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.
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.
This document describes a study examining acute care and one-year outcomes of patients experiencing first-ever acute ischemic stroke in Mexico. The study analyzed data from 1,040 patients enrolled in the PREMIER registry from 59 hospitals across Mexico. Key findings include:
- The most common risk factors were hypertension (64%), obesity (51%), and diabetes (35%).
- Diagnostic procedures and acute treatments like IV thrombolysis were underutilized, with only 0.5% receiving thrombolysis despite 17% arriving within 3 hours of onset.
- The 30-day case fatality rate was 15% and the one-year mortality rate was 29%. At one year, 47% had low or no
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.
This document summarizes a study comparing clinical characteristics of hypertensive intracerebral hemorrhage (ICH) in young patients versus older patients. The study found that young patients had higher blood pressures, smaller hemorrhage volumes, lower rates of ventricular extensions, and a different distribution pattern of ICH locations. Mortality was lower in young patients but they had more disabling outcomes. The findings suggest there are age-related differences in the pathogenesis of hypertensive ICH.
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.
This document provides a summary of the 31st ISACON MP 2017 conference held in Bhopal, Madhya Pradesh from September 30th to October 2nd, 2017. It was well attended by approximately 300 delegates from India and abroad. Pre-conference workshops were held on the 30th covering difficult airways, ultrasound in anesthesia, and chronic pain management. The scientific sessions on the 1st included guest lectures on the history of ISA MP chapter and goal directed fluid therapy. The Dr. S.K. Mehta oration was delivered on low flow anesthesia. Inaugural ceremonies included the welcoming of government officials and the felicitation of senior members. Paper presentations were made for the Dr. T.N.
This document summarizes a study on Guillain-Barré syndrome (GBS) cases in Mexico. The key findings are:
1) GBS cases showed distinct clinical patterns compared to previous studies, with more axonal forms seen than demyelinating patterns.
2) A high frequency of hand weakness onset and axonal variants were observed, with axonal forms accounting for over 40% of cases.
3) Preceding diarrhea was more common among axonal motor axonal neuropathy (AMAN) variant cases than other forms.
This study analyzed the causes of stroke in 50 young patients aged 15-35 years at a tertiary hospital in Pakistan. The most common cause of stroke was infective meningitis (34%), predominantly tuberculosis meningitis. The second most common cause was cardioembolism (20%), mainly due to valvular heart disease. Other major causes included hypertension (14%), pregnancy-related conditions (12%), and systemic lupus erythematosus (4%). Infective meningitis, particularly tuberculosis, was found to be the leading cause of stroke in young patients in this study.
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.
This document describes a study examining acute care and one-year outcomes of patients experiencing first-ever acute ischemic stroke in Mexico. The study analyzed data from 1,040 patients enrolled in the PREMIER registry from 59 hospitals across Mexico. Key findings include:
- The most common risk factors were hypertension (64%), obesity (51%), and diabetes (35%).
- Diagnostic procedures and acute treatments like IV thrombolysis were underutilized, with only 0.5% receiving thrombolysis despite 17% arriving within 3 hours of onset.
- The 30-day case fatality rate was 15% and the one-year mortality rate was 29%. At one year, 47% had low or no
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.
This document summarizes a study comparing clinical characteristics of hypertensive intracerebral hemorrhage (ICH) in young patients versus older patients. The study found that young patients had higher blood pressures, smaller hemorrhage volumes, lower rates of ventricular extensions, and a different distribution pattern of ICH locations. Mortality was lower in young patients but they had more disabling outcomes. The findings suggest there are age-related differences in the pathogenesis of hypertensive ICH.
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.
This document provides a summary of the 31st ISACON MP 2017 conference held in Bhopal, Madhya Pradesh from September 30th to October 2nd, 2017. It was well attended by approximately 300 delegates from India and abroad. Pre-conference workshops were held on the 30th covering difficult airways, ultrasound in anesthesia, and chronic pain management. The scientific sessions on the 1st included guest lectures on the history of ISA MP chapter and goal directed fluid therapy. The Dr. S.K. Mehta oration was delivered on low flow anesthesia. Inaugural ceremonies included the welcoming of government officials and the felicitation of senior members. Paper presentations were made for the Dr. T.N.
This document summarizes a study on Guillain-Barré syndrome (GBS) cases in Mexico. The key findings are:
1) GBS cases showed distinct clinical patterns compared to previous studies, with more axonal forms seen than demyelinating patterns.
2) A high frequency of hand weakness onset and axonal variants were observed, with axonal forms accounting for over 40% of cases.
3) Preceding diarrhea was more common among axonal motor axonal neuropathy (AMAN) variant cases than other forms.
This study analyzed the causes of stroke in 50 young patients aged 15-35 years at a tertiary hospital in Pakistan. The most common cause of stroke was infective meningitis (34%), predominantly tuberculosis meningitis. The second most common cause was cardioembolism (20%), mainly due to valvular heart disease. Other major causes included hypertension (14%), pregnancy-related conditions (12%), and systemic lupus erythematosus (4%). Infective meningitis, particularly tuberculosis, was found to be the leading cause of stroke in young patients in this study.
Role of Left Ventricular Mass Index Versus Left Ventricular Relative Wall Thi...Premier Publishers
This study examined left ventricular geometry in 100 patients with non-cardioembolic ischemic stroke using echocardiography. The study found that concentric remodeling was the most common left ventricular pattern at 43%, followed by normal geometry at 27%, concentric hypertrophy at 22%, and eccentric hypertrophy at 8%. Abnormal left ventricular relative wall thickness was more common than abnormal left ventricular mass index, occurring in 61.4% versus 38.6% of patients. The results suggest that assessing relative wall thickness in addition to mass index can help identify more patients with left ventricular remodeling who may be at increased risk of stroke.
This study investigated factors that influence the need for preoperative vascular imaging before harvesting a vascularized fibular flap. The researchers analyzed 185 angiograms and found significant correlations between lower extremity artery pathology and risk factors like high cholesterol, high blood pressure, coronary heart disease, diabetes, and increased age. Specifically, increased age was the strongest predictor of vessel pathology. The study concludes that preoperative vascular imaging should be performed in patients with medical comorbidities to reduce the risks of flap failure and donor site complications when harvesting a fibular flap.
The document discusses a study analyzing risk factors for cardiac arrhythmias in 402 pediatric patients who underwent cardiac surgery. The study found that arrhythmias occurred in 57 patients (14.2%), with junctional ectopic tachycardia and supraventricular tachycardia being most common. Lower age, lower weight, higher Aristotle Basic Score, longer bypass and clamp times, and use of deep hypothermia were identified as risk factors. Higher score was the only significant independent risk factor based on multivariate analysis.
This document summarizes recent literature on anesthesia for patients with congenital heart disease presenting for noncardiac surgery. It finds that the highest risk patients are infants with a single functioning ventricle, those with suprasystemic pulmonary hypertension, left ventricular outflow tract obstruction, or dilated cardiomyopathy. Understanding the anatomy, physiology, and risks associated with different congenital heart defects and stages of palliation is important for optimizing outcomes. Multidisciplinary planning and careful anesthetic management are also critical to reduce risks in this patient population undergoing noncardiac procedures.
This study evaluated 70 patients with oral clefts to describe their clinical, electrocardiographic, and echocardiographic cardiovascular findings. Sixty percent of patients were male, and most had cleft lip and palate. Forty-four percent had comorbidities. Family history of risk for metabolic syndrome was present in 49% of patients, and one patient was diagnosed with rheumatic heart disease. Electrocardiograms found one case of atrioventricular block, and echocardiograms were abnormal in 36% of patients, including 5 cases of mitral valve prolapse. The findings indicate patients with oral clefts may be prone to acquired heart disease, so cardiovascular follow-up is necessary.
This document summarizes a study examining medical and neurological complications in 279 patients with acute ischemic stroke. The study found that 95% of patients experienced at least one complication. The most common serious medical complication was pneumonia (5%) and the most common serious neurological complication was new or extended cerebral infarction (5%). Medical complications contributed to 51% of deaths within 3 months. Patients with serious medical complications had significantly worse outcomes on functional scales even after accounting for baseline differences.
FIBRILACION AURICULAR EN URGENCIAS THE After Studyjasar
- The study derived and validated a complex model and simplified model to predict 30-day mortality for patients presenting to the emergency department with atrial fibrillation.
- The complex model considered age, vital signs, laboratory results, comorbidities, bleeding risk, and secondary diagnoses, achieving c-statistics of 0.88-0.87.
- The simplified 6-variable TrOPs-BAC model included troponin result, other diagnosis, pulmonary disease, bleeding risk, age over 75, and congestive heart failure, with c-statistics of 0.81 in both cohorts.
This research article compares the safety, efficacy, and cost-effectiveness of primary percutaneous coronary intervention (PCI) versus a pharmaco-invasive strategy for ST-segment elevation myocardial infarction (STEMI) patients in Gaza. 145 patients were randomized to primary PCI or streptokinase fibrinolysis followed by rescue or routine PCI within 2-24 hours. The primary composite endpoint of death, shock, or heart failure at 30 days was similar between groups. However, the pharmaco-invasive strategy had higher rates of major bleeding and required emergency angiography in 39.5% of patients. While index hospitalization costs were lower, the total estimated 30-day cost per 100 patients was higher for the pharmaco-invasive strategy compared
Postoperative chylothorax after cardiothoracicgisa_legal
This study examines the incidence, risk factors, and outcomes of postoperative chylothorax in children undergoing cardiothoracic surgery. The researchers found that the incidence of chylothorax was 3.8% and was significantly higher after heart transplantation, Fontan procedures, and tetralogy of Fallot repairs. Patients with chylothorax had significantly longer hospital stays compared to those without chylothorax. Nutritional management including low fat diets and octreotide were used to treat chylothorax, but surgical interventions provided limited benefit when reserved for severe or prolonged cases. Early diagnosis may reduce the duration of chylothorax.
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
This document summarizes several studies related to advanced heart failure:
1) A study of 2,816 patients found that initial strategy (bridge to transplant vs. destination therapy) impacted outcomes, with bridge to transplant having better survival rates. Strategies often changed over time.
2) A study of 50 patients found that placing an intra-aortic balloon pump through the left axillary artery allowed mobility and was a feasible strategy to bridge patients to heart transplantation.
3) A study comparing everolimus to mycophenolate mofetil in preventing cardiac allograft vasculopathy after heart transplant found everolimus was more effective in reducing intimal thickening and cases of vasculopathy.
BLOOD TRANSFUSIONS ARE ASSOCIATED WITH MORTALITY IN PEDIATRIC PATIENTS WITH S...Texas Children's Hospital
Restrictive thresholds for red blood cell (RBC) transfusion have not been shown to be inferior to liberal transfusion thresholds after cardiac surgery in pediatric or adult patients.1,2
RBC transfusions are associated with readmission due to heart failure (HF) in adults after aortic valve replacements, and with increased risk of right ventricle-pulmonary artery conduit failure in pediatric patients.3,4
Data are limited about RBC transfusions in pediatric patients with HF.
A Primary Percutaneous Coronary (PCI) intervention and pharmaco-invasive Primary Percutaneous Coronary (PCI)
continues to be the optimal reperfusion therapy in patients with anterior ST Elevation Myocardial Infarction (STEMI) however, the optimal treatment in patients with anterior STEM equivalents (wellness and DeWinter syndromes) is unknown.
Penetrating abdominal trauma. Difference in hematic biometry pre and postsurg...Juan de Dios Díaz Rosales
This study analyzed differences between pre-surgical and post-surgical levels of hemoglobin, platelets, leukocytes, and other blood markers in 93 patients with penetrating abdominal trauma who underwent exploratory laparotomy at a hospital in Ciudad Juarez, Mexico. The study found higher mean levels of hemoglobin, hematocrit, platelets, and leukocytes in pre-surgical tests compared to post-surgical tests, with the exception of neutrophils which increased slightly after surgery. While not conclusive, the study provides initial baseline data on expected blood marker levels before and after surgery for penetrating abdominal trauma. Larger multi-institutional studies are still needed to establish more reliable standard values.
1. Recurrent myocardial infarction (MI) after primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) occurs in about 21% of patients and is associated with worse clinical outcomes.
2. Recurrent MI significantly increases the risks of subsequent cardiac mortality, noncardiac mortality, stroke, and bleeding.
3. Early recurrent MIs within 1 day of the initial PPCI are associated with higher unadjusted cardiac mortality compared to later recurrent MIs, but after adjustment, recurrent MIs occurring more than 1 year after PPCI carry the highest risk of cardiac death.
Should atrial fibrillation patients with only 1 nongender related cha2 ds2-v...Bhargav Kiran
1) The study investigated outcomes in AF patients with 0 or 1 non-gender related (NGR) stroke risk factor (CHA2DS2-VASc score of 0-1 in males and 1-2 in females) who were treated or not treated with oral anticoagulation (OAC).
2) Among 2208 AF patients with 0-1 NGR risk factors, those not treated with OAC and with 1 risk factor had higher rates of stroke/embolism (2.09% per year) compared to those with 0 risk factors (adjusted hazard ratio 2.82).
3) Treating patients with 1 NGR risk factor with OAC was associated with a positive net
The guidelines provide evidence-based recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage (ICH). ICH is a medical emergency requiring rapid diagnosis and management, as neurological deterioration is common in the first few hours. Computed tomography (CT) is the recommended imaging modality to rapidly identify acute hemorrhage. Factors such as hematoma expansion, elevated blood pressure, and medical comorbidities should be aggressively managed to reduce morbidity and mortality. Early treatment involves hemostasis, blood pressure control, and preventing medical complications like fever, hyperglycemia and seizures. Additional treatments including clot removal, controlling intracranial pressure and treating hydrocephalus may be considered depending on the severity and location of
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor, Universit...guestc179d8
The document discusses different types of hemorrhagic stroke including primary intracerebral hemorrhage, subarachnoid hemorrhage, and hemorrhage from cerebral amyloid angiopathy. Risk factors for hemorrhagic stroke include hypertension, aging, cigarette smoking, and alcoholism. Management of hemorrhagic stroke focuses on controlling bleeding, removing blood from the brain, managing increased intracranial pressure, and treating any underlying correctable causes.
Intracerebral hemorrhage is an acute extravasation of blood into the brain parenchyma that may extend into ventricles or subarachnoid space. It accounts for 10-15% of strokes and has a 6-month mortality rate of 30-50%. The most common causes are hypertension (78-88%) and cerebral amyloid angiopathy. Treatment involves controlling blood pressure, treating the underlying cause, preventing hematoma expansion, and managing complications. While early surgery was not shown to improve outcomes in the overall STICH trial, it may be beneficial for lobar hemorrhages, which ISTICH-II aims to further evaluate.
This document provides an overview of different types of brain hemorrhages, including extra-axial hemorrhages such as epidural, subdural, and subarachnoid hemorrhages as well as intra-axial intracerebral hemorrhages. CT scans are used to initially diagnose hemorrhages by identifying hyperdense blood. Characteristics, locations, imaging appearances, and complications of each type of hemorrhage are described in detail. The document aims to inform clinicians on the basics and distinguishing features of various brain hemorrhages.
Role of Left Ventricular Mass Index Versus Left Ventricular Relative Wall Thi...Premier Publishers
This study examined left ventricular geometry in 100 patients with non-cardioembolic ischemic stroke using echocardiography. The study found that concentric remodeling was the most common left ventricular pattern at 43%, followed by normal geometry at 27%, concentric hypertrophy at 22%, and eccentric hypertrophy at 8%. Abnormal left ventricular relative wall thickness was more common than abnormal left ventricular mass index, occurring in 61.4% versus 38.6% of patients. The results suggest that assessing relative wall thickness in addition to mass index can help identify more patients with left ventricular remodeling who may be at increased risk of stroke.
This study investigated factors that influence the need for preoperative vascular imaging before harvesting a vascularized fibular flap. The researchers analyzed 185 angiograms and found significant correlations between lower extremity artery pathology and risk factors like high cholesterol, high blood pressure, coronary heart disease, diabetes, and increased age. Specifically, increased age was the strongest predictor of vessel pathology. The study concludes that preoperative vascular imaging should be performed in patients with medical comorbidities to reduce the risks of flap failure and donor site complications when harvesting a fibular flap.
The document discusses a study analyzing risk factors for cardiac arrhythmias in 402 pediatric patients who underwent cardiac surgery. The study found that arrhythmias occurred in 57 patients (14.2%), with junctional ectopic tachycardia and supraventricular tachycardia being most common. Lower age, lower weight, higher Aristotle Basic Score, longer bypass and clamp times, and use of deep hypothermia were identified as risk factors. Higher score was the only significant independent risk factor based on multivariate analysis.
This document summarizes recent literature on anesthesia for patients with congenital heart disease presenting for noncardiac surgery. It finds that the highest risk patients are infants with a single functioning ventricle, those with suprasystemic pulmonary hypertension, left ventricular outflow tract obstruction, or dilated cardiomyopathy. Understanding the anatomy, physiology, and risks associated with different congenital heart defects and stages of palliation is important for optimizing outcomes. Multidisciplinary planning and careful anesthetic management are also critical to reduce risks in this patient population undergoing noncardiac procedures.
This study evaluated 70 patients with oral clefts to describe their clinical, electrocardiographic, and echocardiographic cardiovascular findings. Sixty percent of patients were male, and most had cleft lip and palate. Forty-four percent had comorbidities. Family history of risk for metabolic syndrome was present in 49% of patients, and one patient was diagnosed with rheumatic heart disease. Electrocardiograms found one case of atrioventricular block, and echocardiograms were abnormal in 36% of patients, including 5 cases of mitral valve prolapse. The findings indicate patients with oral clefts may be prone to acquired heart disease, so cardiovascular follow-up is necessary.
This document summarizes a study examining medical and neurological complications in 279 patients with acute ischemic stroke. The study found that 95% of patients experienced at least one complication. The most common serious medical complication was pneumonia (5%) and the most common serious neurological complication was new or extended cerebral infarction (5%). Medical complications contributed to 51% of deaths within 3 months. Patients with serious medical complications had significantly worse outcomes on functional scales even after accounting for baseline differences.
FIBRILACION AURICULAR EN URGENCIAS THE After Studyjasar
- The study derived and validated a complex model and simplified model to predict 30-day mortality for patients presenting to the emergency department with atrial fibrillation.
- The complex model considered age, vital signs, laboratory results, comorbidities, bleeding risk, and secondary diagnoses, achieving c-statistics of 0.88-0.87.
- The simplified 6-variable TrOPs-BAC model included troponin result, other diagnosis, pulmonary disease, bleeding risk, age over 75, and congestive heart failure, with c-statistics of 0.81 in both cohorts.
This research article compares the safety, efficacy, and cost-effectiveness of primary percutaneous coronary intervention (PCI) versus a pharmaco-invasive strategy for ST-segment elevation myocardial infarction (STEMI) patients in Gaza. 145 patients were randomized to primary PCI or streptokinase fibrinolysis followed by rescue or routine PCI within 2-24 hours. The primary composite endpoint of death, shock, or heart failure at 30 days was similar between groups. However, the pharmaco-invasive strategy had higher rates of major bleeding and required emergency angiography in 39.5% of patients. While index hospitalization costs were lower, the total estimated 30-day cost per 100 patients was higher for the pharmaco-invasive strategy compared
Postoperative chylothorax after cardiothoracicgisa_legal
This study examines the incidence, risk factors, and outcomes of postoperative chylothorax in children undergoing cardiothoracic surgery. The researchers found that the incidence of chylothorax was 3.8% and was significantly higher after heart transplantation, Fontan procedures, and tetralogy of Fallot repairs. Patients with chylothorax had significantly longer hospital stays compared to those without chylothorax. Nutritional management including low fat diets and octreotide were used to treat chylothorax, but surgical interventions provided limited benefit when reserved for severe or prolonged cases. Early diagnosis may reduce the duration of chylothorax.
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
This document summarizes several studies related to advanced heart failure:
1) A study of 2,816 patients found that initial strategy (bridge to transplant vs. destination therapy) impacted outcomes, with bridge to transplant having better survival rates. Strategies often changed over time.
2) A study of 50 patients found that placing an intra-aortic balloon pump through the left axillary artery allowed mobility and was a feasible strategy to bridge patients to heart transplantation.
3) A study comparing everolimus to mycophenolate mofetil in preventing cardiac allograft vasculopathy after heart transplant found everolimus was more effective in reducing intimal thickening and cases of vasculopathy.
BLOOD TRANSFUSIONS ARE ASSOCIATED WITH MORTALITY IN PEDIATRIC PATIENTS WITH S...Texas Children's Hospital
Restrictive thresholds for red blood cell (RBC) transfusion have not been shown to be inferior to liberal transfusion thresholds after cardiac surgery in pediatric or adult patients.1,2
RBC transfusions are associated with readmission due to heart failure (HF) in adults after aortic valve replacements, and with increased risk of right ventricle-pulmonary artery conduit failure in pediatric patients.3,4
Data are limited about RBC transfusions in pediatric patients with HF.
A Primary Percutaneous Coronary (PCI) intervention and pharmaco-invasive Primary Percutaneous Coronary (PCI)
continues to be the optimal reperfusion therapy in patients with anterior ST Elevation Myocardial Infarction (STEMI) however, the optimal treatment in patients with anterior STEM equivalents (wellness and DeWinter syndromes) is unknown.
Penetrating abdominal trauma. Difference in hematic biometry pre and postsurg...Juan de Dios Díaz Rosales
This study analyzed differences between pre-surgical and post-surgical levels of hemoglobin, platelets, leukocytes, and other blood markers in 93 patients with penetrating abdominal trauma who underwent exploratory laparotomy at a hospital in Ciudad Juarez, Mexico. The study found higher mean levels of hemoglobin, hematocrit, platelets, and leukocytes in pre-surgical tests compared to post-surgical tests, with the exception of neutrophils which increased slightly after surgery. While not conclusive, the study provides initial baseline data on expected blood marker levels before and after surgery for penetrating abdominal trauma. Larger multi-institutional studies are still needed to establish more reliable standard values.
1. Recurrent myocardial infarction (MI) after primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) occurs in about 21% of patients and is associated with worse clinical outcomes.
2. Recurrent MI significantly increases the risks of subsequent cardiac mortality, noncardiac mortality, stroke, and bleeding.
3. Early recurrent MIs within 1 day of the initial PPCI are associated with higher unadjusted cardiac mortality compared to later recurrent MIs, but after adjustment, recurrent MIs occurring more than 1 year after PPCI carry the highest risk of cardiac death.
Should atrial fibrillation patients with only 1 nongender related cha2 ds2-v...Bhargav Kiran
1) The study investigated outcomes in AF patients with 0 or 1 non-gender related (NGR) stroke risk factor (CHA2DS2-VASc score of 0-1 in males and 1-2 in females) who were treated or not treated with oral anticoagulation (OAC).
2) Among 2208 AF patients with 0-1 NGR risk factors, those not treated with OAC and with 1 risk factor had higher rates of stroke/embolism (2.09% per year) compared to those with 0 risk factors (adjusted hazard ratio 2.82).
3) Treating patients with 1 NGR risk factor with OAC was associated with a positive net
The guidelines provide evidence-based recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage (ICH). ICH is a medical emergency requiring rapid diagnosis and management, as neurological deterioration is common in the first few hours. Computed tomography (CT) is the recommended imaging modality to rapidly identify acute hemorrhage. Factors such as hematoma expansion, elevated blood pressure, and medical comorbidities should be aggressively managed to reduce morbidity and mortality. Early treatment involves hemostasis, blood pressure control, and preventing medical complications like fever, hyperglycemia and seizures. Additional treatments including clot removal, controlling intracranial pressure and treating hydrocephalus may be considered depending on the severity and location of
Cerebral Hemorrhage By Arlyn M. Valencia, M.D. Associate Professor, Universit...guestc179d8
The document discusses different types of hemorrhagic stroke including primary intracerebral hemorrhage, subarachnoid hemorrhage, and hemorrhage from cerebral amyloid angiopathy. Risk factors for hemorrhagic stroke include hypertension, aging, cigarette smoking, and alcoholism. Management of hemorrhagic stroke focuses on controlling bleeding, removing blood from the brain, managing increased intracranial pressure, and treating any underlying correctable causes.
Intracerebral hemorrhage is an acute extravasation of blood into the brain parenchyma that may extend into ventricles or subarachnoid space. It accounts for 10-15% of strokes and has a 6-month mortality rate of 30-50%. The most common causes are hypertension (78-88%) and cerebral amyloid angiopathy. Treatment involves controlling blood pressure, treating the underlying cause, preventing hematoma expansion, and managing complications. While early surgery was not shown to improve outcomes in the overall STICH trial, it may be beneficial for lobar hemorrhages, which ISTICH-II aims to further evaluate.
This document provides an overview of different types of brain hemorrhages, including extra-axial hemorrhages such as epidural, subdural, and subarachnoid hemorrhages as well as intra-axial intracerebral hemorrhages. CT scans are used to initially diagnose hemorrhages by identifying hyperdense blood. Characteristics, locations, imaging appearances, and complications of each type of hemorrhage are described in detail. The document aims to inform clinicians on the basics and distinguishing features of various brain hemorrhages.
This document discusses intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). ICH can be caused by hypertension, cerebral amyloid angiopathy, aneurysms, or bleeding disorders. Common symptoms include sudden headache, weakness on one side of the body, and altered mental status. Treatment focuses on controlling blood pressure, reducing pressure in the brain, and potentially surgically evacuating large bleeds. SAH most often results from aneurysms and presents with a sudden, severe headache. Angiography is used to locate the source of bleeding, and aneurysms are often clipped surgically to prevent rebleeding.
The Anchor: Sports with Household AppliancesAnni Rautio
This document provides the rules for a backyard pool game called "The Anchor". The game involves two teams using a broom to drop a bucket hanging above the center of the pool. Once the bucket hits the water, players can enter the previously off-limits circle area to move the bucket toward their goal using their bodies, but not brooms. The first team to get the bucket to their goal line three times wins the honor of "The Anchor".
This document provides an overview of Sybase SQL Anywhere 12, including its applications like Sybase Central and PowerDesigner. It then describes various database concepts supported in SQL Anywhere 12 like database diagrams, functions, stored procedures, DDL, triggers, XML, and cursors. The remainder of the document outlines the role-based security features for database administrators.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
The document discusses an interdisciplinary collaboration between linguistics and biology to map scientific taxon names to common names in multiple languages. It describes projects including the WBÖ and DBÖ dialect dictionaries, Europeana, and OpenUp!, which aims to provide biological and linguistic metadata. The collaboration would benefit both partners by integrating linguistic expertise on names into the OpenUp! project and biological expertise on taxa into the dictionaries. Web services would be developed to link the two domains and allow bidirectional exchange of data to handle unstable scientific classifications. The goal is to lay foundations for distributed expertise, standards, and open access to linguistic and biological data on taxa names.
This nail polish allows users to create nail art designs using both a brush and pen. With practice, it allows users to paint intricate designs like flowers or animals on their nails without stickers or artificial nails. The container is made of nylon rather than glass, making it lightweight and easy to carry. It comes in various colors and types, including a double pen type, and includes a topcoat and remover. Directions explain how to use the basecoat, paint designs with the pen, add glitter effects, and finish with a topcoat to preserve the nail art. The product can also be used to touch up small scars and rust on cars.
The MoTIF Project: Constructing a Pilot Thesaurus of Irish Folklore Using Fac...Catherine Ryan
Presentation to the Annual Seminar of the Library Association of Ireland's Cataloguing and Metadata Group. National Library of Ireland, November 8th, 2013.
The MoTIF project is a collaborative project undertaken by the Digital Repository of Ireland and the National Library of Ireland.
An organization is considering adopting a learning management system (LMS) to provide online training to employees. An LMS would allow the organization to deliver, track, and manage training programs for staff. It could help improve and standardize training across different departments through a centralized system.
The document discusses various aspects of working as a photographer, including average wages ranging from $35,980 annually and highest paying states/cities, as well as details on paid photography internships focusing on product photography and fashion photography requiring experience and education in the field.
The document summarizes a student's media product which is a magazine for their sixth form school. The student used conventions of real magazines such as a masthead, cover lines, and images to preview contents. However, they also challenged conventions with a "Did You Know" section. The magazine included sections to appeal to different social groups and was aimed at the sixth form audience. Creating the magazine taught the student new skills in Adobe Photoshop, including tools like the Quick Selection Tool and filters.
Similar to Spontaneous intracerebral hemorrhage in Mexico: results from a Multicenter Nationwide Hospital-based Registry on Cerebrovascular Disease (RENAMEVASC)
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.
Predictors of gastrointestinal bleeding in acute intracerebral haemorrhagesulastio
This study evaluated predictors of gastrointestinal bleeding in 51 patients with acute intracerebral hemorrhage. The researchers found that 30% of patients experienced GI bleeding. Multivariate analysis identified three key predictors: larger hematoma size, presence of sepsis, and lower Glasgow Coma Scale scores. Patients with these factors were more likely to experience GI bleeding. The study highlights sepsis as an important and modifiable risk factor for GI bleeding in ICH patients.
Poor short-term outcome in patients with ischaemic stroke.pdfarianiputridevanti
1) Patients with active cancer (AC) who experienced an ischemic stroke were younger, had more severe strokes, and had a higher rate of in-hospital mortality compared to patients with non-active cancer (NAC).
2) AC patients were more likely to have cryptogenic strokes and infarcts in multiple areas of the brain, while NAC patients more often had cardioembolic strokes and small vessel disease.
3) Having AC, a higher NIH Stroke Scale score, and higher C-reactive protein levels were independently associated with in-hospital mortality after experiencing an ischemic stroke.
1. The document discusses a study comparing surgical treatment versus conservative treatment for patients with spontaneous intracerebral hemorrhage who are positive for the "spot sign" on imaging.
2. The study found that while mortality at 90 days was significantly lower in patients who received surgery, there was no significant difference in clinical outcomes like the Glasgow Outcome Scale between the surgical and conservative treatment groups.
3. Therefore, the study concludes that while surgery may reduce mortality risk, it does not clearly provide a clinical outcome benefit over conservative treatment for spot sign positive intracerebral hemorrhage patients.
This study evaluated the use of hand-held echocardiography (HHE) as point-of-care ultrasound scanning (POCUS) to detect potential sources of embolism in 130 patients with non-lacunar ischemic stroke within 24 hours of onset. Main sources of embolism (MSEs) detected by HHE included embolic valvulopathies and severe ventricular dysfunction, and were confirmed in 19.23% of patients by comparison with transthoracic echocardiography (TTE). Large vessel occlusion and chronic heart failure independently predicted the detection of MSEs. HHE also identified an enlarged left atrium as an independent predictor of later detection of atrial fibrillation in patients
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.
This study summarizes a case series of 394 young stroke patients aged 14-47 years who were admitted to a hospital in Rome, Italy between 1992-2001. The annual incidence of young stroke was found to be 8.8 per 100,000 people. Common risk factors included smoking (56%), hypertension (23%), and oral contraceptive use (38% of women). The most common causes of stroke were determined to be cardioembolism (34%), atherothrombosis (12%), and non-atherosclerotic vasculopathies like arterial dissection (14%). Despite limitations, the study highlights the importance of thorough diagnostic evaluation for determining the cause of young ischemic strokes.
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
This study analyzed the causes of stroke in 50 young patients aged 15-35 years at a tertiary hospital in Pakistan. The most common cause of stroke was infective meningitis (34%), primarily tuberculosis meningitis. The second most common cause was cardioembolism (20%), mainly due to valvular heart disease. Other major causes included hypertension (14%), pregnancy-related conditions (12%), and systemic lupus erythematosus (4%). Overall, infectious diseases were the leading cause of stroke in this young patient population.
This study aimed to compare clinical diagnoses of stroke localization to CT scan findings in 110 patients. Clinically, 80.9% were diagnosed with cerebral infarction and 19.1% with cerebral hemorrhage. CT scans confirmed infarction in 83% and hemorrhage in 47.6%. Left parietal/temporo parietal infarction was the most common clinical diagnosis (43 patients) and CT scans confirmed in 41 patients. Middle cerebral artery territory involvement was most frequent. The study concluded that clinical localization of stroke is not always accurate but CT scans help provide confident diagnoses and inform prognosis and treatment.
This study aimed to compare clinical diagnoses of stroke localization to CT scan findings in 110 patients. Clinically, 80.9% were diagnosed with cerebral infarction and 19.1% with cerebral hemorrhage. CT scans confirmed infarction in 83% and hemorrhage in 47.6%. Left parietal/temporo parietal infarction was the most common clinical diagnosis (43 patients) and CT scans confirmed this in 41 patients. Middle cerebral artery territory involvement was most frequent. The study concluded that clinical localization of stroke is not always accurate but CT scans help provide confident diagnoses and inform prognosis and treatment.
The recalibrated thoracic revised cardiac risk index (ThRCRI) aims to predict cardiac risk for patients undergoing lung resection. This study externally validates the ThRCRI in 2,621 patients who underwent lobectomy or pneumonectomy. Patients were grouped into four risk classes by the ThRCRI. The incidence of major cardiac complications increased from 0.9% in the lowest risk class to 18% in the highest risk class, demonstrating the ThRCRI's ability to stratify risk. Bootstrapping analysis supported the ThRCRI's reliability in predicting cardiac risk across different patient populations. The ThRCRI is a useful tool for identifying patients needing further cardiac testing before lung resection.
Unruptured intracranial aneurysms in children with SCDEmily Wyse
Five out of 179 children with sickle cell disease who underwent brain imaging were found to have unruptured intracranial aneurysms, for a prevalence of 2.8%. A total of 18 aneurysms were detected in these 5 patients, with most patients having multiple aneurysms and bilateral involvement. The majority of aneurysms were located in the cavernous and clinoid segments of the carotid circulation. This study suggests that children with sickle cell disease may be at increased risk of developing multiple intracranial aneurysms.
Clinical Profile of Acute Coronary Syndrome among Young AdultsPremier Publishers
Acute Coronary Syndrome accounts for 30% of hospital admissions with cardiovascular diseases. The risk of this syndrome is increasing among the younger adults, and a deep insight into the clinical profile among these patients will help in devising a preventive strategy, in order to alleviate the morbidity and mortality due to the syndrome. A cross sectional study was done among 125 subjects admitted to our tertiary care hospital with Acute Coronary Syndrome. Their risk factors were assessed and a 12 Lead electrocardiogram and 2D Echocardiogram were taken. Cardio III panel which consists of Troponin I, CK MB, BNP by COBAS meter machine was also measured. STEMI was present in 73.6% of the patients, while unstable angina was present in 16%. About 90% of STEMI patients were males and 62% of them were hypertensives. LV Ejection Fraction <30% was found in 9% of STEMI patients. This study elucidates the need for a preventive strategy for primordial prevention of cardiovascular events among young adults. The study envisaged the male, urban preponderance towards these events.
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.
Intracerebral hemorrhage (ICH) with intraventricular hemorrhage (IVH) has high mortality and morbidity. The CLEAR III trial studied 500 patients with ICH and IVH to determine if thrombolysis via ventricular drain improved outcomes compared to saline placebo. The primary outcome of functional independence at 6 months was not significantly different between groups. However, mortality was 50% lower in the thrombolysis group with no increase in bleeding. Thrombolysis may reduce mortality in ICH/IVH patients without increasing risk of rebleeding.
This study analyzed trends in complications from 2000-2012 using a nationwide database of inpatient therapeutic ERCP procedures in the US. The study found:
1) Mortality rates decreased from 1.77% to 1.24%, and time series analysis confirmed this downward trend.
2) Perforation rates increased from 0.07% to 0.10% but time series analysis found no significant trend.
3) GI hemorrhage rates increased from 1.36% to 1.57% and time series analysis confirmed an upward trend.
The study concluded that while therapeutic ERCPs have become safer as shown by decreasing mortality rates, GI hemorrhage rates increased over the same period according to their analysis of
1. A study of 6,856 patients who received intravenous thrombolysis for acute ischemic stroke from 10 European centers found that treatment within 90 minutes of symptom onset was independently associated with excellent 3-month outcome in patients with moderate (NIHSS 7-12) and mild (NIHSS 0-6) stroke severity.
2. For patients with NIHSS 7-12, treatment within 90 minutes was associated with a 37% higher likelihood of excellent outcome compared to later treatment.
3. For patients with mild symptoms (NIHSS 0-6), treatment within 90 minutes was associated with a 51% higher likelihood of full recovery (mRS=0) to overcome the ceiling effect of spontaneous good recovery
Supratentorial intracerebral hemorrhage volume and other CT variables predict...NeurOptics, Inc.
However, it is not practical to obtain repeated serial CT scans in ICH patients to assess for these factors. A noninvasive indicator method of assessing the aforementioned factors would be very useful and could serve as a trigger for repeating a CT scan in a patient with ICH.
1) The 30-day mortality from spontaneous intracerebral hemorrhage (ICH) ranges from 35-52% with half of deaths occurring within two days. Only 12% of patients have mild or no disability at 30 days.
2) Larger initial ICH volume, lower level of consciousness, hematoma growth, intraventricular extension, early neurologic deterioration, preceding use of oral anticoagulants or antiplatelets, and not limiting care are associated with worse prognosis.
3) Patients on oral anticoagulants have mortality rates over 50% and those with hematoma growth are more likely to die or have worse functional outcomes compared to spontaneous ICH.
Similar to Spontaneous intracerebral hemorrhage in Mexico: results from a Multicenter Nationwide Hospital-based Registry on Cerebrovascular Disease (RENAMEVASC) (20)
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.
The document analyzes the direct costs of treating breast cancer patients at the National Institute of Cancerology in Mexico prior to the introduction of immunotherapy. A total of 633 patients treated in 2004 were studied. The costs were calculated for each stage of care including diagnosis/staging, treatment, follow-up, and palliative care. The average annual cost of treatment per patient increased with each successive stage of disease from $6,219.94 for stage I to $9,917.82 for stage IV. The total direct cost of treating all 633 breast cancer patients in 2004 was calculated to be $5,341,805.37. The study concluded that costs of care increased with more advanced disease stages due in part to late
Este documento presenta el caso de una paciente de 23 años que desarrolló una demencia tres años después de una intoxicación crónica por paradiclorobenceno (PDCB). La paciente había ingerido pequeñas cantidades de desodorante que contenía PDCB durante varios meses y luego intentó suicidarse ingiriendo grandes cantidades. Tres años después presentaba síntomas de demencia mixta corticosubcortical. Las imágenes por resonancia magnética mostraron leucoencefalopatía difusa. El PDCB puede causar desmielinización central y
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.
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
Este estudio multicéntrico evaluó la prevalencia de enfermedad arterial periférica (EAP) mediante la medición del índice tobillo-brazo (ITB) en más de 5,000 pacientes mexicanos con factores de riesgo vascular. Se encontró que el 23.8% de los pacientes tenían ITB ≤ 0.9, indicativo de EAP, y el 8.4% tenían ITB > 1.3, indicativo de calcificación arterial. Los factores asociados con ITB anormal incluyeron edad avanzada, hipertensión, diabetes
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
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Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
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).
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
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
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
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Histopathology of Rheumatoid Arthritis: Visual treat
Spontaneous intracerebral hemorrhage in Mexico: results from a Multicenter Nationwide Hospital-based Registry on Cerebrovascular Disease (RENAMEVASC)
1. ORIGINAL
Spontaneous intracerebral hemorrhage in Mexico:
results from a Multicenter Nationwide Hospital-based
Registry on Cerebrovascular Disease (RENAMEVASC)
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 Cerebro
vascular 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.
Key words. Diagnosis. Epidemiology. Intracerebral hemorrhage. Outcome. Stroke.
Introduction
Intracerebral hemorrhage (ICH) is the spontaneous collection of blood within the brain parenchyma, caused by non-traumatic injury or aneurysmal
rupture, whose shape, size and location are age
and etiology dependent [1]. In Western series,
ICH represent 5 to 19% of all cerebrovascular diseases (CVD), with a higher frequency among Hispanics, Asians and African Americans who live in
those countries [2-6]. In Latin America, studies of
hospital series of Ecuador, Mexico, Chile and Argentina reported a frequency of 23 to 40% [7-12].
In Chile, the PISCIS study done in the Iquique
community, the ICH estimated incidence was 27.6/
100,000 inhabitants [10]. In Mexico, the BASID
hospital epidemiology surveillance recording showed
a CVD incidence of 381.3 per 100,000, corresponding to a rate of 55/100,000 for ICH, ie, a frequency of 20.5% [11].
www.neurologia.com Rev Neurol 2011; 53 (12): 705-712
Despite its high prevalence, scarce information
on ICH in our country has been mainly derived
from stroke registries of a single center with its inherent conclusions bias [9-13]. This study analyzes
the clinical spectrum, diagnosis, treatment and
prognosis of ICH in Mexican patients included in a
nation-wide multicenter hospital-based study.
Patients and methods
The Mexican National Registry of Cerebral Vascular Disease (RENAMEVASC) is a multi-hospital
observational study, conducted from November 2002
to October 2004. It was designed by the Mexican
Association of Cerebral Vascular Disease (AMEVASC) to improve CVD awareness in our country
[14-16]. Briefly, investigators from 25 second and
third level hospitals (14 states) included consecutive patients with acute stroke diagnosis that had at
Neurology and Neurosurgery
Department; Hospital Civil Fray
Antonio Alcalde; Guadalajara
(J.L. Ruiz-Sandoval, E. Chiquete,
A. Ochoa-Guzmán, K. Carrillo-Loza).
Neurosciences Department; Centro
Universitario de Ciencias de la
Salud; Universidad de Guadalajara
(J.L. Ruiz-Sandoval). Sciences
Faculty; Universidad Autónoma
de Baja California; Ensenada
(A. Gárate-Carrillo). Stroke Clinic;
Instituto Nacional de Neurología
y Neurocirugía, INNN; México DF
(A. Arauz). Neurology Department;
Hospital Valentín Gómez Farías;
ISSSTE; Zapopan (C. León-Jiménez).
Endovascular Therapy; Instituto
Panvascular de Occidente and
Universidad Autónoma de
Guadalajara (L.M. Murillo-Bonilla).
Neurology Department; Hospital
General de Culiacán (J. VillarrealCareaga). División de Ciencias de
la Salud; Universidad del Valle de
México; Querétaro (F. Barinagarrementería). Neurology Department;
Instituto Nacional de Ciencias Médicas
y Nutrición Salvador Zubirán;
Mexico DF, México (C. Cantú-Brito).
Corresponding author:
Dr. José Luis Ruiz-Sandoval. Servicio
de Neurología y Neurocirugía.
Hospital Civil Fray Antonio Alcalde.
Hospital, 278. CP 44280.
Guadalajara, Jalisco, México.
E-mail:
jorulej-1nj@prodigy.net.mx
Accepted:
14.10.11.
How to cite this article:
Ruiz-Sandoval JL, Chiquete E,
Gárate-Carrillo A, Ochoa-Guzmán A,
Arauz A, León-Jiménez C, et al.
Spontaneous intracerebral
hemorrhage in Mexico: results from
a Multicenter Nationwide Hospitalbased Registry on Cerebrovascular
Disease (RENAMEVASC). Rev Neurol
2011; 53: 705-12.
RENAMEVASC Investigators:
C. Cantú-Brito (Instituto Nacional
de Ciencias Médicas y Nutrición
705
3. Spontaneous intracerebral hemorrhage in Mexico: results from RENAMEVASC
Table I. Clinical condition at hospital admission, ICH topography and etiology, according to age and gender (n = 564).
Gender
Total
Age group
Female
(n = 299)
Male
(n = 265)
p
< 65 years
(n = 298)
≥ 65 years
(n = 266)
p
Risk factors (%)
Hypertension history
63.5
62.9
64.2
NS
59.1
68.4
0.021
Obesity
29.9
31.2
28.5
NS
31.4
28.3
NS
Smoking
23.8
13.8
35.2
< 0.001
24.9
22.6
NS
Alcoholism
18.9
5.4
34.1
< 0.001
20.9
16.6
NS
Diabetes mellitus history
17.7
18.4
17.0
NS
17.1
18.4
NS
Dyslipidemia history
9.1
8.7
9.5
NS
8.1
10.2
NS
Antiplatelets use
9.0
9.5
8.5
NS
5.8
12.5
0.006
Previous ICH
5.2
5.4
5.0
NS
6.1
4.1
NS
Glasgow Coma Scale (%)
NS
0.003
13-15
41.7
41.6
41.8
47.6
35.1
9-12
31.6
31.4
31.8
30.8
32.4
3-8
26.7
27.0
26.4
21.6
32.4
Supratentorial location (%)
Basal ganglia
50.4
44.8
56.6
0.005
47.3
53.8
NS
Lobar
35.1
39.1
30.6
0.033
35.9
34.2
NS
Intraventricular
4.1
4.7
3.4
NS
5.7
2.3
0.039
Infratentorial location (%)
Brainstem
5.5
5.7
5.3
NS
6.7
4.1
NS
Cerebellum
4.8
5.7
3.8
NS
4.4
5.3
NS
Volume, mean (mL)
31.2 ± 32.0
30.2 ± 31.4
32.3 ± 32.7
NS
30.0 ± 30.5
32.4 ± 33.5
NS
43.2
42.3
44.1
NS
40.1
46.6
NS
Ventricular system irruption (%)
Etiology (%)
0.028
<0.001
Hypertensive
70.2
68.9
71.7
60.7
80.8
Undetermined
9.8
11.7
7.5
14.1
4.9
Cerebral vascular malformation
6.9
7.0
6.8
12.8
0.4
Amyloid angiopathy
4.3
4.3
4.2
0.3
8.6
Coagulopathy
3.9
2.7
5.3
6.0
1.5
Miscellaneous
1.8
3.3
0
3.4
0
Recreational drugs/sympathomimetics
1.4
0.7
2.3
2.0
0.8
Anticoagulants/antiplatelets
1.2
1.0
1.5
0.7
1.9
Tumors
0.5
0.3
0.8
0
1.1
NS: not significant. Percentages may not sum up to 100 due to rounding.
www.neurologia.com Rev Neurol 2011; 53 (12): 705-712
707
4. J.L. Ruiz-Sandoval, et al
Table II. ICH topography related to etiology.
Supratentorial
Infratentorial
Basal ganglia
Lobar
Brainstem
Intraventricular
Cerebellum
Putamen
Thalamus
Caudate
Midbrain
Pons
Medulla
Hypertensive (%)
42.4
52.2
91.2
95.8
94.7
33.3
52.4
100.0
70.4
Undetermined (%)
2.0
8.7
5.4
3.4
0
11.1
23.8
0
11.1
Cerebral vascular malformations (%)
12.1
17.4
1.4
0.8
0
33.3
23.8
0
11.1
Amyloid angiopathy (%)
12.1
0
0
0
0
0
0
0
0
Coagulopathy (%)
8.6
4.3
0.7
0
0
11.1
9.5
0
0
Miscellaneous (%)
3.5
0
1.4
0
0
0
0
0
3.7
Recreational drugs/sympathomimetics (%)
2.5
0
0
0
5.3
11.1
4.8
0
0
Anticoagulants/antiplatelets (%)
2.0
8.7
0
0
0
0
0
0
3.7
Tumors (%)
1.5
0
0
0
0
0
0
0
0
Percentages may not sum up to 100 due to rounding.
The median (IQR) admission ICH-GS scale was 8
(7-9) points; 48.7% of patients with 5-7 points, 36.8%
with 8-10 points and 14.6% with 11-13 points. There
were no gender differences in the ICH-GS score.
The most common ICH location was deep supratentorial, mainly in basal ganglia, being more
frequent among males than females (56.6% vs.
44.8%, respectively, p = 0.005). Except for primary
intraventricular ICH, no significant differences regarding to age were observed in the hematoma location. Respecting the etiology, significant differences related to age and gender were observed, with
a higher frequency of hypertensive and amyloid angiopathy causes in patients aged ≥ 65 years compared with those < 65 years (Table I). Differences
respecting ICH etiology between genders were perhaps less relevant, except for a greater use of sympathomimetic drugs in males.
Table II shows the ICH location related to etiology. Hypertension appears as a cause for virtually
any hematoma location, and as expected, CVM was
more common in lobar, intraventricular and midbrain locations, while the amyloid angiopathy etiology had a lobar location only. Coagulopathies less
frequently had a basal ganglia location, being most
common in pons, midbrain or lobar, but it is noteworthy that ICH related to antiplatelets and antico-
708
agulation drugs were more frequent in lobar, intraventricular and cerebellar location (Table II). The
most common location for undetermined ICH etiology was the pons.
The hospital stay had a median of 9 days, with no
differences by age or gender (Table III). Pneumonia
and urosepsis were the most common in-hospital
complications. Patients aged ≥ 65 years had pneumonia more frequently than their younger counterparts (35.3% vs. 23.6%, respectively, p = 0.002).
Functional status at hospital discharge was generally
unfavorable. Only 9.8% of the patients were discharged with minimal neurological deficit and the
mortality rate was 28.4%, increasing to 29.6% to 30
days. Age ≥ 65 years was associated with poor prognosis, in this group there were more cases of death
and severe functional impairment, both at discharge
and at 30 days from the symptoms onset (Table III).
Notably, the association of hematoma volume
and the probability of death at 30 days was related
to ICH location (Fig. 1), so that the greater likelihood of death was observed for those with > 70 mL
hematoma volume in the supratentorial space
(61.8%) and > 20 mL in the infratentorial space (75%).
This observation is supported by a thirty-day Kaplan-Meier actuarial survival analysis (Fig. 2) for volumes > 70 mL and > 20 mL, 40-70 mL and 10-20 mL
www.neurologia.com Rev Neurol 2011; 53 (12): 705-712
5. Spontaneous intracerebral hemorrhage in Mexico: results from RENAMEVASC
Table III. In-hospital evolution and 30-day functional outcome in ICH patients, according to gender and age (n = 564).
Gender
Total
Hospital stay, median (IQR), days
Surgical treatment (%)
Age group
Female
(n = 299)
Male
(n = 265)
9 (5-17)
9 (5-17)
9 (5-16.7)
9.5
9.5
p
p
< 65 years
(n = 298)
≥ 65 years
(n = 266)
NS
10 (6-17)
8 (5-17)
0.38
9.5
NS
8.6
10.5
NS
NS
23.6
35.3
0.002
In-hospital complications (%)
Pneumonia
29.1
26.8
31.7
Urosepsis
12.3
10.4
14.3
NS
10.4
14.3
NS
Arrhythmias
2.0
0.7
3.4
0.020
2.4
1.5
NS
Systemic venous thromboembolism
1.6
1.3
1.9
NS
1.3
1.9
NS
Modified Rankin scale at discharge (%)
NS
<0.001
0-1
9.8
9.7
9.8
14.1
4.9
2-3
20.7
18.7
23.0
24.5
16.5
4-5
41.1
46.2
35.5
37.9
44.7
6
28.4
25.4
31.7
23.5
33.8
Modified Rankin scale at 30 days follow-up (%)
NS
<0.001
0-1
12.1
11.4
12.8
16.8
6.8
2-3
27.3
28.1
26.4
31.9
22.2
4-5
31.0
33.4
28.3
27.5
35.0
6
29.6
27.1
32.5
23.8
36.1
IQR: interquartile range; NS: non significant. Percentages may not sum up to 100 due to rounding.
and < 40 mL and <10 mL, for supra and infratentorial spaces, respectively. Thus, age, GCS at admission, hematoma volume, location and ventricular
irruption were significantly associated with death
at 30 days, all included in the ICH-GS (Fig. 2). Patients with a ICH-GS score of 5 to 7 points showed
a very low probability of death (8%), comparing
with those with a score of 11 to 13 points, which
only 27% survived at 30 days.
Discussion
In this Mexican multicenter study, we observed that
ICH represents one third of all CVD types, being
hypertension its main etiology. The hematoma location was strongly associated with its cause, confirming that early neuroimaging study plus medical
history should orientate to an appropriate diagno-
www.neurologia.com Rev Neurol 2011; 53 (12): 705-712
sis and work-up approach. In addition to age, mortality risk factors were inherent to the acute hematoma characteristics.
These findings have fundamental importance in
public health policy, considering that in Mexico,
hypertension prevalence in the adult population (≥
20 year-age) is 43% and half of these individuals are
not aware of it, therefore, this population is excluded from effective treatment and preventive measures [21]. The latter could explain the high ICH frequency in Mexico, compared to countries like Spain
and the United States [2-5]. However, unidentified
ethnic differences, or suboptimal hypertension control could be associated with an increased ICH frequency in certain ethnic groups, as, for example,
the hypertension frequency in countries like Spain
does not differ significantly from Mexico [22-24],
though the ICH relative frequency among the various forms of acute CVD is greater in this Latin
709
6. J.L. Ruiz-Sandoval, et al
Figure 1. Thirty-day mortality in ICH patients, with respect to hematoma localization and volume.
American country. Moreover, the ICH frequency in
some Latin American populations is getting closer
to those in countries like Korea and China [25],
which suggests a shared genetic background between Asians and Native Americans [26-28].
This study demonstrates the significant health
burden that ICH represents for Mexico, it also
shows that it is the second most common CVD
type, and is associated with significant functional
disability and death, since 60% of ICH patients at 30
days will have a significant functional dependence
for daily living activities or will be dead. Therefore,
an optimal hypertension and associated risk factors
control is mandatory, since an inadequate control is
a major risk factor not only for ICH, but also to
ischemic stroke [29,30].
We notice that the ICH-GS components had an
adequate performance, alone or together, in predicting the short-term ICH death tendency [20]. It
also supports the importance of the hematoma volume location, because it is easier to deduce that the
same hematoma volume in a smaller space, such as
infratentorial, may cause a greater damage than in a
larger space, such as supratentorial. However, this
study was not designed to validate the ICH-GS, either to compare its performance with other wellknown ICH prognostic scales [31-33].
This study has some limitations that should be
noticed to avoid the generalization of its results.
First, the RENAMEVASC study is a hospital registry
based on consecutive patients, making it susceptible
to health institutions participant selection bias. Furthermore, due to the clinical design and objectives
of this registry, the follow-up period is short, pre-
710
cluding the assessment of the functional outcome of
the ICH at medium and long term, which would allow to estimate the real impact of this disease. Nevertheless, this study provides important comparative
data on epidemiology and enhances our clinical
knowledge, showing that it is possible to predict
since the hospital admission which patients would
have a high probability of an adverse outcome, establishing important timely management decisions
and closer relationship with the patient’s family.
In conclusion, the ICH frequency in Mexico is
high, which is comparable to other Latin American
registries. The functional outcome of patients with
ICH is poor in a significant cases proportion. Health
governmental institutions should be involved for
limiting the burden generated by arterial hypertension in Mexico.
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7. Spontaneous intracerebral hemorrhage in Mexico: results from RENAMEVASC
Figure 2. Kaplan-Meier curves showing 30-day survival after ICH as a function of age (a), Glasgow Coma Scale (b), irruption into the ventricular system (c), hematoma volume by
intracranial localization (d), hematoma volume grouped according to ICH-GS scale (e), and ICH-GS scoring (f).
a
15.
16.
17.
18.
19.
20.
21.
c
d
14.
b
e
f
Evaluación de cambios en el tratamiento de la hemorragia
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Hemorragia intracerebral espontánea en México: resultados del Registro Hospitalario Multicéntrico
Nacional en Enfermedad Vascular Cerebral (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.
Palabras clave. Diagnóstico. Epidemiología. Hemorragia intracerebral. Ictus. Pronóstico.
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