Miguel Ángel Villarreal-Alarcón

Posterior Reversible Encephalopathy Syndrome Due to Malignant Hypercalcemia: Physiopathological Considerations

CONTEXT Posterior reversible encephalopathy syndrome (PRES) is a neurological entity characterized by seizures, headache, and reversible subcortical vasogenic edema. It is associated with many etiologies, most often hypertension, chronic renal failure, and chemotherapy. Hypercalcemia is rarely associated with PRES. OBJECTIVE The aim of this study is to describe and discuss a case of PRES that developed in a patient with malignant hypercalcemia, with emphasis on the possible pathophysiological mechanisms involved. PATIENTS AND METHODS A 38-year-old woman presented with altered mental status. She had a 2-month history of lumbar pain of moderate intensity, weight loss, and gastrointestinal complaints, in addition to a mass in her left breast. Her corrected serum calcium was 14.5 mg/dL. She was normotensive, had no focalizing signs, and her cerebrospinal fluid was normal. Despite treatment, her neurological state did not resolve, and she developed severe headaches at day 4 of her admission. Brain magnetic resonance imaging showed a bilateral and symmetric hyperintensity in the occipital and parietal lobes on T2-weighted and fluid-attenuated inversion recovery imaging, a characteristic highly suggestive of PRES. After correction of hypercalcemia, her symptoms and imaging abnormalities resolved. CONCLUSIONS The development of PRES in the setting of severe hypercalcemia is extremely rare. Hypercalcemia could lead to PRES in the absence of hypertension by various mechanisms, including vasospasm, endothelial dysfunction, and an inflammatory state. A high index of suspicion is needed in this setting because hypercalcemia can lead to neurological symptomatology, and prompt diagnosis is essential for adequate treatment.

Medication errors: electronic vs. paper-based prescribing. Experience at a tertiary care university hospital.

PURPOSE It has been estimated that medication errors (ME) are responsible for 7000 deaths each year. Some studies show that electronic prescribing systems have achieved health benefits and patient safety, resulting in a saving of resources. Other studies suggest that they may increase adverse events. OBJECTIVE The objective of this study was to compare medication errors between electronic and paper-based prescription detected during pharmacovigilance. METHODS This was an observational, cross-sectional comparative study of 600 randomized medical records that were systematically reviewed by a pharmacovigilance team, with a deliberate search for ME. Each error was classified according to its severity, National Coordinating Council for Medication Error and Prevention taxonomy and high-risk medications. The number of errors was calculated per 100 prescribed medications, number of errors per record and number of records with an error as a quality indicator. RESULTS A total of 229 ME were found with a mean per record of 0.38 (SD = 0.7), of which 155 corresponded to the paper-based method (1.04, SD = 1.67) and 74 to the electronic-based method (0.29, SD = 0.57) P = <0.001. The use of the electronic method was associated with an OR of 0.59 (95% CI 0.41-0.85) for the recording of at least one ME (P = 0.005), but to a greater severity of ME (<0.001). CONCLUSION The use of the electronic system was associated with a reduction in ME, compared with the paper-based method. Despite this, it was associated with more severe ME.

Esophageal symptoms and their lack of association with high-resolution manometry in systemic sclerosis patients

BACKGROUND The esophageal involvement in systemic sclerosis (SSc) causes impact in the morbidity and mortality. High resolution manometry assesses esophageal involvement. Our aim was to categorize esophageal motor disorder in patients with SSc by HRM. METHODS We carried out an observational, descriptive and cross-sectional study. All patients underwent HRM as well as semi-structured interviews to assess frequency and severity of upper GI symptoms. Patients also completed the gastroesophageal reflux questionnaire (Carlsson-Dent). RESULTS We included 19 patients with SSc, 1 with morphea, and 1 with scleroderma sine scleroderma. Dysphagia and heartburn were the most frequent symptoms (61% each). We found an abnormal HRM in 15 (71.4%) patients. We found no statistically significant association between clinical or demographic variables and an abnormal HRM, or between any upper GI symptom and HRM findings. CONCLUSION We observed a high prevalence of esophageal symptoms and of HRM abnormalities. However, there was no clear association between symptomatology and HRM findings. HRM does not seem to accurately predict upper GI symptomatology.

CREST Syndrome: Clinical Expression of the Disease

A 54-year-old woman presented with a 2-year history of dyspepsia and intermittent dysphagia to solids and athralgias in hands and wrists. At physical examination, we found in the skin telangiectasia on the palate (Fig. A) and palms (Fig. B) and saltand-pepper skin in ears, distal forearm, and lower limb (Fig. C) and sclerodactyly. The tests showed positive antinuclear antibody 1:1280 with centromeric pattern, antitopoisomerase antibody negative, and anticentromere antibody positive 1:10,240. According to the American College of Rheumatology classification criteria, patients with CREST syndromemust meet at least 3 of the following clinical features: calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia. We show some cutaneous presentations of the CREST syndrome and the need to look for them intentionally. In the case of telangiectasias, whose etiology is not fully understood, it is known to occur more in limited sclerosis patients such as in this case. In early stages, they are located in the fingers, hands,