Management of angioedema without urticaria in the emergency department

Angioedema refers to a localized, transient swelling of the deep skin layers or the upper respiratory or gastrointestinal mucosa. It develops as a result of mainly two different vasoactive peptides, histamine or bradykinin. Pathophysiology, as well as treatment, is different in each case; nevertheless, the resulting signs and symptoms may be similar and difficult to distinguish. Angioedema may occur at any location. When the affected area involves the upper respiratory tract, both forms of angioedema can lead to an imminent upper airway obstruction and a life-threatening emergency. Emergency physicians must have a basic understanding of the pathophysiology underlying this process. Angioedema evaluation in the emergency department (ED) should aim to distinguish between histamine- and bradykinin-induced angioedema, in order to provide appropriate treatment to patients. However, diagnostic methods are not available at the ED setting, neither to confirm one mechanism or the other, nor to identify a cause. For this reason, the management of angioedema should rely on clinical data depending on the particular features of the episode and the patient in each case. The history-taking should be addressed to identify a possible etiology or triggering agent, recording complete information for an ulterior diagnostic study in the outpatient clinic. It is mandatory quickly to recognize and treat a potential life-threatening upper airway obstruction or anaphylaxis. This review focuses on the underlying mechanisms and management of histamine- and bradykinin-induced angioedema at the emergency department and provides an update on the currently available treatments.

Prevalence of BRCA1 and BRCA2 mutations in unselected breast cancer patients from Peru

The prevalence of BRCA1 and BRCA2 mutations among breast cancer patients in Peru has not yet been explored. We enrolled 266 women with breast cancer from a National cancer hospital in Lima, Peru, unselected for age or family history. DNA was screened with a panel of 114 recurrent Hispanic BRCA mutations (HISPANEL). Among the 266 cases, 13 deleterious mutations were identified (11 in BRCA1 and 2 in BRCA2), representing 5% of the total. The average age of breast cancer in the mutation-positive cases was 44 years. BRCA1 185delAG represented 7 of 11 mutations in BRCA1. Other mutations detected in BRCA1 included: two 2080delA, one 943ins10, and one 3878delTA. The BRCA2 3036del4 mutation was seen in two patients. Given the relatively low cost of the HISPANEL test, one should consider offering this test to all Peruvian women with breast or ovarian cancer.

Factors influencing response to intravenous lacosamide in emergency situations: LACO-IV study

Status epilepticus (SE) and acute repetitive seizures (ARSs) frequently result in emergency visits. Wide variations in response are seen with standard antiepileptic drugs (AEDs). Oral and intravenous (IV) formulations of lacosamide are approved as adjunctive therapy in the treatment of partial-onset seizures in adults and adolescents. The aim of the retrospective multicenter observational study (LACO-IV) was to analyze data from a large cohort of patients with SE or ARSs of varying severity and etiology, who received IV lacosamide in the emergency setting. Patient clinical data were entered into a database; lacosamide use and efficacy and tolerability variables were analyzed. In SE, IV lacosamide tended to be used mainly in nonconvulsive status epilepticus as second- or third-line treatment. The proportion of patients with no seizures when IV lacosamide was the last drug administered was 76.5% (70.9% SE and 83.7% ARSs). The rate of seizure cessation ≤ 24 h after IV lacosamide administration was 57.1% (49.1% SE and 67.4% ARSs). Of the factors analyzed, a shorter latency from seizure onset to IV lacosamide infusion influenced treatment response significantly. A nonsignificant tendency towards a higher response was seen with lacosamide dose >200mg versus ≤ 200 mg. Analysis of response according to mechanism of action showed no significant differences in response to IV lacosamide in patients receiving prior sodium channel blocker (SCB) or non-SCB AEDs in the overall or SE population; however, in ARSs, a tendency towards a higher response was observed in those receiving non-SCB AEDs. The frequency and nature of adverse events observed were in line with those reported in other studies (somnolence being the most frequent). In the absence of randomized prospective controlled studies of IV lacosamide, our observations suggest that IV lacosamide may be a potential alternative for treatment of SE/ARSs when seizures fail to improve with standard AEDs or when AEDs are contraindicated or not recommended.

Long-term safety and efficacy of eslicarbazepine acetate in patients with focal seizures: results of the 1-year ESLIBASE retrospective study

BACKGROUND

Eslicarbazepine acetate (ESL) is a new antiepileptic drug (AED) licensed as adjunctive therapy in adults with partial-onset or focal seizures.

OBJECTIVE

To evaluate in a clinical practice setting the long-term efficacy and safety of ESL in patients with focal seizures.

METHODS

ESLIBASE was a retrospective study that included all patients with focal seizures who started ESL between January 2010 and July 2012 at 12 hospitals. ESL was prescribed individually according to real-life practice. Efficacy and safety were evaluated over 1 year. Switching from carbamazepine (CBZ) and oxcarbazepine (OXC) was assessed.

RESULTS

Three hundred and twenty-seven patients were included; 78% of patients were taking ≥2 other AEDs at baseline. Most (87%) began ESL because of poor seizure control and 13% because of adverse events (AEs) with CBZ or OXC. After 1 year, 237 patients (72.4%) remained on ESL. At 3, 6 and 12 months, the responder rate was 46.3%, 57.9%, and 52.5%, and 21.0%, 28.0%, and 25.3% of patients were seizure free. The responder rate significantly increased when ESL was combined with a non-sodium channel-targeting drug (non-SC drug) (66.7%) versus an SC drug (47.7%; p<0.001). At 12 months, 40.7% of patients had ≥1 AE; AEs led to treatment discontinuation in 16.2%. Dizziness, nausea, and somnolence were the most common AEs. The tolerability profile improved in >50% of the patients who switched from CBZ or OXC to ESL because of AEs.

CONCLUSIONS

ESL was well tolerated and effective in a real-world setting over 1 year. Side-effect profile improved when OXC and CBZ recipients were switched to ESL.

Combination of corpus callosotomy and vagus nerve stimulation in the treatment of refractory epilepsy

BACKGROUND

Palliative techniques such as partial corpus callosotomy (CC) and vagus nerve stimulation (VNS) may be effective for adequate control of seizures in pharmacoresistant patients who are not candidates for resective surgery.

OBJECTIVE

The objective of this study was to analyze the efficacy of the combination of these two techniques in patients where the first surgery had not achieved adequate control.

MATERIALS AND METHODS

This is a retrospective review of 6 patients with refractory epilepsy in which both types of surgery were performed, CC and VNS. We analyzed variables such as age, sex, age at onset of epilepsy, seizure types, electroencephalogram and magnetic resonance imaging results, and number of pre- and postoperative seizures.

RESULTS

Three patients first underwent VNS and then CC, and 3 patients were treated in reverse order. All patients had some improvement after the first surgery, but they continued to experience persistent falls, so a second palliative technique was used. The mean improvement after both surgeries was 89% (90% in patients first receiving CC and 87% in patients who first underwent VNS).

CONCLUSIONS

In adequately studied patients who are not optimal candidates for resective surgery, palliative surgery is a choice. The combination of VNS and CC shows good results in our series, although the right order to perform both procedures has not been defined. These results should be confirmed in a larger group of patients.

[Descriptive study of behavioural disorders in mild cognitive impairment]

INTRODUCTION

Mild cognitive impairment (MCI) is defined as an abnormality in cognitive function not provoking a noticeable disability in activities of daily living in the affected person. In a group of patients with MCI, we propose to observe and to quantify the presence of behavioral disorders, using the neuropsychiatric inventory (NPI).

PATIENTS AND METHODS

NPI is a known instrument in evaluation of this kind of disorders in patients with dementia, and it is a semi structured interview with a relevant informer or relative to the patient. NPI was applied to a series of 100 cases (61 women and 39 men) of MCI, diagnosed as usual in our settings. Mean age was 74.3 +/- 10 years, and mean MEC (Spanish modified version of MMSE) 25.57 +/- 4.2 (over a maximum of 35 points).

RESULTS

Most prevalent disorder was depression, in 36 % of cases, and other frequent findings were irritability (35%), anxiety (24%) and apathy (19%). In some cases, agitation (4%), abnormal motor behavior (3%) and delusions (1%) were detected. Hallucination, disinhibition and euphoria or elation were not detected in this series.

CONCLUSION

Data show a certain similarity with occidental culture environment, globally considered. The presence of behavioral and psychological disorders in patients with MCI could be a marker for later development of dementia. NPI can be a usable tool when detection and evaluation of these symptoms is required.

Explaining the end of the hominoid experiment in Europe

The Vallesian Crisis involved the extinction of most of the hominoids that settled successfully in Europe during the middle and early Late Miocene, including Dryopithecus, Ankarapithecus and Graecopithecus. This event has been dated at 9.6 Ma, predating by more than one million years the spread of the C4 grasses and the retreat of forests over large parts of the globe at 7-8 Ma. The finding of macrofloral remains in the Terrassa section (Vallès-Penedès Basin) sheds new light on the nature of vegetational change associated with the hominoid extinction. This section presents an abundant late Vallesian vertebrate fauna and has been accurately dated at 9.2 - 9 Ma by paleomagnetism. Therefore, it provides the best indication of the kind of vegetation that occupied the area after the Vallesian Crisis. It is suggested that the extinction of the late Miocene Western European hominoids was not related to the spread of grasses, but to a significant increase of a floral association dominated by deciduous trees.

["Household items" : an alternative task to "animals" in the assessment of semantic verbal fluency: a validation study]

INTRODUCTION

The semantic verbal fluency (SVF) is usually evaluated with the task animals in 1 minute . This is a test widely applied in the screening of cognitive impairment. In our best knowledge there are not other alternatives categories for this task validated in our environment (Spanish as mother tongue, Spain).

OBJECTIVE

To validate the category households items as an alternative parallel task to animals in the assessment of SVF.

PATIENTS AND METHODS

Prospective assessment of two categories (animals and household items) in two groups: normal controls and patients with Alzheimer s disease (AD).

RESULTS

CONTROL GROUP

n= 22 (13 M, 9 W); age: 73 5 years, education: 12 5 years; MMSE MEC 35: 30 4; Animals : 15 4. Percentile distribution 10th: 11; 50th: 15; 90th: 20; household items : 17 4. Percentile distribution: 10th: 12; 50th: 17; 90th: 22. AD group: n= 24 (9 M, 15 W); age: 74 5 years; education: 11 5 years; MMSE MEC 35: 17 8; Animals : 6 3. Percentile distribution: 10th: 2; 50th: 6; 90th: 9; household items : 6 4. Percentile distribution: 10th: 1; 50th: 6; 90th: 11. It is observed a positive correlation between the two categories (Spearman s Rho: 0.83, p< 0.0001).

CONCLUSIONS

Both SVF categories had a similar distribution and a high correlation. This findings demonstrated the validity of the household items as an alternative and parallel form to animals in the assessment of SVF in patients with cognitive impairment or dementia.

Freezing protects against allergy to Anisakis simplex

BACKGROUND

Allergic reactions to Anisakis simplex have been described following ingestion of fish and were thought to be possible even if seafood is frozen or well-cooked.

OBJECTIVE

This study aimed to confirm, by challenge test, that dead A. simplex larvae are not able to trigger allergic reactions in patients with proven hypersensitivity to this parasite.

METHODS

Simple-blind, placebo-controlled, oral challenge tests with frozen A. simplex larvae were performed in 12 patients who had suffered severe anaphylactic reactions after ingestion of seafood and diagnosed of A. simplex hypersensitivity by skin prick test and specific IgE. If no reaction appeared, they were told to eat frozen seafood. 63 patients who had suffered urticaria or urticaria/angioedema by demonstratred hypersensitivity to A. simplex were also advised to eat frozen seafood. All of them were reevaluated 6 months later.

RESULTS

All patients tolerated the dead larvae challenge test. After eating previously frozen seafood at least two times per week, all patients, including those who had suffered anaphylactic reactions and those who had only presented cutaneous manifestations, remained asymptomatic.

CONCLUSIONS

Anisakis simplex-allergic patients tolerate ingestion of dead larvae. It is probable that these patients can eat frozen fish and that a seafood-free diet is not necessary.

[Descriptive study of a serie of patients affected by progressive supranuclear palsy]

INTRODUCTION

Progressive supranuclear palsy is a neurodegenerative disorder affecting diverse neurologic systems. The actual treatment response is poor in most patients.

OBJECTIVE

review of a long series of patients affected by PSP in several aspects.

PATIENTS AND METHODS

A series of patients was reviewed by means of the register questionnaire of PSP in Spain (from PSP Disabling Rating Scale and Staging System). This is carried out on the patients when the diagnostic is done. It was achieved a descriptive of the patients, in several aspects, and an evaluation of the treatment in relation to the dose and the duration.

RESULTS

In general, the age of diagnostic is 66 years, there is not neurological illness in the family, falls and disorders of gait are the most representative parameters. The neuroimage shows fronto temporal atrophy. The treatment response is poor, despite the dose and the duration.

CONCLUSIONS

Our series confirms the typical dates of the illness an the poor response to treatment with L Dopa.

Detection of recurrent malignant melanoma with 99mTc-MIBI scintigraphy

Initial reports suggest that 99mTc-methoxyisobutylisonitrile (MIBI) scanning may be of clinical value in staging patients with malignant melanoma. We carried out a study to evaluate the potential of this technique in the detection of recurrent disease. Whole-body 99mTC-MIBI scans were performed in 81 patients with a history of a surgically excised MM: 28 with known recurrent lesions and 53 during follow-up without evidence of disease. Images started 10 min post-injection, using a dose of 740 MBq. Diagnoses were confirmed by cytological/histological examination or at least one conventional imaging modality. Blinded interpretations of the MIBI scans were performed. Whole-body MIBI scanning correctly detected 68 (92%) of 74 metastatic lesions in the following sites: regional lymph nodes (n=23), non-regional lymph nodes (n=10), skin (n=16), brain/cerebellum (n=6), lung (n=8), bone (n=4) and breast (n=1). The technique failed to detect three subcutaneous regressive lesions (< 1 cm), one liver metastasis, one spleen metastasis and a case of multiple small lesions of the duodenal mucous membrane. In 14 patients the procedure detected previously unknown metastatic lesions. These results suggest that 99mTc-MIBI scanning is an effective imaging modality for whole-body screening of metastatic disease in malignant melanoma patients with the potential to influence treatment planning.