Ascitis en los pacientes oncológicos: Fisiopatogenia y opciones de tratamiento

Ascites, defined as the presence of fluid in the peritoneal cavity, is a finding associated to several pathologies, mainly hepatic and cancer diseases. Between 15 and 50 per cent of patients with cancer develop ascites. Its incidence is high in ovary, breast, endometrium, colon, stomach, pancreas and bronchus cancer. Several factors are involved in its pathogenesis, included high hydrostatic pressure, low colloid-osmotic pressure, increased capillary permeability and fluid leakage to the peritoneal cavity. The ascitic fluid is analyzed for diagnostic (serum-ascitic albumin gradient, amylase and triglyceride levels; cell count, culture and Gram staining; pH, cytology, glucose and fibronectine determination) and therapeutic purposes. A physical examination is essential for the diagnosis, with particular attention to classical signs such as convex flanks, wave sign, pleural effusion sign, limb, pelvic and genital edema, etc. Other specific studies are sometimes required in order to verify the presence of fluid in the abdominal cavity. Its treatment will depend on the etiology. In non-cancer patients, diet salt restriction and diuretics regimes obtain satisfactory results. In cancer patients, intra-peritoneal chemotherapy may be required. Patients with poor or null response are candidates for drainage of the ascitic fluid. This can be done using several techniques such as classical paracentesis, total paracentesis, placement of a semi-permanent or permanent drainage with or without image help, shunts, etc. In order to obtain the maximum benefit with the minimum risk, patient global status must be assessed prior to the procedure. It is concluded that ascites of any etiology encompass diverse physiopathological disorders that require both pharmacological and invasive therapies for their effective management.La ascitis definida como la presencia de fluido en la cavidad peritoneal, es un hallazgo observado en diversas entidades patológicas, principalmente en enfermedades hepáticas y oncológicas. Los pacientes con cáncer desarrollan asicitis en un 15 a 50%. Los carcinomas de ovario, mama, endometrio, colon, estómago, páncreas y bronquios tienen una alta incidencia de ascitis. Su patogénesis involucra varios factores como son: elevación de la presión hidrostática, disminución de la presión coloido-osmótica, aumento en la permeabilidad capilar y escape de líquido a la cavidad peritoneal. El líquido de ascitis es analizado con fines diagnósticos (gradiente de albúmina sérica-ascítica, concentración de amilasa y triglicéridos; cuenta celular, cultivo y tinción de gram; pH, citología, determinación de glucosa y fibronectina) y terapéuticos; siendo de vital importancia la valoración clínica para el diagnóstico, apoyándonos en signos clásicos como son el abombamiento de los flancos, el signo de la ola, signo de efusión pleural, edema de miembros pélvicos, genitales, etc. Y en determinados casos será necesario el apoyo a través de estudios de gabinete para corroborar la presencia de líquido en cavidad abdominal. El tratamiento de esta entidad dependerá de su etiología. En pacientes no oncológicos la restricción de sal en la dieta y los esquemas de diuréticos dan buenos resultados. En pacientes oncológicos puede implementarse la quimioterapia intraperitoneal. Los casos refractarios o con escasa respuesta son candidatos a drenaje del líquido ascítico a través de múltiples técnicas como son la paracentesis clásica, paracentesis total, colocación de drenaje semi-permanente o permanente con o sin la ayuda de imagenología, cortocircuitos, etc., valorando previo procedimiento las condiciones globales del paciente para obtener un máximo beneficio con un mínimo riesgo. Se concluye que la ascitis de cualquier etiología comprende diversas alteraciones fisiopatológicas que han provocado la implementación de diversas modalidades de manejo tanto farmacológico como invasivas para el tratamiento eficaz de la misma

¿Es la Buprenorfina una buena opción en el manejo de dolor postoperatorio?

Background: Pain is one of the most feared outcomes of surgery by patients, yet current practices of pain management are suboptimal. Failure to address acute postoperative pain can have a variety of consequences that affect physical and psychological aspects of the patient. Current perioperative pain management normally consists of opioid therapy, which has been a mainstay for many years. However, use of opioids can have moderate risks, including nausea/vomiting, dizziness, and constipation, or more severe risks, including respiratory depression and immunosupression. Aim: In order to address some of the issues surrounding perioperative pain management, a group of key opinion leaders gathered at an international summit to analyze the current practices of perioperative pain management. One of the topics focused on buprenorphine's role in perioperative pain and the information discussed is presented throughout this article. Conclusion: Buprenorphine has been demonstrated to be effective and safe in many postoperative pain models. Its administration versatility, its manageable side effects, and its use in combination with other analgesics allow buprenorphine therapy to be successful in perioperative pain management.Antecedentes: El dolor es uno de los eventos más temidos por los pacientes después de una cirugía, y en la actualidad el manejo del dolor es subóptimo. La falta de control del dolor agudo postoperatorio puede tener una serie de consecuencias que afectan a los aspectos físicos y emocionales de los pacientes. El manejo habitual del dolor postoperatorio se basa en la utilización de opioides, pilar de tratamiento desde hace muchos años. Sin embargo, el uso de opioides puede tener riesgos moderados, como son las náuseas y vómitos, mareos y constipación, o riesgos más severos que incluyen a la inmunosupresión y depresión respiratoria. Objetivo: Para poder determinar algunos de los factores circundantes del dolor postoperatorio, se realizó una reunión cumbre internacional en la que un grupo de líderes de opinión analizó las prácticas habituales de manejo de dolor postoperatorio. Uno de los temas abordados fue el rol de la buprenorfina en el manejo del dolor perioperatorio, y la información discutida se presenta a lo largo de este artículo. Conclusión: La buprenorfina ha demostrado ser eficaz y segura en muchos modelos de dolor postoperatorio. Su versatilidad de administración, sus efectos secundarios manejables y su posibilidad de ser combinada con otros analgésicos hacen que la buprenorfina sea exitosa en el manejo del dolor perioperatorio

Ceftriaxone and clavulanic acid induce antiallodynia and anti-inflammatory effects in rats using the carrageenan model

Abraham Ochoa-Aguilar,1,2 Rosa Ventura-Martinez,1 Marco Antonio Sotomayor-Sobrino,1 Ruth Jaimez,1 Ulises Coffeen,3 Ariadna Jiménez-González,2 Luis Gerardo Balcázar-Ochoa,1 Rafael Pérez-Medina-Carballo,2 Rodolfo Rodriguez,1 Ricardo Plancarte-Sánchez4 1Pharmacology Department, Faculty of Medicine, National Autonomous University of Mexico, Mexico City, México; 2Research Department, Mexican Faculty of Medicine, La Salle University, Mexico City, México; 3Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico City, México; 4Pain Clinic, National Cancer Institute of Mexico, Mexico City, México Introduction: Ceftriaxone (CFX) and clavulanic acid (CA) are 2 β-lactam molecules widely used as antibiotics. However, several reports of their antiallodynic properties have been published in recent years. Although this effect has been considered mostly due to a GLT1 overexpression, these molecules have also been proven to induce direct immunomodulation. In this work, we determine the acute analgesic effect of CFX and CA in an inflammatory pain model and assess if their administration may induce anti-inflammatory effects. Methods: The carrageenan (Carr) test was used as an inflammatory pain model. Both mechanical and thermal responses were analyzed after CFX and CA administration at different times. A plethysmometer was used to determine inflammation. Also, TNF-α and IL-10 serum concentrations were determined by enzyme-linked immunosorbent assay. Results: Both CFX and CA induced a significant thermal antiallodynic effect 3 and 24 h after administration. Furthermore, CA induced a mechanical antiallodynic effect 30, 60, and 90 min after administration. Moreover, a significant anti-inflammatory effect was found for both molecules 24 h after Carr injection. Also, both CA and CFX modulated TNF-α and IL-10 serum concentrations at different times. Conclusion: Our results provide evidence that both CFX and CA cause an analgesic effect on a Carr inflammatory pain model and that said analgesic effect differs between each β-lactam molecule. Furthermore, this effect may be related to an anti-inflammatory effect of both molecules and a direct TNF-α and IL-10 serum concentration modulation. Keywords: ceftriaxone, clavulanic acid, inflammatory pain, TNF-α concentration, β-lactam molecules, analgesic effect, antiallodynic propertie

Repeated administration of mazindol reduces spontaneous pain-related behaviors without modifying bone density and microarchitecture in a mouse model of complete Freund’s adjuvant-induced knee arthritis

LE Robledo-González,1 A Martínez-Martínez,1 VM Vargas-Muñoz,1 RI Acosta-González,2 R Plancarte-Sánchez,3 M Anaya-Reyes,4 C Fernández del Valle-Laisequilla,5 JG Reyes-García,6 JM Jiménez-Andrade1 1Laboratorio de Farmacología, 2Departamento de Análisis Clínicos, Unidad Académica Multidisciplinaria Reynosa-Aztlán, UAT, Reynosa, Tamaulipas, Mexico; 3Departamento de Anestesiología, Terapia Intensiva y Clínica del Dolor, Instituto Nacional de Cancerología, Mexico City, Mexico; 4Investigación Clínica y Farmacovigilancia, 5Investigación Clínica y Farmacovigilancia, Productos Medix, S.A. de C.V., Mexico City, Mexico; 6Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico Background: The role of dopaminergic system in the development of rheumatoid arthritis-related pain, a major symptom in this disease, has not been explored. Therefore, the antinociceptive effect of mazindol, a dopamine uptake inhibitor, was evaluated in a model of complete Freund’s adjuvant (CFA)-induced arthritis. Furthermore, as studies have shown that the dopaminergic system regulates bone metabolism, the effect of mazindol on bone mass and microarchitecture was determined.Methods: Adult ICR male mice received intra-articular injections of either CFA or saline into the right knee joint every week. Spontaneous pain-like behaviors (flinching and guarding) and locomotor activity were assessed at day 26 post-first CFA, following which, a single intraperitoneally (i.p.) administered dose of mazindol was given (1, 3 and 10 mg/kg). Then, the antinociceptive effect of a repeated administration of 3 mg/kg mazindol (daily, i.p.; day 15–day 26) was evaluated. Additionally, at day 26, the participation of D1-like, D2-like or opioid receptors in the antinociceptive effect of mazindol was evaluated. The effect of mazindol on bone density and microarchitecture was evaluated by micro-computed tomography.Results: Acute administration of mazindol decreased the spontaneous pain-like behaviors in a dose-dependent manner without reducing the knee edema. However, mazindol at 10 mg/kg significantly increased the locomotor activity; therefore, 3 mg/kg mazindol was used for further studies. Repeated administration of 3 mg/kg mazindol significantly decreased the pain-like behaviors without modifying locomotor activity. The antinociceptive effect of mazindol was blocked by administration of a D2-like receptor antagonist (haloperidol), but not by administration of D1-like receptor antagonist (SCH 23390) or an opioid receptor antagonist (naloxone). Repeated administration of mazindol did not significantly modify the density and microarchitecture of periarticular bone of the arthritic and nonarthritic knee joints.Conclusion: Results suggest that mazindol via D2-like receptors has an antinociceptive role in mice with CFA-induced knee arthritis without modifying the bone health negatively. Keywords: dopamine, analgesia, arthritic pain, micro-computed tomograph

Recomendaciones para la buena práctica de la medicina en anestesiología

At present, the Anesthesiology is recognized as a medical discipline and the activities of the anesthesiologist are wide, since it interferes in all the processes that happen during the anesthetic - surgical act. The most common reason of damages or serious complications they are associated with faults in the suitable ventilation of the patient. The aim of the present work is to generate specific and general recommendations directed to specialists of Anesthesiology, from the analysis of the complaints received in the CONAMED. There were analyzed all the complaints received for the specialty of anesthesiology from June, 1996 to May, 2001. Sociodemographic variables were included, information about institution of health and motive of complaint among others. There was included information of the Medical Integral Valuation, to obtain the type of used anesthesia. For the analysis descriptive statistics was used, for this intention it was used SPSS 10.1. Results: there was analyzed a whole of 97 complaints, 74.2 % of the complaints corresponded to the female sex, average of age 34.3 years, the major proportion of the complaints were to institutions of Social Security (67.0%). The proportion of malpractice for type of institution was of 75 % in the private roads, 57.4 % in Social Security and 52.6% in the Public Services. Problems identified with major frequency in the complaints with malpractice were in order: dural puncture, encephalopathy ischemic and cerebral irreversible damage and injury of nervous roots. Five deaths related with anesthesia were identified. The results obtained in the present work as for the problems in the practice of anesthesiology are very similar to the reported ones in the literature and a proportion of cases they can be prevenibles across a better training and supervision of the procedures that are realized.En la actualidad, la Anestesiología se reconoce como una disciplina médica y las actividades del anestesiólogo son amplias, ya que se involucra en todos los procesos que ocurren durante el acto anestésico-quirúrgico. La causa más común de daños o complicaciones serias están asociadas con fallas en la ventilación adecuada del paciente. El objetivo del presente trabajo es emitir recomendaciones generales y específicas, dirigidas a los especialistas de Anestesiología, a partir del análisis de las quejas recibidas en la CONAMED. Se analizaron todas las quejas recibidas en la CONAMED para la especialidad de anestesiología de junio de 1996 a mayo de 2001. Se incluyeron variables sociodemográficas, de la institución de salud y motivo de queja entre otras. Se incluyó información de la Valoración Médica Integral, para obtener el tipo de anestesia utilizada. Para el análisis se empleó estadística descriptiva, para este propósito se utilizó el paquete estadístico SPSS 10.1. Resultados: se analizaron un total de 97 quejas, 74.2% de las quejas correspondieron al sexo femenino, promedio de edad pacientes 34.3 años, la mayor proporción de las quejas correspondió a instituciones de Seguridad Social (67.0%). La proporción de mala práctica por tipo de institución fue de 75% en las privadas, 57.4% en seguridad social y 52.6% en servicios públicos. Los problemas identificados con mayor frecuencia en las quejas con mala práctica fueron: perforación de duramadre, seguida por la encefalopatía anoxoisquémica, el tercer lugar para daño cerebral irreversible y lesión de raíces nerviosas. Se identificaron 5 defunciones relacionadas con la anestesia. Los resultados obtenidos en el presente trabajo en cuanto a los problemas en la práctica de la anestesiología son muy semejantes a los reportados en la literatura y una proporción de casos pueden ser prevenibles a través de una mejor capacitación y supervisión de los procedimientos anestésicos que se realizan