[Long-term effects of dibenzazepines on metabolic parameters: retrospective comparison of carbamazepine, oxcarbazepine and eslicarbazepine acetate in the real world]

INTRODUCTION

Although carbamazepine (CBZ) has strong enzyme-inducing properties, oxcarbazepine (OXC) and eslicarbazepine acetate (ESL) are thought to have a milder effect. These drugs are known to have effects on lipid metabolism and may cause hyponatremia and changes in blood cell counts and liver function tests.

AIM

To compare the long-term effects of three antiepileptic drugs (CBZ, OXC and ESL) on these variables.

PATIENTS AND METHODS

Retrospective cohort study of consecutive patients treated with CBZ, OXC or ESL. Natremia, lipid concentrations, blood cell counts and liver function tests were compared before, during and at the end of the study period.

RESULTS

A total of 292 patients were included. Of these, 143 were treated with CBZ, 55 with OXC and 94 with ESL. CBZ showed a greater impact on lipid metabolism, while OXC was correlated with lower mean sodium levels and a higher frequency of hyponatremia. Lifestyle recommendations related to diet, physical activity and water intake were helpful in overcoming these side effects. No other statistically significant differences were detected.

CONCLUSIONS

While CBZ showed a greater impact on lipid metabolism, OXC displayed a higher frequency of hyponatremia. Lifestyle recommendations may be helpful in overcoming these side effects. No other statistically significant differences were found.

Coordinated representational reinstatement in the human hippocampus and lateral temporal cortex during episodic memory retrieval

Theoretical models of episodic memory have proposed that retrieval depends on interactions between the hippocampus and neocortex, where hippocampal reinstatement of item-context associations drives neocortical reinstatement of item information. Here, we simultaneously recorded intracranial EEG from hippocampus and lateral temporal cortex (LTC) of epilepsy patients who performed a virtual reality spatial navigation task. We extracted stimulus-specific representations of both item and item-context associations from the time-frequency patterns of activity in hippocampus and LTC. Our results revealed a double dissociation of representational reinstatement across time and space: an early reinstatement of item-context associations in hippocampus preceded a later reinstatement of item information in LTC. Importantly, reinstatement levels in hippocampus and LTC were correlated across trials, and the quality of LTC reinstatement was predicted by the magnitude of phase synchronization between hippocampus and LTC. These findings confirm that episodic memory retrieval in humans relies on coordinated representational interactions within a hippocampal-neocortical network.

Episodic memory retrieval is hypothesized to rely on hippocampal reinstatement of item-context associations which drives reinstatement of item information in cortex. Here, the authors confirm this sequence of events, using iEEG recordings from the human hippocampus and lateral temporal cortex.

[Substance related disorder in emergency services: Which attitudes?]

INTRODUCTION

Substance related disorders are more prevalent in emergency services than in the general population, about 20% of individuals in emergency care test positive for alcohol. Emergency services are strategic places to identify alcohol misuse. Attitudes to individuals presenting substance related disorders are important in developing therapeutic relationships and applying interventions.

OBJECTIVE

This study explores the attitudes of an emergency staff to these individuals across a range of roles, and evolution in face of an addictology care improvement.

METHOD

Data were gathered from an emergency service sample from the emergency department of a general hospital in Morlaix (France). We used a short questionnaire, adapted from previous similar French studies.

RESULTS

Twenty-five persons answered the first questionnaire and 18 the second. A self-administrated attitudes questionnaire showed its interest in our study and helped us to identify attitudes and to initiate a reflection on behaviours in emergency care. Moreover, it helped to change attitudes towards individuals presenting substance related disorders. The daily setting of an addictive disorders specialized unit in emergency changed the point of view on addictive disorders of both physicians and nurses. We showed differences in addictive related disorders prevalence perception among patients attending emergency care between the two evaluations. But we also showed that physicians and nurses stressed that it was more difficult to ask patients in emergency care on the second evaluation, after and despite a daily addictive disorders specialized setting. We showed several limits in emergency staff care relationship with patients with substance related disorders. They identified difficulties to talk about addictive disorders, especially in younger and older patients. Regarding literature, we discuss our study limits and different ways of improving addictology care in emergency services.

Perfusion SPECT, SISCOM and PET (18)F-FDG in the assessment of drug- refractory epilepsy patients candidates for epilepsy surgery

AIMS

Brain perfusion SPECT (ictal-interictal), SPECT images and subtraction ictal SPECT coregistered to MRI (SISCOM) and (18)F-FDG-PET (interictal), play an important role in the pre-surgical diagnosis of patients with medically refractory epilepsy. This study aimed to establish: the reproducibility of visual ictal-interictal SPECT and SISCOM analysis altogether with the capacity of SPECT, SISCOM and PET to determine the epileptogenic zone.

MATERIAL AND METHODS

(99m)Tc-HMPAO SPECT ictal-interictal and SISCOM (Analyze 7.0) were performed on 47 refractory epilepsy patients (24 F, 19-60 yrs). In 13 patients, SISCOM was also performed using a new program (Focus DET). Ictal-interictal SPECT and SISCOM images were analysed independently by two nuclear medicine physicians (observer 1 and 2). Kappa concordance coefficient was used to evaluate the reproducibility. In sixteen patients, SPECT, SISCOM and PET findings were compared with the resected area during the surgery, and surgical outcome using Engel scale or with the stereo EEG-(SEEG).

RESULTS

The ictal-interictal SPECT interobserver agreement was 91%, Kappa index 0.86, SISCOM (Analyze 7.0) interobserver agreement percentage was 82%, Kappa index 0.80, Analyze 7.0 showed a higher inconclusive results than visual SPECT analysis. SISCOM FocusDET interobserver agreement was 92%, Kappa index 0.87, with lower inconclusive results than Analyze 7.0. SPECT, SISCOM and PET combined findings identified 87% seizure onset zone: 79% temporal, 26% parieto-temporal and 7% frontal.

CONCLUSIONS

Ictal-interictal SPECT and SISCOM showed a high reproducibility in this sample of patients with drug-refractory epilepsy. SPECT,SISCOM and PET combined findings improved detection of epileptogenic zone in comparison with the individual assessment.

Post-authorisation study of eslicarbazepine as treatment for drug-resistant epilepsy: preliminary results

INTRODUCTION

Eslicarbazepine acetate (ESL) is a new antiepileptic drug (AED) and an analogue to carbamazepine (CBZ) and oxcarbazepine (OXC). In this study, we evaluate initial therapeutic response to ESL and events in the change from CBZ and OXC.

METHODS

We evaluated 61 patients with a broad spectrum of drug-resistant epilepsies in a cross-sectional study. The switch from CBZ and OXC to ESL was carried out in a single night at ratios of 1:1.3 and 1:1mg respectively.

RESULTS

The most common form of epilepsy was temporal lobe epilepsy (62.3%). The most common aetiology was mesial temporal sclerosis (26.2%). Mean follow-up time was 4.7±3.2 months. In 40 patients with a minimum follow-up period of 3 months, monthly median seizure frequency dropped by 63.6% (P<.001) and a reduction of 80% or more was recorded in 30%. Adverse events (AEs) occurred in 54%; all appeared during the titration phase. They were more frequent at doses in excess of 800mg (73.9% vs. 47.4%; P=.042). The most common AE was dizziness (34.4%), which was commonly associated with VPA, LTG and/or LCS consumption (19.2% vs. 45.7%; P=.031). The retention rate at 3 months was 75.4%. A total of 25 patients replaced CBZ or OXC treatment with ESL; any AEs were transient (69.2% for CBZ and 33% for OXC; P=.073). At 3 months after the treatment change, median seizure frequency had decreased by 20% (P<.075).

CONCLUSIONS

ESL is effective in the treatment of focal epilepsies and its early retention rate is > 70%. AEs occurred during the titration phase and corresponded to associated AEDs. A rapid change from CBZ and OXC to ESL treatment can be safely performed.

Antagonism of the cannabinoid CB-1 receptor protects rat liver against ischaemia-reperfusion injury complicated by endotoxaemia

BACKGROUND/AIM

Endotoxaemia can complicate hepatic ischaemia-reperfusion (IR) injury. Endocannabinoids appear to modulate the haemodynamic alterations and cytokine response induced by lipopolysaccharide (LPS). Thus, we aimed to determine the effect of the endocannabinoid CB1-receptor antagonist Rimonabant in a model of hepatic IR injury complicated by endotoxaemia.

METHODS

Sprague-Dawley rats pre-treated with Rimonabant 3 or 10 mg/kg or vehicle underwent partial hepatic IR and lipopolysaccharide (LPS) injection at reperfusion. Liver injury was evaluated by serum alanine aminotransferase (ALT) and necrotic-cell count. The inflammatory response was investigated by assessing hepatic neutrophil infiltration, tumour necrosis factor alpha (TNFalpha), interferon gamma (IFNgamma), interleukin 6 (IL6), and suppressor of cytokine signalling (SOCS) 1 and SOCS3 gene expression by real-time polymerase chain reaction (RT-PCR). Systolic blood pressure and hepatic blood flow were measured as haemodynamic parameters. Finally, lipid peroxidation, glutathione status, and immunoreactive CB1 receptor expression in the liver were also determined.

RESULTS

Liver injury and neutrophil infiltration occurring in the late-phase of LPS-enhanced IR were significantly reduced by CB1-receptor antagonism. Rimonabant-treated rats showed significantly higher gene expression of IFNgamma, IL6, SOCS1 and SOCS3 in "early" reperfusion, while that of TNFalpha was reduced. These findings were associated with increased STAT3 phosphorylation. Furthermore, CB1-receptor antagonism significantly improved the oxidative injury and haemodynamic alterations occurring during reperfusion in untreated rats. Finally, CB1-receptor immunoreactivity was upregulated early after reperfusion.

CONCLUSIONS

This study demonstrates that CB1-receptor antagonism protects the liver against LPS-enhanced IR injury by interfering with the inflammatory response that causes the late, neutrophil-dependent phase of reperfusion injury, although the prevention of the transient endotoxin-related hypotension occurring early during reperfusion may be also involved.

Effects of granulocyte colony stimulating-factor in a rat model of acute liver injury

BACKGROUND/AIM

Controversial experimental observations suggest that granulocyte colony stimulating-factor may promote hepatic regeneration after hepatectomy and chemical injury either by directly stimulating adult liver cells or facilitating the mobilization of bone marrow cells and their homing to the liver. We investigated whether different schedules of granulocyte colony stimulating-factor administration protect against experimental acute liver injury.

METHODS

Acute liver injury was induced in Sprague-Dawley fed rats by injecting a single intraperitoneal dose of carbon tetrachloride. Recombinant human granulocyte colony stimulating-factor or vehicle was given daily after intoxication (4 days) or before (7 days) and after carbon tetrachloride administration. Liver injury and regeneration were assessed 2 and 4 days after damage. Bone marrow cells mobilization was evaluated by the white blood cell count and the assessment of circulating clonogenic haematopoietic progenitors (colony forming unit-cells).

RESULTS

In this experimental model, although granulocyte colony stimulating-factor induced the significant mobilization of colony forming unit-cells, the study cytokine had no effect on liver injury (serum alanine amino transaminase level and necrotic index) and liver regeneration (mitotic index and bromodeoxyuridine incorporation), regardless of the administration schedule.

CONCLUSIONS

This study does not support the conclusion that: (1) granulocyte colony stimulating-factor exerts a protective effect against toxic-induced, non-lethal acute liver injury and (2) promotes hepatocyte regeneration.

Oxidative injury in rat fatty liver exposed to ischemia-reperfusion is modulated by nutritional status

BACKGROUND AND AIMS

Oxidative stress contributes to ischemia-reperfusion injury in fatty livers. This study aimed to determine whether glycogen depletion influences this oxidative injury and whether the administration of glucose can be protective.

METHODS

Rats with choline deficiency-induced fatty liver underwent hepatic ischemia-reperfusion. Experimental groups: (1) fed rats; (2) 18 h fasted rats; (3) 18 h fasted rats supplemented with glucose prior to surgery. The thiobarbituric acid-reactive substances, protein carbonyls and total glutathione concentrations were measured in liver tissue and isolated mitochondria as parameters of oxidative stress before and after ischemia and during reperfusion. The mitochondrial F1-ATPase content and the serum alanine transaminase were also determined.

RESULTS

With respect to fed rats, fasted rats exhibited an increased oxidative injury in both liver tissue and isolated mitochondria throughout the experiment with the only exception of thiobarbituric acid-reactive substances, which were not affected by the nutritional status in liver tissue. Fasted rats showed a significantly lower F1-ATPase content and higher alanine transaminase levels. Glucose supplementation significantly reduced the fasting-associated exacerbation of oxidative stress and liver injury and the F1-ATPase exhaustion.

CONCLUSIONS

These data indicate that the pre-existing hepatic glycogen content modulates the oxidative damage in rat fatty livers exposed to ischemia-reperfusion injury and that the energetic substrate supplementation may represent a clinically feasible protective strategy.

Diagnostic dilemmas in biliary strictures mimicking cholangiocarcinoma

BACKGROUND/AIMS

Bile duct strictures may be malignant or benign. In the absence of previous biliary surgery a precise preoperative diagnosis is often difficult, in particular when a tumor mass is absent in the preoperative radiologic findings.

METHODOLOGY

A review of 179 patients observed between 1982 and 2001 by the same surgical team with a preoperative diagnosis of malignant stricture of the biliary tree. A surgical procedure was performed in 153 of these cases.

RESULTS

The presence of a malignant stricture was confirmed by final pathologic examination in 32 of 38 cases (96%) in which a curative resection was performed. A final diagnosis of inflammatory stricture secondary to choledocholithiasis was made in 3 of the remaining 6 cases (4%), along with one case each of sclerosing cholangitis, granular cell tumor and Mirizzi's syndrome, respectively.

CONCLUSIONS

Precise preoperative evaluation of biliary structures can be very difficult when a tumor mass is absent. Despite the use of invasive procedures and new techniques such as magnetic resonance cholangiopancreatography, a false-positive rate of 4% may be expected. However, whenever a malignancy is not definitely excluded, biliary strictures should be treated as a cholangiocarcinoma.

Mirizzi syndrome with cholecysto-choledocal fistula with a high CA19-9 level mimicking biliary malignancies: a case report

Mirizzi syndrome type II is a form of obstructive jaundice caused by a stone impacted in the gallbladder neck or the cystic duct that impinges on the common hepatic duct with a cholecysto-choledochal fistula. Preoperative recognition is necessary to prevent injury to the common duct during surgery. We present a patient with an operative diagnosis of type II Mirizzi syndrome, which was not originally indicated in the preoperative work-up; in particular endoscopic retrograde cholangiopancreatography showed stenosis of the middle third of the hepatic duct along with markedly elevated serum CA19-9 levels (up to 35,000 U/mL). Surgical specimen examination did not reveal the presence of neoplasia. We performed cholecystectomy and a jejunal loop was brought up and anastomosed to the common duct at the hilar level in a Roux-en-Y fashion. In cases such as ours with extensive fibrosis and inflamed tissue mimicking cholangiocarcinoma or gallbladder carcinoma, a wide hepaticojejunostomy is required to establish adequate biliary drainage.

Fifteen-year experience with pediatric renal transplantation at the Montefiore Medical Center

At Montefiore Medical Center, 140 pediatric recipients have received 155 renal allografts over a 16-year period with an overall 6% mortality. Graft survival was not significantly different based upon race or sex of recipient. Graft survival was significantly better for first time transplants and the youngest recipients. Graft survival was significantly improved using Tacrolimus immunosuppression.

Solitary necrotic nodules of the liver

An experience is reported with solitary necrotic nodules of the liver, rare benign lesions described for the first time in 1983. Two patients were referred to our department because of the presence of hepatic lesions that radiology showed to be suspected secondary liver tumors. At laparotomy, both patients underwent liver resections because the lesions appeared to be malignant. Subsequent histological examination of the surgical specimens revealed that both were solitary necrotic nodules of the liver. These were the only solitary necrotic nodules found in a total of 840 operations carried out in our department since October 1981. Although they are completely benign, solitary necrotic nodules have a similar ultrasound pattern and radiological features to metastases and have been described in the literature during the follow-up of patients with other tumors. Uncertainty remains as to the etiology of these lesions, which still represent an occasional finding in liver surgery.

Renal transplantation in a heterogeneous population: the thirty-year Montefiore Medical Center experience

Based on more than 30 years of renal transplantation experience at Montefiore Medical Center we conclude: 1. Improved patient and graft survival can be achieved in the cadaveric transplant recipient despite increasing co-morbidities. 2. Patients at the extremes of age (< 10 or > 60) can undergo renal transplantation safely, with patient and graft survival rates approaching those of the general recipient population. 3. Results of transplantation in African-Americans are as good as non African-Americans at 3 years. Beyond that point the graft survival curves diverge. Well matched (0-1 HLA mismatches) kidneys in the African-American patient do as well if not better than other ethnic groups. However, African-Americans do not receive as many well matched kidneys as others.

Bile duct hamartomas: diagnostic problems and treatment

Biliary hamartomas are rare, benign malformations of the biliary tract, usually discovered at autopsy or erroneously confused with metastasis or other cystic hepatic lesions. For these reasons it is necessary to consider them in the differential diagnosis. The authors describe three cases of biliary hamartoma in which the definitive diagnosis was obtained only with the use of histologic examination which represents the only means available that can draw conclusions about the real nature of this lesion.

Unsuspected carcinoma of the gall bladder: case report of trocar-site metastasis following laparoscopic cholecystectomy

Cancer of the gall bladder is a rare malignant neoplasm with an unfavourable prognosis. Laparoscopic surgery has brought about the emergence of possible neoplastic diffusion along trocar tracts in cases where unrecognized carcinoma of the gall bladder is present. The authors present a case of neoplastic abdominal diffusion discovered 4 months after laparoscopic cholecystectomy in which histologic examination of the surgical specimen revealed the presence of unrecognized carcinoma of the gall bladder.

Papillary cystic neoplasm of the pancreas: a description of two clinical cases

Papillary-cystic neoplasm of the pancreas is a rare neoplasm principally effecting women in the 2nd and 3rd decades of life. It is considered a low grade malignancy due to it's favourable prognosis and the rarity of metastatic diffusion. Pre-operative diagnosis is rare due to the similarity with other cystic pancreatic lesions. It is for this reason that definitive diagnosis is made at histologic examination of the surgical specimen and total surgical excision represents the therapy of choice. The authors herein describe 2 cases of papillary-cystic neoplasm of the pancreas, thus bringing the total number of cases reported in the world literature to 294.

[Congenital duplication of the gallbladder. A rare case of a trabecular gallbladder]

Duplication of the gallbladder is a congenital anomaly of rare preoperative diagnostic finding, which could be present in an asymptomatic or symptomatic form. The authors report a case of double gallbladder, which becomes clinically manifest through repeated biliary colics. The preoperative diagnostic procedures did not reveal the malformation, but only the presence of lithiasis in one of the gallbladders, in the common bile duct and, for an anomalous insertion of the cystic duct, a suspect cancer of the distal choledochus.

[Congenital anomalies of the gallbladder. A case of retrohepatic gallbladder contained in the coronary ligament]

A case of ectopic gall-bladder located retrohepatically in the coronary ligament is reported. Stress is laid on the interest and extreme rarity of this event which escaped observation at a first explorative laparotomy. Further confirmation is thus provided, within bile way malformations, of the need for attentive intraoperative exploration, including cholangiography.

[Biliojejunoduodenostomy: morphofunctional aspects and radiological problems (author's transl)]

An analysis is made of the anatomofunctional features of biliojejunoduodenostomy, in comparison with different kinds of biliodigestive anastomoses; special attention is paid to roentgensemeiological problems as related to the method of investigation.