Impact of thrombolysis on stroke outcome at 12 months in a population: the Bern stroke project.

BACKGROUND AND PURPOSE: Thrombolysis improves outcome of patients with acute ischemic stroke, but it is unknown whether thrombolysis has a measurable effect on long-term outcome in a defined population. METHODS: We prospectively assessed demographic data, management, and outcome of acute ischemic stroke patients admitted within 48 hours to 18 primary care hospitals of the canton of Bern (969 299 inhabitants) during 12 months. Blinded follow-up was obtained at 3 and 12 months. Predictors of mortality and favorable outcome (modified Rankin Scale score ≤2) at 3 and 12 months using logistic regression were analyzed. RESULTS: From December 2007 to December 2008, 807 patients (mean age, 72 years) were included. Median National Institutes of Health Stroke Scale score on admission was 5; 107 patients (13%) received intravenous, intra-arterial, or mechanical thrombolysis. Estimated cumulative mortality at 3 months was 20.6% and at 12 months 27.4%. Age 75 years or older, higher National Institutes of Health Stroke Scale scores, and higher Charlson comorbidity index were independent predictors of mortality at 3 and 12 months. Estimated favorable outcome at 3 months was 48.2% and at 12 months was 44.6%. Thrombolysis was the only modifiable independent predictor of favorable outcome at 3 (relative risk, 1.49; 95% CI, 1.18-1.89) and 12 months (relative risk, 1.59; 95% CI, 1.24-2.04), whereas age younger than 75 years, male gender, National Institutes of Health Stroke Scale score <4, and lower Charlson comorbidity index were nonmodifiable predictors. CONCLUSIONS: Thirteen percent of acute ischemic stroke patients admitted within 48 hours to Bernese hospitals underwent thrombolysis, which exerted a measurable effect on 3-month outcome in this population. This effect was sustained at 12 months. Age, stroke severity, Charlson comorbidity index, and male gender were independent nonmodifiable predictors of outcome.

Montelukast and Churg-Strauss syndrome.

The association of leukotriene receptor antagonists and Churg-Strauss Syndrome (CSS) has been recognised for several years. However, whether these drugs have a direct pathogenic role remains controversial. The present case describes an asthmatic patient, who developed severe obstructive symptoms and progressive heart failure after two sequential exposures to montelukast. As the patient exhibited a markedly raised blood eosinophil count with diffuse infiltrates on chest x-ray and signs of myocarditis, CSS was suspected. The disease was confirmed by open lung biopsy. The symptoms improved rapidly after administration of high dose immunosuppression with methylprednisolone and cyclophosphamide. This case is noteworthy because the time course of events strongly suggests a direct aetiological role for montelukast in the development of CSS. The pathophysiological mechanism of the association remains unknown.

Search for occult malignancy in patients with deep venous thrombosis. Results of a retrospective cohort study.

QUESTIONS UNDER STUDY: The association of deep vein thrombosis (DVT) and cancer is well established. It is controversial how large the association is and how extensive the evaluation for an underlying cancer should be. PRINCIPLES AND METHODS: 485 patients without a known cancer and a proven DVT formed the cohort of a retrospective study. Newly diagnosed (prevalent) cancers in patients with idiopathic (IDVT) and secondary (SDVT) during the index hospitalisation were compared and the contribution of the steps in an institutional tumour search program was analysed. The incidence of cancer in 204 patients with IDVT and 230 patients with SDVT during follow-up was determined. RESULTS: During the index hospitalisation routine evaluation revealed eleven cancers in 236 patients (4.7% [95%-CI: 2.0-7.3]) with IDVT and five cancers in 249 patients (2.0% [95%-CI: 0.3-3.7]) with SDVT. Combining patient history, clinical examination, routine laboratory tests and chest x-ray showed a sensitivity of 88% and a specificity of 79% for the diagnosis of cancer. Abdominal ultrasound did not significantly increase the yield. 93% of the patients were followed for up to 5 years (mean 32 months). Sixteen cancers occurred in 204 patients (7.8% [95%-CI: 4.0-11.5]) with IDVT and ten in 230 patients (4.35% [95%-CI: 1.7-7.0]) with SVDT (p<0.001). CONCLUSION: Prevalence and incidence of cancer were higher in IDVT patients compared to those with SDVT. Combining patient history, clinical examination, simple laboratory tests, and a routine chest x-ray is an appropriate strategy to detect underlying cancer in patients with IDVT. Routine abdominal ultrasound can safely be omitted.