Objective: To describe and contrast the symptomatic variability of cases with sporadic or non-sporadic Alzheimer’s dementia (DTA + E) with the data obtained from the cases with early familial Alzheimer’s dementia caused by the E280A of the Neurobank of the Neurosciences Group of Antioquia (GNA). Materials and Method: This study was of exploratory – descriptive and correlacional type, 83 donors’ cases were taken with DTA stored in the Neurobank. These cases were divided in two groups, i) a group defined genetically like E280A; and ii) another not carrying group of the mutation (DTA+E); the scoreboards and / or characteristics neuropsychiatric, neuropsychological, neurological and neuropathological of both groups were confirmed. Results: The symptom that showed higher differences between both groups was iteration iteration (DTAF E280A with 1.2% and 18.4% for the DTA+E group). Other symptoms as depression or the time of appearance of progressive loss of memory did not show big differences among groups (DTAF E2080A=55.9%; DTA+E =53.1%) and (DTAF E2080A=55.9%; DTA+E =53.1%). The language disorders that were observed with major frequency among the donors were the loss of the language, mutism, anomia and aphasia. The sign with higher frequency in both groups was lost of sphincter control. The atrophy was with more intensity in the temporary lobes of the brains of the donors with DTA+E (83.3%). The weight of the brain and of the posterior fosse content, they have a moderate, directly proportional and highly significant relation from the statistical point of view. Conclusions: DTA +E has neuropathological differences with DTAF E280A that can be associated with the physiology hereditary from of DTAF E280A.
Artículos Originales
Fístula Carótido Cavernosa. Utilidad del ultrasonido Doppler en el diagnóstico. Cavernous carotid fistula. Utility of Doppler ultrasound in diagnosis.
Introduction. Carotid cavernous fistulas are infrequent vascular malformations that generate a pathological arteriovenous shunt, which compromises ocular function. The definitive diagnosis is established by cerebral arteriography. However, its invasive nature limits its use in follow-up. The aim of this work is to illustrate the value of the study with transcranial doppler ultrasound for the diagnosis of cavernous carotid fistulas and to describe the flow parameters that could be modified. Patients. A retrospective review of the clinical histories of the patients treated with a diagnosis of cavernous carotid fistula was carried out in the stroke unit of the Hermanos Ameijeiras Hospital in Havana, between January 2005 and May 2014. Demographic and disease variables were collected, as well as the results of imaging and ultrasound studies. Results. We describe the clinical and imaging characteristics of three patients in whom carotid cavernous fistula was confirmed. In the two patients with direct communications, an increase of the mean flow velocity in the ophthalmic vein, arterialized, with decrease in pulsatility were registered; in addition to an increase in the diastolic peak velocity in the internal carotid artery ipsilateral to the fistula. In the patient with the indirect fistula the changes were less marked. Conclusion. The ultrasound study was useful in the diagnosis of carotid cavernous fistulas, showing differences in the flow parameters that can be used to classify the fistulas.
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Estatus Epiléptico. Factores Asociados a Una Evolución Desfavorable en un Centro Terciario. Status Epilepticus. Prognostic Variables For An Unfavorable Outcome In A Tertiary Center Of Care.
Introduction. Status Epilepticus (SE) is a frequent neurologic emergency. Little research has been done in South America to evaluate the prognostic variables of mortality and disability in patients with SE. Objective. To determine the variables associated to an unfavorable outcome at hospital discharge in the patients who were treated for SE. Methods. A retrospective study was performed during the period of January 2016–June 2017. A total of 26 patients were diagnosed of SE and its different variants. The effects of clinical, radiological, and electroencephalographic features on hospital outcome according Rankin scale were evaluated Results. Twelve (46.2%) patients had an unfavorable outcome at hospital discharge, while the mortality rate reached 23.1%. There was a predominance of males with a 76.9% of all the patients. The independent variables associated with an unfavorable outcome were the number of comorbidities (p=0.01, OR: 4.27-95%CI1.33-13.6), structural lesions on the Magnetic Resonance Image (MRI) (p=0.04, OR: 3.92-95%CI1.05-14.61) and refractory SE (p=0.01, OR: 12.52-95%CI1.85-84.44). There was also a trend for age (p=0.07 OR: 1.03-95%CI0.99-1.07). While an initial good clinical condition, according to the Glasgow Scale represent a protective factor (p=0.00 OR: 0.49-IC95% 0.29-0.84) of an unfavorable outcome. Conclusions. The unfavorable outcome was marginally associated with patient age, clinical status at the onset of SE according to the Glasgow Coma Scale, as well as brain lesions on brain MRI. Refractory SE and more than 4 comorbidities are predictors of an unfavorable outcome at hospital discharge.
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Neuronavegación en la Planificación Prequirúrgica y en la Cirugía de la Epilepsia Refractaria. Neuronavigation In Pre Surgical Planning And Surgery Of Refractory Epilepsy.
Epilepsy is one of the more frequent neurologic disorders, with an incidence of 50/100,000/year and prevalence between 0.5 and 2% worldwide. A third of these patients suffer focal epilepsy due to epileptogenic lesions evident by neuroimaging new techniques. Epilepsy surgery is the only treatment that can cure refractory epilepsy. Its goal is to remove the epileptogenic lesion with preservation of eloquent areas, and in this case both surgical experience and neuroimaging technology play a pivotal role. Objective. To demonstrate utility of neuronavigation in presurgical planning and surgery of refractory epilepsy. Method. Descriptive, cross sectional and analytic study of 47 performed surgeries (12 resective, 12 palliative and 3 diagnostic) in patients with refractory epilepsy with an average age of 9.93 years (SD 4.1). In 27 patients (57.44%) neuronavigation was used. In patients operated with assistance of neuronavigation, surgical time diminished in 47.17 minutes (p=0.022), hemorrhage in 111.41 ml (p=0.011) and days of hospitalization in 6.68 days (p=0.005) comparing with group without neuronavigation. Complications in the group with neuronavigation were 29.63% compared with 65% in the group without it. (P=0,034). Conclusions. In this study, using neuronavigation in planning and performing surgery in reducing the amount of blood loss, surgical time, days of hospitalization and post surgical complications.
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El Posicionamiento Elevado de Cabeza y Cuerpo Podrían Afectar la Autorregulación Cerebral Dinámica en Pacientes con Enfermedad Silente de Pequeño Vaso Cerebral. Protocolo y Definiciones Operacionales. Head-Up And Body Positioning Might Impair Dynamic Cerebral Autoregulation In Patients With Silent Cerebral Small Vessel Disease. Protocol And Operational Definitions.
Background: Cerebral autoregulation (CA) is the ability of intracranial vessels to maintain a constant cerebral blood flow (CBF) during changes of cerebral perfusion pressure (CPP) related to fluctuations in blood pressure, postural changes or increased metabolic demands. It has been suggested that individuals with silent cerebral small vessel disease (SVD) may have impaired CA, but information is inconclusive. We describe the protocol of a study aimed to assess the association between white matter hyperintensities (WMH) of presumed vascular origin and poor dynamic CA, and to determine the effects of head-up and body positioning in patients with this condition. Methods: Using a case-control study design, we will assess the relationship between severity of WMH and dynamic CA, measured by continuous transcranial Doppler assessment of CBF velocities in the middle cerebral arteries (MCAs) combined with beat-to-beat blood pressure monitoring. Dynamic CA will be analyzed by calculating the mean flow index as the ratio of median arterial pressure and mean flow velocities of the MCAs. Participants will be categorized as case-patients if the MRI shows moderate-to-severe WMH. For every case-patient, an age- and sex-matched healthy individual with no neuroimaging evidence of SVD will be selected as a control. Comment: This study will assess whether head-up and body positioning impairs dynamic CA in the setting of diffuse subcortical damage related to SVD, providing further evidence on the importance of CPP in maintaining the CBF. If positive, the study will provide evidence favoring the stop of aggressive hypertensive therapy or interventions promoting orthostatic hypotension to reduce the risk of further ischemic brain damage in these cases.
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Mortalidad por enfermedades cerebrovasculares en Ecuador 2001- 2015: Estudio de tendencias, aplicación del modelo de regresión joinpoint. Mortality due to cerebrovascular diseases in Ecuador 2001- 2015: a trend study, application of the joinpoint regression model.
Objective. To analyze the mortality trend for cerebrovascular diseases in Ecuador and to identify the presence of changes in the temporal trend using the joinpoint regression model.
Materials and Methods. A mixed ecological study was carried out. Standardized mortality rates for the last 15 years (2001 to 2015) in Ecuador were calculated and stratified by age, sex, and provinces. A joinpoint regression analysis was used for analysis of trends.
Results. From 2001 to 2015, there were 48,621 deaths from cerebrovascular diseases in Ecuador. In the joinpoint regression analysis, age-adjusted rates in men declined from 71.4 to 59.5 deaths per 100,000 population, with an annual decline of 1.51% (p <0.05) in females from 61.2 to 55.5 deaths per 100,000 population, with an annual decrease of 1.11% (p <0.05). In the analysis by provinces, Sucumbíos presented a growing trend of 3.17% per year (p <0.05).
Conclusions. Mortality from cerebrovascular disease has declined in Ecuador in the last 15 years. The downward trend was observed in almost all age demographics.
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Riesgo Cardiovascular Entre Hispanos Residiendo en los Estados Unidos: El Sistema Conductual de Vigilancia de Factores de Riesgo 2013. Hispanic Ethnicity and the Risk of Cardiovascular Disease in the United States: The Behavioral Risk Factor Surveillance System 2013.
Background: Although the leading cause of death among Hispanics living in the United States (US) is cardiovascular disease (CVD), the association between Hispanic ethnicity and CVD has been scarcely explored. Objective: To examine whether being Hispanic is associated with an increased risk of CVD compared with the non-Hispanic US adult population in 2013. Methods: Secondary data analysis of a cross-sectional 2013 Behavioral Risk Factor Surveillance System survey in 2013 (n=486,905). The main exposure variable was Hispanic ethnicity (Mexican, Puerto Rican, Cuban or Spanish origin) and the main outcome variable was self-reported CVD (myocardial infarction/coronary artery disease/angina). The main covariates were sex, age, education, income, healthcare access, exercise, body mass index, current smoking, heavy drinking, diabetes, hypertension and hyperlipidemia. Unadjusted and adjusted logistic regressions were used to assess the effect between ethnicity and self-reported CVD. Odds ratios (OR) and 99% confidence intervals (CI) were calculated. Results: In total, 12% of the study participants were Hispanic (n=57,257). Approximately 24% of Hispanics were 25-34 y/o while (21%) of non-Hispanic were >65 y/o. After adjustment, Hispanics were 30% less likely to report CVD compared with non-Hispanics (OR=0.7; 99%; CI=0.6-0.8). Compared with men, women had a 40% decreased risk of having CVD (OR=0.60; 99% CI=0.5-0.6). Advanced age, lower educational attainment, income <$15,000/year, lack of exercise, smoking, non-heavy drinking, diabetes, hypertension and hyperlipidemia increased statistically significantly the likelihood of reporting CVD. Conclusion: The findings suggest that, in general, Hispanics residing in the US are significantly less likely to self-declare if they had a CVD compared with non-Hispanic Americans. These data suggest that although Hispanics are generally poorer and have less access to education and health services, their self-perceived health is better than in non-Hispanic residents of the US.
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Evaluación Neuropsicológica de la Atención: Test de Símbolos y Dígitos. Neuropsychological Assessment of Attention: Symbols And Digits Test.
Introduction: The symbol digit modality test is a reactive which provides great support in neuropsychological evaluation. Its execution permits to evaluate brain functions such as visual perception, stimuli recognition, attention (focal, selective and sustained), task supervision, interference control among others. Object: The purpose of the current research study was to analyze the normative percentiles of the execution of the test, to identify the performance activity of the reactive according to age group and gender; applying the test in a sample of college students. Method: The sample included 250 university students,142 (56.8%) males and 108 (43.2%) females. The age range of the participants was between 18 and 34 years old (M=21.53, DE=2.25). A transversal, non-experimental, quantitative research model with a correlational scope was used. Results: The correct answer average for the test was 52.83 (DE=13,60) and for percentile P5 31,55 right answers were found; for percentile P75 60,00 right answers, P25 had 46,00 right answers, and for P95 74,45 right answers were found. No significant differences were found for the mean of errors in the test in terms of age group f(3, 246)=0,67, p=0,57 and gender t(248)=0,68, p=0,49 of the participants as comparison factor. Conclusions: Results were discussed based on prior research pointing out the importance of counting with a first statistical parameter of the test as ground for neuropsychological clinical practice in Ecuador.
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Factores de Riesgo Asociados a Parálisis Cerebral en una Poblacion de Niños y Jóvenes Mexicanos. Risk Factors Associated With Cerebral Palsy In A Population Of Mexican Children.
Objectives: To establish the risk factors associated with Cerebral Palsy in a population of Mexican children and compare the results with studies from other countries.Methods: Analytical, retrospective, randomized, observational study, through review of the file and a survey, comparison of proportions. Participants: 230 patients with Cerebral Palsy between 0 and 29 years of age and their biological mothers from a specialized institution in Mexico. Results: We studied 29 risk factors , range 0 to 9 in each patient. Prenatal 244 factors; Perinatal 378, Postnatal 319. Most frequent prenatal risk factors: urinary infection, 99 (43%), and transvaginal bleeding, 61 (27%). Perinatal: perinatal hypoxia, 131 (57%); and prematurity, 116, (50%). Postnatal: convulsive syndrome <2 Years old, 92 (42%); and jaundice, 84 (37%). Conclusions: The most common cerebral palsy associated risk factors were perinatal, which differs from that reported in countries such as Spain, USA and England, where the prenatal ones are. Sweden results are similar to Mexico. It is suggested to carry out prospective studies in this field.
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Deterioro Cognitivo en Pacientes Diabéticos De 55 a 65 Años de Edad. Reporte Final de Estudio Observacional, Transversal en la Ciudad de Guayaquil. Cognitive Impairment In Diabetic Patients Between 55 And 65 Years Old. Final Report Of A Cross-Sectional, Observational Study In Guayaquil City.
Introduction: Diabetes mellitus is a frequent and systemic illness. Deleterious effects on cognition are one of its lesser known consequences. Diabetic individuals are at an increased risk for development of dementia in the future. Objective: To compare cognitive function in middle aged diabetic population with non-diabetic control group, in order to determine high risk population for developing cognitive decline or dementia in the future. Methodology: This is a cross-sectional, observational study conducted in Guayaquil. We studied 309 individuals between the ages of 55 and 65 years, of which 142 were diabetics and 167 were non-diabetic controls. A neuropsychological evaluation was performed to assess memory, attention, executive functioning and processing speed. Results: Group comparisons revealed significant differences between diabetics and non-diabetics in systolic blood pressure (p<.001), hyperlipidemia (p<.001) and cardiovascular risk (p < .001). Cognitive performance, after considering differences in scholarship, was lower in diabetic people (memory p values between .000 and .002; attention p values between .000 and .019; executive function p values between .000 and .001). Correlation between years of disease and cognitive decline was not significant (memory -.055; attention -.040; executive function .0169). Correlation between glycated hemoglobin and cognitive performance was significant for all evaluated functions (memory -.219; attention -.186; executive function -.269). Conclusion: Middle aged diabetic population has lower cognitive performance compared with non diabetics. The identification of individuals at risk for cognitive decline will contribute to the development and implementation of intervention strategies that will allow the slowing of cognitive decline in vulnerable individuals.
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Retardo en la Llegada de Pacientes con Ictus Isquémico a un Hospital Terciario de Ecuador. Delay In The Arrival Of Ischemic Stroke Patients At A Tertiary Hospital In Ecuador.
Introduction. In an Stroke unit, the ischemic stroke treatment with a pharmacological thrombolysis is associated with a better recovery. The aim of this study is to identify the variables having a significant impact in the delay of the arrival of patients at a tertiary hospital. Methods. A prospective and longitudinal study was undertaken in patients with an ischemic stroke diagnosis, who were admitted to the Stroke Unit of Eugenio Espejo Hospital of Quito city in Ecuador in the time period from November 2016 to July 2017. Patients treated with r-Tpa were compared to those who arrived 4,5 hours later. Results. A total of 61 patients were analyzed: of those, 51 arrived 4,5 hours after first symptoms at the hospital, and 10 (16,4%) were thrombolysed in the period of therapeutic window. None of the social, demographic and clinical variables were related to the early arrival, except the history of an atrial fibrillation. In the group of patients who received r-Tpa, a significantly higher percent sought for medical care as a first option compared with those arriving after the 4,5 hours (90 vs 49%, p 0,0170). The greatest impact of the early referral and the thrombolysis concerned the difference of score between the initial medical evaluation and the hospital discharge in the NIHSS scale. Conclusions. The results of this study point out to the unawareness of the stroke and the behavior to follow. The r-Tpa treatment shows clear benefits to the patients in our environment.
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Utilidad del Video EEG en un Hospital Pediátrico de Nivel Terciario Durante el Año 2015. Utility Of Video EEG In A Pediatric Tertiary Hospital During 2015.
The aim was to evaluate the V-EEG usefulness in the differential diagnosis of epilepsy in a Third Level Children’s Hospital during 2015. Materials and Methods: A descriptive study was performed over 90 patients in this unit during 2015. The data was obtained from variables related to indications and results of V-EEG, which were analyzed using descriptive statistics. Results: Fifty three percent of the patients were male. The mean age was 7.7 years (SD ± 4.7 years). The time measured between the first seizure and the V-EEG recording was 4,3 years. Seventy two patients (80%) had epileptic seizures, 12 patients (13,3%) had nonepileptic seizures, while six children (6.7%) had no seizures during the V-EEG monitoring. Ninety three percent of all recordings were successful. Conclusions: It was demonstrated the usefulness of V-EEG monitoring for the differential diagnosis of epilepsy.
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Apnea Obstructiva del Sueño y Neumatización Aberrante de Huesos del Cráneo. Obstructive Sleep Apnea And Aberrant Pneumatization Of Skull Bones.
Objective: We aimed to assess the association between obstructive sleep apnea (OSA) and aberrant pneumatization of skull bones in Amerindians living in rural Ecuador.
Methods: A random sample of community-dwelling individuals aged ≥60 years enrolled in the Atahualpa Project, were invited to undergo a single diagnostic night polysomnography (PSG) at the sleep unit of the Atahualpa Project Community Center. Exams were performed with an Embletta® X100™ Comprehensive Portable PSG System. A board-certified sleep neurologist carried out analyses of sleep efficiency, architecture, arousal indexes, apnea/hypopnea index, oxygen saturation, heart rate and motor activity. CT readings were focused on the presence and distribution of pneumatization of intracranial bones, as assessed by CT with bone window settings.
Results: Thirty-eight participants were included. Mean age was 74.5 ± 6.8 years and 25 (66%) were women. The apnea/hypopnea index ranged from 0.2 to 56 (mean 15.7 ± 14.6) episodes per hour. Fifteen persons (39%) had ≥10 episodes per hour and were considered to have OSA. Abnormal pneumatization of skull bones was noticed in six persons, included five out of 15 (33%) with OSA and one out of 23 (4%) without (p=0.027). Air was found in the temporal squamas in five (bilateral in four), the occipital bones in one, and in both the temporal squamas and the occipital bones in the remaining person.
Conclusion: This study shows a significant association between OSA and aberrant pneumatization of skull bones. These findings are of potential clinical relevance, since these individuals could be at increased risk of painless fractures from minor trauma or may be prone to develop spontaneous cerebrospinal fluid leaks.
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Índice de Pulsatilidad Cerebral en Adultos Mayores con Infarto Lacunar Silente (Proyecto Atahualpa). Cerebral Pulsatility Index In Older Adults With Silent Lacunar Strokes (The Atahualpa Project).
Background: Diagnosis of silent lacunar infarcts is complicated in remote rural areas where MRI is not available. Hospital series have suggested an association between the pulsatility index of intracranial arteries –as assessed by transcranial Doppler –and some neuroimaging signatures of cerebral small vessel disease. We aimed to assess the reliability of cerebral pulsatility indices to identify candidates for MRI screening in population-based studies assessing prevalence of silent lacunar infarctions.
Methods: A random sample of stroke-free Atahualpa residents aged ≥60 years investigated with MRI underwent transcranial Doppler for calculating the pulsatility index (PI) of the middle cerebral artery (MCA). For each person, mean PI was obtained by averaging both MCAs. Using conditional logistic regression for matched pairs data, we evaluated whether the pulsatility index of both MCAs correlate with silent lacunar infarcts.
Results: Silent lacunar infarcts were noticed in 28 (12%) of 234 scanned persons. Six of them were excluded due to poor insonation through transtemporal windows. The remaining 22 participants were considered case-patients and were matched 1:1 with individuals free of infarcts (controls). Moderate-to-severe white matter hyperintensities were noticed in 12 (55%) case-patients and 7 (32%) controls (p=0.228). The mean MCA PI value in the 44 participants was 1.15 ± 0.21, with no difference found across case-patients and controls, after adjustment for white matter hyperintensities (β coefficient: 3.361, 95% C.I.: -0.693 to 7.417, p=0.104).
Conclusions: Cerebral PI should not be used to identify candidates for MRI screening in population-based studies assessing the burden of silent lacunar infarcts.
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Funciones Ejecutivas en Niños Preescolares con y sin Trastorno del Lenguaje. Executive Functions In Preschool Children With And Without Language Disorders.
The objectives of this study were to compare the executive functions (attention, flexibility, inhibitory control, planning and working memory) of preschool children with and without language disorder and to define a profile of executive functions. The design is non-experimental for descriptive/comparative purposes. The sample consisted of 105 children. The group with language disorder was composed of 31 children and 19 girls, average age 4.68 years, of Special Language Schools. The group without language disorder was composed of 15 children and 24 girls, average age 4.98 years, of Public Schools of the city of Concepcion in Chile.
The results show that there is statistically significant evidence to state that the scores obtained by children with language disorders are lower than their peers without language disorder in all the executive functions evaluated, which supports the current literature on the subject. Regarding the profile of executive functions, the function that could predict the presence of language disorder in a preschool is the executive planning function.
It is interesting to continue deepening the profile of executive functions in children with language disorder and their specific relationship with the linguistic problems that these children have.
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Autismo en Ecuador: un Grupo Social en Espera de Atención. Autism In Ecuador: A Social Group Waiting For Attention.
Although increasing historical progresses have been achieved in defining the characteristics on a unusual behavior among people who could be on the autism spectrum disorder, unattended issues remain. Accuray is necessary for a correct diagnosis and urgent attention.
Ecuador is also part of this reality. This study is the first research that has been performed in the country, with 160 school-aged boys and girls coming from the mountains and the coast of Ecuador, 80 diagnosed with autism, and 80 neuro-typical kids. The results reveal the necessity to attend this matter. Surveys and confirmation cases including an innovative way of social insertion analysis show that the diagnostic processes demands important economical resources, and these economical resources could vary according to social insertion, and socio-spatial location; 26% of the children that were part of this study, received between 1 to 5 previous different diagnosis, 13,75% were mistakenly diagnosed; 46,2% of them, that were from the city of Guayaquil, and 23,7% from the city of Quito, spent more than one thousand dollars trying to get the diagnosis. This case-control study with children between ages of 2 and 12 years old, from Quito and Guayaquil, allows us to know the real situation of autism in Ecuador. It reveals major problems regarding on how to obtain a diagnosis, a therapeutic process, most of them related to the socio economical situation of the parents that were part of this study.
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Regulación Emocional en Pacientes con Esquizofrenia: Un Estudio Piloto. Emotion Regulation In Schizophrenia Patients: A Pilot Study.
Background. It has been reported that schizophrenia patients display emotional processing impairments, specifically in the emotion perception domain. However, less is known about other domains of emotional processing, like emotion regulation. Objective. The aim of this study was to assess and compare emotion regulation abilities and neurocognition in schizophrenia patients and healthy controls, as well as to identify correlations between emotion regulation, neurocognition and demographic data. Methods. 9 patients (GE) and 9 controls (GC) were recruited. Demographic data was obtained. To assess emotion regulation, the Mayer-Salovey-Caruso Emotional Intelligence Test -Managing Emotions section- was administered. Finally, a brief neurocognitive assessment was conducted. Results. The GE showed significant poorer performance than the GC in the emotion regulation test as well as in the neurocognitive assessment (p < .05). No correlations were identified between emotion regulation, neurocognition, demographic and clinical data. Discussion and conclusion. Schizophrenia patients show emotion regulation impairment, as well as neurocognitive deficits. Our results are consistent with other studies.
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Tabaquismo y su Asociación con Mortalidad Intrahospitalaria en Pacientes con Ictus Hemorrágico. Cigarette Smoking And Its Association With In-Hospital Mortality In Hemorrhagic Stroke Patients.
Background: Smoking is a well-known reversible risk factor associated with acute ischemic stroke (AIS), however, some data showed that in-hospital mortality rates among smoker’s patients with hemorrhagic stroke is lower when compared with non-smokers patients. The objective of this analysis was to assess in-hospital patient mortality rate between smokers and non-smokers patients with confirmed diagnosis of hemorrhagic stroke. Methods and Results: We analyzed all the data from patients diagnosed with hemorrhagic stroke that were registered in the Florida Stroke database from 2008-2012. Among the 21,013 patients diagnosed with hemorrhagic stroke, 10.9% of patients were smokers. A Multivariable model was used to estimate the adjusted odds ratio of in-hospital mortality rate in smokers versus non-smokers. Smoking was associated with lower in-hospital mortality in hemorrhagic patients. (UOR= 0.71 vs. AOR= 0.75). Other risk factors like hypertension, BMI>40 and hyperlipidemia, remained significantly associated after modeling, and some others like gender, race, health insurance coverage, and diabetes became insignificant. The difference between unadjusted and adjusted odds ratios for smoking (0.71 versus 0.75) indicates no presence of substantial confounding by age and other control variables. Conclusions: Among patients hospitalized for hemorrhagic stroke, smoking is a risk factor for early age of onset, even among those with few vascular risk factors. The persistent association with lower in-hospital mortality after adjusted analyses probably represents other unmeasured confounding, although a biological effect of smoking cannot be excluded. Further clinical and prospective population-based studies are needed to explore variables that contribute to outcomes in these patients.
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Estimación de la Función Cognitiva Premórbida con el Test de Acentuación de Palabras. Estimation Of Premorbid Cognitive Function With The Word Accentuation Test.
Objectives: Premorbid estimation of cognitive function is essential for the interpretation of the presence and severity of actual cognitive impairment. The most reliable method in Spanish speaking countries is with the Word Accentuation Test (WAT) / Test de Acentuación de Palabras (TAP). This is used to predict intelligence test scores by linear regression. Results: In an Ecuadorian sample the TAP was found to have good internal consistency and test-retest reliability. The correlation of the TAP with WAIS-IV full IQ scores was high (r= .827), allowing the development of a regression equation to estimate IQ scores from TAP performance. Furthermore, a sample of dementia patients was found to perform normally on the WAT compared to a matched control group. This suggests that WAT performance holds in the presence of neurological illness with associated cognitive impairment. Conclusions: The WAT has good psychometric properties and can be used to rapidly estimate actual intelligence test scores in healthy participants. It can also estimate premorbid intelligence scores in patients with neurological or psychiatric illnesses, allowing a clearer interpretation of the severity of impairment. This simple assessment could be used in various research and clinical contexts.
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Uso de Toxina Botulínica Tipo A en Pacientes con Espasmo Hemifacial en Cuba. Botulinum Toxin A In Hemifacial Spasm In Cuba.
Objective: To evaluate botulinum toxin A therapy in patients with hemifacial spasm attended in a Neurology Service in Cuba. Patients and methods: 35 patients with hemifacial spasm were treated with botulinum toxin A during 15 months. Some parameters of botulinum toxin were collected including doses, latency, maximum duration and total duration of improvement. Clinical data were determined, such as functional status, gravity, frequency and adverse events. Results: There was a high percentage of female with hemifacial spasm. Most patients showed a latency of 48 hs, maximum duration until 60 days and total duration of improvement of 3 months. Functional status decreased through time, independently of hemifacial spasm onset and its origin. Parameters related to functional status, as gravity and frequency also diminished significantly their categories. Botulinum toxin doses were statistically increased over this treatment, independently of any patient conditions. Only eight patients showed adverse events (facial muscle weakness and ptosis). Conclusions: Recovery of functional status, and low rate of adverse events observed during botulinum toxin treatment might suggest that this therapy seems to be effective and low-risk under our conditions.
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Características Clínicas y Epidemiológicas de los Tumores de Fosa Posterior en Pacientes Pediátricos. Experiencia en un Centro de Referencia Nacional. Clinical And Epidemiological Features Of Posterior Fossa Tumors In Pediatric Patients. Experience Of A National Reference Center.
Objective: To perform a descriptive study of posterior fossa tumors from a sample of patients from a national reference center in Ecuador.
Materials and methods: a descriptive, retrospective, cross-sectional study was performed. Socio-demographic and clinical-epidemiological variables were established for 24 patients under the age of 14, whose clinical records reported a diagnosis of posterior fossa tumor, and who were hospitalized in Baca Ortiz Pediatric Hospital between 2014 and 2016.
Results: There was a 1:1 relationship between males and females, an age distribution of 20,8% of patients younger than 3 years, 33,3% between 3 and 6 years, and 45,8% of patients older than 6 years of age. The most frequent histopathological diagnosis was medulloblastoma with 45,8%, followed by ependymoma with 29,2%, and astrocytoma with 12,5%. 12,5% of patients did not have a biopsy performed. Intracranial hypertension was the most frequent clinical presentation syndrome with 87,5% followed by far less frequent symptoms in our sample.
Conclusions: Scientific evidence about posterior fossa tumors is limited in Ecuador. This study states the need to perform similar and more complete studies of this frequent pediatric brain tumor.
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Atahualpa, Una Población Rural Ideal Para la Práctica de Estudios Epidemiológicos. Atahualpa, An Optimal Rural Setting For The Practice Of Epidemiological Studies
Atahualpa is a rural village located in coastal Ecuador that achieve a number of requisites to be considered as an optimal setting for the practice of epidemiological studies. Atahualpa is an isolated village with a very low index of migration rate. Inhabitants are fairly homogeneous regarding race, lifestyles and diet, which is rich in oily fish. From the racial point of view, inhabitants are Ecuadorian natives with little evidence of cross-breading. Most men are artisan carpenters and most women are homemakers. These coincidences reduce the risk of the presence of unexpected confounders at the time of data analyses. However, this may also cause that data obtained might not be extrapolated to other regions. The practice of studies in neighboring villages, using similar protocols, is needed to validate generality of data obtained in Atahualpa.
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El Proyecto Atahualpa, Protocolo, Definiciones Operacionales y Diseño Inicial. The Atahualpa Project: Protocol, Operational Definitions, And Initial Study Design
Non-communicable diseases are the new health epidemics in developing countries due to increased life expectancy, and changes in lifestyle and dietary habits of the population. The Atahualpa Project was designed as a multi-step population-based cohort study designed to reduce the increasing burden of these conditions in rural Ecuador. The first step of the study followed a 3-Phase design, aimed to get information on demographics and cardiovascular risk factors of Atahualpa residents aged ≥40 years, as well as to assess the prevalence of stroke and ischemic heart disease. During Phase I, participants were screened with standardized questionnaires to evaluate their cardiovascular health and to identify those with suspected stroke or ischemic heart disease. In Phase II, neurologists and cardiologists examined suspected cases of stroke or ischemic heart disease, as well as a random sample of matched negative individuals, to assess prevalence of these conditions. In Phase III, patients with diagnosis of stroke and ischemic heart disease underwent complementary tests for achieving more specific diagnosis. Implementation of public health strategies directed to improve the cardiovascular health status of a given population must be based on studies evaluating specific risk factors at regional levels. Epidemiologic surveys such as the Atahualpa Project may prove cost-effective for improving the cardiovascular health status of people living in Latin American rural villages by increasing the knowledge on the particular needs of these populations.
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Salud Cardiovascular en Habitantes de Atahualpa: Características y Correlatos. Cardiovascular Health Status In Atahualpa Residents: Characteristics And Correlates
Stroke and cardiovascular diseases will be the next epidemics in Latin America due to changes in lifestyle and increased life expectancy. Knowledge of cardiovascular health (CVH) status of the population is mandatory to implement cost-effective strategies directed to reduce the burden of vascular diseases in the region. In the Atahualpa Project, we assessed the CVH status of participants using the metrics proposed by the American Heart Association. The basal study included 616 subjects free of stroke and ischemic heart disease aged ≥40 years. Of these, 2.1% had ideal, 28.1% had intermediate and 69.8% had poor CVH status. Poorest metrics were blood pressure, fasting glucose, and BMI. The odds for having a poor CVH status were increased in persons aged ≥ 60 years and in those with only primary school education. Then, we compared our results with the Hispanic population of the Northern Manhattan Stroke Study (NOMAS), and found that Atahualpa residents had significantly better metrics than those enrolled in the NOMAS, with the exception of fasting glucose levels. Likewise, the odds for having 5 to 7 ideal metrics were also better in Atahualpa residents, irrespective of age. We also conducted a case-control study to assess the CVH status of Atahualpa residents according to their living arrangements, and found that social isolation was associated with a worse CVH status in this population. A couple of studies showed correlation between some sleep related disorders and poor CVH status. We have also started an ongoing program called “known your numbers”, which, together with community talks, is directed to improve the CVH status and to reduce the burden of vascular diseases in the region.
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Sub-estudio de Neuroimagen del Proyecto Atahualpa. Neuroimaging Substudy Of The Atahualpa Project
The Atahualpa Project includes a Neuroimaging sub-study, which consists in the practice of MRIs and MRAs to all participants aged ≥60 years, as well as those presenting with specific neurological complains. Likewise, all participants aged ≥20 years have been invited for the practice of a head CT. MRIs and MRAs have been performed with the use of a Philips Intera 1.5T MRI machine, and TCs with the use of a Philips Brilliance 64 CT scanner, following established protocols. All exams have been independently reviewed by a neurologist and a neuroradiologist, with adequate kappa coefficients for inter-rater agreement. MRIs studies have been focused on the evaluation of global cortical atrophy, posterior parietal atrophy, bicaudate index, Evans index, hippocampal atrophy, signatures of cerebral small vessel disease, and lesions consistent with ischemic or hemorrhagic strokes. By the use of MRI, we have assessed the prevalence of intracranial artery stenosis, intracranial dolichoectasia and variations in the configuration of the circle of Willis. Using CT, we have focused on the diagnosis of neurocysticercosis, pineal gland calcifications, as well as in variations and characteristics of skull bones, cerebellar atrophy, and severity of carotid siphon calcifications. In the present study, we focused on the description of basic protocols used for assessment of previously mentioned lesions of interest.
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Búsqueda de Substitutos Para Estudios de Neuroimagen con Propósitos de Investigación: Experiencia del Proyecto Atahualpa. The Search Of Surrogates For Neuroimaging Studies For Research Purposes: The Atahualpa Project Experience
Diagnosis of many non-communicable neurological diseases require the use of MRI, which is not readily available in remote rural populations. Efforts should be directed to find portable screening diagnostic tools that may help identify candidates for MRI screening. In the Atahualpa Project, all participants aged ≥60 years have been invited for the practice of MRI, and about 80% of them have underwent the procedure. Therefore, we have the unique opportunity to test the accuracy of non-invasive exams to be used as surrogates to MRI for identifying candidates for the practice of this exam. To date, we have assessed the value of the ankle-brachial index (ABI), the reliability of the neutrophil-to-lymphocyte ratio (NLR), the accuracy of hypertensive retinopathy, and the value of transcranial Doppler (TCD) to detect individuals with cerebral small vessel disease. Individuals with an abnormal ABI have 4 times de odds of having a silent lacunar infarct than those with a normal ABI. A high NLR has a poor sensitivity but is highly specific for detecting persons with at least one imaging signature of small vessel disease. Individuals with hypertensive retinopathy Grades 2-3 are almost four times more likely to have moderate-to-severe white matter hyperintensities than those with no- or only Grade 1 retinopathy. Finally, the correlation between the pulsatility indexes of major cerebral arteries with imaging markers of small vessel disease, as assessed by TCD, was poor. We are still in the search of some non-expensive and readily available biomarker that allow the identification of apparently healthy persons at risk of suffering a catastrophic cerebrovascular event.
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Trastornos de Sueño en Residentes de Atahualpa. Sleep Disorders In Atahualpa Residents.
Health problems related to sleep disorders are likely on the rise in rural areas of Latin America, partly related to changes in life style, shift work, and other factors. However, little is known on the burden of these conditions in remote rural settings. In the Atahualpa Project, we have investigated sleep disorders using standardized field instruments associated with sophisticated technology such as polysomnography. A poor sleep quality has been associated with frailty and with the presence of neuroimaging markers of cerebral small vessel disease and global cortical atrophy. On the contrary, dietary intake of oily fish was associated with a better sleep quality. We have also investigated the prevalence and some correlates of the restless legs syndrome (Willis-Ekbom disease), and found a prevalence relatively higher than that described in most other tropical regions, as well as the association of this condition with psychological stress. Finally, a preliminary report shows a high prevalence of moderate-to-severe obstructive sleep apnea in Atahualpa residents aged ≥60 years (27%) and its correlation with diffuse subcortical damage of vascular origin. Further studies are needed to better understand consequences of sleep-related symptoms in underserved populations.
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Alcohol: Consumo, Consecuencias y Complicaciones Neurológicas. Resultados del Proyecto Atahualpa. Alcohol: Intake, Consequences and Neurological Complications. Results From The Atahualpa Project.
Information about the burden and consequences of alcohol intake in rural communities of Latin America is scarce. This study aims to assess the magnitude of alcohol intake in Atahualpa as well as its consequences and prevalence of neurological complications. Male residents aged ≥40 years (n=277) were interviewed with a structured questionnaire designed to evaluate prevalence, drinking patterns and consequences of chronic alcohol intake. Most of them were current drinkers and 40% started drinking below the legal age (18 years). Weekly binge drinking were admitted by 81% individuals, 58% referred physical consequences related to alcohol intake, 59% had social consequences, and 51% recognized alcohol intake as a major economic burden. Individuals who started drinking below the legal age were more often involved in binge drinking and consumed more alcohol than those aged ≥18 years at first regular drink. The relationship between alcohol intake and alcoholic cerebellar degeneration was evaluated by the use of the BARS scale, with 14.6% of individuals having clinically relevant alcoholic cerebellar degeneration. Predictive models showed significant relationships between BARS score margins and years of drinking and the amount of alcohol intake. Our study also provided robust evidence favoring an independent and synergistic effect of age and years of drinking in the relationship between ACD and cognitive decline. This study shows a high prevalence of chronic alcohol intake in community-dwelling men living in Atahualpa.
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Enfermedad Cerebrovascular en Atahualpa: Prevalencia e Incidencia. Cerebrovascular Disease In Atahualpa: Prevalence And Incidence
Stroke burden is on the rise in rural regions of South America. We evaluated prevalence, pattern of subtypes and pathogenetic mechanisms underlying stroke in Atahualpa. In a three-phase epidemiologic study, suspected cases were detected by a door-to-door survey. Then, neurologists evaluated suspected cases and randomly selected negative persons, and confirmed patients underwent complementary exams. We found 20 stroke patients among 642 persons aged ≥ 40 years. Stroke prevalence was 31.15‰ that increased with age. Hypertensive arteriolopathy was the most likely mechanism underlying strokes (55% patients). Extracranial atherosclerotic lesions or cardiac sources of emboli were not found in any case. Comparison of our findings with a previous survey performed in the same village showed an alarming increase in stroke prevalence (from 14.08‰ in 2003 to 31.15‰ in 2012, p=0.03). Thereafter, we conducted an incidence study. For this, first-ever strokes occurring over four years were identified from yearly door-to-door surveys and other overlapping sources. Of 807 stroke-free individuals prospectively enrolled in the Atahualpa Project, follow-up was achieved in 718 (89%), contributing 2,499 years of follow-up (average 3.48±0.95 years). Stroke incidence rate was 2.97 per 100 person-years of follow-up (95% C.I.: 1.73–4.2), which increased to 4.77 (95% C.I.: 1.61–14.1) when only persons aged ≥57 years were considered. Poisson regression models, adjusted for relevant confounders, showed that high blood pressure (IRR: 5.24; 95% C.I.: 2.55–7.93) and severe edentulism (IRR: 5.06; 95% C.I.: 2.28–7.85) were the factors independently increasing stroke incidence. Stroke incidence in Atahualpa is comparable to that reported from the developed world. Besides age and high blood pressure, severe edentulism is a major factor independently predicting incident strokes.
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Deterioro Cognitivo: Prevalencia y Correlatos en una Comunidad Rural Ecuatoriana. Lecciones del Proyecto Atahualpa. Cognitive Decline: Prevalence And Correlates In A Rural Ecuadorian Community. Lessons From The Atahualpa Project.
Assessment of cognitive impairment in rural areas of developing countries is complicated by illiteracy and cross-cultural factors. The Montreal Cognitive Assessment (MoCA) was used to estimate cognitive performance in individuals enrolled in the Atahualpa Project. Some problems were noticed with the use of this test, including issues related to naming animals, as well as the need to adjust a different cutoff for diagnosing mild cognitive decline than that used in highly educated individuals living in developed countries. After correlating MoCA scores with neuroimaging signatures of cortical and subcortical atrophy, a cutoff of 19-20 points would better define cognitive impaired individuals in rural areas. We also noticed that severe edentulism as well as psychological distress were associated with poor cognitive performance in older adults living in Atahualpa. In contrast, our study showed a linear, and dose-dependent, direct relationship between dietary oily fish intake and cognitive performance. We also aimed to assess the independent contribution and the interaction of age, the stroke itself and diffuse subcortical damage in the poor cognitive performance observed in patients with stroke, and noticed that interaction of age and diffuse subcortical damage are major determinants for poor cognitive performance among stroke patients. The total cerebral small vessel disease score can be used as a reliable predictor of poor cognitive performance, although its predictive power is not better than that of isolated neuroimaging signatures of cerebral small vessel disease. Finally, we noticed an inverse relationship between calcium content in the carotid siphon – used as a surrogate of intracranial atherosclerosis – and cognitive performance in our population.
