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Cerebral microbleeds (CMBs) may contribute to cognitive deficits in stroke. Cognitive impairment that does not meet the criteria for dementia (cognitive impairment no dementia [CIND]) is common in stroke, and patients with such impairment can revert to normal cognition.
Objective
To investigate the association of CMBs and remission of poststroke CIND.
Aim
To understand the evolution of poststroke cognitive impairment no dementia (CIND) is bi-directional.
Methods
143 patients with CIND at three months after stroke were recruited and followed up for one year. Remission of CIND was defined as a conversion of cognitive status from CIND to cognitively intact at follow-up. MRI variables in terms of infarction, cerebral microbleeds (CMBs), and white matter hyperintensities (WMHs) and hippocampal volume were analyzed. Logistic regression was performed to find the predictors of the remission of poststroke CIND.
Results
30 (21.0%) out of the 143 patients converted to cognitive intact at follow-up. In univariate comparisons, subjects with remission of CIND had younger age (67.1 ± 9.5 vs.73.6 ± 7.6 years, p < 0.001) and higher education years (5.1 ± 4.0 vs.3.6 ± 4.0, p = 0.039). They also had lower WMHs volume (8.2 ± 8.2 vs. 18.6 ± 19.7 cm3, p < 0.001), lower frequency of CMBs (10.0% vs. 31.0%, p = 0.021) and lower volume of the lateral ventricle (33.3 ± 16.5 vs.42.6 ± 19.4 cm3, p = 0.017). In logistic regression, age (odds ratio [OR] = 0.913, 95%C.I. = 0.866–0.962, p = 0.001) and absence of CMBs (OR = 4.292, 95%C.I. = 1.174–15.625, p = 0.028) were significant predictors of remission of CIND.
Conclusions
Younger age and absence of CMBs predict the remission of poststroke CIND.
Longitudinal studies of predicting dementia conversion of poststroke cognitive impairment no dementia (CIND) are limited.
Objective
To investigate the clinical and imaging predictors of dementia conversion in poststroke patients with CIND.
Aim
To understand dementia conversion of CIND.
Methods
143 patients with CIND (defined as impairment in at least one cognitive domain without meeting the criteria of dementia) at three months after stroke were recruited and followed up for one year. Dementia was diagnosed using the criteria of Diagnostic and Statistical Manual of Mental Disorders (4th edition, DSM-IV). MRI measurements including infarction, microbleeds, white matter hyperintensities (WMHs) and hippocampal volume were conducted. Logistic regression was performed to find the predictors of dementia at follow-up.
Results
16 (11.2%) out of the 143 patients developed dementia 15 months after stroke. In univariate comparisons, subjects with dementia at follow-up had older age (78.0 ± 5.3 vs.71.5 ± 8.5 years, p = 0.003) and higher NIHSS score (7.1 ± 3.5 vs.4.7 ± 3.3, p = 0.005) on admission. They also had higher frequency of old infarcts in the thalamus (31.3% vs. 11.0%, p = 0.025), larger volume of old infarcts (4.2 ± 11.2 vs. 0.7 ± 2.6 cm3, p < 0.001) and WMHs volume (33.2 ± 34.0 vs. 14.2 ± 14.1 cm3, p = 0.016). In logistic regression, age (odds ratio [OR] =1.203, 95%C.I.=1.054-1.373, p = 0.006), NIHSS score on admission (OR = 1.324, 95%C.I.=1.082-1.619, p = 0.006) and WMHs volume (OR = 1.045, 95%C.I.=1.007-1.084, p = 0.019) were significant predictors of dementia at follow-up.
Conclusions
WMHs volume predicts dementia in poststroke patients with CIND, suggesting subcortical ischemic vascular disease was an important origin of poststroke delayed dementia.
Prefrontal cortex and sex difference are involved in verbal fluency network described in normal participants. Stroke patients often have prefrontal cortex atrophy.
Objectives
To investigate whether atrophy in subdivisions of prefrontal cortex and sex difference contribute to verbal fluency in non-aphasic stroke patients.
Aim
To understand the relationship between the atrophy of left dorsolateral prefrontal cortex and verbal performance in elderly poststroke women.
Methods
30 elderly (age> = 60 years old) women with non-aphasic ischemic stroke and 30 age-controlled stroke men recruited. Automatic segmentation methods were used to assess the volume of both sides of the whole prefrontal cortex, anterior cingulate cortex, orbital frontal cortex and dorsalateral prefrontal cortex (DLPFC), as well as white matter lesions (WMLs) volume. Mini-mental state examination (MMSE) and semantic verbal fluency test (VFT, category: foods and animals) were administered at 3 and 15 months after the index stroke.
Results
The mean (s.d) age was 73.3 ± 7.2 in women and 72.1 ± 6.9 in men. Men had higher education years, less diabetes and higher MMSE scores (p < 0.05). At 3 months after stroke, volume of the left DLPFC was significantly correlated with VFT score in women rather than men, even after controlled by age, education years, neurological deficit, diabetes, WMLs volume and infarct location (partial r = 0.477, p = 0.018). At 15 months, this correlation remained significant (partial r = 0.548, p = 0.006) in women.
Conclusion
Sex difference may be present in the neuropsychological mechanism of verbal fluency impairment in patients with cerebrovascular disease.
To report an outbreak of measles with epidemiological link between Hong Kong International Airport (HKIA) and a hospital.
Methods:
Epidemiological investigations, patients’ measles serology, and phylogenetic analysis of the hemagglutinin (H) and nucleoprotein (N) genes of measles virus isolates were conducted.
Results:
In total, 29 HKIA staff of diverse ranks and working locations were infected with measles within 1 month. Significantly fewer affected staff had history of travel than non–HKIA-related measles patients [10 of 29 (34.5%) vs 28 of 35 (80%); P < .01]. Of 9 airport staff who could recall detailed exposure history, 6 (66.7%) had visited self-service food premises at HKIA during the incubation period, where food trays, as observed during the epidemiological field investigation, were not washed after use. Furthermore, 1 airport baggage handler who was admitted to hospital A before rash onset infected 2 healthcare workers (HCWs) known to have 2 doses of MMR vaccination with positive measles IgG and lower viral loads in respiratory specimens. Infections in these 2 HCWs warranted contact tracing of another 168 persons (97 patients and 71 HCWs). Phylogenetic comparison of H and N gene sequences confirmed the clonality of outbreak strains.
Conclusion:
Despite good herd immunity with overall seroprevalence of >95% against measles, major outbreaks of measles occurred among HKIA staff having daily contact with many international pssengers. Lessons from severe acute respiratory syndrome (SARS) and measles outbreaks suggested that an airport can be a strategic epidemic center. Pre-exanthem transmission of measles from airport staff to HCWs with secondary vaccine failure poses a grave challenge to hospital infection control.
To assess the association of diagnostic predictors available in the emergency department (ED) with the outcome diagnosis of severe acute respiratory syndrome (SARS).
Methods:
This retrospective cohort study describes all patients from the Amoy Garden complex who presented to an ED SARS screening clinic during a 2-month outbreak. Clinical and diagnostic predictors were recorded, along with ED diagnoses. Final diagnoses were established independently based on diagnostic tests performed after the ED visit. Associations of key predictors with the final diagnosis of SARS were described.
Results:
Of 821 patients, 205 had confirmed SARS, 35 undetermined SARS and 581 non-SARS. Multivariable logistic regression showed that the strongest predictors of SARS were abnormal chest x-ray (odds ratio [OR] = 17.4), subjective fever (OR = 9.7), temperature >38°C (OR = 6.4), myalgias (OR = 5.5), chills and rigors (OR = 4.0) and contact exposure (OR = 2.6). In a subset of 176 patients who had a complete blood cell count performed, the strongest predictors were temperature ≥38ºC (OR = 15.5), lymphocyte count <1000 (OR = 9.3) and abnormal chest x-ray (OR = 5.7). Diarrhea was a powerful negative predictor (OR = 0.03) of SARS.
Conclusions:
Two components of the World Health Organization case definition — fever and contact exposure — are helpful for ED decision-making, but respiratory symptoms do not discriminate well between SARS and non-SARS. Emergency physicians should consider the presence of diarrhea, chest x-ray findings, the absolute lymphocyte count and the platelet count as significant modifiers of disease likelihood. Prospective validation of these findings in other clinical settings is desirable.
To compare the diagnostic accuracy of emergency department (ED) physicians with the World Health Organization (WHO) case definition in a large community-based SARS (severe acute respiratory syndrome) cohort.
Methods:
This was a cohort study of all patients from Hong Kong’s Amoy Garden complex who presented to an ED SARS screening clinic during a 2-month outbreak. Clinical findings and WHO case definition criteria were recorded, along with ED diagnoses. Final diagnoses were established independently based on relevant diagnostic tests performed after the ED visit. Emergency physician diagnostic accuracy was compared with that of the WHO SARS case definition. Sensitivity, specificity, predictive values and likelihood ratios were calculated using standard formulae.
Results:
During the study period, 818 patients presented with SARS-like symptoms, including 205 confirmed SARS, 35 undetermined SARS and 578 non-SARS. Sensitivity, specificity and accuracy were 91%, 96% and 94% for ED clinical diagnosis, versus 42%, 86% and 75% for the WHO case definition. Positive likelihood ratios (LR+) were 21.1 for physician judgement and 3.1 for the WHO criteria. Negative likelihood ratios (LR–) were 0.10 for physician judgement and 0.67 for the WHO criteria, indicating that clinician judgement was a much more powerful predictor than the WHO criteria.
Conclusions:
Physician clinical judgement was more accurate than the WHO case definition. Reliance on the WHO case definition as a SARS screening tool may lead to an unacceptable rate of misdiagnosis. The SARS case definition must be revised if it is to be used as a screening tool in emergency departments and primary care settings.
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