Validating the usefulness of Sudoscan in ATTRv: a single centre experience

BACKGROUND

Variant transthyretin amyloidosis (ATTRv) can cause sensorimotor and autonomic neuropathy. Objective quantification of sudomotor function may be essential for early diagnosis and early initiation of treatment. The aim of this study is to evaluate the diagnostic value of the Sudoscan® in ATTRv.

METHODS

Electrochemical skin conductance (ESC) was measured in V30M ATTRv patients, asymtomatic V30M carriers and healthy controls. Comparisons between the three groups were made using the Kruskal-Wallis test, and ROC curves were used to estimate the discriminatory power of ESC values between groups.

RESULTS

ESC was measured in 52 ATTRv patients, 107 asymptomatic carriers and 40 healthy controls. ESC was significantly lower in ATTRv patients compared to asymptomatic carriers and healthy controls in both feet and hands; median values are as follows: 40 µS, 78 µS and 81 µS, respectively (p < 0.001), and 53 µS, 69 µS and 74 µS, respectively (p < 0.001). ESC in feet < 70.5 µS had a sensitivity of 89.7% and specificity of 84.6% to discriminate asymptomatic carriers from patients with ATTRv.

CONCLUSION

The determination of ESC by Sudoscan® is a rapid, noninvasive and easily reproducible technique capable of discriminating patients with ATTRv from asymptomatic carriers and healthy controls with adequate sensitivity and specificity.

Sepsis Code: dodging mortality in a tertiary hospital

Introducción

En el hospital de La Princesa comienza el “Código Sepsis” (CSP) en el año 2015, como un grupo multidisciplinar que dota al personal sanitario de herramientas clínicas, analíticas y organizativas, con el objetivo de la detección y el tratamiento precoz del paciente con sepsis. El objetivo de este estudio es evaluar el impacto de la implantación de CSP en la mortalidad y determinar las variables asociadas con un aumento de la misma.

Material y métodos

Se realizó un estudio analítico retrospectivo de los pacientes con activación de la alerta CSP de 2015 a 2018. Se recogieron variables clínico-epidemiológicas, parámetros analíticos y factores de gravedad como el ingreso en Unidades de Cuidados Críticos (UCC) y la necesidad de aminas. La significación estadística se estableció en una p < 0,05.

Resultados

Se incluyeron 1.121 pacientes. La estancia media fue de 16 días y un 32% requirieron ingreso en UCC. La mortalidad mostró una tendencia lineal descendente estadísticamente significativa del 24% en 2015 hasta el 15% en 2018. Las variables predictivas de mortalidad con asociación estadísticamente significativa fueron el lactato > 2 mmol/L, la creatinina > 1,6 mg/dL y la necesidad de aminas.

Conclusiones

La implementación de Código Sepsis disminuye la mortalidad de los pacientes con sepsis y shock séptico. La presencia de una cifra de lactato > 2 mmol/L, los niveles de creatinina > 1,6 mg/dL y/o la necesidad de administrar aminas en las primeras 24 horas, se asocian con un aumento de la mortalidad en el paciente con sepsis.

Val50Met hereditary transthyretin amyloidosis: not just a medical problem, but a psychosocial burden

BACKGROUND

Hereditary transthyretin (TTR) amyloidosis (ATTRv) is a heterogeneous disease with a clinical presentation that varies according to geographical area and TTR mutation. The symptoms of Val50Met-ATTRv are mainly neuropathic and progress to complete disability and death in most untreated patients within 10 to 15 years of diagnosis. The neurological effects may also be accompanied by gastrointestinal impairment, cardiomyopathy, nephropathy and/or ocular deposition. The disease is thus associated with a high degree of patient disability. Accordingly, we aimed to describe the psychosocial burden associated with ATTRv in a group of patients, asymptomatic Val50Met carriers, relatives and caregivers in the endemic focus of the disease in Majorca via a survey addressing various aspects related to psychosocial burden. We performed a an observational, descriptive, cross-sectional and multicentre study in order to analyze the prevalence of self-reported impact of ATTRv disease upon their daily life. In addition to the self-knowledge, fear and burden related to the disease. The survey was disseminated during the regular follow up at the outpatient clinic of the Hospital Universitario Son Llàtzer and during the meetings organized by the Andrade's Disease patients' advocacy group from the Balearic Islands. These meetings were attended also by subjects followed up by the Hospital Universitario Son Espases and their caregivers and relatives. Survey was self-administrated. No intervention was done by the investigators. 85 subjects completed the survey: 61 carrying the TTR-V50M variant and 24 caregivers or relatives.

RESULTS

Our study revealed that, although most of the population studied had had prior contact with ATTRv through affected relatives, there was still a lack of information regarding disease diagnosis. Fear of the genetic test result and psychological issues were common in our population. Moreover, the disease had a stronger impact on the daily life of our patients than that of our asymptomatic carriers. Autonomic symptoms were the main source of burden for relatives and caregivers.

CONCLUSION

Our survey results show high psychosocial burden associated with Val50Met-ATTRv in our area.

Tm(iii) complexes undergoing slow relaxation of magnetization: exchange coupling and aging effects

The present study focuses on the dynamic magnetic behaviour of exchange coupled 3d-4f complexes containing the scarcely investigated non-Kramers Tm³⁺ center, the 3d metal ions being either the low-spin Fe³⁺ (1) or the diamagnetic Co³⁺ (2) ion. Both complexes display field-induced slow relaxation of magnetization. The field and temperature dependences of the relaxation rate provided indication of relevant contributions from quantum tunnelling, direct, Orbach and Raman processes, with only minor effects from exchange coupling interactions. Furthermore, the aged sample of 2 exhibited an additional relaxation process, possibly due to structural modifications accompanied by solvent loss, highlighting the importance of a careful consideration of this factor when analysing the magnetization dynamics in solvated systems.

[Cost effectiveness analysis of the diagnosis of carpal tunnel syndrome using electrophysiological studies]

INTRODUCTION

The high demand for electrophysiological studies (EP studies) in paucisymptomatic patients with suspected carpal tunnel syndrome (CTS) creates overloads in neurological examination departments. Most of these requests in the referenced section of our hospital come from primary health care, however it also comes from other specialists. Many EP Studies for CTS are normal or have minimal alterations so that no change in the therapeutic attitude is required. Thus, it is not clear whether EP studies are cost-effective for suspected CTS without clinical evidence of axonal degeneration.

METHODS

A decision-making and economic evaluation model was made to compare three strategies: option A (EP Studies for all patients with suspected CTS), option B (prior selection by neurologist and EP studies only if axonal CTS was suspected) and option C (prior selection by neurologist and EP studies only if CTS, axonal or otherwise was suspected). The study was conducted over a two month period on patients referred to the neurology department with suspected CTS. EP studies were considered to be the proof that established the final diagnosis. The consequences were determined in terms of correct diagnoses, cost and cost/effectiveness ratio for each strategy. A total number of 188 studies were performed, option C being the most cost-effective, but also the most expensive.

CONCLUSIONS

When there is neurological screening, the cost-effectiveness ratio is better but it is also more expensive. It is recommended to favor option A with intermediate cost and an acceptable cost-effectiveness ratio. However, this also generates great pressure on bud- 45 gets and care facilities which means that CTS diagnosis and criteria for referring patients to the neurological examination departments must be improved.

[Serotonin syndrome: report of two cases and review of the literature]

INTRODUCTION

Serotonin is a neurotransmitter synthesized from tryptophan. It is implied in the regulation of mood, cognition, sleep cycle, synthesis of cerebrospinal fluid, and other processes. Generally, it is implied in human pathology by hypofunction. However, there is a complication of unknown incidence related to treatment with drugs that increase the stimulation of 5-HT1A serotonin receptors, called serotonin syndrome (SS). Clinically, it is characterised by the presence of a triad of mental and autonomic disorders, and motor hyperactivity. This entity has not biological markers and its diagnosis could be done verifying the proposed criteria.

CASE REPORTS

Two cases of SS are presented, one of them related to the combination of risperidone and sertraline, as first report in the literature. Both cases had a favourable outcome employing support measures.

CONCLUSIONS

The physiopathology, the diagnosis, the differential diagnosis, and the treatment are reviewed. We emphasize the potentially high frequency of this disorder, given the growing use of serotonin activity modifying drugs, and the typically benign course of the SS once the support measures are started.

Mannose-binding lectin polymorphisms in a Canary Islands (Spain) population

We have compared the structural and promoter variants of the mannose-binding lectin (MBL) gene in a population from Gran Canaria with that from other populations previously reported. The observed frequencies of the seven alleles of the MBL gene in our population were: HYPA, 0.24; LYQA, 0.22; LYPA, 0.08; LXPA, 0.19; LYPB, 0.17; LYQC, 0.03 and HYPD, 0.07. The frequency of non-producer alleles and of MBL-deficient individuals in our population is higher than in other European and Asian population.

[Intrathecal synthesis of IgG evaluated using different formulas: importance of multivariate analysis in the diagnosis of multiple sclerosis]

INTRODUCTION

Synthesis of IgG is useful data for the diagnosis of multiple sclerosis, and different formulas, both direct and indirect, are used to quantify this. We analyze these formulas with the objective of finding whether certain combinations of them would give better results than the individual formulas on their own.

PATIENTS AND METHODS

We studied the cerebrospinal fluid of 45 patients with neurological disorders and determined the results of the two formulas which are most effective, according to some studies (Reiber's formula and IgG index) together with a direct formula (IgG ratio) and another indirect formula (the 'classical' formula of Tourtellotte).

RESULTS

The IgG index was, in general, the formula which best differentiated between patients with multiple sclerosis and persons with other neurological disorders.

CONCLUSIONS

We found a tendency which supported the original hypothesis that it is possible to use combinations of formulas to obtain better results than individual formulas. This fact may serve as a basis for further studies in which different combinations are tested, including analytical and clinical data, and this may be of use in the diagnosis of multiple sclerosis.

[Normal values for transcranial doppler studies in our medium]

OBJECTIVE

Transcranial Doppler is a technique which is being used ever more frequently in the study of intracranial arteries and is very useful in the study of cerebrovascular disease. The typical values of a healthy population in our country are unknown. The aim of this study was determine mean velocity and pulsatility index reference values in a healthy population.

PATIENTS AND METHOD

Transcranial Doppler basal examination was carried out on 118 healthy volunteers without prior haematological or cerebrovascular conditions. Those found to have extracranial arterial stenoses were excluded as were those in whom bilateral temporal bone hyperostosis did not permit insonation in either middle cerebral arteries. The nine intracranial arteries were sounded systematically at fixed depths. The mean and standard deviations of each variable were calculated for side, age group and sex.

RESULTS

49% were males and average age was of 56 years (range, 21-87 years). A sufficient signal to determine the parameters of the study was obtained in 89% of middle cerebral arteries. Statistically significant differences in mean velocity and pulsatility index were found between age groups and sexes.

CONCLUSIONS

Sex and age must be taken into account in establishing typical patterns in transcranial Doppler examination. Our results enable parameters of typical values to be established for the adult population in Spain.

[Subarachnoid hemorrhage as a form of onset of systemic lupus erythematosus]

INTRODUCTION

The most frequent cause of spontaneous subarachnoid hemorrhage (SAH) is rupture of intracranial arterial aneurysms (> 70%). The remainder are due to many different aetiologies. Although SAH is a relatively common neuropathological finding in systemic lupus erythematosus (SLE), it is normally due to the extent of the intercerebral hemorrhage and not to its isolated presentation.

CLINICAL CASE

We report the case of a 34 year old woman who presented with non-traumatic SAH at the onset of her lupus disorder. The patient was attended for SAH and at the same time a multisystemic disorder and severe thrombocytopenia were found, leading to a diagnosis of SLE. The neuroimaging techniques, selective cerebral arteriography, cerebral and spinal magnetic resonance, and magnetic resonance angiography did not show any vascular malformations. The patient was treated with immunosuppressive therapy, nimodipine, and following angiographic tests, with antiaggregants and anticoagulants.

CONCLUSIONS

The greater frequency of SAH in patients with lupus, as compared to the general population, has been attributed to the presence of intracranial vasculitis. However, neuropathological studies have shown that true vasculitis is very infrequent in the central nervous system of SLE patients. In the case we describe, the first in which SAH appeared at the onset of the disease, we consider that the origin of the hemorrhage was her high arterial blood pressure and thrombopenia.

[Statins (HMG-CoA reductase inhibitors), cholesterol and stroke]

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.

[Record of neurological emergencies at a tertiary care hospital]

INTRODUCTION AND OBJECTIVE

There is a progressive increase in the demand for multidisciplinary attention from the Emergency Medical Services. The objective of this study was to determine the proportion of neurological conditions in the total hospital emergency workload, their demographic composition and medical needs.

PATIENTS AND METHODS

We present an observational study of a cohort of histories of neurological emergencies at a tertiary hospital during a period of one year.

RESULTS

On analysis of all emergencies, 1,592 were neurological conditions. The duty neurologist was consulted in 87.9% of the cases. The average age was 59, and the majority were women (56.3%). Maximum demand was between 14.00 and 19.59 hours. Monday was the day of the week when most were seen. The commonest causes of consultation were change in strength or language, headache and epileptic crises. The complementary investigation done most frequently was a blood test. Cerebral CT scan were done in 31.9% of the patients. The diagnoses most often made, as a group, were cerebrovascular disease followed by epilepsy and headache. The majority of the patients were referred to Primary Care Centres or for neurological consultation. When the patients were grouped according to the specialties with doctors on duty, the second largest group were seen by the emergency neurologist at our hospital.

CONCLUSION

In view of the above results, we consider the presence of a neurologist in the Emergency Department to be fully justified.