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Background and Purpose: Many patients with an acute stroke live in areas without ready access to a Primary or Comprehensive Stroke Center. The formation of care facilities that meet the needs of these patients might improve their care and outcomes and guide them and emergency responders to such centers within a stroke system of care., Methods: The Brain Attack Coalition conducted an electronic search of the English medical literature from January 2000 to December 2012 to identify care elements and processes shown to be beneficial for acute stroke care. We used evidence grading and consensus paradigms to synthesize recommendations for Acute Stroke-Ready Hospitals (ASRHs)., Results: Several key elements for an ASRH were identified, including acute stroke teams, written care protocols, involvement of emergency medical services and emergency department, and rapid laboratory and neuroimaging testing. Unique aspects include the use of telemedicine, hospital transfer protocols, and drip and ship therapies. Emergent therapies include the use of intravenous tissue-type plasminogen activator and the reversal of coagulopathies. Although many of the care elements are similar to those of a Primary Stroke Center, compliance rates of ≥67% are suggested in recognition of the staffing, logistical, and financial challenges faced by rural facilities., Conclusions: ASRHs will form the foundation for acute stroke care in many settings. Recommended elements of an ASRH build on those proven to improve care and outcomes at Primary Stroke Centers. The ASRH will be a key component for patient care within an evolving stroke system of care.

Stroke is the third leading cause of death in the United States, Canada, Europe, and Japan. According to the American Heart Association and the American Stroke Association, there are now 750,000 new strokes that occur each year, resulting in 200,000 deaths, or 1 of every 16 deaths, per year in the United States alone. Endovascular therapy for patients with acute ischemic stroke is an area of intense investigation. The American Stroke Association has given a qualified endorsement of intra-arterial thrombolysis in selected patients. Intra-arterial thrombolysis has been studied in 2 randomized trials and numerous case series. Although 2 devices have been granted FDA phase 3 approval with an indication for mechanical stroke thrombectomy, none of these thrombectomy devices has demonstrated efficacy for the improvement of patient outcomes. The purpose of the present document is to define what constitutes adequate training to perform neuroendovascular procedures in patients with acute ischemic stroke and what performance standards should be adopted to assess outcomes. These guidelines have been written and approved by multiple neuroscience societies that historically have been directly involved in the medical, surgical and endovascular care of patients with acute stroke. These organizations include the Neurovascular Coalition and its participating societies, including the Society of NeuroInterventional Surgery (SNIS), American Academy of Neurology (AAN), American Association of Neurological Surgeons/Cerebrovascular Section (AANS/CNS), and Society of Vascular & Interventional Neurology (SVIN).

Purpose of Review: Obesity is a chronic condition affecting children worldwide. However, the prevalence is higher in asthmatic children. Obese children most likely become obese adults. Understanding the clinical presentation of this subgroup is essential to their clinical management, now and in the future. This review highlights the most recent findings over the past 18 months in understanding the presentation and potential mechanisms of obesity in childhood asthma., Recent Findings: Recent research suggests that inhaled corticosteroid efficacy is reduced in obese asthmatic children whereas ventilatory function and bronchoreactivity appear to be marginally affected. A paucity of studies describing airway inflammation and lung volume measurements in this subgroup limits their clinical characterization. Recent studies indicate metabolic abnormalities that typically manifest with excess adiposity may be associated with asthma, providing an interesting factor in the asthma-obesity link. The inception, persistence and composition of obesity prove important considerations for future studies., Summary: Highlighted is the need for more descriptive airway inflammation studies, lung volume assessments and longitudinal studies to better characterize the obese asthma phenotype in children and understand the pathogenesis from childhood to adulthood. Understanding the manifestations and mechanisms of obese asthma in childhood will help direct clinical management and targeted therapeutic interventions.

Percutaneous vertebroplasty is a minimally invasive, radiologically-guided interventional procedure originally developed in France for the treatment of painful vertebral hemangiomas. The technique consists of the percutaneous puncture of the affected vertebral body, followed by injection of an acrylic polymer to provide bone augmentation and prevent further collapse. The internal "casting" of the trabecular microfractures results in pain relief and vertebral consolidation. Vertebroplasty was quickly adopted for use in metastatic vertebral lesions and hematologic malignancies such as multiple myeloma and lymphoma. The major experience with malignant disease has remained primarily in the European realm; in the United States vertebroplasty is used mainly for the treatment of osteoporotic compression fractures. The reasons underlying this divergence in practice experiences remains unclear, although the explosion of vertebroplasty in the U.S. appears to be driven by an assertive, motivated and well-informed elderly population. In addition, malignant lesions are often challenging and practitioners may shy away from these clinically and technically more difficult patients. The purpose of this article is to introduce the principles of percutaneous vertebroplasty to the North American oncologic community with the hope that it mayfind a greater role in the treatmentof malignant disease affecting the spine.

Recent trials have suggested that low-dose infusional 5-FU is more efficacious when given during radiotherapy than is bolus 5-FU. Additionally, intra-arterial cisplatin for brain tumors has been shown to be associated with both high response rates as well as significant toxicity. A dose escalation study was therefore performed using superselective carboplatin, a cisplatin analogue with a favorable CNS toxicity profile in combination with 6 weeks of infusional 5-FU at 225 mg/m2 and concurrent radiotherapy. Eight patients were treated at the starting dose of 200 mg/m2 carboplatin and 11 patients were treated at 300 mg/m2. No toxicity was observed that was attributable to infusional 5-FU. However, two ischemic events related to the superselective delivery of carboplatin were observed, and one patient was noted to have asymptomatic retinal toxicity from the carboplatin. Of 19 patients, 5 had objective responses with 25% or greater reduction in tumor volumes. Continuous infusional 5-FU can be given in combination with partial brain radiotherapy without significant toxicity. Superselective carboplatin delivery is associated with a low incidence of stroke, but no significant retinal toxicity.

We investigated the biochemical and clinical efficacy of dietary erucic acid (C22:1) therapy for X-linked adrenoleukodystrophy (ALD). In a double-blind crossover study of patients who were on chronic oleic acid (C18:1) therapy, addition of erucic acid to the diet led to a further reduction in plasma hexacosanoic acid (C26:0) concentration. We treated 12 newly diagnosed ALD patients with a diet enriched with erucic acid and oleic acid for 2 to 19 months. Mean plasma C26:0 concentration decreased to normal by 4 weeks, and the C26:0 composition of plasma sphingomyelin and phosphatidylcholine became normal by 4 months on therapy. Fatty acid analysis of postmortem tissues from 1 boy treated for 10 months suggested that dietary erucic acid entered the heart, liver, adrenal gland, and brain. Eight patients remained on treatment long enough (mean, 12 +/- 3 months) to evaluate their clinical response; 6 of these patients with moderate to advanced disease deteriorated neurologically or showed progression of white matter disease on brain magnetic resonance imaging whereas 2 mildly affected patients remained clinically stable after 10 and 19 months. No adverse effects of the diet occurred. We conclude that dietary erucic acid therapy is effective in lowering plasma C26:0 to normal in ALD patients, and may prevent further demyelination in some mildly affected boys.

We present a case of hemispherical spondylosclerosis (HSS) in a middle-aged woman with low back pain. The plain radiographic findings, CT and MR appearance, and pathological examination are described, and the difficulties encountered in differentiating HSS from malignancy and infection are discussed.