Multimodal CT Imaging: Time to Treatment and Outcomes in the IMS III Trial.

BACKGROUND AND PURPOSE: The importance of time in acute stroke is well-established. Using the Interventional Management of Stroke III trial data, we explored the effect of multimodal imaging (CT perfusion and/or CT angiography) versus noncontrast CT alone on time to treatment and outcomes. MATERIALS AND METHODS: We examined 3 groups: 1) subjects with baseline CTP and CTA (CTP+CTA), 2) subjects with baseline CTA without CTP (CTA), and 3) subjects with noncontrast head CT alone. The demographics, treatment time intervals, and clinical outcomes in these groups were studied. RESULTS: Of 656 subjects enrolled in the Interventional Management of Stroke III trial, 90 (13.7%) received CTP and CTA, 216 (32.9%) received CTA (without CTP), and 342 (52.1%) received NCCT alone. Median times for the CTP+CTA, CTA, and NCCT groups were as follows: stroke onset to IV tPA (120.5 versus 117.5 versus 120 minutes; P = .5762), IV tPA to groin puncture (77.5 versus 81 versus 91 minutes; P = .0043), groin puncture to endovascular therapy start (30 versus 38 versus 44 minutes; P = .0001), and endovascular therapy start to end (63 versus 46 versus 74 minutes; P < .0001). Compared with NCCT, the CTA group had better outcomes in the endovascular arm (OR, 2.12; 95% CI, 1.36-3.31; adjusted for age, NIHSS score, and time from onset to IV tPA). The CTP+CTA group did not have better outcomes compared with the NCCT group. CONCLUSIONS: Use of CTA with or without CTP did not delay IV tPA or endovascular therapy compared with NCCT in the Interventional Management of Stroke III trial.

Outcome Differences between Intra-Arterial Iso- and Low-Osmolality Iodinated Radiographic Contrast Media in the Interventional Management of Stroke III Trial.

BACKGROUND AND PURPOSE: Intracarotid arterial infusion of nonionic, low-osmolal iohexol contrast medium has been associated with increased intracranial hemorrhage in a rat middle cerebral artery occlusion model compared with saline infusion. Iso-osmolal iodixanol (290 mOsm/kg H2O) infusion demonstrated smaller infarcts and less intracranial hemorrhage compared with low-osmolal iopamidol and saline. No studies comparing iodinated radiographic contrast media in human stroke have been performed, to our knowledge. We hypothesized that low-osmolal contrast media may be associated with worse outcomes compared with iodixanol in the Interventional Management of Stroke III Trial (IMS III). MATERIALS AND METHODS: We reviewed prospective iodinated radiographic contrast media data for 133 M1 occlusions treated with endovascular therapy. We compared 5 prespecified efficacy and safety end points (mRS 0-2 outcome, modified TICI 2b-3 reperfusion, asymptomatic and symptomatic intracranial hemorrhage, and mortality) between those receiving iodixanol (n = 31) or low-osmolal contrast media (n = 102). Variables imbalanced between iodinated radiographic contrast media types or associated with outcome were considered potential covariates for the adjusted models. In addition to the iodinated radiographic contrast media type, final covariates were those selected by using the stepwise method in a logistic regression model. Adjusted relative risks were then estimated by using a log-link regression model. RESULTS: Of baseline or endovascular therapy variables potentially linked to outcome, prior antiplatelet agent use was more common and microcatheter iodinated radiographic contrast media injections were fewer with iodixanol. Relative risk point estimates are in favor of iodixanol for the 5 prespecified end points with M1 occlusion. The percentage of risk differences are numerically greater for microcatheter injections with iodixanol. CONCLUSIONS: While data favoring the use of iso-osmolal iodixanol for reperfusion of M1 occlusion following IV rtPA are inconclusive, potential pathophysiologic mechanisms suggesting clinical benefit warrant further investigation.

A quasi-experimental, dual-center study of morphine efficacy in patients with burns.

The efficacy of morphine sulfate for the relief of pain and anxiety in patients with burns was investigated in a quasiexperimental, dual-center study. More than 100 patients at two burn centers in Iowa were studied. One of the units used no morphine or morphine derivatives for the control of pain (the no-morphine unit), and the other used moderate to high doses of morphine for the relief of pain (the morphine unit). Patients were asked to rate their pain and anxiety after hydrotherapy and at rest in the afternoon on a daily basis throughout their stays. Side effects were also measured, and nurses made ratings of the patients' pain and anxiety during morning hydrotherapy. Results indicated that pain and anxiety decreased significantly from hydrotherapy to afternoon assessments and decreased significantly during the patient's hospital stay. Unexpectedly, however, patients at the no-morphine unit consistently reported lower levels of pain and anxiety than did patients at the morphine unit. These results could not be explained by differences in burn size or number of surgeries across units. Other possible explanations are offered.

The effect of metiamide, an H2-receptor antagonist, in the prevention of experimental stress ulcers.

Because of evidence that Metiamide, an H2-receptor antagonist, strongly inhibits gastric acid secretion, the present study was designed to test the hypothesis that Metiamide will prevent bile salt-induced stress ulcers during hemorrhagic shock. Forty dogs were bled and maintained for 4 1/2 hr at a mean blood pressure of 40 to 50 mm Hg. In group A, 10 dogs received 300 mg of Metiamide orally 45 min before bleeding and 10 dogs received normal saline. The pylorus was occluded before bleeding and 100 ml of 15 mM bile salt were instilled into the stomach and aspirated at the end of 4 1/2 hr. At the time the animal was killed after 48 hr, no ulcers were seen in the stomachs of dogs treated with Metiamide. Sixty per cent of the dogs in the untreated group developed multiple gross ulcers. In group B the effect of Metiamide on the disappearance rate of H+ ion was measured by instillation of 50 mM HCl + 15 mM bile acid. No difference was noted in the rate of H+ ion disappearance between Metiamide-treated and control dogs. Also, in 5 normotensive dogs the rate of H+ ion disappearance was measured before and after treatment with Metiamide, and the loss of H+ was identical for both periods. Metiamide was effective in preventing stress ulcer in this experimental model. The protective effect of Metiamide is probably due to its inhibitory effect of H+ ion secretion.

Odontogenic adenomatoid tumors associated with orthodontic treatment.

Because of a predilection for occurrence in the anterior jaw in association with an unerupted tooth, the odontogenic adenomatoid tumor (OAT) will sometimes be discovered in the context of an orthodontic procedure to promote and guide eruption of the tooth. Two cases illustrate this situation. Some other lesions that might have a clinical presentation similar to the OAT are named.