Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke

Objective: Accurate prehospital identification of patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO) facilitates direct transport to hospitals that perform endovascular thrombectomy. We hypothesize that a cut-off score of the Cincinnati Prehospital Stroke Scale (CPSS), a simple assessment tool currently used by emergency medical services (EMS) providers, can be used to identify LVO. Methods: Consecutively enrolled, confirmed AIS patients arriving via EMS between August 2012 and April 2014 at a high-volume stroke center in a large city with a single municipal EMS provider agency were identified in a prospective, single-center registry. Head and neck vessel imaging confirmed LVO. CPSS scores were abstracted from prehospital EMS records. Spearman's rank correlation, Wilcoxon rank-sum test, and Student's t-test were performed. Cohen's kappa was calculated between CPSS abstractors. The Youden index identified the optimal CPSS cut-off. Multivariate logistic regression controlling for age, sex, and race determined the odds ratio (OR) for LVO. Results: Of 144 eligible patients, 138 (95.8%) had CPSS scores in the EMS record and were included for analysis. The median age was 69 (IQR 58–81) years. Vessel imaging was performed in 97.9% of patients at a median of 5.9 (IQR 3.6–10.2) hours from hospital arrival, and 43.7% had an LVO. Intravenous tissue plasminogen activator was administered to 29 patients, in whom 12 had no LVO on subsequent vessel imaging. The optimal CPSS cut-off predicting LVO was 3, with a Youden index of 0.29, sensitivity of 0.41, and specificity of 0.88. The adjusted OR for LVO with CPSS = 3 was 5.7 (95% CI 2.3–14.1). Among patients with CPSS = 3, 72.7% had an LVO, compared with 34.3% of patients with CPSS ≤ 2 (p < 0.0001). Conclusions: A CPSS score of 3 reliably identifies LVO in AIS patients. EMS providers may be able to use the CPSS, a simple, widely adopted prehospital stroke assessment tool, with a cut-off score to screen for patients with suspected LVO.     

Impact of Comorbid Psychiatric Disorders on Healthcare Utilization in Patients with Inflammatory Bowel Disease: A Nationally Representative Cohort Study

Digestive Diseases and Sciences - Patients with inflammatory bowel disease (IBD) frequently experience comorbid psychiatric disorders, which negatively impact quality of life. We characterized the...     

Endoscopic ultrasound‐guided fine‐needle aspiration when combined with positron emission tomography improves specificity and overall diagnostic accuracy in unexplained mediastinal lymphadenopathy and staging of non‐small‐cell lung cancer

Background: The aim of this study was to assess the incremental value of endoscopic ultrasound (EUS)‐guided fine‐needle aspiration (FNA) to positron emission tomography (PET) in the diagnosis of unexplained mediastinal lymphadenopathy and staging of non‐small‐cell lung cancer (NSCLC). Methods: Patients who had both EUS‐guided FNA and PET were retrospectively identified from an EUS database at a tertiary hospital. All EUS‐guided FNA were carried out by one endoscopist between August 2002 and April 2005, either for the diagnosis of unexplained mediastinal lymphadenopathy or for the staging of NSCLC. Results of PET and EUS were compared with histology. A true histological positive result was defined as histological involvement in either surgery (mediastinoscopy or resection) or EUS‐guided FNA. A true histological negative result was defined as negative involvement at surgery (mediastinoscopy or resection). Results: Forty‐nine patients who had both PET scanning and EUS‐guided FNA for diagnosis of unexplained mediastinal lymphadenopathy or staging of NSCLC were identified. Of these, 33 (73% males, n = 24, age range = 44–78 years, mean = 62 years) had surgical confirmation of mediastinal lymph node pathology. In these patients, PET alone showed sensitivity, 95%; specificity, 90%; positive predictive value, 87%; negative predictive value, 90% and accuracy, 88%; whereas the addition of EUS‐guided FNA increased the overall specificity and positive predictive value to 100%, with an overall accuracy of 97%. Conclusions: This study suggests that EUS‐guided FNA complements PET by improving the overall specificity and thereby the accuracy for diagnosis of unexplained mediastinal lymphadenopathy. It provides a minimally invasive technique to assess the mediastinum in patients with NSCLC and is particularly valuable in cases in which PET findings are equivocal.     

Nonesterified fatty acids in blood pressure control and cardiovascular complications

The fact that cardiovascular risk factors cluster among individuals with the insulin resistance syndrome strongly suggests a common pathogenetic denominator. For many years, abnormalities of nonesterified fatty acid metabolism have been implicated in the disturbances of carbohydrate and lipid metabolism that characterize the cluster. However, until more recently, evidence implicating fatty acids in the hemodynamic and vascular abnormalities that affect patients with this syndrome was lacking. p] Observations from epidemiological, clinical, and basic science suggest that fatty acids can raise blood pressure and contribute to the development of hypertension. The effects of fatty acids on blood pressure may be mediated in part by inhibition of endothelial nitric oxide synthase activity and endothelium-dependent vasodilation. Fatty acids can also increase α1-adrenoceptor-mediated vascular reactivity and induce vascular smooth muscle migration and proliferation. The adverse effects of fatty acids appear to be mediated in part through induction of oxidative stress. Fatty acids interact with other components of the risk factor cluster, including increased angiotensin II, to synergistically augment oxidative stress in cultured vascular smooth muscle cells. Oxidative stress is implicated in the pathogenesis of insulin resistance, hypertension, vascular remodeling, and vascular complications. A clearer definition of the specific reactive oxygen signaling pathways involved and interventions aimed at altering these pathways could lead to more rationale antioxidant therapy and improved outcomes.     

VAR2CSA domains expressed in Escherichia coli induce cross-reactive antibodies to native protein

The variant surface antigen VAR2CSA is a pregnancy malaria vaccine candidate, but its size and polymorphism are obstacles to development. We expressed 3D7-type VAR2CSA domains in Escherichia coli as insoluble His-tagged proteins (Duffy binding-like [DBL] domains DBL1, DBL3, DBL4, and DBL5) that were denatured and refolded or as soluble glutathione S-transferase-tagged protein (DBL6). Anti-DBL5 antiserum cross-reacted with surface proteins of chondroitin sulfate A (CSA)-binding laboratory strains (3D7-CSA and FCR3-CSA) and a clinical pregnancy malaria isolate, whereas anti-DBL6 antiserum reacted only to 3D7 surface protein. This is the first report that E. coli-expressed VAR2CSA domains induce antibody to native VAR2CSA.     

A retrospective comparison of ring pessary and multicomponent behavioral therapy in managing overactive bladder

Introduction and hypothesis

Overactive bladder (OAB) is a physically, psychologically, and socially disabling condition that affects millions of women worldwide and is especially prevalent postmenopause. The objective of our study was to compare the cure rates of ring pessary with those of multicomponent behavioral therapy in managing overactive bladder.

Methods

We performed a comparative retrospective parallel cohort study of all women whose overactive bladder was treated with multicomponent behavioral therapy or ring pessary over a 42-month period. At the end of the 6-month treatment period, cure was defined as the subjective (self-reported) absence of urinary urgency, frequency, nocturia, and urge incontinence in the preceding 30 days; the objective absence of these symptoms in a 7-day voiding diary; and a Patient Global Impression of Improvement response of “much better” or “very much better.”

Results

Ring pessary and multicomponent behavioral therapy had similar cure rates (29 out of 150 [19 %] vs 46 out of 231 [20 %] respectively, P?=?0.889; OR of 1.04, 95 % confidence interval 0.618–1.742, P?=?0.887). They also produced comparable cure rates in premenopausal (4 out of 31 [13 %] vs 14 out of 68 [21 %], P?=?0.358) and postmenopausal subjects (25/ out of 19 [21 %] vs 32 out of 163 [20 %], P?=?0.776), and in women who had undergone previous treatment (21 out of 108 [19 %] vs 31 out of 176 [18 %], P?=?0.699) and those who had not (8 out of 42 [19 %] vs 15 out of 55 [27 %], P?=?0.345). Logistic regression showed that neither treatment outcome is significantly associated with demographic characteristics; Pelvic Organ Prolapse Quantification at the anterior and posterior vaginal walls and at the vaginal cuff; previous treatment; overactive bladder symptoms; pad usage; or any combination thereof.

Conclusions

Ring pessary has a cure rate similar to that of multicomponent behavioral therapy in managing overactive bladder.     

Driver sleepiness and risk of motor vehicle crash injuries: A population-based case control study in Fiji (TRIP 12)

Introduction

Published studies investigating the role of driver sleepiness in road crashes in low and middle-income countries have largely focused on heavy vehicles. We investigated the contribution of driver sleepiness to four-wheel motor vehicle crashes in Fiji, a middle-income Pacific Island country.

Method

The population-based case control study included 131 motor vehicles involved in crashes where at least one person died or was hospitalised (cases) and 752 motor vehicles identified in roadside surveys (controls). An interviewer-administered questionnaire completed by drivers or proxies collected information on potential risks for crashes including sleepiness while driving, and factors that may influence the quantity or quality of sleep.

Results

Following adjustment for confounders, there was an almost six-fold increase in the odds of injury-involved crashes for vehicles driven by people who were not fully alert or sleepy (OR 5.7, 95%CI: 2.7, 12.3), or those who reported less than 6 h of sleep during the previous 24 h (OR 5.9, 95%CI: 1.7, 20.9). The population attributable risk for crashes associated with driving while not fully alert or sleepy was 34%, and driving after less than 6 h sleep in the previous 24 h was 9%. Driving by people reporting symptoms suggestive of obstructive sleep apnoea was not significantly associated with crash risk.

Conclusion

Driver sleepiness is an important contributor to injury-involved four-wheel motor vehicle crashes in Fiji, highlighting the need for evidence-based strategies to address this poorly characterised risk factor for car crashes in less resourced settings.     

Disparities in Hypertension Among African-Americans: Implications of Insufficient Sleep

Purpose of Review

Sleep deficiency has been proposed as a potential contributor to racial disparities in cardiovascular health. We present contemporary evidence on the unequal burden of insufficient sleep in Blacks/African-Americans and the repercussions for disparate risk of hypertension.

Recent Findings

The prevalence of insufficient sleep is high and rising and has been recognized as an important cardiovascular risk factor. Presumably due to a constellation of environmental, psychosocial, and individual determinants, these risks appear exacerbated in Blacks/African-Americans, who are more likely to experience short sleep than other ethnic/racial groups. Population-based data suggest that the risk of hypertension associated with sleep deficiency is greater in those of African ancestry. However, there is a paucity of experimental evidence linking short sleep duration to blood pressure levels in African-Americans.

Summary

Blacks/African-Americans may be more vulnerable to sleep deficiency and to its hypertensive effects. Future research is needed to unequivocally establish causality and determine the mechanism underlying the postulated racial inequalities in sleep adequacy and consequent cardiovascular risk.

     

Genomic copy number changes of DNA repair genes ERCC1 and ERCC2 in human gliomas

Abnormalities of the genomic region of chromosome 19q13.2–13.4 are a common occurrence in brain malignancies and contain a possible tumor suppressor gene involved in gliomas. Since abnormalities of DNA repair are associated with malignancy, we assessed DNA status of the nucleotide excision repair genes located in this area, viz. ERCC1 and ERCC2.Radiodensitometry was used to assess gene copy number in samples obtained from brain tumor specimens from 24 patients. Nine tumors were of lower grade histology (3 pilocytic astrocytomas, 2 gangliogliomas, 4 astrocytomas); 15 tumors were pathologiclly higher grade (4 anaplastic astrocytomas, 11 glioblastomas). Tumor samples were obtained prior to radiation or chemotherapy. Abnormalities of gene copy number of ERCC1 and ERCC2 were observed in 11/24 specimens (46%). Whereas increased and decreased copy numbers were observed for ERCC1, only decreases in copy number of ERCC2 were seen. Three tumors (all lower grade) showed concurrent allelic loss of ERCC1 and ERCC2. Abnormalities of copy number for these genes were not associated with response to subsequent therapy nor survival. However, allelic loss of ERCC2 was associated with younger age at diagnosis when compared to those specimens which did not show loss. There were no significant differences between lower grade and higher grade tumors with respect to these investigations.Abnormalities in copy number of ERCC1 and ERCC2 are common in glial tumors. Further study of this genomic region is necessary to define the importance of these observations in tumor pathophysiology and treatment.