Multidomain intervention for the prevention of cognitive decline after stroke - a pooled patient-level data analysis

Background and purpose

The aim of this pooled patient‐level data analysis was to test if multidomain interventions, addressing several modifiable vascular risk factors simultaneously, are more effective than usual post‐stroke care for the prevention of cognitive decline after stroke.

Methods

This pooled patient‐level data analysis included two randomized controlled trials using a multidomain approach to target vascular risk factors in stroke patients and cognition as primary outcome. Changes from baseline to 12 months in the trail making test (TMT)‐A, TMT‐B and 10‐words test were analysed using stepwise backward linear mixed models with study as random factor. Two analyses were based on the intention‐to‐treat (ITT) principle using different imputation approaches and one was based on complete cases.

Results

Data from 322 patients (157 assigned to multidomain intervention and 165 to standard care) were analysed. Differences between randomization groups for TMT‐A scores were found in one ITT model (P = 0.014) and approached significance in the second ITT model (P = 0.087) and for complete cases (P = 0.091). No significant intervention effects were found for any of the other cognitive variables.

Conclusion

We found indications that multidomain interventions compared with standard care can improve the scores in TMT‐A at 1 year after stroke but not those for TMT‐B or the 10‐words test. These results have to be interpreted with caution due to the small number of patients.

Diabetes and thrombolysis for acute stroke: a clear benefit for diabetics

BACKGROUND AND PURPOSE

Diabetes is a predictor for poor outcome after thrombolysis in stroke patients, and early post-stroke glycaemia is associated with higher rates of post-thrombolytic symptomatic intracerebral haemorrhages (SICHs). Diabetic stroke patients may nevertheless profit from thrombolysis. Here, we compared outcome data of matched thrombolysed and non-thrombolysed diabetic and non-diabetic stroke patients from a national database.

METHODS

The outcomes of 1079 matched quadruples, each consisting of a thrombolysed diabetic, a non-thrombolysed diabetic, a thrombolysed non-diabetic and a non-thrombolysed non-diabetic case (a total of 4316 cases), enrolled in the Austrian Stroke Unit Registry (2004-2013), were compared. Patients were matched according to sex, age, stroke severity, pre-stroke disability and prior stroke.

RESULTS

A regression model with improvement as depending variable found no effect of diabetes (P = 0.158) or the interaction diabetes × thrombolysis (P = 0.507), whereas the effect of thrombolysis itself was highly significant (P < 0.001). Functional outcome (modified Rankin Scale) was significantly better in thrombolysed than in non-thrombolysed diabetic patients at discharge from the stroke-unit (P < 0.001) and 3 months later (P = 0.006). No significant differences were found in the number of SICHs after thrombolytic treatment between diabetic (4.9%) and non-diabetic strokes (3.5%). Both groups had a higher risk of SICH compared with the non-thrombolysed groups (diabetics 2.6%, non-diabetics 2.5%). Due to lack of documentation, the effect of admission blood glucose on SICH was not investigated.

CONCLUSIONS

Data from this nationwide survey show that diabetic stroke patients receive a substantial benefit from thrombolysis, and therefore diabetic strokes should not be excluded from thrombolytic treatment.

Prevention of post-stroke cognitive decline: a review focusing on lifestyle interventions

BACKGROUND AND PURPOSE

Despite a high prevalence of post-stroke cognitive impairment, therapeutic possibilities are still limited. Stroke and dementia share the same cluster of modifiable risk factors. Thus, lifestyle interventions and strict adherence to medication may not only decrease the risk of recurrent stroke but also the risk of post-stroke cognitive decline.

METHODS

We performed a systematic literature search for randomized clinical trials (RCTs) targeting modifiable risk factors for the prevention of cognitive decline following stroke.

RESULTS

We identified 25 non-pharmacological interventions and eight multiple risk factor interventions in stroke patients using cognition as outcome measure. None of the published trials investigated interventions aimed at the prevention of post-stroke cognitive decline. However, a number of ongoing trials aim at risk factor reduction and include measures on cognition.

CONCLUSION

Evidence for risk factor modification for the prevention of cognitive decline after stroke is scarce and comes mainly from observational studies. There is a need for more RCTs targeting the prevention of post-stroke dementia using lifestyle interventions and a multiple risk factor approach.

The mirror world of motor inhibition: the alien hand syndrome in chronic stroke

Alien hand syndrome (AHS) is rare, but important due to its disabling impact on everyday life. The determining characteristic of AHS is intermanual conflict, a type of inhibitory motor behaviour that occurs against willed action. Its components have previously been described as single case reports, but not as a systematic study. This review includes eight chronic cases, all of which are due to infarcts of the anterior cerebral artery. Clinical investigation included testing of motor behaviour related to everyday activities, such as tying shoelaces, lighting a candle and other bimanual tasks. Video-analysis showed that conflicting behaviour occurs in two distinct forms. One consists of interfering, rudimentary, hesitant and repetitive movements of the (alien) hand, often initiated by movements of the other hand. In some instances, disturbance of ongoing action is seen as spacious, ballistic-like extensions of the whole arm. This was most prevalent in three of the eight cases. In one patient, it was also seen as conflict with both feet (eg, when putting on slippers) or as a conflict of intentions (eg, when planning to enter a room). The other form consisted of massive groping and grasping behaviour as the most dominant features, such as a "tug of war between hands", and was seen in five patients. Avoidance behaviour included sitting on the affected arm, holding it under the table or keeping objects out of reach. Enforcement of such strategies was used for rehabilitation and--although beneficial in the training sessions--carried over very little to everyday life. All cases had two distinct brain lesions, one in the genu or anterior rostrum of the corpus callosum and one in the contralateral frontomedial cortical and subcortical region. Chronic AHS is the only clinical syndrome that shows complex inhibitory motor behaviour in a more or less pure form because it has become detached from the control of motor planning and execution. It can best be understood as sequences of complex inhibitory motor programmes that have become isolated from normal motor planning, which usually suppresses them via the contralateral cortico-subcortical prefrontal circuits and the corpus callosum. Thus, the mirror world of complex motor inhibition becomes clinically visible in such patients.

Disabling neurological syndromes: prevalence amongst hospitalized neurological patients

Neurological patient populations are usually described by diagnosis or in terms of functional disability measures but rarely by their clinical syndromes. A point-prevalence study was conducted assessing 349 neurological inpatients to determine the frequency and co-occurrence of disabling neurological syndromes, considering a wider spectrum including pain, emotional, neuropsychological, vegetative and sensorimotor syndromes. Of the study patients, 61% (n = 224) had sensorimotor syndromes, 53% (n = 185) had neuropsychological disorders, 40% (n = 139) of the patients suffered from pain, emotional disorders were found in 36% (n = 122) and vegetative disorders in 33% (n = 113). Although frequency varied by neurological diagnosis, these disabling conditions were found across all inpatient groups of diagnosis. Similarly, disorders outside the motor domains grouped according to their Barthel Index showed a striking frequency in patients considered as activities of daily living independent, reflecting a wider spectrum of disability that functional measures are not able to capture. Of the study population, 68% (n = 237) suffered from co-occurring disorders from different categories (pain, emotional, neuropsychological, vegetative and sensorimotor syndromes). There is a high prevalence and co-occurrence of disabling syndromes in neurological inpatients. These proportions reflect the neurological workload in a patient population and should be considered in future rehabilitation research and allocation of resources.

Dyslipidemia, elevated LDL cholesterol and reduced nocturnal blood pressure dipping denote lacunar strokes occurring during nighttime

Previous studies have shown a peak occurrence of ischemic stroke in the morning but no consistent finding has been attributed to this. Focused on lacunar strokes we performed a prospective study with a detailed diagnostic protocol including parameters of recent infection, indicators of sleep apnea and cerebral vasoreactivity (CVR), aimed at defining differences in risk profiles between diurnal and nocturnal strokes. Consecutively we included 33 nocturnal and 54 diurnal strokes. Baseline characteristics, known risk factors, stroke severity and topology were not different between groups. The mean low-density lipoprotein (LDL) cholesterol level was significantly higher amongst patients with nocturnal strokes (133.3 +/- 35.2 mg/dl vs. 115.5 +/- 39.8 mg/dl; P = 0.04), as well as the proportion of patients with any dyslipidemia (94% vs. 77.8%; P = 0.047). Twenty-four-hour blood pressure recordings showed a reduced nocturnal decrease of blood pressure in subjects with strokes that occurred between 10 pm and 6 am in comparison with those whose strokes occurred between 6 am and 2 pm (5.0 +/- 7.3% vs. 11.0 +/- 6.7%; P = 0.049). No significant differences were found for parameters of recent infection (including seroreactivity against Chlamydia pneumoniae and cytomegalovirus), CVR, indicators of sleep apnea and the degree of white matter disease assessed by magnetic resonance tomography. Dyslipidemia, especially elevated LDL cholesterol is more prevalent in nocturnal lacunar strokes especially when combined with a reduced nocturnal dipping of blood pressure. This risk factor profile can be regarded as an additional target for stroke prevention.

Chronic porcine two-hit model with hemorrhagic shock and Pseudomonas aeruginosa sepsis

BACKGROUND

Sepsis is still a major cause of death despite well-developed therapeutical strategies such as antibiotics and supportive medication. The aim of this study was to characterize the long-term effects of a two-hit porcine sepsis model with a hemorrhagic shock as 'first hit' followed by a Pseudomonas aeruginosa infusion as 'second hit'.

MATERIALS AND METHODS

Twelve juvenile healthy pigs were anesthetized and hemodynamically monitored. The two-hit group (n = 6) underwent a hemorrhagic shock with a 50% reduction of the mean arterial pressure and/or cardiac index for 45 min, followed by resuscitation, while the control group (n = 6) received no pretreatment. All chronically catheterized conscious pigs were challenged with a P. aeruginosa infusion (1.6 x 10(7) CFU/kg/h for the first 24 h followed by 1.6 x 10(6) CFU/kg/h for the next 24 h) and observed for another 48 h.

RESULTS

The two-hit group showed the following significant differences to the control group: higher APACHE II scores prior to sepsis induction, increased persisting mean pulmonary arterial pressure (MPAP) and pulmonary vascular resistance index (PVRI) during bacterial challenge. In contrast, systemic vascular resistance (SVRI) was reduced at the end of the study. Throughout the observation period, the mean arterial pressure (MAP) was significantly reduced.

CONCLUSIONS

The present study shows that the clinical course and hemodynamic effects of a P. aeruginosa sepsis will be aggravated by a preceding hemorrhagic shock during an observation period of 96 h. This two-hit model represents a valid, clinically relevant experimental protocol in sepsis research.

High-performance liquid chromatographic analysis of cyclosporin G (Nva2-cyclosporine) in human blood

A sensitive high-performance liquid chromatographic method for the analysis of the immunosuppressant cyclosporin G (OG 37-325, Nva2-cyclosporine, CsG) in whole blood has been developed. Sample preparation, employing cyclosporin A (CsA) as internal standard, involves organic extraction with methyl t-butyl ether under sequential acidic and basic conditions. Chromatography is performed using a 2 mm inside diameter x 25 cm column packed with 5 microns octyl (C8) material. An isocratic mobile phase comprised of acetonitrile:methanol:water, at a flow rate of 0.4 ml/min, is utilized. Separation is monitored at 230 nm. Data are also presented that demonstrate the use of CsG as an alternative internal standard to cyclosporin D for liquid chromatographic determinations of CsA.

Algorithms for evaluating the appropriateness of blood transfusion

Medicare regulations and the guidelines of the Joint Commission on Accreditation of Healthcare Organizations require assessment of the appropriateness of transfusions by a hospital committee. A set of criteria maps for component transfusion review by nurses or technical personnel was designed, tested, and modified. The algorithms were based on written guidelines developed by a group of physicians. In the first part of the study, 196 medical records of patients from medical and surgical diagnosis-related groups with the highest utilization of blood (Group I) were screened. Forty patients were excluded because of a preexisting transfusion protocol. Of the remaining 156 patients, 146 (94%) received red cell transfusions, of which 96 percent were indicated, 1 percent not indicated, and 3 percent controversial. Thirty-five patients (22%) received fresh-frozen plasma transfusions, of which 69 percent were indicated, 11 percent not indicated, 17 percent controversial, and 6 percent indeterminate. In the second part of the study, medical records were screened from 99 randomly selected patients who had received red cell transfusions (Group II), and the results were similar to those in Group I. Physician review was necessary in 20 percent of the transfused patients screened with the criteria maps. It is concluded that algorithms for transfusion review can be developed and used easily to fulfill regulatory and accreditation requirements and to plan focused educational programs.

Translational polarity of a mutation in the initiator AUG codon of the lambda cI gene

A PRM-cI-lacZ fusion inserted into the b2 region of bacteriophage lambda was used to isolate mutations affecting expression of both the lambda cI gene and the lacZ gene. One such mutation, a change in the cI initiator codon from AUG to AUA, reduces immunity of a lambda prophage to superinfection, and causes a 60-70% reduction in beta-galactosidase synthesis, even when repressor is supplied in trans. The effect of the mutation on lacZ gene expression is eliminated in a rho- bacterial strain, and the mutation has no effect on transcription initiated at PRM in vitro. Therefore, the effects of the mutation are due to premature p-dependent termination of transcription in the absence of translation of the cI gene, as if the mutation were a nonsense polar mutation.

New mutations in the pRM promoter of bacteriophage lambda

A pRM-cI-lacZ fusion inserted into the b2 region of bacteriophage lambda imm21 was used to isolate mutations in the lambda pRM promoter. Among the mutations causing defects in synthesis of both repressor (cI gene product) and beta-galactosidase, new promoter mutations were identified at positions -11 and -32 relative to the cI transcription start point. Both mutations are changes in conserved (consensus) nucleotides in pRM, but the mutation at -11, which alters a more highly conserved nucleotide, has a somewhat greater effect on promoter function in vitro than does the mutation at -32. We also isolated a mutation at -69 in the repressor-binding site OR1, which presumably prevents activation of pRM by repressor.

Liquid-chromatographic analysis for cyclosporine with use of a microbore column and small sample volume

This liquid-chromatographic assay requires 0.2 to 0.5 mL of whole blood, avoids the use of diethyl ether, and consumes only 10 to 20% of the solvents used in prior methods. Sample preparation involves an acidic extraction with methyl-t-butyl ether, performed in a 13 X 100 mm disposable glass tube, then a short second extraction of the organic phase with sodium hydroxide. After evaporation of the methyl-t-butyl ether, chromatography is performed on an "Astec" 2.0-mm (i.d.) octyl column. We compared results by this procedure with those by use of earlier larger-scale extractions and their respective 4.6-mm (i.d.) columns; analytical recoveries of cyclosporins A and D were comparable with previous findings and results for patients' specimens were equivalent, but the microbore columns provided greatly increased resolution and sensitivity.

Liquid-chromatographic analysis for cyclosporine with use of a microbore column and small sample volume

This liquid-chromatographic assay requires 0.2 to 0.5 mL of whole blood, avoids the use of diethyl ether, and consumes only 10 to 20% of the solvents used in prior methods. Sample preparation involves an acidic extraction with methyl-t-butyl ether, performed in a 13 X 100 mm disposable glass tube, then a short second extraction of the organic phase with sodium hydroxide. After evaporation of the methyl-t-butyl ether, chromatography is performed on an "Astec" 2.0-mm (i.d.) octyl column. We compared results by this procedure with those by use of earlier larger-scale extractions and their respective 4.6-mm (i.d.) columns; analytical recoveries of cyclosporins A and D were comparable with previous findings and results for patients' specimens were equivalent, but the microbore columns provided greatly increased resolution and sensitivity.

A high performance liquid chromatographic assay for tocainide with alternate application for the determination of lidocaine, procainamide, and N-acetylprocainamide

We describe a simple, isocratic high-performance liquid chromatographic method for measuring the oral antiarrhythmic agent tocainide in serum. The extraction requires 200 microliters of serum, is performed on a reverse-phase column, and utilizes the drug mepivacaine as the internal standard. This analytical method can also be used to assay procainamide, n-acetylprocainamide, or lidocaine with minor modifications to either the extraction protocol or the wavelength used to monitor column eluant.

Simultaneous determination of penicillin and cephalosporin antibiotics in serum by gradient liquid chromatography

We describe a "high-performance" liquid-chromatographic method for simultaneously measuring various penicillin and cephalosporin antibiotics. After extraction from serum, which in general is quantitative, the drugs are separated by use of a "Bondapak phenyl" column and a gradient mobile phase. For these drugs retention times depend on the pH of the mobile phase; we present retention times under selected pH conditions.

Simultaneous determination of penicillin and cephalosporin antibiotics in serum by gradient liquid chromatography

We describe a "high-performance" liquid-chromatographic method for simultaneously measuring various penicillin and cephalosporin antibiotics. After extraction from serum, which in general is quantitative, the drugs are separated by use of a "Bondapak phenyl" column and a gradient mobile phase. For these drugs retention times depend on the pH of the mobile phase; we present retention times under selected pH conditions.

The rex gene of bacteriophage lambda is really two genes

Complementation tests among previously isolated rex- mutants of bacteriophage lambda reveal that the mutants comprise two complementation groups, designated rexA and rexB. Because rexB- mutants complement prm- mutants, but rexA- mutants do not, it appears that the rexA gene is coordinately controlled with the cI (repressor) gene under the direction of PRM promoter, but that some other promoter is capable of directing the expression of rexB.

DNA sequence analysis of prm-mutations of coliphage lambda

Nucleotide sequence changes associated with mutation of the prm promoter of bacteriophage lambda have been determined. Prm-mutations have been assigned to two classes. Class I mutations appear to affect the interaction of RNA polymerase with prm; six class I mutations affect four sites, located 14, 33, 38, and 39 bp preceding the prm transcription startpoint. Class II mutations appear to owe their Prm-phenotype to a change in OR, which could prevent activation of prm by repressor. All three class II mutations are in OR 1.

[Aqueous humor levels of gentamicin after parenteral, subconjunctival and topical administration (aithor's transl)]

The purpose of this study was to determine the concentration of Gentamicin in blood serum and primary aqueous humor at varying periods of time after intravenous, intramuscular, subconjunctival and topical administration of Gentamicin. Therapeutic effective levels in primary aqueous humor were measured only after subconjunctival injections. The only broad spectrum antibiotics are the aminoglykosides Gentamicin, Tobramycin, Sisomicin and Amikacin. For prompt treatment of bacterial endophthalmitis without bacterial culture and antibiotic sensitivity testing therefore subconjunctival injection of Gentamicin is necessary.

[Recurrent urinary tract infection in childhood. Diagnosis, treatment, prognosis (author's transl)]

Infection of the urinary tract in childhood is common. It may start already in neonates or infants. Clinical signs are not always present but asymptomatic socalled bacteriuria may occur at any age. The earlier a child contracts the infection the more common are uncharacteristic clinical signs like loss of appetite, a raised temperature, parenchymatous icterus and, finally signs of involvement of the central nervous system. During the last few years purposeful research has established the important fact that, if there has been a urinary tract infection particularly in the first months of life, recurrence may more often be asymptomatic than on the first occasion. A mid-stream specimen is diagnostically valuable. If this does contain any bacteria, then supapubic aspiration from the bladder is useful in enabling us to start a specific, if possible bactericidal, therapy. Asymptomatic bacteriuria may at any time lead to clinical signs of pyelonephritis, particularly during periods of stress. Such silent unrecognized cases of asymptomatic bacteriuria may, we feel, lead to pyelonephritic nephrosis in a so far unknown percentage of cases.