Coccidioides species are the most common etiologic agents of chronic meningitis in regions endemic for coccidioidomycosis. Occasionally, even short-term travel to endemic regions results in the ...acquisition of meningeal disease, so awareness of this complication of coccidioidomycosis is important even in nonendemic areas. The prognosis depends on the early recognition and treatment of the disease, so it is important to be familiar with the varied clinical manifestations, risk factors associated with meningeal involvement, diagnostic challenges, and therapeutic modalities.
We performed a retrospective analysis of 71 cases with coccidioidomycosis involving the CNS seen from 1996 to 2007 at a referral medical center in southern Arizona.
The only presenting symptom found in the majority of patients was headache. Those who were immunocompromised (most commonly HIV/AIDS and chronic steroid therapy) were at increased risk, but diabetics were not at increased risk. There was a preponderance of males (2:1) and people of Hispanic, African, and Asian (especially Pacific Isles) background. CSF anticoccidioidal antibody and culture were frequently negative on presentation, but in these cases, the serum antibody test was usually positive. Imaging studies were helpful in two thirds of cases, most commonly demonstrating basilar meningitis or hydrocephalus, which frequently required ventriculoperitoneal shunting. Most were treated with fluconazole, and prognosis was good for most of those who remained on treatment.
Coccidioidal meningitis remains a diagnostic challenge, but the diagnosis can usually be made successfully when coccidioidal serum and CSF antibodies and cultures are combined with appropriate imaging studies.
The purpose of our study was to describe the quality of life of older adults with seizures or epilepsy and compare its psychosocial impact between those who were new diagnosed and those diagnosed ...before the age of 65.
In-depth face to face interviews with open ended questions were conducted with two participant groups: Incident group: 42 older adults (>65 years) with new onset or newly diagnosed after age of 65; and Prevalent group: 15 older adults (>65 years) diagnosed before age of 65. Interviews were reviewed and coded using a list of themes and results were compared between the two groups. Eight topics were selected from the participants' responses to questions about the psychosocial impact of epilepsy and seizures. The topics were then analyzed and compared between the two groups.
The topics analyzed were: Emotional and physical impact, significant life changes, co-morbidities, information gathering, stigma, AED side effects, changes in relationships and attitude toward diagnosis.
We concluded that the age at onset and duration does seem to have a negative correlation with health related quality of life. However, the perceived health status of older adults with chronic epilepsy was significantly better and reflected in their more positive approach to the diagnosis of seizures or epilepsy probably because they have had a longer opportunity to learn to cope with their diagnosis.
Transitions of care for stroke and TIA Haynes, Helena N; Gallek, Matthew J; Sheppard, Kate G ...
Journal of the American Association of Nurse Practitioners,
October 2015, Volume:
27, Issue:
10
Journal Article
Peer reviewed
The purpose of this study was to identify elements of a stroke population that may affect transitions of care (TOC).
A retrospective analysis of the demographic characteristics of patients from an ...urban primary stroke center with an admitting diagnosis of transient ischemic attack, acute ischemic stroke, subarachnoid hemorrhage, or intracerebral hemorrhage was performed over an 8-month period (N = 276). A subset of this patient sample participated in a telephone survey 1 month after discharge.
Hospital length of stay, age, insurance status, discharge disposition, comorbidities, and readmission rates were identified as important elements affecting TOC for stroke and TIA. Information from patient surveys indicated that emotional health, follow-up with care providers, stroke education, and point of contact are important elements during the transition periods after stroke and TIA.
Both providers and patients should inform the development of a comprehensive TOC program that spans in-hospital to multiple care settings, including the home, which is essential. The advanced practice nurse is ideally suited to successfully lead these programs.
The goal of treating an individual with epilepsy is to have no seizures and no side effects. Limiting availability of medications appears to be a simple way of controlling costs of patient care. This ...approach potentially jeopardizes both efficacy and safety. We argue, in this edition of
, that limiting costs by restricting formularies is detrimental to the patients from an efficacy, safety, and cost perspective.
BACKGROUND AND PURPOSE—If magnetic resonance imaging (MRI) is to compete with computed tomography for evaluation of patients with acute ischemic stroke, there is a need for further improvements in ...acquisition speed.
METHODS—Inclusion criteria for this prospective, single institutional study were symptoms of acute ischemic stroke within 24 hours onset, National Institutes of Health Stroke Scale ≥3, and absence of MRI contraindications. A combination of echo-planar imaging (EPI) and a parallel acquisition technique were used on a 3T magnetic resonance (MR) scanner to accelerate the acquisition time. Image analysis was performed independently by 2 neuroradiologists.
RESULTS—A total of 62 patients met inclusion criteria. A repeat MRI scan was performed in 22 patients resulting in a total of 84 MRIs available for analysis. Diagnostic image quality was achieved in 100% of diffusion-weighted imaging, 100% EPI-fluid attenuation inversion recovery imaging, 98% EPI-gradient recalled echo, 90% neck MR angiography and 96% of brain MR angiography, and 94% of dynamic susceptibility contrast perfusion scans with interobserver agreements (k) ranging from 0.64 to 0.84. Fifty-nine patients (95%) had acute infarction. There was good interobserver agreement for EPI-fluid attenuation inversion recovery imaging findings (k=0.78; 95% confidence interval, 0.66–0.87) and for detection of mismatch classification using dynamic susceptibility contrast-Tmax (k=0.92; 95% confidence interval, 0.87–0.94). Thirteen acute intracranial hemorrhages were detected on EPI-gradient recalled echo by both observers. A total of 68 and 72 segmental arterial stenoses were detected on contrast-enhanced MR angiography of the neck and brain with k=0.93, 95% confidence interval, 0.84 to 0.96 and 0.87, 95% confidence interval, 0.80 to 0.90, respectively.
CONCLUSIONS—A 6-minute multimodal MR protocol with good diagnostic quality is feasible for the evaluation of patients with acute ischemic stroke and can result in significant reduction in scan time rivaling that of the multimodal computed tomographic protocol.
Objective
Most acute ischemic stroke (AIS) patients with unwitnessed symptom onset are ineligible for intravenous thrombolysis due to timing alone. Lesion evolution on fluid‐attenuated inversion ...recovery (FLAIR) magnetic resonance imaging (MRI) correlates with stroke duration, and quantitative mismatch of diffusion‐weighted MRI with FLAIR (qDFM) might indicate stroke duration within guideline‐recommended thrombolysis. We tested whether intravenous thrombolysis ≤4.5 hours from the time of symptom discovery is safe in patients with qDFM in an open‐label, phase 2a, prospective study (NCT01282242).
Methods
Patients aged 18 to 85 years with AIS of unwitnessed onset at 4.5 to 24 hours since they were last known to be well, treatable within 4.5 hours of symptom discovery with intravenous alteplase (0.9mg/kg), and presenting with qDFM were screened across 14 hospitals. The primary outcome was the risk of symptomatic intracranial hemorrhage (sICH) with preplanned stopping rules. Secondary outcomes included symptomatic brain edema risk, and functional outcomes of 90‐day modified Rankin Scale (mRS).
Results
Eighty subjects were enrolled between January 31, 2011 and October 4, 2015 and treated with alteplase at median 11.2 hours (IQR = 9.5–13.3) from when they were last known to be well. There was 1 sICH (1.3%) and 3 cases of symptomatic edema (3.8%). At 90 days, 39% of subjects achieved mRS = 0–1, as did 48% of subjects who had vessel imaging and were without large vessel occlusions.
Interpretation
Intravenous thrombolysis within 4.5 hours of symptom discovery in patients with unwitnessed stroke selected by qDFM, who are beyond the recommended time windows, is safe. A randomized trial testing efficacy using qDFM appears feasible and is warranted in patients without large vessel occlusions. Ann Neurol 2018;83:980–993
Full text
Available for:
BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Abstract Stigma is a common psychological consequence of chronic diseases, including epilepsy; however, little research has been done to determine the effect of stigma on persons with epilepsy, ...especially the elderly. We interviewed 57 older adults with epilepsy to discover the extent and consequences of, and reasons for, epilepsy-related stigma in their lives. Felt stigma was more frequently reported than enacted stigma, with over 70% having experienced this form of stigma. Participants described ignorance and fear of the disease as the foundation of epilepsy-related stigma. The most common response to stigmatizing events was a decrease in epilepsy disclosure to family or friends. Results from this study could inform interventions designed for elderly persons with epilepsy and their support networks, as well as educational campaigns for the general public.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Abstract only
Background:
In 2010 the estimated direct and indirect cost of stroke was $53.9 billion. The long-term burden to society is thought to be much more costly. Whether or not this sum can be ...reduced has been a subject of great debate. Recently, healthcare reform has been a priority for policy makers with health insurance as a prevailing issue. We examined the healthcare records of patients in the US who presented with stroke symptoms in a 10-year period from 2001-2011, and compared them to patients in the state of Arizona as well as our University Hospital in the same time period. We then looked for differences in the cost of stroke with regard to variations in insurance status.
Methods:
The records of 978,813 patients with stroke symptoms in the US from January 2001 through December 2011 were compared with 18,875 Arizona (AZ) patients. This data was evaluated and compared with data obtained from the records of 1,123 patients admitted to the University Medical Center (UMC), and separated by insurance status, discharge location and length of stay (LOS) for different stroke subtypes. The information was gathered from the
get with the guidelines
stroke database and only included hospitals that reported their information.
Results:
The mean LOS for stroke patients in the US, AZ and UMC were: 5.25 days, 4.69 and 4.75 days, respectively. When separated by insurance status, the mean LOS for patients at UMC with Medicare was 4.27 days (n=470), for Medicaid it was 6.17 days (n=150) and 5.13 days (n=464) for private insurance. Compared with insured patients, uninsured patients had a LOS of 8.18 days (n=39; p=.001). Uninsured patients were discharged home without rehab 24.4% of the time compared with only 8.8% of insured patients (p=.001), even though 93.5% of uninsured patients were considered for rehab.
Conclusion:
Uninsured patients had a LOS that was 3.3 days longer than insured patients and had an estimated 72% higher cost of hospitalization. Uninsured patients were almost 3 times less likely than insured patients to be discharged with rehab, and consequently were less likely to achieve long-term functional independence. Ultimately, the price of stroke in the uninsured is paid for by taxpayers, since these patients will require social services granted by the government for disability.
Barriers to risk factor control may differ by race/ethnicity. The goal of this study was to identify barriers to stroke awareness and risk factor management unique to Hispanics as compared to ...non-Hispanic whites (NHWs). We performed a prospective study of stroke patients from an academic Stroke Center in Arizona and surveyed members of the general community. Questionnaires included: the Duke Social Support Index (DSSI), the Multidimensional Health Locus of Control (MHLC) Scale, a stroke barriers questionnaire, and a Stroke Awareness Test. Of 145 stroke patients surveyed (72 Hispanic; 73 NHW), Hispanics scored lower on the Stroke Awareness Test compared to NHWs (72.5% vs. 79.1%, p = 0.029). Hispanic stroke patients also reported greater barriers related to medical knowledge, medication adherence, and healthcare access (p < 0.05 for all). Hispanics scored higher on the "powerful others" sub-scale (11.3 vs. 10, p < 0.05) of the MHLC. Of 177 members of the general public surveyed, Hispanics had lower stroke awareness compared to NHWs and tended to have lower awareness than Hispanic stroke patients. These results suggest that Hispanic stroke patients perceive less control over their health, experience more healthcare barriers, and demonstrate lower rates of stroke literacy. Interventions for stroke prevention and education in Hispanics should address these racial/ethnic differences in stroke awareness and barriers to risk factor control.
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