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Zuo L, Dong Y, Liao X, Hu Y, Pan Y, Yan H, Wang X, Zhao X, Wang Y, Seet RCS, Wang Y, Li Z. Low HALP (Hemoglobin, Albumin, Lymphocyte, and Platelet) Score Increases the Risk of Post-Stroke Cognitive Impairment: A Multicenter Cohort Study. Clin Interv Aging 2024; 19:81-92. [PMID: 38223135 PMCID: PMC10788070 DOI: 10.2147/cia.s432885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/24/2023] [Indexed: 01/16/2024] Open
Abstract
Objective The HALP (hemoglobin, albumin, lymphocyte, and platelet) score is a novel indicator that measures systemic inflammation and nutritional status that has not been correlated with the risk of post-stroke cognitive impairment in patients with acute ischemic stroke or transient ischemic attack (TIA). Methods Study participants were recruited from 40 stroke centers in China. The HALP score was derived using a weighted sum of hemoglobin, albumin, lymphocytes and platelets, and study participants were categorized into 4 groups of equal sizes based on quartiles cutoffs of the HALP score. The Montreal Cognitive Assessment (MoCA)-Beijing Cognitive Assessment Scale (MoCA-Beijing) was performed at 2 weeks and 12 months following stroke onset. Post-stroke cognitive impairment was considered in patients with MoCA-Beijing≤22. Multiple logistic regression methods were employed to evaluate the relationship between the HALP score and the subsequent risk of developing post-stroke cognitive impairment. Results The study population comprised 1022 patients (mean age 61.6±11.0 years, 73% men). The proportion of individuals with MoCA-Beijing≤22 at 2 weeks was 49.2% and 32.4% at one year. Patients in the lowest quartile of HALP score (<36.56) were observed to harbor the highest risk of post-stroke cognitive impairment at 12 months post-stroke/TIA compared to those in the highest quartile (odds ratio=1.59, 95% CI=1.07-2.37, p=0.022), and lower domain scores for executive function, naming, and attention. There were no statistically significant differences between patients in the different quartiles of HALP score and HALP score at 2 weeks post-stroke/TIA. Conclusion The HALP score is a simple score that could stratify the risk of post-stroke cognitive impairment in stroke/TIA patients to facilitate early diagnosis and interventions.
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Affiliation(s)
- Lijun Zuo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yanhong Dong
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Clinical Research Centre, Singapore
| | - Xiaoling Liao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yang Hu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hongyi Yan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xingao Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, People’s Republic of China
- Chinese Institute for Brain Research, Beijing, People’s Republic of China
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Koh JS, Cook AR, Seet RCS. Low incidence of neurological recurrent side effects following COVID-19 reimmunization. QJM 2023; 116:1039. [PMID: 37364012 DOI: 10.1093/qjmed/hcad153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Indexed: 06/28/2023] Open
Affiliation(s)
- J S Koh
- Department of Neurology, National Neuroscience Institute (Tan Tock Seng Hospital Campus), Singapore
| | - A R Cook
- Saw Swee Hock School of Public Health, National University Singapore and National University Health System, Singapore
| | - R C S Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore
- Healthy Longevity Translational Research Programme, Yong Loo Lin School of Medicine, National University Singapore, Singapore
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3
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Jing M, Bao LXY, Seet RCS. Estimated Incidence and Mortality of Stroke in China. JAMA Netw Open 2023; 6:e231468. [PMID: 36862416 DOI: 10.1001/jamanetworkopen.2023.1468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Affiliation(s)
- Mingxue Jing
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Lena X Y Bao
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Raymond C S Seet
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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4
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Lim NA, Teng O, Ng CYH, Bao LXY, Tambyah PA, Quek AML, Seet RCS. Repurposing povidone-iodine to reduce the risk of SARS-CoV-2 infection and transmission: a narrative review. Ann Med 2022; 54:1488-1499. [PMID: 35594333 PMCID: PMC9132411 DOI: 10.1080/07853890.2022.2076902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/22/2022] [Accepted: 05/08/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Accumulating data suggest antiviral effects of povidone-iodine against the Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. This narrative review aims to examine the antiviral mechanisms of povidone-iodine, efficacy of povidone-iodine against the SARS-CoV-2 virus, and safety of povidone-iodine to human epithelial cells and thyroid function. METHODS We searched the electronic databases PubMed, Embase, Cochrane Library, ClinicalTrials.gov and World Health Organization's International Clinical Trials Registry Platform for articles containing the keywords "povidone-iodine", "SARS-CoV-2" and "COVID-19" from database inception till 3 June 2021. RESULTS Despite in vitro data supporting the anti-SARS-CoV-2 effects of povidone-iodine, findings from clinical studies revealed differences in treatment response depending on study settings (healthy vs. hospitalized individuals), treatment target (nasal vs. oral vs. pharynx), method of administration (oral rinse vs. gargle vs. throat spray) and choice of samples used to measure study endpoints (nasopharyngeal vs. saliva). One large-scale clinical trial demonstrated reduction in the incidence of SARS-CoV-2 infection among participants who administered povidone-iodine 3 times daily during an active outbreak. Povidone-iodine is also used to disinfect the oro-pharyngeal space prior to dental or otolaryngology procedures. Although existing data suggest minimal impact of povidone-iodine on thyroid function, high-quality safety data are presently lacking. CONCLUSIONS Povidone-iodine application to the oropharyngeal space could complement existing non-pharmacological interventions to reduce SARS-CoV-2 infection especially in high exposure settings.Key messagesAccumulating data suggest antiviral effects of povidone-iodine against the SARS-CoV-2 virus.Findings from clinical studies reveal differences in treatment response depending on study settings, treatment target, method of administration and choice of samples used to measure study endpoints. One large-scale clinical trial observed reduction in the incidence of SARS-CoV-2 infection among participants who administered povidone-iodine 3 times daily during an active outbreak.Povidone-iodine application to the oropharyngeal space could complement existing non-pharmacological interventions to reduce SARS-CoV-2 infection especially in high exposure settings.
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Affiliation(s)
- Nicole-Ann Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ooiean Teng
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chester Yan Hao Ng
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Lena X. Y. Bao
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Paul Anantharajah Tambyah
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Amy M. L. Quek
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Raymond C. S. Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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5
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Tan BYQ, Siow I, Lee KS, Chen V, Ong N, Gopinathan A, Yang C, Bhogal P, Lam E, Spooner O, Meyer L, Fiehler J, Papanagiotou P, Kastrup A, Alexandrou M, Zubel S, Wu Q, Mpotsaris A, Maus V, Andersson T, Gontu V, Arnberg F, Lee TH, Chan B, Teoh HL, Seet RCS, Sharma V, Yeo LLL. Effect of Sex on Outcomes of Mechanical Thrombectomy in Basilar Artery Occlusion: A Multicentre Cohort Study. Cerebrovasc Dis 2022; 51:639-646. [PMID: 35390799 DOI: 10.1159/000524048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/13/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Identifying differences in outcome of basilar artery occlusion (BAO) between males and females may be useful in aiding clinical management. Recent studies have demonstrated widespread underrepresentation of women in acute stroke clinical trials. This international multicentre study aimed to determine sex differences in outcome after mechanical thrombectomy (MT) for patients with acute BAO. METHODS We performed a retrospective analysis of consecutive patients with BAO who had undergone MT in seven stroke centres across five countries (Singapore, Taiwan, United Kingdom, Sweden, and Germany), between 2015 and 2020. Primary outcome was a favourable functional outcome measured by a modified Ranking Scale (mRS) of 0-3 at 90 days. Secondary outcomes were mRS 0-3 upon discharge, mortality, symptomatic intracranial haemorrhage (sICH) and subarachnoid haemorrhage (SAH). RESULTS Among the 322 patients who underwent MT, 206 (64.0%) patients were male and 116 (36.0%) were female. Females were older than males (mean ± SD 70.9 ± 14.3 years vs. 65.6 ± 133.6 years; p = 0.001) and had higher rates of atrial fibrillation (38.9% vs. 24.2%; p = 0.012). Time from groin puncture to reperfusion was shorter in females than males (mean ± SD 57.2 ± 37.2 min vs. 71.1 ± 50.9 min; p = 0.021). Despite these differences, primary and secondary outcome measures were similar in females and males, with comparable rates of favourable 90-day mRS scores (mean ± SD 46 ± 39.7 vs. 71 ± 34.5; OR = 1.20; 95% confidence interval [CI] = 0.59-2.43; p = 0.611), favourable discharge mRS scores (mean ± SD 39 ± 31.6 vs. 43 ± 25.9; OR = 1.38; 95% CI = 0.69-2.78; p = 0.368) and in-hospital mortality (mean ± SD 30 ± 25.9 vs. 47 ± 22.8; OR = 1.15; 95% CI = 0.55-2.43; p = 0.710. Rates of complications such as sICH (mean ± SD 5 ± 4.3 vs. 9 ± 4.4; OR = 0.46; 95% CI = 0.08-2.66; p = 0.385) and SAH (mean ± SD 4 ± 3.4 vs. 5 ± 2.4; OR = 0.29; 95% CI = 0.03-3.09; p = 0.303) comparably low in both groups. CONCLUSION Females achieved comparable functional outcomes compared with males after undergoing MT for BAO acute ischemic stroke.
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Affiliation(s)
- Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Isabel Siow
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore,
| | - Keng Siang Lee
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Vanessa Chen
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Natalie Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Anil Gopinathan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Cunli Yang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, London, United Kingdom
| | - Erika Lam
- Stroke Department, The Royal London Hospital, Barts NHS Trust, London, United Kingdom
| | - Oliver Spooner
- Stroke Department, The Royal London Hospital, Barts NHS Trust, London, United Kingdom
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany.,First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte, Bremen, Germany
| | - Maria Alexandrou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
| | - Seraphine Zubel
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Qingyu Wu
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | | | - Volker Maus
- Institute of Diagnostic and Interventional Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Vamsi Gontu
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Fabian Arnberg
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Bernard Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Vijay Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
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6
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Tan BYQ, Ho JSY, Leow AS, Chia MLJ, Sia CH, Koh YY, Seetharaman SK, Yang C, Gopinathan A, Teoh HL, Sharma VK, Seet RCS, Chan BPL, Yeo LLL, Tan LF. Effect of frailty on outcomes of endovascular treatment for acute ischaemic stroke in older patients. Age Ageing 2022; 51:6575882. [PMID: 35486669 DOI: 10.1093/ageing/afac096] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND frailty has been shown to be a better predictor of clinical outcomes than age alone across many diseases. Few studies have examined the relationship between frailty, stroke and stroke interventions such as endovascular thrombectomy (EVT). OBJECTIVE we aimed to investigate the impact of frailty measured by clinical frailty scale (CFS) on clinical outcomes after EVT for acute ischemic stroke (AIS) in older patients ≥70 years. METHODS in this retrospective cohort study, we included all consecutive AIS patients age ≥ 70 years receiving EVT at a single comprehensive stroke centre. Patients with CFS of 1-3 were defined as not frail, and CFS > 3 was defined as frail. The primary outcome was modified Rankin Score (mRS) at 90 days. The secondary outcomes included duration of hospitalisation, in-hospital mortality, carer requirement, successful reperfusion, symptomatic intracranial haemorrhage and haemorrhagic transformation. RESULTS a total of 198 patients were included. The mean age was 78.1 years and 52.0% were female. Frail patients were older, more likely to be female, had more co-morbidities. CFS was significantly associated with poor functional outcome after adjustment for age, NIHSS and time to intervention (adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI] 1.04-2.28, P = 0.032). There was trend towards higher mortality rate in frail patients (frail: 18.3%; non-frail: 9.6%; P = 0.080). There were no significant differences in other secondary outcomes except increased carer requirement post discharge in frail patients (frail: 91.6%; non-frail: 72.8%; P = 0.002). CONCLUSIONS frailty was associated with poorer functional outcome at 90 days post-EVT in patients ≥ 70 years.
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Affiliation(s)
- Benjamin Y Q Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jamie S Y Ho
- Academic Foundation Programme, Royal Free London NHS Foundation Trust, London, UK
| | - Aloysius S Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Magdalene L J Chia
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Ching Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ying Ying Koh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Cunli Yang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Anil Gopinathan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Raymond C S Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Li Feng Tan
- Healthy Ageing Programme, Department of Geriatric Medicine, Alexandra Hospital, Singapore, Singapore
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7
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Ng CYH, Lim NA, Bao LXY, Quek AML, Seet RCS. Mitigating SARS-CoV-2 Transmission in Hospitals: A Systematic Literature Review. Public Health Rev 2022; 43:1604572. [PMID: 35296115 PMCID: PMC8906284 DOI: 10.3389/phrs.2022.1604572] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/19/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives: Hospital outbreaks of SARS-CoV-2 infection are dreaded but preventable catastrophes. We review the literature to examine the pattern of SARS-CoV-2 transmission in hospitals and identify potential vulnerabilities to mitigate the risk of infection. Methods: Three electronic databases (PubMed, Embase and Scopus) were searched from inception to July 27, 2021 for publications reporting SARS-CoV-2 outbreaks in hospital. Relevant articles and grey literature reports were hand-searched. Results: Twenty-seven articles that described 35 SARS-CoV-2 outbreaks were included. Despite epidemiological investigations, the primary case could not be identified in 37% of outbreaks. Healthcare workers accounted for 40% of primary cases (doctors 17%, followed by ancillary staff 11%). Mortality among infected patients was approximately 15%. By contrast, none of the infected HCWs died. Several concerning patterns were identified, including infections involving ancillary staff and healthcare worker infections from the community and household contacts. Conclusion: Continuous efforts to train-retrain and enforce correct personal protective equipment use and regular routine screening tests (especially among ancillary staff) are necessary to stem future hospital outbreaks of SARS-CoV-2.
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Affiliation(s)
- Chester Yan Hao Ng
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicole-Ann Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Lena X. Y. Bao
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Amy M. L. Quek
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Raymond C. S. Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- *Correspondence: Raymond C. S. Seet,
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8
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Oh VMS, Seet RCS. The Annals: Welcoming the future of Medicine. Ann Acad Med Singap 2021; 50:877-879. [PMID: 34985098 DOI: 10.47102/annals-acadmedsg.2021530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Vernon M S Oh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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9
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Harpaz D, Bajpai R, Ng GJL, Soljak M, Marks RS, Cheung C, Arumugam TV, Quek AML, Tok AIY, Seet RCS. Blood biomarkers to detect new-onset atrial fibrillation and cardioembolism in ischemic stroke patients. Heart Rhythm 2021; 18:855-861. [PMID: 33561586 DOI: 10.1016/j.hrthm.2021.01.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/27/2021] [Accepted: 01/30/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accumulating data suggest blood biomarkers could inform stroke etiology. OBJECTIVE The purpose of this study was to investigate the performance of multiple blood biomarkers in elucidating stroke etiology with a focus on new-onset atrial fibrillation (AF) and cardioembolism. METHODS Between January and December 2017, information on clinical and laboratory parameters and stroke characteristics was prospectively collected from ischemic stroke patients recruited from the National University Hospital, Singapore. Multiple blood biomarkers (N-terminal pro-brain natriuretic peptide [NT-proBNP], d-dimer, S100β, neuron-specific enolase, vitamin D, cortisol, interleukin-6, insulin, uric acid, and albumin) were measured in plasma. These variables were compared with stroke etiology and the risk of new-onset AF and cardioembolism using multivariable regression methods. RESULTS Of the 515 ischemic stroke patients (mean age 61 years; 71% men), 44 (8.5%) were diagnosed with new-onset AF, and 75 (14.5%) had cardioembolism. The combination of 2 laboratory parameters (total cholesterol ≤169 mg/dL; triglycerides ≤44.5 mg/dL) and 3 biomarkers (NT-proBNP ≥294 pg/mL; S100β ≥64 pg/mL; cortisol ≥471 nmol/l) identified patients with new-onset AF (negative predictive value [NPV] 90%; positive predictive value [PPV] 73%; area under curve [AUC] 85%). The combination of 2 laboratory parameters (total cholesterol ≤169 mg/dL; triglycerides ≤44.5 mg/dL) and 2 biomarkers (NT-proBNP ≥507 pg/mL; S100β ≥65 pg/mL) identified those with cardioembolism (NPV 86%; PPV 78%; AUC 87%). Adding clinical predictors did not improve the performance of these models. CONCLUSION Blood biomarkers could identify patients with increased likelihood of cardioembolism and direct the search for occult AF.
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Affiliation(s)
- Dorin Harpaz
- School of Material Science and Engineering, Nanyang Technological University, Singapore; Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beersheba, Israel; Institute for Sports Research (ISR), Nanyang Technological University, Singapore
| | - Ram Bajpai
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Geelyn J L Ng
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, University Medicine Cluster, National University Health System, Singapore
| | - Michael Soljak
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Department of Primary Care and Public Health, Imperial College London, United Kingdom
| | - Robert S Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beersheba, Israel; The National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Beersheba, Israel; The Ilse Katz Centre for Meso and Nanoscale Science and Technology, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Christine Cheung
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore; Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore
| | - Thiruma Valavan Arumugam
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Amy M L Quek
- Division of Neurology, University Medicine Cluster, National University Health System, Singapore
| | - Alfred I Y Tok
- School of Material Science and Engineering, Nanyang Technological University, Singapore; Institute for Sports Research (ISR), Nanyang Technological University, Singapore
| | - Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, University Medicine Cluster, National University Health System, Singapore.
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10
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Kukumberg M, Zaw AM, Wong DHC, Toh CM, Chan BPL, Seet RCS, Wong PTH, Yim EKF. Characterization and Functional Assessment of Endothelial Progenitor Cells in Ischemic Stroke Patients. Stem Cell Rev Rep 2020; 17:952-967. [PMID: 33170433 PMCID: PMC7653671 DOI: 10.1007/s12015-020-10064-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 11/09/2022]
Abstract
Endothelial dysfunction has been implicated in atherosclerosis, ischemic heart disease, and stroke. Endothelial progenitor cells (EPCs), found in the bone marrow and peripheral blood as rare cell population, demonstrated a high proliferation and differentiation capacity. Understanding how such diseases influence the quantity and functionality of EPCs is essential for the development of novel therapies. This study aims to investigate the factors that affect the quantity and functionality of circulating EPCs in stroke patients and healthy controls. Blood samples were collected once from healthy donors (n = 30) and up to 3 times (within 7 days (baseline), 3 and 12 months post-stroke) from stroke patients (n = 207). EPC subpopulations were isolated with flow cytometry for characterization. The Matrigel tubular formation assay was performed as a measure of functionality. An increased amount of circulating EPCs was observed in stroke patients over 45 years when compared to age-matched healthy individuals. EPCs showed a rising trend in stroke patients over the 12-month post-stroke period, reaching statistical significance at 12 months post-stroke. Isolated CD34+KDR+ cells from stroke patients showed impairment in tubular formation capability when compared to cells from healthy donors. The quantity and vasculogenic function of circulating EPCs in peripheral blood have been effectively evaluated in stroke patients and healthy control donors in this study. Age and stroke are found to be 2 influencing factors on the angiogenic capacity. It is suggested that the increase in EPC number is triggered by the recovery response following ischemic stroke. Graphical abstract ![]()
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Affiliation(s)
- Marek Kukumberg
- Mechanobiology Institute, National University of Singapore, #05-01 T-lab, 5A Engineering Drive 1, Singapore, 117411, Singapore
| | - Aung Moe Zaw
- Department of Chemical Engineering, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada
| | - Daniel H C Wong
- Mechanobiology Institute, National University of Singapore, #05-01 T-lab, 5A Engineering Drive 1, Singapore, 117411, Singapore.,Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, 16, Medical Drive, #04-01, Singapore, 117600, Singapore
| | - Chin Min Toh
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, 16, Medical Drive, #04-01, Singapore, 117600, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Raymond C S Seet
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ride Road, Singapore, 119228, Singapore
| | - Peter T H Wong
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, 16, Medical Drive, #04-01, Singapore, 117600, Singapore
| | - Evelyn K F Yim
- Mechanobiology Institute, National University of Singapore, #05-01 T-lab, 5A Engineering Drive 1, Singapore, 117411, Singapore. .,Department of Chemical Engineering, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada. .,Waterloo Institute for Nanotechnology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada. .,Centre for Biotechnology and Bioengineering, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada.
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11
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Harpaz D, Seet RCS, Marks RS, Tok AIY. Blood-Based Biomarkers Are Associated with Different Ischemic Stroke Mechanisms and Enable Rapid Classification between Cardioembolic and Atherosclerosis Etiologies. Diagnostics (Basel) 2020; 10:E804. [PMID: 33050269 PMCID: PMC7600601 DOI: 10.3390/diagnostics10100804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 09/29/2020] [Accepted: 10/07/2020] [Indexed: 12/22/2022] Open
Abstract
Stroke is a top leading cause of death, which occurs due to interference in the blood flow of the brain. Ischemic stroke (blockage) accounts for most cases (87%) and is further subtyped into cardioembolic, atherosclerosis, lacunar, other causes, and cryptogenic strokes. The main value of subtyping ischemic stroke patients is for a better therapeutic decision-making process. The current classification methods are complex and time-consuming (hours to days). Specific blood-based biomarker measurements have promising potential to improve ischemic stroke mechanism classification. Over the past decades, the hypothesis that different blood-based biomarkers are associated with different ischemic stroke mechanisms is increasingly investigated. This review presents the recent studies that investigated blood-based biomarker characteristics differentiation between ischemic stroke mechanisms. Different blood-based biomarkers are specifically discussed (b-type natriuretic peptide, d-dimer, c-reactive protein, tumor necrosis factor-α, interleukin-6, interleukin-1β, neutrophil-lymphocyte ratio, total cholesterol, triglycerides, low-density lipoprotein, high-density lipoprotein and apolipoprotein A), as well as the different cut-off values that may be useful in specific classifications for cardioembolic and atherosclerosis etiologies. Lastly, the structure of a point-of-care biosensor device is presented, as a measuring tool on-site. The information presented in this review will hopefully contribute to the major efforts to improve the care for stroke patients.
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Affiliation(s)
- Dorin Harpaz
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore;
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel;
| | - Raymond C. S. Seet
- Division of Neurology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore;
| | - Robert S. Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel;
| | - Alfred I. Y. Tok
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore;
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12
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Harpaz D, Seet RCS, Marks RS, Tok AIY. B-Type Natriuretic Peptide as a Significant Brain Biomarker for Stroke Triaging Using a Bedside Point-of-Care Monitoring Biosensor. Biosensors (Basel) 2020; 10:E107. [PMID: 32859068 PMCID: PMC7559708 DOI: 10.3390/bios10090107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/23/2020] [Accepted: 08/24/2020] [Indexed: 05/12/2023]
Abstract
Stroke is a widespread condition that causes 7 million deaths globally. Survivors suffer from a range of disabilities that affect their everyday life. It is a complex condition and there is a need to monitor the different signals that are associated with it. Stroke patients need to be rapidly diagnosed in the emergency department in order to allow the admission of the time-limited treatment of tissue plasminogen activator (tPA). Stroke diagnostics show the use of sophisticated technologies; however, they still contain limitations. The hidden information and technological advancements behind the utilization of biomarkers for stroke triaging are significant. Stroke biomarkers can revolutionize the way stroke patients are diagnosed, monitored, and how they recover. Different biomarkers indicate different cascades and exhibit unique expression patterns which are connected to certain pathologies in the human body. Over the past decades, B-type natriuretic peptide (BNP) and its derivative N-terminal fragment (NT-proBNP) have been increasingly investigated and highlighted as significant cardiovascular biomarkers. This work reviews the recent studies that have reported on the usefulness of BNP and NT-proBNP for stroke triaging. Their classification association is also presented, with increased mortality in stroke, correlation with cardioembolic stroke, and an indication of a second stroke recurrence. Moreover, recent scientific efforts conducted for the technological advancement of a bedside point-of-care (POC) device for BNP and NT-proBNP measurements are discussed. The conclusions presented in this review may hopefully assist in the major efforts that are currently being conducted in order to improve the care of stroke patients.
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Affiliation(s)
- Dorin Harpaz
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore;
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel;
| | - Raymond C. S. Seet
- Division of Neurology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore;
| | - Robert S. Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel;
| | - Alfred I. Y. Tok
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore;
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13
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Tan BYQ, Ho JSY, Sia CH, Boi Y, Foo ASM, Dalakoti M, Chan MY, Ho AFW, Leow AS, Chan BPL, Teoh HL, Seow SC, Kojodjojo P, Seet RCS, Sharma VK, Yeo LLL. Left Atrial Volume Index Predicts New-Onset Atrial Fibrillation and Stroke Recurrence in Patients with Embolic Stroke of Undetermined Source. Cerebrovasc Dis 2020; 49:285-291. [PMID: 32554958 DOI: 10.1159/000508211] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/25/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION It is unclear which surrogate of atrial cardiopathy best predicts the risk of developing a recurrent ischemic stroke in embolic stroke of undetermined source (ESUS). Left atrial diameter (LAD) and LAD index (LADi) are often used as markers of left atrial enlargement in current ESUS research, but left atrial volume index (LAVi) has been found to be a better predictor of cardiovascular outcomes in other patient populations. OBJECTIVE We aim to compare the performance of LAVi, LAD, and LADi in predicting the development of new-onset atrial fibrillation (AF) and stroke recurrence in ESUS. METHODS Between October 2014 and October 2017, consecutive patients diagnosed with ESUS were followed for new-onset AF, ischemic stroke recurrence, and a composite outcome of occult AF and stroke recurrence. LAVi and LADi were measured by transthoracic echocardiogram; "high" LAVi was defined as ≥35 mL/m2 in accordance with American Society of Echocardiography guidelines. RESULTS 185 ischemic stroke patients with ESUS were recruited and followed for a median duration of 2.1 years. Increased LAVi was associated with new-onset AF detection (aOR 1.08; 95% CI 1.03-1.14; p = 0.003) and stroke recurrence (aOR 1.05; 95% CI 1.01-1.10; p = 0.026). Patients with "high" LAVi had a higher likelihood of developing a composite of AF detection and stroke recurrence (HR 3.45; 95% CI 1.55-7.67; p = 0.002). No significant association was observed between LADi and either occult AF or stroke recurrence. CONCLUSIONS LAVi is associated with new-onset AF and stroke recurrence in ESUS patients and may be a better surrogate of atrial cardiopathy.
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Affiliation(s)
- Benjamin Y Q Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jamie Sin Ying Ho
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore, .,Department of Cardiology, National University Heart Centre, Singapore, Singapore,
| | - Yushan Boi
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Anthia S M Foo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mayank Dalakoti
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Mark Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Andrew F W Ho
- Cardiovascular & Metabolic Disorders Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Aloysius S Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Swee Chong Seow
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Raymond C S Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Leonard Leong L Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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14
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Baig S, Shabeer M, Parvaresh Rizi E, Agarwal M, Lee MH, Ooi DSQ, Chia C, Aung N, Ng G, Teo Y, Chhay V, Magkos F, Vidal-Puig A, Seet RCS, Toh SA. Heredity of type 2 diabetes confers increased susceptibility to oxidative stress and inflammation. BMJ Open Diabetes Res Care 2020; 8:8/1/e000945. [PMID: 32049633 PMCID: PMC7039582 DOI: 10.1136/bmjdrc-2019-000945] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE Heredity of type 2 diabetes mellitus (T2DM) is associated with greater risk for developing T2DM. Thus, individuals who have a first-degree relative with T2DM (FDRT) provide a natural model to study factors of susceptibility towards development of T2DM, which are poorly understood. Emerging key players in T2DM pathophysiology such as adverse oxidative stress and inflammatory responses could be among possible mechanisms that predispose FDRTs to develop T2DM. Here, we aimed to examine the role of oxidative stress and inflammatory responses as mediators of this excess risk by studying dynamic postprandial responses in FDRTs. RESEARCH DESIGN AND METHODS In this open-label case-control study, we recruited normoglycemic men with (n=9) or without (n=9) a family history of T2DM. We assessed plasma glucose, insulin, lipid profile, cytokines and F2-isoprostanes, expression levels of oxidative and inflammatory genes/proteins in circulating mononuclear cells (MNC), myotubes and adipocytes at baseline (fasting state), and after consumption of a carbohydrate-rich liquid meal or insulin stimulation. RESULTS Postprandial glucose and insulin responses were not different between groups. Expression of oxidant transcription factor NRF2 protein (p<0.05 for myotubes) and gene (pgroup=0.002, ptime×group=0.016), along with its target genes TXNRD1 (pgroup=0.004, ptime×group=0.007), GPX3 (pgroup=0.011, ptime×group=0.019) and SOD-1 (pgroup=0.046 and ptime×group=0.191) was upregulated in FDRT-derived MNC after meal ingestion or insulin stimulation. Synergistically, expression of target genes of inflammatory transcription factor nuclear factor kappa B such as tumor necrosis factor alpha (pgroup=0.001, ptime×group=0.007) was greater in FDRT-derived MNC than in non-FDRT-derived MNC after meal ingestion or insulin stimulation. CONCLUSIONS Our findings shed light on how heredity of T2DM confers increased susceptibility to oxidative stress and inflammation. This could provide early insights into the underlying mechanisms and future risk of FDRTs for developing T2DM and its associated complications.
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Affiliation(s)
- Sonia Baig
- Medicine, National University of Singapore, Singapore
| | | | | | - Madhur Agarwal
- Medicine, National University of Singapore, Singapore
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | | | - Delicia Shu Qin Ooi
- Department of Paediatrics, National University of Singapore, Singapore
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Chelsea Chia
- Medicine, National University Health System, Singapore
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Nweni Aung
- Medicine, National University of Singapore, Singapore
| | - Geelyn Ng
- Medicine, National University of Singapore, Singapore
| | - Yvonne Teo
- Medicine, National University of Singapore, Singapore
| | - Vanna Chhay
- Medicine, National University of Singapore, Singapore
| | - Faidon Magkos
- Section for Obesity Research, Department of Nutrition, Exercise and Sports, University of Copenhagen, København, Denmark
| | - Antonio Vidal-Puig
- Department of Clinical Biochemistry, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Raymond C S Seet
- Medicine, National University of Singapore, Singapore
- Medicine, National University Health System, Singapore
| | - Sue-Anne Toh
- Medicine, National University of Singapore, Singapore
- Department of Endocrinology, Diabetes and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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15
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Chan SJ, Ng MPE, Zhao H, Ng GJL, De Foo C, Wong PTH, Seet RCS. Early and Sustained Increases in Leukotriene B 4 Levels Are Associated with Poor Clinical Outcome in Ischemic Stroke Patients. Neurotherapeutics 2020; 17:282-293. [PMID: 31520306 PMCID: PMC7007445 DOI: 10.1007/s13311-019-00787-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Leukotriene B4 (LTB4) has been implicated in ischemic stroke pathology. We examined the prognostic significance of LTB4 levels in patients with acute middle cerebral artery (MCA) infarction and their mechanisms in rat stroke models. In ischemic stroke patients with middle cerebral artery infarction, plasma LTB4 levels were found to increase rapidly, roughly doubling within 24 h when compared to initial post-stroke levels. Further analyses indicate that poor functional recovery is associated with early and more sustained increase in LTB4 rather than the peak levels. Results from studies using a rat embolic stroke model showed increased 5-lipoxygenase (5-LOX) expression in the ipsilateral infarcted cortex compared with sham control or respective contralateral regions at 24 h post-stroke with a concomitant increase in LTB4 levels. In addition, neutrophil influx was also observed in the infarcted cortex. Double immunostaining indicated that neutrophils express 5-LOX and leukotriene A4 hydrolase (LTA4H), highlighting the pivotal contributions of neutrophils as a source of LTB4. Importantly, rise in plasma LTB4 levels corresponded with an increase in LTB4 amount in the infarcted cortex, thereby supporting the use of plasma as a surrogate for brain LTB4 levels. Pre-stroke LTB4 loading increased brain infarct volume in tMCAO rats. Conversely, administration of the 5-LOX-activating protein (FLAP) inhibitor BAY-X1005 or B-leukotriene receptor (BLTR) antagonist LY255283 decreased the infarct volume by a similar extent. To conclude, targeted interruption of the LTB4 pathway might be a viable treatment strategy for acute ischemic stroke.
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Affiliation(s)
- Su Jing Chan
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, MD3, 16 Medical Drive, Singapore, 117600, Singapore
| | - Mary P E Ng
- Department of Medicine, Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Hui Zhao
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, MD3, 16 Medical Drive, Singapore, 117600, Singapore
| | - Geelyn J L Ng
- Department of Medicine, Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Chuan De Foo
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, MD3, 16 Medical Drive, Singapore, 117600, Singapore
| | - Peter T-H Wong
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, MD3, 16 Medical Drive, Singapore, 117600, Singapore.
| | - Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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16
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Harpaz D, Koh B, Marks RS, Seet RCS, Abdulhalim I, Tok AIY. Point-of-Care Surface Plasmon Resonance Biosensor for Stroke Biomarkers NT-proBNP and S100β Using a Functionalized Gold Chip with Specific Antibody. Sensors (Basel) 2019; 19:s19112533. [PMID: 31163612 PMCID: PMC6603756 DOI: 10.3390/s19112533] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 12/22/2022]
Abstract
Surface-plasmon-resonance (SPR) is a quantum-electromagnetic phenomenon arising from the interaction of light with free electrons at a metal-dielectric interface. At a specific angle/wavelength of light, the photon's energy is transferred to excite the oscillation of the free electrons on the surface. A change in the refractive-index (RI) may occur, which is influenced by the analyte concentration in the medium in close contact with the metal surface. SPR has been widely used for the detection of gaseous, liquid, or solid samples. In this study, a functionalized specific SPR chip was designed and used in a novel point-of-care SPR module (PhotonicSys SPR H5) for the detection of the stroke biomarkers NT-proBNP and S100β. These biomarkers have proven to be good for stroke diagnosis, with sensitivity and specificity of >85%. Specific detection was done by binding a biomolecular-recognizing antibody onto the Au SPR-chip. Detection was tested in water and plasma samples. NT-proBNP and S100β were detected in a range of concentrations for stroke, from 0.1 ng/mL to 10 ng/mL. The RI of the blank plasma samples was 1.362412, and the lowest concentration tested for both biomarkers showed a prominent shift in the RI signal (0.25 ng/mL NT-proBNP (1.364215) and S100β (1.364024)). The sensor demonstrated a clinically relevant limit-of-detection of less than ng/mL.
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Affiliation(s)
- Dorin Harpaz
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
| | - Brescia Koh
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
| | - Robert S Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- The National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- The Ilse Katz Centre for Meso and Nanoscale Science and Technology, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
| | - Raymond C S Seet
- Division of Neurology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore 117597, Singapore.
| | - Ibrahim Abdulhalim
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- The Ilse Katz Centre for Meso and Nanoscale Science and Technology, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- Department of Electro optics and Photonics Engineering, Ben Gurion University of the Negev, Beer-Sheva 84105, Israel.
| | - Alfred I Y Tok
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
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17
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Baig S, Parvaresh Rizi E, Chia C, Shabeer M, Aung N, Loh TP, Magkos F, Vidal-Puig A, Seet RCS, Khoo CM, Toh SA. Genes Involved in Oxidative Stress Pathways Are Differentially Expressed in Circulating Mononuclear Cells Derived From Obese Insulin-Resistant and Lean Insulin-Sensitive Individuals Following a Single Mixed-Meal Challenge. Front Endocrinol (Lausanne) 2019; 10:256. [PMID: 31068904 PMCID: PMC6491694 DOI: 10.3389/fendo.2019.00256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 04/02/2019] [Indexed: 01/11/2023] Open
Abstract
Background: Oxidative stress induced by nutritional overload has been linked to the pathogenesis of insulin resistance, which is associated with metabolic syndrome, obesity, type 2 diabetes and diabetic vascular complications. Postprandial changes in expression of oxidative stress pathway genes in obese vs. lean individuals, following intake of different types of meals varying in macronutrient composition have not been characterized to date. Here we aimed to test whether/how oxidative stress responses in obese vs. lean individuals are modulated by meal composition. Methods: High-carbohydrate (HC), high-fat (HF), or high-protein (HP) liquid mixed meals were administered to study subjects (lean insulin-sensitive, n = 9 and obese insulin-resistant, n = 9). Plasma levels of glucose and insulin, lipid profile, urinary F2-isoprostanes (F2-IsoP), and expression levels of genes of oxidative stress pathways were assessed in mononuclear cells (MNC) derived from fresh peripheral blood, at baseline and up to 6-h postprandial states. Differences in these parameters were compared between insulin-sensitive/resistant groups undergoing aforementioned meal challenges. Results: Obese individuals exhibited increased pro-oxidant (i.e., CYBB and CYBA) and anti-oxidant (i.e., TXN RD1) gene expression in the postprandial state, compared with lean subjects, regardless of meal type (P interaction for group × time < 0.05). By contrast, lean subjects had higher expression of NCF-4 gene (pro-oxidant) after HC meal and SOD1 gene (anti-oxidant) after HC and HF meals (P interaction for group × meal < 0.05). There was an increase in postprandial level of urinary F2-IsoP in the obese (P < 0.05) but not lean group. Conclusions: These findings may represent an adaptive oxidative response to mitigate increased stress induced by acute nutritional excess. Further, the results suggest an increased predisposition of obese subjects to oxidative stress. Chronic nutritional excess resulting in increases in body weight and adiposity might lead to decompensation leading to worsening insulin resistance and its sequel. Insights from this study could impact on nutritional recommendations for obese subjects at high-risk of cardiovascular diseases.
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Affiliation(s)
- Sonia Baig
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ehsan Parvaresh Rizi
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Medicine, National University Health System, Singapore, Singapore
| | - Chelsea Chia
- Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Muhammad Shabeer
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nweni Aung
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tze Ping Loh
- Department of Laboratory Medicine, National University Health System, Singapore, Singapore
| | - Faidon Magkos
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Singapore Institute of Clinical Sciences (SICS), ASTAR, Singapore, Singapore
| | - Antonio Vidal-Puig
- MRC MDU, Metabolic Research Laboratories, University of Cambridge, Cambridge, United Kingdom
| | - Raymond C. S. Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Medicine, National University Health System, Singapore, Singapore
| | - Chin Meng Khoo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Medicine, National University Health System, Singapore, Singapore
| | - Sue-Anne Toh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Medicine, National University Health System, Singapore, Singapore
- Programme in Cardiovascular and Metabolic Disorders, Duke-National University of Singapore Graduate Medical School, Singapore, Singapore
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: Sue-Anne Toh
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Harpaz D, Eltzov E, Seet RCS, Marks RS, Tok AIY. Point-of-Care-Testing in Acute Stroke Management: An Unmet Need Ripe for Technological Harvest. Biosensors (Basel) 2017; 7:E30. [PMID: 28771209 PMCID: PMC5618036 DOI: 10.3390/bios7030030] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 12/20/2022]
Abstract
Stroke, the second highest leading cause of death, is caused by an abrupt interruption of blood to the brain. Supply of blood needs to be promptly restored to salvage brain tissues from irreversible neuronal death. Existing assessment of stroke patients is based largely on detailed clinical evaluation that is complemented by neuroimaging methods. However, emerging data point to the potential use of blood-derived biomarkers in aiding clinical decision-making especially in the diagnosis of ischemic stroke, triaging patients for acute reperfusion therapies, and in informing stroke mechanisms and prognosis. The demand for newer techniques to deliver individualized information on-site for incorporation into a time-sensitive work-flow has become greater. In this review, we examine the roles of a portable and easy to use point-of-care-test (POCT) in shortening the time-to-treatment, classifying stroke subtypes and improving patient's outcome. We first examine the conventional stroke management workflow, then highlight situations where a bedside biomarker assessment might aid clinical decision-making. A novel stroke POCT approach is presented, which combines the use of quantitative and multiplex POCT platforms for the detection of specific stroke biomarkers, as well as data-mining tools to drive analytical processes. Further work is needed in the development of POCTs to fulfill an unmet need in acute stroke management.
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Affiliation(s)
- Dorin Harpaz
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
| | - Evgeni Eltzov
- Agriculture Research Organization (ARO), Volcani Centre, Rishon LeTsiyon 15159, Israel.
| | - Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore.
| | - Robert S Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- The National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- The Ilse Katz Centre for Meso and Nanoscale Science and Technology, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
| | - Alfred I Y Tok
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
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Wilder-Smith EP, Lirong L, Seet RCS, Lim ECH. Symptoms Associated with Electrophysiologically Verified Carpal Tunnel Syndrome in Asian Patients. ACTA ACUST UNITED AC 2016; 31:326-30. [PMID: 16487635 DOI: 10.1016/j.jhsb.2005.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Revised: 12/23/2005] [Accepted: 12/29/2005] [Indexed: 11/27/2022]
Abstract
Sensory symptoms are crucial for the diagnosis of carpal tunnel syndrome (CTS). We have studied the spectrum of sensory symptoms in 67 cases of neurophysiologically confirmed CTS in Singapore and investigated the correlation of semi-quantitative clinical (‘Historical-Objective’) and neurophysiological (‘Bland’) scales. The range of sensory symptoms was large. The more frequent use of the terms ‘woodenness’ and ‘aching’ rather than ‘pins and needles’ suggests racial and cultural differences in symptom expression, or recognition of previously ignored descriptors. ‘Numbness’ (97%) was the most common descriptive symptom, followed by ‘tingling’ (81%), ‘tightness’ (60%), ‘aching’ (45%), ‘woodenness’ (39%) and ‘pins and needles’ (33%). Less common were ‘deadness’ (27%), prickling (24%), and cramp-like pain (18%). Uncommon sensations included ‘jabbing’ (10%), ‘shooting pain’ (10%), ‘stabbing’ (9%), ‘tight-band like pressure’ (9%), ‘cold’ (8%), ‘crushing’ (6%) and ‘burning’ (6%). The semi-quantitative clinical and neurophysiological scales correlated well (Pearson 0.645, P<0.001).
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Tan BYQ, Wan-Yee K, Paliwal P, Gopinathan A, Nadarajah M, Ting E, Venketasubramanian N, Seet RCS, Chan BPL, Teoh HL, Rathakrishnan R, Sharma VK, Yeo LLL. Good Intracranial Collaterals Trump Poor ASPECTS (Alberta Stroke Program Early CT Score) for Intravenous Thrombolysis in Anterior Circulation Acute Ischemic Stroke. Stroke 2016; 47:2292-8. [PMID: 27491731 DOI: 10.1161/strokeaha.116.013879] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/28/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In acute ischemic stroke, large early infarct size estimated by the Alberta Stroke Program Early CT Score (ASPECTS) is associated with poorer outcomes and is a relative contraindication for recanalization therapies. The state of the intracranial collateral circulation influences the functional outcome and may be a variable to consider before thrombolysis. We evaluated the prognostic effect of the collateral circulation in patients with thrombolyzed acute ischemic stroke who have large early infarct sizes as indicated by low ASPECTS. MATERIALS AND METHODS Patients with anterior circulation acute ischemic stroke who received a computed tomographic angiogram and subsequent treatment with intravenous tissue-type plasminogen activator from 2010 to 2013 were studied. Two independent neuroradiologists determined their ASPECTS. We stratified patients using ASPECTS into 2 groups: large volume infarcts (ASPECTS≤7 points) and small volume infarcts (ASPECTS 8-10). In addition, we evaluated a third group with very large volume infarcts (ASPECTS≤5 points). We then analyzed the 3 subgroups using the Maas, Tan, and ASPECTS-collaterals grading systems of the computed tomographic angiogram intracranial collaterals. Good outcomes were defined by modified Rankin Scale score of 0 to 2 at 3 months. RESULTS A total of 300 patients were included in the final analysis. For patients with very large volume infarcts (ASPECTS≤5 points), univariable analysis showed that younger age, male sex, lower National Institute of Health Stroke Scale (NIHSS), lower systolic blood pressure, and good collaterals by Maas, Tan, or ASPECTS-collaterals grading were predictors of good outcomes. On multivariate analysis, younger age (odds ratio, 0.93; 95% confidence interval, 0.89-0.97; P=0.002) and good collaterals by ASPECTS-collaterals system (odds ratio, 1.34; 95% confidence interval, 1.15-1.57; P<0.001) were associated with good outcomes. CONCLUSIONS In patients with large and very large volume infarcts, good collaterals as measured by the ASPECTS-collaterals system is associated with improved outcomes and can help select patients for intravenous thrombolysis.
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Affiliation(s)
- Benjamin Y Q Tan
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Kong Wan-Yee
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Prakash Paliwal
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Anil Gopinathan
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Mahendran Nadarajah
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Eric Ting
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Narayanaswamy Venketasubramanian
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Raymond C S Seet
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Bernard P L Chan
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Hock L Teoh
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Rahul Rathakrishnan
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Vijay K Sharma
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.)
| | - Leonard L L Yeo
- From the Division of Neurology, Departments of Medicine (B.Y.Q.T., K.W.-Y., P.P., R.C.S.S., B.P.L.C., H.L.T., R.R., V.K.S., L.L.L.Y.) and Diagnostic Imaging (A.G., E.T.), National University Health System, Singapore; Department of Neuroradiology, National Neuroscience Institute, Singapore (M.N.); and Neuroscience Department, Raffles Neuroscience Center, Raffles Medical Group, Singapore (N.V.).
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Yeo LLL, Paliwal P, Low AF, Tay ELW, Gopinathan A, Nadarajah M, Ting E, Venketasubramanian N, Seet RCS, Ahmad A, Chan BPL, Teoh HL, Soon D, Rathakrishnan R, Sharma VK. How temporal evolution of intracranial collaterals in acute stroke affects clinical outcomes. Neurology 2016; 86:434-41. [PMID: 26740681 DOI: 10.1212/wnl.0000000000002331] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 10/09/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We compared intracranial collaterals on pretreatment and day 2 brain CT angiograms (CTA) to assess their evolution and relationship with functional outcomes in acute ischemic stroke (AIS) patients treated with IV tissue plasminogen activator (tPA). METHODS Consecutive AIS patients who underwent pretreatment and day 2 CTA and received IV tPA during 2010-2013 were included. Collaterals were evaluated by 2 independent neuroradiologists using 3 predefined criteria: the Miteff system, the Maas system, and 20-point collateral scale by the Alberta Stroke Program Early CT Score methodology. We stratified our cohort by baseline pre-tPA state of their collaterals and by recanalization status of the primary vessel for analysis. Good outcomes at 3 months were defined by a modified Rankin Scale score of 0-1. RESULTS This study included 209 patients. Delayed collateral recruitment by any grading system was not associated with good outcomes. All 3 scoring systems showed that collateral recruitment on the follow-up CTA from a baseline poor collateral state was significantly associated with poor outcome and increased bleeding risk. When the primary vessel remained persistently occluded, collateral recruitment was significantly associated with worse outcomes. Interestingly, collateral recruitment was significantly associated with increased mortality in 2 of the 3 grading systems. CONCLUSIONS Not all collateral recruitment is beneficial; delayed collateral recruitment may be different from early recruitment and can result in worse outcomes and higher mortality. Prethrombolysis collateral status and recanalization are determinants of how intracranial collateral evolution affects functional outcomes.
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Affiliation(s)
- Leonard L L Yeo
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore.
| | - Prakash Paliwal
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Adrian F Low
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Edgar L W Tay
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Anil Gopinathan
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Mahendran Nadarajah
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Eric Ting
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Narayanaswamy Venketasubramanian
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Raymond C S Seet
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Aftab Ahmad
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Bernard P L Chan
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Hock L Teoh
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Derek Soon
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Rahul Rathakrishnan
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
| | - Vijay K Sharma
- From the Division of Neurology, Department of Medicine (L.L.L.Y., P.P., R.C.S.S., A.A., B.P.L.C., H.L.T., D.S., R.R., V.K.S.), Cardiac Department (A.F.L., E.L.W.T.), and Department of Diagnostic Imaging (A.G., E.T.), National University Health System; Department of Neuroradiology (M.N.), National Neuroscience Institute; and Raffles Neuroscience Centre (N.V.), Raffles Medical Group, Singapore
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Low SW, Teo K, Lwin S, Yeo LLL, Paliwal PR, Ahmad A, Sinha AK, Teoh HL, Wong LYH, Chong VF, Seet RCS, Chan BPL, Yeo TT, Chou N, Sharma VK. Improvement in cerebral hemodynamic parameters and outcomes after superficial temporal artery-middle cerebral artery bypass in patients with severe stenoocclusive disease of the intracranial internal carotid or middle cerebral arteries. J Neurosurg 2015; 123:662-9. [PMID: 26023999 DOI: 10.3171/2014.11.jns141553] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Both the older and the recent extracranial-intracranial (EC-IC) bypass trials for symptomatic carotid occlusion failed to demonstrate a reduction in stroke recurrence. However, the role of superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in patients with symptomatic intracranial stenoocclusive disease has been rarely evaluated. The authors evaluated serial changes in various cerebral hemodynamic parameters in patients with severe stenoocclusive disease of the intracranial internal carotid artery (ICA) or middle cerebral artery (MCA) and impaired cerebral vasodilatory reserve (CVR), treated by STA-MCA bypass surgery or medical treatment. METHODS Patients with severe stenoocclusive disease of the intracranial ICA or MCA underwent transcranial Doppler (TCD) ultrasonography and CVR assessment using the breath-holding index (BHI). Patients with impaired BHI (< 0.69) were further evaluated with acetazolamide-challenge technitium-99m hexamethylpropyleneamine oxime ((99m)Tc HMPAO) SPECT. STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. All patients underwent TCD and SPECT at 4 ± 1 months and were followed up for cerebral ischemic events. RESULTS A total of 112 patients were included. This total included 73 men, and the mean age of the entire study population was 56 years (range 23-78 years). (99m)Tc HMPAO SPECT demonstrated impaired CVR in 77 patients (69%). Of these 77 patients, 46 underwent STA-MCA bypass while 31 received best medical treatment. TCD and acetazolamide-challenge (99m)Tc HMPAO SPECT repeated at 4 ± 1 months showed significant improvement in the STA-MCA bypass group. During a mean follow-up of 34 months (range 18-39 months), only 6 (13%) of 46 patients in the bypass group developed cerebral ischemic events, as compared with 14 (45%) of 31 patients receiving medical therapy (absolute risk reduction 32%, p = 0.008). CONCLUSIONS STA-MCA bypass surgery in carefully selected patients with symptomatic severe intracranial stenoocclusive disease of the intracranial ICA or MCA results in significant improvement in hemodynamic parameters and reduction in stroke recurrence.
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Affiliation(s)
| | | | | | | | | | | | - Arvind K Sinha
- Department of Diagnostic Imaging, National University Hospital System, Singapore; and
| | | | | | - Vincent F Chong
- Department of Diagnostic Imaging, National University Hospital System, Singapore; and
| | | | | | | | | | - Vijay K Sharma
- Division of Neurology, and.,YLL School of Medicine, National University of Singapore, Singapore
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Seet RCS, Wijdicks EFM, Rabinstein AA. Stroke from acute cervical internal carotid artery occlusion: treatment results and predictors of outcome. ACTA ACUST UNITED AC 2014; 69:1615-20. [PMID: 23007611 DOI: 10.1001/archneurol.2012.2569] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Previous studies have not distinguished patients with acute cervical internal carotid artery (ICA) occlusions from those with intracranial occlusions and often consider them together in the same cohort. OBJECTIVES To evaluate the outcomes of patients with stroke from acute cervical ICA occlusion treated with intravenous thrombolysis or primary endovascular procedures and to identify early predictors of functional recovery among these patients. DESIGN Retrospective study. SETTING Academic hospital. PATIENTS We studied patients with ischemic stroke who received intravenous thrombolysis or endovascular treatment for acute cervical ICA occlusion at St Mary's Hospital, Mayo Clinic, Rochester, Minnesota. We evaluated the associations of vascular risk factors, severity of stroke, arterial recanalization, presence of tandem occlusions, and collateral distal flow with functional recovery at 90 days after stroke. MAIN OUTCOME MEASURES Favorable functional recovery (Modified Rankin Scale score, 0-2). RESULTS We identified 21 patients (median age, 67 years; median National Institutes of Health Stroke Scale score at presentation, 13), of whom 13 patients received intravenous thrombolysis and 8 patients underwent primary endovascular treatment. Three patients who received intravenous thrombolysis underwent rescue endovascular treatment. Favorable functional recovery (Modified Rankin Scale score, 0-2) was observed in 7 patients who received intravenous thrombolysis and in 1 patient who underwent primary endovascular treatment. Good collateral distal flow and intracranial tandem occlusions were observed in 6 patients and 12 patients, respectively. Good collateral distal flow, observed more frequently in cigarette smokers, was associated with favorable functional recovery (odds ratio, 20; 95% CI, 2-242; P = .02). CONCLUSIONS Intravenous thrombolysis should be administered as first-line treatment in patients with early acute cervical ICA occlusion. Treatment benefits are accentuated in patients with better collateral circulation.
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Loke WM, Chow AY, Lam Mok Sing K, Lee CYJ, Halliwell B, Lim ECH, Quek AML, Ooi EE, Seet RCS. Augmentation of 5-lipoxygenase activity and expression during dengue serotype-2 infection. Virol J 2013; 10:322. [PMID: 24168271 PMCID: PMC3817354 DOI: 10.1186/1743-422x-10-322] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/22/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Leukotriene B4, a 5-lipoxygenase product of arachidonic acid with potent chemotactic effects on neutrophils, has not been assessed in dengue patients. In this study, plasma leukotriene B4 and serum high-sensitivity C-reactive protein levels were determined in adult patients during the febrile, convalescent and defervescent stages of dengue serotype-2 (DENV-2) infection, and compared with those of age-matched healthy and non-dengue febrile subjects. In vitro studies were performed to examine the effects of live and heat-inactivated DENV-2 on the activities and expression of 5-lipoxygenase in human neutrophils. RESULTS Plasma leukotriene B4 was elevated during the febrile stages of dengue infection compared to levels during convalescence and in study controls. Plasma leukotriene B4 also correlated with serum high-sensitivity C-reactive protein in dengue patients (febrile, r = 0.91, p < 0.001; defervescence, r = 0.87, p < 0.001; convalescence, r = 0.87, p < 0.001). Exposure of human neutrophils to DENV-2 resulted in a significant rise in leukotriene B4; the extent of increase, however, did not differ between exposure to live and heat-inactivated DENV-2. Pre-incubation of either live or heat-inactivated DENV-2 resulted in reduced leukotriene B4 release by neutrophils, indicating that contact with dengue antigens (and not replication) triggers the neutrophil response. Production of leukotriene B4 was associated with an increase in 5-lipoxygenase expression in human neutrophils; addition of MK886 (a 5-lipoxygenase activating protein inhibitor) attenuated further increase in leukotriene B4 production. CONCLUSION These findings provide important clinical and mechanistic data on the involvement of 5-lipoxygenase and its metabolites in dengue infection. Further studies are needed to elucidate the therapeutic implications of these findings.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E, NUHS Tower Block, Kent Ridge Road, Singapore.
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Mazya MV, Lees KR, Markus R, Roine RO, Seet RCS, Wahlgren N, Ahmed N. Safety of intravenous thrombolysis for ischemic stroke in patients treated with warfarin. Ann Neurol 2013; 74:266-74. [PMID: 23744571 DOI: 10.1002/ana.23924] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 04/03/2013] [Accepted: 04/26/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Controversy surrounds the safety of intravenous (IV) tissue plasminogen activator (tPA) in ischemic stroke patients treated with warfarin. The European tPA license precludes its use in anticoagulated patients altogether. American guidelines accept IV tPA use with an international normalized ratio (INR) ≤ 1.7. The influence of warfarin on symptomatic intracerebral hemorrhage (SICH), arterial recanalization, and long-term functional outcome in stroke thrombolysis remains unclear. METHODS We analyzed data from 45,074 patients treated with IV tPA enrolled in the Safe Implementation of Thrombolysis in Stroke (SITS) International Stroke Thrombolysis Register. A total of 768 patients had baseline warfarin treatment with INR ≤ 1.7. Outcome measures were SICH, arterial recanalization, mortality, and functional independence at 3 months. RESULTS Patients on warfarin with INR ≤ 1.7 were older, had more comorbidities, and had more severe strokes compared to patients without warfarin. There were no significant differences between patients with and without warfarin in SICH rates (adjusted odds ratio [aOR] = 1.23, 95% confidence interval [CI] = 0.72-2.11 per SITS-MOST; aOR = 1.26, 95% CI = 0.82-1.70 per European Cooperative Acute Stroke Study II) after adjustment for age, stroke severity, and comorbidities. Neither did warfarin independently influence mortality (aOR = 1.05, 95% CI = 0.83-1.35) or functional independence at 3 months (aOR = 1.01, 95% CI = 0.81-1.24). Arterial recanalization by computed tomography/magnetic resonance angiography trended higher in warfarin patients (62% [37 of 59] vs 55% [776/1,475], p = 0.066). Recanalization approximated by disappearance at 22 to 36 hours of a baseline hyperdense middle cerebral artery sign was increased (63% [124 of 196] vs 55% [3,901 of 7,099], p = 0.022). INTERPRETATION Warfarin treatment with INR ≤ 1.7 did not increase the risk for SICH or death, and had no impact on long-term functional outcome in patients treated with IV tPA for acute ischemic stroke.
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Affiliation(s)
- Michael V Mazya
- Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Seet RCS, Wijdicks EFM, Rabinstein AA. Acute Cervical Internal Carotid Artery Occlusion Stroke—Reply. JAMA Neurol 2013; 70:805. [DOI: 10.1001/jamaneurol.2013.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Seet RCS, Rabinstein AA, Christianson TJH, Petty GW, Brown RD. Bleeding complications associated with warfarin treatment in ischemic stroke patients with atrial fibrillation: a population-based cohort study. J Stroke Cerebrovasc Dis 2013; 22:561-9. [PMID: 23499334 DOI: 10.1016/j.jstrokecerebrovasdis.2013.01.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/28/2013] [Accepted: 01/29/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Bleeding events are the major obstacle to the widespread use of warfarin for secondary stroke prevention. Previous studies have not examined the use of risk stratification scores to estimate lifetime bleeding risk associated with warfarin treatment in a population-based setting. The purpose of this study is to determine the lifetime risk of bleeding events in ischemic stroke patients with atrial fibrillation (AF) undergoing warfarin treatment in a population-based cohort and to evaluate the use of bleeding risk scores to identify patients at high risk for lifetime bleeding events. METHODS The resources of the Rochester Epidemiology Project Medical Linkage System were used to identify acute ischemic stroke patients with AF undergoing warfarin treatment for secondary stroke prevention from 1980 to 1994. Medical information for patients seen at Mayo Clinic and at Olmsted Medical Center was used to retrospectively risk-stratify stroke patients according to bleeding risk scores (including the HAS-BLED and HEMORR2HAGES scores) before warfarin initiation. These scores were reassessed 1 and 5 years later and compared with lifetime bleeding events. RESULTS One hundred patients (mean age, 79.3 years; 68% women) were studied. Ninety-nine patients were observed until death. Major bleeding events occurred in 41 patients at a median of 19 months after warfarin initiation. Patients with a history of hemorrhage before warfarin treatment were more likely to develop major hemorrhage (15% versus 3%, P = .04). Patients with baseline HAS-BLED scores of 2 or more had a higher lifetime risk of major bleeding events compared with those with scores of 1 or less (53% versus 7%, P < .01), whereas those with HEMORR2HAGES scores of 2 or more had a higher lifetime risk of major bleeding events compared with those with scores of 1 or less (52% versus 16%, P = .03). Patients with an increase in the HAS-BLED and HEMORR2HAGES scores during follow-up had a higher remaining lifetime risk of major bleeding events compared with those with no change. CONCLUSIONS Our findings indicate high lifetime bleeding risk associated with warfarin treatment for patients with ischemic stroke. Risk stratification scores are useful to identify patients at high risk of developing bleeding complications and should be recalculated at regular intervals to evaluate the bleeding risk in anticoagulated patients with ischemic stroke.
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Affiliation(s)
- Raymond C S Seet
- Department of Neurology, Mayo Clinic, Rochester, Minnesota; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Affiliation(s)
- R C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Department of Medicine, National University Health System, Singapore.
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Seet RCS, Rabinstein AA. Symptomatic intracranial hemorrhage following intravenous thrombolysis for acute ischemic stroke: a critical review of case definitions. Cerebrovasc Dis 2012; 34:106-14. [PMID: 22868870 DOI: 10.1159/000339675] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Accepted: 05/16/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Symptomatic intracranial hemorrhage (SICH) is a devastating complication of intravenous thrombolysis treatment that is associated with high mortality. Clinical trials, stroke registries and cohort studies employ different case definitions to identify stroke patients with SICH following intravenous thrombolysis. We systematically reviewed the reported rates of SICH following intravenous thrombolysis and compared their consistency with mortality outcomes. METHODS Studies were identified from the PubMed and Embase databases from January 1994 to July 2011 by cross-referencing the following MeSH terms: 'thrombolysis', 'recombinant tissue plasminogen activator', 'rtPA', 'hemorrhagic stroke', 'cerebral hemorrhage', 'hematoma' and 'ischemic stroke'. Demographic information, baseline National Institute of Health Stroke Scale (NIHSS) scores, time from stroke onset to intravenous thrombolysis, SICH and mortality rates were derived from published data in 7 randomized controlled trials, 7 stroke registries and 10 cohort studies (4 multicenter and 6 single center) with more than 200 consecutively recruited patients. Mortality rates were considered as the percentage of patients treated with intravenous thrombolysis who died within 90 days after stroke. RESULTS The mean age of patients included in this analysis was 68.8 years (standard deviation, SD 2.9, range 63-75), of whom 56.3% (SD 4.5, range 45-63) were men. They presented with a mean baseline NIHSS of 12.5 (SD 1.4, range 9-15) and received intravenous thrombolysis 175 min (SD 62, range 120-328) from stroke onset. The overall mean SICH and mortality rates of patients treated with intravenous thrombolysis were 5.6% (SD 2.3) and 14.7% (SD 4.8), respectively. A moderate correlation was observed between the incidence of SICH and mortality in patients treated with intravenous thrombolysis (r = 0.401, p = 0.050). The variation in SICH rates was highest across studies that reported SICH rates using the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria compared with the European Cooperative Acute Stroke Study and National Institute of Neurological Disorders and Stroke (NINDS) criteria. Studies that defined SICH as parenchymal hemorrhage with a neurological decline NIHSS ≥4 occurring within 36 h of intravenous thrombolysis reported a higher consistency between SICH and mortality rates (correlation coefficient 0.631). CONCLUSIONS SICH rates vary considerably between studies and these differences may relate to the differences in the criteria used to define SICH. Until a case definition with high interrater agreement and good correlation with stroke outcomes becomes available, detailed information on the type of bleeding, the extent of NIHSS deterioration, neuroimaging features and the time from thrombolysis to diagnosis of hemorrhage should be reported to permit a correct interpretation of SICH rates.
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Abstract
Botulinum toxin (BTX), the exotoxin of the obligate anaerobe, Clostridium botulinum, is used to ameliorate pain and treat conditions associated with glandular, smooth and skeletal muscle overactivity. The benefits derived from the injection of BTX may be negated by unintended weakness of uninjected muscles. Performance of BTX injections may be facile, requiring only surface marking or clinical-localisation techniques but may be more technically demanding, necessitating the use of equipment, such as electromyography (EMG) or ultrasonography (U/S). Less often, endoscopic, fluoroscopic or computed tomographic (CT) guidance may be required. Despite evidence to support the efficacy of BTX injections in treating many conditions, there is no evidence to support the superiority of any one injection technique over needle localisation using surface anatomy. This is possibly due to the lack of well-designed controlled studies, that is, current studies are hampered by small patient numbers, lack of consistency of injection technique and the application of different rating scales. Intuitively, certain injection techniques are more suited to injection of specific muscles or conditions, for example, U/S or passive-monitoring EMG should be used to treat cervical dystonia, active-monitoring EMG applied for strabismus injections, whereas either active-monitoring EMG or endoscopy is indicated when giving BTX for spasmodic dysphonia. Finally, electrical-stimulation EMG or U/S (or a combination of both) would be most suitable when injecting the forearm muscles for spasticity or writer's cramps.
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Affiliation(s)
- Erle C H Lim
- Division of Neurology, National University Hospital, National University Health System, National University of Singapore, Singapore.
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Seet RCS, Loke WM, Khoo CM, Chew SE, Chong WL, Quek AML, Lim ECH, Halliwell B. Acute effects of cigarette smoking on insulin resistance and arterial stiffness in young adults. Atherosclerosis 2012; 224:195-200. [PMID: 22840427 DOI: 10.1016/j.atherosclerosis.2012.06.060] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 06/05/2012] [Accepted: 06/26/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND It is unclear whether changes in insulin sensitivity or arterial stiffness in cigarette smokers could explain the link between cigarette smoking and diabetes mellitus. The purpose of the study was to evaluate the acute effects of cigarette smoking on insulin resistance and arterial stiffness in a cohort of young healthy adults. METHODS Metabolic risk components, hemodynamic parameters, plasma nitrite/nitrate and high-sensitivity C-reactive protein (hsCRP) levels, were compared between smokers and age- and gender-matched controls (non-smokers). In smokers, these levels were determined 8-h following cigarette abstinence and an hour after smoking. RESULTS One hundred nineteen smokers and age-matched non-smokers (mean age, 32 years; 83% men) were included in this study. Compared with non-smokers, smokers had a significantly higher number of abnormal metabolic risk components, HOMA-IR index and total nitrite/nitrate levels. There were no differences in brachial/central blood pressure, augmentation index and hsCRP between smokers and non-smokers. An hour after smoking, smokers had significantly higher levels of HOMA-IR, total nitrite/nitrate, hsCRP and heart rate compared with baseline levels. By contrast, brachial/central blood pressure and augmentation index were unchanged after cigarette smoking. Baseline vascular and insulin resistance status predicted the extent of rise in the HOMA-IR and augmentation indices acutely after cigarette smoking (adjusted R(2) 0.358 and 0.124, p < 0.001 respectively). CONCLUSIONS Individuals with more advanced vascular damage and insulin resistance are vulnerable to the acute effects of cigarette smoking.
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Affiliation(s)
- Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E, NUHS Tower Block, Kent Ridge Road, Singapore 119228, Singapore.
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Ng KWP, Venketasubramanian N, Yeo LLL, Ahmad A, Loh PK, Seet RCS, Teoh HL, Chan BPL, Sharma VK. Usefulness of CT angiography for therapeutic decision making in thrombolyzing intubated patients with suspected basilar artery thrombosis. J Neuroimaging 2012; 22:351-4. [PMID: 22303927 DOI: 10.1111/j.1552-6569.2011.00689.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND AIMS Acute ischemic stroke (AIS) due to basilar artery thrombosis (BAT) causes high mortality and severe disability. Early neurological assessment and timely thrombolysis might improve outcome. BAT is difficult to diagnose due to wide spectrum of presentation and decreased conscious level. Emergency physicians often intubate BAT patients with airway compromise before arrival of stroke neurologist. We evaluated role of computerized tomography (CT) angiography (CTA) of brain and cervical arteries in early diagnosis of acute BAT in intubated patients and facilitating decision for thrombolysis. METHODS Consecutive AIS patients presenting between 2007 and 2009 within 6 hours of symptom onset, with sudden deterioration in conscious level and intubation before assessment by neurologist, were included. All patients underwent brain CT and CTA. Outcomes were assessed at 3 months. RESULTS Thrombolytic therapy, mainly intravenous tissue plasminogen activator (IV-TPA), was administered to 161 (8.4%) of 1,917 AIS patients during the study period. Acute BAT contributed 10.9% of our cohort. CTA was performed in 152 (94.4%) patients and the rest were excluded due to their impaired renal functions. Five patients (3 males, mean age 72 years) presenting with acute obtundation and airway compromise were intubated, sedated, and paralyzed before assessment by neurologist. CTA showed BAT in all. IV-TPA was initiated at 213 ± 59 minutes in 4 patients while 1 received intraarterial thrombolysis at 13 hours. There was no intracranial hemorrhage. Mean length of hospital stay was 11.8 days. Despite severe stroke at presentation, good functional recovery at 3 months (modified Rankin scale [mRS] 1) occurred in 2 patients; mRS 4 in 1, and 2 died. CONCLUSION In patients with BAT, intubated before assessment by neurologist, CTA might help in confirming the diagnosis and facilitating therapeutic decision making for initiating thrombolysis.
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Affiliation(s)
- Kay W P Ng
- Division of Neurology, National University Hospital, Singapore
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Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a potentially devastating complication of bevacizumab treatment. AIM We examined the clinical features, treatment and outcomes of patients who developed PRES following bevacizumab treatment at our institution and those reported in the literature. DESIGN Retrospective audit and systematic review. METHODS Patients were identified from the Mayo Clinic database and the published literature using 'PubMed' and 'OVID' databases, from January 2006 to June 2010, who developed PRES features within 3 weeks of bevacizumab treatment, who had brain imaging findings of focal vasogenic edema and radiologic proof of reversibility. RESULTS Two patients with definite PRES were identified from our institution and a further 10 cases were identified from the published literature (total, n=12). The mean age of these patients was 52 years (range 4-68 years), four of whom were men and eight women. Headaches (n=7), seizures (n=6), visual disturbances (n=5) and nausea and vomiting (n=3) were the common presenting symptoms. In a majority of patients (n=10), an increase in blood pressure from their baseline values was observed during their acute presentation. PRES resolved following withdrawal of bevacizumab and blood pressure control in all patients. CONCLUSIONS PRES is a catastrophic neurological complication of bevacizumab treatment, which responds favorably to prompt bevacizumab withdrawal and blood pressure control.
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Affiliation(s)
- R C S Seet
- Mayo Clinic, Department of Neurology, W8B, 200 First Street SW, Rochester, MN 55905, USA.
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Seet RCS. Relationship Between Chronic Atrial Fibrillation and Worse Outcomes in Stroke Patients After Intravenous Thrombolysis. ACTA ACUST UNITED AC 2011; 68:1454-8. [DOI: 10.1001/archneurol.2011.248] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Seet RCS, Lee CYJ, Lim ECH, Quek AML, Huang H, Huang SH, Looi WF, Long LH, Halliwell B. Oral zinc supplementation does not improve oxidative stress or vascular function in patients with type 2 diabetes with normal zinc levels. Atherosclerosis 2011; 219:231-9. [PMID: 21840002 DOI: 10.1016/j.atherosclerosis.2011.07.097] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 07/11/2011] [Accepted: 07/12/2011] [Indexed: 02/07/2023]
Abstract
OBJECTIVE There is considerable controversy about what constitutes optimal zinc intakes in patients with type 2 diabetes mellitus. Several studies suggest that higher zinc intakes improve vascular function and decrease oxidative damage. We aimed to assess the effects of zinc supplementation using a range of reliable biomarkers of oxidative damage and vascular function in patients with type 2 diabetes. METHODS Forty male type 2 diabetic patients were supplemented either with 240 mg/day of zinc as zinc gluconate (n=20) or with placebo (n=20) for 3 months. Blood and spot urine samples were taken at baseline, days 3 and 7, months 1, 2 and 3 during supplementation and 1 month after cessation. Serum zinc, reliable biomarkers of oxidative damage (F(2)-isoprostanes, neuroprostanes, cholesterol oxidation products, allantoin) as well as hydroxyeicosatetraenoic acid products and vascular-related indices (augmentation index, pulse wave velocity and aortic pressure) were measured. RESULTS Despite significantly higher levels of serum zinc in the treatment group, markers of oxidative damage, levels of hydroxyeicosatetraenoic acid products and vascular indices were unchanged by zinc supplementation during the four-month study period. CONCLUSION Improving the zinc status in patients with type 2 diabetes with normal zinc levels did not have any impact on oxidative damage and vascular function, and such supplementation may not be generally beneficial in these individuals.
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Affiliation(s)
- Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Seet RCS, Lee CYJ, Chan BPL, Sharma VK, Teoh HL, Venketasubramanian N, Lim ECH, Chong WL, Looi WF, Huang SH, Ong BKC, Halliwell B. Oxidative damage in ischemic stroke revealed using multiple biomarkers. Stroke 2011; 42:2326-9. [PMID: 21700941 DOI: 10.1161/strokeaha.111.618835] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We investigated changes in oxidative damage after ischemic stroke using multiple biomarkers. METHODS Serial blood and urine samples of ischemic stroke subjects and age-matched control subjects were assayed for F₂-isoprostanes, hydroxyeicosatetraenoic acid products, F₄-neuroprostanes, 24-hydroxycholesterol, allantoin, and urate. RESULTS Sixty-six stroke subjects (mean age, 65 years; median National Institutes of Health Stroke Scale 17) and 132 control subjects were recruited. A bimodal pattern of change was observed in plasma and urinary F₂-isoprostanes and plasma 24-hydroxycholesterol. The rise in plasma hydroxyeicosatetraenoic acid products, F₄-neuroprostanes, and allantoin was highest 6 to 12 hours after stroke onset, whereas plasma urate was significantly lower than controls on Days 1 to 3. After adjusting for age and baseline National Institutes of Health Stroke Scale, baseline plasma esterified hydroxyeicosatetraenoic acid products (OR, 1.01; 95% CI, 1.01 to 1.02), plasma urate (1.01; 1.00 to 1.01), and plasma free F₄-neuroprostanes (2.73; 1.76 to 3.93) were associated with 90-day good functional recovery (modified Rankin Scale ≤1). CONCLUSIONS Multiple markers of oxidative damage are increased immediately after stroke and remain elevated for several days. Recognition of these temporal changes may help design better antioxidant treatment trials for acute ischemic stroke.
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Affiliation(s)
- Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Seet RCS, Lee CYJ, Loke WM, Huang SH, Huang H, Looi WF, Chew ES, Quek AML, Lim ECH, Halliwell B. Biomarkers of oxidative damage in cigarette smokers: which biomarkers might reflect acute versus chronic oxidative stress? Free Radic Biol Med 2011; 50:1787-93. [PMID: 21420490 DOI: 10.1016/j.freeradbiomed.2011.03.019] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Revised: 02/28/2011] [Accepted: 03/11/2011] [Indexed: 11/17/2022]
Abstract
Cigarette smoking predisposes to the development of multiple diseases involving oxidative damage. We measured a range of oxidative damage biomarkers to understand which differ between smokers and nonsmokers and if the levels of these biomarkers change further during the act of smoking itself. Despite overnight abstinence from smoking, smokers had higher levels of plasma total and esterified F(2)-isoprostanes, hydroxyeicosatetraenoic acid products (HETEs), F(4)-neuroprostanes, 7-ketocholesterol, and 24- and 27-hydroxycholesterol. Levels of urinary F(2)-isoprostanes, HETEs, and 8-hydroxy-2'-deoxyguanosine were also increased compared with age-matched nonsmokers. Several biomarkers (plasma free F(2)-isoprostanes, allantoin, and 7β-hydroxycholesterol and urinary F(2)-isoprostane metabolites) were not elevated. The smokers were then asked to smoke a cigarette; this acute smoking elevated plasma and urinary F(2)-isoprostanes, plasma allantoin, and certain cholesterol oxidation products compared to presmoking levels, but not plasma HETEs or urinary 8-hydroxy-2'-deoxyguanosine. Smokers showed differences in plasma fatty acid composition. Our findings confirm that certain oxidative damage biomarkers are elevated in smokers even after a period of abstinence from smoking, whereas these plus some others are elevated after acute smoking. Thus, different biomarkers do not measure identical aspects of oxidative stress.
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Affiliation(s)
- Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Seet RCS, Zhang Y, Moore SA, Wijdicks EF, Rabinstein AA. Subtherapeutic international normalized ratio in warfarin-treated patients increases the risk for symptomatic intracerebral hemorrhage after intravenous thrombolysis. Stroke 2011; 42:2333-5. [PMID: 21659639 DOI: 10.1161/strokeaha.111.614214] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE There is uncertainty whether warfarin-treated patients (despite international normalized ratio < 1.7) have increased risks of symptomatic intracerebral hemorrhage after intravenous thrombolysis. METHODS Vascular risk factors, stroke subtype, and outcome measures were compared between warfarin- and nonwarfarin-treated patients undergoing acute thrombolysis within 3 hours of symptom onset. RESULTS From 212 patients (mean age, 74 ± 14 years; 50% men) studied, 14 (6.5%) had prior warfarin use. After adjusting for age, baseline National Institutes of Health Stroke Scale, and stroke subtype, warfarin-treated patients had significantly increased risks of developing symptomatic intracerebral hemorrhage (adjusted OR, 14.7; 95% CI, 1.3 to 54.3). A trend for poorer stroke recovery and increased mortality was observed in warfarin-treated patients on univariate, but not on multivariable, analyses. CONCLUSIONS Warfarin-treated patients with stroke have increased risks of symptomatic intracerebral hemorrhage after thrombolytic treatment. These data raise safety concerns of thrombolytic treatment in warfarin-treated patients with subtherapeutic international normalized ratio.
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Seet RCS, Rabinstein AA, Lindell PE, Uhm JH, Wijdicks EF. Cerebrovascular Events After Bevacizumab Treatment: An Early and Severe Complication. Neurocrit Care 2011; 15:421-7. [DOI: 10.1007/s12028-011-9552-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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41
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Lim KHC, Lee CYJ, Earnest A, Seet RCS, Halliwell B. Does radiotherapy increase oxidative stress? A study with nasopharyngeal cancer patients revealing anomalies in isoprostanes measurements. Free Radic Res 2011; 44:1064-71. [PMID: 20815769 DOI: 10.3109/10715762.2010.499906] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study aimed to examine if exposure to ionizing radiation during clinical radiotherapy (RT) causes increased oxidative damage. Seven patients with nasopharyngeal cancer (NPC) who underwent RT took part in this controlled-trial study. Blood and urine samples were obtained for F(2)-isoprostanes (F(2)-IsoPs) measurement. Urinary F(2)-IsoPs levels were elevated pre-treatment and remained high (but did not increase) during treatment, but decreased to the normal range after treatment. Plasma F(2)-IsoPs decreased significantly after the start of treatment before rising midway through treatment. Levels decreased significantly to below baseline following treatment. However, the patients were observed to have substantially lower levels of plasma esterified arachidonic acid (AA) residues than controls. The data shows that NPC is associated with elevated F(2)-isoprostanes in urine and in plasma after correction for decreased AA levels. RT did not increase these levels and, indeed, was associated with falls in F(2)-IsoPs. The validity and usefulness of correction of plasma F(2)-IsoPs for lowered AA levels is discussed.
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Affiliation(s)
- Keith H C Lim
- Department of Radiation Oncology, National University Cancer Institute, Singapore
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42
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Yang SSY, Seet RCS, Lim ECH. Chewing-induced facial dystonia. Ann Acad Med Singap 2010; 39:740-742. [PMID: 20957311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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43
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Koh GCH, Wong TY, Cheong SK, Lim ECH, Seet RCS, Tang WE, Chua CS. Acceptability of medical students by patients from private and public family practices and specialist outpatient clinics. Ann Acad Med Singap 2010; 39:555-10. [PMID: 20697674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Previous studies on patient acceptance of medical student teaching were from Western populations and in one setting only. However, there has been no prospective study comparing patient acceptability before and after an actual experience. We studied patient acceptability of medical student teaching in private and public family practices and public hospital specialist outpatient clinics in Singapore, and before and after an actual medical student teaching consultation. MATERIALS AND METHODS We conducted an anonymous cross-sectional survey from March through October 2007 of Singaporean or permanent resident patients attending 76 teaching private family practices, 9 teaching public family practices and 8 specialty clinics in a teaching public hospital. We used pre-consultation cross-sectional patient surveys in all three settings. For private family practice setting only, post-consultation patient survey was conducted after an actual experience with medical student presence. RESULTS Out of 5123 patients, 4142 participated in the cross-sectional survey (80.9%) and 1235 of 1519 patients in the prospective cohort study (81.3%). Eighty percent were comfortable with medical students present, 79% being interviewed and 60% being examined. Regarding being examined by medical students, parents of children were least comfortable while patients between 41 to 60 years were most comfortable (adjusted OR = 1.99 [1.55-2.57]). Females were less comfortable with medical student teaching than males. Chinese patients were the least comfortable about being interviewed or examined by medical students among the ethnic groups. Indians were most comfortable with being interviewed by medical students (adjusted OR = 1.38 [1.02-1.86]) but Malays were the most comfortable being examined by them (adjusted OR = 1.32 [1.07-1.62]). Family practice patients were more receptive to medical student teaching than the hospital's specialist outpatients. Common barriers to patient acceptance were lack of assurance of patient privacy, dignity and confidentiality. Actual exposure to medical student teaching did not change levels of patient acceptance. CONCLUSIONS Compared to similar studies from Western countries, Asian patients appear to be less receptive to medical student teaching than Western patients. Family practice settings offer medical students a more receptive learning environment.
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Affiliation(s)
- Gerald C H Koh
- Department of Epidemiology and Public Health, National University of Singapore, Singapore.
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Affiliation(s)
- Erle C. H. Lim
- Yong Loo Lin School of Medicine, Division of Neurology,
and Hand and Reconstructive Microsurgery, National University Hospital, Singapore,
| | - Raymond C. S. Seet
- Yong Loo Lin School of Medicine, Division of Neurology,
and Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Andre E. J. Cheah
- Yong Loo Lin School of Medicine, Division of Neurology,
and Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Aymeric Y. T. Lim
- Yong Loo Lin School of Medicine, Division of Neurology,
and Hand and Reconstructive Microsurgery, National University Hospital, Singapore
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45
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Seet RCS, Lee CYJ, Lim ECH, Tan JJH, Quek AML, Chong WL, Looi WF, Huang SH, Wang H, Chan YH, Halliwell B. Oxidative damage in Parkinson disease: Measurement using accurate biomarkers. Free Radic Biol Med 2010; 48:560-6. [PMID: 19969070 DOI: 10.1016/j.freeradbiomed.2009.11.026] [Citation(s) in RCA: 160] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Revised: 11/06/2009] [Accepted: 11/30/2009] [Indexed: 10/20/2022]
Abstract
Oxidative damage has been implicated in the pathogenesis of Parkinson disease (PD) but the literature data are confusing. Using products of lipid and DNA oxidation measured by accurate methods, we assessed the extent of oxidative damage in PD patients. The levels of plasma F(2)-isoprostanes (F(2)-IsoPs), hydroxyeicosatetraenoic acid products (HETEs), cholesterol oxidation products, neuroprostanes (F(4)-NPs), phospholipase A(2) (PLA(2)) and platelet activating factor-acetylhydrolase (PAF-AH) activities, urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG), and serum high-sensitivity C-reactive protein were compared in 61 PD patients and 61 age-matched controls. The levels of plasma F(2)-IsoPs, HETEs, 7beta-and 27-hydroxycholesterol, 7-ketocholesterol, F(4)-NPs, and urinary 8-OHdG were elevated, whereas the levels of plasma PLA(2) and PAF-AH activities were lower, in PD patients compared to controls (p< 0.05). The levels of plasma F(2)-IsoPs, HETEs, and urinary 8-OHdG were higher in the early stages of PD (p trend< 0.05). There was a significant negative correlation between the cumulative intake of levodopa and urinary 8-OHdG (r= -0.305, p= 0.023) and plasma total HETEs (r= -0.285, p= 0.043). Oxidative damage markers are systemically elevated in PD, which may give clues about the relation of oxidative damage to the onset and progression of PD.
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Affiliation(s)
- Raymond C S Seet
- Department of Medicine, National University of Singapore, Singapore.
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46
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Seet RCS, Lee CYJ, Lim ECH, Quek AML, Yeo LLL, Huang SH, Halliwell B. Oxidative damage in dengue fever. Free Radic Biol Med 2009; 47:375-80. [PMID: 19427377 DOI: 10.1016/j.freeradbiomed.2009.04.035] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 04/02/2009] [Accepted: 04/29/2009] [Indexed: 12/11/2022]
Abstract
Oxidative stress may be important in the pathogenesis of dengue infection. Using accurate markers of oxidative damage, we assessed the extent of oxidative damage in dengue patients. The levels of hydroxyeicosatetraenoic acid products (HETEs), F(2)-isoprostanes (F(2)-IsoPs), and cholesterol oxidation products (COPs) were measured in 28 adult dengue patients and 28 age-matched study controls during the febrile, defervescent, and convalescent stages of infection. We compared the absolute and the percentage change in these markers in relation to key clinical parameters and inflammatory markers. The levels of total HETEs and total HETEs/arachidonate, total F(2)-IsoPs/arachidonate, and COPs/cholesterol were higher during the febrile compared to the convalescent level. Total HETEs correlated positively with admission systolic blood pressure (r=0.52, p<0.05), whereas an inverse relationship was found between 7beta-hydroxycholesterol and systolic and diastolic blood pressure (r=-0.61 and -0.59, respectively, p<0.01). The urinary F(2)-IsoP level was higher in urine during the febrile stage compared to the convalescent level. Despite lower total cholesterol levels during the febrile stage compared to convalescent levels, a higher percentage of cholesterol was found as COPs (7beta-, 24-, and 27-hydroxycholesterol). The levels of platelet-activating factor-acetylhydrolase activity, vascular cellular adhesion molecule-1, tumor necrosis factor-alpha, and high-sensitivity C-reactive protein were higher during the febrile stage compared to their convalescent levels (p<0.01). Markers of oxidative damage are altered during the various stages of dengue infection.
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Affiliation(s)
- Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University Hospital, Singapore 119074.
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Seet RCS, Kasiman K, Gruber J, Tang SY, Wong MC, Chang HM, Chan YH, Halliwell B, Chen CP. Is uric acid protective or deleterious in acute ischemic stroke? A prospective cohort study. Atherosclerosis 2009; 209:215-9. [PMID: 19758590 DOI: 10.1016/j.atherosclerosis.2009.08.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 07/14/2009] [Accepted: 08/07/2009] [Indexed: 12/13/2022]
Abstract
Contrasting observations have been made between serum urate and ischemic stroke outcomes in studies involving Caucasian populations. To assess the hypothesis that urate is associated with stroke outcomes, a prospective follow-up study was performed in a cohort of Asian patients with ischemic stroke. Patients diagnosed with transient ischemic attack, first or recurrent ischemic stroke were included in this study. Serum urate, measured using high-performance liquid chromatography, was correlated with 12-month functional and vascular stroke outcomes. Poor functional outcome was defined as a modified Rankin scale exceeding 2 and vascular outcome was defined as a composite of recurrent stroke, myocardial infarction or vascular death during the study period. A total of 503 patients of mean age 63 (SD 12) years were included. A U-shaped relationship between urate quartiles and poor functional outcomes was demonstrated. More patients with low (<280microM) and high (>410microM) urate levels had poor functional outcomes (36% and 27% respectively), compared to those with urate levels between 340 and 410microM (14%). No significant relationship was observed between urate and vascular outcomes. Depending on its level, serum urate may exhibit protective and deleterious effects on stroke outcomes.
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Affiliation(s)
- Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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48
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Lim ECH, Oh VMS, Koh DR, Seet RCS. The challenges of "continuing medical education" in a pandemic era. Ann Acad Med Singap 2009; 38:724-726. [PMID: 19736579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Closure of medical schools or the barring of "live patient" contact during an epidemic or pandemic is potentially disruptive to medical education. During the SARS epidemic, the use of web-based learning, role play, video vignettes and both live and mannequin-based simulated patients minimised disruptions to medical education. This article examines the pedagogical innovations that allow clinical teaching to continue without medical students examining actual patients, and proposes a contingency plan in the event of future outbreaks that may necessitate similar containment measures.
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Affiliation(s)
- Erle C H Lim
- Department of Medicine, National University Health System, National University of Singapore, Singapore.
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49
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Gruber J, Tang SY, Jenner AM, Mudway I, Blomberg A, Behndig A, Kasiman K, Lee CYJ, Seet RCS, Zhang W, Chen C, Kelly FJ, Halliwell B. Allantoin in human plasma, serum, and nasal-lining fluids as a biomarker of oxidative stress: avoiding artifacts and establishing real in vivo concentrations. Antioxid Redox Signal 2009; 11:1767-76. [PMID: 19388825 DOI: 10.1089/ars.2008.2364] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Urate is the terminal product of purine metabolism in primates, including humans. Urate is also an efficient scavenger of oxidizing species and is thought to be an important antioxidant in human body fluids. Allantoin, the major oxidation product of urate, has been suggested as a candidate biomarker of oxidative stress because it is not produced metabolically. Although urate is converted to allantoin under strongly alkaline pH, such conditions have been used in the past to facilitate extraction of allantoin. We evolved a method for the determination of allantoin concentrations in human plasma and serum by gas chromatography-mass spectrometry without such artifact. With this method, we show that alkaline conditions do indeed cause breakdown of urate, leading to significant overestimation of allantoin concentration in human samples. By using our alternative method, serum samples from 98 volunteers were analyzed, and allantoin levels were found to be significantly lower than was previously reported. The in vivo utility and sensitivity of our method was further evaluated in human nasal-lining fluids. We were able to demonstrate an ozone-induced increase in allantoin, in the absence of increases in either ascorbate or glutathione oxidation products.
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Affiliation(s)
- Jan Gruber
- Centre for Life Sciences, Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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50
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Yang SSY, Seet RCS, Lim ECH. A pain in the neck. Diagnosis: Ependymoma. J Clin Neurosci 2009; 16:683-730. [PMID: 19449468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Sam S Y Yang
- Yong Loo Lin School of Medicine, National University of Singapore, and Division of Neurology, National University Hospital, Singapore
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