Thrombolysis and bridging therapy in patients with acute ischaemic stroke and Covid-19.

BACKGROUND AND PURPOSE: Comorbidity of acute ischaemic stroke with Covid-19 is a challenging condition, potentially influencing the decision of whether to administer intravenous thrombolysis (IVT). We aimed to assess the 1-month outcome in ischaemic stroke patients with Covid-19 infection who received IVT alone or before thrombectomy (bridging therapy). METHODS: As a collaboration initiative promoted by the Italian Stroke Organization, all Italian stroke units (n = 190) were contacted and invited to participate in data collection on stroke patients with Covid-19 who received IVT. RESULTS: Seventy-five invited centers agreed to participate. Thirty patients received IVT alone and 17 received bridging therapy between 21 February 2020 and 30 April 2020 in 20 centers (n = 18, Northern Italy; n = 2, Central Italy). At 1 month, 14 (30.4%) patients died and 20 (62.5%) survivors had a modified Rankin Scale (mRS) score of 3 to 5. At 24 to 36 hours, asymptomatic intracerebral hemorrhage (ICH) was reported in eight (17.4%) patients and symptomatic ICH (sICH) in two (4.3%) patients. Causes of death were severe ischaemic stroke (n = 8), a new ischaemic stroke (n = 2), acute respiratory failure (n = 1), acute renal failure (n = 1), acute myocardial infarction (n = 1), and endocarditis (n = 1). In survivors with a 1-month mRS score of 3 to 5, baseline glucose level was higher, whereas endovascular procedure time in cases of bridging therapy was longer. Baseline National Institutes of Health Stroke Scale glucose and creatinine levels were higher in patients who died. CONCLUSIONS: Intravenous thrombolysis for patients with stroke and Covid-19 was not a rare event in the most affected areas by pandemic, and rates of 1-month unfavorable outcomes were high compared to previous data from the pre-Covid-19 literature. However, risk of sICH was not increased.

The management of patients with acute ischemic stroke while on direct oral anticoagulants (DOACs): data from an Italian cohort and a proposed algorithm.

Approximately 1-2% of patients with non-valvular atrial fibrillation have an acute ischemic stroke (AIS) while on direct oral anticoagulant (DOAC) treatment every year. However, current evidence on stroke subtypes, pathophysiology and factors leading to the failure of DOAC preventive therapy in a "real world" setting is still scanty. This study aimed at investigating whether there is any relationship between DOAC plasma levels and the stroke occurrence, on the basis of the phenotypic classification and pathophysiology of the stroke, in a cohort of DOAC-treated patients admitted to our hospital for AIS over 1-year period. A total of 28 patients had DOAC plasma levels determined in emergency and were included in the study, nine patients receiving dabigatran, 11 rivaroxaban and 8 apixaban. The DOAC levels were low in 8/28 patients (28.6% of the sample), intermediate in 4 (14.3%) and high in 16 (57.1%). The most prevalent stroke subtype was the small vessel disease, according to the A-S-C-O phenotypic classification, in 53.6% of our sample. The most common clinical presentation was "minor stroke" in 71.4% of the cases. There was a significantly higher proportion of patients with high DOAC levels in the small vessel group, compared to the cardioembolic group without other phenotypes. The question arises as to the most suitable clinical management of AIS in these patients on DOACs. In the current absence of clear evidence, taking into account the DOAC levels (low/intermediate/high) and the underlying stroke pathophysiology, we present a flowchart of our proposed clinical management of ischemic stroke in patients while on DOAC.

Electrodiagnostic testing in diabetic neuropathy: Which limb?

Electrodiagnosis of subclinical diabetic neuropathies by nerve conduction studies remains challenging. The question arises about which nerves should be tested and what the best electrodiagnostic protocol to make an early diagnosis of diabetic neuropathies would be. On the basis of our findings and other evidence, which highlighted the remarkable prevalence of electrophysiological abnormalities in nerve conduction studies of the upper limbs, often in the presence of normal lower limb conduction parameters, we suggest that both ulnar and median nerves, in their motor and sensitive component, should be the two target nerves for electrodiagnostic protocols in diabetic neuropathies.

Tinnitus and its relationship with muscle tenderness in patients with headache and facial pain.

OBJECTIVE: This study aimed to examine tinnitus prevalence in patients with different types of headache and the relationship between tinnitus and the pericranial muscle tenderness and cervical muscle tenderness scores. METHODS: A cross-sectional study was conducted of 1251 patients with migraine and/or myogenous pain, arthrogenous temporomandibular joint disorders and tension-type headache. Standardised palpation of the pericranial and cervical muscles was carried out and univariable and multivariable analysis was used to measure the odds ratio of suffering tinnitus by the different diagnoses and muscular tenderness grade. RESULTS: A univariable analysis showed that myogenous pain, pericranial muscle tenderness and cervical muscle tenderness scores, sex, and age were associated with tinnitus. When a multivariable model including only age, sex and a headache diagnosis was used, myogenous pain, migraine and age were found to be associated with tinnitus. When muscle tenderness scores were also included, only the cervical muscle tenderness and pericranial muscle tenderness scores were found to be significantly associated with tinnitus. CONCLUSION: In a population of patients with headache and craniofacial pain, tinnitus was related to increased cervical muscle tenderness and pericranial muscle tenderness scores, rather than to any particular form of headache.

Post-stroke rehabilitation in Italy: inconsistencies across regional strategies.

BACKGROUND: Remarkable differences among European countries have been found in stroke rehabilitation models, owing to the fact that stroke rehabilitation services are embedded in health care systems. Comprehensive data on service utilization by stroke survivors in Italy are lacking, but would be instrumental in improving efficiency and effectiveness of post-acute stroke care, and consequently, in containing costs and improving outcomes. AIM: The purpose of the present study was to survey the Italian regional legislations in order to examine the provision of rehabilitation services for stroke survivors in Italy. DESIGN: This is a cross-sectional, observational study. SETTING: Post-stroke intra- and extra-hospital rehabilitation. POPULATION: All decrees and resolutions as to post-acute stroke rehabilitation were collected from each Italian region. METHOD: All decrees and resolutions were examined by the means of a check list including quantitative and qualitative characteristics, selected in accordance with national official recommendations. Each completed check list was then sent to each regional reference person, who filled in the section on the implementation of the indications and compliance. RESULTS: The study was carried out from November 2009 to September 2010. The documents were collected from 19 out of the 20 Italian regions. The results of the study indicate that there are many, remarkable regional variations in health policies concerning post-stroke care. Instruments for evaluation and criteria for allocating stroke patients to proper rehabilitation setting vary across regions, but data on the potential impact of these variations on clinical outcomes are still lacking. CONCLUSION: The study highlights the issue that, in Italy, delivery of post-stroke rehabilitation services is not uniform nation-wide and varies substantially across regions. The lack of a comprehensive post-acute stroke strategy is a major obstacle to service availability. CLINICAL REHABILITATION IMPACT: The study results advocate the need for a consistent and comprehensive strategic planning of post-stroke rehabilitation in Italy.

Updating on Italian stroke units: the "CCM study".

The stroke units (SUs) have been demonstrated to be efficient and cost effective for acute stroke care. Nevertheless, the level of stroke unit implementation in Italy does not correspond to expectations yet. This study is a survey, which aims at assessing the current status of in-hospital stroke care in the Italian regions and at updating SUs. The survey was conducted by means of a semi-structured questionnaire, based on 18 stroke care "quality indicators", submitted to all the Italian centres that had taken part in the SITS-MOST study, and to other centres advised by the coordinator of SITS studies and by regional opinion leaders of stroke. SUs were defined as acute wards, with stroke-dedicated beds and dedicated teams that had been formally authorised to administer rt-PA. A statistical analysis was performed by a descriptive statistics and logistic regression model. The study was carried out from November 2009 to September 2010. A total of 168 forms were sent out and 153 replies received. Seven centres, which had not performed any thrombolytic treatment, and 16 which did not fulfil the criteria for the definition of SU were excluded from the study. Most of the centres reported more than 100 stroke patient admissions per year, i.e., 122 (84%) from 100 to 500, 18 (12%) more than 500. The 19% of the centres admitted more than 30% of patients within 3 h from the symptom onset and only 30% admitted more than 30% of patients within 4.5 h. The mean number of thrombolyses performed in the last 6 months was 10 for centres with a doctor on duty 24 h a day, 6 for those that have a doctor on duty from 8 a.m. to 8 p.m. and a doctor on call for night, and 5 for centres with a doctor on call 24 h a day. The territorial distribution of the SUs is remarkably heterogeneous: 87 SUs (67%) are located in the North of Italy, 28 (22%) in the central part of Italy and only 15 (11%) in the South. The last few years have witnessed a rise in both the diffusion of SUs and access to thrombolytic therapy in Italy. Despite this, there are a few large areas, mostly in the south, where the requirements of healthcare legislation are not met, and access to a dedicated SU and thrombolytic treatment is still limited and poor.

[A model of intervention on company canteens to promote healthy diet]. / Un modello di intervento sulle mense aziendali per promuovere l'alimentazione corretta.

The Workplace Health Promotion project, operating in the precinct of the Local Health Authority of Bergamo, contemplates that the partaking Companies should develop specific activities ("good practices") in the thematic area of proper nutrition. Six best practices have been defined on the basis of: contextual data, actions deemed most effective by the scientific publications, the "Guidelines for a healthy diet for the Italian, population" released by the Italian National Research Institute for Food and Nutrition the "Directions for healthy snacks for adults" elaborated by the Italian Association of Dietetics and Clinical Nutrition, and the national project "Gaining Health". Twenty-six Companies have chosen to implement good practices in the area of proper nutrition. The results of the undertaken actions have been measured at the first Company which participated in this program, and have been obtained through the administration of a pre- and postintervention questionnaire. The collected data show the efficacy of the proposed practices in modifying some incorrect dietary habits.

The "seagull cry" in a patient with a cerebral arteriovenous malformation.

INTRODUCTION: The "seagull cry" is an acoustic phenomenon heard during duplex ultrasound. It is caused by harmonic covibrations of a vessel wall in the presence of high-velocity blood flow. It has been reported in a few cases of cerebrovascular disease, such as severe intracranial stenosis, vasospasm or carotid-cavernous fistula. MATERIAL AND METHODS: A 35-year-old man underwent transcranial color-coded sonography (TCCS) for work-up of a severe new-onset headache. RESULTS: Doppler spectral analysis of the right intracranial carotid bifurcation revealed multiple pairs of mirror-image parallel strings, and a high-frequency seagull cry was heard. Computed tomography-angiography and magnetic resonance imaging of the brain showed an arteriovenous malformation in the right temporal lobe. DISCUSSION: The seagull cry is a "musical murmur" with single or multiple frequency that sounds like a musical tone. This is the first report of this phenomenon in a cerebral arteriovenous malformation.

Nephrogenic systemic fibrosis: the first Italian gadolinium-proven case.

Nephrogenic systemic fibrosis (NSF) is a systemic disease, recently described in patients with advanced chronic kidney disease (CKD), characterized by progressive scleromyxedema-like fibrotic involvement mainly of the skin. We describe the case of a 66-year-old woman on chronic hemodialysis for end-stage renal failure, also affected by hypothyroidism, secondary hyperparathyroidism and occluding arteriopathy, for which she underwent a contrast-enhanced magnetic resonance angiography of the lower limbs in February 2007. One month later, she began complaining of progressive, painful distal lower limb stiffness, which subsequently spread to all four limbs and to the whole trunk. A deep-skin biopsy, taken from an affected area, showed gadolinium deposits. The case reported is, to best of our knowledge, the first Italian case of NSF. This diagnosis should be considered with care in CKD patients with a recent exposure to a gadolinium-based contrast agent, complaining of limb stiffness, especially in the presence of risk factors.

Effectiveness of an educational and physical programme in reducing headache, neck and shoulder pain: a workplace controlled trial.

This study was an 8-month controlled trial to evaluate the effectiveness of a workplace educational and physical programme in reducing headache and neck and shoulder pain. Central registry office employees (n = 192; study group) and 192 peripheral registry office and central tax office employees (controls) in the city of Turin, Italy were given diaries for the daily recording of pain episodes. After 2 months, the study group only began the educational and physical programme. The primary end-point was the change in frequency of headache and neck and shoulder pain expressed as the number of days per month with pain, and as the proportion of subjects with a >or= 50% reduction of frequency (responder rate). The number of days of analgesic drug consumption was also recorded. Diaries completed for the whole 8 months were available for 169 subjects in the study group and 175 controls. The baseline frequency of headache (days per month) was 5.87 and 6.30 in the study group and in controls; frequency of neck and shoulder pain was 7.12 and 7.79, respectively. Mean treatment effects [days per month, 95% confidence interval (CI)] on comparing the last 2 months vs. baseline were: headache frequency -2.45 (-3.48, -1.43); frequency of neck pain -2.62 (-4.09, -1.16); responder rates (odds ratio, 95% CI) 5.51 (2.75, 11) for headache, 3.10 (1.65, 5.81) for neck and shoulder pain, and 3.08 (1.06, 8.90) for days with analgesic drug consumption. The study suggests that an educational and physical programme reduces headache and neck and shoulder pain in a working community.

Laparoscopic transabdominal preperitoneal (TAPP) hernia repair: surgical phases and complications.

BACKGROUND: This study aimed to determine the nature of complications after transabdominal preperitoneal (TAPP) hernia repair, and to evaluate possible links to intraoperative factors in an effort to reduce the incidence of complications. METHODS: The TAPP procedures for inguinal/femoral hernias performed between 1992 and 2004 at a single center were analyzed retrospectively. Complications were categorized according to severity and stage of the surgical procedure at which they occurred. Individual surgeon performances were examined to determine whether the rates of complications were related to surgeon experience. RESULTS: A total of 1,973 TAPP procedures were reviewed, and 81% of the patients completed 5 years of follow-up evaluation. The 74 complications (3.7%) reported were categorized as follows: 33 major (1.7%) versus 41 minor (2.0%), 66 hernia-related (3.4%) versus 8 laparoscopy-related (0.5%) complications, and 12 recurrences (0.6%). Risk factors for complications included inguinoscrotal hernia (p < or = 0.001), dissection/reduction of the sac (p = 0.02), and surgeon experience (< 50 TAPP procedures; odds ratio, 7.1; 95% confidence interval, 4.2-11.9). CONCLUSIONS: Accuracy in dissection/reduction of the sac improves the outcome of TAPP hernia repair. This effect is related to the experience of the surgeon. Experience performing more than 75 procedures is required for optimal results.