IMPORTANCE Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging, especially in low-and middle-income countries. OBJECTIVE To assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for care of patients with AIS and TIA. DESIGN, SETTING AND PARTICIPANTS This 2-arm cluster-randomized clinical trial assessed 45 hospitals and 2336 patients with AIS and TIA for eligibility before randomization. Eligible hospitals were able to provide care for patients with AIS and TIA in Brazil, Argentina, and Peru. Recruitment started September 12, 2016, and ended February 26, 2018; follow-up ended June 29, 2018. Data were analyzed using the intention-to-treat principle. INTERVENTIONS The multifaceted quality improvement intervention included case management, reminders, a roadmap and checklist for the therapeutic plan, educational materials, and periodic audit and feedback reports to each intervention cluster. MAIN OUTCOMES AND MEASURES The primary outcome was a composite adherence score for AIS and TIA performance measures. Secondary outcomes included an all-or-none composite end point of performance measures, the individual process measure components of the composite end points, and clinical outcomes at 90 days after admission (stroke recurrence, death, and disability measured by the modified Rankin scale). RESULTS A total of 36 hospitals and 1624 patients underwent randomization. Nineteen hospitals were randomized to the quality improvement intervention and 17 to routine care. The overall mean (SD) age of patients enrolled in the study was 69.4 (13.5) years, and 913 (56.2%) were men. Overall mean (SD) composite adherence score for the 10 performance measures in the intervention group hospitals compared with control group hospitals was 85.3% (20.1%) vs 77.8% (18.4%) (mean difference, 4.2%; 95% CI, −3.8% to 12.2%). As a secondary end point, 402 of 817 patients (49.2%) at intervention hospitals received all the therapies that they were eligible for vs 203 of 807 (25.2%) in the control hospitals (odds ratio, 2.59; 95% CI, 1.22-5.53; P = .01). CONCLUSIONS AND RELEVANCE A multifaceted quality improvement intervention did not result in a significant increase in composite adherence score for evidence-based therapies in patients with AIS or TIA. However, when using an all-or-none approach, the intervention resulted in improved adherence to evidence-based therapies.

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The post-polio syndrome (PPS) is an entity characterized for an episode of muscular weakness and/or abnormal muscular fatigue in individuals that had presented acute polio years before. We report the case of PPS in a patient, 40 years, that thirty-five years after had had paralytic poliomyelitis, developed new symptoms of fatigue, muscular atrophy, dyspnea, difficulties in deambulation and muscular and joint pain. The electromyographic findings revealed injuried neurons of the anterior horn of the marrow and reinnervation after muscular tests.

ResumoA segurança da farmacoterapia é essencial para o atendimento de idosos, evitando a polifarmácia inadequada. A desprescrição é um processo de revisão individual dos medicamentos usados por pacientes, que orienta os profissionais a considerar relações desfavoráveis de risco-benefício. Assim, o objetivo do artigo foi revisar a literatura existente relacionando pesquisas clínicas e fatores associados com a desprescrição de medicamentos em idosos. As bases consultadas resultaram em 18 artigos com diferentes tipos de intervenção, metodologia, avaliação pós-intervenção, guias de desprescrição, critérios utilizados e medicamentos descontinuados. Houve proporcionalidade entre os tipos de intervenção, demonstrando que não há um procedimento mais eficaz de descontinuação. Idosos que vivem em locais onde há uma maior estabilidade física e emocional tendem a uma melhor aceitação à desprescrição, assim como a descontinuação gradual se mostrou mais eficiente em polimedicados.Palavras-chave: Desprescrição, Descontinuação, Idosos, Geriatria

COVID-19 induces acute and long-term neurological symptoms. Determining the mechanisms underlying acute neurological disease will lead to a better understanding of long-COVID and late-onset outcomes. Here, we investigate in detail a cohort of COVID-19 patients presenting neurological alterations. Clinical and neurological investigation, brain imaging, and bio-sample analyses were carried out. We tested the possibility that COVID-19 shares molecular links with Alzheimer’s disease (AD)-like neurodegeneration by analyzing the framework of ATN (amyloid, pathologic Tau, and neurodegeneration) biomarkers. Altered cerebrospinal fluid (CSF) Tau and amyloid levels in severe COVID-19 patients were comparable to amnestic mild cognitive impairment (aMCI) and AD patients. Increased CSF pro-inflammatory cytokine IL6 and Tau linked systemic inflammation and disease severity to central nervous system alterations. COVID-19 patients presented an altered CSF proteomic pattern, with inflammatory, coagulopathy, and amyloidosis pathways alterations. Collectively, our findings reveal some molecular links between COVID-19 neurological disease and neurodegeneration biomarkers associated with AD.