Search

Bleeding is the most common preventable cause of death in trauma patients. Acute traumatic coagulopathy is a specific condition with a different pathophysiology from other causes of the massive bleeding. An early identification of the coagulopathy is fundamental to implementing rapid treatment. There have been many changes in the management of massive hemorrhage, for example, the administration of the tranexamic acid and the use of balanced transfusion ratio. This review presents these practical points, some of them with scientific evidence, in order to achieve a beneficial effect for patient outcomes.

SummaryEfficacy and tolerability of tiagabine was evaluated in patients with non-controlled partial seizures in a multicentre, open-label, parallel group study. Tiagabine was administered either two (b.i.d.) or three times daily (t.i.d.) as adjunctive therapy and titrated stepwise to a target of 40mg/day during a 12-week, fixed-schedule titration period; this was followed by a 12-week flexible continuation period. The primary efficacy endpoint was the proportion of patients completing the fixed-schedule titration period. A total of 243 patients were randomised and received treatment, 123 to b.i.d. and 120 to t.i.d. dosing. Fewer patients in the b.i.d. (76 and 62%) than in the t.i.d. (87 and 72%) group completed the fixed-schedule titration period (OR: 0.562; 95% CI: 0.309–1.008; P=0.0532). The median percentage decrease in all types of seizure (excluding status epilepticus) during the fixed schedule titration period was 33.4% for the b.i.d. and 23.8% for the t.i.d. groups (P=0.9634; Van Elteren's test). The proportion of responders was similar for the b.i.d. and t.i.d. groups. There were no significant differences between dosage regimens in the change in median seizure rates from baseline. Adverse events were more frequent during the titration than the continuation period. Most events were mild and related to the central nervous system. Although their incidence was similar between treatment groups, severity was more frequent in the b.i.d. group. Our results suggest that during titration tiagabine is better tolerated with t.i.d. dosing, but during long-term maintenance, a t.i.d. schedule is as effective and well tolerated as b.i.d.

To evaluate Mean Platelet Volume (MPV) and Platelet Distribution Width (PDW) in non-diabetic subjects, according to obstructive sleep apnoea syndrome (OSAS) severity and the associations of these indices with anthropometric characteristics and parameters of breathing function during sleep.We included 610 non-diabetic subjects with suspected OSAS, evaluated by polysomnography. According to their apnoea-hypopnoea index (AHI), patients were divided into Group A (n=148) with AHI5/h; Group B (n=121) with AHI: 5-14.9/h; Group C (n=85) with AHI: 15-29.9/h and Group D (n=256) with AHI ≥ 30/h. MPV and PDW were measured using an automated blood cell counter.MPV was significantly higher in group D (mean value 12.1 ± 1.3 fl) than in groups A (9.8 ± 1.1 fl), B (9.8 ± 1.6 fl), and C (11.5 ± 1.3 fl) (p0.001). The same pattern was observed in PDW values (15.9 ± 2.2 fl for group D and 13.2 ± 2.2 fl for group A, 14.1 ± 2.8 fl for group B, and 15 ± 2.2 fl for group C, p0.001). Significant correlations were seen between MPV and AHI (p0.001), average pulse oxygen saturation (SpO(2)) (p0.001), minimum SpO(2) (p0.001) and percent of the total sleep time with SpO(2) lower than 90% (t90%) (p0.001) during sleep, Arousal Index (p0.001) and Epworth sleepiness scale (ESS) (p=0.028). Similarly, PDW was correlated with AHI (p0.001), average SpO(2) (p=0.001), minimum SpO(2) (p0.001), t90% (p=0.002), and Arousal Index (p0.001).MPV and PDW are higher in non-diabetic patients with severe OSAS and are correlated with different parameters of breathing function during sleep.

Massive hemolysis secondary to sepsis caused by Clostridium perfringens is a rare entity but appears fairly often in the literature. In nearly all published reports, the clinical course is rapid and fatal. We describe the case of a 75-year-old woman with diabetes who was admitted with symptoms consistent with acute cholecystitis. Deteriorating hemodynamics and laboratory findings were consistent with intravascular hemolysis, coagulation disorder, and renal failure. Gram-positive bacilli of the Clostridium species were detected in blood along with worsening indicators of hemolysis. In spite of antibiotic and surgical treatment, hemodynamic support and infusion of blood products, the patient continued to decline and died in the postoperative recovery unit 14 hours after admission. Mortality ranges from 70% to 100% in sepsis due to Clostridium perfringens, and risk of death is greater if massive hemolysis is present, as in the case we report. Only a high degree of clinical suspicion leading to early diagnosis and treatment can improve the prognosis. This bacterium should therefore be considered whenever severe sepsis and hemolysis coincide.

We describe a series of 16 cases in which recombinant activated factor VII (rFVIIa) was used in our postanesthetic recovery unit. The mean age of the patients was 53.5 years (range, 30-84 years). Eleven were men and 5 women. The mean dose of rFVIIa used was 75 microg x kg(-1) (range, 60-90 microg x kg(-1)) and 25% of the patients needed a second dose. All the patients had postoperative bleeding, 62.5% after general surgery, 25% after a liver transplant, and 12.5% after a lung transplant. rFVIIa therapy was effective in 66% of the patients and no adverse thrombotic events related to treatment were observed. rFVIIa can be an efficacious therapeutic option for bleeding and coagulation disorders that are refractory to conventional replacement therapy. Approval to use rFVIIa in this setting and the establishment of indications should be based on further research.

The objective of this work was to produce a scientific evidence-based guide to clinical practice dealing with the basic questions concerning the treatment of epilepsy.A committee of 11 experts belonging to the Andalusia Epilepsy Society, made up of six neurologists, three neuropaediatricians, one neurosurgeon and a pharmacologist, all of whom were deeply involved and experienced in epilepsy, conducted a thorough review of the literature in search of all the evidence available on the proposed subject matter. The following databases were used: MEDLINE, Cochrane Library and the databases of several clinical practice guidelines (National Guideline Clearinghouse, National Institute of Clinical Excellence and the American Academy of Neurology's Clinical Guidelines). The Guide was set out in seven sections and was published in four parts. From a total number of 187 relevant documents, the committee found 63 examples of scientific evidence and 91 therapeutic recommendations. These were tabulated and classified according to the European Federation of Neurological Societies' criteria for producing Clinical Practice Guidelines.The results of this survey provide scientific evidence-based clinical guidelines that are useful, simple and applicable at different levels of health care.

The objective of this work was to produce a scientific evidence-based guide to clinical practice dealing with the basic questions concerning the treatment of epilepsy.A committee of 11 experts belonging to the Andalusia Epilepsy Society, made up of six neurologists, three neuropaediatricians, one neurosurgeon and a pharmacologist, all of whom were deeply involved and experienced in epilepsy, conducted a thorough review of the literature in search of all the evidence available on the proposed subject matter. The following databases were used: MEDLINE, Cochrane Library and the databases of several clinical practice guidelines (National Guideline Clearinghouse, National Institute of Clinical Excellence and the American Academy of Neurology's Clinical Guidelines). The Guide was set out in seven sections and was published in four parts. From a total number of 187 relevant documents, the committee found 63 examples of scientific evidence and 91 therapeutic recommendations. These were tabulated and classified according to the European Federation of Neurological Societies' criteria for producing Clinical Practice Guidelines.The results of this survey provide scientific evidence-based clinical guidelines that are useful, simple and applicable at different levels of health care.

The objective of this work was to produce a scientific evidence-based guide to clinical practice dealing with the basic questions concerning the treatment of epilepsy.A committee of 11 experts belonging to the Andalusia Epilepsy Society, made up of six neurologists, three neuropaediatricians, one neurosurgeon and a pharmacologist, all of whom were deeply involved and experienced in epilepsy, conducted a thorough review of the literature in search of all the evidence available on the proposed subject matter. The following databases were used: MEDLINE, Cochrane Library and the databases of several clinical practice guidelines (National Guideline Clearinghouse, National Institute of Clinical Excellence and the American Academy of Neurology's Clinical Guidelines). The Guide was set out in seven sections and was published in four parts. From a total number of 187 relevant documents, the committee found 63 examples of scientific evidence and 91 therapeutic recommendations. These were tabulated and classified according to the European Federation of Neurological Societies' criteria for producing Clinical Practice Guidelines.The results of this survey provide scientific evidence-based clinical guidelines that are useful, simple and applicable at different levels of health care.

The objective of this work was to produce a scientific evidence-based guide to clinical practice dealing with the basic questions concerning the treatment of epilepsy.A committee of 11 experts belonging to the Andalusia Epilepsy Society, made up of six neurologists, three neuropaediatricians, one neurosurgeon and a pharmacologist, all of whom were deeply involved and experienced in epilepsy, conducted a thorough review of the literature in search of all the evidence available on the proposed subject matter. The following databases were used: MEDLINE, Cochrane Library and the databases of several clinical practice guidelines (National Guideline Clearinghouse, National Institute of Clinical Excellence and the American Academy of Neurology's Clinical Guidelines). The Guide was set out in seven sections and was published in four parts. From a total number of 187 relevant documents, the committee found 63 examples of scientific evidence and 91 therapeutic recommendations. These were tabulated and classified according to the European Federation of Neurological Societies' criteria for producing Clinical Practice Guidelines.The results of this survey provide scientific evidence-based clinical guidelines that are useful, simple and applicable at different levels of health care.

A 35-year-old woman was scheduled for laparoscopic removal of an ovarian tumor. Intravenous metamizol was administered and when pneumoperitoneum was performed she developed severe hypotension and bronchospasm. Anaphylactic reaction was suspected, all drugs were suspended, and 2 doses of intravenous adrenalin (0.2 and 1 mg) were injected followed by continuous perfusion. Because response was slow and given the unknown origin of the tumor, the possibility of a carcinoid crisis was considered. When an intravenous bolus dose of octreotide was administered, pressure recovered, patient was extubated and could be transferred asymptomatic to the recovery ward. Tests later ruled out carcinoid syndrome, whereas tryptase levels in blood extracted during surgery and allergy tests confirmed an anaphylactic reaction to metamizol. Carcinoid crisis can be difficult to distinguish from anaphylactic reaction because the clinical pictures are similar. Anesthetic management of carcinoid crisis has been facilitated by administration of octreotide. Less is known about the use of octreotide to treat hypotension in patients with autonomic neuropathy based mainly on the drug's ability to produce splanchnic vasoconstriction. This is probably the reason why octreotide resolved our patient's shock in a context of systemic vasodilation caused by the anaphylactic reaction.

To review the present knowledge related with gender differences in drug effects, with special emphasis concerning antiepileptic drugs (AEDs).Women and men differ in their response to drugs and these differences can be sometimes clinically relevant. Adverse drug reactions are noticeably more frequent in women, probably due to a combination of cultural and biological factors. Gender differences related to antiepileptic treatment have been observed concerning alterations in bone mineral density and lipid profile due to several AEDs, lamotrigine induced rash and visual field loss caused by vigabatrin. It is also important to study potential drug interactions between AEDs and contraceptives, as well as hormonal replacement therapy (HRT). At this respect, the influence of AEDs on the pharmacokinetics and efficacy of contraceptives are well known, but no data are available concerning the effect of contraceptives on AEDs pharmacology. Likewise, data relative to the eventual interactions arising between HRT and anticonvulsant are lacking.The knowledge about gender differences in the adverse drug reactions and interactions of AEDs is still limited; more information is necessary to optimize anticonvulsant treatment in epileptic women.

The prognosis of rhabdomyolysis is conditioned by the development of acute renal failure which depends of quick preventive measures. Rhabdomyolysis is diagnosed by measuring plasma creatinkinase and it is usually suspected by the presence of previous putative causal factors like traumatisms. Non traumatic rhabdomyolysis usually lacks of clinical relevant antecedents and the syndrome should be suspected by patient clinical symptomatology; unfortunately, this one has been scarcely studied.To describe the semiology observed in patients experiencing non traumatic rhabdomyolysis and to identify which symptoms induced to the subject to go to the emergency room in order to facilitate the diagnostic procedure.We studied the patients with non traumatic rhabdomyolysis (creatinkinase1,000 IU/l) which attended the emergency room in a one year period. We collected data regarding their clinical symptomatology as well as which of them was responsible of his/her coming to the emergency unit. Symptoms were classified in four groups: muscular, urinary, neurological and others.We evaluated 49 patients. The relative frequency of each kind of symptoms was the following: muscular 51%, urinary 18%, neurological 67%, and others 47%. The absolute frequency of the symptoms which caused the consultation were: muscular 16%, urinary 2%, neurological 48%, others 22%, muscular and neurological associated 6%, and neurological and other associated 6%.CK serum levels should be measured in all of the patients attending the emergency unit who exhibit some type of neurological manifestation.

Tiagabine is a new antiepileptic drug which acts by blocking neuronal and glial GABA uptake and it is indicated in the treatment of partial epilepsies. Its pharmacokinetics is lineal, being extensively metabolized in the liver by means of CYP3A4 isoenzyme. Plasma elimination half life ranges between 5-8 hours in healthy volunteers, being markedly reduced when the drug is administered concomitantly with enzyme-inducing antinconvulsants. Tiagabine does not induce nor inhibit hepatic enzymes and, consequently, it does not modify the kinetics of simultaneously prescribed antiepileptic drugs. No relevant kinetic differences have been observed between adults and elderly subjects. Renal impairment does not alter the pharmacokinetic profile of tiagabine; hepatic disease, however, significantly reduces tiagabine elimination and lower daily doses of the drug are necessary in these patients. Although tiagabine elimination half life is short, it has been ascertained that therapeutic efficacy is similar when administered in 2 or 4 divided doses. Tiagabine is usually well tolerated; its most frequent side effects include dizziness, asthenia, nervousness, tremor, diarrhea and depressed mood.

GABA is the major inhibitory neurotransmitter in the brain. It is synthesized by the action of glutamic decarboxylase on glutamate and preferently metabolized by the action of GABA transaminase; it experiences neuronal and glial uptake mediated by four types of highly selective transporters.The hypothesis that abnormalities in GABAergic function can be involved in the physiopathology of epilepsy, specially those of partial origin, is supported by data from proceeding from experimental and human epilepsies, as well as by the fact that agents that inhibit GABAergic function exert a proconvulsant action whereas gabaergic agents frequently act as anticonvulsant. On the last years, therefore, substances with gabaergic activity have been investigated as potential antiepileptic drugs.Tiagabine, a nipecotic acid derivative, selectively inhibits GABA neuronal and glial uptake by blocking one of its transporters. Its antiepileptic activity has been assessed in different experimental model and it is currently used in the clinical treatment of partial epilepsies.

Gentamicin therapy was monitored in 30 patients with severe infection and other concomitant disease states. The application of the nomogram of Hull and Sarubbi [6] produced good plasma levels and disappearance of the infective agent without evidence of drug toxicity in 70% of patients. The remaining 30% did not respond satisfactorily to the treatment and showed low drug serum concentrations; all of them had heavy fluid losses; when we modified their treatment, outside of the nomogram guidelines, we observed a better response. Since gentamicin distributes essentially in extracellular water, subjects who have alterations of body fluids regulation should be carefully controlled.

The pharmacokinetic and clinical efficacy of three theophylline slow-release formulations was studied in 29 children suffering chronic bronchial asthma. Theophylline loading dose was of 6 mg/kg; maintenance dose was adjusted according to therapeutic effect and drug plasma concentrations and ranged to 11.1 to 31.3 mg/kg/daily (means = 22.32 +/- 6.6 mg/kg/daily). Peak theophylline plasma levels were 13.38 +/- 4.83 micrograms/ml and through plasma levels were 8.73 +/- 3.78 micrograms/ml. No difference was found among theophylline formulations for clinical response nor kinetic parameters. Drug plasma half-life varied from 2.9 to 18.2 hr (means = 8.85 +/- 3.64 hr). Theophylline total body clearance and apparent volume of distribution exhibited a marked decrease during chronic drug administration in relation to the values observed after intake of the loading dose. Twenty three of the children reached a good degree of control of bronchospasm and did not require any associated medication.