Door to needle time trends after transition to tenecteplase: A Multicenter Texas stroke registry.

BACKGROUND: Tenecteplase (TNK) is considered a promising option for the treatment of acute ischemic stroke (AIS) with the potential to decrease door-to-needle times (DTN). This study investigates DTN metrics and trends after transition to tenecteplase. METHODS: The Lone Star Stroke (LSS) Research Consortium TNK registry incorporated data from three Texas hospitals that transitioned to TNK. Subject data mapped to Get-With-the-Guidelines stroke variables from October 1, 2019 to March 31, 2023 were limited to patients who received either alteplase (ALT) or TNK within the 90 min DTN times. The dataset was stratified into ALT and TNK cohorts with univariate tables for each measured variable and further analyzed using descriptive statistics. Logistic regression models were constructed for both ALT and TNK to investigate trends in DTN times. RESULTS: In the overall cohort, the TNK cohort (n = 151) and ALT cohort (n = 161) exhibited comparable population demographics, differing only in a higher prevalence of White individuals in the TNK cohort. Both cohorts demonstrated similar clinical parameters, including mean NIHSS, blood glucose levels, and systolic blood pressure at admission. In the univariate analysis, no difference was observed in median DTN time within the 90 min time window compared to the ALT cohort [40 min (30-53) vs 45 min (35-55); P = .057]. In multivariable models, DTN times by thrombolytic did not significantly differ when adjusting for NIHSS, age (P = .133), or race and ethnicity (P = .092). Regression models for the overall cohort indicate no significant DTN temporal trends for TNK (P = .84) after transition; nonetheless, when stratified by hospital, a single subgroup demonstrated a significant DTN upward trend (P = 0.002). CONCLUSION: In the overall cohort, TNK and ALT exhibited comparable temporal trends and at least stable DTN times. This indicates that the shift to TNK did not have an adverse impact on the DTN stroke metrics. This seamless transition is likely attributed to the similarity of inclusion and exclusion criteria, as well as the administration processes for both medications. When stratified by hospital, the three subgroups demonstrated variable DTN time trends which highlight the potential for either fatigue or unpreparedness when switching to TNK. Because our study included a multi-ethnic cohort from multiple large Texas cities, the stable DTN times after transition to TNK is likely applicable to other healthcare systems.

Prion forensics: a multidisciplinary approach to investigate CWD at an illegal deer carcass disposal site.

Infectious prions are resistant to degradation and remain infectious in the environment for several years. Chronic wasting disease (CWD) has been detected in cervids inhabiting North America, the Nordic countries, and South Korea. CWD-prion spread is partially attributed to carcass transport and disposal. We employed a forensic approach to investigate an illegal carcass dump site connected with a CWD-positive herd. We integrated anatomic, genetic, and prion amplification methods to discover CWD-positive remains from six white-tailed deer (Odocoileus virginianus) and, using microsatellite markers, confirmed a portion originated from the CWD-infected herd. This approach provides a foundation for future studies of carcass prion transmission risk.

Variability in the Transition of Care to Poststroke Rehabilitation During the First Wave of COVID-19.

OBJECTIVE: The aim of the study is to evaluate transitions of acute stroke and inpatient rehabilitation facility care during the first wave of COVID-19. DESIGN: This is a retrospective observational study (3 comprehensive stroke centers with hospital-based inpatient rehabilitation facilities) between January 1, 2019, and May 31, 2019 (acute stroke = 584, inpatient rehabilitation facility = 210) and January 1, 2020, and May 31, 2020 (acute stroke = 534, inpatient rehabilitation facility = 186). Acute stroke characteristics included stroke type, demographics, and medical comorbidities. The proportion of patients admitted for acute stroke and inpatient rehabilitation facility care was analyzed graphically and using t test assuming unequal variances. RESULTS: The proportion of intracerebral hemorrhage patients (28.5% vs. 20.5%, P = 0.035) and those with history of transient ischemic attack (29% vs. 23.9%; P = 0.049) increased during the COVID-19 first wave in 2020. Uninsured acute stroke admissions decreased (7.3% vs. 16.6%) while commercially insured increased (42.7% vs. 33.4%, P < 0.001).Acute stroke admissions decreased from 116.5 per month in 2019 to 98.8 per month in 2020 ( P = 0.008) with no significant difference in inpatient rehabilitation facility admissions (39 per month in 2019, 34.5 per month in 2020; P = 0.66).In 2019, monthly changes in acute stroke admissions coincided with inpatient rehabilitation facility admissions.In 2020, acute stroke admissions decreased 80.6% from January to February, while inpatient rehabilitation facility admissions remained stable. Acute stroke admissions increased 12.8% in March 2020 and remained stable in April, while inpatient rehabilitation facility admissions decreased by 92%. CONCLUSIONS: Acute stroke hospitalizations significantly decreased per month during the first wave of COVID-19, with a delayed effect on the transition from acute stroke to inpatient rehabilitation facility care.

Effect of inpatient rehabilitation facility care on ninety day modified Rankin score in ischemic stroke patients.

OBJECTIVE: To determine Inpatient Rehabilitation Facility (IRF) treatment effect on modified Rankin Scale (mRS) scores at 90 days in acute ischemic stroke (AIS) patients. MATERIALS AND METHODS: This prospective cross-sectional study included 738 AIS patients admitted 1/1/2018-12/31/2020 to a Comprehensive Stroke Center with a Stroke Rehabilitation program. We compared outcomes for patients who went directly home versus went to IRF at hospital discharge: (1) acute care length of stay (LOS), (2) National Institutes of Health Stroke Scale (NIHSS) score, (3) mRS score at hospital discharge and 90 days, (4) the proportion of mRS scores ≤ 2 from hospital discharge to 90 days. RESULTS: Among 738 patients, 499 went home, and 239 went to IRF. IRF patients were more likely to have increased acute LOS (10.7 vs 3.9 days; t-test, P<0.0001), increased mean NIHSS score (7.8 vs 4.8; t-test, P<0.0001) and higher median mRS score (3 vs 1, t-test, P<0.0001) compared to patients who went home. At 90 days, ischemic stroke patients who received IRF care were more likely to progress to a mRS ≤ 2 (18.7% increase) compared to patients discharged home from acute care (16.3% decrease). Home patients experienced a one-point decrease in mRS at 90 days compared to those who received IRF treatment (median mRS of 3 vs. 2, t-test, P<0.05). CONCLUSIONS: In ischemic stroke patients, IRF treatment increased the likelihood of achieving mRS ≤ 2 at 90 days indicating the ability to live independently, and decreased the likelihood of mRS decrease, compared with patients discharged directly home after acute stroke care.

Effect of an Interdisciplinary Stroke Consult Service on the Transition to Postacute Rehabilitation.

OBJECTIVE: To evaluate the effect of a physiatry-led stroke consult service on access and time to intensive postacute rehabilitation. DESIGN: Prospective observational study. SETTING: Urban Joint Commission Comprehensive Stroke Center. PARTICIPANTS: Adult (older than 18 years) acute stroke hospital discharges between January 1, 2018, and December 31, 2020 (N=1190). INTERVENTIONS: Weekday huddle rounds were interdisciplinary, which created a pathway to ensure patients with stroke received comprehensive rehabilitation care followed by a virtual rounding tool, allowing clinicians to evaluate plan of care facilitation using the electronic medical record. MAIN OUTCOME MEASURES: Proportion of acute stroke discharges to home, inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF) and onset days to IRF transfer. RESULTS: During the 3-year study period, sociodemographic characteristics, stroke severity at admission, and mortality rates did not change significantly. Discharges of patients with acute stroke patient to IRFs increased 5.9%, from 24.2% in 2018 to 30.1% in 2020. A total of 11% of patients were discharged to SNF in 2018 compared with 8.7% in 2020. Proportion of patients with acute stroke discharged to home decreased 4.9%, from 49.6% in 2018 to 44.7% (P=.0325). For patients with ischemic stroke, the average onset days to IRF transfer decreased 7.5% between 2018 and 2020, from 8 days to 7.4 days. For patients with hemorrhagic stroke, the average onset days decreased 17.5%, from 12 days in 2018 to 9.9 days in 2020. The decrease in onset days were not statistically significant for either stroke type (P=.3794). CONCLUSIONS: Implementation of huddle rounds and a virtual rounding tool by a physiatry-led stroke consult service significantly increased referrals to IRFs, with a concomitant decrease in referrals to SNFs or directly home. Next steps include validating model efficacy, with the goal of implementation at stroke centers in the United States.

COMPARISON OF CHRONIC WASTING DISEASE DETECTION METHODS AND PROCEDURES: IMPLICATIONS FOR FREE-RANGING WHITE-TAILED DEER (ODOCOILEUS VIRGINIANUS) SURVEILLANCE AND MANAGEMENT.

Throughout North America, chronic wasting disease (CWD) has emerged as perhaps the greatest threat to wild cervid populations, including white-tailed deer (WTD; Odocoileus virginianus). White-tailed deer are the most sought-after big game species across North America with populations of various subspecies in nearly all Canadian provinces, the contiguous US, and Mexico. Documented CWD cases have dramatically increased across the WTD range since the mid-1990s, including in Minnesota, US. CWD surveillance in free-ranging WTD and other cervid populations mainly depends upon immunodetection methods such as immunohistochemistry and enzyme-linked immunosorbent assay (ELISA) on medial retropharyngeal lymph nodes and obex. More recent technologies centered on prion protein amplification methods of detection have shown promise as more sensitive and rapid CWD diagnostic tools. Here, we used blinded samples to test the efficacy of real-time quaking-induced conversion (RT-QuIC) in comparison to ELISA for screening tissues collected in 2019 from WTD in southeastern Minnesota, where CWD has been routinely detected since 2016. Our results support previous findings that RT-QuIC is a more sensitive tool for CWD detection than current antibody-based methods. Additionally, a CWD testing protocol that includes multiple lymphoid tissues (e.g., medial retropharyngeal lymph node, parotid lymph node, and palatine tonsil) per animal can effectively identify a greater number of CWD detections in a WTD population than a single sample type (e.g., medial retropharyngeal lymph nodes). These results show that the variability of CWD pathogenesis, sampling protocol, and testing platform must be considered for the effective detection and management of CWD throughout North America.

Q-15 Minutes Vital Sign Documentation Is a Poor Surrogate for Assessing Quality of Care After Acute Ischemic Stroke.

OBJECTIVE: Documenting vital signs and National Institutes of Health Stroke Scale (NIHSS) once every 15 minutes after intravenous thrombolytic therapy for acute ischemic stroke is often used as a metric to assess the quality of care. This study explores the association between "once every 15 minutes" documentation and stroke outcomes. METHODS: This is a retrospective study of the first 2 hours of vital signs and NIHSS documentation after thrombolytic stroke therapy. Sociodemographic and clinical data, including NIHSS, temperature, heart rate, systolic blood pressure, diastolic blood pressure, mean arterial blood pressure, and respiratory rate, were abstracted from the medical record. Missing documentation was examined for association with modified Rankin Scale (mRS) scores and neurologic changes. RESULT: Among 84 patients with a mean age of 68.8 years, there were 2276 documented assessments from an expected 3780. There were 104 clinically significant changes in 1 or more index variables. The most commonly missed documentation occurred during interventional radiology. After controlling for admission NIHSS, there was no significant relationship between the completeness of documentation and discharge mRS score (r2 = 0.047, P = .0561), nor between vital sign documentation and discharge mRS (r2 = 0.003, P = .6338). CONCLUSION: Frequency of documentation does not reflect the quality of care during the early phase of acute stroke treatment.

Exploring Risk for Echinococcosis Spillover in Northern Minnesota Tribal Communities.

Echinococcus spp. are zoonotic cestode parasites with a worldwide distribution and a complex, two-host life cycle involving carnivore definitive hosts and small mammal or ungulate intermediate hosts. Surveillance for Echinococcus spp. in the Midwestern United States (USA) is rare. Using a mixed-methods approach, we examined Echinococcus infection risks in wildlife and domestic dogs in four Minnesota Tribal Nations. We hypothesized that the spillover of Echinococcus spp. into domestic dogs would vary with the presence or absence of suspected wildlife host species and certain behaviors associated with domestic dog ownership, like feeding wildlife host carcasses or frequency of veterinary care. Among 83 dogs tested, three (3.6%) were positive for Echinococcus spp. Despite low prevalence, pet owner survey and focus group findings indicated that dogs encounter peri-domestic wildlife most often when they roam freely or consume wildlife carcasses. This study demonstrates a need for further research into spillover potential of endemic zoonotic Echinococcus spp. in the Midwest USA.

Effect of Booster Vaccination with Inactivated Porcine Epidemic Diarrhea Virus on Neutralizing Antibody Response in Mammary Secretions.

Porcine epidemic diarrhea virus (PEDV) causes acute diarrhea, dehydration in pigs, and high mortality rates in piglets <3 weeks of age. Maternal immunity protects piglets, but information on vaccination before or after natural infection in endemically exposed sow herds is limited. Currently, the recovery goal in sow units infected with PEDV is to become fully naive again or use natural virus infection to develop immune gilts through a feedback program before introduction into the sow herd. Since neutralizing antibodies in the gut are critical for protection against enteric viral infections such as PEDV, we evaluated the effect of a conditionally licensed, adjuvanted inactivated PEDV vaccine on neutralizing antibody levels in milk and colostrum in both naive and previously naturally exposed sow herds. The results illustrate that intramuscular vaccination increased neutralizing antibody titers, and anti-PEDV IgA and IgG in milk and colostrum of sows that were previously infected. Thus, inactivated PEDV vaccines may provide increased protection to piglets nursing on previously infected sows against exposure to PEDV through increased delivery of lactogenic neutralizing antibodies to the enteric site of infection.

The hormonal sensitivity hypothesis: A review and new findings.

Previous women's health practitioners and researchers have postulated that some women are particularly sensitive to hormonal changes occurring during reproductive events. We hypothesize that some women are particularly sensitive to hormonal changes occurring across their reproductive lifespan. To evaluate this hypothesis, we reviewed findings from the existing literature and findings from our own lab. Taken together, the evidence we present shows a recurring pattern of hormonal sensitivity at predictable but different times across the lifespan of some women (i.e., menarche, the premenstrual phase, hormonal contraceptive use, pregnancy, the postpartum period, and menopause). These findings provide support for the hypothesis that there is a subgroup of women who are more susceptible to physical, psychological, and sexual symptoms related to hormonal shifts or abrupt hormonal fluctuations that occur throughout the reproductive lifespan. We propose that this pattern reflects a Hormonal Sensitivity Syndrome.

An indirect enzyme-linked immunosorbent assay for the identification of antibodies to Senecavirus A in swine.

BACKGROUND: Senecavirus A (SVA), a member of the family Picornaviridae, genus Senecavirus, is a recently identified single-stranded RNA virus closely related to members of the Cardiovirus genus. SVA was originally identified as a cell culture contaminant and was not associated with disease until 2007 when it was first observed in pigs with Idiopathic Vesicular Disease (IVD). Vesicular disease is sporadically observed in swine, is not debilitating, but is significant due to its resemblance to foreign animal diseases, such as foot-and-mouth disease (FMD), whose presence would be economically devastating to the United States. IVD disrupts swine production until foreign animal diseases can be ruled out. Identification and characterization of SVA as a cause of IVD will help to quickly rule out infection by foreign animal diseases. METHODS: We have developed and characterized an indirect ELISA assay to specifically identify serum antibodies to SVA. Viral protein 1, 2 and 3 (VP1, VP2, VP3) were expressed, isolated, and purified from E. coli and used to coat plates for an indirect ELISA. Sera from pigs with and without IVD symptoms as well as a time course following animals from an infected farm, were analyzed to determine the antibody responses to VP1, VP2, and VP3. RESULTS: Antibody responses to VP2 were higher than VP1 and VP3 and showed high affinity binding on an avidity ELISA. ROC analysis of the SVA VP2 ELISA showed a sensitivity of 94.2% and a specificity of 89.7%. Compared to IFA, the quantitative ELISA showed an 89% agreement in negative samples and positive samples from 4-60 days after appearance of clinical signs. Immune sera positive for FMDV, encephalomyocarditis virus, and porcine epidemic diarrhea virus antibodies did not cross-react. CONCLUSIONS: A simple ELISA based on detection of antibodies to SVA VP2 will help to differentially diagnose IVD due to SVA and rule out the presence of economically devastating foreign animal diseases.

Characterization of anti-porcine epidemic diarrhea virus neutralizing activity in mammary secretions.

Porcine epidemic diarrhea virus (PEDV) causes a severe clinical enteric disease in suckling neonates with up to 100% mortality, resulting in devastating economic losses to the pork industry in recent years. Maternal immunity via colostrum and milk is a vital source to neonates of passive protection against diarrhea, dehydration and death caused by PEDV. Comprehensive information on neutralizing activity (NA) against PEDV in mammary secretions is critically important for assessing the protective capacity of sows. Therefore, the objectives of this study were to characterize anti-PEDV neutralizing activity in mammary secretions. Anti-PEDV NA was present in colostrum, milk and serum from PEDV-infected sows as determined both by immunofluorescence and ELISA-based neutralizing assays, with neutralization levels higher in colostrum and milk than in serum. The highest NA was observed in colostrum on day 1, and decreased rapidly in milk at day 3, then gradually declined from day 3 to day 19 post-farrowing. Notably, the NA in mammary secretions showed various patterns of decline over time of lactation that may contribute to variation in sow protective capacities. The kinetics of NA decline were associated with total IgA and IgG antibody levels. Neutralizing activity significantly correlated with specific IgA primarily to spike domain 1 (S1) and domain 2 (S2) proteins of PEDV rather than to specific IgG in colostrum. Subsequently, the NA in milk was mainly related to specific IgA to S1 and S2 during lactation.

Past reproductive events as predictors of physical symptom severity during the menopausal transition.

OBJECTIVE: This study aims to determine whether the severity of physical symptoms experienced during perimenopause can be predicted by physical symptoms experienced during past reproductive events (ie, symptoms experienced during pregnancy, the postpartum period, the premenstrual phase, and hormonal contraceptive use). METHODS: Two hundred ninety perimenopausal and postmenopausal women completed a series of questionnaires pertaining to their menopausal symptoms and the severity of both physical and emotional symptoms experienced during past reproductive events. RESULTS: The severity of some physical symptoms experienced during past reproductive events predicted the severity of menopausal physical symptoms. Some symptoms experienced during the premenstrual phase (ie, pain, lack of concentration, and water retention) and physical symptoms experienced during pregnancy were the best unique predictors of menopausal physical symptoms. CONCLUSIONS: The findings suggest that women with a history of more severe physical symptoms during periods of both low (ie, premenstrual phase) and high (ie, pregnancy) hormone exposure are at greatest risk for experiencing severe physical symptoms during the perimenopausal transition.

Absence of porcine circovirus type 1 (PCV1) and high prevalence of PCV 2 exposure and infection in swine finisher herds.

Porcine circovirus (PCV) appeared in 1974 as an unidentified, innocuous viral inhabitant of cell cultures and pigs. Today PCV1 is a contaminant of some human vaccines, and PCV2 is a major pathogen of swine. PCV1 is reportedly ubiquitous in swine but nonpathogenic. Since the interplay of PCV1 and PCV2 in swine might explain variable disease results and shed light on the potential for human exposure, we analyzed in depth the prevalence of PCV1 and PCV2 infection and exposure in the U.S. finishing swine herd. Over 82% of sera from 185 farms were positive for PCV2 by PCR, whereas only 2.4% were positive for PCV1. More than 80% of PCV2 DNA-positive swine were also positive for anti-PCV2 antibodies. PCV1 was only rarely present. Exposure of swine, and therefore humans via pigs, to PCV1 is negligible. We conclude that PCV2 causes a persistent infection in pigs and that PCV1 is absent or rare in swine.