RESUMEN
BACKGROUND AND PURPOSE: Tick-borne encephalitis (TBE) is an infection of the central nervous system (CNS) caused by tick-borne encephalitis virus (TBEV) and transmitted by ticks, with a variety of clinical manifestations. The incidence of TBE in Europe is increasing due to an extended season of the infection and the enlargement of endemic areas. Our objectives are to provide recommendations on the prevention, diagnosis and management of TBE, based on evidence or consensus decisions. METHODS: For systematic evaluation, the literature was searched from 1970 to 2015 (including early online publications of 2016), and recommendations were based on evidence or consensus decisions of the Task Force when evidence-based data were not available. RECOMMENDATIONS: Vaccination against TBE is recommended for all age groups above 1 year in highly endemic areas (≥5 cases/100 000/year), but also for individuals at risk in areas with a lower incidence. Travellers to endemic areas should be vaccinated if their visits will include extensive outdoor activities. Post-exposure prophylaxis after a tick bite is not recommended. A case of TBE is defined by the presence of clinical signs of meningitis, meningoencephalitis or meningoencephalomyelitis with cerebrospinal fluid (CSF) pleocytosis (>5 × 106 cells/l) and the presence of specific TBEV serum immunoglobulin M (IgM) and IgG antibodies, CSF IgM antibodies or TBEV IgG seroconversion. TBEV-specific polymerase chain reaction in blood is diagnostic in the first viremic phase but it is not sensitive in the second phase of TBE with clinical manifestations of CNS inflammation. Lumbar puncture should be performed in all patients with suspected CNS infection unless there are contraindications. Imaging of the brain and spinal cord has a low sensitivity and a low specificity, but it is useful for differential diagnosis. No effective antiviral or immunomodulating therapy is available for TBE; therefore the treatment is symptomatic. Patients with a potentially life threatening meningoencephalitis or meningoencephalomyelitis should be admitted to an intensive care unit. In the case of brain oedema, analgosedation should be deepened; osmotherapy and corticosteroids are not routinely recommended. If intracranial pressure is increased, therapeutic hypothermia or decompressive craniectomy might be considered. Seizures should be treated as any other symptomatic epileptic seizures. CONCLUSIONS: Tick-borne encephalitis is a viral CNS infection that may result in long-term neurological sequelae. Since its incidence in Europe is increasing due to broadening of endemic areas and prolongation of the tick activity season, the health burden of TBE is enlarging. There is no effective antiviral treatment for TBE, but the disease may be effectively prevented by vaccination.
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Virus de la Encefalitis Transmitidos por Garrapatas , Encefalitis Transmitida por Garrapatas/diagnóstico , Encefalitis Transmitida por Garrapatas/prevención & control , Encefalitis Transmitida por Garrapatas/terapia , Vacunación , Consenso , Diagnóstico Diferencial , Europa (Continente) , Humanos , Inmunoglobulina M , MasculinoRESUMEN
OBJECTIVES: There are few data on long-term functional outcome after intracerebral hemorrhage (ICH). We aimed to assess functional dependency and cognitive impairment in long-term survivors of first-ever intracerebral hemorrhage. MATERIALS AND METHODS: Between August and November 2011, we contacted all survivors from a cohort of 134 consecutive patients hospitalized with a first-ever ICH in the period 2005-2009 in a well-defined catchment area. We did an extensive face-to-face follow-up including the National Institute of Health Stroke Scale (NIHSS), the modified Rankin Scale (mRS), the Barthel Index (BI), and the Montreal Cognitive Assessment (MoCA). RESULTS: Fifty-one patients (38%) were alive. Fifty agreed to take part in the follow-up. The median follow-up time was 3.8 years. Thirty-four patients (68%) were independent (mRS 0-2) and 16 (32%) dependent (mRS 3-5). Factors independently associated with dependency were leukoaraiosis score (OR 2.3 per increasing point, P = 0.003) and female sex (OR 5.1, P = 0.038). Twenty-seven patients (61%) had cognitive impairment (MoCA ≤ 23). Factors independently associated with cognitive impairment were age (OR 2.4 per 10 years, P = 0.010) and lobar ICH location (OR 14.1, P = 0.016). CONCLUSIONS: A large proportion of long-term survivors of ICH in Southern Norway live functionally independent lives in their private homes. Dependency is linked to leukoaraiosis and female sex. Cognitive impairment is common and linked to lobar location of ICH.
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Hemorragia Cerebral/mortalidad , Hemorragia Cerebral/fisiopatología , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Trastornos del Conocimiento/diagnóstico , Trastornos del Conocimiento/etiología , Estudios de Cohortes , Femenino , Humanos , Masculino , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
OBJECTIVES: To assess time trends in intravenous thrombolytic (iv tPA) treatment in a general local hospital during a period with organizational changes, especially how movement of treatment start from the emergency room (ER) to the CT laboratory, and changing method of administration of acute antihypertensive medication influenced on door-to-needle time (DNT). MATERIALS AND METHODS: All stroke patients treated with iv tPA have been prospectively enrolled in the Safe Implementation of Treatments in Stroke (SITS) registry. Data from 2007 to 2011 were reviewed. Safety was evaluated by the incidence of symptomatic intracerebral hemorrhage (SICH). Predictors of DNT were assessed by multivariable regression. RESULTS: Two hundred and forty-three patients were treated with iv tPA. The annual treatment rate reached 21.9% of patients with ischemic strokes admitted to the hospital. Median DNT decreased from 36 to 28 min (P ≤ 0.001). The incidence of SICH remained low and was throughout the period 2.5%. Treatment start in the CT laboratory vs in the ER was associated with a reduction in median DNT (P = 0.007). Acute antihypertensive treatment and treatment with warfarin were associated with increased DNT (P = 0.024 and P = 0.003, respectively). Age, gender, baseline NIHSS, onset-to-door time, comorbidity, and method of administration of acute antihypertensive treatment did not influence DNT significantly. CONCLUSIONS: Streamlining of iv tPA logistics can reduce median DNT to <30 min in a general local hospital. Moving treatment start from the ER to the CT laboratory contributed to reduce DNT. Our organizational model was resistant to influence on DNT by patient age, gender, stroke severity, and time to hospital arrival. The incidence of SICH remained low.
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Intervención Médica Temprana/métodos , Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/administración & dosificación , Anciano , Anciano de 80 o más Años , Hemorragia Cerebral/epidemiología , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Accidente Cerebrovascular/complicaciones , Factores de TiempoRESUMEN
AIM: To identify possible risk factors for reduced health-related quality of life (HRQoL) and fatigue after treated Lyme neuroborreliosis (LNB). METHODS: We included 50 patients with LNB and analyzed associations between their demographic, clinical, and laboratory characteristics at baseline and outcome at 30 months assessed by the self-report questionnaires Short Form-36 (SF-36) and Fatigue Severity Scale (FSS). RESULTS: Lower scores in the SF-36 domain Physical Component Summary were associated with pretreatment symptom duration >6 weeks (B = -11.0, P = 0.001) and non-complete recovery at 4 months (B = -5.5, P = 0.037) (R(2) = 0.35). Lower scores in the SF-36 domain Mental Component Summary were associated with non-complete recovery at 4 months (B = -8.9, P = 0.01 (R(2) = 0.14). Higher FSS scores were associated with pretreatment symptom duration >6 weeks (B = 1.4, P = 0.006), high scores on the composite clinical score pretreatment (B = 0.1, P = 0.003), and non-complete recovery at 4 months (B = 1.6, P = 0.005) (R(2) = 0.46). No laboratory test results were associated with these predefined outcomes. CONCLUSIONS: Delayed treatment start, more symptoms and findings before treatment, and non-complete recovery at 4 months after treatment are possible predictors of a poorer HRQoL and more fatigue 30 months after treated LNB. We did not find age, gender, educational level, involvement of the central nervous system, coexisting diseases, or cerebrospinal fluid findings to be associated with reduced HRQoL or fatigue. Our findings should be replicated in future studies before any conclusions can be drawn.
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Fatiga/etiología , Neuroborreliosis de Lyme/complicaciones , Antibacterianos/uso terapéutico , Ceftriaxona/uso terapéutico , Doxiciclina/uso terapéutico , Europa (Continente) , Fatiga/epidemiología , Femenino , Humanos , Neuroborreliosis de Lyme/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Calidad de Vida , Factores de Riesgo , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
OBJECTIVE: Although patients >80 years were excluded in RCTs for tPA treatment of acute ischemic stroke (AIS), many centers treat old patients. We wanted to examine whether age ≥80 years is an independent predictor of outcome after tPA. MATERIALS: We included 77 consecutive patients ≥80 years and 83 patients <80 years treated with tPA within 4.5 h after onset of AIS. Baseline variables were analyzed by multiple stepwise logistic regression analyses against three outcomes: symptomatic intracerebral hemorrhage (sICH), death and good functional outcome (mRS, 0-1) at 3-month follow-up. RESULTS: Age ≥80 years was associated with increased risk of sICH (OR, 18.2 [95% CI, 1.0-324.1], P = 0.048), and death (OR, 3.3 [95% CI, 1.2-9.1], P = 0.018), but not with functional outcome at 3 months. Other factors associated with death were longer onset to treatment time (OTT) (OR, 1.007/min increase [95% CI, 1.00-1.015], P = 0.047), higher NIHSS (OR, 1.12 per point increase [95% CI, 1.04-1.19], P = 0.001), and previous stroke (OR, 4.0 [95% CI, 1.2-13.7], P = 0.03). Predictors of good functional outcome were shorter OTT (OR, 0.99 [95% CI, 0.98-1.00], P = 0.02) and lower NIHSS (OR, 0.80 [95% CI, 0.74-0.87] P ≤ 0.001). CONCLUSION: Age ≥80 years might be an independent risk factor for sICH and death the first 3 months after treatment with tPA for AIS, but does not influence the chance of a good functional outcome. We suggest to treat patients over 80 years with tPA, but be cautious if the time from onset (OTT) is long.
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Isquemia Encefálica/tratamiento farmacológico , Fibrinolíticos/uso terapéutico , Terapia Trombolítica , Activador de Tejido Plasminógeno/uso terapéutico , Enfermedad Aguda , Factores de Edad , Edad de Inicio , Anciano de 80 o más Años , Daño Encefálico Crónico/epidemiología , Daño Encefálico Crónico/etiología , Isquemia Encefálica/epidemiología , Hemorragia Cerebral/inducido químicamente , Comorbilidad , Urgencias Médicas , Femenino , Fibrinolíticos/efectos adversos , Estudios de Seguimiento , Humanos , Masculino , Noruega/epidemiología , Pronóstico , Estudios Prospectivos , Recuperación de la Función , Factores de Riesgo , Índice de Severidad de la Enfermedad , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Activador de Tejido Plasminógeno/efectos adversos , Resultado del TratamientoRESUMEN
In this review, we aim to discuss the definition, clinical and laboratory features, diagnostics, and management of chronic Lyme. Chronic Lyme is a rare condition caused by long-lasting and ongoing infection with the spirochete Borrelia burgdorferi (Bb). The most common manifestations are progressive encephalitis, myelitis, acrodermatitis chronica atrophicans with or without neuropathy, and arthritis. Chronic Lyme is not considered to present with isolated subjective symptoms. Direct detection of Bb has low yield in most manifestations of chronic Lyme, while almost 100% of the cases are seropositive, that is, have detectable Bb IgG antibodies in serum. Detection of Bb antibodies only with Western blot technique and not with ELISA and detection of Bb IgM antibodies without simultaneous detection of Bb IgG antibodies should be considered as seronegativity in patients with long-lasting symptoms. Patients with chronic Lyme in the nervous system (neuroborreliosis) have, with few exceptions, pleocytosis and production of Bb antibodies in their cerebrospinal fluid. Strict guidelines should be applied in diagnostics of chronic Lyme, and several differential diagnoses, including neurological disease, rheumatologic disease, post-Lyme disease syndrome, chronic fatigue syndrome, and psychiatric disease, should be considered in the diagnostic workup. Antibiotic treatment with administration route and dosages according to current guidelines are recommended. Combination antimicrobial therapy or antibiotic courses longer than 4 weeks are not recommended. Patients who attribute their symptoms to chronic Lyme on doubtful basis should be offered a thorough and systematic diagnostic approach, and an open and respectful dialogue.
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Enfermedad de Lyme/diagnóstico , Enfermedad de Lyme/terapia , Enfermedad Crónica , HumanosRESUMEN
PURPOSES: To chart clinical, laboratory, and psychometric profiles in patients who attribute their complaints to chronic Lyme disease. METHODS: We assessed the patients by clinical examination, laboratory tests, and questionnaires measuring fatigue, depression, anxiety, health-related quality of life, hypochondriasis, and illness perceptions. RESULTS: We found no evidence of ongoing Borrelia burgdorferi (Bb) infection in any of the 29 included patients using current diagnostic guidelines and an extended array of tests. Eight (28%) had other well-defined illnesses. Twenty-one (72%) had symptoms of unknown cause, of those six met the suggested criteria for post-Lyme disease syndrome. Fourteen (48%) had presence of anti-Bb antibodies. The patients had more fatigue and poorer health-related quality of life as compared to normative data, but were not more depressed, anxious, or hypochondriacal. Their beliefs about the illness were characterized by negative expectations. CONCLUSION: Our patients, who all attributed their symptoms to chronic Lyme disease, were heterogeneous. None had evidences of persistent Bb infection, but whether current diagnostic criteria are functional in patients with longstanding complaints is controversial. Other well-defined illnesses or sequelae from earlier Lyme disease were probable as main explanatory factor in some cases. The patients were not more depressed, anxious, or hypochondriacal than the normal population, but they had poorer health-related quality of life, more fatigue, and negative expectations about their illness.
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Enfermedad de Lyme/complicaciones , Enfermedad de Lyme/psicología , Adulto , Anciano , Anciano de 80 o más Años , Anticuerpos Antibacterianos/sangre , Enfermedad Crónica , Ensayo de Inmunoadsorción Enzimática , Femenino , Humanos , Immunoblotting , Enfermedad de Lyme/fisiopatología , Masculino , Persona de Mediana Edad , Calidad de Vida , Adulto JovenRESUMEN
BACKGROUND: The aim of this study was to compare neuropsychological (NP) functioning in patients with Lyme neuroborreliosis (LNB) 30months after treatment to matched controls. METHODS: We tested 50 patients with LNB and 50 controls with the trail-making test (TMT), Stroop test, digit symbol test, and California Verbal Learning test (CVLT). A global NP sumscore was calculated to express the number of low scores on 23 NP subtasks. RESULTS: Mean scores were lower amongst LNB-treated patients than amongst controls on tasks assessing attention/executive functions: (Stroop test 4: 77.6 vs. 67.0, P=0.015), response/processing speed (TMT 5: 23.4 vs. 19.2, P=0.004), visual memory (digit symbol recall: 6.6 vs. 7.2, P=0.038), and verbal memory (CVLT list B: 4.68 vs. 5.50, P=0.003). The proportion of patients and controls with NP sumscores within one SD from the mean in the control group (defined as normal) and between one and two SD (defined as deficit) were similar, but more LNB-treated patients than controls had a sumscore more than two SD from the mean (defined as impairment) (8 vs. 1, P=0.014). CONCLUSIONS: As a group, LNB-treated patients scored lower on four NP subtasks assessing processing speed, visual and verbal memory, and executive/attention functions, as compared to matched controls. The distribution of NP dysfunctions indicates that most LNB-treated patients perform comparable to controls, whilst a small subgroup have a debilitating long-term course with cognitive problems.
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Trastornos del Conocimiento/microbiología , Neuroborreliosis de Lyme/psicología , Adulto , Anciano , Estudios de Casos y Controles , Trastornos del Conocimiento/psicología , Europa (Continente) , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Adulto JovenRESUMEN
OBJECTIVE: To examine multiple sclerosis (MS) prevalence, rate of immunomodulatory treatment and frequency of Borrelia burgordorferi (Bb) antibodies in Vest-Agder, Norway. MATERIALS AND METHODS: Patients in the period 1996-2006 who met the Poser criteria for definitive or probable MS were included. Clinical and demographical data, and presence of Bb antibodies were registered. RESULTS: A total of 295 patients were identified. The crude prevalence was 180 per 100,000 population (95% CI=160.9-218.0), age-adjusted prevalence was 186 per 100,000 population (95% CI=166.3-225.3). The age-adjusted incidence rates were 7.5 and 8.0 for 1996-2000 and 2001-2006, respectively. Thirty-eight per cent were treated with immunomodulatory agents when compared to 28% in the rest of the country. Bb serum antibodies were detected in 7% of patients with MS. CONCLUSIONS: Vest-Agder county has the highest prevalence of MS reported in Norway, and a high treatment rate. Bb antibodies were not more prevalent than in healthy individuals.
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Neuroborreliosis de Lyme/epidemiología , Esclerosis Múltiple/tratamiento farmacológico , Esclerosis Múltiple/epidemiología , Adulto , Anticuerpos/análisis , Anticuerpos/sangre , Borrelia burgdorferi/inmunología , Comorbilidad/tendencias , Femenino , Humanos , Factores Inmunológicos/uso terapéutico , Neuroborreliosis de Lyme/inmunología , Masculino , Persona de Mediana Edad , Esclerosis Múltiple/inmunología , Noruega/epidemiología , PrevalenciaRESUMEN
OBJECTIVES: The prognosis after Lyme neuroborreliosis (LNB) is debated. The aim of this study was to assess health-related Quality of Life (QoL) and neurological symptoms 30 months after treatment in European patients with LNB. MATERIALS AND METHODS: In a prospective case-control designed study, we investigated 50 well-characterized patients with LNB who had participated in a treatment trial for LNB 30 months earlier and 50 matched control persons with the health QoL questionnaire Short-Form 36 (SF-36), the Fatigue Severity Scale (FSS), the Montgomery and Åsberg Depression Rating Scale (MADRS), the Starkstein Apathy Scale (SAS), and the Mini Mental State (MMS). Clinical and demographic data were collected by semi-structured interviews and clinical neurological examination. RESULTS: Lyme neuroborreliosis-treated patients scored lower than control persons in the SF-36 domains physical component summary (PCS) (44 vs 51 P < 0.001) and mental component summary (MCS) (49 vs 54 P = 0.010). They also scored lower than control persons in all the SF-36 subscales, except for bodily pain, and on FSS (3.5 vs 2.1 P < 0.001), but not on MMS (28 vs 29 P = 0.106). There was a difference in MADRS (3.1 vs 0. 8 P = 0.003) and SAS (13 vs 11 P = 0.016), but the scores were low in both groups. Fatigue was the most frequently reported symptom among LNB-treated patients (50%). Patients who reported complete recovery (56%) after LNB had similar QoL scores as the controls. CONCLUSION: European persons treated for LNB have poorer health-related QoL and have more fatigue than persons without LNB.
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Neuroborreliosis de Lyme/psicología , Neuroborreliosis de Lyme/terapia , Calidad de Vida/psicología , Adulto , Anciano , Estudios de Casos y Controles , Ensayos Clínicos como Asunto/tendencias , Fatiga/etiología , Fatiga/psicología , Fatiga/terapia , Femenino , Humanos , Neuroborreliosis de Lyme/complicaciones , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Encuestas y Cuestionarios , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND AND PURPOSE: To chart remaining complaints 1 year after treatment for neuroborreliosis, and to identify risk factors for a non-favorable outcome. METHODS: We followed patients treated for neuroborreliosis prospectively, and assessed outcome by a composite clinical score. The impact on outcome of clinical, demographic and laboratory factors were analyzed by univariate analyses and logistic regression. RESULTS: Out of 85 patients 41 (48%) had remaining complaints; 14 had objective findings and 27 subjective symptoms. Remaining complaints were associated with pre-treatment symptom duration >or=6 weeks (OR = 4.062, P = 0.044), high pre-treatment cerebrospinal fluid (CSF) cell count (OR = 1.005, P = 0.001), and female gender (OR = 3.218, P = 0.025). Presence of CSF oligoclonal bands (OCBs) was not analyzed in the logistic regression model due to many missing observations, but was found to be more frequent both pre-treatment (P = 0.004) and after 12 months (P = 0.015) among patients with remaining complaints as compared to patients with complete recovery. Further evaluation showed that objective remaining findings, and not subjective symptoms, were associated with pre-treatment symptom duration >or=6 weeks. No difference in outcome was observed between patients treated with IV ceftriaxone and patients treated with oral doxycycline. CONCLUSION: Remaining complaints are common after neuroborreliosis. The majority of the complaints are subjective. Pre-treatment symptom duration >or=6 weeks, high pre-treatment CSF cell count, and female gender seem to be risk factors for remaining complaints. Presence of CSF OCBs may also predict a non-favorable outcome, but this should be further studied. Whether subjective and objective complaints are associated with different risk factors is also an issue for future studies.
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Neuroborreliosis de Lyme/epidemiología , Neuroborreliosis de Lyme/fisiopatología , Adulto , Anciano , Antibacterianos/uso terapéutico , Ceftriaxona/uso terapéutico , Enfermedad Crónica/epidemiología , Comorbilidad , Doxiciclina/uso terapéutico , Femenino , Humanos , Recuento de Leucocitos/estadística & datos numéricos , Neuroborreliosis de Lyme/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Prospectivos , Factores de Riesgo , Distribución por Sexo , Tiempo , Factores de TiempoRESUMEN
BACKGROUND: Lyme neuroborreliosis (LNB) is a nervous system infection caused by Borrelia burgdorferi sensu lato (Bb). OBJECTIVES: To present evidence-based recommendations for diagnosis and treatment. METHODS: Data were analysed according to levels of evidence as suggested by EFNS. RECOMMENDATIONS: The following three criteria should be fulfilled for definite LNB, and two of them for possible LNB: (i) neurological symptoms; (ii) cerebrospinal fluid (CSF) pleocytosis; (iii) Bb-specific antibodies produced intrathecally. PCR and CSF culture may be corroborative if symptom duration is <6 weeks, when Bb antibodies may be absent. PCR is otherwise not recommended. There is also not enough evidence to recommend the following tests for diagnostic purposes: microscope-based assays, chemokine CXCL13, antigen detection, immune complexes, lymphocyte transformation test, cyst formation, lymphocyte markers. Adult patients with definite or possible acute LNB (symptom duration <6 months) should be offered a single 14-day course of antibiotic treatment. Oral doxycycline (200 mg daily) and intravenous (IV) ceftriaxone (2 g daily) are equally effective in patients with symptoms confined to the peripheral nervous system, including meningitis (level A). Patients with CNS manifestations should be treated with IV ceftriaxone (2 g daily) for 14 days and late LNB (symptom duration >6 months) for 3 weeks (good practice points). Children should be treated as adults, except that doxycycline is contraindicated under 8 years of age (nine in some countries). If symptoms persist for more than 6 months after standard treatment, the condition is often termed post-Lyme disease syndrome (PLDS). Antibiotic therapy has no impact on PLDS (level A).
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Antibacterianos/administración & dosificación , Neuroborreliosis de Lyme/diagnóstico , Neuroborreliosis de Lyme/terapia , Adulto , Factores de Edad , Anticuerpos/análisis , Anticuerpos/líquido cefalorraquídeo , Biomarcadores/análisis , Biomarcadores/líquido cefalorraquídeo , Ceftriaxona/administración & dosificación , Niño , Pruebas Diagnósticas de Rutina/métodos , Doxiciclina/administración & dosificación , Vías de Administración de Medicamentos , Europa (Continente) , Humanos , Neuroborreliosis de Lyme/líquido cefalorraquídeoRESUMEN
AIM: To evaluate hospital delays in thrombolytic treatment before and after organisational changes and community-based treatment rates in a previously inexperienced centre. METHODS: The delays before and after organisational changes made in 2006 were compared using a prospective treatment database. In a 6-month period in 2007, a community-based search was performed for all hospitalisations for ischaemic stroke. The number of patients admitted within the 0-3 h time window and the proportion treated with tissue plasminogen activator were analysed. RESULTS: The number of treatments increased fourfold from 2005 to 2007 with a significant reduction in mean door-to-needle time from 60 min to 38 min (p = 0.002). In the community-based series, 14/137 patients (10%) hospitalised with ischaemic stroke and 13/32 patients (41%) admitted in the 0-3 h window were treated. CONCLUSIONS: An inexperienced stroke centre can rapidly implement the necessary logistics to deliver thrombolysis to a large proportion of patients with acute stroke with short hospital delays. Important factors are probably prenotification of a team and the initiation of thrombolytic treatment in the emergency room.
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Isquemia Encefálica/tratamiento farmacológico , Servicios Médicos de Urgencia/organización & administración , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Atención a la Salud/organización & administración , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Noruega , Estudios Prospectivos , Factores de TiempoRESUMEN
BACKGROUND AND PURPOSE: We examined prospectively the results of withdrawal therapy in 80 patients with probable medication overuse headache. The aim was to identify baseline patient characteristics that might predict outcome after 1 year (end of study). METHODS: We classified patients according to results of withdrawal therapy measured as the improvement of headache days (HD) from baseline to end of study. RESULTS: Thirty-six per cent (29/80) had at least 50% improvement. Sixty-four per cent (51/80) had <50% improvement, and among these, 30% (24/80) had <10% improvement. The following baseline characteristics were associated with poor outcome of withdrawal therapy: use of codeine-containing drugs, low self-reported sleep quality, and high self-reported bodily pain as measured by the quality of life tool SF-36. CONCLUSION: Before suggesting withdrawal therapy, one should probably pay more close attention to sleep problems.
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Analgésicos/efectos adversos , Cefaleas Secundarias/terapia , Trastornos de Cefalalgia/inducido químicamente , Trastornos de Cefalalgia/terapia , Síndrome de Abstinencia a Sustancias , Adulto , Analgésicos Opioides/efectos adversos , Causalidad , Codeína/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Noruega , Dimensión del Dolor , Selección de Paciente , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Autoevaluación (Psicología) , Trastornos del Sueño-Vigilia/complicaciones , Tiempo , Resultado del TratamientoRESUMEN
Several studies have shown the benefit of withdrawal therapy when medication overuse headache (MOH) is suspected. Our aim was to compare the effect of withdrawal therapy in patients followed by a neurologist (group A, n = 42) and a primary care physician (PCP) (group B, n = 38). Patients were randomized to A or B, and follow-up was at 3, 6 and 12 months. Calculated mean headache (MH at 6 months + MH at 12 months)/2 (primary end-point) was similar; A 1.04 (0.87, 1.21) and B 1.02 (0.82, 1.21) (P = 0.87). The number of patients with 50% improvement of headache days was also similar; 14/42 in group A vs. 12/34 in B (P = 0.86) at 3 months, 15/42 vs. 11/33 (P = 0.83) at 6 months and 15/42 vs. 14/38 (P = 0.92) at 12 months. Days without headache during the last 9 months of follow-up were 123 (96, 150) in group A and 137 (112, 161) in B (P = 0.62). After 3 months one-third were classified as MOH. Patients with MOH improved similarly in group A and B, and so did patients without MOH. Within 1 year 7/42 in A and 9/38 in B had recurrent medication overuse (P = 0.43). In summary, there were no significant differences in follow-up results between the two groups.
Asunto(s)
Trastornos de Cefalalgia/prevención & control , Neurología/estadística & datos numéricos , Satisfacción del Paciente/estadística & datos numéricos , Médicos de Familia/estadística & datos numéricos , Trastornos Relacionados con Sustancias/prevención & control , Privación de Tratamiento/estadística & datos numéricos , Adulto , Comorbilidad , Femenino , Estudios de Seguimiento , Trastornos de Cefalalgia/diagnóstico , Trastornos de Cefalalgia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Noruega/epidemiología , Dimensión del Dolor/efectos de los fármacos , Dimensión del Dolor/estadística & datos numéricos , Prevalencia , Trastornos Relacionados con Sustancias/epidemiología , Resultado del TratamientoRESUMEN
Recent studies have suggested a diagnostic role of the B-lymphocyte attracting chemokine (CXCL13) in the cerebrospinal fluid (CSF) in Lyme neuroborreliosis (LNB). Our aim was to evaluate diagnostic accuracy of CSF CXCL13 in a cohort of 59 consecutive patients referred to hospital for suspected LNB. Thirty-seven patients were classified as definite LNB and used as the reference standard. Seven were classified as probable, and seven as possible LNB. Eight patients did not fulfil case definitions and were used as controls.At presentation, CSF CXCL13 was elevated in all patients with definite LNB, as compared to a positive CSF B. burgdorferi (Bb) antibody index (AI) in 33 of 37. Pre-treatment sensitivity of elevated CSF CXCL13 and positive CSF Bb AI was 100 % (95 % CI = 91-100) and 78 % (95 % CI = 75-96) respectively (p = 0.053).Among the eight control patients, CSF CXCL13 was normal in five and only slightly elevated in three, and Bb AI was negative in five. Specificity of CSF CXCL13 and Bb AI was similar 63 % (95 % CI = 31-86) (p = 1.0).CSF CXCL13 was elevated in 6/7 patients with probable LNB and 3/7 patients with possible LNB. Bb AI was negative in all these 14 patients.An additional control group consisted of 31 patients with multiple sclerosis (MS), 11 with non-inflammatory neurological diseases, and ten with verified non-Lyme meningitis and high CSF cell count. CSF CXCL13 was slightly elevated in 15 MS patients, and in nine meningitis patients. Mean CSF CXCL13 was higher in definite LNB (3524 ng/g CSF protein) than in MS (27 ng/g) and non-Lyme meningitis (23 ng/g) (p < 0.001).Four months post-treatment CSF CXCL13 was normalized in 82 % of patients with definite LNB, as compared to a negative Bb AI in 10 % (p < 0.001).CSF CXCL13 may be a useful supplement in early diagnosis of acute LNB.
RESUMEN
The aim of the study was to examine diagnostic sensitivity and temporal course of intrathecal Borrelia burgdorferi (Bb) antibody production in acute Lyme neuroborreliosis (LNB). We recruited consecutive adult patients with LNB diagnosis based on strict selection criteria. Serum and cerebrospinal fluid (CSFs) were obtained, and clinical examination was performed pre-treatment, and 13 days and 4 months post-treatment. Pre-treatment positive Bb antibody index (AI) was detected in 34 of 43 (79%). All nine pre-treatment Bb AI negative patients, and 26 of 34 pre-treatment Bb AI positive patients reported symptom duration <6 weeks. Eight patients, all Bb AI positive, reported symptom duration of 6 weeks or longer. Consequently, pre-treatment diagnostic sensitivity of Bb AI was 74% when symptom duration was <6 weeks, and 100% when 6 weeks or longer. Three patients converted from negative to positive Bb AI status post-treatment. The six patients who were persistently Bb AI negative had lower CSF cell count and protein at presentation, when compared with the patients with positive Bb AI. In conclusion, the diagnostic sensitivity of Bb AI is suboptimal in acute early LNB. Repeated post-treatment Bb AI testing, to confirm or reject LNB diagnosis, is unreliable, as the majority of initial Bb AI negative patients remained negative at follow-up.
Asunto(s)
Anticuerpos/análisis , Anticuerpos/líquido cefalorraquídeo , Líquido Cefalorraquídeo/inmunología , Neuroborreliosis de Lyme/líquido cefalorraquídeo , Neuroborreliosis de Lyme/diagnóstico , Adulto , Antibacterianos/administración & dosificación , Anticuerpos/sangre , Borrelia burgdorferi/inmunología , Líquido Cefalorraquídeo/citología , Diagnóstico Precoz , Reacciones Falso Negativas , Femenino , Humanos , Neuroborreliosis de Lyme/inmunología , Linfocitos/inmunología , Linfocitos/microbiología , Masculino , Persona de Mediana Edad , Valor Predictivo de las PruebasRESUMEN
The purpose of this study was to evaluate the diagnostic sensitivity and specificity of a commercial C6 enzyme immuno assay, QuickC6, in acute Lyme neuroborreliosis (LNB) in endemic areas. Paired sera and cerebral spinal fluids (CSFs) from 60 patients with definite LNB, eight patients with possible LNB, 18 patients with conditions mimicking LNB and 42 persons with noninfectious neurological disease were examined. The case definition of LNB was based on strict criteria during a prospective 4-month follow-up. The sensitivity of QuickC6 was 98% both in sera and CSFs, and the diagnostic specificity was 61% in sera and 88% in CSFs. QuickC6 is a sensitive, simple and cost-effective screening test in serum and CSF in diagnosis of acute LNB. Specificity needs further evaluation.
Asunto(s)
Técnicas para Inmunoenzimas/métodos , Neuroborreliosis de Lyme/diagnóstico , Anticuerpos Antibacterianos/sangre , Anticuerpos Antibacterianos/líquido cefalorraquídeo , Humanos , Neuroborreliosis de Lyme/sangre , Neuroborreliosis de Lyme/líquido cefalorraquídeo , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: A sensitive method to detect intrathecal IgG production is important in diagnosing inflammatory central nervous system (CNS) diseases, including multiple sclerosis (MS). OBJECTIVE: To compare cerebrospinal fluid (CSF) electrophoresis with isoelectric focusing (IEF), immunofixation-peroxidase electrophoresis (IFPE) and high-resolution agarose electrophoresis with protein-staining (HRAGE). METHODS: Paired serum and CSF samples from 307 consecutive patients attending a general neurology clinic were examined with IEF, IFPE and HRAGE. Clinical diagnosis was based on review of the patients' medical records after an average of 4 years. RESULTS: The sensitivity for detecting any inflammatory (autoimmune or infectious) CNS disease (52 patients) was 67% for IEF, 50% for IFPE and 29% for HRAGE. The sensitivity for detecting MS (14 patients) was 93%, 86% and 29% respectively. The sensitivity for detecting clinically isolated syndrome (eight patients) was 75%, 25% and 13% respectively. The number of oligoclonal bands in IEF was higher in inflammatory than in non-inflammatory neurological diseases or symptoms, but similar in MS and other inflammatory diseases. CONCLUSION: IEF is the method of choice in diagnosing intrathecal IgG synthesis.