The single-phase CTA Clot Burden Score is independently associated with DSA ASITN collateral score.

OBJECTIVES: The variation in quality and quantity of collateral status (CS) is in part responsible for a wide variability in extent of neural damage following acute ischemic stroke from large vessel occlusion (AIS-LVO). Single-phase CTA based Clot Burden Score (CBS) is a promising marker in estimating CS. The aim of this study is to assess the relationship of pretreatment CTA based CBS with the reference standard DSA based American Society of Interventional and Therapeutic Neuroradiology (ASITN) CS. METHODS: In this retrospective study, inclusion criteria were as follows: a) Anterior circulation LVO confirmed on CTA from 9/1/2017 to 10/01/2023; b) diagnostic CTA; and c) underwent MT with documented DSA CS. Spearman's rank correlation analysis, multivariate logistic regression and ROC analysis was performed to assess the correlation of CTA CBS with DSA CS. p ≤ 0.05 was considered significant. RESULTS: 292 consecutive patients (median age = 68 years; 56.2% female) met our inclusion criteria. CTA CBS and DSA CS showed significant positive correlation (ρ = 0.51, p < 0.001). On multivariate logistic regression analysis CBS was found to be independently associated with DSA CS (adjusted OR = 1.83, p < 0.001, 95% CI: 1.54-2.19), after adjusting for age, sex, race, hyperlipidemia, hypertension, diabetes, prior stroke or TIA, atrial fibrillation, premorbid mRS, admission NIH stroke scale, and ASPECTS. ROC analysis of CBS in predicting good DSA CS showed AUC of 0.76 (p < 0.001; 95%CI: 0.68-0.82). CBS threshold of > 6 has 84.6% sensitivity and 42.3% specificity in predicting good DSA CS. CONCLUSION: CTA CBS is independently associated with DSA CS and serves as a valuable supplementary tool for collateral status estimation. Further research is necessary to enhance our understanding of the role of CTA CBS in clinical decision-making for patients with AIS-LVO. ADVANCES IN KNOWLEDGE: CBS by indirectly estimating CS has shown to predict outcomes in AIS-LVO patients. No studies report association of CBS with reference standard DSA. In this study we further establish CBS as an independent marker of CS.

Effectiveness and Tolerability of Anti-Calcitonin Gene-Related Peptide Therapy for Migraine and Other Chronic Headaches in Adolescents and Young Adults: A Retrospective Study in the USA.

This retrospective study assesses the efficacy and tolerability of anti-calcitonin gene-related peptide (anti-CGRP) therapy in adolescents and young adults (ages 12-21) with migraine and chronic daily headaches unresponsive to standard treatments. Migraines in this demographic significantly impair school performance, self-esteem, psychological well-being, and cognitive health. These young patients are also particularly sensitive to the side effects of conventional medications, which are often prescribed off-label and come with high insurance denial rates. Medication overuse, including analgesics, triptans, and NSAIDs, is prevalent due to treatment failures. Elevated plasma CGRP levels observed during migraines suggest that anti-CGRP therapies, successful in adult populations, may also benefit this younger age group. Over a three-year period, patients at a specialized pediatric headache center were evaluated for the impact of anti-CGRP treatments, including monoclonal antibodies (erenumab, fremanezumab, and galcanezumab) and small-molecule CGRP receptor antagonists (ubrogepant, rimegepant, and atogepant), administered either alone or in combination with OnabotulinumtoxinA. Data were extracted from the hospital's electronic medical records, and patient progress was consistently documented using a structured template for each clinic visit. Additional patient satisfaction data were collected via telephone follow-ups and patient message reviews. The study included 23 patients, primarily treated for chronic migraine (CM) (78.3%), with a smaller subset addressing episodic migraine (EM), new daily persistent headaches (NDPHs), and post-traumatic headaches (PTHs). Comprehensive demographic and clinical data, including age, treatment duration, history of preventive treatment failures, and comorbidities like psychiatric conditions and sleep disorders, were collected. Anti-CGRP therapies, particularly when combined with traditional treatments or OnabotulinumtoxinA, resulted in significant improvements: 91.3% of patients experienced reduced migraine duration and intensity, 82.6% reported improvements in other bothersome symptoms, and 73.9% saw an improved response to rescue medications. Additionally, 78.3% of patients reported a reduction in their use of rescue medications per week by more than 50%, and emergency room visits were reduced for 56.5% of patients. Significant reductions in headache days were observed in 82.6% of patients after one month and 87% after three months, with nearly 40% experiencing more than a 50% reduction in both periods. The greatest benefits were observed in patients treated for more than six months. Adverse effects were minimal, with 95.7% of patients reporting no side effects, and patient satisfaction was high, with 69.6% opting to continue treatment. Overall, this study highlights the substantial potential of anti-CGRP therapy in improving outcomes for adolescents and young adults with CM and EM, offering a promising approach for a demographic that faces considerable challenges with conventional treatment options. However, further research is needed to confirm these findings and expand clinical applications in this age group.

Palliative care for patients with heart failure and family caregivers in rural Appalachia: a randomized controlled trial.

BACKGROUND: Heart failure (HF) is a debilitating disease with worsening symptoms and family caregiving burden. HF affects more than 8 million Americans. West Virginia has the highest HF death rate in the U.S. and limited healthcare services. This study tested whether the family HF palliative and end-of-life care intervention (FamPALcare) improved patient and caregiver outcomes at 3- and 6-month study endpoints. METHODS: This study used a randomized controlled trial design. Patients with HF and their caregivers were randomly assigned together to the intervention (n = 21) or control (n = 18) group. The intervention included five telephone coaching sessions on the HF home, palliative, and end-of-life care. The outcome data collected at baseline and at 3 and 6 months were from the patients' (a) HF-related health status and depression/anxiety scale scores; and from caregivers' (b) caregiving burden and depression/anxiety scale scores; and (c) anonymous ratings on the 11-item FamPALcare helpfulness scale, completed by the intervention participants. RESULTS: The mean age of the patients was 65.66 (SD = 13.72) years, and 67% were White males. The mean age of the caregivers was 62.05 (SD = 13.14) years, and 77% were White females. Compared to the controls, patients in the intervention group had significantly greater scores for HF-related health status (p < .05) and lower depression/anxiety scores at 6 months, the study endpoint. The family caregivers in the intervention group had significantly lower scores on caregiving burden (p < .05) and depression/anxiety (p < .01) at 3 months. The mean helpfulness rating was M = 4.46 out of 5 (SD = 0.49). CONCLUSIONS: The FamPALcare intervention was found to be effective at improving patient HF-related health status and reducing caregiver burden and improving both patient and caregiver depression and anxiety scores. The FamPALcare HF intervention was found feasible and consistently delivered (fidelity). The FamPALcare intervention's cost-effectiveness and helpfulness ratings information will be used to plan for subsequent clinical trials. TRIAL REGISTRATION: ClinicalTrials.gov NCT04153890, Registered on 4 November 2019, https://clinicaltrials.gov/ct2/show/NCT04153890 .

Selection of Single-Analyte Delta Check Rules with Logistic Regression for Detection of Intravenous Fluid Contamination in a Clinical Chemistry Laboratory.

BACKGROUND: The conventional single-analyte delta check, utilized for identifying intravenous fluid contamination and other preanalytical errors, is known to flag many specimens reflecting true patient status changes. This study aimed to derive delta check rules that more accurately identify contamination. METHODS: Results for calcium, creatinine, glucose, sodium, and potassium were retrieved from 326 103 basic or comprehensive metabolic panels tested between February 2021 and January 2022. In total, 7934 specimens showed substantial result changes, of which 1489 were labeled as either contaminated or non-contaminated based on chart review. These labeled specimens were used to derive logistic regression models and to select the most predictive single-analyte delta checks for 4 common contaminants. Their collective performance was evaluated using a test data set from October 2023 comprising 14 717 specimens. RESULTS: The most predictive single-analyte delta checks included a calcium change by ≤-24% for both saline and Plasma-Lyte A contamination, a potassium increase by ≥3.0 mmol/L for potassium contamination, and a glucose increase by ≥400 mg/dL (22.2 mmol/L) for dextrose contamination. In the training data sets, multi-analyte logistic regression models performed better than single-analyte delta checks. In the test data set, logistic regression models and single-analyte delta checks demonstrated collective alert rates of 0.58% (95% CI, 0.46%-0.71%) and 0.60% (95% CI, 0.49%-0.74%), respectively, along with collective positive predictive values of 79% (95% CI, 70%-89%) and 77% (95% CI, 68%-87%). CONCLUSIONS: Single-analyte delta checks selected by logistic regression demonstrated a low false alert rate.

Early screening of sleep disordered breathing in hospitalized stroke patients high-resolution pulse oximetry as prognostic and early intervention tools in patients with acute stroke and sleep apnea (HOPES TRIAL).

INTRODUCTION: Sleep Disordered Breathing (SDB) has been shown to increase the risk of stroke and despite recommendations, routine evaluation for SDB in acute stroke is not consistent across institutions. The necessary logistics and expertise required to conduct sleep studies in hospitalized patients remain a significant barrier. This study aims to evaluate the feasibility of high-resolution pulse-oximetry (HRPO) for the screening of SDB in acute stroke. Secondarily, considering impact of SDB on acute stroke, we investigated whether SDB at acute stroke predicts functional outcome at discharge and at 3 months post-stroke. METHODS: Patients with acute mild to moderate ischemic stroke underwent an overnight HRPO within 48 h of admission. Patients were divided into SDB and no-SDB groups based on oxygen desaturations index(ODI > 10/h). Stepwise multivariate logistic regression analysis was applied to identify the relevant predictors of functional outcome (favorable [mRS 1-2 points] versus unfavorable [mrS > = 3 points]). RESULTS: Of the 142 consecutively screened patients, 96 were included in the analysis. Of these, 33/96 (34%) were identified as having SDB and were more likely to have unfavorable mRS scores as compared to those without SDB (odds ratio = 2.70, p-value = 0.032). CONCLUSION: HRPO may be a low-cost and easily administered screening method to detect SDB among patients hospitalized for acute ischemic stroke. Patients with SDB (as defined by ODI) have a higher burden of neurological deficits as compared to those without SDB during hospitalization.

The Los Angeles motor scale (LAMS) is independently associated with CT perfusion collateral status markers.

BACKGROUND AND AIM: The Los Angeles Motor Scale (LAMS) is an objective tool that has been used to rapidly assess and predict the presence of large vessel occlusion (LVO) in the pre-hospital setting successfully in several studies. However, studies assessing the relationship between LAMS score and CT perfusion collateral status (CS) markers such as cerebral blood volume (CBV) index, and hypoperfusion intensity ratio (HIR) are sparse. Our study therefore aims to assess the association of admission LAMS score with established CTP CS markers CBV Index and HIR in AIS-LVO cases. MATERIALS AND METHODS: In this prospectively collected, retrospectively reviewed analysis, inclusion criteria were as follows: a) CT angiography (CTA) confirmed anterior circulation LVO from 9/1/2017 to 10/01/2023, and b) diagnostic CT perfusion (CTP). Logistic regression analysis was performed to assess the relationship between admission LAMS with CTP CS markers HIR and CBV Index. p ≤ 0.05 was considered significant. RESULTS: In total, 285 consecutive patients (median age = 69 years; 56 % female) met our inclusion criteria. Multivariable logistic regression analysis adjusting for sex, age, ASPECTS, tPA, premorbid mRS, admission NIH stroke scale, prior history of TIA, stroke, atrial fibrillation, diabetes mellitus, hyperlipidemia, coronary artery disease and hypertension, admission LAMS was found to be independently associated with CBV Index (adjusted OR:0.82, p < 0.01), and HIR (adjusted OR:0.59, p < 0.05). CONCLUSION: LAMS is independently associated with CTP CS markers, CBV index and HIR. This finding suggests that LAMS may also provide an indirect estimate of CS.

Analysis of spontaneous cytomegalovirus clearance after low level reactivation using a pre-emptive treatment threshold of 4,000 IU/mL in allogeneic hematopoietic cell transplant recipients.

BACKGROUND: Cytomegalovirus (CMV) can be a serious complication after allogeneic hematopoietic cell transplant (HCT). CMV viral load is routinely monitored, and pre-emptive therapy is initiated to prevent CMV viremia from developing into CMV organ disease based on institutional thresholds. There is no established universal threshold for pre-emptive therapy and many centers utilize different strategies. METHODS: Allogeneic HCT recipients at WVU Medicine from 2009 to 2021 were routinely initiated on pre-emptive CMV treatment for a PCR viral threshold above 4000 IU/mL. Adult patients with quantifiable values below this threshold, were analyzed to evaluate the rate of spontaneous clearance without initiation of CMV-directed therapy, during their first episode of CMV reactivation. This study excluded any patients that received letermovir prophylaxis. RESULTS: Sixty patients were included in the analysis. The spontaneous clearance rate was 60 %. The risk factors that were associated with a lower spontaneous clearance rate were reactivation within thirty days after transplant (p = 0.031), presence of graft-versus-host-disease (p = 0.031), and CMV PCR values of 2500-4000 IU/mL (p = 0.02). Although these patients had lower rates of spontaneous clearance, they still spontaneously cleared in 42 %, 42 %, and 43 % of the cases, respectively. CONCLUSION: Delaying pre-emptive treatment until a CMV PCR value of 4000 IU/mL is reached appears appropriate and decreases unnecessary treatment toxicity and resistance.

CT Perfusion Derived rCBV < 42% Lesion Volume Is Independently Associated with Followup FLAIR Infarct Volume in Anterior Circulation Large Vessel Occlusion.

Pretreatment CT Perfusion (CTP) parameter rCBV < 42% lesion volume has recently been shown to predict 90-day mRS. In this study, we aim to assess the relationship between rCBV < 42% and a radiographic follow-up infarct volume delineated on FLAIR images. In this retrospective evaluation of our prospectively collected database, we included acute stroke patients triaged by multimodal CT imaging, including CT angiography and perfusion imaging, with confirmed anterior circulation large vessel occlusion between 9 January 2017 and 10 January 2023. Follow-up FLAIR imaging was used to determine the final infarct volume. Student t, Mann-Whitney-U, and Chi-Square tests were used to assess differences. Spearman's rank correlation and linear regression analysis were used to assess associations between rCBV < 42% and follow-up infarct volume on FLAIR. In total, 158 patients (median age: 68 years, 52.5% female) met our inclusion criteria. rCBV < 42% (ρ = 0.56, p < 0.001) significantly correlated with follow-up-FLAIR infarct volume. On multivariable linear regression analysis, rCBV < 42% lesion volume (beta = 0.60, p < 0.001), ASPECTS (beta = -0.214, p < 0.01), mTICI (beta = -0.277, p < 0.001), and diabetes (beta = 0.16, p < 0.05) were independently associated with follow-up infarct volume. The rCBV < 42% lesion volume is independently associated with FLAIR follow-up infarct volume.

Efficacy of delayed pegfilgrastim administration following consolidation therapy with high-dose cytarabine (HiDAC) in acute myeloid leukemia (AML) patients.

PURPOSE: To study the effects of delaying pegfilgrastim administration following high-dose cytarabine (HiDAC) consolidation in AML patients on time to neutrophil count recovery, infectious complications, and survival. METHODS: Single-center retrospective chart review of 55 patients receiving pegfilgrastim as early administration (within 72 h) or delayed administration (after 72 h) of HiDAC. RESULTS: The difference in neutrophil recovery time was similar between the early and delayed groups (18 days versus 19 days, p < 0.28). Infections were seen in four patients in the early administration group following chemotherapy compared to none in the delayed group (p = 0.04). Febrile neutropenia rates were also decreased in the delayed administration group (23.1% versus 10.3%, p = 0.28) as well as a trend towards longer median survival (16 months versus 19 months, p = 0.69) and overall survival (21 months versus 31 months, p = 0.47). CONCLUSION: A difference in time to neutrophil recovery was not observed between the early and delayed administration groups yet decreased infectious complications may support the delayed administration of pegfilgrastim in these patients.

A Phase I Trial of a Methionine Restricted Diet with Concurrent Radiation Therapy.

Methionine is an essential amino acid critical for cell growth and survival. Preclinical evidence suggests a methionine restricted diet (MRD) sensitizes cancer to radiation therapy (RT), without significant adverse effects. However, this has never been evaluated in humans. The purpose of this pilot study was to evaluate the safety and feasibility of concurrent MRD with standard-of-care definitive RT in adults with any non-skin cancer malignancy. The MRD extended from 2 wk before RT initiation, through 2 wk beyond RT completion. The primary endpoint of safety was assessed as rate of grade 3 or higher acute and late toxicities. Feasibility was assessed with quantitative plasma amino acid panel every 2 wk during the MRD (target plasma methionine 13 µM). Nine patients were accrued over a two-year period, with five able to complete the treatment course. The trial was closed due to slow accrual and subjects' difficulty maintaining the diet. No grade 3 or higher adverse events were observed. Subjects' average methionine level was 18.8 µM during treatment, with average nadir 16.8 µM. These findings suggest the safety of concurrent MRD with RT, with toxicities comparable to those expected with RT alone. However, the diet was challenging, and unacceptable to most patients.

Investigation and validation of the TEG6s during rotary wing aeromedical flight.

INTRODUCTION: To improve rural and austere trauma care, hospital-based testing performed at the point of injury may shorten the time lapsed from injury to intervention. This study aimed to evaluate the use of the TEG6s device (Haemonetics(R), Clinton, PA) in a rotary wing aircraft. Prior attempts suffered from limitation related to lack of vibration mitigation. METHODS: This was an investigator-initiated, industry-supported study. Haemonetics provided a TEG6s analyzer. The device underwent a standard validation. It was secured in place on the aircraft using shipping foam for vibration mitigation. Donors provided two tubes of sample blood in one sitting. Paired studies were performed on the aircraft during level flight and in the hospital, using the Global Hemostasis with Lysis Cartridge(Haemonetics (R), Clinton, PA). Both normal and presumed pathologic samples were tested in separate phases. Paired t tests were performed. RESULTS: For normal donors, the mean R for laboratory compared with the aircraft was 6.2 minutes versus 7.2 minutes ( p = 0.025). The mean ± SD Citrated Rapid TEG Maximum Amplitude (CRT MA) was 59.3 ± 5.6 mm and 55.9 ± 7.3 mm ( p < 0.001) for laboratory and aircraft ( p < 0.001). Among normal donors, R was within normal range for 17 of 18 laboratory tests and 18 of 18 aircraft tests ( p > 0.99). During the testing of pathologic samples, the mean R time was 14.8 minutes for laboratory samples and 12.6 minutes for aircraft ( p = 0.02). Aircraft samples were classified as abnormal in 78% of samples; this was not significantly different than laboratory samples ( p = 0.5). CONCLUSION: The use of the TEG6s for inflight viscoelastic testing appears promising. While statistically significant differences are seen in some results, these values are not considered clinically significant. Classifying samples as normal or abnormal demonstrated a higher correlation. Future studies should focus on longer flight times to evaluate for LY30, takeoff, and landing effects. Overall, this study suggests that TEG6s can be used in a prehospital environment, and further study is warranted. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level III.

Early recognition and treatment of OSA in hospitalized patients and its impact on health care utilization in rural population: a real-world study.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is a highly prevalent, yet underdiagnosed, condition. Due to its adverse impact on risk for cardiopulmonary disorders, there is interest in proactive screening of OSA in hospitalized patients. We studied the long-term outcome of such screened patients who were initiated on positive airway pressure therapy. METHODS: Hospitalized patients who screened positive for OSA and were confirmed with postdischarge polysomnography were dichotomized by positive airway pressure therapy adherence and followed for a period of 12 months to evaluate for the composite end point of hospital readmissions and emergency department visits for cardiopulmonary reasons. Cost analysis between the 2 groups was also conducted. RESULTS: A total of 2,042 hospitalized patients were assessed for OSA as part of a hospital sleep medicine program from August 2019-June 2023. Of these, 293 patients were diagnosed with OSA and prescribed positive airway pressure therapy. Of these 293 patients, 108 were adherent to therapy and 185 were nonadherent. The overall characteristics of the groups included a mean (standard deviation) age of 58 years (12.82), mean body mass index (kg/m2) of 39.72 (10.71), 57% male sex, and apnea-hypopnea index of 25.49 (26). Of the patients, 78%, 41%, and 43% had hypertension, congestive heart failure, and diabetes mellitus, respectively. The composite end point of hospital readmissions and emergency department visits for cardiovascular and pulmonary reasons was significantly higher in the nonadherent group than in the adherent group (hazard ratio, 1.24; 95% confidence interval, 1-1.54) (P = .03). The cost of care for both hospital billing as well as professional billing was higher for the nonadherent group ($1,455.60 vs $1,723.50, P = .004 in hospital billing cost and $130.90 vs $144.70, P < .001 in professional billing). Length of stay was higher for nonadherent patients (2.7 ± 5.1 days vs 2.3 ± 5.9 days). CONCLUSIONS: Hospitalized patients diagnosed with OSA and adherent to therapy have reduced readmissions and emergency department visits for cardiopulmonary reasons 12 months after discharge. Adherent patients have reduced cost of health care and length of stay during hospitalizations. CITATION: Sharma S, Stansbury R, Srinivasan P, et al. Early recognition and treatment of OSA in hospitalized patients and its impact on health care utilization in rural population: a real-world study. J Clin Sleep Med. 2024;20(8):1313-1319.

The Relative Cerebral Blood Volume (rCBV) < 42% Is Independently Associated with Collateral Status in Anterior Circulation Large Vessel Occlusion.

Background: The pretreatment CT perfusion (CTP) marker the relative cerebral blood volume (rCBV) < 42% lesion volume has recently been shown to predict 90-day functional outcomes; however, studies assessing correlations of the rCBV < 42% lesion volume with other outcomes remain sparse. Here, we aim to assess the relationship between the rCBV < 42% lesion volume and the reference standard digital subtraction angiography (DSA)-derived American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN) collateral score, hereby referred as the DSA CS. Methods: In this retrospective evaluation of our prospectively collected database, we included acute stroke patients triaged by multimodal CT imaging, including CT angiography and perfusion imaging, with confirmed anterior circulation large vessel occlusion between 1 September 2017 and 1 October 2023. Group differences were assessed using the Student's t test, Mann-Whitney U test and Chi-Square test. Spearman's rank correlation and logistic regression analyses were used to assess associations between rCBV < 42% and DSA CS. Results: In total, 222 patients (median age: 69 years, 56.3% female) met our inclusion criteria. In the multivariable logistic regression analysis, taking into account age, sex, race, hypertension, hyperlipidemia, diabetes, atrial fibrillation, prior stroke or transient ischemic attack, the admission National Institute of Health stroke scale, the premorbid modified Rankin score, the Alberta stroke program early CT score (ASPECTS), and segment occlusion, the rCBV < 42% lesion volume (adjusted OR: 0.98, p < 0.05) was independently associated with the DSA CS. Conclusion: The rCBV < 42% lesion volume is independently associated with the DSA CS.

CT perfusion based rCBF <38% volume is independently and negatively associated with digital subtraction angiography collateral score in anterior circulation large vessel occlusions.

BACKGROUND: Collateral status (CS) is an important biomarker of functional outcomes in patients with acute ischemic stroke secondary to large vessel occlusion (AIS-LVO). Pretreatment CT perfusion (CTP) parameters serve as reliable surrogates of collateral status (CS). In this study, we aim to assess the relationship between the relative cerebral blood flow less than 38% (rCBF <38%), with the reference standard American Society of Interventional and Therapeutic Neuroradiology (ASITN) collateral score (CS) on DSA. METHODS: In this prospectively collected, retrospectively reviewed analysis, inclusion criteria were as follows: (a) CT angiography (CTA) confirmed anterior circulation large vessel occlusion from 9/1/2017 to 10/01/2023; (b) diagnostic CT perfusion; and (c) underwent mechanical thrombectomy with documented ASITN CS. The ratios of the CTP-derived CBF values were calculated by dividing the values of the ischemic lesion by the corresponding values of the contralateral normal region (which were defined as rCBF). Spearman's rank correlation and logistic regression analysis were performed to determine the relationship of rCBF <38% lesion volume with DSA ASITN CS. p ≤ .05 was considered significant. RESULTS: In total, 223 patients [mean age: 67.77 ± 15.76 years, 56.1% (n = 125) female] met our inclusion criteria. Significant negative correlation was noted between rCBF <38% volume and DSA CS (ρ = -0.37, p < .001). On multivariate logistic regression analysis, rCBF <38% volume was found to be independently associated with worse ASITN CS (unadjusted OR: 3.03, 95% CI: 1.60-5.69, p < .001, and adjusted OR: 2.73, 95% CI: 1.34-5.50, p < .01). CONCLUSION: Greater volume of tissue with rCBF <38% is independently associated with better DSA CS. rCBF <38% is a useful adjunct tool in collateralization-based prognostication. Future studies are needed to expand our understanding of the role of rCBF <38% within the decision-making in patients with AIS-LVO.

10-year retention of a comprehensive treatment model of buprenorphine for opioid use disorder.

BACKGROUND: There has been extensive research demonstrating the effectiveness of medications for opioid use disorder (MOUD) but limited investigation into its long-term retention rate. OBJECTIVE: Assess the long-term treatment retention of a buprenorphine-based MOUD clinic with additional stratifications by age and gender. METHODS: This retrospective study analyzed 10-years of data from a MOUD clinic in West Virginia that served 3,255 unique patients during the study period (2009-2019). Retention was measured by summation of total treatment days with a new episode of care defined as re-initiating buprenorphine treatment after 60+ consecutive days of nonattendance. Kaplan-Meier survival analysis, with the log-rank test, was used to compare retention by gender and age. RESULTS: The mean age was 38 (SD = 10.6) and 95% were non-Hispanic white. Irrespective of treatment episode, 56.8% of patients were retained ≥ 90 days, and the overall median time in treatment was 112 days. Considering only the first treatment episode, 48.4% of 3,255 patients were retained at least 90 days and the overall median was 77 days. Female patients had a ≥ 90 day retention rate of 52.2% for the first admission and 60.1% for multiple admissions, both significantly higher than those of male subjects (44.1% and 53.0%). Additionally, patients ≤ 24 years old had the lowest rate of treatment retention, while patients aged ≥ 35 had the highest. CONCLUSIONS: This study adds to the limited data regarding long-term retention in MOUD. Our findings indicate gender and age were highly correlated with retention in MOUD treatment.

Diagnostic utility of 7T neuromelanin imaging of the substantia nigra in Parkinson's disease.

Parkinson's disease (PD) is a prevalent neurodegenerative disorder that presents a diagnostic challenge due to symptom overlap with other disorders. Neuromelanin (NM) imaging is a promising biomarker for PD, but adoption has been limited, in part due to subpar performance at standard MRI field strengths. We aimed to evaluate the diagnostic utility of ultra-high field 7T NM-sensitive imaging in the diagnosis of PD versus controls and essential tremor (ET), as well as NM differences among PD subtypes. A retrospective case-control study was conducted including PD patients, ET patients, and controls. 7T NM-sensitive 3D-GRE was acquired, and substantia nigra pars compacta (SNpc) volumes, contrast ratios, and asymmetry indices were calculated. Statistical analyses, including general linear models and ROC curves, were employed. Twenty-one PD patients, 13 ET patients, and 18 controls were assessed. PD patients exhibited significantly lower SNpc volumes compared to non-PD subjects. SNpc total volume showed 100% sensitivity and 96.8% specificity (AUC = 0.998) for differentiating PD from non-PD and 100% sensitivity and 95.2% specificity (AUC = 0.996) in differentiating PD from ET. Contrast ratio was not significantly different between PD and non-PD groups (p = 0.07). There was also significantly higher asymmetry index in SNpc volume in PD compared to non-PD cohorts (p < 0.001). NM signal loss in PD predominantly involved the inferior, posterior, and lateral aspects of SNpc. Akinetic-rigid subtype showed more significant NM signal loss compared to tremor dominant subtype (p < 0.001). 7T NM imaging demonstrates potential as a diagnostic tool for PD, including potential distinction between subtypes, allowing improved understanding of disease progression and subtype-related characteristics.

The Compensation Index Is Better Associated with DSA ASITN Collateral Score Compared to the Cerebral Blood Volume Index and Hypoperfusion Intensity Ratio.

BACKGROUND: Pretreatment CT Perfusion (CTP) parameters serve as reliable surrogates of collateral status (CS). In this study, we aim to assess the relationship between the novel compensation index (CI, Tmax > 4 s/Tmax > 6 s) and already established CTP collateral markers, namely cerebral blood volume (CBV) index and Hypoperfusion Intensity Ratio (HIR), with the reference standard American Society of Interventional and Therapeutic Neuroradiology (ASITN) collateral score (CS) on DSA. METHODS: In this retrospective study, inclusion criteria were the following: (a) CT angiography confirmed anterior circulation large vessel occlusion from 9 January 2017 to 10 January 2023; (b) diagnostic CT perfusion; and (c) underwent mechanical thrombectomy with documented DSA-CS. Student t-test, Mann-Whitney-U-test and Chi-square test were used to assess differences. Spearman's rank correlation and logistic regression analysis were used to assess associations. p ≤ 0.05 was considered significant. RESULTS: In total, 223 patients (mean age: 67.8 ± 15.8, 56% female) met our inclusion criteria. The CI (ρ = 0.37, p < 0.001) and HIR (ρ = -0.29, p < 0.001) significantly correlated with DSA-CS. Whereas the CBV Index (ρ = 0.1, p > 0.05) did not correlate with DSA-CS. On multivariate logistic regression analysis taking into account age, sex, ASPECTS, tPA, premorbid mRS, NIH stroke scale, prior history of TIA, stroke, atrial fibrillation, diabetes mellitus, hyperlipidemia, heart disease and hypertension, only CI was not found to be independently associated with DSA-CS (adjusted OR = 1.387, 95% CI: 1.09-1.77, p < 0.01). CONCLUSION: CI demonstrates a stronger correlation with DSA-CS compared to both the HIR and CBV Index where it may show promise as an additional quantitative pretreatment CS biomarker.

Evaluation of prolonged magnesium infusion after allogeneic hematopoietic cell transplant.

PURPOSE: Calcineurin inhibitor use after allogeneic hematopoietic cell transplantation (allo-HCT) is associated with significant magnesium wasting. Utilization of a prolonged magnesium infusion is thought to lead to a lower serum peak concentration and therefore, decreased renal wasting of magnesium. In November 2017, our institution implemented a modification to our inpatient electrolyte replacement protocol for allo-HCT recipients that extended the magnesium infusion rate from 4 g/2 h to 4 g/4 h based on this theoretical advantage. The primary objective of this study was to compare the median magnesium requirements per day of admission between patients who received magnesium 4 g/2 h to patients who received magnesium 4 g/4 h. Secondary objectives included a comparison of the per-patient median serum magnesium concentration during admission, as well as the median incremental difference in serum magnesium concentration after intravenous replacement per patient per admission. METHODS: Allo-HCT recipients who received prolonged infusion magnesium infusions were compared to a historical cohort of allo-HCT patients who received shorter IV magnesium infusions. Admissions were included if the patient had received an allo-HCT within 100 days prior, was admitted to the Transplant and Cellular Therapy Unit at WVU Medicine J.W. Ruby Memorial Hospital, and received at least one magnesium infusion and one dose of cyclosporine or tacrolimus. Admissions were excluded if the patient received oral magnesium, total parenteral nutrition, aminoglycosides, amphotericin, carboplatin, cisplatin, or foscarnet. RESULTS: The pre-implementation group consisted of 81 admissions (n = 64 patients), while the post-implementation group consisted of 90 admissions (n = 60 patients). Median magnesium requirements per day of admission were not different between groups at 1.4 g of magnesium in the pre-implementation group and 1.9 g of magnesium in the post-implementation group (P = 0.25). Median serum magnesium concentrations and median incremental difference in serum magnesium concentration after intravenous replacement were also not different between groups: 1.65 mg/dL vs 1.60 mg/dL (P = 0.65) and 0.30 mg/dL vs 0.28 mg/dL (P = 0.67), respectively. CONCLUSIONS: Prolonged infusion of magnesium in allo-HCT recipients receiving CNI therapy does not result in improvement in magnesium retention.

ß-Lactams plus doxycycline versus azithromycin for treatment of severe community-acquired pneumonia in critically ill patients.

OBJECTIVES: Community-acquired pneumonia (CAP) is a significant source of hospital admissions and mortality. Atypical organisms are implicated in up to 40% of cases of CAP diagnoses. We studied the difference in outcomes of severe CAP patients treated with doxycycline versus azithromycin in addition to ß-lactam therapy. PATIENTS AND METHODS: This was a prospective observational cohort study from March 2020 to July 2022 in a medical ICU (MICU) of an academic quaternary medical center. Adults ≥18 years admitted to the MICU receiving doxycycline or azithromycin in addition to ß-lactam therapy for the treatment of CAP were included for analysis. The primary outcomes were in-hospital and 30 day mortality. Secondary outcomes were ICU and hospital length-of-stay, 30 day readmission, days of mechanical ventilation, escalation and duration of antibiotics, adverse effects such as Clostridioides difficile infection and QTc prolongation. RESULTS: Sixty-three patients were in the azithromycin group and eighty-six patients in the doxycycline group. Both groups had similar APACHE IV and CURB-65 scores. The mean Charlson Comorbidity Index score was higher for the doxycycline group compared with the azithromycin group (P = 0.04). There was no statistically significant difference in in-hospital and 30 day mortality between the groups (P = 0.53, P = 0.57). There were no significant differences in any of the secondary outcomes. CONCLUSIONS: MICU patients with severe CAP who received doxycycline versus azithromycin in addition to ß-lactam treatment showed no significant differences in outcomes. These data offer support for inclusion of doxycycline as an alternative regimen in current IDSA recommendations.

Autoimmune and paraneoplastic neurological disorders: A review of relevant neuroimaging findings.

INTRODUCTION: Paraneoplastic neurologic syndromes (PNS) and autoimmune encephalitis (AIE) are immune-mediated disorders. PNS is linked to cancer, while AIE may not Their clinical manifestations and imaging patterns need further elucidation. OBJECTIVE/AIMS: To investigate the clinical profiles, antibody associations, neuroimaging patterns, treatments, and outcomes of PNS and AIE. METHODS: A systematic review of 379 articles published between 2014 and 2023 was conducted. Of the 55 studies screened, 333 patients were diagnosed with either PNS or AIE and tested positive for novel antibodies. Data on demographics, symptoms, imaging, antibodies, cancer associations, treatment, and outcomes were extracted. RESULTS: The study included 333 patients (mean age 54 years, 67% males) with PNS and AIE positive for various novel antibodies. 84% had central nervous system issues like cognitive impairment (53%), rhombencephalitis (17%), and cerebellar disorders (24%). Neuroimaging revealed distinct patterns with high-risk antibodies associated with brainstem lesions in 98%, cerebellar in 91%, hippocampal in 98%, basal ganglia in 75%, and spinal cord in 91%, while low/intermediate-risk antibodies were associated with medial temporal lobe lesions in 71% and other cortical/subcortical lesions in 55%. High-risk antibodies were associated with younger males, deep brain lesions, and increased mortality of 61%, while low/intermediate-risk antibodies were associated with females, cortical/subcortical lesions, and better outcomes with 39% mortality. Associated cancers included seminomas (23%), lung (19%), ovarian (2%), and breast (2%). Treatments included IVIG, chemotherapy, and plasmapheresis. Overall mortality was 25% in this cohort. CONCLUSION: PNS and AIE have distinct clinical and radiological patterns based on antibody profiles. High-risk antibodies are associated with increased mortality while low/intermediate-risk antibodies are associated with improved outcomes. Appropriate imaging and antibody testing are critical for accurate diagnosis.