Quality of life and economic impact of refractory epilepsy in Spain: the ESPERA study.

INTRODUCTION: Despite use of currently available anti-epileptic drugs (AED), 30% of epilepsy patients are not seizure-free. The purpose of this study was to estimate the quality of life and economic impact in Spain of drug-resistant epilepsy (DRE), as defined by the International League Against Epilepsy (ILAE). METHODS: Observational retrospective 12-month study conducted in Spain including adults with focal epilepsy treated with at least two AEDs. Direct costs (€ 2010) were calculated based on health care resources used and their official unit costs. Costs were analysed from the perspectives of the Spanish National Health System (SNS) and society. The impact of DRE on patients' quality of life was examined using the QOLIE 31-P, EQ-5D-3L, and NDDIE questionnaires. RESULTS: We analysed 263 patients out of the 304 recruited. According to ILAE criteria, 70.0% of the patients had drug-resistant epilepsy, while 20.3% achieved seizure freedom. From the viewpoint of the SNS, annual costs for resistant and seizure-free patients were € 4964 and € 2978 respectively (P<.01). Compared to resistant patients, seizure-free patients showed better scores on QOLIE-31P (70.8 vs 56.4, P<.0001) and EQ-5D-3L (75.6 vs 64.7, P<.001). Seizure-free patients showed a lower incidence of major depression compared to resistant patients according to the NDDIE scale (23 vs 8.3%, P<.05). CONCLUSIONS: Results suggest that DRE is associated with increased use of healthcare resources and consequently with higher costs, poorer quality of life and higher incidence of major depression compared to seizure-free patients, thus representing a considerable burden to the SNS and society.

Prediction of early stroke recurrence in transient ischemic attack patients from the PROMAPA study: a comparison of prognostic risk scores.

BACKGROUND: Several clinical scales have been developed for predicting stroke recurrence. These clinical scores could be extremely useful to guide triage decisions. Our goal was to compare the very early predictive accuracy of the most relevant clinical scores [age, blood pressure, clinical features and duration of symptoms (ABCD) score, ABCD and diabetes (ABCD2) score, ABCD and brain infarction on imaging score, ABCD2 and brain infarction on imaging score, ABCD and prior TIA within 1 week of the index event (ABCD3) score, California Risk Score, Essen Stroke Risk Score and Stroke Prognosis Instrument II] in consecutive transient ischemic attack (TIA) patients. METHODS: Between April 2008 and December 2009, we included 1,255 consecutive TIA patients from 30 Spanish stroke centers (PROMAPA study). A neurologist treated all patients within the first 48 h after symptom onset. The duration and typology of clinical symptoms, vascular risk factors and etiological work-ups were prospectively recorded in a case report form in order to calculate established prognostic scores. We determined the early short-term risk of stroke (at 7 and 90 days). To evaluate the performance of each model, we calculated the area under the receiver operating characteristic curve. Cox proportional hazards multivariate analyses determining independent predictors of stroke recurrence using the different components of all clinical scores were calculated. RESULTS: We calculated clinical scales for 1,137 patients (90.6%). Seven-day and 90-day stroke risks were 2.6 and 3.8%, respectively. Large-artery atherosclerosis (LAA) was observed in 190 patients (16.7%). We could confirm the predictive value of the ABCD3 score for stroke recurrence at the 7-day follow-up [0.66, 95% confidence interval (CI) 0.54-0.77] and 90-day follow-up (0.61, 95% CI 0.52-0.70), which improved when we added vascular imaging information and derived ABCD3V scores by assigning 2 points for at least 50% symptomatic stenosis on carotid or intracranial imaging (0.69, 95% CI 0.57-0.81, and 0.63, 95% CI 0.51-0.69, respectively). When we evaluated each component of all clinical scores using Cox regression analyses, we observed that prior TIA and LAA were independent predictors of stroke recurrence at the 7-day follow-up [hazard ratio (HR) 3.97, 95% CI 1.91-8.26, p < 0.001, and HR 3.11, 95% CI 1.47-6.58, p = 0.003, respectively] and 90-day follow-up (HR 2.35, 95% CI 1.28-4.31, p = 0.006, and HR 2.20, 95% CI 1.15-4.21, p = 0.018, respectively). CONCLUSION: All published scores that do not take into account vascular imaging or prior TIA when identifying stroke risk after TIA failed to predict risk when applied by neurologists. Clinical scores were not able to replace extensive emergent diagnostic evaluations such as vascular imaging, and they should take into account unstable patients with recent prior transient episodes.

[Psychosis as the initial manifestation of systemic lupus erythematosus: the role of lupus band test and anti-ribosomal antibodies]. / Psicosis como manifestación inicial de lupus eritematoso sistémico: valor de la prueba de la banda lúpica frente a los anticuerpos antirribosomales.

INTRODUCTION: Diffuse brain disease in systemic lupus erythematous (SLE) can be difficult to assess because of the sparse biological expression of the disorder, resulting in usually normal neuroimaging and laboratory findings. For this reason, it is likely that patients without a previous SLE diagnosis that presented initially with a pure psychiatric disorder, as psychosis or depression, can remain undiagnosed, and, in fact, they are exceptionally reported. As a biological marker, antiribosomal P protein antibodies have been closely related to SLE psychosis although their pathogenic role and specificity is under discussion. CLINICAL CASE: A young woman, without relevant medical history, presented with an acute psychotic catatonic picture, suspected organic in nature due to the existence of persistent mild CSF pleocytosis, while neuroimaging and laboratory studies were negative, including antinuclear and antiribosomal antibodies. Finally, a SLE diagnosis could be established because of a strong lupic band phenomenon in skin biopsy. CONCLUSIONS: It is important to maintain a high suspicion of SLE in acute psychotic patients, especially if atypical features are present. As the biological expression of the disorder in such cases may be elusive, we propose the study of lupus band in skin biopsy for these patients, regardless the absence of antiribosomal antibodies.

[Anesthesia paresthetica: contribution of a new case and evolutive study using magnetic resonance]. / Anestesia parestésica: aportación de un nuevo caso y estudio evolutivo por resonancia magnética.

Patients with subclinical cobalamin deficiency may develop a subacute myeloneuropathy after nitrous oxide anesthesia. Frequently they have hematologic manifestations, however there is only a few reports of spinal lesions shown on MR and particularly of the effects of cobalamin replacement therapy on these lesions. We describe a patient with unsuspected cobalamin deficiency who developed subacute combined degeneration of the spinal cord after nitrous oxide anesthesia. MR showed high intensity in dorsal columns on T2-weighted image, and posterior resolution of abnormalities after therapy. We discuss the importance of preoperative hematologic manifestations for select high risk patients and prevent this complication. On the other hand, we consider MR as a useful tool to improve our knowledge in the pathophysiology of the neurologic manifestations of the process.

[Progression of functional disability in 70 patients with multiple sclerosis]. / Progresión de la incapacidad funcional en 70 pacientes con esclerosis múltiple.

We have carried out a follow-up study in 70 patients that were included in a follow-up protocol when they met the criteria of MS, so as to evaluate the variations in the disability scale per unit of time of follow-up (index of progression) in relation to the several risk factors. There were 31 females and 39 men followed up for 19.6 +/- 12 months. One half of the patients (35) had their first symptoms between 25 and 45 years of age, in 27 the onset was after age 25 and in 8 after age 45. At the end of follow-up 42 patients were classified as having remitting forms, 12 as progressive forms after a remitting phase and 16 as progressive forms from the onset. Significant differences in the evolutive forms were only found in remitting-progressive forms, which had a quicker progression than the purely remitting and chronic progressive forms. The patients who initially had cerebellar symptoms had a quicker progression than those with any other type of presentation. Whereas patients with late onset had a quicker progression than the group with intermediate onset, the patients with early onset had a slower progression.

Inoperable pulmonary aspergilloma: percutaneous CT-guided injection with glycerin and amphotericin B paste in 15 cases.

Fifteen patients with active inoperable pulmonary aspergilloma underwent percutaneous injection of a special therapeutic paste of glycerin and amphotericin B. This paste was warmed just prior to injection, and filling of the lesional cavity was achieved in one session if it was possible to obtain anaerobic conditions for destruction of the aspergilloma. Injection was performed with computed tomographic guidance with use of an 18-gauge flexible needle and with administration of anti-coughing analgesia. Follow-up was continued for 7 months on average. Filling of the lesion cavities required three sessions on average because of cough or bronchospasm. In 12 cases the aspergilloma regressed within 3 months and results at serology became negative. In three cases, there was no change in the cavity, but hemoptysis did not recur. Results in this series confirm the feasibility and efficacy of this palliative treatment.