Performance of RAPID noncontrast CT stroke platform in large vessel occlusion and intracranial hemorrhage detection.

Background: Noncontrast CT (NCCT) is used to evaluate for intracerebral hemorrhage (ICH) and ischemia in acute ischemic stroke (AIS). Large vessel occlusions (LVOs) are a major cause of AIS, but challenging to detect on NCCT. Aims: The purpose of this study is to evaluate an AI software called RAPID NCCT Stroke (RAPID, iSchemaView, Menlo Park, CA) for ICH and LVO detection compared to expert readers. Methods: In this IRB approved retrospective, multicenter study, stand-alone performance of the software was assessed based on the consensus of 3 neuroradiologists and sensitivity and specificity were determined. The platform's performance was then compared to interpretation by readers comprised of eight general radiologists (GR) and three neuroradiologists (NR) in detecting ICH and hyperdense vessel sign (HVS) indicating LVO. Results: A total of 244 cases were included. Of the 244, 115 were LVOs and 26 were ICHs. One hundred three cases did not have LVO nor ICH. Stand-alone performance of the software demonstrated sensitivities and specificities of 96.2 and 99.5% for ICH and 63.5 and 95.1% for LVO detection. Compared to all 11 readers and eight GR readers only respectively, the software demonstrated superiority, achieving significantly higher sensitivities (63.5% versus 43.6%, p < 0.0001 and 63.5% versus 40.9%, p = 0.001). Conclusion: The RAPID NCCT Stroke platform demonstrates superior performance to radiologists for detecting LVO from a NCCT. Use of this software platform could lead to earlier LVO detection and expedited transfer of these patients to a thrombectomy capable center.

The Water to Land Transition Submerged: Multifunctional Design of Pectoral Fins for Use in Swimming and in Association with Underwater Substrate.

Fins of fishes provide many examples of structures that are beautifully designed to power and control movement in water; however, some species also use their fins for substrate-associated behaviors where interactions with solid surfaces are key. Here, we examine how the pectoral fins of ray-finned fish with these multifunctional behavioral demands, in water and on solid surfaces, are structured and function. We subdivide fins used in swimming and substrate contact into two general morphological categories, regionalized vs. generalized fins. Regionalized fins have ventral rays that are free from connecting membrane or in which that membrane is reduced. Dorsally they maintain a more typical membranous fin. While all pectoral fins vary somewhat in their morphology from leading to trailing edge, generalized fins do not have the substantial membrane loss between rays that is seen in regionalized fins and the distal edge anatomy changes gradually along its margin. We add a new case study in regionalized fins with the dwarf hawkfish (Cirrhitichthys falco). Hawkfishes are most often found perching and moving on structures in their environments. During perching, the free ventral rays are in contact with the substrate and splayed. We found that unlike other fish with regionalized pectoral fins, hawkfish maintain use of the dorsal membranous region of its pectoral fin for rhythmic swimming. We found that typically hawkfish bend their ventral free rays under, toward the medial hemitrichs or hold them straight during substrate-associated postures. This appears also to be the case for the ventral free rays of other species with regionalized fins. Generalized fin use for substrate contact was reviewed in round gobies (Neogobius melanostomus). In addition, although their lobe fins are not representative of ray-finned fish anatomy, we explored fin contact on submerged substrates in the Senegal bichir (Polypterus senegalus), which has a generalized distal fin (no free fin rays or distinct membrane regions). Both groups use their pectoral fins for swimming. During substrate-based postures, unlike hawkfish, their distal rays generally bend outward toward the lateral hemitrichs and a large swath of the fin membrane can contact the surface. The alternative demands on multifunctional fins suggest specialization of the mechanosensory system. We review mechanosensation related to fin movement and surface contact. These alternative regionalized and generalized strategies for serving aquatic and substrate-based functions underwater provide opportunities to further investigate specializations, including sensory structures and systems, that accompany the evolution of substrate-based behaviors in vertebrates.

Age-Related Outcomes After Transcatheter Mitral Valve Repair in Patients With Heart Failure: Analysis From COAPT.

OBJECTIVES: The aim of this study was to assess the impact of age on outcomes in patients undergoing transcatheter edge-to-edge repair (TEER) from the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial. BACKGROUND: In the COAPT trial, TEER with the MitraClip device in patients with heart failure (HF) and moderate to severe or severe secondary mitral regurgitation (SMR) reduced the risk for HF hospitalization (HFH) and all-cause mortality compared with maximally tolerated guideline-directed medical therapy (GDMT) alone. There are limited data regarding the effectiveness of MitraClip therapy in elderly patients. METHODS: Patients (n = 614) were grouped by median age at randomization (74 years) and by MitraClip treatment vs GDMT alone. The primary endpoint was the 2-year rate of death or HFH assessed by multivariable Cox regression. RESULTS: Death or HFH within 2 years occurred less frequently after treatment with the MitraClip vs GDMT alone in patients <74 years of age (37.3% vs 64.5%; adjusted HR: 0.41; 95% CI: 0.29-0.59) and ≥74 years of age (51.7% vs 69.6%; adjusted HR: 0.58; 95% CI: 0.42-0.81) (Pint = 0.17). Mortality was also consistently reduced with MitraClip treatment in young and elderly patients (Pint = 0.42). In contrast, elderly patients treated with the MitraClip vs GDMT alone tended to have a lesser reduction of HFH than younger patients (Pint = 0.03). Younger and older patients had similar improvements in quality of life after treatment with the MitraClip compared with GDMT alone. CONCLUSIONS: In the COAPT trial, MitraClip treatment of moderate to severe and severe SMR reduced the composite risk for death or HFH and improved survival and quality of life regardless of age. As such, young and elderly patients with HF and severe SMR benefit from TEER, although elderly patients may not have as great a benefit from the MitraClip device in reducing HFH.

Outcomes After Percutaneous Coronary Intervention in Patients With a History of Cerebrovascular Disease: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium.

BACKGROUND: Because of shared risk factors between coronary artery disease and cerebrovascular disease, patients with a history of transient ischemic attack (TIA) or stroke are at greater risk of developing coronary artery disease, which may require percutaneous coronary intervention (PCI). However, there remains a paucity of research examining outcomes after PCI in these patients. METHODS AND RESULTS: We analyzed consecutive patients who underwent PCI between January 1, 2013, and March 31, 2016, at 47 Michigan hospitals and identified those with a history of TIA/stroke. We used propensity score matching to adjust for differences in baseline characteristics and compared in-hospital outcomes between patients with and without a history of TIA/stroke. We compared rates of 90-day readmission and long-term mortality in a subset of patients. Among 98 730 patients who underwent PCI, 10 915 had a history of TIA/stroke. After matching (n=10 618 per group), a history of TIA/stroke was associated with an increased risk of in-hospital stroke (adjusted odds ratio, 2.04; 95% confidence interval, 1.41-2.96; P<0.001). There were no differences in the risks of other in-hospital outcomes. In a subset of patients with postdischarge data, a history of TIA/stroke was associated with increased risks of 90-day readmission (adjusted odds ratio, 1.22; 95% confidence interval, 1.09-1.38; P<0.001) and long-term mortality (hazard ratio, 1.23; 95% confidence interval, 1.07-1.43; P=0.005). CONCLUSIONS: A history of TIA/stroke was common in patients who underwent PCI and was associated with increased risks of in-hospital stroke, 90-day readmission, and long-term mortality. Given the devastating consequences of post-PCI stroke, patients with a history of TIA/stroke should be counseled on this increased risk before undergoing PCI.

Ninety-Day Readmission and Long-Term Mortality in Medicare Patients (≥65 Years) Treated With Ticagrelor Versus Prasugrel After Percutaneous Coronary Intervention (from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium).

Ticagrelor and prasugrel were found to be superior to clopidogrel for the treatment of acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI); however, the comparative effectiveness of these 2 drugs remains unknown. We compared postdischarge outcomes among older patients treated with ticagrelor versus prasugrel after PCI for ACS. We linked clinical data from PCIs performed in older patients (age ≥65) for ACS at 47 Michigan hospitals to Medicare fee-for-service claims from January 1, 2013, to December 31, 2014, to ascertain rates of 90-day readmission and long-term mortality. We used propensity score matching to adjust for the nonrandom use of ticagrelor and prasugrel at discharge. Logistic regression and Cox proportional hazards models were used to compare rates of 90-day readmission and long-term mortality, respectively. Patients discharged on ticagrelor (n = 1,243) were more frequently older, female, had a history of cerebrovascular disease, and presented with ST- or non-ST-elevation myocardial infarction compared with prasugrel (n = 1,014). After matching (n = 756 per group), there were no significant differences in the rates of 90-day readmission (16.7% ticagrelor vs 14.6% prasugrel; adjusted odds ratio 1.15, 95% confidence interval 0.86 to 1.55, p = 0.35) or 1-year mortality (5.4% ticagrelor vs 3.7% prasugrel; hazard ratio 1.3, 95% confidence interval 0.8 to 2.2, p = 0.31). In conclusion, we found no significant differences in the rates of 90-day readmission or long-term mortality between older patients treated with ticagrelor and patients treated with prasugrel after PCI for ACS. In the absence of randomized data to the contrary, these 2 treatments appear similarly effective.