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Castro P, Ferreira J, Malojcic B, Bazadona D, Baracchini C, Pieroni A, Skoloudik D, Azevedo E, Kaps M. Detection of microemboli in patients with acute ischaemic stroke and atrial fibrillation suggests poor functional outcome. Eur Stroke J 2024; 9:409-417. [PMID: 38149620 DOI: 10.1177/23969873231220508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
INTRODUCTION We investigated the burden of microembolic signals (MES) in patients with acute ischaemic stroke (AIS) and atrial fibrillation (AF), assessing their impact on functional outcomes. PATIENTS AND METHODS This multicentre international prospective cohort study involved patients with AIS and either a known or newly diagnosed anticoagulant-naïve AF. All centres utilised the same transcranial Doppler machine for 1-h monitoring with bilateral 2 MHz probes within 24 h of symptom onset. Recordings underwent MES analysis by a blinded central reader. The primary objectives were to ascertain the MES proportion and its association with functional outcomes assessed by the modified Rankin scale (mRS) score at 90 days. RESULTS Between September 2019 and May 2021, we enrolled 61 patients, with a median age of 78 years (interquartile range 73-83) and a median stroke severity score of 11 (interquartile range 4-18). MES were observed in 14 patients (23%), predominantly unilateral (12/14, 86%), with a median rate of 6 counts/hour (interquartile range 4-18). MES occurrence was higher post-thrombectomy and among those with elevated brain natriuretic peptide levels (p < 0.05). A worse mRS score of 3-6 was more frequent in patients with MES, occurring in 11/14 (79%), compared to those without MES, 20/47 (43%), with an adjusted odds ratio of 5.04 (95% CI, 1.15-39.4), p = 0.04. CONCLUSIONS Nearly a quarter of patients with AIS and AF exhibited silent microembolization after the index event. Detecting MES within 24 h post-stroke (using transcranial Doppler) could signify a marker of poor functional outcomes. Subsequent trials will assess if very early antithrombotic treatment might enhance outcomes in this highly selective group of cardioembolic stroke patients. (Clinicaltrials.gov ID: NCT06018090).
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Mausbach S, van Spankeren T, Hudel H, Schirotzik I, Viard M, Struffert T, Kaps M. TCCD Fusion Imaging to Estimate Intracranial Pressure and Tissue Displacement with Large Hemispheric Infarction. Neurocrit Care 2024; 40:562-567. [PMID: 37415022 DOI: 10.1007/s12028-023-01784-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/12/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Despite breakthroughs in stroke treatment, some patients still experience large infarctions of the cerebral hemispheres resulting in mass effect and tissue displacement. The evolution of mass effect is currently monitored using serial computed tomography (CT) imaging. However, there are patients who are ineligible for transport, and there are limited options for bedside monitoring of unilateral tissue shift. METHODS We used fusion imaging for overlaying transcranial color duplex with CT angiography. This method allows overlay of live ultrasound on top of CT or magnetic resonance imaging scans. Patients with large hemispheric infarctions were eligible to participate. Position data from the source files were used and matched with live imaging and correlation to magnetic probes on the patient's forehead and ultrasound probe. Shift of cerebral parenchyma, displacement of the anterior cerebral arteries, basilary artery and third ventricle were analyzed, as well as pressure on the midbrain, and the displacement of the basilar artery on the head were analyzed. Patients received multiple examinations in addition to standard care of treatment with CT imaging. RESULTS The sensitivity for diagnosing a shift of 3 mm with fusion imaging was 100%, with a specificity of 95%. No side effects or interactions with critical care equipment were recorded. CONCLUSIONS Fusion imaging is an easy method to access and acquire measurements for critical care patients and follow-up of tissue and vascular displacement after stroke. Fusion imaging may be a decisive support for indicating hemicraniectomy.
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Okada C, Kaps M, Walter I, Gautier C, Aurich J, Aurich C. 84 Low plasma progestogen concentration during the early luteal phase delays endometrial development and the beginning of placentation in mares. Reprod Fertil Dev 2022. [DOI: 10.1071/rdv35n2ab84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Geraedts M, Ebbeler D, Timmesfeld N, Kaps M, Berger K, Misselwitz B, Günster C, Dröge P, Schneider M. Long-term outcomes of stroke unit care in older stroke patients: a retrospective cohort study. Age Ageing 2022; 51:6691374. [PMID: 36057988 DOI: 10.1093/ageing/afac197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND older patients are less frequently treated in stroke units (SUs). Clinicians do not seem convinced that older patients benefit from specialised treatment in SU similarly to younger patients. OBJECTIVE our study aimed to compare older patients' long-term outcomes with and without SU treatment. METHODS this study used routinely collected health data of 232,447 patients admitted to hospitals in Germany between 2007 and 2017 who were diagnosed with ischaemic stroke (ICD 10 I63). The sample included 29,885 patients aged ≥90 years. The outcomes analysed were 10-, 30- and 90-day, and 1-, 3- and 5-year mortality and the combinations of death or recurrence, inpatient treatment and increase in long-term care needs. Bivariate chi-square tests and multivariable logistic regression analyses were used, adjusting for the covariates age, sex, co-morbidity, long-term care needs before stroke and socioeconomic status of the patients' region of origin. RESULTS between 2007 and 2017, 57.1% of patients aged <90 years and 49.6% of those aged ≥90 years were treated in a SU. The 1-year mortality rate of ≥90-year-olds was 56.9 and 61.9% with and without SU treatment, respectively. The multivariable-adjusted risk of death in ≥90-year-olds with SU treatment was odds ratio (OR) = 0.67 (95% confidence interval [CI] = 0.62-0.73) 10 days after the initial event and OR = 0.76 (95% CI = 0.71-0.82) 3 years after stroke. CONCLUSIONS even very old patients with stroke benefit from SU treatment in the short and long term. Therefore, SU treatment should be the norm even in older patients.
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Valaikiene J, Schlachetzki F, Azevedo E, Kaps M, Lochner P, Katsanos AH, Walter U, Baracchini C, Bartels E, Školoudík D. Point-of-Care Ultrasound in Neurology - Report of the EAN SPN/ESNCH/ERcNsono Neuro-POCUS Working Group. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:354-366. [PMID: 35512836 DOI: 10.1055/a-1816-8548] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In the last decade, ultrasound examination in neurology has been undergoing a significant expansion of its modalities. In parallel, there is an increasing demand for rapid and high-quality diagnostics in various acute diseases in the prehospital setting, the emergency room, intensive care unit, and during surgical or interventional procedures. Due to the growing need for rapid answers to clinical questions, there is particular demand for diagnostic ultrasound imaging. The Neuro-POCUS working group, a joint project by the European Academy of Neurology Scientific Panel Neurosonology, the European Society of Neurosonology and Cerebral Hemodynamics, and the European Reference Centers in Neurosonology (EAN SPN/ESNCH/ERcNsono Neuro-POCUS working group), was given the task of creating a concept for point-of-care ultrasound in neurology called "Neuro-POCUS". We introduce here a new ultrasound examination concept called point-of-care ultrasound in neurology (Neuro-POCUS) designed to streamline conclusive imaging outside of the ultrasound center, directly at the bedside. The aim of this study is to encourage neurologists to add quick and disease-oriented Neuro-POCUS to accompany the patient in the critical phase as an adjunct not a substitution for computed tomography, magnetic resonance imaging, or standard comprehensive neurosonology examination. Another goal is to avoid unwanted complications during imaging-free periods, ultimately resulting in advantages for the patient.
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Kaps M, Lutzer A, Gautier C, Nagel C, Aurich J, Aurich C. Altrenogest treatment reduces the stress response of three-year-old warmblood mares during their initial equestrian training. Domest Anim Endocrinol 2022; 80:106728. [PMID: 35421809 DOI: 10.1016/j.domaniend.2022.106728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/13/2022] [Accepted: 03/16/2022] [Indexed: 11/25/2022]
Abstract
Horse mares are frequently treated with the progestin altrenogest with the aim to suppress estrous behavior and its negative impact on equestrian performance. Progestogens, however, also have sedative effects in males, and females of different species. The aim of our study was therefore to investigate altrenogest-induced changes in the stress response of female horses during initial equestrian training. Three-yr-old Warmblood mares were randomly assigned to treatment with altrenogest (ALT; 0.044 mg/kg once daily; n = 6) or sunflower oil (CON; n = 5) for 12 wk during training. At predefined steps of the training program (free movement, lunging without and with side reins, lunging with saddle, mounting of a rider, free riding, riding by an unfamiliar rider) salivary cortisol concentration, and heart rate were determined from 60 min before to 120 min after training. The same procedures were performed during repeated gynecologic examinations and 2 novel object tests. Bodyweight and body condition scores (BCS) were assessed at 4-wk intervals. During all training units, salivary cortisol concentration and heart rate increased (P < 0.001), but the increase was smaller in group ALT mares (time x treatment P < 0.001). Gynecologic examinations and novel object tests induced a much smaller increase in cortisol and heart rate (P < 0.001) than equestrian training with no difference between groups ALT and CON. Initially, bodyweight, and BCS decreased during training. The subsequent increase was larger in group ALT vs CON (time x treatment P < 0.05). In conclusion, altrenogest reduced the stress response of 3-yr-old mares to equestrian training. The use of altrenogest during equestrian competitions should therefore be reconsidered.
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Kaps M, Okada CTC, Gautier CM, Aurich J, Aurich C. Increased AMH plasma concentration and small antral follicles - Deslorelin slow release implants as a promising tool for preparation of mares for OPU? J Equine Vet Sci 2022. [DOI: 10.1016/j.jevs.2022.103972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Ebbeler D, Schneider M, Busse O, Berger K, Dröge P, Günster C, Kaps M, Misselwitz B, Timmesfeld N, Geraedts M. Spezialisierung der Schlaganfallversorgung in Deutschland:
Strukturveränderungen im Zeitraum von 2006–2017. DAS GESUNDHEITSWESEN 2021; 85:242-249. [PMID: 34942663 DOI: 10.1055/a-1690-6786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Zusammenfassung
Hintergrund Um die Schlaganfallversorgung zu optimieren, wurden in
Deutschland in den letzten Jahren verschiedene
qualitätsfördernde Maßnahmen (qfM) in regional
unterschiedlichem Maß eingeführt. Ob sich diese
Maßnahmen über die Jahre flächendeckend etabliert
haben, ist unklar.
Methode Für die strukturbezogenen Analysen der Schlaganfallversorgung
in Deutschland wurden alle relevanten dokumentierten Schlaganfälle
(ICD-10) aus den Qualitätsberichten (QB) deutscher
Krankenhäuser und eine repräsentative Stichprobe von
Krankenversicherungsdaten (AOK) im Zeitraum von 2006 (QB)/2007 (AOK)
bis 2017 verwendet. Diese Informationen wurden u. a. durch Angaben
zu zertifizierten Stroke Units der Deutschen Schlaganfall-Gesellschaft (DSG)
und Daten zur Führung von regionalen Schlaganfall-Registern der
Arbeitsgemeinschaft Deutschsprachiger Schlaganfall-Register (ADSR)
ergänzt. Zur Verfolgung der Veränderungen des
Versor-gungsgeschehens im deutschen Bundesgebiet wurden die Daten mit
geografischen Daten (Bundesamt für Kartographie und
Geodäsie) verknüpft. Es erfolgten univariate Analysen der
Daten und eine Trend-Analyse der verschiedenen qfM im Jahresverlauf
(Konkordanzkoeffizient nach Kendall).
Ergebnisse Die QB Analysen zeigten einen Anstieg kodierter
Schlaganfälle in Krankenhäusern mit qfM um
14–20%. In 2006 wurden 80% der Schlaganfälle
(QB) in einem Krankenhaus mit min. einer qfM kodiert, in 2017 95%.
Diese Entwicklungen spiegelten sich auch in den AOK-Routinedaten wider,
wobei in 2007 89% und in 2017 97% der Patient:innen unter
mindestens einer qfM behandelt wurden. Dabei waren in 2007 bei 55%
der behandelnden Krankenhäuser qfM vorhanden, in 2017 bei
72%.
Schlussfolgerung Patient:innen werden inzwischen signifikant häufiger
in Krankenhäusern mit Spezialisierung auf die Schlaganfallversorgung
behandelt. Auch die verschiedenen qfM haben sich im Laufe der Jahre im
gesamten Bundesgebet verbreitet, jedoch existieren noch
Versorgungslücken, die geschlossen werden sollten, damit in Zukunft
alle Patient:innen qualitativ hochwertig behandelt werden
können.
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Geraedts M, Ebbeler D, Timmesfeld N, Kaps M, Berger K, Misselwitz B, Günster C, Dröge P, Schneider M. Quality Assurance Measures and Mortality After Stroke. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:857-863. [PMID: 34730084 PMCID: PMC8948340 DOI: 10.3238/arztebl.m2021.0339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/09/2021] [Accepted: 07/20/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Quality assurance for acute in-hospital care in Germany is based on compulsory comparisons between institutions, so-called external quality assurance (EQA). The effectiveness of EQA has not yet been adequately studied. The purpose of the QUASCH project, which is supported by the Innovation Fund of the Federal Joint Committee, is to investigate the association between EQA and health care outcomes, specifically with respect to stroke. METHODS The analyses were based on data from 379 825 patients insured by the AOK health insurance fund who were acutely admitted to a hospital because of stroke over the period 2007-2017. Data on 47 659 patients were derived from EQA documentation in the state of Hesse, in which stroke EQA had already been introduced in 2003; data on the remaining 332 166 patients were from other federal states, where 117 734 of these patients had been treated under EQA conditions. The association of EQA with mortality over the period of observation was analyzed by multivariate Cox regression, with the following covariates: age, sex, comorbidities, time period of occurrence, nursing care level, type of stroke, socio-economic deprivation in the region of origin, and treatment in a stroke unit. RESULTS Compared to treatment without EQA, mortality risk under EQA in the state of Hesse was significantly lower (hazard ratio [HR]: 0.93; 95% confidence interval: [0.92; 0.95]). The reduction in mortality risk with EQA was somewhat lower in the other federal states (HR: 0.96 [0.95; 0.97]). Treatment in a stroke unit was associated with a mortality risk that was lower still (HR: 0.86 [0.85; 0.87]). Mortality risk rose with age, comorbidities, and need for nursing care; it was lower in women and in persons whose stroke occurred in a later period. CONCLUSION Quality assurance measures are associated with lower mortality risk after stroke. The concentration of care in specially qualified institutions is associated with stronger effects than EQA alone.
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Bulinski C, Viard M, Vlazak A, Habig K, Juenemann M, Best C, Schirotzek I, Kaps M, Krämer HH. Neuromuscular sonography detects changes in muscle echotexture and nerve diameter in ICU patients within 24 h. J Ultrasound 2021; 25:535-545. [PMID: 34870825 PMCID: PMC9402876 DOI: 10.1007/s40477-021-00621-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/25/2021] [Indexed: 11/03/2022] Open
Abstract
Purpose During an ICU stay, changes in muscles and nerves occur that is accessible via neuromuscular sonography. Methods 17 patients recruited from the neurological and neurosurgical ICU (six women; 66 ± 3 years) and 7 healthy controls (three women, 75 ± 3 years) were included. Muscle sonography (rectus abdominis, biceps, rectus femoris and tibialis anterior muscles) using gray-scale values (GSVs), and nerve ultrasound (peroneal, tibial and sural nerves) analyzing the cross-sectional area (CSA) were performed on days 1 (t1), 3 (t2), 5 (t3), 8 (t4), and 16 (t5) after admission. Results Time course analysis revealed that GSVs were significantly higher within the patient group for all of the investigated muscles (rectus abdominis: F = 7.536; p = 0.011; biceps: F = 14.761; p = 0.001; rectus femoris: F = 9.455; p = 0.005; tibialis anterior: F = 7.282; p = 0.012). The higher GSVs were already visible at t1 or, at the latest, at t2 (tibialis anterior muscles). CSA was enlarged in all of the investigated nerves in the patient group (peroneal nerve: F = 7.129; p = 0.014; tibial nerve: F = 28.976, p < 0.001; sural nerve: F = 13.051; p = 0.001). The changes were visible very early (tibial nerve: t1; peroneal nerve: t2). The CSA of the motor nerves showed an association with the ventilation time and days within the ICU (t1 through t4; p < 0.05). Discussion We detected very early changes in the muscles and nerves of ICU-patients. Nerve CSA might be a useful parameter to identify patients who are at risk for difficult weaning. Therefore our observations might be severity signs of neuromuscular suffering for the most severe patients.
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Braun T, Sünner L, Hachenberger M, Müller C, Wietelmann A, Juenemann M, Pons-Kühnemann J, Kaps M, Gerriets T, Tschernatsch M, Roth J, Yenigün M. Microbubble-mediated sonothrombolysis with BR38 of a venous full blood thrombus in a rat embolic stroke model. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1061. [PMID: 34422973 PMCID: PMC8339866 DOI: 10.21037/atm-21-75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/14/2021] [Indexed: 11/30/2022]
Abstract
Background Early recanalization of an occluded vessel is associated with a better clinical outcome in acute ischemic stroke. Intravenous thrombolysis using recombinant tissue plasminogen activator (rt-PA) is only available in a minority of patients and often fails to reopen the occluded vessel. Mechanical recanalization is more effective in this matter but only available for selected patients when a thrombectomy centre can be reached. Therefore, sonothrombolysis might represent an alternative or complementary approach. Here, we tested microbubble-mediated sonothrombolysis (mmSTL) in a thromboembolic stroke model for middle cerebral artery occlusion (MCAO) in rats. Methods Sixty-seven male Wistar rats underwent MCAO using an autologous full blood thrombus and were randomly assigned to four groups receiving rt-PA, mmSTL, a combination of both, or a placebo. Diagnostic workup included neurological examination, assessment of infarct size, and presence of intracerebral haemorrhage by magnetic resonance imaging (MRI) and presence of microbleedings in histological staining. Results Neurological examination revealed no differences between the treatment groups. In all treatment groups, there was a reduction in infarct size 24 hours after MCAO as compared to the placebo (P≤0.05), but there were no differences between the active treatment groups (P>0.05) (placebo 0.75±0.10 cm3; mmSTL 0.43±0.07 cm3; rt-PA 0.4±0.07 cm3; mmSTL + rt-PA 0.27±0.08 cm3). Histological staining displayed intracerebral microbleedings in all animals. The frequency of gross bleeding detected by MRI did not differ between the groups (placebo 3; mmSTL 4; rt-PA 2; mmSTL + rt-PA 2; P>0.05) and was not associated with worse performance in clinical testing (P>0.05). There were no statistical differences in the mortality between the groups (P>0.05). Conclusions Our study showed the efficacy and safety of mmSTL with or without rt-PA in an embolic rat stroke model using a continuous full blood thrombus. Sonothrombolysis might be useful for patients who need to be transported to a thrombectomy centre or for those with distal vessel occlusion.
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Boss EG, Bohmann FO, Misselwitz B, Kaps M, Neumann-Haefelin T, Pfeilschifter W, Kurka N. Quality assurance data for regional drip-and-ship strategies- gearing up the transfer process. Neurol Res Pract 2021; 3:38. [PMID: 34334134 PMCID: PMC8327429 DOI: 10.1186/s42466-021-00136-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stroke patients with large vessel occlusion (LVO) require endovascular therapy (EVT) provided by comprehensive stroke centers (CSC). One strategy to achieve fast stroke symptom 'onset to treatment' times (OTT) is the preclinical selection of patients with severe stroke for direct transport to CSC. Another is the optimization of interhospital transfer workflow. Our aim was to investigate the dynamics of the OTT of 'drip-and-ship' patients as well as the current 'door-in-door-out' time (DIDO) and its determinants at representative regional German stroke units. METHODS We determined the numbers of all EVT treatments, 'drip-and-ship' and 'direct-to-center' patients and their median OTT from the mandatory quality assurance registry of the federal state of Hesse, Germany (2012-2019). Additionally, we captured process time stamps from primary stroke centers (PSC) in a consecutive registry of patients referred for EVT in our regional stroke network over a 3 months period. RESULTS Along with an increase of the EVT rate, the proportion of drip-and-ship patients grew steadily from 19.4% in 2012 to 31.3% in 2019. The time discrepancy for the median OTT between 'drip-and-ship' and 'direct-to-center' patients continuously declined from 173 to 74 min. The largest share of the DIDO (median 92, IQR 69-110) is spent with the organization of EVT and consecutive patient transfer. CONCLUSIONS 'Drip-and-ship' patients are an important and growing proportion of stroke patients undergoing EVT. The discrepancy in OTT for EVT between 'drip-and-ship' and 'direct-to-center' patients has been reduced considerably. Further optimization of the DIDO primarily aiming at the processes after the detection of LVO is urgently needed to improve stroke patient care.
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Schehadat MS, Scherer G, Groneberg DA, Kaps M, Bendels MHK. Outpatient care in acute and prehospital emergency medicine by emergency medical and patient transport service over a 10-year period: a retrospective study based on dispatch data from a German emergency medical dispatch centre (OFF-RESCUE). BMC Emerg Med 2021; 21:29. [PMID: 33750317 PMCID: PMC7941891 DOI: 10.1186/s12873-021-00424-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background The number of operations by the German emergency medical service almost doubled between 1994 and 2016. The associated expenses increased by 380% in a similar period. Operations with treatment on-site, which retrospectively proved to be misallocated (OFF-Missions), have a substantial proportion of the assignment of the emergency medical service (EMS). Besides OFF-Missions, operations with patient transport play a dominant role (named as ON-Missions). The aim of this study is to work out the medical and economic relevance of both operation types. Methods This analysis examined N = 819,780 missions of the EMS and patient transport service (PTS) in the catchment area of the emergency medical dispatch centre (EMDC) Bad Kreuznach over the period from 01/01/2007 to 12/31/2016 in terms of triage and disposition, urban-rural distribution, duration of operations and economic relevance (p < .01). Results 53.4% of ON-Missions are triaged with the indication non-life-threatening patient transport; however, 63.7% are processed by the devices of the EMS. Within the OFF-Mission cohort, 78.2 and 85.8% are triaged or dispatched for the EMS. 74% of all ON-Missions are located in urban areas, 26% in rural areas; 81.3% of rural operations are performed by the EMS. 66% of OFF-Missions are in cities. 93.2% of the remaining 34% of operations in rural locations are also performed by the EMS. The odds for both ON- and OFF-Missions in rural areas are significantly higher than for PTS (ORON 3.6, 95% CI 3.21–3.30; OROFF 3.18, 95% CI 3.04–3.32). OFF-Missions last 47.2 min (SD 42.3; CI 46.9–47.4), while ON-Missions are processed after 79.7 min on average (SD 47.6; CI 79.6–79.9). ON-Missions generated a turnover of more than € 114 million, while OFF-Missions made a loss of almost € 13 million. Conclusions This study particularly highlights the increasing utilization of emergency devices; especially in OFF-Missions, the resources of the EMS have a higher number of operations than PTS. OFF-Missions cause immensely high costs due to misallocations from an economic point of view. Appropriate patient management appears necessary from both medical and economic perspective, which requires multiple solution approaches.
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Braun T, Juenemann M, Viard M, Meyer M, Reuter I, Mausbach S, Doerr JM, Schirotzek I, Prosiegel M, Schramm P, Kaps M, Tanislav C. Flexible endoscopic evaluation of swallowing (FEES) to determine neurological intensive care patients' oral diet. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2021; 23:83-91. [PMID: 32245331 DOI: 10.1080/17549507.2020.1744727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE Dysphagia is common in critically ill neurological patients and is associated with a high mortality and morbidity. Data on the usefulness of flexible endoscopic examination of swallowing (FEES) in neurological intensive care unit (ICU) patients are lacking, raising the need for evaluation. METHOD FEES was performed in neurological intensive care patients suspected of dysphagia. We correlated findings with baseline data, disability status, pneumonia and duration of hospitalisation, as well as a need for mechanical ventilation or tracheotomy. RESULT This analysis consisted of 125 patients with suspected dysphagia. Most of the patients (81; 64,8%) suffered from acute stroke. Dysphagia was diagnosed using FEES in 90 patients (72%). FEES results led to dietary modifications in 80 patients (64%). The outcome at discharge was worse in dysphagic stroke patients diagnosed by FEES as compared to non-dysphagic stroke patients (p = 0.009). Patients without oral diet had higher need for intubation (p = 0.007), tracheotomy (p = 0.032) and higher mortality (p < 0.001) in comparison to patients with at least small amounts of oral intake. CONCLUSION As the clinical assessment of the patients often classified the dysphagia incorrectly, the broad use of FEES in ICU patients might help to adequately adjust patients' oral diet. This knowledge might contribute to lower mortality and morbidity.
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Kaps M, Okada CTC, Gautier C, Aurich J, Scarlet D, Kuhl J, Aurich C. Transient suppression of ovulatory ovarian function in pony mares after treatment with slow-release deslorelin implants. Domest Anim Endocrinol 2021; 74:106505. [PMID: 32846375 DOI: 10.1016/j.domaniend.2020.106505] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 11/16/2022]
Abstract
Behavior during the estrous cycle of mares can affect their performance and therefore inhibition of cyclical ovarian activity is indicated. We hypothesized that implants containing the GnRH analog deslorelin downregulate GnRH receptors and inhibit ovulation in mares. The estrous cycles of Shetland mares were synchronized with 2 injections of a PGF2α analog. One day after the second injection (day 0), mares received 9.4 (group D1, n = 6) and 4.7 mg deslorelin (D2, n = 5) as slow-release implants or 1.25 mg short-acting deslorelin as a control (C, n = 5). Ultrasonography of the reproductive tract and ovaries and observation of estrous behavior and collection of blood samples for analysis of progesterone and LH concentrations were performed every second day until day 10 and thereafter at 5-d intervals. Stimulation tests with the GnRH-agonist buserelin were performed on days 10 and 45. Until day 50, there were less spontaneous ovulations in group D1 (P < 0.01) and estrous behavior was reduced in groups D1 and D2 compared with group C (P < 0.05). The time until first ovulation (D1 62.0 ± 8.6, D2 44.2 ± 14.1, C 22.2 ± 3.1 d, P < 0.05) and the number of days with estrous behavior (P < 0.05) differed among groups. On day 10 after treatment, a GnRH stimulation test revealed interactions between group and time (P < 0.001) in plasma LH concentration that were no longer detectable on day 45 after treatment. In conclusion, long-acting deslorelin implants result in a transient downregulation of pituitary GnRH receptors that is associated with inhibition of ovulation and estrous behavior in Shetland mares.
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Braun T, Juenemann M, Dornes K, El-Shazly J, Schramm P, Bick-Ackerschott S, Kaps M, Gerriets T, Blaes F, Tschernatsch M. BAFF serum and CSF levels in patients with multiple sclerosis and infectious nervous system diseases. Int J Neurosci 2020; 131:1231-1236. [PMID: 32602764 DOI: 10.1080/00207454.2020.1784167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose: Multiple sclerosis (MS) is the most common immune-mediated CNS disease, characterised by demyelination and progressive neurological disability. The B-cell activating factor BAFF has been described as one important factor in the pathophysiology of different autoimmune diseases.Methods: We measured BAFF levels in the serum and cerebrospinal fluid (CSF) in 50 consecutive patients with MS and 35 patients with infectious CNS disease (ID). 52 patients with other, non-inflammatory disorders (OND), served as controls.Results: BAFF-serum levels in ID patients were higher than in patients diagnosed with MS (ID 0.55 ± 0.24 ng/ml, MS 0.43 ± 0.14 ng/ml, OND 0.45 ± 0.24 ng/ml; p = 0.09). Interestingly, MS patients had lower BAFF CSF levels compared to the controls and ID patients, and the CSF levels in the latter were elevated compared to those of the controls (MS 0.17 ± 0.11 ng/ml, OND 0.25 ± 0.14 ng/ml, ID 0.97 ± 0.78 ng/ml; p < 0.001).Conclusions: The ID patients' having higher absolute BAFF levels in the CSF than in the serum indicates that the increased BAFF CSF levels were caused by intrathecal synthesis rather than passive transfer via a disturbed blood-brain-barrier. The significantly decreased BAFF CSF levels in MS patients were a surprising result of our study. Although it has been reported that astrocytes in active MS lesions can express BAFF, the soluble form was not increased in the CSF of MS patients. It remains unclear whether the inflammatory features of active MS plaques are truly represented by the CSF compartment.
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Hasseli R, Fürst MM, Singh P, Müller-Ladner U, Kaps M, Blaes F, Gerriets T, Tschernatsch M. AB0157 IGG FROM PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND SYSTEMIC SCLEROSIS HAVE AN INFLUENCE ON COAGULATION FACTORS IN HUMAN CEREBRAL MICROVASCULAR ENDOTHELIAL CELLS IN-VITRO. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.2631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Endothelial cells from the microvasculature (hBMEC) of the brain show significant morphological and functional differences compared to EC from other anatomical areas. They are characterized by tight junctions, are not fenestrated and show less active transport mechanisms. On the other hand, the mitochondrial density is relatively high in hBMEC due to the high cerebral glucose metabolism.It could be already observed that interferon-α from SLE-sera induces the expression of MHC class I molecules on human dermal microendothelial cell line, but it is not known whether this also occurs on hBMEC. hBMECs can synthesize pro-inflammatory cytokines and chemokines such as IL-1β, but in lower concentrations than human umbilical vein endothelial cells.Patients suffering from systemic lupus erythematosus (SLE) or systemic sclerosis (SSc) show a wide spectrum of central nervous symptoms. Both, SLE and SSc, are characterised by different autoantibodies and endothelial vascular damage, especially in microvessels. 10-40% of patients with SLE suffer from lupus vasculopathy. Vascular dysfunction is one of the earliest pathological changes in SSc. Anti-endothelial autoantibodies (AECA) appear in SLE as well as in SSc and other connective tissue diseases. Research within the last years revealed that AECA play a critical role within the vascular pathogenesis of SLE and SSc. So far there is no evidence that AECA bind to hBMEC and it is not clear whether they have an effect on this special endothelial class.Objectives:In this project, we investigated if autoantibodies against hBMEC are detectable in SLE and SSc patients and if they have an influence on the activation of the endothelium by inducing adhesion molecules and on haemostasis by inducing factors of the clotting cascade.Methods:HiTrap Protein G HP antibody purification columns were used to purify IgG antibodies. Flow cytometry was used for analysis of autoantibodies against human cerebral microvascular endothelial cell line (hCMEC/D3). 26 sera of patients with SLE and 29 sera of patients with SSc were tested for presence of autoantibodies against hCMEC/D3. To analyse in vitro effects on hCMEC/D3, we measured changes in the expression of the following surface proteins: ICAM-1, VCAM-1, MHC class I and II, tissue factor, von-Willebrand-Factor, E-Selectin, P-Selectin, Thrombomodulin, CD73 and t-PA, each before and after three- and 24-hours incubation with IgG-fractions. IgG fractions of 12 SLE patients, 13 SSc patients and 13 healthy control persons (HC) were tested.Results:Autoantibodies against hCMEC/D3 were found in 21 of 26 patients with SLE (81%) and in 19 of 29 patients with SSc (66%) (p > 0.05) but not in healthy donors. After three hours incubation of hCMEC/D3 IgG-fractions, an upregulation of tissue factor by SSc-IgG (6.7% ± 5.2%) compared to HC-IgG (1.1% ± 2.8%, p < 0.01) and to SLE-IgG (1.6% ± 3.9%, p < 0.05), was detectable.There was no significant correlation between changes in surface protein expression and detection of ANA or of anti-hCMEC/D3 antibodies (p > 0.05).No change in expression of ICAM-1, VCAM-1, MHC class I and II, von-Willebrand-Factor, E-Selectin, P-Selectin, Thrombomodulin, CD73 and t-PA could be detected after incubation with IgG-fractions.Conclusion:Both, patients with SLE and patients with SSc showed autoantibodies against hBMEC. IgG fractions of patients with SSc, but not with SLE, induced an upregulation of tissue factor on the cell surface of hCMEC/D3. This could be an indicator for a direct pathogenic effect of AECA on hBMEC and might have an influence on haemostasis by activating the clotting cascade. Inhibition of these antibodies could reduce cerebral involvement of SSc.References:[1]Weksler BB, Subileau EA, Perriere N, et al. Blood-brain barrier-specific properties of a human adult brain endothelial cell line. Faseb J 2005;19:1872-1874.Disclosure of Interests:Rebecca Hasseli: None declared, Magdalena Maria Fürst: None declared, Pratibha Singh: None declared, Ulf Müller-Ladner Speakers bureau: Biogen, Manfred Kaps: None declared, Franz Blaes: None declared, Tibo Gerriets: None declared, Marlene Tschernatsch: None declared
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Juenemann M, Braun T, Schleicher N, Yeniguen M, Schramm P, Gerriets T, Ritschel N, Bachmann G, Obert M, Schoenburg M, Kaps M, Tschernatsch M. Neuroprotective mechanisms of erythropoietin in a rat stroke model. Transl Neurosci 2020; 11:48-59. [PMID: 33312715 PMCID: PMC7702138 DOI: 10.1515/tnsci-2020-0008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 12/15/2019] [Accepted: 01/02/2020] [Indexed: 11/15/2022] Open
Abstract
Objective This study was designed to investigate the indirect neuroprotective properties of recombinant human erythropoietin (rhEPO) pretreatment in a rat model of transient middle cerebral artery occlusion (MCAO). Methods One hundred and ten male Wistar rats were randomly assigned to four groups receiving either 5,000 IU/kg rhEPO intravenously or saline 15 minutes prior to MCAO and bilateral craniectomy or sham craniectomy. Bilateral craniectomy aimed at elimination of the space-consuming effect of postischemic edema. Diagnostic workup included neurological examination, assessment of infarct size and cerebral edema by magnetic resonance imaging, wet–dry technique, and quantification of hemispheric and local cerebral blood flow (CBF) by flat-panel volumetric computed tomography. Results In the absence of craniectomy, EPO pretreatment led to a significant reduction in infarct volume (34.83 ± 9.84% vs. 25.28 ± 7.03%; p = 0.022) and midline shift (0.114 ± 0.023 cm vs. 0.083 ± 0.027 cm; p = 0.013). We observed a significant increase in regional CBF in cortical areas of the ischemic infarct (72.29 ± 24.00% vs. 105.53 ± 33.10%; p = 0.043) but not the whole hemispheres. Infarct size-independent parameters could not demonstrate a statistically significant reduction in cerebral edema with EPO treatment. Conclusions Single-dose pretreatment with rhEPO 5,000 IU/kg significantly reduces ischemic lesion volume and increases local CBF in penumbral areas of ischemia 24 h after transient MCAO in rats. Data suggest indirect neuroprotection from edema and the resultant pressure-reducing and blood flow-increasing effects mediated by EPO.
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Zöllner JP, Konczalla J, Stein M, Roth C, Krakow K, Kaps M, Steinmetz H, Rosenow F, Misselwitz B, Strzelczyk A. Acute symptomatic seizures in intracerebral and subarachnoid hemorrhage: A population study of 19,331 patients. Epilepsy Res 2020; 161:106286. [PMID: 32065924 DOI: 10.1016/j.eplepsyres.2020.106286] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 01/07/2020] [Accepted: 02/04/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Risk factors for acute symptomatic seizures after stroke demonstrated in retrospective analyses should be confirmed in large population studies. While seizures following ischemic stroke have been studied intensively, less is known about seizure predictors in hemorrhagic stroke. This study sought to identify risk factors of acute symptomatic seizures and to elucidate associated short-term (in-hospital) morbidity and mortality rates in primary intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). METHODS We determined the frequency of all acute symptomatic seizures perceived by clinical staff after hemorrhagic stroke in a large population-based registry in a central European region between 2004 and 2016. Further, we analyzed risk factors for seizure occurrence, morbidity, and mortality in univariate and multivariate analyses. RESULTS Of 297,120 stroke patients, 19,331 experienced a hemorrhagic stroke. Frequency of acute seizures (without semiological differentiation) in this subpopulation was 4% (4.0% in ICH and 3.6% in SAH). The risk for acute symptomatic seizures was significantly increased in both stroke types in the presence of an acute non-neurological infection (odds ratio: 2.0 for ICH and 4.2 for SAH). A lower premorbid functional level also significantly increased the seizure risk (odds ratio: 2.0 for ICH and 3.1 for SAH). The odds of in-hospital mortality in the presence of acute seizures were significantly reduced in ICH patients (odds ratio: 0.7) but not in SAH patients. CONCLUSION Acute symptomatic seizures are equally common in ICH and SAH patients in this registry. Seizure risk is invariably increased in the presence of acute non-neurological infection. Mortality is reduced in ICH patients with seizures, but the exact reason for this relationship is not clear and might represent a biased finding.
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Kaps M, Gautier C, Cardoso Okada C, Kuhl J, Aurich J, Aurich C. 157 Effect of a slow-release gonadotrophin-releasing hormone analogue on ovarian activity and oestrous behaviour in mares. Reprod Fertil Dev 2020. [DOI: 10.1071/rdv32n2ab157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Oestrus behaviour in mares can contribute to problems in their handleability and reduced performance in equestrian sports. Therefore, methods of transient suppression of oestrous cyclicity in mares are of interest. The aim of our study was to determine whether treatment of mares with slow-release implants containing the gonadotrophin-releasing hormone (GnRH) analogue deslorelin downregulates pituitary GnRH receptors and reduces ovarian function and oestrous behaviour. Shetland mares (age=11.0±1.4 years; bodyweight=185.5±7kg) were oestrous synchronised with two injections of the prostaglandin F2α analogue luprostiol (3.725mg) at an interval of 12 days. One day after the second injection (Day 0), mares were randomly assigned to three groups: slow-release implant with 9.4mg of deslorelin (Suprelorin, Virbac; group D1; n=6), implant with 4.7mg of deslorelin (group D2; n=5), and intramuscular injection of 1.25mg of short-acting deslorelin (control, group C; n=5). Collection of blood samples for analysis of progesterone, LH, and anti-Müllerian hormone (AMH) using established and validated enzyme immunoassays (Scarlet et al. 2018 Theriogenology 117, 72-77), testing for oestrus-like behaviour with a Shetland stallion, and ultrasonography of the genital tract were performed at 2-day intervals until Day 10 after treatment and at 5-day intervals from there. On Days 10 and 45 after treatment, LH stimulation tests with the GnRH agonist buserelin (4µg IV) were performed. Data were normally distributed; differences among groups were analysed using analysis of variance and subsequent Tukey test. Values are means±s.e.m. In all mares without a corpus luteum on Day 0 (progesterone <1ngmL−1; one mare in group D1 and two in group C), ovulation was detected within 9 days after deslorelin treatment. These ovulations were classified as deslorelin induced, whereas ovulations after Day 10 were classified as spontaneous ovulations. The mean interval from deslorelin until the first spontaneous ovulation was 62.0±8.6, 44.2±14.1, and 22.2±3.1 days in groups D1, D2, and C (P<0.05), respectively. Subsequent oestrous cycles were regular. Oestrus-like behaviour until day 50 was reduced in groups D1 (2.0±0.9 days) and D2 (2.4±1.3 days) compared with group C (6.4±1.2 days; P<0.05). Concentration of plasma LH and AMH decreased in group D1 (P<0.05) but not in groups D2 and C. The GnRH stimulation test on Day 10 resulted in an increase (P<0.001) in plasma LH concentration in group C but not in groups D1 and D2 (treatment×time P<0.05). On Day 45, LH concentration increased in all mares in response to buserelin (NS among groups). Within 100 days of treatment, LH concentrations but not AMH concentrations in mares of group D1 returned to baseline. In conclusion, deslorelin slow-release implants transiently suppress ovarian function and oestrus behaviour in mares. Spontaneous ovulation is delayed in a dose-dependent manner. A decrease in AMH concentration suggests inhibitory effects of deslorelin on small antral follicles. Long-term effects on follicular dynamics and fertility in larger horses also need to be assessed.
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Okada C, Kaps M, Handschuh S, Scarlet D, Aurich C. 61 Low plasma progestin concentration during the early luteal phase impairs equine conceptus development until placentation. Reprod Fertil Dev 2020. [DOI: 10.1071/rdv32n2ab61] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
During the early luteal phase, low progesterone concentrations delay downregulation of endometrial progesterone receptors. This contributes to impaired histotroph production at Day 14 of pregnancy (Beyer et al. 2019 Theriogenology 125, 236-241). Until the beginning of placentation (i.e. Day 37 of pregnancy), nutritional supply of the equine conceptus depends on histotrophy alone. The aim of the present study was to analyse development of the equine conceptus under reduced plasma progesterone concentrations until shortly before placentation. Fertile Haflinger mares (n=11; 4-11 years old) were examined daily by transrectal ultrasonography, and when in oestrus, they were inseminated every 48h until spontaneous ovulation. Mares were randomly assigned to either the treatment group and received the prostaglandin F2α agonist cloprostenol (PGF2α; 125μg) once daily for 3 days after ovulation (Beyer et al. 2019) or the control group and left untreated. After conceptus collection on Day 34, mares were allowed one oestrous cycle for recovery and subsequently assigned to the opposite treatment, thus serving as their own controls. From Day 10 after ovulation, conceptus development including size, uterine fixation, and heartbeat detection was evaluated daily by transrectal ultrasonography. On Day 34, conceptus and fetal membranes were recovered transcervically. The recovered material was weighed, measured, and stored for further analysis. Conceptuses underwent microcomputed tomography that was evaluated by Amira (Thermo Fisher Scientific). Statistical comparison for differences between control and treatment pregnancies was performed by nonparametric Wilcoxon test or chi-square analysis. The day of first visualisation of the conceptus and of the embryo proper and heartbeat did not differ between treatments. Uterine fixation occurred on Day 19.3±0.5 in conceptuses from PGF2α-treated pregnancies but on Day 16.7±0.4 in controls (P<0.05). At 34 days of gestation, the conceptuses from PGF2α-treated mares were smaller (P<0.05) than control conceptuses when measured with ultrasound callipers in utero (maximal length: PGF2α 17.4±0.3mm, control 19.0±0.4mm). Conceptus weight determined after recovery was less in treated pregnancies (PGF2α 2.5±0.2 g; control 3.5±0.3 g; P<0.05). Microcomputed tomography analysis of selected inner organs showed some differences in development. Seven complete pairs of undestroyed conceptuses were available. Mean numbers of 33.4±3.2 and 18.8±7.5 bronchi were detected in control and PGF2α conceptuses, respectively (P<0.05). Heart volume did not differ, but communication between ventricles was detected in only 1/7 control but 5/7 PGF2α conceptuses (P<0.05). The footpad was present in 6/7 control and 0/7 PGF2α conceptuses (P<0.001). In conclusion, subphysiological progesterone concentration during the early luteal phase delays development of the equine conceptus before placentation. The condition may contribute to early conceptus loss in horses, which occurs in up to 20% of pregnancies.
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Braun T, Juenemann M, Viard M, Meyer M, Reuter I, Prosiegel M, Kaps M, Tanislav C. Adjustment of oral diet based on flexible endoscopic evaluation of swallowing (FEES) in acute stroke patients: a cross-sectional hospital-based registry study. BMC Neurol 2019; 19:282. [PMID: 31718562 PMCID: PMC6852733 DOI: 10.1186/s12883-019-1499-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 10/15/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Diagnosing dysphagia in acute stroke patients is crucial, as this comorbidity determines morbidity and mortality; we therefore investigated the impact of flexible nasolaryngeal endoscopy (FEES) in acute stroke patients. METHODS The FEES investigation as performed in acute stroke patients treated at a large university hospital, allocated as a standard procedure for all patients suspected of dysphagia. We correlated our findings with baseline data, disability status, pneumonia, duration of hospitalisation, necessity for mechanical ventilation and treatment on the intensive care unit. The study was designed as a cross-sectional hospital-based registry. RESULTS We investigated 152 patients. The median age was 73; 94 were male. Ischemic stroke was diagnosed in 125 patients (82.2%); 27 (17.8%) suffered intracerebral haemorrhage. Oropharyngeal dysphagia was diagnosed in 72.4% of the patients, and was associated with higher stroke severity on admission (median NIHSS 11 [IQR 6-17] vs. 7 [4-12], p = .013; median mRS 5 [IQR 4-5] vs. 4 [IQR 3-5], p = .012). Short-term mortality was higher among patients diagnosed with dysphagia (7.2% vs. 0%, p = .107). FEES examinations revealed that only 30.9% of the patients had an oral diet appropriate for their swallowing abilities. A change of oral diet was associated with a better outcome at discharge (mRS; p = .006), less need of mechanical ventilation (p = .028), shorter period of hospitalisation (p = .044), and lower rates of pneumonia (p = .007) and mortality (p = .011). CONCLUSION Due to the inability of clinical assessments to detect silent aspiration, FEES might be better suited to identify stroke patients at risk and may contribute to a better functional outcome and lower rates of pneumonia and mortality. Our findings also point to a low awareness of dysphagia, even in a specialised stroke centre. FEES in acute stroke patients helps to adjust the oral diet for the vast majority of stroke patients (69.1%) based on their swallowing abilities, potentially avoiding severe complications.
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Bornstein NM, Saver JL, Diener HC, Gorelick PB, Shuaib A, Solberg Y, Devlin T, Leung T, Molina CA, Skoloudik D, Fiksa J, Krieger D, Andersen G, Berrouschot J, Hobohm C, Schneider D, Griewing B, Endres M, Hausler KG, Kimmig H, Ringleb P, Weimar C, Schilling M, Kohrmann M, Hetzel A, Kaps M, Cheung R, Sobolewski P, Nyke W, Czlonkowska A, Stepien A, Waldemar B, Słowik A, Zbigniewem S, Lubiński I, Portela P, Segure T, Marti-Fabregas J, Alonso M, Nunez A, Miguel MB, Campello A, Arenillas J, Marshall N, Chiu D, Shownkeen H, Rymer M, Sen S, Roubec M, Kuliha M, Lakomý C, Tyl D, Kemlink D, Doležal O, Rekova P, Krejčí V, Christensen A, Belhage B, Maschmann C, Kruse Larsen C, Pott F, Christensen H, Marstrand J, Nielsen JK, Meden P, Prytz S, Rosenbaum S, Hedemann Sorensen JC, Stenhoj Meier K, Schmift Ettrup K, Dupont Hougaard K, Von Wietzel P, Stoll A, Schwetlick H, Pradel H, Hemprich A, Schulz A, Frerich B, Hobohm C, Weise C, Michalski D, Schaller F, Schiefke F, Helmrich J, Pelz J, Schnieder M, Schneider M, Matzen P, Langos R, Müller-Duerwald S, Lukhaup S, Bauer U, Kloppig W, Hiermann E, Mucha G, Soda H, Weinhardt R, Mucha T, Ziegler V, Abbushi A, Hotter B, Winter B, Anthofer B, Noack C, Laubisch D, Heldge Schneider G, Jan Jungehulsing G, Mueller H, Dreier J, Fiebach J, Flechsenhar J, Villringer K, Ebinger M, Rozanski M, Vajkoczy P, Klingebiel R, Steinicke R, Pittl S, Hoffmann S, Maul S, Krause T, Liman T, Plath T, Nowe T, Schmidt W, Fritzsch C, Haas C, Will HG, Haußmann-Betz K, Bayat M, Pordzik T, Hug A, Staff CJ, Lichy C, Eggers G, Kloss M, Bendszus M, Herrmann O, Seeberger R, Schwarting S, Rhode S, Rizos T, Hacke W, Frank B, Bozkurt B, Holle D, Mueller D, Koch D, Shanib H, Sudendey J, Brenck J, Busch K, Gartzen K, Gasser T, Hagenacker T, Buerke B, Prigge G, Minnerup J, Albers J, Wermker K, Schwindt W, Kallmünzer RB, Hauer E, Breuer L, Schellinger P, Kollmar R, Sauer R, Schwab S, Struffert T, Funfack A, Stechmann A, Schlaeger A, Laeppchen C, Schuchardt F, Klingler JH, Reis J, Lambeck J, Friedrich M, Laible M, Wellermeyer P, Beck S, Rutsch S, Niesen WD, Tanislav C, Schaaf H, Kerkmann H, Schirotzek I, Allendörfer J, Wolff S, Yuk-Lun Lau A, Yin Yan Chan A, Siu D, Wong EHC, Chu Wong GK, Leung H, Wong LK, Zhu XL, Yan Soo YO, Ting Tse AC, Kit Leung GK, Leung KM, Ngai Hung K, Wai Mei Kwan M, Man Yu Tse M, Tse P, Hon Chan P, Lee R, Shek Kwan Chang R, Yin Yu Pang S, Fong Kwong Hon S, Cheng TS, Lui WM, Wo Mak WW, Sobota A, Wiater B, Loch B, Wolak G, Łabudzka I, Dabal J, Grzesik M, Sledzinska M, Hatalska-Żerebiec R, Szczuchniak W, Gójska A, Nałęcz D, Gasecki D, Kozera G, Dylewicz Ł, Niekra M, Kwarciany M, Chomik P, Skowron P, Kobayashi A, Chabik G, Makowicz G, Bembenek J, Jędrzejewska J, Karlinski M, Czepiel W, Brodacki B, Staszewski J, Kosek J, Jadczak M, Durka-Kęsy M, Kaluzny K, Ziomek M, Fudala M, Sosnowski Z, Ferens A, Szczygieł E, Banaszkiewicz K, Ziomek M, Wnuk M, Szczepańska-Szerej A, Jach E, Maslanko GE, Wojczal J, Luchowski P, Kowalczyk A, Jakubiak J, Kopcewicz J, Gajda M, Wichlinska-Lubinska M, Rodriguez D, Santamarin E, Pagola J, Lorente Guerrero J, Ribo M, Rubiera M, Maisterra O, Pinero S, Catalina Iglesias V, Plans G, Quesada H, Aparicio Caballero MA, Portela PC, De Diego AB, Garay DS, García Rodriguez MR, Martin OA, Braña SC, Garcia J, Hernandez FM, Catala I, Marti-Vilalta JL, Delgado Mederos R, de Quintana SC, Martinez-Ramirez S, Valcarcel Gonzalez J, Masjuan Vallejo J, Diamantopoulus J, Del Alamo M, Poveda PD, Pastor AG, Carballal CF, Diaz F, Garcia Leal R, Juretschke R, Echabe EA, Sanchez JC, Yanez MR, Garcia RS, Muino RL, Rivas SA, Lopez Gonzalez DM, Cuadrado E, Giralt E, Villalba G, Roquer J, Angel O, Jimenez M, Cedeño RR, Salinas R, Lejarreta S, Silva Y, Fraile A, Calleja A, Cepeda Landínez GA, Tellez N, Garcia Bermejo P, Santos PJ, Herranz RF, Hunt P, Browning D, Violette M, Hoddeson R, Rose J, Zhang J, Mazumdar A, Echiverri H, Chow J, Lovick D, Coleman M, Akhtar N, Sugg R, Zanation A, Germanwala A, Senior B, Huang D, Aucutt-Walter N, Kasner S, LeRoux P, von Kummer R, Palesch Y. Sphenopalatine Ganglion Stimulation to Augment Cerebral Blood Flow. Stroke 2019; 50:2108-2117. [DOI: 10.1161/strokeaha.118.024582] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Many patients with acute ischemic stroke are not eligible for thrombolysis or mechanical reperfusion therapies due to contraindications, inaccessible vascular occlusions, late presentation, or large infarct core. Sphenopalatine ganglion (SPG) stimulation to enhance collateral flow and stabilize the blood-brain barrier offers an alternative, potentially more widely deliverable, therapy.
Methods—
In a randomized, sham-controlled, double-masked trial at 41 centers in 7 countries, patients with anterior circulation ischemic stroke not treated with reperfusion therapies within 24 hours of onset were randomly allocated to active SPG stimulation or sham control. The primary efficacy outcome was improvement beyond expectations on the modified Rankin Scale of global disability at 90 days (sliding dichotomy), assessed in the modified intention-to-treat population. The initial planned sample size was 660 patients, but the trial was stopped early when technical improvements in device placement occurred, so that analysis of accumulated experience could be conducted to inform a successor trial.
Results—
Among 303 enrolled patients, 253 received at least one active SPG or sham stimulation, constituting the modified intention-to-treat population (153 SPG stimulation and 100 sham control). Age was median 73 years (interquartile range, 64–79), 52.6% were female, deficit severity on the National Institutes of Health Stroke Scale was median 11 (interquartile range, 9–15), and time from last known well median 18.6 hours (interquartile range, 14.5–22.5). For the primary outcome, improved 3-month disability beyond expectations, rates in the SPG versus sham treatment groups were 49.7% versus 40.0%; odds ratio, 1.48 (95% CI, 0.89–2.47);
P
=0.13. A significant treatment interaction with stroke location (cortical versus noncortical) was noted,
P
=0.04. In the 87 patients with confirmed cortical involvement, rates of improvement beyond expectations were 50.0% versus 27.0%; odds ratio, 2.70 (95% CI, 1.08–6.73);
P
=0.03. Similar response patterns were observed for all prespecified secondary efficacy outcomes. No differences in mortality or serious adverse event safety end points were observed.
Conclusions—
SPG stimulation within 24 hours of onset is safe in acute ischemic stroke. SPG stimulation was not shown to statistically significantly improve 3-month disability above expectations, though favorable outcomes were nominally higher with SPG stimulation. Beneficial effects may distinctively be conferred in patients with confirmed cortical involvement. The results of this study need to be confirmed in a larger pivotal study.
Clinical Trial Registration—
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT03767192.
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Walter U, Brandt S, Förderreuther S, Hansen HC, Hinrichs H, Kaps M, Müllges W, Weise D. Empfehlungen der Deutschen Gesellschaft für Klinische Neurophysiologie und Funktionelle Bildgebung zur Diagnostik des irreversiblen Hirnfunktionsausfalls. KLIN NEUROPHYSIOL 2019. [DOI: 10.1055/a-0792-0986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
ZusammenfassungGemeinsam mit der Vierten Fortschreibung der Richtlinie der Bundesärztekammer zur Feststellung des irreversiblen Hirnfunktionsausfalls („Hirntod“) im Jahr 2015 erfolgte eine Revision der Empfehlungen der Deutschen Gesellschaft für Klinische Neurophysiologie und Funktionelle Bildgebung (DGKN) zu den ergänzenden elektrophysiologischen (Elektroenzephalografie, frühe akustisch evozierte Potenziale, somatosensorisch evozierte Potenziale) und neurovaskulären (Dopplersonografie, Duplexsonografie) Untersuchungen.Die Empfehlungen der DGKN wurden 2018 in einigen Punkten aktualisiert. Neben redaktionellen Änderungen (u. a. Ersetzen des Begriffs „Eichsignal“ durch „Kalibriersignal“, präzisere Formulierung der zu setzenden Elektroden für die Elektroenzephalografie) wurden Vorgaben zur Bildanzeige bei digitaler Elektroenzephalografie und altersbezogene Mindestgrößen des arteriellen Mitteldruckes bei Kindern für die Doppler- und Duplexsonografie neu aufgenommen. Diese hier präsentierten Empfehlungen stellen die Indikationen, Limitationen, Voraussetzungen und die Durchführung dieser Zusatzverfahren in der Diagnostik des irreversiblen Hirnfunktionsausfalls bei Kindern und Erwachsenen dar.
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Grimm A, Allendörfer J, Bischoff C, Buchner H, Décard B, Kaps M, Schelle T, Schulte-Mattler W, Walter U, Witte O, Nedelmann M, Köhrmann M, Schminke U. Positionspapier der Deutschen Gesellschaft für klinische Neurophysiologie DGKN und der Deutschen Gesellschaft für Ultraschall in der Medizin DEGUM, Sektion Neurologie zur „Wertigkeit des Nerven- und Muskelultraschalls in der Diagnostik neuromuskulärer Erkrankungen“. KLIN NEUROPHYSIOL 2018. [DOI: 10.1055/a-0635-9584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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