Citations

Introduction: Robust leptomeningeal collaterals protect brain from ischemia, yet the determinants of poor collaterals remains unclear. We aimed to identify predictors of poor collaterals in patients with large-vessel occlusive stroke. Methods: We analyzed 112 consecutive patients with middle cerebral artery ± internal carotid artery occlusion from 2012-2016 who presented within 6 hours after stroke symptoms onset. Collaterals on baseline CT-angiogram (poor collaterals ≤50% filling, good collaterals >50% filling) were reviewed blinded to clinical data. Pre-specified predictors of poor collaterals were analyzed with adjusted logistic regression models: including known predictors (age, vascular risk factors and metabolic derangements) and hypothesized predictors (low cardiac output, elevated inflammatory markers, and imaging evidence for chronic cerebral small-vessel disease and chronic steno-occlusive arterial disease). Results: The mean age was 67± 16 years, there were 48% women, 57% white, and median NIHSS was 15 (IQR 11-20). Poor collaterals at baseline were detected in 48%. Multivariable modeling identified that age (aOR 1.8 per 10 years; 95% CI 1.3-2.6; p<0.001), black race (aOR 2.1; 95% CI 1.0-4.5; p=0.043), high blood glucose level (aOR 2.4 per 100 mg/dl; 95% CI 1.1-5.1; p=0.029), and high WMH burden (aOR 6.1; 95%CI 1.8-20.4; p=0.003) were independent predictors of poor collaterals. Associations between low cardiac output, elevated inflammatory markers, intracranial atherosclerosis and poor collaterals did not reach statistical significance (Table). Conclusions: We have identified that advanced age, black race, hyperglycemia, and white matter hyperintensities are predictors of poor collaterals. Independent replication study at another institution is ongoing to further explore the hypothesized predictors.

Background: The importance of physical activity in preventing major vascular events has received increased attention in the past decade. Due to the inclusion of the INTERVENT lifestyle modification program, the CREST2 trial provides a unique opportunity to study physical activity profiles in patients with severe asymptomatic extracranial carotid stenosis. Hypothesis: Based on data from a trial of intracranial stenosis patients, we aimed to evaluate the hypothesis that <40% of carotid stenosis subjects will have optimal physical activity levels. We also assessed key subgroups to determine patterns of physical activity. Methods: We analyzed 1087 CREST2 participants with baseline data on physical activity. The Physician-based Assessment and Counseling for Exercise (PACE) score is recorded for each patient and dichotomized as “in target” (4-8 points) or “out of target” (<4 points). A PACE score of <4 indicates a subject who does not engage in regular exercise. Results are analyzed for the entire trial. Chi square testing and t-tests were performed for evaluation of subgroup differences. Results: The mean age of the study population is 69.5±7.8 years (60% male). The median PACE score at baseline is 4.0 (mean 3.8±2.1; IQR 2 to 6). The Table shows baseline characteristics of patients by mean PACE score. Being male, not having diabetes mellitus, having a body mass index <30kg/m2, being a non-smoker, and not having a history of peripheral arterial disease were associated with significantly higher mean PACE scores (P<0.01). Conclusions: We have defined several patient groups with asymptomatic carotid stenosis that have suboptimal physical activity. These results provide opportunities for targeted efforts to improve primary stroke prevention. These baseline data will also allow investigators to determine if trial involvement and the INTERVENT program leads to improvement in the level of physical activity.

The Ice Hockey Summit III provided updated scientific evidence on concussions in hockey to inform these five objectives: 1) describe sport-related concussion (SRC) epidemiology, 2) classify prevention strategies, 3) define objective, diagnostic tests, 4) identify treatment, and 5) integrate science and clinical care into prioritized action plans and policy. Our action plan evolved from 40 scientific presentations. The 155 attendees (physicians, athletic trainers, physical therapists, nurses, neuropsychologists, scientists, engineers, coaches, and officials) voted to prioritize these action items in the final Summit session. 1) Establish a national and international hockey data base for SRC at all levels, 2) eliminate body checking in Bantam youth hockey games, 3) expand a behavior modification program (Fair Play) to all youth hockey levels, 4) enforce game ejection penalties for fighting in Junior A and professional hockey leagues, 5) establish objective tests to diagnose concussion at point of care (POC), and 6) mandate baseline testing to improve concussion diagnosis for all age groups. Expedient implementation of the Summit III prioritized action items is necessary to reduce the risk, severity, and consequences of concussion in the sport of ice hockey.

AbstractBackgroundThe effect of utilizing transapical (TA) access for transcatheter aortic valve replacement (TAVR) on cardiac function has not been well studied.AimsThe aim of this retrospective study is to determine the direct effects of TA access for TAVR on myocardial function parameters and their correlation with 4‐year survival.MethodsThree hundred and thirty propensity matched patients, who underwent TAVR using Sapien valve (Edwards Lifesciences Corp, Irvine, CA) between February 15, 2012 and June 17, 2016 (115 TA and 115 transfemoral [TF] routes) were studied. The pre‐ and 1 month post‐TAVR echocardiographic features of both groups were compared. The 4‐year survival in both groups was analyzed.ResultsBaseline clinical characteristics, diastolic function parameters, left ventricular (LV) chamber size, and ejection fraction were similar between matched TA and TF groups. At 1 month following TAVR, there was a significant increase in stroke volume index (SVI) in both TA (mean increase 7 cm3/m2; P = 0.03) and TF groups (mean increase 7 cm3/m2; P < 0.001). Left ventricular ejection fraction (LVEF) significantly increased post TF TAVR (mean increase 2%; P = 0.008), but no significant increase was observed post TA TAVR (mean increase 1%; P = 0.27). Both groups had significant improvement in aortic valve (AV) hemodynamics post‐TAVR (P < 0.001). Overall, there were no significant differences in the mean change of SVI, LVEF, or left ventricular end diastolic dimensions (LVEDDs) post TA versus TF TAVR. There was no significant difference in 4‐year survival in the TF compared to TA group (49% vs 50%, P = 0.43).ConclusionBoth TA and TF TAVR were equally associated with favorable changes in LV SVI and AV hemodynamics in 30 days. TA TAVR patients had similar 4 year survival to propensity matched TF TAVR; therefore, TA TAVR remains an acceptable alternative access route in patients not amenable to TF TAVR.

Objective Among neonates of 22 to 29 weeks' gestational age (GA) who required mechanical ventilation for the treatment of respiratory distress syndrome (RDS) and clinically diagnosed pulmonary hypertension (PH), we tested our hypothesis that the association between early treatment with inhaled nitric oxide (iNO) and survival would vary according to birth size and GA. Study Design Because iNO was not randomly prescribed to patients in this cohort, we used propensity score matching to pair a neonate who received iNO at a chronological age of ≤7 days with an unexposed neonate with similar baseline characteristics. The primary outcome was inhospital mortality, which we evaluated based on size for GA and GA strata using the Cox proportional hazards regression model. Results Among 1,531 neonates who met study criteria, we created a propensity score matched cohort of 615 pairs of neonates (iNO-exposed and unexposed). The risk of inhospital mortality for iNO-exposed neonates was observed only in the minority (<10%) who were large for GA, though this finding did not persist when matching for illness severity. Conclusion Early treatment with iNO is not associated with survival in most extremely premature neonates with RDS and clinically diagnosed PH when stratified for birth size or GA.

Background: Limited data exist that show the long-term risks of reinfection and mechanical failure with a contemporary 2-stage exchange protocol for periprosthetic joint infection following total hip arthroplasty. The purpose of this study was to determine the long-term reinfection and mechanical failure rates of 2-stage exchange for periprosthetic joint infection after total hip arthroplasty. Methods: We identified 164 hips (162 patients) with infection after total hip arthroplasty between 1991 and 2006 treated with a 2-stage exchange protocol with no prior treatment for periprosthetic joint infection. With regard to Musculoskeletal Infection Society diagnostic criteria, at least 1 major criterion or 4 of 6 minor criteria were fulfilled in 129 hips (79%). The cumulative incidence with a competing risk of death was calculated for reinfection, aseptic revisions, and all-cause revisions. The risk factors for reinfection were evaluated using Cox proportional hazards regression. Harris hip scores were calculated. The mean age at the time of spacer insertion was 68 years, and 35% of the patients were female. Excluding the patients with <2 years of follow-up, the mean follow-up was 12 years (range, 2 to 21 years). Results: The cumulative incidence of recurrence of infection was 10% at 1 year, 14% at 5 years, and 15% at 10 and 15 years. Seventeen patients (11%) used chronic antibiotic suppression (>6 months), with 7 (41%) of these having recurrent infection at the time of the latest follow-up. Use of chronic antibiotic suppression was the only predictive factor for reinfection (hazard ratio, 4.5 [95% confidence interval (CI), 1.9 to 10.9]; p = 0.001). The cumulative incidence of aseptic femoral and acetabular revisions was 2.6% at 5 years and 3.3% at 10 and 15 years. The cumulative incidence of all-cause revisions was 15% at 5 years and 16% at 10 and 15 years. Dislocation was the most common complication, with 28 dislocations occurring in 20 patients (12%). The mean Harris hip score improved from 52 points prior to spacer insertion to 70 points at 15 years after reimplantation (p < 0.01). Conclusions: The rate of recurrence of infection of 15% for up to 15 years after total hip arthroplasty was similar to previous shorter-term reports of 2-stage exchange for periprosthetic joint infection. Surgeons should anticipate mitigating instability after reimplantation. Implant survivorship free of aseptic loosening and clinical outcomes were preserved for the long term. The role of chronic antibiotic suppression in the long-term treatment of periprosthetic joint infection requires further investigation. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.