Encéphalopathie hyperammoniémique au valproate de sodium

Valproate is a drug commonly prescribed in neurology and psychiatry. Hyperammonemic encephalopathy due to valproate is a severe complication. A 44-year-old man with a past medical history of partial symptomatic epilepsy and alcoholic cirrhosis was admitted for drowsiness. He was receiving valproate and gabapentine. A valproate-induced hyperammonemic encephalopathy was diagnosed on physical examination, generalized slow waves on electroencephalogram and hyperammonemia. Valproate withdrawal led to a progressive recovery of the consciousness, with a rapid normalisation of electroencephalogram and ammonium level. The pathogenesis of this encephalopathy is not clearly established. No correlation has been shown between the severity of encephalopathy, the plasma ammonium level, the valproate dose and its plasma concentration. Additional factors have been pointed out, such as carnitine deficiency or urea cycle enzyme defects. Furthermore, our case suggests an enhancing role of the liver disease in this encephalopathy.     

Profil toxique du lithium : revue exhaustive de la littérature avec méta-analyse des résultats

Objectives

Lithium is a widely used and effective treatment for mood disorders. There has been concern about the safety of lithium but no adequate recent synthesis of the evidence on adverse effects was published in French language. The objective of this study was to produce a clinically informative, systematic toxicity profile of lithium.

Materials and methods

We up-to-dated the systematic review and meta-analysis of randomized controlled trials and observational studies investigating the association between lithium and all reported major adverse effects that we previously published. We searched electronic databases specialist journals, reference lists, textbooks and conference abstracts. We used a hierarchy of evidence which considered RCTs, cohorts, case-control studies and case reports including patients with mood disorders treated with lithium. Outcome measures were renal, thyroid and parathyroid function; weight change, skin disorders, hair disorders and teratogenicity.

Results

Five thousand nine hundred and eighty-eight abstracts were screened for eligibility and 390 studies included in the analysis. On average, glomerular filtration rate was reduced by –9.30 mls/min [95 % CI –12.15 to –6.44, P < 0.001] and urinary concentrating ability was reduced by 15 % of normal maximum. Lithium use may increase rates of renal failure but absolute risk appears to be of the order of 0.3 %. The prevalence of clinical hypothyroidism was increased in patients taking lithium [OR 5.78, 95 % CI 2.00 to 16.67, P = 0.001], whilst thyroid stimulating hormone was increased on average by 4.00 iU/mL [95 % CI 3.90 to 4.10, P =  < 0.001]. Lithium treatment was associated with increased blood calcium [+0.09 mmol/L, 95 % CI 0.02 to 0.09; P = 0.009], and parathyroid hormone [+7.32 pg/mL, 95 % CI 3.42 to 11.23; P < 0.001]. Lithium was associated with more weight gain than placebo [OR 1.89 (1.27 to 2.82) P = 0.002], but not olanzapine [OR 0.32 (0.21 to 0.49) P ≤ 0.001]. There was no statistically significant increased risk of congenital malformations, alopecia, or skin disorders despite many suggesting such associations.

Conclusions

Lithium is associated with increased risk of reduced urinary concentrating ability, hypothyroidism, hyperparathyroidism and weight gain. There is little evidence for a clinically significant reduction in renal function in the majority of patients and the risk of end-stage renal failure is low. The risk of congenital malformations is uncertain; the balance of risks should be considered before lithium is withdrawn during pregnancy. The consistent finding of a high prevalence of hyperparathyroidism means calcium levels should be checked before and during treatment.     

胆管十二指肠间置空肠吻合术治疗肝胆管结石21例临床观察

目的探讨胆管十二指肠间置空肠吻合术治疗肝胆管结石的疗效。方法选取2011年1月～2011年12月扬州市江都区第二人民医院收治的肝胆管结石患者42例,随机分为两组。实验组采取间置空肠吻合术治疗肝胆管结石,对照组使用T管引流术治疗。通过B超或T管胆道造影,评价两种治疗手段的临床价值。结果间置空肠吻合术治疗后,优、良、差病例分别为18、2和1例,优良率95.2%,显著高于对照组。从复发情况看,实验组的复发病例显著少于对照组,差异有统计学意义(P<0.05)。结论胆管十二指肠间置空肠吻合术在治疗肝胆管结石上具有极大的应用价值,是一种有效的治疗方式。