Afasia como síntoma de presentación de una hepatitis A

Hepatitis A virus (HAV) rarely manifests with neurological alterations. There are some reported cases of Guillain-Barré syndrome, acute disseminated encephalomyelitis, epileptic seizures and meningoencephalitis. Cases of meningoencephalitis have some common characteristics. Its diagnosis is based on the presence of lymphocytic meningitis with positive IgM HAV serology. We describe a novel case due to the form of presenta- tion that has not been described yet in the context of HAV, with sudden onset of aphasia and the appearance of digestive symptoms in the following days. The studies performed ruled out other etiologies and the clinical course was favorable with supportive treatment.Raramente el virus de la hepatitis A (VHA) se manifiesta con alteraciones neurológicas. Existen casos reportados de síndrome de Guillain-Barré, encefalomielitis aguda diseminada, crisis epilépticas y meningoencefalitis. Los casos de meningoencefalitis presentan algunas características comunes. Su diagnóstico se apoya en la presencia de meningitis linfocitaria con serología IgM VHA positiva. Describimos un caso novedoso por la forma de presentación, hasta ahora no descrita, en el contexto de VHA, con afasia de inicio brusco y aparición de los síntomas digestivos en los días siguientes. Los estudios realizados descartaron otras etiologías, y la evolución fue favorable con tratamiento de soporte

Treatment of polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is an inflammatory disease characterized by bilateral pain involving predominantly the shoulders and proximal aspects of the arms and less commonly the neck and the pelvic girdle. This review discusses briefly the main epidemiological data and clinical features of this condition. Especial attention is paid in the management of the disease. For this reason, both the classic management and the impact of new therapies are discussed in depth. In general, patients with PMR experience a rapid response to 12.5-25?mg/prednisone/day in less than a week. Patients with poor response to glucocorticoids or with relapsing disease require other therapies aimed mainly to spare glucocorticoids. Among them, methotrexate is the most commonly used. Nevertheless, different studies indicate that this agent yields only a modest effect. Biologic therapies against the main cytokines involved in the pathogenesis of the disease have been used in refractory patients. However, randomized controlled trials do not support the use of anti-tumor necrosis factor agents in PMR. In contrast, several case series and retrospective studies highlight the efficacy of the anti-interleukin-6 receptor tocilizumab in PMR. Nonetheless, controlled trials are needed to fully establish the beneficial effect of this agent. The potential favorable effect of the Janus-kinase inhibitors and new anti-interleukin-6 antagonists remains to be determined

Evaluation of endothelial function and subclinical atherosclerosis in patients with HIV infection

The aim of this study was to analyse the association between human immunodefciency virus (HIV) related clinical and analytical parameters and the presence of subclinical atherosclerosis as well as endothelial dysfunction. This was a prospective cohort study of HIV-positive patients who underwent intima media thickness (IMT) determination and coronary artery calcium scoring to determine subclinical atherosclerosis. To detect endothelial dysfunction, the breath holding index, fow-mediated dilation and the concentration of endothelial progenitor cells (EPCs) were measured. Patients with an IMT? 0.9 mm had an average of 559.3 ± 283.34 CD4/?l, and those with an IMT< 0.9 mm had an average of 715.4 ± 389.92 CD4/?l (p= 0.04). Patients with a low calcium score had a signifcantly higher average CD4 cell value and lower zenith viral load (VL) than those with a higher score (707.7 ± 377.5 CD4/?l vs 477.23 ± 235.7 CD4/?l (p= 0.01) and 7 ×?¬104 ± 5 ×?¬104 copies/ml vs 23.4 × 104 ± 19 × 104 copies/ml (p= 0.02)). The number of early EPCs in patients with a CD4 nadir< 350/ µl was lower than that in those with a CD4 nadir? 350 (p= 0.03). In HIV-positive patients, low CD4 cell levels and high VL were associated with risk of developing subclinical atherosclerosis. HIV patients with CD4 cell nadir < 350/µl may have fewer early EPCs

Long-term safety of OnabotulinumtoxinA treatment in chronic migraine patients: a five-year retrospective study

Background: Real-world studies have shown the sustained therapeutic effect and favourable safety profile of OnabotulinumtoxinA (BoNTA) in the long term and up to 4 years of treatment in chronic migraine (CM). This study aims to assess the safety profile and efficacy of BoNTA in CM after 5 years of treatment in a real-life setting. Methods: We performed a retrospective chart review of patients with CM in relation to BoNTA treatment for more than 5 years in 19 Spanish headache clinics. We excluded patients who discontinued treatment due to lack of efficacy or poor tolerability. Results: 489 patients were included [mean age 49, 82.8% women]. The mean age of onset of migraine was 21.8 years; patients had CM with a mean of 6.4 years (20.8% fulfilled the aura criteria). At baseline, patients reported a mean of 24.7 monthly headache days (MHDs) and 15.7 monthly migraine days (MMDs). In relation to effectiveness, the responder rate was 59.1% and the mean reduction in MMDs was 9.4 days (15.7 to 6.3 days; p < 0.001). The MHDs were also reduced by 14.9 days (24.7 to 9.8 days; p < 0.001). Regarding the side effects, 17.5% experienced neck pain, 17.3% headache, 8.5% eyelid ptosis, 7.5% temporal muscle atrophy and 3.2% trapezius muscle atrophy. Furthermore, after longer-term exposure exceeding 5 years, there were no serious adverse events (AE) or treatment discontinuation because of safety or tolerability issues. Conclusion: Treatment with BoNTA led to sustained reductions in migraine frequency, even after long-term exposure exceeding 5 years, with no evidence of new safety concerns

Functional Connectivity Changes After Initial Treatment With Fingolimod in Multiple Sclerosis

On the basis of recent functional MRI studies, Multiple Sclerosis (MS) has been interpreted as a multisystem disconnection syndrome. Compared to normal subjects, MS patients show alterations in functional connectivity (FC). However, the mechanisms underlying these alterations are still debated. The aim of the study is to investigate resting state (RS) FC changes after initial treatment with fingolimod, a proven anti-inflammatory and immunomodulating agent for MS. We studied 32 right-handed relapsing-remitting MS patients (median Expanded Disability Status Scale: 2.0, mean disease duration: 8.8 years) who underwent both functional and conventional MRI with a 3 Tesla magnet. All assessments were performed 3 weeks before starting fingolimod, then, at therapy-initiation stage and at month 6. Each imaging session included scans at baseline (run1) and after (run2) a 25-min, within-session, motor-practice task, consisting of a paced right-thumb flexion. FC was assessed using a seed on the left primary motor cortex to obtain parametric maps at run1 and task-induced FC change (run2-run1). Comparison between 3-week before- and fingolimod start sessions accounted for a test-retest effect. The main outcome was the changes in both baseline and task-induced changes in FC, between initiation and 6 months. MRI contrast enhancement was detected in 14 patients at initiation and only in 3 at month 6. There was a significant improvement (p &lt; 0.05) in cognitive function, as measured by the Paced Auditory Serial Addition Task, at month 6 compared to initiation. After accounting for test-retest effect, baseline FC significantly decreased at month 6, with respect to initiation (p &lt; 0.05, family-wise error corrected) in bilateral occipito-parietal areas and cerebellum. A task-induced change in FC at month 6 showed a significant increment in all examined sessions, involving not only areas of the sensorimotor network, but also posterior cortical areas (cuneus and precuneus) and areas of the prefrontal and temporal cortices (p &lt; 0.05, family-wise error corrected). Cognitive improvement at month 6 was significantly (p &lt; 0.05) related to baseline FC reduction in posterior cortical areas. This study shows significant changes in functional connectivity, both at baseline and after the execution of a simple motor task following 6 months of fingolimod therapy

Alfabetización en Ciencias de la Tierra

p. 117-129Este trabajo describe qué se entiende por una persona alfabetizada en ciencias de la Tierra y selecciona los conocimientos básicos que debería poseer todo estudiante al finalizar la educación obligatoria, de forma que pueda disponer de una idea global sobre cómo funciona el planeta en que vive. Formula las diez ideas clave que sintetizan esos conocimientos básicos y los conceptos, principios y teorías que las sustentan, así como los procedimientos utilizados para construir estos conocimientos, para refutarlos o validarlos. La propuesta está pensada desde una perspectiva holística, que entiende la Tierra como un sistema en el que se producen interacciones entre sus componentes. Entre ellas se destacan las que tienen lugar entre la humanidad y el planeta.S

Differential clinical characteristics and prognosis of intraventricular conduction defects in patients with chronic heart failure

Intraventricular conduction defects (IVCDs) can impair prognosis of heart failure (HF), but their specific impact is not well established. This study aimed to analyse the clinical profile and outcomes of HF patients with LBBB, right bundle branch block (RBBB), left anterior fascicular block (LAFB), and no IVCDs. Clinical variables and outcomes after a median follow-up of 21 months were analysed in 1762 patients with chronic HF and LBBB (n = 532), RBBB (n = 134), LAFB (n = 154), and no IVCDs (n = 942). LBBB was associated with more marked LV dilation, depressed LVEF, and mitral valve regurgitation. Patients with RBBB presented overt signs of congestive HF and depressed right ventricular motion. The LAFB group presented intermediate clinical characteristics, and patients with no IVCDs were more often women with less enlarged left ventricles and less depressed LVEF. Death occurred in 332 patients (interannual mortality = 10.8%): cardiovascular in 257, extravascular in 61, and of unknown origin in 14 patients. Cardiac death occurred in 230 (pump failure in 171 and sudden death in 59). An adjusted Cox model showed higher risk of cardiac death and pump failure death in the LBBB and RBBB than in the LAFB and the no IVCD groups. LBBB and RBBB are associated with different clinical profiles and both are independent predictors of increased risk of cardiac death in patients with HF. A more favourable prognosis was observed in patients with LAFB and in those free of IVCDs. Further research in HF patients with RBBB is warranted

Función endotelial en esclerosis múltiple y migraña : estudio transversal con comparador activo

RESUMEN:La disfunción endotelial es el primer paso en el desarrollo de la ateroesclerosis. Enfermedades autoinmunes, como la artritis reumatoide (AR), presentan un incremento del riesgo de enfermedad cardiovascular. Varios estudios han demostrado un incremento en la prevalencia de eventos vasculares en pacientes con Esclerosis Múltiple (EM), y en otras patologías como la migraña. Nuestro objetivo es evaluar la presencia de marcadores subclínicos de disfunción en pacientes con EM y migraña sin factores de riesgo en comparación con controles. Un grupo de AR se incluyó como comparador activo. Se realizó análisis bioquímico y ultrasonográfico midiendo el grosor íntima media (GIM), vasodilatación dependiente de endotelio (VDE), vasorreactividad cerebral (VRC) y otras. Los pacientes con EM tenían mayor GIM, menor VDE y VRC que los controles. Los valores ecográficos se correlacionaron con marcadores de inflamación. En migrañosos, las mayores diferencias se observaron en migraña crónica. En conclusión, hemos encontrado una disfunción endotelial en pacientes con EM y en pacientes con migraña, especialmente en la migraña crónica.ABSTRACT: Endothelial dysfunction is an early step in the development of atherosclerosis. Autoimmune diseases, as rheumatoid arthritis (RA), have an increase in the incidence of cardiovascular disease. Several studies showed an increase prevalence of cardiovascular events in Multiple sclerosis (MS) patients, and other disorders as migraine. Our aim is to evaluate the presence of subclinical markers of endothelial dysfunction in MS and migraine patients without cardiovascular risk factors compared with healthy controls. A group of patients with RA followed at our hospital was also enrolled, as an active comparator. Biochemical and ultrasounds examinations were performed measuring the intima media thickness (IMT), flow mediated vasodilation (FMD), cerebral vasorreactivity (CVR) and others. MS patients had a significant higher IMT and lower FMD and VRC than in control group. Ultrasounds values had a highly significant correlation with inflammation biomarkers. Between migraneurs, chronic migraine patients showed higher difference. In summary we found an alteration in the endothelial function in patients with MS, and migraine, especially in chronic migraine

Update on headaches associated with physical exertion

Background Headaches associated with physical exertion include headache precipitated by coughing or other Valsalva maneuvers, headache brought on by prolonged physical exercise, sexual headaches and cardiac cephalalgia. Objective To review and update the clinical characteristics, etiologies, pathophysiology and management of these headaches related to exertion. Methods In depth review of the publications, both in PubMed and in the main textbooks, of the different headaches induced by physical exercise. Results Cough, exercise and sexual headaches can be primary or secondary; therefore, complementary studies are mandatory to rule out structural lesions. However, clinical characteristics, such as an old age and response to indomethacin for cough headache or being a young male and response to beta-blockers for exercise and sexual headaches, plus a normal examination are suggestive of a primary etiology. Etiology for secondary varieties, as posterior fossa lesions for cough headache or vascular malformations for exercise and sexual headaches, are also different. Finally, headache as a distant manifestation of myocardial ischemia, also known as "cardiac cephalalgia", appears at exertion in around two-thirds of cases and typically lasts less than 30 minutes and is relieved by nitroglycerine. Conclusions Primary and secondary cough headache can usually be suspected based on clinical characteristics and separated from exercise and sexual headaches, which share many aspects. Cardiac cephalalgia is not necessarily an exertional headache and should be considered in adult patients with short lasting headaches and patent vascular risk factor

Real need for headache services and their resource consumption: a retrospective observational study on a cohort in Cantabria

Introducción: Las unidades de cefalea surgen por una necesidad de mejorar la asistencia a los pacientes con cefalea; no obstante, se desconocen aspectos importantes de gestión clínica que demuestren su eficiencia. Objetivo: Estimar la necesidad de unidades de cefalea en nuestro medio. Pacientes y métodos: Estudio retrospectivo realizado en dos fases: identificación de las primeras consultas por cefalea durante tres meses consecutivos y recogida de datos asistenciales ocurridos durante un año. Criterios de asistencia en unidades de cefalea: migraña crónica, cefaleas raras, necesidad de técnicas especiales y cefaleas con mala respuesta terapéutica. Resultados: De las 1.418 primeras consultas, en 298 (20,38%) la cefalea fue el motivo asistencial. El 82,9% procedía de atención primaria. La distribución de diagnósticos fue: 54% migraña, 11% cefalea tensional y 35% otras cefaleas. Un total de 108 pacientes cumplía los criterios de derivación a unidades de cefalea: 63 por migraña crónica, 13 por bloqueos nerviosos, 9 por migraña frecuente, 8 por cefaleas trigeminoautonómicas, 5 por necesidad de toxina botulínica y 10 por otros motivos. Los pacientes atendidos por unidades de cefalea acudieron menos veces a urgencias que los de consulta general, se les realizaron menos tomografías cerebrales y se les indicó más toxina botulínica. Conclusión: Las unidades de cefalea están justificadas por gestionar mejor los pacientes con las variantes más graves de cefalea. En nuestro medio se justifican al menos dos consultas semanales para atender un área de 350.000 usuarios del Sistema Nacional de SaludIntroduction: Headache services arise out of a need to improve care for patients with different types of headache; however, some important aspects of clinical management that demonstrate their efficiency remain unknown. Aim: To estimate the need for headache services in our area. Patients and methods: We conducted a retrospective study in two phases: identification of the first visits due to headache during three consecutive months and collection of care data during one year. The care criteria in headache services considered were: chronic migraine, rare headaches, need for special techniques and headaches with poor therapeutic response. Results: Of the 1,418 first visits, in 298 cases (20.38%) the reason for seeking medical attention was headache. Of these, 82.9% were from primary care. The distribution of the diagnoses was: 54%, migraine; 11%, tension-type headache; and 35%, other headaches. Altogether 108 patients met the criteria for referral to headache services: 63 for chronic migraine; 13 for nerve blocks; 9 for frequent migraine; 8 for trigeminal-autonomic cephalgias; 5 due to a need for botulinum toxin; and 10 for other reasons. The patients attended by headache services went to the emergency department less often than those who visited the general outpatient department, had fewer brain scans and more botulinum toxin was indicated. Conclusion: Headache services are justified because they offer better management of patients with the most severe variants of headache. In our country, at least two visits a week are needed to cover an area of 350,000 users of the Spanish National Health Syste