No abstract

Early intravenous thrombolysis has proven to be a safe and effective therapy for selected patients with acute ischemic stroke (AIS). Nowadays, thrombolysis is usually delivered by neurologists in "hub" referral centers. However, only a few among eligible patients actually receive treatment. Barriers to early administration of thrombolysis are represented by delays in presentation to referral centers, in-hospital and transfer delays, as well as changes in symptoms during assessment time. The aim of this study is to evaluate the safety and rate of thrombolysis provided in Emergency Department (ED) of a district hospital without neurological stroke team. Consecutive patients with AIS treated with intravenous thrombolysis were prospectively enrolled in this observational study, conducted between May 2010 and December 2013. The main outcomes evaluated were: mortality, symptomatic intracerebral hemorrhage (ICH), systemic adverse events, and neurological recovery. Secondly, all patients admitted with ischemic stroke were retrospectively screened to assess the reasons for exclusion to treatment and the rate of thrombolysis delivered. During the study period, 43 patients with AIS received intravenous rt-PA treatment. The mortality rate at three months was 9.5 % (4/43; 95 % CI 2.6-22.1) and total ICH at any-time CT scan imaging was 18.6 % (8/43; 8.4-33.4). At seven days or at discharge, 35/43 patients (81.4 %; 66.6-91.6) presented a neurological improvement and 46.5 % (20/43; 31.2-62.3) a complete neurological recovery presenting a normal NIHSS, while 9.5 % of patients remained in steady conditions and other 9.5 % worsened (4/43; 2.6-22.1). Outcomes do not appear to be very different from those reported in SITS-MOST study cohort. Among the overall 732 patients with AIS, 117 (16.0 %; 13.4-18.8) were eligible for age and arrived within the three-hour window of time, and the thrombolysis rate was 5.9 % (43/732; 4.3-7.8). Administration of rt-PA in an ED setting without neurological specialized stroke unit seems to be feasible and safe after adequate training. Thrombolysis rate found seems to be favorably comparable with the national average in specialist stroke units. If such data were confirmed by studies of greater dimension, this may imply the ability to perform thrombolysis even in smaller centers without the neurologist, thus being able to treat a greater number of patients in the times proven effective for thrombolysis.

No abstract

Cardiac glycosides similar to digoxin are produced by different plants in nature. Nerium oleander, commonly grown as an ornamental shrub, can be found worldwide in temperate countries. Intentional or accidental ingestion of any part of the plant can lead to clinically relevant intoxication. A 63-year-old woman came to the emergency department with acute dyspeptic symptoms after eating vegetable soup flavored with unfamiliar flowers she have collected herself. However, the electrocardiography (ECG) showed abnormalities that raised suspicions for an overdose of digoxin-like cardiac glycosides. The patient was not on treatment with digoxin and a careful anamnesis revealed that she had eaten oleander leaves. Digoxin specific Fab antibody fragments were administered for marked bradycardia that was not responding to atropine administration, after counseling with the reference toxicology center. The patient was also treated with activated charcoal and magnesium sulphate, intravenous fluids and pantoprazole. Four days later she was discharged as asymptomatic, with normal sinus rhythm. Emergency physicians should be aware of this type of poisoning, especially in cases with typical ECG alterations in patients not treated with digoxin and medical history of plants ingestion. Cardio-active glycosides are present in different plants, often used inappropriately, with potential toxic effects and harmful drug interactions.