Statistical analysis plan for the multicenter, open, randomized controlled clinical trial to assess the efficacy and safety of intravenous tirofiban vs aspirin in acute ischemic stroke due to tandem lesion, undergoing recanalization therapy by endovascular treatment (ATILA trial).

RATIONALE: In-stent reocclusion after endovascular therapy has a negative impact on outcomes in acute ischemic stroke (AIS) due to tandem lesions (TL). Optimal antiplatelet therapy approach in these patients to avoid in-stent reocclusion is yet to be elucidated. AIMS: To assess efficacy and safety of intravenous tirofiban versus intravenous aspirin in patients undergoing MT plus carotid stenting in the setting of AIS due to TL. SAMPLE SIZE ESTIMATES: Two hundred forty patients will be enrolled, 120 in every treatment arm. METHODS AND DESIGN: A multicenter, prospective, randomized, controlled (aspirin group), assessor-blinded clinical trial will be conducted. Patients fulfilling the inclusion criteria will be randomized at MT onset to the experimental or control group (1:1). Intravenous aspirin will be administered at a 500-mg single dose and tirofiban at a 500-mcg bolus followed by a 200-mcg/h infusion during the first 24 h. All patients will be followed for up to 3 months. STUDY OUTCOMES: Primary efficacy outcome will be the proportion of patients with carotid in-stent thrombosis within the first 24 h after MT. Primary safety outcome will be the rate of symptomatic intracranial hemorrhage. DISCUSSION: This will be the first clinical trial to assess the best antiplatelet therapy to avoid in-stent thrombosis after MT in patients with TL. TRIAL REGISTRATION: The trial is registered as NCT05225961. February, 7th, 2022.

Safety and efficacy of tirofiban in acute ischemic stroke due to tandem lesions undergoing mechanical thrombectomy: A multicenter randomized clinical trial (ATILA) protocol.

Background: In-stent thrombosis after mechanical thrombectomy (MT) worsen outcomes in acute ischemic stroke (AIS) due to tandem lesions (TL). Although an optimal antiplatelet therapy is needed, the best approach to avoid in-stent thrombosis is yet to be elucidated. Hypothesis: Low-dose intravenous tirofiban is superior to intravenous aspirin in avoiding in-stent thrombosis in patients undergoing MT plus carotid stenting in the setting of AIS due to TL. Methods: The ATILA-trial is a multicenter, prospective, phase IV, randomized, controlled (aspirin group as control), assessor-blinded clinical trial. Patients fulfilling inclusion criteria (AIS due to TL, ASPECTS ⩾ 6, pre-stroke modified Rankin Scale ⩽2 and onset <24 h) will be randomized (1:1) at MT onset to experimental (intravenous tirofiban) or control group (intravenous aspirin). Intravenous aspirin will be administered at a 500 mg single dose and tirofiban at a 500 µg bolus followed by a 200 µg/h infusion during first 22 h. All patients will be followed up to 3 months. Sample size estimated is 240 patients. Outcomes: The primary efficacy outcome is the proportion of patients with carotid in-stent thrombosis within the first 24 h after MT. The primary safety outcome is the rate of symptomatic intracranial hemorrhage. Secondary outcomes include functional independence defined as modified Rankin Scale 0-2, proportion of patients undergoing rescue therapy due to in-stent aggregation during MT and carotid reocclusion at 30 days. Discussion: ATILA-trial will be the first clinical trial regarding the best antiplatelet therapy to avoid in-stent thrombosis after MT in patients with TL. Trial registration: NCT0522596.

Predictive Factors for Stroke and TIA Following Carotid Artery Stenting.

PURPOSE: Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. The aim of the present study was to explore independent risk factors to predict cerebrovascular events following CAS to identify high-risk patients and improve the safety of CAS in this population. MATERIALS AND METHODS: HISPANIAS is a national prospective multicenter study that included 14 hospitals that collected data from patients who underwent CAS. We analyzed morbidity and mortality within 30 days after CAS, looking for factors that might be associated with cerebrovascular events (stroke and transient ischemic attack [TIA]). RESULTS: The HISPANIAS cohort included 757 patients: 80.32% were men, the mean age was 70.73 years, and 82.96% underwent symptomatic CAS. Cerebrovascular complications occurred in 42 patients (5.6%), including TIA in 24 patients (70.8% ipsilateral; mean 2.79 days after CAS) and stroke in 18 patients (72.2% ipsilateral; mean 6.72 days after CAS). The main independent clinical predictors of stroke/TIA identified by logistic regression were female sex (odds ratio [OR] 2.29, 95% CI 1.15-4.54) and diabetes (OR 3.29, 95% CI 1.71-6.40). Survival analysis showed that diabetic women, compared with the rest of the patients, had a higher number of events concentrated mainly in the first days after the intervention (p=0.003). CONCLUSION: Cerebrovascular ischemic complications after CAS continue to be a challenge for the management of these patients. Although there are other factors, female sex and the presence of diabetes are emerging as strong risk factors for the development of complications after symptomatic CAS. CLINICAL IMPACT: Carotid artery stenting (CAS) is an effective and minimally invasive method for the treatment of extracranial carotid artery stenosis. Although CAS has been regarded as a reliable and safety approach, some studies reported that CAS was associated with a higher risk of procedure-related stroke. Cerebrovascular complications after CAS continue to be a main problem and a challenge for the management of these patients. Therefore, it is essential to identify the factors involved in the development of these complications. Our study shows that the combination of female sex and diabetes is associated with a clearly worse outcome, with a greater number of events concentrated mainly in the first days. This is different from other studies that have explored each factor separately. It would be interesting to perform separate interventions for this group given the increased risk of complications.

Comparing data from thrombectomy in m2 occlusion and proximal middle cerebral artery.

INTRODUCTION: Mechanical thrombectomy for large vessel occlusion in the anterior circulation has been shown to be beneficial. The question of whether this technique is safe and effective in the distal vasculature remains unanswered. We wanted to compare outcome data from mechanical thrombectomy of M2 branches of the middle cerebral artery (MCA) with those of the M1 segment, and better understand the clinical predictors of these M2 occlusions. METHODS: A retrospective analysis was performed of data prospectively collected between January 2017 and July 2021 from patients with acute ischemic stroke undergoing mechanical thrombectomy of isolated M1 or M2 branches of the MCA. RESULTS: 350 patients were identified, 287 with M1 and 63 with M2 occlusions. Mean age was 70.71 ± 12.55 and 75.21 ± 10.21 years, respectively (p = 0.0083). Baseline Alberta Stroke Program Computed Tomography (ASPECT) score was worse in the M1 cohort (7.68 ± 1.73 vs. 8.32 ± 1.54; p = 0.0079), while there was no significant difference in National Institutes of Health Stroke Scale (NIHSS) scores. No statistical disparity existed in mean procedure duration for each cohort; fewer thrombectomy attempts were required in the M2 cohort (2.01 vs. 1.63; p = 0.0478). There was no statistical difference in total time to recanalization (559.19 vs. 629.97, p = 0.2506). Similar rates of successful reperfusion were observed (Thrombolysis in Ischaemic Stroke score [TICI] ≥ 2b 80.84% vs. 71.43% p = 0.1221). Good outcome (modified Rankin scale ≤ 2) was 56.10 in M1 occlusions and 63.49% on M2 groups. Intracranial haemorrhage rates were similar. CONCLUSIONS: M2 thrombectomy is safe and a significant proportion of patients achieve a good clinical outcome. Advanced age, atrial fibrillation and previous treatment with anticoagulants were predictors for poor outcome. Good outcome was achieved when effective recanalization was obtained.

The neutrophil-lymphocyte ratio as a predictor of steroid response in patients with severe ulcerative colitis: a retrospective cohort study.

In this study we assessed the neutrophil-lymphocyte ratio (NLR) as a predictor of steroid non-response (SNR) in patients with acute severe ulcerative colitis and found a NLR on day 3 (NLR-3) >6.1 as a suitable cutoff point to identify SNR (OR 3.44, 95%CI 1.22-9.66) with sensitivity, specificity, positive predictive value, negative predictive value, and AUROC of 66.75, 63.2%, 35.9%, 86%, and 0.650, respectively. A model including bowel movements, albumin levels, and a NLR-3>6.1 had an AUC of 0.812 to predict SNR, with acceptable calibration.

Intra- or peri-procedural rupture in the endovascular treatment of intracranial aneurysms.

INTRODUCTION: Intra- or peri-procedural aneurysm rupture is one of the most feared adverse effects associated with embolization. Our aim was to report the characteristics of patients suffering intra- or peri-procedural ruptures during embolization of cerebral aneurysms. PATIENTS AND METHODS: Between March 1994 and October 2021, 648 consecutive cerebral aneurysms were treated by endovascular procedure at our facility. Medical records were reviewed retrospectively with emphasis on procedure description, potential risk factors, and clinical outcomes related to intra- or peri-procedural rupture. RESULTS: Of the 648 patients, 17 (2.6%) suffered an intra- or peri-procedural hemorrhagic event. The most common location was the anterior communicating artery. There was no significant difference between previously ruptured and unruptured aneurysms in the incidence of bleeding. In four patients, bleeding was evident within 24 h after the procedure. The clinical evolution at three months was poor and only four patients presented a positive evolution. There were 11 deaths (64.71%). Balloon remodeling was associated with an increased frequency of ruptures, while stenting was a safer treatment. CONCLUSION: Aneurysmal rupture during endovascular therapy is unpredictable, and its occurrence can be devastating. The incidence is quite low although the outcome is frequently poor. Early detection and proper management, including prompt occlusion of the aneurysm, are important to achieve a positive outcome. Anterior communicating artery aneurysms and those treated with balloon catheters have a higher incidence of rupture. A small number of ruptures of uncertain origin occur that go unnoticed in digital subtraction angiograms.

Highlighting the Dystonic Phenotype Related to GNAO1.

BACKGROUND: Most reported patients carrying GNAO1 mutations showed a severe phenotype characterized by early-onset epileptic encephalopathy and/or chorea. OBJECTIVE: The aim was to characterize the clinical and genetic features of patients with mild GNAO1-related phenotype with prominent movement disorders. METHODS: We included patients diagnosed with GNAO1-related movement disorders of delayed onset (>2 years). Patients experiencing either severe or profound intellectual disability or early-onset epileptic encephalopathy were excluded. RESULTS: Twenty-four patients and 1 asymptomatic subject were included. All patients showed dystonia as prominent movement disorder. Dystonia was focal in 1, segmental in 6, multifocal in 4, and generalized in 13. Six patients showed adolescence or adulthood-onset dystonia. Seven patients presented with parkinsonism and 3 with myoclonus. Dysarthria was observed in 19 patients. Mild and moderate ID were present in 10 and 2 patients, respectively. CONCLUSION: We highlighted a mild GNAO1-related phenotype, including adolescent-onset dystonia, broadening the clinical spectrum of this condition. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Three Pediatric Siblings With CADASIL.

BACKGROUND: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a congenital small vessel disease of the brain due to NOTCH3 gene mutations. Although adult-onset CADASIL is well documented, more cases are being described within the pediatric population. We describe three siblings with NOTCH3 mutations with various symptomatic presentations of early-onset CADASIL and one sibling with concurrent moyamoya syndrome. METHODS: Review of electronic medical records of identified patients. RESULTS: A 19-year-old male who has experienced behavioral dysregulation, hallucinations, and memory loss along with a hyperintense signal abnormality in his temporal lobe; his 15-year-old sister who has the mildest presentation in terms of normal imaging results but experiences severe headaches, anxiety, and depression; and the youngest sibling, a 13-year-old with first reported case of a NOTCH3 mutation associated with moyamoya syndrome and a TREX1 gene mutation of uncertain clinical significance. She had multiple strokes before age five years. CONCLUSION: Our set of siblings share many similarities with other reported pediatric cases of CADASIL, all with NOTCH3 gene mutations and with early-onset symptoms that range from abnormalities in the cognitive/behavioral/psychiatric field to neurological deficits, migraines, and strokes. Gene testing and imaging studies in symptomatic children with a family history suggestive of CADASIL might aid in early diagnosis, even though there is no effective therapy. We believe that the correlation of clinical presentations and gene mutations together with increased research into the molecular mechanisms underlying CADASIL (and related arteriopathies such as moyamoya syndrome) are critical to the eventual development of targeted therapies.

Endovascular stroke treatment after 6-24 hours only needs non-contrast CT.

OBJECTIVES: Imaging selected patients with proximal anterior circulation stroke who demonstrate limited infarct may benefit from endovascular treatment beyond conventional time limits. Our aim was to evaluate the results of the EVT group series arriving between 6 and 24 hours from the onset of symptoms with (ASPECTS) ≥7 to our hospital (with 24/7 interventional neuroradiology) comparing them with those obtained in our prospectively registered series arriving between 0 and 6 hours. MATERIALS AND METHODS: The inclusion criteria were ≥18 years, an interval between stroke and endovascular treatment of 6-24 hours, prestroke score mRS 0-2, no intracranial haemorrhage, (NIHSS) scale 8-22 and infarct evaluated by CT scan ≥7 in ASPECTS scale. Data, including patient demographics, neuroimaging findings, procedural details, recanalization rates and 90-day mRS, were collected. RESULTS: Twelve of the 14 (85.71%) endovascular group patients who came to our centre between 6 and 24 hours had good outcomes at 90 days. To confirm our findings, we evaluated patients treated at our centre who met the selection criteria from January 2017 to September 2019. In this period, 382 patients with large vessel occlusion were treated endovascularly. 56 patients met all the criteria for inclusion and exclusion for our study. 31 of these 56 patients (56.36%) obtained a (mRS) scale ≤2 at three months. There was no significant difference (P = 0.063). CONCLUSION: In circumstances of difficult access to MRI or CT perfusion, a computed tomography of ASPECTS ≥7 is sufficient to indicate endovascular treatment in a stroke of known onset between 6 and 24 hours.

Frecuencia del síndrome de Burnout en residentes de Medicina Interna del Hospital de Clínicas

RESUMEN Introducción: el concepto de Síndrome de Burnout ha sido definido como un síndrome de agotamiento emocional, despersonalización y reducción de la satisfacción personal que puede ocurrir entre personal de sanitario. Objetivo: determinar la frecuencia de síndrome de Burnout y factores de riesgo asociados en residentes de Medicina Interna. Material y método: diseño observacional, descriptivo, prospectivo, de corte transversal, que incluyó residentes de Medicina Interna del Hospital de Clínicas (San Lorenzo, Paraguay) en el año 2019. Se aplicó el cuestionario Maslach Burnout Inventory. El cuestionario se aplicó en Google Drive y se envió a los residentes por mensajería instantánea. Resultados: se incluyeron en el estudio 50 residentes, la edad media fue 28,5±3,7 años, 52% fueron mujeres, 78% son solteros. Cumplían los criterios para Burnout 90% de los residentes, de los cuales 51% fueron varones. El sexo masculino, estado civil soltero, trabajo fuera de la residencia y sueño <6 horas diarias se relacionaron con el desarrollo del Síndrome de Burnout (OR <1) pero sin significancia estadística. Conclusión: la frecuencia del síndrome de Burnout en los residentes de Medicina Interna del Hospital de la Facultad de Ciencias Médicas de la Universidad Nacional de Asunción es muy alta. El sexo más afectado fue el masculino y la mayoría en solteros. Se encontró asociación con algunos factores de riesgo, pero sin alcanzar significancia estadística.

ABSTRACT Introduction: The concept of burnout syndrome has been defined as a syndrome of emotional exhaustion, depersonalization and reduction of personal satisfaction that can occur among healthcare personnel. Objective: To determine the frequency of burnout syndrome and associated risk factors in residents of Internal Medicine. Material and method: Observational, descriptive, prospective, cross-sectional design, which included residents of Internal Medicine of the Hospital de Clínicas (San Lorenzo, Paraguay) in 2019. The Maslach Burnout Inventory questionnaire was applied. The questionnaire was applied on Google Drive and sent to residents by instant messaging. Results: Fifty residents were included in the study, the mean age was 28.5±3.7 years, 52% was women and 78% was single. Ninety percent of the residents met the criteria for burnout, and 51% of them were male. Male sex, unmarried marital status, work outside the residence and sleep <6 hours a day were related to the development of burnout syndrome (OR <1) but without statistical significance. Conclusion: The frequency of burnout syndrome in residents of Internal Medicine of the Hospital of the Faculty of Medical Sciences of the National University of Asunción is very high. The most affected sex was male and the majority was single. Association was found with some risk factors, but without statistical significance.

Contrast-induced nephropathy: A dilemma between loss of neurons or nephrons in the setting of endovascular treatment of acute ischemic stroke.

PURPOSE: The aim is to report the incidence and risk factors of contrast-induced nephropathy after the use of iodine-based contrast for the endovascular treatment of acute ischemic stroke. METHODS: Data from patients who underwent neuroendovascular procedures in a center over a period of 22 months were analysed retrospectively. Contrast-induced nephropathy was determined by an increase in serum creatinine level of >25% of baseline or an absolute increase in serum creatinine level of at least 44 µmol/L (0.50 mg/dL) occurring after intravascular administration of contrast media without alternative explanation. The primary outcome measure of this study was the presence of contrast-induced nephropathy in these treated patients. Continuous data were presented as mean ± standard deviation, and categorical data as frequencies or percentages. The comparison was made using Student's t-test or Fisher's test. Logistic regression was performed to find independent contrast-induced nephropathy predictors. All statistical analyses were performed using Microsoft Excel. A p value of less than 0.05 was considered statistically significant. RESULTS: One hundred and eighty-nine patients undergoing endovascular treatment for acute ischemic stroke. Twenty cases of the total cohort (n = 189) presented contrast-induced nephropathy (10.58%). Only diabetes and creatinine levels between 1.3 and 2.5 mg/dL were associated with contrast-induced nephropathy. No patient was treated with dialysis. CONCLUSION: Contrast-induced nephropathy is a relatively common complication after endovascular treatment of acute ischemic stroke and is associated with worse outcome in patients with this condition. However, there is no increase in the frequency of hemodialysis after the use of iodinated contrast medium.

Eficácia e segurança da oxigenoterapia com cânula nasal de alto fluxo na insuficiência respiratória hipercápnica moderada aguda / Efficacy and safety of high-flow nasal cannula oxygen therapy in moderate acute hypercapnic respiratory failure

RESUMO Objetivo: Avaliar a eficácia e a segurança da oxigenoterapia com uso de cânula nasal de alto fluxo no tratamento da insuficiência respiratória hipercápnica moderada em pacientes que não conseguem tolerar ou têm contraindicações para ventilação mecânica não invasiva. Métodos: Estudo prospectivo observacional de 13 meses envolvendo participantes admitidos a uma unidade de terapia intensiva com insuficiência respiratória hipercápnica ou durante o processo de seu desenvolvimento. Os parâmetros clínicos e de troca gasosa foram registrados em intervalos regulares durante as primeiras 24 horas. Os parâmetros finais foram saturação de oxigênio entre 88 e 92%, juntamente da redução do esforço respiratório (frequência respiratória) e da normalização do pH (≥ 7,35). Os participantes foram considerados não responsivos em caso de necessidade de utilização de suporte ventilatório. Resultados: Trinta participantes foram tratados utilizando oxigenoterapia com cânula nasal de alto fluxo. Esta foi uma população mista com exacerbação de doença pulmonar obstrutiva crônica, edema pulmonar cardiogênico agudo, e insuficiência respiratória aguda pós-operatória e pós-extubação. Observou-se melhora não significante na frequência respiratória (28,0 ± 0,9 versus 24,3 ± 1,5; p = 0,22), que foi aparente nas primeiras 4 horas do tratamento. Ocorreu melhora do pH, embora só se tenham obtido níveis normais após 24 horas de tratamento com cânula nasal de alto fluxo (7,28 ± 0,02 versus 7,37 ± 0,01; p = 0,02). A proporção de não responsivos foi de 13,3% (quatro participantes), dos quais um necessitou e aceitou ventilação mecânica não invasiva, e três necessitaram de intubação. A mortalidade na unidade de terapia intensiva foi de 3,3% (um participante), e um paciente morreu após a alta para a enfermaria (mortalidade hospitalar de 6,6%). Conclusão: O oxigenoterapia com cânula nasal de alto fluxo é eficaz para a insuficiência respiratória hipercápnica moderada e ajuda a normalizar os parâmetros clínicos e de troca gasosa, com taxa aceitável de não responsivos que necessitaram de suporte ventilatório.

ABSTRACT Objective: To assess the efficacy and safety of high-flow nasal cannula oxygen therapy in treating moderate hypercapnic respiratory failure in patients who cannot tolerate or have contraindications to noninvasive mechanical ventilation. Methods: A prospective observational 13-month study involving subjects admitted to an intensive care unit with or developing moderate hypercapnic respiratory failure. Clinical and gas exchange parameters were recorded at regular intervals during the first 24 hours. The endpoints were a oxygen saturation between 88 and 92% along with a reduction in breathing effort (respiratory rate) and pH normalization (≥ 7.35). Subjects were considered nonresponders if they required ventilatory support. Results: Thirty subjects were treated with high-flow nasal cannula oxygen therapy. They consisted of a mixed population with chronic obstructive pulmonary disease exacerbation, acute cardiogenic pulmonary edema, and postoperative and postextubation respiratory failure. A nonsignificant improvement was observed in respiratory rate (28.0 ± 0.9 versus 24.3 ± 1.5, p = 0.22), which was apparent in the first four hours of treatment. The pH improved, although normal levels were only reached after 24 hours on high-flow nasal cannula therapy (7.28 ± 0.02 versus 7.37 ± 0.01, p = 0.02). The rate of nonresponders was 13.3% (4 subjects), of whom one needed and accepted noninvasive mechanical ventilation and three required intubation. Intensive care unit mortality was 3.3% (1 subject), and a patient died after discharge to the ward (hospital mortality of 6.6%). Conclusion: High-flow nasal cannula oxygen therapy is effective for moderate hypercapnic respiratory failure as it helps normalize clinical and gas exchange levels with an acceptable rate of nonresponders who require ventilatory support.

Efficacy and safety of high-flow nasal cannula oxygen therapy in moderate acute hypercapnic respiratory failure. / Eficácia e segurança da oxigenoterapia com cânula nasal de alto fluxo na insuficiência respiratória hipercápnica moderada aguda.

OBJECTIVE: To assess the efficacy and safety of high-flow nasal cannula oxygen therapy in treating moderate hypercapnic respiratory failure in patients who cannot tolerate or have contraindications to noninvasive mechanical ventilation. METHODS: A prospective observational 13-month study involving subjects admitted to an intensive care unit with or developing moderate hypercapnic respiratory failure. Clinical and gas exchange parameters were recorded at regular intervals during the first 24 hours. The endpoints were a oxygen saturation between 88 and 92% along with a reduction in breathing effort (respiratory rate) and pH normalization (≥ 7.35). Subjects were considered nonresponders if they required ventilatory support. RESULTS: Thirty subjects were treated with high-flow nasal cannula oxygen therapy. They consisted of a mixed population with chronic obstructive pulmonary disease exacerbation, acute cardiogenic pulmonary edema, and postoperative and postextubation respiratory failure. A nonsignificant improvement was observed in respiratory rate (28.0 ± 0.9 versus 24.3 ± 1.5, p = 0.22), which was apparent in the first four hours of treatment. The pH improved, although normal levels were only reached after 24 hours on high-flow nasal cannula therapy (7.28 ± 0.02 versus 7.37 ± 0.01, p = 0.02). The rate of nonresponders was 13.3% (4 subjects), of whom one needed and accepted noninvasive mechanical ventilation and three required intubation. Intensive care unit mortality was 3.3% (1 subject), and a patient died after discharge to the ward (hospital mortality of 6.6%). CONCLUSION: High-flow nasal cannula oxygen therapy is effective for moderate hypercapnic respiratory failure as it helps normalize clinical and gas exchange levels with an acceptable rate of nonresponders who require ventilatory support.

OBJETIVO: Avaliar a eficácia e a segurança da oxigenoterapia com uso de cânula nasal de alto fluxo no tratamento da insuficiência respiratória hipercápnica moderada em pacientes que não conseguem tolerar ou têm contraindicações para ventilação mecânica não invasiva. MÉTODOS: Estudo prospectivo observacional de 13 meses envolvendo participantes admitidos a uma unidade de terapia intensiva com insuficiência respiratória hipercápnica ou durante o processo de seu desenvolvimento. Os parâmetros clínicos e de troca gasosa foram registrados em intervalos regulares durante as primeiras 24 horas. Os parâmetros finais foram saturação de oxigênio entre 88 e 92%, juntamente da redução do esforço respiratório (frequência respiratória) e da normalização do pH (≥ 7,35). Os participantes foram considerados não responsivos em caso de necessidade de utilização de suporte ventilatório. RESULTADOS: Trinta participantes foram tratados utilizando oxigenoterapia com cânula nasal de alto fluxo. Esta foi uma população mista com exacerbação de doença pulmonar obstrutiva crônica, edema pulmonar cardiogênico agudo, e insuficiência respiratória aguda pós-operatória e pós-extubação. Observou-se melhora não significante na frequência respiratória (28,0 ± 0,9 versus 24,3 ± 1,5; p = 0,22), que foi aparente nas primeiras 4 horas do tratamento. Ocorreu melhora do pH, embora só se tenham obtido níveis normais após 24 horas de tratamento com cânula nasal de alto fluxo (7,28 ± 0,02 versus 7,37 ± 0,01; p = 0,02). A proporção de não responsivos foi de 13,3% (quatro participantes), dos quais um necessitou e aceitou ventilação mecânica não invasiva, e três necessitaram de intubação. A mortalidade na unidade de terapia intensiva foi de 3,3% (um participante), e um paciente morreu após a alta para a enfermaria (mortalidade hospitalar de 6,6%). CONCLUSÃO: O oxigenoterapia com cânula nasal de alto fluxo é eficaz para a insuficiência respiratória hipercápnica moderada e ajuda a normalizar os parâmetros clínicos e de troca gasosa, com taxa aceitável de não responsivos que necessitaram de suporte ventilatório.

Endovascular treatment of stroke in children under 2 years with heart failure and ventricular assist device.

INTRODUCTION: Strokes in children are characterised by a high mortality rate while, at the same time, the low number of cases makes it difficult to gain practical experience. As heart disease is the most common risk factor, and as more and more cardiological interventions are being carried out, an increase in the incidence of paediatric stroke is expected. In some cases a transplant is required. While waiting for a donor, the use of ventricular assist devices may be necessary. These present with a high rate of neurological complications. We present two cases of children under 2 years of age awaiting heart transplantation supported by ventricular assist devices who had a stroke which was treated by endovascular techniques. Case 1: A 16-month-old boy with restrictive cardiomyopathy who was listed for a cardiac transplant. At 20 months he required an implantation of an external biventricular support device (Berlin Heart) and had a left hemisphere stroke at 23 months. An intra-arterial approach was used and produced good clinical results. One month later, a heart transplant was performed successfully. Case 2: An 18-month-old girl with non-compacted dilated cardiomyopathy included in the cardiac transplant programme and in need of a Levitronix Centrimag ventricular assist device presented with an acute left hemisphere stroke at 23 months. An intra-arterial procedure was carried out leading to positive clinical results except for residual right hypertonia. Seven months later she received her transplant. CONCLUSION: As a result of the difficulty in performing arterial puncture, the small vessel calibre and the limitation in the use of iodated contrast, there are certain limitations to endovascular treatment of strokes in children that can lead to complications. A multidisciplinary approach to managing such cases would be helpful.

Clinical Predictors of Hyperperfusion Syndrome Following Carotid Stenting: Results From a National Prospective Multicenter Study.

OBJECTIVES: The aim of the HISPANIAS (HyperperfusIon Syndrome Post-carotid ANgIoplasty And Stenting) study was to define CHS rates and develop a clinical predictive model for cerebral hyperperfusion syndrome (CHS) after carotid artery stenting (CAS). BACKGROUND: CHS is a severe complication following CAS. The presence of clinical manifestations is estimated on the basis of retrospective reviews and is still uncertain. METHODS: The HISPANIAS study was a national prospective multicenter study with 14 recruiting hospitals. CHS was classified as mild (headache only) and moderate-severe (seizure, impaired level of consciousness, or development of focal neurological signs). RESULTS: A total of 757 CAS procedures were performed. CHS occurred in 22 (2.9%) patients, in which 16 (2.1%) had moderate-severe CHS and 6 (0.8%) had mild CHS (only headache). The rate of hemorrhages was 0.7% and was associated with high mortality (20%). Pre-operative predictors of moderate-severe CHS in multivariate analysis were female sex (odds ratio [OR]: 3.24; 95% confidence interval [CI]: 1.11 to 9.47; p = 0.03), older patients (OR: 1.09; 95% CI: 1.01 to 1.17; p = 0.02), left carotid artery treated (OR: 4.13; 95% CI: 1.11 to 15.40; p = 0.03), and chronic renal failure (OR: 6.29; 95% CI: 1.75 to 22.57; p = 0.005). The area under the curve of this clinical and radiological model was 0.86 (95% CI: 0.81 to 0.92; p = 0.001). CONCLUSIONS: The rate of CHS in the HISPANIAS study was 2.9%, with moderate-severe CHS of 2.1%. CHS was independently associated with female sex, older age, history of chronic kidney disease, and a treated left carotid artery. Although further investigations are needed, the authors propose a model to identify high-risk patients and develop strategies to decrease CHS morbidity and mortality in the future.

The consumption of antioxidants protects against cognitive and physical disabilities in aged with obesity.

INTRODUCTION: antioxidants play an important role in the antioxidant defense system. Obesity and the aging process increase oxidative stress. The disruption of the oxidant-antioxidant balance towards oxidant condition could be related to cognitive and physical disabilities. OBJECTIVE: to evaluate the consumption of antioxidants, the oxidative stress status and their relationship with cognitive and functional alterations in aged with obesity. METHOD: a cross-sectional study was conducted with 94 subjects ≥ 60 years stratified by body mass index (BMI) (76.6% were women). The antioxidants intake as well as cognitive and functional status were evaluated by validated surveys. The oxidative stress markers were thiobarbituric acid reactive substances (TBARS) and lipid-hydroperoxides (LOOH). RESULTS: the antioxidants consumption of the participants was below the recommended daily intakes (RDI) independently of the BMI group. Especially, a lower consumption of vitamins E and D, selenium and ß-carotenes was observed. The concentration of TBARS was higher (p < 0.05) in the obese (1.2 µM) versus the normal weight group (0.7 µM). The concentration of LOOH in the normal weight group (17 µM) did not show statistical difference versus obese group (15 µM). The presence of obesity in aged showed an association with walking difficulties. Multivariable analysis adjusted for several variables showed that the intake of selenium, copper and magnesium is associated with lower risk of cognitive and physical disabilities. CONCLUSIONS: aged with obesity showed a higher concentration of peripheral TBARS, walking difficulties and lower intake of antioxidants. The consumption of copper, selenium, and magnesium seems to protect against cognitive and physical disabilities in aged with obesity.