Standardized protocols enable stroke recognition and early treatment of carotid stenosis

OBJECTIVE

This study examined the effect of acute ischemic stroke (AIS) care coordination between vascular surgery and stroke neurology services with primary focus on acute patient stabilization and expeditious carotid endarterectomy (CEA).

METHODS

A standardized AIS protocol was instituted between vascular surgery and stroke neurology services in an academic hospital (group I) that included: (1) rapid patient evaluation and imaging inclusive of brain and carotid computed tomography/magnetic resonance angiography, carotid duplex ultrasound imaging or conventional arteriogram, or both; (2) patient admission to a dedicated stroke unit with minimum 1:2 intensive care nurse-to-patient staffing and a 24-hour available neurointensivist; (3) treatment of all patients with ipsilateral moderate or severe carotid stenosis by CEA with cervical block (158 [81%]) or general anesthesia (38 [19%]). Patient exclusion from undergoing expeditious CEA included (1) stroke in evolution, and (2) dense neurologic deficit or National Institutes of Health Stroke Scale score >15 (severe), or both. Comparisons of data were performed between group I patients and those treated in outlying hospitals (group II) for similar indications. All data were prospectively collected in a computerized database and outcomes evaluated retrospectively.

RESULTS

From November 2002 to November 2012, 369 patients underwent CEA for AIS ≤1 week of presentation. There were 192 patients in group I and 177 in group II. There were no differences in group I and II in mean stroke-to-CEA interval (3.4 vs 3.9 days) or in the performance of eversion CEA (94% vs 97%), respectively. Intraoperative shunt use was greater in group I (28%) than in group II (18%; P = .021). Fewer total neurologic events (stroke or transient ischemic attack) occurred in group I (6 [3.1%] vs 14 [7.3%]; P = .03). No patients died in either group. Postoperative National Institutes of Health Stroke Scale scores available in group I patients showed improvement from preoperative baseline in mild and moderate stroke patients (P < .001).

CONCLUSIONS

In patients with stable acute stroke, early CEA is feasible and relatively safe. Stroke or death occurs in only 1%, and most complications are of nonfatal cardiac origin. A standardized stroke team protocol that is inclusive of stroke neurologists and vascular surgeons allows for expeditious and safe CEA in the setting of an acute stroke.

Glutamate/glutamine and neuronal integrity in adults with ADHD: a proton MRS study

There is increasing evidence that abnormalities in glutamate signalling may contribute to the pathophysiology of attention-deficit hyperactivity disorder (ADHD). Proton magnetic resonance spectroscopy ([1H]MRS) can be used to measure glutamate, and also its metabolite glutamine, in vivo. However, few studies have investigated glutamate in the brain of adults with ADHD naive to stimulant medication. Therefore, we used [1H]MRS to measure the combined signal of glutamate and glutamine (Glu+Gln; abbreviated as Glx) along with other neurometabolites such as creatine (Cr), N-acetylaspartate (NAA) and choline. Data were acquired from three brain regions, including two implicated in ADHD-the basal ganglia (caudate/striatum) and the dorsolateral prefrontal cortex (DLPFC)-and one 'control' region-the medial parietal cortex. We compared 40 adults with ADHD, of whom 24 were naive for ADHD medication, whereas 16 were currently on stimulants, against 20 age, sex and IQ-matched healthy controls. We found that compared with controls, adult ADHD participants had a significantly lower concentration of Glx, Cr and NAA in the basal ganglia and Cr in the DLPFC, after correction for multiple comparisons. There were no differences between stimulant-treated and treatment-naive ADHD participants. In people with untreated ADHD, lower basal ganglia Glx was significantly associated with more severe symptoms of inattention. There were no significant differences in the parietal 'control' region. We suggest that subcortical glutamate and glutamine have a modulatory role in ADHD adults; and that differences in glutamate-glutamine levels are not explained by use of stimulant medication.

Occupational health hazards & efficacy of protective masks in threshing operation

The study was conducted on 20 farm workers to identify the occupational health hazards in threshing operation. Four different protective masks were given and tested on various parameters. Respondents reported respiratory health problems which were mainly due to heat and organic dust in the surroundings. All respondents reported irritation in eyes and throat followed by nose (85.0%) and ears (75.0%). Musculo-skeletal problems were reported showing severe to very severe discomfort in lower arms (m.s. = 3.8), upper back (3.6) and upper arms (3.4). Overall discomfort score (ODS) was 7.6 depicting high level of discomfort. Peak expiratory flow rate was reduced by 6.6 % depicting reduced capacity of lungs after day long work in polluted environment. Hood mask was highly acceptable as it showed lowest breathing resistance. Leakage of dust from sides and rate of sweating was medium. Hence, use of hood mask would be helpful to achieve the ergonomics objective of reducing health problems and improving performance.