Comparison of the Stress and Anxiety to Viral Epidemic-9 and SAVE-6 scales among healthcare workers in Peru.

Introduction: Peru is a country that has a high incidence of viral outbreaks and epidemics, which is why it is necessary to validate a scale that measures anxiety and stress in professionals who are on the front lines of these events. Therefore, our objective was to validate the Peruvian-Spanish version of the Stress and Anxiety to Viral Epidemics-9 items (SAVE-9) scale and to concurrently compare its validity and internal consistency with the SAVE-6 scale among healthcare workers (HCWs). Materials and methods: We conducted a cross-sectional study based on data collected from a self-reported survey in paper-and-pencil format between April and July 2023. A total of 203 HCWs participated in the research. We developed a confirmatory factor analysis (CFA) and item response theory (IRT). We calculated Cronbach's α coefficient and McDonald's ω to assess the internal consistency of the scales. Results: The results show that SAVE-9 (a two-factor model) and SAVE-6 (a one-factor model) provided an excellent fit in the confirmatory factor analysis. Both scales demonstrated strong internal consistency (Cronbach's α 0.85 and 0.86, respectively). Significant correlations were found between the SAVE-9 and SAVE-6 scales and Generalized Anxiety Disorder-7 items scale (r = 0.44 and r = 0.38, respectively, p < 0.001) as well as the Patient Health Questionnaire-9 items (r = 0.39 and r = 0.35, respectively, p < 0.001). The optimal cutoff points for SAVE-9 and SAVE-6 were identified for assessing anxiety, aligned with a GAD-7 score ≥5 points. Conclusion: The Peruvian-Spanish SAVE-9 and SAVE-6 scales are reliable and valid rating scales to assess the anxiety response of HCWs in response to viral epidemics. Though COVID-19 is diminished, these scales will be useful for other viral epidemics in the future.

Peri-ictal psychiatric manifestations in people with epilepsy: An umbrella review.

OBJECTIVE: We aimed to conduct an umbrella review to summarize the existing evidence regarding the prevalence of peri-ictal psychiatric manifestations (PM) in people with epilepsy (PWE) including pre-ictal, ictal, and postictal stages. METHODS: Databases were searched up to June 2023 for systematic reviews (SR) of observational studies that included patients with epilepsy peri-ictal PM. Data selection, data extraction, and risk of bias assessment (with the AMSTAR-2 instrument) were performed by two independent reviewers. We performed a narrative synthesis using previous guidelines. We used a self-developed decision table according to the GRADE system adapted for narrative outcomes if the certainty of outcomes was not determined by systematic review authors. RESULTS: Four SRs were included comprising 66 primary studies (n = 10 217). Three SRs evaluated one period (pre-ictal, ictal, and postictal), and one did not determine it. During the pre-ictal period, the more prevalent symptom was confusion, although with a low certainty (due to the heterogeneity and serious risk of bias). One systematic review that only included case reports evaluated the ictal period, finding mood/anxiety disorders, psychosis, and personality changes. The postictal period included the most PM (anxiety: 45.0% and depressive symptoms: 43.0%), with very low certainty, due to risk of bias, potential publication bias, heterogeneity, and failure to report the confidence intervals. SIGNIFICANCE: With very low certainty, epileptic periods are characterized by a wide spectrum of PM, being postictal symptoms the most prevalent, predominantly anxiety, and depressive symptoms. Further understanding of these PM of epilepsy could improve the attention of the people with epilepsy. PLAIN LANGUAGE SUMMARY: In this review of reviews, we summarize the frequency in which psychiatric manifestations occur in relation to an epileptic seizure. A total of 10 217 patients were reported in the reviews. The most common manifestations included symptoms of anxiety and depression, as well as changes in the normal behavior of the patient. These manifestations occurred most frequently right after the seizure finished.

Epilepsy Care in Latin America and the Caribbean: Overcoming Challenges and Embracing Opportunities.

The burden of epilepsy in the Latin America and the Caribbean (LAC) region causes a profound regional impact on the health care system and significantly contributes to the global epilepsy burden. As in many other resource-limited settings worldwide, health care professionals and patients with epilepsy in LAC countries face profound challenges due to a combination of factors, including high disease prevalence, stigmatization of epilepsy, disparities in access to care, limited resources, substantial treatment gaps, insufficient training opportunities for health care providers, and a diverse patient population with varying needs. This article presents an overview of the epidemiology of epilepsy and discusses the principal obstacles to epilepsy care and key contributors to the epilepsy diagnosis and treatment gap in the LAC region. We conclude by highlighting various initiatives across different LAC countries to improve epilepsy care in marginalized communities, listing strategies to mitigate treatment gaps and facilitate better health care access for patients with epilepsy by enhancing the epilepsy workforce.

Clinical practice guidelines for the diagnosis and management of Duchenne muscular dystrophy: a scoping review.

Introduction: Our objective was to identify recent CPGs for the diagnosis and management of DMD and summarize their characteristics and reliability. Methods: We conducted a scoping review of CPGs using MEDLINE, the Turning Research Into Practice (TRIP) database, Google Scholar, guidelines created by organizations, and other repositories to identify CPGs published in the last 5 years. Our protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses for scoping reviews. To assess the reliability of the CPGs, we used all the domains included in the Appraisal of Guidelines Research and Evaluation II. Results: We selected three CPGs published or updated between 2015 and 2020. All the guidelines showed good or adequate methodological rigor but presented pitfalls in stakeholder involvement and applicability domains. Recommendations were coherent across CPGs on steroid treatment, except for minor differences in dosing regimens. However, the recommendations were different for new drugs. Discussion: There is a need for current and reliable CPGs that develop broad topics on the management of DMD and consider the challenges of developing recommendations for RDs.

Diagnosis of Guillain-Barré syndrome and use of Brighton criteria in Peruvian hospitals / Diagnóstico del Síndrome de Guillain-Barré y uso de los criterios de Brighton en hospitales Peruanos

ABSTRACT Background: Guillain-Barré syndrome (GBS) is an autoimmune disease of the peripheral nervous system that caused multiple epidemiological outbreaks in Peru during 2018 and 2019. It is usually diagnosed using the Brighton criteria (BC). Objective: We aimed to determine the performance of Peruvian neurologists in diagnosing GBS based on the BC, along with its associated factors. Methods: This was a retrospective multicenter cohort study. We included patients diagnosed with GBS between 2007 and 2018 in three public hospitals in Lima, Peru. We collected data regarding demographic, clinical and management characteristics. We evaluated the use of the BC for confirmatory diagnosis of GBS and developed a logistic regression model to identify factors associated with its use. Results: Out of 328 cases, we reviewed 201 available charts. The median age was 48 years, with male predominance. Over half of the patients presented an inadequate motor examination according to their Medical Research Council (MRC) score. Additional testing included lumbar puncture and electrophysiological testing, in over 70% of the cases. The BC showed certainty level 1 in 13.4% and levels 2 and 3 in 18.3%. Neither the quality of the motor examination nor the type of institution showed any association with the BC. Conclusions: Level 1 diagnostic certainty of the BC was met in less than one quarter of the cases with a GBS diagnosis in three centers in Lima, Peru, between 2007 and 2018. This level was not significantly associated with being treated in a specialized institute, rather than in a general hospital.

Resumen Antecedentes: El Síndrome de Guillain-Barré (SGB) es una enfermedad autoinmune del sistema nervioso periférico, causante de brotes epidemiológicos en Perú entre el 2018 y el 2019. El diagnóstico se realiza a través de los Criterios de Brighton (CB). Objetivo: Determinar el desempeño de neurólogos peruanos en diagnosticar SGB basándose en los CB, así como factores asociados. Métodos: Cohorte retrospectiva multicéntrica. Incluimos pacientes diagnosticados con SGB del 2007-2018 en 3 hospitales públicos en Lima, Perú. Recolectamos sus características demográficas, clínicas y de manejo. Evaluamos el uso de los CB para el diagnostico de SGB y empleamos un modelo de regresión logística para identificar los factores asociados con su uso. Resultados: De 328 casos, revisamos 201 historias disponibles. La edad mediana fue 48 años, con predominancia masculina. Mas del 50% de pacientes presento un examen motor inadecuado acorde con el puntaje MRC. Se realizaron exámenes auxiliares como punción lumbar y estudios electrofisiológicos en mas del 70% de pacientes. Se obtuvo un nivel de certeza 1 para los CB en un 13.4% de casos , y un nivel 2 o 3 en un 18.3%. El nivel no estuvo asociado con la calidad del examen motor ni el tipo de institución de atención. Conclusiones: Un diagnostico nivel 1 de certeza acorde con los BC se obtuvó en menos de un cuarto de casos diagnosticados como SGB. Este nivel no estuvo asociado con la atención en una institución especializada, comparado con un hospital general.

Guía de práctica clínica para el diagnóstico y tratamiento de la distrofia muscular de Duchenne. Sociedad Peruana de Neurología. Versión Corta / Clinical Practice Guidelines for diagnosis and treatment of Duchenne muscular dystrophy. Peruvian Neurology Society. Short Version

RESUMEN Objetivo : Elaborar una guía de práctica clínica peruana para el diagnóstico y tratamiento de la Distrofia Muscular de Duchenne y Becker (DMD). Materiales y métodos : Se conformó un grupo elaborador de la guía (GEG) que incluyó médicos especialistas en neurología, neuropediatría, genética y metodología. El GEG formuló ocho preguntas para desarrollar las recomendaciones de la Guía de Práctica Clínica (GPC). Se realizó una búsqueda sistemática en Medline, Scopus y CCRT durante el periodo enero-abril 2021 para responder a las preguntas PICO. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Resultados : Las preguntas PICO, se orientaron para explorar el tamizaje, diagnóstico y tratamiento de la DMD. Se formularon 15 recomendaciones (10 fuertes, 5 condicionales) y 11 puntos de buena práctica clínica Conclusión : Se presenta la guía para el diagnóstico y tratamiento de la DMD, elaborada bajo una metodología basada en las evidencias actuales.

ABSTRACT Objective : to provide evidence-based clinical recommendations for the diagnosis and treatment of Duchenne Muscular Dystrophy. Methods : a guideline development group (GEG) was formed that included specialized physicians in the fields of neurology, neuropediatrics, genetics, and methodology. The GEG asked eight clinical questions to be answered by recommendations in this clinical practice guidelines (CPG). We conducted a systematic search and - when deemed relevant - primary studies in Medline, Scopus, and the Cochrane Controlled Register of Trials during 2021 were reviewed. Evidence was selected to answer each of the clinical questions posed. Certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. In periodic work meetings, the GEG used the GRADE methodology to review the evidence and formulate recommendations, points of good clinical practice, and a diagnosis and treatment flowchart. Results : this CPG addressed eight clinical questions, divided into three topics: screening, diagnosis, and treatment. Based on these questions, fifteen recommendations were formulated (10 strong, 5 conditional) and 11 points for good clinical practice. Conclusion : this paper summarizes the methodology and evidence- based conclusions of the CPG for the diagnosis and treatment of Duchenne muscular dystrophy.

Estudio comparativo de la capacidad denominativa y la memoria episódica de los pacientes con demencia degenerativa / Comparative Study of the Word Capacity and Episodic Memory of Patients with Degenerative Dementia

RESUMEN Introducción: Aunque la ausencia de deterioro de la memoria se consideró entre los criterios diagnósticos para diferenciar la enfermedad de Alzheimer (EA) de la demencia frontotemporal variante conductual (DFTvC), la evidencia actual, en aumento, sería la un importante porcentaje de casos de DFTvC con déficits de la memoria episódica. El presente estudio se diseñó con el fin de comparar el perfil de desempeño de la capacidad denominativa y de la memoria episódica de los pacientes con EA y DFTvC. Métodos: Estudio transversal y analítico con grupo de control (n = 32). Se incluyó a 42 sujetos con probable EA y 22 con probable DFTvC, todos mayores de 60 años. Se utilizaron instrumentos del Uniform Data Set validados en español: Multilingual Naming Test (MINT), historia de Craft-21 y Figura compleja de Benson, entre otros. Resultados: Se observó un mayor promedio de edad entre los pacientes con EA. La capacidad denominativa fue mucho menor en los pacientes con DFTvC que en aquellos con EA, medida según el MINT y el coeficiente de denominación sustantivos/verbos. Todos los pacientes con DFTvC, el 73,81% de aquellos con EAy solo el 31,25% de los controles no lograron reconocer la Figura compleja de Benson. Todas las diferencias fueron estadísticamente significativas (p< 0,001). Resultados: Este estudio confirma el perfil amnésico de los pacientes con EA y revela la disminución de la capacidad denominativa de los pacientes con DFTvC, un área del lenguaje que se afecta típica y tempranamente con las funciones ejecutivas, según recientes hallazgos. Conclusiones: Los pacientes con EA rinden peor en las tareas de memoria episódica verbal y visual, mientras que los pacientes con DFTvC rinden peor en tareas de denominación. Estos hallazgos abren la posibilidad de explorar los mecanismos de participación prefrontal en la memoria episódica, típicamente atribuida al hipocampo.

ABSTRACT Introduction: Although the absence of memory impairment was considered among the Alzheimer's disease diagnostic criteria to differentiate Alzheimer's disease (AD) from Behavioural Variant of Frontotemporal dementia Frontotemporal Dementia (bvFTD), current and growingevidence indicates that a significant Neuropsychological assessment percentage of cases of bvFTD present with episodic memory deficits. In order to compare Memory the performance profile of the naming capacity and episodic memory in patients with AD and bvFTD the present study was designed. Methods: Cross-sectional and analytical study with control group (32 people). The study included 42 people with probable AD and 22 with probable bvFTD, all over 60 years old. Uniform Data Set instruments validated in Spanish were used: Multilingual Naming Test (MINT), Craft-21 history and Benson's complex figure, among others. Results: A higher average age was observed among the patients with AD. The naming capacity was much lower in patients with bvFTD compared to patients with AD, measured according to the MINT and the nouns/verbs naming coefficient. All patients with bvFTD, 73.81% of those with AD and only 31.25% of the control group failed to recognise Benson's complex figure. All differences were statistically significant (p < 0.001). Results:This study confirms the amnesic profile of patients with AD and reveals the decrease in naming capacity in patients with bvFTD, an area of language that is typically affected early on with executive functions, according to recent findings. Conclusions: Patients with AD perform worse in verbal and visual episodic memory tasks, while patients with bvFTD perform worse in naming tasks. These findings open the possibility of exploring the mechanisms of prefrontal participation in episodic memory, typically attributed to the hippocampus.

Toma de decisiones en la práctica clínica: Propuesta de un enfoque basado en evidencia "4E" / Decision-making in clinical practice: "4E" evidence-based framework proposal

Introducción: Las decisiones humanas son parcialmente racionales. En medicina, los escenarios críticos dificultan la toma de decisiones (TD). En esta revisión, proponemos el enfoque "4E" para mejorar la TD de intervenciones. Las "4E" incluyen decisiones: "eficaces" cuando las intervenciones han sido probadas en entornos controlados, "efectivas" cuando las intervenciones han sido probadas en entornos clínicos no controlados o pragmáticos, "eficientes" cuando los beneficios de una nueva intervención se evalúan con relación a sus costos, y decisiones que promuevan "equidad" cuando estas intervenciones se recomiendan de acuerdo con las necesidades del paciente, evitando barreras. El uso de este enfoque podría mejorar la TD en la práctica clínica, pero no es suficiente para garantizar su incorporación y uso. También es importante promover una dinámica organizativa, institucional y política de los sistemas de salud que promuevan el uso crítico de la evidencia para tomar decisiones.

Background:Human decisions are partially rational. In medicine, critical scenarios make decide-making (DM) difficult. In this review, we propose the "4E" approach to improve the DM of interventions. The "4E" approach includes decisions: "effectual" when interventions have been tested in controlled settings, "effective" when interventions have been tested in uncontrolled or pragmatic clinical settings, "efficient" when the benefits of a new intervention are evaluated by its costs, and decisionsthatpromote"equity"whentheseinterventionsare recommended according to the needs of the patient, avoiding barriers. Using this approach could improve DM in clinical practice, but it is not enough to guarantee its incorporation and use. It is also essential to promote the organizational, institutional, and political dynamics of health systems that promote evidence's critical use to make decisions

Clinical-epidemiological characteristics associated with discharge outcomes and seasonality among surviving patients with Guillain-Barré syndrome in a national third-level hospital, Lima, Peru / Características clínico-epidemiológicas asociadas con los resultados al alta y la estacionalidad entre los pacientes sobrevivientes con síndrome de Guillain-Barré en un hospital nacional de tercer nivel, Lima, Peru

ABSTRACT Background: Guillain-Barré syndrome (GBS) is an autoimmune disease that affects the peripheral nervous system. Severe motor deficit (SMD), respiratory impairment, cranial nerve involvement and autonomic dysfunction are associated with a poor prognosis. Objective: To investigate the association between the clinical-epidemiological characteristics and the discharge results among Peruvian patients with GBS. Methods: We carried out a retrospective observational study on patients with GBS who survived until discharge. We used the Brighton Collaboration's criteria and considered Hughes Severity Scale (HSS) scores greater than two to be SMD. We defined the discharge results as an improvement if the HSS score decreased by at least one point from admission to hospital discharge and defined hospital stay as prolonged if > 14 days. Results: We analyzed 92 patients, among whom 70.7% were male. Quadriparesis (81.1%) and hyporeflexia (86.8%) were the most characteristic manifestations. We observed that more than half of the cases were in summer and winter. Gastrointestinal infections were associated with a higher proportion of prolonged stays. The proportion of improvement was lower among patients who had an SMD at hospital admission. We confirmed these results through fitting in multivariate models. Conclusions: The prolonged stay was related to previous gastrointestinal infection, while a less improvement in SMD individuals at admission. Prospective multicenter surveillance systems are needed for monitoring GBS cases in low-income settings like Peru.

RESUMEN Antecedentes: El síndrome de Guillain-Barré (SGB) es una enfermedad autoinmune que afecta al sistema nervioso periférico. Déficit motor severo (DMS), compromiso respiratorio, afectación de pares craneales y disfunción autonómica se asocian con un mal pronóstico. Objetivo: Investigar la asociación entre las características clínico-epidemiológicas y los resultados del alta en pacientes peruanos con SGB. Métodos: Realizamos un estudio observacional retrospectivo de pacientes con SGB supervivientes hasta el alta. Consideramos los criterios de colaboración de Brighton y una escala de severidad de Hughes (ESH) superior a dos como un DMS. Definimos los resultados del alta como una mejoría si el ESH disminuyó en al menos un punto desde el ingreso hasta el alta hospitalaria y una estadía prolongada si el tiempo de hospitalización fue > 14 días. Resultados: Analizamos 92 pacientes, de los cuales el 70,7% eran varones. La cuadriparesia (81,1%) y la hiporreflexia (86,8%) fueron las manifestaciones más características. Observamos más de la mitad de los casos en verano e invierno. Las infecciones gastrointestinales se asociaron con una mayor proporción de estadías prolongadas. La proporción de mejoría fue menor en los pacientes que tenían un DMS al ingreso hospitalario. Confirmamos estos resultados con modelos multivariados ajustados. Conclusiones: La estadía prolongada se relacionó con infección gastrointestinal previa, mientras que una mejoría menor en individuos con DMS al ingreso. Necesitamos sistemas de vigilancia multicéntricos prospectivos para monitorear los casos de SGB en un entorno de bajos ingresos como Perú.

Asociación entre horas laboradas diariamente y presencia de síntomas depresivos en médicos residentes de Perú / Association between daily working hours and depressive symptoms in resident physicians in Peru

RESUMEN Introducción: Los médicos residentes que laboran más horas diarias son propensos a sufrir problemas de salud mental como la depresión, tema que se ha estudiado poco. Por ello, el presente estudio tiene por objetivos determinar la prevalencia de los síntomas depresivos y evaluar la asociación entre el número de horas diarias laboradas y la presencia de síntomas depresivos en residentes del Perú. Métodos: Estudio transversal analítico que usó la base de datos de la Encuesta Nacional para Médicos Residentes-2016, una encuesta voluntaria realizada virtualmente por el Consejo Nacional de Residentado Médico de Perú a médicos que realizaban su residencia en este país. Se consideró presencia de síntomas depresivos una puntuación ≥ 3 con la escala Patient Health Questionnaire-2. Las horas laboradas diariamente se tomaron mediante una pregunta directa. Para evaluar la asociación de interés, se calcularon razones de prevalencia (RP) y sus intervalos de confianza del 95% (IC95%) usando regresiones de Poisson brutas y ajustadas con varianza robusta. Resultados: Se evaluaron las respuestas de 953 residentes (el 41,3% mujeres; media de edad, 32,5 arios), de los que el 14,6% tenía síntomas depresivos. En el análisis ajustado, se encontró que la prevalencia de síntomas depresivos aumentaba por cada hora laborada adicional (RP = 1,11; IC95%, 1,04-1,17). Conclusiones: Uno de cada 7 residentes presentó síntomas depresivos. Por cada hora laborada diariamente extra, la frecuencia de síntomas depresivos aumentó un 11%.

ABSTRACT Introduction: Resident physicians who work more hours a day are prone to suffer mental health problems such as depression, a subject that has been little studied. In this regard, the aim of this study was to determine the prevalence of depressive symptoms and to evaluate the association between the number of daily working hours and depressive symptoms in Peruvian residents. Methods: Analytical cross-sectional study that used the database of the National Survey for Resident Physicians-2016, a voluntary survey issued virtually by the National Council of Medical Residency of Peru to physicians who were undertaking their residency in Peru. The presence of depressive symptoms was considered as having obtained a score ≥3 with the Patient Health Questionnaire-2 scale. The number of hours worked each day was collected through a direct question. To assess the association of interest, prevalence ratios (PR) and their 95% confidence intervals (95% CI) were calculated using crude and adjusted Poisson regressions with robust variance. Results : The responses of 953 residents (41.3% women, mean age: 32.5 years) were evaluated, 14.6% of which presented depressive symptoms. In the adjusted analysis, it was found that the prevalence of depressive symptoms increased for each additional hour worked (PR = 1.11; 95% CI, 1.04-1.17). Conclusions: One in seven residents had depressive symptoms. For every extra daily working hour, the frequency of depressive symptoms increased by 11%.

Chronic meningitis as an initial presentation of Sjögren syndrome / La meningitis crónica como presentación inicial del síndrome de Sjögren

ABSTRACT Sjögren syndrome (SS) is an autoimmune disease, rarely affecting the central nervous system. The case is reported on a 68-year-old male patient who presented with keratocon-junctivitis sicca and xerostomia, during neuropsychological evaluation showed moderate to severe multidomain cognitive impairment. The magnetic resonance showed evidence of hypertrophic pachymeningitis. The CSF study showed pleocytosis, mild proteinuria, and negative cultures. The immune positive profile, Anti SS-A, SS-B and salivary gland biopsy was compatible with SS. The treatment was started with methylprednisolone pulses at a dose of 1g every 24 h for three days, and controlled with maintenance therapy, showing a favorable response. Chronic meningitis is a diagnostic challenge; among the less common causes is hypertrophic pachymeningitis in SS, and less frequently in male patients (1/9). Non-specific neurological manifestations should be considered, such as headaches or neuropsychiatric symptoms, as on some occasions rare cases may be encountered, such as the one described.

RESUMEN El síndrome de Sjögren (SS) es una enfermedad autoinmune que rara vez afecta al sistema nervioso central. En este informe de caso describimos a un paciente varón, de 68 años, que presentó queratoconjuntivitis seca y xerostomía, y a la evaluación neuropsicológica mostró deterioro cognitivo multidominio en grado de moderado a grave. La resonancia magnética mostró evidencia de paquimeningitis hipertrófica. El estudio del LCR mostró pleocitosis, proteinuria leve y cultivos negativos; el perfil inmunológico positivo anti SS-A, SS-B y la biopsia de la glándula salival compatible con SS. El tratamiento se inició con pulsos de metilprednisolona a una dosis de 1 g/cada 24 h/durante 3 días, control con terapia de mantenimiento, mostrando una respuesta favorable. La meningitis crónica es un desafío para el diagnóstico, entre las causas menos frecuentes está la paquimeningitis hipertrófica en el SS, y con menor frecuencia en los pacientes varones (1/9). Se deben considerar manifestaciones neurológicas inespecíficas, como dolores de cabeza o síntomas neuropsiquiátricos, ya que en algunas ocasiones podemos enfrentarnos a casos raros como el descrito.

Neurological diseases in Peru: a systematic analysis of the global burden disease study / Enfermedades neurológicas en el Perú: un análisis sistemático del Global Burden Disease Study

ABSTRACT Background: Disease burden indicators assess the impact of disease on a population. They integrate mortality and disability in a single indicator. This allows setting priorities for health services and focusing resources. Objective: To analyze the burden of neurological diseases in Peru from 1990-2015. Methods: A descriptive study that used the epidemiological data published by the Institute for Health Metrics and Evaluation of Global Burden of Diseases from 1990 to 2015. Disease burden was measured using disability-adjusted life years (DALY) and their corresponding 95% uncertainty intervals (UIs), which results from the addition of the years of life lost (YLL) and years lived with disability (YLD). Results: The burden of neurological diseases in Peru were 9.06 and 10.65%, in 1990 and 2015, respectively. In 2015, the main causes were migraine, cerebrovascular disease (CVD), neonatal encephalopathy (NE), and Alzheimer's disease and other dementias (ADD). This last group and nervous system cancer (NSC) increased 157 and 183% of DALY compared to 1990, respectively. Young population (25 to 44 years old) and older (>85 years old) were the age groups with the highest DALY. The neurological diseases produced 11.06 and 10.02% of the national YLL (CVD as the leading cause) and YLD (migraine as the main cause), respectively. Conclusion: The burden of disease (BD) increased by 1.6% from 1990 to 2015. The main causes were migraine, CVD, and NE. ADD and NSC doubled the DALY in this period. These diseases represent a significant cause of disability attributable to the increase in the life expectancy of our population among other factors. Priority actions should be taken to prevent and treat these causes.

RESUMEN Introducción: Los indicadores de carga de la enfermedad evalúan el impacto que producen las enfermedades en una población. Integran la mortalidad y discapacidad en un solo indicador. Esto permite fijar prioridades para los servicio de salud y enfocar los recursos. Objetivo: Analizar los datos de carga de enfermedades neurológicas en Perú para el periodo 1990-2015. Métodos: Estudio descriptivo de datos del The Institute for Health Metrics and Evaluation de carga de enfermedad global desde el año 1990 al 2015. La medida de carga de la enfermedad utilizada fue los años de vida ajustados por discapacidad y sus correspondientes intervalos de incertidumbre (95%), que resultan de la suma de los años de vida perdidos debido a muerte prematura y los vividos con discapacidad. Resultados: La carga de enfermedades neurológicas en Perú fue de 9,06 y 10,65% en 1990 y 2015, respectivamente. En 2015, las principales causas fueron: migraña, enfermedad cerebrovascular, encefalopatía neonatal, enfermedad de Alzheimer y otras demencias. Este último grupo y el cáncer del sistema nervioso presentaron un incremento del 157 y 183% de los años de vida ajustados por discapacidad con respecto a 1990, respectivamente. Los adultos jóvenes (25 a 44 años) y adultos mayores (>85 años) fueron los grupos de edad con más años de vida ajustado por discapacidad. Las enfermedades neurológicas produjeron el 11.06 y el 10.02% de los años de vida perdidos debido a muerte prematura (enfermedad cerebrovascular como la causa principal) y años vividos con discapacidad (migraña como la causa principal), respectivamente. Conclusiones: La carga de la enfermedad aumentó un 1,6% entre 1990 y 2015. Las principales causas fueron migraña, la enfermedad cerebrovascular y la encefalopatía neonatal. La enfermedad de Alzheimer y otras demencias y cáncer del sistema nervioso duplicaron los años de vida ajustados por discapacidad en este período. Estas enfermedades representan una causa importante de discapacidad atribuible al aumento de la esperanza de vida de nuestra población, entre otros factores. Se deben tomar medidas prioritarias para prevenir y tratar estas causas.

Diagnóstico y tratamiento de la etapa aguda del accidente cerebrovascular isquémico: Guía de práctica clínica del Seguro Social del Perú (EsSalud) / Diagnosis and therapy for the acute stage of ischemic cerebrovascular accident: A clinical practice guideline from Peruvian Social Security (EsSalud)

RESUMEN Objetivo: proveer recomendaciones clínicas basadas en evidencia para el diagnóstico y tratamiento de la etapa aguda del ataque cerebrovascular isquémico en EsSalud. Materiales y métodos: se conformó un grupo elaborador de la guía (GEG) que incluyó médicos especialistas y metodólogos. El GEG formuló 8 preguntas clínicas a ser respondidas por la presente GPC. Se realizó búsquedas sistemáticas de revisiones sistemáticas y -cuando fue considerado pertinente- estudios primarios en Medline y Cochrane Controlled Register of Trials durante el 2018. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buenas prácticas clínicas y el flujograma de diagnóstico y tratamiento. Finalmente, la GPC fue aprobada con Resolución N° 128-IETSI-ESSALUD-2019. Resultados: la presente GPC abordó 8 preguntas clínicas, divididas en cuatro temas: tamizaje, diagnóstico, tratamiento, soporte y rehabilitación. En base a estas preguntas se formularon 28 recomendaciones (8 fuertes y 20 condicionales), 38 puntos de buena práctica clínica, 1 nota de implementación y 2 flujogramas. Conclusión: el presente artículo resume la metodología y las conclusiones basadas en evidencias de la GPC para el diagnóstico y tratamiento de la etapa aguda del ataque cerebrovascular isquémico en EsSalud.

ABSTRACT Objective: to provide evidence based clinical recommendations for the diagnosis and therapy of the acute stage of ischemic cerebrovascular accident in EsSalud. Materials and methods : a group for producing the guideline was conveyed, including specialized physicians and methodologists. The group prepared 8 clinical questions to be answered by the guideline. Systematic searches of previous reviews were performed, and - when it was deemed necessary - primary studies in Medline and the Cochrane Controlled Registry of Trials for 2018 were reviewed. Evidence was selected aiming to respond each one of the proposed clinical questions. Certainty of the evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work sessions, the group used GRADE methodology for reviewing the evidence and generated recommendations, good clinical practice items, and designed flow charts for both diagnosis and therapy. Finally, the guide was approved with the decree N° 128-IETSI-ESSALUD-2019. Results : this clinical practice guideline focused in 8 clinical questions, which were divided into four topics: screening, diagnosis, therapy, support and rehabilitation. On the basis of these questions, 28 recommendations were formulated (8 strong and 20 conditional), 38 items for good clinical practice, 1 implementation note, and 2 flow charts. Conclusion : this paper summarizes both evidence based methodology and conclusions from a new clinical practice guide for diagnosis and therapy of the acute stage of a cerebrovascular accident in EsSalud.

Guía de práctica clínica para el tratamiento quirúrgico de pacientes con urolitiasis en el Seguro Social del Perú (EsSalud) / Clinical practice guideline for the surgical treatment of patients with urolithiasis for the Peruvian Social Security (EsSalud)

Introducción. El presente artículo resume la guía de práctica clínica (GPC) para el tratamiento quirúrgico de pacientes con urolitiasis en el Seguro Social del Perú (EsSalud). Objetivo. Proveer recomendaciones clínicas basadas en evidencias para la para el tratamiento quirúrgico de los pacientes con urolitiasis en EsSalud. Método. Se conformó un grupo elaborador de la guía (GEG) constituido por médicos urólogos y metodólogos, los cuales formularon las preguntas clínicas que fueron respondidas dentro de la presente GPC. Para cada una de estas preguntas se realizó búsquedas de revisiones sistemáticas y de estudios primarios (cuando se consideró pertinente) en PubMed durante el 2018. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas, posteriormente se evaluó la certeza de la evidencia usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Se programaron reuniones de trabajo periódicas en las cuales el GEG revisó la evidencia y formuló recomendaciones, puntos de buenas prácticas clínicas y flujogramas usando la metodología GRADE. La GPC fue aprobada con Resolución N° 66- IETSI-ESSALUD-2018. Resultados. Se abordó 6 preguntas clínicas sobre el tema de tratamiento quirúrgico en urolitiasis. En base a dichas preguntas se formularon 5 recomendaciones (2 recomendaciones fuertes y 3 recomendaciones condicionales), 21 puntos de buena práctica clínica, y 3 flujogramas de manejo. Conclusión. El presente artículo resume la metodología y las conclusiones basadas en evidencias de la GPC para el tratamiento quirúrgico de pacientes con urolitiasis en EsSalud.

Introduction. This article summarizes the clinical practice guide (CPG) for the surgical treatment of patients with urolithiasis in the Social Security of Peru (EsSalud). Objective. To provide clinical recommendations based on evidence for the surgical treatment of patients with urolithiasis in EsSalud. Method. A guideline group (GEG) constituted by urologists and methodologists was formed, who formulated the clinical questions that were answered within the present CPG. For each of these questions systematic searches of systematic reviews and primary studies (when considered pertinent) were carried out in PubMed during 2018. The evidence was selected to answer each one of the clinical questions posed, later the certainty was evaluated of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Regular work meetings were scheduled, in which the GEG reviewed the evidence and made recommendations, points of good clinical practice, and flow charts; using the GRADE methodology. The CPG was approved with Resolution No. 66-IETSI-ESSALUD-2018. Results. Six clinical questions on the subject of surgical treatment in urolithiasis were addressed. Based on these questions, 5 recommendations were formulated (2 strong recommendations and 3 conditional recommendations), 21 points of good clinical practice, and 3 management flow charts. Conclusion. This article summarizes the methodology and conclusions based on evidence from the CPG for the surgical treatment of patients with urolithiasis in EsSalud.

Cambios clínicos de la esclerosis múltiple según modificación de los criterios de McDonald. Hospital Almenara, 2001-2015 / Clinical changes of multiple sclerosis according to modification of the McDonald criteria. Hospital Almenara, 2001-2015

Objetivos. Determinar si las modificaciones en los criterios de McDonald en los últimos 15 años produjeron cambios en las características clínicas y el tiempo de diagnóstico de esclerosis múltiple. Métodos. Se revisaron 91 historias clínicas de pacientes con esclerosis múltiple de los últimos 15 años en el Servicio de Neurología del Hospital Nacional Guillermo Almenara Irigoyen, Lima. Se registraron características clínicas y demográficas de la enfermedad. Los datos se agruparon según la fecha del diagnóstico y los criterios de McDonald vigentes en ese momento: grupo 1 (2001 a 2005), grupo 2 (2005 a 2009) y grupo 3 (2010 a 2015). Resultados. La edad promedio de los pacientes fue 36,2 años, 51,7% fueron mujeres. Las manifestaciones clínicas más frecuentes fueron motoras. El 69,23% fue tipo remitente recurrente (EMRR), 26,37% secundaria progresiva (EMSP) y 4,40% primaria progresiva (EMPP). La discapacidad en EMRR fue leve y en EMSP fue moderada. Los pacientes con EMPP tuvieron discapacidad severa en el grupo 2 y moderada en el grupo 3. El tiempo de enfermedad fue mayor para el grupo 1 y similar en los grupos 2 y 3. Conclusiones. Las manifestaciones clínicas de la enfermedad no han cambiado durante los últimos 15 años. La EMRR fue el tipo más común. En los últimos 5 años hubo un aumento en el diagnóstico de la EMPP y disminución de EMSP por el diagnóstico precoz de la enfermedad. El tiempo de diagnóstico de la enfermedad disminuyó en los últimos 10 años.

Objective. Define if modifications in the McDonald criteria in the last 15 years produced changes in the clinical characteristics and the time of diagnosis of multiple sclerosis. Methods. We revised 91 clinical histories from patients with multiple sclerosis in the last 15 years from the Neurology Service of Hospital Nacional Guillermo Almenara Irigoyen, Lima. We registered clinical and demographical characteristics of the disease. The clinical data were grouped according the date of the diagnosis and McDonald criteria in force at that time: group 1 (2001 to 2005), group 2 (2005 to 2009) and group 3 (2010 to 2015). Results. The average age of the patients was 36,2 years. 51,7% were female. The most common clinical manifestations were motor. 69,23% was a recurrent sender type, 26,37% progressive secondary and 4,40% progressive primary. Disability in recurrent sender type was mild and in the progressive secondary group was moderate. The progressive primary patients had severe disability in group 2 and moderate in group 3. The average disease duration was higher for group 1 and similar in the 2 and 3 groups. Conclusions. The initial manifestations of the disease of patients with multiple sclerosis have not changed during this past 15 years. The predominance of recurrent remitent forms remains the most common but with an increase in progressive primary forms and decrease of progressive secondary group in the last 5 years due to earlier diagnosis of the disease. The time of diagnosis of the disease has decreased in the last 10 years.

¿La medicina científica y el programa Medicina Basada en Evidencia han fracasado? / Has scientific medicine and the EBM program failed?

La medicina científica y el programa de medicina basada en evidencia han fracasado, afirman críticos y detractores. La medicina basad en la evidencia es un programa que busca dar respuesta a la necesidad de sistematizar el conocimiento médico, mejorar el proceso de toma de decisiones en salud y, por ende, mejorar los sistemas de salud. A pesar de su gran difusión no está exenta de críticas, desde cuestionamientos a su enfoque filosófico positivista, a su visión estrictamente biológica y de eficacia y al innegable conflicto de intereses de las investigaciones biomédicas financiadas en su mayoría por la industria farmacéutica. Sin embargo, a pesar de sus limitaciones aún queda un largo camino por desarrollar y sus alcances y beneficios ya se verifican en el ejercicio mismo de las decisiones médicas

According to its critics and detractor, scientific medicine and the Evidence-Based Medicine (EBM) program have failed. EBM is a program that seeks to respond to the need to systematise medical knowledge, improve the decision-making process in health and thus improve health systems. Despite its wide dissemination, it is not without criticism, from the questioning of its positivist philosophical approach, to its strictly biological and of effectiveness vision, and to the undeniable conflict of interests of biomedical research, which is mostly financed by the pharmaceutical industry. However, despite its limitations, there is still a long way to go, and its scope and benefits are already demonstrated in the current making of medical decisions

Factors associated with depression in patients with Parkinson's disease: a multicenter study in Lima, Peru / Fatores associados à depressão em pacientes com doença de Parkinson: um estudo multicêntrico em Lima, Peru

Abstract The diagnosis and treatment of depression in patients with Parkinson's disease (PD) is inadequate, often contributing to a reduced quality of life, rapid disease progression, higher cognitive impairment, and an increased burden of care for family members of patients with PD. Objective: To determine the factors associated with depression in PD and to examine the frequency of depressive symptoms among patients with PD. Methods: This study was an observational, analytical, multicenter study of a cross-sectional cohort, conducted between July 2016 and May 2017. PD patients were recruited from neurology clinics in Lima, Peru. All statistical analyses were performed using descriptive statistics. Bivariate and multivariate logistic regression analyses were calculated using STATA. Results: Out of 124 patients (average age: 68.7 years; 58% males) included in the study 60.5% (75/124) presented with symptoms of depression; only 20% (25/124) received antidepressants. Factors associated with depression in PD included: unemployment, falls, freezing of gait, involuntary movements micrographia, stooped posture, hyposmia, movement disorders in sleep, rapid disease progression, and the use of MAOIs. Furthermore, statistically significant differences were found in disease duration, UPDRS and MMSE scores, Hoehn and Yahr (HY) stage, and length of time taking L-dopa between PD patients with and without depressive symptoms. Conclusion: Factors associated with depressive symptoms in patients with PD were hyposmia, rapid progression of the disease, the use of L-dopa, and use of MAOIs. The frequency of depressive symptoms in patients with PD is high; early diagnosis and prompt treatment are needed to improve their quality of life and the family environment.

Resumo O diagnóstico e tratamento da depressão em pacientes com doença de Parkinson (DP) é inadequado, frequentemente contribuindo para a redução da qualidade de vida, progressão rápida da doença, maior comprometimento cognitivo e aumento da carga de cuidado aos familiares de pacientes com DP. Objetivo: Determinar os fatores associados à depressão na DP e examinar a frequência de sintomas depressivos entre pacientes com DP. Métodos: Este estudo foi um estudo observacional, analítico, multicêntrico, de uma coorte transversal conduzida entre julho de 2016 e maio de 2017. Os pacientes com DP foram recrutados em clínicas de neurologia em Lima, Peru. Todas as análises estatísticas foram realizadas por meio de estatística descritiva. Análises de regressão logística bivariada e multivariada foram calculadas usando STATA. Resultados: Dos 124 pacientes (idade média: 68,7 anos; 58% homens) incluídos no estudo, 60,5% (75/124) apresentaram sintomas de depressão; apenas 20% (25/124) receberam antidepressivos. Os fatores associados à depressão na DP incluíram: desemprego, quedas, congelamento da marcha, movimentos involuntários micrografia, postura inclinada, hiposmia, distúrbios do movimento no sono, progressão rápida da doença e uso de inibidores da MAO. Além disso, houve diferenças estatisticamente significativas encontradas em: duração da doença, escores nas escalas UPDRS e MMSE, estágio Hoehn e Yahr (HY) e tempo de duração da L-dopa entre os pacientes com DP, entre aqueles com e sem sintomas depressivos. Conclusão: Fatores associados a sintomas depressivos em pacientes com DP foram hiposmia, rápida progressão da doença, uso de L-dopa e uso de IMAOs. A frequência de sintomas depressivos em pacientes com DP é alta; o diagnóstico precoce e o tratamento imediato são necessários para melhorar a qualidade de vida e o ambiente familiar.