Development and Validation of a Risk Score for Predicting Ischemic Stroke After Transient Ischemic Attack.

BACKGROUND: A risk stratification scale is essential to identify high-risk patients who had transient ischemic attack (TIA) to prevent subsequent permanent disability caused by ischemic stroke. OBJECTIVE: This study aimed to develop and validate a scoring system to predict acute ischemic stroke within 90 days after TIA in an emergency department (ED). METHODS: We retrospectively analyzed the data of patients with TIA in a stroke registry between January 2011 and September 2018. Characteristics, medication history, electrocardiogram (ECG), and imaging findings were collected. Univariable and multivariable stepwise logistic regression analyses were performed to create an integer point system. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration. Youden's Index was also used to determine the best cutoff value. RESULTS: A total of 557 patients were included, and the occurrence rate of acute ischemic stroke within 90 days after TIA was 5.03%. After multivariable analysis, a new integer point system was created-MESH (Medication Electrocardiogram Stenosis Hypodense) score-which contained medication history (antiplatelet medication taken before admission, 1 point), right bundle branch block on electrocardiogram (1 point), intracranial stenosis ≥ 50% (1 point), and size of the hypodense area on computed tomography (diameter ≥ 4 cm, 2 points). The MESH score showed adequate discrimination (AUC = 0.78) and calibration (HL test = 0.78). The best cutoff value was 2 points, with a sensitivity of 60.71% and specificity of 81.66%. CONCLUSIONS: The MESH score indicated improved accuracy for TIA risk stratification in the ED setting.

External validation of prehospital stroke scales for emergent large vessel occlusion.

BACKGROUND: It is suggested that a prehospital scale should be utilized to identify patients with emergent large vessel occlusion (ELVO). We aimed to perform external validation of nine ELVO scales. METHODS: This single center retrospective observational study included patients with ischemic stroke visiting the emergency department (ED) within 6 h of symptom onset. Participants were excluded if individual items of the National Institute of Health Stroke Scale scores were not recorded or they did not receive brain computed tomography angiography or magnetic resonance imaging before intravenous thrombolysis or endovascular thrombectomy, and within 24 h of ED admission. The first definition of ELVO was emergent occlusion of the internal carotid artery (ICA) and middle cerebral artery segment 1 (M1). The second definition was emergent occlusion of ICA, M1, basilar artery, middle cerebral artery segment 2, anterior cerebral artery segment 1, and posterior cerebral artery segment 1. Area under the receiver operating characteristic curve (AUROC) was constructed to examine discrimination. The sensitivity, specificity, positive predictive value, and negative predictive value of the nine scales under the two ELVO definitions were calculated. RESULTS: A total of 1231 patients were included in the study. No significant differences were observed in the AUROC under the two ELVO definitions. However, sensitivity values of these scales were largely different, ranging from 44.56% to 93.68% under the first ELVO definition. The sensitivity values among scales were also different under the second ELVO definition. CONCLUSION: Stakeholders in the community should choose suitable scales according to their own system conditions.

Adjunctive dexmedetomidine infusion in open living donor hepatectomy: A way to enhance postoperative analgesia and recovery.

BACKGROUND: Open living donor hepatectomy (OLDH) is a highly painful procedure. Advanced strategies for enhancing perioperative analgesia and accelerating recovery are needed for patients undergoing OLDH. This study evaluated the effects of intravenous infusion of dexmedetomidine (DEX) during OLDH on postoperative analgesia and recovery. METHODS: This prospective, randomised, double-blinded, and placebo-controlled study included 34 patients randomised to a control group (group C) and a DEX group (group D). Utilisation of intravenous patient-controlled analgesia (IV-PCA) pump, pain intensity, and postoperative recovery variables were recorded. Moreover, intraoperative anaesthetic consumption, hemodynamic parameters, and fluid status were also recorded. RESULTS: During the first 24 hours after surgery, patients in group D had a lower pain intensity. The cumulative numbers of IV-PCA pump presses and fentanyl consumption within 24 and 48 hours postoperatively in group C were significantly higher than in group D. The time to first IV-PCA attempt was prolonged in group D. In addition, faster flatus passage was observed in group D. Intraoperatively, fewer anaesthetic agents were required in group D. Less fluctuation in hemodynamics and reduced bleeding were also found in group D. CONCLUSIONS: The present study revealed that the addition of intravenous infusion of DEX during OLDH provided several benefits in relieving postoperative pain and promoting recovery. Therefore, we concluded that intraoperative DEX infusion may play an important role in enhancing the recovery of patients undergoing OLDH.

Plasticity of Schwann cells and pericytes in response to islet injury in mice.

AIMS/HYPOTHESIS: Islet Schwann (glial) cells and pericytes are the microorgan's accessory cells positioned at the external and internal boundaries facing the exocrine pancreas and endothelium, respectively, adjacent to the endocrine cells. Plasticity of glial cells and pericytes is shown in the glial scar formation after injury to the central nervous system. It remains unclear whether similar reactive cellular responses occur in insulitis. We applied three-dimensional (3D) histology to perform qualitative and quantitative analyses of the islet Schwann cell network and pericytes in normal, streptozotocin-injected (positive control of gliosis) and NOD mouse models. METHODS: Vessel painting paired with immunostaining of mouse pancreatic tissue was used to reveal the islet Schwann cells and pericytes and their association with vasculature. Transparent islet specimens were prepared by optical clearing to facilitate 3D confocal microscopy for panoramic visualisation of the tissue networks. RESULTS: In-depth microscopy showed that the islet Schwann cell network extends from the peri-islet domain into the core. One week after streptozotocin injection, we observed intra-islet perivascular gliosis and an increase in pericyte density. In early/moderate insulitis in the NOD mice, perilesional gliosis occurred at the front of the lymphocytic infiltration with atypical islet Schwann cell morphologies, including excessive branching and perivascular gliosis. Meanwhile, pericytes aggregated on the walls of the feeding arteriole at the peri- and intralesional domains with a marked increase in surface marker density. CONCLUSIONS/INTERPRETATION: The reactive cellular responses demonstrate plasticity and suggest a stop-gap mechanism consisting of the Schwann cells and pericytes in association with the islet lesion and vasculature when injury occurs.

Resuscitative Endovascular Balloon Occlusion of the Aorta for Traumatic Cardiopulmonary Arrest in the Emergency Department: The First Case With Successful Return of Spontaneous Circulation in Taiwan.

Exsanguinating torso hemorrhage is a leading cause of death in trauma patients. Bleeding leads to hypothermia, acidosis, and coagulopathy, the so-called "lethal triad," and creates a vicious cycle. Therefore, bleeding control tops the priority list in the management of trauma patients. Placement of resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with traumatic non-compressible torso hemorrhage is a developing technique in the emergency departments (EDs) in Taiwan, and it is a possible solution for abdominal and pelvic trauma patients with hemodynamic instability. It not only temporarily controls bleeding below the inflation site but also increases cerebral and coronary circulation. It can create a bridge for definitive care such as an operation or an embolization, possibly preventing death. Compared to thoracotomy followed by an aortic cross clamp, REBOA is a less invasive and possibly, a more efficient way to control the hemorrhage and may lead to better overall survival. The use of REBOA has been proven to be associated with improved survival-to-discharge in severely injured trauma patients. We report a case of out-of-hospital cardiac arrest caused by penetrating injury wherein return of spontaneous circulation was successfully achieved after 39-minute cardiopulmonary resuscitation and REBOA placement in the ED. The REBOA balloon was deflated after bleeding was stopped during the laparotomy operation. The patient was then transferred to the intensive care unit for postoperative care. Unfortunately, the patient passed away approximately 12 hours after the surgery.

Predictors of unfavorable outcome at 90 days in basilar artery occlusion patients.

BACKGROUND: In a previous study, basilar artery occlusion (BAO) was shown to lead to death or disability in 80% of the patients. The treatment for BAO patients in the acute stage includes thrombolysis and intra-arterial thrombectomy, but not all patients benefit from these treatments. Thus, understanding the predictors of outcome before initiating these treatments is of special interest. AIM: To determine the predictors related to the 90-d clinical outcome in patients with BAO in an Asian population. METHODS: We performed a retrospective case review of patients admitted to a tertiary stroke center between 2015 and 2019. We used the international classification of diseases-10 criteria to identify cases of posterior circulation stroke. A neurologist reviewed every case, and patients fulfilling the criteria defined in the Basilar Artery International Cooperation Study were included. We then analyzed the patients' characteristics and factors related to the 90-d outcome. RESULTS: We identified a total of 99 patients as real BAO cases. Of these patients, 33 (33.3%) had a favorable outcome at 90 d (modified Rankin Scale: 0-3). Moreover, 72 patients received intra-arterial thrombectomy, while 13 patients received intravenous tissue-type plasminogen activator treatment. We observed a favorable outcome in 33.3% of the cases and an unfavorable outcome in 66.7% of the cases. We found that the initial National Institutes of Health Stroke Scale (NIHSS) score and several BAO symptoms, including impaired consciousness, tetraparesis, and pupillary abnormalities, were significantly associated with an unfavorable outcome (P < 0.05), while cerebellar symptoms were associated with a favorable outcome (P < 0.05). In the receiver operating characteristic (ROC) analysis, the areas under the ROC curve of initial NIHSS score, impaired consciousness, tetraparesis, cerebellar symptoms, and pupillary abnormalities were 0.836, 0.644, 0.727, 0.614, and 0.614, respectively. Initial NIHSS score showed a higher AUROC (0.836) compared to BAO symptoms. CONCLUSION: The most important predictor of an unfavorable outcome was the initial NIHSS score. BAO symptoms, including tetraparesis, impaired consciousness, and pupillary abnormality were also related to an unfavorable outcome.

Asian American college students' suicide ideation: a mixed-methods study.

The purpose of this mixed-methods study was to explore the phenomenon of suicide ideation among 293 Asian American college students. Guided by T. Joiner's (2005) interpersonal-psychological theory of suicidal behavior, the authors examined the relationships among perceived burdensomeness, thwarted belongingness, self-construals, and suicide ideation. Compared with thwarted belongingness, perceived burdensomeness was a more robust predictor of suicide ideation. However, thwarted belongingness moderated the positive association between perceived burdensomeness and suicide ideation. Furthermore, interdependent self-construal and independent self-construal both weakened the link between perceived burdensomeness and suicide ideation and between thwarted belongingness and suicide ideation. The authors also conducted a qualitative analysis of participants' open-ended responses about their perceptions of why Asian American college students might consider suicide. The authors identified a core phenomenon of unfulfilled expectations as well as 2 broad themes related to this core phenomenon: unfulfilled intrapersonal expectations and unfulfilled interpersonal expectations, comprising the subthemes of (a) family, (b) relationship, (c) cultural differences, and (d) racism. These findings are discussed in terms of implications for suicide-related clinical interventions and primary prevention efforts among Asian American college students.

Temperature-Dependent Superplasticity and Strengthening in CoNiCrFeMn High Entropy Alloy Nanowires Using Atomistic Simulations.

High strength and ductility, often mutually exclusive properties of a structural material, are also responsible for damage tolerance. At low temperatures, due to high surface energy, single element metallic nanowires such as Ag usually transform into a more preferred phase via nucleation and propagation of partial dislocation through the nanowire, enabling superplasticity. In high entropy alloy (HEA) CoNiCrFeMn nanowires, the motion of the partial dislocation is hindered by the friction due to difference in the lattice parameter of the constituent atoms which is responsible for the hardening and lowering the ductility. In this study, we have examined the temperature-dependent superplasticity of single component Ag and multicomponent CoNiCrFeMn HEA nanowires using molecular dynamics simulations. The results demonstrate that Ag nanowires exhibit apparent temperature-dependent superplasticity at cryogenic temperature due to (110) to (100) cross-section reorientation behavior. Interestingly, HEA nanowires can perform exceptional strength-ductility trade-offs at cryogenic temperatures. Even at high temperatures, HEA nanowires can still maintain good flow stress and ductility prior to failure. Mechanical properties of HEA nanowires are better than Ag nanowires due to synergistic interactions of deformation twinning, FCC-HCP phase transformation, and the special reorientation of the cross-section. Further examination reveals that simultaneous activation of twining induced plasticity and transformation induced plasticity are responsible for the plasticity at different stages and temperatures. These findings could be very useful for designing nanowires at different temperatures with high stability and superior mechanical properties in the semiconductor industry.

Effect of Field Triage Training on Emergency Medical Technicians in Taipei City.

Injury is a leading cause of death among young adults. An accurately implemented fi led triage scheme (FTS) by emergency medical technicians (EMTs) is the first step for delivering right patients to the right hospital. However, the training effect of FTS on EMTs with different levels and backgrounds has scarcely been reported. We evaluated training effects of FTS among EMTs in Taipei. Standard FTS contains physiologic status, anatomical sites of injury, and mechanism of injury criteria. The intervention was a 30-minute lecture and pre-and-post tests, each containing five questions about trauma severity judgment (i.e., mechanism of injury [2 questions], anatomic sites of injury [2 questions], and physiological status [1 question]). The change in EMT accuracy was measured before and after training. Subgroup analyses were performed across EMTs with different levels and seniorities. From September 1, 2015 to March 31, 2016, 821 EMTs were enrolled, including 740 EMT-intermediates and 81 paramedics. Overall, EMT accuracy improved after the intervention in the intermediate (73.2% vs. 85.5%, p < 0.05) and paramedic (76.0% vs. 85.7%, p <0.01) groups. All trainees showed improvements in physiology and mechanism criteria, but paramedics showed decreased accuracy in anatomic criteria. The subgroup analysis showed that accuracy positively associated with prehospital care experience for major trauma cases 1 year before the training course, and the anatomical criterion accuracy was adversely associated with paramedic seniority. Field triage training can improve EMT accuracy for FTS. The anatomical aspect is more diffi cult to improve and should be emphasized in FTS training courses.

Using G-FAST to recognize emergent large vessel occlusion: a training program for a prehospital bypass strategy.

INTRODUCTION: The shorter the time between the onset of symptoms and reperfusion using endovascular thrombectomy, the better the functional outcome of patients. A training program was designed for emergency medical technicians (EMTs) to learn the gaze-face-arm-speech-time test (G-FAST) score for initiating a prehospital bypass strategy in an urban city. This study aimed to evaluate the effect of the training program on EMTs. METHODS: All EMTs in the city were invited to join the training program. The program consisted of a 30 min lecture and a 20 min video which demonstrated the G-FAST evaluation. The participants underwent tests before and after the program. The tests included (1) a questionnaire of knowledge, attitudes, confidence, and behaviors towards stroke care; and (2) watching 10 different scenarios in a video and answering questions, including eight sub-questions of G-FAST parameters, and choosing a suitable receiving hospital. RESULTS: In total, 1058 EMTs completed the training program. After the program, significant improvement was noted in knowledge, attitudes, and confidence, as well as scenario judgement. The performance of the EMTs in evaluating G-FAST criteria in comatose patients was relatively poor in the pre-test and improved significantly after the training course. Although the participants answered the G-FAST items correctly, they tended to overtriage the patients and refer them to higher-level hospitals. CONCLUSIONS: A short training program can improve the ability to identify stroke patients and choose a suitable receiving hospital. A future training program could put further emphasis on how to evaluate comatose patients and choose a suitable receiving hospital.

Acute appendicitis complicated with necrotizing fasciitis in a patient with adult-onset Still's disease: A case report.

RATIONALE: Adult-onset Still disease (AOSD) is a rare systemic inflammatory disease of unknown etiology characterized by evanescent salmon-pink rash, spiking fever, arthralgia/ arthritis, and lymphadenopathy. AOSD sometimes was fatal when it is complicated by macrophage activation syndrome (MAS) or hemophagocytic lymphohistiocytosis (HLH). Nonetheless, the literature provides no recommendations for treatment of AOSD patients with severe sepsis. PATIENT CONCERNS: A previously healthy 65-year-old man with history of AOSD was referred to our hospital for persistent right lower quadrant abdominal pain for 2 days. One week later, an abdominal wall abscess and hematoma developed by extravasation from the inferior epigastric vessels, complicated by necrotizing fasciitis of the right thigh and groin region. To our best knowledge, this case was the first reported case of a perforated appendix complicated with necrotizing fasciitis in a patient with AOSD. DIAGNOSES: The patient was diagnosed as acute appendicitis complicated with necrotizing fasciitis and abdominal wall abscess. INTERVENTIONS: This case received intravenous tigecycline injection and daily 10 mg prednisolone initially, and shifted to daily intravenous hydrocortisone 200 mg for suspected MAS or HLH. This patient underwent surgical intervention and debridement for necrotizing fasciitis. OUTCOMES: The patient's symptoms progressed worse rapidly. He died from cytomegalovirus viremia and bacterial necrotizing fasciitis complicated by septic shock. LESSONS: (1) The steroid dose was difficult to titrate when AOSD complicated by sepsis. The differential diagnosis from MAS/HLH with bacterial/viral infection related severe sepsis was difficult but critical for decision making from clinicians and rheumatologists. (2) The conservative treatment with antibiotics for perforated appendix is safe but has a higher failure rate in immunocomprised patients such as systemic lupus erythematosus and AOSD. Early surgical intervention might contribute to better outcome. (3) The abdominal wall abscess can be spread from intra-abdominal lesion through the inferior epigastric vessels which were as weak points of abdominal wall. Imaging examinations contribute to acute diagnosis and help surgeons perform surgical interventions to prevent morbidity and mortality.