Endovascular treatment for acute ischemic stroke patients: implications and interpretation of IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials: A report from the Working Group of International Congress of Interventional Neurology

OBJECTIVE The results of Interventional Management of Stroke (IMS) III, Magnetic Resonance and REcanalization of Stroke Clots Using Embolectomy (MR RESCUE), and SYNTHESIS EXPANSION trials are expected to affect the practice of endovascular treatment for acute ischemic stroke. The purpose of this report is to review the components of the designs and methods of these trials and to describe the influence of those components on the interpretation of trial results. METHODS A critical review of trial design and conduct of IMS III, MR RESCUE, and SYNTHESIS EXPANSION is performed with emphasis on patient selection, shortcomings in procedural aspects, and methodology of data ascertainment and analysis. The influence of each component is estimated based on published literature including multicenter clinical trials reporting on endovascular treatment for acute ischemic stroke and myocardial infarction. RESULTS We critically examined the time interval between symptom onset and treatment and rates of angiographic recanalization to differentiate between "endovascular treatment" and "parameter optimized endovascular treatment" as it relates to the IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials. All the three trials failed to effectively test "parameter optimized endovascular treatment" due to the delay between symptom onset and treatment and less than optimal rates of recanalization. In all the three trials, the magnitude of benefit with endovascular treatment required to reject the null hypothesis was larger than could be expected based on previous studies. The IMS III and SYNTHESIS EXPANSION trials demonstrated that rates of symptomatic intracerebral hemorrhages subsequent to treatment are similar between IV thrombolytics and endovascular treatment in matched acute ischemic stroke patients. The trials also indirectly validated the superiority/equivalence of IV thrombolytics (compared with endovascular treatment) in patients with minor neurological deficits and those without large vessel occlusion on computed tomographic/magnetic resonance angiography. CONCLUSIONS The results do not support a large magnitude benefit of endovascular treatment in subjects randomized in all the three trials. The possibility that benefits of a smaller magnitude exist in certain patient populations cannot be excluded. Large magnitude benefits can be expected with implementation of "parameter optimized endovascular treatment" in patients with ischemic stroke who are candidates for IV thrombolytics.

The ADO index as a predictor of two-year mortality in general practice-based chronic obstructive pulmonary disease cohorts.

BACKGROUND Existing prediction models for mortality in chronic obstructive pulmonary disease (COPD) patients have not yet been validated in primary care, which is where the majority of patients receive care. OBJECTIVES Our aim was to validate the ADO (age, dyspnoea, airflow obstruction) index as a predictor of 2-year mortality in 2 general practice-based COPD cohorts. METHODS Six hundred and forty-six patients with COPD with GOLD (Global Initiative for Chronic Obstructive Lung Disease) stages I-IV were enrolled by their general practitioners and followed for 2 years. The ADO regression equation was used to predict a 2-year risk of all-cause mortality in each patient and this risk was compared with the observed 2-year mortality. Discrimination and calibration were assessed as well as the strength of association between the 15-point ADO score and the observed 2-year all-cause mortality. RESULTS Fifty-two (8.1%) patients died during the 2-year follow-up period. Discrimination with the ADO index was excellent with an area under the curve of 0.78 [95% confidence interval (CI) 0.71-0.84]. Overall, the predicted and observed risks matched well and visual inspection revealed no important differences between them across 10 risk classes (p = 0.68). The odds ratio for death per point increase according to the ADO index was 1.50 (95% CI 1.31-1.71). CONCLUSIONS The ADO index showed excellent prediction properties in an out-of-population validation carried out in COPD patients from primary care settings.

Outcome of aplastic anaemia in children. A study by the severe aplastic anaemia and paediatric disease working parties of the European group blood and bone marrow transplant.

This study analysed the outcome of 563 Aplastic Anaemia (AA) children aged 0-12 years reported to the Severe Aplastic Anaemia Working Party database of the European Society for Blood and Marrow Transplantation, according to treatment received. Overall survival (OS) after upfront human leucocyte antigen-matched family donor (MFD) haematopoietic stem cell transplantation (HSCT) or immunosuppressive treatment (IST) was 91% vs. 87% (P 0·18). Event-free survival (EFS) after upfront MFD HSCT or IST was 87% vs. 33% (P 0·001). Ninety-one of 167 patients (55%) failed front-line IST and underwent rescue HSCT. The OS of this rescue group was 83% compared with 91% for upfront MFD HSCT patients and 97% for those who did not fail IST up-front (P 0·017). Rejection was 2% for MFD HSCT and HSCT post-IST failure (P 0·73). Acute graft-versus-host disease (GVHD) grade II-IV was 8% in MFD graft vs. 25% for HSCT post-IST failure (P < 0·0001). Chronic GVHD was 6% in MFD HSCT vs. 20% in HSCT post-IST failure (P < 0·0001). MFD HSCT is an excellent therapy for children with AA. IST has a high failure rate, but remains a reasonable first-line choice if MFD HSCT is not available because high OS enables access to HSCT, which is a very good rescue option.

Markers of endothelial cell activation and immune activation are increased in patients with severe leptospirosis and associated with disease severity

OBJECTIVES Previous studies concluded that haemorrhage is one of the most accurate prognostic factors of mortality in leptospirosis. Therefore, endothelial cell activation was investigated in relation to disease severity in severe leptospirosis. METHODS Prospective cohort study of severe leptospirosis patients. Plasma levels of sE-selectin and Von Willebrand factor (VWF) were determined. Consequently, an in vitro endothelial cell model was used to assess endothelial activation after exposure to virulent Leptospira. Finally, immune activation, as a potential contributing factor to endothelial cell activation, was determined by soluble IL2-receptor (sIL-2r) and soluble Fas-ligand (sFasL) levels. RESULTS Plasma levels of sE-selectin and VWF strongly increased in patients compared to healthy controls. Furthermore, sE-selectin was significantly elevated (203 ng/ml vs. 157 ng/ml, p < 0.05) in survivors compared to non-survivors. Endothelial cells exposed to virulent Leptospira showed increased VWF expression. E-selectin and ICAM-1 expression did not change. Immunohistochemistry revealed the presence of intracellular Leptospira and qPCR suggested replication. In vivo analysis showed that increased levels of sFasL and sIL-2r were both strongly associated with mortality. Furthermore sIL-2r levels were increased in patients that developed bleeding and significantly correlated to duration of hospital stay. DISCUSSION Markers of endothelial activation and immune activation were associated with disease severity in leptospirosis patients.

Non-self-adjoint graphs

On finite metric graphs we consider Laplace operators, subject to various classes of non-self-adjoint boundary conditions imposed at graph vertices. We investigate spectral properties, existence of a Riesz basis of projectors and similarity transforms to self-adjoint Laplacians. Among other things, we describe a simple way to relate the similarity transforms between Laplacians on certain graphs with elementary similarity transforms between matrices defining the boundary conditions.

Characteristics of Consecutive Esophageal Motility Diagnoses After a Decade of Change

BACKGROUND AND AIMS Combined multichannel intraluminal impedance and esophageal manometry (MII-EM) measures concomitantly bolus transit and pressure changes allowing determination of the functional impact of esophageal motility abnormalities. Ten years ago our laboratory reported MII-EM results in 350 consecutive patients. Since then high-resolution impedance manometry (HRIM) became available and the definitions of ineffective esophageal motility (IEM) and nutcracker esophagus were revised. The aim of this study was to assess the impact of these developments on esophageal function testing. METHODS From August 2012 through May 2013, HRIM was performed in 350 patients referred for esophageal function testing. Each patient received 10 liquid and 10 viscous swallows. While taking advantage of the new technology and revised criteria, HRIM findings were classified according to the conventional criteria to allow more appropriate comparison with our earlier analysis. RESULTS Compared with the study performed 10 years ago, the prevalence of normal manometry (36% vs. 35%), achalasia (7% vs. 8%), scleroderma (1% vs. 1%), hypertensive lower esophageal sphincter (LES) (7% vs. 7%), and hypotensive LES (1% vs. 2%) remained the same, whereas the prevalence of distal esophageal spasm (9% vs. 3%), nutcracker esophagus (9% vs. 3%), and poorly relaxing LES (10% vs. 3%) decreased and the prevalence of IEM increased (20% vs. 31%) significantly. Compared with the early study, normal liquid bolus transit was significantly different in patients with hypertensive LES (96% vs. 57%) and poorly relaxing LES (55% vs. 100%). CONCLUSIONS This study brings to light the increase in prevalence of IEM. In addition, it suggests that the hypertensive LES and poorly relaxing LES may each affect bolus transit in about half of these patients.

Comparison of hand hygiene evaluations: A literature review

Background. Because our hands are the most common mode of transmission for bacteria causing hospital acquired infections, hand hygiene practices are the most effective method of preventing the spread of these pathogens, limiting the occurrence of healthcare-associated infections and reducing transmission of multi-drug resistant organisms. Yet, compliance rates are below 40% on the average. ^ Objective. This culminating experience project is primarily a literature review on hand hygiene to help determine the barriers to hand hygiene compliance and offer solutions on improving these rates and to build on a hand hygiene evaluation performed during my infection control internship completed at Memorial Hermann Hospital during the fall semester of 2005. ^ Method. A review of peer-reviewed literature using Ovid Medline, Ebsco Medline and PubMed databases using keywords: hand hygiene, hand hygiene compliance, alcohol based handrub, healthcare-associated infections, hospital-acquired infections, and infection control. ^ Results. A total of eight hand hygiene studies are highlighted. At a children's hospital in Seattle, hand hygiene compliance rates increases from 62% to 81% after five periods of interventions. In Thailand, 26 nurses dramatically increased compliance from 6.3% to 81.2% after just 7 months of training. Automated alcohol based handrub dispensers improved compliance rates in Chicago from 36.3% to 70.1%. Using education and increased distribution of alcohol based handrubs increased hand hygiene rates from 59% to 79% for Ebnother, from 54% to 85% for Hussein and from 32% to 63% for Randle. Spartanburg Regional Medical Center increased their rates from 72.5% to 90.3%. A level III NICU achieved 100% compliance after a month long educational campaign but fell back down to its baseline rate of 89% after 3 months. ^ Discussion. The interventions used to promote hand hygiene in the highlighted studies varied from low tech approaches such as printed materials to advanced electronic gadgets that alerted individuals automatically to perform hand hygiene. All approaches were effective and increased compliance rates. Overcoming hand hygiene barriers, receiving and accepting feedback is the key to maintaining consistently high hand hygiene adherence. ^

Modern and fossil corals from Palmyra and Christmas islands

The relationship between decadal to centennial changes in ocean circulation and climate is difficult to discern using the sparse and discontinuous instrumental record of climate and, as such, represents a large uncertainty in coupled ocean-atmosphere general circulation models. We present new modern and fossil coral radiocarbon (D14C) records from Palmyra (6°N, 162°W) and Christmas (2°N, 157°W) islands to constrain central tropical Pacific ocean circulation changes during the last millennium. Seasonally to annually resolved coral D14C measurements from the 10th, 12th-17th, and 20th centuries do not contain significant interannual to decadal-scale variations, despite large changes in coral d18O on these timescales. A centennial-scale increase in coral radiocarbon from the Medieval Climate Anomaly (~900-1200 AD) to the Little Ice Age (~1500-1800) can be largely explained by changes in the atmospheric D14C, as determined with a box model of Palmyra mixed layer D14C. However, large 12th century depletions in Palmyra coral D14C may reflect as much as a 100% increase in upwelling rates and/or a significant decrease in the D14C of higher-latitude source waters reaching the equatorial Pacific during this time. SEM photos reveal evidence for minor dissolution and addition of secondary aragonite in the fossil corals, but our results suggest that coral D14C is only compromised after moderate to severe diagenesis for these relatively young fossil corals.

Distribution, genesis and age of the Schlagwasser breccia (Warstein anticline, Rhenish massif)

The name "Schlagwasser breccia" is a synopsis of several debris flows in the Warstein area, which can be derived from the Warstein carbonate platform and the Scharfenberg reef. Though only locally developed, the breccia is important for the understanding of paleogeography and sedimentology in the Eastern Sauerland. Considering this breccia some gravitational-resedimentary slide movements between a high, consisting of reef carbonates, and a basin with flinz beds can be pointed out. From the uppermost Middle Devonian to the lowermost Lower Carboniferous several slides yielded the sedimentary components building up the 30 to 50 m thick polymict breccia. Some breccias were redeposited repeatedly as can be verified by different conodont maxima in single samples. Supplying area was the western part of the Warstein high, from which the slide masses glided off to the East and Southeast, more seldom to the West and Westsouthwest. All conodont zones from the upper Middle Devonian up to the lowermost Carboniferous could be identified in the Schlagwasser breccia. Therefore, an uninterrupted continuous sedimentation must have been prevalent in the supplying area; today this area nearly is denuded of flinz beds and cephalopod limestones. The slide masses spread transgressively to the East up to a substratum consisting of different units as massive limestone, flinz beds and cephalopod limestone; they are overlapped by Hangenberg beds, alum schists and siliceous rocks of the Lower Carboniferous. Parts of the substratum were transported during the progress of the slide masses. Proximal and distal parts of the flow masses can be distinguished by the diameter of the pebbles. Graded bedding and banking structures are marked only rarely. Way of transport was up to 3 km. Differently aged slide masses do not always overlap, but are placed side by side, too. Usually the slide masses do not spread out upon a greater area during sedimentation, but form closely limited debris flows. Synsedimentary fracturing and tilting of the reef platform, epirogenetic movements and seaquakes caused the slides. The entire formation period of the breccia includes about 20 millions of years. The longevity of the events points to solid paleomorphological situations around the eastern margin of the carbonate platform.

Selected Devonian/Carboniferous boundary profiles in the Sauerland area (Rhenish massif)

Selected sections, containing Devonian/Carboniferous boundary beds, are described from the northern and northeastern margin of the Rhenish massif, especially from the Seiler region near Iserlohn and the Warstein area. These sections are from prospecting trenches, quarries and road cuts. The dominantly carbonate sequences were investigated in regard to the development of conodonts. The Devonian/Carboniferous boundary could be placed precisely in both areas by means of the phylogenetic transition from Siphonodella praesulcata to S. sulcata. Compared investigations lead to the following conclusions: - The basal part of the Hangenberg limestone is heterochronous. - The Devonian/Carboniferous boundary lies distinctly below the Hangenberg limestone, i. e. at the same stratigraphical level as the Stockum limestone. - The Imitoceras limestone lens of Stockum and the Stockum limestone represent a special facies within the Hangenberg schists. 80th belong either to the praesulcata- and sulcata-zone or are restricted only to the sulcata-zone. - Protognathodus kuehni appears together with Siphonodella sulcata. Where S. sulcata is lacking, P. kuehni may be considered as a valid index conodont indicating the beginning of the Carboniferous. - The upper part of the Wocklum beds, following above the Wocklum limestone, usually consists up to the lower Carbonilerous boundary in a more or less consistent facies, that of the Hangenberg schists. Only in the section 01 the northeastern wall of the eastern Provincial Quarry at Drewer and in the road profile Rüthen - Nuttlar, the Devonian/Carboniferous boundary is to be placed in a continuous carbonate sequence. - The eastern Provincial Quarry at Drewer is therefore proposed as a new candidate section for the Devonian/Carboniferous boundary stratotype. - In many places the carbonates at the Devonian / Carboniferous boundary and the Hangenberg limestone are characterized by an impoverished conodont fauna. - Using platform conodonts, biofacies models are developed, permitting to conclude on the position of the respective setting 01 sedimentation area, either close to a rise or a basin.

Neptunian dikes and their fillings in carbonates of the Warstein area (northeastern Rhenish massif)

Neptunian dikes and cavities as weil as their fillings are described from Middle to Upper Devonian carbonates of the Warstein area. The genesis of the pre-Upper Carboniferous dikes is due to pre-orogenic synsedimentary tensional movements. Lifting, subsidence and tilting caused joints and cracks, which are enlarged to dikes and cavities on submarine conditions. The post-Upper Carboniferous dikes are based on the orogenesis during Upper Carboniferous time, causing numerous tectonical divisional planes in the sediments. Along these planes a far-reaching karstification took place since mesozoic time. According to their size the cavities are subdivided into macro-, mega- and microdikes. With the exception of one macrodike all the others are limited to the massive limestone. Megadikes especially occur in Upper Devonian cephalopod limestone and in the Erdbach limestone, microdikes can be found in all carbonatic rocks. The dikes follow pre-orogenic, tectonical and sedimentary divisional planes and are orientated to ac-, bc- as well as bedding planes and diagonal directions. The fillings happened down from above either in a solitary event or repeatedly in long-lived dikes during a span of several ten millions of years. More seldom the fillings took place laterally or upside from beneath. The dikes contain - without regard to autochthonous conodont faunas - older and/or younger mixed faunas, too. Occasionally they were used as life district by a trilobite fauna adapted to the dikes. The dikes represent sedimentary pitfalls and conserve sediments eroded in other places. Therefore, by aid of the fillings, it can be demonstrated, that stratigraphic gaps are not absolutely due to primary interruptions of sedimentation, but were caused by reworking. Some dikes contain the distal offsets of slides and suspension streams. Relations between condensation and development of dikes could not be derived in the Warstein area. However, an increase of the frequency of dikes towards east to the eastern margin of the Warstein carbonate platform could be pointed out. This margin is a slope, persisting more than 10 millions of years, between a block and a basin. Evidently cracks and dikes, which were caused by settlements, slides and earth quakes, occured there frequently. The Warstein dikes and cavities, caused by karstification, are filled with terrestrial Lower Cretaceous, marine Upper Cretaceous and terrestrial Pleistocene to Holocene sediments. Tertiary sediments could not be detected.

Nanoinformatics: developing new computing applications for nanomedicine

Nanoinformatics has recently emerged to address the need of computing applications at the nano level. In this regard, the authors have participated in various initiatives to identify its concepts, foundations and challenges. While nanomaterials open up the possibility for developing new devices in many industrial and scientific areas, they also offer breakthrough perspectives for the prevention, diagnosis and treatment of diseases. In this paper, we analyze the different aspects of nanoinformatics and suggest five research topics to help catalyze new research and development in the area, particularly focused on nanomedicine. We also encompass the use of informatics to further the biological and clinical applications of basic research in nanoscience and nanotechnology, and the related concept of an extended ?nanotype? to coalesce information related to nanoparticles. We suggest how nanoinformatics could accelerate developments in nanomedicine, similarly to what happened with the Human Genome and other -omics projects, on issues like exchanging modeling and simulation methods and tools, linking toxicity information to clinical and personal databases or developing new approaches for scientific ontologies, among many others.