Performance of four ischemic stroke prognostic scores in a Brazilian population.

OBJECTIVE: Ischemic stroke (IS) prognostic scales may help clinicians in their clinical decisions. This study aimed to assess the performance of four IS prognostic scales in a Brazilian population. METHOD: We evaluated data of IS patients admitted at Hospital Paulistano, a Joint Commission International certified primary stroke center. In-hospital mortality and modified Rankin score at discharge were defined as the outcome measures. The performance of National Institutes of Health Stroke Scale (NIHSS), Stroke Prognostication Using Age and NIHSS (SPAN-100), Acute Stroke Registry and Analysis of Lausanne (ASTRAL), and Totaled Health Risks in Vascular Events (THRIVE) were compared. RESULTS: Two hundred six patients with a mean ± SD age of 67.58 ± 15.5 years, being 55.3% male, were included. The four scales were significantly and independently associated functional outcome. Only THRIVE was associated with in-hospital mortality. With area under the curve THRIVE and NIHSS were the scales with better performance for functional outcome and THRIVE had the best performance for mortality. CONCLUSION: THRIVE showed the best performance among the four scales, being the only associated with in-hospital mortality.

Performance of four ischemic stroke prognostic scores in a Brazilian population / Desempenho de quatro escalas de prognóstico de AVCI em uma população brasileira

ABSTRACT Objective Ischemic stroke (IS) prognostic scales may help clinicians in their clinical decisions. This study aimed to assess the performance of four IS prognostic scales in a Brazilian population. Method We evaluated data of IS patients admitted at Hospital Paulistano, a Joint Commission International certified primary stroke center. In-hospital mortality and modified Rankin score at discharge were defined as the outcome measures. The performance of National Institutes of Health Stroke Scale (NIHSS), Stroke Prognostication Using Age and NIHSS (SPAN-100), Acute Stroke Registry and Analysis of Lausanne (ASTRAL), and Totaled Health Risks in Vascular Events (THRIVE) were compared. Results Two hundred six patients with a mean ± SD age of 67.58 ± 15.5 years, being 55.3% male, were included. The four scales were significantly and independently associated functional outcome. Only THRIVE was associated with in-hospital mortality. With area under the curve THRIVE and NIHSS were the scales with better performance for functional outcome and THRIVE had the best performance for mortality. Conclusion THRIVE showed the best performance among the four scales, being the only associated with in-hospital mortality.

RESUMO Objetivo Escalas de avaliação prognóstica do acidente vascular cerebral isquêmico (AVCI) podem ajudar decisões clinicas. O objetivo deste estudo foi avaliar o desempenho de quatro escalas prognósticas em uma população brasileira. Método Foram avaliados os dados de pacientes admitidos com AVCI no Hospital Paulistano, um hospital acreditado pela “Joint Commission International”. A mortalidade intra-hospitalar e a escala de Rankin foram definidos como desfechos de evolução clínica. O desempenho de quatro escalas: National Institutes of Health Stroke Scale (NIHSS), Stroke Prognostication Using Age and NIHSS (SPAN-100), Acute Stroke Registry and Analysis of Lausanne (ASTRAL) e Totaled Health Risks in Vascular Events (THRIVE) foi comparado. Resultados Foram incluídos duzentos e seis pacientes, com uma idade média de 67,58 ± 15,5 anos, sendo 55,3% dos sexo masculino. Todas as quatro escalas associaram-se de forma independente com prognóstico funcional. Apenas o THRIVE correlacionou-se com a mortalidade hospitalar. O THRIVE e o NIHSS tiveram melhor desempenho para prognóstico funcional e o THRIVE teve o melhor desempenho para mortalidade pela área sob a curva. Conclusão O THRIVE mostrou-se a escala com melhor performance, sendo a única correlacionada com a mortalidade hospitalar.

Outcome determinants of stroke in a brazilian primary stroke center.

Background. Stroke mortality in Brazil is one of the highest among Western countries. Nonetheless, stroke outcome determinants are still poorly known in this country. In this study we evaluate outcome determinants of stroke in a primary stroke center in São Paulo, Brazil. Methods. We evaluated demographic, clinical, and outcome data of patients with ischemic stroke (IS), transient ischemic attack (TIA), and intracerebral hemorrhage (ICH) admitted at "Hospital Paulistano," São Paulo, Brazil. In-hospital mortality and functional outcome determinants were assessed. Univariate and binary logistic regression analysis were performed. Results. Three hundred forty-one patients were included in the study, 52.2% being male with 66.8 ± 15.7 years. The stroke type distribution was IS: 59.2%, TIA: 29.6%, and ICH: 11.1%. ICH was associated with greater severity and poorer functional outcome. The determinants of poorer functional outcome were higher NIHSS, lower Glasgow score, and lower oxygen saturation level. The most important mortality determinant was the presence of visual symptoms. Conclusions. The stroke mortality and stroke outcome determinants found in the present study do not remarkably differ from studies carried out in developed countries. Stroke prognosis studies are crucial to better understand the high burden of stroke in Brazil.

Determinants of emergency medical services use in a Brazilian population with acute ischemic stroke.

Emergency medical services (EMS) plays a key role in the recognition and treatment of stroke. This study evaluates the determinants of EMS use in a Brazilian population with acute ischemic stroke. We performed a post hoc analysis of prospectively collected data of consecutive patients admitted to a Brazilian tertiary hospital with acute ischemic stroke. Groups were compared according to their mode of arrival to the hospital: those brought by EMS and those arriving at the hospital by their own means. Among 165 patients evaluated between January and December 2009, 17.6% arrived by EMS and 82.4% arrived by their own means. After multivariate adjustment, individuals with higher National Institutes of Health Stroke Scale score at presentation (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.06-1.23 for each point on the National Institutes of Health Stroke Scale score) were more likely to use EMS, as were those with atrial fibrillation (OR, 5.8; 95% CI, 1.41-24.07) and with lower blood pressure at hospital admission (OR, 0.72; 95% CI, 0.56-0.93 for each mm Hg). Patients brought by EMS had trends toward a lower door-to-neuroimaging time and a higher frequency of thrombolysis therapy (13% in EMS users vs 5% in patients arriving by their own means; P = .10). Our data demonstrate that in a Brazilian population with acute ischemic stroke, the patients with more severe stroke, those with atrial fibrillation, and those with lower blood pressure at hospital presentation were more likely to use EMS. EMS use was associated with trends toward a lower door-to-neuroimaging time and a higher frequency of thrombolysis therapy.

Get with the guidelines stroke performance indicators in a brazilian tertiary hospital.

BACKGROUND: Stroke is the fourth leading killer in the US, the first in Brazil and a leading cause of adult long-term disability in both countries. In spite of widespread recommendation, clinical practice guidelines have had limited effect on changing physician behavior. Recognizing that both knowledge and acceptance of guidelines do not necessarily imply guideline adherence, the American Heart Association/American Stroke Association (AHA/ASA) developed a national stroke quality improvement program, the 'Get With The Guidelines (GWTG) stroke'. Even though GWTG has produced remarkable results in the US, other countries have not adopted the program. METHODS: We compared the stroke treatment quality indicators from a private Brazilian tertiary hospital to those published by the GWTG stroke program. Seven predefined performance measures selected by the GWTG stroke program as targets for stroke quality improvement were evaluated: (1) tissue plasminogen activator use in patients who arrived <2 h from symptom onset; (2) antithrombotic medication use within 48 h of admission; (3) deep vein thrombosis prophylaxis within 48 h of admission for nonambulatory patients; (4) discharge use of antithrombotics; (5) discharge use of anticoagulation for atrial fibrillation; (6) dosing of LDL and treatment for LDL >100 mg/dl in patients meeting the National Cholesterol Education Program Adult Treatment Panel (NCEP) III guidelines, and (7) counseling for smoking cessation. RESULTS: A total of 343 consecutive patients with acute ischemic stroke (70.8%) or transient ischemic attack (29.2%) were evaluated from August 2008 to December 2010. Antithrombotic medication within 48 h was used in 98.5% of the eligible patients and deep vein thrombosis prophylaxis in 100%. A total of 123 patients arrived within 2 h from symptoms onset, 23 were eligible for intravenous thrombolysis and 16 were treated (69.5%). All eligible patients were discharged using antithrombotic medication, and 86.9% of the eligible patients who had atrial fibrillation received anticoagulation. Only 56.1% of the eligible patients were treated according to the NCEP III guidelines. Counseling for smoking cessation was done in 63.6% of the eligible patients. CONCLUSIONS: Our study is the first in Brazil and the second outside the US to analyze compliance with the GWTG recommendations. Close attention to a better implementation of these measures may produce an improvement in such results similar to what happened after the full implementation of the program in the US. Whether or not a US disease-based registry such as GWTG can be adopted with success beyond the US is still a matter of debate.

A double-blind randomized controlled trial of low doses of propranolol, nortriptyline, and the combination of propranolol and nortriptyline for the preventive treatment of migraine / Estudo controlado, randomizado e duplo cego do uso de baixas doses de propranolol, nortriptilina e a combinação destas duas drogas no tratamento preventivo da migrânea

Few trials have evaluated combination of two or more drugs in the preventive treatment of migraine. In this study three therapeutic regimens were compared: (a) propranolol, at a dose of 40 mg per day, (b) nortriptyline, at a dose of 20 mg per day, and (c) the combination of these two drugs in these dosages. The groups were matched according to age, gender, and frequency of migraine attacks prior to treatment. The period of treatment was two months and the frequency and intensity of headache attacks of the 30 days pre-treatment period were compared with the frequency of headaches in the treatment period. Fourteen patients in groups A and B and sixteen patients in group C have completed the study. Treatment with propranolol, alone or in combination, was shown to be effective. Treatment with nortriptyline alone was not effective. All three therapeutic regimens were safe and side effects were minimal. The frequency of discontinuation of the study was the same in the 3 groups but no patient left the study due to adverse reactions. The combined therapy proved to be as safe as the monotherapy. Further studies evaluating this and other possible combinations of drugs in higher doses and for longer periods, should more clearly elucidate the role of combined therapy in the treatment of migraine.

Poucos ensaios clínicos têm avaliado o tratamento preventivo da migrânea através da combinação de drogas. Neste estudo, três regimes terapêuticos foram comparados: (a) popranolol, na dose de 40 mg por dia, (b) nortriptilina, na dose de 20 mg por dia e (c) combinação destas duas drogas nestas dosagens. Os grupos foram pareados de acordo com idade, sexo e freqüência de crises previamente ao tratamento. O período de tratamento foi de dois meses e a frequência e a intensidade das crises de cefaléia do período pré-tratamento foram comparadas com as do período de tratamento. Concluíram o estudo 14 pacientes do grupo A, 14 do grupo B e 16 do grupo C. Os tratamentos com propranolol, isolado ou em associação mostraram-se eficazes. O tratamento com nortriptilina isolada não se mostrou eficaz para a redução do número de dias com cefaléia. Todos os três regimes terapêuticos foram seguros e os efeitos colaterais foram mínimos. A freqüência de abandono do estudo foi a mesma nos 3 grupos e nenhum paciente abandonou o estudo devido a reações adversas. A terapia combinada mostrou-se tão segura quanto a monoterapia. Estudos futuros avaliando esta e outras possíveis combinações de drogas, em doses maiores e por períodos mais longos, deverão elucidar mais claramente o papel da terapia combinada no tratamento da migrânea.

A double-blind randomized controlled trial of low doses of propranolol, nortriptyline, and the combination of propranolol and nortriptyline for the preventive treatment of migraine.

Few trials have evaluated combination of two or more drugs in the preventive treatment of migraine. In this study three therapeutic regimens were compared: (a) propranolol, at a dose of 40 mg per day, (b) nortriptyline, at a dose of 20 mg per day, and (c) the combination of these two drugs in these dosages. The groups were matched according to age, gender, and frequency of migraine attacks prior to treatment. The period of treatment was two months and the frequency and intensity of headache attacks of the 30 days pre-treatment period were compared with the frequency of headaches in the treatment period. Fourteen patients in groups A and B and sixteen patients in group C have completed the study. Treatment with propranolol, alone or in combination, was shown to be effective. Treatment with nortriptyline alone was not effective. All three therapeutic regimens were safe and side effects were minimal. The frequency of discontinuation of the study was the same in the 3 groups but no patient left the study due to adverse reactions. The combined therapy proved to be as safe as the monotherapy. Further studies evaluating this and other possible combinations of drugs in higher doses and for longer periods, should more clearly elucidate the role of combined therapy in the treatment of migraine.

Involvement of the central nervous system in patients with dengue virus infection.

The findings of a neurological evaluation in 85 patients with confirmed, acute, dengue virus infection are described. Signs of central nervous system involvement were present in 18 patients (21.2%). The most frequent neurological symptom was mental confusion. The frequency of neurological involvement did not differ between patients with primary and secondary dengue infection, and the prevalence of central nervous system involvement in dengue fever and dengue hemorrhagic fever also did not differ significantly. The presence of CNS involvement did not influence the prognosis of dengue infection. Dengue viral CSF RNA was found in 7 of 13 patients submitted to a spinal tap, the CSF viral load being less than 1000 copies/ml. PCR was negative in serum samples obtained from three patients on the same day as the CSF samples, suggesting that the dengue virus actively enters the CNS and that the presence of the virus in the CNS does not result from passive crossing of the blood-brain barrier.

Sensitivity and specificity of three ELISA-based assays for discriminating primary from secondary acute dengue virus infection.

BACKGROUND: Discrimination between primary and secondary dengue virus infection traditionally has been performed using the hemagglutination inhibition (HI) test. However, this test has practical limitations and disadvantages. OBJECTIVE: To evaluate the ability of three ELISA-based methods (IgG avidity test, IgM/IgG ratio and IgG titer) to discriminate primary from secondary dengue infection. STUDY DESIGN: Serum samples from convalescent-phase patients with confirmed acute, primary (n=46) or secondary (n=33) dengue virus infection were tested using three ELISA-based methods. A ROC curve was employed to establish the cut-off points and to evaluate the ability of the three methods to distinguish between acute, primary and secondary dengue virus infection. RESULTS: All three assays exhibited sensitivity and negative predictive values of 100% for defining secondary infection. The specificity and positive predictive values were respectively 97.8% and 93.7% for the IgG avidity test, 95.7% and 88.2% for the IgM/IgG ratio assays, and 97.8% and 93.7% for the IgG titer assay. CONCLUSION: All three ELISA-based assays proved reliable tools for discriminating between acute, primary and secondary dengue virus infection when using serum samples from convalescent-phase patients.

Prevalence and impact of headache and migraine among Pomeranians in Espirito Santo, Brazil / Prevalência e impacto da cefaléia entre pomeranos do interior do Espírito Santo

This is the first study to assess the prevalence of headache and migraine among Pomeranian descendents in Brazil. A high prevalence of headache in the last 6 months was found (53.2 percent). Most headache sufferers were diagnosed as having migraine (55 percent). More women reported to have headache than men (65 percent and 33.8 percent, respectively). Migraine was the most common headache found among women (62.2 percent). Among men migraine was responsible for only 37.8 percent of the cases of headache. A high impact of headache was found, especially among migraineurs. Most of the headache sufferers declared to seek medical assistance for headache (67 percent) and most of them used to take common analgesics for headache relief. None of them was under prophylactic therapy.

Este estudo é o primeiro a avaliar a prevalência da cefaléia e da migrânea entre descendentes de pomeranos no Brasil. Demonstrou-se alta prevalência de cefaléia (53,2 por cento), sendo que a migrânea foi responsável por 55 por cento das cefaléias. Houve maior prevalência de cefaléia entre as mulheres (65 por cento) do que entre os homens (33,8 por cento). Entre as mulheres verificou-se maior prevalência de migrânea (62,2 por cento) sobre as outras cefaléias (37,8 por cento). Entre os homens a migrânea foi responsável por apenas 34,6 por cento dos casos de cefaléia. Verificou-se importante impacto da cefaléia nesta população, especialmente entre os portadores de migrânea. A maior parte (67 por cento) dos portadores de cefaléia recebia algum tipo de orientação médica em relação ao problema, e a maioria fazia uso de medicamentos analgésicos comuns. Nenhum dos indivíduos estava em tratamento profilático.

Frequency and features of delayed alcohol-induced headache among university students.

The aim of this study was to describe the frequency and features of delayed alcohol-induced headache (DAIH) among university students. Ninety-five students were administered a headache questionnaire approximately 12 hours after have being exposed to high alcohol intake. Headache was mostly diffuse (44.4%), bilateral (92.5%), and throbbing (48.1%). This headache was usually severe and with important morbidity. Previous migraine has significantly increased the risk of DAIH.

Prevalence and impact of headache and migraine among Pomeranians in Espirito Santo, Brazil.

This is the first study to assess the prevalence of headache and migraine among Pomeranian descendents in Brazil. A high prevalence of headache in the last 6 months was found (53.2%). Most headache sufferers were diagnosed as having migraine (55%). More women reported to have headache than men (65% and 33.8%, respectively). Migraine was the most common headache found among women (62.2%). Among men migraine was responsible for only 37.8% of the cases of headache. A high impact of headache was found, especially among migraineurs. Most of the headache sufferers declared to seek medical assistance for headache (67%) and most of them used to take common analgesics for headache relief. None of them was under prophylactic therapy.

Recurrent neuromyelitis optica with diffuse central nervous system involvement: case report.

Several demyelinating disorders can affect children. The differential diagnosis between these diseases is usually an arduous task. Diagnostic criteria have been proposed for some of these disorders, however most of them have not yet been clinically and prospectively validated. Here we present a case of a ten year-old boy with recurrent bilateral optic neuritis and spinal cord involvement. Clinical and cerebrospinal fluid data have fulfilled diagnostic criteria for Devic's neuromyelitis optica (NMO). The differential diagnosis with multiple sclerosis (MS) has become troublesome since not only optic nerves and spinal cord were involved. In one of the relapses a left hemiparesis with facial involvement was registered. Magnetic resonance imaging was also compatible with MS. This case illustrates that CNS demyelinating disorders can fulfill diagnostic criteria for more than one demyelinating disease, making the clinical judgment an important tool in the management of these patients.

Recurrent neuromyelitis optica with diffuse central nervous system involvement: case report

Diversas doenças desmielinizantes podem ocorrer em crianças, sendo muitas vezes o diagnóstico diferencial entre elas difícil. Critérios diagnósticos têm sido propostos para algumas destas entidades, entretanto nenhum deles pode ser considerado definitivo. O objetivo deste trabalho é apresentar o caso de um paciente de 10 anos de idade, com quadro recorrente de neurite óptica bilateral e mielopatia. Os dados clínicos e liquóricos preencheram critérios para o diagnóstico de neuromielite óptica de Devic. O diagnóstico diferencial foi especialmente difícil em relação à esclerose múltipla, pois não apenas os nervos ópticos e medula foram acometidos, visto que em um dos surtos registrou-se hemiparesia, com acometimento facial. A ressonância magnética foi também compatível com esclerose múltipla. Este caso ilustra que pacientes com doenças desmielinizantes do SNC podem preencher critérios diagnósticos para mais de uma delas, o que torna o julgamento clínico uma ferramenta ainda importante na abordagem e condução clínica destes casos.