Frequency and Patterns of Brain Infarction in Patients With Embolic Stroke of Undetermined Source: NAVIGATE ESUS Trial.

BACKGROUND AND PURPOSE: The spectrum of brain infarction in patients with embolic stroke of undetermined source (ESUS) has not been well characterized. Our objective was to define the frequency and pattern of brain infarcts detected by magnetic resonance imaging (MRI) among patients with recent ESUS participating in a clinical trial. METHODS: In the NAVIGATE ESUS trial (New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial Versus ASA to Prevent Embolism in Embolic Stroke of Undetermined Source), an MRI substudy was carried out at 87 sites in 15 countries. Participants underwent an MRI using a specified protocol near randomization. Images were interpreted centrally by those unaware of clinical characteristics. RESULTS: Among the 918 substudy cohort participants, the mean age was 67 years and 60% were men with a median (interquartile range) of 64 (26-115) days between the qualifying ischemic stroke and MRI. On MRI, 855 (93%) had recent or chronic brain infarcts that were multiple in 646 (70%) and involved multiple arterial territories in 62% (401/646). Multiple brain infarcts were present in 68% (510/755) of those without a history of stroke or transient ischemic attack before the qualifying ESUS. Prior stroke/transient ischemic attack (P<0.001), modified Rankin Scale score >0 (P<0.001), and current tobacco use (P=0.01) were associated with multiple infarcts. Topographically, large and/or cortical infarcts were present in 89% (757/855) of patients with infarcts, while in 11% (98/855) infarcts were exclusively small and subcortical. Among those with multiple large and/or cortical infarcts, 57% (251/437) had one or more involving a different vascular territory from the qualifying ESUS. CONCLUSIONS: Most patients with ESUS, including those without prior clinical stroke or transient ischemic attack, had multiple large and/or cortical brain infarcts detected by MRI, reflecting a substantial burden of clinical stroke and covert brain infarction. Infarcts most frequently involved multiple vascular territories. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02313909.

Cerebral venous thrombosis in Argentina: clinical presentation, predisposing factors, outcomes and literature review.

BACKGROUND: Cerebral venous thrombosis (CVT) is a rare medical condition that primarily affects young adults. The clinical spectrum is broad and its recognition remains a challenge for clinicians. Limited information is available on CVT in Argentina. Our goal was to report the results of the first National registry on CVT in Argentina and to compare clinical presentation, predisposing factors and outcomes with other international registries. MATERIAL AND METHOD: The Argentinian National Registry on CVT (ANR-CVT) is a multicenter retrospective cohort study comprising patients aged 18 and older with a diagnosis of CVT from January 2015 to January 2019. We evaluated demographics, predisposing factors, clinical presentation, and radiological characteristics (e.g. number of involved sinuses, venous infarction or hemorrhage on CT and MRI scans at admission), therapeutic interventions and functional outcomes at discharge and at 90 days. Our results were compared to a literature review of CVT registries. RESULTS: Overall, one hundred and sixty-two patients met the inclusion criteria. The mean age was 42 (±17) years; 72% were women. Seventy percent of patients were younger than 50 years. The most common presenting symptom was headache (82%). The transverse sinus was the most common site of thrombosis (70%) followed by the sigmoid sinus (46%). The main predisposing factor in women was contraceptive use (44%), 3% of the events occurred during pregnancy and 9% during the puerperium. Participants 50 years and older had a higher frequency on malignancy related (7.5% vs. 30%, p = 0.0001) and infections (2% vs. 11%, p = 0.001). The modified Rankin Scale (mRS) ≤2 at discharge was 81% and the rate of mortality at discharge was 4%. At 90 days, the mRS≤2 was 93%. When the ANR-CVT was compared with larger registries from Europe and Asia, the prevalence of cancer among patients with CVT was two to five-fold higher (15% vs. 7% and 3%, respectively; p = 0.002 and p < 0.001). Anticoagulation rates at discharge were also higher (94%) compared to registries from Asia (ASCVT - 68%) or Turkey (VENOST - 67%). CONCLUSION: Participants in the first ANR-CVT had a low mortality and disability at 90 days. Clinical and radiological characteristics were similar to CVT from other international registries with a higher prevalence of cancer. There was a high variability in treatment adherence to guidelines as reflected by anticoagulation rates (range 54.5%-100%) at discharge.

Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a developmental condition characterised by symptoms of inattention, hyperactivity and impulsivity, along with deficits in executive function, emotional regulation and motivation. The persistence of ADHD in adulthood is a serious clinical problem.ADHD significantly affects social interactions, study and employment performance.Previous studies suggest that cognitive-behavioural therapy (CBT) could be effective in treating adults with ADHD, especially when combined with pharmacological treatment. CBT aims to change the thoughts and behaviours that reinforce harmful effects of the disorder by teaching people techniques to control the core symptoms. CBT also aims to help people cope with emotions, such as anxiety and depression, and to improve self-esteem. OBJECTIVES: To assess the effects of cognitive-behavioural-based therapy for ADHD in adults. SEARCH METHODS: In June 2017, we searched CENTRAL, MEDLINE, Embase, seven other databases and three trials registries. We also checked reference lists, handsearched congress abstracts, and contacted experts and researchers in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating any form of CBT for adults with ADHD, either as a monotherapy or in conjunction with another treatment, versus one of the following: unspecific control conditions (comprising supportive psychotherapies, no treatment or waiting list) or other specific interventions. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures suggested by Cochrane. MAIN RESULTS: We included 14 RCTs (700 participants), 13 of which were conducted in the northern hemisphere and 1 in Australia.Primary outcomes: ADHD symptomsCBT versus unspecific control conditions (supportive psychotherapies, waiting list or no treatment)- CBT versus supportive psychotherapies: CBT was more effective than supportive therapy for improving clinician-reported ADHD symptoms (1 study, 81 participants; low-quality evidence) but not for self-reported ADHD symptoms (SMD -0.16, 95% CI -0.52 to 0.19; 2 studies, 122 participants; low-quality evidence; small effect size).- CBT versus waiting list: CBT led to a larger benefit in clinician-reported ADHD symptoms (SMD -1.22, 95% CI -2.03 to -0.41; 2 studies, 126 participants; very low-quality evidence; large effect size). We also found significant differences in favour of CBT for self-reported ADHD symptoms (SMD -0.84, 95% CI -1.18 to -0.50; 5 studies, 251 participants; moderate-quality evidence; large effect size).CBT plus pharmacotherapy versus pharmacotherapy alone: CBT with pharmacotherapy was more effective than pharmacotherapy alone for clinician-reported core symptoms (SMD -0.80, 95% CI -1.31 to -0.30; 2 studies, 65 participants; very low-quality evidence; large effect size), self-reported core symptoms (MD -7.42 points, 95% CI -11.63 points to -3.22 points; 2 studies, 66 participants low-quality evidence) and self-reported inattention (1 study, 35 participants).CBT versus other interventions that included therapeutic ingredients specifically targeted to ADHD: we found a significant difference in favour of CBT for clinician-reported ADHD symptoms (SMD -0.58, 95% CI -0.98 to -0.17; 2 studies, 97 participants; low-quality evidence; moderate effect size) and for self-reported ADHD symptom severity (SMD -0.44, 95% CI -0.88 to -0.01; 4 studies, 156 participants; low-quality evidence; small effect size).Secondary outcomesCBT versus unspecific control conditions: we found differences in favour of CBT compared with waiting-list control for self-reported depression (SMD -0.36, 95% CI -0.60 to -0.11; 5 studies, 258 participants; small effect size) and for self-reported anxiety (SMD -0.45, 95% CI -0.71 to -0.19; 4 studies, 239 participants; small effect size). We also observed differences in favour of CBT for self-reported state anger (1 study, 43 participants) and self-reported self-esteem (1 study 43 participants) compared to waiting list. We found no differences between CBT and supportive therapy (1 study, 81 participants) for self-rated depression, clinician-rated anxiety or self-rated self-esteem. Additionally, there were no differences between CBT and the waiting list for self-reported trait anger (1 study, 43 participants) or self-reported quality of life (SMD 0.21, 95% CI -0.29 to 0.71; 2 studies, 64 participants; small effect size).CBT plus pharmacotherapy versus pharmacotherapy alone: we found differences in favour of CBT plus pharmacotherapy for the Clinical Global Impression score (MD -0.75 points, 95% CI -1.21 points to -0.30 points; 2 studies, 65 participants), self-reported depression (MD -6.09 points, 95% CI -9.55 points to -2.63 points; 2 studies, 66 participants) and self-reported anxiety (SMD -0.58, 95% CI -1.08 to -0.08; 2 studies, 66 participants; moderate effect size). We also observed differences favouring CBT plus pharmacotherapy (1 study, 31 participants) for clinician-reported depression and clinician-reported anxiety.CBT versus other specific interventions: we found no differences for any of the secondary outcomes, such as self-reported depression and anxiety, and findings on self-reported quality of life varied across different studies. AUTHORS' CONCLUSIONS: There is low-quality evidence that cognitive-behavioural-based treatments may be beneficial for treating adults with ADHD in the short term. Reductions in core symptoms of ADHD were fairly consistent across the different comparisons: in CBT plus pharmacotherapy versus pharmacotherapy alone and in CBT versus waiting list. There is low-quality evidence that CBT may also improve common secondary disturbances in adults with ADHD, such as depression and anxiety. However, the paucity of long-term follow-up data, the heterogeneous nature of the measured outcomes, and the limited geographical location (northern hemisphere and Australia) limit the generalisability of the results. None of the included studies reported severe adverse events, but five participants receiving different modalities of CBT described some type of adverse event, such as distress and anxiety.

Systematic review and meta-analysis of respiratory syncytial virus infection epidemiology in Latin America.

Respiratory syncytial virus (RSV) is a frequent cause of acute respiratory infection and the most common cause of bronchiolitis in infants. The aim of this systematic review and meta-analysis was to obtain a comprehensive epidemiological picture of the data available on disease burden, surveillance, and use of resources in Latin America. Pooled estimates are useful for cross-country comparisons. Data from published studies reporting patients with probable or confirmed RSV infection in medical databases and gray literature were included from 74 studies selected from the 291 initially identified. When considering all countries, the largest pooled percentage RSV in low respiratory tract infection patients was found in the group between 0 and 11 months old, 41.5% (95% CI 32.0­51.4). In all countries, percentages were increasingly lower as older children were included in the analyses. The pooled percentage of RSV in LRTIs in the elderly people was 12.6 (95% CI 4.2­24.6). The percentage of RSV infection in hospitalized newborns was 40.9% (95% CI 28.28­54.34). The pooled case fatality ratio for RSV infection was 1.74% (95% CI 1.2­2.4) in the first 2 years of life. The average length of stay excluding intensive care unit admissions among children with risk factors for severe disease was 12.8 (95% CI 8.9­16.7) days, whereas it averaged 7.3 (95% CI 6.1/8.5) days in otherwise healthy children.We could conclude that infants in their first year of age were the most vulnerable population. To our knowledge, this is the first systematic review on RSV disease burden and use of health resources in Latin America.

[Cross-sectional study on the determinants of work stress for nurses and intention of leaving the profession]. / Studio trasversale sui determinanti di stress lavorativo per gli infermieri e sull'intenzione di abbandono della professione.

INTRODUCTION: Occupational stress is one of the main causes of sick leaves among healthcare professionals and it determines high costs to health systems. Monitoring occupational related stress can be an important tool for policy makers. The Italian nursing research gave little attention to nurses' occupational stress. The aims of this study is to estimate the prevalence of occupational stress and evaluate risks factors among Italian nurses in order to evaluate health promotion intervention. METHODS: Cross-sectional study on a convenience sample of nurses from three Italian public hospitals was carried out. The Nursing Stress Scale was administrated together with socio-demographic data information(age, occupational age, family structure etc). The Nursing Stress Scale includes 34 items with a score from 0 to 3. Seven areas of job related stress are investigate in the scale: conflict with physicians, inadequate training, lack of support, conflict with other nurses, workload, uncertainty about treatments, death and suffering. Scores were calculated for each item and for each area. Associations between stress scores and socio-demographic data were analyzed. RESULTS: 231 nurses participated to the study. The two stress areas with the highest scores were "workload" (1.58) and "death and suffering" (1.39). Among the 13 items that exceed the overall mean stress score (i.e. 1.07), five belong to the "workload" area. "Watching a suffering patient" is the single item with the highest mean score. Demographic data associated to higher stress scores are, female gender (p=0.03) and working with night shifts (p=0.02). Intention to leave the nursing profession is associated to higher stress scores (p=0.002). Age, occupational age, time to commute to work, number of children, having disabled relatives at home, were not correlated to higher stress scores. CONCLUSIONS: Our study provides data regarding nurses' occupational stress that was not available before. This data may be useful for policy makers to plan preventive interventions for nurses' job related stress and to reduce nurses' intention to leave.

[Pharmacological treatment in early rehabilitation after ischemic stroke]. / Farmacoterapia en rehabilitación temprana posterior el accidente cerebrovascular isquémico.

There is a wealth of information on early pharmacological supportive treatment for early rehabilitation following acute ischemic stroke. This review aims to provide healthcare professionals involved in rehabilitating patients with a summary of the available evidence to assist with decision-making in their daily clinical practice. A search for randomized clinical trials and observational studies published between 1/1/2000 and 28/8/2022 was performed using PubMed, Cochrane and Epistemonikos as search engines with language restriction to english and spanish. The selected studies included patients older than 18 with acute ischemic stroke undergoing early rehabilitation. The outcomes considered for efficacy were: motor function, language, and central pain. The selected pharmacological interventions were: cerebrolysin, levodopa, selegiline, amphetamines, fluoxetine, citalopram, escitalopram, antipsychotics, memantine, pregabalin, amitriptyline and lamotrigine. Evidence synthesis and evaluation were performed using the GRADE methodology. This review provided a summary of the evidence on pharmacological supportive care in early rehabilitation of post-acute ischemic stroke patients. This will make it possible to improve current recommendations with the aim of collaborating with health decision-making for this population.

Existe una gran cantidad de información sobre el tratamiento de apoyo farmacológico temprano para la rehabilitación posterior a un accidente cerebrovascular isquémico agudo. El objetivo de esta revisión es ofrecer a los profesionales de la salud involucrados en la rehabilitación de los pacientes un resumen de la evidencia disponible que colabore con la toma de decisiones en su práctica clínica diaria. Se realizó una búsqueda de ensayos clínicos aleatorizados y estudios observacionales publicados entre el 1/1/2000 y el 28/8/2022 utilizando como motor de búsqueda PubMed, Cochrane y Epistemonikos con restricción de idioma a ingles y español. Los estudios seleccionados incluyeron pacientes mayores de 18 años con un accidente cerebrovascular isquémico agudo sometidos a rehabilitación temprana. Los desenlaces considerados para eficacia fueron: función motora, lenguaje y dolor. Las intervenciones farmacológicas seleccionadas fueron: cerebrolisina, levodopa, selegilina, anfetaminas, fluoxetina, citalopram, escitalopram, antipsicóticos, memantine, pregabalina, amitriptilina y lamotrigina. Se realizó síntesis y evaluación de la evidencia utilizando metodología GRADE. Esta revisión proporcionó un resumen de evidencia sobre el tratamiento de apoyo farmacológico en la neuro-rehabilitación temprana de pacientes post accidente cerebrovascular isquémico agudo. Esto permitirá mejorar las recomendaciones actuales con el objetivo de colaborar con la toma de decisiones en salud para esta población.

http://www.D-MELD.com, the Italian survival calculator to optimize donor to recipient matching and to identify the unsustainable matches in liver transplantation.

Optimization of donor-recipient match is one of the exciting challenges in liver transplantation. Using algorithms obtained by the Italian D-MELD study (5256 liver transplants, 21 Centers, 2002-2009 period), a web-based survival calculator was developed. The calculator is available online at the URL http://www.D-MELD.com. The access is free. Registration and authentication are required. The website was developed using PHP scripting language on HTML platform and it is hosted by the web provider Aruba.it. For a given donor (expressed by donor age) and for three potential recipients (expressed by values of bilirubin, creatinine, INR, and by recipient age, HCV, HBV, portal thrombosis, re-transplant status), the website calculates the patient survival at 90days, 1year, 3years, and allows the identification of possible unsustainable matches (i.e. donor-recipient matches with predicted patient survival less than 50% at 5 years). This innovative approach allows the selection of the best recipient for each referred donor, avoiding the allocation of a high-risk graft to a high-risk recipient. The use of the D-MELD.com website can help transplant surgeons, hepatologists, and transplant coordinators in everyday practice of matching donors and recipients, by selecting the more appropriate recipient among various candidates with different prognostic factors.

[Recommendations For The Management Of Spontaneous Intracerebral Hemorrhage During Hospitalization]. / Recomendaciones en el Abordaje del Hematoma Intracerebral Espontáneo Durante la Internación.

Stroke is the leading cause of neurological disability in people over 40 years of age and the fourth leading cause of death in Argentina. In the last ten years, the indexed publications related to the treatment of ischemic stroke were more numerous than those of hemorrhagic stroke. The objective of this material is to provide local and updated recommendations for the management of patients with spontaneous intracerebral hemorrhage during hospitalization. For the writing of this manuscript, diferent specialists were convened to form working groups. Ten central topics expressed as epidemiology, initial care, imaging, blood pressure treatment, reversal of antithrombotics, indication for surgery, seizure prophylaxis, prognosis, prevention of complications and resumption of antithrombotics were raised. For each topic, the most frequent questions of daily practice were raised through PICO questions. After a systematic review of the literature, recommendations were generated, evaluated using the GRADE system and agreed between authors and patients.

El accidente cerebrovascular (ACV) constituye la principal causa de discapacidad de origen neurológico en los adultos mayores a 40 años y la cuarta causa de muerte en Argentina. En los últimos diez años las publicaciones indexadas relacionadas al tratamiento del ACV isquémico fueron más numerosas que las de ACV hemorrágico. El objetivo de este material es proporcionar recomendaciones locales y actualizadas del abordaje de pacientes con hematoma intraparenquimatoso espontáneo durante la internación. Para la redacción de este manuscrito se convocó a especialistas en esta enfermedad que conformaron grupos de trabajo. Se plantearon 10 tópicos centrales expresados como epidemiologia, atención inicial, imágenes, tratamiento de la presión arterial, reversión de antitrombóticos, indicación de cirugía, profilaxis anticonvulsivante, pronóstico, prevención de complicaciones y reinicio de antitrombóticos. De cada tópico se plantearon mediante preguntas PICO los interrogantes más frecuentes de la práctica diaria. Luego de una revisión sistemática de la literatura, se generaron recomendaciones evaluadas mediante sistema GRADE y consensuadas entre autores y pacientes.

Ultrasound of Small Bowel Obstruction: A Pictorial Review.

Small bowel obstruction (SBO) is a common condition requiring urgent attention that may involve surgical treatment. Imaging is essential for the diagnosis and characterization of SBO because the clinical presentation and results of laboratory tests may be nonspecific. Ultrasound is an excellent initial imaging modality for assisting physicians in the rapid and accurate diagnosis of a variety of pathologies to expedite management. In the case of SBO diagnosis, ultrasound has an overall sensitivity of 92% (95% CI: 89-95%) and specificity of 93% (95% CI: 85-97%); the aim of this review is to examine the criteria for the diagnosis of SBO by ultrasound, which can be divided into diagnostic and staging criteria. The diagnostic criteria include the presence of dilated loops and abnormal peristalsis, while the staging criteria are represented by parietal and valvulae conniventes alterations and by the presence of free extraluminal fluid. Ultrasound has reasonably high accuracy compared to computed tomography (CT) scanning and may substantially decrease the time to diagnosis; moreover, ultrasound is also widely used in the monitoring and follow-up of patients undergoing conservative treatment, allowing the assessment of loop distension and the resumption of peristalsis.

Prostanoids for critical limb ischaemia.

BACKGROUND: Peripheral arterial occlusive disease (PAOD) is a common cause of morbidity and mortality due to cardiovascular diseases in the general population. While numerous treatments have been adopted for different disease stages, there is no option other than amputation for patients presenting with critical limb ischaemia (CLI), unsuitable for rescue or reconstructive intervention. OBJECTIVES: To determine the effectiveness and safety of prostanoids in patients presenting with CLI. SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched October 2009) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched 2009, Issue 4) for publications describing randomised controlled trials (RCTs) of prostanoids for CLI. We ran additional searches in MEDLINE, EMBASE, LILACS, and SciSearch, and we also contacted pharmaceutical companies and experts, in order to identify unpublished data and trials still underway. SELECTION CRITERIA: Randomised controlled trials describing efficacy and safety of prostanoids compared with placebo or other pharmacological control treatments, in patients presenting with CLI, without chance of rescue or reconstructive intervention. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. Disagreements were resolved by consensus or by the third author. MAIN RESULTS: We retrieved 532 citations which after the first screening resulted in 111 potential studies. Finally, after exclusion of studies of poor quality and a lack of sufficient information, 20 trials were included in the review.Prostanoids seem to have efficacy regarding rest-pain relief (risk ratio (RR) 1.32, 95% confidence interval (CI) 1.10 to 1.57; P = 0.003), and ulcer healing (RR 1.54, 95% CI 1.22 to 1.96). Iloprost also shows favourable results regarding major amputations (RR 0.69, 95% CI 0.52 to 0.93). The more frequently reported adverse events when using prostanoids were headache, facial flushing, nausea, vomiting and diarrhoea. AUTHORS' CONCLUSIONS: Despite some positive results regarding rest-pain relief, ulcer healing and amputations, there is no conclusive evidence based on this meta-analysis of the long-term effectiveness and safety of different prostanoids in patients with CLI. Further well-conducted, high quality randomised double-blinded trials should be performed.

Interferon Beta for primary progressive multiple sclerosis.

BACKGROUND: This is an updated Cochrane review of the previous version published (Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006643. DOI: 10.1002/14651858.CD006643.pub2).Therapeutic trials with ss-interferon in Multiple Sclerosis (MS) have mainly focused on remitting-relapsing multiple sclerosis (RRMS), demonstrating a reduction in relapse rate. However, there is not enough evidence about their efficacy in patients with primary progressive multiple sclerosis (PPMS). OBJECTIVES: Identify and summarize the evidence that ss-interferon is beneficial and safe in patients with PPMS. SEARCH STRATEGY: We searched the Cochrane MS Group Trials Register (May 2009); The Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Library, (2009, Issue 2); MEDLINE (PubMed) (January 1966 to May 2009), EMBASE (January 1974 to May 2009); NICE (January 1999 to May 2009); LILACS (January 1986 to May 2009); Screening of reference lists of all primary studies found; Contact and inquiry of drug manufactures and multiple sclerosis experts. SELECTION CRITERIA: Randomized double or single blind, placebo-controlled trials of recombinant ss-interferon in patients with PPMS including trials of MS which report separate outcomes in subgroups of patients with PPMS. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted and assessed trials' quality according to the criteria outlined in The Cochrane Handbook. MAIN RESULTS: Of 1777 potential studies evaluated, only two Randomized Control Trials (123 patients) were included. ss-interferon treatment compared to placebo did not show differences regarding the proportion of patients with progression of the disease (RR 0.89, 95% CI 0.55 to1.43), and it was associated with a greater frequency of treatment-related adverse events (RR 1.90, 95% CI 1.45-2.48). One of the trials evaluated the MRI secondary outcome pre-specified in the protocol. This trial showed that at two years the numbers of active lesions on brain MRI scan in ss-interferon arm were significantly lower than in placebo arm (weighted mean difference -1.3, 95% CI -2.15 to -0.45, P = 0.003); also, the number of participants with active lesions was significantly higher in placebo arm vs. ss-interferon arm at two years (RR 0.43, 95% CI 0.22 to 0.86, P = 0.02). AUTHORS' CONCLUSIONS: Limited data on the effect of ss-interferon treatment on PPMS exists. Only two single-centre placebo controlled trials of interferon beta have been done. Based on this review, the included studies showed that ss-interferon treatment was not associated with reduced disability progression in PPMS patients. However, the trial population was too small to allow definitive conclusions on the efficacy of ss-interferon therapy in PPMS patients. Larger research studies need to be done in patients with PPMS in order to clarify whether ss-interferon is effective in this population.

Toxic compounds in a cutlery microenterprise: A case study.

BACKGROUND: The aim of this study was to characterize solid particulate aerosol derived from a cutlery microenterprise and to investigate substances associated with activities performed within the work environment. OBJECTIVE: Suspended particulate matter (SPM) was collected at different locations in the cutlery workshop and near machines used by workers, using passive sampling devices fitted with polytetrafluoroethylene filters, onto which total particulate material was deposited. The substances present in the SPM were analyzed using gas chromatography-mass spectrometry (GC-MS). RESULTS: Identification of the substances was performed using the National Institute of Standards (NIST) library and automated mass spectral deconvolution and identification system. (AMDIS) software, considering at least 70% probability. The concentration of total dust, obtained using a gravimetric method, was approximately 1 mg.m-3. CONCLUSION: The toxic substances found in the SPM included halogenated hydrocarbons (containing chlorine, fluorine, and iodine) and aromatic hydrocarbons. The toxic substances included naphthalene, which is classified as carcinogenic.

Recent respiratory infection predicts atherothrombotic stroke: case-control study in a Buenos Aires healthcare system.

BACKGROUND AND PURPOSE: Increasing evidence links infections to atherosclerosis. Case-control and cohort studies have found that infections, especially respiratory and dental, are associated with coronary heart disease. However, data on the association of infections with cerebrovascular disease are limited, especially beyond Europe and the United States. We assessed the relationship between recent infections and atherothrombotic disease in a South American cohort. METHODS: We conducted a case-control study of 105 cases and 354 control subjects in a Buenos Aires healthcare system matched by age (mean age, 73.2+/-12.3 and 72.9+/-12.8 years), sex, and major cardiovascular risk factors. Cases were patients hospitalized with atherothrombotic ischemic stroke from December 2006 to October 2007. Control subjects were randomly assigned from an electronic outpatient database. Data from the preceding year on inpatient and ambulatory respiratory, urinary and abdominal infections as well as peripheral white blood cell count were collected. RESULTS: Infections were more frequent in cases than control subjects (29% versus 13%; OR, 2.6; 95% CI, 1.4 to 4.5; P=0.0004); however, this was driven by community-acquired respiratory tract infections (19% versus 6%; OR, 3.9; 95% CI, 1.9 to 8; P<0.001) because there were no differences between cases and control subjects for other types of infection. Respiratory tract infections were the most prevalent type of infection during the 3 months before an atherothrombotic ischemic event, occurring more in cases compared with control subjects (17% versus 4%; OR, 5; 95% CI, 2.2 to 11.3; P<0.001). In multivariable analysis adjusting for major vascular risk factors, history of respiratory infection in the prior year was associated more with cases than control subjects (OR, 4.9; 95% CI, 2.3 to 10.2;P<0.001). White blood cell count was slightly higher in cases versus control subjects (7602+/-2058 versus 7121.6+/-1947, P=0.01). CONCLUSIONS: In this South American cohort, recent respiratory tract infections were significantly associated with atherothrombotic stroke, suggesting that prompt identification and treatment of individuals with or at risk for these infections may mitigate the burden from this type of stroke.

Interferon beta for primary progressive multiple sclerosis.

BACKGROUND: Therapeutic trials with ss-interferon in Multiple Sclerosis (MS) have mainly focused on remitting-relapsing multiple sclerosis (RRMS), demonstrating a reduction in relapse rate. However, there is not enough evidence about their efficacy in patients with primary progressive multiple sclerosis (PPMS). OBJECTIVES: Identify and summarize the evidence that ss-interferon is beneficial and safe in patients with PPMS. SEARCH STRATEGY: We searched (until April 2008) the Cochrane MS Group Trials Register; The Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Library, (2008, Issue 3,); MEDLINE (PubMed) (January 1966 to April 2008), EMBASE (January 1974 to April 2008); NICE (January 1999 to April 2008); LILACS (January 1986 to April 2008); Screening of reference lists of all primary studies found; Contact and inquiry of drug manufactures and multiple sclerosis experts. SELECTION CRITERIA: Randomized double or single blind, placebo-controlled trials of recombinant ss-interferon in patients with PPMS including trials of MS which report separate outcomes in subgroups of patients with PPMS. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted and assessed trials' quality according to the criteria outlined in The Cochrane Handbook. MAIN RESULTS: Of 1280 potential studies evaluated, only two Randomized Control Trials (123 patients) were included. ss-interferon treatment compared to placebo did not show differences regarding the proportion of patients with progression of the disease (RR 0.89, 95% CI 0.55 to1.43), and it was associated with a greater frequency of treatment-related adverse events (RR 1.90, 95% CI 1.45-2.48). One of the trials evaluated the MRI secondary outcome pre-specified in the protocol. This trial showed that at two years the numbers of active lesions on brain MRI scan in ss-interferon arm were significantly lower than in placebo arm (weighted mean difference -1.3, 95% CI -2.15 to -0.45, P = 0.003); also, the number of participants with active lesions was significantly higher in placebo arm vs. ss-interferon arm at two years (RR 0.43, 95% CI 0.22 to 0.86, P = 0.02). AUTHORS' CONCLUSIONS: Limited data on the effect of ss-interferon treatment on PPMS exists. Only two single-centre placebo controlled trials of interferon beta have been done. Based on this review, the included studies showed that ss-interferon treatment was not associated with reduced disability progression in PPMS patients. However, the trial population was too small to allow definitive conclusions on the efficacy of ss-interferon therapy in PPMS patients. Larger research studies need to be done in patients with PPMS in order to clarify whether ss-interferon is effective in this population.

Embolic stroke secondary to cardiac papillary fibroelastoma.

INTRODUCTION: Papillary fibroelastoma is the most common primary cardiac valvular tumor. Historically, papillary fibroelastoma was an incidental autopsy finding, deemed to have no clinical significance. More recently, reports of symptomatic cases of papillary fibroelastoma with complications such as myocardial infarction and stroke suggest it should be considered a potentially dangerous lesion. In this report, we describe the clinical and echocardiographic findings of 3 patients with cardiac papillary fibroelastoma who presented with cerebral vascular events. OBJECTIVE: To describe the clinical and echocardiographic findings of 3 patients with cardiac papillary fibroelastoma (CPF) who presented cerebral vascular events. METHODS: Describe the findings of 3 patients and review of the literature. RESULTS: We report 3 cases with cerebral ischemic events associated with the presence of CPF that were confirmed by histopathological examination. CONCLUSIONS: Cardiogenic embolism is recognized increasingly as an important cause of stroke, accounting of 20% of ischemic strokes. Cardioembolic stroke is largely preventable. The likelihood of recurrence is relatively high for most cardioembolic sources and therefore secondary stroke prevention is fundamental. TEE allowed to characterize well-established sources of embolism, and it was the best diagnostic approach in our patients. Magnetic resonance imaging was used in 1 of these patients, while it confirmed the presumptive diagnosis of cardiac tumor. The first-choice treatment of symptomatic CPF is surgical excision which must be performed as early as possible to reduce the risk of early recurrences of embolic events. The use of TEE in the evaluation of cerebral vascular events is not routinely performed, this method must be considered in patients for whom the cause of cerebrovascular ischemia is unclear, after noninvasive neurovascular studies.

Transesophageal echocardiography findings in lacunar stroke.

BACKGROUND: Transesophageal echocardiography (TEE) constitutes a valuable tool in patients with stroke and cardiac embolization, but its indication is controversial in lacunar stroke. The purpose of this study was to assess the findings of TEE in lacunar stroke. METHODS: Initial symptoms, brain computed tomography or magnetic resonance imaging, and TEE were performed for all patients with ischemic stroke admitted consecutively to our department of neurology. The subtype of ischemic stroke (lacunar v large-vessel stroke) was also reviewed. RESULTS: In all, 124 patients with ischemic stroke were identified and lacunar syndrome occurred in 46. Major risk factor of embolization in patients with lacunar stroke and indication for anticoagulation were detected in 20% (9 of 46). We compared findings in both groups (lacunar v nonlacunar stroke) to evaluate the differences in the presence of major risk factor for embolization, Chi square = 0.07, P = .8 (odds ratio 95% CI = 0.35-2.18). Characteristics of the 9 patients with lacunar stroke and major risk of embolization show that history of lacunar ischemic stroke was present in all the patients of this group. DISCUSSION: The results of the study suggest that TEE may be necessary to obtain a complete evaluation to optimize preventive treatment in patients with clinical and radiologic presentation that suggest lacunar infarct, particularly in cases with a history of ischemic stroke, in which a potential cardiac source of embolization may be detected.

[Retroperitoneal abscess by suppurative psoas. Case report]. / Ascesso retroperitoneale da psoite suppurativa. Caso clinico.

A 51 years old male was admitted to our Emergency Department because a severe pain in the right lumbar area irradiating to homolateral thigh, with fever. Abdomen and pelvis TC scan revealed a big retroperitoneal abscess. An urgent laparotomy was performed. It showed a huge retroperitoneal purulent collection extending caudally to right thigh and all around urinary bladder. The fluid collections were drained and a sample was sent for biological examination. There was the evidence of enterococcus faecalis and specific antibiotic treatment was done. The patient was discharged after 33 days in good general conditions. The aim of this study is to emphasize the difficulty in clinical diagnosis of this pathology due to the lack specific symptoms and signs, and the occasional difficulty to find the original cause of the condition. Moreover we remark the utility of CT scan and of selective collection drainage.

A systematic review about the epidemiology of primary progressive multiple sclerosis in Latin America and the Caribbean.

Novel epidemiological data has appeared in recent years in Latin America (LATAM) regarding the epidemiology of multiple sclerosis (MS); however, most of this information is related to all MS subtypes, and no specific data was collected regarding the primary progressive form of MS (PPMS). The objective of this study was to perform an updated systematic review of the epidemiology of PPMS in LATAM. METHODS: We conducted a systematic review of published epidemiological articles of PPMS from January 1997 to June 2017. RESULTS: No incidence data were found regarding PPMS. Differentiated prevalence was reported in 7 studies and ranged from 0.13 to 1.1 cases of PPMS per 100,000 inhabitants. Regarding subtype frequency, PPMS was observed in 10% of affected patients in proportional meta-analysis. No data about mortality were found. CONCLUSION: The study provides information on discriminated epidemiological features of PPMS in the region. The frequency observed was low in terms of prevalence. Follow up studies considering survival milestones and incidence data could provide a better understanding of the disease in the region.

Farmacoterapia en rehabilitación temprana posterior al accidente cerebrovascular isquémico / Pharmacological treatment in early rehabilitation after ischemic stroke

Resumen Existe una gran cantidad de información sobre el tratamiento de apoyo farmacológico temprano para la rehabilitación posterior a un accidente cerebrovascular isquémico agudo. El objetivo de esta revisión es ofrecer a los profesionales de la salud involucrados en la rehabilitación de los pacientes un resumen de la evidencia disponible que colabore con la toma de decisiones en su práctica clínica diaria. Se realizó una búsqueda de ensayos clínicos aleatorizados y estudios observacionales publicados entre el 1/1/2000 y el 28/8/2022 utilizando como motor de búsqueda PubMed, Cochrane y Epistemonikos con restricción de idioma a ingles y español. Los estudios seleccionados incluyeron pacientes mayores de 18 años con un accidente cerebrovascular isquémico agudo sometidos a rehabilitación temprana. Los desenlaces considerados para eficacia fueron: función motora, lenguaje y dolor. Las intervenciones farmacológicas seleccionadas fueron: cerebrolisina, levodopa, selegilina, anfetaminas, fluoxetina, citalopram, escitalopram, antipsicóticos, memantine, pregabalina, amitriptilina y lamotrigina. Se realizó síntesis y evaluación de la evidencia utilizando metodología GRADE. Esta revisión proporcionó un resumen de evidencia sobre el tratamiento de apoyo farmacológico en la neuro-rehabilitación temprana de pacientes post accidente cerebrovascular isquémico agudo. Esto permitirá mejorar las recomendaciones actuales con el objetivo de colaborar con la toma de decisiones en salud para esta población.

Abstract There is a wealth of information on early pharmacological supportive treatment for early rehabilitation following acute ischemic stroke. This review aims to provide healthcare professionals involved in rehabilitating patients with a summary of the available evidence to assist with decision-making in their daily clinical practice. A search for randomized clinical trials and observational studies published between 1/1/2000 and 28/8/2022 was performed using PubMed, Cochrane and Epistemonikos as search engines with language restriction to english and spanish. The selected studies included patients older than 18 with acute ischemic stroke undergoing early rehabilitation. The outcomes considered for efficacy were: motor function, language, and central pain. The selected pharmacological interventions were: cerebrolysin, levodopa, selegiline, amphetamines, fluoxetine, citalopram, escitalopram, antipsychotics, memantine, pregabalin, amitriptyline and lamotrigine. Evidence synthesis and evaluation were performed using the GRADE methodology. This review provided a summary of the evidence on pharmacological supportive care in early rehabilitation of post-acute ischemic stroke patients. This will make it possible to improve current recommendations with the aim of collaborating with health decision-making for this population.