Particularităţi clinico-evolutive ale miasteniei gravis

Myasthenia Gravis (MG) is an autoimmune disorder, which affects acute or chronic neuromuscular junction. The disease is clinically manifested with muscular fatigability and motor weakness of affected segments, frequently delayed diagnosis explained by unpredictable evolution, like long term recoveries or myasthenic crisis with respiratory failure requiring assisted ventilation. It was performed a retrospective study on 28 cases of MG, to assess the clinical-evolutive aspects of the disease

Miastenia gravis: protocol clinic naţional PCN-285

Catedra Neurologie, USMF „Nicolae Testemiţanu”, Laboratorul Vertebroneurologie, IMSP Institutul de Neurologie şi NeurochirurgieAcest protocol clinic naţional a fost elaborat de grupul de lucru al Ministerului Sănătăţii al Republicii Moldova (MS RM), constituit din specialiştii IMSP Institutului de Neurologie şi Neurochirurgie şi Universităţii de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”. Protocolul clinic naţional este elaborat în conformitate cu ghidurile clinice internaţionale actuale privind miastenia gravis şi va servi drept bază pentru elaborarea protocoalelor instituţionale (extras din protocolul clinic naţional aferent pentru instituţia dată, fără schimbarea structurii, numerotaţiei capitolelor, tabelelor, figurilor, casetelor etc.) în baza posibilităţilor reale ale fiecărei instituţii în anul curent. La recomandarea MS RM pentru monitorizarea protocoalelor instituţionale pot fi folosite formulare suplimentare, care nu sunt incluse în protocolul clinic naţional

Tratamentul farmacologic al dependenţei de opiacee: protocol clinic naţional (ediția III) PCN - 225

Acest protocol a fost elaborat de către grupul de lucru al Ministerului Sănătăţii, Catedrei de psihiatrie, narcologie şi psihologie medicală, USMF „Nicolae Testemiţanu”, IMSP Dispensarul Republican de Narcologie, în colaborare cu organizaţiile internaționale și naționale active în domeniu. PCN este elaborat în conformitate cu ghidurile clinice internaţionale actuale privind dependența prin consum de opiacee la persoanele adulte şi va servi drept bază pentru elaborarea protocoalelor instituţionale, în funcție de posibilitățile reale ale fiecărei instituții. La recomandarea Ministerului Sănătăţii pentru monitorizarea protocoalelor instituţionale pot fi folosite formulare suplimentare, care nu sunt incluse în PCN. PCN a fost consultat în cadrul grupului de lucru pe Îmbunătățirea tratamentului farmacologic al dependenței de opiacee. Elaborarea PCN s-a efectuat de către grupul de lucru cu participarea experţilor Agenției Națiunilor Unite pentru Combaterea Drogurilor și Criminalității (UNODC) în Moldova, precum şi specialiştilor din cadrul Organizaţiei Mondiale a Sănătăţii (OMS) și Agenția ONU pentru HIV/SIDA (UNAIDS)

Tulburări mentale şi de comportament legate de consumul de alcool: protocol clinic naţional PCN-20

IMSP Dispensarul Republican de Narcologie, USMF „Nicolae Testemițanu”Acest protocol a fost elaborat de grupul de lucru al Ministerului Sănătăţii, constituit din reprezentanţii IMSP Dispensarul Republican de Narcologie, catedra Psihiatrie, Narcologie şi Psihologie Medicală și Școala de Management în Sănătatea Publică a USMF „Nicolae Testemiţeanu”. Protocolul naţional este elaborat în conformitate cu ghidurile internaţionale actuale privind alcoolismul cronic la persoanele adulte şi poate servi drept bază pentru elaborarea protocoalelor instituţionale, reieşind din posibilităţile reale ale fiecărei instituţii . La recomandarea Ministerului Sănătăţii pentru monitorizarea protocoalelor instituţionale pot fi folosite formulare suplimentare, care nu sunt incluse în protocolul clinic naţional

Complicating autoimmune diseases in myasthenia gravis: A review

Myasthenia gravis (MG) is a rare autoimmune disease of skeletal muscle endplates. MG subgroup is relevant for comorbidity, but usually not accounted for. MG patients have an increased risk for complicating autoimmune diseases, most commonly autoimmune thyroid disease, systemic lupus erythematosus and rheumatoid arthritis. In this review, we present concomitant autoimmune disorders associated with the different MG subgroups, and show how this influences treatment and prognosis. Concomitant MG should always be considered in patients with an autoimmune disorder and developing new neuromuscular weakness, fatigue or respiratory failure. When a second autoimmune disorder is suspected, MG should be included as a differential diagnosis

Age dependency of ischaemic stroke subtypes and vascular risk factors in western Norway: The Bergen Norwegian Stroke Cooperation Study

Objectives: Age dependency of acute ischaemic stroke aetiology and vascular risk factors have not been adequately evaluated in stroke patients in Norway. Aims of this study were to evaluate how stroke subtypes and vascular risk factors vary with age in a western Norway stroke population. Materials and methods: Patients aged 15–100 years consecutively admitted to our neurovascular centre with acute ischaemic stroke between 2006 and 2012 were included. The study population was categorized as young (15–49 years), middle-aged (50–74 years) or elderly (≥75 years). Stroke aetiology was defined by TOAST criteria. Risk factors and history of cardiovascular disease were recorded. Results: In total, 2484 patients with acute cerebral infarction were included: 1418 were males (57.3%). Mean age was 70.8 years (SD ± 14.9), 228 patients were young, 1126 middle-aged, and 1130 were elderly. The proportion of large-artery atherosclerosis and of small-vessel occlusion was highest among middle-aged patients. The proportion of cardioembolism was high at all ages, especially among the elderly. The proportion of stroke of other determined cause was highest among young patients. Some risk factors (diabetes mellitus, active smoking, angina pectoris, prior stroke and peripheral artery disease) decreased among the elderly. The proportions of several potential causes increased with age. Conclusion: The proportion of stroke subtypes and vascular risk factors are age dependent. Age 50–74 years constitutes the period in life where cardiovascular risk factors become manifest and stroke subtypes change

Early neurological worsening in acute ischaemic stroke patients

Objectives: Neurological worsening in acute ischaemic stroke patients is common with significant morbidity and mortality. Aims: To determine the factors associated with early neurological worsening within the first 9 h after onset of acute ischaemic stroke. Materials & methods: The National Institute of Health Stroke Scale (NIHSS) was used to assess stroke severity. Early neurological worsening was defined as NIHSS score increase ≥4 NIHSS points within 9 h of symptom onset compared to NIHSS score within 3 h of symptom onset. Patients with early neurological worsening were compared to patients with unchanged or improved NIHSS scores. Results: Of the 2484 patients admitted with ischaemic stroke, 552 patients had NIHSS score within 3 h of symptom onset, and 44 (8.0%) experienced early neurological worsening. The median NIHSS on admission was 8.4 in both groups. Early neurological worsening was associated with low body temperature on admission (P = 0.01), proximal compared to distal MCA occlusion (P = 0.007) and with ipsilateral internal carotid artery stenosis >50% or occlusion (P = 0.04). Early neurological worsening was associated with higher NIHSS day 7 (P < 0.001) and higher mortality within 7 days of stroke onset (P = 0.005). Conclusions: Early neurological worsening has serious consequences for the short-term outcome for patients with acute ischaemic stroke and is associated with low body temperature on admission, and with extracranially and intracranially large-vessel stenosis or occlusion

A pragmatic approach to sonothrombolysis in acute ischaemic stroke: The Norwegian randomised controlled sonothrombolysis in acute stroke study (NOR-SASS)

Background: Ultrasound accelerates thrombolysis with tPA (sonothrombolysis). Ultrasound in the absence of tPA also accelerates clot break-up (sonolysis). Adding intravenous gaseous microbubbles may potentiate the effect of ultrasound in both sonothrombolysis and sonolysis. The Norwegian Sonothrombolysis in Acute Stroke Study aims in a pragmatic approach to assess the effect and safety of contrast enhanced ultrasound treatment in unselected acute ischaemic stroke patients. Methods/Design: Acute ischaemic stroke patients ≥18 years, with or without visible arterial occlusion on computed tomography angiography (CTA) and treatable ≤ 4½ hours after symptom onset, are included in NOR-SASS. NOR-SASS is superimposed on a separate trial randomising patients with acute ischemic stroke to either tenecteplase or alteplase (The Norwegian Tenecteplase Stroke Trial NOR-TEST). The NOR-SASS trial has two arms: 1) the thrombolysis-arms (NOR-SASS A and B) includes patients given intravenous thrombolysis (tenecteplase or alteplase), and 2) the no-thrombolysis-arm (NOR-SASS C) includes patients with contraindications to thrombolysis. First step randomisation of NOR-SASS A is embedded in NOR-TEST as a 1:1 randomisation to either tenecteplase or alteplase. Second step NOR-SASS randomisation is 1:1 to either contrast enhanced sonothrombolysis (CEST) or sham CEST. Randomisation in NOR-SASS B (routine alteplase group) is 1:1 to either CEST or sham CEST. Randomisation of NOR-SASS C is 1:1 to either contrast enhanced sonolysis (CES) or sham CES. Ultrasound is given for one hour using a 2-MHz pulsed-wave diagnostic ultrasound probe. Microbubble contrast (SonoVue®) is given as a continuous infusion for ~30 min. Recanalisation is assessed at 60 min after start of CEST/CES. Magnetic resonance imaging and angiography is performed after 24 h of stroke onset. Primary study endpoints are 1) major neurological improvement measured with NIHSS score at 24 h and 2) favourable functional outcome defined as mRS 0–1 at 90 days. Discussion: NOR-SASS is the first randomised controlled trial designed to test the superiority of contrast enhanced ultrasound treatment given ≤4½ hours after stroke onset in an unselected acute ischaemic stroke population eligible or not eligible for intravenous thrombolysis, with or without a defined arterial occlusion on CTA. If a positive effect and safety can be proven, contrast enhanced ultrasound treatment will be an option for all acute ischaemic stroke patients. EudraCT No 201200032341; www.​clinicaltrials.​gov NCT01949961

The Norwegian tenecteplase stroke trial (NOR-TEST): randomised controlled trial of tenecteplase vs. alteplase in acute ischaemic stroke

Background: Alteplase is the only approved thrombolytic agent for acute ischaemic stroke. The overall benefit from alteplase is substantial, but some evidence indicates that alteplase also has negative effects on the ischaemic brain. Tenecteplase may be more effective and less harmfull than alteplase, but large randomised controlled phase 3 trials are lacking. The Norwegian Tenecteplase Stroke Trial (NOR-TEST) aims to compare efficacy and safety of tenecteplase vs. alteplase. Methods/Design: NOR-TEST is a multi-centre PROBE (prospective randomised, open-label, blinded endpoint) trial designed to establish superiority of tenecteplase 0.4 mg/kg (single bolus) as compared with alteplase 0.9 mg/kg (10% bolus + 90% infusion/60 minutes) for consecutively admitted patients with acute ischaemic stroke eligible for thrombolytic therapy, i.e. patients a) admitted <4½ hours after symptoms onset; b) admitted <4½ hours after awakening with stroke symptoms c) receiving bridging therapy before embolectomy. Randomisation tenecteplase:alteplase is 1:1. The primary study endpoint is favourable functional outcome defined as modified Rankin Scale 0–1 at 90 days. Secondary study endpoints are: 1) haemorrhagic transformation (haemorrhagic infarct/haematoma); 2) symptomatic cerebral haemorrhage on CT 24–48 hours; 3) major neurological improvement at 24 hours; 4) recanalisation at 24–36 hours; 5) death. Discussion: NOR-TEST may establish a novel approach to acute ischaemic stroke treatment. A positive result will lead to a more effective, safer and easier treatment for all acute ischaemic stroke pasients. NOR-TEST is reviewed and approved by the Regional Committee for Medical and Health Research Ethics (2011/2435), and The Norwegian Medicines Agency (12/01402). NOR-TEST is registered with EudraCT No 2011-005793-33 and in ClinicalTrials.gov (NCT01949948)