Resumen ejecutivo sobre la optimización del abordaje multidisciplinar e integrado de la polimialgia reumática y la arteritis de células gigantes en la Comunidad de Madrid / Executive summary on the optimization of the multidisciplinary and integrated approach to polymyalgia rheumatica and giant cell arteritis in Madrid region

La polimialgia reumática y la arteritis de células gigantes pueden suponer una emergencia médica en la que el retraso en su correcto diagnóstico y manejo terapéutico pueden asociar complicaciones graves. Con el objetivo de mejorar la atención de los pacientes con estas patologías en el entorno de la Comunidad de Madrid, se diseñó un estudio para identificar las causas y las posibles soluciones para hacer frente los problemas relacionados con el diagnóstico de estas patologías. Tras un análisis preliminar, se identificaron 11 áreas de mejora relacionadas con cuatro aspectos diferenciados del proceso asistencial: coordinación y protocolos, equipamientos, formación y concienciación sobre las patologías y experiencia del paciente. De todas ellas, se priorizó resolver aquellas relacionadas con la generación de protocolos de abordaje integral de las patologías y que contemplen todas las especialidades y niveles asistenciales implicados. Otro aspecto crucial es el incremento del grado de sospecha clínica de estas patologías. (AU)

Polymyalgia rheumatica and giant cell arteritis can be a medical emergency in which a delay in correct diagnosis and therapeutic management can cause serious complications. With the aim of improving the care of patients with these pathologies in the Community of Madrid, a study was designed to identify the causes and possible solutions to address the problems related to the diagnosis of these pathologies. After the analysis, 11 areas of improvement related to four different aspects of the care process were identified: coordination and protocols, equipment, training and awareness of pathologies, and patient experience. Of all the areas identified, it was considered a priority to resolve those related to the generation of protocols for the comprehensive management of the pathologies, which include all the specialties and levels of care involved. Another crucial aspect is the increase in the degree of clinical suspicion of these pathologies. (AU)

Resumen ejecutivo sobre la optimización del abordaje multidisciplinar e integrado de la polimialgia reumática y la arteritis de células gigantes en la Comunidad de Madrid / Executive summary on the optimization of the multidisciplinary and integrated approach to polymyalgia rheumatica and giant cell arteritis in Madrid region

La polimialgia reumática y la arteritis de células gigantes pueden suponer una emergencia médica en la que el retraso en su correcto diagnóstico y manejo terapéutico pueden asociar complicaciones graves. Con el objetivo de mejorar la atención de los pacientes con estas patologías en el entorno de la Comunidad de Madrid, se diseñó un estudio para identificar las causas y las posibles soluciones para hacer frente los problemas relacionados con el diagnóstico de estas patologías. Tras un análisis preliminar, se identificaron 11 áreas de mejora relacionadas con cuatro aspectos diferenciados del proceso asistencial: coordinación y protocolos, equipamientos, formación y concienciación sobre las patologías y experiencia del paciente. De todas ellas, se priorizó resolver aquellas relacionadas con la generación de protocolos de abordaje integral de las patologías y que contemplen todas las especialidades y niveles asistenciales implicados. Otro aspecto crucial es el incremento del grado de sospecha clínica de estas patologías. (AU)

Polymyalgia rheumatica and giant cell arteritis can be a medical emergency in which a delay in correct diagnosis and therapeutic management can cause serious complications. With the aim of improving the care of patients with these pathologies in the Community of Madrid, a study was designed to identify the causes and possible solutions to address the problems related to the diagnosis of these pathologies. After the analysis, 11 areas of improvement related to four different aspects of the care process were identified: coordination and protocols, equipment, training and awareness of pathologies, and patient experience. Of all the areas identified, it was considered a priority to resolve those related to the generation of protocols for the comprehensive management of the pathologies, which include all the specialties and levels of care involved. Another crucial aspect is the increase in the degree of clinical suspicion of these pathologies. (AU)

Executive summary on the optimization of the multidisciplinary and integrated approach to polymyalgia rheumatica and giant cell arteritis in Madrid region.

Polymyalgia rheumatica and giant cell arteritis can be a medical emergency in which a delay in correct diagnosis and therapeutic management can cause serious complications. With the aim of improving the care of patients with these pathologies in the Community of Madrid, a study was designed to identify the causes and possible solutions to address the problems related to the diagnosis of these pathologies. After the analysis, 11 areas of improvement related to four different aspects of the care process were identified: coordination and protocols, equipment, training and awareness of pathologies, and patient experience. Of all the areas identified, it was considered a priority to resolve those related to the generation of protocols for the comprehensive management of the pathologies, which include all the specialties and levels of care involved. Another crucial aspect is the increase in the degree of clinical suspicion of these pathologies.

The Direct Referral to Endovascular Center criteria: a proposal for pre-hospital evaluation of acute stroke in the Madrid Stroke Network.

BACKGROUND AND PURPOSE: For patients with acute ischaemic stroke due to large-vessel occlusion, it has recently been shown that mechanical thrombectomy (MT) with stent retrievers is better than medical treatment alone. However, few hospitals can provide MT 24 h/day 365 days/year, and it remains unclear whether selected patients with acute stroke should be directly transferred to the nearest MT-providing hospital to prevent treatment delays. Clinical scales such as Rapid Arterial Occlusion Evaluation (RACE) have been developed to predict large-vessel occlusion at a pre-hospital level, but their predictive value for MT is low. We propose new criteria to identify patients eligible for MT, with higher accuracy. METHODS: The Direct Referral to Endovascular Center criteria were defined based on a retrospective cohort of 317 patients admitted to a stroke center. The association of age, sex, RACE scale score and blood pressure with the likelihood of receiving MT were analyzed. Cut-off points with the highest association were thereafter evaluated in a prospective cohort of 153 patients from nine stroke units comprising the Madrid Stroke Network. RESULTS: Patients with a RACE scale score ≥ 5, systolic blood pressure <190 mmHg and age <81 years showed a significantly higher probability of undergoing MT (odds ratio, 33.38; 95% confidence interval, 12-92.9). This outcome was confirmed in the prospective cohort, with 68% sensitivity, 84% specificity, 42% positive and 94% negative predictive values for MT, ruling out 83% of hemorrhagic strokes. CONCLUSIONS: The Direct Referral to Endovascular Center criteria could be useful for identifying patients suitable for MT.

Reliability of the minimum basic dataset for diagnoses of cerebrovascular disease. / Fiabilidad del conjunto mínimo básico de datos en el diagnóstico de la enfermedad cerebrovascular.

INTRODUCTION: The minimum basic dataset is the largest available hospital care administrative database that is used in clinical studies and hospital management in association with diagnosis-related groups (DRGs). In 2011, the quality of the national MBDS in hospital discharges was audited, in order to assess its reliability. This paper presents a sub-analysis of the results from that analysis which are referred to cerebrovascular disease (CVD). METHODS: Using all discharge reports from the Spanish MBDS in 2009, a representative sample was obtained by stratified sampling and 11 209 records were evaluated. Outcome indicators were obtained to measure any differences observed between the national MBDS being evaluated and the hospital's original MBDS. Analysis of codes for CVD as a primary diagnosis was performed for ICD-9-CM diagnostic categories 430 through 438. We evaluated error rates in the selection and classification of main diagnoses, as well as in DRG assignment. RESULTS: There were 397 discharges of cases of CVD which included 21 different DRGs. Diagnostic coding showed a concordance rate of 81.87%; the selection error rate was 2.26% and the classification error rate was 15.87%. The error rate in the DRG was 16.12% and associated with the greatest impact on the mortality risk level. CONCLUSIONS: While the errors we observed must be taken into account, data suggest that the quality of the MBDS for CVD is sufficient to ensure delivery of valid information. The hospital discharge registry serves as a valuable tool for use in studies of this disease.

The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis mimicking an acute stroke.

BACKGROUND AND PURPOSE: The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) can present as sudden onset of focal neurological deficits which are clinically and radiologically indistinguishable from an ischaemic stroke. Its diagnosis requires a lumbar puncture (LP), which contraindicates intravenous thrombolytic therapy (IV-tPA). METHODS: All patients referred to our stroke centre as a stroke code resulting in a final diagnosis of HaNDL syndrome from June 2005 to June 2015 were retrospectively analysed. RESULTS: Nine cases were identified: seven women and two men (mean age 27.6 years, range 15-51). Clinical onset consisted of isolated aphasia (two) and aphasia with right hemiparesis/hemiparaesthesia (seven). All patients had headache in the acute setting, lasting 2-12 h. Cranial computed tomography (CT) and CT angiography (CTA) were normal in all patients. Perfusion CT was performed in seven patients, showing left hemispheric focal hypoperfusion in five cases; the remaining two were normal. Five patients were initially diagnosed as stroke and treated uneventfully with IV-tPA. Cranial magnetic resonance imaging within 48 h was normal in all cases. LP performed in all patients showed pleocytosis (range 17-351 cells/mm(3) ), high protein levels (range 0.4-1.6 g/l) and normal glucose levels. All cases recovered within 12 h and suffered a second episode within 72 h. Patients were asymptomatic between episodes and after remission. CONCLUSIONS: The decision to thrombolyse or perform an LP in HaNDL patients mimicking a stroke is difficult in the acute setting. Perfusion CT can provide misleading results and CTA may be useful in ruling out occlusion of a cerebral vessel.

Afectación del sistema nervioso central en la infección invasiva por Streptococcus agalactiae en adultos / Central nervous system involvement in adult patients with invasive infection caused by Streptococcus agalactiae

Introducción: El Streptococcus agalactiae (S. agalactiae) es un germen frecuentemente colonizador asintomático y causante de sepsis neonatal y puerperal. Las infecciones en adultos, fuera del embarazo, son poco frecuentes. No se conoce la frecuencia de complicaciones neurológicas en adultos con infección invasiva por este microorganismo. Hemos estudiado la frecuencia y las características de la afectación del sistema nervioso central (SNC) en pacientes adultos con infección invasiva por S. agalactiae. Pacientes y métodos: Se revisó a todos los pacientes adultos con infección invasiva por S. agalactiae en un hospital terciario entre 2003 y 2011. Resultados: En 75 pacientes se aisló S. agalactiae en sangre, líquido cefalorraquídeo o líquido articular. De ellos, 7 (9,3%) tuvieron afectación neurológica: 5 hombres y 2 mujeres no embarazadas, con edades entre 20 y 62 años. Los diagnósticos fueron: absceso epidural secundario a espondilodiscitis con compresión medular, meningitis bacteriana aguda, ictus isquémico como presentación de endocarditis bacteriana (2 pacientes cada uno) y meningoventriculitis tras neurocirugía y derivación ventricular. Un paciente con endocarditis por S. agalactiae y S. aureus falleció en la fase aguda y otra a los 3 meses por neoplasia metastásica. El resto se recuperó sin secuelas. En todos los casos, hubo factores predisponentes sistémicos para la infección y 5 (71,4%) tenían rotura de barrera mucocutánea como posible origen de la infección. Conclusiones: La afectación del SNC es relativamente frecuente en pacientes adultos con infección invasiva por S. agalactiae. El aislamiento de S. agalactiae debe hacer investigar causas predisponentes sistémicas y causas de rotura de barrera mucocutánea, sobre todo en meningitis

Introduction: Streptococcus agalactiae is frequently an asymptomatic coloniser and a cause of neonatal and puerperal sepsis. Infections in nonpregnant adults are uncommon. The frequency of neurological complications caused by invasive infection with this microorganism in adults remains unknown. Here, we study the frequency and characteristics of central nervous system (CNS) involvement in adults with invasive S. agalactiae infection. Patients and methods: Review of all adults with invasive S. agalactiae infection between 2003 and 2011 in a tertiary hospital. Results: S. agalactiae was isolated from blood, CSF or synovial fluid in 75 patients. Among them, 7 (9,3%) displayed neurological involvement: 5 men and 2 nonpregnant women, aged between 20 and 62 years. Diagnoses were spinal epidural abscess due to spondylodiscitis with spinal cord compression; acute bacterial meningitis; ischemic stroke as presentation of bacterial endocarditis (2 patients each); and meningoventriculitis after neurosurgery and ventricular shunting. One patient with endocarditis caused by S. agalactiae and S. aureus died in the acute phase, and another died 3 months later from metastatic cancer. The other patients recovered without sequelae. All patients had systemic predisposing factors for infection and 5 (71,4%) had experienced disruption of the mucocutaneous barrier as a possible origin of the infection. Conclusions: CNS involvement is not uncommon in adult patients with invasive infection caused by S. agalactiae. Isolating S. agalactiae, especially in cases of meningitis, should lead doctors to search for predisposing systemic disease and causes of mucocutaneous barrier disruption

Central nervous system involvement in adult patients with invasive infection caused by Streptococcus agalactiae.

INTRODUCTION: Streptococcus agalactiae is frequently an asymptomatic coloniser and a cause of neonatal and puerperal sepsis. Infections in nonpregnant adults are uncommon. The frequency of neurological complications caused by invasive infection with this microorganism in adults remains unknown. Here, we study the frequency and characteristics of central nervous system (CNS) involvement in adults with invasive S. agalactiae infection. PATIENTS AND METHODS: Review of all adults with invasive S. agalactiae infection between 2003 and 2011 in a tertiary hospital. RESULTS: S. agalactiae was isolated from blood, CSF or synovial fluid in 75 patients. Among them, 7 (9,3%) displayed neurological involvement: 5 men and 2 nonpregnant women, aged between 20 and 62 years. Diagnoses were spinal epidural abscess due to spondylodiscitis with spinal cord compression; acute bacterial meningitis; ischemic stroke as presentation of bacterial endocarditis (2 patients each); and meningoventriculitis after neurosurgery and ventricular shunting. One patient with endocarditis caused by S. agalactiae and S. aureus died in the acute phase, and another died 3 months later from metastatic cancer. The other patients recovered without sequelae. All patients had systemic predisposing factors for infection and 5 (71,4%) had experienced disruption of the mucocutaneous barrier as a possible origin of the infection. CONCLUSIONS: CNS involvement is not uncommon in adult patients with invasive infection caused by S. agalactiae. Isolating S. agalactiae, especially in cases of meningitis, should lead doctors to search for predisposing systemic disease and causes of mucocutaneous barrier disruption.

[Stroke mimics: a challenge for the emergency physician]. / Imitadores del ictus: un reto para el médico de urgencias.

BACKGROUND: To study the number of patients diagnosed with a stroke in the emergency service of a first level hospital and the proportion of these patients who were finally stroke mimics, as well as to describe and analyze the variables that can help in differential diagnosis in hospital emergency services. METHOD: Nine month prospective study. All patients evaluated in emergency services and admitted with a diagnosis of stroke were included. Different clinical variables were analyzed that included prior history, history of the current event, general physical and neurological examination, NIHSS classification and Oxfordshire Community Stroke Project Classification. The final diagnosis was made by a panel of experts with access to clinical characteristics, image studies and other tests. The univariate and multivariate analysis determined the characteristics that help in distinguishing strokes from stroke mimics. RESULTS: One hundred and forty-four cases of stroke were registered; the final sample was made up of 140 patients. The final diagnosis was stroke in 103 out of 140 (73.6%) and stroke mimic in the rest. Eleven variables predicted the diagnosis in patients with a suspected stroke: age over 70 years (p=0.012), NIHSS classification > 5, reaching a clinical classification (p=0.019) capable of determining the exact start (p=0.000), abnormal vascular findings (p=0.014), gaze deviation (p=0.042), sight loss (p=0.052) and extensor plantar response (p=0.025) favored diagnosis of stroke, while epileptic seizures (p=0.029), neurological symptoms not congruent with the vascular territory (p=0.022) and abnormal findings in other systems (p=0.14) favored diagnosis of stroke mimic. CONCLUSION: Stroke mimics constitute one-third of the patients admitted from emergency services as strokes, with a highly varied etiology. Achieving a suitable clinical history and a precise physical examination is of great importance and can help less experienced doctors.

Imitadores del ictus: un reto para el médico de urgencias / Stroke mimics: a challenge for the emergency physician

Fundamento: Estudiar el número de pacientes diagnosticados de ictus en el servicio de urgencias hospitalario de un hospital de primer nivel y la proporción de estos pacientes que finalmente eran pseudoictus, así como describir y analizar las variables que pueden ayudar en el diagnóstico diferencial en los servicios de urgencias hospitalarios. Método: Estudio prospectivo de 9 meses. Se incluyeron todos los pacientes valorados en el servicio de Urgencias e ingresados con el diagnóstico de ictus. Se analizaron diversas variables clínicas que incluían la historia previa, la historia del evento actual, el examen físico general y neurológico y la clasificación del NIHSS y de la Oxforshire Community Stroke. El diagnóstico final se realizó por un panel de expertos con acceso a las características clínicas, estudios de imagen y otras pruebas. El análisis univariante y multivariado determinó las características que ayudan a distinguir los ictus de los pseudoictus. Resultados: Se registraron 144 casos de ictus; la muestra final la conformó 140 pacientes. El diagnóstico final fue de ictus en 103 de 140 (73,6%) y de pseudoictus en el resto. Once variables predecían el diagnóstico en pacientes que se presentaban con sospecha de ictus: la edad superior a 70 años (p=0,012), una clasificación del NIHSS > 5, lograr una clasificación clínica (p=0,019) capaz de determinar el comienzo exacto (p=0,000), hallazgos vasculares anormales (p=0,014), desviación de la mirada (p=0.042), pérdida de la visión (p=0,052) y reflejo plantar extensor (p=0,025) favorecían el diagnóstico de ictus, mientras que las crisis comiciales (p=0,029), los síntomas neurológicos no congruentes con el territorio vascular (p=0,022) y los hallazgos anormales en otros sistemas (p=0,14) favorecían el diagnostico de pseudoictus. Conclusión: Los pseudoictus constituyeron un tercio de los pacientes ingresados desde el servicio de Urgencias como ictus siendo la etiología muy variada. Lograr una historia clínica adecuada y un examen físico preciso es de gran importancia y puede ayudar a facultativos menos experimentados (AU)

Background: To study the number of patients diagnosed with a stroke in the emergency service of a first level hospital and the proportion of these patients who were finally stroke mimics, as well as to describe and analyze the variables that can help in differential diagnosis in hospital emergency services. Method: Nine month prospective study. All patients evaluated in emergency services and admitted with a diagnosis of stroke were included. Different clinical variables were analyzed that included prior history, history of the current event, general physical and neurological examination, NIHSS classification and Oxford shire Community Stroke Project Classification. The final diagnosis was made by a panel of experts with access to clinical characteristics, image studies and other tests. The univariate and multivariate analysis determined the characteristics that help in distinguishing strokes from stroke mimics. Results: One hundred and forty-four cases of stroke were registered; the final sample was made up of 140 patients. The final diagnosis was stroke in 103 out of 140 (73.6%) and stroke mimic in the rest. Eleven variables predicted the diagnosis in patients with a suspected stroke: age over 70 years (p=0.012),NIHSS classification > 5, reaching a clinical classification (p=0.019) capable of determining the exact start (p=0.000), abnormal vascular findings (p=0.014), gaze deviation (p=0.042), sight loss (p=0.052) and extensor plantar response (p=0.025) favored diagnosis of stroke, while epileptic seizures (p=0.029), neurological symptoms not congruent with the vascular territory (p=0.022) and abnormal findings in other systems (p=0.14) favored diagnosis of stroke mimic. Conclusion: Stroke mimics constitute one-third of the patients admitted from emergency services as strokes, with a highly varied etiology. Achieving a suitable clinical history and a precise physical examination is of great importance and can help less experienced doctors (AU)

Off-label intravenous thrombolysis in acute stroke.

BACKGROUND AND PURPOSE: Therapy for stroke with intravenous tissue plasminogen activator (IV-tPA) is hampered by tight licensing restrictions; some of them have been discussed in recent literature. We assessed the safety and effectiveness of off-label IV-tPA in the clinical settings. METHODS: Retrospective analysis of all the patients treated with IV-tPA at our Stroke Unit. Patients were divided into two groups by licence criteria [on-label group (OnLG), off-label group (OffLG)]. Primary outcome measures were symptomatic intracranial haemorrhages (sICH), major systemic haemorrhages, modified Rankin scale (mRS) and mortality rate at 3months. RESULTS: Five hundred and five patients were registered, 269 (53.2%) were assigned to OnLG and 236 (46.9%) to OffLG. Inclusion criteria for the OffLG were aged >80 years (129 patients), time from onset of symptoms to treatment over 3h (111), prior oral anticoagulant treatment with International Normalised Ratio≤1.7 (41), combination of previous stroke and diabetes mellitus (14), surgery or severe trauma within 3months of stroke (13), National Institutes of Health Stroke Scale score over 25 (11), intracranial tumours (5), systemic diseases with risk of bleeding (7) and seizure at the onset of stroke (2). No significant differences were identified between both groups regarding the proportion of sICH (OnLG 2.2% vs. OffLG 1.6%, P=0.78) or the 3-month mortality rate (11.1% vs. 19%: odds ratio (OR), 1.49; 95% CI, 0.86-2.55; P=0.14). Multivariate analysis showed no significant differences in functional independence at 3months between both groups (mRS <3 64.3% vs. 50.4%: OR mRS >2 1.7; 95% CI, 0.96-2.5; P=0.07). CONCLUSION: Intravenous thrombolysis may be safe and efficacious beyond its current label restrictions.

Anastomosis carotidovertebrobasilar persistente: arteria hipoglosa / No disponible

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