Exploring the Chagas disease-Stroke 'Connection': Findings from a Large Multicenter Study.

INTRODUCTION: Strokes are traditionally attributed to risk factors like aging, hypertension, diabetes, and atherosclerosis. Chagas disease has emerged as an important risk factor for stroke in Latin American. Our study aims at describing the largest cohort of patients with Chagas disease and ischemic stroke and determining variables associated with stroke recurrence and cardioembolic cause. METHODS: This study is the result of a national multicenter cohort study conducted in Brazil. The study spanned from January 2009 to December 2016 and involved a comprehensive retrospective analysis of medical records of patients with both Chagas disease and stroke. This cohort comprised 499 individuals from diverse Brazilian regions, focusing on vascular risk factors and the epidemiological variables associated with Chagas disease and stroke. RESULTS: Our findings underscore the significant prevalence of traditional vascular risk factors among Chagas disease patients who had stroke. 81% of patients had hypertension, 56% dyslipidemia and 25% diabetes. We observed a 29.7% recurrence rate, especially within the cardioembolic subgroup. 56% of the patients had embolic stroke of undetermined source (ESUS). Specific EKG abnormalities were associated with an increased risk of cardioembolic etiology (with three altered results increasing 81fold the chance of the stroke being of cardioembolic nature). Age emerged as a protective factor (OR:0.98, CI 0.970 - 0.997) against cardioembolic etiology. Anticoagulation therapy was associated with reduced risk (OR:0.221 |CI 0.104 - 0.472), highlighting the importance of accurate etiological classification. Conversely, female gender(OR:1.83 CI 1.039 - 3.249) emerged as a significant risk factor for stroke recurrence. CONCLUSION: This study significantly advances our epidemiological understanding of the intersection between Chagas disease and stroke. It emphasizes the critical need for extensive epidemiological investigations, a deeper comprehension of stroke recurrence determinants, and accurate etiological classification to reduce the ESUS population. Our findings have substantial clinical implications, suggesting the need of control of vascular risk factors and comorbidities and hold promise for improving patient care and reducing the burden of Chagas disease and stroke worldwide.

Predictors of azathioprine and mycophenolate mofetil response in patients with neuromyelitis optica spectrum disorder: A cohort study.

BACKGROUND: Relapse rates of 47 % have been reported in patients with neuromyelitis optica (NMOSD) using Azathioprine (AZA) and mycophenolate mofetil (MMF). Prediction of non-responders could help determine which patients are most likely to benefit from newer monoclonal antibody treatments from the outset. OBJECTIVES: To identify predictors of AZA and MMF treatment response in NMOSD. METHODS: Multicenter cohort study of NMOSD patients from Brazil and the United Kingdom, treated with AZA and MMF. An unsatisfactory response was defined as one severe or two non-severe attacks in a year. Cox regression was used to identify predictive factors of unsatisfactory response to AZA and MMF. RESULTS: 103 NMOSD patients, mean age 38 years, 83% female, and 65% of Black ethnic group were included. An unsatisfactory IS response was observed in 42% of patients over 2.5 years (IQR 1.0-8.8) years. A severe preceding attack was more common in non-responders (31.1% x 76.7%, p = <0.001). In multivariable analysis, severe attack (RR 3.13; 95 % CI 1.37-7.18, p = 0.007) or higher annualized relapse rate (RR 4.84; 95 % CI 2.01-11.65, p = < 0.001) predicted an unsatisfactory response. Interestingly, Black NMOSD patients had a lower risk of poor response (RR 0.39, 95 % CI 0.17-0.85, p = 0.019). CONCLUSION: Severe attack and a higher annualized relapse rate before AZA or MMF initiation were associated with an unsatisfactory IS response. In patients with these characteristics, treatment with higher-efficacy drugs should be considered from the outset.

Morbimortality and determinants of reperfusion in ischemic stroke

SUMMARY BACKGROUND: Cerebrovascular accident (or stroke) and ischemic heart disease are the the major causes of death in the world. It is estimated that about 85% of strokes are ischemic in origin. Reperfusion therapy in the acute phase of ischemic stroke with a recombinant human tissue plasminogen activator is effective, but some factors influence the success of this treatment. OBJECTIVE: The aim of this study was to evaluate clinical aspects and possible determinants for reperfusion after venous thrombolysis. METHODS: This is a retrospective, cross-sectional, observational study based on a review of hospital records of inpatients diagnosed with ischemic stroke treated with intravenous thrombolysis, the main outcome being reperfusion or not. RESULTS: Data from this study revealed a predominance of females in the group of reperfused patients and males in the non-reperfused group, both maintaining moderate severity on the National Institutes of Health Stroke Scale and admission without statistical significance (p>0.18). In addition, the mean admission severity score was 13.2 for the group of reperfused patients and 14.2 for those not reperfused, and the mean ejection fraction of both groups was within normal functionality, with a mean of 0.50 for reperfused patients and 0.62 for non-reperfused patients. CONCLUSION: We found an association between successful venous chemical thrombolysis reperfusion and lower mortality in patients with acute stroke.

Reperfusion therapy for acute ischemic stroke: where are we in 2023?

Over the last three decades, stroke care has undergone significant transformations mainly driven by the introduction of reperfusion therapy and the organization of systems of care. Patients receiving treatment through a well-structured stroke service have a much higher chance of favorable outcomes, thereby decreasing both disability and mortality. In this article, we reviewed the scientific evidence for stroke reperfusion therapy, including thrombolysis and thrombectomy, and its implementation in the public health system in Brazil.

Nas últimas três décadas, o tratamento do AVC sofreu transformações significativas, impulsionadas principalmente pela introdução das terapias de reperfusão e pela organização dos serviços de AVC. Os pacientes que recebem tratamento em um serviço de AVC bem estruturado têm uma probabilidade muito maior de resultados favoráveis, diminuindo assim a incapacidade funcional e a mortalidade. Neste artigo, revisamos as evidências científicas para as terapias de reperfusão do AVC, incluindo trombólise e trombectomia e sua implementação no sistema público de saúde no Brasil.

Morbimortality and determinants of reperfusion in ischemic stroke.

BACKGROUND: Cerebrovascular accident (or stroke) and ischemic heart disease are the the major causes of death in the world. It is estimated that about 85% of strokes are ischemic in origin. Reperfusion therapy in the acute phase of ischemic stroke with a recombinant human tissue plasminogen activator is effective, but some factors influence the success of this treatment. OBJECTIVE: The aim of this study was to evaluate clinical aspects and possible determinants for reperfusion after venous thrombolysis. METHODS: This is a retrospective, cross-sectional, observational study based on a review of hospital records of inpatients diagnosed with ischemic stroke treated with intravenous thrombolysis, the main outcome being reperfusion or not. RESULTS: Data from this study revealed a predominance of females in the group of reperfused patients and males in the non-reperfused group, both maintaining moderate severity on the National Institutes of Health Stroke Scale and admission without statistical significance (p>0.18). In addition, the mean admission severity score was 13.2 for the group of reperfused patients and 14.2 for those not reperfused, and the mean ejection fraction of both groups was within normal functionality, with a mean of 0.50 for reperfused patients and 0.62 for non-reperfused patients. CONCLUSION: We found an association between successful venous chemical thrombolysis reperfusion and lower mortality in patients with acute stroke.

Reperfusion therapy for acute ischemic stroke: where are we in 2023? / Terapia de reperfusão para o acidente vascular isquêmico agudo: onde estamos em 2023?

Abstract Over the last three decades, stroke care has undergone significant transformations mainly driven by the introduction of reperfusion therapy and the organization of systems of care. Patients receiving treatment through a well-structured stroke service have a much higher chance of favorable outcomes, thereby decreasing both disability and mortality. In this article, we reviewed the scientific evidence for stroke reperfusion therapy, including thrombolysis and thrombectomy, and its implementation in the public health system in Brazil.

Resumo Nas últimas três décadas, o tratamento do AVC sofreu transformações significativas, impulsionadas principalmente pela introdução das terapias de reperfusão e pela organização dos serviços de AVC. Os pacientes que recebem tratamento em um serviço de AVC bem estruturado têm uma probabilidade muito maior de resultados favoráveis, diminuindo assim a incapacidade funcional e a mortalidade. Neste artigo, revisamos as evidências científicas para as terapias de reperfusão do AVC, incluindo trombólise e trombectomia e sua implementação no sistema público de saúde no Brasil.

Predictors of Neurodevelopment in Microcephaly Associated with Congenital Zika Syndrome: A Prospective Study.

The municipality of Salvador, situated in Brazil, distinguished itself as the epicenter of the emergence of microcephaly related to congenital manifestations of Zika syndrome. Despite the anticipated significant developmental setbacks in these children, research has indicated a varied range of outcomes, with certain instances even reflecting minimal developmental delay. Our objective was to pinpoint determinants that could forecast developmental anomalies in children diagnosed with microcephaly associated with congenital Zika syndrome (CZS). METHODOLOGY: A forward-looking clinical and neurodevelopmental examination was conducted focusing on neonates diagnosed with microcephaly with CZS, birthed between September 2015 and April 2016 at the Hospital Geral Roberto Santos, in Salvador city. That infants were monitored up to their third year by a multiprofessional team. Child development was assessed using the composite Bayley III score. Undertaken by two blinded experts, cranial CT scan analysis was performed during the neonate period for the detection of brain abnormalities and to quantify ventricle enlargement, measured by Evans' index (EI). RESULTS: Fifty newborns were evaluated with a median head circumference of 28 cm (interquartile range 27-31 cm). EI was associated with neurodevelopmental delay at three years and remained significant after adjustment for head circumference. A 0.1-point increase in EI was associated with a delay of 3.2 months in the receptive language (p = 0.016), 3.4 months in the expressive language (p = 0.016), 3.4 months in the cognitive (p = 0.016), 2.37 months in the gross motor (p = 0.026), and 3.1 months in the fine motor (p = 0.021) domains. CONCLUSIONS: EI predicted neurodevelopmental delay in all Bayley domains in children with microcephaly associated with CZS.

Effects of three physical exercise modalities on respiratory function of older adults with Parkinson's disease: A randomized clinical trial.

INTRODUCTION: Deficits in respiratory function of patients with Parkinson's disease contribute to aspiration pneumonia, one of the main causes of mortality in this population. The aim of this study was to evaluate the effects of functional training, bicycle exercise, and exergaming on respiratory function of elderly with Parkinson's disease. METHODS: A randomized clinical trial with single blinding was conducted in a public reference outpatient clinic for the elderly. The participants were randomly assigned to three groups. Group 1 was submitted to functional training (n = 18); group 2 performed bicycle exercise (n = 20), and group 3 trained with Kinect Adventures exergames (n = 20). The sessions performed lasted 8 weeks with a frequency of three 50-min sessions per week. The primary outcome was the forced expiratory volume in the first second; and the secondary outcomes were forced vital capacity, peak expiratory flow, and maximum inspiratory and expiratory pressures. RESULTS: The interventions performed did not improve the forced expiratory volume in the first second, forced vital capacity, and peak expiratory flow. However, group 2 improved (p = 0.03) maximum expiratory pressure (from 65.5cmH2O to 73.1cmH2O) (effect size 0.47), and group 3 increased (p = 0.03) maximum inspiratory pressure (from -61.3cmH2O to -71.6cmH2O) (effect size 0.53). CONCLUSIONS: No effect was found on lung volume, forced respiratory flow and capacity of the participants with Parkinson's disease submitted to three different modalities of motor training. However, bicycle exercise and exergaming have improved expiratory and inspiratory muscle strength, respectively. NCT02622737.

Brazilian autoimmune encephalitis network (BrAIN): antibody profile and clinical characteristics from a multicenter study.

Background: The frequency of antibodies in autoimmune encephalitis (AIE) may vary in different populations, however, data from developing countries are lacking. To describe the clinical profile of AIE in Brazil, and to evaluate seasonality and predictors of AIE in adult and pediatric patients. Methods: We evaluated patients with possible AIE from 17 centers of the Brazilian Autoimmune Encephalitis Network (BrAIN) between 2018 and 2022. CSF and serum were tested with TBAs and CBAs. Data on clinical presentation, complementary investigation, and treatment were compiled. Seasonality and predictors of AIE in adult and pediatric populations were analyzed. Results: Of the 564 patients, 145 (25.7%) were confirmed as seropositive, 69 (12.23%) were seronegative according to Graus, and 58% received immunotherapy. The median delay to diagnosis confirmation was 5.97 ± 10.3 months. No seasonality variation was observed after 55 months of enrolment. The following antibodies were found: anti-NMDAR (n=79, 54%), anti-MOG (n=14, 9%), anti-LGI1(n=12, 8%), anti-GAD (n=11, 7%), anti-GlyR (n=7, 4%), anti-Caspr2 (n=6, 4%), anti-AMPAR (n=4, 2%), anti-GABA-BR (n=4, 2%), anti-GABA-AR (n=2, 1%), anti-IgLON5 (n=1, 1%), and others (n=5, 3%). Predictors of seropositive AIE in the pediatric population (n=42) were decreased level of consciousness (p=0.04), and chorea (p=0.002). Among adults (n=103), predictors of seropositive AIE were movement disorders (p=0.0001), seizures (p=0.0001), autonomic instability (p=0.026), and memory impairment (p=0.001). Conclusion: Most common antibodies in Brazilian patients are anti-NMDAR, followed by anti-MOG and anti-LGI1. Only 26% of the possible AIE patients harbor antibodies, and 12% were seronegative AIE. Patients had a 6-month delay in diagnosis and no seasonality was found. Findings highlight the barriers to treating AIE in developing countries and indicate an opportunity for cost-effect analysis. In this scenario, some clinical manifestations help predict seropositive AIE such as decreased level of consciousness, chorea, and dystonia among children, and movement disorders and memory impairment among adults.

Psychometric properties of the Brazilian-Portuguese version of the Falls Behavioral Scale in people with Parkinson's disease.

PURPOSE: To verify the psychometric properties of the Brazilian-Portuguese version of the Falls Behavioral (FaB-Brazil) Scale in Parkinson's disease (PD). MATERIAL AND METHODS: Participants (n = 96) were assessed by disease-specific, self-report and functional mobility measures. Internal consistency of the FaB-Brazil scale was evaluated using Cronbach's alpha and inter-rater and test-retest reliability using intraclass correlation coefficients (ICC). The standard error of measurement (SEM), minimal detectable change (MDC), ceiling and floor effects, and convergent and discriminative validity were evaluated. RESULTS: Internal consistency was moderate (α = 0.77). Excellent inter-rater (ICC = 0.90; p < 0.001) and test-retest (ICC = 0.91; p < 0.001) reliability were found. The SEM was 0.20 and MDC was 0.38. Ceiling and floor effects were not found. Convergent validity was established by the positive correlations between the FaB-Brazil scale and age, modified Hoehn and Yahr, PD duration, Movement Disorders Society-Unified Parkinson's Disease Rating Scale, Motor Aspects of Experiences of Daily Living, Timed Up & Go and 8-item Parkinson's Disease Questionnaire, and negative correlations between the FaB-Brazil scale and community mobility, Schwab & England, and Activities-specific Balance Confidence scale. Females showed greater protective behaviors than males; recurrent fallers showed greater protective behaviors than non-recurrent fallers (p < 0.05). CONCLUSIONS: The FaB-Brazil scale is reliable and valid for assessing people with PD.

Fall-related behaviors should be part of the fall risk assessment of community-dwelling people with Parkinson's disease.The Brazilian-Portuguese version of the Fall Behavioral (FaB-Brazil) Scale is reliable and valid for assessing everyday behaviors and actions related to falling in community-dwelling people with Parkinson's disease.The FaB-Brazil scale may be used to tailor individualized fall prevention programs.

Outcomes of recurrent stroke in patients with atrial fibrillation according to presumed etiology / Desfecho de AVC recorrente em pacientes com fibrilação atrial de acordo com etiologia presumida

Abstract Background Atrial fibrillation (AF) is a potent risk factor for stroke. The presence of competing etiologies can modify disease outcomes and demand different treatment strategies. Objective The primary purpose of the study was to examine the differences in outcomes for patients with AF admitted with a recurrent stroke, stratified according to the presumed etiology of the stroke. Methods We analyzed AF patients admitted for a recurrent ischemic stroke in an academic comprehensive stroke center. Recurrent strokes were categorized as "Cardioembolic", meaning AF without any competing mechanism, versus "Undetermined" etiology due to competing mechanisms. We used logistic regression to test the association between recurrent stroke etiology and favorable outcome (discharge home), after accounting for important covariates. Results We included 230 patients, with a mean age 76.9 (SD ± 11.3), 52.2% male, median National Institute of Health Stroke Scale (NIHSS) score of 7 (IQR 2-16). Patients with cardioembolic stroke (65.2%) had higher median NIHSS 8.5 (3-18) versus 3 (1-8) and were more likely to be treated with reperfusion therapies. The favorable outcome was reached by 64 patients (27.8%), and in-hospital mortality was 15.2% overall. After adjustment, there was no difference in outcome between patients with cardioembolic versus undetermined stroke etiology (odds ratio for discharge home: 1.41; 95% CI: 0.65-3.15). Conclusions In this single-center sample of AF patients with history of stroke, there was no difference in discharge outcomes between those with cardioembolic and those with undetermined stroke etiology. This question warrants examination in larger samples to better understand the importance of the stroke mechanism and secondary prophylaxis.

Resumo Antecedentes Fibrilação atrial (FA) é um fator de risco importante para AVC. A presença de mecanismos concorrentes para o AVC pode modificar o desfecho e demandar estratégias de tratamento diferentes. Objetivo O objetivo primário do estudo foi examinar diferenças no desfecho de pacientes com FA admitidos por um AVC recorrente, sendo estratificados de acordo com a etiologia presumida do AVC. Métodos Nós analisamos pacientes com FA admitidos por conta de AVC recorrente em um centro acadêmico terciário de AVC. Os casos de AVC recorrentes foram classificados como "Cardioembólicos", sendo FA sem outros mecanismos alternativos, versus aqueles de etiologia "Indeterminada" por conta de mecanismos concorrentes. Foi usada regressão logística para testar a associação entre a etiologia do AVC recorrente e desfecho favorável (alta direto para casa) após controle para covariáveis importantes. Resultados Nós incluímos 230 pacientes, com uma idade média 76,9 anos (DP ± 11.3), 52.2% homens, com um escore mediano do National Institute of Health Stroke Scale (NIHSS) de 7 (IIQ 2-16). Pacientes com AVC cardioembólicos (65,2%) tiveram um escore de NIHSS mediano mais alto 8,5 (3-18) versus 3 (1-8), e com maior chance de tratamento com terapias de reperfusão. O desfecho favorável ocorreu em 64 pacientes (27,8%) e a mortalidade institucional foi de 15,2% no total. Após ajustes, não encontramos diferença no desfecho entre pacientes com AVC cardioembólico versus AVC de etiologia indeterminada (odds ratio para alta para casa: 1,41; 95% IC: 0,65-3,15). Conclusões Nessa amostra de pacientes com FA e história de AVC recorrente de centro único, não houve diferença no desfecho de alta entre aqueles com AVC cardioembólico e aqueles com etiologia indeterminada. Essa questão deve ser examinada em amostras maiores para melhor compreender a importância do mecanismo do AVC e a profilaxia secundária.

Outcomes of recurrent stroke in patients with atrial fibrillation according to presumed etiology.

BACKGROUND: Atrial fibrillation (AF) is a potent risk factor for stroke. The presence of competing etiologies can modify disease outcomes and demand different treatment strategies. OBJECTIVES: The primary purpose of the study was to examine the differences in outcomes for patients with AF admitted with a recurrent stroke, stratified according to the presumed etiology of the stroke. METHODS: We analyzed AF patients admitted for a recurrent ischemic stroke in an academic comprehensive stroke center. Recurrent strokes were categorized as "Cardioembolic", meaning AF without any competing mechanism, versus "Undetermined" etiology due to competing mechanisms. We used logistic regression to test the association between recurrent stroke etiology and favorable outcome (discharge home), after accounting for important covariates. RESULTS: We included 230 patients, with a mean age 76.9 (SD ± 11.3), 52.2% male, median National Institute of Health Stroke Scale (NIHSS) score of 7 (IQR 2-16). Patients with cardioembolic stroke (65.2%) had higher median NIHSS 8.5 (3-18) versus 3 (1-8) and were more likely to be treated with reperfusion therapies. The favorable outcome was reached by 64 patients (27.8%), and in-hospital mortality was 15.2% overall. After adjustment, there was no difference in outcome between patients with cardioembolic versus undetermined stroke etiology (odds ratio for discharge home: 1.41; 95% CI: 0.65-3.15). CONCLUSIONS: In this single-center sample of AF patients with history of stroke, there was no difference in discharge outcomes between those with cardioembolic and those with undetermined stroke etiology. This question warrants examination in larger samples to better understand the importance of the stroke mechanism and secondary prophylaxis.

ANTECEDENTES: Fibrilação atrial (FA) é um fator de risco importante para AVC. A presença de mecanismos concorrentes para o AVC pode modificar o desfecho e demandar estratégias de tratamento diferentes. OBJETIVOS: O objetivo primário do estudo foi examinar diferenças no desfecho de pacientes com FA admitidos por um AVC recorrente, sendo estratificados de acordo com a etiologia presumida do AVC. MéTODOS: Nós analisamos pacientes com FA admitidos por conta de AVC recorrente em um centro acadêmico terciário de AVC. Os casos de AVC recorrentes foram classificados como "Cardioembólicos", sendo FA sem outros mecanismos alternativos, versus aqueles de etiologia "Indeterminada" por conta de mecanismos concorrentes. Foi usada regressão logística para testar a associação entre a etiologia do AVC recorrente e desfecho favorável (alta direto para casa) após controle para covariáveis importantes. RESULTADOS: Nós incluímos 230 pacientes, com uma idade média 76,9 anos (DP ± 11.3), 52.2% homens, com um escore mediano do National Institute of Health Stroke Scale (NIHSS) de 7 (IIQ 2­16). Pacientes com AVC cardioembólicos (65,2%) tiveram um escore de NIHSS mediano mais alto 8,5 (3­18) versus 3 (1­8), e com maior chance de tratamento com terapias de reperfusão. O desfecho favorável ocorreu em 64 pacientes (27,8%) e a mortalidade institucional foi de 15,2% no total. Após ajustes, não encontramos diferença no desfecho entre pacientes com AVC cardioembólico versus AVC de etiologia indeterminada (odds ratio para alta para casa: 1,41; 95% IC: 0,65­3,15). CONCLUSõES: Nessa amostra de pacientes com FA e história de AVC recorrente de centro único, não houve diferença no desfecho de alta entre aqueles com AVC cardioembólico e aqueles com etiologia indeterminada. Essa questão deve ser examinada em amostras maiores para melhor compreender a importância do mecanismo do AVC e a profilaxia secundária.

Effects of inspiratory muscle training on the severity of obstructive sleep apnea in individuals after stroke: a protocol for a randomized controlled trial.

BACKGROUND: Obstructive sleep apnea (OSA) is the most common form of sleep-disordered breathing in cerebrovascular diseases, requiring a multidisciplinary approach. There are few studies evaluating the effects of inspiratory muscle training (IMT) in individuals with OSA and the findings regarding the possible effect on apnea hypopnea index (AHI) reduction are controversial. OBJECTIVE: This protocol for a randomized clinical trial will assess the effects of IMT on the severity of obstructive sleep apnea, sleep quality, and daytime sleepiness in individuals after stroke participating in a rehabilitation program. METHODS: This study will be a randomized controlled trial with blinded assessors. Forty individuals after stroke will randomized to two groups. For 5 weeks, both groups will participate in the rehabilitation program activities, including aerobic exercise, resistance training, and educational class when they will receive guidance on the behavioral management of OSA. The experimental group will also perform high-intensity IMT 5 times a week, for 5 weeks, consisting initially of five sets of five repetitions achieving 75% of the maximal inspiratory pressure, increasing one set each week, totaling nine sets at the end of training. The primary outcome will be the severity of OSA measured as AHI at 5 weeks. Secondary outcomes will include sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI) and daytime sleepiness measured by Epworth Sleepiness Scale (ESS). Outcomes will be collected by a researcher blinded to group allocation at baseline (week 0), after intervention (week 5), and 1 month beyond intervention (week 9). TRIAL REGISTRATION: Clinical Trials Register: NCT05135494.

Predictors of Falls with Injuries in People with Parkinson's Disease.

Background: Falls are frequent in Parkinson's disease (PD), but there is lack of information about predictors of injurious falls. Objectives: To determine predictors of falls with injuries in people with PD; to compare circumstances and consequences of falls in single and recurrent fallers. Methods: Participants (n = 225) were assessed by disease-specific, self-report, and balance measures, and followed-up for 12 months with a diary to record falls, their circumstances, and injuries. Univariate and multivariate analyses were performed. Circumstances and consequences of falls presented by single and recurrent fallers were compared. Results: A total of 805 falls were analyzed, 107 (13%) were falls with injuries. Multivariate logistic regression model revealed that greater PD duration and higher balance confidence were protective factors; better balance during gait, outdoor falls, and falls related to extrinsic factors were risk factors for falls with injuries, when compared to falls with no injuries. Multivariate multinomial regression model revealed that, when compared to zero fall, past falls and daily levodopa equivalent dose were predictors of falls with injuries; these predictors together with disability were predictors of falls with no injuries. Single falls (n = 27; 3%) were more common outdoors because of extrinsic factors, whereas recurrent falls (n = 778; 97%) were more common indoors because of intrinsic factors. Single falls led to more injuries than recurrent falls (P < 0.05). Conclusions: Different predictors of falls with injuries were obtained when different outcomes were compared. It should be noted that falls with injuries might be influenced by fall-related activities and environmental factors. Single and recurrent falls differed on circumstances and consequences.

Development of a new non invasive prognostic stroke scale (NIPSS) including triage elements for sleep apnea and peripheral artery disease.

BACKGROUND: Although sleep apnea and peripheral artery disease are prognostic factors for stroke, their added benefit in the acute stage to further prognosticate strokes has not been evaluated. OBJECTIVES: We tested the accuracy in the acute stroke stage of a novel score called the Non-Invasive Prognostic Stroke Scale (NIPSS). PATIENTS AND METHODS: Prospective cohort with imaging-confirmed ischemic stroke. Clinical data, sleep apnea risk score (STOPBANG) and blood pressure measures were collected at baseline. Primary outcome was the 90-day modified Rankin Scale (mRS), with poor outcome defined as mRS 3-6. Area under the ROC curve (AUC) was calculated for NIPSS and compared to six other stroke prognostic scores in our cohort: SPAN-100 index, S-SMART, SOAR, ASTRAL, THRIVE, and Dutch Stroke scores. RESULTS: We enrolled 386 participants. After 90 days, there were 56% with poor outcome, more frequently older, female predominant and with higher admission National Institute of Health Stroke Scale (NIHSS). Four variables remained significantly associated with primary endpoint in the multivariable model: age (OR 1.87), NIHSS (OR 7.08), STOPBANG category (OR 1.61), and ankle-braquial index (OR 2.11). NIPSS AUC was 0.86 (0.82-0.89); 0.83 (0.79-0.87) with bootstrapping. When compared to the other scores, NIPSS, ASTRAL, S-SMART and DUTCH scores had good abilities in predicting poor outcome, with AUC of 0.86, 0.86, 0.83 and 0.82, respectively. THRIVE, SOAR and SPAN-100 scores were fairly predictive. DISCUSSION AND CONCLUSIONS: Non-invasive and easily acquired emergency room data can predict clinical outcome after stroke. NIPSS performed equal to or better than other prognostic stroke scales.

Cross-cultural adaptation and psychometric properties of the Brazilian-Portuguese version of the Falls Behavioral (FaB-Brazil) Scale.

PURPOSE: To develop and cross-culturally adapt a Brazilian-Portuguese version of the Falls Behavioral Scale (FaB-Brazil) and to verify its psychometric properties. MATERIAL AND METHODS: The translation and cross-cultural adaptation process of the scale followed standard guidelines. The FaB-Brazil scale was applied to 93 community-dwelling older people. Cronbach's alpha was calculated to evaluate internal consistency and the intraclass correlation coefficient (ICC) to evaluate interrater and test-retest reliability. The standard error of measurement (SEM), minimal detectable change (MDC), ceiling and floor effects, convergent and discriminative validity were evaluated. A significance level of .05 was set for statistical analyses. RESULTS: Internal consistency was moderate (α = 0.73). An excellent inter-rater (ICC = 0.93; p < 0.001) and a good test-retest (ICC = 0.79; p < 0.001) reliability were found. The SEM was 0.27 and MDC was 0.53. Neither ceiling nor floor effects were found. Convergent validity was established by the positive correlations between the FaB-Brazil scale, age, and functional mobility, and by the negative correlations between the FaB-Brazil scale and balance confidence, community mobility and EuroQol-5D (p < 0.05). No significant differences were found between males and females and between non-fallers and fallers. CONCLUSIONS: Our results offer evidence for the reliability and validity of the FaB-Brazil scale for community-dwelling older people.Implications for RehabilitationFall-related behaviors should be part of the fall risk assessment of community-dwelling older people.The Brazilian-Portuguese version of the Falls Behavioral Scale (FaB-Brazil) is reliable and valid for assessing fall-related behaviors in community-dwelling older people.The FaB-Brazil scale may be used to raise awareness about potential fall hazards and to guide fall prevention programs.

Stroke Is Associated with Refractory Hypertension among Resistant and Refractory Patients in a Cross-Sectional Study

Abstract Background Refractory hypertension (RfH) is a severe phenotype of resistant hypertension (RH) linked to higher risk of stroke and other adverse cardiovascular events, but knowledge about it is still lacking. Objectives To evaluate the association between RfH and stroke. Methods We conducted a cross-sectional study in a referral clinic for patients with severe hypertension in the period from 2018 to 2020. RH was defined as uncontrolled blood pressure (BP) despite the use of 3 antihypertensive agents, including a diuretic, or the use of ≥ 4 agents regardless of BP control. RfH was defined as lack of BP control despite use of ≥ 5 antihypertensive agents. Individuals were classified as RfH or RH, and multivariate logistic regression models were constructed to examine the association between RfH and stroke. Results We evaluated a total of 137 patients; 81% were female, and 93,3% were Black or multiracial. The mean age was 64.4 years. Stroke was more prevalent in the RfH group (35.7%), in comparison to the RH group (12.8%) (p value = 0.01). Unadjusted odds ratio (OR) and 95% confidence interval (CI) for factors associated with stroke were RfH (OR 3.77; 95% CI 1.45 to 9.80), systolic BP (OR 1.02; 95% CI 1.002 to 1.04) and diastolic BP (OR 1.03; 95% CI 1.001 to 1.06). Adjusted OR for factors associated with stroke were RfH (OR 3.55; 95% CI 1.02 to 12.42), systolic BP (OR 1.02; 95% CI 0.99 to 1.05) and diastolic BP (OR 1.01; 95% CI 0.96 to 1.06). Conclusion RfH was associated with higher prevalence of stroke. Efforts are required to better understand this association to prevent adverse cardiovascular outcomes in these patients.

Assessment of Immune and Clinical Response in Patients with Mucosal Leishmaniasis Treated with Pentavalent Antimony and Pentoxifylline.

Mucosal leishmaniasis (ML) is a severe form of tegumentary leishmaniasis associated with a persistent inflammatory response. High levels of TNF, IFN-γ, CXCL9 and CXCL10 are found in ML patients, and the association of pentoxifylline with antimony is more effective in decreasing the healing time in ML patients when compared to antimony alone. The present study aimed to investigate the existence of a correlation between cytokine and chemokine production and ML severity and evaluate the potential value of cytokine and chemokine production as marker of therapeutic response in ML patients. This prospective study included 86 subjects in an area of endemic Leishmania braziliensis transmission. Patients diagnosed with ML were classified into clinical stages ranging from I to V according to disease severity. TNF, IFN-γ, CXCL9 and CXCL10 levels were quantified in the supernatant of the mononuclear cell cultures by ELISA before and after treatment with antimony alone or antimony plus pentoxifylline. The median TNF level in the group with mild disease (Stages I-II) was 1064 pg/mL (142-3738 pg/mL), while, in the group with moderate or severe disease (Stages III-V), it was 1941 pg/mL (529-5294 pg/mL) (p = 0.008). A direct correlation was observed between ML clinical severity and levels of TNF production (r = 0.44, p = 0.007). Patients who were treated with antimony and pentoxifylline healed significantly faster than those treated with antimony alone (52 vs. 77 days, hazard ratio = 0.60; 95% confidence interval = 0.38-0.95, p = 0.013). Therapeutic failure was higher in the group that received antimony alone (25% vs. 7%; p = 0.041). There was a significant decrease in CXCL9 after therapy of ML in both groups (p = 0.013; p = 0.043). TNF levels are associated with the severity of mucosal diseases, and pentoxifylline associated with antimony should be the recommended therapy for ML in countries where liposomal amphotericin B is not available.

Predictors of functional communication in people with aphasia after stroke.

BACKGROUND: Aphasia, the most common language disorder secondary to stroke, has been associated with increased mortality, longer hospitalization and rehabilitation times, worse performance in daily activities, increased financial burden, and short- and long-term complications. Aphasia can negatively impact functional communication skills, including social networks, social activities, relationships with other people and social support. OBJECTIVE: To evaluate patients with poststroke aphasia in their respective residences to investigate potential predictors of functional communication. METHODS: The prospective cohort included patients with poststroke aphasia aged 18 years or older who resided in the city of Salvador, Northeastern Brazil. Following discharge from the Stroke Unit (SU), the individuals themselves, or their guardians, were contacted by telephone to schedule a home visit no less than three months after discharge. At baseline, sociodemographic and clinical data were collected, in addition to the scores on the National Institutes of Health Stroke Scale (NIHSS) and modified Barthel Index (mBI). The American Speech-Language-Hearing Association Functional Assessment of Communication Skills for Adults (ASHA FACS) was applied at the patients' homes. Multivariate linear regression was employed using the total score on the ASHA FACS as the outcome of interest. RESULTS: A multivariate analysis of the associated factors identified using the linear regression revealed that only functional capacity (as assessed by the mBI) upon discharge from the SU remained as an independent predictor of functional communication performance (ß = 0.042; 95% confidence interval [95%CI] = 0.013-0.071; p = 0.002). CONCLUSION: The functional capacity to perform daily activities, evaluated upon discharge from a stroke unit, was identified as a potential predictor of functional communication performance, regardless of the time elapsed after the stroke.

ANTECEDENTES: A afasia, distúrbio de linguagem mais comum secundário ao acidente vascular cerebral (AVC), está associada ao aumento da mortalidade, a um maior tempo de internação e reabilitação, ao pior desempenho nas atividades diárias, ao aumento da carga financeira, e às complicações de curto e longo prazos. Pode impactar negativamente as habilidades de comunicação funcional, incluindo atividades sociais, relacionamento com outras pessoas, e o apoio social. OBJETIVO: Avaliar pacientes com afasia pós-AVC em suas respectivas residências para investigar potenciais preditores de comunicação funcional. MéTODOS: A coorte prospectiva incluiu pacientes com afasia pós-AVC com 18 anos de idade ou mais, residentes em Salvador, Brasil. Após a alta da Unidade de AVC (UAVC), os próprios indivíduos, ou seus responsáveis, foram contatados por telefone para agendamento de visita domiciliar no mínimo três meses após a alta. Inicialmente, foram coletados dados sociodemográficos e clínicos, além das pontuações na National Institutes of Health Stroke Scale (NIHSS) e no Índice de Barthel modificado (IBM). O American Speech-Language-Hearing Association Functional Assessment of Communication Skills for Adults (ASHA FACS) foi aplicado no domicílio dos pacientes. A regressão linear multivariada foi empregada usando a pontuação total no ASHA FACS como o desfecho de interesse. RESULTADOS: A análise multivariada por meio de regressão linear revelou que apenas a capacidade funcional avaliada na alta da UAVC permaneceu como preditor independente do desempenho da comunicação funcional (ß = 0,042; intervalo de confiança de 95% [IC95%] = 0,013­0,071; p = 0,002). CONCLUSãO: A capacidade funcional para realizar as atividades diárias, avaliada na alta hospitalar, foi identificada como potencial preditor do desempenho da comunicação funcional, independente do tempo desde o AVC.