Psychogenic nonepileptic seizures in Latin America: A survey describing current practices.

OBJECTIVE: Psychogenic nonepileptic seizures (PNES) are one of the most common differential diagnoses of epilepsy. This study provides an overview of diagnostic and treatment services for patients with PNES across Latin America. METHODS: In 2017-2018, clinicians practicing in Latin America with responsibilities for patients with PNES were contacted to respond to a survey regarding the management of this disorder developed by the International League Against Epilepsy (ILAE) PNES Task Force. RESULTS: Three hundred and sixty responses from 17 Latin American countries were analyzed. Most respondents were neurologists (81%) under 40 years of age (61%). Fifty-seven percent of professionals stated that they personally diagnose PNES, but only 33% stated that they provide follow-up, and only 20% that they recommend treatment. Many participants (54%) characterized themselves as either unfamiliar with the diagnosis or inexperienced in arranging treatment. Most respondents reported having access to brain magnetic resonance imaging (MRI; 88%) and routine electroencephalogram (EEG; 71%), 64% have the access to video-EEG longer than 8 h, and 54% of professionals performed video-EEG to confirm PNES diagnoses. Although cognitive-behavioral therapy was recognized as the treatment of choice (by 82% of respondents), there was little access to it (60%). In contrast, a high proportion of respondents reported using antidepressant (67%), antiseizure (57%), and antipsychotic medications (54%) as treatments for PNES. SIGNIFICANCE: This study reveals several deficiencies in the diagnosis and treatment of patients with PNES in Latin America. The barriers are reinforced by lack of knowledge among the specialists and poor healthcare system support. There is inadequate access to prolonged video-EEG and psychotherapy. An inappropriate use of antiseizure medicines seems commonplace, and there are low follow-up rates by neurologists after the diagnosis. Multidisciplinary guidelines are required to improve the approach of patients with PNES.

Forced normalization: A systematic review.

OBJECTIVE: Forced normalization (FN) is an intriguing phenomenon characterized by the emergence of psychiatric disturbances following the establishment of seizure control or reduction in the epileptic activity in a patient with previous uncontrolled epilepsy. We aim to describe the clinical characteristics of the condition. METHODS: We conducted a systematic review on MEDLINE, EMBASE, Cochrane, and Scielo from January 1953 to January 2018. Clinical, electrographic, and imaging data were gathered. We considered all outcomes in children and adults. We performed no meta-analyses due to the limited available data. RESULTS: Of 2606 abstracts identified, 36 fulfilled the FN diagnostic criteria; 193 FN episodes were evaluated and 77 of them were analyzed extensively. Sixty percent of cases were female. Mean age ± standard deviation (SD) was 28.3 ± 14.2 years. The majority of patients had focal (80%) symptomatic (44%) epilepsy. Most patients reported a high ictal frequency (58%) and were on polytherapy (51%). Patients presented psychosis (86.4%), mood disorders (25.8%), and dissociation (4.5%) as the main manifestations. In the psychosis group, persecutory (52.6%) and reference (47.3%) delusions were frequent. FN was provoked by an antiepileptic drug (AED) (48.5%) mainly levetiracetam, epilepsy surgery (31.8%), or vagus nerve stimulation (13.6%). Treatment was homogeneous including anticonvulsant withdrawal (47%) or taper (25%); antipsychotics were initiated in the majority of cases (73%). Psychiatric symptoms were partially controlled in 35%, with complete resolution of symptoms in the remaining 65% of cases. The majority of patients (87%) with AED trigger and withdrawal presented complete resolution of symptoms in comparison to 28.5% of patients triggered by surgery. SIGNIFICANCE: Forced normalization is an entity whose pathophysiology remains uncertain. Antipsychotic drug use does not predict complete resolution of psychiatric symptoms in comparison with AED withdrawal. Although there is a positive response to treatment in patients with FN triggered by drugs, the prognosis is obscure in patients with surgery triggered FN.

Epilepsy, Physical Activity and Sports: A Narrative Review.

People with epilepsy (PWE) are less physically active compared with the general population. Explanations include prejudice, overprotection, unawareness, stigma, fear of seizure induction and lack of knowledge of health professionals. At present, there is no consensus on the role of exercise in epilepsy. This paper reviews the current evidence surrounding the risks and benefits associated with physical activity (PA) in this group of patients. In the last decade, several publications indicate significant benefits in physiological and psychological health parameters, including mood and cognition, physical conditioning, social interaction, quality of life, as well as potential prevention of seizure presentation. Moreover, experimental studies suggest that PA provides mechanisms of neuronal protection, related to biochemical and structural changes including release of ß-endorphins and steroids, which may exert an inhibitory effect on the occurrence of abnormal electrical activity. Epileptic discharges can decrease or disappear during exercise, which may translate into reduced seizure recurrence. In some patients, exercise may precipitate seizures. Available evidence suggests that PA should be encouraged in PWE in order to promote wellbeing and quality of life. There is a need for prospective randomized controlled studies that provide stronger clinical evidence before definitive recommendations can be made.

Costos de bolsillo de pacientes con diagnóstico de tuberculosis en Colombia / Out-of-pocket costs of patients diagnosed with tuberculosis in Colombia

Introducción. La tuberculosis (TB) es una enfermedad infecto-contagiosa producida por micobacterias; según datos de la Organización Mundial de la Salud, un tercio de la población mundial está infectada. Para combatirla se ha empleado la estrategia DOTS (Directly Observed Therapy Short Course), efectiva para el diagnóstico, tratamiento y monitoreo de la tuberculosis. Objetivo. Estimar costos de bolsillo que asumen los pacientes con tuberculosis, que reciben tratamiento bajo la estrategia DOTS. Diseño. Estudio observacional descriptivo, prospectivo. Lugar. Tres ciudades de Colombia (Medellín, Montería y Quibdó). Participantes. Pacientes con diagnóstico de TB. Intervenciones. Se utilizó un instrumento de recolección que incluía variables relacionadas con los costos de bolsillo directos e indirectos. El análisis se hizo en el programa SPSS versión 17,0 y STATA 11; a las variables cuantitativas se les estimó media y desviación estándar, mientras que a las cualitativas proporciones. Resultados. Participaron 91 pacientes que se encontraban en tratamiento bajo la estrategia DOTS. El promedio de edad fue 39,3±20 años; la mayoría vivía con sus familiares. Los ingresos mensuales de los pacientes tuvieron una media de 422 863 COP (1€ = 3 149 COP) y los gastos directos más altos generados por el tratamiento fueron los destinados al desplazamiento y ayudas diagnósticas, con una media de 8 181 y 7 630 COP, respectivamente. Conclusiones. Los costos asumidos por los pacientes bajo la estrategia DOTS fueron altos, incluso cuando el tratamiento se entrega gratuitamente. La modificación de la estrategia para evitar costos en los pacientes podría impactar disminuyendo el abandono del tratamiento por los mismos.

Introduction: Tuberculosis (TB) is a contagious disease caused by mycobacteria. According to the World Health Organization, one third of the world's population is infected. The directly observed therapy short course (DOTS) strategy has been used effective for the diagnosis, treatment and monitoring of tuberculosis. Objective: To estimate the out-of-pocket costs of TB patients who receive treatment under the DOTS strategy. Design: Descriptive prospective and observational study. Setting: Three cities in Colombia (Medellin, Monteria and Quibdo). Participants: Patients diagnosed with TB. Interventions: An instrument was used that included variables related to direct and indirect out-of-pocket costs. The analysis was done using the SPSS version 17.0 and STATA 11; mean and standard deviation were estimated for quantitative variables, and proportions for qualitative variables. Results: The DOTS strategy was applied in 91 patients. The average age was 39.3 ± 20 years; most patients lived with their families. The monthly income of the patients was 422 863 COP (1€ = 3 149 COP) in average and the higher direct costs generated by the treatment were those for traveling and diagnostic aids, with an average cost of 8 181 and 7 630 COP respectively. Conclusions: The costs assumed by patients under the DOTS strategy were high, even when treatment was provided free of charge. The modification of the strategy to avoid costs in patients could decrease treatment dropout.

Mixoma atrial: más que una neoplasia benigna / Atrial myxoma: more than a beningn neoplasm

RESUMEN Los tumores cardíacos son parte del diagnóstico diferencial en el estudio de las masas intracardíacas, junto con vegetaciones, trombos, calcificaciones valvulares, entre otros. Su localización, tamaño y movilidad pueden dar lugar a importantes implicaciones funcionales y anatómicas que determinan la presentación clínica. Describimos el caso de una mujer de 51 años de edad, quien se presentó con cuadro sugestivo de un síndrome coronario agudo, pero gracias a los hallazgos ecocardiográficos se le diagnosticó un tromboembolismo pulmonar originado por un mixoma en la aurícula derecha con posterior verificación histopatológica..

Cardiac tumors are part of the differential diagnosis in the study of intra-cardiac masses along with vegetations, thrombi, valvular calcifications among others. Their localization, size and mobility can lead to major anatomical and functional implications determining the clinical presentation. We describe the case of a 51 year-old female, who presented with complains suggestive of an acute coronary syndrome, in which an echocardiographic showed it a pulmonary embolism caused by a right atrial myxoma with histopathological verification was made.

Caracterización epidemiológica de las infecciones nosocomiales en un hospital de tercer nivel de atención de la ciudad de Medellín, Colombia: enero 2005 – junio 2009 / Characterization of hospital-acquired infections in a third-level hospital in Medellin, Colombia: January 2005-June 2009

Objetivo: describir las características epidemiológicas de las infecciones nosocomiales reportadas en un hospital universitario de tercer nivel de complejidad en Medellín, Colombia, durante enero 2005 –junio 2009.Metodología: estudio observacional descriptivo. Se obtuvo información de las infecciones nosocomiales mediante las bases de datos manejadas por el Comité de Vigilancia Epidemiológica de la institución en las historias clínicas de los pacientes. Se realizó un análisis descriptivo por medio de medidas de tendencia central y porcentajes.Resultados: se identificaron 1 136 infecciones nosocomiales en 953 pacientes diferentes, para una tasa global de infección intrahospitalaria de 2.2 casos por cada 100 egresos. Un 63.7% de los pacientes estaba compuesto por mujeres, la medianade la edad fue 37 años (RIQ 21–60.3), la mediana de estancia hospitalaria de 11 días (RIQ 5–24) días. Las infecciones nosocomiales más comunes fueron la del sitio operatorio (25.9%), y la del tracto urinario (16.3%). Los microorganismos aislados más comunes fueron: Escherichia coli (27.9%), Staphylococcus aureus (17.9%), y Klebsiella pneumoniae (11.1%).En general, no se encontró que el aumento en el número de camas se viera acompañado de un aumento en la tasa de infecciones nosocomiales.Conclusión: las infecciones nosocomiales son relativamente poco comunes en la institución estudiada, cuando se compara con instituciones similares tanto nacional como internacional.

Objective: the purpose of the following study was to perform an epidemiological characterization of hospital-acquired Infectionsreported in a third level of complexity university hospital in Colombia, from January 2005- June 2009. Methods: we conducted an observational and descriptive study. Information regarding the occurrence of Hospital-AcquiredInfections was initially obtained from the Hospital’s Epidemiologic Surveillance Committee Databases, additional details of every patient were obtained from their respective clinical records. A descriptive analysis was conducted using measures ofcentral tendency and percentages.Results: a total of 1 136 hospital-acquired infections occurring in 953 patients were included, for an overall risk of 2.2 infections per 100 hospital discharges. Most patients were female, 63.7%, with a median age of 37 years (IQR 21–60.3) and a median length of hospital stay of 11 (IQR 5–24) days. The most common infections, along with their relative frequencies, were: surgicalsite infections (25.9%), and urinary tract infections (16.3%). The most commonly isolated microorganisms were: Escherichia coli (27.9%), Staphylococcus aureus (17.9%), and Klebsiella pneumoniae (11.1%). In general, we did not find that the increasein the number of beds was accompanied by an increase in the rate of nosocomial infections. Conclusion: nosocomial infections are relatively rare in the studied institution, when compared with similar institutions both nationally and internationally.