1. A study of 6,856 patients who received intravenous thrombolysis for acute ischemic stroke from 10 European centers found that treatment within 90 minutes of symptom onset was independently associated with excellent 3-month outcome in patients with moderate (NIHSS 7-12) and mild (NIHSS 0-6) stroke severity.
2. For patients with NIHSS 7-12, treatment within 90 minutes was associated with a 37% higher likelihood of excellent outcome compared to later treatment.
3. For patients with mild symptoms (NIHSS 0-6), treatment within 90 minutes was associated with a 51% higher likelihood of full recovery (mRS=0) to overcome the ceiling effect of spontaneous good recovery
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The purpose of the study is to provide information about the database of 1421 adult patients with acute ischemic stroke (IS) developing ≤ 48 hours before admitting, research methods, study protocol, and clinical predictors of the evolving stroke course (EIS).
Methods and Materials: EIS outlined as an increase of NIHSS ≥ 2 points within seven days or in-hospital lethal outcome. Clinical, demographic, instrumental, laboratory data acquisition, as well as the IS course variant and the functional outcome assessment, were carried out prospectively. Statistical analyses were performed using R V.3.2.5 statistical package software and IBM SPSS Statistics 26.0.
Results: The incidence of EIS reached 30.0%. The average age of patients with EIS was 72.6±10.2 years, compare the age of patients without EIS - 68.1±11.3 years; p = 0.005. Female sex increased the odds of EIS (OR, 1.36; 95% CI 1.08-1.73). Total anterior carotid stroke (OR, 7.78; 95% CI 5.91-10.23), the initial NIHSS score > 14 points (OR, 3.74; 95% CI 2.83-4.94), and the right anterior circulation was also associated with EIS (OR, 1.30; 95% CI 1.02-1.66). The odds of EIS were significantly higher in the presence of diabetes mellitus (OR, 1.29; 95% CI 1.01-1.66), cerebral artery stenosis ≥ 70% (OR, 1.96; 95% CI 1.30-2.93), atrial fibrillation (OR, 1.89; 95% CI 1.51-2.39), congestive heart failure (OR, 1.90; 95% CI 1.51-2.39), and peripheral artery disease (OR, 1.69; 95% CI 1.27-2.25). Respiratory (OR, 2.82; 95% CI 2.22-3.59), gastrointestinal (OR, 1.34; 95% CI 1.05-1.70), and urologic diseases (OR, 2.10; 95% CI 1.65-2.66), stroke-associated infection (OR, 3.47; 95% CI 2.09-5.76), and gradual development of initial IS symptoms before admitting increased the odds of progression of the neurological deficit during treatment (OR, 2.37; 95% CI 1.78-3.15)were associated with the evolving clinical course of IS. The patients with the EIS compared with patients without EIS, showed higher serum levels of glucose (p < 0.001), urea (p = 0.001), creatinine (p < 0.001), sodium (p = 0.025), and direct bilirubin (p = 0.015). Potassium level in EIS group was lower than in the group without EIS (p < 0.001). In patients with EIS, a higher amount of RBC (p = 0.030) and WBC (p < 0.001) was found.
Conclusion: The in-hospital database contains information about EIS by the bases subtypes of IS, patient demography, cardiovascular risk factors, comorbid pathology, clinical and laboratory tests, instrumental methods of examination, medications, the severity of neurological deficit, and post-stroke outcome.
Modeling of Longitudinal Pulse Rate, Respiratory Rate and Blood Pressure Meas...Premier Publishers
Congestive heart failure (CHF) is a chronic condition that happens when the heart’s muscle becomes too damaged to adequately pump the blood around your body. The main objective of this study was to modeling the longitudinal pulse rate, respiratory rate and blood pressure measurements from congestive heart failure patients under follow up at Tikur Anbessa Specialized Hospital. This retrospective cohort study was based on secondary data obtained from Tikur Anbessa Specialized Hospital. Modeling approach of longitudinal data analysis was applied by suing Linear Mixed Models to identify risk factors and to compare efficiency of the models. Fit statistics showed that the joint model resulted in better fit to the data than the separate models, implying a significant association among the two end points. Based on the joint model for SBP, diagnosis history, family history, NYHA class, and time, and for DBP, age, weight, sex, family history, NYHA class, and time are the significant factors, at 5% level of significance. The joint model fitted the data better than the separate models. The result from the joint model suggested a strong association between the evolutions and a slowly increasing evolution of the association between PR and RR also, between SBP and DBP. Thus, fitting joint model is recommended for researches to any types of multivariate response variable together jointly.
Comparison of clinical, radiological and outcome characteristics of ischemic ...MIMS Hospital
Here is the latest publication from the department of Neurology in the Journal of Neurology Research, titled, ’Comparison of Clinical, Radiological and Outcome Characteristics of Ischemic Strokes in Different Vascular Territories’ authored by Ashraf V Valappila, c, Dhanya T Janardhanana, Praveenkumar Raghunatha, Abdulla Cherayakkatb, Girija ASa
Increased risk of ischemic stroke associated with new onset atrial fibrillation complicating acute coronary syndrome- a systematic review and meta-analysis
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The purpose of the study is to provide information about the database of 1421 adult patients with acute ischemic stroke (IS) developing ≤ 48 hours before admitting, research methods, study protocol, and clinical predictors of the evolving stroke course (EIS).
Methods and Materials: EIS outlined as an increase of NIHSS ≥ 2 points within seven days or in-hospital lethal outcome. Clinical, demographic, instrumental, laboratory data acquisition, as well as the IS course variant and the functional outcome assessment, were carried out prospectively. Statistical analyses were performed using R V.3.2.5 statistical package software and IBM SPSS Statistics 26.0.
Results: The incidence of EIS reached 30.0%. The average age of patients with EIS was 72.6±10.2 years, compare the age of patients without EIS - 68.1±11.3 years; p = 0.005. Female sex increased the odds of EIS (OR, 1.36; 95% CI 1.08-1.73). Total anterior carotid stroke (OR, 7.78; 95% CI 5.91-10.23), the initial NIHSS score > 14 points (OR, 3.74; 95% CI 2.83-4.94), and the right anterior circulation was also associated with EIS (OR, 1.30; 95% CI 1.02-1.66). The odds of EIS were significantly higher in the presence of diabetes mellitus (OR, 1.29; 95% CI 1.01-1.66), cerebral artery stenosis ≥ 70% (OR, 1.96; 95% CI 1.30-2.93), atrial fibrillation (OR, 1.89; 95% CI 1.51-2.39), congestive heart failure (OR, 1.90; 95% CI 1.51-2.39), and peripheral artery disease (OR, 1.69; 95% CI 1.27-2.25). Respiratory (OR, 2.82; 95% CI 2.22-3.59), gastrointestinal (OR, 1.34; 95% CI 1.05-1.70), and urologic diseases (OR, 2.10; 95% CI 1.65-2.66), stroke-associated infection (OR, 3.47; 95% CI 2.09-5.76), and gradual development of initial IS symptoms before admitting increased the odds of progression of the neurological deficit during treatment (OR, 2.37; 95% CI 1.78-3.15)were associated with the evolving clinical course of IS. The patients with the EIS compared with patients without EIS, showed higher serum levels of glucose (p < 0.001), urea (p = 0.001), creatinine (p < 0.001), sodium (p = 0.025), and direct bilirubin (p = 0.015). Potassium level in EIS group was lower than in the group without EIS (p < 0.001). In patients with EIS, a higher amount of RBC (p = 0.030) and WBC (p < 0.001) was found.
Conclusion: The in-hospital database contains information about EIS by the bases subtypes of IS, patient demography, cardiovascular risk factors, comorbid pathology, clinical and laboratory tests, instrumental methods of examination, medications, the severity of neurological deficit, and post-stroke outcome.
Modeling of Longitudinal Pulse Rate, Respiratory Rate and Blood Pressure Meas...Premier Publishers
Congestive heart failure (CHF) is a chronic condition that happens when the heart’s muscle becomes too damaged to adequately pump the blood around your body. The main objective of this study was to modeling the longitudinal pulse rate, respiratory rate and blood pressure measurements from congestive heart failure patients under follow up at Tikur Anbessa Specialized Hospital. This retrospective cohort study was based on secondary data obtained from Tikur Anbessa Specialized Hospital. Modeling approach of longitudinal data analysis was applied by suing Linear Mixed Models to identify risk factors and to compare efficiency of the models. Fit statistics showed that the joint model resulted in better fit to the data than the separate models, implying a significant association among the two end points. Based on the joint model for SBP, diagnosis history, family history, NYHA class, and time, and for DBP, age, weight, sex, family history, NYHA class, and time are the significant factors, at 5% level of significance. The joint model fitted the data better than the separate models. The result from the joint model suggested a strong association between the evolutions and a slowly increasing evolution of the association between PR and RR also, between SBP and DBP. Thus, fitting joint model is recommended for researches to any types of multivariate response variable together jointly.
Comparison of clinical, radiological and outcome characteristics of ischemic ...MIMS Hospital
Here is the latest publication from the department of Neurology in the Journal of Neurology Research, titled, ’Comparison of Clinical, Radiological and Outcome Characteristics of Ischemic Strokes in Different Vascular Territories’ authored by Ashraf V Valappila, c, Dhanya T Janardhanana, Praveenkumar Raghunatha, Abdulla Cherayakkatb, Girija ASa
Increased risk of ischemic stroke associated with new onset atrial fibrillation complicating acute coronary syndrome- a systematic review and meta-analysis
OPEN ACCESS: Prognostic implications of conversion from non-shockable to shoc...Emergency Live
The prognostic significance of conversion from non-shockable to shockable rhythms in patients with initial non-shockable rhythms who experience out-of-hospital cardiac arrest (OHCA) remains unclear. We hypothesized that the neurological outcomes in those patients would improve with subsequent shock delivery following conversion to shockable rhythms, and that the time from initiation of cardiopulmonary resuscitation by emergency medical services personnel to the first defibrillation (shock delivery time) would influence those outcomes. READ MORE HERE: http://ccforum.com/content/18/5/528/abstract#
Elevated Tissue Doppler E/E' on Index Admission Can Help Identify Patients at...crimsonpublishersOJCHD
Readmissions for congestive Heart Failure (CHF) are a major healthcare problem that contributes significantly to the overall healthcare expenditure. About 24% of patients are readmitted to the hospital within 30 days of discharge. We investigated whether a non-invasive estimate of left atrial filling pressure, an elevated ratio of early trans mitral flow velocity to early diastolic mitral annular velocity (E/E'), during the index admission for CHF could independently predict 30 day readmission.
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The goal of the study was to identify the most significant prognostic clinical criteria for the survival of patients with ischemic stroke (IS) within 1 year of observation.
Methods and Materials: The object of the clinical prospective study was 1421 patients with IS hospitalized in 2002-2015 in the neurological (stroke) departments of the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital. Analyzing the obtained data, we adhered to the prospective-specimen-collection, retrospective evaluation design of the study. The primary endpoint of the study was the patient's death from any reason within one year of the development of IS. Information on poststroke all-cause mortality was obtained through linkages to the official source - the centralized archive of deaths of residents of the city of Minsk. Patients without a confirmed death date were censored at the date last known alive. All patients that were alive at one year are assumed to be censored at that time. The collection of clinical, demographic, neuroimaging, laboratory data, as well as the final determination of the stroke outcome, was performed blindly with respect to survival data.
Results: To build the model, 22 multivariate clinical indicators were used that demonstrated the relationship with post-stroke survival at the stage of preliminary data analysis: stroke subtype according the Oxfordshire Community Stroke Project, age, gender, the severity of the neurological deficit according to the NIHSS scale at hospitalization, previous stroke or TIA, the presence of arterial hypertension, atrial fibrillation, myocardial atherosclerosis, congestive heart failure, diabetes mellitus, peripheral arterial diseases, alcohol abuse, level of creatinine, glucose, urea, potassium, sodium in blood, amount of hemoglobin, erythrocytes and leukocytes on the 1st day of treatment, the level of systolic and diastolic blood pressure in the hospital admission department.
In the construction of a survival decision tree of patients with IS, of the 22 initially embedded parameters, only 6 independent predictors were finally included in the prognostic model: the stroke subtype according to the OCSP, the presence of a lacunar infarction, the severity of neurologic deficit at hospitalization according NIHSS, level of urea and glucose in the blood, and the presence of congestive heart failure.
A Pre Experimental Study to Assess the Effectiveness of Structured Teaching P...ijtsrd
Statement of problem A Pre Experimental Study to Assess the Effectiveness of Structured Teaching Programme on Knowledge Regarding Cardio Pulmonary Resuscitation Among Gnm 2nd Year Students of Desh Bhagat University School of Nursing, Mandi Gobindgarh, Punjab. Material and method A pre experimental research design were used for the present study. A study sample of 50 students of GNM 2nd year were selected by non probability purposive sampling technique. The data was collected by self structured questionnaire regarding cardio pulmonary resuscitation among BGNM 2nd year students in Desh Bhagat University School of Nursing Mandi Gobindgarh, Punjab. The data was analyzed in terms of objectives of the study using descriptive and inferential statistics in terms of frequency, percentage distribution, mean, Standard deviation,‘t' value, and chi square. Results As per percentage distribution of student according to age and gender it was found that Maximum students were in 21yrs 64 followed by, in 20yrs 20 in above 21years 12 and in 19 yrs 4 included in age group. Majority of students were females 82 and only 18 were male students. As per religion and area of residence Most of the students were belongs to sikh religion 90 , than 6 had Hindu and only 4 had Muslim, Maximum students were living in rural area 72 and only 28 were living in urban area. In post test maximum number of 70 the subjects had good knowledge score followed by subjects who had average knowledge score 30 regarding cardio pulmonary resuscitation. The Knowledge score was calculated by ‘t' test and the value was 3.42 Conclusion It was concluded that STP was effective as evidence by the results as the difference between pre test and post test knowledge score regarding cardio pulmonary resuscitation. The knowledge and skills of GNM students can be improved through STP after Posttest. Ms. Ramanpreet Kaur | Dr. Priyanka Chaudhary | Nazpreet Kaur "A Pre-Experimental Study to Assess the Effectiveness of Structured Teaching Programme on Knowledge Regarding Cardiopulmonary Resuscitation (CPR) among GNM" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-6 , October 2021, URL: https://www.ijtsrd.com/papers/ijtsrd47648.pdf Paper URL : https://www.ijtsrd.com/medicine/nursing/47648/a-preexperimental-study-to-assess-the-effectiveness-of-structured-teaching-programme-on-knowledge-regarding-cardiopulmonary-resuscitation-cpr-among-gnm/ms-ramanpreet-kaur
Serum Uric Acid and Outcome after Acute Ischemic Stroke: PREMIER StudyErwin Chiquete, MD, PhD
Background: Current evidence shows that uric acid is a potent
antioxidant whose serum concentration increases rapidly
after acute ischemic stroke (AIS). Nevertheless, the relationship
between serum uric acid (SUA) levels and AIS
outcome remains debatable. We aimed to describe the
prognostic significance of SUA in AIS. Methods: We studied
463 patients (52% men, mean age 68 years, 13% with glomerular
filtration rate <60 />2) at 30 days, or with
any outcome measure at 3, 6 or 12 months poststroke. After
adjustment for age, gender, stroke type and severity (NIHSS
<9),><24 h. Conclusions: A low SUA
concentration is modestly associated with a very good
short-term outcome. Our findings support the hypothesis
that SUA is more a marker of the magnitude of the cerebral
infarction than an independent predictor of stroke outcome.
Introduction: Chronic Kidney Disease (CKD) is a worldwide public health problem and it is increasing over time. Cardiovascular disease is a major concern for patients with end stage renal disease, especially those on hemodialysis. It is the leading cause of death among patients with chronic kidney
disease, particularly in dialysis population.
A less-invasive-approach-of-medial-meniscectomy-in-rat-a-model-to-target-earl...science journals
In order for insulin to exert its biological actions on target cells in peripheral tissues like muscle and adipose tissues, Insulin must pass through the endothelial barrier into the interstitium.
OPEN ACCESS: Prognostic implications of conversion from non-shockable to shoc...Emergency Live
The prognostic significance of conversion from non-shockable to shockable rhythms in patients with initial non-shockable rhythms who experience out-of-hospital cardiac arrest (OHCA) remains unclear. We hypothesized that the neurological outcomes in those patients would improve with subsequent shock delivery following conversion to shockable rhythms, and that the time from initiation of cardiopulmonary resuscitation by emergency medical services personnel to the first defibrillation (shock delivery time) would influence those outcomes. READ MORE HERE: http://ccforum.com/content/18/5/528/abstract#
Elevated Tissue Doppler E/E' on Index Admission Can Help Identify Patients at...crimsonpublishersOJCHD
Readmissions for congestive Heart Failure (CHF) are a major healthcare problem that contributes significantly to the overall healthcare expenditure. About 24% of patients are readmitted to the hospital within 30 days of discharge. We investigated whether a non-invasive estimate of left atrial filling pressure, an elevated ratio of early trans mitral flow velocity to early diastolic mitral annular velocity (E/E'), during the index admission for CHF could independently predict 30 day readmission.
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The goal of the study was to identify the most significant prognostic clinical criteria for the survival of patients with ischemic stroke (IS) within 1 year of observation.
Methods and Materials: The object of the clinical prospective study was 1421 patients with IS hospitalized in 2002-2015 in the neurological (stroke) departments of the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital. Analyzing the obtained data, we adhered to the prospective-specimen-collection, retrospective evaluation design of the study. The primary endpoint of the study was the patient's death from any reason within one year of the development of IS. Information on poststroke all-cause mortality was obtained through linkages to the official source - the centralized archive of deaths of residents of the city of Minsk. Patients without a confirmed death date were censored at the date last known alive. All patients that were alive at one year are assumed to be censored at that time. The collection of clinical, demographic, neuroimaging, laboratory data, as well as the final determination of the stroke outcome, was performed blindly with respect to survival data.
Results: To build the model, 22 multivariate clinical indicators were used that demonstrated the relationship with post-stroke survival at the stage of preliminary data analysis: stroke subtype according the Oxfordshire Community Stroke Project, age, gender, the severity of the neurological deficit according to the NIHSS scale at hospitalization, previous stroke or TIA, the presence of arterial hypertension, atrial fibrillation, myocardial atherosclerosis, congestive heart failure, diabetes mellitus, peripheral arterial diseases, alcohol abuse, level of creatinine, glucose, urea, potassium, sodium in blood, amount of hemoglobin, erythrocytes and leukocytes on the 1st day of treatment, the level of systolic and diastolic blood pressure in the hospital admission department.
In the construction of a survival decision tree of patients with IS, of the 22 initially embedded parameters, only 6 independent predictors were finally included in the prognostic model: the stroke subtype according to the OCSP, the presence of a lacunar infarction, the severity of neurologic deficit at hospitalization according NIHSS, level of urea and glucose in the blood, and the presence of congestive heart failure.
A Pre Experimental Study to Assess the Effectiveness of Structured Teaching P...ijtsrd
Statement of problem A Pre Experimental Study to Assess the Effectiveness of Structured Teaching Programme on Knowledge Regarding Cardio Pulmonary Resuscitation Among Gnm 2nd Year Students of Desh Bhagat University School of Nursing, Mandi Gobindgarh, Punjab. Material and method A pre experimental research design were used for the present study. A study sample of 50 students of GNM 2nd year were selected by non probability purposive sampling technique. The data was collected by self structured questionnaire regarding cardio pulmonary resuscitation among BGNM 2nd year students in Desh Bhagat University School of Nursing Mandi Gobindgarh, Punjab. The data was analyzed in terms of objectives of the study using descriptive and inferential statistics in terms of frequency, percentage distribution, mean, Standard deviation,‘t' value, and chi square. Results As per percentage distribution of student according to age and gender it was found that Maximum students were in 21yrs 64 followed by, in 20yrs 20 in above 21years 12 and in 19 yrs 4 included in age group. Majority of students were females 82 and only 18 were male students. As per religion and area of residence Most of the students were belongs to sikh religion 90 , than 6 had Hindu and only 4 had Muslim, Maximum students were living in rural area 72 and only 28 were living in urban area. In post test maximum number of 70 the subjects had good knowledge score followed by subjects who had average knowledge score 30 regarding cardio pulmonary resuscitation. The Knowledge score was calculated by ‘t' test and the value was 3.42 Conclusion It was concluded that STP was effective as evidence by the results as the difference between pre test and post test knowledge score regarding cardio pulmonary resuscitation. The knowledge and skills of GNM students can be improved through STP after Posttest. Ms. Ramanpreet Kaur | Dr. Priyanka Chaudhary | Nazpreet Kaur "A Pre-Experimental Study to Assess the Effectiveness of Structured Teaching Programme on Knowledge Regarding Cardiopulmonary Resuscitation (CPR) among GNM" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-6 , October 2021, URL: https://www.ijtsrd.com/papers/ijtsrd47648.pdf Paper URL : https://www.ijtsrd.com/medicine/nursing/47648/a-preexperimental-study-to-assess-the-effectiveness-of-structured-teaching-programme-on-knowledge-regarding-cardiopulmonary-resuscitation-cpr-among-gnm/ms-ramanpreet-kaur
Serum Uric Acid and Outcome after Acute Ischemic Stroke: PREMIER StudyErwin Chiquete, MD, PhD
Background: Current evidence shows that uric acid is a potent
antioxidant whose serum concentration increases rapidly
after acute ischemic stroke (AIS). Nevertheless, the relationship
between serum uric acid (SUA) levels and AIS
outcome remains debatable. We aimed to describe the
prognostic significance of SUA in AIS. Methods: We studied
463 patients (52% men, mean age 68 years, 13% with glomerular
filtration rate <60 />2) at 30 days, or with
any outcome measure at 3, 6 or 12 months poststroke. After
adjustment for age, gender, stroke type and severity (NIHSS
<9),><24 h. Conclusions: A low SUA
concentration is modestly associated with a very good
short-term outcome. Our findings support the hypothesis
that SUA is more a marker of the magnitude of the cerebral
infarction than an independent predictor of stroke outcome.
Introduction: Chronic Kidney Disease (CKD) is a worldwide public health problem and it is increasing over time. Cardiovascular disease is a major concern for patients with end stage renal disease, especially those on hemodialysis. It is the leading cause of death among patients with chronic kidney
disease, particularly in dialysis population.
A less-invasive-approach-of-medial-meniscectomy-in-rat-a-model-to-target-earl...science journals
In order for insulin to exert its biological actions on target cells in peripheral tissues like muscle and adipose tissues, Insulin must pass through the endothelial barrier into the interstitium.
Copyright 2016 American Medical Association. All rights reserv.docxmelvinjrobinson2199
Copyright 2016 American Medical Association. All rights reserved.
Intensive vs Standard Blood Pressure Control
and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years
A Randomized Clinical Trial
Jeff D. Williamson, MD, MHS; Mark A. Supiano, MD; William B. Applegate, MD, MPH; Dan R. Berlowitz, MD; Ruth C. Campbell, MD, MSPH;
Glenn M. Chertow, MD; Larry J. Fine, MD; William E. Haley, MD; Amret T. Hawfield, MD; Joachim H. Ix, MD, MAS; Dalane W. Kitzman, MD;
John B. Kostis, MD; Marie A. Krousel-Wood, MD; Lenore J. Launer, PhD; Suzanne Oparil, MD; Carlos J. Rodriguez, MD, MPH;
Christianne L. Roumie, MD, MPH; Ronald I. Shorr, MD, MS; Kaycee M. Sink, MD, MAS; Virginia G. Wadley, PhD; Paul K. Whelton, MD;
Jeffrey Whittle, MD; Nancy F. Woolard; Jackson T. Wright Jr, MD, PhD; Nicholas M. Pajewski, PhD; for the SPRINT Research Group
IMPORTANCE The appropriate treatment target for systolic blood pressure (SBP) in older
patients with hypertension remains uncertain.
OBJECTIVE To evaluate the effects of intensive (<120 mm Hg) compared with standard
(<140 mm Hg) SBP targets in persons aged 75 years or older with hypertension
but without diabetes.
DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial of patients aged
75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT).
Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015.
INTERVENTIONS Participants were randomized to an SBP target of less than 120 mm Hg
(intensive treatment group, n = 1317) or an SBP target of less than 140 mm Hg (standard
treatment group, n = 1319).
MAIN OUTCOMES AND MEASURES The primary cardiovascular disease outcome was a
composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a
myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death
from cardiovascular causes. All-cause mortality was a secondary outcome.
RESULTS Among 2636 participants (mean age, 79.9 years; 37.9% women), 2510 (95.2%)
provided complete follow-up data. At a median follow-up of 3.14 years, there was a
significantly lower rate of the primary composite outcome (102 events in the intensive
treatment group vs 148 events in the standard treatment group; hazard ratio [HR], 0.66
[95% CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107 deaths, respectively; HR, 0.67
[95% CI, 0.49-0.91]). The overall rate of serious adverse events was not different between
treatment groups (48.4% in the intensive treatment group vs 48.3% in the standard
treatment group; HR, 0.99 [95% CI, 0.89-1.11]). Absolute rates of hypotension were 2.4% in
the intensive treatment group vs 1.4% in the standard treatment group (HR, 1.71 [95% CI,
0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23 [95% CI, 0.76-2.00]), 4.0% vs
2.7% for electrolyte abnormalities (HR, 1.51 [95% CI, 0.99-2.33]), 5.5% vs 4.0% for acute
kidney injury (HR, 1.41 [95% CI, 0.98-2.04]), and 4.9% vs 5.5% for inj.
Copyright 2016 American Medical Association. All rights reserv.docxbobbywlane695641
Copyright 2016 American Medical Association. All rights reserved.
Intensive vs Standard Blood Pressure Control
and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years
A Randomized Clinical Trial
Jeff D. Williamson, MD, MHS; Mark A. Supiano, MD; William B. Applegate, MD, MPH; Dan R. Berlowitz, MD; Ruth C. Campbell, MD, MSPH;
Glenn M. Chertow, MD; Larry J. Fine, MD; William E. Haley, MD; Amret T. Hawfield, MD; Joachim H. Ix, MD, MAS; Dalane W. Kitzman, MD;
John B. Kostis, MD; Marie A. Krousel-Wood, MD; Lenore J. Launer, PhD; Suzanne Oparil, MD; Carlos J. Rodriguez, MD, MPH;
Christianne L. Roumie, MD, MPH; Ronald I. Shorr, MD, MS; Kaycee M. Sink, MD, MAS; Virginia G. Wadley, PhD; Paul K. Whelton, MD;
Jeffrey Whittle, MD; Nancy F. Woolard; Jackson T. Wright Jr, MD, PhD; Nicholas M. Pajewski, PhD; for the SPRINT Research Group
IMPORTANCE The appropriate treatment target for systolic blood pressure (SBP) in older
patients with hypertension remains uncertain.
OBJECTIVE To evaluate the effects of intensive (<120 mm Hg) compared with standard
(<140 mm Hg) SBP targets in persons aged 75 years or older with hypertension
but without diabetes.
DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial of patients aged
75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT).
Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015.
INTERVENTIONS Participants were randomized to an SBP target of less than 120 mm Hg
(intensive treatment group, n = 1317) or an SBP target of less than 140 mm Hg (standard
treatment group, n = 1319).
MAIN OUTCOMES AND MEASURES The primary cardiovascular disease outcome was a
composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a
myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death
from cardiovascular causes. All-cause mortality was a secondary outcome.
RESULTS Among 2636 participants (mean age, 79.9 years; 37.9% women), 2510 (95.2%)
provided complete follow-up data. At a median follow-up of 3.14 years, there was a
significantly lower rate of the primary composite outcome (102 events in the intensive
treatment group vs 148 events in the standard treatment group; hazard ratio [HR], 0.66
[95% CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107 deaths, respectively; HR, 0.67
[95% CI, 0.49-0.91]). The overall rate of serious adverse events was not different between
treatment groups (48.4% in the intensive treatment group vs 48.3% in the standard
treatment group; HR, 0.99 [95% CI, 0.89-1.11]). Absolute rates of hypotension were 2.4% in
the intensive treatment group vs 1.4% in the standard treatment group (HR, 1.71 [95% CI,
0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23 [95% CI, 0.76-2.00]), 4.0% vs
2.7% for electrolyte abnormalities (HR, 1.51 [95% CI, 0.99-2.33]), 5.5% vs 4.0% for acute
kidney injury (HR, 1.41 [95% CI, 0.98-2.04]), and 4.9% vs 5.5% for inj.
The Midwest Stroke Action Alliance recently hosted a panel of health experts on the risks of venous thromboembolism (VTE which is commonly referred to as blood clots).
The health experts on the panel were:
- Mark J. Alberts, MD (Clinical Vice-Chair for Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center)
- Laurie Paletz, BSN, PHN, RN-BC (Stroke Program Coordinator, Cedars-Sinai Medical Center)
- Michael W. Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)
Stroke is a leading cause of death and disability in the U.S., with 800,000 cases occurring each year. Each year in the United States, an estimated 300,000 cases of VTE occur. Mortality can be as high as 3.8 percent in patients with deep vein thrombosis (DVT) and 38.9 percent in those with pulmonary embolism (PE). VTE is associated with a high risk of death in the U.S. and Europe, with an estimated incidence rate of 1 in 1,000 patients. VTE is particularly common after a stroke. Approximately 20 percent of hospitalized immobile stroke patients will develop DVT, and 10 percent a PE.
Techniques in Neurosurgery & Neurology
Authors:
Irina Gontschar1 and Igor Prudyvus2
1Student, Health Information Management and Insurance Billing Program by the EVANS Community Adult School, Los Angeles, USA
2Chief Application Support Analysts, EPAM Systems, Minsk, Belarus
Abstract
Introduction: The purpose of the study is to identify the independent clinical predictors of the evolving ischemic stroke (EIS) according to the tree-structured model.
Methods and Materials: The objects of the study were 1421 patients with ischemic stroke (IS), hospitalized within 48 hours from the development of the initial symptoms. Patients with IS were admitted to the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital (Belarus) in 2002-2014 years. Evolving clinical course of the stroke is defined as an increase in the severity of neurological deficit by 2 or more points on the NIHSS scale or the death of the patient during the first seven days of hospitalization. The research is characterized due to the prospective-data-collection, and the retrospective evaluation design. The statistical method of decision trees and an algorithm of the conditional inference trees were used to create the prognostic model of EIS. Statistical data analysis was carried out applying the software packages of R V.3.2.5 and IBM SPSS Statistics 26.0.
Results: The rate of EIS reached 30%. The patients with EIS were 72.6±10.2 years old, patients without EIS - 68.1±11.3 years; p = 0.005. Previously, 22 clinical, demographic, laboratory variables accommodated in the computer database were included in the conditional inference trees statistical algorithm. The prognostic statistical model of EIS has been constructed. The following independent predictors of evolving IS were identified: the stroke subtype according to the Oxford Community Stroke Project classification, the serum urea level, and red blood cell number in the total blood count. The accuracy of the statistical model reaches 0.77 (95% CI: 0.75; 0.80), the sensitivity is 0.52, the specificity - 0.88, PPV - 0.66, and NPV - 0.81; p < 0.001.
Conclusion: The tree-structural model allowed us to identify the independent clinical predictors of EIS.
Keywords: Cerebral infarction, Clinical characteristics, Clinical course, Conditional inference trees algorithm, Decision tree, Evolving ischemic stroke, Model, Predictor, Prognosis, Stroke deterioration
Debemos cambiar el paradigma! Para la reanimación del paciente politraumatizado en shock hemorrágico, debemos ser tremendamente cuidadosos y conservadores con el aporte de cristaloides o coloides!
Shock hemorrágico en el paciente politraumatizado, no debe tratarse con fisiológico, Ringer o gelatinas! Mientras más de estos productos reciban, peor pronóstico tiene nuestro paciente.
En este contexto, no debe administrarse nada que no aporte a transportar oxigeno o que colabore con la coagulación!
No más reanimación tipo ATLS, donde se recomendaba 2lt de suero fisiológico y solicitar exámenes para evaluar coagulación y ver necesidad de productos sanguíneos... NO MÁS!!!
Conceptos Claves:
- politraumatizado + shock = hemorrágico (abdomen, tórax, extremidades)
- control anatómico del sangrado es vital!
- no reanimar contra presión arterial, reanimar contra perfusión
- si necesita volumen; aportar fluidos que aporten a la coagulación o a transportar oxígeno
- recuerden calcio y ácido tranexámico
- hosp pequeño, o 1rio o 2ndario: esfuerzos en traslado
- hospital cuidado definitivo: protocolo transfusión masiva, hipotensión permisiva, cirugía control de daño, UCI
Methods: The current clinical study was conducted at Gaza city. It involved 90 patients who were scheduled for coronary angioplasty procedure. The patients were divided into three groups: The first group (n = 30), underwent BMS implantation and received colchicine 0.5 mg twice daily for six months. The second group (n = 30), underwent BMS implantation alone. The third group (n = 30) underwent DES implantation. All the patients were followed up for six months. The primary endpoint was clinical ISR at 6months. Secondary endpoints included Target Vessel Revascularization (TVR) and Stent Thrombosis (ST).
Novel Method for Automated Analysis of Retinal Images: Results in Subjects wi...Mutiple Sclerosis
Michele Cavallari, Claudio Stamile, Renato Umeton, Francesco Calimeri, and Francesco Orzi
Morphological analysis of the retinal vessels by fundoscopy provides noninvasive means for detecting and staging systemic microvascular damage. However, full exploitation of fundoscopy in clinical settings is limited by paucity of quantitative, objective information obtainable through the observer-driven evaluations currently employed in routine practice. Here, we report on the development of a semiautomated, computer-based method to assess retinal vessel morphology. The method allows simultaneous and operator-independent quantitative assessment of arteriole-to-venule ratio, tortuosity index, and mean fractal dimension. The method was implemented in two conditions known for being associated with retinal vessel changes: hypertensive retinopathy and Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL). The results showed that our approach is effective in detecting and quantifying the retinal vessel abnormalities. Arteriole-to-venule ratio, tortuosity index, and mean fractal dimension were altered in the subjects with hypertensive retinopathy or CADASIL with respect to age- and gender-matched controls. The interrater reliability was excellent for all the three indices (intraclass correlation coefficient ≥ 85%). The method represents simple and highly reproducible means for discriminating pathological conditions characterized by morphological changes of retinal vessels. The advantages of our method include simultaneous and operator-independent assessment of different parameters and improved reliability of the measurements.
Blood pressure at hospital admission and outcome after primary intracerebral ...Erwin Chiquete, MD, PhD
Introduction: The importance of the admission blood pressure (BP) for intracerebral
hemorrhage (ICH) outcome is not completely clear. Our objective was to
analyze the clinical impact of BP at hospital arrival in patients with primary ICH.
Material and methods: We studied 316 patients (50% women, mean age:
64 years, 75% with hypertension history) with acute primary ICH. The first BP reading
at admission was evaluated for its association with neuroimaging findings
and outcome. A Cox proportional hazards model and Kaplan-Meier analyses
were constructed to evaluate factors associated with in-hospital mortality.
Results: Intraventricular irruption occurred in 52% of cases. A high frequency
of third ventricle extension was observed in patients with BP readings in the
upper quartiles of the distribution (systolic, diastolic, or mean arterial pressure).
Blood pressure readings did not correlate with hematoma volumes. In-hospital
case fatality rate was 46% (63% among those with ventricular irruption). Systolic
BP (SBP) > 190 mm Hg was independently associated with in-hospital mortality
in supratentorial (n = 285) ICH (hazard ratio: 1.19, 95% confidence interval:
1.02-1.38, for the highest vs. the lowest quartile) even after adjustment for
known strong predictors (age, ICH volume, Glasgow coma scale and ventricular
extension). Blood pressure was not significantly associated with ventricular
extension or outcome in patients with infratentorial ICH.
Conclusions: A high BP on admission is associated with an increased risk of
intraventricular extension and early mortality in patients with supratentorial
ICH. However, a significant proportion of patients with high BP readings without
ventricular irruption still have an increased risk of death.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
3. 2 Stroke October 2013
stroke severity subgroups of acute ischemic stroke patients.
Because only 6% of patients had OTT <70 minutes in this
study, we evaluated effect of OTT≤90 minutes. This is a rel-
evant time-point, because the number needed to treat doubles
from 4.5 to 9 for patients with OTT 91 to 180, compared with
OTT≤90 minutes.2
Patients and Methods
Study Setting
The current observational study is a joint project of 10 European
stroke centers. The study was approved by the relevant authorities in
each participating center, if required. This study was approved in the
coordinating center (Helsinki) as a registry, but did not require ethical
board review.
Data from individual consecutive patients were collected as previ-
ously described.4
The merged cohort included 7106 patients treated
between 1998 and 2012. OTT or 3-month modified Rankin scale
(mRS) values were not available for 250 patients, who were excluded.
The final cohort comprised 6856 eligible patients. Excellent outcome
was defined as 3-month mRS 0 to 1. None of the patients received
additional therapies, such as an endovascular procedure.
Statistical Analyses
Because of non-normal distribution of all treatment delays, age, and
NIHSS, data are presented as median and interquartile range. Groups
were compared with the independent samples Mann–Whitney U or χ2
test, as appropriate. First, for the whole population, we constructed a
model of logistic regression with excellent outcome (and separately
mortality) as dependent variable. This model included age as continu-
ous variable, baseline NIHSS, sex, OTT, glucose level on admission,
presence of symptomatic intracranial hemorrhage (sICH) according to
European Cooperative Acute Stroke Study-2 (ECASS-2) criteria, and
year of admission (to counteract possible effect of overall improve-
ment in stroke care over time). Thereafter, population was divided
into 3 subgroups, based on tertiles of baseline NIHSS: 0 to 6 points,
7 to 12 points, and >12 points.3
Separately for each NIHSS subgroup,
similar models of binary logistic regression were constructed, and
following parameters were forced into the model: age, sex, OTT≤ 90
minutes, glucose level on admission, intracranial hemorrhage (ICH),
year of admission, and also age*sex interaction to exclude confound-
ing. Statistical significance was set at 0.05 (2-tailed). Analyses were
performed on IBM SPSS version 18 (IBM Corp, Armonk, NY).
Results
Demographics and baseline characteristics are outlined in
the Table. Altogether, 19% of patients received thromboly-
sis within 90 minutes from symptom onset. For the whole
cohort, OTT decrease per minute was independently asso-
ciated with excellent outcome after adjusting for age, sex,
baseline NIHSS, admission glucose level, and year of treat-
ment (odds ratio [OR], 0.999; 95% confidence interval [CI],
0.998–0.999; P<0.001).
Focusing on early versus late treatment, OTT≤90 minutes
was independently associated with 3-month mRS 0 to 1 in
patients with baseline NIHSS 7 to 12 (OR, 1.37; 95% CI,
1.11–1.70; P=0.004], but not in patients with NIHSS>12 (OR,
1.00; 95% CI, 0.76–1.32; P=0.99) nor NIHSS 0 to 6 (OR,
1.04; 95% CI, 0.78–1.39; P=0.80). To overcome the possible
ceiling effect from spontaneous better prognosis of patients
with mild symptoms (NIHSS, 0–6), in the secondary analy-
sis, we studied association of OTT≤90 minutes with 3-month
Table. Demographics and Baseline Characteristics of the Merged Cohort
Parameter All Patients, n=6856 NIHSS, 0–6; n=2161 NIHSS, 7–12; n=2164 NIHSS>12; n=2531
Age, y 72 (61–79) 69 (59–77) 72 (61–79) 74 (64–81)
Women 3133 (45.7%) 41.6% 45.4% 50.7%
Baseline NIH Stroke Scale 10 (6–16) 4 (3–5) 9 (8–11) 17 (15–20)
Baseline NIH Stroke Scale, mean
(range)
11 (0–41) 4.2 (0–6) 9.3 (7–12) 18 (13–41)
Onset-to-treatment time, min 135 (101–178) 140 (104–180) 136 (103–177) 133 (100–175)
Onset-to-treatment time, 3–4.5 h, % 16.0 19.6 16.1 12.6
Onset-to-door time, min 82 (59–120) 87 (60–127) 85 (60–120) 75 (55–114)
Door-to-needle time, min 45 (27–67) 43 (26–65) 44 (26–67) 45 (28–69)
Medical history
Diabetes mellitus 1118 (16.3%) 21.1% 18.2% 20.6%
Previous stroke 864 (12.6%) 15.3% 16.2% 14.7%
Coronary heart disease 1042 (15.2%) 19.1% 18.4% 22.3%
Atrial fibrillation 1680 (24.5%) 22.8% 26.9% 37.9%
Hypertension 3901 (56.9%) 69.5% 68.4% 70.4%
Dyslipidemia 2242 (32.7%) 46.2% 39.4% 35.4%
Pathogenesis
Large artery atherosclerosis 1118 (16.3%) 15.7% 16.5% 16.0%
Cardioembolism, high source 3085 (45.0%) 36.1% 41.4% 53.5%
Small vessel disease 425 (6.2%) 11.3% 7.2% 1.7%
Other determined 267 (3.9%) 3.3% 3.8% 4.4%
Unknown, multiple, not studied 1961 (28.6%) 32.6% 30.2% 24.3%
If not otherwise stated, continuous data are presented as median (IQR). IQR indicates interquartile range; NIH, National Institutes of
Health; and NIHSS, National Institutes of Health Stroke Scale.
by guest on August 25, 2013http://stroke.ahajournals.org/Downloaded from
4. Strbian et al Ultra-Early Thrombolysis 3
mRS=0 in this subgroup of patients. An independent associa-
tion was observed with the corresponding OR of 1.51 (95%
CI, 1.14–2.01); P0.01. There was no interaction between
age and sex in any of the models. We did not find any asso-
ciation between ultra-early thrombolysis and 3-month mortal-
ity in the whole cohort (P=0.85) or in subgroups of NIHSS
(P=0.48/0.89/0.33).
Patients with OTT≤90 minutes had smaller proportion of
any ICH (14.8% versus 17.6%; P=0.027) and nonsignifi-
cantly smaller proportion of symptomatic ICH (3.7% versus
4.5%; P=0.20). Both any ICH and sICH were independently
inversely associated with excellent outcome in a regression
model comprising the entire cohort (OR, 0.06; 95% CI, 0.03–
0.12 for sICH and OR, 0.30; 95% CI, 0.25–0.36 for any ICH;
both P0.001), and separately per all tertiles of NIHSS score
(ORs in tertiles 0.06/0.08/0.04 for sICH and 0.29/0.43/0.40
for any ICH; all P0.001).
Discussion
We validated our single-center findings3
on effect of early
versus late thrombolysis in a cohort from 10 stroke centers.
Almost 20% of all patients were treated within 90-minute
OTT. In the primary analysis, thrombolysis within this time
period was independently associated with excellent outcome
in patients with moderate baseline stroke severity (NIHSS,
7–12), but not in patients with mild or severe symptoms.
Possible explanation for this seemingly selective extra benefit
may be explained by predictive effect of NIHSS10 on pres-
ence of proximal cerebral artery occlusion,5–7
and less likely
excellent outcome in such patients.8
NIHSS10 is also a com-
mon cut-off in patient selection for endovascular approaches.9
Another possible explanation is higher proportion of car-
dioembolism and lower proportion of small vessel disease
in patients with NIHSS12. Based on the detailed analysis
of relevant parameters studied in patients treated within 90
minutes and 90 minutes (Table I in the online-only Data
Supplement), we observed larger percentage of any ICH in
patients with NIHSS12 treated 90 minutes (*P0.05), but
not in case of sICH. Furthermore, there was higher propor-
tion of females in patients with NIHSS 7 to 12 treated 90
minutes, but sex and age*sex interaction was not associated
with outcome.
Our finding that patients with mild symptoms (NIHSS7)
seem to benefit less from ultra-early treatment may be
explained by a ceiling effect from the spontaneously better
prognosis and is supported by recently published International
Stroke Trial-3 (IST-3),10
although a smaller recent study sug-
gested differently.11
Patients with mild symptoms usually have
small infarcted brain volumes because of peripheral vessel
occlusions or central occlusions with good collaterals. In both
cases, infarct volume reduction because of ultra-early treat-
ment might be very small to be detectable by mRS. Indeed,
when excellent 3-month outcome was set to mRS 0, we found
an independent association of ultra-early thrombolysis in this
subgroup of patient.
As opposed to our previous report,3
we did not find any
association of ultra-early thrombolysis with mortality. This
may be because of the limited number of patients treated
ultra-early in the current cohort. Most cases of cardioembo-
lism were caused by atrial fibrillation, but we do not have data
on more detailed analysis of other high-risk sources of cardio-
embolism. This higher percentage might have had influenced
the effects observed; however, the proportions were very simi-
lar in subgroups of patients treated within and 90 minutes,
and presence of cardioembolism did not influence the results
of the primary analysis.
In conclusion, ultra-early IV thrombolysis increases the
likelihood of excellent outcome in patients with moderately
severe symptoms, and in secondary analysis also in those with
mild symptoms. A portion of benefit might stem from lower
frequencies of ICH in these patients.12
All measures must be
taken to reduce OTT as much as possible.
Disclosures
Dr Ringleb has received lecture fees (10 000€) from Boehringer
Ingelheim, the manufacture of Alteplase, and is German national
coordinator of Safe Implementation of Thrombolysis in Stroke.
Dr Michel has received speaker fees from Boehringer Ingelheim;
honoraria from scientific advisory boards from Boehringer
Ingelheim; and travel support from Boehringer Ingelheim. He uses
all this funding and honoraria for stroke research and education.
Dr Ollikainen is a member of Speaker’s Bureau from Boehringer
Ingelheim. Dr Mattle has received speaker’s and consulting fees
and educational and research grants from Boehringer Ingelheim,
Genzyme. Dr Egelter has received honoraria for advisory boards
or travel grants; modest: Boehringer Ingelheim. Dr Leys has re-
ceived travel grants from Boehringher Ingelheim and is a member
of advisory board at Boehringher Ingelheim. Dr Numminen has
received travel grants or lecture fees from Boehringer Ingelheim.
Dr Köhrmann is a member of advisory boards for Boehringer
Ingelheim and has received speaker’s honoraria from Boehringer
Ingelheim. Dr Hacke has received honoraria for advisory boards
and steering committee duties from Boehringer Ingelheim. He
has also received honoraria for presentations at satellite symposia
from Boehringer Ingelheim. He has received an unlimited scientific
grant to perform European Cooperative Acute Stroke Study-4 from
Boehringer Ingelheim. Dr Tatlisumak has received research grant
from Boehringer Ingelheim. He is a member of consultant/advisory
board and Speaker’s bureau at Boehringer Ingelheim. The other
authors have no conflicts to report.
References
1. Saver JL. Time is brain–quantified. Stroke. 2006;37:263–266.
2. Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC, et al;
ECASS, ATLANTIS, NINDS and EPITHET rt-PA Study Group. Time to
treatment with intravenous alteplase and outcome in stroke: an updated
pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials.
Lancet. 2010;375:1695–1703.
3. Strbian D, Soinne L, Sairanen T, Häppölä O, Lindsberg PJ, Tatlisumak T,
et al. Ultra-early thrombolysis in acute ischemic stroke is associated with
better outcome and lower mortality. Stroke. 2010;41:712–716.
4. Nardi K, Engelter S, Strbian D, Sarikaya H, Arnold M, Casoni F, et al;
Lipid Profile in Thrombolysis Study Group. Lipid profiles and outcome
in patients treated by intravenous thrombolysis for cerebral ischemia.
Neurology. 2012;79:1101–1108.
5. Olavarría VV, Delgado I, Hoppe A, Brunser A, Cárcamo D, Díaz-Tapia
V, et al. Validity of the NIHSS in predicting arterial occlusion in cerebral
infarction is time-dependent. Neurology. 2011;76:62–68.
6. Nakajima M, Kimura K, Ogata T, Takada T, Uchino M, Minematsu K.
Relationships between angiographic findings and National Institutes of
Health Stroke Scale Score in cases of hyperacute carotid ischemic stroke.
AJNR Am J Neuroradiol. 2004;25:238–241.
7. Fischer U, Arnold M, Nedeltchev K, Brekenfeld C, Ballinari P, Remonda
L, et al. NIHSS score and arteriographic findings in acute ischemic
stroke. Stroke. 2005;36:2121–2125.
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5. 4 Stroke October 2013
8. Ntaios G, Faouzi M, Michel P. The effect of thrombolysis on short-
term improvement depends on initial stroke severity. J Neurol.
2012;259:524–529.
9. Khatri P, Hill MD, Palesch YY, Spilker J, Jauch EC, Carrozzella JA, et
al; Interventional Management of Stroke III Investigators. Methodology
of the Interventional Management of Stroke III Trial. Int J Stroke.
2008;3:130–137.
10. The IST-3 Collaborative Group. The benefits and harms of intravenous
thrombolysis with recombinant tissue plasminogen activator within 6 h
of acute ischaemic stroke (the Third International Stroke Trial [IST-3]): a
randomised controlled trial. Lancet. 2012;379:2352.
11. Urra X, Ariño H, Llull L, Amaro S, Obach V, Cervera Á, et al. The out-
come of patients with mild stroke improves after treatment with systemic
thrombolysis. PLoS One. 2013;8:e59420.
12. Strbian D, Sairanen T, Meretoja A, Pitkäniemi J, Putaala J, Salonen O,
et al; Helsinki Stroke Thrombolysis Registry Group. Patient outcomes
from symptomatic intracerebral hemorrhage after stroke thrombolysis.
Neurology. 2011;77:341–348.
by guest on August 25, 2013http://stroke.ahajournals.org/Downloaded from
6. Online Supplement
Ultra-early intravenous stroke thrombolysis: do all patients benefit similarly?
(Brief Report)
1
Daniel Strbian, MD, PhD; 2
Peter Ringleb, MD, PhD; 3
Patrik Michel, MD; 4
Lorenz Breuer, MD; 5
Jyrki Ol-
likainen, MD; 6
Kei Murao, MD; 7
Julian D Seiffge, MD; 8
Simon Jung, MD; 9
Victor Obach, MD, 8,10
Bruno
Weder, MD; 3
Ashraf Eskandari, RN; 7
Henrik Gensike, MD; 9
Angel Chamorro, MD, PhD 8
Heinrich P. Mat-
tle, MD; 7
Stefan Engelter, MD; 6
Didier Leys, MD, PhD; 5
Heikki Numminen, MD, PhD; 4
Martin Köhrmann,
MD, PhD; 2
Werner Hacke, MD, PhD; 1
Turgut Tatlisumak, MD, PhD
Supplemental Table I. Analysis of selected parameters per NIHSS and OTT category
NIHSS 0-6 NIHSS 7-12 NIHSS12parameter
OTT =90 OTT90 OTT =90 OTT90 OTT =90 OTT90
mRS 1 (0-2) 1 (0-2) 1 (1-3) 2 (1-3) 4 (2-5) 4 (2-6)
age 68 (58-75) 69 (59-77) 70 (60-77) 72 (61-80) 73 (64-81) 74 (64-82)
females 35.4% 41.5% 40.0% 46.2%* 50.9% 50.8%
NIHSS 5 (4-5) 4 (3-5) 9 (8-11) 9 (8-11) 17 (15-20) 17 (15-20)
any ICH, % 6.9% 8.9% 14.5% 14.9% 21.1% 26.8%*
sICH, % 1.5% 2.2% 3.4% 4.4% 5.5% 6.7%
CE, % 33.9% 36.6% 39.5% 41.8% 54.7% 53.2%
SVD, % 13.8% 10.7% 9.5% 6.7% 1.8% 1.7%
Data are presented as median (interquartile range) or %. *p0.05
mRS: modified Rankin Scale; NIHSS: National Institutes of Health Stroke Scale; OTT: onset-to-
treatment time; ICH: intracerebral hemorrhage; sICH: symptomatic ICH; CE: cardioembolism;
SVD: small-vessel disease.
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