Shared decision making in the treatment of multiple sclerosis: A consensus based on Delphi methodology.

Shared decision making is a way of incorporating patients' preferences and values into the decisions regarding the treatment and follow-up plan for the condition that affects them. It is currently applied mainly in the context of chronic disorders for which there is no cure available but nevertheless many therapeutic alternatives, such as multiple sclerosis (MS). Current views and opinions on shared decision making for the treatment of MS are discussed in this consensus based on a modified Delphi method that included a group of neurologists from Argentina. A set of statements was defined by the experts and seeks to serve as a guide to apply this concept in clinical practice.

Argentinean recommendations on the identification of treatment failure in relapsing remitting multiple sclerosis patients.

One of the biggest challenges in multiple sclerosis (MS) is the definition of treatment response/failure in order to optimize treatment decisions in affected patients. The objective of this consensus was to review how disease activity should be assessed and to propose recommendations on the identification of treatment failure in RRMS patients in Argentina. METHODS: A panel of experts in neurology from Argentina, dedicated to the diagnosis and care of MS patients, gathered both virtually and in person during 2016 and 2017 to carry out a consensus recommendation on the identification of treatment failure in RRMS patients. To achieve consensus, the methodology of "formal consensus-RAND/UCLA method" was used. RESULTS: Recommendations were established based on published evidence and the expert opinion. Recommendations focused on disease management, disease activity markers and treatment failure identification were determined. Main consensus were: ≥2 relapses during the first year of treatment and/or ≥3 new or enlarged T2 or T1 GAD+ lesions and/or sustained increase of ≥2 points in EDSS or ≥100% in T25FW defines treatment failure in RRMS patients. CONCLUSIONS: The recommendations of this consensus guidelines attempts to optimize the health care and management of patients with MS in Argentina.

Enfermedad de creutzfeldt-jakob. Presentación de un caso / Creutzfeldt-jakob disease. A case report

La enfermedad de Creutzfeld-Jakob es una enfermedad degenerativa subaguda del encéfalo clasificada dentro de las encefalopatías espongiformes transmisibles. La incidencia en el mundo entero es de 1 /1 millón. En la Argentina, no existen datos para evaluación de incidencia ni mortalidad. Desde 1945 a 1997 se informaron 50 casos confirmados con anatomía patológica. La edad promedio de los pacientes afectados fue de 55, 8 años. La relación hombre-mujer fue 1:0,70 . Se presenta el caso clínico de una mujer de 72 años ,que comienza 40 días previos al ingreso con diplopía, alteraciones en el campo visual y en la visión en colores, acúfenos, cambios en la conducta y alteraciones del ritmo sueño-vigilia. Luego se agregan alteraciones en la marcha, desviaciones posturales y debilidad de miembros inferiores hasta llegar a la postración. Se interpreta el cuadro como demencia subaguda con etiología desconocida. La RMI de cerebro mostró lesiones focales difusas en sustancia blanca; el EEG complejos de 1/segundo periódicas, difusamente distribuidas, por lo que se sospecha encefalopatía espongiforme de Creutzfeldt-Jakob. La determinación de proteína 14-3-3 en líquido cefalorraquídeo, fué positiva. Se realiza tratamiento de sostén, presentando estabilidad inicial, pero desarrolla en forma posterior una neumonía intrahospitalaria y fallece. Se toma biopsia cerebral post mortem donde se observan cambios espongiformes en todas las capas, con lo que se obtiene diagnóstico definitivo. Se presenta dicho caso por su baja frecuencia de presentación y la complejidad del diagnóstico diferencial de las demencias subagudas.

Creufeldt-Jakob disease is a transmissible spongiform encephalopathy (TSE) that affects the CNS with no treatment and ominous prognosis in less than a year. It may occur in an inherited, infectious or sporadic form with a prevalence of less than 1 case/per million worldwide.There are no exact data in Argentina on the incidence or mortality of this disease, but between 1945 and 1997, 50 cases were confirmed either by biopsy or autopsy. It affects patients in their fifties (mean 55.8 years) with a slight prevalence in men (1:0.7). The clinical case of a 72 year old woman is presented here. Symptoms started 40 days before being admitted at the hospital with diplopia, visual field and color vision alterations, acufens, behavioral changes, and sleep/wake rhythm alterations. Later, walking alterations, postural deviations, and weakness in lower limbs appeared leading to patient postration. The case is interpreted as sub-acute dementia of unknown etiology. The brain MRI scan showed diffused white-matter focal lesions; the EEG showed periodic 1/second, diffusely distributed complexes, thus Creutzfeldt-Jakob spongiform encephalopathy is suspected. Protein 14-3-3 determination in cerebroespinal fluid was positive. Support treatment is carried out, showing initial stability; however, the patient later develops intra-hospital pneumonia and dies. A brain biopsy is performed and spongiform changes are observed in all the layers, thus obtaining the final diagnosis. This case is presented because of its low occurrence and the complexity of differential diagnosis of sub-acute dementias.