CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity

INTRODUCTION

The WHO Surgical Safety Checklist (SSC) is a communication tool that improves teamwork and patient outcomes. SSC effectiveness is dependent on implementation fidelity. Administrative audits fail to capture most aspects of SSC implementation fidelity (ie, team communication and engagement). Existing research tools assess behaviours during checklist performance, but were not designed for routine quality assurance and improvement. We aimed to create a simple tool to assess SSC implementation fidelity, and to test its reliability using video simulations, and usability in clinical practice.

METHODS

The Checklist Performance Observation for Improvement (CheckPOINT) tool underwent two rounds of face validity testing with surgical safety experts, clinicians and quality improvement specialists. Four categories were developed: checklist adherence, communication effectiveness, attitude and engagement. We created a 90 min training programme, and four trained raters independently scored 37 video simulations using the tool. We calculated intraclass correlation coefficients (ICC) to assess inter-rater reliability (ICC>0.75 indicating excellent reliability). We then trained two observers, who tested the tool in the operating room. We interviewed the observers to determine tool usability.

RESULTS

The CheckPOINT tool had excellent inter-rater reliability across SSC phases. The ICC was 0.83 (95% CI 0.67 to 0.98) for the sign-in, 0.77 (95% CI 0.63 to 0.92) for the time-out and 0.79 (95% CI 0.59 to 0.99) for the sign-out. During field testing, observers reported CheckPOINT was easy to use. In 98 operating room observations, the total median (IQR) score was 25 (23-28), checklist adherence was 7 (6-7), communication effectiveness was 6 (6-7), attitude was 6 (6-7) and engagement was 6 (5-7).

CONCLUSIONS

CheckPOINT is a simple and reliable tool to assess SSC implementation fidelity and identify areas of focus for improvement efforts. Although CheckPOINT would benefit from further testing, it offers a low-resource alternative to existing research tools and captures elements of adherence and team behaviours.

To evaluate the prevalence of spontaneous portosystemic shunts in decompensated cirrhosis patients and its prognostic significance

INTRODUCTION

Spontaneous portosystemic shunts (SPSS) are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates, probably as a consequence of worsening portal hypertension, but without achieving an effective protection against cirrhosis complications. This study was conducted to detect the prevalence of portosystemic shunts in liver cirrhosis patients and analyze its prognostic role.

METHOD

We conducted a prospective observational study, where 92 patients with decompensated cirrhosis were evaluated based on history, physical examination, biochemical tests and abdominal computed tomography (CT) angiography findings. A follow-up was done after six months for the development of cirrhosis-related complications.

RESULTS

Of the 92 cirrhotic patients, 57.6% had SPSS (large SPSS + small SPSS) detected by multi-detector computed tomographic angiography. Overall, we found large SPSS in 24 (26.1%) patients, small SPSS in 29 (31.5%) patients and no shunt in 39 (42.4%) patients. Among the shunts, the splenorenal shunt is the most frequent type (25, 27.2%) followed by the paraumbilical shunt (20.7%). Previous decompensating events, including hepatic encephalopathy, ascites, spontaneous bacterial peritonitis and gastrointestinal bleed, were experienced more frequently by the large SPSS group followed by the small SPSS and without SPSS groups. Regarding follow-up, decompensating episodes of hepatic encephalopathy developed more frequently in patients with large SPSS (41.7%) than in patients with small SPSS (24.1%) followed by patients without SPSS (12.8%).

CONCLUSION

In summary, all cirrhotic patients should be studied with radiological imaging to detect the presence of portosystemic shunts. In several cases, patients with large SPSS had a more impaired liver function and more frequent complications of portal hypertension. So, these patients would probably benefit from a closer surveillance and more intensive therapy.

A Review of the MINDSPACE Framework for Nudging Health Promotion During Early Stages of the COVID-19 Pandemic

The coronavirus disease (COVID-19) pandemic has highlighted the link between individual behavior and public health, along with the importance of evidence-based efforts to promote prosocial individual behavior. Insights from behavioral science can inform the design of effective behavior change techniques, or nudges, to influence individual behavior. The MINDSPACE framework organizes 9 behavioral science principles that can be used to guide policy design: Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitments, and Ego. Using MINDSPACE as an organizing framework, this article provides a review of the literature on nudges to influence prosocial behaviors relevant during a pandemic: handwashing, avoidance of social gatherings, self-isolation and social distancing, and sharing public health messages. Additionally, empirical evidence on the use of nudges during the first several months of the COVID-19 pandemic in 2020 is summarized. Recommendations regarding the use of nudges to achieve public health policy goals during pandemics are provided. Organizational leaders, policymakers, and practitioners can use nudges to promote public health when mandates are not politically feasible or enforceable.

Particle composition and morphology over urban environment (New Delhi): Plausible effects on wheat leaves

Particulate matter (PM) deposition on leaves adversely affects physical, chemical and biological nature of agricultural crops resulting in their loss of productivity and yield. Wheat being a staple food in major parts of Northern India and around the World, has been selected for research purpose by designing a study to explore the probable effects of PM deposition on wheat leaves and wheat crops to ensure the food security. PM₅ (Particulate matter with aerodynamic diameter <5 μm) and Dry Deposited Particulate Matter (DDPM) on wheat leaves (Leaf_DDPM) were collected from the wheat crop field in Indian Agriculture Research Institute (IARI), New Delhi for growing and harvesting season of wheat crops (i.e. December 2014 to April 2015). The EDS (Energy Dispersive Spectroscopy) analysis was used for this study and the individual particle analysis revealed the presence of both acidic and alkaline components like C, Al, Si, Fe, Ca, K, S and Mg. The offline characterization tool i.e. SEM (Scanning Electron Microscope) was utilized for obtaining the micrographs which clearly showed the presence of some angular, sharp-edged and spherical particles consisting of both smooth and rough texture. Apart from that, prevalence of slightly non-spherical particles with aspect ratio of range (>1.20-1.40) and CIR (>0.70-0.80) for both PM₅ and leaf_DDPM were observed. The size distribution of individual particles for both PM₅(#194 particles) and Leaf_DDPM(#657 particles) revealed that Surface Equivalent Radius (SER) and Volume Equivalent Radius (VER) of particles observed to be 0.40-0.80 μm while surface area to be 0-1 μm². These particles may easily block stomatal openings (with typical diameter range: 42-51 μm) of wheat leaves and damage internal leaf tissues while particle VER determines the interaction of incoming solar radiation with leaf surfaces. Average PM₅ concentrations ± Standard deviations (μg/m³) were reported to be 231.05 ± 113.03. The XRF (X-Ray Fluorescence) spectrometer analysis of bulk PM₅ revealed the concentrations of non-carbonaceous elements (μg/m³) as N (67.34 ± 16.09), Si (27.44 ± 11.01), Al (7.79 ± 3.37), S (3.88 ± 2.24), Na (2.29 ± 0.94), Mg (1.65 ± 0.62), K (0.51 ± 0.26), Ca (0.60 ± 0.26), Fe (0.54 ± 0.26), Cr (1.10 ± 0.70), Zn (0.05 ± 0.03), P (0.10 ± 0.03), Cu (0.07 ± 0.06). The dominant elemental oxides were calculated as SiO₂, Al₂O₃, SO₄^2-, Na₂O, MgO, K₂O, CaO, Fe₂O₃, Cr₂O₃, ZnO, P₂O₅, Cu₂O with variable concentrations. In high humid conditions, with relative humidity (~85%) during the vegetative and flowering growth stages of wheat crops, presence of C and S rich acidic and hygroscopic particles may cause the corrosion of wheat leaves that ultimately affect the wheat crops.

Patterns of care and outcomes for second-line targeted therapy in metastatic renal cell carcinomas: A registry based analysis

AIM

Patterns of care for metastatic renal cell carcinomas (mRCC) have seen tremendous reform in the last decade. Here, we present our pattern of care in second-line targeted therapy for mRCC.

METHODS

Patients with mRCC treated with second-line therapy were included from a prospective database. Demographics, risk stratification, and treatment details were noted. Event-free survival (EFS) and overall survival (OS) was calculated using Kaplan-Meier method. Log-rank test was used to identify factors affecting EFS and OS. Multivariate analysis was performed using cox regression.

RESULTS

Nearly 21.7% (46/212) of patients received second-line targeted treatment. Heng score for risk stratification showed 21.7% of patients in low risk, 36.9% in intermediate, and 34.8% in high risk group. Everolimus followed by pazopanib were the most common second-line therapies used in 65.2% and 13% of patients, respectively. The estimated median EFS was 3.5 months (95% confidence interval [CI] 2.7-4.26 months) and estimated median OS from the start of second-line therapy was 6.2 months (95% CI 3.4-9.0 months) with a median follow-up of 4.3 months. On univariate log-rank analysis, EFS of more than 6 months with first-line therapy was associated with improvement in EFS with second-line therapy (9.5 vs. 2.0 months; hazard ratio (HR) 0.364; P = 0.002). There was no factor independently associated with EFS or OS on multivariate analysis.

CONCLUSION

Patterns of care for second line targeted therapy tend to vary with setting. A longer EFS with first-line therapy predicts improved outcomes with second-line treatment.

Phycoremediation of textile wastewater by unicellular microalga Chlorella pyrenoidosa

The potential application of microalga Chlorella pyrenoidosa was investigated for phycoremediation of textile wastewater. Two 15 days batch experiment containing autoclaved and unautoclaved textile wastewater were performed to measure the efficiency of alga to remediate the wastewater. Experiments were set at equivalent external conditions and pollutant load was measured on alternate of 5 days to determine the pollutant removal efficiency of alga. Alga was found to be more efficient in removal of pollutants load in autoclaved wastewater; agents of eutrophication such as nitrate and phosphate are reduced by 62% ±0.5 and 87% ±0.7 respectively while organic load in terms of BOD is reduced by 81% ±0.2 whereas, In unautoclaved wastewater in presence of algal-bacterial consortium, nitrate and phosphate were removed by 81% ±1 and 36% ±2.2 while BOD is reduced by 73% ±1.6 only. Another time dependent experiment of dye removal was also performed to measure the adsorption potential of selected dried algal biomass. An equal amount of dried algal biomass was introduced to various range of textile wastewater simulated with methylene blue (MB) dye. The maximum colour removal was observed afterduration of 30 minutes by dry algal biomass.

The neuropsychological profile of children at high risk of developing an eating disorder

BACKGROUND

There is a large body of evidence indicating that eating disorders (EDs) are characterized by particular neuropsychological profiles. We aimed to further explore whether impairments in neuropsychological functioning previously found in ED groups are present prior to onset, or are secondary to the disorder. Method This is the first study to explore neuropsychological functioning in children born to a mother with a lifetime ED, who are therefore at high risk of developing an ED, in a large cohort sample. We investigated intelligence and attention at age 8 years (n = 6201) and working memory (WM) and inhibition at age 10 years (6192) in children who are at high risk of developing an ED, compared to children who are not.

RESULTS

The children of women with lifetime anorexia nervosa (AN) showed high full-scale and performance IQ, increased WM capacity, better visuo-spatial functioning, and decreased attentional control. The children of women with lifetime bulimia nervosa (BN) showed comparatively poor visuo-spatial functioning.

CONCLUSIONS

Our findings suggest that high intelligence, increased WM capacity and impaired attentional control might be intermediate phenotypes on the pathway between genetic vulnerability and the development of an ED.

Effect of head circumference on parameters of pattern reversal visual evoked potential in healthy adults of central India

Visual evoked response testing has been one of the most exciting clinical tools to be developed from neurophysiologic research in recent years and has provided us with an objective method of identifying abnormalities of the afferent visual pathways. Investigation were carried out to see whether the head circumference influence the pattern reversal visual evoked potential (PRVEP) parameters. The study comprised of pattern reversal visual evoked potential (PRVEP) recordings in 400 eyes of 200 normal subjects. Two hundred fourty eight eyes were males and 152 eyes were from 76 female subjects recruited from the Central Indian population in the age range of 40-79 years. Visual evoked potential (VEP) recordings were performed in accordance to the standardized methodology of International Federation of Clinical Neurophysiology (IFCN) Committee Recommendations and International Society for Clinical Electrophysiology of Vision (ISCEV) Guidelines and montages were kept as per 10-20 International System of EEG Electrode placements. The stimulus configuration in this study consisted of the transient pattern reversal method in which a black and white checker board was generated (full field) and displayed on a VEP Monitor by an electronic pattern regenerator inbuilt in an Evoked Potential Recorder (RMS EMG EP MARK II). VEP latencies, duration and amplitude were measured in all subjects and the data were analyzed. The correlation of all the electrophysiological parameters with head circumference was evaluated by Pearson's correlation co-efficient (r) and its statistical significance was evaluated. The prediction equations for all the VEP parameters with respect to head circumference were derived. We found a positive correlation of P 100 latency and N 155 latency with mean head circumference, while a highly significant negative correlation were noted of P 100 amplitude with head circumference. N 70 latency was significantly correlated with head circumference. P 100 duration showed in negative correlation with head circumference. These findings suggest that VEP latencies, duration and amplitude are influenced by the head circumference of the individual in a sample of healthy subjects and head circumference can be a useful predictor of VEP peak latencies, amplitude and duration.

Learning from labeled and unlabeled data using a minimal number of queries

The considerable time and expense required for labeling data has prompted the development of algorithms which maximize the classification accuracy for a given amount of labeling effort. On the one hand, the effort has been to develop the so-called "active learning" algorithms which sequentially choose the patterns to be explicitly labeled so as to realize the maximum information gain from each labeling. On the other hand, the effort has been to develop algorithms that can learn from labeled as well as the more abundant unlabeled data. Proposed in this paper is an algorithm that integrates the benefits of active learning with the benefits of learning from labeled and unlabeled data. Our approach is based on reversing the roles of the labeled and unlabeled data. Specifically, we use a Genetic Algorithm (GA) to iteratively refine the class membership of the unlabeled patterns so that the maximum a posteriori (MAP) based predicted labels of the patterns in the labeled dataset are in agreement with the known labels. This reversal of the role of labeled and unlabeled patterns leads to an implicit class assignment of the unlabeled patterns. For active learning, we use a subset of the GA population to construct multiple MAP classifiers. Points in the input space where there is maximal disagreement amongst these classifiers are then selected for explicit labeling. The learning from labeled and unlabeled data and active learning phases are interlaced and together provide accurate classification while minimizing the labeling effort.

Quality of hospital care in African American and white patients with ischemic stroke and TIA

OBJECTIVE

To examine whether differences exist in the in-hospital diagnostic evaluation and treatment of African American and white patients with ischemic stroke (IS) and TIA.

METHODS

The authors used a state-wide hospital-based stroke registry prototype designed to measure and track the quality of acute stroke care. Weighted descriptive statistics for each racial group are reported for the following variables, which were deemed to be potential confounders of the association between race and the quality of stroke care: age, gender, insurance status, emergency medical services arrival, functional status on presentation, modified Rankin score at discharge, stroke subtype, neurologist involved in care, and stroke pathway utilization. The magnitude and significance of the associations between race and each quality indicator of in-hospital acute stroke care were determined by separate multiple logistic regression models, adjusting for all potential confounding variables.

RESULTS

Among patients admitted with IS and TIA who were alive at discharge (n = 1,837), 340 (18.5%) were African American and 1497 (81.5%) were white. After multivariate analysis, African Americans were less likely to have a door-to-CT time of less than 25 minutes (odds ratio [OR] 0.13 [CI 0.049 to 0.32]), obtain cardiac monitoring (OR 0.54 [CI 0.29 to 1.03]), undergo dysphagia screening (OR 0.69 [CI 0.50 to 0.95]), and receive smoking cessation counseling (OR 0.27 [CI 0.17 to 0.42]).

CONCLUSIONS

Quality of hospital care for African American and white patients with acute ischemic stroke and TIA was similar in many respects. However, African Americans were less likely to receive a CT within 25 minutes of arrival, cardiac monitoring, dysphagia screening, and smoking cessation counseling.

Age- and diet-related increase in transepithelial colon permeability of Fischer 344 rats

When transepithelial permeability of rat distal colon is evaluated on the basis of transepithelial electrical resistance, age does not have an effect. Age likewise did not affect the decrease in resistance brought about by phorbol ester exposure. However, age was shown to correlate with increased transepithelial permeability when diffusion of the nonelectrolyte, D-mannitol, was used as an indicator. A phorbol ester-induced increase in transepithelial permeability to D-mannitol was observed to increase with age. Basal permeability to D-mannitol was significantly higher in older rats when the animals were allowed to age on a high-fat diet. Distance from the rectum was shown to be a potential complicating factor in these studies, since distal colon closer to the rectum was observed to have lower transepithelial permeability. The potential effect of such increased leakiness on the increased frequency of colon cancer in older individuals is discussed.

Greater Cincinnati/Northern Kentucky Stroke Study: volume of first-ever ischemic stroke among blacks in a population-based study

BACKGROUND AND PURPOSE

The volume of ischemic stroke on CT scans has been studied in a standardized fashion in acute stroke therapy trials with median volumes between 10.5 to 55 cm(3). The volume of first-ever ischemic stroke in the population is not known.

METHODS

The first phase of the population-based Greater Cincinnati/Northern Kentucky Stroke Study identified all ischemic strokes occurring in blacks in the greater Cincinnati region between January and June of 1993. The patients in this phase of the study who had a first-ever ischemic clinical stroke were identified, and the volume of ischemic stroke was measured.

RESULTS

There were 257 verified clinical cases of ischemic stroke, of which 181 had a first-ever ischemic infarct. Imaging was available for 150 of these patients, and 79 had an infarct on the CT or MRI study that was definitely or possibly related to the clinical symptoms. For these patients, volumetric measurements were performed by means of the modified ellipsoid method. The median volume of first-ever ischemic stroke for the 79 patients was 2.5 cm(3) (interquartile range, 0.5 to 8.8 cm(3)). There was a significant relation between location of lesion and infarct size (P<0.001) and between volume and mechanism of stroke (P=0.001).

CONCLUSIONS

The volume of first-ever ischemic stroke among blacks in our population-based study is smaller than has been previously reported in acute stroke therapy trials. The large proportion of small, mild strokes in blacks may be an important reason for the low percentage of patients who meet the inclusion criteria for tissue plasminogen activator. Further study is necessary to see if these results are generalizable to a multiracial population.

Apolipoprotein E phenotype and the efficacy of intravenous tissue plasminogen activator in acute ischemic stroke

We used stored plasma samples from 409 patients in the National Institute of Neurological Diseases and Stroke (NINDS) tissue plasminogen activator (t-PA) Stroke Trial to examine the relationship between an apolipoprotein (Apo) E2 or an Apo E4 phenotype and a favorable outcome 3 months after stroke, the risk of intracerebral hemorrhage, and the response to intravenous t-PA therapy. For the 27 patients with an Apo E2 phenotype who were treated with t-PA, the odds ratio (OR) of a favorable outcome at 3 months was 6.4 [95% confidence interval (CI) 2.7-15.3%] compared to the 161 patients without an Apo E2 phenotype who were treated with placebo. The 190 patients treated with t-PA who did not have an Apo E2 phenotype also had a greater, though less pronounced, likelihood of a favorable outcome (OR 2.0, 95% CI 1.2-3.2%) than patients without an Apo E2 phenotype treated with placebo. For the 31 patients with an Apo E2 phenotype treated with placebo, the OR of a favorable 3 month outcome was 0.8 (95% CI 0.4-1.7%) compared to the 161 patients without an Apo E2 phenotype treated with placebo. This interaction between treatment and Apo E2 status persisted after adjustment for baseline variables previously associated with 3 month outcome, for differences in the baseline variables in the two treatment groups and in the Apo E2-positive and -negative groups, and for a previously reported time-to-treatment x treatment interaction (p = 0.03). Apo E4 phenotype, present in 111 (27%) of the 409 patients, was not related to a favorable 3 month outcome, response to t-PA, 3 month mortality, or risk of intracerebral hemorrhage. We conclude that the efficacy of intravenous t-PA in patients with acute ischemic stroke may be enhanced in patients who have an Apo E2 phenotype, whereas the Apo E2 phenotype alone is not associated with a detectable benefit on stroke outcome at 3 months in patients not given t-PA. In contrast to prior studies of head injury and stroke, we could not detect a relationship between Apo E4 phenotype and clinical outcome.

Finding the most powerful measures of the effectiveness of tissue plasminogen activator in the NINDS tPA stroke trial

BACKGROUND AND PURPOSE

We sought to identify the most powerful binary measures of the treatment effect of tissue plasminogen activator (tPA) in the National Institute of Neurological Disorders and Stroke (NINDS) rTPA Stroke Trial.

METHODS

Using the Classification and Regression Tree (CART) algorithm, we evaluated binary cut points and combination of binary cut points with the 4 clinical scales and head CT imaging measures in the NINDS tPA Stroke Trial at 4 times after treatment: 2 hours, 24 hours, 7 to 10 days, and 3 months. The first analysis focused on detecting evidence of "early activity" of tPA with the use of outcome measures derived from the 2-hour and 24-hour clinical and radiographic measures. The second analysis focused on longer-term outcome and "efficacy" and used outcome measures derived from 7- to 10-day and 3-month measures. After identifying the cut points with the ability to classify patients into the tPA and placebo groups using part I data from the trial, we then used data from part II of the trial to validate the results.

RESULTS

Of the 5 most powerful outcome measures for early activity of tPA, 4 involved the National Institutes of Health Stroke Scale (NIHSS) score at 24 hours or changes in the NIHSS score from baseline to 24 hours. The best overall single outcome measure was an NIHSS score </=2 at 24 hours, which provided an odds ratio of 5.4 (95% CI, 2.4 to 12.1) and a projected sample size of 58 per treatment group assuming an alpha of 0.05 (2-sided test) and a power of 80% using part I data. The top 2 and 3 of the top 5 outcome measures for detecting the longer-term efficacy of tPA also involved the NIHSS score. A Rankin score of 0 or 1 at 3 months was the third most powerful outcome measure. Outcome measures identified by CART from part I data were not as sensitive in detecting the effectiveness of tPA when applied to part II data.

CONCLUSIONS

Measures using the NIHSS and a Rankin score </=1 were the most sensitive discriminators of the effectiveness of tPA in the NINDS tPA Stroke Trial compared with the other clinical and radiological measures. The outcome measures identified in this exploratory analysis (eg, NIHSS score </=2 at 24 hours) would be best used as an outcome measure in future phase II trials of recanalization begun within the first 3 hours after stroke onset, with inclusion and exclusion criteria similar to those in the NINDS tPA Stroke Trial.

Loss of estrogen receptor (ER) expression in endometrial tumors is not associated with de novo methylation of the 5' end of the ER gene

Normal endometrium, an estrogen-responsive tissue, expresses the estrogen receptor (ER) alpha gene. Loss of ER expression, the basis for which is currently unknown, is often seen in advanced stage, poor prognosis endometrial tumors. The ER gene undergoes de novo methylation with high frequency in a wide variety of human tumors, including ER-negative breast cancers. In this study, we used several bisulfite-based detection methods to assess whether loss of ER positivity in endometrial tumors is associated with aberrant methylation of the ER gene. Although extensive methylation of a 600-bp region at the 5' end of the gene was seen in two endometrial carcinoma cell lines, none of the 55 CpGs in this region was methylated in 25 of 26 ER-deficient endometrial carcinomas.

Incidence rates of first-ever ischemic stroke subtypes among blacks: a population-based study

BACKGROUND AND PURPOSE

The aim of this study was to determine the incidence rates of ischemic stroke subtypes among blacks.

METHODS

Hospitalized and autopsied cases of stroke and transient ischemic attack among the 187 000 blacks in the 5-county region of greater Cincinnati/northern Kentucky From January 1, 1993, through June 30, 1993, were identified. Incidence rates were age- and sex-adjusted to the 1990 US population. Subtype classification was performed after extensive review of all available imaging, laboratory data, clinical information, and past medical history. Case-control comparisons of risk factors were made with age-, race-, and sex-matched control subjects.

RESULTS

Annual incidence rates per 100 000 for first-ever ischemic stroke subtypes among blacks were as follows: uncertain cause, 103 (95% confidence interval [CI], 80 to 126); cardioembolic, 56 (95% CI, 40 to 73); small-vessel infarct, 52 (95% CI, 36 to 68); large vessel, 17 (95% CI, 8 to 26); and other causes, 17 (95% CI, 9 to 26). Of the patients diagnosed with an infarct of uncertain cause, 31% underwent echocardiography, 45% underwent carotid ultrasound, and 48% had neither. Compared with age-, race-, and sex- (proportionally) matched control subjects from the greater Cincinnati/northern Kentucky region, the attributable risk of hypertension for all causes of first-ever ischemic stroke is 27% (95% CI, 7 to 43); for diabetes, 21% (95% CI, 11 to 29); and for coronary artery disease, 9% (95% CI, 2 to 16). For small-vessel ischemic stroke, the attributable risk of hypertension is 68% (95% CI, 31 to 85; odds ratio [OR], 5.0), and the attributable risk of diabetes is 30% (95% CI, 10 to 45; OR, 4.4). For cardioembolic stroke, the attributable risk of diabetes is 25% (95% CI, 4 to 41; OR, 3.1).

CONCLUSIONS

Stroke of uncertain cause is the most common subtype of ischemic stroke among blacks. Cardioembolic stroke and small-vessel stroke are the most important, identifiable causes of first-ever ischemic stroke among blacks. The incidence rates of cardioembolic and large-vessel stroke are likely underestimated because noninvasive testing of the carotid arteries and echocardiography were not consistently obtained in stroke patients at the 18 regional hospitals. Most small-vessel strokes in blacks can be attributed to hypertension and diabetes.

Underlying structure of the National Institutes of Health Stroke Scale: results of a factor analysis. NINDS tPA Stroke Trial Investigators

BACKGROUND AND PURPOSE

No stroke scale has been validated as an outcome measure using data from a clinical trial demonstrating a positive therapeutic effect. Therefore, we proposed to use data from the National Institute of Neurological Disorders and Stroke (NINDS) tPA Stroke Trial to determine whether the National Institutes of Health Stroke Scale (NIHSS) was valid in patients treated with tissue plasminogen activator (tPA) and to explore the underlying clinimetric structure of the NIHSS.

METHODS

We performed an exploratory factor analysis of NIHSS data from Part 1 (n=291) of the NINDS tPA Stroke Trial to derive a hypothesized underlying factor structure. We then performed a confirmatory factor analysis of this structure using NIHSS data from Part 2 of the same trial (n=333). We then tested whether this final factor structure could be found in tPA- and placebo-treated patients serially over time after stroke treatment. Using 3-month outcome data, we tested for an association between the NIHSS and other measures of stroke outcome.

RESULTS

The exploratory analysis suggested that there were 2 factors underlying the NIHSS, representing left and right brain function, confirming the content validity of the scale. An alternative structure composed of 4 factors could be derived, with a better goodness of fit: the first 2 factors could represent left brain cortical and motor function, respectively, and the second 2 factors could represent right brain cortical and motor function, respectively. The same factor structures were then found in tPA and placebo patient groups studied serially over time, confirming the exploratory analysis. All 3-month clinical outcomes were associated with each other at subsequent time points, confirming predictive validity.

CONCLUSIONS

This is the first study of the validity of a stroke scale in patients treated with effective stroke therapy. The NIHSS appeared to be valid in patients with acute stroke and for finding treatment-related differences. The scale was valid when used serially over time after stroke, up to 3 months, and showed good agreement with other measures of outcome.

Early surgical treatment for supratentorial intracerebral hemorrhage: a randomized feasibility study

BACKGROUND AND PURPOSE

The safety and the effectiveness of the surgical treatment of spontaneous intracerebral hemorrhage (ICH) remain controversial. To investigate the feasibility of urgent surgical evacuation of ICH, we conducted a small, randomized feasibility study of early surgical treatment versus current nonoperative management in patients with spontaneous supratentorial ICH.

METHODS

Patients with spontaneous supratentorial ICH who presented to 1 university and 2 community hospitals were randomized to surgical treatment or best medical treatment. Principal eligibility criteria were ICH volume >10 cm(3) on baseline CT scan with a focal neurological deficit, Glasgow Coma Scale score >4 at the time of enrollment, randomization and therapy within 24 hours of symptom onset, surgery within 3 hours of randomization, and no evidence for ruptured aneurysm or arteriovenous malformation. The primary end point was the 3-month Glasgow Outcome Scale (GOS). A good outcome was defined as a 3-month GOS score >3.

RESULTS

Twenty patients were randomized over 24 months, 9 to surgical intervention and 11 to medical treatment. The median time from onset of symptoms to presentation at the treating hospitals was 3 hours and 17 minutes, the time from randomization to surgery was 1 hour and 20 minutes, and the time from onset of symptoms to surgery was 8 hours and 35 minutes. The likelihood of a good outcome (primary outcome measure: GOS score >3) for the surgical treatment group (56%) did not differ significantly from the medical treatment group (36%). There was no significant difference in mortality at 3 months. Analysis of the secondary 3-month outcome measures showed a nonsignificant trend toward a better outcome in the surgical treatment group versus the medical treatment group for the median GOS, Barthel Index, and Rankin Scale and a significant difference in the National Institutes of Health Stroke Scale score (4 versus 14; P=0.04).

CONCLUSIONS

Very early surgical treatment for acute ICH is difficult to achieve but feasible at academic medical centers and community hospitals. The trend toward less 3-month morbidity with surgical intervention in patients with spontaneous supratentorial ICH warrants further investigation of very early clot removal in larger randomized clinical trials.

Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy

BACKGROUND AND PURPOSE

Ischemic changes identified on CT scans performed in the first few hours after stroke onset, which are thought to possibly represent early cytotoxic edema and development of irreversible injury, may have important implications for subsequent treatment. However, insecurity and conflicting data exist over the ability of clinicians to correctly recognize and interpret these changes. We performed a detailed review of selected baseline CT scans from the NINDS rt-PA Stroke Trial to test agreement among experienced stroke specialists and other physicians on the presence of early CT ischemic changes.

METHODS

Seventy baseline CT scans from the NINDS Stroke Trial were read and classified for the presence or absence of various early findings of ischemia by 16 individuals, including NINDS trial investigators, other neurologists, other emergency medicine physicians, and radiology or stroke fellows. CT scans included normal scans and scans from patients who later developed symptomatic intracranial hemorrhage, as well as scans on which the NINDS rt-PA Stroke Trial neuroradiologist identified clear-cut early CT changes. For each CT finding, kappa-statistics were used to assess the proportion of agreement beyond chance.

RESULTS

kappa-Values (95% confidence interval [CI]) ranged from 0.20 (-0.20, 0.61) (fair agreement) to 0.41 (0.37, 0.45) (moderate agreement) among the 16 viewers, and the kappa-value was only 0.39 (0.29, 0.49) (fair) in answer to the question "do early CT changes involve more than one third of the MCA [middle cerebral artery] territory?" There was substantial variability within each specialty group and between groups. kappa-Values were only fair to moderate even among physicians experienced in selecting and treating acute stroke patients with rtPA. Observed agreement ranged from 68% to 85%. Physicians agreed on the finding of early CT changes involving >33% of the MCA territory 77% of the time, although the kappa-value of 0.39 suggested only moderate agreement beyond chance.

CONCLUSIONS

There is considerable lack of agreement, even among experienced clinicians, in recognizing and quantifying early CT changes. Improved methods of recognizing and quantifying early ischemic brain damage are needed.

Immunophenotypic diagnosis of acute leukemia by using decision tree induction

We describe a model for decision making for bone marrow immunophenotypic analysis of acute leukemia. In this study, we used decision tree induction as an information processing system for the analysis of flow cytometry immunophenotype results of bone marrow specimens obtained for the diagnosis of acute leukemia. By using decision tree analysis, we queried which antibodies and at what percentage cut-offs led to particular diagnoses. Flow cytometry results of up to 27 monoclonal antibodies from bone marrow specimens of 175 adult and pediatric cases were used: acute lymphoblastic leukemia (n = 80), myeloid leukemia (n = 44), mixed lineage (n = 16), and reactive marrow (n = 35). The percentage of positive cells was used as input data, and the diagnoses were used as output of the information processing system. Results of the decision tree showed an easy, accurate, and intuitive algorithm that can delineate a hierarchy of antibodies relevant to diagnosis. A correct discrimination of acute myeloid and lymphoid leukemia from benign bone marrow can be inferred by using the results of four to eight from a panel of up to 27 antibodies with an accuracy of 95%. Here, we describe a computer-aided model that uses decision tree induction applied to flow cytometry immunophenotype data. If generalizable, this technique may be an alternative approach to modeling complex information like that seen in hematopathology and may complement the immunologist's interpretation, along with cytochemistry and morphology results, in the diagnosis of acute leukemia.

Acute stroke: delays to presentation and emergency department evaluation

STUDY OBJECTIVE

To document prehospital and inhospital time intervals from stroke onset to emergency department evaluation and to identify factors associated with presentation to the ED within 3 hours of symptom onset, the current time window for thrombolytic therapy.

METHODS

Patients admitted through the ED with a diagnosis of stroke were identified through admitting logs. Time intervals were obtained from EMS runsheets and ED records. Information regarding first medical contact, education, and income was obtained by patient interview. Baseline variables were analyzed to assess association with ED arrival within 3 hours of symptom onset; variables significant on univariate analysis were placed in a multivariable model.

RESULTS

There were 151 stroke patients (59% white and 41% black). Time of stroke onset and time to ED arrival were documented for 119 patients (79%). The median time from stroke onset to ED arrival was 5.7 hours; 46 patients (30%) presenting within 3 hours. Of those with times recorded, the median time from stroke onset to EMS arrival was 1.7 hours. Multivariable logistic regression identified use of EMS (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.3 to 12.1) and white race (OR, 3.5; 95% CI, 1.3 to 10) as being independently associated with ED arrival within 3 hours of symptom onset. Median time from ED arrival to physician evaluation was 20 minutes. Median time from ED arrival to computed tomographic evaluation was 72 minutes. When patients were asked the main reason they sought medical attention, 40% (60/141) of those able to be interviewed said that they themselves did not decide to seek medical attention, but rather a friend or family member told them they should go to the hospital.

CONCLUSION

The median time from stroke onset to ED evaluation was 5.7 hours, with almost a third of patients presenting within 3 hours. Use of EMS and white race were independently associated with arrival within 3 hours.

Retinol and retinoic acid bind to a surface cleft in bovine beta-lactoglobulin: a method of binding site determination using fluorescence resonance energy transfer

Two potential ligand binding sites in the lipocalin beta-lactoglobulin have been postulated for small hydrophobic molecules such as retinol or retinoic acid. An agreement on one of the two alternatives, an interior cavity or a surface cleft, however, has not been achieved. In order to discriminate between these two possibilities, we measured the efficiency of fluorescence resonance energy transfer between the two intrinsic Trp-residues of beta-lactoglobulin and the ligands retinol, retinoic acid and bis-ANS. Using the crystallographic coordinates of beta-lactoglobulin, this efficiency could be accurately computed for both the interior cavity and the surface cleft as ligand binding sites. For the surface cleft, the theoretical value was found to be in excellent agreement with the measured value, whereas for the interior cavity any reasonable agreement would require a dramatic ligand-induced conformational change that can be ruled out due to the protein's known structural stability. Our conclusion that these ligands bind to the surface pocket rather than the interior cavity was further confirmed by competitive binding studies.

Hypertension and its treatment in the NINDS rt-PA Stroke Trial

BACKGROUND AND PURPOSE

We examined the frequency, course, and treatment of hypertension in the NINDS rt-PA Stroke Trial.

METHODS

Blood pressure (BP) was measured at the time of admission, at randomization, and then 36 times during the first 24 hours after randomization. Patients with a systolic BP of >185 mm Hg and a diastolic BP of >110 mm Hg at admission were defined as hypertensive before randomization, and those with a systolic BP of >180 mm Hg or a diastolic BP of >105 mm Hg within the first 24 hours after randomization were defined as hypertensive after randomization. Standardized clinical assessments were conducted at 24 hours and at 3 months. Post hoc analyses were conducted to evaluate the association of antihypertensive therapy with clinical outcomes.

RESULTS

Of the 624 patients, 121(19%) had hypertension on admission and 372 (60%) had hypertension in the 24 hours after randomization. The use of antihypertensive therapy before randomization (tPA 9%, placebo 9%) and after randomization (tPA 24%, placebo 29%) was similar between placebo- and tPA-treated patients. No adverse effects of prerandomization antihypertensive therapy on 3-month favorable outcome were detected for either the placebo- or tPA-treated groups. For placebo patients with hypertension in the 24 hours after randomization, clinical outcome measures were similar for those patients who did and did not receive antihypertensive therapy after randomization (P > or = 0.26); antihypertensive therapy was not associated with declines in BP (P = 0.44) or with abrupt declines (P = 0.14). Those tPA patients who were hypertensive after randomization and received antihypertensive therapy were less likely to have a favorable outcome at 3 months (P < 0.01) than those who were hypertensive and did not receive antihypertensive therapy.

CONCLUSIONS

The frequency of hypertension and the use of antihypertensive therapy were similar between the tPA and placebo groups in the NINDS rt-PA Stroke Trial. In the placebo group, antihypertensive therapy was not associated with less favorable outcomes at 3 months; postrandomization antihypertensive therapy was associated with less favorable outcomes for the tPA patients who were hypertensive. However, because of the nonrandomized use of antihypertensive therapy and the many post hoc comparisons leading to type 1 errors, the significance of this observation is unclear. Careful attention to BP and gentle management remain warranted for stroke patients treated with tPA.

Public perception of stroke warning signs and knowledge of potential risk factors

CONTEXT

Decreasing the time from stroke onset to hospital arrival and improving control of stroke risk factors depend on public knowledge of stroke warning signs and risk factors.

OBJECTIVE

To assess current public knowledge of stroke warning signs and risk factors.

DESIGN

A population-based telephone interview survey using random digit dialing conducted in 1995.

SETTING

The Greater Cincinnati, Ohio, metropolitan area, the population of which is similar to that of the United States overall in age, sex, percentage of blacks, and economic status.

PARTICIPANTS

Respondents with age, race, and sex that matched the population of patients with acute stroke.

MAIN OUTCOME MEASURES

Knowledge of risk factors for stroke and warning signs of stroke as defined by the National Institute of Neurological Disorders and Stroke.

RESULTS

Telephone calls were made to 17634 households, which yielded 2642 demographically eligible individuals. Interviews were completed by 1880 respondents (response rate, 71.2%). A total of 1066 respondents (57%) correctly listed at least 1 of the 5 established stroke warning signs, and of all respondents, 1274 (68%) correctly listed at least 1 of the established stroke risk factors. Of the respondents, 469 (57%) of 818 respondents with a history of hypertension listed hypertension, 142 (35%) of 402 respondents who were current smokers listed smoking, and 32 (13%) of 255 respondents with diabetes listed diabetes as a risk factor for stroke. Compared with those younger than 75 years, respondents 75 years or older were less likely to correctly list at least 1 stroke warning sign (60% vs 47%, respectively; P<.001) and were less likely to list at least 1 stroke risk factor (72% vs 56%, respectively; P<.001).

CONCLUSION

Considerable education is needed to increase the public's awareness of the warning signs and risk factors for stroke. Respondents with self-reported risk factors for stroke are largely unaware of their increased risk. The population at greatest risk for stroke, the very elderly, are the least knowledgeable about stroke warning signs and risk factors.

The Greater Cincinnati/Northern Kentucky Stroke Study: preliminary first-ever and total incidence rates of stroke among blacks

BACKGROUND AND PURPOSE

The Greater Cincinnati/Northern Kentucky Stroke Study was designed to be the first large, population-based metropolitan study of temporal trends in stroke incidence rates and outcome within a biracial population.

METHODS

We are identifying all hospitalized and autopsied cases of stroke and transient ischemic attack (TIA) among the 1.3 million inhabitants of a five-county region of Greater Cincinnati/Northern Kentucky for the period 7/1/93-6/30/94. We have already prospectively monitored for out-of-hospital stroke and TIAs for this same time period at 128 screening sites, including a random sample of all primary care physicians and nursing homes in the region. We have already identified all hospitalized and autopsied cases of stroke and TIA among blacks for 1/1/93-6/30/93 and report preliminary incidence rates for this 6-month period.

RESULTS

The overall incidence rate for all first-ever hospitalized or autopsied stroke (excluding TIAs) among blacks in the Greater Cincinnati region was 288 per 100000 (95% CI, 250 to 325, age- and sex-adjusted to 1990 US population). The overall incidence rate for first-ever and recurrent stroke (excluding TIAs) was 411 per 100000 (95% CI, 366 to 456). By comparison, the overall incidence rate of first-ever stroke among whites in Rochester, Minn, during the period 1985-1989 was 179 per 100000 (95% CI, 164 to 194, age- and-sex adjusted to 1990 US population). The incidence rates among blacks in Greater Cincinnati were substantially greater than the rates among whites in Rochester, Minn, for all age categories except ages 75 and older, for which the rates were similar.

CONCLUSIONS

We conservatively estimate that 731100 first-ever or recurrent strokes occurred in the United States during 1996. Studies of first-ever as well as total stroke among biracial and representative populations are critical for understanding temporal trends in the incidence rate and the burden of stroke in the US population.

State-dependent weights for neural associative memories

In this article we study the effect of dynamically modifying the weight matrix on the performance of a neural associative memory. The dynamic modification is implemented by adding, at each step, the outer product of the current state, scaled by a suitable constant eta, to the correlation weight matrix. For single-shot synchronous dynamics, we analytically obtain the optimal value of eta. Although knowledge of the noise percentage is required for calculating the optimal value of eta, a fairly good choice of eta can be made even when the amount of noise is not known. Experimental results are provided in support of the analysis. The efficacy of the proposed modification is also experimentally verified for the case of asynchronous updating with transient length > 1.

Patients' awareness of stroke signs, symptoms, and risk factors

BACKGROUND AND PURPOSE

We sought to determine knowledge at the time of symptom onset regarding the signs, symptoms, and risk factors of stroke in patients presenting to the emergency department with potential stroke.

METHODS

Patients admitted from the emergency department with possible stroke were identified prospectively. A standardized, structured interview with open-ended questions was performed within 48 hours of symptom onset to assess patients' knowledge base concerning stroke signs, symptoms, and risk factors.

RESULTS

Of the 174 eligible patients, 163 patients were able to respond to the interview questions. Of these 163 patients, 39% (63) did not know a single sign or symptom of stroke. Unilateral weakness (26%) and numbness (22%) were the most frequently noted symptoms. Patients aged > or = 65 years were less likely to know a sign or symptom of stroke than those aged < 65 years (percentage not knowing a single sign or symptom, 47% versus 28%, P = .016). Similarly, 43% of patients did not know a single risk factor for stroke. The elderly were less likely to know a risk factor than their younger counterparts.

CONCLUSIONS

Almost 40% of patients admitted with a possible stroke did not know the signs, symptoms, or risk factor of a stroke. Further public education is needed to increase awareness of the warning signs and risk factors of stroke.

Early stroke recognition: developing an out-of-hospital NIH Stroke Scale

OBJECTIVE

To develop an abbreviated and practical neurologic scale that could assist emergency medical services or triage personnel in identifying patients with stroke.

METHODS

A prospective, observational, cohort study was performed at university-based EDs. Participants were 74 patients treated in a thrombolytic stroke trial and 225 consecutive non-stroke patients evaluated during 4 random 12-hour shifts in the ED. Scores on the NIH Stroke Scale were obtained for all patients by physicians. Items of this scale were modified and recoded to a binomial (normal or abnormal) scale. Serial univariate analyses using chi 2 were performed to rank items. Recursive partitioning was then performed to develop the decision rule for predicting the presence of stroke.

RESULTS

Three items identified 100% of patients with stroke: facial palsy, motor arm, and dysarthria. An Abbreviated NIH Stroke Scale based on these items had a sensitivity of 100% and a specificity of 92%. A proposed Out-of-hospital NIH Stroke Scale consisting of facial palsy, motor arm, and a combination of dysarthria and best language items (abnormal speech) had a sensitivity of 100% and a specificity of 88%.

CONCLUSION

Using the derivation data set, a proposed Out-of-hospital NIH Stroke Scale had a high sensitivity and specificity for identifying patients with stroke when performed by physicians in this group of 299 ED patients. Prospective studies of other health care professionals using the scale in the out-of-hospital arena are needed.

Clinical application of the Ottawa ankle rules for the use of radiography in acute ankle injuries: an independent site assessment

OBJECTIVE

Previous studies show that the clinical criteria known as the Ottawa ankle rules (OAR), used for determining the need for radiographs of the ankle when a fracture is suspected, have a sensitivity of 100%, a specificity of 50%, and an overall reduction in radiographs of the ankle of 28%. The purpose of this study was to further assess the clinical usefulness of the OAR when implemented in an emergency department of a level 1 trauma center.

SUBJECTS AND METHODS

Over a 1-year period, all patients who were between 18 and 55 years old and who presented to the emergency department with blunt ankle trauma were examined by emergency department clinicians who used the OAR to determine the need for ordering ankle radiographs.

RESULTS

Of 926 patients with blunt ankle trauma, 759 met OAR criteria for ordering radiographs of the ankle. Of these patients, 152 were found to have a fracture. Another 167 of the patients were determined not to need ankle radiographs. Through either telephone contact or medical records review. 152 (91%) of these 167 patients were successfully followed up for the purpose of detecting any missed fractures. Two missed fractures were discovered, but only one required plaster immobilization. Based on these numbers, overall sensitivity using the OAR was 99% (confidence interval, 95-100%), and specificity was 22%. We found an overall 16% reduction in the number of ankle films ordered.

CONCLUSION

When implemented at a level 1 trauma center, the OAR can adequately screen for ankle fractures.

Early hemorrhage growth in patients with intracerebral hemorrhage

BACKGROUND AND PURPOSE

The goal of the present study was to prospectively determine how frequently early growth of intracerebral hemorrhage occurs and whether this early growth is related to early neurological deterioration.

METHODS

We performed a prospective observational study of patients with intracerebral hemorrhage within 3 hours of onset. Patients had a neurological evaluation and CT scan performed at baseline, 1 hour after baseline, and 20 hours after baseline.

RESULTS

Substantial growth in the volume of parenchymal hemorrhage occurred in 26% of the 103 study patients between the baseline and 1-hour CT scans. An additional 12% of patients had substantial growth between the 1- and 20-hour CT scans. Hemorrhage growth between the baseline and 1-hour CT scans was significantly associated with clinical deterioration, as measured by the change between the baseline and 1-hour Glasgow Coma Scale and National Institutes of Health Stroke Scale scores. No baseline clinical or CT prediction of hemorrhage growth was identified.

CONCLUSIONS

Substantial early hemorrhage growth in patients with intracerebral hemorrhage is common and is associated with neurological deterioration. Randomized treatment trials are needed to determine whether this early natural history of ongoing bleeding and frequent neurological deterioration can be improved.

Thrombolytic therapy for cerebral infarction

Until recently, no clinically effective therapy for acute ischemic stroke has been available. Recent advances in the use of thrombolytic therapy for ischemic stroke appear promising in clinical care. As the use of thrombolytic therapy in acute stroke progress, emergency physicians (EPs) will become increasingly involved in its implementation. The EP must be cognizant of both prior and ongoing investigations in acute ischemic stroke therapy. To that end, this article reviews research in the field of thrombolytic therapy for acute ischemic stroke.

Neural network analysis of flow cytometry immunophenotype data

Acute leukemia is one of the leading malignancies in the United States with a mortality rate strongly influenced by the phenotype. This phenotype is based on detection of cell associated antigens normally expressed during leucopoietic differentiation. In this regard, leukemia classified as lymphoid or myeloid by phenotype is also classified as a candidate for the corresponding chemotherapy protocol. Additionally, the subtype of leukemia based on the degree of differentiation and cell maturity influence prognosis, response to treatment, and median survival times. In this paper, we analyze immunophenotype flow cytometry data toward categorization of leukemia into subcategories based on lineage and differentiation antigen expression. Twenty-eight inputs (derived from the mean fluorescence intensity of up to 27 antibodies, and an additional binary input denoting the past diagnosis of leukemia) are used as input to a neural classifier to categorize a total of 170 cases into the lineage and differentiation categories of leukemia. The neural classifier consisted of a feed forward network trained using back propagation. A complexity regulation term (weight decay) was used to improve the generalization performance of the neural classifier. A training error of 0.0% and a generalization error of 10.3% was obtained for categorization based on lineage, while a training error of 0.0% and a generalization error of 10.0% was obtained for categorization based on differentiation. These results indicate that objective classification of multifaceted phenotypes in leukemia can be achieved for analyzing multiparameter data in flow cytometry and further categorization into the prognostic subtypes.