Impact of a series of measures for optimisation hospital code stroke care on door-to-needle times

INTRODUCTION

Time continues to be a fundamental variable in reperfusion treatments for acute ischaemic stroke. Despite the recommendations made in clinical guidelines, only around one-third of these patients receive fibrinolysis within 60minutes. In this study, we describe our experience with the implementation of a specific protocol for patients with acute ischaemic stroke and evaluate its impact on door-to-needle times in our hospital.

METHODS

Measures were gradually implemented in late 2015 to shorten stroke management times and optimise the care provided to patients with acute ischaemic stroke; these measures included the creation of a specific on-call neurovascular care team. We compare stroke management times before (2013-2015) and after (2017-2019) the introduction of the protocol.

RESULTS

The study includes 182 patients attended before implementation of the protocol and 249 attended after. Once all measures were in effect, the overall median door-to-needle time was 45minutes (vs 74 minutes before, a 39% reduction; P<.001), with 73.5% of patients treated within 60minutes (a 47% increase; P<.001). Median overall time to treatment (onset-to-needle time) was reduced by 20minutes (P<.001).

CONCLUSIONS

The measures included in our protocol achieved a significant, sustained reduction in door-to-needle times, although there remains room for improvement. The mechanisms established for monitoring outcomes and for continuous improvement will enable further advances in this regard.

Impact of a series of measures for optimisation hospital code stroke care on door-to-needle times

INTRODUCTION

Time continues to be a fundamental variable in reperfusion treatments for acute ischaemic stroke. Despite the recommendations made in clinical guidelines, only around one-third of these patients receive fibrinolysis within 60minutes. In this study, we describe our experience with the implementation of a specific protocol for patients with acute ischaemic stroke and evaluate its impact on door-to-needle times in our hospital.

METHODS

Measures were gradually implemented in late 2015 to shorten stroke management times and optimise the care provided to patients with acute ischaemic stroke; these measures included the creation of a specific on-call neurovascular care team. We compare stroke management times before (2013-2015) and after (2017-2019) the introduction of the protocol.

RESULTS

The study includes 182 patients attended before implementation of the protocol and 249 attended after. Once all measures were in effect, the overall median door-to-needle time was 45minutes (vs 74 minutes before, a 39% reduction; P<.001), with 73.5% of patients treated within 60minutes (a 47% increase; P<.001). Median overall time to treatment (onset-to-needle time) was reduced by 20minutes (P<.001).

CONCLUSIONS

The measures included in our protocol achieved a significant, sustained reduction in door-to-needle times, although there remains room for improvement. The mechanisms established for monitoring outcomes and for continuous improvement will enable further advances in this regard.

Recommendations for vaccination in patients with multiple sclerosis who are eligible for immunosuppressive therapies: Spanish consensus statement

BACKGROUND

The recent development of highly effective treatments for multiple sclerosis (MS) and the potential risk of infectious complications require the development of prevention and risk minimisation strategies. Vaccination is an essential element of the management of these patients. This consensus statement includes a series of recommendations and practical scenarios for the vaccination of adult patients with MS who are eligible for highly effective immunosuppressive treatments.

METHODOLOGY

A formal consensus procedure was followed. Having defined the scope of the statement, we conducted a literature search on recommendations for the vaccination of patients with MS and specific vaccination guidelines for immunosuppressed patients receiving biological therapy for other conditions. The modified nominal group technique methodology was used to formulate the recommendations.

DEVELOPMENT

Vaccination in patients who are candidates for immunosuppressive therapy should be considered before starting immunosuppressive treatment providing the patient's clinical situation allows. Vaccines included in the routine adult vaccination schedule, as well as some specific ones, are recommended depending on the pre-existing immunity status. If immunosuppressive treatment is already established, live attenuated vaccines are contraindicated. For vaccines with a correlate of protection, it is recommended to monitor the serological response in an optimal interval of 1-2 months from the last dose.

[Relationship between homocysteinaemia and sympathetic skin response in Parkinson's disease]

INTRODUCTION

High levels of homocysteine linked to treatment with levodopa have been observed in patients with Parkinsons disease (PD). Our aim was to assess the influence of serum homocysteine levels and other PD-related on the sympathetic skin response.

PATIENTS AND METHODS

An observational, cross-sectional study was conducted that consecutively included patients with PD. We unilaterally assessed the sympathetic skin response in the upper limbs. We measured the influence of PD severity (measured by the Hoehn and Yahr and the Schwab and England scales, and the Unified Parkinson Disease Rating Scale) and blood homocysteine, vitamin B12 and folic acid levels on the latency and amplitude of the sympathetic skin response.

RESULTS

A total of 78 patients were enrolled, and all achieved a sympathetic skin response. In the bivariate analysis, latency was significantly correlated with age, age at PD onset and homocysteinaemia levels. The presence of hyper-homocysteinemia was associated with a longer latency. The amplitude was only correlated with the score on the Schwab and England scale. In the multivariate analysis, age was the only variable that showed a significant association with the latency duration and homocysteine levels.

CONCLUSION

A direct association could not be established between the increase in homocysteinaemia levels and sympathetic skin response dysfunction in PD. The results of the multivariate analysis suggest that latency prolongation in elderly patients could be due to the fact that these patients have higher blood levels of homocysteinaemia.

Effect of optic neuritis on progressive axonal damage in multiple sclerosis patients

Objective: The objective of this research was to study the effect of optic neuritis (ON) on axonal damage in multiple sclerosis (MS) patients. Specifically, we compared changes over 2 years in the retinal nerve fibre layer (RNFL) between affected and contralateral eyes in MS patients with a prior history of ON.

Methods: Thirty-four patients with one unilateral definitive episode of ON were included and underwent a complete ophthalmic examination, optical coherence tomography (OCT), scanning laser polarimetry, visual evoked potentials (VEP) and pattern electroretinogram (pERG). All patients were re-evaluated at 12 and 24 months. Parameters were compared between ON-affected and contralateral eyes in an initial exploration and over the course of the follow-up. Correlations between parameter changes were analysed.

Results: RNFL thickness and functional parameters showed more affection in ON eyes ( p ≤ 0.05), but changes in measurements during the study were similar between both groups of eyes.

Conclusions: Progressive axonal loss can be detected in the optic nerve, but ON is not a risk factor for increased chronic damage in MS patients without ophthalmic relapses. Loss of the RNFL is caused by progressive degeneration associated with the disease.

[Effect of treatment in loss of retinal nerve fibre layer in multiple sclerosis patients]

OBJECTIVE

To evaluate the effect of pathogenic treatments in the reduction of the retinal nerve fibre layer (RNFL) in patients with Multiple Sclerosis (MS) by means of ocular imaging technologies.

MATERIAL AND METHODS

A total 155 eyes of 79 patients with MS were enrolled in this study. All patients underwent a complete ophthalmic examination including best corrected visual acuity using Snellen chart, colour vision using Ishihara pseudoisochromatic plates, visual field examination, optical coherence tomography (OCT), scanning laser polarimetry (GDx) and visual evoked potentials. The patients were re-evaluated after a one year period and changes were assessed in order to detect differences between treatments using the Anova statistical test. The patients were divided into four groups: 1) Patients without treatment, 2) Patients treated with interferon beta-1a, 3) Subjects who received interferon beta-1b, 4) Patients treated using glatiramer acetate.

RESULTS

There were no statistically significant differences between patients with or without treatment and between the four groups (P>0.05, t test), but functional and structural parameters showed greater loss in RNFL thickness in non-treated patients. Temporal quadrant RNFL thickness measured by OCT was the parameter with the highest variation (reduction of 4.97μm in patients without treatment vs 1.08μm in treated patients).

CONCLUSIONS

MS pathogenic treatment may be a protective factor in the RNFL loss that is associated to the disease progression. More studies are needed.

[Atrophy of the retinal nerve fibre layer in multiple sclerosis patients. Prospective study with two years follow-up]

OBJECTIVE

To evaluate the changes over two years in the retinal nerve fibre layer (RNFL) of patients with multiple sclerosis (MS). To compare the ability of optical coherence tomography (OCT), scanning laser polarimetry (GDx), visual evoked potentials (VEP) and visual field examination to detect axonal loss in these patients.

MATERIAL AND METHODS

Fifty eyes of MS patients without episodes or optic neuritis during follow-up were enrolled in this study. All patients underwent a complete ophthalmic examination that included visual acuity (VA), colour vision, refractive evaluation, visual field examination, OCT, GDx and VEP. All the patients were re-evaluated over a period of 12 and 24 months. Correlations between parameters were analysed by Pearson's test.

RESULTS

There were changes in the RNFL thickness in MS patients with a 12 and 24-month follow-up. Differences between baseline and 2-year evaluation were statistically significant (p ≤ 0.05, t test) in the mean, superior and inferior RNFL thickness and macular volume provided by OCT, while no significant differences were found using functional parameters (VA, colour vision, visual field and VEP) and GDx. The greater differences were obtained in the inferior RNFL thickness (113.67 frente a 105.39 μm, p < 0.001). Correlations were observed between structural parameters using GDx and TCO.

CONCLUSIONS

Progressive axonal loss can be detected in the optic nerve of MS patients. Measurements provided by TCO are useful tools to evaluate structural abnormalities in the RNFL and changes in macular volume, however these changes were not detected using functional tests or GDx.

[Quality as management tool. Actions to improve efficiency in neurological care]

INTRODUCTION

Quality of care involves meeting the needs and expectations of patients with the lowest consumption of resources and in accordance with scientific knowledge. In this context it is important to know if the changes in medical care procedures based on scientific and technical aspects of the quality positively impacts both efficiency measures and perceived quality.

METHODS

Prospective study carried out during the 2000-2006 period at the neurology department of a public hospital with has 1303 beds. Changes in medical care introduced: adequacy of a high resolution hospitalization zone, setting up of three care pathways (transient ischemic attach [TIA], multiple sclerosis exacerbation and first epileptic seizure) and practice guidelines for stroke, and implementation of neurological care at the emergency department.

RESULTS

There has been an increase in the number of patients treated in the emergency department of the hospital (17%), although the number of admissions has stabilized. In the neurology department, the number of admissions has decreased by 20%, especially those arising from TIA (decrease by 47%), the average stay has been reduced by 30% (especially in demyelinating and vascular disease, which has fallen by 50%). Adjusted average length of stay has remained below 1 and the complexity index above 1. Satisfaction with the information and health care has undergone little change.

CONCLUSIONS

The changes in clinical practice to improve the quality of care have been associated with improvements in the efficiency indicators but not in patient satisfaction. The improvement in the perceived quality probably requires specific actions.

[Pseudoballism secondary to spinal trauma]

INTRODUCTION

Ballism is a rare movement disorder that presents with violent and wide amplitude flinging movements of the limbs, mainly caused by injury in the contralateral subthalamic nucleus or its afferent or efferent connections.

CLINICAL CASE

We describe the case of a 50-year old male who had ballistic movements after a cervical trauma. He subsequently developed choreoathetoid movements and a distonic attitude in the left upper limb later. A C2-C3 sensory level and proprioceptive loss in this limb were the main findings in the examination. The cervical magnetic resonance showed a transverse linear spinal lesion at C1 level that affected most of its section.

CONCLUSIONS

This case stands outs because of the wide abnormal movements spectrum secondary to spinal proprioceptive pathway injury: ballistic, choreoathetoid, and distonic movements. Choreoathetoid movements occurring in association with loss of propioception have been called pseudochoreoathetosis. We propose the term pseudoballism to define the movements that were observed during the acute phase in this patient.

[Importance and factors related to chronic fatigue in multiple sclerosis]

INTRODUCTION

The importance of fatigue in multiple sclerosis (MS) is determined by its high frequency and it is an important cause of disability.

OBJECTIVE

To determine factors that are related to the presence of chronic fatigue in patients with MS.

PATIENTS AND METHODS

The series comprises patients with MS, consecutively attended in the demyelinizating diseases unit, who met the following criteria: clinically definite MS (RR or SP), MS duration of more than two years, and no relapses during the previous month. Analyzed variables were as follows: chronic fatigue, demographic data, functional systems, EDSS, ISS, ESS, disease activity, Hamilton, depression scale GHQ-28, PSQI, and interferon. Statistical study: bivariate and multivariate analysis by logistic regression.

RESULTS

A hundred patients were included, 72 female and 28 male. Mean age was 39.27 years. Of the 100 patients 88 had RR disease and 12 SP disease. MS mean duration was 11.2 years. Mean EDSS 2.54. Chronic fatigue was 53 %. The presence of depression increased the probability of chronic fatigue 3.6 fold, and every point in PSQI-7 increases it 3.5 fold.

CONCLUSION

Depression and the PSQI-7 subscale (day sleep dysfunction) are the only variables independently related to chronic fatigue in patients with MS.

[Sleep disorders in multiple sclerosis]

INTRODUCTION

To determine the frequency of sleep disorders in multiple sclerosis (MS) patients and their relation with other manifestations of the disease.

METHODS

Selected patients had clinically definite MS (relapsing-remitting and secondary progressive forms) and duration of the disease over two years. They were serially evaluated at the unit of demyelinating diseases of a third level hospital. The following scales were applied: the Pittsburgh Sleep Quality Index, the Hamilton Depression Rating Scale, EDSS, ISS and ESS. Statistical analysis by means of non parametric test and logistic regression was carried out.

RESULTS

One hundred patients were included (72% women and 28% males). Mean age was 39 years. Eighty eight were relapsing-remitting forms and the rest secondary progressive forms. Mean EDSS was: 2.5. Mean duration of evolution: 11.2 years. The prevalence of sleep disorders was 36%. Age, sex, evolutionary form, degree of disability and chronic fatigue did not relate with the sleep disorders in these patients. In the multivariant analysis by means of logistic regression, we found that every point more in Hamilton's scale multiplies the probability of presenting sleep disorders by 1.2.

CONCLUSIONS

Depression is the only variable that independently relates, with the presence of sleep disorders in MS patients.

[Predicting factors for depression in multiple sclerosis]

INTRODUCTION

We assess frequency and intensity of depression in multiple sclerosis (MS) patients, the degree at which it is detected and its relationship to the treatment with beta interferon and other clinical and paraclinical factors.

METHODS

The series comprises MS patients, seen in the Demyelinating Disease Unit of a tertiary hospital, who fulfilled the following criteria: clinically defined MS (relapsing-remitting or secondary progressive), disease duration greater than two years and absence of relapses during the month prior to the study. The variables analyzed were detection and assessment of depression with the Hamilton Depression Scale, general demographic data, functional systems, EDSS, ISS, ESS, Pittsburgh Sleep Quality Index, interferon treatment, chronic fatigue and a series of analytical variables. Statistical study: both variate and multivariate analysis by logistic regression.

RESULTS

100 patients (72 female and 28 male). Mean age: 39.27 years. RR MS form, 88%, and SPMS form, 12 %. Mean evolution time, 11.2 years. Mean EDSS, 2.54. Depression was present in 44 % of the patients in our group and was not related to neurological degree of disability, disease evolution time, clinical form, interferon treatment, or to sleep disorders. However, depression was related to the presence of both chronic fatigue and ESS scores.

CONCLUSIONS

Depression is common in MS patients and is associated with the presence of chronic fatigue and a worse social status.

[Modifications of the lipid metabolism induced by interferon beta in multiple sclerosis patients and its relationship with the disease activity]

INTRODUCTION

It has been recently suggested that total cholesterol and low density lipoproteins (LDL) levels can behave as biological markers of activity in demyelinating diseases. Thus, our aim has been to describe the modifications of the plasma levels of total cholesterol and triglyceride due to treatment with interferon-beta in multiple sclerosis (MS) patients and to determine their relationship with the disease activity.

PATIENTS AND METHODS

Study of the follow-up of MS patients under treatment with interferon-beta. Clinical and analytical controls were performed before initiating treatment and than at 1, 3, 6, 12, 18 and 24 months of its initiation.

RESULTS

Fifty six patients have been studied, 41 of them women. Mean age was 37.4 years. Fifty were relapsing- remitting forms and the rest secondary progressive forms. The mean plasma levels of triglyceride increased and total cholesterol levels diminished during the 24 months of treatment with interferon, mainly in the first 3 months. No statistically significant relationship was found between disease activity and mean plasma levels of triglyceride and total cholesterol before the beginning of the treatment and during the period of follow-up.

CONCLUSIONS

Treatment with interferon-beta in the MS patients originates changes in the plasma lipid profile, but neither these changes nor the plasma lipid levels before the treatment behave as biological markers of disease activity.

Public health surveillance and incidence of adulthood Guillain-Barré syndrome in Spain, 1998-1999: the view from a sentinel network of neurologists

Temporal variation in Guillain-Barré syndrome (GBS) warrants monitoring in certain situations. This study sought to describe a public-health-based GBS surveillance service in Spain and conduct pilot surveillance in the period 1998-1999. Neurologists from 11 hospitals countrywide, serving a population of 3.9 million, reported all patients, ages 20 years or over, admitted to hospital with suspected GBS. Cases that did not belong to the designated hospital catchment area or failed to fulfill diagnostic criteria after follow- up were excluded. Reported monthly incidence was compared against predicted incidence obtained from retrospective data (1985-1997) using a reported method based on 97.5% percentile values. Alarm thresholds for 2000 onwards were obtained by applying the same method to the updated 1985-1999 series. During the 2-year period, 98 GBS cases were reported, yielding an overall age-adjusted incidence of 1.26 per 100 000 population, with a breakdown by sex of 1.83 for males and 0.76 for females. Monthly incidence remained below or was similar to the corresponding threshold limit value. Seasonality with highest incidence in winter was more pronounced in the elderly. Preceding events, mainly respiratory infections, were identified in 71% of patients. Pilot two-year GBS surveillance in Spain resulted neither in alarm nor in preventive measures. Adult GBS incidence in Spain might be monitored by a surveillance system set up at short notice when a possible threat is perceived. A monthly incidence of over 3 per 100 000 person-years in the population aged 20 years or older would exceed threshold values.

Corticosteroids, ibuprofen, and acetaminophen for IFN -1a flu symptoms in MS: A randomized trial

OBJECTIVE

To compare the efficacy of acetaminophen, ibuprofen, and prednisone in the treatment of interferon beta-1a (IFNbeta-1a) flu-like syndrome (FLS).

METHODS

Patients with relapsing-remitting multiple sclerosis initiating treatment with IM IFNbeta-1a were randomized in a multicenter, randomized, double-blind, controlled trial to receive acetaminophen 500 mg before and 6 and 12 hours after each injection, ibuprofen 400 mg before and 6 and 12 hours after each injection, or prednisone 60 mg daily for 1 week, plus tapering. Patients were instructed to keep a daily diary of fever severity, myalgia, chills, headache, and asthenia for 27 days. The sum of the scores of individual symptoms was used to obtain a daily FLS index. The primary outcome was the FLS index area under the curve (AUC) corrected by the number of measurement days.

RESULTS

Eighty-four patients were randomized at 11 hospitals: acetaminophen (n = 28), ibuprofen (n = 28), and corticosteroids (n = 28). No differences were detected between treatments in the mean AUC of the FLS index. With limitation of the analysis to the days of IM IFNbeta-1a injection, differences favoring ibuprofen were observed in the mean FLS index (p = 0.0007).

CONCLUSIONS

No prophylactic treatment for flu-like syndrome seems to be superior to another in terms of overall well-being during the first month of IM IFNbeta-1a therapy. However, ibuprofen confers better control of symptoms immediately following IM IFNbeta-1a injection.

Guillain-Barré syndrome in Spain, 1985-1997: epidemiological and public health views

Retrospective demographic information and hospital record data were collected for 337 patients resident in Spain who had validated Guillain-Barré syndrome (GBS) diagnoses and clinical onset during the period 1985-1997 and had been admitted to 11 centres, covering a population of 3.9 million. The European age-adjusted GBS incidence per 100,000 for 1985-1997 among the population aged 20 and over was 0.85, with a breakdown of 1.14 in men and 0.58 in women. Incidence increased with age and time, with occasional rises that mimicked outbreaks and occurred at irregular 2- to 4-year intervals, mainly in winter. Spatial variation was modest. Respiratory and gastrointestinal infections respectively constituted 49.3 and 19.3% of recorded preceding events. The 97.5% intercentile limit, obtained from the 1985-1997 monthly incidences using predictions from a Poisson model, was proposed as the threshold value for pilot epidemiological surveillance of GBS in 1998-1999.

Evaluation of handicap and socio-economic status in patients with multiple sclerosis--data from a population-based survey in the sanitary area of Calatayud, northern Spain

There are a few reports about handicap and socio-economic status in patients with multiple sclerosis (MS) based on epidemiological studies. The objective of our work is to evaluate handicap in patients with multiple sclerosis in the sanitary area of Calatayud, northern Spain, as well as the socio-economic situation--in comparison with patients from other parts off the world. In this study we included 34 patients with clinically definite MS found in a long-term and prospective population-based survey. For assessing the handicap degree and socio-economic status we used the Environmental Status Scale (ESS) recommended by the International Federation of MS. We compared the results with those found in 1116 patients from 7 different international series. The global mean score in ESS was 9.9 (sd 9.3, range 0-31). The mean score for the item "actual work status" was 3.3 (sd 2.3, range 0-5), for the item "financial/economic status" was 1 (sd 1.7, range 0-5), for the item "personal residence/home" was 0.8 (sd 1, range 0-4), for the item "personal assistance" was 1.2 (sd 1.7, range 0-5), for the item "transportation" was 1.5 (sd 1.7, range 0-5), for the item "community health services" was 0.7 (sd 1.3, range 0-5) and for "social activity" was 1.3 (sd 1.5, range 0-4). In the comparative assessment we found that our patients were better in all items, but in the item "actual work status" where our patients yielded higher scores than those obtained in other series. Socio-economic status measured with ESS correlates well with the degree of impairment measured with EDSS and it is more favourable than previously recognized, except for "actual work status" item. The high rate of labour incapacity in our series could be due to the considerable restrictions handicapped people have to cope with in order to find employment in rural areas.

[Hypoxic encephalopathy and cortical laminar necrosis]

INTRODUCTION

Cortical laminar necrosis is characterized by destruction of the cerebral cortex, mainly of the third layer, in situations of reduced energy supply to the brain. The cerebral lesions caused are known through studies made at autopsies, but there are few descriptions in the literature of the neuroimaging changes. We report the case of a patient who suffered hypoxic encephalopathy secondary to prolonged status epilepticus, and in whom cerebral MR showed changes compatible with cortical laminar necrosis.

CLINICAL CASE

A 16 year old girl who had been epileptic since infancy presented with a state of generalized tonic-clonic convulsions followed by coma. Three weeks later she was mute, had a blink reflect to threats and followed visual stimuli with eye movements but no voluntary motor or verbal response. She also showed generalized hypertonia and fine tremor of her arms, which she moved spontaneously with no asymmetry. After two months her clinical condition became stable. Cerebral MR at this time showed diffuse hypersignal of the cortex and basal ganglia in T2 and FLAIR sequences and hyposignal of the subcortical white matter associated with a marked hypersignal delimiting the grooves of convexity in T1 sequences.

CONCLUSIONS

Situations of prolonged hypoxia, such as in status epilepticus, lead to necrosis of layers of the cerebral cortex. Clinically this is seen as the appearance of hypoxic encephalopathy and radiologically as characteristic alterations of neuroimaging known as cortical laminar necrosis.

[Demyelinating pseudotumoral lesion prior to a primary cerebral lymphoma]

INTRODUCTION

Some case of demyelinating pseudotumoral lesions preceding the appearance of primary cerebral lymphoma have been reported. The relation between the two conditions is not known. We report the case of a woman in whom a demyelinating pseudotumoral lesion had been diagnosed on biopsy and who developed a primary cerebral lymphoma 13 months later.

CLINICAL CASE

In October 1997 a 38 year old woman presented with a secondarily generalized focal motor seizure. Neuroimaging showed a left frontal tumour with marked oedema and uptake of contrast medium. Based on the clinicoradiological suspicion of a primary cerebral tumour or metastasis, treatment was started with dexamethasone. Approximately two weeks later a stereotaxic biopsy was done, in which there was demyelination with conservation of the axons and perivascular inflammatory infiltration with polyclonal T and B lymphocytes. The diagnosis was 'a pseudotumoral form of a demyelinating disease'. Thirteen months later the patient had episodes of falling to the floor, followed by subsequent slight confusion and difficulty in speaking. On neuroimaging studies (cerebral CAT and MR) there was a tumour of the left basal ganglia, considerable oedema and homogeneous marking following the injection of contrast. Anatomopathological study of the lesion showed a B cell lymphoma.

CONCLUSION

In cases of pseudotumoral demyelinating lesions the possibility of a primary cerebral lymphoma of the central nervous system must be remembered.

Prevalence of multiple sclerosis in the sanitary district of Calatayud, Northern Spain: is Spain a zone of high risk for this disease?

We undertook an epidemiologic study to ascertain the prevalence of multiple sclerosis (MS) in the Sanitary District of Calatayud, in the north-east of Spain.

METHODS

The study was performed from October 1990 to July 1996. The total number of residents in the area was 58,591. An extensive search was carried out to identify all cases of known or suspected MS through general practitioners and specialists, sanitary authorities in the area, the reference hospital, the Spanish Multiple Sclerosis Society, the newspaper and radio.

RESULTS

April 1, 1995 was chosen as prevalence day. The crude prevalence rate for the area was 58 per 100,000 (95% CI: 39-78). The approximate annual incidence rate was 2.6/100,000 (1980-1989).

CONCLUSIONS

This study and others conducted recently in Spain show that MS is more prevalent than was previously thought and afflicts at least 53-65 per 100,000 population.

Neurological impairment in alpha-mannosidosis: a longitudinal clinical and MRI study of a brother and sister

Neurological development over a period of 25 years and MRI findings are reported in two members of the same family affected by mannosidosis type II. Progressive axial and appendicular cerebellar syndrome, moderate hearing loss and deterioration of gait were present in both patients. Neuropsychological deficiency was severe, but progression over the years was not observed except in the woman's speech capacity. Neither of the patients showed clinical improvement. A progressive corticosubcortical atrophy stands out in the brain neuroimaging studies, especially at the vermian cerebellar level. The osseous cranial deformities are very characteristic and include brachycephaly, thickening of the calvaria at the expense of the diploe, and poor pneumatization of the sphenoid. Neither of our cases showed an empty sella turcica.

[Severe polyneuropathy after using nitrous oxide as an anesthetic. A preventable disease?]

INTRODUCTION

Nitrous oxide is a commonly used anaesthetic agent. One complication of this is due to its capacity to inactivate cobalamin. Therefore, in patients with poor reserves of vitamin B12, neurological and hematological alterations may be induced after a short period of exposure to nitrous oxide.

CLINICAL CASE

A 69 year old man was anesthetized for three hours with 50% nitrous oxide during a surgical operation. Two weeks later he complained of severe mixed, mainly sensory polyneuropathy and was unable to walk. On diagnostic studies, vitamin B12 levels were found to be 18 pg/ml. The Shilling test confirmed that there was lack of intrinsic factor. In the preoperative studies a striking increase in motor conduction velocity was observed. Neurophysiological studies showed that there was mixed polyneuropathy, predominantly axonal. After starting treatment with hydroxycobalamin there was marked improvement and the patient became able to walk unaided.

CONCLUSION

Since nitrous oxide may cause serious neurological alterations in patients with subclinical deficits of cobalamin, which may not always be accompanied by hematological changes, we consider the need for determination of plasma levels of vitamin B12 and if possible, of methylmalonic acid and homocysteine in elderly patients who are to have general anesthetics involving nitrous oxide.

Prevalence of Parkinson's disease in lower Aragon, Spain

OBJECTIVE

We attempted to measure the prevalence of Parkinson's disease (PD) and to improve PD diagnosis in Lower Aragon (LA), a rural area located in northeast Spain with an elderly population numbering 60,724.

METHODS

Hospital records and a questionnaire targeted at general practitioners and retirement home personnel were used for case finding. Neurologic diagnoses were ascertained by a neurologist using a clinicoepidemiologic protocol and established diagnostic criteria after examining 84% of patients diagnosed with PD. Using stratified analysis, a comparison was run against reported PD prevalence from worldwide door-to-door surveys.

RESULTS

On the prevalence date, 134 individuals were found to be affected with PD. The prevalence per 100,000 population was 220.6 (crude) and 121.9 when age-adjusted using the European Standard Population. Prevalence increased with age, declining at 90 years and over. Questionnaires returned by general practitioners disclosed 20% of the prevalent PD cases. The prevalence of PD in pooled European populations was 2.56 times (95% confidence interval [CI]: 2.02-3.24) greater than that found in our study.

CONCLUSION

PD prevalence in Lower Aragon ranks at levels similar to those reported for white populations (European and non-European). One out of two individuals with PD was estimated to be undiagnosed before and three out of eight after the study.

Study of HLA as a predisposing factor and its possible influence on the outcome of multiple sclerosis in the sanitary district of Calatayud, northern Spain

The relationship between multiple sclerosis (MS) and the HLA antigens DR2 and DQ1 is well recognised, but, in Spain, it has not been clearly defined. The aim of our study was to investigate the relationship between MS and HLA antigens in the sanitary district of Calatayud, northern Spain, and to correlate these antigens with the progression of the disease. Thirty-four patients were selected from a long-term (October 1990 to July 1996) prospective survey in the region where there was a prevalence rate of 58 per 100,000 population. The HLA antigens were determined in 31 patients. A control group of 895 people of Caucasian race was recruited from the same population. We performed serologic tests on all participants. Nucleotide typing was carried out in DR2-positive patients. The most frequent antigens in excess in MS were: A19 (odds ratio, OR: 2.29, p = 0.04), B5 (OR: 2.85, p = 0.02), B41 (OR: 7.65, p = 0.04), CW7 (OR: 3.4, p = 0.004), DR6 (OR: 6.18, p = 0.0001) and DR10 (OR: 3.4, p = 0. 004). The DR2 antigen was also more frequent in MS patients (39%) than in controls (19%; OR: 2.69, p = 0.01). All positive DR2 patients showed the DR15(2) split but not the DR16(2) split. The frequency of antigens CW4 and DR1 was lower in MS patients than in controls. The CW4 antigen was detected in 12% of the patients and in 33% of the controls (OR: 0.28, p = 0.04). The DR1 antigen was found in 20% of the controls and in none of the MS patients (OR: undefined, p = 0.01). The DQ1 antigen was observed in 68% of the patients and in 50% of the controls (OR: 2.1, p = 0.07). We did not find any relationship between HLA antigens and progression of the disease. Although we found that DR2 antigen is linked to MS, we also found other antigens related to the disease. This suggests a genetic heterogeneity in our geographic area. We also concluded that the DR1 antigen may play a protective role, as it was detected in 20% of the controls and in none of the MS cases.

[Depression and Parkinson disease]

OBJECTIVE

Depression occurs more often in Parkinson's disease (PD) than in other chronic illnesses with important disability. The relationship between the depression level and some clinical features of PD remains controversial. Frequency of depression in these patients has been estimated and relationship between this symptom with some clinical features of PD.

METHODS

A diagnosis of PD was taken according to the United Kingdom Parkinson's Disease Society Brain Bank criteria. Depression status was rated with Geriatric Depression Scale (GDS).

RESULTS

Sixty-two patients (56%), 24 male and 38 female, were depressed at the time of study. The frequency of depression was higher in female (61% vs 39%, p < 0.05) and younger patients with a significant difference (p < 0.001). 53.4% of the patients became depressed previous of beginning PD symptoms, being 71% female (p < 0.05). Patients with depression had had PD longer than patients without depression (7.7 vs 5.3 years old, respectively; p < 0.05). Patients with depression were found to be more affected on motor rating scales (p < 0.01).

CONCLUSIONS

Depression was found in 56% of PD patients, with female predominance (61%). Frequency of depression was higher in younger patients. Depression was associated with duration of PD and an inverse relationship between depression and cognitive status was found.

[Cognition deterioration in Parkinson's disease: associated risk factors]

INTRODUCTION

Frequency estimation of dementia in Parkinson's disease (PD) has often been the source of controversy owing to variations in the case selection methods and diagnosis criteria used. We examined the frequency of dementia and differences found in some clinical features between PD patients with or without cognitive impairment, to determine the risk factors for incident dementia in PD patients.

METHODS

A diagnosis of PD was taken according to the United Kingdom Parkinson's Disease Society Brain Bank criteria. Subjects were considered as affected from cognitive impairment if Minimental State Examination score was below to 21.

RESULTS

Cognitive impairment was present in 36% of PD patients. The mean age was higher in PD patients with cognitive impairment (76 vs 69 years old, respectively; p < 0.001). The age onset of PD was higher in patients with cognitive impairment (68 vs 63 years old, respectively; p < 0.01). The rate of PD patients with low educational level were higher in patients with cognitive impairment (59 vs 30%, respectively; p < 0.01). Patients with cognitive impairment had higher rating scale score (p < 0.001).

CONCLUSIONS

Cognitive impairment was present in 36% of examined PD patients, based in our operative diagnostic criteria. The cognitive status decrease continuously with age. It's also evidence an inverse relation between educational level and rating scale score with cognitive impairment.

[Electro-clinical and neuroimaging studies in epilepsy in elderly patients]

INTRODUCTION

Due to the aging population in developed countries, epidemiological studies show an increasing tendency to the prevalence of epilepsy in the elderly.

PATIENTS AND METHODS

During 54 months, we have studied the electroclinical and neuroimaging features in outpatients older than 60, with active epilepsy. Every patient was interviewed by one of the authors. Then, we have reviewed the medical records about the clinical features, EEG and neuroimaging (NI) studies and seizures frequency (SF) outcome. Differences in crude proportions were assessed by chi 2 test for independence by 2 x 2 tables.

RESULTS

The study was been performed in 78 patients with 70.3 +/- 7.3 years of mean age at review. Partial seizures were significantly related with an higher SF at onset and, in the series of complex partial seizures was more frequent a temporal EEG topography. There was predominance of men, NI abnormal, symptomatic etiology and SF at onset > or = 1 by day in that patients who started their epilepsy after 60 years. A 51.3% was seizures-free in the last year and in 80% the SF was improved a 50% or more from the beginning.

CONCLUSION

A significantly greater percentage of patients remained with seizures in four cases: in those with a SF at onset greater than 1 every day, in those suffering complex partial seizures, in women and in patients with temporal EEG topography.

Brucellar spinal epidural abscess

Spinal epidural abscesses account for approximately one of every 10, 000 admissions to tertiary hospitals. The midthoracic vertebrae are the most frequently affected, whilst the cervical spine is involved in fewer patients. Staphylococcus aureus is identified as the cause in most cases of epidural abscess; other bacteria responsible include Gram-negative bacteria, Streptococcus species and Brucella species. We report the case of a patient with cervical spondylodiscitis at level C4-C5 and an epidural abscess which was compressing the spinal cord and the retropharyngeal space. The previous symptoms of brucellosis were atypical. We discuss the clinical manifestations, diagnosis, treatment and prognosis of the case.

[Polyneuropathy caused by vitamin B12 deficiency secondary to chronic atrophic gastritis and giardiasis]

INTRODUCTION

In chronic atrophic gastritis atrophy of the stomach glands leads to intrinsic factor deficit, with consequent failure to absorb vitamin B12 and gastric achylia, which predisposes to Giardia infection which in itself leads to depletion of vitamin B12. We describe the case of a patient with peripheral and central nervous system pathology due to lack of vitamin B12 secondary to the combined effect of these two disorders.

CLINICAL CASE

A 54 year old woman consulted us for paraesthesia and weakness of the legs which had been progressive for the previous two years. She presented with tactile hypoaesthesia, hypoparaesthesia, distal hyperreflexia and dysymmetry of the legs, ataxic-spastic gait and a positive Romberg sign. The investigations carried out showed the serum vitamin B12 level to be 3 pg/ml (N: 180-900), hemoglobin 13 g/dl and MCV 111 fl with MCHC 348/dl; neurophysiological studies: compatible with demyelinating motor polyneuropathy. Schilling test: deficit of absorption of vitamin B12 which was corrected on administration of intrinsic factor; gastroscopy; atrophic gastritis which confirmed the morbid anatomy findings. There was also flora containing Helicobacter and massive Giardia infection. Replacement and antibiotic therapy was followed by complete remission of the clinical picture.

CONCLUSION

We emphasize the excellent clinical response to treatment in spite of the time elapsed since onset of symptoms.

[Ocular myasthenia: clinical course and strategies for treatment]

INTRODUCTION

Ocular myasthenia gravis is a localized form of myasthenia in which only the extra-ocular muscles are clinically affected, namely the levator palpebrae superioris and orbicularis oculi. Two years after onset of the ocular condition, it became generalized in 44-53% of the patients.

OBJECTIVE

1. To describe the clinical features, diagnostic characteristics and clinical course of seven patients who fulfilled the criteria for diagnosis of ocular myasthenia and in whom the condition did not become generalized: 2. Review recent papers on this. Material and methods. We studied seven patients (two men and two women) diagnosed as having ocular myasthenia gravis, and followed them up for at least three years.

RESULTS

The average age was 56.5. The clinical findings were of ptosis of the eyelids and diplopia. All seven patients were treated with pyridostigmine. In six cases prednisone was also given and in one patient thymectomy was done. There was a satisfactory result in all cases.

CONCLUSIONS

The basic treatment of ocular myasthenia is with anticholinesterases and corticosteroids. Occasionally other immunosuppressives may be required. Prednisone seems to reduce the number of patients who go on to develop the generalized form.

[Determining factors in decisions regarding cardio-pulmonary resuscitation in patients with cerebral hemorrhage]

INTRODUCTION AND OBJECTIVE

Some medical factors related with cardiopulmonary resuscitation (CPR) outcome are known. Moreover, there are other factors, not strictly medical ones, as age, gender, race and socioeconomic status, that influence on decisions of CPR. The aim of this study was to analyse the influence of all this factors on in-hospital CPR of the patients with intracerebral hemorrhage.

MATERIAL AND METHODS

This retrospective study comprised all the consecutive patients hospitalized with spontaneous intracerebral hemorrhage who died within 30 days of hospital admission in a public hospital during the period 1987-1994. We used stepwise logistic regression to identify variables that had a significant independent relation with decision of CPR.

RESULTS

We identified 73 patients, 50 men and 23 women. Their mean age was 61 years. RCP was performed in 25 patients (34%). A logistic regression revealed that age (OR 0.8), Glasgow score on admission (OR 0.67) and time of death (OR 1.2) were significantly associated with CPR decision.

CONCLUSIONS

CPR was less probable in aged even though they had better level of consciousness on admission. Moreover, CPR was less probable early in the morning.

[Myelitis and optic neuritis caused by varicella]

INTRODUCTION

Varicella mainly affects children between 1 and 14 years old. It is the initial infection caused by the Varicella-Zoster virus. It is characterized by a vesicular cutaneous eruption, fever and generally good prognosis. The neurological complications caused by the Varicella-Zoster virus are infrequent and include: meningitis, encephalitis, cerebellar ataxia, Reye's syndrome, myelitis, optic neuritis, mononeuropathy, polyneuropathy, necrosis of the retina and cerebral arteritis.

CLINICAL CASE

We present the unusual case of a woman patient aged 18 who presented with myelitis 15 days after having a varicella rash. Analysis of the cerebrospinal fluid showed intrathecal production of antibodies against the Varicella-Zoster virus. Fourteen days after resolution of the myelitis, she presented with unilateral optic neuritis which remitted without sequelae, (as did the myelitis). Cerebral and medullary MR showed no alterations.

CONCLUSIONS

The pathogenesis leading to involvement of the nervous system is still not well defined. Direct invasion by the virus has been postulated, particularly in Herpes-Zoster (reinfection by Varicella-Zoster), as immunological phenomena which may be more frequent with Varicella (initial infection by Varicella-Zoster virus). In our case there were two short episodes of neurological involvement: optic neuritis and myelitis, with a satisfactory clinical course after giving corticosteroids. This makes one think of immunological mechanisms rather than direct invasion of the central nervous system by the Varicella-Zoster virus.

["Locked-in" syndrome due to hyperglycemia]

INTRODUCTION

Hypoglycemia can cause a diffuse brain malfunction and sometimes a focal neurological deficiency, that could lead to a mistaken diagnosis of cerebrovascular disease.

CLINICAL CASE

We describe the case of a 67 year old man, with diabetes mellitus type II treated with glibenclamide, that was referred to our hospital due to worsening of his chronic obstructive pulmonary disease. On the fifth day following admission he developed acute weakness in the right extremities and experienced difficulty in talking: six hours later he was conscious, with normal eye movements, but there was an absence of spontaneous facial motility and to pain; he showed complete cuadraplegia and bilateral Babinski. A determination of glycemia was made with the result of 24 mg/dl; after immediate treatment with glucose solution intravenously the patient recovered in a few minutes.

CONCLUSION

This clinical observation reminds us of the importance of determining blood glucose in the assessment of any acute neurological dysfunction.

[Multiple sclerosis as a cause of partial complex epilepsy]

INTRODUCTION

Although the epileptic seizures (ES) have been described on patients with multiple sclerosis (MS), the causal relationship is not clear. Seizure's prevalence in this illness is low and their apparition concerning the MS course is variable, but more common after MS diagnosis. The predominant crises are generalized or partial with secondary generalization; the partial complex seizures have rarely referred.

CLINICAL CASES AND CONCLUSIONS

We presented two patients with ES in the MS course. In the first case is arrived to MS diagnosis upon appearing the crisis, having presented two previous cerebral lesions in another level. In both cases demyelinating lesion was located in the temporal lobe, agreeing with EEG anomaly and seizures type.

[Sensory-motor polyneuropathy associated with lung tuberculosis: presentation of two new cases]

The association of active tuberculosis with changes in the peripheral nervous system is not well defined, although it is included amongst the neuro-muscular disorders of the peripheral nerve diseases due to infective agents. We describe the case of two patients with sensory-motor polyneuropathy and coexistant active pulmonary tuberculosis which was untreated prior to diagnosis of the peripheral nervous system disorder. In both cases the condition was sub-acute and did not improve until treatment was begun. Anti-tuberculosis treatment was followed by marked improvement of both the pulmonary tuberculosis and of the polyneuropathy. The close chronological relationship of both clinical pictures with the therapeutic response supports the hypothesis of the pathogenesis of the peripheral nervous system disorder being mediated by an anomolous immune response, initiated by the infection with Koch's bacillus.

[Phenotype variability in adrenoleukodystrophy. Presentation of three new cases and a review of literature]

INTRODUCTION

Adrenoleukodystrophy is a hereditary recessive sex-linked disorder with very variable phenotype expression, including classical infantil ALD, adrenomyeloneuropathy (AMN) in adults and sex-linked Addison's disease. Clinical observations. Three affected patients are presented. The first showed signs of myeloneuropathy from the age of 38 and diagnosis was made by showing raised serum and fibroblasts levels of very long chain fatty acids (C26:0). In the second case symptoms started at the age of 13 and cerebral and peripheral nervous system changes developed progressively. This patient's brother was the third case, showing symptoms when he was 21 and developing cerebral, medullary and peripheral nervous system involvement. In the latter two cases, diagnosis was made by showing intracytoplasmatic trilaminary inclusions in the nervous system.

CONCLUSIONS

It is important to recognize the different varieties of this disease in view of the possibilities of genetic counselling and of the therapeutic implications which are currently being evaluated.

[Thyroid ophthalmopathy ad a unique clinical manifestation of thyrotoxicosis]

Thyroid ophthalmopathy (TO) or Graves ophthalmopathy embraces a broad range of eye abnormalities which up to 90% of patients with hyperthyroidism (HT) are affected with. In some 10% of TO patients, this may begin oligosymptomatically, often with double vision and with neither clinical nor biochemical signs of thyroid disease. It is imperative to carry out a differential diagnosis with countless other causes for double vision and other eye socket processes. Ophthalmopathy may also occur in patients with hypothyroidism and for this reason some authors prefer to refer to it as dysthyroid orbitopathy. We present four cases of TO in which double vision was the first clinical sign of TO which in one case became severe, in two cases preceded hyperthyroid symptomatology and in the remaining case happened after hyperthyroidism had been corrected. The most valuable diagnostic test was orbit computerised tomography (CT) scan, which proved positive in all cases, and that, along with clinical tests and thyroid function data, confirmed a diagnosis of TO. All initially improved with corticosteroids although none completely regained eye movement during the time they were under supervision. The same happens in about 50% of patients who do not respond to treatment either with corticosteroids or with radiotherapy, and response is usually incomplete in those who do so respond.

[Clinico-epidemiologic study of bacterial meningitis in Aragon]

BACKGROUND

The aim of the present study was to know the incidence, etiology, prognostic factors and rate of mortality of bacterial meningitis in Aragón (Spain).

METHODS

The clinical records of all the patients with bacterial meningitis seen in the hospitals in Aragón (Spain), from 1985 to 1988 inclusive were reviewed.

RESULTS

The mean of the annual rates of incidence for Aragón (Spain) was 7.52/100,000 inhabitants. In patients under the age of 15 years the most frequent etiologies were Neisseria meningitidis (59.0%), Haemophilus influenzae (13.7%) and Streptococcus pneumoniae (9.4%); the global rate of mortality was 3.5% similar to that of sequelae. In those over the age of 14 years, the most frequent etiologies were N. meningitidis (33%), S. pneumoniae (18.4%) and Staphylococcus spp. (13.6%); the rate of global mortality was 19.5% and that of sequelae 10.8% with resistance of S. pneumoniae to penicillin and/or ampicillin in 45.5% of the cases in children and in 26.3% in adults. No significant evolutive differences related with the existence of resistances or the administration of antibiotics prior to lumbar punction were observed in any of the age groups.

CONCLUSIONS

N. meningitidis is the main etiologic agent in Aragón in both children and adults. The greatest rates of mortality and sequelae were observed in the youngest and oldest age groups with a similar relation being seen in infection by gramnegative bacilli and S. pneumoniae, thus making these patients to be considered as being at high risk.

[The validity of the system of obligatory disease declaration for the epidemiologic surveillance of meningococcal meningitis]

In Spain meningococcic meningitis is a disease of obligatory declaration which is declared under the name of "Meningococcic infection". In this section other process are also included with the declaration being made under suspicion, with no knowledge of the degree of fulfillment and the significance of the official data. To know this the clinical history of meningitis patients of all the hospitals in Aragon from January 1985 to December 1988 were reviewed comparing the results with those from the system of obligatory disease declaration. The degree of fulfillment for meningococcic meningitis was 90% with the annual rates of incidence of meningococcic meningitis being 1.11 to 2.13 fold higher, according to hospitalary data, higher than the rates of the obligatory disease declaration system.