Clinical profile and prognosis of patients with posterior circulation stroke

Background: Posterior circulation stroke is less common than stroke involving the anterior circulation. An understanding of the Posterior circulation stroke phenomenology and mechanisms requires knowledge of neurovascular anatomy and of the structure-function relationships of this region of the brain. Identifying mechanisms of stroke is essential so that appropriate preventive therapies may be instituted.Methods: A prospective study was conducted over a period of 1 year after obtaining permission from institutional ethics committee. Recently diagnosed cases of posterior circulation stroke from medicine and neurology wards were enrolled, who fulfilled inclusion criteria.Results: Most common age for posterior circulation stroke in this study was 41-70 years of age with median age of 56.5 years. It is more common in males (55%) than females (45%). Ischemic posterior circulation stroke is more common (63.15%) than haemorrhagic posterior circulation stroke (36.85%). Most common presenting feature of posterior circulation was ataxia (77.3%). Most common risk factor for posterior circulation stroke was hypertension (60.5%) followed by dyslipidemia (55.26%). Most common site of involvement in ischemic posterior circulation stroke was cerebellum (37.5%) followed by occipital lobe (24%). Commonest site of bleed found was cerebellum (64.4%) followed by pons (35.6%). Mortality in posterior circulation stroke in present study was 15.78%.Conclusions: Posterior circulation stroke present with a wide variety of symptoms. Episodes are often staggering and more protracted than those of anterior circulation stroke. Further studies are needed to determine the safest and most effective treatment modalities for the various types of posterior circulation stroke

Study of etiology, clinical profile and predictive factors of spontaneous bacterial peritonitis in cirrhosis of liver

Background: Spontaneous bacterial peritonitis (SBP) is one of the potentially lethal complication of liver cirrhosis and is defined as infected ascites in the absence of any recognizable secondary cause of infection. Majority of the SBP cases are caused by organism from the gastrointestinal tract mainly aerobic gram-negative organisms- Escherichia coli being the most common etiological agent.Methods: It was a prospective observational study done over a period of 1 year in a tertiary care hospital. 50 patients from medical and gastroenterology wards were included in the study. Patients above 12 year of age with diagnosed cirrhosis of liver and documented evidence of SBP were included. Pregnant females, patients who refused to give consent, patients with a documented evidence of intra-abdominal source of infection or patients with ascitis due to non-hepatic causes were excluded.Results: The high serum bilirubin and creatinine levels were associated with higher mortality rate. Hepatic encephalopathy is associated with worse outcome. The outcome of the patient in relation to the grades of ascitis, liver enzymes, prothrombin time, international normalised ratio (INR), Child pugh grades, ascitic fluid polymorphonuclear leucocyte count, ascitic fluid culture and blood culture were not statistically significant.Conclusions: A high index of suspicion should exist for SBP in patients with cirrhosis and ascitis. Serum creatinine and bilirubin levels are strong predictors of mortality. Hepatic encephalopathy has a strong association with mortality in patients with spontaneous bacterial peritonitis

Central nervous system tuberculomata presenting as internuclear ophthalmoplegia

Central nervous system (CNS) tuberculoma can have variable presentation depending upon the site and number of tuberculomata. We are reporting a rare case of a 15 years old girl who presented to our hospital with binocular diplopia on right gaze. Clinical examination revealed left sided internuclear ophthalmoplegia and dysdiadochokinesia and ataxia on left side. Magnetic Resonance Imaging (MRI) of brain revealed multiple tuberculomata in both cerebral hemispheres, cerebellum, left half of medulla and pons. This case highlights the need for a high degree of suspicion for CNS tuberculosis in patients presenting with internuclear ophthalmoplegia.KEYWORDS: Brainstem; Tuberculoma; Internuclear; Ophthalmoplegia; SyndromeontInternet Journal of Medical Update 2012 January;7(1):59-6

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline