André Rêgo

Introduction: Besides dosage, monitoring, and adverse effects, difficulties in accessing treatment contribute to the overall burden associated with medication. Collecting multiple sclerosis (MS) and migraine medications from Hospital Pharmacy Services (HPS) improves adherence, but the distance from home and the time-consuming process may negatively affect patients' lives. We aimed to evaluate the impact of collecting MS/migraine therapy from HPS. Methods: This was a single-centre, observational, cross-sectional study based on an anonymous online questionnaire. The questionnaire included data on treatment collection, satisfaction with treatment [Patient Global Impression of Change (PGIC)], and disability scales (MSIS-29 for MS; MIDAS for migraine). Adults with MS/migraine who had been collecting medication from HPS for more than 3 months were included. Descriptive statistics were performed using SPSS®. Results: Among 145 participants (MS = 108; migraine = 37), 64.8% were women, with a median age of 48 years. The average scale scores were PGIC: 5/7; MSIS-29: 42.0%; MIDAS: 21/90. 85.5% of patients collected their medication themselves; however, 34.5% of those responsible for collection frequently or very frequently missed work to do so. On average, patients spent 1.1 hours (σ = 1.0) to reach the hospital (mean distance: 16.1 km, σ = 13.4) and a mean of 1.1 hours (σ = 0.6) waiting at the HPS. The estimated annual time spent (ATS) on medication collection was 13.5 hours/year (σ = 12.4). Waiting time at the HP was a predictor of satisfaction with the collection method, which had a median score of 3 (1 = strongly disagree, 5 = strongly agree), negatively correlating with ATS (p < 0.001, R² = 0.7 and 0.9). Most participants (73.1%) preferred collecting their medication from a community pharmacy. Conclusion: For patients with MS and migraine, optimizing the hospital or community medication dispensing process could imply a significant improvement in their quality of life.

Introdução: A inclusão do nervo óptico (NO) nos critérios de disseminação no espaço (DIS) para o diagnóstico de esclerose múltipla (EM) foi proposta em 2016 pelo grupo Magnetic Ressonance Imaging in Multiple Sclerosis. Contudo, existia evidência insuficiente para incluir esta recomendação na revisão de 2017 dos critérios de McDonald. O nosso objetivo foi investigar o efeito de incluir o NO avaliado por potenciais evocados visuais (PEV) como quinta localização nos critérios de DIS para o diagnóstico de EM, em doentes com síndrome clínico isolado (CIS) típico. Métodos: Estudámos doentes que se apresentaram com CIS entre 2012 e 2019 em dois hospitais portugueses, com avaliação inicial completa, incluindo ressonância magnética crânio-encefálica e medular, e PEV. Aplicámos retrospetivamente os critérios de McDonald 2017 e um conjunto de critérios modificados que incluíam o NO avaliado por PEV na DIS. Avaliámos a performance dos dois conjuntos de critérios para predizer conversão em esclerose múltipla clinicamente definida (EMCD) e/ou atividade imagiológica. Resultados: Incluímos 76 doentes, 25% com nevrite ótica como CIS. Os PEV identificaram envolvimento assintomático do NO em 12,3% dos CIS-não nevrite ótica. Vinte e sete (35.5%) doentes converteram em EMCD e 37 (48,7%) apresentaram atividade imagiológica durante o follow-up (mediana = 3,12 anos, 1,04 – 8,36). Cinquenta e nove por cento iniciaram terapêutica modificadora da doença antes da conversão em EMCD. Os critérios de DIS modificados em combinação com disseminação no tempo foram mais sensíveis (77,8% vs 74,1%), mas menos específicos (57,1% vs 61,2%) para predizer EMCD, e mais sensíveis (73,2% vs 65,9%) e igualmente específicos (65,7% vs 65,7%) para predizer EMCD ou actividade imagiológica, mas estas diferenças não foram estatisticamente significativas. Os critérios modificados permitiram o diagnóstico de 3 doentes adicionais no baseline (42/76 vs 39/76), em média 9 meses antes do cumprimento dos critérios de McDonald 2017. Conclusão: Embora a inclusão do NO avaliado por PEV nos critérios de DIS tenha levado à correta identificação de mais doentes com EM, na nossa amostra não permitiu um aumento estaticamente significativo da sensibilidade de diagnóstico. Ainda assim, o nosso trabalho apoia a necessidade de discussão da inclusão do NO nos critérios de DIS na futura revisão dos critérios de diagnóstico de EM.

Background and purpose: There is scarce clinical information about the clinical profile of patients with acute ischaemic stroke with previously undiagnosed major vascular risk factors (UMRFs).Methods: This was a retrospective analysis of data from the Acute Stroke Registry and Analysis of Lausanne registry between 2003 and 2018 with univariate and multivariate logistic regression analyses comparing clinical profiles of patients with UMRFs to patients with at least one previously diagnosed MRF (DMRF).Results: In all, 4354 patients (median age 70 years [interquartile range 15.2], 44.7% female) were included after excluding 763 (14.9%) for lack of consent and three for missing information. Amongst 1125 (25.8%) UMRF patients, 69.7% (n = 784) had at least one newly diagnosed MRF and the others none. The newly detected MRFs were dyslipidaemia (61.4%), hypertension (23.7%), atrial fibrillation (10.2%), diabetes mellitus (5.2%), ejection fraction <35% (2.0%) and coronary disease (1.0%). Comparing UMRF patients to DMRF patients, multivariate analysis showed a positive association with lower age, non‐Caucasian ethnicity, contraceptive use (<55 years old), smoking (≥55 years old) and patent‐foramen‐ovale‐related stroke mechanism. A negative association was found with pre‐stroke antiplatelet use and higher body mass index. Functional outcome did not differ. Cerebrovascular recurrences were similar between groups.Conclusions: In this large single‐centre cohort, 69.7% of patients with acute ischaemic stroke and UMRF were newly diagnosed with at least one new MRF, the most common being dyslipidaemia, hypertension or atrial fibrillation. Patients of the UMRF group were younger, more often smokers and on contraceptives, and had more patent‐foramen‐ovale‐related strokes.

Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease of the central nervous system (CNS) caused by the polyoma John Cunningham (JC) virus. This virus is rarely pathogenic in immunocompetent individuals, being associated with profound cellular immunosuppression. We present a case of a 72-year-old woman with schizoaffective disorder who presented to the emergency department with dysarthria and right hemiataxia. The initial computer tomography was normal and the diagnosis of ischemic stroke was first assumed. However, during hospitalization there was a progressive worsening of symptoms with cerebellar ataxia, and the magnetic resonance revealed a lesion in the right middle cerebellar peduncle hypointense in T1 and hyperintense on T2/fluid attenuated inversion recovery (FLAIR) sequence, suggestive of PML. Although the first cerebrospinal fluid analysis was negative, the second one was positive for the JC virus. Furthermore, due to radiological and clinical progression, mirtazapine was started and the patient underwent a course of intravenous immunoglobulin, with no response. In parallel, causes of immunosuppression were investigated, which led to the diagnosis of idiopathic CD8+ lymphocytopenia. Due to rapid progression of symptoms and radiological worsening of lesions, pembrolizumab was administered. After the first administration of pembrolizumab there was a transitory clinical stabilization. However, shortly after the second administration of pembrolizumab, the patient developed stridor with bilateral vocal cord paralysis and subsequent symptom progression, which led to the death of the patient three months after the appearance of initial symptoms. In conclusion, we report a case of a PML in a patient with idiopathic CD8+ lymphocytopenia, enhancing the need for a high suspicion index for this entity as well as for occult and less frequent forms of immunosuppression. Although there have been various case reports of favourable outcomes with pembrolizumab for PML, more research is needed, particularly to identify patient factors that might be associated with better responses to this therapy.

Background Persistent headache attributed to past stroke (PHAPS) is a controversial entity, recently included in the third edition of the International Classification of Headache Disorders (ICHD-3) despite being described only in retrospective studies. Objective To determine the frequency and characteristics of PHAPS in patients admitted with acute stroke. Methods We selected all patients with headache associated with acute stroke (HAAS) from a prospective, single-center registry of patients with acute stroke admitted to a Neurology ward between November 2018 and December 2019. We analyzed demographic, clinical, and neuroimaging data. We assessed the follow-up with a phone call questionnaire at 6 to 12 months. Results Among 121 patients with acute stroke, only 29 (24.0%) had HAAS. From these, 6 (5.0%) were lost to follow-up. In total, 23 (20.0%) patients answered the 6- to 12-month follow-up questionnaire and were included in this study. The median age of the sample was 53 years (interquartile range [IQR]: 38–78 years), and there was no sex predominance. Of the 10 patients (8,3%) that had persistent headache, 8 (6.6%) suffered from previous chronic headaches; however, they all mentioned a different kind of headache, and 1 (0,8%) probably had headache secondary to medication. Conclusions In the present study, only 10 out of 121 stroke patients (8.3%) referred persistent headache at the 6- to 12-month follow-up, but the majority already suffered from previous chronic headache, which raises the question that the actual prevalence of PHAPS may be lower than previously reported.