Barriers to patient recruitment in a poststroke neurorehabilitation multicenter trial in Brazil.

There is a high demand for stroke rehabilitation in the Brazilian public health system, but most studies that have addressed rehabilitation for unilateral spatial neglect (USN) after stroke have been performed in high-income countries. Therefore, the aim of this study was to analyze USN patient recruitment in a multicenter noninvasive brain stimulation clinical trial performed in Brazil and to provide study design recommendations for future studies. We evaluated the reasons for exclusion of patients from a multicenter, randomized, double-blinded clinical trial of rehabilitation of USN patients after stroke. Clinical and demographic variables were compared between the included and excluded patients. A descriptive statistical analysis was performed. Only 173 of the 1953 potential neglect patients (8.8%) passed the initial screening. After screening evaluation, 87/173 patients (50.3%) were excluded for clinical reasons. Cognitive impairment led to the exclusion of 21/87 patients (24.1%). Low socioeconomic status led to the exclusion of 37/173 patients (21.4%). Difficulty obtaining transportation to access treatment was the most common reason for their exclusion (16/37 patients, 43.3%). The analyzed Brazilian institutions have potential for conducting studies of USN. The recruitment of stroke survivors with USN was restricted by the study design and limited financial support. A history of cognitive impairment, intracranial stenting or craniectomy, and lack of transportation were the most common barriers to participating in a multicenter noninvasive brain stimulation trial among patients with USN after stroke.

Barriers to patient recruitment in a poststroke neurorehabilitation multicenter trial in Brazil

There is a high demand for stroke rehabilitation in the Brazilian public health system, but most studies that have addressed rehabilitation for unilateral spatial neglect (USN) after stroke have been performed in high-income countries. Therefore, the aim of this study was to analyze USN patient recruitment in a multicenter noninvasive brain stimulation clinical trial performed in Brazil and to provide study design recommendations for future studies. We evaluated the reasons for exclusion of patients from a multicenter, randomized, double-blinded clinical trial of rehabilitation of USN patients after stroke. Clinical and demographic variables were compared between the included and excluded patients. A descriptive statistical analysis was performed. Only 173 of the 1953 potential neglect patients (8.8%) passed the initial screening. After screening evaluation, 87/173 patients (50.3%) were excluded for clinical reasons. Cognitive impairment led to the exclusion of 21/87 patients (24.1%). Low socioeconomic status led to the exclusion of 37/173 patients (21.4%). Difficulty obtaining transportation to access treatment was the most common reason for their exclusion (16/37 patients, 43.3%). The analyzed Brazilian institutions have potential for conducting studies of USN. The recruitment of stroke survivors with USN was restricted by the study design and limited financial support. A history of cognitive impairment, intracranial stenting or craniectomy, and lack of transportation were the most common barriers to participating in a multicenter noninvasive brain stimulation trial among patients with USN after stroke.

Aporte de la biología molecular en el diagnóstico de infecciones respiratorias agudas / Contribution of multiplex respiratory molecular panel to the diagnosis of acute respiratory infections

Objective: To assess the performance of multiplex-PCR for diagnosis of respiratory viruses in parallel with direct fluorescence assay (DFA). We assessed the performance and co-infection diagnosis of molecular respiratory panel PCR (MRP-PCR) and DFA in hospitalized and outpatients. Results: 8535 samples were included, 1792 tested by MRP-PCR (46.9% positive) and 6743 by DFA (35.1% positive). MRP-PCR diagnosed co-infection in 21.3% and DFA in 1.8% of the samples. Rhinovirus was the most common virus in any age group. In 210 patients both tests were done; 100 were positive by MRP-PCR and 18 by DFA. Positive concordance value was 6.2%. 85 samples were positive only by MRP-PCR and in 42 of them only novel respiratory viruses were identified. Performance of MRP-PCR was statistically significant compared DFA for traditional respiratory viruses. Discussion: Multiplex PCR has shown better sensitivity, may expand the etiologic spectrum of respiratory infections and detect a higher number of co-infections.

Objetivo: Evaluar la contribución del panel respiratorio molecular por reacción en cadena de la polimerasa-multiplex (PRM-RPC) en paralelo a la de inmunofluorescencia directa (IFD) al diagnóstico de infecciones respiratorias. Analizamos y comparamos el rendimiento y diagnóstico de co-infección de PRM-RPC con IFD en pacientes hospitalizados y ambulatorios. Resultados: Se analizaron 8535 muestras; 1792 por PRM-RPC (46,9% positivas) y 6743 por IFD (35,1% positivas). La co-infección fue 21,3% por PRM-RCP y 1,8% por IFD. El virus más frecuente fue rinovirus a toda edad. Se analizaron 210 pacientes por ambos métodos; resultaron positivas 100 por PRM-RPC y 18 por IFD, concordancia positiva de 6,2%. 85 muestras fueron solo positivas por PRM-RPC, 42 diagnosticaron nuevos virus respiratorios. El rendimiento de PRM-RPC fue significativamente mayor que el de IFD para virus respiratorios tradicionalmente diagnosticados. Conclusiones: La RCP-multiplex tiene mejor sensibilidad, podría expandir el espectro etiológico de infecciones respiratorias y detectar un mayor número de co-infecciones comparado a IFD.

Un caso de leucemia aguda linfocítica (ALL), tipo B con un inusual rearreglo cromosómico / A case of acute lymphocytic leukemia (ALL), B with an unusual type chromosomal rearrangement

Presentamos los hallazgos cromosómicos de una mujer de cuatro años de edad con trombocitopenia. El cariotipo demostró un 1(7) q(10) como una posible deleción en 11q23 y un cuestionable rearreglo en 9p. Los estudios por FISH de ambas interfase del núcleo y metafase de la célula, usando la fase de reposo MLL y caracterización de la prueba instrumental en el gen MLL, el cual fue encriptado por análisis citogenético convencional. Específicamente, el patrón FISH fue consistente con una inserción de la región 5' del gen MLL dentro de un cromosoma 4 hacia la banda q21, mas estrechamente una variante 1(4;11) (q 21;g23). Este caso ejemplifica la importancia del FISH y su consiguiente caracterización de casos precursores B-cell all, sin algún significado pronóstico de anormalidad cromosómica.

We present the chromosome findings in a 4-year-old female with thrombocytopenia. The karyotype showed an i(7)(q10) as well as a possible deletion on 11q23 and a questionable rearrangement on 9p. FISH studies on both interphase nuclei and metaphase cells using the MLL break apart rearrangement probe were instrumental in the characterization of an MLL gene rearrangement , which was cryptic by conventional cytogenetic analysis. Specifically, the FISH pattern was consistent with an insertion of the 5' region of the MLL gene into one chromosome 4 at band q21, most likely a variant t(4;11)(q21;q23). This case exemplifies the importance of FISH in the further characterization of precursor B-cell ALL cases without any apparent prognostically significant chromosome abnormalities.

Verapamil overdose: case report and review of the literature.

OBJECTIVE: To report the presentation and controversies regarding therapy of an 18-year-old man following a life-threatening ingestion of verapamil. CASE SUMMARY: An 18-year-old man ingested large quantities of dipyridamole, trimethoprim/sulfamethoxazole, amoxicillin, and verapamil. He presented to an outlying hospital and was initially conscious. Soon thereafter, the patient had a seizure; he required intubation, developed cardiac conduction abnormalities, and became hypotensive. The patient required pharmacologic pressors and a pacemaker for transfer to our institution. At our institution, vigorous fluid resuscitation, cardiac pacing, and careful attention to acid/base and electrolyte management provided the basis of therapy. The patient recovered without deficit and was discharged from the intensive care unit five days later. DISCUSSION: Current controversies regarding the management of verapamil overdose are reviewed. Removal of the drug by gastric lavage is a mainstay of therapy. Administration of syrup of ipecac is contraindicated. Although specific recommendations for calcium dosing in the overdose situation have not been rigorously studied, maintenance of a normal serum ionized calcium concentration is suggested. An exogenous catecholamine, rather than dopamine, may be the drug of choice for treating hypotension. Cardiopulmonary bypass provides a method for drug removal in cases of severe toxicity; however, this invasive method requires further study. Management of fluid/electrolyte, acid/base, and ventilation abnormalities is required to treat large ingestions of verapamil. Treatment guidelines for critical care clinicians are provided.