Treatment rates with intravenously administered tissue plasminogen activator (IV-tPA) in acute ischemic stroke (IS) remain low in Asian populations. Various logistic obstacles and higher anticipated ...bleeding risk in Asians are major concerns. We report on the feasibility and safety of IV-tPA therapy at our tertiary care center. Consecutive acute IS patients eligible for thrombolysis were treated with low-dose (maximum 50 mg) IV-tPA between January 2000 and September 2006 and with standard-dose (maximum 90 mg) IV-tPA between October 2006 and May 2008. The efficacy of IV-tPA was assessed by the modified Rankin Scale (mRS) score at 3 months and by absolute changes in the National Institute of Health Stroke Scale (NIHSS) score at hospital discharge and 3 months. The safety of IV-tPA was assessed by the rate of symptomatic intracranial hemorrhage (SICH). A total of 130 patients were included (mean age, 60 ± 13years; 60% males; median NIHSS score, 14). A total of 48 patients received low-dose IV-tPA, and 82 patients received standard-dose IV-tPA. The median onset to treatment time was 160 minutes. Some 59% of the patients achieved functional independence (mRS score 0-1) at 3 months with standard-dose tPA, compared with 35% in the low-dose group ( P = .011). SICH occurred more frequently with the low dose (14.5%) than with the standard dose (1.2%; P = .004). In a multivariate logistic regression model, lower admission NIHSS score (odds ratio OR = 0.78 per 1-point increase; 95% confidence interval CI = 0.70-0.88), lower pretreatment blood glucose level (OR = 0.76 per 1 mmol/L increase; 95% CI = 0.60-0.95), shorter time from symptom onset to IV-tPA bolus (OR = 0.97 per 1-minute increase; 95% CI = 0.94-1.0), and standard-dose IV-tPA (OR = 12.49; 95% CI = 2.9-53.89) were associated with a higher likelihood for functional independence at 3 months. Our data indicate that standard-dose IV-tPA (0.9 mg/kg) was feasible and safe for treating acute IS in our multiethnic Asian population in Singapore.
Transcranial Doppler Sharma, Vijay K; Wong, Ka Sing; Alexandrov, Andrei V
Frontiers of neurology and neuroscience,
01/2016, Letnik:
40
Journal Article
Recenzirano
Transcranial Doppler ultrasonography (TCD) is the only diagnostic modality that provides a reliable evaluation of intracranial blood flow patterns in real-time. The physiological information obtained ...from TCD is complementary to the anatomical details obtained from other neuroimaging modalities. TCD is relatively cheap, can be performed bedside, and allows monitoring in acute emergency settings. TCD criteria for intracranial stenosis have been validated against various forms of angiographic studies and serve as reliable tools for screening, diagnostic as well as follow up purposes. TCD findings of intracranial stenosis have acceptable accuracy parameters for anterior as well as posterior circulation. Extended applications of TCD, especially emboli monitoring and assessment of vasomotor reactivity, provide important information about the pathophysiology of cerebrovascular ischemia and risk stratification. Therefore, TCD has become an integral component of the armamentarium of stroke neurologists for understanding stroke etiopathogenesis, planning and monitoring definitive treatment and determining the prognosis. We present the basic principles of TCD, techniques of test performance, diagnostic methods as well as some of the advanced applications of TCD in patients with intracranial stenosis.
Background
Randomized controlled trials provide high-level evidence, but the necessity to include selected patients may limit the generalisability of their results.
Methods
Comparisons were made of ...baseline and outcome data between patients with acute ischemic stroke (AIS) recruited into the alteplase-dose arm of the international, multi-center, Enhanced Control of Hypertension and Thrombolysis Stroke study (ENCHANTED) in the United Kingdom (UK), and alteplase-treated AIS patients registered in the UK Sentinel Stroke National Audit Programme (SSNAP) registry, over the study period June 2012 to October 2015.
Results
There were 770 AIS patients (41.2% female; mean age 72 years) included in ENCHANTED at sites in England and Wales, which was 19.5% of alteplase-treated AIS patients registered in the SSNAP registry. Trial participants were significantly older, had lower baseline neurological severity, less likely Asian, and had more premorbid symptoms, hypertension and atrial fibrillation. Although ENCHANTED participants had higher rates of symptomatic intracerebral hemorrhage than those in SSNAP, there were no differences in onset-to-treatment time, levels of disability (assessed by the modified Rankin scale) at hospital discharge, and mortality over 90 days between groups.
Conclusions
Despite the high level of participation, equipoise over the dose of alteplase among UK clinician investigators favored the inclusion of older, frailer, milder AIS patients in the ENCHANTED trial.
Clinical trial registration
Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01422616
Introduction: Skeletal age had been assessed by comparison between maturation of hand-wrist with stages of cervical vertebrae or canine calcification stages in past and this had been closely related ...to craniofacial growth. The importance of pubertal growth spurt in various types of orthodontic therapies is already established. Aims and Objectives: Hence, this study was aimed to evaluate the relationship of skeletal maturity by hand-wrist with cervical vertebral maturation indicators and canine calcification stages. Materials and Methods: The study consisted of randomly selected 90 children from Lucknow population with 45 males (age range 10-13 years) and 45 females (age range 9-12 years). Lateral Cephalogram, hand-wrist x-ray, and periapical x-rays of maxillary and mandibular right canines were taken. Statistical Analysis: Mean, standard deviation was calculated of different groups. Correlation was made among cervical vertebral maturation, hand wrist maturation, and canine calcification stages at various age groups. Results: There was strong correlation between skeletal maturation indicator and cervical vertebral maturation indicator for both male (0.849) and female (0.932), whereas correlation between skeletal maturation indicator and canine calcification was good for both male and female (0.635, 0.891). Conclusion: It was concluded that cervical vertebral maturation indicator and canine calcification stages can also be used for assessing skeletal maturity.
The optimal dose of recombinant tissue plasminogen activator (rtPA) for acute ischaemic stroke (AIS) remains controversial, especially in Asian countries. We aimed to update the evidence regarding ...the use of low-dose versus standard-dose rtPA. We performed a systematic literature search across MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL) from inception to 22 August 2016 to identify all related studies. The outcomes were death or disability (defined by modified Rankin Scale 2–6), death, and symptomatic intracerebral haemorrhage (sICH). Where possible, data were pooled for meta-analysis with ORs and corresponding 95% CIs by means of random-effects or fixed-effects meta-analysis. We included 26 observational studies and 1 randomised controlled trial with a total of 23 210 patients. Variable doses of rtPA were used for thrombolysis of AIS in Asia. Meta-analysis shows that low-dose rtPA was not associated with increased risk of death or disability (OR 1.13, 95% CI 0.95 to 1.33), or death (OR 0.86, 95% CI 0.74 to 1.01), or decreased risk of sICH (OR 1.06, 95% CI 0.65 to 1.72). The results remained consistent when sensitivity analyses were performed including only low-dose and standard-dose rtPA or only Asian studies. Our review shows small difference between the outcomes or the risk profile in the studies using low-dose and/or standard-dose rtPA for AIS. Low-dose rtPA was not associated with lower risk of death or disability, death alone, or sICH.
A strong relationship exists between the severity of carotid stenosis and early stroke risk. Inflammation is believed to be an important event for atherosclerotic plaque destabilization and ...subsequent thromboembolism. (18)F-FDG can image atherosclerotic inflammation, providing information about plaque biology, which may serve as a useful biomarker for the assessment of early stroke risk.
In many intracranial disease states, monitoring of intracranial pressure (ICP) is essential to evaluate response to the therapeutic measures as well as estimation of prognosis. Although, direct ...estimation of ICP is reliable, it is invasive and not possible in all patients. Transcranial Doppler (TCD) ultrasonography is a bedside and noninvasive technique that provides reliable and real-time information about cerebral hemodynamics. We present a case of extensive and progressive cerebral venous sinus thrombosis in which TCD served as an excellent tool for monitoring ICP and the serial observations correlated closely with clinical status and ophthalmological findings.
Major cases of poisoning are associated with organophosphates. Cholinergic effects and an intermediate phase seen with organophosphate poisoning may implicate myopathy. Creatine kinase is a marker of ...muscle tissue damage. This study aimed to find out the mean serum creatine kinase among organophosphate poisoning cases in a tertiary care centre.
A descriptive cross-sectional study was carried out among organophosphate poisoning cases in a tertiary care hospital from 13 October 2017 to 30 March 2018. Ethical approval was taken from the Institutional Review Committee Reference number: 117(6-11-E) 2/074/075. Blood samples were assayed for serum acetylcholinesterase in the pharmacology laboratory and for serum creatine kinase and lactate dehydrogenase in the biochemistry laboratory. Low serum acetylcholinesterase was taken as the basis for the establishment of organophosphate poisoning. A convenience sampling technique was used. Point estimate and 95% Confidence Interval were calculated.
Among 103 organophosphate poisoning cases, the mean serum creatine kinase was 931.35±446.60 IU/l (845.10-1017.60, 95% Confidence Interval).
The mean serum creatine kinase level among organophosphate poisoning cases was higher than in other studies done in similar settings.
acetylcholinesterase; creatine kinase; organophosphate poisoning; rhabdomyolysis.
The principles of inter‐species dose extrapolation are poorly understood and applied. We provide an overview of the principles underlying dose scaling for size and dose adjustment for ...size‐independent differences. Scaling of a dose is required in three main situations: the anticipation of first‐in‐human doses for clinical trials, dose extrapolation in veterinary practice and dose extrapolation for experimental purposes. Each of these situations is discussed. Allometric scaling of drug doses is commonly used for practical reasons, but can be more accurate when one takes into account species differences in pharmacokinetic parameters (clearance, volume of distribution). Simple scaling of drug doses can be misleading for some drugs; correction for protein binding, physicochemical properties of the drug or species differences in physiological time can improve scaling. However, differences in drug transport and metabolism, and in the dose–response relationship, can override the effect of size alone. For this reason, a range of modelling approaches have been developed, which combine in silico simulations with data obtained in vitro and/or in vivo. Drugs that are unlikely to be amenable to simple allometric scaling of their clearance or dose include drugs that are highly protein‐bound, drugs that undergo extensive metabolism and active transport, drugs that undergo significant biliary excretion (MW > 500, ampiphilic, conjugated), drugs whose targets are subject to inter‐species differences in expression, affinity and distribution and drugs that undergo extensive renal secretion. In addition to inter‐species dose extrapolation, we provide an overview of dose extrapolation within species, discussing drug dosing in paediatrics and in the elderly.
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