Can the ischemic penumbra be identified on noncontrast CT of acute stroke?

BACKGROUND AND PURPOSE: Early ischemic changes on noncontrast CT in acute stroke include both hypoattenuation and brain swelling, which may have different pathophysiological significance. METHODS: Noncontrast CT and CT perfusion brain scans from patients with suspected acute stroke <6 hours after onset were reviewed. Five raters independently scored noncontrast CTs blind to clinical data using the Alberta Stroke Program Early CT Score (ASPECTS). Each ASPECTS region was scored as hypodense or swollen. A separate reviewer measured time to peak and cerebral blood volume in each ASPECTS region on CT perfusion. Time to peak and cerebral blood volume were compared for each region categorized as normal, hypodense, or isodense and swollen. RESULTS: Scans of 32 subjects a median 155 minutes after onset yielded 228 regions with both CT perfusion and noncontrast CT data. Isodense swelling was associated with significantly higher cerebral blood volume (P=0.016) and with penumbral perfusion (posttest:pretest likelihood ratio 1.44 [95% CI: 0.68 to 2.90]), whereas hypodensity was associated with more severe time to peak delay and with core perfusion (likelihood ratio 3.47 [95% CI: 1.87 to 6.34]). Neither isodense swelling nor hypodensity was sensitive for prediction of perfusion pattern, but appearances were highly specific (87.2% and 91.0% for penumbra and core, respectively). Intrarater agreement was good or excellent, but interrater agreement for both hypodensity and swelling was poor. CONCLUSIONS: Regions exhibiting hypoattenuation are likely to represent the infarct core, whereas regions that are isodense and swollen have increased cerebral blood volume and are more likely to signify penumbral perfusion. Although noncontrast CT is not sensitive for detection of core and penumbra, appearances are specific. Some information on tissue viability can therefore be obtained from noncontrast CT.

Phosphorus and other soil components in a dairy effluent sprayfield within the central Florida Ridge.

There is concern that P from dairy effluent sprayfields will leach into groundwater beneath Suwannee River basins in northern Florida. Our purpose was to describe the effects of dairy effluent irrigation on the movement of soil P and other nutrients within the upper soil profile of a sprayfield over three 12-mo cycles (April 1998-March 2001). Effluent P rates of 70, 110, and 165 kg ha(-1) cycle(-1) were applied to forages that were grown year-round. The soil is a deep, excessively drained sand (thermic, uncoated Typic Quartzipsamment). Mean P concentration in soil water below the rooting zone (152-cm depth) was < or = 0.1 mg L(-1) during 11 3-mo periods. Mehlich-1-extractable (M1) P, Al, and Ca in the topsoil increased over time but did not change in subsoil depths of 25 to 51, 51 to 71, 71 to 97, and 97 to 122 cm. Topsoil Ca increased as effluent rate increased. High Ca levels were found in dairy effluent (avg.: 305 mg L(-1)) and supplemental irrigation water (avg.: 145 mg L(-1)) which likely played a role in retaining P in the topsoil. An effect of effluent rate on P and Al concentrations in the topsoil was not detected, probably due to large and variable quantities present at project initiation. The P retention capacity (i.e., Al plus Fe) increased in the topsoil because Al increased. Dairy effluent contained Al (avg.: 31 mg L(-1)). Phosphorus saturation ratio (PSR) increased over time in the topsoil but not in subsoil layers. Regardless of effluent rate, the P retention capacity and PSR of subsoil, which contained 119 to 229 mg kg(-1) of Al, should be taken into account when assessing the risk of P moving below the rooting zone of most forage crops.

Computed tomography angiography for the evaluation of carotid atherosclerotic plaque: correlation with histopathology of endarterectomy specimens.

BACKGROUND AND PURPOSE: The goal of this study was to determine the efficacy of CT angiography for the characterization of plaque morphology and composition in carotid atherosclerotic disease. METHODS: Fifty-five patients undergoing carotid endarterectomy were imaged preoperatively with single-slice spiral CT angiography. One hundred sixty-five endarterectomy sections were examined histologically at selected levels through the distal common and proximal internal carotid arteries. Plaque density was measured (in Hounsfield units) on axial CT sections, and the presence or absence of ulceration was noted. These observations were compared with the histological findings at corresponding levels. Data were analyzed with 2-sample t tests and 1-way analysis of variance (ANOVA). RESULTS: ANOVA testing showed a statistically significant decrease in CT attenuation values with increasing plaque lipid but with a very high standard deviation of values. No other histological factor showed a statistically significant link with CT attenuation. Plaque ulceration was detected by CT with a sensitivity of 60% and a specificity of 74%. CONCLUSIONS: Analysis of plaque attenuation with single-slice spiral CT does not give useful information concerning plaque composition. The predictive value of CT for the detection of plaque ulceration was moderate. Single-slice CT angiography is insufficiently robust to be a useful tool for the characterization of carotid plaque composition and morphology.

The effect of surveillance and appreciative inquiry on puerperal infections: a longitudinal cohort study in India.

OBJECTIVE: To evaluate the effects of an intervention comprising surveillance and an organisational change called Appreciative Inquiry on puerperal infections in hospitals in Gujarat state, India. METHODS: This longitudinal cohort study with a control group was conducted over 16 months between 2010 and 2012. Women who delivered in six hospitals were followed-up. After a five month pre-intervention period, the intervention was introduced in three hospitals. Monthly incidence of puerperal infection was recorded throughout the study in all six hospitals. A chi-square test and logistic regression were used to examine for associations, trends and interactions between the intervention and control groups. FINDINGS: Of the 8,124 women followed up, puerperal infections were reported in 319 women (3.9%) over the course of the study. Puerperal sepsis/genital tract infections and urinary tract infections were the two most common puerperal infections. At the end of the study, infection incidence in the control group halved from 7.4% to 3.5%. Levels in the intervention group reduced proportionately even more, from 4.3% to 1.7%. A chi-square test for trend confirmed the reduction of infection in the intervention and control groups (p<0.0001) but the trends were not statistically different from one another. There was an overall reduction of infection by month (OR = 0.94 95% CI 0.91-0.97). Risk factors like delivery type, complications or delivery attendant showed no association with infection. CONCLUSION: Interruption of resource flows in the health system occurred during the intervention phase, which may have affected the findings. The incidence of infection fell in both control and intervention groups during the course of the study. It is not clear if appreciative inquiry contributed to the reductions observed. A number of practical and methodological limitations were faced. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN03513186.

Community pharmacists' perceptions of barriers to communication with migrants.

OBJECTIVES: Effective communication by pharmacists is essential to ensure patient safety in terms of provision and use of medications by patients. Global migration trends mean community pharmacists increasingly encounter patients with a variety of first languages. The aim of this study was to explore community pharmacists' perceptions of communication barriers during the provision of care to A8 (nationals from central/Eastern European states) migrants. METHODS: A qualitative face-to-face interview study of purposively sampled community pharmacists, North East Scotland. KEY FINDINGS: Participants (n = 14) identified a number of barriers to providing optimal care to A8 migrants including: communication (information gathering and giving); confidentiality when using family/friends as translators; the impact of patient healthcare expectations on communication and the length of the consultation; and frustration with the process of the consultation. CONCLUSIONS: Several barriers were specific to A8 migrants but most seemed pertinent to any group with limited English proficiency and reflect those found in studies of healthcare professionals caring for more traditional UK migrant populations. Further research is needed using objective outcome measures, such as consultation recordings, to measure the impact of these perceived barriers on pharmacist-patient consultations. Language and cultural barriers impact on the quality of pharmacist-patient communication and thus may have patient safety and pharmacist training implications.