Short and long-term impact of four sets of actions on acute ischemic stroke management in Rhône County, a population based before-and-after prospective study.

BACKGROUND: Optimizing access to recanalization therapies in acute ischemic stroke patients is crucial. Our aim was to measure the short and long term effectiveness, at the acute phase and 1 year after stroke, of four sets of actions implemented in the Rhône County. METHODS: The four multilevel actions were 1) increase in stroke units bed capacity and development of endovascular therapy; 2) improvement in knowledge and skills of healthcare providers involved in acute stroke management using a bottom-up approach; 3) development and implementation of new organizations (transportation routes, pre-notification, coordination by the emergency call center physician dispatcher); and 4) launch of regional public awareness campaigns in addition to national campaigns. A before-and-after study was conducted with two identical population-based cohort studies in 2006-7 and 2015-16 in all adult ischemic stroke patients admitted to any emergency department or stroke unit of the Rhône County. The primary outcome criterion was in-hospital management times, and the main secondary outcome criteria were access to reperfusion therapy (either intravenous thrombolysis or endovascular treatment) and pre-hospital management times in the short term, and 12-month prognosis measured by the modified Rankin Scale (mRS) in the long term. RESULTS: Between 2015-16 and 2006-7 periods ischemic stroke patients increased from 696 to 717, access to reperfusion therapy increased from 9 to 23% (p < 0.0001), calls to emergency call-center from 40 to 68% (p < 0.0001), first admission in stroke unit from 8 to 30% (p < 0.0001), and MRI within 24 h from 18 to 42% (p < 0.0001). Onset-to-reperfusion time significantly decreased from 3h16mn [2 h54-4 h05] to 2h35mn [2 h05-3 h19] (p < 0.0001), mainly related to a decrease in delay from admission to imaging. A significant decrease of disability was observed, as patients with mild disability (mRS [0-2]) at 12 months increased from 48 to 61% (p < 0.0001). Pre-hospital times, however, did not change significantly. CONCLUSIONS: We observed significant improvement in access to reperfusion therapy, mainly through a strong decrease of in-hospital management times, and in 12-month disability after the implementation of four sets of actions between 2006 and 2016 in the Rhône County. Reducing pre-hospital times remains a challenge.

Explantation of phakic intraocular lenses: causes and outcomes.

PURPOSE: To describe reasons for explantation of anterior and posterior chamber phakic intraocular lenses (pIOLs), as well as outcomes of the surgery. METHODS: The medical files of patients who underwent pIOL explantation due to complications were reviewed. All patients were divided into three groups based on the type of explanted pIOL: anterior chamber angle-supported (AS pIOL), anterior chamber iris-fixated (IF pIOL), and posterior chamber (PC pIOL). RESULTS: Sixty-two eyes of 41 patients were evaluated. There were 26 (41.9%), 16 (25.8%), and 20 (32.2%) eyes in the AS pIOL, IF pIOL, and PC pIOL groups, respectively. The mean interval between the implantation and removal of the pIOL (i.e., survival time) was 13.6 ± 8.1 years (range 0.01-21.22 years). The mean follow-up after the explantation was 22.5 ± 4.0 months (range 11.3-28.7 months). The main causes of explantation were cataract in the PC pIOL group (60%) and chronic endothelial cell loss in the AS pIOL group (53.8%) and IF pIOL group (56.2%). Overall, the procedure most often combined with pIOL explantation was phacoemulsification and implantation of a posterior chamber IOL (40.3%), followed by keratoplasty (9.6%). Intraoperative complications were significantly more common in the AS pIOL group than the other groups (p < 0.001). CONCLUSIONS: Explantation of anterior chamber pIOLs due to severe endothelial cell loss and the proportion of keratoplasty was more common in patients with a relatively long survival time. Therefore, patients with pIOL implantation should be monitored regularly after surgery.

Deep anterior lamellar keratoplasty techniques; predescemetic versus big bubble: Anterior segment optical coherence tomography study.

PURPOSE: To compare the visual and refractive outcomes and anterior segment optical coherence tomography (AS-OCT) findings of 2 different deep anterior lamellar keratoplasty (DALK) techniques in the treatment of advanced keratoconus with and without successful big bubble formation. METHODS: In this retrospective comparative case series, data from 79 consecutive eyes of 69 patients who underwent either big bubble (group 1, n: 62) or manual DALK (group 2, n: 17) were analyzed. The visual and refractive results, keratometric values and residual stromal thickness were assessed. Patients were seen at 1, 3, 6 and 12 months after the procedure and 1 month after complete suture removal. RESULTS: A big bubble was successfully obtained in 62 eyes (78.5%; group 1) and manual dissection was performed in the 17 remaining eyes (21.5%; group 2). The final best spectacle-corrected visual acuity (BSCVA) was 0.38 logMAR and 0.55 logMAR in Group 1 and 2, respectively (P<0.05). At the final visit, BSCVA≤0.30 logMAR was achieved in 80% and 60.8% of eyes in Groups 1 and 2, respectively (P<0.001). Groups 1 and 2 were comparable in terms of mean keratometry: 47.80D±2.81D (range, 41.30D to 54.2D) versus 45.90D±3.62D (range, 41.10D to 53.8 D), respectively; (P=0.56) and keratometric astigmatism: 3.81D± 2.1D (range, 1.0D to 6.20D) versus 3.56D±1.92D (range 1.2D to 6.85D), respectively; (P=0.40) at the final follow-up. The mean residual stromal thickness was 36.90±17.80µm in group 2. CONCLUSION: The presence of residual posterior corneal stroma when big bubble formation is not successfully achieved in DALK is correlated with lower postoperative visual acuity.

Maternal blood biomarkers and adverse pregnancy outcomes: a systematic review and meta-analysis.

Background: Pregnancy is a vulnerable period for the mother and the infant and exposures to environmental chemicals in utero can influence neonatal morbidity and mortality. There is a momentum toward understanding and exploring the current maternal biological mechanisms specific to in utero effects, to improve birth outcomes. This study aims to examine the current understanding of the role of biomarkers that may be associated with term of pregnancy, infant birth weights and infant development in utero.Methods: Electronic searches were conducted in PubMed, Embase, OvidMD, and Scopus databases; and all relevant research articles in English were retrieved. Studies were selected if they evaluated maternal blood plasma/serum biomarkers proposed to influence adverse birth outcomes in the neonate. Data were extracted on characteristics, quality, and odds ratios from each study and meta-analysis was conducted.Results: A total of 54 studies (35 for meta-analysis), including 43,702 women, 50 plasma markers and six descriptors of birth outcomes were included in the present study. The random effect point estimates for risk of adverse birth outcomes were 1.61(95%CI: 1.39-1.85, p < 0.0001) for inflammation-related biomarkers and 1.65(95%CI: 1.22-2.25, p = 0.0013) for growth factor/hormone-related biomarkers. All subgroups of plasma markers showed significant associations with adverse birth outcomes with no apparent study bias.Conclusions: The two subsets of plasma markers identified in this study (inflammation-related and growth factor/hormone-related) may serve as potentially valuable tools in the investigation of maternal molecular mechanisms, especially select pathways underlying inflammatory and immunological mediation in terms of modulating adverse infant outcomes. Future large, prospective cohort studies are needed to validate the promising plasma biomarkers, and to examine other maternal biological matrices such as cervicovaginal fluid and urine.

Evaluation of lamina cribrosa in angioid streaks using spectral-domain optical coherence tomography enhanced depth imaging.

PURPOSE: To investigate retinal nerve fiber layer (RNFL) thickness, anterior lamina cribrosa depth (ALD) and laminar thickness (LT) in eyes with angioid streaks (AS) in comparison with healthy eyes. METHODS: Patients with AS (n=32 eyes) and age-matched healthy subjects (n=42 eyes) underwent enhanced depth imaging with spectral domain optical coherence tomography of the optic nerve head. RNFL thickness was obtained automatically by using the Heidelberg software. The ALD was defined as the vertical distance between the Bruch's membrane openings as reference plane and the anterior border of the lamina cribrosa. The LT was measured as the distance between the anterior and posterior borders of the lamina cribrosa. RNFL thickness, ALD and LT were compared between the AS and healthy eyes adjusting for axial length. RESULTS: The mean age was 51.7±8.0 years for AS patients and 53.8±10.2 years for control subjects (P=0.34). The mean RNFL thickness was 88.6±17.6µm in AS eyes and 102.1±8.3µm in control eyes; the difference between the groups was significantly significant. ALD was 350.9±70.8µm in AS eyes and 432.5±82.1µm in control eyes, while LT was 166.3±41.0µm in AS eyes and 241.3±43.2µm in control eyes. ALD and LT were also significantly thinner in AS eyes than control eyes (P=0.003, P<0.001; respectively). CONCLUSION: Enhanced depth imaging revealed that eyes with AS demonstrate thinner RNFL, ALD and LT compared with normal eyes. Further studies with a larger sample size are needed to understand the relationship between these findings and the morphologic changes and pathogenesis of AS.

Assessment of paranasal sinus parameters according to ancient skulls' gender and age by using cone-beam computed tomography.

BACKGROUND: The aim of this study was to determine whether paranasal sinus dimensions and volume can be useful to identify gender and age estimation for ancient skulls using cone-beam computed tomography (CBCT) images. MATERIALS AND METHODS: CBCT scans of 32 ancient skulls of approximately 1000 years of age were included in this retrospective study. The gender and age estimation of the skulls were made by an independent anthropologist, which was considered as the gold standard. Paranasal sinuses' dimensions (width and height) and volumes of each sinus were measured from the CBCT data set that was linked to the three-dimensional rendering software (Anatomage, Invivo 5.2). All measurements were performed by an independent observer. Intra-observer analysis was made. Mann-Whitney and Kruskal-Wallis tests were used to compare paranasal sinus parameters in terms of age estimation and gender (p < 0.05). RESULTS: The results demonstrated no statistically significant difference between measurements (p < 0.05). The measurements were found to be highly reprodu- cible. The mean volumes of frontal and sphenoid sinus were found to be higher in males. The distance from anterior-posterior wall of sphenoid sinus in axial sec- tions is larger in males (p > 0.05). The frontal sinus width and volume increased statistically with age above 60 years of age (p > 0.05). CONCLUSIONS: The paranasal volume and dimensions' measurements from CBCT data can be a promising technique to determine gender and age of ancient skulls because of its lower voxel sizes and higher resolution.

The coexistence of eosinophilic esophagitis with allergic rhinitis.

OBJECTIVE: Eosinophilic esophagitis (EoE) is diagnosed with the presence of characteristic esophageal symptoms and eosinophilic infiltration of the esophageal mucosa after other causes of eosinophilia are excluded. EoE has been reported to co-occur with some allergic diseases. In this study, we evaluated the co-existence of EoE in Ear-Nose-Throat (ENT) outpatient clinic patients with allergic rhinitis (AR). PATIENTS AND METHODS: The study group consists of 67 AR patients (AR group) and the control group (CG) was formed with 53 cases with dyspepsia symptoms. Symptoms of AR and CG groups were compared in terms of endoscopic and histological findings. Moreover, in AR group, accompanying symptoms, immunoglobulin E (IgE), skin prick test (SPT) positivity, Helicobacter pylori (H. pylori) presence, endoscopic findings and biopsy results were compared between patients with EoE and those without. RESULTS: Seven of the cases with AR were diagnosed with EoE. Reflux symptoms were more common in patients with EoE (71.4%). The presence of H. pylori was similar between groups. Blood IgE levels were significantly higher among EoE patients compared to those without EoE (p = 0.003). SPT positivity was present in the 85.7% of patients with EoE and 50% of the patients without EoE (p = 0.113). Allergens were more likely to be mites Dermatophagoides farinae and Dermatophagoides pteronyssinus in patients with EoE (p = 0.042 and p = 0.034 respectively). CONCLUSIONS: The most common symptom among patients with EoE is reflux. In AR patients with EoE, serum IgE levels were higher compared to those without EoE. In AR patients with reflux symptoms, high serum IgE levels, and especially in patients whose tests are positive for allergy to mites, referral to a gastroenterologist for EoE evaluation may be recommended.

Association of weather and air pollution interactions on daily mortality in 12 Canadian cities.

It has been well established that both meteorological attributes and air pollution concentrations affect human health outcomes. We examined all cause nonaccident mortality relationships for 28 years (1981-2008) in relation to air pollution and synoptic weather type (encompassing air mass) data in 12 Canadian cities. This study first determines the likelihood of summertime extreme air pollution events within weather types using spatial synoptic classification. Second, it examines the modifying effect of weather types on the relative risk of mortality (RR) due to daily concentrations of air pollution (nitrogen dioxide, ozone, sulfur dioxide, and particulate matter <2.5 µm). We assess both single- and two-pollutant interactions to determine dependent and independent pollutant effects using the relatively new time series technique of distributed lag nonlinear modeling (DLNM). Results display dry tropical (DT) and moist tropical plus (MT+) weathers to result in a fourfold and twofold increased likelihood, respectively, of an extreme pollution event (top 5 % of pollution concentrations throughout the 28 years) occurring. We also demonstrate statistically significant effects of single-pollutant exposure on mortality (p < 0.05) to be dependent on summer weather type, where stronger results occur in dry moderate (fair weather) and DT or MT+ weather types. The overall average single-effect RR increases due to pollutant exposure within DT and MT+ weather types are 14.9 and 11.9 %, respectively. Adjusted exposures (two-way pollutant effect estimates) generally results in decreased RR estimates, indicating that the pollutants are not independent. Adjusting for ozone significantly lowers 67 % of the single-pollutant RR estimates and reduces model variability, which demonstrates that ozone significantly controls a portion of the mortality signal from the model. Our findings demonstrate the mortality risks of air pollution exposure to differ by weather type, with increased accuracy obtained when accounting for interactive effects through adjustment for dependent pollutants using a DLNM.

Changing air mass frequencies in Canada: potential links and implications for human health.

Many individual variables have been studied to understand climate change, yet an overall weather situation involves the consideration of many meteorological variables simultaneously at various times diurnally, seasonally, and yearly. The current study identifies a full weather situation as an air mass type using synoptic scale classification, in 30 population centres throughout Canada. Investigative analysis of long-term air mass frequency trends was completed, drawing comparisons between seasons and climate zones. We find that the changing air mass trends are highly dependent on the season and climate zone being studied, with an overall increase of moderate ('warm') air masses and decrease of polar ('cold') air masses. In the summertime, general increased moisture content is present throughout Canada, consistent with the warming air masses. The moist tropical air mass, containing the most hot and humid air, is found to increase in a statistically significant fashion in the summertime in 46% of the areas studied, which encompass six of Canada's ten largest population centres. This emphasises the need for heat adaptation and acclimatisation for a large proportion of the Canadian population. In addition, strong and significant decreases of transition/frontal passage days were found throughout Canada. This result is one of the most remarkable transition frequency results published to date due to its consistency in identifying declining trends, coinciding with research completed in the United States (US). We discuss relative results and implications to similar US air mass trend analyses, and draw upon research studies involving large-scale upper-level air flow and vortex connections to air mass changes, to small-scale meteorological and air pollution interactions. Further research is warranted to better understand such connections, and how these air masses relate to the overall and city-specific health of Canadians.

Demographical, laboratory and associated findings in patients with perniosis.

BACKGROUND: Perniosis is a cold-induced inflammatory disorder of the acral areas. The objective of this study was to investigate the demographic characteristics, associated factors, clinical and laboratory findings in patients with perniosis and to compare those findings between patients who had recurrent and acute disease. METHODS: Thirty-four patients with perniosis were investigated retrospectively for age, gender, occupation, smoking and diet histories, associated diseases, family history of perniosis, precipitating factors, the month of onset and the duration of perniosis, the distribution of the lesions and the results of laboratory investigations. RESULTS: Fifteen patients were male and 19 were female. The ages of the patients ranged from 15 to 57 years. Thirteen patients were working as sales people, which was the most common occupation. Sixteen patients were smokers. While 25 of the patients had encountered perniosis for the first time, in 9 of the patients, there were recurrent lesions. Diseases other than perniosis were recorded in 6 of the patients. The laboratory tests revealed mild leukopenia in 2, antinuclear antibody (ANA) positivity in 3, mild rise in albumin level in serum protein electrophoresis in 1 patient. ANA positivity was significantly higher in patients with recurrent disease. CONCLUSION: Perniosis was more common in women and below 40 years. We found no significant laboratory findings except ANA positivity in patients with recurrent perniosis.

Multilevel assessment of atherosclerotic extent using a 40-section multidetector scanner after transient ischemic attack or ischemic stroke.

BACKGROUND AND PURPOSE: The first part of this study assessed the potential of MDCT with a CTA examination of the aorta and the coronary, cervical, and intracranial vessels in the etiologic work-up of TIA or ischemic stroke compared with established imaging methods. The objective of the second part of this study was to assess the atherosclerotic extent by use of MDCT in these patients. MATERIALS AND METHODS: From August 2007 to August 2011, a total of 96 patients with ischemic stroke or TIA without an evident cardioembolic source were enrolled. All patients underwent MDCT. Atherosclerotic extent was classified in 0, 1, 2, 3, and 4 atherosclerotic levels according to the number of arterial territories (aortic arch, coronary, cervical, intracranial) affected by atherosclerosis defined as ≥ 50% cervical, intracranial, or coronary stenosis or ≥ 4-mm aortic arch plaque. RESULTS: There were 91 patients who had an interpretable MDCT. Mean age was 67.4 years (± 11 years), and 75 patients (83.3%) were men. The prevalence of 0, 1, 2, 3, and 4 atherosclerotic levels was 48.3%, 35.2%, 12.1%, 4.4%, and 0%, respectively. Aortic arch atheroma was found in 47.6% of patients with 1 atherosclerotic level. The combination of aortic arch atheroma and cervical stenosis was found in 63.6% of patients with ≥ 2 atherosclerotic levels. Patients with ≥ 2 atherosclerotic levels were older than patients with < 2 atherosclerotic levels (P = .04) in univariate analysis. CONCLUSIONS: MDCT might be useful to assess the extent of atherosclerosis. It could help to screen for high-risk patients who could benefit from a more aggressive preventive strategy.

The prevalence of chronic and episodic migraine in children and adolescents.

BACKGROUND AND PURPOSE: Migraine is the most important cause of headache leading to a decrease in the quality of life in children and adolescents. The prevalence of episodic (EM) and chronic migraine (CM) increases with increasing age, which especially focused in recent years. METHODS: To evaluate the prevalence and determinants of migraine in children and adolescents, we performed this school-based epidemiological study. First part of the study was performed in 2001 that included 5562 children. Second part of the study was performed in 2007 in adolescents including 1155 young. After the main reports published, we made a new analysis in the database that focused on migraine. RESULTS: Totally, 10.4% of the children, predominantly the girls, received the diagnosis of migraine when they grew older (1.7% CM, 8.6% EM). CM frequency increased with increasing ages (doubled at 12 years, P = 0.035). The significant risk factors for having CM were found to be age, gender, and father and sibling headache histories. Most of the clinical characteristics of migraine are far from classical knowledge in children with CM. In adolescents, 18.6% were diagnosed as migraine (1.5%CM, 17.1%EM) with a predominance of girls without age difference. When they reached puberty after 6 years, double the number of cases with CM was headache free. Most of the young changed their headache characteristics during the follow-up period independent from management strategies. CONCLUSIONS: Our results showed that CM is an important cause of headache in both children and adolescents with some defining headache characteristics and risk factors concentrated in different age-groups.

Treatment of congenital ichthyosis with acitretin: a case report.

The authors assessed the clinical efficacy, tolerability and safety of acitretin in a patient with ichthyosis. A newborn infant with ichthyosis who presented at birth with collodion baby appearance, was treated with acitretin. A moderate response to acitretin therapy (1 mg/kg/day) administered for 6 months was observed, with improvement in cutaneous lesions. Clinical improvement was achieved shortly after treatment. The treatment resulted in a satisfactory improvement in the skin condition of the case. The tolerance to the drug was good. Side effects were not observed. The oral acitretin treatment is efficient in severe congenital ichthyosis.

Air pollution and hospitalization for venous thromboembolic disease in Chile.

BACKGROUND: Ambient air pollution is a risk factor for stroke and myocardial infarction, possibly because of alterations in coagulation that influence the arterial circulation. Whether air pollution influences diseases associated with peripheral venous thrombogenesis remains largely unknown. OBJECTIVES: To determine the association between air pollution and venous thromboembolic disease (VTE) in a sample of the general population. METHODS: A time-series analysis was used to test the association between daily air pollution and VTE hospitalizations in Santiago between 2001 and 2005. Results were adjusted for long-term trends, day of the week and average daily humidex. RESULTS: From a population of 5.4 million, there were, on average, 2.3 admissions for VTE per day. Pooled estimates of relative risk (RR) [95% confidence interval (CI)] of hospitalization for venous disease were: 1.07 (1.05, 1.09) for a 58.4 p.p.b. increase in ozone (O(3)); 1.06 (1.02, 1.09) for a 5.85 p.p.b. increase in sulphur dioxide (SO(2)); 1.08 (1.03, 1.12) for a 29.25 microg/m(3) increase in nitrogen dioxide (NO(2)); and 1.05 (1.03, 1.06) for a 20.02 microg/m(3) increase in particulate matter < or = 2.5 microm in mean aerodynamic diameter (PM(2.5)). For pulmonary embolism (PE) results were: 1.10 (1.07, 1.13) for O(3); 1.05 (1.02, 1.08) for SO(2); 1.07 (1.04, 1.09) for NO(2); and 1.05(1.03, 1.06) for PM(2.5), respectively. CONCLUSION: Air pollution appears to be a risk factor for venous thrombosis and PE, a disease with a significant fatality rate.

Acute stroke and heart attack management within a four-hour time window.

BACKGROUND AND PURPOSE: Although brain embolism is a uncommon complication of myocardial infarction, sequential treatment of cerebral and coronary artery occlusion within a 4-hour time window is unusual. SUMMARY: of case A 60 year-old man experienced successful intravenous recombinant thrombolysis (tPA) for acute middle cerebral artery (MCA) occlusion followed by efficient angioplasty stenting of a troponin-negative coronary occlusion which, while painless, involved clear electrocardiographic abnormalities. Both pathologies were treated within a 4-hour time window. CONCLUSION: Acute brain and heart ischemia may be successfully treated within a 4-hour time window, thanks to an efficient multidisciplinary approach.

Homocysteine, vitamin B12 and folic acid levels in psoriasis patients.

BACKGROUND: Hyperhomocysteinaemia is a risk factor for atherosclerotic cardiovascular disease, stroke, peripheral arterial occlusive disease and venous thrombosis. An association between psoriasis and cardiovascular diseases has been reported. AIM: The aim of our study was to examine serum homocysteine, folic acid and vitamin B12 levels in psoriasis patients. MATERIAL AND METHODS: We performed a cross-sectional study in 70 consecutive outpatients with chronic plaque psoriasis and 70 age- and gender-matched controls. Serum levels of homocysteine, vitamin B12 and folic acid levels were measured in both groups. RESULTS: Serum homocysteine, folic acid and vitamin B12 levels did not differ between patient and control groups. In psoriasis patients, homocysteine levels correlated directly with psoriasis severity as measured by psoriasis area and severity index. Serum homocysteine level inversely correlated with serum folic acid levels in the patient group. DISCUSSION: Homocysteine levels correlated with psoriasis area and severity index in the patient group, which shows the disease severity. The increase in cardiovascular mortality with the severity of psoriasis might be also due to the effects of homocysteine.

Loxosceles reclusa bite to the eyelid.

PURPOSE: The authors report a case of Loxosceles reclusa infestation on the eyelid. METHODS: The specimen collected by swabbing the lesions with gauze was tested by using a venom-specific enzyme-linked immunosorbent assay. Loxosceles venom was detected in specimen. The patient was managed with conservative therapy that included saline compresses and ocular lubrication. RESULTS: The case presented with severe edema and necrosis on the left upper eyelid. On laboratory examination, a significant left shift of white blood cell count was detected. Although residual scar of the eyelid and punctate epitheliopathy on the inferior of cornea was detected, vision was not impaired. CONCLUSIONS: Supportive therapy may be reasonable treatment for Loxosceles reclusa infestation on the eyelids. The presence of venom proteins detected with an enzyme-linked immunosorbent assay technique is beneficial for supporting the diagnosis of Loxosceles envenomatio.