The costs of stroke in Spain by aetiology: the CONOCES study protocol.

INTRODUCTION: Patients with stroke associated with non-valvular atrial fibrillation (NVAF) are a specific group, and their disease has a considerable social and economic impact. The primary objective of the CONOCES study, the protocol of which is presented here, is to compare the costs of stroke in NVAF patients to those of patients without NVAF in Spanish stroke units from a societal perspective. MATERIALS AND METHODS: CONOCES is an epidemiological, observational, naturalistic, prospective, multicentre study of the cost of the illness in a sample of patients who have suffered a stroke and were admitted to a Spanish stroke unit. During a 12-month follow-up period, we record sociodemographic and clinical variables, score on the NIH stroke scale, level of disability, degree of functional dependency according to the modified Rankin scale, and use of healthcare resources (hospitalisation at the time of the first episode, readmissions, outpatient rehabilitation, orthotic and/or prosthetic material, medication for secondary prevention, medical check-ups, nursing care and formal social care services). Estimated monthly income, lost work productivity and health-related quality of life measured with the generic EQ-5D questionnaire are also recorded. We also administer a direct interview to the caregiver to determine loss of productivity, informal care, and caregiver burden. RESULTS AND CONCLUSIONS: The CONOCES study will provide more in-depth information about the economic and clinical impact of stroke according to whether or not it is associated with NVAF.

[Application of a clinical pathway for the treatment of transient ischaemic attacks: implementation strategies and appraisal at two years]. / Aplicación de una vía clínica para el tratamiento del accidente isquémico transitorio: estrategias de implantación y evaluación a los dos años.

INTRODUCTION: Management of cerebral vascular pathologies by means of clinical pathways allows us to make cost effective use of resources, to enhance health care quality and to obtain a greater degree of satisfaction in patients. AIMS: To assess the efficiency of applying a clinical pathway designed for the treatment of transient ischemic attacks (TIA) by monitoring a series of indicators that enable us to detect existing problems, to introduce any corrections that are needed and to draw conclusions that can be useful in the future. PATIENTS AND METHODS: To this end, a clinical pathway was drawn up with the general agreement of the members of our service and the different professionals involved in caring for these patients. Analyses were performed to study the data from 1998 to 2001, prior to implementation of the pathway, and from 2002 and 2003, which were the first years in which it was being applied. Altogether 1,433 patients with a diagnosis of TIA were hospitalised during this period, 554 of whom were admitted during the years 2002 and 2003. RESULTS: Of this group, the pathway was initially applied in 123 cases and 62 completed it. The mean stay in hospital was reduced from 9.2 days in 2000 to 5.7 days in 2003. The mean stay of patients who fulfilled all the requirements of the pathway was only 2.9 days. As far as the survey on satisfaction is concerned, 97% of patients said they were satisfied or very satisfied with the care they had received. CONCLUSIONS: The application of a clinical pathway in the treatment of TIA resulted in a high degree of satisfaction among the patients who were treated and a notable reduction in the mean stay in hospital.

[Sarcoidosis: the presentation of a case with clinical features limited to the nervous system]. / Sarcoidosis: presentación de un caso con clínica restringida al sistema nervioso.

INTRODUCTION: Neurological pathology as the initial form of sarcoidosis is exceptional. Neurosarcoidosis represents 5% of all cases. Central nervous system involvement is more frequent in the acute forms of this illness, whilst myositis and peripheral neuropathy are more common in chronic sarcoidosis. CLINICAL CASE: A 60 year old woman presented with peripheral facial diplegia, diminished visual acuity and bilateral papilloedema, dysarthria and unsteady gait with left lateropulsion and paresia and dysesthesia of the distal parts of the limbs. X-ray and laboratory findings were normal. Gammography with Gallium 67 citrate showed mediastimal adenopathy. Neurographic study was compatible with mixed polyneuropathy and lumbar puncture showed aseptic meningitis. The diagnosis of neurosarcoidosis was confirmed by histopathological study of the skin and sural nerve. DISCUSSION AND CONCLUSIONS: When the presenting features of sarcoidosis are neurological, as in this case, diagnosis is difficult and pathology studies showing the presence of non-caseous granulomas are essential. Biopsy of the sural nerve may be very useful. Although the pathogenesis of sarcoid neuropathology is not completely clear, finding non-caseous granulomas associated with vasculitis in the nerve biopsy indicates that both disease processes may be involved in the peripheral nerve lesion.

[Ischemic stroke and auricular septal aneurysm: six cases]. / Ictus isquémico y aneurisma del septo auricular: estudio de seis casos.

INTRODUCTION: Aneurysms of the atrial septum (AAS) are uncommon. They have been considered to be related to embolic phenomena. They are usually associated with other cardiac anomalies, especially persistence of the formen ovale. PATIENTS AND METHODS: We studied six patients diagnosed during a period of 24 months as having ischemic ictus and AAS. They were investigated for vascular risk factors and possible causes of cardiac embolism by means of ECG, transthoracic and transoesophagic echography (ETE). Cases with the clinical characteristics of embolism were anticoagulated. RESULTS: Five patients were men with an average age of 47.6 years. Three had the clinical features of established ictus, one of RIND and two of AIT. Three patients had vascular risk factors. The TSA study showed pathology of the carotid arteries to be present in three patients. In all six cases the AAS was identified on ETE. There were no thrombi in the atria in any case, and in two there was left-right communication. In four patients the condition was considered to have a cardio-embolic origin. No patient has had further episodes of cerebral ischaemia. DISCUSSION: It seems there is a certain risk of cerebral embolus associated with AAS. The simultaneous presence of alterations in cardiac rhythm together with other structural cardiac pathology seems to have a synergic effect on this. Paradoxical embolism, arrhythmias and intra-aneurysmal thrombi appear to be the mechanisms involved in the appearance of emboli. The best therapeutic approach is still unknown. New studies are therefore necessary to establish whether or not it is necessary to anticoagulate these patients.

[Quality as management tool. Actions to improve efficiency in neurological care]. / La calidad como herramienta de gestión. Actuaciones para mejorar la eficiencia en la atención neurológica.

INTRODUCTION: Quality of care involves meeting the needs and expectations of patients with the lowest consumption of resources and in accordance with scientific knowledge. In this context it is important to know if the changes in medical care procedures based on scientific and technical aspects of the quality positively impacts both efficiency measures and perceived quality. METHODS: Prospective study carried out during the 2000-2006 period at the neurology department of a public hospital with has 1303 beds. Changes in medical care introduced: adequacy of a high resolution hospitalization zone, setting up of three care pathways (transient ischemic attach [TIA], multiple sclerosis exacerbation and first epileptic seizure) and practice guidelines for stroke, and implementation of neurological care at the emergency department. RESULTS: There has been an increase in the number of patients treated in the emergency department of the hospital (17%), although the number of admissions has stabilized. In the neurology department, the number of admissions has decreased by 20%, especially those arising from TIA (decrease by 47%), the average stay has been reduced by 30% (especially in demyelinating and vascular disease, which has fallen by 50%). Adjusted average length of stay has remained below 1 and the complexity index above 1. Satisfaction with the information and health care has undergone little change. CONCLUSIONS: The changes in clinical practice to improve the quality of care have been associated with improvements in the efficiency indicators but not in patient satisfaction. The improvement in the perceived quality probably requires specific actions.

[Wernicke encephalopathy in patients given parenteral nutrition]. / Encefalopatía de Wernicke en pacientes sometidos a nutrición parenteral.

Wernicke's encephalopathy is caused by thiamin deficiency and can be recognized by severe neurological symptoms that are occasionally accompanied by systemic signs. The syndrome is often found in alcoholics, although other causes have also been identified, such as intravenous feeding, in which the main pathogenic mechanisms are the administration of carbohydrates and the low standard dose of vitamin B1--in relation to the increase in metabolic load--delivered in a medium of substances that favor inactivation of the vitamin. We present 3 intravenously fed patients who developed the syndrome, even though in 2 cases they were given thiamin. Only the third patient's history included chronic alcoholism, and this patient also suffered severe cardiac symptoms and amaurosis. We believe that the amount of thiamin provided through parenteral nutrition, as well as the medium in which it is delivered, must be reviewed.

[The evaluation of cognitive deterioration in transient ischemic attacks]. / Valoración del deterioro cognitivo en el accidente isquémico transitorio (AIT).

We compared the degree of dementia in a group of 41 patients who, four years previously, had presented a first TIA with that of 31 healthy controls of similar age. For pathogenic diagnosis the Hachinski and Gustafson-Nilsson scales were applied, while mental state was evaluated by the Folstein, Blessed, GDS and CDR tests. We performed in all cases cerebral CT and several MR. The findings associated with dementia were the presence of multi-infarctions, leucoaraiosis or lacunes in the cerebral CT and the presentation of new ischemic episodes, sphincterian or gait disturbances and focal deficits. There were no differences with the control group in the cases only presenting one TIA. Polyglobulia was the only factor significantly associated with vascular dementia in these patients.

[Neurological disease due to the varicella-zoster virus without a skin lesion]. / Afección neurológica por virus varicela-zoster sin lesión cutánea.

We studied three cases of inflammatory neurological disease and serological evidence of varicella-zoster viral (VZV) infection without cutaneous manifestation. They corresponded to a case of cranial multi-neuritis, a case of aseptic meningitis, and another case of meningoencephalitis. Despite the infrequency of any such association, the spectrum of the neurological diseases associated with VZV without skin lesions is quite wide. We are motivated to present our experience by the belief that it is important to think about this possible etiology based on inflammatory areas at different levels of the Nervous System in patients who are still immunocompetent.

[Thromboangiitis obliterans with cerebral involvement]. / Tromboangeítis obliterante con isquemia cerebral.

We report the case of a male with Buerger's disease and neurologic involvement. Cerebral arteriography showed multiple distal arterial obliterans with left-sided Moya-moya phenomena. Thromboangiitis obliterans is a chronic segmental occlusive disease affecting medium-sized and small arteries and veins throughout the body. Neurologic signs are rare, occurring in fewer than 2 % of cases, and most often found on the cortical surface and adjacent territories. We review the most common signs of this entity and its main diagnostic difficulties.