Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials.

BACKGROUND: A larger therapeutic window for stroke treatment requires a significant change in the organization of emergency services, avoiding the increase in number of imaging exams and indirectly the time to treatment. OBJECTIVE: To highlight the relation between faster clinical evaluation and stroke over-suspicion and consequently excessive imaging acquisition. To identify predictors of ischemic stroke and stroke mimics (SM), aiming for better patient selection for comprehensive neuroimaging and reperfusion therapies. METHODS: Retrospective, cohort, observational, single-center study that reviewed all consecutive files of patients presenting with acute neurological symptoms who underwent CT scan or MRI from July 1, 2016 to July 1, 2017. RESULTS: 736 patient files were reviewed. 385 patients (52.3%) presented with confirmed acute ischemic infarct, 93 (12.6%) had another brain lesion mimicking acute ischemia, and 258 (35.1%) had normal imaging. Acute stroke was more frequent in elderly patients with atrial fibrillation, arterial hypertension, or dysarthria or right motor impairment. Stroke mimic was associated with female patients with low vascular risk factors, low NIHSS, and patients with decreased level of consciousness or symptoms suggestive of posterior circulation. DISCUSSION: 47.7% of all patients seen at the stroke unit did not have acute stroke lesions. Clinical assessment data have been used to provide indicators of acute stroke and stroke mimic patients, and symptoms corresponding to acute stroke and stroke mimic seem to be similar in the literature. CONCLUSION: Considering that the number of patients admitted for stroke treatment will increase even further with a larger therapeutic window for mechanical thrombectomy and for thrombolysis, a diagnostic decision-making algorithm for stroke patients is required in order to reinforce the suspicion of stroke indicating an urgent MRI.

Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials / Imitadores de AVC em unidades de AVC. Avaliação após alterações impostas por ensaios randomizados

Abstract A larger therapeutic window for stroke treatment requires a significant change in the organization of emergency services, avoiding the increase in number of imaging exams and indirectly the time to treatment. Objective: To highlight the relation between faster clinical evaluation and stroke over-suspicion and consequently excessive imaging acquisition. To identify predictors of ischemic stroke and stroke mimics (SM), aiming for better patient selection for comprehensive neuroimaging and reperfusion therapies. Methods: Retrospective, cohort, observational, single-center study that reviewed all consecutive files of patients presenting with acute neurological symptoms who underwent CT scan or MRI from July 1, 2016 to July 1, 2017. Results: 736 patient files were reviewed. 385 patients (52.3%) presented with confirmed acute ischemic infarct, 93 (12.6%) had another brain lesion mimicking acute ischemia, and 258 (35.1%) had normal imaging. Acute stroke was more frequent in elderly patients with atrial fibrillation, arterial hypertension, or dysarthria or right motor impairment. Stroke mimic was associated with female patients with low vascular risk factors, low NIHSS, and patients with decreased level of consciousness or symptoms suggestive of posterior circulation. Discussion: 47.7% of all patients seen at the stroke unit did not have acute stroke lesions. Clinical assessment data have been used to provide indicators of acute stroke and stroke mimic patients, and symptoms corresponding to acute stroke and stroke mimic seem to be similar in the literature. Conclusion: Considering that the number of patients admitted for stroke treatment will increase even further with a larger therapeutic window for mechanical thrombectomy and for thrombolysis, a diagnostic decision-making algorithm for stroke patients is required in order to reinforce the suspicion of stroke indicating an urgent MRI.

Resumo Uma janela terapêutica maior para o tratamento do AVC exige uma mudança significativa na organização dos serviços de emergência, para evitar o aumento do número de exames de imagem e indiretamente o tempo de tratamento. Objetivo: destacar a relação entre avaliação clínica mais rápida e suspeita de acidente vascular cerebral e, consequentemente, aquisição de imagem excessiva, e identificar preditores de acidente vascular cerebral isquêmico e imitações de acidente vascular cerebral (SM), visando uma melhor seleção de pacientes para terapias abrangentes de neuroimagem e reperfusão. Métodos: estudo observacional de coorte retrospectivo, em centro único, que revisou todos os arquivos consecutivos de pacientes com sintomas neurológicos agudos submetidos à tomografia computadorizada ou ressonância magnética de 1 de julho de 2016 a 1 de julho de 2017. Resultados: Foram revisados 736 prontuários. 385 pacientes (52,3%) apresentaram infarto isquêmico agudo confirmado, 93 (12,6%) apresentaram outra lesão cerebral imitando isquemia aguda e 258 (35,1%) apresentaram imagem normal. O AVC agudo foi mais frequente em pacientes idosos com fibrilação atrial, hipertensão arterial, ou disartria ou comprometimento motor direito. A imitação de acidente vascular cerebral foi associada a pacientes do sexo feminino com baixos fatores de risco vascular, NIHSS baixo e pacientes com diminuição do nível de consciência ou sintomas sugestivos de circulação posterior. Discussão: 47,7% de todos os pacientes atendidos na unidade de AVC não apresentaram lesões agudas de AVC. Conclusão: Considerando que o número de pacientes admitidos para tratamento de AVC aumentará ainda mais com uma janela terapêutica maior para trombectomia e trombólise IV, é necessário um algoritmo de tomada de decisão diagnóstica para pacientes com AVC, a fim de reforçar a suspeita de AVC indicando uma imagem cerebral urgente.

Prevalence, predictors and outcomes of potential drug-drug interactions in left ventricular failure: considerable factors for quality use of medicines

Hospitalized patients with left ventricular failure (LVF) are at high risk for potential drug-drug interactions (pDDIs) and its related adverse effects owing to multiple risk factors such as old age, comorbidities and polypharmacy. This cross-sectional study conducted in two tertiary care hospitals aim to identify frequency, levels and predictors of pDDIs in LVF patients. Data about patients' demographic, hospital stay, medication therapy, sign/symptoms and laboratory test results were collected for 385 patients with LVF. Micromedex Drug-Reax® was used to screen patients' medication profiles for pDDIs. Overall prevalence and severity-wise prevalence of pDDIs were identified. Chi-square test was performed for comparative analysis of various variables. Logistic regression was applied to determine the odds-ratios (OR) for predictors of pDDIs. The prevalence of pDDIs was 96.4% (n=371). Overall 335 drug-interacting pairs were detected, which were presented in a total of 2870 pDDIs. Majority of pDDIs were of major- (48.9%) and moderate-severity (47.5%). Logistic regression analysis shows significant association of >6 all types of pDDIs with >12 drugs as compared with <8 drugs (OR=16.5; p=<0.001). Likewise, there was a significant association of >4 major-pDDIs with men as compared with female (OR=1.9; p=0.007) and >12 drugs as compared with <8 drugs (OR=10.9; p=<0.001). Hypotension (n=57), impaired renal function (23) and increased blood pressure (22) were the most frequent adverse outcomes associated with pDDIs. This study shows high prevalence of pDDIs in LVF patients. Majority of pDDIs were of major- and moderate-severity. Male patients and those prescribed greater number of medicines were more exposed to major-pDDIs

Drug-Drug Interactions in Hepatitis Patients: Do these Interactions Matter in Clinical Perspectives?

INTRODUCTION AND AIM: Hepatitis patients usually present with comorbidities and polypharmacy which increases risk of potential drug-drug interactions (pDDIs). We explored frequency, levels, predictors, and clinical relevance of pDDIs in hospitalized hepatitis patients. MATERIAL AND METHODS: Retrospective cohort study was used. Clinical profiles of 413 hepatitis patients were reviewed for pDDIs using Micromedex-DrugReax. Frequency, levels and clinical relevance of pDDIs were reported. Logistic regression analysis was used to calculate odds-ratios for predictors. RESULTS: Of total 413 patients, pDDIs were reported in 55.2%. Major-pDDIs were found in 35% patients. Total 660 pDDIs were identified, of which, 304 (46%) were of major-severity and 299 (45%) of moderateseverity. Patient's profiles of top-10 major-pDDIs were presented with signs/symptoms such as fever, hepatomegaly, anorexia, jaundice, hypertension, tachycardia, bradycardia, & pedal edema; and abnormalities in labs such as electrolytes-level, alanine aminotransferase, blood urea nitrogen, bilirubin-level, & serum creatinine. Significant association was observed for the presence of pDDIs with > 9 prescribed medicines (p < 0.001), hospitalization of > 5 days (p = 0.03), and stroke as comorbidity (p = 0.05). Moreover, odds of exposure to major-pDDIs were significantly higher in patients taking > 9 prescribed medicines (p < 0.001), hospitalization of > 5 days (p = 0.002), and stroke as comorbidity (p = 0.002). CONCLUSION: We observed hepatitis patients presented with a considerable number of clinically relevant pDDIs. Attention should be given to widespread major-pDDIs and their potential adverse outcomes. Clinically relevant parameters, such as labs and signs/symptoms should be monitored particularly in high risk patients having polypharmacy, prolong hospitalization, and stroke as comorbidity.

Sarcoidosis mimicking primary sclerosing cholangitis requiring liver transplantation.

Sarcoidosis is a systemic granulomatous disease of unknown etiology. The association of the cholestatic pattern usually seen in sarcoidosis, with biliary duct changes resembling primary sclerosing cholangitis (PSC) is rare. Liver transplantation permits the histological evaluation of the complete explanted liver, making the diagnosis more reliable. In conclusion we present our experience with two patients with sarcoidosis requiring liver transplantation, who presented with clinical and radiological findings characteristics of primary sclerosing cholangitis.