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Background: The relationship between timing of direct enteral feeding tube (DET; gastrostomy/jejunostomy) placement and outcomes after stroke is unknown. Methods: We used the Ontario Stroke Registry and linked administrative databases to identify patients with acute stroke between 2003-2013 who received DET during hospital admission. We used multiple logistic regression and Cox proportional hazard models to determine the association between time from admission to DET placement and outcomes of severe disability at discharge (modified Rankin Scale score 4-5) and 30-day mortality after DET placement, adjusting for age, sex, co-morbidities, stroke type, stroke severity, intensive care or stroke unit admission, palliation, and hospital type. Results: 1,342 patients met our inclusion criteria. There was a lower hazard of 30-day mortality for each week in delay to DET placement (adjusted HR 0.89, 95%CI 0.80 to 0.99), but higher odds of severe disability (adjusted OR 1.36, 95%CI 1.14 to 1.62). Patients with DET placement within 1 week had the highest 30-day mortality compared to subsequent weeks (adjusted HR 1.59, 95%CI 1.05 to 2.4). Conclusions: Delayed DET placement after stroke is associated with lower 30-day mortality but greater disability. Thirty-day mortality was highest in those who received DET within 1 week of admission. These associations may inform decisions regarding timing of DET placement after stroke.
Background: Dysphagia is a common and devastating complication after acute stroke. Percutaneous endoscopic gastrostomy (PEG) tubes are often placed for persistent dysphagia. However, little is known regarding outcomes after PEG tube placement. Methods: We used a 10-year Ontario Stroke Registry to shed light on the clinical outcomes of patients with PEG tube insertion after ischemic stroke or intracranial hemorrhage compared to patients with only NG tubes, including rate of pneumonia, disability, and mortality. Results: Using propensity score matching, 1,793 patients were successfully matched and had similar baseline characteristics. Compared with NG, patients with PEG had a higher rate of pneumonia (32.6% vs. 20.6%; RR 1.59), higher disability at discharge (modified Rankin Scale Score 3-5; 74.0% vs. 65.4%; RR 1.13), and higher rate of long-term care placement (27.1% vs. 9.3%; RR 2.9). >From stroke onset, there was a lower rate of death in patients with PEG compared to NG at 30 days (15.3% vs. 34.3%; RR 0.45) but no difference at 2 years (52.8% vs. 53.5%; RR 0.99, p=0.71). *All significant p <0.0001. Conclusions: In conclusion, PEG tube placement after stroke may prolong survival in patients with poor outcomes. Our study provides a framework for discussions between physicians, patients, and families with regards to expected prognosis after PEG tube placement.
Background: In patients with acute stroke, nasogastric (NG) tubes are commonly inserted for feeding when dysphagia is identified, and percutaneous endoscopic gastrostomy (PEG) tubes are placed for severe or persistent dysphagia. However, little is known regarding predictors of PEG insertion. Methods: We used the Ontario stroke registry from 2003-2013 to identify baseline characteristics of all patients with NG or PEG tube insertion after stroke. We used multiple logistic regression with backwards selection to determine variables that were independent predictors of PEG tube insertion during admission. Results: 4002 patients with NG and 1903 patients with PEG were included in the analysis. Independent predictors of PEG were: Age (80+ vs. <60; odds ratio [OR] 1.70), past history of stroke (OR 1.17), higher stroke severity (severe vs. mild stroke; OR 1.37), stroke unit admission (OR 1.46), and dysphagia screening (OR 1.52). Factors associated with reduced odds of PEG insertion were: Prior history of peptic ulcer disease (OR 0.70), prior independence (OR 0.78), dementia (OR 0.76), palliative status (OR 0.49), and thrombolysis (OR 0.66). *All p<0.01 Conclusions: The strongest predictors of PEG were older age, higher stroke severity, stroke unit admission and dysphagia screening. Patients with dementia had reduced odds of PEG. Thrombolysis also reduced odds of PEG and may be protective.
Background: Bedside dysphagia screening is recommended for all patients with acute ischemic stroke, in order to detect swallowing impairment early and prevent complications. However, limited data are available on outcomes associated with failing a dysphagia screen. Methods: We used the Ontario Stroke Registry to identify patients who were admitted to Regional Stroke Centres from 2010-2013 and received a dysphagia screen within 72 hours. We used multivariable regression to determine outcomes of patients who failed the dysphagia screen. Results: Among 5145 patients who underwent dysphagia screening, 2458 (47.8%) failed and 2687 (52.2%) passed. Patients who failed had more co-morbidities and presented with more severe strokes (mean NIHSS 11.0 vs. 5.4). Among those who failed, 9% required permanent feeding tubes, versus 0.1% among those who passed. After controlling for age, co-morbidities, and stroke severity, failing a bedside swallowing screen remained highly predictive of poor outcomes, including decubitus ulcer (adjusted odds ratio aOR 10.5), pneumonia (aOR 4.6), discharge to long-term care (aOR 4.1) and 30-day mortality (aOR 4.5; 16.6% vs. 2.2%). *All p <0.0001 Conclusions: Patients who failed a dysphagia screen on admission had dramatically worse outcomes after controlling for baseline factors. A bedside dysphagia screen provides immediate risk stratification for acute stroke patients and can be used to guide appropriate care.
Background: Dysphagia is a devastating complication of stroke and can lead to malnutrition, immobility, aspiration pneumonia, and death. Guidelines advocate screening all patients with acute stroke for swallowing impairment. However, previous research suggests only 60% are screened, and it is unclear what factors contribute to receiving dysphagia screening. Methods: We used the Ontario Stroke Registry to identify patients who were admitted to Regional Stroke Centres from 2010-2013. We used multivariable regression to identify predictors of receiving a dysphagia screen within 72 hours. Results: Among 7172 patients with acute ischemic stroke, 1705 patients (23.8%) did not undergo screening. Factors increasing the odds of being tested were: Stroke unit admission (adjusted odds ratio aOR 6.5), presenting with speech deficits (aOR 1.9) or weakness (aOR 1.5), or receiving thrombolysis (aOR 1.9). Seizure (aOR 0.49) and mild stroke (aOR 0.59 vs moderate stroke) decreased the odds of being tested. Among those with mild strokes who received a swallowing screen, 33% failed. *All p<0.0001. Conclusions: Patients with mild stroke are at risk of not being screened for dysphagia, despite a significant fail rate among those tested. This may expose untested patients to a higher risk of complications from dysphagia, and suggests a gap in process of care that should be addressed.
This paper briefly describes the principle of operation and science goals of the AMANDA high energy neutrino telescope located at the South Pole, Antarctica. Results from an earlier phase of the telescope, called AMANDA-BIO, demonstrate both reliable operation and the broad astrophysical reach of this device, which includes searches for a variety of sources of ultrahigh energy neutrinos: generic point sources, Gamma-Ray Bursts and diffuse sources. The predicted sensitivity and angular resolution of the telescope were confirmed by studies of atmospheric muon and neutrino backgrounds. We also report on the status of the analysis from AMANDA-II, a larger version with far greater capabilities. At this stage of analysis, details of the ice properties and other systematic uncertainties of the AMANDA-II telescope are under study, but we have made progress toward critical science objectives. In particular, we present the first preliminary flux limits from AMANDA-II on the search for continuous emission from astrophysical point sources, and report on the search for correlated neutrino emission from Gamma Ray Bursts detected by BATSE before decommissioning in May 2000. During the next two years, we expect to exploit the full potential of AMANDA-II with the installation of a new data acquisition system that records full waveforms from the in-ice optical sensors.
SAO 244567 (= Hen 1357) is a very young planetary nebula. It was discovered by Parthasarathy et al. (1993, A and A 267, L19). Based on the spectrum obtained around 1950 Henize (1976, ApJ Suppl 30, 491) classified it as a B or A type H-alpha emission line star. The optical spectrum of SAO 244567 obtained in 1971 shows that it was a post-AGB B1 supergiant at that time. It has turned into a planetary nebula within the last 20 years (Parthasarathy et al. 1995, A and A 300, L25).
Despite the great progress which is being continuously made towards direct photoelectric recording, it is almost certain that for many years to come photographic plates will remain the most common means for detecting images of stars and stellar spectra, whether directly or through the intermediary of an image intensifier.
The photographic image of the spectrum of a star contains an enormous wealth of information whose utilization is one of the most important tasks of observational astrophysics. To achieve this task many difficult problems must be solved, the first being to express the information in a form which lends itself to further processing.
This is usually done by means of two different kinds of instruments.
Introduction. The Cerrado is the largest biome in the state of
Minas Gerais, Brazil; it presents an enormous biodiversity represented by fruit species,
highlighting murici (Byrsonima verbascifolia). The objective of our study
was to investigate the physical and physicochemical characteristics, occurrence and
concentration of carotenoids, vitamin C, vitamin E and folates in murici fruits from the
Cerrado of Minas Gerais, Brazil. Materials and methods. Titratable acidity
was determined by volumetric neutralization, pH by potentiometry, soluble solids by
refractometry, moisture using an oven, ash using a muffle furnace, protein by the
micro-Kjeldahl method, total dietary fiber by the non-enzymatic gravimetric method and
lipids by Soxhlet extraction; carotenoids and vitamin C were analyzed by HPLC-DAD, and
vitamin E and folates by HPLC with fluorescence detection. Results and
discussion. The murici pulp contained 7.47 g·100 g–1 carbohydrates,
5.13 g·100 g–1 lipids, 13.58 g·100 g–1 fibers and 71.58 g·100 g–1 moisture. The pH,
titratable acidity and soluble solids were 3.93, 0.77 g citric acid·100 g–1 and
10.73 °Brix, respectively. The results indicated that the fruit is an excellent source of
fiber and vitamin C (27.24 mg·100 g–1), a good source of vitamin E (1819.72 μg·100 g–1)
for children and a source for adults and pregnant women. Folates were not found in murici.
Conclusion. Murici stands out with regard to its nutritional value and can
contribute significantly to the supply of nutrients, especially fiber and vitamin C. Thus,
consumption of these fruits should be encouraged among families residing in the Cerrado
and in other regions of Brazil.
This research deals with the fall of the Sikhote-Alin iron meteorite on the morning of 12 February 1947, at about 00:38 h Utrecht, in a remote area in the territory of Primorsky Krai in Eastern Siberia (46°09′36″N, 134°39′22″E). The area engulfed by the meteoritic fall was around 48 km2, with an elliptic form and thousands of craters. Around the large craters the trees were torn out by the roots and laid radially to the craters at a distance of 10–20 m; the more distant trees had broken tops. This research investigated through dendrocronology n.6 Scots pine trees (Pinus Sibirica) close to one of the main impact craters. The analysis of growth anomalies has shown a sudden decrease since 1947 for 4–8 years after the meteoritic impact. Tree growth stress, detected in 1947, was analysed in detail through wood microsection that confirmed the winter season (rest vegetative period) of the event. The growth stress is mainly due to the lost crown (needle lost) and it did not seem to be caused due to direct damages on trunk and branches (missing of resin ducts).
Laser ablation technique has been successfully used for the deposition of CdSe and CdTe/CdSe multilayers on Si(100) and Si(l11) substrates. X-ray analysis showed that CdSe/Si films were highly oriented. Their orientation changed from (100) to (002) by varying the substrate temperature from 473 to 673K. High orientation was also obtained on multilayered polycrystalline structures of CdSe and CdTe on Si(lll). Photoluminescence experiments have also been carried out on the deposited films.
Although human visceral leishmaniasis (VL) is a notifiable disease in Italy, there is evidence that the actual number of cases is far higher than that notified. A programme for active surveillance of VL in the 14 Italian endemic regions was launched by the Istituto Superiore di Sanità. We report data collected during a 3-year period of active surveillance in Campania, a south Tyrrhenian region covering 4·5% of the Italian territory. Out of 120 clinically suspected cases referred to medical and diagnostic references centres, there were 52 confirmed VL cases (17·3/year), i.e. 10-fold more than previously notified. Most of the infection sites were in rural areas or peripheral districts of towns in hilly parts of Naples province. An epidemic cluster of 10 cases was identified in a microfocus of Caserta province. The biochemical analysis of 23 Leishmania stocks showed a zymodeme composition indicating Campania as an old and well-established focus of VL. The data obtained emphasize that the present notification system for VL in Italy is inadequate.
To evaluate hand hygiene compliance in 2 adult step-down units (SDUs).
A 6-month (from March to September 2007), controlled trial comparing 2 SDUs, one with a feedback intervention program (ie, the intervention unit) and one without (ie, the control unit).
Two 20-bed SDUs at a tertiary care private hospital.
Hand hygiene episodes were measured by electronic recording devices and periodic observational surveys. In the intervention unit, feedback was provided by the SDU nurse manager, who explained twice a week to the healthcare workers the goals and targets for the process measures.
A total of 117,579 hand hygiene episodes were recorded in the intervention unit, and a total of 110,718 were recorded in the control unit (P = .63). There was no significant difference in the amount of chlorhexidine used in the intervention and control units (34.0 vs 26.7 L per 1,000 patient-days; P = .36) or the amount of alcohol gel used (72.5 vs 70.7 L per 1,000 patient-days; P = .93). However, in both units, healthcare workers used alcohol gel more frequently than chlorhexidine (143.2 vs 60.7 L per 1,000 patient-days; P < .001). Nosocomial infection rates in the intervention and control units, respectively, were as follows: for bloodstream infection, 3.5 and 0.79 infections per 1,000 catheter-days (P = .18); for urinary tract infection, 15.8 and 15.7 infections per 1,000 catheter-days (P = .99); and for tracheostomy-associated pneumonia, 10.7 and 5.1 infections per 1,000 device-days (P = . 13). There were no cases of infection with vancomycin-resistant enterococci and only a single case of infection with methicillin-resistant Staphylococcus aureus (in the control unit).
The feedback intervention regarding hand hygiene had no significant effect on the rate of compliance. Other measures must be used to increase and sustain the rate of hand hygiene compliance.
We characterized two samples consisting of photoresist layers on silicon with square arrays of square holes by spectroscopic ellipsometry (SE) and Mueller matrix polarimetry (MMP). Hole lateral dimensions and depths were determined by fitting either SE data taken in conventional planar geometry or MMP data in general conical diffraction configurations. A method for objective determination of the optimal measurement conditions based on sensitivity and parameter correlations is presented. When applied to MMP, this approach showed that for one of the samples the optimal incidence angle was 45°, much below the widely used 70° value. The robustness of the dimensional characterisation based on MMP is demonstrated by the high stability of the results provided by separated fits of the data taken at different azimuthal angles.
We report a case of a 58-year-old man suffering from stiff-person syndrome and recurrent peripheral vertigo.
A case report and a review of the recent literature on stiff-person syndrome are presented.
The patient presented with recurrent episodes of vertigo with a pure peripheral pattern and with concomitant episodes of burning muscle pain, muscle twitching, weight gain and fatigue, worsening with tension or stress that also occurred in periods without vertigo. Cochlear examinations only showed presbyacusis-like hearing loss. The diagnosis of stiff-person syndrome was made with electromyographic examination and from findings in the blood and cerebrospinal fluid of high titres of anti-glutamic acid decarboxylase (GAD67) autoantibodies. In a two-year follow-up period, therapy for stiff-person syndrome abolished episodes of both stiffness and vertigo.
As far as we know, no other clinical case of acute vestibular damage with a possible correlation with anti-glutamic acid decarboxylase antibodies has been described. Peripheral vertigo possibly related to a lack of gamma aminobutyric acid underlines a possible role of gamma aminobutyric acid as a neurotransmitter in the peripheral vestibular system.