Tratamiento con daptomicina en pacientes con bacteriemia

Community-acquired bacteremias assciated with healthcare and, especially, those of nosocomial origin, are mainly caused by Gram-positive microorganisms. Notable among this group are Staphylococcus spp, with an incidence of methicillin resistance of approximately 30% in S. aureus and of 70% in coagulase-negative staphylococcus, which is higher in patients admitted to intensive care units. Vancomycin has been the most widely used antibiotic in these situations but its toxicity, especially in the kidney, and reports of failure when used for the treatment of methicillin-resistant S. aureus (MRSA) and with a vancomycin MIC > 1 mg/L have led to the search for other treatments.Daptomycin is a new lipopeptide antibiotic that has been shown to be not inferior to vancomycin in a pivotal clinical trial in patients with bacteremia and right endocarditis due to S. aureus. Recent guidelines and consensus documents place daptomycin as an ideal alternative in these situations, indicating its use in MRSA bacteremia with a vancomycin MIC > 1 mg/L, as well as in patients whose renal dysfunction excludes the use of vancomycin therapy. Evidence of worse prognosis in MRSA bacteremia when empirical treatment is inappropriate has led to the recommendation of daptomycin as the first-choice drug in critically ill patients with suspected Gram-positive bacteremic infection and renal dysfunction and/or in hospitals where there is a high prevalence of MRSA with a MIC > 1 mg/L. The recommended dose in severely ill patients should be higher than 6 mg/kg/day.     

Rescate con rituximab en paciente con liquen plano esofágico refractario

Esophageal lichen planus (ELP) is a rare condition with unknown prevalence that can sometimes be underestimated due to the subtle and nonspecific findings of diagnostic workup. Oral lesions rarely extend to the esophageal mucosa, but when they do, the most frequent symptoms are dysphagia and odynophagia. There is often a significant delay in diagnosis and inadequate treatment. We report the case of a 59-year-old woman diagnosed with ELP, successfully treated with rituximab, a chimeric monoclonal antibody that depletes CD20+B cells. To our knowledge, this is only the second report of this treatment in ELP.     

Leishmaniasis visceral en un paciente con artritis reumatoide en tratamiento con metotrexato

A large number of complications have been associated with rheumatoid arthritis (RA), those of infectious etiology being of special relevance. Their high incidence is closely linked to the use of immunosuppressive medication.The spectrum of agents causing opportunistic infections in patients with RA is very broad; however, there are relatively few cases of Leishmania infection, especially in patients not being treated with biological drugs.     

Tratamiento con daptomicina en el paciente anciano y con pluripatología

Serious Gram-positive bacterial infections are a major cause of morbidity and mortality among older adults and can pose a significant challenge to clinicians. Although more than 50% of patients treated with daptomycin are > 65 years old, there are few data evaluating the efficacy and safety of daptomcyn in this population. Analysis of data from patients > 65 years old included in the Cubicin Outcomes Registry and Experience (CORE), a multicenter, retrospective registry designed to collect post-marketing clinical data on patients who received daptomycin, and in its European version, the EUCORE, showed similar rates of efficacy and safety in this population to those in younger patients, suggesting that daptomycin is also a valuable option in older patients with serious Gram-positive infections.     

Eficacia del tratamiento con leflunomida en pacientes con artritis psoriásica

Psoriatic arthritis (PsA) occurs in 1-3% of the population and 25% of affected patients require systemic therapy. The drugs used in PsA have been developed for other diseases, mainly rheumatoid arthritis (RA), and there are no clinical trials supporting their efficacy and safety in these patients. Leflunomide (LFN) inhibits the activation and proliferation of T-lymphocytes and is considered to be a disease-modifying drug for RA.TOPAS is an international, randomized, placebo-controlled clinical trial of the efficacy of LFN in PsA patients. A total of 186 patients were included and randomized to receive placebo or LFN at a loading dose of 100 mg/day for 3 days followed by 20 mg/day orally for 24 weeks. The primary and secondary efficacy endpoints were the Psoriatic Arthritis Response Criteria (PsARC) and the American College of Rheumatology (ACR20) response rates, respectively. The results show that LFN was significantly more effective than placebo in both primary and secondary efficacy endpoints (58.9% of the patients from the LFN group were responders compared with 29.7% of those in the placebo group, p < 0.0001). Analysis of patients according to the Psoriasis Area Severity Index (PASI) score (50, 75 and 90) showed the same results, with statistically significant differences favoring the LFN-treated group in comparison with placebo (30.4%, 17.4% and 9.8% compared with 18.9%, 7.8% and 2.2%, respectively). The patient's quality of life (dermatology life quality index [DLQI]) significantly improved in treated patients compared with the placebo group (scores corresponding to symptoms/feelings, p = 0.0092, daily activities, p = 0.013 and personal relationships, p = 0.030 compared with placebo). Improvements in cutaneous symptoms were observed from week 4 in the LFN group and continued to increase throughout the 24-week study period.OSPAL is an observational trial that evaluated the efficacy of LFN in 330 outpatients with PsA. The patients received an LFN loading dose of 100 mg/day for 3 days followed by 20 mg/day LFN for 24 weeks. Seventy-seven patients on methotrexate therapy who were unresponsive to treatment were administered LFN at 20 mg/day over 24 weeks as an add-on. The overall response rates were clearly higher in OSPAL (78.1%) than in TOPAS (60%). This finding is highly important since observational studies more realistically reflect daily clinical practice than randomized, controlled studies. The main differences found between pre- and post-LFN treatment were observed in improvements in pain (84.2%), dactylitis (49.7%), fatigue (64.7%) and skin disease (“very good” 57.7%) (all p < 0.001). At the end of treatment, 75% of patients evaluated their skin condition as “good” or “very good” and 80% reported mild or no fatigue. Finally, the safety and tolerance analysis revealed no unexpected adverse events.In conclusion, the TOPAS and OSPAL clinical trials indicate that LFN is an efficacious and first-line therapeutic option for the treatment of PsA, providing therapeutic benefits for rheumatic symptoms and positive effects on dactylitis and cutaneous symptoms.     

Tentato suicidio con glibenclamide

Riassunto Viene descritto un caso di tentato suicidio con glibenclamide (250 mg, pari a circa 35 mg/kg) in una donna non diabetica di 16 anni. Dopo rapido risveglio dal coma, permase tendenza spontanea all'ipoglicemia per circa 4 giorni. Dopo 112 h, una prova di carico orale con glucosio metteva in evidenza ridotta tolleranza glicidica e scarsa risposta insulinemica. Dopo 17 giorni, un nuovo test al glucosio dimostrava notevole incremento insulinemico con modeste variazioni glicemiche, come se le cellule B fossero rimaste iperreattive allo stimolo glicidico.

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Summary A case of attempted suicide with glibenclamide (250 mg equivalent to about 35 mg/kg) in a nondiabetic girl of 16 years is described. After rapid recovery from coma the patient had a spontaneous tendency to hypoglycemia for about 4 days. An oral glucose tolerance test taken at 112 hrs elicited decreased glucose tolerance and a poor plasma insulin response. After 17 days a repeat test revealed considerable plasma insulin increase with small blood glucose variations, as if the B-cells had remained over-responsive to the glucose stimulus.

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Zusammenfassung Es wird über den Selbstmordversuch mit Glibenclamid (250 mg, entsprechend etwa 35 mg/kg) einer 16 jährigen Nichtdiabetikerin berichtet. Nach rascher Überwindung des Komas zeigte die Patientin eine spontane Tendenz zur Hypoglykämie, die etwa 4 Tage anhielt. Eine Glukosebelastungsprobe nach 112 h zeigte verminderte Glukosetoleranz und ungenügenden Anstieg des Plasmainsulins. Eine wiederholte Belastungsprobe nach 17 Tagen zeigte einen erheblichen Anstieg des Plasmainsulins schon bei bescheidenen Erhöhungen des Blutzuckerspiegels, als ob die B-Zellen eine Hyperreaktivität gegen den Glukosereiz entwickelt hätten.

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Resumen Se describe el caso de suicidio frustrado con glibenclamida (250 mg aproximadamente que equivalen a 35 mg/kg) de una mujer no diabética de 16 años. Tras haberse reanimado rapidamente del estado comatoso, le quedó tendencia espontánea a la hipoglucemia durante cuatro días. Transcurridas 112 h, la prueba con carga oral de glucosa ponía en evidencia una tolerancia glucídica reducida y una reacción insulinémica escasa. Diecisiete días después, un nuevo test a la glucosa demostraba un incremento insulinémico notable con modestas variaciones glicémicas, tal como si las células B siguiesen acusando hiperreactividad al estímulo glucídico.

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Résumé On décrit le cas d'une tentative de suicide par le glybenclamide (250 mg, soit 35 mg/kg environ) dans une femme non diabétique âgée de 16 ans. Après un réveil rapide du coma, une tendance spontanée à l'hypoglycémie demeura pendant 4 jours environ. Après 112 h, un test d'administration orale de glucose mettait en évidence une tolérance glucidique réduite ainsi qu'une réponse insulinémique limitée. Après 17 jours, un nouveau test au glucose indiquait un accroissement sensible insulinémique avec des variations glycémiques modestes, comme si les cellules B demeuraient hyperréactives au stimulus glucidique.

     

Preguntas y respuestas relacionadas con tabaquismo en pacientes con EPOC. Aplicación de metodología con formato PICO

The ALAT and SEPAR Treatment and Control of Smoking Groups have collaborated in the preparation of this document which attempts to answer, by way of PICO methodology, different questions on health interventions for helping COPD patients to stop smoking.The main recommendations are: (i) moderate-quality evidence and strong recommendation for performing spirometry in COPD patients and in smokers with a high risk of developing the disease, as a motivational tool (particularly for showing evidence of lung age), a diagnostic tool, and for active case-finding; (ii) high-quality evidence and strong recommendation for using intensive dedicated behavioral counselling and drug treatment for helping COPD patients to stop smoking; (iii) high-quality evidence and strong recommendation for initiating interventions for helping COPD patients to stop smoking during hospitalization with improvement when the intervention is prolonged after discharge, and (iv) high-quality evidence and strong recommendation for funding treatment of smoking in COPD patients, in view of the impact on health and health economics.     

Preguntas y respuestas relacionadas con tabaquismo en pacientes con EPID. Aplicación de metodología con formato PICO

IntroductionThe Smoking and the Diffuse Interstitial Lung Diseases (ILD) groups of ALAT and SEPAR collaborated in the preparation of this document.Materials and methodsThis document uses PICO methodology to answer various questions on the relationship between tobacco use and diffuse ILD.Results and conclusionsThe main recommendations are: a) moderate level of evidence and strong recommendation to consider smoking as a risk factor for the development and/or modification of the progression of diffuse ILD; b) moderate level of evidence to identify an increase in mortality in diffuse ILD, irrespective of histologic pattern. Low evidence for ascribing it to smoking and strong recommendation for the early identification of patients with diffuse ILD. Further studies are needed to evaluate the effect of smoking cessation in patients with diffuse ILD; c) low level of evidence and weak recommendation for defining the impact of passive smoking in diffuse ILD; d) low level of evidence to demonstrate that smoking cessation improves the outcomes of patients diagnosed with diffuse ILD and strong recommendation to advise smoking cessation in smokers with diffuse ILD, and e) low level of evidence to support the clinical or epidemiological usefulness of active case finding for diffuse ILD in smoking cessation programs, and strong recommendation justifying the performance of spirometry in active case finding, based not on current smoking status, but on previous accumulated consumption, even in asymptomatic cases.     

Encefalitis con estatus convulsivo localizado en una paciente con lupus eritematoso sistémico

We describe a 42-year old woman with inactive systemic lupus erythematosus (SLE) at the time of her visit. She presented with an atypical movement disorder and partial continuous epilepsy. A brain biopsy excluded cerebral vasculitis and tumoral processes. We discuss the differential diagnosis of status epilepticus in a patient with systemic lupus erythematosus.