Presentation, Management, and Outcomes of Acute Stroke in Palestine.

Background Stroke is a leading cause of death and disability in the Middle East. Data on the uptake of evidence-based practices are limited in the region. We aimed to examine patterns of stroke presentation, management, and outcomes at public Palestinian hospitals. Methods and Results Comprehensive data from all patients with acute stroke admitted to 2 public hospitals in the West Bank of Palestine were prospectively collected. Acute stroke presentation patterns, in-hospital evaluation and management, mortality, and stroke complications were evaluated. Data were available for 150 patients with acute stroke between September 2017 and May 2018. The mean ( SD ) age was 65 (14) years and 49% were women. Only 25% of patients utilized ambulance services for transportation to the hospital. All patient received head computed tomography scans, although few received other investigations such as magnetic resonance imaging (8%) or carotid Doppler (4%). Most patients with ischemic stroke received antiplatelet therapy (98%), although none received thrombolysis. Only 17% received physical therapy evaluation. In-hospital mortality was 12%, 23% of patients had at least 1 poststroke complication, and the median modified Rankin Score at discharge was 4 (interquartile range, 2-5). Conclusions We identified high stroke mortality and discharge disability rates in Palestine. Key evidence-based gaps were highlighted, suggesting opportunities for quality improvement.

Implementing Evidence-Based Practices for Acute Stroke Care in Low- and Middle-Income Countries.

PURPOSE OF REVIEW: Most strokes occur in low- and middle-income countries where resources to manage patients are limited. We explore the resources required to providing optimal acute stroke care and review barriers to implementing evidence-based stroke care in settings with limited resources using the World Stroke Organization's Global Stroke Services Action Plan framework. RECENT FINDINGS: Major advances have been made during the past few decades in stroke prevention, treatment, and rehabilitation. These advances have been translated into practice in many high-income countries, but their uptake remains suboptimal in low- and middle-income countries. The review highlights the resources required to providing optimal acute stroke care in settings with limited resources. These resource levels were divided into minimal, essential, and advanced resources depending on the availability of stroke expertise, diagnostics, and facilities. Resources were described for the three stages of acute care: early diagnosis and management, acute management and prevention of complications, and early discharge and rehabilitation. Barriers to providing acute care at each of these stages in low- and middle-income countries are reviewed, explaining that some barriers persist in essential or advanced settings where some aspects of organized stroke units are available.

Interobserver concordance for endoscopic ultrasonography-guided fine-needle aspiration on-site cytopathology.

INTRODUCTION: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is an accurate method of diagnosing and staging gastrointestinal and thoracic malignancy. A key issue in maximizing FNA accuracy is to ensure that an adequate specimen is obtained. On-site cytopathology increases the diagnostic yield of EUS-FNA. However, this increases the time and costs. Physicians trained in EUS and in pathology are capable of interpreting cytologic adequacy from EUS-FNA specimens. Furthermore, on-site interpretation by the endoscopist could reduce cost and procedure duration. The learning curve of endossonographers in on-site cytopathology and how they could contribute in EUS-FNA accuracy increase is unknown. OBJECTIVE: To determine the interobserver concordance of on-site cytopathology interpretation of EUS-FNA specimens by comparing endosonographers trained in cytology with a physician cytopathologist. METHODS: A prospective blinded study comparing one endossonographer with one physician cytopathologist. The study was developed in the Santa Casa Medical School, Brazil from February to November 2012. Fifteen different cases of EUS-FNA were analysed, in a total of 50 slides. Each observer described the slides for the adequate or not of tissue sampling, and classified as benign, suspicious, malign or undefined. The analyses were then matched. RESULTS: We analyzed the concordance of 50 slides description made by the endossonographer and physician cytopathologist, according to enough material, cellular group identification and final diagnosis. Kappa (κ) indexes were: Presence of material κ = 0.480 (P < 0.001); presence of malignance κ = 0.808 (P < 0.001); in subepithelial lesions κ = 0.615 (P = 0.06); in pancreatic lesions κ = 0.675 (P < 0.001); in mediastinal lesions κ = 0.243 (P = 0.128). CONCLUSION: Our study showed that endosonographers and cytopathologists had good concordance in EUS-FNA specimens on-site cytopathology interpretation, except in mediastinal/pulmonary cases.

Relevance of endoscopic ultrasound in the management of esophagus cancer therapy.

INTRODUCTION: The objective of this case series study by retrospective analysis was to determine the relevance of endoscopic ultrasound (EUS) in therapeutic decision esophageal cancer. MATERIAL AND METHODS: Using medical records of the Department of Endoscopy of Santa Casa de São Paulo, we have collected data from 16 patients, in 4 years, diagnosed of esophageal cancer, and presented in the form of clinical cases to a specialist surgeon in esophageal cancer and a clinical oncologist, for therapeutic evaluation before and after the outcome of EUS. RESULTS: Both of them choose non-resective and not curative methods (68.8% by surgeon vs. 87.5% oncologist) before EUS. The best treatment by the surgeon was chemotherapy and palliative radiotherapy associated (25%) and palliative endoscopic prostheses (25%), and by the oncologist, neoadjuvant chemotherapy and radiotherapy associated (56.2%). After EUS, the resective surgical treatment was the both choice in only 6.2% of cases, and the rest of 93.8%, non-resective. The surgeon choice was chemotherapy and palliative radiotherapy associated (44%), and oncologist choice was neoadjuvant chemotherapy and radiotherapy associated (44%). Analysis by the Chi-square method, comparing respective versus non-resective treatment, surgeon versus oncologist, with and without the EUS, obtained values of P = 0.39 and P = 0.46, respectively. The comparison between healing and non-healing treatment had the same P value. Regarding the change in behavior (resective vs. non-resective), there was a change of approach by the surgeon in 25% of cases (P = 0.17) and the oncologist moved conduct in 6.25% of cases. Comparing the changing of behavior among experts, the P value was 0.33. Despite evidence of behavior change after the EUS, the statistical point of view, the P value had no significant relevance. The main factor involved is probably due to a reduced number of sample cases. However, this is a pilot study, and is needed other with a larger number of cases. CONCLUSION: The data obtained allow us to conclude that EUS proved to be an important test for the change in staging and therapeutic management of esophageal cancer.

Influence of layer, size and organ of subepithelial lesions of upper gastrointestinal tract in outcomes of endoscopic ultrasound-guided fine-needle aspiration.

INTRODUCTION: The endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has emerged as a minimally invasive and safe method for material procurement in the differential diagnosis of subepithelial lesions (SEL) of upper gastrointestinal tract (UGT), especially in suspicious lesions of gastrointestinal stromal tumors (GIST). There are few studies discussing the factors that influence the EUS-FNA in the diagnosis of SEL. AIM: To establish possible associations between lesion size, layer and organ of origin with the outcome of EUS-FNA in patients with SELs of UGT. METHODS: A retrospective analysis using data of patients referred to French-Brazilian Center of EUS of endoscopy Department of Santa Casa de São Paulo Hospital, with previous endoscopic diagnosis of SEL, which underwent EUS-FNA from May 2006 to August 2011. RESULTS: A total of 222 patients were submitted to EUS. 15 with extrinsic compressions and 207 with SEL. Of these, 89 underwent to EUS-FNA. Ninety-two SEL were diagnosed on EUS and punctured. The EUS-FNA was positive in 58.7%. In lesions measuring 2-3 cm and >3 cm, the EUS-FNA was positive in 80% and 72%, respectively (P < 0.001). CONCLUSION: The size of SELs was the only variable that influenced the outcome of EUS-FNA. Best results are achieved in lesions larger than 2 cm.

Efficient method for mycobacterial DNA extraction in blood cultures aids rapid PCR identification of Mycobacterium tuberculosis and Mycobacterium avium.

The study presented here evaluated the utility of several methods of extracting mycobacterial nucleic acids from positive blood culture samples and examined the effect of each method on the performance of an in-house PCR used directly in the peripheral blood of 80 patients with AIDS to identify Mycobacterium spp. The modified Boom method for extracting DNA from blood cultures proved to be the most efficient, with subsequent PCR analysis yielding 100% positivity (7 samples positive for M. avium and 5 for M. tuberculosis). Only three of 12 patients with a positive blood culture had a PCR result positive for M. avium in peripheral blood. The identification of mycobacteria by PCR in blood culture took about 3 days, reducing the time to diagnosis by several weeks. These results demonstrate that PCR is a sensitive and quick method for identifying mycobacteria, especially when a good DNA extraction method is applied.

The phosphodiesterase inhibitor, pentoxifylline, alters rat intestinal epithelial cell proliferation via changes in the expression of transforming growth factors.

BACKGROUND: Phosphodiesterase (PDE) inhibitors, among which pentoxifylline (PTX), are candidate molecules for the treatment of TNF-alpha-dependent inflammatory diseases. Based on the controversial effects of PTX observed in experimentally-induced colitis, the aim of this work was to analyse its influence on intestinal epithelial cell proliferation and growth factor expression using the well-established IEC18 cell line. METHODS: The effects of PTX, and of an activation (addition of dibutyryl-cAMP, db-cAMP) or inhibition (by a specific cAMP-protein kinase inhibitor, PKI) of the cAMP pathway, were examined after 3 days of culture. The IEC18 cell proliferation and [3H] thymidine incorporation, as well as the expression of TGF-alpha, TGF-beta1 and -beta2 mRNAs, were analysed in basal culture conditions and in the presence of the pro-inflammatory cytokine, TNF-alpha. RESULTS: PTX, like exogenous db-cAMP, inhibited in a dose-dependent manner the basal and TNF-alpha-modulated IEC18 cell proliferation; this effect was partly prevented by PKI. We confirmed that PTX induced a dose-related increase in intracellular cAMP. Concomitantly, the expression of TGF-alpha mRNA dropped and that of TGF-beta2 increased. Addition of db-cAMP instead of PTX also decreased TGF-alpha mRNA, but did not change TGF-beta2 transcripts. The decrease in the expression of TGF-alpha mRNA caused by PTX and db-cAMP was completely abolished by PKI; in contrast, TGF-beta2 remained unaltered. Yet, anti-TGF-beta2 antibodies partially restored the PTX-inhibited cell proliferation. CONCLUSION: The phosphodiesterase inhibitor, PTX, inhibits IEC18 cell proliferation via a differential modulation of TGF-alpha and TGF-beta2 expression. The drop in TGF-alpha mRNA is related to increasing intracellular cAMP, whereas the effect upon TGF-beta2 appears cAMP-independent.

Cytokine gene expression during postnatal small intestinal development: regulation by glucocorticoids.

BACKGROUND: In the intestinal mucosa, numerous cytokines produced by the epithelium, fibroblasts, and immune cells were shown to affect epithelial differentiation and proliferation through epithelial-mesenchymal and epithelial-immune cell interactions. To date, the importance of cytokines in postnatal development of the rat small intestine has not been established. AIM: To investigate the developmental changes in expression of mucosal cytokines in the postnatal maturation of the rat small intestinal epithelium and their regulation by glucocorticoids (GC). METHODS: Mucosal maturation was assessed by the onset of sucrase-isomaltase (SI) mRNA, analysed by in situ hybridisation. The amount of transforming growth factor beta1 (TGF-beta1), beta2 (TGF-beta2), tumour necrosis factor alpha (TNF-alpha), interleukin 1beta (IL-1beta), and TGF-alpha was analysed by reverse transcription-polymerase chain reaction (RT-PCR) in mucosal extracts from weaning (14-21 days old) and adult rats, or one day after an injection of hydrocortisone (HC) in 11 day old rats. Similarly, expression of cytokines and the regulatory effect of GC were studied on cultured subepithelial myofibroblasts cloned from postnatal jejunum and ileum cultured in the absence or presence of dexamethasone (DX). RESULTS: TGF-beta1, TGF-beta2, and IL-1beta decreased during the third week of life while levels of TNF-alpha increased and TGF-alpha remained constant. In parallel, SI transcripts increased and showed a progressive accumulation in the apical part of the enterocytes first localised at the base of the villi from 18 days onwards. Interestingly, precocious induction of SI mRNA by HC paralleled the decrease in expression of TGF-beta isoforms and of IL-1beta. All cytokines were expressed in the myofibroblast cell lines. In addition, the results showed that TNF-alpha was differentially expressed in basal culture conditions and after DX stimulation in jejunal and ileal myofibroblasts. DX decreased IL-1beta but not the TGF-beta isoforms, similar to that in vivo. CONCLUSIONS: This study shows that mucosal cytokines are developmentally regulated and that GC are potentially involved in this regulation in parallel with maturation of the gut mucosa at weaning.

Oral ciprofloxacin for treatment of severe infections.

Twenty adult patients with severe infections were treated with oral ciprofloxacin, 500 or 750 mg twice daily. Treatment ranged from 8 to 25 days. Efficacy was good: 14 patients (70%) were cured, four (20%) improved and there were only two (10%) failures. Tolerance was very satisfactory, the most common side-effects being mild gastrointestinal symptoms (three patients). Only one adverse laboratory result was observed: a transient rise in blood urea nitrogen and creatinine levels. None of the adverse effects led to discontinuation of treatment. Thus, ciprofloxacin presents as a promising drug for treatment of severe infections caused by susceptible organisms when ambulatorial therapy, at least during a large part of the treatment, is possible and desirable.

[The Q wave in the electrocardiogram: necrosis or an electrically inactive area? Myocardial pseudoinfarct]. / Onda Q do eletrocardiograma: necrose ou zona eletricamente inativa? O pseudo-infarto do miocárdio.

Six patients with Q-wave myocardial infarction in the ECG, two with coronary disease, two with metabolic alterations, one with acute myocarditis and another with ischemic stroke had an improvement of ECG tracings with disappearance of the Q wave. All had normal plasmatic levels of CPK and CKMB. It is believed that metabolic transitory disturbance of the myocardium increases the rest transmembrane potential turning the cell nonresponsive to electrical stimulus and without mechanical activity (inactive electrical zone, not a necrosis zone, which is an anatomo-pathological diagnosis).

[Analysis of fever in 58 cases of infective endocarditis]. / Análise da febre em 58 casos de endocardite infecciosa.

PURPOSE: To evaluate if fever is an objective criterion in the assessment of response to antibiotic therapy and in the prognosis of patients undergoing treatment for infective endocarditis (IE). METHODS: Fifty-eight cases of IE, occurring from January 1980 to December 1989 have been analysed retrospectively in this study. Emphasis was given to the clinical history and body temperature changes during the first five weeks of treatment. Patients were divided in three groups according to the number of febrile peaks per week. Temperature was assessed weekly from each patient's highest peak weighed average. RESULTS: At the first exam, 52 patients (86.2%) presented fever. All patients had at least one episode of fever during their hospitalization. There seemed to be a relation between the number of febrile peaks during a one week period and the mean body temperature, so that these patients who presented four or more peaks in a week had a higher mean body temperature than those with two or less febrile peaks during the week. After the second week of treatment, patients with two or less febrile peaks had a 93.1% survival and average of 35.5 days of hospitalization, whereas those with three or more febrile peaks had 63.6% survival and an average of 47.5 days of hospitalization. CONCLUSION: The results of this study show that the intensity of fever is linked to the number of febrile peaks per week, regardless to treatment duration. Should there be three or more febrile peaks weekly after the second week of treatment, therapeutic strategy should be reviewed, considering even surgical treatment. In many cases, the persistence of fever represented the clinical expression of complications which determined a higher mortality rate and a longer hospitalization.

[Infective endocarditis. Study of 83 cases at the Hospital da Santa Casa de São Paulo]. / Endocardite infecciosa. Estudo de 83 casos no Hospital da Santa Casa de São Paulo.

PURPOSE: To analyse clinical aspects, diagnosis and treatment of infective endocarditis (IE), in order to guide medical procedures and indicate the surgical treatment. PATIENTS AND METHODS: 83 patients were submitted to clinical treatment of IE between January 1980 and December 1987; clinical aspects, laboratory and pathologic-anatomy findings, the site of infection and the entrance of micro-organism were studied. RESULTS: 37 (44.6%) patients were males. Fever was present in 75 (90.4%) cases, cardiac murmur in 76 (91.5%), splenomegaly in 28 (33.7%) and heart failure (III and IV) in 32 (39.8%) patients. Blood culture was positive in 55.5%; staphylococcus 50% of blood cultures; anemia was present in 66 cases (79.5%) and high serum mucoprotein in 58 (92%); echocardiography was 85.7% positive. The mortality was 39.76%; congestive heart failure was the main cause of death; 78.1% of these ones occurred in the first 15 days of antibiotic-therapy. The mitral valve was the one most impaired and the most frequent entrance of micro-organisms in oropharynx. CONCLUSION: Congestive heart failure, sepsis and systemic embolisms were the main complications that led the patient to death in course of IE, usually before 15 days of antibiotic-therapy. In these cases, we may hypothesize that prompt surgical treatment could have diminished the mortality of IE.