Síndrome hemofagocítico como causa de encefalopatía subaguda / Haemophagocytic syndrome as a cause of subacute encephalopathy

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Mobile platform for treatment of stroke: A case study of tele-assistance.

This article presents the technological solution of a tele-assistance process for stroke patients in acute phase in the Seville metropolitan area. The main objective of this process is to reduce time from symptom onset to treatment of acute phase stroke patients by means of telemedicine, regarding mobility between an intensive care unit ambulance and an expert center and activating the pre-hospital care phase. The technological platform covering the process has been defined following an interoperability model based on standards and with a focus on service-oriented architecture focus. Messaging definition has been designed according to the reference model of the CEN/ISO 13606, messages content follows the structure of archetypes. An XDS-b (Cross-Enterprise Document Sharing-b) transaction messaging has been designed according to Integrating the Healthcare Enterprise profile for archetype notifications and update enquiries.This research has been performed by a multidisciplinary group. The Virgen del Rocío University Hospital acts as Reference Hospital and the Public Company for Healthcare as mobility surroundings.

Development, Implementation, and Evaluation of a Telemedicine Service for the Treatment of Acute Stroke Patients: TeleStroke.

BACKGROUND: Health care service based on telemedicine can reduce both physical and time barriers in stroke treatments. Moreover, this service connects centers specializing in stroke treatment with other centers and practitioners, thereby increasing accessibility to neurological specialist care and fibrinolytic treatment. OBJECTIVE: Development, implementation, and evaluation of a care service for the treatment of acute stroke patients based on telemedicine (TeleStroke) at Virgen del Rocío University Hospital. METHODS: The evaluation phase, conducted from October 2008 to January 2011, involved patients who presented acute stroke symptoms confirmed by the emergency physician; they were examined using TeleStroke in two hospitals, at a distance of 16 and 110 kilometers from Virgen del Rocío University Hospital. We analyzed the number of interconsultation sheets, the percentage of patients treated with fibrinolysis, and the number of times they were treated. To evaluate medical professionals' acceptance of the TeleStroke system, we developed a web-based questionnaire using a Technology Acceptance Model. RESULTS: A total of 28 patients were evaluated through the interconsultation sheet. Out of 28 patients, 19 (68%) received fibrinolytic treatment. The most common reasons for not treating with fibrinolysis included: clinical criteria in six out of nine patients (66%) and beyond the time window in three out of nine patients (33%). The mean "onset-to-hospital" time was 69 minutes, the mean time from admission to CT image was 33 minutes, the mean "door-to-needle" time was 82 minutes, and the mean "onset-to-needle" time was 150 minutes. Out of 61 medical professionals, 34 (56%) completed a questionnaire to evaluate the acceptability of the TeleStroke system. The mean values for each item were over 6.50, indicating that respondents positively evaluated each item. This survey was assessed using the Cronbach alpha test to determine the reliability of the questionnaire and the results obtained, giving a value of 0.97. CONCLUSIONS: The implementation of TeleStroke has made it possible for patients in the acute phase of stroke to receive effective treatment, something that was previously impossible because of the time required to transfer them to referral hospitals.

[Factors that affect time delays to fibrinolytic treatment in ischaemic stroke]. / Factores que influyen en la demora del tratamiento fibrinolitico en el ictus isquémico.

INTRODUCTION: Extending the thrombolytic therapy window in ischaemic stroke to 4.5 hours has proved to be useful and safe, but a prompt response remains a decisive factor. AIM: To analyse the factors that delay treatment. PATIENTS AND METHODS: After activating the Stroke Code procedure, the consecutive cases of stroke attended in the emergency department throughout the year 2006 were recorded; data included their clinical and epidemiological features, origin, means of transport and delay times in the process. RESULTS: Of the total number of patients with ischaemic stroke, 10.1% finished the emergency study with a median of 1 hour to decide to carry out treatment within 3 hours, and 13.1% of them between 3 and 4.5 hours, with a median of 2 hours and 6 minutes. For the analysis of all the variables, 498 patients were selected; 39% were admitted to hospital within the first 3 hours and 11.2% between 3 and 4.5 hours of the onset of symptoms. The use of the emergency telephone system, transport by mobile ICU or ambulance and an impaired level of consciousness, sight or, to a lesser extent, language or speech were related to shorter delay times. CONCLUSIONS: The factors that depended on the actual patient, in general, did not shorten the delay time. Clinical severity, the presence of informants and activating the emergency system shortened intervention times.

Factores que influyen en la demora del tratamiento fibrinolítico en el ictus isquémico / Factors that affect time delays to fibrinolytic treatment in ischaemic stroke

Introducción. Ampliar la ventana terapéutica trombolítica del ictus isquémico hasta las 4,5 horas se ha demostrado útil y seguro, pero la celeridad en la respuesta sigue siendo determinante. Objetivo. Analizar los factores que demoran el tratamiento. Pacientes y métodos. Tras activar el dispositivo Código Ictus, se registraron los casos consecutivos de ictus atendidos en urgencias durante el año 2006, sus características clínicas, epidemiológicas, procedencia, modo de traslado y demoras del proceso. Resultados. Del total de pacientes con ictus isquémico, el 10,1% concluyó el estudio de urgencias con una mediana de 1 hora para decidir tratar en las 3 horas y el 13,1%, entre las 3 y 4,5 horas con una mediana de 2 horas y 6 minutos. Para el análisis de todas las variables se seleccionó a 498 pacientes; el 39% ingresó en las primeras 3 horas y el 11,2% entre las 3 y 4,5 horas del inicio de los síntomas. El uso del sistema telefónico de emergencias, el traslado en UCI móvil o ambulancia y el déficit en el nivel de conciencia, visual o, en menor grado, del lenguaje o habla incidieron en una demora menor. Conclusiones. Los factores dependientes del propio paciente, en general, no disminuyeron la demora. La gravedad clínica, la presencia de informadores y la activación del sistema de emergencias acortaron los tiempos en las actuaciones (AU)

Introduction. Extending the thrombolytic therapy window in ischaemic stroke to 4.5 hours has proved to be useful and safe, but a prompt response remains a decisive factor. Aim. To analyse the factors that delay treatment. Patients and methods. After activating the Stroke Code procedure, the consecutive cases of stroke attended in the emergency department throughout the year 2006 were recorded; data included their clinical and epidemiological features, origin, means of transport and delay times in the process. Results. Of the total number of patients with ischaemic stroke, 10.1% finished the emergency study with a median of 1 hour to decide to carry out treatment within 3 hours, and 13.1% of them between 3 and 4.5 hours, with a median of 2 hours and 6 minutes. For the analysis of all the variables, 498 patients were selected; 39% were admitted to hospital within the first 3 hours and 11.2% between 3 and 4.5 hours of the onset of symptoms. The use of the emergency telephone system, transport by mobile ICU or ambulance and an impaired level of consciousness, sight or, to a lesser extent, language or speech were related to shorter delay times. Conclusions. The factors that depended on the actual patient, in general, did not shorten the delay time. Clinical severity, the presence of informants and activating the emergency system shortened intervention times (AU)

[False diagnoses of strokes in emergency departments]. / Falsos diagnósticos de ictus en los servicios de urgencias.

INTRODUCTION: Diagnosing a stroke can sometimes be difficult. There are a number of mimic conditions that can lead to false diagnoses. AIM: To examine false diagnoses of acute stroke. PATIENTS AND METHODS: We reviewed the medical histories with diagnoses of acute stroke -i.e. ischaemic or haemorrhagic stroke and transient ischaemic attack (TIA)- for a three-month period. Alternative diagnoses were established in doubtful stroke cases (without meeting the World Health Organisation stroke criteria). RESULTS: Altogether there were 358 patients: 110 TIA, 191 ischaemics and 57 haemorrhagics. In all, 65 false diagnoses were selected, which represented 18.2% of the total number (41.8% of the cases of TIA) and 31.8% of the strokes admitted in the emergency department. The subtypes of false diagnoses were: 46 TIA (70.8%), 18 ischaemics (27.7%) and one haemorrhagic (1.5%). The alternative diagnoses were the following: syncope/pre-syncope in 10.8% of cases (n = 7); confusional syndrome/disorientation in 21.5% (n = 14); lowered level of consciousness in 27.7% (n = 18); generalised weakness in 6.2% (n = 4); dizziness/vertigo in 3.1% (n = 2); isolated dysarthria in 10.8% (n = 7); epileptic seizure in 6.2% (n = 4); and others in 13.8% (n = 9). A total of 71.7% could be attributed to systemic causes. The mean age was 79 years and 64.6% were females (n = 42). Computerised tomography of the head was performed in 70.8% of the cases (n = 46). A neurologist assessed 7.7% of them (n = 5). The destination on being discharged was: primary care (53.3%), visit to neurology department (31.7%), visit internal medicine department (6.7%), hospitalisation in neurology department (1.7%), hospitalisation in other specialties (1.7%), transfer (1.7%) and death (3.3%). CONCLUSIONS: False diagnoses of cerebrovascular diseases are common. In emergency departments almost half of the diagnoses of TIA may be wrong. Most false diagnoses refer to TIA (70%) and occur in elderly patients, can be attributed to systemic causes, have not been assessed by a neurologist and are referred to primary care. Hospital stroke registries that include emergency patients may be overestimated, especially in the number of cases of TIA.

Falsos diagnósticos de ictus en los servicios de urgencias / False diagnoses of strokes in emergency departments

Introducción. El diagnóstico de ictus en ocasiones puede ser difícil. Existen numerosas condiciones simuladoras que pueden dar lugar a falsos diagnósticos. Objetivo. Estudiar falsos diagnósticos de ictus agudo. Pacientes y métodos. Revisamos las historias con diagnóstico de ictus agudo –isquémico, hemorrágico y accidente isquémico transitorio (AIT)– durante tres meses. Ante ictus dudosos (sin criterios de ictus según la Organización Mundial de la Salud) se establecieron diagnósticos alternativos. Resultados. El total fue de 358 pacientes: 110 AIT, 191 isquémicos y 57 hemorrágicos. Se seleccionaron 65 falsos diagnósticos, correspondientes al 18,2% del total (el 41,8% de los AIT) y al 31,8% de los ictus de alta en urgencias (el 46,4% de los AIT). Los subtipos de falsos diagnósticos fueron: 46 AIT (70,8%), 18 isquémicos (27,7%) y uno hemorrágico (1,5%). Los diagnósticos alternativos fueron: síncope/presíncope en el 10,8% de los casos (n = 7); síndrome confusional/desorientación en el 21,5% (n = 14); disminución del nivel de conciencia en el 27,7% (n = 18); debilidad generalizada en el 6,2% (n = 4); mareo/ vértigo en el 3,1% (n = 2); disartria aislada en el 10,8% (n = 7); crisis epiléptica en el 6,2% (n = 4); y otros en el 13,8% (n = 9). Fue atribuible a causas sistémicas el 71,7%. La edad media fue de 79 años y el 64,6% eran mujeres (n = 42). Se realizó tomografía computarizada craneal al 70,8% (n = 46). El 7,7% fue valorado por el neurólogo (n = 5). El destino en el momento del alta fue: atención primaria (53,3%), consultas de neurología (31,7%), consultas de medicina interna (6,7%), hospitalización en neurología (1,7%), hospitalización en otras especialidades (1,7%), traslado (1,7%) y fallecimiento (3,3%). Conclusiones. Los falsos diagnósticos de enfermedades cerebrovasculares son frecuentes. En los servicios de urgencias casi la mitad de diagnósticos de AIT pueden ser erróneos. La mayoría de los falsos diagnósticos corresponden a AIT (70%), son pacientes ancianos, atribuibles a causas sistémicas, no valorados por neurología y remitidos a atención primaria. Los registros hospitalarios de ictus que incluyen pacientes de urgencias pueden estar sobreestimados, principalmente los AIT (AU)

Introduction. Diagnosing a stroke can sometimes be difficult. There are a number of mimic conditions that can lead to false diagnoses. Aim. To examine false diagnoses of acute stroke. Patients and methods. We reviewed the medical histories with diagnoses of acute stroke –i.e. ischaemic or haemorrhagic stroke and transient ischaemic attack (TIA)– for a three-month period. Alternative diagnoses were established in doubtful stroke cases (without meeting the World Health Organisation stroke criteria). Results. Altogether there were 358 patients: 110 TIA, 191 ischaemics and 57 haemorrhagics. In all, 65 false diagnoses were selected, which represented 18.2% of the total number (41.8% of the cases of TIA) and 31.8% of the strokes admitted in the emergency department. The subtypes of false diagnoses were: 46 TIA (70.8%), 18 ischaemics (27.7%) and one haemorrhagic (1.5%). The alternative diagnoses were the following: syncope/pre-syncope in 10.8% of cases (n = 7); confusional syndrome/disorientation in 21.5% (n = 14); lowered level of consciousness in 27.7% (n = 18); generalised weakness in 6.2% (n = 4); dizziness/vertigo in 3.1% (n = 2); isolated dysarthria in 10.8% (n = 7); epileptic seizure in 6.2% (n = 4); and others in 13.8% (n = 9). A total of 71.7% could be attributed to systemic causes. The mean age was 79 years and 64.6% were females (n = 42). Computerised tomography of the head was performed in 70.8% of the cases (n = 46). A neurologist assessed 7.7% of them (n = 5). The destination on being discharged was: primary care (53.3%), visit to neurology department (31.7%), visit internal medicine department (6.7%), hospitalisation in neurology department (1.7%), hospitalisation in other specialties (1.7%), transfer (1.7%) and death (3.3%). Conclusions. False diagnoses of cerebrovascular diseases are common. In emergency departments almost half of the diagnoses of TIA may be wrong. Most false diagnoses refer to TIA (70%) and occur in elderly patients, can be attributed to systemic causes, have not been assessed by a neurologist and are referred to primary care. Hospital stroke registries that include emergency patients may be overestimated, especially in the number of cases of TIA (AU)

[Miller-Fisher syndrome: clinical features, associated infections and clinical course in 8 cases]. / Síndrome de Miller-Fisher: hallazgos clínicos, infecciones asociadas y evolución en 8 pacientes.

BACKGROUND AND OBJECTIVE: Miller-Fisher syndrome (MFS) is considered the most common variant of Guillain-Barré syndrome (GBS) and is characterized by the clinical triad of ophthalmoplegia, ataxia and areflexia. Respiratory involvement and relapses are unusual. Patients with MFS usually have a good recovery and no residual deficits. We describe the clinical features, associated infections and evolution in eight patients with MFS. PATIENTS AND METHOD: Eight cases of MFS and sixty-one of GBS were studied between 1994 and 2003. All cases showed the clinical triad of MFS without major limb weakness or other signs suggestive of CNS involvement. RESULTS: The proportion of MFS with respect to GBS during the same period was 13.1%. Four had a positive serology for Epstein-Barr virus, Salmonella enteritidis, Chlamydia pneumoniae and Mycoplasma pneumoniae. Our cases showed facial palsy (75%), dysphagia (75%), pupillary abnormalities (37.5%) and ventilation support (37.5%). Antiganglioside antibodies, determined in three cases (4 episodes), were positive [GQ1b (50%) and GD1b (50%)]. In all cases, there was a markedly reduced amplitude of the distal sensory as well as frequent axonal degeneration signs. The oldest three patients relapsed and required ventilation support. CONCLUSIONS: We report for the first time an association between S. enteritidis and C. pneumoniae and MFS. Older patients in our series suffered a faster disease progression with need of ventilation support. We conclude that an older age correlates with poor prognosis and relapses.

Síndrome de Miller-Fisher: hallazgos clínicos, infecciones asociadas y evolución en 8 pacientes / Miller-Fisher syndrome: clinical features, associated infections and evolution in 8 cases

FUNDAMENTO Y OBJETIVO: El síndrome de Miller-Fisher (SMF) se considera la variante más común del síndrome de Guillain-Barré, y se caracteriza por la tríada clínica oftalmoplejía, ataxia y arreflexia. La afección respiratoria y las recidivas son raras. Normalmente la recuperación es buena sin déficit residuales. El objetivo de este trabajo es describir los hallazgos clínicos, infecciones asociadas y evolución en 8 pacientes con SMF. PACIENTES Y MÉTODO: Entre 1994 y 2003 se estudió a 8 pacientes con SMF. Todos presentaron la tríada clínica característica, sin debilidad importante en los miembros ni otros signos indicativos de afección del sistema nervioso central. RESULTADOS: La proporción de SMF respecto al síndrome de Guillain-Barré en el mismo período fue del 13,1 por ciento. Cuatro presentaron serologías positivas para el virus de Epstein-Barr, Salmonella enteritidis, Chlamydia pneumoniae y Mycoplasma pneumoniae. Hubo parálisis facial en el 75 por ciento, disfagia en el 75 por ciento, anormalidades pupilares en un 37,5 por ciento y necesidad de soporte respiratorio en un 37,5 por ciento. La determinación de anticuerpos antigangliósidos se realizó en 3 casos (4 episodios), el 50 por ciento fue positivo para GQ1b y el 50 por ciento para GD1b. En todos los casos había una marcada reducción de la amplitud sensitiva distal y frecuentes signos de degeneración axonal. De los 6 casos tratados con inmunoglobulinas intravenosas, solamente un caso no respondió ni con éstas ni con plasmaféresis. Los 3 pacientes de mayor edad presentaron recidiva y precisaron de soporte ventilatorio. CONCLUSIONES: Se describe la asociación de S. enteritidis y C. pneumoniae con SMF. Los pacientes de mayor edad en nuestra serie sufrieron una progresión más rápida, presentaron degeneración axonal en los estudios electrofisiológicos y precisaron de soporte ventilatorio, de modo que una mayor edad se asoció a peor pronóstico y recidivas (AU)