Abstract TP50: Rescue Thrombolysis Or Hemorrhage Reversal In The Emergency Room After Transport By Mobile Stroke Treatment Unit

Introduction: Mobile Stroke Treatment Units (MSTU) can reduce time to pre-arrival intravenous thrombolysis (IVtPA) and reversal for intracerebral hemorrhage (ICH). We are reporting our experience as a comprehensive stroke center (CSC) receiving MSTU patients.

Methods: We retrospectively reviewed consecutive patients transported by MSTU to our academic CSC from May 2019-May 2021 for suspected stroke. The Columbus MSTU is owned by a separate health system, but is a collaborative venture with 3 CSCs and Columbus Division of Fire, operating daily from 7am-7pm. Data was abstracted on demographics, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, and IVtPA administration.

Results: Among 144 patients transported to our CSC by MSTU, mean age was 66 years (range, 21-99) and 84 (88%) were female. Mean initial NIHSS was 8.6 (range, 0 to 32) and 84 (58.2%) had a final diagnosis of stroke. IVtPA was administered in 26 (18.1%) with a mean LKN to IVtPA time of 109 minutes (range, 41 to 243). Among 26 patients treated with IVtPA, 18 (69.2%) received IVtPA in MSTU and 8 (30.8%) received rescue IVtPA in CSC Emergency Room (ER). 14 patients underwent thrombectomy with median door-to-groin time of 63.5 minutes (range, 28 to 129). We identified 10 (6.9%) cases that received rescue thrombolysis or reversal for ICH after arrival to the CSC ER. Dispatch data was available in 7 of these patients. The median dispatch to on-scene time was 7 minutes (range, 5 to 17). Median dispatch to CSC ER arrival was 53 minutes (range, 40 to 88). Among patients who received rescue therapy in CSC ER, 8 received IVtPA and 2 received reversal for ICH (prothrombin complex concentrate for warfarin and cryoprecipitate/transhexamic acid for IVtPA). Among the 8 MSTU patients who received IVtPA in the CSC ER, reasons included clinical worsening en route (1), new collateral information obtained at the CSC ER (4), and other (3).

Conclusion: In our series of suspected stroke patients evaluated by MSTU, 6.9% of the overall cases received rescue stroke treatment after arrival to the CSC ER. Among MSTU patients who received IVtPA, 30% had thrombolytic treatment after arrival to the CSC ER. Further studies are warranted to assess limitations of MSTU care.

Abstract MP24: Pitfalls of Mobile Stroke Treatment Unit - A Single Center Review

Introduction: Although Mobile Stroke Treatment Units (MSTU) can reduce time to intravenous thrombolysis (IVtPA), limitations in MSTU care have not been well described.

Methods: We retrospectively reviewed consecutive patients transported by MSTU to our academic comprehensive stroke center (CSC) from May 2019 to August 2020 for suspected stroke to assess for potential limitations of care. The Columbus MSTU is owned by a separate health system, but represents a collaborative venture with 3 CSCs and the Columbus Division of Fire, operating daily from 7am-7pm. Data was abstracted on demographics, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, and IVtPA administration.

Results: Among 93 patients transported to our CSC by MSTU, the mean age was 65 years (range, 21-93) and 61 (66%) were female. The mean initial NIHSS was 7.1 (range, 0 to 33) and 52 (55.9%) had a final diagnosis of stroke (4 hemorrhagic, 48 ischemic). IVtPA was administered in 15 (16.1%) with a mean LKN to IVtPA time of 120 minutes (range, 41 to 243). Among 15 patients treated with IVtPA, 10 received IVtPA in MSTU and 5 in CSC ED. In 7 patients who underwent thrombectomy, mean door to groin time was 57 minutes (range, 28 to 88). Among the overall group, 9 (9.7%) cases were identified with limitations in MSTU care, including 2 patients who received IVtPA by MSTU that were more than 10% off from ideal dosing (underdosed by 9mg and overdosed by 21mg), 1 warfarin-associated hemorrhage requiring intubation who did not receive reversal in MSTU but did upon arrival to CSC ED, and 5 patients who received IVtPA after arrival to CSC ED. The reasons for withholding IVtPA included inability to confirm LKN, patient declination, lack of translator, incorrect LKN, and seizure requiring intubation. The LKN to IVtPA time was significantly longer in the ED compared to MSTU (197 vs 82 minutes, p <0.0001).

Conclusion: In our series of suspected stroke patients evaluated by MSTU, gaps identified within MSTU acute stroke care were related to limitations of resources and included errors in weight-based IVtPA dosing, inability to administer IVtPA, or reversal for anti-coagulation related hemorrhage. Clinicians need to be aware of potential pitfalls of MSTU evaluation.

Severe epidermolysis bullosa/Kindler syndrome-like phenotype of an autoinflammatory syndrome in a child

A 5-year-old boy presented with generalized cutaneous erosions, severe scarring, depigmentation and contractures affecting major joints. The lesions had initially affected his ears, nose, feet, and the genital and ocular mucosa, leading to significant depigmentation, scarring, contractures and mutilation. The whole of the trunk and limbs were involved at the time of presentation, with the exception of some islands of spared skin on the proximal thighs, legs, nipples and external genitalia. Electron microscopy revealed a split in the sublamina densa with the absence of anchoring fibrils, suggestive of dystrophic epidermolysis bullosa (EB). Immunofluorescence antigen mapping demonstrated a broad reticulate pattern of staining with collagen IV, VII, and laminin 332 in the floor of the blister, suggestive of Kindler syndrome. Next-generation sequencing revealed a de novo heterozygous missense mutation (a variant of unknown significance) in exon 22 of the phospholipase-C gamma 2 gene (PLCG2), which resulted in a substitution of serine by asparagine at codon 798 (p.Asp798Ser), a result that was validated using Sanger sequencing. The child was diagnosed with PLCG2-associated antibody deficiency and immune dysregulation (PLAID)/autoinflammation and PLCG2-associated antibody deficiency and immune dysregulation (APLAID) syndrome. The cutaneous and corneal erosions, inflammation and scarring of this magnitude, and the eventual result of death have not been described previously for the PLAID/APLAID spectrum previously. In conclusion, this was an unusual acquired autoinflammatory severe EB-like disease that may be associated with de novo PLCG2 mutation.

Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Unsuspected Infective Endocarditis

OBJECTIVE

Infective endocarditis (IE) is considered to be an absolute contraindication for intravenous tissue plasminogen activator treatment (IVtPA) in acute ischemic stroke (AIS). However, during the hyperacute stroke evaluation, the exclusion of IE may be difficult. We sought to report the prevalence of undiagnosed IE in AIS patients who received IVtPA.

METHODS

We reviewed consecutive patients hospitalized at our comprehensive stroke center from January 1, 2014 to March 31, 2019 who received IVtPA for suspected AIS and identified patients diagnosed with IE. Data was abstracted on demographics, medical history, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, culture results, and 90 day modified Rankin Scale (mRS). Good functional outcome was defined as mRS ≤ 2.

RESULTS

Among 1022 AIS patients who received IVtPA, 5 patients (0.5%) were ultimately diagnosed with IE. Among the 5 patients with IE, the mean age was 53.4 years (range, 25-74) and 3 (60%) were female. The majority 4 (80%) were white. Medical risk factors for IE were present in 3 (60%) and included intravenous drug use (1) and dialysis (2). Initial NIHSS was 4.6 (range, 1 to 8). Fever was present on initial presentation in only 1 patient (102.7 F). The mean time from LKN to IVtPA was 3.0 hours (range, 1.9 to 4.4). Vascular imaging showed middle cerebral artery (MCA) occlusion in 4 (80%) and no occlusion in 1 (20%). One patient underwent endovascular thrombectomy. Two patients (40%) developed hemorrhagic complications, including 1 patient who developed subarachnoid hemorrhage due to mycotic cerebral aneurysm rupture. Blood culture results included MRSE (1), Streptococcus viridans (2) and negative (2). TEE in all patients showed vegetations on the mitral valve. No patients had good functional outcomes, and the mean 3 month mRS was 4.8 (range, 3 to 6). The 90 day mortality was 60%.

CONCLUSION

In a series of AIS patients who received IVtPA by academic vascular neurologists, the risk of undiagnosed IE was low (0.5%). Fever was not commonly present during initial evaluation in IE presenting with AIS. Despite affecting younger patients with initial mild deficits, AIS patients with IE who received IVtPA had poor functional outcomes.

Lorazepam timing for acute convulsive seizure control (LoTASC)

INTRODUCTION

Guidelines specify early administration of benzodiazepines (BZD) for the management of convulsive status epilepticus. The distinction between acute convulsive seizure and status epilepticus can be misconstrued resulting in BZD administration prior to a patient meeting criteria of status epilepticus. Early BZD administration may theoretically lead to systemic vital instability. Our study aims to assess if administering lorazepam, for convulsive seizures <5 min, causes vital instability.

METHODS

This is a retrospective study analyzing patients who presented with a seizure lasting <5 min between 2011 and 2016. Continuous variables of lorazepam receivers versus non- receivers were analyzed using t-test for parametric and Mann-Whitney U test for nonparametric data. Categorical variables were analyzed using Chi-Square Test. Subsequently, subjects were analyzed through univariate and multivariate regression models to determine predictors of vital instability.

RESULTS

Out of 1052 subjects initially screened, 165 were included. Of these, 91 (55 %) received lorazepam, and 74 (45 %) did not. Through univariate and multivariate analyses, there was a significantly higher incidence of vital instability (defined as receipt of a vasopressor or intubation) in patients who received lorazepam (OR = 6.76, 95 % CI = 1.48, 30.95) (p = 0.014). This was dose-dependent (p < 0.0001). It was responsible for 22.5 % of the vital instability. Lorazepam administration significantly prolonged the intensive care unit (ICU) length of stay (0 days [IQR 0 - 0] vs [IQR 0-2.3]; p = 0.038).

CONCLUSION

Our study suggests that lorazepam administration for acute convulsive seizures not meeting convulsive status epilepticus criteria may lead to iatrogenic vital instability and need for ICU admission.

Abstract WP262: Intravenous Thrombolysis in Acute Ischemic Stroke Patients With Infective Endocarditis

Introduction: Infective endocarditis (IE) is considered to be an absolute contraindication for intravenous tissue plasminogen activator treatment (IVtPA) in acute ischemic stroke. However during the hyperacute stroke evaluation, the exclusion of IE may be difficult.

Methods: We reviewed consecutive patients hospitalized at our comprehensive stroke center from January 1, 2014 to March 31, 2019 with acute ischemic stroke who received IVtPA and identified patients who were diagnosed with infective endocarditis. Data was abstracted on demographics, medical history, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, culture results, and 90 day modified Rankin Scale (mRS). Good functional outcome was defined as mRS ≤ 2.

Results: Among 1022 acute ischemic stroke patients who received IVtPA, 5 patients (0.5%) were ultimately diagnosed with IE. Among the 5 patients with IE, the mean age was 53.4 years (range, 25-74) and 3 (60%) were female. The majority, 4 (80%) were white. Medical risk factors for IE were present in 3 (60%) and included intravenous drug use (1) and dialysis (2). Initial NIHSS was 4.6 (range, 1 to 8). Fever was present on initial presentation in only 1 patient (102.7 F). All patients met criteria for IVtPA and there were no protocol violations. The mean time from LKN to IVtPA was 3.0 hours (range, 1.9 to 4.4). Vascular imaging showed MCA occlusion in 4 (80%) and no occlusion in 1 (20%). One patient underwent endovascular thrombectomy with Thrombolysis in cerebral infarction scale 2A recanalization. Two patients (40%) developed hemorrhagic complications, including 1 patient who developed subarachnoid hemorrhage on Hospital Day #2 due to mycotic cerebral aneurysm. The blood culture results included MRSE (1), Streptococci viridans (2) and negative (2). TEE in all patients showed vegetations on the mitral valve. No patients had good functional outcome, and the mean 3 months mRS was 4.8 (range, 3 to 6).

Conclusions: In a large series of acute ischemic stroke patients who received IVtPA, undiagnosed IE is rare (0.5%). Fever was not commonly present during initial evaluation. Despite affecting younger patients with initial mild deficits, patients with IE had poor functional outcomes.

Management of ureteropelvic junction obstruction in children-a roundtable discussion

The investigation, management and follow-up of paediatric ureteropelvic junction obstruction is not standardized. The Young Pediatric Urology Committee of the European Society of Pediatric Urology interviewed five experts in the field on various aspects of management and compared this with published literature.

Urachal remnant causing umbilical in-drawing during micturition

The urachus is a vestigial remnant of the allantois, which is normally obliterated during fetal life to become the median umbilical ligament, which runs between the urinary bladder and umbilicus in adults. Failure of obliteration leaves a tubular urachal remnant, which may present with disease. We report a unique case of a urachal remnant causing umbilical pain and in-drawing on micturition in a nine-year-old boy. There was no urine discharge from the umbilicus and in-drawing did not occur on defecation. His urinary stream was normal. High frequency ultrasonography revealed a thick band with a narrow, anechoic, fluid filled central channel. Exploration via an infraumbilical curvilinear incision identified a thick urachal band that could be traced to the dome of the bladder. This was excised flush with the bladder. The patient remains well at nine months following surgery with complete cessation of symptoms.

Modified tubularized incised plate urethroplasty in distal hypospadias repair: Stepwise technique with validated functional and cosmetic outcome

OBJECTIVE

To describe modification of the tubularized incised plate urethroplasty (TIP) for distal hypospadias, and assess its efficacy, and functional and cosmetic outcomes.

METHODS

A prospective evaluation of a consecutive series of patients operated for primary distal hypospadias was conducted at a tertiary reference center. A standardized modification of the TIP (mTIP) procedure was performed on a 10 French catheter. Clinical data were collected in a dedicated database. Intraoperative variables, postoperative complications and outcomes, by means of uroflowmetries and a validated (HOPE) questionnaire, were assessed. Efficacy was evaluated with the reported complications: functional outcome was evaluated with uroflowmetries and cosmetic assessment by a validated questionnaire (HOPE). A descriptive statistical analysis was performed.

RESULTS

Of the 112 boys operated between 30/09/2011 and 1/04/2014, 50 completed long-term follow-up with functional and esthetic evaluation, as required for inclusion. Median age at surgery was 25 months (range 14-156); median follow-up time was 21.5 months (range 6-48). Complications requiring re-intervention occurred in 2/50 boys. Uroflowmetry presented a bell-shaped curve in 47/50 boys, and the median HOPE score was 9.5 (range 7.6-10.0).

CONCLUSION

The mTIP procedure provided satisfactory long-term functional and cosmetic outcomes, as validated by uroflowmetries and standardized questionnaire.

Clofazimine in the treatment of extensively drug-resistant tuberculosis with HIV coinfection in South Africa: a retrospective cohort study

BACKGROUND

Extensively drug-resistant (XDR) tuberculosis (TB) and HIV coinfection is associated with low cure rates and high mortality. Clofazimine has shown activity in vitro against Mycobacterium tuberculosis, but clinical experience with clofazimine in XDR-TB and HIV coinfection is limited.

METHODS

This was a retrospective cohort study of adult XDR-TB patients in KwaZulu-Natal, South Africa, treated with either a clofazimine- or non-clofazimine-containing XDR-TB treatment regimen. The primary outcome measure was TB culture conversion at 6 months. Survival analysis and multivariate logistic regression compared time to event in different strata and identified risk factors for TB culture conversion.

RESULTS

Between August 2009 and July 2011, eligible XDR-TB patients (n = 85) were initiated on treatment for XDR-TB. Most patients (86%) were HIV-infected and receiving antiretroviral therapy (90%). Patients receiving a clofazimine-containing regimen (n = 50) had a higher percentage of culture conversion (40%) compared with patients (n = 35) receiving a non-clofazimine regimen (28.6%). On multivariate analysis, there was a 2-fold increase in TB culture conversion at 6 months (hazard rate ratio 2.54, 95% CI 0.99-6.52, P = 0.05) in the group receiving a clofazimine-containing regimen. Adverse effects due to clofazimine were minor and rarely life-threatening.

CONCLUSIONS

Clofazimine was associated with improved culture conversion in the treatment of XDR-TB/HIV. Adverse effects were minor and non-life-threatening. Based on these preliminary data, further study of clofazimine in XDR-TB/HIV treatment is warranted. Given the present low rates of culture conversion in XDR-TB treatment, we recommend empirical inclusion of clofazimine in treatment regimens for XDR-TB.

Systematic review of clofazimine for the treatment of drug-resistant tuberculosis

The increased incidence of drug-resistant tuberculosis has created an urgent necessity for the development of new and effective anti-tuberculosis drugs and for alternative therapeutic regimens. Clofazimine (CFZ) is a fat-soluble riminophenazine dye used in the treatment of leprosy worldwide. CFZ has also been used as a Group 5 drug in the treatment of tuberculosis (TB). A large cohort study from Bangladesh published in 2010 described a treatment regimen for multidrug-resistant tuberculosis (MDR-TB) including CFZ as being highly effective against MDR-TB. We searched multiple databases for studies published through February 2012 that reported use of CFZ in MDR- and extensively drug-resistant TB (XDR-TB) treatment regimens. We identified nine observational studies (6 MDR-TB and 3 XDR-TB) including patients with drug-resistant TB treated with CFZ. Overall, 65% (95% confidence interval [95%CI] 54-76) of the patients experienced favorable outcomes, defined as either cure or treatment completion. Using random effects meta-analysis, 65% (95%CI 52-79) of those with MDR-TB and 66% (95%CI 42-89) of those with XDR-TB experienced favorable treatment outcomes. High-quality prospective cohort studies and clinical trials examining the effect of CFZ as part of drug-resistant TB treatment regimens are needed.

Synthesis and Pharmacological Evaluation of Azetidin-2-ones and Thiazolidin-4-ones Encompassing Benzothiazole

Various 7-chloro-6-fluoro-2-arylidenylaminobenzo(1,3)thiazole (2a-h) have been synthesized by the condensation of 7-chloro-6-fluoro-2-aminobenzo(1,3)thiazole (1) with different aromatic aldehydes. The Schiff's bases on reaction with acetyl chloride, chloroacetyl chloride and phenyl acetyl chloride yielded 1-(7-chloro-6-fluorobenzothiazol-2-yl)-3,4-substituted-aryl-azetidin-2-ones (3a-x). Similarly, cyclization of Schiff's base with thioglycolic acid furnished 3-(7-chloro-6-fluoro-benzothiazol-2-yl)-2-substituted–arylthiazolidin-4-ones (4a-h). The structures of the newly synthesized compounds have been established on the basis of their spectral data and elemental analysis. Some selected compounds were evaluated for antiinflammatory, analgesic, CNS depressant and skeletal muscle relaxant activity.

The Genotoxicity of DNA Intercalating Drug 8-Methoxy pyrimido [4′,5′:4,5]thieno(2,3-b)quinoline-4(3H)-one

8-methoxypyrimido[4',5':4,5]thieno(2,3-b)quinoline-4(3H)-one (MPTQ) is known to have antitumor and cytotoxic activities on various types of tumors. This compound showed a strong clastogenic effect on bone marrow cells of Swiss albino mice treated in vivo (17.5-35 mg/kg body weight). MPTQ induced micronuclei formation (MN) at doses of 17.5, 23.3, and 35 mg/kg. Dose and time-yield effect of MPTQ was studied in the case of chromosome aberration assay. MPTQ induced a statistically significant increase in the frequency of chromosome aberrations and micronuclei induction. The drug induced significant abnormal sperms even in the sperm shape abnormality assay. Based on the data reported in the literature, we have tried to establish the relationship between the clastogenic effect observed and process of MPTQ intercalation into DNA and the formation of protein-associated DNA-strand breaks probably promoted by topoisomerase enzymes.

8-Methly-4-(3-diethylaminopropylamino) pyrimido [4′,5′;4,5] thieno (2,3–b) quinoline (MDPTQ), a quinoline derivate that causes ROS-mediated apoptosis in leukemia cell lines

The present study reports the biological activity of 8-methyl-4-(3-diethylamino-propylamino) pyrimido [4';5';4,5] thieno (2,3-b) quinoline (MDPTQ), a quinoline derivative structurally related to ellipticine and suggests a possible mechanism through which the compound induces apoptosis in carcinoma cell lines. Out of the 8 cell lines used in the study as representatives of different types of cancer, MDPTQ was found to be effective only against leukemia cell lines (HL-60 and K-562) whereas it had no effect on normal human bone marrow cells (BMC) which were used as controls. Fall mitochondrial membrane potential and increased reactive oxygen species (ROS) were mainly responsible for inducing apoptosis in the two cell lines. Cell death was demonstrated by increase in caspase 3 activity as well as phosphatidyl serine exposure. Pre-incubation with N-acetylcysteine (NAC) reduced the increased ROS and caspase 3 activity as well as phosphatidyl serine exposure. MDPTQ also caused cell cycle arrest in these cell lines. The above study for the first time reports the mode of action of a quinoline derivative, which could be a possible future candidate for leukemia therapy. However, there are lot of questions that need to be answered in terms of signalling pathways and its effects on animal models.

Hereditary sacrococcygeal teratoma--not the same as its sporadic counterpart!

Sacrococcygeal teratoma (SCT) can be sporadic or familial and there appear to be different characteristics to these entities. It can be an isolated anomaly or occur as part of the Currarino triad, when it is associated with anorectal malformations and sacral anomalies. We present a case of familial sacrococcygeal teratoma and discuss its relationship to previously published reports, drawing conclusions regarding embryogenesis, diagnosis, screening and management.