Renata Dal-Prá Ducci

General practice physician knowledge about headache: evaluation of the municipal continual medical education program

OBJECTIVE Headache is a common condition not always managed satisfactorily by primary care providers (PCPs). In an effort to improve headache care, the Curitiba City Hall in consortia with Hospital de Clínicas da Universidade Federal do Paraná - Brazil developed an educational program directed to the PCPs. The goal of the project was to evaluate, to update and to train the PCP on headache knowledge and care. METHOD The program was designed to have a theoretical phase and a practical phase. Knowledge on headache and medical care of headache were surveyed before and after the theoretical phase thorough a specific questionnaire. RESULTS Significant improvement in post-CME scores on headache prevalence (p<0.001), migraine diagnosis (p<0.001) and management (p=0.01), secondary headache diagnosis (p=0.005) and management (p=0.005) was reached by the respondents. CONCLUSION Improvement in post-CME scores confirms that the program had a significant immediate impact on the PCPs knowledge directly affecting the patients health.

Cessação de tabagismo em pacientes de um hospital universitário em Curitiba

OBJECTIVE To determine the prevalence of smoking and the frequency of smoking cessation counseling among patients at a university hospital, as well as to compare smokers and former smokers in terms of smoking history. METHODS A cross-sectional study involving 629 patients at the Federal University of Paraná Hospital de Clínicas, located in the city of Curitiba, Brazil. RESULTS Of the 629 patients, 206 (32.7%) were male, 76 (12.1%) were smokers, 179 (28.5%) were former smokers, and 374 (59.5%) were nonsmokers. The mean age of the patients was 49.9 ± 15.0 years (range, 18-84 years). Of the 76 smokers and 179 former smokers, 72 (94.7%) and 166 (92.7%), respectively, were questioned about tobacco use. Smoking history and degree of nicotine dependence were higher among the former smokers (p = 0.0292 and p = 0.0125, respectively). Gender, age at smoking initiation, physician inquiry about tobacco use, and smoking cessation counseling were comparable between the two groups. The smoking cessation rate was 0.70. The prevalence of heavy smoking varied by gender and by age bracket, being higher in males and in the 41-70 year age bracket. CONCLUSIONS The smoking prevalence in this group of patients was lower than that reported for patients at another university hospital, for adults in Curitiba, and for adults in Brazil. The smoking cessation rate was higher in these patients than in the general population of Curitiba. Smokers and former smokers differed regarding age, smoking history, and degree of nicotine dependence. Heavy smoking and a moderate or high degree of nicotine dependence were not obstacles to smoking cessation.

Clinical follow-up of pregnancy in myasthenia gravis patients

This study aimed to analyze the outcome and impact of pregnancy in women with myasthenia gravis (MG). Obstetric and clinical data were retrospectively analyzed before, during and after pregnancy. Predictors of outcome were studied. We included 35 pregnancies from 21 MG patients. In the course of MG symptoms in 30 pregnancies with live births, 50% deteriorated (mainly during the second trimester, p = 0.028), 30% improved, and 20% remained unchanged. The deterioration group had more frequent abnormal repetitive nerve stimulation (RNS) (p = 0.028) and lower myasthenia gravis composite (MGC) scores (p = 0.045) before pregnancy. The improvement group was associated with higher MGC scores (p = 0.012) before pregnancy. The no-change group was associated with longer duration of MG (p = 0.026) and normal RNS (p = 0.008) before pregnancy. The course of MG in the second pregnancy was different from that in the previous pregnancy in 65.3% of cases. Obstetric complications were reported in 20 pregnancies; the most common was preterm premature rupture of membranes (PPROM) (25.8%), and the most severe were abortion (11.4%) and fetal death (2.9%). Most of the patients delivered via caesarean section (66.7%). Spinal anesthesia was performed in 73.3%. Transient neonatal myasthenia gravis occurred in 12.9% of live-born infants, and no predictors were found. In conclusion, severity and duration of MG, RNS and treatment influence MG and pregnancy. Pregnant MG patients have greater rates of PPROM and caesarean delivery. Our data suggest that duration of MG, MGC and RNS before pregnancy may be useful in helping to predict the course of MG during pregnancy.

Childhood acute bacterial meningitis: risk factors for acute neurological complications and neurological sequelae.

OBJECTIVE To assess acute neurological complications and neurological sequelae of childhood acute bacterial meningitis in order to determine possible warning signs. METHODS This retrospective study evaluated children with acute bacterial meningitis (between 1 month and 14 years of age) admitted between 2003 and 2006. RESULTS Of the 44 patients studied, 17 (38.6%) had acute neurological complications. Seizure was the most frequent (31.8%) complication. Patients with acute neurological complications showed a higher frequency of lower neutrophil count (p = 0.03), seizure at admission (p < 0.01), and S. pneumoniae as the etiologic agent (p = 0.01). Risk factors for the development of acute neurological complications were S. pneumoniae (odds ratio [OR] = 6.4, confidence interval [CI] 1.7-24.7) and neutrophil count < 60% (p < 0.01). Of the 35 patients who were followed up, 14 had neurological sequelae (40%). Behavioral change (22.9%) was the most frequent sequela. Seizures at admission (OR = 5.6, CI 1.2-25.9), cerebrospinal fluid protein concentration > 200 mg/dL (p < 0.01), and cerebrospinal fluid glucose concentration/glycemia ratio (p < 0.01) were identified as risk variables for sequelae. CONCLUSION Neutrophil count < 60%, seizure at admission, and S. pneumoniae as the etiologic agent were identified as warning signs for acute neurological complications, while protein levels, cerebrospinal fluid glucose concentration/glycemia ratio, and seizure at admission were seen as risk factors for neurological sequelae.

Catamenial and oral contraceptive-induced exacerbation of chorea in chorea-acanthocytosis: Case report

This letter to the editor focuses on a case report involving the exacerbation of chorea in chorea-acanthocytosis (ChAc) during treatment with an oral contraceptive (OC) in a 38-year-old woman.

Does the side of middle cerebral artery compromise matters in the mortality after thrombolysis in ischemic stroke

UNLABELLED The impact of the side in middle cerebral artery (MCA) ischemic stroke is not well established. Our aim was to analyze the differences between right (RMCA) and left middle cerebral artery (LMCA) stroke in patients submitted to intravenous thrombolysis and the influence of the affected side in the patients mortality after 3 months. METHOD Patients with MCA ischemic stroke submitted to intravenous thrombolysis from March 2010 to December 2011 at two Brazilian Stroke Centers were included. Differences between patients with RMCA and LMCA stroke were identified by univariate analysis. RESULTS Forty-five patients with RMCA stroke and 67 with LMCA stroke were analyzed. Patients with LMCA had a higher incidence of atrial fibrillation (p = 0.031), although patients with RMCA more often had a previous ischemic stroke (p = 0.034). The mortality over 3 months was similar for either side (OR = 1.20 ;0.37 - 4.29, p = 0.772). CONCLUSION The side of the MCA ischemic stroke did not influence the patients mortality.

Sodium nitroprusside: low price and safe drug to control BP during thrombolysis in AIS

This study analyzes the use of sodium nitroprusside (SN) as an option to reduce blood pressure (BP) below 180/105 mmHg during the management of acute ischemic stroke (AIS) in patients submitted to intravenous thrombolysis.Method The sample was composed by 60 patients who had AIS and were submitted to intravenous rtPA, split in two groups: half in the control group (CG) with BP < 180/105 mmHg and half in SN group with BP > 180/105 mmHg. Outcome variables were any hemorrhagic transformation (HT); the presence of symptomatic HT, National Institute of Health Stroke Scale (NIHSS) after 24 hours of treatment; the independence on discharge and death until three months after stroke onset.Results There were no statistical differences between both groups to any of the outcome variables analyzed.Conclusion The SN might be safe for BP control during thrombolysis to AIS.

Meropenem-induced myoclonus: A case report

A 61-year-old woman was seen at the intensive care unit because of myoclonic status. Her medical history included arterial hypertension, dyslipidemia and diabetes. In the previous year she had been hospitalized because of dilated cardiomyopathy (ejection fraction 21%) and non-sustained ventricular tachycardia. At that time she was managed with an implantable cardiac defibrillator. On this admission she complained of precordial pain and had heart failure with a cold and dry profile, for which she was given vasoactive drugs and an intra-aortic balloon. Her coronary angiography was unremarkable, but a lower limb echo-Doppler revealed a high-flow arteriovenous fistula between the right superficial femoral artery and vein. The fistula was not managed surgically because of the patient’s clinical status. In the following days her dyspnea worsened, requiring non-invasive ventilation, and her central catheter became colonized. She developed oliguria, vomiting, hypoglycemia, syncope and cardiac arrest, which was successfully managed with cardiopulmonary resuscitation (CPR). A urinary infection ensued 5 days later and as her renal function had decreased, intravenous meropenem 1000 mg/day was started (dosing for CrCl of 10–25 mL/min: 500–1500 mg/day). Soon after

Exclusive bed for thrombolysis. A simple measure that allows 85% of ischemic stroke patients to be treated in the first hour

The door-to-needle time is an important goal to reduce the time to treatment in intravenous thrombolysis. Objective Analyze if the inclusion of an exclusive thrombolytic bed reduces the door-to-needle time. Method One hundred and fifty patients admitted for neurological evaluation with ischemic stroke were separated in two groups: in the first, patients were admitted in the Emergency Room for intravenous thrombolysis (ER Group); in the second, patients were admitted in an exclusive thrombolytic bed in the general neurology ward (TB Group). Results Sixty-eight (86.0%) patients from TB Group were treated in the first 60 minutes of arrival as compared to 48 (67.6%) in the ER Group (p = 0.011). Conclusion The introduction of a thrombolytic bed in a general hospital setting can markedly reduce the door-to-needle time, allowing more than 85% of patients to be treated within the first hour of admission.

Factors Related to Cardioembolism as Major Predictors of Poor Survival after First-Ever Middle Cerebral Artery Stroke Treated with Thrombolysis

Background and Purpose: Prognostic factors related to mortality rates after stroke have been reported; however, most studies included different treatments and did not focus solely on ischemic stroke. The study aimed to report the short- and long-term survival and predictors of death in patients with first-ever ischemic stroke in the middle cerebral artery (MCA) territory, submitted to intravenous thrombolysis (IVT). Methods: A prospective observational cohort study of patients with first-ever ischemic stroke in the MCA territory treated with IVT from March 2010 to February 2015 was conducted, and patients were followed up until May 2015. The Kaplan-Meier method was used to estimate the cumulative case fatality rates. The potential prognostic factors were identified using Cox proportional hazards regression analysis. Results: A total of 169 patients, 51% women of mean age of 64.1 ± 12.9 years were followed up for a median time of 23.6 (8.1-36.2) months. At the end of the study, 53 (31.4%) patients had died. The estimated cumulative case fatality rate was 41.8% for 5 years. Chronic heart failure (hazards ratio [HR] 2.89, 95% CI 1.43-5.84, p = 0.003), atrial fibrillation (HR 3.88, 95% CI 1.30-11.57, p = 0.015), and symptomatic intracerebral hemorrhage (SICH; HR 7.83, 95% CI 3.43-17.92, p < 0.001) were significant unfavorable independent outcome predictors. The most frequent cause of death was infection (46%). Conclusions: Stroke in the MCA territory has a high mortality rate, even in patients treated with IVT. SICH, atrial fibrillation, and chronic heart failure are modifiable factors related to cardioembolism that need to be aggressively targeted for improved outcomes after stroke.