Search

Rapid reversal of coagulopathy is recommended in warfarin-associated intracerebral hemorrhage (WAICH). However, rapid correction of the INR has not yet been proven to improve clinical outcomes, and the rate of correction with fresh-frozen plasma (FFP) can be variable. We sought to determine whether faster INR reversal with FFP is associated with decreased hematoma expansion and improved outcome. We performed a retrospective analysis of a prospectively collected cohort of consecutive patients with WAICH presenting to an urban tertiary care hospital from 2000 to 2013. Patients with baseline INR > 1.4 treated with FFP and vitamin K were included. The primary outcomes are occurrence of hematoma expansion, discharge modified Rankin Scale (mRS), and 30-day mortality. The association between timing of INR reversal, ICH expansion, and outcome was investigated with logistic regression analysis. 120 subjects met inclusion criteria (mean age 76.9, 57.5% males). Median presenting INR was 2.8 (IQR 2.3–3.4). Hematoma expansion is not associated with slower INR reversal [median time to INR reversal 9 (IQR 5–14) h vs. 10 (IQR 7–16) h, p = 0.61]. Patients with ultimately poor outcome received more rapid INR reversal than those with favorable outcome [9 (IQR 6–14) h vs. 12 (8–19) h, p = 0.064). We find no evidence of an association between faster INR reversal and either reduced hematoma expansion or better outcome.

To better understand factors influencing spiritual care during critical illness, we examined the use of spiritual care in patients hospitalized with intracerebral hemorrhage (ICH), a frequently disabling and fatal disease. Specifically, the study was designed to examine which demographic and clinical characteristics were associated with chaplain visits to critically ill patients. The charts of consecutive adults (>18) with spontaneous ICH presenting to a single academic medical center between January 2014 and September 2015 were reviewed. Chaplains visited 86 (32%) of the 266 patients. Family requests initiated the majority of visits (57%). Visits were disproportionately to Catholic patients and those with more severe injury. Even among Catholics, 28% of those who died had no chaplaincy visit. Standardized chaplaincy screening methods and note templates may help maximize access to spiritual care and delineate the religious and spiritual preferences of patients and families.

Background: Atrial fibrillation (AF) has a substantial genetic basis. Identification of individuals at greatest AF risk could minimize the incidence of cardioembolic stroke. Methods: To determine whether genetic data can stratify risk for development of AF, we examined associations between AF genetic risk scores and incident AF in 5 prospective studies comprising 18 919 individuals of European ancestry. We examined associations between AF genetic risk scores and ischemic stroke in a separate study of 509 ischemic stroke cases (202 cardioembolic [40%]) and 3028 referents. Scores were based on 11 to 719 common variants (≥5%) associated with AF at P values ranging from −3 to −8 in a prior independent genetic association study. Results: Incident AF occurred in 1032 individuals (5.5%). AF genetic risk scores were associated with new-onset AF after adjustment for clinical risk factors. The pooled hazard ratio for incident AF for the highest versus lowest quartile of genetic risk scores ranged from 1.28 (719 variants; 95% confidence interval, 1.13–1.46; P =1.5×10 −4 ) to 1.67 (25 variants; 95% confidence interval, 1.47–1.90; P =9.3×10 −15 ). Discrimination of combined clinical and genetic risk scores varied across studies and scores (maximum C statistic, 0.629–0.811; maximum ΔC statistic from clinical score alone, 0.009–0.017). AF genetic risk was associated with stroke in age- and sex-adjusted models. For example, individuals in the highest versus lowest quartile of a 127-variant score had a 2.49-fold increased odds of cardioembolic stroke (95% confidence interval, 1.39–4.58; P =2.7×10 −3 ). The effect persisted after the exclusion of individuals (n=70) with known AF (odds ratio, 2.25; 95% confidence interval, 1.20–4.40; P =0.01). Conclusions: Comprehensive AF genetic risk scores were associated with incident AF beyond associations for clinical AF risk factors but offered small improvements in discrimination. AF genetic risk was also associated with cardioembolic stroke in age- and sex-adjusted analyses. Efforts are warranted to determine whether AF genetic risk may improve identification of subclinical AF or help distinguish between stroke mechanisms.

BACKGROUND: Chronic urticaria (CU) is characterized by the recurrence of itchy hives and/or angioedema for more than 6 weeks. AWARE (A World-wide Antihistamine-Refractory Chronic Urticaria Patient Evaluation) is a multinational study designed to document the real-life treatment situation, burden of disease and clinical resource usage of H1-antihistamine-refractory CU patients.OBJECTIVE: To examine baseline data from Scandinavian AWARE patients.METHODS: AWARE is a prospective, non-interventional, multinational, umbrella design study, which includes adults (≥18 years) with a confirmed CU diagnosis (>2 months) that is refractory to H1-antihistamines. Baseline patient characteristics, disease activity (urticaria control test [UCT]), pharmacological treatment, comorbidities and healthcare usage were documented by the treating physician. Quality of life (QoL; dermatology life quality index [DLQI]; chronic urticaria quality of life questionnaire [CU-Q2 oL; Danish patients only]) and work productivity and activity impairment (WPAI) scores were also assessed.RESULTS: Overall, 158 CU patients from seven centres in Denmark (n = 80), Norway (n = 50) and Sweden (n = 28) were included in this baseline analysis. Mean age and BMI were 40.3 years and 26.5 kg/m(2) , respectively. The majority of patients were female (69.6%), had uncontrolled CU (75.6%; UCT score CONCLUSION: Adult Scandinavian H1-antihistamine-refractory CU patients reported high rates of healthcare usage and QoL impairment. Rates of pharmacological treatment use were low before study enrolment but increased to almost 100% during the baseline visit.

OBJECTIVE To develop a research priority list for the International Stroke Genetics Consortium (ISGC). BACKGROUND Previously, stroke progress review groups and other activities provided an opportunity for members within the field to develop priorities for research. These filtered into larger categories which then published the top research priorities of their given field. However, these review groups are no longer forming and thus there has been no clear direction on what the research priorities and needs for stroke genetics research. DESIGN/METHODS We polled members of the stroke genetics community from around the world including collaborations of the major stroke genetics research efforts currently under way asking each respondent to provide their top 3 research priorities. Each priority was then sorted by the authors into major categories based upon the type of suggestion made. The results were presented for commentary and feedback during the presentation. RESULTS Deeper Phenotyping related topics were presented in 84% of respondent top research priorities. These included topics related to ethnic/racial variation, third world countries, deeper evaluation of subtypes of stroke. Translational science related topics were present in 40% of respondent top research priorities and consisted of translating our current findings into a greater understanding of their relationship to stroke and clinical pathophysiology. Pooling of our resources through data banking and sample banking was a topic in 36% of respondents. Recovery/outcome related topics were suggested in 32% of respondents and utilizing novel techniques such as epigenetics, whole genome sequencing, proteomics and metabolomics were present in 28% of respondents. Other topics were not present in more than 25% of the responses for top research priorities. CONCLUSIONS To summarize, greater sample size and research within subtypes and endophenotypes of stroke was the top research priority of the ISGC. In addition, translating our existing findings, pooling our resources, recovery/outcomes research and utilization of novel techniques were among the top research priorities of the ISGC. A working group will be assembled to draft the ISGC Research Priorities paper.

BACKGROUNDS AND PURPOSE: Although new methods for genetic analyses are rapidly evolving, there are currently knowledge gaps in how to detect Mendelian forms of stroke. METHODS: We performed whole exome sequencing (WES) in 22 probands, under 56 years at their first ischemic stroke episode, from multi-incident stroke families. With the use of a comprehensive stroke-gene panel we searched for variants in stroke-related genes. The probands’ clinical stroke subtype was related to clinical characteristics previously associated with pathogenic variants in these genes. Relatives were genotyped in seven families to evaluate stroke-gene variants of unknown significance. In two larger families with embolic stroke of unknown source (ESUS), WES was performed in additional members to examine the possibility to identify new stroke-genes. RESULTS: Six of 22 probands carried pathogenic or possibly pathogenic variants in genes reported to be associated with their stroke subtype. A known pathogenic variant in NOTCH3 and a possibly pathogenic variant in ACAD9 gene were identified. A novel JAK2:c.3188G>A (p.Arg1063His) mutation was seen in a proband with ESUS and pro-thrombotic status. However, penetrance in the family was incomplete. COL4A2:c.3368A>G (p.Glu1123Gly) was detected in two probands but did not co-segregate with the disease in their families. WES in multiple members of two pedigrees with ESUS revealed possibly pathogenic variants in genes not previously associated with stroke, GPR142:c.148C>G (p.Leu50Val), and PTPRN2:c.2416A>G (p.Ile806Val); LRRC1 c.808A>G (p.Ile270Val), SLC7A10c.1294dupG (p.Val432fs), IKBKB: c.1070C>T (p.Ala357Val), and OXGR1 c.392G>A (p.Arg131His), respectively. CONCLUSIONS: Screening with WES using a comprehensive stroke-gene panel may identify rare monogenic forms of stroke, but careful evaluation of clinical characteristics and potential pathogenicity of novel variants remain important. In our study, the majority of individuals with familial aggregation of stroke lacked any identified genetic causes.

Background and Purpose— In this study, we aim to investigate the association of computed tomography–based markers of cerebral small vessel disease with functional outcome and recovery after intracerebral hemorrhage. Methods— Computed tomographic scans of patients in the ERICH study (Ethnic and Racial Variations of Intracerebral Hemorrhage) were evaluated for the extent of leukoaraiosis and cerebral atrophy using visual rating scales. Poor functional outcome was defined as a modified Rankin Scale (mRS) of ≥3. Multivariable logistic and linear regression models were used to explore the associations of cerebral small vessel disease imaging markers with poor functional outcome at discharge and, as a measure of recovery, change in mRS from discharge to 90 days poststroke. Results— After excluding in-hospital deaths, data from 2344 patients, 583 (24.9%) with good functional outcome (mRS of 0–2) at discharge and 1761 (75.1%) with poor functional outcome (mRS of 3–5) at discharge, were included. Increasing extent of leukoaraiosis ( P for trend, 0.01) and only severe (grade 4) global atrophy (odds ratio, 2.02; 95% CI, 1.22–3.39, P =0.007) were independently associated with poor functional outcome at discharge. Mean (SD) mRS change from discharge to 90-day follow-up was 0.57 (1.18). Increasing extent of leukoaraiosis ( P for trend, 0.002) and severe global atrophy (β [SE], −0.23 [0.115]; P =0.045) were independently associated with less improvement in mRS from discharge to 90 days poststroke. Conclusions— In intracerebral hemorrhage survivors, the extent of cerebral small vessel disease at the time of intracerebral hemorrhage is associated with poor functional outcome at hospital discharge and impaired functional recovery from discharge to 90 days poststroke.

Background Previous studies assessing the association between body mass index ( BMI ) and atrial fibrillation ( AF ) did not account for time‐varying covariates, which may be affected by previous BMI . We illustrate how the g‐formula can account for time‐varying confounding. Methods and Results We included 4392 participants from the Framingham Heart Study who were AF free at ages 45 to 55 years, and followed them for up to 20 years. We estimated hazard ratios ( HR s) comparing time‐varying nonobese versus obese with Cox models. We used the g‐formula to compare nonobese versus obese and 10% annual decrease in BMI (until normal weight is reached) versus natural course. We estimated HR s and differences in restricted mean survival times, the mean difference in time alive and AF free. We adjusted for sex, age, and time‐varying risk factors. Cox models indicated that nonobese participants had a decreased rate of AF versus obese participants ( HR , 0.83; 95% CI , 0.72–0.97). G‐formula analyses comparing everyone had they been nonobese versus obese yielded stronger associations ( HR , 0.73; 95% CI , 0.58–0.91). The restricted mean survival time was 19.22 years had everyone been nonobese and 19.03 years had everyone been obese (difference, 2.25 months; 95% CI, −0.66 to 5.16). When assessing a 10% annual decrease in BMI , the association was weaker ( HR 0.96; 95% CI , 0.86–1.08). Conclusions Decreased BMI was associated with a lower rate of AF after accounting for time‐varying covariates that depend on previous exposure using the g‐formula, which Cox models cannot accommodate. Absolute measures like the restricted mean survival time difference offer context to relative measures of association.

BACKGROUND: Early diagnosis of atrial fibrillation (AF) and treatment with anticoagulation may prevent strokes. OBJECTIVES: To determine whether AF risk can be estimated accurately using routinely ascertained features in the electronic health record (EHR) and whether AF risk associates with stroke. METHODS: Using a multi-institutional EHR, we identified 412,085 individuals aged 45–95 without prevalent AF between 2000–2014. We derived and validated a prediction model for five-year AF risk using split-sample validation, and compared model performance with other methods of AF risk assessment. RESULTS: Within five years, 14,334 individuals developed AF. In the derivation sample (n=7,216 AF events/206,042 total), the optimal risk model included: sex, age, race, smoking, height, weight, diastolic blood pressure, hypertension, hyperlipidemia, heart failure, coronary heart disease, valvular disease, prior stroke, peripheral arterial disease, chronic kidney disease, hypothyroidism, and quadratic terms for height, weight, and age. In the validation sample (n=7,118 AF events/206,043 total) the AF risk model demonstrated good discrimination (C-statistic 0.777, 95%CI 0.771–0.783) and calibration (0.99, 95%CI 0.96–1.01). Model discrimination and calibration were favorable to CHARGE-AF (C-statistic 0.753, 95%CI 0.747–0.759;calibration slope 0.72, 95%CI 0.71–0.74), C(2)HEST (C-statistic 0.754, 95%CI 0.747–0.762;calibration slope 0.44, 95%CI 0.43–0.45), and CHA(2)DS(2)-VASc (C-statistic 0.702, 95%CI 0.693–0.710;calibration slope 0.37, 95%CI 0.36–0.38). AF risk discriminated incident stroke (n=4,814, C-statistic 0.684; 95%CI 0.677–0.692) and stroke within 90 days of incident AF (n=327, C-statistic 0.789; 95%CI 0.764–0.814). CONCLUSIONS: A model developed in a real-world EHR predicted AF accurately and stratified stroke risk. Incorporating AF prediction into EHRs may enable risk-guided screening for AF. Condensed Abstract: Early diagnosis of atrial fibrillation (AF) and treatment with anticoagulation may prevent strokes. We sought to determine whether AF risk can be estimated accurately using routinely ascertained features in the electronic health record (EHR). Within a large multi-institutional EHR sample including over 400,000 individuals, we derived and validated a prediction model for five-year AF risk and compared model performance to alternative methods of AF risk estimation. The model exhibited good discrimination and calibration, performing favorably to CHARGE-AF, C(2)HEST, and CHA(2)DS(2)-VASc. Accurate estimation of AF risk in a real-world EHR is feasible and may enable risk-guided screening for AF.

Supplemental Digital Content is available in the text., Background: Hyaluronic acid (HA), a large glycosaminoglycan involved in proliferation, migration, and tissue repair, is suggested to be an important factor for keratinocyte activation and re-epithelialization. The experimental hypothesis of this study was that HA accelerates re-epithelialization, and we aimed to investigate the effect of exogenous intradermal HA during deep dermal, incisional wound healing in vivo in humans, the primary endpoint being re-epithelialization. Methods: A total of 8 standardized deep dermal incisional wounds (depth 1.6 mm, width 1.8 mm) per subject were induced in 10 healthy volunteers. Two of the wound sites per subject were pretreated with injections of HA and 2 with saline solution. At 2 time points (24 hours and 14 days), 2 biopsies for each treatment group (one for histology and one for proteomics) were taken. Skin erythema was measured at 24-hour intervals for 14 days as a surrogate measurement of inflammation. Results: At 24 hours, 8 of 9 wounds pretreated with HA showed complete re-epithelization, whereas none of the wounds pretreated with saline had re-epithelized. Wounds pretreated with HA also showed a 10-fold regulation of 8 identified proteins involved in wound healing compared to wounds treated with saline solution. No difference in inflammation, as measured as erythema, could be seen between any of the groups. Conclusions: We conclude that HA accelerates re-epithelialization and stimulates an altered protein expression in vivo in human deep dermal incisional skin wounds, but has no effect on the inflammation process as measured by erythema.

Obesity is the predominant cause of non-alcoholic fatty liver disease (NAFLD), which is associated with insulin resistance and diabetes. NAFLD includes a spectrum of pathologies that starts with simple steatosis, which can progress to non-alcoholic steatohepatitis (NASH) with the commission of other factors such as the enhancement of reactive oxygen species (ROS). Biliverdin reductase A (BVRA) reduces biliverdin to the antioxidant bilirubin, which may serve to prevent NAFLD, and possibly the progression to NASH. To further understand the role of BVRA in hepatic function, we used CRISPR-Cas9 technology to target the Blvra gene in the murine hepa1c1c7 hepatocyte cell line (BVRA KO). BVRA activity and protein levels were significantly lower in BVRA KO vs. wild-type (WT) hepatocytes. Lipid accumulation under basal and serum-starved conditions was significantly (p 0.05) higher in BVRA KO vs. WT cells. The loss of BVRA resulted in the reduction of mitochondria number, decreased expression of markers of mitochondrial biogenesis, uncoupling, oxidation, and fusion, which paralleled reduced mitochondrial oxygen consumption. BVRA KO cells exhibited increased levels of ROS generation and decreased levels of superoxide dismutase mRNA expression. In conclusion, our data demonstrate a critical role for BVRA in protecting against lipid accumulation and oxidative stress in hepatocytes, which may serve as a future therapeutic target for NAFLD and its progression to NASH.

Background: Observational studies found an inverse correlation between cholesterol levels and risk of spontaneous intracerebral hemorrhage (ICH). We investigated whether the cumulative burden of known genetic risk loci for cholesterol levels influences the risk of sustaining an ICH. Methods: We utilized genetic risk scores (GRSs) to model the cumulative burden of cholesterol-related common genetic variants (CGVs). GRSs were constructed using an approach that allows the implementation of GRS analysis by combining summary statistics from GCVs known to influence the exposure (cholesterol levels) and outcome (ICH) of interest. Summary statistics were identified and abstracted using the Cerebrovascular Disease Knowledge Portal. For cholesterol levels (derivation dataset), we abstracted summary statistics for independent CGVs associated with cholesterol levels at p-5 in a large genetic meta-analysis that included data from Kaiser Permanente, UK Biobank and Global Lipids Genetics Consortium. We excluded CGVs at CETP , a cholesterol-related locus known to modify ICH risk. For ICH (testing dataset), we abstracted summary statistics from a meta-analysis of 5 genetic studies. Results: We identified 711 CGVs associated with cholesterol levels in the derivation dataset (study population 76,627, mean age 56 [SD 9], female sex 44,856 [59%]). Summary statistics were available for 468 of these CGVs in the ICH testing dataset (study population 3,026, mean age 67 [SD 10], female sex 1,362 [45%]). The GRSs for total cholesterol (OR 0.87, 95%CI 0.73-1.01; p =0.04), LDL (OR 0.78, 95%CI 0.65-0.91; p =0.0002) and triglycerides (OR 1.18, 95%CI 1.04-1.32; p =0.02) were associated with risk of all ICH. After stratifying by location, the association became stronger for deep ICH and total cholesterol (OR 0.77, 95%CI 0.61-0.93; p =0.001) and LDL (OR 0.70, 95%CI 0.55-0.85; p =8x10 -6 ). Only the triglycerides-based GRS was associated with lobar ICH (OR 1.26, 95%CI 1.08-1.44; p =0.01). Conclusions: The cumulative burden of cholesterol-related mutations is associated with risk of ICH. Our results point to an inverse correlation between genetically-determined total cholesterol and LDL levels and ICH risk. These associations are stronger for deep ICH.

Background and Objective: Cerebral small vessel disease (CSVD) is a chronic, cumulative cerebrovascular disease and is the most common cause of intracerebral hemorrhage (ICH). The effects of pre-existing CSVD on the severity of acute ICH are incompletely understood. We aim to clarify associations between computed tomography (CT) markers of CSVD and 1) acute ICH volume and 2) presence and severity of concomitant intraventricular hemorrhage (IVH). Methods: Baseline CT scans of patients from the Ethnic and Racial Variations of Intracerebral Hemorrhage (ERICH) study were evaluated for the extent of leukoaraiosis and cerebral atrophy using visual rating scales and for the Graeb Score, as a measure of IVH severity. ICH volume was measured on baseline CT scans using semi-automated software. The associations of leukoaraiosis and atrophy and ICH volume, IVH presence and the Graeb Score were tested using multivariable linear, ordinal and binary logistic regression models. Secondary analyses were stratified by hemorrhage location (lobar versus non-lobar). Bonferroni correction was applied. Results: The study included 2579 patients, 774 (30.0%) with a lobar ICH and 1805 (70.0%) with a non-lobar ICH. Median ICH volume was higher for lobar ICH and non-lobar ICH was more frequently associated with IVH. Increasing grades of central, cortical and total atrophy were inversely and dose-dependently associated with baseline ICH volume (P for trend Conclusions: In this study, increasing grades of cerebral atrophy were associated with smaller ICH volume and decreased risk of IVH presence and severity, while increasing extent of leukoaraiosis was associated with higher risk of IVH. These findings suggest that cerebral atrophy might be protective in the setting of acute ICH. Future studies are needed to confirm our findings and identify the underlying mechanisms.

Introduction: Oldest old (age ≥80 years) survivors of Intracerebral Hemorrhage (ICH) may be at higher risk for stroke recurrence, reflecting increasing hypertension severity with aging. Dedicated longitudinal studies of ICH in the oldest old are lacking, yet urgently needed as they represent an ever-increasing proportion of survivors. We sought to determine whether: 1) oldest old ICH survivors are at higher risk for stroke recurrence; 2) hypertension severity accounts for disparities in stroke recurrence risk across age categories. Methods: We analyzed data from survivors of primary ICH, enrolled in a single-center prospective study. Exposures of interest include patients’ demographics, medical history, ICH characteristics, Blood Pressure (BP) measurements and medications exposures during follow-up. Outcomes of interest included ICH and/or ischemic stroke events during follow-up. Results: We enrolled 1464 ICH survivors (441 ≥80 years and 1023 Conclusion: Oldest old ICH survivors are more likely to be female, white non-Hispanic, to present with lobar ICH, and to demonstrate inadequate blood pressure control. They are at higher risk for stroke recurrence, with hypertension severity playing a pivotal role. Future ICH studies will benefit from focusing on blood pressure control among oldest old survivors.

Background: Intracerebral hemorrhage (ICH) and small vessel ischemic stroke (SVS) are the most severe manifestation of cerebral small vessel disease (CSVD) with no established preventive approaches beyond hypertension management. Cross-phenotype analysis of these two correlated diseases will improve statistical power to detect novel genetic factors for CSVD, elucidating underlying disease mechanisms that may form the basis for future treatments. Methods: We performed genome-wide association studies (GWAS) for ICH by location in 1,813 ICH patients (797 lobar and 1,005 nonlobar) and 1,711 stroke-free controls after imputation using Haplotype Reference Consortium reference panels. Each ICH GWAS by location was meta-analyzed with GWAS summary statistics for SVS from MEGASTROKE ( Malik et al. 2018 ), using “Multi-Trait Analysis of GWAS” (MTAG; Turley et al. 2018 ) to integrate GWAS summary data across traits and generate combined trait-specific effect estimates. Results: By combining GWAS datasets using MTAG, our functional sample size increased to 241,024 participants (6,255 ICH or SVS cases and 234,769 controls). Genome-wide significant (P < 5x10 -8 ) associations were observed for the nonlobar ICH model enhanced by SVS with 1) rs2758605 (MTAG P-value [P] = 2.6x10 -11 ) at 1q22; 2) rs72932727 (P = 1.7x10 -8 ) at 2q33; and 3) rs9515201 (P = 5.3x10 -10 ) at 13q34. The MTAG association strengths of these loci were at least one order of magnitude more significant than those from their individual GWAS. According to the GTEx database, rs2758605 (1q22), rs72932727 (2q33) and rs9515201 (13q34) are significant cis-eQTLs for PMF1 (P = 1x10 -4 in nerve), NBEAL1 , ICA1L , and CARF (P < 7.7x10 -7 in artery tibial) and COL4A2 and COL4A1 (P < 0.008 in thyroid), respectively. Conclusion: Our cross-phenotype study of ICH and SVS reveals two novel CSVD loci, including 2q33 and 13q34. The 2q33 locus was recently identified in a GWAS of white matter hyperintensity burden ( Jian et al. 2018 ). We also identified the same PMF1 association as previously seen in ICH ( Woo et al. 2014 ), supporting the validity of this novel multi-trait approach. We have begun to replicate these associations and to identify functional causal variants in independent whole genome sequencing studies of ICH.

Introduction: Oral Anticoagulation Therapy (OAT) resumption after ICH is a dilemma due to increased risk of recurrent ICH, particularly after lobar ICH caused by underlying Cerebral Amyloid Angiopathy (CAA). Apolipoprotein E ( APOE ) ε2/ε4 alleles are risk factors for recurrent CAA-related ICH. Hypothesis: APOE genotype predicts lobar ICH recurrence after OAT-ICH. Methods: We enrolled survivors of lobar OAT-ICH in a prospective single-center study to determine whether APOE ε2/ε4: 1) are associated with ICH recurrence following OAT-ICH, using time-to-event analyses; 2) improved prediction of ICH recurrence when added to MRI-based CAA markers (cerebral microbleeds [CMBs], white matter hyperintensities [WMH], expanded peri-vascular spaces [EPVS], and cortical superficial siderosis [CSS]), using Harrell’s C-statistic; 3) could be incorporated in a classification scheme to predict ICH recurrence, as defined by recursive partitioning analysis (RPA). Results: We followed 110 lobar OAT-ICH survivors for a median time of 52.2 months (IQR: 33.5-61.7). We observed 26 recurrent ICH events, corresponding to an annual recurrence rate of 5.7%. APOE ε2/ε4 variants were associated with ICH recurrence following OAT-ICH (ε2: HR 2.14, 95% CI 1.20-3.82; ε4: HR 1.50, 95% CI 1.21-3.47). These associations remained significant after adjusting for anticoagulation status, antiplatelet use, CMBs, WMH, EPVS, and CSS. Inclusion of APOE genotype alongside MRI data resulted in improved predictive ability for ICH recurrence (Harrell’s C: 0.76 vs. 0.68, p=0.034). RPA revealed that APOE ε2/ε4 stratified likelihood of ICH recurrence among otherwise low risk individuals based on MRI data alone (Figure). Conclusions: APOE genotype predicts lCH recurrence following lobar OAT-ICH, and improves predictive performance when added to established neuroimaging markers. APOE-based lobar ICH recurrence prediction warrants further investigation and may affect clinical practice.

Introduction: Survivors of Intracerebral Hemorrhage (ICH) are at high risk for cognitive impairment. Previous studies clarified that Cerebral Small Vessel Disease (CSVD) is a primary contributor to post-ICH dementia, but these observations have failed to transform clinical or research practice standards to date. We sought to determine whether a validated MRI CSVD scoring system could readily predict cognitive impairment after ICH. Methods: We analyzed data from ICH survivors with no history of prior cognitive impairment, enrolled in a single-center prospective study. We reviewed MRI scans to compute: 1) a validated 6-point score for CSVD burden based on presence of microbleeds, white matter hyperintensities, lacunes and >20 basal ganglia enlarged perivascular spaces; 2) cortical atrophy. We quantified cognitive performance by: 1) administering the Telephone Interview for Cognitive Status (TICS) test; 2) identifying diagnosis of dementia based on medical records. We utilized linear mixed model analyses to identify predictors of changes in TICS score, and Cox regression to identify predictors of new-onset dementia. We calculated CSVD score cut-offs to maximize sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for diagnosis of dementia. Results: We enrolled 612 primary ICH survivors, and followed them for a median of 46.3 months (Inter-Quartile Range: 35.5-58.7). A total of 214/612 (35%) participants developed dementia. Increasing CSVD scores were associated with faster cognitive decline (Coeff -0.25, Standard Error 0.02) and dementia diagnosis (Hazard Ratio 1.33, 95% CI 1.08-1.64). Age, increasing atrophy scale score, lower TICS score at baseline and systolic blood pressure were also independently associated with faster cognitive decline and new-onset dementia (all p Conclusion: This validated CSVD score is strongly associated with cognitive performance after ICH, with excellent predictive performance for future diagnosis of dementia. Our results support its implementation in clinical care and in future studies of post-ICH dementia.

Introduction: Identification of patients with stroke from large vessel occlusion (LVO), including into extended time windows, is a current medical imperative. Capacity challenges limit transfer of all patients with clinical deficit to receiving hospitals, while referring hospitals desire patient retention if transfer is not indicated. The use of CT angiography (CTA) provides the most reliable option for LVO screening at the referring hospital. We evaluate the utilization of CTA within our Telestroke network. Methods: A CTA protocol was developed for Telestroke referring hospitals and disseminated through the network (25 centers) in a staggered fashion. CTA was encouraged for all patients with NIHSS of ≥6 and presentation Results: Prior to the protocol implementation CTA was utilized at none of the Telestroke referring hospitals. The CTA protocol was disseminated by March 2018. Between March and August 2018 there were a total of 623 Telestroke consults (185 video); 75 patients met inclusion criteria. CTA was obtained by the referring hospital in 65 cases (86%). Reasons for not obtaining a referring hospital CTA were vascular anatomical complexities (aortic dissection, multiple systemic emboli) in 2 patients, medical comorbid concerns (anaphylaxis with prior contrast, endocarditis, hemodynamic instability) in 3 patients, transfer to a different facility (2 patients), declined by family, and not indicated based on Telestroke video evaluation due to lacunar syndrome (1 patient each). Of patients with CTAs, 34 remained at the referring hospital (52%) based on CTA findings. Conclusions: We demonstrate a pragmatic approach to the challenge of LVO triage up to 24 hours within the tele-stroke network. Our approach demonstrated high rates of CTA adoption within a short timeframe (5 months), and may provide a model to be replicated in other Telestroke environments. While retention rates of over 52% at the referring hospital are encouraging, subsequent data will provide information regarding further triage implications for these patients.

Introduction: Previous studies have shown conflicting results regarding the risk of symptomatic intracerebral hemorrhage (sICH) following thrombolysis for acute ischemic stroke in the setting of dual antiplatelet therapy (DAPT) use prior to the index stroke. We explored the temporal trend in the rates of sICH and the safety of IV tPA among patients treated with thrombolytics while on DAPT. Methods: Using local GWTG stroke registry data from three large comprehensive stroke centers in Northeast, South and West, we included 2,851 confirmed stroke patients who received tPA from 01/2008 - 06/2018 and plotted the temporal trend of sICH frequency over time, using the GWTG definition of ICH documented by imaging within 36 hours of thrombolysis and with clinical deterioration attributable to hemorrhage. We compared rates of sICH and serious systemic hemorrhage (>3 transfused units of blood within 7 days) between 3 groups of patients stratified by prior antiplatelet use: Group 1- no antiplatelet use, Group 2- monotherapy, Group 3 - DAPT. Results: Of the total 2,851 patients treated with IV tPA, 132 (4.6%) had sICH and 27 (0.9%) had serious systemic hemorrhage. Temporal trends showed a decrease in the overall rates of sICH from 2008 to 2017. The proportion of cases differed by group with 68.7% in Group 1, 31.3% in Group 2 and 4.0% in Group 3. Within Group 2, aspirin was the most common drug (28.1% Aspirin, 2.5% Clopidogrel, 0.7% others). Rates of sICH did not differ by Group (4.5%, 4.8% and 3.5% in Group 1, 2 and 3 respectively (NS). Conclusion: Rates of sICH after IV tPA decreased overtime in our centers, perhaps due to tPA use in milder stroke patients, and better patient selection and post-tPA management. The rate of sICH was similar in patients with no, single or dual antiplatelet therapy before the stroke, suggesting that the concurrent use of DAPT is not a concern prior to thrombolysis. Further studies are needed to confirm our findings.

Introduction: Risk of lobar and non-lobar intracerebral hemorrhage (ICH) varies among blacks, whites and Hispanics. We sought to determine whether these differences could be due to variability in the effects of Apolipoprotein E (APOE) epsilon (ε) alleles, the most potent genetic risk factor for ICH. Methods: Primary ICH cases and controls were collected from US and European sites contributing to the International Stroke Genetic Consortium (ISGC). We meta-analyzed the effects of APOE allele status on ICH risk applying a two-stage clustering approach based on race/ethnicity and the contributing study. Models were adjusted for age, sex, history of hypertension, hypercholesterolemia, warfarin, statin and antiplatelet use, smoking and alcohol use. A propensity score analysis was used to model the influence of APOE against the burden of hypertension across races/ethnicities. Results: 13,124 subjects (54.5% male, median age 66 years) were included. In whites, APOE ε2 (odds ratio (OR)=1.85, 95% confidence interval (CI)=1.27-2.69, p Conclusion: APOE ε4 and ε2 alleles affect lobar ICH risk variably by race and ethnicity. Associations are confirmed in whites but can be shown in Hispanics only when the excess burden of hypertension is propensity score-matched. Further studies are needed to explore interactions between APOE alleles and environmental exposures that vary by race and ethnicity in representative populations at risk for ICH.

Introduction: Intracerebral hemorrhage (ICH) is the most severe subtype of stroke with a high mortality rate and majority of survivors suffering significant disability. The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study prospectively recruited 1000 white, 1000 black and 1000 Hispanic spontaneous ICH cases. Herein, we report the main results of the predictors of 3 month outcome after ICH. Hypothesis: We hypothesized that ICH Score variables of age, ICH volume, ICH location, presence of intraventricular hemorrhage (IVH), and presenting Glasgow Coma Scale would predict long-term disability in addition to prior validation of mortality. Methods: Between 2010-2015, cases were prospectively recruited with uniform phenotype definitions, centralized neuroimaging review and with telephone follow-up at 3 months. Apolipoprotein E genotyping was performed centrally. Individual characteristics were screened for association under a logistic regression model, 90-day mRS ≥ 4 versus 0-3, and those meeting P Results: The Table presents the prevalence/average of each variable entering the final multivariate model for association with poor (mRS 4-6) compared to good (mRS 0-3) outcome at 3 months. When analyses were repeated excluding withdrawal of care, overall Graeb (IVH) score fell out of the model (with presence of IVH replacing it) but the remaining variables were retained and in the same direction of effect. C-statistic for the multivariate model = 0.884 compared to 0.763 for ICH score alone (p=1.7E-22). Conclusion: ICH score elements were validated as predictive of 3 month outcome. Novel baseline characteristics such as white matter hyperintensity as well as subsequent clinical events that may affect outcomes were identified. Location specific results to be presented.

Skin-targeting microscale medical devices are becoming popular for therapeutic delivery and diagnosis. We used cryo-SEM, fluorescence lifetime imaging microscopy (FLIM), autofluorescence imaging microscopy and inflammatory response to study the puncturing and recovery of human skin ex vivo and in vivo after discretised puncturing by a microneedle array (Nanopatch®). Pores induced by the microprojections were found to close by ~25% in diameter within the first 30 min, and almost completely close by ~6 h. FLIM images of ex vivo viable epidermis showed a stable fluorescence lifetime for unpatched areas of ~1000 ps up to 24 h. Only the cells in the immediate puncture zones (in direct contact with projections) showed a reduction in the observed fluorescence lifetimes to between ~518–583 ps. The ratio of free-bound NAD(P)H (α1/α2) in unaffected areas of the viable epidermis was ~2.5–3.0, whereas the ratio at puncture holes was almost double at ~4.2–4.6. An exploratory pilot in vivo study also suggested similar closure rate with histamine administration to the forearms of human volunteers after Nanopatch® treatment, although a prolonged inflammation was observed with Tissue Viability Imaging. Overall, this work shows that the pores created by the microneedle-type medical device, Nanopatch®, are transient, with the skin recovering rapidly within 1–2 days in the epidermis after application. Refereed/Peer-reviewed

Skin microdialysis (SMD) is a versatile sampling technique that can be used to recover soluble endogenous and exogenous molecules from the extracellular compartment of human skin. Due to its minimally invasive character, SMD can be applied in both clinical and preclinical settings. Despite being available since the 1990s, the technique has still not reached its full potential use as a tool to explore pathophysiological mechanisms of allergic and inflammatory reactions in the skin. Therefore, an EAACI Task Force on SMD was formed to disseminate knowledge about the technique and its many applications. This position paper from the task force provides an overview of the current use of SMD in the investigation of the pathogenesis of chronic inflammatory skin diseases, such as atopic dermatitis, chronic urticaria, psoriasis, and in studies of cutaneous events during type 1 hypersensitivity reactions. Furthermore, this paper covers drug hypersensitivity, UVB-induced- and neurogenic inflammation, and drug penetration investigated by SMD. The aim of this paper is to encourage the use of SMD and to make the technique easily accessible by providing an overview of methodology and applications, supported by standardized operating procedures for SMD in vivo and ex vivo. Electronic supplementary material The online version of this article (10.1186/s13601-019-0262-y) contains supplementary material, which is available to authorized users.

Background: Genome-wide association studies have identified multiple loci associated with stroke. However, the specific stroke subtypes affected, and whether loci influence both ischemic and hemorrhagic stroke, remains unknown. For loci associated with stroke, we aimed to infer the combination of stroke subtypes likely to be affected, and in doing so assess the extent to which such loci have homogeneous effects across stroke subtypes. Methods: We performed Bayesian multinomial regression in 16 664 stroke cases and 32 792 controls of European ancestry to determine the most likely combination of stroke subtypes affected for loci with published genome-wide stroke associations, using model selection. Cases were subtyped under 2 commonly used stroke classification systems, TOAST (Trial of Org 10172 Acute Stroke Treatment) and causative classification of stroke. All individuals had genotypes imputed to the Haplotype Reference Consortium 1.1 Panel. Results: Sixteen loci were considered for analysis. Seven loci influenced both hemorrhagic and ischemic stroke, 3 of which influenced ischemic and hemorrhagic subtypes under both TOAST and causative classification of stroke. Under causative classification of stroke, 4 loci influenced both small vessel stroke and intracerebral hemorrhage. An EDNRA locus demonstrated opposing effects on ischemic and hemorrhagic stroke. No loci were predicted to influence all stroke subtypes in the same direction, and only one locus (12q24) was predicted to influence all ischemic stroke subtypes. Conclusions: Heterogeneity in the influence of stroke-associated loci on stroke subtypes is pervasive, reflecting differing causal pathways. However, overlap exists between hemorrhagic and ischemic stroke, which may reflect shared pathobiology predisposing to small vessel arteriopathy. Stroke is a complex, heterogeneous disorder requiring tailored analytic strategies to decipher genetic mechanisms.

Comment inThe yin and yang of magnesium and calcium: New genetic insights for stroke? [Neurology. 2019]; International audience; Objective To determine whether serum magnesium and calcium concentrations are causally associated with ischemic stroke or any of its subtypes using the mendelian randomization approach. Methods Analyses were conducted using summary statistics data for 13 single-nucleotide polymorphisms robustly associated with serum magnesium (n = 6) or serum calcium (n = 7) concentrations. The corresponding data for ischemic stroke were obtained from the MEGASTROKE consortium (34,217 cases and 404,630 noncases). Results In standard mendelian randomization analysis, the odds ratios for each 0.1 mmol/L (about 1 SD) increase in genetically predicted serum magnesium concentrations were 0.78 (95% confidence interval [CI] 0.69-0.89; p = 1.3 × 10 −4) for all ischemic stroke, 0.63 (95% CI 0.50-0.80; p = 1.6 × 10 −4) for cardioembolic stroke, and 0.60 (95% CI 0.44-0.82; p = 0.001) for large artery stroke; there was no association with small vessel stroke (odds ratio 0.90, 95% CI 0.67-1.20; p = 0.46). Only the association with cardioembolic stroke was robust in sensitivity analyses. There was no association of genetically predicted serum calcium concentrations with all ischemic stroke (per 0.5 mg/dL [about 1 SD] increase in serum calcium: odds ratio 1.03, 95% CI 0.88-1.21) or with any subtype. Conclusions This study found that genetically higher serum magnesium concentrations are associated with a reduced risk of cardioembolic stroke but found no significant association of genetically higher serum calcium concentrations with any ischemic stroke subtype.

Intracerebral haemorrhage and small vessel ischaemic stroke (SVS) are the most acute manifestations of cerebral small vessel disease, with no established preventive approaches beyond hypertension management. Combined genome-wide association study (GWAS) of these two correlated diseases may improve statistical power to detect novel genetic factors for cerebral small vessel disease, elucidating underlying disease mechanisms that may form the basis for future treatments. Because intracerebral haemorrhage location is an adequate surrogate for distinct histopathological variants of cerebral small vessel disease (lobar for cerebral amyloid angiopathy and non-lobar for arteriolosclerosis), we performed GWAS of intracerebral haemorrhage by location in 1813 subjects (755 lobar and 1005 non-lobar) and 1711 stroke-free control subjects. Intracerebral haemorrhage GWAS results by location were meta-analysed with GWAS results for SVS from MEGASTROKE, using ‘Multi-Trait Analysis of GWAS’ (MTAG) to integrate summary data across traits and generate combined effect estimates. After combining intracerebral haemorrhage and SVS datasets, our sample size included 241 024 participants (6255 intracerebral haemorrhage or SVS cases and 233 058 control subjects). Genome-wide significant associations were observed for non-lobar intracerebral haemorrhage enhanced by SVS with rs2758605 [MTAG P-value (P) = 2.6 × 10(−8)] at 1q22; rs72932727 (P = 1.7 × 10(−8)) at 2q33; and rs9515201 (P = 5.3 × 10(−10)) at 13q34. In the GTEx gene expression library, rs2758605 (1q22), rs72932727 (2q33) and rs9515201 (13q34) are significant cis-eQTLs for PMF1 (P = 1 × 10(−4) in tibial nerve), NBEAL1, FAM117B and CARF (P < 2.1 × 10(−7) in arteries) and COL4A2 and COL4A1 (P < 0.01 in brain putamen), respectively. Leveraging S-PrediXcan for gene-based association testing with the predicted expression models in tissues related with nerve, artery, and non-lobar brain, we found that experiment-wide significant (P < 8.5 × 10(−7)) associations at three genes at 2q33 including NBEAL1, FAM117B and WDR12 and genome-wide significant associations at two genes including ICA1L at 2q33 and ZCCHC14 at 16q24. Brain cell-type specific expression profiling libraries reveal that SEMA4A, SLC25A44 and PMF1 at 1q22 and COL4A1 and COL4A2 at 13q34 were mainly expressed in endothelial cells, while the genes at 2q33 (FAM117B, CARF and NBEAL1) were expressed in various cell types including astrocytes, oligodendrocytes and neurons. Our cross-phenotype genetic study of intracerebral haemorrhage and SVS demonstrates novel genome-wide associations for non-lobar intracerebral haemorrhage at 2q33 and 13q34. Our replication of the 1q22 locus previous seen in traditional GWAS of intracerebral haemorrhage, as well as the rediscovery of 13q34, which had previously been reported in candidate gene studies with other cerebral small vessel disease-related traits strengthens the credibility of applying this novel genome-wide approach across intracerebral haemorrhage and SVS.

Introduction: Intracerebral hemorrhage (ICH) is the most severe subtype of stroke. Its mortality rate is high, and the majority of survivors suffer significant disability. The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study prospectively recruited 1000 non-Hispanic white, 1000 non-Hispanic black, and 1000 Hispanic spontaneous ICH cases to study the epidemiology and genomics of ICH. Herein, we report the primary determinants of 3-month outcome after ICH in a large, multi-ethnic cohort. Methods: Between 2010 and 2015, cases were prospectively recruited with uniform data collection and phenotype definitions, centralized neuroimaging review, and telephone follow-up at 3 months. Individual characteristics were screened for association with 3-month outcome of modified Rankin Scale (mRS) ≥4 versus ≤3 under a logistic regression model, and those meeting P

Preeclampsia is a pregnancy-specific disorder of new-onset hypertension linked to placental ischemia. While obesity is a major risk factor for preeclampsia, not all obese pregnant women develop pregnancy-induced hypertension or preeclampsia. Previously, we reported that placental ischemia-induced hypertension is dependent upon intact signaling of the sympathetic nervous system. Moreover, in various models of obesity, blockade of MC4R (melanocortin-4 receptor) signaling protects against the development of hypertension via suppression of the sympathetic nervous system. Less is known about this pathway during obese pregnancy. Although blockade of MC4R may lead to increased body weight during pregnancy, we tested the hypothesis that placental ischemia-induced hypertension is attenuated in obese MC4R-deficient pregnant rats. On gestational day 14, MC4R wild-type or heterozygous-deficient (MC4R-def) rats were subjected to chronic placental ischemia via the reduced uterine perfusion pressure procedure or Sham surgery then examined on gestational day 19. In Sham MC4R-def versus Sham wild-type pregnant rats, there was increased body weight, fat mass, and circulating leptin levels but they had similar fetus weights. Reduced uterine perfusion pressure reduced fetus weights in both strains. Reduced uterine perfusion pressure increased blood pressure in wild-type rats but this response was significantly attenuated in MC4R-def rats, although blood pressure was elevated in Sham MC4R-def over Sham wild-type. These data indicate that while obese MC4R-def pregnant rats have higher blood pressure during pregnancy, placental ischemia-induced hypertension is attenuated in obese MC4R-def pregnant rats. Thus, obese women with abnormal MC4R signaling may be less susceptible to the development of placental ischemia-induced hypertension.

Intracerebral haemorrhage in the elderly is a severe manifestation of common forms of cerebral small vessel disease. Nearly 60% of intracerebral haemorrhage survivors will develop clinical manifestations of small vessel disease progression including recurrent haemorrhage, ischaemic stroke, dementia, late-life depression and gait impairment within 5 years. Blood pressure measurements following intracerebral haemorrhage are strongly associated with this risk. However, aggressive blood pressure lowering in the elderly carries substantial risks. In order to determine whether there might be an opportunity to select individuals at the highest risk for small vessel disease progression for aggressive blood pressure reduction, we investigated whether APOE gene variants ɛ2/ɛ4 modify the association between blood pressure and small vessel disease clinical progression after intracerebral haemorrhage. We conducted a single-centre longitudinal study at a tertiary care referral centre (Massachusetts General Hospital in Boston, MA, USA), analysing 716 consecutive survivors of acute intracerebral haemorrhage, enrolled from January 2006 to December 2016. We conducted research interviews at the time of enrolment and obtained APOE genotypes from peripheral venous blood samples. We followed patients longitudinally by means of validated phone-based research encounters, aimed at gathering measurements of systolic and diastolic blood pressure, as well as information on small vessel disease clinical outcomes (including recurrent haemorrhage, incident ischaemic stroke, incident dementia, incident depression and incident gait impairment). APOE ε4 and systolic blood pressure were associated with the risk of recurrent haemorrhage, ischaemic stroke and post-haemorrhage dementia, depression and gait impairment (all P, Intracerebral haemorrhage is a severe manifestation of cerebral small vessel disease, alongside ischaemic stroke, dementia, depression and gait impairment. We found that systolic blood pressure and APOE ε4 interact to increase risk of small vessel disease disorders. Genetic screening may, therefore, inform hypertension treatment goals for intracerebral haemorrhage survivors., Graphical Abstract Graphical Abstract

BackgroundCapillary refill (CR) time is traditionally assessed by ‘naked-eye’ inspection of the return to original colour of a tissue after blanching pressure. Few studies have addressed intra-observer reliability or used objective quantification techniques to assess time to original colour. This study compares naked-eye assessment with quantified CR (qCR) time using polarisation spectroscopy and examines intra-observer and interobserver agreements in using the naked eye.MethodA film of 18 CR tests (shown in a random fixed order) performed in healthy adults was assessed by a convenience sample of 14 doctors, 15 nurses and 19 secretaries (Department of Emergency Medicine, Linköping University, September to November 2017), who were asked to estimate the time to return to colour and characterise it as ‘fast’, ‘normal’ or ‘slow’. The qCR times and corresponding naked-eye time assessments were compared using the Kruskal-Wallis test. Three videos were shown twice without observers’ knowledge to measure intra-observer repeatability. Intra-observer categorical assessments were compared using Cohen’s Kappa analysis. Interobserver repeatability was measured and depicted with multiple-observer Bland-Altman plotting. Differences in naked-eye estimation between professions were analysed using ANOVA.ResultsNaked-eye assessed CR time and qCR time differ substantially, and agreement for the categorical assessments (naked-eye assessment vs qCR classification) was poor (Cohen’s kappa 0.27). Bland-Altman intra-observer repeatability ranged from 6% to 60%. Interobserver agreement was low as shown by the Bland-Altman plotting with a 95% limit of agreement with the mean of ±1.98 s for doctors, ±1.6 s for nurses and ±1.75 s for secretaries. The difference in CR time estimation (in seconds) between professions was not significant.ConclusionsOur study suggests that naked-eye-assessed CR time shows poor reproducibility, even by the same observers, and differs from an objective measure of CR time.

The development of formulation concepts for improved skin tissue oxygenation, including methods for measuring oxygen (O2) transport across biological barriers, are important research topics with respect to all processes that are affected by the O2 concentration, such as radiation therapy in oncology treatments, wound healing, and the general health status of skin. In this work we approach this topic by a novel strategy based on the antioxidative enzyme catalase, which is naturally present in the skin organ where it enables conversion of the reactive oxygen species hydrogen peroxide (H2O2) into O2. We introduce various applications of the skin covered oxygen electrode (SCOE) as an in-vitro tool for studies of catalase activity and function. The SCOE is constructed by placing an excised skin membrane directly on an O2 electrode and the methodology is based on measurements of the electrical current generated by reduction of O2 as a function of time (i.e. chronoamperometry). The results confirm that a high amount of native catalase is present in the skin organ, even in the outermost stratum corneum (SC) barrier, and we conclude that excised pig skin (irrespective of freeze-thaw treatment) represents a valid model for ex vivo human skin for studying catalase function by the SCOE setup. The activity of native catalase in skin is sufficient to generate considerable amounts of O2 by conversion from H2O2 and proof-of-concept is presented for catalase-based transdermal O2 delivery from topical formulations containing H2O2. In addition, we show that this concept can be further improved by topical application of external catalase on the skin surface, which enables transdermal O2 delivery from 50 times lower concentrations of H2O2. These important results are promising for development of novel topical or transdermal formulations containing low and safe concentrations of H2O2 for skin tissue oxygenation. Further, our results indicate that the O2 production by catalase, derived from topically applied S. epidermidis (a simple model for skin microbiota) is relatively low as compared to the O2 produced by the catalase naturally present in skin. Still, the catalase activity derived from S. epidermidis is measurable. Taken together, this work illustrates the benefits and versatility of the SCOE as an in vitro skin research tool and introduces new and promising strategies for transdermal oxygen delivery, with simultaneous detoxification of H2O2, based on native or topically applied catalase.

ObjectiveTo describe the relationship between intraventricular hemorrhage (IVH) expansion and long-term outcome and to use this relationship to select and validate clinically relevant thresholds of IVH expansion in 2 separate intracerebral hemorrhage (ICH) populations.MethodsWe used fractional polynomial analysis to test linear and nonlinear models of 24-hour IVH volume change and clinical outcome with data from the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT)-ICH study. The primary outcome was poor clinical outcome (modified Rankin Scale [mRS] score 4–6) at 90 days. We derived dichotomous thresholds from the selected model and calculated diagnostic accuracy measures. We validated all thresholds in an independent single-center ICH cohort (Massachusetts General Hospital).ResultsOf the 256 patients from PREDICT, 127 (49.6%) had an mRS score of 4 to 6. Twenty-four–hour IVH volume change and poor outcome fit a nonlinear relationship, in which minimal increases in IVH were associated with a high probability of an mRS score of 4 to 6. IVH expansion ≥1 mL (n = 53, sensitivity 33%, specificity 92%, adjusted odds ratio [aOR] 2.68, 95% confidence interval [CI] 1.11–6.46) and development of any new IVH (n = 74, sensitivity 43%, specificity 85%, aOR 2.53, 95% CI 1.22–5.26) strongly predicted poor outcome at 90 days. The dichotomous thresholds reproduced well in a validation cohort of 169 patients.ConclusionIVH expansion as small as 1 mL or any new IVH is strongly predictive of poor outcome. These findings may assist clinicians with bedside prognostication and could be incorporated into definitions of hematoma expansion to inform future ICH treatment trials.

Background and Purpose— Whether to resume oral anticoagulation treatment after intracerebral hemorrhage (ICH) remains an unresolved question. Previous studies focused primarily on recurrent stroke after ICH. We sought to investigate the association between cardioembolic stroke risk, oral anticoagulation therapy resumption, and functional recovery among ICH survivors in the absence of recurrent stroke. Methods— We conducted a joint analysis of 3 observational studies: (1) the multicenter RETRACE study (German-Wide Multicenter Analysis of Oral Anticoagulation Associated Intracerebral Hemorrhage); (2) the Massachusetts General Hospital ICH study (n=166); and (3) the ERICH study (Ethnic/Racial Variations of Intracerebral Hemorrhage; n=131). We included 941 survivors of ICH in the setting of active oral anticoagulation therapy for prevention of cardioembolic stroke because of nonvalvular atrial fibrillation and without evidence of ischemic stroke and recurrent ICH at 1 year from the index event. We created univariable and multivariable models to explore associations between cardioembolic stroke risk (based on CHA 2 DS 2 -VASc scores) and functional recovery after ICH, defined as achieving modified Rankin Scale score of ≤3 at 1 year for participants with modified Rankin Scale score of >3 at discharge. Results— In multivariable analyses, the CHA 2 DS 2 -VASc score was associated with a decreased likelihood of functional recovery (odds ratio, 0.83 per 1 point increase; 95% CI, 0.79–0.86) at 1 year. Anticoagulation resumption was independently associated with a higher likelihood of recovery, regardless of CHA 2 DS 2 -VASc score (odds ratio, 1.89; 95% CI, 1.32–2.70). We found an interaction between CHA 2 DS 2 -VASc score and anticoagulation resumption in terms of association with increased likelihood of functional recovery (interaction P =0.011). Conclusions— Increasing cardioembolic stroke risk is associated with a decreased likelihood of functional recovery at 1 year after ICH, but this association was weaker among participants resuming oral anticoagulation therapy. These findings support, including recovery metrics, in future studies of anticoagulation resumption after ICH.

Context. An instrument is needed to facilitate a brief, but effective, counseling interaction between a patient and a provider. Such an instrument should raise patients’ awareness of their behavioral patterns and indicate their likelihood of weight loss statistically. Objective. To determine if the Lifestyle Questionnaire–Weight Management (LQ-WM) contains statistical properties that discriminate subjects’ weight trajectories. Design and Participants. A convenience sample of 269 college students at Utah Valley University in Orem, Utah, were administered the LQ-WM and a weight history questionnaire. Main Outcome Measure. A Lifestyle Score was created by subtracting the amount of self-reported unhealthy behaviors from the amount of healthy behaviors in the previous week. Results. The Lifestyle Score was significantly different among subjects who reported recently losing, maintaining, or gaining weight recently ( P < .001) and in the previous year ( P < .05). The Lifestyle Score was also significantly different among individuals losing weigh rapidly, moderately, and slowly ( P < .05). Conclusions. This pilot study of the statistical properties of the LQ-WM supports that higher Lifestyle Scores associate with weight loss cross-sectionally. Future studies should examine its statistical properties longitudinally and with diverse samples to assess its suitability for clinical practice.

In patients with severe hemophilia B, gene therapy that is mediated by a novel self-complementary adeno-associated virus serotype 8 (AAV8) vector has been shown to raise factor IX levels for periods of up to 16 months. We wanted to determine the durability of transgene expression, the vector dose-response relationship, and the level of persistent or late toxicity.We evaluated the stability of transgene expression and long-term safety in 10 patients with severe hemophilia B: 6 patients who had been enrolled in an initial phase 1 dose-escalation trial, with 2 patients each receiving a low, intermediate, or high dose, and 4 additional patients who received the high dose (2×10(12) vector genomes per kilogram of body weight). The patients subsequently underwent extensive clinical and laboratory monitoring.A single intravenous infusion of vector in all 10 patients with severe hemophilia B resulted in a dose-dependent increase in circulating factor IX to a level that was 1 to 6% of the normal value over a median period of 3.2 years, with observation ongoing. In the high-dose group, a consistent increase in the factor IX level to a mean (±SD) of 5.1±1.7% was observed in all 6 patients, which resulted in a reduction of more than 90% in both bleeding episodes and the use of prophylactic factor IX concentrate. A transient increase in the mean alanine aminotransferase level to 86 IU per liter (range, 36 to 202) occurred between week 7 and week 10 in 4 of the 6 patients in the high-dose group but resolved over a median of 5 days (range, 2 to 35) after prednisolone treatment.In 10 patients with severe hemophilia B, the infusion of a single dose of AAV8 vector resulted in long-term therapeutic factor IX expression associated with clinical improvement. With a follow-up period of up to 3 years, no late toxic effects from the therapy were reported. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT00979238.).

The computed tomography angiography (CTA) spot sign is a validated predictor of hematoma expansion and poor outcome in supratentorial intracerebral hemorrhage (ICH), but patients with brainstem ICH have typically been excluded from the analyses. We investigated the frequency of spot sign and its relationship with hematoma expansion and outcome in patients with primary pontine hemorrhage (PPH). We performed a retrospective analysis of PPH cases obtained from a prospectively collected cohort of consecutive ICH patients who underwent CTA. CTA first-pass readings for spot sign presence were analyzed by two trained readers. Baseline and follow-up hematoma volumes on non-contrast CT scans were assessed by semi-automated computer-assisted volumetric analysis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratio, and accuracy of spot sign for prediction of in-hospital mortality were calculated. 49 subjects met the inclusion criteria of whom 11 (22.4 %) showed a spot sign. In-hospital mortality was higher in spot sign-positive versus spot sign-negative subjects (90.9 vs 47.4 %, p = 0.020). Spot sign showed excellent specificity (95 %) and PPV (91 %) in predicting in-hospital mortality. Absolute hematoma growth, defined as parenchymal and intraventricular hematoma expansion of any amount, was significantly higher in spot sign-positive versus spot sign-negative subjects (13.72 ± 20.93 vs 3.76 ± 8.55 mL, p = 0.045). As with supratentorial ICH, the CTA spot sign is a common finding and is associated with higher risk of hematoma expansion and mortality in PPH. This marker may assist clinicians in prognostic stratification.

Background: In both Sweden and Australia high incidence rates of skin cancer have become a major health problem. In prevention and risk communication, it is important to have reliable ways for identifying people with risky sun habits. In this study the validity and reliability of the questionnaire Sun Exposure Protection Index (SEPI), developed to assess individuals sun habits and their propensity to increase sun protection during routine, often brief, clinical encounters, has been evaluated. The aim of our study was to evaluate validity and reliability of the proposed SEPI scoring instrument, in two countries with markedly different ultraviolet radiation environments (Sweden and Australia). Method: Two subpopulations in Sweden and Australia respectively were asked to fill out the SEPI together with the previously evaluated Readiness to Alter Sun Protective Behaviour questionnaire (RASP-B) and the associated Sun-protective Behaviours Questionnaire. To test reliability, the SEPI was again filled out by the subjects one month later. Results: Comparison between SEPI and the questions in the Sun-protective Behaviours Questionnaire, analyzed with Spearmans Rho, showed good correlations regarding sun habits. Comparison between SEPI and RASP-B regarding propensity to increase sun protection showed concurrently lower SEPI mean scores for action stage, but no difference between precontemplation and contemplation stages. The SEPI test-retest analysis indicated stability over time. Internal consistency of the SEPI, assessed with Cronbachs alpha estimation showed values marginally lower than the desired >0.70 coefficient value generally recommended, and was somewhat negatively affected by the question on sunscreen use, likely related to the classic "sunscreen paradox". There were some differences in the performance of the SEPI between the Swedish and Australian samples, possibly due to the influence of "available" sunlight and differing attitudes to behaviour and protection "at home" and on vacation. Conclusions: SEPI appears to be a stable instrument with an overall acceptable validity and reliability, applicable for use in populations exposed to different UVR environments, in order to evaluate individual sun exposure and protection. (C) 2015 The Authors. Published by Elsevier Ltd. Funding Agencies|County Council of Ostergotland, Sweden

Penstemon × jonesii is described as having flowers with the colors of “Tyrian rose,” “amaranth purple,” or “red-purple to maroon.” It has been recorded only in localized areas of southwestern Utah and just over the border of Arizona, where both putative parents commonly occur in sandy soils. Penstemon × jonesii has been reported and widely accepted as a natural hybrid of P. laevis × P. eatonii, though no research has been conducted to verify this assumption. We examined claims of its hybrid origin by making interspecific reciprocal first-generation hybrid plants from the 2 suspected parental species (P. eatonii and P. laevis) as well as by making second-generation hybrids through backcrossing to both parental species. Using 9 Penstemon simple sequence repeat (SSR), or microsatellite, markers, we examined the allelic variation among natural populations of P. × jonesii, P. eatonii, and P. laevis in southwestern Utah. These SSR data, in conjunction with our controlled crosses, support claims that P. × jonesii likely descends from hybridization events between P. eatonii and P. laevis. Flower color of the typical P. × jonesii reported in the literature and found in herbarium samples does not resemble the flower color of F1P. eatonii × P. laevis hybrids from our controlled crosses. However, in subsequent controlled backcrossing of the F1 hybrids to P. eatonii, we found blossom morphotypes and corolla colors matching previous descriptions of P. × jonesii. We also observed many hybrids with lighter corolla colors, such as light pinks, pinkish yellows, and lavender, which are not recorded in the literature or found in herbarium specimens. Field surveys for natural color variation in P. × jonesii populations also revealed greater flower color variation than previously reported, which should be considered as part of this hybrid taxa as well, though the predominant floral colors of P. × jonesii are “Tyrian rose,” “amaranth purple,” and “red-purple to maroon,” which suggests some selective bias. We suggest that pollinator preference for dark red to purple blooms may be responsible for this phenomenon.

BACKGROUND: Intraventricular hemorrhage (IVH) and white matter lesion (WML) severity are associated with higher rates of death and disability in intracerebral hemorrhage (ICH). A prior report identified an increased risk of IVH with greater WML burden but did not control for location of ICH. We sought to determine whether a higher degree of WML is associated with a higher risk of IVH after controlling for ICH location. METHODS: Utilizing the patient population from two large ICH studies; the Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study and the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study, we graded WML using the Van Swieten Scale (0-1 for mild, 2 for moderate, and 3-4 for severe WML) and presence or absence of IVH in baseline CT scans. We used multivariable regression models to adjust for relevant covariates. RESULTS: Among 3023 ICH patients, 1260 (41.7%) had presence of IVH. In patients with IVH, the proportion of severe WML (28.6%) was higher compared with patients without IVH (21.8%) (p

Background: Cytokines and growth factors have been implicated in the initiation and propagation of vascular disease. Observational studies have shown associations of their circulating levels with stroke. Our objective was to explore whether genetically determined circulating levels of cytokines and growth factors are associated with stroke and its etiologic subtypes by conducting a 2-sample Mendelian randomization (MR) study. Methods: Genetic instruments for 41 cytokines and growth factors were obtained from a genome-wide association study of 8293 healthy adults. Their associations with stroke and stroke subtypes were evaluated in the MEGASTROKE genome-wide association study data set (67 162 cases; 454 450 controls) applying inverse variance–weighted meta-analysis, weighted-median analysis, Mendelian randomization–Egger regression, and multivariable Mendelian randomization. The UK Biobank cohort was used as an independent validation sample (4985 cases; 364 434 controls). Genetic instruments for monocyte chemoattractant protein-1 (MCP-1/CCL2) were further tested for association with etiologically related vascular traits by using publicly available genome-wide association study data. Results: Genetic predisposition to higher MCP-1 levels was associated with higher risk of any stroke (odds ratio [OR] per 1 SD increase, 1.06; 95% CI, 1.02–1.09; P =0.0009), any ischemic stroke (OR, 1.06; 95% CI, 1.02–1.10; P =0.002), large-artery stroke (OR, 1.19; 95% CI, 1.09–1.30; P =0.0002), and cardioembolic stroke (OR, 1.14; 95% CI, 1.06–1.23; P =0.0004), but not with small-vessel stroke or intracerebral hemorrhage. The results were stable in sensitivity analyses and remained significant after adjustment for cardiovascular risk factors. Analyses in the UK Biobank showed similar associations for available phenotypes (any stroke: OR, 1.08; 95% CI, 0.99–1.17; P =0.09; any ischemic stroke: OR, 1.07; 95% CI, 0.97–1.18; P =0.17). Genetically determined higher MCP-1 levels were further associated with coronary artery disease (OR, 1.04; 95% CI, 1.00–1.08; P =0.04) and myocardial infarction (OR, 1.05; 95% CI, 1.01–1.09; P =0.02), but not with atrial fibrillation. A meta-analysis of observational studies showed higher circulating MCP-1 levels in patients with stroke in comparison with controls. Conclusions: Genetic predisposition to elevated circulating levels of MCP-1 is associated with higher risk of stroke, in particular with large-artery stroke and cardioembolic stroke. Whether targeting MCP-1 or its receptors can lower stroke incidence requires further study.

Background and Purpose— Noncontrast computed tomographic (CT) hypodensities represent an alternative to the CT angiography spot sign (SS) to predict intracerebral hemorrhage (ICH) expansion. However, previous studies suggested that these markers predicted hematoma expansion independently from each other. We investigated whether the integration of SS and hypodensity (HD) improved the stratification of ICH expansion risk. Methods— A single-center cohort of consecutive patients with ICH was retrospectively analyzed. Patients with available CT angiography, baseline, and follow-up noncontrast CT images available were included. Trained readers reviewed all the images for SS and HD presence, and the study population was classified into 4 groups: SS and HD negative (SS−HD−), SS positive only (SS+HD−), HD positive only (SS−HD+), and SS and HD positive (SS+HD+). ICH expansion was defined as hematoma growth >33% or >6 mL. The association between SS and HD presence and ICH expansion was investigated with multivariable logistic regression. Results— A total of 745 subjects qualified for the analysis (median age, 73 years; 54.1% men). The rates of ICH expansion were 9.3% in SS−HD−, 25.8% in SS+HD−, 27.4% in SS−HD+, and 55.6% in SS+HD+ patients ( P P =0.002 and odds ratio, 3.02, P P Conclusions— Integration of SS and HD improves the stratification of hematoma growth risk and may help the selection of patients with ICH for antiexpansion treatment in clinical trials.

Preeclampsia (PE), a disorder of new‐onset maternal hypertension and vascular dysfunction during pregnancy, is thought to be linked to placental ischemia‐induced release of prohypertensive factors and reductions of vasoprotective factors in the maternal circulation. Although markers of sympathetic nervous activity are elevated in experimental models of placental ischemia‐induced hypertension and women with PE compared with their normal pregnant counterparts, the importance of adrenergic receptor signaling in the development of hypertension in PE is unknown. Therefore, we tested the hypothesis that adrenergic receptor blockade attenuates the development of placental ischemia‐induced hypertension in rats. Wistar Hannover rats underwent reduced uterine perfusion pressure (RUPP) or Sham surgeries on gestational day 14. By day 19, mean arterial blood pressure (MAP) was increased in RUPP over Sham rats. Groups of RUPP and Sham pregnant rats received terazosin and propranolol (3 mg/kg per day of each via subcutaneous osmotic minipump) to block α 1‐ and β‐adrenergic receptors, respectively, beginning on gestational day 14. Adrenergic blockade significantly attenuated the development of hypertension in the RUPP rats with a slight blood pressure‐lowering response in the Sham, normal pregnant rats by day 19. In conclusion, these data implicate that placental ischemia‐induced hypertension involves adrenergic receptor signaling to promote increases in blood pressure during PE.

Background Thrombin-based formulations have been used for topical hemostasis in surgery for decades. However, the number of randomized clinical trials comparing bovine vs human thrombin is limited. Study Design A randomized, double-blind, non-inferiority phase II study evaluated the hemostatic efficacy and safety of plasma-derived topical thrombin (human) Grifols (TTH-Grifols; Instituto Grifols SA) vs bovine THROMBIN JMI (BT-JMI; GenTrac Inc) (2:1 ratio) in vascular, hepatic, soft tissue, and spinal operations. The primary efficacy end point was the percentage of patients achieving hemostasis at target bleeding sites with mild to moderate bleeding (response) within 5 minutes (T5) of treatment application. Non-inferiority was met if the lower limit of the 95% CI of the response ratio of TTH-Grifols relative to BT-JMI by T5 exceeded 0.8. Secondary efficacy variables were the cumulative response by 3 and 4 minutes (T3 and T4), and the number of treatment failures. Safety parameters were assessed. Results Randomized patients in TTH-Grifols and BT-JMI groups were n = 137 and n = 68, respectively. In modified intention-to-treat population, rates of hemostasis by T5 were 78.3% (94 of 120) in TTH-Grifols and 80.3% (49 of 61) in BT-JMI (response ratio: 0.973; 95% CI 0.833 to 1.135). Rates of hemostasis in vascular, hepatic, soft tissue, and spinal operations ranged from 75.0% to 82.5% for TTH-Grifols and from 54.5% to 91.7% for BT-JMI. No significant differences in adverse events were observed between treatment groups. Antibodies to bovine factor V antigen were detected in 2 patients exposed to BT-JMI and in none exposed to TTH-Grifols. Conclusions The TTH-Grifols was safe and well tolerated as a local hemostatic agent and was non-inferior to BT-JMI. No antibodies to thrombin developed in TTH-Grifols-treated patients.

ObjectiveAPOE ε2 and ε4 alleles have been associated with lobar intracerebral hemorrhage (ICH) in predominately white populations; we sought to evaluate whether this held true among black and Hispanic populations.MethodsThe Ethnic/Racial Variations of Intracerebral Hemorrhage study is a prospective, multicenter case-control study of ICH among white, black, and Hispanic participants. Controls were recruited to match cases based on age, ethnicity/race, sex, and geographic location. APOE genotyping and ICH location was determined blinded to clinical data.ResultsThere were 907 cases of lobar ICH and 2,660 controls with APOE results. Both APOE ε2 (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1–2.0, p = 0.01) and APOE ε4 (OR 2.0, 95% CI 1.5–2.6, p < 1 × 10−4) were associated with lobar ICH among white participants. Among black participants, neither APOE ε2 (OR 1.0, 95% CI 0.7–1.5, p = 0.97) nor APOE ε4 (OR 1.0, 95% CI 0.7–1.4, p = 0.90) were independent risk factors for lobar ICH. Similarly, among Hispanic participants, neither APOE ε2 (OR 1.0, 95% CI 0.6–1.8, p = 0.89) nor APOE ε4 (OR 1.2, 95% CI 0.8–1.7, p = 0.36) were associated with lobar ICH. Hypertension was a significant risk factor for lobar ICH in all 3 racial/ethnic groups.ConclusionIn contrast to Caucasian patients, in which amyloid risk factors predominate in lobar ICH, we found that hypertension was the predominant risk factor for lobar ICH. While APOE alleles are a risk factor for lobar ICH in white patients, they appear to have a much lower effect in lobar ICH in African American and Hispanic American populations. This suggests APOE ε2 and APOE ε4 do not affect lobar ICH risk homogeneously across ethnic populations. In addition, hypertension has a prominent role in lobar ICH risk, particularly among minorities.