Consenso experto sobre el uso clínico de los tratamientos por vía tópica en el manejo del dolor neuropático periférico / No disponible

Objetivo: Proponer a partir del consenso de un panel de expertos de ambito estatal que integre la experiencia clinica y la evidencia disponible mas actual, recomendaciones sobre el uso clinico de los tratamientos por via topica para el manejo del dolor neuropatico periferico (DNP). Métodos: Se proponen, a partir de una revision bibliografica sobre las distintas opciones terapeuticas topicas en DNP, una serie de criterios profesionales y recomendaciones clinicas para la mejora del uso de dichos agentes topicos. Se empleo el metodo Delphi modificado en dos rondas para contrastar las opiniones de un panel nacional de 52 reconocidos expertos, seleccionados mediante una estrategia en “bola de nieve” de entre el colectivo de anestesiologos de unidades del dolor (94 %) y otros especialistas (neurologos y traumatologos). Se evaluaron 61 recomendaciones clinicas agrupadas en 6 areas tematicas: a) DNP: tratamiento topico versus sistemico (11 items); b) dolor neuropatico postquirurgico, postraumatico y munones dolorosos (12 items); c) neuralgia posherpetica, intercostal y del trigemino (9 items); d) DNP por atrapamiento (8 items); e) sindrome de dolor regional complejo (11 items); y f) neuropatia diabetica (ND) y otras polineuropatias (por VIH, alcohol, toxicidad, etc.) (10 items). Se empleo una escala ordinal de tipo Likert de 9 puntos (desacuerdo/ acuerdo) para evaluar cada recomendacion. Tras la primera ronda de encuesta, se facilito al panel informacion del resultado (resultados estadisticos y opiniones libres de los panelistas) y se solicito la reconsideracion del voto sobre los items no consensuados. Resultados: Tras la primera ronda del panel se logró consenso en 37 de las 61 cuestiones planteadas. Al final de la segunda ronda el acuerdo ascendió hasta 46 ítems (75 %). En general, se aprecia consenso entre los expertos sobre la conveniencia de introducir los tratamientos tópicos en primera línea de tratamiento del DNP y sobre su mejor aceptación por los pacientes frente a los sistémicos. Asimismo, fue criterio compartido que la combinación de estos fármacos tópicos con los tratamientos sistémicos es una opción a considerar en el manejo de varios tipos de DNP. También se alcanzó un alto grado de acuerdo en aceptar, desde un punto de vista fisiopatológico, la indicación del tratamiento con parche de capsaicina al 8 % para varios tipos de DNP. Conclusión: Los expertos en el manejo clínico del DNP muestran un elevado nivel de acuerdo profesional con diversas recomendaciones terapéuticas analizadas en el estudio. La difusión de tales recomendaciones puede ayudar a la mejora del manejo rutinario de fármacos tópicos para el dolor neuropático en nuestro sistema sanitario (AU)

Objective: To propose consensus from a panel of state level that integrates clinical experience and the most current evidence, recommendations on the clinical use of topical treatments for the management of peripheral neuropathic pain (PNP). Methods: We propose, based on a literature review on topical therapeutic options in PNP, a series of professional standards and clinical recommendations for improving the use of these topical agents. We used the modified Delphi method in two rounds to contrast the views of a national panel of 52 renowned experts, selected by a “snowball” strategy among the group of anesthesiologists pain units (94 %) and other specialists (neurologist and trauma). We evaluated 61 clinical recommendations grouped into 6 areas: a) PNP systemic versus topical treatment (11 items); b) postsurgical neuropathic pain, post-traumatic and painful stumps (12 items); c) post-herpetic neuralgia, intercostal and trigeminal (9 items); d) PNP entrapment (8 items); e) CRPS (11 items); and f) diabetic neuropathy (DN) and other polyneuropathy (HIV, alcohol, toxicity, etc.) (10 items). We used a Likert- type ordinal scale of 9 points (disagree/agree) to evaluate each recommendation. After the first round of the survey, information was provided requested to reconsider the vote on itemsnot agree. Results: After the first round the panel consensus was achieved in 37 of the 61 issues raised. At the end of the second round of the agreement amounted to 46 (75 %). In general, there was consensus among experts on whether to introduce topical treatment in first line treatment of PNP and its greater acceptance by patients compared with systemic. He was also a shared view consider in the management of various types of PNP. Also reached a high level of agreement to accept, from a physiological point of view, the indication for treatment with capsaicin patch 8 % for various types of PNP. Conclusions: Experts in the clinical management of PNP show a high level of professional agreement with various therapeutic recommendations for study. The dissemination of such recommendations can help improving the routine management of topical drugs for neuropathic pain in our health system (AU)

[Peripheral and optical myeloneuropathy in a folic acid deficient alcoholic patient]. / Mieloneuropatía periférica y óptica en un paciente alcohólico deficiente en ácido fólico.

INTRODUCTION: In Western countries, neurological disorders secondary to toxic nutritional problems usually present as isolated cases that are generally associated to identifiable causes (alcoholism, eating disorders, absorption disorders, use of medicines) that reduce the availability of basic nutrients, especially B group vitamins, but also folic acid (FA). The optic nerves and the peripheral axons are frequent target organs in this type of pathology, but leukoencephalopathy and spinal cord involvement may also appear, often in combination. CASE REPORT: We describe the case of a 38-year-old female smoker with a heavy alcohol habit, who developed a subacute clinical pattern of, predominantly axonal, sensitive peripheral polyneuropathy, with vegetative fibre involvement. She also presented involvement of the posterior spinal cord, which gave rise to an ataxic disorder in the gait, as well as a severe bilateral retrobulbar optic neuropathy. Likewise, she presented macrocytosis (MCV: 118) due to megaloblastosis. She was also found to have a FA deficit but a normal vitamin B12 metabolism. With the help of supplementary vitamins, stopping drinking and the regularisation of her diet, the patient presented progressive clinical improvement, and was able to walk without support at 3 months and almost completely recovered her sight, which was corroborated by an improvement in the studies of both visual and somatosensorial evoked potentials. CONCLUSIONS: In our community, alcoholism is a frequent cause of nutritional deficiencies, which lead to neurological problems. FA is one of the nutrients that become deficient in alcoholics. More and more descriptions are being reported of peripheral polyneuropathy, retrobulbular optic neuropathy, myelopathy or leukoencephalopathy associated to FA deficiency, above all in patients with a history of alcoholism.

Mieloneuropatía periférica y óptica en un paciente alcohólico deficiente en ácido fólico / Peripheral and optical myeloneuropathy in a folic acid deficient alcoholic patient

Introducción. En los países occidentales, los trastornos neurológicos secundarios a problemas toxiconutricionales suelen presentarse como casos aislados, generalmente asociados a causas identificables (alcoholismo, aberraciones dietéticas, trastornos de la absorción, uso de fármacos), que disminuyen la disponibilidad de algunos nutrientes básicos, fundamentalmente vitaminas del grupo B, pero también de ácido fólico (AF). Los nervios ópticos y los axones periféricos son dianas frecuentes en este tipo de patologías, pero también pueden aparecer, frecuentemente en combinación, leucoencefalopatía y afectación medular. Caso clínico. Mujer de 38 años, fumadora y con hábito alcohólico importante, que desarrolló un cuadro subagudo de polineuropatía periférica, sensitiva, con afectación de las fibras vegetativas, y de predominio axonal, junto a afectación cordonal posterior, que provocó trastorno atáxico de la marcha, así como neuropatía óptica retrobulbar bilateral grave. Igualmente presentaba macrocitosis (VCM: 118) debida a megaloblastosis. Se halló deficiencia de AF con un metabolismo de la vitamina B12 normal. Con suplementos vitamínicos, el abandono del hábito alcohólico y la normalización de la dieta, la paciente presentó una mejoría clínica progresiva, y fue capaz de deambular sin apoyo a los tres meses, con una recuperación casi completa de la función visual, todo ello corroborado por una mejoría en los resultados de los estudios de potenciales evocados, tanto visuales como somatosensoriales. Conclusiones. En nuestro medio, el alcoholismo es una causa frecuente de deficiencias nutricionales, que ocasionan problemas neurológicos. El AF es uno de los nutrientes que se hace deficitario en el alcoholismo. Cada vez aparecen más descripciones de polineuropatía periférica, neuropatía óptica retrobulbar, mielopatía o leucoencefalopatía asociadas a una deficiencia de AF, sobre todo en pacientes con abuso de alcohol (AU)

Introduction. In Western countries, neurological disorders secondary to toxic-nutritional problems usually present as isolated cases that are generally associated to identifiable causes (alcoholism, eating disorders, absorption disorders, use of medicines) that reduce the availability of basic nutrients, especially B group vitamins, but also folic acid (FA). The optic nerves and the peripheral axons are frequent target organs in this type of pathology, but leukoencephalopathy and spinal cord involvement may also appear, often in combination. Case report. We describe the case of a 38-year-old female smoker with a heavy alcohol habit, who developed a subacute clinical pattern of, predominantly axonal, sensitive peripheral polyneuropathy, with vegetative fibre involvement. She also presented involvement of the posterior spinal cord, which gave rise to an ataxic disorder in the gait, as well as a severe bilateral retrobulbar optic neuropathy. Likewise, she presented macrocytosis (MCV: 118) due to megaloblastosis. She was also found to have a FA deficit but a normal vitamin B12 metabolism. With the help of supplementary vitamins, stopping drinking and the regularisation of her diet, the patient presented progressive clinical improvement, and was able to walk without support at 3 months and almost completely recovered her sight, which was corroborated by an improvement in the studies of both visual and somatosensorial evoked potentials. Conclusions. In our community, alcoholism is a frequent cause of nutritional deficiencies, which lead to neurological problems. FA is one of the nutrients that become deficient in alcoholics. More and more descriptions are being reported of peripheral polyneuropathy, retrobulbular optic neuropathy, myelopathy or leukoencephalopathy associated to FA deficiency, above all in patients with a history of alcoholism (AU)