Palliative Care and the Self-Fulfilling Prophecy in Stroke Patients: is There Anything to Fear? A Retrospective Study of Patients Who Died During Hospitalization in a Quaternary Care Hospital.

BACKGROUND AND PURPOSE: Primary palliative care (PC) aims to improve the quality of life for patients with acute ischemic stroke but is often misinterpreted as withdrawal of care. The self-fulfilling prophecy withdrawal bias is feared in this context of PC's early implementation. This study evaluates stroke patients who died in the hospital to determine the impact of PC evaluation. METHODS: A retrospective descriptive analysis of patients who died from acute ischemic stroke was conducted. The study included patients aged ≥18 years admitted to the Stroke Unit of a quaternary hospital in Brazil from January 2017 to December 2018. The impact of PC assessment on outcomes was analyzed, with significance set at 5%. RESULTS: Among the patients who died during hospitalization as a result of an ischemic stroke (n = 77), 39 (%) were assessed by the palliative care team. There was no difference in the total length of stay or duration of antibiotic therapy. Logistic regression corrected for significant variables from the univariate analysis revealed that PC evaluation was associated with a 31-fold increase in opioid use (P < 0.001), a nearly 14-fold increase in discharges to the ward, and a threefold reduction in ICU length of stay (P = 0.011). CONCLUSION: PC team involvement was associated with higher rates of discharge to the floors, inferring more time spent with family and increased opioid use, suggesting better symptom control, without reducing the overall length of stay or duration of antibiotic therapy. This underscores that PC does not equate to withdrawal of care.

Clinical Challenges of Acute Porphyria in the Young Adult.

Porphyria is a metabolic disorder caused by a mutation in the heme biosynthetic pathway, with vague symptomatology and rare prevalence. A triad of hyponatremia, intermittent seizures, and abdominal pain should raise suspicion for porphyria. The diagnosis is based on increased blood porphobilinogen levels and genetic mutations. Treatment involves Dextrose-10 administration followed by hematin infusions as soon as possible. A maintenance dose of hematin is required in some cases. Here, we report a delayed diagnosis of acute intermittent porphyria (AIP) in an 18-year-old female, who first presented with severe anemia attributed to iron deficiency from menstrual blood loss. After discharge, she was readmitted with bilateral lower extremity and abdominal pain, hyponatremia, and seizure attributed to polypharmacy. During this second hospitalization, she was transferred to our hospital complaining of chest pain, shortness of breath, markedly decreased weakness, dysphagia, and hallucinations. After an extensive workup, she was diagnosed with AIP, and Dextrose-10 and hemin infusion were started. Our patient was found to have a missense mutation in the Hydroxymethylbilane synthase gene. She recovered after an extended ICU stay of 45 days and was discharged with a moderate improvement of weakness. Early diagnosis is necessary to prevent severe manifestations and long-term sequelae, such as axonal neuropathy, which occurred in the presented case.