Meningitis in a community with a high prevalence of tuberculosis and HIV infection

OBJECTIVES: To evaluate the spectrum of aetiologies, and distinguishing clinical and laboratory features, of meningeal infection in a community with a high prevalence of tuberculosis (TB) and HIV infection. SETTING: A hospital serving mineworkers, originating from rural areas of Southern Africa. DESIGN: Prospective cohort of 60 consecutive lumbar punctures (LPs), performed for suspected meningitis. MEASUREMENTS: Clinical history and examination; concurrent cerebrospinal fluid (CSF) and blood samples; mortality status six months after entry to study. RESULTS: 38 of 57 patients (66.7%) were HIV-1 positive, 59.5% of whom had a CD4 count <200 cells/mm3. Nine patients had tuberculous meningitis (TBM) and two had tuberculomas; four developed disease while on TB therapy. There was one case of multidrug, and two of isoniazid-resistant TBM. There were nine episodes of cryptococcal meningitis (seven patients), nine of aseptic meningitis, two of neurosyphilis and 20 normal LPs, including four with AIDS dementia complex (ADC). Ten patients with meningococcal infection, part of a larger outbreak, were significantly younger (p=0.004). All patients with tuberculous, cryptococcal (most immune-suppressed p<0.001) and aseptic meningitis were HIV-1 positive. Within six months, 19 patients had died. Death was associated with HIV positivity (p=0.004), low CD4 count (p<0.001) and a diagnosis of cryptococcal meningitis, CNS TB or ADC. CONCLUSION: HIV has a major impact on the burden of disease and mortality, with a predominance of opportunistic chronic meningitides, despite a meningococcal outbreak, in this community. Of concern is the development of TBM despite therapy, and the emergence of drug-resistant strains.     

Cryptococcal infection in patients with clinically diagnosed meningitis in a tertiary care center

A retrospective analysis of 326 clinically diagnosed cases with meningitis over a period of five-and-a-half years was carried out to determine the prevalence of cryptococcal infection, its associated risk factors and therapeutic outcome. Fifty-four (16.6%) patients with cryptococcal meningitis were identified by smear examination, culture and/or cryptococcal antigen latex agglutination test. Records of 45 cryptococcal meningitis patients were available; 18 (40%) of them were apparently healthy immunocompetent individuals, 13 (28.9%) had human immunodeficiency virus (HIV) infection, 9 (20%) were renal transplant recipients, 4 (8.9%) were diabetic and 1 (2.2%) had systemic lupus erythematosus. Ten (22.2%) patients died and 11 (24.4%) patients (all HIV-positive) left against medical advice. The present study indicates that cryptococcal infection is associated with high mortality. Presenting symptoms being indistinguishable from other causes of central nervous system infection, all patients with a clinical diagnosis of meningitis, irrespective of their immune status should be investigated for cryptococcal infection.     

基本临床及实验室资料在成人结核性脑膜炎中的诊断价值

目的 以基本的临床及实验室资料为基础寻找成人结核性脑膜炎和新型隐球菌性脑膜炎的鉴别点,并建立相应诊断规则.方法 实验对象为中山大学附属第三医院2000年～2008连续住院的成人患者,包括100例结核性脑膜炎患者及119例新型隐球菌性脑膜炎患者,并分析其基本的临床及实验室资料.运用logistic回归分析寻找可独立预测结核性脑膜炎的危险因素,并建立相应的诊断规则.结果 Logistic回归分析得出六项可独立预测结核性脑膜炎的危险因素:性别、神志改变、视听损害、脑脊液蛋白、脑脊液白细胞数及合并颅外结核.利用上述因素建立的诊断规则其诊断结核性脑膜炎的灵敏度为78.0%,特异度为95.2%,阳性预测价值92.9%,阴性预测价值84.4%.结论 基本的临床及实验室资料有助于帮助鉴别结核性脑膜炎和新型隐球菌性脑膜炎,可在实验室条件不够完善的广大基层医院应用.     

Cerebrospinal fluid cytokines and matrix metalloproteinases in human immunodeficiency seropositive and seronegative patients of tuberculous meningitis

Background:

Some important clinical differences exist between human immunodeficiency virus (HIV)-seropositive and HIV-seronegative patients. Alterations in the cerebrospinal fluid (CSF) cytokines and matrix metalloproteinase have been noted in tuberculous meningitis. In HIV-infected patients, the immunopathogenesis is expected to be different.

Materials and Methods:

In this study, 64 patients of tuberculous meningitis (28 HIV seropositive and 36 seronegative) were included. The patients were followed up for six months. Cerebrospinal fluid (CSF) samples of tuberculous meningitis patients and 20 controls were subjected to tissue necrosis factor (TNF)-α, interleukin (IL)-1β, interferon (IFN)-γ, IL-10, matrix metalloproteinase (MMP)-2, and MMP-9 estimations. The levels were correlated with the patients’ baseline clinical characteristics, CSF parameters, neuroimaging findings, and the outcome. The outcome was assessed and modified with the Barthel index.

Results:

The CSF cytokines and MMP levels were significantly elevated in tuberculous meningitis when compared with the controls. There was no significant difference seen between HIV seropositive and seronegative tuberculous meningitis, except for the IL-1β level, which was significantly lower in the HIV-infected patients. The cytokine and MMP levels did not correlate with the baseline clinical characteristics, disease severity, cerebrospinal fluid characteristics, neuroimaging findings, and outcome.

Conclusion:

In conclusion, HIV infection did not affect a majority of the CSF cytokines and MMP levels in tuberculous meningitis except for IL-1β level. None of the estimated inflammatory parameters correlated with the outcome.     

Culture positive tuberculous meningitis: clinical indicators of poor prognosis.

Few studies have evaluated culture positive tuberculous meningitis (TBM) as a group. We evaluated certain clinical factors in culture positive TBM which could be associated with a poorer outcome. Out of 40 consecutive TBM patients seen over a period of 4 years in a tertiary referral hospital, 18 culture positive and non-human immunodeficiency virus (HIV) related cases were studied. The mean age was 37.9 +/- 14.9 years (range 9-63); five were males and 13 females. None had any associated active chronic medical illness. Patients (44.4%) started on antituberculous treatment within 24 h of admission. Treatment was initiated at a median time of 48 h upon admission in hospital. Univariate analysis revealed a significant correlation between hydrocephalus (P = 0.007) and poor morbidity and mortality. The other clinical factors were not statistically significant: age (P = 0.36): sex (P = 0.49); symptom duration (P = 0.69); BCG vaccination (P = 0.65); cerebral infarct (P = 0.63); extrameningeal spread (P = 1.00); steroids (P = 1.00); time to treatment (P = 0.94) and stage of disease (P = 0.11). Hydrocephalus was the only significant factor predisposing culture positive TBM patients to a poorer outcome. There was also a trend towards a poorer prognosis in those with advanced stage of the disease.     

Serial MRI to determine the effect of dexamethasone on the cerebral pathology of tuberculous meningitis: an observational study

BACKGROUND: Adjunctive dexamethasone increases survival from tuberculous meningitis, but the underlying mechanism is unclear. We aimed to determine the effect of dexamethasone on cerebral MRI changes and their association with intracerebral inflammatory responses and clinical outcome in adults treated for tuberculous meningitis. METHODS: Cerebral MRI was undertaken, when possible, at diagnosis and after 60 days and 270 days of treatment in adults with tuberculous meningitis admitted to two hospitals in Vietnam. Patients were randomly assigned either dexamethasone (n=24) or placebo (n=19) and received 9 months of treatment with standard first-line antituberculosis drugs. We assessed associations between MRI findings, treatment allocation, and resolution of fever, coma, cerebrospinal fluid inflammation, and neurological outcome. FINDINGS: 83 scans were done for 43 patients: 19 given placebo, 24 given dexamethasone. Basal meningeal enhancement (82%) and hydrocephalus (77%) were the most common presenting findings. Fewer patients had hydrocephalus after 60 days of treatment with dexamethasone than after placebo treatment (p=0.217). Tuberculomas developed in 74% of patients during treatment and in equal proportions in the treatment groups; they were associated with long-term fever, but not relapse or poor clinical outcome. The basal ganglia were the most common site of infarction; the proportion with infarction after 60 days was halved in the dexamethasone group (27%vs 58%, p=0.130). INTERPRETATION: Dexamethasone may affect outcome from tuberculous meningitis by reducing hydrocephalus and preventing infarction. The effect may have been under-estimated because the most severe patients could not be scanned.     

Outcome predictors for severe obsessive-compulsive patients in intensive residential treatment

Intensive residential treatment (IRT) is an effective management approach for those with severe obsessive-compulsive disorder (OCD). This study aimed to identify IRT response predictors for clinical and research use. Consecutive subjects admitted to the Massachusetts General Hospital/McLean OCD Institute (OCDI) between February 1997 and June 2003 were included (N=476). IRT responder and non-responder group characteristics were compared using t-tests and chi(2) analyses. Multiple regression analysis modeled relationships between final OCD severity (Yale-Brown Obsessive-Compulsive scale scores) and predictor variables, while accounting for multicollinearity and potential outliers. Treatment responders comprised 59.3% of the treatment sample. Responders had significantly fewer males (p=0.02), lower depression severity (p=0.03), poorer psychosocial functioning (p=0.03) and fewer tic disorders (0.04), but were not different with respect to admission length, age, marital or employment status, OCD onset, family OCD history, treatment or admission history. In the final regression model, decreased initial OCD severity (p<0.001), female gender (p=0.003) and better initial psychosocial functioning (Work and Social Adjustment scale scores) (p=0.003) were predictors of less severe OCD at discharge (adjusted R-square=0.28). Depression severity (Beck Depression Inventory scores) and insight were not predictive of treatment outcome. Future research is necessary to elucidate putative relationships between gender and OCD psychopathology, and to understand the interplay of psychosocial factors, OCD severity and treatment outcome.     

Predictors of Infarction in Tuberculous Meningitis in Indian Patients

BackgroundStroke is a devastating complication of tuberculous meningitis (TBM) and is an important determinant of its outcome. We propose a model which would help to predict development of infarction or cerebrovascular events in patients of TBM.MethodsA prospective study with n=129 patients of TBM were evaluated for predictors and outcomes of stroke. A diagnostic grid was formulated with clinical, laboratory and radiology as parameters to predict the vascular outcomes. All patients were followed up for mortality and disability on the basis of modified rankin score (mRS). MRI & CSF cytokines TNF–alpha, IFN- gamma & IL-6,8, 10 were measured at baseline and 3 months. The diagnosis of TBM included definite, probable & possible types and stage I & II with early and late onset of symptoms respectively.ResultsThe mortality was 16.2% and 19.4% of all patients developed stroke. The mean GCS, barthel index and mRS at admission was 57.03± 9.5,10.2±2.3 & 3.3±0.03 respectively mild to moderate infection and functional limitation. Barthel index (BI) happened to be a strong predictor [F=32.6, p=0.001, t=15.5, βeta coefficient =0.002] followed by biomarker TNF-α [F=18.9, p=0.02, t= -2.07, βeta coefficient=-0.04]. N=25 patients developed stroke with TNF-α, IL-6, IFN -γ showing statistically significant increase in all the stroke affected TBM (95% CI; 4.5 to 1.2; p=0.003). At 3 months, it was observed that mRS was statistically significant between stage I & II (95% CI; 5.4 to 2.1; p=0.04).ConclusionsOur data revealed that 19.4% patients developed vascular events during the hospital stay or follow up. We recruited late onset TBM as compared to early onset. BI, TNF-α, IL6 are most potent predictors of stroke post TBM.     

联合检测CRP,IL-6,Procalcitonin水平在成人脑膜炎诊断中的应用价值

目的 探讨联合检测C-反应蛋白(CRP)、白介素-6(IL-6)、降钙素原(Procalcitonin)水平在成人脑膜炎诊断中的应用价值。方法 选取病毒性脑膜炎患者30例为病毒组,结核性脑膜炎患者30例为结核组,化脓性脑膜炎患者30例为化脓组; 同时选取体检健康者30例为对照组,检测4组血清中CRP,IL-6,Procalcitonin的表达水平; 用ROC曲线下面积分析CRP,IL-6,Procalcitonin水平对成人脑膜炎的诊断价值。结果 健康人群血清中CRP和IL-6的表达水平均比成人脑膜炎患者低,且在病毒性脑膜炎、结核性脑膜炎和化脓性脑膜炎患者中表达水平有明显差异,血清中Procalcitonin的表达水平在化脓性脑膜炎患者中最高(P<0.05),结核性脑膜炎患者次之(P<0.05),健康人群再次之(P<0.05),病毒性脑膜炎患者中最低(P<0.05)。CRP高表达与成人脑膜炎患者脑脊液中蛋白水平呈正相关(r=0.826,P<0.001); Procalcitonin高表达与成人脑膜炎患者脑脊液中葡萄糖水平呈正相关(r=0.866,P<0.001)。诊断病毒性脑膜炎患者与体检健康者CRP,IL-6,Procalcitonin水平的灵敏度分别为83%、87%、87%,特异度为83%、87%、87%; 诊断结核性脑膜炎患者与体检健康者CRP,IL-6,Procalcitonin水平的灵敏度分别为93%、87%、87%,特异度为67%、73%、87%; 诊断化脓性脑膜炎患者与体检健康者CRP,IL-6,Procalcitonin水平的灵敏度分别为87%、87%、87%,特异度为87%、73%、87%; CRP,IL-6和Procalcitonin水平对成人脑膜炎的联合诊断的灵敏度为88.89%,特异度为83.33%,准确度为87.50%。结论 CRP,IL-6,Procalcitonin水平可作为辅助诊断成人脑膜炎的潜在标志物。     

Adjunctive thalidomide therapy for childhood tuberculous meningitis: results of a randomized study

Childhood tuberculous meningitis is associated with serious long-term sequelae, including mental retardation, behavior disturbances, and motor handicap. Brain damage in tuberculous meningitis results from a cytokine-mediated inflammatory response, which causes vasculitis and obstructive hydrocephalus. Thalidomide, a potent tumor necrosis factor alpha inhibitor, was well tolerated and possibly showed some clinical benefit in children with tuberculous meningitis during a pilot study. The purpose of the present study was to assess the effect of adjunctive thalidomide in addition to standard antituberculosis and corticosteroid therapy on the outcome of tuberculous meningitis. Thalidomide (24 mg/kg/day orally) or placebo was administered in a double-blind randomized fashion for 1 month to patients with stage 2 or 3 tuberculous meningitis. The study was terminated early because all adverse events and deaths occurred in one arm of the study (thalidomide group). Thirty of the 47 children enrolled received adjunctive thalidomide, of whom 6 (20%) developed a skin rash, 8 (26%) hepatitis, and 2 (6%) neutropenia or thrombocytopenia. Four deaths (13%) occurred in patients with very severe neurologic compromise at baseline; two deaths were associated with a rash. Motor outcome after 6 months of antituberculosis therapy was similar in the two groups, even though the thalidomide group showed greater neurologic compromise on admission. In addition, the mean IQ of the two treatment groups did not differ significantly (mean IQ thalidomide group 57.8 versus mean IQ control group 67.5; P = .16). These results do not support the use of adjunctive high-dose thalidomide therapy in the treatment of tuberculous meningitis.     

Guidelines for the diagnosis and management of neurological complications of HIV infection

The spectrum of neurological complications of HIV-infection has remained unchanged through the years, but its epidemiology changed remarkably as a result of the introduction of highly active antiretroviral therapy (HAART). Guidelines for the diagnosis and treatment of cerebral toxoplasmosis, cryptococcal meningitis, progressive multifocal leukoencephalopathy, CMV encephalitis, CMV polyradiculomyelitis, tuberculous meningitis, primary CNS lymphoma, HIV dementia, HIV myelopathy and HIV polyneuropathy are given with a grading of evidence and recommendations.     

Discrimination between viral and nonviral meningitis by visually analyzed and quantitative electroencephalography.

A prospective study was conducted to assess the ability of the visually analyzed electroencephalogram (VEEG), the quantitative EEG (QEEG) and the Glasgow Coma Scale (GCS) to discriminate between patients with viral and nonviral meningitis. The 55 subjects, aged 14-75 years, fell into one of the following categories: viral (n = 12), bacterial (n = 19), tuberculous (n = 16) or cryptococcal (n = 8) meningitis. EEG recordings and Glasgow Coma Scale (GCS) scores were obtained within 48 hours of admission to hospital. The sensitivity of the VEEG and QEEG for the prediction of patients with nonviral meningitis (true positives in this context) attained reasonably high values of 70% and 80%, respectively. In contrast, the sensitivity of the GCS was only 38%. Each of the three tests achieved high degrees of consistency in this regard with positive predictive values of 94% or better. The specificity for each of the three tests was high, 100% for the VEEG and the GCS and 82% for the QEEG indicating a high probability for the correct prediction of viral meningitis (true negatives). The consistency of this prediction was, however, poor due to negative predictive values of only 53% for the QEEG, 48% for the VEEG and 32% for the GCS. The QEEG results did not reveal any obvious advantages over the VEEG. Rather the assessment of the occurrence of particular VEEG abnormalities showed that patients with delta abnormalities had a very high probability of nonviral meningitis. At the other end of the spectrum, all normal VEEGs occurred in viral meningitis. In important respects the predictive ability of the EEG was superior to that of the GCS. While there was statistically significant agreement between the VEEG and GCS, the degree of agreement was poor. This study indicates that the EEG is a valuable and probably underestimated test in the acute phase of meningitis and provides complementary information to the GCS.     

基于单中心的中枢神经系统感染的疾病谱及预后分析

目的 探究中枢神经系统感染(central nervous system infection,CNSI)的疾病谱及预后分析.方法 回顾性分析河南科技大学第一附属医院神经内科2019年5月至2020年12月收治的102例CNSI患者的病例资料,分析临床基线资料,统计CNSI患者的发病率、病死率.结果 102例CNSI患者...     

Lipid profile,statin use,and outcome after intravenous thrombolysis for acute ischaemic stroke

BACKGROUND: Low cholesterol levels have been associated with an increased risk of haemorrhagic stroke. This study investigated whether lipid levels or prior statin use influence outcome in patients with acute ischaemic stroke treated with IV thrombolysis. METHODS: The relation between admission lipid levels or statin use and both the development of symptomatic intracerebral haemorrhage (sICH) and 3-months functional outcome was assessed in a prospective hospital-based stroke registry comprising 252 patients treated with IV tissue plasminogen activator (tPA). The fasting status of the patients was unknown. Favourable outcome at 3 months was defined as a modified Rankin scale score 相似文献   

Bacterial meningitis in Hong Kong: 10-years' experience

OBJECTIVE: We studied the etiology, clinical features and outcome of patients with bacterial meningitis from an urban Chinese city over a 10-years period. METHODS: We reviewed the files of all persons aged 15-years old or above diagnosed with community-acquired bacterial meningitis from a regional hospital. The clinical findings, relevant laboratory and imaging results as well as outcome were recorded in cases with microbiological evidence of meningitis. Neurosurgical and pediatric patients were excluded. RESULTS: Sixty-five patients between the ages of 15 and 86 years of age (mean 52 years) were identified of whom 18 (28%) died. The four most common causes were Mycobacteria tuberculosis (46%), Streptococcus pneumoniae (11%), Streptococcus suis (9%) and Klebsiella pneumoniae (8%). Neisseria meningitidis and Haemophilus influenzae were rare pathogens. The annual incidence of community-acquired bacterial meningitis was 1.27/100,000 adults. Delay in treatment was associated with a poorer prognosis (p<0.001, OR=38.84, CI=7.33-205.80). CONCLUSION: The causative organisms found in this region of China differ from that reported from Europe and the US; tuberculous meningitis is the most common cause of bacterial meningitis.     

The possible role of cerebrospinal fluid adenosine deaminase activity in the diagnosis of tuberculous meningitis in adults.

We studied an adenosine deaminase (ADA) activity in the cerebrospinal fluid (CSF) of 182 patients with meningitis. The patients were subdivided into four groups, (1) 36 cases of tuberculous meningitis; (2) 130 cases of viral or aseptic meningitis; (3) nine cases of bacterial meningitis; (4) seven cases of cryptococcal meningitis. Mean+/-S.D. ADA activity was 12.76+/-7.53 U/l in group 1; 2.58+/-2.37 U/l in group 2; 7.38+/-3.27 U/l in group 3; 7.42+/-4.38 U/l in group 4. Comparing the ADA activity in each group with the other groups, the difference is significant (P<0.001), except between groups 3 and 4. The sensitivity of the test for group 1 compared with group 2 was 0.83 and the specificity was 0.95 when a cut-off value of 7 U/l was used. When group 1 was compared with groups 3 and 4, the sensitivity was 0.58 and the specificity was 0.89 and 0.71 with groups 3 and 4, respectively, when a cut-off value of 10 U/l was used. Values >15 U/l were not observed in any of the non-tuberculous meningitis patients; therefore, ADA activity >15 U/l could be a strong indication of tuberculous meningitis. We conclude that a determination of CSF ADA can aid in the early differential diagnosis of tuberculous meningitis.     

A review of tuberculous meningitis at Auckland City Hospital,New Zealand

The clinical features, investigations, treatment and outcome were studied in 104 patients with definite or probable tuberculous meningitis. The diagnosis of definite tuberculous meningitis required the growth of Mycobacterium tuberculosis from cultures, or a positive polymerase chain reaction (PCR) assay for M. tuberculosis. In probable tuberculous meningitis, cultures and the PCR assay were negative, but other causes of meningitis were excluded and there was a response to anti-tuberculosis treatment. Of the 104 patients, 36% had a poor outcome (severe disability, persistent vegetative state or death), 12% moderate disability and 52% good recovery. A diagnosis of definite tuberculous meningitis, the severity of the symptoms at presentation and the occurrence of a stroke were significant predictors of a poor outcome. The most common reasons for a delayed diagnosis were presentation with mild symptoms wrongly attributed to a systemic infection, incorrectly attributing CSF abnormalities to non-tuberculous bacterial meningitis and failure to diagnose extraneural tuberculosis associated with meningitis. Recognition of the difficulties in making a diagnosis of tuberculous meningitis may facilitate earlier diagnosis in the future.     

脑脊液腺苷脱氨酶与血清5’-核苷酸酶在结核性脑膜炎诊断中的价值

目的探讨脑脊液腺苷脱氨酶(CSF-ADA)与血清5’-核苷酸酶(5’-NT)在结核性脑膜炎诊断与鉴别诊断中的价值。方法回顾性分析40例结核性脑膜炎患者(病例组)与36例病毒性脑膜炎患者(对照组)的一般资料、脑脊液、血液学及影像学检查结果,重点探讨CSF-ADA与血清5’-NT在结核性脑膜炎中的诊断价值。结果病例组CSF-ADA和血清5’-NT水平显著高于对照组(P<0.001)。根据CSF-ADA与血清5’-NT的接收者操作特性曲线(ROC),CSF-ADA>4.40 U/L或血清5’-NT>4.85 U/L被认为是诊断的阳性结果,显示出高的敏感性与特异性,CSF-ADA的敏感度为92.5%,特异度为89%;血清5’-NT的敏感度为95%,特异度为70%。当联合CSF-ADA与血清5’-NT诊断结核性脑膜炎,即CSF-ADA>4.40 U/L或(和)血清5’-NT>4.85 U/L,其敏感性最高,其灵敏度为97.5%,特异度为73.5%,阳性似然比(PLR)为3.68,阴性似然比(NLR)为0.03。结论在结核性脑膜炎的诊断中,CSF-ADA与血清5’-NT可以起到快速、简单、相对准确的诊断作用。当CSF-ADA或(和)血清5’-NT明显升高时,可尽早怀疑结核性脑膜炎,同时结合临床表现、其他脑脊液、血液学及影像学结果综合诊断。     

Thrombectomy in ischemic stroke patients with alberta stroke program early computed tomography score 4-5 and 0-3: Factors associated with favorable outcome

ObjectivesRecently published results of the ANGEL-ASPECT and SELECT2 trials suggest that stroke patients presenting with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) benefit from mechanical thrombectomy. Purpose of this retrospective study was to identify factors that are associated with a favorable outcome in patients with low ASPECTS of 4-5 and 0-3 undergoing mechanical thrombectomy.Material and methodsAll patients reported in the quality registry of the German Society for Neuroradiology that were treated between 2018 and 2020 were analyzed. Favorable outcome was defined as a National Institute of Health Stroke Scale (NIHSS) score of less than 9 at dismissal. Successful recanalization was defined as Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b. Multivariable logistic regression analyses were performed to assess the association of baseline and treatment variables with favorable outcome.Results621 patients were included in the analysis, thereof 495 with ASPECTS 4-5 and 126 with ASPECTS 0-3. In patients with ASPECTS 4-5patients with favorable outcome had less severe neurological symptoms at admission with median NIHSS of 15 vs. 18 (p<0.001), had less often wake-up strokes (44% vs. 81%, p<0.001), received more often iv-lysis (37% vs. 30%, p<0.001), had more often conscious sedation (29% vs. 16%, p<0.001), had a higher rate of successful recanalization (94% vs. 66% and lower times from groin puncture to recanalization. In multivariate regression analysis lower NIHSS at admission (aOR 0.87, CI 0.89-0.91) and successful recanalization (aOR 3.96, CI 2-8.56) were associated with favorable outcome. For ASPECTS 0-3, patients with favorable outcome had lower median NIHSS at admission (16 vs. 18 (p<0.001), lower number of passes (1 vs. 3, p=0.003) and a higher rate of successful recanalization (94% vs. 66%, p<0.001) and lower times from groin puncture to recanalization. In multivariate regression analysis lower NIHSS at admission (aOR 0.87, CI 0.81-0.94) and successful recanalization, (aOR 11.19, CI 3.19-55.53), were associated with favorable outcome.ConclusionFull recanalization with low groin punction to recanalization times and low number of passes were associated with favorable outcome in patients with low ASPECTS.     

Hospitalization of elderly in an Acute-Care Geriatric Department

Hospital admissions following emergency visits of elderly people are frequent. This admission modality is often problematic both for the patients and the emergency healthcare professionals. Direct admission from home (or nursing home) in acute geriatric units (AGU) has been developed but has never been prospectively assessed. We conducted a 6-month prospective observational study to compare the 97 patients admitted through the emergency room (ER) in the AGU of Bichat's hospital to the 76 patients admitted directly. Collected data included socio-demographic and medical baseline data, clinical severity score at admission, cause of hospitalization, final diagnosis, in-hospital occurrence of urinary retention and of pressure ulcer, length of stay, discharge disposition and mortality. No significant differences between the groups were found for most baseline characteristics, clinical severity score, occurrence of pressure ulcers, length of stay and mortality. However ER patients were significantly older (88±6 vs 86±7 years, p =?0.04) and had more often history of arrhythmia (29% vs 15%, p=0.02) and protein-energy malnutrition preceding admission (63% vs 46%, p=0.03). Falls as admission cause was more common in ER patients while unexplained health status or functional decline were most common in those admitted directly. Clinical outcomes were less favourable in ER patients with significantly more urinary retentions (25% vs 4%, p=0.0002) and transfers to rehabilitation units (48% vs 31%, p=0.04). The patients admitted directly returned more often at home without additional social support (53% vs 30%, p=0.001). Direct admission in AGU is feasible, medically effective and provides an?alternative to attending an emergency room. This admission modality could be specially suitable for elder people suffering from an unexplained functional or health status declines. Further studies are necessary to support the hypothesis that quality gains and cost-effective measures may be achieved by dissemination of such an admission modality at the hospital.