Undiagnosed major risk factors in acute ischaemic stroke patients: frequency, profile, stroke mechanisms and outcome.

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.

[Evaluation of the Knowledge of Women of Childbearing Age with Epilepsy about the Impact of Their Disease in Contraception, Pregnancy and Breastfeeding: A Multicenter Cross-Sectional Study]. / Avaliação do Conhecimento das Mulheres com Epilepsia em Idade Fértil sobre o Impacto da sua Doença na Contraceção, Gravidez e Amamentação: Um Estudo Transversal Multicêntrico.

INTRODUCTION: The interaction of antiseizure medication with contraceptives, its potential teratogenicity and implications in pregnancy and breastfeeding are aspects to consider in the neurological care of women with epilepsy of childbearing age. To ensure the commitment in therapeutic decisions and the appropriate planning of maternity, it is essential that women are informed about the implications of their disease in these domains. The main aim of this study was to assess the knowledge of women of childbearing age with epilepsy concerning the impact of epilepsy in contraception, pregnancy and breastfeeding. As secondary aims we defined (1) the demographic, clinical and therapeutic characterization of this group of patients, (2) the identification of variables that correlated with the level of knowledge of women with epilepsy, and (3) the identification of preferential methods to acquire new knowledge about epilepsy. MATERIAL AND METHODS: The study was observational, cross-sectional and multicentric, and was carried out in five hospitals of the Lisbon metropolitan area. After identifying all women of childbearing age with epilepsy followed in the epilepsy clinic of each center, we applied an electronic questionnaire based on a non-systematic review of the literature. RESULTS: One hundred and fourteen participants were validated, with a median age of 33 years. Half of the participants were on monotherapy, and the majority had no seizures in the last six months. We identified important gaps in the participants' knowledge. Sections about complications and administration of antiseizure medication during pregnancy were the ones with the worst results. None of the clinical and demographic variables correlated with the final questionnaire score. Having had a previous pregnancy and the desire to breastfeed in a future pregnancy were positively correlated with the performance in breastfeeding section. Face-to-face discussion during medical outpatient visits was selected as the preferential method to learn about epilepsy, and the internet and social media were the least preferred ones. CONCLUSION: The knowledge of women of childbearing age with epilepsy in the Lisbon metropolitan area concerning the impact of epilepsy in contraception, pregnancy and breastfeeding seems to have significant gaps. Medical teams should consider engaging in patient education particularly during outpatient clinics.

Introdução: A interação dos fármacos anticrise epilética com os métodos contracetivos, a sua potencial teratogenicidade e as implicações na gravidez e amamentação são aspetos a considerar no acompanhamento de mulheres com epilepsia em idade fértil. Para o seu desejado envolvimento nas decisões terapêuticas e o adequado planeamento da maternidade, é essencial que as mulheres estejam corretamente informadas acerca das implicações da sua doença. O objetivo principal do presente estudo foi avaliar o conhecimento das mulheres com epilepsia em idade fértil sobre o impacto da epilepsia na contraceção, gravidez e amamentação. Como objetivos secundários definiram-se (1) a caracterização demográfica, clínica e terapêutica deste grupo de doentes, (2) a identificação de variáveis correlacionadas com o nível de conhecimento das mulheres com epilepsia, e (3) a identificação de meios e suportes preferenciais para aquisição de novos conhecimentos sobre epilepsia. Material e Métodos: O estudo foi observacional, transversal e multicêntrico, tendo decorrido em cinco centros hospitalares da região metropolitana de Lisboa. Após identificação das mulheres com epilepsia em idade fértil seguidas na Consulta de Epilepsia de cada centro, aplicou-se um questionário eletrónico construído após revisão não sistemática da literatura. Resultados: Foram validadas 114 participantes, com uma idade mediana de 33 anos. Metade das participantes apresentavam-se sob monoterapia, tendo a maioria a epilepsia controlada há pelo menos seis meses. Identificaram-se importantes lacunas no conhecimento das participantes. Conceitos sobre complicações dos fármacos anticrise epilética e a sua administração durante a gravidez motivaram piores resultados. Não houve correlação entre variáveis clinico-demográficas e o resultado no questionário. A ocorrência de gravidez prévia e o desejo de amamentar numa gravidez futura correlacionaram-se com o desempenho na secção sobre amamentação. A discussão oral na consulta foi a forma preferencial para aquisição de novos conhecimentos sobre epilepsia, tendo a internet e as redes sociais sido os meios menos escolhidos. Conclusão: O conhecimento das mulheres com epilepsia em idade fértil na área metropolitana de Lisboa sobre o impacto da sua doença na contraceção, gravidez e amamentação parece apresentar lacunas importantes. A educação para a saúde deste grupo deverá constituir uma preocupação por parte das equipas médicas, devendo privilegiar-se a consulta como local de ensino.

Characterization of persistent headache attributed to past stroke.

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.

ANTECEDENTES: A cefaleia persistente atribuída a acidente vascular cerebral (AVC) prévio é uma entidade controversa, recentemente incluída na terceira edição da Classificação Internacional de Transtornos da Cefaleia (International Classification of Headache Disorders, ICHD-3), apesar de descrita apenas em estudos restrospectivos. OBJETIVO: Determinar a frequência e as características do acidente vascular cerebral prèvio em doentes admitidos com AVC agudo. MéTODOS: Selecionamos todos os doentes com cefaleia associada a AVC agudo de um registro unicêntrico e prospectivo de doentes admitidos no serviço de Neurologia entre novembro de 2018 e dezembro de 2019. Analisamos dados demográficos, clínicos e imagiológicos. Reavaliamos aos 6 a 12 meses por questionário telefónico. RESULTADOS: Entre os 121 doentes admitidos com AVC agudo, apenas 29 (24,0%) tinham cefaleia associada a AVC agudo. Destes, 6 (5,0%) perderam-se no seguimento. Ao todo, 23 (20,0%) responderam ao questionário e foram incluídos. A idade mediana foi de 53 anos (intervalo interquartílico [IIQ]: 38­78 anos), e não houve predominância de gênero. Dos 10 doentes (8,3%) que apresentam cefaleia persistente, 8 (6,6%) tinham histórico de cefaleia; no entanto todos mencionaram um tipo diferente de cefaleia, e 1 (0,8%) provavelmente tinha cefaleia secundária a medicação. CONCLUSõES: Neste estudo, apenas 10 em 121 doentes (8,3%) mencionaram cefaleia persistente aos 6 a 12 meses de seguimento, mas a maioria sofria de cefaleia prévia, pelo que a real prevalência de acidente vascular cerebral prèvio pode ser inferior à descrita nos estudos realizados até a data.

Characterization of persistent headache attributed to past stroke / Caracterização da cefaleia persistente atribuída a acidente vascular cerebral prévio

Abstract 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.

Resumo Antecedentes A cefaleia persistente atribuída a acidente vascular cerebral (AVC) prévio é uma entidade controversa, recentemente incluída na terceira edição da Classificação Internacional de Transtornos da Cefaleia (International Classification of Headache Disorders, ICHD-3), apesar de descrita apenas em estudos restrospectivos. Objetivo Determinar a frequência e as características do acidente vascular cerebral prèvio em doentes admitidos com AVC agudo. Métodos Selecionamos todos os doentes com cefaleia associada a AVC agudo de um registro unicêntrico e prospectivo de doentes admitidos no serviço de Neurologia entre novembro de 2018 e dezembro de 2019. Analisamos dados demográficos, clínicos e imagiológicos. Reavaliamos aos 6 a 12 meses por questionário telefónico. Resultados Entre os 121 doentes admitidos com AVC agudo, apenas 29 (24,0%) tinham cefaleia associada a AVC agudo. Destes, 6 (5,0%) perderam-se no seguimento. Ao todo, 23 (20,0%) responderam ao questionário e foram incluídos. A idade mediana foi de 53 anos (intervalo interquartílico [IIQ]: 38-78 anos), e não houve predominância de gênero. Dos 10 doentes (8,3%) que apresentam cefaleia persistente, 8 (6,6%) tinham histórico de cefaleia; no entanto todos mencionaram um tipo diferente de cefaleia, e 1 (0,8%) provavelmente tinha cefaleia secundária a medicação. Conclusões Neste estudo, apenas 10 em 121 doentes (8,3%) mencionaram cefaleia persistente aos 6 a 12 meses de seguimento, mas a maioria sofria de cefaleia prévia, pelo que a real prevalência de acidente vascular cerebral prèvio pode ser inferior à descrita nos estudos realizados até a data.

Progressive Multifocal Leukoencephalopathy Associated With Idiopathic CD8+ Lymphocytopenia.

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.

Opinions, beliefs and knowledge of people with multiple sclerosis on COVID-19 pandemic and vaccine.

BACKGROUND: Considering the potential COVID-19 impact on pwMS health and the importance of vaccination for this population, we decided to assess: (a) pwMS' beliefs and knowledge on COVID-19 pandemic; (b) their acceptance towards COVID-19 vaccination and (c) pwMS' opinions on general vaccination. METHODS: Observational study, based on a cross-sectional (10-20th September 2020) online survey, conducted in a cohort of pwMS' followed at two Portuguese hospitals. The survey included measures to characterize the sample and a questionnaire designed to assess the topics defined for this study. RESULTS: 270 respondents completed the full survey (response rate 58.2%). pwMS greatest concern during the pandemic was an aggravation of MS, especially by patients older than 50 years old. Almost 40% of the patients older than 50 felt that the pandemic negatively affected their MS related medical assistance. Most patients believed they would recover from COVID-19 infection. More than half of the responders feared a MS aggravation if they got COVID-19; this was more pronounced in patients with progressive MS. About 12% of the participants did not want to be vaccinated and almost 40% was unsure. Regarding vaccines in general, almost a third of the participants feared their side effects or MS related complications. CONCLUSION: Having knowledge of pwMS' opinions on COVID-19 pandemic impact and vaccination is useful to better address these issues. Fears and expectations towards vaccination must be discussed with pwMS.

Stiff person spectrum disorders: An illustrative case series of their phenotypic and antibody diversity.

Stiff person spectrum disorders (SPSD) are a broad group of immune-mediated disorders. Clinical presentations include classical stiff person syndrome (SPS), focal SPS, and progressive encephalomyelitis with rigidity and myoclonus (PERM). The most frequently associated antibodies are anti-GAD65, anti-GlyR, anti-amphiphysin, and anti-DPPX. Immunotherapy is the primary treatment modality. We present an illustrative case series of three patients: anti-GlyR antibody-mediated PERM presenting as rapidly progressive dementia; anti-amphiphysin antibody-mediated SPS; and SPS presentation with anti-Zic4 antibodies, spasmodic laryngeal stridor and fluctuating eyelid ptosis. Clinical characteristics, CSF findings, neurophysiological features, adequate immunological assays and a high suspicion index are essential for prompt diagnosis and management.

Immediate effects of an anchor system on the stability limit of individuals with chronic dizziness of peripheral vestibular origin.

INTRODUCTION: The symptoms associated with chronic peripheral vestibulopathy exert a negative impact on the independence and quality of life of these individuals, and many individuals continue to suffer from these symptoms even after conventional vestibular rehabilitation. OBJECTIVE: To evaluate the acute effect of an anchor system for balance evaluation of patients with chronic dizziness who failed to respond to traditional vestibular rehabilitation. METHODS: Subjects over 50 years of age, presenting with chronic dizziness and postural instability of peripheral vestibular origin, participated in the study. The limit of stability was evaluated in three positions using the Balance Master® system: Position 1, standing with the arms along the body; Position 2, standing with the elbows bent at 90° (simulating holding the anchors); and Position 3, with the elbows bent at 90° holding the anchors. The variables of movement latency, endpoint excursion and directional control of movement were evaluated. RESULTS: Using the anchor system, significant reduction of time in the response at the beginning of the movement compared to Position 1 (p<0.05); increased endpoint excursion in the left lateral direction compared to Position 1 (p<0.05); and more directional control of movement in the anterior and posterior directions (p<0.05) compared to the other positions, were found. CONCLUSION: While using the system anchor, individuals with chronic peripheral vestibulopathy showed an immediate improvement in the stability limit in relation to the movement latency, endpoint excursion, and directional control of movement variables, suggesting that the haptic information aids postural control.

Consensus of the Brazilian Society of Infectious Diseases and Brazilian Society of Clinical Oncology on the management and treatment of Kaposi's sarcoma

Kaposi's sarcoma is a multifocal vascular lesion of low-grade potential that is most often present in mucocutaneous sites and usually also affects lymph nodes and visceral organs. The condition may manifest through purplish lesions, flat or raised with an irregular shape, gastrointestinal bleeding due to lesions located in the digestive system, and dyspnea and hemoptysis associated with pulmonary lesions. In the early 1980s, the appearance of several cases of Kaposi's sarcoma in homosexual men was the first alarm about a newly identified epidemic, acquired immunodeficiency syndrome. In 1994, it was finally demonstrated that the presence of a herpes virus associated with Kaposi's sarcoma called HHV-8 or Kaposi's sarcoma herpes virus and its genetic sequence was rapidly deciphered. The prevalence of this virus is very high (about 50%) in some African populations, but stands between 2% and 8% for the entire world population. Kaposi's sarcoma only develops when the immune system is depressed, as in acquired immunodeficiency syndrome, which appears to be associated with a specific variant of the Kaposi's sarcoma herpes virus. There are no treatment guidelines for Kaposi's sarcoma established in Brazil, and thus the Brazilian Society of Clinical Oncology and the Brazilian Society of Infectious Diseases developed the treatment consensus presented here.

Consensus of the Brazilian Society of Infectious Diseases and Brazilian Society of Clinical Oncology on the management and treatment of Kaposi's sarcoma.

Kaposi's sarcoma is a multifocal vascular lesion of low-grade potential that is most often present in mucocutaneous sites and usually also affects lymph nodes and visceral organs. The condition may manifest through purplish lesions, flat or raised with an irregular shape, gastrointestinal bleeding due to lesions located in the digestive system, and dyspnea and hemoptysis associated with pulmonary lesions. In the early 1980s, the appearance of several cases of Kaposi's sarcoma in homosexual men was the first alarm about a newly identified epidemic, acquired immunodeficiency syndrome. In 1994, it was finally demonstrated that the presence of a herpes virus associated with Kaposi's sarcoma called HHV-8 or Kaposi's sarcoma herpes virus and its genetic sequence was rapidly deciphered. The prevalence of this virus is very high (about 50%) in some African populations, but stands between 2% and 8% for the entire world population. Kaposi's sarcoma only develops when the immune system is depressed, as in acquired immunodeficiency syndrome, which appears to be associated with a specific variant of the Kaposi's sarcoma herpes virus. There are no treatment guidelines for Kaposi's sarcoma established in Brazil, and thus the Brazilian Society of Clinical Oncology and the Brazilian Society of Infectious Diseases developed the treatment consensus presented here.

Avaliação de combinações de técnicas alternativas de construção e montagem de blocos de tissue microarray / Evaluation of alternative technique combinations of building and preparation of tissue microarrays blocks

INTRODUÇÃO E OBJETIVOS: O objetivo deste estudo foi pesquisar diferentes métodos alternativos de tissue microarray (TMA) à técnica original e conduzir adaptações desses, combinando diferentes métodos de punção das amostras teciduais e de montagem dos blocos de TMA, de modo a introduzir no Laboratório de Patologia Bucal da Faculdade de Odontologia de Pernambuco da Universidade de Pernambuco (LPBFOP/UPE) técnicas de TMA facilmente operáveis, reproduzíveis e de baixo custo. RESULTADOS: Foram reproduzidas quatro técnicas de punção dos blocos doadores e duas de montagem dos blocos de TMA, resultando em oito combinações possíveis. Para cada combinação, foram confeccionados três blocos de TMA, contendo nove, 16 e 32 amostras, respectivamente, e avaliadas quanto a perda de amostras, custo, tempo de confecção e dificuldade. Para blocos com nove amostras, a combinação 2 mostrou-se a mais adequada; para blocos com 16, a combinação 6 foi constatada como a mais eficiente; e para blocos com 32, a combinação 1 apresentou o melhor custo-benefício. CONCLUSÃO: Foi concluído que a escolha da combinação a ser utilizada depende do número de amostras a serem colocadas nos blocos de TMA.

INTRODUCTION AND OBJECTIVES: The aim of this study was to investigate different alternative tissue microarray (TMA) techniques and to make adaptations, combining different tissue punch and TMA block construction techniques in order to introduce easily reproducible, operational and cost effective TMA techniques in the Oral Pathology Laboratory of Pernambuco College of Dentistry, State University of Pernambuco. METHODS: Four donor punch techniques and two TMA block construction techniques were performed, resulting in a total of eight possible combinations. For each combination three TMA blocks were made, containing 9, 16 and 32 samples, respectively. They were evaluated as to sample loss, cost effectiveness, construction time and difficulty. RESULTS: For blocks with 9 samples, combination 2 was the most appropriate; for blocks with 16, combination 6 was the most efficient; and for blocks with 32, combination 1 was the most cost effective. CONCLUSION: It was concluded that the combination choice depends on the number of samples to be put in TMA blocks.

Lesöes gástricas na hipertensäo portal: gastrite e/ou gastropatia congestiva / Gastric lesions in portal hypertension: gastritis and/or congestive gastropathy

Pacientes com hipertensäo portal apresentam com frequência alteraçöes na mucosa gástrica. Essas lesöes, do ponto de vista histológico, podem ter características de processo congestivo e/ou inflamatório. Os autores estudaram 37 pacientes entre esquistossomóticos e cirróticos. A mucosa gástrica mostrou alteraçöes histológicas em 91,8 por cento. Dos 34 pacientes que tinham alteraçäo, 13 (38,2 ppor cento) apresentaram gastropatia da hipertensäo portal, 15 (44,1 por cento), gastrite, e 6 (17,6 por cento), os dois tipos de lesäo. O H pylori estava presente em todos os casos com diagnóstico histológico de gastrite e ausente nos de gastropatia. O exame histopatológico foi essencial para a definiçäo das alteraçöes gástricas na hipertensäo pportal