COMT Val158Met polymorphism is associated with post-traumatic stress disorder and functional outcome following mild traumatic brain injury

Mild traumatic brain injury (mTBI) results in variable clinical trajectories and outcomes. The source of variability remains unclear, but may involve genetic variations, such as single nucleotide polymorphisms (SNPs). A SNP in catechol-o-methyltransferase (COMT) is suggested to influence development of post-traumatic stress disorder (PTSD), but its role in TBI remains unclear. Here, we utilize the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study to investigate whether the COMT Val¹⁵⁸Met polymorphism is associated with PTSD and global functional outcome as measured by the PTSD Checklist – Civilian Version and Glasgow Outcome Scale Extended (GOSE), respectively. Results in 93 predominately Caucasian subjects with mTBI show that the COMT Met¹⁵⁸ allele is associated with lower incidence of PTSD (univariate odds ratio (OR) of 0.25, 95% CI [0.09–0.69]) and higher GOSE scores (univariate OR 2.87, 95% CI [1.20–6.86]) 6-months following injury. The COMT Val¹⁵⁸Met genotype and PTSD association persists after controlling for race (multivariable OR of 0.29, 95% CI [0.10–0.83]) and pre-existing psychiatric disorders/substance abuse (multivariable OR of 0.32, 95% CI [0.11–0.97]). PTSD emerged as a strong predictor of poorer outcome on GOSE (multivariable OR 0.09, 95% CI [0.03–0.26]), which persists after controlling for age, GCS, and race. When accounting for PTSD in multivariable analysis, the association of COMT genotype and GOSE did not remain significant (multivariable OR 1.73, 95% CI [0.69–4.35]). Whether COMT genotype indirectly influences global functional outcome through PTSD remains to be determined and larger studies in more diverse populations are needed to confirm these findings.     

Predictive Factors for Intracerebral Hemorrhage in Patients with Cavernous Angiomas

Abstract

Objectives: Prediction of intracerebral hemorrhage (ICH) in patients with cavernous angiomas is not totally elucidated. The aims of our study were to determine the rate of cerebral hemorrhage, its associated factors, and the clinical outcome in patients with cavernous angiomas in a Hispanic population.

Methods: We studied 133 patients with cavernous angiomas. The patients were classified into two groups depending on whether they presented an ICH. A comparative analysis of demographics and clinical data, neuroimaging characteristics, and prognosis was carried out in patients with and without hemorrhage. The hemorrhage rate (expressed as the percentage per patient per year) was also estimated.

Results: Seventy–eight patients (59%) had hemorrhage. Non–lobar location of angiomas was associated with hemorrhage [OR 4.82 (CI 95% 2.17–10.73; p=<0.001)]. In contrast, factors associated with a decreased risk of hemorrhage were a family history of epilepsy [OR 0.30 (CI 95% 0.10–0.79; p=0.016)] and lobar location of the angiomas [OR 0.21 (CI 95% 0.09–0.46; p=<0.001)]. The hemorrhagic rate of 1.71% per patient per year was influenced by the location. It was only 1.22% per patient per year in lobar angiomas and 2.33, 2.39, and 2.82% per patient per year for brainstem, cerebellum, and deep hemispheric angiomas, respectively.

Conclusions: The non–lobar location of cavernous angiomas gives a higher risk of hemorrhage in our Mexican mestizo population, without the hemorrhage being related to either age or sex.     

Association between plasma lipid levels and migraine in subjects aged ≥50 years: preliminary data from the Zabùt Aging Project

We evaluated the association between lipid levels and migraine using cross-sectional, population-based data of 1809 subjects aged ≥50 years; 151 subjects with migraine and 1658 nonmigraineurs were included. Diagnosis of migraine was carried out using the criteria of the International Headache Society. The following plasma lipids were collected: total cholesterol (TC), lowdensity lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG). Only TC (p<0.003) and LDL-C levels (p<0.004) were significantly higher in migraineurs than nonmigraineurs. After multiple adjustments, only elevated TC (≥220 mg/dl) was significantly associated with migraine (OR [95% CI]=1.6 [1.1–2.3]); this association increased in elderly males with migraine (OR [95% CI]=3.8 [1.4–9.9]). According to our results, TC plasma levels should be closely monitored in elderly males with migraine.

     

Off-label-dosing of non-vitamin K-dependent oral antagonists in AF patients before and after stroke: results of the prospective multicenter Berlin Atrial Fibrillation Registry

Aims

We aimed to analyze prevalence and predictors of NOAC off-label under-dosing in AF patients before and after the index stroke.

Methods

The post hoc analysis included 1080 patients of the investigator-initiated, multicenter prospective Berlin Atrial Fibrillation Registry, designed to analyze medical stroke prevention in AF patients after acute ischemic stroke.

Results

At stroke onset, an off-label daily dose was prescribed in 61 (25.5%) of 239 NOAC patients with known AF and CHA₂DS₂-VASc score ≥ 1, of which 52 (21.8%) patients were under-dosed. Under-dosing was associated with age ≥ 80 years in patients on rivaroxaban [OR 2.90, 95% CI 1.05–7.9, P = 0.04; n = 29] or apixaban [OR 3.24, 95% CI 1.04–10.1, P = 0.04; n = 22]. At hospital discharge after the index stroke, NOAC off-label dose on admission was continued in 30 (49.2%) of 61 patients. Overall, 79 (13.7%) of 708 patients prescribed a NOAC at hospital discharge received an off-label dose, of whom 75 (10.6%) patients were under-dosed. Rivaroxaban under-dosing at discharge was associated with age ≥ 80 years [OR 3.49, 95% CI 1.24–9.84, P = 0.02; n = 19]; apixaban under-dosing with body weight ≤ 60 kg [OR 0.06, 95% CI 0.01–0.47, P < 0.01; n = 56], CHA₂DS₂-VASc score [OR per point 1.47, 95% CI 1.08–2.00, P = 0.01], and HAS-BLED score [OR per point 1.91, 95% CI 1.28–2.84, P < 0.01].

Conclusion

At stroke onset, off-label dosing was present in one out of four, and under-dosing in one out of five NOAC patients. Under-dosing of rivaroxaban or apixaban was related to old age. In-hospital treatment after stroke reduced off-label NOAC dosing, but one out of ten NOAC patients was under-dosed at discharge.

Clinical trial registration

NCT02306824.

     

Association of C-reactive protein with mild cognitive impairment

BackgroundInflammation is proposed to play a role in the development of Alzheimer's disease, and may also be involved in the pathogenesis of mild cognitive impairment (MCI). This study examined the association of inflammatory markers in serum or plasma with prevalent MCI and MCI subtypes in a population-based sample.MethodsOlmsted County, MN, residents aged 70–89 years on October 1, 2004, were evaluated using the Clinical Dementia Rating Scale, a neurological evaluation, and neuropsychological testing. Information ascertained for each participant was reviewed by an expert panel of neuropsychologists, physicians, and nurses, and a diagnosis of normal cognition, MCI, or dementia was made by consensus. C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis alpha (TNFα), and adiponectin were measured at baseline.ResultsAmong 313 subjects with MCI and 1570 cognitively normal subjects, a CRP level in the upper quartile (>3.3 mg/L) was significantly associated with MCI (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.00–2.01) and with nonamnestic MCI (OR, 2.05; 95% CI, 1.12–3.78) after adjusting for age, sex, and years of education. However, there was no association with amnestic MCI (OR, 1.21; 95% CI, 0.81–1.82). No association was observed with the other inflammatory markers.ConclusionsPlasma CRP is associated with prevalent MCI and with nonamnestic MCI in elderly, nondemented persons in a population-based setting. These findings suggest the involvement of inflammation in the pathogenesis of MCI.     

Increased risk of dementia in people with previous exposure to general anesthesia: A nationwide population-based case–control study

BackgroundDementia, which leads to disability, is one of the important diseases occurring among older populations. However, the exact mechanism of the disease remains unknown. The potential risk factor of general anesthesia (GA) in the development of dementia is a controversial topic. Therefore, this study aimed to evaluate the association between previous exposure to different GA types and the incidence of dementia.MethodsUsing the claims data of 1 million insured residents covered by Taiwan's universal health insurance from 2005 to 2009, 5345 newly diagnosed dementia patients older than 50 years were eligible for the study group. The control group, which consisted of 21,380 individuals without dementia, was matched for age, gender, and index date. GA was categorized into three subtypes: endotracheal tube intubation general anesthesia (ETGA), intravenous injection general anesthesia (IVGA) or intramuscular injection general anesthesia (IMGA), and heavy sedation. The multiple logistic regression model was used for analyses.ResultsIndividuals exposed to surgery under ETGA (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.25–1.44) and those exposed to surgery under IVGA or IMGA (OR, 1.28; 95% CI, 1.14–1.43) were at significantly higher risk of dementia in a dose–response relationship (P < .0001), whereas surgery under heavy sedation was not associated with increased risk of dementia (OR, 1.04; 95% CI, 0.68–1.59). The dementia risk for subjects with diabetes mellitus who received surgery under ETGA (OR, 1.59; 95% CI, 1.42–1.78), hypertension (OR, 1.98; 95% CI, 1.78–2.21), atherosclerosis (OR, 1.35; 95% CI, 1.22–1.50), or after having experienced a stroke (OR, 3.52; 95% CI, 3.13–3.97), but no interaction was found between surgery under ETGA and depression for the risk of dementia.ConclusionsA history of previous exposure to surgery under GA might be associated with an increased risk of dementia, particularly in subjects who have undergone repeated exposure to GA. In addition, subjects who had received surgery under ETGA with comorbidities such as stroke, hypertension, diabetes mellitus, and atherosclerosis could have a potential relationship with dementia risk.     

Plasma trimethylamine N-oxide,a gut microbe–generated phosphatidylcholine metabolite,is associated with autism spectrum disorders

ObjectiveThe compositions of the gut microbiota and its metabolites were altered in individuals with Autism Spectrum Disorder (ASD). The aim of this study was to assess whether plasma levels of gut-derived metabolite trimethylamine N-oxide (TMAO) were associated with ASD and the degree of symptom severity.MethodsFrom September 2017 to January 2019, a total of three hundred and twenty-eight Chinese children (164 with ASD and 164 their age-sex matched control subjects) aged 3–8 years were included. TMAO levels in plasma were determined using high-performance liquid chromatography tandem mass spectrometry (LC/MS/MS). Logistic regression analysis was used to examine the TMAO-ASD association.ResultsIn the study, the median age of the ASD group was 5 years (interquartile range [IQR], 4–6 years) and 129 (78.7%) were boys. The median plasma levels of TMAO in children with ASD and typically-developing (TD) children at admission were 4.2 (IQR, 3.0–5.6) μmol/l and 3.0 (2.0–4.4) μmol/l, respectively (P < 0.001). For each 1 μmol/l increase of plasma TMAO, the unadjusted and adjusted risk of ASD would be increased by 54% (with the odds ratios [OR] of 1.54; 95% confidence intervals [CI]: 1.32–1.78; P < 0.001) and 27% (1.27 [1.10–1.45], P < 0.001), respectively. Symptom severity was classified as mild-to-moderate (CARS < 37) for 66 children with ASD (40.2%). In these children, the plasma levels of TMAO were lower than in the 98 children with ASD (59.8%) whose symptoms were classified as severe (CARS > 36) (3.5[2.5–4.9] μmol/l vs. 4.5(3.7–6.0) μmol/l; P < 0.001). For each 1 μmol/l increase of plasma TMAO, the unadjusted and adjusted risk of severe autism would be increased by 61% (with the OR of 1.61 [95% CI 1.28–2.01], P < 0.001) and 31% (1.31 [1.08–1.49], P < 0.001), respectively.ConclusionsElevated plasma levels of TMAO were associated with ASD and symptom severity.     

Association of VDR gene polymorphisms with risk of relapsing-remitting multiple sclerosis in an Iranian Kurdish population

Purpose: The purpose of this study was to evaluate the association of VDR Apa-I, Bsm-I, Fok-I, Taq-I single nucleotide polymorphisms (SNPs) with multiple sclerosis (MS) risk in an Iranian Kurdish population.

Materials and methods: A population including of 118 patients and 124 healthy matched controls were recruited to the study. Genotyping of the SNPs was accomplished using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).

Results: The frequency of allele T of Fok-I (P = 0.003) and allele C of Taq-I (P = 0.0003) was significantly different between case and control subjects and showed significant association with risk of MS (OR = 1.84, 95% CI = 1.23–2.76; OR = 1.98, 95% CI = 1.36–2.87, respectively). CT genotype (OR = 1.7, 95% CI = 1.05–2.99) of Fok-I and CC genotype (OR = 2.18, 95% CI = 1.05–4.52) of Taq-I showed a predisposing effect. Combined TT+TC vs. CC for Fok-I (OR = 2.15, 95% = CI 1.29–3.60) and combined CC+TC vs. TT for Taq-I (OR = 2.58, 95% CI 1.51–4.40) were susceptibility genotypes for MS. Apa-I and Bsm-I were not significantly associated with risk of MS (OR < 1, P > 0.05) and any genotypes in any genetic models were not significantly different between cases and controls (P > 0.05).

Conclusion: As a result, Fok-I and Taq-I showed significant association with risk of MS, while Apa-I and Bsm-I were not observed to be related to the risk of the disease in this population.     

Outcomes among patients with primary angiitis of the CNS: A Nationwide United States analysis

BackgroundPrimary angiitis of the central nervous system (PACNS) is a relapsing-remitting disease with a heterogeneous course. Case series have delineated the long-term disease course but not acute outcomes or their determinants. The national United States hospital burden of PACNS has not been quantified.MethodsAnalysis of the United States Nationwide Readmissions Database (2016–2018) to characterize the frequency of PACNS hospitalizations, demographic features, inpatient mortality, and discharge outcomes.ResultsDuring the 3-year study period, unweighted 1843 (weighted 3409) patients with PACNS were admitted to the 1078 Healthcare Cost and Utilization Project HCUP participating hospitals; with weighting, this value indicates that 1136 patients were admitted each year to US hospitals, representing yearly 0.01 cases per 100 000 national hospitalizations. The majority of patients were hospitalized in metropolitan teaching hospitals (81.6%). The median age at admission was 54.9 (IQR: 44.0–66.5) years and 59.4% were women. Neurologic manifestations included ischemic stroke in 38.2%, transient ischemic attack in 20.2%, seizure disorder in 22.8%, and intracranial hemorrhage in 13.0%. Overall, 60.0% of patients were discharged home, 35.0% discharged to a rehabilitation facility or nursing home and 5.0% died before discharge. Patient features independently associated with the discharge to another facility or death included older age (odds ratio [OR], 1.03 [95% CI, [1.03–1.04]]), male sex (OR, 1.22 [1.04–1.43]), intraparenchymal hemorrhage (OR, 1.41 [1.08–1.84]), ischemic stroke (OR, 2.79 [2.38–3.28]), and seizure disorder (OR, 1.57 [1.31–1.89]).ConclusionOur study showed PACNS is still a rare inflammatory disorder of the blood vessels of the central nervous system suggesting an annual hospitalization of 5.1 cases per 1,000,000 person-years in the more diverse and contemporary US population. Overall, 4 in 10 had unfavorable discharge outcome, being unable to be discharged home, and 1 in 20 died before discharge.     

Motor imagery as a complementary technique for functional recovery after stroke: a systematic review

Objective: To evaluate factors associated with 1-year mortality after discharge for acute stroke.

Methods: In this retrospective cohort study, we studied 305 patients with ischemic stroke or intracerebral hemorrhage discharged in 2010/2011. We linked Get With The Guidelines®-Stroke clinical data with New York State administrative data and used multivariate regression models to examine variables related to 1-year all-cause mortality poststroke.

Results: The mean age was 68.6 ± 14.8 years and 51.1% were women. A total of 146 (47.9%) were discharged directly home, 96 (31.5%) to inpatient rehabilitation facilities (IRFs), and 63 (20.7%) to skilled nursing facilities (SNFs). Overall, 24 (7.9%) patients died within 1-year post-discharge. Older age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.00–1.10), higher National Institutes of Health Stroke Scale (NIHSS) on admission (OR 1.10, 95% CI 1.03–1.17), and discharge destination (IRF vs. home, OR 0.10, 95% CI 0.01–0.94; and SNF vs. home, OR 2.22, 95% CI 0.71–6.95) were factors associated with 1-year all-cause mortality. When ambulation status at discharge was added to the model, ambulation with assistance and non-ambulation were significantly associated with mortality (ambulatory with assistance vs. ambulatory, OR 9.42, 95% CI 1.87–47.61; nonambulatory vs. ambulatory, OR 12.65, 95% CI 1.89–84.89).

Conclusions: While age and NIHSS on admission are important predictors of long-term outcomes, factors at discharge – ambulation status at discharge and discharge destination – are associated with 1-year mortality post-discharge for acute stroke and therefore could represent therapeutic targets to improve long-term survival in future studies.     

Noncontrast computed tomography markers of outcome in intracerebral hemorrhage patients

ABSTRACT

Objectives: The characterization of markers capable of predicting clinically significant hematoma growth (HG) in patients with intracerebral hemorrhage (ICH) may be useful for the selection of patients for clinical trials. The use of several noncontrast computed tomography (NCCT) markers has been suggested to stratify the risk of HG. The aim of this study was to analyze HG prediction using different NCCT markers in patients with spontaneous ICH.

Methods: Single-hospital retrospective study of patients with spontaneous ICH, who underwent initial NCCT <24 hours after symptom onset. Clinical characteristics were collected and two independent observers analyzed hemorrhage characteristics, volumes and 8 NCCT markers. HG was defined as a growth of ≥33% or ≥6mL in follow-up CT and 30-day survival was collected.

Results: 328 patients were included. The most frequent NCCT marker was ‘any hypodensity’ (68.0%) and the less frequent was the blend sign (11.6%). HG occurred in 22.1% of patients and the only independent predictors for HG were ‘any hypodensity’ (OR=3.32, 95%CI=1.18–9.34, p=0.023) and the swirl sign (OR=3.98, 95%CI=1.41–11.21, p=0.009). Although all NCCT markers were more frequent in patients who died within 30 days, the only independent predictors were ‘irregular margins’ (OR=4.54, 95%CI=1.63–12.66, p=0.004) and the satellite sign (OR=2.49, 95%CI=1.07–5.75, p=0.034). NCCT markers with greater sensitivity for HG were ‘any hypodensity’ and the swirl sign, although with poor positive predictive values and poor areas under the curve.

Conclusion: Even though some NCCT markers are independent predictors of HG and 30-day survival, they have suboptimal diagnostic test performances for such outcomes.

Abbreviation: OR: odds ratio; 95%CI: 95% confidence interval     

Social and behavioral predictors of insufficient sleep among African Americans and Caucasians

BackgroundFew studies have examined the social and behavioral predictors of insufficient sleep.ObjectiveTo assess the social and behavioral predictors of insufficient sleep in the U.S. population.MethodsData from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) were analyzed. Telephone interviews were conducted in six representative states that completed the optional sleep module. A total of 31,059 respondents were included in the present analysis. BRFSS-provided weights were applied to analyses to adjust for the use of complex design.ResultsThe mean age for the sample was 56 ± 16 years, with 63% of the sample being female; 88% identified as non-Hispanic white and 12% identified as non-Hispanic black; 42% were not married and 8% did not have a high school degree. The prevalence of insufficient sleep (<7 hours) was 37%. Multivariate-adjusted logistic regression revealed associations of four important factors with insufficient sleep, which were: working more than 40 hours per week [OR = 1.65, p < 0.001, 95% CI = 1.65–1.66], black race/ethnicity [OR = 1.37, p < 0.001, 95% CI = 1.37–1.38], history of heart disease [OR = 1.26, p < 0.001, 95% CI = 1.25–1.28], care-giving to family/friends [OR = 1.50, p < 0.001, 95% CI = 1.49–1.51], and lack of social and emotional support [OR = 1.24, p < 0.001, 95% CI = 1. 23–1.25].ConclusionSocial and behavioral predictors of health uniquely contribute to the report of insufficient sleep and should be considered when developing programs to increase awareness of the adverse effects of insufficient sleep.     

Novel peripheral blood cell ratios: Effective 3-month post-mechanical thrombectomy prognostic biomarkers for acute ischemic stroke patients

BackgroundRed blood cell distribution width to platelet ratio (RPR), Monocyte to high-density lipoprotein ratio (MHR), and Neutrophil to lymphocyte ratio (NLR) are novel inflammatory biomarkers in laboratory tests, which are associated with clinical outcomes in malignancy, cardiovascular and cerebrovascular diseases. This study aimed to determine their predictive value for the prognosis of acute ischemic stroke after mechanical thrombectomy (MT).MethodsA total of 286 patients with acute ischemic stroke (AIS) admitted to a tertiary stroke center in China between January 2018 and February 2020 were treated by MT. Demographic characteristics, risk factors, clinical data, laboratory parameters, and clinical outcomes were recorded. The clinical outcome was disability or death at discharge or 90 days (defined as a modified Rankin Scale score of 3–6). The relationship between RPR, MHR, and NLR and functional outcomes was investigated by binary Logistic regression analysis, and further assessed by receiver operating characteristic curve (ROC). The Kaplan-Meier method was used to analyze the survival rate of prognosis factors.ResultsA total of 286 patients with AIS underwent MT (median age, 70.00; Interquartile range [IQR], 63.00–77.00; 41.6% female). Patients with unfavorable outcome showed higher RPR, MHR, and NLR than those with favorable outcome (RPR, [8.63; IQR, 6.30–10.78] vs [6.17; IQR, 5.11–7.35], P < 0.001; MHR, [0.40; IQR, 0.31–0.53] vs [0.34; IQR, 0.27–0.47], P = 0.005; NLR, [5.28; IQR, 3.63–8.02] vs [3.44; IQR, 2.63–4.63], P < 0.001). In multivariate and ROC curve analysis, higher RPR (>8.565) (odds ratio [OR], 1.671; 95% confidence interval [CI], 1.127–2.479; P = 0.011) and higher MHR (>0.368) (OR, 9.374; 95% CI, 1.160–75.767; P = 0.036), higher NLR (>4.030) (OR, 1.957; 95% CI, 1.382–2.770; P < 0.001) were independently associated with unfavorable outcome. The combined predictive value of the three indexes was higher than that of a single index. Kaplan-Meier survival curve analysis showed that the 90-day survival rate (82.1% vs 66.2%) was significantly different between the low RPR group and the high RPR group (χ² = 4.960, P = 0.026).ConclusionHigher RPR, MHR, and NLR might be independent risk factors for predicting 3-month poor prognosis in patients with AIS who underwent MT.     

Polypharmacy in nursing home residents with severe cognitive impairment: Results from the SHELTER Study

ObjectivePharmacological treatment of older adults with cognitive impairment represents a challenge for prescribing physicians, and polypharmacy is common in these complex patients. The aim of the current study is to assess prevalence and factors related to polypharmacy in a sample of nursing home (nursing home) residents with advanced cognitive impairment.MethodsWe conducted a cross-sectional analysis of 1449 nursing home residents with advanced cognitive impairment participating to the Services and Health for Elderly in Long Term Care (SHELTER) project, a study collecting information on residents admitted to 57 nursing home in eight countries. Data were collected using the International Resident Assessment Instrument (InterRAI) for long-term care facilities. Polypharmacy status was categorized into three groups: nonpolypharmacy (zero to four drugs), polypharmacy (five to nine drugs), and excessive polypharmacy (≥10 drugs).ResultsPolypharmacy was observed in 735 residents (50.7%) and excessive polypharmacy was seen in 245 (16.9%). Compared with nonpolypharmacy, excessive polypharmacy was associated directly with ischemic heart disease (odds ratio [OR], 3.68; 95% confidence interval [CI], 2.01–6.74), diabetes mellitus (OR, 2.66; 95% CI; 1.46–4.84), Parkinson's disease (OR, 2.84; 95% CI, 1.36–5.85), gastrointestinal symptoms (OR, 1.20; 95% CI, 1.43–3.39), pain (OR, 3.12; 95% CI, 1.99–4.89), dyspnea (OR, 2.57; 95% CI, 1.31–5.07), and recent hospitalization (OR, 2.56; 95% CI, 1.36–5.85). An inverse relation with excessive polypharmacy was shown for age (OR, 0.74; 95% CI, 0.59–0.93), activities of daily living disability (OR, 0.79; 95% CI, 0.63–0.99) and presence of a geriatrician on the nursing home staff (OR, 0.36; 95% CI, 0.20–0.64).ConclusionPolypharmacy and excessive polypharmacy are common among nursing home residents with advanced cognitive impairment. Determinants of polypharmacy status includes not only comorbidities, but also specific symptoms, age, and functional status. A geriatrician in the facility is associated with lower prevalence of excessive polypharmacy.     

Postconcussion symptom reporting is not associated with diffusion tensor imaging findings in the subacute to chronic phase of recovery in military service members following mild traumatic brain injury

Introduction: The purpose of this study was to examine the relation between white matter integrity of the brain and postconcussion symptom reporting following mild traumatic brain injury (MTBI).

Method: Participants were 109 U.S. military service members (91.7% male) who had sustained a MTBI (n = 88) or orthopedic injury without TBI (trauma controls, TC, n = 21), enrolled from the Walter Reed National Military Medical Center, Bethesda, Maryland. Participants completed a battery of neurobehavioral symptom measures and underwent diffusion tensor imaging (DTI; General Electric 3T) of the whole brain, on average 44.9 months post injury (SD = 42.3). Measures of fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) were generated for 18 regions of interest (ROIs). Participants in the MTBI group were divided into two subgroups based on International Classification of Diseases–10th Revision (ICD–10) Category C criteria for postconcussion syndrome (PCS): PCS-present (n = 41) and PCS-absent (n = 47).

Results: The PCS-present group had significantly worse scores on all 13 neurobehavioral measures than the PCS-absent group (p < .001, d = 0.87–2.50) and TC group (p < .003, d = 0.84–2.06). For all ROIs, there were no significant main effects across the three groups for FA, MD, AD, and RD (all ps >.03). Pairwise comparisons revealed no significant differences for all ROIs when using FA and RD, and only two significant pairwise differences were found between PCS-present and PCS-absent groups when using MD and AD [i.e., anterior thalamic radiation and cingulate gyrus (supracallosal) bundle].

Conclusions: Consistent with past research, but not all studies, postconcussion symptom reporting was not associated with white matter integrity in the subacute to chronic phase of recovery following MTBI.     

Incidencia,pronóstico y predicción de la transformación hemorrágica tras el tratamiento revascularizador del ictus

IntroductionHaemorrhagic transformation is a major complication of acute ischaemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial haemorrhage (ICH) after revascularisation therapy.MethodsWe conducted a retrospective, single-centre study including 235 patients with AIS who underwent intravenous recombinant tissue plasminogen activator (IV-rtPA) therapy and/or endovascular treatment. A binary logistic regression model was used to determine the variables associated with ICH, parenchymal haematomas (PH), modified Rankin Scale (mRS) scores, and mortality.ResultsICH was detected in 57 (30 with PH) of 183 patients included. Mechanical thrombectomy, either alone (OR 3.3 [1.42-7.63], P=.005) or in combination with IV-rtPA (OR 3.39 [1,52-7.56], P=.003), was associated with higher risk of ICH, while higher Alberta Stroke Program Early CT scores (OR 0.71 [0.55-0.91], P=.007) were associated with lower risk. Patients with older age (OR 1.07 [1.02-1.13], P=.006) and occlusion of the terminal branch of the internal carotid artery (OR 4.03 [1.35-11.99], P = .012) had a higher risk of PH, while the use of IV-rtPA alone (OR 0.24 [0.08-0.68], P=.008) was associated with lower risk of PH. Only PH was associated with disability as measured by the mRS (OR 3.2 [1.17-8.76], P=.02) and higher mortality (OR 5.06 [1.65-15.5], P=.005).ConclusionsGreater understanding about the predictors of ICH, mRS scores, and mortality could enable better selection of patients and treatments.     

Genetically Predicted Cardiac Troponin I Concentrations and Risk of Stroke and Atrial Fibrillation

ObjectivesObservational studies have shown that elevated circulating cardiac troponin I (cTnI) concentrations were linked to higher risk of stroke and atrial fibrillation, but the causality remains unclear. Therefore, we used mendelian randomization to assess the potential causal effects of cTnI concentrations on the risk of stroke, its subtypes and atrial fibrillation.Materials and methodsThe instrumental variables for circulating cTnI concentrations were selected from a genome-wide association study meta-analysis of 48,115 European individuals. We examined the associations of circulating cTnI concentrations with stroke, ischemic stroke, ischemic stroke subtypes (cardioembolic, large artery, small vessel stroke), intracerebral hemorrhage and atrial fibrillation.ResultsGenetically predicted elevated circulating cTnI concentrations were associated with higher risk of cardioembolic stroke (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.20–2.68; P = 0.004), but not associated with large artery stroke, small vessel stroke, total stroke, ischemic stroke and intracerebral hemorrhage. Additionally, we also found that elevated cTnI concentrations were causally linked to higher risk of atrial fibrillation (OR, 1.30; 95% CI, 1.10–1.53; P = 0.003).ConclusionsThis study provides evidence that genetically predicted circulating cTnI concentrations are causally linked to higher risk of cardioembolic stroke and atrial fibrillation.     

Electromyographic comparison of conventional machine strength training versus bodyweight exercises in patients with chronic stroke

Objective: To investigate whether bodyweight exercises can induce comparable levels of muscle activity as conventional machine exercises in chronic stroke patients.

Methods: Eighteen patients performed three repetitions of bilateral- and unilateral machine leg press and the bodyweight exercises chair rise and hip thrust. Surface electromyography (EMG) was recorded from 10 lower extremity muscles and normalized to maximal EMG (nEMG) of the non-paretic leg.

Results: For the paretic leg, the bodyweight exercises showed comparable levels of nEMG in 6 out of 10 muscles compared with the bilateral leg press. Vastus lateralis nEMG was higher during bilateral leg press compared with hip thrust (38% [95% CI 33–42] vs. 10% [95% CI 6–15], p < 0.0001) and chair rise (38% [95% CI 33–42] vs. 27% [95% CI 22–32], p < 0.0001). Vastus medialis nEMG was higher during bilateral leg press compared with hip thrust (34% [95%CI 27–40] vs. 8% [95% CI 2–15], p < 0.0001). Unilateral leg press showed higher nEMG compared with bilateral leg press in biceps femoris (28% [95% CI 23–34] vs. 19% [95% CI 13–24], p = 0.0009), gluteus maximus (32% [95% CI 23–41] vs. 25% [95% CI 16–34], p < 0.05), and vastus medialis (42% [95% CI 36–48] vs. 34% [95% CI 27–40], p = 0.0013).

Discussion: In patients with chronic stroke, bodyweight exercises activate the majority of the lower limb muscles to comparable levels as bilateral leg press performed in machine. In addition, unilateral leg press was superior to the bilateral leg press and both bodyweight exercises.     

Intra-arterial thrombolysis as adjunct to mechanical thrombectomy in acute ischemic stroke patients in the United States: A case control analysis

BackgroundAlthough observational studies have reported favorable clinical outcomes associated with intra-arterial thrombolysis as adjunct to mechanical thrombectomy, the cost and length of hospitalization associated with this intervention has not been studied.MethodsWe analyzed the nationally representative data of the United States data from Nationwide Inpatient Sample (NIS) to compare hospitalization cost and duration in addition to other outcomes in patients receiving (n = 1990) with those not receiving intra-arterial thrombolysis (n = 1990) in acute ischemic stroke patients undergoing mechanical thrombectomy using a case control design matched for age, gender, and presence of aphasia, hemiplegia, neglect, coma/stupor, hemianopsia and dysphagia.ResultsThere was no difference in the median hospitalization cost in patients treated with intra-arterial thrombolysis compared with those not treated with intra-arterial thrombolysis: $36,992 [28,361 to 54,336] versus $35,440 [24,383 to 50,438], (regression coefficient 2,485 [-1,947 to 6,917], p = 0.27). There was no difference in the median length of hospitalization in patients treated with intra-arterial thrombolysis compared with those not treated with intra-arterial thrombolysis: 6 days [3 to 10] versus 6 days [4 to 10], (regression coefficient -0.34 [-1.47 to 0.80], p = 0.56). There was no difference in odds of home-discharge (OR 1.02 95%CI 0.72-1.43, p = 0.93) or post-procedural intracranial hemorrhage (OR 1.16 95%CI 0.83-1.64, p = 0.39) between the two groups.ConclusionsWe did not observe an increase in the cost or length of hospitalization associated with the use of intra-arterial thrombolysis as adjunct to mechanical thrombectomy in acute ischemic stroke patients. If the ongoing randomized clinical trials demonstrate therapeutic efficacy in reducing death or disability, this intervention has a high likelihood of being beneficial overall.