Consensus statement of the Spanish Society of Neurology on the treatment of multiple sclerosis and holistic patient management in 2023.

The last consensus statement of the Spanish Society of Neurology's Demyelinating Diseases Study Group on the treatment of multiple sclerosis (MS) was issued in 2016. Although many of the positions taken remain valid, there have been significant changes in the management and treatment of MS, both due to the approval of new drugs with different action mechanisms and due to the evolution of previously fixed concepts. This has enabled new approaches to specific situations such as pregnancy and vaccination, and the inclusion of new variables in clinical decision-making, such as the early use of high-efficacy disease-modifying therapies (DMT), consideration of the patient's perspective, and the use of such novel technologies as remote monitoring. In the light of these changes, this updated consensus statement, developed according to the Delphi method, seeks to reflect the new paradigm in the management of patients with MS, based on the available scientific evidence and the clinical expertise of the participants. The most significant recommendations are that immunomodulatory DMT be started in patients with radiologically isolated syndrome with persistent radiological activity, that patient perspectives be considered, and that the term "lines of therapy" no longer be used in the classification of DMTs (> 90% consensus). Following diagnosis of MS, the first DMT should be selected according to the presence/absence of factors of poor prognosis (whether epidemiological, clinical, radiological, or biomarkers) for the occurrence of new relapses or progression of disability; high-efficacy DMTs may be considered from disease onset.

Current-limiting and ultrafast system for the characterization of resistive random access memories.

A new system for the ultrafast characterization of resistive switching phenomenon is developed to acquire the current during the Set and Reset process in a microsecond time scale. A new electronic circuit has been developed as a part of the main setup system, which is capable of (i) applying a hardware current limit ranging from nanoampers up to miliampers and (ii) converting the Set and Reset exponential gate current range into an equivalent linear voltage. The complete system setup allows measuring with a microsecond resolution. Some examples demonstrate that, with the developed setup, an in-depth analysis of resistive switching phenomenon and random telegraph noise can be made.

[Clinical and therapeutic differences in neuro-ophthalmological involvement secondary to syphilis]. / Diferencias clinicas y terapeuticas de la afectacion neurooftalmologica secundaria a sifilis.

INTRODUCTION. There are many forms of neuro-ophthalmological involvement secondary to syphilis, and not all of them are well known. Our aim is to determine the clinical and therapeutic differences in these patients. CASE REPORTS. Our sample included eight patients diagnosed with an ocular and neuro-ophthalmological disorder due to syphilis over the years 2012 and 2013. Five of them presented uveitis, pan-eveitis being the most frequent, with three cases. Two cases presented papilloedema and another displayed retrobulbar optic neuropathy. A total of 62.5% were diagnosed with neurosyphilis, the presence of which was related with compromise of the optic nerve (p = 0.035). None of them gave positive for VDRL in cerebrospinal fluid and they were diagnosed by the presence of FTA antibodies together with high protein levels in cerebrospinal fluid, lymphocytic pleocytosis or intrathecal synthesis of antibodies. In the absence of uveitis, diagnosis was delayed by a mean time of 2.6 months (p = 0.047). All the patients, except one who required a vitrectomy, progressed favourably with intravenous antibiotic therapy. CONCLUSIONS. In cases of neuro-ophthalmological compromise, whether inflammatory or non-inflammatory, the physician must bear syphilis in mind as a potential causation in order to avoid delays in the diagnosis, since early well-tailored treatment can prevent permanent loss of sight.

TITLE: Diferencias clinicas y terapeuticas de la afectacion neurooftalmologica secundaria a sifilis.Introduccion. Existen multiples formas de afectacion neurooftalmologica secundaria a sifilis, no siempre bien conocidas. Nuestro objetivo es conocer las diferencias clinicas y de tratamiento en estos pacientes. Casos clinicos. Se incluyeron ocho pacientes diagnosticados de afectacion ocular y neurooftalmologica por sifilis durante los años 2012 y 2013. Cinco presentaron uveitis, siendo la panuveitis la forma mas frecuente, con tres casos. Dos casos presentaron papiledema, y otro, neuropatia optica retrobulbar. Un 62,5% fue diagnosticado de neurosifilis, cuya presencia se relaciono con la afectacion del nervio optico (p = 0,035). Ninguno de ellos presento positividad para VDRL en el liquido cefalorraquideo, y se diagnosticaron por la presencia de anticuerpos FTA junto con hiperproteinorraquia, pleocitosis linfocitaria o sintesis intratecal de anticuerpos. En ausencia de uveitis, se produjo un retraso diagnostico medio de 2,6 meses (p = 0,047). Todos los pacientes, salvo uno que preciso vitrectomia, evolucionaron favorablemente con antibioterapia intravenosa. Conclusiones. En casos de afectacion neurooftalmologica, inflamatoria y no inflamatoria, el clinico debe tener en cuenta la sifilis como potencial etiologia para evitar un retraso diagnostico, puesto que un adecuado tratamiento precoz puede evitar una perdida de vision permanente.

Incidence and predictive factors of delirium in hospitalised neurological patients.

INTRODUCTION: Delirium is a condition with a high prevalence in hospitalised patients (10%-30%), and it has important prognostic implications. There are few prospective studies of the incidence of delirium in Spain, and most of these were carried out in surgical wards or intensive care units. Our objective is to calculate the incidence of delirium in a neurological department and describe characteristics of affected patients. METHODS: Longitudinal descriptive study including all patients admitted to the neurology department in an 8-week period. The CAM score for diagnosing delirium was recorded on the first, second and fifth day of hospitalisation and we recorded demographic data, medical history, analytical data (including inflammatory markers), use of anticholinergic treatments, cognitive and functional state at admission, reason for admission, length of stay, and other events during hospitalisation. RESULTS: We studied 115 patients and found an incidence of delirium of 16.52%. There was a significant correlation between delirium and age, cognitive state at admission according to the Pfeiffer test, functional situation at admission according to the Canadian Neurological Scale, kidney failure, history of stroke, anticholinergic treatment, erythrocyte sedimentation rate, and C-reactive protein. These patients were also hospitalised for longer periods of time. CONCLUSIONS: These results confirm a high incidence of delirium in our geographical area. Although additional studies with larger samples are needed, we would like to emphasise the importance of several risk factors which may enable early detection of patients who are at risk for developing delirium during hospitalisation. This would permit preventive action and early treatment for these patients.

[Atypical evolution of liver hemangioma: a report of two cases]. / Evolución atípica del hemangioma hepático: a propósito de dos casos.

We present and illustrate two cases of atypical evolution of liver hemangiomas studied with magnetic resonance imaging. In the first case, the lesion was associated with capsular retraction and became progressively smaller until it completely disappeared. The second case involved a woman taking birth control pills in whom the lesion grew progressively larger, doubling its diameter.

[Shattered kidney in a patient with asymptomatic chronic hydronephrosis. Case report and literature review]. / Estallido renal en paciente con hidronefrosis crónica asintomática. A propósito de un caso y revisión de la literatura.

The incidence of renal anomalies in patients who suffer a renal trauma is around 4.4 and 19%. We introduce a case of a patient whose first sign of a chronic hydronefrosis was a renal burst secondary to an abdominal trauma.

[Sexual dysfunction management in multiple sclerosis]. / Abordaje de la disfunción sexual en la esclerosis múltiple.

INTRODUCTION: Sexual dysfunction is a frequent disorder associated to multiple sclerosis, that contributes to the worsening of life quality of these patients. AIM: To ascertain how it is managed in a demyelinating disease unit. PATIENTS AND METHODS: It was done an anonymous poll to multiple sclerosis patients in a demyelinating disease unit. The following variables were analysed: age, sex, marital status, education degree, sexual dysfunction, vesical dysfunction, gait disturbances and duration of illness. RESULTS: 67 of 97 patients answered. 74.6% females. Average age was 43.7 years. Average developing time was 11.3 years. 58% of the patients had vesical dysfunction. 43% had sexual dysfunction. There was relation with statistical significance between sexual and vesical dysfunction but not among the rest of variables. 63% of the patients with sexual dysfunction had never talked about this problem with their doctors. That the patient talked about sexual dysfunction was related with the fact that the neurologist asked for or not, and if sexual dysfunction was an important problem for the patient. The neurologist had asked for dysfunction sexual symptoms to 30% of the patients, and this was more frequent if the patient was male and if he or she had gait disturbances. CONCLUSIONS: Sexual dysfunction is a frequent and important problem for patients with multiple sclerosis. According to our results, this problem is raised up in an insufficient manner as much for patients as for neurologists.

Congenital endplate acetylcholinesterase deficiency responsive to ephedrine.

The authors describe two patients with congenital myasthenic syndrome (CMS) with end plate acetylcholinesterase (AChE) deficiency caused by mutations in the collagenic tail (ColQ) of AChE: a homozygous C-terminal Y230S mutation in Patient 1 and Y430S and a C-terminal splice-site mutation in Patient 2. In Patient 1, a Prostigmin (neostigmine bromide) test failed to distinguish between AChE deficiency and a slow-channel CMS. Both patients responded dramatically to ephedrine therapy.

[Prostate cancer in the Community of Madrid in the year 2000. III. Study of tumor extent]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. III--Estudio de extensión tumoral.

OBJECTIVE: To identify a potential relationship between two variables, risk of metastasis and use of imaging techniques, in an extension study in prostate cancer patients diagnosed in the Autonomous Community of Madrid in 2000. MATERIAL AND METHODS: 1,127 patients with available data on the tumour extension study were analysed. Performance and non performance of bone scans and CTs were correlated to risk variables for developing metastasis as described in the literature (PSA, Gleason and stage) and to therapy administered. RESULTS: The proportion of patients with risk variables for metastasis when bone scans were performed was between 7% to 14% greater than in patients with no variables. No differences were seen for CTs based on risk variables. With matching risk variables, more imaging techniques were used in patients receiving radiotherapy that in those managed with prostatectomy. CONCLUSION: Based on current recommendations imaging techniques were used in excess in the extension study in patients with no risk variables for metastasis. Conduct of a further study in the Autonomous Community seems advisable to confirm the likelihood of implementing such recommendations considering our prevalence of metastatic disease.

[Prostate cancer in the Community of Madrid in the year 2000. IV. Treatment]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. IV Tratamiento.

OBJECTIVE: To know the therapeutic options used in patients diagnosed with prostate cancer in the Autonomous Community of Madrid in 2000. MATERIAL AND METHODS: The study was conducted on 1,745 patients referred by hospitals taking part in the study. Data on treatment used was available for 1,104 (63%) patients. Treatment modality was correlated to clinical stage and patient age. RESULTS: Most frequent choice was hormone therapy (35%) followed by radical prostatectomy (34%) and radiotherapy (25%). Prostatectomy was most commonly used in patients with localised (42.3%) disease while hormone therapy was preferred for locally advanced (45.6%) or disseminated (94%) disease. There are significant differences in therapeutic indications between the various Health areas participating in the survey. Median age of patients with localised and locally advanced disease was lower in patients managed with prostatectomy (65 and 64 years, respectively) than in those managed with radiotherapy (70 and 69 years, respectively). CONCLUSION: The therapeutic modality indicated by urologists in the Madrid Autonomous Community for managing patients with prostate cancer generally meets with literature recommendations.

[The prostate cancer in the community of Madrid in 2000 I.- Incidence]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. I--Incidencia.

OBJECTIVE: To know the incidence in the year 2000 of prostate cancer in the Autonomous Community of Madrid and its breakdown by Health Areas. MATERIAL AND METHOD: Study of histologically confirmed prostate cancer case reports and retrospective data acquisition for 2000 in the Autonomous Community of Madrid, both from Public and Private Health Care hospitals. RESULTS: Gross incidence of prostate cancer in the Autonomous Community of Madrid was 100.4 cases per 100,000 males. The incidence adjusted for the Spanish, European and Worldwide population was 120.1, 103.5 and 68.6 cases per 100,000 males, respectively. Mean age at diagnosis was 70 +/- 7.8 (40-94) years, median of 70 years. The age group with higher incidence was 70 to 79 years. CONCLUSIONS: The incidence of prostate cancer in the Autonomous Community of Madrid is lower than that in the US but higher than in most countries or regions in the EU. The different way of using PSA testing in the Health Areas of the Autonomous Community may explain the differences seen in terms of incidence by Area.

[The prostate cancer in the community of Madrid in 2000. II Presentation and diagnosis]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. II--Presentación y diagnóstico.

OBJECTIVE: To know the presentation form, diagnostic method and clinical stage at the time of diagnosis in subjects with prostate cancer (PC) in the Autonomous Community of Madrid in 2000. MATERIAL AND METHOD: Data from 1745 patients with histologically confirmed prostate cancer obtained from 15 Hospitals participating in the study was analysed. The variables studied were: associated disease, reason for visiting the hospital, digital rectal examination (DRE), PSA, diagnostic method, graded Gleason score, tests performed in the tumoral extension study and tumour staging. The qualitative variables are given in percentages of the overall number and the quantitative variables are expressed as the median, standard deviation, maximum and minimum values and 25%, 50% (median) and 75% percentiles. RESULTS: 67% cases had an associated disease. In most (75%) patients the reason for visiting the hospital was prostatic syndrome. DRE revealed that 42.7% has no tumour. At the time of diagnosis half the patients had PSA levels lower than or equal to 11 ng/ml. Transrectal ultrasound-guided biopsy was used for diagnosis in 93% subjects. The most commonly reported Gleason scores were 6 (31.3%) and 7 (28.7%). In 75% subjects the disease was considered to be clinically limited to the prostate, in 12.5% locally advanced and in 12.5% metastatic. CONCLUSIONS: Most patients came to the hospital because of symptoms not related to PC. Transrectal ultrasound-guided biopsy is confirmed as the choice technique for PC diagnosis. When a comparison is made to historical series in our Autonomous Community a pattern of earlier diagnosis can be seen.

[Comparative study between different conjunctival tissue adhesives]. / Estudio comparativo entre diferentes adhesivos conjuntivales.

PURPOSE: To evaluate efficacy and clinical and histopathological tolerance of a new acrylic tissue adhesive (ADAL-2) compared to sutures (Vicryl) and other available tissue adhesives (Tisuacryl) for their use in conjunctival surgery. METHODS: This was an experimental study performed in New Zealand albino rabbits with conjunctival dissection and closure by ADAL-2. Groups treated with Vicryl and Tisuacryl were compared regarding efficacy, clinical, and histological tolerance at 7, 28 and 42 days. RESULTS: Efficacy was similar in the three methods of conjunctival repositioning evaluated. Tolerance to ADAL-2 was similar to that of Vicryl suture and tolerance to ADAL-2 was superior to that to Tisuacryl. Histopathological results with ADAL-2 and Tisuacryl are similar. CONCLUSIONS: ADAL-2 tissue adhesive is an efficient and very well tolerated alternative for conjunctival closure in ophthalmic surgery.

[ADAL-1(R): a new synthetic adhesive for use in strabismus surgery]. / ADAL-1(R): Nuevo adhesivo sintético de uso en cirugía del estrabismo.

PURPOSE: To evaluate the efficacy and tolerance of ADAL-1(R), a new adhesive in strabismus surgery. METHODS: Three groups of 10 eyes each of 30 albino rabbits underwent superior rectus muscle recession 4 mm, 1(st) group of 10 eyes using the new adhesive, sacrified after one week, 2(nd) group of 10 eyes also with ADAL-1(R), sacrificed after one month and the 3(rd) group (control) of 10 eyes using Dexon 6/0 suture, sacrificed after one month. Clinical evaluation was done at the 1(st) postoperative day, at one week and at one month. The presence of residue of the adhesive, its hardness and the condition of the muscle were all studied after sacrificing the animal. Descriptive study was done for the 1(st) and the 2(nd) group, within the 2(nd) group significant changes along the follow up period were studied using the Friedman test and also differences between the 2(nd) and the suture group were examined using the Fisher's Exact Test. RESULTS: The inflammatory reaction was evaluated between absent and mild in 80% of the cases, both in the 2(nd) and the control group. In the ADAL-1(R) group there were significant statistical differences between 1(st) and 4(th) week (p=0.0002). In the 2(nd) group, 80% of the muscles were attached to the planed position and 20% were slightly displaced, while in the control group 90% of the muscles were attached to the planed position, and 10% were slightly displaced, however there is no significant difference between the two groups p=0.5 (Fisher's Exact Test). CONCLUSION: ADAL-1(R), a new adhesive, could replace sutures in strabismus surgery, giving rise to a rapid and efficient adhesion between muscles and sclera and well tolerated by the ocular tissues.

[Diagnostic role of magnetic resonance in the renal involvement in nocturnal paroxysmal hemoglobinuria]. / Papel diagnóstico de la resonancia magnética en la afectación renal en la hemoglobinuria paroxística nocturna.

Paroxysmal nocturnal haemoglobinuria or Machiafava-Micheli disease is an acquired clonal stem cell disorder characterized by defective haematopoiesis, which results in an increased sensitivity of the erythrocytes to complement-mediated intravascular haemolysis. Renal damage is rare but it can lead to chronic renal failure. Micro-infarctions due to repeated episodes of microvascular thrombosis and cortical haemosiderosis are thought to be the main contributors to the development of chronic renal failure in paroxysmal nocturnal haemoglobinuria. Magnetic resonance imaging provides characteristic images of the kidney. We describe a patient with cortical haemosiderosis and show the magnetic resonance features.

[Leukocytes and primary intracerebral hemorrhage]. / Leucocitos y hemorragia intracerebral primaria.

INTRODUCTION AND OBJECTIVE: The association between the leucocyte count and prognosis observed in ischemic cerebrovascular disease and subarachnoid hemorrhage has rarely been reported in primary intracerebral hemorrhage. The objective of our study is to assess the importance of the number of leukocytes in the peripheral blood during the first 24 hours for prognosis of mortality. PATIENTS AND METHODS: We made a prospective analysis of supratentorial primary intracerebral hemorrhages seen during the first 24 hours during the period 1987-1994. We evaluated the relationship between age, sex, size of hematoma, blood found in the ventricles, level of consciousness on admission, survival and prognosis after 30 days, level of glucaemia, arterial hypertension and leucocyte count. RESULTS: We considered 186 primary intracerebral hemorrhages (64% men and 36% women); the average age was 64 years (Standard Deviation: 10 years). There were 63% deep and 37% lobar hemorrhages. Thirty five percent of the patients died. Leucocytosis was associated with survival (p = 0.003), prognosis (p = 0.0005) and intraventricular bleeding (p = 0.03). We found a significant relationship between the size of the hematoma (r = 0.256; df = 186; p < 0.0001), level of glycaemia on admission (r = 0.282; df = 186; p < 0.0001), level of consciousness (r = -0.263; df = 186, p < 0.0001) and leukocyte count. CONCLUSIONS: The peripheral blood leucocyte count was significantly associated with prognosis and increased mortality. It may therefore be considered to be another parameter of bad prognosis in primary intracerebral hemorrhage.

[Early presentation of crises and the development of epilepsy in cerebral intra-parenchymatous hemorrhage]. / Presentación precoz de crisis y evolución de la epilepsia en la hemorragia intraparenquimatosa cerebral.

PATIENTS AND METHODS: Of a total of 283 patients with spontaneous or hypertensive cerebral intraparenchymatous hemorrhage, 18 (6.3%), with no previous epilepsy, had crises whilst being followed-up for a period of between 2 and 7 years. In 14 cases the hematoma was lobar and 4 involved the basal ganglia or thalamus. In 8 cases (2.8% of all hemorrhage), these crises occurred during the first 24 hours, or as a first symptom of intraparenchymatous hemorrhage. One patient presented with status epilepticus with generalized crises and two had subentrant secondarily generalized partial crises at the time of the ictus. Treatment with anti-epileptic drugs was started in 13 patients. Twelve patients (4.2% of the hemorrhages) developed symptomatic epilepsy with partial crises with or without secondary generalization. RESULTS AND CONCLUSIONS: The maximum rate of recurrence was four crises per year. However, in one patient, reduction of the dose of medication led to the appearance of status epilepticus. Patients with crises of late onset developed epilepsy more often than those who had early crises. In those with crises there was a predominance of bilobular involvement with participation of the parietal lobe and extension of the hematoma or oedema to the cerebral cortex.