This study analyzed 231 patients with aneurysmal subarachnoid hemorrhage (SAH) from 25 Mexican hospitals to describe clinical characteristics, risk factors, and outcomes. Hypertension was the main risk factor associated with SAH. Most aneurysms (92%) were located in the anterior circulation and 15% of patients had multiple aneurysms. The median hospital stay was 23 days. Invasive treatments like clipping or coiling were performed in 69% of patients. The in-hospital mortality rate was 20% due to neurological causes. 25% of patients were discharged with significant neurological impairment.
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The purpose of the study is to provide information about the database of 1421 adult patients with acute ischemic stroke (IS) developing ≤ 48 hours before admitting, research methods, study protocol, and clinical predictors of the evolving stroke course (EIS).
Methods and Materials: EIS outlined as an increase of NIHSS ≥ 2 points within seven days or in-hospital lethal outcome. Clinical, demographic, instrumental, laboratory data acquisition, as well as the IS course variant and the functional outcome assessment, were carried out prospectively. Statistical analyses were performed using R V.3.2.5 statistical package software and IBM SPSS Statistics 26.0.
Results: The incidence of EIS reached 30.0%. The average age of patients with EIS was 72.6±10.2 years, compare the age of patients without EIS - 68.1±11.3 years; p = 0.005. Female sex increased the odds of EIS (OR, 1.36; 95% CI 1.08-1.73). Total anterior carotid stroke (OR, 7.78; 95% CI 5.91-10.23), the initial NIHSS score > 14 points (OR, 3.74; 95% CI 2.83-4.94), and the right anterior circulation was also associated with EIS (OR, 1.30; 95% CI 1.02-1.66). The odds of EIS were significantly higher in the presence of diabetes mellitus (OR, 1.29; 95% CI 1.01-1.66), cerebral artery stenosis ≥ 70% (OR, 1.96; 95% CI 1.30-2.93), atrial fibrillation (OR, 1.89; 95% CI 1.51-2.39), congestive heart failure (OR, 1.90; 95% CI 1.51-2.39), and peripheral artery disease (OR, 1.69; 95% CI 1.27-2.25). Respiratory (OR, 2.82; 95% CI 2.22-3.59), gastrointestinal (OR, 1.34; 95% CI 1.05-1.70), and urologic diseases (OR, 2.10; 95% CI 1.65-2.66), stroke-associated infection (OR, 3.47; 95% CI 2.09-5.76), and gradual development of initial IS symptoms before admitting increased the odds of progression of the neurological deficit during treatment (OR, 2.37; 95% CI 1.78-3.15)were associated with the evolving clinical course of IS. The patients with the EIS compared with patients without EIS, showed higher serum levels of glucose (p < 0.001), urea (p = 0.001), creatinine (p < 0.001), sodium (p = 0.025), and direct bilirubin (p = 0.015). Potassium level in EIS group was lower than in the group without EIS (p < 0.001). In patients with EIS, a higher amount of RBC (p = 0.030) and WBC (p < 0.001) was found.
Conclusion: The in-hospital database contains information about EIS by the bases subtypes of IS, patient demography, cardiovascular risk factors, comorbid pathology, clinical and laboratory tests, instrumental methods of examination, medications, the severity of neurological deficit, and post-stroke outcome.
Techniques in Neurosurgery & Neurology
Authors:
Irina Gontschar1 and Igor Prudyvus2
1Student, Health Information Management and Insurance Billing Program by the EVANS Community Adult School, Los Angeles, USA
2Chief Application Support Analysts, EPAM Systems, Minsk, Belarus
Abstract
Introduction: The purpose of the study is to identify the independent clinical predictors of the evolving ischemic stroke (EIS) according to the tree-structured model.
Methods and Materials: The objects of the study were 1421 patients with ischemic stroke (IS), hospitalized within 48 hours from the development of the initial symptoms. Patients with IS were admitted to the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital (Belarus) in 2002-2014 years. Evolving clinical course of the stroke is defined as an increase in the severity of neurological deficit by 2 or more points on the NIHSS scale or the death of the patient during the first seven days of hospitalization. The research is characterized due to the prospective-data-collection, and the retrospective evaluation design. The statistical method of decision trees and an algorithm of the conditional inference trees were used to create the prognostic model of EIS. Statistical data analysis was carried out applying the software packages of R V.3.2.5 and IBM SPSS Statistics 26.0.
Results: The rate of EIS reached 30%. The patients with EIS were 72.6±10.2 years old, patients without EIS - 68.1±11.3 years; p = 0.005. Previously, 22 clinical, demographic, laboratory variables accommodated in the computer database were included in the conditional inference trees statistical algorithm. The prognostic statistical model of EIS has been constructed. The following independent predictors of evolving IS were identified: the stroke subtype according to the Oxford Community Stroke Project classification, the serum urea level, and red blood cell number in the total blood count. The accuracy of the statistical model reaches 0.77 (95% CI: 0.75; 0.80), the sensitivity is 0.52, the specificity - 0.88, PPV - 0.66, and NPV - 0.81; p < 0.001.
Conclusion: The tree-structural model allowed us to identify the independent clinical predictors of EIS.
Keywords: Cerebral infarction, Clinical characteristics, Clinical course, Conditional inference trees algorithm, Decision tree, Evolving ischemic stroke, Model, Predictor, Prognosis, Stroke deterioration
Spontaneous intracerebral hemorrhage in Mexico: results from a Multicenter Na...Erwin Chiquete, MD, PhD
José L. Ruiz-Sandoval, Erwin Chiquete, Alejandra Gárate-Carrillo, Ana Ochoa-Guzmán, Antonio Arauz,
Carolina León-Jiménez, Karina Carrillo-Loza, Luis M. Murillo-Bonilla, Jorge Villarreal-Careaga,
Fernando Barinagarrementería, Carlos Cantú-Brito, and the RENAMEVASC investigators
Introduction. Scarce information exists on intracerebral hemorrhage (ICH) in Latin America, and the existent is derived
from single-center registries with non-generalizable conclusions. The aim of this study is to describe the frequency, etiology,
management and outcome of ICH in Mexico.
Patients and methods. We studied consecutive patients with ICH pertaining to the National Multicenter Registry on Cerebrovascular
Disease (RENAMEVASC), conducted in 25 centers from 14 states of Mexico. The Intracerebral Hemorrhage Grading
Scale (ICH-GS) at admission was used to assess prognosis at 30 days follow-up.
Results. Of 2,000 patients with acute cerebrovascular disease registered in RENAMEVASC, 564 (28%) had primary ICH
(53% women; median age: 63 years; interquartile range: 50-75 years). Hypertension (70%), vascular malformations (7%)
and amyloid angiopathy (4%) were the main etiologies. In 10% of cases etiology could not be determined. Main ICH
locations were basal ganglia (50%), lobar (35%) and cerebellum (5%). Irruption into the ventricular system occurred in
43%. Median score of ICH-GS was 8 points: 49% had 5-7 points, 37% had 8-10 points and 15% had 11-13 points. The 30-day
case fatality rate was 30%, and 31% presented severe disability. The 30-day survival was 92% for patients with ICH-GS 5-7
points, whereas it decreased to 27% in patients with ICH-GS 11-13 points.
Conclusions. In Mexico, ICH represents about a third of the forms of acute cerebrovascular disease, and the majority of
patients present severe disability or death at 30 days of follow-up. Hypertension is the main cause; hence, control of this important cardiovascular risk factor should reduce the health burden of ICH.
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The goal of the study was to identify the most significant prognostic clinical criteria for the survival of patients with ischemic stroke (IS) within 1 year of observation.
Methods and Materials: The object of the clinical prospective study was 1421 patients with IS hospitalized in 2002-2015 in the neurological (stroke) departments of the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital. Analyzing the obtained data, we adhered to the prospective-specimen-collection, retrospective evaluation design of the study. The primary endpoint of the study was the patient's death from any reason within one year of the development of IS. Information on poststroke all-cause mortality was obtained through linkages to the official source - the centralized archive of deaths of residents of the city of Minsk. Patients without a confirmed death date were censored at the date last known alive. All patients that were alive at one year are assumed to be censored at that time. The collection of clinical, demographic, neuroimaging, laboratory data, as well as the final determination of the stroke outcome, was performed blindly with respect to survival data.
Results: To build the model, 22 multivariate clinical indicators were used that demonstrated the relationship with post-stroke survival at the stage of preliminary data analysis: stroke subtype according the Oxfordshire Community Stroke Project, age, gender, the severity of the neurological deficit according to the NIHSS scale at hospitalization, previous stroke or TIA, the presence of arterial hypertension, atrial fibrillation, myocardial atherosclerosis, congestive heart failure, diabetes mellitus, peripheral arterial diseases, alcohol abuse, level of creatinine, glucose, urea, potassium, sodium in blood, amount of hemoglobin, erythrocytes and leukocytes on the 1st day of treatment, the level of systolic and diastolic blood pressure in the hospital admission department.
In the construction of a survival decision tree of patients with IS, of the 22 initially embedded parameters, only 6 independent predictors were finally included in the prognostic model: the stroke subtype according to the OCSP, the presence of a lacunar infarction, the severity of neurologic deficit at hospitalization according NIHSS, level of urea and glucose in the blood, and the presence of congestive heart failure.
Comparison of clinical, radiological and outcome characteristics of ischemic ...MIMS Hospital
Here is the latest publication from the department of Neurology in the Journal of Neurology Research, titled, ’Comparison of Clinical, Radiological and Outcome Characteristics of Ischemic Strokes in Different Vascular Territories’ authored by Ashraf V Valappila, c, Dhanya T Janardhanana, Praveenkumar Raghunatha, Abdulla Cherayakkatb, Girija ASa
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The purpose of the study is to provide information about the database of 1421 adult patients with acute ischemic stroke (IS) developing ≤ 48 hours before admitting, research methods, study protocol, and clinical predictors of the evolving stroke course (EIS).
Methods and Materials: EIS outlined as an increase of NIHSS ≥ 2 points within seven days or in-hospital lethal outcome. Clinical, demographic, instrumental, laboratory data acquisition, as well as the IS course variant and the functional outcome assessment, were carried out prospectively. Statistical analyses were performed using R V.3.2.5 statistical package software and IBM SPSS Statistics 26.0.
Results: The incidence of EIS reached 30.0%. The average age of patients with EIS was 72.6±10.2 years, compare the age of patients without EIS - 68.1±11.3 years; p = 0.005. Female sex increased the odds of EIS (OR, 1.36; 95% CI 1.08-1.73). Total anterior carotid stroke (OR, 7.78; 95% CI 5.91-10.23), the initial NIHSS score > 14 points (OR, 3.74; 95% CI 2.83-4.94), and the right anterior circulation was also associated with EIS (OR, 1.30; 95% CI 1.02-1.66). The odds of EIS were significantly higher in the presence of diabetes mellitus (OR, 1.29; 95% CI 1.01-1.66), cerebral artery stenosis ≥ 70% (OR, 1.96; 95% CI 1.30-2.93), atrial fibrillation (OR, 1.89; 95% CI 1.51-2.39), congestive heart failure (OR, 1.90; 95% CI 1.51-2.39), and peripheral artery disease (OR, 1.69; 95% CI 1.27-2.25). Respiratory (OR, 2.82; 95% CI 2.22-3.59), gastrointestinal (OR, 1.34; 95% CI 1.05-1.70), and urologic diseases (OR, 2.10; 95% CI 1.65-2.66), stroke-associated infection (OR, 3.47; 95% CI 2.09-5.76), and gradual development of initial IS symptoms before admitting increased the odds of progression of the neurological deficit during treatment (OR, 2.37; 95% CI 1.78-3.15)were associated with the evolving clinical course of IS. The patients with the EIS compared with patients without EIS, showed higher serum levels of glucose (p < 0.001), urea (p = 0.001), creatinine (p < 0.001), sodium (p = 0.025), and direct bilirubin (p = 0.015). Potassium level in EIS group was lower than in the group without EIS (p < 0.001). In patients with EIS, a higher amount of RBC (p = 0.030) and WBC (p < 0.001) was found.
Conclusion: The in-hospital database contains information about EIS by the bases subtypes of IS, patient demography, cardiovascular risk factors, comorbid pathology, clinical and laboratory tests, instrumental methods of examination, medications, the severity of neurological deficit, and post-stroke outcome.
Techniques in Neurosurgery & Neurology
Authors:
Irina Gontschar1 and Igor Prudyvus2
1Student, Health Information Management and Insurance Billing Program by the EVANS Community Adult School, Los Angeles, USA
2Chief Application Support Analysts, EPAM Systems, Minsk, Belarus
Abstract
Introduction: The purpose of the study is to identify the independent clinical predictors of the evolving ischemic stroke (EIS) according to the tree-structured model.
Methods and Materials: The objects of the study were 1421 patients with ischemic stroke (IS), hospitalized within 48 hours from the development of the initial symptoms. Patients with IS were admitted to the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital (Belarus) in 2002-2014 years. Evolving clinical course of the stroke is defined as an increase in the severity of neurological deficit by 2 or more points on the NIHSS scale or the death of the patient during the first seven days of hospitalization. The research is characterized due to the prospective-data-collection, and the retrospective evaluation design. The statistical method of decision trees and an algorithm of the conditional inference trees were used to create the prognostic model of EIS. Statistical data analysis was carried out applying the software packages of R V.3.2.5 and IBM SPSS Statistics 26.0.
Results: The rate of EIS reached 30%. The patients with EIS were 72.6±10.2 years old, patients without EIS - 68.1±11.3 years; p = 0.005. Previously, 22 clinical, demographic, laboratory variables accommodated in the computer database were included in the conditional inference trees statistical algorithm. The prognostic statistical model of EIS has been constructed. The following independent predictors of evolving IS were identified: the stroke subtype according to the Oxford Community Stroke Project classification, the serum urea level, and red blood cell number in the total blood count. The accuracy of the statistical model reaches 0.77 (95% CI: 0.75; 0.80), the sensitivity is 0.52, the specificity - 0.88, PPV - 0.66, and NPV - 0.81; p < 0.001.
Conclusion: The tree-structural model allowed us to identify the independent clinical predictors of EIS.
Keywords: Cerebral infarction, Clinical characteristics, Clinical course, Conditional inference trees algorithm, Decision tree, Evolving ischemic stroke, Model, Predictor, Prognosis, Stroke deterioration
Spontaneous intracerebral hemorrhage in Mexico: results from a Multicenter Na...Erwin Chiquete, MD, PhD
José L. Ruiz-Sandoval, Erwin Chiquete, Alejandra Gárate-Carrillo, Ana Ochoa-Guzmán, Antonio Arauz,
Carolina León-Jiménez, Karina Carrillo-Loza, Luis M. Murillo-Bonilla, Jorge Villarreal-Careaga,
Fernando Barinagarrementería, Carlos Cantú-Brito, and the RENAMEVASC investigators
Introduction. Scarce information exists on intracerebral hemorrhage (ICH) in Latin America, and the existent is derived
from single-center registries with non-generalizable conclusions. The aim of this study is to describe the frequency, etiology,
management and outcome of ICH in Mexico.
Patients and methods. We studied consecutive patients with ICH pertaining to the National Multicenter Registry on Cerebrovascular
Disease (RENAMEVASC), conducted in 25 centers from 14 states of Mexico. The Intracerebral Hemorrhage Grading
Scale (ICH-GS) at admission was used to assess prognosis at 30 days follow-up.
Results. Of 2,000 patients with acute cerebrovascular disease registered in RENAMEVASC, 564 (28%) had primary ICH
(53% women; median age: 63 years; interquartile range: 50-75 years). Hypertension (70%), vascular malformations (7%)
and amyloid angiopathy (4%) were the main etiologies. In 10% of cases etiology could not be determined. Main ICH
locations were basal ganglia (50%), lobar (35%) and cerebellum (5%). Irruption into the ventricular system occurred in
43%. Median score of ICH-GS was 8 points: 49% had 5-7 points, 37% had 8-10 points and 15% had 11-13 points. The 30-day
case fatality rate was 30%, and 31% presented severe disability. The 30-day survival was 92% for patients with ICH-GS 5-7
points, whereas it decreased to 27% in patients with ICH-GS 11-13 points.
Conclusions. In Mexico, ICH represents about a third of the forms of acute cerebrovascular disease, and the majority of
patients present severe disability or death at 30 days of follow-up. Hypertension is the main cause; hence, control of this important cardiovascular risk factor should reduce the health burden of ICH.
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The goal of the study was to identify the most significant prognostic clinical criteria for the survival of patients with ischemic stroke (IS) within 1 year of observation.
Methods and Materials: The object of the clinical prospective study was 1421 patients with IS hospitalized in 2002-2015 in the neurological (stroke) departments of the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital. Analyzing the obtained data, we adhered to the prospective-specimen-collection, retrospective evaluation design of the study. The primary endpoint of the study was the patient's death from any reason within one year of the development of IS. Information on poststroke all-cause mortality was obtained through linkages to the official source - the centralized archive of deaths of residents of the city of Minsk. Patients without a confirmed death date were censored at the date last known alive. All patients that were alive at one year are assumed to be censored at that time. The collection of clinical, demographic, neuroimaging, laboratory data, as well as the final determination of the stroke outcome, was performed blindly with respect to survival data.
Results: To build the model, 22 multivariate clinical indicators were used that demonstrated the relationship with post-stroke survival at the stage of preliminary data analysis: stroke subtype according the Oxfordshire Community Stroke Project, age, gender, the severity of the neurological deficit according to the NIHSS scale at hospitalization, previous stroke or TIA, the presence of arterial hypertension, atrial fibrillation, myocardial atherosclerosis, congestive heart failure, diabetes mellitus, peripheral arterial diseases, alcohol abuse, level of creatinine, glucose, urea, potassium, sodium in blood, amount of hemoglobin, erythrocytes and leukocytes on the 1st day of treatment, the level of systolic and diastolic blood pressure in the hospital admission department.
In the construction of a survival decision tree of patients with IS, of the 22 initially embedded parameters, only 6 independent predictors were finally included in the prognostic model: the stroke subtype according to the OCSP, the presence of a lacunar infarction, the severity of neurologic deficit at hospitalization according NIHSS, level of urea and glucose in the blood, and the presence of congestive heart failure.
Comparison of clinical, radiological and outcome characteristics of ischemic ...MIMS Hospital
Here is the latest publication from the department of Neurology in the Journal of Neurology Research, titled, ’Comparison of Clinical, Radiological and Outcome Characteristics of Ischemic Strokes in Different Vascular Territories’ authored by Ashraf V Valappila, c, Dhanya T Janardhanana, Praveenkumar Raghunatha, Abdulla Cherayakkatb, Girija ASa
Cerebral Venous Thrombosis in a Mexican Multicenter Registry of Acute Cerebro...Erwin Chiquete, MD, PhD
Background: Cerebral venous thrombosis (CVT) is a rare form of cerebrovascular
disease that is usually not mentioned in multicenter registries on all-type acute
stroke. We aimed to describe the experience on hospitalized patients with CVT in
a Mexican multicenter registry on acute cerebrovascular disease. Methods: CVT
patients were selected from the RENAMEVASC registry, which was conducted
between 2002 and 2004 in 25 Mexican hospitals. Risk factors, neuroimaging,
and 30-day outcome as assessed by the modified Rankin scale (mRS) were analyzed.
Results: Among 2000 all-type acute stroke patients, 59 (3%; 95% CI, 2.3-3.8%) had
CVT (50 women; female:male ratio, 5:1; median age, 31 years). Puerperium (42%),
contraceptive use (18%), and pregnancy (12%) were the main risk factors in women.
In 67% of men, CVTwas registered as idiopathic, but thrombophilia assessment was
suboptimal. Longitudinal superior sinus was the most frequent thrombosis location
(78%). Extensive (.5 cm) venous infarction occurred in 36% of patients. Only 81% of
patients received anticoagulation since the acute phase, and 3% needed decompressive
craniectomy. Mechanical ventilation (13.6%), pneumonia (10.2%) and systemic
thromboembolism (8.5%) were the main in-hospital complications. The 30-day case
fatality rate was 3% (2 patients; 95% CI, 0.23-12.2%). In a Cox proportional hazards
model, only age ,40 years was associated with a mRS score of 0 to 2 (functional independence;
rate ratio, 3.46; 95% CI, 1.34-8.92). Conclusions: The relative frequency
of CVT and the associated in-hospital complications were higher than in other registries.
Thrombophilia assessment and acute treatment was suboptimal. Young age
is the main determinant of a good short-term outcome.
Introduction: Chronic Kidney Disease (CKD) is a worldwide public health problem and it is increasing over time. Cardiovascular disease is a major concern for patients with end stage renal disease, especially those on hemodialysis. It is the leading cause of death among patients with chronic kidney
disease, particularly in dialysis population.
Elevated Tissue Doppler E/E' on Index Admission Can Help Identify Patients at...crimsonpublishersOJCHD
Readmissions for congestive Heart Failure (CHF) are a major healthcare problem that contributes significantly to the overall healthcare expenditure. About 24% of patients are readmitted to the hospital within 30 days of discharge. We investigated whether a non-invasive estimate of left atrial filling pressure, an elevated ratio of early trans mitral flow velocity to early diastolic mitral annular velocity (E/E'), during the index admission for CHF could independently predict 30 day readmission.
Hello,
I am Anoop "Business Development Executive" at India based professional Company "Brief Soft Technologies Pvt. Ltd."We are offering high quality and affordable mobile application development solutions.
My Skype : andrew_briefsoft
Cerebral Venous Thrombosis in a Mexican Multicenter Registry of Acute Cerebro...Erwin Chiquete, MD, PhD
Background: Cerebral venous thrombosis (CVT) is a rare form of cerebrovascular
disease that is usually not mentioned in multicenter registries on all-type acute
stroke. We aimed to describe the experience on hospitalized patients with CVT in
a Mexican multicenter registry on acute cerebrovascular disease. Methods: CVT
patients were selected from the RENAMEVASC registry, which was conducted
between 2002 and 2004 in 25 Mexican hospitals. Risk factors, neuroimaging,
and 30-day outcome as assessed by the modified Rankin scale (mRS) were analyzed.
Results: Among 2000 all-type acute stroke patients, 59 (3%; 95% CI, 2.3-3.8%) had
CVT (50 women; female:male ratio, 5:1; median age, 31 years). Puerperium (42%),
contraceptive use (18%), and pregnancy (12%) were the main risk factors in women.
In 67% of men, CVTwas registered as idiopathic, but thrombophilia assessment was
suboptimal. Longitudinal superior sinus was the most frequent thrombosis location
(78%). Extensive (.5 cm) venous infarction occurred in 36% of patients. Only 81% of
patients received anticoagulation since the acute phase, and 3% needed decompressive
craniectomy. Mechanical ventilation (13.6%), pneumonia (10.2%) and systemic
thromboembolism (8.5%) were the main in-hospital complications. The 30-day case
fatality rate was 3% (2 patients; 95% CI, 0.23-12.2%). In a Cox proportional hazards
model, only age ,40 years was associated with a mRS score of 0 to 2 (functional independence;
rate ratio, 3.46; 95% CI, 1.34-8.92). Conclusions: The relative frequency
of CVT and the associated in-hospital complications were higher than in other registries.
Thrombophilia assessment and acute treatment was suboptimal. Young age
is the main determinant of a good short-term outcome.
Introduction: Chronic Kidney Disease (CKD) is a worldwide public health problem and it is increasing over time. Cardiovascular disease is a major concern for patients with end stage renal disease, especially those on hemodialysis. It is the leading cause of death among patients with chronic kidney
disease, particularly in dialysis population.
Elevated Tissue Doppler E/E' on Index Admission Can Help Identify Patients at...crimsonpublishersOJCHD
Readmissions for congestive Heart Failure (CHF) are a major healthcare problem that contributes significantly to the overall healthcare expenditure. About 24% of patients are readmitted to the hospital within 30 days of discharge. We investigated whether a non-invasive estimate of left atrial filling pressure, an elevated ratio of early trans mitral flow velocity to early diastolic mitral annular velocity (E/E'), during the index admission for CHF could independently predict 30 day readmission.
Hello,
I am Anoop "Business Development Executive" at India based professional Company "Brief Soft Technologies Pvt. Ltd."We are offering high quality and affordable mobile application development solutions.
My Skype : andrew_briefsoft
Maria Fladvad highlights in her presentation how social innovation can be created from the creation of networks and sharing of ideas between different European regions.
Hello,
I am Anoop "Business Development Executive" at India based professional Company "Brief Soft Technologies Pvt. Ltd."We are offering high quality and affordable mobile application development solutions.
Spontaneous intracerebral hemorrhage in Mexico: results from a Multicenter Na...Erwin Chiquete, MD, PhD
Introduction. Scarce information exists on intracerebral hemorrhage (ICH) in Latin America, and the existent is derived
from single-center registries with non-generalizable conclusions. The aim of this study is to describe the frequency, etiology,
management and outcome of ICH in Mexico.
Patients and methods. We studied consecutive patients with ICH pertaining to the National Multicenter Registry on Cerebrovascular
Disease (RENAMEVASC), conducted in 25 centers from 14 states of Mexico. The Intracerebral Hemorrhage Grading
Scale (ICH-GS) at admission was used to assess prognosis at 30 days follow-up.
Results. Of 2,000 patients with acute cerebrovascular disease registered in RENAMEVASC, 564 (28%) had primary ICH
(53% women; median age: 63 years; interquartile range: 50-75 years). Hypertension (70%), vascular malformations (7%)
and amyloid angiopathy (4%) were the main etiologies. In 10% of cases etiology could not be determined. Main ICH
locations were basal ganglia (50%), lobar (35%) and cerebellum (5%). Irruption into the ventricular system occurred in
43%. Median score of ICH-GS was 8 points: 49% had 5-7 points, 37% had 8-10 points and 15% had 11-13 points. The 30-day
case fatality rate was 30%, and 31% presented severe disability. The 30-day survival was 92% for patients with ICH-GS 5-7
points, whereas it decreased to 27% in patients with ICH-GS 11-13 points.
Conclusions. In Mexico, ICH represents about a third of the forms of acute cerebrovascular disease, and the majority of
patients present severe disability or death at 30 days of follow-up. Hypertension is the main cause; hence, control of this
important cardiovascular risk factor should reduce the health burden of ICH.
Acute care and one-year outcome of Mexican patients with first-ever acute isc...Erwin Chiquete, MD, PhD
Introduction. Information on acute care and outcome of Mexican patients with ischaemic stroke is lacking. The aim of this
report is to provide results of a first step stroke surveillance system and outcome at one year of follow-up.
Patients and methods. In the PREMIER study 1,376 patients from 59 Mexican hospitals were included from January 2005
to June 2006. Of these, 1,040 (52% women, mean age 67.5 years) with first-ever cerebral infarction are here analyzed.
Five visits were completed during the one year follow-up.
Results. Main risk factors were hypertension (64%), obesity (51%) and diabetes (35%). Total anterior circulation stroke
syndrome occurred in 19% of patients, partial anterior in 38%, lacunar in 26% and posterior stroke syndrome in 17% cases.
In 8% the stroke mechanism was large-artery atherosclerosis, in 18% cardioembolism, in 20% lacunar, in 6% miscellaneous
mechanisms and in 42% the mechanism was undetermined, mainly due to a low use of diagnostic resources. Although 17%
of patients arrived in < 3 h from stroke onset, only 0.5% had IV thrombolysis. Only 1% received endarterectomy or stenting.
The 30-day case fatality rate was 15%. At one-year of follow-up, 47% had a modified Rankin score 0-2 (independent), 23%
had 2-5 (dependent) and 29% died. One-year acute ischaemic stroke recurrence rate was 8%.
Conclusion. In Mexico a significant proportion of patients arrive on time for thrombolysis, but very few receive this therapy.
There is a low use of diagnostic resources to assign aetiology. Thirty-day case fatality rate doubles at 1-year after acute
ischaemic stroke.
Serum Uric Acid and Outcome after Acute Ischemic Stroke: PREMIER StudyErwin Chiquete, MD, PhD
Background: Current evidence shows that uric acid is a potent
antioxidant whose serum concentration increases rapidly
after acute ischemic stroke (AIS). Nevertheless, the relationship
between serum uric acid (SUA) levels and AIS
outcome remains debatable. We aimed to describe the
prognostic significance of SUA in AIS. Methods: We studied
463 patients (52% men, mean age 68 years, 13% with glomerular
filtration rate <60 />2) at 30 days, or with
any outcome measure at 3, 6 or 12 months poststroke. After
adjustment for age, gender, stroke type and severity (NIHSS
<9),><24 h. Conclusions: A low SUA
concentration is modestly associated with a very good
short-term outcome. Our findings support the hypothesis
that SUA is more a marker of the magnitude of the cerebral
infarction than an independent predictor of stroke outcome.
ORIGINAL ARTICLENeuromuscular complications after hematopo.docxalfred4lewis58146
ORIGINAL ARTICLE
Neuromuscular complications after hematopoietic stem
cell transplantation
Susanne Koeppen & Abhiyrahmi Thirugnanasambanthan &
Michael Koldehoff
Received: 19 December 2013 /Accepted: 20 March 2014 /Published online: 29 March 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose The aim of this study was to analyze the occurrence
of neuromuscular symptoms in recipients of allogeneic hema-
topoietic stem cell transplantation (HSCT) for treatment of
malignant hematopoietic disease.
Methods Among 247 outpatients after allogeneic HSCT, we
conducted a prospective non-interventional study between
July 2011 and August 2013. During follow-up visits, clinical
and electrophysiological findings were correlated to the pres-
ence of autoantibodies/alloantibodies and to frequencies of
lymphocyte subpopulations in peripheral blood.
Results Resulting in an incidence of 8.1 %, 20 patients were
diagnosed with neuromuscular complications at a median
onset of 12 months post-transplant. Five patients (25 %) were
identified with polyneuropathy (PNP), ten patients (50 %)
with combined PNP and myopathy, four patients (20 %) with
myopathy or polymyositis (PM), and one patient (5 %) with
myasthenia gravis (MG). Immune-mediated sensorimotor
PNP after HSCT is characterized by a predominantly axonal
lesion and can be overlapping with neurotoxic side effects.
The latency between HSCT and development of PM varied
between 60 days and 72 months. In general, PM occurs
parallel to graft-versus-host disease (GvHD) after tapering of
immunosuppressive medication. Typical clinical features are
proximal bilateral limb weakness with muscle atrophy. Auto-
antibodies (Ab) were detected in 12 patients, myositis-specific
Ab only in one patient. In patients with progressive
neurological symptoms, a decrease in the CD4/CD8 T cell
ratio was observed.
Conclusions GvHD-related myositis appeared similar to idi-
opathic myositis regarding clinical and electromyographical
findings. As outcome measure, sequential analysis of lympho-
cyte subpopulations in peripheral blood seems to be more
suitable than Ab measurements. Whereas peripheral neuropa-
thies are commonly observed shortly after HSCT, MG is a rare
complication in the late post-HSCT phase.
Keywords Allogeneic hematopoietic stem cell
transplantation . Graft-versus-host disease . Polyneuropathy .
Polymyositis . Myasthenia gravis
Abbreviations
AChR Ab Acetylcholine receptor antibody
AL Acute leukemia
ALL Acute lymphocytic leukemia
ANA Antinuclear antibodies
AML Acute myeloid leukemia
Ab Autoantibodies
CK-MB Creatine kinase-MB
CLL Chronic lymphocytic leukemia
CML Chronic myeloid leukemia
GvHD Graft-versus-host disease
HSCT Hematopoietic stem cell transplantation
ND Not done
MCL Mantle cell lymphoma
MG Myasthenia gravis
MM Multiple myeloma
MPN Myeloproliferative neoplasm
OMF Osteomyelofibrosis
PM Polymyositis
PNP Polyneuropathy
S. Koeppen (*): A. Thirugnanasambanthan
Department of Neurology, Medical School, Un.
Novel Method for Automated Analysis of Retinal Images: Results in Subjects wi...Mutiple Sclerosis
Michele Cavallari, Claudio Stamile, Renato Umeton, Francesco Calimeri, and Francesco Orzi
Morphological analysis of the retinal vessels by fundoscopy provides noninvasive means for detecting and staging systemic microvascular damage. However, full exploitation of fundoscopy in clinical settings is limited by paucity of quantitative, objective information obtainable through the observer-driven evaluations currently employed in routine practice. Here, we report on the development of a semiautomated, computer-based method to assess retinal vessel morphology. The method allows simultaneous and operator-independent quantitative assessment of arteriole-to-venule ratio, tortuosity index, and mean fractal dimension. The method was implemented in two conditions known for being associated with retinal vessel changes: hypertensive retinopathy and Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL). The results showed that our approach is effective in detecting and quantifying the retinal vessel abnormalities. Arteriole-to-venule ratio, tortuosity index, and mean fractal dimension were altered in the subjects with hypertensive retinopathy or CADASIL with respect to age- and gender-matched controls. The interrater reliability was excellent for all the three indices (intraclass correlation coefficient ≥ 85%). The method represents simple and highly reproducible means for discriminating pathological conditions characterized by morphological changes of retinal vessels. The advantages of our method include simultaneous and operator-independent assessment of different parameters and improved reliability of the measurements.
A less-invasive-approach-of-medial-meniscectomy-in-rat-a-model-to-target-earl...science journals
In order for insulin to exert its biological actions on target cells in peripheral tissues like muscle and adipose tissues, Insulin must pass through the endothelial barrier into the interstitium.
Mortalidad asociada al diagnóstico de síndrome de Guillain-Barré en adultos i...Erwin Chiquete, MD, PhD
Mortality associated with a diagnosis of Guillain-Barré syndrome in adults of Mexican health institutions
Introduction. Guillain-Barré syndrome (GBS) is a neurological emergency representing the main cause of flaccid paralysis
around the world, affecting all age groups. Little is known about the essential epidemiology of GBS in most Latin American
countries.
Aim. To determine the mortality associated with the diagnosis of GBS in hospital discharges during 2010 in hospitals of
the Ministry of Health, Mexico.
Patients and methods. We analyzed the database of hospital discharges of institutions pertaining to the Ministry of
Health. Study cases were identified by the code G61.0 of the International Classification of Diseases, 10th revision (ICD-10).
We excluded records of patients younger than 18 years and patients without complete demographic information.
Results. During the year 2010 there were 2,634,339 discharges from hospitals of the Ministry of Health. We identified a
total of 467 hospitalizations due to GBS in adults (median age: 41 years; 62.1% male) from 121 health institutions of the
32 Republic States. The highest frequency of GBS hospitalizations occurred during summer and fall. The median hospital
stay was 8 days. The hospital mortality rate was 10.5%. The probability of death was directly associated with age, without
a particular trend regarding gender, hospital care or state.
Conclusions. In 2010 GBS hospital mortality in this part of the Mexican health system was higher than that reported in
contemporary studies. A seasonal association was observed regarding the frequency of hospitalizations for GBS.
Key words. Climate. Epidemiology. Guillain-Barré syndrome. Mortality. Mexico.
Rogelio Domínguez-Moreno, Paulina Tolosa-Tort, Anais Patiño-Tamez, Alejandra Quintero-Bauman,
Deisy K. Collado-Frías, María G. Miranda-Rodríguez, Obet J. Canela-Calderón, Pablo Hurtado-Valadez,
Raúl de Gante-Castro, Karoll M. Ortiz-Guillén, Bruno Estañol-Vidal, Horacio Sentíes-Madrid,
Guillermo García-Ramos, Carlos Cantú-Brito, José Luis Ruiz-Sandoval, Erwin Chiquete
Seroepidemiology of Toxoplasma gondii infection in drivers involved in road t...Erwin Chiquete, MD, PhD
Background: The prevalence of toxoplasmosis in the general population of Guadalajara, Mexico, is around 32%.
Toxoplasmosis can cause ocular lesions and slowing of reaction reflexes. Latent toxoplasmosis has been related
with traffic accidents. We aimed to assess the prevalence of anti-Toxoplasma gondii antibodies and visual
impairments related with traffic accidents in drivers from the metropolitan Guadalajara.
Methods: We prospectively evaluated the prevalence of IgG and IgM anti-T. gondii antibodies in 159 individuals
involved in traffic accidents, and in 164 control drivers never involved in accidents. Cases of toxoplasmosis
reactivation or acute infection were detected by PCR in a subset of 71 drivers studied for the presence of T. gondii
DNA in blood samples. Ophthalmologic examinations were performed in drivers with IgG anti-T. gondii antibodies
in search of ocular toxoplasmosis.
Results: Fifty-four (34%) traffic accident drivers and 59 (36%) controls were positive to IgG anti-T. gondii antibodies
(p = 0.70). Among the 113 seropositive participants, mean anti-T. gondii IgG antibodies titers were higher in traffic
accident drivers than in controls (237.9 ± 308.5 IU/ml vs. 122.9 ± 112.7 IU/ml, respectively; p = 0.01 by Student’s t
test, p = 0.037 by Mann–Whitney U test). In multivariate analyses, anti-T. gondii IgG antibody titers were consistently
associated with an increased risk of traffic accidents, whereas age showed an inverse association. The presence of
IgM-anti-T. gondii antibodies was found in three (1.9%) subjects among traffic accident drives, and in two (1.2%)
controls. Three (4.2%) samples were positive for the presence of T. gondii DNA, all among seropositive individuals.
No signs of ocular toxoplasmosis were found in the entire cohort. Moreover, no other ocular conditions were found
to be associated with the risk of traffic accidents in a multivariate analysis.
Conclusions: Anti-T. gondii antibody titers are associated with the risk of traffic accidents. We could not determine
any association of ocular toxoplasmosis with traffic accidents. Our results warrant further analyses in order to clarify
the link between toxoplasmosis and traffic accidents.
Tiempo de llegada hospitalaria y pronóstico funcional después deun infarto ce...Erwin Chiquete, MD, PhD
Introducción: La información sobre el tiempo de llegada hospitalaria después de un infartocerebral (IC) se ha originado en países con unidades especializadas en ictus. Existe poca infor-mación en naciones emergentes. Nos propusimos identificar los factores que influyen en eltiempo de llegada hospitalaria a 1, 3 y 6 h y su relación con el pronóstico funcional después delictus.Métodos: Se analizó la información de pacientes con IC incluidos en el estudio Primer RegistroMexicano de Isquemia Cerebral (PREMIER) que tuvieran tiempo definido desde el inicio de lossíntomas hasta la llegada hospitalaria. El desenlace funcional se evaluó mediante la escalamodificada de Rankin a los 30 días, 3, 6 y 12 meses.Resultados: De 1.096 pacientes con IC, 61 (6%) llegaron en < 1 h, 250 (23%) en < 3 h y 464 (42%)en < 6 h. Favorecieron la llegada temprana en < 1 h: el antecedente familiar de cardiopatíaisquémica y ser migra˜noso; en < 3 h: edad 40-69 a˜nos, antecedente familiar de hipertensión,antecedente personal de dislipidemia y cardiopatía isquémica, así como la atención en hospitalprivado; en < 6 h: antecedente familiar de hipertensión, ser migra˜noso, ictus previo, cardiopatíaisquémica y atención en hospital privado. La llegada hospitalaria tardía se asoció a ictus lacunary alcoholismo. Solo el 2,4% recibió trombólisis. Independientemente de la trombólisis, la llegadaen < 3 h se asoció a menor mortalidad a los 3 y 6 meses, además de menos complicacionesintrahospitalarias.
Comportamiento del barorreflejo en pacientes con síncope vasovagal durante el...Erwin Chiquete, MD, PhD
Caroline Malamud-Kessler, Bruno Estañol-Vidal, Óscar Infante-Vázquez, Miguel Campos-Sánchez,
Erwin Chiquete
Introducción. El síncope mediado neuralmente, también conocido como síncope vasovagal, se define como la pérdida
súbita y transitoria del estado de alerta como consecuencia de un descenso brusco y profundo de la presión arterial.
Objetivo. Conocer las diferencias de los parámetros hemodinámicos que median el barorreflejo durante el ortostatismo
activo en pacientes con diagnóstico clínico de síncope vasovagal y sujetos sanos.
Sujetos y métodos. Estudio transversal, observacional y comparativo. Se incluyeron 20 pacientes con diagnóstico de síncope
neuralmente mediado y 30 controles, a los que se les practicó la prueba de ortostatismo activo y se les registró por
finometría la presión arterial sistólica (PAS) y la frecuencia cardíaca (intervalo entre latidos) de manera continua (latido a
latido) y no invasiva.
Resultados. Los pacientes con síncope presentaron una PAS basal con una media significativamente mayor que la de los
sanos. Las magnitudes medidas desde la PAS basal demostraron una diferencia significativa, que era de menor valor en el
grupo de los controles. No se demostraron diferencias entre grupos en la caída de la PAS desde el primer pico, recuperación
de la PAS desde la sima o en las latencias medidas en la frecuencia cardíaca.
Conclusiones. La PAS basal y la caída de la PAS medida desde la basal en posición supina fue mayor en los pacientes con
síncope mediado neuralmente que en los sujetos sanos. La magnitud de la elevación de la frecuencia cardíaca tuvo una
tendencia a ser mayor en el grupo de pacientes en comparación con el grupo control. Esto sugiere una hiperactividad
simpática en los pacientes con síncope
Delírium en adultos que reciben cuidados paliativos: revisión de laliteratura...Erwin Chiquete, MD, PhD
Delírium en adultos que reciben cuidados paliativos: revisión de laliteratura con un enfoque sistemáticoSofía Sánchez-Romána, Cristina Beltrán Zavalab, Argelia Lara Solaresby ErwinChiquetea,∗
El delírium en pacientes que reciben cuidados paliativos es frecuente y constituyeun importante reto de diagnóstico y tratamiento. Nuestro objetivo fue realizar en 2 fases unanálisis bibliométrico de la evidencia científica reciente (2007 a 2012) sobre diagnóstico y tra-tamiento del delírium en adultos en cuidados paliativos. En la fase 1 (estudios descriptivos yrevisiones narrativas) se identificaron 133 artículos relevantes: 73 trataron el tema del delíriumde forma secundaria y en 60 artículos como tema principal. Sin embargo, solo se identificaron4 estudios observacionales prospectivos en los que el delírium fue central. De 135 artículos iden-tificados en la fase 2 (ensayos clínicos o estudios descriptivos sobre tratamiento del delírium enpacientes paliativos), solo 3 fueron sobre prevención o tratamiento: 2 estudios retrospectivosy un ensayo clínico sobre prevención multicomponente en pacientes con cáncer. Gran parte dela literatura reciente corresponde a revisiones que hablan de estudios realizados hace másde una década en pacientes diferentes a los que reciben cuidados paliativos. En conclusión, laevidencia científica reciente sobre el delírium en cuidados paliativos es escasa y subóptima.Urgen estudios prospectivos que se enfoquen específicamente en esta población altamentevulnerable.
Central Adiposity and Mortality after First-Ever Acute Ischemic StrokeErwin Chiquete, MD, PhD
Erwin Chiquete a José L. Ruiz-Sandoval c Luis Murillo-Bonilla e
Carolina León-Jiménez g Bertha Ruiz-Madrigal d, f Erika Martínez-López d, f
Sonia Román d, f Arturo Panduro d, f Alma Ramos b Carlos Cantú-Brito
Background: The waist-to-height ratio (WHtR) may be a better
adiposity measure than the body mass index (BMI). We
evaluated the prognostic performance of WHtR in patients
with acute ischemic stroke (AIS). Methods: First, we compared
WHtR and BMI as adiposity measures in 712 healthy
adults by tetrapolar bioimpedance analysis. Thereafter,
baseline WHtR was analyzed as predictor of 12-month allcause
mortality in 821 Mexican mestizo adults with first-ever
AIS by a Cox proportional hazards model adjusted for baseline
predictors. Results: In healthy individuals, WHtR correlated
higher than BMI with total fat mass and showed a higher
accuracy in identifying a high percentage of body fat (p <
0.01). In AIS patients a U-shaped relationship was observed
between baseline WHtR and mortality (fatality rate 29.1%).
On multivariate analysis, baseline WHtR ≤ 0.300 or >0.800 independently
predicted 12-month all-cause mortality (h
José L. Ruiz-Sandoval, Guadalupe Ramírez-Guzmán,
Erwin Chiquete and Ángel Vargas-Sánchez
A 45-year-old garbage collector was referred to our department
with a history of tonic-clonic seizures and risky
sexual behavior (anilingus). A neurological examination was
normal. Contrast-enhanced cranial CT showed calcified lesions
and viable parasites compatible with a diagnosis of
massive non-encephalitic neurocysticercosis. Oral metallic
implants impeded performing brain MRI. Hepatitis and HIV
serologies were negative. The patient was discharged with
steroids and an anticonvulsant. Delayed cysticidal therapy
was planned; however, albendazole therapy was immediately
initiated in another hospital, which led to brain edema, uncontrolled
seizures, rostrocaudal deterioration and death.
Cestoda infections are rare in developed countries (1). In
contrast, neurocysticercosis is a leading cause of adult-onset
epilepsy in Latin America. Massive infections are classified
as encephalitic or non-encephalitic (2). In patients with the
encephalitic presentation, cysticidal drugs can cause extensive
parasite lysis and aggravate brain inflammation (2). In
patients with non-encephalitic massive neurocysticercosis,
cysticidal therapy is usually considered; (2) however, rapid
initiation of antiparasitic medications can launch an encephalitic
process.
Cost of care according to disease-modifying therapy in Mexicans with relapsin...Erwin Chiquete, MD, PhD
Miguel A. Macı´as-Islas • Isaac F. Soria-Cedillo • Merced Velazquez-Quintana •
Victor M. Rivera • Vero´nica I. Baca-Muro • Edith A. Lemus-Carmona • Erwin Chiquete
Limited data exist on the costs of care of
patients with multiple sclerosis (MS) in low- to middleincome
nations. The purpose of this study was to describe
the economic burden associated with care of Mexican
patients with relapsing-remitting MS in a representative
sample of the largest institution of the Mexican public
healthcare system. We analysed individual data of 492
patients (67 % women) with relapsing-remitting MS registered
from January 2009 to February 2011 at the Mexican
Social Security Institute. Direct costs were measured about
the use of diagnostic tests, disease-modifying therapies
(DMTs), symptoms control, medical consultations,
relapses, intensive care and rehabilitation. Four groups
were defined according to DMT alternatives: (1) interferon
beta (IFNb)-1a, 6 million units (MU); (2) IFNb-1a, 12MU;
(3) IFNb-1b, 8MU; and (4) glatiramer acetate. All patients
received DMTs for at least 1 year. The most frequently
used DMT was glatiramer acetate (45.5 %), followed by
IFNb-1a 12MU (22.6 %), IFNb-1b 8MU (20.7 %), and
IFNb-1a 6MU (11.2 %). The mean cost of a specialised
medical consultation was €74.90 (US $107.00). A single
relapse had a mean total cost of €2,505.97 (US $3,579.96).
No differences were found in annualised relapse rates and
costs of relapses according to DMT. However, a significant
difference was observed in total annual costs according to
treatment groups (glatiramer acetate being the most
expensive), mainly due to differences in unitary costs of
alternatives. From the public institutional perspective,
when equipotent DMTs are used in patients with comparable
characteristics, the costs of DMTs largely determine
the total expenses associated with care of patients with
relapsing-remitting MS in a middle-income country.
Blood pressure at hospital admission and outcome after primary intracerebral ...Erwin Chiquete, MD, PhD
Introduction: The importance of the admission blood pressure (BP) for intracerebral
hemorrhage (ICH) outcome is not completely clear. Our objective was to
analyze the clinical impact of BP at hospital arrival in patients with primary ICH.
Material and methods: We studied 316 patients (50% women, mean age:
64 years, 75% with hypertension history) with acute primary ICH. The first BP reading
at admission was evaluated for its association with neuroimaging findings
and outcome. A Cox proportional hazards model and Kaplan-Meier analyses
were constructed to evaluate factors associated with in-hospital mortality.
Results: Intraventricular irruption occurred in 52% of cases. A high frequency
of third ventricle extension was observed in patients with BP readings in the
upper quartiles of the distribution (systolic, diastolic, or mean arterial pressure).
Blood pressure readings did not correlate with hematoma volumes. In-hospital
case fatality rate was 46% (63% among those with ventricular irruption). Systolic
BP (SBP) > 190 mm Hg was independently associated with in-hospital mortality
in supratentorial (n = 285) ICH (hazard ratio: 1.19, 95% confidence interval:
1.02-1.38, for the highest vs. the lowest quartile) even after adjustment for
known strong predictors (age, ICH volume, Glasgow coma scale and ventricular
extension). Blood pressure was not significantly associated with ventricular
extension or outcome in patients with infratentorial ICH.
Conclusions: A high BP on admission is associated with an increased risk of
intraventricular extension and early mortality in patients with supratentorial
ICH. However, a significant proportion of patients with high BP readings without
ventricular irruption still have an increased risk of death.
Hepatitis C virus infection and type 2 diabetes mellitus in Mexican patients. Erwin Chiquete, MD, PhD
34. Chiquete E, Ochoa-Guzmán A, García-Lamas L, Anaya-Gómez F, Gutiérrez-Manjarrez JI, Sánchez-Orozco LV, Godínez-Gutiérrez SA, Maldonado M, Román S, Panduro A. Hepatitis C virus infection and type 2 diabetes mellitus in Mexican patients. Rev Med Inst Mex Seguro Soc. 2012;50(5):481-6. [PMID: 23282259]
Atherothrombotic Disease, Traditional Risk Factors, and 4-Year Mortality in a...Erwin Chiquete, MD, PhD
Erwin Chiquete, MD, PhD
Background: Atherothrombosis is becoming the leading cause of chronic morbidity in developing countries. This
epidemiological transition will represent an unbearable socioeconomic burden in the near future. We investigated
factors associated with 4-year all-cause mortality in a Latin American population at high risk.
Hypothesis: Largely modifiable risk factors as well as polyvascular disease are the main predictors of 4-year all-cause and
cardiovascular mortality in this Latin American cohort.
Methods: We analyzed 1816 Latin American stable outpatients (62.3% men, mean age 67 years) with symptomatic
atherothrombosis (87.1%) or with multiple risk factors only (12.9%), in the Reduction of Atherothrombosis for Continued
Health registry.
Results: Of patients with symptomatic atherothrombosis, 57.3% had coronary artery disease, 32% cerebrovascular disease,
and 11.7% peripheral artery disease at baseline (9.1% polyvascular). The main risk factors were hypertension (76%),
hypercholesterolemia (60%), and smoking (52.3%) in patients with established atherothrombosis; and hypertension
(89.7%), diabetes (80.8%), and hypercholesterolemia (73.9%) in those with risk factors only. Four-year all-cause mortality
steeply increased with none (6.8%), 1 (9.2%), 2 (15.5%), and 3 (29.2%) symptomatic arterial disease locations. In patients
with only 1 location, cardiovascular mortality was significantly higher with peripheral artery disease (11.3%) than with
cerebrovascular disease (6%) or coronary artery disease (5.1%). Significant baseline predictors of 4-year all-cause mortality
were congestive heart failure (hazard ratio [HR]: 3.81), body mass index<20 (HR: 2.32), hypertension (HR: 1.84), polyvascular
disease (HR: 1.69), and age ≥65 years (HR: 1.47), whereas statin use (HR: 0.49) and body mass index ≥30 (HR: 0.58) were
associated with a reduced risk.
Conclusions: Hypertension was the main modifiable risk factor for atherothrombosis and all-cause mortality in this Latin
José L. Ruiz-Sandoval, Erwin Chiquete,
Lucía E. Álvarez-Palazuelos, Miguel
A. Andrade-Ramos & Luis R. Rodríguez-
Rubio
Osmotic demyelination syndrome (ODS) is the
damage over the central nervous system caused by several
electrolytes, metabolic and toxic disorders. We aimed to
describe cases of unusual forms of ODS. In a 9-year period,
25 consecutive patients with ODS (15 men; mean age
42 years) were registered in our referral institution, among
them, four (16 %) with atypical neuroimaging findings
were abstracted for this communication. None of them
presented cardiorespiratory arrest, head trauma, seizures,
neuromyelitis optica spectrum or contact with toxic
chemicals. Case 1 was a 33-year-old alcoholic man without
hypertension or electrolyte imbalance, who presented a
classic central pontine myelinolysis (CPM) and a hemorrhage
within the pons. Case 2 was a 34-year-old alcoholic
man with hypoglycemia and hyponatremia who presented
CPM and diffuse bihemispheric extrapontine myelinolysis
(EPM) after correction of serum sodium. Case 3 was a
52-year-old woman with mild hypokalemia and hyponatremia
(inadequately corrected), who presented a peduncular
and cerebellar EPM. Case 4 was a 67-year-old
woman who had a suicidal attempt with antidepressants
and carbamazepine without impaired consciousness, who
complicated with mild hyponatremia associated with a
classical CPM and a spinal cord EPM. Case 2 died and the
rest remained with variable neurological impairments at
last follow-up visit. With modern neuroimaging, the
so-called atypical forms of ODS may not be as rare as
previously thought; however, they could have a more
adverse outcome than the classical ODS.
An Expandable Prosthesis with Dual Cage-and-Plate Function in a Single Device...Erwin Chiquete, MD, PhD
Juan J. Ramı´rez, Erwin Chiquete, Juan J. Ramı´rez, Jr., Ernesto Go´mez-Limo´n, and Juan M. Ramı´rez
An expandable vertebral body prosthesis with dual cage-and-plate function in a single
device (JR prosthesis) was designed to test the hypothesis that this modular system can
provide the biomechanical requirements for immediate and durable spine stabilization
after corpectomy. Cadaver assays were performed with a stainless steal device to test fixation
and adequacy to the human spine anatomy. Then, 14 patients with vertebral tumors
(eight metastatic) underwent corpectomy and vertebral body replacement with a titaniummade
JR prosthesis. All patients had neurological deficit, severe pain and spine instability
prior to surgery. Mean pain score before surgery on a visual analog scale decreased from
7.6e3.0 points after operation ( p 5 0.002). All patients achieved at least one grade of
improvement in the Frankel score ( p 5 0.003), excepting the three patients with Frankel
grade A before surgery. Two patients with renal cell carcinoma died during the following
4 days after surgery. The remaining patients attained a painless and stable spine immediately,
which was maintained for long periods (mean follow-up: 25.4 months). No significant
infections or implant failures were registered. A nonfatal case of inferior vena cava
surgical injury was observed (repaired during surgery without further complications). In
conclusion, the JR prosthesis stabilizes the spine immediately after surgery and for the
rest of the patients’ life. To our knowledge, this is the first report on the clinical experience
of any expandable vertebral body prosthesis with dual cage-and-plate function in
a single device.
Expression profile of BRCA1 and BRCA2 genes in premenopausal Mexican women wi...Erwin Chiquete, MD, PhD
Gloria Loredo-Pozos, Erwin Chiquete,
Antonio Oceguera-Villanueva, Arturo Panduro,
Fernando Siller-Lo´pez, Martha E. Ramos-Márquez
Low BRCA1 gene expression is associated with
increased invasiveness and influences the response of
breast carcinoma (BC) to chemotherapeutics. However,
expression of BRCA1 and BRCA2 genes has not been
completely characterized in premenopausal BC. We analyzed
the clinical and immunohistochemical correlates of
BRCA1 and BRCA2 expression in young BC women. We
studied 62 women (mean age 38.8 years) who developed
BC before the age of 45 years. BRCA1 and BRCA2 mRNA
expression was assessed by reverse transcriptase-polymerase
chain reaction (RT-PCR) and that of HER-2 and
p53 proteins by immunohistochemistry. Body mass index
(BMI) C27 (52%) and a declared family history of BC
(26%) were the main risk factors. Ductal infiltrative adenocarcinoma
was found in 86% of the cases (tumor size
[5 cm in 48%). Disease stages I–IV occurred in 2, 40, 55,
and 3%, respectively (73% implicating lymph nodes).
Women aged B35 years (24%) had more family history of
cervical cancer, stage III/IV disease, HER-2 positivity, and
lower BRCA1 expression than older women (P-.05).
BRCA1 and BRCA2 expression correlated in healthy, but
not in tumor tissues (TT). Neither BRCA1 nor BRCA2
expression was associated with tumor histology, differentiation,
nodal metastasis or p53 and HER-2 expression.
After multivariate analysis, only disease stage explained
BRCA1 mRNA levels in the lowest quartile. Premenopausal
BC has aggressive clinical and molecular
characteristics. Low BRCA1 mRNA expression is associated
mainly with younger ages and advanced clinical stage
of premenopausal BC. BRCA2 expression is not associated
with disease severity in young BC women.
En conclusión, la neurotoxicidad por exposición
crónica a PDCB es rara y ha sido poco descrita
en la bibliografía. Las propiedades lipofílicas de
este compuesto producen desmielinización central,
y dan lugar a leucoencefalopatía difusa,
supra e infratentorial. Las manifestaciones más
frecuentemente descritas son agudas, y son de
interés particular, en nuestro paciente, las manifestaciones
cognitivas de tipo demenciales en
un seguimiento a largo plazo. Las recomendaciones
domésticas deben dirigirse a evitar el
contacto por parte de los menores de edad con
este compuesto, así como a su eventual sustitución
por productos menos tóxicos.
Hemorragia intracerebral espontánea en México: resultados del Registro Hospit...Erwin Chiquete, MD, PhD
José L. Ruiz-Sandoval, Erwin Chiquete, Alejandra Gárate-Carrillo, Ana Ochoa-Guzmán, Antonio Arauz,
Carolina León-Jiménez, Karina Carrillo-Loza, Luis M. Murillo-Bonilla, Jorge Villarreal-Careaga,
Fernando Barinagarrementería, Carlos Cantú-Brito, investigadores RENAMEVASC
Introducción. Existe poca información respecto a la hemorragia intracerebral (HIC) en América Latina, y la existente ha
sido derivada de registros hospitalarios de un solo centro con conclusiones no generalizables. El objetivo de este estudio
es describir la frecuencia, etiología, manejo y desenlace clínico de la HIC en México.
Pacientes y métodos. Se estudiaron pacientes consecutivos con HIC incluidos en el Registro Nacional Mexicano de Enfermedad
Vascular Cerebral (RENAMEVASC), conducido en 25 centros de 14 estados de la República Mexicana. Se usó la
Intracerebral Hemorrhage Grading Scale (ICH-GS) para estimar el pronóstico a 30 días.
Resultados. De 2.000 pacientes con ictus agudo en el RENAMEVASC, 564 (28%) presentaron HIC espontánea (53% mujeres;
edad media: 63 años; rango intercuartílico: 50-75 años). La hipertensión arterial (70%), las malformaciones vasculares
(7%) y la angiopatía amiloidea (4%) fueron las causas más frecuentes. No se determinó la etiología en el 10% de
los casos. Las localizaciones más frecuentes fueron ganglionar (50%), lobar (35%) y cerebelosa (5%). La irrupción hacia
el sistema ventricular ocurrió en el 43%. La mediana en la escala ICH-GS al ingreso hospitalario fue de 8 puntos: el 49%
presentó 5-7 puntos; el 37%, 8-10 puntos, y el 15%, 11-13 puntos. La tasa de mortalidad a 30 días fue del 30%, y el 31%
mostró discapacidad grave. La sobrevida a 30 días fue del 92% en pacientes con 5-7 puntos en la escala ICH-GS, mientras
que se redujo al 27% en aquellos con 11-13 puntos.
Conclusiones. En México, la HIC representa casi un tercio de las formas de enfermedad vascular cerebral aguda, y la mayoría de los pacientes que la padecen presentan discapacidad funcional grave o muerte a 30 días. La hipertensión es la principal causa, por lo que el control de este importante factor de riesgo debería reducir la carga sanitaria de la HIC.
Presión arterial sistólica y pronóstico funcional en pacientes con enfermedad...Erwin Chiquete, MD, PhD
Manuel Baños-González, Carlos Cantú-Brito, Erwin Chiquete, Antonio Arauz, José Luís Ruiz-Sandoval, Jorge Villarreal-Careaga, Fernando Barinagarrementeria, José Juan Lozano y los investigadores RENAMEVASC
Objetivo: Analizar la asociación de la presión arterial sistólica (PAS) al ingreso hospitalario
y la evolución clínica a 30 días en pacientes con enfermedad vascular cerebral (EVC) aguda.
Métodos: El REgistro NAcional Mexicano de Enfermedad VAScular Cerebral (RENAMEVASC) es un registro
hospitalario multicéntrico realizado de noviembre de 2002 a octubre de 2004. Se registraron
2000 pacientes con distintos síndromes clínicos de EVC aguda confirmados por neuroimagen. La
estratificación de la evolución clínica se realizó mediante la escala de Rankin modificada.
Resultados: Se analizaron 1721 pacientes con registro de la PAS: 78 (4.5%) con isquemia cerebral
transitoria, 894 (51.9%) con infarto cerebral, 534 (30.9%) con hemorragia intracerebral,
165 (9.6%) con hemorragia subaracnoidea y 50 (2.9%) con trombosis venosa cerebral. De los
1036 (60.2%) pacientes con el antecedente de hipertensión, sólo 32.4% tenía un tratamiento
regular. La tasa de mortalidad a 30 días presentó un patrón en J con respecto a la PAS, de
tal manera que el riesgo de muerte fue máximo en <100><100>65 años (RR: 2.16, IC 95%: 1.74 - 2.67).
Conclusión: Tanto la hipotensión como la hipertensión arterial significativa al ingreso hospitalario
se asocian a un pronóstico adverso en la EVC aguda. No obstante, un buen pronóstico
funcional se puede lograr en un amplio rango de cifras de PAS.
Estudio multicéntrico INDAGA. Índice tobillo-brazo anormal en población mexic...Erwin Chiquete, MD, PhD
Carlos Cantú-Brito, Erwin Chiquete, Manuel Duarte-Vega, Alberto Rubio-Guerra, Martín Herrera-Cornejo, Jacobo Nettel-García
Introducción: la enfermedad arterial periférica (EAP) está asociada
con elevada morbimortalidad cardiovascular por aterosclerosis.
El objetivo de esta investigación fue conocer la prevalencia
de EAP y sus factores determinantes en la población mexicana.
Métodos: determinación del índice tobillo-brazo (ITB) mediante
Doppler en población con alto riesgo para EAP. Se consideró un
ITB ≤ 0.9 como indicador de EAP. El ITB > 1.3 se consideró
indicador indirecto de calcificación y rigidez arterial.
Resultados: de 5101 pacientes, 1212 (23.8 %) tuvieron ITB ≤ 0.9 y
431 (8.4 %) ITB > 1.3 (incluyendo 1 % con arterias incompresibles).
Los factores asociados con ITB ≤ 0.9 fueron la edad, la hipertensión
arterial, la diabetes mellitus, el tabaquismo, la dislipidemia y
el antecedente de eventos vasculares. El ITB > 1.3 se asoció
con la edad, el sexo masculino, la diabetes mellitus, el tabaquismo
previo y el antecedente de eventos vasculares. Una proporción
elevada de pacientes con vasculopatía periférica identificada
por el ITB ≤ 0.9 manifestó pocos o ningún síntoma.
Conclusiones: existe elevada prevalencia de ITB anormal en la
población mexicana portadora de factores de riesgo vascular.
La medición del ITB puede ayudar a identificar a los pacientes
que precisan intensificación de la prevención secundaria y de
tratamiento más agresivo.
Registro multicéntrico internacional para evaluar la práctica clínica en paci...Erwin Chiquete, MD, PhD
Antecedentes: Se carece aún de información sobre las características de la atención médica otorgada a mexicanos
con diabetes mellitus tipo 2 (DT2). Nuestro objetivo fue describir el estado actual en el manejo de la DT2 en México.
Métodos: De 17,232 pacientes registrados a nivel mundial en el estudio DMPS (International Diabetes Management
Practices Study), 2,620 (15%) correspondieron a registros de México. Se recabó información sobre características clínicas
y demográficas, y sobre condiciones del manejo e impacto de la DT2 en la condición clínica y social del paciente.
Además, se analiza el grado de control y logro de metas de manejo. Resultados: El diagnóstico de DT2 lo estableció
un médico general en un 76%. Solo un cuarto de los pacientes tenía una presión arterial (PA) < 130/80 mmHg, a pesar
de que el 97% tenía tratamiento antihipertensivo. El manejo para la DT2 fue con dieta y ejercicio exclusivamente en un 5%,
con hipoglucemiantes orales (HO) en un 66% (solos o combinados), con HO e insulina en un 18%, o con insulina sola en
un 11%. Solo un 31% de los pacientes tuvo una hemoglobina glucosilada A1c (HbA1c) < 7%. El automonitoreo lo practicaron
un 50% de los pacientes y un 26% recibió formal educación en diabetes. La impresión del médico tratante sobre
el control del paciente no coincidió con lo observado en HbA1c. Un 8% de los pacientes se ausentaron de su trabajo en
los tres meses previos debido a complicaciones de DT2 (15 días perdidos en promedio). Conclusiones: En México,
la calidad en el control metabólico de pacientes con DT2 podría presentar deficiencias importantes. La impresión
personal del médico sobre el control metabólico no es consistente con los datos objetivos aquí analizados.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
DISSERTATION on NEW DRUG DISCOVERY AND DEVELOPMENT STAGES OF DRUG DISCOVERYNEHA GUPTA
The process of drug discovery and development is a complex and multi-step endeavor aimed at bringing new pharmaceutical drugs to market. It begins with identifying and validating a biological target, such as a protein, gene, or RNA, that is associated with a disease. This step involves understanding the target's role in the disease and confirming that modulating it can have therapeutic effects. The next stage, hit identification, employs high-throughput screening (HTS) and other methods to find compounds that interact with the target. Computational techniques may also be used to identify potential hits from large compound libraries.
Following hit identification, the hits are optimized to improve their efficacy, selectivity, and pharmacokinetic properties, resulting in lead compounds. These leads undergo further refinement to enhance their potency, reduce toxicity, and improve drug-like characteristics, creating drug candidates suitable for preclinical testing. In the preclinical development phase, drug candidates are tested in vitro (in cell cultures) and in vivo (in animal models) to evaluate their safety, efficacy, pharmacokinetics, and pharmacodynamics. Toxicology studies are conducted to assess potential risks.
Before clinical trials can begin, an Investigational New Drug (IND) application must be submitted to regulatory authorities. This application includes data from preclinical studies and plans for clinical trials. Clinical development involves human trials in three phases: Phase I tests the drug's safety and dosage in a small group of healthy volunteers, Phase II assesses the drug's efficacy and side effects in a larger group of patients with the target disease, and Phase III confirms the drug's efficacy and monitors adverse reactions in a large population, often compared to existing treatments.
After successful clinical trials, a New Drug Application (NDA) is submitted to regulatory authorities for approval, including all data from preclinical and clinical studies, as well as proposed labeling and manufacturing information. Regulatory authorities then review the NDA to ensure the drug is safe, effective, and of high quality, potentially requiring additional studies. Finally, after a drug is approved and marketed, it undergoes post-marketing surveillance, which includes continuous monitoring for long-term safety and effectiveness, pharmacovigilance, and reporting of any adverse effects.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
1. Aneurysmal Subarachnoid Hemorrhage in a Mexican
Multicenter Registry of Cerebrovascular Disease: The
RENAMEVASC Study
´ ´
Jose L. Ruiz-Sandoval, MD,*† Carlos Cantu, MD, PhD,‡ Erwin Chiquete, MD, PhD,*†
´ ´
Carolina Leon-Jimenez, MD,x Antonio Arauz, MD, PhD,k Luis M.
Murillo-Bonilla, MD, MSc,{ Jorge Villarreal-Careaga, MD,#
´
Fernando Barinagarrementerıa, MD,** and The RENAMEVASC Investigators
Background: Information on risk factors and outcome of persons with aneurysmal
subarachnoid hemorrhage (SAH) in Mexico is unknown. We sought to describe
the clinical characteristics, risk factors, and outcome at discharge of Mexican pa-
tients with aneurysmal SAH. Methods: A first-step surveillance system was con-
ducted on consecutive cases confirmed by 4-vessel angiography from November
2002 to October 2004 in 25 tertiary referral centers. Age- and sex-matched control
subjects were randomly selected by a 1:1 factor, for multivariate analysis on risk fac-
tors. Results: We studied 231 patients (66% women; mean age 52 years, range 16-90
years). In 92%, the aneurysms were in the anterior circulation, and 15% had more
than two aneurysms. After multivariate analysis, hypertension (odds ratio 2.46,
95% confidence interval 1.59-3.81) and diabetes mellitus (odds ratio 0.34, 95% confi-
dence interval 0.17-0.68) were directly and inversely associated with aneurysmal
SAH, respectively. Median hospital stay was 23 days (range 2-98 days). Invasive
treatment was performed in 159 (69%) patients: aneurysm clipping in 126 (79%), en-
dovascular coiling in 29 (18%), and aneurysm wrapping in 4 (2%). The in-hospital
mortality was 20% (mostly due to neurologic causes), and 25% of patients were dis-
charged with a modified Rankin score of 4 or 5. Conclusions: Hypertension is the
main risk factor for aneurysmal SAH in hospitalized patients from Mexico. The fe-
male:male ratio is 2:1. A relatively low in-hospital mortality and a high frequency of
invasive interventions are observed. However, a high proportion of patients are dis-
charged with important neurologic impairment. Key Words: Cerebral aneurysm—
epidemiology—outcome—risk factors—subarachnoid hemorrhage.
Ó 2009 by National Stroke Association
From the *Department of Neurology and Neurosurgery, Hospital
Received May 22, 2008; revision received September 1, 2008;
Civil de Guadalajara ‘‘Fray Antonio Alcalde’’, †Department of Neuro-
accepted September 11, 2008.
sciences, Centro Universitario de Ciencias de la Salud, Universidad ´
Address correspondence to Jose L. Ruiz-Sandoval, MD, Servicio de
de Guadalajara, ‡Department of Neurology, Instituto Nacional de ´ ´
Neurologıa y Neurocirugıa, Hospital Civil de Guadalajara ‘‘Fray An-
´ ´ ´
Ciencias Medicas y Nutricion ‘‘Salvador Zubiran,’’ Mexico City,
tonio Alcalde,’’ Hospital 278, Guadalajara, Jalisco, Mexico 44280.
´ ´
xDepartment of Neurology, Hospital Regional Gomez Farıas, Zapo-
E-mail: jorulej-1nj@prodigy.net.mx.
´ ´
pan, kStroke Clinic, Instituto Nacional de Neurologıa y Neurocirugıa,
1052-3057/$—see front matter
Mexico City, {Department of Neurology, Instituto Panvascular de Oc-
Ó 2009 by National Stroke Association
cidente, Guadalajara, #Department of Neurology, Hospital General
doi:10.1016/j.jstrokecerebrovasdis.2008.09.019
´ ´
de Culiacan; and **Department of Neurology, Hospital Angeles Quer-
´ ´
etaro, Mexico.
48 Journal of Stroke and Cerebrovascular Diseases, Vol. 18, No. 1 (January-February), 2009: pp 48-55
2. ANEURYSMAL SUBARACHNOID HEMORRHAGE IN MEXICAN HOSPITALS 49
Depending on the population and study design, it is es- nonneurologic clinics or services (e.g., internal medicine,
timated that subarachnoid hemorrhage (SAH) accounts gastroenterology, and endocrinology facilities); (2) medical
for less than 10% of the clinical forms of acute cerebrovas- students and their families; and (3) volunteers from out-
cular disease.1,2 On the other hand, SAH as a result of rup- side the hospitals. The internal committee of ethics of every
ture of intracranial aneurysms accounts for approximately participating center approved the study and the inclusion
3% of all strokes2 and for 85% of all SAH cases.3 Its clinical of control subjects. Informed consent was obtained from
impact is greater than it appears considering only the fre- the patient, control subject, or the patient’s legal proxy.
quency of this condition as it affects otherwise healthy Mean arterial pressure (MAP) was calculated from the
young adults. systolic blood pressure (SBP) and diastolic blood pressure
Information regarding frequency, associated risk factors, (DBP) measurements at admittance to the emergency de-
and outcome of persons with SAH in Mexico is unknown. partment as follows: MAP 5 DBP 1 0.412 (SBP – DBP).8,9
´
To address this issue, the Asociacion Mexicana de Enfer- This formula corrects for the spurious variation of MAP
medad Vascular Cerebral created the Registro Nacional in hypertensive persons; therefore, it is best suited for co-
Mexicano de Enfermedad Vascular Cerebral (RENAME- horts with a high frequency of high blood pressure.8 Hy-
VASC),4 which is a nationwide, nongovernmental, nonin- pertension and diabetes mellitus were defined as
dustry-sponsored, multicentric register of consecutive established by standard guidelines.10,11 For the purpose
patients with acute cerebrovascular disease hospitalized of the current report, smoking was defined as the con-
in Mexico. The initial purpose of this national registry sumption (either past or current) of 5 or more cigarettes
was to conduct a first-step stroke surveillance system, for at least 2 days per week during 12 months or more,
which implies the systematic registering of patients with and alcoholism as more than two alcoholic drinks per
acute cerebrovascular disease admitted to a hospital or day (on average). Vasospasm was defined by means of
clinic-based facility and following up of the patients until a single angiography of 4 vessels during the diagnostic
discharge from hospital or death.5 The aim of this RENA- work-up, at any time of the hospital stay.
MEVASC report on SAH was to describe the clinical and Parametric continuous variables are expressed as geo-
demographic characteristics, risk factors, and outcome at metric means and SD, or minimum and maximum. Non-
discharge of Mexican patients hospitalized for aneurysmal parametric continuous variables are expressed as
SAH, with a nationwide representation. medians. As the median age of the study group was 51
years, we divided the cohort into people aged 49 years
Methods or younger and 50 years or older to analyze the associa-
tion of age with risk factors, clinical characteristics, and
Patients
outcome. To compare quantitative variables distributed
This prospective hospital-based multicentric registry between two groups, Student t test and Mann-Whitney
was conducted from November 2002 to October 2004 in U test were performed in distributions of parametric
25 tertiary referral centers from 14 Mexican states.4 Consec- and nonparametric variables, respectively. Chi-square
utive patients were registered if a suspected acute ischemic statistics (i.e., Pearson Chi-square or Fisher exact test, as
or hemorrhagic stroke was confirmed by head computed corresponded) were used to compare nominal variables
tomography scan or magnetic resonance imaging. A stan- in bivariate analyses. To find independent risk factors
dardized, structured questionnaire was used to collect for aneurysmal SAH (as compared with control subjects)
clinical and demographic data from the patient or primary a multivariate analysis was constructed by a binary logis-
guardian and medical records by the local investigator. tic regression model. Independent variables were chosen
Other data registered included in-hospital management if P was less than .1 in bivariate analyses, but relevant
and outcome at discharge and at 3 months follow-up. nonsignificant variables remained in the model for adjust-
The patient’s functional status was classified by the modi- ment. Subsequently a forward-stepwise method was per-
fied Rankin scale.4 All data were sent to a reference center formed. Adjusted odds ratios with 95% confidence
in hard version and electronically captured by two investi- intervals that resulted in final step of the model are pro-
gators, after completion of the registering deadline. For the vided. The fitness of the model was evaluated by using
purpose of this report, patients with SAH due to ruptured the Hosmer-Lemeshow goodness-of-fit test, which was
intracranial aneurysms confirmed by 4-vessel angio- considered as reliable if P was greater than .20. All P
graphic techniques were included.6,7 To compare the fre- values reported are 2-sided and regarded as significant
quency of putative risk factors between patients with when P was less than .05. Software (SPSS v 13.0) was
aneurysmal SAH and the general population, 231 age- used for all calculations.
and sex-matched ambulatory persons without history of
SAH were included as control subjects. These people
Results
were registered explicitly for the purpose of this study
and consisted of persons without any known neurologic A total of 2000 patients with acute cerebrovascular dis-
disease: (1) relatives of patients who attend to ease were included in the registry: 1092 ischemic stroke
3. 50 J.L. RUIZ-SANDOVAL ET AL.
(either infarct or transient ischemic attack), 580 intracere- in patients 50 years or older than in younger persons;
bral hemorrhage, 59 cerebral venous thrombosis, and 269 nonetheless, more seizures were reported in the latter
nontraumatic SAH. All patients included pertained to the group. Single aneurysms occurred in 85% cases (Table
Latin American bioethnic group. In all, 38 patients were 4). In 92% patients the lesions were located at the anterior
excluded because they had a cause of SAH other than circulation. There were no differences in vascular topog-
ruptured aneurysms, or because they lacked angiogra- raphy according to age or sex (Table 4). Other anatomic
phy. Therefore, after applying selection criteria, 231 pa- characteristics of the aneurysms, such as size, neck, and
tients were analyzed. There were 153 (66%) women and dome, were not registered.
78 (34%) men, with a mean age of 51.8 years (median 51 Duration of the hospital stay had a median of 23 days
years, range 16-90). In all, 55 (24%) patients were younger (range 2-98 days) (Table 5). In all, 157 (68%) patients re-
than 40 years and 49 (21%) were 65 years or older. Hyper- quired entering the intensive care department at any
tension was more frequent among patients than control time of their hospitalization, whereas 74 (32%) patients
subjects, whereas few cases of diabetes mellitus were ob- were treated completely in general wards. The need for
served in the SAH group (Table 1). After multivariate mechanical ventilation occurred in 91 (39%) cases. We
analysis controlled for potential confounders, hyperten- lacked information regarding the time to angiography
sion remained a significant risk and diabetes an inversely or time to surgery or endovascular intervention after hos-
associated factor for aneurysmal SAH. Table 2 shows the pital arrival. Invasive treatment of the aneurysms was
distribution of risk factors among patients, stratified by performed in 159 (69%) patients by using the following
sex and age. Alcohol consumption and smoking were techniques: clipping of ruptured aneurysm in 126 (79%
more common in men than in women. Hypertension of those surgically treated), endovascular coiling in 29
and diabetes mellitus were more frequent in patients 50 (18%, all of them performed in a single center), and aneu-
years or older than in younger persons. rysm wrapping in 4 (2%) patients. The type of manage-
The onset of the clinical manifestations was registered ment (any invasive intervention v only medical
in 184 cases; of these, 69 (37.5%) occurred during the first treatment) did not differ with age (P 5 .31, for persons
12 hours of the day (at awakening in 8%, n 5 19) and in aged $ 50 v younger individuals), sex (P 5 .45, for men
115 (62.5%) during the afternoon or night. No monthly v women), or aneurysm topography (P 5 .20, for anterior
or seasonal patterns in hospitalization for aneurysmal v posterior circulation); however, aneurysm wrapping
SAH were identified. The hemorrhage was preceded by was performed only for aneurysms of the anterior circula-
a physical effort in 29 (12%) cases and by emotional stress tion (P , .001). Hydrocephalus was observed in 22%
in 11 (5%) (without differences according to age or sex). cases; of them, 72% received a shunting procedure. Pneu-
Table 3 shows the clinical manifestations and laboratory monia was the most frequent systemic complication (87/
work-up at hospital arrival. The main features were head- 231, 38%), followed by urinary tract infections (47/231,
ache, vomiting, and impaired consciousness. More men 20%), cardiac arrhythmia (17/231, 7%), and lower-limb
than women presented to hospital with a Glasgow deep-vein thrombosis (4/231, 2%). In all, 46 (20%) pa-
Coma Scale score greater than 13 (80% v 59%, respec- tients died in the hospital; 25 (54%) with a neurologic
tively; P 5 .002). Impaired consciousness at event onset cause, 13 (28%) with a systemic nonneurologic complica-
and higher blood pressure measures were more frequent tion, and 8 (17%) with both groups of causes. At
Table 1. Case-control analysis on risk factors for aneurysmal subarachnoid hemorrhage: Bivariate analysis and a multivariate
logistic regression model
Group
Variable Patients (n 5 231) Control subjects (n 5 231) P value* Multivariate OR (95% CI)y
Age, y, mean (range) 51.6 (16-90) 51.6 (16-90) .99 NS
Female, n (%) 156 (66) 156 (66) .99 NS
Hypertension, n (%) 96 (42) 67 (29) .005 2.46 (1.59-3.81)
Diabetes mellitus, n (%) 16 (7) 35 (15) .005 0.34 (0.17-0.68)
Alcoholism, n (%) 30 (13) 35 (15) .50 NS
Current smoker, n (%) 68 (29) 61 (26) .47 NS
Former smoker, n (%) 15 (6) 12 (5) .55 NS
Abbreviations: CI, confidence interval; NS, not significant; OR, odds ratio.
*P value for differences between patient and control groups; Student t test or Fisher exact test, as appropriate.
yHosmer-Lemeshow goodness-of-fit test: Chi-square 5 0.48, 2 df, P 5 .98. The rest of the variables that resulted with P $ .1 in bivariate
analysis remained in the multivariate model for adjustment; however, their multivariate ORs are not shown to avoid confusion.
4. ANEURYSMAL SUBARACHNOID HEMORRHAGE IN MEXICAN HOSPITALS 51
Table 2. Risk factors for aneurysmal subarachnoid hemorrhage stratified by sex and age
Sex Age, y
Variable Total Male Female P value* #49 $50 P valuey
Age, y, mean (range) 51.6 (16-90) 49.1 (16-90) 52.8 (17-90) .89 38.1 (16-49) 63.0 (50-90) ,.001
Hypertension, n (%) 96 (42) 29 (37) 67 (44) .33 26 (24) 70 (56) ,.001
Diabetes mellitus, n (%) 16 (7) 6 (8) 10 (6) .74 2 (2) 14 (11) .005
Alcoholism, n (%) 30 (13) 21 (27) 9 (6) ,.001 13 (12) 17 (14) .76
Current smoker, n (%) 68 (29) 30 (38) 38 (25) .03 35 (33) 33 (26) .27
Former smoker, n (%) 43 (19) 19 (24) 24 (16) .11 18 (17) 25 (20) .56
*P value for differences between men and women; Student t test or Fisher exact test, as appropriate.
yP value for differences between persons 49 years old or younger and 50 years of age or older; Student t test or Fisher exact test, as appropriate.
discharge, 25 (11%) had severe disabilities with depen- SAH among forms of stroke has been reported to be
dence on others for activities of daily living, 33 (14%) around 15%.13-15
with partial dependence and walking impairment, 43 We found that the main risk factor for aneurysmal SAH
(19%) with disabilities but able to walk without assis- was hypertension, whereas diabetes mellitus was in-
tance, 30 (13%) with mild disabilities, 30 (13%) with min- versely related with this condition; which is consistent
imal impairment, and 23 (10%) completely asymptomatic with previous studies.16 According to other reports,17-20
(Table 5). Table 6 shows the analyses on in-hospital mor- we found that the female:male ratio is 2:1. A high number
tality according to different clinical scales. Of note, the of persons younger than 40 years was observed, contrast-
presence of radiographic findings typical of cerebral vaso- ing with the respective frequency reported for other coun-
spasm was not associated with in-hospital mortality. tries, including those with a very high incidence of
SAH.17,21 This phenomenon could be due at least in part
Discussion
to the high proportion of young Mexican inhabitants.
Cerebrovascular disease is the fourth cause of death in Other possible explanations could be that congenital vas-
the general population of Mexico, accounting for more cular abnormalities and other conditions associated with
than 27,000 (5.5% of total) deaths by 2006.12 In previous the aneurysm formation or rupture has a high representa-
hospital series from Mexico, the proportion of cases of tion in our young population, or that the young have
Table 3. Clinical manifestations and laboratory analysis at hospital arrival, stratified by sex and age
Sex Age, y
Variable Total Male Female P value* #49 $50 P valuey
Headache, n (%) 209 (90) 67 (89) 142 (94) .21 99 (94) 110 (91) .34
Vomiting, n (%) 152 (66) 48 (61) 104 (68) .33 72 (68) 80 (64) .53
Probable seizures, n (%) 49 (21) 17 (22) 32 (21) .87 31 (29) 18 (14) .006
Impaired consciousness at 130 (56) 32 (41) 98 (64) .001 50 (47) 80 (64) .01
event onset, n (%)
Systolic blood pressure, mm 142 (28) 137 (21) 145 (30) .09 134 (24) 149 (29) .01
Hg, mean (SD)z
Mean arterial pressure, mm 110 (18) 107 (15) 111 (20) .10 105 (17) 113 (19) .004
Hg, mean (SD)z
Pulse pressure, mm Hg, mean 55 (21) 51 (16) 57 (22) .07 50 (16) 60 (23) .002
(SD)z
Glucose, mg/dL, mean (SD) 136 (63) 136 (68) 136 (60) .98 130 (58) 142 (67) .17
International normalized ratio, 1.11 (0.17) 1.10 (0.15) 1.13 (0.18) .54 1.13 (0.17) 1.09 (0.17) .40
mean (SD)
Hematocrit, %, mean (SD) 40 (6) 43 (7) 39 (5) ,.001 40 (7) 41 (6) .28
Platelets, 310-4, mean (SD) 24.6 (8.4) 22.3 (7.6) 25.8 (8.6) .003 25.0 (9.4) 24.2 (7.4) .45
*P value for differences between men and women; Fisher exact test or Student t test, as appropriate.
yP value for differences between persons 49 years old or younger and 50 years of age or older; Fisher exact test or Student t test, as appropriate.
zData available on 224 persons.
5. 52 J.L. RUIZ-SANDOVAL ET AL.
Table 4. Number and vascular topography of the intracranial aneurysms as assessed by angiographic studies
Sex Age, y
Variable Total Male Female #49 $50
No. of aneurysms*
1, n (%) 197 (85) 67 (86) 130 (85) 91 (86) 106 (85)
.1, n (%) 34 (15) 11 (14) 23 (15) 15 (14) 19 (15)
Anterior circulation (n 5 213, 92%)y
Posterior communicating artery, n (%) 64 (28) 20 (26) 44 (29) 28 (26) 36 (29)
Anterior communicating artery, n (%) 61 (26) 22 (28) 39 (26) 25 (24) 36 (29)
Middle cerebral artery, n (%) 46 (20) 16 (21) 30 (20) 23 (22) 23 (18)
Internal carotid artery (supraclinoid), 27 (12) 8 (10) 19 (12) 16 (15) 11 (9)
n (%)
Internal carotid artery (opthalmic), n 15 (6) 4 (5) 11 (7) 7 (6) 8 (6)
(%)
Posterior circulation (n 5 18, 8%)z
Posterior cerebral artery, n (%) 5 (2) 0 (0) 5 (3) 2 (2) 3 (2)
Basilar artery, n (%) 7 (3) 4 (5) 3 (2) 1 (1) 6 (5)
Vertebral artery, n (%) 6 (3) 4 (5) 2 (1) 4 (4) 2 (2)
*P 5 .99, for comparison in frequency of number of aneurysms between men and women; and P 5 .85, for comparison between persons 49
years old or younger and 50 years of age or older; Fisher exact test.
yP 5 .93, for comparison in homogeneity of aneurysmal localization of the anterior circulation between men and women; and P 5 .57, for
comparison between persons 49 years old or younger and 50 years of age or older; Pearson Chi square.
zP 5 .06, for comparison in homogeneity of aneurysmal localization of the posterior circulation between men and women; and P 5 .15, for
comparison between persons 49 years old or younger and 50 years of age or older; Pearson Chi square.
a low prehospital mortality and reach the hospital more to the patient and possibly a high chance of being surgi-
frequently than do older persons. cally treated.24
The rate of microsurgical intervention or endovascular We observed a lower mortality than that previously re-
therapy was higher in our study, as compared with other ported.19,23-27 Our explanation to this finding is that RE-
reports.19,22,23 Indeed, this is possibly due to the fact that NAMEVASC is a hospital-based study on persons who
our cohort corresponds to patients hospitalized in urban reached medical assistance in urban teaching hospitals,
teaching hospitals, where the patients are treated almost and who had a diagnosis based on 4-vessel angiography.
entirely with microsurgical clipping.24 In the United Many patients with the extreme medical conditions after
States, higher rates of any invasive procedure in the urban SAH could be lost in the prehospital part of their disease
setting were observed, when compared with rural facili- evolution, due to a wrong diagnosis or death. Also, some
ties.23 In Mexico most of the invasive procedures are patients who arrived at our centers may not have been
performed in governmental teaching hospitals or in correctly diagnosed as having SAH, or may not have
public-insurance settings, which implies a minimal cost been documented by angiography and thus, were not
Table 5. Events during hospitalization and clinical outcome at discharge stratified by sex and age
Sex Age, y
Variable Total Male Female P value* #49 $50 P valuey
Days of hospitalization, median 23 (2-98) 24 (3-92) 23 (2-98) .81 19 (2-98) 28 (2-82) .24
(minimum and maximum)
In-hospital systemic complications, n 107 (46) 34 (44) 73 (48) .55 43 (41) 64 (51) .11
(%)
Modified Rankin score at discharge .77 .03
0-2, n (%) 83 (36) 29 (37) 54 (35) 46 (43) 37 (30)
3-6, n (%) 148 (64) 49 (63) 99 (65) 60 (57) 88 (70)
*P value for differences between men and women; Mann-Whitney U test or Fisher exact test as appropriate.
yP value for differences between persons 49 years old or younger and 50 years of age or older; Mann-Whitney U test or Fisher exact test, as
appropriate.
6. ANEURYSMAL SUBARACHNOID HEMORRHAGE IN MEXICAN HOSPITALS 53
Table 6. In-hospital mortality according to clinical and brain imaging characteristics at hospital arrival
Sex Age, y In-hospital death
Variable Total Male Female P value* #49 $50 P valuey Present Absent P valuez
Hunt-Hess scalex .09 .04 .001
Grade I-II, n (%) 133 (66) 51 (74) 82 (62) 72 (73) 61 (59) 14 (40) 119 (71)
Grade III-V, n (%) 69 (34) 51 (38) 18 (26) 26 (27) 43 (41) 21 (60) 48 (29)
Fisher scale// .86 .34 ,.001
Grade I-II, n (%) 52 (26) 17 (25) 35 (26) 28 (29) 24 (23) 0 (0) 52 (31)
Grade III-IV, n (%) 149 (74) 52 (75) 97 (74) 68 (71) 81 (77) 34 (100) 115 (69)
Glasgow Coma Scale{ .007 .01 ,.001
Points 13-15, n (%) 149 (67) 61 (80) 88 (59) 78 (76) 71 (59) 17 (39) 132 (73)
Points 9-12, n (%) 43 (19) 9 (12) 34 (23) 12 (11) 31 (25) 14 (33) 29 (16)
Points 3-8, n (%) 32 (14) 6 (8) 26 (18) 13 (13) 19 (16) 12 (28) 20 (11)
Cerebral vasospasm# .36 .67 .99
Present, n (%) 88 (44) 26 (39) 62 (47) 41 (43) 47 (46) 15 (44) 73 (45)
Absent, n (%) 110 (56) 40 (61) 70 (53) 55 (57) 55 (54) 19 (56) 91 (55)
*P value for differences between men and women; Pearson Chi square or Fisher exact test, as appropriate.
yP value for differences between persons 49 years old or younger and 50 years of age or older; Pearson Chi square or Fisher exact test, as
appropriate.
zP value for differences between fatal and nonfatal cases; Pearson Chi square or Fisher exact test, as appropriate.
x
Data available on 202 persons.
//
Data available on 201 persons.
{
Data available on 224 persons.
#
Data available on 198 persons.
registered. It is well known that many patients die before compared with non-Hispanic whites,1,30,31 population-
they reach medical attention or diagnosis, and a consider- based studies on stroke incidence have shown that the
able proportion of patients are missed during an emer- proportion of aneurysmal SAH among subtypes of
gency department visit, mainly due to a wrong cerebrovascular disease is less than 10%, which includes
diagnostic impression.28 populations with Mexican ancestry.30,31 A long-term
As expected,7 the global neurologic impairment and follow-up was not possible for all patients of our registry,
SAH grade at hospital arrival were associated with in- and only 35% persons of our sample were followed up for
hospital mortality, and notably, the vasospasm did not ex- 3 months or more (data not shown). A population-based
plain any effect on short-term outcome. However, our study on incidence, conditioning factors, and long-term
definition of vasospasm was limited, based on a single an- outcome of persons with aneurysmal SAH in Mexico is
giography performed at any time during hospitalization, urgently needed. This issue will be certainly solved by
which is not a standard procedure to define this very dy- the US National Institutes of Health–sponsored Brain
namic phenomenon. Therefore, the consequences and Attack Surveillance in Durango City (BASID) Study. The
magnitude of clinically significant vasospasm could not RENAMEVASC prospective study is the first attempt in
be described with precision. This problem represents describing the general characteristics of aneurysmal
a limitation of our study. Nevertheless, vasospasm is SAH in Mexico with a nonsponsored and completely
not the only factor associated with neurologic worsening voluntary multicentric organization. Person-oriented
after SAH and its contribution on outcome may be small, data were registered with clinical and radiologic informa-
as could be inferred from clinical trials aimed to prevent tion on aneurysmal topography and short-term outcome,
or reverse vasospasm to change the fate of SAH.29 information that could be hardly provided in prospective
Indeed, our study has other limitations. This is a hospi- nonsponsored studies.
tal-based registry with a rather small sample size on pa- In conclusion, hypertension is the main risk factor for
tients admitted to referral centers with neurosurgical aneurysmal SAH in Mexico; however, other contributing
departments, which may favor hospitalization of patients risk factors could not be completely excluded with the
suitable for a surgical intervention, with the correspond- methodology of this study.6,15 The female:male ratio of
ing high recording of the hemorrhagic forms of cerebro- hospitalized patients with aneurysmal SAH is 2:1, and
vascular disease (i.e., intracerebral hemorrhage and a considerably high proportion of patients are young.
SAH).13-15 Although it has been recognized that hemor- Most aneurysms are solitary and located at the anterior
rhagic stroke is more frequent among Hispanics, when circulation. We observed a high rate of invasive therapy,
7. 54 J.L. RUIZ-SANDOVAL ET AL.
owing to the characteristics of our study design and the 3. van Gijn J, Kerr RS, Rinkel GJE. Subarachnoid hemor-
Mexican health care system. A low in-hospital mortality rhage. Lancet 2007;369:306-318.
was observed, possibly due to a low registering of fatal ´
4. Arauz A, Cantu C, Ruiz-Sandoval JL, et al. Short-term
prognosis of transient ischemic attacks: Mexican multi-
cases that occurred before aneurysm documentation.
center stroke registry [in Spanish]. Rev Invest Clin 2006;
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tiative. Lancet Neurol 2004;3:391-393.
The RENAMEVASC Investigators: Steering Committee 6. Matsuda M, Watanabe K, Saito A, et al. Circumstances,
´ ´
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The following centers and investigators participated in the gram for the sphygmomanometric calculation of the
´
RENAMEVASC study: C. Cantu-Brito (Instituto Nacional de mean arterial pressure. Heart 2000;84:64.
9. Chiquete E, Ruiz-Sandoval MC, Alvarez-Palazuelos LE,
Ciencias Me ´ dicas y Nutricion Salvador Zubiran, Ciudad de
´ ´
et al. Hypertensive intracerebral hemorrhage in the
Me ´ xico); A. Arauz-Gongora, L. Murillo-Bonilla, and L.
´
very elderly. Cerebrovasc Dis 2007;24:196-201.
´
Hoyos (Instituto Nacional de Neurologıa y Neurocirugıa, ´ 10. Chobanian AV, Bakris GL, Black HR, et al. The seventh re-
Ciudad de Me ´ xico); J. L. Ruiz-Sandoval and E. Chiquete port of the joint national committee on prevention, detec-
(Hospital Civil de Guadalajara, Jalisco); J. Villarreal-Careaga tion, evaluation, and treatment of high blood pressure:
´
and F. Guzman-Reyes (Hospital General de Culiacan, ´ The JNC 7 report. JAMA 2003;289:2560-2572.
11. American Diabetes Association. Diagnosis and classifica-
Sinaloa); F. Barinagarrementeria (Hospital Angeles de Quer-
tion of diabetes mellitus. Diabetes Care 2006;28:S37-S42.
´ ´ ´ ´
etaro, Queretaro); J. A. Fernandez (Hospital Juarez, Ciudad ´
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´
de Mexico); B. Torres (Hospital General de Leon, Guana- ´ ´
Mexico, 2006. Available from: URL:http://www.salud.
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juato); C. Leon-Jimenez (Hospital Regional ISSSTE, Zapopan, gob.mx/. Accessed April 2, 2008.
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Jalisco); I. Rodrıguez-Leyva (Hospital General de San Luis 13. Chiquete E, Ruiz-Sandoval JL. Prehospital events and in-
´
Potosı, San Luis Potosi); R. Rangel-Guerra (Hospital Univer- hospital mortality after acute stroke in a Mexican cohort
´ ´ [in Spanish]. Rev Mex Neuroci 2007;8:41-48.
sitario de Nuevo Leon, Monterrey, Nuevo Leon); M. Banos ˜
14. Gardeal G, Segura MA, Ramos F, et al. Intracranial aneu-
(Hospital General de Balbuena, Ciudad de Mexico); L. ´
rysms: Review of 100 cases in a period of 12 years at the
´
Espinosa and M. de la Maza (Hospital San Jose de Monterrey, General Hospital of Mexico [in Spanish]. Arch Neurocien
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Nuevo Leon); H. Colorado (Hospital General ISSSTE, Vera- (Mex) 1996;1:288-291.
cruz, Veracruz); M. C. Loy-Gerala (Hospital General de Pue- 15. Connolly ES Jr, Poisik A, Winfree CJ, et al. Cigarette
bla, Puebla); J. Huebe-Rafool (Hospital General de Pachuca, smoking and the development and rupture of cerebral
aneurysms in a mixed race population: Implications for
Hidalgo); G. Aguayo Leytte (Hospital General de Aguasca-
population screening and smoking cessation. J Stroke
lientes, Aguascalientes); G. Tavera-Guittings (Hospital
Cerebrovasc Dis 1999;8:248-253.
General ISSSTE, Campeche, Campeche); V. Garcia-Talavera 16. Feigin VL, Rinkel GJ, Lawes CM, et al. Risk factors for
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(Hospital IMSS ‘‘La Raza,’’ Ciudad de Mexico); O. Ibarra y subarachnoid hemorrhage: An updated systematic
M. Segura (Hospital General de Morelia, Morelia); J. L. review of epidemiological studies. Stroke 2005;
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Coahuila); J. M. Escamilla (Hospital de la Marina Nacional, Neurosurg Psychiatry 2007;78:1365-1372.
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