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Introducción: Hasta donde se tiene conocimiento, en México esta indagación representa el primer trabajo multicéntrico que estudia el grado de desarrollo de la aptitud clínica en cuatro unidades de medicina familiar del Sector Salud. Por consiguiente, la interrogante de investigación es ¿cuál es el grado de desarrollo de la aptitud clínica en tres instituciones de salud? Este estudio proveerá conocimientos que permitirán emprender investigaciones en las cuales se ensayen estrategias educativas que propicien el desarrollo de esta aptitud. Objetivo: Determinar el grado de desarrollo de la aptitud clínica en residentes de medicina familiar de cuatro sedes académicas. Método: Diseño prospectivo, transversal, observacional y multicéntrico. Se estudió toda la matrícula del ciclo académico 2019-2020 con consentimiento informado. Se construyó un instrumento que evaluó la variable “aptitud clínica” mediante ocho indicadores y 182 ítems; la validez conceptual, de contenido y confiabilidad se valoró por cinco médicos familiares con experiencia docente y en investigación educativa. Resultados: De las cuatro sedes, las calificaciones globales más altas en los indicadores fueron alcanzadas por los R1 de la Unidad de Medicina Familiar #20 del Instituto Mexicano del Seguro Social (UMF20 IMSS), R2 y R3 del Hospital General de Zona #1 (HGZMF1 IMSS). Los R1 de la UMF20 alcanzaron los más altos puntajes en 3/8 indicadores. Los R2 y R3 del HGZMF1 lograron las más altas puntuaciones en 2/8 indicadores. Se estimaron diferencias entre R1 (n = 46), entre R2 (n = 47) y entre R3 (n = 40) de las cuatro sedes por indicador y no se encontraron diferencias estadísticas significativas en ningún caso. Conclusiones: El grado de desarrollo de la aptitud clínica se puede considerar de nivel medio en las cuatro sedes académicas. Esto, en parte, se puede explicar porque el instrumento exploró situaciones clínicas problematizadas, que exigieron al residente la reflexión crítica sobre su experiencia clínica antecedente.

Objective We describe the clinical, electroencephalograph^ and neuroimaging findings of older patients with typical absence status epilepticus (ASE). Methods This investigation was a retrospective analysis of prospectively collected consecutive patients between January 2011 and October 2021. All patients ≥60 years with impairment of awareness and continuous generalized, rhythmic, synchronous and symmetric epileptiform discharges and normal background on video-electroencephalogram (vEEG) were included. Results Six patients were identified with a diagnosis of typical ASE. The mean age was 67 years. Five could be classified as idiopathic generalized epilepsy (IGE) though two had been erroneously categorized as cryptogenic focal epilepsy (FE). In one, the episode of ASE was thought to represent the beginning of late-onset IGE (de novo late-onset typical ASE). In all cases, ASE was controlled within the first 24 hours. Significance Typical ASE is a rare cause of confusion in the elderly population requiring urgent vEEG evaluation. It most frequently represents reactivation of a previous IGE, in effect related to patients with epilepsy with onset in childhood or adolescence, not previously diagnosed or treated, representing rather the debut of (de novo) late-onset IGE.

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development. Methods: We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)—a composite of life expectancy, education, and income measures—into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation. Findings: Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24–51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34–69) and the youngest in the low HDI tier (median 28 years, IQR 20–38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6–32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55–5·2) and high HDI tier (2·26, 1·23–4·15), but not the low HDI tier (1·66, 0·61–4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17–2·49). Interpretation: Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices. Funding: National Institute for Health Research Global Health Research Group.

BACKGROUND Phrenic nerve injury (PNI) is a complication of lung transplantation related to the surgical procedure and associated with increased morbidity. However, the incidence and risk factors, specifically regarding surgical techniques, have not been adequately studied. METHODS We conducted a prospective single-center study over 4-years, in recipients of lung transplantation with a normal pretransplant phrenic nerve conduction study (PNCS). Diaphragm ultrasound and PNCS were performed in the first 21 postoperative days and PNI was defined when both tests were abnormal. Patients were followed up until hospital discharge. The association between transplant characteristics and PNI was analyzed by using logistic regression models. RESULTS Two hundred eleven lung grafts implanted in 127 patients were included in the study. After lung transplantation, PNI was diagnosed in 43.3% of the subjects and 29% of the operated hemithorax. Regression logistic model showed that the variables related to PNI were female gender (p = 0.02), bilateral lung transplantation (BLT) (p = 0.001), right lung graft (p = 0.003), clamshell incision ( p = 0.01), mediastinal adhesions (p = 0.002), longer operative time (p = 0.003), intraoperative extracorporeal support ( p = 0.02), and blood transfusion ( p = 0.003). Conversely, age >61 years (p = 0.008) and higher thoracic diameter (p = 0.04) were protective factors. The use of electrocautery , cardiac mechanical retractors, and diaphragmatic traction was not associated with PNI. Morbidity was increased without any difference in mortality. CONCLUSIONS PNI is a frequent complication after lung transplantation, associated with higher morbidity. Mainly risk factors were age, BLT, female gender, and variables related to surgical difficulties. Lung graft in the right hemithorax and mediastinal adhesiolysis were the most relevant technical variables.

We describe the pathophysiological consequences and long-term neurological outcome of a patient with acute brain injury (ABI) in whom intracortical electroencephalography (iEEG) captured an episode of prolonged focal non-convulsive status epilepticus (NCSE) that remained undetectable on scalp electroencephalography. A 53-year-old right-handed woman was admitted to hospital due to a large frontal left intraparenchymal hematoma. Over two and a half days, we captured recurrent non-convulsive electrographic and electroclinical seizures compatible with the diagnosis of intracortical focal NCSE. The patient remained sedated and a burst-suppression pattern was obtained. We also performed invasive brain multimodality monitoring including iEEG and measurements of intracranial pressure (ICP), partial brain tissue oxygenation (PbtO2) and brain temperature. During non-convulsive electrographic and electroclinical seizures, the values of PbtO2 decreased and those of ICP increased. Six months later, brain MRI revealed encephalomalacia localized to the left paramedial fronto-basal region. The neuropsychological assessment carried out one year after the injury showed scores below average in verbal learning memory, motor dexterity and executive functions. In summary, iEEG is a feasible innovative invasive technique that may be used to record non-convulsive electrographic and electroclinical seizures which remain invisible on the surface. Intracortical focal NCSE causes metabolic changes such as reduced brain oxygenation and an increase in ICP that can further damage previously compromised brain tissue.

Background The role of vitamin D status in COVID-19 patients is a matter of debate. Objectives To assess serum 25-hydroxyvitamin D (25OHD) levels in hospitalized patients with COVID-19 and to analyze the possible influence of vitamin D status on disease severity. Methods Retrospective case–control study of 216 COVID-19 patients and 197 population-based controls. Serum 25OHD levels were measured in both groups. The association of serum 25OHD levels with COVID-19 severity (admission to the intensive care unit, requirements for mechanical ventilation, or mortality) was also evaluated. Results Of the 216 patients, 19 were on vitamin D supplements and were analyzed separately. In COVID-19 patients, mean ± standard deviation 25OHD levels were 13.8 ± 7.2 ng/mL, compared with 20.9 ± 7.4 ng/mL in controls (P Conclusions 25OHD levels are lower in hospitalized COVID-19 patients than in population-based controls and these patients had a higher prevalence of deficiency. We did not find any relationship between vitamin D concentrations or vitamin deficiency and the severity of the disease.

Motor epilepsia partialis continua (EPC) is a frequent and widely described variant of simple focal motor status epilepticus. However, lingual EPC is an unusual epileptic condition. We present a case of lingual EPC secondary to low-grade glioma in which the EEG and neuroimaging features were particularly remarkable. The video-EEG showed lateralized periodic discharges with superimposed rhythmic activity and frequent recurrent focal epileptic seizures. Moreover, brain magnetic resonance imaging showed a right temporo-insular cortico-subcortical lesion which was hyperintense on FLAIR, suggestive of low-grade glioma. In addition, diffusion-weighted imaging and arterial spin labelling series showed restricted diffusion in the right temporo-insular and parietal cortex and increased cerebral flow, respectively. All these findings are in keeping with changes related to persistent focal status epilepticus. Finally, we review the literature and discuss the differential diagnosis of this rare epileptic entity. [Published with video sequence].

Evaluate the bispectral index (BIS) monitoring to detect delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH).A single-center prospective study in patients with aSAH. BIS monitoring was recorded during 25-120 min in two periods, within the initial 72 h (BIS1) and between days 4 and 6 (BIS2) from admission. The median for each exported BIS parameter was analyzed. Transcranial Doppler (TCD) sonography was simultaneously performed with BIS1 (TCD1) and BIS2 (TCD2) monitoring. A multivariate logistic regression model was built to identify the variables associated with DCI.Sixty-four patients were included and 16 (25%) developed DCI. During BIS2 monitoring, significant differences were found in BIS value (left, p = 0.01; right, p = 0.009), 95% spectral edge frequency (left and right, p = 0.04), and total power (left and right, p = 0.04). In multivariable analysis, vasospasm on TCD2 (OR 42.8 [95% CI 3.1-573]; p = 0.005), a median BIS2 value85 in one or both sides (OR 6.2 [95% CI 1.28-30]; p = 0.023), and age (OR 1.08 [95% CI 1.00-1.17]; p = 0.04) were associated with the development of DCI.BIS value is the most useful BIS parameter for detecting DCI after aSAH. Pending further validation, BIS monitoring might be even more accurate than TCD.

The research has to main objectives: design a voice app (to work with emotional intelligence using a spoken test), as an alternative tool (as a help to a psychologist), that offers the possibility to have a better approach to students from “UT Tehuacán”; using Alexa skill kit to develop the tool. This voice app will ask a series questions to students as part of different psychologist test to detect early emotional patterns. The main goal is to understand how emotions work within students during day, and how to process them in a better way; this way the student can have information to deal to their feelings more efficiently and fulfil their personal goals. This information, will be stored by the app in Amazon Web Service AWS, and it also will be analysed by a backend service; this service will get data to make charts. The research design is transversal, because the data will be obtained in a single moment; it is also applicative due to it seeks to apply acquired knowledge to solve a situation, because it has as objective to find one or more variables in a population; in this case (detect early emotional patterns). In order to support the psycho-pedagogy department and the different educative programs to know possible problems students may have, and find if those problems can be a reason to quit school. For this reason this project can be use as a tool to make decisions.

Background Lung transplantation (LT) requires complex multidisciplinary organization and constitutes a therapeutic option and a life-saving procedure. Although the number of lung recipients continues to increase, neurological complications and death rates following lung transplantation are still higher than desirable. Purpose This study aims to analyse the neuroimaging findings in a cohort of adult patients with LT. Material and Methods A retrospective cohort study of all lung transplant recipients (344 patients: 205 men and 139 women) at a single institution from January 2011 to January 2020. The collected data included demographic features, clinical data and evaluation of the imaging findings. We also recorded the date of neurological complication(s) and the underlying disease motivating lung transplantation. Results We found an elevated rate of neuroimaging findings in patients following LT with 32.6% of positive studies. In our cohort, the average time after LT to a neurological complication was 4.9 months post-transplant. Encephalopathy, critical illness polyneuropathy and stroke, in that order, were the most frequent neurological complications. Structural abnormalities in brain imaging were more often detected using MRI than CT for indications of encephalopathy and seizures. Conclusions LT recipients constitute an especially vulnerable group that needs close surveillance, mainly during the early post-transplant period.

espanolLa lactancia materna (LM) tiene beneficios en la salud del binomio madre-hijo. El abandono y las barreras para realizar la practica de amamantar se relacionan con cuestiones biologicas, ambientales, culturales, sociales e individuales, entre otras. Todas ellas tienen influencia del conocimiento y actitudes que se adquiere durante la vida. La poblacion universitaria, es una generacion de adultos que forman un criterio integral sobre LM en funcion de la dinamica social. El objetivo del presente trabajo fue analizar el nivel de conocimiento y las actitudes de los estudiantes universitarios respecto a los beneficios de la lactancia materna en la salud. Se observo bajo nivel de conocimiento entre la poblacion universitaria sobre aspectos de importancia tales como, la duracion de la LM exclusiva, la reduccion del riesgo en el desarrollo de obesidad, infecciones de oido, diarrea o alergias alimentarias, especialmente en estudiantes que no fueron del area de la salud. Respecto a las actitudes, se identifico una alta aceptacion social de la practica de la LM. Sin embargo, los estudiantes consideran a la alimentacion con formula como una opcion mas practica. Es necesario realizar investigaciones que integren diversos sectores de la sociedad que permitan explicar los cambios en acciones y comportamientos hacia la LM. EnglishBreastfeeding (BF) has health benefits for the mother-child dyad. Abandonment and barriers to breastfeeding are related to factors at different levels that include biological, environmental, cultural, social, individual issues, among others. All of them are shaped by the knowledge and attitude that are acquired during life. The university population is a generation of adults who develop a comprehensive criterion on BF based on social dynamics. The objective of the present work was to analyze the level of knowledge and attitudes that university students have regarding the health benefits of BF. It was observed a low level of the knowledge about relevant aspects such as the duration of exclusive BF, the risk reduction in the development of obesity, ear infections, diarrhea or food allergies. Regarding attitude, a high level of social acceptance of the BF practice was identified. However, formula feeding is considered a more practical option. It is necessary to carry out further research that integrates various sectors of society that allow explaining the changes in actions and behaviors towards BF.

The exact pathophysiology of stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs) remains unknown. The aim of this report is to describe the case of a patient that suffered from a vertebrobasilar stroke in whom asymmetric SIRPIDs due to a large right thalamic and mesencephalic infarction were observed. This case can provide some data that allows us to understand the mechanisms that potentially could be implicated in the origin of this fascinating electroencephalographic phenomenon.

We describe the case of an elderly woman with an episode of ambulatory de novo absence status epilepticus of late onset (DNASLO) after oral treatment with cefuroxime. A high level of suspicion of DNASLO in cases of unexplained confusion in adults or elderly subjects taking cephalosporins is essential to prompt an emergency EEG and, in turn, rapidly achieve an appropriate diagnosis and enable optimal treatment.

To determine the optimal observation period (OBP) in adults with a clinical diagnosis of brain death (BD) using electroencephalography (EEG) or computerized tomography angiography (CTA). We conducted a retrospective observational analysis of adult patients with a diagnosis of BD from January 2000 to February 2017. The optimal OBP was defined as the minimum time interval from the first complete clinical neurological examination (CNE) that ensures that neither a second CNE nor any ancillary test (AT) performed after this period would fail to confirm BD. The study sample included 447 patients. In the supratentorial group, the first AT confirmed BD in 389 cases (98%), but in 8 (2%) cases the complementary test was incongruent. In this group, 8 of 245 patients in whom the first AT was carried out within the first 2 h after a complete CNE had a non-confirmatory test of BD versus none of 152 in whom the first AT was delayed more than 2 h (3.0% vs 0.0%; p = 0.026). In the infratentorial group, we found a higher probability of obtaining a first non-confirmatory AT of BD (34% vs 2%; p = 0.0001) and an OBP greater than 32.5 h was necessary to confirm a BD diagnosis. We found important differences in the confirmation of BD diagnosis between primary supratentorial and infratentorial lesion, and identified an optimal OBP of 2 h in patients with supratentorial lesions. By contrast, in primary posterior fossa/infratentorial lesions, the determination of an optimal OPB remains less accurate and hence more challenging.

Objetivos: describir la respuesta a un tratamiento integral de pacientes con diabetes mellitus tipo 2 (dm2) que padecen depresión o ansiedad. Métodos: estudio cuasiexperimental, se evaluó una muestra de 39 pacientes, derechohabientes de una clínica de medicina familiar en la Ciudad de México, durante el periodo de febrero a junio de 2017. Se incluyeron pacientes con dm2 descontrolada con diagnóstico de depresión o ansiedad evaluadas mediante las escalas de Zung y Beck, respectivamente. Se les otorgó manejo integral, que incluyó ajuste farmacológico, intervención psicoeducativa y nutricional. Se realizó una evaluación posterior al tratamiento y se recolectaron nuevos parámetros clínicos y bioquímicos. Se utilizó la prueba de rangos de Wilcoxon para relacionar los valores de hemoglobina glucosilada y para comparar los resultados del instrumento para depresión y ansiedad antes y después del tratamiento. Resultados: se obtuvo una media de edad de 52±8.12 años de edad, con 59% (n=23) del sexo femenino. Las medias en la preintervención fueron: 10.29±2.29% para HbA1c, 53.1±8.47 puntos para depresión y 14.82±8.08 puntos para ansiedad. Los resultados postintervención fueron: 7.53±1.56% para HbA1c, 45.12±8.83 puntos para depresión y 9.38±7.28 puntos para ansiedad; con diferencias estadísticamente significativas pConclusiones: el tratamiento integral en pacientes con diabetes mellitus tipo 2, reduce los niveles de HbA1c y el grado de la sintomatología de la depresión o ansiedad; se requieren estudios más amplios para evaluar la efectividad del tratamiento.

Nonconvulsive status epilepticus (NCSE) in adults represents a constellation of conditions producing ongoing ictal impairment with myriad clinical presentations. These may vary from minimal obtundation, to psychosis to coma for which electroencephalography is essential to diagnosis. Treatment is highly variable and is tailored to the level of consciousness, probable outcome and underlying etiology. There is a new and emerging understanding of the nature of NCSE, its classification and the challenges in treatment. The aim of this article is to review the classic and most recent literature on NCSE in adults focusing attention on the clinical settings in which NCSE frequently occurs, in order to improve awareness of the issues involved in electroclinical diagnosis, treatment and prognostication.

Background Fat embolism syndrome (FES) is a rare complication of long-bone fractures and joint reconstruction surgery. To the best of our knowledge, we describe the clinical, electrophysiological, neuroimaging, and neuropathological features of the first case of super-refractory nonconvulsive status epilepticus (sr-NCSE) secondary to fat embolism. Clinical case An 82-year-old woman was transferred to our intensive care unit because of a sudden decrease of consciousness level, right hemiparesis, and acute respiratory failure in the early postoperative period of knee prosthesis surgery. Brain computed tomography (TC) including angio-CT and CT perfusion was normal. An urgent video-electroencephalography (v-EEG) evaluation showed continuous sharp-and slow-wave at 2.0–2.5 Hz in keeping with the diagnosis of generalized NCSE. Epileptiform discharges ceased after the administration of 5 mg of intravenous diazepam, and background activity constituted by diffuse theta waves was observed without clinical improvement. Treatment with levetiracetam (1000 mg/day) and sedation with propofol and midazolam were initiated. Moreover, continuous v-EEG monitoring was also started. Despite antiepileptic therapy, epileptiform activity recurred after the interruption of profound sedation, and valproate and lacosamide were added during the ensuing days. Magnetic resonance imaging (MRI) disclosed small scattered foci of acute ischemic infarcts and diffuse petechiae involving the basal ganglia and pons and centrum semiovale in keeping with fat embolism. Super-refractory nonconvulsive status epilepticus remained without control for 2 weeks. Finally, the patient died. The clinical autopsy revealed a bilateral lung fat embolism associated with a hemorrhagic infarction in the left lower lobe. Fatty lesions were also seen in the intestine and pancreas. Scattered microscopic cerebral infarcts associated with fat emboli in the capillaries were noticed, affecting both supra- and infratentorial structures. In addition, occasional focal areas of ischemic injury showing filiform neurons with reactive astrocytic gliosis background consistent with acute lesions were observed in CA3. Conclusions Fat embolism should be considered a potential cause of sr-NCSE. This article is part of a Special Issue entitled "Status Epilepticus".

Introduction Metaldehyde self-poisoning in adults is uncommon and, to the best of our knowledge, an episode of super-refractory nonconvulsive status epilepticus (sr-NCSE) following an suicide attempt has not been previously demonstrated. Case report A 68-year-old woman was admitted to our Intensive Care Unit (ICU) in coma. On neurologic examination, the pupils were reactive, brainstem reflexes were present and plantar responses were flexor bilaterally. Routine laboratory tests were unremarkable. Arterial blood gas analysis revealed a mixed acidosis. A computed tomography (CT) scan of the brain and angio-CT were normal. The family confirmed that the patient had had suicidal ideation, and they had discovered a bag of slug killer (metaldehyde 5%) in her room. Two hours after the admission at the ICU, her neurological state remained unchanged. Sedation with intravenous propofol and antiepileptic therapy with levetiracetam (1000 mg/24 h) were started. The next day, propofol infusion was stopped but the level of consciousness of the patient did not improve. A video-electroencephalograhy (v-EEG) showed continuous generalized paroxysms of spike-wave and sharp-slow wave complexes compatible with the diagnosis of generalized NCSE. On day 3, the episode of NCSE was controlled. Finally, 15 days after ICU admission she was discharged with a normal neurological examination. Conclusion This clinical case highlights that in comatose patients as consequence of metaldehyde poisoning, a v-EEG evaluation should be perform in order to rule out the existence of NCSE.

Aim The aim of this study was to determine the prognosis of 26 consecutive adults with alpha coma (AC), theta coma (TC) or alpha-theta coma (ATC) following CRA and to describe the clinical setting and EEG features of these patients. Methods We retrospective analyzed a prospectively collected cohort of adult patients diagnosed as having AC, TC or ATC after CRA between January 2008 and June 2016. None of patients included in this analysis underwent therapeutic hypothermia (TH). Neurological outcome was expressed as the best score 6 months after CRA using the five-point Glasgow-Pisttsburgh Cerebral Performance Categories (CPC) Results Twenty-six patients were identified with a diagnosis of postanoxic AC, TC or ATC coma. There were 20 (77%) men and 6 (23%) women. The mean age was 63?±?16?years. The most frequent EEG pattern was TC (21 patients, 80%), followed by AC (3 patients, 12%) and ATC (2 patients, 8%). The cardiac rhythm as primary origin of the CRA was ventricular fibrillation (VF) in 16 patients (61.5%), asystole in 8 patients (34.6%) and ventricular tachycardia (VT) in one patient (3.8%). The presence of EEG reactivity was present in 8 patients (30%). The mortality rate was 85%. Of the 4 surviving patients, two (3.8%) had moderate disability (CPC 2), one (3.8%) had severe disability (CPC 3) and one (3.8%) reached a good recovery. The age was significantly lower in survivors 46.2?±?10.8 versus nonsurvivors 63.3?±?15.5 (p?=?0.04). There was increased association of EEG reactivity with survival (p?=?0.07). Conclusion Hypoxic-ischemic AC, TC and ATC are associated with a poor prognosis and a high rate of mortality. In younger patients with AC, TC and ATC and incomplete forms showing reactivity on the EEG, there is a greater probability of clinical recovery.

Background. Subclinical seizures are ictal electrographic discharges lacking signs of clinical seizures, behavioural alteration or subjective symptoms. The diagnosis and detection of this type of non-convulsive seizures remain challenging, and information is scarce regarding this electroclinical picture in subjects with gliomas. The aim of this report is to describe two patients with gliomas who, after treatment with surgery and radiotherapy, exhibited subclinical seizures on video-EEG monitoring, as a manifestation of recurrence or progression of their brain tumour. Methods. Case report and video-EEG monitoring analysis. Results. Two patients with gliomas were admitted to our neurosurgical unit after a generalized tonic-clonic seizure. Brain MRI revealed a recurrence of their tumour. The use of video-EEG monitoring allowed the detection and characterization of subclinical seizures in both patients that otherwise would have gone undetected. In both cases, subclinical seizures arose from the frontal lobe and were not associated with motor manifestations or subjective symptoms. Conclusions. We emphasize that the existence of subclinical seizures in patients with gliomas is likely to be underestimated, and can occur in advanced progressive tumours. It is important to carry out continuous video-EEG monitoring in brain tumour patients who have had recent clinical seizures in order to be able to detect subclinical seizures and make appropriate diagnosis.

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We retrospectively analysed the clinical characteristics, electroencephalogram (EEG) records, brain magnetic resonance imaging (MRI) scans, antiepileptic therapy and prognosis of a case series with ambulatory non-convulsive status epilepticus (NCSE) which evolved into a malignant form (mNCSE). mNCSE was defined as NCSE that continues or recurs five days or more after the onset of general anaesthesia, including those cases where NCSE recurs upon reduction or withdrawal of anaesthetic therapy. Four women and two men were studied. The mean age was 42.8 years (range: 19-63 years). Two of six patients had a previous diagnosis of epilepsy. Four patients died. Two patients had a good outcome with return to consciousness and activities of daily life, and one of these subjects developed temporal lobe epilepsy. In four patients, the cause of mNCSE was encephalitis. Clinical presentation was complex partial status epilepticus (CPSE) in three patients and generalised NCSE (GNCSE) in the other three. Two of the latter had encephalitis and one was diagnosed with progressive myoclonus epilepsy (PME) of Lafora type. The mean duration of the NCSE episode was 47.5 days (range: 9-139 days; SD: 53.1). In three patients, continuous or rhythmic focal epileptiform discharges were the EEG pattern at onset. In the other three, continuous rhythmic generalised spike-wave, polyspike-wave or sharp slow-wave complexes were observed. Antiepileptic treatment was heterogeneous and patients were treated with an average of 6.0 AEDs (range: 3-10; SD: 3.0). In summary, mNCSE is a severe epileptic condition that occurs often in the context of encephalitis or pre-existing epilepsy. Both CPSE and GNCSE may occur. Although high mortality is associated with mNCSE, some patients may survive with normal or good recovery.

Nonconvulsive status epilepticus (NCSE) represents an important percentage of status epilepticus in adults, but detailed studies of both NCSE proper and comatose NCSE are lacking. We retrospectively analyzed a prospectively collected series of 50 adult patients with a diagnosis of NCSE whose electroencephalograms (EEGs) have been interpreted for a period of 10 years by the same investigator.Two groups, NCSE proper and comatose NCSE were considered. All clinical, EEGs, neuroimaging data, antiepileptic treatment and outcome were analyzed.Thirty-two patients (64%) had NCSE proper and 18 patients (36%) comatose NCSE. The mean age was 56 years (range 19-89 years). Fourteen (44%) were diagnosed with absence status epilepticus (ASE), one had simple partial status epilepticus (SPSE) and 17 (53%) had complex partial status epilepticus (CPSE). The mean episode duration (33.2±13.9 versus 60.6±34.0), mean number of antiepileptic drugs (AEDs) (1.46±0.5 versus 2.77±1.39) and neuroimaging anomalies (50% versus 16%) was significantly greater in the partial/focal NCSE proper subgroup than in the ASE subgroup. The mean age (56.0±19.9 versus 69.4±12.1), number of elderly individuals (46% versus 77%), mean duration of the episode (49.1±30.4 versus 153.3±142.6), mortality rate (6% versus 61%) and admission at ICU (18% versus 83%) was significantly higher in the comatose NCSE group than in the NCSE proper group (p.05). Conversely, a previous history of chronic epilepsy was significantly more frequent (62% versus 5.6%) in the NCSE proper group. The mean duration of comatose NCSE was significantly greater in the surviving subgroup (102.5±29.1 versus 233.1±65.3; p.05).Our study demonstrates that there are sufficient differences regarding age of onset, history of previous epilepsy, episode duration, mortality rate and clinical presentation between NCSE proper and comatose NCSE to recommend adoption in clinical practice. These results should be taken into account when developing future classifications and therapeutic trials on NCSE.A distinction between NCSE proper (ambulatory forms of NCSE) and comatose NCSE is useful in the clinical practice and, therefore, it should taken in account in the design of future investigations on this heterogeneous epileptic condition.

Introduccion y objetivos El objetivo de este estudio es analizar el valor del electrocardiograma (ECG) en la prediccion del lugar de la lesion en la arteria descendente anterior, en relacion a sus ramas primera septal y primera diagonal, en pacientes con infarto agudo de miocardio anterior. Metodo Se analiza de forma retrospectiva a 90 pacientes con infarto agudo de miocardio anterior ingresados consecutivamente en la Unidad Coronaria, desde julio de 1998 a mayo de 2000. Se estudian los cambios electrocardiograficos y se correlacionan con el lugar de la lesion de la arteria descendente anterior determinada por angiografia coronaria. Resultados Los parametros mas utiles para predecir el lugar de la lesion de la arteria descendente anterior en el infarto agudo de miocardio anterior son: a) para la lesion proximal a la primera septal: la elevacion del segmento ST en aVR (p Conclusiones En el infarto agudo de miocardio anterior, el ECG es util para predecir el lugar de la lesion de la arteria descendente anterior en relacion con sus ramas primera septal y primera diagonal.

Background. Status epilepticus, particularly non-convulsive status epilepticus (NCSE), is a frequent complication in patients with altered renal function receiving treatment with intravenous cefepime. To the best of our knowledge, we report the first case, illustrated by video-EEG, of a critically ill patient receiving treatment with cefepime who developed an episode of confirmed symptomatic myoclonic status epilepticus (MSE) . Methods. Case report and video-EEG. Results. A 60-year-old man, who had received a liver transplant due to alcoholic cirrhosis one year ago, was admitted to our intensive care unit due to septic shock. Computed tomography revealed a prostatic abscess as cause of his sepsis. On Day 27, a respiratory infection due to Pseudomona aeruginosa was diagnosed, and treatment with intravenous cefepime (2 g/8 hours) was initiated. On Day 32, his mental status deteriorated and he developed inattention, a reduced level of consciousness, and multifocal and generalised continuous myoclonic jerks. A video-EEG study was compatible with the diagnosis of symptomatic MSE. On Day 35, cefepime was stopped and general anaesthesia with midazolam was started in order to achieve a faster clinical improvement. We used the BIS-Vista™ monitor to guide general anaesthesia and detect potential episodes of NCSE. On Day 40, an EEG confirmed the existence of moderate diffuse encephalopathy. Finally, the patient died as a consequence of severe heart failure . Conclusions. Cefepime may be a cause of MSE in non-anoxic comatose patients. Clinicians should be aware of this possibility when evaluating comatose patients on cephalosporin therapy in order to establish a correct diagnostic approach and accurate prognosis. [ Published with video sequences]

To describe the causes and outcome of adult patients with preserved electroencephalographic activity despite clinical findings suggesting brain death (BD), and its impact on organ donation.Retrospective study of the clinical and electroencephalography (EEG) data of all adult patients admitted to our hospital between January 2001 and December 2011 in whom a comprehensive clinical diagnosis of BD was reached following absence of brainstem reflexes and confirmatory apnea tests, were obtained. All patients with clinical findings suggesting BD and an EEG showing brain activity were selected for the analysis. We calculated the brain death interval (BDI) as the time between the first complete clinical examination and confirmatory ancillary test, or the time between the first and second complete clinical examination for BD, in order to analyze the impact on family consent for organ donation.A complete clinical examination and EEG were diagnostic in 289 patients. In 279 (96.5%), the first EEG showed electrocerebral inactivity corroborating the clinical findings of BD. The mean BDI in this group was 4.2 ± 5.8h (median; 1.8[1.0-3.5]). This value was significantly lower than in the group in which only two full clinical evaluations were performed (p0.0001). In 10 out 289 (3.5%), the first EEG showed at least some brain activity. The mean BDI in this group was 27.2 ± 13.8h (median; 22.9 [19.1-31.2]). In two cases, a third EEG was necessary before obtaining electrocerebral inactivity. A BDI6h, was positively associated with a family refusal for organ donation (p=0.02).The rate of EEGs with electrocerebral activity despite clinical findings suggesting BD was only 3.5%. It occurred most frequently with severe brainstem damage. Although in this small percentage of patients, BD diagnosis was notably delayed, in the great majority of cases the use of EEG shortened the BDI. In our series, a BD diagnosis delay6h negatively affected consent for organ donation.The use of EEG can decrease the time interval for brain death diagnosis.

We describe the case of a 69-year-old woman admitted to our intensive care unit (ICU) after 20 minutes of resuscitation from acute cardiopulmonary arrest. The patient developed a stimulus-sensitive postanoxic myoclonus in the following hours. The electroencephalogram (EEG) showed diffuse bursts of sharp activity against a completely suppressed background. This case report highlights the importance of carrying out a protocol of multiple and multimodal sensory stimulation when recording an EEG in comatose patients admitted to the ICU.

Compartment syndromes and ischemic contractures after ankle fractures are exceedingly rare. We report a case in which a Weber type-C ankle fracture resulted in an unrecognized compartment syndrome and ischemic contracture of deep posterior compartment of the leg. Six weeks after injury, the patient had an obvious deformity and clawing of the toes. The deformities were corrected by lengthening the flexor hallucis longus and the flexor digitorum longus. Full correction of all clawed toes was evident. A deep posterior compartment syndrome may follow an ankle fracture and should be considered in any patient with unrelenting pain in the immediate postoperative period. (J Am Podiatr Med Assoc 98(5): 404–407, 2008)

La colonoscopia flexible se ha convertido en una tecnica ampliamente empleada en el diagnostico y tratamiento de la patologia colorrectal. Considerada como un procedimiento relativamente seguro, no esta exenta sin embargo de complicaciones, entre las que se incluyen la tromboflebitis, distension abdominal, episodios vasovagales, hemorragia, perforacion y rotura esplenica. La perforacion colonica tras colonoscopia oscila entre un 0.03 y 0.65% en las colonoscopias diagnosticas y entre 0.073 y 2.14 % en procedimientos terapeuticos. En este trabajo presentamos la aparicion de un enfisema subcutaneo progresivo con neumotorax bilateral y neumoperitoneo durante la realizacion de una colonoscopia, sin objetivarse en la cirugia la existencia de perforacion intestinal alguna.

The goal of this study was to analyze the value of electrocardiography in predicting the site of the lesion in the left anterior descending coronary artery, in relation to the first septal and the first diagonal branches, in patients with acute anterior myocardial infarction.Ninety consecutive patients who were admitted to the coronary unit with acute anterior myocardial infarction from July 1998 to May 2000 were studied retrospectively. The electrocardiographic changes were analyzed and correlated with the site of the lesion in the anterior descending artery, as determined by coronary angiography.The most useful parameters in predicting the site of the lesion in the left anterior descending coronary artery in acute anterior myocardial infarction are: 1) For lesions proximal to the first septal branch, ST-segment elevation in aVR (p0.001) and the absence of Q wave in V4-V6 (p = 0.01). 2) For lesions proximal to the first diagonal branch, abnormal Q wave in aVL (p = 0.01) and ST depression in III (p = 0.05). 3) For lesions proximal to both the first septal and first diagonal branches, ST elevation in aVR (p0.001), abnormal Q wave in aVL (p = 0.02), and absence of Q wave in V4-V6 (p = 0.01). 4) For lesions distal to both the first septal and first diagonal branches, abnormal Q wave in V4-V6 (p = 0.001) and absence of ST depression in III (p0.001).In acute anterior myocardial infarction, electrocardiography is useful for predicting the site of the lesion in the left anterior descending coronary artery in relation to the first septal and the first diagonal branches.

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Purpose to describe the characteristics of the color density spectral array (CDSA) of bilateral bispectral index (b-BIS) monitoring system in patients with comatose nonconvulsive status epilepticus (NCSE). We hypothesized that CDSA could be helpful for monitoring NCSE in critically subjects if continuous EEG (cEEG) is not available. Methods we retrospectively analyzed comatose patients admitted to our neurological intensive care unit (NICU) from 2011 to 2014 with a diagnosis of definitive NCSE that underwent b-BIS monitoring for at least 24h to guide anesthetic sedation. Clinical, electroencephalography and neuroimaging findings were analyzed. Moreover, all parameters from the b-BIS data including the CDSA were reviewed during periods of NCSE (NCSE pattern) and profound sedation (sedation pattern). Results 15 NCSE patients were included. The delay from the diagnosis of NCSE to the onset of b-BIS monitoring was 8 (0.5–31)h and total time of b-BIS monitoring 7.8±6.5 days. CDSA during NCSE pattern was characterized by continuous or intermittent red and dark red tones, spectral edge frequency (SEF) in the delta-theta range, with or without asymmetry and BIS number trend with significant variability. In contrast, CDSA during sedation revealed predominance of orange, yellow, green and occasionally blue tones, SEF in the alpha-beta range, absence of asymmetry and stability of BIS number. Conclusions b-BIS monitoring system and, in particular, CDSA used by nonexpert NICU personnel may be helpful to follow-up episodes of NCSE, to detect recurrences of nonconvulsive seizures (NCSzs), and to monitor profound anesthetic therapy in comatose patients when cEEG is not available.

We report the case of a patient with an extensive right cerebral hematoma complicated by focal nonconvulsive status epilepticus (NCSE) in whom the use of the new bilateral BIS-Vista™ monitor was helpful in managing profound sedation and antiepileptic treatment in the absence of continuous EEG monitoring (CEEG). The analysis of color density spectral array (CDSA) showed stereotyped changes indicative of recurrent focal nonconvulsive seizures (NCSz) and NCSE. We noted a close correlation between NCSz and BIS value changes. EEGs during working hours always confirmed the persistence of focal NCSE. After several days of sedation, CDSA disclosed a gradual resolution of NCSE that was also confirmed by electroencephalography. The patient died of cardiorespiratory complications a few days later.