Clinician Perspectives Regarding the Impact of Information Technology on Multidisciplinary Tumor Boards: A National Comprehensive Cancer Network Survey.

PURPOSE: Multidisciplinary tumor boards (MTBs) support high-quality cancer care. Little is known about the impact of information technology (IT) tools on the operational and technical aspects of MTBs. The National Comprehensive Cancer Network EHR Oncology Advisory Group formed a workgroup to investigate the impact of IT tools such as EHRs and virtual conferencing on MTBs. METHODS: The workgroup created a cross-sectional survey for oncology clinicians (eg, pathology, medical, surgical, radiation, etc) participating in MTBs at 31 National Comprehensive Cancer Network member institutions. A standard invitation e-mail was shared with each EHR Advisory Group Member with a hyperlink to the survey, and each member distributed the survey to MTB participants at their institution or identified the appropriate person at their institution to do so. The survey was open from February 26, 2022, to April 26, 2022. Descriptive statistics were applied in the analysis of responses, and a qualitative thematic analysis of open-ended responses was completed. RESULTS: Individuals from 27 institutions participated. Almost all respondents (99%, n = 764 of 767) indicated that their MTBs had participants attending virtually. Most indicated increased attendance (69%, n = 514 of 741) after virtualization with the same or improved quality of discussion (75%, n = 557 of 741) compared with in-person MTBs. Several gaps between the current and ideal state emerged regarding EHR integration: 57% (n = 433 of 758) of respondents noted the importance of adding patients for MTB presentation via the EHR, but only 40% (n = 302 of 747) reported being able to do so most of the time. Similarly, 87% (n = 661 of 760) indicated the importance of documenting recommendations in the EHR, but only 53% (n = 394 of 746) reported this occurring routinely. CONCLUSION: Major gaps include the lack of EHR integration for MTBs. Clinical workflows and EHR functionalities could be improved to further optimize EHRs for MTB management and documentation.

Increasing clinician participation in tobacco cessation by an implementation science-based tobacco cessation champion program.

BACKGROUND: We designed a process to increase tobacco cessation in an academic center and its widely distributed network community sites using clinical champions to overcome referral barriers. METHODS: In 2020 a needs assessment was performed across the City of Hope Medical Center and its 32 community treatment sites. We reviewed information science strategies to choose elements for our expanded tobacco control plan, focusing on distributed leadership with tobacco cessation champions. We analyzed smoking patterns in patients with cancer before and following program implementation. We evaluated the champion experience and measured tobacco abstinence after 6 months of follow-up. RESULTS: Cancer center leadership committed to expanding tobacco control. Funding was obtained through a Cancer Center Cessation Initiative (C3I) grant. Multi-disciplinary leaders developed a comprehensive plan. Disease-focused clinics and community sites named cessation champions (a clinician and nurse) supported by certified tobacco treatment specialists. Patient, staff, clinician, and champion training/education were developed. Roles and responsibilities of the champions were defined. Implementation in pilot sites showed increased tobacco assessment from 80.8 to 96.6%, increased tobacco cessation referral by 367%, and moderate smoking abstinence in both academic (27.2%) and community sites (22.5%). 73% of champions had positive attitudes toward the program. CONCLUSION: An efficient process to expand smoking cessation in the City of Hope network was developed using implementation science strategies and cessation champions. This well-detailed implementation process may be helpful to other cancer centers, particularly those with a tertiary care cancer center and community network.

Establishing a research informatics program in a public healthcare system: a case report with model documents.

While much is known about governance models for research informatics programs in academic medical centers and similarly situated cancer centers, community and public health systems have been less well-characterized. As part of implementing an enterprise research governance framework, leaders in the Los Angeles County Department of Health Services established a research informatics program, including research data warehousing. The strategy is focused on high-priority, patient-centered research that leverages the investment in health IT and an efficient, sustained contribution from 2 affiliated Clinical Translational Sciences Institutes. This case study describes the foundational governance framework and policies that were developed. We share the results of several years of planning, implementation, and operations of an academically funded research informatics service core embedded in a large, multicenter county health system. We include herein a Supplementary Appendix of governance documents that may serve as pragmatic models for similar initiatives.

Patient generated health data and electronic health record integration in oncologic surgery: A call for artificial intelligence and machine learning.

In this review, we aim to assess the current state of science in relation to the integration of patient-generated health data (PGHD) and patient-reported outcomes (PROs) into routine clinical care with a focus on surgical oncology populations. We will also describe the critical role of artificial intelligence and machine-learning methodology in the efficient translation of PGHD, PROs, and traditional outcome measures into meaningful patient care models.

Brain ultrasound for diagnosis and prognosis in the neurological intensive care unit: a mini review for current development.

Objective: Transcranial doppler ultrasonography (TCD) is one of the few tools in the Neurological Intensive Care Unit (NICU) that allows for real-time monitoring of cerebral blood flow while also being non-invasive. This review examines the current use of TCD monitoring in the NICU. Method: We completed a literature review using Google Scholar and Pubmed. Relevant articles were included in this review. Results: The role of TCD in the NICU continues to evolve since its infancy in the 1980s. TCD use is now standard of care of for some neurological maladies. The significant advantages of TCD include convenience of use, non-invasive nature, bedside operation, high accuracy, and absence of interference from external factors such as temperature and sedatives. Conclusion: This review examines the current use of TCD monitoring in the NICU. Through review and continued development of similar non invasive technologies NICU care continues to innovate and evolve. Abbreviation: TCD: Transcranial Doppler.

Prehospital stroke care, a narrative review.

Stroke is a leading cause of disability in the United States and current treatment for stroke is limited to two modalities with well-defined time restraints. The prehospital setting is a significant and relatively easy setting for innovation in stroke care, as the most clinical decisions are made within the first several hours of symptom onset. In this review, we look at recent innovations in improving prehospital care for acute stroke including the conception of mobile stroke units, the ongoing development of stroke models for emergency providers, barriers to prehospital care, and the innovation of new telephone applications. Although there are notable improvements in acute stroke care, additional research is needed to further improve on current models and technologies.

Vein of Labbe thrombosis, a near-miss.

Emergency department visits for a headache are relatively common, and in most cases, the etiologies of the headache are typically benign. We present a case of a patient who presented to the emergency room for new onset of unremitting unilateral headache. She subsequently had two hospital visits and three separate imaging modalities to identify vein of Labbe thrombosis. The vein of Labbe is a relatively smaller vein which runs superficially and laterally. In our patient, a cerebral venous thrombosis (CTV) was unable to identify vein of Labbe thrombosis, requiring eventually a magnetic resonance imaging (MRI) with and without contrast to identify the culprit etiology. CTV is frequently used in the acute setting due to its speed of acquisition and shorter wait times in the hospital. For patients that fit criteria for venous sinus thrombosis, we caution the use of CTV in identifying the causative etiology, and would consider the MRI as a better imaging modality for these patients.

Previous hypertensive hemorrhage increases the risk for bleeding and ischemia for PCI patients on dual antiplatelet therapy.

OBJECTIVES: The use of antiplatelet therapy after intracerebral hemorrhage remains controversial, while the use of dual antiplatelet therapy (DAPT) is required after cardiac stenting. In this study, we examine the risk of bleeding and ischemic events for PCI patients with a history of hypertensive hemorrhage on DAPT. METHODS: A total of 128 cases and 153 controls were selected from Chinese patients with cardiac stenting on dual anti-platelet therapy for a single-center retrospective case-control study. Patients with a history of hypertensive hemorrhage were selected for the case group, while patients with a history of hypertension were chosen as control. All patients were on aspirin 100 mg and clopidogrel 75 mg after cardiac stenting, and were followed for a duration of 12-48 months. The primary outcomes were intracerebral hemorrhage, major bleeding, and major adverse cardiovascular and cerebrovascular events. RESULTS: A history of previous hypertensive hemorrhage was not found to be a risk factor for intracerebral hemorrhage and major bleeding while on dual anti-platelet therapy. However, a history of either hypertensive hemorrhage or coronary artery disease was independently found to be risk factors for major adverse cardiovascular and cerebrovascular events. On sub-group analysis, patients with a history of hypertensive hemorrhage within 12 months were found to be at higher risk for bleeding on dual anti-platelet therapy, while patients with history of hypertensive hemorrhage outside of 12 months on dual anti-platelet therapy did not have the same increased risk. CONCLUSION: A history of hypertensive hemorrhage and coronary heart disease were two independent risk factors for major adverse cardiovascular and cerebrovascular events in PCI patients taking DAPT. A history of hypertensive hemorrhage less than 12 months had an increased risk for recurrent intracerebral hemorrhage and major bleeding in PCI patients taking DAPT.

Association of CT perfusion and postoperative cognitive dysfunction after off-pump coronary artery bypass grafting.

OBJECTIVE: To investigate the relationship between an abnormal CT perfusion scan and postoperative cognitive dysfunction, as measured by changes in MoCA and MMSE scores, after off-pump coronary artery bypass grafting (OPCABG). METHODS: Eight hundred and thirteen patients were selected who underwent OPCABG between August 2010 and September 2013. Cognitive function was assessed before operation and at seven days post-op. CT perfusion scan was obtained preoperatively and was used to divide patients into two groups: abnormal perfusion and normal perfusion groups. RESULTS: (1) Logistic regression analysis showed that perfusion abnormalities (OR, 3.012; 95% CI, 1.660-5.463; P < 0.05) were an independent risk factor for postoperative cognitive dysfunction (POCD). (2) 556 patients with CT perfusion scans were divided into normal perfusion and abnormal perfusion groups: incidence of POCD in the abnormal perfusion group is significantly higher than the control group (21.6 vs 8.6%, P < 0.05); MMSE scores were significantly lower in patients with abnormal perfusion before and after surgery. MoCA scores demonstrated a significant drop after surgery for all patients with abnormal perfusion (P < 0.05). The abnormal perfusion group had a significant reduction in the visuospatial/executive and naming scores in the MoCA as compared to normal perfusion (P < 0.05). CONCLUSION: Abnormal CT perfusion is a significant risk factor for postoperative cognitive dysfunction, and has the most impact on visuospatial/executive and naming functions.

Coexistence of High Fibrinogen and Low High-density Lipoprotein Cholesterol Levels Predicts Recurrent Cerebral Venous Thrombosis.

BACKGROUND: Cerebral venous thrombosis (CVT) may lead to serious neurological disorders; however, little is known about the risk factors for recurrent CVT. Our aim was to determine the association between elevated fibrinogen and decreased high-density lipoprotein cholesterol (HDL-C) levels with recurrent CVT. METHODS: This retrospective cohort study included participants if they had a first episode of objectively defined CVT and were admitted to Xuan Wu Hospital, Capital Medical University from August 2005 to September 2009. Demographic and clinical variables were collected, as well as laboratory parameters, including plasma fibrinogen and HDL-C. Patients with CVT were followed for recurrent symptomatic CVT. Follow-up was through the end of September 2010. Potential predictors of recurrence were analyzed using Cox survival analysis. RESULTS: At the end of the follow-up, 95 patients were eligible for the study. Twelve of 95 patients (12.6%) had recurred CVT. The median time of recurrence was 7 months (range: 1-39 months). Eight of these 12 (66.7%) experienced recurrence within the first 12 months after their initial CVT. The recurrence rate of CVT was 2.76 per 100 patient-years. Multivariate Cox regression analysis demonstrated that the coexistence of high fibrinogen (>4.00 g/L) and low HDL-C (<1.08 mmol/L) levels at baseline was the only independent predictor for recurrent CVT (hazard ratio: 4.69; 95% confidence interval: 1.10-20.11; P < 0.05). Of the twelve patients with recurrent CVT in our study, 7 (58.3%) had high fibrinogen plus low HDL-C levels. All 7 of these patients took warfarin for 3-12 months, and 6 of 7 had recurrent CVT after the discontinuation of anticoagulant treatment. CONCLUSIONS: Concomitant high fibrinogen and low HDL-C levels may be associated with recurrence of CVT. The effect of potential risk factors related to atherothrombosis on recurrent CVT should be closely monitored.

The threshold of cortical electrical stimulation for mapping sensory and motor functional areas.

This study aimed to investigate the threshold of cortical electrical stimulation (CES) for functional brain mapping during surgery for the treatment of rolandic epilepsy. A total of 21 patients with rolandic epilepsy who underwent surgical treatment at the Beijing Institute of Functional Neurosurgery between October 2006 and March 2008 were included in this study. Their clinical data were retrospectively collected and analyzed. The thresholds of CES for motor response, sensory response, and after discharge production along with other threshold-related factors were investigated. The thresholds (mean ± standard deviation) for motor response, sensory response, and after discharge production were 3.48 ± 0.87, 3.86 ± 1.31, and 4.84 ± 1.38 mA, respectively. The threshold for after discharge production was significantly higher than those of both the motor and sensory response (both p<0.05). A negative linear correlation was found between the threshold of after discharge production and disease duration. Using the CES parameters at a stimulation frequency of 50 Hz and a pulse width of 0.2 ms, the threshold of sensory and motor responses were similar, and the threshold of after discharge production was higher than that of sensory and motor response.

Anatomical study of endoscope-assisted far lateral keyhole approach to the ventral craniocervical region with neuronavigational guidance.

BACKGROUND: Image-guided neurosurgery, endoscopic-assisted neurosurgery and the keyhole approach are three important parts of minimally invasive neurosurgery and have played a significant role in treating skull base lesions. This study aimed to investigate the potential usefulness of coupling of the endoscope with the far lateral keyhole approach and image guidance at the ventral craniocervical junction in a cadaver model. METHODS: We simulated far lateral keyhole approach bilaterally in five cadaveric head specimens (10 cranial hemispheres). Computed tomography-based image guidance was used for intraoperative navigation and for quantitative measurements. Skull base structures were observed using both an operating microscope and a rigid endoscope. The jugular tubercle and one-third of the occipital condyle were then drilled, and all specimens were observed under the microscope again. We measured and compared the exposure of the petroclivus area provided by the endoscope and by the operating microscope. Statistical analysis was performed by analysis of variance followed by the Student-Newman-Keuls test. RESULTS: With endoscope assistance and image guidance, it was possible to observe the deep ventral craniocervical junction structures through three nerve gaps (among facial-acoustical nerves and the lower cranial nerves) and structures normally obstructed by the jugular tubercle and occipital condyle in the far lateral keyhole approach. The surgical area exposed in the petroclival region was significantly improved using the 0° endoscope (1147.80 mm(2)) compared with the operating microscope ((756.28 ± 50.73) mm(2)). The far lateral retrocondylar keyhole approach, using both 0° and 30° endoscopes, provided an exposure area ((1147.80 ± 159.57) mm(2) and (1409.94 ± 155.18) mm(2), respectively) greater than that of the far lateral transcondylar transtubercular keyhole approach ((1066.26 ± 165.06) mm(2)) (P < 0.05). CONCLUSIONS: With the aid of the endoscope and image guidance, it is possible to approach the ventral craniocervical junction with the far lateral keyhole approach. The use of an angled-lens endoscope can significantly improve the exposure of the petroclival region without drilling the jugular tubercle and occipital condyle.

Early prediction of poor outcome in severe hemispheric stroke by EEG patterns and gradings.

OBJECTIVES: To find out the EEG abnormal patterns in massive cerebral hemispheric infarction (MCHI) and their correlation with poor outcome, and to construct an EEG grading for predicting the outcome of MCHI patients. METHODS: Between 2000 and 2010, 162 patients with MCHI who met the selection criterions were selected for this study. All the patients underwent EEG examinations within 3 days after stroke onset and repeated on day 2 and 3. We classified the EEG recordings into 9 patterns and anglicized the correlation between EEG patterns and outcome. Then according to the results of the correlation between EEG patterns and outcome we constructed an EEG grading for predicting the outcome of MCHI patients. RESULTS: We revealed that patterns of dominant alpha without reactivity, RAWOD, burst-suppression, α/θ-coma, epileptiform activity (without burst-suppression), and generalized suppression were correlated to poor outcome. We further modified the Young grading according to the correlation between EEG patterns and outcome. We found that the modified grading was superior to existing EEG gradings in predicting the outcome of MCHI patients, and it could predict the outcome of MCHI more accurately. CONCLUSIONS: MCHI is common in N-ICU (Neurology Intensive Care Unit). The EEG analysis would detect the degree of brain lesion during the ischemia within the acute stage after stroke onset. The EEG evaluation might assist the neurophysicians to predict outcome of patients and make decisions on the treatments.

At low doses ethanol maintains blood-brain barrier (BBB) integrity after hypoxia and reoxygenation: a brain slice study.

Post-ischemia ethanol (EtOH) treatments have been shown to exhibit neuroprotective effects in stroke. However, the mechanisms underlying these effects and those on blood-brain barrier (BBB) integrity have yet to be elucidated. In the present study, we determined whether administering differing concentrations of EtOH alter the expressions of BBB integral proteins, including aquaporins-4 and -9 (AQP-4, AQP-9), matrix metallopeptidases-2 and -9 (MMP-2, MMP-9), zonula occludens-1 (ZO-1), and basal lamina (laminin). We employed an organotypic brain slice culture model that utilizes oxygen-glucose deprivation followed by reoxygenation (OGD/R). Brain slices were obtained from 10-day-old Sprague-Dawley rats and divided into the following five groups (n = 8 subjects per group): (1) control, (2) hypoxia (OGD/R), no EtOH, (3) OGD/R and 10 mM EtOH, (4) OGD/R and 30 mM EtOH, and (5) OGD/R and 90 mM EtOH. To assess BBB integrity, levels of AQPs, MMPs, ZO-1, and laminin were determined by Western blot. Compared to control, OGD/R without EtOH significantly increased AQP-4, AQP-9, MMP-2, and MMP-9 levels, while decreasing ZO-1 and laminin levels. All EtOH concentration treatments (groups 3 through 5) significantly reduced the expressions of AQP-4, AQP-9, MMP-2, and MMP-9, compared to the OGD/R, non-alcohol treated slices. Furthermore, compared to the OGD/R without EtOH group, the 30 mM EtOH treatment significantly increased ZO-1 and laminin levels. In contrast, the 90 mM EtOH level neither enhanced the reduction in AQP and MMP levels nor increased ZO-1 or basal lamina expressions observed in the 30 mM treatment. In conclusion, at an optimal dose of 30 mM, EtOH improves the expressions of MMP-2, MMP-9, AQP-4, AQP-9, ZO-1, and basal laminin, previously altered by OGD/R. These effects may indicate a beneficial effect of EtOH on BBB integrity after stroke.

Clinical outcomes of fast MRI-based trombolysis in wake-up strokes compared to superacute ischemic strokes within 12 hours.

BACKGROUND: It is unknown whether thrombolysis is beneficial in patients with Wake-Up Ischemic Strokes (WUIS). This study compares the clinical outcomes of MRI-based intravenous thrombolysis in patients with hyperacute ischemic stroke presenting within 12 hours of symptom onset against WUIS patients receiving the same therapy. METHODS: Patients presenting within 12 hours of acute stroke symptom onset and those with WUIS confirmed by CT, and without intracranial hemorrhage, were encouraged to perform an emergent brain MRI scan to confirm the diagnosis of hyperacute ischemic stroke [hyper-intense in diffusion-weighted imaging (DWI) and no hypo-intense change in T2-weighted imaging (T2WI) or FLAIR]. These patients then received intravenous thrombolytic therapy with tissue-type plasminogen activator (rt-PA). All patients were divided into either stroke presenting within 12 hours or WUIS. The clinical outcomes were assessed by the modified Rankin Scale (mRS) and the Barthal Index (BI) at baseline and at 90 days after the thrombolysis therapy. RESULTS: A total of 427 patients presenting with stroke like symptoms were given a MRI scan. Of these, 240 patients had confirmed diagnosis of hyperacute ischemic stroke (WUIS, n = 68, 68/116 = 58·62% versus within 12 hour, n = 172, 172/311 = 55·3%). Altogether, 186 patients (138 in within 12 hours group, and 48 in WUIS group) received intravenous thrombolytic therapy with rt-PA. No significant differences were found in clinical outcomes between the two groups at the baseline and at 90 days after the thrombolysis therapy. Also, no difference was found in the incidence rate of secondary hemorrhage (including both of asymptomatic and symptomatic) and mortality rate between the two groups. CONCLUSION: Our study suggested that MRI-based intravenous thrombolysis is safe and effective in both of patients' hyperacute stroke within 12 hours of symptom onset and WUIS.

Effects of comprehensive education protocol in decreasing pre-hospital stroke delay among Chinese urban community population.

BACKGROUND AND PURPOSE: Studies have shown that awareness of early stroke symptoms and the use of ambulances are two important factors in decreasing pre-hospital stroke delay. The purpose of this study is to evaluate a comprehensive educational stroke protocol in improving stroke response times. METHOD: Two urban communities in Beijing (population ≍50 000), matched in economic status and geography, were enrolled in this study. A comprehensive educational protocol, which included public lectures and distribution of instructive material for the community and its medical staff, was implemented from August 2008 to December 2010. Surveillance of new onset stroke in both communities was carried out during the same period. Pre-hospital delay time and percentage of patients using emergency medical services (EMS) were compared between the two communities. RESULTS: After comprehensive educational protocol, we found that: (i) pre-hospital delay (time from stroke symptom onset to hospital arrival) decreased from 180 to 79 minutes, (ii) the proportion of patients arriving within three hours of stroke onset increased from 55·8% to 80·4%, (iii) pre-hospital delay of stroke patients with symptoms of paralysis, numbness, and speech impediments was decreased, and (iv) the proportion of stroke patients calling for EMS increased from 50·4% to 60·7%. CONCLUSION: The comprehensive educational stroke protocol was significantly effective in decreasing pre-hospital stroke delay.

Leptin's effect on accelerated fracture healing after traumatic brain injury.

OBJECTIVE: To investigate mechanisms behind the faster rehabilitation of limb fractures when associated with traumatic brain injury (TBI). METHODS: New Zealand rabbits were divided into TBI group and sham-operation group for four studies as follows: (1) blood and cerebrospinal fluid (CSF) were drawn on days 1, 3, and 7 to demonstrate changes in serum leptin, growth hormone (GH), insulin-like growth factor 1 (IGF-1), and CSF leptin; (2) bone defection was created by drilling in the tibial bone and either leptin or normal saline was injected into rabbit's cerebellomedullary cistern. X-ray was taken at 1 days, 2 weeks, and 5 weeks and evaluated by criteria to determine rate of bone healing; (3) FITC-labeled rabbit leptin was injected into TBI and sham-operation groups, and frozen sections of rabbit brain were observed to identify differences in central nervous system (CNS) leptin by fluorescence; (4) polymerase chain reaction (PCR) was used to evaluate the expression of leptin production by brain tissue. RESULTS: Serum and CSF leptin, GH, and IGF-1 concentrations were found to be higher in the TBI group than the sham-operation group at days 1, 3, and 7 (P<0·05). CSF leptin of the TBI group was positively correlated with serum leptin on day 1 (P<0·05), and positively correlated with GH and IGF-1 on days 3 and 7 (P<0·05). X-ray criteria demonstrated that leptin administration caused significantly faster healing calluses at 3 and 5 weeks as compared to control animals (P<0·05). FITC-labeled leptin study demonstrated that TBI animals had stronger expression of leptin in the brain than sham-operated animals. However, PCR of brain tissue leptin showed no significant differences between TBI and sham-operated animals in the expression of leptin. CONCLUSIONS: Our study suggests that increased CSF leptin, likely from blood-brain barrier breakdown, combined with elevated serum GH and IGF-1 after TBI, leads to accelerated fracture healing.

Acute administration of ethanol reduces apoptosis following ischemic stroke in rats.

In recent studies, acute ethanol administration appears to play a neuroprotective role during ischemic stroke. We sought to confirm these findings by identifying if ethanol-derived neuroprotection is associated with a reduction in apoptosis. Ethanol at 0.5 and 1.5 g/kg doses was given by intraperitoneal injections to Sprague-Dawley rats after 2h of middle cerebral artery (MCA) occlusion, followed by reperfusion. We quantified apoptotic cell death in each of the treatment groups with ELISA, and measured pro- and anti-apoptotic protein expression with Western blot analysis. Cell death was significantly increased in rats after ischemia and was subsequently significantly reduced by the administration of 1.5 g/kg of ethanol. We found that the 1.5 g/kg dose promoted the expression of pro-survival factors and decreased the expression of apoptotic proteins at 3h after reperfusion. This effect was maintained at 24h for Caspase-3 and apoptosis-inducing factor (AIF), although not for Bcl-2, Bcl-xL, and Bcl-2-associated X (Bax). Administration of 0.5 g/kg of ethanol was not as effective in regulating protein expression as the 1.5 g/kg dose. Our study suggests that administration of ethanol at a dose of 1.5 g/kg after stroke - which provides rat blood alcohol levels equivalent to the legal driving limit - produces a differential protein profile, with increased expression of anti-apoptotic proteins and decrease in pro-apoptotic factors. This results in a significant reduction of neuronal apoptosis and is neuroprotective in ischemia-reperfusion injury.