[Access to orphan drugs for the treatment of spinal muscular atrophy in Spain]. / Acceso a medicamentos huérfanos para el tratamiento de la atrofia muscular espinal en España.

INTRODUCTION: Spinal muscular atrophy (SMA) is a rare disease whose diagnosis and treatment are complex. In Spain, there are two orphan medicines that are currently financed by the state, nusinersen and onasemnogene abeparvovec and, a third in process, risdiplam. The objective was to detect possible causes of inequity in the diagnosis and treatment of SMA in Spain. MATERIALS AND METHOD: Descriptive study realized in two phases: a first phase of bibliographic revision and a second phase of semi-structured interviews with clinical experts in SMA in Andalusia, Castilla-La Mancha, Catalonia and Murcia. RESULTS: The number of centers, services or units of reference, the availability of regional autonomous plans for rare diseases and pilot programs of neonatal screenings can regulate access to treatments. The number of new patients diagnosed per year is estimated between one and six in the four autonomous communities (ACs) of Spain studied. Differences were not found in logistical resources. Two of the four ACs studied have regional autonomous plans for rare diseases, however, their utility has only had relevance in one of two of the ACs. CONCLUSIONS: Important differences in access to nusinersen were not identified in the studied ACs The diagnosis of SMA requires clinical specialized experts and specialized centers for early intervention of disease-modifying therapies.

TITLE: Acceso a medicamentos huérfanos para el tratamiento de la atrofia muscular espinal en España.Introducción. La atrofia muscular espinal (AME) es una enfermedad rara cuyo diagnóstico y tratamiento es complejo. En España hay dos medicamentos huérfanos financiados por el Sistema Nacional de Salud, nusinersén y onasemnogén abeparvovec, y un tercero, risdiplam, pendiente. El objetivo fue analizar el acceso a los fármacos modificadores de la AME y detectar posibles causas de inequidad. Materiales y método. Estudio descriptivo realizado en dos fases: revisión bibliográfica y entrevistas semiestructuradas a expertos clínicos en AME de las comunidades autónomas (CC. AA.) de Andalucía, Castilla-La Mancha, Cataluña y Murcia. Resultados. El número de centros, servicios o unidades de referencia, la disponibilidad de planes autonómicos para enfermedades raras y los programas piloto de cribado neonatal pueden modular el acceso a los nuevos tratamientos farmacológicos. El número de nuevos pacientes diagnosticados al año se estimó entre uno y seis en cada una de las CC. AA. estudiadas. Dos de las cuatro CC. AA. estaban participando en ensayos clínicos. El tiempo desde la prescripción a la administración de nusinersén estaba entre siete y 60 días. Sólo Cataluña comunicó experiencia con onasemnogén abeparvovec a 30 de junio de 2022. Dos CC. AA. de las cuatro estudiadas disponen de plan autonómico para enfermedades raras; no obstante, se identificó como relevante para el tratamiento de la AME sólo en una de ellas. Conclusiones. No se identificaron diferencias importantes en el acceso al nusinersén en las CC. AA. estudiadas. El diagnóstico de la AME requiere personal clínico experto y centros especializados para iniciar precozmente los tratamientos modificadores de la enfermedad.

Delphi consensus on recommendations for the treatment of spinal muscular atrophy in Spain (RET-AME consensus).

INTRODUCTION: Spinal muscular atrophy (SMA) is a neurodegenerative disease caused by a biallelic mutation of the SMN1 gene, located on the long arm of chromosome 5, and predominantly affects the motor neurons of the anterior horn of the spinal cord, causing progressive muscle weakness and atrophy. The development of disease-modifying treatments is significantly changing the natural history of SMA, but uncertainty remains about which patients can benefit from these treatments and how that benefit should be measured. METHODOLOGY: A group of experts specialised in neurology, neuropediatrics, and rehabilitation and representatives of the Spanish association of patients with SMA followed the Delphi method to reach a consensus on 5 issues related to the use of these new treatments: general aspects, treatment objectives, outcome assessment tools, requirements of the treating centres, and regulation of their use. Consensus was considered to be achieved when a response received at least 80% of votes. RESULTS: Treatment protocols are useful for regulating the use of high-impact medications and should guide treatment, but should be updated regularly to take into account the most recent evidence available, and their implementation should be assessed on an individual basis. Age, baseline functional status, and, in the case of children, the type of SMA and the number of copies of SMN2 are characteristics that should be considered when establishing therapeutic objectives, assessment tools, and the use of such treatments. The cost-effectiveness of these treatments in paediatric patients is mainly influenced by early treatment onset; therefore, the implementation of neonatal screening is recommended. CONCLUSIONS: The RET-AME consensus recommendations provide a frame of reference for the appropriate use of disease-modifying treatments in patients with SMA.

[Ethical aspects of specific precautions programs in patients infected or colonised by multidrug-resistant microorganisms in a hospital setting]. / Aspectos éticos de los programas de precauciones específicas de contacto en pacientes infectados o colonizados por microorganismos multirresistentes en el ámbito hospitalario.

The approach to public health, patient safety and quality of care has led to analysing health situations or problems from a population perspective, in a wide way and giving priority to factors that can normally be left in the background from a clinical point of view. For years, the problem of the use and abuse of antimicrobials, the increase and diffusion of microorganisms resistant to them, cross-transmission, and healthcare related infections have been prioritised both nationally and internationally. To combat these problems, various strategies are being developed and put into practice, from the policies of rational use and optimization of antimicrobials, surveillance, and control of infections related to health care, to training information and awareness strategies. One of the pillars of surveillance and control is the correct application of standard and specific precautions, which within the framework of these comprehensive programs aim to control the transmission of microorganisms of special microbiological and/or epidemiological interest through a series of measures. In hospitals, the application of these precautions (single room, barrier measures, restrictions on access to rooms, waste management…) in patients infected or colonised by these microorganisms can have different repercussions, both for patients and the professionals that attend them, and it is considered pertinent that the protocols and/or programs of specific precautions explicitly include the analysis of the ethical aspects in their preparation, implementation, and monitoring.

Dry sweat as sample for metabolomics analysis.

Sweat is gaining popularity in clinical metabolomics as this biofluid is non-invasively sampled and its composition is modified by several pathologies. There is a lack of standardized strategies for collection of human sweat. Most studies have been carried out with fresh sweat collected after stimulation. A promising and simple alternative is sampling dry sweat by a solid support impregnated with a suited solvent. This research was aimed at comparing the metabolomics coverage provided by dry sweat collected by two solid supports (gauzes and filter papers) impregnated with different solvents. The dissolved dry sweat was analyzed by a dual approach: gas chromatography-mass spectrometry (GC-MS) and liquid chromatography-tandem mass spectrometry (LC-MS/MS). Among the tested sampling strategies, filter paper impregnated with 1:1 (v/v) ethanol‒phosphate buffer resulted the combination providing the highest metabolomics coverage (tentative identification of one hundred seventy-five compounds). Dry and fresh sweat were compared by using pools from the same individuals to evaluate compositional differences. Families of metabolites such as carnitines, sphingolipids and N-acyl-amino acids, among others, were exclusively identified in dry sweat. Comparison of both samples allowed concluding that dry sweat is better for analysis of low polar metabolites and fresh sweat is more suited for polar compounds. As most of the identified metabolites are involved in key biochemical pathways, this study opens interesting possibilities to the use of dry sweat as a source of metabolite markers for specific disorders. Sampling of dry sweat could provide a standardized approach for collection of this biofluid, thus overcoming the variability limitations of fresh sweat.

Untargeted characterization of extracts from Cannabis sativa L. cultivars by gas and liquid chromatography coupled to mass spectrometry in high resolution mode.

Elucidation of Cannabis composition is required to evaluate the potential of this plant for pharmacological uses, but also for implementation in breeding programs with agronomical purposes. The aim of the present study was to develop a method for untargeted analysis of polar and non-polar Cannabis extracts. For this purpose, extracts from 17 cultivars of Cannabis sativa L. were analyzed by gas chromatography-time-of-flight/mass spectrometry (GC-TOF/MS) and liquid chromatography quadrupole time-of-flight tandem mass spectrometry (LC-QTOF MS/MS) in high resolution mode. One hundred sixty-nine compounds were identified in the extracts by searching MS and MS/MS information. Among identified families, there were mainly cannabinoids, terpenoids, lipids and flavonoids, but also some interesting compounds such as amino and organic acids, among others. Relative contents of terpenoids and cannabinoids in the same cultivars grown in greenhouse and field were compared. Compositional differences in the profile of terpenoids and cannabinoids between both types of grown conditions were found.

Early electrophysiological findings in Fisher-Bickerstaff syndrome. / Hallazgos electrofisiológicos precoces en síndrome Fisher-Bickerstaff.

INTRODUCTION: The term Fisher-Bickerstaff syndrome (FBS) has been proposed to describe the clinical spectrum encompassing Miller-Fisher syndrome (MFS) and Bickerstaff brainstem encephalitis. The pathophysiology of FBS and the nature of the underlying neuropathy (demyelinating or axonal) are still subject to debate. This study describes the main findings of an early neurophysiological study on 12 patients diagnosed with FBS. PATIENTS AND METHODS: Retrospective evaluation of clinical characteristics and electrophysiological findings of 12 patients with FBS seen in our neurology department within 10 days of disease onset. Follow-up electrophysiological studies were also evaluated, where available. RESULTS: The most frequent electrophysiological finding, present in 5 (42%) patients, was reduced sensory nerve action potential (SNAP) amplitude in one or more nerves. Abnormalities were rarely found in motor neurography, with no signs of demyelination. The cranial nerve exam revealed abnormalities in 3 patients (facial neurography and/or blink reflex test). Three patients showed resolution of SNAP amplitude reduction in serial neurophysiological studies, suggesting the presence of reversible sensory nerve conduction block. Results from cranial MRI scans were normal in all patients. CONCLUSION: An electrophysiological pattern of sensory axonal neuropathy, with no associated signs of demyelination, is an early finding of FBS. Early neurophysiological evaluation and follow-up are essential for diagnosing patients with FBS.

Observational pilot study of patients with carpal tunnel syndrome treated with Nucleo CMP Forte™.

AIM: Carpal tunnel syndrome (CTS) is a very common entrapment neuropathy characterized by pain and paresthesia in the territory of the median nerve. Although this syndrome has a considerable impact on the patient's quality of life, its medical treatment is far from optimal. MATERIAL & METHODS: We performed an observational study to evaluate Nucleo CMP ForteTM in patients with electromyography-confirmed, mild-moderate CTS. Pain was assessed using a visual analog scale, electromyogram and the SF-36. RESULTS: Pain decreased significantly after 6 months. Quality of life improved significantly in the pain dimensions. No significant differences were observed in electromyographic findings. No adverse events were reported. CONCLUSIONS: Nucleotides could prove useful for the nonsurgical treatment of CTS. Further studies are necessary to confirm this.

Functional limitation of the masticatory system in patients with bulbar involvement in amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) with bulbar dysfunction affects the motor neurons responsible for controlling the muscles in the jaw, face, soft palate, pharynx, larynx and tongue. This cross-sectional study aimed to determine the functional limitation of the jaw in patients with ALS and bulbar dysfunction who had upper motor neuron (UMN), lower motor neuron (LMN) or balanced involvement. One hundred and fifty-three patients with ALS and 23 controls were included. All participants answered using the 8-item Jaw Functional Limitation Scale (JFLS-8). Patients with ALS were grouped by neurologic examination as follows: non-bulbar ALS, bulbar UMN-predominant ALS; bulbar LMN-predominant ALS; and bulbar balanced (UMN + LMN) ALS. Jaw limitation between the different groups was compared using the Kruskal-Wallis test. Patients with non-bulbar ALS had similar mandibular limitations to healthy participants. Only patients with balanced UMN and LMN bulbar manifestations reported greater difficulties in chewing soft food or in jaw mobility compared to the non-bulbar ALS group. Patients with bulbar involvement also had greater difficulties in chewing tough food or chicken and in swallowing and talking compared to the non-bulbar group, regardless of whether UMN or LMN predominant. No significant differences were found between the groups in smiling and yawning difficulties. Bulbar involvement in patients with ALS is associated with functional limitation of the masticatory system. However, balanced bulbar UMN and LMN involvement is associated with the worst impairments in chewing soft food and in opening the jaw widely.

Metabolomics analysis of human sweat collected after moderate exercise.

Sweat is a promising biofluid scarcely used in clinical analysis despite its non-invasive sampling. A more frequent clinical use of sweat requires to know its whole composition, especially concerning to non-polar compounds, and the development of analytical strategies for its characterization. The aim of the present study was to compare different sample preparation strategies to maximize the detection of metabolites in sweat from humans collected after practicing moderate exercise. Special emphasis was put on non-polar compounds as they have received scant attention in previous studies dealing with this biofluid. Sample preparation by liquid-liquid extraction (LLE) using extractants with different polarity index was compared to deproteination. Then, derivatization by methoxymation with subsequent silylation was compared to direct analysis of sweat extracts to check the influence of derivatization on the subsequent determination of volatile organic compounds (VOCs). 135 compounds were tentatively identified by combining spectral and retention time information after analysis by gas chromatography coupled to mass spectrometry in high resolution mode (GC-TOF/MS). Lipids, VOCs, benzenoids and other interesting metabolites such as alkaloids and ethanolamines were identified. Among the tested protocols, methyoxiamination plus silylation after LLE with dichloromethane was the best option to obtain a representative snapshot of sweat metabolome collected from different body parts after moderate exercise. Passive and active sweat pools from a cohort of volunteers (n = 6) were compared to detect compositional differences which can be explained by the sampling process and sweating induction. As most of the identified compounds are metabolites involved in key biochemical pathways, this study opens new opportunities to extend the applicability of human sweat as a source of metabolite biomarkers of pathologies or specific processes such as dehydration or nutritional unbalance.

Development of a method for enhancing metabolomics coverage of human sweat by gas chromatography-mass spectrometry in high resolution mode.

Sweat has recently gained popularity as clinical sample in metabolomics analysis as it is a non-invasive biofluid the composition of which could be modified by certain pathologies, as is the case with cystic fibrosis that increases chloride levels in sweat. However, the whole composition of sweat is still unknown and there is a lack of analytical strategies for sweat analysis. The aim of the present study was to develop and validate a method for metabolomic analysis of human sweat by gas chromatography-time of flight/mass spectrometry (GC-TOF/MS) in high resolution mode. Thus, different sample preparation strategies were compared to check their effect on the profile of sweat metabolites. Sixty-six compounds were tentatively identified by the obtained MS information. Amino acids, dicarboxylic acids and other interesting metabolites such as myo-inositol and urocanic acid were identified. Among the tested protocols, methyoxiamination plus silylation after deproteinization was the most suited option to obtain a representative snapshot of sweat metabolome. The intra-day repeatability of the method ranged from 0.60 to 16.99% and the inter-day repeatability from 2.75 to 31.25%. As most of the identified metabolites are involved in key biochemical pathways, this study opens new possibilities to the use of sweat as a source of metabolite biomarkers of specific disorders.

[Perception and attitudes of health professionals from a health area regarding influenza vaccination]. / Percepción y actitud de los profesionales de un área de salud frente a vacunación antigripal.

OBJECTIVE: Influenza is an infectious, acute and highly contagious disease, and vaccination remains the most effective prevention measure. Health professionals are considered at risk because of their daily exposure with patients. Vaccine coverage among health professionals in Spain is relatively low. The aim of this paper is to describe and analyse the perception and attitudes about influenza vaccination among health professionals from a health care area. METHOD: A descriptive cross-sectional study was conducted using a web application method (EUSurvey). Data were analysed using descriptive, bivariate, and multivariate (logistic regression) analysis using R-project statistical software. RESULTS: A total of 161 professionals (17.9%) responded to the online survey, 54.0% women (n=87) and 45.9% men (n=74). Influenza vaccination rate coverage among health professionals was 34.7%. The main reason reported by health professionals for getting vaccinated was to protect themselves (98.1%), to protect their family (72.6%), and to protect their patients (65.4%). On the other hand, the reasons for health professionals that reported not getting vaccinated was because of the lack of information about it (37.4%), fear of adverse reactions (22.2%), not having had time (14.1%), and considering that the vaccine does not work (14.1%). Multivariate analysis showed that the main factors for not getting vaccinated was to be female, type of service (administrative, medical-surgical and surgical), lack of information, and not been vaccinated before. CONCLUSIONS: In order to increase vaccine uptake among health care personnel, information on the benefits of influenza vaccinations must be increased. Vaccination strategies should be targeted at those groups with lower coverage and are at high risk.

Study of sample preparation for quantitative analysis of amino acids in human sweat by liquid chromatography-tandem mass spectrometry.

The determination of physiological levels of amino acids is important to aid in the diagnosis and treatment of several diseases and nutritional status of individuals. Amino acids are frequently determined in biofluids such as blood (serum or plasma) and urine; however, there are less common biofluids with different concentration profiles of amino acids that could be of interest. One of these biofluids is sweat that can be obtained in a non-invasive manner and is characterized by low complex composition. The analysis of amino acids in human sweat requires the development of sample preparation strategies according to the sample matrix and small collected volume. The influence of sample preparation on the quantitative analysis of amino acids in sweat by LC-MS/MS has been assessed through a comparison between two strategies: dilution of sweat and centrifugal microsolid-phase extraction (c-µSPE). In both cases, several dilution factors were assayed for in-depth knowledge of the matrix effects, and the use of c-µSPE provided the best results in terms of accuracy. The behavior of the target analytes was a function of the dilution factor, thus providing a pattern for sample preparation that depended on the amino acid to be determined. The concentration of amino acids in sweat ranges between 6.20 ng mL(-1) (for homocysteine) and 259.77 µg mL(-1) (for serine) with precision, expressed as relative standard deviation, within 1.1-21.4%.

A review on enzyme and ultrasound: A controversial but fruitful relationship.

A critical review on the effect of ultrasound (US) on enzymes and their biocatalytic action is presented here. Discussion on the information users of US acquire before utilizing the different devices, and the importance they give to US frequency is constant along the review. The authors have gone into the different areas in which the US-enzyme binomial has been applied. The lack of enough information on the US-enzyme-working conditions under which each piece of research has been developed, and the necessity to provide complete information on the data and metadata to give enough light on each piece of research (and thus on the potential comparison of results from different studies) are critically exposed. With this aim, the study has been divided into the positive effect of US on enzymes to favor the production of metabolites, polymers or proteins; and the degradation, inhibition or activation of the biocatalyst under US application. Also the effect of US on enzyme production and the main fields of application of the US-enzyme binomial are discussed.

Ultrasound: a subexploited tool for sample preparation in metabolomics.

Metabolomics, one of the most recently emerged "omics", has taken advantage of ultrasound (US) to improve sample preparation (SP) steps. The metabolomics-US assisted SP step binomial has experienced a dissimilar development that has depended on the area (vegetal or animal) and the SP step. Thus, vegetal metabolomics and US assisted leaching has received the greater attention (encompassing subdisciplines such as metallomics, xenometabolomics and, mainly, lipidomics), but also liquid-liquid extraction and (bio)chemical reactions in metabolomics have taken advantage of US energy. Also clinical and animal samples have benefited from US assisted SP in metabolomics studies but in a lesser extension. The main effects of US have been shortening of the time required for the given step, and/or increase of its efficiency or availability for automation; nevertheless, attention paid to potential degradation caused by US has been scant or nil. Achievements and weak points of the metabolomics-US assisted SP step binomial are discussed and possible solutions to the present shortcomings are exposed.

Ultrasound-assisted extraction and in situ derivatization.

Ultrasound (US) is a type of energy of growing interest for analytical chemists. The favorable effect of US on mass transfer between two phases in the same or different state has been widely demonstrated as did the number of chemical reactions accelerated/improved under ultrasonic influence. The action of US on both mass transfer and chemical reaction developed in a simultaneous manner results in a synergistic effect as a consequence of the "removal" of the target extracted species by conversion into a product. Both US-assisted solid-liquid extraction and liquid-liquid extraction have been developed with in situ derivatization at the meso- and microscale and the advantages involved in their implementation are discussed in this article.

Familial Creutzfeldt-Jakob disease with E200K mutation presenting with neurosensorial hypoacusis.

Creutzfeldt-Jakob disease (CJD) is characterised by rapidly progressive dementia, myoclonus, ataxia, visual disturbances and motor dysfunction. Most of the cases are sporadic. Only 10% to 15% are familial, and the most frequent point mutation is E200K. A 53-year-old man presented with subacute progressive bilateral hypoacusis, with tinnitus in the left ear. During the following months, his hypoacusis worsened and he progressively developed bilateral stocking-type paresthaesia and gait instability. An audiometric examination showed bilateral neurosensorial hypoacusis and nerve conduction studies showed a mixed axonal polyneuropathy. A CT scan and MRI of the brain were normal and the electroencephalography (EEG) showed non-specific changes. He died of respiratory infection 10 months after onset of symptoms. Neuropathological examination showed neuronal loss, punctate, synaptic-like deposits of protease-resistant prionic protein (PrP(RES)) in the cerebral and cerebellar cortices and auditory nuclei. This is a rare case of sporadic CJD presenting with hearing loss.

Sensory-motor polyradiculoneuropathy as the first manifestation of sternum bone plasmacytoma only revealed by bone scintigraphy.

Bone plasmacytoma is a rare plasma cell neoplasm that can present with a polyradiculoneuropathy. A 57-year-old man presented with 2-month history of progressive weakness and numbness of both legs. Neurological examination showed symmetric distal weakness, reduced vibration senses in limbs and areflexia. CSF had high protein content. Electrophysiological evaluation revealed a demyelinating sensory-motor polyneuropathy. IgG-lambda paraprotein was present in serum. Full skeletal survey, spinal MRI and body CT-scan were normal. 99mTc-methylene-dyphosphonate scintigraphy (99mTc-MDP) revealed a solitary accumulation in the sternum. Biopsy of the lesion demonstrated a plasmacytoma. We emphasize that 99mTc-MDP scintigraphy can be a useful screening procedure for patients with polyradiculoneuropathy and occult bone plasmacytoma.

Musk-antibody positive myasthenia gravis presenting with isolated neck extensor weakness.

Dropped head sign is characterized by the gradual forward sagging of the head due to weakness of neck extensor muscles. This may be a prominent sign of several neuromuscular disorders and may be an isolated feature of myasthenia gravis (MG). We describe a patient with isolated neck extensor weakness, eletrophysiological findings suggesting myasthenia gravis and positive MuSK antibodies. This case supports that finding anti-MuSK antibodies may be extremely helpful in dropped head patients and negative acetylcholine receptor antibodies especially if needle EMG does not reveal myopathic or neurogenic patterns.