A high-urgency stroke code reduces in-hospital delays in acute ischemic stroke: a single-centre experience.

Timely treatment is essential in acute ischemic stroke as the chances of recovery diminish over time, so efforts are necessary to streamline in-hospital pathways and reduce delays. Here, we analyse the interventions to reduce door-to-needle time in stroke patients suitable for intravenous thrombolysis at the Emergency Department of San Carlo Borromeo Hospital, Milan, Italy. All stroke patients consecutively treated with intravenous thrombolysis at our centre from January 1, 2013 to December 31, 2015 were included in this analysis. The main interventions adopted were (1) continuous education of personnel, (2) reconsideration of blood tests and identify the ones really affecting treatment decision, (3) approval of a new high-urgency Stroke Code activated as soon as the triage nurse comes to know of a potential thrombolysis candidate. Median door-to-needle time progressively decreased from 103 min (iqr 78-120) in 2013, to 92 min (iqr 72-112) in 2014, and to 37 min (iqr 27-58) with the new Stroke Code (p < 0.001) in 2015. Simultaneously, median onset-to-treatment time decreased from 177 min (iqr 142-188) in 2013, to 155 min (iqr 141-198) in 2014, and to 114 min (iqr 86-160) with the new Stroke Code (p < 0.001 and p 0.005, respectively). We did not observe any significant difference in bleeding risks or deaths, whereas the likelihood of favourable outcome (mRS 0-2) increased. Streamlining in-hospital pathways with progressive interventions significantly decreases door-to-needle time and onset-to-treatment time and may contribute to improve stroke outcomes.

Stroke care in young patients.

The aims of this study were (i) to evaluate the clinical features of a consecutive series of young patients with ischemic stroke and (ii) to assess the changes in the clinical management of these patients over the study period. All consecutive cases of young adults aged 16 to 44 years, with ischemic stroke, that were admitted between 2000 and 2005 in 10 Italian hospitals were included. We retrospectively identified 324 patients. One or more vascular risk factors were present in 71.5% of the patients. With respect to the diagnostic process, an increase in the frequency of cerebral noninvasive angiographic studies and a decrease in the use of digital subtraction angiography were observed (P < 0.001 and P = 0.03, resp.). Undetermined causes decreased over 5-year period of study (P < 0.001). The diagnosis of cardioembolism increased. Thrombolysis was performed for 7.7% of the patients. PFO closure (8%) was the most frequently employed surgical procedure. In conclusion, the clinical care that is given to young patients with ischemic stroke changed over the study period. In particular, we detected an evolution in the diagnostic process and a reduction in the number of undetermined cases.

Quality assurance of RapidArc in clinical practice using portal dosimetry.

OBJECTIVE: Quality assurance data from five centres were analysed to assess the reliability of RapidArc radiotherapy delivery in terms of machine and dosimetric performance. METHODS: A large group of patients was treated with RapidArc radiotherapy and treatment data recorded. Machine quality assurance was performed according to Ling et al (Int J Radiat Oncol Biol Phys 2008;72:575-81). In addition, treatment to a typical clinical case was delivered biweekly as a constancy check. Pre-treatment dosimetric validation of plan delivery was performed for each patient. All measurements and computations were performed at the depth of the maximum dose in water according to the GLAaS method using electronic portal imaging device measurements. Evaluation was carried out according to a gamma agreement index (GAI, the percentage of field area passing the test); the threshold dose difference was 3% and the threshold distance to agreement was 3 mm. RESULTS: A total of 275 patients (395 arcs) were included in the study. Mean delivery parameters were 31.0±20.0° (collimator angle), 4.7±0.5° s(-1) (gantry speed), 343±134 MU min(-1) (dose rate) and 1.6±1.4 min (beam-on time) for prescription doses ranging from 1.8 to 16.7 Gy/fraction. Mean deviations from the baseline dose rate and gantry speed ranged from -0.61% to 1.75%. Mean deviations from the baseline for leaf speed variation ranged from -0.73% to 0.41%. The mean GAI of repeated clinical fields was 99.2±0.2%. GAI varied from 84.7% to 100%; the mean across all patients was 97.1±2.4%. CONCLUSION: RapidArc can provide a reliable and accurate delivery of radiotherapy for a variety of clinical conditions.

Effectiveness of stereotactic body radiotherapy in the treatment of inoperable early-stage lung cancer.

BACKGROUND: Non-small cell lung cancer (NSCLC) is the leading cause of cancer death worldwide. Stereotactic body irradiation offers a non-invasive treatment modality for patients with early stage NSCLC who are not amenable to surgery or other invasive approaches because of their poor medical condition. PATIENTS AND METHODS: Forty-three inoperable patients with NSCLC were treated with SBRT at our institution. A mean total dose of 30.5 Gy in 1-4 fractions was applied. The median follow-up duration was 14 months (range 6-36 months). RESULTS: The actuarial survival at two years was 53%: two patients died from cancer progression whereas a further 8 patients died from comorbidities. Acute toxicity was practically absent, with 7 (16.3%) patients suffering from grade 1 symptoms and two from (4.6%) grade II effects. At the time of this report, only 1 patient had grade II and 6 patients (13.9%) grade I chronic symptoms. CONCLUSION: Our results compare favourably with recently published studies and confirm that stereotactic radiotherapy has the potential to produce high local control rates with a low risk of lung toxicity in patients not amenable to curative resection. The low grade of side-effects is encouraging for shortening the treatment using a greater dose per fraction.

The stroke in an emergency: the grey areas.

In spite of the development of advanced technologies, diagnosis and therapy for an ictus in emergency still pose difficulties in a significant percentage of cases. Diagnostic problems are encountered both when faced with focal symptoms and in the presence of disturbances to consciousness, confusional states, vertigo or cephalea. The most significant therapeutic problems, on the other hand, are encountered in the case of extended cardioembolic ischaemias, haemorrhages from venous thrombosis and intradural arterial dissections (eventual antithrombotic treatment), when faced with a large cerebral oedema (eventual medical and/or surgical treatment), or in indicating surgery for intraparenchymal haemorrhages or symptomatic stenotic carotids.

Brainstem involvement in Legionnaires' disease.

OBJECTIVE: To report a case of Legionella pneumonia with unusual neurologic involvement. INTERVENTION: Chest X-ray, lumbar puncture, magnetic imaging of the brain, electroencephalography, audiometry, brainstem acoustic evoked potentials and institution of oral antibiotics and steroids. MAIN RESULT: Gradual clinical improvement of neurologic and pulmonary illness within 4 weeks. CONCLUSION: Legionellosis should be considered in the differential diagnosis of neurologic involvement in the setting of pneumonia.

Early phase combined therapeutic management of acute ischaemic stroke.

An adequate treatment of ischaemic stroke in the early phase (28-48 h) is the most important factor for a better outcome. Thrombolysis with rTPA (within 3 h) and oral ASA 300 mg/days are the first therapeutic misures. Continuous monitoring of cardiological and haemodinamic parameters allows early detection of cardiac disturbances. Treatment of hypertension, low haematic oxigenation, hyperglicaemia, seizures and hypertermia is basic to improve outcome. Pharmacological therapy is only one of the components of effective multidisciplinary integrated management of ischaemic stroke; we remind also the precocity of rehabilitation procedures and an accurate psychological assessment.

Cervical cerebral artery dissection: a multicenter prospective study (preliminary report).

Forty-nine cases of dissection of the internal carotid and vertebral arteries are reported in our prospective multicenter study of 35 men and 14 women, with a mean age of 46.77 years. (range 17-60 years). We evaluated etiology, clinical manifestations, investigative techniques, and treatment. Thirty-one patients had so-called spontaneous dissections, although in the remaining 18 minimal or obvious trauma was considered as the etiological factor. Headache and neck pain occurred in 32 patients (65.3%). Local neurological manifestations were present in 15 patients (30.6%) and ischemic cerebral symptoms were present in 41 patients (83.6%). The most-relevant of the diagnostic tools are duplex sonography, magnetic resonance angiography, and angiography. Anticoagulation with heparin followed by warfarin was the treatment of choice in most of our patients. Complete recovery is reported in 14 patients (28.5%); 41 patients showed cerebral ischemic symptoms, of which 13 (26.5%) had good functional recovery. In 28 (57.1%), the NIHSS score decreased from 6.68 to 3.31 during hospitalization.

Clinical features of 24 patients on regular hemodialysis treatment (RDT) for 16-23 years in a single unit.

Careful investigation of the clinical conditions of patients on maintenance hemodialysis for about 20 years in a single dialysis unit was of great interest for evaluation of the pathological consequences in long-term survivors of insufficient correction of uremia and of the dialysis treatment "per se". We analyzed the outcomes for a cohort of 116 patients who started RDT before 1976 and the clinical conditions of the 24 patients still on RDT in our unit at the end of 1991 (average duration of treatment = 222 +/- 23 months). Actuarial survival was 72% at 10 years and 43% at 20 years. Rehabilitation of the 24 survivors was rather good: 13 were able to work, 8 were retired or unable to work, but able to care for most personal needs. Actual body weight, anthropometric parameters and biochemical parameters revealed a well-preserved nutritional status. Anemia improved from 23 +/- 7 at the start of RDT to 31 +/- 8 in the 21 patients never treated with erythropoietin. Blood pressure was normal without therapy in 18 patients and elevated in 6. Mild-to-moderate left ventricular hypertrophy was present in all the 6 patients with arterial hypertension and in only 6 of the 18 normotensive patients. The ratio of early diastolic filling to filling during atrial contraction (E/A ratio) was < 1 in 16 patients: it was 1.05 +/- 0.43 in 9 patients with stable intradialysis blood pressure and significantly lower (0.73 +/- 0.15) in 12 patients with recurrent intradialysis hypotension. Supraventricular arrhythmias were detected by Holter monitoring in 41% and ventricular arrhythmias in 35% of patients. Extensive vascular calcifications were present (in 100% of patients in the abdominal aorta), but only 4 patients showed clinical signs of peripheral vascular disease. Subperiosteal resorption was detected radiologically in the hands of 59% of patients. Bone histology, interpretable for only 20 patients, revealed no bone lesions in 1 case (5%), mild mixed osteodystrophy in 3 cases (15%), advanced mixed osteodystrophy in 5 cases (25%), osteodystrophy with predominant hyperparathyroidism in 2 cases (10%), osteodystrophy with predominant osteomalacia in 6 cases (30%), and aplastic bone disease in 3 cases (15%). Moderate aluminum staining was found in only 4 patients and was more marked in earlier biopsies taken before withdrawal of the aluminium-containing phosphate-binding drugs.(ABSTRACT TRUNCATED AT 400 WORDS)