Air Pollution Is Associated with Cognitive Deterioration of Alzheimer's Disease.

INTRODUCTION: Dementia is one of the major causes of disability and dependency among older people worldwide. Alz-heimer's disease (AD), the most common cause of dementia among the elderly, has great impact on the health-care system of developed nations. Several risk factors are suggestive of an increased risk of AD, including APOE-ε4, male, age, diabetes mellitus, hypertension, and low social engagement. However, data on risk factors of AD progression are limited. Air pollution is revealed to be associated with increasing dementia incidence, but the relationship between air pollution and clinical AD cognitive deterioration is unclear. METHODS: We conducted a case-control and city-to-city study to compare the progression of AD patients in different level of air-polluted cities. Clinical data of a total of 704 AD patients were retrospectively collected, 584 residences in Kaohsiung and 120 residences in Pingtung between 2002 and 2018. An annual interview was performed with each patient, and the Clinical Dementia Rating score (0 [normal] to 3 [severe stage]) was used to evaluate their cognitive deterioration. Air pollution data of Kaohsiung and Pingtung city for 2002-2018 were retrieved from Taiwan Environmental Protection Administration. Annual Pollutant Standards Index (PSI) and concentrations of particulate matter (PM10), sulfur dioxide (SO2), ozone (O3), nitrogen dioxide (NO2), and carbon monoxide (CO) were obtained. RESULTS: The PSI was higher in Kaohsiung and compared with Pingtung patients, Kaohsiung patients were exposed to higher average annual concentrations of CO, NO2, PM10, and SO2. AD patients living in Kaohsiung suffered from faster cognitive deterioration in comparison with Pingtung patients (log-rank test: p = 0.016). When using multivariate Cox proportional hazards regression analysis, higher levels of CO, NO2, PM10, and SO2 exposure were associated with increased risk of AD cognitive deterioration. Among all these air pollutants, high SO2 exposure has the greatest impact while O3 has a neutral effect on AD cognitive deterioration. CONCLUSIONS: Air pollution is an environment-related risk factor that can be controlled and is associated with cognitive deterioration of AD. This finding could contribute to the implementation of public intervention strategies of AD.

Student Behavior Recognition System for the Classroom Environment Based on Skeleton Pose Estimation and Person Detection.

Human action recognition has attracted considerable research attention in the field of computer vision, especially for classroom environments. However, most relevant studies have focused on one specific behavior of students. Therefore, this paper proposes a student behavior recognition system based on skeleton pose estimation and person detection. First, consecutive frames captured with a classroom camera were used as the input images of the proposed system. Then, skeleton data were collected using the OpenPose framework. An error correction scheme was proposed based on the pose estimation and person detection techniques to decrease incorrect connections in the skeleton data. The preprocessed skeleton data were subsequently used to eliminate several joints that had a weak effect on behavior classification. Second, feature extraction was performed to generate feature vectors that represent human postures. The adopted features included normalized joint locations, joint distances, and bone angles. Finally, behavior classification was conducted to recognize student behaviors. A deep neural network was constructed to classify actions, and the proposed system was able to identify the number of students in a classroom. Moreover, a system prototype was implemented to verify the feasibility of the proposed system. The experimental results indicated that the proposed scheme outperformed the skeleton-based scheme in complex situations. The proposed system had a 15.15% higher average precision and 12.15% higher average recall than the skeleton-based scheme did.

Application of DynaCT angiographic reconstruction in balloon pulmonary angioplasty.

OBJECTIVES: To investigate the feasibility and accuracy of balloon pulmonary angioplasty (BPA) using DynaCT angiographic reconstruction guidance. METHODS: Thirty-four BPAs (23 CTEPH patients) targeting 175 pulmonary arteries were included. Eleven BPAs (2D group) were guided by DSA two-dimensional angiography. Another twenty-three BPAs (3D group) were guided using DynaCT angiographic reconstruction. The volume rendering (VR) method was used to obtain a three-dimensional image of the blood vessels. This image was used as a reference to continue BPA treatment under the guidance of vascular three-dimensional reconstruction technology. Procedure durations and radiation exposure data were compared between the two groups using Mann-Whitney U test. RESULTS: Using the DynaCT angiographic reconstruction technique, more target vessels were treated in a single BPA procedure (5.83 ± 2.33 vs 3.73 ± 1.10 vessels per BPA, p = 0.008) in a shorter operation time (3.58 ± 0.61 vs 4.49 ± 0.91 h, p = 0.002). Overall, the dose area product (DAP) was significantly higher for the 2D group than for the 3D group (13,901.82 ± 5549.69 vs 4682.82 ± 1950.64, p < 0.001). The use of the DynaCT angiographic reconstruction technique to guide BPA required a lower dose of contrast agent (225.22 ± 48.70 vs 292.73 ± 76.82 mL, p = 0.013) and less radiation exposure. CONCLUSIONS: The use of DynaCT angiographic reconstruction guidance in patients undergoing BPA is feasible and accurate. Images of DynaCT angiographic reconstruction may be beneficial for optimizing the operative process in BPA with reduced radiation exposure. KEY POINTS: • BPA guidance by DynaCT angiographic reconstruction is feasible and accurate. • DynaCT angiographic reconstruction may be beneficial for optimizing the operative process. • DynaCT angiographic reconstruction can reduce patient radiation dose due to multi-times of BPA sessions.

Quantifying source apportionment for ambient haze: An image haze extraction approach with air quality monitoring data.

The annual average concentration of fine particles (PM2.5) in Taiwan has been decreasing yearly. However, ambient haze has not abated and visibility is still poor. This study proposes a method for quantifying the source apportionment of ambient haze from various constituents, namely measured PM2.5, moisture, and secondary organic aerosols (SOA, represented by the sum of measured O3 and NO2 levels). This study's model-based demisting technology integrated image haze extracting technology with air quality monitoring data. The images for haze extraction were from the instant cameras of the Taiwan Environmental Protection Agency's air quality monitoring stations (AQMSs). Results indicate that haze constituents with the product of light extinction and scene depth have very high correlation (R2 ≥ 0.8452), which demonstrate that this quantification approach was successful. The contributions of ambient haze from various constituents had quarterly and regional variations in the eastern, northern, central, and southern regions of Taiwan, which are slightly, lowly, moderately, and heavily contaminated areas, respectively. Each area was assigned a selected representative AQMS to represent its ambient haze characteristics. Cases where the dominant contributors to haze were PM2.5, moisture, and SOA were studied, in addition to the event days of PM2.5 and ozone. We detail the limits of this approach, especially with regard to the use of images. This approach can help administrators understand the composition of ambient haze to generate effective haze strategies and policies. Residents can use this method to determine the health effects of daily haze.

Aspirin use associated with amyotrophic lateral sclerosis: a total population-based case-control study.

BACKGROUND: The association of aspirin use and nonsteroid anti-inflammatory drug (NSAID) use with amyotrophic lateral sclerosis (ALS) risk is unclear. This study determined whether use of any individual compound is associated with ALS risk by conducting a total population-based case-control study in Taiwan. METHODS: A total of 729 patients with newly diagnosed ALS who had a severely disabling disease certificate between January 1, 2002, and December 1, 2008, comprised the case group. These cases were compared with 7290 sex-, age-, residence-, and insurance premium-matched controls. Drug use by each Anatomical Therapeutic Chemical code was analyzed using conditional logistic regression models. False discovery rate (FDR)-adjusted P values were reported in order to avoid inflating false positives. RESULTS: Of the 1336 compounds, only the 266 with use cases exceeding 30 in our database were included in the screening analysis. Without controlling for steroid use, the analysis failed to reveal any compound that was inversely associated with ALS risk according to FDR criteria. After controlling for steroid use, we found use of the following compounds to be associated with ALS risk: aspirin, diphenhydramine (one of the antihistamines), and mefenamic acid (one of the NSAIDs). A multivariate analysis revealed that aspirin was independently inversely associated with ALS risk after controlling for diphenhydramine, mefenamic acid, and steroid use. The inverse association between aspirin and ALS was present predominately in patients older than 55 years. CONCLUSIONS: The results of this study suggested that aspirin use might reduce the risk of ALS, and the benefit might be more prominent for older people.

More severe hypoxemia is associated with better subjective sleep quality in obstructive sleep apnea.

BACKGROUND: Perceived sleep quality may play an important role in diagnosis and therapy for obstructive sleep apnea (OSA). However, few studies have assessed factors that are associated with perceived sleep quality in OSA patients. Hypoxemia depresses the central nervous system and attenuates the perceived respiratory load in asthmatic patients. This study aimed to investigate the factors related to perceived sleep quality, focusing on the role of hypoxemia. METHODS: Polysomnography studies of 156 OSA patients were reviewed. Traditional polysomnographic parameters, including parameters of oxy-hemoglobin saturation (SpO2), were calculated, and the sleep questionnaire and scales were used. Considering the possible pitfalls of absolute values of SpO2 and individualized responses to hypoxemia, the amplitude of desaturation was further computed as "median SpO2 minus lowest 5 % SpO2 "and "highest 5 % SpO2 minus median 5 % SpO2". Correlations between these parameters and perceived sleep quality, represented as the Pittsburgh sleep quality index (PSQI), were performed. Multiple linear regression analysis was also conducted to investigate the factors associated with the PSQI. RESULTS: Although the PSQI was not correlated with the apnea-hypopnea index (r = -0.113, p = 0.162) and oxygen desaturation index (r = -0.085, p = 0.291), the PSQI was negatively correlated with "median SpO2 minus lowest 5 % SpO2" (r = -0.161, p = 0.045). After adjusting for age, total sleep time, the periodic limb movements index, tendency of depression, and the lowest 5 % SpO2, the "median SpO2 minus lowest SpO2" was still a significant predictor for a lower PSQI (ß = -0.357, p = 0.015). CONCLUSIONS: More severe hypoxemia is associated with better perceived sleep quality among OSA patients. This paradox may be associated with hypoxemia-related impairment of perception. The effect of hypoxemia did not appear to be significant in relatively mild hypoxemia but become significant in severe hypoxemia." Median SpO2 minus lowest 5 % SpO2" may also be a better predictor of perceived sleep quality than the apnea-hypopnea index because of the disproportionate effects of hypoxemia. Additionally, further studies are necessary to confirm the role of hypoxemia on perceived sleep quality and identify the possible threshold of hypoxemia in OSA patients.

Beta2-adrenergic agonist use and the risk of multiple sclerosis: a total population-based case-control study.

OBJECTIVE: The aim of this study was to investigate whether the use of fenoterol, a beta2-adrenergic agonist, was associated with multiple sclerosis (MS) risk by conducting a total population-based case-control study in Taiwan. METHODS: A total of 578 patients with newly diagnosed MS who had a severely disabling disease (SDD) certificate between January 1, 2002 and December 1, 2008 comprised the case group. These cases were compared with 2890 gender-, age-, residence-, and insurance premium-matched controls. Fenoterol use was analyzed using a conditional logistic regression model that controlled for asthma, chronic obstructive pulmonary disease (COPD), salbutamol and steroid use. RESULTS: Compared with the group of people who did not use fenoterol, the adjusted odds ratios were 0.67 (95% confidence interval (CI) = 0.48-0.93, p = 0.016) for the group prescribed fenoterol below 2.25 cumulative defined daily dose (cDDD) and 0.49 (95% CI = 0.33-0.71, p < 0.001) for the group with a cumulative fenoterol use of more than 2.25 cDDD. The dose-response relationship was similar within the non-asthma patients. The associations were similar between males and females, but differences between age groups were observed. CONCLUSIONS: The results of this study suggest that fenoterol use may reduce the risk of MS.

Life-threatening anaphylactoid shock caused by recombinant tissue plasminogen activator.

Recombinant tissue plasminogen activator (rt-PA) is currently the only approved agent for treating acute ischemic stroke. However, rt-PA may cause fatal symptomatic intracranial hemorrhage and other adverse effects like bleeding complications and allergic reactions. Patients taking angiotensin-converting enzyme (ACE) inhibitors have increased risk of allergic reactions. This report is about a patient with a history of ACE inhibitor intake who experienced life-threatening anaphylactoid shock during rt-PA administration. The relationship between rt-PA and ACE inhibitor was also discussed.

Predictors of in-hospital mortality and prognosis in patients with large hemispheric stroke receiving decompressive craniectomy.

OBJECTIVE: Decompressive craniectomy reduces fatality in patients with space-occupying infarctions. However, mortality remains high. We aimed to identify predictors of in-hospital mortality and outcomes in a cohort of patients with large hemispheric stroke receiving decompressive craniectomy. METHODS: We retrospectively reviewed all patients diagnosed with complete middle cerebral artery infarction and receiving decompressive craniectomy. Hospital characteristics were compared among different groups (survivors versus non-survivors, good outcome versus poor outcome). A total of 71 consecutive patients were enrolled. RESULTS: From 2004 January to 2010 April, 71 patients were enrolled whose mean age was 65.11 ± 13.13 years and 33 (46.5%) of these were men. The in-hospital mortality was 28.2% overall. Of the patients who survived and were discharged, 37 (77.1%) had poor outcome (mRS 4-6) and 11 (22.9%) had good outcome (mRS 0-3). Pre-operation brain computed tomography (CT) hypodensity volume (p = 0.001) was significantly associated with mortality. In binary logistic regression model, pre-operation brain CT hypodensity volume (OR = 1.015; 95% CI, 1.001 to 1.030) and age (OR = 1.112; 95% CI, 1.017 to 1.215) were both significantly associated with outcomes. CONCLUSIONS: In patients with large hemispheric stroke receiving decompressive craniectomy, pre-operation brain CT hypodensity volume was significantly associated with in-hospital mortality whereas age was not. Pre-operation brain CT hypodensity volume and age were predictors of outcomes in those who survived the acute phase.

The rapid-eye-movement sleep behavior disorder in Chinese-Taiwanese patients.

AIMS: While the features of rapid-eye-movement sleep behavior disorder (RBD) have been reported in Caucasian patients, the characteristics of Chinese-Taiwanese patients with RBD have never been examined. METHODS: Subjects were retrospectively recruited between April 2005 and February 2008 from the neurological clinic and sleep laboratory in the Department of Neurology of Kaohsiung Medical University Hospital. A total of 70 consecutive subjects fulfilling the criteria for RBD were recruited. RESULTS: The records of standard overnight polysomnography in patients with RBD were analyzed retrospectively. Twenty-five (35.7%) of the patients were female; the mean age of diagnosis was 67 years and the mean age of symptom onset was 60 years. Among patients with idiopathic RBD, there were 28 men (61%) and 18 women (39%). Nocturnal wandering in the bedroom was reported in 11 cases and out of the bedroom in seven cases. Nineteen patients (27.1%) had accidental falling from bed and 27 patients (38.6%) had sleep-related injury that resulted in ecchymosis and laceration of the head, face or limbs. CONCLUSIONS: We found that some features in Chinese-Taiwanese patients with RBD were different from Caucasian patients, such as a greater female ratio, lower injury episodes during sleep and more sleep wandering.

Effect of levetiracetam on truncal tic in neuroacanthocytosis.

We report on an uncommon manifestation of neuroacanthocytosis in a 31-year-old woman and the successful use of levetiracetam in the treatment of her neurological symptoms. Truncal tic is one of the major presenting features of this patient. We find that Levetiracetam, a new antiepileptic drug, was effective in eliminating this patient's truncal jerks and motor tic manifestations, such as eyelid blinking and head nodding. Levetiracetam can therefore be considered as a choice for the symptomatic therapy in neuroacanthocytosis.

Statin use after intracerebral hemorrhage: a 10-year nationwide cohort study.

INTRODUCTION: Although statin therapy is beneficial to patients with ischemic stroke, statin use, and intracerebral hemorrhage (ICH) remain a concern. ICH survivors commonly have comorbid cardiovascular risk factors that would otherwise warrant cholesterol-lowering medication, thus emphasizing the importance of assessing the characteristics of statin therapy in this population. METHODS: We performed a cohort study by using 10 years of data collected from the National Health Insurance Research Database in Taiwan. We enrolled 726 patients admitted for newly diagnosed ICH from January 1, 2001 to December 31, 2010. The patients were categorized into high- (92), moderate- (545), and low-intensity (89) statin groups, and into hydrophilic (295) and lipophilic (431) statin groups. The composite outcomes included all-cause mortality, recurrent ICH, ischemic stroke, transient ischemic attack, and acute coronary events. RESULTS: The patients in the low-intensity group did not differ significantly from the patients in the high-intensity group in risk of all-cause mortality (adjusted hazard ratio [aHR] = 0.65, 95% confidence interval [CI] = 0.28-1.55) and recurrent ICH (aHR = 0.66, 95% CI = 0.30-1.44). In contrast, the patients in the hydrophilic group had a significantly lower risk of recurrent ICH than did those in the lipophilic group (aHR = 0.69, 95% CI = 0.48-0.99). We determined no significant differences in other composite endpoints between hydrophilic and lipophilic statin use. CONCLUSION: Hydrophilic statin therapy is associated with a reduced risk of recurrent ICH in post-ICH patients. The intensity of statin use had no significant effect on recurrent ICH or other components of the composite outcome. Additional studies are required to clarify the biological mechanisms underlying these observations.

Early Statin Use and the Progression of Alzheimer Disease: A Total Population-Based Case-Control Study.

The protective effect of statin on Alzheimer disease (AD) is still controversial, probably due to the debate about when to start the use of statin and the lack of any large-scale randomized evidence that actually supports the hypothesis. The purpose of this study was to examine the protective effect of early statin use on mild-to-moderate AD in the total Taiwanese population.This was a total population-based case-control study, using the total population of Taiwanese citizens seen in general medical practice; therefore, the findings can be applied to the general population. The study patients were those with newly diagnosed dementia (ICD-9 290.x) and prescribed any acetylcholinesterase inhibitors (AChEI) from the Taiwan National Health Insurance dataset in 1997 to 2008. The newly diagnosed eligible mild-to-moderate AD patients were traced from the dates of their index dates, which was defined as the first day to receive any AChEI treatment, back to 1 year (exposure period) to categorize them into AD with early statin use and without early statin use. Early statin use was defined as patients using statin before AChEI treatment. Alzheimer disease patients with early statin use were those receiving any statin treatment during the exposure period. Then, we used propensity-score-matched strategy to match these 2 groups as 1:1. The matched study patients were followed-up from their index dates. The primary outcome was the discontinuation of AChEI treatment, indicating AD progression.There were 719 mild-to-moderate AD-paired patients with early statin use and without early statin use for analyses. Alzheimer disease progression was statistically lower in AD patients with early statin use than those without (P = 0.00054). After adjusting for other covariates, mild-to-moderate AD patients with early stain use exhibited a 0.85-risk (95% CI = 0.76-0.95, P = 0.0066) to have AD progression than those without.Early statin use was significantly associated with a reduction in AD progression in mild-to-moderate AD patients. The future randomized trial studies can confirm our findings.

Angiotensin-converting enzyme inhibitors and amyotrophic lateral sclerosis risk: a total population-based case-control study.

IMPORTANCE: Although several studies have shown that use of angiotensin-converting enzyme inhibitors (ACEIs) potentially decreased amyotrophic lateral sclerosis (ALS) risk in animal models, to our knowledge, there has been no human study in the literature discussing this issue. OBJECTIVE: To investigate the association between the use of ACEIs and the risk for developing ALS. DESIGN, SETTING, AND PARTICIPANTS: This case-control study was conducted using the total population of Taiwanese citizens seen in general medical practice; therefore, the findings can be applied to the general population. The case group comprised 729 patients with newly diagnosed ALS and a severely disabling disease certificate between January 1, 2002, and December 31, 2008. These cases were compared with 14,580 sex-, age-, residence-, and insurance premium-matched control individuals. EXPOSURES: Use of ACEIs was analyzed using a conditional logistic regression model that controlled for other antihypertensives, aspirin, steroids, nonsteroidal anti-inflammatory drugs, Charlson Comorbidity Index score, length of hospital stay, and number of outpatient visits. The cumulative defined daily dose (cDDD), which indicates the exposed duration of drug use, was estimated as the sum of dispensed DDD of drug and compared with the risk for ALS. MAIN OUTCOMES AND MEASURES: All patients with ALS fulfilled El Escorial criteria in this study. Medical claim data past 1 to 5 years of ALS first diagnosis date for patients and claim data from their matched control individuals were included in the analysis. RESULTS: There was a dose-dependent inverse association between ACEI use and the risk for developing ALS. When compared with patients who did not use ACEIs, the adjusted odds ratios were 0.83 (95% CI, 0.65-1.07; P = .15) for the group prescribed ACEIs lower than 449.5 of the cDDD and 0.43 cDDD (95% CI, 0.26-0.72; P = .001) for the group with a cumulative ACEI use of greater than 449.5 cDDD. The association was most predominant in men older than 55 years. CONCLUSIONS AND RELEVANCE: Use of ACEIs exhibited a dose-dependent inverse association with ALS. This study demonstrated a 57% risk reduction in the chance for developing ALS in people who used ACEIs greater than 449.5 cDDD in 4 years.

Using a blood pressure harmonic variability index to monitor the cerebral blood flow condition in stroke patients.

OBJECTIVE: Beat-to-beat cardiovascular variability analysis provides important information on the autonomic control. Bilateral radial arterial blood pressure waveforms (BPW) in stroke patients were compared to explore the efficacy of frequency-domain variability index in evaluating bilateral differences in the cerebral blood-flow condition. METHODS: Five-minute BPW signals were obtained in 22 stroke patients (Group S) and 21 healthy volunteers (control Group C). Amplitude proportions of the acquired pulses and their coefficient of variance (CVn) were calculated for 1st-10th harmonics to evaluate the blood pressure harmonic variability (BPHV). RESULTS: In Group S, CV1-CV7 were significantly larger on the stroke side than on the contralateral side. CV1, CV3-CV5 and CV7 were significantly larger on the stroke side in Group S than on either side in Group C. CONCLUSIONS: We first demonstrate the feasibility of using BPHV index to noninvasively detect the bilateral difference in cerebral vascular resistance in stroke patients. Two main indexes could be developed based on the present results: (1) bilateral differences in BPHV in stroke patients; (2) BPHV differences between normal and stroke subjects. It might have meaning in developing an easy-to-perform, noninvasive and continuous monitoring technique to improve the early detection and disease progress monitoring for stroke.

Rapid-eye-movement sleep behavior disorder secondary to acute aseptic limbic encephalitis.

Rapid-eye-movement (REM) sleep behavior disorder (RBD) is a parasomnia characterized by complex motor activity associated with dreaming during REM sleep. RBD may be idiopathic or associated with various neurological diseases involving the brainstem. The association of RBD and limbic system impairment was unclear. We report a 46-year-old man with acute aseptic limbic encephalitis in association with RBD. The patient presented with subacute onset of anterograde/retrograde amnesia and persistent fever. Abnormal nocturnal behavior during sleep consisted of waving hands to fight and kicking legs. Brain magnetic resonance imaging showed damage on the bilateral unci and medial temporal lobes. Cerebrospinal fluid analysis indicated aseptic encephalitis. A polysomnography revealed augmented phasic activity in the submental and bilateral tibialis anterior muscles during REM sleep. Our finding suggests that limbic system impairment may lead to the occurrence of RBD.

Eligibility for recombinant tissue plasminogen activator in acute ischemic stroke: way to endeavor.

BACKGROUND: The eligibility for recombinant tissue plasminogen activator (rtPA) is rare. We analyze the reasons for exclusion from rtPA among patients who were admitted to our hospital within 3 h. METHODS: A strict protocol for hyperacute stroke was set in a university teaching hospital. Consecutive patients activating the protocol from June 2004 to October 2005 were prospectively registered and entered into a computerized database. The patients were excluded from rtPA according to the modified exclusion criteria from the National Institute of Neurological Disorders and Stroke rtPA trial. RESULTS: Of the 182 patients activating the protocol, only 11 (6.04%) received intravenous rtPA and 4 (2.2%) IA thrombolysis. Patients were excluded for multiple reasons, and the main reasons for exclusion were minor or improving stroke (46.15%), hypertension (35.16%), insufficient time to complete studies or onset beyond 3 h after reconfirmation (24.17%) and intracranial hemorrhage (15.93%). Of 167 excluded patients, 72 (43.11%) were excluded by a single criterion, 53 (31.73%) by 2 criteria and 29 (17.36%) by 3 criteria. The mean time from hospital arrival to presentation to a neurologist was 9.24 +/- 15.11 min (n = 164, median = 8.00, mode = 10, range = 0-65). The mean time from hospital arrival to computed tomography (CT) was 21.67 +/- 23.95 min (n = 167, median = 20.00, mode = 10, range = 4-68). CONCLUSION: An intrahospital stroke code was implemented to minimize intrahospital delay. However, only 11 patients received intravenous rtPA and 4 IA thrombolysis at our hospital from June 2004 to October 2005. The result brings into question the neurologist's conservative interpretation of the criteria and the necessity to clearly define some criteria. Furthermore an intrahospital stroke code should also be implemented for inpatients to maximize the eligibility for rtPA.