[Hyperammonaemic encephalopathy due to valproic acid]. / Encefalopatía hiperamoniémica por ácido valproico.

INTRODUCTION: One of the less frequent idiosyncratic side effects of valproic acid (VPA) is encephalopathy. Here we report one case. CASE REPORT: An 83-year-old female with no relevant past history, who received treatment with VPA following a post-traumatic subarachnoid haemorrhage and two convulsive seizures. A few days later, she was admitted to the Emergency Department because of a progressive clinical picture of mental slowness, nauseas and apathy. The systemic examination was normal. Neurologically, the most striking features were inattention and disorientation, despite her having a good level of consciousness, and mental confusion. Levels of VPA were within the below-therapeutic range and the basic lab findings (including hepatic profile) were normal, except for hyperammonaemia. Neuroimaging studies and cerebrospinal fluid analysis were also normal. An electroencephalogram (EEG) showed signs of severe diffuse encephalopathy with slow, triphasic waves and a non-convulsive epileptic status was therefore ruled out. After withdrawing the VPA, the patient's condition improved until her basal situation was reached in 48 hours and the EEG became normal, as did her ammonium levels. CONCLUSION: When faced with a patient who has recently been taking VPA and who presents a clinical picture of mental confusion, the possibility of encephalopathy due to said drug must be taken into consideration.

Encefalopatía hiperamoniémica por ácido valproicomage / Hyperammonaemic encephalopathy due to valproic acid

Uno de los efectos adversos idiosincrásicos menos frecuentes del ácido valproico (VPA) es la encefalopatía.Presentamos un caso. Caso clínico. Mujer de 83 años sin antecedentes de interés, que tras sufrir una hemorragiasubaracnoidea postraumática y dos crisis epilépticas, recibe tratamiento con VPA. Pocos días después ingresa en Urgencias por cuadro progresivo de torpeza mental, náuseas y apatía. La exploración sistémica era normal. Neurológicamente destacaba la inatención y la desorientación a pesar de un buen nivel de conciencia y la confusión mental. Los niveles de VPA estabanen rango infraterapéutico y la analítica básica (incluido el perfil hepático) era normal, salvo por una hiperamoniemia. También eran normales los estudios de neuroimagen y el análisis del líquido cefalorraquídeo. Un electroencefalograma (EEG) reveló signos de encefalopatía difusa grave con ondas trifásicas y ondas lentas, por lo que se descartó un estado epiléptico noconvulsivo. Tras retirar el VPA, la paciente mejoró hasta su situación basal en 48 horas, y el EEG se normalizó, al igual que los niveles de amonio. Conclusión. Ante cualquier paciente al que se le haya instaurado VPA recientemente, y que presente uncuadro de confusión mental, es preciso considerar una encefalopatía por dicho fármaco

One of the less frequent idiosyncratic side effects of valproic acid (VPA) is encephalopathy. Here wereport one case. Case report. An 83-year-old female with no relevant past history, who received treatment with VPA following a post-traumatic subarachnoid haemorrhage and two convulsive seizures. A few days later, she was admitted to the Emergency Department because of a progressive clinical picture of mental slowness, nauseas and apathy. The systemic examination wasnormal. Neurologically, the most striking features were inattention and disorientation, despite her having a good level of consciousness, and mental confusion. Levels of VPA were within the below-therapeutic range and the basic lab findings (including hepatic profile) were normal, except for hyperammonaemia. Neuroimaging studies and cerebrospinal fluid analysiswere also normal. An electroencephalogram (EEG) showed signs of severe diffuse encephalopathy with slow, triphasic waves and a non-convulsive epileptic status was therefore ruled out. After withdrawing the VPA, the patient’s condition improved untilher basal situation was reached in 48 hours and the EEG became normal, as did her ammonium levels. Conclusion. When faced with a patient who has recently been taking VPA and who presents a clinical picture of mental confusion, the possibility of encephalopathy due to said drug must be taken into consideration

Adsorption of methabenzthiazuron on six allophanic and nonallophanic soils: effect of organic matter amendment.

This article reports on methabenzthiazuron [1-(1,3-benzothiazol-2-yl)-1,3-dimethylurea] (MBT) adsorption process on six agricultural allophanic and nonallophanic soils. The effect of amendment with exogenous organic matter was also studied. Adsorption kinetic fits an hyperbolic model. MBT adsorption reached an apparent equilibrium within 2 h and followed a second-order reaction. The maximum adsorbed amounts for natural soils ranged from 32 to 145 microg g(-1). Rate constants were considered relatively low (0.27-1.5 x 10(-4) [microg g(-1)](1-n) s-1); the slow process was attributed to a combined effect of difussion and adsorption. MBT adsorption fits the Freundlich model with r values > or =0.998 at P < or = 0.001 significance levels. Kf and Freundlich exponents (l/n) ranged from 5.3 to 82.1 cm3 g(-1) and from 0.66 to 0.73, respectively. Kf values for soils with a low organic matter content were lower than that obtained from the only typical allophanic soil derived from volcanic ash under study. Lineal regression analysis between Kf and organic matter content of nonallophanic soils gave a correlation coefficient of 0.980 (P = 0.02). Dispersion of Kd values together with close values of K(OM) indicate that organic matter (OM) was the principal component responsible for MBT adsorption in unamended soils. Addition of peat decreased soil pH and increased adsorption capacity for allophanic and nonallophanic soils. Kinetic experiments showed enhancements of Xmax values and lower rate constants.

Absence of the superior vena cava: difficulties for pacemaker implantation.

Endocardial pacemaker electrode implantation can be difficult in patients with anomalous superior vena cava (SVC). Venography and CAT scan showed that the patient lacked SVC venous drainage and that systemic veins drained into the inferior vena cava through the azygos vein. A temporary stimulation electrode was placed by puncture of the femoral vein, permanent stimulation by venotomy of the epigastric vein, with the electrode inserted through the external iliac vein.

Diagnosis of secondary myelodysplastic syndromes (MDS) following autologous transplantation should not be based only on morphological criteria used for diagnosis of de novo MDS.

Secondary myelodysplastic syndromes (MDS) are increasingly being reported after autologous transplantation. Transient dysplastic changes have also been observed after this type of treatment. However, to the best of our knowledge no systematic morphological analysis has been performed to determine the influence of stem cell transplantation on bone marrow morphology. In 53 patients undergoing autologous transplantation, we evaluated the bone marrow, before and 6 and 12 months after the transplant, in order to analyze the appearance of dyshemopoietic changes, assessed according to a pre-established score. We also studied 25 bone marrow samples obtained at the time of diagnosis, prior to treatment, but we did not find morphological atypia. Six months after transplant, cellularity and thrombopoiesis had decreased in 38% and 49% of patients respectively, although 1 year after the process they were normal in most cases. Myelodysplasia was already present in bone marrow before transplantation and continued to be in evidence for a long time afterwards. This suggests that chemotherapy and radiotherapy used prior to transplantation are responsible for dysplastic changes. The myeloid line was the most affected with 100% of patients showing dysgranulopoiesis 1 year after autografting. Cytopenias were observed in 51% and 44% of patients 6 and 12 months after transplantation. Moreover, concomitant presence of cytopenia and myelodysplasia was observed in 37.7% of patients at 6 months after transplantation and 25% at 12 months, and therefore they could be diagnosed with MDS. These data contrast with the incidence of secondary MDS reported in earlier publications. According to these findings, the value of the French-American-British Co-operative Group criteria for the diagnosis of MDS following autologous transplantation is questionable. Moreover, since dyshemopoietic features are almost always present after autologous transplant, morphological criteria are not useful for early recognition of patients with secondary MDS after transplantation.

Randomized prospective study comparing cost-effectiveness of teicoplanin and vancomycin as second-line empiric therapy for infection in neutropenic patients.

BACKGROUND AND OBJECTIVE: The current health-care philosophy dictates that new therapies should always be evaluated for their economic impact. Along with acquisition cost, the cost of delivery, monitoring, adverse effects and treatment failure must also be considered when determining the total cost of therapy. These auxiliary costs can be significant and greatly alter the overall cost of a drug treatment. We conducted a prospective randomized study to evaluate the efficacy, safety and cost of vancomycin and teicoplanin therapy in patients with neutropenia, after the failure of empirical treatment with a combination of piperacillin/tazobactam and amikacin. DESIGN AND METHODS: Seventy-six febrile episodes from 66 patients with hematologic malignancies under treatment, neutropenia (neutrophils <500/mm3) and fever (38 degrees C twice or 38.5 degrees C once) resistant to the combination piperacillin/tazobactam and amikacin were included in the study. RESULTS: Primary success of second-line therapy was obtained in 35 cases (46%) with no significant difference between vancomycin (17/38) and teicoplanin arms (18/38). No difference in renal or hepatic toxicity related to the antibiotic therapy was observed. The average cost per patient according to glycopeptide used was $450+/-180 for the teicoplanin group and $473+/-347 for the vancomycin group. Interestingly, in the teicoplanin arm, drug acquisition accounted for 97% of the total cost, while in the vancomycin arm administration and monitoring play an important role in overall costs. INTERPRETATION AND CONCLUSIONS: In conclusion, our pharmacoeconomic analysis demonstrates that teicoplanin and vancomycin can be administered in neutropenic hematologic patients with similar efficacy and direct costs.