Background and purpose
We analyzed the incidence and causes of oral anticoagulant (OAC) cessation and subsequent stroke after OAC withdrawal in a cohort of Korean stroke patients with atrial ...fibrillation.
Methods
The Korean Atrial Fibrillation Evaluation Registry in Ischemic Stroke patients (K‐ATTENTION) is a multicenter cohort study, merging stroke registries from 11 tertiary centers in Korea. The number of OAC interruption episodes and the reasons were reviewed from hospital records. Stroke after OAC withdrawal was defined when a patient experienced ischaemic stroke within 31 days after OAC withdrawal. Clinical variables were compared between patients who experienced stroke recurrence during OAC interruption and those who did not experience recurrence.
Results
Among 3213 stroke patients with atrial fibrillation, a total of 329 episodes of OAC interruption were detected in 229 patients after index stroke (mean age 72.9 ± 8.3 years, 113 female patients). The most frequent reason for OAC withdrawal was poor compliance 103 episodes (31.3%) followed by extracranial bleeding 96 episodes (29.2%). Stroke after OAC withdrawal was noted in 13 patients. Mean age, vascular risk factor profile and mean CHA2DS2‐VASc score were not significantly different between patients with and without recurrent stroke.
Conclusions
A considerable number of stroke patients with atrial fibrillation experienced temporary interruption of OAC after index stroke, which was associated with stroke recurrence of 4.0 cases per 100 interruption episodes.
The purpose of this study was to evaluate the clinical usefulness of static and dynamic variables for the prediction of fluid responsiveness in children under general anaesthesia.
Thirty-three ...mechanically ventilated children received 10 ml kg−1 colloid for 10 min while stable during surgery. Arterial pressure, heart rate, central venous pressure (CVP), and pleth variability index (PVI), in addition to variation in systolic pressure, pulse pressure (including Δdown and Δup), respiratory aortic blood flow velocity (ΔVpeak), and inferior vena cava diameter were measured before and after volume expansion. Patients were classified as responders to fluid loading if their stroke volume index (SVI) increased by at least 10%.
There were 15 volume responders and 18 non-responders. Of the variables examined, ΔVpeak (r=0.516, P=0.004) and PVI (r=0.49, P=0.004) before volume expansion were significantly correlated with changes in SVI. The receiver-operating characteristic (ROC) curve analysis showed that PVI and ΔVpeak predicted fluid responsiveness. Areas under the ROC curves of PVI and ΔVpeak were statistically larger than that of CVP (P=0.006 and 0.014, respectively). However, those of other variables were similar to that of CVP.
ΔVpeak and PVI can be used to predict fluid responsiveness in mechanically ventilated children under general anaesthesia. The other static and dynamic variables assessed in this study were not found to predict fluid responsiveness significantly in children.
ClinicalTrials.gov, NCT01364103.
Gastric ultrasound is a valid tool for non-invasive assessment of the nature and volume of gastric contents in adults and children. Perioperative fasting guidelines recommend oral carbohydrates up to ...2 h before elective surgery. We evaluated gastric volume in children using ultrasound before and after drinking carbohydrate fluids before surgery.
Paediatric patients younger than 18 yr old undergoing elective surgery were enrolled. Initial ultrasound assessment of gastric volume was performed after fasting for 8 h. Two hours before surgery, patients were given carbohydrate drinks: 15 ml kg−1 for patients younger than 3 yr old and 10 ml kg−1 for those more than 3 yr old. Before induction of general anaesthesia, the gastric volume was reassessed. Parental satisfaction scores (0+totally satisfied, 10+totally dissatisfied) and complications were recorded.
Of the 86 enrolled patients, 79 completed the study; three refused to ingest the requested volume, and surgery was delayed for more than 2 h in four patients. The mean (sd) of the initial and second ultrasound measurements were 2.09 (0.97) and 1.85 (0.94) cm2, respectively (P+0.01; mean difference 0.24 cm2, 95% confidence interval 0.06–0.43). The median (interquartile range) satisfaction score was 2.4 (0–6). Two instances of postoperative vomiting and one instance of postoperative nausea occurred.
Carbohydrate fluids ingested 2 h before surgery reduced the gastric volume and did not cause serious complications in paediatric patients. Parents were satisfied with the preoperative carbohydrate drink. Children may benefit from drinking carbohydrate fluids up to 2 h before elective surgery.
cris.nih.go.kr (KCT0001546).
Primary cosmic-ray elemental spectra have been measured with the balloon-borne Cosmic Ray Energetics And Mass (CREAM) experiment since 2004. The third CREAM payload (CREAM-III) flew for 29 days ...during the 2007-2008 Antarctic season. Energies of incident particles above 1 TeV are measured with a calorimeter. Individual elements are clearly separated with a charge resolution of ∼0.12 e (in charge units) and ∼0.14 e for protons and helium nuclei, respectively, using two layers of silicon charge detectors. The measured proton and helium energy spectra at the top of the atmosphere are harder than other existing measurements at a few tens of GeV. The relative abundance of protons to helium nuclei is 9.53 0.03 for the range of 1 TeV/n to 63 TeV/n. This ratio is considerably smaller than other measurements at a few tens of GeV/n. The spectra become softer above ∼20 TeV. However, our statistical uncertainties are large at these energies and more data are needed.
Background The GlideScope® intubating device has been reported to provide a comparable or superior laryngoscopic view compared with direct laryngoscopy in adults. This study compared the use of the ...GlideScope® with direct laryngoscopy for the laryngoscopic view and intubation time in children. Methods The laryngoscopic view in 203 children was scored using both the Macintosh laryngoscope and the GlideScope® using Cormack and Lehane (C&L) grades. After scoring each laryngoscopic view with and without BURP, the patients were randomly allocated to two groups. The trachea was intubated using direct laryngoscopy (Group DL, n=100) or the GlideScope® (Group GS, n=103). We compared C&L grades for the two views in the same patient, and also the time to intubate for each group. Results The GlideScope® improved the view without BURP in the patients with C&L grade 2 (16/26, P<0.01) and with C&L grades 3 and 4 (7/11, P<0.05). The view with BURP was also improved by the GlideScope® in C&L grade 2 (4/9, P<0.05) and with C&L grades 3 and 4 (4/5, P=0.059). The mean time for tracheal intubation was 36.0 (17.9) s in the GS group and 23.8 (13.9) s in the DL group (P<0.001). Conclusions In children, the GlideScope® provided a laryngoscopic view equal to or better than that of direct laryngoscopy but required a longer time for intubation.
Abstract
Pronounced changes in the Arctic environment add a new potential driver of anomalous weather patterns in midlatitudes that affect billions of people. Recent studies of these ...Arctic/midlatitude weather linkages, however, state inconsistent conclusions. A source of uncertainty arises from the chaotic nature of the atmosphere. Thermodynamic forcing by a rapidly warming Arctic contributes to weather events through changing surface heat fluxes and large-scale temperature and pressure gradients. But internal shifts in atmospheric dynamics—the variability of the location, strength, and character of the jet stream, blocking, and stratospheric polar vortex (SPV)—obscure the direct causes and effects. It is important to understand these associated processes to differentiate Arctic-forced variability from natural variability. For example in early winter, reduced Barents/Kara Seas sea-ice coverage may reinforce existing atmospheric teleconnections between the North Atlantic/Arctic and central Asia, and affect downstream weather in East Asia. Reduced sea ice in the Chukchi Sea can amplify atmospheric ridging of high pressure near Alaska, influencing downstream weather across North America. In late winter southward displacement of the SPV, coupled to the troposphere, leads to weather extremes in Eurasia and North America. Combined tropical and sea ice conditions can modulate the variability of the SPV. Observational evidence for Arctic/midlatitude weather linkages continues to accumulate, along with understanding of connections with pre-existing climate states. Relative to natural atmospheric variability, sea-ice loss alone has played a secondary role in Arctic/midlatitude weather linkages; the full influence of Arctic amplification remains uncertain.
Summary
Atelectasis occurs in the majority of children undergoing general anaesthesia. Lung ultrasound has shown reliable sensitivity and specificity for diagnosing anaesthesia‐induced atelectasis. ...We assessed the effects of a recruitment manoeuvre on atelectasis using lung ultrasound in infants undergoing general anaesthesia. Forty infants, randomly allocated to either a recruitment manoeuvre group or a control group, received volume‐controlled ventilation with 5 cmH2O positive end‐expiratory pressure. Lung ultrasound examination was performed twice in each patient, the first a minute after starting mechanical ventilation of the lungs and the second at the end of surgery. Patients in the recruitment manoeuvre group received ultrasound‐guided recruitment manoeuvres after each lung ultrasound examination. The incidence of significant anaesthesia‐induced atelectasis at the second lung ultrasound examination was less in the recruitment manoeuvre group compared with the control group (25% vs. 80%; p = 0.001; odds ratio (OR) 0.083; 95% confidence interval (CI): 0.019–0.370). The median (IQR range) lung ultrasound scores for consolidation and B‐lines on the second examination were lower in the recruitment manoeuvre group compared with the control group; 6.0 (3.0–9.3 0.0–14.0) vs. 13.5 (11.0–16.5 8.0–23.0); p < 0.001 and 6.5 (3.0–12.0 0.0–28.0) vs. 15.0 (10.8–20.5 7.0–28.0); p < 0.001, respectively. The lung ultrasound scores for consolidation on the first and second examinations showed a negative correlation with age (r = −0.340, p = 0.008; r = −0.380, p = 0.003). We conclude that ultrasound‐guided recruitment manoeuvres with positive end‐expiratory pressure proved useful in reducing the incidence of anaesthesia‐induced atelectasis in infants, although 5 cmH2O positive end‐expiratory pressure alone was not sufficient to eliminate it. In addition, the younger the patient, the more susceptible they were to atelectasis.
The cause of chronic inflammatory periodontitis, which leads to the destruction of periodontal ligament and alveolar bone, is multifactorial. An increasing number of studies have shown the clinical ...significance of NLRP3-mediated low-grade inflammation in degenerative disorders, but its causal linkage to age-related periodontitis has not yet been elucidated. In this study, we investigated the involvement of the NLRP3 inflammasome and the therapeutic potential of NLRP3 inhibition in age-related alveolar bone loss by using in vivo and in vitro models. The poor quality of alveolar bones in aged mice was correlated with caspase-1 activation by macrophages and elevated levels of IL-1β, which are mainly regulated by the NLRP3 inflammasome, in periodontal ligament and serum, respectively. Aged mice lacking Nlrp3 showed better bone mass than age-matched wild-type mice via a way that affects bone resorption rather than bone formation. In line with this finding, treatment with MCC950, a potent inhibitor of the NLRP3 inflammasome, significantly suppressed alveolar bone loss with reduced caspase-1 activation in aged mice but not in young mice. In addition, our in vitro studies showed that the addition of IL-1β encourages RANKL-induced osteoclastogenesis from bone marrow–derived macrophages and that treatment with MCC950 significantly suppresses osteoclastic differentiation directly, irrelevant to the inhibition of IL-1β production. Our results suggest that the NLRP3 inflammasome is a critical mediator in age-related alveolar bone loss and that targeting the NLRP3 inflammasome could be a novel option for controlling periodontal degenerative changes with age.
Background and purpose
The rate at which the chance of a good outcome of endovascular stroke therapy (EVT) decays with time when eligible patients are selected by baseline diffusion‐weighted magnetic ...resonance imaging (DWI‐MRI) and whether ischaemic core size affects this rate remain to be investigated.
Methods
This study analyses a prospective multicentre registry of stroke patients treated with EVT based on pretreatment DWI‐MRI that was categorized into three groups: small Diffusion‐Weighted Imaging Alberta Stroke Program Early Computed Tomography Score (DWI‐ASPECTS) (8–10), moderate (5–7) and large (<5) cores. The main outcome was a good outcome at 90 days (modified Rankin Scale 0–2). The interaction between onset‐to‐groin puncture time (OTP) and DWI‐ASPECTS categories regarding functional outcomes was investigated.
Results
Ultimately, 985 patients (age 69 ± 11 years; male 55%) were analysed. Potential interaction effects between the DWI‐ASPECTS categories and OTP on a good outcome at 90 days were observed (Pinteraction = 0.06). Every 60‐min delay in OTP was associated with a 16% reduced likelihood of a good outcome at 90 days amongst patients with large cores, although no associations were observed amongst patients with small to moderate cores. Interestingly, the adjusted rates of a good outcome at 90 days steeply declined between 65 and 213 min of OTP and then remained smooth throughout 24 h of OTP (Pnonlinearity = 0.15).
Conclusions
Our study showed that the probability of a good outcome after EVT nonlinearly decreased, with a steeper decline at earlier OTP than at later OTP. Discrepant effects of OTP on functional outcomes by baseline DWI‐ASPECTS categories were observed. Thus, different strategies for EVT based on time and ischaemic core size are warranted.
Background and purpose
High blood pressure (BP) at presentation is associated with poor outcomes in acute ischaemic stroke, but serial BP measurements may better delineate the clinical implications ...of BP. The aim was to investigate the association between various BP parameters and functional outcomes in acute ischaemic stroke patients treated with endovascular thrombectomy (EVT).
Methods
This study reports a retrospective analysis of a prospective registry of a comprehensive stroke centre. Patients treated with EVT due to large vessel occlusion in the anterior circulation were enrolled. BP was measured hourly during the first 24 h after admission. Associations of various BP parameters, including BP variability, with functional outcomes at 3 months, including good outcomes (modified Rankin Scale score of 0–2), were analysed.
Results
Of the 378 enrolled patients (mean age 70 ± 11 years, male 54.2%), 313 (82.8%) achieved successful reperfusion after EVT, and 149 (39.4%) had good outcomes at 3 months. Higher mean systolic BP each 10 mmHg increase, odds ratio 0.82 (0.69–0.97) and higher systolic successive variation (SV) each 10% increase, odds ratio 0.37 (0.18–0.76) were associated with a reduced likelihood of achieving good outcomes. In addition, reperfusion status after EVT moderated the influence of higher systolic SV on good outcomes (Pint = 0.05).
Conclusion
The results showed that a higher mean systolic BP and systolic SV during the first 24 h of EVT reduced the likelihood of good outcomes at 3 months. The effects of these parameters on outcomes are more substantial amongst patients with successful reperfusion after EVT, suggesting that different BP control strategies should be employed according to reperfusion status.
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