h every 3 days. doses mediate 37.84 ± 16.34 µg/h. All the patients began simultaneous treatment with cetirizina 10 mg/day orally in nocturnal unique dose during one month. Since them, we administered dimetindeno gel in those patients with persistence of exanthema, erythema or pruritus, when They stopped orally. It was valued like: 1. Good local tolerability only with orally: those patients who had not any local adverse reaction after one month of orally treatment and continué similar 6 months later. 2. Good local tolerability with orally + topical theraphy: those patients whom after suspending orally one month later, local adverse reaction persisted and after the topical theraphy administration, had not any local adverse reactions and continué similar 6 months later. 3. Regular local tolerability with orally + topical theraphy: those patients whom after suspending orally one month later, local adverse reaction persisted and after the topical teraphy administration had continued with slight and tolerable erythema and pruritus 6 months later. 4. Bad local tolerability only with orally: those patients whom after one month with orally treatment had severe erythema and pruritus and they had stopped treatment with buprenorphine T.D.S. 5. Bad local tolerability orally + topical theraphy: those patients whom after suspending orally one month later, persisted erythema and pruritus and after topical theraphy administration did not send the reaction adverse, stopping buprenorphine T.D.S. Results: GOOD: 56 patients (70%) orally only and orally + topical theraphy. FAIR: 7 patients (8.75%) orally + topical theraphy. BAD: 17 patients (21.25%) orally and orally + topical theraphy, they had suspended treatment. Conclusions: The results were good without local adverse reaction and persisting in the time in a high percentage of the patients following with the topical theraphy after one month orally. It had not any patient with local tumidity neither allergic reaction. It had not observed any variation of analgesic efficacy, so that, it had not changed of drug liberation because the previous topical theraphy of dimetindeno (AU)

Mortalidad asociada a la depresión en pacientes hospitalizados en medicina interna y seguidos en atención primaria: factores etiopatogénicos y “autopsia biopsicosocial” / No disponible

No disponible

Hiponatremia sintomática secundaria a tratamientos con oxcarbacepina / Symptomatic hyponatremia after the use of oxcarbazepine

La oxcarbacepina es un análogo de la carbamacepina utilizada para el tratamiento de la epilepsia y el dolor neuropático. Su espectro de efectos secundarios es sensiblemente inferior a la carbamacepina. Sin embargo, tiene una capacidad mayor de producir hiponatremia. Generalmente esta hiponatremia, que es dosis-dependiente, es asintomática cuando aparece y está favorecida por otras circunstancias concomitantes que pueden disminuir los niveles de sodio, como ocurre con la toma de ciertos fármacos (diuréticos). En raras ocasiones esta hiponatremia inducida por oxcarbacepina puede provocar síntomas que potencialmente pueden llevar al paciente a estados de encefalopatía si no se detectan a tiempo. Presentamos el caso de una paciente con hiponatremia provocada por la asociación de oxcarbacepina e hidroclorotiazida. En este caso se pudo constatar por las circustancias que se dieron que la disminución de los niveles de sodio era debida al efecto de los dos fármacos en conjunto y no por separado (AU)

Oxcarbazepine is a ketoanalogue of carbamazepine used for the treatment of epilepsy and neuropatic pain. However, oxcarbazepine is more likely to cause hyponatremia. Generally, hyponatremia is dose-dependant and asymptomatic, and is favoured by circumstances that cause a decrease in sodium levels, as the use of certain drugs (diuretics). If undetected, hyponatremia might occasionally cause severe symptoms leading to encephalopathy. A case of a patient with hyponatremia caused by the association of oxcarbazepine and hidroclorotiazide is reported. In this instance, the decrease of sodium levels was due to the association both drugs and not to the effect of each one separatedly (AU)

Trough to peak ratio of once-daily lisinopril and twice-daily captopril in patients with essential hypertension.

The objective of this study was to assess the antihypertensive effect and the trough to peak (T:P) ratio of lisinopril and captopril, in patients with essential hypertension. After 2 weeks of placebo, 69 of 115 eligible patients had office diastolic blood pressure (DBP) between 90 and 114 mm Hg and daytime average DBP above 85 mm Hg during a 25-h ambulatory BP monitoring (ABPM) and were randomised to receive lisinopril (20 mg once daily) or captopril (50 mg twice daily) for 4 weeks. Office and ambulatory BP were then repeated. Indices of 24-h BP and T:P ratios were calculated and compared. Both drugs significantly reduced both office and ambulatory BP. The final BP obtained with lisinopril was less than with captopril. On office measurement, 75% of the patients treated with lisinopril and 44% on captopril were controlled (P < 0.001), but responses by ABPM were not significantly different. T:P ratios calculated in all patients were 0.75 and 0.66 for lisinopril and captopril respectively, but in patients who responded to each drug the corresponding ratios were 0.78 and 0.73. In conclusion both 20 mg once-daily lisinopril and 50 mg captopril twice-daily achieve a favourable T:P ratio in patients with essential hypertension.

Lipoprotein (a) levels in patients undergoing continuous ambulatory peritoneal dialysis.

Most researchers have found increases of lipoprotein (a) [Lp(a)] in uremic patients, as well as in those undergoing hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD). The mechanisms for this increase remain unclear. We studied 71 patients undergoing CAPD, 48 men and 23 women. According to the time spent on CAPD, the patients were divided into three groups: group 0: 29 patients at the starting off point of dialysis treatment; group I: 22 patients with an average stay of 15.2 months; group II: 20 patients with an average stay of 69.3 months on CAPD. We have only observed significant increases of Lp(a) levels in those patients initiating the dialysis, but no significant differences are found in the other groups undergoing CAPD for longer periods when compared to the control group. We found no significant relation between Lp(a) levels and peritoneal protein loss, and not with absorption of glucose from the dialysate either. We have found a positive and significant correlation between Lp(a) levels and urinary protein loss (r = 0.41; p < 0.001). It is possible that an element associated with proteinuria might have an effect on the metabolism of Lp(a) in CAPD patients.

[Clinico-epidemiologic study of bacterial meningitis in Aragon]. / Estudio clinicoepidemiológico de las meningitis bacterianas en Aragón.

BACKGROUND: The aim of the present study was to know the incidence, etiology, prognostic factors and rate of mortality of bacterial meningitis in Aragón (Spain). METHODS: The clinical records of all the patients with bacterial meningitis seen in the hospitals in Aragón (Spain), from 1985 to 1988 inclusive were reviewed. RESULTS: The mean of the annual rates of incidence for Aragón (Spain) was 7.52/100,000 inhabitants. In patients under the age of 15 years the most frequent etiologies were Neisseria meningitidis (59.0%), Haemophilus influenzae (13.7%) and Streptococcus pneumoniae (9.4%); the global rate of mortality was 3.5% similar to that of sequelae. In those over the age of 14 years, the most frequent etiologies were N. meningitidis (33%), S. pneumoniae (18.4%) and Staphylococcus spp. (13.6%); the rate of global mortality was 19.5% and that of sequelae 10.8% with resistance of S. pneumoniae to penicillin and/or ampicillin in 45.5% of the cases in children and in 26.3% in adults. No significant evolutive differences related with the existence of resistances or the administration of antibiotics prior to lumbar punction were observed in any of the age groups. CONCLUSIONS: N. meningitidis is the main etiologic agent in Aragón in both children and adults. The greatest rates of mortality and sequelae were observed in the youngest and oldest age groups with a similar relation being seen in infection by gramnegative bacilli and S. pneumoniae, thus making these patients to be considered as being at high risk.

Increased activity of the Na(+)-dependent Cl(-)-HCO3- anion exchanger in erythrocytes of patients with essential hypertension.

OBJECTIVE: To study the activity of the Na(+)-dependent Cl(-)-HCO3- anion exchanger in erythrocytes of patients with essential hypertension. DESIGN: The study was performed in cells from 48 untreated essential hypertensive patients and 30 normotensive controls with similar age- and sex- distribution. METHODS: The activity of the Na(+)-dependent anion exchanger was determined by measuring the 4,4'-diisothiocyanostilbene-2,2'-disulfonate (DIDS) sensitive Li+ influx in fresh cells incubated into a medium containing Li2CO3. RESULTS: The DIDS-sensitive Li+ influx was higher in hypertensives than controls. With the 100% confidence (upper) limit of the normotensive population as a cut-off point, a subgroup of 11 hypertensives had an abnormally high activity of the Na(+)-dependent Cl(-)-HCO3- anion exchanger. Compared with patients with normal exchanger activity, patients with increased exchanger activity were characterized by the following: higher frequency of family history of hypertension; lower serum high-density lipoprotein cholesterol levels and higher plasma aldosterone concentrations. After multiple regression analysis, the DIDS-sensitive Li+ influx was inversely correlated with high-density lipoprotein cholesterol levels. CONCLUSIONS: These results show the presence of a new abnormality of erythrocyte Na+ transport in essential hypertension--increased activity of the Na(+)-dependent Cl(-)-HCO3- anion exchanger. In addition, our findings suggest that from the clinical point of view, patients with this transport abnormality represent a particular subset of essential hypertensives.

[Adaptation and validation of a test on knowledge about diabetes mellitus]. / Adaptación y validación de un test de conocimientos sobre la diabetes mellitus.

OBJECTIVE: To adapt and validate a Spanish language medium test, of theoretical general knowledge of diabetes mellitus (questionnaire from the University of Michigan). To determine the validity of the concurrent and discriminatory content and establish reliability. DESIGN: The study was observational. Validity was verified prior to data collection. To analyse the concurrent and discriminatory validity, a questionnaire was used in personal interview with the patients, and the degree of knowledge evaluated on certain variables. SETTING: Hospital outpatient endocrinology consultations. PATIENTS: 167 diabetic patients were chosen at random, from the outpatient visits. 14 patients who had developed hearing, or language problems, or who had problems of a psychological nature, were excluded. Only 1 patient refused to answer the questionnaire. MAIN MEASUREMENTS AND RESULTS: Validity of the content was confirmed after careful analysis of the questions on the questionnaire by medical specialists in endocrinology. It was found that the test had adequate concurrence (p less than 0.01) when the average general knowledge levels of certain group of patients are compared. It also had acceptable discriminatory validity (r = 0.56: p less than 0.0001) and reliability (alpha: 0.84; p less than 0.45). CONCLUSIONS: Adaptation and validation has been obtained for a test of theoretical general knowledge on diabetes mellitus, and the test was found to be applicable to the population under study.