Factors Associated With Participation in the Chronic Disease Self-Management Program: Findings From the SUCCEED Trial.

BACKGROUND AND PURPOSE: Self-management programs may improve quality of life and self-efficacy for stroke survivors, but participation is low. In a randomized controlled trial of a complex, multidisciplinary, team-based secondary stroke prevention intervention, we offered participants Chronic Disease Self-Management Program (CDSMP) workshops in addition to clinic visits and home visits. To enhance participation, workshops were facilitated by community health workers who were culturally and linguistically concordant with most participants and scheduled CDSMP sessions at convenient venues and times. Over time, we implemented additional strategies such as free transportation and financial incentives. In this study, we aimed to determine factors associated with CDSMP participation and attendance. METHODS: From 2014 to 2018, 18 CDSMP workshop series were offered to 241 English and Spanish-speaking individuals (age ≥40 years) with recent stroke or transient ischemic attack. Zero-inflated Poisson regression was used to identify factors associated with participation and attendance (ie, number of sessions attended) in CDSMP. Missing values were imputed using multiple imputation methods. RESULTS: Nearly one-third (29%) of intervention subjects participated in CDSMP. Moderate disability and more clinic/home visits were associated with participation. Participants with higher numbers of clinic and home visits (incidence rate ratio [IRR], 1.06 [95% CI, 1.01-1.12]), severe (IRR, 2.34 [95% CI, 1.65-3.31]), and moderately severe disability (IRR, 1.55 [95% CI, 1.07-2.23]), and who enrolled later in the study (IRR, 1.12 [95% CI, 1.08-1.16]) attended more sessions. Individuals with higher chaos scores attended fewer sessions (IRR, 0.97 [95% CI, 0.95-0.99]). CONCLUSIONS: Less than one-third of subjects enrolled in the SUCCEED (Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities) intervention participated in CDSMP; however, participation improved as transportation and financial barriers were addressed. Strategies to address social determinants of health contributing to chaos and engage individuals in healthcare may facilitate attendance. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01763203.

Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED).

BACKGROUND: Recurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population. METHODS/DESIGN: In this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care. DISCUSSION: If this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01763203 .

Calcified parenchymal central nervous system cysticercosis and clinical outcomes in epilepsy.

OBJECTIVE: This study aimed to compare clinical outcomes including seizure frequency and psychiatric symptoms between patients with epilepsy with neuroimaging evidence of past brain parenchymal neurocysticercosis infection, patients with other structural brain lesions, and patients without structural neuroimaging abnormalities. MATERIAL AND METHODS: The study included retrospective cross-sectional analysis of all patients treated for epilepsy in a community-based adult neurology clinic during a three-month period. RESULTS: A total of 160 patients were included in the analysis, including 63 with neuroimaging findings consistent with past parenchymal neurocysticercosis infection, 55 with structurally normal brain neuroimaging studies, and 42 with other structural brain lesions. No significant differences were detected between groups for either seizure freedom (46.03%, 50.91%, and 47.62%, respectively; p=0.944) or mean seizure frequency per month (mean=2.50, S.D.=8.1; mean=4.83, S.D.=17.64; mean=8.55, S.D.=27.31, respectively; p=0.267). Self-reported depressive symptoms were more prevalent in those with parenchymal neurocysticercosis than in the other groups (p=0.003). No significant differences were detected for prevalence of self-reported anxiety or psychotic symptoms. CONCLUSIONS: Calcified parenchymal neurocysticercosis results in refractory epilepsy about as often as other structural brain lesions. Depressive symptoms may be more common among those with epilepsy and calcified parenchymal neurocysticercosis; consequently, screening for depression may be indicated in this population.

Whole brain CT perfusion deficits using 320-detector-row CT scanner in TIA patients are associated with ABCD2 score.

BACKGROUND: Transient ischemic attacks (TIA) are cerebral ischemic events without infarction. The uses of CT perfusion (CTP) techniques such as cerebral blood volume (CBV), time to peak (TTP), mean transit time (MTT) and cerebral blood flow (CBF) provide real time data about ischemia. It has been shown that CTP changes occur in less sensitive CTP scanners in patients with TIA. Larger detector row CTP (whole brain perfusion studies) may show that CTP abnormalities are more prevalent than previously noted. It is also unclear if these changes are associated with TIA severity. OBJECTIVE: To demonstrate that TIA patients are associated with perfusion deficits using whole brain 320-detector-row CT perfusion, and to determine an association between ABCD2 score and perfusion deficit using whole brain perfusion. METHODS: We retrospectively reviewed all TIA patients for CTP deficits from 2008-2010. Perfusion imaging was reviewed at admission; and it was determined if a perfusion deficit was present along with vascular territory involved. RESULTS: Of 364 TIA patients, 62 patients had CTP deficits. The largest group of patients had MCA territory involved with 48 of 62 patients (77.42%). The most common perfusion abnormality was increased TTP with 46 patients (74.19%). The ABCD2 score was reviewed in association with perfusion deficit. Increased age >60, severe hypertension (>180/100 mmHg), patients with speech abnormalities, and duration of symptoms >10 min were associated with a perfusion deficit but history of diabetes or minimal/moderate hypertension (140/90-179/99 mmHg) was not. There was no association between motor deficit and perfusion abnormality. CONCLUSION: Perfusion deficits are found in TIA patients using whole brain CTP and associated with components of the ABCD2 score.

Patient satisfaction and resident postgraduate year status.

PURPOSE: Patient satisfaction has been recognized as an important variable affecting healthcare behavior. However, there are limited data on the relationship between doctor post-graduate year (PGY) status and patient satisfaction with provider interpersonal skills and humanistic qualities. The authors aims to assess this relationship using an American Board of Internal Medicine (ABIM) questionnaire. DESIGN/METHODOLOGY/APPROACH: Participants were: patients attending a primary care clinic at a large urban academic hospital; and physicians treating them. The survey questionnaire was the ABIM patient satisfaction instrument; ten questions pertaining to humanistic qualities and communication skills with responses from poor to excellent. Mann Whitney U test and multi-variable logistic regression analyses were used to explore score differences by PGY level. FINDINGS: The postgraduate year one (PGY1) had higher patient-satisfaction levels compared to PGY2/PGY3 residents. The PGY1 level residents were more likely to score in the 90th percentile and this remained constant even after adjusting for confounders. RESEARCH LIMITATIONS/IMPLICATIONS: The research was a single-center study and may have been subject to confounding factors such as patient personality types and a survey ceiling effect. The survey's cross-sectional nature may also be a potential limitation. Practical implications - Patient satisfaction varies significantly with PGY status. Though clinical skills may improve with increasing experience, findings imply that interpersonal and humanistic qualities may deteriorate. ORIGINALITY/VALUE: The study is the first to assess patient satisfaction with PGY status and provides evidence that advanced trainees may need support to keep their communication skills and humanistic qualities from deteriorating as stressors increase to ensure optimal patient satisfaction.

When the Tree Branch Affects the Fruits: A Case of Celiac Artery Dissection.

Arterial dissection is a laceration of an artery or arterial bed, that can extend to contiguous arteries and lead to accumulation of blood providing a great risk for thrombi formation, and possible ischemic events. Celiac artery dissection is a very rare pathology, with an unknown prevalence and a pathophysiology that still needs to be elucidated. Diagnosis has increased in the last decade due to higher imaging modalities and accessibility of such that provide simpler identification, as well as which treatment should be applied to a particular patient. In this case report, we present a 44-year-old male with abdominal pain, found to have on computed tomography angiography (CTA) a dissection of the celiac artery with extension to the splenic artery, causing multiple splenic infarcts, demonstrating that such lesions can be the cause of unexplained thrombosis in a certain patient population. Due to its complex presentation, management can differ based on the characteristics of the dissection as well as organ involvement, these modalities range from anticoagulation to surgical or endoscopic intervention. This case highlights the rare occurrence of an isolated dissection at a visceral artery causing thrombosis in a relatively healthy patient.

Semaglutide-Induced Lupus Erythematosus With Multiorgan Involvement.

We report the case of a 76-year-old female who presented with a new onset of petechial rash in her lower extremities after the introduction of a new agent, semaglutide. She started taking this medication three months before her presentation at an initial dosage of 0.5 mg subcutaneously every week. She noticed a 15-pound weight loss and debilitating fatigue within that timeframe. She stopped taking the medication due to nontolerance and GI upset (nausea and vomiting) about a week before her hospitalization. She denied the use of any other agents. Initial lab work revealed elevated transaminases, alkaline phosphatase, total bilirubin, and inflammatory markers. A CT of the abdomen revealed mild cirrhosis and hepatosplenomegaly. Other causes for cirrhosis were effectively ruled out with negative viral hepatitis, ceruloplasmin levels, and the HFE gene. An autoimmune panel was conducted, yielding positive antinuclear antibody (ANA), anti-histone antibodies, elevated double-stranded DNA, as well as low complement levels supporting evidence of drug-induced lupus (DIL). Anti-mitochondrial M2 and anti-smooth antibodies were also detected, indicating a possible overlap syndrome with autoimmune hepatitis. Perinuclear anti-neutrophil cytoplasmic antibodies (P-ANCA) and anti-neutrophil cytoplasmic autoantibodies (C-ANCA) were negative and ruled out the possibility of ANCA-associated vasculitis. The patient's condition improved with pulse-dose steroids, leading to an improvement in liver function tests. Consequently, the decision to perform skin and liver biopsies was deferred. She was discharged with a tapering dose of steroids and scheduled for outpatient follow-up to monitor her progress. This case report can offer insights to healthcare providers regarding the potential side effects of GLP-1 RAs in their patient population.

A Tale of Two Afflictions: Transverse Myelitis and COVID-19 in a Young Female Patient.

Acute transverse myelitis (ATM) is a syndrome of multiple etiologies, with acute or subacute onset in which inflammation of the spinal cord results in neurological deficits, including weakness, sensory loss, and autonomic dysfunction. It is often associated with infectious or autoimmune etiologies but can be considered idiopathic when extensive workup is negative. We present a case of a young African American female who presented with acute onset of bilateral lower extremity weakness, loss of sensation, and autonomic dysfunction. On physical exam, she had absent lower extremity reflexes, 0-1/5 power, and markedly diminished sensation with no pain/temperature discrimination with an abdominal sensory level at T4. There was no upper extremity involvement. She was incidentally found to be COVID-19-positive and denied ever being vaccinated in the past. MRI of the spine revealed diffuse signal abnormality within the cervical and thoracic spine extending to the conus, and an MRI of the brain showed two white matter lesions in the frontal lobes. Lumbar puncture showed lymphocytic pleocytosis and elevated protein; Gram stain did not reveal any pathogen. The patient was treated initially with high doses of steroids with minimal response. She underwent multiple sessions of plasmapheresis with good tolerance and response. Differential diagnoses considered for this case were Guillain Barre syndrome, neuromyelitis optica (NMO), multiple sclerosis, SLE-induced transverse myelitis, or infectious cases. All lab work and workup came back negative for these diseases, leaving us with an interesting culprit: COVID-19 associated. There have been few cases mentioned in the literature of transverse myelitis caused by COVID-19, and this remains a possibility, as all other causes were ruled out.

Epstein-Barr Virus (EBV)-Associated Myopericarditis Provoking Severe Heart Failure in an Immunocompetent Young Male.

Myopericarditis, a rare inflammatory condition affecting the heart and its surrounding layers, can lead to serious consequences if not promptly diagnosed and treated. A recent case involved a 28-year-old man with no significant medical history who developed severe chest pain and was diagnosed with myopericarditis induced by the Epstein-Barr virus (EBV). The patient's symptoms, imaging, and lab test results suggest myopericarditis. Initially, he was treated with non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine, and upon discharge, he continued with NSAIDs, as well as guideline-directed medical therapy, including an angiotensin-converting enzyme inhibitor, beta blocker, and SGLT2 inhibitor. Close follow-up with the cardiology and heart failure programs was planned. This case highlights the rare occurrence of this condition in individuals with a healthy immune system.

Clopidogrel responsiveness in stroke patients on a chronic aspirin regimen.

This study evaluated the antiplatelet effects of clopidogrel (CPG) in patients sustaining acute ischemic stroke who were already receiving chronic outpatient aspirin therapy (81-325 mg/day). Platelet function was measured using 3 different "point-of-care" platelet function analyzers: the Thrombelastograph hemostasis system, the Accumetrics VerifyNow system, and the Chronolog 570VS impedance aggregometer. Platelet function was assessed before administration of a 300-mg CPG loading dose and again at 26 hours and 64 hours after this loading dose along with a 75-mg daily maintenance dose. All 3 instruments detected marked inhibition of platelet function at 26 hours and 64 hours after CPG administration. There were significant variations among the 3 instruments in monitoring antiplatelet responses to aspirin and CPG; however, these variations were eliminated when the platelet function results were corrected for baseline platelet variability. The percentage of patients who were poor responders to CPG after switching from aspirin depended on the measurement instrument used, but was higher at 26 hours after CPG administration than at 64 hours after CPG administration. Our findings indicate that poor response to antiplatelet agents in general, and to CPG in particular, is a function of the measuring instrument. The correction for baseline platelet variability results in similar levels of platelet inhibition measured by the 3 platelet function analyzers. Future studies are warranted to examine the association between ex vivo CPG-induced platelet inhibition and clinical outcomes in patients with ischemic stroke.

Sugar Swing After Surgery: Hyperinsulinemic Hypoglycemia With Possible Nesidioblastosis After Roux-en-Y Gastric Bypass Surgery.

Bariatric surgery is a procedure performed to achieve weight loss and manage obesity. However, it can result in various complications including post-surgical hypoglycemia. Nesidioblastosis is a rare hypoglycemic syndrome marked by diffuse hyperplasia of pancreatic ß cells with distinct histologic features. Recent case reports have indicated an association of nesidioblastosis with certain bariatric procedures, often specifically linked to Roux-en-Y gastric bypass (RYGB) surgery. In this case report, we describe a 78-year-old male with a complex medical history who presented with altered mental status and severe hypoglycemia (13 mg/dL), despite having no history of diabetes or use of hypoglycemic medications. The patient's clinical condition improved after receiving a 50% intravenous dextrose injection and subsequently placed on a 10% dextrose infusion. Adrenal insufficiency was ruled out with normal cortisol level, and tests for ß-hydroxybutyrate, dehydroepiandrosterone (DHEA) sulfate, and hypoglycemia panels were all negative. However, further investigations were significant for elevated serum insulin, C-peptide, and proinsulin levels. The patient then underwent an abdominal computed tomography (CT) scan, which revealed a grossly normal liver, spleen, pancreas, and adrenal glands, along with evidence of prior gastric bypass surgery. Further evaluation confirmed a history of Roux-en-Y gastric bypass surgery, which was performed to address morbid obesity and obstructive sleep apnea. Following the procedure, the patient began experiencing hypoglycemic episodes. Subsequently, the patient was diagnosed with hyperinsulinemic hypoglycemia with possible nesidioblastosis. This diagnosis was made based on severe recurrent postprandial hypoglycemia, accompanied by elevated endogenous insulin production, and a pancreas that appeared grossly normal on imaging. The patient was treated with acarbose to prevent carbohydrate-driven blood sugar and insulin spikes, octreotide to inhibit insulin secretion, and dietary guidance to avoid high glycemic index foods. This case emphasizes the potential link between bariatric surgeries and metabolic disturbances, underscoring the importance of identifying uncommon hypoglycemic syndromes.

Blood pressure management and evolution of thrombolysis-associated intracerebral hemorrhage in acute ischemic stroke.

BACKGROUND: There is limited knowledge on the radiographic features of thrombolysis-induced hemorrhage. The factors that influence early hematoma expansion have not been elucidated. METHODS: Patients presenting with a symptomatic intracerebral hemorrhage (ICH) as a result of intravenous (IV) thrombolysis with tissue plasminogen activator (tPA) for acute ischemic stroke and had noncontrast computed tomographic (CT) scans of the head were included in this retrospective study. Calculation of hematoma volumes was obtained. Analysis of covariance was used to evaluate for the effect of baseline blood pressure (BP) on initial hematoma volume and further growth. RESULTS: Of 267 patients who were treated with intravenous tPA for acute ischemic stroke at our facility between January 1, 2005 and December 31, 2009, 17 patients developed symptomatic ICH and were included in the final analysis. There was a positive correlation between baseline level of systolic BP after thrombolysis and initial hematoma volume (r = 0.46; P = .03) but not for the diastolic BP (r = 0.07; P = .40). There was a significant increase in mean hematoma volume expansion when comparing results between the first and second CT scans (median 9 hours, 22 minutes; 14.9 ± 19.6 cm(3) to 26.0 ± 26.7 cm(3); P = .04). There was also a negative association between the reduction of systolic BP and hematoma growth (r = -0.67; P = .02), but no correlation with change in diastolic BP (r = -0.22; P = .28). CONCLUSIONS: Once diagnosed, thrombolysis-induced symptomatic ICH undergoes significant early expansion in size. Systolic BP may play a role in hematoma expansion.

Serum lipid profiles are associated with disability and MRI outcomes in multiple sclerosis.

BACKGROUND: The breakdown of the blood-brain-barrier vascular endothelium is critical for entry of immune cells into the MS brain. Vascular co-morbidities are associated with increased risk of progression. Dyslipidemia, elevated LDL and reduced HDL may increase progression by activating inflammatory processes at the vascular endothelium. OBJECTIVE: To assess the associations of serum lipid profile variables (triglycerides, high and low density lipoproteins (HDL, LDL) and total cholesterol) with disability and MRI measures in multiple sclerosis (MS). METHODS: This study included 492 MS patients (age: 47.1 ± 10.8 years; disease duration: 12.8 ± 10.1 years) with baseline and follow-up Expanded Disability Status Score (EDSS) assessments after a mean period of 2.2 ± 1.0 years. The associations of baseline lipid profile variables with disability changes were assessed. Quantitative MRI findings at baseline were available for 210 patients. RESULTS: EDSS worsening was associated with higher baseline LDL (p = 0.006) and total cholesterol (p = 0.001, 0.008) levels, with trends for higher triglyceride (p = 0.025); HDL was not associated. A similar pattern was found for MSSS worsening. Higher HDL levels (p < 0.001) were associated with lower contrast-enhancing lesion volume. Higher total cholesterol was associated with a trend for lower brain parenchymal fraction (p = 0.033). CONCLUSIONS: Serum lipid profile has modest effects on disease progression in MS. Worsening disability is associated with higher levels of LDL, total cholesterol and triglycerides. Higher HDL is associated with lower levels of acute inflammatory activity.

Acquired localized cutis laxa of the face: a rare presentation.

We report a rare case of acquired localized cutis laxa in a teenage boy, without any preceding skin lesions. The area affected was the midface, extending to the chin, and involving the ears, leading to a prematurely aged appearance. Only five such cases have been previously published in the literature.

Corrigendum to "Gender and Ethnicity Based Differences in Clinical and Laboratory Features of Myasthenia Gravis".

[This corrects the article DOI: 10.1155/2015/197893.].

Presenting Symptoms and Disease Severity in Multiple Sclerosis Patients.

INTRODUCTION: The study aims to determine an association between presenting symptoms in multiple sclerosis and measures of disease severity, including the expanded disability status score (EDSS) and MRI based lesion volumes. METHODS: Data was collected as part of a larger 3 year MS study, from 2014 to 2017, to compare Vitamin A levels and MS progression. All data was collected from a single clinical site. Demographic data as well as date of diagnosis and use of disease modifying therapies. Patients not able to obtain MRIs or lab tests and histories of vitamin abnormalities were excluded from the study. 29 patients met inclusion criteria. We chose presenting symptoms of vision, balance, sensory function, and motor function as these represented the most common manifestations of the disease and mirror the domains of the EDSS, which is the most commonly used scale for MS disease severity. We also included neuroimaging based lesion volume as another objective measure for comparison. RESULTS: Although duration of disease was different between comparator groups, no significant difference was found between them when EDSS and lesion volumes were compared. There was a difference in lesion volumes when comparing those patients that had presenting symptoms of visual changes or balance symptoms with those presenting with sensory changes. CONCLUSIONS: This study supports the notion that presenting symptoms are not associated with EDSS independent disease duration. It also verifies that severity of disease is not associated with lesion volumes. However, sensory symptoms as a presenting symptom was associated with less lesion volumes in our study.

Laboratory factors associated with symptomatic hemorrhagic conversion of acute stroke after systemic thrombolysis.

BACKGROUND: Laboratory factors associated with hemorrhagic conversion (HC) after Intravenous thrombolysis with rtPA (IVT) for Acute Ischemic Stroke (AIS) remain nebulous despite advances in our knowledge of AIS. This study aimed to investigate the laboratory factors predisposing to HC in AIS patients receiving IVT. METHODS: We retrospectively reviewed the medical records of patients who received IV tPA for AIS at our comprehensive stroke center over a 9.6-year period. Besides age, gender, NIHSS, history of diabetes mellitus (DM), history of atrial fibrillation (Afib), we gathered their laboratory data including International Normalized Ratio (INR), lipid panel, serum albumin, serum creatinine, hemoglobin A1c (HbA1c), and admission blood glucose. Post-thrombolysis brain imagings were reviewed to evaluate for symptomatic ICH (sICH). The mean values of above mentioned laboratory data were compared between the group with sICH and patients with no sICH. Univariate and multivariate logistic regression were performed to evaluate the association of the laboratory findings with presence of sICH. sICH was defined as ICH causing an increase in NIHSS ≥4. RESULTS: Of the 794 subjects in this study 51 (6.4%) had sICH. In the univariate analysis, patients who developed sICH had significantly higher NIHSS on admission (14.2 ± 5.4 vs 11.2 ± 6.5, p < .001), LDL-cholesterol (113.3 mg/dl ±36.9 vs. 101.8 mg/dl ± 38.2, p = .032), HbA1c (6.9% ± 2.3 vs. 6.1 ± 1.3, p = .003) and lower levels of Albumin (3.5 g/dl ±0.4 vs. 3.9 g/dl ± 0.5, p < .001). Furthermore, a higher prevalence of history of DM (45% vs. 21.6%, p = .020) and Afib (25.4% vs. 10.4%, p = .028) was found in subjects who developed sICH. There were no significant group differences regarding age, sex, total cholesterol, blood glucose on admission, serum creatinine or INR levels (p > .05). After adjusting for multiple covariates, lower Albumin level and and higher HbA1c were significantly associated with an increased risk for sICH development (p < .05). Chances of sICH increased by 33% for every 1 g/dl below a normal albumin level of 4.0 g/dl (p < .05). CONCLUSION: Lower endogenous albumin level and higher HbA1c have shown to predispose to a higher risk of sICH after IVT for AIS and might be good predictors of sICH post IVT.

Effect of a Coordinated Community and Chronic Care Model Team Intervention vs Usual Care on Systolic Blood Pressure in Patients With Stroke or Transient Ischemic Attack: The SUCCEED Randomized Clinical Trial.

Importance: Few stroke survivors meet recommended cardiovascular goals, particularly among racial/ethnic minority populations, such as Black or Hispanic individuals, or socioeconomically disadvantaged populations. Objective: To determine if a chronic care model-based, community health worker (CHW), advanced practice clinician (APC; including nurse practitioners or physician assistants), and physician team intervention improves risk factor control after stroke in a safety-net setting (ie, health care setting where all individuals receive care, regardless of health insurance status or ability to pay). Design, Setting, and Participants: This randomized clinical trial included participants recruited from 5 hospitals serving low-income populations in Los Angeles County, California, as part of the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) clinical trial. Inclusion criteria were age 40 years or older; experience of ischemic or hemorrhagic stroke or transient ischemic attack (TIA) no more than 90 days prior; systolic blood pressure (BP) of 130 mm Hg or greater or 120 to 130 mm Hg with history of hypertension or using hypertensive medications; and English or Spanish language proficiency. The exclusion criterion was inability to consent. Among 887 individuals screened for eligibility, 542 individuals were eligible, and 487 individuals were enrolled and randomized, stratified by stroke type (ischemic or TIA vs hemorrhagic), language (English vs Spanish), and site to usual care vs intervention in a 1:1 fashion. The study was conducted from February 2014 to September 2018, and data were analyzed from October 2018 to November 2020. Interventions: Participants randomized to intervention were offered a multimodal coordinated care intervention, including hypothesized core components (ie, ≥3 APC clinic visits, ≥3 CHW home visits, and Chronic Disease Self-Management Program workshops), and additional telephone visits, protocol-driven risk factor management, culturally and linguistically tailored education materials, and self-management tools. Participants randomized to the control group received usual care, which varied by site but frequently included a free BP monitor, self-management tools, and linguistically tailored information materials. Main Outcomes and Measures: The primary outcome was change in systolic BP at 12 months. Secondary outcomes were non-high density lipoprotein cholesterol, hemoglobin A1c, and C-reactive protein (CRP) levels, body mass index, antithrombotic adherence, physical activity level, diet, and smoking status at 12 months. Potential mediators assessed included access to care, health and stroke literacy, self-efficacy, perceptions of care, and BP monitor use. Results: Among 487 participants included, the mean (SD) age was 57.1 (8.9) years; 317 (65.1%) were men, and 347 participants (71.3%) were Hispanic, 87 participants (18.3%) were Black, and 30 participants (6.3%) were Asian. A total of 246 participants were randomized to usual care, and 241 participants were randomized to the intervention. Mean (SD) systolic BP improved from 143 (17) mm Hg at baseline to 133 (20) mm Hg at 12 months in the intervention group and from 146 (19) mm Hg at baseline to 137 (22) mm Hg at 12 months in the usual care group, with no significant differences in the change between groups. Compared with the control group, participants in the intervention group had greater improvements in self-reported salt intake (difference, 15.4 [95% CI, 4.4 to 26.0]; P = .004) and serum CRP level (difference in log CRP, -0.4 [95% CI, -0.7 to -0.1] mg/dL; P = .003); there were no differences in other secondary outcomes. Although 216 participants (89.6%) in the intervention group received some of the 3 core components, only 35 participants (14.5%) received the intended full dose. Conclusions and Relevance: This randomized clinical trial of a complex multilevel, multimodal intervention did not find vascular risk factor improvements beyond that of usual care; however, further studies may consider testing the SUCCEED intervention with modifications to enhance implementation and participant engagement. Trial Registration: ClinicalTrials.gov Identifier: NCT01763203.

Langerhans cell histiocytosis presenting as hypopigmented papules.

A 1(1/2)-year-old boy with Langerhans cell histiocytosis presented with a frontal bone mass showing features of eosinophilic granuloma. He subsequently developed multiple asymptomatic discrete hypopigmented papules on the face, trunk and extremities, which, on histology, were confirmed as Langerhans cell histiocytosis, a presentation hitherto unreported in literature. He responded well to surgery and chemotherapy.

Dysphagia and Tongue Deviation: A Rare Case of Collett-Sicard Syndrome after Blunt Head Trauma.

The jugular foramen and the hypoglossal canal are both apertures located at the base of the skull. Multiple lower cranial nerve palsies tend to occur with injuries to these structures. The pattern of injuries tend to correlate with the combination of nerves damaged. Case Report: A 28-year-old male was involved in an AVP injury while crossing the highway. Exam showed a GCS of 15 AAOx3, with dysphagia, tongue deviation to the right, uvula deviation to the left and a depressed palate. Initial imaging showed B/L frontal traumatic Sub-Arachnoid Hemorrhages (tSAH), Left Frontal Epidural Hematoma and a Basilar Skull Fracture. On second look by a trained Neuroradiologist c At 3 month follow up, patient's tongue normalized to midline and his dysphagia resolved. Discussion: Collette-Sicard syndrome is a rare condition/syndrome characterized by unilateral palsy of CN: IX, X, XII. This condition has been rarely described as a consequence of blunt head trauma. In most cases, the condition is self-limiting with patients regaining most to all of their neurological functions within 6 months. Nerve traction injuries and soft tissue edema compressing the cranial nerves are the leading two hypothesis. In conclusion, injuries with focal neurological deficits which were not apparent on initial imaging should be reviewed by relevant experts with concomitant knowledge of the patient's history.