[Quality as management tool. Actions to improve efficiency in neurological care]. / La calidad como herramienta de gestión. Actuaciones para mejorar la eficiencia en la atención neurológica.

INTRODUCTION: Quality of care involves meeting the needs and expectations of patients with the lowest consumption of resources and in accordance with scientific knowledge. In this context it is important to know if the changes in medical care procedures based on scientific and technical aspects of the quality positively impacts both efficiency measures and perceived quality. METHODS: Prospective study carried out during the 2000-2006 period at the neurology department of a public hospital with has 1303 beds. Changes in medical care introduced: adequacy of a high resolution hospitalization zone, setting up of three care pathways (transient ischemic attach [TIA], multiple sclerosis exacerbation and first epileptic seizure) and practice guidelines for stroke, and implementation of neurological care at the emergency department. RESULTS: There has been an increase in the number of patients treated in the emergency department of the hospital (17%), although the number of admissions has stabilized. In the neurology department, the number of admissions has decreased by 20%, especially those arising from TIA (decrease by 47%), the average stay has been reduced by 30% (especially in demyelinating and vascular disease, which has fallen by 50%). Adjusted average length of stay has remained below 1 and the complexity index above 1. Satisfaction with the information and health care has undergone little change. CONCLUSIONS: The changes in clinical practice to improve the quality of care have been associated with improvements in the efficiency indicators but not in patient satisfaction. The improvement in the perceived quality probably requires specific actions.

La calidad como herramienta de gestión. Actuaciones para mejorar la eficienciaen la atención neurológica / Quality as management tool. Actions to improve efficiency in neurological care

Introducción. La calidad asistencial supone satisfacer las necesidadesy expectativas de los pacientes con el menor consumo de recursosy de acuerdo al conocimiento científico. En este contexto esimportante conocer si los cambios en los procesos asistenciales basadosen aspectos científico-técnicos de la calidad repercuten positivamentetanto en medidas de eficiencia como de calidad percibida.Métodos. Estudio prospectivo durante el período 2000-2006realizado en el servicio de neurología de un hospital de tercer nivelde la red del Sistema Nacional de Salud que dispone de 1.303 camas.Cambios asistenciales introducidos: adecuación de una zona de hospitalizaciónde alta resolución, implantación de tres vías clínicas(accidente isquémico transitorio [AIT], exacerbación de esclerosismúltiple y primera crisis epiléptica) y del proceso de atención al pacientecon ictus y mejora de la atención neurológica en el servicio deurgencias.Resultados. En el hospital se ha producido un incremento en elnúmero de urgencias atendidas (17%), estabilizándose el número deingresos. En neurología ha disminuido el número de ingresos en un20%, especialmente los debidos a AIT (disminución del 47 %), la estanciamedia se ha reducido en un 30% (especialmente en patologíavascular y desmielinizante, donde ha disminuido un 50 %), elíndice de estancia media ajustada al funcionamiento se ha mantenidopor debajo de 1 y el índice de complejidad por encima de 1. La satisfaccióncon la información y atención médica han experimentadopocos cambios.Conclusiones. Los cambios de práctica clínica para mejorar lacalidad asistencial se han asociado con mejoras en los indicadores deeficiencia, pero no en los de satisfacción del paciente. La mejora decalidad percibida probablemente requiera actuaciones específicas (AU)

Introduction. Quality of care involves meeting the needsand expectations of patients with the lowest consumption of resourcesand in accordance with scientific knowledge. In this contextit is important to know if the changes in medical care proceduresbased on scientific and technical aspects of the qualitypositively impacts both efficiency measures and perceived quality.Methods. Prospective study carried out during the 2000-2006period at the neurology department of a public hospital with has1303 beds. Changes in medical care introduced: adequacy of ahigh resolution hospitalization zone, setting up of three carepathways (transient ischemic attach [TIA], multiple sclerosis exacerbationand first epileptic seizure) and practice guidelines forstroke, and implementation of neurological care at the emergencydepartment.Results. There has been an increase in the number of patientstreated in the emergency department of the hospital (17%),although the number of admissions has stabilized. In the neurologydepartment, the number of admissions has decreased by20%, especially those arising from TIA (decrease by 47 %), theaverage stay has been reduced by 30% (especially in demyelinatingand vascular disease, which has fallen by 50%). Adjustedaverage length of stay has remained below 1 and the complexityindex above 1. Satisfaction with the information and health carehas undergone little change.Conclusions. The changes in clinical practice to improvethe quality of care have been associated with improvements in theefficiency indicators but not in patient satisfaction. The improvementin the perceived quality probably requires specific actions (AU)

Epilepsias refractarias en pediatría. Diagnóstico y tratamiento / Refractory epilepsy in pediatrics: diagnosis and treatment

El concepto de farmacorresistencia adquiere importancia a medida que se dispone de más recursos terapéuticos, puesto que plantea la necesidad de establecer unos criterios de indicación y de tiempos de introducción de cada uno de ellos. No hay una definición uniforme de epilepsia farmacorresistente aplicable a toda edad y a todo síndrome antiepilético. Entre los criterios más frecuentemente considerados están la incapacidad para llevar una vida normal, el número de antiepilépticos ensayados (habitualmente 2 o más), la presencia de efectos indeseables intolerables o la ineficacia del tratamiento, la frecuencia de las crisis y la duración de los síntomas, que es esencial en la población pediátrica, en la que el cuadro epiléptico puede asociar problemas de desarrollo. En los niños, una definición operativa de farmacorresistencia incluiría criterios de predictividad que permitirían encarar alternativas terapéuticas, como un planteamiento quirúrgico más precoz para preservar el desarrollo psicomotor, basado en que la plasticidad cerebral depende directamente de la maduración – y por tanto, de la edad – y en evitar los efectos negativos sobre el desarrollo cerebral de crisis repetidas o prolongadas y de los efectos tóxicos de las medicaciones. En primera línea de tratamiento están los fármacos antiepilépticos, y en segundo lugar la cirugía en los casos de ciertas lesiones localizadas mediante técnicas de neuroimagen y origen de las crisis claramente atribuibles a esas lesiones. Enlos demás casos deben valorarse las alternativas de forma individual, habitualmente paliativas, como otras intervenciones quirúrgicas, los estimuladores vagales, la dieta cetógena, las inmunoglobulinas o los corticoides

The concept of drug resístanse become increasingly important as more treatment modalities become available, since it makes ir necessary to establish criteria of choice for the different therapeutic approaches. There is no single definition of medically refractory epilepsy, applicable to every age or to every epileptic syndrome. The criteria most commonly considered are the inability to lead a normal life, the number of antiepileptic drugs (AED) tried (usually two or more), intolerable side effects or the inefficiency of the treatment, seizure frequency and the duration of symptoms, which is essential in the pediatric population, where epilepsy can be related to developmental defects. In children, an operative definition of drug resistance should include prediction criteria that would enable the establishment of therapeutic alternatives, such as an earlier surgical treatment. The purpose of this would be preserve psychomotor development, based on the fact that cerebral plasticity depends directly on maturation and, thus, on age, and to avoid the negative effects on brain development, of repeated or prolonged seizures and AED side effects. The first line on treatment are AED, followed by surgery in cases of certain lesions located by means of neuroimaging techniques, when the source of seizures is clearly attributable to these lesions. In the remaining cases, other options, usually palliative, must be assessed individually. These include other surgical procedures, vagus nerve stimulation, ketogenic diet, immunoglobulins or corticosteroids

Importancia y factores relacionados con la fatiga crónica en la esclerosis múltiple / Importance and factors related to chronic fatigue in multiple sclerosis

Introducción. La importancia de la fatiga en la esclerosis múltiple (EM) viene determinada por la elevada frecuencia con la que aparece y por ser una causa importante de incapacidad. Objetivo. Conocer los factores relacionados con la presencia de fatiga crónica en una serie hospitalaria de pacientes con EM. Pacientes y métodos. Se incluyeron pacientes con EM atendidos de forma consecutiva en la unidad de enfermedades desmielinizantes de un hospital terciario que cumplían los siguientes criterios: EM clínicamente definida (RR o SP), duración de la EM superior a 2 años y ausencia de recaídas en el último mes. Se analizaron las siguientes variables: fatiga crónica, datos demográficos generales, sistemas funcionales, EDSS, ISS, ESS, actividad de la enfermedad, escala de depresión de Hamilton, GHQ-28, índice de calidad de sueño de Pittsburg y tratamiento con interferón. Se llevó a cabo estudio estadístico utilizando análisis bivariante y multivariante mediante regresión logística. Resultados. La serie comprende 100 pacientes (72 mujeres y 28 varones). La edad media fue 39,27 años. Un 88 % de los casos tenían una EM RR y un 12 % EM SP. El tiempo medio de evolución fue 11,2 años. El EDSS medio fue de 2,54. Un 53 % de los casos presentó fatiga crónica. Las únicas variables que se asociaron de forma estadísticamente significativa con la presencia de fatiga crónica fueron la depresión y la disfunción del sueño diurna, de forma que la presencia de depresión multiplica por 3,6 la probabilidad de fatiga crónica y cada punto de más en el PSQI-7 la multiplica por 3,5. Conclusión. La depresión y la disfunción del sueño diurna son las únicas variables que se relacionan de forma independiente con la fatiga crónica entre los pacientes con EM

Introduction. The importance of fatigue in multiple sclerosis (MS) is determined by its high frequency and it is an important cause of disability. Objective. To determine factors that are related to the presence of chronic fatigue in patients with MS. Patients and methods. The series comprises patients with MS, consecutively attended in the demyelinizating diseases unit, who met the following criteria: clinically definite MS (RR or SP), MS duration of more than two years, and no relapses during the previous month. Analyzed variables were as follows: chronic fatigue, demographic data, functional systems, EDSS, ISS, ESS, disease activity, Hamilton, depression scale GHQ-28, PSQI, and interferon. Statistical study: bivariate and multivariate analysis by logistic regression. Results. A hundred patients were inclued, 72 female and 28 male. Mean age was 39.27 years. Of the 100 patients 88 had RR disease and 12 SP disease. MS mean duration was 11.2 years. Mean EDSS 2.54. Chronic fatigue was 53 %. The presence of depression increased the probability of chronic fatigue 3.6 fold, and every point in PSQI-7 increases it 3.5 fold. Conclusion. Depression and the PSQI-7 subscale (day sleep dysfunction) are the only variables independently related to chronic fatigue in patients with MS

[Importance and factors related to chronic fatigue in multiple sclerosis]. / Importancia y factores relacionados con la fatiga crónica en la esclerosis múltiple.

INTRODUCTION: The importance of fatigue in multiple sclerosis (MS) is determined by its high frequency and it is an important cause of disability. OBJECTIVE: To determine factors that are related to the presence of chronic fatigue in patients with MS. PATIENTS AND METHODS: The series comprises patients with MS, consecutively attended in the demyelinizating diseases unit, who met the following criteria: clinically definite MS (RR or SP), MS duration of more than two years, and no relapses during the previous month. Analyzed variables were as follows: chronic fatigue, demographic data, functional systems, EDSS, ISS, ESS, disease activity, Hamilton, depression scale GHQ-28, PSQI, and interferon. Statistical study: bivariate and multivariate analysis by logistic regression. RESULTS: A hundred patients were included, 72 female and 28 male. Mean age was 39.27 years. Of the 100 patients 88 had RR disease and 12 SP disease. MS mean duration was 11.2 years. Mean EDSS 2.54. Chronic fatigue was 53 %. The presence of depression increased the probability of chronic fatigue 3.6 fold, and every point in PSQI-7 increases it 3.5 fold. CONCLUSION: Depression and the PSQI-7 subscale (day sleep dysfunction) are the only variables independently related to chronic fatigue in patients with MS.

[Sleep disorders in multiple sclerosis]. / Trastornos del sueño en la esclerosis múltiple.

INTRODUCTION: To determine the frequency of sleep disorders in multiple sclerosis (MS) patients and their relation with other manifestations of the disease. METHODS: Selected patients had clinically definite MS (relapsing-remitting and secondary progressive forms) and duration of the disease over two years. They were serially evaluated at the unit of demyelinating diseases of a third level hospital. The following scales were applied: the Pittsburgh Sleep Quality Index, the Hamilton Depression Rating Scale, EDSS, ISS and ESS. Statistical analysis by means of non parametric test and logistic regression was carried out. RESULTS: One hundred patients were included (72% women and 28% males). Mean age was 39 years. Eighty eight were relapsing-remitting forms and the rest secondary progressive forms. Mean EDSS was: 2.5. Mean duration of evolution: 11.2 years. The prevalence of sleep disorders was 36%. Age, sex, evolutionary form, degree of disability and chronic fatigue did not relate with the sleep disorders in these patients. In the multivariant analysis by means of logistic regression, we found that every point more in Hamilton's scale multiplies the probability of presenting sleep disorders by 1.2. CONCLUSIONS: Depression is the only variable that independently relates, with the presence of sleep disorders in MS patients.

Factores predictores de depresión en la esclerosis múltiple / Predicting factors for depression in multiple sclerosis

Introducción. Se valua la frecuencia e intensidad de la depresión entre los pacientes con esclerosis múltiple (EM), el grado en que se detecta y su relación con el tratamiento mediante interferón beta y otros factores clínicos y paraclínicos. Métodos. Pacientes con EM atendidos en la unidad de enfermedades desmielinizantes de un hospital terciario que cumplían los siguientes criterios: EM clínicamente definida (remitente-recurrente o secundaria progresiva), duración de la EM superior a 2 años y ausencia de recaídas en el último mes. Variables analizadas: detección y graduación de la depresión mediante la Escala de Depresión de Hamilton, datos demográficos generales, sistemas funcionales, EDSS, ISS, ESS, actividad de la enfermedad, índice de calidad de sueño de Pittsburgh, tratamiento con interferón, fatiga crónica y una serie de variables analíticas. Estudio estadístico: análisis bivariante y multivariante mediante regresión logística. Resultados. Cien pacientes (72 mujeres y 28 varones). Edad media: 39,27 años. EM forma RR, 88 por ciento, y SP, 12 por ciento. Tiempo medio de evolución, 11,2 años. EDSS media, 2,54. La depresión estaba presente en el 44 por ciento de los pacientes de nuestra serie y no se relacionó con el grado de afectación neurológica, con el tiempo de evolución de la enfermedad, la forma clínica, el tratamiento mediante interferón ni con los trastornos del sueño, pero sí con la presencia de fatiga crónica y con la puntuación en la ESS. Conclusiones. La depresión es frecuente entre los pacientes con EM y se asocia con la presencia de fatiga crónica y una peor situación social (AU)

[Predicting factors for depression in multiple sclerosis]. / Factores predictores de depresión en la esclerosis múltiple.

INTRODUCTION: We assess frequency and intensity of depression in multiple sclerosis (MS) patients, the degree at which it is detected and its relationship to the treatment with beta interferon and other clinical and paraclinical factors. METHODS: The series comprises MS patients, seen in the Demyelinating Disease Unit of a tertiary hospital, who fulfilled the following criteria: clinically defined MS (relapsing-remitting or secondary progressive), disease duration greater than two years and absence of relapses during the month prior to the study. The variables analyzed were detection and assessment of depression with the Hamilton Depression Scale, general demographic data, functional systems, EDSS, ISS, ESS, Pittsburgh Sleep Quality Index, interferon treatment, chronic fatigue and a series of analytical variables. Statistical study: both variate and multivariate analysis by logistic regression. RESULTS: 100 patients (72 female and 28 male). Mean age: 39.27 years. RR MS form, 88%, and SPMS form, 12 %. Mean evolution time, 11.2 years. Mean EDSS, 2.54. Depression was present in 44 % of the patients in our group and was not related to neurological degree of disability, disease evolution time, clinical form, interferon treatment, or to sleep disorders. However, depression was related to the presence of both chronic fatigue and ESS scores. CONCLUSIONS: Depression is common in MS patients and is associated with the presence of chronic fatigue and a worse social status.

[Preventive prophylactic treatment in posttraumatic epilepsy]. / Tratamiento preventivo-profiláctico de la epilepsia postraumática.

Posttraumatic epilepsy (PTE) represents about 2 3% of all the etiologies of epilepsy. The so called early seizures , which appear in the first week after the traumatic brain injury (TBI), are related to the severity of the injury; they do not have an strictly epileptic mechanism, but they become a risk factor to the development of PTE. PTE appears in 5% of all the patients suffering from all TBI, and in 15 20% of the patients suffering from a severe TBI. However, the endpoint uses to be to use antiepileptic drugs (AEDs) as prophylactic treatment in all well established PTE. The efficacy of classic antiepileptic drugs (Phenobarbital, Phenytoin, Carbamazepine, Valproate acid) to control the kindling effect has not been confirmed yet as a prophylactic treatment for PTE. Prophylactic efficacy of other drugs, like lipid peroxidation inhibitors, neuroprotectors (especially antioxidants), glutamic receptor blockers, NMDA receptor blockers, and drugs that modulate apoptosis via caspasas inhibition; however, they constitute new ways of therapeutic investigation with a strong experimental basis. Our recommended therapeutic strategy is not to administrate AEDs indiscriminately, but analyzing risk factors, designing a careful prevention for late seizures using AEDs with proven efficacy in partial seizures and with the best achievable tolerability; being also attentive to the possible use of new drugs in the future, like lipid peroxidation inhibitors, and drugs designed to inhibit other excitotoxic, ionic or oxidative processes.

Tratamiento preventivo-profiláctico de la epilepsia postraumática / Preventive-prophylactic treatment in posttraumatic epilepsy

La epilepsia postraumática (EPT) representa un 2-3 por ciento de las causas de todas las epilepsias. Las llamadas `crisis cerebrales tempranas o precoces' aparecidas en la primera semana posterior al TCE, son proporcionales a la gravedad del mismo, no tienen mecanismo estrictamente epiléptico, pero son factor de riesgo para la formación de EPT. Ésta aparece en el 5 por ciento de todos los TCE, y en el 15-20 por ciento de los graves. Por ello no se aconseja el tratamiento profiláctico con fármacos antiepilépticos (FAE) en todos los TCE. En cambio, se concluye que deben administrarse FAE como tratamiento de la EPT bien definida. La eficacia de los FAE clásicos (Fb, fenitoína, carbamacepina, valproato) para controlar el efecto kindling no se ha confirmado en su administración profiláctica de la EPT. Todavía no está suficientemente probada la eficacia profiláctica de inhibidores de la peroxidación lipídica, diversos neuroprotectores, especialmente antioxidantes, bloqueantes del receptor glutamato y de los NMDA, y moduladores de la apoptosis por inhibición de las caspasas, aunque constituyan nuevas vías de investigación terapéutica de fuerte base experimental. Como estrategia terapéutica se recomienda no administrar FAE indiscriminadamente, sino analizando factores de riesgo, hacer una cuidadosa prevención de las crisis sintomáticas agudas, hasta ahora con fenitoína, y programar la profilaxis tardía con fármacos eficaces en crisis focales y de la máxima tolerabilidad posible, contemplando la posible incorporación en un próximo futuro de inhibidores de la peroxidación lipídica y de otros procesos excitotóxicos, iónicos y oxidativos (AU)

[Electro-clinical and neuroimaging studies in epilepsy in elderly patients]. / Estudio electroclínico y de neuroimagen en epilepsia en el anciano.

INTRODUCTION: Due to the aging population in developed countries, epidemiological studies show an increasing tendency to the prevalence of epilepsy in the elderly. PATIENTS AND METHODS: During 54 months, we have studied the electroclinical and neuroimaging features in outpatients older than 60, with active epilepsy. Every patient was interviewed by one of the authors. Then, we have reviewed the medical records about the clinical features, EEG and neuroimaging (NI) studies and seizures frequency (SF) outcome. Differences in crude proportions were assessed by chi 2 test for independence by 2 x 2 tables. RESULTS: The study was been performed in 78 patients with 70.3 +/- 7.3 years of mean age at review. Partial seizures were significantly related with an higher SF at onset and, in the series of complex partial seizures was more frequent a temporal EEG topography. There was predominance of men, NI abnormal, symptomatic etiology and SF at onset > or = 1 by day in that patients who started their epilepsy after 60 years. A 51.3% was seizures-free in the last year and in 80% the SF was improved a 50% or more from the beginning. CONCLUSION: A significantly greater percentage of patients remained with seizures in four cases: in those with a SF at onset greater than 1 every day, in those suffering complex partial seizures, in women and in patients with temporal EEG topography.

[Therapeutic benefits of monotherapy with lamotrigine]. / Beneficio terapéutico de la monoterapia con lamotrigina.

OBJECTIVE: To analyze the overall therapeutic benefit (effect on seizures and quality of life) in 100 patients, aged 14-89 years, treated with lamotrigine (LTG) as primary (25) or secondary (75) monotherapy, followed up for between one and six years. PATIENTS AND METHODS: The patients were selected for treatment, under open observation, and not randomized at all. Thirty patients suffered from generalized seizures and 70 from partial crises, with progression to generalized tonic-clonic crises in 36 cases. The usual LTG serum level when bi-therapy was used was 2 to 4 mg and was similar with monotherapy. The predominant dosage of LTG (100 to 200 mg) was similar for monotherapy and for bi-therapy in those treated with valproate, as compared with 200-400 mg in most of those in whom the associated drug was carbamazepine (24), phenobarbital (14), phenytoin (6) or other drug, with a considerable reduction in dose (of 100 mg to 250 mg) when they were treated by monotherapy instead. RESULTS: Overall therapeutic benefit was obtained in 79 cases, partly due to suppression or reduction of the seisures, or maintenance free of them, but mainly due to correction of the side-effects, especially somnolence, attention disorders, obesity, tremor, ataxia, reduced global productivity, hyperlipidaemia and liver enzyme changes. CONCLUSION: Lamotrigine was more effective and better tolerated in smaller doses as monotherapy, and better than other drugs in reference to quality of life, especially by the supression of side-effects, demonstrating that it is valuable in obtaining overall improvement of the disease and its consequences.

[Cerebral ischemia and epilepsy]. / Enfermedad cerebral isquémica y epilepsia.

INTRODUCTION: We review the characteristics and evolution of epileptic crises (EC) related to non-hemorrhagic ictus. Patients and methods. Since June 1994 we have studied patients with EC both at the time of the ictus (acute symptomatic crises, ASC) and later (remote symptomatic crises RSC). One hundred and fifteen fulfilled the criteria and were followed-up until recurrence of EC, death or the end of the study (30.06.98). There were 66 men and 49 women (average age at the time of ictus = 67.4 +/- 12 years). RESULTS: Ninety one patients had RSC; reversible ischemic neurological deficit (DNIR) (50%), atherothrombotic pathology (58.5%) and anterior territory (70%) predominated. There was a similar proportion of partial and generalized crises (51.5% compared with 48.5%). Fifteen patients had presented with ASC. Thirty-nine patients presented with ASC, with predominance of established ictus (48.5%), atherothrombotic pathology (56.5%), anterior territory (82%) and generalized crises (59%). There was recurrence in 50.5% of those with RSC (follow-up 18.5 +/- 24 months). STATISTICAL ANALYSIS: there was a predominance of ASC in patients with established ictus and RSC in the case of DNIR. In cases of abnormal EEG there was a greater proportion of patients with a history of ASC. In patients over 60 years old, CSR was commoner. In those with atherothrombosis there was a predominance of one crisis and in patients with embolisms two or more crises. There were more recurrences in patients with no previous history of ASC (p = 0.001), those with all the anterior territory affected (p = 0.002), those < 59 years old (p = 0.01), those previously untreated (p = 0.04) and those with abnormal EEG (p = 0.03). There was an increased RR in the abnormal EEG, involvement of the entire anterior territory and age < 59 years. Multivariate analysis showed that the probability of recurrence increased 1.23 times when there was a previous history of ASC; 14.73 times if the EEG was abnormal, and 18.12 times when both these factors were present.

[Electroclinical and neuroimaging studies in epilepsy]. / Estudio electroclínico y de neuroimagen en epilepsia.

INTRODUCTION AND MATERIAL: During 54 months, we have studied the electro-clinical and neuroimaging features in outpatients with active epilepsy. Each patient was interviewed for one of us. Then, we have reviewed the medical records about both the clinical featuring. EEG and neuroimaging (NI) studies and seizures frequency (SF) outcome. Differences in crude proportions were assessed by chi 2 test for independence by 2 x 2 tables. RESULTS AND CONCLUSIONS: It has been 207 patients with 49 +/- 19.6 years of mean age at review. Partial seizures was significantly related with both a higher SF at onset and politherapy. Also, with a focal EEG distribution but only in case of complex partial seizures. Abnormal NI was significantly more frequent in oldest patients. A greater proportion of patients were in politherapy in four situation: SF at onset > 1 by day, a focal EEG distribution, duration of epilepsy longer than 20 years and age of onset lesser than 60 years. A 37.2% was seizures-free in the last year and in 34% the SF was improved a 50% or more from the beginning. A significantly greater proportion of patients was following with seizures in four cases: when the SF at onset has been > or = 1 by day, being partial seizures, women and having politherapy.

[Polyneuropathy caused by vitamin B12 deficiency secondary to chronic atrophic gastritis and giardiasis]. / Polineuropatía por déficit de vitamina B12 secundaria a gastritis crónica atrófica y giardiasis.

INTRODUCTION: In chronic atrophic gastritis atrophy of the stomach glands leads to intrinsic factor deficit, with consequent failure to absorb vitamin B12 and gastric achylia, which predisposes to Giardia infection which in itself leads to depletion of vitamin B12. We describe the case of a patient with peripheral and central nervous system pathology due to lack of vitamin B12 secondary to the combined effect of these two disorders. CLINICAL CASE: A 54 year old woman consulted us for paraesthesia and weakness of the legs which had been progressive for the previous two years. She presented with tactile hypoaesthesia, hypoparaesthesia, distal hyperreflexia and dysymmetry of the legs, ataxic-spastic gait and a positive Romberg sign. The investigations carried out showed the serum vitamin B12 level to be 3 pg/ml (N: 180-900), hemoglobin 13 g/dl and MCV 111 fl with MCHC 348/dl; neurophysiological studies: compatible with demyelinating motor polyneuropathy. Schilling test: deficit of absorption of vitamin B12 which was corrected on administration of intrinsic factor; gastroscopy; atrophic gastritis which confirmed the morbid anatomy findings. There was also flora containing Helicobacter and massive Giardia infection. Replacement and antibiotic therapy was followed by complete remission of the clinical picture. CONCLUSION: We emphasize the excellent clinical response to treatment in spite of the time elapsed since onset of symptoms.

[Grouped crises and status epilepticus in complex partial epilepsy]. / Crisis agrupadas y status epiléptico en epilepsia parcial compleja.

INTRODUCTION: In complex partial crises (CPC) some characteristics of the way in which they occur may be helpful in localizing the focus of origin in the cerebral cortex. Thus, the appearance of any kind of status epilepticus will not predominate depending on the origin of the epileptic focus, but the complex partial state will be rare when the origin is temporal and more frequent when the origin is frontal. The appearance of CPC in a cluster form is, on the other hand, characteristic of crises originating in the frontal lobe. MATERIAL AND METHODS: We review the clinical history of 151 epileptics with CPC, evaluating the way in which the crises appear, together with other clinical data. We define the start of the crisis in a specific lobe, when this was the site of maximum voltage of the epileptic anomaly or of maximum phase opposition. RESULTS: 10% of the patients showed grouping of their CPC; in the remainder the appearance was isolated, 15% showed status epilepticus at some point in their illness. We found a statistical difference when relating this to the anomalous topography of the EEG; between 15% and 42% more patients with status epilepticus were counted when the topography of the anomaly in the EEG was extratemporal. There was also between 37.2% and 76.4% more patients with cluster crises in the cases with an extratemporal focus.

[Complex partial seizures: the localization value of automatisms]. / Crisis parciales complejas: valor localizador de los automatismos.

INTRODUCTION: The clinical findings in complex partial crises may help our understanding of the different foci and vias of epileptogenesis. MATERIAL AND METHODS: We analyse automatisms and findings on EEG and neuroimaging in 151 patients with different types of partial epilepsy, seeking to establish a possible correlation between the type of automatism and cerebral localization. RESULTS AND CONCLUSIONS: The relative frequency of automatisms was: oro-alimentary 30%, mimicking 11%, gestures 35%, ambulatory 19% and verbal 13%. There was a statistically significant difference between the type of automatism and the topography of the EEG and neuroimaging findings. There were more gesture and oro-alimentary automatisms in patients with temporal anomalies, both on EEG and on neuroimaging, than in those with extratemporal alterations.

[Multiple sclerosis as a cause of partial complex epilepsy]. / Esclerosis múltiple como causa de crisis parciales complejas.

INTRODUCTION: Although the epileptic seizures (ES) have been described on patients with multiple sclerosis (MS), the causal relationship is not clear. Seizure's prevalence in this illness is low and their apparition concerning the MS course is variable, but more common after MS diagnosis. The predominant crises are generalized or partial with secondary generalization; the partial complex seizures have rarely referred. CLINICAL CASES AND CONCLUSIONS: We presented two patients with ES in the MS course. In the first case is arrived to MS diagnosis upon appearing the crisis, having presented two previous cerebral lesions in another level. In both cases demyelinating lesion was located in the temporal lobe, agreeing with EEG anomaly and seizures type.