Experiencia del uso de terapia biológica en pacientes con enfermedad inflamatoria intestinal en un hospital público / Experience in the use of biological therapy in IBD patients in a public hospital

Biological therapy plays an important role in the treatment of inflammatory bowel disease (IBD). However, the use of these drugs is limited due to fears about their side effects. Aim: To report the experience with the use of infliximab/adalimumab in IBD patients in a public hospital. Material and Methods: Descriptive study of a historical cohort of IBD patients treated with infliximab and adalimumab between April 2012 and July 2014. The clinical response was considered favourable when general, intestinal and extra intestinal symptoms subsided after the induction therapy. In addition, endoscopic and/or imaging response was evaluated at three and six months of treatment. Results: Fifteen out of 162 patients, aged 17 to 52 years (7 women) were included. Seven had Crohn´s Disease, 7 had ulcerative colitis and one had non-classifiable IBD. Biological therapy was indicated due to conventional refractory disease in all patients. All patients received combined treatment with immunosuppressive medications. A favorable clinical response was observed in 93 percent after induction therapy and 73 percent showed endoscopic/imagining remission after 3-6 months. Only one patient experienced side effects associated to the biological therapy, which did not result in discontinuation or treatment interruption. Conclusions: In this cohort of IBD patients treated in a public hospital, the use of infliximab/adalimumab was associated with favorable clinical and endoscopic evolution, post induction therapy with no major side effects.

La terapia biológica tiene un papel fundamental en el tratamiento de la enfermedad inflamatoria intestinal (EII). Sin embargo, el uso de estos fármacos es escaso debido a los costos y los temores sobre los efectos secundarios. Objetivo: Dar a conocer la experiencia en el uso de infliximab/adalimumab en pacientes con EII atendidos en un hospital público de nuestro país. Material y Métodos: Estudio descriptivo de una cohorte histórica de pacientes con EII tratados con infliximab y adalimumab entre abril de 2012 y julio de 2014. La respuesta clínica fue considerada favorable cuando los síntomas generales, intestinales y extra-intestinales desaparecieron después de la terapia de inducción. Además se evaluó la respuesta endoscópica/radiológica a los 3 y 6 meses de tratamiento. Resultados: De un total de 162 pacientes con EII, 15 fueron tratados con terapia biológica, con edad entre 17-52 años (7 mujeres). Siete presentaban el diagnóstico de enfermedad de Crohn, siete colitis ulcerosa y uno EII no clasificable. En todos se inició terapia biológica debido a la presencia de refractariedad a la terapia convencional. Todos recibieron terapia combinada con inmunosupresores. Se observó una respuesta clínica favorable en 93 por ciento después de la terapia de inducción y 73 por ciento tuvo una mejoría endoscópica después de 3-6 meses. Sólo un paciente presentó un evento adverso a terapia biológica, el cual no motivó la interrupción del tratamiento. Conclusiones: En esta cohorte de pacientes con EII tratados en un hospital público, el uso de infliximab/adalimumab se asoció con mejoría clínica y endoscópica post terapia de inducción, sin mayores efectos secundarios.

Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment.

OBJECTIVE: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. MATERIAL AND METHODS: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. RESULTS: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. CONCLUSIONS: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.

Intoxicación por Nerium oleander / Nerium oleander poisoning

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Influencia del antecedente de diabetes mellitus en la gravedad y evolución intrahospitalaria de un infarto cerebral / Influence of previous diagnosis of diabetes mellitus in the stroke severity and in-hospital outcome in acute cerebral infarction

Introducción. Se analiza si el diagnóstico previo de diabetes mellitus (DM) influye en la gravedad al ingreso y en la evolución hospitalaria de los pacientes con infarto cerebral (IC) agudo. Métodos. Estudio observacional durante el período 1998- 2004. Se seleccionan pacientes con IC. Se comparan dos grupos (pacientes con y sin antecedentes de DM) analizándose: antecedentes personales, subtipo etiológico de ictus, gravedad al ingreso (Escala Canadiense [EC] de ictus) complicaciones intrahospitalarias, mortalidad, estancia media y estado funcional al alta (Escala de Rankin modificada [ERm]). Resultados. Se incluyeron 2.213 pacientes con IC agudo; 661 con antecedentes de DM (29,9 %) Éstos tuvieron una mayor edad, mayor frecuencia de hipertensión, dislipemia, cardiopatía isquémica, vasculopatía periférica e IC previo. Los infartos aterotrombóticos y lacunares fueron más frecuentes entre los pacientes con antecedentes de DM. Éstos tuvieron mayor porcentaje de infección urinaria (4,7 frente a 2,6 %; p < 0,05), fracaso multiorgánico (3,3 frente a 1,8 %; p<0,05), ictus en evolución (6,1 frente a 3,4%; p<0,01), ictus recurrente (3,3 frente a 1,7 %; p < 0,05) y aumento del volumen del infarto (2,6 frente a 1,1%; p<0,05) sin diferencias significativas en gravedad al ingreso, mortalidad, estancia media y estado funcional al alta. El antecedente de DM estuvo asociado a un mayor riesgo de complicaciones intrahospitalarias (odds ratio: 1,377; intervalo de confianza del 95%: 1,053-1,799). Conclusiones. Los pacientes con antecedentes de DM no presentaron mayor gravedad al ingreso, pero sí mayor riesgo de desarrollo de complicaciones (AU)

Introduction. To analyze if previous diagnosis of diabetes influences stroke severity and in-hospital outcome in acute cerebral infarction (CI) patients. Methods. Observational study between 1998–2004 with inclusion of consecutive patients with CI. Risk factors, stroke subtype, severity on admission (Canadian Stroke Scale [CSS]), in-hospital complications, mortality, length of stay and stroke outcome (modified Rankin Scale [mRS]) in CI patients with and without previous diagnosis of diabetes were compared. Results. A total of 2,213 consecutive acute stroke patients; 661 with previous history of diabetes (29,9%) were included. These patients were older, had more rate of hypertension, dyslipidemia, coronary arterial disease, peripheral vascular disease and previous stroke than non-diabetic patients. Atherotrombotic and lacunar infarction were more frequent in diabetic patients. They also had more in-hospital complications as urinary tract infection (4.7 % vs 2.6 %; p < 0.05), multiple organ dysfunction syndrome (3.3% vs 1.8%; p<0.05), deteriorating stroke (6.1 % vs 3.4 %; p < 0.01), recurrent stroke (3.3% vs 1.7%; p<0.05) and increase of infarction volume (2.6 % vs 1.1%; p<0.05), with no differences in stroke severity at admission, mortality, length of in-hospital stay and stroke outcome. Previous history of diabetes was independently associated with in-hospital complications (OR: 1.377; CI 95%: 1.053-1.799). Conclusions. Previous diagnosis of diabetes is not associated by itself to higher stroke severity on admission although a greater risk of in-hospital complications is found (AU)

Thrombolysis and neuroprotection in cerebral ischemia.

Stroke is a major cause of death and disability worldwide. The resulting burden on society grows with the increase in the incidence of stroke. The term brain attack was introduced to describe the acute presentation of stroke and emphasize the need for urgent action to remedy the situation. Though a large number of therapeutic agents, like thrombolytics, NMDA receptor antagonists, calcium channel blockers and antioxidants, have been used or are being evaluated, there is still a large gap between the benefits of these agents and the properties of an ideal drug for stroke. So far, only thrombolysis with rtPA within a 3-hour time window has been shown to improve the outcome of patients with ischemic stroke. Understanding the mechanisms of injury and neuroprotection in these diseases is important to target news sites for treating ischemia. Better evaluation of the drugs and increased similarity between the results of animal experimentation and in the clinical setting requires critical assessment of the selection of animal models and the parameters to be evaluated. Our laboratory has employed a rat embolic stroke model to investigate the combination of rtPA with citicoline as compared to monotherapy alone and investigated whether neuroprotection should be provided before or after thrombolysis in order to achieve a greater reduction of ischemic brain damage.

[The advantages of a stroke unit in the treatment of intracerebral hemorrhage]. / Beneficio de la Unidad de Ictus en el tratamiento de la hemorragia intracerebral.

INTRODUCTION: The efficacy of a stroke unit in the management of acute cerebrovascular disease has, in general, been widely demonstrated. Our analysis seeks to determine whether this efficacy is maintained in intracerebral hemorrhage. PATIENTS AND METHODS: We studied the patients with intracerebral hemorrhage attended in the Neurology Department by the stroke team in 1994 and during the first years of its activity (1995-1996), analysing the average time of stay, complications, functional state and destiny of the patient after discharge. RESULTS: We recorded 151 patients (58 in 1994, 46 in 1995 and 57 in 1996) who made up 10.1% of the total number of strokes. We observed a significant reduction in average stay (p < 0.01), with improved score on the Rankin scale at the time of discharge (p < 0.005). Similarly there were fewer complications and those statistically significant were: hydrocephaly (p < 0.05), rebleeding (p < 0.05), sepsis (p < 0.1) and renal failure (p < 0.01). Discharge home remained stable although there was a significant increase in transport of patients to rehabilitation centres (p < 0.05) and reduction in patients sent to long-term care institutions. CONCLUSIONS: The specific integrated care given by stroke unit result in improved course of the illness in patients with intracerebral hemorrhage, with fewer complications, reduced hospital stay, better functional state and better possibilities of rehabilitation after discharge.

Beneficio de la unidad de ictus en el tratamiento de la hemorragia intracerebral / The advantages of a stroke unit in the treatment of intracerebral hemorrhage

Introducción. La eficacia de la Unidad de Ictus (UI) en el manejo de la enfermedad cerebrovascular aguda ha sido, en general, ampliamente demostrado. Analizamos si esta eficacia se mantiene en la hemorragia intracerebral (HIC). Pacientes y métodos. Estudiamos los pacientes con HIC atendidos en el Servicio de Neurología por el equipo de ictus en 1994 y durante los dos primeros años de funcionamiento de la UI (1995-96), analizando el tiempo de estancia media, complicaciones, estado funcional y destino del paciente tras recibir el alta. Resultados. Contabilizamos 151 pacientes (48 en 1994, 46 en 1995 y 57 en 1996), que constituían el 10,1 por ciento de los ictus totales. Observamos una reducción significativa de la estancia media (p< 0,01), con una mejor puntuación en la escala Rankin en el momento del alta (p< 0,005). Asimismo, apreciamos una disminución de complicaciones, de las cuales eran estadísticamente significativas: hidrocefalia (p< 0,05), resangrado (p< 0,05), sepsis (p< 0,01) e insuficiencia renal (p< 0,01). Las altas a domicilio se mantienen estables, si bien se observa un aumento significativo de traslados a centros de rehabilitación (p< 0,05) y la disminución de pacientes derivados a centros de enfermos crónicos (p< 0,05). Conclusiones. La atención específica e integrada que ofrece la UI determina una mejor evolución de los pacientes con HIC, con menor número de complicaciones, reducción de estancia hospitalaria, mejor estado funcional y mayores posibilidades de rehabilitación tras el alta (AU)