[Retrospective comparative analysis of antidementia medication persistence patterns in Spanish Alzheimer's disease patients treated with donepezil, rivastigmine, galantamine and memantine]. / Analisis comparativo de los patrones de persistencia de medicaciones antidemencia en una cohorte retrospectiva de pacientes con demencia de tipo Alzheimer tratados con donepecilo, rivastigmina, galantamina y memantina en Espana.

INTRODUCTION AND AIM: Dementia of Alzheimer type has become the most frequent type of dementia in our environment. Treatment persistence is a crucial factor to delay patient functional and cognitive impairment. The aim of the present study was to determine treatment persistence in usual care settings with four different antidementia drugs: donepezil, rivastigmine, galantamine and memantine in a cohort of patients with Alzheimer's dementia in Spain. PATIENTS AND METHODS: An Alzheimer type dementia retrospective cohort study was performed in 13 Primary Care Health Centers in Spain. The study included patients treated between January 2000 and March 2005. RESULTS: A total of 299 patients (44.8% female), mean age 77.9 years, were included: 101 donepezil (33.8.%), 105 rivastigmine (35.1%), 51 galantamine (17.1%) and 42 memantine (14.0%). Mean treatment duration was significantly different depending on therapy type, showing higher values for donepezil patients (mean: 83.3 weeks; 95% CI: 72.7-93.9) than for the other cholinesterase inhibitors: rivastigmine (mean: 76.6 weeks; 95% CI: 66.0-87.3), galantamine (mean: 65.8 weeks; 95% CI: 55.3-76.3) and memantine (60.9 weeks; 95% CI: 48.8-73.1), p = 0.049. Overall treatment persistence was significantly different between drugs, with again donepezil showing higher persistence (median time: 70.3 weeks; 95% CI: 49.8-90.7) than with the others drugs: rivastigmine (median time: 56.1 weeks; 95% CI: 36.1-76.2), galantamine (median time: 56.7 weeks; 95% CI: 41.1-72.3) and memantine (median time: 52.1 weeks; 95% CI: 35.2-69.1), log-rank = 10.16; p = 0.017. CONCLUSION: This study showed significative differences in the global treatment persistence among the considered drug-cholinesterase inhibitors, showing higher persistence resulting in patients treated with donepezil compared to those who received rivastigmine, galantamine or memantine.

Análisis comparativo de los patrones de persistencia de medicaciones antidemencia en una cohorte retrospectiva de pacientes con demencia de tipo Alzheimer tratados con donepecilo, rivastigmina, galantamina y memantina en España / Retrospective comparative analysis of antidementia medication persistence patterns in spanish alzheimer’s disease patients treated with donepezil, rivastigmine, galantamine and memantine

Introducción y objetivos. La demencia de tipo Alzheimeres la causa más frecuente de demencia en nuestro entorno. La persistenciadel tratamiento es un factor crucial para demorar el deteriorofuncional y cognitivo del paciente. El objetivo de este estudioha sido determinar la persistencia del tratamiento con cuatro medicacionesantidemencia (donepecilo, rivastigmina, galantamina ymemantina) en una cohorte de pacientes con enfermedad de Alzheimeren España. Pacientes y métodos. Se realizó un estudio retrospectivoen 13 centros de atención primaria en España. Los pacientesincluidos fueron tratados entre enero de 2000 y marzo de2005. Resultados. Se incluyeron un total de 299 pacientes (44,8%mujeres) con una edad media de 77,9 años: 101 se trataron condonepecilo (33,8%), 105 con rivastigmina (35,1%), 51 con galantamina(17,1%) y 42 con memantina (14,0%). La duración media deltratamiento fue significativamente diferente entre los anticolinesterásicos(p = 0,049), siendo superior en los pacientes tratados condonepecilo (media: 83,3 semanas; IC 95%: 72,7-93,9), que con elresto de agentes terapéuticos: rivastigmina (media: 76,6 semanas;IC 95%: 66,0-87,3), galantamina (media: 65,8 semanas; IC 95%:55,3-76,3) y memantina (media: 60,9 semanas; IC 95%: 48,8-73,1).La persistencia global del tratamiento fue significativamente diferenteentre los tratamientos (log-rank = 10,16; p = 0,017), siendosuperior con donepecilo (mediana: 70,3 semanas; IC 95%: 49,8-90,7) que con el resto de terapias: rivastigmina (mediana: 56,1 semanas;IC 95%: 36,1-76,2), galantamina (mediana: 56,7 semanas;IC 95%: 41,1-72,3) y memantina (mediana: 52,1 semanas; IC 95%:35,2-69,1). Conclusiones. El estudio ha mostrado diferencias significativasen la persistencia global de los distintos tratamientos antidemenciaconsiderados, siendo superior en aquellos pacientes tratadoscon donepecilo respecto a los tratados con rivastigmina,galantamina o memantina

Introduction and aim. Dementia of Alzheimer type has become the most frequent type of dementia in our environment.Treatment persistence is a crucial factor to delay patient functional and cognitive impairment. The aim of the present studywas to determine treatment persistence in usual care settings with four different antidementia drugs: donepezil, rivastigmine,galantamine and memantine in a cohort of patients with Alzheimer’s dementia in Spain. Patients and methods. An Alzheimertype dementia retrospective cohort study was performed in 13 Primary Care Health Centers in Spain. The study includedpatients treated between January 2000 and March 2005. Results. A total of 299 patients (44.8% female), mean age 77.9 years,were included: 101 donepezil (33.8.%), 105 rivastigmine (35.1%), 51 galantamine (17.1%) and 42 memantine (14.0%). Meantreatment duration was significantly different depending on therapy type, showing higher values for donepezil patients (mean:83.3 weeks; 95% CI: 72.7-93.9) than for the other cholinesterase inhibitors: rivastigmine (mean: 76.6 weeks; 95% CI: 66.0-87.3),galantamine (mean: 65.8 weeks; 95% CI: 55.3-76.3) and memantine (60.9 weeks; 95% CI: 48.8-73.1), p = 0.049. Overalltreatment persistence was significantly different between drugs, with again donepezil showing higher persistence (mediantime: 70.3 weeks; 95% CI: 49.8-90.7) than with the others drugs: rivastigmine (median time: 56.1 weeks; 95% CI: 36.1-76.2),galantamine (median time: 56.7 weeks; 95% CI: 41.1-72.3) and memantine (median time: 52.1 weeks; 95% CI: 35.2-69.1),log-rank = 10.16; p = 0.017. Conclusion. This study showed significative differences in the global treatment persistenceamong the considered drug-cholinesterase inhibitors, showing higher persistence resulting in patients treated with donepezilcompared to those who received rivastigmine, galantamine or memantine

[Stevens-Johnson syndrome, toxic epidermal necrolysis and phenytoin. Factors linked to a higher risk]. / Síndrome de Stevens-Johnson, necrólisis epidérmica tóxica y fenitoína. Factores asociados a un aumento del riesgo.

INTRODUCTION: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe, although not very common, clinical skin pictures that are usually related to the use of medication. Several antiepileptic drugs, including phenytoin, have been linked to SJS/TEN. Some authors have described an increased risk for SJS/TEN when phenytoin is associated to radiotherapy, while others report the possibility of an increased risk when it is associated to corticoids. DEVELOPMENT: This work includes a review of the spontaneous reports of suspected cases of phenytoin-linked SJS/TEN recorded in the database of the Pharmacovigilance Department at Pfizer-España between October 2000 and December 2003. Nine cases compatible with SJS/TEN were found; four occurred in cancer patients that had received radiotherapy, three of whom were also treated with corticoids. DISCUSSION AND CONCLUSIONS: After reviewing the spontaneously reported cases in the database of the Pharmacovigilance Department at Pfizer-España as well as the cases in the literature, it can be concluded that when it comes to indicating a prophylactic antiepileptic treatment for cancer patients with cerebral metastasis, the clinician must take into account the existence of a greater risk of SJS/TEN if the patient is going to receive radiotherapy. If the patient already presents a history of skin rashes following administration of an antiepileptic drug, care must be taken in choosing another because phenytoin together with carbamazepine, phenobarbital and lamotrigine have all been linked to SJS/TEN. Cross-sensitivity of carbamazepine and barbiturates with phenytoin has been observed. Gabapentin and valproic acid could be considered as therapeutic options in such cases.

Síndrome de Stevens-Johnson, necrólisis epidérmica tóxica y fenitoína. Factores asociados a un aumento del riesgo / Stevens-Johnson syndrome, toxic epidermal necrolysis and phenytoin. Factors linked to a higher risk

Introducción. El síndrome de Stevens-Johnson (SSJ) y la necrólisis epidérmica tóxica (NET) son cuadros cutáneos graves, aunque poco frecuentes, que en la mayoría de los casos se relacionan con el consumo de fármacos. Varios antiepilépticos se han asociado a SSJ/NET, entre ellos la fenitoína. Algunos autores han descrito un aumento del riesgo de SSJ/NET cuando la fenitoína se asocia a radioterapia, y otros han informado de la posibilidad de un mayor riesgo cuando se asocia al empleo de corticoides. Desarrollo. En este trabajo se realiza una revisión de las notificaciones espontáneas de sospecha de SSJ/NET asociados a fenitoína registradas en la base de datos del Departamento de Farmacovigilancia de Pfizer-España, desde octubre de 2000 hasta diciembre de 2003.Se han recogido nueve casos compatibles con SSJ/NET; cuatro ocurrieron en pacientes oncológicos que habían recibido radioterapia y, además, tres de ellos se trataron también con corticoides.Discusión y conclusiones. Tras revisar los casos de notificación espontánea de la base de datos del Departamento de Farmacovigilancia de Pfizer-España, y tras revisar los casos de la literatura, se concluye que a la hora de indicar un tratamiento antiepiléptico profiláctico en pacientes oncológicos con metástasis cerebrales, debería valorarse la existencia de un mayor riesgo de presentar SSJ/NET si el paciente va a recibir radioterapia. Si el paciente ya presenta antecedentes de reacción cutánea con un antiepiléptico, la elección de otro debe realizarse con precaución, ya que tanto la fenitoína, como la carbamacepina, el fenobarbital y la lamotrigina se han asociado a SSJ/NET, y se ha observado sensibilidad cruzada de la carbamacepina y los barbitúricos con la fenitoína. La gabapentina y el ácido valproico podrían considerarse como opciones terapéuticas en estos casos (AU)

Introduction. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe, although not very common, clinical skin pictures that are usually related to the use of medication. Several antiepileptic drugs, including phenytoin, have been linked to SJS/TEN. Some authors have described an increased risk for SJS/TEN when phenytoin is associated to radiotherapy, while others report the possibility of an increased risk when it is associated to corticoids. Development. This work includes a review of the spontaneous reports of suspected cases of phenytoin-linked SJS/TEN recorded in the database of the Pharmacovigilance Department at Pfizer-España between October 2000 and December 2003. Nine cases compatible with SJS/TEN were found; four occurred in cancer patients that had received radiotherapy, three of whom were also treated with corticoids. Discussion and conclusions. After reviewing the spontaneously reported cases in the database of the Pharmacovigilance Department at Pfizer-España as well as the cases in the literature, it can be concluded that when it comes to indicating a prophylactic antiepileptic treatment for cancer patients with cerebral metastasis, the clinician must take into account the existence of a greater risk of SJS/TEN if the patient is going to receive radiotherapy. If the patient already presents a history of skin rashes following administration of an antiepileptic drug, care must be taken in choosing another because phenytoin together with carbamazepine, phenobarbital and lamotrigine have all been linked to SJS/TEN. Cross-sensitivity of carbamazepine and barbiturates with phenytoin has been observed. Gabapentin and valproic acid could be considered as therapeutic options in such cases (AU)

[What treatment should be given for multiple sclerosis at the present time?]. / Qué tratamiento debemos emplear actualmente en la esclerosis múltiple?

OBJECTIVE: This communication aims to describe an approach suitable for the general neurologist or neurologist specialized in treating other disorders, to the current treatment of multiple sclerosis. DEVELOPMENT AND CONCLUSIONS: We discuss the treatments for recovery from the symptoms of an acute attack and those which modify the natural course of the illness (reduce the frequency and severity of attacks and/or prevent their progression). The attacks are treated with corticosteroids or ACTH. Both treatments have been shown on clinical trials to cause rapid improvement of the acute symptoms of an attack. In the progressive forms, the usefulness of high doses of corticosteroids has not been shown. Nor is there evidence that long term corticosteroid treatment, either daily or monthly, is of use in reducing the number of attacks or progression of the disease, although serious side-effects have been seen. At the moment, the interferons are the most popular treatment for multiple sclerosis. They have been the first drugs to modify the course of the disorder. Finally, we describe some of the most generally used treatments and some under investigation, although they are not widely used since it is still not clear exactly how they affect the course of the disease.

¿Qué tratamiento debemos emplear actualmente en la esclerosis múltiple? / What treatment should be given for multiple sclerosis at the present time?

Objetivo. Esta comunicación pretende ofrecer una visión al neurólogo general o al neurólogo especializado en otras enfermedades sobre cuáles son las líneas terapéuticas actuales del tratamiento de la esclerosis múltiple. Desarrollo y conclusiones. Hablaremos de los tratamientos que favorecen la recuperación de los síntomas consecuencia del brote, y de aquellos que modifican la evolución natural de la enfermedad (reducen la frecuencia y gravedad de los brotes y/o previenen la progresión). Los brotes se tratan con corticosteroides o con ACTH. Ambos tratamientos han demostrado en los ensayos clínicos que producen una rápida mejoría en los síntomas agudos del brote. En las formas progresivas, no está demostrada la utilidad del tratamiento con corticoterapia intravenosa en dosis altas. Tampoco se ha demostrado que el tratamiento con corticosteroides de forma crónica, bien en administración diaria o bien mediante pulsos mensuales, sea útil ni para reducir la tasa de brotes ni para evitar la progresión de la enfermedad y, en cambio, produce importantes efectos secundarios. Los interferones son los fármacos estrella en el tratamiento actual de la esclerosis múltiple y han sido los primeros que han demostrado su capacidad para modificar favorablemente el curso de la enfermedad. Por último, se exponen algunos de los tratamientos más utilizados o que están en estudio, pero cuyo uso no está ampliamente difundido por no haber quedado aún claro cómo influyen en el curso de la enfermedad (AU)

[Hypolipemic treatment in the prevention of atherosclerotic plaque complications]. / Tratamiento hipolipemiante en la prevención de las complicaciones de la placa aterosclerótica.

INTRODUCTION AND OBJECTIVE: Hypercholesterolemia has been shown to be a definite risk factor for coronary disease, although its relevance in cerebrovascular disease is more controversial. This study reviews the part played by different hypolipemic treatments in primary and secondary prevention of the complications of atherothrombotic diseases, particularly stroke. DEVELOPMENT: We based our study mainly on the HMG-CoA inhibitors (3-hydroxyl 3 methyl glutaryl coenzyme A) reductase, or statins++. This group of drugs acts by inhibiting the synthesis of cholesterol and increasing the expression of LDL-c receptors, achieving a 25-35% lowering of plasma LDL-c levels. In diverse clinical trials they have been shown to have a beneficial effect in the prevention of cardiovascular disease. The results of these studies indicate that, in addition to their purely hypolipemic effect, other anti-atherothrombotic mechanisms are involved. We analyze the main studies on hypolipemic drugs in the primary and secondary prevention of coronary and cardiovascular disease. CONCLUSIONS: The role of statins is clearly defined in reduction of the risk of overall and cardiovascular mortality, and also in reduction of the incidence of cardiovascular incidents in patients with a past history of coronary disease and a cholesterol level over 155 mg/dl. Reduction of the risk from cerebrovascular disease has only been observed in primary prevention studies (patients with a past history of coronary disease). Therefore, we shall have to await the results of the clinical trials currently being carried out to determine the true role of statins in the secondary prevention of cerebrovascular disease.

[What sort of stroke requires patient admittance to the hospital? Factors for deciding on hospitalization]. / Cómo es el ictus del paciente que ingresamos? Factores de decisión en la hospitalización.

OBJECTIVE: To study main factors determining medical decision in admitting patients with acute cerebrovascular disease (ACVD). PATIENTS AND METHODS: This is an observational and transversal study. We analyze a hospitalary cohort made by all consecutive patients with ACVD coming to Emergency Room to Hospital Universitario de la Princesa during 1 year. Neurologist on call made on his/her own decision to admit the patient to hospital. Clinical and epidemiological characteristics of those patients admitted with those who went home are compared. RESULTS: 517 patients were studied, 147 had transient ischemic attacks (TIA) and 370 had a stroke, 12.3% TIA and 68.4% stroke patients were hospitalized. Age, Canadian Stroke Scale (CSS) on admission, subtype of stroke, atrial fibrillation and abnormal EKG, old lesions in CT, previous TIA and/or CVD, diminished conscious level, orientation and language, sphincter control and evolution time greater than 48 hours were statistically significative in deciding admission. Logistic regression analysis (84.2% total predictive value) showed independent predictive value in age, CSS, previous CVD and some subtypes of stroke (ischemic non lacunar and hemorrhage). CONCLUSIONS: We hospitalize younger patients, with a worse clinical condition and overall hemorrhagic stroke. The percentage of admissions among TIA patients is low. On the other hand, date, time and physicians-team features do not affect the percentage of admissions.

[Admission to hospital versus home care for stroke]. / Hospitalización versus asistencia domiciliaria en el ictus.

The incidence and prevalence of cerebrovascular disease is very high. This is a major sanitary problem. There are no studies comparing the management of acute stroke as inpatient or outpatient, publications about each of these items are analyzed. General Practitioners may play a very important role, not only at the first step in the attention of stroke patients. Admission criteria for stroke and hospitalization span for its different ethiopathogenic types are revised.

Effect of fiber supplements on internal bleeding hemorrhoids.

BACKGROUND/AIMS: The aim of this study is to assess prospectively the effect of fiber additions on internal bleeding hemorrhoids. MATERIALS AND METHODS: Fifty patients with bleeding internal hemorrhoids are studied and randomized in two groups. Patients in the study group were treated with a commercially available preparation of Plantago Ovata and those in the control group were treated with a placebo. Endoscopy was performed on every patient before and after treatment to establish: a) the degree of hemorrhoidal prolapse, b) the number of congested hemorrhoidal cushions and c) contact bleeding hemorrhoids. RESULTS: During the 15 days of treatment, the average number of bleeding episodes was 4.8 +/- 3.8 for the study group versus 6.4 +/- 3 for the control group (n.s.). During the following 15 days, it decreased to 3.1 +/- 2.7 in the study group versus 5.5 +/- 3.2 (p < 0.05) in the control group and in the last 10 days of treatment a further reduction to 1.1 +/- 1.4 was found in the study group versus 5.5 +/- 2.9 (p < 0.001). The number of congested hemorrhoidal cushions diminished from 2.6 +/- 1 to 1.6 +/- 2.2 after fiber treatment (p < 0.01) and no differences were found in the control group. In the fiber group, hemorrhoids bled on contact in 5 out of 22 patients before treatment and in none after treatment; no differences were found in the control group. No modification of the degree of prolapse was observed after treatment. CONCLUSION: Addition of dietary fiber may improve internal bleeding hemorrhoids although with no immediate effect. Fiber addition should be ensured in patients who refuse invasive treatment, waiting for a more defined form of treatment, or with contraindications.

[Crohn's disease of the duodenum complicated by sclerosing cholangitis and pancreatitis]. / Enfermedad de Crohn duodenal complicada con colangitis esclerosante y pancreatitis.

We describe the case of a 27 year-old man with Crohn's Disease of the duodenum associated with pancreatitis and cholestatic syndrome secondary to sclerosing cholangitis. Pancreatitis resolved along with the clinical improvement of Crohn's Disease. This case supports the concept of an association between duodenal Crohn's Disease, sclerosing cholangitis and pancreatitis.