First Pass Effect and Location of Occlusion in Recanalized MCA M1 Occlusions.

Background: The first pass effect has been shown to improve clinical outcomes in patients with middle cerebral artery (MCA) M1 occlusions. Objective: To determine the rates of first pass effect in MCA M1 occlusions and determine if proximal or distal location of occlusion modified clinical outcomes. Methods: Patients with recanalized MCA M1 occlusions who underwent endovascular thrombectomy (EVT) were reviewed to determine the effect of first pass effect (FPE) and location of occlusion on clinical outcomes. MCA occlusions were classified as proximal if they included the first two thirds of the MCA and involved the lenticulostriate vessels, or distal if they did not. Results: We included 261 patients of which 27% achieved FPE. Of the cohort, there were 91 (35%) proximal MCA occlusions and 170 (65%) distal MCA occlusions. Baseline demographics and treatment time metrics were comparable across both groups. There was a trend toward good clinical outcome in patients with or without a FPE (60 vs. 46%; p = 0.06), however a higher rate of excellent clinical outcome was noted in patients with FPE (46 vs. 30%; p = 0.02). When compared by location, patients with distal MCA occlusions had a higher rate of excellent clinical outcome (40 vs. 25%; p = 0.02). Multivariable analysis showed that distal MCA occlusion was the strongest predictor of an excellent clinical outcome and first pass effect. Conclusion: Patients with MCA M1 occlusions with FPE have a higher rate of excellent clinical outcomes compared to those who did not. Location of MCA occlusion appears to modify rates of first pass effect and excellent clinical outcomes.

A Naturalistic Study of Outcomes for Durable Remission in Patients With Bipolar Disorder.

OBJECTIVE: Bipolar disorder is a severe mental illness affecting emotional stability, physical health, and quality of life. In a previous study, we identified medications associated with remission in patients with bipolar disorder. The objective of the current study was to determine the status of the patients after 3 additional years, as well as the medications associated with remission. METHODS: Data were extracted from clinical records. The criteria for remission in both the original study and the follow-up were 12 continuous months of euthymia, mild symptoms, and no clinical relapse. Active illness was defined as <12 months of remission. Statistical comparisons were made between the remitted and active illness groups on demographics and medication regimens. RESULTS: The original study contained 121 patients, 52 of whom were available for follow-up. Of the 121 patients from the original study, 53 (43.8%) were remitted for at least 12 months. Follow-up data were available for 19 of those patients, 15 of whom continued in remission while 4 relapsed. Of the 68 patients who were still ill at the end of the first study, follow-up data were available for 33 patients, 18 of whom had achieved remission at the time of follow-up while 15 continued to be ill. Remitted patients were more likely to be receiving a mood stabilizer (P=0.022) or a combination of a mood stabilizer and an antidepressant (P=0.004). CONCLUSIONS: On the basis of our results, mood stabilizers and antidepressants were associated with remission in long-term follow-up. Remission may ultimately be possible for many patients who did not succeed initially.

Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience.

BACKGROUND: Data on the implementation of prehospital large vessel occlusion (LVO) scales to identify and triage patients with acute ischemic stroke (AIS) in the field are limited, with the majority of studies occurring outside the USA. OBJECTIVE: To report our long-term experience of a US countywide emergency medical services (EMS) acute stroke triage protocol using the Rapid Arterial oCclusion Evaluation (RACE) score. METHODS: Our prospective database was used to identify all consecutive patients triaged within Lucas County, Ohio by the EMS with (1) a RACE score ≥5, taken directly to an endovascular capable center (ECC) as RACE-alerts (RA) and (2) a RACE score <5, taken to the nearest hospital as stroke-alerts (SA). Baseline demographics, RACE score, time metrics, final diagnosis, treatments, and clinical and angiographic outcomes were captured. The sensitivity and specificity for patients with a RACE score ≥5 with LVO, eligible for mechanical thrombectomy (MT), were calculated. RESULTS: Between July 2015 and June 2018, 492 RA and 1147 SA were triaged within our five-hospital network. Of the RA, 37% had AIS secondary to LVOs. Of the 492 RA and 1147 SA, 125 (25.4%) and 38 (3.3%), respectively, underwent MT (OR=9.9; 95% CI 6.8 to 14.6; p<0.0001). Median times from onset-to-ECC arrival (74 vs 167 min, p=0.03) and dispatch-to-ECC arrival (31 vs 46 min, p=0.0002) were shorter in the RA-MT than in the SA-MT cohort. A RACE cut-off point ≥5 showed a sensitivity and specificity of 0.77 and 0.75 for detection of patients with LVO eligible for MT, respectively. CONCLUSIONS: We have demonstrated the long-term feasibility of a countywide EMS-based prehospital triage protocol using the RACE Scale within our hospital network.

Monitored Anesthesia Care by Sedation-Trained Providers in Acute Stroke Thrombectomy.

Background: Mechanical thrombectomy (MT) for ischemic stroke can be performed under local anesthesia (LA), conscious sedation (CS), or general anesthesia (GA). The need for monitoring by anesthesia providers may be resource intensive. We sought to determine differences in outcomes of MT when sedation is performed by an anesthesia team compared to sedation-trained providers. Methods: We performed a retrospective analysis on patients who were screened by a pre-hospital stroke severity screening tool and underwent MT at two stroke centers. Baseline characteristics, time metrics, sedatives, peri-procedural intubation, complications, and outcomes were recorded. Good outcome was defined as modified Rankin score of ≤2. Results: We analyzed 104 patients (sedation-trained provider = 63, anesthesia team = 41) between July 2015 and December 2017. In the sedation-trained provider group, four patients required intervention by an anesthesia team. There were no differences in patients receiving LA (sedation-trained provider 24% vs. anesthesia team 27% p = 0.82), CS (70 vs. 63%, p = 0.53), or GA (6 vs. 10%, p = 0.71) between groups. Sedation-trained providers were more likely to use only one drug during the procedure (62 vs. 34%, p = 0.009). The rate of procedural complications (9.5 vs. 4.5%, p = 0.48), good outcome (56 vs. 39%, p = 0.11), and mortality (22 vs. 24%, p = 0.82) was similar between groups. Sedation by provider type did not predict functional outcome or mortality at 3 months. Conclusions: Sedation-trained providers are capable of delivering appropriate sedation without compromising patient safety. The use of "as needed" anesthesia teams for MT may have considerable effect on resource allocation and cost.

Recapturing the art of therapeutic breast massage during breastfeeding.

Milk expression is a normal part of breastfeeding, but in developed countries in particular, the focus tends to center on mechanical expression. In Russia, there is a long tradition of hands-on techniques that continues in the present day and includes mothers turning to providers trained in hand expression and breast massage techniques to resolve breastfeeding complications including engorgement, plugged ducts, and mastitis. As observed over the course of several trips to Russia, Russian clinicians routinely combine hand expression with breast massage for the treatment of milk stasis, engorgement, and plugged ducts. A better understanding of these hands-on techniques to assist in resolution of complications may provide additional treatment options for the lactation community.