Outcomes in severe middle cerebral artery ischemic stroke.

BACKGROUND: Severe middle cerebral artery stroke (MCA) is associated with a high rate of morbidity and mortality. We assessed the hypothesis that patient-specific variables may be associated with outcomes. We also sought to describe under-recognized patient-centered outcomes. METHODS: A consecutive, multi-institution, retrospective cohort of adult patients (≤70 years) was established from 2009 to 2011. We included patients with NIHSS score ≥15 and infarct volume ≥60 mL measured within 48 h of symptom onset. Malignant edema was defined as the development of midline brain shift of ≥5 mm in the first 5 days. Exclusion criterion was enrollment in any experimental trial. A univariate and multivariate logistic regression analysis was performed to model and predict the factors related to outcomes. RESULTS: 46 patients (29 female, 17 male; mean age 57.3 ± 1.5 years) met study criteria. The mortality rate was 28% (n = 13). In a multivariate analysis, only concurrent anterior cerebral artery (ACA) involvement was associated with mortality (OR 9.78, 95% CI 1.15, 82.8, p = 0.04). In the malignant edema subgroup (n = 23, 58%), 4 died (17%), 7 underwent decompressive craniectomy (30%), 7 underwent tracheostomy (30%), and 15 underwent gastrostomy (65%). CONCLUSIONS: Adverse outcomes after severe stroke are common. Concurrent ACA involvement predicts mortality in severe MCA stroke. It is useful to understand the incidence of life-sustaining procedures, such as tracheostomy and gastrostomy, as well as factors that contribute to their necessity.

Public health system partnerships: role for local boards of health in preparing the future public health workforce.

The Institute of Medicine's report, Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century, recommended that public health education be accessible to undergraduate students. Promoting access to public health education will ideally contribute to a well-educated public health workforce, thus assuring the fulfillment of the public health mission. In response to this call to action, the authors examined the current practice, feasibility, and value in developing a functional partnership between academic institutions and local boards of health in preparing future public health professionals. Local boards of health in New England were surveyed to: (1) establish a baseline of existing working relationships between them and nearby academic institutions; (2) examine the barriers that inhibit the development of their collaborations with academic partners; and (3) assess how they jointly advance public health workforce development. Despite the main barriers of a lack of time, staff, and funding that are often cited for the absence of collaborations between institutions, one New England state, in particular, reported that their academic institution and local board of health partnerships were important and effective. The authors discuss how academic-practice collaborations hold the potential to combine basic public health principles with leadership and governance experience offered by local boards of health. Such partnerships are underutilized and have the potential to integrate core public health concepts while facilitating applied experiential learning opportunities in a professional public health setting, thus contributing to the development of the future public health workforce.

Prediction of poor outcome in cerebellar infarction by diffusion MRI.

OBJECTIVE: Identification of patients with posterior fossa infarction at risk for neurological deterioration remains a challenge. MRI-based assessments of MCA infarction can predict poor outcome. Similar quantitative imaging measures after cerebellar stroke have not been studied. We tested the hypothesis that MRI-based volumetric assessment of cerebellar infarcts can provide reliable information for the prediction of poor outcome. DESIGN: We retrospectively identified 44 consecutive subjects (age 55.2 ± 13) with cerebellar stroke who underwent MRI with diffusion-weighted imaging (DWI) (median 63.7 h). Subjects were divided into poor (n = 13) and good outcomes (n = 31). Poor outcome was defined as having at least one of the following criteria: (1) mortality, (2) decompressive craniectomy, (3) ventriculostomy, and (4) decrease level of consciousness. DWI and cerebellar volume were defined on apparent diffusion coefficient maps. The ratio of the lesion volume to the whole cerebellum volume was calculated (rVolume). MEASUREMENTS AND MAIN RESULTS: Logistic regression revealed that lesion volume and rVolume were associated with increased risk of poor outcome, even after adjusting for age and NIHSS (χ(2) = 8.2230, p < 0.0042; χ(2) = 8.3992, p < 0.0038, respectively). The receiver operating characteristic curve with age, NIHSS, and volume or rVolume achieved an AUC of 0.816 (95 % CI 0.678-0.955) and 0.831 (95 % CI 0.6989-0.9636), respectively. CONCLUSIONS: Quantitative volumetric measurement predicts poor outcome of cerebellar stroke patients, even when controlling for age and NIHSS. Quantitative analysis of diffusion MRI may assist in identification of patients with cerebellar stroke at highest risk of neurological deterioration. Prospective validation is warranted.

Engaging local public health system partnerships to educate the future public health workforce.

The Institute of Medicine concluded that keeping the public healthy required a well-educated public health workforce, thus leading to its recommendation that "all undergraduates should have access to education in public health" [2]. In response to this call, the authors examined the current practice, feasibility, and value in strengthening (or building) a functional collaborative model between academic institutions and practitioners from local health departments to educate tomorrow's public health workforce. Local and regional health departments in New England were surveyed to: (1) establish a baseline of existing working relationships between them and nearby academic institutions; (2) examine the barriers that inhibit the development of collaborations with academic partners; (3) assess how they jointly promote public health workforce development; and (4) analyze which essential public health services their partnership addresses. Despite the lack of financial resources often cited for the absence of academic-local health department collaborations, some New England states reported that their academic institution and local public health department partnerships were valued and productive. The authors discuss how effective academic-community collaborations have the potential to facilitate a broad-based appreciation of public health among students via a wide array of public health curricula and applied experiential learning opportunities in public health settings. The authors propose a model for how to combine basic public health lessons with practical experience and leadership offered by local health departments, in order to foster a real understanding of public health, its importance, practice, and relevance in today's society from a public health workforce perspective.

Bone morphogenetic protein 4 mediates human embryonic germ cell derivation.

Human primordial germ cells (PGCs) have proven to be a source of pluripotent stem cells called embryonic germ cells (EGCs). Unlike embryonic stem cells, virtually little is known regarding the factors that regulate EGC survival and maintenance. In mice, the growth factor bone morphogenetic protein 4 (BMP4) has been shown to be required for maintaining mouse embryonic stem cells, and disruptions in this gene lead to defects in mouse PGC specification. Here, we sought to determine whether recombinant human BMP4 could influence EGC derivation and/or human PGC survival. We found that the addition of recombinant BMP4 increased the number of human PGCs after 1 week of culture in a dose-responsive manner. The efficiency of EGC derivation and maintenance in culture was also enhanced by the presence of recombinant BMP4 based on alkaline phosphatase and OCT4 staining. In addition, an antagonist of the BMP4 pathway, Noggin, decreased PGC proliferation and led to an increase in cystic embryoid body formation. Quantitative real-time (qRT)-polymerase chain reaction analyses and immunostaining confirmed that the constituents of the BMP4 pathway were upregulated in EGCs versus PGCs. Downstream activators of the BMP4 pathway such as ID1 and phosphorylated SMADs 1 and 5 were also expressed, suggesting a role of this growth factor in EGC pluripotency.

A review of interventions to reduce tobacco use in colleges and universities.

BACKGROUND: Interventions have been designed to reduce the prevalence of smoking in college/university students. This review presents a summary and synthesis of the interventions published in English from 1980 to the present. METHODS: Seven databases were searched for relevant published articles, and reference lists were examined for additional published studies. The studies were categorized as (1) individual approaches, such as on-campus cessation programs, and (2) institutional approaches, such as smoke-free policies. The studies were categorized by type of institution and geographic location, study design, sample demographics, and outcomes. RESULTS: Fourteen studies were identified; only five received a "satisfactory" rating based on evaluation criteria. Most studies were based on convenience samples, and were conducted in 4-year institutions. Seven studies used comparison groups, and three were multi-institutional. Individual approaches included educational group sessions and/or individual counseling that were conducted on campus mostly by healthcare personnel. None used nicotine replacement or other medications for cessation. The quit rates for both smokeless tobacco and cigarette users varied, depending on definitions and duration of follow-up contact. Institutional interventions focused mainly on campus smoking restrictions, smoke-free policies, antitobacco messages, and cigarette pricing. Results indicated that interventions can have a positive influence on student behavior, specifically by reducing tobacco use (i.e., prevalence of cigarette smoking and use of smokeless products, amount smoked) among college students, and increasing acceptability of smoking policies and campus restrictions among both tobacco users and nonusers. CONCLUSIONS: While some promising results have been noted, rigorous evaluations of a wider range of programs are needed, along with studies that address cultural and ethnic diversity on campuses.

Survey of restaurants regarding smoking policies.

The New Hampshire Indoor Smoking Act was implemented in 1994 to protect the public's health by regulating smoking in enclosed places. A survey was conducted of New Hampshire restaurants to determine smoking policies, to determine restaurant characteristics associated with smoking policies, and to evaluate compliance with the Indoor Smoking Act. A list of New Hampshire restaurants was obtained from a marketing firm. Establishments were selected randomly until 400 had completed a 22-question telephone survey. Forty-four percent of restaurants permitted smoking. Characteristics positively associated with permitting smoking were being a non-fast-food restaurant, selling alcohol, selling tobacco, and having greater than the median number of seats. Of restaurants permitting smoking, 96.1% had a designated smoking area, 87.0% had a ventilation system to minimize secondhand smoke, 83.6% had a physical barrier between smoking and nonsmoking areas, and 53.1% exhibited signs marking the smoking area. Forty percent of restaurants permitting smoking met all four requirements of the Indoor Smoking Act. Smoking policies differ, by type of restaurant. Compliance with the Indoor Smoking Act is low.