Evaluation of Post-thrombolytic Events to Determine Appropriate ICU Monitoring Duration for Patients with Ischemic Stroke

BACKGROUND

Standard treatment for eligible patients presenting with acute ischemic stroke (AIS) is thrombolysis with tissue plasminogen activators alteplase or tenecteplase. Current guidelines recommend monitoring patients in an intensive care unit (ICU) for 24 h after thrombolytic therapy. However, recent studies have questioned the need for prolonged ICU monitoring. This retrospective cohort study aims to identify potential candidates for early transition to a lower level of care by assessing risk factors for neurological deterioration, symptomatic intracranial hemorrhage (sICH), or need for ICU intervention within 24 h post-thrombolysis.

METHODS

This retrospective cohort study included adult patients 18 years and older with AIS who received thrombolysis. Patients were excluded if they were transferred to another facility, if they were transitioned to comfort care or hospice care within 24 h, or if they lacked imaging and National Institutes of Health Stroke Scale (NIHSS) score data. The primary end point was incidence of sICH between 0-12 and 12-24 h. Secondary end points included the need for ICU intervention and rates of neurological deterioration.

RESULTS

The analysis included 204 patients who received the full dose of alteplase. Among them, ten patients (4.9%) developed sICH, with the majority (n = 7) occurring within 12 h post-thrombolysis. Sixty-two patients required ICU interventions within 12 h compared with four patients after 12 h. Twenty-four patients had neurological deterioration within 12 h, and seven patients had neurological deterioration after 12 h. Multivariable analysis identified mechanical thrombectomy and increased blood pressure at presentation as predictors of ICU need beyond 12 h post-thrombolysis.

CONCLUSIONS

Our study demonstrates that sICH, neurological deterioration, and need for ICU intervention rarely occur beyond 12 h after thrombolytic administration. Patients presenting with blood pressures < 140/90 mm Hg, NIHSS scores < 10, and not undergoing mechanical thrombectomy may be best candidates for early de-escalation. Larger prospective studies are needed to more fully evaluate the safety, feasibility, and financial impact of early transition out of the ICU.

Marine Animal Forests of the World: Definition and Characteristics

The term Marine Animal Forest (MAF) was first described by Alfred Russel Wallace in his book “The Malay Archipelago” in 1869. The term was much later re-introduced and various descriptions of MAFs were presented in great detail as part of a book series. The international research and conservation communities have advocated for the future protection of MAFs and their integration into spatial plans and, in response, there are plans to include the characteristics of MAFs into national policies and international directives and conventions (i.e. IUCN, CBD, OSPAR, HELCOM, Barcelona Convention, European directives, ABJN policies etc.). Some MAF ecosystems are already included in international and national conservation and management initiatives, for instance, shallow water coral reefs (ICRI, ICRAN) or cold-water coral reefs and gardens and sponge aggregations (classified as Vulnerable Marine Ecosystems, VMEs), but not as a group together with other ecosystems with similar ecological roles. Marine Animal Forests can be found in all oceans, from shallow to deep waters. They are composed of megabenthic communities dominated by sessile suspension feeders (such as sponges, corals and bivalves) capable of producing three-dimensional frameworks with structural complexity that provide refuge for other species.

MAFs are diverse and often harbour highly endemic communities. Marine animal forests face direct anthropogenic threats and they are not protected in many regions, particularly in deep-sea environments. Even though MAFs have been already described in detail, there are still fundamental knowledge gaps regarding their geographical distribution and functioning. A workshop was dedicated to clarifying the definition of MAFs, characterising their structure and functioning, including delineating the ecosystem services that they provide and the threats upon them. The workshop was organised by Working Group 2 of the EU-COST Action “MAF-WORLD” (hereafter WG2), which is responsible for collating and promoting research on mapping, biogeography and biodiversity of MAFs, to identify and reduce these knowledge gaps. Herein, we report on this workshop and its outputs.

A world of taxonomic pain: cryptic species, inexplicable host-specificity, and host-induced morphological variation among species of Bivesicula Yamaguti, 1934 (Trematoda: Bivesiculidae) from Indo-Pacific Holocentridae, Muraenidae and Serranidae

The taxonomy of species of Bivesicula Yamaguti, 1934 is analysed for samples from holocentrid, muraenid and serranid fishes from Japan, Ningaloo Reef (Western Australia), the Great Barrier Reef (Queensland), New Caledonia and French Polynesia. Analysis of three genetic markers (cox1 mtDNA, ITS2 and 28S rDNA) identifies three strongly supported clades of species and suggests that Bivesicula as presently recognized is not monophyletic. On the basis of combined morphological, molecular and biological data, 10 species are distinguished of which five are proposed as new. Bivesicula Clade 1 comprises seven species of which three are effectively morphologically cryptic relative to each other; all seven infect serranids and four also infect holocentrids. Bivesicula Clade 2 comprises three species of which two are effectively morphologically cryptic relative to each other; all three infect serranids and one also infects a muraenid. Bivesicula Clade 3 comprises two known species from apogonids and a pomacentrid, and forms a clade with species of Paucivitellosus Coil, Reid & Kuntz, 1965 to the exclusion of other Bivesicula species. Taxonomy in this genus is made challenging by the combination of low resolving power of ribosomal markers, the existence of regional cox1 mtDNA populations, exceptional and unpredictable host-specificity and geographical distribution, and significant host-induced morphological variation.

Acculturation and mental distress among Russian and Iranian migrants in Germany

Several studies have stressed a correlation between difficulties in acculturation and mental distress or even mental disorders. The stress related to the process of acculturation can lead to depressive symptoms by way of changes in the activity of the HPA axis. However, it remains difficult to measure acculturation stress, as difficulties in acculturation strongly depend on subjective interpretations of every day experiences. The association between acculturation stress and mental distress was examined in two different migrant groups in Germany, 202 migrants of Russian and 100 of Iranian origin. In both migrant groups a significant correlation between acculturation stress and mental distress was found, yet no significant association between acculturation stress and length of residency in Germany. These findings will have to be replicated with representative samples and also with other migrant groups, both in and out of treatment. Considering the fact that the Russian sample was younger and nonetheless had relatively high acculturation stress scores, prevention of future mental health problems among migrants will have to focus on easing the process of integration into the host society.

Economic performance and cost-effectiveness of using a DEC-salt social enterprise for eliminating the major neglected tropical disease, lymphatic filariasis

Background

Salt fortified with the drug, diethylcarbamazine (DEC), and introduced into a competitive market has the potential to overcome the obstacles associated with tablet-based Lymphatic Filariasis (LF) elimination programs. Questions remain, however, regarding the economic viability, production capacity, and effectiveness of this strategy as a sustainable means to bring about LF elimination in resource poor settings.

Methodology and principal findings

We evaluated the performance and effectiveness of a novel social enterprise-based approach developed and tested in Léogâne, Haiti, as a strategy to sustainably and cost-efficiently distribute DEC-medicated salt into a competitive market at quantities sufficient to bring about the elimination of LF. We undertook a cost-revenue analysis to evaluate the production capability and financial feasibility of the developed DEC salt social enterprise, and a modeling study centered on applying a dynamic mathematical model localized to reflect local LF transmission dynamics to evaluate the cost-effectiveness of using this intervention versus standard annual Mass Drug Administration (MDA) for eliminating LF in Léogâne. We show that the salt enterprise because of its mixed product business strategy may have already reached the production capacity for delivering sufficient quantities of edible DEC-medicated salt to bring about LF transmission in the Léogâne study setting. Due to increasing revenues obtained from the sale of DEC salt over time, expansion of its delivery in the population, and greater cumulative impact on the survival of worms leading to shorter timelines to extinction, this strategy could also represent a significantly more cost-effective option than annual DEC tablet-based MDA for accomplishing LF elimination.

Significance

A social enterprise approach can offer an innovative market-based strategy by which edible salt fortified with DEC could be distributed to communities both on a financially sustainable basis and at sufficient quantity to eliminate LF. Deployment of similarly fashioned intervention strategies would improve current efforts to successfully accomplish the goal of LF elimination, particularly in difficult-to-control settings.

With less than three years remaining for meeting the initial 2020 target set by WHO for accomplishing the global elimination of Lymphatic Filariasis (LF), concerns are emerging regarding the feasibility of meeting this goal using the current tablet-based Mass Drug Administration strategy. Salt fortified with the antifilarial drug, diethylcarbamazine (DEC), could offer an intervention that avoids many of the barriers connected with tablet-based elimination programs. We analyzed the economic performance and cost-effectiveness of a novel DEC-salt social enterprise developed and tested in Léogâne arrondissement, Haiti, as a particularly significant strategy for accomplishing sustainable LF elimination in such complex settings. We show that because of increasing revenue from the sale of the DEC salt over time, expansion of its delivery in the population, and the adverse effect of continuous consumption of the drug on worms, the delivery of DEC through a salt enterprise can represent a significantly more cost-effective option than annual DEC tablet-based MDA for accomplishing LF elimination in settings, like Léogâne. We indicate that development of policy and research into how to deploy similarly-fashioned interventions, or work with the salt industry to increase population use of medicated salt, would improve present efforts to successfully accomplish the elimination of LF.

Substitution treatment and HCV/HIV-infection in a sample of 31 German prisons for sentenced inmates

Injection drug use (IDU) and IDU-related infectious diseases such as hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections are highly prevalent among prisoners worldwide. However, little is known about the prevalence of IDUs, HCV/HIV and the availability of respective treatment options in German prisons. Data provided by prison physicians of 31 prisons, representing 14,537 inmates, were included in this analysis. The proportion of IDUs among all prisoners was 21.9%. Substitution treatment was available in three out of four prisons (74.2%). Overall, 1137 substitution treatments were provided annually with a wide range of treatment aims. The prevalence rate was 14.3% for HCV and 1.2% for HIV. Around 5.5% of all HCV-infected prisoners were in antiviral treatment annually, 86.5% of all HIV-positive inmates in antiretroviral HIV-treatment. Generally, substitution treatment, and HCV and HIV testing and treatment are available. However, due to abstinence-orientated treatment aims, substitution treatment is rarely available as maintenance treatment, and HCV/HIV-treatment is mainly provided for patients with an existing treatment before imprisonment. The inconsistent data quality necessitates changes in prison-related policy to improve surveillance and to generate aggregated data in German prisons. The selection process in this analysis might lead to overestimating the provision of substitution and antiviral HCV-treatment.

Hepatitis C treatment uptake and adherence among injecting drug users in the Czech Republic

BACKGROUND

Injecting drug users (IDUs) represent a major subpopulation of hepatitis C virus (HCV)-infected people in developed countries. Yet their uptake to treatment is generally low despite well-documented effectiveness of HCV treatment among former and active IDUs. The present study represents the first attempt to describe the HCV treatment coverage among IDUs and identify factors that affect treatment uptake in the Czech Republic.

METHODS

From January to March 2011, a questionnaire survey was conducted among viral hepatitis treatment centres in the Czech Republic.

RESULTS

From a total of 76 identified hepatitis treatment centres existing in the country, 39 provided HCV treatment to (mainly former or abstaining) IDUs in 2010. Most clinicians reported being cautious in initiating HCV treatment in IDUs. Abstinence, a screening phase before treatment initiation, opioid substitution treatment and an external evaluation by a specialist were often prerequisites for skrting treatment. However, HCV treatment centres rarely provided drug-use specific services. Financial constraints were also reported, further limiting the inclusion of IDUs into treatment, as non-users are widely preferred to active drug users. Clinicians reported no difference in treatment uptake and adherence between drug users and non-users, nor between opioid and methamphetamine users.

CONCLUSION

A number of system- and provider-related factors limit HCV treatment in IDUs in the Czech Republic, despite permissive national clinical guidelines. Targeting these factors is crucial to reduce HCV prevalence at population level.

Quality of life profiles and changes in the course of maintenance treatment among 1,015 patients with severe opioid dependence

INTRODUCTION

Studies indicate that different areas of mental, physical, social and daily life functioning need to be considered in order to improve intervention outcomes in substance user patients. The aim of the study was to assess health-related quality of life (HRQOL) in patients diagnosed with opioid dependence as compared to healthy controls and patients diagnosed with depression and schizophrenia.

METHODS

A total of 1,015 outpatients diagnosed with opioid dependence were investigated during 12 months of maintenance treatment. HRQOL (MSQoL), addiction (EUROP-ASI), and sociodemographic characteristics were assessed.

RESULTS

HRQOL in opioid dependence improved significantly (p < .001), but was lower as compared to that of healthy controls and patients diagnosed with schizophrenia. HRQOL in opioid dependence comprises addiction-specific aspects, most importantly low material satisfaction, physical health, and social stability.

CONCLUSIONS

HRQOL measurement provides valuable information for course and outcome in opioid dependence treatment.

Quality of life under maintenance treatment with heroin versus methadone in patients with opioid dependence

BACKGROUND

There is increasing evidence that health-related quality of life (HRQOL) is associated with a successful treatment and better outcome in opioid addiction. The aim of the present study was the longitudinal investigation of HRQOL in patients with severe opioid dependence, who were randomly assigned to four groups of medical and psychosocial treatment: heroin (diacetylmorphine) versus methadone and case management (CM) versus psychoeducation (PSE) respectively.

METHODS

HRQOL (MSQoL) and physical health (OTI) were investigated in 938 subjects, who participated in the German multi-centre study examining the effects of heroin-assisted treatment in patients with severe opioid dependence. Data for the present analysis were taken from baseline and 12-month follow up.

RESULTS

Under both forms of maintenance and psychosocial treatment HRQOL improved significantly during the observation period. HRQOL improvement under maintenance with heroin exceeded improvement under methadone, especially with regard to subjective physical health. HRQOL improvement was significantly associated with better expert-rated physical health. Further analyses showed significant better improvement of HRQOL in subjects treated with PSE compared with CM.

CONCLUSIONS

The advantage of heroin with regard to the improvement of HRQOL may be partially explained by a better improvement of physical health under maintenance with heroin compared with methadone, which highlights the importance of a comprehensive model of health care for patients with severe opioid dependence. Future studies need to investigate the benefits of PSE for patients in maintenance therapy.

Is heroin-assisted treatment effective for patients with no previous maintenance treatment? Results from a German randomised controlled trial

BACKGROUND/AIMS

Until now, the medical prescription of diamorphine (heroin) has been suggested as suitable for patients who have failed previous maintenance treatments. The aim of this paper is to assess the effects of diamorphine on opioid-dependent patients with no previous maintenance treatment experience (NPME).

METHODS

The German heroin trial compared diamorphine versus methadone maintenance treatment and included 107 patients with NPME. This paper is a sub-analysis of these patients.

RESULTS

When comparing this subsample with the rest of the participants in the study, large baseline differences were found, showing a more severe drug use profile in patients with NPME. However, no differences were found in terms of treatment outcome and treatment retention. In the subsample with NPME, outcome measures on the reduction of illicit drug use were significantly better under diamorphine compared to methadone treatment, while there was no difference in health outcomes.

CONCLUSION

Controlled studies are now necessary to examine whether diamorphine treatment could be considered as one of several options in treating severely opioid-dependent patients, regardless of previous maintenance treatment experience.

Effects of psychiatric comorbidity on treatment outcome in patients undergoing diamorphine or methadone maintenance treatment

BACKGROUND

Comorbid psychiatric disorders among opioid-dependent patients are associated with several negative outcome factors. However, outcomes of maintenance treatment have not been sufficiently established, and no evidence is available with respect to heroin-assisted treatment (HAT).

METHODS

For patients in the German heroin trial outcome measures were analyzed for HAT versus methadone maintenance treatment (MMT) both for patients with and without a comorbid diagnosis according to CIDI.

RESULTS

47.2% of the sample had at least one comorbid psychiatric diagnosis, mainly neurotic, stress-related or somatoform (F4) or affective (F3) disorders. HAT had a better outcome than MMT concerning improvement of health and reduction of illicit drug use in both comorbid and non-comorbid patients, but weaker effects were found in the comorbid group.

CONCLUSIONS

The better outcome of HAT also in comorbid patients suggests that psychiatric comorbidity should be an inclusion criterion for HAT. The weaker advantage of HAT may be due to pharmacological or methodological reasons.

Substitution Treatment and HCV / HIV Infection in a Sample of 31 German Prisons for Sentenced Inmates

Injection drug use (IDU) and IDU-related infectious diseases such as hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections are highly prevalent among prisoners worldwide. However, little is known about the prevalence of IDUs and HCV/HIV and the availability of respective treatment options in German prisons. Data, provided by prison physicians of 31 prisons, representing 14,187 inmates, were included in this analysis. The proportion of IDUs among all prisoners was 21.9%. Substitution treatment was available in three out of four prisons (74.2%). Overall, 1,137 substitution treatments were provided annually with a wide range of treatment aims. The prevalence rate was 14.3% for HCV and 1.2% for HIV. Around 5.5% of all HCV-infected prisoners were in antiviral treatment annually, 86.5% of all HIV-positive subjects in antiretroviral HIV treatment.

Generally, substitution treatment, HCV and HIV testing and treatment are available. However, due to abstinence-oriented treatment aims substitution treatment is rarely available as maintenance treatment, and HCV/HIV treatment is mainly provided for patients with an existing treatment before imprisonment. The inconsistent data quality necessitate changes in prison related policy are needed, to improve surveillance and to generate aggregated data in German prisons. The selection process in this analysis might lead to overestimating the provision substitution - and antiviral HCV-treatment.

Physical and Mental Health in Severe Opioid Dependent Patients Within a Randomised Controlled Maintenance Treatment Trial

Background:

Injection drug users (IDUs) frequently suffer from somatic and mental co-morbidity. The effects of different opioid maintenance protocols on these parameters have not been systematically studied yet.

Methods:

This study was conducted as a 12-month open-label multi-centre randomised controlled trial to test a heroin- vs. methadone based protocol.

Results:

515 patients were randomised to the heroin-assisted and 500 to the methadone-assisted treatment program. Baseline scores were as follows: OTI-HSS 19.0 (±5.2), BMI 22.6 (±3.5), pathologic electro-/echocardiogram 20.4% (n=582) / 13.9% (n=491), positive HBV-, HCV- and HIV-serology 65.7% (n=863) / 86.5% (n=855) / 9.2% (n=951), positive tuberculin test 9.1% (n=318), KPS 71.4 (±12.9), Global Severity Index (GSI; SCL-90-R) 69.2 (±10.6), GAF 53.6 (±11.7) (all parameters not significant between treatment groups). Improvement after 12 months of treatment differed significantly between treatment groups (heroin vs. methadone): OTI-HSS 8.1 (±5.2) vs. 10.6 (±6.4), BMI 24.5 (±4.3) vs. 23.7 (±4.1), KPS 78.2 (±12.8) vs. 74.2 (±13.3), GSI 58.6 (±13.7) vs. 62.0 (±13.2), GAF 63.0 (±13.3) vs. 56.2 (±15.0) (ANOVA, all p=.000). The frequency of pathologic echocardiograms after 12 months was significantly lower in the heroin compared to the methadone group. Within the heroin group, completers benefited stronger than drop-outs. The remaining parameters did not differ between baseline and 12 months and between treatment groups.

Conclusion:

Integration of severe injection drug users either in methadone or heroin assisted maintenance treatment has positive effects on most change sensitive physical and mental variables. In this patient group heroin assisted treatment showed superior results compared to methadone.

[Prevention of hepatitis C virus infection in drug users]

The high prevalence and incidence rates of the hepatitis C virus (HCV) infections in drug users demonstrate the urgent necessity for a coordinated national prevention strategy. In the shadow of HIV/AIDS the necessary attention to the rapid spreading of the hepatitis C in drug users was started late, without being able to reach the public attention level of HIV/AIDS. The present efforts in the primary and secondary prevention of the hepatitis C in drug users are obviously not sufficient to reduce the prevalence with long-lasting results. Substitution treatment is of central relevance in the prevention of hepatitis C in opiate-dependent subjects, but requires, as current data of the HCV incidence of substituted opiate dependents illustrate, a stronger HCV-specific accentuation. Further settings, which are relevant for the group of intravenous drug users, have to be accessed and sensitized. Furthermore structural and political efforts are necessary, in order to develop a systematic and evidence-based answer to the challenge of the HCV spreading in drug users, in particular due to the fact that a German HCV strategy is still lacking.

Therapie der chronischen Hepatitis C im Rahmen einer heroingestützten Behandlung

HISTORY AND FINDINGS

A 37-year-old man with a 19-years history of injection drug use (IDU) who had acquired a chronic hepatitis C virus (HCV-) infection 9 years ago, entered the German clinical study on heroine assisted treatment ("Modellprojekt zur heroingestützten Behandlung Opiatabhängiger"). Before study onset he received buprenorphine maintainance treatment, while at the same time engaging in illicit IDU (heroine, cocaine). He lived in a caravan and was on social welfare.

INVESTIGATIONS

PCR revealed a genotype 2 and an HCV-viral load of 310,000 IU/ml. Liver biopsy showed a moderate chronic active hepatitis and a mild portal fibrosis without signs of liver cirrhosis.

DIAGNOSIS, TREATMENT AND COURSE

Within the heroine-assisted treatment program the patient injected heroine under medical supervision several times a day and attended the standardized psychosocial program that comprised an intensive education on HCV-infection. Within a period of ten months of physical and social stabilization he managed to stop illicit drug use, found stable housing and started to work. We then initiated treatment of HCV-infection. Subcutaneous pegylated interferon alpha-2a, peroral ribavirin and intravenous heroine were administered as directly observed therapy. Based on the close mashed care of the heroine assisted treatment setting, side effects were well controllable and reversible after the end of antiviral therapy. A sustained response was obtained.

CONCLUSION

After careful indication, heroine-assisted treatment with particularly intensive medical and psychological care can offer appropriate conditions for a save and successful treatment of hepatitis C as well as for a sustained result.

Switching From Cyclosporine to Tacrolimus Leads to Improved Disease-Specific Quality of Life in Patients After Kidney Transplantation

BACKGROUND

Advances in transplantation medicine are linked to improved efficacy of immunosuppressive agents. At the same time, these agents endanger medical success by side effects that may impair survival and quality of life (QOL). This study examined whether conversion to tacrolimus-based immunosuppression due to cyclosporine-related side effects improved. QOL in patients after kidney transplantation.

METHODS

In total 64 patients (29 men) with an average age of 51 years (SD+/-12) who had received a kidney allograft an average of 5.6 years (SD+/-4) before conversion participated. The reasons for conversion were cardiovascular/metabolic (n=26) or periodontal/dermatological side effects (n=38) of cyclosporine therapy. QOL was assessed before conversion and in average 7 months thereafter by a global (SF-36) and a disease-specific instrument (ESRD-SCL).

RESULTS

Disease-specific QOL (ESRD-SCL, global index) improved significantly (P<.001, explanation of variance [EV]=16.6%) after conversion from cyclosporine to tacrolimus. In detail, cardiac and renal dysfunction (P<.01, EV=12.9%) as well as increased growth of gum and hair (P<.0001, EV=53.2%) were significantly reduced at end of the study. However, global QOL (SF-36) remained unchanged.

CONCLUSION

Regardless of the indication (cardiovascular or cosmetic), switching to tacrolimus due to cyclosporine-related side effects improved disease-specific QOL within the short term.