To analyze the differences in characteristics and prognosis between alcoholic and nonalcoholic patients with Wernicke encephalopathy (WE).
A retrospective observational cohort of 468 patients ...diagnosed with WE with at least 2 Caine criteria was selected from all patients discharged with a diagnosis of WE from 21 medical centers in Spain from January 1, 2000, through December 31, 2012. Demographic, clinical, and outcome variables were described.
Among the 468 patients, the most common risk factor was alcoholism (n=434 92.7%). More than one-third of patients (n=181 38.7%) had the classic WE triad of symptoms (ocular signs, cerebellar dysfunction, and confusion). Among 252 patients for whom magnetic resonance imaging data were available, 135 (53.6%) had WE-related lesions and 42 (16.7%) had cerebellar lesions. Of the 468 patients, 25 (5.3%) died during hospitalization. Alcoholic patients presented more frequently than nonalcoholic patients with cerebellar signs (P=.01) but less frequently with ocular signs (P=.02). Alcoholic patients had a significantly higher frequency of hyponatremia (P=.04) and decreased platelet count (P=.005) compared with nonalcoholics. Alcoholic patients were diagnosed earlier than nonalcoholics (median time to diagnosis, 1 vs 4 days; P=.001) and had shorter hospitalizations (13 vs 23 days; P=.002).
Compared with nonalcoholic patients, alcoholic patients with WE are more likely to present with cerebellar signs and less likely to have ocular signs. Diagnosis may be delayed in nonalcoholic patients. Mortality in the present series was lower than described previously.
Despite guidelines and recommendations, Wernicke's encephalopathy (WE) treatment lacks evidence, leading to clinical practice variability.
Given the overall lack of information on thiamine use for WE ...treatment, we analyzed data from a large, well-characterized multicenter sample of patients with WE, examining thiamine dosages; factors associated with the use of different doses, frequencies, and routes; and the influence of differences in thiamine treatment on the outcome.
This retrospective study was conducted with data from 443 patients from 21 centers obtained from a nationwide registry of the Spanish Society of Internal Medicine (from 2000 to 2012). Discharge codes and Caine criteria were applied for WE diagnosis, and treatment-related (thiamine dosage, frequency, and route of administration) demographic, clinical, and outcome variables were analyzed.
We found marked variability in WE treatment and a low rate of high-dose intravenous thiamine administration. Seventy-eight patients out of 373 (20.9%) received > 300mg/day of thiamine as initial dose. Patients fulfilling the Caine criteria or presenting with the classic WE triad more frequently received parenteral treatment. Delayed diagnosis (after 24h hospitalization), the fulfillment of more than two Caine criteria at diagnosis, mental status alterations, and folic acid deficiency were associated significantly with the lack of complete recovery. Malnutrition, reduced consciousness, folic acid deficiency, and the lack of timely thiamine treatment were risk factors for mortality.
Our results clearly show extreme variability in thiamine dosages and routes used in the management of WE. Measures should be implemented to ensure adherence to current guidelines and to correct potential nutritional deficits in patients with alcohol use disorders or other risk factors for WE.
•There is extreme variability in thiamine dosages and routes used in the management of Wernicke encephalopathy.•It is essential to correct nutritional deficits in patients with alcohol use disorders and other risk factors for Wernicke encephalopathy.•Physicians should consider treating Wernicke encephalopathy in high-risk patients even in the absence of diagnostic criteria.
data regarding the association between Wernicke encephalopathy (WE) and alcoholic liver disease (ALD) are scarce in spite of alcohol consumption being the main risk factor for WE.
to describe the ...frequency of ALD in a cohort of patients diagnosed with WE and alcohol use disorders (AUDs) and to compare the characteristics of WE patients with and without ALD.
we conducted an observational study in 21 centers through a nationwide registry of the Spanish Society of Internal Medicine. WE Caine criteria were applied and demographic, clinical, and outcome variables were analyzed.
434 patients were included in the study, of which 372 were men (85.7%), and the mean age was 55 ± 11.8 years. ALD was present in 162 (37.3%) patients and we found a higher percentage of cases with tremor, flapping and hallucinations in the ALD group. A total of 22 patients (5.0%) died during admission (7.4% with ALD vs 3.7% without ALD; P = 0.087). Among the ALD patients, a relationship between mortality and the presence of anemia (Odds ratio OR=4.6 Confidence interval CI95% 1.1–18.8; P = 0.034), low level of consciousness (OR=4.9 CI95% 1.1–21.2; P = 0.031) and previous diagnosis of cancer (OR=10.3 CI95% 1.8–59.5; P = 0.009) was detected. Complete recovery was achieved by 27 patients with ALD (17.8%) and 71 (27.8%) without ALD (P = 0.030).
the association of WE and ALD in patients with AUDs is frequent and potentially linked to differences in clinical presentation and to poorer prognosis, as compared to alcoholic patients with WE without ALD.
•The association of Wernicke encephalopathy and alcoholic liver disease in patients with alcohol use disorders is frequent.•Diagnosis of Wernicke encephalopathy in patients with alcoholic liver disease can be harder due to clinical differences.•Patients with alcoholic liver disease and wernicke encephalopathy have worse prognosis.•The presence of Wernicke encephalopathy should prompt the assessment of alcoholic liver disease.
Kounis syndrome is a new clinical entity defined as the occurrence of acute coronary syndromes caused by inflammatory mediators. It was first described in 1991, and since then, new individual case ...description is helping to delineate its pathogenesis and treatment. Three variants of Kounis syndrome have been described: vasospastic allergic angina (type I), allergic and atheromatous myocardial infarction (type II), and coronary artery stent thrombosis demonstrating the presence of eosinophils and mast cells (type III).
Two new cases of type I and type II Kounis syndrome are presented emphasizing its distinct treatment dilemmas.
El síndrome de Kounis (SK) es una nueva entidad clínica definida como la aparición simultánea de síntomas alérgicos y de un síndrome coronario agudo. Desde su descripción inicial en el año 91 se han ido sumando revisiones y descripciones de casos que están permitiendo conocer mejor su patogénesis. Desde el año 2010 se han definido tres variantes de dicho síndrome: angina alérgica vasoespástica (tipo I), infarto de miocardio alérgico (tipo II) y trombosis intrastent con trombo oclusivo infiltrado por eosinófilos y mastocitos.
En el presente artículo describimos un caso de SK tipo I y otro caso de SK tipo II, discutiendo acerca del tratamiento pautado en dichos casos.
El síndrome de Kounis, angina alérgica o infarto de miocardio alérgico, fue descrito en 1991 por Kounis y Zavras como la aparición de manera simultánea, de eventos coronarios agudos y síntomas ...alérgicos anafilácticos/anafilactoides. Actualmente hay descritos en la literatura tres subtipos, el tipo I sin enfermedad coronaria, el tipo II con enfermedad coronaria y el tipo III en pacientes que sufren trombosis de un stent farmacoactivo. En la actualidad continúa siendo poco conocido con cerca de unas 100 entradas en Pubmed que reúnen casos, series de casos y revisiones. La epidemiología es desconocida y no existen guías de práctica clínica que establezcan el tratamiento de elección. Presentamos dos casos clínicos de este síndrome diagnosticados en nuestro centro.
Background and objectives: Independent validations of the ABCD2
score used to predict stroke development have reported conflicting results,
and besides expert opinion as to proper diagnostic approach ...and
best treatment differs widely. A model predictive power can be modified
by the concomitant use of effective diagnostic and pharmacological
treatments. We aimed to determine the predictive power of the ABCD2
score while simultaneously providing patients with current urgent recommended
treatments and recording their early and long term health
outcomes.
Methods: Data were retrospectively collected from all the patients presenting
with a TIA for a whole year and were followed for another whole
year. Physicians completed data forms with the ABCD2 score when patients
arrived at the emergency department (ED).We calculated sensitivity,
specificity for predicting stroke at 7 and 30 days after visiting the
ED using the high-risk cutpoint of an ABCD2 score ≥ 4.Univariate Cox
proportional hazards regression modelling was performed for ABCD2
score to estimate the hazard ratios relative to the low-risk category and
to assess the effect of the individual components of the ABCD2 score
and other potential risk factors to predict stroke development.
Results: We enrolled 172 patients (mean age 71 yr, 51 % women) with
a new incident diagnosis of TIA. The mean (SD) ABCD2 score was 4.2
(1.4). There were 7 new TIA, 17 non fatal strokes and 3 fatal strokes. Intrahospital
mortality was 1.7% and 8.7% during the 1 year follow up. An
ABCD2 score of ≥ 4 had a sensitivity of 88% and 82 % for a stroke at 7
and 30 days respectively, a poor specificity of 30%. Negative predictive
value at 7 days was 98%. ABCD2 score ≥ 4 had no significant predictive
value for stroke within 7 days (hazard ratio HR, 3.49; 95%CI, 0.42 to
27.93) and 30 days (HR, 1.97; 95%CI, 0.43 to 9.13) of the event. Only
diabetes predicted an increased likelihood of stroke over the first week
(HR, 5.47; 95%IC 1.43 to 20.95) and over the first month (HR, 3.60;
95%IC 1.08 to 12).
Conclusions: An ABCD2 score of < 4 has a good negative predictive
value (98%) for stroke development within the first 7 days. However,
the low positive predictive value of the ABCD2 score fails to predict
with a high level of confidence the future occurrence of a stroke. It was
only being diabetic that was significantly related to the probability of
stroke development. TIA probably justifies early accurate identification of
the underlying TIA etiology for nearly all presentations. We recommend
adding a systematic Brain CT, carotid ultrasound and ECG within 24
hours while concomitantly starting urgent treatment.
Introducción y objetivo: Las validaciones de la escala ABCD2 para predecir
un Ictus después de un AIT han sido contradictorias y la opinión de los
expertos sobre cual es mejor método de diagnóstico y tratamiento son muy
variables. Además el poder predictivo de las escalas puede variar mucho si al
mismo tiempo se usan procesos diagnósticos y terapéuticos efectivos en variar
el curso de la enfermedad. Nuestro objetivo es evaluar el poder predictivo
real de la escala ABCD2 cuando al mismo tiempo a los pacientes se les somete
a métodos diagnósticos adecuados y tratamientos efectivos urgentes.
Metodología: Se recogieron de manera retrospectiva todos los pacientes
con diagnóstico de AIT que acudieron a un hospital terciario durante un año
y fueron seguidos prospectivamente durante 1 año. Los datos de la escala
ABCD2 fueron los que presentaban al momento de llegada a urgencias. Calculamos
cual era la sensibilidad, especificidad y poder discriminatorio de una
puntuación ≥ 4 para predecir la aparición de un Ictus a los 7 y 30 días. Se
aplicó un modelo de regresión univariante de Cox a la escala ABCD2 para
estimar el cociente de riesgo relativo a la categoría de bajo riesgo y valorar
la capacidad predictiva de ictus de sus componentes individuales y de otros
potenciales predictores de riesgo.
Resultados: Incluimos 172 pacientes (edad media 71 años, 51% mujeres)
con un nuevo diagnóstico de AIT. La puntuación media de la escala ABCD2
fue de 4.2 ± 1.4. Se produjeron 7 nuevos AIT, 17 Ictus no fatales y 3 ictus
fatales durante el seguimiento. La mortalidad intrahospitalaria fue del 1.7%
y la total durante el seguimiento de 1 año del 8.7 %. Una puntuación en la
escala de ABCD2 de ≥ 4 tenía una sensibilidad del 88% y del 82% para predecir
un ictus a los 7 y 30 días respectivamente, con una pobre especificidad
del 30%.El valor predictivo negativo a 7 dias fue del 98%. Una puntuación
ABCD2 ≥ 4 no tuvo valor predictivo significativo de ictus a los 7 días (hazard
ratio HR, 3.49; 95%CI, 0.42 to 27.93) ni a 30 días (HR, 1.97; 95%CI, 0.43
to 9.13). Como componente individual, solo la diabetes predijo la probabilidad
de desarrollar un ictus en la primera semana (HR, 5.47; 95%IC 1.43 to
20.95) y durante el primer mes (HR, 3.60; 95%IC 1.08 to 12).
Conclusiones: Un ABCD2 < 4 tiene un buen valor predictivo negativo (98%)
para descartar el desarrollo de un ictus en los próximos 7 días. Sin embargo,
su bajo valor predictivo positivo no permite predecir con seguridad el desarrollo
de un ictus. Solo la variable diabetes de la escala se asoció con una
probabilidad relevante de tener un ictus. Probablemente cualquier tipo de
presentación de AIT justifica la búsqueda rápida de la etiología subyacente.
Consideramos que en el AIT, independientemente de la escala ABCD2, se
debe realizar en menos de 24 horas un TAC cerebral, ECG, e imagen de
carótida, mientras al mismo tiempo se inicia tratamiento preventivo urgente.
ABSTRACT Background and objectives: Independent validations of the ABCD2 score used to predict stroke development have reported conflicting results, yet expert opinion as to proper diagnostic ...approach and best treatment differs widely. A model predictive power can be modified by the concomitant use of effective diagnostic and pharmacological treatments. We aimed to determine the predictive power of the ABCD2 score while simultaneously providing patients with current urgent recommended treatments and recording their early and long term health outcomes. Methods: Data was retrospectively collected from all the patients presenting with a TIA for a whole year and were followed for another whole year. Physicians completed data forms with the ABCD2 score when patients arrived at the emergency department (ED).We calculated sensitivity, specificity for predicting stroke at 7 and 30 days after visiting the ED using the high-risk cutpoint of an ABCD2 score ≥ 4.Univariate Cox proportional hazards regression modelling was performed for ABCD2 score to estimate the hazard ratios relative to the low-risk category and to assess the effect of the individual components of the ABCD2 score and other potential risk factors to predict stroke development. Results: We enrolled 172 patients (mean age 71 yr, 51 % women) with a new incident diagnosis of TIA. The mean (SD) ABCD2 score was 4.2 (1.4). There were 12 new TIA, 21 non fatal strokes and 3 fatal strokes. Intrahospital mortality was 1.7% and 12% during the 1 year follow up. An ABCD2 score of ≥ 4 had a sensitivity of 88% and 82 % for a stroke at 7 and 30 days respectively, with a poor specificity of 30%. Negative predictive value at 7 days was 98%. ABCD2 score ≥ 4 had no significant predictive value for stroke within 7 days (hazard ratio HR, 3.49; 95%CI, 0.42 to 27.93) and 30 days (HR, 1.97; 95%CI, 0.43 to 9.13) of the event. Only diabetes predicted an increased likelihood of stroke over the first week (HR, 5.47; 95%IC 1.43 to 20.95) and over the first month (HR, 3.60; 95%IC 1.08 to 12). Conclusions: The accuracy of the ABCD2 score fails to help us make treatment decisions except for its negative predictive value (98%). It was only being diabetic that was significantly related to the probability of stroke development. TIA probably justifies early accurate identification of the underlying TIA etiology for nearly all presentations. We recommend adding a systematic Brain CT, carotid ultrasound and ECG within 24 hours while concomitantly starting urgent treatment. RESUMEN Introducción y objetivo: Las validaciones de la escala ABCD2 para predecir un Ictus después de un AIT han sido contradictorias y la opinión de los expertos sobre cual es mejor método de diagnostico y tratamiento son muy variables. Ademas los el poder predictivo de las escalas puede variar mucho si al mismo tiempo se usan procesos diagnósticos y terapéuticos efectivos en variar el curso de la enfermedad. Nuestro objetivo es evaluar el poder predictivo real de la escala ABCD2 cuando al mismo tiempo a los pacientes se les somete a métodos diagnósticos adecuados y tratamientos efectivos urgentes. Metodología: Se recogieron de manera retrospectiva todos los pacientes que acudieron a un hospital terciario durante un año y fueron seguidos prospectivamente durante 1 año. Los datos de la escala ABCD2 fueron los que presentaban al momento de llegada a urgencias. Calculamos cual era la sensibilidad, especificidad y poder discriminatorio de una puntuación ≥ 4 para predecir la aparición de un Ictus a los 7 y 30 días. Se aplicó un modelo de regresión univariante de Cox a la escala ABCD2 para estimar el cociente de riesgo correspondiente a la categoría de bajo riesgo y valorar la capacidad predictiva de ictus de sus componentes individuales y de otros potenciales predictores de riesgo. Resultados: Incluimos 172 pacientes ( edad media 71 años, 51% mujeres) con un nuevo diagnostico de AIT. La puntuación media de la escala ABCD2 fue de 4.2 ± 1.4. Se produjeron 12 nuevos AIT, 21 Ictus no fatales y 3 ictus fatales durante el seguimiento. La mortalidad intrahospitalaria fue del 1.7% y la total durante el seguimiento de 1 año del 12 %. Una puntuación en la escala de ABCD2 de ≥ 4 tenia una sensibilidad del 88% y del 82% para predecir un ictus a los 7 y 30 días respectivamente, con una pobre especificidad del 30%.El valor predictivo negativo a 7 dias fue del 98%. Una puntuación ABCD2 ≥ 4 no tuvo valor predictivo significativo de ictus a los 7 días (hazard ratio HR, 3.49; 95%CI, 0.42 to 27.93) ni a 30 días (HR, 1.97; 95%CI, 0.43 to 9.13). Como componente individual, solo la diabetes predijo la probabilidad de desarrollar un ictus en la primera semana (HR, 5.47; 95%IC 1.43 to 20.95) y durante el primer mes (HR, 3.60; 95%IC 1.08 to 12). Conclusiones: El poder discriminativo de la escala ABCD2 no ayuda a tomar decisiones de tratamiento salvo por su valor predictivo negativo del 98%. Solo la variable diabetes de la escala se asocio con una probabilidad relevante de tener un ictus.Probablemente cualquier tipo de presentación de AIT justifica la búsqueda rápida de la etiologia subyacente. Consideramos que en el AIT, independientemente de la escala ABCD2 , se debe realizar en menos de 24 horas un TAC cerebral, ECG, e imagen de carótida, mientras al mismo tiempo se inicia tratamiento preventivo urgente.
The COVID-19 pandemic highlighted the dangers of airborne pathogen transmission. SARS-CoV-2 is known to be transmitted through aerosols; however, little is known about the dynamics of these aerosols ...in real environments, the conditions, and the minimum viral load required for infection. Efficiently measuring and capturing pathogens present in the air would help to understand the infection process. Air samplers usually take several hours to obtain an air sample. In this work a fast (1-2 min) method for capturing bioaerosols into a liquid medium has been tested in hospital rooms with COVID-19 patients. This fast sampling allows detecting transient levels of aerosols in the air. SARS-CoV-2 RNA is detected in aerosols from several hospital rooms at different levels. Interestingly, there are sudden boosts of the SARS-CoV-2 load in the air, suggesting that SARS-CoV-2 could be released abundantly at certain moments. These results show that the distribution of SARS-CoV-2-containing aerosols is not homogeneous in the hospital room. This technology is a fast and effective tool for capturing airborne matter in a very short time, which allows for fast decision-making any kind of hazard in the air is detected. It is also useful for a better understanding of aerosols dynamics.
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