Outcome of intravenous thrombolysis in stroke patients weighing over 100 kg.

Background: Intravenous thrombolysis with alteplase for ischemic stroke is fixed at a maximal dose of 90 mg for safety reasons. Little is known about the clinical outcomes of stroke patients weighing >100 kg, who may benefit less from thrombolysis due to this dose limitation. Methods: Prospective data on 1,479 consecutive stroke patients treated with intravenous alteplase in six Swiss stroke units were analyzed. Presenting characteristics and the frequency of favorable outcomes, defined as a modified Rankin scale (mRS) score of 0 or 1, a good outcome (mRS score 0-2), mortality and symptomatic intracranial hemorrhage (SICH) were compared between patients weighing >100 kg and those weighing ≤100 kg. Results: Compared to their counterparts (n = 1,384, mean body weight 73 kg), patients weighing >100 kg (n = 95, mean body weight 108 kg) were younger (61 vs. 67 years, p < 0.001), were more frequently males (83 vs. 60%, p < 0.001) and more frequently suffered from diabetes mellitus (30 vs. 13%, p < 0.001). As compared with patients weighing ≤100 kg, patients weighing >100 kg had similar rates of favorable outcomes (45 vs. 48%, p = 0.656), good outcomes (58 vs. 64%, p = 0.270) and mortality (17 vs. 12%, p = 0.196), and SICH risk (1 vs. 5%, p = 0.182). After multivariable adjustment, body weight >100 kg was strongly associated with mortality (p = 0.007) and poor outcome (p = 0.007). Conclusion: Our data do not suggest a reduced likehood of favorable outcomes in patients weighing >100 kg treated with the current dose regimen. The association of body weight >100 kg with mortality and poor outcome, however, demands further large-scale studies to replicate our findings and to explore the underlying mechanisms.

Statin treatment is associated with improved prognosis in patients with AF-related stroke.

BACKGROUND/OBJECTIVES: The most recent ACC/AHA guidelines recommend high-intensity statin therapy in ischemic stroke patients of presumably atherosclerotic origin. On the contrary, there is no specific recommendation for the use of statin in patients with non-atherosclerotic stroke, e.g. strokes related to atrial fibrillation (AF). We investigated whether statin treatment in patients with AF-related stroke is associated with improved survival and reduced risk for stroke recurrence and future cardiovascular events. METHODS: All consecutive patients registered in the Athens Stroke Registry with AF-related stroke and no history of coronary artery disease nor clinically manifest peripheral artery disease were included in the analysis and categorized in two groups depending on whether statin was prescribed at discharge. The primary outcome was overall mortality; the secondary outcomes were stroke recurrence and a composite cardiovascular endpoint comprising of recurrent stroke, myocardial infarction, aortic aneurysm rupture or sudden cardiac death during the 5-year follow-up. RESULTS: Among 1602 stroke patients, 404 (25.2%) with AF-related stroke were included in the analysis, of whom 102 (25.2%) were discharged on statin. On multivariate Cox-proportional-hazards model, statin treatment was independently associated with a lower mortality (hazard-ratio (HR): 0.49, 95%CI:0.26-0.92) and lower risk for the composite cardiovascular endpoint during the median 22months follow-up (HR: 0.44, 95%CI:0.22-0.88), but not with stroke recurrence (HR: 0.47, 95%CI:0.22-1.01, p: 0.053). CONCLUSIONS: In this long-term registry of patients with AF-related stroke, statin treatment was associated with improved survival and reduced risk for future cardiovascular events.

The diagnostic challenge of progressive pseudorheumatoid dysplasia (PPRD): A review of clinical features, radiographic features, and WISP3 mutations in 63 affected individuals.

Progressive pseudorheumatoid dysplasia (PPRD) is a genetic, non-inflammatory arthropathy caused by recessive loss of function mutations in WISP3 (Wnt1-inducible signaling pathway protein 3; MIM 603400), encoding for a signaling protein. The disease is clinically silent at birth and in infancy. It manifests between the age of 3 and 6 years with joint pain and progressive joint stiffness. Affected children are referred to pediatric rheumatologists and orthopedic surgeons; however, signs of inflammation are absent and anti-inflammatory treatment is of little help. Bony enlargement at the interphalangeal joints progresses leading to camptodactyly. Spine involvement develops in late childhood and adolescence leading to short trunk with thoracolumbar kyphosis. Adult height is usually below the 3rd percentile. Radiographic signs are relatively mild. Platyspondyly develops in late childhood and can be the first clue to the diagnosis. Enlargement of the phalangeal metaphyses develops subtly and is usually recognizable by 10 years. The femoral heads are large and the acetabulum forms a distinct "lip" overriding the femoral head. There is a progressive narrowing of all articular spaces as articular cartilage is lost. Medical management of PPRD remains symptomatic and relies on pain medication. Hip joint replacement surgery in early adulthood is effective in reducing pain and maintaining mobility and can be recommended. Subsequent knee joint replacement is a further option. Mutation analysis of WISP3 allowed the confirmation of the diagnosis in 63 out of 64 typical cases in our series. Intronic mutations in WISP3 leading to splicing aberrations can be detected only in cDNA from fibroblasts and therefore a skin biopsy is indicated when genomic analysis fails to reveal mutations in individuals with otherwise typical signs and symptoms. In spite of the first symptoms appearing in early childhood, the diagnosis of PPRD is most often made only in the second decade and affected children often receive unnecessary anti-inflammatory and immunosuppressive treatments. Increasing awareness of PPRD appears to be essential to allow for a timely diagnosis. © 2012 Wiley Periodicals, Inc.

Percutaneous coronary interventions prior to coronary artery bypass surgery.

BACKGROUND AND AIM OF THE STUDY: Percutaneous coronary interventions (PCI) are frequently performed before coronary artery bypass graft (CABG) surgery. This study sought to evaluate postoperative outcomes, and incidence of recurrent target ischemia in vessels with prior PCI in patients who had PCI prior to CABG compared to only CABG patients. METHODS: A review included CABG patients operated from 2000 to 2012. PCI prior to CABG patients were compared with patients having had CABG on native coronary arteries. Demographic and risk factors, including hospital morbidity, mortality, and recurrent target vessel ischemia at follow-up (FU), were compared. Major end-points were statistical differences of postoperative morbidity and reintervention rates due to symptomatic graft failure or target vessel ischemia during FU. RESULTS: Twenty-four percent of 1669 isolated CABG patients had PCI prior to CABG, with an increasing percentage during recent years. Demographics, risk factors, comorbidities and mortality rates were similar. Incidence of postoperative hemorrhage (OR 1.9; 95% CI 1.1-3.2; p = 0.02), perioperative myocardial infarction rate (p = 0.02), neurological deficits (OR 3.5; 95% CI 1.2-9.7; p = 0.02) and re-intervention rate for symptomatic graft or target vessel occlusion were higher in pretreated patients (OR 1.8; 95% CI 1.1-3.0; p = 0.01). CONCLUSIONS: PCI prior to CABG increases the risk for postoperative morbidity. Increased postoperative hemorrhage could be attributed to ongoing double anti-platelet therapy. doi: 10.1111/jocs.12514 (J Card Surg 2015;30:313-318).

Intracranial Aneurysm Rupture Is Predicted by Measures of Solar Activity.

OBJECTIVE: The cause precipitating intracranial aneurysm rupture remains unknown in many cases. It has been observed that aneurysm ruptures are clustered in time, but the trigger mechanism remains obscure. Because solar activity has been associated with cardiovascular mortality and morbidity, we decided to study its association to aneurysm rupture in the Swiss population. METHODS: Patient data were extracted from the Swiss SOS database, at time of analysis covering 918 consecutive patients with angiography-proven aneurysmal subarachnoid hemorrhage treated at 7 Swiss neurovascular centers between January 1, 2009, and December 31, 2011. The daily rupture frequency (RF) was correlated to the absolute amount and the change in various parameters of interest representing continuous measurements of solar activity (radioflux [F10.7 index], solar proton flux, solar flare occurrence, planetary K-index/planetary A-index, Space Environment Services Center [SESC] sunspot number and sunspot area) using Poisson regression analysis. RESULTS: During the period of interest, there were 517 days without recorded aneurysm rupture. There were 398, 139, 27, 12, 1, and 1 days with 1, 2, 3, 4, 5, and 6 ruptures per day. Poisson regression analysis demonstrated a significant correlation of F10.7 index and RF (incidence rate ratio [IRR] = 1.006303; standard error (SE) 0.0013201; 95% confidence interval (CI) 1.003719-1.008894; P < 0.001), according to which every 1-unit increase of the F10.7 index increased the count for an aneurysm to rupture by 0.63%. A likewise statistically significant relationship of both the SESC sunspot number (IRR 1.003413; SE 0.0007913; 95% CI 1.001864-1.004965; P < 0.001) and the sunspot area (IRR 1.000419; SE 0.0000866; 95% CI 1.000249-1.000589; P < 0.001) emerged. All other variables analyzed showed no significant correlation with RF. CONCLUSIONS: We found greater radioflux, SESC sunspot number, and sunspot area to be associated with an increased count of aneurysm rupture. The clinical meaningfulness of this statistical association must be interpreted carefully and future studies are warranted to rule out a type-1 error.

Strokes in the anterior circulation: comparison between bridging and intravenous thrombolysis.

BACKGROUND AND PURPOSE: To compare safety and efficacy of bridging approach with intravenous (IV) thrombolysis in patients with acute anterior strokes and proximal occlusions. PATIENTS AND METHODS: Consecutive patients with ischemic anterior strokes admitted within a 4 h 30 min window in two different centers were included. The first center performed IV therapy (alteplase 0.6 mg/kg) during 30 min and, in absence of clinical improvement, mechanical thrombectomy with flow restoration using a Solitaire stent (StS); the second carried out IV thrombolysis (alteplase 0.9 mg/kg) alone. Only T, M1 or M2 occlusions present on CT angiography were considered. Endpoints were clinical outcome and mortality at 3 months. RESULTS: There were 63 patients in the bridging and 163 in the IV group. No significant differences regarding baseline characteristics were observed. At 3 months, 46% (n = 29) of the patients treated in the combined and 23% (n = 38) of those treated in the IV group had a modified Rankin scale (mRS) of 0-1 (P < 0.001). A statistical significant difference was observed for all sites of occlusion. In a logistic regression model, National Institute of Health Stroke Scale (NIHSS) and bridging therapy were independent predictors of good outcome (respectively, P = 0.001 and P = 0.0018). Symptomatic hemorrhage was documented in 6.3% vs 3.7% in the bridging and in the IV group, respectively (P = 0.32). There was no difference in mortality. CONCLUSIONS: Our results suggest that patients treated with a bridging approach were more likely to have minimal or no deficit at all at 3 months as compared to the IV treated group.

Place actuelle de la papillotomie chirurgicale transduodénale [Current status of surgical transduodenal papillotomy].

The treatment of biliary lithiasis has changed during the past 20 years. Cholecystectomy remains the gold standard for cholelithiasis, but many options are available for calculi of the common bile duct. Among them are surgical open or laparoscopic choledochotomy, biliary-enteric anastomosis, transduodenal sphincterotomy (TDS), endoscopic sphincterotomy. With the aim to describe the current place of TDS, we reviewed the patients operated on in our department between 1976 and 1992. We found 78 patients with a mean age of 58 years (26-89 years). 34 (43%) of them had acute cholecystitis, with 26 being operated on urgently. 47 (60%) were jaundiced, 15 (19%) had pancreatitis and 12 (15%) had cholangitis before operation. Indications for TDS have been impacted stone or absence of progression of the contrast medium on intraoperative cholangiography in 71 patients (91%). 3 patients died (1 pulmonary embolism, 1 sepsis of pulmonary origin, 1 MOF syndrome complicating preoperative necrotizing pancreatitis). 30 patients (38%) had complications, of which 20 were directly related to TDS. Hemorrhage occurred in 4 cases, and resolved spontaneously without transfusion. Hyperamylasemia occurred in 17 instances, but clinical pancreatitis developed in only 1 case, with complete resolution. 1 duodenal fistula healed after conservative therapy. No death is attributable directly to TDS. Today, the importance of endoscopic sphincterotomy is increasing. This retrospective study shows that TDS, if performed with caution, does not increase the operative risks even in emergent operations. During surgical exploration of the common bile duct, TDS is indicated to remove an impacted stone, or as a bilio-enteric anastomosis if multiple stones are present with a thin common duct.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardioinhibitory reflex due to a karate kick: a case report.

This article describes the case of a 17-year-old adolescent boy who received a foot kick in the trunk area from an expert in karate. He presented with immediate cardiocirculatory arrest. After a prolonged resuscitation, he was transferred to a hospital where he died 5 days later without ever regaining consciousness. Postmortem investigations including autopsy, radiology, histology, toxicology, and postmortem chemistry were performed that showed signs of multiple organ failure, an acute hemorrhage in the region of the celiac plexus, and signs of medical resuscitation. No preexisting disease, particularly those concerning the heart, was objectified. The cause of death was attributed to multiple organ failure after a prolonged cardiocirculatory arrest. Concerning the origin of the cardiac arrest, 2 hypotheses were considered-a cardioinhibitory reflex and a cardiac contusion (commotio cordis). Because of the presence of traumatic lesions in the celiac plexus, the first hypothesis was finally submitted. This case is reported because rare cases of sudden death from celiac reflex are described in the literature where it is almost impossible to find references with accurate documentation. The presented case confirms the importance of detailed documentation of the circumstances and postmortem investigations to establish a diagnosis of death due to cardioinhibitory reflex.

Rainaominaisuuksien hallinta paperikoneen tuotantokapasiteetin nostossa

Työssä selvitettiin perälaatikon muuttujien kuten huuliraon, huulisuihkun osumakohdan rintapöydälle, ohivirtauksen ja sivuvirtausten määrän sekä suihkusuhteen vaikutus formaatio-, neliömassa- ja kuituorientaatioprofiileihin. Analysoitiin huulisuureiden muutosten vaikutus rainanmuodostuksessa. Formaatiotasoa seurattiin koneella olevan vianilmaisinjärjestelmän mittauksen avulla ja kuituorientaatiota paperin poikkiratanäytteistä tehdyistä laboratoriomittauksista. Vianilmaisinjärjestelmän formaatiomittaus todettiin toimivaksi tarvittavan versiopäivityksen jälkeen. Selvitettiin huulisuureiden säädettävyyden ikkuna ja mahdolliset kehityskohteet. Kehitettäessä optimiprofiilien ajomallia raskaammille neliömassoille havaitsimme investointitarpeet kuten jäykempi huulilista perälaatikolle, määrämittaukset sivuvirtauksille ja tarvittavat parannukset kosteusprofiilin säätöön.

Thrombin-receptor antagonist vorapaxar in acute coronary syndromes

Background: Vorapaxar is a new oral protease-activated-receptor 1 (PAR-1) antagonist that inhibits thrombin-induced platelet activation. Methods: In this multinational, double-blind, randomized trial, we compared vorapaxar with placebo in 12,944 patients who had acute coronary syndromes without ST-segment elevation. The primary end point was a composite of death from cardiovascular causes, myocardial infarction, stroke, recurrent ischemia with rehospitalization, or urgent coronary revascularization. RESULTS: Follow-up in the trial was terminated early after a safety review. After a median follow-up of 502 days (interquartile range, 349 to 667), the primary end point occurred in 1031 of 6473 patients receiving vorapaxar versus 1102 of 6471 patients receiving placebo (Kaplan-Meier 2-year rate, 18.5% vs. 19.9%; hazard ratio, 0.92; 95% confidence interval [CI], 0.85 to 1.01; P = 0.07). A composite of death from cardiovascular causes, myocardial infarction, or stroke occurred in 822 patients in the vorapaxar group versus 910 in the placebo group (14.7% and 16.4%, respectively; hazard ratio, 0.89; 95% CI, 0.81 to 0.98; P = 0.02). Rates of moderate and severe bleeding were 7.2% in the vorapaxar group and 5.2% in the placebo group (hazard ratio, 1.35; 95% CI, 1.16 to 1.58; P<0.001). Intracranial hemorrhage rates were 1.1% and 0.2%, respectively (hazard ratio, 3.39; 95% CI, 1.78 to 6.45; P<0.001). Rates of nonhemorrhagic adverse events were similar in the two groups. Conclusions: In patients with acute coronary syndromes, the addition of vorapaxar to standard therapy did not significantly reduce the primary composite end point but significantly increased the risk of major bleeding, including intracranial hemorrhage. (Funded by Merck; TRACER ClinicalTrials.gov number, NCT00527943.)

The potential of 3T high-resolution magnetic resonance imaging for diagnosis, staging, and follow-up of retinoblastoma.

We demonstrate the value of high-resolution magnetic resonance imaging (MRI) in diagnosing, staging, and follow-up of retinoblastoma during eye-saving treatment. We have included informative retinoblastoma cases scanned on a 3T MRI system from a retrospective retinoblastoma cohort from 2009 through 2013. We show that high-resolution MRI has the potential to detect small intraocular seeds, hemorrhage, and metastatic risk factors not visible with fundoscopy (e.g., optic nerve invasion and choroidal invasion), and treatment response. Unfortunately, however, the diagnostic accuracy of high-resolution MRI is not perfect, especially for subtle intraocular seeds or minimal postlaminar optic nerve invasion. The most important application of MRI is the detection of metastatic risk factors, as these cannot be found by fundoscopy and ultrasound.

Complications liées aux piercings [Complications of body piercing].

Au sein de la population générale, de plus en plus de personnes arborent des piercings, en particulier parmi les jeunes adultes. Hormis les réactions inflammatoires et les infections locales, les complications liées à ces piercings sont méconnues. Les personnes ne sont en général pas informées des risques avant de réaliser un piercing et leurs antécédents, traitements médicamenteux ou comorbidités éventuelles, sont largement négligés par les personnes qui réalisent le geste. Les complications sont le plus souvent locales et bénignes, mais des complications sérieuses et parfois mortelles ont été décrites dans la littérature. Cet article propose une revue des problématiques possibles auxquelles pourrait être confronté un médecin de premier recours, face à un patient qui souhaiterait réaliser un piercing ou présenterait des complications suite à la mise en place d'un tel dispositif. The trend of body piercing has grown in popularity in the past decade within the general population and especially among young adults. Complications of body piercing include local inflammation and infections, but severe complications are also possible and largely underestimated. People are usually not aware of the risks before making a piercing, and their medical history, medication and comorbidities are largely neglected by the people who realise the piercing. This article presents a review of the complications that a primary care physician may observe, for a patient who wishes to make a piercing, or presents complications due to the implementation of such a device.

Médecine d'urgence [Emergency medicine: updates 2013].

New evidences published this year are susceptible to change the management of several medical emergencies. Combined antiplatelet therapy might be beneficial for the management of TIA or minor stroke and rapid blood pressure lowering might improve the outcome in patients with intracerebral hemorrhage. A restrictive red cell transfusion strategy is indicated in case of upper digestive bleeding and coagulation factors concentrates are superior to fresh frozen plasma for urgent warfarin reversal. Prolonged systemic steroid therapy is not warranted in case of acute exacerbation of BPCO, and iterative physiotherapy is not beneficial after acute whiplash. Finally, family presence during cardiopulmonary resuscitation may reduce post-traumatic stress disorder among relatives.

Surgery for unruptured arteriovenous malformations of the brain is better than conservative management for selected cases : a prospective cohort study

Object. The aim of this study was to identify patients who are likely to benefit from surgery for unruptured brain arterriovenous malformations (ubAVMs). Methods. The authors' database was interrogated for the risk and outcome of hemorrhage after referral and the out- come from surgery. Furthermore, the outcome from surgery incorporated those cases excluded from surgery because of perceived greater risk (sensitivity analysis). Finally, a comparison was made for the authors' patients between the natural history and surgery. Data were collected for 427 consecutively enrolled patients with ubAVMs in a database that in- cluded patients who were conservatively managed. Kaplan-Meier analysis was performed on patients observed for more than 1 day to determine the risk of hemorrhage. Variables that may influence the risk of first hemorrhage were assessed using Cox proportional hazard regression models and Kaplan-Meier life table analyses from referral until the first occur- rence of the following: hemorrhage, treatment, or last review. The outcome from surgery (leading to a new permanent neurological deficit with last review modified Rankin Scale [mRS] score > 1) was determined. Further sensitivity analy- sis was made to predict risk from surgery for the total ubAVM cohort by incorporating outcomes of surgical cases as well as cases excluded from surgery because of perceived risk, and assuming an adverse outcome for these excluded cases. Results. A total of 377 patients with a ubAVM were included in the analysis of the risk of hemorrhage. The 5-year risk of hemorrhage for ubAVM was 11.5%. Hemorrhage resulted in an mRS score > 1 in 14 cases (88% [95% CI 63%-98%]). Patients with Spetzler-Ponce Class A ubAVMs treated by surgery (n = 190) had a risk from surgery of 1.6% (95% CI 0.3%-4.8%) for a permanent neurological deficit leading to an mRS score > 1 and 0.5% (95% CI< 0.1%-3.2%) for a permanent neurological deficit leading to an mRS score > 2. Patients with Spetzler-Ponce Class B ubAVMs treated by surgery (n = 107) had a risk from surgery of 14.0% (95% CI 8.6%-22.0%) for a permanent neurological deficit leading to an mRS score > 1. Sensitivity analysis of Spetzler-Ponce Class B ubAVMs, including those in patients excluded from surgery, showed that the true risk for surgically eligible patients may have been as high as 15.6% (95% CI 9.9%-23.7%) for mRS score > 1, had all patients who were perceived to have a greater risk experienced an adverse outcome. Patients with Spetzler-Ponce Class C ubAVMs treated by surgery (n = 44) had a risk from surgery of 38.6% (95% CI 25.7%-53.4%) for a permanent neurological deficit leading to an mRS score >1. Sensitivity analysis of Class C ubAVMs, including those harbored by patients excluded from surgery, showed that the true risk for surgically eligible patients may have been as high as 60.9% (95% CI 49.2%-71.5%) for mRS score > 1, had all patients who were perceived to have a greater risk experienced an adverse outcome. Conclusion. Surgical outcomes for Spetzler-Ponce Class ubAVMs are better than those for conservative management.

Methods of Jet to Wire Speed Ratio Determination and Its Effect in Paper and Board Manufacture

Suihku/viira-nopeussuhde on perälaatikon huulisuihkun ja viiran välinen nopeusero. Se vaikuttaa suuresti paperin ja kartongin loppuominaisuuksiin, kuten formaatioon sekä kuituorientaatioon ja näin ollen paperin lujuusominaisuuksiin. Tämän johdosta on erityisen tärkeää tietää todellinen suihku/viira-nopeussuhde paperin- ja kartonginvalmistuksessa. Perinteinen suihku/viira-nopeussuhteen määritysmenetelmä perustuu perälaatikon kokonaispaineeseen. Tällä menetelmällä kuitenkin todellinen huulisuihkun nopeus saattaa usein jäädä tietämättä johtuen mahdollisesta virheellisestä painemittarin kalibroinnista sekä laskuyhtälön epätarkkuuksista. Tämän johdosta on kehitetty useita reaaliaikaisia huulisuihkun mittausmenetelmiä. Perälaatikon parametrien optimaaliset asetukset ovat mahdollista määrittää ja ylläpitää huulisuihkun nopeuden “on-line” määrityksellä. Perälaatikon parametrejä ovat mm. huulisuihku, huuliaukon korkeusprofiili, reunavirtaukset ja syöttövirtauksen tasaisuus. Huulisuihkun nopeuden on-line mittauksella paljastuu myös muita perälaatikon ongelmakohtia, kuten mekaaniset viat, joita on perinteisesti tutkittu aikaa vievillä paperin ja kartongin lopputuoteanalyyseillä.