[Effect of transcraneal magnetic stimulation on the motor recovery of the thoracic limb in cerebrovascular disease -a systematic review]. / Efecto de la estimulacion magnetica transcraneal sobre la recuperacion motora del miembro toracico en la enfermedad vascular cerebral. Revision sistematica.

INTRODUCTION: There have been studies in which contralesional inhibitory and ipsilesional excitatory transcranial magnetic stimulation (TMS) has been used as coadjuvant therapy in the motor rehabilitation of the thoracic limb in patients. However, there is no consensus regarding the stimulation variables or their clinical outcomes. AIM: To describe the results of clinical trials where TMS has been applied in rehabilitation in patients with cerebrovascular disease (CVD). PATIENTS AND METHODS: A systematic review of the PubMed database was performed. The articles cataloged as originals in English, whose population had limitation of thoracic limb after CVD were selected. Pilot studies, as well as studies in which patients under pharmacological treatment included any intervention other than physical or occupational therapy were excluded. Given their heterogeneity, it was not possible to apply inferential statistics, only descriptive statistics were use. RESULTS: Seven studies were identified; 259 cases with an age of 64.3 ± 4.28 years (range: 35-89 years) were reported. The TMS protocols, for the most part, were performed by contralesional inhibitory type stimulation. There were positive results in five studies. CONCLUSION: In accordance with the results obtained, we observed that TMS could contribute to the improvement of motor control of the thoracic limb in patients with sequelae due to CVD.

TITLE: Efecto de la estimulacion magnetica transcraneal sobre la recuperacion motora del miembro toracico en la enfermedad vascular cerebral. Revision sistematica.Introduccion. Existen estudios donde se ha utilizado la estimulacion magnetica transcraneal (EMT) inhibitoria contralesional y excitatoria ipsilesional como terapia coadyuvante en la rehabilitacion motora del miembro toracico; sin embargo, no existe un consenso respecto a las variables de estimulacion ni sobre sus resultados clinicos. Objetivo. Describir los resultados de los ensayos clinicos donde se ha aplicado EMT en la rehabilitacion en pacientes con enfermedad vascular cerebral (EVC). Pacientes y metodos. Se realizo la revision sistematica de la base de datos PubMed. Fueron seleccionados los estudios catalogados como originales en idioma ingles, cuya poblacion tuvo afectacion de miembro toracico tras una EVC. Se excluyeron todos los estudios piloto, ademas de estudios que incluyeran pacientes bajo tratamiento farmacologico o alguna intervencion diferente a terapia fisica u ocupacional. Dada la heterogeneidad percibida en los estudios, no fue posible aplicar estadistica inferencial, unicamente se empleo estadistica descriptiva. Resultados. Fueron seleccionados siete estudios. Se identificaron 259 casos con una edad media de 64,3 ± 4,28 años (rango: 35-89 años). Los protocolos de EMT, en su mayoria, se realizaron mediante estimulacion de tipo inhibitoria contralesional. Hubo resultados positivos en cinco estudios. Conclusion. De acuerdo con los resultados obtenidos, existen indicios de que la EMT podria contribuir a la mejoria del control motor del miembro toracico en los pacientes con secuelas por EVC.

[Treatment of refractory aggressiveness by amygdalotomy and posteromedial hypothalamotomy by radiofrequency]. / Tratamiento de la agresividad refractaria mediante amigdalotomia e hipotalamotomia posteromedial por radiofrecuencia.

INTRODUCTION: Since, under certain circumstances, defensive or attacking behaviours display a pattern of motor dominance, as observed in subjects who participate in contact or fighting sports, aggressive behaviour was considered to have a dominant motor pattern. With the aim of preventing the functional problems reported with bilateral lesion procedures involving both the central nucleus of the amygdala and the posteromedial hypothalamus, the decision was made to combine them; thus, an amygdalotomy of the central nucleus of the amygdala and a posteromedial hypothalamotomy were to be performed simultaneously and unilaterally, on the basis of the motor dominance of the patient determined by means of the Edinburgh test. PATIENTS AND METHODS: This study describes the surgical experience in a series of nine patients diagnosed with refractory neuroaggressive syndrome. As part of the study protocol, a magnetic resonance brain scan was performed to rule out the presence of neoplasms, vascular diseases, infections and degenerative disorders. The degree of aggressiveness was quantified using Yudofsky's Overt Aggression Scale. Additionally, manual dominance was determined by means of the Edinburgh test. RESULTS AND CONCLUSIONS: Good control of aggressiveness was seen immediately. In some cases it was necessary to reduce the antipsychotic or benzodiazepine medication, as it was seen to increase aggressiveness. Only one case required a second surgical intervention. Follow-up was achieved in 100% of the cases at 24 months and 78% at 36 months.

TITLE: Tratamiento de la agresividad refractaria mediante amigdalotomia e hipotalamotomia posteromedial por radiofrecuencia.Introduccion. Dado que, en algunas circunstancias, las conductas defensivas o de ataque muestran un patron de dominancia motora, tal como se observa en los sujetos dedicados a los deportes de contacto o de lucha, se considero que la conducta agresiva tiene un patron motor dominante. Con el fin de evitar los problemas funcionales descritos con los procedimientos de lesion bilateral tanto del nucleo central de la amigdala como del hipotalamo posteromedial, se decidio combinarlos; es decir, realizar amigdalotomia del nucleo central de la amigdala e hipotalamotomia posteromedial de manera unilateral y simultanea, basandose en la dominancia motora del paciente mediante la prueba de Edimburgo. Pacientes y metodos. Este estudio muestra la experiencia quirurgica en una serie de nueve pacientes con el diagnostico de sindrome neuroagresivo resistente al tratamiento farmacologico. Dentro del protocolo de estudio, se les realizo resonancia magnetica cerebral para descartar la presencia de neoplasias, enfermedades vasculares, infecciones y trastornos degenerativos. El grado de agresividad se cuantifico mediante la escala global de agresividad de Yudofsky. Adicionalmente, se determino la dominancia manual a traves de la prueba de Edimburgo. Resultados y conclusiones. El buen control de la agresividad se observo de modo inmediato. En algunos casos fue necesario reducir la medicacion de antipsicoticos o benzodiacepinas, ya que aumentaban la agresividad. Solo un caso requirio una segunda cirugia. Se logro seguimiento del 100% de los casos en 24 meses y del 78% en 36 meses.

[Cervantes and Shakespeare, two Renaissance neurologists]. / Cervantes y Shakespeare, dos neurologos renacentistas.

TITLE: Cervantes y Shakespeare, dos neurologos renacentistas.

[Clinical audits of the procedure of the total hip arthroplasty and its impact on the improvement of the quality care]. / Auditorías clínicas del procedimiento de la artroplastia total de cadera y su impacto en la mejora de la calidad asistencial.

BACKGROUND: Clinical audits are critical and systematic quality analysis of medical care. Total hip arthroplasty (THA) is a routine practice and cost-effective, although there is little information on the quality of care of it. OBJECTIVE: To evaluate the impact of a clinical audit cycle in the quality of care in the primary THA procedures for non-traumatic cause. PATIENTS AND METHODS: A series of two audits (first audit in 2005 and second one in 2007) were performed. Patients of both sexes with non-traumatic primary THA and with a follow-up of 6 months were included. Time (days) in hospital stay and the rate (percentage) of readmissions were used as indicators of management; and as indicators of clinical practice: the index (percentage) of dislocation and the rate (percentage) of infection. Both audits were compared with respect to these indicators. RESULTS: A total of 160 patients (79 and 81, first and second audit respectively) were analysed. Management indicators: median (range) of hospital stay was 8 (7-78) and 7 (6-16), p<0.001, and the percentage of readmissions 5% (4/79) and 0 (0/81), p=0.057. Indicators of clinical practice: the rate of dislocation was 8% (6/79) and 0 (0/81), p=0.013, and the rate of infection 1% (1/79) and 1% (1/81), p=1. A multivariate analysis did not find other factors related to these indicators. CONCLUSIONS: The implementation of a clinical audit cycle has improved the quality of care of primary THA procedures for non-traumatic cause.

Consumption costs of inappropriate medicines estimated from bulk purchase data: The example of NSAids in Guatemala.

OBJECTIVE: In contexts where access to medicines is limited or troublesome, it may be important to identify the cases in which there exists access to medicines, but where this access is "inefficient" because it results in non-healing, avoidable toxicity or excessive cost in conditions of similar efficacy. Despite obvious limitations, bulk medicines purchase data of public institutions used to be the only available approximation on what is consumed in some countries. The aim of this study was to describe the results of a qualitative analysis of bulk consumption data, focusing on nonsteroidal anti-inflammatory drugs (NSAIDs) as an example. METHOD: The list of all drugs purchased by the Health Ministry of Guatemala in 2004 was quantitatively and qualitatively analyzed both according to the number of units and value. All NSAIDs bought during that period were analyzed in order to find potential intervention areas which could be addressed to improve drug selection. RESULTS: The studied list included 693 products with a value of 102 million US dollars. Among the top-20 purchased medicines by defined daily doses (DDDs) were several NSAIDs (including aceclofenac, meloxicam and piroxicam). Ranitidine, ciprofibrate and dimethicone were also among these top-20 drugs. In addition, aceclofenac was among the top-20 drugs according to value. The cost of "second-line" NSAIDs was several times higher than the "first-line" diclofenac or ibuprofen. Providing equal efficacy and similar toxicity exists, a theoretical switch from second- to first-line NSAIDs could save up to 2,377 million US dollars/year. CONCLUSIONS: Although it is an old and well-known method, the analysis of bulk consumption data continues to provide information that may help to identify areas of potential improvement in settings without many resources. In the present theoretical example, educative interventions addressed to rational selection of NSAIDs could save more than 2% of the annual drug expenditure of the country. Co-ordinated actions addressed to other drugs could decrease inefficient drug expenditure and improve the quality of health-care.

Bilateral lunate intraosseous ganglia.

An intraosseous ganglion is a relatively uncommon, benign, cyst-like lesion that occurs in young and middle-aged adults. Most commonly seen adjacent to the hip, ankle, knee, or wrist, they are histologically identical to their soft tissue counterparts. A review of the literature revealed only two previously reported examples of bilateral symmetrical ganglia of the lunate bones.

[Forensic medical implications of anticoagulant treatments]. / Implications médico-légales des traitements anticoagulants.

Several types of accidents related to anticoagulant treatment can lead to legal procedures, including: thromboembolic post-operative complications associated with lack of anticoagulant prophylaxis and leading to sequelae or death; severe hemorrhagic or thromboembolic accidents attributed to poor management of anticoagulant therapy; complications with sequelae or death resulting from heparin-induced thrombopenia, either with standard or low-molecular weight heparin and associated with poor surveillance of platelet counts. The exceptional nature of accidents leading to legal procedures (24 legal cases in Pr Natali's experience) and the small number of other cases reported should not lead to underestimating the importance of precise rules for anticoagulation treatments. In 7 cases, there was no anticoagulant prophylaxis after surgery. Recent consensus conferences have proposed a definition of small, moderate or high risk of thrombosis as a function of patient status and surgical procedure. Expert working groups have defined the operated patients for which pharmacological anti-coagulation is necessary. In 19 other cases, management of the treatment protocol was insufficient leading to severe hemorrhage with sequelae, severe thromboembolism, or late diagnosis of heparin-induced thrombocytopenia because of insufficient surveillance of platelet counts. Recent advances in laboratory tests for the diagnosis of heparin-induced thrombocytopenia should be emphasized. To these case reports can be added other observations in a small number of complaints resulting from unadvisable treatment combinations, poor surveillance of a thromboembolic event or dangerous invasive exploration.