Stroke with large vessel occlusion in the posterior circulation: IV thrombolysis plus thrombectomy versus IV thrombolysis alone

Efficacy and safety of mechanical thrombectomy (MT) for stroke with posterior circulation large vessel occlusion (LVO) is still under debate. We aimed to compare the outcomes of stroke patients with posterior circulation LVO treated with intravenous thrombolysis (IVT) (< 4.5 h after symptom onset) plus MT < 6 h after symptom onset with those treated with IVT alone (< 4.5 h after symptom onset). Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analysed. We identified 409 IRETAS patients treated with IVT plus MT and 384 SITS-ISTR patients treated with IVT alone. IVT plus MT was significantly associated with higher rate of sICH (ECASS II) compared with IVT alone (3.1 vs 1.9%; OR 3.984, 95% CI 1.014-15.815), while the two treatments did not differ significantly in 3-month mRS score ≤ 3 (64.3 vs 74.1%; OR 0.829, 95% CI 0.524-1.311). In 389 patients with isolated basilar artery (BA) occlusion, IVT plus MT was significantly associated with higher rate of any ICH compared with IVT alone (9.4 vs 7.4%; OR 4.131, 95% CI 1.215-14.040), while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with higher rate mRS score ≤ 2 (69.1 vs 52.1%; OR 2.692, 95% CI 1.064-6.811) and lower rate of death (13.8 vs 27.1%; OR 0.299, 95% CI 0.095-0.942) in patients with distal-segment BA occlusion, while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with lower rate of mRS score ≤ 3 (37.1 vs 53.3%; OR 0.137, 0.009-0.987), mRS score ≤ 1 (22.9 vs 53.3%; OR 0.066, 95% CI 0.006-0.764), mRS score ≤ 2 (34.3 vs 53.3%; OR 0.102, 95% CI 0.011-0.935), and higher rate of death (51.4 vs 40%; OR 16.244, 1.395-89.209) in patients with proximal-segment BA occlusion. Compared with IVT alone, IVT plus MT was significantly associated with higher rate of sICH per ECASS II definition in patients with stroke and posterior circulation LVO, while two treatment groups did not differ significantly in 3-month mRS score ≤ 3. IVT plus MT was associated with lower rate of mRS score ≤ 3 compared with IVT alone in patients with proximal-segment BA occlusion, whereas no significant difference was found between the two treatments in primary endpoints in patients isolated BA occlusion and in the other subgroups based on site occlusion.

Functional and radiological outcomes after bridging therapy versus direct thrombectomy in stroke patients with unknown onset: Bridging therapy versus direct thrombectomy in unknown onset stroke patients with 10-point ASPECTS

BACKGROUND AND PURPOSE

The aim was to assess functional and radiological outcomes after bridging therapy (intravenous thrombolysis plus mechanical thrombectomy) versus direct mechanical thrombectomy (MT) in unknown onset stroke patients.

METHODS

A cohort study was conducted on prospectively collected data from unknown onset stroke patients who received endovascular procedures at ≤6 h from symptom recognition or awakening time.

RESULTS

Of the 349 patients with a 10-point Alberta Stroke Program Early Computed Tomography Score (ASPECTS), 248 received bridging and 101 received direct MT. Of the 134 patients with 6-9-point ASPECTS, 123 received bridging and 111 received direct MT. Each patient treated with bridging was propensity score matched with a patient treated with direct MT for age, sex, study period, pre-stroke disability, stroke severity, type of stroke onset, symptom recognition to groin time (or awakening to groin time), ASPECTS and procedure time. In the two matched groups with 10-point ASPECTS (n = 73 vs. n = 73), bridging was associated with higher rates of excellent outcome (46.6% vs. 28.8%; odds ratio 2.302, 95% confidence interval 1.010-5.244) and successful recanalization (83.6% vs. 63%; odds ratio 3.028, 95% confidence interval 1.369-6.693) compared with direct MT; no significant association was found between bridging and direct MT with regard to rate of symptomatic intracerebral hemorrhage (0% vs. 1.4%). In the two matched groups with 6-9-point ASPECTS (n = 45 vs. n = 45), no significant associations were found between bridging and direct MT with regard to rates of excellent functional outcome (44.4% vs. 31.1%), successful recanalization (73.3% vs. 76.5%) and symptomatic intracerebral hemorrhage (0% vs. 0%).

CONCLUSIONS

Bridging at ≤ 6 h of symptom recognition or awakening time was associated with better functional and radiological outcomes in unknown onset stroke patients with 10-point ASPECTS.

Sleep quality and duration are associated with performance in maximal incremental test

BACKGROUND AND OBJECTIVE

Inadequate sleep patterns may be considered a trigger to development of several metabolic diseases. Additionally, sleep deprivation and poor sleep quality can negatively impact performance in exercise training. However, the impact of sleep duration and sleep quality on performance during incremental maximal test performed by healthy men is unclear. Therefore, the purpose of the study was to analyze the association between sleep pattern (duration and quality) and performance during maximal incremental test in healthy male individuals.

METHODS

A total of 28 healthy males volunteered to take part in the study. Sleep quality, sleep duration and physical activity were subjectively assessed by questionnaires. Sleep pattern was classified by sleep duration (>7h or <7h of sleep per night) and sleep quality according to the sum of measured points and/or scores by the Pittsburgh Sleep Quality Index (PSQI). Incremental exercise test was performed at 35 watts for untrained subjects, 70 watts for physically active subjects and 105 watts for well-trained subjects.

RESULTS

HR_max was correlated with sleep quality (r=0.411, p=0.030) and sleep duration (r=-0.430, p=0.022). Participants reporting good sleep quality presented higher values of W_max, VO_2max and lower values of HR_max when compared to participants with altered sleep. Regarding sleep duration, only W_max was influenced by the amount of sleeping hours per night and this association remained significant even after adjustment by VO_2max.

CONCLUSION

Sleep duration and quality are associated, at least in part, with performance during maximal incremental test among healthy men, with losses in W_max and HR_max. In addition, our results suggest that the relationship between sleep patterns and performance, mainly in W_max, is independent of fitness condition.

Aerobic training program for the enhancements of HR and VO2 off-kinetics in elite judo athletes

AIM

The purpose of this study was to investigate the physiologic and performance changes with the addition of high-intensity interval training (HIIT) to a traditional judo programme.

METHODS

Nine elite judokas (6 males and 3 females; age: 20±4 yrs; body mass: 69±2 kg; height: 172±7 cm; judo practice time: 13±6 yrs; weekly training volume: 13±5 hours, mean±SD) were recruited to perform a 12-week specific aerobic training program, which consisted of 2 session/week of 30-min continuous run at 60% at Vmax and one session/week of high-intensity interval training 15x1-min at 90% of Vmax with 1 min of active recovery at 60% of Vmax. Before and after the intervention all athletes performed a graded maximal exercise Test to measure maximal oxygen consumption (V̇O2max), ventilatory threshold (VT), maximal velocity (Vmax), heart rate (HR) and V̇O2 off kinetics. V̇O2 and HR recovery kinetics were evaluated on a breath-by-breath basis using a single component exponential function. Anaerobic capacity during specific movements was assessed with the Special judo fitness Test (SJFT).

RESULTS

The maximal speed reached during the maximal aerobic power test significantly increaseed (P=0.04), but V̇O2max did not change. τ of HR and of V̇O2 recovery significantly decreased by 17.3% (P=0.04) and 22.0% (P<0.01), respectively. VT increased (6.6%; P=0.03) and the SJFT Index improved (12%; P<0.001) 12% after training.

CONCLUSION

The aerobic fitness of elite judokas may be improved by adding aerobic routines to the normal training enhancing the recovery capacity.

Influence of the aerobic fitness on time spent at high percentage of maximal oxygen uptake during a high-intensity intermittent running

This study aimed to evaluate absolute and relative (%V.O2max) oxygen uptake (total, during effort and pause), and time spent above 90% of V.O2max during high-intensity intermittent running in subjects with different training status. Fourteen males were evaluated and divided (moderate and high aerobic power) according to their V.O2max obtained in an incremental treadmill test to volitional exhaustion. They were then submitted to high-intensity intermittent aerobic exercise (1 min:1 min at maximum velocity attained during the treadmill test, totalling 4 km). A Student's t test for independent data was conducted to identify differences between groups. The moderate aerobic power group spent more time above 90% V.O2max compared to the high aerobic power group (30.2 ±9.1%; 7.3±6%, respectively, P=0.001). Moreover, the moderate aerobic power group presented lower V.O2total (P=0.011), V.O2effort (P=0.007), higher V.O2total (%V.O2), V.O2effort (P<0.001), V.O2pause (V.O2max%) (P=0.006) compared with the high aerobic power group. There was no difference in V.O2pause between groups (P=0.091), the difference between V.O2 effort and pause was greater for the high aerobic power group compared with the moderate group (4.4±2.1; 7.8±2 mL.kg-1.min-1; P=0.009) and the difference between V.O2 effort and pause (%V.O2max) was not different between groups. To conclude, these results demonstrated that individuals with better aerobic fitness spent less time above 90% of the V.O2max and that this response can be due to better capacity to recover during the pause.

The influence of karate practice level and sex on physiological and perceptual responses in three modern karate training modalities

Objective

The aim of the present study was to examine the influence of karate practice level (national vs international level) and sex (women vs men) on physiological and perceptual responses in three modern karate training modalities (tactical-technical (TT), technical-development (TD), and randori).

Method

The study included 18 karatekas participating in an eight-session training camp of four TT, two TD, and two randori. During each session, the percentage of maximal heart rate (HR), blood lactate concentration [La^-], and rating of perceived exertion (RPE) were assessed.

Results

The main results showed that the percentage of maximal HR was significantly higher in women than in men regardless of practice level or training modality (70.3 ± 4.1 vs 66.2 ± 6.3, respectively). Moreover, [La^-] and RPE were significantly lower in international-level karatekas compared with their national-level counterparts whatever the sex or training modality ([La^-] = 11.4 ± 2.6 vs 8.3 ± 2.4 mmol · L^-1 and RPE = 3.6 ± 1.2 vs 4.3 ± 1.5, respectively). Last, physiological and perceptual responses were significantly higher during randori in comparison with TT and TD for both sexes.

Conclusion

The combination of [La^-] and RPE thus seems to be a good indicator for discriminating between national- and international-level karatekas, and randori seems to be an effective means to reproduce official karate sparring.

Maximum number of repetitions, total weight lifted and neuromuscular fatigue in individuals with different training backgrounds

The aim of this study was to evaluate the performance, as well as neuromuscular activity, in a strength task in subjects with different training backgrounds. Participants (n = 26) were divided into three groups according to their training backgrounds (aerobic, strength or mixed) and submitted to three sessions: (1) determination of the maximum oxygen uptake during the incremental treadmill test to exhaustion and familiarization of the evaluation of maximum strength (1RM) for the half squat; (2) 1RM determination; and (3) strength exercise, four sets at 80% of the 1RM, in which the maximum number of repetitions (MNR), the total weight lifted (TWL), the root mean square (RMS) and median frequency (MF) of the electromyographic (EMG) activity for the second and last repetition were computed. There was an effect of group for MNR, with the aerobic group performing a higher MNR compared to the strength group (P = 0.045), and an effect on MF with a higher value in the second repetition than in the last repetition (P = 0.016). These results demonstrated that individuals with better aerobic fitness were more fatigue resistant than strength trained individuals. The absence of differences in EMG signals indicates that individuals with different training backgrounds have a similar pattern of motor unit recruitment during a resistance exercise performed until failure, and that the greater capacity to perform the MNR probably can be explained by peripheral adaptations.

Aerobic profile of climbers during maximal arm test

This study compared measurements of upper body aerobic fitness in elite (EC; n=7) and intermediate rock climbers (IC; n=7), and a control group (C; n=7). Subjects underwent an upper limb incremental test on hand cycle ergometer, with increments of 23 W · min(-1), until exhaustion. Ventilation (VE) data were smoothed to 10 s averages and plotted against time for the visual determination of the first (VT1) and second (VT2) ventilatory thresholds. Peak power output was not different among groups [EC=130.9 (±11.8) W; IC=122.1 (±28.4) W; C=115.4 (±15.1) W], but time to exhaustion was significantly higher in EC than IC and C. VO(2 PEAK) was significantly higher in EC [36.8 (±5.7) mL.kg(-1).min(-1)] and IC [35.5 (±5.2) mL.kg(-1).min(-1)] than C [28.8 (±5.0) mL.kg(-1).min(-1)], but there was no difference between EC and IC. VT1 was significantly higher in EC than C [EC=69.0 (±9.4) W; IC=62.4 (±13.0) W; C=52.1 (±11.8) W], but no significant difference was observed in VT2 [EC=103.5 (±18.8) W; IC=92.0 (±22.0) W; C=85.6 (±19.7) W]. These results show that elite indoor rock climbers elicit higher aerobic fitness profile than control subjects when measured with an upper body test.

Effects of recovery type after a judo combat on blood lactate removal and on performance in an intermittent anaerobic task

AIM

The objective of this study was to verify the effects of active (AR) and passive recovery (PR) after a judo match on blood lactate removal and on performance in an anaerobic intermittent task (4 bouts of upper body Wingate tests with 3-min interval between bouts; 4WT).

METHODS

The sample was constituted by 17 male judo players of different competitive levels: A) National (Brazil) and International medallists (n. 5). B) State (São Paulo) medallists (n. 7). C) City (São Paulo) medallists (n. 5). The subjects were submitted to: 1) a treadmill test for determination of V.O2peak and velocity at anaerobic threshold (VAT); 2) body composition; 3) a 5-min judo combat, 15-min of AR or PR followed by 4WT.

RESULTS

The groups did not differ with respect to: body weight, V.O2peak, VAT, body fat percentage, blood lactate after combats. No difference was observed in performance between AR and PR, despite a lower blood lactate after combat (10 and 15 min) during AR compared to PR. Groups A and B performed better in the high-intensity intermittent exercise compared to athletes with lower competitive level (C).

CONCLUSION

The ability to maintain power output during intermittent anaerobic exercises can discriminate properly judo players of different levels. Lactate removal was improved with AR when compared to PR but AR did not improve performance in a subsequent intermittent anaerobic exercise.

[High-dose chemotherapy, G-CSF and the use of peripheral blood progenitor cells in patients with poor-prognosis neuroblastoma]

In the past decade there has been an increasing use of high dose of chemo-radiotherapy in the treatment of poor prognosis solid tumors of childhood. The autologous bone marrow transplantation is the most used technique for circumventing the infectious and haemorrhagic complications occurring in the prolonged period of myelotoxicity. The faster recovery assured by the peripheral blood progenitor cells (PBPC) makes this procedure an attractive alternative. The advent of new apheretic modalities and the use of combinations of active antineoplastic drugs with various growth factors, such as G-CSF, GM-CSF and IL-3, has allowed to collect and concentrate the mononuclear fraction of peripheral blood leukocytes. The optimal timing for the collection is a crucial point and the utilization of flow cytometry for the determinations of circulating CD34+ cells in the peripheral blood is so far the best indicator for successful apheresis. The authors describe their experience in 16 children affected by poor prognosis neuroblastoma who had undergone high dose chemotherapy followed by G-CSF administration and PBPC collection. The details of apheretic techniques and the characteristics of conditioning regimen and haematologic recovery after PBPC reinfusion are also presented.

Collection of peripheral blood hematopoietic progenitors (PBHP) from patients with severe aplastic anemia (SAA) after prolonged administration of granulocyte colony-stimulating factor

The aim of this study was to test whether prolonged administration of granulocyte colony-stimulating factor (G-CSF) would allow the collection by leukapheresis of PBHP in patients with SAA. For this purpose, nine SAA patients, 7 to 46 years old, six of whom were enrolled at diagnosis of their disease and three after previous immunosuppression had failed, were treated with antilymphocyte globulin (ALG) (day 1 to 5), cyclosporin A (5 mg/kg/d orally) (day 6 to 90) and G-CSF 5 micrograms/kg/d (day 6 to 90). A total of 40 leukaphereses were performed, (range 2 to 7 per patient), between days +10 and +168 from G-CSF treatment. White blood cell count at the time of harvest ranged from 1.2 to 18.1 x 10(9)/L. Results can be summarized as follows: the median number of cells collected per patient was 5.0 x 10(8)/kg (range 2.6 to 18.7), the median number of CD34+ cells was 1.8 x 10(6)/kg (range 0.27 to 3.8) and the median number of colony-forming units granulocyte-macrophage (CFU-GM) was 3.9 x 10(4)/kg (range 0 to 39). Twenty leukaphereses performed between days +33 and +77 of G-CSF treatment grew granulocyte macrophages and erythroid colonies in vitro. No colony growth was obtained from 20 leukaphereses performed before day +33 or after day +80. In six patients the total number of CFU-GM recovered were in the range described for autologous peripheral blood stem cell grafts. (2.6 to 39 x 10(4)/kg). In conclusion, this study suggests that circulating hematopoietic progenitors can be recovered after ALG priming and after at least 1 month of G-CSF treatment in a proportion of patients with SAA. Whether these cells will be suitable for autologous transplantation remains to be determined.

A rosetting test with papain-treated erythrocytes (RBC) for the detection of a minor erythrocyte population (chimerism) with different antigenic expressivity

A rosetting test with papain-treated erythrocytes was set up and evaluated for the detection of minor erythrocyte populations (chimerism), which can be distinguished by their antigenic differences. The test, for Rh system antigenic differences, has been able to detect erythrocyte populations with a 0.5: 1000 density and a sensitivity 3-4 times as high as that of the antiglobulin test. Critical elements for the optimization of the test are: the final ratio between papain-treated erythrocytes and erythrocytes examined (2:1); the specificity check of the antiserum used which, considering the increased sensitivity, must be performed by the rosetting test itself; the accurate and delicate resuspension of the final pellet. Some disadvantages are the impossibility to detect antigenicity that can be altered by papain and, above all, the scarce possibility of quantifying, if not roughly, the size of the minor population.

Childhood systemic lupus erythematosus: a review of 30 cases

We review 30 cases of pediatric systemic lupus erythematosus followed over an 8-year period at our institution. The female to male ratio was 3.3:1; the age at diagnosis ranged between 3.5 and 16 years. On first admission, renal involvement was detected in the majority of the patients, as assessed by laboratory findings and/or clinical manifestations. Other frequently observed symptoms were fever, skin rashes, arthralgias and/or arthritis and serositis. All of the patients were treated with corticosteroids and most of them also received immunosuppressive drugs in order to control disease activity. Two patients were lost to the follow-up, five died and only one of the 23 evaluable patients is off therapy after a median follow-up of 5 years. This study confirms that pediatric systemic lupus erythematosus is a very aggressive disease.

Mononuclear cell (MNC) concentration from the marrow harvest by automatic system

The availability of reliable and standardizable procedures with low contamination risk and less prominent loss in MNC, would solve the existing perplexities about the systematic use of this passage. We tried to experiment Areman's et al protocol that utilizes the CS 3000 blood cell processor without gradient, making some changes and comparing the results with those achieved with the COBE 2991 on Ficoll. Some aspects should be defined, but the preliminary results are undoubtedly of great interest.

Positive direct antiglobulin test in a pediatric patient following high-dose cisplatin

A positive direct antiglobulin test (DAT) and hemolytic anemia are uncommon side effect of cisplatin (CDDP) therapy. A 9-year-old girl treated for extraosseus Ewing's sarcoma with a multiagent regimen, including 200 mg/m2 CDDP preceded by vincristine (VCR) and cyclophosphamide (CY), developed a positive DAT, followed by hemolytic anemia. When CDDP therapy was discontinued, the DAT became negative and no signs of anemia were observed during the maintenance treatment, which included VCR and actinomycin D.

[Total body irradiation, vincristine in continuous infusion and high-dose melphalan with transplant of autologous bone marrow in the treatment of neuroblastoma]

High dose chemo-radiotherapy followed by autologous bone marrow transplantation (ABMT) is known to be an effective treatment in stage IV neuroblastoma (NB). Since October '84, 19 children with NB (12 relapsed or resistant: Group A; 7 in first CR: Group B) received ablative therapy (AT) consisting of VCR (4 mg/mg), L-PAM (140 mg/mg) and fractionated TBI (1000 Rads). Induction strategy at diagnosis or at relapse included high dose Peptichemio, 2-3 cycles of Vincristine-Cyclophosphamide--high dose Platinum and surgery. Bone marrow was harvested after 2 evaluation proved negative by cytomorphology, histology and immunofluorescence. Mononuclear cells (median 6.7 x 10(7)/kg) were cryopreserved and reinfused without purging. At the time of AT in Group A8 children were in CR, 4 had minimal diseases; in Group B 6 were in CR and one in PR. One toxicity-related death occurred on day 7 in a child in first CR; median duration of granulocytopenia 0.5 x 10(9)/l and thrombocytopenia less than 50 x 10(9)/l were 20 days (R: 9-40) and 27 days (R: 11-51) respectively. Persistent immune thrombocytopenia occurred in 4 children. Fever higher tha 38 degrees C developed in all patients: sepsis was documented in 6 patients. Extramedullary toxicity was moderate: GI tract was the most affected. Two out of 5 children who received AT having residual disease achieved CR; relapse or progression of disease occurred in all these patients. Four out of 8 children in second or subsequent CR and 4 out of 5 in first CR are alive and well at 3-12 months (median 7).(ABSTRACT TRUNCATED AT 250 WORDS)