Cecal volvulus secondary to mesodiverticular band.

Meckel's diverticula are one of the most common gastrointestinal anomalies, yet mesodiverticular bands are rare. The treatment of these bands commonly requires surgery. A healthy patient in his 20s presented to the emergency department with a 1 day history of acute onset abdominal pain. Computed tomography imaging was consistent with volvulus of the large intestine. In the operating room, the patient was noted to have a band between the ileal mesentery and tip of a Meckel's diverticulum, consistent with a mesodivertiular band, through which cecum had volvulized. The patient underwent resection. The patient recovered without major complications. Mesodiverticular bands are rare, but may present as hemoperitoneum, small bowel obstruction, or volvulus. Pre-operative diagnosis of a mesodiverticular band is often difficult and they are most commonly diagnosed intraoperatively. Treatment should include surgery and may include simple lysis of the band, bowel resection, or more extensive resection if other pathology is present.

Risk factors and ambulatory outcome in ischemic stroke patients with pre-stroke depression.

OBJECTIVE: It is well known that post-stroke depression might be a negative factor for stroke recovery, however there is limited evidence to establish the link between pre-stroke depression and stroke outcome such motor recovery. The objective is to determine clinical risk factors in ischemic stroke patients with pre-stroke depression that are associated functional ambulatory outcome. METHODS: Data from acute ischemic patients from a regional stroke registry were collected for consecutive recombinant tissue plasminogen activator(rtPA)-treated acute ischemic stroke patients between January 2010 and June 2016. Logistic regression model was used to predict risk factors that served as predictive variables, while the increase or reduce odds of improvement in ambulatory outcome was considered as the primary outcome. Multicollinearity and possible interactions among the independent variables were analyzed using the variance inflation factor. RESULTS: A total of 1446 patients were eligible for recombinant tissue plasminogen activator (rtPA) and 596 of these patients received rtPA. Of the 596 ischemic stroke patients, 286 patients presented with recent pre-stroke depression, 310 had no pre-stroke depression. Carotid artery stenosis (OR = 11.577, 95% CI, 1.281-104.636, P = 0.029) and peripheral vascular disease (OR = 18.040, 95% CI, 2.956-110.086, P = 0.002) were more likely to be associated with increase odds of improvement in ambulation in patients with no pre-stroke depression treated with rtPA, while antihypertensive medications (OR = 0.192, 95% CI, 0.035-1.067, P = 0.050),previous TIA (OR = 0.177, 95% CI, 0.038-0.818, P = 0.027), and congestive heart failure (OR = 0. 0.160, 95% CI, 0.030-0.846, P = 0.031) were associated with reduced odds of improvement in ambulation. In addition, carotid artery stenosis (OR = 0.078, 95% CI, 0.10-0.614, P = 0.015, congestive heart failure (OR = 0.217, 95% CI, 0.318-0.402, P = 0.030), previous TIA (OR = 0.444, 95% CI, 0.517-0.971, P = 0.012), higher NIHSS scores ((OR = 0.887, 95% CI, 0.830-0.948, P < 0.001), and antihypertensive medications (OR = 0.810, 95% CI, 0.401-0.529, P = 0.019) were associated with the reduced odd of improvement in ambulation in an ischemic stroke population with pre-stroke depression treated with rtPA. CONCLUSION: Our findings indicate that more risk factors were associated with the decreased odds of an improvement in ambulation following thrombolytic therapy in an ischemic stroke population with pre-stroke depression when compared with those without pre-stroke depression. This finding maybe helpful in the development of management strategies to increase the use of thrombolytic therapy for pre-stroke depressed ischemic stroke to increased their eligibility for rtPA.

Gender and thrombolysis therapy in acute ischemic stroke patients with incidence of obesity.

OBJECTIVE: To investigate clinical risk factors that were associated with gender differences in thrombolysis therapy in stroke patients with incidence of obesity. METHOD: Retrospective data of obese acute ischemic stroke patients were extracted from a stroke registry between January 2010 and June 2016. Gender differences in exclusion from rtPA or thrombolysis therapy were determined following an adjustment for differences in demographics, clinical risk factors using multiple regression analysis. Significant interactions between variables in the regression models were determined using variance inflation factors. RESULTS: A total of 1105 obese stroke patients were admitted, 549 were excluded from rtPA of which 51.7% were males and 48.3% were females. Among obese male stroke patients, age > 80 years (OR = 1.029, 95% CI, 1.005-1.054, P = 0.016), a history of peripheral vascular disease (OR = 3.008, 95% CI, 0.989-9.153, P = 0.052), and an elevated diastolic blood pressure (OR = 1.018, 95% CI, 1.001-1.035, P = 0.038) were associated with exclusion from rtPA therapy. In obese female stroke patients, coronary artery disease was associated with exclusion from rtPA (OR = 2.478, 95% CI, 1.270-4.836, P = 0.008) while antihypertensive therapy was associated with inclusion for rtPA (OR = 0.326, 95% CI, 0.139-0.764). CONCLUSION: Elderly obese male stroke patients with elevated diastolic blood pressure, history of peripheral vascular disease, and obese female stroke patients with a history of coronary artery disease were more likely to be excluded from rtPA.

Gender and thrombolysis therapy in stroke patients with incidence of dyslipidemia.

BACKGROUND: When untreated, dyslipidemia is a higher risk factor for stroke and stroke-related mortality in men than in women. However, when dyslipidemia is treated the risk reduction is the same, but men benefited from mortality reduction more than women. Whether there is a gender difference in exclusion criteria for the use of recombinant tissue plasminogen activator (rtPA) or thrombolysis therapy in an acute ischemic stroke subpopulation with dyslipidemia is yet to be investigated. METHOD: In a dyslipidemic stroke population obtained from a stroke registry, gender differences in exclusion risk factors were determined using clinical and demographic variables. Univariate analysis compared the recombinant tissue plasminogen activator (rtPA) group and the no rtPA group. Multiple regression analysis was used to determine demographic and clinical factors associated with inclusion and exclusion for rtPA in the total dyslipidemic stroke population and the subsets of the male and female population. The regression model was tested using the Hosmer-Lemeshow test, for the overall correct classification percentage. Significant interactions and multicollinearity between independent variables were examined using variance inflation factors. RESULTS: A total of 769 patients presented with acute ischemic stroke with incidence dyslipidemia; 325 received rtPA while 444 were excluded from rtPA. Of those excluded from rtPA, 54.30% were female and 45.72% were male. In an adjusted analysis, female patients with increased age (OR = 1.024, 95% CI, 1.001-1.047, P < 0.05), with a history of carotid artery stenosis (OR = 7.063, 95% CI, 1.506-33.134, P < 0.05), and previous stroke (OR = 1.978, 95% CI, 1.136-3.442, P < 0.05) were more likely to be excluded from rtPA. Male patients with atrial fibrillation (OR = 2.053, 95% CI, 1.059-3.978, P = 0.033), carotid artery stenosis (OR = 2.400, 95% CI, 1.062-5.424, P = 0.035), and previous stroke (OR = 1.785, 95% CI, 1.063-2.998, P = 0.028) were more likely to be excluded from rtPA. CONCLUSION: Although there are some similarities in the clinical risk factors for exclusion in both male and female stroke patients with incidence of dyslipidemia, there are differences as well. Elderly female stroke patients with incidence of dyslipidemia are more likely to be excluded from rtPA, even after adjustment for the effect of confounding variables. Further research should focus on how identified clinical risk factors can be targeted and managed to improve the use of rtPA in elderly female acute ischemic stroke population with incidence of dyslipidemia.

Effect of antihypertensive medications on thrombolysis therapy and outcomes in acute ischemic stroke patients.

There are concerns that specific risk factors may alter the benefits of thrombolysis in stroke patients with controlled contraindications including hypertension. The objective of this study was to evaluate the association between clinical risk factors and outcomes in ischemic stroke patients that received thrombolysis therapy pretreated with antihypertensive medications. Using data obtained from a stroke registry, a non-randomized retrospective data analysis was conducted on patients with the primary diagnosis of acute ischemic stroke with hypertension pretreated with antihypertensive medications. The association between clinical risk factors and functional ambulatory outcome was determined using logistic regression while odd ratios (OR) were used to predict the odds of achieving improved ambulatory outcome in thrombolysis treatment status. Improved or poor functional ambulatory outcome was considered as the end point in our analysis. A total of 4665 acute ischemic stroke patients were identified, of whom 1446 (31.0%) were eligible for thrombolysis, while 3219 were not, and 595 received rtPA, of whom 288 were on antihypertensive medications, while 233 were not. In the rtPA group with antihypertensive (anti-HTN) medication, only NIHSS score (OR = 1.094, 95% CI, 1.094-1.000, P = 0.005) was associated with improved functional outcome while patients with congestive heart failure (OR = 0.385, 95% CI, 0.385-0.159, P = 0.035) and patients with a history of previous TIA (OR = 0.302, 95% CI, 0.302-0.113, P = 0.017) were more likely to be associated with poor functional outcomes. Congestive heart failure and TIA are independent predictors of functional outcomes in stroke patients pretreated with antihypertensive medications prior to thrombolysis therapy.

Stroke and dyslipidemia: clinical risk factors in the telestroke versus non-telestroke.

BACKGROUND: Clinical risk factors related to not administering thrombolysis to acute ischemic stroke patients with incidence dyslipidemia is not clear. This issue was investigated in telestroke and non-telestroke settings. METHODS: We analyzed retrospective data collected from a stroke registry to compare exclusion risk factors in the telestroke and non-telestroke. We performed multivariate analysis was performed to identify risk factors that may result in exclusion from rtPA. Variance inflation factors were used to examine multicollinearity and significant interactions between independent variables in the model, while Hosmer-Lemeshow test, Cox & Snell were used to determine the fitness of the regression models. RESULTS: A greater number of patients with acute ischemic stroke with incidence dyslipidemia were treated in the non-telestroke (285) when compared with the telestroke network (187). Although non-telestroke admitted more patients than the telestroke, the telestroke treated more patients with rtPA (89.30%) and excluded less (10.70%), while the non-telestroke excluded from rtPA (61.40%). In the non-telestroke, age (adjusted OR, 0.965; 95% CI, 0.942-0.99), blood glucose level (adjusted OR, 0.995; 95% CI, 0.99-0.999), international normalized ratio (adjusted OR, 0.154; 95% CI, 0.031-0.78),congestive heart failure(CHF) (adjusted OR, 0.318; 95% CI, 0.109-0.928), previous stroke (adjusted OR, 0.405; 95% CI, 0.2-0.821) and renal insufficiency (adjusted OR, 0.179; 95% CI, 0.035-0.908) were all directly linked to exclusion from rtPA. In the telestroke, only body mass index (adjusted OR, 0.911; 95% CI, 0.832-0.997) significantly excluded acute ischemic stroke patients with incidence dyslipidemia from thrombolysis therapy. CONCLUSION: Despite having more patients with acute ischemic stroke that present incidence dyslipidemia, the non-telestroke patients had more clinical risk factors that excluded more patients from rtPA when compared with telestroke. Future studies should focus on how identified clinical risk factors can be managed to improve the use of rtPA in the non-telestroke setting. Moreover, the optimization of the risk-benefit ratio of rtPA by the telestroke technology can be advanced to the non-telestroke setting to improve the use of thrombolysis therapy.

Functional Outcome Measures of Recombinant Tissue Plasminogen Activator-Treated Stroke Patients in the Telestroke Technology.

The efficiency of telestroke programs in improving the rates of recombinant tissue plasminogen activator (rtPA) in stroke patients has been reported. Previous studies have reported favorable treatment outcomes with the use of telestroke programs to improve the use of rtPA, but functional outcomes are not fully understood. This study investigated the effect of telestroke technology in the administration of rtPA and related functional outcomes associated with baseline clinical variables. Retrospective data of a telestroke registry were analyzed. Univariate analysis was used to compare demographic and clinical variables in the rtPA group and the no rtPA group and between the improved functional ambulation group and the no improvement group. A stepwise binary logistic regression identified factors associated with improved functional outcome in the total telestroke population and in the subset of the telestroke population who received rtPA. In adjusted analysis and elimination of any multicollinearity for patients who received rtPA in the telestroke setting, obesity (odds ratio [OR] = 2.138, 95% confidence interval [CI], 1.164-3.928, P < .05), higher systolic blood pressure at the time of presentation (OR = 1.015, 95% CI, 1.003-1.027, P < .05), and baseline high-density lipoprotein at the time of admission (OR = 1.032, 95% CI, 1.005-1.059, P < .05) were associated with improved functional outcomes. Increasing age (OR = 0.940, 95% CI, 0.916-0.965, P < .0001) and higher calculated National Institutes of Health Stroke Scale (OR = 0.903, 95% CI, 0.869-0.937) were associated with a poorer outcome in rtPA-treated patients. Telestroke technology improves functional outcomes at spoke stations where neurological expertise is unavailable. Further studies are necessary to determine how telestroke technology can be optimized, especially to improve contraindications and increase eligibility for thrombolysis therapy.

Clinical Risk Factors in Thrombolysis therapy: Telestroke Versus Nontelestroke.

BACKGROUND: The objective of this study is to determine clinical risk factors associated with exclusion from thrombolysis in telestroke and nontelestroke settings. These risk factors may offer clues for optimization of thrombolysis therapy in acute ischemic stroke population. MATERIALS AND METHODS: Retrospective data of patients with acute ischemic stroke via telestroke and nontelestroke assessment were analyzed. Univariate analysis was used to compare the recombinant tissue plasminogen activator (rtPA) group and the no rtPA group. A stepwise binary logistic regression identified factors associated with inclusion and exclusion from rtPA in the total telestroke population and the subsets of the telestroke population. RESULTS: Telestroke patients were more likely to be directly admitted rather than being initially evaluated in the emergency department (70.3% versus 9.9%) and were also substantially more likely to receive rtPA (89.5% versus 38.5%). In the nontelestroke group, patients with acute ischemic stroke were more likely to be excluded from rtPA if they possessed higher international normalized ratios (odds ratio [OR] = 4.978 [1.503-16.488]) or had a history of congestive heart failure (OR = 2.524 [1.213-5.252]), previous stroke (OR = 2.172 [1.286-3.667]), or renal dysfunction (OR = 4.204 [1.33-13.281]). The telestroke group only had 1 variable deemed statistically significant in its association with rtPA status. Patients who were directly admitted were less likely to be excluded from receipt of rtPA (OR = .322 [.112-0.927]). CONCLUSIONS: Factors associated with exclusion from rtPA in the nontelestroke setting did not exclude patients with acute ischemic stroke from thrombolysis therapy in the telestroke setting. Telestroke may offer methods for optimization of the risk-benefit ratio of rtPA, equipping clinicians to efficiently make treatment decisions.

In a stroke cohort with incident hypertension; are more women than men likely to be excluded from recombinant tissue-type Plasminogen Activator (rtPA)?

BACKGROUND: The treatment outcomes in the use of rt-PA have been reported. Some studies reported worse outcome in women than men, while others presented opposing data. Using data from a hospital-based stroke registry, we investigated evidence of gender difference and determined exclusion criteria in a stroke population with incidence of hypertension. METHOD: In a stroke population of women and men with incident of hypertension from a stroke registry, demographics and clinical factors were compared. Univariate analysis was used to determine gender differences, while multivariable models adjusted for demographic and clinical variables. RESULTS: Among the 669 stroke patients with incident of hypertension that were excluded from rt-PA treatment, 362 were female and 307 were male. Female patients with increasing age (OR = 0.956-0.984, P < 0.001), diabetes mellitus (OR = 0.095-0.559, P = 0.001), higher NIH stroke scale score (OR = 1.019-1.090, P = 0.002), previous stroke (OR = 0.337-0.850, P = 0.008), diabetes medication (OR = 1.200-7.724, P = 0.019), and INR (OR = 0.033-0.597, P = 0.008) are more likely to be excluded. Male patients with a history of a previous stroke (OR = 0.265-0.704, P = 0.001), risk of mortality (OR = 0.803-0.950, P = 0.002), higher NIH stroke scale score(OR = 1.101-1.276, P < 0.001), cholesterol reducing medication (OR = 1.191-2.910, P = 0.006), weakness at presentation(OR = 1.207-4.421, P = 0.011), and INR (OR = 0.016-0.243, P < 0.001) are more likely to be excluded. CONCLUSION: Women have a worse outcome than men in an untreated acute ischemic stroke population, but when treated, women have a better treatment outcome compared to men. In a hypertensive stroke population, the clinical variables for the exclusion criteria for women and men are significantly different, even after adjustment for confounding variables.

Thrombolysis Therapy in Specialized and Non-specialized Stroke Units.

BACKGROUND: The benefits of a special stroke care unit (SSCU) over a non-specialized stroke care unit (NSSCU) is well documented in the literature. However, there are concerns that the benefits seen in the SSCU do not consider clinical risk factors that affect thrombolysis therapy. METHOD: Retrospective data were collected from a stroke registry between January 1, 2010-June 30, 2016. Univariate analysis determined differences in exclusion criteria between the SSCU and NSSCU, while multivariable binary logistic regression adjusted for confounding variables. RESULT: Of the 1,446 acute ischemic stroke patients eligible for rtPA, 34.0% of patients were admitted to the NSSCU, while 58.02% were admitted to the SSCU. For patients excluded from receiving rtPA in the SSCU: age >80 (OR = 1.024-1.037, p = <0.001), altered level of consciousness (OR = 1.551-2.363, p = 0.041), risk of mortality (OR = 1.090-1.166, p = 0.012), previous stroke (OR = 1.638-2.338, p = 0.007) were the exclusion criteria from rtPA. In the NSSCU, age >80 (OR = 1.026-1.046, p = 0.012), history of atrial fibrillation (OR = 2.494-4.629, p = 0.004), diabetes (OR = 2.377-5.576, p = 0.047) and previous stroke (OR = 2.782-4.785, p = <0.001) were associated with exclusion from rtPA. CONCLUSION: More patients are likely to be excluded from rtPA in the NSSCU if they present with history of atrial fibrillation, diabetes, and in the SSCU if they present with altered level of consciousness and are at risk of mortality. Improvement in the management of baseline clinical risk factors would improve thrombolysis use for better patient outcomes in specialized and non specialized stroke units.

Investigation of Gender Differences and Exclusive Criteria in a Diabetic Acute Ischemic Stroke Population Treated with Recombinant Tissue-Type Plasminogen Activator (rtPA).

BACKGROUND: Many studies have reported that women who survive stroke have less favorable outcomes than men in the use of rtPA, while others reported worse outcomes in men than women. The gender difference in the exclusion criteria in a diabetic stroke population is not fully understood. This issue was investigated in this study. METHOD: In a diabetic stroke population from a stroke registry of data collected between January 2010 to June 30, 2016, the gender difference was determined using demographics and clinical factors. Comparison was determined using univariate analysis while multivariable model was used to adjust for the effect of confounding variables. RESULTS: In a diabetic stroke population of 439 patients, more females were excluded than males (P < 0.0001, OR = 2.323). The male exclusion was associated with atrial fibrillation (P = 0.011, OR = 3.697), carotid artery stenosis (P = 0.023, OR = 5.001), and cholesterol reducer (P = 0.037, OR = 0.409). In the female diabetic stroke population, exclusion from rtPA therapy was associated with language disturbances (P = 0.039, OR = 0.372), history of previous stroke (P = 0.005, OR = 3.276), antihypertensive medication use (P = 0.013, OR = 0.163), and antidiabetic medication use (P = 0.031, OR = 0.324). CONCLUSION: In a stroke population, women have a worse outcome than men in an untreated acute ischemic stroke population, but when treated there is no significant difference, suggesting a better treatment outcome for women compared to men. In a diabetic stroke population, the clinical variables for the exclusion criteria for women and men are significantly different, even after adjustment for confounding variables.