Experience with tocilizumab in patients with neuromyelitis optica spectrum disorders.

INTRODUCTION: Neuromyelitis optica spectrum disorders (NMOSD) are immune-mediated inflammatory disorders of the central nervous system involving astrocytes, B lymphocytes, anti-aquaporin 4, and such inflammatory mediators as interleukin-6. Several immunosuppressants are used in their treatment. Tocilizumab, an interleukin-6 receptor antagonist, may be a treatment option. METHOD: We performed an observational, retrospective study analysing parameters of effectiveness (annualised relapse rate, disability, and radiological progression) and safety of tocilizumab in patients with NMOSD in whom previous immunosuppressant treatment had failed. We aimed to evaluate the effectiveness and safety of tocilizumab in clinical practice in patients with NMOSD not responding to other immunosuppressants. RESULTS: Five patients with NMOSD were analysed. Sixty percent of patients were women; mean age at diagnosis was 50±5.3 years and mean progression time was 4.5±3.6 years. Previously administered immunosuppressants were rituximab (in all 5), cyclophosphamide (2), and azathioprine (1). Mean time of exposure to tocilizumab was 2.3±1 years. Mean annualised relapse rate was 1.8±1.3 in the year prior to the introduction of tocilizumab and 0.2±0.4 the year after (P<.05), representing a reduction of 88.9%. CONCLUSIONS: In our experience, tocilizumab is safe and effective in patients with NMOSD showing no response to other immunosuppressants.

Tratamiento inmunosupresor en pulsos en esclerosis múltiple durante el desescalado de la epidemia por SARS-CoV-2. Algoritmo de seguridad / Pulse immunosuppressive therapy for multiple sclerosis during the SARS-CoV-2 lockdown de-escalation plan: Safety algorithm

INTRODUCCIÓN: La pandemia por SARS-CoV-2 está condicionando los abordajes diagnósticos, terapéuticos y asistenciales establecidos en esclerosis múltiple (EM). Durante las fases inicial y pico de la epidemia, los fármacos modificadores del curso de la EM caracterizados por ser inmunosupresores administrados en pulsos (TIP), vieron pospuesta su administración debido a la incertidumbre sobre su influencia en la infección, principalmente en contagiados/contagiosos asintomáticos/presintomáticos. El objetivo de este trabajo es presentar un algoritmo basado en criterios de seguridad que permita reanudar los TIP durante la fase de desescalado. MÉTODOS: Se elabora un algoritmo, cuya estructura se sustenta en la experiencia clínica en EM de los autores y en una revisión bibliográfica del conocimiento acumulado, que facilita la detección de contagiosos asintomáticos, presintomáticos o con síntomas leves de SARS-CoV-2, con el objetivo de evitar la administración de TIP y contagios por contacto prolongado en hospital de día (HdD). RESULTADOS: Algoritmo con doble filtro clínico-microbiológico consistente en la aplicación telemática de un listado de comprobación de síntomas y después realización de PCR para SARS-CoV-2 en exudado nasofaríngeo, a las 48 y 24 h antes del TIP programado respectivamente. CONCLUSIÓN: Considerando el balance beneficio-riesgo, la aplicación del algoritmo resultaría ventajosa pese a que no se conoce la proporción real de asintomáticos/presintomáticos contagiosos. La realización sistemática de PCR, como test con mayor sensibilidad en la fase presintomática de la infección, en combinación con un sistema de detección precoz de síntomas, reduciría contagios y favorecería la identificación de pacientes con riesgo antes de su exposición a TIP

INTRODUCTION: The COVID-19 pandemic is changing approaches to diagnosis, treatment, and care provision in multiple sclerosis (MS). During both the initial and peak phases of the epidemic, the administration of disease-modifying drugs, typically immunosuppressants administered in pulses, was suspended due to the uncertainty about their impact on SARS-CoV-2 infection, mainly in contagious asymptomatic/presymptomatic patients. The purpose of this study is to present a safety algorithm enabling patients to resume pulse immunosuppressive therapy (PIT) during the easing of lockdown measures. METHODS: We developed a safety algorithm based on our clinical experience with MS and the available published evidence; the algorithm assists in the detection of contagious asymptomatic/presymptomatic cases and of patients with mild symptoms of SARS-CoV-2 infection with a view to withdrawing PIT in these patients and preventing new infections at day hospitals. RESULTS: We developed a clinical/microbiological screening algorithm consisting of a symptom checklist, applied during a teleconsultation 48hours before the scheduled session of PIT, and PCR testing for SARS-CoV-2 in nasopharyngeal exudate 24hours before the procedure. CONCLUSION: The application of our safety algorithm presents a favourable risk-benefit ratio despite the fact that the actual proportion of asymptomatic and presymptomatic individuals is unknown. Systematic PCR testing, which provides the highest sensitivity for detecting presymptomatic cases, combined with early detection of symptoms of SARS-CoV-2 infection may reduce infections and improve detection of high-risk patients before they receive PIT

Pulse immunosuppressive therapy for multiple sclerosis during the SARS-CoV-2 lockdown de-escalation plan: Safety algorithm. / Tratamiento inmunosupresor en pulsos en esclerosis múltiple durante el desescalado de la epidemia por SARS-CoV-2. Algoritmo de seguridad.

INTRODUCTION: The COVID-19 pandemic is changing approaches to diagnosis, treatment, and care provision in multiple sclerosis (MS). During both the initial and peak phases of the epidemic, the administration of disease-modifying drugs, typically immunosuppressants administered in pulses, was suspended due to the uncertainty about their impact on SARS-CoV-2 infection, mainly in contagious asymptomatic/presymptomatic patients. The purpose of this study is to present a safety algorithm enabling patients to resume pulse immunosuppressive therapy (PIT) during the easing of lockdown measures. METHODS: We developed a safety algorithm based on our clinical experience with MS and the available published evidence; the algorithm assists in the detection of contagious asymptomatic/presymptomatic cases and of patients with mild symptoms of SARS-CoV-2 infection with a view to withdrawing PIT in these patients and preventing new infections at day hospitals. RESULTS: We developed a clinical/microbiological screening algorithm consisting of a symptom checklist, applied during a teleconsultation 48hours before the scheduled session of PIT, and PCR testing for SARS-CoV-2 in nasopharyngeal exudate 24hours before the procedure. CONCLUSION: The application of our safety algorithm presents a favourable risk-benefit ratio despite the fact that the actual proportion of asymptomatic and presymptomatic individuals is unknown. Systematic PCR testing, which provides the highest sensitivity for detecting presymptomatic cases, combined with early detection of symptoms of SARS-CoV-2 infection may reduce infections and improve detection of high-risk patients before they receive PIT.

Neuropatía aislada del sexto nervio craneal. Una manifestación inusual de preeclampsia / Isolated sixth nerve palsy: An unusual manifestation of preeclampsia

No disponible

Experience with tocilizumab in patients with neuromyelitis optica spectrum disorders. / Experiencia con tocilizumab en pacientes con espectro de la neuromielitis óptica.

INTRODUCTION: Neuromyelitis optica spectrum disorders (NMOSD) are immune-mediated inflammatory disorders of the central nervous system involving astrocytes, B lymphocytes, anti-aquaporin 4, and such inflammatory mediators as interleukin-6. Several immunosuppressants are used in their treatment. Tocilizumab, an interleukin-6 receptor antagonist, may be a treatment option. METHOD: We performed an observational, retrospective study analysing parameters of effectiveness (annualised relapse rate, disability, and radiological progression) and safety of tocilizumab in patients with NMOSD in whom previous immunosuppressant treatment had failed. We aimed to evaluate the effectiveness and safety of tocilizumab in clinical practice in patients with NMOSD not responding to other immunosuppressants. RESULTS: Five patients with NMOSD were analysed. Sixty percent of patients were women; mean age at diagnosis was 50±5.3 years and mean progression time was 4.5±3.6 years. Previously administered immunosuppressants were rituximab (in all 5), cyclophosphamide (2), and azathioprine (1). Mean time of exposure to tocilizumab was 2.3±1 years. Mean annualised relapse rate was 1.8±1.3 in the year prior to the introduction of tocilizumab and 0.2±0.4 the year after (P <.05), representing a reduction of 88.9%. CONCLUSIONS: In our experience, tocilizumab is safe and effective in patients with NMOSD showing no response to other immunosuppressants.

Development and validation of a brief electronic screening test for cognitive impairment in multiple sclerosis (SCI-MS Test).

OBJECTIVE: Although cognitive impairment (CI) is common in multiple sclerosis (MS), it is difficult to suspect in patients with low disability and there is a lack of brief and effective CI screening tools with a define cut-off point to be used during routine clinic visits. This study aims to validate the Electronic Screening Cognitive Impairment in Multiple Sclerosis (SCI-MS) test for CI among MS patients. METHODS: Cross-sectional, observational study that included adult patients, diagnosed with MS, Expanded Disability Status Scale (EDSS) score ≤6.5, without relapses within the last 2 months and no depression symptoms. The SCI-MS test consists of two modules: questionnaire (SCI-MS-Q) and pictogram matching tool (SCI-MS-P) measured for score and time. At inclusion, patients completed the Beck Depression Inventory (BDI-II test), the Brief Repeatable Battery of Neuropsychological Test (BRB-N) and the SCI-MS. The SCI-MS feasibility, test-retest reliability and predictive validity were assessed. RESULTS: A total of 194 patients (59.3% female) were included: mean (SD) age of 42 (9) years, mean time since diagnosis of 10 (7) years, 89.7% relapsing-remitting MS, and median (Q1-Q3) EDSS of 2.0 (1.0-3.5). According to BRB-N, 26.8% of patients had CI. Internal consistency was high (Cronbach alpha: 0.97). The intra-class correlation coefficient was 0.88 for the SCI-MS-Q, 0.09 for the SCI-MS-P score and 0.48 for the SCI-MS-P time, corresponding to AUC of the ROC curves of 0.571, 0.574 and 0.714, respectively. For a clinically significant cut-off point of ≥60 seconds, the reached CI sensitivity of SCI-MS-P time was 0.75 and the specificity 0.51. CONCLUSION: SCI-MS showed good psychometric properties. SCI-MS-P time of pictogram completion had an acceptable diagnostic accuracy of CI in MS patients with low disability. SCI-MS-P time of pictogram completion tool is an easy and quick score that can help neurologists to early identify CI in MS patients that should be further assessed to confirm CI diagnosis and to describe its characteristics and mainly affected domains.

Leishmaniasis cutánea agresiva en paciente con esclerosis múltiple tratada con fingolimod / Aggressive cutaneous leishmaniasis in a patient with multiple sclerosis treated with fingolimod

No disponible

[Progressive encephalitis due to anti-DPPX antibodies: a case with good response to treatment with rituximab]. / Encefalitis progresiva por anticuerpos anti-DPPX: un caso con buena respuesta al tratamiento con rituximab.

TITLE: Encefalitis progresiva por anticuerpos anti-DPPX: un caso con buena respuesta al tratamiento con rituximab.

[Prevalence of multiple sclerosis in the Region of Murcia]. / Prevalencia de la esclerosis multiple en la Region de Murcia.

INTRODUCTION: Multiple sclerosis (MS) is a demyelinating inflammatory disease of the central nervous system with immune-mediated pathogenesis. Recent research points to an increase in its prevalence, and a number of studies relate Epstein-Barr virus (EBV) with its aetiology. AIMS: This study seeks to analyse the prevalence of MS in the Region of Murcia, and includes a description of the clinical characteristics at the time of onset of the disease, and of the EBV serological status of patients with MS. PATIENTS AND METHODS: We conducted a retrospective epidemiological study based on a sample consisting of the population living within the central-west healthcare area of the Region of Murcia (257,865 inhabitants). Clinical and serological data extracted from different sources were analysed. RESULTS: Prevalence of MS in the population under study: 88 cases/100,000 inhabitants. Prevalence of MS together with isolated demyelinating syndrome: 98.4 cases/100,000 inhabitants. Mean incidence of MS: 5.8 cases/100,000 inhabitants/year. At the onset of MS, 67.8% were females, 81.9% presented a relapsing-remitting course, the mean age was 31.4 years, the sensory system was the most frequently compromised (45.1%), onset was monofocal in 55.4% and the degree of disability on the Expanded Disability Status Scale was 2.1 points. The seroprevalence of EBV was 99.3%. The reactivation of EBV infection was related to the clinical activity of MS in 10 patients (45.4%). CONCLUSIONS: Currently, the prevalence of MS in the Region of Murcia is similar to that estimated in other Spanish autonomous regions. The study confirms the trend of increased prevalence observed over the last few decades.

TITLE: Prevalencia de la esclerosis multiple en la Region de Murcia.Introduccion. La esclerosis multiple (EM) es una enfermedad inflamatoria desmielinizante del sistema nervioso central con patogenia inmunomediada. Recientes estudios indican un aumento de su prevalencia, y numerosos trabajos relacionan el virus de Epstein-Barr (VEB) con su etiologia. Objetivo. Analisis de prevalencia de la EM en la Region de Murcia, incluyendo la descripcion de las caracteristicas clinicas en el momento del inicio de la enfermedad, y del estado serologico del VEB de los pacientes con EM. Pacientes y metodos. Estudio epidemiologico retrospectivo, tomando como muestra la poblacion residente en el area sanitaria centro-oeste de la Region de Murcia (257.865 habitantes). Se analizan datos clinicos y serologicos extraidos de diferentes fuentes. Resultados. Prevalencia de la EM en la poblacion estudiada: 88 casos/100.000 habitantes. Prevalencia de la EM junto con el sindrome desmielinizante aislado: 98,4 casos/100.000 habitantes. Incidencia media de la EM: 5,8 casos/100.000 habitantes/año. En el inicio de la EM, el 67,8% eran mujeres, el 81,9% presentaba un curso recurrente-remitente, la edad media era de 31,4 años, el sistema funcional mas frecuentemente afectado era el sensitivo (45,1%), el inicio fue monofocal en el 55,4% y el grado de discapacidad en la Expanded Disability Status Scale era de 2,1 puntos. La seroprevalencia del VEB fue del 99,3%. La reactivacion de la infeccion por VEB se relaciono con actividad clinica de EM en 10 pacientes (45,4%). Conclusiones. Actualmente, la prevalencia de la EM en la Region de Murcia es similar a la estimada en otras comunidades autonomas españolas. El estudio confirma la tendencia de incremento de prevalencia observada en las ultimas decadas.

Hemorrhage/contrast staining areas after mechanical intra-arterial thrombectomy in acute ischemic stroke: imaging findings and clinical significance.

BACKGROUND AND PURPOSE: The aim of this study was to report the CT evolution and clinical significance of HCA after intra-arterial mechanical thrombectomy (revascularization by using retrievers and/or other mechanical devices without concomitant delivery of intra-arterial thrombolytics) in our patients. These lesions are common after intra-arterial thrombolysis, being considered a negative prognostic sign. Their significance after pure mechanical thrombectomy remains unknown. MATERIALS AND METHODS: Forty-eight patients were treated with mechanical thrombectomy by using retrievable stents between April 2010 and February 2011. All patients underwent initial (first 24 hours) and follow-up (48-72 hours) nonenhanced CT. We retrospectively analyzed the clinical and radiologic data of the patients with HCA and compared them with controls. RESULTS: Fifteen of 48 patients presented with HCA. The site of occlusion was the MCA in 7 patients, both the extra- and intracranial segments of the ICA in 6, and the intracranial ICA in 2. In 7 patients, previous intravenous thrombolysis was administered. Complete recanalization (TICI 3) was achieved in 12 patients, and incomplete recanalization (TICI 2b), in 3. The location of HCA was the subarachnoid space in 6 patients, the brain parenchyma in 4 patients, and both in 5 patients. The HCA were asymptomatic in all patients. There was no statistical difference in final NIHSS score reduction (NIHSS pretreatment-NIHSS at discharge) between patients and controls. CONCLUSIONS: In our series, HCA are common after mechanical thrombectomy but do not carry an increased risk of symptomatic hemorrhage or negative prognosis. These data might be related to the high rate of recanalization and the absence of intra-arterial thrombolytics.

Spasticity improvement in patients with relapsing-remitting multiple sclerosis switching from interferon-ß to glatiramer acetate: the Escala Study.

BACKGROUND: A recent pilot study suggested spasticity improvement during glatiramer acetate (GA) treatment in multiple sclerosis (MS) patients who previously received interferon-ß (IFN-ß). OBJECTIVE: To evaluate changes in spasticity in MS patients switching from IFN-ß to GA. METHODS: Observational, multicentre study in patients with relapsing-remitting MS (RRMS) and spasticity switching from IFN-ß to GA. The primary endpoint comprised changes on Penn Spasm Frequency Scale (PSFS), Modified Ashworth Scale (MAS), Adductor Tone Rating Scale (ATRS), and Global Pain Score (GPS) at months 3 and 6 after starting GA. RESULTS: Sixty-eight evaluable patients were included (mean age,41.7±9.5 years; female,70.6%; mean time from MS diagnosis to starting GA,7.6±5.7 years). Previous treatments were subcutaneous IFN-ß1a in 42.6% patients, intramuscular IFN-ß1a in 41.2% and IFN-ß1b in 32.4%, whose mean durations were 3.5±3.3, 2.7±2.5 and 4.4±3.6 years, respectively. Statistically significant reductions in mean scores on all spasticity measurements were observed from baseline to month 3 (PSFS, 1.7±0.9 vs 1.4±0.6, p<0.01; MAS, 0.7±0.5 vs 0.6±0.5, p<0.01; highest MAS score, 1.9±0.8 vs 1.7±0.8, p<0.01; ATRS, 1.6±0.6 vs 1.4±0.6, p<0.01; GPS, 29.4±22.1 vs 24.7±19.4, p<0.01) and from baseline to month 6 (PSFS, 1.7±0.9 vs 1.3±0.6, p<0.01; MAS, 0.7±0.5 vs 0.5±0.5, p<0.01; highest MAS score, 1.9±0.8 vs 1.5±0.9, p<0.01; ATRS, 1.6±0.6 vs 1.3±0.6, p<0.01; GPS, 29.4±22.1 vs 19.1±14.8, p<0.01). CONCLUSION: Spasticity improvement in terms of spasm frequency, muscle tone and pain can be noted after three months and prolonged for six months of GA treatment.

Esclerosis concéntrica de Baló / Balo’s concentric sclerosis

No disponible

[Carotid revascularisation using angioplasty and stent in 134 consecutive cases in a reference hospital: a risky technique?]. / 134 casos consecutivos de revascularización carotídea mediante angioplastia y stent en un centro de referencia: ¿una técnica de riesgo?

INTRODUCTION: Carotid revascularisation (CR) using angioplasty and stent (ASC) is an effective procedure in the prevention of ischaemic stroke, but with a controversial morbidity and mortality in the different studies conducted in this field. METHODS: The results of the ASCs performed in the Virgen de la Arrixaca University Hospital (Murcia) between January 2006 and April 2009 were analysed (epidemiology, indication, grade of residual stenosis and procedure complications). All patients subjected to ASC were pre-selected and followed up by neurologists, and they followed a strict medical protocol for performing the procedure. All ASCs were performed by a team consisting of two surgeons, an anaesthetist and a nurse. RESULTS: A total of 134 ASC were performed. The mean age of our patients was 72.7 years, with the large majority (75%) being male. The most prevalent diseases were, high blood pressure (81%), smoking (66.4%), and diabetes (38.1%). The most common indications for CR were symptomatic carotid stenosis with a level of stenosis of 75-99%, either in the left (33.6%) or right (32.1%), followed by asymptomatic stenosis combined with risk factors (11.2% in the left side and 10.4% in the right side). A level of stenosis less than 30% was achieved in 132 of the 134 ASC (98.5%). performed. Five patients (3.7%) had complications associated with the procedure, of which four were different clinical presentations of a re-perfusion syndrome and one an asymptomatic thrombosis of the stent. CONCLUSIONS: ASC is a complex technique that must be performed by appropriately trained specialists. The performing a minimum number of procedures per year and an admission protocol controlled by Neurology are essential conditions for a low rate of complications. Under these conditions, the morbidity and mortality of the technique is no higher than that of endarterectomy.

134 casos consecutivos de revascularización carotídea mediante angioplastia y stent en un centro de referencia: ¿una técnica de riesgo? / Carotid revascularisation using angioplasty and stent in 134 consecutive cases in a reference hospital: A risky technique?

Introducción: La revascularización carotídea mediante angioplastia y stent (ASC) es un procedimiento eficaz en la prevención del ictus isquémico, pero con una morbimortalidad periprocedimiento muy discutida en los diferentes estudios realizados al respecto.Métodos: Se analizan los resultados (epidemiología, tipo de indicación, grado de estenosis residual y complicaciones periprocedimiento) de las ASC realizadas en el Hospital Universitario Virgen de la Arrixaca entre enero de 2006 y abril de 2009. Todos los pacientes sometidos a ASC fueron preseleccionados y seguidos por neurólogos, y siguieron un protocolo médico estricto para la realización del procedimiento. Todas las ASC fueron llevadas a cabo por un equipo formado por dos intervencionistas, un anestesista y un enfermero. Resultados: Se realizaron 134 ASC. La edad media de nuestros pacientes fue de 72,7 años, con predominio del sexo masculino (75%). Las patologías más prevalentes fueron la hipertensión arterial (81%), el tabaquismo (66,4%), y la diabetes (38,1%). La indicación de RC más frecuente fue la estenosis carotídea sintomática con grado de estenosis 75-99%, tanto izquierda (33,6%) como derecha (32,1%), seguida de las estenosis asintomáticas asociadas a factores de riesgo (11,2% en el lado izquierdo y 10,4% en el lado derecho). En 132 de las 134 ASC (98,5%) se consiguió un grado de estenosis residual menor al 30%. Cinco pacientes (3,7%) presentaron complicaciones relacionadas con el procedimiento, de las cuales cuatro correspondieron a diferentes presentaciones clínicas del síndrome de reperfusión y una, a una trombosis asintomática del stent.Conclusiones: La ASC es una técnica compleja que debe ser llevada a cabo por especialistas con una capacitación adecuada. La realización de un número mínimo de procedimientos al año, y la existencia de un protocolo de ingreso controlado por Neurología son condiciones imprescindibles para una tasa de complicaciones (AU)

Introduction: Carotid revascularisation (CR) using angioplasty and stent (ASC) is an effective procedure in the prevention of ischaemic stroke, but with a controversial morbidity and mortality in the different studies conducted in this field.Methods: The results of the ASCs performed in the Virgen de la Arrixaca University Hospital (Murcia) between January 2006 and April 2009 were analysed (epidemiology, indication, grade of residual stenosis and procedure complications). All patients subjected to ASC were pre-selected and followed up by neurologists, and they followed a strict medical protocol for performing the procedure. All ASCs were performed by a team consisting of two surgeons, an anaesthetist and a nurse. Results: A total of 134 ASC were performed. The mean age of our patients was 72.7 years, with the large majority (75%) being male. The most prevalent diseases were, high blood pressure (81%), smoking (66.4%), and diabetes (38.1%). The most common indications for CR were symptomatic carotid stenosis with a level of stenosis of 75-99%, either in the left (33.6%) or right (32.1%), followed by asymptomatic stenosis combined with risk factors (11.2% in the left side and 10.4% in the right side). A level of stenosis less than 30% was achieved in 132 of the 134 ASC (98.5%). performed. Five patients (3.7%) had complications associated with the procedure, of which four were different clinical presentations of a re-perfusion syndrome and one an asymptomatic thrombosis of the stent. Conclusions: ASC is a complex technique that must be performed by appropriately trained specialists. The performing a minimum number of procedures per year and an admission protocol controlled by Neurology are essential conditions for a low rate of complications. Under these conditions, the morbidity and mortality of the technique is no higher than that of endarterectomy (AU)

Ictus carotídeo secundario a apoplejía hipofisaria. Respuesta favorable a trombosis intravenosa / No disponible

No disponible