Search

The analysis of extracellular vesicles (EV) in blood samples is under intense investigation and holds the potential to deliver clinically meaningful biomarkers for health and disease. Technical variation must be minimized to confidently assess EV-associated biomarkers, but the impact of pre-analytics on EV characteristics in blood samples remains minimally explored. We present the results from the first large-scale EV Blood Benchmarking (EVBB) study in which we systematically compared 11 blood collection tubes (BCT; six preservation and five non-preservation) and three blood processing intervals (BPI; 1, 8 and 72 h) on defined performance metrics (n = 9). The EVBB study identifies a significant impact of multiple BCT and BPI on a diverse set of metrics reflecting blood sample quality, ex-vivo generation of blood-cell derived EV, EV recovery and EV-associated molecular signatures. The results assist the informed selection of the optimal BCT and BPI for EV analysis. The proposed metrics serve as a framework to guide future research on pre-analytics and further support methodological standardization of EV studies., (© 2023 The Authors. Journal of Extracellular Vesicles published by Wiley Periodicals, LLC on behalf of the International Society for Extracellular Vesicles.)

Background: Reproducible detection of inherited variants with whole genome sequencing (WGS) is vital for the implementation of precision medicine and is a complicated process in which each step affects variant call quality. Systematically assessing reproducibility of inherited variants with WGS and impact of each step in the process is needed for understanding and improving quality of inherited variants from WGS., Results: To dissect the impact of factors involved in detection of inherited variants with WGS, we sequence triplicates of eight DNA samples representing two populations on three short-read sequencing platforms using three library kits in six labs and call variants with 56 combinations of aligners and callers. We find that bioinformatics pipelines (callers and aligners) have a larger impact on variant reproducibility than WGS platform or library preparation. Single-nucleotide variants (SNVs), particularly outside difficult-to-map regions, are more reproducible than small insertions and deletions (indels), which are least reproducible when > 5 bp. Increasing sequencing coverage improves indel reproducibility but has limited impact on SNVs above 30×., Conclusions: Our findings highlight sources of variability in variant detection and the need for improvement of bioinformatics pipelines in the era of precision medicine with WGS., (© 2021. The Author(s).)

Background: Asymmetric inferior petrosal sinuses (IPS) are not infrequently encountered during bilateral IPS sampling. There is little data on whether IPS symmetry influences success in predicting the adenoma side in patients with ACTH-dependent Cushing's syndrome (CS)., Objective: To assess the influence of IPS drainage patterns on detection of an adenoma in CS., Methods: Retrospective single-center cohort analysis reviewing records of patients with CS and negative MRI findings who subsequently underwent BIPSS., Results: BIPSS was performed in 38 patients with a mean age of 45±15 years. The overall technical success rate was 97% for bilateral cannulation. Asymmetric IPS were observed in 11 (39%) patients with Cushing's disease (CD). A side-to-side ACTH ratio was not significantly different between patients with symmetric outflow and those with asymmetric outflow at baseline (8.6±2.7 versus 16.4±6.0; P=0.45), but ratios were significantly different after ovine corticotropin-releasing hormone (oCRH) stimulation (6.0±2.5 versus 35.7±22.5; P=0.03). BIPSS correctly predicted the side of the adenoma in 25 (96%) patients with CD. Prediction was better when the venous outflow was symmetric (100%) rather than asymmetric (93%), although the difference was not significant (P=0.42). Remission from CS was achieved in 32 patients (87%), independent of the symmetry of IPS., Conclusions: Bearing in mind the sample size of this audit, asymmetric IPS at least do not seem to diminish the accuracy of diagnosis of ACTH-dependent CS, nor do they influence the clinical outcome., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Viral genome sequencing has guided our understanding of the spread and extent of genetic diversity of SARS-CoV-2 during the COVID-19 pandemic. SARS-CoV-2 viral genomes are usually sequenced from nasopharyngeal swabs of individual patients to track viral spread. Recently, RT-qPCR of municipal wastewater has been used to quantify the abundance of SARS-CoV-2 in several regions globally. However, metatranscriptomic sequencing of wastewater can be used to profile the viral genetic diversity across infected communities. Here, we sequenced RNA directly from sewage collected by municipal utility districts in the San Francisco Bay Area to generate complete and nearly complete SARS-CoV-2 genomes. The major consensus SARS-CoV-2 genotypes detected in the sewage were identical to clinical genomes from the region. Using a pipeline for single nucleotide variant calling in a metagenomic context, we characterized minor SARS-CoV-2 alleles in the wastewater and detected viral genotypes which were also found within clinical genomes throughout California. Observed wastewater variants were more similar to local California patient-derived genotypes than they were to those from other regions within the United States or globally. Additional variants detected in wastewater have only been identified in genomes from patients sampled outside California, indicating that wastewater sequencing can provide evidence for recent introductions of viral lineages before they are detected by local clinical sequencing. These results demonstrate that epidemiological surveillance through wastewater sequencing can aid in tracking exact viral strains in an epidemic context., (Copyright © 2021 Crits-Christoph et al.)

Importance: Achieving complete reperfusion is a key determinant of good outcome in patients treated with mechanical thrombectomy (MT). However, data on treatments geared toward improving reperfusion after incomplete MT are sparse., Objective: To determine whether administration of intra-arterial urokinase is safe and improves reperfusion after failed or incomplete MT., Design, Setting, and Participants: This observational cohort study included a consecutive sample of patients treated with second-generation MT from January 1, 2010, through August 4, 2017. Data were collected from the prospective registry of a tertiary care stroke center. Of 1274 patients screened, 69 refused to participate, and 993 met the observational studies inclusion criteria of a large vessel occlusion in the anterior circulation. Data were analyzed from September 1, 2017, through September 20, 2019., Intervention: One hundred patients received intra-arterial urokinase after failed or incomplete MT using manual microcatheter injections., Main Outcomes and Measures: Primary safety outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the Prolyse in Acute Cerebral Thromboembolism II criteria. Secondary end points included 90-day mortality and 90-day functional independence (defined as modified Rankin Scale score of ≤2). Efficacy was evaluated angiographically, applying the Thrombolysis in Cerebral Infarction (TICI) scale., Results: After exclusion of patients with posterior circulation strokes and those treated with intra-arterial thrombolytics only, 993 patients were included in the final analyses (median age, 74.6 [interquartile range, 62.6-82.2] years; 505 [50.9%] women). Additional intra-arterial urokinase was administered in 100 patients (10.1%). The most common reason for administering intra-arterial urokinase was incomplete reperfusion (TICI<3) after MT (53 [53.0%]). After adjusting for baseline characteristics underlying case selection, intra-arterial urokinase was not associated with an increased risk of sICH (adjusted odds ratio [aOR], 0.81; 95% CI, 0.31-2.13) or 90-day mortality (aOR, 0.78; 95% CI, 0.43-1.40). Among 53 cases of partial or near-complete reperfusion and treated with intra-arterial urokinase, 32 (60.4%) had early reperfusion improvement, and 18 of 53 (34.0%) had an improvement in TICI grade. Correspondingly, patients treated with intra-arterial urokinase had higher rates of functional independence after adjusting for the selection bias favoring a priori poor TICI grades in the intra-arterial urokinase group (aOR, 1.93; 95% CI, 1.11-3.37)., Conclusions and Relevance: In selected patients, adjunctive treatment with intra-arterial urokinase during or after MT was safe and improved angiographic reperfusion. Systemic evaluation of this approach in a multicenter prospective registry or a randomized clinical trial seems warranted.

Competing Interests: Competing interests: None declared.

Purpose: Knowledge about the localization and outcome of iatrogenic dissection (ID) during endovascular treatment of acute ischemic stroke (AIS) is limited. We aimed to determine the frequency, clinical aspects and morphology of ID in endovascular AIS treatment and to identify predictors of this complication., Methods: Digital subtraction angiography (DSA) of ID carried out during endovascular treatment between January 2000 and March 2012 have been re-evaluated. The ID localization and morphology were analyzed and related to the interventional techniques. Baseline clinical and radiological findings, treatment modality and outcome were compared with patients without ID., Results: Out of 866 patients 18 (2%) suffered an ID (44% female, median age 64 years). Localization was extracranial in 15 (83%, 14 internal carotid artery and 1 vertebral artery) and intracranial in 3 (17%; 1 vertebrobasilar dissection and 2 in the anterior circulation). Of the IDs 5 (28%) resulted in a high-degree, 3 (17%) in a moderate, 5 (28%) in a mild and 5 (28%) in no stenosis and 8 IDs were stented in the acute phase. At 3 months 7 (42%) patients had a favorable outcome (modified Rankin score mRS ≤ 2) and 6 (33%) patients had died. Patients with ID had a different stroke etiology (p = 0.041), were more likely to be smokers (44% versus 19%, p = 0.015) and were more likely to be treated with mechanical thrombectomy (100% versus 60%, p < 0.001). Although two ID patients had relevant complications, the outcome did not differ between the groups., Conclusion: The occurrence of ID is a rare complication of endovascular AIS treatment associated with smoking and mechanical thrombectomy.

Background: Sequencing-based detection and characterization of viruses in complex samples can suffer from lack of sensitivity due to a variety of factors including, but not limited to, low titer, small genome size, and contribution of host or environmental nucleic acids. Hybridization-based target enrichment is one potential method for increasing the sensitivity of viral detection via high-throughput sequencing., Results: This study expands upon two previously developed panels of virus enrichment probes (for filoviruses and for respiratory viruses) to include other viruses of biodefense and/or biosurveillance concern to the U.S. Department of Defense and various international public health agencies. The newly expanded and combined panel is tested using carefully constructed synthetic metagenomic samples that contain clinically relevant amounts of viral genetic material. Target enrichment results in a dramatic increase in sensitivity for virus detection as compared to shotgun sequencing, yielding full, deeply covered viral genomes from materials with Ct values suggesting that amplicon sequencing would be likely to fail. Increased pooling to improve cost- and time-effectiveness does not negatively affect the ability to obtain full-length viral genomes, even in the case of co-infections, although as expected, it does decrease depth of coverage., Conclusions: Hybridization-based target enrichment is an effective solution to obtain full-length viral genomes for samples from which virus detection would fail via unbiased, shotgun sequencing or even via amplicon sequencing. As the development and testing of probe sets for viral target enrichment expands and continues, the application of this technique, in conjunction with deeper pooling strategies, could make high-throughput sequencing more economical for routine use in biosurveillance, biodefense and outbreak investigations.

Cerebral oximetry using near-infrared spectroscopy (NIRS) allows for continuous monitoring of cerebral perfusion and immediate treatment of hemodynamic perturbations. In configurations used in current clinical practice, NIRS optodes are placed on the patient`s forehead and cerebral oxygen saturation (ScO 2 ) is determined in bilateral frontal cortical samples. However, focal cerebral ischemic lesions outside of the NIRS field of view may remain undetected. The objective of this observational case-series study was to investigate ScO 2 measurements in patients with acute iatrogenic stroke not located in the frontal cortical region. Adult patients undergoing cardiac surgery with cardiopulmonary bypass or interventional cardiology procedures and suffering stroke in the early postoperative period were identified from the Bernese Stroke Registry and analyzed for their intraoperative ScO 2 values and brain imaging data. Main outcome measures were the ScO 2 values, computed tomography and magnetic resonance imaging findings. In six patients, the infarct areas were localized in the vascular territories of the posterior and/or dorsal middle cerebral arteries. One patient had watershed stroke and another one excellent collaterals resulting in normal cerebral blood volume and only subtle decrease of cerebral blood flow in initially critically perfused watershed brain areas. Intraoperative ScO 2 values were entirely unremarkable or nonindicative for brain damage. Our results indicate that uneventful intraoperative NIRS monitoring does not exclude severe cerebral ischemia due to the limited field of view of commercially available NIRS devices. False negative NIRS may occur as a consequence of stroke localized outside the frontal cortex., (© 2018 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Background and Purpose: Anemia is associated with worse outcome in stroke, but the impact of anemia with intravenous thrombolysis or endovascular therapy has hardly been delineated. The aim of this study was to analyze the role of anemia on infarct evolution and outcome after acute stroke treatment., Methods: 1158 patients from Bern and 321 from Los Angeles were included. Baseline data and 3 months outcome assessed with the modified Rankin Scale were recorded prospectively. Baseline DWI lesion volumes were measured in 345 patients and both baseline and final infarct volumes in 180 patients using CT or MRI. Multivariable and linear regression analysis were used to determine predictors of outcome and infarct growth., Results: 712 patients underwent endovascular treatment and 446 intravenous thrombolysis. Lower hemoglobin at baseline, at 24h, and nadir until day 5 predicted poor outcome (OR 1.150-1.279) and higher mortality (OR 1.131-1.237) independently of treatment. Decrease of hemoglobin after hospital arrival, mainly induced by hemodilution, predicted poor outcome and had a linear association with final infarct volumes and the amount and velocity of infarct growth. Infarcts of patients with newly observed anemia were twice as large as infarcts with normal hemoglobin levels., Conclusion: Anemia at hospital admission and any hemoglobin decrease during acute stroke treatment affect outcome negatively, probably by enlarging and accelerating infarct growth. Our results indicate that hemodilution has an adverse effect on penumbral evolution. Whether hemoglobin decrease in acute stroke could be avoided and whether this would improve outcome would need to be studied prospectively., Competing Interests: The authors have declared that no competing interests exist.

OBJECTIVE Cerebral hyperperfusion syndrome (CHS) is a rare but devastating complication of carotid endarterectomy (CEA). This study sought to determine whether quantitative hemodynamic assessment using MR angiography can stratify CHS risk. METHODS In this prospective trial, patients with internal carotid artery (ICA) stenosis were randomly selected for pre- and postoperative quantitative phase-contrast MR angiography (QMRA). Assessment was standardized according to a protocol and included Doppler/duplex sonography, MRI, and/or CT angiography and QMRA of the intra- and extracranial supplying arteries of the brain. Clinical and radiological data were analyzed to identify CHS risk factors. RESULTS Twenty-five of 153 patients who underwent CEA for ICA stenosis were randomly selected for pre- and postoperative QMRA. QMRA data showed a 2.2-fold postoperative increase in blood flow in the operated ICA (p < 0.001) and a 1.3-fold increase in the ipsilateral middle cerebral artery (MCA) (p = 0.01). Four patients had clinically manifested CHS. The mean flow increases in the patients with CHS were significantly higher than in the patients without CHS, both in the ICA and MCA (p < 0.001). Female sex and a low preoperative diastolic blood pressure were the clearest clinical risk factors for CHS, whereas the flow differences and absolute postoperative flow values in the ipsilateral ICA and MCA were identified as potential radiological predictors for CHS. CONCLUSIONS Cerebral blood flow in the ipsilateral ICA and MCA as assessed by QMRA significantly increased after CEA. Higher mean flow differences in ICA and MCA were associated with the development of CHS. QMRA might have the potential to become a noninvasive, operator-independent screening tool for identifying patients at risk for CHS.

Stroke due to hypoperfusion or emboli is a devastating adverse event of cardiac surgery, but early detection and treatment could protect patients from an unfavorable postoperative course. Hypoperfusion and emboli can be detected with transcranial Doppler of the middle cerebral artery (MCA). The measured blood flow velocity correlates with cerebral oxygenation determined clinically by near-infrared spectroscopy (NIRS) of the frontal cortex. We tested the potential advantage of a spatially extended NIRS in detecting critical events in three cardiac surgery patients with a whole-head fiber holder of the FOIRE-3000 continuous-wave NIRS system. Principle components analysis was performed to differentiate between global and localized hypoperfusion or ischemic territories of the middle and anterior cerebral arteries. In one patient, we detected a critical hypoperfusion of the right MCA, which was not apparent in the frontal channels but was accompanied by intra- and postoperative neurological correlates of ischemia. We conclude that spatially extended NIRS of temporal and parietal vascular territories could improve the detection of critically low cerebral perfusion. Even in severe hemispheric stroke, NIRS of the frontal lobe may remain normal because the anterior cerebral artery can be supplied by the contralateral side directly or via the anterior communicating artery., ((2018) COPYRIGHT Society of Photo-Optical Instrumentation Engineers (SPIE).)

Background and Purpose: Some authors use FLAIR imaging to select patients for stroke treatment. However, the effect of hyperintensity on FLAIR images on outcome and bleeding has been addressed in only few studies with conflicting results., Methods: 466 patients with anterior circulation strokes were included in this study. They all were examined with MRI before intravenous or endovascular treatment. Baseline data and 3 months outcome were recorded prospectively. Focal T2 and FLAIR hyperintensities within the ischemic lesion were evaluated by two raters, and the PROACT II classification was applied to assess bleeding complications on follow up imaging. Logistic regression analysis was used to determine predictors of bleeding complications and outcome and to analyze the influence of T2 or FLAIR hyperintensity on outcome., Results: Focal hyperintensities were found in 142 of 307 (46.3%) patients with T2 weighted imaging and in 89 of 159 (56%) patients with FLAIR imaging. Hyperintensity in the basal ganglia, especially in the lentiform nucleus, on T2 weighted imaging was the only independent predictor of any bleeding after reperfusion treatment (33.8% in patients with vs. 18.2% in those without; p = 0.003) and there was a non-significant trend for more bleedings in patients with FLAIR hyperintensity within the basal ganglia (p = 0.069). However, there was no association of hyperintensity on T2 weighted or FLAIR images and symptomatic bleeding or worse outcome., Conclusion: Our results question the assumption that T2 or FLAIR hyperintensities within the ischemic lesion should be used to exclude patients from reperfusion therapy, especially not from endovascular treatment.

Background and Purpose: Randomized controlled trials have shown that bridging endovascular therapy (EVT) after intravenous thrombolysis (IVT) therapy improves outcome in patients with stroke with large-artery anterior circulation stroke compared with IVT alone. It remains unknown whether IVT adds any benefit to EVT in these patients. The aim of this study was to assess recanalization rates and thrombus dislocation before initiation of EVT in patients receiving bridging therapy., Methods: All patients in the Bernese stroke registry (2008-2015) in whom bridging therapy was considered were included in this analysis. Relevant recanalization before EVT, thrombus dislocation and increase in thrombus load between initial and control imaging were assessed retrospectively., Results: A total of 319 patients were included. Relevant recanalization before EVT occurred in 8.8% and thrombus dislocation in 7.2% of patients before EVT. Recanalization rates were significantly higher in distal compared with large and more proximal vessel occlusions of the anterior circulation (occlusion of internal carotid artery, 5.4%; middle cerebral artery segment M1, 8.1%; middle cerebral artery segment M2, 17.6%) and in drip-and-ship patients compared with mother-ship patients. In multivariable regression analysis the occlusion site was the only independent predictor of relevant recanalization before EVT (P = 0.046)., Conclusions: Relevant recanalization after IVT and prior to EVT in patients receiving bridging therapy was highly dependent on the occlusion site. These findings suggest that future randomized controlled trials should consider occlusion site and treatment paradigm to specify patients who benefit most from bridging therapy in comparison to EVT or IVT alone., (© 2017 EAN.)

Background and Purpose: General anesthesia during endovascular treatment of acute ischemic stroke may have an adverse effect on outcome compared with conscious sedation. The aim of this study was to examine the impact of the type of anesthesia on the outcome of patients with acute ischemic stroke treated with the Solitaire stent retriever, accounting for confounding factors., Materials and Methods: Four-hundred one patients with consecutive acute anterior circulation stroke treated with a Solitaire stent retriever were included in this prospective analysis. Outcome was assessed after 3 months by the modified Rankin Scale., Results: One-hundred thirty-five patients (31%) underwent endovascular treatment with conscious sedation, and 266 patients (69%), with general anesthesia. Patients under general anesthesia had higher NIHSS scores on admission (17 versus 13, P < .001) and more internal carotid artery occlusions (44.6% versus 14.8%, P < .001) than patients under conscious sedation. Other baseline characteristics such as time from symptom onset to the start of endovascular treatment did not differ. Favorable outcome (mRS 0-2) was more frequent with conscious sedation (47.4% versus 32%; OR, 0.773; 95% CI, 0.646-0.925; P = .002) in univariable but not multivariable logistic regression analysis ( P = .629). Mortality did not differ ( P = .077). Independent predictors of outcome were age (OR, 0.95; 95% CI, 0.933-0.969; P < .001), NIHSS score (OR, 0.894; 95% CI, 0.855-0.933; P < .001), time from symptom onset to the start of endovascular treatment (OR, 0.998; 95% CI, 0.996-0.999; P = .011), diabetes mellitus (OR, 0.544; 95% CI, 0.305-0.927; P = .04), and symptomatic intracerebral hemorrhage (OR, 0.109; 95% CI, 0.028-0.428; P = .002)., Conclusions: In this single-center study, the anesthetic management during stent retriever thrombectomy with general anesthesia or conscious sedation had no impact on the outcome of patients with large-vessel occlusion in the anterior circulation., (© 2017 by American Journal of Neuroradiology.)

Cocoa agroforests like the cabrucas of Brazil's Atlantic forest are among the agro-ecosystems with greatest potential for biodiversity conservation. Despite a global trend for their intensification, cocoa agroforests are also being abandoned for socioeconomic reasons especially on marginal sites, because they are incorporated in public or private protected areas, or are part of mandatory set-asides under Brazilian environmental legislation. However, little is known about phylogenetic structure, the processes of forest regeneration after abandonment and the conservation value of former cabruca sites. Here we compare the vegetation structure and composition of a former cabruca 30-40 years after abandonment with a managed cabruca and mature forest in the Atlantic forest region of Espirito Santo, Brazil. The forest in the abandoned cabruca had recovered a substantial part of its original structure. Abandoned cabruca have a higher density (mean ± CI95 %: 525.0 ± 40.3 stems per ha), basal area (34.0 ± 6.5 m 2 per ha) and species richness (148 ± 11.5 species) than managed cabruca (96.0 ± 17.7; 24.15 ± 3.9 and 114.5 ± 16.0, respectively) but no significant differences to mature forest in density (581.0 ± 42.2), basal area (29.9.0 ± 3.3) and species richness (162.6 ± 15.5 species). Thinning (understory removal) changes phylogenetic structure from evenness in mature forest to clustering in managed cabruca, but after 30-40 years abandoned cabruca had a random phylogenetic structure, probably due to a balance between biotic and abiotic filters at this age. We conclude that abandoned cocoa agroforests present highly favorable conditions for the regeneration of Atlantic forest and could contribute to the formation of an interconnected network of forest habitat in this biodiversity hotspot.

Background and Purpose: For patients with cerebral vasospasm refractory to medical and hemodynamic therapies, endovascular therapies often remain the last resort. Data from studies in large cohorts on the efficacy and safety of multiple immediate endovascular interventions are sparse. Our aim was to assess the feasibility and safety of multiple repeat instant endovascular interventions in patients with cerebral vasospasm refractory to medical, hemodynamic, and initial endovascular interventions., Materials and Methods: This was a single-center retrospective study of prospectively collected data on patients with cerebral vasospasm refractory to therapies requiring ≥3 endovascular interventions during the course of treatment following aneurysmal subarachnoid hemorrhage. The primary end point was functional outcome at last follow-up (mRS ≤2). The secondary end point was angiographic response to endovascular therapies and the appearance of cerebral infarctions., Results: During a 4-year period, 365 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Thirty-one (8.5%) met the inclusion criteria. In 52 (14%) patients, ≤2 endovascular interventions were performed as rescue therapy for refractory cerebral vasospasm. At last follow-up, a good outcome was noted in 18 (58%) patients with ≥3 interventions compared with 31 (61%) of those with ≤2 interventions ( P = .82). The initial Hunt and Hess score of ≤2 was a significant independent predictor of good outcome (OR, 4.7; 95% CI, 1.2-18.5; P = .03), whereas infarcts in eloquent brain areas were significantly associated with a poor outcome (mRS 3-6; OR, 13.5; 95% CI, 2.3-81.2; P = .004)., Conclusions: Repeat instant endovascular intervention is an aggressive but feasible last resort treatment strategy with a favorable outcome in two-thirds of patients with refractory cerebral vasospasm and in whom endovascular treatment has already been initiated., (© 2017 by American Journal of Neuroradiology.)

Background: Symptomatic intracerebral hemorrhage (sICH) after bridging thrombolysis for acute ischemic stroke is a devastating complication. We aimed to assess whether the additional administration of aspirin during endovascular intervention increases bleeding rates., Methods: We retrospectively compared bleeding complications and outcome in stroke patients who received bridging thrombolysis with (tPA+ASA) and without (tPA-ASA) aspirin during endovascular intervention between November 2008 and March 2014. Furthermore, we analyzed bleeding complications and outcome in antiplatelet naïve patients with those with prior or acute antiplatelet therapy., Results: Baseline characteristics, previous medication, and dosage of rtPA did not differ between 50 tPA+ASA (39 aspirin naïve, 11 preloaded) and 181 tPA-ASA patients (p>0.05). tPA+ASA patients had more often internal carotid artery (ICA) occlusion (p<0.001), large artery disease (p<0.001) and received more often acute stenting of the ICA (p<0.001). 10/180 (5.6%) tPA-ASA patients and 3/49 (6.1%) tPA+ASA patients suffered a sICH (p = 1.0). Rates of asymptomatic intracerebral hemorrhage, systemic bleeding complications and outcome did not differ between both groups (p>0.1). There were no differences in bleeding complications and mortality among 112 bridging patients with antiplatelet therapy (62 preloaded, 39 acute administration, 11 both) and 117 antiplatelet naïve patients. In a logistic regression analysis, aspirin administration during endovascular procedure was not a predictor of sICH., Conclusion: Antiplatelet therapy before or during bridging thrombolysis in patients with acute ischemic stroke did not increase the risk of bleeding complications and had no impact on outcome. This finding has to be confirmed in larger studies., Competing Interests: Several co-authors of this study received financial honoraries: UF was a consultant for Covidien and Co-PI of the SWIFT DIRECT study. JG: Consultancy for Medtronic (Global PI of STAR Study and Co-PI of the Swift Direct Trial), Consultancy for Penumbra (CEC member of the Promise Study). MA received honoraria for advisory boards from Astra Zeneca, Bayer, BMS, Boehringer Ingelheim, Covidien, Daiichi Sankyo and Pfizer. There are no patents, products in development, or marketed products to declare. This does not alter the authors’ adherence to all PLOS ONE policies on sharing data and materials. The others have no other competing interests to declare.

The production of tropical agricultural commodities, such as cocoa ( Theobroma cacao ) and coffee ( Coffea spp.), the countries and communities engaged in it, and the industries dependent on these commodities, are vulnerable to climate change. This is especially so where a large percentage of the global supply is grown in a single geographical region. Fortunately, there is often considerable spatial heterogeneity in the vulnerability to climate change within affected regions, implying that local production losses could be compensated through intensification and expansion of production elsewhere. However, this requires that site-level actions are integrated into a regional approach to climate change adaptation. We discuss here such a regional approach for cocoa in West Africa, where 70 % of global cocoa supply originates. On the basis of a statistical model of relative climatic suitability calibrated on West African cocoa farming areas and average climate projections for the 2030s and 2050s of, respectively, 15 and 19 Global Circulation Models, we divide the region into three adaptation zones: (i) a little affected zone permitting intensification and/or expansion of cocoa farming; (ii) a moderately affected zone requiring diversification and agronomic adjustments of farming practices; and (iii) a severely affected zone with need for progressive crop change. We argue that for tropical agricultural commodities, larger-scale adaptation planning that attempts to balance production trends across countries and regions could help reduce negative impacts of climate change on regional economies and global commodity supplies, despite the institutional challenges that this integration may pose.

Objective: There is mixed evidence regarding neural change following cognitive training. Brain activation increase, decrease, or a combination of both may occur. We investigated training-induced neural change using two different memory training approaches., Methods: Very preterm born children (aged 7-12 years) were randomly allocated to a memory strategy training, an intensive working memory practice or a waiting control group. Before and immediately after the trainings and the waiting period, brain activation during a visual working memory task was measured using fMRI and cognitive performance was assessed., Results: Following both memory trainings, there was a significant decrease of fronto-parietal brain activation and a significant increase of memory performance. In the control group, no neural or performance change occurred after the waiting period., Conclusion: These pilot data point towards a training-related decrease of brain activation, independent of the training approach. Our data highlight the high training-induced plasticity of the child's brain during development.

Background: Treatment of complex intracranial aneurysms requires strategic pre-interventional or preoperative planning. In addition to modern three-dimensional (3D) rotational angiography, computed tomography angiography (CTA) or magnetic resonance angiogram (MRA), a solid, tangible 3D model may improve anatomical comprehension and treatment planning. A 3D rapid prototyping (RP) technique based on multimodal imaging data was evaluated for use in planning of treatment for complex aneurysmal configurations., Methods: Six patients with complex aneurysms were selected for 3D RP based on CTA and 3D rotational angiography data. Images were segmented using image-processing software to create virtual 3D models. Three-dimensional rapid prototyping techniques transformed the imaging data into physical 3D models, which were used and evaluated for interdisciplinary treatment planning., Results: In all cases, the model provided a comprehensive 3D representation of relevant anatomical structures and improved understanding of related vessels. Based on the 3D model, primary bypass surgery with subsequent reconstruction of the aneurysm was then considered advantageous in all but one patient after simulation of multiple approaches., Conclusions: Preoperative prediction of intraoperative anatomy using the 3D model was considered helpful for treatment planning. The use of 3D rapid prototyping may enhance understanding of complex configurations in selected large or giant aneurysms, especially those pretreated with clips or coils.

Purpose: Arterial spin labeling (ASL) magnetic resonance imaging to assess cerebral blood flow (CBF) is of increasing interest in basic research and in diagnostic applications, since ASL provides similar information to positron emission tomography about perfusion in vascular territories. However, in patients with steno-occlusive arterial disease (SOAD), CBF as measured by ASL might be underestimated due to delayed bolus arrival, and thus increased spin relaxation. We aimed to estimate the extent to which bolus arrival time (BAT) was delayed in patients with SOAD and whether this resulted in underestimation of CBF., Methods: BAT was measured using digital subtraction angiography (DSA) in ten patients with high-grade stenosis of the middle carotid artery (MCA). Regional CBF was assessed with pseudocontinuous ASL., Results: BATs were nonsignificantly prolonged in the stenotic hemisphere 4.1±2.0 s compared with the healthy hemisphere 3.3±0.9 s; however, there were substantial individual differences on the stenotic side. CBF in the anterior and posterior MCA territories were significantly reduced on the stenotic hemisphere. Severe stenosis was correlated with longer BAT and lower quantified CBF., Conclusion: ASL-based perfusion measurement involves a race between the decay of the spins and the delivery of labeled blood to the region of interest. Special caution is needed when interpreting CBF values quantified in individuals with altered blood flow and delayed circulation times. However, from a clinician's point of view, an accentuation of hypoperfusion (even if caused by underestimation of CBF due to prolonged BATs) might be desirable since it indexes potentially harmful physiologic deficits.

The West African cocoa belt, reaching from Sierra Leone to southern Cameroon, is the origin of about 70% of the world's cocoa (Theobroma cacao), which in turn is the basis of the livelihoods of about two million farmers. We analyze cocoa's vulnerability to climate change in the West African cocoa belt, based on climate projections for the 2050s of 19 Global Circulation Models under the Intergovernmental Panel on Climate Change intermediate emissions scenario RCP 6.0. We use a combination of a statistical model of climatic suitability (Maxent) and the analysis of individual, potentially limiting climate variables. We find that: 1) contrary to expectation, maximum dry season temperatures are projected to become as or more limiting for cocoa as dry season water availability; 2) to reduce the vulnerability of cocoa to excessive dry season temperatures, the systematic use of adaptation strategies like shade trees in cocoa farms will be necessary, in reversal of the current trend of shade reduction; 3) there is a strong differentiation of climate vulnerability within the cocoa belt, with the most vulnerable areas near the forest-savanna transition in Nigeria and eastern Côte d'Ivoire, and the least vulnerable areas in the southern parts of Cameroon, Ghana, Côte d'Ivoire and Liberia; 4) this spatial differentiation of climate vulnerability may lead to future shifts in cocoa production within the region, with the opportunity of partially compensating losses and gains, but also the risk of local production expansion leading to new deforestation. We conclude that adaptation strategies for cocoa in West Africa need to focus at several levels, from the consideration of tolerance to high temperatures in cocoa breeding programs, the promotion of shade trees in cocoa farms, to policies incentivizing the intensification of cocoa production on existing farms where future climate conditions permit and the establishment of new farms in already deforested areas., (Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.)

On 29 June 2015, Liberia's respite from Ebola virus disease (EVD) was interrupted for the second time by a renewed outbreak ("flare-up") of seven confirmed cases. We demonstrate that, similar to the March 2015 flare-up associated with sexual transmission, this new flare-up was a reemergence of a Liberian transmission chain originating from a persistently infected source rather than a reintroduction from a reservoir or a neighboring country with active transmission. Although distinct, Ebola virus (EBOV) genomes from both flare-ups exhibit significantly low genetic divergence, indicating a reduced rate of EBOV evolution during persistent infection. Using this rate of change as a signature, we identified two additional EVD clusters that possibly arose from persistently infected sources. These findings highlight the risk of EVD flare-ups even after an outbreak is declared over.

Background and Purpose: Five randomized controlled trials have consistently shown that mechanical thrombectomy (MT) in addition to best medical treatment (±intravenous tissue-type plasminogen activator) improves outcome after acute ischemic stroke in patients with large artery anterior circulation stroke. Whether direct MT is equally effective as combined intravenous thrombolysis with MT (ie, bridging thrombolysis) remains unclear., Methods: We retrospectively compared clinical and radiological outcomes in 167 bridging patients with 255 patients receiving direct MT because of large artery anterior circulation stroke. We matched all patients from the direct MT group who would have qualified for intravenous tissue-type plasminogen activator with controls from the bridging group, using multivariate and propensity score analyses. Functional independence was defined as modified Rankin Scale score of 0 to 2., Results: From February 2009 to August 2014, 40 patients from the direct MT group would have qualified for bridging thrombolysis but were treated with MT only. Clinical and radiological characteristics did not differ from the bridging cohort, except for higher rates of hypercholesterolemia (P=0.019), coronary heart disease (P=0.039), and shorter intervals from symptom onset to endovascular intervention (P=0.01) in the direct MT group. Functional independence, mortality, and intracerebral hemorrhage rates did not differ (P>0.1). After multivariate matching analysis outcome in both groups did not differ, except for lower rates of asymptomatic intracerebral hemorrhage (P=0.023) and lower mortality (P=0.007) in the direct MT group., Conclusions: In patients with large anterior circulation stroke, direct mechanical intervention seems to be equally effective as bridging thrombolysis. A randomized trial comparing direct MT with bridging therapy is warranted., (© 2016 American Heart Association, Inc.)

The increasing demand for agricultural commodities is a major cause of tropical deforestation. However, pressure is increasing for greater sustainability of commodity value chains. This includes the demand to establish new crop plantations and pasture areas on already deforested land so that new forest clearing for agriculture is minimized. Where tree crops are planted as part of agroforestry systems on deforested land, this amounts to a form of re-agro-forestation which can generate environmental benefits in addition to crop production. Here, we discuss a case where agroforestry systems based on cocoa ( Theobroma cacao ) are being established on crop and pasture land in the south of Pará state, Brazilian Amazon. The adoption of cocoa by farmers and ranchers of the region is stimulated by the coincidence of (1) favorable prospects for cocoa on the national and international markets including the expectation of a global cocoa supply gap; (2) environmental policies obliging land owners to reforest excess cleared land with native trees, with agroforests based on the native cocoa tree being an economically attractive option; and (3) biophysical conditions (especially soil fertility) favorable for growing cocoa in part of the region. We show that in the state of Pará at least 1.26 million hectares of naturally high-fertility soils in deforested areas outside legally protected and indigenous lands are potentially suitable for cocoa production with low agrochemical inputs, sufficient to make a significant contribution to closing the predicted supply gap. Their actual suitability depends on their state of degradation after years of pasture use and the availability of technologies and finance to convert them into tree crop agroforests. We discuss the significant environmental benefits of pasture re-agro-forestation with cocoa-based systems, including reduced emissions of up to 135 Mg of carbon per hectare compared to the historically common scenario of planting cocoa after forest clearing. We identify important research questions related to the scaling up of this practice and the maximization of its environmental benefits. We conclude that the coincidence of the afore-mentioned factors could drive a re-agro-forestation frontier in this part of the Amazon, with potential for positive outcomes in terms of commodity production while generating social and environmental benefits.