Disparities in the Use of Intravenous t-PA among Ischemic Stroke Patients: Population-based Recent Temporal Trends.

OBJECTIVE: To explore a 5-year comparison of disparities in intravenous t-PA (IV t-PA) use among acute ischemic stroke (AIS) patients based on race, gender, age, ethnic origin, hospital status, and geographic location. METHODS: We extracted patients' demographic information and hospital characteristics for 2010 and 2014 from the New York Statewide Planning and Research Cooperative System (SPARCS). We compared disparities in IV t-PA use among AIS patients in 2010 to that in 2014 to estimate temporal trends. Multiple logistic regression was performed to compare disparities based on demographic variables, hospital designation, and geographic location. RESULTS: Overall, there was approximately a 2% increase in IV t-PA from 2010 to 2014. Blacks were 15% less likely to receive IV t-PA compared to Whites in 2014, but in 2010, there was no difference. Patients aged 62-73 had lower odds of receiving IV t-PA than age group ≤61 in both 2010 and 2014. Designated stroke centers in the Lower New York State region were associated with reduced odds of IV t-PA use in 2010 while those located in the Upper New York State region were associated with increased odds of IV t-PA use in both 2010 and 2014, compared to their respective nondesignated counterparts. Gender, ethnic origin, and insurance status were not associated with IV t-PA utilization in both 2010 and 2014. CONCLUSION: Overall IV t-PA utilization among AIS patients increased between 2010 and 2014. However, there are evident disparities in IV t-PA use based on patient's race, age, hospital geography, and stroke designation status.

[Definition and treatment of stroke over the centuries].

Stroke was already diagnosed in the ancient times. For hundreds of years the treatment of this disease has changed radically. According to the current WHO definition, stroke is a clinical syndrome caused by focal or generalized brain injury that lasts more than 24 hours or leads to death and has no other cause than vascular. Stroke constitutes a big social and economic problem, as it can lead to death or disability. In the highly developed countries stroke is the third most common cause of adult deaths, the second leading cause of dementia, and the most common cause of disability. The consequences of stroke also include epilepsy and depression. In the twentieth century, stroke was only treated symptomatically and rehabilitation was limited to passive exercises. The first breakthrough in ischemic stroke therapy was the introduction of aspirin (ASA), followed by intravenous thrombolysis using recombinant tissue plasminogen activator (rtPA), initially available in our country only in the drug programs, and since 2009 it has been reimbursed by the National Health Fund (NFZ). Gradually invasive stroke treatment has been developed. Mechanical thrombectomy is currently only performed in selected centers, giving hope for more effective stroke treatment. The purpose of this work was to show how stroke treatment has changed over the centuries.

Acute Digital Ischemia Associated with Closed Injury.

Injury of an artery has a significantly worse prognosis for the patient than a venous injury. Blunt injuries of lower limb digital arteries with the development of acute ischemia present a very rare phenomenon. A crush mechanism with a defect of the non-wetted surface of vessel's inner part and the development of subsequent thromboischemic lesion is essential for the development of ischemia. We report a blunt injury of the right lower limb in a patient after incorrect stepping with subsequent lesion of digital arteries and the development of acute acral ischemia of the right toes.

In-hospital outcomes after primary percutaneous coronary intervention according to left ventricular ejection fraction.

BACKGROUND: The primary objective of primary percutaneous coronary intervention (pPCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) is not only to restore the blood flow in the infarct-related artery, but also to save the patients' quality and duration of their life. Since left ventricular ejection fraction (LVEF) is a known predictor of clinical outcomes in STEMI patients, the possible association between characteristics of a large group of patients who undergo pPCI with LVEF and death was evaluated. METHODS: This prospective cohort study included 304 patients who had undergone pPCI between 2009 and 2011. The association between LVEF and in-hospital outcomes of patients was assessed. RESULTS: LVEF ≤ 25%, 25% < LVEF < 50%, and LVEF ≥ 50% were presented in 23 (7.6%), 150 (49.3%), and 128 (42.1%) of the patients, respectively. Three patients (0.01%) died before echocardiography. There was no significant difference among aforementioned three groups regarding baseline characteristics, except age (P = 0.012) and sex (P = 0.016). Cumulative number of cardiogenic shock and death were 7 (2.3%) and 22 (7.2%), respectively; with significant differences between three LVEF groups. Age more than 70 years old, pulmonary edema, systolic blood pressure < 100 mm Hg, shock, post-PCI thrombolysis in myocardial infarction (MI) flow grade, corrected thrombolysis in MI frame count, angiographic success and ST-segment resolution showed significant association with death (P < 0.050). CONCLUSION: This study not only demonstrates that LVEF ≤ 50% is associated with a higher incidence of in-hospital adverse events, but also identifies characteristics that are strongly correlated with the risk of LVEF ≤ 50% and death after pPCI.

Revisión a partir de un caso clínico: flegmasia cerulea dolens / Flegmasia cerulea dolens: clinical case and literature review

La Flegmasia Cerulea Dolens (FCD) es una complicación poco frecuente de la trombosis venosa profunda extensa. Caracterizada por edema masivo, dolor intenso y cianosis. En la trombosis y oclusión aguda de los troncos venosos proximales (ilíacas, vena cava inferior), la congestión puede alcanzar gran severidad, con atrapamiento masivo de líquido intersticial, lo que puede llevar a oliguria y al shock. La extremidad adquiere un aspecto céreo (flegmasia cerulea dolens) por compromiso del drenaje venoso de la extremidad. El aumento de presión intersticial puede llegar a interferir con la perfusión arterial, dando un color pálido (flegmasia alba dolens) e incluso producir isquemia distal en el pie (gangrena venosa), con una alta mortalidad asociada. Hasta el momento, no existe consenso en su tratamiento, la anticoagulación con heparina, trombectomía quirúrgica, terapia trombolítica, fasciotomía y la amputación han sido algunos de los tratamientos propuestos. Presentamos una revisión de flegmasia cerulea dolens en relación a un caso clínico.

The Phlegmasia caerulea dolens (PCD) is an uncommon, severe form of deep venous thrombosis. Characterized by massive edema, severe pain and cyanosis. In the acute thrombosis and occlusion of major venosus channels (iliac and cava inferior) the congestion can reach a massive intersticial fluid secuestration, that can lead to a oliguria and to a shock. The leg acquires a cereo aspect (phlegmasia caerulea dolens) by significantly compromised venous outflow. The increase of the interstitial pressure can interfere with the arterial perfusion, giving a pale color (phlegmasia alba dolens) and can even produce distal ischemia on the foot (venous gangrene), that is a cause of high mortality. Until now, there are no consensus about its treatment. Anticoagulation with heparin, surgical thrombectomy, trombolysis therapy, fasciotomy and amputation had been some of the purposed treatments. We present a review, related to a clinical case, of the Phlegmasia caerulea dolens.

Protocolo Cask en pacientes con infarto agudo de miocardio, estudio descriptivo de un grupo de pacientes, período 1999-2001 / Cask protocol in patients with acute myocardial infarction, descriptive study of a group of patients, period 1999-2001

Tipo de estudio: descriptivo, clínico, transversal, prospectivo. Objetivo: Usar terapéuticamente el protocolo CASK (Captopril, ácido acetilsalicílico, trombolisis con estreptoquinasa SK), en todo paciente con diagnóstico de infarto de miocardio trasmural. Métodos: Estudio de cohorte con seguimiento de 2 años de pacientes ingresados por infarto agudo de miocardio en los años 1999, 2000 y 2001 en la Unidad de Cuidados Intensivos del hospital Dr. Teodoro Maldonado Carbo de la ciudad de Guayaquil, Ecuador. Se analizó el tiempo trascurrido del evento coronario agudo, infarto de miocardio y su periodo óptimo de inicio de la fibrinólisis con estreptoquinasa SK, criterios de reperfusión e índice de morbimortalidad del evento coronario. Resultados: Un universo de 263 pacientes, con infarto de miocardio ingresados: 86% fueron tratados con el protocolo Cask, durante las primeras 6 horas del evento coronario, Captopril 6.25mg vo stat, BID, ácido acetilsalicílico tab. 100mg ,150mg vo stat, día, y fibrinólisis con estreptoquinasa SK, 15000.000ui iv en 100cc de dextrosa al 5% pasar en una hora, período óptimo alcanzado como lo recomienda el Colegio Americano de Cardiología. El resto 14%, no recibieron fibrinólisis por ser tardíos, de 12-24 horas, debutan con infarto de miocardio subendocárdico, por no tener elevación del segmento ST, contraindicación 2%, retraso prehospitalario, > 24 horas, u otras causas 3%; los pacientes tratados presentaban los factores de riesgo cardiaco mayores, el retraso medio de administrar el fibrinolítico SK, fue de 270 minutos, en cuarto lugar en relación al estudio PRÍAMHO.

Study type: descriptive, clinical, transversal, prospective. Objectives: The therapeutic use of the CASK protocol, Captopril, acetylsalicylic acid, trombolysis with streptoquinasa SK, in all patients with diagnosis of trasmural myocardial infarct. Methods: Cohort study with a 2 year follow up of patients admitted with acute myocardial infarction in the years 1999, 2000, 2001 to the Intensive Care Unit of the Teodoro Maldonado Carbo Hospital of Guayaquil, Ecuador. The time of the acute coronary event, myocardial infarction, and its optimal period for beginning of fibrinolysis with streptoquinasa SK, reperfusion criteria and index of morbimortality were analyzed. Results: An universe of 263 patients, admitted with myocardial infarct: 86% were treated with the Cask protocol, during the initial 6 hours of the coronary event, Captopril 6.25mg vo stat, BID, acetylsalicylic acid tab.100mg, 150mg vo stat, day, and fibrinolysis with streptoquinasa SK, 15000.000ui iv in 100 dextrose cc to 5% passed in 1 hour, period optimal as recommended by the American School of Cardiology. Resting 14% did not receive fibrinolysis, for being late, of 12-24 hours, debut with subendocardic myocardial infarct, for not having elevation of the ST segment, contraindication 2%, prehospitalarian delay, >24 hours, or other causes 3%, treated patients presented the highest cardiac risk factors, median delay of administering the fibrinolytic SK, was of 270 minutes, in 4th place in relation to the PRÍAMHO study.