InterMiG: international differences in the therapeutic approach to migraine patients in specialized headache centers

Antidepressiu; Migranya; Tractament preventiuAntidepresivo; Migraña; Tratamiento preventivoAntidepressant; Migraine; Preventive treatmentBackground There is currently a wide therapeutic arsenal for migraine patients, without a single first-line preventive drug and we choose the different available alternatives taking into account comorbidities, national guidelines, previous treatments and personal experiences. Our objective was to evaluate the differences in the use of migraine treatments between neurologists from different countries. Methods This is a multi-centre observational study carried out by neurologists from specialized headache units in seven countries, retrospective with consecutive inclusion of all patients presenting with a migraine diagnosis, over a period of three months. Results A total of 734 patients were recruited but only 600 were considered in the analysis in order to homogenize the patient cohorts from countries: 200 Spain (ES), 100 Italy (IT), 85 Russia (RUS), 80 Germany (DE), 60 Portugal (PT), 45 Poland (PL) and 30 Australia (AU). 85.4 % of patients were women with a mean age of 42.6 ± 11.8 years. Considering previous and current preventive treatment, the order of use was: antidepressants (69.3 %), antiepileptic drugs (54.7 %), beta-blockers and antihypertensive drugs (49.7 %), OnabotulinumtoxinA (44.0 %) and others (36.2 %). Statistically significant differences were found between all pharmacological classes: antidepressants were commonly used in all countries, with the exception of Poland (AU: 76.7 %, IT: 71.0 %, DE: 60.0 %, PL: 31.1 %, PT: 71.7 %, RUS: 70.6 %, ES: 78.5 %; p < 0.0001); antiepileptic drugs were more frequently prescribed in Portugal, Australia and Spain (AU: 73.3 %, IT: 40.0 %, DE: 37.5 %, PL: 48.9 %, PT: 85.0 %, RUS: 29.4 % and ES: 69.0 %; p < 0.0001); beta-blockers and antihypertensive drugs were frequently used in all countries except Italy (AU: 60.0 %, IT: 14.0 %, DE: 53.8 %, PL: 48.9 %, PT: 68.3 %, RUS: 49.4 % and ES: 59.0 %; p < 0.0001); BTX-A were predominately used in Spain, Italy and Australia (AU:56.7 %, IT:58.0 %, DE:20.0 %, PL: 42.2 %, PT: 26.7 %, RUS: 24.7 % and ES: 58.5 %; p < 0.0001) and others were most frequently used in Poland (AU: 0.0 %, IT: 19.0 %, DE: 42.5 %, PL: 95.6 %, PT: 31.7 %, RUS: 3.5 % and ES: 49.5 %; p < 0.0001). If only patients without comorbidities are considered (200/600), statistically differences between countries persist in all preventive treatments. Conclusions There is heterogeneity in the choice of preventive treatment between different countries. Prospective comparative studies of the different oral and subcutaneous alternatives would help to create a global therapeutic algorithm that would guarantee the best option for our patients.This work did not receive any funds

Evaluation of the Impact of the COVID-19 Lockdown in the Clinical Course of Migraine

Objective: Previous studies have demonstrated that emotional stress, changes in lifestyle habits and infections can worsen the clinical course of migraine. We hypothesize that changes in habits and medical care during coronavirus disease 2019 (COVID-19) lockdown might have worsened the clinical course of migraine. Design: Retrospective survey study collecting online responses from migraine patients followed-up by neurologists at three tertiary hospitals between June and July 2020. Methods: We used a web-based survey that included demographic data, clinical variables related with any headache (frequency) and migraine (subjective worsening, frequency, and intensity), lockdown, and symptoms of post-traumatic stress. Results: The response rate of the survey was 239/324 (73.8%). The final analysis included 222 subjects. Among them, 201/222 (90.5%) were women, aged 42.5 ± 12.0 (mean±SD). Subjective improvement of migraine during lockdown was reported in 31/222 participants (14.0%), while worsening in 105/222 (47.3%) and was associated with changes in migraine triggers such as stress related to going outdoors and intake of specific foods or drinks. Intensity of attacks increased in 67/222 patients (30.2%), and it was associated with the subjective worsening, female sex, recent insomnia, and use of acute medication during a headache. An increase in monthly days with any headache was observed in 105/222 patients (47.3%) and was related to symptoms of post-traumatic stress, older age and living with five or more people. Conclusions: Approximately half the migraine patients reported worsening of their usual pain during the lockdown. Worse clinical course in migraine patients was related to changes in triggers and the emotional impact of the lockdown. © 2021 The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine

Usefulness of multiparametric computerized tomography findings in the differential diagnosis of stroke mimics of epileptic origin: A preliminary study

Objetivo: Tras la activación del código ictus, hasta un 30% de los pacientes presentan cuadros imitadores del ictus, siendo la epilepsia el más frecuente. Evaluamos la utilidad de la TC cerebral multiparamétrica para la diferenciación de los déficit de origen comicial versus vascular. Material y métodos: Estudio observacional retrospectivo con recogida prospectiva de datos. Se revisan imágenes de TC multiparamétrica de pacientes atendidos como código ictus durante un año que finalmente fueron diagnosticados de etiología comicial. Resultados: N = 11 (varones 36%, edad media 74,5 a˜nos). Tres pacientes presentaban focalidad neurológica derecha, 4 focalidad izquierda y 4 afasia aislada. El tiempo máximo desde el inicio de la clínica hasta la realización de la TC multiparamétrica fue de 8,16 h. La TC perfusión fue normal en 2 pacientes. Nueve pacientes mostraron alargamiento/acortamiento del tiempo al pico (Tmáx), siendo los mapas de flujo y volumen variables. El electroencefalograma se realizó con un tiempo máximo de evolución desde el inicio de la clínica de 47,6 h. Cuatro registros mostraron hallazgos compatibles con estatus epiléptico, 2 actividad epileptiforme focal y los 5 restantes lentificación poscrítica ipsolateral a las anomalías de la TC perfusión. Conclusión: El alargamiento del tiempo al pico en una distribución cortical multilobar en ausencia de oclusión de gran vaso y con respeto de ganglios de la base ha resultado el parámetro más sensible para la diferenciación de estas entidades en nuestra serie. Consideramos que la TC cerebral multiparamétrica es una herramienta rápida, disponible y útil para el diagnóstico diferencial de síntomas neurológicos deficitarios de inicio brusco debidos a etiología comicial que son atendidos como código ictus.Objective: Thirty percent of the patients for whom code stroke is activated have stroke mimics, the most common being epilepsy. Our purpose was to evaluate the usefulness of multiparametric CT for differentiating between seizure-related symptoms and vascular events. Material and methods: We conducted a retrospective observational study; data were gathered prospectively during one year. We studied multiparametric CT images of patients admitted following code stroke activation and finally diagnosed with epilepsy. Results: The study included a total of 11 patients; 36% were men and mean age was 74.5 years. Three patients had right hemisphere syndrome, 4 displayed left hemisphere syndrome, and the remaining 4 had isolated aphasia. Maximum time from symptom onset to multiparametric CT study was 8.16 hours. Perfusion CT results were normal in 2 patients. Nine patients showed longer or shorter times to peak (Tmax); cerebral blood volume (CBV) and cerebral blood flow (CBF) maps varied. EEG was performed a maximum of 47.6 hours after symptom onset. Four patients showed findings compatible with status epilepticus, 2 displayed focal epileptiform activity, and 5 showed post-ictal slowing ipsilateral to perfusion CT abnormalities. Conclusion: The most sensitive parameter for differentiating between stroke and epilepsy in our series was increased time to peak in multilobar cortical locations in the absence of largevessel occlusion and basal ganglia involvement. Multiparametric CT is a fast, readily available, and useful tool for the differential diagnosis of acute-onset neurological signs of epileptic originin patients initially attended after code stroke activatio

Cómo y cuándo derivar un paciente con cefalea secundaria y otros tipos de dolores craneofaciales desde Urgencias y Atención Primaria: recomendaciones del Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología

Introducción: Cuando se sospecha que estamos ante una cefalea secundaria y se deriva un paciente a Urgencias o a la consulta de Neurología es importante saber qué exploraciones complementarias son oportunas hacer en cada caso, además de saber posteriormente cuál es el circuito adecuado que ha de seguir el paciente. Por este motivo, el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología (GECSEN) ha decidido crear unas recomendaciones consensuadas que establezcan un protocolo de derivación de pacientes con cefalea y/o neuralgias craneofaciales. Desarrollo: Se ha contactado con neurólogos jóvenes con interés y experiencia en cefalea y con la Junta Directiva del GECSEN han desarrollado este documento que, por razones prácticas, se ha dividido en 2 artículos. El primero centrado en las cefaleas primarias y neuralgias craneofaciales, y este centrado en las cefaleas secundarias y otros dolores craneofaciales. El enfoque es práctico, con tablas que resumen los criterios de derivación con exploraciones complementarias y otros especialistas a los que derivar, para que sea útil y facilite su uso en nuestra práctica asistencial diaria. Conclusiones: Esperamos ofrecer una guía y herramientas para mejorar la toma de decisiones ante un paciente con cefalea valorando exploraciones a priorizar y que circuitos seguir para así evitarla duplicación de consultas y retrasos en el diagnóstico y en el tratamiento

Headache: What to ask, how to examine, and which scales to use. Recommendationsof the Spanish Society of Neurology’s Headache Study Group

Introducción: La cefalea es el motivo de consulta neurológico más prevalente en los distintos niveles asistenciales, donde la anamnesis y exploración son primordiales para realizar un diagnóstico y tratamiento adecuados. Con la intención de unificar la atención de esta patología, el Grupo de Estudio de Cefalea de la Sociedad Española de Neurología (GECSEN) ha decidido elaborar unas recomendaciones consensuadas para mejorar y garantizar una adecuada asistencia en atención primaria, urgencias y neurología. Metodología: El documento es práctico, sigue el orden de la dinámica de actuación durante una consulta: anamnesis, escalas que cuantifican el impacto y la discapacidad y exploración. Además, finaliza con pautas para realizar un seguimiento adecuado y un manejo de las expectativas del paciente con el tratamiento pautado.Conclusiones: Esperamos ofrecer una herramienta que mejore la atención al paciente con cefalea para garantizar una asistencia adecuada y homogénea a nivel nacional.Introduction: Headache is the most common neurological complaint at the different levelsof the healthcare system, and clinical history and physical examination are essential in thediagnosis and treatment of these patients. With the objective of unifying the care given topatients with headache, the Spanish Society of Neurology’s Headache Study Group (GECSEN)has decided to establish a series of consensus recommendations to improve and guaranteeadequate care in primary care, emergency services, and neurology departments.Methods: With the aim of creating a practical document, the recommendations follow thedynamics of a medical consultation: clinical history, physical examination, and scales quantif-ying headache impact and disability. In addition, we provide recommendations for follow-upand managing patients’ expectations of the treatment.Conclusions: With this tool, we aim to improve the care given to patients with headache inorder to guarantee adequate, homogeneous care across Spain

BRIVA-LIFE–A multicenter retrospective study of the long-term use of brivaracetam in clinical practice

Objectives: Evaluate long-term effectiveness and tolerability of brivaracetam in clinical practice in patients with focal epilepsy. Materials and Methods: This was a multicenter retrospective study. Patients aged =16 years were started on brivaracetam from November 2016 to June 2017 and followed over 1 year. Data were obtained from medical records at 3, 6 and 12 months after treatment initiation for evaluation of safety- and seizure-related outcomes. Results: A total of 575 patients were included in analyses; most had been treated with =4 lifetime antiepileptic drugs. Target dosage was achieved by 30.6% of patients on the first day. Analysis of primary variables at 12 months revealed that mean reduction in seizure frequency was 36.0%, 39.7% of patients were =50% responders and 17.5% were seizure-free. Seizure-freedom was achieved by 37.5% of patients aged =65 years. Incidence of adverse events (AEs) and psychiatric AEs (PAEs) was 39.8% and 14.3%, respectively, and discontinuation due to these was 8.9% and 3.7%, respectively. Somnolence, irritability, and dizziness were the most frequently reported AEs. At baseline, 228 (39.7%) patients were being treated with levetiracetam; most switched to brivaracetam (dose ratio 1:10-15). Among those who switched because of PAEs (n = 53), 9 (17%) reported PAEs on brivaracetam, and 3 (5.7%) discontinued because of PAEs. Tolerability was not highly affected among patients with learning disability or psychiatric comorbidity. Conclusions: In a large population of patients with predominantly drug-resistant epilepsy, brivaracetam was effective and well-tolerated; no unexpected AEs occurred over 1 year, and the incidence of PAEs was lower compared with levetiracetam

Guidance on Monitoring of Marine Litter in European Seas

This publication is a Reference Report by the Joint Research Centre of the European Commission.The MSFD Technical Subgroup on Marine Litter was tasked to deliver guidance so that European Member States could initiate programmes for monitoring of Descriptor 10 of the MSFD. The present document provides the recommendations and information needed to commence the monitoring required for marine litter, including methodological protocols and categories of items to be used for the assessment of litter on the Beach, Water Column, Seafloor and Biota, including a special section on Microparticles

Cómo y cuándo derivar un paciente con cefalea secundaria y otros tipos de dolores craneofaciales desde Urgencias y Atención Primaria: recomendaciones del Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología

Introducción: . Cuando se sospecha que estamos ante una cefalea secundaria y se deriva un paciente a Urgencias o a la consulta de Neurología es importante saber qué exploraciones complementarias son oportunas hacer en cada caso, además de saber posteriormente cuál es el circuito adecuado que ha de seguir el paciente.Por este motivo, el Grupo de Estudio de Cefaleas de la Sociedad Espanola ˜ de Neurología (GECSEN) ha decidido crear unas recomendaciones consensuadas que establezcan un protocolo de derivación de pacientes con cefalea y/o neuralgias craneofaciales. Desarrollo: Se ha contactado con neurólogos jóvenes con interés y experiencia en cefalea y con la Junta Directiva del GECSEN han desarrollado este documento que, por razones prácticas, se ha dividido en 2 artículos. El primero centrado en las cefaleas primarias y neuralgias craneofaciales, y este centrado en las cefaleas secundarias y otros dolores craneofaciales. El enfoque es práctico, con tablas que resumen los criterios de derivación con exploraciones complementarias y otros especialistas a los que derivar, para que sea útil y facilite su uso en nuestra práctica asistencial diaria. Conclusiones: Esperamos ofrecer una guía y herramientas para mejorar la toma de decisiones ante un paciente con cefalea valorando exploraciones a priorizar y que circuitos seguir para así evitarla duplicación de consultas y retrasos en el diagnóstico y en el tratamiento. © 2017 Publicado por Elsevier Espana, ˜ S.L.U. en nombre de Sociedad Espanola ˜ de Neurolog´ıa. Este es un art´ıculo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/ licenses/by-nc-nd/4.0/)

CGRP en migraña: de la fisiopatología a la terapéutica

Introducción En los últimos años se ha observado que moléculas como el péptido relacionado con el gen de la calcitonina (CGRP) y, en menor grado, el péptido activador de la adenilato-ciclasa pituitaria estaban elevadas durante los ataques de migraña y en la migraña crónica tanto en líquido cefalorraquídeo como en suero y que su reducción farmacológica tenía una significación clínica con una mejoría en la migraña de los pacientes. Es lógico por tanto que una de las principales líneas de investigación en migraña se base en el papel del CGRP en la fisiopatología de esta entidad. Desarrollo Desde el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología nos planteamos la redacción de este documento, cuyo objetivo es abordar, basándonos en la evidencia publicada, cuestiones tan importantes como el papel del CGRP en la fisiopatología de la migraña, el mecanismo de acción de los anticuerpos monoclonales y de los gepantes, el análisis crítico de los resultados de los diferentes estudios, el perfil del paciente que podría ser candidato al tratamiento con anticuerpos monoclonales y su impacto en términos de farmacoeconomía. Conclusiones El desarrollo clínico de los gepantes, antagonistas del CGRP, para el tratamiento agudo del ataque de migraña y de los anticuerpos monoclonales contra ligando y contra el receptor del CGRP ofrecen resultados esperanzadores para nuestros pacientes. Introduction It has been observed in recent years that levels of such molecules as calcitonin gene–related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase–activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients’ migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity. Development The Spanish Society of Neurology''s Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics. Conclusions The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p&lt;0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p&lt;0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised