Genetic testing in children with nephrolithiasis and nephrocalcinosis.

BACKGROUND: Diagnosing genetic kidney disease has become more accessible with low-cost, rapid genetic testing. The study objectives were to determine genetic testing diagnostic yield and examine predictors of genetic diagnosis in children with nephrolithiasis/nephrocalcinosis (NL/NC). METHODS: This retrospective multicenter cross-sectional study was conducted on children ≤ 21 years old with NL/NC from pediatric nephrology/urology centers that underwent the Invitae Nephrolithiasis Panel 1/1/2019-9/30/2021. The diagnostic yield of the genetic panel was calculated. Bivariate and multiple logistic regression were performed to assess for predictors of positive genetic testing. RESULTS: One hundred and thirteen children (83 NL, 30 NC) from 7 centers were included. Genetic testing was positive in 32% overall (29% NL, 40% NC) with definite diagnoses (had pathogenic variants alone) made in 11.5%, probable diagnoses (carried a combination of pathogenic variants and variants of uncertain significance (VUS) in the same gene) made in 5.4%, and possible diagnoses (had VUS alone) made in 15.0%. Variants were found in 28 genes (most commonly HOGA1 in NL, SLC34A3 in NC) and 20 different conditions were identified. Compared to NL, those with NC were younger and had a higher proportion with developmental delay, hypercalcemia, low serum bicarbonate, hypophosphatemia, and chronic kidney disease. In multivariate analysis, low serum bicarbonate was associated with increased odds of genetic diagnosis (ß 2.2, OR 8.7, 95% CI 1.4-54.7, p = 0.02). CONCLUSIONS: Genetic testing was high-yield with definite, probable, or possible explanatory variants found in up to one-third of children with NL/NC and shows promise to improve clinical practice. A higher resolution version of the Graphical abstract is available as Supplementary information.

Detecting Aspiration During FEES with Narrow Band Imaging in a Clinical Setting.

The use of narrow band imaging (NBI) during flexible endoscopic evaluation of swallowing (FEES) is recognised as an emerging technology to improve the contrast of the test fluid during endoscopic dysphagia evaluation. This study tested the hypothesis that the use of NBI in FEES would improve the detection of laryngeal penetration and aspiration in patients with unilateral vocal fold paralysis/paresis (UVFP), a typically difficult population in which to detect the presence of aspiration with FEES. Twenty-one consecutive outpatients with UVFP were evaluated with FEES using white light (WL) and NBI under 150 test conditions (75 WL & 75 NBI). Three speech pathologists, highly experienced in FEES using WL but novices to using NBI, rated laryngeal penetration and aspiration for green dyed thin fluid (5 ml and 90 ml) and mildly thick fluid (5 ml) milk, and were compared to two raters more experienced in using NBI during FEES. Laryngeal penetration and aspiration were significantly higher for larger volumes (90 ml) (p < 0.05). With NBI-naïve raters, there was a trend towards lower intra-rater and inter-rater reliability compared to WL on all bolus trials reaching significance on mildly thick fluid (p < 0.01). There was lower rater confidence when using NBI compared to WL in NBI-naïve raters to detect aspiration (p < 0.01). Sensitivity was lower regardless of NBI experience; 80.77-84.21% with WL compared to 46.15-50.00% with NBI. Findings indicate that the improved contrast of a dyed opaque milk trial under WL may negate the potential benefits of using NBI to increase the contrast of the test fluid and supports the use of an opaque test fluid such as milk. NBI may also not be as useful to clinicians with no experience with the altered light condition, and can result in lower sensitivity in even the experienced user.

Evaluation and fetal intervention in severe fetal hydronephrosis.

PURPOSE OF REVIEW: Fetal hydronephrosis secondary to congenital anomalies of the kidney and urinary tract (CAKUT) can adversely affect neonates in the postnatal period with long-term consequences. A prenatal diagnosis of CAKUT can have an early fetal intervention to minimize these consequences. This review aims to provide an overview of the possible fetal intervention with severe hydronephrosis. RECENT FINDINGS: Clinical course and outcomes of CAKUT are predicted based on biochemical markers and radiological findings. In spite of advancements and accurately diagnosing the severity of hydronephrosis, there are many controversies surround on selection of cases with antenatal hydronephrosis (ANH) that will benefit from fetal intervention. Despite better diagnosis and techniques fetal intervention is limited to mainly lower urinary tract obstruction patients to improve amniotic fluid volume and assist in lung development. SUMMARY: ANH can potentially detect the severity of congenital renal anomalies but unable to recognize a specific disease. A multidisciplinary approach is required to diagnose and properly stage cases of severe CAKUT and potential surgical intervention can be considered.

Lower urinary tract obstruction: fetal intervention based on prenatal staging.

The authors present an overview of lower urinary tract obstruction (LUTO) in the fetus with a particular focus on the insult to the developing renal system. Diagnostic criteria along with the challenges in estimating long-term prognosis are reviewed. A proposed prenatal LUTO disease severity classification to guide management decisions with fetal intervention to maintain or salvage in utero and neonatal pulmonary and renal function is also discussed. Stage I LUTO (mild form) is characterized by normal amniotic fluid index after 18 weeks, normal kidney echogenicity, no renal cortical cysts, no evidence of renal dysplasia, and favorable urinary biochemistries when sampled between 18 and 30 weeks; prenatal surveillance is recommended. Stage II LUTO is characterized by oligohydramnios/anhydramnios, hyperechogenic kidneys but absent renal cortical cysts or apparent signs of renal dysplasia and favorable fetal urinary biochemistry; fetal vesicoamniotic shunting (VAS) or fetal cystoscopy is indicated to prevent pulmonary hypoplasia and renal failure. Stage III LUTO is oligohydramnios/anhydramnios, hyperechogenic kidneys with cortical cysts and renal dysplasia and unfavorable fetal urinary biochemistry after serial evaluation; fetal vesicoamniotic shunt may prevent severe pulmonary hypoplasia but not renal failure. Stage IV is characterized by intrauterine fetal renal failure, defined by anhydramnios and ultrasound (US) findings suggestive of severe renal dysplasia, and is associated with death in 24 h of life or end-stage renal disease (ESRD) within the first week of life; fetal vesicoamniotic shunt and fetal cystoscopy are not indicated.

Defining and predicting 'intrauterine fetal renal failure' in congenital lower urinary tract obstruction.

BACKGROUND: The aim of this study was to identify predictors of 'intrauterine fetal renal failure' in fetuses with severe congenital lower urinary tract obstruction (LUTO). METHODS: We undertook a retrospective study of 31 consecutive fetuses with a diagnosis of LUTO in a tertiary Fetal Center between April 2013 and April 2015. Predictors of 'intrauterine fetal renal failure' were evaluated in those infants with severe LUTO who had either a primary composite outcome measure of neonatal death in the first 24 h of life due to severe pulmonary hypoplasia or a need for renal replacement therapy within 7 days of life. The following variables were analyzed: fetal bladder re-expansion 48 h after vesicocentesis, fetal renal ultrasound characteristics, fetal urinary indices, and amniotic fluid volume. RESULTS: Of the 31 fetuses included in the study, eight met the criteria for 'intrauterine fetal renal failure'. All of the latter had composite poor postnatal outcomes based on death within 24 h of life (n = 6) or need for dialysis within 1 week of life (n = 2). The percentage of fetal bladder refilling after vesicocentesis at time of initial evaluation was the only predictor of 'intrauterine fetal renal failure' (cut-off <27 %, area under the time-concentration curve 0.86, 95 % confidence interval 0.68-0.99; p = 0.009). CONCLUSION: We propose the concept of 'intrauterine fetal renal failure' in fetuses with the most severe forms of LUTO. Fetal bladder refilling can be used to reliably predict 'intrauterine fetal renal failure', which is associated with severe pulmonary hypoplasia or the need for dialysis within a few days of life.

Sexual activity as a trigger for intracranial hemorrhage.

BACKGROUND: Intracranial hemorrhage (ICH) has been reported in association with sexual activity. A case-series of patients with ICH following sexual activity is presented to further elucidate the role of the physiologic sexual response as a trigger of ICH. METHOD: A retrospective review of the medical record was performed, identifying patients presenting with ICH temporally related to sexual activity. Clinical and radiographic data were collected and reported. RESULTS: Sixteen patients presented with non-traumatic ICH temporally related to sexual activity. Eight (50 %) patients presented with aneurysmal subarachnoid hemorrhage, four (25 %) with angiogram-negative subarachnoid hemorrhage, two (12.5 %) with a ruptured arteriovenous malformation, and two (12.5 %) with an intracerebral basal ganglia hemorrhage. Overall average age was 49.9 (range, 28-74) years. Sexual activity involved male-female intercourse in 14 (87.5 %) patients and masturbation in 2 (12.5 %) patients. CONCLUSIONS: Sexual-activity-related ICH is rare and includes various etiologies. The human sexual response in associated with dramatic increases in arterial blood pressure, which likely underlies the association.

Rates of Adverse Events and Outcomes among Stroke Patients Admitted to Primary Stroke Centers.

BACKGROUND AND PURPOSE: To identify the beneficial effects of primary stroke centers (PSCs) certification by Joint Commission (JC), we compared the rates of in-hospital adverse events and discharge outcomes among ischemic stroke patients admitted to PSCs and those admitted to non-PSC hospitals in the United States. METHODS: We obtained the data from the Nationwide Inpatient Sample from 2010 and 2011. The analysis was limited to states that publicly reported hospital identity. PSCs were identified by matching the Nationwide Inpatient Sample hospital files with the list provided by JC. The analysis was limited to patients (age ≥18 years) discharged with a principal diagnosis of ischemic stroke (International Classification of Disease, 9th Revision, codes 433.x1, 434.x1). RESULTS: We identified a total of 123,131 ischemic stroke patients from 28 states. A total of 72,982 (59.3%) patients were admitted to PSCs. After adjusting for age, gender, race or ethnicity, comorbidities, All Patients Refined Diagnosis Related Groups (APR-DRG)-based disease severity, and hospital teaching status, patients admitted to PSCs were at lower risk of in-hospital adverse events complications: pneumonia (odds ratio [OR], .8; 95% confidence interval [CI], .7-.8) and sepsis (OR, .7; 95% CI, .6-.8). Patients admitted to PSCs were more likely to receive thrombolysis (OR, 1.6; 95% CI, 1.5-1.7). The mean cost of hospitalization (95% CI) of the patients was significantly higher in patients admitted at PSCs compared with those admitted at non PSC hospitals $47621 (47099-48144) vs. $35229 (34803-35654), P < .0001). The patients admitted to PSCs had lower inpatient mortality (OR, .8; 95% CI, .8-.9) and were more likely to be discharged with none to minimal disability (OR, 1.1; 95% CI, 1.0-1.1). CONCLUSIONS: Compared with non-PSC admissions, patients admitted to PSCs are less likely to experience hospital adverse events and more likely to experience better discharge outcomes.

Treatment outcomes of standard (high dose) cisplatin and non-standard chemotherapy for locally advanced head and neck cancer.

INTRODUCTION: Concurrent chemoradiotherapy with high-dose (HD) cisplatin is the standard treatment for locally advanced head and neck squamous cell carcinoma (LA-HNSCC). Due to the higher treatment-related adverse effects with standard therapy, alternative regimens (non-standard therapy), namely, lower dose weekly cisplatin, carboplatin/paclitaxel, or cetuximab are considered. There is, however, no consensus on non-standard regimens. We aimed to investigate the efficacy and safety profile of these regimens. METHODS: This single centre retrospective cohort study included all consecutive adult patients with newly diagnosed LA-HNSCC treated with either standard or non-standard regimens between January 2016 and April 2021. The primary outcome was 2-year failure-free survival (FFS). The secondary outcomes included acute toxicities, hospitalisation rates, dose modifications, treatment failure rates (TFR), and overall survival. RESULTS: About 235 patients were included in the final analysis; median age was 61 years (IQR 55-67), and 87% were male. Most had oropharyngeal tumours (85.5%) and p16-positivity was frequent (80%). About 56% received non-standard regimens: weekly cisplatin = 79 and non-cisplatin = 48. These patients had higher Charlson Comorbidity Index (CCI; p < .001) and lower European Cooperative Oncology Group (ECOG)-0 (p = .003). There was no difference in 2-year FFS (hazard ratio [HR] = 1.16; 95% confidence interval - [CI] 0.65-2.05), hospitalisation and grade-3 toxicity rates between the two regimens. Nausea and vomiting were lower in the non-standard regimen (3.0% vs. 16%, p < .001). Dose reductions, adjusted for age, sex, and CCI, were less likely in the non-standard regimen (OR = 2.36; 95%-CI: 1.01-5.49, p = .007). CONCLUSIONS: We demonstrated similar efficacy of lower dose weekly cisplatin and carboplatin/paclitaxel regimens and better safety profile of weekly cisplatin compared to standard HD cisplatin regimens for LA-HNSCC. Multicenter randomised control trials are required in HD cisplatin-ineligible patients.

Predictors of percutaneous endoscopic gastrostomy tube placement in patients with severe dysphagia from an acute-subacute hemispheric infarction.

This study investigated the influence of age, National Institutes of Health Stroke Scale (NIHSS) score, time from stroke onset, infarct location and volume in predicting placement of a percutaneous endoscopic gastrostomy (PEG) tube in patients with severe dysphagia from an acute-subacute hemispheric infarction. We performed a retrospective analysis of a hospital-based patient cohort to analyze the effect of the aforementioned variables on the decision of whether or not to place a PEG tube. Consecutive patients were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes for acute ischemic stroke, Current Procedural Terminology (CPT)-4 codes for a formal swallowing evaluation by a speech pathologist, and procedure codes for PEG placement over a 5-year period from existing medical records at our institution. Only patients with severe dysphagia were enrolled. A total of 77 patients met inclusion criteria; 20 of them underwent PEG placement. The relationship between age (dichotomized; < and ≥75 years), time from stroke onset (days), NIHSS score, acute infarct lesion volume (dichotomized; < and ≥100 cc), and infarct location (ie, insula, anterior insula, periventricular white matter, inferior frontal gyrus, motor cortex, or bilateral hemispheres) with PEG tube placement were analyzed using logistic regression analysis. In univariate analysis, NIHSS score (P = .005), lesion volume (P = .022), and presence of bihemispheric infarction (P = .005) were found to be the main predictors of interest. After multivariate adjustment, only NIHSS score (odds ratio [OR], 1.15; 90% confidence interval [CI], 1.02-1.29; P = .04) and presence of bihemispheric infarcts (OR, 4.67; 90% CI, 1.58-13.75; P = .018) remained significant. Our data indicates that baseline NIHSS score and the presence of bihemispheric infarcts predict PEG placement during hospitalization from an acute-subacute hemispheric infarction in patients with severe dysphagia. These results require further validation in future studies.

Aberrant ectatic internal carotid artery in the middle ear.

We report the case of a 34-year-old man with pulsatile tinnitus and a reddish mass in the anteroinferior quadrant of the middle ear. Physical examination and imaging were unable to establish a diagnosis, so an exploratory tympanotomy was performed. Exploration revealed the presence of an ectatic aberrant internal carotid artery in the middle ear. Aberrations of the internal carotid artery in the middle ear are rare. Even so, our case is unusual in that all initial investigations had failed to establish the diagnosis. This case highlights the limitations of modern imaging techniques in certain situations.

High prevalence of previous antiplatelet drug use in patients with new or recurrent ischemic stroke: Buffalo metropolitan area and Erie County stroke study.

STUDY OBJECTIVE: To determine the proportion of patients in a large metropolitan population who developed ischemic stroke despite having received antiplatelet drug therapy, and their associated characteristics and in-hospital outcomes. DESIGN: Retrospective, cross-sectional study. SETTING: Eleven hospitals in western New York State. PATIENTS: One thousand five hundred eighty-two patients with new or recurrent ischemic stroke who were admitted to one of the 11 study hospitals between January 1 and December 31, 2000, and for whom data were available regarding previous drug therapy. MEASUREMENTS AND MAIN RESULTS: The proportion of patients taking antiplatelet drugs before the onset of stroke was determined. Demographic and clinical characteristics, stroke subtypes, in-hospital bleeding complications, mortality, and discharge drugs were compared between patients with and those without previous antiplatelet drug use. Previous use of antiplatelet drugs was observed in 642 (41%) of the 1582 patients admitted with ischemic stroke. The antiplatelet drugs were aspirin alone (494 patients), clopidogrel alone (70), aspirin and clopidogrel (36), aspirin in combination with other antiplatelet drugs (20), and others (22). Patients with previous use of antiplatelet drugs were older and more likely to have hypertension, diabetes mellitus, hyperlipidemia, and a history of cardiovascular disease. The proportion of patients with large-vessel disease was greater among patients with previous use of antiplatelet drugs. Patients with previous use of antiplatelet drugs were more likely to be discharged with aspirin, clopidogrel, and an aspirin-dipyridamole combination. CONCLUSION: The relatively high proportion of patients who developed ischemic stroke despite taking antiplatelet drugs observed in this regional hospital-based study mandates clinical trials specifically addressing therapeutic intervention for this group of patients.

Utility of SUVmax on 18 F-FDG PET in detecting cervical nodal metastases.

BACKGROUND: The presence of cervical lymph node metastasis is an important prognostic factor for patients with head and neck squamous cell carcinomas (HNSCC). Accurate assessment of lymph node metastasis in these patients is essential for appropriate prognostic and management purposes. Here, we evaluated the effectiveness of the maximum standardized uptake value (SUVmax) on positron emission tomography (PET) in assessing lymph node metastasis in HNSCC prior to surgery. METHODS: A retrospective review of 74 patients with HNSCC who underwent PET/CT prior to neck dissection were examined. Pre-operative PET/CT scans were reviewed by two experienced nuclear medicine physicians and SUVmax of the largest node in each nodal basin documented. These were compared with the histology results of the neck dissection. RESULTS: A total of 359 nodal basins including 86 basins with metastatic nodes were evaluated. A nodal SUVmax ≥3.16 yielded a sensitivity of 74.4 % and specificity of 84.9 % in detecting metastatic nodes. The nodal SUVmax/Liver SUVmax ratio was found on receiver operating characteristic (ROC) to be effective in detecting metastatic nodes with an area under ROC curve of 0.90. A nodal SUVmax/Liver SUVmax ratio ≥0.90 yielded a sensitivity of 74.1 % and specificity of 93.4 %. By comparison, visual inspection yielded sensitivities of 66.3 and 61.6 % in observers 1 and 2 respectively. The corresponding specificities were 77.7 and 86.5 %. CONCLUSIONS: Nodal SUVmax and nodal SUVmax/liver SUVmax are both useful in the pre-operative detection of metastatic nodes with the latter being superior to visual inspection. The ratio is likely to be more useful as it corrects for inter-scanner variability.

Bilateral peritonsillar abscess revisited.

Bilateral peritonsillar abscess is uncommon. When it does occur; patients usually present with sore throat; other clinical signs and symptoms may differ from those usually associated with unilateral peritonsillar abscess. We describe 2 cases of bilateral peritonsillar abscess that were successfully treated with needle aspiration of both sides with a 14-gauge intravenous cannula. Needle aspiration is an accepted form of treatment for unilateral peritonsillar abscess, but to the best of our knowledge, its use as a sole treatment modality (with observation under intravenous antibiotic coverage) for bilateral peritonsillar abscess has not been previously reported in the literature. We also believe that the incidence of acute bilateral peritonsillar abscess may be higher than the rates that have been reported in the literature. Finally, we recommend that the threshold for imaging be low for any patient who is suspected of having acute bilateral peritonsillar abscess to avoid any delay in diagnosis and treatment.

Supraglottic immunoglobulin-G4 related plasma cell granuloma: case report and literature review.

BACKGROUND: Granuloma of the upper aerodigestive tract is a rare presentation of immunoglobulin-G4 (IgG4)-related disease. Since the disease process was defined in 2003, only 2 cases affecting the laryngopharynx have been reported in the literature. METHODS AND RESULTS: A 62-year-old white man presented with persistent productive cough of brown sputum, globus symptoms, dysphagia, odynophagia, dysphonia, otalgia, and general malaise over a period of 2 months. Investigations revealed IgG4-positive plasma cell granuloma of the supraglottic region. This was successfully treated with oral corticosteroids. CONCLUSION: Because IgG4 testing is not performed routinely, management recommendations have been poorly defined. We reviewed the literature and discuss herein the clinical characteristics, pathology, diagnosis, and management. The authors theorize that IgG4-related disease involving the larynx and pharynx may be more common than suggested by the paucity of reported cases.

Medicolegal considerations with intravenous tissue plasminogen activator in stroke: a systematic review.

Background. Intravenous tPA (tissue plasminogen activator) therapy remains underutilized in patients with Acute Ischemic Stroke (AIS). Anecdotal data indicates that physicians are increasingly liable for administering and for failure to administer tPA. Methods. An extensive search of Medline, Embase, Westlaw, LexisNexis Legal, and Google Scholar databases was performed. Case studies that involved malpractice litigation in ischemic stroke and thrombolytic therapy were analyzed systematically. Results. We identified 789 ischemic stroke litigation cases, of which 46 cases were related to intravenous tPA and stroke litigation. Case descriptions of 40 cases were available. Data for verdicts were available for 38 patients. The most frequent plaintiff claim was related to failure to administer intravenous tPA (38, 95%). Only 2 (5.0%) claim involved complications of treatment with tPA. Hospitals were defendants in majority of the 36 cases. Physicians were involved in 33 cases. While ED physicians were involved in 25 (60.52%) cases, neurologists were involved in 8 (20.0%) cases. There were 26 (65%) defendant-favored and 12 (30%) plaintiff-favored verdicts. Conclusion. Physicians and hospitals are at an increased risk of litigation in patients with AIS when in IV-tPA is being considered for treatment. While majority of the cases litigated were cases where tPA was not administered, only about 1 in 20 cases was litigated when complications occurred.

ABCD2 Score and Large-Artery Atherosclerosis.

BACKGROUND AND PURPOSE: Extracranial stenosis (ECS) or intracranial stenosis (ICS) are independent risk factors for stroke after transient ischemic attack (TIA). We examined the association of the age, blood pressure, clinical features, duration of symptoms and diabetes (ABCD2) score, a validated risk prediction model for stroke after TIA, and the presence of ICS or ECS. METHODS: Vascular imaging and ABCD2 scores were obtained in a retrospective cohort of 77 consecutive patients diagnosed with TIA in a single center emergency department. The association between vascular stenosis and ABCD2 scores and how each related to clinical outcome was examined. RESULTS: In all, 30 (39.2%) TIA patients had 37 stenotic lesions; 15 (40.5%) stenotic lesions were ICS and 22 (59.5%) stenotic lesions were ECS. A total of 7 patients (9.5%) had both ECS and ICS lesions. Patients with ABCD2 > 3 were more likely to have ICS (odds ratio [OR] = 6.25, confidence interval [CI] 1.39-32.44, P = .009) and ECS (OR = 5.25, CI = 1.56-17.66, P = .005). Of the 37 stenotic lesions, 21 (56.7%) were symptomatic; 4 (19.2%) of these had an ABCD2 ≤ 3. At 7 days, there were 4 ischemic strokes, 3 had previously demonstrated symptomatic stenotic lesions, and all had ABCD2 scores > 3. CONCLUSIONS: Compared to patients in the low-risk ABCD2 scores, the patients with medium- to high-risk ABCD2 scores are more likely to have symptomatic and asymptomatic vascular stenotic lesions. However, 1 in 5 patients with low-risk ABCD2 score has symptomatic stenotic lesions, indicating ABCD2 score does not identify all patients with symptomatic stenotic lesions.

Predictors of occult paroxysmal atrial fibrillation in cryptogenic strokes detected by long-term noninvasive cardiac monitoring.

Background and Purpose. Paroxysmal Atrial fibrillation/Flutter (PAF) detection rates in cryptogenic strokes have been variable. We sought to determine the percentage of patients with cryptogenic stroke who had PAF on prolonged non-invasive cardiac monitoring. Methods and Results. Sixty-two consecutive patients with stroke and TIA in a single center with a mean age of 61 (+/- 14) years were analyzed. PAF was detected in 15 (24%) patients. Only one patient reported symptoms of shortness of breath during the episode of PAF while on monitoring, and 71 (97%) of these 73 episodes were asymptomatic. A regression analysis revealed that the presence of PVCs (ventricular premature beats) lasting more than 2 minutes (OR 6.3, 95% CI, 1.11-18.92; P = .042) and strokes (high signal on Diffusion Weighted Imaging) (OR 4.3, 95% CI, 5-36.3; P = .041) predicted PAF. Patients with multiple DWI signals were more likely than solitary signals to have PAF (OR 11.1, 95% CI, 2.5-48.5, P < .01). Conclusion. Occult PAF is common in cryptogenic strokes, and is often asymptomatic. Our data suggests that up to one in five patients with suspected cryptogenic strokes and TIAs have PAF, especially if they have PVCs and multiple high DWI signals on MRI.

Clinical significance of serum zinc levels in cerebral ischemia.

Background. Zinc mediates several vital physiological, enzymatic and cellular functions. The association between serum zinc and stroke outcome has not been previously evaluated. Methods. This single center retrospective study was conducted on consecutive stroke (n = 158) and TIA (n = 74) patients. We sought to determine whether serum zinc concentrations in patients with acute ischemic strokes were associated with stroke severity and poor functional status at discharge, respectively. Results. Overall, out of the 224 patients analyzed (mean age 67 years), 35.7% patients had low zinc levels (65 mcg/dL). Patients with stroke (n = 152) were more likely to have low zinc levels (OR = 2.62, CI 1.92-3.57, P < .003) compared to patients with TIA (n = 72). For patients with stroke (n = 152), multivariate analysis showed that low serum zinc levels (OR 2.82, CI 1.35-5.91, P = .035) and strokes with admission severe strokes (NIHSS > 8) (OR 2.68, CI 1.1-6.5, P = .03) were independently associated with poor functional status (MRS > 3) at discharge from the hospital. Conclusion. Low serum zinc concentrations are associated with more severe strokes on admission and poor functional status at discharge.

Can ABCD score predict the need for in-hospital intervention in patients with transient ischemic attacks?

BACKGROUND: The ABCD(2) score is increasingly being used to triage patients with transient ischemic attack (TIA). Whether the score can predict the need for in-hospital intervention (IHI), other than initiation of antiplatelets and statins, is unknown. AIMS: The ability of the ABCD(2) score to predict IHI would strengthen the rationale to use it as a decision-making tool. We thus conducted this study to investigate the relationship between the ABCD(2) score and IHI. METHODS: We analyzed prospectively collected data from consecutive TIA patients over 12 months. We determined ABCD(2) upon admission and collected the results of in-hospital evaluation, treatments initiated during hospitalization, and follow-up status. We defined IHI as arterial revascularization or anticoagulation required during admission. We used chi-square for trend to examine the association between ABCD(2) and IHI. RESULTS: We studied 121 patients. Fourteen (12%) had small infarcts on diffusion magnetic resonance imaging; 38 (31%) had a new risk factor recognized during admission [hyperlipidemia (n = 9), hypertension (1), diabetes (1), carotid stenosis >/= 50% (16), other arterial occlusive lesions (7), and potential cardioembolic source (4)]. Their percentages increased with higher ABCD(2) scores. However, among 12 patients (10%) with IHI, ABCD(2) score categories were equally distributed (10% in 0-3, 9% in 4-5, and 10% in 6-7; p = 0.8). One patient (0.8%) worsened during hospitalization; none had a stroke during follow-up. CONCLUSION: Patients with an ABCD(2) score