Triphasic waves and brain atrophy in patients with acute encephalopathy / Ondas trifásicas y atrofia cerebral en pacientes con encefalopatía aguda

Abstract Introduction: Triphasic waves (TW) constitute an electroencephalographic pattern associated with certain kinds of encephalopathy. Brain atrophy may be a predisposing factor linked with TW. Objective: To compare the degree of brain atrophy and white matter disease between patients with acute encephalopathy with and without TW. Methods: A retrospective observational study including adult patients with encephalopathy, with and without TW, hospitalized between 2016 and 2017. The degree of brain atrophy and white matter lesion were defined using the Global Cortical Atrophy and Age Related White Matter Changes (ARWMC) scales, respectively. Scores were compared between groups. Mortality rates were registered. Results: Sixteen patients with TW were identified matched by age and sex with 30 patients without TW. The mean age was 80 years in the TW group. Women represented 87.5%. Multifactorial encephalopathy was the most frequent diagnosis followed by metabolic encephalopathy. Patients with TW had more brain atrophy (10.43 vs 6.9, p= 0.03). Mean ARWMC was 9.43±6.5 and 8.5 ±7.89 in patients with and without TW respectively (p= 0.5). Mortality rate was higher in the TW group (31.25 vs 6.66% p= 0.02). Conclusions: Patients with acute encephalopathy and TW had higher degree of cerebral atrophy. It is possible that this structural alteration predisposes to the appearance of TW. There was no significant difference in white matter lesion degree. The mortality of the TW group was high, so future studies are necessary to determine their prognostic value.

Resumen Introducción: Las ondas trifásicas (OT) constituyen un patrón electroencefalográfico asociado con diversas encefalopatías. La atrofia cerebral podría predisponer a su aparición. Objetivo: Comparar el grado de atrofia cerebral y de lesión de sustancia blanca en pacientes con encefalopatía aguda con y sin OT. Métodos: Estudio observacional retrospectivo, incluyó pacientes adultos con encefalopatía aguda con y sin OT internados entre 2016 y 2019. El grado de atrofia cerebral y de lesión de sustancia blanca se definieron según las escalas Global Cortical Atrophy y Age Related White Matter Changes (ARWMC), respectivamente. Se compararon los puntajes entre grupos. Se registró la mortalidad. Resultados: Se identificaron 16 pacientes con OT y 30 sin OT pareados según edad y sexo. La edad promedio del grupo con OT fue 80 años. El 87.5% fueron mujeres. La encefalopatía multifactorial fue el diagnóstico más frecuente seguido de la encefalopatía metabólica. El grado de atrofia fue mayor en pacientes con OT (10.43 vs 6.9, p= 0.03). El puntaje ARWMC fue 9.43 ±6.5 y 8.5 ±7.89 en pacientes con y sin OT respectivamente (p= 0.5). La mortalidad fue mayor en el grupo con OT (31.25 vs 6.66% p= 0.02). Conclusiones: Pacientes con encefalopatía aguda y OT tuvieron mayor grado de atrofia cerebral. Dicha alteración estructural podría relacionarse con la aparición de OT. No hubo diferencias significativas en el grado de lesión de sustancia blanca. La mortalidad del grupo con OT fue elevada. Son necesarios estudios para determinar su valor pronóstico.

Análisis de publicidades sobre medicamentos neurológicos recibidos durante la consulta médica / Analysis of advertising on neurological drugs received during the medical consultation

Resumen La publicidad y promoción de medicamentos por parte de la industria farmacéutica ejerce influencia sobre la prescripción médica y, en algunos casos, la información provista es incompleta o sesgada. El objetivo fue analizar las publicidades entregadas por representantes médicos y determinar si la información era apropiada para la prescripción racional. Es un estudio prospectivo (marzo a noviembre 2018) mediante la recolección de publicidades impresas recibidas aleatoriamente en centros de neurología. Se evaluó si cumplían los criterios éticos establecidos por la OMS, utilizando como referencia prospectos de la Administración Nacional de Medicamentos, Alimentos y Tecnología médica (ANMAT), la Food and Drugs Administration (FDA) y libros de farmacología. Un comité de médicos farmacólogos analizó si el contenido de los folletos era engañoso según la OMS. Se analizaron 60 publicidades, siendo antiepilépticos y antidepresivos los más publicitados. El 33.3% (n = 20) incluían prospectos acordes según ANMAT. Un caso presentaba indicación off-label. Los folletos ex ponían el mecanismo de acción en el 31.7% (n = 19), las reacciones adversas medicamentosas 40% (n = 24), la posología en el 45% (n = 27), las contraindicaciones 38.3% (n = 23) y en 36.7% (n = 22) las precauciones necesarias. La información brindada era falaz en el 80% (n = 48) y el 53.3% (n = 32) tenían imágenes capcio sas. El 69.2% (n = 18) de los gráficos eran capciosos. En el presente trabajo, la información brindada por la publicidad médica sería insuficiente para conocer y prescribir nuevos fármacos. La falta de información en la posología, contraindicaciones, mecanismos de acción y reacciones adversas no contribuyen al uso racional de medicamentos.

Abstract Drug promotion and advertisement by pharmaceutical industry influence medical prescription and, in some cases, the information provided is incomplete or biased. The objective was to analyze the advertisements deliv ered by medical representatives and determine if the information was appropriate for rational prescribing. It is a prospective study (March to November 2018) by collecting print advertisements randomly received in neurology centers. It was evaluated if they met the ethical criteria established by the WHO, using as a reference leaflets from Administración Nacional de Medicamentos, Alimentos y Tecnología Médica (ANMAT), Food and Drugs Ad ministration (FDA) and pharmacology books. A committee of pharmacology physicians analyzed if the content of the pamphlets was misleading according to the WHO. Sixty advertisements were analyzed, being anti-epileptics and antidepressants the most advertised drugs. The 33.3% (n = 20) of them included leaflets in accordance to ANMAT. One case presented an "off-label" indication. Drug action was presented in 31.7% (n = 19) of the pam phlets, adverse reactions in 40% (n = 24), posology in 45% (n = 27), contraindications in 38.3% (n = 23) and the necessary precautions in 36.7% (n = 22) of them. The information provided was false in 80% (n = 48) and 53.3% (n = 32) contained misleading images; and 69.2% (n = 18) of the graphics were false. The information provided by medical advertisements analyzed in this study would be insufficient to know and prescribe a new drug. Lack of information in posology, contraindication, drug action and adverse reactions do not contribute to rational use of medications.

Validation of the Argentine version of the Memory Binding Test (MBT) for Early Detection of Mild Cognitive Impairment / Validação da versão argentina do Memory Binding Test (MBT) para a detecção precoce do transtorno cognitivo leve

ABSTRACT. Background: "Forgetfulness" is frequent in normal aging and characteristic of the early stages of dementia syndromes. The episodic memory test is central for detecting amnestic mild cognitive impairment (MCI). The Memory Binding Test (MBT) is a simple, easy and brief memory test to detect the early stage of episodic memory impairment. Objective: To validate the Argentine version of the MBT in a Latin American population and to estimate the diagnostic accuracy as a tool for early detection of MCI. Methods: 88 subjects (46 healthy controls and 42 patients with amnestic MCI) matched for age and educational level were evaluated by an extensive neuropsychological battery and the memory binding test. Results: A significantly better performance was detected in the control group; all MBT scales were predictive of MCI diagnosis (p<.01). The MBT showed high sensitivity (69%) and high specificity (88%), with a PPV of 93% and a NPV of 55% for associative paired recall. A statistically significant difference (c2=14,164, p<.001) was obtained when comparing the area under the curve (AUC) of the MBT (0.88) and the MMSE (0.70). Conclusion: The Argentine version of the MBT correlated significantly with the MMSE and the memory battery and is a useful tool in the detection of MCI. The operating characteristics of the MBT are well suited, surpassing other tests commonly used for detecting MCI.

RESUMO. "Esquecimento" é queixa frequente no envelhecimento normal e também ocorre nos primeiros estágios de síndromes demenciais. Testes de memória episódica são fundamentais para detectar comprometimento cognitivo amnéstico (CCL). O teste de Memória Associativa (Memory Binding Test-MBT) é um teste fácil e breve para detectar a fase inicial de perda de memória episódica. Objetivo: Validar a versão argentina do MBT e estimar a sua acurácia como instrumento diagnóstico para a detecção precoce do CCL. Métodos: 88 indivíduos (46 controles saudáveis ​​e 42 pacientes com CCL amnéstico), emparelhados por idade e nível educacional, foram avaliados com extensa bateria neuropsicológica e o MBT. Resultados: Um desempenho significativamente melhor foi detectada no grupo controle; todas as escalas do MBT foram preditivas do diagnóstico de CCL (p<0,01). O MBT apresentou alta sensibilidade (69%) e alta especificidade (88%), com valor preditivo (VP) positivo de 93% e e VP negativo de 55% para a recordação dos itens associados (associative paired recall). Diferença estatisticamente significativa (c2=14,164, p<0,001) foi obtida quando foram comparadas as áreas sob as curvas (AUC) do MBT (0,88) e o Mini-Exame do Estado Mental (MEEM) (0,70). Conclusão: A versão argentina do MBT correlacionou-se significativamente com o MEEM e com a bateria de memória e é uma ferramenta útil na detecção de CCL. As características operacionais do MBT são bem adequadas, superando outros testes usualmente utilizados para a detecção de CCL.

Cognition in a multiple system atrophy series of cases from Argentina / Cognição em uma série dos casos de atrofia de múltiplos sistemas da Argentina

Cognitive dysfunction may occur in 17-40% of patients with multiple system atrophy (MSA). It has been suggested a milder cognitive impairment in cerebellar (MSA-C) than in parkinsonian variant (MSA-P). However, differences in cognitive profiles remain under discussion. Objective To evaluate cognitive features in a series of patients with “probable MSA” from Argentina. Method After informed consent was obtained, an extensive cognitive tests battery was administered. Nine patients (6 MSA-P and 3 MSA-C) composed the sample. Results Depression was detected in 43% of patients. Seven patients showed at least one cognitive domain impairment. Temporospatial orientation, visuospatial abilities, executive and attentional functions, episodic memory and language were compromised in MSA-P, while MSA-C dysfunction was restricted to attentional and executive domains. Conclusion Despite the small sample size, our findings could suggest a more widespread cognitive impairment in MSA-P than MSA-C. .

Disfunção cognitiva pode ocorrer em 17-40 % dos pacientes com atrofia de múltiplos sistemas (AMS). Alguns estudos têm sugerido a presença de disfunção cognitiva mais leve nos pacientes com AMS do tipo cerebelar (AMS-C) do que na variante parkinsoniana (AMS-P). Objetivo Avaliar os perfis cognitivos de uma série de pacientes argentinos com “Provável AMS”. Método Foram selecionados 6 AMS-P e 3 AMS–C aos quais foi aplicada uma extensa bateria de testes cognitivos. Resultados Depressão foi detectada em 43% dos pacientes. Sete pacientes apresentaram comprometimento de pelo menos um domínio cognitivo. As funções de orientação temporo-espacial, habilidades visuo-espaciais, função executiva e de atenção, memória episódica e linguagem foram comprometidas em pacientes com AMS-P. Nos pacientes com AMS-C as dificuldades cognitivas ficaram restritas às funções executivas e de atenção. Conclusão Apesar do pequeno tamanho da amostra, nossos achados sugerem que pacientes com AMS-P apresentam um comprometimento cognitivo mais amplo do que pacientes com AMS-C. .

Medicamentos utilizados para trastornos cognitivos: Análisis de un millón y medio de prescripciones en la Argentina / Drugs used for cognitive impairment: Analysis of 1.5 million prescriptions in Argentina

Los costos originados por trastornos cognitivos y demencias son significativos para los sistemas de salud. Según guías nacionales e internacionales, los fármacos recomendados para su tratamiento son inhibidores de colinesterasa (donepecilo, galantamina y rivastigmina) y memantina. En la Argentina también son utilizados otros nootrópicos, galantamina, rivastigmina, vasodilatadores, vitaminas y antioxidantes. El objetivo del presente estudio es describir y comparar el patrón de prescripción de drogas para el tratamiento de trastornos cognitivos y demencias en las distintas regiones del país. Se realizó un estudio observacional retrospectivo a partir de las prescripciones (1 814 108 envases) realizadas en la práctica clínica habitual durante el segundo semestre del 2008 y el primer y segundo semestre del 2009. El trabajo fue realizado sobre la población total del Instituto Nacional de Servicios Sociales para Jubilados y Pensionados. Se analizaron variables demográficas, cantidad y tasa de prescripciones, presentaciones y dosis utilizadas por regiones. Considerando todo el país, memantina fue la droga más prescripta en esos períodos, con un total de 570 893 envases. Memantina, donepecilo, rivastigmina e idebenona presentaron un incremento en las tasas de prescripción 2008-2009. Analizando los cambios regionales en tasas de prescripción, la memantina aumentó en el Noroeste y Noreste argentino, la idebenona en el Noroeste y la Patagonia y el donepecilo en el Noreste. Grupos de fármacos no recomendados fueron altamente prescriptos en todas las regiones del país. Algunos fueron indicados en adultos jóvenes o de mediana edad.

Cognitive impairment and dementia treatment costs are significant for health systems. According to national and international guidelines, recommended drugs for treatment of dementias are cholinesterase inhibitors (donepezil, galantamine, rivastigmine) and memantine. Despite these guidelines recommendations, other nootropics, vasodilators and antioxidants are often used in Argentina. The purpose of this study was to describe and compare the prescription pattern of commonly used drugs for the treatment of cognitive disorders and dementia in different regions of Argentina. An observational, retrospective study of 1 814 108 recipes prescribed to National Institute of Social Services for Retired and Pensioners outpatients during the during the second half of 2008 and the first and second half of 2009 was performed, taking in count the whole country and also different Argentina´s regions. Demographic variables, quantity and rate of prescriptions, dosage forms and strengths were analyzed. Considering the entire country, memantine was the most prescribed drug in these periods (570 893 packages). An increase in the memantine, donepezil, rivastigmine and idebenone rates of prescription was observed. Prescription rate of memantine increased in the North-West and North-East regions, that of idebenone in the North-East region and Patagonia and donepezil in the North-East region. Non recommended drugs were highly prescribed in all the analyzed regions. Some of them were indicated to young and middle-aged patients.

Consenso para el tratamiento de las metástasis cerebrales / Consensus about cerebral metastases treatment

El avance en la terapia oncológica ha hecho del tratamiento de las metástasis cerebrales un factor primordial en el tiempo de sobrevida y la calidad de vida de los pacientes con cáncer. A pesar de que existen numerosas publicaciones sobre el tema, no existe todavía un consenso sobre la mejor estrategia terapéutica, problablemente por la heterogeneidad de la población en términos de estado funcional, tipo de neoplasia, control sistémico de la enfermedad y número y localización de las lesiones en el sisteman nervioso central. Nuestro objetivo es presentar recomendaciones generales basadas en un análisis racional para guiar el manejo práctico de las metástasis cerebrales. Con este propósito, un equipo multidisciplinario integrado por neurocirujanos, neurooncólogos, neuropatólogos, radioterapeutas y neurólogos fue convocado para conducir una búsqueda minuciosa en las publicaciones en inglés y español a través de PubMed (1980-2006) coincidiendo con el comienzo del empleo de la resonancia magnética en la práctica médica. Se seleccionaron revisiones y artículos originales con un n=o>a 20. También se incluyeron capítulos de libros escritos por expertos conocidos. La evaluación de la literatura así como la experiencia de los autores permitió el desarrollo del "Consenso para el Tratamiento de las Metástasis Cerebrales". Finalmente los autores esperan que elpresente trabajo contribuya a un abordaje multidisciplinario para el manejo de las metástasis cerebrales con recomendaciones simples y prácticas y probablemente estimule nuevos desarrollos en este campo. Palabras clave: cirugía, metástasis cerebrales, quimioterapia, radioterapia

The advances in oncological therapies has made brain metastases treatment a major factor influencing the survival time and the quality of life patients with cancer. Although there are numerous publications on the issue, there is no consensus about the best treatment strategy. This is probably due to population heterogeneity in terms of functional status, type of neoplasia, control of the systemic disease, and the number and localization of the lesions in the cetral nervous system. Our objective is to present general recommendations based on a rational analysis in order to guide the practical management of brain metastases. With this purpose, a multidisciplinary team composed by neurosurgeons, neurooncologists, neuropathologist, radiotherapist and neurologists were brought together to conduct athrough search in english and spanish publications through PubMed (1980-2006). The starting period was set at the beginning of the use of magnetic resonance in medical practice. Reviews and original articles with n=or>20 were selected. Also, book chapters of renowned authors in the different consulted areas were included. The assessment of the literature, in addition to the experience of the authors allowed the development of "Consensus for the treatment of Brain Metastases". Finally, the authors expect that the present work will contribute to the multidisciplinary approach in the management of brain metastases with simple and practical recommendations, and probably stimulating future developments in this field. Key words: cerebral metastasis, chemotherapy, radiotherapy, surgery.

Pseudoaneurisma micótico de la arteria carótida extracraneana por infección parafaríngea / Extracranial carotid pseudoaneurysm within a parapharyngeal infection

El 5 por ciento de los aneurismas micóticos (AM) se ubica en el territorio carotídeo y la localización en su sector extracraneal es extremadamente rara...Se presenta un paciente con pseudoaneurisma micótico de la arteria carótida extracraneal secundario a infección parafaríngea, complicado con infarto cerebral y tratado con ligadura de vaso