Rejuvenation of the Midface

In this article, the interested reader will learn when and how to apply different techniques on their patients, with the goal of safe, effective, natural looking, and long-lasting midface rejuvenation.

"If I had been given that information back then": An interpretive description exploring the information needs of adults with cerebral palsy looking back on their transition to adulthood

BACKGROUND

Young people with cerebral palsy (CP) and their families have identified lack of information received during the transition to adulthood as a barrier to successful outcomes. To date, few studies have explored the information needs, preferences, timing, and method of provision from the perspective of individuals with CP.

METHOD

The methodological approach to this qualitative study was interpretive description. Nine adults living with CP, between the ages of 20 and 40, were purposively recruited in Ontario, Canada, to explore, retrospectively, their information needs during the transition to adulthood. Participants completed a 1-hour interview that explored their experiences seeking and receiving information. Interviews were transcribed verbatim, and data were analysed to create a thematic description of adults' experiences with information.

RESULTS

Three themes emerged: (a) "Recognizing and supporting information needs," which highlighted the importance of support systems to assist young people in receiving and seeking information throughout the transition; (b) "Getting creative," which highlighted strategies young people use when confronted with environmental barriers when seeking information; and (c) "Gaps and advice for the future," which highlighted the need for real-life opportunities, during the transition to adulthood, to experience some of the responsibilities of adult life.

CONCLUSION

Clinicians assisting young people with CP need purposefully to foster knowledge and skills during the transition to adulthood. They should be not only providers of information but also enablers of opportunities for immersion in real-life experiences to prepare for adult life. It is important for young people to have the opportunity to discuss challenges and exchange information with their peers.

Factor VIII in Acute Cerebral Ischemia Pilot Study: Biomarker in Patients With Large Vessel Occlusion?

We conducted a prospective serial laboratory cohort study to assess the correlation of factor VIII (FVIII) levels in response to thrombolysis in patients with large vessel occlusion (LVO) and acute ischemic stroke (AIS). Patients with AIS with anterior circulation LVO were eligible for enrollment if treated within 4.5 hours from last seen normal with intravenous tissue plasminogen activator (tPA). Patients (n = 29) had a mean age of 71 years and median National Institute of Health Stroke Scale of 14. Baseline pre-tPA FVIII was not significantly correlated with clot burden score (-0.147, P = .447) or vessel recanalization (-0.133, P = .499). Median FVIII decreased significantly from baseline to 6 hours post-tPA (282% to 161%, P = .002), but delta in FVIII level did not correlate with vessel recanalization (0.013, P = .948). There was no difference between median FVIII level at baseline and 90 days post-AIS. FVIII level decreased significantly after tPA, but baseline FVIII level and early change in FVIII level were not significant predictors of clot burden, vessel recanalization after thrombolysis, or symptomatic hemorrhage.

Abstract TP129: Factor VIII in Acute Cerebral Ischemia Trial - Biomarker in Patients with Large Vessel Occlusion?

Introduction: Baseline elevated Factor VIII (FVIII) level is a significant independent predictor of stroke occurrence and severity. We conducted a prospective serial laboratory cohort study to assess the correlation of FVIII levels in response to thrombolysis in patients with large vessel occlusion (LVO) and acute ischemic stroke (AIS).

Methods: AIS patients with anterior circulation LVO were enrolled within 4.5 hours from last seen normal. Baseline and serial FVIII levels were obtained to determine whether FVIII serves as a surrogate marker of clot burden and if FVIII levels or changes predict (1) recanalization with intravenous tissue plasminogen activator (IV tPA) or (2) symptomatic intracranial hemorrhage (sICH) following tPA. Linear and logistic regression analyses were used to determine significant predictors.

Results: Patients (n=29) had a mean age of 71years, median NIHSS of 15, 62% were of black race and 48% were female. Baseline pre -tPA FVIII was not significantly correlated with clot burden score (-0.15, p=0.45) or vessel recanalization (-0.13, p=0.50). Median FVIII decreased significantly from baseline to 6hrs post-tPA (282% to 161%, p=0.0024), but delta in FVIII level did not correlate with vessel recanalization (0.01, p=0.95). No patient had sICH. There was no difference between median FVIII level at baseline and 90 days post AIS.

Interpretation: FVIII level decreased significantly after tPA, but baseline FVIII level and early change in FVIII level were not significant predictors of clot burden, vessel recanalization after treatment with IV tPA, or symptomatic hemorrhage. This trial provided no evidence to support the value of acute FVIII level as a biomarker in AIS due to LVO. The physiology behind the decrease in FVIII level after tPA remains unknown.

Abstract WMP69: Predictive Value of Diagnostic Testing for Detection of Deep Vein Thrombosis in Ischemic Stroke Patients with Intracardiac Shunt

Background: In the pursuit of stroke etiology, cardiac imaging with bubble study often reveals an intracardiac shunt. We sought to determine the yield of bilateral lower extremity ultrasound (BLE US) and magnetic resonance venography (MRV) of the pelvis in detection of deep vein thrombosis (DVT) as a source for paradoxical embolization in patients with ischemic stroke who have an intracardiac shunt.

Methods: Patients admitted with AIS from 2008 through 2015 were included if the presence of intracardiac shunt was confirmed via echocardiography with bubble study. We examined the frequency of DVT (DVT+) among patients who had BLE US only, MRV pelvis only, or both BLE US and MRV. We then compared patients with evidence of DVT (DVT+) to those without evidence of DVT (DVT-).

Results: Among 1,992 patients with AIS, 145 patients had confirmed evidence of an intracardiac shunt; of these, 40 patients (27.6%) had neither BLE US nor MRV studies, 29 patients (20.0%) had BLE US only, 4 patients (2.8%) had MRV only, and 72 patients (49.7%) had both BLE US and MRV. Among those with BLE US only, 2 patients (6.9%) were DVT+; of those who had MRV only, 2 patients (50.0%) were DVT+; of those who had both BLE US and MRV, 11 (15.3%) were DVT+. Overall, 14.3% of patients with an intracardiac shunt and work-up for DVT were found to have an occult DVT. No statistically significant differences were detected in demographic, baseline, in-hospital, or discharge characteristics when comparing DVT+ and DVT- patients.

Discussion: The findings of this study support the use of BLE US and MRV to detect occult DVT among ischemic stroke patients with intracardiac shunt. In our sample population, 14.3% of patients were positive for occult DVT though no patient characteristics were associated with predicting the presence of DVT. This supports the need for adequate DVT screening in patients with AIS and positive bubble study.

Abstract TP186: High Hospital Mortality Among Non-black Stroke Patients with Metabolic Syndrome

Introduction: Limited information is available on race based stroke outcomes among patients with metabolic syndrome.

Methods: We conducted a retrospective review of acute ischemic stroke patients between 2008 and 2015 who were admitted to stroke service at a comprehensive stroke center. Patients were categorized to have metabolic syndrome if they have three of the four criteria (history of hypertension or diabetes or triglycerides ≥ 150 mg/dl or high density lipoprotein (HDL) < 50 mg/dl for women or < 40 mg/dl for men). Patients with metabolic syndrome were grouped based on their race. Primary outcome was modified Rankin Scale score at discharge. Secondary outcomes measures were neurological worsening, hospital mortality, in-hospital complications, discharge stroke scale, and length of stay.

Results: Total 659 patients were found to have metabolic syndrome. Among these patients, 206 (31%) were non-black and 453 (69%) were of black race. Compared to non-black patients with metabolic syndrome, black patients were more likely to be women (56% vs. 35%, p<0.0001) and have a prior history of stroke (55% vs. 35%, p<0.0001). Median admission diastolic blood pressure was higher among blacks compared to non-blacks (92 vs. 87mmHg, p = 0.0093). Higher proportion of black patients were on anti-platelets (67% vs. 56%, p = 0.01), statins (83% vs. 71%; p =0.001), and anti-hypertensive medications at home (90% vs. 81%, p = 0.001). Non-blacks had higher triglycerides (188 vs. 132 mg/dl, p<0.0001) and lower HDL levels (36 vs. 44 mg/dl, p< 0.0001). There was no difference in discharge modified Rankin Scale score among the groups. In-hospital myocardial infarction was significantly more frequent among non-blacks (9% vs. 4%, p = 0.03). In-hospital mortality was significantly higher in the non-black group (11% vs. 6%, p = 0.02).

Conclusion: Non-black race was associated with higher in-hospital mortality among patients with metabolic syndrome admitted for stroke. Further exploration of higher mortality among this group of patients is warranted to improve stroke outcomes.