Exploring the Chagas disease-Stroke 'Connection': Findings from a Large Multicenter Study.

INTRODUCTION: Strokes are traditionally attributed to risk factors like aging, hypertension, diabetes, and atherosclerosis. Chagas disease has emerged as an important risk factor for stroke in Latin American. Our study aims at describing the largest cohort of patients with Chagas disease and ischemic stroke and determining variables associated with stroke recurrence and cardioembolic cause. METHODS: This study is the result of a national multicenter cohort study conducted in Brazil. The study spanned from January 2009 to December 2016 and involved a comprehensive retrospective analysis of medical records of patients with both Chagas disease and stroke. This cohort comprised 499 individuals from diverse Brazilian regions, focusing on vascular risk factors and the epidemiological variables associated with Chagas disease and stroke. RESULTS: Our findings underscore the significant prevalence of traditional vascular risk factors among Chagas disease patients who had stroke. 81% of patients had hypertension, 56% dyslipidemia and 25% diabetes. We observed a 29.7% recurrence rate, especially within the cardioembolic subgroup. 56% of the patients had embolic stroke of undetermined source (ESUS). Specific EKG abnormalities were associated with an increased risk of cardioembolic etiology (with three altered results increasing 81fold the chance of the stroke being of cardioembolic nature). Age emerged as a protective factor (OR:0.98, CI 0.970 - 0.997) against cardioembolic etiology. Anticoagulation therapy was associated with reduced risk (OR:0.221 |CI 0.104 - 0.472), highlighting the importance of accurate etiological classification. Conversely, female gender(OR:1.83 CI 1.039 - 3.249) emerged as a significant risk factor for stroke recurrence. CONCLUSION: This study significantly advances our epidemiological understanding of the intersection between Chagas disease and stroke. It emphasizes the critical need for extensive epidemiological investigations, a deeper comprehension of stroke recurrence determinants, and accurate etiological classification to reduce the ESUS population. Our findings have substantial clinical implications, suggesting the need of control of vascular risk factors and comorbidities and hold promise for improving patient care and reducing the burden of Chagas disease and stroke worldwide.

Reperfusion therapy for acute ischemic stroke: where are we in 2023?

Over the last three decades, stroke care has undergone significant transformations mainly driven by the introduction of reperfusion therapy and the organization of systems of care. Patients receiving treatment through a well-structured stroke service have a much higher chance of favorable outcomes, thereby decreasing both disability and mortality. In this article, we reviewed the scientific evidence for stroke reperfusion therapy, including thrombolysis and thrombectomy, and its implementation in the public health system in Brazil.

Nas últimas três décadas, o tratamento do AVC sofreu transformações significativas, impulsionadas principalmente pela introdução das terapias de reperfusão e pela organização dos serviços de AVC. Os pacientes que recebem tratamento em um serviço de AVC bem estruturado têm uma probabilidade muito maior de resultados favoráveis, diminuindo assim a incapacidade funcional e a mortalidade. Neste artigo, revisamos as evidências científicas para as terapias de reperfusão do AVC, incluindo trombólise e trombectomia e sua implementação no sistema público de saúde no Brasil.

Measurement Properties of Clinical Instruments for Assessing Manual Wheelchair Mobility in Individuals With Spinal Cord Injury: Systematic Review.

OBJECTIVE: To evaluate the measurement properties of clinical instruments used to assess manual wheelchair mobility in individuals with spinal cord injury (SCI). DATA SOURCES: This systematic review was conducted according to the Consensus-Based Standards for the Selection of Health Measurement Instruments guidance and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The search was conducted up to December 2021 on MEDLINE/PubMed, Cochrane Central Register of Controlled Trials, Web of Science, Biblioteca Regional de Medicina, and Cumulative Index to Nursing and Allied Health databases without time restriction. STUDY SELECTION: Peer-reviewed original research articles that examined any clinical wheelchair mobility and/or skill assessment instrument among adults with SCI and reported data on at least one measurement property or described the development procedure were evaluated independently by two reviewers. DATA EXTRACTION: Data were independently extracted according to Consensus-Based Standards for the Selection of Health Measurement Instruments methodology. Measurement property results from each study were independently rated by two reviewers as sufficient, insufficient, indeterminate, or inconsistent. The evidence for each measurement property was rated as high, moderate, low, or very low (Grading of Recommendations, Assessment, Development, and Evaluation). Recommendations for highly-rated instruments were performed. DATA SYNTHESIS: Twenty-nine studies with 21 instruments were identified. The methodological quality of studies ranged from insufficient to sufficient, and the quality of evidence ranged from very low to high. Six instruments reported content validity. Reliability and construct validity were the most studied measurement properties. Structural validity and invariance for cross-cultural measurement were not reported. The highly rated instruments were the Wheelchair Outcome Measure and Wheelchair Skills Test Questionnaire. CONCLUSIONS: Although numerous instruments for assessing wheelchair mobility and/or skills among individuals with SCI were identified, not many measurement properties have been sufficiently established. The Wheelchair Outcome Measure and Wheelchair Skills Test Questionnaire show the current best potential to be recommended for clinical and research use. Further studies are needed to strengthen or change these recommendations.

Trends in Intensive Care Admissions and Outcomes of Stroke Patients Over 10 Years in Brazil: Impact of the COVID-19 Pandemic.

BACKGROUND: The coronavirus 2019 (COVID-19) pandemic affected stroke care worldwide. Data from low- and middle-income countries are limited. RESEARCH QUESTION: What was the impact of the pandemic in ICU admissions and outcomes of patients with stroke, in comparison with trends over the last 10 years? STUDY DESIGN AND METHODS: Retrospective cohort study including prospectively collected data from 165 ICUs in Brazil between 2011 and 2020. We analyzed clinical characteristics and mortality over a period of 10 years and evaluated the impact of the pandemic on stroke outcomes, using the following approach: analyses of admissions for ischemic and hemorrhagic strokes and trends in in-hospital mortality over 10 years; analysis of variable life-adjusted display (VLAD) during 2020; and a mixed-effects multivariable logistic regression model. RESULTS: A total of 17,115 stroke admissions were analyzed, from which 13,634 were ischemic and 3,481 were hemorrhagic. In-hospital mortality was lower after ischemic stroke as compared with hemorrhagic (9% vs 24%, respectively). Changes in VLAD across epidemiological weeks of 2020 showed that the rise in COVID-19 cases was accompanied by increased mortality, mainly after ischemic stroke. In logistic regression mixed models, mortality was higher in 2020 compared with 2019, 2018, and 2017 in patients with ischemic stroke, namely, in those without altered mental status. In hemorrhagic stroke, the increased mortality in 2020 was observed in patients 50 years of age or younger, as compared with 2019. INTERPRETATION: Hospital outcomes of stroke admissions worsened during the COVID-19 pandemic, interrupting a trend of improvements in survival rates over 10 years. This effect was more pronounced during the surge of COVID-19 ICU admissions affecting predominantly patients with ischemic stroke without coma, and young patients with hemorrhagic stroke.

Economic impact of pharmaceutical services on polymedicated patients: A systematic review.

BACKGROUND: Polypharmacy is commonly related to poor drug adherence, decreased quality of life and inappropriate prescribing in eldery. Furthermore, this condition also leads to a higher utilization of health services resources, due to the increased risk of adverse drug events, length of stays in hospitals and readmissions rates after discharge. OBJECTIVE: This Systematic Review aimed to synthesize the current evidence that evaluates pharmaceutical services on polymedicated patients, from an economic perspective. METHODS: Systematic searches were conducted in MEDLINE, SCOPUS and Cochrane Library databases to identify studies that were published until January 2021. Experimental and observational studies were included in this review, using strict inclusion/exclusion criteria and were assessed for quality using the following tools: RoB and ROBINS-I. Two independent reviewers selected the articles and extracted the data. RESULTS: 3,662 articles were retrieved from the databases. After the screening, 18 studies were included: 9 experimental and 9 observational studies. The studies reported that the integration of the pharmacist as a member of the healthcare team provides an optimized use of pharmacotherapy to polymedicated patients and contributes to health promotion, providing reduction of spending on medication, reduction of expenses related to emergency care and hospitalizations and other medical expenses. The ECRs made cost-effectiveness or cost-benefit analysis, and most of the Non Randomized studies had statistically significant cost savings even considering the expenses of pharmaceutical assistance. Experimental studies reported a cost reduction varying between US$ 193 to US$ 4,966 per patient per year. Furthermore, observational studies estimated a cost reduction of varying from US$ 3 to US$ 2,505 per patient per year. The cost savings are related to decrease in emergency visits and hospitalizations, through pharmacist intervention (medication review and pharmacotherapy follow-up). CONCLUSIONS: Considering the set of studies included, pharmaceutical care services directed to polymedicated patients may cooperate to save financial resources. Most of the interventions showed positive economic trends and also contributed to improving clinical parameters and quality of life. However, due to the majority of the studies having exploratory or qualitative methodology, it is essential to carry out more robust studies, based on full economic evaluation.

Distance sampling surveys reveal 17 million vertebrates directly killed by the 2020's wildfires in the Pantanal, Brazil.

Anthropogenic factors have significantly influenced the frequency, duration, and intensity of meteorological drought in many regions of the globe, and the increased frequency of wildfires is among the most visible consequences of human-induced climate change. Despite the fire role in determining biodiversity outcomes in different ecosystems, wildfires can cause negative impacts on wildlife. We conducted ground surveys along line transects to estimate the first-order impact of the 2020 wildfires on vertebrates in the Pantanal wetland, Brazil. We adopted the distance sampling technique to estimate the densities and the number of dead vertebrates in the 39,030 square kilometers affected by fire. Our estimates indicate that at least 16.952 million vertebrates were killed immediately by the fires in the Pantanal, demonstrating the impact of such an event in wet savanna ecosystems. The Pantanal case also reminds us that the cumulative impact of widespread burning would be catastrophic, as fire recurrence may lead to the impoverishment of ecosystems and the disruption of their functioning. To overcome this unsustainable scenario, it is necessary to establish proper biomass fuel management to avoid cumulative impacts caused by fire over biodiversity and ecosystem services.

Clinical and radiological features of severe acute respiratory syndrome coronavirus 2 meningo-encephalitis.

BACKGROUND AND PURPOSE: This case illustrates for the first time the clinical and radiological evolution of SARS-CoV-2 meningo-encephalitis. METHODS: A case of a SARS-CoV-2 meningo-encephalitis is reported. RESULTS: A 65-year-old man with COVID-19 presenting with meningo-encephalitis without respiratory involvement is described. He had fever, diarrhea and vomiting, followed by diplopia, urinary retention and sleepiness. Examination disclosed a convergence strabismus and ataxia. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis, oligoclonal bands and increased interleukin 6 level. SARS-CoV-2 was detected in the CSF through reverse transcriptase polymerase chain reaction, but not in nasopharyngeal, tracheal secretion and rectal samples. Brain magnetic resonance imaging showed lesions on white matter hemispheres, the body and splenium of the corpus callosum and resembling the projection of corticospinal tract, remarkably on cerebellar peduncles. CONCLUSIONS: This demonstrates the challenges in diagnosing COVID-19 in patients with neurological presentations.

Artificial Inteligence-Based Decision for the Prediction of Cardioembolism in Patients with Chagas Disease and Ischemic Stroke.

BACKGROUND: Chagas disease (CD) and ischemic stroke (IS) have a close, but poorly understood, association. There is paucity of evidence on the ideal secondary prophylaxis and etiological determination, with few cardioembolic patients being identified. AIMS: This study aimed to describe a multicenter cohort of patients with concomitant CD and IS admitted in tertiary centers and to create a predictive model for cardioembolic embolism in CD and IS. MATERIALS AND METHODS: We retrospectively studied data obtained from electronic medical and regular medical records of patients with CD and IS in several academic, hospital-based, and university hospitals across Brazil. Descriptive analyses of cardioembolic and non-cardioembolic patients were performed. A prediction model for cardioembolism was proposed with 70% of the sample as the derivation sample, and the model was validated in 30% of the sample. RESULTS: A total of 499 patients were analyzed. The median age was similar in both groups; however, patients with cardioembolic embolism were younger and tended to have higher alcoholism, smoking, and death rates. The predictive model for the etiological classification showed close relation with the number of abnormalities detected on echocardiography and electrocardiography as well as with vascular risk factors. CONCLUSIONS: Our results replicate in part those previously published, with a higher prevalence of vascular risk factors and lower median age in patients with cardioembolic etiology. Our new model for predicting cardioembolic etiology can help identify patients with higher recurrence rate and therefore allow an optimized strategy for secondary prophylaxis.

Stroke Care during the COVID-19 Pandemic: International Expert Panel Review.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions. SUMMARY: The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.

Randomization of endovascular treatment with stent-retriever and/or thromboaspiration versus best medical therapy in acute ischemic stroke due to large vessel occlusion trial: Rationale and design.

BACKGROUND: RESILIENT is a prospective, multicenter, randomized phase III trial to test the safety, efficacy, and cost-effectiveness of mechanical thrombectomy as compared to medical treatment alone in patients treated under the less than ideal conditions typically found in the public healthcare system of a developing country. METHODS: Subjects must fulfill the following main inclusion criteria: symptom onset ≤8 h, age ≥18 years, baseline NIHSS ≥8, evidence of intracranial ICA or proximal MCA (M1 segment) occlusion, ASPECTS ≥6 on CT or >5 on DWI-MRI and be either ineligible for or unresponsive to intravenous alteplase. The primary end-point is the distribution of disability levels (on the modified Rankin Scale, mRS) at 90 days under the intention-to-treat principle. RANDOMIZATION: Randomization is performed under a minimization process using age, baseline NIHSS, intravenous alteplase use, occlusion site and center. DESIGN: The trial is designed with an expectation of a 10% difference in the proportion of favorable outcome (mRS 0-2 at 90 days) common odds ratio of 1.615. PRIMARY OUTCOME: Projected sample size is 690 subjects with pre-planned interim analyses at 174, 346, and 518 subjects. SECONDARY OUTCOMES: Secondary end-points include: 90-day functional independence (mRS ≤2), mRS shift stratified for treatment with IV rt-PA at 90 days, infarct volume on 24 h CT or MRI, early dramatic response (NIHSS 0-2 or improvement ≥8 points) at 24 h, vessel recanalization evaluated by CTA or MRA at 24 h, and the post-procedure rate of successful reperfusion (defined as a modified Treatment in Cerebral Infarction 2b or greater). Safety variables are mortality at 90 days, symptomatic intracranial hemorrhage at 24 h and procedure-related complications.

Latin American Consensus Statement for the Use of Contrast-Enhanced Transcranial Ultrasound as a Diagnostic Test for Detection of Right-to-Left Shunt.

BACKGROUND: The role of patent foramen ovale is a field of debate and current publications have increasing controversies about the patients' management in young undetermined stroke. Work up with echocardiography and transcranial Doppler (TCD) can aid the decision with better anatomical and functional characterization of right-to-left shunt (RLS). Medical and interventional strategy may benefit from this information. SUMMARY: a group of experts from the Latin American participants of the Neurosonology Research Group (NSRG) of World Federation of Neurology created a task force to review literature and describe the better methodology of contrast TCD (c-TCD). All signatories of the present consensus statement have published at least one study on TCD as an author or co-author in an indexed journal. Two meetings were held while the consensus statement was being drafted, during which controversial issues were discussed and voted on by the statement signatories. The statement paper was reviewed and approved by the Executive Committee of the NSRG of the World Federation of Neurology. The main objective of this consensus statement is to establish a standardization of the c-TCD technique and its interpretation, in order to improve the informative quality of the method, resulting in expanding the application of TCD in the clinical setting. These recommendations optimize the comparison of different diagnostic methods and encourage the use of c-TCD for RLS screening and complementary diagnosis in multicenter studies.

Epidemiology of concurrent Chagas disease and ischemic stroke in a population attending a multicenter quaternary rehabilitation network in Brazil.

BACKGROUND AND PURPOSE: Chagas disease and ischemic stroke (IS) have a close but poorly understood correlation. In endemic settings, continued transmission over time has resulted in increasing prevalence of both asymptomatic infection and cardiomyopathy with increasing age. Latin America has made substantial progress towards Chagas disease control. Although several epidemiological studies have been conducted, information regarding epidemiology and distribution of IS in Chagas disease is still lacking. METHODS: We retrospectively studied the electronic medical record data of all patients with both IS and Chagas disease admitted at SARAH Hospitals across Brazil from 2009 to 2013 to make epidemiological quantifications and statistical inferences. RESULTS: A total of 279 patients with Chagas disease and IS were analyzed from 7729 IS-related admissions, indicating a median prevalence of 3.6% of Chagas disease in IS patients in our cohort. Mean age was 60 years, with female predominance (65%). Most of the cases were from Bahia (61%), followed by Minas Gerais (19%) and Goiás (9.7%). Low-income cities, with decreased access to healthcare, showed the highest number of cases. Distribution of vascular risk factors and outcome after stroke differed among the units. According to current guidelines, secondary prevention was inadequate in 60% of patients. CONCLUSIONS: Chagas disease was common in IS patients; prevalence of concurrent Chagas disease and IS was high in some regions of the country. However, the infection frequency seems to be reduced in the last few years. Public health issues for improving the treatment of Chagas disease and IS are urgently needed.

Overground gait training promotes functional recovery and cortical neuroplasticity in an incomplete spinal cord injury model.

AIM: Evidence suggests that task-specific gait training improves locomotor impairments in people with incomplete spinal cord injury (SCI); however, plastic changes in brain areas remain poorly understood. The aim of this study was to examine the possible effects of a task-specific overground gait training on locomotor recovery and neuroplasticity markers in the cortex, cerebellum, and lumbar spinal cord in an experimental model of incomplete-SCI. MAIN METHODS: Using a blind, basic experimental design, 24 adult Wistar rats underwent a surgical procedure and were allocated into sham, non-trained SCI (SCI), and trained SCI (Tr-SCI) groups. On postoperative day 14, trained animals started a 4-week overground gait training program. All groups were subjected to weekly assessment of locomotor recovery of the hind limbs. On postoperative day 40, brain and lumbar spinal cord structures were dissected and processed for biochemical analysis of the synaptophysin, microtubule-associated protein 2 (MAP-2), and brain-derived neurotrophic factor (BDNF). KEY FINDINGS: Tr-SCI group showed greater locomotor function recovery compared with non-trained SCI from the postoperative day 21 (p < 0.05). The training was able to improve the neuroplasticity markers synaptophysin, MAP-2, and BDNF expressions in motor cortex (p < 0.05), but not in the cerebellum and in the spinal cord for trained SCI group compared to non-trained. SIGNIFICANCE: Task-specific overground gait training improves locomotor recovery in a rat model of incomplete thoracic-SCI. Furthermore, training promotes motor cortex plasticity, evidenced for increasing expression of the neuroplasticity markers that may support the functional recovery.

Effect of a Quality Improvement Intervention on Adherence to Therapies for Patients With Acute Ischemic Stroke and Transient Ischemic Attack: A Cluster Randomized Clinical Trial.

IMPORTANCE: Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging, especially in low- and middle-income countries. OBJECTIVE: To assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for care of patients with AIS and TIA. DESIGN, SETTING AND PARTICIPANTS: This 2-arm cluster-randomized clinical trial assessed 45 hospitals and 2336 patients with AIS and TIA for eligibility before randomization. Eligible hospitals were able to provide care for patients with AIS and TIA in Brazil, Argentina, and Peru. Recruitment started September 12, 2016, and ended February 26, 2018; follow-up ended June 29, 2018. Data were analyzed using the intention-to-treat principle. INTERVENTIONS: The multifaceted quality improvement intervention included case management, reminders, a roadmap and checklist for the therapeutic plan, educational materials, and periodic audit and feedback reports to each intervention cluster. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite adherence score for AIS and TIA performance measures. Secondary outcomes included an all-or-none composite end point of performance measures, the individual process measure components of the composite end points, and clinical outcomes at 90 days after admission (stroke recurrence, death, and disability measured by the modified Rankin scale). RESULTS: A total of 36 hospitals and 1624 patients underwent randomization. Nineteen hospitals were randomized to the quality improvement intervention and 17 to routine care. The overall mean (SD) age of patients enrolled in the study was 69.4 (13.5) years, and 913 (56.2%) were men. Overall mean (SD) composite adherence score for the 10 performance measures in the intervention group hospitals compared with control group hospitals was 85.3% (20.1%) vs 77.8% (18.4%) (mean difference, 4.2%; 95% CI, -3.8% to 12.2%). As a secondary end point, 402 of 817 patients (49.2%) at intervention hospitals received all the therapies that they were eligible for vs 203 of 807 (25.2%) in the control hospitals (odds ratio, 2.59; 95% CI, 1.22-5.53; P = .01). CONCLUSIONS AND RELEVANCE: A multifaceted quality improvement intervention did not result in a significant increase in composite adherence score for evidence-based therapies in patients with AIS or TIA. However, when using an all-or-none approach, the intervention resulted in improved adherence to evidence-based therapies. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02223273.

Cerebral infarct topography of atrial fibrillation and Chagas disease.

BACKGROUND: Chagas disease (CD) and ischemic stroke (IS) have a significant but poorly understood correlation. There is paucity of evidence regarding secondary prophylaxis of IS and etiological causes. OBJECTIVES: To compare arterial stroke topography and the respective morbidities and mortality in patients with CD of undetermined and cardioembolic etiologies and with cardioembolic IS (atrial fibrillation [AF]). METHODS: We compared vascular topography and outcomes using data obtained from the electronic medical records of all patients with IS with either CD (with cardioembolic or undetermined etiology) or AF, admitted to SARAH Hospital Brasilia between 2009 and 2013. RESULTS: A total of 115 patients were investigated: 49 involving AF, 23 involving CD of unclear etiology, and 43 involving CD of cardioembolic etiology. Middle cerebral artery stroke was predominant in all groups, although more frequent in patients with CD of undetermined etiology. No significant difference was found in the arterial territories. Hemodynamic stroke was predominant among CD patients who experienced cardioembolic events. AF patients had worse modified Rankin scale scores upon admission and a higher mortality rate than CD patients in both categories. CONCLUSIONS: Stroke topography is not useful in determining the etiological diagnosis. Patients with AF and IS are more likely to have worse outcomes than are those with CD and IS. The autonomic nervous system could be affected in patients with CD.

An international cluster-randomized quality improvement trial to increase the adherence to evidence-based therapies for acute ischemic stroke and transient ischemic attack patients: Rationale and design of the BRIDGE STROKE Trial.

BACKGROUND: Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging especially in low- and middle-income countries. OBJECTIVES: The aim of this study is to assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for AIS and TIA patients care. DESIGN: We designed a pragmatic, 2-arm cluster-randomized trial involving 36 clusters and 1624 patients from Brazil, Argentina, and Peru. Hospitals are randomized to receive a multifaceted quality improvement intervention (intervention group) or to routine care (control group). The BRIDGE Stroke multifaceted quality improvement intervention includes case management, reminders, health care providers' educational materials (including treatment algorithms), interactive workshops, and audit and feedback reports. Primary outcome is a composite adherence score to AIS and TIA performance measures. Secondary outcomes include an "all or none" composite end point to performance measures, the individual components of the composite end points, and clinical outcomes at 90 days following admission (stroke recurrence, death, and disability measured by the modified Rankin scale). SUMMARY: The BRIDGE Stroke Trial is an international pragmatic evaluation of a multifaceted quality improvement intervention. If effective, this intervention could be potentially extended widely to improve the quality of care and outcomes of patients with AIS or TIA.

Machado de Assis' Original Sin.

Machado de Assis (1839-1908) suffered from temporal lobe epilepsy, probably with origin in the non-dominant hemisphere. The evidence for this is provided by the detailed reports of the characteristics of his seizures by his contemporaries and by his correspondence with other writers. He was treated with bromides and homeopathy. It is unclear whether his neurological disorder influenced his artistic performance. What is evident is that he was deeply ashamed of the disease - he avoided the word "epilepsy" and just wrote about it in his personal correspondence with friends in the last years of his life. Though controversial, he had no clear traces of personality disorders linked to his temporal lobe epilepsy. Despite all his adversities, including being "mulatto," having a stutter, being of humble origins, and epileptic in a period when there was no efficacious therapy and a profound stigma associated with the disease, Machado de Assis became one of the most important Brazilian writers of all times.