Giuseppe Re

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.

Efficacy of transarterial targeted treatments on survival of patients with hepatocellular carcinoma. An Italian Experience

Background. Most patients with hepatocellular carcinoma (HCC) are not suitable for surgical therapy. Systemic chemotherapy, immunotherapy, and hormonotherapy have not had convincingly acceptable results. Therefore, transarterial catheter‐targeted therapies such as intraarterial chemotherapy (IAC), possibly followed by transcatheter arterial chemoembolization (TACE), have been proposed.

Orthostatic Hypotension As Cause of Syncope in Patients Older Than 65 Years Admitted to Emergency Departments for Transient Loss of Consciousness

BACKGROUND Syncope due to orthostatic hypotension (OH) refers to loss of consciousness caused by hypotension induced by the upright position; it is an important risk factor for fall-related physical injuries, especially in the elderly adults. We evaluated the prevalence of OH syncope and the clinical characteristics of patients older than 65 years with syncope due to OH in the Evaluation of Guidelines in Syncope Study 2 group population. METHODS Two hundred fifty nine patients older than 65 years consecutively admitted to the emergency department because of loss of consciousness in a period of a month were submitted to a standardized protocol approved by the European Task Force for the diagnosis of syncope; all the patients were studied by a trained physician who interacted with a central supervisor as the management of syncope was concerned, using a decision-making software. RESULTS Prevalence of OH syncope was 12.4%. Patients with OH syncope were more likely to be affected by Parkinsons disease and by other neurological diseases. ST changes and longer values of QTc were found in OH syncope group, and they took a greater number of diuretics, nitrates, and digoxin. In multivariate analysis, Parkinsons disease (p = .001) and use of nitrates (p = .001) and diuretics (p = .020) were independently related to OH syncope. CONCLUSIONS In patients older than 65 years, Parkinsons disease and neurological comorbidity are strictly related to OH syncope. Moreover, this study suggests the independent link between OH syncope and the use of vasoactive drugs, identifying the majority of cases as adverse drug reaction, a preventable risk factor for syncope and falls in the older population.

Evidence-Based Diagnosis of Nontraumatic Headache in the Emergency Department: A Consensus Statement on Four Clinical Scenarios

Objective.—To provide to emergency department (ED) physicians with guidelines for diagnosis of patients with nontraumatic headaches.

Myocardial Damage and Rhabdomyolysis Associated with Prolonged Hypoxic Coma Following Opiate Overdose

CASE REPORT We report a case of biopsy proven myocardial damage after opiate-induced rhabdomyolysis. Myocardial biopsy showed focal lesions formed by small mononuclear inflammatory cells with a few neutrophils, associated with degenerated and necrotic myocardial fibers, interstitial edema and congestion of intrinsic blood vessels. These findings were similar to those seen with other drug overdoses if combined with strenuous muscular effort or hypoxic coma. We hypothesize that myocardial damage is a consequence of intracapillary myohypoxia associated with prolonged hypoxic coma following opiate overdose.

Whole Bowel Irrigation After Delayed Release Fenfluramine Overdose

We report a patient who intentionally ingested a large amount of delayed release fenfluramine and was successfully treated with whole bowel irrigation. To our knowledge this is the first case of this kind to be reported in the literature. This therapeutic method, commonly used for acute poisonings with enteric coated and other modified release pharmaceuticals appears effective and risk-free in the treatment of delayed release fenfluramine overdose.