Digital flashcards and medical physiology performance: a dose-dependent effect.

Use of digital flashcards promotes active recall, spaced repetition, and self-assessment academic principles. This work explores the association and dose-dependent effect of this study method and locomotor (LP) and cardiovascular physiology (CP) grades. A single-faculty cohort study of medical LP and CP students was conducted, and 155 and 676 flashcards, respectively, were created through Moodle. An exploratory analysis examined three exam results (2019), and a confirmatory study used a fourth exam (2021) in another CP cohort. Of 685 students enrolled, 558 participated in the exploratory analysis: 319 (69%) for LP and 311 (84%) for CP, of which 203 LP and 267 CP students were flashcard users. Median grades were higher among flashcard users, and the number of cards reviewed was positively correlated with grades (r = 0.275 to 0.388 for LP and r = 0.239 to 0.432 for CP, P < 0.001). Multiple linear regression models confirmed a positive dose-dependent association between results and the number of flashcards studied: for every 100 LP cards reviewed, exam grades increased 0.44-0.75 on a 0-20 scale range (P < 0.001), and for every 1,000 CP flashcards, results raised 0.81-1.08 values (P < 0.05). These findings were confirmed in the 2021 CP cohort of 269 participants, of whom 67% were flashcard users. Digital flashcard revision has a consistent positive dose-dependent association on LP and CP grades.NEW & NOTEWORTHY Implementing flashcard-based strategies is a feasible way to promote active recall, spaced repetition, and self-assessment, and students are highly adherent to these initiatives. There is a positive dose-dependent association between the number of flashcards reviewed and physiology grades. These results are consistent across different physiology subjects, under different cohorts, over short and medium terms.

Anticoagulation after intracerebral hemorrhage in patients with atrial fibrillation: between Scylla and Charybdis.

BACKGROUND: Oral anticoagulants (OAC) are indicated in patients with atrial fibrillation (AF) and high risk of ischemic stroke. However, the introduction of anticoagulation in patients with AF and previous intracerebral hemorrhage (ICH) is controversial. We aimed to better understand the efficacy and safety of OAC in this context and to assess the factors that may influence this decision. METHODS: In a single-center retrospective observational study, patients with AF and ICH who survived hospitalization at a level A Stroke Unit between 2009 and 2018 were included. Patients were followed for two years after discharge. Data were collected regarding the introduction or not of OAC and the occurrence of major thrombotic/hemorrhagic events and death. RESULTS: Ninety-five patients (75.2 ± 9.9 years) were included and 40 patients (42.1%) started OAC. Patients were more likely to initiate anticoagulation if they had: mechanical prosthetic valves, previous AF (p = 0.005) and previous OAC therapy (p < 0001); and less if they had previous hemorrhagic stroke (p < 0.005). During follow-up, 10.5% had at least one major hemorrhagic event (60% anticoagulated), 20% had at least one major thrombotic event (all non-anticoagulated) and 20% died. The only factor associated with the risk of bleeding was ICH score (OR:2.49 per 1-point increase; 95%CI:1.14-5.46). Patients who initiated anticoagulation had lower mortality than non-anticoagulated (OR:0.296; 95%CI:0.090-0-975). Previous ICH and higher CHA2DS2-VASc were associated with higher mortality. CONCLUSION: In this retrospective series, anticoagulation reduced thrombotic events and overall mortality in patients admitted for ICH and AF, without a significant increase in bleeding risk.

Heart failure patients have enhanced cerebral autoregulation response in acute ischemic stroke.

The cerebrovascular effects of a failing heart-pump are largely unknown. Chronic heart failure (HF) might cause pre-conditioning effect on cerebral hemodynamics but not study so far in acute stroke. We aimed to investigate if HF induces effects in dynamic cerebral autoregulation (CA), within 6 h of symptom-onset through chronic stage of ischemic stroke. We enrolled 50 patients with acute ischemic stroke. Groups with (N = 8) and without HF and 20 heathy controls were compared. Arterial blood pressure (Finometer) and cerebral blood flow velocity (transcranial Doppler) were monitored within 6 and at 24 h from symptom-onset and at 3 months. We assessed dynamic CA by transfer function analysis and cardiac disease markers. HF associated with higher phase (better dynamic CA) at ischemic hemisphere within 6 (p = 0.042) and at 24 h (p = 0.006) but this effect was not evident at 3 months (p > 0.05). Gain and coherence trends were similar between groups. We found a positive correlation between phase and admission troponin I levels (Spearman's r = 0.348, p = 0.044). Our findings advances on the knowledge of how brain and heart interact in acute ischemic stroke by showing a sustained dynamic cerebral autoregulation response in HF patients mainly with severe aortic valve disease. Understanding the physiological mechanisms that govern this complex interplay can be useful to find novel therapeutic targets which can improve outcome in ischemic stroke.

NT-pro-BNP correlates with disease severity and predicts outcome in cerebral haemorrhage patients: Cohort study.

BACKGROUND: Intracerebral haemorrhage (ICH) is a devastating condition, with more than half of patients dying or becoming dependent after such an event. Natriuretic peptides, frequently used in the management of heart failure, have been shown to correlate with disease severity and prognosis in brain disorders. The aim of this study was to test the hypothesis that NT-pro-BNP correlates with disease severity and is an independent prognostic marker for non-traumatic ICH patients. METHODS: A consecutive sample of 201 non-traumatic ICH patients, who were non-comatose on admission and medically treated in a stroke unit, were evaluated for in-hospital mortality and three-month functional dependency (modified Rankin Scale >2). NT-pro-BNP measurement was performed after admission. Independent predictors of the outcomes in study were assessed using logistic regression and the incremental value of NT-pro-BNP on three previously validated severity scores was evaluated using the variation in C-statistic (Δc). Values of p < .05 were considered significant. RESULTS: In-hospital mortality rate was 8.0%, and 40.3% of patients achieved good functional outcome. NT-pro-BNP correlated with hematoma volume (r = 0.186) and amount of intraventricular blood (r = 0.240). Higher levels of NT-pro-BNP were independently associated with death (Expß = 1.650) and functional dependency (Expß = 1.449). NT-pro-BNP increased the discrimination of the ICH-GS for mortality prediction (Δc = 0.043) and of FUNC and ICH scores for functional outcome prediction (Δc = 0.060 and 0.055 respectively). Admission NT-pro-BNP levels were independently associated with hematoma size. CONCLUSIONS: NT-pro-BNP is an independent prognostic factor for low-risk non-traumatic ICH patients and a valid marker of disease severity in this patient population.

Assessment and Comparison of the Four Most Extensively Validated Prognostic Scales for Intracerebral Hemorrhage: Systematic Review with Meta-analysis.

BACKGROUND/OBJECTIVE: Intracerebral hemorrhage (ICH) is a devastating disorder, responsible for 10% of all strokes. Several prognostic scores have been developed for this population to predict mortality and functional outcome. The aim of this study was to determine the four most frequently validated and most widely used scores, assess their discrimination for both outcomes by means of a systematic review with meta-analysis, and compare them using meta-regression. METHODS: PubMed, ISI Web of Knowledge, Scopus, and CENTRAL were searched for studies validating the ICH score, ICH-GS, modified ICH, and the FUNC score in ICH patients. C-statistic was chosen as the measure of discrimination. For each score and outcome, C-statistics were aggregated at four different time points using random effect models, and heterogeneity was evaluated using the I2 statistic. Score comparison was undertaken by pooling all C-statistics at different time points using robust variance estimation (RVE) and performing meta-regression, with the score used as the independent variable. RESULTS: Fifty-three studies were found validating the original ICH score, 14 studies were found validating the ICH-GS, eight studies were found validating the FUNC score, and five studies were found validating the modified ICH score. Most studies attempted outcome prediction at 3 months or earlier. Pooled C-statistics ranged from 0.76 for FUNC functional outcome prediction at discharge to 0.85 for ICH-GS mortality prediction at 3 months, but heterogeneity was high across studies. RVE showed the ICH score retained the highest discrimination for mortality (c = 0.84), whereas the modified ICH score retained the highest discrimination for functional outcome (c = 0.80), but these differences were not statistically significant. CONCLUSIONS: The ICH score is the most extensively validated score in ICH patients and, in the absence of superior prediction by other scores, should preferably be used. Further studies are needed to validate prognostic scores at longer follow-ups and assess the reasons for heterogeneity in discrimination.

Prognostic models for intracerebral hemorrhage: systematic review and meta-analysis.

BACKGROUND: Prognostic tools for intracerebral hemorrhage (ICH) patients are potentially useful for ascertaining prognosis and recommended in guidelines to facilitate streamline assessment and communication between providers. In this systematic review with meta-analysis we identified and characterized all existing prognostic tools for this population, performed a methodological evaluation of the conducting and reporting of such studies and compared different methods of prognostic tool derivation in terms of discrimination for mortality and functional outcome prediction. METHODS: PubMed, ISI, Scopus and CENTRAL were searched up to 15th September 2016, with additional studies identified using reference check. Two reviewers independently extracted data regarding the population studied, process of tool derivation, included predictors and discrimination (c statistic) using a predesignated spreadsheet based in the CHARMS checklist. Disagreements were solved by consensus. C statistics were pooled using robust variance estimation and meta-regression was applied for group comparisons using random effect models. RESULTS: Fifty nine studies were retrieved, including 48,133 patients and reporting on the derivation of 72 prognostic tools. Data on discrimination (c statistic) was available for 53 tools, 38 focusing on mortality and 15 focusing on functional outcome. Discrimination was high for both outcomes, with a pooled c statistic of 0.88 for mortality and 0.87 for functional outcome. Forty three tools were regression based and nine tools were derived using machine learning algorithms, with no differences found between the two methods in terms of discrimination (p = 0.490). Several methodological issues however were identified, relating to handling of missing data, low number of events per variable, insufficient length of follow-up, absence of blinding, infrequent use of internal validation, and underreporting of important model performance measures. CONCLUSIONS: Prognostic tools for ICH discriminated well for mortality and functional outcome in derivation studies but methodological issues require confirmation of these findings in validation studies. Logistic regression based risk scores are particularly promising given their good performance and ease of application.

[Cardiorenal syndrome and its pathophysiological implications]. / Síndrome cardiorrenal e suas implicações fisiopatológicas.

Cardiorenal syndrome is a pathophysiological condition in which combined cardiac and renal dysfunction amplifies individual organs failure progression. Therefore, morbidity and mortality is higher in this group patients. Its incidence has increased due to increased longevity and because patients survive more years with cardiac and/or renal dysfunction. The aim of the present paper is the revision of the most recent advances in this area. For a better comprehension and systematization of this syndrome it is suggested a classification in various subtypes (I-V). Type I reflects an abrupt worsening of cardiac function leading to acute kidney injury. Type II results from chronic abnormalities in cardiac function (chronic heart failure) causing progressive and potentially irreversible kidney disease. Type III consists of an abrupt worsening of renal function (acute kidney lesion) causing acute cardiac dysfunction (heart failure, arrhythmia or ischemia). Type IV describes a state of chronic kidney disease contributing to decrease cardiac function, ventricular hypertrophy, and/or increased risk of adverse cardiovascular events. Type V reflects a systemic condition causing both: cardiac and renal dysfunction. The clinical use of recently identified biomarkers can be an additional tool in the early diagnosis and stratification of this syndrome. This classification can be particularly useful in the identification of underlying abnormalities and in the establishment of an effective therapeutic approach.