Clinical characteristics and outcome of intracerebral hemorrhage in young adults

Data on determinants of prognosis after intracerebral hemorrhage (ICH) in young adults are scarce. Our aim was to identify clinical determinants of prognosis after ICH in adults aged 18–50. We investigated 98 consecutive patients with an ICH, aged 18–50 years, admitted to our hospital between 1980 and 2010. Collected ICH characteristics included presenting symptoms, etiology, location, severity and Glasgow Coma Scale (GCS). Outcomes were case-fatality (death within 30 days), poor functional outcome (modified Rankin Scale >2), long-term mortality and recurrent ICH. We assessed discriminatory power of factors associated with case-fatality [area under receiver operating curve (AUC)]. Case-fatality was 20.4 % (n = 20) and well predicted by the GCS (AUC 0.83). Among 30-day survivors, a poor functional outcome at discharge was present in 51.3 %. During a mean follow-up of 11.3 years mortality was only increased in patients aged 40–50 years [standardized mortality ratio 4.8 (95 % CI 2.3–8.6)], but not in patients aged 18–40 years. Recurrent ICH occurred in 6 patients [10-year cumulative incidence 12.2 % (95 % CI 1.5–22.9 %)], all with the index ICH attributable to structural vascular malformations. Prognosis after ICH in young adults is poor, mainly due to high case-fatality, that is well predicted by the GCS. An exception is 30-day survivors <40 years, who have a similar risk of dying as the general population. Recurrence risk is especially present in patients with structural vascular malformations, whereas risk seems to be very low in other patients.     

Primary Care in the Emergency Department – An Untapped Resource for Public Health Research and Innovation

With rising patient volumes and increasingly complex cases, the specialty of emergency medicine faces a growing array of challenges. Efforts have been made to improve patient throughput, yet little attention has been directed to the increasing amount of primary care delivered in emergency departments (EDs) for chronic disease states such as hypertension and diabetes. Management of chronic medical conditions is traditionally seen as beyond the purview of the ED, and emergency physicians tend to defer critical aspects of related patient care to other components of the healthcare continuum. As a result, vulnerable patients are often forced to navigate exceedingly complex and fragmented systems of care with little guidance, which often leads to inadequate treatment and exposure to increased risk for development of potentially avoidable complications. As evidenced by our experience with hypertension in an under resourced community, there is a crucial need for emergency physicians to espouse their role as providers of healthcare across the acuity spectrum and lead the way in defining regionally relevant solutions to better manage patients with chronic medical problems.     

The next era of transcatheter aortic valve replacement: A case illustrating the benefit of a fully re‐positionable,re‐sheathable,and retrievable prosthesis

While transcatheter aortic valve replacement (TAVR) is an accepted treatment modality in appropriately selected patients there remain modest complication rates. New TAVR devices, through novel design features, may overcome some of these complications. We present the first case of full re‐sheathing and retrieval of a Lotus Valve to facilitate a change in prosthesis size. © 2013 Wiley Periodicals, Inc.     

Monitoring polio supplementary immunization activities using an automated short text messaging system in Karachi,Pakistan

Problem

Polio remains endemic in many areas of Pakistan, including large urban centres such as Karachi.

Approach

During each of seven supplementary immunization activities against polio in Karachi, mobile phone numbers of the caregivers of a random sample of eligible children were obtained. A computer-based system was developed to send two questions – as short message service (SMS) texts – automatically to each number after the immunization activity: “Did the vaccinator visit your house?” and “Did the enrolled child in your household receive oral polio vaccine?” Persistent non-responders were phoned directly by an investigator.

Local setting

A cluster sampling technique was used to select representative samples of the caregivers of young children in Karachi in general and of such caregivers in three of the six “high-risk” districts of the city where polio cases were detected in 2011.

Relevant changes

In most of the supplementary immunization activities investigated, vaccine coverages estimated using the SMS system were very similar to those estimated by interviewing by phone those caregivers who never responded to the SMS messages. In the high-risk districts investigated, coverages estimated using the SMS system were also similar to those recorded – using lot quality assurance sampling – by the World Health Organization.

Lessons learnt

For the monitoring of coverage in supplementary immunization activities, automated SMS-based systems appear to be an attractive and relatively inexpensive option. Further research is needed to determine if coverage data collected by SMS-based systems provide estimates that are sufficiently accurate. Such systems may be useful in other large-scale immunization campaigns.     

Platelet-rich plasma preparation using three devices: Implications for platelet activation and platelet growth factor release

Background: In this study, three commercial systems for the preparation of platelet-rich plasma (PRP) were compared and platelet growth factors release was measured.

Methods: Ten healthy volunteers donated whole blood that was fractionated by a blood cell separator, and a table-top centrifuge to prepare PRP. Furthermore, an autologous growth factor filter was used to concentrate PRP fractionated by the blood cell separator. PRP was subsequently activated with autologously produced thrombin to degranulate the platelets to measure platelet-derived growth factor-AB (PDGF-AB), transforming growth factor-beta (TGF-β), insulin-like growth factor-1 (IGF-1), and vascular endothelial growth factor (VEGF).

Results: PRP contained significantly higher platelet counts compared with baseline values (p < 0.001). PDGF-AB concentrations were increased more than 18-fold in the platelet gel supernatant when the cell-separator and GPS were used, whereas only a 3-fold increase was seen with the AGF.

Conclusion: The three PRP devices enable the preparation of PRP for the release of high concentrations of platelet growth factor, but showed different harvesting capacities for the collection of concentrated platelets. The administration of thrombin for PRP activation resulted in the release of high concentrations of PDGF-AB and TGF-β but only when PRP had not been activated during the preparation process in vitro.     

DWI Reversal Is Associated with Small Infarct Volume in Patients with TIA and Minor Stroke

BACKGROUND AND PURPOSE:More than half of patients with TIA/minor stroke have ischemic lesions on early DWI, which represent irreversibly damaged tissue. The presence and volume of DWI lesions predict early deterioration in this population. We aimed to study the rate and implications of DWI reversal in patients with TIA/minor stroke.MATERIALS AND METHODS:Patients with TIA/minor stroke were prospectively enrolled and imaged within 24 hours of onset. Patients were followed for 3 months with repeat MR imaging either at day 30 or 90. Baseline DWI/PWI and follow-up FLAIR final infarct volumes were measured.RESULTS:Of 418 patients included, 55.5% had DWI and 37% had PWI (time-to-peak of the impulse response ≥2 seconds'' delay) lesions at baseline. The median time from symptom onset to baseline and follow-up imaging was 13.4 (interquartile range, 12.7) and 78.73 hours (interquartile range, 60.2), respectively. DWI reversal occurred in 5.7% of patients. The median DWI lesion volume was significantly smaller in those with reversal (0.26 mL, interquartile range = 0.58 mL) compared with those without (1.29 mL, interquartile range = 3.6 mL, P = .002); 72.7% of DWI reversal occurred in cortically based lesions. Concurrent tissue hypoperfusion (time-to-peak of the impulse response ≥2 seconds) was seen in 36.4% of those with DWI reversal versus 62.4% without (P = .08). DWI reversal occurred in 3.3% of patients with penumbral patterns (time-to-peak of the impulse response ≥6 seconds − DWI) > 0 and in 6.8% of those without penumbral patterns (P = .3). The severity of hypoperfusion, defined as greater prolongation of time-to-peak of the impulse response (≥2, ≥4, ≥6, ≥8 seconds), did not affect the likelihood of DWI reversal (linear trend, P = .147). No patient with DWI reversal had an mRS score of ≥2 at 90 days versus 18.2% of those without reversal (P = .02).CONCLUSIONS:DWI reversal is uncommon in patients with TIA/minor stroke and is more likely to occur in those with smaller baseline lesions. DWI reversal should not have a significant effect on the accuracy of penumbra definition.

Multiple studies have shown that more than half of patients with TIA/minor stroke have evidence of acute ischemic tissue injury on early DWI.^1–3 The presence and the volume of DWI lesions carry a negative prognostic value in this population.^4–6 The DWI-restricted lesions are thought to represent the irreversibly damaged ischemic core.⁷ This premise was recently brought into question by studies suggesting a high rate of DWI lesion reversal in patients with stroke who had undergone thrombolytic therapy.^8,9 A recent systematic review of the published literature on DWI hyperintense tissue outcome reported variable rates of DWI reversal (0%–83%), with a mean reversal rate of 24% in patients with ischemic stroke.¹⁰ In most patients, the size of the acute infarct correlated with both the final infarct volume on follow-up T2/FLAIR imaging and the clinical outcome.^11,12 Most previous work on DWI reversal has been undertaken in patients with moderate-to-severe strokes. Patients with TIA or minor stroke have smaller volumes of ischemia and potentially may have a higher likelihood of reversal. Previous imaging studies have reported reversal of the DWI signal in patients with TIA, but these were relatively small series, without scheduled follow-up imaging and DWI reversal was not studied systematically.^13–15Potentially salvageable tissue known as the “ischemic penumbra” represents viable tissue at risk of infarct that has not yet infarcted.¹⁶ Various methods are used to define the ischemic penumbra on MR imaging, including the mismatch between perfusion and diffusion¹⁷ or clinical-diffusion mismatch.¹⁸ All of these definitions rely on DWI lesions representing irreversibly damaged ischemic core.DWI reversibility, therefore, has implications in both accurate assessment of ischemic core and penumbra and outcome prediction.We, therefore, aimed to determine the rate and characteristics of DWI reversal in 2 large prospective imaging cohorts of patients with TIA/minor stroke. We studied the correlation among the DWI lesion volume, lesion location, concurrent baseline hypoperfusion on perfusion-weighted imaging, the severity of the perfusion deficit, and the reversal of DWI signal on follow-up FLAIR/T2 imaging in this population.