RESUMO
Importance: The pathophysiologic mechanisms of Guillain-Barré syndrome (GBS) associated with Zika virus (ZIKV) infection may be indicated by differences in clinical features. Objective: To identify specific clinical features of GBS associated with ZIKV infection. Design, Setting, and Participants: During the ZIKV epidemic in Puerto Rico, prospective and retrospective strategies were used to identify patients with GBS who had neurologic illness onset in 2016 and were hospitalized at all 57 nonspecialized hospitals and 2 rehabilitation centers in Puerto Rico. Guillain-Barré syndrome diagnosis was confirmed via medical record review using the Brighton Collaboration criteria. Specimens (serum, urine, cerebrospinal fluid, and saliva) from patients with GBS were tested for evidence of ZIKV infection by real-time reverse transcriptase-polymerase chain reaction; serum and cerebrospinal fluid were also tested by IgM enzyme-linked immunosorbent assay. In this analysis of public health surveillance data, a total of 123 confirmed GBS cases were identified, of which 107 had specimens submitted for testing; there were 71 patients with and 36 patients without evidence of ZIKV infection. Follow-up telephone interviews with patients were conducted 6 months after neurologic illness onset; 60 patients with and 27 patients without evidence of ZIKV infection participated. Main Outcomes and Measures: Acute and long-term clinical characteristics of GBS associated with ZIKV infection. Results: Of 123 patients with confirmed GBS, the median age was 54 years (age range, 4-88 years), and 68 patients (55.3%) were male. The following clinical features were more frequent among patients with GBS and evidence of ZIKV infection compared with patients with GBS without evidence of ZIKV infection: facial weakness (44 [62.0%] vs 10 [27.8%]; P < .001), dysphagia (38 [53.5%] vs 9 [25.0%]; P = .005), shortness of breath (33 [46.5%] vs 9 [25.0%]; P = .03), facial paresthesia (13 [18.3%] vs 1 [2.8%]; P = .03), elevated levels of protein in cerebrospinal fluid (49 [94.2%] vs 23 [71.9%]; P = .008), admission to the intensive care unit (47 [66.2%] vs 16 [44.4%]; P = .03), and required mechanical ventilation (22 [31.0%] vs 4 [11.1%]; P = .02). Six months after neurologic illness onset, patients with GBS and evidence of ZIKV infection more frequently reported having excessive or inadequate tearing (30 [53.6%] vs 6 [26.1%]; P = .03), difficulty drinking from a cup (10 [17.9%] vs 0; P = .03), and self-reported substantial pain (15 [27.3%] vs 1 [4.3%]; P = .03). Conclusions and Relevance: In this study, GBS associated with ZIKV infection was found to have higher morbidity during the acute phase and more frequent cranial neuropathy during acute neuropathy and 6 months afterward. Results indicate GBS pathophysiologic mechanisms that may be more common after ZIKV infection.
Assuntos
Síndrome de Guillain-Barré/diagnóstico , Síndrome de Guillain-Barré/virologia , Infecção por Zika virus/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Síndrome de Guillain-Barré/epidemiologia , Hispânico ou Latino , Humanos , Pessoa de Meia-Idade , Adulto Jovem , Infecção por Zika virus/epidemiologiaRESUMO
OBJECTIVE: Vitamin D deficiency has been associated with increased risk and adverse outcomes in many clinical settings including cardiovascular disease, stroke, and critically ill patients. Therefore we aimed to determine whether vitamin D deficiency had any effect in aneurysmal subarachnoid hemorrhage (aSAH) clinical outcomes. METHODS: A retrospective record review was conducted in a tertiary community hospital in Puerto Rico. Adult patients admitted to the neurosurgical intensive care unit with a diagnosis of aSAH from January 2013 to July 2014, who had a 25-hydroxyvitamin-D level drawn, were included. RESULTS: A total of 40 patients were admitted with a diagnosis of aSAH, and 33 met the inclusion criteria. Overall, 81% of patients were vitamin D deficient or insufficient. Subjects were grouped into those with vitamin D deficiency (n = 13) and those without (n = 20). Except for a larger prevalence of coronary artery disease, all other baseline parameters were similar. No significant difference in hospital mortality was observed (P = 0.676). The percentage of vasospasms, vasopressor use, hydrocephalus, and infections was also similar. An increase in length of neurosurgical intensive care unit stay and respiratory failure was observed in the vitamin D-deficient group, but it was not statistically significant. CONCLUSION: A high prevalence of vitamin D deficiency and insufficiency was found among patients admitted with a diagnosis of aSAH in this cohort. Despite this no difference in clinical outcomes was observed in patients when compared by vitamin D group. Further studies are needed to assess potential effects of vitamin D deficiency in this patient population including long term follow-up after discharge.
Assuntos
Mortalidade Hospitalar , Tempo de Internação/estatística & dados numéricos , Hemorragia Subaracnóidea/mortalidade , Hemorragia Subaracnóidea/cirurgia , Deficiência de Vitamina D/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Comorbidade , Feminino , Humanos , Incidência , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Porto Rico/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento , Adulto JovemRESUMO
Guillain-Barré syndrome (GBS) is a postinfectious autoimmune disorder characterized by bilateral flaccid limb weakness attributable to peripheral nerve damage (1). Increased GBS incidence has been reported in countries with local transmission of Zika virus, a flavivirus transmitted primarily by certain Aedes species mosquitoes (2). In Puerto Rico, three arthropod-borne viruses (arboviruses) are currently circulating: Zika, dengue, and chikungunya. The first locally acquired Zika virus infection in Puerto Rico was reported in December 2015 (3). In February 2016, the Puerto Rico Department of Health (PRDH), with assistance from CDC, implemented the GBS Passive Surveillance System (GBPSS) to identify new cases of suspected GBS (4). Fifty-six suspected cases of GBS with onset of neurologic signs during January 1-July 31, 2016, were identified. Thirty-four (61%) patients had evidence of Zika virus or flavivirus infection; the median age of these patients was 55 years (range = 21-88 years), and 20 (59%) patients were female. These 34 patients were residents of seven of eight PRDH public health regions. All 34 patients were hospitalized and treated with intravenous immunoglobulin G (IVIg), the standard treatment for GBS; 21 (62%) required intensive care unit admission, including 12 (35%) who required endotracheal intubation and mechanical ventilation. One patient died of septic shock after treatment for GBS. Additionally, 26 cases of neurologic conditions other than GBS were reported through GBPSS, including seven (27%) in patients with evidence of Zika virus or flavivirus infection. Residents of and travelers to Puerto Rico and countries with active Zika virus transmission should follow recommendations for prevention of Zika virus infections.* Persons with signs or symptoms consistent with GBS should promptly seek medical attention. Health care providers in areas with ongoing local transmission seeing patients with neurologic illnesses should consider GBS and report suspected cases to public health authorities.
Assuntos
Surtos de Doenças , Síndrome de Guillain-Barré/epidemiologia , Vigilância da População , Infecção por Zika virus/transmissão , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Porto Rico/epidemiologia , Adulto Jovem , Zika virus/isolamento & purificação , Infecção por Zika virus/epidemiologiaRESUMO
OBJECTIVE: Puerto Rico (PR) has undergone rapid changes during the last decades. Some of these involve the health care system and the delivery of care to the critically ill patient. With this in mind, we investigated how the intensive care units throughout our island's hospitals are organized so that we could establish a profile of the adult intensive care units (ICU) in PR. METHODS: From January 1, 2010 through April 30, 2010, questionnaires were distributed by e-mail or fax to every hospital that maintained a critical care unit. The questionnaires asked for such details as the structure of the unit; whether is use on an open or closed model; the number of beds in the unit; the total number of faculty members in the unit; the credentials of the unit's medical faculty and nursing staff; whether critical care service was available, and the different people in-charge of the unit during the day and at night. RESULTS: A total of 33 questionnaires were distributed, of which 19 were collected and analyzed. Among the ICU directors who responded, the predominant specialty was cardiology. Surprisingly, only 26% of the hospitals had critical care specialists. In most of the institutions, an internist or a primary care physician was on site during the day, this individual directly supervised patients and had decision making authority. At night, however, patients were managed by supervising nurse with limited ability to medically identified patient complications, though primary care physician was always available by phone if a critical decision needed to be made. Some of the units used protocols as part of their medical-management armamentarium. CONCLUSION: Although only a small percentage of the island's ICUs participated in our project, the study's findings serve as evidence of the need to re-evaluate the delivery of care to the critically ill population.
Assuntos
Cuidados Críticos/organização & administração , Unidades de Terapia Intensiva/organização & administração , Protocolos Clínicos , Cuidados Críticos/tendências , Enfermagem de Cuidados Críticos , Atenção à Saúde , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Medicina , Modelos Teóricos , Supervisão de Enfermagem , Equipe de Assistência ao Paciente , Porto Rico , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Adequate adrenal response is fundamental for the maintenance of physiological homeostasis in the setting of trauma and severe illness. Patients with neurogenic shock are at risk of severe consequences if adrenal insufficiency (AI) is not rapidly identified and treated. OBJECTIVE: To analyze the incidence of AI in patients with acute cervical spinal cord injury and its effect on in-hospital complications. METHODS: The medical records of patients older than 18 years who were admitted to the adult neurosurgery service at the University District Hospital as the result of neurogenic shock after acute cervical spinal cord injury from January 2004 to December 2009 were reviewed retrospectively. RESULTS: One hundred ninety-nine patients were admitted with acute cervical spinal cord injury. A total of 37 patients met the pre-established criteria for neurogenic shock. The incidence of AI in patients with neurogenic shock was 22%. The average random cortisol was 9.3 µg/dL in patients with AI versus 29.2 µg/dL in non-AI. The presence of AI was positively correlated with complications and an increase in the risk of intubation (P = 0.01 and P = 0.002). The 30-day mortality rate in patients with AI was 13% compared with the 3% in the non-AI group (P = 0.39). CONCLUSIONS: Adrenal insufficiency is a poorly recognized complication in patients with acute cervical spinal cord injury and its aggressive treatment is of utmost importance to avoid further neurological injury.