Repercusión de la introducción de neurología en un hospital comarcal de Andalucía / Impact of introducing neurology into a local hospital in Andalusia

Introducción: En Andalucía la mortalidad por ictus duplica la de otras autonomías lo que podría relacionarse con que, a diferencia del resto de CC. AA., sólo 3 de 17 hospitales comarcales cuentan con neurología. El objetivo de este estudio fue evaluar la repercusión de la introducción de un neurólogo en un hospital comarcal de Andalucía en la evaluación y evolución de pacientes con ictus.Métodos: Se realizó un estudio observacional de los ictus ingresados en el primer trimestre de 2006. Se analizaron indicadores de calidad, mortalidad y dependencia comparando los pacientes atendidos por neurología o medicina general. Resultados: En el primer trimestre de 2006 ingresaron 116 pacientes con ictus. Se detectaron diferencias significativas en la realización de las pruebas complementarias necesarias para el diagnóstico (Doppler, ecocardio). La estancia media fue significativamente menor en neurología. Se detectó una reducción absoluta de 39,1% de mortalidad y un incremento absoluto del 35,7% de pacientes independientes al final del seguimiento. Los únicos factores que reducen de forma independiente la estancia y la mortalidad son la atención por neurología durante el ingreso y una menor discapacidad al ingreso.Conclusión: La atención especializada por neurología es eficaz y coste-efectiva por la reducción en estancia hospitalaria, mortalidad y dependencia. La implantación de neurología en los hospitales comarcales de Andalucía es prioritaria para garantizar la equidad en el territorio nacional. Este objetivo debería incluirse en el Plan Andaluz de Atención al Ictus como paso previo para constituir una red de equipos/unidades de ictus (AU)

Introduction: The stroke mortality rate in Andalusia is twice that of other autonomous communities. This could be associated with the absence of neurologists in most local hospitals in this community, unlike in the rest of Spain. The objective of this study was to evaluate the impact of incorporating a neurologist to evaluate and monitor stroke patients in a local hospital in Andalusia. Methods: An observational study was conducted on stroke cases admitted in the first quarter of 2006. Quality indicators, mortality rates, and incapacity rates at follow-up were analysed, comparing groups with and without neurological care. Results: A total of 116 stroke patients were admitted. There were significant differences in tests performed to diagnose patients (Doppler and echocardiography). The mean hospital stay was significantly lower with neurology care. There was a 39.1% absolute decrease in mortality and a 35.7% absolute increase in capacity for daily life activities was also observed. Neurological care and a lower incapacity level at admission were the only two factors independently associated with a decrease in length of hospital stay and mortality.Conclusion: Specialised care by a neurologist is effective in reducing length of hospital stay, mortality and incapacity. The incorporation of neurologists in local hospitals in Andalusia should be a priority to guarantee equal care in all autonomous communities in Spain. This objective should be included in the Plan Andaluz de Atención al Ictus as a first step in forming a network of stroke units and teams (AU)

Fiabilidad del diagnóstico de ictus en urgencias / Reliability of stroke diagnosis in emergency departments

Introducción: Tanto en el Plan de atención sanitaria al ictus como en la Estrategia en ictus del Sistema Nacional de Salud se establece que solo se realizará fibrinólisis en los hospitales con unidad de ictus. Sin embargo, en Andalucía el Plan andaluz de atención al ictus incluye dentro de la cartera de servicios del equipo de ictus en los hospitales comarcales la realización de fibrinólisis prescindiendo de la figura del neurólogo en el tratamiento agudo del ictus. El objetivo de este estudio es evaluar si los médicos de urgencias realizan adecuadamente el diagnóstico de ictus. Métodos: Se recogieron los diagnósticos realizados en urgencias y al alta de hospitalización de todos los pacientes ingresados por motivos neurológicos en el hospital comarcal Infanta Elena durante el año 2006. Se analizó la validez del diagnóstico realizado en urgencias. Resultados: El número de ingresos por patología neurológica fue de 655 pacientes en 2006, representando el ictus un 76%. Aunque la sensibilidad del diagnóstico de ictus en urgencias resultó alta (95%), la especificidad del diagnóstico era muy baja (52%) y el valor predictivo positivo de un 75%. Conclusiones: Aplicar la fibrinólisis sobre la base del diagnóstico de ictus en urgencias implica someter a un riesgo no justificado de hemorragia cerebral a un número importante de pacientes diagnosticados erróneamente. Este riesgo hace cuestionable éticamente la administración de dicho tratamiento en los hospitales comarcales en las condiciones actuales. No solo es importante que el tratamiento fibrinolítico sea accesible a la población sino que dicho tratamiento se realice de forma segura por neurólogos en unidades de ictus (AU)

Introduction: According to the Spanish Stroke Health Care Plan and the Spanish Health National Service Stroke Strategy, thrombolysis should only be performed in hospitals with Stroke Units. However, the Andalusian Stroke Health Care Plan includes, within the list of services of the Stroke Team, the need to have a neurologist present for the performing of thrombolysis in local hospitals. The objective of this study is to evaluate whether emergency doctors are able to achieve a reliable diagnosis of stroke in order to safely perform thrombolysis. Methods: The diagnoses on hospital admission and discharge of all patients admitted for neurological reasons in 2006 in the community Hospital Infanta Elena (Huelva, Andalusia) were collected. The reliability of diagnosis performed by emergency doctors was analysed.Results: A total of 655 patients were admitted to the hospital for neurological reasons, and 76% of them were diagnosed as strokes. The sensitivity of stroke diagnosis made by emergency doctors was very high (97%), but specificity and positive predictive value of that diagnosis was low (52% and 75%, respectively). Conclusions: To apply thrombolysis based of the diagnosis of a stroke by emergency doctors may subject a significant number of erroneously diagnosed patients to an unnecessary risk of brain haemorrhage. This risk makes performing thrombolysis in community hospitals ethically questionable in these circumstances. Although it is important to have thrombolytic treatment available to everyone, this treatment must be performed safely by neurologists Stroke Units (AU)

[Reliability of stroke diagnosis in emergency departments]. / Fiabilidad del diagnóstico de ictus en urgencias.

INTRODUCTION: According to the Spanish Stroke Health Care Plan and the Spanish Health National Service Stroke Strategy, thrombolysis should only be performed in hospitals with Stroke Units. However, the Andalusian Stroke Health Care Plan includes, within the list of services of the Stroke Team, the need to have a neurologist present for the performing of thrombolysis in local hospitals. The objective of this study is to evaluate whether emergency doctors are able to achieve a reliable diagnosis of stroke in order to safely perform thrombolysis. METHODS: The diagnoses on hospital admission and discharge of all patients admitted for neurological reasons in 2006 in the community Hospital Infanta Elena (Huelva, Andalusia) were collected. The reliability of diagnosis performed by emergency doctors was analysed. RESULTS: A total of 655 patients were admitted to the hospital for neurological reasons, and 76% of them were diagnosed as strokes. The sensitivity of stroke diagnosis made by emergency doctors was very high (97%), but specificity and positive predictive value of that diagnosis was low (52% and 75%, respectively). CONCLUSIONS: To apply thrombolysis based of the diagnosis of a stroke by emergency doctors may subject a significant number of erroneously diagnosed patients to an unnecessary risk of brain haemorrhage. This risk makes performing thrombolysis in community hospitals ethically questionable in these circumstances. Although it is important to have thrombolytic treatment available to everyone, this treatment must be performed safely by neurologists Stroke Units.

Impact of introducing neurology into a local hospital in Andalusia.

INTRODUCTION: The stroke mortality rate in Andalusia is twice that of other autonomous communities. This could be associated with the absence of neurologists in most local hospitals in this community, unlike in the rest of Spain. The objective of this study was to evaluate the impact of incorporating a neurologist to evaluate and monitor stroke patients in a local hospital in Andalusia. METHODS: An observational study was conducted on stroke cases admitted in the first quarter of 2006. Quality indicators, mortality rates, and incapacity rates at follow-up were analysed, comparing groups with and without neurological care. RESULTS: A total of 116 stroke patients were admitted. There were significant differences in tests performed to diagnose patients (Doppler and echocardiography). The mean hospital stay was significantly lower with neurology care. There was a 39.1% absolute decrease in mortality and a 35.7% absolute increase in capacity for daily life activities was also observed. Neurological care and a lower incapacity level at admission were the only two factors independently associated with a decrease in length of hospital stay and mortality CONCLUSION: Specialised care by a neurologist is effective in reducing length of hospital stay, mortality and incapacity. The incorporation of neurologists in local hospitals in Andalusia should be a priority to guarantee equal care in all autonomous communities in Spain. This objective should be included in the Plan Andaluz de Atención al Ictus as a first step in forming a network of stroke units and teams.

[A descriptive analysis of the demand for ambulatory neurological care in the health district of Huelva]. / Análisis descriptivo de la demanda de asistencia neurológica ambulatoria en un área sanitaria de Huelva.

INTRODUCTION: In recent years the demand for ambulatory neurological care has risen. Studying this situation can help to improve health care planning and the quality of the referrals from primary care. AIM: To analyse a number of variables involved in the first visits referred from primary care to neurology services. PATIENTS AND METHODS: We conducted a prospective, descriptive study in which data was consecutively collected about 500 new patients from primary care who had appointments for a visit to general neurology services in the health district of the province of Huelva. Demographic features, the reason for referral, initial diagnoses and the case resolution index were analysed. RESULTS: Mean age was 51 years old, and patients were predominantly female (63.4%). The most frequent diagnoses were headaches (42.8%) and cognitive impairment (12%). In 8.2% of cases the referred patients had no neurological pathology. Data showed that 40.2% were discharged after the first visit. CONCLUSIONS: The demographic characteristics and reasons for the visit were similar to those previously published on other regions in Spain. The high percentage of direct discharges translates into a poor selection of the patients referred from primary care. Improving the quality of referrals would make it possible to enhance the efficiency of ambulatory neurological care.

Análisis descriptivo de la demanda de asistencia neurológica ambulatoria en un área sanitaria de Huelva / A descriptive analysis of the demand for ambulatory neurological care in the health district of Huelva

Introducción. En los últimos años se ha incrementado la demanda de asistencia neurológica ambulatoria. Su estudio puede contribuir a mejorar la planificación sanitaria y la calidad de las derivaciones desde atención primaria. Objetivo. Analizar diversas variables de las primeras visitas remitidas desde atención primaria a las consultas de neurología. Pacientes y métodos. Estudio prospectivo descriptivo en el que se recogieron de forma consecutiva los datos de 500 pacientes nuevos procedentes de atención primaria citados en una consulta de neurología general en el área sanitaria de la provincia de Huelva. Se analizaron las características demográficas, el motivo de derivación, los diagnósticos iniciales y el índice de resolución de los casos. Resultados. La media de edad fue de 51 años, con un predominio femenino (63,4%). Los diagnósticos más frecuentes fueron las cefaleas (42,8%) y el deterioro cognitivo (12%). El 8,2% de los pacientes remitidos no tenía ninguna patología neurológica. El 40,2% fue dado de alta tras la primera visita. Conclusiones. Las características demográficas y los motivos de consulta son similares a los publicados previamente en otras comunidades españolas. El elevado porcentaje de altas directas traduce una escasa selección de los pacientes remitidos desde atención primaria. La mejora en la calidad de las derivaciones permitiría mejorar la eficiencia de la asistencia neurológica ambulatoria

Introduction. In recent years the demand for ambulatory neurological care has risen. Studying this situation can help to improve health care planning and the quality of the referrals from primary care. Aim.To analyse a number of variables involved in the first visits referred from primary care to neurology services. Patients and methods. We conducted a prospective, descriptive study in which data was consecutively collected about 500 new patients from primary care who had appointments for a visit to general neurology services in the health district of the province of Huelva. Demographic features, the reason for referral, initial diagnoses and the case resolution index were analysed. Results. Mean age was 51 years old, and patients were predominantly female (63.4%). The most frequent diagnoses were headaches (42.8%) and cognitive impairment (12%). In 8.2% of cases the referred patients had no neurological pathology. Data showed that 40.2% were discharged after the first visit. Conclusions. The demographic characteristics and reasons for the visit were similar to those previously published on other regions in Spain. The high percentage of direct discharges translates into a poor selection of the patients referred from primary care. Improving the quality of referrals would make it possible to enhance the efficiency of ambulatory neurological care

Distonía aguda tras picadura de avispa / Acute dystonia following a wasp sting

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[Uremic myopathy]. / Miopatía urémica.

INTRODUCTION: The neurological features of chronic renal failure are very varied. Uremic myopathy is a controversial condition. In most cases it is related to the secondary hyperparathyroidism which these patients develop, and its characteristics are superimposed on their osteomalacia myopathy. CLINICAL CASES AND CONCLUSIONS: We report two patients with terminal chronic renal failure on hemodialysis who complained on difficulty with walking. The clinical findings, laboratory and neurophysiological investigations and the histopathological report of the muscle biopsy were similar to those of osteomalacia myopathy. The muscle weakness of patients with terminal chronic renal failure is related to many factors. The most important of these is the secondary hyperparathyroidism which leads to osteomalacia myopathy. On muscle biopsy there was isolated fibre necrosis of both types 1 and 2 (case 1) and of type 2 alone (case 2), which is considered to be the commonest finding. Although treatment with high doses of vitamin D3, or its hydroxylated metabolites, has been recommended, it was not effective in our patients.

Miopatía urémica / Uremic myopathy

Introducción. Las manifestaciones neurológicas de la insuficiencia renal crónica son muy variadas. La miopatía urémica es una entidad controvertida, relacionada en la mayoría de los casos con el frecuente hiperparatiroidismo secundario que estos pacientes desarrollan, y sus características son superponibles a la miopatía osteomalácica. Casos clínicos y conclusiones. Se presentan los casos de dos pacientes con insuficiencia renal crónica terminal sometidos a hemodiálisis que comenzaron con dificultad para la marcha. Las manifestaciones clínicas, el estudio analítico y neurofisiológico, así como los hallazgos histopatológicos de la biopsia muscular fueron similares a los de la miopatía osteomalácica. La debilidad muscular en los pacientes con insuficiencia renal crónica terminal se relaciona con numerosos factores, de los cuales el más importante es el hiperparatiroidismo secundario que condiciona una miopatía osteomalácica. En la biopsia muscular se objetivó necrosis aislada de fibras, tanto del tipo 1 y 2 (caso 1), como del tipo 2 solamente (caso 2), siendo el hallazgo que se considera más frecuente. Aunque se ha preconizado el tratamiento con altas dosis de vitamina D3, o sus metabolitos hidroxilizados, éste no fue eficaz en nuestros pacientes (AU)

[Lumbosacral plexopathy as a form of presentation of an aneurysm of the iliac artery]. / Plexopatía lumbosacra como forma de presentación de un aneurisma de la arteria ilíaca.

INTRODUCTION: The etiology of lumbosacral plexopathy is often due to compression. One of the less common causes of this is aneurysm of the iliac artery. However, 13% of the patients with this disorder initially have symptoms of plexus irritation or deficit. CLINICAL CASE: We describe the case of a 42 year-old-man, with no previous medical history, who complained of right-sided sciatica for the previous three months. On examination there were clinical signs of a lesion of the right lumbosacral plexus. On CT of the pelvis and MR of the lumbar spine there were images compatible with an aneurysm of the right iliac artery. This diagnosis was confirmed on arteriography. Treatment was surgical (aneurysmography and right iliofemoral by-pass). The pain disappeared and the motor deficit improved considerably. CONCLUSION: When a patient presents with lumbosacral plexopathy, an iliac aneurysm should be considered as a possible etiological factor. In such cases early diagnosis is essential, since surgical treatment will usually resolve the clinical problem.

[Pourfour du Petit syndrome]. / Síndrome de Pourfour du Petit.

The Pourfour du Petit's syndrome is characterized by the unilateral appearance of mydriasis, lid retraction and exophthalmos. It suggests the existence of a localized oculosympathetic hyperactivity. It tends be to caused by injuries that suppose a stimulus of the sympathetics fibers at level of the proximal portion of the first dorsal root or in the cervical sympathetic chain. We report the clinical case of a young patient who developed a Pourfour du Petit's syndrome secondary to a small condrosarcoma of the proximal portion of the first rib. The observation of this syndrome is exceptional but its knowledge permits, by the great topographic value that possesses, a rapid identification of the causative injury.

[Bilateral hypoacusia and basilar dolichoectasia]. / Hipoacusia bilateral y dolicoectasia basilar.

INTRODUCTION: The clinical findings of basilar dolichoectasia (DB) are caused by compression of the cranial nerves, vertebrobasilar ischaemia, hydrocephaly and compression of the brainstem. Hypoacusia as an isolated finding in DB is very rare. CLINICAL CASE: We describe the case of a 48-year-old hypertensive man with bilateral hypoacusia as an isolated finding in DB. Diagnosis was made on MR, and arteriography showed changes characteristic of an anomalous blood vessel. CONCLUSIONS: In patients with hypoacusia of uncertain aetiology, specially if they are also hypertensive, one should rule out the possibility of DB using cerebral magnetic resonance or angioresonance.

[The use of FD-6 monoclonal antibody in diagnosing and detecting the carriers of familial amyloidotic polyneuropathy type I]. / Utilidad del anticuerpo monoclonal FD-6 para el diagnóstico y la detección de portadores en la polineuropatía amiloidótica familiar tipo I.

Familial amyloidotic polyneuropathy type I (FAF-I) is caused by a specific genetic mutation that gives rise to a transthyretin anomaly whose presence in serum constitutes the biochemical marker for this disease. We studied the serum of 7 patients and 16 asymptomatic members of their immediate families using ELISA with FD-6 monoclonal antibody to detect the transthyretin anomaly. Positive results were found for the 7 patients, including the 2 patients whose disease was apparently sporadic, and 12 carriers were detected among the family members. This technique makes sural nerve biopsy unnecessary for establishing a diagnosis in patients whose clinical signs are consistent with FAP-I. Asymptomatic carriers are also detected, facilitating appropriate genetic counseling.

[Peripheral neuropathy in progressive systemic sclerosis]. / Neuropatía periférica en la esclerosis sistémica progresiva.

We report a patient that developed a sensorimotor polyneuropathy more than a year before the appearance of the typical clinical signs of progressive systemic sclerosis. A sural nerve biopsy showed epineural vasculitis with involvement of the basal membrane of the endoneural vessels, without proliferation of the connective tissue.

[Benign amaurosis fugax]. / Amaurosis fugax benigna.

In young patients episodes of amaurosis fugax usually correspond to processes not related with atherosclerosis of the extracranial vessels such as migraine, cardiac embolism, vasospasm, vasculitis, oral contraceptives or hematologic disease. In 11% of the cases, however, no cause can be found. These idiopathic cases generally have a benign course and their frequency decreases spontaneously allowing them to be described as benign amaurosis fugax. We describe four cases of amaurosis fugax in which no responsible cause was found despite extensive clinical, laboratory ultrasonographic and angiographic studies. The episodes progressively remitted. In these cases of benign amaurosis fugax the risk of a permanent deficit is exceptional and treatment is not necessary.