Search

Purpose: Anterior iris-claw phakic intraocular lens (pIOL) implantation is a treatment option for refractive, ametropic patients. However, the postoperative accommodative ability has not been systematically researched. Dynamic stimulation aberrometry allows the objective and dynamical measurement of accommodation by observing ocular aberrations during the accommodation process. We investigated the dynamic accommodative ability after pIOL implantation compared with a healthy age- and gender-matched control group. Design: Clinical, comparative case–control study. Subjects: We included patients aged 18–50 years that either underwent pIOL implantation > 1 month ago or served as a healthy, phakic control group. Methods: The accommodative ability and pupil dynamics of both groups were investigated using dynamic stimulation aberrometry. The method allows the analysis of dynamic parameters during accommodation, such as the accommodation speed. A 1:1 propensity score matching was conducted based on the patients’ age and gender. Main Outcome Measures: Parameters of objective accommodation, such as accommodative amplitude and pupil dynamic during accommodation. Results: Fifty-eight healthy, phakic eyes < 50 years of age and 21 eyes after pIOL implantation to correct myopia (pIOL, Verisyse, AMO, Inc) were enrolled. Patients that underwent anterior pIOL implantation were examined on average 24 ± 18 months after surgery. After matching, the mean age of both groups was not significantly different (35 ± 8 vs. 34 ± 8 years). No significant difference in dynamic parameters of accommodation or the accommodative amplitude (2.8 ± 1.4 and 2.9 ± 1.4 diopters [D] for pIOL and control group, P = 0.82) were seen. Maximum and minimum pupil sizes were not significantly different. The change in pupil size during deaccommodation was significantly faster in patients after pIOL implantation (P < 0.001). Conclusions: Dynamic stimulation aberrometry allowed the objective, dynamic, measurement of wavefronts in subjects with accommodative amplitudes up to 7 D. Phakic intraocular lens implantation does not impair the accommodative ability. It alters pupil dynamics during deaccommodation. Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Summary: Gestational gigantomastia (GGM) is a rare condition characterized by a massive overgrowth of breast tissue during pregnancy. Surgical sanction may be required when conservative measures fail. In this study, we report the case of a 29-year-old woman who presented with an evolutive GGM responsible for physical and emotional distress, despite medical treatment. A multidisciplinary decision was made to induce delivery at 32 weeks. In the postdelivery period, the patient developed breast wounds, complicated with septic cardiomyopathy. An emergency bilateral mastectomy was then carried out, together with banking of both nipple-areola complexes. Thereafter, delayed bilateral 2-stage breast reconstruction was started at 12 months with subcutaneous tissue expanders, later on followed by implants removal and autologous reconstruction with bilateral deep inferior epigastric artery perforator flaps and bilateral nipple replantation.

Background: Postoperative analgesia after knee arthroplasty forms a basis for an optimal range of motion after surgery. Femoral nerve blocks are established as a sensory nerve blockade but at the expense of quadriceps weakness delaying postoperative mobilization. The adductor canal block (ACB) similarly provides sensory blockade but preserves quadriceps function. If ACB is performed intraoperatively, it would reduce the time and cost needed for ACBs. This study aimed at investigating possible landmarks making it feasible to perform ACB intraoperatively. Material and methods: Twenty-seven knees were used. The superior pole of the patella, medial epicondyle, and adductor tubercle was proposed as landmarks to perform the ACB through a medial parapatellar approach. A needle was directed toward the adductor tubercle until a tactile feedback was felt. Ten to 15 mL India ink were injected using this technique. The adductor canal was dissected to visualize the ink spread and determine whether the saphenous nerve and the nerve to vastus medialis were exposed to the ink. Results: The anatomic landmarks were easily identified in all knees. The ACB resulted in the saphenous nerve and nerve to vastus medialis being bathed in ink consistently. A volumetric relationship was noted with the injectate. No injury to the neurovascular structures was observed. Conclusions: An accurate and safe technique with reliable anatomic landmarks was presented to perform an ACB. In addition, an increase in injected ink volume correlated to an increase in the spread of ink; thus, we postulate that 10 mL of local anesthetic may be sufficient for an adequate regional block.

Background:. Ulnar styloid fractures (USFs) are often associated with distal radial fractures (DRFs). When unstable DRFs are treated surgically, any associated USF is most commonly left untreated. The purpose of this study was to evaluate the effect of a concomitant USF on outcome after surgical stabilization of a DRF. Methods:. Data from 2 randomized controlled trials on the treatment of unstable DRFs were pooled. The effect of a USF on the QuickDASH, EQ-5D, pain, and range of motion at 2 years was evaluated. Results:. Two hundred and eighty-one patients were included; 177 (63%) had an associated, untreated USF. An unadjusted analysis demonstrated no significant difference in functional or patient-reported outcome measures (PROMs) at 2 years between patients with or without a concomitant USF. When controlling for confounding factors, the presence of a USF did not predict change in any of the PROMs from baseline to 2 years. A concomitant USF also did not predict change in grip strength or range of motion, except for a small effect on extension (−4.1°; 95% confidence interval, −7.5° to −0.8°; p = 0.02), which probably does not have clinical relevance. Conclusions:. A USF in combination with a DRF does not affect PROMs, range of motion, or grip strength. We recommend that concomitant USFs be left untreated when treating a DRF with surgical fixation. Level of Evidence:. Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Introduction Post-COVID-19 syndrome affects approximately 10-25% of people suffering from COVID-19 infection, irrespective of initial COVID-19 severity. Fatigue is one of the major symptoms, occurring in 30-90% of people with post-COVID-19 syndrome. This study aims at describing factors associated with fatigue in people with Post-COVID-19 seen in our newly established Post-Covid clinic. Methods This retrospective single center study included 42 consecutive patients suffering from Post-COVID-19 syndrome treated at the Department of Neurology, University Hospital Bern, between 11/2020 and05/2021. Clinical phenomenology of Post-COVID-19 syndrome with a special focus on fatigue and risk factor identification was performed using Mann-Whitney U Test, Pearson Correlation, and Chi-Quadrat-Test. Results Fatigue (90.5%) was the most prevalent Post-COVID-19 symptom followed by depressive mood (52.4%) and sleep disturbance (47.6%). Fatigue was in mean severe (Fatigue severity scale (FSS) mean 5.5 points (95% Confidence interval (95CI) 5.1 - 5.9, range .9 - 6.9, n = 40), and it was unrelated to age, COVID-19 severity or sex. The only related factors with fatigue severity were daytime sleepiness and depressed mood. Conclusion Fatigue is the main symptom of the Post-COVID-19 syndrome in our cohort. Further studies describing this syndrome are needed to prepare the healthcare systems for the challenge of treating patients with Post-COVID-19 syndrome.

Background:. Few studies have assessed long-term complications in women undergoing implant-based breast reconstruction with use of an acellular dermal matrix (ADM). This study compared outcomes over 5 years in women undergoing breast reconstruction procedures with and without ADM. Methods:. Complications data in patients enrolled in the prospective Continued Access Reconstruction/Revision Expansion trial were segregated by use of ADM versus no ADM in patients undergoing primary breast reconstruction or revision-reconstruction. Continued Access Reconstruction/Revision Expansion trial evaluated long-term safety and effectiveness of shaped, textured, silicone implants. Results:. Of the 9502 women, 257 had primary (n = 160) or revision-reconstruction (n = 97) with ADMs; 9245 had primary (n = 6977) or revision-reconstruction (n = 2268) without ADMs. Capsular contracture rates in primary reconstruction were lower with ADM than without at year 5 (3.2% versus 7.4%); rates were similar at year 1 (≤2.4%). Capsular contracture rates in revision-reconstruction were lower with ADM than without at year 5 (1.4% versus 8.9%); rates were similar at year 1 (≤2.5%). Seroma rates were low and sustained for all cohorts throughout the 5 years (≤2.9%). Reoperation rates increased over time in all cohorts, with similar rates between groups (2.4%–47.3% from week 4 to year 5 across cohorts). Other trends over time included lower rates for asymmetry and implant malposition with ADM than without. Conclusion:. These long-term data suggest that the use of ADM in breast reconstruction procedures may provide a benefit in reducing complications, such as capsular contracture, and may sustain low rates of seroma.

Background:. Prepectoral implant-based breast reconstruction is an alternative to subpectoral/dual-plane reconstruction. Methods:. This study examined outcomes of prepectoral reconstruction using a meta-analysis of data pooled with data from our previous review. Thirty studies were included. Results:. Explantation, seroma, and infection were the most common complications with no animation deformity reported. Significantly lower odds of infection were observed with prepectoral compared with dual-plane reconstruction. Conclusions:. Current literature suggests that prepectoral reconstruction may be associated with lower rates of postsurgical infections.

Immunoglobulin (Ig) G4-related disease is a recently described syndrome characterized by mass forming lymphoplasmacytic tissue infiltration and elevated serum IgG4 concentrations usually affecting middle-aged or older individuals. Lymphadenopathy is frequently observed and is sometimes the first or only manifestation of the disease. We report a case of IgG4-related disease mimicking Hodgkin lymphoma in a 13-year-old girl. The patient presented with progressive unilateral cervical lymphadenopathy of several months duration. Biopsy showed follicular hyperplasia with progressive transformation of germinal centers. Interfollicular areas were expanded by small lymphocytes, histiocytes, eosinophils and fibrosis with occasional CD30 positive cells initially concerning for interfollicular Hodgkin lymphoma. Immunohistochemical analysis revealed an intrafollicular plasmacytosis with an IgG4-positive/IgG-positive plasma cell ratio of 50% supporting a diagnosis of IgG4-related lymphadenopathy, progressively transformed germinal centers type. Laboratory studies were supportive with elevated serum IgG4 (178 mg/dL) and IgE (30.40 kU/L) levels along with an elevated serum IgG4/IgG ratio (0.16). Very few cases of IgG4-related disease have been described in children. Within this age group, there is considerable clinical overlap between IgG4-related disease associated lymphadenopathy and Hodgkin lymphoma. In addition, lymphadenopathy secondary to IgG4-related disease demonstrates substantial histologic diversity with the potential to simulate the inflammatory background and fibrosis of Hodgkin lymphoma. The importance of accurate diagnosis is underscored by the prognostic implications considering the marked response of the syndrome to steroid therapy. In addition, appropriate follow up is critical to monitor for relapse and additional organ involvement.

Context: Acute megakaryoblastic leukemia (AMKL) is a rare myeloid leukemia, occurring in 1%–5% of all adult acute myeloid leukemia (AML) cases. AMKL is characterized by a leukemic blast population positive for factor VIII, CD41a, CD42b, and/or CD61 with extensive myelofibrosis. Although various cytogenetic abnormalities are commonly reported, the association between constitutional trisomy 21 and AMKL has been of particular interest, because of the near universal presence of GATA1 mutation in such cases. Objective and Design: We report a case of AMKL in an adult presenting with extensive bone marrow necrosis in which cytogenetic studies revealed three copies of chromosome 21 as part of a complex karyotype; however, sequencing of the GATA1 gene revealed no mutation. Results: The patient was an adult male who presented with extensive bone marrow necrosis, making definitive diagnosis difficult. Autopsy studies using a multimodality approach identified AMKL with a complex karyotype, including trisomy 21. Sanger sequencing of the GATA1 gene showed a germline configuration without a mutation. Conclusions: To our knowledge, this is the first reported case of an adult with AMKL with acquired trisomy 21 in which the GATA1 mutation was investigated and the second reported case of AMKL presenting with extensive bone marrow necrosis. We will present a diagnostic approach to AMKL in which extensive bone marrow necrosis renders examination of the bone marrow difficult. Furthermore, we will examine the absence of the GATA1 mutation in a case of AMKL with trisomy 21 in an adult.

A geomagnetic jerk was seen in Swarm satellite data in 2017 over the Pacific region. We invert time series of spatial gradient secular variation data between 2014 and 2020, reduced to a grid of points at satellite altitude, for spatially- and temporally-regularized core surface flow. Pacific region flow acceleration was almost constant before and after the jerk, with a sharp change, especially in the azimuthal component, at the jerk epoch, despite the temporal regularization. Azimuthal acceleration is oppositely signed either side of 160°W, where it effectively vanishes, and also reverses sign at the jerk epoch. Acceleration features drift westward at about 900 km year -1 . Unlike previous studies, the evidence presented here for low latitude waves does not depend on imposing flow equatorial symmetry, quasi- or tangential geostrophy, or band-pass filtering, and has no reliance on stochastic models or numerical simulations., (© 2022. The Authors.)

Several studies show an increased risk of coronary heart disease (CHD) among people with obesity, but it is largely unknown whether this association also depends on a familial predisposition to obesity. This study examined if associations between Body Mass Index (BMI) or waist circumference (WC) and incident CHD differed among Danish female nurses with and without familial overweight and obesity. Analyses were based on data from the Danish Nurse Cohort (n = 20,701). Self-reported height, weight and self-measured WC were assessed in 1999, as was information on familial overweight/obesity, defined as having one or both parents with overweight/obesity. Information on the development of or death from CHD was collected from nationwide Danish registries in 2015. Analyses were based on Cox proportional hazard regression models adjusted for potential confounding factors. Both BMI and WC were directly associated with CHD risk, but we found no evidence of effect modification from familial predisposition to obesity. Hence a familial predisposition to obesity does not seem to influence the risk of CHD associated with general or central obesity., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Objective: To determine the relationship between gout flare rate and self-categorization into remission, low disease activity (LDA), and patient acceptable symptom state (PASS)., Methods: Patients with gout self-categorized as remission, LDA, and PASS, and reported number of flares over the preceding 6 and 12 months. Multinomial logistic regression was used to determine the association between being in each disease state (LDA and PASS were combined) and flare count, and self-reported current flare. A distribution-based approach and extended Youden index identified possible flare count thresholds for each state., Results: Investigators from 17 countries recruited 512 participants. Remission was associated with a median recalled flare count of zero over both 6 and 12 months. Each recalled flare reduced the likelihood of self-perceived remission compared with being in higher disease activity than LDA/PASS, by 52% for 6 months and 23% for 12 months, and the likelihood of self-perceived LDA/PASS by 15% and 5% for 6 and 12 months, respectively. A threshold of 0 flares in preceding 6 and 12 months was associated with correct classification of self-perceived remission in 58% and 56% of cases, respectively., Conclusion: Flares are significantly associated with perceptions of disease activity in gout, and no flares over the prior 6 or 12 months is necessary for most people to self-categorize as being in remission. However, recalled flare counts alone do not correctly classify all patients into self-categorized disease activity states, suggesting that other factors may also contribute to self-perceived gout disease activity., (Copyright © 2021 by the Journal of Rheumatology.)

Objective: Compelling evidence supports a treat-to-target (T2T) strategy for optimal outcomes in rheumatoid arthritis (RA). There is limited knowledge regarding the factors that impede implementation of T2T, particularly in a setting where adherence to T2T is protocol-specified. We aimed to assess clinical factors that associate with failure to adhere to T2T., Methods: Patients with RA from 10 countries who were starting or changing conventional synthetic disease-modifying antirheumatic drugs and/or starting tumor necrosis factor inhibitors were followed for 2 years. Participating physicians were required per protocol to adhere to the T2T strategy. Factors influencing adherence to T2T low disease activity (T2T-LDA; 44-joint count Disease Activity Score ≤ 2.4) were analyzed in 2 types of binomial generalized estimating equations models: (1) including only baseline features (baseline model); and (2) modeling variables that inherently vary over time as such (longitudinal model)., Results: A total of 571 patients were recruited and 439 (76.9%) completed 2-year followup. Failure of adherence to T2T-LDA was noted in 1765 visits (40.5%). In the baseline multivariable model, a high number of comorbidities (OR 1.10, 95% CI 1.02-1.19), smoking (OR 1.32, 95% CI 1.08-1.63) and high number of tender joints (OR 1.03, 95% CI 1.02-1.04) were independently associated with failure to implement T2T, while anticitrullinated protein antibody/rheumatoid factor positivity (OR 0.63, 95% CI 0.50-0.80) was a significant facilitator of T2T. Results were similar in the longitudinal model., Conclusion: Lack of adherence to T2T in the RA BIODAM cohort was evident in a substantial proportion despite being a protocol requirement, and this could be predicted by clinical features. [Rheumatoid Arthritis (RA) BIODAM cohort; ClinicalTrials.gov: NCT01476956].

Objective: The Outcome Measures in Rheumatology Soluble Biomarker Working Group initiated an international, multicenter, prospective study, the Rheumatoid Arthritis (RA) BIODAM cohort, to generate resources for the clinical validation of candidate biomarkers predictive of radiographic progression. This first report describes the cohort, clinical outcomes, and radiographic findings., Methods: Patients with RA from 38 sites in 10 countries starting or changing conventional synthetic disease-modifying antirheumatic drugs and/or starting tumor necrosis factor inhibitors were followed for 2 years. Participating physicians were required to adhere to a treat-to-target strategy. Biosamples (serum, urine) were acquired every 3 months, radiography of hands and feet every 6 months, and ultrasound of hands and feet every 3 months in a subset. Primary endpoint was radiographic progression by the Sharp/van der Heijde score., Results: A total of 571 patients were recruited and 439 (76.9%) completed 2-year followup. At baseline, the majority was female (76%), mean age 55.7 years, and mean disease duration 6.5 years. Patients had a mean of 8.4 swollen and 13.6 tender joints, 44-joint count Disease Activity Score (DAS44) 3.8, 77.7% rheumatoid factor-positive or anticitrullinated protein antibody-positive. Percentage of patients in DAS and American College of Rheumatology remission at 2 years was 52.2% and 27.1%, respectively. Percentage of patients with radiographic progression (> 0.5) at 1 and 2 years was 38.2% and 59.9%, respectively., Conclusion: The RA BIODAM prospective study succeeded in generating an extensive list of clinical, imaging (2343 radiographs), and biosample (4638 sera) resources that will be made available to expedite the identification and validation of biomarkers for radiographic damage endpoints. (Clinicaltrials.gov: NCT01476956, clinicaltrials.gov/ct2/show/NCT01476956).

We present the geomagnetic field model COV-OBS.x2 that covers the period 1840-2020. It is primarily constrained by observatory series, satellite data, plus older surveys. Over the past two decades, we consider annual differences of 4-monthly means at ground-based stations (since 1996), and virtual observatory series derived from magnetic data of the satellite missions CHAMP (over 2001-2010) and Swarm (since 2013). A priori information is needed to complement the constraints carried by geomagnetic records and solve the ill-posed geomagnetic inverse problem. We use for this purpose temporal cross-covariances associated with auto-regressive stochastic processes of order 2, whose parameters are chosen so as to mimic the temporal power spectral density observed in paleomagnetic and observatory series. We aim this way to obtain as far as possible realistic posterior model uncertainties. These can be used to infer for instance the core dynamics through data assimilation algorithms, or an envelope for short-term magnetic field forecasts. We show that because of the projection onto splines, one needs to inflate the formal model error variances at the most recent epochs, in order to account for unmodeled high frequency core field changes. As a by-product of the core field model, we co-estimate the external magnetospheric dipole evolution on periods longer than 2 years. It is efficiently summarized as the sum of a damped oscillator (of period 10.5 years and decay rate 55 years), plus a short-memory (6 years) damped random walk., Competing Interests: Competing interestsThe authors declare having no competing interest., (© The Author(s) 2020.)

We present the CHAOS-7 model of the time-dependent near-Earth geomagnetic field between 1999 and 2020 based on magnetic field observations collected by the low-Earth orbit satellites Swarm , CryoSat-2, CHAMP, SAC-C and Ørsted, and on annual differences of monthly means of ground observatory measurements. The CHAOS-7 model consists of a time-dependent internal field up to spherical harmonic degree 20, a static internal field which merges to the LCS-1 lithospheric field model above degree 25, a model of the magnetospheric field and its induced counterpart, estimates of Euler angles describing the alignment of satellite vector magnetometers, and magnetometer calibration parameters for CryoSat-2. Only data from dark regions satisfying strict geomagnetic quiet-time criteria (including conditions on IMF B z and B y at all latitudes) were used in the field estimation. Model parameters were estimated using an iteratively reweighted regularized least-squares procedure; regularization of the time-dependent internal field was relaxed at high spherical harmonic degree compared with previous versions of the CHAOS model. We use CHAOS-7 to investigate recent changes in the geomagnetic field, studying the evolution of the South Atlantic weak field anomaly and rapid field changes in the Pacific region since 2014. At Earth's surface a secondary minimum of the South Atlantic Anomaly is now evident to the south west of Africa. Green's functions relating the core-mantle boundary radial field to the surface intensity show this feature is connected with the movement and evolution of a reversed flux feature under South Africa. The continuing growth in size and weakening of the main anomaly is linked to the westward motion and gathering of reversed flux under South America. In the Pacific region at Earth's surface between 2015 and 2018 a sign change has occurred in the second time derivative (acceleration) of the radial component of the field. This acceleration change took the form of a localized, east-west oriented, dipole. It was clearly recorded on ground, for example at the magnetic observatory at Honolulu, and was seen in Swarm observations over an extended region in the central and western Pacific. Downward continuing to the core-mantle boundary, we find this event originated in field acceleration changes at low latitudes beneath the central and western Pacific in 2017., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Objective: To analyze the association between enthesitis, synovitis, and peritenon extensor tendon inflammation (PTI) in psoriatic arthritis (PsA)., Methods: PsA patients with swelling of metacarpophalangeal joints were included. Greyscale and power Doppler (PD) were used for synovitis and PTI ultrasound identification. Madrid Sonographic Enthesis Index (MASEI) was used for enthesitis assessment. PD activity was evaluated using PD item of MASEI and PD Outcome Measures in Rheumatology (OMERACT) definition., Results: Synovitis had no association with enthesitis. PTI was associated with PD MASEI and PD OMERACT. Only PD OMERACT showed a positive correlation with PTI., Conclusion: In PsA, PTI is associated to enthesitis, as opposed to synovitis.

Objective: The Outcome Measures in Rheumatology (OMERACT) Ultrasound (US) Working Group (WG) operates research activities for the validation of US as an outcome measurement instrument according to the Filter 2.0 framework., Methods: Original publications on definitions and scoring systems for pathophysiological manifestations and elementary lesions of various rheumatic disorders were reviewed from the onset of the WG research in 2005., Results: Definitions and scoring systems according to new terminology are provided., Conclusion: We have redefined OMERACT US pathology and elementary lesions as well as scoring systems, which are now proposed for OMERACT approval for application in clinical trials.

Objective: To evaluate the intraobserver and interobserver reliability of the ultrasonographic (US) assessment of subtalar joint (STJ) synovitis in patients with rheumatoid arthritis (RA)., Methods: Following a Delphi process, 12 sonographers conducted an US reliability exercise on 10 RA patients with hindfoot pain. The anteromedial, posteromedial, and posterolateral STJ was assessed using B-mode and power Doppler (PD) techniques according to an agreed US protocol and using a 4-grade semiquantitative grading score for synovitis [synovial hypertrophy (SH) and signal] and a dichotomous score for the presence of joint effusion (JE). Intraobserver and interobserver reliability were computed by Cohen's and Light's κ. Weighted κ coefficients with absolute weighting were computed for B-mode and PD signal., Results: Mean weighted Cohen's κ for SH, PD, and JE were 0.80 (95% CI 0.62-0.98), 0.61 (95% CI 0.48-0.73), and 0.52 (95% CI 0.36-0.67), respectively. Weighted Cohen's κ for SH, PD, and JE in the anteromedial, posteromedial, and posterolateral STJ were -0.04 to 0.79, 0.42-0.95, and 0.28-0.77; 0.31-1, -0.05 to 0.65, and -0.2 to 0.69; 0.66-1, 0.52-1, and 0.42-0.88, respectively. Weighted Light's κ for SH was 0.67 (95% CI 0.58-0.74), 0.46 (95% CI 0.35-0.59) for PD, and 0.16 (95% CI 0.08-0.27) for JE. Weighted Light's κ for SH, PD, and JE were 0.63 (95% CI 0.45-0.82), 0.33 (95% CI 0.19-0.42), and 0.09 (95% CI -0.01 to 0.19), for the anteromedial; 0.49 (95% CI 0.27-0.64), 0.35 (95% CI 0.27-0.4), and 0.04 (95% CI -0.06 to 0.1) for posteromedial; and 0.82 (95% CI 0.75-0.89), 0.66 (95% CI 0.56-0.8), and 0.18 (95% CI 0.04-0.34) for posterolateral STJ, respectively., Conclusion: Using a multisite assessment, US appears to be a reliable tool for assessing synovitis of STJ in RA.

Background and Purpose: In patients identified at referring facilities with acute ischemic stroke caused by a large vessel occlusion, bypassing the emergency department (ED) with direct transport to the neuroangiography suite may safely shorten reperfusion times., Methods: We conducted a single-center retrospective review of consecutive patients transferred to our facility for consideration of endovascular therapy. Patients were identified as admitted directly to the neuroangiography suite (DAN), transferred to the ED before intra-arterial therapy (ED-IA), and transferred to the ED but did not receive IA therapy (ED-IV)., Results: A retrospective review of a prospectively maintained database of transfer patients between January 2013 and October 2016 with large vessel occlusions identified 108 ED-IV patients and 261 patients who underwent mechanical thrombectomy (DAN=111 patients and ED-IA=150 patients). There were no differences in baseline characteristics among the 3 groups. The median computed tomography ASPECTS (Alberta Stroke Program Early CT Score) was lower in the ED-IV group versus the ED-IA and DAN groups (8 versus 9; P =0.001). In the DAN versus ED-IA cohort, there were comparable rates of TICI2b/3 recanalization and access to recanalization time. There was significantly faster hospital arrival to groin access time in the DAN cohort (81 minutes versus 22 minutes; P =0.001). Functional independence at 90 days was comparable in the DAN versus ED-IA cohorts but worse in the ED-IV group (43% versus 44% versus 22%; P =0.001)., Conclusions: DAN is safe, feasible, and associated with faster times of hospital arrival to recanalization. The clinical benefit of this approach should be assessed in a prospective randomized trial., (© 2017 American Heart Association, Inc.)

An established conceptualization of visual cortical function is one in which ventral regions mediate object perception while dorsal regions support spatial information processing and visually guided action. This division has been contested by evidence showing that dorsal regions are also engaged in the representation of object shape, even when actions are not required. The critical question is whether these dorsal, object-based representations are dissociable from ventral representations, and whether they play a functional role in object recognition. We examined the neural and behavioral profile of patients with impairments in object recognition following ventral cortex damage. In a functional magnetic resonanace imaging experiment, the blood oxygen level-dependent response in the ventral, but not dorsal, cortex of the patients evinced less sensitivity to object 3D structure compared with that of healthy controls. Consistently, in psychophysics experiments, the patients exhibited significant impairments in object perception, but still revealed residual sensitivity to object-based structural information. Together, these findings suggest that, although in the intact system there is considerable crosstalk between dorsal and ventral cortices, object representations in dorsal cortex can be computed independently from those in ventral cortex. While dorsal representations alone are unable to support normal object perception, they can, nevertheless, support a coarse description of object structural information., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

The use of telecommunications technology to provide the healthcare services, telemedicine, has been in use since the 1860s. The use of technology has ranged from providing medical care to far-off places during wartimes to monitoring physiological measurements of astronauts in space. Since the 1990s, reports have been published on diagnoses of neurological diseases with the use of video links. Studies confirm that the neurological examinations, including the National Institutes of Health Stroke Scale, performed during teleneurology are dependable. The transfer of stroke patients in rural hospitals to bigger medical centers delays treatment while there exists current and projected shortage of neurologists. Telestroke provides the solution. Patients suspected of acute stroke need a noncontrast computerized tomography (CT) scan for tissue plasminogen activator administration. Vascular imaging such as CT angiography, magnetic resonance angiography, and digital subtraction angiography can help show large-vessel occlusion or critical stenosis responsive to endovascular therapy. A standard protocol can be followed to decide a vascular modality of choice, considering advantages and disadvantages of each imaging modality. Telestroke solves the problems of distance and of shortage of neurologists. Neuroimaging plays a vital role in the delivery of telestroke, and the telestroke doctor should be comfortable with making a decision on selecting an appropriate vascular imaging modality., (Copyright © 2016 by the American Society of Neuroimaging.)

Objectives: Spontaneous intracerebral hemorrhage (ICH) results in high morbidity and mortality. A target for therapy might be hematoma expansion, which occurs in a significant proportion of patients, and can be exacerbated by antiplatelet medications, such as aspirin. It is not clear whether platelet transfusion neutralizes aspirin. The Aspirin Response Test (ART) is commonly ordered in this patient population, but it is not clear whether the results of this test can help select patients for transfusion of platelets. The aim of our study is to investigate whether a selected group of ICH patients, those with reduced platelet activity ("aspirin responders"), will benefit from platelet transfusion., Materials and Methods: This retrospective study included 63 patients who were taking aspirin but no other antithrombotic medication prior to the ICH. For each patient, we measured hematoma size by head CT on admission and compared with follow-up head CT 1 day later., Results: In the general cohort, 41% of transfused patients and 29% of non-transfused patients had a hematoma expansion. In the "aspirin responders" group, 46% of transfused patients and 22% of non-transfused patients had an expansion., Conclusions: Our data suggest that platelet transfusion following an ICH in "aspirin responders" does not reduce hematoma expansion rates in those patients. A larger prospective study is needed., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background and Purpose: The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial showed a trend for reduced all-cause mortality and positive secondary safety end point outcomes. We present further analyses of the mortality and severe disability data from the Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial., Materials and Methods: The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial was a multicenter, randomized, controlled trial that evaluated the safety and effectiveness of the NeuroFlo catheter in patients with stroke. The current analysis was performed on the as-treated population. All-cause and stroke-related mortality rates at 90 days were compared between groups, and logistic regression models were fit to obtain ORs and 95% CIs for the treated versus not-treated groups. We categorized death-associated serious adverse events as neurologic versus non-neurologic events and performed multiple logistic regression analyses. We analyzed severe disability and mortality by outcomes of the mRS. Patient allocation was gathered by use of a poststudy survey., Results: All-cause mortality trended in favor of treated patients (11.5% versus 16.1%; P = .079) and stroke-related mortality was significantly reduced in treated patients (7.5% versus 14.2%; P = .009). Logistic regression analysis for freedom from stroke-related mortality favored treatment (OR, 2.41; 95% CI, 1.22, 4.77; P = .012). Treated patients had numerically fewer neurologic causes of stroke-related deaths (52.9% versus 73.0%; P = .214). Among the 90-day survivors, nominally fewer treated patients were severely disabled (mRS 5) (5.6% versus 7.5%; OR, 1.72; 95% CI, 0.72, 4.14; P = .223). Differences in allocation of care did not account for the reduced mortality rates., Conclusions: There were consistent reductions in all-cause and stroke-related mortality in the NeuroFlo-treated patients. This reduction in mortality did not result in an increase in severe disability.

Background: Intravenous thrombolysis is the only therapy for acute ischemic stroke that is approved by the US Food and Drug Association. The use of telemedicine in stroke makes it possible to bring the expertise of academic stroke centers to underserved areas, potentially increasing the quality of stroke care., Methods: All consecutive admissions for stroke were reviewed for 1 year before telemedicine implementation and for variable periods thereafter. A retrospective review identified 2588 admissions for acute stroke between March 2005 and December 2008 at 12 hospitals participating in a telestroke network, including 919 patients before telemedicine was available and 1669 patients after telemedicine was available. The primary outcome measure was the rate of intravenous tissue plasminogen activator (IV tPA) use before and after telemedicine implementation., Results: One hundred thirty-nine patients received IV tPA in both study phases, with 26 (2.8%) patients treated before starting telemedicine and 113 (6.8%) after starting telemedicine (P < .001). Incorrect treatment decisions occurred 7 times (0.39%), with 2 (0.2%) pretelemedicine and 5 (0.3%) posttelemedicine (P = .70). Arrivals within 3 hours from symptom onset were more frequent in the posttelemedicine compared to the pretelemedicine phases (55 [6%] vs 159 [9.5%]; P = .002). Among the patients treated with IV tPA, symptomatic intracranial hemorrhage occurred in 2 patients (1 [10.7%] pretelemedicine vs 1 [1.8%] posttelemedicine; P = .34)., Conclusions: Telestroke implementation was associated with an increased rate of thrombolytic use in remote hospitals within the telemedicine network., (Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Acute treatment of ischemic stroke patients presenting more than eight-hours after symptom onset remains limited and largely unproven. Partial aortic occlusion using the NeuroFlo catheter can augment cerebral perfusion in animals. We investigated the safety and feasibility of employing this novel catheter to treat ischemic stroke patients eight-hours to 24 h following symptom onset., Methods: A multicenter, single-arm trial enrolled ischemic stroke patients at nine international academic medical centers. Eligibility included age 18-85 years old, National Institutes of Health stroke scale (NIHSS) score between four and 20, within eight-hours to 24 h after symptom onset, and perfusion-diffusion mismatch confirmed by magnetic resonance imaging. The primary outcome was all adverse events occurring from baseline to 30 days posttreatment. Secondary outcomes included stroke severity on neurological indices through 90 days. This study is registered with ClinicalTrials.gov, number NCT00436592., Results: A total of 26 patients were enrolled. Of these, 25 received treatment (one excluded due to aortic morphology); five (20%) died. Favorable neurological outcome at 90 days (modified Rankin score 0-2 vs. 3-6) was associated with lower baseline NIHSS (P  <  0·001) and with longer duration from symptom discovery to treatment. There were no symptomatic intracranial hemorrhages or parenchymal hematomas. Asymptomatic intracranial hemorrhage was visible on computed tomography in 32% and only on microbleed in another 20%., Conclusions: Partial aortic occlusion using the NeuroFlo catheter, a novel collateral therapeutic strategy, appears safe and feasible in stroke patients eight-hours to 24 h after symptom onset., (© 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.)

Intravenous tissue plasminogen activator (tPA) for acute ischemic stroke must be provided in an appropriate setting. The best way to provide thrombolysis in small community hospitals remains uncertain. Medical records were reviewed of tPA treatments at a stroke center between January 2002 and October 2005. The stroke center provides phone consultation for acute stroke to smaller hospitals in the region. Subjects were classified into 3 groups: tPA started at referring hospitals before transfer (treat and transfer group), tPA started at the stroke center after transfer (transfer and treat group), and the control group of patients who presented directly to the stroke center and received tPA (stroke center group). We recorded the patient and treatment characteristics, protocol deviations, symptomatic intracranial hemorrhage (ICH), and in-hospital deaths. There were 133 patients in the treat and transfer group, 35 patients in the transfer and treat group, and 86 patients in the stroke center group. Time from onset to treatment was similar in the treat and transfer and the stroke center groups, but the door-to-needle time was shorter by 12 minutes in the latter (P=.02). Fifty-five protocol deviations occurred in 38% patients in the treat and transfer group, compared with 6% in the stroke center group (P<.001). The most common deviations were related to time window violations and incorrect tPA dosing. Symptomatic ICH occurred in 8.2%, with no significant difference between the groups. Neither community hospital treatment nor protocol deviation was a predictor of symptomatic ICH or in-hospital mortality. Our findings indicate the need for improved protocol adherence for stroke thrombolysis in patients presenting to small community hospitals., (Copyright © 2010 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Hypertension, diabetes, obesity, and dyslipidemia are risk factors that characterize metabolic syndrome (MetS), which increases the risk for stroke by 40%. In a preliminary study, our aim was to evaluate cerebrovascular reactivity and oxygen metabolism in subjects free of vascular disease but with one or more of these risk factors. Volunteers (n=15) 59±15 (mean±SD)years of age clear of cerebrovascular disease by magnetic resonance angiography but with one or more risk factors were studied by quantitative positron emission tomography for measure ment of cerebral blood flow, oxygen consumption, oxygen extraction fraction (OEF), and acetazolamide cerebrovascular reactivity. Eight of ten subjects with MetS risk factors had OEF >50%. None of the five without risk factors had OEF >50%. The presence of MetS risk factors was highly correlated with OEF >50% by Fisher's exact test (p<0.007). The increase in OEF was significantly (P<0.001) correlated with cerebral metabolic rate for oxygen. Increased OEF was not associated with compromised acetazolamide cerebrovascular reactivity. Subjects with one or more MetS risk factors are characterized by increased cerebral oxygen consumption and ischemic stress, which may be related to increased risk of cerebrovascular disease and stroke.

Background and Purpose: There is considerable heterogeneity in practice patterns between sedation in the intubated state vs nonintubated state during endovascular acute stroke therapy. We sought to compare clinical and radiographic outcomes between these 2 sedation modalities., Methods: Consecutive patients with acute stroke due to middle cerebral artery-M1 segment occlusion treated with endovascular therapy between January 2006 and July 2009 were identified in our interventional acute stroke database. Level of sedation was determined as intubated (IS) vs nonintubated (NIS) state. Final infarct volumes on follow-up imaging and clinical outcomes at 3 to 6 months were obtained., Results: A total of 126 patients were included (73 [58%] NIS vs 53 [42%] IS). In IS patients, intensive care unit length of stay was longer (6.5 vs 3.2 days, P=0.0008). Intraprocedural complications were lower in NIS patients compared with IS patients (5/73 [6%] vs 8/53 [15%], respectively), but the difference was not significant (P=0.13). In univariate and multivariate analyses, NIS was significantly associated with in-hospital mortality (odds ratio=0.32, P=0.011), good clinical outcome (odds ratio=3.06, P=0.042), and final infarct volume (odds ratio=0.25, P=0.004)., Conclusions: In endovascular acute stroke therapy, treatment of patients in NIS appears to be as safe as treatment in IS and may result in more favorable clinical and radiographic outcomes. Our preliminary observations derived from this retrospective study await confirmation from prospective trials.

Background: The frequency with which intravenous thrombolysis for acute ischemic stroke results in normal clinical and radiographic status is currently unknown., Methods: Patients who received intravenous thrombolysis at community hospitals and a stroke center were retrospectively analyzed for occurrence of normal imaging after tissue plasminogen activator (tPA) treatment. The cases were classified as nonischemic process (stroke mimic), transient ischemic attack (TIA) or ischemic stroke. The occurrence rate and predictors of each condition were sought., Results: Of 254 patients who received tPA, 9 (3.5%) had a nonischemic process, 23 (9.1%) had TIA, and 222 (87%) were diagnosed with ischemic stroke. Nonischemic process patients were younger and were more likely to have received tPA at a community hospital than those with TIA or stroke. TIA was associated with lower pretreatment serum glucose, prevalence of coronary artery disease and stroke severity but not to time to treatment., Conclusion: Over 10% of patients who receive tPA for cerebral ischemia do not develop ischemic injury. tPA use for a nonischemic process is infrequent but is associated with community hospital use.

Objective: Intra-arterial therapies are being used more frequently in patients presenting with acute cerebral occlusions, but they have been limited by the potential for hemorrhage. We sought to determine whether pretreatment computed tomography perfusion parameters might help to identify patients at a higher risk of developing intracranial hemorrhage after intra-arterial stroke revascularization treatment., Methods: We retrospectively reviewed all patients at the University of Pittsburgh Medical Center and Michigan State University who underwent computed tomography perfusion imaging of the brain before intra-arterial thrombolysis between January 2006 and June 2007. Demographic information, angiographic variables, and types of endovascular interventions were recorded. The mean transit time and cerebral blood volumes were recorded for the ipsilateral and contralateral middle cerebral artery territories. A binary logistic regression model was constructed to determine the independent predictors of developing intracranial hemorrhage., Results: A total of 57 patients (33 from the University of Pittsburgh and 24 from Michigan State University) with a mean age of 66 +/- 13 years and mean National Institutes of Health Stroke Scale scores of 16 +/- 5 were studied. The overall recanalization (Thrombolysis in Myocardial Infarction Trial scale 2 or 3 flow) was 72% for the cohort, and the overall rate of parenchymal hemorrhage was 5 of 57 (9%) patients. The overall hemorrhage rate was 19 of 57 (33%) patients. The only variable found to be predictive of the development of hemorrhage after intervention was reduced pretreatment cerebral blood volume (odds ratio, 0.49; 95% confidence interval, 0.35-0.91; P < 0.022)., Conclusion: A reduced pretreatment ipsilateral cerebral blood volume value before endovascular revascularization of an acute middle cerebral artery or internal carotid artery occlusion significantly increases the risk of an intracranial hemorrhage.

The authors provide an overview of current clinical neuroimaging techniques for acute ischemic stroke. The pathophysiology of ischemic stroke is briefly reviewed, especially as it pertains to cerebral blood flow. There are three important goals that must be met in the imaging of an acute ischemic stroke: (1) to quantitate the extent of infarction already present; (2) to quantitate the amount of salvageable brain remaining; and (3) to identify the presence of arterial stenosis or occlusion that is both responsible for the stroke and potentially amenable to treatment. Methods of quantifying the degree of infarction, by magnetic resonance imaging or computed tomography, are compared. Techniques for measuring cerebral blood flow, to quantify tissue at risk, are detailed and compared. The quantification of cerebral blood flow is discussed in detail. Methods of visualizing the cerebral circulation are illustrated.

Background and Purpose: We sought to find predictors for hemorrhagic complications in patients with acute ischemic stroke treated with multimodal endovascular therapy., Materials and Methods: We retrospectively reviewed patients with acute ischemic stroke treated with multimodal endovascular therapy from May 1999 to March 2006. We reviewed clinical and angiographic data, admission CT Alberta Stroke Programme Early CT Score (ASPECTS), and the therapeutic endovascular interventions used. Posttreatment CT scans were reviewed for the presence of a parenchymal hematoma or hemorrhagic infarction based on defined criteria. Predictors for these types of hemorrhages were determined by logistic regression analysis., Results: We identified 185 patients with a mean age of 65+/-13 years and mean National Institutes of Health Stroke Scale score of 17+/-4. Sixty-nine patients (37%) developed postprocedural hemorrhages: 24 (13%) parenchymal hematomas and 45 (24%) hemorrhagic infarctions. Patients with tandem occlusions (odds ratio [OR] 4.6 [1.4-6.5], P<.016), hyperglycemia (OR 2.8 [1.1-7.7], P<.043), or treated concomitantly with intravenous (IV) tissue plasminogen activator (tPA) and intra-arterial (IA) urokinase (OR 5.1 [1.1-25.0], P<.041) were at a significant risk for a parenchymal hematoma. Hemorrhagic infarction occurred significantly more in patients presenting with an ASPECTS

Conversion disorders often present with dramatic physical presentations suggestive of severe organic disease. We present the case of a young woman who presented to the Emergency Department with a dense left hemiparesis suggestive of a severe acute stroke. Emergent referral to a regional stroke center facilitated rapid medical evaluation, exclusion of organic disease, and confirmation of conversion disorder as the etiology for the symptoms. This report highlights the dramatic clinical presentations that may result from conversion disorders as well as the benefits of rapid medical evaluation by specialty stroke centers.

Identification of increased stroke risk in a population of symptomatic patients with occlusive vascular disease (OVD) is presently accomplished by measurement of oxygen extraction fraction (OEF) or cerebrovascular reserve (CVR). However, many regions identified by compromised CVR are not identified by OEF. Our aim was to determine whether the response of OEF to acetazolamide, namely, oxygen extraction fraction response (OEFR) would identify those hemispheres in hemodynamic compromise with normal OEF. Nine patients symptomatic with transient ischemic attacks and strokes, and with occlusive vascular disease were studied. Anatomical MRI scans and T2-weighted images were used to identify and grade subcortical white matter infarcts. PET cerebral blood flow (CBF) and OEF were measured after acetazolamide. The relationship between CVR and oxygen extraction fraction response (OEFR) showed that positive OEFR occurred after acetazolamide despite normal baseline OEF values. The two hemispheres with positive OEFR were also associated with severe (> 3 cm) subcortical white matter infarcts. We found that the OEFR was highly correlated with CVR and identified hemispheres that were hemodynamically compromised despite normal baseline OEF.

Background: Intravenous tissue plasminogen activator (tPA) is the only approved therapy for acute ischemic stroke, although only 2% of patients with stroke receive intravenous tPA nationally., Objective: To determine the rate of tPA use for stroke in the Cleveland, Ohio, community and the reasons why patients were excluded from thrombolysis treatment., Design: Retrospective cohort study., Setting: Community. Subjects Patients admitted because of stroke to the 9 Cleveland Clinic Health System hospitals from June 15, 1999, to June 15, 2000., Main Outcome Measures: Utilization of intravenous tPA and reasons for ineligibility., Results: There were 1923 admissions for ischemic stroke in the 1-year period. Of these, 288 (15.0%) arrived within the 3-hour time window, and approximately 6.9% were considered eligible for tPA. The most common reasons for exclusion among patients arriving within 3 hours were mild neurologic impairment and rapidly improving symptoms. The overall rate of tPA use among patients presenting within 3 hours was 19.4%, and the rate of use among eligible patients was 43.4% (n = 56). The use of tPA did not differ significantly according to race or sex., Conclusions: Only 15% of patients arrived within the 3-hour time window for intravenous tPA, making delay in presentation the most common reason patients were ineligible for i.v. thrombolysis. Neurologic criteria were the second most common group of exclusions. Overall tPA use was low, but it was used in nearly half of all patients with no documented contraindications. Intravenous tPA use in a community setting can compare favorably with the rate of use seen in academic medical settings.

Background: Based on empirical experience, hypothermia has long been known to be a potent putative neuroprotectant. Recent insights into the mechanisms of central ischemia and reperfusion suggest reasons why hypothermia may be an ideal modality for extending the time window for thrombolytic stroke therapy., Review Summary: Hypothermia protects brain tissue from the effects of ischemia in multiple ways. It retards energy depletion, reduces intracellular acidosis, and lessens the ischemic overdose of excitatory neurotransmitters. This attenuates the influx of intracellular calcium, the herald of subsequent neuronal death. Additionally, hypothermia suppresses synthesis of oxygen free radicals involved in secondary damage associated with reperfusion. It also suppresses the mechanisms related to blood-brain barrier degeneration and post-ischemic remodeling. Animal and human data show that deep hypothermia is primarily protective and is used in several cardiothoracic and neurosurgical applications, and that mild hypothermia enhances recovery after focal and global ischemic brain injuries. Preliminary data on hypothermia in human stroke also show promising potential. Current methods of instituting hypothermia, including patient selection, temperature and timing, cooling methods, and complications are reviewed in detail., Conclusions: Neuroprotection conferred by mild to moderate hypothermia is likely to undergo phase III clinical trials in various clinical settings. Novel technology promises a broad application even outside intensive care settings. Preliminary studies suggest that mild to moderate hypothermia is a useful adjunct to thrombolytic therapy for stroke. Timing, degree, and duration rules are being developed and methods of cooling further perfected to optimize the safety and efficacy of this promising approach.

Preliminary clinical trials suggest that therapeutic hypothermia might improve the outcomes of patients with acute stroke. Definitive trials are under way.

Laparoscopic cholecystectomy has become an accepted alternative to open cholecystectomy. The purpose of this paper is to review the first 150 laparoscopic cholecystectomies performed at our institution. Hospital and clinic charts were reviewed to obtain demographic information. Anesthesia time and length of hospital stay were recorded. The incidence of intraoperative cholangiogram and laser use were calculated. The type and overall rate of complications were determined, as were complication rates for specific patient subsets. Learning curves by individual surgeons were plotted and hospital costs recorded. Six staff surgeons performed or attempted laparoscopic cholecystectomy on 150 (118 female, 32 male) symptomatic patients. The average age was 43.9 years (range, 18-77). Sixty-five patients (43.3%) had undergone previous abdominal surgery. The average duration of anesthesia was 120.8 min (SD +/- 43.5). Eighteen patients (12.0%) had intraoperative cholangiograms, and 16 procedures (10.7%) employed the laser for dissection. Ten procedures (6.7%) were converted to open cholecystectomy at the discretion of the individual surgeon. Three patients (2.0%) were found to have acute cholecystectomy. Average hospitalization was 1.4 days (SD +/- 1.64). The overall complication rate was 9.3%. Complication rate by age was 7.2% (age < 50 years) versus 13.2% (age > or = 50 years). The complication rate in overweight patients was 15.52% compared with a rate of 5.43% for those not overweight (overweight was arbitrarily defined as > 175 lb for women, > 200 lb for men). The complication rate in patients who had previous abdominal surgery was 8.5% compared with 9.9% in patients who had not had previous abdominal surgery.(ABSTRACT TRUNCATED AT 250 WORDS)