Abstract in English:

Abstract Background In recent years, there has been growing interest in applying quality improvement methodologies to healthcare processes. One such approach is the Find, Organize, Clarify, Understand, Select-Plan, Do, Check, and Act (FOCUS-PDCA) cycle. Objective To evaluate the effectiveness of the FOCUS-PDCA cycle in the management of dysphagia in patients with cerebral infarction. Methods We conducted a comprehensive literature search on the PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, and Wanfang databases for articles published up to October 31st, 2024, following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Randomized controlled trials and high-quality retrospective studies comparing the FOCUS-PDCA cycle with conventional care were included. The primary outcomes were swallowing function, quality of life, neurological and limb functions, and complication rates. Data were pooled using random-effects models, and heterogeneity was assessed using the I2 statistic. Results We included 6 studies involving 638 patients. The FOCUS-PDCA group showed significant improvements in swallowing function (standardized mean difference [SMD] = 1.65; 95%CI: 0.08–3.21), quality of life (SMD = 2.16; 95%CI: 0.54–3.79), and neurological and limb functions (SMD = 1.03; 95%CI: 0.07–2.00) compared with the conventional care group. The FOCUS-PDCA approach significantly reduced complication rates (risk ratio = 0.48; 95%CI: 0.32–0.68). Conclusion The FOCUS-PDCA cycle appears to be an effective strategy to improve outcomes in patients with cerebral infarction and dysphagia. However, more high-quality studies are needed to confirm these findings and guide clinical practice.

Abstract in English:

Abstract Background Rapid eye movement (REM) sleep behavior disorder (RBD) is characterized by recurrent dream enactment behaviors like sleep-related vocalization and/or complex motor behaviors. Objective To investigate the discriminative role of the validated Turkish version of the 9-Item Innsbruck REM Sleep Behavior Disorder Inventory (IRBD-9-Turkish) for idiopathic RBD (iRBD) in patients with obstructive sleep apnea (OSA). Methods The current multicenter study was prospectively conducted in 13 accredited sleep centers in 10 different cities in Türkiye. Clinical data was obtained through a preformed questionnaire, and all participants were submitted to a full-night video-polysomnography (video-PSG) session in a sleep laboratory. Results A total of 105 patients (mean age: 58.3 ± 11.6 years; 68.6% of male subjects) were prospectively and consecutively enrolled in the study; 51 patients (48.6%) presented iRBD, and 54 (51.4%), OSA, 19 (35.2%) of whom presented abnormal nocturnal behaviors (NBs) demonstrated by clinical and video-PSG findings associated with arousal reactions secondary to apneas and hypopneas. The cut-off value of the IRBD-9 was higher in patients with OSA-NBs than in those with OSA without NBs (p < 0.001), with a sensitivity of 0.765 and a specificity of 0.667, resulting in a correct diagnosis of NBs in 75% of patients with OSA. The receiver operating characteristic (ROC) curves for Factor I (items 1, 2, 3, 6, and 8) and Factor II (items 4, 5, 7, and 9) of the IRBD-9-Turkish showed that both factors were able to distinguish patients with iRBD from those with OSA, but only Factor I distinguishes patients with iRBD from those with OSA-NBs. Conclusion The present study demonstrated a very high sensitivity and specificity of the IRBD-9-Turkish not only in patients with iRBD, but also in patients with OSA.

Abstract in English:

Abstract Background The natural history of amyotrophic lateral sclerosis (ALS), the prognoses, and the survival times are fields of considerable interest that are scarcely studied in South American countries. Objective To describe the survival of a representative cohort of Uruguayan ALS patients, and to identify covariates associated with survival using different analyses. Methods Survival was assessed using the Kaplan-Meier method. Different Cox proportional hazards functions were used to identify independent prognostic predictors since the diagnosis: classic, stratified, and truncated. Results We included 166 definite and probable ALS patients. The median follow-up was of 13.6 years. An analysis was performed according to the recruitment groups: prevalent, exhaustive incident, and non-exhaustive incident cases. The median survival since the diagnosis was longer in the prevalent group (33 months) than in the exhaustive incident (22 months) and non-exhaustive incident (14 months) groups. The median survival time of the entire cohort from onset to death was 37 months and 23 months from the diagnosis. Factors related to survival from diagnosis to death were: age at onset, bulbar region onset, clinical form, and progression rate. Conclusion The present study described the role of clinical and demographic factors in ALS survival in the Uruguayan population and shed light on differences involving survival models and the temporal bias produced by the lack of precision in determining the onset of the disease.

Abstract in English:

Abstract Background Stroke has been a leading cause of death in Brazil throughout the past three decades. Although several cities in the country have implemented urgent/emergency stroke care units, the impact of the hospital type (public versus private) has not been evaluated. Objective To compare the mortality and survival of patients admitted with stroke to two private hospitals without stroke units with a public hospital with a stroke unit. Methods We conducted a historical cohort in the city of Joinville, Southern Brazil. Stroke patients admitted to a public hospital with a stroke unit were compared with those admitted to private hospitals without stroke units in terms of fatality rate and 30-day survival between January 2018 and December 2020. The Cox regression was used. Results Of the 4,508 patients, 85.6% were from public hospital, and 14.4%, from the 2 private hospitals. The crude mortality rate was of 11.4% among the public hospital patients, and of 9.1% among the patients from the private hospitals (p = 0.085). In the multivariate analysis, there was no difference in mortality between patients treated in the public hospital with a stroke unit (hazard ratio = 1.21; 95%CI: 0.87–1.68; p = 0.262) and those admitted to the 2 private hospitals without a stroke unit. Conclusion Stroke units are an important public policy that minimizes the impact of stroke.

Abstract in English:

Abstract Background Botulinum toxin type A (BoNT-A) is considered the first-line therapy for cervical dystonia. Objective To compare, in a randomized trial, the efficacy of treatment with BoNT-A guided by ultrasound (US) and electromyography (EMG) in patients with idiopathic cervical dystonia. Methods A total of 40 patients (20 in each group; mean age: 54 years; 45% of female subjects; mean disease duration: 10.7 years) were randomized to either US- or EMG-guided BoNT-A treatment. The efficacy of BoNT-A was assessed through changes in the scores on the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) before and 4 to 6 weeks after the treatment. The differences in the absolute and relative changes in the total TWSTRS scores and in its components (severity, incapacity, and pain) between the groups were evaluated. Results The US and EMG groups were well balanced in relation to baseline and demographic characteristics. After the BoNT-A treatment, there was a mean reduction in the TWSTRS score of 8 points (relative reduction of 23%) equally between the US and EMG groups (mean difference in absolute decrease of 0.1 point; p = 0.97; and mean difference in relative decrease of 2%; p = 0.89). There were no differences in the declines in the scores on the TWSTRS components, nor when the improvements in the TWSTRS scores were dichotomized as more significant or lower reductions (all p-values > 0.3). Conclusion The present randomized trial did not demonstrate any difference in improvements between BoNT-A treatment guided by US or EMG in patients with idiopathic cervical dystonia. Clinical Trial Registration ReBEC Identifier: RBR-33dd4p4.

Abstract in English:

Abstract Background Arterial ischemic stroke (AIS) is an increasingly common disorder in childhood that causes severe mortality and morbidity. Objective To emphasize the importance of early diagnosis and treatment of AIS cases, as well as the early initiation of physical therapy. Methods We retrospectively reviewed the medical records of 23 patients aged 1 month to 18 years, who were admitted with acute neurological complaints and diagnosed radiologically with AIS at the Bursa Yüksek İhtisas Training and Research Hospital, a tertiary healthcare facility, between January 2016 and June 2020. Results Neurological deficit was the most common (12 patients; 52%) complaint, followed by seizure in 5 patients (21%), facial paralysis in 5 patients (21%), and visual impairment in 3 patients (13%). We performed brain computed tomography (CT) scans in 12 (52%) patients at the first application, and infarction was detected in 8 (66%). Infarction was in the cerebrum in 19 (82%) patients. Mutations of the methylenetetrahydrofolate reductase (MTHFR; A1298C and 677C > T) gene were found most frequently. Cardiac anomalies were detected in 7 (30%) patients, and 2 patients had ventriculoperitoneal shunts. Conclusion Arterial ischemic stroke presents very different clinical findings, such as hiccups, anisocoria, and upward gaze paralysis. We wanted to emphasize the importance of cranial CT scanning because sometimes MRI is not always easily performed in children. Concomitant conditions, such as intracranial operation, ventriculoperitoneal shunt, and hypochondroplasia, may increase the risk of stroke.

Abstract in English:

Abstract Background Updating multiple sclerosis (MS) diagnostic criteria over recent decades may have impacted disability progression. Objective To assess the effects of the passage of time and changes in diagnostic criteria on disability. Methods A retrospective study of Brazilian people with relapsing-remitting MS from 1994 to 2019. Descriptive analysis compared three periods based on admission: Epoch 1 (1994–2001), 2 (2002–2010), and 3 (2011–2019). Cox regressions were performed for the outcomes of the expanded disability status scale (EDSS) 6.0 and conversion to secondary progressive MS (SPMS). We compared the three Epochs in sequence, the Poser with all McDonald criteria combined, and Poser versus each McDonald criteria (2001, 2005, 2010, and 2017). A multivariate logistic regression assessed the impact of diagnostic criteria on patients reaching EDSS 6.0. Results Time to diagnosis and treatment decreased across Epochs. For reaching EDSS 6.0, the Cox regression indicated a hazard ratio (HR) 63% lower for Epoch 3 compared with 1, an HR 50% lower for the McDonald criteria combined, and an HR 65% lower for McDonald 2010 compared with Poser. Regarding the conversion to SPMS, the HR was 53% lower for Epoch 3, 48% lower for the McDonald criteria combined, and 64% lower for McDonald 2010. The multivariate logistic regression demonstrated that incomplete recovery of initial symptoms was the main prognostic factor for reaching EDSS 6.0. However, transitioning diagnostic criteria from Poser to McDonald 2001 and 2005 decreased these odds by 54%. Conclusion Newer diagnostic criteria have reduced the likelihood of reaching EDSS 6.0 and converting to SPMS over the past 25 years.

Abstract in English:

Abstract Background Some studies demonstrated the role of statin therapy in improving outcomes after coil embolization or surgical clipping of cerebral aneurysm. However, the benefit of statins after pipeline embolization device (PED) for intracranial aneurysms is not well established. Objective To evaluate the effects of statins on hemorrhagic and ischemic complications as well as on complete occlusion of aneurysm in the treatment with PED. Methods We searched the PubMed, Embase, and Cochrane Library databases for articles published from their inception to November 2024. Data were collected from observational studies comparing statin to no statin therapy following pipeline embolization. Results Four studies were included, comprising 2,822 patients and 3,063 aneurysms, 127 of which were ruptured and 4 of which received adjunctive coil embolization. Total hemorrhagic complication was reduced in the statin group (risk ratio [RR] = 0.50; 95%CI: 0.29–0.85; p = 0.010; I2 = 0%) but did not reveal difference in restricted propensity score-matched (PSM) analysis (RR= 0.50; 95%CI: 0.24–1.07 p = 0.073; I2 = 27%). There was no difference between the groups in complete occlusion of aneurysm rate at the last follow-up (RR = 0.94; 95%CI: 0.88–1.00; p = 0.055; I2 = 8.0%) or total ischemic complications (RR = 1.48; 95%CI: 1.06–2.07; p = 0.021; I2 = 0%). Conclusion Statin use significantly reduced hemorrhagic complications after PED; however, this result should be interpreted cautiously due to study limitations. No significant differences were noted in complete occlusion rates or ischemic complications between the groups.

Abstract in English:

Abstract Aneurismal subarachnoid hemorrhage (aSAH) is a condition with elevated mortality and morbidity, which usually affects a working-age population, leading to a high socioeconomic burden. Among those who survive the initial bleeding, approximately 30% will experience delayed cerebral ischemia (DCI), which is a significant factor in poor outcomes. However, it is potentially reversible if appropriate treatment is promptly initiated. The amount of blood present on the initial computed tomography (CT) scan, assessed through the modified Fisher scale (mFisher), and the patient's neurological status upon admission, are the strongest predictors of DCI. Early prevention is essential and typically involves administration of enteral nimodipine and the maintenance of euvolemia, while other treatment options have limited supporting evidence. Diagnosing remains a challenge, primarily due to its reliance on clinical examinations. This is more pronounced in high-grade aSAH patients who are unconscious or sedated. In such cases, additional methods may be necessary, such as transcranial Doppler (TCD), continuous electroencephalography (cEEG), or CT with perfusion (CTP). Treatment aims to prevent cerebral infarction and poor clinical outcomes, and it is based on hemodynamic optimization, hypertension induction, cardiac output augmentation, and endovascular therapy. Nevertheless, randomized data on DCI management remains scarce, highlighting the urgent need for more studies and a better understanding of this SAH complication. Addressing this gap may lead to more effective preventive strategies and treatments, which is crucial for improving the prognosis of these patients.

Abstract in English:

Abstract Social determinants of health, including neighborhood and built environment factors, play a crucial but underexplored role in epilepsy incidences. Among these, air pollution emerges as a potentially-preventable driver of epilepsy and adverse health outcomes. Evidence is accumulating on the effects of air pollution on the brain, especially in stroke and neurodegenerative disorders; however, the specific impact on epilepsy remains underresearched, potentially due to the complexities of studying this condition. The present narrative review addresses a critical knowledge gap by exploring: 1) the role of air pollution in epilepsy epidemiology; 2) the biological mechanisms of air pollution in the brain in the context of epilepsy; and 3) how air pollution affects the management of people living with epilepsy. We outline vital questions and actionable interventions regarding the role of air pollution in epilepsy.

Abstract in English:

Abstract In the nineteenth century, neurology was in its infancy as an organized medical specialty. At that time, seizures were often attributed, under the guise of scientific explanations, to moral causes or behaviors. The medical literature from this period contains references to poor parental care as a cause of epilepsy and descriptions of seizures being inherited alongside other undesirable traits. Temperance was praised, while gluttony was associated with epileptic fits. Unwanted sexual behaviors, such as masturbation, were also considered a risk factor for seizures. Women were thought to be more prone to epilepsy due to their behaviors and emotional disposition. These accounts illustrate the interplay between neurological science and the prevailing social norms of the era.