Study of hemostatic biomarkers in acute ischemic stroke by clinical subtype.

BACKGROUND: We studied the usefulness of hemostatic biomarkers in assessing the pathology of thrombus formation, subtype diagnosis, prognosis in the acute phase of cerebral infarction, and differences between various hemostatic biomarkers. METHODS: Our study included 69 patients with acute cerebral infarction who had been hospitalized within 2 days of stroke onset. Fibrin monomer complex (FMC), soluble fibrin (SF), D-dimer, thrombin-antithrombin III complex, fibrinogen, antithrombin III, and fibrin/fibrinogen degradation products (FDPs) were assayed as hemostatic biomarkers on days 1, 2, 3, and 7 of hospitalization. RESULTS: In the cardioembolic (CE) stroke group, FMC and SF levels were significantly higher on days 1 and 2 of hospitalization, and D-dimer levels were significantly higher on day 1 of hospitalization, compared to the noncardioembolic (non-CE) stroke group. FDP levels were significantly higher at all times in the CE group compared to the non-CE group. Neither the National Institute of Health Stroke Scale (NIHSS) used during hospitalization nor the modified Rankin Scale (mRS) used at discharge found any significant correlations to hemostatic biomarkers, but the NIHSS score during hospitalization was significantly higher in the CE group than in the non-CE group. CONCLUSIONS: Measurements of hemostatic biomarkers, such as FMC, SF, and D-dimer on the early stage of cerebral infarction are useful for distinguishing between CE and non-CE stroke.

Community-acquired pneumonia distinguished from influenza infection based on clinical signs and symptoms during a novel (swine) influenza A/H1N1 pandemic.

AIMS: The numbers of patients with influenza-like illnesses increase during influenza outbreaks. A study was undertaken to distinguish community-acquired pneumonia (CAP) from influenza based on clinical signs and symptoms. METHODS: This retrospective study investigated patients with positive results in the rapid influenza antigen test and those diagnosed with CAP during an influenza A/H1N1 pandemic. Significant factors for predicting risk for CAP within 48 hrs from onset and at diagnosis were selected by multiple regression analysis. RESULTS: Within 48 hrs of onset and at diagnosis, age and coarse crackles significantly increased the risk of CAP whereas sick contact, sore throat, and rhinorrhoea significantly decreased the risk of CAP. Duration of illness, sputum, dyspnoea, chest pain, and coarse crackles also significantly increased the risk of CAP at diagnosis. CONCLUSIONS: CAP differed somewhat from influenza even within 48 hrs of onset and the differences became even more evident thereafter.

Predictors of poor outcome in patients with acute cerebral infarction.

BACKGROUND AND PURPOSE: Plasma D-dimer levels are elevated during the acute phase of cerebral infarction (CI). We investigated whether the D-dimer level on admission and other clinical characteristics could be used to predict the poor outcome of patients with acute CI. METHODS: The clinical characteristics and plasma D-dimer levels measured within 3 days of onset were compared according to outcome among patients with acute CI. RESULTS: In total, 359 consecutive patients (mean age, 71.8 years) were examined, of which 174 had a poor outcome [score on the modified Rankin scale (mRS) ≥3] at 30 days after hospitalization. The mean mRS score was higher and a poor outcome was observed more frequently among women than among men (p<0.001 for each). The proportions of women, cardioembolism, atrial fibrillation, advanced age (≥75 years), prior history of CI or transient ischemic attack, and elevated D-dimer level (≥1.0 µg/mL) were significantly higher among patients with a poor outcome than among those with a good outcome. A multivariate analysis showed that elevated D-dimer level [≥1.0 µg/mL; odds ratio (OR), 2.45; 95% confidence interval (95% CI), 1.52-3.89; p<0.01], advanced age (OR, 1.93; 95% CI, 1.21-3.07; p<0.01), and female gender (OR, 1.75; 95% CI, 1.08-2.83; p=0.02) were independent predictors of a poor outcome. CONCLUSIONS: Certain clinical characteristics (gender and advanced age) and an elevated D-dimer level upon admission can be used to predict the outcome of patients with acute CI at 30 days after hospitalization.

Significance of the progression of respiratory symptoms for predicting community-acquired pneumonia in general practice.

BACKGROUND AND OBJECTIVE: Early diagnosis improves outcomes in patients with community-acquired pneumonia (CAP). However, prediction of CAP based on symptoms and signs is difficult. The present study investigated the evaluation of progression of symptoms as a factor for predicting the occurrence of CAP in general practice. METHODS: Consecutive patients (n = 406) suspected of having CAP on routine clinical examination were studied retrospectively. Selection of patients with suspected CAP was based on progression of symptoms after 5 days, as well as published criteria. Diagnostic yields for the recommended criteria and our proposed criteria were then compared. Scoring systems for the prediction of CAP were designed, based on the results of multiple regression analysis. The diagnostic performance of these systems, including or excluding symptom progression, was compared using the areas under receiver operating characteristic curves. RESULTS: The sensitivity and specificity of the recommended criteria and our proposed criteria were 0.75 and 0.44, and 0.93 and 0.38, respectively. Sputum production, dyspnoea, fever > 38 degrees C, heart rate > 100 beats/min, decreased breath sounds, coarse crackles and progression of symptoms significantly increased the likelihood of CAP. Areas under receiver operating characteristic curves analysis showed that the diagnostic prediction of CAP was significantly improved when the scoring system included progression of symptoms. CONCLUSIONS: Progression of symptoms was a significant factor for predicting CAP and selecting patients who required CXR. Inclusion of progression of symptoms among the other recommended criteria, namely, dyspnoea, fever > 38 degrees C, heart rate > 100 beats/min and abnormal chest findings, improved prediction of the incidence of CAP in general practice.

[Case of branch atheromatous disease presenting capsular warning syndrome].

We report a case of branch atheromatous disease (BAD) presenting capsular warning syndrome, who subsequently showed a complete recovery by the combination therapy as described below. A 54-year-old man with untreated hypertension was admitted to our hospital because of dysarthria and right hemiplegia. The NIHSS on admission was 12 points, but his symptoms soon completely disappeared during examination. After admission administration of aspirin, heparin, atorvastatin and t-PA were started, but stereotyped episodes of dysarthria and the right hemiplegia occurred repeatedly. We added plasma expander, and he thereafter revealed no further ischemic episodes at 22 hours from admission. Over all, he had 15 times of transient ischemic attack with no lasting deficit. The DWI scan obtained 5 hours after the onset demonstrated a high-intensity region in the left putamen to corona radiata. MRA showed no significant abnormalities. He had been diagnosed as having branch atheromatous disease with capsular warning syndrome. The present case suggests that combination therapy including t-PA and plasma expander may be effective to BAD presenting capsular warning syndrome.

[Two cases of cardioembolic stroke with stepwise progression].

We reported two patients of cardioembolic stroke with stepwise progression. Magnetic resonance angiography (MRA) or computed tomographic angiography (CTA) showed narrowing of the middle cerebral artery (MCA) in both patients at the acute phase of onset. Case 1 was classified as "undetermined" based on the TOAST classification although his electrocardiogram revealed atrial fibrillation. Case 2 was classified as "large artery atherosclerosis" with no evidence of cardioembolic source at the acute phase of onset. Follow-up MRA was performed at seventeen days after the onset in case 1 and ten days after the onset in case 2 respectively, which showed complete recanalization of the MCA in each case. The presence of cardioembolic source was also detected in both patients at that time, resulting in the final diagnosis of cardioembolic stroke. Cardioembolic stroke may occasionally present in a stepwise manner suggesting a thrombotic process. When MRA shows stenosis or occlusion of the arteries supplying the cortical areas at the acute phase of onset, it is advisable to examine recanalization of these arteries by follow-up MRA with simultaneous efforts to find out the possible embolic source.