In this editorial, we seek to focus attention of neurointerventionists and stroke physicians towards a systems approach to the intra-arterial management of acute ischemic stroke. We highlight the need to pay attention to the overall sequence and workflow of a neurointerventional procedure rather than individual steps. We also stress the importance of novel outcome measures in analyzing procedural efficacy when managing patients with acute ischemic stroke.
acute ischemic stroke, outcome measures, systems based approach, endovascular, intra-arterial
Faster recanalization correlates with better outcomes in acute ischemic stroke. We analyzed times from arrival in ER to end of treatment in patients undergoing endovascular treatment for acute ischemic stroke at our institution.
We retrospectively studied patients who underwent IA procedures for stroke from 2005 to 2009 noting the times of arrival to ER, CT scan, arrival to DSA, arterial puncture and recanalization from our endovascular database. A subgroup analysis was performed based on administration of GA, use of mechanical devices and whether the procedure was performed during regular hours or after hours.
Of 101 patients, 53 were male, with a median age of 66 years (range 18-87). There were 81 anterior circulation strokes. Median ER to CT time was 22 min (2-1025), CT to DSA arrival time 80 min (range 4-990), DSA arrival to puncture time 24 min (range 0-75) and puncture to recanalization time 84 min (range 11-206). 23.3% of patients had an ER to CT time interval of > 60 min and 71.3 % had a CT to DSA time interval of > 60 min contributing to significant in-hospital delays. For subgroup analysis the Mann-Whitney test was used. No significant differences in CT to DSA arrival (p=0.8), DSA arrival to puncture (p=0.1) and puncture to recanalization (p=0.59) times were noted between patients with and without GA. No significant difference was noted in puncture to recanalization times with or without device (p=0.78). 39 cases were done during regular (R) hours and 62 after (A) hours. Median ER to CT time (R=18 min, A = 27 min, p 0.02), CT to DSA arrival time (R=64 min, A=90 min, p 0.004) and DSA arrival to puncture time (R=18 min, A=25 min, p 0.003) was significantly higher after hours.
ER to CT and CT to DSA arrival times in patients undergoing endovascular stroke therapy show wide variability and therefore, considerable scope for reduction. Time differences during regular and after hours should serve as a reminder to make efforts to reduce overall ischemic times in spite of staffing patterns and resource availability.
stroke, thrombolysis, recanalization, tPA
We describe our experience with balloon-assisted rapid intermittent sequential coiling (BRISC) of complex wide-necked aneurysms as an alternative to stent-assisted coiling. We use this technique in patients with acutely ruptured aneurysms, where antithrombotic treatment prior to stent deployment may not be advisable, and where the vascular anatomy is unfavorable for stenting. This is a retrospective analysis of 11 wide-necked aneurysms treated with this technique from June 2008 to January 2010. Results were analyzed in terms of aneurysm occlusion, procedural complications like thromboembolism, dissection/vasospasm, groin hematoma and any recurrence on follow-up. Coiling was successfully attempted in all cases (100%). Immediate angiographic results showed complete occlusion (class 1) in 8/11, residual neck (class II) in 3/11 and no residual aneurysm (class III) Procedural complications were local thrombus formation in 3/11 procedures but no symptomatic thromboembolism, dissection in 1/11 and groin hematoma in 1/11. There was no morbidity or mortality. On follow-up study, there was one recurrence, which was subsequently coiled. In our opinion, this technique may provide an alternative to stent-assisted coiling in patients with ruptured aneurysm where antithrombotic treatment prior to stent deployment may not be advisable and in the presence of vascular anatomy unsuitable for stenting.
balloon-assisted coiling, BRISC, complex wide-necked aneurysms
Aneurysms of the lenticulostriatal perforating arteries are rare and either involve the middle cerebral artery-perforator junction or are located distally in basal ganglia. We describe a rare ruptured fusiform lenticulostriatal perforating artery aneurysm arising from a proximal M2 MCA branch, discerned on superselective microcatheter angiography, presenting solely with subarachnoid hemorrhage (SAH).
A 50-year-old previously healthy man presented with diffuse SAH and negative CT angiogram. Cerebral angiogram demonstrated a 2 mm fusiform aneurysm presumably arising from the right lateral lenticulostriate perforator but the exact origin of the perforator was unclear. Superselective angiography was required to precisely delineate the aneurysm and its vessel of origin and directly influenced treatment planning (surgical trapping).
Superselective microcatheter angiography provides both an option for endovascular therapy as well as more accurate delineation for surgical planning for these rare aneurysms.
aneurysm, lenticulostriatal perforating arteries, subarachnoid hemorrhage, microcatheter angiography, endovascular
Lipomas are benign tumors, composed of fat cells of the adult type. While lipomas on the trunk and limbs are common, they are rare in the upper aerodigestive tract. Here we report a case of laryngeal lipoma presented with a complaint of change of voice.
The association of serum trace elements like selenium, zinc and copper has been found in different types of cancer. This study was conducted to see the serum level of these three trace elements in cancer esophagus patients. Biopsy confirmed cancer esophagus, 24 patients (12 males, 12 females, mean age 54.5±11.65 year with 23 healthy subjects (16 males, 7 females, mean age 44 ±13.82 years) were included in this study. Both control and study group patients were of same socio-economic status and dietary habits. Serum zinc and copper level were estimated using standard absorption spectrometer technique and serum selenium by Hydride generation method.
We observed significant low serum levels of zinc and selenium while high level of serum copper in carcinoma esophagus patients, as compared with normal healthy controls. This shows an association of serum selenium zinc and copper with cancer esophagus.
Cancer esophagus; Serum Zinc; Copper and Selenium; Atomic absorption spectrophotometer; Hydride generation; A.A.S.
The role of embolisation in the treatment of small (< 3cm) brain arteriovenous malformations (AVMs) has not been elucidated. We reviewed our experience using embolisation in the treatment of small AVMs and correlated a proposed grading system based on the angioarchitecture to the percentage obliteration achieved by embolisation.
Eighty-one small AVMs in 80 patients were embolised from 1984 to 1999. The age range was from 3 to 72 years. The AVMs were given a score from 0 to 6 based on the angioarchitecture. The assigned scores were as follows: nidus (fistula = 0, < 1 cm = 1,1-3 cm = 2), type of feeding arteries (cortical = 0, perforator or choroidal = 1), number of feeding arteries (single = 0, multiple -2) and number of draining veins (single = 0\ multiple - 1). Angiographic results based on percentage obliteration were grouped into three categories: complete, 66-99%, and 0-65%.
The goal of embolisation was cure in 27 AVMs, pre-surgical in 23, pre-radiosurgery in 26, and elimination of an aneurysm in five. Embolisation achieved complete obliteration in 22 (27%) of the 81 AVMs. In the AVMs where the goal was cure, 19 (70%) of 27 were completely obliterated. In the AVMs with angioarchitecture scores of 0-2, 12 (86%) of 14 were cured, with scores of 3-4, 8 (34%) of 24 were cured and with scores of 5-6, 2 (4%) of 44 were cured. Embolisation resulted in transient morbidity of 5.0%, permanent morbidity of 2.5%, and mortality of 1.2%. There were no complications in AVMs with scores of 0-2.
Embolisation is an effective treatment of small AVMs when the angioarchitecture is favourable (scores 0-2). This includes pure fistulas and AVMs with a single, pial, feeding artery.
arteriovenous malformations, embolisation, microsurgery, radiosurgery, grading system, intracranial haemorrhage
BACKGROUND—Over the last 10 years there has
been a fourfold increase in cases of tuberculosis in Harare, Zimbabwe.
The use of molecular epidemiology to understand tuberculosis
transmission in this epidemic has been hampered by the availability of
suitable culture facilities. A study was therefore undertaken to
explore the potential of spoligotyping, a polymerase chain reaction
based technique that does not require tuberculosis culture.
METHODS—Adults attending a chest clinic with
clinical or radiological pulmonary tuberculosis and one smear positive
sputum were enrolled over one month. Demographic, socioeconomic, and
clinical data were gathered using a standardised questionnaire.
Molecular fingerprinting of genomic DNA recovered from sputum was
performed by spoligotyping.
RESULTS—Sixty one subjects (median age 28 years (range 18-73); 61% men) were recruited and 57 provided adequate
sputum samples. Recent rural-urban migration or immigration was not
common; 40% of subjects lived in crowded living conditions. DNA
suitable for spoligotyping was recovered from 28 patients and 20 different genotypes of Mycobacterium tuberculosis were
identified. Fifteen patients were infected with an M
tuberculosis strain shared by one or more individuals. Patients infected with a shared spoligotype were not closely linked
geographically within Harare, but were more likely to live in
overcrowded conditions (69% versus 23%; odds ratio 6.85 (95% CI 1.2 to 47), p = 0.026). Analysis of the patients' original rural family
homes revealed two geographically related spoligotype clusters.
CONCLUSIONS—Spoligotyping may yield
valuable molecular typing information in populations where tuberculosis
culture is not available. This novel technique requires further
development and evaluation in larger epidemiological studies.
BACKGROUND: Polymerase chain reaction (PCR) amplification of Mycobacterium tuberculosis DNA offers the potential of a sensitive and specific diagnostic test for tuberculosis. To evaluate this technique from the clinician's perspective, samples were collected from patients with chronic respiratory disease and the sensitivity and specificity of a newly introduced commercially available PCR kit (Amplicor) was compared with that of an established method to detect the target sequence IS6110. METHODS: Sputum or bronchial washings from patients with active tuberculosis, previously treated tuberculosis or other selected respiratory illnesses were analysed by both techniques and their sensitivity and specificity determined. RESULTS: Amplicor was more specific than IS6110 in the diagnosis of active infection (98% versus 79%). Both techniques were equally sensitive (92%). CONCLUSION: These results suggest that analysis of respiratory samples by Amplicor PCR in inner city populations of patients has greater specificity for a diagnosis of active tuberculosis than PCR for IS6110, and thus Amplicor PCR may aid the clinician in making a diagnosis of active tuberculosis.
Widespread use of DNA restriction fragment length polymorphism (RFLP) to differentiate strains of Mycobacterium tuberculosis to monitor the transmission of tuberculosis has been hampered by the need to culture this slow-growing organism and by the level of technical sophistication needed for RFLP typing. We have developed a simple method which allows simultaneous detection and typing of M. tuberculosis in clinical specimens and reduces the time between suspicion of the disease and typing from 1 or several months to 1 or 3 days. The method is based on polymorphism of the chromosomal DR locus, which contains a variable number of short direct repeats interspersed with nonrepetitive spacers. The method is referred to as spacer oligotyping or "spoligotyping" because it is based on strain-dependent hybridization patterns of in vitro-amplified DNA with multiple spacer oligonucleotides. Most of the clinical isolates tested showed unique hybridization patterns, whereas outbreak strains shared the same spoligotype. The types obtained from direct examination of clinical samples were identical to those obtained by using DNA from cultured M. tuberculosis. This novel preliminary study shows that the novel method may be a useful tool for rapid disclosure of linked outbreak cases in a community, in hospitals, or in other institutions and for monitoring of transmission of multidrug-resistant M. tuberculosis. Unexpectedly, spoligotyping was found to differentiate M. bovis from M. tuberculosis, a distinction which is often difficult to make by traditional methods.
Mycobacterium tuberculosis isolates from 167 patients attending three London hospitals were analyzed by two techniques for strain differentiation. A significant number of isolates that appeared identical with the recently developed spoligotyping system could be distinguished from each other by IS6110 restriction fragment length polymorphism analysis, with the latter technique demonstrating a generally higher level of discrimination. Spoligotyping, on the other hand, was particularly useful for analysis of isolates with low IS6110 copy numbers, and use of the two techniques in tandem provided an optimal approach to the identification of clusters with epidemiological evidence consistent with recent transmission. Spoligotyping can be applied directly to clinical samples by PCR and provides an important tool for the rapid detection of nosocomial transmission of individual strains.
AIMS--A retrospective analysis of children with post-traumatic endophthalmitis was performed to determine if microbiological differences exist between this disease in the paediatric population compared with this disease in adults. METHOD--Twelve cases of post-traumatic endophthalmitis in children were analysed to determine characteristics of this disease in youth. Patient ages varied from 18 months to 13 years; the mean age was 8 years. Gram positive organisms were isolated in eight eyes, Gram negative organisms from four eyes, fungus from one eye, and negative cultures in three eyes. The most common isolates were streptococcal species (56.6%) and staphylococcal species (22.2%). Vitrectomy was performed on eight (66.7%) eyes. RESULTS--Visual acuity of 20/200 or better was obtained in eight eyes (66.7%). Three eyes had vision less than 5/200. One eye developed phthisis bulbi. Nine (75%) patients were younger than 10 years of age, and six (66.7%) of these nine obtained a final visual acuity of 20/200 or better. CONCLUSION--Useful vision can be obtained in children with post-traumatic endophthalmitis with early, aggressive treatment. The microbiology of paediatric post-traumatic endophthalmitis differs from adult disease with streptococcal species as the most common infecting organisms.
Many diseases are being spread in the word by micro organisms. This necessitates the development of cost effective and easily available antimicrobial medicines. Plants have generally been source of alkaloids, steroids, terpenoids, carbohydrates, amino acids, vitamins, glycosides and various pigments. The chemical exploitation of varieties of indigenous plants is therefore likely to offer a cost effective treatment for many diseases leading to the development of the nation and welfare of the society. The present communication reports that hydrocarbons, triterpenes and phytosterols present in Alstonia scholaris, are responsible for its medicinal value.
PCR amplification of a species-specific 2-kb KpnI fragment of variable size located 10 kb upstream of the katG gene was used to subdivide 130 clinical isolates of Mycobacterium tuberculosis. Seven subtypes were identified, and their frequencies were distributed normally with respect to the size of the amplified product.
Two candidate methods for the recovery and detection of viruses in soil were subjected to round robin comparative testing by members of the American Society for Testing and Materials D19:24:04:04 Subcommittee Task Group. Selection of the methods, designated "Berg" and "Goyal," was based on results of an initial screening which indicated that both met basic criteria considered essential by the task group. Both methods utilized beef extract solutions to achieve desorption and recovery of viruses from representative soils: a fine sand soil, an organic muck soil, a sandy loam soil, and a clay loam soil. One of the two methods, Goyal, also used a secondary concentration of resulting soil eluants via low-pH organic flocculation to achieve a smaller final assay volume. Evaluation of the two methods was simultaneously performed in replicate by nine different laboratories. Each of the produced samples was divided into portions, and these were respectively subjected to quantitative viral plaque assay by both the individual, termed independent, laboratory which had done the soil processing and a single common reference laboratory, using a single cell line and passage level. The Berg method seemed to produce slightly higher virus recovery values; however, the differences in virus assay titers for samples produced by the two methods were not statistically significant (P less than or equal to 0.05) for any one of the four soils. Despite this lack of a method effect, there was a statistically significant laboratory effect exhibited by assay titers from the independent versus reference laboratories for two of the soils, sandy loam and clay loam.
The purpose of this study was to provide a clearer understanding of virus adsorption, focusing specifically on the role of electrostatic interactions between virus particles and adsorbent surfaces. The adsorption of poliovirus 1, reovirus types 1 and 3, and coliphages MS-2 and T2 to colloidal silica synthetically modified to carry either positive or negative surface charge was evaluated. Adsorption experiments were performed by combining virus and silica in 0.1-ionic-strength buffers of pH 4.0, 6.4, and 8.5. Samples agitated for specified adsorption periods were centrifuged to pellet adsorbent particles plus adsorbed virus, and the supernatants were assayed for unadsorbed virus. All viruses adsorbed exclusively to negatively charged silica at pH values below their isoelectric points, i.e., under conditions favoring a positive surface charge on the virions. Conversely, all viruses adsorbed exclusively to positively charged silica at pH values above their isoelectric points, i.e., where virus surface charge is negative. Viruses in near-isoelectric state adsorbed to all types of silica, albeit to a lesser degree.
Fecal indicator bacteria were isolated from water and sediment samples obtained from a sewage sludge disposal site in the Middle Atlantic. Some were found to be resistant to several antimicrobial agents. Isolation of these microbes 30 months after cessation of sludge dumping indicates their survivability in the environment.
Human enteric viruses were detected in samples of water, crabs, and bottom sediments obtained from two sewage sludge disposal sites in the Atlantic Ocean. Viruses were isolated from sediments 17 months after the cessation of sludge dumping. These findings indicate that, under natural conditions, viruses can survive for a long period of time in the marine environment and that they may present potential public health problems to humans using these resources for food and recreation. The isolation of viruses in the absence of fecal indicator bacteria reinforces previous observations on the inadequacy of these bacteria for predicting the virological quality of water and shellfish.
To select a tentative standard method for detection of viruses in sludge the American Society for Testing and Materials D19:24:04:04 Subcommittee Task Group initiated round robin comparative testing of two procedures that, after initial screening of several methodologies, were found to meet the basic criteria considered essential by the task group. Eight task group member laboratories agreed to perform round robin testing of the two candidate methods, namely, The Environmental Protection Agency or low pH-AlCl3 method and the Glass or sonication-extraction method. Five different types of sludge were tested. For each particular type of sludge, a single laboratory was designated to collect the sludge in a single sampling, make samples, and ship it to the participating laboratories. In most cases, participating laboratories completed all the tests within 48 h of sample arrival. To establish the reproducibility of the methods, each laboratory tested each sludge sample in triplicate for the two candidate virus methods. Each processed sludge sample was quantitatively assayed for viruses by the procedures of each individual round robin laboratory. To attain a more uniform standard of comparison, a sample of each processed sample from all laboratories was reassayed with one cell line and passage number by a single laboratory (Environmental Protection Agency Environmental Monitoring and Support Laboratory, Cincinnati, Ohio). When the data were statistically analyzed, the Environmental Protection Agency method was found to yield slightly higher virus recoveries for all sludge types, except the dewatered sludge. The precisions of both methods were not significantly different.(ABSTRACT TRUNCATED AT 250 WORDS)
The distribution and quantitation of enteroviruses among water, suspended solids, and compact sediments in a polluted estuary are described. Samples were collected sequentially from water, suspended solids, fluffy sediments (uppermost layer of bottom sediments), and compact sediment. A total of 103 samples were examined of which 27 (26%) were positive for virus. Polioviruses were recovered most often, followed by coxsackie B viruses and echoviruses 7 and 29. Virus was found most often attached to suspended solids: 72% of these samples were positive, whereas only 14% of water samples without solids yielded virus. Fluffy sediments yielded virus in 47% of the samples, whereas only 5% of compact bottom-sediment samples were positive. When associated with solids, poliovirus and rotavirus retained their infectious quality for 19 days. The same viruses remained infectious for only 9 days when freely suspended in seawater. Collection of suspended solids at ambient water pH appears to be very useful for the detection of virus; it has advantages over collecting and processing large volumes of water, with accompanying pH adjustment and salt addition for processing.
A simple method for concentration and detection of rotavirus and enteroviruses in the blue crab is described. Virus was separated from tissue homogenates at pH 9.5, concentrated by adsorption to protein precipitates at pH 3.5, and recovered by elution of precipitates at pH 9.2. Test samples of 12 to 15 ml were produced from an initial 100 g of crab tissues. Cat-floc precipitation was used to remove sample toxicity for cell cultures. Recovery effectiveness averaged 52% with poliovirus 1, echovirus 7, and coxsackievirus B5 and 23% with rotavirus SA11.
Membrane adsorption-elution techniques have made it possible to concentrate and detect small numbers of viruses in large volumes of water and wastewater, but no such methods are available for quantitative recovery of bacteria. A number of waterborne disease outbreaks of "unknown etiology" in the United States are suspected to have been caused by pathogens present in numbers too small to be detected by currently available methodology. The present study reports on the use of positively charged depth filters for the concentration and detection of bacteria in large volumes of tap water. In this method, dechlorinated tap water was passed, under positive pressure, through positively charged filter media (Zetaplus, 05S). More than 90% of seeded bacteria adsorbed to these filters at ambient pH levels. Adsorbed bacteria were eluted by passing a small volume of Trypticase soy broth in the direction opposite of the influent flow. By this method, Escherichia coli and Salmonella serovar B organisms in 20 liters of tap water were concentrated in a final volume of 50 ml, with an average recovery efficiency of greater than or equal to 30%.
This report demonstrates how electropositive filters can be used to enhance the removal of microorganisms and other negatively charged particles from water. It was shown that electropositive depth filters were capable of adsorbing viruses and endotoxins many times smaller than the average pore size of the filter. Electronegative filters of similar porosity or electropositive filters that had been treated to destroy the positive charge were almost ineffective under similar conditions for the removal of viruses and small latex spheres. The results of this study indicate that electropositive filters are highly effective in the removal of a wide range of contaminants over a wide range of pH values and ionic conditions.