Impact of the COVID-19 pandemic on the organisation of stroke care. Madrid Stroke Care Plan

La sobrecarga asistencial y los cambios organizativos frente a la pandemia de COVID-19 podrían estar repercutiendo en la atención al ictus agudo en la Comunidad de Madrid. Métodos: Encuesta estructurada en bloques: características del hospital, cambios en infraestructura y recursos, circuitos de código ictus, pruebas diagnósticas, rehabilitación y atención ambulatoria. Análisis descriptivo según el nivel de complejidad en la atención del ictus (disponibilidad o no de unidad de ictus y de trombectomía mecánica). Resultados: De los 26 hospitales del SERMAS que atienden urgencias en adultos, 22 cumplimentaron la encuesta entre el 16 y 27 de abril. El 95% han cedido neurólogos para atender a pacientes afectados por la COVID-19. Se han reducido camas de neurología en el 89,4%, modificado los circuitos en urgencias para ictus en el 81%, con circuitos específicos para sospecha de infección por SARS-CoV2 en el 50%, y en el 42% de los hospitales los pacientes con ictus agudo positivos para SARS-CoV2 no ingresan en camas de neurología. Ha mejorado el acceso altratamiento, con trombectomía mecánica las 24 h en el propio hospital en 10 hospitales, y sehan reducido los traslados interhospitalarios secundarios. Se ha evitado el ingreso de pacientescon ataque isquémico transitorio o ictus leve (45%) y se han incorporado consultas telefónicaspara seguimiento en el 100%.Conclusiones: Los cambios organizativos de los hospitales de la Comunidad de Madrid frente ala pandemia por SARS-Co2 han modificado la dedicación de recursos humanos e infraestructurasde las unidades de neurología y los circuitos de atención del ictus, realización de pruebasdiagnósticas, ingreso de los pacientes y seguimientoThe overload of the healthcare system and the organisational changes made inresponse to the COVID-19 pandemic may be having an impact on acute stroke care in the Regionof Madrid.Methods: We conducted a survey with sections addressing hospital characteristics, changes ininfrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation,and outpatient care. We performed a descriptive analysis of results according to the level ofcomplexity of stroke care (availability of stroke units and mechanical thrombectomy).Results: The survey was completed by 22 of the 26 hospitals in the Madrid Regional HealthSystem that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent ofhospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neuro-logy ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathwayswere modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neu-rology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy wasimproved in 10 hospitals, which resulted in a reduction in the number of secondary hospitaltransfers. The admission of patients with transient ischaemic attack or minor stroke was avoi-ded in 45% of hospitals, and follow-up through telephone consultations was implemented in100%.Conclusions: The organisational changes made in response to the SARS-Co2 pandemic in hos-pitals in the Region of Madrid have modified the allocation of neurology department staff andinfrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions,and outpatient follow-u

Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program recommendations

La pandemia por COVID-19 ha obligado a una reorganización de los sistemas sanitarios y ha comportado una saturación excepcional de sus recursos. En este contexto es vital asegurar la atención al ictus agudo y optimizar los procesos asistenciales del código ictus para reducir el riesgo de contagios y racionalizar el uso de recursos hospitalarios. Para ello, desde el Grupo Multidisciplinar Ictus Madrid proponemos una serie de recomendaciones. Métodos Revisión bibliográfica no sistemática de las publicaciones disponibles con los términos «stroke» y «COVID-19» o «coronavirus» o «SARS-CoV-2», así como otras conocidas por los autores. En base a esta se redacta un documento de recomendaciones que es sometido a consenso por el Grupo Multidisciplinar Ictus Madrid y su Comité de Neurología. Resultados Las recomendaciones se estructuran en cinco líneas fundamentales: 1) coordinar la actuación para garantizar el acceso a la asistencia hospitalaria de los pacientes con ictus; 2) reconocer a los pacientes con ictus potencialmente infectados por COVID-19, 3) organización adecuada para garantizar la protección de los profesionales sanitarios frente al riesgo de contagio por COVID-19, 4) en la realización de neuroimagen y otros procedimientos que conlleven contactos de riesgo de infección COVID-19 hay que procurar reducirlos y asegurar la protección, y 5) alta y seguimiento seguros procurando optimizar la ocupación hospitalaria. Resumimos el procedimiento de forma esquemática con el acrónimo CORONA (COordinar, Reconocer, Organizar, Neuroimagen, Alta). Conclusiones Estas recomendaciones pueden servir de apoyo para la organización del sistema sanitario en la atención al ictus agudo y la optimización de sus recursos, garantizando la protección de sus profesionalesThe COVID-19 pandemic has forced a reorganization of healthcare systems and an exceptional saturation of their resources. In this context, it is vital to ensure acute stroke care and optimize the care processes of the stroke code to reduce the risk of contagion and rationalize the use of hospital resources. To do this, the Ictus Madrid Multidisciplinary Group proposes a series of recommendations. Methods Non-systematic bibliographic review of the available publications with the terms «stroke» and «COVID-19» or «coronavirus» or «SARS-CoV-2», as well as other already known for the authors. We provide a document of recommendations as a result of the consensus of the Ictus Madrid Multidisciplinary Group and its Neurology Committee. Results Our recommendations are structured on five lines: (1) coordinate to guarantee the access to hospital care for stroke patients, (2) recognize potentially COVID-19 infected stroke patients, (3) organize to ensure the protection of healthcare professionals from COVID-19 infections, (4) neuroimaging and other procedures potentially associated to risks for COVID-19 infection should be reduced and secured to avoid contagion, and (5) at home as soon as possible and supported follow-up to optimize hospital occupancy. The procedure is shown summarized under the acronym CORONA (COordinate, Recognize, Organize, Neuroimaging, At home). Conclusions These recommendations can support the organization of healthcare services for acute stroke care and the optimization of their resources, guaranteeing the protection of healthcare professional

Cell membrane fatty acid composition in Type 1 (insulin-dependent) diabetic patients: Relationship with sodium transport abnormalities and metabolic control

We have studied the fatty acid composition of erythrocyte membrane phospholipids in nine Type 1 (insulin-dependent) diabetic patients and nine healthy control subjects. Cell membranes from the diabetic patients showed a marked decrease in the total amount of polyunsaturated fatty acids (19.0%±2.2 vs 24.6%±1.4, p<0.0001) mainly at the expense of docosahexaenoic acid C22∶6(n3) (2.9%±1.1 vs 5.3%±1.3, p<0.001), and arachidonic acid C20∶4 n6 (12.0%±1.6 vs 15.1%±0.6, p<0.0005). Conversely, the total amount of saturated fatty acids was significantly increased (p<0.05) and the polyunsaturated/saturated ratio was decreased in the Type 1 diabetic patients (p<0.00005). Neither the time from diagnosis, nor C-peptide levels, correlated with parameters indicating a poor metabolic control of Type 1 diabetes. However, C22∶6(n−3) and total n−3 content significantly correlated with HbA1c (r=−0.79 and r=−0.88, respectively, p<0.01), fructosamine (r=−0.71 and r=−0.74, respectively, p<0.05), and Na+-K+ ATPase activity (maximal rate/Km quotient) (r=0.78 and r=0.71, respectively, p<0.05). In conclusion we have found marked alterations of cell membrane lipid composition in Type 1 diabetic patients. These cell membrane abnormalities in lipid content were related to sodium transport systems and to poor metabolic control. Either diet, or the diabetic state, might be responsible for the observed cell membrane abnormalities. A dietary intervention study might differentiate the role of diet and diabetes in the reported cell membrane alterations

Levetiracetam efficacy in patients with Lennox-Gastaut syndrome. Presentation of a case

Introduction: The Lennox-Gastaut syndrome (LGS) is one of the most severe epileptic encephalopathies of childhood, characterized by electro-clinical triad of generalized peak-slow wave activity (PSW) in the electroencephalogram (EEG), multiple types of seizures and development delay. This paper intends to describe the syndrome in a patient with a history of hypoxic-ischaemic encephalopathy and Lennox-Gastaut syndrome, and a good response to treatment with levetiracetam (LEV). Method: Descriptive study on the development of a 3 year old child with intrauterine asphyxia, multi-organ failure, metabolic acidosis, hypovolaemic shock, and seizures with cerebral oedema, who developed a West syndrome, resistant to drug treatment. The semiology of seizures progressively changed to generalized episodes of hypertonia and myoclonus, with slow spike-wave electroencephalographic activity. Results: With the diagnosis of Lennox-Gastaut syndrome the patient was treated with levetiracetam, showing a substantial improvement in the cognitive sphere, in the control of seizures, and electroencephalographic findings. Conclusions: Lennox-Gastaut syndrome is one of the most severe epileptic syndromes in paediatric patients. Levetiracetam can help cognitive improvement, and contribute to seizure control in these patients. Resumen: Introducción: El síndrome de Lennox-Gastaut (SLG) es una de las encefalopatías epilépticas más severas de la infancia, caracterizada por la tríada electroclínica de actividad generalizada de punta onda lenta (POL) en el electroencefalograma (EEG), múltiples tipos de crisis epilépticas y retraso mental. Con este trabajo pretendemos describir el cuadro sindrómico en un paciente con antecedente de encefalopatía hipóxico-isquémica y SLG, y su respuesta al tratamiento con levetiracetam (LEV). Método: Estudio descriptivo evolutivo de un niño de 3 años con antecedentes obstétricos de asfixia intrauterina y repercusión multiorgánica, acidosis metabólica, shock hipovolémico y crisis convulsivas con edema cerebral que a los pocos meses de edad desarrolla un síndrome de West, resistente al tratamiento farmacológico. Progresivamente, la semiología de las crisis cambia a episodios de hipertonía generalizada y mioclonías, con actividad electroencefalográfica de punta-onda lenta. Resultados: Con el diagnóstico de SLG se inicia tratamiento con LEV, observándose una mejoría sustancial en la esfera cognitiva, en el control de las crisis, y en los hallazgos electroencefalográficos. Conclusiones: El SLG es uno de los síndromes epilépticos más graves en los pacientes pediátricos, tanto por su semiología como por su farmacorresistencia. El levetiracetam puede producir una mejoría cognitiva, además de contribuir al control de las crisis en estos pacientes. Keywords: Childhood, Epilepsy, Electroencephalogram, Lennox-Gastaut syndrome, Levetiracetam, Palabras clave: Infancia, Epilepsia, Electroencefalograma, Síndrome de Lennox-Gastaut, Levetiraceta

Eficacia del levetiracetam en pacientes con síndrome de Lennox-Gastaut. Presentación de un caso

Resumen: Introducción: El síndrome de Lennox-Gastaut (SLG) es una de las encefalopatías epilépticas más severas de la infancia, caracterizada por la tríada electroclínica de actividad generalizada de punta onda lenta (POL) en el electroencefalograma (EEG), múltiples tipos de crisis epilépticas y retraso mental. Con este trabajo pretendemos describir el cuadro sindrómico en un paciente con antecedente de encefalopatía hipóxico-isquémica y SLG, y su respuesta al tratamiento con levetiracetam (LEV). Método: Estudio descriptivo evolutivo de un niño de 3 años con antecedentes obstétricos de asfixia intrauterina y repercusión multiorgánica, acidosis metabólica, shock hipovolémico y crisis convulsivas con edema cerebral que a los pocos meses de edad desarrolla un síndrome de West, resistente al tratamiento farmacológico. Progresivamente, la semiología de las crisis cambia a episodios de hipertonía generalizada y mioclonías, con actividad electroencefalográfica de punta-onda lenta. Resultados: Con el diagnóstico de SLG se inicia tratamiento con LEV, observándose una mejoría sustancial en la esfera cognitiva, en el control de las crisis, y en los hallazgos electroencefalográficos. Conclusiones: El SLG es uno de los síndromes epilépticos más graves en los pacientes pediátricos, tanto por su semiología como por su farmacorresistencia. El levetiracetam puede producir una mejoría cognitiva, además de contribuir al control de las crisis en estos pacientes. Abstract: Introduction: The Lennox-Gastaut syndrome (LGS) is one of the most severe epileptic encephalopathies of childhood, characterized by electro-clinical triad of generalized spike-wave activity, slow (POL) in the electroencephalogram (EEG), multiple types of seizures and development delay. This paper intends to describe the syndrome in a patient with a history of hypoxic-ischaemic encephalopathy and Lennox-Gastaut syndrome, and a good response to treatment with levetiracetam (LEV). Method: Descriptive study on the development of a 3 year old child with intrauterine asphyxia, multiorgan failure, metabolic acidosis, hypovolemic shock, and seizures with cerebral oedema, who developed a West syndrome, resistant to drug treatment. The semiology of seizures progressively changed to generalized episodes of hypertonia and myoclonus, with slow spike-wave electroencephalographic activity. Results: With the diagnosis of Lennox-Gastaut syndrome the patient was treated with levetiracetam, showing a substantial improvement in the cognitive sphere, in the control of seizures, and electroencephalographic findings. Conclusions: Lennox-Gastaut syndrome is one of the most severe epileptic syndromes in paediatric patients. Levetiracetam can help cognitive improvement, and contribute to seizure control in these patients. Palabras clave: Infancia, Epilepsia, Electroencefalograma, Síndrome de Lennox-Gastaut, Levetiracetam, Keywords: Childhood, Epilepsy, Electroencephalogram, Lennox-Gastaut syndrome, Levetiraceta

Sodium transport kinetics, cell membrane lipid composition, neural conduction and metabolic control in type 1 diabetic patients. Changes after a low-dose n-3 fatty acid dietary intervention

[Background]: A decreased content of n–3 fatty acids in erythrocyte membrane of type 1 diabetic patients, which is inversely related to plasma levels of HbA1c, has been reported previously. Our aim in this study was to observe the changes after a low-dose n–3 fatty acid (330 mg/day docosahexaenoic acid and 630 mg/day eicosapentanoic acid) dietary intervention in the lipid composition of cell membrane and metabolic control (measured according to plasma HbA1c levels). Since changes in both parameters may alter transmembrane sodium transport or influence parameters measuring target organ damage, we also studied the neural conduction quality and activity of four sodium transporters.[Methods]: Eighteen type 1 diabetic patients were randomly assigned to continue their usual diet (control group) or to supplement their diet with a daily low dose of n–3 fatty acids (supplemented group). The changes between baseline and end values of the following parameters were compared: HbA1c, lipid and phospholipid composition of cell membrane, activity of four ion carriers and neural conduction quality.[Results]: The dietary supplementation caused statistically significant changes in membrane lipid composition, particularly an increase of C22:6 (n–3) and the total n–3 fatty acid (respectively +0.90 ± 1.14% vs. –0.44 ± 1.23% and +1.36 ± 1.62% vs. –0.5 ± 1.80%, p < 0.05). After the dietary supplementation, we also observed a significant decrease of HbA1c (–2.00 ± 1.9% vs. –0.13 ± 0.48%, p < 0.05), without significant changes in the dose of insulin required, an increase in the motor conduction velocity by the median nerve (+2.12 ± 1.35 m/s vs. –0.8 ± 2.34 m/s, p < 0.05) and a decrease of the Vmax of the Na+-Li+ countertransport (–96.6 ± 111.2 vs. +58.1 ± 81.3 μmol/l cell/h–1, p < 0.01).[Conclusion]: A low-dose omega–3 fatty acid dietary supplementation may change the fatty acid composition of the cell membrane and improve the metabolic control of diabetes. Using this dose, we also observed a decrease of the maximal rate of Na+-Li+ countertransport and a slight improvement of neural conduction

Insights into structure-activity relationships of somatostatin analogs containing mesitylalanine

The non-natural amino acid mesitylalanine (2,4,6-trimethyl-L-phenylalanine; Msa) has an electron-richer and a more conformationally restricted side-chain than that of its natural phenylalanine counterpart. Taking these properties into account, we have synthesized ten somatostatin analogs containing Msa residues in different key positions to modify the intrinsic conformational flexibility of the natural hormone. We have measured the binding affinity of these analogs and correlated it with the main conformations they populate in solution. NMR and computational analysis revealed that analogs containing one Msa residue were conformationally more restricted than somatostatin under similar experimental conditions. Furthermore, we were able to characterize the presence of a hairpin at the pharmacophore region and a non-covalent interaction between aromatic residues 6 and 11. In all cases, the inclusion of a D-Trp in the eighth position further stabilized the main conformation. Some of these peptides bound selectively to one or two somatostatin receptors with similar or even higher affinity than the natural hormone. However, we also found that multiple incorporations of Msa residues increased the life span of the peptides in serum but with a loss of conformational rigidity and binding affinity

High frequency of endoluminal thrombus in patients with ischaemic stroke following AARS-CoV-2 infection

Background: Ischaemic stroke may be a major complication of SARS-CoV-2 infection. Studying and characterising the different aetiological subtypes, clinical characteristics, and functional outcomes may be valuable in guiding patient selection for optimal management and treatment. Methods: Data were collected retrospectively on consecutive patients with COVID-19 who developed acute focal brain ischaemia (between 1 March and 19 April 2020) at a tertiary university hospital in Madrid (Spain). Results: During the study period, 1594 patients were diagnosed with COVID-19. We found 22 patients with ischaemic stroke (1.38%), 6 of whom did not meet the inclusion criteria. The remaining 16 patients were included in the study (15 cases of ischaemic stroke and one case of transient ischaemic attack).Median baseline National Institutes of Health Stroke Scale score was 9 (interquartile range: 16), and mean (standard deviation) age was 73 years (12.8). Twelve patients (75%) were men. Mean time from COVID-19 symptom onset to stroke onset was 13 days. Large vessel occlusion was identified in 12 patients (75%).We detected elevated levels of D-dimer in 87.5% of patients and C-reactive protein in 81.2%. The main aetiology was atherothrombotic stroke (9 patients, 56.3%), with the predominant subtype being endoluminal thrombus (5 patients, 31.2%), involving the internal carotid artery in 4 cases and the aortic arch in one. The mortality rate in our series was 44% (7 of 16 patients). Conclusions: In patients with COVID-19, the most frequent stroke aetiology was atherothrombosis, with a high proportion of endoluminal thrombus (31.2% of patients). Our clinical and laboratory data support COVID-19–associated coagulopathy as a relevant pathophysiological mechanism for ischaemic stroke in these patients. Resumen: Introducción: El ictus isquémico puede ser una complicación grave en los pacientes con infección por SARS-CoV-2.Estudiar y caracterizar los diferentes subtipos etiológicos, las características clínicas y el pronóstico funcional podrá resultar útil en la selección de pacientes para un manejo y tratamiento óptimos. Métodos: La recogida de variables se hizo de forma retrospectiva en pacientes consecutivos con infección por COVID-19 que desarrollaron un episodio de isquemia cerebral focal (entre el 1 de Marzo 1, 2020, y el 19 de Abril, 2020). Se llevó a cabo en un hospital universitario de tercer nivel en la Comunidad de Madrid. (España). Resultados: Durante el período de estudio 1594 pacientes fueron diagnosticados de infección por COVID 19. Identificamos 22 pacientes con ictus isquémico (1.38%), de estos no cumplieron los criterios de inclusión 6. Un total de 16 pacientes con isquemia cerebral focal constituyeron la serie del estudio (15 con ictus isquémico y 1 con accidente isquémico transitorio).En la valoración basal en el National Institutes of Health Stroke Scale (NIHSS) la mediana fue de 9 (Rango Intercuartil RIQ: 16), la edad media fue de 73 años (DE ± 12.8). 12 pacientes fueros varones (75%). El tiempo desde los síntomas de COVID-19 hasta el ictus fue de 13 días. Se encontró oclusión de gran vaso en 12 pacientes (75%).El dímero –D estuvo elevado en el 87.5% y la proteína C reactiva en el 81.2% de los casos. La etiología más frecuente del ictus isquémico fue la aterotrombosis (9 pacientes, 56.3%) con un subtipo predominante que fue el trombo endoluminal sobre placa de ateroma (5 pacientes, 31.2%), 4 de ellos en la arteria carótida interna y uno de ellos en el arco aórtico. La mortalidad en nuestra serie fue del 44% (7 de 16 pacientes). Conclusiones: En los pacientes con ictus y COVID-19 la etiología más frecuente fue la aterotrombótica con una elevada frecuencia de trombo endoluminal sobre placa de ateroma (31.2% de los pacientes). Nuestros hallazgos clínicos y de laboratorio apoyan la coagulopatía asociada a COVID-19 como un mecanismo etiopatogénico relevante en el ictus isquémico en este contexto