Consensus statement of the Spanish Society of Neurology on the treatment of multiple sclerosis and holistic patient management in 2023.

The last consensus statement of the Spanish Society of Neurology's Demyelinating Diseases Study Group on the treatment of multiple sclerosis (MS) was issued in 2016. Although many of the positions taken remain valid, there have been significant changes in the management and treatment of MS, both due to the approval of new drugs with different action mechanisms and due to the evolution of previously fixed concepts. This has enabled new approaches to specific situations such as pregnancy and vaccination, and the inclusion of new variables in clinical decision-making, such as the early use of high-efficacy disease-modifying therapies (DMT), consideration of the patient's perspective, and the use of such novel technologies as remote monitoring. In the light of these changes, this updated consensus statement, developed according to the Delphi method, seeks to reflect the new paradigm in the management of patients with MS, based on the available scientific evidence and the clinical expertise of the participants. The most significant recommendations are that immunomodulatory DMT be started in patients with radiologically isolated syndrome with persistent radiological activity, that patient perspectives be considered, and that the term "lines of therapy" no longer be used in the classification of DMTs (> 90% consensus). Following diagnosis of MS, the first DMT should be selected according to the presence/absence of factors of poor prognosis (whether epidemiological, clinical, radiological, or biomarkers) for the occurrence of new relapses or progression of disability; high-efficacy DMTs may be considered from disease onset.

Psychodynamic Psychotherapy for Postpartum Depression: A Systematic Review.

OBJECTIVES: Postpartum depression estimated prevalence in women is between 5 and 26% and it has adverse effects both on the mother, infant and her partner. Psychological treatments have proved to be effective for women with mild-to-moderate symptoms. Whereas several systematic reviews have assessed the effects of different psychological interventions for postpartum depression, such as cognitive-behavioural therapy or interpersonal therapy, no review assessing psychodynamic therapy has been carried out. A systematic review was conducted to evaluate the efficacy of psychodynamic therapy for postpartum depression. METHODS: Studies were identified using the following databases: PsycINFO, Psycarticles and Pubmed over January 2023. The requirements for the studies were the following: they had to be quantitative, available in English, including a psychodynamic intervention targeting treatment or prevention of postpartum depression which starts during pregnancy or within the first 12 months after giving birth. Case studies, qualitative studies or studies focused on improving parent-infant relationship or infant outcome were excluded from this research. RESULTS: Seven trials including 521 women met the inclusion criteria. In summary, three randomized controlled trials and four longitudinal studies were found. The most frequently used assessment tool was EPDS, five were individual interventions and the other two were group interventions. DISCUSSION: All studies reported the efficacy of psychodynamic interventions for postpartum depression, both in home and clinical settings and both in group and individual format. The limited number of trials, small sample sizes and lack of appropriate control groups were the main limitations. CONCLUSIONS FOR PRACTICE: Psychodynamic therapy is probably efficient intervention for postpartum depression. Future research with strong methodological designs is needed to confirm these findings. SIGNIFICANCE: What is already known on this subject? Several systematic reviews have assessed the effects of different psychological interventions for postpartum depression, but no review assessing psychodynamic therapy has been carried out. What this study adds? A systematic review was conducted to evaluate the efficacy of psychodynamic therapy for postpartumdepression. This makes the systematic review a unique contribution to the literature.

Endovascular Treatment of Spleno-Mesenteric-Portal Vein Thrombosis During Orthotopic Liver Transplant: 20 Years Later.

PURPOSE: Our purpose is to present our experience in endovascular treatment of portal vein thrombosis (PVT) during orthotopic liver transplant (OLT), initial stages, and long-term follow-up. MATERIALS AND METHODS: Between May 1994 and December 2019 we performed 1246 OLTs. A total of 170 (13.64%) had some grade of PVT at the time of OLT. Since May 2000 we have performed endovascular procedures during OLT in 52 patients with PVT grade III to IV Yerdel classification. Our research consists of the 49 patients with more than 1 year of follow-up. The initial surgical technique was eversion thromboendovenectomy when the portal flow was not adequate. Intraoperative portography and endovascular treatments were taken via the graft umbilical vein, one of the recipients' mesenteric veins, the recipient portal vein, or the graft portal vein. If the cause was an obstructive or incomplete thrombus removal, venoplasty and primary stent placement were performed. RESULTS: Primary stent placement was achieved in 47 of 49 patients (95.9%): adequate portal perfusion in the allograf and portal hypertension were achieved. None of the patients died during surgery or at 30 days. At long-term follow-up, 3 patients (6.1%) had a portal vein rethrombosis due to no related causes. Cumulative survival rates were 89.7%, 79.3%, and 65.5% at 1, 5, and 10 years. CONCLUSIONS: Stent placement in PVT during OLT is a safe and effective procedure to resolve liver graft perfusion. It is an anatomic and physiological derivation that guarantees appropriate hepatopetal portal flow to avoid rethrombosis and portal hypertension, with low mortality and morbility.

Alcohol and psychotropic substance use in female spanish victims of intimate partnet violence / Consumo de alcohol y sustancias psicotrópicas en mujeres españolas víctimas de violencia de género en la pareja

BACKGROUND: Studies show high use of alcohol among American women who are victims of intimate partner violence (IPV), but not in Spanish victims. This study examines hazardous drinking, use of psychotropic substances, and the relationship with psychopathological symptoms in Spanish women who are victims of IPV. METHOD: 50 battered women and 50 control women from general population were assessed. RESULTS: Hazardous drinking in women victims of IPV (18.4% and 24.5%) was higher than in previous Spanish studies, and lower than in controls (no significant difference). Women victims of IPV showed a significantly higher use of psychotropic medication than controls (40% vs. 20%). For women victims of IPV, psychopathological symptoms were not related to use of alcohol, but use of psychotropic medication was related to post-traumatic arousal. CONCLUSIONS: Results suggest that Spanish women victims of IPV may resort to psychotropic medication rather than alcohol to cope with their symptoms

ANTECEDENTES: los estudios muestran un alto consumo de alcohol en las mujeres maltratadas americanas, pero no en las españolas. Este estudio examina en mujeres maltratadas españolas: el consumo de riesgo de alcohol, el consumo de sustancias psicotrópicas y la relación con los síntomas psicopatológicos. MÉTODO: 50 mujeres maltratadas y 50 mujeres controles de la población general fueron evaluadas. RESULTADOS: el consumo de riesgo de alcohol en mujeres maltratadas (18,4% y 24,5%) fue superior al encontrado en los estudios españoles previos, e inferior a los controles (sin diferencias significativas). Las mujeres maltratadas mostraban un consumo de psicofármacos significativamente mayor que las controles (40% vs. 20%). En las mujeres maltratadas, los síntomas psicopatológicos no estaban relacionados con el consumo de alcohol, sin embargo el consumo de psicofármacos se relacionaba con la activación postraumática. CONCLUSIONES: los resultados sugieren que las mujeres maltratadas españolas pueden recurrir a los psicofármacos en lugar de al alcohol para hacer frente a sus síntomas

Alcohol and psychotropic substance use in female Spanish victims of intimate partner violence.

BACKGROUND: Studies show high use of alcohol among American women who are victims of intimate partner violence (IPV), but not in Spanish victims. This study examines hazardous drinking, use of psychotropic substances, and the relationship with psychopathological symptoms in Spanish women who are victims of IPV. METHOD: 50 battered women and 50 control women from general population were assessed. RESULTS: Hazardous drinking in women victims of IPV (18.4% and 24.5%) was higher than in previous Spanish studies, and lower than in controls (no significant difference). Women victims of IPV showed a significantly higher use of psychotropic medication than controls (40% vs. 20%). For women victims of IPV, psychopathological symptoms were not related to use of alcohol, but use of psychotropic medication was related to post-traumatic arousal. CONCLUSIONS: Results suggest that Spanish women victims of IPV may resort to psychotropic medication rather than alcohol to cope with their symptoms.

Un sistema organizado de atención al ictus evita diferencias en la evolución de los pacientes en relación con el momento de su ingreso en una unidad de ictus / A stroke care management system prevents outcome differences related to time of stroke unit admission

Introducción: Existe evidencia de que el ingreso de pacientes con ictus en diferentes periodos laborales influye en su evolución. Analizamos la evolución de los pacientes con relación al momento del ingreso en una unidad de ictus. Métodos: Estudio retrospectivo. Se agrupó a los pacientes considerando los siguientes periodos: a) día de la semana, b) periodo del año y c) turno de trabajo. Analizamos características demográficas, tipo y gravedad del ictus y porcentaje de trombólisis. Determinamos la evolución precoz considerando: la National Institute of Heath Stroke Scale (NIHSS), complicaciones neurológicas (CN) y mortalidad hospitalaria, y situación funcional (SF) a 3 meses mediante la escala modificada de Rankin. Resultados: Se incluyó a 1.250 pacientes. Las CN fueron más frecuentes durante el fin de semana que en los días laborales, sin influir en la mortalidad hospitalaria. Respecto a la SF a 3 meses, el 67,0% de pacientes ingresados en días laborales vs. 60,7% durante el fin de semana (p = 0,096), el 65,5% de los pacientes ingresados durante los meses académicos vs. 63,5% durante las vacaciones de verano (p = 0,803) eran independientes. No identificamos diferencias significativas en la mortalidad a 3 meses según el día o periodo del año; sin embargo, para la variable turno de trabajo, el 13,2% de los pacientes ingresados durante la mañana, el 11,5% por la tarde y el 6,0% durante el turno de noche fallecieron (p = 0,017). Observamos una tendencia a realizar más fibrinólisis en días laborables, turno de la mañana y meses académicos. Conclusiones: El momento del ingreso en la unidad de ictus no influyó en la evolución precoz ni en la situación de independencia a 3 meses

Introduction: Evidence supports that admitting patients with stroke during different hospital work periods is related to distinct outcomes. We aimed to analyse outcomes in patients according to the period and time of admission to the stroke unit. Methods: Retrospective study. For purposes of data analysis, patients were grouped according to the following time periods: a) day of the week, b) period of the year, c) shift. We analysed demographic characteristics, stroke type and severity, and the percentage undergoing thrombolysis in each group. The measures used to evaluate early outcomes were the National Institutes of Health Stroke Scale (NIHSS), neurological complications (NC), and in-hospital mortality. Functional outcome at 3 months was determined using the modified Rankin scale. Results: The stroke unit admitted 1250 patients. We found NC to be slightly more frequent for weekend admissions than for weekday admissions, but this trend does not seem to have influenced in-hospital mortality. Regarding functional outcome at 3 months, 67.0% of weekday vs. 60.7% of weekend admissions were independent (P=.096), as were 65.5% of patients admitted during the academic months vs. 63.5% of those admitted during summer holidays (P=.803). We identified no significant differences in 3-month mortality linked to the day or period of admission; however, for the variable ‘shift’, 13.2% of the patients died during the morning shift, 11.5% during the afternoon shift, and 6.0% during the night shift (P=.017). We identified a trend toward higher rates of thrombolysis administration on weekdays, during the morning shift, and during the academic months. Conclusions: Time of admission to the stroke unit did not affect early outcomes or functional independence at 3 months

Posttraumatic Stress Symptomatology in Pre-Hospital Emergency Care Professionals Assaulted by Patients and/or Relatives: Importance of Severity and Experience of the Aggression.

Exposure to violence from patients or relatives causes problems in emergency departments. To assess the development of posttraumatic symptoms in pre-hospital emergency care professionals assaulted by patients and/or relatives, it may be crucial to establish preventive measures at different levels. This study examined 358 pre-hospital emergency care professionals assaulted by patients and/or relatives. The aims of the present study were (a) to assess the presence of posttraumatic symptoms and posttraumatic stress disorder (PTSD) and (b) identify compliance diagnoses for PTSD depending on the experience of aggression (presence of fear, helplessness, or horror during the aggression), the perceived severity of aggression, and socio-demographic variables (gender, age, profession, employment status, and work experience). The results show that the experience of aggression with fear, helplessness, or horror is associated with the presence of posttraumatic symptoms related to re-experiencing but is not related to avoidance and emotional numbing and arousal. Furthermore, the perception of aggression as severe was associated with the presence of symptoms related to re-experiencing. These results are presented and discussed.

A stroke care management system prevents outcome differences related to time of stroke unit admission.

INTRODUCTION: Evidence supports that admitting patients with stroke during different hospital work periods is related to distinct outcomes. We aimed to analyse outcomes in patients according to the period and time of admission to the stroke unit. METHODS: Retrospective study. For purposes of data analysis, patients were grouped according to the following time periods: a) day of the week, b) period of the year, c) shift. We analysed demographic characteristics, stroke type and severity, and the percentage undergoing thrombolysis in each group. The measures used to evaluate early outcomes were the National Institutes of Health Stroke Scale (NIHSS), neurological complications (NC), and in-hospital mortality. Functional outcome at 3 months was determined using the modified Rankin scale. RESULTS: The stroke unit admitted 1250 patients. We found NC to be slightly more frequent for weekend admissions than for weekday admissions, but this trend does not seem to have influenced in-hospital mortality. Regarding functional outcome at 3 months, 67.0% of weekday vs. 60.7% of weekend admissions were independent (P=.096), as were 65.5% of patients admitted during the academic months vs. 63.5% of those admitted during summer holidays (P=.803). We identified no significant differences in 3-month mortality linked to the day or period of admission; however, for the variable 'shift', 13.2% of the patients died during the morning shift, 11.5% during the afternoon shift, and 6.0% during the night shift (P=.017). We identified a trend toward higher rates of thrombolysis administration on weekdays, during the morning shift, and during the academic months. CONCLUSIONS: Time of admission to the stroke unit did not affect early outcomes or functional independence at 3 months.

Orthotopic Liver Transplantation in an Adult With Biliary Atresia, Situs Inversus, and Inferior Cava Vein Absence: A Case Report.

BACKGROUND: We report the case of a 34-year-old man who underwent Kasai portoenterostomy for biliary atresia at 6 weeks of age. In 2011, pulmonary hypertension was diagnosed and he began treatment with sildenafil. In 2012, he presented with an episode of upper gastrointestinal bleeding secondary to esophageal varices resistant to treatment. Later, he exhibited liver dysfunction. He was included on the waiting list for transplantation on May 29, 2013, with a Model for End-stage Liver Disease score of 24. METHODS: He underwent liver transplantation with an isogroup graft from a brain dead donor on June 9, 2013. Native hepatectomy was laborious owing to important collateral circulation and adhesions after previous operations, which had injured loops of the small bowel (SB). Orthotopic implantation was accomplished with direct anastomosis of the upper liver cava vein to the right atrium of the receiver. Portal and arterial anastomoses were performed as usual. Biliary reconstruction surgery by hepatojejunostomy was delayed 24 hours owing to SB loops injuries. RESULTS: Graft viability was confirmed by normal hepatic function. Postoperative complications included abdominal compartment syndrome treated by decompressing laparotomy, severe pulmonary alveolar hemorrhage resolved with artery embolization and endotracheal intubation, intraabdominal abscess requiring percutaneous drain, and stroke requiring long-term rehabilitation. He is currently asymptomatic, presents normal graft function, and receives sildenafil because of pulmonary hypertension. CONCLUSIONS: The association of situs inversus and biliary atresia is low. There is no consensus on the optimal operative approach to liver transplantation. An individualized assessment and multidisciplinary patient management are required.

Situación funcional tras un ictus y experiencia acumulada de una unidad de ictus / Functional outcome of stroke and the cumulative experience of a stroke unit

Objetivo: Los pacientes con un ictus tienen más probabilidades de supervivencia e independencia si son atendidos en una unidad de ictus. La información disponible en nuestro entorno acerca de la influencia del aprendizaje sobre estos resultados es escasa. Analizamos la situación funcional y mortalidad en nuestros pacientes en función de la experiencia acumulada en una unidad de ictus. Pacientes y métodos: Estudio de cohortes retrospectivo de pacientes ingresados en una unidad de ictus. Diferenciamos 2 grupos según el año de ingreso: grupo A (julio 2007-diciembre 2009) y grupo B (enero 2010-diciembre 2011), analizando la evolución precoz en función de la puntuación en la escala de ictus del National Institute of Health y la mortalidad al alta y la situación funcional a medio plazo en función de la mortalidad y estado funcional según la escala Rankin a los 3 meses. Resultados: Se incluyó a 1.070 pacientes. No se obtuvo diferencias entre los grupos ni en la evolución favorable (68,3% vs. 63,9), ni en la mortalidad tanto hospitalaria (5,1% vs. 6,6%), como a los 90 días (12,8% vs. 13,1%), siendo mayor el porcentaje de independientes a los 90 días en el grupo B (56,3% vs. 65,5%: p = 0,03). El análisis multivariante ajustado por subtipo de ictus y tratamiento fibrinolítico mantuvo la asociación entre la independencia y el período de ingreso. Conclusiones: La probabilidad de independencia funcional de nuestros pacientes aumentó con la experiencia acumulada de nuestra Unidad de Ictus sin observarse diferencias en la mortalidad

Objective: Patients with acute stroke are more likely to survive and achieve independence if they are treated in a stroke unit. Available information in our setting is scarce. We analyse the outcomes of our patients on the basis of cumulative experience in a stroke unit. Patients and methods: A retrospective cohort study of patients admitted to a stroke unit. We differentiate between two groups according to the year of admission: group A (July 2007-December 2009) and group B (January 2010-December 2011), analysing early outcome based on the score on the National Institute of Health stroke salce and mortality at discharge, and medium-term outcome in terms of mortality and functional status according to the modified Rankin scale at three months. Results: A total 1070 patients were included. There were no differences between groups with respect to favourable outcome (68.3% vs 63.9), hospital mortality (5.1% vs 6.6%), or 90-day mortality (12.8% vs 13.1%). The percentage of patients who were independent at 90 days was greater in group B (56.3% vs 65.5%, P = .03). In the multivariate analysis adjusted for stroke subtype and fibrinolytic therapy, the association between patient independence and admission period remained present. Conclusions: The probability of functional independence in our patients increased alongside accumulated experience in our stroke unit with no differences in mortality

Functional outcome of stroke and the cumulative experience of a stroke unit.

OBJECTIVE: Patients with acute stroke are more likely to survive and achieve independence if they are treated in a stroke unit. Available information in our setting is scarce. We analyse the outcomes of our patients on the basis of cumulative experience in a stroke unit. PATIENTS AND METHODS: A retrospective cohort study of patients admitted to a stroke unit. We differentiate between two groups according to the year of admission: group A (July 2007-December 2009) and group B (January 2010-December 2011), analysing early outcome based on the score on the National Institute of Health stroke scale and mortality at discharge, and medium-term outcome in terms of mortality and functional status according to the modified Rankin scale at three months. RESULTS: A total 1070 patients were included. There were no differences between groups with respect to favourable outcome (68.3% vs 63.9), hospital mortality (5.1% vs 6.6%), or 90-day mortality (12.8% vs 13.1%). The percentage of patients who were independent at 90 days was greater in group B (56.3% vs 65.5%, P=.03). In the multivariate analysis adjusted for stroke subtype and fibrinolytic therapy, the association between patient independence and admission period remained present. CONCLUSIONS: The probability of functional independence in our patients increased alongside accumulated experience in our stroke unit with no differences in mortality.

La evaluación de la calidad de vida en personas con demencia / Quality of life assessment in patients with dementia

La calidad de vida (CV) es una de las variables resultado más importantes para estudiar la eficacia de intervenciones en personas con demencia. Sin embargo, su evaluación es difícil porque: a) este es un constructo complejo para el que no existe una aproximación teórica o conceptual unificada, y b) porque al tratarse de personas con deterioro cognitivo se complica enormemente la obtención de información fiable. En este trabajo se revisan diferentes métodos e instrumentos dirigidos a este fin. Es importante tener en cuenta la visión subjetiva de la propia persona evaluada pues las evaluaciones de personas próximas tienden a subestimar la CV. A pesar de que el campo necesita más desarrollo, se concluye que el instrumento de elección es el QOL-AD, por ser sensible al cambio, correlacionar con medidas de salud, estar traducido a varios idiomas y poder administrarse a personas con puntuaciones bajas en el MMSE(AU)

Quality of life (QoL) is one of the most important outcome variables in the study of the efficacy of interventions with people with dementia. However, its assessment is difficult 1) because it is a complex construct for which there is no unified theoretical or conceptual approach, and 2) because of the inherent difficulties in the cognitive impairments of the people under study. In this work different methods and instruments to this end are reviewed, and related findings are discussed. It is important to take into account the subjective view of the assessed person, as assessments done by proxies tend to underestimate QoL. In spite of the need for further development in this field, it is concluded that the instrument of choice is the QOL-AD, as it is change-sensitive, it correlates with health measurements, it is translated into several languages and it can be administered to people with low MMSE scores(AU)

[Quality of life assessment in patients with dementia]. / La evaluación de la calidad de vida en personas con demencia.

Quality of life (QoL) is one of the most important outcome variables in the study of the efficacy of interventions with people with dementia. However, its assessment is difficult 1) because it is a complex construct for which there is no unified theoretical or conceptual approach, and 2) because of the inherent difficulties in the cognitive impairments of the people under study. In this work different methods and instruments to this end are reviewed, and related findings are discussed. It is important to take into account the subjective view of the assessed person, as assessments done by proxies tend to underestimate QoL. In spite of the need for further development in this field, it is concluded that the instrument of choice is the QOL-AD, as it is change-sensitive, it correlates with health measurements, it is translated into several languages and it can be administered to people with low MMSE scores.

Prognostic and developmental factors in patients receiving liver transplant due to hepatocellular carcinoma: one center's experience in the north of Spain.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most frequent types of tumor. The aim of this study was to determine the survival of patients who had received liver transplants as a result of the disease. METHODS: This observational follow-up study included 150 patients who received liver transplantations from June 1994 to December 2007. The study considered epidemiological and staging variables, tumor descriptions, and follow-up variables. We employed Kaplan-Meier methodology together with a Cox multivariate regression analysis. RESULTS: The incidence of tumor relapse was 13.3%, with survival rates at 1, 3, and 5 years of 89.3%, 73.1%, and 61.4%, respectively. Variables that showed an independent effect to predict mortality were the degree of histological differentiation and of macrovascular invasion. Patients with poorly differentiated HCC had a 4.03 fold (95% confidence interval [CI]: 1.61-10.06) greater possibility of dying. Macrovascular involvement increased the risk of death (relative risk = 2.23), an effect that was at the limit of significance (95% CI 0.99-5.04). CONCLUSIONS: The survival rate was consistent with the literature. Poor tumor differentiation and macrovascular involvement were independent predictors of mortality.

[Validation of supra-aortic trunks ultrasound in the diagnosis of atherosclerotic disease of the internal carotid artery. Comparison of the results with angiography]. / Validación del estudio ultrasonológico de troncos supraaórticos en el diagnóstico de la enfermedad aterosclerótica de la arteria carótida interna. Comparación de los resultados con los de angiografía.

INTRODUCTION: Arteriosclerosis of the extra-cranial arteries is believed to be responsible for almost one-third of all ischaemic strokes. The sound diagnosis of the degree of stenosis is essential in deciding the best therapeutic strategy. Although cerebral angiography is considered the reference technique, ultrasound study (UST) is a more readily available, non-invasive and well-established procedure for quantifying carotid stenosis. However, on being a dependent exploratory technique, it is recommended that each laboratory validates its results against angiography. OBJECTIVES: To establish the validity of the neuro-ultrasound study in our laboratory for use in the diagnosis of extracranial atheromatous disease, and determine its capacity to quantify the degree of stenosis in the internal carotid artery. MATERIAL AND METHODS: A retrospective study of patients with extracranial carotid atheromatous disease, in whom the diagnostic process was carried out with carotid ultrasound as well as supra-aortic trunk digital-subtraction angiography. RESULTS: A total of 254 carotids were evaluated and the degree of stenosis being classified into > 50%, 70-99% and 100%. The UST for the first group had a sensitivity (Se) of 97%, a specificity (Sp) of 90%, a positive predictive value (PPV) of 94.6% and a negative predictive value (NPV) of 94.2%. The second group had an Se of 96.4%, Sp 93%; PPV 94.4% and NPV 95.4%. The respective values for carotid occlusion were, 85%, 96.8%, 80% and 97.8%. CONCLUSIONS: Our data validates the ability of UST performed in our Laboratory to diagnose the degree of carotid stenosis.

Validación del estudio ultrasonológico de troncos supraaórticos en el diagnóstico de la enfermedad aterosclerótica de la arteria carótida interna. Comparación de los resultados con los de angiografía / Validation of supra-aortic trunks ultrasound in the diagnosis of atherosclerotic disease of the internal carotid artery. Comparison of the results with angiography

Introducción: Se considera que la arteriosclerosis de las arterias extracraneales causa casi un tercio de los ictus isquémicos. El diagnóstico certero del grado de estenosis es fundamental para indicar la mejor estrategia terapéutica. Si bien la angiografía cerebral se considera la técnica de referencia, el estudio ultrasonográfico (EUS) es un procedimiento más disponible, no invasivo y bien establecido en la cuantificación de la estenosis carotídea. Sin embargo, al ser una técnica dependiente del explorador, se recomienda que cada laboratorio valide sus resultados frente a la angiografía. Objetivos: Establecer, en nuestro laboratorio, la validez del estudio neurosonológico en el diagnóstico de la enfermedad ateromatosa extracraneal y determinar su capacidad para cuantificar el grado de estenosis de la arteria carótida interna. Material y métodos: Estudio retrospectivo de los pacientes con enfermedad ateromatosa carotídea extracraneal en cuyo proceso diagnóstico se realizó tanto ultrasonografía carotídea como angiografía por sustracción digital de troncos supraaórticos. Resultados: Se evaluaron 254 carótidas clasificando el grado de estenosis en > 50%, 70-99% y 100%. Para el primer grupo el EUS obtuvo una sensibilidad del 97%, una especificidad del 90%, un valor predictivo positivo (VPP) del 94,6% y un VP negativo (VPN) del 94,2%. En el segundo grupo, se obtuvo: sensibilidad, 96,4%; especificidad, 93%; VPP, 94,4%, y VPN, 95,4%. Para la oclusión carotídea los valores respectivos fueron del 85, el 96,8, el 80 y el 97,8%. Conclusiones: Nuestros datos validan la capacidad del EUS realizado en nuestro laboratorio para el diagnóstico del grado de estenosis carotídea (AU)

Introduction: Arteriosclerosis of the extra-cranial arteries is believed to be responsible for almost one-third of all ischaemic strokes. The sound diagnosis of the degree of stenosis is essential in deciding the best therapeutic strategy. Although cerebral angiography is considered the reference technique, ultrasound study (UST) is a more readily available, non-invasive and well-established procedure for quantifying carotid stenosis. However, on being a dependent exploratory technique, it is recommended that each laboratory validates its results against angiography. Objetives: To establish the validity of the neuro-ultrasound study in our laboratory for use in the diagnosis of extracranial atheromatous disease, and determine its capacity to quantify the degree of stenosis in the internal carotid artery. Material and methods: A retrospective study of patients with extracranial carotid atheromatous disease, in whom the diagnostic process was carried out with carotid ultrasound as well as supra-aortic trunk digital-subtraction angiography. Results: A total of 254 carotids were evaluated and the degree of stenosis being classified into > 50%, 70-99% and 100%. The UST for the first group had a sensitivity (Se) of 97%, a specificity (Sp) of 90%, a positive predictive value (PPV) of 94.6% and a negative predictive value (NPV) of 94.2%. The second group had an Se of 96.4%, Sp 93%; PPV 94.4% and NPV 95.4%. The respective values for carotid occlusion were, 85%, 96.8%, 80% and 97.8%. Conclusions: Our data validates the ability of UST performed in our Laboratory to diagnose the degree of carotid stenosis (AU)

[Stroke in the very old. Care in neurology units versus others general medical ward]. / Ictus en pacientes muy mayores. Análisis comparativo entre una unidad de neurología y otros servicios de medicina.

INTRODUCTION: The aim of this study is to compare the diagnosis, management, clinical course and outcome of the very major patients with acute stroke in our sanitary area. METHOD: Retrospective collection of data from a hospital-based registry, between January 2002 and March 2004, 130 stroke patients aged 84 and older admitted consecutively. We compared the patients admitted to the neurology unit (NU) to those admitted to other services (GWs). Demographic analysis, risk factors, morbidity to hospital admission (dementia, cancer, previous stroke and laboratory variables), neurological deficit measured for Canadian Neurological Scale (CNS) score, diagnostic studies, length of stay, outcomes variables (in-hospital mortality, complications developed during hospitalization and Rankin scale at hospital discharge) and need for institutionalization were analyzed. RESULTS: from a total of 130 patients, 44 (34,1 %) admitted to NU and 85 (65,9 %) to GWs. No difference was seen in demographic analysis, risk factors, morbidity to hospital admission, neurological deficit and outcomes variables. Length of stay was 8,4 days; 5,5 in the NU and 12,87 days among patients in the GWs (p=0,0001). There are significant differences in diagnostic studies in favor to NU (p < 0,05). Among the patients admitted into GWs the percentage of institutionalization to the discharge was of 28,8 % opposite to 5,6 % in the NU (p=0,006). CONCLUSIONS: There are not evidences of age discrimination for access to neurological units for demographic, risk factors, morbidity or neurological deficit. The diagnostic process is more rigorous and less costly in the NU than in the GWs.