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

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

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

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

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

Efectos de un programa autónomo de locomoción refleja adaptado a la recuperación de la mano del paciente neurológico crónico adulto. Estudio piloto pretest-postest / Effects of the autonomous application of an adapted reflex locomotion program on the neurological hand of the chronic adult patient. Pretest–posttest pilot trial

Antecedentes: La recuperación de la función de la mano es uno de los aspectos más complejos para los pacientes que han sufrido las secuelas de un daño neurológico. Objetivo: Evaluar los efectos a corto plazo sobre el miembro superior afectado de la realización autónoma de un ejercicio de locomoción refleja adaptado a la sedestación en el paciente neurológico crónico. Método: Diseño pretest-postest. Participaron 13 pacientes (8 mujeres) con edad media de 47,61 (DE 16,03). Posibilidad de pinza y abducción de hombro mínima de 30°. Se realizaron 3sesiones en 2semanas consecutivas, entrenando al paciente para realizar el ejercicio en su casa sin ayuda. Se valora el efecto de la terapia antes y después de la primera sesión, a las 2semanas y 3meses después. Se midieron la prensión con el test de Sollerman y la velocidad y la función global del brazo afecto con el Box-Block test. Resultados: En la 1.ª sesión en Box-Block pasó de 18,6 a 22,6 cubos (p <0,002). Resultados mantenidos en 2.ª y 3.ª evaluación. En el Sollerman test, pasó de una media de 41,4 a 46,9 puntos (p <0,003) en 1.ª evaluación y 47,15 puntos en 2.ª (p <0,002). A los 3meses se mantienen los efectos (0,005). Conclusiones: La aplicación de un programa de locomoción refleja adaptado a la sedestación en pacientes con secuelas en el miembro superior, ofrece la posibilidad al paciente de autogestionar la terapia aumentando su intensidad. Se mejoran con ello la función y la movilidad del miembro superior a corto plazo. (AU)

Background: The recovery of hand function is one of the most complex aspects for patients who have suffered the sequelae of neurological damage. Objective: To evaluate the short-term effects on the affected upper limb of the autonomous performance of a reflex locomotion exercise adapted to sitting in chronic neurological patients. Method: Pretest–postest design. Thirteen patients (8 women) participated with a mean age of 47.61 (SD 16.03). Possibility of clamping and minimum shoulder abduction of 30°. Three sessions were held in 2consecutive weeks, training the patient to perform the exercise at home without assistance. The effect of the therapy is assessed before and after the first session, at 2weeks and 3months later. Grip was measured with the Sollerman test, and the speed and global function of the affected arm with the Box–Block test. Results: In the 1st session in Box–Block it went from 18.6 to 22.6 cubes (P<.002). Results maintained in 2nd and 3rd evaluation. In the Sollerman test, it went from an average of 41.4–46.9 pts. (p<.003) in 1st evaluation, and 47.15 pts. in 2nd (P<0.002). After 3months the effects are maintained (.005). Conclusions: The application of a reflex locomotion program adapted to sitting in patients with sequelae in the upper limb, offers the patient the possibility of self-managing therapy by increasing its intensity. This improves the function and mobility of the upper limb in the short term. (AU)

Current-limiting and ultrafast system for the characterization of resistive random access memories.

A new system for the ultrafast characterization of resistive switching phenomenon is developed to acquire the current during the Set and Reset process in a microsecond time scale. A new electronic circuit has been developed as a part of the main setup system, which is capable of (i) applying a hardware current limit ranging from nanoampers up to miliampers and (ii) converting the Set and Reset exponential gate current range into an equivalent linear voltage. The complete system setup allows measuring with a microsecond resolution. Some examples demonstrate that, with the developed setup, an in-depth analysis of resistive switching phenomenon and random telegraph noise can be made.

Corea secundaria a encefalitis estriatal por anticuerpos CV2/CRMP5. Descripción de un caso y revisión de la literatura / Chorea secondary to striatal encephalitis due to anti-CV2/CRMP5 antibodies. Case description and review of the literature

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[Clinical and therapeutic differences in neuro-ophthalmological involvement secondary to syphilis]. / Diferencias clinicas y terapeuticas de la afectacion neurooftalmologica secundaria a sifilis.

INTRODUCTION. There are many forms of neuro-ophthalmological involvement secondary to syphilis, and not all of them are well known. Our aim is to determine the clinical and therapeutic differences in these patients. CASE REPORTS. Our sample included eight patients diagnosed with an ocular and neuro-ophthalmological disorder due to syphilis over the years 2012 and 2013. Five of them presented uveitis, pan-eveitis being the most frequent, with three cases. Two cases presented papilloedema and another displayed retrobulbar optic neuropathy. A total of 62.5% were diagnosed with neurosyphilis, the presence of which was related with compromise of the optic nerve (p = 0.035). None of them gave positive for VDRL in cerebrospinal fluid and they were diagnosed by the presence of FTA antibodies together with high protein levels in cerebrospinal fluid, lymphocytic pleocytosis or intrathecal synthesis of antibodies. In the absence of uveitis, diagnosis was delayed by a mean time of 2.6 months (p = 0.047). All the patients, except one who required a vitrectomy, progressed favourably with intravenous antibiotic therapy. CONCLUSIONS. In cases of neuro-ophthalmological compromise, whether inflammatory or non-inflammatory, the physician must bear syphilis in mind as a potential causation in order to avoid delays in the diagnosis, since early well-tailored treatment can prevent permanent loss of sight.

TITLE: Diferencias clinicas y terapeuticas de la afectacion neurooftalmologica secundaria a sifilis.Introduccion. Existen multiples formas de afectacion neurooftalmologica secundaria a sifilis, no siempre bien conocidas. Nuestro objetivo es conocer las diferencias clinicas y de tratamiento en estos pacientes. Casos clinicos. Se incluyeron ocho pacientes diagnosticados de afectacion ocular y neurooftalmologica por sifilis durante los años 2012 y 2013. Cinco presentaron uveitis, siendo la panuveitis la forma mas frecuente, con tres casos. Dos casos presentaron papiledema, y otro, neuropatia optica retrobulbar. Un 62,5% fue diagnosticado de neurosifilis, cuya presencia se relaciono con la afectacion del nervio optico (p = 0,035). Ninguno de ellos presento positividad para VDRL en el liquido cefalorraquideo, y se diagnosticaron por la presencia de anticuerpos FTA junto con hiperproteinorraquia, pleocitosis linfocitaria o sintesis intratecal de anticuerpos. En ausencia de uveitis, se produjo un retraso diagnostico medio de 2,6 meses (p = 0,047). Todos los pacientes, salvo uno que preciso vitrectomia, evolucionaron favorablemente con antibioterapia intravenosa. Conclusiones. En casos de afectacion neurooftalmologica, inflamatoria y no inflamatoria, el clinico debe tener en cuenta la sifilis como potencial etiologia para evitar un retraso diagnostico, puesto que un adecuado tratamiento precoz puede evitar una perdida de vision permanente.

Incidencia y factores predictivos del delírium en pacientes neurológicos hospitalizados / Incidence and predictive factors of delirium in hospitalised neurological patients

Introducción: El delírium es una afección con una prevalencia elevada entre los pacientes ingresados (10-30%), con importantes implicaciones pronósticas. Existen pocos estudios prospectivos de incidencia en España y la mayoría se han realizado en plantas quirúrgicas o en unidades de cuidados intensivos. Nuestro objetivo es conocer su incidencia en una planta de neurología y describir las características de estos pacientes. Métodos: Se ha realizado un estudio longitudinal descriptivo, incluyendo a todos los pacientes ingresados en la planta de neurología durante 8 semanas, realizándose la escala CAM para el diagnóstico de delírium el primero, segundo y quinto días de ingreso y recogiéndose de cada paciente datos demográficos, antecedentes patológicos, analíticos (incluyendo marcadores inflamatorios), toma de fármacos anticolinérgicos, situación cognitiva y funcional al ingreso, causa de ingreso, tiempo de estancia y eventos durante la misma. Resultados: Se estudió a 115 pacientes con una incidencia de delírium del 16,52%. Se observó una relación significativa con la edad, la situación cognitiva al ingreso valorada por el test de Pfeiffer, la situación funcional al ingreso medida por la escala Canadiense, la insuficiencia renal, los antecedentes de ACV, la toma de fármacos con actividad anticolinérgica, VSG y PCR. Se observó, además, una mayor estancia media en estos pacientes. Conclusiones: Estos resultados confirman una alta incidencia de esta afección en nuestro medio y, aunque son necesarios más estudios, con muestras mayores, destacamos la importancia de unos factores de riesgo que podrían contribuir a una detección precoz de pacientes en riesgo de desarrollar delírium durante el ingreso, permitiendo actividades preventivas y un tratamiento precoz de estos pacientes (AU)

Intruduction: Delirium is a condition with a high prevalence in hospitalised patients (10%-30%), and it has important prognostic implications. There are few prospective studies of the incidence of delirium in Spain, and most of these were carried out in surgical wards or intensive care units. Our objective is to calculate the incidence of delirium in a neurological department and describe characteristics of affected patients. Methods: Longitudinal descriptive study including all patients admitted to the neurology department in an 8-week period. The CAM score for diagnosing delirium was recorded on the first, second and fifth day of hospitalisation and we recorded demographic data, medical history, analytical data (including inflammatory markers), use of anticholinergic treatments, cognitive and functional state at admission, reason for admission, length of stay, and other events during hospitalisation. Results: We studied 115 patients and found an incidence of delirium of 16.52%. There was a significant correlation between delirium and age, cognitive state at admission according to the Pfeiffer test, functional situation at admission according to the Canadian Neurological Scale, kidney failure, history of stroke, anticholinergic treatment, erythrocyte sedimentation rate, and C-reactive protein. These patients were also hospitalised for longer periods of time. Conclusions: These results confirm a high incidence of delirium in our geographical area. Although additional studies with larger samples are needed, we would like to emphasise the importance of several risk factors which may enable early detection of patients who are at risk for developing delirium during hospitalisation. This would permit preventive action and early treatment for these patients (AU)

Incidence and predictive factors of delirium in hospitalised neurological patients.

INTRODUCTION: Delirium is a condition with a high prevalence in hospitalised patients (10%-30%), and it has important prognostic implications. There are few prospective studies of the incidence of delirium in Spain, and most of these were carried out in surgical wards or intensive care units. Our objective is to calculate the incidence of delirium in a neurological department and describe characteristics of affected patients. METHODS: Longitudinal descriptive study including all patients admitted to the neurology department in an 8-week period. The CAM score for diagnosing delirium was recorded on the first, second and fifth day of hospitalisation and we recorded demographic data, medical history, analytical data (including inflammatory markers), use of anticholinergic treatments, cognitive and functional state at admission, reason for admission, length of stay, and other events during hospitalisation. RESULTS: We studied 115 patients and found an incidence of delirium of 16.52%. There was a significant correlation between delirium and age, cognitive state at admission according to the Pfeiffer test, functional situation at admission according to the Canadian Neurological Scale, kidney failure, history of stroke, anticholinergic treatment, erythrocyte sedimentation rate, and C-reactive protein. These patients were also hospitalised for longer periods of time. CONCLUSIONS: These results confirm a high incidence of delirium in our geographical area. Although additional studies with larger samples are needed, we would like to emphasise the importance of several risk factors which may enable early detection of patients who are at risk for developing delirium during hospitalisation. This would permit preventive action and early treatment for these patients.

Evolución atípica del hemangioma hepático: a propósito de dos casos / Atypical evolution of liver hemangioma: a report of two cases

Presentamos e ilustramos dos casos de evolución atípica de hemangiomas hepáticos estudiados con resonancia magnética (RM). En el primer caso, la lesión disminuyó progresivamente de tamaño hasta llegar a la remisión completa y se asoció a una retracción capsular. En el segundo caso, en una paciente que tomaba anticonceptivos orales, la lesión presentó un crecimiento progresivo llegando a doblar su diámetro (AU)

We present and illustrate two cases of atypical evolution of liver hemangiomas studied with magnetic resonance imaging. In the first case, the lesion was associated with capsular retraction and became progressively smaller until it completely disappeared. The second case involved a woman taking birth control pills in whom the lesion grew progressively larger, doubling its diameter (AU)

[Atypical evolution of liver hemangioma: a report of two cases]. / Evolución atípica del hemangioma hepático: a propósito de dos casos.

We present and illustrate two cases of atypical evolution of liver hemangiomas studied with magnetic resonance imaging. In the first case, the lesion was associated with capsular retraction and became progressively smaller until it completely disappeared. The second case involved a woman taking birth control pills in whom the lesion grew progressively larger, doubling its diameter.

Absceso cerebral por Mycobacterium tuberculosis / Brain abscess due to Mycobacterium tuberculosis

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[Shattered kidney in a patient with asymptomatic chronic hydronephrosis. Case report and literature review]. / Estallido renal en paciente con hidronefrosis crónica asintomática. A propósito de un caso y revisión de la literatura.

The incidence of renal anomalies in patients who suffer a renal trauma is around 4.4 and 19%. We introduce a case of a patient whose first sign of a chronic hydronefrosis was a renal burst secondary to an abdominal trauma.

Estallido renal en paciente con hidronefrosis crónica asintomática. A propósito de un caso y revisión de la literatura / Shattered kidney in a patient with asimptomatic chronic hydronephrosis. Case report and literature review

Se estima que la presencia de anomalías renales en pacientes que sufren un traumatismo renal oscila entre el 4,4 y el 19%. Presentamos un caso de un paciente cuya primera manifestación de una hidronefrosis crónica fue un estallido renal secundario a un traumatismo abdominal

The incidence of renal anomalies in patients who suffer a renal trauma is around 4.4 and 19%. We introduce a case of a patient whose first sign of a chronic hydronefrosis was a renal burst secondary to an abdominal trauma

[Sexual dysfunction management in multiple sclerosis]. / Abordaje de la disfunción sexual en la esclerosis múltiple.

INTRODUCTION: Sexual dysfunction is a frequent disorder associated to multiple sclerosis, that contributes to the worsening of life quality of these patients. AIM: To ascertain how it is managed in a demyelinating disease unit. PATIENTS AND METHODS: It was done an anonymous poll to multiple sclerosis patients in a demyelinating disease unit. The following variables were analysed: age, sex, marital status, education degree, sexual dysfunction, vesical dysfunction, gait disturbances and duration of illness. RESULTS: 67 of 97 patients answered. 74.6% females. Average age was 43.7 years. Average developing time was 11.3 years. 58% of the patients had vesical dysfunction. 43% had sexual dysfunction. There was relation with statistical significance between sexual and vesical dysfunction but not among the rest of variables. 63% of the patients with sexual dysfunction had never talked about this problem with their doctors. That the patient talked about sexual dysfunction was related with the fact that the neurologist asked for or not, and if sexual dysfunction was an important problem for the patient. The neurologist had asked for dysfunction sexual symptoms to 30% of the patients, and this was more frequent if the patient was male and if he or she had gait disturbances. CONCLUSIONS: Sexual dysfunction is a frequent and important problem for patients with multiple sclerosis. According to our results, this problem is raised up in an insufficient manner as much for patients as for neurologists.

Abordaje de la disfunción sexual en la esclerosis múltiple / Sexual dysfunction management in multiple sclerosis

Introducción. La disfunción sexual es un trastorno frecuente asociado a la esclerosis múltiple (EM) y contribuye al empeoramiento de la calidad de vida de estos pacientes. Objetivo. Valorar cómo se aborda este tema en una unidad de enfermedades desmielinizantes. Pacientes y métodos. Encuesta de respuesta anónima a pacientes con EM de una unidad de enfermedades desmielinizantes. Variables analizadas: edad, sexo, estado civil, nivel de escolarización, disfunción sexual, disfunción vesical, trastornos de la marcha y tiempo de evolución. Análisis bivariante y regresión logística. Resultados. Respondieron 67 de 97 pacientes. El 74,6% eran mujeres. Edad media: 43,7 años. Tiempo medio de evolución: 11,3 años. El 58% tenía disfunción vesical. La disfunción sexual estaba presente en el 43% de los pacientes. Observamos relación estadísticamente significativa entre la disfunción sexual y la disfunción vesical, pero no con el resto de las variables analizadas. El 63% de los pacientes con disfunción sexual no había comentado nunca este problema con el neurólogo. Las variables que se relacionan de forma independiente con que el paciente hable con el especialista de disfunción sexual son que se le interrogue a este respecto y que sea un problema importante en relación con su enfermedad. El neurólogo había preguntado por síntomas de disfunción sexual al 30% de los pacientes y el hecho de preguntar se relacionó con que el paciente fuera varón y con que tuviera trastornos en la marcha. Conclusión. La disfunción sexual es un problema frecuente e importante para los pacientes con EM. Según nuestros resultados, se aborda de manera insuficiente

Introduction. Sexual dysfunction is a frequent disorder associated to multiple sclerosis, that contributes to the worsening of life quality of these patients. Aim. To ascertain how it is managed in a demyelinating disease unit. Patients and methods. It was done an anonymous poll to multiple sclerosis patients in a demyelinating disease unit. The following variables were analysed: age, sex, marital status, education degree, sexual dysfunction, vesical dysfunction, gait disturbances and duration of illness. Results. 67 of 97 patients answered. 74.6% females. Average age was 43.7 years. Average developing time was 11.3 years. 58% of the patients had vesical dysfunction. 43% had sexual dysfunction. There was relation with statistical significance between sexual and vesical dysfunction but not among the rest of variables. 63% of the patients with sexual dysfunction had never talked about this problem with their doctors. That the patient talked about sexual dysfunction was related with the fact that the neurologist asked for or not, and if sexual dysfunction was an important problem for the patient. The neurologist had asked for dysfunction sexual symptoms to 30% of the patients, and this was more frequent if the patient was male and if he or she had gait disturbances. Conclusions. Sexual dysfunction is a frequent and important problem for patients with multiple sclerosis. According to our results, this problem is raised up in an insufficient manner as much for patients as for neurologists

Congenital endplate acetylcholinesterase deficiency responsive to ephedrine.

The authors describe two patients with congenital myasthenic syndrome (CMS) with end plate acetylcholinesterase (AChE) deficiency caused by mutations in the collagenic tail (ColQ) of AChE: a homozygous C-terminal Y230S mutation in Patient 1 and Y430S and a C-terminal splice-site mutation in Patient 2. In Patient 1, a Prostigmin (neostigmine bromide) test failed to distinguish between AChE deficiency and a slow-channel CMS. Both patients responded dramatically to ephedrine therapy.

[Prostate cancer in the Community of Madrid in the year 2000. III. Study of tumor extent]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. III--Estudio de extensión tumoral.

OBJECTIVE: To identify a potential relationship between two variables, risk of metastasis and use of imaging techniques, in an extension study in prostate cancer patients diagnosed in the Autonomous Community of Madrid in 2000. MATERIAL AND METHODS: 1,127 patients with available data on the tumour extension study were analysed. Performance and non performance of bone scans and CTs were correlated to risk variables for developing metastasis as described in the literature (PSA, Gleason and stage) and to therapy administered. RESULTS: The proportion of patients with risk variables for metastasis when bone scans were performed was between 7% to 14% greater than in patients with no variables. No differences were seen for CTs based on risk variables. With matching risk variables, more imaging techniques were used in patients receiving radiotherapy that in those managed with prostatectomy. CONCLUSION: Based on current recommendations imaging techniques were used in excess in the extension study in patients with no risk variables for metastasis. Conduct of a further study in the Autonomous Community seems advisable to confirm the likelihood of implementing such recommendations considering our prevalence of metastatic disease.