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BACKGROUND: A high proportion of coronavirus disease 2019 (COVID-19) survivors may develop long-term cognitive impairment. We aimed to develop a multivariate causal model exposing the links between COVID-19-associated biomarkers, illness-related variables, and their effects on cognitive performance. METHODS: In this prospective study, we assess the potential drivers for the development of cognitive impairment in patients with severe COVID-19 pneumonia aged ≥ 18 years at 6-month follow-up after hospital discharge, using the Montreal Cognitive Assessment (MoCA). Patients with pre-existing cognitive impairment were excluded. Laboratory results at hospital admission were clustered by principal component analysis (PCA) and included in a path analysis model evaluating the causal relationship between age, comorbidities, hypoxemia, invasive mechanical ventilation (IMV) requirement, in-hospital delirium, and cognitive performance. RESULTS: We studied 92 patients: 54 (58.7%) men and 38 (41.3%) women, with median age of 50 years (interquartile range 42-55), among whom 50 (54.4%) tested positive for cognitive impairment at 6-month follow-up. Path analysis revealed a direct link between the thrombo-inflammatory component of PCA (C-reactive protein, fibrinogen, and neutrophils) and hypoxemia severity at hospital admission. Our model showed that low PaO2/FiO2 ratio values, unlike the thrombo-inflammatory component, had a direct effect on cognitive performance, independent from age, in-hospital delirium, and invasive mechanical ventilation. CONCLUSION: In this study, biomarkers of thrombo-inflammation in COVID-19 and low PaO2/FiO2 had a negative effect on cognitive performance 6 months after hospital discharge. These results highlight the critical role of hypoxemia as a driver for impaired cognition in the mid-term.
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COVID-19 , Disfunção Cognitiva , Adolescente , COVID-19/complicações , Disfunção Cognitiva/etiologia , Feminino , Humanos , Hipóxia/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial , SARS-CoV-2RESUMO
BACKGROUND: The prompt recognition of an acute neurovascular syndrome by the patient or a bystander witnessing the event can directly influence outcome. We aimed to study the predictive value of the medical history and clinical features recognized by the patients' bystanders to preclassify acute stroke syndromes in prehospital settings. METHODS: We analyzed 369 patients: 209 (56.6%) with acute ischemic stroke (AIS), 107 (29.0%) with intracerebral hemorrhage (ICH), and 53 (14.4%) with subarachnoid hemorrhage (SAH). All patients had neuroimaging as diagnostic gold standard. We constructed clinical prediction rules (CPRs) with features recognized by the bystanders witnessing the stroke onset to classify the acute neurovascular syndromes before final arrival to the emergency room (ER). RESULTS: In all, 83.2% cases were referred from other centers, and only 16.8% (17.2% in AIS, 15% in ICH, and 18.9% in SAH) had direct ER arrival. The time to first assessment in ≤ 3 h occurred in 72.4% (73.7%, 73.8%, and 64.2%, respectively), and final ER arrival in ≤ 3 h occurred in 26.8% (32.1%, 15.9%, and 28.3%, respectively). Clinical features referred by witnesses had low positive predictive values (PPVs) for stroke type prediction. Language or speech disorder + focal motor deficit showed 63.3% PPV, and 77.0% negative predictive value (NPV) for predicting AIS. Focal motor deficit + history of hypertension had 35.9% PPV and 78.8% NPV for ICH. Headache alone had 27.9% PPV and 95.3% NPV for SAH. In multivariate analyses, seizures, focal motor deficit, and hypertension increased the probability of a time to first assessment in ≤ 3 h, while obesity was inversely associated. Final ER arrival was determined by age and a direct ER arrival without previous referrals. CONCLUSION: CPRs constructed with the witnesses' narrative had only adequate NPVs in the prehospital classification of acute neurovascular syndromes, before neuroimaging confirmation.
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Isquemia Encefálica , Acidente Vascular Cerebral , Hemorragia Cerebral , Serviço Hospitalar de Emergência , Humanos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , SíndromeRESUMO
OBJECTIVES: The frequency and implications of peripheral artery disease (PAD) in some risk groups are not entirely characterized in Latin America. We studied PAD prevalence, risk factors, and six-month outcomes in stable outpatients with a history of a recent acute coronary syndrome (ACS), or at high coronary risk. METHODS: We recruited 830 outpatients in 43 Mexican sites (median age: 64.8 years; 57.8% men). Inclusion criteria were age >18 years, and ACS within 30 days, or age <55 years plus ≥2 major vascular risk factors, or age ≥55 years plus ≥1 vascular risk factors. Patients received standardized assessments at baseline and six-month follow-up for medical history, ankle-brachial index (ABI), and the Edinburgh Claudication Questionnaire (ECQ). RESULTS: ABI <0.8 was found in 10.5%, <0.9 in 22.5%, >1.3 in 4.8%, and >1.4 in 3.6%, without differences according to sex or selection criteria. Positive ECQ was found in 7.6%. ABI <0.9 was directly associated with age, diabetes, ACS, and chronic kidney disease, but inversely associated with BMI >27. The six-month case-fatality and atherothrombotic events rates were 1.6% and 3.6%, respectively. In patients with ABI <0.9 and ABI <0.8, the six-month case-fatality rates were 2.5% (p = 0.27) and 5.4% (p = 0.03), respectively. In a Cox proportional-hazards model, baseline factors associated with death were age ≥65, ABI <0.8, and ACS. CONCLUSIONS: Subclinical PAD is more common than symptomatic claudication in high-risk coronary outpatients. Low ABI is associated with reduced short-term survival in patients with recent ACS or at high coronary risk.
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Síndrome Coronariana Aguda/epidemiologia , Pacientes Ambulatoriais , Doença Arterial Periférica/epidemiologia , Trombose/epidemiologia , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice Tornozelo-Braço , Doenças Assintomáticas , Feminino , Fatores de Risco de Doenças Cardíacas , Humanos , Masculino , México/epidemiologia , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Prevalência , Prognóstico , Sistema de Registros , Medição de Risco , Trombose/diagnóstico , Trombose/mortalidade , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: The recognition of stroke symptoms by patients or bystanders directly affects the outcomes of patients with acute cerebrovascular disease. OBJECTIVE: The objective of the study was to assess the predictive value of the medical his- tory and clinical features recognized by the patients' bystanders to classify neurovascular syndromes in pre-hospital settings. METHODS: We included 150 stroke patients of two Mexican referral centers: 50 with acute ischemic stroke (AIS), 50 with intracerebral hemorrhage (ICH), and 50 with subarachnoid hemorrhage (SAH). The performance of clinical prediction rules (CPR) to identify the stroke types was evaluated with features recognized by the patients' bystanders before hospital arrival. The impact of CPRs on early arrival and in-hospital mortality was also analyzed. RESULTS: Overall, 72% of the patients had previous medical evaluations in other centers before final referral to our hospitals, and therefore, only 45% had a final onset- to-door time <6 h, even when the first medical assessment had occurred in ≤1 h in 75% of cases. Clinical features noticed by the patients' bystanders had low positive predictive values (PPV) for any stroke type. The CPR "language or speech disor- der + focal motor deficit" had 93% sensitivity and a negative predictive value (NPV) of 84% to distinguish AIS. In SAH, head- ache alone showed a sensitivity of 84% and NPV of 97%. No CPR had an adequate performance on ICH. CPRs were not as- sociated with final onset-to-door time. Altered consciousness, age ≥65 years, indirect arrival with stops before final referral, and atrial fibrillation increased in-hospital mortality. CONCLUSION: Clinical features referred by the witness of a neurovascular emergency have limited PPV, but adequate NPV in ruling-out AIS and SAH among stroke types. The use of CPRs had no impact on onset-to-door time or in-hospital mortality when the final arrival to a third-level center occurs with previous medical refer- rals.
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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 ml/min at hospital arrival) with AIS pertaining to the multicenter registry PREMIER, who had SUA measurements at hospital presentation. Multivariate models were constructed to analyze the association of SUA with functional outcome as assessed by the modified Rankin scale (mRS) at 30-day, 3-, 6- and 12-month follow-up. A mRS 0-1 was regarded as a very good outcome. RESULTS: Mean SUA concentration at hospital arrival was 6.1 ± 3.7 mg/dl (362.8 ± 220.0 µmol/l). Compared with cases with higher SUA levels at hospital admission, patients with ≤4.5 mg/dl (≤267.7 µmol/l; the lowest tertile of the sample) had more cases of a very good 30-day outcome (30.5 vs. 18.9%, respectively; p = 0.004). SUA was not associated with mortality or functional dependence (mRS >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), time since event onset, serum creatinine, hypertension, diabetes and smoking, a SUA ≤4.5 mg/dl (≤267.7 µmol/l) was positively associated with a very good short-term outcome (odds ratio: 1.76, 95% confidence interval: 1.05-2.95; negative predictive value: 81.1%), but not at 3, 6 or 12 months of follow-up. When NIHSS was entered in the multivariate model as a continuous variable, the independent association of SUA with outcome was lost. Compared with cases with higher levels, patients with SUA ≤4.5 mg/dl (≤267.7 µmol/l) were more frequently younger than 55 years, women, with mild strokes, with normal serum creatinine and fewer had hypertension. The time since event onset to hospital arrival was not significantly associated with AIS severity or SUA levels; nevertheless, a nonsignificant tendency was observed for patients with severe strokes and high SUA levels arriving in <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.
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Isquemia Encefálica/sangue , Hiperuricemia/sangue , Acidente Vascular Cerebral/sangue , Ácido Úrico/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/reabilitação , Distribuição de Qui-Quadrado , Avaliação da Deficiência , Feminino , Humanos , Hiperuricemia/diagnóstico , Modelos Logísticos , Masculino , México , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Recuperação de Função Fisiológica , Sistema de Registros , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Reabilitação do Acidente Vascular Cerebral , Fatores de Tempo , Adulto JovemRESUMO
OBJECTIVE: to measure the frequency of type 2 diabetes mellitus (T2DM) in patients with confirmed HCV infection. METHODS: we studied 125 adults reactive to anti-HCV antibodies (62.4 % women, mean age 46.8 years) who received confirmatory RT-PCR testing for viremia (63.2 % HCV-RNA-positive). RESULTS: twenty-two patients had T2DM (17.6 %, 95 % confidence interval: 11.8-25.3 %; mean National prevalence: 14.4 %), more frequent among patients with detectable viremia than in negative cases (23.3 % vs. 9.6 %, respectively; p = 0.04), and among those with advanced liver disease, than in compensated patients (28.9 % vs. 11.3 %, respectively; p = 0.01). Fourteen (17.7 %) patients received interferon-based treatment and 6 (42.8 %) had sustained virology response. None of the 6 responders had T2DM, but 2 of the 8 (25 %) non-responders had diabetes. T2DM patients were older than those without diabetes (57.7 vs. 44.5 years, p < 0.001), and after multivariate analysis, only age was significantly associated with diagnosis of T2DM. CONCLUSIONS: T2DM was highly prevalent among patients with chronic HCV infection. Age was the most important determining factor.
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Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/epidemiologia , Hepatite C/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , México , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
Introduction: Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may develop coronavirus disease 2019 (COVID-19). Risk factors associated with death vary among countries with different ethnic backgrounds. We aimed to describe the factors associated with death in Mexicans with confirmed COVID-19. Material and methods: We analysed the Mexican Ministry of Health's official database on people tested for SARS-CoV-2 infection by real-time reverse transcriptase-polymerase chain reaction (rtRT-PCR) of nasopharyngeal fluids. Bivariate analyses were performed to select characteristics potentially associated with death, to integrate a Cox-proportional hazards model. Results: As of May 18, 2020, a total of 177,133 persons (90,586 men and 86,551 women) in Mexico received rtRT-PCR testing for SARS-CoV-2. There were 5332 deaths among the 51,633 rtRT-PCR-confirmed cases (10.33%, 95% CI: 10.07-10.59%). The median time (interquartile range, IQR) from symptoms onset to death was 9 days (5-13 days), and from hospital admission to death 4 days (2-8 days). The analysis by age groups revealed that the significant risk of death started gradually at the age of 40 years. Independent death risk factors were obesity, hypertension, male sex, indigenous ethnicity, diabetes, chronic kidney disease, immunosuppression, chronic obstructive pulmonary disease, age > 40 years, and the need for invasive mechanical ventilation (IMV). Only 1959 (3.8%) cases received IMV, of whom 1893 were admitted to the intensive care unit (96.6% of those who received IMV). Conclusions: In Mexico, highly prevalent chronic diseases are risk factors for death among persons with COVID-19. Indigenous ethnicity is a poorly studied factor that needs more investigation.
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BACKGROUND AND AIM: Obesity increases the risk of atrial fibrillation (AF) while it may impact the outcome of patients with AF. The clinical implications of this relationship are not completely clear. We aimed to analyze the association of traditional anthropometric measures of excessive adiposity with 12 month case fatality rate (CFR) in patients with AF. METHODS: This was a multicenter, longitudinal, observational study on adults with documented AF, excluding records of AF secondary to reversible causes. Anthropometric variables were registered at baseline, and a central committee validated the 12 month outcomes. RESULTS: We studied 1193 patients (median age: 69.14 years, 55.2% women). At baseline, rhythm control was established for 476 (39.9%) subjects, while frequency control was offered to 717 (60.1%) participants. The 12 month all-cause CFR was 8.9%. A high basal body mass index (BMI), waist-to-height ratio (WHtR) and waist circumference (WC) were associated with lower CFR in bivariate analyses. In a Cox-proportional hazards model, variables associated with 12 month all-cause CFR were BMI categories (HR: 0.736, 95% CI: 0.584-0.928), chronic heart failure (HR: 1.738, 95% CI: 1.127-2.680), chronic kidney disease (HR: 2.269, 95% CI: 1.162-4.429) and carotid stenosis >50% (HR: 5.342, 95% CI: 1.661-17.181). CONCLUSION: The risk of death at one year in patients with AF is inversely associated with a high BMI and directly associated with the presence of chronic kidney disease, carotid stenosis, and chronic heart failure in this cohort of patients with AF. The causes and implications of this apparent obesity paradox should be addressed in the future.
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Fibrilação Atrial/etiologia , Obesidade/complicações , Idoso , Fibrilação Atrial/complicações , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Obesidade/fisiopatologia , Fatores de Risco , Fatores de TempoRESUMO
BACKGROUND AND PURPOSE: Cerebellar venous infarction or hemorrhage due to isolated venous thrombosis of the posterior fossa is a rare form of intracranial vein thrombosis that can be unsuspected in clinical practice. METHODS: We studied 230 patients with intracranial vein thrombosis, identifying 9 (3.9%: 7 women, mean age 34 years) with neuroimaging or histopathologic evidence of localized posterior fossa vein thrombosis causing parenchymal injury limited exclusively to the cerebellum. RESULTS: All patients had an insidious presentation suggesting other diagnoses. Intracranial hypertension (n=6) and cerebellar (n=4) syndromes were the main clinical presentations. Intracranial vein thrombosis was idiopathic in 3 patients; associated with puerperium in 3; and with contraceptives, protein C deficiency, and dehydration in 1 case each. CT was abnormal but not diagnostic in 5 patients, showing a cerebellar hypodensity with fourth ventricle compression and variable hydrocephalus in 5 patients, and cerebellar hemorrhage in 2. Conventional MRI provided diagnosis in 6 cases, showing the causal thrombosis and cerebellar involvement; angiography was practiced in 2 of them, confirming the findings identified by MRI. In the other 3 patients, diagnosis was reached by histopathology. Thromboses were localized at the straight sinus (n=4), lateral sinuses (n=3), and superior petrosal vein (n=2). The acute case fatality rate was 22.2% (n=2), 1 (11.1%) patient was discharged in a vegetative state, 1 (11.1%) was severely disabled, and 5 (55.6%) were moderately disabled. CONCLUSIONS: Isolated venous thrombosis of the posterior fossa is infrequent and implies a challenging diagnosis. Risk factors for intracranial vein thrombosis and atypical cerebellar findings on CT should lead to further MRI assessment.
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Infarto Encefálico/etiologia , Doenças Cerebelares/etiologia , Fossa Craniana Posterior/patologia , Trombose Intracraniana/diagnóstico , Trombose Venosa/diagnóstico , Adolescente , Adulto , Veias Cerebrais/diagnóstico por imagem , Veias Cerebrais/patologia , Fossa Craniana Posterior/diagnóstico por imagem , Feminino , Humanos , Trombose Intracraniana/complicações , Masculino , Pessoa de Meia-Idade , Radiografia , Trombose Venosa/complicaçõesRESUMO
ABSTRACT Background: The recognition of stroke symptoms by patients or bystanders directly affects the outcomes of patients with acute cerebrovascular disease. Objective: The objective of the study was to assess the predictive value of the medical history and clinical features recognized by the patients bystanders to classify neurovascular syndromes in pre-hospital settings. Methods: We included 150 stroke patients of two Mexican referral centers: 50 with acute ischemic stroke (AIS), 50 with intracerebral hemorrhage (ICH), and 50 with subarachnoid hemorrhage (SAH). The performance of clinical prediction rules (CPR) to identify the stroke types was evaluated with features recognized by the patients bystanders before hospital arrival. The impact of CPRs on early arrival and in-hospital mortality was also analyzed. Results: Overall, 72% of the patients had previous medical evaluations in other centers before final referral to our hospitals, and therefore, only 45% had a final onset-to-door time <6 h, even when the first medical assessment had occurred in ≤1 h in 75% of cases. Clinical features noticed by the patients bystanders had low positive predictive values (PPV) for any stroke type. The CPR language or speech disorder + focal motor deficit had 93% sensitivity and a negative predictive value (NPV) of 84% to distinguish AIS. In SAH, headache alone showed a sensitivity of 84% and NPV of 97%. No CPR had an adequate performance on ICH. CPRs were not associated with final onset-to-door time. Altered consciousness, age ≥65 years, indirect arrival with stops before final referral, and atrial fibrillation increased in-hospital mortality. Conclusion: Clinical features referred by the witness of a neurovascular emergency have limited PPV, but adequate NPV in ruling-out AIS and SAH among stroke types. The use of CPRs had no impact on onset-to-door time or in-hospital mortality when the final arrival to a third-level center occurs with previous medical referrals.
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BACKGROUND: The body mass index (BMI) is based on the original concept that body weight increases as a function of height squared. As an indicator of obesity the modern BMI assumption postulates that adiposity also increases as a function of height in states of positive energy balance. OBJECTIVE: To evaluate the BMI concept across different adiposity magnitudes, in both children and adults. METHODS: We studied 975 individuals who underwent anthropometric evaluation: 474 children and 501 adults. Tetrapolar bioimpedance analysis was used to assess body fat and lean mass. RESULTS: BMI significantly correlated with percentage of body fat (%BF; children: r=0.893; adults: r=0.878) and with total fat mass (children: r=0.967; adults: r=0.953). In children, body weight, fat mass, %BF and waist circumference progressively increased as a function of height squared. In adults body weight increased as a function of height squared, but %BF actually decreased with increasing height both in men (r=-0.406; p<0.001) and women (r=-0.413; p<0.001). Most of the BMI variance in adults was explained by a positive correlation of total lean mass with height squared (r(2)=0.709), and by a negative correlation of BMI with total fat mass (r=-0.193). CONCLUSIONS: Body weight increases as a function of height squared. However, adiposity progressively increases as a function of height only in children. BMI is not an ideal indicator of obesity in adults since it is significantly influenced by the lean mass, even in obese individuals.
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Índice de Massa Corporal , Sobrepeso/diagnóstico , Adiposidade , Adulto , Composição Corporal , Estatura , Criança , Estudos Transversais , Impedância Elétrica , Feminino , Humanos , Masculino , México/epidemiologia , Pessoa de Meia-Idade , Obesidade/diagnóstico , Obesidade/epidemiologia , Sobrepeso/epidemiologia , Inquéritos e Questionários , Magreza , Circunferência da Cintura , Relação Cintura-QuadrilRESUMO
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.
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OBJECTIVE: To obtain a blood pressure reading is mandatory during either the general or specialized physical examination. This study describes factors associated with the accomplishment of blood pressure measurement in the first neurological consultation. METHODS: We studied first ambulatory neurology consultations in a Mexican referral hospital. Demographic characteristics, diagnostic category of referral, final diagnosis and data on physical examination were collected to establish a logistic regression analysis in order to identify factors associated with the accomplishment of blood pressure measurement. RESULTS: Over 8 months 778 outpatients were studied. The most frequent diagnoses for first consultation were headache (26%), epilepsy (14%) and stroke (13%). Only in 39% (n=301) of the outpatients blood pressure was registered, among them, 30% had normal blood pressure, 43% had 121-139/81-89 mmHg, 20% had 140-159/90-99 mmHg and 7% had ≥ 160/100 mmHg. The independent factors that favored the practice of BP determination in multivariable analysis were >65 years of age (odds ratio: 2.26; 95% confidence interval: 1.52-3.36) and headache complaint (odds ratio: 1.81, 95% confidence interval: 1.30-2.53). Notably, only 43% of patients with stroke had blood pressure registration, even when these stroke patients had blood pressure readings, they had higher blood pressure than with other diagnoses (p<0.05). CONCLUSION: Blood pressure registration was frequently omitted from the first neurological consultation, particularly in outpatients who might need it the most.
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Determinação da Pressão Arterial/estatística & dados numéricos , Técnicas de Diagnóstico Neurológico , Exame Físico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto JovemRESUMO
BACKGROUND AND AIM: Complications of diabetes comprise the leading cause of death in Mexico. We aimed to describe the characteristics of management and achievement of therapeutic targets in Mexican patients with diabetes mellitus. METHODS: We analyzed data from 2642 Mexican patients with type 1 (T1D, n=203, 7.7%) and type 2 diabetes (T2D, n=2439, 92.3%) included in the third wave of the International Diabetes Management Practices Study. RESULTS: Of T2D patients, 63% were on oral glucose-lowering drugs (OGLD) exclusively (mostly metformin), 11% on insulin, 22% on OGLD plus insulin, and 4% on diet and exercise exclusively. T2D patients on insulin were more likely to be trained on diabetes, but they were older, had worse control, longer disease duration and more chronic complications than patients on OGLD only. Glycated hemoglobin (HbA1c) <7% was achieved by 21% and 37% of T1D and T2D patients, respectively. Only 5% of T1D and 3% of T2D attained the composite target of HbA1c <7%, blood pressure <130/80 mmHg and low-density lipoprotein cholesterol <100 mg/dl. T1D patients had less macrovascular but more microvascular complications, compared with T2D patients. Late complications increased with disease duration, so that about 80% of patients after 20 years of diagnosis have at least one late complication. Reaching the target HbA1c <7% was associated with a reduced number of microvascular but not with less macrovascular complications. CONCLUSION: A great proportion of these Mexican patients with diabetes did not reach therapeutic targets. Insulin was used mostly in complicated cases with advanced disease.
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Diabetes Mellitus/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea , LDL-Colesterol/sangue , Terapia Combinada , Comorbidade , Estudos Transversais , Complicações do Diabetes/epidemiologia , Diabetes Mellitus/dietoterapia , Diabetes Mellitus/tratamento farmacológico , Dieta para Diabéticos , Quimioterapia Combinada , Terapia por Exercício , Feminino , Hemoglobinas Glicadas/análise , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Masculino , México , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
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.
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Hemorragia Cerebral/epidemiologia , Hemorragia Cerebral/fisiopatologia , Transtornos Cerebrovasculares/epidemiologia , Transtornos Cerebrovasculares/fisiopatologia , Sistema de Registros , Idoso , Hemorragia Cerebral/etiologia , Hemorragia Cerebral/terapia , Transtornos Cerebrovasculares/etiologia , Transtornos Cerebrovasculares/terapia , Diagnóstico Diferencial , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , México/epidemiologia , Pessoa de Meia-Idade , Fatores de Risco , Resultado do TratamentoRESUMO
INTRODUCTION: The 'obesity paradox' is the decreasing risk of death after cardiovascular disease, with a high body mass index (BMI), even when BMI is a risk factor for vasculopathy, in the first place. Our aim was to analyze the influence of obesity on the functional recovery after ischemic stroke. PATIENTS AND METHODS: We studied 510 patients who survived a first-ever acute ischemic stroke, without cerebrovascular disease history, and without recurrence or death after 12 months of follow-up. We also studied 501 healthy subjects who received tetrapolar bioimpedance analysis to compare the waist-to-height ratio (WHtR), abdominal circumference and BMI, as adiposity indices, in order to apply them in stroke patients. RESULTS: In healthy individuals, WHtR performed better than BMI or abdominal circumference in predicting body fat. In a Cox proportional hazards model adjusted for multiple covariables, age (hazard ratio, HR = 1.11; 95% confidence interval, 95% CI = 1.08-1.14), NIHSS score (HR = 1.03; 95% CI = 1.01-1.05) and WHtR > 70 (HR = 2.44; 95% CI = 1.33-4.48) were associated with a high risk of attaining a modified Rankin scale more or equal than 3 at 12 months after stroke; whereas BMI > 35 (HR = 0.33; 95% CI = 0.11-0.98) was protector. CONCLUSION: As reflected by WHtR, the excess of adiposity increases the chance of severe disability after ischemic stroke. Since BMI reflects also total lean mass, it is risky to conclude that there is a protective effect of obesity alone in the functional recovery after stroke; nevertheless, it is possible that a certain magnitude of body mass is necessary to prevent severe disability in stroke survivors.
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Isquemia Encefálica/complicações , Isquemia Encefálica/reabilitação , Obesidade/complicações , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recuperação de Função Fisiológica , Adulto JovemRESUMO
Objective: To obtain a blood pressure reading is mandatory during either the general or specialized physical examination. This study describes factors associated with the accomplishment of blood pressure measurement in the first neurological consultation. Methods: We studied first ambulatory neurology consultations in a Mexican referral hospital. Demographic characteristics, diagnostic category of referral, final diagnosis and data on physical examination were collected to establish a logistic regression analysis in order to identify factors associated with the accomplishment of blood pressure measurement. Results: Over 8 months 778 outpatients were studied. The most frequent diagnoses for first consultation were headache (26%), epilepsy (14%) and stroke (13%). Only in 39% (n = 301) of the outpatients blood pressure was registered, among them, 30% had normal blood pressure, 43% had 121-139/81-89mmHg, 20% had 140-159/90-99mmHg and 7% had ≥ 160/100mmHg. The independent factors that favored the practice of BP determination in multivariable analysis were >65 years of age (odds ratio: 2.26; 95% confidence interval: 1.52-3.36) and headache complaint (odds ratio: 1.81, 95% confidence interval: 1.30-2.53). Notably, only 43% of patients with stroke had blood pressure registration, even when these stroke patients had blood pressure readings, they had higher blood pressure than with other diagnoses (p< 0.05). Conclusion: Blood pressure registration was frequently omitted from the first neurological consultation, particularly in outpatients who might need it the most.
Objetivo: La medición de la presión arterial es mandatoria durante el examen físico general o especializado. Este estudio describe factores asociados al cumplimiento de la medición de la presión arterial en la primera consulta neurológica. Métodos: Realizamos un estudio sobre consultas neurológicas ambulatorias en un hospital de referencia mexicano. Se recolectaron características demográficas, categoría diagnóstica de referencia, diagnóstico final y datos sobre el examen físico para construir un análisis de regresión logística con el objetivo de identificar factores asociados con el cumplimiento de la medición de la presión arterial. Resultados: Durante 8 meses estudiamos a 778 pacientes. Los diagnósticos de envío más frecuentes fueron cefalea (26%), epilepsia (14%) y enfermedad cerebrovascular (13%). Solo en el 39% (n = 301) de los pacientes se midió la presión arterial y, de entre ellos, el 30% presentaron presión arterial normal, el 43% 121-139/81-89mmHg, el 20% 140-159/90-99mmHg y el 7% ≥ 160/100 mmHg. En un análisis multivariable, la edad > 65 años (razón de momios: 2.26, intervalo de confianza del 95%: 1.52-3.36) y cefalea como motivo de consulta (razón de momios: 1.81, intervalo de confianza del 95%: 1.30-2.53) fueron los factores independientes asociados al registro de la presión arterial. De manera notable, solo al 43% de los pacientes con enfermedad cerebrovascular se les había registrado la presión sanguínea; estos pacientes la tenían más elevada que los pacientes con otros diagnósticos (p <0.05). Conclusión: En este estudio con frecuencia se omitió el registro de la presión arterial en la primera consulta neurológica, especialmente en pacientes que podrían necesitarlo más.