Prevalence, correlates, and prognosis of peripheral artery disease in rural ecuador-rationale, protocol, and phase I results of a population-based survey: an atahualpa project-ancillary study

Background. Little is known on the prevalence of peripheral artery disease (PAD) in developing countries. Study design. Population-based study in Atahualpa. In Phase I, the Edinburgh claudication questionnaire (ECQ) was used for detection of suspected symptomatic PAD; persons with a negative ECQ but a pulse pressure ≥65 mmHg were suspected of asymptomatic PAD. In Phase II, the ankle-brachial index will be used to test reliability of screening instruments and to determine PAD prevalence. In Phase III, participants will be followed up to estimate the relevance of PAD as a predictor of vascular outcomes. Results. During Phase I, 665 Atahualpa residents aged ≥40 years were enrolled (mean age: 59.5 ± 12.6 years, 58% women). A poor cardiovascular health status was noticed in 464 (70%) persons of which 27 (4%) had a stroke and 14 (2%) had ischemic heart disease. Forty-four subjects (7%) had suspected symptomatic PAD and 170 (26%) had suspected asymptomatic PAD. Individuals with suspected PAD were older, more often women, and had a worse cardiovascular profile than those with nonsuspected PAD. Conclusions. Prevalence of suspected PAD in this underserved population is high. Subsequent phases of this study will determine whether prompt detection of PAD is useful to reduce the incidence of catastrophic vascular diseases in the region

Predictors of Recurrent Stroke After Embolic Stroke of Undetermined Source in the RE‐SPECT ESUS Trial

Risk factors; Secondary prevention; Stroke predictorsFactores de riesgo; Prevención secundaria; Predictores de accidentes cerebrovascularesFactors de risc; Prevenció secundària; Predictors d'accidents cerebrovascularsBackground We sought to determine recurrent stroke predictors among patients with embolic strokes of undetermined source (ESUS). Methods and Results We applied Cox proportional hazards models to identify clinical features associated with recurrent stroke among participants enrolled in RE‐SPECT ESUS (Randomized, Double‐Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) trial, an international clinical trial evaluating dabigatran versus aspirin for patients with ESUS. During a median follow‐up of 19 months, 384 of 5390 participants had recurrent stroke (annual rate, 4.5%). Multivariable models revealed that stroke or transient ischemic attack before the index event (hazard ratio [HR], 2.27 [95% CI, 1.83–2.82]), creatinine clearance <50 mL/min (HR, 1.69 [95% CI, 1.23–2.32]), male sex (HR, 1.60 [95% CI, 1.27–2.02]), and CHA2DS2‐VASc ≥4 (HR, 1.55 [95% CI, 1.15–2.08] and HR, 1.66 [95% CI, 1.21–2.26] for scores of 4 and ≥5, respectively) versus CHA2DS2‐VASc of 2 to 3, were independent predictors for recurrent stroke. Conclusions In RE‐SPECT ESUS trial, expected risk factors previously linked to other common stroke causes were associated with stroke recurrence. These data help define high‐risk groups for subsequent stroke that may be useful for clinicians and for researchers designing trials among patients with ESUS.This study was supported by Boehringer Ingelheim

Changing pattern of neurocysticercosis in an urban endemic center (Guayaquil, Ecuador)

Objective: To confirm recent evidence suggesting a change in the pattern of disease expression of neurocysticercosis, manifested by a decreasing number of severe and recent infections. Methods: Retrospective cohort of 246 neurocysticercosis patients residing in Guayaquil, evaluated over 20 years (1990 to 2009). Eighty-seven patients were seen from 1990 to 1994, 58 from 1995 to 1999, 57 from 2000 to 2004, and 44 from 2005 to 2009. Neurocysticercosis was classified as active or inactive according to neuroimaging findings. Patients with parenchymal, subarachnoid or ventricular cystic lesions were considered to have active disease, and those with calcifications and chronic arachnoiditis were classified as inactive. Results: Mean age was 36.6 +/- 20 years, and 61% were women. The relative prevalence of active and inactive cases varied according to the year of evaluation. Active neurocysticercosis was found in 63% of patients seen between 1990 and 1994, in 48% between 1995 and 1999, in 47% between 2000 and 2004, and in only 18% between 2005 and 2009 (p<0.0001). Together with reduction of active cases, there was an increased prevalence of asymptomatic infections over the years (from 17.2% between 1990 and 1994 to 54.5% between 2005 and 2009; p<0.0001). Conclusion: In this single-center cohort, the relative prevalence of active cases of neurocysticercosis reduced over the past years, suggesting a decreased incidence of new infections. Improved sanitation together with widespread use of cysticidal drugs were the most likely causes of these findings. (c) 2011 Elsevier B.V. All rights reserved

Isolated brainstem cysticercosis: A review

Review of patients with isolated brainstem cysticercus to outline the features of this form of neurocysticercosis. MEDLINE and manual search of patients with isolated brainstem cysticercus. Abstracted data included: demographic profile, clinical manifestations, neuroimaging findings, evolutive stage of parasites neurocysticercosis, therapy, and follow-up. Twenty-nine patients were reviewed. Of these, 22 (76%) came from India. Mean age was 31 years, and 72% were men. Parasites were located in midbrain (16 patients), pons (12 patients), and medulla (one patient). All but three lesions were less than 10mm in diameter and most were at or near the midline. Most common clinical forms of presentation were isolated paresis of the third cranial nerve, internuclear ophthalmoplegia, and crossed brainstem syndromes. Neuroimaging studies showed colloidal cysticercus in 24 patients, vesicular cysts in four, and a calcification in one. Fourteen patients received cysticidal drugs, eight were treated with steroids alone, and three received no therapy at all. The remaining four patients underwent surgical resection of the lesion. Twenty-seven patients recovered completely and the remaining two were left with mild sequelae. Control neuroimaging studies showed complete or partial resolution of the lesion in the 18 patients in whom they were performed. Isolated brainstem cysticercosis is rare. Clinical and neuroimaging findings on admission allowed a correct differentiation of this condition from other space-occupying lesions of the brainstem (tuberculomas, abscesses, gliomas) in most patients. The prognosis is benign provided the patients receive prompt therapy

Characteristics of 478 very old neurologic outpatients evaluated over 20 years in Guayaquil, Ecuador

There is scarce information on the diseases affecting very old neurologic outpatients in the developing world. We evaluated 478 neurologic outpatients aged 80 years or more over a 20-year period, to analyze data concerning reason for consultation, diagnosis and follow-up. The mean age was 83.9 +/- A 3.8 years, and 59% were women. Most common reasons for consultation were cognitive decline (24.7%), focal deficits (22.8%) and movement disorders (19.7%). Common categories of neurologic diseases included cerebrovascular (27.4%), degenerative (27.2%) and diseases of uncertain/unknown etiology (20.5%). We found significant variations in the reasons for consultation and in the prevalence of some neurologic diseases according to the year in which patients were evaluated. During the past few years, cognitive decline outnumbered patients with focal neurologic deficits and movement disorders. From 1990 to 1994, degenerative diseases accounted for only 14.5% of our patients, but from 2005 on, these conditions were responsible for 33.9% of the cases. When analyzing pre-existing conditions and diseases occurring at follow-up, we identified a subset of older patients who developed stroke and Alzheimer's disease/mild cognitive impairment. There was a dynamic pattern of neurologic diseases over the years, with significant variations in the reason for consultation and the category of disease. Nowadays, distribution of neurologic symptoms and diseases in our population of very old neurologic patients is more similar to that reported from the developed world than it was 20 years ago

Is the rate of cerebral hemorrhages declining among stroke patients in South America?

Recent stroke registries suggest that the rate of cerebral hemorrhages is declining among stroke patients in South America. High rates of cerebral hemorrhages (approaching 40% of stroke cases) reported in pioneer registries during the 1990s have not been duplicated in more recent studies. In contrast, almost all studies recruiting patients from 2003 on, reported less than 20% of cerebral hemorrhages among their stroke patients. Intermediate rates of hemorrhagic strokes (from 25% to 27%) were noted among registries recruiting patients by the end of the 20th century and the start of the new Millennium. We also noted a significant declining rate of hemorrhagic stroke over the past 20 years at our Institution. In a series of 651 consecutive first-ever stroke patients included in the Hospital-Clínica Kennedy stroke registry (Guayaquil), cerebral hemorrhages accounted for 26·3% of patients recruited between 1990 and 1994 but for only 16·5% of those seen between 2005 and 2009 (P = 0·03). More longitudinal studies are needed to confirm these findings and to determine whether the reported declining rate of hemorrhagic strokes in South America is related to increase life expectancy of the population, or to changes in lifestyle, dietary habits, or some other specific stroke risk factors not well evaluated so far

Movement Disorders Among Adult Neurological Outpatients Evaluated over 20 Years in Guayaquil, Ecuador

There is little information available on the evolutive pattern of patients with movement disorders in developing countries. We analyzed 579 consecutive adults with movement disorders and prospectively evaluated them at our institution (Department of Neurological Sciences, Kennedy Clinic, Guayaquil, Ecuador) from 1990 to 2009. Mean age was 62.9±17.5 years, and 50.8% were men. Patients presented with tremor/rigidity (55%), involuntary movements (23.5%) and abnormalities of stance and gait (21.5%). Overall, 45% of our patients had degenerative disorders of the nervous system. We found significant increases in the relative prevalence of tremor/rigidity and abnormalities of stance and gait, and this reflected an increase in the number of patients with degenerative diseases over the study years. We found a dynamic pattern of movement disorders over the years. Today, causes and relative prevalence of these conditions in our population is more similar to that reported from the developed world than it was 20 years ago

Reduced percentage of neurocysticercosis cases among patients with late-onset epilepsy in the new millennium

Objective: To determine if the number of neurocysticercosis cases among patients with late-onset epilepsy has decreased over the past two decades. Design: Retrospective cohort study of 431 consecutive patients with recurrent seizures starting after the age of 20 years evaluated at our Institution from 1990 to 2009. Methods: Patients were classified according to the year in which they were first seen. Group I included 129 patients evaluated between 1990 and 1994, Group II included 108 patients evaluated between 1995 and 1999, Group III included 106 patients evaluated between 2000 and 2004. and Group IV included 88 patients evaluated between 2005 and 2009. We correlated the percentage of persons with cryptogenic and symptomatic epilepsy between the groups to determine if there was any change in the causes of late-onset epilepsy. Results: One hundred seventy-one patients had cryptogenic and 260 had symptomatic epilepsy. Common causes of symptomatic epilepsy were neurocysticercosis in 120 cases, cerebrovascular disease in 68, and brain tumors in 40. We found a reduction in the number of patients with symptomatic epilepsy (p = 0.0007) as well as a reduction in the number of neurocysticercosis cases (p = 0.0004) over the study years. There was a reduction in the weight of neurocysticercosis as an etiological factor for symptomatic late-onset epilepsy related to a drop in the number of patients with this condition evaluated between 2005 and 2009 (p = 0.0045). Conclusion: The number of neurocysticercosis cases among patients with late-onset epilepsy has changed over the years. This parasitic disease is no longer the most common cause of symptomatic late-onset epilepsy in our population. (c) 2012 Elsevier B.V. All rights reserved