Emergent Premedication for Contrast Allergy Prior to Endovascular Treatment of Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Management of contrast media allergies may lead to treatment delays in patients with acute ischemic stroke undergoing endovascular therapy. The optimal premedication strategy remains unclear. The aim of this report was to analyze our experience with emergent administration of premedication regimens before endovascular therapy. MATERIALS AND METHODS: We retrospectively reviewed prospective data for all patients undergoing endovascular therapy from 2012 to 2019 at an academic comprehensive stroke center. Records of patients with documented contrast allergy were reviewed and analyzed. Data collected included stroke risk factors and characteristics, historical contrast reaction details, premedication regimens administered, and signs or symptoms of allergic reaction developing post-endovascular therapy. Hospital arrival time to endovascular therapy was compared with that in those who did not have a history of contrast allergy. RESULTS: We analyzed 1521 patients undergoing endovascular therapy; 60 (4%) had documented contrast allergies and constituted the study cohort. The median age was 73 years (interquartile range, 66-81 years), and 65% were women. The median time from premedication to contrast was 24 minutes (interquartile range, 0-36 minutes). Forty-three patients (72%) proceeded directly to endovascular therapy; in 17 patients, the first contrast exposure was CTA. Time from hospital arrival to endovascular therapy was not slower for patients with documented allergies (96 versus 134 minutes, P = .32). No patients experienced a contrast media reaction. CONCLUSIONS: In a single-institution cohort study of 60 consecutive patients with documented contrast allergies undergoing endovascular therapy with emergent premedication en route to (or in) the neuroangiography suite, no patients experienced allergic symptoms. This pragmatic approach may be safe for patients who have documented contrast media allergies.

Multicenter Postmarket Analysis of the Neuroform Atlas Stent for Stent-Assisted Coil Embolization of Intracranial Aneurysms.

BACKGROUND AND PURPOSE: The Neuroform Atlas is a new microstent to assist coil embolization of intracranial aneurysms that recently gained FDA approval. We present a postmarket multicenter analysis of the Neuroform Atlas stent. MATERIALS AND METHODS: On the basis of retrospective chart review from 11 academic centers, we analyzed patients treated with the Neuroform Atlas after FDA exemption from January 2018 to June 2019. Clinical and radiologic parameters included patient demographics, aneurysm characteristics, stent parameters, complications, and outcomes at discharge and last follow-up. RESULTS: Overall, 128 aneurysms in 128 patients (median age, 62 years) were treated with 138 stents. Risk factors included smoking (59.4%), multiple aneurysms (27.3%), and family history of aneurysms (16.4%). Most patients were treated electively (93.7%), and 8 (6.3%) underwent treatment within 2 weeks of subarachnoid hemorrhage. Previous aneurysm treatment failure was present in 21% of cases. Wide-neck aneurysms (80.5%), small aneurysm size (<7 mm, 76.6%), and bifurcation aneurysm location (basilar apex, 28.9%; anterior communicating artery, 27.3%; and middle cerebral artery bifurcation, 12.5%) were common. A single stent was used in 92.2% of cases, and a single catheter for both stent placement and coiling was used in 59.4% of cases. Technical complications during stent deployment occurred in 4.7% of cases; symptomatic thromboembolic stroke, in 2.3%; and symptomatic hemorrhage, in 0.8%. Favorable Raymond grades (Raymond-Roy occlusion classification) I and II were achieved in 82.9% at discharge and 89.5% at last follow-up. mRS ≤2 was determined in 96.9% of patients at last follow-up. The immediate Raymond-Roy occlusion classification grade correlated with aneurysm location (P < .0001) and rupture status during treatment (P = .03). CONCLUSIONS: This multicenter analysis provides a real-world safety and efficacy profile for the treatment of intracranial aneurysms with the Neuroform Atlas stent.

Assessment of microsatellites in estimating inter- and intraspecific variation among Neotropical Crocodylus species.

We tested microsatellites that were developed for the saltwater crocodile (Crocodylus porosus) for cross-species amplification and to provide an estimate of inter- and intraspecific variation among four species of Neotropical crocodiles (C. rhombifer, C. intermedius, C. acutus, and C. moreletii). Our results indicated that with the exception of 2 loci in C. intermedius, all 10 microsatellite loci were successfully amplified in the 4 species, producing a set of variably sized alleles that ranged in number between 2 and 14 alleles per locus. Similarly, private alleles (i.e., unique alleles) also were reported in all 4 species for at least 3 loci. The mean observed and expected heterozygosities (averaged across species for all 10 loci combined) ranged from 0.39 to 0.77 and from 0.44 to 0.78, respectively. In addition to this, we evaluated these microsatellites in 2 populations of C. acutus and C. moreletii to assess their utility in estimating intraspecific levels of polymorphisms. These microsatellites also showed considerable allelic variation in population level analysis. The set of 10 microsatellite loci in our study had the potential to be used as a tool in population and conservation genetic studies of Neotropical crocodiles.

Preoperative Onyx embolization of aggressive vertebral hemangiomas.

We report the first use of Onyx in the embolization of spinal tumors in 2 cases of aggressive vertebral hemangioma. In both cases, Onyx embolization provided effective preoperative tumor devascularization after the initial prolonged particulate embolization with Embospheres made little overall impact. Onyx enables a more rapid and visible embolization than particles and is less technically demanding than traditional liquid embolic agents, such as n-butyl cyanoacrylate.

Bone density effects of continuous estrone sulfate and varying doses of medroxyprogesterone acetate. Ogen/Provera Study Group.

OBJECTIVE: To establish the optimum oral daily dose of medroxyprogesterone acetate with estrone sulfate for 2 years to maintain bone density. METHODS: A multicenter, double-blind study involved 568 postmenopausal women given estrone sulfate, 1.25 mg, and randomized to receive 2.5, 5, or 10 mg of medroxyprogesterone acetate. Bone density analyses of the lumbar spine and femoral neck were done at baseline and 12 and 24 months. RESULTS: There was a significant increase from baseline to 24 months in mean lumbar spine (4.0% +/- 0.27%) and femoral neck (3.2% +/- 0.28%) bone density, with no significant differences between the treatment groups. Factors most influencing bone density changes were baseline bone density and treatment duration. Significant increases were seen in the spine over 2 years; in the hip, those occurred in the first 12 months only. In both sites, lower baseline bone density resulted in greater increases. In the spine only, no previous hormone replacement therapy, higher body mass index, more than 2 years postmenopause, and nonsmoking resulted in greater gains. Once those covariates and center-to-center variations were corrected for, in the spine, the 10-mg group had smaller increases than the other groups. Changes were unrelated to age, parity, calcium, and alcohol intakes in either site. CONCLUSION: Daily estrone sulfate, 1.25 mg, with 2.5, 5, or 10 mg medroxyprogesterone acetate was effective for preventing bone loss in postmenopausal women.

Fertility of fully breast-feeding women in the early postpartum period.

OBJECTIVE: To examine bleeding between 6 and 8 weeks postpartum in fully breast-feeding women and its association with fertility as assessed by hormone analysis. METHODS: Seventy-two fully breast-feeding women were followed prospectively from 42 days postpartum. Vaginal bleeding was recorded daily. Women who experienced bleeding were compared with women who did not with respect to time of ovulation and time of first menses. RESULTS: Nearly half of the women experienced some vaginal bleeding or spotting between 6 and 8 weeks postpartum. These women eventually menstruated and ovulated earlier than the women who did not bleed, but the differences were not significant. The study had 34% and 45% power to detect a 20% difference in the proportion menstruating and ovulating, respectively, at 6 months postpartum, and 10% and 16% power to detect the same differences at 1 year. Seven women experienced ovarian follicular development before day 56, but neither bleeding nor follicular development was associated with ovulation in any woman in the first 8 weeks postpartum. CONCLUSIONS: It is unlikely that vaginal bleeding in fully breast-feeding women in the first 8 weeks postpartum represents a return to fertility.

Breastfeeding and the symptothermal method.

This prospective study was conducted among experienced users of periodic abstinence methods in Sydney, Montreal, and Birmingham (England) in order to describe the relationship between a laboratory measurement of ovulation and the natural symptoms of fertility during breastfeeding. Daily urinary estrogen and pregnanediol glucuronide assays were used to estimate the date of ovulation and to determine potentially fertile days. A standard set of Symptothermal Method (STM) rules was applied to daily STM records to assess the correspondence of the natural symptoms of fertility to the underlying hormonal profile. The STM symptoms and rules accurately identified 77-94 percent of the women's potentially fertile days, but abstinence was also recommended on about half of the days when the women were not fertile. An integrated set of common rules for STM use during breastfeeding is highly sensitive but not specific in its ability to screen for ovulation.

PIP: Periodic abstinence from sexual intercourse as a pregnancy prevention technique is sometimes the sole method used by women. The effectiveness of this technique is based on the woman's ability to fully understand her own menstrual cycle. Factors like breastfeeding and endocrine irregularities have been shown to interfere with a women's ability to determine periods of fertility. This article reports on a prospective study on the relationship between breastfeeding and hormonal levels, as a measurement of fertility, in women using periodic abstinence. The 73 women in this study were from England, Canada, and Australia. All women were breastfeeding. Daily symptothermal method (STM) records, which documented the cervical mucus conditions and basal body temperature, were kept. All women had experienced healthy pregnancies. Chi-square analysis and the analysis of variance (ANOVA) were the statistical methods employed. Significantly less abstinence is recommended by the STM rules during the anteovulation stage than during either of the later stages. Significantly less abstinence is also recommended during amenorrhea than after the first menstrual period. During the anteovulation stage, significantly fewer days were reported with fertile-type mucus than later stages. First ovulations were reported in 48 women (65%) during amenorrhea; of these, 25 (52%) were characterized as having adequate luteinization for conception. The STM method used in this study was considered to be sensitive but lacked specificity.

Is the lactational amenorrhea method a part of natural family planning? Biology and policy.

The lactational amenorrhea method is a natural method of family planning for women who breastfeed their infants. The underlying physiology results in a natural suppression of ovulation, and the concomitant amenorrhea, induced by exclusive (or almost exclusive) breastfeeding. This in addition to the infant's age of 6 months or less and specific feeding pattern are the parameters used to identify the possible return of fertility. The lactational amenorrhea method provides at least 98% protection against pregnancy. Data from a recent multicenter study of breastfeeding support the use of the lactational amenorrhea method as a natural family planning method. The lactational amenorrhea method can be incorporated into natural family planning programs and teaching.

PIP: An introduction of the lactational amenorrhea method (LAM) if natural family planning for fully breastfeeding postpartum women is presented based on the Bellagio Consensus Statement and a study at centers in Australia, England and Canada. Natural family planning programs have until recently advised women to accept a 7-12 week period of natural infertility after childbirth, and to improve results of natural family planning by weaning the baby early to obtain regular menstrual cycles so they can use their prior natural method. Now that more women are breastfeeding, and lactational amenorrhea is being studied worldwide, it is recognized that LAM is about 98% effective for the 1st 6 months postpartum in fully breastfeeding women. The collaborative study found that the 1st ovulation occurred on Day 264 in Canada and 237 in Australia on average. An algorithm for questioning a mother to learn if she is a candidate for LAM from the Bellagio Consensus is included. MOre research needs to be done on the significance of spotting, how intense breastfeeding must be, whether any supplementation of use of a pacifier is possible, whether the pregnancy rate can be reduced, and what program changes are needed to put LAM into effect.

Breast-feeding and natural family planning.

The records of 50 Australian postpartum women who intended to breast-feed for longer than 6 months were analyzed. Fifty percent of the women breast-fed longer than 12 months, and 50% resumed menses by 40 weeks after childbirth. Fifty-four women provided records of mucus and BBT for at least 4 weeks before resumption of menses. Ovulation before menses while fully breast-feeding was probable in only one woman. Fifty percent of the first postpartum cycles had a short luteal phase. Thirty-two women chose NEP to avoid pregnancy during the study period. Mucus and BBT proved to be a good marker of ovulation during postpartum cycles. The mean number of days available for intercourse according to the Ovulation Method was 22.6 days between 6 and 12 postpartum weeks, and 12 days during the 4 weeks before menses. Confidence in NFP during lactational amenorrhoea and first postpartum cycles is analyzed. Finally, research aimed at improving the teaching and use of NFP for postpartum breast-feeding women is described.

Natural family planning indicators of ovulation.

Indirect evidence of the occurrence of ovulation, which is generally accepted, is an increase in plasma or serum progesterone. Pelvic ultrasonography can estimate the probable time of ovulation within 12 h. There is a close association between the rise in progesterone, luteinizing hormone (LH) and oestrogen peaks and ovulation. A WHO study reported that ovulation occurred at a median time of 8 h after the rise in plasma progesterone, 15 h after the LH peak and 24 h after the oestrogen peak. The basal body temperature (BBT) method is the most effective in determining the premenstrual infertile period, but it is unreliable for an accurate determination of ovulation and the postmenstrual infertile period. Nor is BBT an effective method of predicting ovulation during postpartum lactational amenorrhoea. Therefore, BBT is usually used as a secondary indicator of ovulation and is combined with more reliable indicators. Observed changes in cervical mucus patterns can be used to define the probable fertile period, although this method produces a wide range of days. The peak mucus symptom is closely correlated with ovulation. Mucus symptoms can be used as a guide for the timing of blood or urine samples for estimation of LH, oestrogen and progesterone or their metabolites. Symptothermal methods incorporate other symptoms such as cervical changes, intermenstrual pain, breast tenderness and backaches, but these are secondary signs of ovulation and are recommended to be used in conjunction with mucus and BBT.

PIP: Natural family planning (NFP) methods are based on the observation over the course of the menstrual cycle of specific signs and symptoms that result from changes in circulating blood levels of ovarian steroids, estrogen, and progesterone. There is a close association between the rise in progesterone, luteinizing hormone (LH), and estrogen peaks and ovulation. The basal body temperature (BBT) method is often incorporated in NFP methods that use 2 or more signs and symptoms of ovulation and is a simple, inexpensive way to determine the premenstrual infertile period. However, this method is not accurate in estimation of the day of ovulation, the postmenstrual infertile period, or the prediction of ovulation during postpartum lactational amenorrhea. The observation of changes in cervical mucus patterns can be used to define the probable fertile period of the menstrual cycle, but produces a wide range of days. The peak mucus symptom further can be used as a guide for the timing of blood or urine samples for the estimation of LH, estrogen, or progesterone. Changes in the morphology of the cervix, intermenstrual pain, vaginal bleeding, breast tenderness, vulval swelling, and backache have been incorporated into symptothermal NFP methods as secondary indicators of ovulation and can be used in conjunction with BBT and mucus observation. Under development are a number of electronic devices that will increase the ability to accurately determine the fertile and infertile phases of the menstrual cycle. A critical future need is more research on the reliability of NFP methods in breastfeeding women and the possibility that an increase in the volume of mucus may be a marker of the return of ovulation in lactating women.

Radioimmunoassay of prolactin in blood spotted on filter paper.

In this method for estimating prolactin, 50 microL of whole blood obtained by finger puncture is spotted onto filter paper and blood-spot samples are "punched out" with a 3-mm (diameter) paper punch. The blood is extracted with aqueous buffers and the prolactin measured in large batches by radioimmunoassay. Results were identical with those for prolactin in serum. Prolactin in blood spots is stable at room temperature for up to one week and for several months at -20 degrees C. This simple technique for obtaining blood samples for prolactin estimation has particular potential for field studies of lactating women.

Effect of breast-feeding status on prolactin secretion and resumption of menstruation.

This study investigated prospectively the effect of supplementary breast feeding on the duration of lactational amenorrhoea and serum prolactin levels during prolonged breast feeding in a group of 34 Australian mothers. Although supplementary feeding correlated statistically with the decline in mean serum prolactin levels and the subsequent resumption of menstruation, critical analysis of the data revealed that serum prolactin levels were declining with time before the introduction of supplementary feeding. It was concluded that the resumption of menstruation during prolonged lactational amenorrhoea is associated with the introduction of supplementary infant feeding, but other factors may be more important in this process. The good correlation between the decline in serum prolactin levels and the return of cyclic ovarian activity in individual mothers suggests that measurement of serum prolactin level may be a useful predictive index for returning fertility during breast feeding.

PIP: This study investigated prospectively the effect of supplementary breastfeeding on the duration of lactational amenorrhea and serum prolactin levels during prolonged breastfeeding in a group of 34 Australian mothers. Although supplementary feeding correlated statistically with the decline in mean serum prolactin levels and the subsequent resumption of menstruation, critical analysis of the data revealed that serum prolactin levels were declining with time before the introduction of supplementary feeding. It was concluded that the resumption of menstruation during prolonged lactational amenorrhea is associated with the introduction of supplementary infant feeding, but that other factors may be more important in this process. A good correlation between the decline in serum prolactin levels and the return of cyclic ovarian activity in individual mothers suggests that the measurement of serum prolactin level may be a useful predictive index for the return of fertility during breastfeeding.

The hormonal and ecological correlates of lactation infertility.

Some factors that may influence the results of studies of breastfeeding behavior in different cultures are identified. Findings of some of the demographic studies of rural areas in the so-called less developed nations are contrasted with studies in urbanized areas of such nations, as well as with studies from developed nations. A review of the physiology of lactation, specifically the role of prolactin is given along with some preliminary findings from the author's ongoing research in Australia.

Integrated concentrations of prolactin in breast-feeding mothers.

Mean 24-hour integrated concentrations of serum prolactin (PRL) in 8 breast-feeding mothers (62 +/- 10.4 microgram/l) was significantly higher than in 4 control subjects (14.8 +/- 3.3 microgram/l). No correlation was found between the mean integrated concentrations and time after delivery or breast-feeding status. There was no relationship between the mean integrated concentration of PRL or the basal PRL and the frequency of feedings, the total suckling time, the mean interval between feedings or the longest interval between feedings in the 24-hour period. The study provides conclusive evidence for increased prolactin secretion in long-term puerperal lactation.

Prolactin secretion during prolonged lactational amenorrhoea.

Basal serum prolactin levels were elevated up to 66 weeks postpartum in lactating amenorrhoeic women. The serum prolactin level in fully breast-feeding women was significantly higher than in women who were partially breast-feeding. The mean basal serum prolactin level in menstruating, lactating women was significantly higher than the mean level in women who had weaned and had normal menstrual cycles. The rise in prolactin due to suckling was seen up to 66 weeks postpartum. The marked variability and lack of reproducibility of individual suckling responses may obscure the importance of prolactin secretion in the postpartum period. Nevertheless, this study confirms that prolactin secretion is increased in women with prolonged lactational amenorrhoea.