Prospective, Multicenter, Controlled Trial of Mobile Stroke Units.

BACKGROUND: Mobile stroke units (MSUs) are ambulances with staff and a computed tomographic scanner that may enable faster treatment with tissue plasminogen activator (t-PA) than standard management by emergency medical services (EMS). Whether and how much MSUs alter outcomes has not been extensively studied. METHODS: In an observational, prospective, multicenter, alternating-week trial, we assessed outcomes from MSU or EMS management within 4.5 hours after onset of acute stroke symptoms. The primary outcome was the score on the utility-weighted modified Rankin scale (range, 0 to 1, with higher scores indicating better outcomes according to a patient value system, derived from scores on the modified Rankin scale of 0 to 6, with higher scores indicating more disability). The main analysis involved dichotomized scores on the utility-weighted modified Rankin scale (≥0.91 or <0.91, approximating scores on the modified Rankin scale of ≤1 or >1) at 90 days in patients eligible for t-PA. Analyses were also performed in all enrolled patients. RESULTS: We enrolled 1515 patients, of whom 1047 were eligible to receive t-PA; 617 received care by MSU and 430 by EMS. The median time from onset of stroke to administration of t-PA was 72 minutes in the MSU group and 108 minutes in the EMS group. Of patients eligible for t-PA, 97.1% in the MSU group received t-PA, as compared with 79.5% in the EMS group. The mean score on the utility-weighted modified Rankin scale at 90 days in patients eligible for t-PA was 0.72 in the MSU group and 0.66 in the EMS group (adjusted odds ratio for a score of ≥0.91, 2.43; 95% confidence interval [CI], 1.75 to 3.36; P<0.001). Among the patients eligible for t-PA, 55.0% in the MSU group and 44.4% in the EMS group had a score of 0 or 1 on the modified Rankin scale at 90 days. Among all enrolled patients, the mean score on the utility-weighted modified Rankin scale at discharge was 0.57 in the MSU group and 0.51 in the EMS group (adjusted odds ratio for a score of ≥0.91, 1.82; 95% CI, 1.39 to 2.37; P<0.001). Secondary clinical outcomes generally favored MSUs. Mortality at 90 days was 8.9% in the MSU group and 11.9% in the EMS group. CONCLUSIONS: In patients with acute stroke who were eligible for t-PA, utility-weighted disability outcomes at 90 days were better with MSUs than with EMS. (Funded by the Patient-Centered Outcomes Research Institute; BEST-MSU ClinicalTrials.gov number, NCT02190500.).

Enhanced dispatch and rendezvous doubles the catchment area and number of patients treated on a mobile stroke unit.

INTRODUCTION: Mobile Stroke Units (MSUs) deliver acute stroke treatment on-scene in coordination with Emergency Medical Services (EMS). One criticism of the MSU approach is the limited range of a single MSU. The Houston MSU is evaluating MSU implementation, and we developed a rendezvous approach as an innovative solution to expand the range and number of patients treated. METHODS: In addition to direct 911 dispatch of our MSU to the scene within our 7-mile catchment area, we empowered more distant EMS units to activate the MSU. We also monitored EMS radio communications to identify possible patients. For these distant patients, the MSU met the EMS unit en route to the stroke center and treated the patient at that intermediate location. The distribution of the distance from MSU base station to site of stroke and time from 911 alert to tissue plasminogen activator (tPA) bolus were compared between patients treated on-scene and by rendezvous using Wilcoxon rank sum test. RESULTS: Over 4 years, 338 acute ischemic stroke patients were treated with tPA on our MSU. Of these, 169 (50%) were treated on-scene after MSU dispatch at a median of 6.4 miles (IQR 6.4 miles) from MSU base station. 169 (50%) were treated by 'rendezvous' pathway with assessment and treatment of stroke a median of 12.4 miles from base (IQR 5.5 miles) (p< 0.0001). Time (min) from MSU alert to tPA bolus did not differ: 36.0 ± 10.0 for on-scene vs 37.0 ± 10.0 with rendezvous (p=0.65). 13% of patients alerted via direct 911 dispatch were treated vs 44% of rendezvous patients. CONCLUSION: Adding a rendezvous approach to an MSU dispatch pathway doubles the range of operations and the number of patients treated by an MSU in an urban area, without incurring delay.

Time to Decision and Treatment With tPA (Tissue-Type Plasminogen Activator) Using Telemedicine Versus an Onboard Neurologist on a Mobile Stroke Unit.

BACKGROUND AND PURPOSE: Mobile stroke units (MSUs) can speed treatment with intravenous tPA (tissue-type plasminogen activator). We previously showed substantial agreement between a telemedicine-based vascular neurologist (TM-VN) and an onboard vascular neurologist (OB-VN) for the evaluation of patients with stroke for tPA eligibility on an MSU. However, the time efficiency of the telemedicine-based evaluation remained uncertain. In this study, we examined the speed of decision and treatment from MSU arrival for the TM-VN compared with an OB-VN. METHODS: In 50 consecutive situations, the TM-VN served as the primary decision maker. Times from MSU arrival to tPA decision and tPA bolus were compared with the same metrics for when the OB-VN served as the primary decision maker. RESULTS: Time to tPA decision for the TM-VN was 21 minutes (interquartile range, 16.25-26) versus 18 minutes (interquartile range, 14-22) for the OB-VN (P=0.01). Initiation of tPA bolus was 24 minutes (interquartile range, 19.75-30) for the TM-VN versus 24 minutes (interquartile range, 19-27.75) for the OB-VN (P=0.5). CONCLUSIONS: Assessment by a TM-VN is comparable with an OB-VN in making decisions about tPA administration on an MSU and does not lead to treatment delays. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02190500.

Conundrum of a Large Bowel Neoplasm: Collision Tumor.

A 79-year-old Hispanic man was admitted to the intensive care unit with symptomatic iron-deficiency anemia and watery diarrhea. Radiological images revealed diffuse colonic wall thickening, a soft-tissue fullness in the ascending colon, and multiple mesenteric lymphadenopathies. Colonoscopy showed multiple aphthous ulcers throughout the colon and a large deep ulcer with irregular raised borders in the rectosigmoid area. Histological exam of the ulcers showed severe ulcerative colitis, while biopsy of the deep ulcer revealed a well-differentiated adenocarcinoma. Colectomy specimen was consistent with colliding diffuse large B-cell lymphoma and adenocarcinoma.

Diagnostic Yield of Video Capsule Endoscopy for Small Bowel Bleeding: Eight Consecutive Years of Experience at the VA Caribbean Healthcare System.

OBJECTIVE: To evaluate the diagnostic yield of video capsule endoscopy (VCE) in patients with small bowel gastrointestinal bleeding and examine the impact of this diagnostic technology on the clinical management of this complaint. METHODS: This was a retrospective study in which all patients who underwent VCE (May 7, 2003 - December 31, 2011) were included. Records were reviewed for the type of bleeding (overt vs. occult; when present), demographic data, lab results, and capsule endoscopy findings. Information regarding medical treatment (i.e., endoscopic intervention, surgical therapy, or both) was also recorded. RESULTS: A total of 229 subjects were included in the study. Most were men; the mean age of all the subjects was 69.8 years. Of the 229 VCEs, 154 (67.3%) were done because of occult bleeding and 75 (32%) because of overt bleeding. VCEs were normal in 34 (14.9%) cases and non-diagnostic in 15 (6.6%). Angiodysplasia, erosions, and ulcers were the most common findings (48.5%, 24.5%, and 10.92% respectively). Active bleeding was reported in 7 cases (3%). Nearly 20% of the 229 cases required either endoscopic or surgical intervention. CONCLUSION: In our study, VCE achieved a diagnostic yield of 78.6%. In 1 of every 5 subjects, video capsule endoscopy led to the identification of small bowel lesions that required either endoscopic or surgical resection, rather than conservative treatment with iron replacement. VCE proved to be a very useful investigative tool, not only for establishing the source of bleeding but also, most importantly, for directing the appropriate therapy for lesions that would otherwise have been missed by conventional studies.

Evaluation of two human dental pulp stem cell cryopreservation methods.

Dental pulp is a promising source of mesenchymal stem cells for use in cell therapy and regenerative medicine. Methods for storing stem cells with minimum compromise of cell viability, differentiation capacity and function should be developed for clinical and research applications. The aim of this study was to evaluate whether human dental pulp stem cells (hDPSCs) isolated and cryopreserved for 1, 7 and 30 days maintain viability and expression of specific stem cell markers. Human dental pulp stem cells were isolated from 23 healthy patients aged 18 to 31 years. Dental pulp was enzymatically dissociated, and CD105+ cells were separated using the Miltenyi™ system. The hDPSCs were cryopreserved using the Kamath and Papaccio methods. Post-cryopreservation viability was measured by flow cytometry (7AAD) and by the expression of the phenotype markers CD105+/ CD73+, CD34-/CD45-. The Papaccio method showed greater cell viability for cells that had been frozen for 30 days (59.5%) than the Kamath method (56.2%), while the Kamath method provided better results for 1 day (65.5%) and 7 days (56%). Post-cryopreservation expression of the markers CD105+/CD34- was greater after 1 and 7 days with the Kamath method and CD105+/CD45- were expressed after all 3 cryopreservation times. There was greater expression of CD73+ in the hDPSCs after 1 and 7 days with the Kamath method, and after 30 days with the Papaccio method. These results suggest that hDPSCs express mesenchymal stem cell markers after cryopreservation. However, cryopreservation time may affect marker expression, probably by altering the spatialconfiguration of cell membrane proteins or by compromising cells at a certain level of differentiation.

Primary Enteropathy-Associated T-Cell Lymphoma Type 2: An Emerging Entity?

Intestinal T-cell lymphoma is a rare hematological malignancy that can present as primary intestinal lymphoma or as a manifestation of systemic disease. Primary involvement accounts for approximately 0.1% to 0.5% of all colorectal neoplasms. It is an aggressive disease with a poor prognosis and low survival rate. Inflammatory bowel disease, celiac disease, immunosuppression, and infectious etiologies, such as Epstein-Barr and human T-lymphotropic viruses, have been reported as risk factors, but no direct causal link has been established. Herein, we examine the case of a Hispanic man 69 years of age diagnosed with positive CD3, CD7, CD8, CD43, and Bcl-2 diffuse primary colorectal T-cell lymphoma. The patient did not exhibit a concomitant autoimmune or genetic disease. Because of the patient's history of polyps, surveillance colonoscopy was performed and the diagnosis was confirmed.

Evaluation of two human dental pulp stem cell cryopreservation methods / Evaluación de dos métodos de criopreservación de células troncales de pulpa dental humana

La pulpa dental es una fuente promisoria de células madre mesenquimales para ser utilizadas en terapia celular y medicina regenerativa. El desarrollo de métodos que permitan almacenar las células madre con mínimo compromiso de la viabilidad celular, capacidad de diferenciación y función es necesario para aplicaciones clínicas e investigación. El objetivo de este estudio fue evaluar si las células troncales depulpa dental humana (hDPSCs) aisladas y criopreservadas durante 1, 7 y 30 días conservan la viabilidad y expresiónde marcadores específicos de células troncales pos crio-preservación. Para esto, las hDPSCs se aislaron de 23pacientes sanos entre 18 y 31 años. La pulpa dental se disoció enzimáticamente, y las células CD105+ se separaron mediante el sistema Miltenyi™. Posteriormente, las hDPSCs se criopreservaron utilizando el método de Kamath y de Papaccio, se evaluó la viabilidad pos crio-preservación porcitometría de flujo (7AAD) y la expresión de marcadores CD105+/ CD73+, CD34-/CD45-. El método de Papaccio, mostró mayor viabilidad celular a los 30 días (59,5 por ciento)comparado con el método de Kamath, a 1 día (65,5%) y 7 días (56%) respectivamente. Se observó mayor expresión de los marcadores CD105+/CD34- a 1 y 7 días pos-criopreservación con el método Kamath y CD105+/CD45- a los 3 tiempos decriopreservación. CD73+ presentó mayor expresión en las hDPSCs a las 24 horas y 7 días con el método de Kamath, y al mes con el método Papaccio. Estos resultados sugieren que las hDPSCs expresan marcadores de células troncales mesenquimales postcriopreservación. Sin embargo el tiempo de criopreservación podría modificar la expresión de los marcadores probablemente por alterarla configuración espacial de las proteínas de membrana celular; o por comprometer a las células a cierto grado de diferenciación.

Dental pulp is a promising source of mesenchymal stem cells for use in cell therapy and regenerative medicine. Methods for storing stem cells with minimum compromise of cell viability, differentiation capacity and function should be developed for clinical and research applications. The aim of this study was toevaluate whether human dental pulp stem cells (hDPSCs)isolated and cryopreserved for 1, 7 and 30 days maintain viability and expression of specific stem cell markers. Human dental pulp stem cells were isolated from 23 healthy patients aged 18 to 31 years. Dental pulp was enzymatically dissociated, and CD105+ cells were separated using the Miltenyi™ system.The hDPSCs were cryopreserved using the Kamath andPapaccio methods. Post-cryopreservation viability wasmeasured by flow cytometry (7AAD) and by the expression of the phenotype markers CD105+/ CD73+, CD34-/CD45-. The Papaccio method showed greater cell viability for cells that had been frozen for 30 days (59.5%) than the Kamath method (56.2%), while the Kamath method provided better results for 1 day (65.5%) and 7 days (56%). Post-cryopreservation expression of the markers CD105+/CD34- was greater after 1 and 7 days with the Kamath method and CD105+/CD45- were expressed after all 3 cryopreservation times. There was greaterexpression of CD73+ in the hDPSCs after 1 and 7 days with the Kamath method, and after 30 days with the Papaccio method. These results suggest that hDPSCs express mesenchymal stem cell markers after cryopreservation. However, cryopreservationtime may affect marker expression, probably by altering the spatialconfiguration of cell membrane proteins or by compromising cells at a certain level of differentiation.