Malignant TFE3-rearranged perivascular epithelioid cell neoplasm (PEComa) presenting as a subcutaneous mass.

Perivascular epithelioid cell neoplasms (PEComas) are a group of mesenchymal tumours with concurrent melanocytic and myogenic differentiation. Although many cases are sporadic, PEComas can be associated with tuberous sclerosis. A distinct subset of deep-seated PEComas has been shown to carry TFE3 fusions. To our knowledge, this is the first reported case of primary subcutaneous malignant PEComa with molecular confirmation of TFE3 gene rearrangement.

Feasibility and safety of inducing modest hypothermia in awake patients with acute stroke through surface cooling: A case-control study: the Copenhagen Stroke Study.

BACKGROUND AND PURPOSE: Hypothermia reduces neuronal damage in animal stroke models. Whether hypothermia is neuroprotective in patients with acute stroke remains to be clarified. In this case-control study, we evaluated the feasibility and safety of inducing modest hypothermia by a surface cooling method in awake patients with acute stroke. METHODS: We prospectively included 17 patients (cases) with stroke admitted within 12 hours from stoke onset (mean 3.25 hours). They were given hypothermic treatment for 6 hours by the "forced air" method, a surface cooling method that uses a cooling blanket with a flow of cool air (10 degrees C). Pethidine was given to treat compensatory shivering. Cases were compared with 56 patients (controls) from the Copenhagen Stroke Study matched for age, gender, initial stroke severity, body temperature on admission, and time from stroke onset to admission. Blood cytology, biochemistry, ECGs, and body temperature were monitored during hypothermic treatment. Multiple regression analyses on outcome were performed to examine the safety of hypothermic therapy. RESULTS: Body temperature decreased from t(0)=36.8 degrees C to t(6)=35.5 degrees C (P:<0.001), and hypothermia was present until 4 hours after therapy (t(0)=36.8 degrees C versus t(10)=36.5 degrees C; P:=0.01). Mortality at 6 months after stroke was 12% in cases versus 23% in controls (P:=0. 50). Final neurological impairment (Scandinavian Stroke Scale score at 6 months) was mean 42.4 points in cases versus 47.9 in controls (P:=0.21). Hypothermic therapy was not a predictor of poor outcome in the multivariate analyses. CONCLUSIONS: Modest hypothermia can be achieved in awake patients with acute stroke by surface cooling with the "forced air" method, in combination with pethidine to treat shivering. It was not associated with a poor outcome. We suggest a large, randomized clinical trial to test the possible beneficial effect of induced modest hypothermia in unselected patients with stroke.

Admission body temperature predicts long-term mortality after acute stroke: the Copenhagen Stroke Study.

BACKGROUND AND PURPOSE: Body temperature is considered crucial in the management of acute stroke patients. Recently hypothermia applied as a therapy for stroke has been demonstrated to be feasible and safe in acute stroke patients. In the present study, we investigated the predictive role of admission body temperature to the long-term mortality in stroke patients. METHODS: We studied 390 patients with acute stroke admitted within 6 hours from stroke onset. Admission clinical characteristics (age, sex, admission stroke severity, admission blood glucose, cardiovascular risk factor profile, and stroke subtype) were recorded for patients with hypothermia (body temperature < or =37 degrees C) versus patients with hyperthermia (body temperature >37 degrees C). Univariately the mortality rates for all patients were studied by Kaplan-Meier statistics. To find independent predictors of long-term mortality for all patients, Cox proportional-hazards models were built. We included all clinical characteristics and body temperature as a continuous variable. RESULTS: Patients with hyperthermia had more severe strokes and more frequently diabetes, whereas no difference was found for the other clinical characteristics. For all patients mortality rate at 60 months after stroke was higher for patients with hyperthermia (73 per 100 cases versus 59 per 10 cases, P=0.001). When body temperature was studied in a multivariate Cox proportional-hazards model, a 1 degrees C increase of admission body temperature independently predicted a 30% relative increase (95% CI, 4% to 57%) in long-term mortality risk. For 3-month survivors we found no association between body temperature and long-term survival when studied in a multivariate Cox proportional hazard model (hazards ratio, 1.11 per 1 degrees C; 95% CI, 0.82 to 1.52). CONCLUSION: Low body temperature on admission is considered to be an independent predictor of good short-term outcome. The present study suggests that admission body temperature seems to be a major determinant even for long-term mortality after stroke. Hypothermic therapy in the early stage in which body temperature is kept low for a longer period after ictus could be a long-lasting neuroprotective measure.

Human striatal L-dopa decarboxylase activity estimated in vivo using 6-[18F]fluoro-dopa and positron emission tomography: error analysis and application to normal subjects.

DOPA decarboxylase is the enzyme directly responsible for the synthesis of the neurotransmitters dopamine and serotonin, and indirectly of noradrenaline, in brain. We used the decarboxylation coefficient (k3D) of 6-[18F]fluoro-DOPA (FDOPA) to denote the relative activity of L-DOPA decarboxylase in vivo in the human brain. To determine the relative enzyme activity with positron emission tomography (PET), we evaluated the model that separates the metabolism into compartments of nondiffusible and diffusible (i.e., transient) tracer metabolites. Error analysis indicated that the least-squares optimization alone was not sufficient to yield accurate estimates of k3D in the presence of the inherent error of PET. To improve the accuracy of the k3D estimates by optimizing the number of parameters, we introduced biological constraints which included a tracer partition volume (Ve) common to frontal cortex and striatum, and a fixed ratio (q) between the blood-brain barrier transport coefficients of O-methyl-[18F]fluoro-DOPA and FDOPA, the two sources of radioactivity in plasma. We found that a two-step analysis yielded sufficiently accurate estimates of k3D. The two steps include the initial estimation of the partition volume in frontal cortex and the subsequent use of this value to determine k3D in striatum and other structures. We studied twelve healthy controls (age 45 +/- 15 years). The average k3D value was 0.081 +/- 0.024 min-1 (coefficient of variation (COV) 30%) for caudate nucleus, 0.074 +/- 0.013 min-1 (COV 18%) for putamen, and 0.010 +/- 0.005 min-1 (COV 50%) for cerebral cortex.

Blood-brain transfer and metabolism of 6-[18F]fluoro-L-dopa in rat.

In a study designed to reveal the rates of blood-brain transfer and decarboxylation of fluoro-L-3,4-dihydroxyphenylalanine (FDOPA), we discovered a major discrepancy between the DOPA decarboxylase activity reported in the literature and the rate of FDOPA decarboxylation measured in the study. "Donor" rats received intravenous injections of 6 mCi fluorine-18-labeled FDOPA. The donor rats synthesized methyl-FDOPA. Arterial plasma, containing both FDOPA and methyl-FDOPA, was sampled from the donor rats at different times and reinjected into "recipient" rats in which it circulated for 20 s. The blood-brain clearance of the mixture of labeled tracers in the plasma was determined by an integral method. The individual permeabilities were determined by linear regression analysis, according to which the average methyl-FDOPA permeability in the blood-brain barrier was twice that of FDOPA, which averaged 0.037 ml g-1 min-1. The permeability ratio was used to determine the fractional clearance from the brain of FDOPA (and hence of methyl-FDOPA), which averaged 0.081 min-1. In the striatum, the measured average FDOPA decarboxylation rate constant (kD3) was 0.010 min-1, or no more than 1% of the rate of striatal decarboxylation of DOPA measured in vitro and in vivo. We interpreted this finding as further evidence in favor of the hypothesis that striatum has two dopamine (DA) pools, of which only DA in the large pool is protected from metabolism. Hence, no more than 1% of the quantity of fluoro-DA theoretically synthesized was actually retained in striatum.

Quantification of neuroreceptors in the living human brain: IV. Effect of aging and elevations of D2-like receptors in schizophrenia and bipolar illness.

In a previous study of 10 drug-naive schizophrenic patients, the density of D2 dopamine receptors was found to be elevated in the caudate nucleus. The study raised questions about the influence of the age of the patients, the relationship of receptor density to psychosis, and the accuracy of the method used to obtain this evidence. Using positron emission tomography and constrained analysis of the brain uptake of the radioligand N-[11C]methyl-spiperone ([11C]NMSP), we tested four questions: Were the assumptions underlying the quantitation valid? Is there an age decline of the density of D2-like dopamine receptors in drug-naive schizophrenia and bipolar illness? If so, is it different from that observed in normal aging? Are D2-like dopamine receptors elevated at any age in either drug-naive schizophrenic or psychotic bipolar illness patients? NMSP and haloperidol partition volumes and plasma protein fractions were not significantly different among patient groups and normal volunteers. The model-derived assay of radioligand metabolites in plasma was confirmed by high-performance liquid chromatography in the patient groups. D2-like dopamine receptors declined with age, and the slope did not differ significantly between the schizophrenic patients, bipolar affective illness patients, and normal controls. Taking the effect of age into account, increases in D2 dopamine receptor density were found in seven psychotic patients with bipolar affective illness compared with seven nonpsychotic patients and 24 control subjects as well as in 22 drug-naive schizophrenic patients compared with the 24 control subjects.

Stroke recurrence: predictors, severity, and prognosis. The Copenhagen Stroke Study.

We compared stroke severity, risk factors, and prognosis in patients with recurrent versus first-ever stroke. In the Copenhagen Stroke Study, we prospectively studied 1,138 unselected patients with acute stroke. Stroke was recurrent in 265 (23%) despite most of these patients being given prophylactic treatment prior to recurrence. Only 12% of patients with atrial fibrillation were receiving anticoagulant treatment prior to recurrence. In multivariate analysis, recurrence was more frequently associated with a history of TIA, atrial fibrillation, male gender, and hypertension, but not with age, daily alcohol consumption, smoking, diabetes, ischemic heart disease, serum cholesterol, or hematocrit. Mortality was almost doubled compared with patients with a first-ever stroke. In survivors, however, both neurologic and functional outcomes and the speed of recovery were, in general, similar in the two groups. Despite similar neurologic impairments, patients with recurrence contralateral to their first stroke had markedly more severe functional disability after completed rehabilitation than patients with ipsilateral recurrence, implying that the ability to compensate functionally is decreased in patients with contralateral recurrence. Our findings emphasize the importance of consistent anticoagulant treatment for stroke patients with atrial fibrillation and close blood pressure control in stroke patients with hypertension. Other prophylactic measures are needed in patients in whom ASA fails to prevent recurrence. Patients with recurrent stroke have a markedly higher mortality than patients with a first-ever stroke, but those who survive recover as well and as fast as patients with a first-ever stroke. However, if recurrence is contralateral to the first stroke, functional recovery is poorer.

Factors delaying hospital admission in acute stroke: the Copenhagen Stroke Study.

Medical treatment of stroke is dependent on a narrow therapeutic time window. We prospectively analyzed the influence of demographic, medical, and pathophysiologic factors on admission delay in 1,197 unselected, acute stroke patients. Twenty five percent were admitted within 3 1/2 hours, 35% within 6 hours, 50% within 14 hours, and 68% within 24 hours after stroke onset. Living alone (odds ratio [OR] 1.75, 95% CI 1.3 to 2.3) and retired working status (OR 1.61, 95% CI 1.01 to 2.54) delayed admission. A well-working social network thus seems important to early admission. The milder the stroke, the higher was the risk of delayed admission (OR 1.25 per 10 points decrease in stroke severity [Scandinavian Neurological Stroke Scale score on admission], 95% CI 1.14 to 1.36). A history of TIA increased the relative chance of early admission by odds 1.64 (95% CI 1.06 to 2.54). Other factors such as age, sex, diabetes, hypertension, ischemic heart disease, other comorbidity, previous stroke, headache, aphasia, apraxia, anosognosia, neglect, lowered consciousness, mental status (Mini-Mental State Examination) and type of stroke (hemorrhage/infarct) had no independent influence on admission time. Admission was markedly delayed in most patients. This represents a major barrier to medical treatment. Patients with the most severe strokes are admitted early, but patients with milder symptoms should also be encouraged to seek immediate admission. The observation that a history of TIA reduced admission time indicates that an increase in public awareness and knowledge may reduce delay and save precious time.

Osseous manifestations of SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome.

The SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome includes a complex group of disorders characterized by peculiar bone lesions, most commonly involving the anterior chest wall, and sometimes accompanied by dermatologic manifestations. The clinical and radiographic features of this syndrome are well described, but few studies have examined the histologic features of the bone lesions. We describe the clinical, radiographic, and histologic features of the osseous lesions encountered in eight patients with a clinical diagnosis of SAPHO syndrome. The patients included five female and three male patients ranging in age from 5 to 63 years (mean, 35.3 years). The most common clinical presentation was pain related to the sites of osseous involvement. Two patients also had some form of pustular dermatosis. The radiographic features of the osseous lesions varied but often suggested the possibility of a neoplasm. Nine pathologic specimens were available for review, five from the clavicle, two from the first rib, one from the calcaneus/cuboid, and one from the tibia. The histologic features varied but seemed related to the duration of the patients' musculoskeletal symptoms. Early lesions contained acute inflammation, edema, and prominent periosteal bone formation, histologically indistinguishable from ordinary bacterial osteomyelitis, whereas late lesions demonstrated markedly sclerotic bone trabeculae with prominent marrow fibrosis and only mild chronic inflammation; one of these biopsies appeared virtually identical to Paget's disease. One biopsy was performed after an intermediate duration of symptoms and contained prominent chronic inflammation only. The histologic findings in SAPHO are variable and nonspecific and may depend on the duration of disease, but it is important to recognize the spectrum of histologic changes possible in the syndrome and to realize that clinicopathologic correlation is necessary to avoid misdiagnosis and unnecessary long-term antibiotic therapy.

Sarcomas arising in dermatofibrosarcoma protuberans: a reappraisal of biologic behavior in eighteen cases treated by wide local excision with extended clinical follow up.

There is a prevailing view that sarcomas arising in dermatofibrosarcoma protuberans (DFSP) have a higher risk of metastasis than ordinary DFSP, but these data are based on cases with variable and often suboptimal treatment. There has not been a large study of sarcomas arising in DFSP in which all cases were treated by wide local excision, thereby arguably altering outcome. Clinicopathologic features of 18 cases of sarcomas arising in DFSP treated by wide local excision and having follow up of at least 5 years were analyzed. An estimate of the proportion of sarcoma and DFSP was made. The number of mitotic figures and degree of CD34 immunoreactivity were assessed in each case. The cohort included 13 females and 5 males (age, 23-87 yrs; median, 47 yrs). The tumors involved the trunk (7), scalp (4), extremities (4), and inguinal region (3), and ranged from 1.5 to 7 cm (median, 4 cm). Sarcoma occurred de novo in 15 cases and in a recurrence in three. Sarcomas resembled fibrosarcoma (17) or malignant fibrous histiocytoma (1) and occupied between 20% and 80% of the tumor (median, 60%). Mitotic activity ranged from 2 to 16 per 10 high-power field (HPF; median 7 per 10 HPF) in the sarcomatous component and 0 to 3 per 10 HPF (median, 1 per 10 HPF) in the DFSP component. All tumors expressed CD34 in the DFSP component but only nine (50%) in the sarcomatous component. All patients were treated by wide local excision with negative margins; three additionally received radiation. Four patients (22%) developed recurrences, but none developed metastasis during the follow-up period of 62 months to 17 years (median, 81.5 mos). In contrast to earlier studies, we demonstrate that patients with sarcomas arising in DFSP do not have an increased risk of distant metastasis within a 5-year follow-up period, provided they are treated by wide local excision with negative margins. This probably reflects the fact that wide local excision results in eradication of local tumor, thereby eliminating the source for subsequent dissemination. However, we cannot completely exclude the possibility that tumors in which clear margins are achieved represent a less aggressive subset, as has been suggested for high-grade extremity sarcomas. Previous studies showing increased metastasis for sarcomas arising in DFSP should be re-evaluated to determine if, with treatment stratification, metastatic rate varies.

Dedifferentiated chondrosarcoma with rhabdomyosarcomatous differentiation.

Dedifferentiated chondrosarcomas are primary bone tumors characterized by the presence of both low-grade cartilaginous and high-grade sarcomatous components. The high-grade component usually shows histologic features of either malignant fibrous histiocytoma or fibrosarcoma. We are aware of only 10 published cases in which the high-grade component showed rhabdomyosarcomatous differentiation. To further clarify the clinical, radiographic, and pathologic features of this unusual variant, we report three additional cases of dedifferentiated chondrosarcoma with rhabdomyosarcomatous differentiation. The patients included two men and one woman; their mean age was 63 years. Tumors originated in the pelvis (ilium), scapula, and tibia. Two patients presented with radiographic findings typical of dedifferentiated chondrosarcoma, including a geographic, lytic lesion with areas of mineralization suggestive of cartilage in close association with a permeative component. The third patient presented with a primarily lytic, destructive lesion of the right iliac wing. Histologically, the tumors contained lobules of well-differentiated chondrosarcoma associated with a high-grade sarcoma with prominent rhabdomyoblasts. Immunohistochemical stains for actin and desmin were positive in all three tumors, and electron microscopy revealed evidence of skeletal muscle differentiation. All three patients died with metastatic disease, 1, 6, and 12 months postoperatively. This histologic variant of dedifferentiated chondrosarcoma is rare, but it shows radiographic and clinical features similar to "conventional" dedifferentiated chondrosarcoma, including a very poor prognosis.

Recurrence of desmoid tumor in a multivisceral transplant patient with Gardner's syndrome.

BACKGROUND: Desmoid tumors are locally invasive fibromatous tumors, which, in patients with Gardner's syndrome, usually occur in the abdominal wall or intra-abdominally. After excision, they tend to recur, often leading to multiple bowel resections. METHODS: This is a report of the clinical course of a patient with Gardner's syndrome and desmoid tumor who had multiple enterectomies and gradually developed short-gut syndrome. He required prolonged parenteral nutrition, which damaged the liver. The patient underwent a multivisceral transplantation as a life-saving procedure. RESULTS: After the transplant, the desmoid tumor recurred in the thoracic wall twice and was successfully resected. It also recurred in the abdominal cavity, compressing the intestinal loops; the tumor was excised uneventfully, leaving the graft intact. The recurrent tumors were all of recipient origin. CONCLUSIONS: Intestinal and multivisceral transplantation could be considered in patients with short-gut syndrome caused by recurrent desmoid tumor. In the case of posttransplant tumor recurrence, resection is the only option recommended.

Fluorine nuclear magnetic resonance: calibration and system optimization.

Fluorine-19 magnetic resonance imaging (MRI) offers advantages for imaging organs and tissues. 19F is readily synthesized into a variety of compounds and offers the potential for in-vivo imaging as a complement to hydrogen MRI. The purpose of this work was to determine the minimum detection sensitivity for a fluorinated compound (CF3-CO2H) as a function of pulse sequence, interpulse times (TE, TI, and TR), gradient values and the number of data averages. CF3-CO2H was chosen because it has a single spectral line and exhibits a minimal frequency shift under the experimental conditions used for this experiment. A resistance MR scanner operating at a resonance frequency of 6.255 MHz was used for imaging both fluorine (.156 T) and hydrogen (.147 T). Critical factors determining the minimum detection sensitivity included system signal-to-noise ratio (S/N), acquisition time, relaxation times (T1, T2), and sample volume. Samples were measured over the range of 0.05 M to 20.0 M and showed a linear relationship between signal strength and concentration. The minimum detection sensitivity was 0.1 M. Use of higher static fields and optimized coils as well as improved system signal-to-noise ratios will improve detection sensitivity. We conclude that imaging of fluorine on low-field system is feasible, although it is necessary to optimize many parameters to maximize detection sensitivity.

Multiple cutaneous plexiform schwannomas. Report of a case and review of the literature with particular reference to the association with types 1 and 2 neurofibromatosis and schwannomatosis.

Plexiform schwannomas are relatively rare, benign peripheral nerve sheath tumors, which usually arise in either the dermis or subcutaneous tissue, although rare cases originate in skeletal muscle or other deep somatic soft tissue sites. These tumors may occur singly or as multiple lesions and may be localized to one anatomic site or diffusely distributed. Rare cases have been associated with "schwannomatosis" as well as type 1 neurofibromatosis (von Recklinghausen's disease). We report an unusual case of multiple cutaneous plexiform schwannomas associated with bilateral acoustic neuromas as well as other intracranial and intraspinal neoplasms. In addition, we examine the relationship between the various forms of cutaneous schwannoma, particularly the plexiform variant, and both types 1 and 2 neurofibromatosis; we also examine several purported cases of schwannomatosis.

Mesial temporal sclerosis. A clinicopathologic study of 27 patients, including 5 with coexistent cortical dysplasia.

OBJECTIVE: Mesial temporal sclerosis (MTS) is a fairly well-recognized cause of intractable epilepsy. Its coexistence with cortical dysplasia is less commonly described. Herein, we describe the clinical and pathologic features of MTS, including cases in which cortical dysplasia was also identified. DESIGN: Retrospective surgical series of 27 patients. SETTING: Tertiary referral center with a high volume of epilepsy surgery. PATIENTS: Patients with medically intractable epilepsy who underwent hippocampal resections and in whom an unequivocal histologic diagnosis of MTS could be made. RESULTS: The patients studied included 18 males and 9 females ranging in age from 15 to 48 years (mean 32 years). Mesial temporal sclerosis was characterized by severe neuronal loss accompanied by gliosis occurring in the CA1/prosubiculum (27 patients, 100%), focally in the dentate gyrus (12 patients, 44%), and in the CA4 region (11 patients, 41%). Five patients (24%) had coexistent cortical dysplasia with increased molecular layer neurons (five patients), gyral fusion (two patients), diffuse architectural disorganization of the cortex (one patient), and clusters of atypical neurons and glial cells within the cortex (one patient). Twenty-five (93%) of the 27 patients had white matter neuronal heterotopia. Follow-up data were available for each patient (mean 23 months). Twenty-two of the patients are free of seizures postoperatively, including all five with coexistent cortical dysplasia; the five remaining patients have fewer seizures. There appeared to be no difference clinically between patients with MTS and no dysplasia and those with coexistent cortical dysplasia. CONCLUSION: We conclude that (1) MTS most severely involves the CA1/prosubiculum and CA4 regions of the hippocampus (the dentate gyrus may also be focally severely involved); (2) MTS and cortical dysplasia do occasionally exist; and (3) surgical outcome for MTS appears to be independent of coexistent cortical dysplasia.

[The risk of suicide in cancer patients derived from a cancer registry]. / Etude du risque de suicide chez les patients cancéreux à partir d'un registre du cancer.

The incidence of suicide among cancer patients has been examined in several previous epidemiological studies, which have suggested an increased risk especially in the period following diagnosis. The role of factors which may modulate the risk, such as individual patient characteristics or that of cancer (site, prognosis or type of treatment), have not been systematically studied and available results are often contradictory. In Geneva, the existence of a tumor registry, which follows patients continuously until the cause of death is known, has enabled us to conduct a cohort study on all incident cases of cancer registered for the years 1970 to 1983. The risk of suicide (SMR) was found to be significantly elevated for both sexes in the first two years following diagnosis. Thereafter, the risk diminished, and for the entire 15 year period considered, the risk remained significantly elevated only for women. The effect of variables which may have modulated the risk was examined through a logistic regression analysis comparing cases and controls selected from the same cohort. The risk was significantly lower for married patients. No difference between sex was observed, but the risk of suicide appeared to be increased in the elderly, as well as in foreigners, and to be reduced in upper socio-economic classes. Risk could be higher with neoplasms of the digestive tract and lower with those of the breast. Because incidence of suicide is relatively low, studies may lack statistical power to detect a moderately increased risk. Nonetheless, these results confirm part of previous results and contribute further to the study of this problem.

[First treatment demands for drug abuse: and indicator of developmental trends]. / Les premières demandes de traitement pour toxicomanie: un indicateur des tendances évolutives du phénomène.

The county of Geneva, Switzerland, is part of an international multi-city survey under the auspices of the Council of Europe. This survey is designed to use common indicators for assessing and comparing drug misuse and its evolution in participating cities and regions. Its aim is to improve the strategies for controlling drug misuse. The first indicator under study is the "first treatment demand". Its objectives are to evaluate the treatment demand as well as the evolution of drug misuse in terms of patient characteristics, so as to optimise prevention and treatment policies. All treatment demands for drug misuse that meet the study's entry criteria are recorded in a permanent and centralized data bank, through an anonymous encoded form filled in by the treatment centers at the time of the demand. Later demands by the same patient are merged with the precedent ones. In this way, both the totality of treatment demands and the subset of first demands can be analyzed and information about individual trajectories can be collected. The introduction of this indicator is subjected to various problems due first of all to the illicit character of drug misuse. In particular, the necessary measures to guarantee strict confidentiality make it more difficult to obtain reliable data, especially for the merging of different treatment demands by the same patient. This paper reports on the introduction of the indicator in Geneva and its anticipated results.

Early infection and prognosis after acute stroke: the Copenhagen Stroke Study.

BACKGROUND AND PURPOSE: Infection is a frequent complication in the early course of acute stroke and may adversely affect stroke outcome. In the present study, we investigate early infection developing in patients within 3 days of admission to the hospital and its independent relation to recovery and stroke outcome. In addition, we identify predictors for early infections, infection subtypes, and their relation to initial stroke severity. METHODS: In the community-based Copenhagen Stroke Study, 1,156 unselected patients were examined for early infection. Stroke severity was assessed with the Scandinavian Stroke Scale (SSS) on admission and at discharge. Multiple logistic and linear regression analyses were used to determine independent relations to early infection. Relevant stroke risk factors, admission stroke severity, and body temperature were included in the analysis. RESULTS: Of the subjects studied, 19.4% developed early infection. In women, 68% of the early infections were urinary tract infections, and in men, 49% of the early infections were pneumonias. Independent predictors of early infection were advanced age (OR per 10 years, 1.24; 95% CI, 1.02-1.64), female gender (OR, 2.0; 95% CI, 1.3-3.0), and decreased SSS score on admission (OR per 10 points, 0.69; 95% CI, 0.62-0.78). The presence of early infection prolonged hospital stay by a mean of 9.3 days (P < .0001) but not death during hospital stay (P = .78), stroke severity at discharge (P = .32), or rate of discharge to nursing home (P = .17). CONCLUSION: Advanced age, female gender, and increased stroke severity independently predict development of early infection. The present study indicates that early infection does not influence outcome in acute stroke patients per se, but it delays patient discharge from the hospital.

[Seizures in acute apoplexy. Predisposing factors and significance for prognosis]. / Krampeanfald ved akut apopleksi. Disponerende faktorer og prognostisk betydning.

The aim of the study was to determine the relationships between seizures during the early phase of stroke (early seizures, ES) and stroke outcome, and to identify predictors of ES. The study was prospective, consecutive and community-based, and included 1197 patients with acute stroke. We determined the number and type of seizures, initial stroke severity, infarct size, mortality, and outcome in survivors. Stroke severity was measured on admission, weekly, and at discharge using the Scandinavian Stroke Scale (SSS). Multiple logistic and linear regression outcome analyses included relevant confounders and potential predictors. Fifty patients (4.2%) had seizures within 14 days of the stroke. In the multivariate analyses, only initial stroke severity was related to ES. For each 10-point increase in stroke severity (SSS score), the relative risk of ES increased by a factor of 1.65 (95% confidence interval, 1.4 to 1.9) (p < 0.0001). ES did not influence the risk of death during hospital stay (p = 0.56). In survivors, ES was related to a better outcome, equivalent to an improvement in SSS score of 5.7 points (SE [b] = 1.8; p = 0.002). The decisive factor of ES was initial stroke severity. ES per se was not related to mortality. Surprisingly, in survivors, ES predicted a better outcome. We explain this finding by a relatively larger ischaemic penumbra in patients who have ES after a stroke.

[Pattern of admissions of patients with apoplexy. Time connection between symptom onset and admission and relation to medical and social factors. The Copenhagen Stroke Study]. / Indlaeggelsesmønster for patienter med apopleksi. Tidsmaessig sammenhaeng mellem symptomdebut og indlaeggelse og relation til medicinske og sociale faktorer. The Copenhagen Stroke Study.

The purpose of the study was to study admission delay in patients with stroke, and to analyze the influence of demographic, medical, and pathophysiological factors on admission delay. The study was prospective and consecutive and included 1197 unselected patients admitted with acute stroke from a well-defined catchment area in Copenhagen. Only 35% were admitted within the first six hours from stroke onset, and 50% of the patients were admitted later than 14 hours from stroke onset. Living alone (OR 1.75, 95% CI 1.3 to 2.3) and retired working status (OR 1.6, 95% CI 1.01 to 1.54) delayed admission. A well-functioning social network thus seems important to early admission. The milder the stroke, the higher was the risk of delayed admission (OR 1.25 per 10 points increase in stroke severity (Scandinavian Neurological Stroke Scale on admission), 95% CI 1.06 to 2.54. Other factors such as age, sex, diabetes, hypertension, ischaemic heart disease, other comorbidity, previous stroke, headache, aphasia, apraxia, anosognosia, neglect, lowered consciousness, mental status, and type of stroke had no independent influence on admission time. However, a history of TIA increased the chance of early admission by odds 1.64 (95% CI 1.01 to 2.54), indicating that an increase in public awareness and knowledge may reduce delay and save precious time.