Valproate-induced delirium in a demented patient.

In this study we report a case of valproate-induced delirium in a patient affected with Alzheimer's disease (AD). A 75-year-old woman with AD presented moderate cognitive impairment associated to behavioral disorders, characterized by aggression, agitation, severe insomnia. She was treated with galantamine, promazine, acetylsalicylic acid and pantoprazole. Since behavioral disorders worsened more and more, home neurological consultation was asked. The neurologist prescribed a mood stabilizer, sodium valproate 500 mg daily for the first week and then, twice a day and stopped promazine. After an apparent initial benefit, about 16 days later, patient suddenly developed hyperactive delirium. It was characterized by worsening of insomnia and agitation, severe confusion, delusions, visual hallucinations alternated to sedation. She became progressively unable to walk and completely dependent in daily living activities. An urgent geriatric consultation was performed at patient's home; physical examination showed mild dehydration, normal blood pressure. Oxygen saturation and electrocardiogram were normal. Sodium valproate was immediately stopped and rehydration was performed. The patient was admitted to a Geriatric Unit, where organic and metabolic damages were excluded. During the hospital stay the patient was agitated, aggressive, confused; intramuscular haloperidol 5mg and saline intravenous infusion 1500 cc daily were performed, they were partly successful. Three days after she was discharged and continued treatment with oral haloperidol 5mg daily. One week later the patient recovered and she is at present healthy. This is a case report of valproate-induced delirium. The Naranjo scale scored 7, classifying this drug-related event as probable. The present case report suggests the need for minimizing the use of psychoactive drugs in elderly demented patients, whether possible; age-related changes in pharmacokinetics and pharmacodynamics suggest the opportunity of a careful evaluation and a slow titration of treatments in these patients.

Dosificación de vancomicina en pacientes en hemodiálisis / No disponible

Dado el amplio uso de vancomicina en hemodiálisis (HD) es necesario adecuar la dosificación a las actuales membranas de diálisis, asegurando niveles óptimos. Objetivo: Valorar si, en HD, tras 1 gramo intravenoso (IV) los niveles plasmáticos de vancomicina se encuentran en rango terapéutico. Material y métodos: Estudio de cohorte transversal que incluye 28 pacientes en HD 3 veces/semana tratados con vancomicina entre el 15/2/2006 y el 14/2/2007. Sead ministró 1 gramo IV durante la última hora de HD, determinando niveles antes y después de la sesión siguiente(preHD1, postHD1) y antes de la 2ª sesión siguiente(preHD2). Resultados: De los 28 pacientes, 5 presentaban 3determinaciones y 5 presentaban 2 y el resto 1. De las 43muestras, 19 eran hombres (44,2%) y 24 mujeres (55,8%),con edad media 70 ± 8,4 años. La dosis de 1 gramo correspondía a > 15 mg/kg en 31 pacientes (72,1%) y < 15 mg/kgen 12 (27,9%). El 44,2% utilizaban polietersulfona de alta permeabilidad (PES-AP), 7% eval, 32,5% polietersulfona de media-baja permeabilidad (PES-BP) y 16,3% poliacrilonitrilo. El nivel medio preHD1 fue 7,06 mcg/ml, 7,5 mcg/mlpara la dosis > 15 mg/kg y 6 mcg/ml para < 15 mg/kg (p <0,05). El 16,3% presentó niveles por debajo del rango terapéutico, siendo 6,45% para una dosis > 15 mg/kg frente a 41,67% para la dosis < 15 mg/kg. Respecto a los dializadores, los niveles más bajos se observaron con PES-AP (5,95 mcg/ml) y los más elevados con PES-BP (7,27 mcg/ml) (p no significativa). Ningún paciente con PES-BP se encontró en rango infraterapéutico, frente a 31,58% con PES-AP (p = 0,07). Los valores postHD1 y preHD2 se encontraban en niveles subóptimos, tanto la media como los que recibían > 15 mg/kg y < 15 mg/kg, y en todos los dializadores. Conclusiones: La administración de 1 gramo IV de vancomicina cada 5-7 días no es adecuado para pacientes en HD, sobre todo cuando se utilizan membranas de alto flujo. Mientras no se actualizan las pautas de dosificación es necesario monitorizar los niveles prediálisis del fármaco para evitar concentraciones infraterapéuticas (AU)

Vancomycin is widely used in haemodialysis (HD) patients for treating infections of vascular access due to St. Aureus. To avoid subtherapeutic levels it is important to know the adequate dosing in patients undergoing haemodialysis with high flux membranes. Objective: The aim of this study was to evaluate whether HD patients treated with 1 g intravenous (IV) vancomycin reached optimum plasma levels. Material and methods: In a crossover design we studied 28 chronic HD patients, 3 times a week, treated with vancomycin between 15/2/2006 and 14/2/2007. Antibiotic wasgiven at dose of 1 g during the last hour of dialysis session. Plasma levels of vancomycin were measured immediately before next HD (preHD1) and after (postHD1), and prior to the beginning of the second next session (preHD2). We evaluated age, sex, dry height, week Kt/V and the type of membrane used. Results: Of 28 patients, 5 were analysed 3 times, 2 were analysed twice and 9 were analysed once. There were 43 samples, 19 men (44.2%) and 24 women (55.8%), with a mean age of 70 ± 8,4 years. 1 g dose is equivalent to > 15 mg/kg in 31 patients (72.1%) and < 15 mg/kg in 12 (27.9%). The type of membrane used was high flux polyetersulfone (PES-AP) (44.2%), eval (7%), medium-low polyetersulfone (PES-BP) (32.5%) and polyacrylonitrile (16.3%). PreHD1 mean concentration results for the total population was 7.06 mg/ml, being 16.3% bellow optimum levels. There were not difference between patients treated with dose > 15 mg/kg (7.5 mg/ml) and < 15 mg/kg (6 m/ml). When the dose administered was > 15 mg/kg, 6.45% results were subtherapeutic, whereas if the dose was < 15 mg/kg, 41.67% values were bellow optimum levels (p < 0.05). With regard to the dialyzers used, the lowest concentrations were observed with PES-AP (5.95 mg/ml) and the highest values were observed with PES-BP (7.27 mg/ml) (p no significance). No patient using PESBP versus 31.58% patients using PES-AP showed suboptimum values (p = 0,07). All postHD1 and preHD2 results were in subtherapeutic range (mean values, dose > and < 15 mg/kg and all types of membrane). Conclusions: Based on the above results, the vancomycin dosing schedule of 1 g IV every 5-7 days is not recommended for patients undergoing haemodialysis with high flux membranes. Since there are not guidelines for handling this antibiotic in these patients our findings suggest that it may be necessary to monitorize predialysis plasma levels to avoid subtherapeutic values (AU)

[Vancomycin dosing in hemodialysis patients]. / Dosificación de vancomicina en pacientes en hemodiálisis.

UNLABELLED: Vancomycin is widely used in haemodialysis (HD) patients for treating infections of vascular access due to St. Aureus. To avoid subtherapeutic levels it is important to know the adequate dosing in patients undergoing haemodialysis with high flux membranes. OBJECTIVE: The aim of this study was to evaluate whether HD patients treated with 1 g intravenous (IV) vancomycin reached optimum plasma levels. MATERIAL AND METHODS: In a crossover design we studied 28 chronic HD patients, 3 times a week, treated with vancomycin between 15/2/2006 and 14/2/2007. Antibiotic was given at dose of 1 g during the last hour of dialysis session. Plasma levels of vancomycin were measured immediately before next HD (preHD1) and after (postHD1), and prior to the beginning of the second next session (preHD2). We evaluated age, sex, dry height, week Kt/V and the type of membrane used. RESULTS: Of 28 patients, 5 were analysed 3 times, 2 were analysed twice and 9 were analysed once . There were 43 samples, 19 men (44,2%) and 24 women (55,8%), with a mean age of 70 +/- 8,4 years. 1 g dose is equivalent to > 15 mg/kg in 31 patients (72,1%) and < 15 mg/kg in 12 (27,9%). The type of membrane used was high flux polyetersulfone (PES-AP) (44,2%), eval (7%), medium-low polyetersulfone (PES-BP) (32,5%) and polyacrylonitrile (16,3%). PreHD1 mean concentration results for the total population was 7,06 mg/ml, being 16,3% bellow optimum levels. There were not difference between patients treated with dose > 15 mg/kg (7,5 mg/ml) and < 15 mg/kg (6 m/ml). When the dose administered was > 15 mg/kg, 6,45% results were subtherapeutic, whereas if the dose was < 15 mg/kg, 41,67% values were bellow optimum levels (p<0,05). With regard to the dialyzers used, the lowest concentrations were observed with PES-AP (5,95 mg/ml) and the highest values were observed with PES-BP (7,27 mg/ml) (p no significance). No patient using PES-BP versus 31,58% patients using PES-AP showed suboptimum values (p> or =0,07). All postHD1 and preHD2 results were in subtherapeutic range (mean values, dose > and < 15 mg/kg and all types of membrane). CONCLUSIONS: Based on the above results, the vancomycin dosing schedule of 1 g IV every 5-7 days is not recommended for patients undergoing haemodialysis with high flux membranes. Since there are not guidelines for handling this antibiotic in these patients our findings suggest that it may be necessary to monitorize predialysis plasma levels to avoid subtherapeutic values.

[Telemedicine applied to Nephrology. Another form of consultation]. / Telemedicina aplicada a la nefrología. Otra forma de consulta.

UNLABELLED: In 2004, according to socio- demographic criteria and to the improvement in the welfare quality, we incorporated to the portfolio of services of our section a work tool that meant a novel technology; the "telemedicine". The Objective has been to asses the utility of telemedicine in the follow- up of the renal patients, bringing the consultation of nephrology closer to the patient's home as well as the relationship between two welfare levels. MATERIAL AND METHOD: Retrospective and descriptive study of the patients with renal pathology treated in the consultation of telenephrology at our hospital in a period of time of 27 months (November 2004-January 2007). Such study is carried out in primary care centers of our sanitary area (4 centers). The general practician (G.P) starts up the system by elaborating a document of derivation to the consultation of "telenephrology". All this information is included in a computerized data base that arrives via "Intranet" at the Hospital. From the consultation of Telenephrology the question is answered in real- time and through a system of videoconference. RESULTS: A total of 105 first consultations have been made. 52 men and 53 women between 18 and 94 years of age. The diagnoses made in the consultation of Telenephrology have been: HTA (essential and secondary): 90 (85.7%). IRC: 61 (58%). Diabetic Nefropathy: 17 (16%). Renal Polycystic: 3 (2.8%). Urinary Lithiasis: 2 (1.9%). Congenital malformations: 1 (0.95%). Obstructive Nefropathy: 1 (0.95%). Chronic Glomerulonephritis: 6 (5.7%). Urinary infection: 1 (0.95%). Absence of renal pathology: 5 (4.8%). Some of the diagnoses coincide in several patients. The causes of the IRC have been Nephroangioesclerosis: 33. Diabetic Nefropathy: 14. Not drafted: 8. Disease to glomerular: 2. Urinary Lithiasis: 2. Renal Polycystic: 1. Ischemic Nephropathy: 1. 82 out of the 90 patients with HTA had essential arterial hypertension and 8 suffered from secondary HTA. The causes of this were: 5 HTA of parenquimatous renal origin. 2 vasculorrenal HTA and one with a primary hyperaldosteronism. The associated factors of risk to the observed HTA have been: Dyslipemia: 29. Diabetes méllitus: 29. Hyperuricemia: 11. Obesity: 12. CONCLUSION: The telecare in nephrology is possible promoting also the approach between two welfare levels, without a decrease in the quality of assistance. That way, we can get a lower number of hospital visits and, subsequently, a saving in sanitary transport as well as in hospital consultations.

Retrospective evaluation of adverse drug reactions induced by nonsteroidal anti-inflammatory drugs.

BACKGROUND AND OBJECTIVE: Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most widely prescribed drugs, and their use can be complicated by the development of adverse drug reactions (ADRs). The aim of this study was to assess the frequency of NSAID-induced ADRs in hospitalised patients in the Clinical Divisions of the Catanzaro and Cosenza hospitals. METHODS: We retrospectively analysed NSAID-induced ADRs after evaluating all ADRs recorded by the Clinical Divisions of the Catanzaro and Cosenza hospitals over a 10-year period, from January 1995 to December 2004. RESULTS: NSAIDs were found to be responsible for 55.2% of the episodes of ADRs overall. Diclofenac and aspirin (acetylsalicylic acid) were the drugs most frequently involved in the development of ADRs, while the skin was the body system most susceptible to NSAID-induced ADRs (43%). We determined that the drug-ADR relationship was probable in 62% of the reports; withdrawal of NSAID therapy led to a resolution of the clinical features of ADRs in 86% of episodes. CONCLUSION: NSAID therapy represents a common cause of ADRs in hospitalised patients. Their use should be carefully considered, especially in the presence of polydrug therapy.

Comparison of the efficacy of new and conventional antipsychotic drugs in the treatment of behavioral and psychological symptoms of dementia (BPSD).

This double-blind study evaluated the efficacy and safety of risperidone or olanzapine vs. promazine in the treatment of behavioral and psychological symptoms in dementia(BPSD). Patients were required to be 65 years or older, to have DSM-IV diagnoses of Alzheimer's disease (AD), vascular dementia (VD) or a combination of both. A brain computerized tomography (CT) was performed for all the patients; 60 demented patients,27 men (45 %) and 33 women (55 %) were selected for this study. The University of California Los Angeles neuropsychiatric inventory (NPI) was administered at baseline, then after 4 and 8 weeks. Patients had at least a score of 24 or more. The Hoehn and Yahr scale was used for evaluating parkinsonism. The scales were administered by an examinator who was not aware of the kind of treatment of the patients. After a wash-out period of 10 days,20 patients, 9 men and 11 women, mean age 76.6 +/- 6.0 years, were randomly assigned torisperidone 1 mg daily in divided doses (morning and bedtime) (Group A); 20 patients, 9 men and 11 women, mean age 82.5 +/- 9.3 years were randomly assigned to olanzapine 5mg at bedtime (Group B), and 20 patients, 9 men and 11 women, mean age 77.6 +/- 4.6 years, were randomly assigned to promazine 50 mg daily (morning and bedtime) (Group C). In case of lack of clinical response, after 4 weeks, the dose could be increased to 2 mg/day of risperidone, 10 mg/day of olanzapine, and to 100 mg/day of promazine in the respective groups. Repeated measures ANOVA was used for the statistical analysis of rating scales over time (baseline, 4 and 8 weeks). At the end of the 8th week, a global improvement was obtained in 80% of patients treated with risperidone and olanzapine, vs. 65 % of patients treated with promazine (p < 0.01). The results show that risperidone in doses of 1-2 mg/day and olanzapine in doses of 5-10 mg/day are effective and safe in the treatment of BPSD. Risperidone presents a major and dose-dependent antidopaminergic action and seems to be preferable when hallucinations and delusions are prevailing symptoms, even if it gives good results on aggression and wandering. Olanzapine seems to be faster in its sedative effect, probably for H1 receptor blockade. Moreover, 5-HT6 antagonism may favor acetylcholine release and this explains why these patients have not presented a cognitive worsening. However, both drugs are comparable or even superior to promazine, with significantly fewer side effects of both anticholinergic and extrapyramidal character.

Metastasizing renal cell carcinoma and acquired renal cystic disease in a hemodialysis patient.

Acquired renal cystic disease is an entity which is characterized by the progressive substitution of the atrophic renal parenchyma by multiple cysts in patients with renal insufficiency. Its main complications are hemorrhage and tumorous degeneration. The case discussed is a 57-year-old patient with terminal renal insufficiency secondary to interstitial nephropathy, who, following 6 years of treatment with hemodialysis and renal transplantation, developed a state of persistent hematuria requiring nephrectomy of the left kidney. Histological study revealed multiple cysts of monostratified epithelium with intracavitary projections, multiform adenomas and multifocal malignant tumorous polymorphism. The patient died in a state of progressive cachexia with pleural and hepatic metastasis.

Aluminium transfer in bicarbonate dialysis using a sorbent regenerative system: an in vitro study.

Because of the known presence of aluminium oxide in the Redy cartridge and the increased solubility of aluminium (A1) in alkaline solution, an in vitro study was performed to measure the release of A1 from the Redy cartridge and its potential transfer across a dialyser membrane. The use of bicarbonate rinsed Redy cartridges was associated with significant release of A1 and its subsequent transfer across the cellulose acetate membrane. Bicarbonate dialysis with the Redy system is not recommended for maintenance haemodialysis.