Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

Using mHealth to enhance TB referrals in a tribal district of India

Background: A mobile health (mHealth) technology based application was developed to help rural health care providers (RHCPs) identify and refer presumptive tuberculosis (TB) patients to the nearest microscopy centre for sputum examination using mobile applications on their smart phones. Objective: To determine the feasibility and yield of presumptive TB case referrals by RHCPs using mHealth technology. Methods: The project was implemented in the tribal population of Khunti District, Jharkhand State, India, from April 2012 to February 2015. 'ComCare', a mobile application designed as an aid for health care providers, was introduced and RHCPs were trained in its use. Results: Of 171 RHCPs who were formally trained to identify and refer presumptive TB patients, 30 were trained in the use of the mobile application. There were 35 referrals of presumptive TB patients per RHCP using the mobile application, and four each by RHCPs who were not using the application. Of the 194 TB cases diagnosed, RHCPs using the application contributed 127 (i.e., 4 TB cases per RHCP), while other RHCPs contributed 67 (0.5 TB case per RHCP). Conclusion: mHealth technology was highly effective, and increased both public and private health care provider accountability to patients.

Comparison on extraction yield of sennoside A and sennoside B from senna (Cassia angustifolia) using conventional and non conventional extraction techniques and their quantification using a validated HPLC-PDA detection method

Senna is an important medicinal plant and is used in many Ayurvedic formulations. Dianthraquinone glucosides are the main bioactive phytochemicals present in leaves and pods of senna. The extraction efficiency in terms of yield and composition of the extract of senna prepared using both conventional (cold percolation at room temperature and refluxing) and non conventional (ultrasound and microwave assisted solvent extraction as well as supercritical fluid extraction) techniques were compared in the present study. Also a rapid reverse phase HPLC-PDA detection method was developed and validated for the simultaneous determination of sennoside A and sennoside B in the different extracts of senna leaves. Ultrasound and microwave assisted solvent extraction techniques were more effective in terms of yield and composition of the extracts compared to cold percolation at room temperature and refluxing methods of extraction.

Carotid Webs and Recurrent Ischemic Strokes in the Era of CT Angiography

BACKGROUND AND PURPOSE

Carotid webs may cause recurrent ischemic stroke. We describe the prevalence, demographics, clinical presentation, imaging features, histopathology, and stroke risk associated with this under-recognized lesion.

MATERIALS AND METHODS

A carotid web was defined on CTA as a thin intraluminal filling defect along the posterior wall of the carotid bulb just beyond the carotid bifurcation on oblique sagittal section CTA that was seen as a septum on axial CTA. Using a prospective case series from April 2013 to April 2014, we describe the demographics, spectrum of imaging features on CTA, and histopathology of these carotid webs. From a retrospective analysis of patients at our center from May 2012 to April 2013 who had a baseline head and neck CTA followed by a brain MR imaging within 1-2 days of the CTA, we determine the period prevalence of carotid webs and the prevalence of ipsilateral stroke on imaging.

RESULTS

In the prospective series, the mean age was 50 years (range, 41-55 years); 5/7 patients were women. Recurrent stroke was seen in 5/7 (71.4%) patients with the carotid web; time to recurrence ranged from 1 to 97 months. Histopathology suggested a high probability of fibromuscular dysplasia. In the retrospective series, carotid webs were seen in 7/576 patients for a hospital-based-period prevalence of 1.2% (95% CI, 0.4%-2.5%). Two of these 7 patients had acute stroke in the vascular territory of the carotid web.

CONCLUSIONS

A carotid web may contribute to recurrent ischemic stroke in patients with no other determined stroke mechanism. Intimal variant fibromuscular dysplasia is the pathologic diagnosis in most cases. The prevalence of carotid web is low, while the optimal management strategy remains unknown.

Metal nanocluster light-emitting devices with suppressed parasitic emission and improved efficiency: exploring the impact of photophysical properties

Here we investigate the photophysical properties of Au(0)@Au(i)-thiolate nanoclusters by controlling the degree of aggregation, and measure electrochemical energy levels to design a metal nanocluster-based thin film LED (MNC-LED) structure. These efforts allow us to implement MNC-LEDs with luminance exceeding 40 cd m(-2) and external quantum efficiency exceeding 0.1% with clearly visible orange emission. It is also demonstrated that by varying the sizes of nanoclusters, the electroluminescence spectrum of the device can be tuned to the infrared emission, indicating the possibility of exploiting metal nanocluster emitters for use over a wide spectral range.

Towards a resolution of the proton form factor problem: new electron and positron scattering data

There is a significant discrepancy between the values of the proton electric form factor, G(E)(p), extracted using unpolarized and polarized electron scattering. Calculations predict that small two-photon exchange (TPE) contributions can significantly affect the extraction of G(E)(p) from the unpolarized electron-proton cross sections. We determined the TPE contribution by measuring the ratio of positron-proton to electron-proton elastic scattering cross sections using a simultaneous, tertiary electron-positron beam incident on a liquid hydrogen target and detecting the scattered particles in the Jefferson Lab CLAS detector. This novel technique allowed us to cover a wide range in virtual photon polarization (ϵ) and momentum transfer (Q(2)) simultaneously, as well as to cancel luminosity-related systematic errors. The cross section ratio increases with decreasing ϵ at Q(2)=1.45  GeV(2). This measurement is consistent with the size of the form factor discrepancy at Q(2)≈1.75  GeV(2) and with hadronic calculations including nucleon and Δ intermediate states, which have been shown to resolve the discrepancy up to 2-3  GeV(2).

SWI/SNF chromatin remodeling enzymes in melanocyte differentiation and melanoma

Epidermal melanocytes are pigment-producing cells derived from the neural crest that protects skin from the damaging effects of solar radiation. Malignant melanoma, a highly aggressive cancer, arises from melanocytes. SWI/SNF enzymes are multiprotein complexes that remodel chromatin structure and have extensive roles in cellular differentiation. Components of the complex have been found to be mutated or lost in several human cancers. This review focuses on studies that implicate SWI/SNF enzymes in melanocyte differentiation and in melanoma.

Early reperfusion rates with IV tPA are determined by CTA clot characteristics

BACKGROUND AND PURPOSE

An ability to predict early reperfusion with IV tPA in patients with acute ischemic stroke and intracranial clots can help clinicians decide if additional intra-arterial therapy is needed or not. We explored the association between novel clot characteristics on baseline CTA and early reperfusion with IV tPA in patients with acute ischemic stroke by using classification and regression tree analysis.

MATERIALS AND METHODS

Data are from patients with acute ischemic stroke and proximal anterior circulation occlusions from the Calgary CTA data base (2003-2012) and the Keimyung Stroke Registry (2005-2009). Patients receiving IV tPA followed by intra-arterial therapy were included. Clot location, length, residual flow within the clot, ratio of contrast Hounsfield units pre- and postclot, and the M1 segment origin to the proximal clot interface distance were assessed on baseline CTA. Early reperfusion (TICI 2a and above) with IV tPA was assessed on the first angiogram.

RESULTS

Two hundred twenty-eight patients (50.4% men; median age, 69 years; median baseline NIHSS score, 17) fulfilled the inclusion criteria. Median symptom onset to IV tPA time was 120 minutes (interquartile range = 70 minutes); median IV tPA to first angiography time was 70.5 minutes (interquartile range = 62 minutes). Patients with residual flow within the clot were 5 times more likely to reperfuse than those without it. Patients with residual flow and a shorter clot length (≤15 mm) were most likely to reperfuse (70.6%). Patients with clots in the M1 MCA without residual flow reperfused more if clots were distal and had a clot interface ratio in Hounsfield units of <2 (36.8%). Patients with proximal M1 clots without residual flow reperfused 8% of the time. Carotid-T/-L occlusions rarely reperfused (1.7%). Interrater reliability for these clot characteristics was good.

CONCLUSIONS

Our study shows that clot characteristics on CTA help physicians estimate a range of early reperfusion rates with IV tPA.

Pituitary tuberculoma

Tuberculosis of pituitary gland is rare. We report a case of tuberculosis of pituitary gland in a 68-year-old male presented with holocranial headache of four months duration with left temporal hemianopia, with visual acuity of 6/6, without any localizing sign. Magnetic resonance imaging showed a sellar ring enhancing mass with suprasellar extension. Patient was taken up for surgery and put on antitubercular treatment and hormone replacement therapy.

Nonfamilial cherubism

Cherubism is a non neoplastic progressive heredity disease affecting the jaw bones. It is a benign disease with a characteristic symmetrical involvement of the maxilla and mandible. It usually affects children before 5 years of age, with painless progressive swelling of the cheeks, frequently associated with dental malformations. Here, we are presenting a case report of a 12-year-old boy suffering from cherubism.

Search for lepton flavour violation in the eμ continuum with the ATLAS detector in [Formula: see text]pp collisions at the LHC

This paper presents a search for the t-channel exchange of an R-parity violating scalar top quark ([Formula: see text]) in the e±μ∓ continuum using 2.1 fb-1 of data collected by the ATLAS detector in [Formula: see text]pp collisions at the Large Hadron Collider. Data are found to be consistent with the expectation from the Standard Model backgrounds. Limits on R-parity-violating couplings at 95 % C.L. are calculated as a function of the scalar top mass ([Formula: see text]). The upper limits on the production cross section for pp→eμX, through the t-channel exchange of a scalar top quark, ranges from 170 fb for [Formula: see text] to 30 fb for [Formula: see text].

Measurement of the ZZ production cross section and limits on anomalous neutral triple gauge couplings in proton-proton collisions at sqrt[s] = 7 TeV with the ATLAS detector

A measurement of the ZZ production cross section in proton-proton collisions at sqrt[s] = 7 TeV using data corresponding to an integrated luminosity of 1.02 fb(-1) recorded by the ATLAS experiment at the LHC is presented. Twelve events containing two Z boson candidates decaying to electrons and/or muons are observed, with an expected background of 0.3 ± 0.3(stat)(-0.3)(+0.4)(syst) events. The cross section measured in a phase-space region with good detector acceptance and for dilepton masses within the range 66 to 116 GeV is σ(ZZ → ℓ+ ℓ- ℓ+ ℓ-)(fid) = 19.4(-5.2)(+6.3)(stat)(-0.7)(+0.9)(syst) ± 0.7(lumi) fb. The resulting total cross section for on-shell ZZ production, σ(ZZ)(tot) = 8.5(-2.3)(+2.7)(stat)(-0.3)(+0.4)(syst) ± 0.3(lumi) pb, is consistent with the standard model expectation of 6.5(-0.2)(+0.3) pb calculated at the next-to-leading order in QCD. Limits on anomalous neutral triple gauge boson couplings are derived.

P2-13-09: First Statewide Experience with Telephone Delivery of Cancer Genetic Counseling

Background: National guidelines and multiple professional medical societies recommend genetic counseling as the standard of care for women with a personal and/or family history suggestive of a hereditary cancer syndrome. In addition, the ability to provide risk assessment and genetic counseling is a requirement for accreditation of breast centers by organizations such as the National Accreditation Program for Breast Centers (NAPBC) and the Commission on

Cancer. However, there is clear evidence that this standard is not being achieved. Many individuals are undergoing genetic testing for these syndromes without adequate pre- and post-test counseling and, on the other hand, many individuals who are appropriate for genetic testing are not being identified and referred for genetic counseling and therefore not receiving potentially life-saving genetic information and services. A number of factors have been identified as contributors to these poor public health outcomes, including a lack of available genetic counseling services due to a limited number of trained genetics professionals and their limited geographic distribution. Research has demonstrated the effectiveness of cancer genetic counseling delivered by telephone, but to date, almost no real-world experience has been reported. We provided statewide access to board-certified genetic counselors via telephone in Michigan beginning in February 2010 and report our experience with the first 200 patients at risk for hereditary breast and ovarian cancer.

Materials and Methods: Baseline data were analyzed for all Michigan patients undergoing telephone genetic counseling through Informed Medical Decisions since service delivery began in February 2010. Variables include demographics, geographic location, personal cancer history, family cancer history, Gail risk and test appropriateness criteria.

Results: Analysis has been completed on the first 200 patients referred for consideration of hereditary breast and ovarian cancer. Outcomes include testing, results and, where applicable, reasons testing was not pursued, patient and provider satisfaction, as well as trends over time in patient volumes, providers using the service and uptake by geographic location.

Conclusion: Based on statewide experience in Michigan, telephone cancer genetic counseling is a viable method for service delivery in the real world. The Michigan experience can serve as a cost-effective model for improving genetic services in other locations with limited access to genetic experts.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-13-09.

Calcified epidural hematoma in pediatric age group: A report of two cases

The authors present a rare case of calcified (ossified) chronic epidural hematoma developed in a six-and-a-half-year-old female patient who was operated for cerebellar astrocytoma 6 months earlier. There was no history of trauma. Ossified epidural hematoma was seen as an incidental finding in the follow-up in computed tomography scan after 6 months of primary glioma surgery. Ossified chronic epidural hematoma with thick collagenous wall and newly formed bone on dura was excised. The development of calcified chronic subdural hematoma after decompressive intracranial surgery is a well-known occurrence, but the fact that a calcified epidural hematoma, which is rare and which can also develop after decompressive surgery, and the occurrence of calcified (ossified) epidural hematoma after postfossa a glioma surgery is not yet reported. The second case is a 9-year-old male anemic child with a history of fall while playing 5 months earlier who presented with headache of 3 months duration. He had bifrontal calcified epidural hematoma operated by craniotomy and excision of calcified dural edge.

Laparoscopic kidney transplantation: an initial experience

Laparoscopic donor nephrectomy has the advantages of less pain, early ambulation and shorter hospitalization compared to open donor nephrectomy. Kidney recipient surgery is, however, traditionally performed by open surgery. Our aim was to study feasibility and safety of laparoscopic kidney transplantation (LKT). After permission from Internal Review Board, LKT was performed in four patients. All kidneys were procured from deceased donors. Left kidney was used for LKT and transplanted in left iliac fossa while right kidney was used for standard open kidney transplantation (OKT). All transplantation procedures were performed successfully. Cold ischemia time varied between 4 h and 14 h. For LKT, mean time for anastomosis was 65 (range 62-72) min, mean operative time was 3.97 (range 3.5-5) h, mean blood loss was 131.25 mL (range 45-350) mL. Mean wound length was 7 cm in LKT group and 18.4 cm in OKT group. Delayed graft function was observed in one patient in each group. One patient was lost in OKT group due to posttransplant bacterial meningitis. At 6 months, both groups have comparable value of serum creatinine. In conclusion, LKT is technically feasible and safe. Long term outcome needs to be evaluated in a larger study.

Identification and metabolite profiling of Sitophilus oryzae L. by 1D and 2D NMR spectroscopy

The polyphagous insect Sitophilus oryzae L. (Coleoptera:Curculionidae) has a tremendous adaptability in feeding behaviour, making it a serious invasive pest of stored cereals. The present study identifies the metabolite composition of Sitophilus oryzae (S. oryzae) using Nuclear Magnetic Resonance (NMR) spectroscopy. Assignment of 1D-proton by NMR, 1H-1H COSY, 2D-TOCSY 1H-1H, had been done. Amongst the various biochemically important metabolites isoleucine, valine, leucine, beta-hydroxybutyrate, lysine, glutamate, glutamine, proline, lactate, alanine, di-methylamine, alpha-glucose, beta-glucose, choline, glycerophosphorylcholine and tyrosine are present in S. oryzae. In wheat-fed S. oryzae, the presence of threonine and the absence of lactate is observed. In rice-fed S. oryzae, however, the presence of lactate and the absence of threonine were observed. Barley-fed S. oryzae shows presence of both tyrosine and lactate. It is concluded that the pest S. oryzae has adaptability on different stored cereals and grains, depicting the presence of earlier reported metabolites. The present study aims to identify the key metabolic components and associated enzymes in Sitophilus oryzae fed on different cereals.

Recurrent multifocal primary amyloidosis of urinary bladder

Primary localized amyloidosis of bladder is rare. We report a case of recurrence of multifocal primary amyloidosis of urinary bladder. Cystoscopy revealed a diffuse left lateral wall lesion with normal surrounding mucosa. Histopathological examination of the specimen revealed urinary bladder amyloidosis with negative surgical margins. Recurrent urinary bladder amyloidosis was confirmed 3 months after the first resection. Close follow-up is recommended.

Management of Calculi in A Donor Kidney

INTRODUCTION

We evaluated the safety and efficacy of ex vivo ureteroscopy (ExURS) and extracorporeal shock wave lithotripsy (ESWL) as means of rendering a donated kidney stone-free in living related and deceased donor renal transplantation.

MATERIAL AND METHODS

Three cases with calculi in donor kidneys were managed; 1 was from a living related donor and 2 were from deceased donors. Immediately after cold perfusion, ExURS was performed with iced saline solution in 2 cases. Access to the collecting system was via the ureteral stump. Calculi were fragmented with pneumatic intracorporeal lithotripsy and fragments were removed with forceps. Posttransplantation ESWL was given to 1 patient for migration of a small lower caliceal calculus in the upper ureter in 1 allograft of a dual-kidney transplantation.

RESULTS

Access to the renal collecting system and stone fragmentation was technically successful in both cases. Indwelling ureteral stents were kept during transplantation in all cases. There were no intraoperative or postoperative ureteral complications. Following ESWL, stone was fragmented and cleared on its own within a week. At mean follow up of 2.2 years no new stone formed in any recipient or donor.

CONCLUSIONS

ExURS was technically feasible to render a stone-bearing kidney stone- free without compromising ureteral integrity or renal allograft function. ESWL could be performed at a later date.

Exposure to chronic noise and fractionated X-ray radiation elicits biochemical changes and disrupts body weight gain in rat

The aim was to assess the developmental and biochemical effects resulting from separate and combined exposures to radiation and noise in adult male Sprague-Dawley rats. For 21 days, animals were exposed daily (1) to whole-body 121 kVp X-ray exposure (cumulative dose=5 Gy), (2) to random intermittent noise band-limited between 0.4 and 20 kHz; 2 h day(-1) 86 decibels (dB) and (3) to combined exposures. Control animals were housed under ambient noise conditions 55 dB A-weighted (dBA) and sham-exposed to X-rays. Body weight gain was significantly reduced in animals exposed to either X-rays or noise, and the loss was more pronounced in animals exposed to both conditions. Neither plasma adrenocorticotropic hormone (ACTH) nor corticosterone was altered by the treatment conditions. This study corroborated previous reports that ionizing radiation exposure increased plasma levels of 8-hydroxy-2'-deoxyguanosine (8-OHDG), but no effect was observed in animals co-exposed to chronic noise. Plasma big-endothelin-1 (Big ET-1) was significantly reduced in animals exposed to a combination of noise and X-rays. The results indicated that (1) adaptation to chronic noise appeared to occur at the level of the hypothalamic pituitary adrenal (HPA) response, in spite of a compromise in overall body weight gain; and (2) ionizing radiation exposure might alter systems activated by stressor exposure and/or act independently to influence health outcomes.

Laser extraction of entrapped leads

Removing entrapped pacing and defibrillator leads has been greatly simplified by making use of the excimer laser extractor. Sixty-two leads were successfully removed, although where appropriate, portions of the lead remained in place in 10 cases. There were two serious complications, one tear of the superior vena cava during an ICD extraction and one tear of the atrium during an atrial lead extraction. Both were controlled successfully through emergency sternotomy. Although extracting entrapped leads has been much simplified by making use of the laser extractor, the process is not free of serious complications. Those involved in explanting leads should be aware of the outcomes and be prepared for emergent management.