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A 1995 National Institute of Neurological Disorders (NINDS) study found benefit for intravenous tissue plasminogen activator (tPA) in acute ischemic stroke (AIS). The symptomatic intracranial hemorrhage (SICH) rate in the NINDS study was 6.4%, which may be deterring some physicians from using this medication.
Starting December 1, 1998, patients with AIS in London, Ontario were treated according to NINDS criteria with one major exception; those with approximately greater than one-third involvement of the idealized middle cerebral artery (MCA) territory on neuroimaging were excluded from treatment. The method used to estimate involvement of one-third MCA territory involvement bears the acronym ICE and had a median kappa value of 0.80 among five physicians. Outcomes were compared to the NINDS study.
Between December 1, 1998 and February 1, 2000, 30 patients were treated. Compared to the NINDS study, more London patients were treated after 90 minutes (p<0.00001) and tended to be older. No SICH was observed. Compared to the treated arm of the NINDS trial, fewer London patients were dead or severely disabled at three months (p=0.04). Compared to the placebo arm of the trial, more patients made a partial recovery at 24 hours (p=0.02), more had normal outcomes (p=0.03) and fewer were dead or severely disabled at three months (p=0.004).
The results of the NINDS study were closely replicated and, in some instances, improved upon in this small series of Canadian patients, despite older age and later treatment. These findings suggest that imaging exclusion criteria may optimize the benefits of tPA.
Objectives: To summarize the clinical characteristics and outcomes of pediatric sports-related concussion (SRC) patients who were evaluated and managed at a multidisciplinary pediatric concussion program and examine the healthcare resources and personnel required to meet the needs of this patient population. Methods: We conducted a retrospective review of all pediatric SRC patients referred to the Pan Am Concussion Program from September 1st, 2013 to May 25th, 2015. Initial assessments and diagnoses were carried out by a single neurosurgeon. Return-to-Play decision-making was carried out by the multidisciplinary team. Results: 604 patients, including 423 pediatric SRC patients were evaluated at the Pan Am Concussion Program during the study period. The mean age of study patients was 14.30 years (SD: 2.32, range 7-19 years); 252 (59.57%) were males. Hockey (182; 43.03%) and soccer (60; 14.18%) were the most commonly played sports at the time of injury. Overall, 294 (69.50%) of SRC patients met the clinical criteria for concussion recovery, while 75 (17.73%) were lost to follow-up, and 53 (12.53%) remained in active treatment at the end of the study period. The median duration of symptoms among the 261 acute SRC patients with complete follow-up was 23 days (IQR: 15, 36). Overall, 25.30% of pediatric SRC patients underwent at least one diagnostic imaging test and 32.62% received referral to another member of our multidisciplinary clinical team. Conclusion: Comprehensive care of pediatric SRC patients requires access to appropriate diagnostic resources and the multidisciplinary collaboration of experts with national and provincially-recognized training in TBI.
Sildenafil citrate has been shown to enhance neurogenesis, angiogenesis, synaptogenesis, and neurological outcome by augmentation of cyclic guanosine monophosphate (cGMP) levels in animal models of ischemic stroke. Whether sildenafil citrate may be helpful for recovery in human stroke is unknown at this time.
A 41-year-old woman with locked-in syndrome due to pontine infarction began receiving 150 mg of oral sildenafil citrate daily on a compassionate use basis in August 2003 and continues treatment at this time. Magnetoencephalography (MEG) was performed at 12 and 17 months after stroke.
No serious adverse events have occurred. Significant milestone recoveries including standing, use of both arms, talking, and full return of swallowing have occurred, particularly after nine months of treatment. The MEG showed a significantly increased amplitude in the somatosensory cortex.
Daily use of high dose sildenafil citrate appears to be safe in this patient with stroke resulting in locked-in syndrome. Further studies will be required to establish safety and efficacy.
The observation of an intraluminal common carotid artery thrombus overlying a wall defect at ultrasonography or angiography is unusual. To our knowledge, there are no previous reports of a free-floating thrombus in the common carotid artery.
A 45-year-old woman who was previously healthy and on no medications presented with acute hemiparesis and aphasia. Following testing that included carotid duplex and trancranial Doppler ultrasonography, diffusion-weighted magnetic resonance imaging, and digital subtraction angiography, the patient underwent emergency open embolectomy. No underlying wall defect was seen at the time of imaging or surgery. No obvious hypercoagulable state could be identified. Her NIH Stroke Scale score improved from 26 at admission to 2 at three months and 1 at one year.
Multimodal imaging may have improved diagnosis and management in this patient with a unique finding. The source of the thrombus remains obscure.
To compare the inter-observer reliability of Alberta Stroke Programme Early CT Scoring (ASPECTS) with the ICE (Idealize-Close-Estimate) method of estimating > 1/3 middle cerebral artery territory (MCAT) infarction amongst stroke neurologists and to determine how well ASPECT Scoring predicts > 1/3 MCAT infarctions in acute ischemic stroke (AIS).
The European Cooperative Acute Stroke Study suggested that > 1/3 involvement of the MCAT on early CT scan was a risk factor for symptomatic intracerebral hemorrhage (SICH) following treatment with tissue plasminogen activator (tPA) for AIS but, in the absence of a systematic method of estimation had poor interobserver reliability (Kappa 0.49). The ICE method was developed to standardize the approach to estimating early MCAT infarct size and has very good interobserver reliability (Kappa 0.72). ASPECTS has comparable interobserver reliability and is reported to predict both neurological outcome and SICH.
Five stroke neurologists were tested with 40 AIS CT scans. Each performed blinded independent assessments of early ischemic changes with both ASPECTS and ICE. The reference standard was majority opinion of 1/3 MCAT determination of five neuroradiologists. A receiver operator curve (ROC) was constructed and likelihood ratios (LR) were calculated. Chance corrected agreement (kappa) and chance independent agreement (phi) were calculated for both methods, and analysis of variance was used to calculate reliability by intraclass correlation coefficient (ICC) for ASPECTS.
The LR for a positive test (> 1/3 MCAT) were extremely large and conclusive (approaching infinity) for ASPECTS of 0-3; were large and conclusive (30, 20, and 10) for ASPECTS of 4, 5, and 6 respectively; was an unhelpful 1 for ASPECTS of 7, and were again extremely large and conclusive (approaching zero) for ASPECTS of 8-10. A ROC plot supported an ASPECTS cutoff of < 7 as best for 1/3 MCAT estimation (94% sensitivity and 98% specificity). Kappa and Phi statistics were moderately good for both ASPECTS and ICE (0.7). ICC for ASPECTS was 0.8.
When experienced stroke neurologists utilize a formalized method of quantifying early ischemic changes on CT, either ASPECTS or ICE, the interobserver agreement and reliability are satisfactory. ASPECTS allows for a strong and conclusive estimation of the presence of 1/3 MCAT involvement and a cutoff point of < 7 results in best test performance.
The controversial presidential election of 2000 triggered a wide variety of electoral reforms in many states. We examine the impact of a state's politics, ethnicity, and fiscal health on the passage of these reforms. Using state-level data from 2001 and 2002, we find that the partisan make-up of state government frequently influenced the fate of these reforms. States with a divided government or high party competition tended not to adopt several key electoral reforms, while partisanship and the interaction of partisanship and minority representation influenced the adoption of others. Fiscal constraints and institutional arrangements had less impact on reform adoption. Overall, our findings suggest that electoral reforms were shaped more by political factors than by fiscal concerns or any objective need for reform.
The publication of the latest rating of doctoral programs by the National Research Council (NRC 1995) has sparked great interest among university faculties. For some, the results vindicated years of focused efforts to improve their department's capacity, performance, and image. For others, it generated frustration because of the small change in scores from previous NRC rankings. And for still others, the NRC report occasioned soul-searching or defensive rationalization, including complaints that the reputational rankings did not reflect the “true” quality of the faculty (Magner 1995).
The NRC study conducted surveys of faculty in each of 41 scientific fields to learn about each doctoral-granting faculty's reputation for scholarly quality (93Q) and for the effectiveness of their doctoral program (93E). In addition, the NRC gathered information about the performance of departments (number of publications, citations to the publications of faculty, and external funding) as well as some other characteristics of the faculty (number of faculty, number of full professors) and doctoral student enrollments (number of students enrolled, number of Ph.D.'s granted in recent years). With these data, it is possible to explore the extent to which reputations are responsive to the performance of the faculty as well as to other department characteristics.
We reassess the debate over Soviet citizen politics in the USSR during the Brezhnev era. We argue the need for a more complex model of citizen participation in the USSR before Gorbachev if we are to have an accurate baseline for evaluating changes in regime-society relations. We examine the connections between individual attitudes and individual behavior and show that political participation under the “old regime” was not nearly as one-dimensional and devoid of effect as many previous researchers (and current Soviet leaders) have described it. Many forms of political participation in the Soviet Union before Gorbachev did not fit the stereotype of a psychologically disengaged citizenry driven to participate only by coercion, a desire to conform, or a quest for particularized benefits from public officials.
Theories of regime-society relations in Communist states stress the central role of coercion in maintaining political control. Based on a survey of Soviet emigrants, we examine whether Soviet citizens are deterred from nonconformity by the punitive actions of the KGB (individual deterrence), a perception of the KGB's coercive potential (general deterrence), or mistrust of other people. We find that few respondents were directly coerced by the KGB (and those who were had engaged in the most serious kinds of nonconformity); that those who had punitive contacts with the KGB in the past were not deterred from subsequent nonconformity; that the KGB's competent image was a general deterrent; and that trust in other people facilitated both nonconformist and compliant political activism. Those who came of political age under Khrushchev and Brezhnev were more likely to be involved in both kinds of activism than those who came of age under Stalin.
Students of Soviet affairs have long been concerned with how the Soviet political elite generates popular support. The conventional view of the Soviet system before the death of Stalin is summed up in a chapter in Merle Fainsod's How Russia Is Ruled entitled: “Terror as a System of Power.” That chapter's first sentence is, “Terror is the linchpin of modern totalitarianism” (Fainsod 1961: 354). Seweryn Bialer's later formulation, describing the Stalinist period, is similar: “[TJerror functioned principally not as a tool of social change, but as a normal method of rule and governance” (Bialer 1980: 12).
If it is true that “totalitarian dictatorship may be regarded as a substitute for other forms of coordination with a stronger groundwork in popular consensus” (Moore 1954), then the critical question is: What has been the method of achieving consensus, or support, for the established political order in the Soviet Union, once terror was no longer the main instrument of control? It is worth recalling Vera Dunham's observation that “In Stalin's time – and even in Stalin's worst times – the regime was supported by more than simple terror, a truism still overlooked from time to time” (Dunham 1976: 13). But the balance of methods of generating mass support is said to have shifted in the post-Stalin era (by Dunham's account, in the late Stalin era).
Two main methods of generating mass support for the Soviet system in the post-Stalin era have been emphasized in the scholarly literature: (a) agitation, propaganda, or, more generally, education; and (b) the manipulation of material rewards.