Time Is Brain: Prehospital Emergency Medical Services Response Times for Suspected Stroke and Effects of Prehospital Interventions.

OBJECTIVES: To compare prehospital time for patients with suspected stroke in Florida with the American Stroke Association (ASA) time benchmarks, and to investigate the effects of dispatch notification and stroke assessment scales on prehospital time. PATIENTS AND METHODS: A retrospective analysis was performed using data from Florida's Emergency Medical Services Tracking and Reporting System database. All patients with suspected stroke transported to a treatment center from January 1, 2018, through December 31, 2018, were analyzed. Time intervals from 911 call to hospital arrival were evaluated and compared with ASA benchmarks. RESULTS: In 2018, 11,577 patients with suspected stroke were transported to a hospital (mean age, 71.5±15.7 years; 51.5% women). The median alarm-to-hospital time was 33.98 minutes (27.8 to 41.4), with a total emergency medical services (EMS) time of 32.30 minutes (26.5 to 39.478). The on-scene time was the largest time interval with a median of 13.28 minutes (10.0 to 17.4). Emergency medical services encounters met the ASA benchmarks for time in 58% to 62% of the EMS encounters in Florida (recommended 90%; P<.001). The total EMS time was reduced when a stroke notification was reported by the dispatch center (32.00 minutes vs 32.62 minutes; P=.006) or when a stroke assessment scale was used by the EMS personnel (31.88 minutes vs 32.96 minutes; P=.005). CONCLUSION: This study reveals a substantial opportunity for improvement in stroke care in Florida. Two prehospital EMS stroke interventions seem to reduce prehospital time for patients with suspected stroke. Adoption of these interventions might improve the stroke systems of care.

Predictors of Ventriculoperitoneal shunting following Subarachnoid Hemorrhage treated with External Ventricular Drainage.

BACKGROUND/OBJECTIVES: Aneurysmal subarachnoid hemorrhage (aSAH) is commonly associated with hydrocephalus due to subarachnoid hemorrhage blood products obstructing cerebrospinal fluid outflow. Hydrocephalus after aSAH is routinely managed with temporary external ventricular drainage (EVD) followed by standard EVD weaning protocols, which determine the need for ventriculoperitoneal shunting (VPS). We sought to investigate aSAH patients who initially passed EVD weaning trials and had EVD removal, but later presented with recurrent, delayed, symptomatic hydrocephalus requiring a VPS. METHODS: We conducted a retrospective review of all patients at our tertiary care medical center who presented with aSAH, requiring an EVD. We analyzed variables associated with ultimate VPS dependency during hospitalization. RESULTS: We reviewed 489 patients with aSAH over a 6-year period (2008-2014). One hundred and thirty-eight (28.2%) developed hydrocephalus requiring a temporary EVD. Forty-four (31.9%) of these patients died or had withdrawal of care during admission, and were excluded from final analysis. Of the remaining 94 patients, 29 (30.9%) failed their clamp trial and required VPS. Sixty-five (69.1%) patients passed their clamp trial and were discharged without a VPS. However, 10 (15.4%) of these patients developed delayed hydrocephalus after discharge and ultimately required VPS [mean (range) days after discharge, 97.2 (35-188)]. Compared to early VPS, the delayed VPS group had a higher incidence of symptomatic vasospasm (90.0% vs 51.7%; P = 0.03). When comparing patients discharged from the hospital without VPS, delayed VPS patients also had higher 6- and 12-month mortality (P = 0.02) and longer EVD clamp trials (P < 0.01) than patients who never required VPS but had an EVD during hospitalization. Delayed hydrocephalus occurred in only 7.8% of patients who passed the initial EVD clamp trial, compared to 14.3% who failed the initial trial and 80.0% who failed 2 or more trials. CONCLUSION: Patients who failed their initial or subsequent EVD clamp trials had a small, but increased risk of developing delayed hydrocephalus ultimately requiring VPS. Additionally, the majority of patients who presented with delayed hydrocephalus also suffered symptomatic vasospasm. These associations should be further explored and validated in a larger prospective study.

Pancreaticoduodenectomy for complex pancreaticoduodenal trauma: A case series

@#<p style="text-align: justify;">Pancreaticoduodenectomy (Whipple's) procedure is indicated for complex  pancreatic  injuries,  with  immediate  reconstruction  for stable  patients  and  delayed  reconstruction  for  unstable  patients. This study aimed to review the authors' experience with trauma-related  Whipple's  procedure  at  the  East  Avenue  Medical  Center (EAMC).<br /><strong>METHODS: </strong>This study reviews cases where Whipple's procedure was performed from 2011 to 2015 at EAMC.  Data collected included age, gender, mechanism of injury, presentation, patient Injury Severity Score (ISS), time interval between injury to presentation, associated injury, surgical procedure, time and type of surgical reconstruction after resection complications and 30-day mortality.<br /><strong>RESULTS: </strong>During the 5 year period, 4 patients underwent Whipple's. All patients were male, mean age of 33.25 (range 29-48). Penetrating gunshot trauma was the predominant mechanism of injury (75% of cases) whereas peritonitis was the most common presentation (75% of cases). Mean ISS score is 29.5 (range 25-37).  Among them, 2 underwent  initial  resection  with  delayed  reconstruction  and  the other 2 underwent immediate reconstruction. Pancreaticojejunostomy was done for all pancreatic reconstruction. Cholecystojejunostomy (75%) and Choledochojejunostomy (25%) for biliary enteric conduit. Complications included pancreatic leak (50%), sepsis (25%) and pneumonia  (25%).  Overall,  30-day  mortality  rate  was  25%.Pancreatic leak was noted on all patients without stent placed on the pancreatic anastomosis. <br /><strong>CONCLUSION:</strong> Use of stents in pancreatic anastomosis in Whipple's for trauma may lessen the pancreatic leak rates, further studies are needed to prove this.  Cholecystojejunostomy can be an option for biliary enteric continuity, but further studies are needed to identify long tem patency rates.</p>

Last Glacial mammals in South America: a new scenario from the Tarija Basin (Bolivia).

The chronology, sedimentary history, and paleoecology of the Tarija Basin (Bolivia), one of the richest Pleistocene mammalian sites in South America, are revised here based on a multidisciplinary study, including stratigraphy, sedimentology, geomorphology, paleontology, isotope geochemistry, and (14)C geochronology. Previous studies have indicated a Middle Pleistocene age for this classic locality. We have been able to obtain a series of (14)C dates encompassing all the fossil-bearing sequences previously studied in the Tarija Basin. The dated layers range in age from about 44,000 to 21,000 radiocarbon years before present (BP), indicating that the Tarija fauna is much younger than previously thought. Glacial advances correlated to marine isotopic stages (MIS) 4 and 2 (ca. 62 and 20 ka BP, respectively) are also documented at the base and at the very top of the Tarija-Padcaya succession, respectively, indicating that the Bolivian Altiplano was not dry but sustained an ice cap during the Last Glacial Maximum. The results of this multidisciplinary study enable us to redefine the chronological limits of the Tarija sequence and of its faunal assemblage and to shift this paleontological, paleoclimatological, and paleoecological framework to the time interval from MIS 4 to MIS 2.

Analysis of expressed sequence tags from two starvation, time-of-day-specific libraries of Neurospora crassa reveals novel clock-controlled genes.

In an effort to determine genes that are expressed in mycelial cultures of Neurospora crassa over the course of the circadian day, we have sequenced 13,000 cDNA clones from two time-of-day-specific libraries (morning and evening library) generating approximately 20,000 sequences. Contig analysis allowed the identification of 445 unique expressed sequence tags (ESTs) and 986 ESTs present in multiple cDNA clones. For approximately 50% of the sequences (710 of 1431), significant matches to sequences in the National Center for Biotechnology Information database (of known or unknown function) were detected. About 50% of the ESTs (721 of 1431) showed no similarity to previously identified genes. We hybridized Northern blots with probes derived from 26 clones chosen from contigs identified by multiple cDNA clones and EST sequences. Using these sequences, the representation of genes among the morning and evening sequences, respectively, in most cases does not reflect their expression patterns over the course of the day. Nevertheless, we were able to identify four new clock-controlled genes. On the basis of these data we predict that a significant proportion of the expressed Neurospora genes may be regulated by the circadian clock. The mRNA levels of all four genes peak in the subjective morning as is the case with previously identified ccgs.

Characterization of blue-light and developmental regulation of the photolyase gene phr1 in Trichoderma harzianum.

Blue light and development regulate the expression of the phr1 gene of the filamentous fungus Trichoderma harzianum. The predicted product of phr1, the DNA repair enzyme photolyase, is likely to help protect Trichoderma, which grows in the soil as a mycoparasite or saprophyte, from damage upon emergence and exposure to ultraviolet-c. phr1 is transiently expressed in mycelium and conidiophores after illumination. phr1 mRNA also accumulates in conidiophores during development and spore maturation. As no other genes displaying rapid, direct light regulation have been described previously in this organism, we have characterized the fluence and time dependence of phr1 induction, and its relation to sporulation and photoreactivation. Induction is transient following a pulse, and, with slower decay, in continuous light. This implies that the photoreceptor, transducers or response are capable of adaptation. About two-fold more light is required to induce phr1 than conidiation, but this difference is modest, so both responses could use the same or similar chromophore. Adenosine 3':5'-cyclic monophosphate bypasses the requirement for light for sporulation, while atropine prevents sporulation even after photoinduction. Light regulation of phr1, however, is indifferent to both these effectors. Induction of photolyase expression behaves as a direct, rapid response to light, independent of the induction of sporulation. Indeed, illumination of mature spores increases their capacity for photoreactivation. Blue light seems to warn the organism against the harmful effects of short wave-lengths, inducing phr1 expression and sporulation by pathways that are, at least in part, distinct.

Rapid blue light regulation of a Trichoderma harzianum photolyase gene.

Photolyases and blue light receptors belong to a superfamily of flavoproteins that make use of blue and UVA light either to catalyze DNA repair or to control development. We have isolated a DNA photolyase gene (phr1) from Trichoderma harzianum, a common soil fungus that is of interest as a biocontrol agent against soil-borne plant pathogens and as a model for the study of light-dependent development. The sequence of phr1 is similar to other Class I Type I eukaryotic photolyase genes. Low fluences of blue light rapidly induced phr1 expression both in vegetative mycelia, which lack photoprotective pigments, and, to a greater extent, in conidiophores. Thus, visible light induces the development of pigmented, resistant spores as well as the expression of phr1, perhaps announcing in this way the imminent exposure to the more damaging short wavelengths of sunlight. Light induction of phr1 in non-sporulating mutants shows that a complete sporulation pathway is not required for photoregulation. The light requirements for photoinduction of phr1 were not altered in dimY photoperception mutants. This suggests that photoinduction of sporulation and of photolyase expression is distinct in their photoreceptor system or in the transduction of the blue light signal.