Collateral status, hyperglycemia, and functional outcome after acute ischemic stroke

BACKGROUND

Mixed data exist regarding the association between hyperglycemia and functional outcome after acute ischemic stroke when accounting for the impact of leptomeningeal collateral flow. We sought to determine whether collateral status modifies the association between treatment group and functional outcome in a subset of patients with large vessel occlusion enrolled in the Stroke Hyperglycemia Insulin Network Effort (SHINE) trial.

METHODS

In this post-hoc analysis, we analyzed patients enrolled into the SHINE trial with anterior circulation large vessel occlusion who underwent imaging with CT angiography prior to glucose control treatment group assignment. The primary analysis assessed the degree to which collateral status modified the effect between treatment group and functional outcome as defined by the 90-day modified Rankin Scale score. Logistic regression was used to model the data, with adjustments made for thrombectomy status, age, post-perfusion thrombolysis in cerebral infarction (TICI) score, tissue plasminogen activator (tPA) use, and baseline National Institutes of Health Stroke Scale (NIHSS) score. Five SHINE trial centers contributed data for this analysis. Statistical significance was defined as a p-value < 0.05.

RESULTS

Among the 1151 patients in the SHINE trial, 57 with angiographic data were included in this sub-analysis, of whom 19 had poor collaterals and 38 had good collaterals. While collateral status had no effect (p = 0.855) on the association between glucose control treatment group and functional outcome, patients with good collaterals were more likely to have a favorable functional outcome (p = 0.001, OR 5.02; 95% CI 1.37-16.0).

CONCLUSIONS

In a post-hoc analysis using a subset of patients with angiographic data enrolled in the SHINE trial, collateral status did not modify the association between glucose control treatment group and functional outcome. However, consistent with prior studies, there was a significant association between good collateral status and favorable outcome in patients with large vessel occlusion stroke.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier is NCT01369069. Registration date is June 8, 2011.

Abstract TMP25: The Visual Field Rapid Analysis Device (vrad) Is Safe, Effective And Easy To Use

Background: Acute telestroke consults rely on a rapid, accurate NIH Stroke Scale. An important sign in cortical-based ischemic strokes is a Visual Field Deficit (VFD) contributing up to 3 points on the NIHSS affecting treatment decisions. Remote confrontational VFD testing is challenging and requires a trained assistant. We created a simple, rapid, telecart peripheral device to remotely administer a standardized VF test . The “ V isual fields R apid A ssessment D evice” ( VRAD ) is a wearable eye-glasses device. The device flashes LED lights in the 4 quadrants of each eye via remote control by a teleprovider allowing real-time control and interpretation.

Methods: The VRAD Phase I study examined FDA-related human design factors of comfort, speed, and ease of use with direct use of VRAD. The results guided optimization of the prototype in preparation for the Phase II validation clinical trial. Subjects were randomly-selected, consented adult UVA Stroke Unit inpatients, with confirmed ischemic strokes. Following each VF test, blinded teleproviders, the patient ,and the telepresenter (nurse) completed a brief binary response questionnaire with open-ended comments. Biostatistical analysis: N= 20 subjects; 95% confidence interval with precision of +/- 10%.

Results: The vast majority of patients, presenters, and providers (95-100%) reported VRAD testing was easy to understand and rapid. Patients: The device was comfortable (90%); 10% felt the stimulus light was too bright and 5% too dim. All identified when the light was on and had enough time to respond. Presenters: All reported rapid testing; 75% felt the device was easy to don on patients. The device was “sturdy and durable” 90%, “easy to use” 75%, “easy to clean” 70%, and “easy to connect” 60%. Providers: Reported the device sufficiently screened standard VFs (90%). All agreed they could remotely administer the test in various settings.

Conclusion: The VRAD Phase I trial found the device to be safe, effective, easy to use, and comfortable by patients, providers, and presenters. Based on the results, an upgraded prototype was manufactured for our upcoming Phase II Non-Inferiority Validation Trial (Fall 2021). This data is a proof-of-concept of the value of teleneurology peripheral tools in remote settings.

Hypoxia-induced changes in protein s-nitrosylation in female mouse brainstem

Exposure to hypoxia elicits an increase in minute ventilation that diminishes during continued exposure (roll-off). Brainstem N-methyl-D-aspartate receptors (NMDARs) and neuronal nitric oxide synthase (nNOS) contribute to the initial hypoxia-induced increases in minute ventilation. Roll-off is regulated by platelet-derived growth factor receptor-β (PDGFR-β) and S-nitrosoglutathione (GSNO) reductase (GSNOR). S-nitrosylation inhibits activities of NMDAR and nNOS, but enhances GSNOR activity. The importance of S-nitrosylation in the hypoxic ventilatory response is unknown. This study confirms that ventilatory roll-off is virtually absent in female GSNOR(+/-) and GSNO(-/-) mice, and evaluated the location of GSNOR in female mouse brainstem, and temporal changes in GSNOR activity, protein expression, and S-nitrosylation status of GSNOR, NMDAR (1, 2A, 2B), nNOS, and PDGFR-β during hypoxic challenge. GSNOR-positive neurons were present throughout the brainstem, including the nucleus tractus solitarius. Protein abundances for GSNOR, nNOS, all NMDAR subunits and PDGFR-β were not altered by hypoxia. GSNOR activity and S-nitrosylation status temporally increased with hypoxia. In addition, nNOS S-nitrosylation increased with 3 and 15 minutes of hypoxia. Changes in NMDAR S-nitrosylation were detected in NMDAR 2B at 15 minutes of hypoxia. No hypoxia-induced changes in PDGFR-β S-nitrosylation were detected. However, PDGFR-β phosphorylation increased in the brainstems of wild-type mice during hypoxic exposure (consistent with roll-off), whereas it did not rise in GSNOR(+/-) mice (consistent with lack of roll-off). These data suggest that: (1) S-nitrosylation events regulate hypoxic ventilatory response; (2) increases in S-nitrosylation of NMDAR 2B, nNOS, and GSNOR may contribute to ventilatory roll-off; and (3) GSNOR regulates PDGFR-β phosphorylation.

Complete suppression of neoclassical tearing modes with current drive at the electron-cyclotron-resonance frequency in ASDEX upgrade tokamak

Noninductive current drive has been performed in the tokamak ASDEX upgrade by injection of radiofrequency waves at the second harmonic of the electron-cyclotron frequency in order to suppress unwanted disturbances of the magnetic-field configuration. The current has been driven parallel [co-electron cyclotron current drive (ECCD)] and antiparallel (counter-ECCD) to the plasma current to compare the effect of heating with direct current drive in the magnetic island. For the first time it has been shown experimentally that total stabilization of neoclassical tearing modes is possible with co-ECCD. The experiments verify the role of direct current drive as opposed to local heating.

Simultaneous attainment of high electron and ion temperatures in discharges with internal transport barriers in ASDEX upgrade

Internal transport barriers have been demonstrated to exist also under conditions with T(e) approximately T(i) approximately 10 keV and predominant electron heating of the tokamak core region. Central electron cyclotron heating was added to neutral beam injection-heated ASDEX Upgrade discharges with a preexisting internal transport barrier, established through programmed current ramping leading to shear reversal. Compared to a reference internal transport barrier discharge without electron cyclotron resonance heating, the electron heat conductivity in the barrier region was found not to increase, in spite of a fivefold increase in electron heat flux, and also angular momentum and ion energy transport did not deteriorate.

Atypical endogenous opioid systems in mice in relation to an auto-addiction opioid model of anorexia nervosa

We have proposed that the atypical opioid system in the mouse may be representative of that in the anorexia nervosa patient and may account for a biological predisposition to the disorder. This is in the context of our auto-addiction model of anorexia nervosa in which endogenous opioids play a critical role in its etiology. Morphine activation of the endogenous opioid systems increases food intake and causes sedation in most species, including normal humans and rats. In contrast in BALB/C mice, morphine causes anorexia and hyperactivity, which we suggest may be true in the anorexia nervosa patient. A variety of atypical opioid systems have been demonstrated in different mouse strains, based on other responses. The present study examines these strains with reference to the responses relevant to our anorexia nervosa model. Three patterns are described--anorexia with hyperactivity (BALB/C and C57BL/6J mice), anorexia without hyperactivity (DBA/J mice), and a biphasic curve with hyperphagia at low doses and anorexia and hyperactivity at higher doses (CF-1 mice). Only female mice were used. These atypical opioid systems may reflect a spectrum of biological predispositions to the disorder. These strain differences may also provide useful correlations of the genetic determinants of various opiate responses and provide useful comparisons in characterizing the essential features responsible for the atypical responses.