Denial in the first days of acute stroke.

Denial is a disorder of self-awareness that is frequent after acute stroke, with potential negative influence in the care of patients. The aim of this study was to describe the presence and correlates of denial in acute stroke. We assessed denial in a sample of 180 consecutive acute stroke patients (< or =4 days) and in a control group of 50 acute coronary patients using the Denial of Illness Scale (DIS).41% (74) acute stroke patients (mean DIS score=4.1, SD=2.2, range 0 to 10) and 24% (12) acute coronary patients (mean DIS score=3.2, SD=1.5, range 0 to 10) presented denial (chi(2)=4.19, p=.04; U=3405.50, p=.01). Denial was more frequent and severe in patients with lower educational level (chi(2) = 5.04, p=.04; U=2110.50; p=.01), neglect (chi(2) = 21.38, p=.00; U=1130.50; p=.00), cognitive impairment (chi(2) = 6.27, p=.02; U=1181.50; p=.01) and after hemispherical lesions (chi(2) =4.68, p=.05; U=1982.50; p=.04). In logistic regression low educational level, neglect and cognitive impairment were independent factors predicting denial in stroke patients (R(2)= 21%). Patients with denial can express depressive symptoms. Patients with denial had a worse outcome at discharge (chi(2) =4.91, p=.04; U=2918.00; p=.03). Denial is a frequent phenomenon after acute stroke. We propose that there is a multifactorial model for the emergence of denial, lower educational as a predisposing condition, and acute stroke due to hemisphere lesion and causing neglect and cognitive impairment as precipitating events. All these factors limit patients' assessment of their condition and body functions.

Delirium in acute subarachnoid haemorrhage.

BACKGROUND: Delirium may be a presenting feature in acute subarachnoid haemorrhage (SAH). The aim of this study was to investigate the risk factors for delirium in acute SAH and to analyse the relation between delirium and location and amount of haematic densities and hydrocephalus. METHODS: We assessed delirium in a sample of 68 consecutive patients with acute (< or =4 days) SAH (33 aneurysmal, 33 non-aneurysmal, including 9 with perimesencephalic haemorrhage), before aneurysmal treatment, using DSM-IV-R criteria and the Delirium Rating Scale (DRS). DRS scores were related to: (1) the total amount of haematic densities at 10 basal cisterns/fissures and in the 4 ventricles, using a validated rating scale, (2) the haematic densities in the prepontine cistern and the convexity of the brain and (3) hydrocephalus, using the bicaudate index, obtained from a review of admission CT scans. RESULTS: Eleven acute SAH patients presented with delirium. Older age (U = 316.5, p = 0.04), alertness disturbance (chi(2) = 5.1, p = 0.02, OR = 7.6, 95% CI = 1.5-37.3), aphasia (U = 61.5, p = 0.007) and a Hunt and Hess score >2 (U = 362.5, p = 0.02) were associated with delirium. Higher amounts of intraventricular haematic densities (chi(2) = 4.43, p = 0.04, U = 158, p = 0.001) and hydrocephalus (U = 215, p = 0.009) were also associated with higher DRS scores. Two delirious patients had basofrontal haematomas. CONCLUSIONS: Delirium was detected in 16% of acute SAH patients. Intraventricular bleeding, hydrocephalus and basofrontal haematomas contribute to the pathogenesis of delirium, through damage to anatomical networks subserving sustained attention, declarative memory and the expression of emotional behaviour.

Delirium in the first days of acute stroke.

BACKGROUND AND PURPOSE: Delirium is an acute, transient disorder of cognition and consciousness with fluctuating intensity. The aim of this study was to investigate the presence and the risk factors for delirium in the first days after stroke onset. PATIENTS AND METHODS: We assessed delirium prospectively in a sample of 218 consecutive patients (mean age 57 years) with an acute (/= 10). RESULTS: 29 (13%) acute stroke patients (mean DRS score = 13.2, SD = 2.3) and only one (2 %) acute coronary patient had delirium (chi(2) = 5.2, p = 0.02). In nine patients delirium was secondary to stroke without any additional cause, in 10 patients there were also medical complications and in the remaining 10 there were multiple potential causes for delirium. Delirium was more frequent after hemispherical than after brainstem/cerebellum strokes (p = 0.02). No other statistically significant associations with stroke locations were found. Medical complications (OR = 4.3; 95% CI = 1.8 to 10.2), neglect (OR = 3.5; 95% CI = 1.3 to 9.2), intracerebral haemorrhage (OR = 3.1; 95% CI = 1.3 to 7.5) and age >/= 65 (OR = 2.4; 95% CI = 1.0 to 5.8) were independent factors to the development of delirium in stroke patients. CONCLUSION: Delirium was more frequent in stroke than in coronary acute patients. Among stroke patients, delirium was most frequent in older patients, in those with neglect, with medical complications and with intracerebral haemorrhages. These findings indicated that delirium in acute stroke patients 1) is not a non-specific consequence of acute disease and hospitalisation and 2) is secondary to hemisphere brain damage and to metabolic disturbances due to medical complications.

Psychomotor and anxiolytic effects of mexazolam in patients with generalised anxiety disorder.

OBJECTIVE: The primary aim of this study was to evaluate the psychomotor effects of mexazolam versus placebo in patients with generalised anxiety disorder (GAD). PATIENTS AND METHODS: This was a multicentre, randomised, double-blind, parallel-group clinical trial in 60 outpatients with GAD (Diagnostic and Statistical Manual of Mental Disorders-4(th) edition [DSM-IV] criteria). After a placebo run-in period, patients were assigned to mexazolam 1mg three times daily (n = 32) or placebo (n = 28) for 21 days. Effects on psychomotor performance were evaluated with the Leeds Psychomotor Test Battery (critical flicker fusion threshold, recognition, motor and total reaction time). The Hamilton Anxiety Rating Scale (HAM-A) and the Clinical Global Impression (CGI) were used to evaluate the patients' clinical status (secondary objective). RESULTS: At neither assessment were any statistically significant differences detected between mexazolam and placebo for CGI, critical flicker fusion, and the different reaction times. The HAM-A total and the HAM-A somatic scores indicated a statistically significant therapeutic effect for mexazolam vs placebo after 1 week of treatment but not after 3 weeks. The most prominent adverse event with mexazolam was mild drowsiness. CONCLUSIONS: Mexazolam in a therapeutically effective dosage regimen does not impair psychomotor performance to a clinically relevant extent.

Meningite bacteriana: análise retrospectiva em um hospital universitário / Bacterial meningitis: retrospective analysis in a community hospital

Com o objetivo de avaliar a incidência e a evoluçào da meningite em um hospital comunitário, analisamos retrospectivamente os pacientes internados na Clínica Médica do HU-USP de janeiro de 1985 à dezembro de 1993. Estudamos 79 casos, excluindo-se 29 pacientes com meningitis tuberculosa ou criptocócica. A média de idade foi de 29 anos, com predominância do sexo masculino, a média de tempo de internação de 9,7 dias e a média de temperatura de admissão de 38,6ºC. Os achados mais freqüentes foram: cefaléia, febre, vômitos, lesões cutânes de aparecimento recente e confusão mental. Analisam-se os resultados obtidos do exame de líquor e tomografia computadorizada. Quatorze pacientes foram tratados somente com medicação sintomática, com boa evoluçào. Os pacientes receberam antibióticos por 8,8 dias, em média, permanecendo com febre, em média, por 4 dias. Setenta e três pacientes tiveram alta hospitalar, quatro pacientes evoluíram para óbito e dois foram transferidos. Concluímos que a incidência predominou em uma faixa bastante jovem; a taxa geral de mortalidade encontrada foi de 5,1(per cent); grande número de pacientes não apresentava sinais de irritaçào meníngea na admissão (au)

Miosite tropical / Tropical myositis

Os autores descrevem seis casos de miosite tropical ou piomiosite que ocorreram na Divisao de Clinica Medica do Hospital Universitario da USP durante o periodo de 1985 a 1992. O Staphylococcus aureus foi o agente responsavel por este quadro infeccioso sendo isolado a partir de abscessos musculares em quatro casos e de hemoculturas em dois casos. A antibioticoterapia adequada associada a drenagem cirurgica determinou evolucao satisfatoria, sem mortalidade e sequelas osteomusculares.