Headache: pregnancy and breastfeeding. Recommendations of the Spanish Society of Neurology's Headache Study Group

Embarazo; Lactancia; CefaleaPregnancy; Breastfeeding; HeadacheEmbaràs; Lactància; CefaleaIntroducción La cefalea es uno de los motivos de consulta más comunes en neurología, siendo más frecuente durante la edad reproductiva. Por ello, es habitual encontrar en nuestras consultas pacientes embarazadas o en periodo de lactancia con dicha queja. Es importante conocer las opciones farmacológicas más seguras, cuáles no se deben emplear, así como cuándo sospechar cefaleas secundarias. Por este motivo, el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología ha elaborado una guía con las recomendaciones consensuadas acerca de los algoritmos diagnósticos y terapéuticos que se deben emplear durante el embarazo y la lactancia. Desarrollo Esta guía ha sido redactada por un grupo de jóvenes neurólogos con especial interés y experiencia en cefaleas en colaboración con la Junta Directiva del Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología. Las recomendaciones se centran en los fármacos aconsejados en las cefaleas primarias más frecuentes, tanto en su fase aguda como preventiva. En una segunda parte se aborda cuándo sospechar y qué pruebas realizar ante una posible cefalea secundaria durante el embarazo y la lactancia. Conclusiones Esperamos que esta guía resulte de utilidad y permita su aplicación práctica en la consulta diaria. Asimismo, que sirva para actualizar y mejorar el conocimiento del manejo de las cefaleas durante estas etapas, para actuar con mayor confianza ante estas pacientes.Introduction Headache is one of the most common neurological complaints, and is most frequent during reproductive age. As a result, we are routinely faced with pregnant or breastfeeding women with this symptom in clinical practice. It is important to know which pharmacological choices are the safest, which should not be used, and when we should suspect secondary headache. To this end, the Spanish Society of Neurology's Headache Study Grouphas prepared a series of consensus recommendations on the diagnostic and therapeutic algorithms that should be followed during pregnancy and breastfeeding. Development This guide was prepared by a group of young neurologists with special interest and experience in headache, in collaboration with the Group's Executive Committee. Recommendations focus on which drugs should be used for the most frequent primary headaches, both during the acute phase and for prevention. The second part addresses when secondary headache should be suspected and which diagnostic tests should be performed in the event of possible secondary headache during pregnancy and breastfeeding. Conclusions We hope this guide will be practical and useful in daily clinical practice and that it will help update and improve understanding of headache management during pregnancy and breastfeeding, enabling physicians to more confidently treat these patients

Search for dark matter produced in association with a hadronically decaying vector boson in pp collisions at sqrt (s) = 13 TeV with the ATLAS detector

A search is presented for dark matter produced in association with a hadronically decaying W or Z boson using 3.2 fb−1 of pp collisions at View the MathML sources=13 TeV recorded by the ATLAS detector at the Large Hadron Collider. Events with a hadronic jet compatible with a W or Z boson and with large missing transverse momentum are analysed. The data are consistent with the Standard Model predictions and are interpreted in terms of both an effective field theory and a simplified model containing dark matter

Strong floristic distinctiveness across Neotropical successional forests

Forests that regrow naturally on abandoned fields are important for restoring biodiversity and ecosystem services, but can they also preserve the distinct regional tree floras? Using the floristic composition of 1215 early successional forests (≤20 years) in 75 human-modified landscapes across the Neotropic realm, we identified 14 distinct floristic groups, with a between-group dissimilarity of 0.97. Floristic groups were associated with location, bioregions, soil pH, temperature seasonality, and water availability. Hence, there is large continental-scale variation in the species composition of early successional forests, which is mainly associated with biogeographic and environmental factors but not with human disturbance indicators. This floristic distinctiveness is partially driven by regionally restricted species belonging to widespread genera. Early secondary forests contribute therefore to restoring and conserving the distinctiveness of bioregions across the Neotropical realm, and forest restoration initiatives should use local species to assure that these distinct floras are maintained

Intravenous thrombolysis with recombinant tissue plasminogen activator in vascular warning syndromes

Introduction: Vascular warning syndromes constitute a neurological emergency due to their associated high risk of established stroke. At present, there is no strong evidence indicating the best treatment for these patients. The aim of this paper is to describe the function of intravenous rt-PA thrombolysis in the treatment of vascular warning syndromes. Material and methods: We reviewed our hospital records and the literature to find patients with neurologically fluctuating profiles and who underwent intravenous rt-PA thrombolysis. Results: We retrieved 3 cases from our hospital records and 19 from the literature (15 males and 7 females). Mean age was 68.7 ± 9 years (range: 52 to 84 years). The mean number of episodes before treatment was 4 (range: 2 to 15 episodes). The maximum NIH stroke scale (NIHSS) scores ranged from 6 to 22 in different patients. We obtained 24-hour post-treatment NIHSS scores in 8 cases; of these cases, 6 (75%) had a score of 0, and the other 2 (25%) had a score of 12. The modified Rankin Score calculated at 3 months of treatment was 0 or 1 in 18 patients (81.8%); these 18 comprised 8 of the 10 patients with lacunar warning syndromes (80%), 6 of the 7 with basilar warning syndromes (85.7%), and 4 of the 5 with fluctuating non-lacunar, non-basilar warning syndromes (80%). Conclusions: Intravenous rt-PA treatment may constitute an effective and safe therapeutic alternative for patients with neurovascular fluctuations. However, well-designed studies are needed to determine the role of intravenous rt-PA thrombolysis in cases of vascular warning syndrome. Resumen: Introducción: Los síndromes de alarma vascular constituyen una situación de urgencia neurológica, debido a su alto riesgo de ictus establecido. Actualmente no existe evidencia firme sobre cuál debe ser el tratamiento de elección en estos casos. El objetivo de este trabajo es describir el papel de la trombólisis con rTPA intravenosa en el tratamiento de los síndromes de alarma vascular. Material y métodos: Se revisaron los casos propios y los existentes en la literatura en los que se hubiese tratado con rTPA intravenoso a los pacientes con clínica neurológica fluctuante. Resultados: Se obtuvieron 3 casos propios y 19 recogidos de la literatura (15 varones y 7 mujeres). La edad media fue de 68,7 ± 9 años (rango: 52-84 años). La frecuencia media de episodios antes del tratamiento fue de 4 (rango: 2-15 episodios). La puntuación en la escala NIH (NIHSS) máxima estuvo en un rango entre 6-22 según cada caso. Se dispuso de la NIHSS a las 24 h del tratamiento en 8 de los casos: en 6 (75%) fue de 0, y en 2 (25%) de 12. La escala de Rankin modificada (ERm) a los 3 meses del tratamiento fue de 0-1 en 18 (81,8%) de los pacientes: 8/10 (80%) en los síndromes de alarma lacunar, 6/7 (85,7%) en los síndromes de alarma basilar y 4/5 (80%) en pacientes con fluctuaciones que no entraban dentro de estos 2 grupos. Conclusiones: El tratamiento con rTPA intravenoso podría suponer una alternativa terapéutica eficaz y segura en los pacientes con clínica neurovascular fluctuante, aunque se necesitan estudios bien diseñados que establezcan de forma clara cuál es el papel real de la trombólisis intravenosa con rTPA en los síndromes de alarma vascular. Keywords: Thrombolysis, Capsular warning syndrome, Vascular warning syndrome, Basilar warning syndrome, Ischaemic stroke, Acute stroke, Treatment, Palabras clave: Trombólisis, Síndrome de alarma capsular, Síndrome de alarma vascular, Síndrome de alarma basilar, Ictus isquémico, Ictus agudo, Tratamient

Trombólisis intravenosa con activador tisular del plasminógeno recombinante en los síndromes de alarma vascular

Resumen: Introducción: Los síndromes de alarma vascular constituyen una situación de urgencia neurológica, debido a su alto riesgo de ictus establecido. Actualmente no existe evidencia firme sobre cuál debe ser el tratamiento de elección en estos casos. El objetivo de este trabajo es describir el papel de la trombólisis con rTPA intravenosa en el tratamiento de los síndromes de alarma vascular. Material y métodos: Se revisaron los casos propios y los existentes en la literatura en los que se hubiese tratado con rTPA intravenoso a los pacientes con clínica neurológica fluctuante. Resultados: Se obtuvieron 3 casos propios y 19 recogidos de la literatura (15 varones y 7 mujeres). La edad media fue de 68,7 ± 9 años (rango: 52-84 años). La frecuencia media de episodios antes del tratamiento fue de 4 (rango: 2-15 episodios). La puntuación en la escala NIH (NIHSS) máxima estuvo en un rango entre 6-22 según cada caso. Se dispuso de la NIHSS a las 24 h del tratamiento en 8 de los casos: en 6 (75%) fue de 0, y en 2 (25%) de 12. La escala de Rankin modificada (ERm) a los 3 meses del tratamiento fue de 0-1 en 18 (81,8%) de los pacientes: 8/10 (80%) en los síndromes de alarma lacunar, 6/7 (85,7%) en los síndromes de alarma basilar y 4/5 (80%) en pacientes con fluctuaciones que no entraban dentro de estos 2 grupos. Conclusiones: El tratamiento con rTPA intravenoso podría suponer una alternativa terapéutica eficaz y segura en los pacientes con clínica neurovascular fluctuante, aunque se necesitan estudios bien diseñados que establezcan de forma clara cuál es el papel real de la trombólisis intravenosa con rTPA en los síndromes de alarma vascular. Abstract: Introduction: Vascular warning syndromes constitute a neurological emergency due to their associated high risk of established stroke. At present, there is no strong evidence indicating the best treatment for these patients. The aim of this paper is to describe the function of intravenous rt-PA thrombolysis in the treatment of vascular warning syndromes. Material and methods: We reviewed our hospital records and the literature to find patients with neurologically fluctuating profiles and who underwent intravenous rt-PA thrombolysis. Results: We retrieved 3 cases from our hospital records and 19 from the literature (15 males and 7 females). Mean age was 68.7±9 years (range: 52-84 years). The mean number of episodes before treatment was 4 (range: 2-15 episodes). The maximum NIHSS scores ranged from 6 to 22 in different patients. We obtained 24-hour post-treatment NIHSS scores in 8 cases; of these cases, 6 (75%) had a score of 0, and the other 2 (25%) had a score of 12. The Modified Rankin Score calculated at 3 months of treatment was 0 or 1 in 18 patients (81.8%); these 18 comprised 8 of the 10 patients with lacunar warning syndromes (80%), 6 of the 7 with basilar warning syndromes (85.7%), and 4 of the 5 with fluctuating non-lacunar, non-basilar warning syndromes (80%). Conclusions: Intravenous rt-PA treatment may constitute an effective and safe therapeutic alternative for patients with neurovascular fluctuations. However, well-designed studies are needed to determine the role of intravenous rt-PA thrombolysis in cases of vascular warning syndrome. Palabras clave: Trombólisis, Síndrome de alarma capsular, Síndrome de alarma vascular, Síndrome de alarma basilar, Ictus isquémico, Ictus agudo, Tratamiento, Keywords: Thrombolysis, Capsular warning syndrome, Vascular warning syndrome, Basilar warning syndrome, Ischemic stroke, Acute stroke, Treatmen

The MIGREX study: Prevalence and risk factors of sexual dysfunction among migraine patients

Background: Migraine attacks have a high impact on daily activities. There is limited research on the burden of migraine on sexual functioning. Objective: To determine the prevalence of sexual dysfunction in patients with migraine and its relationship with migraine features and comorbidities. Method: This is a cross-sectional study. We included migraine patients between 18 and 60 years-old from 8 Headache Clinics in Spain. We recorded demographic data and migraine features. Patients fulfilled a survey including comorbidities, Arizona Sexual Experiences Scale, Hospital Anxiety and Depression Scale and a questionnaire about migraine impact on sexual activity. A K-nearest neighbor supervised learning algorithm was used to identify differences between migraine patients with and without sexual dysfunction. Results: We included 306 patients (85.6% women, mean age 42.3 ±11.1 years). A 41.8% of participants had sexual dysfunction. Sexual dysfunction was associated with being female (OR [95% CI]: 2.42 [1.17–5.00]; p < 0.001), being older than 46.5 years (4.04 [2.48–6.59]; p < 0.001), having chronic migraine (2.31 [1.41–3.77]; p = 0.001), using preventive medication (2.45 [1.35–4.45]; p = 0.004), analgesic overusing (3.51 [2.03–6.07]; p < 0.001), menopause (4.18 [2.43–7.17]; p < 0.001) and anxiety (2.90 [1.80–4.67]; p < 0.001) and depression (6.14 [3.18–11.83]; p < 0.001). However, only female gender, age, menopause and depression were the statistically significant variables selected in the model to classify migraine patients with or without sexual dysfunction (Accuracy [95% CI]: 0.75 (0.62–0.85), Kappa: 0.48, p = 0.005). Conclusions: Sexual dysfunction is frequent in migraine patients visited in a headache clinic. However, migraine characteristics or use of preventive medication are not directly associated with sexual dysfunction. Instead, risk factors for sexual dysfunction were female gender, higher age, menopause and depression. Resumen: Antecedentes: La migraña tiene un alto impacto en las actividades diarias, pero los datos sobre el impacto de la migraña en el funcionamiento sexual son limitados. Objetivo: Determinar la prevalencia de disfunción sexual en pacientes con migraña y su relación con las características y comorbilidades de la migraña. Métodos: Este es un estudio transversal. Se incluyeron pacientes con migraña de entre 18 y 60 años de ocho consultas de cefalea en España. Registramos datos demográficos y características de migraña. Los pacientes completaron una encuesta que incluía comorbilidades, la Escala de Experiencias Sexuales de Arizona, la Escala de Ansiedad y Depresión Hospitalaria y un cuestionario sobre el impacto de la migraña en la actividad sexual. Se usó un algoritmo de aprendizaje supervisado (k-nearest neighbors) para identificar diferencias entre pacientes con migraña, con y sin disfunción sexual. Resultados: Se incluyeron 306 pacientes (85,6% mujeres, edad media 42,3 ± 11,1 años). El 41,8% de los participantes tenía disfunción sexual. La disfunción sexual se asoció con ser mujer (OR [95%]: 2,42 [1,17-5,00]; p < 0,001), tener más de 46,5 años (4,04 [2,48-6,59]; p < 0,001), tener migraña crónica (2,31 [1,41-3,77]; p = 0,001), uso de medicación preventiva (2,45 [1,35-4.45]; p = 0,004), uso excesivo de analgésicos (3,51 [2,03-6,07]; p < 0,001), menopausia (4,18 [2,43-7,17]; p < 0,001), ansiedad (2,90 [1,80-4,67]; p < 0,001) y depresión (6,14 [3,18-11,83]; p < 0,001). Sin embargo, solo el sexo femenino, la edad, la menopausia y la depresión fueron las variables estadísticamente significativas seleccionadas en el modelo para clasificar a los pacientes con migraña, con o sin disfunción sexual (precisión [IC 95%]: 0,75 (0,62-0,85), kappa: 0,48, p = 0,005). Conclusiones: La disfunción sexual es frecuente en pacientes con migraña que son visitados en una consulta de cefalea. Sin embargo, las características de la migraña o el uso de medicamentos preventivos no están directamente asociados con la disfunción sexual. En cambio, el sexo femenino, mayor edad, menopausia y depresión son los factores de riesgo para la disfunción sexual en este grupo de pacientes

Effectiveness of the combination elvitegravir/cobicistat/tenofovir/emtricitabine (EVG/COB/TFV/FTC) plus darunavir among treatment-experienced patients in clinical practice : A multicentre cohort study

Background: The aim of this study was to investigate the effectiveness and tolerability of the combination elvitegravir/cobicistat/tenofovir/emtricitabine plus darunavir (EVG/COB/TFV/FTC + DRV) in treatment-experienced patients from the cohort of the Spanish HIV/AIDS Research Network (CoRIS). Methods: Treatment-experienced patients starting treatment with EVG/COB/TFV/FTC + DRV during the years 2014-2018 and with more than 24 weeks of follow-up were included. TFV could be administered either as tenofovir disoproxil fumarate or tenofovir alafenamide. We evaluated virological response, defined as viral load (VL) < 50 copies/ml and < 200 copies/ml at 24 and 48 weeks after starting this regimen, stratified by baseline VL (< 50 or ≥ 50 copies/ml at the start of the regimen). Results: We included 39 patients (12.8% women). At baseline, 10 (25.6%) patients had VL < 50 copies/ml and 29 (74.4%) had ≥ 50 copies/ml. Among patients with baseline VL < 50 copies/ml, 85.7% and 80.0% had VL < 50 copies/ml at 24 and 48 weeks, respectively, and 100% had VL < 200 copies/ml at 24 and 48 weeks. Among patients with baseline VL ≥ 50 copies/ml, 42.3% and 40.9% had VL < 50 copies/ml and 69.2% and 68.2% had VL < 200 copies/ml at 24 and 48 weeks. During the first 48 weeks, no patients changed their treatment due to toxicity, and 4 patients (all with baseline VL ≥ 50 copies/ml) changed due to virological failure. Conclusions: EVG/COB/TFV/FTC + DRV was well tolerated and effective in treatment-experienced patients with undetectable viral load as a simplification strategy, allowing once-daily, two-pill regimen with three antiretroviral drug classes. Effectiveness was low in patients with detectable viral loads

Strong floristic distinctiveness across Neotropical successional forests

Forests that regrow naturally on abandoned fields are important for restoring biodiversity and ecosystem services, but can they also preserve the distinct regional tree floras? Using the floristic composition of 1215 early successional forests (≤20 years) in 75 human-modified landscapes across the Neotropic realm, we identified 14 distinct floristic groups, with a between-group dissimilarity of 0.97. Floristic groups were associated with location, bioregions, soil pH, temperature seasonality, and water availability. Hence, there is large continental-scale variation in the species composition of early successional forests, which is mainly associated with biogeographic and environmental factors but not with human disturbance indicators. This floristic distinctiveness is partially driven by regionally restricted species belonging to widespread genera. Early secondary forests contribute therefore to restoring and conserving the distinctiveness of bioregions across the Neotropical realm, and forest restoration initiatives should use local species to assure that these distinct floras are maintained

Multidimensional tropical forest recovery

Tropical forests disappear rapidly because of deforestation, yet they have the potential to regrow naturally on abandoned lands. We analyze how 12 forest attributes recover during secondary succession and how their recovery is interrelated using 77 sites across the tropics. Tropical forests are highly resilient to low-intensity land use; after 20 years, forest attributes attain 78% (33 to 100%) of their old-growth values. Recovery to 90% of old-growth values is fastest for soil (12 decades). Network analysis shows three independent clusters of attribute recovery, related to structure, species diversity, and species composition. Secondary forests should be embraced as a low-cost, natural solution for ecosystem restoration, climate change mitigation, and biodiversity conservation