[Family planning in men and women with multiple sclerosis. Analysis of the Andalusian Registry (2018-2022)]. / Planificación familiar en hombres y mujeres con esclerosis múltiple. Análisis del Registro Andaluz (2018-2022).

INTRODUCTION: The Andalusian Registry of Pregnancies in patients with multiple sclerosis is the largest Spanish registry on multiple sclerosis (MS) and family planning. For the first time, it includes information on the fertility of men with MS. The influence of the use of a disease-modifying treatment (DMT) on the health of the foetus/newborn and the impact of breastfeeding on MS are also analysed. SUBJECTS AND METHODS: This is a multicentre, prospective and observational study. Recruitment of patients took place between December 2018 and December 2020. Women were followed up for one year after delivery. Altogether 100 women and 16 men were included, with a total of 103 newborn infants. RESULTS: The annualised relapse rate of the women with MS decreased significantly during pregnancy (from 0.23 to 0.065). A total of 11.2% of patients resorted to assisted reproductive techniques in order to conceive a child. No association was found between the use of a DMT at conception and/or pregnancy and the risk of miscarriage, prematurity or low birth weight. Over half the women with MS (54.2%) chose to breastfeed (26.7% of them while on a DMT). CONCLUSIONS: MS does not affect the fertility of men. Neither does the use of a DMT at the time of conception affect their fertility or their children's health. Assisted reproductive techniques did not have a negative impact on the course of MS. Breastfeeding is a common practice among women with MS and there is no evidence of positive or negative effects on disease progression.

TITLE: Planificación familiar en hombres y mujeres con esclerosis múltiple. Análisis del Registro Andaluz (2018-2022).Introducción. El Registro Andaluz de Embarazos en pacientes con esclerosis múltiple (EM) es el mayor registro español sobre EM y planificación familiar. Por primera vez se incluye información sobre la fertilidad de hombres con EM. También se analizan la influencia del uso de un tratamiento modificador de la enfermedad (TME) en la salud del feto o recién nacido y el impacto de la lactancia materna en la EM. Sujetos y métodos. Es un estudio observacional, prospectivo y multicéntrico. El reclutamiento de pacientes se hizo entre diciembre de 2018 y diciembre de 2020. El seguimiento de las mujeres tras el parto fue de un año. Se incluyó a 100 mujeres y 16 hombres, con un total de 103 recién nacidos. Resultados. La tasa anualizada de brotes de las mujeres con EM descendió durante el embarazo de forma significativa (de 0,23 a 0,065). Un 11,2% de los pacientes recurrieron a técnicas de reproducción asistida para conseguir la gestación. No se encontró relación entre el uso de un TME en la concepción y/o embarazo y el riesgo de aborto, prematuridad o bajo peso al nacer. El 54,2% de las mujeres con EM optaron por dar lactancia (el 26,7% de ellas usando un TME). Conclusiones. La EM no afecta a la fertilidad de los hombres. Tampoco influye en ésta, ni en la salud de sus hijos, el uso de un TME en el momento de la concepción. Las técnicas de reproducción asistida no impactaron negativamente en la evolución de la EM. La lactancia se impone como una práctica habitual entre las mujeres con EM y no se evidencian efectos positivos o negativos sobre la evolución de la enfermedad.

[The role of olanzapine in Parkinsonian dopaminergic psychosis]. / Papel de la olanzapina en la psicosis dopaminérgica parkinsoniana.

INTRODUCTION: The drug induced psychosis (DIP) that appears in Parkinson s disease (PD) is a frequent complication which is difficult to deal with therapeutically. Treatment is based on lowering the amount of antiparkinson drugs or using classical neuroleptics (haloperidol), which in both cases deteriorates motor function. Recently, antipsychotic drugs have appeared which are called atypical (AA) due to their scarce or null motor effects. METHOD: We carried out a review of the research work that has been published in which one of these AA, olanzapine (OLZ), was used to treat the DIP that appears in PD patients. The results obtained show OLZ to be an effective antipsychotic drug. However, the data on its capacity to deteriorate motor function is contradictory and it has not been possible to pinpoint the reasons why this adverse side effect appears in some patients and not in others. The causes that have been suggested, although they do not account for all the cases, are the use of high doses of OLZ and the prior existence of dementia. Moreover, some cases of OLZ induced agranulocytosis have been detected, although it was thought that this side effect within the AA was exclusive to clozapine. CONCLUSION: Although it is effective as an antipsychotic drug, there exists contradictory data about the capacity of OLZ to deteriorate the state of patients suffering from Parkinson s disease, which means that it does not seem to be the first choice drug in the DIP that appears in PD.

[Anticonvulsant hypersensitivity syndrome with severe repercussions in the skin and kidneys due to carbamazepine]. / Síndrome de hipersensibilidad por antiepilépticos con repercusión cutánea y renal grave por carbamacepina.

INTRODUCTION: Anticonvulsant hypersensitivity syndrome (AHS) is characterised by fever, skin rashes and involvement of the internal organs. Owing to the low frequency with which it appears and its high clinical heterogeneity, it is not always suspected. Moreover, the symptoms often overlap with those of a vasculitis or of an infection. The most commonly associated antiepileptic drugs (AED) are the aromatic agents. We report the case of a female patient who developed AHS with several different AED and presented an especially severe kidney and skin disorder due to carbamazepine (CBZ). CASE REPORT: We describe the case of a 26-year-old woman who, after being diagnosed as suffering from secondarily generalised partial seizures, began treatment with 200 mg/12 hours CBZ. A few weeks later, she developed itchy skins lesions compatible with exanthematic pustulosis, together with acute kidney failure requiring haemodialysis. A biopsy study of the kidney revealed immunoallergic tubulointerstitial nephropathy, which is a lesion that has only very occasionally been reported in relation to CBZ therapy. The patient also presented a moderate rise in the level of transaminases and leukocytosis with eosinophilia. She was discharged from hospital without AED but suffered new seizures and was treated with phenytoin and, later, with valproic acid, both as monotherapy. With these drugs she developed AHS consisting in fever, rashes, eosinophilia and subclinical hepatitis. In epicutaneous tests with anticonvulsants, the three AED presented a positive reading, as well as others. The patient was treated with tiagabine, and there were no further hypersensitivity phenomena and a good control of seizures was achieved. CONCLUSIONS: AHS is an infrequent, but potentially serious, clinical entity and must therefore be suspected in patients taking AED who develop fever, rashes or disorders affecting the internal organs.

[Calculating how long phenytoin intoxication lasts]. / Cálculo de la duración de una intoxicación por fenitoína.

INTRODUCTION: We report a case of intoxication with phenytoin (DPH), in which the actual time required for it to disappear was compared with that estimated using linear regression. CASE REPORT: A 23-year-old female with tonic-clonic seizures, receiving chronic therapy with DPH 300 mg/day. The patient came to hospital because of tremors, balance disorders, vomiting and headaches. Neurologically, she presented horizontal nystagmus in the two extreme gazes, generalised hyperreflexia and ataxic gait. Cranial CAT scan and cerebrospinal fluid were both normal. Serum concentration of DPH was found to be 60.2 mg/L. When DPH concentration is >8-10 mg/L, its rate of elimination diminishes disproportionately and the risk of toxicity increases. Use of mathematical methods makes it possible to calculate the time required for a toxic concentration to come down to therapeutic values. In our patient the DPH took 204 hours to drop below the toxic level (20 mg/L), whereas by using a linear regression with only two different concentrations a figure of 155 hours was obtained. CONCLUSIONS: The method employed here can be useful as a quick, simple and easily applicable way of estimating the time a toxic concentration of DPH takes to return to a normal level.

[Multiple calcified cerebral lesions, probably due to metastasis]. / Multiples lesiones cerebrales calcificadas de probable origen metastásico.

INTRODUCTION: Metastases are an infrequent (though possible) cause of cerebral calcifications due to the speed with which they grow. We report the case of a patient in whom some metastatic looking calcified cerebral lesions led to the discovery that she was suffering from lung cancer. CASE REPORT: Woman, aged 60, with no antecedents of interest except hyperlipaemia who came to clinic after suffering from alterations of her higher functions for three weeks. Nothing abnormal was found during the general exploration. Neurologically, she was found to have sensory aphasia together with impaired gnosia and praxis. A brain CAT scan revealed several calcified cerebral lesions throughout both hemispheres, associated with perilesional edema and mass effect with contrast enhancement. Cerebral MRI confirmed these findings. X ray of the thorax was normal but the thoracic CAT scan revealed a spiculated lesion that suggested a malign primary lung neoplasia. CONCLUSION: The presence of cerebral calcifications with perilesional edema and contrast enhancement forces us to rule out a metastatic origin. Although no respiratory clinical features are present, a study of the lungs should be performed as they are the most probable source of the aetiology.

[When should a brain scan with HMPAO be performed to diagnose brain death?]. / ¿Cuando realizar una gammagrafía cerebral con HMPAO en el diagnóstico de muerte encefálica?

INTRODUCTION: Current Spanish law defines the criteria to be met in the case of brain death (BD) and the complementary tests to confirm it, although they do not always need to be carried out. In Spain one of the most frequently used methods is the electroencephalogram (EEG), which has its shortcomings in patients who are under sedation with barbiturates. Transcranial Doppler (TCD) offers a number of advantages in the diagnosis of BD, but it also has certain limitations. In these cases, a cerebral perfusion scan (CPS) with HMPAO can be very useful. CASE REPORTS: We describe the case of two patients who were admitted to the Intensive Care Unit with serious traumatic brain injuries. Progress was unfavourable and the findings of the clinical exploration were compatible with BD. Since we were dealing with patients under barbiturate therapy, the EEGs were complex and difficult to interpret. TCD was difficult to perform in both cases because of loss of brain matter and displacement of intracranial structures, respectively. CPS, however, allowed us to confirm the diagnosis of BD. CONCLUSION: Although it has obvious advantages, TCD cannot always be performed to confirm BD diagnosis. In these cases, CPS can be an extremely valuable tool

[Overestimation of the degree of stenosis in the intracranial internal carotid artery determined by magnetic resonance angiography compared to conventional arteriography]. / Sobreestimación del grado de estenosis de la arteria carótida interna intracraneal por la angiorresonancia respecto a la arteriografía convencional.

INTRODUCTION: In the evaluation of stenoses of the extracranial internal carotid artery (ICA), there are studies that suggest that magnetic resonance angiography (MRA) can be a substitute for conventional arteriography (CA), although it seems it has a tendency to overestimate the degree of stenosis. No similar comparison of the two techniques has been conducted in intracranial ICA. We report the case of a patient suffering from an acute ischemic stroke and symptomatic intracranial stenosis that was overestimated when MRA was used, compared to the results obtained using CA. CASE REPORT: We report the case of a 64-year-old male with a history of arterial hypertension, hypercholesterolemia and intermittent claudication who visited the emergency department because of the sudden onset of paresthesias in the left hemiface and hand. The cranial tomography scan performed in the emergency unit ruled out any acute bleeding or early signs of a stroke. Magnetic resonance (MR) diffusion imaging showed an acute ischemic stroke in the right parietal cortex. Extracranial MRA was normal and in the intracranial area a 73% stenosis was detected in the cavernous segment of the right ICA, whereas the use of CA showed the stenosis to be only 55%. On repeating the MRA to rule out a possible rechanneling of the ICA, the image obtained was exactly the same as the earlier one. CONCLUSIONS: Our observations suggest that, as occurs with the extracranial part, MRA tends to magnify the degree of stenosis in the intracranial vessels, and this technique would therefore appear to be less efficient than CA in the evaluation of intracranial stenoses.

[Confirmation of cortical lesions of progressive prosopagnosia by cerebral SPECT]. / Confirmación de lesiones corticales de la prosopagnosia progresiva mediante la SPECT cerebral.

We present the case of a 78 year old man admitted to the hospital with progressive memory disorder. Neuropsychological examination showed inability to recognize familiar faces (prosopagnosia). MRI documented cortical atrophy, which did not explain the neurological deficit. CT did not show abnormalities. Most patients with prosopagnosia present brain atrophy, as they are more than 65 years old. Scanning by SPECT revealed hypoperfusion in the right parietotemporal region, which was worse in a later examination.

[Treatment of psychosis in Parkinson]. / Tratamiento de la psicosis parkinsoniana.

INTRODUCTION: Parkinson's disease (PD) is a chronic idiopathic neurodegenerative disorder in which there is a dopamine deficit that produces motor and other disturbances, such as autonomic, sensory and neuropsychiatric disorders, including psychosis. Psychosis in PD, which is characterised by the existence of hallucinations and delusions, is a frequent and disabling problem for the patient; it is stressing for caregivers and difficult to manage for the physician, since it predisposes the patient to higher rates of morbidity and mortality and to institutionalisation. AIM: To carry out a review of the literature on the treatment of psychosis in PD. DEVELOPMENT: In this paper we review several different aspects of psychosis in PD, such as the diagnostic criteria, pathophysiology, predisposing factors, clinical features and, above all, management, which includes the use of atypical antipsychotics (after attempts have been made to reduce the antiparkinson medication to a limit marked by the loss of motor autonomy). Additionally, we also review the evidence that is currently available on other pharmaceuticals for use to treat psychosis in PD (anticholinesterases, drugs that act on serotonin receptors and so forth). CONCLUSIONS: Psychosis in PD is a problem that is difficult to treat, with a poorly understood pathophysiology, in which the most important means of combating it (in addition to prevention and reduction of dopaminergic medication, if possible) is the use of atypical antipsychotics. Other treatments which are now offering still very preliminary, but promising, results could well end up becoming the first line of treatment for this condition in the near future.

[Ziprasidone in Parkinsonian dopamine psychosis]. / Ziprasidona en la psicosis dopaminérgica parkinsoniana.

INTRODUCTION: The dopamine psychosis that appears in Parkinson's disease (PDP) is a complication that is often related with frequent intake of antiparkinsonian agents, especially levodopa and dopamine agonists. Morbidity and the risk of being institutionalised are increased in such patients and therapeutic management is difficult. Its treatment is based on reducing the intake of antiparkinsonian drugs or the use of atypical antipsychotics, due to the fact that they have scarce or no motor effects (at least in theory). In this work, we examine the role that ziprasidone (ZPS) can play in PDP. DEVELOPMENT: We reviewed the studies in which ZPS was used to treat PDP that have appeared in the literature. To date, very few studies have been conducted and only a small number of patients were included in each case. Nevertheless, it seems that, at doses below those used in schizophrenia (20-80 mg/day), ZPS is an effective antipsychotic. In general, the extrapyramidal side effects that do appear are infrequent and mild. Pathological laughter was detected in some patients. The drug was well tolerated and safe. CONCLUSIONS: ZPS seems to be an effective antipsychotic for PDP, with scarce or no extrapyramidal side effects; it is also safe and well tolerated. In view of the scarcity of studies and patients, however, further research is needed (if possible, by means of double-blind randomised trials) to be able to assess the true role of ZPS in PDP.

[Hyperammonaemic encephalopathy due to valproic acid]. / Encefalopatía hiperamoniémica por ácido valproico.

INTRODUCTION: One of the less frequent idiosyncratic side effects of valproic acid (VPA) is encephalopathy. Here we report one case. CASE REPORT: An 83-year-old female with no relevant past history, who received treatment with VPA following a post-traumatic subarachnoid haemorrhage and two convulsive seizures. A few days later, she was admitted to the Emergency Department because of a progressive clinical picture of mental slowness, nauseas and apathy. The systemic examination was normal. Neurologically, the most striking features were inattention and disorientation, despite her having a good level of consciousness, and mental confusion. Levels of VPA were within the below-therapeutic range and the basic lab findings (including hepatic profile) were normal, except for hyperammonaemia. Neuroimaging studies and cerebrospinal fluid analysis were also normal. An electroencephalogram (EEG) showed signs of severe diffuse encephalopathy with slow, triphasic waves and a non-convulsive epileptic status was therefore ruled out. After withdrawing the VPA, the patient's condition improved until her basal situation was reached in 48 hours and the EEG became normal, as did her ammonium levels. CONCLUSION: When faced with a patient who has recently been taking VPA and who presents a clinical picture of mental confusion, the possibility of encephalopathy due to said drug must be taken into consideration.

[Transient ischemic attack]. / Accidente isquémico transitorio.

During recent years a new definition for transient ischemic attack (TIA) has been proposed. This has been based on the advances in neuroimaging techniques and because it has been observed that most TIA last only a few minutes. Brain damage must be ruled out and TIA duration can be no longer than one hour. TIA increases the chance of stroke or vascular episodes, above all during the first days and of other vascular diseases such as ischemic heart disease. It is a prevalent condition which must be considered as an emergency even though the patient is usually asymptomatic. For the initial evaluation, routine blood test, electrocardiogram, chest X-ray, brain computed tomography and extra and intracranial ultrasonography study must be performed. Treatment is based on the control of risk factors and antithrombotic therapy.