Uso y abuso de opioides en el área norte de la provincia de Cádiz / Use and abuse of opioids analgesics in the northern area of the Cádiz province

Introducción: La utilización de opioides en dolor crónico no oncológico (DCNO) es controvertida porque no está demostrada su utilidad a largo plazo. Hay pocos estudios sobre dependencia y adicción; del mismo modo se ha descrito un aumento de mortalidad en pacientes que reciben altas dosis de opioides en DCNO. Por esto, nos propusimos analizar a los pacientes que superaban la dosis diaria definida, DDD, en el área norte de la provincia de Cádiz. La DDD es la dosis diaria de mantenimiento media en adultos. Material y métodos: El área norte de la provincia de Cádiz tiene una población aproximada de 420.000 habitantes. Se detectaron a los pacientes que superaban la DDD de opiáceos en diciembre de 2014. Estudiamos la historia clínica de todos estos pacientes. Resultados: Se encontraron 23 pacientes que, por lo menos, duplicaban la DDD del opiáceo utilizado. Por tanto, la incidencia en nuestra área era de un paciente por cada 18.000 habitantes. Cuatro de ellos son pacientes oncológicos (17 %), el resto de dolor crónico no oncológico (83 %). Predomina claramente el dolor tipo osteo-articular (65 %), siendo el diagnóstico más frecuente el síndrome postlaminectomía con 8 casos (35 %). La edad media era de 58 años, oscilando entre la más joven, 34 años, que era la que más dosis consumía, y la de más edad con 84 años. La DDD/día mayor es la de la paciente más joven con 34 veces la DDD, 2 con ocho veces la DDD, 2 con siete veces la DDD, dos con cinco veces la DDD, 1 con cuatro veces, 4 con tres veces y, por último, 11 pacientes que consumían el doble de la DDD. Todos los pacientes tomaban un opiáceo para el dolor irruptivo, la gran mayoría (17 pacientes) tomaban comprimidos de fentanilo oral transmucoso (Effentora® o Actiq®). La mayoría de los pacientes tomaban oxicodona (7) o fentanilo transdérmico (8), como opioide de acción retardada. Dos pacientes no tomaban ningún opioide de acción retardada. Se observó que once pacientes (47 %) tenían algún antecedente psiquiátrico, dos de ellos tuvieron algún intento de autolisis. Conclusiones: El uso inadecuado de opioides se da sobre todo en pacientes no oncológicos. Había una relación clara con patología psiquiátrica. Hay relaciones de uso inadecuado y abuso de opiáceos con los de acción rápida, sobre todo fentanilos, aunque el abuso de opioides es poco frecuente, con lo que hay que ser cautos en iniciar tratamiento en DCNO. Hay que reevaluar de manera periódica la eficacia de los opioides, considerando la derivación a la Unidad de Dolor cuando la dosis de morfina supere los 180 mg de morfina o equivalente (AU)

Introduction: The treatment of chronic noncancer pain (CNCP) with opioids is controversial because its effectiveness on the long-term outcomes has not been proven. The few trials focusing on dependence and addiction demonstrated increased mortality among CNCP patients receiving high doses of opioids. We therefore decided to analyze patients living in the northern area of the province of Cadiz who had exceeded the defined daily dose (DDD). The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults. Materials and methods: The northern area of Cadiz has a population of 360,000 inhabitants. Patients who exceeded the DDD of opioid in December 2014 were identified. The clinical history of each of these patients was studied retrospectively. Results: Twenty-three patients were identified who at least needed to double the DDD of their opioids. Consequently, the incidence of patients exceeding the DDD in the area under consideration was 1 per 15,000 inhabitants. Four of these were cancer patients (17 %) while the others suffered from CNCP (83 %). CNCP in these patients predominantly was of the osteo-articular type of pain (65 %), with the failed back syndrome, occurring in 8 cases (35 %), representing the most frequent diagnosis. Patient ages ranged from 34 to 84 Y with a median of 58 Y. The youngest of these (34 Y) requiring the largest amounts of drugs. The daily consumption of this youngest patient corresponded to 34 times the DDD, two other patients took 8 times the DDD, 1 four times, 4 three times and, finally, 11 patients needed to double the DDD. Todos los pacientes tomaban un opiáceo para el dolor irruptivo, la gran mayoría (17 pacientes) tomaban comprimidos de fentanilo oral transmucoso, effentora o actiq. Most of the patients were taking opioids for breaktrough pain, the vast majority of these (17 patients) using transmucosal fentanyl citrate formulations, i.e. Effentora® or Actiq®. Most of the patients took oxycodone (7) or transdermal fentanyl (8), as delayed action opioid. Two patients were not taking opioids with delayed action. It was noted that 11 patients (47 %) had a psychiatric history, 2 of them had a suicide attempt. Conclusions: The inappropriate use of opioids occurs mainly in non-cancer patients. There was a clear relationship with psychiatric disorders. There are relations of misuse and abuse of fast-acting drugs, especially fentanyls. Although the abuse of opioids is rare, so we must be cautious about starting treatment CNCP. It shoulf be bourne in mind that in these patients the effectiveness of opioids needs to be reassessed periodically, considering referral to the pain unit when opioid requirements exceeding 180 mg of morphine or its equivalent (AU)

Progress in stem cell therapy for major human neurological disorders.

Human neurological disorders such as Alzheimer's disease (AD), Parkinson's disease, stroke or spinal cord injury are caused by the loss of neurons and glial cells in the brain or spinal cord in the Central Nervous System (CNS). Stem cell technology has become an attractive option to investigate and treat these diseases. Several types of neurons and glial cells have successfully been generated from stem cells, which in some cases, have ameliorated some dysfunctions both in animal models of neurological disorders and in patients at clinical level. Stem cell-based therapies can be beneficial by acting through several mechanisms such as cell replacement, modulation of inflammation and trophic actions. Here we review recent and current remarkable clinical studies involving stem cell-based therapy for AD and stroke and provide an overview of the different types of stem cells available nowadays, their main properties and how they are developing as a possible therapy for neurological disorders.

Early mortality after cardiac transplantation: comparison of demographic, clinical, biological and surgical variables.

Cardiac transplantation is the last alternative for those patients in terminal heart failure. However, its mortality is high, and approximately 20% of patients die in the first month after cardiac transplantation. We retrospectively reviewed 116 patients transplanted at our center in the last 6 years. Data about clinical, biological and surgical variables were collected. We undertook a multivariate analysis in order to find differences between those patients who died in the first month and those who survived. We found statistically significant differences in total ischemia time (P = .036) and extracorporeal circulation time (P = .001), with those patients that died in the first month having longer times. We also found a statistically significant difference in the weight of the recipient, with those recipients that died in the first month having a higher weight (P = .03). No statistically significant differences were found in the other variables. Of particular interest was the absence of a significant association in both groups (survival <1 month vs survival >1 month) in the variables related to pulmonary hypertension (pulmonary half-time pressure, pulmonary systolic pressure, vascular pulmonary resistances).

Stereological study of the external urethral sphincter in the female urethra of the lamb: a new model for studies on urinary continence.

Some of the morphometrical features and functional properties of the lamb external urethral sphincter (EUS) were determined by means of ATPase histochemistry. In this study, eight female urethras of 2- to 3-month-old lambs were used. The samples were studied by using an unbiased stereological design and were statistically evaluated with a Kolmogorov-Smirnov test. Additionally, the mechanical activity of the different fibre types was analysed by measuring the isometric changes in tension induced by electrical field stimulation (EFS) of intrinsic nerves. The lamb EUS has an average fibre density of 1142.37 fibres/mm(2) (SD = 279.33). Our data showed the predominance of fast-twitch fibres or type II fibres, with a proportion of 30% (type I) and 70% (type II) in all cases. These percentages remained the same along the length of the EUS. However, a clear tendency to increase the number of both fibre types in the mid-EUS was observed. Interestingly, type I and II fibres are intermingled throughout the whole lamb EUS. Dynamic parameters of the contraction induced in lamb EUS preparations by EFS of intramural nerves, were intermediate between fast- and slow-twitch muscles. Furthermore, contractile activity showed no decrease in amplitude upon repetitive stimulation, suggesting the presence of a mixture of fibre types, in which fast but fatigue-resistant fibres (probably type IIA) seem to predominate. Our results indicate that lambs could be suggested as a new biological model to study those pathological processes, which involve the sphincteric regulation of the EUS.

Neurochemical heterogeneity of the thalamic reticular and perireticular nuclei in developing rabbits: patterns of calbindin expression.

The thalamic reticular nucleus (TRN) forms an essential part of the circuits that link the thalamus to the cortex, whereas the perireticular thalamic nucleus (PRN) consists of scattered neurons that are located in the internal capsule, in close relation to the TRN. A common feature of these nuclei in different species is the immunoreactivity for some calcium binding proteins with a developmental pattern of expression. In the present study, sections from rabbits at different ages were examined to determine the calbindin (CB) expression in the developing TRN and PRN at the first stages of development. These CB-expressing cells constitute an important subpopulation of neurons in the caudal half of the developing TRN. In the adult, there are still positive CB somata in the middle and caudal halves of the nucleus. In the PRN, where the developmental pattern of CB expression has not been described before, the number of CB perireticular cells decreases progressively. Our results, together with previous data in the rabbit suggest the existence of remarkable neurochemical heterogeneity in the TRN and PRN of the rabbit.

The thalamic reticular and perireticular nuclei in developing rabbits: patterns of parvalbumin expression.

Due to its strategic position, the thalamic reticular nucleus (TRN) plays an important role within the thalamo-cortical circuits. The perireticular thalamic nucleus (PRN) is a smaller group of cells, which is associated with the TRN and lies among the fibres of the internal capsule (IC). Studies of nuclei in rodents and carnivores have been conducted employing a number of different tools. The use of calcium-binding proteins is one example. It needs to be noted that rabbits have been regarded as intermediate between rodents and carnivores in relation to local GABAergic circuits. In the present study, sections from rabbits at different ages (prenatal, postnatal and adult) were examined to determine the parvalbumin (PV) expression in the developing TRN and PRN. In the TRN, there is one wave of PV expression during development, from caudal parts of the nucleus towards the rostral pole. At E22 there is already an incipient PV expression. In the adult stage, the TRN is completely positive to PV. The present study clearly indicates the presence of the PRN in the developing rabbit. The first PV positive cells were visible at E24, meanwhile the immunoreactivity was at its maximum at early postnatal stages (P0-P8). Two different types of perireticular cells in the IC were identified and the changes concerning neuronal morphology and orientation were described. The comparison between these results and previous data obtained in rats, ferrets or cats suggest that rabbits could represent an intermediate stage in the evolution of thalamic circuits and could be considered as useful neurobiological model.

Age-related changes in the ventricular system of the dog brain.

The cerebral ventricles represent cavities of the brain which are used for diagnostic purposes. Although a wide variety of age related changes have been described in the Central Nervous System (CNS) of many species, few studies about the effect of ageing on the canine brain have been published until now. However, to date there is no previous data concerning the ventricular system of dogs. The present study deals with the morphometry of the various parts of the cerebral cavities of the German Shepherd dog by means of Batson's casts and the possible changes which take place in the ventricular system with age and/or sex. In this study, two age groups were considered: young (2-5 years) and old (10-12 years). A total number of forty seven dogs (12 young males, 13 old males, 13 young females and 9 old females), weighing 34-42 kg, were used for experimentation. Our results describe the enlargement which takes place in the ventricular system with age, which is probably related to a general age-related atrophy of neural tissue. On the contrary, there are no remarkable changes related to sex. These age-related changes are similar to the best known changes which occur in the human species. Our data could corroborate the usefulness of the dog as a natural animal model for the study of normal ageing and neurodegenerative diseases.

Calbindin D28k and parvalbumin immunoreactivity in the rabbit superior colliculus: an anatomical study.

The expression pattern of two calcium binding proteins (CaBP), calbindin D28k (CB) and parvalbumin (PV), in the superior colliculus (SC) of the adult rabbit, as well as the morphology of the immunoreactive cells were examined. The study was performed on 12 rabbits. Coronal sections from postmortem SC were analyzed by light microscopy, and drawings of CaBP-labeled cells were obtained using a drawing tube. No previous information is available on either the CB/PV expression or the morphology of CB/PV positive cells in the SC of the adult rabbit. Therefore, in this study we show that CB neurons and neuropil form three main tiers: the first located within the stratum zonale (SZ) and the upper part of the stratum griseum superficiale (SGS), the second located within the stratum griseum intermedium (SGI), and the third, located within the medial and central areas of the stratum griseum profundum (SGP). In contrast to this layer labeling, almost no CB-positivity is found within the other collicular layers. On the other hand, the densest concentration of PV labeled cells and terminals is found within a single dense tier that spanned the ventral part of the startum griseum superficiale (SGS) and the dorsal part of the stratum opticum (SO). Anti-PV neurons are also scattered through the deeper layers below the dense tier. In contrast, almost no anti-PV labeled neurons or neuropil are found within the stratum zonale (SZ) and upper SGS. This distribution represents a new pattern of sublamination in the SC of this species. All the previously described cell types in other mammals are observed in the rabbit SC: marginal cells, horizontal cells, pyriform cells, narrow-field vertical cells, wide-field vertical cells, and stellate/multipolar cells. Detailed drawings of all these cellular types are represented to show their complete morphology. The results of this study indicate that both CB and PV are present in a variety of neurons, which present a number of homologies between mammals, but have a different location and/or distribution, according to the different species. These findings are thus relevant to better understand the organisation of the SC in mammals.

A quantitative study of ganglion cells in the goat retina.

As in a number of mammals, the most prominent feature of the ganglion-cell layer in the retina of the murciano-granadina goat is an increase in the density of ganglion cells in the central area, as well as a concentration along a ridge extending horizontally across the retina, below the optic disc, and in the upper temporal retina. Thus, there is an area of maximum density and two streaks that are known as the 'horizontal' and 'vertical' streak. The isodensity lines of ganglion-cell distribution is toughly concentric, with their values varying from 304 cells/mm2 in the periphery to 3592 cells/mm2 in the central area, with the cells densely packed. There were some individual differences amongst the animal studied, although all of them were purebred animals.

Spinal cord central canal of the German shepherd dog: morphological, histological, and ultrastructural considerations.

This study deals with some macroscopical, microscopical, and ultrastructural aspects of the spinal cord central canal of the German shepherd dog. The caudal end of the spinal cord is constituted by the conus medullaris, which may extend to the first sacral vertebra, the terminal ventricle, and the filum terminale. The latter structure is considered as internum (second to third sacral vertebrae) or externum (fifth caudal vertebra), according to its relation to the dura mater. Occasionally, there is a second anchorage which is close to the level of the sixth caudal vertebra. The central canal is surrounded by a ciliated ependymal epithelium, which differs depending upon the levels. The most caudal part of the filum terminale bears a columnar ciliated ependymal epithelium surrounded by two layers of glia and pia mater, which separate the central canal from the subarachnoid space. Microfil injections show a communication between the cavity and the subarachnoid space, as the plastic is able to pass through the ependymal epithelium. At the level of the terminal ventricle there are real separations of the ependymal epithelium, which seem to connect the lumen of the spinal canal with the subarachnoid space. These structures probably constitute one of the drainage pathways of the cerebrospinal fluid. The diameter of the central canal is related to the age of the animal. However, even in very old animals the spinal cord central canal reaches the tip of the filum terminale and remains patent until death. At the ultrastructural level the ependymal cells present villi, located on cytoplasmic projections, cilia, dense mitochondria, and oval nuclei.

A quantitative study of ganglion cells in the German shepherd dog retina.

As in the number of mammals, the most prominent feature of the ganglion-cell layer in the retina of the German shepherd dog is the sharp increase in the density of ganglion cells in the central area. There is an area of maximum density and also a 'cat-like' visual streak, located dorsal to the optic disc. The isodensity lines of ganglion-cell distribution is roughly concentric. Their values vary from 5300-13,000 cells/mm2 in the central area, with the cells densely packed, to 1000 cells/mm2 or less in the periphery, where the cells are sparsely distributed. There were some individual differences amongst the animals studied, although all of them were pure-bred dogs. This suggests that the configuration of the retina in the canine species is not only dependent on the breed itself but also on some other parameters such as phylogenetic heritage, environment, aptitude, lifestyle, or even training.