[Sepsis Code: dodging mortality in a tertiary hospital]. / Código Sepsis: esquivando la mortalidad en un hospital terciario.

OBJECTIVE: In the hospital of La Princesa, the "Sepsis Code" (CSP) began in 2015, as a multidisciplinary group that provides health personnel with clinical, analytical and organizational tools, with the aim of the detection and early treatment of patients with sepsis. The objective of this study is to evaluate the impact of CSP implantation on mortality and to determine the variables associated with an increase in it. METHODS: A retrospective analytical study of patients with CSP alert activation from 2015 to 2018 was conducted. Clinical-epidemiological variables, analytical parameters, and severity factors such as admission to critical care units (UCC) and the need for amines were collected. Statistical significance was established at p < 0.05. RESULTS: We included 1,121 patients. The length of stay was 16 days and 32% required admission to UCC. Mortality showed a statistically significant linear downward trend from 24% in 2015 to 15% in 2018. The predictive mortality variables with statistically significant association were lactate > 2 mmol/L, creatinine > 1.6 mg/dL and the need for amines.>5.0%, mortality at the time of chart review 62.0%, and 6-months-post-discharge readmission 47.7%. CONCLUSIONS: The implementation of Sepsis Code decreases the mortality of patients with sepsis and septic shock. The presence of a lactate > 2 mmol/L, creatinine > 1.6 mg/dL and/or the need to administer amines in the first 24 hours, are associated with an increase in mortality in the patient with sepsis.

Initial clinical outcomes and prognostic variables in the implementation of a Code Sepsis in a high complexity University Hospital.

OBJECTIVE: To assess the impact of the first months of application of a Code Sepsis in a high complexity hospital, analyzing patient´s epidemiological and clinical characteristics and prognostic factors. METHODS: A long-term observational study was carried out throughout a consecutive period of seven months (February 2015 - September 2015). The relationship with mortality of risk factors, and analytic values was analyzed using uni- and multivariate analyses. RESULTS: A total of 237 patients were included. The in-hospital mortality was 24% at 30 days and 27% at 60 days. The mortality of patients admitted to Critical Care Units was 30%. Significant differences were found between the patients who died and those who survived in mean levels of creatinine (2.30 vs 1.46 mg/dL, p <0.05), lactic acid (6.10 vs 2.62 mmol/L, p <0.05) and procalcitonin (23.27 vs 12.73 mg/dL, p<0.05). A statistically significant linear trend was found between SOFA scale rating and mortality (p<0.05). In the multivariate analysis additional independent risk factors associated with death were identified: age > 65 years (OR 5.33, p <0.05), lactic acid > 3 mmol/L (OR 5,85, p <0,05), creatinine > 1,2 mgr /dL (OR 4,54, p <0,05) and shock (OR 6,57, P <0,05). CONCLUSIONS: The epidemiological, clinical and mortality characteristics of the patients in our series are similar to the best published in the literature. The study has identified several markers that could be useful at a local level to estimate risk of death in septic patients. Studies like this one are necessary to make improvements in the Code Sepsis programs.

Tm(iii) complexes undergoing slow relaxation of magnetization: exchange coupling and aging effects.

The present study focuses on the dynamic magnetic behaviour of exchange coupled 3d-4f complexes containing the scarcely investigated non-Kramers Tm3+ center, the 3d metal ions being either the low-spin Fe3+ (1) or the diamagnetic Co3+ (2) ion. Both complexes display field-induced slow relaxation of magnetization. The field and temperature dependences of the relaxation rate provided indication of relevant contributions from quantum tunnelling, direct, Orbach and Raman processes, with only minor effects from exchange coupling interactions. Furthermore, the aged sample of 2 exhibited an additional relaxation process, possibly due to structural modifications accompanied by solvent loss, highlighting the importance of a careful consideration of this factor when analysing the magnetization dynamics in solvated systems.

Análisis coste-efectividad del diagnóstico del síndrome del túnel carpiano mediante estudio electrofisiológico / Cost effectiveness analysis of the diagnosis of carpal tunnel syndrome using electrophysiological studies

Introducción. La elevada demanda de estudios electrofisiológicos(EEF) en pacientes paucisintomáticos con sospechade síndrome del túnel carpiano (STC) crea una sobrecargaen gabinetes de exploraciones. En el sector de referenciade nuestro hospital estas solicitudes provienen en su mayoríade atención primaria, pero también de otras especialidades.Muchos EEF en STC son normales o con alteraciones levesy por ello su resultado no conlleva una modificación dela actitud terapéutica. Por tanto, ante una sospecha de STCsin evidencia clínica de degeneración axonal no está claro siel EEF resulta coste-efectivo.Métodos. Realizamos un modelo de decisión y evaluacióneconómica que compara tres estrategias: opción A (EEFa todos los pacientes remitidos con sospecha de STC), opciónB (cribado previo por neurólogo y EEF sólo si sospechade STC axonal) y opción C (cribado previo por neurólogo yEEF sólo si sospecha de STC, axonal o no). Estudiamos durante2 meses a pacientes remitidos al gabinete de neurologíapor sospecha de STC. El EEF se consideró como la pruebaque establecía el diagnóstico final. De cada estrategia se determinaronlas consecuencias en términos de diagnósticoscorrectos, costes y relación coste/efectividad (C/E). Se realizóademás un análisis de sensibilidad. El total de estudiosrealizados fue 188, siendo la opción C la mejor relación C/E,pero también la más costosa.Conclusiones. Si hay «cribado neurológico» la relaciónC/E es mejor, pero resulta más cara. Sería recomendable potenciarla opción A, con un coste intermedio y una relaciónC/E aceptable. Sin embargo, ello genera una gran presiónasistencial y presupuestaria en los centros del sistema públicode salud, por lo que es necesario mejorar también eldiagnóstico y los criterios de derivación del STC (AU)

Introduction. The high demand for electrophysiologicalstudies (EP studies) in paucisymptomatic patientswith suspected carpal tunnel syndrome (CTS) createsoverloads in neurological examination departments.Most of these requests in the referenced section of ourhospital come from primary health care, however it alsocomes from other specialists. Many EP Studies for CTSare normal or have minimal alterations so that no changein the therapeutic attitude is required. Thus, it is notclear whether EP studies are cost-effective for suspectedCTS without clinical evidence of axonal degeneration.Methods. A decision-making and economic evaluationmodel was made to compare three strategies: option A(EP Studies for all patients with suspected CTS), option B(prior selection by neurologist and EP studies only ifaxonal CTS was suspected) and option C (prior selectionby neurologist and EP studies only if CTS, axonal orotherwise was suspected). The study was conducted overa two month period on patients referred to the neurologydepartment with suspected CTS. EP studies were consideredto be the proof that established the final diagnosis.The consequences were determined in terms of correctdiagnoses, cost and cost/effectiveness ratio for each strategy.A total number of 188 studies were performed,option C being the most cost-effective, but also the mostexpensive.Conclusions. When there is neurological screening,the cost-effectiveness ratio is better but it is also moreexpensive. It is recommended to favor option A with intermediatecost and an acceptable cost-effectiveness ratio.However, this also generates great pressure on bud-45 gets and care facilities which means that CTS diagnosis and criteria for referring patients to the neurologicalexamination departments must be improved (AU)

[Cost effectiveness analysis of the diagnosis of carpal tunnel syndrome using electrophysiological studies]. / Análisis coste-efectividad del diagnóstico del síndrome del túnel carpiano mediante estudio electrofisiológico.

INTRODUCTION: The high demand for electrophysiological studies (EP studies) in paucisymptomatic patients with suspected carpal tunnel syndrome (CTS) creates overloads in neurological examination departments. Most of these requests in the referenced section of our hospital come from primary health care, however it also comes from other specialists. Many EP Studies for CTS are normal or have minimal alterations so that no change in the therapeutic attitude is required. Thus, it is not clear whether EP studies are cost-effective for suspected CTS without clinical evidence of axonal degeneration. METHODS: A decision-making and economic evaluation model was made to compare three strategies: option A (EP Studies for all patients with suspected CTS), option B (prior selection by neurologist and EP studies only if axonal CTS was suspected) and option C (prior selection by neurologist and EP studies only if CTS, axonal or otherwise was suspected). The study was conducted over a two month period on patients referred to the neurology department with suspected CTS. EP studies were considered to be the proof that established the final diagnosis. The consequences were determined in terms of correct diagnoses, cost and cost/effectiveness ratio for each strategy. A total number of 188 studies were performed, option C being the most cost-effective, but also the most expensive. CONCLUSIONS: When there is neurological screening, the cost-effectiveness ratio is better but it is also more expensive. It is recommended to favor option A with intermediate cost and an acceptable cost-effectiveness ratio. However, this also generates great pressure on bud- 45 gets and care facilities which means that CTS diagnosis and criteria for referring patients to the neurological examination departments must be improved.

[Serotonin syndrome: report of two cases and review of the literature]. / Síndrome serotoninérgico: presentación de dos casos y revisión de la bibliografía.

INTRODUCTION: Serotonin is a neurotransmitter synthesized from tryptophan. It is implied in the regulation of mood, cognition, sleep cycle, synthesis of cerebrospinal fluid, and other processes. Generally, it is implied in human pathology by hypofunction. However, there is a complication of unknown incidence related to treatment with drugs that increase the stimulation of 5-HT1A serotonin receptors, called serotonin syndrome (SS). Clinically, it is characterised by the presence of a triad of mental and autonomic disorders, and motor hyperactivity. This entity has not biological markers and its diagnosis could be done verifying the proposed criteria. CASE REPORTS: Two cases of SS are presented, one of them related to the combination of risperidone and sertraline, as first report in the literature. Both cases had a favourable outcome employing support measures. CONCLUSIONS: The physiopathology, the diagnosis, the differential diagnosis, and the treatment are reviewed. We emphasize the potentially high frequency of this disorder, given the growing use of serotonin activity modifying drugs, and the typically benign course of the SS once the support measures are started.

Síndrome serotoninérgico: presentación de dos casos y revisión de la bibliografía / Serotonin syndrome: report of two cases and review of the literature

Introducción. La serotonina es un neurotransmisor sintetizado a partir del triptófano que interviene en la regulación del estado anímico, los procesos cognitivos, el ciclo del sueño y la síntesis del líquido cefalorraquídeo, entre otros procesos. Su implicación en patología humana se debe, generalmente, a hipofunción. Sin embargo, existe una complicación, cuya incidencia real no se conoce, del tratamiento con fármacos que incrementan la estimulación sobre los receptores 5-HT1A de la serotonina, el síndrome serotoninérgico (SS). Desde el punto de vista clínico, se caracteriza por la presencia de una tríada consistente en alteraciones mentales, datos de disfunción autonómica e hiperactividad motora. Esta entidad no posee ningún marcador biológico, y su diagnóstico se basa en la verificación de los criterios propuestos. Casos clínicos. Se presentan dos casos de SS, uno de ellos secundario a la combinación de risperidona y sertralina, descrita por primera vez en la literatura. En ambos casos, la evolución fue favorable con el empleo de medidas de soporte. Conclusiones. Se revisan la fisiopatología, el diagnóstico, el diagnóstico diferencial y el tratamiento del SS. Se quiere destacar la alta frecuencia potencial de este trastorno, ligada al empleo cada vez mayor de fármacos modificadores de la actividad serotoninérgica, y la habitual benignidad del mismo una vez reconocido e instauradas las medidas de soporte oportunas

Introduction. Serotonin is a neurotransmitter synthesized from tryptophan. It is implied in the regulation of mood, cognition, sleep cycle, synthesis of cerebrospinal fluid, and other processes. Generally, it is implied in human pathology by hypofunction. However, there is a complication of unknown incidence related to treatment with drugs that increase the stimulation of 5-HT1A serotonin receptors, called serotonin syndrome (SS). Clinically, it is characterised by the presence of a triad of mental and autonomic disorders, and motor hyperactivity. This entity has not biological markers and its diagnosis could be done verifying the proposed criteria. Case reports. Two cases of SS are presented, one of them related to the combination of risperidone and sertraline, as first report in the literature. Both cases had a favourable outcome employing support measures. Conclusions. The physiopathology, the diagnosis, the differential diagnosis, and the treatment are reviewed. We emphasize the potentially high frequency of this disorder, given the growing use of serotonin activity modifying drugs, and the typically benign course of the SS once the support measures are started

Mannose-binding lectin polymorphisms in a Canary Islands (Spain) population.

We have compared the structural and promoter variants of the mannose-binding lectin (MBL) gene in a population from Gran Canaria with that from other populations previously reported. The observed frequencies of the seven alleles of the MBL gene in our population were: HYPA, 0.24; LYQA, 0.22; LYPA, 0.08; LXPA, 0.19; LYPB, 0.17; LYQC, 0.03 and HYPD, 0.07. The frequency of non-producer alleles and of MBL-deficient individuals in our population is higher than in other European and Asian population.

[Intrathecal synthesis of IgG evaluated using different formulas: importance of multivariate analysis in the diagnosis of multiple sclerosis]. / Síntesis intratecal de IgG valorada mediante diferentes fórmulas: interés del análisis multivariante para el diagnóstico de esclerosis múltiple.

INTRODUCTION: Synthesis of IgG is useful data for the diagnosis of multiple sclerosis, and different formulas, both direct and indirect, are used to quantify this. We analyze these formulas with the objective of finding whether certain combinations of them would give better results than the individual formulas on their own. PATIENTS AND METHODS: We studied the cerebrospinal fluid of 45 patients with neurological disorders and determined the results of the two formulas which are most effective, according to some studies (Reiber's formula and IgG index) together with a direct formula (IgG ratio) and another indirect formula (the 'classical' formula of Tourtellotte). RESULTS: The IgG index was, in general, the formula which best differentiated between patients with multiple sclerosis and persons with other neurological disorders. CONCLUSIONS: We found a tendency which supported the original hypothesis that it is possible to use combinations of formulas to obtain better results than individual formulas. This fact may serve as a basis for further studies in which different combinations are tested, including analytical and clinical data, and this may be of use in the diagnosis of multiple sclerosis.

Síntesis intratecal de IgG valorada mediante diferentes fórmulas:interés del análisis multivariantepara el diagnóstico de esclerosis múltiple / Intrathecal synthesis of IgG evaluated using different formulas: the use of multivariate analysis for the diagnosis of multiple sclerosis

Introducción. La síntesis de IgG es un dato útil en el diagnóstico de esclerosis múltiple, y para cuantificarla se emplean diferentes fórmulas, directas o indirectas. Analizamos dichas fórmulas con el objetivo de ver si existen combinaciones de las mismas con mejor rendimiento que las individuales. Pacientes y métodos. Hemos estudiado el líquido cefalorraquídeo en 45 pacientes con enfermedades neurológicas y hemos determinado los resultados de las dos fórmulas que, según algunos trabajos, son más eficaces (fórmula de Reiber e índice de IgG), junto con una fórmula directa (ratio de IgG) y otra fórmula indirecta (la `clásica' de Tourtellotte). Resultados. El índice de IgG fue la fórmula que presentó la capacidad más alta para discriminar, en general, entre pacientes con esclerosis múltiple e individuos con otra enfermedad neurológica. Conclusiones. Encontramos una tendencia que apoya la hipótesis inicial de que es posible utilizar combinaciones de fórmulas que ofrezcan mejores rendimientos que las fórmulas individuales. Este hecho puede ser el punto de partida para otros estudios, en los que se prueben combinaciones diferentes, incluso de datos analíticos y clínicos, los cuales puedan mejorar nuestra capacidad para diagnosticar la esclerosis múltiple (AU)

[Normal values for transcranial doppler studies in our medium]. / Valores de normalidad del estudio Doppler transcraneal en nuestro medio.

OBJECTIVE: Transcranial Doppler is a technique which is being used ever more frequently in the study of intracranial arteries and is very useful in the study of cerebrovascular disease. The typical values of a healthy population in our country are unknown. The aim of this study was determine mean velocity and pulsatility index reference values in a healthy population. PATIENTS AND METHOD: Transcranial Doppler basal examination was carried out on 118 healthy volunteers without prior haematological or cerebrovascular conditions. Those found to have extracranial arterial stenoses were excluded as were those in whom bilateral temporal bone hyperostosis did not permit insonation in either middle cerebral arteries. The nine intracranial arteries were sounded systematically at fixed depths. The mean and standard deviations of each variable were calculated for side, age group and sex. RESULTS: 49% were males and average age was of 56 years (range, 21-87 years). A sufficient signal to determine the parameters of the study was obtained in 89% of middle cerebral arteries. Statistically significant differences in mean velocity and pulsatility index were found between age groups and sexes. CONCLUSIONS: Sex and age must be taken into account in establishing typical patterns in transcranial Doppler examination. Our results enable parameters of typical values to be established for the adult population in Spain.

[Record of neurological emergencies at a tertiary care hospital]. / Registro de urgencias neurológicas en un hospital de tercer nivel.

INTRODUCTION AND OBJECTIVE: There is a progressive increase in the demand for multidisciplinary attention from the Emergency Medical Services. The objective of this study was to determine the proportion of neurological conditions in the total hospital emergency workload, their demographic composition and medical needs. PATIENTS AND METHODS: We present an observational study of a cohort of histories of neurological emergencies at a tertiary hospital during a period of one year. RESULTS: On analysis of all emergencies, 1,592 were neurological conditions. The duty neurologist was consulted in 87.9% of the cases. The average age was 59, and the majority were women (56.3%). Maximum demand was between 14.00 and 19.59 hours. Monday was the day of the week when most were seen. The commonest causes of consultation were change in strength or language, headache and epileptic crises. The complementary investigation done most frequently was a blood test. Cerebral CT scan were done in 31.9% of the patients. The diagnoses most often made, as a group, were cerebrovascular disease followed by epilepsy and headache. The majority of the patients were referred to Primary Care Centres or for neurological consultation. When the patients were grouped according to the specialties with doctors on duty, the second largest group were seen by the emergency neurologist at our hospital. CONCLUSION: In view of the above results, we consider the presence of a neurologist in the Emergency Department to be fully justified.

[Statins (HMG-CoA reductase inhibitors), cholesterol and stroke]. / Estatinas (inhibidores de la HMG-CoA reductasa), colesterol e ictus.

The HMG-CoA reductase inhibitors (known as statins) have been shown to reduce morbi-mortality of vascular origin, including transitory ischemic accidents and cerebral infarcts, in a large group of patients. The implications, both clinical and of costs, oblige us to consider analysis of the existing evidence and the answers to a number of questions arising in a field which has not yet received much attention from neurologists.

[Subarachnoid hemorrhage as a form of onset of systemic lupus erythematosus]. / Hemorragia subaracnoidea como forma de debut de lupus eritematoso sistémico.

INTRODUCTION: The most frequent cause of spontaneous subarachnoid hemorrhage (SAH) is rupture of intracranial arterial aneurysms (> 70%). The remainder are due to many different aetiologies. Although SAH is a relatively common neuropathological finding in systemic lupus erythematosus (SLE), it is normally due to the extent of the intercerebral hemorrhage and not to its isolated presentation. CLINICAL CASE: We report the case of a 34 year old woman who presented with non-traumatic SAH at the onset of her lupus disorder. The patient was attended for SAH and at the same time a multisystemic disorder and severe thrombocytopenia were found, leading to a diagnosis of SLE. The neuroimaging techniques, selective cerebral arteriography, cerebral and spinal magnetic resonance, and magnetic resonance angiography did not show any vascular malformations. The patient was treated with immunosuppressive therapy, nimodipine, and following angiographic tests, with antiaggregants and anticoagulants. CONCLUSIONS: The greater frequency of SAH in patients with lupus, as compared to the general population, has been attributed to the presence of intracranial vasculitis. However, neuropathological studies have shown that true vasculitis is very infrequent in the central nervous system of SLE patients. In the case we describe, the first in which SAH appeared at the onset of the disease, we consider that the origin of the hemorrhage was her high arterial blood pressure and thrombopenia.