Daniel Prefasi

High-Density Lipoprotein: A Novel Marker for Risk of In-Hospital Infection in Acute Ischemic Stroke Patients?

Background: Several studies have shown that high-density lipoprotein (HDL) cholesterol provides protection against bacterial infections. Our aim was to investigate the influence of HDL cholesterol levels on the risk of developing in-hospital infectious complications after an acute ischemic stroke (IS) as well as the possible effect of prestroke statin treatment on this association. Methods and Results: Observational study that included consecutive IS patients during a 5-year period (2006-2010). We analyzed vascular risk factors, prestroke treatments (including statins), laboratory data (including HDL cholesterol levels), stroke severity, and the development of infectious complications (pneumonia, urinary tract infection and sepsis). A multivariate analysis that included HDL cholesterol levels, prior statin treatment and the interaction between both variables was performed to identify those factors associated with the presence of infectious complications. A total of 1,385 patients were included, 130 of whom (9.4%) developed in-hospital infections. The receiver operating characteristic curve showed the predictive value of HDL cholesterol with an area under the curve of 0.597 (95% CI, 0.526-0.668; p = 0.006) and pointed to 38.5 mg/dl of HDL cholesterol (65.5% sensitivity and 53.4% specificity) as the optimal cutoff level for developing infectious complications during hospitalization. An HDL cholesterol level ≥38.5 mg/dl was an independent predictive factor for lower risk of infection (OR 0.308; 95% CI 0.119-0.795), whereas prestroke statin treatment was not associated with the development of infection. Conclusions: An HDL cholesterol level ≥38.5 mg/dl was independently associated with lower risk for developing infectious complications in acute IS patients. Statins do not influence this association.

Antiphospholipid antibodies correlate with stroke severity and outcome in patients with antiphospholipid syndrome.

Abstract Background: Our goal was to analyze the association of the level of antiphospholipid antibodies (aPLs) with stroke severity and outcome in patients with antiphospholipid syndrome (APS). Methods: Observational study included consecutive patients with ischemic stroke younger than 55 years (2007–2012). We analyzed serum levels of aPLs, including anticardiolipin (aCL) antibodies, anti-β2-glycoprotein I antibodies (anti-β2GPI) and antiprothrombin antibodies (aPS/PT) within the first 48 h after admission, and again, in the case of a positive result, at least 12 weeks after the first measurement. Stroke severity was measured by the National Institutes of Health Stroke Scale (NIHSS), and the three-month stroke outcome by the modified Rankin Scale (mRS). Multiple linear regression models were used to analyze the correlation between the aPLs and stroke severity and outcome. Results: Overall 255 stroke patients were included, 22 (8.6%) with APS. Among them, a positive correlation was found between immunoglobulin M (IgM) aCL levels within 48 h and NIHSS (rho = 0.471; p = 0.027), as well as a tendency toward a positive correlation between immunoglobulin G (IgG) anti-β2GPI levels within 48 h and three-month mRS (rho = 0.364; p = 0.096). Multiple linear regression analyses showed a positive correlation between levels of IgM aCL < 48 h and the NIHSS (β-coefficient [standard error; SE] = 0.127 [0.044]), as well as the levels of IgG anti-β2GPIwithin 48 h and the three-month mRS (β-coefficient [SE] = 0.034 [0.011]). Conclusions: In young stroke patients with APS, serum levels of IgM aCL within 48 h are correlated with stroke severity and levels of IgG anti-β2GPI within 48 h are correlated with three-month outcomes.

The utility of the RoPE score in cryptogenic stroke patients ≤50 years in predicting a stroke-related patent foramen ovale

Dear editor, Up in to one-third of young ischemic stroke patients, no etiology is found despite multiple diagnostic procedures. The prevalence of patent foramen ovale (PFO) in general population is &25%, with a greater frequency of PFO in stroke than in controls, although its role in stroke pathogenesis has been discussed. The risk of paradoxical embolism (RoPE) study has proposed a score to identify when PFO is related to stroke pathogenesis or is only and incidental find. The RoPE score was developed in patients of all ages, suggesting that a higher score could be associated with a greater probability of stroke-related PFO than incidental. Furthermore, a lower recurrence rate in patients with higher RoPE scores has been reported. Our aim is to validate the RoPE score in a cohort of cryptogenic stroke (CS) patients up to 50 years and to identify the cutoff point with the highest likelihood that PFO is related to the stroke. An observational study with inclusion of consecutive CS patients 50 years admitted to a Stroke Center from 2007 to 2013 was designed. A ROC curve was performed to identify the RoPE score with the highest sensitivity and specificity to detect the presence of a patent foramen ovale (PFO). Finally, we performed the PFO-attributable fraction of stroke in patients with a RoPE score greater and lower than the selected cutoff point, using Bayes theorem. Overall, 58 CS patients 50 years were included. No patients had RoPE score 0–3, 8 with 4–5, 11 patients with 6 and 7, and 28 patients had 8–10 points. The identified cutoff point was 7 (under curve area 0.704), sensitivity 69.4%, specificity 62.5%. RoPE score >7 was significantly associated with a greater PFO frequency (53.6% vs. 10%; P1⁄4 0.001). A PFO-attributable fraction of RoPE 7 group was 0% (95% CI: 0– 7.5) compared to 71.1% (95% CI: 35–87.3) for RoPE> 7 group (Table 1). This is the first study that provides an external validation of the RoPE score in CS patients up to 50 years old, suggesting its robustness in identifying whether the PFO is stroke-related or incidental. RoPE score >7 is the best cutoff point to identify CS patients in whom the PFO is more likely to be related to stroke.

Oclusión carotídea bilateral y estenosis progresiva de arterias vertebrales posradioterapia en paciente joven

We appreciate the letter by Benito et al. emphasising the possible association between orthostatic tremor and vitamin B12 deficiency, which highlights the causal association between these 2 entities and the existing literature on this subject. Indeed, being aware of this association, and given the medical history of the patient, we did review her vitamin B12 levels. At the time they were between 249 and 421 pmol/l (132—857) and mean corpuscular volume was around 85 fL (80—96) in successive analyses conducted between 2006 and 2009, when we first started treating her. The patient had a history of gastric neoplasm in 2006 that required total gastrectomy and cholecystectomy, as well as monthly intramuscular supplements of vitamin B12, from 2006 until the present time. However, the clinical onset of instability in the lower limbs took place in 1996, 10 years before the history of gastric neoplasm and subsequent gastrectomy that caused the vitamin B12 deficit.

Can we improve the early detection of atrial fibrillation in a stroke unit? Detection rate of a monitor with integrated detection software:

Introduction: It is unknown whether monitors that include atrial fibrillation recognition software (AF-RS) increase the rate of early atrial fibrillation (AF) detection in acute stroke. We aimed to evaluate the AF detection rate of an AF-RS monitor and compare it with standard monitoring. Methods: This was a retrospective, single-centre observational study conducted on consecutive patients with acute transient ischaemic attack or brain infarction attended in a stroke unit (SU) with six beds. Five beds had a standard monitor with a three-lead electrocardiogram (ECG)-tracing monitor that did not automatically detect AF, and one bed had a 12-lead ECG monitor with integrated AF-RS. All patients were monitored for at least 24 h and underwent a daily ECG during their stay in the SU. In case of unknown stroke aetiology, the patients underwent 24 h Holter monitoring. Results: A total of 76 patients were included: 59 patients in the standard monitor group and 17 patients in the AF-RS monitor group. The mean age was 72.11 (±13.09) years, and 59.2% were men. A total of 20 new cases of AF were identified. The AF-RS monitor showed a higher rate of AF detection than the standard devices (57.1% vs 7.7%, p=0.031). The AF-RS monitor showed sensitivity, specificity, positive predictive value, and negative predictive values of 57.1%, 100%, 100% and 76.9%, respectively. For the standard monitors, these values were 7.7%, 100%, 100% and 79.3%, respectively. Conclusion: The monitor with AF-RS demonstrated a higher detection rate for AF than standard ECG monitoring in acute stroke patients in a SU.