OnabotulinumtoxinA en el tratamiento de la odontalgia atípica: descripción de un caso clínico / OnabotulinumtoxinA in the treatment of atypical odontalgia: description of a clinical case

La odontalgia atípica (OA) se define como un dolor dental continuo en uno o varios dientes, en ocasiones precedido por procedimientos dentales, y que tras un examen completo no se detecta patología dental. Se presupone un origen neuropático cuya respuesta a tratamientos locales y sistémicos es insatisfactoria. Presentamos el caso clínico de una paciente de 50 años con OA tras extracción dental, que presentó una reducción significativa del dolor después del tratamiento local con OnabotulinumtoxinA (OnabotA) en el área sintomática. La respuesta a la administración de OnabotA en esta paciente concuerda con las observadas previamente en series reducidas de casos, por lo que podría ser una alternativa terapéutica en este tipo de dolores de difícil control

Atypical odontalgia (AO) is defined as a continuous dental pain in the area of one or several teeth, sometimes preceded by dental procedures in the absence of signs of dental pathology after complete examination. It is thought to have a neuropathic origin in which the response to local and systemic treatment is insufficient. We present the case of a 50-year-old patient with AO after dental extraction, who presented a significant reduction in pain after local treatment with OnabotulinumtoxinA (OnabotA) in the symptomatic area. The response to the administration of OnabotA in this patient is in line with what had previously been observed in small series of cases, so it could be a therapeutic alternative in this type of pain that is difficult to control

[OnabotulinumtoxinA in the treatment of atypical odontalgia: description of a clinical case]. / OnabotulinumtoxinA en el tratamiento de la odontalgia atípica: descripción de un caso clínico.

Atypical odontalgia (AO) is defined as a continuous dental pain in the area of one or several teeth, sometimes preceded by dental procedures in the absence of signs of dental pathology after complete examination. It is thought to have a neuropathic origin in which the response to local and systemic treatment is insufficient. We present the case of a 50-year-old patient with AO after dental extraction, who presented a significant reduction in pain after local treatment with OnabotulinumtoxinA (OnabotA) in the symptomatic area. The response to the administration of OnabotA in this patient is in line with what had previously been observed in small series of cases, so it could be a therapeutic alternative in this type of pain that is difficult to control.

Aplicación práctica de los test cognitivos breves / Practical application of brief cognitive tests

Introducción: Los test cognitivos breves (TCB) pueden ayudar a detectar el deterioro cognitivo (DC) en el ámbito asistencial. Se han desarrollado y/o validado varios TCB en nuestro país, pero no existen recomendaciones específicas para su uso. Desarrollo: Revisión de estudios sobre el rendimiento diagnóstico en la detección del DC llevados a cabo en España con TCB que requieran menos de 20 min y recomendaciones de uso consensuadas por expertos, sobre la base de las características de los TCB y de los estudios disponibles. Conclusión: El Fototest, el Memory Impairment Screen (MIS) y el Mini-Mental State Examination (MMSE) son las opciones más recomendables para el primer nivel asistencial, pudiendo añadirse otros test (Test del Reloj [TR] y test de fluidez verbal [TFV]) en caso de resultado negativo y queja o sospecha persistente (aproximación escalonada). En el segundo nivel asistencial es conveniente una evaluación sistemática de las distintas áreas cognitivas, que puede llevarse a cabo con instrumentos como el Montreal Cognitive Assessment, el MMSE, el Rowland Universal Dementia Assessment o el Addenbrooke's Cognitive Examination, o bien mediante el uso escalonado o combinado de herramientas más simples (TR, TFV, Fototest, MIS, Test de Alteración de la Memoria y Eurotest). El uso asociado de cuestionarios cumplimentados por un informador (CCI) aporta valor añadido a los TCB en la detección del DC. La elección de los instrumentos vendrá condicionada por las características del paciente, la experiencia del clínico y el tiempo disponible. Los TCB y los CCI deben reforzar -pero nunca suplantar- el juicio clínico, la comunicación con el paciente y el diálogo interprofesional

Introduction: Brief cognitive tests (BCT) may help detect cognitive impairment (CI) in the clinical setting. Several BCT have been developed and/or validated in our country, but we lack specific recommendations for use. Development: Review of studies on the diagnostic accuracy of BCT for CI, using studies conducted in Spain with BCT which take less than 20 min. We provide recommendations of use based on expert consensus and established on the basis of BCT characteristics and study results. Conclusion: The Fototest, the Memory Impairment Screen (MIS) and the Mini-Mental State Examination (MMSE) are the preferred options in primary care; other BCT (Clock Drawing Test [CDT], test of verbal fluency [TVF]) may also be administered in cases of negative results with persistent suspected CI or concern (stepwise approach). In the specialised care setting, a systematic assessment of the different cognitive domains should be conducted using the Montreal Cognitive Assessment, the MMSE, the Rowland Universal Dementia Assessment, the Addenbrooke's Cognitive Examination, or by means of a stepwise or combined approach involving more simple tests (CDT, TVF, Fototest, MIS, Memory Alteration Test, Eurotest). Associating an informant questionnaire (IQ) with the BCT is superior to the BCT alone for the detection of CI. The choice of instruments will depend on the patient's characteristics, the clinician's experience, and available time. The BCT and IQ must reinforce - but never substitute - clinical judgment, patient-doctor communication, and inter-professional dialogue

Practical application of brief cognitive tests.

INTRODUCTION: Brief cognitive tests (BCT) may help detect cognitive impairment (CI) in the clinical setting. Several BCT have been developed and/or validated in our country, but we lack specific recommendations for use. DEVELOPMENT: Review of studies on the diagnostic accuracy of BCT for CI, using studies conducted in Spain with BCT which take less than 20 min. We provide recommendations of use based on expert consensus and established on the basis of BCT characteristics and study results. CONCLUSION: The Fototest, the Memory Impairment Screen (MIS) and the Mini-Mental State Examination (MMSE) are the preferred options in primary care; other BCT (Clock Drawing Test [CDT], test of verbal fluency [TVF]) may also be administered in cases of negative results with persistent suspected CI or concern (stepwise approach). In the specialised care setting, a systematic assessment of the different cognitive domains should be conducted using the Montreal Cognitive Assessment, the MMSE, the Rowland Universal Dementia Assessment, the Addenbrooke's Cognitive Examination, or by means of a stepwise or combined approach involving more simple tests (CDT, TVF, Fototest, MIS, Memory Alteration Test, Eurotest). Associating an informant questionnaire (IQ) with the BCT is superior to the BCT alone for the detection of CI. The choice of instruments will depend on the patient's characteristics, the clinician's experience, and available time. The BCT and IQ must reinforce - but never substitute - clinical judgment, patient-doctor communication, and inter-professional dialogue.

[Preventive prophylactic treatment in posttraumatic epilepsy]. / Tratamiento preventivo-profiláctico de la epilepsia postraumática.

Posttraumatic epilepsy (PTE) represents about 2 3% of all the etiologies of epilepsy. The so called early seizures , which appear in the first week after the traumatic brain injury (TBI), are related to the severity of the injury; they do not have an strictly epileptic mechanism, but they become a risk factor to the development of PTE. PTE appears in 5% of all the patients suffering from all TBI, and in 15 20% of the patients suffering from a severe TBI. However, the endpoint uses to be to use antiepileptic drugs (AEDs) as prophylactic treatment in all well established PTE. The efficacy of classic antiepileptic drugs (Phenobarbital, Phenytoin, Carbamazepine, Valproate acid) to control the kindling effect has not been confirmed yet as a prophylactic treatment for PTE. Prophylactic efficacy of other drugs, like lipid peroxidation inhibitors, neuroprotectors (especially antioxidants), glutamic receptor blockers, NMDA receptor blockers, and drugs that modulate apoptosis via caspasas inhibition; however, they constitute new ways of therapeutic investigation with a strong experimental basis. Our recommended therapeutic strategy is not to administrate AEDs indiscriminately, but analyzing risk factors, designing a careful prevention for late seizures using AEDs with proven efficacy in partial seizures and with the best achievable tolerability; being also attentive to the possible use of new drugs in the future, like lipid peroxidation inhibitors, and drugs designed to inhibit other excitotoxic, ionic or oxidative processes.

Tratamiento preventivo-profiláctico de la epilepsia postraumática / Preventive-prophylactic treatment in posttraumatic epilepsy

La epilepsia postraumática (EPT) representa un 2-3 por ciento de las causas de todas las epilepsias. Las llamadas `crisis cerebrales tempranas o precoces' aparecidas en la primera semana posterior al TCE, son proporcionales a la gravedad del mismo, no tienen mecanismo estrictamente epiléptico, pero son factor de riesgo para la formación de EPT. Ésta aparece en el 5 por ciento de todos los TCE, y en el 15-20 por ciento de los graves. Por ello no se aconseja el tratamiento profiláctico con fármacos antiepilépticos (FAE) en todos los TCE. En cambio, se concluye que deben administrarse FAE como tratamiento de la EPT bien definida. La eficacia de los FAE clásicos (Fb, fenitoína, carbamacepina, valproato) para controlar el efecto kindling no se ha confirmado en su administración profiláctica de la EPT. Todavía no está suficientemente probada la eficacia profiláctica de inhibidores de la peroxidación lipídica, diversos neuroprotectores, especialmente antioxidantes, bloqueantes del receptor glutamato y de los NMDA, y moduladores de la apoptosis por inhibición de las caspasas, aunque constituyan nuevas vías de investigación terapéutica de fuerte base experimental. Como estrategia terapéutica se recomienda no administrar FAE indiscriminadamente, sino analizando factores de riesgo, hacer una cuidadosa prevención de las crisis sintomáticas agudas, hasta ahora con fenitoína, y programar la profilaxis tardía con fármacos eficaces en crisis focales y de la máxima tolerabilidad posible, contemplando la posible incorporación en un próximo futuro de inhibidores de la peroxidación lipídica y de otros procesos excitotóxicos, iónicos y oxidativos (AU)

[Therapeutic benefits of monotherapy with lamotrigine]. / Beneficio terapéutico de la monoterapia con lamotrigina.

OBJECTIVE: To analyze the overall therapeutic benefit (effect on seizures and quality of life) in 100 patients, aged 14-89 years, treated with lamotrigine (LTG) as primary (25) or secondary (75) monotherapy, followed up for between one and six years. PATIENTS AND METHODS: The patients were selected for treatment, under open observation, and not randomized at all. Thirty patients suffered from generalized seizures and 70 from partial crises, with progression to generalized tonic-clonic crises in 36 cases. The usual LTG serum level when bi-therapy was used was 2 to 4 mg and was similar with monotherapy. The predominant dosage of LTG (100 to 200 mg) was similar for monotherapy and for bi-therapy in those treated with valproate, as compared with 200-400 mg in most of those in whom the associated drug was carbamazepine (24), phenobarbital (14), phenytoin (6) or other drug, with a considerable reduction in dose (of 100 mg to 250 mg) when they were treated by monotherapy instead. RESULTS: Overall therapeutic benefit was obtained in 79 cases, partly due to suppression or reduction of the seisures, or maintenance free of them, but mainly due to correction of the side-effects, especially somnolence, attention disorders, obesity, tremor, ataxia, reduced global productivity, hyperlipidaemia and liver enzyme changes. CONCLUSION: Lamotrigine was more effective and better tolerated in smaller doses as monotherapy, and better than other drugs in reference to quality of life, especially by the supression of side-effects, demonstrating that it is valuable in obtaining overall improvement of the disease and its consequences.

[Statins (HMG-CoA reductase inhibitors), cholesterol and stroke]. / Estatinas (inhibidores de la HMG-CoA reductasa), colesterol e ictus.

The HMG-CoA reductase inhibitors (known as statins) have been shown to reduce morbi-mortality of vascular origin, including transitory ischemic accidents and cerebral infarcts, in a large group of patients. The implications, both clinical and of costs, oblige us to consider analysis of the existing evidence and the answers to a number of questions arising in a field which has not yet received much attention from neurologists.

[Mitochondrial diseases and stroke]. / Enfermedades mitocondriales e ictus.

We review the mitochondrial diseases in which cerebrovascular changes are seen, such as the MERRF syndrome (myoclonic epilepsy and ragged red fibers) or the Kearns-Sayre syndrome (progressive external ophthalmoplegia, retinitis pigmentaria, cerebellar disorders and disorders of cardiac conduction), focusing on the syndrome involving mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS). We consider the different clinical aspects, diagnostic methods, pathophysiological mechanisms of the cerebrovascular involvement as well as therapeutic approaches.

[Systemic autoimmune diseases with neurocutaneous alterations]. / Enfermedades autoinmunes sistémicas con afectación cutaneoneural.

Autoimmune diseases depend on the pathologic activation of cellular clones, potentially harmful, against soft tissues. They can be classified into systemic and organ-specific diseases. In the systemic subtype, in which the abnormal hyperactivity is not as specific, the most remarkable component of the clinical syndrome is frequently the presence of neurological and/or cutaneous manifestations. This article reviews the major pathogenic mechanisms involved in the principal systemic autoimmune conditions including connective tissue diseases (rheumatoid arthritis, systemic lupus erythematosus, polimyositis, dermatomyositis, scleroderma, mixed connective tissue disease, Sjögren's syndrome, overlap syndromes) and vasculitic syndromes (nodous polyarteritis, giant cell arteritis. Wegener's granulomatosis. Behçet disease, microscopic polyarteritis, cryoglobulinemia) as well as their clinical manifestations, focused mainly on neurocutaneous characteristics.