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Enrique C Leira

Publications and source records attributed to Enrique C Leira.

11 recordsLinked to original sources
PubMed2006

Feasibility of acute clinical trials during aerial interhospital transfer.

BACKGROUND AND PURPOSE: In rural America, patients are often first seen at a small community hospital and then transferred to a tertiary care center by helicopter for further care. If acute clinical research were feasible during the aerial interhospital transport, more patients might be enrolled in trials at a critical earlier stage. METHODS: Prospective data were collected for all aerial transfers of a university-based helicopter service from April 2005 to January 2006. Flight nurses were educated about stroke research and offered certification and participation. Data collected included patient characteristics and the availability of relatives to provide surrogate consent. RESULTS: All 12 flight nurses completed the institutional review board certification requirements and collected data on 215 transfers. Sixty-one patients had acute stroke or myocardial events (MIs). The median time from symptom onset to helicopter arrival at an outside hospital was 213 minutes (range, 90 to 2135) for ischemic stroke (n=12), 186 (45 to 1332) for intracranial hemorrhage (n=28), and 157 (47 to 1044) for MI (n=21). A relative was available in >74% of those transfers. A trial with a 4-hour window would permit enrollment of 67% of the ischemic strokes, 82% of intracranial hemorrhage cases, and 76% of MI patients. CONCLUSIONS: Clinical trials are feasible during aerial interhospital transport of patients. Flight nurses became successful investigators in clinical research and were exposed to potentially eligible patients with the ability to consent either directly or through surrogates. This approach could improve current clinical trial recruitment in rural areas, as well as permit testing of inflight ancillary interventions to improve outcome during patient transport.

Acute Disease↗
PubMed2005

Improving pilot response to in-flight strokes: a randomized controlled trial.

BACKGROUND: When a passenger suffers an in-flight stroke (IFS), the pilot decides when to expedite access to ground care. Pilot pro-activeness towards IFS could improve outcome and should be promoted. Unfortunately, little is known about a pilot's stroke pro-activeness or limiting factors. METHODS: Randomized controlled trial of an educational intervention (American Stroke Association, 30-slide stroke awareness lecture) through an internet-based computer system using pilot students and instructors as subjects. Pilots completed pre-intervention and post-intervention tests of 25 simulated in-flight scenarios that describe strokes and other neurological and medical symptoms. Outcomes chosen were the percentage of pilots that would use a medical radio service, declare an emergency on board, or divert to the nearest airport for each scenario. RESULTS: Participant pilots (n = 104) were less likely to respond to IFS than to myocardial infarction (p < 0.001). Fear of retaliation by an employer was the most important modifiable limitation. The educational program increased the simulated rate of emergency declarations for in-flight vertebrobasilar strokes (p < 0.001) and subarachnoid hemorrhage (p < 0.001). CONCLUSIONS: Pilot-simulated response to certain IFS improves immediately after this educational intervention, which should be disseminated in schools and airlines. Further studies are needed to determine the long-term benefits of this intervention and the impact on actual diversion rates. Companies should also review their policies to shield pilots from retaliation when altering the flight plan for patients.

Aviation↗
PubMed2005

Blood pressure surge precedes intracerebral hemorrhage.

INTRODUCTION: Most patients with acute intracerebral hemorrhage (ICH) have very high blood pressure (BP) on presentation, but it is unclear whether such pressure elevation is the cause or a consequence of the ICH. This controversy could be clarified by determining the exact temporal relationship between the BP elevation and the onset of the ICH. Several case reports have attributed ICH to specific situations in which the BP was inferred to be high. Unfortunately, those cases lacked continuous monitoring of BP and neurological exam. METHODS: Single case observation in a University-based tertiary medical center. RESULTS: A neurologically intact 64-year-old woman whose BP and neurological status were monitored during admission to a medical intensive care unit. The patient suddenly developed a decreased level of consciousness and a right hemispheric syndrome 3.5 hours after demonstrating systolic BP values in the range 200 mmHg. An unenhanced computed tomography scan of the brain demonstrated a right ICH. CONCLUSION: In this monitored case, the BP surge clearly preceded the onset of neurological symptoms by 3.5 hours, supporting the view that the acute BP elevation was the cause of ICH.

Blood Pressure↗
PubMed2005

Cerebral air embolism secondary to intra-aortic balloon pump rupture.

INTRODUCTION: Cerebral air embolism is a neurological emergency. It has been reported following cardiac catheterization, central venous catheter insertion, and cardiothoracic surgery. METHODS AND RESULTS: We report a case of massive cerebral air embolism secondary to intra-aortic balloon pump (IABP) rupture. Computed tomography (CT) of the brain showed serpiginous hypodensities following the sulci associated with hypodense brain parenchymal lesions. CONCLUSION: The prompt recognition of cerebral air embolism secondary to IABP rupture requires a high level of suspicion and is confirmed by head CT.

Embolism, Air↗
PubMed2004

Can we predict early recurrence in acute stroke?

BACKGROUND: The prevention of early recurrent stroke, which worsens outcomes after a cerebral infarction, is a major objective for acute stroke therapy. The ability to predict which patients are at risk for early recurrence would be useful for both the management and design of clinical trials. METHODS: Using the prospective database with the 1,266 stroke patients admitted in the TOAST study, we analyzed all the patients who had suffered either a transient ischemic attack (TIA) or a recurrent stroke within 3 months after stroke, and their possible association with 20 selected clinical variables. Both univariate and stepwise regression analyses were performed. RESULTS: Sixty-two patients (4.9%) had a second stroke, and 47 patients (3.7%) had at least one TIA. No particular high-risk period was observed. Early recurrent stroke was associated with the large artery atherosclerosis subtype. A prior history of TIA increased the odds for recurrent stroke (OR = 2.52; 1.16-5.46) or poststroke TIA (OR = 3.46; 1.59-7.48). In addition, patients who had a TIA after the stroke had a 17% chance of having an early recurrent stroke, as compared with 4.4% among those that did not (p = 0.001). CONCLUSION: Our present ability to identify patients at risk for early recurrence based on baseline clinical features remains limited. While the presence of TIA before or after the stroke denotes a subgroup of acute stroke patients at higher risk for early recurrence in the first 3 months, no other factors reliably identify high-risk patients.

Acute Disease↗
PubMed2003

Continuous or emergent EEG: can bedside caregivers recognize epileptiform discharges?

OBJECTIVE: When emergent or continuous EEG monitoring is carried out to detect subclinical seizures, expert interpretation of the results is usually not immediately available. We assessed the ability to recognize epileptiform discharges among various nonexpert bedside caregivers. A second objective was to determine whether such skill improves with a simple educational intervention. DESIGN AND SETTING: A prospective cohort study with an educational intervention in a university-based tertiary medical center. PARTICIPANTS: All 125 neurology and neurosurgery residents, intensive care fellows, critical care and neurological floor nurses, and EEG technicians were offered participation. Of these, 50 completed the study and provided 2,398 EEG responses. INTERVENTIONS: A computer-based PowerPoint lecture designed to teach recognition of epileptiform discharges. MEASUREMENTS AND RESULTS: (a) Average number of correct responses in identifying epileptiform discharges in a computer-based pre-test consisting of 24 EEG questions. (b) Impact of the educational intervention as measured by change in the mean average score in a similar post-test. The rate of correct responses by group ranged from 46% for medical critical care nurses to 94% for EEG technicians. Overall mean correct response rate was 14.72 (61%) for the pre-test, and increased to 16.06 (67%) in for post-test (p=0.002). CONCLUSIONS: Recognition of epileptiform discharges by bedside caregivers is disturbingly low. A simple educational intervention only modestly improved such ability. Therefore we should not rely on nontrained personnel to interpret emergent or continuous recordings. EEG technicians are an exception, and their skill could be utilized during emergent studies.

Cohort Studies↗
PubMed2003

Early recovery after cerebral ischemia risk of subsequent neurological deterioration.

Given the high short-term risk of stroke after transient ischemic attack, we hypothesized that substantial acute neurological recovery in patients presenting with cerebral ischemia would be associated with a greater risk of subsequent neurological deterioration due to recurrent cerebral ischemia. Data from the Trial of ORG10172 in Acute Stroke Treatment, a randomized trial of the heparinoid danaparoid, were analyzed to determine whether substantial acute recovery, defined as an improvement of greater than or equal to 75% on National Institutes of Health Stroke Scale (NIHSS) between baseline and 24 hours, was associated with a greater risk of subsequent deterioration, defined as a worsening on the NIHSS between day 1 and day 90. Of 1,184 subjects meeting entry criteria, 63 (5.3%) had substantial acute recovery. Subsequent deterioration was more common in those with substantial acute recovery compared with others (48 vs 33%; p = 0.028 by Fisher's exact test). In multivariable models, substantial acute recovery remained an independent predictor of subsequent deterioration (odds ratio, 3.0; 95% confidence interval, 1.7-5.2; p < 0.001). Among patients with acute cerebral ischemia, those who recover substantially within 24 hours may be at greater risk of subsequent neurological deterioration due to causes other than hemorrhage.

Aged↗