Giuseppe Azzimondi

Fever in Acute Stroke Worsens Prognosis A Prospective Study

Background and Purpose No definitive data are yet available on the effects of body temperature on neurological damage after cerebral ischemia in humans. Experimental animal models have provided much evidence, but to our knowledge, only two studies on the relationship between fever and prognosis of stroke in humans have been published. The aim of our study was to investigate the prognostic role of fever in the first 7 days of hospitalization in a cohort of patients admitted to our hospital for acute stroke. Methods We analyzed the data of 183 patients included in a prospective observational prognostic study. Vital status at 30 days was considered the main outcome and was obtained for all patients. Age, level of consciousness, and glycemia at the time of hospitalization were considered covariates for an exact logistic regression analysis. The maximum temperature recorded during the first 7 days dichotomized as “no or low fever” versus “high fever” was added to the model. Death within 10 days, taken as a secondary outcome suggestive of death from neurological causes, was analyzed with exact permutation tests. Results Of the 183 patients analyzed in this study, 43% had fever during the first 7 days after hospitalization. The mean value of the maximum temperature recorded during the first 7 days in the 78 febrile patients was 38.3°C, and the median was 37.9°C. Onset of fever occurred in only 15% of febrile patients during the first day and in 49% on the second. The prognostic roles of age, level of consciousness, and glycemia were confirmed by exact logistic regression. Degree of consciousness impairment was the strongest prognostic variable, with an odds ratio (OR) of 11.4 (95% confidence interval [CI], 4.4 to 31.6). High fever (maximum temperature recorded during the first 7 days ≥37.9°C) was an independent factor for a worse prognosis, with an OR of 3.4 (95% CI, 1.2 to 9.5). The OR of dying within 10 days versus dying between 11 and 30 days was 4.9 (95% CI, 1.2 to 25.2) in patients with high fever with respect to all other patients. Conclusions Fever in the first 7 days was an independent predictor of poor outcome during the first month after a stroke. No data were available on the underlying causes of fever, but the higher risk of death in the first 10 days, most frequently attributed to neurological mechanisms, suggested that high temperature was an independent component of poor prognosis and not only an epiphenomenon of other complications in the course after a stroke. In agreement with animal studies, we found that patients with higher temperature had a worse stroke outcome.

Multiple Sclerosis with Very Late Onset: Report of Six Cases and Review of the Literature

Multiple sclerosis (MS) usually starts in young adulthood. However, the disease may appear late or very late in life. We report 6 cases with onset after the age of 59 years and review the literature. As in early onset disease, the diagnosis is mainly clinical. Laboratory findings and paraclinical evidence may support the diagnosis of clinical data are not sufficient. In elderly patients clinical history and laboratory data should be thoroughly appraised to exclude conditions more common in old age such as vascular diseases.

Accuracy of ICD-9 codes in identifying ischemic stroke in the General Hospital of Lugo di Romagna (Italy)

Abstract. We assessed the sensitivity and the positive predictive value (PPV) of the ICD-9 codes in identifying ischemic strokes. The study involved the cross-sectional comparison between patients with an ischemic stroke diagnosis made by neurologists and patients with the 434 or 436 discharge codes. Sensitivity of the codes (all diagnostic levels and first level respectively) was 82% and 76%; PPV: 71% and 76%. The annual crude incidence of ischemic stroke was 2.62 per 1000 based on verified strokes and 3.03 per 1000 based on 434 or 436 coded medical records (at all diagnostic levels). Thirty-day case fatality ratio was 22.3% in verified strokes and 36.8% among patients diagnosed with codes 434 or 436 but without stroke (all levels). Our results disclosed inaccuracy in use of the ICD-9 codes in the diagnosis of ischemic stroke in the general hospital of Lugo di Romagna, Ravenna Province, Italy. The misdiagnosis of patients could be influenced by the degree of severity of clinical features. Epidemiological data and cost-analysis forecasts based only on the ICD-9 system must be considered with caution.

Comparative Study of the Prevalence of Dementia in Two Sicilian Communities with Different Psychosocial Backgrounds

The role of education and psychosocial environment as factors for the development of dementia is controversial. We carried out a comparative study on the prevalence of dementia among persons over 74 years of age in two Sicilian municipalities, Troina and S. Agata Militello, with different psychosocial backgrounds. A two-stage survey was performed for both samples. In stage 1 the Mini Mental Status Examination (previously validated for the cutoff score with 100% sensitivity and the highest specificity) was used to screen a 50% random sample of persons over 74 years of age. In those referred to stage 2, the diagnosis of dementia was made by a neurologist according to DSM-III R. Three hundred and sixty-five subjects were recruited in Troina and 408 in S. Agata Militello. The minimal estimates of dementia prevalence were 21.9% (21.9% men, 21.9% women) in Troina and 28.4% (26.6% men, 29.6% women) in S. Agata Militello. Although intrasample multiple logistic exact analysis (demented vs. unproven demented) indicated poor formal education and manual occupation as risk factors for dementia, and intersample comparison (Troina vs. S. Agata Militello) showed that these variables were more frequent in Troina, we did not find a higher prevalence of dementia in this community. We discuss this apparently ambiguous result and suggest that psychosocial and cultural variables might be considered multiple interacting factors with different protective or predisposing roles for dementia. Higher or lower risk could then be the result of this complex interaction in different populations.

Prevalence of dementia among elderly people in Troina, Sicily

We performed a two-stage survey on the prevalence of dementia among people aged over 74 in Troina, northern Sicily, Italy. During the first stage people were screened by the Mini Mental Status Examination (MMSE), previously validated in our population for the cut-off score with 100% sensitivity and the best specificity to diagnose dementia. During the second stage people scoring 19 or less at the MMSE test were invited to be examined by a neurologist who diagnosed dementia according toDSM-III R. Out of 365 subjects of the initial sample 347 were screened by MMSE test and 163 scored 19 or less. Of these, 135 were neurologically and neuropsychologically examined in the second stage, and 80 proved to be demented. The minimal estimate of prevalence of dementia in our sample was 21.9% (21.9% men, 21.8% women). The poor education and psychosocial life may be the underlying condition favoring dementia in this sample of elderly people.

Incidence of stroke among inpatients in a large Italian hospital.

The incidence of stroke among inpatients is not known. The aim of our study was to investigate the incidence of stroke not preceded by evident iatrogenic factors such as surgical or medical procedures in a cohort of inpatients in a large Italian general hospital. Methods From January 1, 1992, to December 31, 1992, we evaluated patients referred to our neurology department with a suspected diagnosis of stroke that occurred during hospitalization. Patients presenting with stroke as a complication of iatrogenic causes were excluded. We calculated the incidence rate of first-ever stroke in our cohort (crude and among patients aged older than 50 years), thereafter adjusting these rates for age to the general population of the city district of Bologna (Italy). Results In 1992, 22 inpatients had a first-ever stroke with no evidence of iatrogenic factors. The crude stroke incidence rate was 11.08/1000 per year (95% confidence interval, 6.95 to 16.73). The age-adjusted rate was 5.46 (95% confidence interval, 3.42 to 8.24). Conclusions The incidence rate of first-ever stroke among hospitalized patients is higher than those reported in community-based studies. Higher frequency of coronary artery disease among our patients could explain our findings. Further studies are needed to identify possible predisposing factors (individual or environmental) for stroke among inpatients.

Recurrent 'migrainelike' episodes in patients with HIV disease.

Recurrent transient neurological deficits have been described in human immunodeficiency virus (HIV)‐infected subjects, but their frequency, pathogenesis, and outcome are still unsettled.

ACUTE GENERALIZED DYSTONIA DUE TO A BILATERAL LESION OF BASAL GANGLIA MAINLY AFFECTING THE NUCLEI PALLIDI

We describe a case of acute generalized dystonia due to bilateral damage to the basal ganglia, mainly affecting the globi pallidi. The lesion was probably related to a hypoxic condition following a heroin injection. Therapy with pimozide almost completely controlled the dystonia.SommarioDescriviamo un caso di distonia acuta generalizzata conseguente a un danno bilaterale dei gangli della base interessante principalmente i nuclei pallidi. Verosimilmente la lesione era causata da uno stato ipossico secondario a iniezione di eroina. La terapia con pimozide è stata efficace nel controllare la distonia.

Arachnoid cyst in the region of the fourth ventricle mimicking clinical picture of normal pressure hydrocephalus

Arachnoid cysts in the region of the fourth ventricle are rarely reported. Two cases with intraventricular arachnoid cysts (one in the fourth and one in the right lateral) manifesting normal pressure hydrocephalus have been described in the previous literature. Here we report a clinically similar case in which the cyst was wedged in cerebellar vermis and compressed the fourth ventricle. Slow enlargement of the cyst could explain the clinical picture. The removal of the cyst resulted in a marked improvement of the symptoms despite the lack of significant changes in ventricular size.