Forma clínica indeterminada da doença de Chagas e o risco potencial de evento isquêmico / Indeterminate clinical form of Chagas disease and the potencial risk of ischemic event / Forma clínica indeterminada de la enfermedad de Chagas y potencial riesgo de evento isquémico

Acidentes vasculares cerebrais ou isquêmicos transitórios são eventos raros em pacientes jovens sem fatores de risco clássicos, correspondendo muitas vezes a eventos não definidos etiologicamente e caracterizados como fenômenos tromboembólicos criptogênicos. A doença de Chagas é um fator de risco que deve ser considerado como potencial causa etiológica quando especificamos áreas endêmicas, tanto pelo conhecido mecanismo cardioembólico de acometimento cardíaco como pelas demais formas sem acometimento cardíaco, uma vez que já é descrita como fator de risco independente para doenças cerebrovasculares. Este estudo demonstra, por meio de um relato de caso, o desfecho de uma paciente portadora da doença de Chagas crônica, na forma indeterminada, sem fatores de risco clássicos. A paciente foi acometida por um ataque isquêmico transitório, tendo como etiologia presumida a doença de Chagas, que pode determinar um perfil pró-inflamatório e pró-coagulante, de modo a corroborar a tese de que o prognóstico da forma indeterminada pode não ser benigno. A associação entre a forma indeterminada e as doenças cerebrovasculares incorre na necessidade de anexar ao protocolo de investigação de acidente vascular encefálico (AVE) criptogênicos da doença de Chagas, quando se refere a áreas endêmicas, bem como em alertar as áreas da saúde para essa forma da doença, como forma de ajudar em medidas de prevenção de fenômenos tromboembólicos encefálicos.

Transient strokes or ischemic attacks are rare events in young patients without classic risk factors, often corresponding to events not defined etiologically and characterized as cryptogenic thromboembolic phenomena. Chagas disease is a risk factor that should be considered as a potential etiological cause when specifying endemic areas, both for the cardioembolic mechanism and for other forms without cardiac involvement, since it is described as an independent risk factor for cerebrovascular diseases. This study shows, by means of a case report, the outcome of a patient with chronic indeterminate Chagas disease without classic risk factors. The patient was affected by a transient ischemic attack, with the presumed etiology being Chagas disease, which can determinate a pro-inflammatory and pro-coagulant profile, thus corroborating that the prognosis of the indeterminate form may not be benign. The association between the indeterminate form and stroke incurs in the need to attach to the investigation protocol for cryptogenic stroke of Chagas disease, when referring to endemic areas, as well as to take a better look at this form to help in prevention measures for encephalic thromboembolic phenomena.

Los accidentes cerebrovasculares o accidentes isquémicos transitorios son eventos raros en pacientes jóvenes sin factores de riesgo clásicos, que a menudo corresponden a eventos no definidos etiológicamente caracterizándose como fenómenos tromboembólicos criptogénicos. La enfermedad de Chagas es un factor de riesgo que debe ser considerado como una posible causa etiológica cuando especificamos áreas endémicas, tanto por el conocido mecanismo cardioembólico de afectación cardíaca como por otras formas sin afectación cardíaca, puesto que la enfermedad ya está descrita como factor de riesgo independiente de enfermedades cerebrovasculares. Este estudio demuestra, a partir de un reporte de caso, el desenlace de un paciente con enfermedad de Chagas crónica en forma indeterminada sin factores de riesgo clásicos. La paciente sufrió un ataque isquémico transitorio, con la enfermedad de Chagas como presunta etiología, lo que puede determinar un perfil proinflamatorio y procoagulante, por lo que corroboró con la tesis de que el pronóstico de la forma indeterminada puede no ser tan benigno. La asociación entre la forma indeterminada y las enfermedades cerebrovasculares incurre en la necesidad de adjuntar la enfermedad de Chagas al protocolo de investigación de accidente cerebrovascular (ACV) criptogénico cuando se habla de áreas endémicas, así como de incrementar la visión de las áreas de salud a esta forma de enfermedad, para así contribuir con las medidas preventivas de los fenómenos tromboembólicos cerebrales.

Stroke and transient ischemic attacks related to antiplatelet or warfarin interruption / Acidente vascular cerebral e ataques isquêmicos transitórios relacionados à interrupção de antiplaquetários ou varfarina

ABSTRACT Patients on anticoagulant or antiplatelet therapy are often required to discontinue these medications before and during surgical or invasive procedures. In some cases, the patient stops the treatment without medical supervision. These situations may increase stroke risk. Objective To identify the ischemic stroke and transient ischemic attack (TIA) prevalence related to length of time of discontinuation of antiplatelet or vitamin K antagonist therapy, in a group of inpatients from a specialized neurological hospital in Brazil. Methods Cross-sectional, retrospective and descriptive study of stroke inpatients for three years. Medical reports were reviewed to find study participants, stroke characteristics, risk factors, reasons and time of drug interruption. Results In three years, there were 360 stroke and TIA inpatients, of whom 27 (7.5%) had a history of antiplatelet or vitamin K antagonist interruption correlated with the time of the event (81% ischemic stroke, 19% TIA). The median time between antiplatelet interruption and an ischemic event was five days, and 62% of events occurred within seven days after drug suspension. For vitamin K antagonists, the average time to the ischemic event was 10.4 days (SD = 5.7), and in 67% of patients, the time between drug discontinuation and the event was 7-14 days. The most frequent reason for drug suspension was patient negligence (37%), followed by planned surgery or invasive examination (26%) and side effects, including hemorrhage (18.5%). Conclusion Antiplatelet or vitamin K antagonist suspension has a temporal relationship with the occurrence of stroke and TIA. Since these events are preventable, it is crucial that healthcare professionals convince their patients that drug withdrawal can cause serious consequences.

RESUMO Pacientes em terapia anticoagulante ou antiagregante plaquetária frequentemente são solicitados a descontinuar essas medicações antes e durante procedimentos cirúrgicos ou invasivos. Se o paciente interromper tratamento sem supervisão médica, poderá aumentar de risco de acidente vascular cerebral (AVC). Objetivo Identificar prevalência de AVC isquêmico e ataque isquêmico transitório (AIT) associados à descontinuação de terapia antiplaquetária ou coumarínicos em pacientes internados em hospital especializado em atendimento neurológico no Brasil. Métodos Estudo transversal, retrospectivo de três anos, descritivo dos pacientes hospitalizados por AVC. A revisão de relatórios médicos determinou características do AVC, fatores de risco, motivos e tempo de interrupção medicamentosa. Resultados Em três anos, foram internados 360 pacientes por AVC ou AIT; destes, 27 interromperam temporariamente terapia antiplaquetária ou coumarínicos relacionando ao evento (81% acidente vascular cerebral isquêmico, 19% AIT). A prevalência foi de 7,5%. O tempo médio entre interrupção antiplaquetária e evento foi cinco dias, com 62% deles ocorrendo até sete dias após suspensão medicamentosa. Para coumarínicos, o tempo médio foi 10,4 dias (d.p.= 5,7), em 67% dos casos o tempo entre a descontinuação medicamentosa e o evento foi 7-14 dias. O motivo mais frequente para suspensão do medicamento foi negligência do paciente (37%), seguido por cirurgia planejada ou exame invasivo (26%) e efeitos colaterais, incluindo hemorragia (18,5%). Conclusão Suspensão de terapia de antiplaquetários ou coumarínicos tem relação temporal com ocorrência de AVC e de AIT. Esses eventos são passíveis de serem evitados, sendo imprescindível que profissionais de saúde convençam seus pacientes das consequências graves da retirada do medicamento.

The cost of stroke in private hospitals in Brazil: a one-year prospective study / O custo do AVC em hospitais privados no Brasil: um estudo prospectivo

ABSTRACT Few studies from low- and middle-income countries have assessed stroke and cerebral reperfusion costs from the private sector. Objective To measure the in-hospital costs of ischemic stroke (IS), with and without cerebral reperfusion, primary intracerebral hemorrhage (PIH), subarachnoid hemorrhage (SAH) and transient ischemic attacks (TIA) in two private hospitals in Joinville, Brazil. Methods Prospective disease-cost study. All medical and nonmedical costs for patients admitted with any stroke type or TIA were consecutively determined in 2016-17. All costs were adjusted to the gross domestic product deflator index and purchasing power parity. Results We included 173 patients. The median cost per patient was US$3,827 (IQR: 2,800-8,664) for the 131 IS patients; US$2,315 (IQR: 1,692-2,959) for the 27 TIA patients; US$16,442 (IQR: 5,108-33,355) for the 11 PIH patients and US$28,928 (IQR: 12,424-48,037) for the four SAH patients (p < 0.00001). For the six IS patients who underwent intravenous thrombolysis, the median cost per patient was US$11,463 (IQR: 8,931-14,291), and for the four IS patients who underwent intra-arterial thrombectomy, the median cost per patient was US$35,092 (IQR: 31,833-37,626; p < 0.0001). A direct correlation was found between cost and length of stay (r = 0.67, p < 0.001). Conclusions Stroke is a costly disease. In the private sector, the costs of cerebral reperfusion for IS treatment were three-to-ten times higher than for usual treatments. Therefore, cost-effectiveness studies are urgently needed in low- and middle-income countries.

RESUMO Poucos estudos determinam o custo do AVC em países de baixa e média renda nos setores privados. Objetivos Mensurar o custo hospitalar do tratamento do(a): AVC isquêmico com e sem reperfusão cerebral, hemorragia intracerebral primária (HIP), hemorragia subaracnóidea e ataque isquêmico transitório (AIT) em hospitais privados de Joinville, Brasil. Métodos Estudo prospectivo de custo de doença. Os custos médicos e não médicos dos pacientes admitidos com qualquer tipo de AVC ou AIT foram consecutivamente verificados em 2016-17. Os valores foram ajustados ao índice do deflator do produto interno bruto e à paridade do poder de compra. Resultados Nós incluímos 173 pacientes. A mediana de custo por paciente foi de US$ 3.827 (IQR: 2.800-8.664) para os 131 pacientes com AVC isquêmico; US$ 2.315 (1.692-2.959) para os 27 pacientes com AIT; US$ 16.442 (5.108-33.355) para os 11 pacientes com HIP e US$ 28.928 (12.424-48.037) para os quatro pacientes com HSA (p < 0,00001). Para seis pacientes submetidos à trombólise intravenosa, a mediana do custo por paciente foi de US$ 11.463 (8.931-14.291) e, para quatro pacientes submetidos à trombectomia intra-arterial, a mediana de custo por paciente foi de US$ 35.092 (31.833-37.626; p < 0,0001). Uma correlação direta foi encontrada entre custo e tempo de permanência (r = 0,67, p < 0,001). Conclusão O AVC é uma doença cara. Em ambiente privado, os custos da reperfusão cerebral foram de três a dez vezes superiores aos tratamentos habituais do AVC isquêmico. Portanto, estudos de custo-efetividade são urgentemente necessários em países de baixa e média rendas.

The cost of stroke in a public hospital in Brazil: a one-year prospective study / Custo do AVC em um hospital público no Brasil: um estudo prospectivo de um ano

ABSTRACT Low- and middle-income countries face tight health care budgets, not only new resources, but also costly therapeutic resources for treatment of ischemic stroke (IS). However, few prospective data about stroke costs including cerebral reperfusion from low- and middle-income countries are available. Objective To measure the costs of stroke care in a public hospital in Joinville, Brazil. Methods We prospectively assessed all medical and nonmedical costs of inpatients admitted with a diagnosis of any stroke or transient ischemic attack over one year, analyzed costs per type of stroke and treatment, length of stay (LOS) and compared hospital costs with government reimbursement. Results We evaluated 274 patients. The total cost for the year was US$1,307,114; the government reimbursed the hospital US$1,095,118. We found a significant linear correlation between LOS and costs (r = 0.71). The median cost of 134 IS inpatients who did not undergo cerebral reperfusion (National Institutes of Health Stroke Scale [NIHSS] median = 3 ) was US$2,803; for IS patients who underwent intravenous (IV) alteplase (NIHSS 10), the median was US$5,099, and for IS patients who underwent IV plus an intra-arterial (IA) thrombectomy (NIHSS > 10), the median cost was US$10,997. The median costs of a primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack were US$2,436, US$8,031 and US$2,677, respectively. Conclusions Reperfusion treatments were two-to-four times more expensive than conservative treatment. A cost-effectiveness study of the IS treatment option is necessary.

RESUMO Os países de baixa e media renda enfrentam orçamentos apertados na saúde, não somente devido aos novos recursos terapêuticos, mas relacionado ao custo oneroso do tratamento do acidente vascular cerebral. No entanto, poucos dados prospectivos sobre os custos do AVC, incluindo reperfusão cerebral de países de baixa e média renda estão disponíveis. Objetivo Mensurar os custos do atendimento ao AVC em um hospital público. Métodos Avaliamos prospectivamente todos os custos médicos e não médicos de pacientes internados com diagnóstico de acidente vascular cerebral ou AIT durante 1 ano, analisamos os custos por tipo de AVC e tratamento, tempo de permanência e comparamos os custos hospitalares com o reembolso governamental. Resultados Foram avaliados 274 pacientes. O custo total em um ano foi de US$ 1.307,114; o governo reembolsou o hospital no valor de US$ 1.095.118. Encontramos uma correlação linear significativa entre LOS e custos (r = 0,71). A mediana do custo do AVCI em 134 pacientes que não sofreram reperfusão cerebral (National Institutes of Health Stroke Scale [NIHSS] mediana = 3) foi de US$ 2.803; para pacientes submetidos a alteplase intravenosa (IV) (NIHSS 10), a mediana foi de US$ 5.099 e para os pacientes submetidos a trombectomia intra-arterial (IA) (NIHSS > 10), o custo mediano foi de US$ 10.997. A mediana do custo de uma hemorragia intracerebral primária, hemorragia subaracnóidea e AIT foram de US$ 2.436, US$ 8.031 e US$ 2.677, respectivamente. Conclusões Os tratamentos de reperfusão foram duas a quatro vezes mais caros do que o tratamento conservador. Estudo de custo-efetividade para o tratamento do AVC são necessários.

The relation between echocardiographic epicardial fat thickness and cha2ds2-vasc score in patients with sinus rhythm

Abstract Objective: To evaluate the predictive value of epicardial fat thickness (EFT) in CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category) score risk groups. Methods: A total of 158 consecutive patients (75 females, 83 males, mean age 70.8±6.3 years) admitted routinely for cardiologic control were divided into two groups according to their CHA2DS2-VASc scores (scores 0 and 1 were regarded as low risk, and score ≥2 as high risk). One hundred twenty-five of 158 patients had a high-risk score. Results: Mean EFT was significantly higher in the high-risk group than in the low-risk group (4.34±0.62 vs. 5.37±1.0; P<0.001). EFT was positively correlated with CHA2DS2-VASc score (r=0.577, P<0.001). According to receiver operating characteristics (ROC) analysis, EFT value of 4.4 mm was found to be predictive of high risk in CHA2DS2-VASc score with 80% of sensitivity and 79% of specificity (C-statistic = 0.875, P<0.001, 95% confidence interval [CI] = 0.76-0.90). And according to multivariate logistic regression analysis, EFT was an independent predictor of high thromboembolic risk in terms of CHA2DS2-VASc score. Conclusion: Our findings suggest that echocardiographic EFT measurement could provide additional information on assessing cardiovascular risks, such as thromboembolic events, and individuals with increased EFT should receive more attention to reduce unfavorable cardiovascular risk factors and the development of future cardiovascular events.

Get With The Guidelines®-Stroke performance indicators in patients with transient ischemic attack / Indicadores de desempenho do programa "Get With The Guidelines®-Stroke" em pacientes com ataque isquêmico transitório

ABSTRACT Get With The Guidelines®-Stroke is an in-hospital program for improving stroke care by promoting adherence to scientific guidelines. Of the patients with transient ischemic attack (TIA), 10-15% have a stroke within three months, and many patients do not receive the recommended interventions to prevent this outcome. Objective: The goal of this study was to assess the adherence to stroke quality indicators in patients with TIA. Methods: This retrospective observational study evaluated consecutive patients admitted to a primary stroke center with TIA or acute ischemic stroke (AIS) from August 2008 to December 2013. Six quality indicators applicable to both TIA and AIS were analyzed and compared between groups. Results: A total of 357 patients with TIA and 787 patients with AIS were evaluated. Antithrombotic medication use within 48 hours of admission, discharge use of anticoagulation for atrial fibrillation and counseling for smoking cessation were similar between groups. In the TIA group, discharge use of antithrombotic medication (95% versus 98%; p = 0.01), lipid-lowering treatment (57.7% versus 64.1%; p < 0.01) and stroke education (56.5% versus 74.5%; p < 0.01) were all less frequently observed compared with patients with AIS. Conclusions: The adherence to some of the Get With The Guidelines®-Stroke quality indicators was lower in patients with TIA than in patients with AIS. Measures should be undertaken to reinforce the importance of such clinical interventions in patients with TIA.

RESUMO O "Get With The Guidelines®-Stroke (GWTG-S)" é um programa hospitalar criado para melhorar os cuidados em pacientes com AVC ao promover a adesão às diretrizes. Dez a quinze porcento dos pacientes com ataque isquêmico transitório terão um AVC em 3 meses, sendo que muitos não recebem intervenções de prevenção secundária recomendadas. Objetivo: Avaliar a adesão aos indicadores de qualidade do programa GWTG em pacientes com ataque isquêmico transitório. Métodos: Este estudo retrospectivo observacional avaliou pacientes consecutivos admitidos em um centro de AVC com suspeita de ataque isquêmico transitório ou AVC isquêmico agudo de agosto/2008 a dezembro/2013. Seis indicadores de qualidade aplicáveis tanto ao ataque isquêmico transitório quanto ao AVC isquêmico agudo foram analisados e comparados entre os grupos. Resultados: Um total de 357 pacientes com ataque isquêmico transitório e 787 pacientes com AVC isquêmico agudo foram avaliados. O uso de antiagregante dentro das primeiras 48 horas da admissão, liberação na alta com anticoagulante para fibrilação atrial e aconselhamento para cessação do tabagismo foram similares entre os grupos. No grupo com ataque isquêmico transitório, o uso de antiagregante na alta hospitalar, o tratamento com estatina e a educação sobre o AVC foram observados menos frequentemente quando comparados ao grupo de pacientes com AVC isquêmico agudo. Conclusões: A adesão a alguns dos indicadores de qualidade do programa GWTG-S foi mais baixa em pacientes com ataque isquêmico transitório quando compara a pacientes com AVC isquêmico agudo. Medidas devem ser tomadas para reforçar a importância dessas intervenções em pacientes admitidos com ataque isquêmico transitório.

Uninterrupted Use of Oral Anticoagulants for the Ablation of Atrial Flutter: A Single Center Cohort of 154 Patients / Uso Ininterrupto de Anticoagulantes Orais na Ablação de Flutter Atrial Istmo-Cavotricuspídeo Dependente: Coorte Unicêntrica de 154 Pacientes

Abstract Background: The uninterrupted use of oral anticoagulation (OAC) with vitamin K antagonists (VKAs) for electrophysiology procedures has been more and more recommended. The clinical practice in our service recommends the continuous use of these drugs for atrial flutter ablation. There is little evidence as to the uninterrupted use of non-vitamin K antagonist oral anticoagulants (NOACs) in this scenario. Objective: To compare the rates of complications related with the uninterrupted use of different types of oral anticoagulants in patients referred to atrial flutter (AFL) ablation. Methods: Historical, single-center cohort of ablation procedures by AFL conducted from November 2012 to April 2016. The primary outcome was the occurrence of hemorrhagic or embolic complication during the procedure. The secondary outcome was the occurrence of stroke or transient ischemic attack (TIA) in follow-up. The statistical significance level was 5%. Results: There were 288 ablations per AFL; 154 were carried out with the uninterrupted use of OAC (57.8% with VKA and 42.2% with NOAC). Mean age was 57 ± 13 years. The rate of hemorrhagic complication during the procedure was 3% in each group (p = NS). The rate of stroke/TIA was, respectively, of 56/1,000 people-year in the VKA group against zero/1,000 people-year in the NOAC group (p = 0.02). Conclusion: In our population there were no hemorrhagic complications regarding the procedure of OAC use uninterruptedly, including NOACs. There was higher occurrence of stroke/TIA in the follow-up of the group of patients undergoing VKAs; however, this difference may not only be a result of the type of OAC used.

Resumo Fundamento: O uso ininterrupto de anticoagulação oral (ACO) com antagonistas da vitamina K (AVKs) para procedimentos de eletrofisiologia está sendo cada vez mais recomendado. A prática clínica em nosso serviço é de uso continuado dessas drogas para ablação de flutter atrial. Existem poucas evidências quanto ao uso ininterrupto dos anticoagulantes orais não antagonistas da vitamina K (NOACs) nesse cenário. Objetivos: Comparar as taxas de complicações relacionadas ao uso ininterrupto de diferentes tipos de anticoagulantes orais em pacientes referidos para ablação por flutter atrial (FLA). Métodos: Coorte histórica e unicêntrica dos procedimentos de ablação por FLA realizados no período de novembro de 2012 a abril de 2016. O desfecho primário foi o de ocorrência de complicação hemorrágica ou embólica durante o procedimento. O desfecho secundário foi o de ocorrência de acidente vascular cerebral (AVC) ou acidente isquêmico transitório (AIT) no acompanhamento. O nível de significância estatística adotado foi de 5%. Resultados: Foram incluídas 288 ablações por FLA; 154 foram feitas com uso ininterrupto de ACO (57,8% com AVK e 42,2% com NOAC). A idade média foi de 57 ± 13 anos. A taxa de complicação hemorrágica durante o procedimento foi de 3% em cada grupo (p = NS). A taxa de AVC/AIT foi, respectivamente, de 56/1.000-pessoas-ano no grupo AVK contra zero/1.000-pessoas-ano no grupo NOAC (p = 0,02). Conclusão: Em nossa população não ocorreram complicações hemorrágicas relacionadas ao procedimento com uso de ACO de forma ininterrupta, incluindo NOACs. Houve maior ocorrência de AVC/AIT no seguimento no grupo de pacientes em uso de AVK, contudo essa diferença pode não ser decorrente apenas do tipo de ACO em uso.

Ondas de choque en población deportiva y no deportiva: resultados preliminares / Extracorporeal shockwave terapy in sports and non-sports population: preliminary results

Antecedentes: Las alteraciones inflamatorias y calcificantes de las partes blandas son trastornos con importante repercusión económica y social. Su tratamiento puede realizarse con fármacos o con terapia física, ante cuyo fracaso, la cirugía era el último escalón terapéutico existente. En los últimos años se está utilizando una alternativa no quirúrgica para tratarlas: la aplicación de ondas de choque extracorpóreas. El objetivo de este trabajo es comprobar la capacidad para disminuir el dolor en diferentes alteraciones con esta técnica terapéutica y definir las pautas de aplicación. Métodos: Se trataron 18 deportistas y 12 pacientes de la población normal todos con alguna alteración: espolón calcáneo, tendinitis calcificada y no calcificada y fascitis plantar. Los resultados se evaluaron por la escala analógica visual de dolor y por la ecografía, antes y después del tratamiento. Resultados: Hubo un porcentaje de reducción del dolor de 100%, siendo la población normal atendida la que mostró síntomas de una mejor evolución en el período de tiempo evaluado. Conclusiones: Se concluye que agotadas las medidas terapéuticas médicas y de terapia física, el tratamiento con ondas de choque extracorpóreas es una buena alternativa al empleo de la cirugía.

Background: Inflammatory and calcifying diseases of the soft tissues are disorders having significant economical and social repercussions. They can be treated with drugs or physical therapy, and if these fail, surgery used to be the last existing therapeutic step. In recent years, a non-surgical alternative is being used to treat them, the application of extracorporeal shock waves. This work aims to verify the capacity of this therapeutic technique to diminish pain and to define its application rules. Method: We treated 18 athletes and 12 patients from normal population with heel spurs, calcified and noncalcified tendonitis and plantar fasciitis. The results were evaluated with a visual analogical scale of pain and by echography, prior to treatment and after. Results: The treatment was effective in 100% of the subjects. Conclusions: We conclude that once the medical therapeutic and the physical therapy measures are used up, treatment with shock waves is a good alternative to using surgery.

Indicadores de salud mental asociados a riesgo psicosocial laboral en un hospital público / Psychosocial stress among health care workers

Background: Health care workers are exposed to high stress levels and psychosocial risks. The imbalance between the invested efforts and received rewards acquires special importance in this setting. Aim: To assess the psychosocial risk level and its relationship with depression, distress and psychotropic drug use among health care workers. Material and Methods: Seven hundred eighty two workers (602 females; 180 males) answered self-administered questionnaires to measure psychosocial risk and mental health. Results: Twenty five percent of respondents used psychotropic drugs, 34% had a high level of distress and 23% had depressive symptoms. They also reported a low level of decisional latitude (48%), high emotional demands (47%), low social support (41%) and a significant effort-reward imbalance (67%). Those exposed to job strain (high demands and low decisional latitude), iso-strain (job strain plus low social support), and effort-reward imbalance were twice as likely to suffer symptoms of depression and elevated distress compared to non-exposed subjects. Conclusions: There are high levels of psychosocial stress among health care workers.

Score for atrial fibrillation detection in acute stroke and transient ischemic attack patients in a Brazilian population: The acute stroke atrial fibrillation scoring system

OBJECTIVE: Atrial fibrillation is a common arrhythmia that increases the risk of stroke by four- to five-fold. We aimed to establish a profile of patients with atrial fibrillation from a population of patients admitted with acute ischemic stroke or transient ischemic attack using clinical and echocardiographic findings. METHODS: We evaluated patients consecutively admitted to a tertiary hospital with acute ischemic stroke or transient ischemic attack. Subjects were divided into an original set (admissions from May 2009 to October 2010) and a validation set (admissions from November 2010 to April 2013). The study was designed as a cohort, with clinical and echocardiographic findings compared between patients with and without atrial fibrillation. A multivariable model was built, and independent predictive factors were used to produce a predictive grading score for atrial fibrillation (Acute Stroke AF Score-ASAS). RESULTS: A total of 257 patients were evaluated from May 2009 to October 2010 and included in the original set. Atrial fibrillation was diagnosed in 17.5% of these patients. Significant predictors of atrial fibrillation in the multivariate analysis included age, National Institutes of Health Stroke Scores, and the presence of left atrial enlargement. These predictors were used in the final logistic model. For this model, the area under the receiver operating characteristic curve was 0.79. The score derived from the logistic regression analysis was The model developed from the original data set was then applied to the validation data set, showing the preserved discriminatory ability of the model (c statistic = 0.76). CONCLUSIONS: Our risk score suggests that the individual risk for atrial fibrillation in patients with acute ischemic stroke can be assessed using simple data, including age, National Institutes of Health Stroke Scores at admission, and the presence of left atrial enlargement. .

Ataque isquémico transitorio: incidencia de accidente cerebrovascular fatal / Transient ischemic attack: incidence of fatal stroke

El AIT (ataque isquémico transitorio) se considera predictor de ACV. El seguimiento a seis meses mostró un riesgo cercano al 10%. Son dos espectros de la enfermedad cerebro vascular isquémica de alto impacto en la morbi-mortalidad a nivel mundial. Objetivo: evaluar la incidencia de ACV en pacientes con AIT hospitalizados en dos instituciones con seguimiento a 180 días. Metodología: estudio de cohorte, el AIT se definió por historia y examen clínico, excluyendo el infarto por neuroimagen. Se evaluó el riesgo de ACV con la escala ABCD2, documentándolo por neuroimagen. Resultados: ingresaron 85 casos (abril 2012/ abril 2013). Edad promedio 68.1 años (DE 13.5), 62.4% mujeres. Los factores de riesgo más frecuentes fueron HTA (69.4%), dislipidemia (56.4%), tabaquismo (31.1%) y antecedente de ACV (18.8%). El 24.6% presentó ACV (n:19), con dos fallecimientos (2.4%). El ABCD2 ≥ 5 fue predictor de ACV, HR 4.7 [IC 95% 1.1-20.7]. Entre los pacientes con previo antecedente de ACV, la mitad de ellos repitió el evento (8/16), HR 2.2 [IC 95% 0.81-6.1]. Conclusión: hay alta incidencia de ACV después de AIT. Se requieren estudios con muestra de mayor tamaño.

Transient ischemic attacks (TIAs) are considered predictors of CVA. A six-month follow-up showed a risk of nearly 10%. There are two spectrums of ischemic cerebrovascular disorders with high impact on morbidity and mortality worldwide. Objective: to assess the incidence of CVAs after a 180-day follow-up in patients with prior TIA hospitalized in two institutions. Methodology: a cohort study: TIA was defined by medical record and physical exam, excluding infarct by neuroimaging. CVA risk was assessed using the ABCD2 scale and documented by neuroimaging. Results: eighty-five cases were admitted between April, 2012 and April, 2013; mean age was 68.1 years (SD 13.5); 62.4% were females. The most frequent risk factors were, ATH (69.4%), dyslipidemia (56.4%), smoking (31.1%) and prior stroke (18.8%). A CVA occurred in 24.6% (n: 19), accounting for 2 deaths (2.4%). An ABCD2 score ≥ 5 was a predictor of CVA, HR 4.7 [CI 95% 1.1-20.7]. Of patients with a prior CVA half presented a new event (8/16), HR 2.2 [CI 95% 0.81-6.1]. Conclusion: there is a high incidence of CVA after a TIA. Studies with a larger sample size are required.

Chlamydia pneumoniae and stroke: is there a direct relationship? / Chlamydia pneumoniae e acidente vascular cerebral aterotrombótico: existe relação direta?

OBJECTIVE: To investigate the possible relationship between atherothrombotic stroke and Chlamydia pneumoniae. METHOD: 150 patients with carotid atherothrombosis were enrolled. The casuistic was divided in three groups: ischemic stroke (IS): 65 patients; transient ischemic attack (TIA): 26 patients; and control: 59. The IS or TIA onset was up to 30 days from the beginning of the study. Carotid atheromatoses was diagnosed by Doppler-ultrasonography. Patients with cardioembolic risk or non-atherothrombotic origin were excluded. Comparisons were done between the three groups, and within each group according to the different age sub-groups, to the main arteries affected, and to the atherogenic risk factors. Bacteria detection was done using polimerase chain reaction. RESULTS: Only one patient tested positive for C. pneumoniae belonging to the control group. CONCLUSION: These results do not suggest that C. pneumoniae participated in the onset of IS or TIA or that it has a role in carotid plaque destabilization.

OBJETIVO: Investigar a possível relação entre Chlamydia pneumoniae e acidente vascular cerebral aterotrombótico (AVC). MÉTODO: 150 pacientes com aterotrombose carotídea foram estudados. A casuística foi dividida em 3 grupos: AVC: 65 pacientes; ataque isquêmico transitório (AIT): 26 pacientes e controles: 59. O início do AVC ou AIT era até 30 dias da inclusão no estudo. A ateromatose carotídea foi diagnosticada por ultrassonografia com Doppler. Os pacientes com risco cárdio-embólico ou sem evidência de aterotrombose foram excluídos. Foram estabelecidas comparações entre os 3 grupos e dentro de cada grupo, formado sub-grupos de acordo com diferentes idades, território arterial comprometido e fatores de risco. A detecção da bactéria foi feita por reação de polimerização em cadeia. RESULTADOS: Somente um paciente, pertencente ao grupo controle, teve resultado positivo. CONCLUSÃO: Estes achados não sugerem que a C. pneumoniae participe no desencadeamento do AVC ou AIT ou que tenha papel na desestabilização da placa.

Stroke management in a university hospital in the largest South American city / Manejo do acidente vascular cerebral em um hospital universitário na maior cidade da América do Sul

OBJECTIVE: To describe characteristics and provision of care for patients admitted with cerebrovascular disorders (CVD), focusing on ischemic stroke (IS), in a large, public, academic hospital in São Paulo, Brazil. METHOD: We retrieved information about 357 patients with CVD admitted to the Neurology Emergency Department (NED) and Neurology Ward (NW) of our institution. We described patient characteristics and management of IS in NED and in NW. RESULTS: IS was diagnosed in 79.6 percent of CVD patients admitted to NED; 2.7 percent were submitted to thrombolysis. Extent of IS investigation and management were significantly different in NED and NW. CONCLUSION: IS patients in our center were younger than in developed countries. IS management was significantly influenced by patient characteristics. This information can aid in planning strategies to decrease stroke burden.

OBJETIVO: Descrever características e manejo de pacientes internados com diagnóstico de doença cerebrovascular (DCV), enfocando principalmente o acidente vascular cerebral isquêmico (AVCI), em um hospital público universitário em São Paulo. MÉTODO: Coletamos informações de 357 pacientes com DCV internados no Pronto-Socorro de Neurologia (PSN) e na Enfermaria de Neurologia (EN) de nossa instituição. Descrevemos características dos pacientes e manejo do AVCI no PSN e na EN. RESULTADOS: O AVCI foi diagnosticado em 79,6 por cento dos pacientes com DCV admitidos no PSN; 2,7 por cento foram submetidos a trombólise. A extensão da investigação e o manejo da doença foram significativamente diferentes no PSN e na EN. CONCLUSÃO: os pacientes com AVCI em nosso centro foram mais jovens que em países desenvolvidos. O manejo do AVCI foi influenciado significativamente pelas características dos pacientes. Estas informações podem auxiliar no planejamento de estratégias para diminuir as conseqüências das DCV em nosso meio.

Accidente cerebrovascular isquémico en mayores de 80 años / Acute ischemic stroke in patients aged 80 or older

En los pacientes de edad avanzada, el perfil de factores de riesgo vascular y el subtipo de accidente cerebrovascular (ACV) es diferente en comparación con pacientes más jóvenes. El objetivo del presente trabajo fue describir el perfil de factores de riesgo y subtipo de ACV isquémico en nuestra población de pacientes ancianos. Incluimos a pacientes mayores de 80 años con diagnóstico de ACV isquémico y ataque isquémico transitorio (AIT) entre junio de 2003 y junio de 2006. De 535 pacientes con eventos cerebrovasculares isquémicos, en 366 casos el diagnóstico fue de ACV y 169 de AIT. El 33.5% (179 pacientes) fueron mayores de 80 años. La edad media fue de 84.4 ± 4.4 años. Los factores de riesgo más frecuentes fueron: hipertensión arterial 82.7%, dislipemia 40.2% y fibrilación auricular 24.6%. El subtipo de ACV que se presentó con mayor frecuencia fue la enfermedad de pequeñas arterias en un 41.7%, seguido por el evento cardioembólico en el 19.7%, enfermedad de gran arteria 6%, otras causas en el 0.8%. De los factores de riesgo vasculares tradicionales, los más significativos fueron hipertensión e hipercolesterolemia. Estos datos son coincidentes con estudios epidemiológicos previos y explican la mayor incidencia de infartos lacunares.

Young and old age stroke groups have different vascular risk profiles for cerebral ischemic events. The objective of the study was to describe the risk factor profile and stroke subtype in this population of very elderly people. We included patients over 80 years old with diagnosis of ischemic stroke and transient ischemic attack registered between June 2003 and June 2006. We described the demographic data and subtype of ischemic stroke. Of 535 patients with cerebrovascular ischemic events, the final diagnosis was stroke in 366 cases and transient ischemic attack in 169. Of these patients 33.5% were over 80 years old (179). The mean age was 84.4 ± 4.4 years. The most frequent risk factors were: hypertension 82.7%, dyslipemia 40.2% and atrial fibrillation 24.6%. Stroke subtype was: large artery disease 6%, cardioembolic stroke 19.7%, small artery disease 41.7%, and other causes 0.8%. Among traditional risk factors for stroke in our very elderly patients, the most significant were hypertension and dyslipemia. This agrees with previous epidemiological studies. The high incidence of small artery disease in our patients may be explained by the risk factor profile.

Isquemia cerebral transitoria y riesgo de infarto cerebral isquémico / Transitory cerebral isquemia and risk of cerebral ischemic stroke

La enfermedad vascular cerebral es la principal causa de hospitalización neurológica en el mundo. Costa Rica no es la excepción; en nuestros hospitales cada día es más frecuente el número de pacientes que ingresan con infartos cerebrales isquémicos. Esta común enfermedad obedece a la prevalencia de enfermedades crónicas con la hipertensión arterial, diabetes mellitus, dislipidemias, tabaquismo y la alta expectativa de vida de los costarricenses, todos considera dos factores de riesgo. Aproximadamente un 80 por ciento de los infartos cerebrales son isquémicos secundarios a la oclusión arterial aguda de un territorio vascular específico, el restante 20 por ciento corresponde a la variante hemorrágica. Las secuelas neurológicas secudarias a esta entidad son la principal causa de discapacidad crónica en los pacientes y conlleva una alta morbilidad y mortalidad. Aunque muchos sufren el infarto cerebral isquémico en forma aguda, otro grupo de pacientes experimenta uno o varios episodios previos de isquemia cerebral transitoria, lo cual los pone en riesgo de sufrir un infarto cerebral isquémico durante un periodo corto, es decir son pacientes vulnerables. Esta revisión pretende actualizar los conocimientos médicos, especialmente para aquellos que trabajan en la atención primaria y en los servicios de urgencias hospitalarias, que reconozcan a este grupo de pacientes y les brinden la atención médica necesaria para de prevenir un infarto cerebral isquémico. La isquemia cerebral transitoria debe ser considerada como una emergencia neurológica. Descriptores: Isquemia cerebral transitoria, emergencia neurológica, infarto cerebral isquémico.

Prevalence of cardiovascular conditions and health services utilization in Puerto Rico, 2001

OBJECTIVE To study the prevalence of cardiovascular conditions and health services utilization in Puerto Rico, 2001. METHODS All medical claims for coronary heart disease (ICD-9 410-414), hypertension (ICD-9 401-405), congestive heart failure (ICD-9 428) and cerebrovascular accidents and transient ischemia (ICD-9:430-438.9) submitted for reimbursement purposes to an insurance company (private and public sector) in Puerto Rico in 2001 were identified. Prevalence and medical care utilization concerning cardiovascular conditions was estimated with 95% confidence. RESULTS Overall prevalence of cardiovascular conditions was 13.5% (95% CI: 11.68%-15.44%), being larger in the private sector (16.0%; 95% CI: 15.98%-16.08% vs. 11.7%; 95% CI: 11.62%-11.77%). Although in both sectors prevalence increased with age, at same age groups was two times higher in the private sector. Hypertension was the most prevalent condition (9.7; 95% CI: 8.14%-11.41%) being higher in females (10.4; 95% CI: 10.37%-10.51%) than in males (8.9; 95% CI: 8.81%-8.96%). The health service utilization (physician's office visits, emergency room visits, and hospital admissions) was higher in males. However, it varies by sectors. CONCLUSIONS Significant difference exists in the prevalence of cardiovascular conditions and health services utilization among private and public sectors in Puerto Rico. The observed differences among the private and public populations imply that there are factors such as socioeconomic status, education, lifestyles, environmental hazards in neighborhoods, and health habits that could be involved in the differences