Neutrophil-Lymphocyte ratio is associated with poor clinical outcome after mechanical thrombectomy in stroke in patients with COVID-19

Background

The neutrophil–lymphocyte ratio (NLR) is emerging as an important biomarker of acute physiologic stress in a myriad of medical conditions, and is a confirmed poor prognostic indicator in COVID-19.

Objective

We sought to describe the role of NLR in predicting poor outcome in COVID-19 patients undergoing mechanical thrombectomy for acute ischemic stroke.

Methods

We analyzed NLR in COVID-19 patients with large vessel occlusion (LVO) strokes enrolled into an international 12-center retrospective study of laboratory-confirmed COVID-19, consecutively admitted between March 1, 2020 and May 1, 2020. Increased NLR was defined as ≥7.2. Logistic regression models were generated.

Results

Incidence of LVO stroke was 38/6698 (.57%). Mean age of patients was 62 years (range 27–87), and mortality rate was 30%. Age, sex, and ethnicity were not predictive of mortality. Elevated NLR and poor vessel recanalization (Thrombolysis in Cerebral Infarction (TICI) score of 1 or 2a) synergistically predicted poor outcome (likelihood ratio 11.65, p  =  .003). Patients with NLR > 7.2 were 6.8 times more likely to die (OR 6.8, CI95% 1.2–38.6, p  =  .03) and almost 8 times more likely to require prolonged invasive mechanical ventilation (OR 7.8, CI95% 1.2–52.4, p  =  .03). In a multivariate analysis, NLR > 7.2 predicted poor outcome even when controlling for the effect of low TICI score on poor outcome (NLR p  =  .043, TICI p  =  .070).

Conclusions

We show elevated NLR in LVO patients with COVID-19 portends significantly worse outcomes and increased mortality regardless of recanalization status. Severe neuro-inflammatory stress response related to COVID-19 may negate the potential benefits of successful thrombectomy.

Interpersonal Violence and Psychological Well-Being: Perspectives of Low-Income Patients, Social Workers, and Medical Doctors in Mexico City, Mexico

The violence epidemic in Mexico is becoming more widespread. Using a social-ecological framework, the current study sought to understand interpersonal violence among those impoverished communities in Mexico City, Mexico. Participants were recruited from Community Health Centers located within districts that were densely populated, had high rates of poverty and marginalization, and where people experience complex social needs. Semi-structured interviews were conducted with patients, social workers, and medical doctors (N = 15) who were either receiving or providing services in these centers. Data were analyzed using an inductive, thematic approach. Analysis resulted in three themes: (a) interpersonal violence permeates all settings in which people live and interact; (b) social and cultural factors increase the risk of becoming a perpetrator or victim of interpersonal violence; and (c) interpersonal violence is closely intertwined with mental health. Rapid changes within gender roles and expectations in Mexico, combined with widening income inequality, are shifting dynamics within families that may be inherently linked to interpersonal violence. Our findings support the conceptualization of interpersonal violence at the four levels of the social-ecological framework: individual, relationship, community, and societal. Prevention and interventions for violence reduction must be applied across the four levels simultaneously. Community-level efforts should go toward strengthening existing community health centers and equipping primary care providers with training and resources on the screening and triaging of patients encountering interpersonal violence.

Efficacy and safety of topical finasteride spray solution for male androgenetic alopecia: a phase III, randomized, controlled clinical trial

Background

Oral finasteride is a well‐established treatment for men with androgenetic alopecia (AGA), but long‐term therapy is not always acceptable to patients. A topical finasteride formulation has been developed to minimize systemic exposure by acting specifically on hair follicles.

Objectives

To evaluate the efficacy and safety of topical finasteride compared with placebo, and to analyse systemic exposure and overall benefit compared with oral finasteride.

Methods

This randomized, double‐blind, double dummy, parallel‐group, 24‐week study was conducted in adult male outpatients with AGA at 45 sites in Europe. Efficacy and safety were evaluated. Finasteride, testosterone and dihydrotestosterone (DHT) concentrations were measured.

Results

Of 458 randomized patients, 323 completed the study and 446 were evaluated for safety. Change from baseline in target area hair count (TAHC) at week 24 (primary efficacy endpoint) was significantly greater with topical finasteride than placebo (adjusted mean change 20.2 vs. 6.7 hairs; P < 0.001), and numerically similar between topical and oral finasteride. Statistically significant differences favouring topical finasteride over placebo were observed for change from baseline in TAHC at week 12 and investigator‐assessed change from baseline in patient hair growth/loss at week 24. Incidence and type of adverse events, and cause of discontinuation, did not differ meaningfully between topical finasteride and placebo. No serious adverse events were treatment related. As maximum plasma finasteride concentrations were >100 times lower, and reduction from baseline in mean serum DHT concentration was lower (34.5 vs. 55.6%), with topical vs. oral finasteride, there is less likelihood of systemic adverse reactions of a sexual nature related to a decrease in DHT with topical finasteride.

Conclusion

Topical finasteride significantly improves hair count compared to placebo and is well tolerated. Its effect is similar to that of oral finasteride, but with markedly lower systemic exposure and less impact on serum DHT concentrations.

Incidence, Characteristics and Outcomes of Large Vessel Stroke in COVID-19 Cohort: An International Multicenter Study

BACKGROUND

While there are reports of acute ischemic stroke (AIS) in coronavirus disease 2019 (COVID-19) patients, the overall incidence of AIS and clinical characteristics of large vessel occlusion (LVO) remain unclear.

OBJECTIVE

To attempt to establish incidence of AIS in COVID-19 patients in an international cohort.

METHODS

A cross-sectional retrospective, multicenter study of consecutive patients admitted with AIS and COVID-19 was undertaken from March 1 to May 1, 2020 at 12 stroke centers from 4 countries. Out of those 12 centers, 9 centers admitted all types of strokes and data from those were used to calculate the incidence rate of AIS. Three centers exclusively transferred LVO stroke (LVOs) patients and were excluded only for the purposes of calculating the incidence of AIS. Detailed data were collected on consecutive LVOs in hospitalized patients who underwent mechanical thrombectomy (MT) across all 12 centers.

RESULTS

Out of 6698 COVID-19 patients admitted to 9 stroke centers, the incidence of stroke was found to be 1.3% (interquartile range [IQR] 0.75%-1.7%). The median age of LVOs patients was 51 yr (IQR 50-75 yr), and in the US centers, African Americans comprised 28% of patients. Out of 66 LVOs, 10 patients (16%) were less than 50 yr of age. Among the LVOs eligible for MT, the average time from symptom onset to presentation was 558 min (IQR 82-695 min). A total of 21 (50%) patients were either discharged to home or discharged to acute rehabilitation facilities.

CONCLUSION

LVO was predominant in patients with AIS and COVID-19 across 2 continents, occurring at a significantly younger age and affecting African Americans disproportionately in the USA.

Thrombectomy for Primary Distal Posterior Cerebral Artery Occlusion Stroke: The TOPMOST Study

Importance

Clinical evidence of the potential treatment benefit of mechanical thrombectomy for posterior circulation distal, medium vessel occlusion (DMVO) is sparse.

Objective

To investigate the frequency as well as the clinical and safety outcomes of mechanical thrombectomy for isolated posterior circulation DMVO stroke and to compare them with the outcomes of standard medical treatment with or without intravenous thrombolysis (IVT) in daily clinical practice.

Design, Setting, and Participants

This multicenter case-control study analyzed patients who were treated for primary distal occlusion of the posterior cerebral artery (PCA) of the P2 or P3 segment. These patients received mechanical thrombectomy or standard medical treatment (with or without IVT) at 1 of 23 comprehensive stroke centers in Europe, the United States, and Asia between January 1, 2010, and June 30, 2020. All patients who met the inclusion criteria were matched using 1:1 propensity score matching.

Interventions

Mechanical thrombectomy or standard medical treatment with or without IVT.

Main Outcomes and Measures

Clinical end point was the improvement of National Institutes of Health Stroke Scale (NIHSS) scores at discharge from baseline. Safety end point was the occurrence of symptomatic intracranial hemorrhage and hemorrhagic complications were classified based on the Second European-Australasian Acute Stroke Study (ECASSII). Functional outcome was evaluated with the modified Rankin Scale (mRS) score at 90-day follow-up.

Results

Of 243 patients from all participating centers who met the inclusion criteria, 184 patients were matched. Among these patients, the median (interquartile range [IQR]) age was 74 (62-81) years and 95 (51.6%) were female individuals. Posterior circulation DMVOs were located in the P2 segment of the PCA in 149 patients (81.0%) and in the P3 segment in 35 patients (19.0%). At discharge, the mean NIHSS score decrease was -2.4 points (95% CI, -3.2 to -1.6) in the standard medical treatment cohort and -3.9 points (95% CI, -5.4 to -2.5) in the mechanical thrombectomy cohort, with a mean difference of -1.5 points (95% CI, 3.2 to -0.8; P = .06). Significant treatment effects of mechanical thrombectomy were observed in the subgroup of patients who had higher NIHSS scores on admission of 10 points or higher (mean difference, -5.6; 95% CI, -10.9 to -0.2; P = .04) and in the subgroup of patients without IVT (mean difference, -3.0; 95% CI, -5.0 to -0.9; P = .005). Symptomatic intracranial hemorrhage occurred in 4 of 92 patients (4.3%) in each treatment cohort.

Conclusions and Relevance

This study suggested that, although rarely performed at comprehensive stroke centers, mechanical thrombectomy for posterior circulation DMVO is a safe, and technically feasible treatment option for occlusions of the P2 or P3 segment of the PCA compared with standard medical treatment with or without IVT.

Quantified ischemic core's radiological hypodensity and risk of parenchymal hematoma in > 4.5 h-window stroke thrombectomy

We aimed to study the relationship between the ischemic core’s (IC) radiological hypodensity and the risk of parenchymal haematoma after endovascular therapy (EVT) in acute ischemic stroke (AIS) presenting > 4.5 h from onset. We studied AIS patients with a proximal anterior circulation occlusion > 4.5 h from symptoms onset treated with primary EVT. The IC regions of interest (ROI) were manually delineated on pretreatment CT within the affected hemisphere and their specular ROIs on the unaffected side. IC hypodensity ratio was calculated by dividing mean Hounsfield Unit (HU) value from all ROIs in affected/unaffected hemisphere. Primary endpoint: parenchymal hematoma (PH) type hemorrhagic transformation. Secondary: poor long-term clinical outcome. From May 2015 to November 2018, 648 consecutive AIS patients received reperfusion therapies and 107 met all inclusion criteria. PH after EVT was diagnosed in 33 (31%) patients. In bivariate analyses, IC hypodensity ratio (p < 0.001) and minimum HU value (p = 0.008) were associated with PH. A lower IC hypodensity ratio [OR < 0.001 (< 0.001–0.116) p 0.016] predicted PH but not poor clinical outcome in multivariable logistic regression models. A lower IC radiological density predicted a higher risk of PH in > 4.5 h-window AIS patients treated with primary EVT, although it was not independently associated with a worse clinical outcome.

Brain Atrophy and the Risk of Futile Endovascular Reperfusion in Acute Ischemic Stroke

Background and Purpose- We aimed to evaluate the impact of brain atrophy on long-term clinical outcome in patients with acute ischemic stroke treated with endovascular therapy, and more specifically, to test whether there are interactions between the degree of atrophy and infarct volume, and between atrophy and age, in determining the risk of futile reperfusion. Methods- We studied consecutive patients with acute ischemic stroke with proximal anterior circulation intracranial arterial occlusions treated with endovascular therapy achieving successful arterial recanalization. Brain atrophy was evaluated on baseline computed tomography with the global cortical atrophy scale, and Evans index was calculated to assess subcortical atrophy. Infarct volume was assessed on control computed tomography at 24 hours using the formula for irregular volumes (A×B×C/2). Main outcome variable was futile recanalization, defined by functional dependence (modified Rankin Scale score >2) at 3 months. The predefined interactions of atrophy with age and infarct volume were studied in regression models. Results- From 361 consecutive patients with anterior circulation acute ischemic stroke treated with endovascular therapy, 295 met all inclusion criteria. Futile reperfusion was observed in 144 out of 295 (48.8%) patients. Cortical atrophy affecting parieto-occipital and temporal regions was associated with futile recanalization. Total global cortical atrophy score and Evans index were independently associated with futile recanalization in an adjusted logistic regression. Multivariable adjusted regression models disclosed significant interactions between global cortical atrophy score and infarct volume (odds ratio, 1.003 [95%CI, 1.002-1.004], P<0.001) and between global cortical atrophy score and age (odds ratio, 1.001 [95% CI, 1.001-1.002], P<0.001) in determining the risk of futile reperfusion. Conclusions- A higher degree of cortical and subcortical brain atrophy is associated with futile endovascular reperfusion in anterior circulation acute ischemic stroke. The impact of brain atrophy on insufficient clinical recovery after endovascular reperfusion appears to be independently amplified by age and by infarct volume.

Some naturally occurring radionuclides (NORM) in a river affected by acid mining drainages

The mining activities performed in the Iberian Pyrite Belt (south of Spain) have generated since long-time acid mining drainage (AMD) inputs to the Odiel River and its tributaries. These inputs are continuing nowadays, with origin mostly in the abandoned mines that cover the area, provoking a steady-state situation where the river waters present very low pH and very high concentrations of different heavy metals. In this work, the behavior of several natural radionuclides (²¹⁰Po, Th- and U-isotopes) in water and sediment samples collected in the Odiel River and its tributaries have been analyzed and their levels determined looking for assessing the radiological environmental impact of the AMD.

Perceptions of Mexican women regarding barriers in mental Heath Services in primary care

BACKGROUND

The recent mental health care reforms in Mexico call for the regular evaluation of the services provided. This involves analyzing the opinions of those who utilize them on a daily basis, particularly women, since they are the main health service users. This study explores the barriers to mental health care perceived by a group of women attending primary care centers.

METHOD

A qualitative methodological approach was chosen. The participants were purposively selected, using the snowball technique. Semi-structured interviews were analyzed using the thematic analysis.

RESULTS

Three sets of factors representing barriers to care were identified in the participants' discourse. The first is linked to systemic barriers such as a lack of familiarity with the way the service operates, and irregularities in the consultations and appointment schedules that are not always geared to women's needs. The second concerns the social stigma associated with emotional and/or mental disorders and their care while the third involves the characteristics of psychologists and their professional work.

CONCLUSIONS

In order to overcome some of the barriers identified, users should be given information on the work of mental health professionals, which would help dispel certain misconceptions and sensitize them to the importance of this type of treatment in achieving overall health. There is also a need to make psychologists aware of the living conditions and socio-cultural context of the women who attend these health facilities.

"This Is How We Work Here": Informal Logic and Social Order in Primary Health Care Services in Mexico City

People who work in health care facilities participate in a shared set of tacit agreements, attitudes, habits, and behaviors that contribute to the functioning of those institutions, but that can also cause conflict. This phenomenon has been addressed tangentially in the study of bureaucratic practices in governmental agencies, but it has not been carefully explored in the specific context of public health care centers. To this end, we analyzed a series of encounters among staff and patients, as well as the situations surrounding the services offered, in public primary care health centers in Mexico City, based on Erving Goffman's concepts of social order, encounter, and situation, and on the concepts of formal and informal logic. In a descriptive study over the course of 2 years, we carried out systematic observations in 19 health centers and conducted interviews with medical, technical, and administrative staff, and psychologists, social workers, and patients. We recorded these observations in field notes and performed reflexive analysis with readings on three different levels. Interviews were recorded, transcribed, and analyzed through identification of thematic categories and subcategories. Information related to encounters and situations from field notes and interviews was selected to triangulate the materials. We found the social order prevailing among staff to be based on a combination of status markers, such as educational level, seniority, and employee versus contractor status, which define the distribution of workloads, material resources, and space. Although this system generates conflicts, it also contributes to the smooth functioning of the health centers. The daily encounters and situations in all of these health centers allow for a set of informal practices that provide a temporary resolution of the contradictions posed by the institution for its workers.

Barriers to Integrating Mental Health Services in Community-Based Primary Care Settings in Mexico City: A Qualitative Analysis

OBJECTIVE

Despite the high prevalence of mental disorders in Mexico, minimal mental health services are available and there are large gaps in mental health treatment. Community-based primary care settings are often the first contact between patients and the health system and thus could serve as important settings for assessing and treating mental disorders. However, no formal assessment has been undertaken regarding the feasibility of implementing these services in Mexico. Before tools are developed to undertake such an assessment, a more nuanced understanding of the microprocesses affecting mental health service delivery must be acquired.

METHODS

A qualitative study used semistructured interviews to gather information from 25 staff in 19 community-based primary care clinics in Mexico City. Semistructured interviews were analyzed by using the meaning categorization method. In a second phase of coding, emerging themes were compared with an established typology of barriers to health care access.

RESULTS

Primary care staff reported a number of significant barriers to implementing mental health services in primary care clinics, an already fragile and underfunded system. Barriers included the following broad thematic categories: service issues, language and cultural issues, care recipient characteristics, and issues with lack of knowledge.

CONCLUSIONS

Results indicate that the implementation of mental health services in primary care clinics in Mexico will be difficult. However, the information in this study can help inform the integration of mental health into community-based primary care in Mexico through the development of adequate evaluative tools to assess the feasibility and progress of integrating these services.

Predicting Women’s Utilization of Primary Care Mental Health Services in Mexico City

Objective: To analyze factors associated with and predicting Mexican women seeking primary care mental health services (PCMHS) and provide suggestions to increase PCMHS utilization. Method: We administered a questionnaire to (N = 456) female patients in Mexico City primary care clinics. We conducted chi-square analyses of seeking PCMHS and sociodemographic variables, perceptions of and experiences with PCMHS. Our results and literature review guided our logistic regression model. Results: Women referred to a mental health provider (MHP; odds ratio [OR] = 10.81, 95% CI = 3.59-32.51), whose coping mechanisms included talking to a MHP (OR = 5.53, 95% CI = 2.10-14.53), whose primary worry is loneliness (OR = 8.15, 95% CI = 1.20-55.10), and those who follow doctor’s orders; were more likely to seek PCMHS (OR = 0.28, 95% CI = 0.09-0.92). Conclusions: Primary care providers play a fundamental role in women’s decisions to seek PCMHS. Proper referrals to PCMHS should be encouraged.

The value of oxybutynin in transdermal patches for treating overactive bladder

CONTEXT

There is currently a broad therapeutic arsenal of drugs for treating overactive bladder syndrome (OAB). However, there is still a need for new compounds and for improving known drugs in terms of efficacy, compliance and tolerability.

OBJECTIVE

To report the scientific evidence on the safety and efficacy of transdermal oxybutynin (OXY-TDS) for treating OAB.

MATERIAL AND METHODS

A systematic review without time restrictions was conducted until May 2015 in the MEDLINE/PubMed database. We also performed a manual review of abstracts published in international urogynaecology congresses.

RESULTS

The evaluated studies show that patients treated with OXY-TDS experience a significant reduction in urinary incontinence episodes compared with placebo, which is comparable to that observed in patients treated with oral oxybutynin or with tolterodine. In all of the studies, we observed improvements in symptoms from the second or third week of treatment and in a sustained manner until the end of treatment (6, 12 or 24 weeks). The clinical practice study also showed improved quality of life, achieving benefits in numerous patient profiles, with an efficacy independent of previous treatments. The safety of the drug was demonstrated in the various patient profiles.

CONCLUSIONS

OXY-TDS represents an effective alternative for the symptomatic treatment of adult patients with OAB, which, thanks to its pharmacokinetic profile, better tolerability, different administration method and dosage, could represent an added value in treating special populations.

Influence of the Fukushima Dai-ichi nuclear accident on Spanish environmental radioactivity levels

This paper presents measurements of the effect of the atmospheric radioactive release from the Fukushima Dai-ichi nuclear power station at three sites belonging to the Spanish environmental monitoring system. Measured values varied depending on the locations of the sites in Spain and their respective climatic characteristics. (134)Cs, (136)Cs, (137)Cs, (131)I, and (132)Te activity concentrations in filter samples were studied and associated levels of (131)I fallout were estimated from wet and dry deposition. Particulate aerosol activity concentrations ranges, in μBq/m(3), were 1.63-3080 ((131)I), 2.8-690 ((137)Cs), 1.3-620 ((134)Cs) and 3.6-330 ((132)Te), while the associated (131)I fallout was roughly estimated to be less than 20 Bq/m(2), Gaseous (131)I was also detected and the (131)I-gaseous/(131)I-total ratio increased at the three stations from approximately 0.75 at the end of March to 0.85-0.9 during the first few days of April. Finally, the presence of (131)I in some crucial parts of the food chain was also studied. (131)I was detected in samples from goat's and cow's milk (maximum levels of 1.11 Bq/L) and in broadleaf plants (maximum level 1.42 Bq/kg).

[Evaluation of a physical exercise and nutritional guidance program given to workers at a health institute]

OBJECTIVE

To report on the results of the first stage of the Pause for Your Health program, designed to promote physical exercise during the work journey day in addition to an eating plan to contribute to the employees' general well-being.

MATERIAL AND METHODS

The participants were 36 employees of a national institute on health working at a research area. The indicators assessed before and after the program were: sedentary lifestyle, cardiovascular adaptation to exercise test, anthropometric measures, serico-lipoglycemic profile, blood pressure, perception of lifestyle and general well-being and finally opinion about program.

RESULTS

Data showed significant changes in five anthropometric indicators, the most significant was waist circumference. As to clinical assessment, the most prominent change was observed in glucose level. The results also showed that people who were overweight at the start of the program at the end of it lost weight, which was statistically significant.

CONCLUSIONS

Participants showed attitude of great involvement regarding physical activity and increased awareness of the best way to eat. One of the immediate benefits of using this program was that it allowed identifying risk factors among the employees and increased motivation to participate and to take specific measures regarding their health care.

Pharmacological compliance and acceptability of lansoprazole orally disintegrating tablets in primary care

OBJECTIVE

To evaluate the pharmacological compliance of patients treated with lansoprazole orally disintegrating tablets (LODT) in Primary Care (PC) and their acceptability of this formulation.

RESEARCH DESIGN AND METHODS

A multicenter, observational, cross-sectional study involving 433 PC physicians that included 433 patients aged at least 18 years, either diagnosed with gastroesophageal reflux disease (GERD) or taking LODT to prevent NSAID-induced gastric ulcers. Compliance with LODT treatment was assessed with the Haynes-Sackett self-reported test. Acceptability was based on global patient assessment, rating the drug's organoleptic characteristics and properties recorded with a self-administered 15-item ad hoc questionnaire with 2 and 5-point Likert-type scales.

RESULTS

423 patients (mean age 50.6 years, SD = 13.4) were evaluable for the main endpoint. Of these, 57.16% were men and 53.5% were treated with 30 mg doses of LODT for an average of 37.8 days (SD = 35.5). Compliance was achieved by 92.4% of the patients, mean percentage of compliance was 93.3. Demographical and clinical variables had no effect on compliance. Treatment with LODT was assessed as 'acceptable' or 'highly acceptable' by 91.7% of the sample. One adverse reaction, not serious, was reported by one patient (0.2%).

CONCLUSIONS

In this observational study, compliance with lansoprazole orally disintegrating tablets was very high. Patients reported that this formulation improved their compliance. LODT was clearly preferred to previous medication and the drug was well tolerated.

Crossover, double-blind clinical trial comparing almotriptan and ergotamine plus caffeine for acute migraine therapy

In this randomized, double-blind, crossover clinical trial, adult patients treated two migraine attacks: one with almotriptan 12.5 mg and the other with ergotamine 2 mg plus caffeine 200 mg. Treatment with almotriptan was associated with a significantly greater proportion of patients achieving 2-h pain free (20.9% vs. 13.7%; P < 0.05) and 2-h pain relief (57.7% vs. 44.5%; P < 0.01) compared with ergotamine plus caffeine therapy; significant differences were not seen at 1 h. Rates for sustained pain free and sustained pain free plus no adverse events (AEs) also were significantly greater after almotriptan treatment than after the use of ergotamine plus caffeine (P < 0.05). Almotriptan was associated with a significantly lower rate of photophobia at 90 min (P < 0.05), phonophobia at 60, 90, and 120 min (P < 0.05 to <0.01), and nausea and vomiting at 90 and 120 min (P < 0.01) compared with ergotamine plus caffeine. A significantly greater proportion of patients were more satisfied with almotriptan than with ergotamine plus caffeine (P < 0.05). Sixteen patients reported adverse events during almotriptan treatment and 27 patients reported AEs during the ergotamine plus caffeine therapy. Most AEs were mild-to-moderate and did not result in treatment-related discontinuations. In conclusion, almotriptan was associated with significantly greater efficacy for treating migraine compared with ergotamine plus caffeine, was generally well tolerated and was associated with greater rate of treatment satisfaction.

[Therapeutic strategies used by neurologists and primary care physicians in the symptomatic treatment of migraine. Findings from Strategia-I and Strategia-II opinion studies]

INTRODUCTION

Few studies have been carried out on the subject of stratification of medical care for migraines, and even fewer have been conducted with the aim of determining the attitudes adopted by physicians towards their patients when dealing with this issue. Strategia-I and II studies were designed for this purpose.

SUBJECTS AND METHODS

The sample consisted of 162 neurologists and 3,168 Primary Care physicians (PCP). Participants in the studies filled out an opinion survey that was produced ad hoc and included the different possible strategies, namely a) Stepped care between attacks (the patient takes medication during several attacks and, if it is not effective, it is replaced by another in successive attacks); b) Stepped care within attacks (the patient treats his or her seizures with medication and, if it does not work, another is used as rescue medication); and c) Stratified care (the physician classifies the patient according to the degree of disability produced by the migraine and recommends the most appropriate drug at the start).

RESULTS

Most participants in the study (90.7% of neurologists, 85.2% of PCP) reported using a single strategy. Stratified care was found to be the preferred choice by both collectives (67.6% of neurologists, 43.8% of PCP; p < 0.0001). Only 16% of the respondents admitted using some disability scale. Nonsteroidal antiinflammatory drugs are the medication chosen if disability is mild-moderate, while triptans are preferred if it is moderate-severe (92.9% of neurologists, 78.8% of PCP; p < 0.001).

CONCLUSIONS

The strategy based on stratified care is the most widely used in visits to Neurology and Primary Care in Spain, although there are significant differences between the two collectives. Triptans are perceived as being the ideal medication in situations involving moderate-severe disability.

[Almotriptan in the treatment of migraine attacks in clinical practice: results of the TEA 2000 observational study]

BACKGROUND

Almotriptan, the most recent drug of the triptan family, has shown good efficacy and tolerability profile in clinical trials.

OBJECTIVE

To assess almotriptan's tolerability and effectiveness in the setting of routine clinical practice.

PATIENTS AND METHODS

1,643 patients diagnosed of migraine according to IHS criteria were recruited by 317 neurologists in the TEA 2000 study. Patients were instructed to report data on migraine attacks in a diary for a three months follow-up period. Data from 4,253 migraine attacks were obtained.

RESULTS

The incidence of adverse events was 0.02 per migraine attack (3,9 % of patients). Subjective clinical improvement after 30 minutes (33.2 y 37.1 %), pain improvement after 2 hours (65.5 % and 70.2 %), pain free response after 2 hours (26.6 % and 29.2 %), recurrence between 2 and 24 hours (21.2 % and 17 %) and a complete response by 24 hours (18.6 % and 22.9 %) were found. These results were obtained in both "intention to treat" and "per protocol" analyses, being even much better when only low pain intensity attacks were considered.

CONCLUSIONS

The TEA 2000 study results demonstrate good effectiveness and excellent tolerability profile of almotriptan 12.5 mg in the daily clinical neurological practice. The results of this study confirm those obtained in clinical trials carried out before almotriptan was introduced into the market and that it is a good therapeutic choice for the symptomatic treatment for migraine attacks.

Antisocial behavior: its relation to selected sociodemographic variables and alcohol and drug use among Mexican students

This study is part of the National School Survey on drug use by high school students in Mexico. The validity, reliability, and results of the Antisocial Acts Scale in Mexico City (n = 3,501) are discussed. Using factorial analyses of the Antisocial Acts Scale, two major sources of variability were observed. The first one is related to antisocial acts with severe social consequences, in which violence and drug selling are included, and the second one is related to thefts. Significant differences were found in the number of offenses among groups of different gender, age, and occupation during the previous year. More antisocial acts were perpetrated by alcohol and drug users than by nonusers. In a logistic regression model, it was found that the main risk factors for perpetrating antisocial acts were being male, using alcohol, and using other drugs.

Right ventricular bypass for palliation of cardiac sarcoma

A 33-year-old woman with a nonresectable right ventricular sarcoma and pulmonary outflow tract obstruction underwent a right ventricular bypass operation for symptomatic relief. The patient had an uneventful recovery and was asymptomatic on discharge, without jugular plethora or hepatomegaly. We consider this procedure to be an excellent palliative treatment of malignant right ventricular obstructive symptoms for improving the patient's quality of life.

Low flow veno-venous ECMO: an experimental study

Clinical use of extracorporeal membrane oxygenation (ECMO) and carbon dioxide removal (ECCO 2R) have become well established techniques for the treatment of severe respiratory failure; however they require full cardiopulmonary bypass, representing major procedures with high morbidity. We theorized the possibility of an efficient low flow veno-venous extracorporeal membrane gas exchange method. Four mongrel 12 kg dogs were submitted to veno-venous extracorporeal membrane gas exchange via a jugular dialysis catheter using a low flow (10 ml/min) roller pump and a membrane oxygenator for a period of four hours. Respiratory rate was set at 4 breaths/min with a FiO 2 of 21% and ventilatory dead space was increased. Adequate gas exchange was obtained (pO 2139, pCO 224, Sat 99.4%), without major hemodynamic changes or hematuria. Our results demonstrate the feasibility of a low flow, less aggressive system. Further research should be considered.

[Poisoning by paralytic molluscan toxins in Oaxaca]

Toxic Red Tides are caused by marine dinoflagellates which synthesize neurotoxins that accumulate in bivalve mollusks. Upon ingestion, these shellfish can cause paralysis and death. During the month of December, 1989, 99 cases of Paralytic Shellfish Poisoning in the areas of Salina Cruz and Huatulco, Oaxaca, were reported; three of which died. The majority of the cases involved the ingestion of oysters and clams. A short time later, the Red Tide was reported appearing. One hundred and fifteen seafood samples were analyzed through a biologic test in mice to determine the quantity of saxitoxin. Oysters and clams showed levels reaching 4 000 U.R. Laboratory analysis of seawater found very high quantities of Gimnodinium catenatum and Gonyaulax catenella. The control measures consisted of the prohibition of the harvest and sale of all bivalve mollusks as well as a public warning to avoid the consumption of such shellfish.

[Heart position as a determinant of the voltage of the R wave in healthy subjects]

Although many factors have been reported to change the R wave amplitude of the electrocardiogram, the direct measurement without any consideration, has been the method of choice, which leads to controversial findings. We hypothesized that body mass index and heart position are the main modifiers of the R wave amplitude. To test this hypothesis 80 normal subjects were studied with standard electrocardiograms in which correlation with constitutional variables were performed and were also analyzed according to the electrocardiographic heart position. R wave amplitude showed a non-significant inverse relationship to body mass except in severe overweight subjects (p less than 0.05). When analyzed by position, levorotated and S1, S2, S3 hearts showed a significant increase in R wave voltage whereas horizontal and dextrorotated ones showed a diminished amplitude (p less than 0.01) independent of body weight. There was no relation between R wave voltage and body surface. We conclude that: Body mass is not an important modifier of R wave amplitude in thin, normal and light overweight subjects. Heart position may induce significant variation of R wave voltage according to the degree of the projection of the left ventricular electric field to the anterior thoracic surface.