Evidence Of Stroke Research Articles

Integrated psychology support and comprehensive cognitive evaluation improves access to special education services for children with sickle cell disease.

Children with sickle cell disease (SCD) are at risk for cognitive deficits. Limited data describe whether comprehensive cognitive evaluation improves education resources and whether caregivers perceive the assessment as beneficial. We tested our two hypotheses: (a) an integrated comprehensive cognitive evaluation program in children with SCD results in increased special education services allocation; and (b) caregivers will value comprehensive cognitive evaluation services provided. In a tertiary care medical facility, as part of quality improvement project, in a before-and-after evaluation between March 2011 and July 2014, we examined the impact of targeted comprehensive cognitive evaluation on change in special education services. We also evaluated the caregiver's perception regarding the utility of the provided services. A total of 21% (42 of 196) students (median age 11 years, range 3-18) with SCD were referred for cognitive assessment due to overt stroke (n = 11), silent stroke (n = 14), or concerns about cognitive or academic functioning without evidence of strokes (n = 17). At baseline, 45.2% received special education services and after the comprehensive cognitive evaluation 86.7% received special education services (P < 0.001). Among 33 caregivers who completed the survey, 97% reported that the assessment was helpful and 60% indicated that assessment led to beneficial changes for their children at school. Education advocacy coupled with comprehensive cognitive assessment in students with SCD improved access to special education services, and caregivers uniformly endorse this service as having added value.

Abstract MP15: Validation of Phenotyping Algorithms for Stroke From Electronic Health Records Using Natural Language Processing

Background: Accurate identification of stroke cases from electronic health record (EHR) is needed for efficient and valid clinical and epidemiology research. A number of studies have evaluated the validity of using ICD-9 and ICD-10 codes for stroke identification. Previous research results show that sensitivity and positive predictive value (PPV) for stroke identification is the lowest among all other cerebrovascular diseases, with notable differences observed by stroke pathological subtypes. While most prevalent cerebrovascular disease cases can be detected using 430-438/I60-I69 collectively, more accurate and comprehensive stroke phenotyping algorithm is needed to identify incident stroke cases from EHR. In our work, we compared case identification results using ICD-codes exclusively with ICD plus a natural language processing (NLP) algorithm. Methods: We developed the NLP part of our stroke algorithm using a list of expert provided stroke-related keywords, which covers transient ischemic attack (TIA), ischemic stroke, and hemorrhagic stroke. We validated the hybrid (ICD+NLP) algorithm and compared it with ICD-exclusive algorithm in a previously established atrial fibrillation cohort (n=5,062). Clinical notes and ICD codes of all patients after the incident AF event were reviewed by two nurse abstracters to confirm new stroke incidences. All past clinical notes and ICD codes of a subset of patients (n=402) were reviewed to confirm lifetime (prior and current) stroke cases. Manual abstraction results were considered the gold standard for evaluation of ICD only and ICD+NLP automatic extraction. Sensitivity and positive predictive values (PPV) of both algorithms were calculated. Results: Among 5,062 patients, 593 patients were confirmed to have suffered a stroke after atrial fibrillation while 4,469 patients were confirmed with no EHR evidence of stroke after AF. The ICD-exclusive algorithm had a sensitivity of 47.2% and a PPV of 47.8% for detecting new stroke incidences. The hybrid stroke algorithm achieved a sensitivity of 92.4% and a PPV of 60.6% for extraction of incident stroke. For extraction of lifetime stroke cases, the hybrid approach achieved a sensitivity of 93.9% and a PPV of 88.7%. Performance of new stroke incidence extraction is limited because past/current stroke mentions in clinical notes are difficult to distinguish by our NLP algorithm (may be a future direction). Conclusions: We developed and validated a stroke algorithm that performed well for identifying incident and lifetime stroke cases. The addition of NLP into the stroke algorithm improved the sensitivity and PPV of compared to an ICD-exclusive algorithm.

Neurological complications after cardiac surgery: a retrospective case-control study of risk factors and outcome

BackgroundTo evaluate incidence, risk factors, and outcomes of postoperative neurological complications in patients undergoing cardiac surgery.MethodsA total of 2121 patients underwent cardiac surgery between August, 2008 and December, 2013; 91/2121 (4.3%) underwent brain computed tomography (70/91, 77%) or magnetic resonance imaging (21/91, 23%) scan because of major stroke (37/2121, 1.7%) and a spectrum of transient neurological episodes as well as transient ischemic attacks and delirium /psychosis/seizures (54/2121, 2.5%). The mean age was 65.3 ± 12.1 years and 60 (65.9%) were male. Variables were compared among study- and matched-patients (n = 113) without neurological deficits.ResultsA total of 37/2121 (1.7%) patients had imaging evidence of stroke. Radiological examinations were done 5.72 ± 3.6 days after surgery. Patients with and without imaging evidence of stroke had longer intensive care unit length of stay (LOS) (13.8 ± 14.7 and 12.9 ± 15 days vs. 5.7 ± 12.1 days, respectively (p < 0.001) and hospital LOS (53 ± 72.8 and 35.5 ± 29.8 days vs. 18.4 ± 29.2 days, respectively (p < 0.001) than the control group. The hospital mortality of patients with and without imaging evidence of stroke was higher than the control group (7/37 patients [19%], and 12/54 patients [22%] vs. 4/115 patients [3%], respectively (p < 0.001). Multivariate analysis showed that bilateral internal carotid artery stenosis of any grade (p < .001), and re-do operations (p = .013) increased the risk of postoperative neurological complications.ConclusionsNeurological complications after cardiac surgery increase hospitalization and mortality even in patients without radiologic evidence of stroke. Bilateral internal carotid artery stenosis of any grade, suggesting a diffuse patient propensity toward atherosclerosis, and re-do operations increase the risk of postoperative neurological complications.

Diabetes Mellitus and Cognition-A Non Invasive Study

Background Diabetes mellitus is increasing worldwide due to improved lifestyle modifications. Particularly more common in developing countries. Peripheral, central and autonomic neuropathy are the most common complications of diabetes mellitus, which if not detected early can lead to early disability. Event related potential P300 is a non invasive test to detect one of the higher functions of brain namely cognition. The present study was conducted to evaluate impact of diabetes mellitus and its duration on cognition. Aims & Objectives To investigate neurophysiological alterations of higher brain functions in patients with diabetes mellitus. Materials & Method Auditory P300 event related potentials were recorded in 60 diabetic patients (NIDDM & IDDM) attending medical out patient department of Bapuji & Chigateri hospital, Davangere, who had no evidence of stroke, dementia, or any other neurological illness. The P300 wave latencies in diabetic patients were compared with those in neurologically healthy control subjects, with consideration of duration of diabetes and analyzed by using unpaired student T test for comparison between cases and controls and one way ANOVA for multiple group comparisons within diabetics based on duration of diabetes. Results Diabetics had significantly longer P300 latencies and reduced P300 amplitudes than control subjects. There was a positive correlation between prolongation of latencies and duration of diabetes mellitus. Conclusion The present study suggests that diabetes does relate significantly to cognitive decline. ERP P300 can be a useful neurophysiological test to detect cognitive decline early in diabetics and also beneficial to the clinician for further management of the patient.

The Prevalence of Stroke Survivors in Urban Slums in Enugu, Nigeria

Background: Stroke is one of the commonest non-communicable diseases and the commonest cause of death in adult neurology wards. Stroke preva-lence in sub Saharan Africa has dramatically increased over the past decades possibly due to changing life styles, poverty, poor health infrastructures which had led to increased risk factors for stroke. Poor nutrition and lack of access to standard medical care, predispose to high rates of stroke morbidity and mor-tality hence possible low prevalence. Little is known about the prevalence of stroke in people with low socio-economic status in Nigeria. Objectives: The main objective of this study was to determine the prevalence of stroke in two urban slums in south east Nigeria. Materials and Methods: This was a cross sectional descriptive study carried out in two slums in Enugu, South East Nige-ria. Participants were screened using a stroke specific questionnaire and further examined by two independent neurologists for evidence of focal neurological deficits. Analysis was done by SPSS version 22. Results: A total of 1440 par-ticipants were surveyed in the study; 769 (53.4) females and 671 (46.6%) males. About 22.3% (321) screened positive for various neurological diseases out of which 17 (5.3%) had evidence for stroke giving an overall prevalence of 1.2% (males 9 (1.3%) vs females 8 (1%) p = 0.6). The mean age of stroke sur-vivors was 60.1 years, similar in males and females (p = 0.6). The odds ratio for stroke from 40 years showed progress increment doubling between 60 and 70 years and tripled between 40 and 70 years. Age, lower level of education, positive history of hypertension, sickle cell disease, leg swelling and use of snuff positively are correlated with clinical diagnosis of stroke. Conclusion: The prevalence of stroke in two urban slums in Enugu metropolis was 12/1000. Hypertension, diabetes, use of snuff, and low levels of education were signifi-cant risk factors for stroke. Public health educational measures, promoting prevention and early detection of diabetes should be encouraged.

Transient Neurologic Deficit without Vascular Pathology Correlates with Reversible Focal Hypoperfusion on Arterial Spin Labeled Perfusion Imaging

AbstractWe present the case of a 16-year-old boy with altered mental status and magnetic resonance imaging demonstrating left hemispheric hypoperfusion without evidence of stroke, based on arterial spin labeling (ASL) and dynamic contrast-enhanced perfusion imaging. Vessel imaging on magnetic resonance angiography and computed tomography angiography, in addition to an echocardiogram, showed no evidence of an embolic source. Electroencephalography showed left posterior temporal slowing. Within 8 hours, he was awake and alert but with receptive aphasia, and within 24 hours his symptoms completely resolved. Repeat ASL perfusion imaging demonstrated complete resolution of the perfusion abnormality, and diffusion imaging revealed no areas of infarct. This report demonstrates the correlation between a transient neurologic deficit and reversible focal hypoperfusion measured by ASL cerebral perfusion.

Current Status of Neuromonitoring in Cardiac Surgery

Brain injury often complicates cardiac surgery with a wide spectrum of neurologic dysfunction running from evidence of stroke to cognitive impairment. Global or regional brain hypoxia represents the common cause of brain injury as the consequence of a mismatch between the oxygen demand and supply to the brain tissue. Whatever the etiological mechanism of the brain damage (cerebral embolism, hypo and/or hyper cerebral perfusion, hypoxia, and the systemic inflammatory response), the continuous intraoperative neuromonitoring should assess the cerebral blood flow and oxygenation and the brain function. The expanded role of the intraoperative neurologic monitoring in cardiac surgery setting has allowed the neurologic adverse events to be promptly detected. The main advantage of the intraoperative neuromonitoring is that they are noninvasive, portable, and reliable. The current literature, though showing low grade of evidence, suggests that intraoperative neuromonitoring may be protective against neurologic adverse events.

Lung Transplantation and the Routine Use of Cardiopulmonary Bypass and Median Sternotomy: Experience at the Ochsner Multi-Organ Transplant Institute.

From 1990-2005 at Ochsner Medical Center in New Orleans, LA, cardiopulmonary bypass (CPB) was used only when necessary during lung transplantation surgeries. Ochsner's lung transplant program was closed for more than 4 years after Hurricane Katrina, and since the program's reestablishment in 2010, the majority of lung transplantation surgeries have been performed with the patient on CPB and with a median sternotomy incision. The purpose of this study was to compare the outcomes of the CPB and non-CPB groups. After institutional review board approval, we conducted a retrospective review of the entire program using the Ochsner lung transplant database to identify patients in the non-CPB group from 1990-2005 and in the CPB group from 2010-2014. We calculated 1- and 3-year survival rates for each patient and reviewed medical records for evidence of stroke, the need for operative reexploration, and venous stenosis. We also performed a subgroup analysis of the first 20 consecutive patients undergoing lung transplantation on CPB with median sternotomy from February 2010 through April 2011 to examine intraoperative blood product use, the quantity of blood products administered, CPB cannulation and pump complications, ischemic time, and primary graft dysfunction. Of the 208 patients in the non-CPB group, 74% had 1-year graft survival and 55% had 3-year survival following transplantation. After February 2010, 79 patients underwent lung transplantation on CPB with median sternotomy, and 90% of those patients had 1-year graft survival. Of the 46 patients available for 3-year follow-up, 59% were alive with functional grafts. The difference in 1-year survival rates between the 2 cohorts was statistically significant. Two deaths, 3 strokes, and 5 reexplorations of the chest for bleeding occurred during the perioperative time period in the CPB group, but no mortality was associated with these perioperative events. One patient who had perioperative complications died within the first year; the death was attributable to gastric perforation. Patients' early outcomes appear to have improved with the use of CPB and median sternotomy; however, 3-year survival is similar to the non-CPB group. Technical benefits of CPB with median sternotomy include decreased warm ischemia time during graft implantation, controlled hemodynamics and reperfusion, avoidance of single-lung ventilation of a freshly implanted graft, and the option to open the left atrium for implantation of a venous cuff without using a clamp. The surgical exposure facilitated by CPB with median sternotomy for lung transplantation appears to be a safe and feasible approach for lung transplantations.

Abstract TMP87: Early Surgery for Infective Endocarditis with Stroke Does Not Increase Post-operative Neurological Complications: What are We Waiting For?

Introduction: Ischemic and hemorrhagic stroke often complicate infective endocarditis (IE). Optimal timing of surgical intervention for IE with stroke remains controversial. We compared neurological outcomes of early and delayed valve surgery for IE complicated by stroke. Methods: We reviewed 73 patients with acute IE by Duke Criteria who underwent brain imaging (CT, MRI, or cerebral angiogram) before valve operations between December 2014 and August 2016. Date of IE diagnosis was defined as date of antibiotic initiation. Early surgery was defined as valve replacement ≤14 days from date of IE diagnosis and delayed surgery as &gt;14 days. Neurological complication is defined as delirium &gt;72 hours after extubation and cessation of sedation, new ischemic or hemorrhagic stroke. Results: Among 73 patients who underwent valve replacement surgery, 71 had evidence of stroke on imaging: 54 patients with acute or subacute ischemic infarct, 9 patients with evidence of intracerebral hemorrhage, and 8 patients with subarachnoid hemorrhage. The median time from IE diagnosis to surgery was 9 days. Forty patients had early surgery, and 33 patients had late surgery. Early surgery group had fewer patients with history of ischemic stroke (55% vs 79%, p=0.033), fewer acute or subacute infarcts on imaging (63% vs 88% p=0.016), but more native valve infections (73% vs 45%, p=0.018). The incidence of post-operative stroke was similar between both groups (2.5% vs 9%, p=0.32). In the delayed group, ischemic strokes occurred in 4 patients awaiting surgery. Hypertension and diabetes mellitus were associated with post-operative neurological complications (p&lt;0.05), but pre-operative stroke on imaging was not. Conclusion: In IE patients with acute stroke, early surgery does not appear to increase post-operative neurological complications.

Abstract WP38: Lower Fluid Attenuated Inversion Recovery Magnetic Resonance Imaging Signal Intensity After Acute Ischemic Stroke is Associated With Better Discharge Outcomes in Thrombolysed Patients

Background: Increases in FLAIR MRI signal intensity (SI) after acute ischemic stroke (AIS) have been proposed as “tissue clocks”, reflecting the degree of ischemic injury and potential for recovery in brain tissue. We hypothesize that lower SI increases will be a biomarker for less severe tissue injury and hence is potentially salvageable. To test this, we investigated patients who were treated with tPA to determine whether better outcomes were associated with lower FLAIR SI. Methods: Using our Get with the Guidelines database, we retrospectively analyzed AIS patients admitted between 2011 to 2013 who received full-dose tPA based on institutional protocols. Patients were included if they received a CT scan at our hospital before tPA therapy, and MRI performed &lt; 1 h post CT included a usable FLAIR scan and evidence of stroke on acute DWI. SI ratio (SIR) was calculated on the FLAIR by selecting region of interests in hyperintense FLAIR areas that coincided with the acute DWI lesion and matching contralateral regions. Logistic regression analysis was performed using forward stepwise analysis to combine age, sex, admission NIHSS, SIR and onset-to-treatment (OTT) time to predict discharge outcome. Good outcome was defined as discharge to home or in-patient rehabilitation hospital. Results: There were 129 AIS patients who received tPA, and 57 met our imaging criteria. Patient characteristics were: mean±SD age 70±15 years, median [IQR] NIHSS 13 [7-18], OTT 2.1±1.1 h, time-to-MRI 2.1±1.0 h, 58% female and median SIR 1.13 [1.05-1.26]. On a univariate basis, only age (P&lt;0.0001) and NIHSS (P=0.005) were significant predictors of outcome. However, multivariate analysis showed that combining age (P=0.019), NIHSS (P=0.022), and SIR (P=0.018) was able to predict good discharge outcome with 100% [95% CI 63-100%] specificity and 90% [77-96%] sensitivity. Using age and NIHSS alone, resulted in the same specificity but only 71% [56-83%] sensitivity. Discussion: Controlling for age and admission NIHSS, we found that lower FLAIR SIR was a significant predictor of discharge outcome while OTT was not. This suggests that “tissue clocks” may be more accurate than “time clocks” for predicting tissue outcome, and ultimately functional outcome.

A neurocognitive approach to recovery of movement following stroke

Background: Most of the therapeutic and research interest following stroke has been directed toward motor impairments, relegating sensory and cognitive aspects involved in the quality of movement to a secondary role. Despite current neurophysiological advances, there are few studies in physical therapy that include all these aspects in stroke patients.Objectives: The present work aimed to review the involvement of mirror neurons in recovering the quality of post-ictal movement in a physical therapy intervention.Major findings: Neurocognitive Therapeutic Exercise (NTE) is a therapeutic approach that includes observation and motor imagery, among others, as perceptual and cognitive functions that generate experiences and afferent information flows without motor activity. Although this approach has shown to be effective on pain and function in shoulder and knee disorders, there is a paucity of evidence in stroke. NTE considers recovery as a learning process, the movement as a means to know and the body as a surface receptor for information. Aspects such as increasing experience, feedback or mirror neurons’ functions are used to allow movements to be improved quantitatively and qualitatively. This could be achieved through the activation of pre-existing neural patterns before the stroke.Conclusions: The neurocognitive approach represents a novel and safe therapeutic intervention supported by neuroscience research. Its implementation in physical therapy could facilitate motor learning in stroke patients. Nevertheless, further research into cognitive strategies in neurological rehabilitation is required to demonstrate their effectiveness.

Enzyme Replacement Therapy Stabilized White Matter Lesion Progression in Fabry Disease

Background: The central nervous system manifestations in Fabry disease (FD) include progressive white matter lesions (WMLs) and stroke. Due to progressive microvascular involvement, men and women with FD over 35 years of age develop WMLs. Moreover, the prevalence of stroke has been estimated to be 12 times higher in FD compared with the general population. Enzyme replacement therapy (ERT) is available and has shown beneficial effects on renal, cardiac, and peripheral nerve function in FD, but the ERT effect on the progression of WMLs, or the reduction in cerebrovascular events, remains unknown. Methods: The WML burden and the effect of agalsidase beta 1 mg/kg biweekly on WML progression were assessed longitudinally in a Phase 4 agalsidase-beta placebo-controlled analysis of untreated and treated FD patients with mild-to-moderate renal involvement (serum creatinine measurements of ≥1.2 mg/dl and <3.0 mg/dl). The primary end point was the difference in the number of patients with increased WML burden between the agalsidase beta and placebo groups at the end of treatment. The diameters of the WMLs were determined manually using axial flow-attenuated-inversion-recovery-weighted magnetic resonance imaging (MRI) scans taken at baseline and follow-up. Results: MRI scans from 41 FD patients (mean age 43.9, age range 20-68, 3 females; n = 25 on ERT, n = 16 on placebo) were analyzed. WML burden was present in 63% of patients at baseline, increased over a mean of 27 months (range 12-33 months) follow-up, and correlated with left ventricular hypertrophy (LVPW). Patients with previous or recent strokes (n = 11, 39-68 years) showed an increase in the number of WMLs (p = 0.005). A greater proportion of younger patients (≤50 years) on ERT (n = 18) had stable WML burden compared with younger patients in the placebo group (n = 13): 44% (8 of 18) versus 31% (4 of 13), p = 0.014. The number needed to treat was 8. Conclusions: This FD patient cohort, with mild-to-moderate renal involvement, had a significant WML burden and high inter-individual variability associated with the degree of LVPW but not the degree of kidney dysfunction. These advanced patients with increased LVPW and stroke evidence may have had a higher cerebrovascular risk. The WML burden in patients on ERT was more likely to remain stable, compared with patients on placebo. Thus, ERT may reduce the progression of vascular disease, even in advanced FD patients, suggesting that early treatment may stabilize WML progression and stroke risk.

Conservative Versus Liberal Approach in Blood Transfusion in Patients Presenting With Hematemesis: A Look at a Minority Population in a Community Hospital

Introduction: The threshold for packed red blood cell (PRBC) transfusion in patients with hematemesis is controversial. Recent European literature has suggested following a more restrictive approach in transfusing these patients. However, very limited data is available about this patient population in the U.S. In this project, we investigated the outcomes of both the conservative and liberal approaches in transfusing PRBC in patients with hematemesis. Methods: We retrospectively reviewed charts of patients who presented with hematemesis to the Brooklyn hospital center for a 2 year period. Demographic, clinical, and laboratory data was collected. The patients were categorized into 2 groups based on the hemoglobin that triggered the transfusion. Group A (<7 G/dL), group B (≥ 7G/dL). SAS software was used for data analysis. Results: Our cohort included 169 subjects among which 104 were African Americans and 46 Hispanics. Group A included 86 subjects and Group B has 83 subjects. Acute coronary syndrome was reported in 4.6% of Group A in comparison to 7.2% in Group B (P 0.2). Acute heart failure was reported in 11.6% of Group A in comparison to 21.6% of group B (P 0.003). Renal function has worsened in 8.1% of group A and 18% of group B (P 0.003). There was no difference reported in evidence of strokes in both groups. Mortality was 11% in group A in comparison to 21% in group B. Conclusion: This limited study in a predominantly minority population shows a trend toward decreased incidence of cardiac events, renal events and mortality in the less transfused group.

Risk and resilience factors for grade retention in youth with sickle cell disease

Youth with sickle cell disease (SCD) are at higher risk for grade retention than healthy peers. This is salient because research suggests grade retention is ineffective and places youth at additional risk for negative outcomes. The aims of the present study were to identify possible risk factors for grade retention in youth with SCD and to examine positive family functioning as a possible resilience factor. Data were extracted from phase 3 of the Cooperative Study of Sickle Cell Disease, a multisite, longitudinal study of individuals with SCD. Participants were 370 youth, aged 6-16 years, with complete data on history of grade retention. Collected data included demographics, history of grade retention, disease severity factors, evidence of stroke, family functioning, and academic achievement. A logistic regression model predicting grade retention was calculated. Increasing age, lower reading achievement, and lower family cohesion were predictive of higher likelihood of grade retention. Also, high family achievement-orientation moderated the negative effects of increasing age on likelihood of grade retention, such that at increasing levels of family achievement-orientation, the relationship between age and grade retention decreased. These findings suggest the need for interventions that promote connectedness and achievement-orientation in families of youth with SCD. Research is also needed to further explore other possible risk or resilience factors for grade retention in this population, such as school absenteeism.

Hydrocephalus Associated with Minor Intraventricular Hemorrhage in Patient Undergoing Maintenance Hemodialysis

A 72-year-old woman on dialysis acutely developed disturbed consciousness and severe hypertension. Head computed tomography (CT) demonstrated only ventriculomegaly without bleeding. Her consciousness level further deteriorated after dialysis using heparin, and subsequent head CT revealed a new, minor intraventricular hemorrhage. Hemorrhage-associated hydrocephalus was diagnosed, and the installation of a ventriculoperitoneal shunt resulted in good recovery. The patient might have experienced minor repeated bleeding and developed latent post-hemorrhagic hydrocephalus. Even minor bleeding could cause acute exacerbation of hydrocephalus; therefore, clinicians should be alert to hydrocephalus when a dialysis patient develops disturbed consciousness without any evidence of stroke on head CT.

Objective cardiac markers and cerebrovascular lesions in Indian seniors

Cardiovascular risk factors are implicated in cerebrovascular disease, resulting in cognitive impairment. This study investigated the relationship between objective cardiac markers and cerebral changes in older Indian adults with and without dementia. Dementia patients with major electrocardiographic (EKG) abnormalities were 8.19 times more likely to have evidence of stroke on magnetic resonance imaging (MRI) compared with patients with no EKG abnormalities (p<.05). The relationship between major EKG abnormalities and stroke on MRI was not significant for patients without dementia. Objective cardiac markers may identify MRI cerebrovascular lesions in patients with dementia, and thus guide neuroimaging allocation in resource-poor areas.

Caseload, management and treatment outcomes of patients with hypertension and/or diabetes mellitus in a primary health care programme in an informal setting.

In three primary health care clinics run by Médecins Sans Frontières in the informal settlement of Kibera, Nairobi, Kenya, we describe the caseload, management and treatment outcomes of patients with hypertension (HT) and/or diabetes mellitus (DM) receiving care from January 2010 to June 2012. Descriptive study using prospectively collected routine programme data. Overall, 1465 patients were registered in three clinics during the study period, of whom 87% were hypertensive only and 13% had DM with or without HT. Patients were predominantly female (71%) and the median age was 48 years. On admission, 24% of the patients were obese, with a body mass index (BMI) > 30 kg/m2. Overall, 55% of non-diabetic hypertensive patients reached their blood pressure (BP) target at 24 months. Only 28% of diabetic patients reached their BP target at 24 months. For non-diabetic patients, there was a significant decrease in BP between first consultation and 3 months of treatment, maintained over the 18-month period. Only 20% of diabetic patients with or without hypertension achieved glycaemic control. By the end of the study period,1003 (68%) patients were alive and in care, one (<1%) had died, eight (0.5%) had transferred out and 453 (31%) were lost to follow-up. Good management of HT and DM can be achieved in a primary care setting within an informal settlement. This model of intervention appears feasible to address the growing burden of non-communicable diseases in developing countries.

Carotid Duplex Findings in Patients With Acute Type A Dissection

Many patients with acute type A aortic dissection present with neurologic symptoms and have abnormal carotid duplex ultrasound (CDU) findings. We performed an analysis to determine the characteristics of CDU in acute type A aortic dissection. A prospectively maintained aortic database was queried for consecutive patients who underwent repair of acute type A aortic dissection between January 2002 and December 2011. Patients who had CDU during their hospitalization were reviewed. Analysis was performed to determine risk of pre- and postoperative stroke. We repaired 288 acute type A aortic dissection patients of which 87 patients had CDU during their hospitalization. Of the 87 patients, 61 (70%) had findings consistent with proximal dissection. Abnormalities noted on CDU included dissection flap on B-mode imaging, a second pulsed waveform after the initial systolic upstroke, and a widened and jagged systolic peak (Fig). A dissection flap extending into the common carotid arteries was visualized in 18 (21%) patients and was associated with preoperative stroke in 4 (22%) compared with 7 (10%) in those without a visualized dissection flap (P = .108). Overall, 20 of 288 (7%) patients had evidence of stroke at presentation. Aortic dissection should be considered in the presence of certain abnormal carotid waveforms-even in the absence of a visualized dissection flap. Recognition of these abnormal waveform patterns may expedite accurate diagnosis.

Long-term exposure to traffic-related air pollution and the risk of death from hemorrhagic stroke and lung cancer in Shizuoka, Japan

A number of studies have linked exposure to long-term outdoor air pollution with cardiopulmonary disease; however, the evidence for stroke is limited. Furthermore, evidence with the risk for lung cancer (LC) is still inconsistent. We, therefore, evaluated the association between long-term exposure to traffic-related air pollution and cause-specific mortality. Individual data were extracted from participants of an ongoing cohort study in Shizuoka, Japan. A total of 14,001 elderly residents completed questionnaires and were followed from December 1999 to January 2009. Annual individual nitrogen dioxide (NO2) exposure data, as an index for traffic-related exposure, were modeled using a Land Use Regression model and assigned to the participants. We then estimated the adjusted hazard ratios (HRs) and their confidence intervals (CIs) associated with a 10μg/m3 elevation in NO2 for all-cause or cause-specific mortality using time-varying Cox proportional hazards models. We found positive associations of NO2 levels with all-cause (HR=1.12, 95% CI: 1.07–1.18), cardiopulmonary disease (HR=1.22, 95% CI: 1.15–1.30), and LC mortality (HR=1.20, 95% CI: 1.03–1.40). Among cardiopulmonary disease mortality, not only the risk for ischemic heart disease (HR=1.27, 95% CI: 1.11–1.47) but also the risks for stroke were elevated: intracerebral hemorrhage (HR=1.28, 95% CI: 1.05–1.57) and ischemic stroke (HR=1.20, 95% CI: 1.04–1.39). The present study supports the existing evidence that long-term exposure to traffic-related air pollution increases the risk of cardiopulmonary as well as LC mortality, and provides additional evidence for adverse effects on intracerebral hemorrhage as well as ischemic stroke.

Acute varicella zoster encephalitis without evidence of primary vasculopathy in a case-series of 20 patients

Varicella zoster virus (VZV) is a leading cause of acute viral encephalitis but little is known about its clinical, biological and imaging features. Furthermore, the most favourable treatment regimen has not been determined. We studied a prospective cohort of 20 HIV-negative patients presenting with acute VZV encephalitis caused by primary infection or reactivation. VZV was identified in 16 of 20 cases by PCR detection of the DNA in the cerebrospinal fluid. The four remaining cases occurred during or soon after a VZV rash. The median age of the 17 adults was 76 (19-86) years; the three other patients were children (0.5-5 years). Three patients were immunocompromised. Nine adult patients presented with a rash. Eighteen patients presented with fever and an acute encephalitic syndrome: diffuse brain dysfunction, focal neurological signs, seizures and cranial nerve palsies. Three patients presented with either ventricular or subdural haemorrhage, one with myelitis, and one with asymptomatic stenosis of the middle cerebral artery. The imaging was either normal or revealed non-specific abnormalities such as cortical atrophy but no evidence of stroke. All patients were given acyclovir at various dosages and durations but the case fatality rate remained high (15%) and sequelae were frequently observed either at discharge or at follow-up 3 years later.