[Clinical and care implications of the 10-year application of a cerebrovascular diseases register. Descriptive analysis of the last 1000 patients and comparative with the first 1000 patients]. / Implicaciones clínicas y asistenciales de la aplicación durante 10 años de un registro de enfermedades cerebrovasculares. Análisis descriptivo de los últimos 1.000 pacientes y comparativo con los 1.000 primeros pacientes.

BACKGROUND: There are few studies which analyze clinical and patients' care implications of the continuous application of acute stroke registry. PATIENTS AND METHODS: A prospective study was carried out on 2,000 consecutive patients with acute stroke who were admitted in the neurology department over a period of 10 years (1986-1995). A descriptive clinical analysis of the last 1,000 patients (1986-1991) and a comparative clinical analysis between the last 1,000 patients and the first 1,000 patients (1991-1995) were performed. CT scan and/or MRI were performed in all patients. We used a previously validated registry and we studied clinical and assistance implications of its systematic use. RESULTS: Between the last 1,000 patients and the first 1,000 patients there were significant differences in the frequency of transient ischaemic attacks (TIA) (15% vs 9%; p < 0.0001), lacunar infarcts (20.5% vs 17%; p < 0.04), cardioembolic infarcts (22.3% vs 12.4%; p < 0.0001), infarcts of undetermined cause (7.5% vs 15%; p < 0.0005), intraparenchymatous hemorrhage (9% vs 14%; p < 0.0005), in-hospital mortality (13.8% vs 16.7%; p = 0.07, NS) and mean length of hospital stay (16.5 vs 19.5 days; p < 0.005). CONCLUSIONS: The continuous application of stroke registry brought major interest to the care of stroke patients, resulting in a higher admission rate of TIA patients, a better diagnosis of cardioembolic and lacunar stroke and fewer infarcts of undetermined cause. A decrease in the mean length of hospital stay was observed as well as a lower in-hospital mortality rate.

[Early recurrence of spectacular shrinking deficit as a form of presentation in a cardio-embolic infarct]. / Recurrencia precoz de la regresión espectacular del déficit hemisférico neurológico como forma de presentación de un infarto cardioembólico.

INTRODUCTION: Spectacular shrinking deficit (SSD) is a little known neurovascular syndrome with a monophasic clinical course. It was observed in 4.8% (11 of 231 patients) with cardio-embolic cerebral infarcts in the records of patients with cerebrovascular disease at our hospital. CLINICAL CASE: We present the only patient in our records (0.04% of the cardio-embolic infarcts and 0.06% of the patients in the series, which consists of 1,500 consecutive patients with stroke studied over a period of 8 years) with recurrent SSD, which was the form of presentation of rheumatic mitral valve disease with atrial fibrillation. DISCUSSION: As far as we know, the recurrent clinical course of SSD has not previously been described. The clinical case presented shows that early recurrence is possible in SSD. CONCLUSIONS: The possibility of the presentation of a cerebral infarct of cardioembolic origin in the form of recurrent SSD should be borne in mind. Early recurrence of SSD should also be taken into account to avoid bias in selecting patients for clinical trials to be carried out during the acute phase of cerebrovascular disease.

Ischemic stroke of unusual cause: clinical features, etiology and outcome.

The clinical features, etiology and neurological outcome of ischemic stroke of unusual cause (ISUC) have rarely been reported. We retrospective reviewed all patients with this stroke subtype entered in the Sagrat Cor Hospital of Barcelona Stroke Registry, which includes data from 2000 consecutive first-ever stroke patients admitted to the hospital between 1986 and 1995. Patients with previous ischemia and/or hemorrhagic stroke were excluded. Topographic, anamnestic, clinical and neuroimaging characteristics of ISUC were assessed. Predictors of this stroke subtype were determined by logistic regression analysis. Ischemic stroke of unusual etiology was diagnosed in 70 patients (32 men and 38 women), with a mean +/- SD age of 52 +/- 22.4 years. This stroke subtype accounted for 4.3% of all first-ever strokes and 6% of all first-ever brain infarcts. Etiologies included hematological disorders in 17 cases, infection in 11, migraine stroke in 10, cerebral infarction secondary to venous thrombosis in nine, primary inflammatory vascular conditions in six and miscellaneous causes in 17. In the multivariate analysis after excluding cerebral venous thrombosis (n = 9) and arterial dissection (n = 4), because of typical clinical and radiological features, independent predictors of ISUC included 45 years of age or less (odds ratio [OR] 14.8), seizures (OR 6.8), headache (OR 5.2), hemianopia (OR 2.6) and occipital lobe involvement (OR 3.0). Patients with ISUC presented a lower in-hospital mortality rate (7.1% vs. 14.4%; P < 0.05), were more frequently symptom free at discharge (35.7% vs. 25.80%; P < 0.05) and experienced a longer mean length of hospital stay (23.7 days vs. 18.2 days; P = 0.06) than non-ISUC patients. We conclude that ISUC is infrequent, etiologies are numerous and hematologic disorders are the most frequent cause. We emphasize the better prognosis and the need to distinguish it from other ischemic stroke subtypes which have a different treatment approach and outcome.

[Effect of home hospitalization in the reduction of traditional hospitalization and frequency of emergencies in heart failure]. / Efecto de la hospitalización a domicilio en la reducción de la hospitalización convencional y frecuentación de urgencias en la insuficiencia cardíaca.

OBJECTIVE: Medical care to patients with heart failure (HF) entails high needs in health care and social resources. Hospital at home (HH) is a potentially useful care alternative for these patients. MATERIALS AND METHODS: Observational study with 110 elderly patients with non complicated HF admitted to an HH unit. Patients were treated with educational support (clinical, dietetic and pharmacologic) and intensive home follow-up. Conventional hospital admissions and visits to the Emergency Department were analyzed during the 90 days before and after HH. RESULTS: After HH, conventional hospital admissions decreased by 86% and visits to the Emergency Department by 91%. The mean Barthel Index changed from 74 to 77 (p < 0.05, in all cases). Ninety-six percent of patients were satisfied or very satisfied with HH. CONCLUSIONS: In elderly patients with non complicated HF, the intervention of an HH unit reduces conventional hospital admissions and the number of visits to the Emergency Department, the personal satisfaction degree is high and the functional capacity does not worsen.

[Community collection of syringes by parenteral drug users complementary to syringe exchange programs]. / RECOJE: recogida comunitaria de jeringas por usuarios de drogas por vía parenteral como complemento a los programas de intercambio.

OBJECTIVES: To contribute to harm reduction in injecting drug users (IDUs) by the implementation of a programme to withdraw abandoned syringes from public places, as well as to collaborate on the social reinsertion of IDUs. METHODS: Descriptive study of the Syringe Withdrawal Community (RECOJE in Spanish), carried out from 1997 to 1999 by IDUs, the We Are Helpful Association (ASUT in Spanish) and the Social and Health Prevention and Attention Service (SAPS in Spanish) of the Red Cross, in Ciutat Vella (Barcelona, Spain). RESULTS: 4,332 syringes were withdrawn, 849 in 1997, 1,324 in 1998 and 2,159 in 1999. The mean number of syringes withdrawn each time was 57 33. 45 different IDUs worked in RECOJE. 74.2% of the abandoned syringes were found in parks, gardens, car parks and open spaces. CONCLUSIONS: RECOJE can be a valid programme for harm reduction complementary to the exchange syringe programmes. It could improve the self-esteem, external image and organization of IDUs, contributing to their social reinsertion.

Sleep-related breathing disorders: impact on mortality of cerebrovascular disease.

The aim of the study was to analyse the impact of sleep-related breathing disorders in a 2-yr survival follow-up of patients with a first ever stroke or transient ischaemic attack. The study followed 161 patients. Complete neurological assessment was performed in order to determine cerebrovascular risk factors, functional disability, and parenchymatous and vascular localisation, as well as stroke subtype categorisation. A sleep study was carried out using a portable respiratory recording device, The entire cohort was followed over a mean period of 22.8 months. The main outcome event was death and time of survival since the neurological event. A multivariate Cox's model was estimated. The patients were ages 72+/-9 yrs (mean+/-SD), and had a body mass index of 26.6+/-3.9 kg x m(-2) and apnoea/hypopnoea index (AHI) of 21.2+/-15.7. Overall, mortality occurred in 22 cases, and the survival rate was 86.3%. Vascular disease accounted for 63.6% of deaths. Multivariate analysis selected four independent variables associated with mortality: 1) age; 2) AHI, with an implied 5% increase in mortality risk for each additional unit of AHI; 3) involvement of the middle cerebral artery; and 4) the presence of coronary disease. In conclusion, the findings suggest that sleep-related breathing disorders are an independent prognostic factor related to mortality after a first episode of stroke.

Time course of sleep-related breathing disorders in first-ever stroke or transient ischemic attack.

To investigate the prevalence and behavior of sleep-related breathing disorders (SRBDs) associated with a first-ever stroke or transient ischemic attack (TIA), we prospectively studied 161 consecutive patients admitted to our stroke unit. Complete neurological assessment was performed to determine parenchymatous and vascular localization of the neurological lesion. Stroke subtype was categorized as TIA, ischemic (IS), or hemorrhagic (HS). A portable respiratory recording (PRR) study was performed within 48-72 h after admission (acute phase), and subsequently after 3 mo (stable phase). During the acute phase, 116 patients (71.4%) had an apnea-hypopnea index (AHI) > 10 events/h and 45 (28%) had an AHI > 30. No relationships were found between sleep-related respiratory events and the topographical parenchymatous location of the neurological lesion or vascular involvement. Cheyne-Stokes breathing (CSB) was observed in 42 cases (26.1%). There were no significant differences in SRBD according to the stroke subtype except for the central apnea index (CAI). During the stable phase a second PRR was performed in 86 patients: 53 of 86 had an AHI > 10 and 17 of 86 had an AHI > 30. The AHI and CAI were significantly lower than those in the acute phase (16.9 +/- 13.8 versus 22.4 +/- 17.3 and 3.3 +/- 7.6 versus 6.2 +/- 10.2, respectively) (p < 0.05) while the obstructive apnea index (OAI) remained unchanged. CSB was observed in 6 of 86 patients. The prevalence of SRBD in patients with first-ever stroke or TIA is higher than expected from the available epidemiological data in our country. No correlation was found between neurological location and the presence or type of SRBD. Obstructive events seem to be a condition prior to the neurological disease whereas central events and CSB could be its consequence.

RECOJE: recogida comunitaria de jeringas por usuarios dedrogas por vía parenteral como complemento a los programasde intercambio / Community collection of syringes by parenteral drug users complementary to syringe exchange programs

Objetivo: Reducir riesgos para los usuarios de drogas por vía parenteral (UDVP) y la comunidad a través de un programa de recogida de jeringas abandonadas en lugares públicos y contribuir a la reinserción social de los UDVP. Método: Estudio descriptivo de la recogida comunitaria de jeringas (RECOJE) abandonadas, realizada entre 1997 y 1999por UDVP, la asociación somos útiles (ASUT) y el servicio de atención y prevención sociosanitaria (SAPS) de la Cruz Roja,en la Ciutat Vella de Barcelona. Resultados: Se recogieron 4.332 jeringas; 849 en 1997, 1.324en 1998 y 2.159 en 1999. La media de jeringas recogidas por salida fue de 57 ± 33. Un total de 45 UDVP realizaron RECOJE. La mayoría de jeringas (74,2%) se localizaron en parques, jardines, aparcamientos y descampados. Conclusiones: La recogida comunitaria de jeringas es un programa válido para la reducción de riesgos, complementario al intercambio de jeringas. Mejora la autoestima, imagen externa y organización de los UDVP y contribuye a su reinserción social (AU)

Objectives: To contribute to harm reduction in injecting drug users (IDUs) by the implementation of a programme to withdraw abandoned syringes from public places, as well as to collaborate on the social reinsertion of IDUs. Methods: Descriptive study of the Syringe Withdrawal Community(RECOJE in Spanish), carried out from 1997 to 1999by IDUs, the We Are Helpful Association (ASUT in Spanish)and the Social and Health Prevention and Attention Service(SAPS in Spanish) of the Red Cross, in Ciutat Vella (Barcelona,Spain).Results: 4,332 syringes were withdrawn, 849 in 1997,1,324 in 1998 and 2,159 in 1999. The mean number of syringes withdrawn each time was 57 ± 33. 45 different IDUs worked in RECOJE. 74.2% of the abandoned syringes were found in parks, gardens, car parks and open spaces. Conclusions: RECOJE can be a valid programme for harm reduction complementary to the exchange syringe programmes. It could improve the self-esteem, external image and organization of IDUs, contributing to their social reinsertion (AU)

Efecto de la hospitalización a domicilio en la reducción de la hospitalización convencional y frecuentación de urgencias en la insuficiencia cardíaca / Effect of hospital at home in the reduction of conventional hospitalization and emergency visits in heart failure

Objetivo. La atención de pacientes afectados de insuficiencia cardíaca comporta unas necesidades elevadas de recursos sanitarios y sociales. La hospitalización a domicilio (HaD) es una alternativa asistencial potencialmente útil en estos pacientes. Material y métodos. En este estudio observacional 110 pacientes ancianos con IC no complicada, ingresados en una unidad de HaD se trataron con soporte educacional (clínico, dietético y farmacológico) y seguimiento domiciliario intensivo. Se analizaron los ingresos en hospitalización convencional y la frecuentación del servicio de Urgencias durante los 90 días previos y posteriores a la HaD. Resultados. Tras la HaD, los ingresos en hospitalización convencional se redujeron el 86 por ciento y la frecuentación del servicio de urgencias el 91 por ciento. El índice medio de Barthel pasó de 74 a 77 (p < 0,05 en todos los casos). El 96 por ciento estaban satisfechos o muy satisfechos con la HaD. Conclusiones. En pacientes ancianos con insuficiencia cardíaca no complicada la intervención de una unidad de HaD reduce los ingresos en hospitalización convencional y la frecuentación de urgencias, el grado de satisfacción personal es elevado y no empeora la capacidad funcional (AU)

Efecto de la incontinencia urinaria y la dependencia para la alimentación en la institucionalización de pacientes geriátricos agudos / Effect of urinary incontinence and dependence for feeding on the institutionalization of acute geriatric patients

OBJETIVO: Valorar el efecto de la presencia de incontinencia urinaria (IU) y dependencia para la alimentación (DA) en la institucionalización de pacientes ancianos atendidos por una unidad de valoración geriátrica en un hospital de agudos. MATERIAL Y MÉTODOS: Estudio prospectivo observacional donde se analiza en 302 pacientes geriátricos consecutivos ingresados por patología aguda médica y quirúrgica, la presencia de IU y DA, así como la patología al ingreso, la comorbilidad existente, el estado cognitivo, la funcionalidad, el soporte social y el destino hacia instituciones geriátricas al alta hospitalaria. RESULTADOS: El 51,9 per cent de los pacientes presentaban IU y el 39,7 per cent DA. En general los pacientes con IU y DA, mostraron peores puntuaciones en los tests de Barthel y Pfeiffer, 33,8 (DE 18,4) vs 60,1 (DE 17,0) y 2,91 (DE 3,5) vs 0,27 (DE 1,0) (p< 0,0001) respectivamente, a la vez que un mayor índice de comorbilidad de Charlson, 1,95 (DE 1,7) vs 1,23 (DE 1,59) (p< 0,01). La institucionalización se observó en 46 pacientes (15,23 per cent) con IU y DA vs 5 pacientes (1,56 per cent) sin IU ni DA (p< 0,0001). CONCLUSIONES: La IU y la DA son frecuentes en nuestro medio hospitalario y aisladas o asociadas se constituyen como factores de riesgo para la institucionalización de pacientes geriátricos atendidos por patología aguda (AU)