Quality monitoring of acute stroke care in Rhineland-Palatinate, Germany, 2001-2006.

BACKGROUND AND PURPOSE: Quality monitoring projects are useful tools to improve the quality and to assess temporal trends of stroke care in larger populations. METHODS: In Rhineland-Palatinate, Germany, a statewide, hospital-based, acute stroke care quality monitoring project was started in 2001. Initially, participation was mandatory for all hospitals with dedicated stroke units and from 2006 onward was mandatory for all hospitals. Quality monitoring included a structured data assessment and quality indicators for procedural measures. RESULTS: Between 2001 and 2006, the numbers of patients registered annually (N=6389 vs N=10 610), admission <3 hours after stroke onset (28.2% vs 34.6%), admission via emergency medical systems (38.1% vs 50.3%), and treatment in stroke units (44.3% vs 59.5%) increased significantly (P<0.0001, respectively). In ischemic stroke, use of thrombolytic therapy increased (for patients admitted <3 hours after onset, 6.5% vs 14.1%), whereas therapy with high-dose heparin declined (24.5% vs 6.0%, P<0.0001). Several quality indicators (performance of neuroimaging and Doppler/duplex sonography, neuroimaging <3 hours after admission) showed stable results at a high level; more patients received echocardiography (62.2% vs 74.0%), but fewer patients were rapidly examined by extracranial Doppler/duplex sonography (68.7% vs 62.8%, P<0.0001). Diagnosis and treatment of hypertension and hyperlipidemia, use of aspirin and combined aspirin/dipyridamole, and diagnosis of atrial fibrillation increased (P<0.0001, respectively). Use of oral anticoagulation remained stable at approximately 38% of patients with cardioembolism. CONCLUSIONS: Although these results reflect high standards of acute stroke care and improvements regarding early admission, thrombolytic therapy, and several secondary preventive measures, there is still the potential for further improvement regarding thrombolysis, use of oral anticoagulation and statins, and admission to stroke units, for example.

Neurological symptoms accompanying urinary tract infections.

The spectrum of para-infectious neurological symptoms was examined by a retrospective study of 57 patients admitted with acute neurological symptoms which were eventually interpreted as secondary to urinary tract infection. The symptoms encountered most frequently were confusion, gait disturbances, and drowsiness. Patients with Parkinson's disease, multiple sclerosis or a previous stroke often experienced a deterioration of their preexisting neurological deficits. We suggest that para-infectious encephalopathy (PE) is a mild form of septic encephalopathy with a distinct clinical pattern.

Prevalence of taste disorders in idiopathic and B. burgdorferi-associated facial palsy.

The frequency of taste disorders in idiopathic facial palsy (IFP) and B. burgdorferi-associated facial palsy (BFP) was retrospectively assessed in a cohort of patients with acute peripheral facial palsy (AFP). A significant (>10/microl) CSF pleocytosis was found in 17% of the patients who underwent lumbar puncture for AFP. In two centres, 26 patients with BFP were identified by CSF and serological criteria. The control group (patients with IFP) consisted of 59 patients from one of the centres in whom BFP was excluded by CSF examination. AFP patients of both centres are routinely questioned about taste disorders according to the hospitals' standards. A taste disorder was found in 46% of the IFP and 31% of the BFP cases (not significant). About one-third of the BFP patients complained of radicular or back pain. We conclude that a history of taste disorder is not helpful in distinguishing clinically between BFP and IFP.

Anisotropy of callosal motor fibers in combination with transcranial magnetic stimulation in the course of motor development.

OBJECTIVES: The corpus callosum (CC) represents a key structure for hand motor development and is accessible to investigation by diffusion tensor magnetic resonance imaging (DTI) and transcranial magnetic stimulation (TMS). To identify quantifiable markers for motor development, we combined DTI with TMS. MATERIALS AND METHODS: We examined groups of 11 healthy preschool-aged children, 10 healthy adolescents, and 10 healthy adults with both, DTI and TMS/ipsilateral silent period (iSP). DTI-values for fractional anisotropy (FA) were calculated for areas I to V of the CC. ISP-values for latency, duration, and extent of electromyography suppression were calculated. RESULTS: FA was significantly lower in areas II to IV of the CC in children as compared with adults (P < 0.05). In area III, where callosal motor fibers cross the CC, FA differed significantly between children and adolescents (P < 0.05). TMS parameters demonstrated significant age-related differences in duration and extent of iSP (P < 0.05). No significant differences were detected regarding latency of iSP. CONCLUSIONS: The maturation of callosal motor fiber connectivity seems to reflect the degree of interhemispheric inhibition between the motor cortices with anisotropy of callosal motor fibers being a potential marker for motor development.

A girl with headache, confusion and green urine.

The case of a 17-year-old girl with a history of headache, blurred vision, confusion, ataxia and syncope is presented. On admission, she had already recovered except for a slurring of speech. Her urine was found to be green. Screening for illegal drugs was negative, but gas chromatography with subsequent mass spectroscopy (GC-MS) revealed an extremely high concentration of flupirtine.

Canalicular magnetic stimulation lacks specificity to differentiate idiopathic facial palsy from borreliosis in children.

OBJECTIVE: To investigate the role of transcranial magnetic stimulation (TMS) to differentiate between idiopathic facial nerve palsy (iFNP) and facial nerve palsy due to borreliosis (bFNP). PATIENTS AND METHODS: Transcranial and intracanalicular magnetic and peripheral electrical stimulation of the facial nerve together with clinical grading according to the House and Brackmann scale were performed in 14 children and adolescents with facial palsy (median age 11.5 yr, range 4.6-16.5 yr). Serum and cerebrospinal fluid (CSF) were evaluated for antibodies against Borrelia burgdorferi and CSF cell count, glucose and protein content were screened with methods of routine laboratory testing. Data of patients were compared with normal values established in 10 healthy subjects (median age 10.2 yr, range 5.1-15.3 yr). RESULTS: Patients with iFNP showed a significant decrease in MEP amplitude to canalicular magnetic stimulation compared with healthy controls (p=0.03). However, MEP amplitude did not discriminate sufficiently between the two groups, because the ranges of dispersion of MEP amplitudes overlapped. Patients with bFNP had normal MEP amplitudes to canalicular magnetic stimulation compared with normal subjects. CONCLUSION: Diagnostic assessment by TMS failed to provide a reliable diagnostic criterion for distinguishing between iFNP and bFNP in children and adolescents.