The randomized study of enteral nutrition with rapid versus conventional administration in acute stroke patients; the protocol of rapid EN trial.

Rationale: Enteral nutrition is beneficial for stroke patients with oral intake difficulties. However, it is time consuming and may interfere with routine medical care. Therefore, there is a clinical benefit if enteral nutrition can be safely administered in a short time. Although our retrospective study showed the safety of rapid administration, it remains unclear whether rapid administration of enteral nutrition is as safe as conventional administration. Aim: The randomized study of Enteral Nutrition with Rapid versus conventional administration in acute stroke patients (Rapid EN trial) aims to clarify the safety of rapid feeding of enteral nutrition compared with conventional feeding. Methods and design: This is an investigator-initiated, multicenter, prospective, randomized, open-label, blinded end-point clinical trial. Eligible criteria include acute stroke patients who have difficulty with oral intake defined as severe altered consciousness (Japan Coma Scale 10-300) or modified water swallowing test <4. The target enrollment is 700 patients, with 350 patients receiving rapid enteral nutrition at a rate of 100 mL in 5 min (Rapid EN group) and 350 patients receiving conventional enteral nutrition at a rate of 100 mL in 30 min (Conventional EN group). Study outcome: The primary outcome is the incidence of one or more complications of vomiting or diarrhea or pneumonia within 7 days would be non-inferior in the rapid EN group compared to the conventional EN group. Secondary outcomes were total time spent on enteral nutrition within 7 days from enteral nutrition, the incidence of vomiting, diarrhea and pneumonia within 3 or 7 days, and the rate of favorable clinical outcome. Discussion: Since no previous reports have focused on the speed of administration, we felt it was necessary to prove the safety of rapid administration. If this study shows positive results, it will not only benefit patients, but also reduce the burden of medical care. We believe this study is novel and will be useful in clinical practice. Clinical trial registration: https://rctportal.niph.go.jp/s/detail/um?trial_id=UMIN000046610 Identifier UMIN000046610.

Biallelic variants in LARS1 induce steatosis in developing zebrafish liver via enhanced autophagy.

BACKGROUND: Biallelic pathogenic variants of LARS1 cause infantile liver failure syndrome type 1 (ILFS1), which is characterized by acute hepatic failure with steatosis in infants. LARS functions as a protein associated with mTORC1 and plays a crucial role in amino acid-triggered mTORC1 activation and regulation of autophagy. A previous study demonstrated that larsb-knockout zebrafish exhibit conditions resembling ILFS. However, a comprehensive analysis of larsb-knockout zebrafish has not yet been performed because of early mortality. METHODS: We generated a long-term viable zebrafish model carrying a LARS1 variant identified in an ILFS1 patient (larsb-I451F zebrafish) and analyzed the pathogenesis of the affected liver of ILFS1. RESULTS: Hepatic dysfunction is most prominent in ILFS1 patients during infancy; correspondingly, the larsb-I451F zebrafish manifested hepatic anomalies during developmental stages. The larsb-I451F zebrafish demonstrates augmented lipid accumulation within the liver during autophagy activation. Inhibition of DGAT1, which converts fatty acids to triacylglycerols, improved lipid droplets in the liver of larsb-I451F zebrafish. Notably, treatment with an autophagy inhibitor ameliorated hepatic lipid accumulation in this model. CONCLUSIONS: Our findings suggested that enhanced autophagy caused by biallelic LARS1 variants contributes to ILFS1-associated hepatic dysfunction. Furthermore, the larsb-I451F zebrafish model, which has a prolonged survival rate compared with the larsb-knockout model, highlights its potential utility as a tool for investigating the pathophysiology of ILFS1-associated liver dysfunction.

Remote neuro-endovascular consultation using a secure telemedicine system: A feasibility study.

BACKGROUND: Telemedicine has been rapidly implemented under COVID-19 conditions, to assess the ability to use an audio-visual telemedicine system for neuro-endovascular remote consultation. METHODS: The system consists of a live streaming function for angiography and an operating room (OR) camera using a smartphone application (JOIN; Allm Inc, Tokyo, Japan) in conjunction with verbal communication using the Zoom app. The system allows us to display multiple angiographic images in addition to streaming video from the 4K camera recording the operator's procedure and from the 4K camera showing the OR view on the monitor of any smart device. RESULTS: The operator was able to speak with the senior supervisor through a bone conduction headphone and to talk to assistants or radiology technicians without any hearing difficulties. The remote supervisor was able to check the streaming images, which had almost the same imaging quality as real digital subtraction angiogram (DSA) monitors, and he could advise the handling of devices and preparation through the 4K video camera systems. The DSA image delay was within 2 s. CONCLUSION: A remote consultation system with real-time audio-visual capability may play an important role in acute stroke management and maintain the quality of patient care under COVID-19 conditions.

Comparison of Clinical Outcomes After Stent-Assisted Coiling with 3 Types of Self-Expanding Laser-Cut Stents in Patients with Wide-Necked Intracranial Aneurysms.

OBJECTIVE: We report the clinical outcomes of stent-assisted coiling for wide-necked intracranial aneurysms using 3 low-profile laser-cut stents and compare the results according to stent type. METHODS: All patients treated with stent-assisted coiling for their intracranial aneurysms at our hospital between July 2010 and September 2019 were reviewed. We selected patients with Enterprise, Neuroform EZ, or Neuroform Atlas stents who underwent imaging follow-up and investigated aneurysm and stent features, stent-related complications, recanalization, and retreatment rates. We compared the retreatment risk among the patients treated with the 3 stent types using Kaplan-Meier survival analysis and Cox regression analysis. RESULTS: We evaluated 364 consecutive cases (103 Enterprise, 105 Neuroform EZ, and 156 Neuroform Atlas stents). Neuroform Atlas was more frequently used in distal vessels: 8 (7.8%) Enterprise, 2 (1.9%) Neuroform EZ, and 41 (26.3%) Neuroform Atlas cases, respectively. The median follow-up durations were 6.49, 4.91, and 1.24 years for the Enterprise, Neuroform EZ, and Neuroform Atlas cases, respectively, and retreatment was performed in 11 (10.1%), 9 (8.6%), and 6 (3.8%) cases. In the first 2 years of follow-up, the estimated retreatment risk ratios for Neuroform EZ and Neuroform Atlas with Enterprise as reference were 0.63 (95% confidence interval, 0.24-1.65; P = 0.35) and 0.54 (95% confidence interval, 0.18-1.59; P = 0.26), respectively. CONCLUSIONS: Neuroform Atlas stents were more frequently deployed in small-caliber vessels compared with the other 2 types of stents. The complication rate and retreatment risk until at least 1 year after the aneurysm treatment appeared to be similar for the 3 stent types.

[Chronic Encapsulated Intracerebral Hematoma Associated with Arteriovenous Malformation, Shrinking after Feeder Embolization with Clinical Improvement:A Case Report].

Chronic encapsulated intracerebral hematoma(CEIH)with arteriovenous malformation(AVM)is rare. We report a case of CEIH shrinking after feeder embolization for AVM. A 60-year-old man experiencing headaches for 2 weeks was admitted to our hospital due to intracerebral hematoma detected by MRI. The hematoma was shown as a low-density mass lesion on CT scans. Angiography and enhanced MRI showed an AVM in the right temporal lobe associated with the CEIH. Mild disturbance of consciousness and headaches gradually worsened, as the CEIH grew. Before AVM resection, feeder embolization was performed. On the day after the embolization, symptoms improved and the CEIH shrunk in size. A week following the embolization, the AVM including the partial hematoma capsule was resected without neurological deficit. Previous literature showed similarities between CEIH and chronic subdural hematoma(CSDH)in clinical features and pathological findings of the capsule. This case indicated that feeder embolization might be a treatment option for CEIH with AVM, such as embolization of middle meningeal artery for intractable CSDH.