Racial differences in time to blood pressure control of aneurysmal subarachnoid hemorrhage patients: A single-institution study.

BACKGROUND AND PURPOSE: Aneurysmal subarachnoid hemorrhage occurs in approximately 30,000 patients annually in the United States. Uncontrolled blood pressure is a major risk factor for aneurysmal subarachnoid hemorrhage. Clinical guidelines recommend maintaining blood pressure control until definitive aneurysm securement occurs. It is unknown whether racial differences exist regarding blood pressure control and outcomes (HLOS, discharge disposition) in aneurysmal subarachnoid hemorrhage. Here, we aim to assess whether racial differences exist in 1) presentation, 2) clinical course, and 3) outcomes, including time to blood pressure stabilization, for aSAH patients at a large tertiary care medical center. METHODS: We conducted a retrospective review of adult aneurysmal subarachnoid hemorrhage cases from 2013 to 2019 at a single large tertiary medical center. Data extracted from the medical record included sex, age, race, insurance status, aneurysm location, aneurysm treatment, initial systolic and diastolic blood pressure, Hunt Hess grade, modified Fisher score, time to blood pressure control (defined as time in minutes from first blood pressure measurement to the first of three consecutive systolic blood pressure measurements under 140mmHg), hospital length of stay, and final discharge disposition. RESULTS: 194 patients met inclusion criteria; 140 (72%) White and 54 (28%) Black. While White patients were more likely than Black patients to be privately insured (62.1% versus 33.3%, p < 0.001), Black patients were more likely than White patients to have Medicaid (55.6% versus 15.0%, p < 0.001). Compared to White patients, Black patients presented with a higher median systolic (165 mmHg versus 148 mmHg, p = 0.004) and diastolic (93 mmHg versus 84 mmHg, p = 0.02) blood pressure. Black patients had a longer median time to blood pressure control than White patients (200 minutes versus 90 minutes, p = 0.001). Black patients had a shorter median hospital length of stay than White patients (15 days versus 18 days, p < 0.031). There was a small but statistically significant difference in modified Fisher score between black and white patients (3.48 versus 3.17, p = 0.04).There were no significant racial differences present in sex, Hunt Hess grade, discharge disposition, complications, or need for further interventions. CONCLUSION: Black race was associated with higher blood pressure at presentation, longer time to blood pressure control, but shorter hospital length of stay. No racial differences were present in aneurysmal subarachnoid hemorrhage associated complications or interventions.

Effectiveness of Continuous Hypertonic Saline in Acute Ischemic Infarcts: A Radiographic and Clinical Evaluation.

OBJECTIVE: The role of continuous hypertonic saline (HS) infusion in the management of malignant cerebral edema is controversial. We evaluated patients presenting with large anterior circulation territory infarcts and compared radiographic and clinical outcomes to evaluate the effects of continuous HS. METHODS: This was a retrospective review of patients with malignant ischemic strokes who were initially managed with continuous HS versus routine medical management. Radiographic parameters of cerebral edema and clinical parameters were collected at different time intervals after admission. Rates and timing of surgery, mortality, and complications were also collected. RESULTS: The study included 43 patients: 26 in group 1 (HS) and 17 in group 2 (no HS). Both cohorts had comparable baseline clinical and radiographic parameters. There was no difference between rates and timing of surgery, complications, and mortality. Mean midline shift was significantly greater in the HS group at interval 1 (12-36 hours, P = 0.003) and interval 2 (36-60 hours, P = 0.030), and mean change in midline shift from initial interval to interval 1 was significantly greater in the HS group (P = 0.019). CONCLUSIONS: Despite the widespread use of continuous HS in acute ischemic infarcts, only a limited number of studies have evaluated its efficacy, and virtually no studies have studied its effect on radiographic progression and rates of decompressive surgery. Results of this study indicate that there is no benefit of continuous HS. In fact, there may be worsening of cerebral edema with administration of continuous HS. In addition, there are no differences in prevention or delay of decompressive surgery or in overall mortality.

Multidisciplinary Concussion Management: A Model for Outpatient Concussion Management in the Acute and Post-Acute Settings.

OBJECTIVE: To describe a model of multidisciplinary concussion management and explore management methods in the acute and post-acute settings. SETTING: A multidisciplinary concussion management program within a large health system. PARTICIPANTS: Patients with sports and non-sports-related concussions aged 14 to 18 years with persisting concussion symptoms at 4 weeks postinjury or beyond. DESIGN: Pilot randomized controlled trial comparing a subsymptom threshold exercise program with standard-of-care treatment in the post-acute setting. MAIN MEASURES: Beck Depression Inventory-II and the Post-Concussion Scale-Revised. RESULTS: Across groups, 60% improvement in concussion symptoms was noted. After removing the influence of depression, the intervention showed a large effect on symptom reduction, with participants in the intervention group improving more than those in the control group. There was no difference in response to the intervention by the sports and nonsports groups. CONCLUSION: Results demonstrate that exercise intervention is effective in reducing symptoms in adolescents with persisting symptoms. The finding that participants in the control group who underwent education, light activity, and sophisticated monitoring still had meaningful recovery supports the utility of active engagement in a multidisciplinary management program. Finally, depression had a clinically meaningful effect on recovery, highlighting the need for targeted intervention of noninjury factors relevant to persisting symptoms.

Common Data Elements for Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Working Group on Hospital Course and Acute Therapies-Proposal of a Multidisciplinary Research Group.

INTRODUCTION: The Common Data Elements (CDEs) initiative is a National Institute of Health/National Institute of Neurological Disorders and Stroke (NINDS) effort to standardize naming, definitions, data coding, and data collection for observational studies and clinical trials in major neurological disorders. A working group of experts was established to provide recommendations for Unruptured Aneurysms and Aneurysmal Subarachnoid Hemorrhage (SAH) CDEs. METHODS: This paper summarizes the recommendations of the Hospital Course and Acute Therapies after SAH working group. Consensus recommendations were developed by assessment of previously published CDEs for traumatic brain injury, stroke, and epilepsy. Unruptured aneurysm- and SAH-specific CDEs were also developed. CDEs were categorized into "core", "supplemental-highly recommended", "supplemental" and "exploratory". RESULTS: We identified and developed CDEs for Hospital Course and Acute Therapies after SAH, which included: surgical and procedure interventions; rescue therapy for delayed cerebral ischemia (DCI); neurological complications (i.e. DCI; hydrocephalus; rebleeding; seizures); intensive care unit therapies; prior and concomitant medications; electroencephalography; invasive brain monitoring; medical complications (cardiac dysfunction; pulmonary edema); palliative comfort care and end of life issues; discharge status. The CDEs can be found at the NINDS Web site that provides standardized naming, and definitions for each element, and also case report form templates, based on the CDEs. CONCLUSION: Most of the recommended Hospital Course and Acute Therapies CDEs have been newly developed. Adherence to these recommendations should facilitate data collection and data sharing in SAH research, which could improve the comparison of results across observational studies, clinical trials, and meta-analyses of individual patient data.

Expression of the pho regulon interferes with induction of the uhpT gene in Escherichia coli K-12.

The uptake of hexose 6-phosphates in Escherichia coli is mediated by the transporter UhpT, the synthesis of which is induced by the presence of glucose 6-phosphate (glucose 6-P) in the medium. Since this protein functions as an anion exchanger, it is generally assumed to be geared for the use of sugar phosphates as a carbon source. However, the question was unresolved whether this transporter can also provide the cells with glucose 6-P as a phosphate source. It is demonstrated in this work that UhpT-mediated glucose 6-P uptake does not allow the cells to grow on glucose 6-P as phosphate source. Hence, the expression of UhpT under phosphate limitation would not be particularly advantageous and some form of interaction between the uhp system and the Pi-limitation-inducible pho regulon, the products of which are involved in phosphate acquisition, may be anticipated. Indeed, the use of an uhpT-lacZ fusion revealed that much higher concentrations of the inducer glucose 6-P were required to elevate uhpT transcription when the pho regulon was expressed. This interference was the result of degradation of glucose 6-P by one of the products of the pho regulon, the periplasmic enzyme alkaline phosphatase. The specific form of interaction between the Pho and Uhp systems is designated inducer degradation.

The phosphate-binding protein of Escherichia coli is not essential for P(i)-regulated expression of the pho regulon.

Disruption of pstS encoding the P(i)-binding protein in Escherichia coli generally leads to the constitutive expression of the pho regulon. We demonstrate that P(i)-controlled expression is restored when the activity of the P(i) transporter PitA or PitB is increased. Apparently, PstS is not an essential component of the signal transduction pathway.

Autoamplification of a two-component regulatory system results in "learning" behavior.

We have tested the hypothesis that the autoamplification of two-component regulatory systems results in "learning" behavior, i.e., that bacteria respond faster or more extensively to a signal when a similar signal has been perceived in the past. Indeed, the induction of alkaline phosphatase activity upon phosphate limitation was faster if the cultures had been limited for phosphate previously, and this faster response correlated with the autoamplification of the cognate two-component system.

Activation by gene amplification of pitB, encoding a third phosphate transporter of Escherichia coli K-12.

Two systems for the uptake of inorganic phosphate (P(i)) in Escherichia coli, PitA and Pst, have been described. A revertant of a pitA pstS double mutant that could grow on P(i) was isolated. We demonstrate that the expression of a new P(i) transporter, PitB, is activated in this strain by a gene amplification event.

Polymer surface science.

Molecular level studies of the structure and mechanical properties of polymer surfaces have been carried out by sum frequency generation (SFG) surface vibrational spectroscopy and atomic force microscopy (AFM). The surfaces of different grades of polyethylene and polypropylene have been characterized-including during the glass transition and when mechanically stretched. Copolymers that have hard and soft segments with different glass transition temperatures show phase separation, an effect of hydrogen bonding between the hard and soft segments, that influences their adhesive and friction properties. AFM and SFG show that low surface energy additives migrate to the surface and alter the surface mechanical properties. Polymers, where the chemical nature of the end groups is different from the backbone, show surface segregation of the hydrophobic part of the chain in air and the hydrophilic part in water. Likewise, in miscible polymer blends, surface segregation of the more hydrophobic component in air and the more hydrophilic component in water is observed. This area of surface science requires increased attention because of the predominance of polymers as structural materials and as biomaterials.

Sequence, chromophore extraction and 3-D model of the photoactive yellow protein from Rhodobacter sphaeroides.

The photoactive yellow protein (pyp) gene has been isolated from Rhodobacter sphaeroides by probing with a homologous PCR-product. A sequence analysis shows that this pyp gene encodes a 124 AA protein with 48% identity to the three known PYPs. Downstream from pyp, a number of adjacent open reading frames were identified, including a gene encoding a CoA-ligase homologue (pCL). This latter protein is proposed to be involved in PYP chromophore activation, required for attachment to the apoprotein. We have demonstrated the presence of the chromophoric group, previously identified in PYP from Ectothiorhodospira halophila as trans 4-hydroxy cinnamic acid, in phototrophically cultured R. sphaeroides cells by capillary zone electrophoresis. The basic structure of the chromophore binding pocket in PYP has been conserved, as shown by a 3D model of R. sphaeroides PYP, constructed by homology-based molecular modelling. In addition, this model shows that R. sphaeroides PYP contains a characteristic, positively charged patch.

The xanthopsins: a new family of eubacterial blue-light photoreceptors.

Photoactive yellow protein (PYP) is a photoreceptor that has been isolated from three halophilic phototrophic purple bacteria. The PYP from Ectothiorhodospira halophila BN9626 is the only member for which the sequence has been reported at the DNA level. Here we describe the cloning and sequencing of the genes encoding the PYPs from E.halophila SL-1 (type strain) and Rhodospirillum salexigens. The latter protein contains, like the E.halophila PYP, the chromophore trans p-coumaric acid, as we show here with high performance capillary zone electrophoresis. Additionally, we present evidence for the presence of a gene encoding a PYP homolog in Rhodobacter sphaeroides, the first genetically well-characterized bacterium in which this photoreceptor has been identified. An ORF downstream of the pyp gene from E.halophila encodes an enzyme, which is proposed to be involved in the biosynthesis of the chromophore of PYP. The pyp gene from E.halophila was used for heterologous overexpression in both Escherichia coli and R.sphaeroides, aimed at the development of a holoPYP overexpression system (an intact PYP, containing the p-coumaric acid chromophore and displaying the 446 nm absorbance band). In both organisms the protein could be detected immunologically, but its yellow color was not observed. Molecular genetic construction of a histidine-tagged version of PYP led to its 2500-fold overproduction in E.coli and simplified purification of the heterologously produced apoprotein. HoloPYP could be reconstituted by the addition of p-coumaric anhydride to the histidine-tagged apoPYP (PYP lacking its chromophore). We propose to call the family of photoactive yellow proteins the xanthopsins, in analogy with the rhodopsins.

The clinical value of quantitative dynamic scintigraphy in salivary gland disorders.

Salivary gland scintigraphy with [99mTc]pertechnetate was performed in a group of 11 subjects without any known salivary pathology, and in a group of 12 xerostomic patients. Time-activity curves, normalized to background, were generated for each of the four major salivary glands in both groups, and averaged into single curves, representing the function of each gland. Comparing the two sets of curves (patients vs controls) demonstrates that utilizing our "normalization" approach enables one not only to determine whether one group of dynamic curves is significantly different from another, but to decide which of the glands are normal and which are malfunctioning. The sensitivity, specificity, accuracy and predictive values of this procedure are all above 0.90.

The antiemetic activity of droperidol administered by intramuscular injection during cisplatin chemotherapy: a pilot study.

The antiemetic activity of escalating doses of droperidol was evaluated in ten patients undergoing chemotherapy with cisplatin regimens. Major antiemetic activity was achieved in five patients, two patients had less nausea and vomiting as compared with prior prochlorperazine therapy, and three patients were refractory to droperidol. No dose-response relationship was observed. Sedation occurred in nine patients, and two patients experienced dystonic reactions. Droperidol is a relatively safe and effective antiemetic for patients undergoing chemotherapy with cisplatin.

Induction bleomycin infusion in head and neck cancer.

Twenty-one male patients with previously untreated advanced squamous cell carcinoma of the head and neck were treated with an induction regimen of bleomycin 15 mg/m2 I.V. bolus followed by a continuous 24-hour I.V. infusion at a dose of 15 mg/m2/day for 7 days. One week following induction therapy, patients were reevaluated for response and then received definitive therapy with surgery and/or radiation therapy. The chemotherapy yielded a major response rate of 33% (one CR, six PR). Toxic manifestations of this regimen were mild, consisting of fever, alopecia, rash, and mucositis. There was no pulmonary toxicity detected. The response rate obtained with bleomycin infusion is inferior to the combination of cis-platinum with a bleomycin infusion as induction therapy in previously untreated patients with squamous cell carcinoma of the head and neck.

Continuous vindesine infusion in advanced head and neck cancer.

Sixteen patients with advanced squamous cell carcinoma of the head and neck were treated with a 48-hour I.V. vindesine infusion. The dosage was 3 mg/m2/48 hours every 2 weeks. Toxicity consisted of leukopenia, paresthesias, and phlebitis. Major objective responses were seen in four patients (one CR, three PR), with a median duration of 4 months.