Headache related to personal protective equipment in healthcare workers during COVID-19 pandemic in Mexico: baseline and 6-month follow-up.

BACKGROUND AND AIM: Headaches related to the use of personal protective equipment (PPE) could affect performance at work in healthcare personnel. Our aim was to describe the prevalence and risk factors for headaches related to PPE, in the personnel of a specialized coronavirus disease 2019 (COVID-19) tertiary hospital. METHODS: In this cross-sectional survey study, we invited healthcare workers from COVID-19 referral center in Mexico (May 22-June 19, 2020) to answer a standardized structure questionnaire on characteristics of new-onset PPE-related headache or exacerbation of primary headache disorder. Participants were invited regardless of whether they had a current headache to avoid selection bias. This is the primary analysis of these data. RESULTS: Two hundred and sixty-eight subjects were analyzed, 181/268 (67.5%) women, 177/268 (66%) nurses, mean age 28 years. The prevalence of PPE-related headache was 210/268 (78.4%). Independent risk factors were occupation other than physician (OR 1.59, 95% CI 1.20-2.10), age > 30 years (OR 2.54, 95% CI 1.25-5.14), and female sex (OR 3.58, 95% CI 1.86-6.87). In the 6-month follow-up, 13.1% of subjects evolve to chronic headache, with stress as predictive risk factor. CONCLUSION: The frequency of PPE-associated headache is high, and a subgroup could evolve to chronic headache. More studies are necessary to improve the knowledge about this condition.

COVID-19-related diffuse posthypoxic leukoencephalopathy and microbleeds masquerades as acute necrotizing encephalopathy.

BACKGROUND: The complications of coronavirus disease 2019 (COVID-19), the clinical entity caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), are not limited to the respiratory system. Leukoencephalopathy with microbleeds is increasingly seen in patients with COVID-19. New information is needed to delineate better the clinical implications of this infectious disease. CASE REPORT: A 46-year-old man with confirmed SARS-CoV-2 infection was admitted to the intensive care unit (ICU) with severe COVID-19. After transfer to the general wards, the patient was noted drowsy, disorientated, with slow thinking and speech. A brain MRI showed bilateral symmetrical hyperintense lesions in the deep and subcortical whiter matter, involving the splenium of the corpus callosum, as well as multiple microhemorrhages implicating the splenium and subcortical white matter. No contrast-enhanced lesions were observed in brain CT or MRI. CSF analysis showed no abnormalities, including a negative rtRT-PCR for SARS-CoV-2. An outpatient follow-up visit showed near-complete clinical recovery and resolution of the hyperintense lesions on MRI, without microbleeds change. CONCLUSION: We present the case of a survivor of severe COVID-19 who presented diffuse posthypoxic leukoencephalopathy, and microbleeds masquerading as acute necrotizing encephalopathy. We postulate that this kind of cerebral vasogenic edema with microbleeds could be the consequence of hypoxia, inflammation, the prothrombotic state and medical interventions such as mechanical ventilation and anticoagulation.

[Myasthenia gravis in adults of institutions pertaining to the Mexican public health system: an analysis of hospital discharges during 2010]. / Miastenia gravis (MG) en adultos de instituciones pertenecientes al sistema público sanitario mexicano: un análisis de egresos hospitalarios durante el año 2010.

INTRODUCTION: Epidemiological studies on myasthenia gravis (MG) in Mexico is mainly derived from experiences in referral centers. OBJECTIVE: To describe the epidemiological characteristics of hospital discharges during 2010 with the diagnosis of MG in adults hospitalized in the Mexican public health system. METHODS: We consulted the database of hospital discharges during 2010 of the National Health Information System (Ministry of Health, IMSS, IMSS oportunidades, ISSSTE, PEMEX, and the Ministry of Defense). The MG records were identified by the code G70.0 of the International Classification of Diseases 10th revision. RESULTS: During 2010 there were 5,314,132 hospital discharges (4,254,312 adults). Among them, 587 (0.01%) were adults with MG (median age: 47 years, 60% women). Women with MG were significantly younger than men (median age: 37 vs. 54 years, respectively; p < 0.001). The median hospital stay was six days. The case fatality rate was 3.4%, without gender differences. Age was associated with the probability of death. CONCLUSIONS: We confirmed the bimodal age-gender distribution in MG. The in-hospital case fatality rate in Mexico is consistent with recent reports around the world.

Neurologic manifestations in hospitalized patients with COVID-19 in Mexico City.

BACKGROUND: The coronavirus disease 2019 (COVID-19) is a systemic entity that frequently implies neurologic features at presentation and complications during the disease course. We aimed to describe the characteristics and predictors for developing in-hospital neurologic manifestations in a large cohort of hospitalized patients with COVID-19 in Mexico City. METHODS: We analyzed records from consecutive adult patients hospitalized from March 15 to June 30, 2020, with moderate to severe COVID-19 confirmed by reverse transcription real-time polymerase chain reaction (rtRT-PCR) for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Neurologic syndromes were actively searched by a standardized structured questionnaire and physical examination, confirmed by neuroimaging, neurophysiology of laboratory analyses, as applicable. RESULTS: We studied 1,072 cases (65% men, mean age 53.2±13 years), 71 patients had pre-existing neurologic diseases (diabetic neuropathy: 17, epilepsy: 15, history of ischemic stroke: eight, migraine: six, multiple sclerosis: one, Parkinson disease: one), and 163 (15.2%) developed a new neurologic complication. Headache (41.7%), myalgia (38.5%), dysgeusia (8%), and anosmia (7%) were the most common neurologic symptoms at hospital presentation. Delirium (13.1%), objective limb weakness (5.1%), and delayed recovery of mental status after sedation withdrawal (2.5%), were the most common new neurologic syndromes. Age, headache at presentation, preexisting neurologic disease, invasive mechanical ventilation, and neutrophil/lymphocyte ratio ≥9 were independent predictors of new in-hospital neurologic complications. CONCLUSIONS: Even after excluding initial clinical features and pre-existing comorbidities, new neurologic complications in hospitalized patients with COVID-19 are frequent and can be predicted from clinical information at hospital admission.

Bilateral Forearm Transplantation in Mexico: 2-Year Outcomes.

BACKGROUND: Patients with proximal forearm and arm transplantation have obtained and/or maintained function of the elbow joint and full active range of motion of the extrinsic muscles of the hand, but with diminished protective sensibility and a lack of good function of the intrinsic muscles. These patients have improved function, as measured by the Disabilities of the Arm, Shoulder and Hand questionnaire. METHODS: We report the case of a 52-year-old man who suffered a high-voltage electrical burn requiring amputation of his upper limbs. He underwent bilateral proximal forearm transplantation in Mexico City in May 2012. RESULTS: At 2-year follow-up, immunosuppressive treatment has not led to metabolic, oncologic, or infectious complications. Keloid scars developed at the graft-recipient interface. There have been 4 acute rejections: the fourth was treated with methylprednisolone, rituximab, and immunoglobulin. Chronic rejection has not been detected. The extrinsic muscles of the wrist and digits have good function. Although the intrinsic muscles demonstrated electrical activity 15 months postoperatively, clinically, they are nonuseful. After 2 years, hand function is sufficient to allow the patient to grasp lightweight and medium-sized objects. The patient's Disabilities of the Arm, Shoulder and Hand questionnaire score improved from 50.00 points to 30.83 points, and his Hand Transplantation Score System rating is good, at 69/73 (right/left) of 100. The patient and his family are very satisfied with the functional and aesthetic outcomes. CONCLUSIONS: Upper arm or proximal forearm transplantation is a reconstructive option for patients who have experienced amputation because of trauma.

Multidrug resistance-1 (MDR-1) in autoimmune disorders IV. P-glycoprotein overfunction in lymphocytes from myasthenia gravis patients.

Multidrug resistance (MDR) mechanisms have been widely studied in cancer. Among them, P-glycoprotein (P-gp) overfunction has been associated with resistance to several antineoplastic agents. The physiological role of P-gp involves hormone and metabolite secretion, bacterial product detoxification, and transport of several drugs to the extracellular space, thus inhibiting their toxic or therapeutic effects. The study of MDR-1 in diseases of autoimmune origin has just recently emerged. Corticosteroids remain the mainstay therapy for autoimmune diseases. As prednisone (PDN) is transported by P-gp, the aim of this study was to evaluate the P-gp function in lymphocytes from myasthenia gravis (MG) patients. Thirty MG patients and 25 healthy controls were studied. Peripheral blood mononuclear cells were isolated by gradient centrifugation and incubated with daunorubicin (DNR) (a fluorescent drug extruded by P-gp). Functional activity of P-gp was analyzed by flow cytometry. Results were expressed as percentage of gated lymphocytes able to efflux DNR. Overall, MG patients showed increased numbers of lymphocytes with functional P-gp activity when compared with controls (x = 4.92 +/- 5.26% vs. x = 0.7 +/- 0.48%, respectively) (P < 0.0001). When patients were classified as responders (n = 21) or refractory (n = 9) to treatment, the latter group exhibited higher values of functional P-gp (x = 10.18 +/- 6.39%) when compared to the responder group (x = 2.66 +/- 2.45%) (P = 0.0076). These data suggest, on the one hand, that drug resistance may be induced by long-term treatment or by high PDN doses and, on the other, emphasize the need for the study of P-gp antagonists in order to improve the current therapeutical schemes for the treatment of MG.

Nuevos tratamientos contra la migraña / New treatments against migraine

Resumen: La migraña es una enfermedad con alta prevalencia y discapacitante que afecta a población económicamente activa, por lo que representa un problema de salud pública. En la actualidad la gran mayoría de pacientes aptos para recibir tratamiento preventivo no lo reciben, ya sea por desconocimiento del médico o por la complejidad o efectos adversos de los tratamientos disponibles. Existen nuevos fármacos que actúan en la vía del péptido relacionado con el gen de la calcitonina (gepantes y anticuerpos monoclonales) y en el agonismo selectivo del receptor 1F de serotonina, que han mostrado efectividad clínica con pocos efectos adversos. Su eficacia, sin embargo, pudiera no ser mayor a la de los fármacos ya conocidos. Al momento se han aprobado tres anticuerpos monoclonales (erenumab, galcanezumab y fremanezumab) y se cuenta con estudios de fase III de otros grupos farmacológicos, por lo anterior, es importante actualizar los conocimientos de estos nuevos focos terapéuticos y del mecanismo de acción de estos nuevos tratamientos que pronto estarán disponibles.

Abstract: Migraine is a disease with high prevalence and disability that affects the economically active population, so it represents a public health problem. Nowadays, the vast majority of patients who are candidates for preventive treatment do not receive it, either due to lack of knowledge of the physician or because of the complexity and/or adverse effects of the available treatments. There are new drugs that act in the calcitonin generelated peptide pathway (gepants and monoclonal antibodies) and in the selective agonism of the serotonin 1F receptor, which have shown clinical effectiveness with few adverse effects. Its efficacy, however, may not be greater than that of the drugs already known. At the moment three monoclonal antibodies have been approved (erenumab, galcanezumab and fremanezumab) and there are studies of phase III of other pharmacological groups. Therefore, it is important to update the knowledge associated with these new therapeutic focuses and the mechanism of action of these new treatments that will be available soon.

Importancia del manejo de la hipertensión endocraneana en meningitis criptocócica en pacientes con síndrome de inmunodeficiencia adquirida. Informe de dos casos / Importance of management of elevated intracranial pressure associated with cryptococcal meningitis in patients with acquired immunodeficiency syndrome. A report of two cases

Se presentan dos casos de criptococosis meníngea e hipertensión endocraneana severa en pacientes con infección por virus de inmunodeficiencia humana (VIH). La hipertensión endocraneana se presentó al momento del diagnóstico y persistió a pesar del tratamiento antifúngico adecuado (anfotericina B, 5-fluocitosina inicialmente y después fluconazol). La presencia de hipertensión endocraneana y aracnoiditis es capaz de condicionar cefalea intensa, crisis convulsivas y alteraciones visuales y auditivas. En la tomografía axial computarizada no había dilatación ventricular, ni lesiones focales. Ambos casos se manejaron, además de anfotericina B y fluconazol, con punciones lumbares repetidas y colocación de válvula lumboperitoneal derivativa (VLP) en vista de persistencia de la hipertensión endocraneana. En un paciente hubo pérdida de visión por atrofia del nervio óptico en un ojo. Después de un año de seguimiento, uno de los pacientes falleció por progresión de su enfermedad; el otro continúa vivo, sin evidencia de enfermedad neurológica. La hipertensión endocraneana es una manifestación frecuente de meningitis criptocócica en pacientes con síndrome de inmunodeficiencia adquirida (SIDA) que requiere manejo diagnóstico y tratamiento apropiados. La hipertensión endocraneana en pacientes con SIDA y meningitis criptocócica debe tratarse con medidas encaminadas a reducir la presión intracraneal, las cuales incluyen punciones lumbares repetidas y, en algunos casos, sistemas de derivación como válvula lumboperitoneal o válvula ventrículo-peritoneal

Un caso de enfermedad de Hallervorden-Spatz con hallazgos de resonancia magnética / Case report of Hallervorden-Spatz disease with magnetic resonance findings

La enfermedad de Hallervorden y Spatz (EHS) es una entidad rara, progresiva y degenerativa de los ganglios basales que inicia en la primera o segunda décadas de la vida. Se caracteriza por signos extrapiramidales y demencia progresiva. Se transmite de forma autosómica recesiva, aunque 15 por ciento de los casos son esporádicos. No existe por el momento un marcador biológico para hacer el diagnóstico antemortem. El hallazgo postmórtem incluye depósitos de hierro en el globo pálido y zona reticulada de la sustancia negra. La imagen por resonancia magnética (IRM) en T2 muestra lesiones simétricas e hipointensas en el globo pálido con un centro hiperintenso dando lugar al signo del ojo de tigre. Se reporta el primer caso de un paciente mexicano con EHS esporádico, con cuadro clínico y hallazgos de IRM característicos

Horizontal appendicular dysmetria in four patients with a typical wallenbergïs syndrome / Dismetría apendicular horizontal en cuatro pacientes con síndrome de Wellenberg típica

Durante la fase aguda del síndrome de Wallenberg aparece dismetría apendicular ipsilateral. La dismetría es mayor en la extremidad superior. Estos pacientes tienen también una forma especial de dismetría ocular que se caracteriza por movimientos sacádicos hipermétricos hacia el lado de la lesión e hipométricos hacia el lado opuesto. Examinamos cuatro pacientes con síndrome de Wallenberg en la fase aguda y encontramos dismetría horizontal de la extremidad correspondiente. Los movimientos hipermétricos de la mano y el brazo estuvieron presentes hacia el lado de la lesión y la hipometría estuvo presente hacia el lado opuesto. Este tipo de dismetría está relacionado probablemente al mismo mecanismo patofisiológico que subyace a los movimientos ocular dismétricos en el síndrome de Wallenberg. La dismetría tiende a desaparecer con el tiempo aunque continúa presente.

El otro genoma: El concepto clínico de las citopatías mitocondriales o enfermedades de la fosforilación oxidativa / The other genome: clinical spectrum of mitochondrial cytopathies or oxidative phosphorylation diseases

El estudio de las anormalidades del DNA mitocondrial y de su relaicón con trastornos a nivel de la fosforilación oxidativa y cadena de transporte de electrones ha permitido la descripción de una gama de síndromes denominados enfermedades o citopatías mitocondriales. El objetivo del presente trabajo es hacer una revisión de los aspectos clínicos más relevantes de este diverso grupo de enfermedades, y proponer un algoritmo diagnóstico, con la finalidad de que los médicos que atienden a estos pacientes puedan considerarlas dentro del espectro de diagnósticos diferenciales en los casos pertinentes

Hiperventilación central neurogénica en infarto pontino / Central neurogenic hyperventilación associated to a unilateral basal pontine infraction

La hiperventilación central neurogénica en pacientes con preservación del estado de alerta es una entidad rara que sucede como manifestación de lesiones tegmentarias pontinas bilaterales, especialmente neoplasias como linfomas del SNC y gliomas, así como lesiones traumáticas. Los mecanismos fisiopatológicos no se conocen y no existe un tratamiento eficaz para esta entidad. Reportamos un caso de hiperventilación central asociada a un infarto basal pontino unilateral.