38 research outputs found
Transcranial Doppler as Transcranial Doppler as a method of screening for sickling crises in children with sickle cell anemia
No full textIntrodução: A anemia falciforme é a principal causa de acidente vascular cerebral (AVC) na infância. Velocidades de fluxo cerebral aumentadas avaliadas por Doppler transcraniano (DTC) podem predizer risco elevado para AVC e estão relacionadas a anemia mais grave. O objetivo do estudo foi avaliar se velocidades aferidas por DTC podem predizer complicações vasoclusivas além do AVC. Método: Incluídos no estudo pacientes entre 2 e 16 anos, com anemia falciforme, submetidos à triagem com DTC no Hospital das Clínicas da Faculdade de Medicina de Botucatu entre janeiro de 2012 e outubro de 2018. Foram coletados em prontuário eletrônico o perfil genotípico e dados demográficos dos pacientes, além dos exames de DTC realizados durante o seguimento, comparando esses parâmetros à presença de crises de falcização. Foram realizadas análises de sobrevivência por modelos de fragilidade simples em que cada variável preditora foi analisada separadamente em relação ao tempo para a ocorrência de uma crise de falcização mensurado em dias. Resultados: Foram incluídos no estudo 47 pacientes; seis foram excluídos por fazerem seguimento em outro serviço; dois por não apresentarem dados em prontuário; e dois por terem mais de 17 anos. Apresentaram relação com crises falcêmicas em análise univariada a velocidade de pico sistólico em artéria cerebral média HR 1,01 (1,00 a 1,02) p = 0,04; velocidade final diastólica em artéria cerebral média HR 1,02 (1,01 a 1,04) p = 0,01, velocidade média de fluxo em artéria basilar HR 1,02 (1,00 a 1,04) p = 0,04, hemoglobina HR 0,49 (0,38 a 0,65) p < 0,001, hematócrito HR 0,78 (0,71 a 0,85) p < 0,001, leucócitos HR 1,1 (1,05 a 1,15) p < 0,001, plaquetas HR 0,997 (0,994 a 0,999) p = 0,02 e reticulócitos HR 1,14 (1,06 a 1,23) p < 0,001. Após análise multivariada das variáveis, nenhuma apresentou relação com os desfechos. Discussão: Nossos resultados sugerem que o DTC pode ser um método eficaz de rastreio de síndromes vasoclusivas além do AVC. O fato de muitos pacientes estarem em uso de hidroxiureia ou hemotransfusão, poucos pacientes com exames de Doppler alterados e pequena amostra pode ter contribuído para perda da relação após análise multivariada. Conclusão: O exame de DTC é um método não invasivo e pode ser útil para rastreio de síndromes vasoclusivas em pacientes com anemia falciforme.Introduction: Sickle cell anemia is the leading cause of childhood stroke. Increased cerebral flow velocities assessed by transcranial Doppler (TCD) can predict high risk for stroke and are related to more severe anemia. The aim of the study was to evaluate whether speeds measured by TCD can predict vasocclusive complications in addition to stroke. Method: Were evaluated patients between 2 and 16 years old, with sickle cell anemia, who underwent screening with TCD at the Clinical Hospital of the Botucatu Medical School between January 2012 and October 2018. The genotypic profile and demographic data were collected from electronic medical records. of the patients, in addition to the TCD exams performed during the follow-up, comparing the presence of sickling crises. Survival analyzes were performed using simple frailty models in which each predictor variable was analyzed separately in relation to the time for the occurrence of a sickling crisis measured in days. Results: We evaluated 47 patients in the period, 6 were excluded for being followed up in another service, two for not presenting data in medical records and two were over 17 in the period. Variables related to sickle-cell crises in univariate analysis were systolic peak velocity in the middle cerebral artery HR 1.01 (1.00 to 1.02) P = 0.04; final diastolic velocity in mean cerebral artery HR 1.02 (1.01 to 1.04) P = 0.01, mean flow velocity in basilar artery HR 1.02 (1.00 to 1.04) P = 0, 04, hemoglobin HR 0.49 (0.38 to 0.65) p <0.001, hematocrit HR 0.78 (0.71 to 0.85) P <0.001, leukocytes HR 1.1 (1.05 to 1, 15) p <0.001, platelets HR 0.997 (0.994 to 0.999) P = 0.02 and reticulocytes HR 1.14 (1.06 to 1.23) P <0.001. After multivariate analysis none of the evaluated variables were statistically significant. Discussion: Our results suggest that TCD may be an effective method of screening for vasocclusive syndromes in addition to stroke. The fact that many patients are using hydroxyurea or blood transfusion, few patients with altered Doppler exams and a small sample may have contributed to the loss of the relationship after multivariate analysis. Conclusion: The TCD test is a non invasive exam that can be an usefull method for screening for vasocclusive syndromes in patients with sickle cell anemia
New Insights and Old Questions in Acute Stroke Blood Pressure Control
No full textDepartment of Neurology Psychology and Psychiatry São Paulo State University (UNESP) Medical School, District of Rubião Junior, No NumberDepartment of Internal Medicine São Paulo State University (UNESP) Medical School, District of Rubião Junior, No NumberDepartment of Neurology Psychology and Psychiatry São Paulo State University (UNESP) Medical School, District of Rubião Junior, No NumberDepartment of Internal Medicine São Paulo State University (UNESP) Medical School, District of Rubião Junior, No Numbe
Respiratory Function and Grip Strength in the Acute Phase of Stroke Are Associated with Stroke Severity and Disability at Hospital Discharge
No full textIntroduction. Stroke can lead to musculoskeletal and respiratory dysfunction, chronic deconditioning, and functional limitations, as well as long-term complications. Objective. The aim of this study was to evaluate the association between respiratory function and grip strength in the acute phase of stroke and stroke severity, disability, and autonomy in the long term. Methods. This was a cohort study including 46 patients in the stroke unit. The stroke patients were assessed in the stroke unit at the following moments: at admission by the clinical and haemodynamic stability, demographic and anthropometric data, hand grip strength, stroke severity by National Institutes of Health Stroke Scale (NIHSS) score, and respiratory function using a manovacuometer; during hospitalization by clinical complications and the length of stay; and at hospital discharge and 90 days after discharge by the degrees of functional capacity and dependence using NIHSS, modified Rankin scale (mRs), and Barthel index. Data analysis was performed by multiple linear regression to verify the association between respiratory function and grip strength and the outcomes. Results. The median length of stay in the stroke unit was 7 days. A negative correlation was found between the palmar prehension strength on the unaffected side and mRs at discharge (beta=-0.034, p=0.049). The NIHSS scores at discharge (beta=-0.016, p=0.011) were negatively correlated with the MEP. The Barthel index at discharge was positively correlated with the palmar prehension strength on the unaffected side (beta=0.480, p=0.023). Conclusion. It was concluded that a loss of grip strength is associated with a loss of ability and autonomy at discharge and poor respiratory function is associated with stroke severity at discharge.Univ Estadual Paulista, UNESP, Botucatu Med Sch, Botucatu, SP, BrazilFed Univ Triangulo Mineiro UFTM, Dept Appl Phys Therapy, Uberaba, MG, BrazilUniv Estadual Paulista, UNESP, Botucatu Med Sch, Rehabil Ctr, Botucatu, SP, BrazilUniv Estadual Paulista, UNESP, Botucatu Med Sch, Stroke Unit, Botucatu, SP, BrazilUniv Estadual Paulista, UNESP, Botucatu Med Sch, Dept Internal Med, Botucatu, SP, BrazilUniv Estadual Paulista, UNESP, Botucatu Med Sch, Dept Neurol Psychol & Psychiat, Botucatu, SP, BrazilUniv Estadual Paulista, UNESP, Botucatu Med Sch, Botucatu, SP, BrazilUniv Estadual Paulista, UNESP, Botucatu Med Sch, Rehabil Ctr, Botucatu, SP, BrazilUniv Estadual Paulista, UNESP, Botucatu Med Sch, Stroke Unit, Botucatu, SP, BrazilUniv Estadual Paulista, UNESP, Botucatu Med Sch, Dept Internal Med, Botucatu, SP, BrazilUniv Estadual Paulista, UNESP, Botucatu Med Sch, Dept Neurol Psychol & Psychiat, Botucatu, SP, Brazi
Coorte Brasileira de pacientes com AVC embólico de fonte indeterminada (ESUS) em um hospital universitário
No full textEmbolic stroke of undetermined source (ESUS) is an important group of cryptogenic strokes that are in evidence due recent ongoing trials. We reviewed medical records at discharge from the stroke unit of all patients who met ESUS criteria and attended our institution between February 2016 and July 2017. Among 550 stroke patients, 51 had ESUS. We found that hypertension (60%), diabetes mellitus (34%), and smoking (36%) were the most prevalent risk factors. The mean National Institutes of Health Stroke Scale (NIHSS) scores were 7 at admission and 4 at discharge, while median scores on the modified Rankin scale were 0 and 2 at admission and discharge, respectively. Our sample had similar ages, risk factors prevalence and NIHSS scores at admission and discharge when compared with European and North American cohorts. Although a small cohort, our study suggests that the ESUS population is similar in countries with different health financing.Neurology Psychiatry and Psycology Department Botucatu Medical School São Paulo State University (Unesp)Botucatu Medical School São Paulo State University (Unesp)Neurology Division Internal Medicine Department Hospital de Clínicas Federal University of ParanáDepartment of Neurology University of CampinasInternal Medicine Department Medical School São Paulo State University (Unesp)Department of Applied Physical Therapy Federal University of Triângulo Mineiro (UFTM)Neurology Psychiatry and Psycology Department Botucatu Medical School São Paulo State University (Unesp)Botucatu Medical School São Paulo State University (Unesp)Internal Medicine Department Medical School São Paulo State University (Unesp
Dysphagia and tube feeding after stroke are associated with poorer functional and mortality outcomes
No full textBackground & aims: Stroke is the leading cause of disability in adult life. Oropharyngeal dysphagia occurs in 65–90% of patients, and its identification in the acute phase of stroke can prevent complications. The aim of this study was to verify whether oropharyngeal dysphagia during stroke hospitalization is associated with functional capacity, as assessed by the modified Rankin Scale (mRs), and mortality 90 days after stroke. Materials and methods: A prospective cohort study evaluating 201 patients hospitalized in the Stroke Unit was carried out. Dysphagia was evaluated during hospitalization using both a specific protocol to evaluate swallowing biomechanics and the Functional Oral Intake Scale (FOIS), in which FOIS 1–3 reflects tube feeding, 4–5 reflects oral feeding requiring food consistency changes, and 6–7 reflects oral feeding with no changes in food consistency. An mRs≥3 at 90 days after discharge was considered disability. The data were adjusted for the National Institute of Health Stroke Scale score, sex, age, stroke-associated pneumonia, type of stroke, and presence of thrombolysis. The significance level was set at 5%. Results: Of the 201 patients evaluated, 42.8% (86) who had dysphagia were older, had a higher severity of stroke, and pneumonia rate. A FOIS score of 6–7 was a protective factor against disability (mRs≥3) (OR: 0.17; CI: 0.005–0.56; p = 0.004), and tube feeding use at hospital discharge increased the risk of mRs≥3 (OR: 14.97; CI: 2.68–83.65; p = 0.002) and mortality (OR: 9.79; CI: 2.21–43.4; p = 0.003) within 90 days after stroke. Pneumonia was the leading cause of death, however dysphagia and tube feeding at discharge were associated with death from any cause. Conclusion: Dysphagia or tube feeding use at discharge are markers of poor prognosis after the first stroke. Our data suggest the importance of early evaluation of dysphagia and closely monitoring the tube fed patients following stroke.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Department of Internal Medicine Sao Paulo State University (Unesp) Medical SchoolDepartment of Neurology Psychology and Psychiatry Sao Paulo State University (Unesp) Medical SchoolDepartment of Internal Medicine Sao Paulo State University (Unesp) Medical SchoolDepartment of Neurology Psychology and Psychiatry Sao Paulo State University (Unesp) Medical Schoo
Effect of ankle-foot orthosis on functional mobility and dynamic balance of patients after stroke
No full textIntroduction:Stroke is the principal cause of impairment in the motor function and gait of adults. One of the resources used in rehabilitation to optimize gait is a prescription of ankle-foot orthosis (AFO), and the most prescribed AFOs are Fixed AFO and Articulated AFO; however, it is not known which of these options is more effective for these individuals. The aim of this study is to evaluate the impact of different types of ankle-foot orthosis functional mobility and dynamic balance in stroke patients.Methods:Prospective randomized controlled clinical trial with 2 parallel groups will be conducted, and the aim is to recruit 50 patients with stroke diagnosis within 1 year, who indicated that they use both types of orthotics, who had a previous Rankin score less than or equal to 3, and who obtained AFO orthosis through the Hospital Clinics at the Botucatu Medical School (HCBMS) São Paulo, Brazil. After a specific evaluation by a physiotherapist, the patient will receive 1 of the AFO types via randomization. After 30 days, the patient will be reevaluated. The primary outcomes will be balance and mobility, which will be evaluated by the Time Up Go Test (TUG) and Tinetti's Scale of Mobility and Balance (TSMB). The secondary outcomes will be quality of life and the levels of anxiety and depression, which will be evaluated with the European (5D) Quality of Life Scale (Euroqol) and Hospital Anxiety and Depression Scale (HADS). Group allocation will be not concealed because the blinding of participants and of therapists that provide intervention is not possible, and all analyses will be based on an intention-To-Treat principle. This study was approved by the Human Research Ethics Committee of the São Paulo State University UNESP, number 2.367.953. The results will be published in relevant journal.Discussion:The results of this study will contribute to clinical practice by identifying the type of AFO orthosis that is more suitable for this condition, helping to standardize prescription of these orthoses by professionals, and guiding future research studies on this subject, which is still incompletely defined in the literature.Trial registration:RBR-6SF2VV (March 5, 2018).Rehabilitation Department Sao Paulo State University (UNESP Botucatu Medical SchoolDepartment of Internal Medicine Sao Paulo State University (UNESP Botucatu Medical SchoolDepartment of Applied Physical Therapy Federal University of Triângulo Mineiro (UFTM)Department of Neurology Psychology and Psychiatry Sao Paulo State University (UNESP)Rehabilitation Department Sao Paulo State University (UNESP Botucatu Medical SchoolDepartment of Internal Medicine Sao Paulo State University (UNESP Botucatu Medical SchoolDepartment of Neurology Psychology and Psychiatry Sao Paulo State University (UNESP
Segurança da dose de radiação efetiva recebida durante internação por acidente vascular cerebral
No full textBackground: Neuroimaging is widely used for diagnosis and treatment of stroke. However, little is known about whether the radiation doses received by patients comply with international safety guidelines. Objectives: The aim of this study was to evaluate the effective radiation dose received while in hospital for stroke and analyze its safety according to current guidelines. Methods: This cross-sectional study included 109 patients who were hospitalized and diagnosed with ischemic stroke. The National Institutes of Health Stroke Scale was used to evaluate stroke severity, the Bamford clinical classification was used for topography, and the TOAST classification was used for etiology. The computed tomography dose index and size-specific dose estimates were used to calculate the effective radiation dose (ERD) received while in hospital. A Mann-Whitney test was used to compare the ERD received by thrombolysed and non-thrombolysed patients. Non-parametric statistics were used to analyze the data with a 95% confidence interval. Results: During the study period, the median ERD received was 10.9 mSv. Length of stay was not associated with radiation exposure. No differences were demonstrated in ERD according to stroke etiology or Bamford clinical classification. Patients who had CT perfusion (only or in addition to CT or angiotomography) received the highest ERD (46.5 mSv) and the difference compared to those who did not (10.8 mSv) was statistically significant (p<0.001). No differences were found in the ERD between thrombolysed and non-thrombolysed patients. There was no correlation between ERD while in hospital and stroke severity. Conclusions: According to the current national guidelines, the protocol for examining images at our stroke unit is safe in terms of the ERD received by the patient while in hospital. There was no difference in the ERD received by patients stratified by thrombolytic treatment or stroke severity.Universidade Estadual Paulista – UNESP, SPDepartamento de Fisioterapia Aplicada Universidade Federal do Triângulo Mineiro – UFTM, MGUniversidade Estadual Paulista – UNESP, S
Clinical and Functional Outcomes of Patients Receiving Cerebral Reperfusion Therapy: A Stroke Databank Study in Brazil
No full textObjectives: Cerebral reperfusion therapy is recommended for the treatment of acute ischemic stroke. However, the outcomes of patients receiving this therapy in middle- and low-income countries should be better defined. This study aimed to evaluate the clinical and functional outcomes of cerebral reperfusion therapy in patients with ischemic stroke. Materials and Methods: This retrospective study included patients with ischemic stroke treated with cerebral reperfusion therapy, including intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and IVT with MT. The primary outcomes were death and disability, assessed using the modified Rankin scale (mRS), and stroke severity, assessed using the National Institutes of Health Stroke Scale (NIHSS), after intervention and 90 days after ictus. The association between the type of treatment and the primary outcome was assessed using binary logistic regression after adjusting for confounding variables. Furthermore, receiver operating characteristic (ROC) curves were generated to identify the cutoff point of the NIHSS score that could best discriminate the mRS score in all types of treatments. Results: Patients (n = 291) underwent IVT only (n = 241), MT (n = 21), or IVT with MT (n = 29). In the IVT with MT group, the incidence of death within 90 days increased by five times (OR, 5.192; 95% CI, 2.069–13.027; p = 0.000), prevalence of disability increased by three times (OR, 3.530; 95% CI, 1.376–9.055; p = 0.009) and NIHSS score increased after IVT (from 14.4 ± 6.85 to 17.8 ± 6.36; p = 0.045). There was no significant difference between the initial NIHSS score and that after MT (p = 0.989). Patients' NIHSS score that increased or decreased by 2.5 points had a sensitivity of 0.74 and specificity of 0.65, indicating severe disability or death in these patients. Conclusion: Altogether, a 2.5-point variation in NIHSS score after reperfusion is an indicator of worse outcomes. In our particular context, patients receiving the combination of IVT and MT had inferior results, which probably reflects challenges to optimize MT in LMIC.Department of Neurology Psychology and Psychiatry Botucatu Medical School (UNESP)Department of Applied Physical Therapy Federal University of Triângulo MineiroDepartment of Internal Medicine Botucatu Medical School (UNESP)Department of Neurology Psychology and Psychiatry Botucatu Medical School (UNESP)Department of Internal Medicine Botucatu Medical School (UNESP
Long-term effect of non-invasive brain stimulation on hemispatial neglect, functional outcomes, and mortality after stroke: ELETRON trial extend
No full textIntroduction: Our primary clinical trial indicated that anodal stimulation of the right posterior parietal region associated with specific and perceptual task training was superior to placebo in reducing stroke-induced hemispatial neglect (HN) immediately after the treatment protocol. However, our primary study did not investigate whether this benefit was maintained in the long term after stroke. Therefore, this study aimed to evaluate the long-term effects of the protocol applied in the ELETRON trial on outcomes associated with HN, functionality, and mortality. Methods: This was a pilot, multicenter, prospective, randomized, double-blind trial in patients with HN after stroke who underwent either active tDCS (anodal tDCS or C-tDCS) or sham tDCS in addition to specific and perceptual task training. The outcomes were evaluated on the last day of the session and after 1 year of stimulation (follow-up). Daily evolution rates were calculated as the difference between the values observed between the moments divided by the follow-up time for each individual. The primary outcome was the rate of HN evolution according to the BIT-C scale. The secondary outcome was CBS evolution rate. The exploratory outcomes were the evolution rate of functional disability and autonomy assessed by FIM and BI, quality of life assessed by EQ 5D, stroke severity using the NIHSS, and functional dependence assessed by mRS. Death was examined separately. A linear regression model with a time-adjusted identity link function was used to explain the evolution rates of each outcome of A-tDCS and C-tDCS as a function of sham tDCS. Survival models were adjusted to compare mortality groups. Results: The evolution rate of BIT-C was not different between A-tDCS (B = 3.18; CI: −4.84–11.19; p = 0.438) and C-tDCS (B = −0.95; CI: −8.97–7.07; p = 0.816) with sham. The secondary and exploratory outcomes showed the same pattern. In addition, there were no statistically significant differences in mortality over time between A-tDCS and S-tDCS (B = 0.322; 95 % CI 0.284–6.707; p = 0.689) and between C-tDCS and S-tDCS (B = −0.798; 95 % CI 0.063–3.195; p = 0.425). Conclusion: The benefits of A-tDCS and C-tDCS were maintained for all long-term post-stroke outcomes. Trial registration: RBR-78jvzx - Brazilian Registry of Clinical Trials (Rebec), registered on March 13, 2016.Department of Internal Medicine Botucatu Medical School (UNESP), São PauloDepartment of Public Health Botucatu Medical School (UNESP), São PauloStroke Unit Botucatu Medical School (UNESP), São PauloDepartment of Neurosciences and Behavioral Sciences Hospital das Clínicas Ribeirão Preto Medical School University of São Paulo, São PauloDepartment of Applied Physical Therapy at Federal University of Triângulo Mineiro (UFTM), Minas GeraisDepartment of Neurocience and Mental Health Botucatu Medical School (UNESP), São PauloDepartment of Internal Medicine Botucatu Medical School (UNESP), São PauloDepartment of Public Health Botucatu Medical School (UNESP), São PauloStroke Unit Botucatu Medical School (UNESP), São PauloDepartment of Neurocience and Mental Health Botucatu Medical School (UNESP), São Paul
Evaluating the performance of the PRISMA-7 frailty criteria for predicting disability and death after acute ischemic stroke: PRISMA-7 - Disability or Death after Stroke
No full textObjectives: We aimed to evaluate the predictive performance of the PRISMA-7 frailty criteria regarding the composite outcome of disability or death in patients with an acute ischemic stroke, and to compare it with the Frailty Index and the National Institutes of Health Stroke Scale (NIHSS). Materials and methods: This prospective cohort study involved all patients aged ≥ 40 years admitted with an acute ischemic stroke between March 2019 and January 2020. We performed survival analyses, calculated risk ratios, sensitivity, specificity, and predictive values for the combined outcome of disability or death according to the presence of frailty as determined by the PRISMA-7 and the Frailty Index, and stroke severity based on the NIHSS. Results: In 174 patients with acute ischemic stroke, being frail in the week before the stroke according to the PRISMA-7 was associated with a Risk Ratio of 4·50 (95%CI 1·77-11·43, P <0·001) and a Positive Predictive Value of 89% (95%CI 77-99%) for being disabled or dead 90 days after the stroke, and a Hazard Ratio of 3·33 (95%CI 1·48-7·51, P = 0·004) for the survival outcome. The predictive performance of the PRISMA-7 was not significantly different from the Frailty Index or the NIHSS. Conclusions: We provide evidence that the PRISMA-7 frailty criteria may be a useful prognostication tool in acute ischemic stroke.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Department of Internal Medicine Botucatu Medical School Sao Paulo State University (UNESP)Department of Applied Physical Therapy Federal University of Triângulo Mineiro (UFTM)Institute of Mental Health University of Nottingham Medical SchoolDepartment of Rehabilitation Botucatu Medical School Sao Paulo State University (UNESP)Department of Surgical Specialties and Anesthesiology Botucatu Medical School Sao Paulo State University (UNESP)Department of Neurology Psychology and Psychiatry Botucatu Medical School Sao Paulo State University (UNESP)Department of Internal Medicine Botucatu Medical School Sao Paulo State University (UNESP)Department of Rehabilitation Botucatu Medical School Sao Paulo State University (UNESP)Department of Surgical Specialties and Anesthesiology Botucatu Medical School Sao Paulo State University (UNESP)Department of Neurology Psychology and Psychiatry Botucatu Medical School Sao Paulo State University (UNESP
