Thrombolysis of stroke mimics via telestroke.

BACKGROUND: The rate of intravenous tissue plasminogen activator (IVtPA) administered to stroke mimics (SM) occurs in 24%-44% of telestroke series. METHODS: We reviewed 270 suspected acute ischaemic stroke (AIS) patients who were evaluated by telestroke and received IVtPA from 1 July 2016 to 30 September 2017 at our academic comprehensive stroke centre. RESULTS: Among 270 AIS patients who received IVtPA via telestroke, 64 (23.7%) were diagnosed with SM. Compared with patients who had a stroke, the SM group was younger (mean age 56.4 vs 68.2, p<0.0001), more likely to be female (60.9% vs 45.6%, p=0.0324) and had longer door-to-needle times (85.3 vs 69.9, p=0.0008). The most common SM diagnoses were migraine 26 (40.6%), conversion disorder 12 (18.8%), encephalopathy 7 (10.9%) and unmasking (9.4%). Among the SM, migraine and conversion disorder were younger compared with the other subgroups (p<0.001). Functional exam elements were noted more frequently in conversion disorder (66.7%) and migraine (34.6%), but rare in other diagnoses (p=0.006). Among the SM, 23 (35.9%) had a history of a prior similar episodes, and 15 (23.4%) had a history of more than 5 spells. CONCLUSIONS: In our telestroke programme, 23.7% of those administered thrombolysis had a final diagnosis of SM.

Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Unsuspected Infective Endocarditis.

OBJECTIVE: Infective endocarditis (IE) is considered to be an absolute contraindication for intravenous tissue plasminogen activator treatment (IVtPA) in acute ischemic stroke (AIS). However, during the hyperacute stroke evaluation, the exclusion of IE may be difficult. We sought to report the prevalence of undiagnosed IE in AIS patients who received IVtPA. METHODS: We reviewed consecutive patients hospitalized at our comprehensive stroke center from January 1, 2014 to March 31, 2019 who received IVtPA for suspected AIS and identified patients diagnosed with IE. Data was abstracted on demographics, medical history, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, culture results, and 90 day modified Rankin Scale (mRS). Good functional outcome was defined as mRS ≤ 2. RESULTS: Among 1022 AIS patients who received IVtPA, 5 patients (0.5%) were ultimately diagnosed with IE. Among the 5 patients with IE, the mean age was 53.4 years (range, 25-74) and 3 (60%) were female. The majority 4 (80%) were white. Medical risk factors for IE were present in 3 (60%) and included intravenous drug use (1) and dialysis (2). Initial NIHSS was 4.6 (range, 1 to 8). Fever was present on initial presentation in only 1 patient (102.7 F). The mean time from LKN to IVtPA was 3.0 hours (range, 1.9 to 4.4). Vascular imaging showed middle cerebral artery (MCA) occlusion in 4 (80%) and no occlusion in 1 (20%). One patient underwent endovascular thrombectomy. Two patients (40%) developed hemorrhagic complications, including 1 patient who developed subarachnoid hemorrhage due to mycotic cerebral aneurysm rupture. Blood culture results included MRSE (1), Streptococcus viridans (2) and negative (2). TEE in all patients showed vegetations on the mitral valve. No patients had good functional outcomes, and the mean 3 month mRS was 4.8 (range, 3 to 6). The 90 day mortality was 60%. CONCLUSION: In a series of AIS patients who received IVtPA by academic vascular neurologists, the risk of undiagnosed IE was low (0.5%). Fever was not commonly present during initial evaluation in IE presenting with AIS. Despite affecting younger patients with initial mild deficits, AIS patients with IE who received IVtPA had poor functional outcomes.

Impacts of PM2.5 on respiratory system among traffic policemen.

BACKGROUND: Malaysian traffic policemen are constantly exposed to unhealthy air in the outdoor environment, which results in various health problems. This study investigates the relationship of the personal exposure level to PM2.5 and lung functions in traffic policemen in Kuala Lumpur and Johor Bahru. METHODS: A pulmonary function test using a spirometer was carried out to measure the lung function of the traffic policemen. The personal exposure level to PM2.5 was measured using a pump with a PVC filter and 5.0µm pore size. A questionnaire requesting the background data, such as age, height, and weight, was also used for testing lung function abnormalities. RESULTS: The PM2.5 personal exposure level was found to be significantly related to lung function (predicted FEV1 and predicted FVC) at p-value < 0.05. CONCLUSIONS: Traffic policemen are mainly exposed to physical hazards from traffic pollutants emitted by vehicles, such as fine particles and particulate matter. The findings of this study indicate that there is a trend of lung function deterioration among traffic policemen. These baseline data can serve as a reference for the top management of traffic police to aid in the development of occupational safety and health guidelines for police officers, as the traffic police are not covered by the Occupational Safety and Health Act (OSHA, Act 514 1994).

Early neurologic decline in acute ischemic stroke patients receiving thrombolysis with large vessel occlusion and mild deficits.

BACKGROUND: We sought to determine the rate of early neurologic decline (END) in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) who presented with mild deficits and received intravenous tissue plasminogen activator (IVtPA). METHODS: Among 1022 patients with AIS who received IVtPA from 2014 to 2019, we identified 313 (30.6%) with LVO, of which 94 (30%) presented with National Institute of Health Stroke Scale (NIHSS) score ≤7. Thirteen patients were excluded, leaving 81 for analysis. END was defined as NIHSS worsening of ≥4 points within 24 hours. RESULTS: Among 81 patients with LVO and low NIHSS score, the mean age was 65.8 years (range 25-93) and 41% were female. The mean time to IVtPA from last known well was 2.5 hours (range 0.8-7). LVO sites were as follows: 5 (6%) carotid, 23 (28%) M1, and 53 (65%) M2 occlusions. Among the 81 patients, 28 (34.6%) had END, and these patients were older (70.8 vs 63.2 years, p=0.036). The mean change in NIHSS score at 24 hours in those with END was 10.4 (range 4-22). Patients with END were less likely to be discharged home (25% vs 66%, p=0.004). CONCLUSIONS: Among patients with LVO AIS who received IVtPA, 30% presented with initial mild deficits. END occurred in one-third of LVO patients with initial mild deficits despite receiving IVtPA. Clinicians should be aware that the natural history of LVO with initial mild deficits is not benign and these patients are eligible for rescue thrombectomy in the 24-hour window if they deteriorate.

High-Powered Police Motorcycle: Muscle Discomfort Among Malaysian Traffic Police Riders

@#Discomfort due to riding a motorcycle is an issue that need to be addressed as it has long-term effects of musculoskeletal disorders on motorcyclists especially among occupational motorcyclist. Thus, this study was conducted to analyse the rating of muscle discomfort and correlation with the risk factors among traffic police riders. A cross-sectional study was carried out among 137 male traffic police riders (high-powered motorcycle) with the age between 20 to 39 years old. The 100-mm visual analogue scale questionnaire included ratings of perceived discomfort scales for 20 specific body regions was used in the study. The results indicate that the lower back (left and right) were the highest mean of discomfort which were 56.6 mm and 55.9 mm respectively. This followed with right (48.5±36.2 mm) and left (48.4±30.3 mm) upper back, and right hand (47.0±33.0 mm). The mean of overall discomfort ratings for all regions were more than 20 mm. Besides, there is a strong positive significant correlation between duration of ridings (hours) and overall discomfort ratings (p<0.01, r=0.785) and moderate positive correlation between year of traffic police motorcycle riding experience and overall discomfort ratings (p<0.01, r=0.410). As a conclusion, cumulative riding hours, riding experience and no support of the back area of the body in motorcycle seat, are the most concern in this study as this are the contributing factors to the muscle discomfort among traffic police riders while riding high-powered motorcycle. Thus, this study suggested an additional feature is needed in current motorcycle design in order to enhance comforts of traffic police riders. Also, it will improve the condition of traffic police riders’ discomfort and indirectly also improve their work and health performance as well as productivity.

The Spectrum of Nontraumatic Convexity Subarachnoid Hemorrhage.

BACKGROUND: Nontraumatic convexity subarachnoid hemorrhage (cSAH) is a nonaneurysmal variant that is associated with diverse etiologies. METHODS: With IRB approval, we retrospectively reviewed consecutive nontraumatic cSAH from July 1, 2006 to July 1, 2016. Data were abstracted on demographics, medical history, neuroimaging, etiology, and clinical presentation. RESULTS: We identified 94 cases of cSAH. The cases were classified according to the following etiologies: reversible cerebral vasoconstriction syndrome (RCVS) 17 (18%), cerebral amyloid angiopathy (CAA) 15 (16%), posterior reversible encephalopathy syndrome 16 (17%), cerebral venous thrombosis 10 (11%), large artery occlusion 7 (7%), endocarditis 6 (6%), and cryptogenic 25 (27%). Early rebleeding occurred in 9 (10%) patients. Time from initial imaging to CT rebleeding was 40 hours (range, 5-74). CAA was associated with the highest mean age at 75.8 and RCVS the lowest at 47.6 years (P< .0001). Among patients with RCVS, initial vascular imaging was negative in 6 (35%), and repeat imaging documented vasoconstriction at a mean delay of 5 days (range, 3-16). CONCLUSION: There were significant differences among the subgroups in cSAH, with CAA presenting as older men with transient neurological deficits, and RCVS presenting as younger women with thunderclap headache. Rebleeding was seen in 10% of cSAH patients. One-third of RCVS patients with cSAH required repeat vascular imaging to diagnose vasoconstriction.

Factors Associated with Fever in Intracerebral Hemorrhage.

BACKGROUND: Fever is common in patients with intracerebral hemorrhage (ICH). We sought to identify predictors of fever in patients hospitalized with ICH, and compare infectious fever with noninfectious fever. METHODS: A retrospective review on consecutive spontaneous ICH patients from April 2009 to March 2010 was performed. Fever was defined as temperature 100.9°F or higher and attributed to infectious versus noninfectious etiology, based upon the National Healthcare Safety Network criteria. Univariate analysis and multivariable logistic regression model were used to determine factors associated with fever and with infection. RESULTS: Among the 351 ICH patients, 136 (39%) developed fever. Factors associated with fever included mean ICH volume, intraventricular hemorrhage (IVH), external ventricular drain (EVD) placement or surgical evacuation, positive microbial cultures, longer length of stay (LOS), and higher in-hospital mortality. Among patients with fever, 96 (71%) were noninfectious and 40 (29%) were infectious. Infectious fever was associated with higher LOS. Noninfectious fever was associated with higher in-hospital mortality. In multivariable analysis, ICH volume (OR = 1.01, P = .04), IVH (OR = 2.0, P = .03), EVD (OR = 3.7, P < .0001), and surgical evacuation (OR = 6.78, P < .0001) were significant predictors of fever. Infectious fever (OR = 5.26, P = .004), EVD (OR = 4.86, P = .01), and surgical evacuation (OR = 4.77, P = .04) correlated with prolonged LOS when dichotomized using a median of 15 days. CONCLUSIONS: Fever is common in ICH patients and is not associated with a clear infectious etiology in the majority of patients. Patients with noninfectious fever have higher in-hospital mortality, but survivors have shorter LOS. Further studies are warranted to better understand fevers in ICH.

Participation in a Tele-Stroke Program Improves Timeliness of Intravenous Thrombolysis Delivery.

BACKGROUND: We sought to assess the effects of participation in a tele-stroke program on timeliness of intravenous tissue plasminogen activator (IVtPA) administration. METHODS: Among 259 consecutive acute ischemic stroke patients treated with IVtPA through the Rush tele-stroke program, we compared two cohorts: Period 1 (July 2011 to June 2013) and Period 2 (July 2013 to July 2014). We collected data on demographics, National Institutes of Health Stroke Scale (NIHSS), and times of last known normal (LKN), initiation of tele-stroke consult, and IVtPA administration. RESULTS: The mean age was 69.6 years, 56% were female, the mean NIHSS was 11.8, and 41.7% patients were transferred to the hub site. The mean time from initiation of tele-stroke consult to IVtPA administration was 42.2 min. Time from initiation of tele-stroke consult to IVtPA administration improved from Period 1 to Period 2 (49.9 min vs. 35 min, p < 0.0001). This improvement was due to faster mean time from initiation of tele-stroke consult to IVtPA advised (17.4 min vs. 12.5 min, p < 0.0001) and faster mean time from IVtPA advised to administration (33.1 min vs. 22.5 min, p < 0.0001). The mean time from LKN to IVtPA given was also significantly improved (148.6 min vs. 160.9 min, p 0.045). CONCLUSIONS: Participation in a tele-stroke program associated with improvement in the timeliness of IVtPA delivery.

Pesticide Application, Dermal Exposure Risk And Factors Influenced Distribution On Different Body Parts Among Agriculture Workers

@#Agriculture sector accounts significant numbers of injuries and fatalities in the workplace particularly related to pesticide management. Among three main pathways of pesticide exposure, dermal contact is the most common route, which exposure usually occurs during pesticide mixing/loading, application, harvesting and other farming activities. This review aims to present and discuss several vital components of pesticide dermal exposure among agriculture workers, as well as pesticide application in agriculture sector in Malaysia involving different commodity agriculture sub-sectors. Pesticide exposure was discussed from perspective of three pesticide management activities (i.e. preparation, application and cleaning) that contribute to the risk of exposure through three routes (i.e. emission, deposition, transfer). Moreover, this paper also discussed pesticide dermal exposure risk assessment methods which can be defined into exposure assessment and effect assessment. The exposure rate was affected by various factors such as application equipment, application rate and duration, type of pesticide formulation, pesticide management stage, usage of personal protective equipment, training and aptitude of the applicator as well as environmental factors (i.e. temperature, humidity, wind speed and direction). The factors mention earlier have been used to explain the exposure distribution over different parts of the body and support the fact that pesticide type was not a major factor in total exposure.

High ABCD2 Scores and In-Hospital Interventions following Transient Ischemic Attack.

BACKGROUND AND PURPOSE: Following transient ischemic attack (TIA), there is increased risk for ischemic stroke. The American Heart Association recommends admission of patients with ABCD2 scores ≥3 for observation, rapid performance of diagnostic tests, and potential acute intervention. We aimed to determine if there is a relationship between ABCD2 scores, in-hospital ischemic events, and in-hospital treatments after TIA admission. METHODS: We reviewed consecutive patients admitted between 2006 and 2011 following a TIA, defined as transient focal neurological symptoms attributed to a specific vascular distribution and lasting <24 h. Three interventions were prespecified: anticoagulation for atrial fibrillation, carotid or intracranial revascularization, and intravenous or intra-arterial reperfusion therapies. We compared rates of in-hospital recurrent TIA or ischemic stroke and the receipt of interventions among patients with low (<3) versus high (≥3) ABCD2 scores. RESULTS: Of 249 patients, 11 patients (4.4%) had recurrent TIAs or strokes during their stay (8 TIAs, 3 strokes). All 11 had ABCD2 scores ≥3, and no neurological events occurred in patients with lower scores (5.1 vs. 0%; p = 0.37). Twelve patients (4.8%) underwent revascularization for large artery stenosis, 16 (6.4%) were started on anticoagulants, and no patient received intravenous or intra-arterial reperfusion therapy. The ABCD2 score was not associated with anticoagulation (p = 0.59) or revascularization (p = 0.20). CONCLUSIONS: Higher ABCD2 scores may predict early ischemic events after TIA but do not predict the need for intervention. Outpatient evaluation for those with scores <3 would potentially have delayed revascularization or anticoagulant treatment in nearly one-fifth of 'low-risk' patients.

MRI Detection of Cerebral Infarction in Subarachnoid Hemorrhage.

OBJECTIVE: To investigate magnetic resonance imaging (MRI) detection of cerebral infarction (CI) in patients presenting with subarachnoid hemorrhage (SAH). BACKGROUND: CI is a well-known complication of SAH that is typically detected on computed tomography (CT). MRI has improved sensitivity for acute CI over CT, particularly with multiple, small, or asymptomatic lesions. METHODS: With IRB approval, 400 consecutive SAH patients admitted to our institution from August 2006 to March 2011 were retrospectively reviewed. Traumatic SAH and secondary SAH were excluded. Data were collected on demographics, cause of SAH, Hunt Hess and World Federation of Neurosurgical Societies grades, and neuroimaging results. MRIs were categorized by CI pattern as single cortical (SC), single deep (SD), multiple cortical (MC), multiple deep (MD), and multiple cortical and deep (MCD). RESULTS: Among 123 (30.8 %) SAH patients who underwent MRIs during their hospitalization, 64 (52 %) demonstrated acute CI. The mean time from hospital admission to MRI was 5.7 days (range 0-29 days). Among the 64 patients with MRI infarcts, MRI CI pattern was as follows: MC in 20 (31 %), MCD in 18 (28 %), SC in 16 (25 %), SD in 3 (5 %), MD in 2 (3 %), and 5 (8 %) did not have images available for review. Most infarcts detected on MRI (39/64 or 61 %) were not visible on CT. CONCLUSIONS: The use of MRI increases the detection of CI in SAH. Unlike CT studies, MRI-detected CI in SAH tends to involve multiple vascular territories. Studies that rely on CT may underestimate the burden of CI after SAH.

Periprocedural Risk of Stroke Is Elevated in Patients with End-Stage Renal Disease on Hemodialysis.

OBJECTIVE: To describe the most common clinical factors and stroke etiologies in a case series of patients with end-stage renal disease on hemodialysis (ESRD/HD) with transient ischemic attack (TIA) or ischemic stroke (IS). BACKGROUND: Prior studies have shown that patients on HD are at an elevated risk of stroke, but these studies have focused on the overall stroke risk. This case series sought to determine the percentage of acute ischemic events that occur during or immediately after HD. METHODS: ICD-9 codes were used to identify IS and TIA patients with ESRD/HD admitted to the stroke service from August 22, 2011, to June 21, 2014. Charts were reviewed to determine the age, sex, and race/ethnicity of the cohort. TIA/IS diagnosis was confirmed by a vascular neurologist. Clinical factors were assessed, including: onset during or shortly after HD, defined as occurring within 12 h of HD; the presence of a lesion on diffusion-weighted MRI; hypotension, hyponatremia, or hypoglycemia at symptom onset; the stroke etiology; the presence of focal neurologic deficits; whether the patient was in the window period for intravenous tissue plasminogen activator (IVtPA) upon presentation, and whether the patient received IVtPA. RESULTS: We identified 34 ESRD/HD patients with a diagnosis of TIA/stroke in the specified time period. A majority of patients (70.6%) were African American. Patient age ranged from 32 to 84 years, with a median age of 67 years. Twenty-seven patients (79.4%) had confirmed ischemic infarcts on diffusion-weighted MRI. Seven patients (20.6%) were diagnosed with TIA. In 13 patients (38.2%), symptom onset occurred during or shortly after HD. Of these 13 patients, 8 (61.5%) had symptom onset during HD. Three patients (8.8%) had documented hypotension near the time of symptom onset, and 2 (5.9%) were hyponatremic on presentation to the emergency department. The distribution of stroke etiologies was as follows: 4 (11.8%) watershed distribution, 1 (2.9%) large artery atherosclerosis, 2 (20.6%) small vessel disease, 10 (29.4%) cardioembolic, and 9 (26.5%) cryptogenic. In 28 patients (82.4%), focal neurologic deficits were observed on presentation. Nine patients (26.5%) arrived within the window period for IVtPA, and 4 (11.8%) were eligible and received IVtPA. CONCLUSIONS: Of all patients with ESRD on HD admitted to the stroke service over the study period, over one third (38.3%) had the onset of their ischemic event during or shortly after HD, and nearly one quarter (23.5%) had the onset during HD. While clinicians may be tempted to attribute neurologic changes after HD to metabolic etiologies, they should also be aware that HD represents a period of elevated risk for acute ischemia.

PFO Closure for Cryptogenic Stroke.

A patent foramen ovale (PFO) is a common finding in the general population and has been theorized to be a mechanism for ischemic stroke primarily due to a deep venous thrombus embolizing through the shunt into the arterial circulation. There has been much debate regarding the association between PFO and stroke, especially in the case of a cryptogenic stroke (i.e., stroke of unknown etiology) in a younger patient without other risk factors. Traditionally, when a PFO is detected, antithrombotic therapy to mitigate risk of a future ischemic event has been the mainstay of treatment. More recently, both surgical and transcatheter closure of a PFO have been widely utilized. However, there are only few randomized controlled trials assessing the efficacy of PFO closure for stroke prevention.

Defining breast cancer intrinsic subtypes by quantitative receptor expression.

PURPOSE: To determine intrinsic breast cancer subtypes represented within categories defined by quantitative hormone receptor (HR) and HER2 expression. METHODS: We merged 1,557 cases from three randomized phase III trials into a single data set. These breast tumors were centrally reviewed in each trial for quantitative ER, PR, and HER2 expression by immunohistochemistry (IHC) stain and by reverse transcription-quantitative polymerase chain reaction (RT-qPCR), with intrinsic subtyping by research-based PAM50 RT-qPCR assay. RESULTS: Among 283 HER2-negative tumors with <1% HR expression by IHC, 207 (73%) were basal-like; other subtypes, particularly HER2-enriched (48, 17%), were present. Among the 1,298 HER2-negative tumors, borderline HR (1%-9% staining) was uncommon (n = 39), and these tumors were heterogeneous: 17 (44%) luminal A/B, 12 (31%) HER2-enriched, and only 7 (18%) basal-like. Including them in the definition of triple-negative breast cancer significantly diminished enrichment for basal-like cancer (p < .05). Among 106 HER2-positive tumors with <1% HR expression by IHC, the HER2-enriched subtype was the most frequent (87, 82%), whereas among 127 HER2-positive tumors with strong HR (>10%) expression, only 69 (54%) were HER2-enriched and 55 (43%) were luminal (39 luminal B, 16 luminal A). Quantitative HR expression by RT-qPCR gave similar results. Regardless of methodology, basal-like cases seldom expressed ER/ESR1 or PR/PGR and were associated with the lowest expression level of HER2/ERBB2 relative to other subtypes. CONCLUSION: Significant discordance remains between clinical assay-defined subsets and intrinsic subtype. For identifying basal-like breast cancer, the optimal HR IHC cut point was <1%, matching the American Society of Clinical Oncology and College of American Pathologists guidelines. Tumors with borderline HR staining are molecularly diverse and may require additional assays to clarify underlying biology.

Stress-induced cardiomyopathy.

OBJECTIVES: Reversible stress-induced cardiac dysfunction is frequently seen as a complication of a multitude of acute stress states, in particular neurologic injuries. This dysfunction may be difficult to distinguish between that caused by myocardial ischemia and may impact both the treatment strategies and prognosis of the underlying condition. Critical care practitioners should have an understanding of the epidemiology, pathophysiology, clinical characteristics, precipitating conditions, differential diagnosis, and proposed treatments for stress-induced cardiomyopathy. DATA SOURCES: MEDLINE database search conducted from inception to August 2014, including the search terms "tako-tsubo," "stress-induced cardiomyopathy," "neurogenic cardiomyopathy," "neurogenic stress cardiomyopathy," and "transient left ventricular apical ballooning syndrome". In addition, references from pertinent articles were used for a secondary search. STUDY SELECTION AND DATA EXTRACTION: After review of peer-reviewed original scientific articles, guidelines, and reviews resulting from the literature search described above, we made final selections for included references and data based on relevance and author consensus. DATA SYNTHESIS: Stress-induced cardiomyopathy occurs most commonly in postmenopausal women. It can be precipitated by emotional stress, neurologic injury, and numerous other stress states. Patients may present with symptoms indistinguishable from acute coronary syndrome or with electrocardiogram changes and wall motion abnormalities on echocardiogram following neurologic injury. Nearly all patients will have an elevated cardiac troponin. The underlying etiology is likely related to release of catecholamines, both locally in the myocardium and in the circulation. Differential diagnosis includes myocardial infarction, myocarditis, neurogenic pulmonary edema, and nonischemic cardiomyopathy. Although the natural course of stress-induced cardiomyopathy is resolution, treatment strategies include sympathetic blockade and supportive care. CONCLUSIONS: Stress-induced cardiomyopathy may mimic myocardial infarction and is an important condition to recognize in patients with underlying stress states, particularly neurologic injuries.