Resistance to apoptosis in complicated Crohn's disease: Relevance in ileal fibrosis

BACKGROUND AND AIMS

The stiffening of the extracellular matrix, and changes in its cellular and molecular composition, have been reported in the pathogenesis of fibrosis. We analyze the mechanisms that perpetuate ileal fibrosis in surgical resections of complicated Crohn's disease patients.

METHODS

Ileal resections were obtained from affected and non-affected tissue of stenotic or penetrating Crohn's disease behavior. Ilea from non-IBD patients were used as control tissue. All samples underwent RNA sequencing. Human small intestinal fibroblasts were treated for 48 h with IL-1β, TFGβ1, PDGFB or TNF-α. Resistance to apoptosis was analysed by RT-PCR, western blot and immunohistochemistry in ileal tissue and by RT-PCR and FACS in cultured cells.

RESULTS

Growth factor-driven signaling pathways and increased RAS GTPase activity were up-regulated in affected ilea in which we found expression of both the antiapoptotic molecule MCL1 and the transcription factor ETS1 in submucosal fibroblasts, and a senescence-associated secretory phenotype. In cultured intestinal fibroblasts, PDGFB induced an ETS1-mediated resistance to apoptosis that was associated with the induction of both of TGFB1 and IL1B, a cytokine that replicated the expression of SASP detected in ileal tissue. ETS1 drove fibroblast polarization between inflammatory and fibrogenic phenotypes in IL1β-treated cells.

CONCLUSIONS

Our data show resistance to apoptosis in complicated ileal CD, and demonstrate that PDGFB induce an ETS1-mediated resistance to apoptosis associated with an inflammatory and fibrogenic pattern of expression in intestinal fibroblasts. Results point to PDGFRB, IL1R1 or MCL1 as potential targets against ileal fibrosis.

Surgery for inflammatory bowel disease in Spain: How are we doing? Initial results of a nationwide prospective registry

INTRODUCTION

Inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), requires a multidisciplinary approach, and surgery is commonly needed. The aim of this study was to evaluate the types of surgery performed in these patients in a nationwide study by hospital type, global postoperative complications, and quality of life after surgery.

METHODS

A prospective, multicenter, national observational study was designed to collect the results of surgical treatment of IBD in Spain. Demographic characteristics, medical-surgical treatments, postoperative complications and quality of life were recorded with a one-year follow-up. Data were validated and entered by a surgeon from each institution.

RESULTS

A total of 1134 patients (77 centers) were included: 888 CD, 229 UC, and 17 indeterminate colitis. 1169 surgeries were recorded: 882 abdominal and 287 perianal. Before surgery, 81.6% of the patients were evaluated by a multidisciplinary committee, and the mean preoperative waiting time for elective surgery was 2.09 ± 2 meses (P > .05). Overall morbidity after one year of follow-up was 16%, and the major complication rate was 36.4%. Significant differences were observed among centers in complex CD surgeries. Overall quality of life improved after surgery.

CONCLUSIONS

There is heterogeneity in the surgical treatment of IBD among Spanish centers. Differences were observed in patients with highly complex surgeries. Overall quality of life improved with surgical treatment.

ECCO Topical Review: Roadmap to Optimal Peri-Operative Care in IBD

BACKGROUND AND AIMS

Despite the advances in medical therapies, a significant proportion of patients with inflammatory bowel diseases [IBD] require surgical intervention. This Topical Review aims to offer expert consensus practice recommendations for peri-operative care to optimize outcomes of IBD patients who undergo surgery.

METHODS

A multidisciplinary panel of IBD healthcare providers systematically reviewed aspects relevant to peri-operative care in IBD. Consensus statements were developed using Delphi methodology.

RESULTS

A total of 20 current practice positions were developed following systematic review of the current literature covering use of medication in the peri-operative period, nutritional assessment and intervention, physical and psychological rehabilitation and prehabilitation, and immediate postoperative care.

CONCLUSION

Peri-operative planning and optimization of the patient are imperative to ensure favourable outcomes and reduced morbidity. This Topical Review provides practice recommendations applicable in the peri-operative period in IBD patients undergoing surgery.

Early and Delayed Infarct Growth in Patients Undergoing Mechanical Thrombectomy: A Prospective, Serial MRI Study

BACKGROUND

We studied the evolution over time of diffusion weighted imaging (DWI) lesion volume and the factors involved on early and late infarct growth (EIG and LIG) in stroke patients undergoing endovascular treatment (EVT) according to the final revascularization grade.

METHODS

This is a prospective cohort of patients with anterior large artery occlusion undergoing EVT arriving at 1 comprehensive stroke center. Magnetic resonance imaging was performed on arrival (pre-EVT), <2 hours after EVT (post-EVT), and on day 5. DWI lesions and perfusion maps were evaluated. Arterial revascularization was assessed according to the modified Thrombolysis in Cerebral Infarction (mTICI) grades. We recorded National Institutes of Health Stroke Scale at arrival and at day 7. EIG was defined as (DWI volume post-EVT-DWI volume pre-EVT), and LIG was defined as (DWI volume at 5d-DWI volume post-EVT). Factors involved in EIG and LIG were tested via multivariable lineal models.

RESULTS

We included 98 patients (mean age 70, median National Institutes of Health Stroke Scale score 17, final mTICI≥2b 86%). Median EIG and LIG were 48 and 63.3 mL in patients with final mTICI<2b, and 3.6 and 3.9 cc in patients with final mTICI≥2b. Both EIG and LIG were associated with higher National Institutes of Health Stroke Scale at day 7 (ρ=0.667; P<0.01 and ρ=0.614; P<0.01, respectively). In patients with final mTICI≥2b, each 10% increase in the volume of DWI pre-EVT and each extra pass leaded to growths of 9% (95% CI, 7%-10%) and 14% (95% CI, 2%-28%) in the DWI volume post-EVT, respectively. Furthermore, each 10% increase in the volume of DWI post-EVT, each extra pass, and each 10 mL increase in TMax6s post-EVT were associated with growths of 8% (95% CI, 6%-9%), 9% (95% CI, 0%-19%), and 12% (95% CI, 5%-20%) in the volume of DWI post-EVT, respectively.

CONCLUSIONS

Infarct grows during and after EVT, especially in nonrecanalizers but also to a lesser extent in recanalizers. In recanalizers, number of passes and DWI volume influence EIG, while number of passes, DWI, and hypoperfused volume after the procedure determine LIG.

Inflammatory Bowel Diseases Benefit from Enhanced Recovery After Surgery [ERAS] Protocol: A Systematic Review with Practical Implications

BACKGROUND

Enhanced Recovery After Surgery [ERAS] is widely adopted in patients undergoing colorectal surgery, with demonstrated benefits. Few studies have assessed the feasibility, safety, and effectiveness of ERAS in patients with inflammatory bowel diseases [IBD]. The aim of this study was to investigate the current adoption and outcomes of ERAS in IBD.

METHODS

This PRISMA-compliant systematic review of the literature included all articles reporting on adult patients with IBD who underwent colorectal surgery within an ERAS pathway. PubMed/MEDLINE, Cochrane Library, and Web of Science were searched. Endpoints included ERAS adoption, perioperative outcomes, and ERAS items more consistently reported, with associated evidence levels [EL] [PROSPERO CRD42021238653].

RESULTS

Out of 217 studies, 16 totalling 2347 patients were included. The median number of patients treated was 50.5. Malnutrition and anaemia optimisation were only included as ERAS items in six and four articles, respectively. Most of the studies included the following items: drinking clear fluids until 2 h before the surgery, fluid restriction, nausea prophylaxis, early feeding, and early mobilisation. Only two studies included postoperative stoma-team and IBD-team evaluation before discharge. Highest EL were observed for ileocaecal Crohn's disease resection [EL2]. Median in-hospital stay was 5.2 [2.9-10.7] days. Surgical site infections and anastomotic leaks ranged between 3.1-23.5% and 0-3.4%, respectively. Complications occurred in 5.7-48%, and mortality did not exceed 1%.

CONCLUSIONS

Evidence on ERAS in IBD is lacking, but this group of patients might benefit from consistent adoption of the pathway. Future studies should define if IBD-specific ERAS pathways and selection criteria are needed.

Ischaemic stroke as a complication of cardiac catheterisation. Clinical and radiological characteristics, progression, and therapeutic implications

INTRODUCTION

Ischaemic stroke is the most common neurological complication of cardiac catheterisation. This study aims to analyse the clinical and prognostic differences between post-catheterisation stroke code (SC) and all other in-hospital and prehospital SC.

METHODS

We prospectively recorded SC activation at our centre between March 2011 and April 2016. Patients were grouped according to whether SC was activated post-catheterisation, in-hospital but not post-catheterisation, or before arrival at hospital; groups were compared in terms of clinical and radiological characteristics, therapeutic approach, functional status, and three-month mortality.

RESULTS

The sample included 2224 patients, of whom 31 presented stroke post-catheterisation. Baseline National Institutes of Health Stroke Scale score was lower for post-catheterisation SC than for other in-hospital SC and pre-hospital SC (5, 10, and 7, respectively; P=.02), and SC was activated sooner (50, 100, and 125minutes, respectively; P<.001). Furthermore, post-catheterisation SC were more frequently due to transient ischaemic attack (38%, 8%, and 9%, respectively; P<.001) and less frequently to proximal artery occlusion (17.9%, 31.4%, and 39.2%, respectively; P=.023). The majority of patients with post-catheterisation strokes (89.7%) did not receive reperfusion therapy; 60% of the patients with proximal artery occlusion received endovascular treatment. The mortality rate was 12.95% for post-catheterisation strokes and 25% for all other in-hospital strokes. Although patients with post-catheterisation stroke had a better functional prognosis, the adjusted analysis showed that this effect was determined by their lower initial severity.

CONCLUSIONS

Post-catheterisation stroke is initially less severe, and presents more often as transient ischaemic attack and less frequently as proximal artery occlusion. Most post-catheterisation strokes are not treated with reperfusion; in case of artery occlusion, mechanical thrombectomy is the preferred treatment.

Can the green energies improve the sustainability of electrochemically-assisted soil remediation processes?

The green powering of electrochemically-assisted soil remediation processes had been strongly discouraged. Low remediation efficiencies have been reported as a consequence of the reversibility of the transport processes when no power is applied to the electrodes, due to the intermittent powering of renewable sources. However, it has been missed a deeper evaluation from the environmental point of view. This work goes further and seeks to quantify, using life cycle assessment tools, the environmental impacts related to the electro-kinetic treatments powered by different sources: grid (Spanish energy mix), photovoltaic and wind sources. The global warming potential and the ozone depletion showed higher environmental impacts in case of using green energies, associated with the manufacturing of the energy production devices. In contrast to that, results pointed out the lowest water consumption for the treatment powered with solar panels. The huge water requirements to produce energy, considering a Spanish energy mix, drop the sustainability of this powering strategy in terms of water footprint. Regarding toxicities, the pollutant toxicity was highly got rid of after 15 days of treatment, regardless the powering source used. Nevertheless, the manufacturing of energy and green energy production devices has a huge impact into the toxicity of the remediation treatments, increasing massively the total toxicity of the process, being this effect less prominent by the electro-kinetic treatment solar powered. In view of the overall environmental impact assessed, according to mid and endpoint impact categories, it can be claimed that, despite the high energy requirements and affectation to the global warming potential, the use of solar power is a more sustainable alternative to remediate polluted soils by electrochemical techniques.

Understanding the local and remote source contributions to ambient O3 during a pollution episode using a combination of experimental approaches in the Guadalquivir valley, southern Spain

The Guadalquivir Valley is one of three major O₃ hotspots in Spain. An airborne and surface measurement campaign was carried out from July 9th to 11th, 2019 to quantify the local/regional O₃ contributions using experimental approaches. Air quality and meteorology data from surface measurements, a microlight aircraft, a helium balloon, and remote sensing data (TROPOMI-NO2-ESA) were used to obtain the 3D distribution of O₃ and various tracer pollutants. O₃ accumulation over 2.5 days started with inputs from oceanic air masses transported inland by sea breezes, which drew O₃ and its precursors from a local/regional origin to the northeastern end of the basin. The orographic-meteorological setting of the valley caused vertical recirculation of the air masses inside the valley that caused the accumulation by increasing regional background O₃ concentration by 25-30 ppb. Furthermore, possible Mediterranean O₃ contributions and additional vertical recirculation through the entrainment zone of the convective boundary layer also contributed. Using particulate matter finer than 2.5 μm (PM_2.5), ultrafine particles (UFP), and black carbon (BC) as tracers of local sources, we calculated that local contributions increased regional O₃ levels by 20 ppb inside specific pollution plumes transported by the breeze into the valley, and by 10 ppb during midday when flying over an area with abundant agricultural burning during the morning. Air masses that crossed the southern boundaries of the Betic system at mid-altitude (400-1850 m a.s.l.) on July 10th and 11th may have provided additional O₃. Meanwhile, a decreasing trend at high altitudes (3000-5000 m a.s.l.) was observed, signifying that the impact of stratospheric O₃ intrusion decreased during the campaign.

Toward more sustainable photovoltaic solar electrochemical oxidation treatments: Influence of hydraulic and electrical distribution

Powering electrochemical technologies with renewable energies is a promising way to get more sustainable environmental remediation techniques. However, the operational conditions of those processes must be optimized to undergo fast and efficient treatments. In this work, the influence of electrical and hydraulic connections in the performance of a set of two electrolyzers directly powered by photovoltaic panels was evaluated. Despite both electrolyzers were assembled using the same electrode material, they showed different performances. Results indicate that the electrolyzer with higher ohmic resistance and higher overpotential attained a greater production of oxidant species, being produced under the most efficient strategy around 4.8 and 15.1 mmol of oxidants per Ah by electrolyzer 1 and 2, respectively. Nevertheless, an excess of oxidant production because of an inefficient energy management, led to low removal efficiencies as a consequence of a waste of energy into undesirable reactions. Regarding the hydraulic distribution of wastewater between the cells, it was found to influence on the total remediation attained, being the serial connection 2.5 and 1.8 more efficient than a parallel wastewater distribution under series and parallel electrical strategies, respectively. Regarding electrical strategies, parallel connections maximize the use of power produced by the photovoltaic panels. Furthermore, this allows the system to work under lower current densities, reducing the mass transfer limitations. Considering both advantages, a hydraulic connection of the cells in series and an electrical connection in parallel was found to reach the highest specific removal of pollutant, 2.52 mg clopyralid (Wh)^-1. Conversely, the opposite strategy (parallel hydraulic connection-series electrical connection) showed the lowest remediation ratio, 0.48 mg clopyralid (Wh)^-1. These results are important to be considered in the design of electrolytic treatments of waste directly powered by photovoltaic panels, because they show the way to optimize the cells stack layout in full-scale applications, exhibiting significant impact on the sustainability of the electrochemical application.

Does intensification with UV light and US improve the sustainability of electrolytic waste treatment processes?

This work aims to assess the influence of ultrasounds (US) application or ultraviolet (UV) light irradiation on the efficiency and sustainability of the treatment of wastes by conductive diamond electrochemical oxidation (CDEO). To do this, a life cycle assessment (LCA) is carried out in order to quantify the environmental impacts of the intensified CDEO processes. Inventories of three bench scale remediation plants (CDEO, Sono-CDEO and Photo-CDEO) in which the different technologies are implemented are performed by means of Ecoinvent 3.3 data base. AWARE, USEtox, IPPC and ReCiPe methodologies are used to quantify the environmental burden into 5 midpoint (water footprint, global warming 100a, ozone layer depletion, human toxicity, freshwater ecotoxicity) and 17 endpoint impact categories. Photo-CDEO attains the faster and more efficient removal in terms of energy consumed. All impact categories are lower in the case in which UV light irradiation is coupled to the CDEO treatment, particularly if the electrolyte does not contain chloride anions. From the point of view of toxicity and ecotoxicity, it is essential to achieve a complete mineralization, because of the intermediates generated into wastes containing chloride anions can become more hazardous than the initial pesticide. The operation of these technologies at large current densities shows positive results from the sustainability point of view, despite the huge environmental impact related to the energy production. Data notice that almost a 99.0% of the total global warming potential is mainly due to the electricity required during the electrochemical treatment, being higher by the sono and photo CDEO treatments because of the use of additional devices. Nevertheless, this issue can be overcome by means of using renewable energies as power sources of these remediation treatments. According to results, it can be claimed that the electrochemical technologies may successfully compete with other AOPs in terms of sustainability.

Improving sustainability of electrolytic wastewater treatment processes by green powering

This work focuses on the evaluation of the impact of powering electrolytic wastewater treatment processes with grid or renewable energy on the sustainability of this electrochemical remediation technology. To face this goal, it was performed an inventory of three bench-scale plants made up by the same treatment technology but powered from different supplies: connected to grid and directly coupled with solar photovoltaic panels or a wind turbine. Results show that the powering mode can significantly affect the environmental risks of the treatment, not only in terms of electricity demand but also on the formation of intermediates, which are more important in the cases in which the intensity profile varied. A life cycle assessment (LCA) is carried out in order to quantify the environmental impacts of green powering electrolytic wastewater treatment processes. Ecoinvent 3.3 data base, AWARE, USEtox, IPPC and ReCiPe methodologies are used to quantify the environmental burden into 5 midpoint (water footprint, global warming 100a, ozone layer depletion, human toxicity, freshwater ecotoxicity) and 17 endpoint impact categories. All impact categories are higher in the case in which the supplied power cames from a electricity grid mix. For the removal of 0.1 g 2,4-dichlorophenoxyacetic acid (2,4D) per liter (functional unit) of treated wastewater releases 0.14 kg CO₂ eq. If the energy is provided by a wind turbine or a solar panel the processes emit 0.020 kg CO₂ eq and 0.019 kg CO₂ eq, respectively. A comparison of the impact based on the grid mix used in different countries is also made, which has pointed out the relevance of this input on the sustainability of the environmental electrochemical technologies.

Strategies for powering electrokinetic soil remediation: A way to optimize performance of the environmental technology

The electro-kinetic remediation of soils using different powering strategies has been studied, in order to clarify which is the best strategy to couple solar powering with this remediation technology, in a context of developing more sustainable electrochemical remediation technologies. Direct powering from photovoltaic panels (Case a), application of constant electric fields with the same average value of Case a (Case b) and application of constant specific power with the same average value of Case a (Case c) have been compared. Results show an outstanding influence of the powering strategy on the removal efficiency of clopyralid (model of herbicide used in this work). The direct use of solar power profiles obtained the lowest removal efficiencies, which contrasts with the higher expected sustainability of this powering strategy. Reversion of pollutant transport overnight and extreme electric field values at noon help to explain the lower efficiency of this strategy. Evaporation mechanisms are promoted by operating at extreme large electric fields. In addition, harsher conditions lead to a higher negative soil affectation in terms of regions affected by extreme pHs, water contents and/or conductivities and to lower specific pollutant removals. Therefore, maximum efficiencies were found for Case b (constant electric potential gradient) with a total removal over 110 g kWh^-1 and only a slight affectation into the final soil properties.

Brain embolization of a healthy artery fragment as a complication of a cardiac catheterization

Ischemic stroke is the most common neurological complication of cardiac catheterization resulting in a high morbidity and mortality. We present a 44-year-old man admitted for vasospastic angina that suffered a right middle cerebral artery (MCA) occlusion after a cardiac catheterization. Mechanical thrombectomy was indicated and complete arterial recanalization was achieved. The material obtained showed a fragment of a healthy artery. Partial radial endarterectomy and cerebral embolization may be a rare complication of cardiac catheterization.

Tamoxifen Failure in Medullary Thyroid Carcinoma

We report the results of short-term tamoxifen treatment (20 mg two times a day orally) in 2 patients with metastatic medullary thyroid carcinoma. Patient A had a rapid tumor progression with development of Cushing's syndrome before initiation of tamoxifen treatment. Patient B had a slowly progressive course. In both cases, neither clinical nor biochemical improvement were observed, after 1 and 3 months of tamoxifen therapy, respectively.

Posttreatment Infarct Volumes when Compared with 24-Hour and 90-Day Clinical Outcomes: Insights from the REVASCAT Randomized Controlled Trial

BACKGROUND AND PURPOSE

Endovascular therapy has become the standard of care for patients with disabling anterior circulation ischemic stroke due to proximal intracranial thrombi. Our aim was to determine whether the beneficial effect of endovascular treatment on functional outcome could be explained by a reduction in posttreatment infarct volume in the Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT) trial.

MATERIALS AND METHODS

The REVASCAT trial was a multicenter randomized open-label trial with blinded outcome evaluation. Among 206 enrolled subjects (endovascular treatment, n = 103; control, n = 103), posttreatment infarct volume was measured in 204 subjects. Posttreatment infarct volumes were compared with treatment assignment and recanalization status. Appropriate statistical models were used to assess the relationship among baseline clinical and imaging variables, posttreatment infarct volume, the 24-hour NIHSS score, and functional status with the 90-day modified Rankin Scale score.

RESULTS

The median posttreatment infarct volume in all subjects was 23.7 mL (interquartile range = 68.9 mL) and 16.3 mL (interquartile range = 50.2 mL) in the endovascular treatment arm and 38.6 mL (interquartile range = 74.9 mL) in the control arm (P = .02 for endovascular treatment versus control subjects). Baseline NIHSS (P < .01), site of occlusion (P < .03), baseline NCCT ASPECTS (P < .01), and recanalization status (P = .02) were independently associated with posttreatment infarct volume. Baseline NIHSS (P < .01), time from symptom onset to randomization (P = .02), treatment type (P = .04), and recanalization status (P < .01) were independently associated with the 24-hour NIHSS scores. The 24-hour NIHSS score strongly mediated the relationship between treatment type and 90-day mRS (P < .01 for indirect effect when adjusted for age), while posttreatment infarct volume did not (P = .26).

CONCLUSIONS

Endovascular treatment saves brain and improves 90-day clinical outcomes primarily through a beneficial effect on the 24-hour stroke severity.

Outcomes After Direct Thrombectomy or Combined Intravenous and Endovascular Treatment Are Not Different

Background and Purpose—

Whether intravenous thrombolysis adds a further benefit when given before endovascular thrombectomy (EVT) is unknown. Furthermore, intravenous thrombolysis delays time to groin puncture, mainly among drip and ship patients.

Methods—

Using region-wide registry data, we selected cases that received direct EVT or combined intravenous thrombolysis+EVT for anterior circulation strokes between January 2011 and October 2015. Treatment effect was estimated by stratification on a propensity score. The average odds ratios for the association of treatment with good outcome and death at 3 months and symptomatic bleedings at 24 hours were calculated with the Mantel–Haenszel test statistic.

Results—

We included 599 direct EVT patients and 567 patients with combined treatment. Stratification through propensity score achieved balance of baseline characteristics across treatment groups. There was no association between treatment modality and good outcome (odds ratio, 0.97; 95% confidence interval, 0.74–1.27), death (odds ratio, 1.07; 95% confidence interval, 0.74–1.54), or symptomatic bleedings (odds ratio, 0.56; 95% confidence interval, 0.25–1.27).

Conclusions—

This observational study suggests that outcomes after direct EVT or combined intravenous thrombolysis+EVT are not different. If confirmed by a randomized controlled trial, it may have a significant impact on organization of stroke systems of care.

On the origin of the highest ozone episodes in Spain

The 2000-2015 occurrences of the highest ozone (O₃) pollution episodes in Spain were evaluated to investigate their origin. To this end, data series available for urban and regional background (UB and RB), traffic (TR) and industrial (IN) sites were analysed separately and intercompared. Results evidenced that during these 16years mean O₃ levels in the RB sites did not change significantly, and remained constantly high. However, there is a clear increase at the TR and UB sites. Although sensitivity analysis is needed to interpret the cause of this increasing trend, this might be caused probably by the lower O₃ titration intensity due to the preferential abatement of NO vs NO₂, as supported from the neutral trend of O_X (NO₂+O₃) at these sites. We found that the exceedances of the hourly information threshold for O₃ (>180μg/m³) are recorded mostly at UB and IN sites located in seven areas of Spain (specific hotspots or at the tail end of large urban plumes), and that these increased during summer heatwaves (i.e. 2003 and 2015). Although the external contribution of regional-to-subcontinental transported O₃ might be relevant during the highest O₃ episodes in the Western Mediterranean, our results evidenced that in the above specific areas, regional-local O₃ production decisively contributes to the exceedances of the information threshold. Also that the human protection threshold and the AOT40 are more frequently exceeded in the Central, Southern and Mediterranean sides of the Iberian Peninsula. The design of effective episode abatement measures is quite complex in those conditions, due to both the nonlinearity of the chemical processes of O₃ formation and destruction, and to the interplay with the complex meteorological setting, causing frequent recirculation and in situ aging of air masses. However, the combination of meteorological forecasting of the main recirculation processes and sensitivity analysis of NO_X/VOC emission abatement measures might be powerful tools to evaluate the effectiveness of potential O₃ mitigation strategies. Finally we would like to highlight that the current UB, RB, IN and TR classification (somewhat subjective) is not adequate to interpret the origin of O₃ exceedances in complex areas of Southern Europe. Thus, a UB station recording exceedances, and located in a small city in the tail end of an urban plume of a large city, receives not only the contribution from its own UB, but mainly from the specific high O₃ RB caused by the urban plume transport.

Unwanted detachment of the Solitaire device during mechanical thrombectomy in acute ischemic stroke

Background

The use of retrievable stents for endovascular clot retrieval has dramatically improved successful revascularization and clinical outcome in selected patients with acute stroke.

Objective

To describe the rate and clinical consequences of unwanted spontaneous detachment of these devices during mechanical thrombectomy.

Methods

We studied 262 consecutive patients treated with the retrievable stent, Solitaire, for acute ischemic stroke between November 2008 and April 2015. Clinical, procedural, and outcome variables were compared between patients with and without unexpected detachment of this device. Detachment was classified as proximal to the stent proximal marker (type A) or distal to the marker (type B). Poor functional outcome was defined as modified Rankin scale score >2 at 90 days.

Results

Unwanted detachment occurred in 6/262 (2.3%) cases, four of type A and two of type B. Stent recovery was possible in three patients, all of ‘type A’, but in none of ‘type B’. The number of prior passes was higher in patients with undesired detachment (3 (2–5) vs 2 (1–3), p=0.007). Detachment was associated with higher rate of symptomatic intracranial hemorrhage (SICH) (33.3% vs 4.3%, p=0.001), poorer outcome (100% vs 54.8%, p=0.028), and higher mortality rate at 90 days (50% vs 17%, p=0.038).

Conclusions

Unwanted detachment of a Solitaire is an uncommon complication during mechanical thrombectomy in patients with acute ischemic stroke and is associated with the clot retrieval attempts, SICH, poor outcome, and higher mortality.

Access to Endovascular Treatment in Remote Areas

Background and Purpose—

Since demonstration of the benefit of endovascular treatment (EVT) in acute ischemic stroke patients with proximal arterial occlusion, stroke care systems need to be reorganized to deliver EVT in a timely and equitable way. We analyzed differences in the access to EVT by geographical areas in Catalonia, a territory with a highly decentralized stroke model.

Methods—

We studied 965 patients treated with EVT from a prospective multicenter population-based registry of stroke patients treated with reperfusion therapies in Catalonia, Spain (SONIIA). Three different areas were defined: (A) health areas primarily covered by Comprehensive Stroke Centers, (B) areas primarily covered by local stroke centers located less than hour away from a Comprehensive Stroke Center, and (C) areas primarily covered by local stroke centers located more than hour away from a Comprehensive Stroke Center. We compared the number of EVT×100 000 inhabitants/year and time from stroke onset to groin puncture between groups.

Results—

Baseline characteristics were similar between groups. Throughout the study period, there were significant differences in the population rates of EVT across geographical areas. EVT rates by 100 000 in 2015 were 10.5 in A area, 3.7 in B, and 2.7 in C. Time from symptom onset to groin puncture was 82 minutes longer in group B (312 minutes [245–435]) and 120 minutes longer in group C (350 minutes [284–408]) compared with group A (230 minutes [160–407]; P <0.001).

Conclusions—

Accessibility to EVT from remote areas is hampered by lower rate and longer time to treatment compared with areas covered directly by Comprehensive Stroke Centers.

Abstract WP27: Endovascular Treatment Improves Executive Functioning in Acute Ischemic Stroke

Background: Endovascular treatment has demonstrated benefit in functional outcomes after acute stroke but the effect on cognitive outcomes has not been explored yet.

Hypothesis: Our hypothesis is that endovascular treatment is associated with better cognitive outcome after ischemic stroke.

Methods: REVASCAT (Randomized Trial of Revascularization with Solitaire FR Device versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting within Eight Hours of Symptom Onset) enrolled 206 patients with stroke of anterior circulation<8h and without cognitive impairment at onset that were randomized to receive thrombectomy or best medical treatment. Executive function was measured by means of Trail Making tests (TM-A and B) at 90 day. Time of completion of each test and number of errors were recorded.

Results: Excluding deaths, 120 patients were able to complete TM-A in due time (less than 5 min), 61 in thrombectomy and 59 controls (p=NS), and 65 patients could complete TM-B, 39 in thrombectomy and 26 controls (p=0.026). Time required to complete TM-A was not different between groups but controls needed more time (unadjusted Beta,1.0; 95%CI, 0.15-1.84) than thrombectomy patients to complete TM-B.

Conclusion: Patients treated with thrombectomy showed more frequently preserved and faster executive functioning compared to controls 3 months after stroke.

Biotechnological strategies to improve production of microbial poly-(3-hydroxybutyrate): a review of recent research work

Poly-(3-hydroxybutyrate) [P(3HB)] is a polyester synthesized as a carbon and energy reserve material by a wide number of bacteria. This polymer is characterized by its thermo-plastic properties similar to plastics derived from petrochemical industry, such as polyethylene and polypropylene. Furthermore, P(3HB) is an inert, biocompatible and biodegradable material which has been proposed for several uses in medical and biomedical areas. Currently, only few bacterial species such as Cupriavidus necator, Azohydromonas lata and recombinant Escherichia coli have been successfully used for P(3HB) production at industrial level. Nevertheless, in recent years, several fermentation strategies using other microbial models such as Azotobacter vinelandii, A. chroococcum, as well as some methane-utilizing species, have been developed in order to improve the P(3HB) production and also its mean molecular weight.

Impact of a comprehensive stroke centre on the care of patients with acute ischaemic stroke due to cervical artery dissection

INTRODUCTION

Cervical artery dissection (CAD) is the cause of 2% to 3% of ischaemic strokes and 10% to 25% of the ischaemic strokes in young people. Our objective is to evaluate whether implementation of a comprehensive stroke centre (CSC) improves the diagnosis and modifies the prognosis of patients with acute stroke due to CAD.

PATIENTS AND METHODS

Retrospective study of a registry of consecutive patients with acute stroke due to CAD. They were classified according to the period of care at our centre: pre-CSC (October 2004-March 2008, 42 months) or post-CSC (April 2008-June 2012, 51 months). We compared baseline characteristics, methods of diagnosis, treatment and outcome of these patients in both periods.

RESULTS

Nine patients were diagnosed with CAD in pre-CSC and 26 in post-CSC, representing 0.8% and 2.1% of all ischaemic strokes treated in each period, respectively. The diagnosis of CAD was made within the first 24 hours in 42.3% of the patients in post-CSC versus 0% in pre-CSC, by using urgent cerebral angiography as a diagnostic test in 46.2% of cases in the second period compared to 0% in the first. Both severity of stroke (median NIHSS score 11 vs. 3, P=.014) and time to neurological care (265 min vs 148, P=.056) were higher in the post-CSC period. Endovascular treatment was performed in 34.3%, and all treatments were post-CSC. The functional outcome was comparable for both periods.

CONCLUSIONS

Implementation of a CSC increases the frequency of the diagnosis of CAD, as well as the treatment options for these patients in the acute phase of stroke.

Prognostic value of changes in resting-state functional connectivity patterns in cognitive recovery after stroke: A 3T fMRI pilot study

Resting‐state studies conducted with stroke patients are scarce. First objective was to explore whether patients with good cognitive recovery showed differences in resting‐state functional patterns of brain activity when compared to patients with poor cognitive recovery. Second objective was to determine whether such patterns were correlated with cognitive performance. Third objective was to assess the existence of prognostic factors for cognitive recovery. Eighteen right‐handed stroke patients and eighteen healthy controls were included in the study. Stroke patients were divided into two groups according to their cognitive improvement observed at three months after stroke. Probabilistic independent component analysis was used to identify resting‐state brain activity patterns. The analysis identified six networks: frontal, fronto‐temporal, default mode network, secondary visual, parietal, and basal ganglia. Stroke patients showed significant decrease in brain activity in parietal and basal ganglia networks and a widespread increase in brain activity in the remaining ones when compared with healthy controls. When analyzed separately, patients with poor cognitive recovery (n = 10) showed the same pattern as the whole stroke patient group, while patients with good cognitive recovery (n = 8) showed increased activity only in the default mode network and fronto‐temporal network, and decreased activity in the basal ganglia. We observe negative correlations between basal ganglia network activity and performance in Semantic Fluency test and Part A of the Trail Making Test for patients with poor cognitive recovery. A reverse pattern was observed between frontal network activity and the abovementioned tests for the same group. Hum Brain Mapp 35:3819–3831, 2014. © 2014 The Authors. Human Brain Mapping published by Wiley Periodicals, Inc.

Abstract W P11: A Clinical Scale to Predict Futile Arterial Recanalization in Acute Stroke Patients with Anterior Circulation Arterial Occlusion Treated with Endovascular Therapies

Introduction: Futile arterial recanalization (FAR), considered as a lack of functional recovery despite complete recanalization, is observed in up to 30-50% of acute stroke patients treated with endovascular therapy. We aimed to develop a prognostic scale based on baseline clinical and radiological factors to predict FAR.

Methods: Prospective analysis of consecutive stroke patients with anterior circulation occlusion treated with endovascular therapy (97% mechanical thrombectomy with stent-retrievers). Complete recanalization was considered as a TICI 2b-3. FAR was defined as a modified Rankin scale >2 at 90 days in patients with complete recanalization. Baseline factors associated with FAR were detected on univariate analysis and were used to compose the predictive scale.

Results: From a total of 229 patients with anterior arterial occlusion, 166 (72.5%) achieved complete recanalization. FAR was observed in 80/166 (48.2%). Factors significantly associated with FAR were included to compose the predictive scale as follow: Age (scoring 0 if ≤70 and 1 if >70 years old), history of diabetes mellitus (0 if absent, 1 if present), history of hypertension (0 if absent, 1 if present), NIHSS (1 if NIHSS ≤10, 2 if NIHSS 10-19, 3 if NIHSS>19), ASPECTS (1 if ASPECTS 9-10, 2 if ASPECTS 7-8, 3 if ASPECTS<7) and i.v tPA use (0 if yes, 1 if not). The higher the scale score, the higher the risk of FAR (Figure). The scale showed a good predictive value of FAR (c-statistics 0.71). A scale score <5 was associated with a low rate of FAR (25%) whereas a score >7 increased FAR up to 86%.

Conclusion: We developed a simple scale that can easily predict futile arterial recanalization (FAR) in stroke patients with large arterial occlusion treated with endovascular therapies. A larger validation study is necessary to confirm the utility of this predictive scale.

Safety and effectiveness of endovascular treatment of stroke with unknown time of onset

BACKGROUND

Currently, treatment options for patients with strokes with unknown time of onset (UKO) remain limited. With the advance of neuroimaging and endovascular treatment (EVT), selected patients might have a chance of a therapeutic option. We sought to compare clinical outcome after EVT in patients with known time of stroke onset (KO) and in those with UKO.

METHODS

We prospectively registered consecutive patients with acute large artery occlusion of the anterior territory who underwent EVT. Multimodal MR or Alberta Stroke Program early CT score (ASPECTS) and transcranial color-coded Duplex sonography were used to select patients for EVT. Recanalization, periprocedural complications, intracranial hemorrhage (ICH) and outcome were recorded. Symptomatic ICH (sICH) was defined as a worsening of ≥4 points in the National Institutes of Health Stroke Scale (NIHSS) score within 36 h in any bleeding. Favorable outcome was defined as a modified Rankin score ≤2 at 3 months.

RESULTS

A total of 141 patients were studied, 109 with KO and 32 with UKO. Mean age was 66.5 versus 64.7 years (p = 0.005) and median baseline NIHSS was 18 versus 17 (p = 0.095), respectively. Prior IV tPA was more frequently administered to KO patients (62.4 vs. 9.4%, p < 0.001), whereas patient selection using multimodal MR was more frequent in patients with UKO (78.1 vs. 45.4%, p < 0.001). Median time from stroke onset or from the last time the patient was seen well to groin puncture and to recanalization was significantly longer in patients with UKO, but no differences were found in the duration of the procedure. For KO/UKO patients recanalization was seen in 77.1 vs. 65.7% (p = 0.084), sICH occurred in 10 versus 0% (p = 0.061) and favorable outcome at 3 months was achieved in 41.3 versus 50% (p = 0.382), respectively.

CONCLUSIONS

Clinical outcomes in this series of EVT in ischemic stroke patients due to large anterior arterial occlusion with salvageable brain are similar for patients treated with KO and UKO. These data support a randomized study of EVT in extended or uncertain time windows..

Hyperintensity of distal vessels on FLAIR is associated with slow progression of the infarction in acute ischemic stroke

BACKGROUND

Hyperintensity of distal vessels on FLAIR-MRI has been associated with a higher grade of arterial collaterals and a smaller infarct volume in acute stroke patients. No studies analyze the influence of the hyperintense vessel (HV) sign on the speed of the ischemia progression during the first hours. Our aim was to study the association of the HV sign with progression of infarction in acute stroke patients.

METHODS

From a prospectively derived stroke database, we retrospectively selected acute stroke patients with a large artery occlusion of the anterior circulation admitted to our comprehensive stroke center with available baseline CT scan and a multimodal MRI carried out thereafter to make a decision about endovascular treatment. Progression of the ischemic area was calculated as the difference in the Alberta Stroke Program Early CT Scan (ASPECTS) score between CT scan and diffusion-weighted imaging (DWI). Slow progression was considered as no change or 1 point decrease on the ASPECTS score between both exams. The presence of HV on FLAIR sequence was graded as absent, subtle or prominent by two readers.

RESULTS

A total of 70 patients were included in the study. Mean time between baseline CT and MRI was 124 ± 82 min. ASPECTS score on baseline CT was 10 in 34% of patients, 9 in 49% and 8 or less in 17%. ASPECTS score was 2 (1-3) points lower in the DWI and this decrease did not correlate with the time elapsed between the two exams. Distal HV sign was observed in 57/70 (81%) patients (subtle in 33 and prominent in 24). HV was more frequently observed in patients with proximal artery occlusion. There were no differences regarding stroke severity, stroke subtype and ASPECTS score on baseline CT between groups. Patients with prominent HV showed a lower progression of the ischemic area [median ASPECTS score decrease, 1 (1-0)] compared with patients with subtle HV [median ASPECTS score decrease, 2 (2-1)] and patients with absence of HV [median ASPECTS score decrease, 3 (4-3)] (p < 0.001). Prominent HV was independently associated with slow progression of ischemia in a multivariate logistic regression analysis adjusted by systolic blood pressure on admission, site of occlusion and time elapsed between both neuroimaging exams compared to the absence of HV (OR, 16.2; 95% CI, 2.1-123.1) and to subtle HV sign (OR, 6.1; 95% CI, 1.5-23.9).

CONCLUSION

HV sign on FLAIR, especially if prominent, is associated with a slow progression of the ischemic area in acute stroke patients with cerebral artery occlusion of the anterior circulation. This radiological sign may predict the speed of the ischemia progression, opening an opportunity for reperfusion therapies in longer time windows.

Time to recanalization and risk of symptomatic intracerebral haemorrhage in patients treated with intravenous thrombolysis

BACKGROUND AND PURPOSE

To test whether time to recanalization is associated with a progressive risk of symptomatic intracerebral haemorrhage (SICH) after intravenous alteplase (IVT), we conducted a serial transcranial duplex monitoring study up to 24 h after IVT in a cohort of 140 patients with acute ischaemic stroke attributed to large artery occlusion in the anterior circulation.

METHODS

Patients were classified in four groups according to the time to complete recanalization (Thrombolysis in Brain Ischaemia, TIBI grades 4 or 5) after alteplase bolus: <2 h (n = 53), 2-6 h (n = 9), 6-24 h (n = 32) and no recanalization (NR) at 24 h (n = 46). SICH was defined as any haemorrhagic transformation with National Institute of Health Stroke Scale (NIHSS) score worsening ≥ 4 points (European Australian Acute Stroke Study II, ECASS II criteria) or parenchymal haematoma type 2 with neurological worsening (SITS-MOST criteria) in the 24-36 h CT. Favourable outcome was defined as modified Rankin score ≤ 2 at 3 months.

RESULTS

There were no differences between the groups of patients who recanalized at each time frame regarding localization of the occlusion (P = 0.29), stroke severity at baseline (P = 0.22) and age (P = 0.06). SICH (ECASS/SITS-MOST) was observed in 5.7%/5.7% of the patients who recanalized in <2 h, in 0%/0% of the patients who recanalized between 2-6 h, in 3.1%/3.1% of the patients who recanalized within 6-24 h and in 2.2%/0% of those patients who did not recanalize at 24 h. The rate of favourable outcome according to the time of recanalization was 79.2%, 50%, 46.9% and 34.1% (P < 0.001).

CONCLUSIONS

Our findings are in line with the literature showing a relationship between time to recanalization and functional outcome after IVT in acute stroke, but they do not confirm a progressive increase in the rate of SICH.

Long-term results of surgery plus fibrin sealant for anal fistula

AIM

The long-term recurrence rate of fibrin glue treatment was analysed in patients with trans-sphincteric cryptoglandular fistula operated by a two-phase procedure: (i) fistulectomy with seton placement; (ii) fibrin sealant (Tissucol Duo®, Baxter) insertion in the track.

METHOD

Clinical data were collected prospectively for all patients operated between 2004 and 2010. The statistical association of clinical variables and recurrence was analysed and a disease-free curve was constructed using the Kaplan-Meier method.

RESULTS

Twenty-eight consecutive patients (mean age 48.3 ± 13.3 years; 22 men) were enrolled in the study. Middle and high trans-sphincteric fistulae were diagnosed in 20 (71.4%) and eight (28.6%) patients. Seven (25%) had secondary track formation. The mean interval between the first operation and the fibrin sealant treatment was 12.5 ± 7.6 months. There were no complications related to the procedure. Nine (32.1%, 95% CI 17.9-50.7%) patients developed recurrence between 3 and 27 months after fibrin sealant treatment. Disease-free curves showed that the highest probability of recurrence occurred in the first 2 years. No incontinence was found at a mean follow-up of 20.6 (3-60) months among the 67.8% patients with no evidence of recurrence.

CONCLUSION

Fibrin sealant is safe and simple. The healing rate is satisfactory without the risk of incontinence.

The Barcelona-Asymptomatic Intracranial Atherosclerosis (AsIA) study: prevalence and risk factors

BACKGROUND AND PURPOSE

The ongoing population-based Barcelona-Asymptomatic Intracranial Atherosclerosis (Barcelona-AsIA) study is a prospective study that plans to investigate the natural history of asymptomatic intracranial atherosclerosis (AsIA) in a Caucasian-Mediterranean population, which remains unknown until now. The present study aims to determine the prevalence of AsIA and associated risk factors in the final study cohort.

METHODS

Crossover, population-based study of a representative sample (randomly selected from our reference population) older than 50 with a moderate-high vascular risk assessed by the vascular equation REGICOR and prior history of neither stroke nor ischemic heart disease. Anthropometric, demographic, clinical data and blood samples were collected at baseline. All individuals underwent a complete extracranial and transcranial color-coded duplex (TCCD) examination. TCCD criteria were used to identify and classify the degree of intracranial stenoses.

RESULTS

A total of 933 subjects (64% men, mean age 66.3 years) were included in the study. One or more intracranial stenoses were detected at baseline in 80 subjects (8.6%) of whom 31 (3.3%) had moderate-severe lesions. The higher the REGICOR scores the greater the prevalence of AsIA (6.6%, 10.2% and 25% for REGICOR scores 5-9, 10-14 and ≥15, p<0.001). Diabetes (OR 2.95; 95% CI (1.68-5.18); p<0.001), age (OR 1.05; 95% CI (1.02-1.08); p=0.001) and hypertension (OR 1.78; 95% CI (1.02-3.13); p=0.04) were independently associated with any degree of AsIA, while diabetes (OR 2.85; 95% CI (1.16-6.96); p=0.02) and age kept independently associated with moderate-severe AsIA.

CONCLUSION

The prevalence of AsIA and moderate-severe AsIA in stroke-free Caucasians with a moderate-high vascular risk were 8.6% and 3.3% respectively. Diabetes and age were independently associated with moderate-severe AsIA.

Association of growth factors with arterial recanalization and clinical outcome in patients with ischemic stroke treated with tPA

SUMMARY BACKGROUND

Growth factors (GF) such as vascular endothelial growth factor (VEGF), angiopoietin-1 (Ang-1) and granulocyte-colony stimulating factor (G-CSF) have been associated with greater efficacy of tissue plasminogen activator (tPA) in experimental studies.

OBJECTIVES

To study the association of these GF with arterial recanalization and clinical outcome in patients with acute ischemic stroke treated with tPA.

METHODS

We prospectively studied 79 patients with ischemic stroke attributable to MCA occlusion treated with i.v. tPA within the first 3 h from onset of symptoms. Continuous transcranial color-coded sonography (TCCS) was performed during the first 2 h after tPA bolus to assess early MCA recanalization. Hemorrhagic transformation (HT) was classified according to ECASS II definitions. Good functional outcome was defined as a Rankin scale score of 0-2 at 90 days. GF levels were determined by ELISA.

RESULTS

Mean serum levels of VEGF, G-CSF and Ang-1 at baseline were significantly higher in patients with early MCA recanalization (n = 30) (all P < 0.0001). In the multivariate analysis, serum levels of VEGF (OR, 1.03), G-CSF (OR, 1.02) and Ang-1 (OR, 1.07) were independently associated with early MCA recanalization (all P < 0.0001). On the other hand, patients with parenchymal hematoma (PH) (n = 20) showed higher levels of Ang-1 (P < 0.0001). Ang-1 (OR, 1.12; P < 0.0001) was independently associated with PH, whereas patients with good outcome (n = 38) had higher levels of G-CSF (P < 0.0001). G-CSF was independently associated with good outcome (OR, 1.12; P = 0.036).

CONCLUSIONS

These findings suggest that GF may enhance arterial recanalization in patients with ischemic stroke treated with t-PA, although they might increase the HT.

Mechanical thrombectomy with the Solitaire AB device in large artery occlusions of the anterior circulation: a pilot study

BACKGROUND AND PURPOSE

To describe the safety and effectiveness of a self-expanding and fully retrievable stent (Solitaire AB; ev3 Inc, Plymouth, MN) in revascularization of patients with acute ischemic stroke.

METHODS

Prospective, single-center study of 20 patients with an acute ischemic stroke attributable to a large artery occlusion of the anterior circulation within the first 8 hours from symptoms onset (median National Institutes of Health Stroke Scale, 19 [interquartile range, 15-23]). The occlusion site was middle cerebral artery in 12 patients, proximal internal carotid artery/middle cerebral artery tandem occlusion in 3 patients, and terminus internal carotid artery in 5 patients. Thrombectomy was used as rescue therapy in 2 patients who were refractory to intra-arterial plasminogen activator, and in 3 patients in whom successful recanalization with the MERCI retriever was not achieved.

RESULTS

Successful revascularization defined as thrombosis in cerebral ischemia grade 2b or 3 was achieved in 18 of 20 (90%) treated vessels, and 16 patients showed immediate restoration of flow after stent deployment. The mean number of passes for maximal recanalization was 1.4, and the median (quartiles) time from groin puncture to recanalization was 50 (38-71) minutes. No case required adjuvant therapy after deployment of the embolectomy device. No significant procedural events occurred. Symptomatic intracranial hemorrhage was found in 2 (10%) patients, 4 (20%) patients died during the 90-day follow-up period, and 45% of patients showed good functional outcome at 3 months (modified Rankin Scale score <or=2).

CONCLUSIONS

These results suggest that the Solitaire AB device can rapidly, safely, and effectively retrieve clots from the middle cerebral artery and terminus internal carotid artery within 8 hours from symptoms onset.

Iron-related brain damage in patients with intracerebral hemorrhage

BACKGROUND AND PURPOSE

Iron plays a detrimental role after experimental intracerebral hemorrhage (ICH). This study investigates whether high-serum ferritin levels are associated with poor outcome in patients with ICH.

METHODS

We studied 92 consecutive patients with primary hemispheric ICH within the first 12 hours from onset of symptoms (median, 3.3 hours). National Institute of Health Stroke Scale score, ICH, and peripheral edema volumes were measured at admission, 72 hours, and 7 days. Serum levels of ferritin and biomarkers of the inflammatory response were determined. The adjusted effect of ferritin on the full range of Rankin scale was analyzed by a general linear model.

RESULTS

Fifty-one patients (55.4%) had poor outcome (Rankin score >2). Older age, higher stroke severity, larger hematoma volume, intraventricular extension, mass effect, and higher IL-6 and ferritin levels at baseline (270.6 [SD 81.4] vs 74.6 [SD 43.4] ng/mL; P<0.001) were associated with poor outcome. The higher the ferritin quartile, the worse the Rankin score. For every ferritin quartile, the Rankin score increased by a mean of 1.4 points (95% CI, 1.04-1.69) after adjusting for prognostic variables. Ferritin levels remained stable for 72 hours and did not correlate with acute phase reactants.

CONCLUSIONS

High-serum ferritin levels at admission are independently associated with poor outcome in patients with ICH. These findings may suggest a neurotoxic effect of increased body iron stores in patients with hemorrhagic stroke.

Photochemical model evaluation of the surface ozone impact of a power plant in a heavily industrialized area of southwestern Spain

The characterization and evaluation of the impact that an industry is likely to have on the surrounding ozone levels is one of many problems confronting air quality managers and should be taken into consideration when authorizing its installation. The correct management of an environment, in terms of monitoring existing industries and planning new activities, requires adequate knowledge of the processes sustained by the industrial emissions therein. This paper explores the improvements in air quality management arising from taking into account the uncertainties involved in the photochemical modeling of the impact of an industry on surface ozone levels. For this, we evaluate the impact on ozone levels of a power plant located in an industrial area of southwestern Spain (Huelva). The evaluation takes into account the effects of both emissions' uncertainty and the non-linear chemistry between ozone and its precursors, thus providing a probable range of increase over the normative values (hourly and 8-hourly maximums) defined in the European Directive. The proposed methodology is easily applicable by air quality managers. Advanced modeling techniques were used for the power plant assessment, MM5 atmospheric modeling system, and air quality model CAMx. The results from meteorology and ozone forecasts have shown acceptable agreement with the observations. The spatial distribution of the impact is found to be strongly determined by mesoscale meteorological processes, which are reinforced by the local orography; there is also a marked temporal evolution. The industrial plume is observed to induce a decrease (or maintenance) of the ozone levels near the emission source (0-10km), and an increase in the ozone concentrations farther away (with maximums between 10 and 50km). In fact, in the meteorological episodes with a predominance of local breeze circulations, impacts have been detected at distances of more than 100km from the emission source. Sensitivity of the power plant impact to variations in ozone precursor emissions is described, and the scenarios and the points in the domain presenting higher sensitivity and registering larger impacts are also identified. The results show that the largest impacts take place in emission scenarios where the NO(x) has been reduced with respect to the base case scenario. In contrast, in scenarios where the VOC emissions are reduced with respect to the base case scenario, the impact is smaller or remains unchanged. This is important in areas like the study case, where there is a high percentage of biogenic VOC emissions and the industrial areas are close to natural protected areas and agricultural fields.

Influence of antiplatelet pre-treatment on the risk of intracranial haemorrhage in acute ischaemic stroke after intravenous thrombolysis

BACKGROUND

Pre-treatment with antiplatelet agents (AP) is present amongst 30% of acute stroke patients. Previous studies have shown conflicting results on the effect of these drugs regarding haemorrhagic transformation after thrombolytic therapy. The hypothesis that pre-treatment with AP may increase the risk of cerebral haemorrhage (ICH) after intravenous tissue plasminogen activator (tPA) was assessed.

METHODS

Retrospective study of consecutive prospectively registered patients with acute ischaemic stroke treated with iv tPA (n = 235) in the last 5 years. Baseline characteristics and prior AP therapy were registered on admission. Computed tomography (CT) scan was performed on admission and 24-36 h after tPA. ICH was classified according to the ECASS II criteria into haemorrhagic infarction and parenchymal haematoma (PH). Symptomatic intracerebral haemorrhage (SICH) was defined as a worsening of > or = 4 points in the NIHSS score during the first 36 h in any haemorrhage subtype.

RESULTS

Seventy-two (30.6%) patients were pre-treated with AP (55 aspirin, 14 clopidogrel, 2 aspirin + clopidogrel, 1 triflusal). PH was observed in 33 (14.1%) patients (PH1 13, PH2 12, PHr 8) of whom 16 were symptomatic. Male gender (78.8% vs. 21.2%, P = 0.036), prior AP therapy (54.5% vs. 26.9%, P = 0.001), stroke severity (median NIHSS, 17 vs. 12, P = 0.005) and early CT signs of infarction (12.5% vs. 2.1%, P = 0.004) were associated with PH. The adjusted odds ratios of PH for patients pre-treated with AP therapy was 3.5 (1.5-7.8, P = 0.002) and for SICH 1.9 (0.6-5.9, P = 0.2).

CONCLUSIONS

Pre-treatment with AP is associated with an increased risk of PH after intravenous thrombolysis in patients with acute ischaemic stroke.

Body temperature and response to thrombolytic therapy in acute ischaemic stroke

OBJECTIVE

To determine the relationship between body temperature (BT), arterial recanalization, functional outcome, and hemorrhagic transformation (HT) of cerebral infarction in patients treated with i.v. tissue plasminogen activator (tPA).

METHODS

We studied 254 patients treated with tPA within 3 h from stroke onset. National Institute of Health Stroke Scale score, BT, and transcranial Doppler ultrasound (n = 99) on admission and at 24 h were recorded. Hypodensity volume and HT were evaluated on CT at 24-36 h. Poor outcome (Rankin Scale > 2) was evaluated at 3 months.

RESULTS

Arterial recanalization at 24 h was found in 70.7% of patients, HT in 24.8% (symptomatic in 4.7%) and poor outcome in 44.1%. Baseline BT was not associated with greater stroke severity at admission or at 24 h, HT or poor outcome. However, BT at 24 h correlated to stroke severity (P < 0.001) and hypodensity volume (P < 0.001) at 24 h, and was higher in patients who did not recanalize (P = 0.001), had symptomatic HT (P = 0.063) and poor outcome (P < 0.001). The adjusted odds ratio of poor outcome for patients with BT at 24 h > or = 37 degrees C was 2.56 (1.19-5.50, P = 0.016).

CONCLUSION

Body temperature > or =37 degrees C at 24 h, but not at baseline, is associated with a lack of recanalization, greater hypodensity volume and worse outcome in stroke patients treated with tPA.

Metabolic syndrome and resistance to IV thrombolysis in middle cerebral artery ischemic stroke

OBJECTIVE

The metabolic syndrome (MetS) is a cluster of vascular risk factors associated with a prothrombotic state. We aimed to evaluate the impact of MetS on the response to systemic tPA treatment in patients with acute middle cerebral artery (MCA) ischemic stroke.

METHODS

We studied 100 consecutive patients with ischemic stroke with MCA occlusions on prebolus transcranial Doppler (TCD) examination treated with tPA following SITS-MOST criteria. MetS was diagnosed following AHA/NHLBI-2005 criteria. Resistance to thrombolysis was defined as the absence of TCD-assessed complete MCA recanalization 24 hours after tPA infusion. Infarct volume was measured on CT scans. Long-term clinical outcome was evaluated by the modified Rankin scale (mRS) score at day 90.

RESULTS

Fifty-eight (58%) patients fulfilled MetS criteria. Median prebolus NIH Stroke Scale score was 17. Forty (42%) patients showed resistance to clot dissolution, and 53 (53%) had poor clinical outcomes (mRS > 2). A multivariable-adjusted logistic regression model identified MetS as independently associated with resistance to thrombolysis (OR 4.7, 95% CI [1.7-13.6], p = 0.004). In the whole sample, MetS was associated with mRS > 2 (OR 2.4 [1.1-5.4], p = 0.03), although this association was no longer significant after multivariable adjustment. However, in patients with atherothrombotic stroke, MetS emerged as an independent predictor of poor long-term outcome (adjusted OR 13.9 [1.3-148.7], p = 0.02).

CONCLUSION

In our series, the metabolic syndrome was associated with a poor response to thrombolysis in patients with acute middle cerebral artery occlusions, as reflected by a higher resistance to clot dissolution.

Sensitivity analysis of surface ozone to modified initial and boundary conditions in both rural and industrial zones

Abstract. A three-dimensional air quality model based on a set of chemical species mass conservation equations describes the time evolution of chemical species in the atmosphere. In order to solve this set of equations, proper choices of initial and boundary conditions are needed. Ideally, initial and boundary conditions should be determined on the basis of observations. However, since such high-resolution observations are generally not available, it becomes necessary to use other information sources to specify the initial and boundary values. The fact that both the initial and the boundary conditions are specified with some degree of presumption makes it important to evaluate their influence in the model results. In this paper we present a study of the impact of initial and boundary concentrations on the modelled surface ozone concentration over two environments: Huelva and Badajoz, an industrial and a rural zone, respectively. The impacts are analysed for the same meteorological period (10–15 August 2003).

The impact of biogenic VOC emissions on photochemical ozone formation during a high ozone pollution episode in the Iberian Peninsula in the 2003 summer season

Abstract. Throughout Europe the summer of 2003 was exceptionally warm, especially July and August. The European Environment Agency (EEA) reported several ozone episodes, mainly in the first half of August. These episodes were exceptionally long-lasting, spatially extensive, and associated to high temperatures. In this paper, the 10$ndash;15 August 2003 ozone pollution event has been analyzed using meteorological and regional air quality modelling. During this period the threshold values of the European Directive 2002/3/EC were exceeded in various areas of the Iberian Peninsula. The aim of this paper is to computationally understand and quantify the influence of biogenic volatile organic compound (BVOC) emissions in the formation of tropospheric ozone during this high ozone episode. Being able to differentiate how much ozone comes from biogenic emissions alone and how much comes from the interaction between anthropogenic and biogenic emissions would be helpful to develop a feasible and effective ozone control strategy. The impact on ozone formation was also studied in combination with various anthropogenic emission reduction strategies, i.e., when anthropogenic VOC emissions and/or NOx emissions are reduced. The results show a great dependency of the BVOC contribution to ozone formation on the antropoghenic reduction scenario. In rural areas, the impact due to a NOx and/or VOC reduction does not change the BVOC impact. Nevertheless, within big cities or industrial zones, a NOx reduction results in a decrease of the biogenic impact in ozone levels that can reach 85 μg/m3, whereas an Anthropogenic Volatile Organic Compound (AVOC) reduction results in a decrease of the BVOC contribution on ozone formation that varies from 0 to 30 μg/m3 with respect to the contribution at the same points in the 2003 base scenario. On the other hand, downwind of the big cities, a decrease in NOx produces a minor contribution of biogenic emissions and a decrease in AVOCs results in greater contributions of BVOCs to the formation of ozone.

Simvastatin in the acute phase of ischemic stroke: a safety and efficacy pilot trial

Although statins are being used for secondary prevention of ischemic stroke, recent experimental data have shown new pleiotropic effects of these drugs responsible for their role in neuroprotection. We conducted a pilot, double-blind, randomized, multicenter clinical trial to study for the first time safety and efficacy of simvastatin in the acute phase of ischemic stroke. Simvastatin/placebo was given at 3-12 h from symptom onset to 60 patients with cortical strokes. Efficacy on the evolution of several inflammation markers [interleukin (IL)-6, IL-8, IL-10, monocyte chemoattractant protein-1, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, C-reactive protein, sApo/Fas, tumor necrosis factor-alpha, E-selectin, L-selectin and nitrites+nitrates] and neurological outcome was evaluated at baseline, day 1, 3, 5, 7 and 90. No differences were found amongst the biomarkers studied regarding treatment allocation. Although simvastatin patients improved significantly by the third day (46.4% vs. 17.9%, P = 0.022), a non-significant increase in mortality and greater proportion of infections (odds ratio 2.4, confidence interval 1.06-5.4) in the simvastatin group were the main safety concerns. Therefore, a larger clinical trial is needed to confirm the net benefit of this therapeutic approach.

Clinical and manometric results of endorectal advancement flaps for complex anal fistula

BACKGROUNDS AND AIM

Endorectal advancement flap repair is a well-recognized method for the treatment of complex anorectal fistula. The purpose of this study was to prospectively assess the clinical and functional results of endorectal advancement flaps for complex anorectal fistula and to identify factors that affect outcome.

MATERIALS AND METHODS

A prospective study of 56 patients was performed. Clinical and functional results were studied using the Wexner continence scale and anal manometry before and after surgery. Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis.

RESULTS

Sixty endorectal flaps were constructed in 56 patients. Mean age was 49 years (range 24-74). The fistula was of cryptoglandular origin in 91.1% cases. Mean follow-up was 43.8 months. The technique was repeated in four patients because of recurrence (7.1%), with subsequent healing in all cases. There were significant reductions in maximum resting pressure 3 months after surgery (83.6+/-33.2 vs 45.6+/-18.3, p<0.001) and maximum squeeze pressure (208.8+/-91.5 vs 169.5+/-75, p<0.001). Before surgery, five patients (8.9%) reported incontinence symptoms. After surgery, 78.6% patients had normal continence, seven patients (12.5%) complained of minor incontinence, and five (9%) had major continence disturbances. None of the variables studied (age, sex, previous fistula surgery, rectovaginal fistula, and Crohn's disease) affected the outcome of the procedure in multivariate analysis.

CONCLUSIONS

Endorectal advancement flap repair is an effective technique for complex anal fistula, with a low recurrence rate (7.1%). Patients (21.4%) reported disturbed anal continence. It is still not possible to identify factors that are predictive of failure or incontinence.