[Cost effectiveness analysis of the diagnosis of carpal tunnel syndrome using electrophysiological studies]

INTRODUCTION

The high demand for electrophysiological studies (EP studies) in paucisymptomatic patients with suspected carpal tunnel syndrome (CTS) creates overloads in neurological examination departments. Most of these requests in the referenced section of our hospital come from primary health care, however it also comes from other specialists. Many EP Studies for CTS are normal or have minimal alterations so that no change in the therapeutic attitude is required. Thus, it is not clear whether EP studies are cost-effective for suspected CTS without clinical evidence of axonal degeneration.

METHODS

A decision-making and economic evaluation model was made to compare three strategies: option A (EP Studies for all patients with suspected CTS), option B (prior selection by neurologist and EP studies only if axonal CTS was suspected) and option C (prior selection by neurologist and EP studies only if CTS, axonal or otherwise was suspected). The study was conducted over a two month period on patients referred to the neurology department with suspected CTS. EP studies were considered to be the proof that established the final diagnosis. The consequences were determined in terms of correct diagnoses, cost and cost/effectiveness ratio for each strategy. A total number of 188 studies were performed, option C being the most cost-effective, but also the most expensive.

CONCLUSIONS

When there is neurological screening, the cost-effectiveness ratio is better but it is also more expensive. It is recommended to favor option A with intermediate cost and an acceptable cost-effectiveness ratio. However, this also generates great pressure on bud- 45 gets and care facilities which means that CTS diagnosis and criteria for referring patients to the neurological examination departments must be improved.

[Intrathecal synthesis of IgG evaluated using different formulas: importance of multivariate analysis in the diagnosis of multiple sclerosis]

INTRODUCTION

Synthesis of IgG is useful data for the diagnosis of multiple sclerosis, and different formulas, both direct and indirect, are used to quantify this. We analyze these formulas with the objective of finding whether certain combinations of them would give better results than the individual formulas on their own.

PATIENTS AND METHODS

We studied the cerebrospinal fluid of 45 patients with neurological disorders and determined the results of the two formulas which are most effective, according to some studies (Reiber's formula and IgG index) together with a direct formula (IgG ratio) and another indirect formula (the 'classical' formula of Tourtellotte).

RESULTS

The IgG index was, in general, the formula which best differentiated between patients with multiple sclerosis and persons with other neurological disorders.

CONCLUSIONS

We found a tendency which supported the original hypothesis that it is possible to use combinations of formulas to obtain better results than individual formulas. This fact may serve as a basis for further studies in which different combinations are tested, including analytical and clinical data, and this may be of use in the diagnosis of multiple sclerosis.

Lack of association of serum lipoprotein (a) levels with type-2 diabetes mellitus in patients with angiographically defined coronary artery disease

Multiple studies have demonstrated that elevated serum lipoprotein (a) [Lp(a)] levels are independent predictors for coronary artery disease (CAD) in subjects without diabetes mellitus (DM). However, their contribution in patients with DM is controversial and still requires clarification. We determined serum Lp(a) levels in 355 consecutive Caucasian patients (271 men and 84 women) with angiographically documented CAD, and in 100 control subjects (58 men and 42 women) who were clinically free of cardiovascular disease. In addition, the association of serum Lp(a) levels with type-2 DM in patients with CAD was investigated after reassigning patients according to the diagnosis of type-2 DM (61 men and 40 women with type-2 DM and 210 men and 44 women without). No gender differences in Lp(a) levels were observed between men and women (patients and control subjects). Patients with CAD had higher Lp(a) levels than the control subjects (33 (14-74) vs. 13 (9-29) mg/dl, P<0.001). Elevated Lp(a) levels (defined as >90th percentile of controls) were significantly more prevalent in men and women with CAD (35% and 28%, respectively) than in control subjects (13% and 10%, respectively). Serum Lp(a) levels correlated with LDL cholesterol (r=0.22, P<0.001) and apo B levels (r=0.18, P<0.03) in patients and control subjects. Stepwise discriminant analysis revealed that Lp(a) was an independent risk factor for the presence of CAD, independent of smoking, hypertension, type-2 DM, LDL and HDL cholesterol or apo A1 and B levels. When patients were studied according to the spread of CAD (evaluated as the number of narrowed vessels), no differences in serum Lp(a) levels were observed, nor was there a higher prevalence of elevated Lp(a) levels. Finally, when patients were re-assigned according to the diagnosis of type-2 DM, no effect of apo B and LDL-C levels on Lp(a) was found (r=0.06, P=n.s. and 40.14, P=n.s., respectively) and serum Lp(a) levels neither associated nor contributed to the extent of CAD. Our results showed that serum Lp(a) levels are increased in patients with angiographically documented CAD, but there were no significant differences between diabetic and non-diabetic patients, which indicates that elevated Lp(a) levels are specifically associated with CAD but not with type-2 DM.

[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.

["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.

[Pineal gland cysts: clinical and radiological course]

We describe the clinical and radiologic evolution of pineal gland cysts found in computed tomography or magnetic resonance images in 12 patients. The patients had complained of headache and/or lateralized sensory symptoms. None had signs of intracranial hypertension or tectal dysfunction. Only one patient, who had partial epilepsy and a large cyst, was treated by ventriculo-cystic shunt; the rest were treated conservatively. The follow-up period in 11 patients was from 2 to 5 years. No changes were observed in cyst size or radiological characteristics; nor did signs of tectal dysfunction develop. In patients with no signs or symptoms directly attributable to these cysts, surgery can be avoided if no radiological changes are found upon follow-up.

[Complex partial seizures: the localization value of automatisms]

INTRODUCTION

The clinical findings in complex partial crises may help our understanding of the different foci and vias of epileptogenesis.

MATERIAL AND METHODS

We analyse automatisms and findings on EEG and neuroimaging in 151 patients with different types of partial epilepsy, seeking to establish a possible correlation between the type of automatism and cerebral localization.

RESULTS AND CONCLUSIONS

The relative frequency of automatisms was: oro-alimentary 30%, mimicking 11%, gestures 35%, ambulatory 19% and verbal 13%. There was a statistically significant difference between the type of automatism and the topography of the EEG and neuroimaging findings. There were more gesture and oro-alimentary automatisms in patients with temporal anomalies, both on EEG and on neuroimaging, than in those with extratemporal alterations.

[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.

[A descriptive epidemiological study of a neurological outpatient clinic]

OBJECTIVE

To evaluate the clinical, diagnostic, therapeutic and functional aspects of a Neurology Outpatient Clinic.

MATERIAL AND METHOD

An epidemiological survey was made of 552 neurology patients first seen in the Neurology Outpatient Clinic during a three month period.

RESULTS

There was a predominance of women (57.6%). The average age was 45.1 years in both sexes. 84.7% of the patients were sent by their family doctor. There was an average wait of nine days. Complementary investigations were asked for in 56% of the patients (cerebral CT scan in 13.7%, MR in 5%, EEG in 21%, ENG-EMG in 5.7%). The diagnostic groups were headache 30%, followed by vascular pathology (11.7%); psychiatric, syncopes, extrapyramidal syndromes, epilepsy and vertigo each made up 6-7% of the total. 53% of patients attending for the first time received no treatment. The most commonly used drugs were: calcium antagonists (20%), antidepressives (15%), antiepileptics (10%), platelet antiaggregants (8.4%), anti-Parkinson drugs (7.3%) and beta-blockers (4.6%).

CONCLUSIONS

Since there is a great demand for neurological attention (as with other specialties) more neurologists are required. Headache was the commonest reason for consultation. Improved selection of the patients, particularly the psychiatric patients and those with psychosomatic pathology, would considerably reduce the number of patients seen.

[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.

[The usefulness of adenosine triphosphate in supraventricular paroxysmal tachycardias]

With the objective to evaluate adenosine triphosphate (ATP) usefulness in supraventricular paroxysmal tachycardia (SPT), doses of 0.25 mg/kg, of ATP are administered fastly i.v. in bolus, to fifty consecutive patients with SPT resistant to vagal stimulation maneuvers. The effect achieved allowed to identify two groups: a) 39 patients in whom tachycardia was interrupted; b) 11 patients in whom tachycardia did not cease, but the induced transient provoked atrial-ventricular (A-V) blockage allowed to identify the underlying mechanism of tachycardia (in 6 of them atrial tachycardia and in 5 atrial flutter). In both groups the ATP effect was present in less than 30 seconds. In seven patients (five from group (a) and two from group b) the QRS duration was over 0.12 s. Six patients had a left ventricular ejection fraction below 30%. Side effects were frequent, but always short. ATP could become the drug of choice in the treatment of SPT without response to vagal maneuvers, due to the fact that, to its therapeutic activity, it must be added its diagnostic usefulness, its fast action and metabolization, together with the fact that it does not induce severe side effects.

[Lipomatous hypertrophy of the interatrial septum. Report of 2 cases diagnosed in vivo]

Lipomatous hypertrophy of intervenous tubercle is a clinicopathological entity characterized by an accumulation of not capsulated fatty tissue, with its thickness exceeding 15 mm, in the atrial septum, above the fossa ovalis, at the intervenous level and protruding into the right atrium. It can be clinically associated with atrial electric abnormalities such as disorders of the atrial conduction and supraventricular arrhythmias, difficulty of the venous return and sudden death. Nowadays its diagnosis is not difficult using non invasive image techniques. We present two cases of lipomatous hypertrophy of intervenous tubercle which were suspected by echocardiography. In one of them we used transthoracic echocardiography and in the other one transesophageal echocardiography. The diagnostic was latter confirmed by magnetic nuclear resonance and axial computerized tomography.

[Isolated congenital diverticulum of the left ventricle]

Congenital diverticulum of the left ventricle is an uncommon cardiac malformation. We present a 45 years old woman, previously asymptomatic. The symptoms and electrocardiogramas suggested ischemic heart disease. The left ventriculogram demonstrated an isolated apical diverticulum, although the coronary arteries were normal. We will consider the etiopathogeny, classification, clinical history, diagnosis and treatment of the isolated apical diverticulum.