Análisis de las unidades docentes de neurología en España y cumplimientode los criterios de acreditación / Analysis of the neurology teaching unit in Spain and compliance of accreditation criteria

Introducción. Ante la promulgación de la Ley de Ordenación dela Profesiones Sanitarias y la publicación del nuevo programa de laespecialidad de neurología, la Comisión Nacional de Neurología considerónecesario conocer la situación actual de las unidades docentes(UD) acreditadas para la especialidad en lo referente a los criterios deacreditación vigentes. El objetivo de este trabajo es conocer dichasituación.Métodos. Estudio transversal mediante una encuesta de cumplimentaciónvoluntaria (cuestionario ad hoc) remitida por correoen el año 2005 a todas UD acreditadas en ese momento. Incluyópreguntas específicas respecto a los requerimientos estructurales,humanos y de organización contemplados en dichos criterios deacreditación.Resultados. Se remitieron 64 cuestionarios (porcentaje de respuesta:76,6%). El 87 % de las UD cumplían los requisitos estructuralespara la asistencia neurológica, aunque el 21 % tenían menos de4 despachos para consulta y menos de 15 camas neurológicas. El 25%de las UD no cumplían los requisitos en lo referente a los facultativos deplantilla con dedicación a tiempo completo. Aunque prácticamente el100% cumplían los requisitos organizativos cuantitativos asistenciales,sólo el 69 % refirieron tener guardias de neurología, aunque porel diseño del cuestionario no es posible conocer su grado de tutorización.Prácticamente el 100% cumplen los requisitos de docencia einvestigación.Conclusiones. Aunque el grado de cumplimiento de los actualesCA es alto, existen deficiencias preocupantes, fundamentalmente enrelación al número de facultativos de plantilla contratados a tiempocompleto y a la disponibilidad de guardias de neurología debidamentetutorizadas (AU)

Introduction. Faced with the promulgation of the HealthCare Professionals Ordinance Law and the publication of the newprogram of the Neurology training, the National Committee ofneurology has considered it necessary to know the current situationof the Teaching Units (TU) accredited for the neurology trainingin regards to the existing accreditation criteria (AC). Thepurpose of this study is to know said situation.Methods. A cross-sectional study performed by a voluntarilyfilled-out survey (ad hoc questionnaire) sent by regular mailin the year 2005 to all the TU accredited at that time. It includedspecific questions regarding the structural, human andorganizational requirements contemplated in those accreditationcriteria.Results. A total of 64 questionnaires were sent (response percentage:76.6%). Eighty seven percent of the TU met the structuralrequirements for neurological care, although 21 % had fewerthan 4 offices for visits and fewer than 15 neurology beds. A totalof 25 % of the TU did not met the requirements in regards to fulltimestaff members. Although almost 100% met the quantitativecare organizational requirements, only 69 % reported that therewere neurology duties. However, the grade of the tutorial systemcould not be known due to the survey design. Almost 100% metthe teaching and research requirements.Conclusions. Although the compliance grade of the currentAC is high, there are important deficiencies, basically related tothe number of full-time staff professionals and the availability ofduly tutorized neurology duties (AU)

[Analysis of the neurology teaching unit in Spain and compliance of accreditation criteria]. / Análisis de las unidades docentes de neurología en España y cumplimiento de los criterios de acreditación.

INTRODUCTION: Faced with the promulgation of the Health Care Professionals Ordinance Law and the publication of the new program of the Neurology training, the National Committee of neurology has considered it necessary to know the current situation of the Teaching Units (TU) accredited for the neurology training in regards to the existing accreditation criteria (AC). The purpose of this study is to know said situation. METHODS: A cross-sectional study performed by a voluntarily filled-out survey (ad hoc questionnaire) sent by regular mail in the year 2005 to all the TU accredited at that time. It included specific questions regarding the structural, human and organizational requirements contemplated in those accreditation criteria. RESULTS: A total of 64 questionnaires were sent (response percentage: 76.6%). Eighty seven percent of the TU met the structural requirements for neurological care, although 21 % had fewer than 4 offices for visits and fewer than 15 neurology beds. A total of 25 % of the TU did not met the requirements in regards to full-time staff members. Although almost 100% met the quantitative care organizational requirements, only 69 % reported that there were neurology duties. However, the grade of the tutorial system could not be known due to the survey design. Almost 100% met the teaching and research requirements. CONCLUSIONS: Although the compliance grade of the current AC is high, there are important deficiencies, basically related to the number of full-time staff professionals and the availability of duly tutorized neurology duties.

[Neuropathic pain as the reason for visiting Neurology: an analysis of its frequency]. / El dolor neuropático como motivo de consulta en Neurología: análisis de su frecuencia.

INTRODUCTION: Neuropathic pain (NP) is defined as pain that begins with or is caused by a primary injury or by a dysfunction in the nervous system. AIMS: Our aim was to evaluate how often patients visit Neurology as outpatients with NP as the main reason for referral. PATIENTS AND METHODS: A descriptive, cross sectional study was carried out on the use of the health care services; patients attended for the first time in a Neurology Screening visit were included consecutively. The variables studied were the following: the number of first visits and the total number of patients attended per visiting session, rate of patients with NP per visiting day, the topography and probable causation of the NP, and the rate of patients referred to the monographic NP clinic; the different quantitative variables are expressed in terms of their mean and standard deviation (SD), whereas the qualitative variables are given as their absolute value and the percentage. A total of 1,972 patients were attended, of whom 1,422 (72.1%) were first visits, with an average of 17.5 (SD: 2.5) new patients per visiting session. RESULTS: In all 113 patients clinically diagnosed with NP were identified, which represents a rate of 7.95% of the first visits. CONCLUSIONS: NP may be among the most frequent causes of the demand for neurological ambulatory care. The most common causes of NP were found to be trigeminal neuralgia, post-herpes neuralgia and diabetic polyneuropathy.

El dolor neuropático como motivo de consulta en Neurología: análisis de su frecuencia / Neuropathic pain as the reason for visiting neurology: an analysis of its frequency

Introducción. El dolor neuropático (DN) se define como aquel dolor iniciado o causado por una lesión primaria o por una disfunción en el sistema nervioso. Objetivo. Evaluar la frecuencia con la que los pacientes con DN como motivo principal de derivación se remiten a una consulta ambulatoria de Neurología. Pacientes y métodos. Se trata de un estudio descriptivo, transversal sobreutilización de los servicios sanitarios; se incluyeron consecutivamente los pacientes atendidos por primera vez en una consulta de Neurología de selección; variables estudiadas: número de primeras visitas y número total de pacientes atendidos por sesión de consulta, tasa de pacientes con DN por día de consulta, la topografía y probable etiología del DN, y la tasa de pacientes remitidos a la consulta monográfica de DN; las diferentes variables cuantitativas se expresarán con su media y desviación estándar (DE), mientras que en las variables cualitativas esto se hará con su valor absoluto y el porcentaje. Se atendieron 1.972 pacientes, de los cuales 1.422(72,1%) fueron primeras visitas, con una media de 17,5 (DE: 2,5) pacientes nuevos por sesión de consulta. Resultados. Se identificaron113 pacientes con diagnóstico clínico de DN, lo que supone una tasa del 7,95% de las primeras visitas. Conclusiones. El DN puede estar entre las causas más frecuentes de demanda de asistencia neurológica ambulatoria. Las causas más frecuentes de DN fueron la neuralgia del trigémino, la neuralgia posherpética y la polineuropatía diabética (AU)

Introduction. Neuropathic pain (NP) is defined as pain that begins with or is caused by a primary injury or by a dysfunction in the nervous system. Aims. Our aim was to evaluate how often patients visit Neurology as outpatients with NPas the main reason for referral. Patients and methods. A descriptive, cross sectional study was carried out on the use of the health care services; patients attended for the first time in a Neurology Screening visit were included consecutively. The variables studied were the following: the number of first visits and the total number of patients attended per visiting session, rate of patients with NP per visiting day, the topography and probable causation of the NP, and the rate of patients referred to the monographic NP clinic; the different quantitative variables are expressed in terms of their mean and standard deviation (SD), whereas the qualitative variables are given as their absolute value and the percentage. A total of 1,972patients were attended, of whom 1,422 (72.1%) were first visits, with an average of 17.5 (SD: 2.5) new patients per visiting session. Results. In all 113 patients clinically diagnosed with NP were identified, which represents a rate of 7.95% of the first visits. Conclusions. NP may be among the most frequent causes of the demand for neurological ambulatory care. The most common causes of NP were found to be trigeminal neuralgia, post-herpes neuralgia and diabetic polyneuropathy (AU)

[An update on the diagnosis of vascular dementia]. / Actualización en el diagnóstico de la demencia vascular.

INTRODUCTION: Vascular dementia (VD) is the second most frequent cause of dementia after Alzheimer's disease in western societies. It includes a heterogeneous group of disorders in which vascular factors are believed to play a vital role in the development of cognitive impairment. Aims and development. Our aim was to determine what instruments can be used to diagnose VD and to what extent such a diagnosis is reliable. To this end, we review the diagnostic criteria that have been used up to now, the role played by neuropsychology, the value of neurosonology studies, and the growing development of neuroimaging techniques, especially magnetic resonance. CONCLUSIONS: Current diagnostic criteria for VD select a group that is clinically and aetiologically very heterogeneous. Such criteria need shifting towards new evidence-based criteria derived from analyses of population studies that focus on the early stages of the disease and that make a proper distinction between patients with mixed dementia. The subcortical subtype of vascular cognitive impairment (SVCI) is a form of vascular impairment that is more homogeneous and which selects more representative patients with a more predictable clinical pattern, natural history, response to treatment and prognosis. These characteristics make SVCI cases an ideal group for comparisons between clinical trials and studies.

Actualización en el diagnóstico de la demencia vascular / An update on the diagnosis of vascular dementia

Introduction. Vascular dementia (VD) is the second most frequent cause of dementia after Alzheimer’s disease in western societies. It includes a heterogeneous group of disorders in which vascular factors are believed to play a vital role in the development of cognitive impairment. Aims and development. Our aim was to determine what instruments can be used to diagnose VD and to what extent such a diagnosis is reliable. To this end, we review the diagnostic criteria that have been used up to now, the role played by neuropsychology, the value of neurosonology studies, and the growing development of neuroimaging techniques, especially magnetic resonance. Conclusions. Current diagnostic criteria for VD select a group that is clinically and aetiologically very heterogeneous. Such criteria need shifting towards new evidence-based criteria derived from analyses of population studies that focus on the early stages of the disease and that make a proper distinction between patients with mixed dementia. The subcortical subtype of vascular cognitive impairment (SVCI) is a form of vascular impairment that is more homogeneous and which selects more representative patients with a more predictable clinical pattern, natural history, response to treatment and prognosis. These characteristics make SVCI cases an ideal group for comparisons between clinical trials and studies (AU)

Introducción. La demencia vascular (DV) es la segunda causa de demencia tras la enfermedad de Alzheimer en la sociedad occidental. Incluye un grupo heterogéneo de trastornos en los que se piensa que los factores vasculares desempeñan un papel esencial en el desarrollo del deterioro cognitivo. Objetivo y desarrollo. Nuestro objetivo es analizar con qué instrumentos y con qué fiabilidad somos capaces de diagnosticar la DV. Para ello, revisamos los criterios diagnósticos existentes hasta la actualidad, el papel de la neuropsicología, del estudio neuroecográfico y el creciente desarrollo de las técnicas de neuroimagen, en especial la resonancia magnética. Conclusión. Los criterios diagnósticos actuales para la DV seleccionan a un grupo clínica y etiológicamente muy heterogéneo, y es necesario modificarlos hacia unos nuevos criterios basados en evidencias, derivados del análisis de estudios poblacionales que se centren en la enfermedad en sus estadios iniciales, y que diferencien adecuadamente a los pacientes con demencia mixta. El subtipo de deterioro cognitivo vascular subcortical (DCVS) representa una forma de deterioro vascular más homogéneo y que selecciona a pacientes más representativos, con un cuadro clínico, evolución, respuesta al tratamiento y pronóstico más predecibles. Estas características hacen del DCVS un grupo ideal para la comparabilidad de estudios y ensayos clínicos (AU)

[Differences between Spanish ischemic stroke patients and those from Central and Northern Europe. A case-control study]. / Diferencias entre pacientes con ictus isquémico españoles frente a centro y nordeuropeos: un estudio de casos y controles.

INTRODUCTION: Studies conducted in the American population have revealed the existence of differences in cerebral vascular pathologies and in the prevalence of vascular risk factors between races. The few studies carried out in Hispanic populations have found a higher prevalence of diabetes mellitus, as well as a lower frequency of cardioembolic strokes and extracranial carotid atheromatosis, in comparison with whites of Anglo-Saxon extraction. PATIENTS AND METHODS: We performed a case-control study in which one case was paired with two controls, according to age and sex. The cases were people from Central and Northern Europe and the controls were Spaniards. All of them had been admitted to hospital because of ischemic stroke or TIA. We compared the frequency of conventional risk factors (RF), the subtype of ischemic stroke and the results from carotid duplex scans. The odds ratio and confidence intervals (CI) at 95% were calculated for paired data. RESULTS: Arterial hypertension (AHT) was less frequent in the cases, with an OR of 0.45 (CI 0.24-0.83). No statistically significant differences were found in the prevalence of diabetes, hypercholesterolemia, heart disease and atrial fibrillation. Fast recovery stroke and TIA were observed more frequently in the cases than in the controls (OR: 3.73; CI: 1.72-8.07), which we interpreted as being due to a bias in admissions. Carotid duplex scanning revealed stenosis > 70% in 21.9% of the cases and in 13% of the controls. CONCLUSIONS: This study did not reveal any differences between Spaniards and Northern Europeans in conventional RF, except for a higher prevalence of AHT in Spaniards. Severe carotid pathology seems to be less frequent in Spaniards. Future research should take into account other RFs (such as cholesterol subfractions, homocysteine, etc.), which are possibly race-linked and may account for the differences described.

Diferencias entre pacientes con ictus isquémico españoles frente a centro y nordeuropeos: un estudio de casos y controles / Differences between Spanish ischemic stroke patients and those from Central and Northern Europe. A case-control study

Introducción. Algunos estudios realizados en población americana han demostrado diferencias entre razas en la patología vascular cerebral y en la prevalencia de los factores de riesgo va-cular. Los pocos estudios sobre población hispana han encontrado una mayor prevalencia de diabetes mellitus, así como una menor frecuencia de ictus cardioembólico y de ateromatosis carotídea extracraneal, en comparación a la raza blanca de origen sajón. Pacientes y métodos. Realizamos un estudio de casos y controles apareando un caso con dos controles, por edad y sexo. Los casos eran personas procedentes del centro y norte de Europa y los controles, personas españolas. Todos se habían hospitalizado por ictus isquémico o AIT. Comparamos la frecuencia de factores de riesgo(FR) convencionales, el subtipo de ictus isquémico y el estudio por ecografía Doppler de las carótidas. Calculamos la odds ratio y los intervalos de confianza (IC) al 95% para datos apareados. Resultados. Los casos presentaron con menor frecuencia hipertensión arterial(HTA), con una OR de 0,45 (IC 0,24-0,83). No encontramos diferencias estadísticamente significativas en la prevalencia de diabetes, hipercolesterolemia, cardiopatía y fibrilación auricular. Obtuvimos una mayor frecuencia de ictus con mejoría rápida y de AIT en los casos que en los controles (OR de 3,73, IC: 1,72-8,07), que interpretamos como un sesgo de ingreso. La ecografía Doppler de las carótidas demostró estenosis superior al 70% en el 21,9% de los casos y en el 13% de los controles. Conclusiones. El presente estudio no revela diferencias entre españoles y noreuropeos en los factores de riesgo convencionales, salvo por una mayor prevalencia de HTA enlos pacientes españoles. La patología carotídea grave parece ser menos frecuente en los españoles. Sería conveniente para futuros trabajos el tener en cuenta otros FR (subfracciones de colesterol,homocisteína, etc.), posiblemente ligados a la raza y que pueden explicar las diferencias descritas

Introduction. Studies conducted in the American population have revealed the existence of differences incerebral vascular pathologies and in the prevalence of vascular risk factors between races. The few studies carried out in Hispanic populations have found a higher prevalence of diabetes mellitus, as well as a lower frequency of cardio-embolic strokes and extracranial carotid atheromatosis, in comparison with whites of Anglo-Saxon extraction. Patients and methods. We performed a case-control study in which one case was paired with two controls, according to age and sex. The cases were people from Central and Northern Europe and the controls were Spaniards. All of them had been admitted to hospital because of ischemic stroke or TIA. We compared the frequency of conventional risk factors (RF), the subtype of ischemic stroke and the results from carotid duplex scans. The odds ratio and confidence intervals (CI) at 95% were calculated for paired data. Results. Arterial hypertension (AHT) was less frequent in the cases, with an OR of 0.45 (CI0.24-0.83). No statistically significant differences were found in the prevalence of diabetes, hypercholesterolemia, heart disease and atrial fibrillation. Fast recovery stroke and TIA were observed more frequently in the cases than in the controls(OR: 3.73; CI: 1.72-8.07), which we interpreted as being due to a bias in admissions. Carotid duplex scanning revealed stenosis > 70% in 21.9% of the cases and in 13% of the controls. Conclusions. This study did not reveal any differences between Spaniards and Northern Europeans in conventional RF, except for a higher prevalence of AHT in Spaniards. Severe carotid pathology seems to be less frequent in Spaniards. Future research should take into account other RFs (such as cholesterol subfractions, homocysteine, etc.), which are possibly race-linked and may account for the differences described

[Present and future of neurology in Spain]. / Presente y futuro de la neurología española.

This is a document prepared by the Spanish Society of Neurology (SEN), which was given to the President of Spain (Mr. José María Aznar) last September with the main aim of examining the current situation of Neurology in our country. It analyses the present and future of Neurology in clinical assistance, teaching and research. To prepare this document the criteria of patients' associations has been considered, including the Declaration of Madrid which has been subscribed by thirty of these associations. In spite of its relevant development in the previous decades, the current situation of Neurology in Spain is far from the ideal. To reach the recommendable menber of 3 or 4 neurologists per 100,000 inhabitants it is necessary to duplicate the present number of neurologists which has been estimated around 2/100,000; this situation is especially urgent in some Autonomous Communities. The most important problems in neurological assistance are: inadequate follow-up of the chronic outpatients, low numbers of neurological beds and of duties of Neurology, as well as of neurological case of patients with urgent neurological disorders. It is also necessary to increase the number of professors of Neurology to adequately cover pregraduate teaching; again there are important differences in teaching positions among Autonomous Communities. Neurology residence should be prolonged from 4 to 5 years. Finally, it is necessary to support the appearance of superespecialised units and to promote a coordinated research with other close specialities including basic neuroscience.

[Multiple sclerosis incidence in the Alcoi Health district. 12-year-long study (1986-1997)]. / Incidencia de la esclerosis múltiple en el área sanitaria de Alcoi. Estudio de 12 años (1986-1997).

INTRODUCTION: To date, epidemiological studies on multiple sclerosis in Spain have been basically prevalence studies, and the data on incidence recorded have been the result of different methodologies, with no definition of the criteria for inclusion. OBJECTIVE: To carry out a study of incidence with prospective collection/review of cases over a prolonged period of time. PATIENTS AND METHODS: Over 12 years, between 1 March 1986 and 31 December 1997, we collected data prospectively for patients with a definite diagnosis of multiple sclerosis. The year of incidence was considered to be when the patient fulfilled clinical criteria for diagnosis of the disease. RESULTS: On 31 December 1997 in the Alcoi Health District there were 54 patients with clinically defined multiple sclerosis (a prevalence of 41.28 cases per 100,000 inhabitants). Of these, 45 patients were diagnosed during the period studied, with an average incidence of 2.82 cases per 100,000 inhabitants per year. Only 15 patients were confirmed before 1986. CONCLUSIONS: This is the most prolonged study of the incidence of multiple sclerosis carried out in Spain. The figures found for incidence are in contrast to those found in previous years for prevalence and incidence. Analysis of the data suggests that the incidence of multiple sclerosis in the Alcoi district has changed and has increased since the second half of the 1980s.

[The prevalence of multiple sclerosis in the Alcoi Health district]. / Prevalencia de la esclerosis múltiple en el área sanitaria de Alcoi.

INTRODUCTION: The epidemiological studies done in Spain in recent years show higher figures for the prevalence of multiple sclerosis than before. Spain is therefore now in the area with a high risk of contracting the disease. OBJECTIVE: We have made a new study to confirm the current prevalence of the disorder in the Alcoi Health District. PATIENTS AND METHODS: Between 1 March 1986 and the prevalence day, 31 December 1997 we recorded the patients with definite or probable multiple sclerosis, as defined on Poser's criteria, after intensive fieldwork and reevaluation of all possible patients by a neurologist from the Neurology Unit. On the prevalence day there were 130,786 inhabitants in the district. RESULTS: On the prevalence day we found 54 patients with definite multiple sclerosis and no patient with probable multiple sclerosis. The rate of prevalence was 41.28 cases per 100,000 inhabitants (95% CI: 31-53.6). During the study we counted an incidence of 45 cases with an average rate of 2.82 cases per 100,000 inhabitants per year. We also describe the clinical characteristics of the patients. CONCLUSIONS: The rate of prevalence found is much higher than that described for the district in studies using similar methodology. This increase, together with the discrepancy between the incidence found and the prevalence, makes us consider that possibly the prevalence has increased in recent years.

Incidencia de la esclerosis múltiple en el área sanitaria de Alcoi. Estudio de 12 años (1986-1997) / The incidence of multiple sclerosis in the Alcoi health district. A 12 year study (1986-1997)

Introducción. Los estudios epidemiológicos sobre esclerosis múltiple en España han sido hasta la fecha estudios fundamentalmente de prevalencia, y los datos de incidencia descritos se han recogido con metodología dispar, sin precisar los criterios de inclusión.Objetivo. Realizar un estudio de incidencia con recogida prospectiva de los casos a lo largo de un período prolongado de tiempo. Pacientes y métodos. A lo largo de 12 años, desde el 1 de marzo de 1986 al 31 de diciembre de 1997, se han recogido de forma prospectiva aquellos enfermos con diagnóstico de esclerosis múltiple definida. Se ha considerado como año de incidencia aquel en el que los pacientes cumplían criterios clínicos de la enfermedad. Resultados. El 31 de diciembre de 1997 había en el área de Alcoi 54 pacientes con esclerosis múltiple clínicamente definida (prevalencia de 41,28 casos por 100.000 habitantes). De ellos, 45 pacientes fueron incidentes a lo largo del período del estudio, con una tasa media de incidencia de 2,82 casos por 100.000 habitantes y año. Únicamente 15 pacientes fueron incidentes con anterioridad a 1986. Conclusiones. Este estudio es el más prolongado de los realizados sobre la incidencia de la esclerosis múltiple en España. Las cifras de incidencia halladas contrastan con los datos de prevalencia y la incidencia de los años anteriores. El análisis de los datos sugiere que la incidencia de la esclerosis múltiple en el área de Alcoi ha variado, incrementándose desde la segunda mitad de los años 80 (AU)

Prevalencia de la esclerosis múltiple en el área sanitaria de Alcoi / The prevalence of multiple sclerosis in the Alcoi health district

Introducción. Los estudios epidemiológicos llevados a cabo los últimos años en España muestran cifras de prevalencia de la esclerosis múltiple superiores a las anteriormente descritas, y sitúan a nuestro país dentro de un área de riesgo elevado de padecer la enfermedad. Objetivo. Se ha realizado un nuevo estudio en el área sanitaria de Alcoi para comprobar la prevalencia actual de la enfermedad. Pacientes y métodos. Desde el 1 de marzo de 1986 hasta el día de prevalencia, el 31 de diciembre de 1997, se han recogido aquellos pacientes con diagnóstico de esclerosis múltiple definida o probable según los criterios de Poser, tras realizar un intensivo trabajo de campo y reevaluar a todos los posibles pacientes por un neurólogo de la Unidad de Neurología. El día de prevalencia el número de habitantes del área era 130.786. Resultados. El día de prevalencia se encontraron 54 pacientes con esclerosis múltiple definida y ningún paciente con esclerosis múltiple probable. La tasa de prevalencia fue de 41,28 casos por 100.000 habitantes (IC del 95 por ciento: 31-53,6). A lo largo del estudio se contabilizaron 45 casos incidentes con una tasa media de 2,82 casos por 100.000 habitantes y año. Se describen asimismo las características clínicas de los pacientes. Conclusiones. La tasa de prevalencia hallada es muy superior a la descrita previamente en la zona con estudios de similar metodología. Este incremento, junto a la discrepancia entre la incidencia encontrada y la prevalencia, hacen pensar en la posibilidad de un aumento de la prevalencia en los últimos años (AU)