Guía de tratamiento de la alteración aguda del estado mental. Academia Iberoamericana de Neurología Pediátrica / Guide for the treatment of acute altered mental status. Iberoamerican Academy of Pediatric Neurology

La alteración aguda del estado mental en pediatría se refiere a un cambio repentino y significativo en la función cerebral y el nivel de conciencia de un niño. Puede manifestarse como confusión, desorientación, agitación, letargo o incluso pérdida de la conciencia. Esta condición es una emergencia médica, y requiere una evaluación y una atención inmediatas. Existen diversas causas de alteración aguda del estado mental en niños, algunas de las cuales incluyen infecciones del sistema nervioso central, como la meningitis o la encefalitis, los traumatismos craneoencefálicos, los trastornos metabólicos, las convulsiones o las intoxicaciones, entre otras. Este estudio tuvo como objetivo analizar, preparar y calificar la bibliografía actual para determinar las mejores recomendaciones sobre el tratamiento ante casos de alteración aguda del estado mental en pediatría de diferentes causas. El estudio se basó en la calificación de expertos en el campo para poder determinar la calificación de las recomendaciones, además de ser sometido a la revisión por parte del comité científico de la Academia Iberoamericana de Neurología Pediátrica. Nuestra guía representa una ayuda para el tratamiento de este síntoma inespecífico desde un enfoque básico y avanzado, aplicable por cualquier neurólogo pediatra.(AU)

In pediatric patients, an acute altered mental status refers to a sudden and significant change in a child’s brain function and level of consciousness. It may manifest as confusion, disorientation, agitation, lethargy or even a loss of consciousness. This condition is a medical emergency, and requires immediate evaluation and attention. There are several causes of acute altered mental status in children, including infections of the central nervous system such as meningitis or encephalitis, traumatic brain injury, metabolic disorders, seizures and poisoning, among others. The aim of this study was to analyse, prepare and classify the current literature in order to determine the best recommendations for the treatment of cases of acute altered mental status with various causes in pediatric patients. The study was based on opinions from experts in the field in order to classify the recommendations, and was submitted to the scientific committee of the Iberoamerican Academy of Pediatric Neurology for review. Our guide is an aid for the treatment of this non-specific symptom based on a basic and advanced approach, which can be applied by any pediatric neurologist.(AU)

Documento de consenso de la Sociedad Española de Neurología sobre el tratamiento de la esclerosis múltiple y manejo holístico del paciente 2023 / Consensus statement of the Spanish Society of Neurology on the treatment of multiple sclerosis and holistic patient management in 2023

El último documento de consenso del Grupo de Estudio de Enfermedades Desmielinizantes de la Sociedad Española de Neurología sobre el tratamiento de la esclerosis múltiple (EM) data del año 2016. Aunque muchas consideraciones continúan todavía vigentes, desde entonces se han producido cambios significativos en el manejo y tratamiento de esta enfermedad, motivados no solo por la aprobación de nuevos fármacos con diferentes mecanismos de acción, sino también por la evolución de conceptos otrora consolidados. Esto ha permitido abordar situaciones especiales como el embarazo y la vacunación desde otra perspectiva, e incluir nuevas variables en la toma de decisiones en práctica clínica, como plantear tratamiento modificador de la enfermedad (TME) de alta eficacia en fases tempranas, considerar la perspectiva del paciente y utilizar nuevas tecnologías como monitorización remota. Estos cambios han motivado la presente actualización del consenso mediante metodología Delphi, con el objetivo de reflejar el nuevo paradigma de manejo del paciente con EM basándose en la evidencia científica y la experiencia clínica de los participantes. Entre las principales conclusiones destacan como recomendaciones: iniciar TME inmunomodulador en el síndrome radiológico aislado con actividad radiológica persistente, evaluar la perspectiva del paciente y abandonar la terminología «líneas de tratamiento» en la clasificación de los TME (consenso mayor del 90%). Tras el diagnóstico de EM la elección del primer TME debería considerar la presencia/ausencia de factores de mal pronóstico (epidemiológicos, clínicos, radiológicos y biomarcadores) para la aparición de nuevos brotes o progresión de discapacidad, pudiendo plantear desde el inicio TME de alta eficacia. (AU)

The last consensus statement of the Spanish Society of Neurology's Demyelinating Diseases Study Group on the treatment of multiple sclerosis (MS) was issued in 2016. Although many of the positions taken remain valid, there have been significant changes in the management and treatment of MS, both due to the approval of new drugs with different action mechanisms and due to the evolution of previously fixed concepts. This has enabled new approaches to specific situations such as pregnancy and vaccination, and the inclusion of new variables in clinical decision-making, such as the early use of high-efficacy disease-modifying therapies (DMT), consideration of the patient's perspective, and the use of such novel technologies as remote monitoring. In the light of these changes, this updated consensus statement, developed according to the Delphi method, seeks to reflect the new paradigm in the management of patients with MS, based on the available scientific evidence and the clinical expertise of the participants. The most significant recommendations are that immunomodulatory DMT be started in patients with radiologically isolated syndrome with persistent radiological activity, that patient perspectives be considered, and that the term “lines of therapy” no longer be used in the classification of DMTs (> 90% consensus). Following diagnosis of MS, the first DMT should be selected according to the presence/absence of factors of poor prognosis (whether epidemiological, clinical, radiological, or biomarkers) for the occurrence of new relapses or progression of disability; high-efficacy DMTs may be considered from disease onset. (AU)

Consensus statement of the Spanish Society of Neurology on the treatment of multiple sclerosis and holistic patient management in 2023.

The last consensus statement of the Spanish Society of Neurology's Demyelinating Diseases Study Group on the treatment of multiple sclerosis (MS) was issued in 2016. Although many of the positions taken remain valid, there have been significant changes in the management and treatment of MS, both due to the approval of new drugs with different action mechanisms and due to the evolution of previously fixed concepts. This has enabled new approaches to specific situations such as pregnancy and vaccination, and the inclusion of new variables in clinical decision-making, such as the early use of high-efficacy disease-modifying therapies (DMT), consideration of the patient's perspective, and the use of such novel technologies as remote monitoring. In the light of these changes, this updated consensus statement, developed according to the Delphi method, seeks to reflect the new paradigm in the management of patients with MS, based on the available scientific evidence and the clinical expertise of the participants. The most significant recommendations are that immunomodulatory DMT be started in patients with radiologically isolated syndrome with persistent radiological activity, that patient perspectives be considered, and that the term "lines of therapy" no longer be used in the classification of DMTs (> 90% consensus). Following diagnosis of MS, the first DMT should be selected according to the presence/absence of factors of poor prognosis (whether epidemiological, clinical, radiological, or biomarkers) for the occurrence of new relapses or progression of disability; high-efficacy DMTs may be considered from disease onset.

Repercussions of the Emergency neurological life support on scientific literature: a bibliometric study / Repercussões do Emergency neurological life support na literatura científica: um estudo bibliométrico

Abstract Background In 2012, the Neurocritical Care Society launched a compilation of protocols regarding the core issues that should be addressed within the first hours of neurological emergencies - the Emergency neurological life support (ENLS). Objective We aim to evaluate this repercussion through a bibliometric analysis. Methods We searched Scopus on October 2022 for articles mentioning ENLS. The following variables were obtained: number of citations; number of citations per year; number of publications per year; year of publication; research type; research subtype; country of corresponding author and its income category and world region; journal of publication and its 5-year impact factor (IF); and section where ENLS appeared. Results After applying eligibility criteria, we retrieved 421 articles, published from 2012 to 2022. The mean number of citations per article was 17.46 (95% Confidence Interval (CI) = 8.20-26.72), while the mean number of citations per year per article was 4.05 (95% CI = 2.50-5.61). The mean destiny journal 5-year IF was 5.141 (95% CI = 4.189-6.093). The majority of articles were secondary research (57.48%; n= 242/421) of which most were narrative reviews (71.90%; n= 174/242). High-Income countries were the most prominent (80.05%; n= 337/421 articles). There were no papers from low-income countries. There were no trials or systematic reviews from middle-income countries. Conclusion Although still low, the number of publications mentioning ENLS is increasing. Articles were mainly published in journals of intensive care medicine, neurology, neurosurgery, and emergency medicine. Most articles were published by authors from high-income countries. The majority of papers were secondary research, with narrative review as the most frequent subtype.

Resumo Antecedentes Em 2012, a Neurocritical Care Society lançou uma compilação de protocolos sobre as questões centrais que devem ser abordadas nas primeiras horas de emergências neurológicas - Emergency neurological life support (ENLS). Objetivo Avaliar a repercussão do ENLS por meio de uma análise bibliométrica. Métodos A base de dados Scopus foi utilizada em outubro de 2022 para a busca por artigos mencionando o ENLS. As seguintes variáveis foram obtidas: número de citações; número de citações por ano; número de publicações por ano; ano de publicação; tipo de pesquisa; país do autor correspondente e sua categoria de renda; revista de publicação e seu fator de impacto de 5 anos (IF); e seção onde o ENLS apareceu. Resultados Os 421 artigos incluídos foram publicados de 2012 a 2022. A média de citações por artigo foi de 17.46 (intervalo de confiança (IC) 95% = 8.20-26.72), enquanto a de citações por ano por artigo foi de 4.05 (IC95% = 2.50-5.61). O IF médio por revista foi de 5.14 (IC95% = 4.19-6.09). A maioria dos artigos era de pesquisa secundária (57.48%; n= 242/421), dos quais a maioria eram revisões narrativas (71.90%; n= 174/242). Os países de alta renda foram os mais prolíficos (80.05%; n= 337/421 artigos). Não houve publicações de países de baixa ou média renda. Conclusão Embora ainda baixo, o número de publicações mencionando o ENLS vem aumentando recentemente. A maioria dos artigos foram publicados em revistas de medicina intensiva, neurologia, neurocirurgia e medicina de emergência. Artigos de pesquisa secundária foram os mais comuns, com revisões narrativas sendo o subtipo mais frequente.

Independência funcional, aspectos clínicos e fatores sociodemográficos em pacientes na fase aguda do Acidente Vascular Cerebral: uma análise de associação / Functional independence, clinical aspects, and sociodemographic factors in patients in the acute phase of stroke: an association analysis

RESUMO Objetivo Analisar a associação da independência funcional com aspectos clínicos de comprometimento neurológico, a localização e extensão do dano neuronal e os fatores sociodemográficos em pacientes na fase aguda do AVC. Método Estudo analítico de recorte transversal, realizado com 90 pacientes adultos e idosos acometidos por AVC isquêmico, que tiveram admissão no ambiente hospitalar nas primeiras 24 horas após o evento vascular. A coleta dos dados referentes aos aspectos clínicos e fatores sociodemográficos foi realizada pelo prontuário eletrônico e/ou entrevista para descrever o perfil dos pacientes, Oxfordshire Community Stroke Project, Alberta Stroke Programme Early CT Score, National Institute of Health Stroke Scale e a Medida de Independência Funcional. Resultados O comprometimento neurológico, de acordo com a National Institute of Health Stroke Scale, foi associado à funcionalidade nas primeiras 24 horas após o AVC. Além disso, a presença de hipertensão arterial, idade, trabalho inativo, tabagismo e extensão do dano neuronal estiveram associados à dependência funcional, mas não permaneceram no modelo final deste estudo. Conclusão A dependência funcional está associada à hipertensão arterial, idade, trabalho inativo, tabagismo, extensão do dano neuronal e grau de comprometimento neurológico nas primeiras 24 horas após o evento vascular. Além disso, um nível mais elevado de comprometimento neurológico foi independentemente associado a níveis aumentados de dependência funcional.

ABSTRACT Purpose To analyze the association of functional independence with clinical aspects of neurological impairment, the location and extent of neuronal damage and sociodemographic factors in patients in the acute phase of stroke. Methods Analytical cross-sectional study in 90 adult and older patients affected by ischemic stroke, admitted to the hospital within 24 hours of the vascular event. Sociodemographic factors and clinical aspects data were collected from electronic medical records and/or interviews in order to depict the patients'profile, Oxfordshire Community Stroke Project, Alberta Stroke Programme Early CT Score, National Institute of Health Stroke Scale, and Functional Independence Measure. Results Neurological impairment, according to the National Institute of Health Stroke Scale, was associated with functioning in the first 24 hours after the stroke. Furthermore, the presence of arterial hypertension, age, inactive work, smoking and extent of neuronal damage were associated with functional dependence, but did not remain in the final model of this study. Conclusion Functional dependence is associated with arterial hypertension, age, inactive work, smoking, extent of neuronal damage, and degree of neurological impairment in the first 24 hours after the vascular event. Furthermore, a higher level of neurological impairment was independently associated with increased levels of functional dependence.

Clinical applications of neurofeedback based on sensorimotor rhythm: a systematic review and meta-analysis.

Background: Among the brain-machine interfaces, neurofeedback is a non-invasive technique that uses sensorimotor rhythm (SMR) as a clinical intervention protocol. This study aimed to investigate the clinical applications of SMR neurofeedback to understand its clinical effectiveness in different pathologies or symptoms. Methods: A systematic review study with meta-analysis of the clinical applications of EEG-based SMR neurofeedback performed using pre-selected publication databases. A qualitative analysis of these studies was performed using the Consensus tool on the Reporting and Experimental Design of Neurofeedback studies (CRED-nf). The Meta-analysis of clinical efficacy was carried out using Review Manager software, version 5.4.1 (RevMan 5; Cochrane Collaboration, Oxford, UK). Results: The qualitative analysis includes 44 studies, of which only 27 studies had some kind of control condition, five studies were double-blinded, and only three reported a blind follow-up throughout the intervention. The meta-analysis included a total sample of 203 individuals between stroke and fibromyalgia. Studies on multiple sclerosis, insomnia, quadriplegia, paraplegia, and mild cognitive impairment were excluded due to the absence of a control group or results based only on post-intervention scales. Statistical analysis indicated that stroke patients did not benefit from neurofeedback interventions when compared to other therapies (Std. mean. dif. 0.31, 95% CI 0.03-0.60, p = 0.03), and there was no significant heterogeneity among stroke studies, classified as moderate I2 = 46% p-value = 0.06. Patients diagnosed with fibromyalgia showed, by means of quantitative analysis, a better benefit for the group that used neurofeedback (Std. mean. dif. -0.73, 95% CI -1.22 to -0.24, p = 0.001). Thus, on performing the pooled analysis between conditions, no significant differences were observed between the neurofeedback intervention and standard therapy (0.05, CI 95%, -0.20 to -0.30, p = 0.69), with the presence of substantial heterogeneity I2 = 92.2%, p-value < 0.001. Conclusion: We conclude that although neurofeedback based on electrophysiological patterns of SMR contemplates the interest of numerous researchers and the existence of research that presents promising results, it is currently not possible to point out the clinical benefits of the technique as a form of clinical intervention. Therefore, it is necessary to develop more robust studies with a greater sample of a more rigorous methodology to understand the benefits that the technique can provide to the population.

Neurofobia entre médicos residentes en los servicios de urgencias / Neurophobia among resident physicians in the emergency service

Introducción La neurofobia se define como el miedo hacia la neurología que surge de la incapacidad para aplicar los conocimientos teóricos a situaciones clínicas prácticas. Este fenómeno parece no limitarse únicamente a estudiantes de medicina, pero no se dispone de estudios previos en el ámbito de urgencias. Este trabajo valora la percepción de conocimientos en las distintas patologías neurológicas urgentes por parte de médicos en formación y posibles motivos de neurofobia. Material y métodos. Se trata de un estudio transversal multicéntrico mediante encuestas autoadministradas a médicos en formación de todo el Servicio Aragonés de Salud. Se interrogó sobre su miedo a la neurología y otras especialidades médicas, posibles causas y percepción de conocimientos en patologías neurológicas en el servicio de urgencias. Resultados Se obtuvieron 134 respuestas. El 27,6% (37) sufría neurofobia. La neurología fue la tercera disciplina que mayor interés despertó, pero se considera la de mayor dificultad. Las áreas en las que mayor seguridad mostraron fueron las cefaleas y la patología vascular. Donde mayor inseguridad existía fue en la neuromuscular, la neurooftalmología y la lesión medular aguda. En ninguna de las áreas hubo un porcentaje mayor del 50% que se sintiera seguro o muy seguro. Conclusiones La neurofobia está presente entre los médicos en formación que desempeñan su labor en los servicios de urgencias. Su distribución depende del grado de exposición a los pacientes. Los neurólogos debemos desempeñar un papel activo en la formación de nuevos especialistas y promover la colaboración con los servicios de urgencias. (AU)

INTRODUCTION Neurophobia is defined as the fear towards clinical neurology caused by the inability to apply theoretical knowledge to practical clinical situations. This phenomenon is not restricted to medical students and has never been studied before in the Emergency Department. We aimed to study how resident doctors perceive their knowledge in neurology and urgent neurological conditions as well as possible causes for said fears. MATERIALS AND METHODS Cross-sectional multicentric study using self-administered surveys sent to medical residents within the Aragon Health Service. They were questioned about their fear of neurology and other medical specialties, possible causes, and perception of knowledge in neurological pathologies and subareas in the emergency service. RESULTS We obtained 134 responses. 27.6% (37) suffered from neurophobia. Despite neurology being considered the most difficult discipline, it did also arouse the third most interest among the students. The areas where they showed the most confidence were headaches and vascular pathology. The areas where they felt the most insecure were neuromuscular diseases, neuro-ophthalmology, and spinal cord injury. In none of the areas surveyed, the percentage of respondents who felt secure exceeded 50%. CONCLUSIONS Neurophobia is prevalent among trainee doctors working in the emergency department. Their confidence correlates with the degree of exposure to patients. Neurologist must play an active role in the education of new specialist and promote the collaboration with emergency departments. (AU)

La asistencia telefónica de las enfermedades neurológicas: una revisión sistemática / Telephone assistance for neurological diseases: a systematic review

Introducción y objetivo: Es conocido que parte de la asistencia a los pacientes neurológicos se presta por teléfono, pero desconocemos las enfermedades que se atienden de esta manera y qué partes de la asistencia se proporcionan así. Pretendemos averiguarlo a través de esta revisión bibliográfica. Materiales y métodos: Se han revisado sistemáticamente las referencias sobre asistencia telefónica a enfermedades neurológicas accesibles a través de las plataformas PubMed, Embase y Cochrane, sin fecha de inicio y hasta el 3 de abril de 2022. Se encontraron 618 referencias, de las que 219 no pasaron los criterios de exclusión, por lo que se revisaron 399. Resultados: Hay un aumento de publicaciones en los últimos años y, aunque la demencia no es la enfermedad más prevalente, es el área de la neurología con más publicaciones sobre asistencia telefónica. Le siguen los ictus, el traumatismo craneoencefálico, la esclerosis múltiple, la enfermedad de Parkinson y trastornos del movimiento, la epilepsia, las enfermedades neuromusculares y otras. Discusión y conclusiones. Las demencias son las enfermedades con más referencias bibliográficas sobre su asistencia telefónica a pesar de no ser las más prevalentes. Con frecuencia, el teléfono se utiliza para administrar escalas diagnósticas o apoyar a los cuidadores, y es especialmente útil en enfermedades que dificultan la movilidad y acudir presencialmente.(AU)

Introduction and aim: While part of the care for neurological patients is done by telephone, it is not well known what neurological diseases and which part of that care is provided by telephone. Our goal is to find it out through a bibliographic review. Materials and methods: References on telephone care for neurological diseases accessible through the PubMed, Embase, and Cochrane platforms have been systematically reviewed, with an unspecified start date and up to March 2022. We found 618 references, and as 219 did not pass the exclusion criteria, 399 were finally included in the review. Results: Dementia is the area of neurology with more publications about its telephone assistance. It is followed by stroke, head trauma, multiple sclerosis, Parkinson’s disease and movement disorders, epilepsy, neuromuscular disorders, and others. Discussion and conclusions: Dementias are the diseases with more bibliographic references on their telephone assistance despite not being the most prevalent. The telephone is frequently used to administer diagnostic scales or support caregivers and is particularly useful in diseases that limit mobility and attending a medical practice.(AU)

Jean-Martin Charcot: the polymath / Jean-Martin Charcot: o polímata

Abstract Jean-Martin Charcot, widely regarded as a leading founder of modern neurology, made substantial contributions to the understanding and characterization of numerous medical conditions. His initial focus was on internal medicine, later expanding to include neuropathology, general neurology, and eventually emerging fields such as neuropsychology and neuropsychiatry. Furthermore, Charcot's intellectual pursuits extended beyond medicine, encompassing research in art history, medical iconography, sociology, religious studies, and the arts, solidifying his status as a polymath.

Resumo Jean-Martin Charcot, amplamente considerado como um proeminente fundador da neurologia moderna, fez contribuições substanciais para a compreensão e a caracterização de várias condições médicas. Seu foco inicial era a medicina interna, expandindo-se posteriormente para incluir a neuropatologia, a neurologia geral e, por fim, campos emergentes como a neuropsicologia e a neuropsiquiatria. Além disso, as buscas intelectuais de Charcot foram além da medicina, abrangendo pesquisas em história da arte, iconografia médica, sociologia, estudos religiosos e artes, solidificando seu status de polímata.

A web-based survey to map the electromyography practice in Brazil / Uma enquete via internet para mapear a prática de eletromiografia no Brasil

Abstract Background Detailed information about the electromyography practice in Brazil is largely unavailable. Objective To evaluate where and how electromyography is performed in Brazil, as well as regional disparities and the professional and academic credentials of electromyographers. Methods We conducted an internet-based survey of active Brazilian electromyographers. The websites of health insurance companies, professional academies, medical cooperatives, online search engines, and social networks in each Brazilian state were screened and we evaluated the credentials of each electromyographer listed in the Brazilian Federal Medical Board (BFMB) registration website and their online curricula vitae in the Brazilian National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico, CNPq, in Portuguese). We also evaluated the same parameters in a control group of non-electromyographer neurologists randomly matched by geographical distribution and gender. Results We found 469 electromyographers (384 neurologists and 85 non-neurologists), with a male predominance. In total, 81.9% were BFMB-certified neurologists, 49.9%, BFMB-certified clinical neurophysiologists, and 10.4%, BFMB-certified physiatrists. Among the non-neurologists, 48.2% were physiatrists. Most electromyographers practiced in states on the Southern and Southeastern regions of Brazil. When adjusted by population, the Federal District and the states of Mato Grosso do Sul and Goiás presented the highest of eletromyographers density. Electromyographers were not more likely to have current/past academic affiliations. Conclusion In Brazil, electromyography is performed predominantly by neurologists, and half of them are BFMB-certified clinical neurophysiologists. The present study highlights regional disparities and may guide government-based initiatives, for instance, to improve the diagnosis of leprosy and the management of neuromuscular disorders within the Brazilian territory.

Resumo Antecedentes Informações detalhadas sobre a prática de eletromiografia no Brasil são em grande parte indisponíveis. Objetivo Avaliar onde e como a eletromiografia é realizada no Brasil, as disparidades regionais, e as credenciais profissionais e acadêmicas dos eletromiografistas. Métodos Realizamos uma enquete via internet de eletromiografistas brasileiros ativos. Foram rastreados sites de operadoras de planos de saúde, academias profissionais médicas, cooperativas médicas, ferramentas de busca online e redes sociais em cada estado brasileiro. Em seguida, avaliamos as credenciais de cada eletromiografista listado no site de registro do Conselho Federal de Medicina (CFM) e seus curricula vitae online no Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Também avaliamos os mesmos parâmetros em um grupo controle de neurologistas não eletromiografistas pareados aleatoriamente por distribuição geográfica e gênero. Resultados Encontramos 469 eletromiografistas (384 neurologistas e 85 não neurologistas), com predominância do sexo masculino. Ao todo, 81,9% eram neurologistas com certificação confirmada pelo site do CFM, 49,9%, neurofisiologistas clínicos com certificação confirmada pelo site do CFM, e 10,4%, fisiatras com certificação confirmada pelo mesmo site. Entre os não neurologistas, 48,2% eram fisiatras. A maioria dos eletromiografistas atuava nos estados do Sul e do Sudeste. Quando ajustados pela população, o Distrito Federal e os estados de Mato Grosso do Sul e Goiás apresentaram a maior densidade de eletromiografistas. Os eletromiografistas não eram mais propensos a ter vínculos acadêmicos atuais/passados. Conclusão No Brasil, a eletromiografia é realizada predominantemente por neurologistas, e metade deles são neurofisiologistas clínicos com certificação confirmada pelo site do CFM. Este estudo destacou as disparidades regionais, e pode orientar ações governamentais para, por exemplo, melhorar o diagnóstico da hanseníase e o manejo das doenças neuromusculares no território brasileiro.

Impacto de las nuevas tecnologías en la neurología en España. Revisión del Comité Ad-Hoc de Nuevas Tecnologías de la Sociedad Española de Neurología / Impact of new technologies on neurology in Spain. Review by the New Technologies Ad-Hoc Committee of the Spanish Society of Neurology

Introducción: Las nuevas tecnologías (NT) están cada vez más presentes en el ámbito biomédico. Utilizando la definición de consenso de NT del Comité Ad-Hoc de Nuevas Tecnologías de la Sociedad Española de Neurología (SEN), se evalúa su impacto en la neurología española a través de las comunicaciones de las reuniones anuales de la SEN. Material y métodos: Se define el concepto de NT en neurología como una tecnología novedosa o aplicación de una tecnología anterior, caracterizada por un cierto grado de coherencia persistente en el tiempo, con potencial de tener impacto en el presente y futuro de la neurología. Se plantea un estudio descriptivo tomando como fuente las comunicaciones de las reuniones de la SEN desde 2012 hasta 2018 y analizando los tipos de NT empleadas, la subespecialidad, así como su distribución territorial. Resultados: De las 8.139 comunicaciones presentadas, 299 estaban relacionadas con NT (3,7%), incluyendo 120 pósteres y 179 comunicaciones orales, variando desde el 1,6% en 2012 hasta el 6,8% en 2018. Los tipos de tecnología mayormente representados fueron neuroimagen avanzada (24,7%), biosensores (17,1%), electrofisiología y neuroestimulación (14,7%) y telemedicina (13,7%). Las áreas neurológicas con mayor empleo de NT fueron trastornos del movimiento (18,4%), enfermedades cerebrovasculares (15,7%) y demencias (13,4%). Madrid fue la comunidad que presentó más comunicaciones (32,8%), seguida por Cataluña (26,8%) y Andalucía (9,0%). Conclusiones: Las comunicaciones sobre NT siguen una tendencia creciente. El número de NT empleadas ha ido aumentando de manera paralela a la disponibilidad tecnológica. Se encontraron comunicaciones en todas las subespecialidades neurológicas, con una distribución geográfica heterogénea.(AU)

Introduction: New technologies (NT) are increasingly widespread in biomedicine. Using the consensus definition of NT established by the New Technologies Ad-Hoc Committee of the Spanish Society of Neurology (SEN), we evaluated the impact of these technologies on Spanish neurology, based on communications presented at Annual Meetings of the SEN. Material and methods: We defined the concept of NT in neurology as a novel technology or novel application of an existing technology, characterised by a certain degree of coherence persisting over time, with the potential to have an impact on the present and/or future of neurology. We conducted a descriptive study of scientific communications presented at the SEN's annual meetings from 2012 to 2018, analysing the type of NT, the field of neurology, and the geographical provenance of the studies. Results: We identified 299 communications related with NT from a total of 8,139 (3.7%), including 120 posters and 179 oral communications, ranging from 1.6% of all communications in 2012 to 6.8% in 2018. The technologies most commonly addressed were advanced neuroimaging (24.7%), biosensors (17.1%), electrophysiology and neurostimulation (14.7%), and telemedicine (13.7%). The neurological fields where NT were most widely employed were movement disorders (18.4%), cerebrovascular diseases (15.7%), and dementia (13.4%). Madrid was the region presenting the highest number of communications related to NT (32.8%), followed by Catalonia (26.8%) and Andalusia (9.0%). Conclusions: The number of communications addressing NT follows an upward trend. The number of NT used in neurology has increased in parallel with their availability. We found scientific communications in all neurological subspecialties, with a heterogeneous geographical distribution.(AU)

Environmental exposure to pesticides and Amyotrophic Lateral Sclerosis in the South of Spain.

OBJECTIVE: To determine if there is a relationship between environmental exposure to pesticides and the prevalence of Amyotrophic Lateral Sclerosis (ALS) in Andalusia. METHOD: We carried out a case-control study using the logistic regression method to verify the relationship between the prevalence of ALS in the area exposed to pesticides versus the unexposed area, through the Odds Ratio statistical test. RESULTS: The study population consisted of 519 individuals diagnosed with ALS between January 2016 and December 2018 according to the CMBD (Minimum Basic Data Set) as cases. In the control group, we have 8,384,083 individuals obtained from data from the National Institute of Statistics (INE). The Odds Ratio (OR) was used as a measure of association between cases and controls, obtaining an OR between 0.76 and 1.08 for the confidence interval of the CI (95%). CONCLUSIONS: Despite the existence of various studies that suggest a possible association between environmental exposure to pesticides and the risk of Amyotrophic Lateral Sclerosis, our analysis of the Andalusian population did not find significant evidence of this association.

Environmental exposure to pesticides and Amyotrophic Lateral Sclerosis in the South of Spain / Exposición ambiental a pesticidas y esclerosis lateral amiotrófica en el sur de España

Objective: To determine if there is a relationship between environmental exposure to pesticides and the prevalence of Amyotrophic Lateral Sclerosis (ALS) in Andalusia. Method: We carried out a case–control study using the logistic regression method to verify the relationship between the prevalence of ALS in the area exposed to pesticides versus the unexposed area, through the Odds Ratio statistical test. Results: The study population consisted of 519 individuals diagnosed with ALS between January 2016 and December 2018 according to the CMBD (Minimum Basic Data Set) as cases. In the control group, we have 8,384,083 individuals obtained from data from the National Institute of Statistics (INE). The Odds Ratio (OR) was used as a measure of association between cases and controls, obtaining an OR between 0.76 and 1.08 for the confidence interval of the CI (95%). Conclusions: Despite the existence of various studies that suggest a possible association between environmental exposure to pesticides and the risk of Amyotrophic Lateral Sclerosis, our analysis of the Andalusian population did not find significant evidence of this association.(AU)

Objetivo: Analizar si existe una relación entre la exposición ambiental a pesticidas y la prevalencia de esclerosis lateral amiotrófica (ELA) en Andalucía. Métodos: Realizamos un estudio de casos y controles con regresión logística para esclarecer la relación entre la prevalencia de ELA en el área expuesta a pesticidas vs. el área sin exposición, mediante el cálculo de razón de probabilidades (odds ratio [OR]). Resultados: Incluimos un grupo de casos, con 519 individuos diagnosticados de ELA entre enero de 2016 y diciembre de 2018, obtenidos del conjunto mínimo básico de datos, y un grupo control con 8.384.083 individuos obtenidos de la base de datos del Instituto Nacional de Estadística. Se utilizó la OR para medir la asociación entre casos y controles, con un intervalo de confianza del 95% de 0,76-1,08. Conclusiones: A pesar de que varios estudios sugieren una posible asociación entre la exposición ambiental a pesticidas y un aumento en el riesgo de ELA, nuestro estudio sobre la población andaluza no halló datos significativos en favor de dicha hipótesis.(AU)

Recomendaciones para la coordinación de los servicios de Neurología y Neurorradiología en la atención a pacientes con esclerosis múltiple / Recommendations for the coordination of Neurology and Neuroradiology Departments in the management of patients with multiple sclerosis

Introducción: El uso de la resonancia magnética (RM) está ampliamente extendido en el diagnóstico y el seguimiento de los pacientes con esclerosis múltiple (EM). La coordinación entre los servicios de Neurología y Neurorradiología es clave para la realización e interpretación de estudios radiológicos de la manera más eficaz posible. Sin embargo, esta coordinación es susceptible de mejoras en una gran parte de los hospitales nacionales. Métodos: Un panel de 17 neurólogos y neurorradiólogos de 8 hospitales españoles, presencialmente y a través de comunicación online, consensuaron una guía de buenas prácticas en la coordinación en EM. La guía se estableció en 4 fases: 1) definición del alcance de la guía y metodología del estudio; 2) revisión bibliográfica sobre buenas prácticas o recomendaciones en el uso de la RM en EM; 3) discusión y búsqueda de consenso entre los expertos; y 4) formalización y validación de los contenidos para elaborar el documento de consenso. Resultados: Se consensuaron un total de 9 recomendaciones dirigidas a la mejora de la coordinación entre los servicios de Neurología y Neurorradiología, que se pueden resumir en: 1) estandarizar las solicitudes de RM, informes y planificación; 2) crear protocolos compartidos para los estudios de RM; 3) establecer comités multidisciplinares y sesiones de coordinación, y 4) generar canales de comunicación formales entre los profesionales de ambos departamentos. Conclusiones: Se espera que las recomendaciones consensuadas sirvan de guía para optimizar la coordinación entre neurólogos y neurorradiólogos y que repercutan en la mejora del diagnóstico y seguimiento de los pacientes con EM.(AU)

Introduction: Magnetic resonance imaging (MRI) is widely used for the diagnosis and follow-up of patients with multiple sclerosis (MS). Coordination between Neurology and Neuroradiology departments is crucial for performing and interpreting radiological studies as efficiently and as accurately as possible. However, improvements can be made in the communication between these departments in many Spanish hospitals. Methods: A panel of 17 neurologists and neuroradiologists from 8 Spanish hospitals held in-person and online meetings to draft a series of good practice guidelines for the coordinated management of MS. The drafting process included 4 phases: 1) establishing the scope of the guidelines and the methodology of the study; 2) literature review on good practices or recommendations on the use of MRI in MS; 3) discussion and consensus between experts; and 4) validation of the contents. Results: The expert panel agreed a total of 9 recommendations for improving coordination between neurology and neuroradiology departments. The recommendations revolve around 4 main pillars: 1) standardising the process for requesting and scheduling MRI studies and reports; 2) designing common protocols for MRI studies; 3) establishing multidisciplinary committees and coordination meetings; and 4) creating formal communication channels between both departments. Conclusions: These consensus recommendations are intended to optimise coordination between neurologists and neuroradiologists, with the ultimate goal of improving the diagnosis and follow-up of patients with MS.(AU)

Factores de riesgo en la cefalea pospunción dural / Risk factors in post-dural puncture headache

Objetivos Este estudio tiene como objetivo la determinación de la incidencia de CPPD y la identificación de factores predisponentes en su aparición. Método Se lleva a cabo un estudio descriptivo, de carácter prospectivo en 57 pacientes a los que se les realiza una punción lumbar. Para ello, se han analizado variables relativas a factores de riesgo derivado del paciente, factores clínicos y del procedimiento con la presencia de CPPD. La incidencia de CPPD ha sido de 38,6% y entre los factores asociados a su aparición se ha identificado la edad joven y el antecedente de cefalea previa. Resultados La incidencia de CPPD ha sido mayor en mujeres, siendo de mayor intensidad en este grupo, si bien es necesaria la realización de estudios con mayor tamaño muestra. Conclusiones Debemos tener presente los factores asociados a la aparición de una CPPD como son: la edad joven, el antecedente de cefalea y la percepción de dificultad del proceso, para una mejor información a los pacientes y una optimización de la técnica empleada (AU)

Introduction Post-dural puncture headache (PDPH) is the most common complication following lumbar puncture. However, its incidence varies according to the series consulted. Different factors associated with its onset have been identified. Objectives The purpose of this study is to determine the incidence of PDPH and to identify predisposing factors for its appearance. Method Prospective, descriptive study in 57 patients who underwent lumbar puncture procedures. To this end, variables associated with patient-related risk factors, clinical and procedural factors with the presence of PDPH were analysed. The incidence of PDPH was 38.6% and factors associated with onset included young age and previous history of headache. Results The incidence of PDPH was higher in women and presented greater intensity in this group, though studies with a larger sample size would need to be conducted. Conclusions We must bear in mind the factors associated with the appearance of PDPH, which include: young age, history of headache, and the perception of procedural difficulty, to better inform patients and optimise the techniques used (AU)

Ictus isquémico agudo por oclusión en tándem de la arteria carótida interna y la arteria cerebral posterior fetal: tratamiento endovascular / Acute tandem occlusion stroke in internal carotid artery and fetal posterior cerebral artery: endovascular management

Introducción: Cuando la arteria cerebral posterior se origina desde la arteria carótida interna con un segmento P1 ausente, se denomina arteria cerebral posterior de origen fetal (ACPF). No está claro si la ACPF aumenta el riesgo de ictus isquémico agudo, y el tratamiento endovascular del ictus isquémico agudo debido a la oclusión aguda de la ACPF no está bien establecido. Caso clínico: Presentamos un caso de ictus isquémico agudo debido a la oclusión en tándem de la arteria carótida interna y la arteria cerebral posterior fetal ipsilateral tratado con éxito mediante la colocación de una endoprótesis en la lesión proximal y trombectomía mecánica de la lesión distal, con excelentes resultados neurológicos y funcionales. Conclusión: Aunque se necesitan más investigaciones para determinar el mejor tratamiento de estos pacientes, el tratamiento endovascular de la oclusión de la arteria cerebral posterior fetal es factible.(AU)

Introduction: When the posterior cerebral artery arises from the internal carotid artery with an absent P1 segment, it is called fetal posterior cerebral artery (FPCA). It is unclear whether FPCA increases the risk of acute ischemic stroke, and the endovascular treatment of acute ischemic stroke due to acute occlusion of FPCA is not well established. Case report: We report a case of acute ischemic stroke due to tandem occlusion of internal carotid artery and ipsilateral fetal posterior cerebral artery treated successfully with acute stenting of proximal lesion and mechanical thrombectomy of distal lesion with excellent neurological and functional outcomes. Conclusion: Although further investigations are needed to determine the best treatment of these patients, endovascular treatment of fetal posterior cerebral artery occlusion is feasible.(AU)

Neurofobia entre los estudiantes de medicina de una universidad española: experiencias más allá de la anglosfera / Neurophobia among undergraduate medical students: a European experience beyond the Anglosphere

Introducción: Definimos neurofobia como el miedo a las neurociencias y la neurología clínica, fundamentalmente asociado a la falta de capacidad del estudiante para aplicar sus conocimientos teóricos. Esta sensación, bien contrastada en el sistema anglosajón, ha sido poco estudiada en otros territorios europeos y nunca en nuestro país. Nuestro objetivo es analizar si este miedo hacia la neurología también existe entre estudiantes de una universidad española. Material y métodos. Estudio mediante encuestas autoadministradas a estudiantes de segundo, cuarto y sexto año de medicina de la Universidad de Zaragoza durante los cursos académicos 2020-2021 y 2021-2022. Cuestionario de 18 preguntas que recoge la percepción hacia la neurología y el resto de las neurociencias y su comparación con respecto a otras especialidades médicas. Resultados: De los 320 encuestados, el 34,1% sufriría neurofobia y tan sólo el 31,2% tendría claro a qué se dedica un neurólogo. A pesar de ser la especialidad considerada más difícil, es también la que mayor interés despierta. Los principales motivos para ese miedo son una enseñanza eminentemente teórica (59,4%), la neuroanatomía (47,8%) y una falta de integración entre las asignaturas de neurociencias (39,5%). Las soluciones consideradas de mayor peso por los alumnos para revertir esta situación irían en esa línea. Conclusiones: La neurofobia es también un problema en la formación universitaria española. Identificada la metodología docente como una de sus causas fundamentales, los neurólogos tenemos la oportunidad y la obligación de intentar revertir esta situación. Para ello, será necesario participar activamente en la formación de los futuros médicos desde las etapas más tempranas del grado.(AU)

Introduction: Neurophobia is defined as the fear of the neural sciences and clinical neurology that is due to the students’ inability to apply their knowledge of basic sciences to clinical situations. This phenomenon, well documented in the Anglosphere, has seldom been studied in other European countries and never in our country. Our study aimed to determine whether said fear existed among Spanish medical students. Material and methods: A self-administered questionnaire with 18 items was sent to medical students in the second, fourth and sixth years of medical school at a Spanish university during the academic years 2020-2021 and 2021-2022. They were questioned about their fears regarding neurology and neurosciences, causes and potential solutions. Results: Out of 320 responses, 34.1% suffered from neurophobia and only 31.2% felt confident they knew what neurologists do. Despite Neurology being considered the most difficult discipline, it did also arouse the most interest among the students. Main reasons identified for neurophobia were too theoretical lectures (59.4%), neuroanatomy (47.8%), and a lack of integration between neuroscience subjects (39.5%). Solutions considered most important by the students to reverse this situation went along those lines. Conclusion: Neurophobia is prevalent among Spanish medical students too. Having identified the teaching methodology as one of its fundamental causes, neurologists have the opportunity and obligation to reverse this situation. We should strive for more proactive involvement of neurologists at earlier stages of medical education.

Atuação da fisioterapia nas emergências neurológicas na Unidade de Urgência e Emergência / The practice of physiotherapy in neurological emergencies of the Urgency and Emergency Unit

Introdução: O Pronto Socorro é destinado a prestar assistência cujos agravos à saúde necessitam de atendimento imediato. Uma estratégia para atender as demandas desse serviço é a formação de equipes interdisciplinares. Objetivos: Analisar a atuação fisioterapêutica nos pacientes com emergências neurológicas internados, identificar os recursos fisioterapêuticos utilizados e associar com o desfecho clínico do paciente. Métodos: Estudo retrospectivo observacional descritivo. A coleta de dados foi realizada por meio de análises dos prontuários fisioterapêuticos. Resultados: O diagnóstico clínico mais prevalente foi de Acidente Vascular Encefálico isquêmico. As principais intervenções realizadas foram mobilização passiva e alongamentos. A comparação de proporções entre mobilização precoce e desfecho foi significante, assim como entre desfecho e extubação. Conclusões: A atuação do fisioterapeuta no Pronto Socorro é ampla, sendo realizada por meio de diversos recursos, principalmente mobilização precoce e manejo ventilatório, levando ao favorecimento do desfecho clínico do paciente. Contudo, mais pesquisas nessa área são necessárias.

Introduction: The Emergency Unit is assigned to provide assistance to health problems that require immediate care. One strategy to meet the demands of this service is the creation of interdisciplinary teams. Objectives: To analyze the physiotherapeutic work in hospitalized patients with neurological emergencies, to identify the physiotherapeutic resources used and to associate them with the patient's clinical outcome. Methods: Retrospective, observational and descriptive study. The information was collected through analysis of physical therapy records. Results: The prevailing clinical diagnosis was ischemic stroke. The main interventions performed were passive mobilization and stretching. The comparison between the proportions of early mobilization and outcome was significant, as well as between clinical outcome and extubation. Conclusions: The work of the physical therapist in the Emergency Unit is vast, and it is carried out through several resources, mainly early mobilization and ventilatory management, aiding the patient's clinical outcome. However, more studies are necessary in this field.

Ketogenic therapy in childhood and adolescence: recommendations of the Brazilian experts group / Terapia cetogênica na infância e adolescência: recomendações do grupo de especialistas brasileiros

Abstract Ketogenic dietary therapies (KDTs) are a safe and effective treatment for pharmacoresistant epilepsy in children. There are four principal types of KDTs: the classic KD, the modified Atkins diet (MAD), the medium-chain triglyceride (MCT) diet, and the low glycemic index diet (LGID). The International Ketogenic Diet Study Group recommends managing KDTs in children with epilepsy. However, there are no guidelines that address the specific needs of the Brazilian population. Thus, the Brazilian Child Neurology Association elaborated on these recommendations with the goal of stimulating and expanding the use of the KD in Brazil.

Resumo As terapias dietéticas cetogênicas (TDC) são um tratamento seguro e eficaz para epilepsia farmacorresistente em crianças. Existem quatro tipos principais de TDCs: a dieta cetogênica (DC) clássica, a dieta de Atkins modificada (DAM), a dieta de triglicerídeos de cadeia média (DTCM) e a dieta de baixo índice glicêmico (DBIG). O Grupo Internacional de Estudos de Dietas Cetogênicas (International Ketogenic Diet Study Group) propõe recomendações para o manejo da DC em crianças com epilepsia. No entanto, faltam diretrizes que contemplem as necessidades específicas da população brasileira. Assim, a Associação Brasileira de Neurologia Infantil elaborou essas recomendações com o objetivo de estimular e expandir o uso da DC no Brasil.

Risk factors in post-dural puncture headache.

INTRODUCTION: Post-dural puncture headache (PDPH) is the most common complication following lumbar puncture. However, its incidence varies according to the series consulted. Different factors associated with its onset have been identified. OBJECTIVES: The purpose of this study is to determine the incidence of PDPH and to identify predisposing factors for its appearance. METHOD: Prospective, descriptive study in 57 patients who underwent lumbar puncture procedures. To this end, variables associated with patient-related risk factors, clinical and procedural factors with the presence of PDPH were analysed. The incidence of PDPH was 38.6% and factors associated with onset included young age and previous history of headache. RESULTS: The incidence of PDPH was higher in women and presented greater intensity in this group, though studies with a larger sample size would need to be conducted. CONCLUSIONS: We must bear in mind the factors associated with the appearance of PDPH, which include: young age, history of headache, and the perception of procedural difficulty, to better inform patients and optimise the techniques used.