Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada.

BACKGROUND: Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada. METHODS: We used the Ontario Road Network File database linked with the 2016 Ontario Acute Stroke Care Resource Inventory to estimate the proportion of people in rural communities, defined as those with a population size <10,000, who were within 30, 60, and 240 minutes of travel time by car from stroke care services, including brain imaging, thrombolysis treatment centers, stroke units, stroke prevention clinics, inpatient rehabilitation facilities, and endovascular treatment centers. RESULTS: Of the 1,496,262 people residing in rural communities, the majority resided within 60 minutes of driving time to a center with computed tomography (85%), thrombolysis (81%), a stroke unit (68%), a stroke prevention clinic (74%), or inpatient rehabilitation (77.0%), but a much lower proportion (32%) were within 60 minutes of driving time to a center capable of providing endovascular thrombectomy (EVT). CONCLUSIONS: Most rural Ontario residents have appropriate geographic access to stroke services, with the exception of EVT. This information may be useful for jurisdictions seeking to optimize the regional organization of stroke care services.

Transition to seizure: ictal discharge is preceded by exhausted presynaptic GABA release in the hippocampal CA3 region.

How the brain transitions into a seizure is poorly understood. Recurrent seizure-like events (SLEs) in low-Mg2+/ high-K+ perfusate were measured in the CA3 region of the intact mouse hippocampus. The SLE was divided into a "preictal phase," which abruptly turns into a higher frequency "ictal" phase. Blockade of GABA(A) receptors shortened the preictal phase, abolished interictal bursts, and attenuated the slow preictal depolarization, with no effect on the ictal duration, whereas SLEs were blocked by glutamate receptor blockade. In CA3 pyramidal cells and stratum oriens non-fast-spiking and fast-spiking interneurons, recurrent GABAergic IPSCs predominated interictally and during the early preictal phase, synchronous with extracellularly measured recurrent field potentials (FPs). These IPSCs then decreased to zero or reversed polarity by the onset of the higher-frequency ictus. However, postsynaptic muscimol-evoked GABA(A) responses remained intact. Simultaneously, EPSCs synchronous with the FPs markedly increased to a maximum at the ictal onset. The reversal potential of the compound postsynaptic currents (combined simultaneous EPSCs and IPSCs) became markedly depolarized during the preictal phase, whereas the muscimol-evoked GABA(A) reversal potential remained unchanged. During the late preictal phase, interneuronal excitability was high, but IPSCs, evoked by local stimulation, or osmotically by hypertonic sucrose application, were diminished, disappearing at the ictal onset. We conclude that the interictal and early preictal states are dominated by GABAergic activity, with the onset of the ictus heralded by exhaustion of presynaptic release of GABA, and unopposed increased glutamatergic responses.

A case of pulmonary arterial hypertension associated with adult hemophagocytic lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is an aggressive, life-threatening syndrome of excessive immune activation. Presentation is most common among the pediatric population, and cases in adults are rare. The number of nonhematologic presentations described in relation to HLH has been growing. We present a case involving a woman who developed HLH after autologous stem cell transplantation for mantle cell lymphoma. Months later, she received a diagnosis of pulmonary arterial hypertension (PAH) while undergoing treatment for her HLH. To our knowledge, PAH associated with adult HLH has only been described in the literature once before. PAH may now be a potential differential diagnosis for patients with HLH who present with respiratory symptoms.

The association between rural residence and stroke care and outcomes.

BACKGROUND: Little is known about stroke care and outcomes in those residing in rural compared to urban areas. METHODS: We conducted a cohort study on a population-based sample of patients with stroke or transient ischemic attack seen at 153 acute care hospitals in the province of Ontario, Canada, between April 1, 2008 and March 31, 2011. Based on their primary residence, patients were categorized as residing in a rural (population<10,000), medium urban (population 10,000-99,999) or large urban (population≥100,000) area. In the study sample of 15,713, we compared processes of stroke care (use of thrombolysis, stroke unit care, investigations, consultations and treatments) and outcomes (30-day mortality, disability at discharge) in those from rural and urban areas, with multivariable models constructed to evaluate the association between rural residence and outcomes after adjustment for potential confounders. RESULTS: Patients from rural areas were less likely than those from urban areas to receive stroke unit care, brain imaging within 24 h, carotid imaging, and consultations from neurologists, physiotherapists, occupational therapists and speech language pathologists, and were less likely to be transferred to inpatient rehabilitation facilities. Use of antithrombotic agents and lipid lowering therapy was similar in rural and urban residents, as was disability at discharge. There was a trend toward higher 30-day mortality in rural compared to urban residents (adjusted hazard ratio 1.14; 95% confidence interval 0.99-1.32). CONCLUSION: Rural residence is associated with lower use of key stroke care interventions after stroke. Future work should focus on developing interventions to address gaps in stroke care in rural areas.