Validación de la versión española de la Escala Cognitiva de Montreal (MoCA) como herramienta de cribado de deterioro cognitivo asociado a la esclerosis múltiple / Validation of the Spanish-language version of the Montreal Cognitive Assessment as a screening test for cognitive impairment in multiple sclerosis

Introducción: Las baterías neuropsicológicas empleadas tradicionalmente para el diagnóstico del deterioro cognitivo (DC) en la esclerosis múltiple son pruebas complejas que conllevan mucho tiempo. Se necesitan test más simples para detectar el DC en la práctica clínica diaria.ObjetivoEvaluar la validez diagnóstica y la fiabilidad de la escala Montreal Cognitive Assessment (MoCA) como herramienta de cribado de DC en la esclerosis múltiple frente a la Batería Neuropsicológica Breve.Material y métodosSe seleccionaron 52 pacientes (61,5% mujeres, edad media [desviación estándar] 41,7 [11,5] años). Se analizaron la fiabilidad (consistencia interna, interobservador y test-retest) y la validez de constructo (análisis factorial, coeficiente de correlación de Pearson y coeficiente de determinación) y de criterio (curva ROC, sensibilidad, especificidad, acuerdo global, valores predictivos positivo y negativo, cocientes de probabilidad positivo y negativo y nomograma de Fagan).ResultadosLa prevalencia de DC fue del 21,2% según la Batería Neuropsicológica Breve y del 25% según el MoCA. El MoCA mostró buena consistencia interna (alfa de Cronbach 0,822) y buena fiabilidad interobservador y test-retest (coeficiente de correlación intraclase de 0,80 y 0,96, respectivamente). El coeficiente de correlación entre la puntuación total de la Batería Neuropsicológica Breve y el MoCA fue de 0,82. El punto óptimo de corte en la curva ROC fue 25-26, con una sensibilidad del 91% y una especificidad del 93%.ConclusiónEl MoCA es una herramienta de cribado válida y fiable para la detección de DC en pacientes con esclerosis múltiple. (AU)

Introduction: The neuropsychological batteries traditionally used for the assessment of cognitive impairment (CI) in patients with multiple sclerosis are complex tests requiring a long time to administer. Simpler tests are needed to detect cognitive impairment in daily clinical practice.ObjectiveWe aimed to evaluate the diagnostic validity and reliability of the Montreal Cognitive Assessment (MoCA) test as a screening tool for CI in patients with multiple sclerosis, as compared against the Brief Neuropsychological Battery.Material and methodsWe recruited 52 patients with multiple sclerosis (61.5% women; mean age [standard deviation]: 41.7 [11.5] years). We analysed the reliability (internal consistency, interobserver reliability, and test-retest reliability), construct validity (factor analysis, Pearson correlation coefficient, and coefficient of determination), and criterion validity (ROC curve, sensitivity, specificity, total agreement, positive and negative predictive values, positive and negative likelihood ratios, and Fagan nomogram) of the MoCA test in this population.ResultsThe prevalence of CI was 21.2% according to findings from the Brief Neuropsychological Battery, and 25% according to the MoCA test. The MoCA test showed good internal consistency (Cronbach alpha, 0.822) and interobserver and test-retest reliability (intraclass correlation coefficient 0.80 and 0.96, respectively). The correlation coefficient between total Brief Neuropsychological Battery and MoCA test scores was 0.82. The optimal cut-off point on the ROC curve was 25-26, yielding 91% sensitivity and 93% specificity.ConclusionThe MoCA test is a valid and reliable tool for screening for CI in patients with multiple sclerosis. (AU)

Validation of the Spanish-language version of the Montreal Cognitive Assessment as a screening test for cognitive impairment in multiple sclerosis.

BACKGROUND: The neuropsychological batteries traditionally used for the assessment of cognitive impairment (CI) in patients with multiple sclerosis are complex tests requiring a long time to administer. Simpler tests are needed to detect cognitive impairment in daily clinical practice. OBJECTIVE: We aimed to evaluate the diagnostic validity and reliability of the Montreal Cognitive Assessment (MoCA) test as a screening tool for CI in patients with multiple sclerosis, as compared against the Brief Neuropsychological Battery. MATERIAL AND METHODS: We recruited 52 patients with multiple sclerosis (61.5% women; mean age [standard deviation]: 41.7 [11.5] years). We analysed the reliability (internal consistency, interobserver reliability, and test-retest reliability), construct validity (factor analysis, Pearson correlation coefficient, and coefficient of determination), and criterion validity (ROC curve, sensitivity, specificity, total agreement, positive and negative predictive values, positive and negative likelihood ratios, and Fagan nomogram) of the MoCA test in this population. RESULTS: The prevalence of CI was 21.2% according to findings from the Brief Neuropsychological Battery, and 25% according to the MoCA test. The MoCA test showed good internal consistency (Cronbach alpha, 0.822) and interobserver and test-retest reliability (intraclass correlation coefficient 0.80 and 0.96, respectively). The correlation coefficient between total Brief Neuropsychological Battery and MoCA test scores was 0.82. The optimal cut-off point on the ROC curve was 25-26, yielding 91% sensitivity and 93% specificity. CONCLUSION: The MoCA test is a valid and reliable tool for screening for CI in patients with multiple sclerosis.

Validation of the Spanish-language version of the Montreal Cognitive Assessment as a screening test for cognitive impairment in multiple sclerosis. / Validación de la versión española de la Escala Cognitiva de Montreal (MoCA) como herramienta de cribado de deterioro cognitivo asociado a la esclerosis múltiple.

INTRODUCTION: The neuropsychological batteries traditionally used for the assessment of cognitive impairment (CI) in patients with multiple sclerosis are complex tests requiring a long time to administer. Simpler tests are needed to detect cognitive impairment in daily clinical practice. OBJECTIVE: We aimed to evaluate the diagnostic validity and reliability of the Montreal Cognitive Assessment (MoCA) test as a screening tool for CI in patients with multiple sclerosis, as compared against the Brief Neuropsychological Battery. MATERIAL AND METHODS: We recruited 52 patients with multiple sclerosis (61.5% women; mean age [standard deviation]: 41.7 [11.5] years). We analysed the reliability (internal consistency, interobserver reliability, and test-retest reliability), construct validity (factor analysis, Pearson correlation coefficient, and coefficient of determination), and criterion validity (ROC curve, sensitivity, specificity, total agreement, positive and negative predictive values, positive and negative likelihood ratios, and Fagan nomogram) of the MoCA test in this population. RESULTS: The prevalence of CI was 21.2% according to findings from the Brief Neuropsychological Battery, and 25% according to the MoCA test. The MoCA test showed good internal consistency (Cronbach alpha, 0.822) and interobserver and test-retest reliability (intraclass correlation coefficient 0.80 and 0.96, respectively). The correlation coefficient between total Brief Neuropsychological Battery and MoCA test scores was 0.82. The optimal cut-off point on the ROC curve was 25-26, yielding 91% sensitivity and 93% specificity. CONCLUSION: The MoCA test is a valid and reliable tool for screening for CI in patients with multiple sclerosis.

Adiponectin and graft vascular disease after cardiac transplantation.

Graft vascular disease (GVD) is a form of accelerated atherosclerosis that involves the transplanted heart, affecting more than 40% of patients after follow-up of 5 years. According to some authors, adiponectin concentration is a prognostic factor for progression of coronary atherosclerosis. Following this line of research, the objective of the present study was to analyze the relationship between adiponectin concentration and development of GVD in 52 cardiac transplant recipients. Patients were divided into 2 groups according to findings at intravascular ultrasound: group 1 with 21 patients without GVD, and group 2 with 31 patients with GVD. Patients with GVD were further divided into 2 additional groups according to results of coronary angiography: group 3 with 35 patients without GVD, and group 4 with 17 patients with any degree of GVD. No significant differences (P=.50) were observed insofar as adiponectin concentration between groups 1 and 2, and groups 3 and 4. Significant differences in adiponectin concentration were observed when the sex of the patient was considered (P=.002), with higher concentrations detected in women. Serious cardiac events were more common in patients with GVD (P=.001). Mean time between transplantation and diagnosis of GVD was 67 months in group 1, 107 months in group 2, 71 months in group 3, and 101 months in group 4. Significant differences were observed between groups 1 and 2 (P=.030).

Accuracy of MRI criteria for dissemination in space for the diagnosis of multiple sclerosis in patients with clinically isolated syndromes.

The MRI Barkhof-Tintoré criteria have proved to be highly specific for predicting conversion to clinically definite multiple sclerosis in patients with clinically isolated syndromes (CIS), but lacked an optimal sensitivity. In order to improve the accuracy of early multiple sclerosis diagnosis, new imaging criteria have been proposed by Swanton et al. We aimed to evaluate the accuracy of both MRI criteria for dissemination in space to predict conversion from CIS to clinically definite multiple sclerosis. We studied 79 CIS patients with baseline MRI performed within the first 3 months after onset. The sensitivity and specificity of both MRI criteria to predict conversion to clinically definite multiple sclerosis were analysed. The time to develop clinically definite multiple sclerosis from CIS onset, according to each imaging criteria, was studied by Kaplan-Meier survival curves. The overall conversion rate was 75.7% with a median follow-up of 57 months. Barkhof- Tintoré's criteria showed a sensitivity of 71.9% and a specificity of 77.2%. Swanton's criteria had a sensitivity of 91.2% and a specificity of 68.1%. Both MRI criteria identified CIS patients with higher risk and faster conversion to clinically definite multiple sclerosis. Swanton's criteria are simpler and more sensitive than Barkhof-Tintoré's criteria, with a slight decrease in specificity. These results reinforce their use in multiple sclerosis diagnosis.

[Evaluation of high risk syncope referred from emergency department]. / Evaluación del síncope de alto riesgo remitido desde el Servicio de Urgencias.

INTRODUCTION: High-risk syncope (over aged 60, abnormal electrocardiogram, syncope without prodromes and/or background of cardiovascular disease) is associated with high mortality. More detailed attention to that which may often be considered as an emergency should be given. We have evaluated the activity of a specialized service in the care of syncope in an internal medicine service. MATERIAL AND METHODS: We have collected a series of patients diagnosed in the emergency service of "syncope." The patients were referred to the specialized unit in the care of syncope and evaluated in less than 72h. We analyzed the tests made to establish a pathophysiological diagnosis of syncope. RESULTS: A total of 107 consecutive patients were studied, 82 of whom met the criteria for being at risk of syncope. All underwent an echocardiography and outpatient Holter. A total of 23 studies were performed with tilt test, 4 electrophysiological studies were performed and 2 were implanted with an insertable Holter. A specific diagnosis could be established in 73 patients. Three patients were diagnosed with a neurological disease. The most frequent cause of the syncope was neuromediated (41 patients). After a mean follow-up of over 2 years, total mortality (9 patients) was not related with the syncope. CONCLUSIONS: A specialized service in the care of high-risk syncope increases the percentage of patients with a definitive diagnosis.

Evaluación del síncope de alto riesgo remitido desde el Servicio de Urgencias / Evaluation of high risk syncope referred from emergency department

Introducción El síncope de alto riesgo (más de 65 años, electrocardiograma anormal, síncope sin pródromos y/o antecedentes de patología cardiovascular) se asocia a una elevada mortalidad. Parece aconsejable una atención más detallada de la que puede ofrecerse en Urgencias. Hemos evaluado la actividad de una consulta monográfica de síncope en un Servicio de Cardiología. Material y métodos Hemos recogido una serie de enfermos diagnosticados en Urgencias de «sincope». Los enfermos fueron remitidos a la consulta monográfica de síncope y evaluados en menos de 72h. Hemos analizado las pruebas realizadas para establecer un diagnóstico fisiopatológico del síncope. Resultados Estudiamos 107 pacientes consecutivos, de los que 82 cumplían criterios de síncope de riesgo. A todos se les realizó una ecocardiografía y un Holter ambulatorio. Se realizaron 23 estudios con mesa basculante, 4 estudios electrofisiológicos, y se implantaron 2 Holter insertables. En 73 pacientes pudimos establecer un diagnóstico concreto. Tres pacientes fueron diagnosticados de una enfermedad neurológica. La causa más frecuente del síncope fue la neuromediada (41 pacientes). Tras un seguimiento medio superior a 2 años, la mortalidad total (9 pacientes) no se relacionó con el síncope. Conclusiones Una consulta especializada en síncope de alto riesgo aumenta el porcentaje de pacientes con diagnóstico definitivo(AU)

Introduction High-risk syncope (over aged 60, abnormal electrocardiogram, syncope without prodromes and/or background of cardiovascular disease) is associated with high mortality. More detailed attention to that which may often be considered as an emergency should be given. We have evaluated the activity of a specialized service in the care of syncope in an internal medicine service. Material and methods We have collected a series of patients diagnosed in the emergency service of “syncope.” The patients were referred to the specialized unit in the care of syncope and evaluated in less than 72h. We analyzed the tests made to establish a pathophysiological diagnosis of syncope. Results A total of 107 consecutive patients were studied, 82 of whom met the criteria for being at risk of syncope. All underwent an echocardiography and outpatient Holter. A total of 23 studies were performed with tilt test, 4 electrophysiological studies were performed and 2 were implanted with an insertable Holter. A specific diagnosis could be established in 73 patients. Three patients were diagnosed with a neurological disease. The most frequent cause of the syncope was neuromediated (41 patients). After a mean follow-up of over 2 years, total mortality (9 patients) was not related with the syncope. Conclusions A specialized service in the care of high-risk syncope increases the percentage of patients with a definitive diagnosis(AU)

Marcadores analíticos de enfermedad vascular del injerto en el trasplante cardiaco / Laboratory test markers of graft vascular disease in heart transplant patients

La enfermedad vascular del injerto (EVI) afecta a más del 40% de los pacientes trasplantados cardiacos a los 5 años de seguimiento y es la primera causa de muerte después del primer año postraplante cardiaco. El objetivo es demostrar la relación entre las concentraciones de adiponectina y otras citocinas con el desarrollo de EVI y sus distintos grados de severidad. Material y metodología: incluimos 21 pacientes a los que se realiza coronariografía-IVUS (ecografía intracoronaria) para el diagnóstico de EVI y determinamos las cifras de adiponectina. Tenían EVI por coronariografía 10 pacientes y por IVUS 14 pacientes. Resultados: No se encontraron diferencias estadísticamente significativas en los niveles de adiponectina en función de la existencia de EVI diagnosticada por coronariografía ni en función del grado de severidad de la EVI por IVUS. Se encontraron asociaciones estadísticamente significativas entre la existencia de EVI diagnosticada por IVUS y las concentraciones de IL-6 (p=0,025) con mayores concentraciones de IL6 en los que no tenían EVI o era de grado leve y entre la existencia de EVI por coronariografía y los niveles de BNP (p=0,014) con niveles más elevados de BNP en los que tenían EVI. Se encontró una relación entre el sexo y los niveles de adiponectina (p=0,025) con niveles superiores en las mujeres. Había una relación estadísticamente significativa entre la aparición de eventos cardiacos mayores (MACE) y la existencia de EVI diagnosticada por coronariografía (p=0,012) (AU)

Graft vascular disease (GVD) affects over 40% of all heart transplant patients after 5 years of follow-up, and is the first cause of death after the first post-transplantation year. A study is made of the relationship between the concentrations of adiponectin and other cytokines and the development of GVD and its different degrees of severity. Material and methods: The study included 21 patients subjected to coronariography-intravascular ultrasound (IVUS) for the diagnosis of GVD, with the determination of adiponectin levels. GVD was identified by coronariography in 10 patients and by IVUS in 14 patients. Results: There were no statistically significant differences in adiponectin levels according to the existence of GVD diagnosed by coronariography, or according to the severity of GVD as determined by IVUS. Statistically significant correlations were recorded between the presence of GVD diagnosed by IVUS and the concentrations of IL-6 (p=0.025), with higher IL-6 levels in those without GVD or with only mild GVD; and between the presence of GVD determined by coronariography and the levels of BNP (p=0.014) – higher levels of this protein being found in the patients with GVD. A relationship was observed between patient gender and adiponectin levels (p=0.025), with higher concentrations in women. A statistically significant relationship was seen between the appearance of major adverse cardiac events (MACEs) and the existence of GVD as diagnosed by coronariography (p=0.012) (AU)

Infections in cardiac transplant recipients: clinical and microbiological characteristics and consequences.

INTRODUCTION: Infections are one of the main complications that cause morbidity and mortality in cardiac transplant recipients. We sought to establish the incidence of infections, identify the predisposing factors and determine their consequences. PATIENTS: A prospective study of 30 patients who received cardiac transplantations in our hospital from July 2003 to May 2005. RESULTS: Of the 30 transplant recipients, 93.3% were men (average age, 48 years); the average age of the women was 53 years. The incidence of infection was 70%: 21 episodes of infection. The main clinical symptoms were bacteriemia (28%), pneumonia (19%), and surgical wound infections (14%). The etiology of the infection, as established in 12 cases (57%), was bacterial (66%), viral (25%), or fungal (9%). The most common microorganisms were cytomegalovirus and coagulase-negative staphylococcus. None of the donors had a history of infection. There was a higher frequency of serious complications, such as renal failure (12.9%), respiratory insufficiency (9.6%), and multiorgan failure (9.6%) among patients with versus without infections (P < .05). The 1-year survival rate of patients with infections was similar to that of patients with no infections (83% vs 88%, P = NS). CONCLUSIONS: The incidence of infections was 70%. Bacteremia, pneumonia, and surgical wound infections occurred most frequently. Cytomegalovirus and coagulase-negative staphylococcus were the most frequent microorganisms. Patients with infections had the most serious complications, but their survival rate was similar to that of patients free of this complication.

Use of oral sildenafil in patients with irreversible pulmonary hypertension not eligible for heart transplantation.

Heart transplantation is contraindicated in patients with acute irreversible pulmonary hypertension (PH), but new drugs are opening up therapeutic possibilities. Sildenafil citrate is a nonselective pulmonary vasodilator that is being used in our hospital to treat several patients with PH and which has allowed the inclusion of 1 patient on the waiting list for heart transplantation. A 20-year-old man with Becker muscular dystrophy was diagnosed at the age of 19 years with dilated cardiomyopathy with severe pulmonary artery systolic pressure (PH = 60 mm Hg). A pretransplantation study, including a right hemodynamic analysis with an acute vasodilator test using intravenous epoprostenol, revealed the irreversible character of the PH. Inasmuch as the administration of dobutamine did not achieve an adequate reduction of PH, oral sildenafil was started (25 mg every 12 hours) as salvage therapy. An echocardiogram obtained 2 months after starting sildenafil therapy showed normal right cavities, previously dilated, as well as minimal protosystolic tricuspid regurgitation without PH. A new right hemodynamic study performed after 4 months showed a reduction in pulmonary vascular resistance, from 8 U to 3.5 U Woods. As a result, the patient has now been included on the waiting list for heart transplantation. The promising example of this patient confirms the necessity to carry out controlled trials to establish definitively the indications for the use of sildenafil in patients with irreversible PH.