Hospital treatment of patients with ischemic stroke or transient ischemic attack using the "Get With The Guidelines" program

BACKGROUND: Adherence to evidence-based interventions for hospitalized patients who have experienced a stroke is suboptimal. We examined the association of process improvement and Internet-based data collection and decision support with stroke care. METHODS: A 1-year intervention study to assess performance measure adherence in hospitals using the "Get With The Guidelines-Stroke" program. The program included 18 410 patients with ischemic stroke or transient ischemic attack admitted to 99 volunteer community and teaching hospitals. Data from eligible patients in the preintervention baseline period were compared with data from 4 subsequent quarters for 12 acute care or secondary prevention measures and an all-or-none measure of care based on 7 prespecified measures. RESULTS: Significant improvements from baseline to the fourth quarter were seen in 11 of 13 measures: use of thrombolytic medications for patients with ischemic stroke presenting within 2 hours of onset, 23.5% vs 40.8% (P < .001); early use of antithrombotic medications, 88.2% vs 95.2% (P < .001); antithrombotic medications prescribed at discharge, 91.0% vs 97.9% (P < .001); anticoagulation agents for atrial fibrillation, 81.4% vs 96.5% (P < .001); smoking cessation counseling, 38.3% vs 54.5% (P < .001); lipid treatment for low-density lipoprotein levels 100 mg/dL or greater, 58.7% vs 77.0% (P < .001); diabetes mellitus treatment, 48.5% vs 83.5% (P = .001); and weight reduction counseling 32.5% vs 43.4% (P < .001). The all-or-none measure increased from 50.2% to 58.0% (P < .001). Complications from thrombolytic medications and prophylaxis for deep venous thrombosis did not change. CONCLUSION: Statistically and clinically significant improvement in 11 of 13 quality improvement measures for the treatment of patients hospitalized for cerebrovascular disease was seen in hospitals participating in the Get With The Guidelines program.     

树突状细胞与肝脏疾病

免疫反应的产生首先是由抗原提呈细胞(antigenpresenting cells,APC)捕获抗原,经其加工处理后将抗原信息传递给T,B淋巴细胞,从而引发一系列的特异性免疫应答.APC包括树突状细胞(dendritic cells,DC)、巨噬细胞(MΦ)、B细胞等,其中DC是人体内最具潜能的抗原提呈细胞(APC),能在体内外直接激活纯真(naive)T细胞,提呈抗原给MHC-Ⅰ类限制性CD8+和MHC-Ⅱ类限制性CD4+T淋巴细胞,诱导特异性免疫应答[1-6].     

瑞典老年高血压试验(STOP-Hypertension)

标　　题　瑞典老年高血压试验中的发病率及病死率作　　者　ＤａｈｌｏｆＢ,ＬｉｎｄｈｏｌｍＬＨ,ＨａｎｓｓｏｎＬ,ｅｔａｌ.　　参考文献　Ｌａｎｃｅｔ,1991,338:1281～1285研究的疾病　高血压病。目　　的　是为了评估抗高血压药物治疗对70～84岁老年高血压患者的益处岁的高血压患者,基础血压≥180/90ｍｍＨｇ,或舒张压≥105ｍｍＨｇ。进入试验前12个月内有心肌梗死、脑卒中、体位性低血压及血压>230/120ｍｍＨｇ者已除外。随　　访　随访1～4年,平均25个月。治疗方案　患者被随机安排接受药物或安慰剂治疗,药物治疗任选下列四种方案…     

Entry screening to delay local transmission of 2009 pandemic influenza A (H1N1)

Background  

After the WHO issued the global alert for 2009 pandemic influenza A (H1N1), many national health agencies began to screen travelers on entry in airports, ports and border crossings to try to delay local transmission.     

Molecular basis of altered red blood cell membrane properties in Southeast Asian ovalocytosis: role of the mutant band 3 protein in band 3 oligomerization and retention by the membrane skeleton

Southeast Asian ovalocytosis (SAO) is an asymptomatic trait characterized by rigid, poorly deformable red cells that resist invasion by several strains of malaria parasites. The underlying molecular genetic defect involves simple heterozygous state for a mutant band 3 protein, which contains a deletion of amino acids 400 through 408, linked with a Lys 56-to-Glu substitution (band 3-Memphis polymorphism). To elucidate the contribution of the mutant SAO band 3 protein to increased SAO red blood cell (RBC) rigidity, we examined the participation of the mutant SAO band 3 protein in increased band 3 attachment to the skeleton and band 3 oligomerization. We found first that SAO RBC skeletons retained more band 3 than normal cells and that this increased retention preferentially involved the mutant SAO band 3 protein. Second, SAO RBCs contained a higher percentage of band 3 oligomer-ankyrin complexes than normal cells, and these oligomers were preferentially enriched by the mutant SAO protein. At the ultrastructural level, the increased oligomer formation of SAO RBCs was reflected by stacking of band 3-containing intramembrane particles (IMP) into longitudinal strands. The IMP stacking was not reversed by treating SAO RBCs in alkaline pH (pH 11), which is known to weaken ankyrin-band 3 interactions, or by removing the cytoplasmic domain of band 3 from SAO membranes with trypsin. Finally, we found that band 3 protein in intact SAO RBCs exhibited a markedly decreased rotational mobility, presumably reflecting the increased oligomerization and the membrane skeletal association of the SAO band 3 protein. We propose that the mutant SAO band 3 has an increased propensity to form oligomers, which appear as longitudinal strands of IMP and exhibit increased association with membrane skeleton. This band 3 oligomerization underlies the increase in membrane rigidity by precluding membrane skeletal extension, which is necessary for membrane deformation.     

Advance Hospital Notification by EMS in Acute Stroke Is Associated with Shorter Door-to-Computed Tomography Time andIncreased Likelihood of Administration of Tissue-Plasminogen Activator

Background. Rapid brain imaging is a critical step in facilitating the use of intravenous (IV) tissue-plasminogen activator (tPA) or catheter-based thrombolysis. We hypothesized that advance notification by emergency medical services (EMS) would shorten emergency department (ED) arrival-to-computed tomography (CT) time andincrease the use of IV andintra-arterial thrombolysis, even at a tertiary care stroke center with high baseline rates of tPA use. Methods. We analyzed data on all acute stroke patients transported from March 2004 to June 2005 by EMS from the scene to our facility arriving ≤6 hours from symptom onset. We reviewed digital voice recordings of all EMS communications to our hospital andin-hospital time intervals andoutcomes from our stroke database. Results. Among the 118 patients who met criteria, there were no significant differences between those with notification (n = 44) andthose without (n = 74) in terms of age, gender, history of prior stroke, median National Institutes of Health Stroke Scale (NIHSS) score in the ED, proportion with mild stroke (NIHSS score ≤4), or mean onset-to-ED arrival time. Door-to-CT time was 17% shorter (40 vs. 47 minutes, p = 0.01) in the advance-notification group, andthrombolysis occurred twice as often (41% vs. 21%, p = 0.04). Conclusion. Advance notification of patient arrival by EMS shortened time to CT andwas associated with a modest increase in the use of thrombolysis at our hospital. This occurred even with protocols in place to shorten the time to CT for all acute stroke patients. Further research is needed to understand how to increase rates of advance notification by EMS in potential tPA candidates.     

"Hemicrania continua": another headache absolutely responsive to indomethacin

Two cases suffering from a headache apparently at variance with well recognized headaches are described. It is characterized by a steady, non-paroxysmal, probably severe to moderately severe hemicrania localized anteriorly or anteroposteriorly and is not associated with nausea. Indomethacin exerts an absolute, persistent and clearly dose-dependent effect on this headache, which differs from unilateral headache syndromes such as cluster headache and cervicogenic headache in its temporal pattern and indomethacin response. It differs from chronic paroxysmal hemicrania in its temporal pattern and in the lack of accompanying symptoms.