Developing and Implementing a Web-Based Branching Logic Survey to Support Psychiatric Crisis Evaluations of Individuals With Developmental Disabilities: Qualitative Study and Evaluation of Validity.

BACKGROUND: Individuals with developmental disabilities (DD) experience increased rates of emotional and behavioral crises that necessitate assessment and intervention. Psychiatric disorders can contribute to crises; however, screening measures developed for the general population are inadequate for those with DD. Medical conditions can exacerbate crises and merit evaluation. Screening tools using checklist formats, even when designed for DD, are too limited in depth and scope for crisis assessments. The Sources of Distress survey implements a web-based branching logic format to screen for common psychiatric and medical conditions experienced by individuals with DD by querying caregiver knowledge and observations. OBJECTIVE: This paper aims to (1) describe the initial survey development, (2) report on focus group and expert review processes and findings, and (3) present results from the survey's clinical implementation and evaluation of validity. METHODS: Sources of Distress was reviewed by focus groups and clinical experts; this feedback informed survey revisions. The survey was subsequently implemented in clinical settings to augment providers' psychiatric and medical history taking. Informal and formal consults followed the completion of Sources of Distress for a subset of individuals. A records review was performed to identify working diagnoses established during these consults. RESULTS: Focus group members (n=17) expressed positive feedback overall about the survey's content and provided specific recommendations to add categories and items. The survey was completed for 231 individuals with DD in the clinical setting (n=161, 69.7% men and boys; mean age 17.7, SD 10.3; range 2-65 years). Consults were performed for 149 individuals (n=102, 68.5% men and boys; mean age 18.9, SD 10.9 years), generating working diagnoses to compare survey screening results. Sources of Distress accuracy rates were 91% (95% CI 85%-95%) for posttraumatic stress disorder, 87% (95% CI 81%-92%) for anxiety, 87% (95% CI 81%-92%) for episodic expansive mood and bipolar disorder, 82% (95% CI 75%-87%) for psychotic disorder, 79% (95% CI 71%-85%) for unipolar depression, and 76% (95% CI 69%-82%) for attention-deficit/hyperactivity disorder. While no specific survey items or screening algorithm existed for unspecified mood disorder and disruptive mood dysregulation disorder, these conditions were caregiver-reported and working diagnoses for 11.7% (27/231) and 16.8% (25/149) of individuals, respectively. CONCLUSIONS: Caregivers described Sources of Distress as an acceptable tool for sharing their knowledge and insights about individuals with DD who present in crisis. As a screening tool, this survey demonstrates good accuracy. However, better differentiation among mood disorders is needed, including the addition of items and screening algorithm for unspecified mood disorder and disruptive mood dysregulation disorder. Additional validation efforts are necessary to include a more geographically diverse population and reevaluate mood disorder differentiation. Future study is merited to investigate the survey's impact on the psychiatric and medical management of distress in individuals with DD.

Intraoral pencil core granuloma with retained pencil lead.

Foreign body impactions can be frequently seen in childhood as children have a habit of putting different objects in the mouth. These impacted foreign bodies if not removed timely, at times can lead to severe reactions leading to granuloma formation. A simple injury, if ignored, can result in severe damage to oral tissue and even loss of the permanent tooth. Therefore, all penetrating injuries should be carefully assessed and treated timely. This study describes a rarest intraoral case of pencil core granuloma with retained graphite lead inside it that led to severe tissue reactions. Pencil core granuloma has been reported extra orally and on limbs. This case report describes the rarest case reported intraorally.

Robotic Surgery: At the Crossroads of a Data Explosion.

BACKGROUND: For the last 20 years, controversies in robotic surgery focused on cost reduction, development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics [Leal Ghezzi and Campos in World J Surg 40:2550-2557, 2016]. METHODS: This review explores the robotic systems which are currently indicated for use or development in gastrointestinal/abdominal surgery. These systems are reviewed and analyzed for clinical impact in these areas. In a MEDLINE search of articles with the search terms abdominal, gastrointestinal, review and robotic surgery, a total of 4306 total articles as of 2021 were assessed. Publicly available information, highest cited articles and reviews were assessed by the authors to determine the most significant regarding clinical outcomes. RESULTS: Despite this increased number of articles related to robotic surgery, ongoing controversies have led to limitation in the use of current and future robotic surgery platforms [Connelly et al. in J Robotic Surg 14:155-165, 2020]. Newer robotic platforms have limited studies or analysis that would allow meaningful definite conclusions. A multitude of new scenarios are possible due to this limited information. CONCLUSION: Robotic surgery is in evolution to a larger conceptual field of computationally enhanced surgery (CES). Various terms have been used in the literature including computer-assisted surgery or digital Surgery [Ranev and Teixeira in Surg Clin North Am 100:209-218, 2020]. With the growth of technological changes inherent in CES, the ability to validate these improvements in outcomes will require new metrics and analytic tools. This learning feedback and metric analysis will generate the new opportunities in simulation, training and application [Julian and Smith in Int J Med Robot 15:e2037, 2019].

Mechanical thrombectomy is efficacious in patients with pre-stroke moderate disability.

INTRODUCTION: Patients with ischaemic stroke due to large vessel occlusion (LVO) can be treated successfully with mechanical thrombectomy (MT) and/or intravenous thrombolysis. In the landmark trials, MT was only performed for those with no functional disability prior to stroke (mRS 0-2). There are limited data available regarding clinical outcomes for patients with pre-stroke moderate disability (mRS ≥ 3). The aims of this study were to analyse the clinical outcomes and financial implications in regard to accommodation costs of performing MT in patients with pre-stroke mRS = 3. METHODS: An observational cohort study was performed of 802 patients with anterior circulation LVO ischaemic stroke who underwent MT between October 2016 and January 2020 at three tertiary hospitals. Patient demographics, premorbid mRS, stroke and interventional data, 90-day mRS and accommodation situation were recorded. RESULTS: Eighty-two patients with anterior circulation LVO ischaemic stroke were pre-stroke mRS 3. 38% had a good clinical outcome, as defined by mRS 3 at 90 days. Mortality rate was 38%. The majority of patients presented from home (83%) and greater than one third of those returned home during the 90 days post treatment. 81% of patients had no increase in accommodation cost at 90 days. CONCLUSION: Patients with pre-stroke moderate disability may benefit from MT if they are appropriately selected. This may result in fewer patients requiring nursing home placement and less financial burden on the public health system, indicating significant savings are possible.

Cell surface and extracellular proteins of potentially probiotic Lactobacillus reuteri as an effective mediator to regulate intestinal epithelial barrier function.

The present study aimed to evaluate the potential of cell surface and extracellular proteins in regulation of intestinal epithelial barrier (IEB) function. Eight potentially probiotic L. reuteri strains were evaluated for presence of mapA gene and its expression on co-culturing with the Caco-2 cells. The ability of untreated (Viable), heat-inactivated, 5 M LiCL treated L. reuteri strains as well as their cell-free supernatant (CFS) to modulate expression of IEB function genes (hBD-2, hBD-3, claudin-1 and occludin) was also evaluated. Caco-2 cells were treated with cell surface and extracellular protein extracts and investigated for change in expression of targeted IEB function genes. The results showed that mapA gene is present in all the tested L. reuteri strains and expression of mapA and its receptors (anxA13 and palm) increase significantly on co-culturing of L. reuteri and Caco-2 cells. Also, up-regulated expression of IEB function genes was observed on co-culturing of L. reuteri (viable, heat-inactivated and CFS) and their protein extracts with Caco-2 cells in contrast to down-regulation observed with the pathogenic strain of Salmonella typhi. Therefore, this study concludes that the cell surface and extracellular protein from L. reuteri act as an effective mediator molecules to regulate IEB function.

First line transradial access for posterior circulation stroke intervention; initial 12-month experience at a high volume thrombectomy center.

BACKGROUND: The Neurointerventional Surgery Standards and Guidelines Committee has advocated the use of transradial access in the setting of posterior circulation stroke intervention, however there is a paucity of published data on this approach. The purpose of this study is to present 12-months of prospectively collected data from a high volume thrombectomy center following the adoption of a first line transradial approach for posterior circulation stroke intervention. METHODS: A range of data on patient characteristics, procedural metrics, complications and outcomes was prospectively collected between August 2018 - August 2019 following the adoption of first line transradial access for posterior circulation stroke intervention at a high volume thrombectomy center. RESULTS: Transradial access was successful in 22/23 cases (96%), median arteriotomy to reperfusion time was 24 min (IQR 18-40), good angiographic outcome (mTICI 2b-3) was achieved in all cases and good clinical outcome (mRs 0-2) was achieved in 61% of cases. No intracranial or radial artery access site complications occurred. CONCLUSION: The fast procedure times, excellent outcomes and low complication rates achieved in this prospective 12-month study indicate that transradial access is a viable first line strategy in posterior circulation stroke intervention.

Housing Subsidies and Housing Stability are Associated with Better HIV Medical Outcomes Among Persons Who Experienced Homelessness and Live with HIV and Mental Illness or Substance Use Disorder.

Among 958 applicants to a supportive housing program for low-income persons living with HIV (PLWH) and mental illness or a substance use disorder, we assessed impacts of housing placement on housing stability, HIV care engagement, and viral suppression. Surveillance and administrative datasets provided medical and residence information, including stable (e.g., rental assistance, supportive housing) and unstable (e.g., emergency shelter) government-subsidized housing. Sequence analysis identified a "quick stable housing" pattern for 67% of persons placed by this program within 2 years, vs. 28% of unplaced. Compared with unplaced persons not achieving stable housing quickly, persons quickly achieving stable housing were more likely to engage in care, whether placed (per Poisson regression, ARR: 1.14;95% CI 1.09-1.20) or unplaced (1.19;1.13-1.25) by this program, and to be virally suppressed, whether placed (1.22;1.03-1.44) or unplaced (1.26, 1.03-1.56) by this program. Housing programs can help homeless PLWH secure stable housing quickly, manage their infection, and prevent transmission.

RESUMEN: Unas 958 personas de bajos recursos y quienes viven con VIH y enfermedades mentales o bien presentan problemas de abuso de sustancias solicitaron a un programa de vivienda complementada con servicios de apoyo. Entre ellas, se evaluó los impactos de la colocación en viviendas sobre la estabilidad en la misma, así como la participación en los cuidados médicos para el VIH, y la supresión de la carga viral. Las bases de datos administrativas y del registro de vigilancia brindaron información médica y domiciliar, incluyendo información sobre vivienda estable (por ejemplo, asistencia de pago de renta a largo plazo, o vivienda complementada con servicios de apoyo) y vivienda inestable (por ejemplo, alojamiento de emergencia temporal) subsidiada por el gobierno. El método "análisis de secuencia" permitió identificar una pauta caracterizada por estabilidad domiciliar conseguida de modo ligero (es decir, de forma oportuna) en el 67% de las personas quienes fueron colocadas por este programa dentro de un lapso de dos años, comparado con 28% de las personas quienes no fueron colocadas. En comparación con las personas quienes no fueron colocadas y no lograron estabilidad de vivienda de modo ligero, las personas quienes lograron estabilidad de vivienda de modo ligero tuvieron una mayor probabilidad de participar en cuidados médicos, ya sea que fueran colocadas (según regresión de Poisson, cociente de riesgo ajustado: 1.14; intervalo de confianza de 95%: 1.09-1.20) o no fueran colocadas (1.19, 1.13-1.25) por este programa, así como de lograr la supresión de la carga viral, ya sea que fueran colocadas (1.22, 1.03-1.44) o no fueran colocadas (1.26, 1.03-1.56) por este programa. Los programas que facilitan la colocación en o el pago de vivienda y apoyo en el mismo pueden ayudar a las personas con VIH y sin hogar obtener vivienda estable de modo ligero, controlar su infección, y prevenir la transmisión.

In Vivo Implications of Potential Probiotic Lactobacillus reuteri LR6 on the Gut and Immunological Parameters as an Adjuvant Against Protein Energy Malnutrition.

The present study investigated the impact of probiotic Lactobacillus reuteri LR6 on the gut and systemic immunity using protein energy malnourished (PEM) murine model. Thirty male Swiss albino mice were divided into five groups: control (C), malnourished (M), probiotic fermented milk (PFM), skim milk (SM), and bacterial suspension (BS) with six mice per group. Group C was fed with conventional diet throughout the study while the other groups were fed with protein calorie restricted diet until the development of malnutrition. After development of malnutrition, group M was continued with the restricted diet while other groups were fed with re-nourished diet supplemented with PFM, SM, and BS for 1 week, respectively. Thereafter, mice were sacrificed and different histological, microbiological, and immunological parameters were studied. Probiotics feeding in PEM model as fermented product or bacterial suspension improved the intestinal health in terms of intact morphology of colonic crypts, normal goblet cells, and intact lamina propria with no inflammation in large intestine, absence of fibrosis, and no inflammation in spleen. The number of secretory IgA+ cells was significantly higher in group PFM and BS. Also, increase in the phagocytic percentage of the macrophages and bone marrow derived dendritic cells (DCs) were observed in the PFM and BS group in comparison to the group M. In comparison to the group M and SM, lactobacilli, bifidobacteria, and Firmicutes counts were significantly higher in the group PFM and BS. This study concludes that probiotic supplementation to re-nutrition diet could emerge as wonder therapeutics against PEM.

Air retrieval for clot retrieval; time-metrics and outcomes of stroke patients from rural and remote regions air-transported for mechanical thrombectomy at a state stroke unit.

BACKGROUND: Providing thrombectomy services to rural or remote regions with small, dispersed populations presents a particular challenge. Sustaining local thrombectomy services is not viable given the low throughput of cases, therefore large vessel occlusion (LVO) stroke patients require emergent transfer, often by air, to the closest high volume urban thrombectomy unit. The aim of this paper is to present logistical, time-metric data and outcome data on LVO stroke patients that have been aeromedically retrieved for thrombectomy from the vast, 2,500,000-km2 rural catchment of the Western Australian state thrombectomy unit. METHODS: The prospectively collected state thrombectomy registry was reviewed and all patients that underwent thrombectomy for LVO strokes following aeromedical retrieval from remote or rural catchments were identified. Multiple logistic and time-metric data points were recorded and outcomes were compared to a cohort of urban patients treated over the same period. RESULTS: Over a 2-year period 30 patients underwent thrombectomy following aeromedical retrieval, either by helicopter or fixed wing aircraft, from rural and remote regions of Western Australia. The mean aeromedical retrieval distance was 393 km while the maximum retrieval distance was over 2600 km. The mean ictus to recanalization time was 657 min, an mTICI 2b-3 recanalization was achieved in 93% of cases and 62% of anterior circulation, and 50% of posterior circulation LVO stroke patients achieved functional independence at 90-days. Outcome data for rural patients compared favourably to urban patients treated over the same time period. CONCLUSION: With the availability of an efficient aeromedical retrieval service, LVO stroke patients in rural and remote regions can achieve excellent outcomes following transfer to a high volume thrombectomy unit, even if distances involved are very large.

Digitally Augmented Learning in Implant Dentistry.

The economic forces in the dental education industry yield a high cost for a dental degree, yet the financial return for this education yields a small margin above the costs for this degree. Industries with unfavorable return to investment ratios tend to be vulnerable to changes. Productive technologies are emerging that may be useful in improving the return to investment ratios in dental education. Virtual reality and online learning provide productive value that could be useful to the dental education industry. A description and use cases of virtual reality in dental implantology education are provided.

Supportive Housing and Its Relationship With Diabetes Diagnosis and Management Among Homeless Persons in New York City.

Supportive housing addresses a fundamental survival need among homeless persons, which can lead to reduced risk of diabetes mellitus and improved diabetes care. We tested the association between supportive housing and diabetes outcomes among homeless adults who were eligible for New York City's supportive housing program in 2007-2012. We used multiple administrative data sources, identifying 7,525 Medicaid-eligible adults. The outcomes included receiving medical evaluation and management services, hemoglobin A1C and lipid testing (n = 1,489 persons with baseline diabetes), and incidence of new diabetes diagnoses (n = 6,036 persons without baseline diabetes) in the 2 years postbaseline. Differences in these outcomes by placement were estimated using inverse-probability-of-treatment weighting. Placed persons were more likely to receive evaluation and management services (relative risk (RR) = 1.03, 95% confidence interval (CI): 1.01, 1.04) than unplaced persons. For those with baseline diabetes, placed persons were more likely to receive hemoglobin A1C tests (RR = 1.10, 95% CI: 1.02, 1.19) and lipid tests (RR = 1.09, 95% CI: 1.02, 1.17). For those without baseline diabetes, placement was also associated with lower risk of new diabetes diagnoses (RR = 0.87, 95% CI: 0.76, 0.99). These findings show that benefits of supportive housing may be extended to diabetes care and prevention.

Impact of supportive housing on substance use-related health care utilization among homeless persons who are active substance users.

PURPOSE: Homeless persons with a substance use disorder (SUD) are at high risk of emergency department (ED) visits and hospitalizations. We evaluated the impact of supportive housing on SUD-related ED visits and hospitalizations among active substance users experiencing chronic homelessness. METHODS: We matched 1558 homeless adults eligible for a New York City supportive housing program who had a SUD (2007-2012) to Medicaid claims data. We examined SUD-related hospitalizations and ED visits 2 years posteligibility. We calculated stabilized inverse probability of treatment weights using baseline demographic and clinical characteristics and used doubly robust estimators to compare rates between persons placed into supportive housing and those eligible but not placed. We also examined outpatient SUD treatment. RESULTS: Placed persons were hospitalized and visited EDs for substance use at significantly lower rates than persons not placed into housing (adjusted rate ratio, 0.70; 95% confidence interval, 0.56-0.88 and adjusted rate ratio, 0.46; 95% confidence interval, 0.31-0.68, respectively) 2 years posteligibility. Placed persons had increased odds of a new episode of SUD treatment and initiating treatment. CONCLUSIONS: Supportive housing placement was associated with decreases in SUD-related hospitalizations and ED visits and with increased odds of new episodes of SUD outpatient treatment among homeless persons with SUD.

Gastric Lipohyperplasia Presenting as Gastric Polyposis: the First Case Report and Morphometric Study of Additional 127 Bariatric Specimens with a Proposal for Diagnostic Criteria.

INTRODUCTION: Excessive fat accumulation in the gastrointestinal tract is pathologic. Gastric mucosal polyposis due to excessive submucosal fat infiltration in a bariatric partial gastrectomy specimen was encountered, which has not been described in the literature. This observation prompted us to assess the extent of fat in gastric submucosa and study the incidence of mucosal polyposis due to submucosal fat accumulation in morbidly obese patients. MATERIALS AND METHODS: Archived pathology slides of 128 bariatric partial gastrectomy specimens including the index case and 89 control cases obtained from Whipple's procedure were examined. The amount of submucosal fat was categorized as 0 (no fat), 1 (up to 70% fat), and 2 (> 70% fat). The maximum submucosal fat thickness was measured with the interval cutoff of 5 mm and 10 mm. RESULTS: Of the 128 cases, 90 (70.3%) were category 1 and 31 (24.2%) were category 2. Maximum submucosal fat thickness was > 10 mm in 3 (2.3%) cases including the index case. The extent of submucosal fat accumulation correlated with the body mass index. The frequencies of category 2 and > 10 mm of fat thickness were higher in the bariatric patient group compared with the control group. CONCLUSION: We propose a submucosal fat thickness of > 10 mm and diffuse (> 70%) fat accumulation as diagnostic criteria for gastric lipohyperplasia. Using these criteria, the prevalence of gastric lipohyperplasia in the morbidly obese population is 2.3%. A subset of these may present as gastric mucosal polyps.

Transvenous coil embolization with intra-operative cone beam CT assistance in the treatment of hypoglossal canal dural arteriovenous fistulae.

BACKGROUND: Hypoglossal canal dural arteriovenous fistulae (HC-dAVF) are a rare subtype of skull base fistulae involving the anterior condylar confluence or anterior condular vein within the hypoglossal canal. Transvenous coil embolization is a preferred treatment strategy, however delineation of fistula angio-architecture during workup and localization of microcatheter tip during embolization remain challenging on planar DSA. For this reason, our group have utilized intra-operative cone beam CT (CBCT) and selective cone beam CT angiography (sCBCTA) as adjuncts to planar DSA during workup and treatment. The purpose of this article is to present our experience in the treatment of HC-dAVF using transvenous coil embolization (TVCE) with cone beam CT assistance, describing our technique as well as presenting our angiographic and clinical outcomes. METHODS: Ten patients with symptomatic HC-dAVF were treated using TVCE with intra-operative cone beam CT assistance. Prospectively collected data regarding clinical and angiographic results and complication rates was recorded and reviewed. RESULTS: Complication-free fistula occlusion was achieved in our entire patient cohort. The dominant symptom of pulsatile tinnitus resolved in all 10 patients. CONCLUSIONS: This study demonstrates that TVCE with CBCT assistance is a highly effective treatment option for HC-dAVF, achieving complication-free fistula occlusion in our entire patient cohort. We have found low-dose sCBCTA and CBCT to be an extremely useful adjunct to planar DSA imaging during both workup and treatment of these rare fistulae.

Impact of a New York City Supportive Housing Program on Housing Stability and Preventable Health Care among Homeless Families.

OBJECTIVE: To assess the impact of a New York City supportive housing program on housing stability and preventable emergency department (ED) visits/hospitalizations among heads of homeless families with mental and physical health conditions or substance use disorders. DATA SOURCES: Multiple administrative data from New York City and New York State for 966 heads of families eligible for the program during 2007-12. STUDY DESIGN: We captured housing events and health care service utilization during 2 years prior to the first program eligibility date (baseline) and 2 years postbaseline. We performed sequence analysis to measure housing stability and compared housing stability and preventable ED visits and hospitalizations between program participants (treatment group) and eligible applicants not placed in the program (comparison group) via marginal structural modeling. DATA COLLECTION/EXTRACTION METHODS: We matched electronically collected data. PRINCIPAL FINDINGS: Eighty-seven percent of supportive housing tenants experienced housing stability in 2 years postbaseline. Compared with unstably housed heads of families in the comparison group, those in the treatment group were 0.60 times as likely to make preventable ED visits postbaseline (95% CI = 0.38, 0.96). CONCLUSIONS: Supportive housing placement was associated with improved housing stability and reduced preventable health care visits among homeless families.

Impact of a New York City supportive housing program on Medicaid expenditure patterns among people with serious mental illness and chronic homelessness.

BACKGROUND: A rapid increase of Medicaid expenditures has been a serious concern, and housing stability has been discussed as a means to reduce Medicaid costs. A program evaluation of a New York City supportive housing program has assessed the association between supportive housing tenancy and Medicaid savings among New York City housing program applicants with serious mental illness and chronic homelessness or dual diagnoses of mental illness and substance use disorder, stratified by distinctive Medicaid expenditure patterns. METHODS: The evaluation used matched data from administrative records for 2827 people. Sequence analysis identified 6 Medicaid expenditure patterns during 2 years prior to baseline among people placed in the program (n = 737) and people eligible but not placed (n = 2090), including very low Medicaid coverage, increasing Medicaid expenditure, low, middle, high, and very high Medicaid expenditure patterns. We assessed the impact of the program on Medicaid costs for 2 years post-baseline via propensity score matching and bootstrapping. RESULTS: The housing program was associated with Medicaid savings during 2 years post-baseline (-$9526, 95% CI = -$19,038 to -$2003). Stratified by Medicaid expenditure patterns, Medicaid savings were found among those with very low Medicaid coverage (-$15,694, 95% CI = -$35,926 to -$7983), increasing Medicaid expenditures (-$9020, 95% CI = -$26,753 to -$1705), and high Medicaid expenditure patterns (-$14,450, 95% CI = -$38,232 to -$4454). Savings were largely driven by shorter psychiatric hospitalizations in the post-baseline period among those placed. CONCLUSIONS: The supportive housing program was associated with Medicaid savings, particularly for individuals with very low Medicaid coverage, increasing Medicaid expenditures, and high Medicaid expenditures pre-baseline.

Embolization for the treatment of intractable epistaxis: 12 month outcomes in a two centre case series.

OBJECTIVE: Embolization is a treatment option for intractable epistaxis; however, concerns regarding tissue necrosis, stroke and blindness persist in the literature. METHODS: A retrospective review of patients from September 2010 to January 2016 treated with embolization for epistaxis was performed. No patient was excluded. Follow-up was 12 months and no patient was lost. RESULTS: 62 embolizations on 59 patients occurred. 21 cases were taking anticoagulants, P2Y12 inhibiting agents or had a systemic coagulopathy. Embolized territories typically involved bilateral distal internal maxillary arteries with unilateral or bilateral facial arteries with polyvinyl alcohol particles. 60 cases had procedural general anaesthesia. There were no major complications. Six died of unrelated causes. Of the surviving 53 patients, excluding the 3 patients with hereditary haemorrhagic telangiectasia, 5 had recurrent epistaxis post-embolization. Four were taking P2Y12 inhibiting and/or anticoagulants, none of which required surgery, prolonged packing or repeat embolization. This group had a propensity to recur compared with cases taking aspirin only or no antiplatelet/anticoagulant (77.8 vs 97.1%, p = 0.04). The fifth underwent repeat embolization after previously only having ipsilateral distal internal maxillary and facial arteries treated. CONCLUSION: Embolization for epistaxis is safe and effective. Of those who had recurrent epistaxis post embolization, most were taking P2Y12 inhibition and/or anticoagulation. We prefer bilateral distal internal maxillary artery and unilateral facial artery embolization under general anaesthesia for optimal safety and efficacy. Advances in knowledge: Embolization with this technique seems to facilitate superior outcomes without complications despite the large proportion of patients taking anticoagulating or P2Y12 inhibiting agents.

Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre.

BACKGROUND AND PURPOSE: Endovascular thrombectomy (EVT) improves the functional outcome when added to best medical therapy, including alteplase, in patients with acute ischaemic stroke secondary to large vessel occlusion (LVO) in the anterior circulation. However, the evidence for EVT in alteplase-ineligible patients is less compelling. It is also uncertain whether alteplase is necessary in patients with successful recanalization by EVT, as the treatment effect of EVT may be so powerful that bridging alteplase may not add to efficacy and may compromise safety by increasing bleeding risks. We aimed to survey the proportion of patients suitable for EVT who are alteplase-ineligible and to compare the safety and effectiveness of standard care of acute large artery ischaemic stroke by EVT plus thrombolysis with that of EVT alone in a tertiary hospital clinical stroke service. METHODS: We performed a retrospective analysis of acute ischaemic stroke patients treated with EVT at our centre between October 2013 and April 2016, based on a registry with prospective and consecutive patient collection. Individual patient records were retrieved for review. Significant early neurological improvement was defined as a NIHSS score of 0-1, or a decrease from baseline of ≤8, at 24 h after stroke onset. RESULTS: Fifty patients with acute ischaemic stroke secondary to LVO in the anterior circulation received EVT in this period, of whom 21 (42%) received concurrent alteplase and 29 (58%) EVT alone. The 2 groups had similar baseline characteristics and similar outcomes. Significant neurological improvement at 24 h occurred in 47.6% of the patients with EVT and bridging alteplase and in 51.7% of the patients with EVT alone (p = 0.774). Mortality during acute hospitalization was 20% for the bridging alteplase group versus 7.1% for EVT alone (p = 0.184). Intracranial haemorrhage rates were 14.3% for bridging alteplase versus 20.7% for EVT alone (p = 0.716). Local complications, groin haematoma (23.8 vs. 10.3%) and groin pseudoaneurysms (4.8 vs. 0%) (p = 0.170), were not significantly different. CONCLUSION: Our study highlights the relatively large proportion of patients suitable for EVT who have a contraindication to alteplase and raises the hypothesis that adding alteplase to successful EVT may not be necessary to optimize functional outcome. The results are consistent with observational data from other endovascular centres and support a randomised controlled trial of EVT versus EVT with bridging alteplase.