Thrombectomy with Conscious Sedation Compared with General Anesthesia: A DEFUSE 3 Analysis

BACKGROUND AND PURPOSE

The optimal patient sedation during mechanical thrombectomy for ischemic stroke in the extended time window is unknown. The purpose of this study was to assess the impact of patient sedation on outcome in patients undergoing thrombectomy 6-16 hours from stroke onset.

MATERIALS AND METHODS

Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 (DEFUSE 3) was a multicenter, randomized, open-label trial of thrombectomy for ICA and M1 occlusions in patients 6-16 hours from stroke onset. Subjects underwent thrombectomy with either general anesthesia or conscious sedation at the discretion of the treating institution.

RESULTS

Of the 92 patients who were randomized to intervention, 26 (28%) underwent thrombectomy with general anesthesia and 66 (72%) underwent thrombectomy with conscious sedation. Baseline clinical and imaging characteristics were similar among all groups. Functional independence at 90 days was 23% for general anesthesia, 53% for conscious sedation, and 17% for medical management (P = .009 for general anesthesia versus conscious sedation). Conscious sedation was associated with a shorter time from arrival in the angiosuite to femoral puncture (median, 14 versus 18 minutes; P = 0.05) and a shorter time from femoral puncture to reperfusion (median, 36 versus 48 minutes; P = .004). Sixty-six patients were treated at sites that exclusively used general anesthesia (n = 14) or conscious sedation (n = 52). For these patients, functional independence at 90 days was significantly higher in the conscious sedation subgroup (58%) compared with the general anesthesia subgroup (21%) (P = .03).

CONCLUSIONS

Patients who underwent thrombectomy with conscious sedation in the extended time window experienced a higher likelihood of functional independence at 90 days, a lower NIHSS score at 24 hours, and a shorter time from femoral puncture to reperfusion compared with those who had general anesthesia. This effect remained robust in institutions that only treated patients with a single anesthesia technique.

Epidemiology of classical risk factors in stroke patients in the Middle East

The Middle East (ME) is an ethnically and economically diverse region. A systematic review of all stroke studies conducted in the ME was carried out, with the aim of determining the prevalence of classic vascular risk factors (CRFs) across this region. Additionally, the prevalence of CRFs in the ME was compared to that of a US cohort. Prospective and retrospective ME stroke studies published from 1994 to 2014 were searched for that specifically reported on the prevalence of CRFs. The Z test for proportions was used to determine the significance of differences in CRF rates between the ME and non-ME studies. A total of 21,724 stroke patients from 13 nations in the ME were included. The prevalence rates for CRFs in the ME stroke population were hypertension, 62.1%; diabetes, 33.1%; dyslipidaemia, 36.8%; ischaemic heart disease, 24.6%; smoking, 19.3%; and atrial fibrillation, 13.6%. Compared to the US cohort, ME patients had a lower prevalence of all CRFs except diabetes (P < 0.0001) and smoking (P = 0.05). Compared with stroke patients in the USA, those in the ME have a significantly higher prevalence of diabetes and smoking. Education and lifestyle modification is perhaps the most effective strategy in reducing the risk of stroke in this population.

The Timing of School Transitions and Early Adolescent Problem Behavior

This longitudinal study investigates whether rural adolescents who transition to a new school in sixth grade have higher levels of risky behavior than adolescents who transition in seventh grade. Our findings indicate that later school transitions had little effect on problem behavior between sixth and ninth grades. Cross-sectional analyses found a small number of temporary effects of transition timing on problem behavior: Spending an additional year in elementary school was associated with higher levels of deviant behavior in the Fall of Grade 6 and higher levels of antisocial peer associations in Grade 8. However, transition effects were not consistent across waves and latent growth curve models found no effects of transition timing on the trajectory of problem behavior. We discuss policy implications and compare our findings with other research on transition timing.

Associations between reasons to attend and late-high school dropout

This study addressed (1) whether there were unique profiles of student self-reported reasons for attending school among 10(th) graders, (2) whether these profiles were differentially associated with late high-school dropout, and (3) whether parent characteristics differed across profiles. Using data from the Educational Longitudinal Study of 2002 (N = 15,362), five latent classes were found. The first class (49%) reported intrinsic, identified/introjected, and external motivations for attending school. The second class (32%) attended for identified/introjected and external reasons, while the third class (11%) reported intrinsic and identified/introjected reasons. The final two classes reported only identified/introjected (5%) or external (4%) motivations. Individuals in the identified/introjected and external classes were at greatest risk of dropping out between 10(th) and 12(th) grade. A host of parenting characteristics differed across class, with students in the intrinsic-identified/introjected-external class displaying the most favorable pattern of results. Implications for dropout prevention and academic promotion programs are discussed.

Dyadic Interaction: Greater than the Sum of its Parts?

The study of dyadic interaction plays a major role in infancy research. To advance conceptually-informed measurement of dyadic interaction and integration across studies, we examined factor structure of individual parents' and infants' measures and dyadic measures from face-to-face interactions in two samples of 6-mo-old infants and their parents: mothers from a demographically heterogeneous sample (N = 164) and mothers and fathers (N = 156) from a Caucasian middle-class sample. Results suggested: a) individual and dyadic measures, and parents' and infants' behaviors contribute independent information, b) measures of both valence and process are needed, c) there are context-general and context-specific qualities, and d) structure of dyadic interaction is more similar among mother-infant dyads from independent samples than between mother- and father-infant dyads within the same sample. Future research should use multiple measures incorporating valence, temporal processes, contextual influences, and behaviors of individual partners along with dyadic measures to adequately assess the quality of dyadic interaction.

The multifaceted impact of peer relations on aggressive-disruptive behavior in early elementary school

Following a large, diverse sample of 4,096 children in 27 schools, this study evaluated the impact of 3 aspects of peer relations, measured concurrently, on subsequent child aggressive-disruptive behavior during early elementary school: peer dislike, reciprocated friends' aggressiveness, and classroom levels of aggressive-disruptive behavior. Teachers rated child aggressive-disruptive behavior in 1st and 3rd grades, and peer relations were assessed during 2nd grade. Results indicated that heightened classroom aggressive-disruptive behavior levels were related to proximal peer relations, including an increased likelihood of having aggressive friends and lower levels of peer dislike of aggressive-disruptive children. Controlling for 1st grade aggressive-disruptive behavior, the three 2nd grade peer experiences each made unique contributions to 3rd grade child aggressive-disruptive behavior. These findings replicate and extend a growing body of research documenting the multifaceted nature of peer influence on aggressive-disruptive behavior in early elementary school. They highlight the importance of the classroom ecology and proximal peer relations in the socialization of aggressive-disruptive behavior.

The influence of classroom aggression and classroom climate on aggressive-disruptive behavior

Research suggests that early classroom experiences influence the socialization of aggression. Tracking changes in the aggressive behavior of 4,179 children from kindergarten to second-grade (ages 5-8), this study examined the impact of 2 important features of the classroom context--aggregate peer aggression and climates characterized by supportive teacher-student interactions. The aggregate aggression scores of children assigned to first-grade classrooms predicted the level of classroom aggression (assessed by teacher ratings) and quality of classroom climate (assessed by observers) that emerged by the end of Grade 1. Hierarchical linear model analyses revealed that first-grade classroom aggression and quality of classroom climate made independent contributions to changes in student aggression, as students moved from kindergarten to second grade. Implications for policy and practice are discussed.

Double Jeopardy: Child and School Characteristics That Predict Aggressive-Disruptive Behavior in First Grade

High rates of aggressive-disruptive behavior exhibited by children during their initial years of elementary school increase their risk for significant behavioral adjustment problems with teachers and peers. The purpose of the present study was to examine the unique and combined contributions of child vulnerabilities and school context to the development of aggressive-disruptive student behavior during first grade. Parent ratings and child interviews assessed three child characteristics associated with risk for the development of aggressive behavior problems in elementary school (aggressive-disruptive behaviors at home, attention problems, and social cognitions) in a sample of 755 first-grade children in four demographically diverse American communities. Two school characteristics associated with student aggressive-disruptive behavior problems (low-quality classroom context, school poverty levels) were also assessed. Linear and multilevel analyses showed that both child and school characteristics made independent and cumulative contributions to the development of student aggressive-disruptive behavior at school. Although rates of student aggressive-disruptive behavior varied by gender and race, the predictive model generalized across all groups of children in the study.

Fibroblast growth factors, their receptors and signaling

Fibroblast growth factors (FGFs) are small polypeptide growth factors, all of whom share in common certain structural characteristics, and most of whom bind heparin avidly. Many FGFs contain signal peptides for secretion and are secreted into the extracellular environment, where they can bind to the heparan-like glycosaminoglycans (HLGAGs) of the extracellular matrix (ECM). From this reservoir, FGFs may act directly on target cells, or they can be released through digestion of the ECM or the activity of a carrier protein, a secreted FGF binding protein. FGFs bind specific receptor tyrosine kinases in the context of HLGAGs and this binding induces receptor dimerization and activation, ultimately resulting in the activation of various signal transduction cascades. Some FGFs are potent angiogenic factors and most play important roles in embryonic development and wound healing. FGF signaling also appears to play a role in tumor growth and angiogenesis, and autocrine FGF signaling may be particularly important in the progression of steroid hormone-dependent cancers to a hormone-independent state.

A brief history of endoscopy

Endoscopy has revolutionized surgery. However, this recent revolution would not have been possible without the history of a series of technological breakthroughs in instrumentation, light sources, optics/photography, insufflation, and energy sources.

Extracorporeal shock wave lithotripsy: a study of renal stone differences

The extracorporeal shock wave lithotriptor (ESWL or lithotriptor) is a new, revolutionary, noninvasive method of treating renal calculi. It offers a safer, cheaper and more effective method of treatment compared to the traditional open surgery. Its history dates back only to 1980--and to 1985 at HCA Wesley Medical Center in Wichita, where research is just beginning. Initial research focused on ESWL versus traditional open surgery, but more recent research is investigating elements within the ESWL treatment. This article presents an investigation of renal stone size in relation to number of ESWL treatments needed per stone, number of shock waves per treatment, length of hospital stay post-lithotripsy, and hospital costs per length of stay during HCA Wesley's first year of operation. The subjects in this study consisted of approximately every third patient who received an ESWL treatment and were grouped according to stone sizes of less than 2 cm and those greater than 2 cm. A questionnaire was used, and after data were collected from the patient's charts and billing, a t-test for independent samples was used for analysis.