Intravenous thrombolysis for patients with in-hospital stroke onset: propensity-matched analysis from the Safe Implementation of Treatments in Stroke-East registry.

BACKGROUND AND PURPOSE: Recent cross-sectional study data suggest that intravenous thrombolysis (IVT) in patients with in-hospital stroke (IHS) onset is associated with unfavorable functional outcomes at hospital discharge and in-hospital mortality compared to patients with out-of-hospital stroke (OHS) onset treated with IVT. We sought to compare outcomes between IVT-treated patients with IHS and OHS by analysing propensity-score-matched data from the Safe Implementation of Treatments in Stroke-East registry. METHODS: We compared the following outcomes for all propensity-score-matched patients: (i) symptomatic intracranial hemorrhage defined with the safe implementation of thrombolysis in stroke-monitoring study criteria, (ii) favorable functional outcome defined as a modified Rankin Scale (mRS) score of 0-1 at 3 months, (iii) functional independence defined as an mRS score of 0-2 at 3 months and (iv) 3-month mortality. RESULTS: Out of a total of 19 077 IVT-treated patients with acute ischaemic stroke, 196 patients with IHS were matched to 5124 patients with OHS, with no differences in all baseline characteristics (P > 0.1). Patients with IHS had longer door-to-needle [90 (interquartile range, IQR, 60-140) vs. 65 (IQR, 47-95) min, P < 0.001] and door-to-imaging [40 (IQR, 20-90) vs. 24 (IQR, 15-35) min, P < 0.001] times compared with patients with OHS. No differences were detected in the rates of symptomatic intracranial hemorrhage (1.6% vs. 1.9%, P = 0.756), favorable functional outcome (46.4% vs. 42.3%, P = 0.257), functional independence (60.7% vs. 60.0%, P = 0.447) and mortality (14.3% vs. 15.1%, P = 0.764). The distribution of 3-month mRS scores was similar in the two groups (P = 0.273). CONCLUSIONS: Our findings underline the safety and efficacy of IVT for IHS. They also underscore the potential of reducing in-hospital delays for timely tissue plasminogen activator delivery in patients with IHS.

Long-chain polyunsaturated fatty acid status in obesity: a systematic review and meta-analysis.

Long-chain polyunsaturated fatty acid (LCPUFA) status has recently been related to the pathogenesis of obesity. Our aims were to systematically review observational studies investigating LCPUFA status from different blood compartments in overweight or obese subjects and to assess the relationship between LCPUFA profile and obesity. The Ovid MEDLINE, Scopus and Cochrane Library CENTRAL databases were searched from inception to January 2014. The meta-analysis showed significant differences in the LCPUFA composition of total plasma lipids, plasma phospholipids and plasma cholesteryl esters between overweight or obese subjects and controls. Dihomo-γ-linolenic acid (DGLA) values were significantly higher in overweight or obese subjects compared with controls in all the investigated biomarkers. In addition, the DGLA/linoleic acid ratio (surrogate parameter for Δ6 desaturase activity) in plasma phospholipids was significantly elevated (mean difference [MD]: 0.05; 95% confidence interval [CI]: 0.02, 0.08; n = 280), while the arachidonic acid/DGLA ratio (surrogate parameter for Δ5 desaturase activity) was significantly decreased (MD: -0.55; 95% CI: -0.71, -0.39; n = 347) in overweight or obese subjects compared with controls. The results of the present meta-analysis confirm that LCPUFA profile is altered in obesity and suggest that the differences observed in desaturase activities may be responsible for the disturbed LCPUFA metabolism in obesity.

Benefit of thrombolysis for stroke is maintained around the clock: results from the SITS-EAST Registry.

BACKGROUND AND PURPOSE: The outcome of thrombolysis for early morning and sleep time strokes may be worse because of uncertainty of stroke onset time or differences in logistics. The aim of the study was to analyze if stroke outcome after intravenous thrombolysis differs depending on time of day when the stroke occurs. METHODS: The data collected in the Safe Implementation of Treatments in Stroke - Eastern Europe (SITS-EAST) Registry between September 2000 and December 2011 were used. Strokes were categorized as night-time 00:00-07:59, day-time 08:00-15:59 and evening-time 16:00-23:59 and were compared in terms of several outcome measures. All results were adjusted for baseline differences. RESULTS: A total of 8878 patients were enrolled: 18% had night-time, 54% day-time and 28% evening-time strokes. Onset-to-treatment time in patients with night-time strokes was 10 min longer than in day-time and evening-time strokes (P < 0.001). Symptomatic intracerebral hemorrhage by ECASS II definition occurred in 5.6%, 5.6% and 5.3% (adjusted P = 0.41) of the night-time, day-time and evening-time stroke patients, respectively; by SITS definition it occurred in 2.5%, 1.9% and 1.3% (adjusted P = 0.013) and by NINDS definition in 7.8%, 7.6% and 7.5% (adjusted P = 0.74). Patients with night-time, day-time and evening-time strokes achieved modified Rankin Scale score 0-1 in 33%, 31%, 31% (adjusted P = 0.34) and 0-2 in 52%, 51%, 50% (adjusted P = 0.23), and 13%, 15%, 16% respectively of patients died (adjusted P = 0.17) by 3 months. CONCLUSIONS: The time when stroke occurs (day versus evening versus night) does not affect the outcome after thrombolysis despite the fact that patients with night-time strokes have worse time management.

The Debrecen Stroke Database: demographic characteristics, risk factors, stroke severity and outcome in 8088 consecutive hospitalised patients with acute cerebrovascular disease.

BACKGROUND: High stroke mortality in central-eastern European countries might be due to higher stroke incidence, more severe strokes or less effective acute care than in countries with lower mortality rate. Hospital databases usually yield more detailed information on risk factors, stroke severity and short-term outcome than population-based registries. PATIENTS AND METHODS: The Debrecen Stroke Database, data of 8088 consecutively hospitalised patients with acute cerebrovascular disease in a single stroke centre in East Hungary between October 1994 and December 2006, is analysed. Risk factors were recorded and stroke severity on admission was scored by the Mathew stroke scale. The modified Glasgow outcome scale was used to describe patient condition at discharge. RESULTS: Mean age was 68+/-13 years, 11.4% had haemorrhagic stroke. The rate of hypertension on admission was 79% in men, and 84% in women, 40.3% of men and 19.8% of women were smokers, and 34% of all patients had a previous cerebrovascular disease in their history. Case fatality was 14.9%, and 43% had some disability at discharge. Outcome at discharge was worse with higher age, higher glucose, higher blood pressure, higher white cell count and erythrocyte sedimentation rate and more severe clinical signs on admission. In multivariate analysis admission blood pressure lost its significance in predicting outcome. CONCLUSIONS: In this large Hungarian stroke unit database hypertension on admission, smoking and previous cerebrovascular disease were more frequent than in most western databases. These findings indicate major opportunities for more efficient stroke prevention in this and probably other eastern European countries.

Rapid 'glycaemic swings' induce nitrosative stress, activate poly(ADP-ribose) polymerase and impair endothelial function in a rat model of diabetes mellitus.

AIM/HYPOTHESIS: Postpandrial hyperglycaemia is a significant risk factor for the development of macrovascular diseases. There is no clear agreement in the field whether these alterations result from hyperglycaemic episodes or from exaggerated alterations ('glycaemic swings') in blood glucose. We compared the effect of stable high glucose with a model of poorly maintained insulin-controlled diabetes (on average lower glucose, but with large glycaemic swings) on the development of endothelial dysfunction in rats. METHODS: Intermediate- or long-acting insulin was used to reduce mean blood glucose levels. One group of animals had stable low glucose levels, while animals in the other group exhibited rapid changes ('swings') in their blood glucose concentration. Acetylcholine-induced endothelium-dependent vascular relaxation of the thoracic aorta was measured. Immunohistochemistry, western blot analysis and flow cytometry were used to determine nitrotyrosine formation and poly(ADP-ribose) accumulation in the aorta, in circulating leucocytes and in bone marrow cells. RESULTS: Steady normalisation of blood glucose levels (a model of well-controlled diabetes) protected against the development of endothelial dysfunction, poly(ADP-ribose) polymerase (PARP) activation and nitrotyrosine production. However, impairment of endothelium-dependent relaxation was found in the animals undergoing glycaemic swings, even though the fructosamine levels in these animals were lower than in the untreated diabetic rats. This was associated with elevated PARP activation in the aorta and in bone marrow cells that was similar to or even more pronounced than that seen in the untreated diabetic animals. CONCLUSIONS/INTERPRETATION: Large glycaemic swings exert deleterious cardiovascular effects in diabetes mellitus, in part via enhanced activation of the PARP pathway.

[Diffusing capacity for carbon monoxide (T(LCO)) and oxygen saturation during exercise in patients with cystic fibrosis]. / Capacité de transfert du monoxyde de carbone (TLCO) et saturation artérielle à l'exercice chez les patients atteints de mucoviscidose.

OBJECTIVES: To estimate the value of diffusing capacity for carbon monoxide (T(LCO)) in patients with cystic fibrosis and to evaluate its ability to predict arterial desaturation during exercise. METHOD: Fourty-four patients (9-30 years) with cystic fibrosis performed pulmonary function tests with measure of T(LCO) and a bicycle incremental exercise test. They represent a wide variation in disease severity: mean Shwachman score: 77.8 (range: 40-100), mean FEV1%: 72.8 (range: 17-131). This study investigated the relationship between T(LCO), lung volumes and exercise data. RESULTS: T(LCO) remained normal for a long time in patients with cystic fibrosis: 82% of them show a normal T(LCO) (mean value: 91.3% of predicted). T(LCO) was significantly correlated with FEV(1), residual volume, maximal work load and maximum oxygen uptake. A fall in arterial oxygen saturation was uncommon in our study (five patients) and not significantly correlated with T(LCO). CONCLUSIONS: T(LCO) is a good criter of severity of cystic fibrosis but remains unreliable to predict values above which physical activity is safe, without arterial desaturation. Exercise tests should be proposed in order to evaluate exercise adaptation of each patient and determine which factor limits maximal performance.

[Spontaneous resolution of a giant pulmonary bulla]. / Disparition spontanée d'une bulle géante.

There are different causes leading to formation of pulmonary bullae, in particular tuberculosis. There is some debate concerning the pathophysiology of bullae extension although two mechanisms are put forward: partial obstruction of the airways and elastic recoil of adjacent lung parenchyma with a negative pressure in the bullae. Pulmonary function tests are highly perturbed in patients with giant bullae. The natural history of bullae is enlargement although spontaneous regression is rarely described. Bullae should be resected in selected patients, others require careful follow-up. We present the case of a man with tuberculosis who developed a giant pulmonary bulla that regressed spontaneously in a few years.

[Minimally invasive screw fixation of the intracapsular femoral neck fracture in elderly patients]. / Die minimal-invasive Schraubenosteosynthese der medialen Schenkelhalsfraktur bei betagten Patienten.

INTRODUCTION: Increasing life expectancy is associated with an increase of geriatric fractures such as intracapsular femoral neck fractures. Their treatment by arthroplasty imposes a significant burden on our health care system. METHODS: In an open clinical study we investigated the complication rate of a less expensive and less invasive, femoral head saving operative procedure. Between June 1997 and June 2000, 205 intracapsular femoral neck fractures of elderly patients (mean age 78.1 +/- 11.8 years) were fixed with cannulated screws. RESULTS: Seventy-seven percent were displaced fractures and 15.6% were impacted Garden I fractures. Reoperation after internal fixation occurred in 38 patients. The most frequent cause of reoperation was secondary arthroplasty due to redisplacement (14x), femoral head necrosis (10x) and non-union (7x). Implant removal (4x), wound hematoma (1x) and femoral head penetration by screws (2x) were other causes for reoperation. CONCLUSION: Less invasive cannulated screw fixation of intracapsular femoral neck fractures should be considered as a treatment option, because it is a smaller and less expensive operation than prosthetic replacement. Adequate reduction and screw placement, however, are a prerequisite for successful outcome.

[Early diagnosis and management of femur head necrosis in young adult age]. / A fiatal felnöttkori combfejelhalás korai felismerése és gyógyítása.

There are a lot factors in the genesis of the ischemic femoral head necrosis. In the early stage the intraosseous pressure increases without any clinical or radiological sign. The disease is often bilateral. The early diagnosis (NMR) is essential in the treatment. In the case of a severe femoral head necrosis the radiological investigation of the other side is obligatory, in order to diagnose the early stage of the disease and to prevent the progression of the collapse with core decompression. The object of the adequate treatment of the collapsed femoral head is to release the pain and to avoid the total destruction of the femoral head. The untreated femoral head necrosis results in a painful, arthritic hip, where spontaneous regeneration is limited, and takes 8-10 years. With osteotomy and revascularisation the results are good, and the regeneration takes about 2-3 years. As a result of this treatment, the patients have a moderately limited function, and minimal limping. Rehabilitation is possible into the original profession, or into a somewhat easier job. Remodellation of the femoral head in younger patients following the revascularisation procedure has been observed in our experience in the last few years.

Non-operative or operative treatment for undisplaced femoral neck fractures: a comparative study of 122 non-operative and 125 operatively treated cases.

We present a series of 247 undisplaced femoral neck fractures, of which 122 were primarily treated non-operatively, and 125 with primary operative stabilization. The background parameters did not differ significantly in the two groups. The length of hospitalization was 1 week shorter in the operatively treated group. They started to walk bearing full weight at an average of 11 days earlier. Two-thirds of the operatively treated but only one-quarter of the non-operatively treated patients were able to walk alone when they left hospital. General complications were recorded in 19 of the non-operatively and in four of the operatively treated patients during their hospitalization. Early displacement (within 6 weeks) was noted in 20 per cent of the non-operatively treated patients who required late operation. However, there was no early displacement in the operatively treated group. We therefore recommend primary operative stabilization of undisplaced femoral neck fractures.

[Is remodeling still possible after collapse in femur head necrosis?]. / Ist die Remodellierung nach Kollaps bei Hüftkopfnekrose doch möglich?

A case of a femoral head necrosis, with collapsed joint surface after fracture of the femoral neck will be presented. Following varisation osteotomy, the necrotic parts of the bone was removed and filled with cancellous bone. A standardized bone block of the iliac crest was implanted into the hole. After the operation the patient was painfree. The X-rays showed the improvement of the bony structure and later a spherical remodeling of the femoral head. This result is in opposition with the earlier opinion of the disability of femoral head remodeling in adults. It is technically very important to pack tight the hole in the femoral head with cancellous bone chips after necrectomy, and to ensure the revascularisation with vascularised bone block.

[Osteosynthesis of femoral neck fractures by double-cannulated screws (preliminary report)]. / A combnyaktörés osteosynthesise két cannulalt (furatos) csavarral. (Elözetes jelentés).

Authors report on a new osteosynthesis based on the double nailing of femoral neck fracture and screwing, and developed from the "Uppsala" double screwing. The preliminaries of the double cannulated screwing method, its advantages, the experiences gained in 30 cases operated in one year and the early results are described.

[Management of inveterate Monteggia-injuries (role of the interosseous membrane)]. / A nem friss Monteggia-sérülés kezelése (a membrana interossea szerepe).

Authors give a literary review of the pathomorphology and distribution of the Monteggia injuries. The necessity of the correct reduction of the ulna and the role of the interosseous membrane, the strength of which is able alone to eliminate the luxation of the radial head and to keep it on its proper place, are underlined and stressed. With the demonstration of a 9 week old injury it is proven: it is possible to restore the severely damaged elbow function with an adequate operative treatment.

[Bilateral fractures of the proximal end of the radius]. / Kétoldali proximális radiusvég törések.

Authors describe in connection with two cases of their own the vulnerability of the elbow joint originating from the physiological valgus position of this joint, i.e. the effect of the so-called "valgus stress". In the available literature no description of bilateral synchronous fracture of the radial head was found. They think, because of the bilateral injury, the correct operative therapy with the aim of reaching whole function, the stable osteosynthesis promising good result even in the fracture of the radial neck with major dislocation allowing also an early functional treatment, important.

[Management of pseudarthrosis of the olecranon]. / Az olecranon álízület kezelése.

Authors briefly summarized the classification, the causes and origin of the pseudoarthroses. The pseudoarthrosis of the olecranon may play an important role in the development of the disturbances of the movement in the elbow joint. In connection with 3 cases of their own the possibilities to restore the badly damaged joint and to eliminate function disturbances are demonstrated.

[Significance of the fracture type for treatment of femoral neck fractures]. / Die Bedeutung der Bruchform für die Behandlung der Schenkelhalsfrakturen.

The authors report on the results obtained with surgical treatment of 470 femoral neck fractures, which they analyzed with reference to the type of break. The found that a fracture line with a zig-zag course signified the best prognosis for both healing and stability, whereas fractures with a posterior fragment had a poorer prognosis. The results support the urgency of the operation and confirm the higher proportion of cases treated for jagged fractures among those with good results.

Significance of urgent (within 6h) internal fixation in the management of fractures of the neck of the femur.

The value of internal fixation of fractures of the neck of the femur within 6 h was assessed in a review of a 3-year series. Three groups were compared, in which the operation was performed within 6 h, between 6 and 24 h and after 24 h respectively. The time and quality of union and the incidence of collapse of the head of the femur were significantly better in the first group. The difference in the results between the other two groups was not significant. In view of these data the authors recommend the internal fixation of fractures of the neck of the femur within 6 h.