Long-term effects of cognitive rehabilitation on brain, functional outcome and cognition in Parkinson's disease.

BACKGROUND AND PURPOSE: Cognitive rehabilitation has demonstrated efficacy in producing short-term cognitive and brain changes in patients with Parkinson's disease (PD). To date, no study has assessed the long-term effects of cognitive rehabilitation using neuroimaging techniques in PD. The aim was to assess the longitudinal effects of a 3-month cognitive rehabilitation programme evaluating the cognitive, behavioural and neuroimaging changes after 18 months. METHODS: Fifteen patients with PD underwent a cognitive, behavioural and neuroimaging assessment at pre-treatment (T0 ), post-treatment (T1 ) and after 18 months (T2 ). This study examined the long-term effects (from T0 to T2 ) and the maintenance of the changes (from T1 to T2 ). T1-weighted, diffusion-weighted, functional magnetic resonance imaging during both a resting-state and a memory paradigm were acquired. Voxel-based morphometry and tract-based spatial statistics were used for grey and white matter analyses. A region-of-interest-to-region-of-interest approach was used for resting-state functional connectivity (FC) and a model-based approach was used for brain activation during the memory paradigm. RESULTS: Patients with PD showed increased cognitive performance, decreased functional disability, increased brain FC and activation at T2 compared with T0 (P < 0.05, FDR). Moreover, patients showed maintenance of the improvements in cognition and functionality, and maintenance of the increased brain FC and activation at T2 compared with T1 . However, significant grey matter reduction and alterations of white matter integrity were found at T2 (P < 0.05, FWE). CONCLUSIONS: Findings suggest that the improved cognitive performance and increased brain FC and activation after cognitive rehabilitation were significantly maintained after 18 months in patients with PD, despite the structural brain changes, consistent with a progression of neurodegenerative processes.

Colecistitis alitiásica en un consumidor de heroína por vía intravenosa / Acalculous cholecystitis in an intravenous heroin consumer

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Indicaciones de la resonancia magnética en la lumbalgia de adultos / Indications for magnetic resonance imaging for low back pain in adults

Introducción: La lumbalgia genera numerosas consultas. La resonancia magnética (RM) es una opción diagnóstica en el manejo de alguno de estos pacientes. Sin embargo, su uso inadecuado supone una pérdida de recursos que obliga a disponer de guías que ayuden a los clínicos en la toma de decisiones y permita una mejor gestión de los recursos. Objetivo: Establecer las principales indicaciones clínicas de RM en los casos de dolor lumbar en adultos. Material y métodos: Se empleó el método de uso apropiado RAND/UCLA: tras una revisión sistemática en mayo de 2012 se elaboró un listado con posibles indicaciones de RM ante lumbalgia que un panel de expertos multidisciplinar puntuó desde 1, «totalmente inapropiado», a 9 «totalmente apropiado». Se realizó una primera ronda de puntuación online, se presentaron y discutieron los resultados en una reunión presencial y se realizó una ronda final online. La RM se consideró apropiada en cada indicación si la puntuación mediana era de 6,5 o mayor y había acuerdo (empleando el índice IPRAS). Resultados: La RM se consideró apropiada ante sospecha afectación tumoral, sospecha de infección espinal, sospecha de fractura a pesar de radiografía negativa, lumbalgia con dolor de ritmo inflamatorio, déficit neurológico progresivo/grave, dolor muy severo y que progresa de intensidad y lumbalgia subaguda o crónica con irradiación radicular con fracaso en el tratamiento. Conclusiones: La indicación de RM parece basarse en la sospecha de enfermedad grave secundaria. La metodología empleada permite establecer indicaciones de RM que pueden ser de utilidad tanto al clínico como al gestor sanitario (AU)

Introduction: Low back pain is a common disorder that generates many medical consultations. Magnetic Resonance Imaging (MRI) is commonly used in the clinical management of some of these patients. However, the cost of inappropriate MRI use is high, so there is a need to develop guidelines to help physicians make correct decisions and optimize available resources. Objective: To determine the main clinical indications for MRI scanning in adults with low backpain. Material and methods: The RAND/UCLA appropriateness method was used: After a systematic review (May 2012), a list of the clinical indications for MRI scanning in patients with low back pain was prepared. A multidisciplinary expert panel scored each indication from 1, «totally inappropriate» to 9,«totally appropriate». A first on-line round, an in-person panel meeting, where results of the first round were discussed, and a final second on-line round were arranged. A clinical indication was considered appropriate if the median score was 6.5 or higher, and there was agreement between experts (IPRAS index was used). Results: An MRI test is considered appropriate if cancer, spinal infection or a fracture, even with a negative X-ray test is suspected.; if there is inflammatory back pain; severe/progressive neurological deficit; severe and progressive low back pain; subacute or chronic low back pain with radicular involvement unresponsive to conservative therapy. Conclusions: Clinical indications for a MRI scanning are based on the suspicion of a secondary serious pathology. This methodology helps to set clinical indications for MRI, and may be of great value for both clinicians and health managers (AU)

[Indications for magnetic resonance imaging for low back pain in adults]. / Indicaciones de la resonancia magnética en la lumbalgia de adultos.

INTRODUCTION: Low back pain is a common disorder that generates many medical consultations. Magnetic Resonance Imaging (MRI) is commonly used in the clinical management of some of these patients. However, the cost of inappropriate MRI use is high, so there is a need to develop guidelines to help physicians make correct decisions and optimize available resources. OBJECTIVE: To determine the main clinical indications for MRI scanning in adults with low back pain. MATERIAL AND METHODS: The RAND/UCLA appropriateness method was used: After a systematic review (May 2012), a list of the clinical indications for MRI scanning in patients with low back pain was prepared. A multidisciplinary expert panel scored each indication from 1, «totally inappropriate¼ to 9, «totally appropriate¼. A first on-line round, an in-person panel meeting, where results of the first round were discussed, and a final second on-line round were arranged. A clinical indication was considered appropriate if the median score was 6.5 or higher, and there was agreement between experts (IPRAS index was used). RESULTS: An MRI test is considered appropriate if cancer, spinal infection or a fracture, even with a negative X-ray test is suspected.; if there is inflammatory back pain; severe/progressive neurological deficit; severe and progressive low back pain; subacute or chronic low back pain with radicular involvement unresponsive to conservative therapy. CONCLUSIONS: Clinical indications for a MRI scanning are based on the suspicion of a secondary serious pathology. This methodology helps to set clinical indications for MRI, and may be of great value for both clinicians and health managers.

Brief report: the adolescent Child-to-Parent Aggression Questionnaire: an examination of aggressions against parents in Spanish adolescents.

The objective of this study was to develop a questionnaire to assess child-to-parent aggression in adolescents and to document the extent of the problem. The questionnaire developed in this study, the Child-to-Parent Aggression Questionnaire (CPAQ), includes forms of physical and psychological aggression directed at both the mother and the father. It also includes open questions about the reasons for the aggressive acts. The CPAQ was completed by a sample of 2719 adolescents (age range: 13-18 years old, 51.4% girls). Confirmatory factor analysis supported a four-factor correlated structure (physical aggression against mother, physical aggression against father, psychological aggression against mother, and psychological aggression against father). Psychological and physical aggression against the mother was more frequent than against the father. However, there were no differences with regard to severe forms of aggression. Girls scored significantly higher on all indicators of psychological aggression, including severe psychological aggression. Nevertheless, except for the prevalence of physical aggression against mothers, which was higher in females, there were no significant differences in physical aggression against parents. Finally, the reasons provided by the adolescents for the aggression included both instrumental (e.g., to obtain permission to get home late and to access their computers) and reactive reasons (e.g., anger and self-defense). These findings highlight the complexity of child-to-parent aggression in adolescence.

Indicación de resonancia magnética ante cefalea en adultos: resultados siguiendo el método RAND/UCLA de uso apropiado / Indication of magnetic resonance imaging in cases of headaches in adults: results following the RAND/UCLA appropriateness method

Introducción. El número de peticiones de resonancia magnética (RM) en los sistemas sanitarios es cada vez mayor. La RM craneal es una de las localizaciones más frecuentes, cuya mala utilización supone una pérdida de recursos, lo que obliga a disponer de guías que ayuden a los clínicos en la toma de decisiones y permita una mejor gestión de los recursos. Objetivo. Establecer las principales indicaciones de RM en los casos de cefalea en adultos. Materiales y métodos. Se utilizó el método de uso apropiado RAND/UCLA: tras una revisión sistemática se elaboró un listado con posibles indicaciones de RM ante cefalea que un panel de expertos puntuó del 1 (‘totalmente inapropiado’) al 9 (‘totalmente apropiado’). Se realizó una primera ronda de puntuación online, luego se presentaron y se discutieron los resultados en una reunión presencial y se emprendió una ronda final online. La RM se consideró apropiada en cada indicación si la puntuación mediana era de 6,5 o mayor y había acuerdo (empleando el índice IPRAS). Resultados. La RM se consideró apropiada ante: nueva cefalea, nueva cefalea en paciente inmunodeprimido, cefalea intensa súbita, cefalea con sintomatología neurológica focal, cefalea postural, cefalea por esfuerzo físico o maniobras de Valsalva, sospecha de trombosis del seno venoso, afectación sistémica, cefalea progresiva, cefalea en embarazada, cefalalgia trigeminal autonómica o traumatismo craneal grave con focalidad. Conclusiones. La indicación parece resumirse en cefaleas con sospecha de patología secundaria. La metodología empleada permite establecer indicaciones de RM que pueden ser de utilidad tanto para el clínico como para el gestor sanitario (AU)

Introduction. The number of requests for magnetic resonance imaging (MRI) scans in healthcare systems is continually on the rise. An MRI scan of the head is one of the most frequent locations, which if used inappropriately entails a loss of resources. Consequently, guidelines are needed to help the physician make decisions and allow better management of resources Aim. To establish the key indications of MRI scans in cases of adults with headache. Materials and methods. The RAND/UCLA appropriateness method was used, that is, following a systematic review, a list of possible indications of MRI in cases of headache was drawn up. This list was then assessed by a panel of experts and given a score between 1 (‘totally inappropriate’) and 9 (‘totally appropriate’). An initial round of scoring was carried out online, the results were then discussed at a face-to-face meeting of the experts and finally another online round was undertaken. MRI was considered appropriate in each indication if the mean score was 6.5 or higher and there was agreement among the experts (using the IPRAS index).Results. MRI scanning was considered appropriate in cases of: new headache, new headache in immunodeficient patients, sudden intense headache, headache with focal neurological symptoms, postural headache, headache due to physical effort or Valsalva manoeuvres, suspected thrombosis in the venous sinuses, systemic involvement, progressive headache, headache in pregnancy, autonomic trigeminal headache or severe cranial traumatic injury with focus. Conclusions. It seems that indication can be summed up in headaches with a suspected secondary pathology. The methodology employed makes it possible to establish MRI indications that can be useful both in clinical practice and for healthcare management practitioners (AU)

Hipointensidad subcortical reversible en secuencia T2 en crisis convulsivas secundarias a cetoacidosis diabética / Subcortical reversible T2-weighed hypointensities in seizures secondary to diabetic ketoacidosis

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[Magnetic resonance imaging in long-term assessment after surgery for aortic coarctation]. / Valoración a largo plazo con resonancia magnética en pacientes corregidos de coartación de aorta.

OBJECTIVES: Spin echo or gradient echo magnetic resonance imaging provides enough information to plan patient management and can be completed with the use of three-dimensional magnetic resonance angiography to evaluate the need for reintervention, assess follow-up, or discharge the patient. PATIENTS AND METHODS: From 1990-2003, we evaluated 101 patients after initial corrective surgery for aortic coarctation at the age of 3.1 +/- 3 years, with subsequent postoperative assessment at 1 year and again 12.4 +/- 4.2 years later. No mortality was registered during the follow-up. Corrective surgery was performed in 32 patients (31.6 %) before the first month of life. All the patients were evaluated with spin-echo and echo gradient and 34 were evaluated with magnetic resonance angiography. The patients were classified into two groups: group A consisted of 68 patients (11 < 1 month old) with no complications. End-to-end anastomosis was performed in 55, the Alvarez technique in five, the Waldhausen technique in six, and conduit in two. Group B consisted of 33 patients complicated with early aortic recoarctation (21 corrected before the age of 1 month). End-to-end anastomosis was performed in 29, the Alvarez technique in two, and grafting in two. During the follow-up, 43 reinterventions were performed. Isthmus diameter/descending aorta diameter at the diaphragmatic level and repaired site diameter/descending aorta diameter at the diaphragmatic level were measured. RESULTS: Group A: the isthmus diameter/descending aorta diameter at the diaphragmatic level index was 0.92 +/- 0.08 and the repaired site diameter/ descending aorta diameter at diaphragmatic level index was 0.90 +/- 0.05. Twenty-three patients were assessed by means of three-dimensional magnetic resonance angiography, which revealed two late stenosis (one in a 10-year-old patient with an end-to-end anastomosis performed previously, and another in an 18-year-old patient with a proximal and distal obstructed conduit). Group B: the isthmus diameter/descending aorta diameter index was 0.84 +/- 0.1 and the repaired site diameter/ descending aorta diameter index was 0.82 +/- 0.11. Eleven patients were assessed by means of three-dimensional magnetic resonance angiography, which revealed five stenosis indexes (0.53-0.73) surgically corrected before the age of 2 months, four with an initial technique based on end-to-end anastomosis and one with a graft. CONCLUSIONS: Our results support the influence of young age, the use of end-to-end anastomosis and grafts in recoarctation and their late influence on recurrent recoarctation. The patients in group A were discharged in childhood or adulthood after periodic follow-up every 5 years with magnetic resonance angiography for 18 years with results within the normal range, while patients in group B required longer follow-up.

Valoración a largo plazo con resonancia magnética en pacientes corregidos de coartación de aorta / Magnetic resonance imaging in long-term assessment after surgery for aortic coarctation

Objetivos La resonancia con spin-eco o ecogradiente da una información suficiente que puede completarse con la angiorresonancia tridimensional para decidir una reintervención, controlar un seguimiento o dar el alta. Pacientes y métodos Durante el período 1990-2003 evaluamos 101 pacientes intervenidos inicialmente a los 3,1 ± 3 años, con estudio posterior al año y a los 12,4 ± 4,2 años de su intervención. No presentaron mortalidad en el seguimiento. Un total de 32 (31,6 %) fueron corregidos antes del mes de vida. Todos se estudiaron con spin-eco y ecogradiente y 34 con angiorresonancia. Los pacientes se dividieron en dos grupos: grupo A, con 68 pacientes, sin complicaciones (11 menores de un mes) con cirugía término-terminal 55, Álvarez 5, Waldhausen 6 y conducto en 2 casos; grupo B, con 33 pacientes complicados con recoartación precoz (21 corregidos antes de un mes), cirugía término-terminal 29, Álvarez 2 y parche en 2 casos. Durante el tiempo de seguimiento se realizaron 43 reintervenciones. Se midieron índices diámetro istmo/diámetro aorta descendente a la altura del diafragma e índice diámetro zona intervenida/diámetro aorta descendente en el diafragma. Resultados En el grupo A, el índice istmo/aorta descendente a la altura del diafragma era 0,92 ± 0,08 y el índice zona intervenida/aorta descendente en el diafragma, 0,9 ± 0,05. Un total de 23 fueron revisados con angiografía tridimensional. Se vieron dos estenosis tardías en un paciente de 10 años operado de término-terminal y en otro paciente de 18 años, un conducto con obstrucción distal y proximal. En el grupo B: el índice istmo/aorta descendente era 0,84 ± 0,1 y el índice zona intervenida/aorta descendente, 0,82 ± 0,11. De estos pacientes, 11 fueron revisados con angiorresonancia, 5 con reestenosis índice (0,53-0,73) intervenidos antes de los 2 meses, 4 con técnica inicial término-terminal y otro con parche. Conclusiones Nuestros resultados apoyan la influencia de la edad precoz, la técnica término-terminal y el parche en la recoartación y su influencia tardía en la rerrecoartaciones. Los pacientes del grupo A pueden ser dados de alta en edad juvenil-adulta, tras seguimientos periódicos cada cinco años con resonancia magnética durante 18 años si los resultados están dentro de la normalidad, mientras que los del grupo B necesitan controles más prolongados

Objectives Spin echo or gradient echo magnetic resonance imaging provides enough information to plan patient management and can be completed with the use of three-dimensional magnetic resonance angiography to evaluate the need for reintervention, assess follow-up, or discharge the patient. Patients and methods From 1990-2003, we evaluated 101 patients after initial corrective surgery for aortic coarctation at the age of 3.1 ± 3 years, with subsequent postoperative assessment at 1 year and again 12.4 ± 4.2 years later. No mortality was registered during the follow-up. Corrective surgery was performed in 32 patients (31.6 %) before the first month of life. All the patients were evaluated with spin-echo and echo gradient and 34 were evaluated with magnetic resonance angiography. The patients were classified into two groups: group A consisted of 68 patients (11 < 1 month old) with no complications. End-to-end anastomosis was performed in 55, the Alvarez technique in five, the Waldhausen technique in six, and conduit in two. Group B consisted of 33 patients complicated with early aortic recoarctation (21 corrected before the age of 1 month). End-to-end anastomosis was performed in 29, the Alvarez technique in two, and grafting in two. During the follow-up, 43 reinterventions were performed. Isthmus diameter/descending aorta diameter at the diaphragmatic level and repaired site diameter/descending aorta diameter at the diaphragmatic level were measured. Results Group A: the isthmus diameter/descending aorta diameter at the diaphragmatic level index was 0.92 ± 0.08 and the repaired site diameter/ descending aorta diameter at diaphragmatic level index was 0.90 ± 0.05. Twenty-three patients were assessed by means of three-dimensional magnetic resonance angiography, which revealed two late stenosis (one in a 10-year-old patient with an end-to-end anastomosis performed previously, and another in an 18-year-old patient with a proximal and distal obstructed conduit). Group B: the isthmus diameter/descending aorta diameter index was 0.84 ± 0.1 and the repaired site diameter/ descending aorta diameter index was 0.82 ± 0.11. Eleven patients were assessed by means of three-dimensional magnetic resonance angiography, which revealed five stenosis indexes (0.53-0.73) surgically corrected before the age of 2 months, four with an initial technique based on end-to-end anastomosis and one with a graft. Conclusions Our results support the influence of young age, the use of end-to-end anastomosis and grafts in recoarctation and their late influence on recurrent recoarctation. The patients in group A were discharged in childhood or adulthood after periodic follow-up every 5 years with magnetic resonance angiography for 18 years with results within the normal range, while patients in group B required longer follow-up

[Magnetic resonance imaging and lung perfusion scintigraphy in tetralogy of Fallot following surgery]. / Resonancia magnética y gammagrafía de perfusión pulmonar en casos de tetralogía de Fallot operados.

OBJECTIVE: To evaluate pulmonary arteries in patients with tetralogy of Fallot following surgery with quantified lung perfusion scintigraphy and magnetic resonance imaging. MATERIAL AND METHODS: From January 1985 to December 1999, 47 patients who underwent surgery between 1985 and 1999 were studied. To obtain values of normality, 45 infants with no pulmonary artery disease were assessed with lung perfusion scintigraphy (right lung flow: 54-61%, left lung flow: 38.7-46%) and magnetic resonance imaging axial view (right/left pulmonary artery branch diameter ratio: 1-1.1). Patients with stenosis underwent catheterization. RESULTS: Group 1: 27 patients with normal parameters. Group 2: nine patients with left pulmonary branch stenosis and irregularities in all parameters; left/right branch diameter ratio 0.51 and left lung perfusion 26.3 +/- 7.9%, r correlation ratio 65%, p < 0.005, left branch pressure gradient 34.4 +/- 17.9 mm Hg, rate-gradient r 89%, p < 0.001. Group 3: five patients with right pulmonary branch stenosis and irregularities in all parameters; right/left branch diameter ratio 0.52, reduced right lung perfusion 32 +/- 11%, with a stenotic branch gradient of 40 +/- 19 mm Hg., rate/gradient ratio r 72%, p < 0.005; gradient/perfusion ratio r 82%, p < 0.003. Group 4: Six patients with bilateral stenosis, reduced diameter in the stenotic area with normal perfusion in both lungs and bilateral gradient. Eighteen patients with stenosis underwent re-operation, with favorable outcome in 14. CONCLUSION: Magnetic resonance imaging and quantified lung perfusion scintigraphy provide useful information in the follow-up of tetralogy of Fallot.

Cerebral toxoplasmosis after autologous peripheral blood stem cell transplantation.

Toxoplasmosis appears to be a rare opportunistic protozoal infection following haematopoietic stem cell transplantation (HSCT). Most cases have been reported in allogeneic HSCT recipients, with only anecdotal reports of infection occurring after autologous transplantation. Reported here is the case of a patient who developed cerebral toxoplasmosis following autologous peripheral blood stem cell transplantation for non-Hodgkin's lymphoma.

[Low grade astroblastoma: pathological and magnetic resonance findings]. / Astroblastoma de baixo grau: Achados patológicos e da ressonância magnética.

INTRODUCTION: The astroblastoma is an uncommon type of glial tumour. It accounts for less than 1% of all tumours of the central nervous system. It originates in the tanicytes, ependymal cells present in the embryo and usually seen in adolescents and young adults. Radiologically it presents as a well delimited, heterogeneous tumour with a solid component which takes up contrast and is cystic, giving the same signal as cerebrospinal fluid (CSF). The pathological characteristics are of the formation of radial astroblastic pseudorosettes with perivascular hyalinization. CASE REPORT: An 18 year old woman presented with a 15 month history of motor deficit of her right limbs with occasional left frontal headache and horizontal diplopia on looking towards the left. On examination there was minimal claudication of the right limbs and bilateral papilloedema. Magnetic resonance showed a very well circumscribed left prefrontal neoplasm of heterogeneous aspect, with areas of solid and cystic appearance in the different sequences. The area of cystic appearance did not show the CSF signal in all sequences of the pulse. The tumour was totally excised. On histological study there were radial astroblastic pseudorosettes with perivascular hyalinization, with two mitoses per 10 fields of great magnification and the final diagnosis was of low grade astroblastoma. The apparently cystic portion was composed of friable gelatinous tissue. Fifteen months after her operation the patient is still asymptomatic. CONCLUSION: We report the radiological and pathological findings of a low grade astroblastoma.

Astroblastoma de bajo grado: hallazgos patológicos y en resonancia magnética / Low grade astroblastoma: pathological findings and on magnetic resonance

Introducción. El astroblastoma es un tumor de estirpe glial muy poco frecuente. Constituye menos del 1 por ciento de todas las neoplasias del sistema nervioso central. Tiene su origen en los tanicitos, células ependimarias presentes en edad embrionaria y suele aparecer en adolescentes y adultos jóvenes. Radiológicamente se presenta como una tumoración bien delimitada, heterogénea, con componente sólido que capta contraste y quístico con señal idéntica a la del líquido cefalorraquídeo (LCR). Patológicamente se caracteriza por la formación de pseudorrosetas astroblásticas radiales con hialinización perivascular. Caso clínico. Mujer de 18 años con un cuadro de 15 meses de evolución de un déficit motor de extremidades derechas acompañada ocasionalmente de una cefalea frontal izquierda y de diplopía horizontal en la mirada a la izquierda. La exploración mostró una mínima claudicación de extremidades derechas y un edema de papila bilateral. La resonancia reveló una neoplasia prefrontal izquierda muy bien circunscrita de aspecto heterogéneo con áreas de apariencia sólida y quística en las diferentes secuencias. El área de apariencia quística no tenía la señal del LCR en todas las secuencias de pulso. El tumor fue resecado de forma completa. Patológicamente se caracterizaba por la formación de pseudorrosetas astroblásticas radiales con hialinización perivascular con dos mitosis por 10 campos de gran aumento y el diagnóstico final fue de astroblastoma de bajo grado. La porción aparentemente quística correspondía a tejido gelatinoso friable. La paciente permanece asintomática 15 meses después de la intervención. Conclusión. Presentamos los hallazgos radiológicos y patológicos de un astroblastoma de bajo grado (AU)

Treatment of acute leukemia in children: recent advances and future challenges.

Recently advances have been made in the treatment of acute leukemia in children, it is now possible to cure more than 70% of children with acute lymphoblastic leukemia. With the introduction of more intensive chemotherapy regimens in patients at higher risk of relapse and the identification of cases that could be less intensely treated to diminish long-term toxicity, it could be possible to improve these excellent results. In contrast, pediatric acute myeloid leukaemia seems to be a more heterogeneous disease and its response to conventional chemotherapy is not as uniform. Introduction of new and more efficacious therapies is necessary to improve the poor outcome, especially among patients with high-risk features.