Behandlung des akuten Hirninfarktes [Treatment of acute stroke -- an overview]

This paper provides an overview on the actual state of acute therapy in patients with ischemic stroke. The discussion focusses on intravenous and intraarterial thrombolysis, antithrombotic therapy, and the treatment of medical and neurological complications, and therapy recommendations are presented. Finally ongoing studies, particularly those concerning thrombolysis with glycoprotein IIb/IIIa receptor blockers and ultrasound-assisted thrombolysis, are presented.

Accès à la thrombolyse lors d'AVC: rôle des secours préhospitaliers et des médecins de premier recours [Access to thrombolysis in stroke: place of the rescue system and of the primary care physician].

Thrombolysis is the most effective treatment improving the outcome of patients suffering from acute stroke. Moreover, its effectiveness increases when administrated as quick as possible after the onset of the first symptoms. Prehospital selection of patients and their immediate transfer to stroke center are the principal factors allowing the practice of thrombolysis within the authorized time frame. On the basis of regional Swiss French data, it seems that patients evaluated by emergency physician and their direct transfer in an acute stroke unit reduces delays and allows for a higher thrombolysis rate.

Intravenous thrombolysis in nonagenarians with ischemic stroke.

Background and Purpose-Demographic changes will result in a rapid increase of patients age >= 90 years (nonagenarians), but little is known about outcomes in these patients after intravenous thrombolysis (IVT) for acute ischemic stroke. We aimed to assess safety and functional outcome in nonagenarians treated with IVT and to compare the outcomes with those of patients age 80 to 89 years (octogenarians).Methods-We analyzed prospectively collected data of 284 consecutive stroke patients age >= 80 years treated with IVT in 7 Swiss stroke units. Presenting characteristics, favorable outcome (modified Rankin scale [mRS] 0 or 1), mortality at 3 months, and symptomatic intracranial hemorrhage (SICH) using the National Institute of Neurological Disorders and Stroke (NINDS) and Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria were compared between nonagenarians and octogenarians.Results-As compared with octogenarians (n=238; mean age, 83 years), nonagenarians (n=46; mean age, 92 years) were more often women (70% versus 54%; P=0.046) and had lower systolic blood pressure (161 mm Hg versus 172 mm Hg; P=0.035). Patients age >= 90 years less often had a favorable outcome and had a higher incidence of mortality than did patients age 80 to 89 years (14.3% versus 30.2%; P=0.034; and 45.2% versus 22.1%; P=0.002; respectively), while more nonagenarians than octogenarians experienced a SICH (SICHNINDS, 13.3% versus 5.9%; P=0.106; SICHSITS-MOST, 13.3% versus 4.7%; P=0.037). Multivariate adjustment identified age >= 90 years as an independent predictor of mortality (P=0.017).Conclusions-Our study suggests less favorable outcomes in nonagenarians as compared with octogenarians after IVT for ischemic stroke, and it demands a careful selection for treatment, unless randomized controlled trials yield more evidence for IVT in very old stroke patients. (Stroke. 2011; 42: 1967-1970.)

Early mobilization out of bed after ischaemic stroke reduces severe complications but not cerebral blood flow: a randomized controlled pilot trial.

OBJECTIVE: To evaluate whether early mobilization after acute ischaemic stroke is better than delayed mobilization with regard to medical complications and if it is safe in relation to neurological function and cerebral blood flow. DESIGN: Randomized controlled pilot trial of early versus delayed mobilization out of bed with incidence of severe complications as the primary outcome. SETTING: Acute stroke unit in the neurology department of a University Hospital. PARTICIPANTS: Fifty patients after ischaemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score >6 were recruited. INTERVENTION: All patients were treated with physiotherapy immediately after their admission. In the early protocol patients were mobilized out of bed after 52 hours, in the delayed protocol after seven days. RESULTS: Eight out of 50 randomized patients were excluded from the per-protocol analysis because of early transfer to other hospitals. There were 2 (8%) severe complications in the 25 early mobilization patients and 8 (47%) in the 17 delayed mobilization patients (P < 0.006). There were no differences in the total number of complications or in clinical outcome. In the 26 patients (62%) who underwent serial transcranial Doppler ultrasonography, no blood flow differences were found. CONCLUSION: We found an apparent reduction in severe complications and no increase in total complications with an early mobilization protocol after acute ischaemic stroke. No influence on neurological three-month outcomes or on cerebral blood flow was seen. These results justify larger trials comparing mobilization protocols with possibly even faster mobilization out of bed than explored here.

Vitamin d and stroke: promise for prevention and better outcome.

The role of vitamin D (VitD) has recently been expanded beyond bone homeostasis and regulation of calcium levels. VitD deficiency has been proposed as a new risk factor for cardiovascular disease, including stroke. Low 25(OH)VitD levels are very common among post-stroke patients, probably due to their limited mobility and decreased sunlight exposure along with a higher prevalence of malnutrition, and they have been associated with previous and incident cerebrovascular events. Contributing mechanisms have been linked to the association of VitD deficiency with the presence of hypertension, diabetes mellitus and atherosclerosis. Moreover, there is experimental evidence demonstrating that VitD exerts neuroprotective effects, such as stimulation of neurotrophic factors, quenching of oxidative hyperactivity and regulation of neuronal death, as well as antithrombotic properties. It is plausible that VitD supplementation could be a beneficial intervention for the prevention and/or treatment of cerebrovascular disease possibly by decreasing the aforementioned cerebrovascular risk factors and simultaneously by improving neurologic and cognitive functions, thereby reducing falls and fractures in post-stroke patients. However, study results are still conflicting and data from large, randomized clinical trials are needed to clarify these speculations.

Provenance and family variation of Pinus caribaea var. hondurensis from Guatemala and Honduras, grown in Brazil, Colombia and Venezuela

Pinus caribaea var. hondurensis (Sénécl) Barr. & Golf. is a tropical pine that naturally occurs in lowland areas of Belize, El Salvador, Guatemala, Honduras, Nicaragua, and eastern Mexico. It has been one of the most studied tropical pines and the one with the most commercial importance in Brazil. The objective of this work was to select the best provenances for plantations and best trees in families for the establishment of seed orchards. For that a trial with five provenances and 47 open-pollinated families was planted near Planaltina, Federal District, in the Cerrado Region of Brazil. The provenances tested were Poptun (Guatemala), Gualjoco, Los Limones, El Porvenir and Santa Cruz de Yojoa (Honduras) and assessed at 12 years of age. Poptun and Gualjoco had larger volume, and Los Limones and El Porvenir the lowest incidence of forks and foxtails. Individual tree heritabilities for volume, stem form and branch diameter were 0.34, 0.06, and 0.26 respectively. More than 90% of the trees had defects, common in unimproved P. caribaea. Selection criteria for quality traits need to be relaxed in the first generation of breeding to allow for larger genetic gains in productivity. Results from this test compared with P. caribaea var. hondurensis trials in other Brazilian, Colombian and Venezuelan sites suggest that provenance x site and family x site interactions are not as strong as in other pine species.

Genotype and environment interaction on soybean yield in Mato Grosso State, Brazil

The objective of this work was to investigate the genotype-environment interaction in Mato Grosso State, MT. The relative importance of locations, years, sowing dates and cultivars and their interactions was analyzed from data collected in regional yield trials performed in a randomized complete block design with four replications, from 1994-1995 through 1999-2000, in nine locations and two sowing dates. Individual and pooled analyses of variance over years and locations were performed. Complementary analyses of variances partitioned MT State in two main and five smaller regions, respectively: North and South of Cuiabá; and MT-South-A (Pedra Preta area), MT-South-B (Rondonópolis and Itiquira), MT-East (Primavera do Leste and Campo Verde), MT-Central (Nova Mutum, Lucas do Rio Verde and Sorriso) and MT-Parecis (Campo Novo dos Parecis and Sapezal). Locations are relatively more important than years for yield testing soybeans in the MT State, therefore, investment should be made in increasing locations rather than years to improve experimental precision. Partitioning the MT State into regions has little impact on soybean yield testing results and, consequently, on the efficiency of the soybean breeding program in the State. Breeding genotypes with broad adaptation for the MT State is an efficient strategy for cultivar development.

Effect of white-matter lesions on the risk of periprocedural stroke after carotid artery stenting versus endarterectomy in the International Carotid Stenting Study (ICSS): a prespecified analysis of data from a randomised trial.

BACKGROUND: Findings from randomised trials have shown a higher early risk of stroke after carotid artery stenting than after carotid endarterectomy. We assessed whether white-matter lesions affect the perioperative risk of stroke in patients treated with carotid artery stenting versus carotid endarterectomy. METHODS: Patients with symptomatic carotid artery stenosis included in the International Carotid Stenting Study (ICSS) were randomly allocated to receive carotid artery stenting or carotid endarterectomy. Copies of baseline brain imaging were analysed by two investigators, who were masked to treatment, for the severity of white-matter lesions using the age-related white-matter changes (ARWMC) score. Randomisation was done with a computer-generated sequence (1:1). Patients were divided into two groups using the median ARWMC. We analysed the risk of stroke within 30 days of revascularisation using a per-protocol analysis. ICSS is registered with controlled-trials.com, number ISRCTN 25337470. FINDINGS: 1036 patients (536 randomly allocated to carotid artery stenting, 500 to carotid endarterectomy) had baseline imaging available. Median ARWMC score was 7, and patients were dichotomised into those with a score of 7 or more and those with a score of less than 7. In patients treated with carotid artery stenting, those with an ARWMC score of 7 or more had an increased risk of stroke compared with those with a score of less than 7 (HR for any stroke 2·76, 95% CI 1·17-6·51; p=0·021; HR for non-disabling stroke 3·00, 1·10-8·36; p=0·031), but we did not see a similar association in patients treated with carotid endarterectomy (HR for any stroke 1·18, 0·40-3·55; p=0·76; HR for disabling or fatal stroke 1·41, 0·38-5·26; p=0·607). Carotid artery stenting was associated with a higher risk of stroke compared with carotid endarterectomy in patients with an ARWMC score of 7 or more (HR for any stroke 2·98, 1·29-6·93; p=0·011; HR for non-disabling stroke 6·34, 1·45-27·71; p=0·014), but there was no risk difference in patients with an ARWMC score of less than 7. INTERPRETATION: The presence of white-matter lesions on brain imaging should be taken into account when selecting patients for carotid revascularisation. Carotid artery stenting should be avoided in patients with more extensive white-matter lesions, but might be an acceptable alternative to carotid endarterectomy in patients with less extensive lesions. FUNDING: Medical Research Council, the Stroke Association, Sanofi-Synthélabo, the European Union Research Framework Programme 5.

Key locations for soybean genotype assessment in Central Brazil

The objective of this work was to identify key locations for the establishment of soybean (Glycine max) genetic breeding programs, in the Central Region of Brazil. Grain yield data of three maturity groups of soybean genotypes, from regional trials conducted over three years, at 18 locations in Brazilian Cerrado were used. A key location for the early phases of the breeding program was defined as the site that best classifies the winning genotypes in the region. Key locations for the final phases were defined as those sites that best represent each environmental stratum, in relation to the adaptability of the respective winning genotype. This adaptability was estimated by additive main effects and multiplicative interaction (AMMI) model analysis, using the distance between the score of each location in a stratum and the score of the winning genotype, which characterizes such stratum in an AMMI biplot. The locations that best classified the winning genotypes over space and time were Mineiros, Placas and Rio Verde. For the final phases of genotype selection, with data from the three maturity group, the recommended locations were: Buritis, Chapadão do Céu, Iraí, Pamplona, Placas, Planaltina, Rio Verde, Sacramento, Senador Canedo, Uberaba, and Uberlândia.

Comparative study of the mandarin hybrid fruit characteristics: Nova, Murcott and Ortanique in Capão Bonito SP, Brazil

The Murcott tangor represent 20% of the tangerines trees in São Paulo State being the second more grown. Their fruits have good acceptance in the market cause of the good characteristics presented as: size, attractive internal and external color, transport resistance, high juice rate and industry potential. It is necessary to study the behavior of others varieties, in order to amplify the diversity of tangerine industry, which show suitable characteristics to the fresh fruit market and that make possible different harvest season. Many tangerine varieties, selected from the Citrus Germplasm Bank of the do Centro Avançado de Pesquisa Tecnológica do Agronegócio de Citros "Sylvio Moreira"/IAC, belong to trials carried out in 15 places in São Paulo State. The Capão Bonito area, south-west of the state, is one of this places where the Nova tangelo, the Ortanique and the Murcott tangors are showing quite good results about their fruit qualities. This paper had as an objective to compare the fruit characteristics of the Nova tangelo, the Murcott and the Ortanique tangors grafted on two rootstocks: Rangpur lime and Cleopatra mandarin. Accordingly to the gotten results, is possible to conclude that Nova and Ortanique had shown weight, width, fruit shape and juice percent, similar to the Murcott. In compliance with the harvest season, the Nova present suitable conditions to fresh fruit market in May and June. By the other hand the Murcott fruits can be harvested in July to August and the Ortanique in August to September. For this reason, is possible extend the harvest season of this mandarin-like, from two to five month, occurring inclusive in a period out of the crop at the north hemisphere.

European Stroke Organisation (ESO) guidelines for the management of temperature in patients with acute ischemic stroke.

BACKGROUND: Hyperthermia is a frequent complication in patients with acute ischemic stroke. On the other hand, therapeutically induced hypothermia has shown promising potential in animal models of focal cerebral ischemia. This Guideline Document presents the European Stroke Organisation guidelines for the management of temperature in patients with acute ischemic stroke. METHODS: A multidisciplinary group identified related questions and developed its recommendations based on evidence from randomized controlled trials elaborating the Grading of Recommendations Assessment, Development, and Evaluation approach. This Guideline Document was reviewed within the European Stroke Organisation and externally and was approved by the European Stroke Organisation Guidelines Committee and the European Stroke Organisation Executive Committee. RESULTS: We found low-quality evidence, and therefore, we cannot make any recommendation for treating hyperthermia as a means to improve functional outcome and/or survival in patients with acute ischemic stroke and hyperthermia; moderate evidence to suggest against routine prevention of hyperthermia with antipyretics as a means to improve functional outcome and/or survival in patients with acute ischemic stroke and normothermia; very low-quality evidence to suggest against routine induction of hypothermia as a means to improve functional outcome and/or survival in patients with acute ischemic stroke. CONCLUSIONS: The currently available data about the management of temperature in patients with acute ischemic stroke are limited, and the strengths of the recommendations are therefore weak. We call for new randomized controlled trials as well as recruitment of eligible patients to ongoing randomized controlled trials to allow for better-informed recommendations in the future.

Impact of anthracnose on the yield of soybean subjected to chemical control in the north region of Brazil

ABSTRACT Losses due to soybean anthracnose, caused by Colletotrichum truncatum, have not been systematically quantified in the field, and the efficacy of chemical control of this disease is not known. This study shows an estimate of losses associated with the disease in soybean crops in the north of the country. Two trials with cv. M9144 RR were carried out in commercial fields in Tocantins State in the 2010/2011 and 2011/2012 growing seasons, in randomized blocks, with four replicates. Foliar applications were performed on plants at R1/R2 and R5.2 stages, employing CO2-pressurized equipment and application volume of 200 L ha-1. Nine fungicides and one untreated control were compared, and the disease gradients in the two seasons were obtained. The percentage of infected pods was calculated at the R6 stage. Grain yield ranged from 3,288 to 3,708 kg/ha in the untreated plots in 2010/2011 and 2011/2012, respectively, and from 3,282 to 4,110 kg/ha in the treated plots. In the 2010/2011 season, only azoxystrobin + cyproconazole significantly reduced the disease incidence, compared to untreated control plots, not differing from the remaining treatments. In the 2011/2012 season, there were no significant differences between treated and untreated plots. Highly significant correlations (p < 0.01) were found between yield and soybean anthracnose incidence on pods in both years (r = -0.85). For each 1% increment in the disease incidence, c. 90 kg/ha of soybean grain were lost. The current study determined that significant losses due to anthracnose occur in commercial crops in the north of the country and highlighted the limitation of chemical control as anthracnose management method.

"Cara inchada" of cattle, an infectious, apparently soil antibiotics-dependant periodontitis in Brazil

The objective of this review on the investigation of "cara inchada" in cattle (CI), pursued over the last 30 years, was to elucidate the pathogenicity of the disease and come to proper conclusions on its etiology. CI has been widely considered to be of nutritional origin, caused primarily by mineral deficiency or imbalance. However, the disease consists of a rapidly progressive periodontitis, affecting the periodontal tissues at the level of the premolars and molars during the period of tooth eruption generally starting in young calves. The disease led to great economic losses for farmers in central-western Brazil, after the occupation of new land for cattle raising in the 1960s and 1970s. The lateral enlargement of the maxillary bones of affected calves gave the disease the popular name of "cara inchada", i.e., swollen or enlarged face. The enlargement was found to be due to a chronic ossifying periostitis resulting from the purulent alveolitis of CI. Black-pigmented non-saccharolytic Bacteroides melaninogenicus, always together with Actinomyces (Corynebacterium) pyogenes, were isolated in large numbers from the periodontal lesions. B. melaninogenicus could be isolated in small numbers also from the marginal gingiva of a few healthy calves maintained on CI-free farms. "In vitro"-assays showed that streptomycin and actinomycin, as well as the supernatants of cultivates of actinomycetes from soils of CI-prone farms, applied in subinhibitory concentrations to the bacteria tested, enhanced significantly (up to 10 times) the adherence of the black-pigmented B.melaninogenicus to epithelial cells of the bovine gingiva. The antibiotics are apparently produced in large quantities by the increased number of soil actinomycetes, including the genus Streptomyces, that develop when soil microflora are modified by cultivating virgin forest or "Cerrado" (tree-savanna) for the first time for cattle grazing. The epidemiology of CI now provides strong evidence that the ingestion with the forage of such antibiotics could possibly be an important determinant factor for the onset and development of this infectious periodontitis. The antibiotic enhanced adherence of B.melaninogenicus to the sulcus-epithelium of the marginal gingiva, is thought to allow it to colonize, form a plaque and become pathogenic. There is experimental evidence that this determinant factor for the development of the periodontitis is present also in the milk of the mothers of CI-diseased calves. It has been shown that the bacteria isolated from the periodontal CI-lesions produce enzymes and endotoxins capable of destroying the periodontal tissues. The epidemiology of CI, with its decline in incidence and its disappearance after several years, could be explained by the fact that the former equilibrium of the microflora of the once undisturbed virgin soil has been reached again and that the number of antibiotic producing actinomycetes has been anew reduced. By this reasoning and all the data available, CI should be considered as a multifactorial infectious disease, caused primarily by the anaerobic black-pigmented non-saccharolytic Bacteroides melaninogenicus, always together with the micro-anaerobic Actinomyces pyogenes. Accordingly, the onset and development of the infectious periodontitis is apparently determined by ingestion with the forage of subinhibitory concentrations of antibiotics produced in recently cultivated virgin soils. This hypothesis is supported by the recent observation of renewed outbreaks of CI-periodontitis in former CI-prone areas, following fresh cultivation after many years. The infectious nature of CI is confirmed by trials in which virginiamycin was used efficiently for the oral treatment of CI-diseased cattle. Previously it has been shown, that spiramycin and virginiamycin, used as additives in mineral supplements, prevented CI-periodontitis.

Resistance of Amaranthus retroflexus to acetolactate synthase inhibitor herbicides in Brazil

When in competition with cotton, Amaranthus retroflexus can cause high yield losses. Due to the limited availability of selective herbicides registered for post emergence control of this weed, the same herbicides have been used repeated times over the last few years, which may have selected resistant biotypes. Biotypes of A. retroflexus collected from the main areas of cotton cultivation in Brazil were submitted to dose-response trials, by applying the herbicides trifloxysulfuron-sodium and pyrithiobac-sodium in doses equivalent to 0, ¼, ½, 1, 2 and 4 times the recommended rates. Resistance to ALS inhibitors was confirmed in biotypes of A. retroflexus. Biotype MS 2 from Mato Grosso do Sul, was cross-resistant to both trifloxysulfuron-sodium and pyrithiobac-sodium, while biotype MS 1 was resistant to trifloxysulfuron-sodium only. Likewise, singular and cross resistance was also confirmed in biotypes from Goiás (GO 3, GO 4 and GO 6), in relation to trifloxysulfuron­sodium and pyrithiobac-sodium. One biotype from Mato Grosso (MT 13) was not resistant to any of the ALS inhibitors evaluated in this work.

Two variants of HIV-1 B serotype are transmitted heterosexually in São Paulo, Brazil

HIV-1 variability may have an important impact on transmission and pathogenicity. Better characterization of the HIV epidemic in Brazil is necessary for the development of vaccine trials in this country. We analyzed sera from 108 HIV-1-infected volunteers from São Paulo City to determine serotype and reactivity for V3 motifs of HIV in this population, and the relationship to transmission mode. We concluded that the HIV-1 B serotype is frequent among heterosexually infected women, even in the absence of anal sex, and that two major V3 motifs, GPGR and GWGR, had similar prevalence among women (48% and 52%, respectively) and men (56% and 44%, respectively). We also observed an equal distribution of these strains regardless of their CD4+ T cell counts, clinical status, and mode of transmission. Even though V3 serology for HIV-1 subtyping is an inexpensive tool for use in developing countries, additional methods, such as heteroduplex mobility assay and direct DNA sequencing, should be included to determine HIV-1 genetic diversity.