Racial disparities in access to, and outcomes of, acute ischaemic stroke treatments in the USA.

BACKGROUND: Racism contributes to higher comorbid risk factors and barriers to preventive measures for black Americans. Advancements in systems of care, tissue plasminogen activator (tPA) availability and endovascular thrombectomy (ET) have impacted practice and outcomes while outpacing contemporary investigation into acute ischaemic stroke (AIS) care disparities. We examined whether recent data suggest ongoing disparity in AIS interventions and outcomes, and if hospital characteristics affect disparities. METHODS: We examined 2016-2019 fee-for-service Medicare inpatient data. We ran unadjusted logistic regression models to calculate ORs and 95% CI for two interventions (tPA and ET) and four outcomes (inpatient mortality, 30-day mortality, discharge home and outpatient visit within 30 days), with the main predictor black versus white race, additionally adjusting for demographics, hospital characteristics, stroke severity and comorbidities. RESULTS: 805 181 AIS admissions were analysed (12.4% black, 87.6% white). Compared with white patients, black patients had reduced odds of receiving tPA (OR 0.71, 95% CI 0.69 to 0.74, p<0.0001) and ET (0.69, 95% CI 0.65 to 0.72, p<0.0001). After tPA, black patients had reduced odds of 30-day mortality (0.77, 95% CI 0.72 to 0.82, p<0.0001), discharge home (0.72, 95% CI 0.68 to 0.77, p<0.0001) and outpatient visit within 30 days (0.89, 95% CI 0.84 to 0.95, p=0.0002). After ET, black patients had reduced odds of 30-day mortality (0.71, 95% CI 0.63 to 0.79, p<0.0001) and discharge home (0.75, 95% CI 0.64 to 0.88, p=0.0005). Adjusted models showed little difference in the magnitude, direction or significance of the main effects. CONCLUSIONS: Black patients were less likely to receive AIS treatments, and if treated had lower likelihood of 30-day mortality, discharge home and outpatient visits. Despite advancements in practice and therapies, racial disparities remain in the modern era of AIS care and are consistent with inequalities previously identified over the last 20 years. The impact of hospital attributes on AIS care disparities warrants further investigation.

Cerebral Venous Sinus Thrombosis in an Immunocompetent HIV Patient.

Cerebral venous sinus thrombosis (CVST) is an uncommon manifestation in patients with the human immunodeficiency virus (HIV) due to the virus's prothrombotic state. Our case involves a 41-year-old Hispanic male with a past medical history of HIV on bictegravir/emtricitabine/tenofovir/alafenamide (Biktarvy), hyperlipidemia, post-traumatic stress disorder, hypogonadism with the cessation of testosterone injections one month prior, and generalized anxiety disorder who presented with retro-orbital headache, intermittent bilateral blurry vision, and flashing lights in the lower lateral left eye for one week. Vitals signs and laboratory studies were within normal limits aside from new iron deficiency anemia. Neurological exam was unremarkable. Computed tomography (CT) of the head showed evidence of a subacute cerebral infarct with hemorrhagic transformation in the right superior parietal lobe. Magnetic resonance imaging (MRI) of the brain with contrast revealed a small thrombosed cortical vein with surrounding hemorrhage and edema in the same location, in addition to a partial thrombosis of the adjacent superior sagittal sinus, which was confirmed by magnetic resonance venogram (MRV). Although cerebral angiography was performed, no intervention was attempted for the partially occluded sagittal sinus. HIV viral load was undetectable with a robust cluster of differentiation (CD) 4 count on therapy. The patient was treated with strict blood pressure control, a statin, and a heparin drip. He remained stable and was discharged on enoxaparin injections with bridging to warfarin. In summary, appropriate lab testing, imaging, and high clinical suspicion are required for proper diagnosis and treatment of venous thromboembolism (VTE) or CVST in an HIV-positive patient.

Design, Synthesis, and Evaluation of a Luminescent Cholesterol Mimic.

The development of new chemical tools with improved properties is essential to chemical and cell biology. Of particular interest is the development of mimics of small molecules with important cellular function that allow the direct observation of their trafficking in a cell. To this end, a novel 15-azasterol has been designed and synthesized as a luminescent cholesterol mimic for the monitoring of cholesterol trafficking. The brightness of this probe, which is ∼32-times greater than the widely used dehydroergosterol probe, is combined with resistance to photobleaching in solution and in human fibroblasts and an exceptionally large Stokes-like shift of ∼150-200 nm. The photophysical properties of the probe have been studied experimentally and computationally, suggesting an intersystem crossing to the triplet excited state with subsequent phosphorescent decay. Molecular dynamics simulations show a similar binding mode of cholesterol and the azasterol probe to NPC proteins, demonstrating the structural similarity of the probe to cholesterol.