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Resume Notre etude a pour but d’evaluer la prevalence d’usage de stupefiants parmi les victimes d’AVC (accidents vasculaires cerebraux) et AIT (accidents ischemiques transitoires) âgees de moins de 55 ans. La premiere partie de cette etude publiee l’annee derniere s’est focalisee sur l’analyse statistique des resultats de depistage de drogues recueillis ces dix dernieres annees au CHU de Poitiers. Les resultats ayant montre une forte prevalence de l’usage de cannabis par rapport aux autres drogues (opiaces, cocaine et amphetamines) chez cette population, cette seconde partie est consacree uniquement aux cas positifs au cannabis et se focalise notamment sur le lien entre l’usage de cette drogue et la survenue d’AVC ou d’AIT en s’appuyant sur la biliographie existante sur le sujet. Trente neuf patients ayant recemment consomme du cannabis et ayant presente un AVC ischemique (constitue ou AIT) ou hemorragique ont ete inclus et leur dossiers medicaux revus afin d’obtenir des donnees generales (âge, sexe, frequence de consommation de cannabis) mais egalement des donnees sur l’AVC (topographie, etiologie envisagee). L’analyse de ces donnees permet d’essayer de mieux comprendre la physiopathologie en lien avec l’usage de cannabis et la survenue d’AVC chez le sujet jeune. Les donnees de cette etude ainsi que la bibliographie disponible sur le sujet permettent d’avancer diverses hypotheses qui restent difficiles a apprehender meme si le syndrome de vasoconstriction cerebrale reversible semble la plus probable. La notion de temporalite (proximite entre le dernier joint et l’AVC, ou augmentation de consommation recente) presente dans de nombreux cas plaide en faveur d’un lien de causalite fort. L’arret du cannabis qui permet la disparition du surrisque est le seul conseil a retenir pour les cliniciens, les toxicologues et les patients.

Summary Background Two billion peripheral venous catheters are sold globally each year, but the optimal skin disinfection and types of devices are not well established. We aimed to show the superiority of disinfection with 2% chlorhexidine plus alcohol over 5% povidone iodine plus alcohol in preventing infectious complications, and of closed integrated catheters, positive displacement needleless-connectors, disinfecting caps, and single-use prefilled flush syringes used in combination (innovation group) over open catheters and three-way stopcocks for treatment administration (standard group) in preventing catheter failure. Methods We did an open-label, randomised-controlled trial with a two-by-two factorial design, for which we enrolled adults (age ≥18 years) visiting the emergency department at the Poitiers University Hospital, France, and requiring one peripheral venous catheter before admission to the medical wards. Before catheter insertion, patients were randomly assigned (1:1:1:1) using a secure web-based random-number generator to one of four treatment groups based on skin preparation and type of devices (innovative devices or standard devices; 2% chlorhexidine plus alcohol or 5% povidone iodine plus alcohol). Primary outcomes were the incidence of infectious complications (local infection, catheter colonisation, or bloodstream infections) and time between catheter insertion and catheter failure (occlusion, dislodgment, infiltration, phlebitis, or infection). This study is registered with ClinicalTrials.gov , NCT03757143 . Findings 1000 patients were recruited between Jan 7, and Sept 6, 2019, of whom 500 were assigned to the chlorhexidine plus alcohol group and 500 to the povidone iodine plus alcohol group (250 with innovative solutions and 250 with standard devices in each antiseptic group). No significant interaction was found between the two study interventions. Local infections occurred less frequently with chlorhexidine plus alcohol than with povidone iodine plus alcohol (0 [0%] of 496 patients vs six [1%] of 493 patients) and the same was observed for catheter colonisation (4/431 [1%] vs 70/415 [17%] catheters among the catheters cultured; adjusted subdistribution hazard ratio 0·08 [95% CI 0·02–0·18]). Median time between catheter insertion and catheter failure was longer in the innovation group compared with the standard group (50·4 [IQR 29·6–69·4] h vs 30·0 [16·6–52·6] h; p=0·0017). Minor skin reactions occurred in nine (2%) patients in the chlorhexidine plus alcohol group and seven (1%) patients in the povidone iodine plus alcohol group. Interpretation For skin antisepsis, chlorhexidine plus alcohol provides greater protection of peripheral venous catheter-related infectious complications than does povidone iodine plus alcohol. Use of innovative devices extends the catheter complication-free dwell time. Funding Becton Dickinson.

We analysed our one-year surgical activity in a spoke 'COVID-19 free' centre during the pandemic in South Italy.From Feb 2020 to Feb 2021 we performed 800 operations (40% in emergency and 60% of major surgery). We applied restrictive measures for the access of patients in our department from 15/2/2020 after several cases of unclear fever. Visitors were not allowed to stay in the ward.In the first period of lockdown, from March to June 2020, in our Region, biomolecular test was indicated only for symptomatic people. We organized the hospitalization with a sealed compartment system (that we defined "boing system") in which the patient stationed in an 'isolation room' for at least 48 hours upon the entry. From July 2020 molecular test were made to all patients before hospitalization. The boing system remains for emergency recovery.In the first phase of pandemia we chose to subject patients to serological examination based on the IgM assay to consider them negative. We organized the hospitalization with a sealed compartment system (that we defined "boing system") CONCLUSION: In the first phase of the pandemic the serological examination has shown high specificity in identifying positive patients for COVID 19. In that period we supposed that patients with negative serology could be considered non-contagious Neither patients or staff has been resulted positive to SarS CoV2 test.Covid 19, Emercency Surgery, Spoke Center, Pandemia, Serological Tests.Abbiamo analizzato la nostra attività chirurgica nell’arco dell’anno pandemico dal Febbraio 2020 al Febbraio 2021. In questo lasso di tempo il nostro Presidio Ospedaliero, il ‘D Camberlingo’ di Francavilla Fontana – ASL Brindisi, era stato designato, ed è tuttora, centro ‘Covid- 19 free’. Nonostante le restrizioni alla nostra attività elettiva abbiamo eseguito 800 interventi, il 40% dei quali in regime d’urgenza con un 60 % di interventi di chirurgia maggiore. Dal 15/2/2020 dopo aver notato diversi casi di febbre poco chiara abbiamo applicato misure più restrittive per l’accesso dei pazienti nel nostro reparto di degenza. Ai visitatori non è stato più permesso di rimanere nel reparto. Nel primo periodo di lockdown, da marzo a giugno 2020, nella nostra Regione, il test biomolecolare è stato suggerito solo per le persone sintomatiche. In questa fase fase della pandemia abbiamo scelto di sottoporre i pazienti ad esame sierologico basato sul dosaggio delle IgM. L’assenza di tali anticorpi ci permetteva di considerarli negativi. Abbiamo organizzato il ricovero con un sistema a compartimenti stagni, definito “sistema boing”, in cui il paziente stazionava in una “stanza di isolamento” per almeno 48 ore dal momento dell’ingresso. Da luglio 2020 sono stati effettuati test molecolari a tutti i pazienti prima del ricovero. Il ‘sistema boing’ è rimasto tuttora per i pazienti ricoverati in regime d’urgenza. Questi ultimi infatti restano in stanza di isolamento in attesa dell’esito del tampone molecolare a cui vengono sottoposti. Nella prima fase della pandemia l’esame sierologico ha mostrato un’elevata specificità nell’individuare pazienti positivi al Sars-CoV2. Grazie a questo sistema di compartimenti stagni, al tempestivo ricorso al test sierologico e/o molecolare in caso di sintomi sospetti e all’utilizzo della laparoscopia con trocar con sistemi di aspirazione incorporata non abbiamo registrato positività al nuovo coronavirus né tra il personale né tra i ricoverati.

To evaluate the risk of endometriosis recurrence according to the mode of delivery (cesarean section vs. vaginal birth) in patients who had become pregnant with a live birth after surgery for endometriosis.A retrospective cohort study. A Cox proportional-hazards regression was performed to evaluate the risk factors for endometriosis recurrence at 36 months of follow-up after the last pregnancy.Academic hospital.Patients who have had ≥1 pregnancy with a live birth following conservative surgery for ovarian endometriosis performed from January 2009 to December 2016 at our institution.Patients who underwent ≥1 cesarean section after surgery for endometriosis.The recurrence rate of endometriosis after live-birth pregnancies obtained after the first surgery for endometriosis.Patients with a history of ≥1 cesarean section after surgery for endometriosis have a higher risk of endometriosis recurrence than the patients who have had a vaginal birth, with an adjusted hazard ratio of 2.25 (95% confidence interval, 1.27-3.96).A cesarean section after surgery for endometriosis is associated with a twofold high risk of endometriosis recurrence with respect to vaginal birth. A different follow-up approach may be needed in those patients, and avoiding inappropriate indications for cesarean sections in pregnant patients with a history of surgery for endometriosis is necessary.

Background: We aimed to investigate if the carotid intima-media thickness (IMT) at baseline and the HAD2S score, composed of the sum of single risk factors (hypertension, age ≥ 75 years, diabetes, dyslipidemia, smoking), were predictive of plaque progression. Methods: We performed a retrospective analysis on real-life prospectively collected data from patients with any detectable carotid plaque at follow up. The plaque score, calculated at baseline (T0) and at a median follow up of 36.6 months (IQR 39.6–34.3) (T3), was defined as 0: no plaque or stenosis < 30%; 1: stenosis in the range 30–49%; 2: in the range 50–69%; 3: in the range 70–99% and 4: occlusion. Carotid IMT was measured at T0 and T3; HAD2S score was calculated at baseline. Results: We included 340 patients with a mean age of 69.9 (9.1) years and 25.3% subjects had plaque progression. Individuals with progression had a median HAD2S score of 3 (1) while those without progression had 2 (1). Patients with progression had a mean baseline IMT of 0.86 (0.17) while those without progression had 0.77 (0.18) (p < 0.0001). A correlation between progression and baseline IMT was found (p = 0.002). Conclusion: Baseline IMT could be considered a predictor of progression. Patients with progression had an HAD2S score higher than those without evolution.

Resume Selon les recommandations de la Societe francaise neurovasculaire, tout accident vasculaire cerebral (AVC) survenant chez un sujet jeune necessite une recherche etiologique complete. Cela inclut notamment une recherche de l’usage de stupefiant. L’objectif de cette etude est donc d’evaluer la prevalence d’usage de stupefiants parmi les victimes d’AVC âgees de moins de 55 ans ainsi que l’interet du depistage systematique de drogues chez ces memes sujets. Une analyse retrospective de tous les resultats des prelevements urinaires et sanguins, issus de l’unite neurovasculaire du service de neurologie du CHU de Poitiers, recus au laboratoire de toxicologie et pharmacocinetique entre septembre 2007 et septembre 2017 a ete menee. Durant cette periode, 673 patients en provenance de l'unite concernee ont eu un depistage urinaire. Soixante-seize patients ont eu un depistage positif soit 11,3 % des cas. La repartition des cas positifs pour les 4 familles de stupefiants etait la suivante : cannabis 47 (57 %), opiaces 34 (42 %), cocaine 1 (1 %), amphetamines 0. Parmi les 34 cas positifs en opiaces dans l’urine, seul 1 cas s’est avere positif aussi dans le sang (morphine). Parmi les 47 cas positifs au cannabis dans l’urine, 28 ont ete retrouves positifs au THC-COOH dans le sang (5 negatifs, 14 non confirmes) dont 15 avec presence de THC. L’usage d’opiaces est difficile a evaluer puisqu’il n’est pas forcement possible de differencier un usage therapeutique d’une conduite addictive. Enfin, dans notre etude, le pourcentage d’usagers de cannabis est estime a 7 %, ce qui pose la question deja evoquee d’un lien entre AVC et usage de cannabis.

While postoperative stroke is a known complication of Transcatheter Aortic Valve Implantation (TAVI), predictors of early stroke occurrence have not been specifically reviewed. The objective of this study was to estimate the predictors and incidence of stroke during the first 30 days post-TAVI.A cohort of 506 consecutive patients having undergone TAVI between January 2017 and June 2019 was extracted from a prospective database. Preoperative, intraoperative and postoperative characteristics were analyzed by univariate analysis followed by logistic regression to find predictors of the occurrence of stroke or death within the first 30 days after the procedure.Incidence of stroke within 30 days post-TAVI was 4.9%, [CI 95% 3.3-7.2], i.e., 25 strokes. Four out of the 25 patients (16%) with a stroke died within 30 days post-TAVI. After logistic regression analysis, the predictors of early stroke related to TAVI were: CHA2Ds2VASc score ≥ 5 (odds ratio [OR] 2.62; 95% CI: 1.06-6.49; p = .037), supra-aortic access vs. femoral access (OR: 9.00, 95%CI: 2.95-27.44; p = .001) and introduction post-TAVI of a single vs. two or three antithrombotic agents (OR: 5.13; CI 95%: 1.99 to 13.19; p = .001). Over the 30-day period, bleeding occurred in 28 patients (5.5%), in 25 of whom, it was associated with femoral or iliac artery access injury. Anti-thrombotic regimen was not associated with bleeding; two patients out of 48 (4.1%) bled with a single anti-thrombotic regimen vs. 26 patients out of 458 (5.6%) with a dual or triple anti-thrombotic regimen (p = 0.94). The overall 30-day mortality rate was 3.9%, [95% CI 2.5-6.0]. Patients with a single post-TAVI antithrombotic agent (OR: 44.07 [CI 95% 13.45-144.39]; p .0001) and patients with previous coronary artery bypass surgery or coronary artery stenting (OR: 6.16, [CI 95% 1.99-21.29]; p = .002) were at significantly higher risk of death within the 30-day period.In this large-scale single-center retrospective study, a single post-TAVI antithrombotic regimen independently predicted occurrence of early stroke or death. Dual or triple antithrombotic regimen was not associated with a higher risk of bleeding and should be considered as an option in patients undergoing TAVI.

Objectives We aimed to confirm the sensitivity and specificity of contrast transcranial Doppler (cTCD) in the detection of right‐to‐left shunt (RLS) compared to the current reference standard (i.e., transesophageal echocardiography—TEE) in patients aged

Background: Variance from guideline-directed care for glucose and temperature control remains unknown in the United States at a time when priorities have shifted to ensure rapid diagnosis and treatment of acute stroke patients. However, protocol-driven nursing surveillance for control of hyperglycemia and hyperthermia has been shown to improve patient outcomes. Methods: We conducted an observational pilot study to assess compliance with American guidelines for glucose and temperature control and association with discharge outcomes in consecutive acute stroke patients admitted to 5 US comprehensive stroke centers. Data for the first 5 days of stroke admission were collected from electronic medical records and entered and analyzed in SPSS using descriptive statistics, Mann-Whitney U test, Student t tests, and logistic regression. Results: A total of 1669 consecutive glucose and 3782 consecutive temperature measurements were taken from a sample of 235 acute stroke patients; the sample was 87% ischemic and 13% intracerebral hemorrhage. Poor glucose control was found in 33% of patients, and the most frequent control method ordered (35%) was regular insulin sliding scale without basal dosing. Poor temperature control was noted in 10%, and 39% did not have temperature recorded in the emergency department. Lower admission National Institutes of Health Stroke Scale score and well-controlled glucose were independent predictors of favorable outcome (discharge modified Rankin Scale score, 0–2) in reperfusion patients. Conclusion: Glucose and temperature control may be overlooked in this era of rapid stroke diagnosis and treatment. Acute stroke nurses are well positioned to assume leadership of glucose and temperature monitoring and treatment.

To assess the usefulness of transcranial Doppler CO2 reactivity (CO2R) for prediction of ipsilateral ischemic stroke in carotid artery stenosis and occlusion with a meta-analysis of prospective studies based on individual patient data.We searched Medline, Biosis Previews, Science Citation Index, The Cochrane Library, and EMBASE for studies in which patients with severe carotid artery stenosis or occlusion underwent Doppler CO2R testing (inhalation of CO2 or breath-holding) and were prospectively followed for ipsilateral ischemic stroke. Individual data from 754 patients from 9 studies were included. We used percentage cerebral blood flow velocity increase (pCi) during hypercapnia as the primary CO2R measure, and defined impaired reactivity as pCi20% increase.In a multiple regression model, impaired CO2R was independently associated with an increased risk of ipsilateral ischemic stroke (hazard ratio [HR] 3.69; confidence interval [CI] 2.01, 6.77; p0.0001). Risk prediction was similar for recently symptomatic vs asymptomatic patients. Using continuous values of pCi, a significant association between decreasing pCi and increasing risk of ipsilateral stroke was found: HR of 1.64 (95% CI 1.33, 2.02; p0.0001) per 10% decrease in pCi. For patients with asymptomatic internal carotid artery stenosis only (n = 330), a comparable stroke risk prediction was found: increasing HR 1.95 (95% CI 1.26, 3.04; p = 0.003) per 10% decrease in pCi.This analysis supports the usefulness of CO2R in risk prediction for patients with severe carotid artery stenosis or occlusion, both in recently symptomatic and asymptomatic patients. Further studies should evaluate whether treatment strategies in asymptomatic patients based on CO2R could improve patient outcomes.

Background To assess the utility of previously developed scoring systems, we compared SEDAN, named after the components of the score (baseline blood Sugar, Early infarct signs and (hyper) Dense cerebral artery sign on admission computed tomography scan, Age, and National Institutes of Health Stroke Scale on admission), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-arterial Therapy (HIAT), and HIAT-2 scoring systems among patients receiving systemic (intravenous [IV] tissue plasminogen activator [tPA]) and endovascular (intra-arterial [IA]) treatments. Methods We retrospectively reviewed all IV tPA and IA patients presenting to our center from 2008-2011. The scores were assessed in patients who were treated with IV tPA only, IA only, and a combination of IV tPA and IA (IV-IA). We tested the ability of THRIVE to predict discharge modified Rankin scale (mRS) 3-6, HIAT and HIAT-2 discharge mRS 4-6, and SEDAN symptomatic intracerebral hemorrhage (sICH). Results Of the 366 patients who were included in this study, 243 had IV tPA only, 89 had IA only, and 34 had IV-IA. THRIVE was predictive of mRS 3-6 in the IV-IA (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.30-2.91) and the IV group (OR, 1.71; 95% CI, 1.43-2.04), but not in the IA group. HIAT was predictive of mRS 4-6 in the IA (OR, 3.55; 95% CI, 1.65-7.25), IV (OR, 3.47; 95% CI, 2.26-5.33), and IV-IA group (OR, 6.48; 95% CI, 1.41-29.71). HIAT-2 was predictive of mRS 4-6 in the IA (OR, 1.39; 95% CI, 1.03-1.87) and IV group (OR, 1.36; 95% CI, 1.18-1.57), but not in the IV-IA group. SEDAN was not predictive of sICH in the IA or the IV-IA group, but was predictive in the IV group (OR, 1.54; 95% CI, 1.01-2.36). Conclusions Our study demonstrated that although highly predictive of outcome in the original study design treatment groups, prediction scores may not generalize to all patient samples, highlighting the importance of validating prediction scores in diverse samples.

Cerebral vasomotor reactivity (CVR) is reduced in patients with diabetes mellitus (DM), and glucose variability (GV) might be responsible for cerebrovascular damage.Studying patients with insulin resistance without DM, we explored the role of GV in impairing CVR.We studied 18 metabolic syndrome (MS) patients without DM, 9 controls (C), and 26 patients with DM.Groups were compared in terms of CVR, GV, and 24-hour blood pressure. To evaluate the impact of acute hyperglycemia on CVR, a hyperglycemic clamp was performed in MS patients and controls.Baseline CVR was reduced in DM vs C and MS (C vs DM = 20.2, 95% CI = 3.5-36.9, P = .014; and MS vs DM = 22.2, 95% CI = 8.6-35.8, P = .001), but similar between MS and C (MS vs C = 2.0, 95% CI = -14.7 to 18.7, P = .643). During acute hyperglycemia, CVR fell in MS and C to values comparable to DM. GV progressively increased from C to MS to DM. In MS, CVR at 120 minutes and GV displayed a negative correlation (r = -0.48, P = .043), which did not change after controlling for mean 24-hour systolic and diastolic blood pressure. In MS, the CVR reduction was significantly correlated to GV (r = 0.55, P = .02).GV is increased in patients with MS but without DM and is the major predictor of CVR reduction induced by acute hyperglycemia, possibly representing the earliest cause of cerebrovascular damage in DM.

Background: Prior stroke within 3 months excludes patients from thrombolysis; however, patients may have computed tomography (CT) evidence of prior infarct, often of unknown time of origin. We aimed to determine if the presence of a previous infarct on pretreatment CT is a predictor of hemorrhagic complications and functional outcomes after the administration of intravenous (IV) tissue plasminogen activator (tPA). Methods: We retrospectively analyzed consecutive patients treated with IV tPA at our institution from 2009-2011. Pretreatment CTs were reviewed for evidence of any prior infarct. Further review determined if any hemorrhagic transformation (HT) or symptomatic intracerebral hemorrhage (sICH) were present on repeat CT or magnetic resonance imaging. Outcomes included sICH, any HT, poor functional outcome (modified Rankin Scale score of 4-6), and discharge disposition. Results: Of 212 IV tPA-treated patients, 84 (40%) had evidence of prior infarct on pretreatment CT. Patients with prior infarcts on CT were older (median age, 72 versus 65 years; P = .001) and had higher pretreatment National Institutes of Health Stroke Scale scores (median, 10 versus 7; P = .023). Patients with prior infarcts on CT did not experience more sICH (4% versus 2%; P = .221) or any HT (18% versus 14%; P = .471). These patients did have a higher frequency of poor functional outcome at discharge (82% versus 50%; P < .001) and were less often discharged to home or inpatient rehabilitation center (61% versus 73%; P = .065). Conclusions: Visualization of prior infarcts on pretreatment CT did not predict an increased risk of sICH in our study and should not be viewed as a reason to withhold systemic tPA treatment after clinically evident strokes within 3 months were excluded.

Background: Neuromodulation techniques, i.e. repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), can modify cerebral hemodynamics. High frequency rTMS appeared to decrease cerebral vasomotor reactivity (VMR), while there is still poor evidence about the effect of low frequency (LF) rTMS on cerebral blood flow (CBF) and VMR. Hypothesis: The present study aimed to test if LF rTMS decreases CBF and increases cerebral VMR. Monolateral or bilateral hemispheric involvement and duration of the effect were considered. A possible role of autonomic nervous system in CBF and VMR modulation was also investigated. Methods: Twenty-four right-handed healthy subjects underwent randomly real (12) or sham (12) 20-min 1-Hz rTMS on left primary motor cortex. Mean flow velocity and VMR of middle cerebral arteries were evaluated by means of transcranial Doppler before (T0), after 10 min (T1) and after 2 (T2), 5 (T3) and 24 h (T4) from rTMS. Heart rate variability (HRV) was studied within the same timing interval, assessing low frequency/high frequency (LF/HF) ratio as index of autonomic balance. Results: After real rTMS compared with sham stimulation, MFV decreased bilaterally at T1 (F = 3.240, P = .030) while VMR increased bilaterally (F = 5.116, P = .002) for at least 5 h (T3). LF/HF ratio decreased early after real rTMS (F = 2.881, P = .040). Conclusion: 1-Hz rTMS may induce a bilateral long-lasting increase of VMR, while its effect on MFV is short-lasting. Moreover, HRV changes induced by rTMS suggest a possible autonomic nervous system modulation.

We sought to investigate potential racial disparities in early outcomes of young individuals with stroke in an international multicenter study. We evaluated consecutive patients with first-ever acute stroke aged 18-45 years from prospective databases involving 12 tertiary-care stroke centers in North America (n = 2), Europe (n = 6), and Asia (n = 4). Demographics, vascular risk factors, stroke subtypes, pre-stroke functional status, stroke severity, blood pressure parameters, and serum glucose at hospital admission were documented. The outcome events of interest were 30-day mortality and 30-day favorable functional outcome (FFO) defined as modified-Rankin Scale score of 0-1. A total of 1,134 young adults (mean age 37.4 ± 7.0 years; 58.8 % men; 48.6 % Whites, 23.9 % Blacks, and 27.5 % Asians; median baseline National Institutes of Health Stroke Scale score 6 points, interquartile range 2-13) were included in the analyses. The 30-day stroke mortality and FFO rates differed (p < 0.001) across races. After adjusting for potential confounders, race was independently associated with 30-day mortality (p = 0.026) and 30-day FFO (p = 0.035). Blacks had a fourfold higher odds of 30-day stroke mortality in comparison to Asians (OR 4.00; 95 % CI 1.38-11.59; p = 0.011). Whites also had an increased likelihood of 30-day stroke mortality in comparison to Asians (OR 3.59; 95 % CI 1.28-10.03; p = 0.015). Blacks had a lower odds of 30-day FFO in comparison to Whites (OR 0.57; 95 % CI 0.35-0.91; p = 0.018). Racial disparities in early outcomes following first-ever stroke in young individuals appear to be independent of other known outcome predictor variables. Whites appear to have higher likelihood of 30-day FFO and Asians have lower odds of 30-day stroke mortality.

Kiwifruit is an important cause of allergy. Although several allergens have been identified in this food ( www.allergome.org ), data on the number and clinical relevance of kiwifruit allergenic proteins are still fragmentary. With the aim of providing a contribution to the description of the complete kiwifruit allergome, we have investigated the immunological features of pectin methylesterase (PME) and its inhibitor (PMEI) purified from the natural source. Specific IgE to PME (Act d 7) and PMEI (Act d 6) were recorded in patients with kiwifruit allergies by immunoblotting, multiplex microarray-based immunoassay and skin testing (ST). Compared to the results obtained by the microarray system, the percentage of subjects detected positive to Act d 6 was much higher in the immunoblotting. Conversely, a similar percentage of subjects positive to Act d 7 was estimated in both the in vitro tests. Few subjects compared to in vitro testing gave a positive response on ST. In the case of Act d 7 this could be ascribed to the glycan side chain recognized by cross-reactive carbohydrate determinants (CCD)-specific IgE. In fact, Act d 7 fell in the cluster of glycoallergens (including Api m 1, Cup a 1, Hor v 17, Ole e 1, Pla a 2) immobilized on the microarray and recognized by CCD-specific IgE. A comparative analysis of different kiwifruit allergens (Act d 1, 2, 5, 6, 7, 11) revealed that only Act d 7 fell in this cluster, whereas Act d 2, although reported to be glycosylated, fell outside, thus suggesting the lack of sugars bound to this molecule. The subsequent biochemical characterization confirmed that Act d 2 is not a glycoallergen. In conclusion, Act d 7 and 6 seem to be rarely involved in causing symptoms in kiwifruit allergic patients. Nevertheless they are useful to understand a single patient profile and the mechanism of protein allergenicity. In addition, in this study the use of a multiplex test system has provided more information than expected, thus contributing to both the immunological and biochemical characterization of the immobilized allergens.

The effect of carotid artery stenting (CAS) on cognitive function is still debated. Cerebral microembolism, detectable by post-procedural diffusion-weighted imaging (DWI) lesions, has been suggested to predispose to cognitive decline. Our study aimed at evaluating the effect of CAS on cognitive profile focusing on the potential role of cerebral microembolic lesions, taking into consideration the impact of factors potentially influencing cognitive status (demographic features, vascular risk profile, neuropsychological evaluation at baseline and magnetic resonance (MR) markers of brain structural damage). Thirty-seven patients with severe carotid artery stenosis were enrolled. Neurological assessment, neuropsychological evaluation and brain MR were performed the day before CAS (E0). Brain MR with DWI was repeated the day after CAS (E1), while neuropsychological evaluation was done after a 14-month median period (E2). Volumes of both white matter hyperintensities and whole brain were estimated at E0 on axial MR FLAIR and T1w-SE sequences, respectively. Unadjusted ANOVA analysis showed a significant CAS*DWI interaction for MMSE (F=7.154(32), p=.012). After adjusting for factors potentially influencing cognitive status CAS*DWI interaction was confirmed for MMSE (F=7.092(13), p=.020). Patients with DWI lesions showed a mean E2-E0 MMSE reduction of -3.1, while group without DWI lesions showed a mean E2-E0 MMSE of +1.1. Our study showed that peri-procedural brain microembolic load impacts negatively on cognitive functions, independently from the influence of patients-related variables.

Background: The presence of Janus Kinase 2 (JAK2) V617F mutation represents a major diagnostic criterion for detecting myeloproliferative neoplasms (MPN) and even in the absence of overt MPN, JAK2 V617F mutation is associated with splanchnic vein thrombosis. However, the actual prevalence and diagnostic value of the JAK2 V617F mutation in patients with cerebral venous thrombosis (CVT) are not known. The aims of this study were to assess the prevalence of JAK2 V617F mutation in a large group of consecutive CVT patients, to detect clinical, biological, and radiological features associated with the mutation, and to determine the long-term venous thrombosis recurrence rate in CVT patients with JAK2 mutation but without overt MPN in order to recommend the best preventive treatment. Methods: This was a prospective study conducted on consecutive patients with a first-ever radiologically confirmed CVT. JAK2 V617F mutation analysis was assessed in all the study subjects. JAK2 V617F-positive patients were followed up to detect new venous thrombotic events. Results: Of the 125 included subjects, 7 were found to have JAK2 V617F mutation (5.6%; 95% CI 2.3-11.2). Older age (p = 0.039) and higher platelet count (p = 0.004) were independently associated with JAK2 V617F positivity in patients without overt MPN. During a mean follow-up period of 59 (SD 46) months, 2 JAK2 V617F-positive patients presented with 4 new venous thromboembolic events. Conclusions: Screening for the JAK2 V617F mutation in CVT patients seems to be useful even in the absence of overt MPN and/or in the presence of other risk factors for CVT because of its relatively high prevalence and the risk of thrombosis recurrence.

Background and Purpose— After cerebral venous thrombosis (CVT), the risk of venous thrombotic events was estimated at 2% to 3% for a new CVT and 3% to 8% for extracranial events. However, because of the paucity of prospective studies, the clinical course of CVT is still largely unknown. We aimed to prospectively evaluate the rate of thrombosis recurrence in a cohort of CVT patients with a long-term follow-up and to detect predisposing factors for recurrence. Methods— Consecutive CVT patients with complete clinical, radiological, biological, and genetic data were systematically followed up. New venous thrombotic events were detected after hospital readmission and imaging confirmation. Results— One-hundred eighty-seven patients (mean age 45±18 years, 67% women) with angiographically confirmed CVT were included. Cause was found in 73% of patients. Coagulation abnormality and JAK2 gene mutation were detected in 20% and 9%, respectively. Median follow-up length was 73 months (range 1–247 months). Mean duration of the oral anticoagulant treatment was 14 months. Mortality rate was 2.5% per year, with 2% in-hospital mortality. During follow-up, CVT reoccurred in 6 patients, whereas 19 subjects had a symptomatic extracranial venous thrombotic event, with cumulative venous thrombotic recurrence rates of 3% at 1 year, 8% at 2 years, 12% at 5 years, and 18% at 10 years. A previous venous thrombotic event (hazard ratio, 2.8; P =0.018), presence of cancer or malignant hemopathies (hazard ratio, 3.2; P =0.039), and unknown CVT causes (hazard ratio, 2.81; P =0.024) were independently associated with recurrence. Conclusions— In our cohort of CVT patients followed on average for >6 years, subjects with a previous venous thrombotic event, cancer/malignant hemopathies, and unknown CVT causes were found to be at higher risk of recurrence.

Background: In the USA, stable intravenous tissue plasminogen activator (IV tPA) patients have traditionally been cared for in an intensive care unit (ICU). We examined the safety of using an acuity-adaptable stroke unit (SU) to manage IV tPA patients. Methods: We conducted an observational study of consecutive patients admitted to our acuity-adaptable SU over the first 3 years of operation. Safety was assessed by symptomatic intracerebral hemorrhage (sICH) rates, systemic hemorrhage (SH) rates, tPA-related deaths, and transfers from SU to ICU; cost savings and length of stay (LOS) were determined. Results: We admitted 333 IV tPA patients, of which 302 were admitted directly to the SU. A total of 31 (10%) patients had concurrent systemic hemodynamic or pulmonary compromise warranting direct ICU admission. There were no differences in admission National Institutes of Health Stroke Scale scores between SU and ICU patients (9.0 versus 9.5, respectively). Overall sICH rate was 3.3% ( n = 10) and SH rate was 2.9 ( n = 9), with no difference between SU and ICU patients. No tPA-related deaths occurred, and no SU patients required transfer to the ICU. Estimated hospital cost savings were US$362,400 for ‘avoided’ ICU days, and hospital LOS decreased significantly ( p = 0.001) from 9.8 ± 15.6 days (median 5) in year 1, to 5.2 ± 4.8 days (median 3) by year 3. Conclusions: IV tPA patients may be safely cared for in a SU when nurses undergo extensive education to ensure clinical competence. Use of the ICU solely for monitoring may constitute significant overuse of system resources at an expense that is not associated with additional safety benefit.

Background: In the Australian QASC Trial (Lancet 2013), better glucose and fever control improved 90 day outcomes when nurses adhered to strict monitoring/treatment protocols. We examined variance from guideline specific care for glucose and fever in an American sample. Methods: An observational study was conducted to assess compliance with AHA/ASA stroke guidelines for glucose and fever control in consecutive acute stroke patients from 5 different U.S. Stroke Centers. The first 5-days of glucose/temperature data were analyzed along with demographics and outcome measures. Results: A total of 1669 consecutive glucose and 3782 consecutive temperature measurements were taken from a sample of 235 acute stroke patients; the sample was 87% ischemic and 13% ICH, with admission median NIHSS 4.0 (range 0-34) and ICH score median 1 (range 0-5). 26% of ischemic strokes received IVtPA and/or thrombectomy. HbA1c was 5.7 + .65 (median range 4.8-11.2) in non-DM diagnosed patients vs. 8.3 + 2.3 (range 5.0-14.1; 95%CI=1.9-3.1; p180 mg/dL for >4 hours in 33% during hospitalization (Table), and the most frequent method (35%) for glucose control was regular insulin sliding scale. Temperature was >37.5 o (noncompliant with European/Australian [E/A] standards) for >4 hours in 27% of patients, and >38 o (noncompliant with US standards) for >4 hours in 10% of patients; 8% were out-of-control >8 hours (range 9-96, median 16.5 hours out-of-control) and 39% did not have temperature measured in the ED. mRS and LOS were significantly worse if temperature exceeded the E/A and US standards (Table). Temperature control to o C was an independent predictor (p Conclusions: Our study underscores the need for more vigilant control of glucose and temperature by nurses at U.S. hospitals. Given the time-sensitive ability of brain to recover from ischemia, even short-term non-compliance may have detrimental effects.

Few apple cultivars are widespread in the markets worldwide. The characterisation of cultivars available only in local markets could reveal fruits with sufficiently low amounts of allergens to be tolerated by at least some allergic subjects. This study was focused on the characterisation of 10 ancient and 2 widespread apple cultivars cultivated in Southern Italy. Pomological characterisation showed good sensory features and high manipulation resistance for most of the selected ancient cultivars. Individual patterns of allergenic components were obtained when IgE, IgG and IgG4 inhibition tests were performed on a multiplexed allergen microarray, using sera from allergic subjects as probes. Results obtained allow the selection of potentially hypo- or hyper-allergenic apple cultivars. In addition, this study describes a possible use of allergen microarray technology to quickly investigate the potential allergenicity of specific foods that, after additional tests, can be considered for the inclusion in the diet of individual allergic subjects.

SummaryBackground Specific food-dependent exercise-induced anaphylaxis (S-FDEIAn) is a distinct form of food allergy in which symptoms are elicited by exercise performed after ingesting food to which the patient has become sensitised. Non-specific FDEIAn (NS-FDEIAn) is a syndrome provoked by exercise performed after ingesting any food. Objective We sought to identify the culprit allergenic molecules in patients with FDEIAn, combining ‘classic’ allergy testing with an allergenic molecule-based microarray approach for IgE detection. Methods All subjects were evaluated who reported at least one episode of anaphylaxis in association with physical exercise performed within 4 h after a meal. We performed skin prick tests (SPT) with commercial food extracts, prick plus prick tests (P + P) with fresh foods (P + P), and serum specific IgE assays by means of both the ImmunoCAP (CAP) and the ISAC 89 microarray system (ISAC). Results Among our 82 FDEIAn patients, the most frequent suspected foods were tomato, cereals, and peanut. SPT, P + P, and CAP displayed different degrees of sensitivity. Each test disclosed some positivities not discovered by others. Seventy-nine subjects were positive to at least one food (49 to more than 20), whereas three were negative. All suspected foods were positive to at least one of SPT, P + P, and CAP. When tested using the ISAC, 64 (78%) subjects were positive to Pru p 3 [peach lipid transfer protein (LTP)], 13 were positive to other food allergen molecules, and five displayed negative results to all food allergenic molecules. Overall, 79 patients probably had S-FDEIAn and the other 3 NS-FDEIAn. Conclusions Multiple food hypersensitivity represents a clinical hallmark of a large percentage of FDEIAn patients. The very high prevalence of IgE to the LTP suggests a role of this allergen group in causing S-FDEIAn.

Background: Sézary syndrome (SS) is the aggressive leukemic form of cutaneous T cell lymphoma characterized by erythroderma, the presence of a malignant circulating T memory cells with skin homing potential, and the ability to produce a variety of Th2 soluble factors, such as IL-4 and IL-5. We measured total and specific IgE in SS patients as a further parameter of a Th2-skewed immune system, and studied their clinical impact. Methods: Specific IgE production in a cohort of 55 SS patients was evaluated by the molecule-based ISAC microarray system. We then evaluated survival times and the hazard ratios in this cohort by Kaplan-Meier and Cox methods. Results: Twenty-four (43.6%) SS patients had specific IgE to both environmental and food allergens. For survival analysis, patients found positive to at least one allergen were defined as IgE+. By comparing IgE+ versus IgE– we found a significant difference in the median survival times, 2.9 versus 8.9 years (p < 0.001). Conversely, no survival difference could be observed when total IgE levels were considered. IgE+ patients had higher levels of CD60+CD49–CD4+ T cells, which also represent another worse prognostic index recently identified. Conclusion: SS patients had specific IgE to both environmental and food allergens. IgE+ SS patients had a significant lower survival rate. High levels of CD60–CD49+CD4+ T cells associated with an IgE– phenotype allow the identification of a restricted group of long survivor SS patients. Therefore, specific measurement of IgE seems to be useful in discriminating survival.

European (Dermatophagoides pteronyssinus) and American (Dermatophagoides farinae) house dust mite species are considered the most common causes of asthma and allergic symptoms worldwide. Der p 1 protein, one of the main allergens of D. pteronyssinus, is found in high concentration in mites faecal pellets, which can became easily airborne and, when inhaled, can cause perennial rhinitis and bronchial asthma. Here we report the isolation of the Der p 1 gene from an Italian strain of D. pteronyssinus and the PVX-mediated expression of its mature form (I-rDer p 1) in Nicotiana benthamiana plants. Human sera from characterized allergic patients were used for IgE binding inhibition assays to test the immunological reactivity of I-rDer p 1 produced in N. benthamiana plants. The binding properties of in planta produced I-rDer p 1 versus the IgE of patients sera were comparable to those obtained on Der p 1 preparation immobilized on a microarray. In this paper we provide a proof of concept for the production of an immunologically active form of Der p 1 using a plant viral vector. These results pave the way for the development of diagnostic allergy tests based on in planta produced allergens.

OBJECTIVE The effect of glycemic variability (GV) on cardiovascular risk has not been fully clarified in type 2 diabetes. We evaluated the effect of GV, blood pressure (BP), and oxidative stress on intima-media thickness (IMT), left ventricular mass index (LVMI), flow-mediated dilation (FMD), and sympathovagal balance (low frequency [LF]/high frequency [HF] ratio) in 26 type 2 diabetic patients (diabetes duration 4.41 ± 4.81 years; HbA1c 6.70 ± 1.25%) receiving diet and/or metformin treatment, with no hypotensive treatment or complications. RESEARCH DESIGN AND METHODS Continuous glucose monitoring (CGM) data were used to calculate mean amplitude of glycemic excursion (MAGE), continuous overall net glycemic action (CONGA)-2, mean blood glucose (MBG), mean postprandial glucose excursion (MPPGE), and incremental area under the curve (IAUC). Blood pressure (BP), circadian rhythm, and urinary 15-F2t-isoprostane (8-iso-prostaglandin F2α [PGF2α]) were also evaluated. Subjects were divided into dipper (D) and nondipper (ND) groups according to ΔBP. RESULTS IMT and LVMI were increased in ND versus D (0.77 ± 0.08 vs. 0.68 ± 0.13 [P = 0.04] and 67 ± 14 vs. 55 ± 11 [P = 0.03], respectively). MBG, MAGE, and IAUC were significantly associated with LF/HF ratio at night (r = 0.50, P = 0.01; r = 0.40, P = 0.04; r = 0.41, P = 0.04, respectively), MPPGE was negatively associated with FMD (r = −0.45, P = 0.02), and CONGA-2 was positively associated with LVMI (r = 0.55, P = 0.006). The Δsystolic BP was negatively associated with IMT (r = −0.43, P = 0.03) and with LVMI (r = −0.52, P = 0.01). Urinary 8-iso-PGF2α was positively associated with LVMI (r = 0.68 P < 0.001). CONCLUSIONS An impaired GV and BP variability is associated with endothelial and cardiovascular damage in short-term diabetic patients with optimal metabolic control. Oxidative stress is the only independent predictor of increased LV mass and correlates with glucose and BP variability.

To cite this article: D’Avino R, Bernardi ML, Wallner M, Palazzo P, Camardella L, Tuppo L, Alessandri C, Breiteneder H, Ferreira F, Ciardiello MA, Mari A. Kiwifruit Act d 11 is the first member of the ripening-related protein family identified as an allergen. Allergy 2011; 66: 870–877. Abstract Background: Kiwifruit is an important cause of food allergy. A high amount of a protein with a molecular mass compatible with that of Bet v 1 was observed in the kiwifruit extract. Objective: To identify and characterize kirola, the 17-kDa protein of green kiwifruit (Act d 11). Methods: Act d 11 was purified from green kiwifruit. Its primary structure was obtained by direct protein sequencing. The IgE binding was investigated by skin testing, immunoblotting, inhibition tests, and detection by the ISAC microarray in an Italian cohort and in selected Bet v 1-sensitized Austrian patients. A clinical evaluation of kiwi allergy was carried out. Results: Act d 11 was identified as a member of the major latex protein/ripening-related protein (MLP/RRP) family. IgE binding to Act d 11 was shown by all the applied testing. Patients tested positive for Act d 11 and reporting symptoms on kiwifruit exposure were found within the Bet v 1-positive subset rather than within the population selected for highly reliable history of allergic reactions to kiwifruit. Epidemiology of Act d 11 IgE reactivity was documented in the two cohorts. IgE co-recognition of Act d 11 within the Bet v 1-like molecules is documented using the microarray IgE inhibition assay. Conclusions: Act d 11 is the first member of the MLP/RRP protein family to be described as an allergen. It displays IgE co-recognition with allergens belonging to the PR-10 family, including Bet v 1.

Summary Background Allergy diagnostic systems sometimes give false positive or negative results. In this respect, the influence of protein conformational changes on the allergen–IgE interaction sites is worthy to be investigated. Objective To investigate the influence of different experimental conditions on the structural properties and IgE reactivity of kiwellin (Act d 5) as a model system. Methods Act d 5 was purified from the natural source. To study its conformational features, experiments of circular dichroism (CD) in different media were performed. The IgE reactivity was investigated by skin testing, immunoblotting and ISAC microarray system, in a population of kiwifruit allergic subjects. Results CD experiments indicated that Act d 5 has a mainly helical structure and the conformation is strongly affected by the experimental conditions. The protein is more structured in low polarity media and at acidic pH values, similar to those of the natural source. Eleven subjects of 29 (38%) allergic to kiwifruit were positive to purified natural Act d 5 by skin test. Among them, three patients (10%) showed a reaction only to Act d 5 at pH 4.5, and three (10%) showed a reaction only to the allergen in standard neutral conditions. No one of the 11 subjects with positive skin test recognized Act d 5 immobilized on the ISAC system. Eight of nine subjects detected Act d 5 by IgE immunoblotting. One subject did not recognize the sequence epitopes of Act d 5 in IgE immunoblotting experiments and reacted to the skin test only when the allergen was in acidic conditions. Conclusions and Clinical Relevance The conformation and IgE reactivity of Act d 5 are affected by the physico-chemical characteristics of the solvent. These findings suggest that the assay conditions influence the results of the diagnostic systems by modulating the pattern of exposed antigenic epitopes. Cite this as: M. L. Bernardi, D. Picone, L. Tuppo, I. Giangrieco, G. Petrella, P. Palazzo, R. Ferrara, M. Tamburrini, A. Mari and M. A. Ciardiello, Clinical & Experimental Allergy, 2010 (40) 1819–1826.

Objectif Selon les recommandations de la Societe francaise de neurologie vasculaire, tout accident vasculaire cerebral (AVC) survenant chez un sujet jeune necessite une recherche etiologique complete. Cela inclut notamment une recherche de l’usage de stupefiants. L’objectif de cette etude est donc d’evaluer la prevalence d’usage de stupefiants parmi les victimes d’AVC ou d’accident ischemique transitoire (AIT) âgees de moins de 55 ans ainsi que l’interet du depistage systematique de drogues chez ces memes sujets. Un second objectif est de discuter de l’usage de drogues et en particulier du cannabis comme facteur de risque d’AVC chez le sujet jeune. Methodes Une analyse retrospective de tous les resultats des prelevements urinaires et sanguins, issus de l’unite neurovasculaire du service de neurologie du CHU de Poitiers, recus au laboratoire de toxicologie et pharmacocinetique entre septembre 2007 et septembre 2017 a ete menee. Ont ete inclus dans cette etude, a la fois les resultats de depistages urinaires et les resultats de confirmations sanguines. Les depistages urinaires ont ete effectues par immunochimie (KIMS) avec un seuil a 50 ng/mL pour le THC-COOH, 300 ng/mL pour les opiaces et la cocaine et 500 ng/mL pour les amphetamines. Les confirmations sanguines ont ete effectuees par chromatographie gazeuse ou liquide couplee a la spectrometrie de masse. Resultats Six cent deux depistages urinaires ont ete effectues en provenance de l’unite concernee. L’âge median des patients etait de 46 ans et la repartition des sexes etait de 58,3 % d’hommes et 41,7 % de femmes. Soixante-treize resultats se sont averes positifs soit 12,1 % des echantillons. La repartition des cas positifs pour les 4 familles de stupefiants etait la suivante : cannabis 42 (58 %), opiaces 30 (41 %), cocaine 1 (1 %), amphetamines 0. Pour les cas positifs, la moyenne d’âge s’etablissait a 41 ans avec une majorite d’hommes (68,5 %). Parmi les 30 cas positifs aux opiaces dans l’urine, seulement 3 cas se sont aussi averes positifs dans le sang (morphine : 2 ; et codeine : 1). Parmi les 42 cas positifs au cannabis dans l’urine, 25 ont ete retrouves positifs au THC-COOH dans le sang dont 17 avec presence de THC (3 negatifs, 3 doublons, 11 non confirmes). Cinq cas ont ete exclus pour un diagnostic autre qu’un AVC. Il est note parmi les cas restants 31 AVC ischemiques constitues et 6 AIT. Aucun AVC hemorragique n’a ete observe. Les territoires majoritairement atteints sont les arteres sylviennes (21) et les arteres cerebelleuses (6). Pour 24 % des cas, les etiologies sont vraisemblablement en lien avec l’usage de cannabis (5 vascularites et 4 causes cardiaques emboligenes liees a la consommation de cannabis). A ces chiffres peuvent s’ajouter 10 cas pour lesquels l’etiologie reste inconnue. Diverses hypotheses peuvent etre avancees pour expliquer le role potentiel du cannabis comme facteur de risque d’AVC : tachycardie, hypotension orthostatique, pic hypertensif, vasculopathie, ou vasospasme. Une majorite des patients concernes sont des consommateurs chroniques de cannabis (≥ 1 fois par jour). Il est note une tendance a la recidive pour certains patients. Conclusion Les liens entre la consommation de cannabis et le risque d’AVC ont deja ete decrits, mais l’augmentation du nombre d’usagers chroniques et de la teneur en THC des resines et herbes ainsi que l’apparition des cannabinoides synthetiques laissent a penser que le nombre de patients atteints pourrait augmenter. Il est important de favoriser un sevrage total en cannabis chez ces patients ayant deja subi un AVC, d’autant plus s’il est prouve que ces patients ont tendance a recidiver.

Summary Background The availability of allergenic molecules and high-throughput microtechnologies allow the collection of a large number of IgE results at the same time in a single test. This can be carried out applying the test in the routine diagnostic work-up. Objective The aim of this study was to make a cross-sectional evaluation of the raw prevalence of IgE reactivity to allergenic molecules in serum samples from a cohort of Italian patients using an innovative tool. Methods The ISAC, a microarray system, has been used for specific IgE detection using 75 different allergenic molecules. Sera were collected from 23 077 unselected consecutive individuals complaining about any allergic disease. Results Sixteen thousand four hundred and eight of 23 077 patients had IgE to at least one of 75 allergenic molecules. The top-ranked molecules in this cohort were Cup a 1 (42.7%), Der f 2 (38.7%), and Phl p 1 (37.9%), whereas all the other allergens tested scored in a range between 36.8% and 0.04%, including the first food allergen, Pru p 3, ranked 15th (9.79%). Prevalence varied quite markedly depending on the age range considered, and showing a different behaviour in the lifetime sensitization process. Unsupervised two-way hierarchical clustering analysis generated distinctive patterns of reactivity as the result of IgE recognition of either homologous allergens belonging to different biological sources or non-homologous belonging to the same biological source. Conclusions Allergen-based microarray is a tool for the detection of IgE-related sensitization to panels of allergens and gives a more precise and comprehensive evaluation for an IgE-based epidemiology. This insight brings data for better understanding of the sensitization process.

Background Transcranial Doppler (TCD) studies demonstrated that cerebral vasomotor reactivity (VMR) can predict the outcome of carotid artery occlusion (CAO). Near-infrared spectroscopy (NIRS) is a non-invasive optical method for assessing hemoglobin (Hb) oxygenation parameters. The purpose of this study was to evaluate the role of NIRS parameters as prognostic markers of stroke occurrence in patients with CAO. Methods Sixty-five patients (46 men, mean age 68.8 years) with CAO were enrolled. Forty-two patients had previous cerebrovascular events (15 TIA, 27 minor stroke), the remaining 23 were asymptomatic. All subjects underwent simultaneous TCD and NIRS examination at rest and after hypercapnia. All patients completed follow-up (median, 36 months). Results During follow-up, 11 strokes occurred. Cerebral VMR measured by TCD had a prognostic role in stroke occurrence (p = 0.042). The increase in Hb oxygen saturation detected by NIRS during hypercapnia predicted the occurrence of new cerebrovascular events, although without an overt significance (p = 0.058). Hb oxygen saturation at rest, however, failed to be of prognostic value (p = 0.65). Conclusions NIRS is potentially useful in monitoring cerebral oxygenation; however, at present NIRS does not effectively predict the outcomes of stroke or vascular death in patients with CAO. This study does confirm the primary role of TCD VMR in the outcome of carotid disease.

Introduction In the hyperacute phase of ischemic stroke, a 0° position is recommended to increase cerebral perfusion in nonhypoxic patients able to tolerate lying flat. However, use of 0° positioning is not uniformly applied in clinical practice, most likely due to concerns of aspiration pneumonia. We aimed to determine the risk of pneumonia associated with 0° head of bed positioning in acute stroke patients treated with thrombolytic therapy. Methods A retrospective descriptive study was conducted using prospectively collected, consecutive acute ischemic stroke patients treated with IVtPA whose head of bed was positioned at 0° for the first 24 h. Rates of hospital-acquired pneumonia were determined using a strict adjudication process to insure accuracy of pneumonia diagnoses. Quantitative characteristics were analyzed in SPSS to compare differences between “true” pneumonia cases and nonpneumonia cases. Results Twenty-four of 333 (7.2%) patients had mention the diagnosis of pneumonia in the registry and/or medical record. Of these cases, only 15 (4.5%) met evidence-based diagnostic criteria for hospital-acquired pneumonia. The 15 adjudicated cases had similar median admission NIHSS scores to nonpneumonia cases (10 vs. 9, respectively; P = ns), but were older (74 ± 15 vs. 64 ± 17 years; mean difference 9.889, 95 CI = 1.2–18.6; P = 0.026). A total of eight patients with pneumonia were intubated and mechanically ventilated, and one patient received bilevel positive airway pressure ventilation during the 0° positioning period. Pneumonia cases had significantly longer hospitalizations (14.5 ± 12 vs. 6.6 ± 9 days; mean difference 7.97, 95% CI = 1.1–14.8; P = 0.026) and higher median discharge mRS score (4 vs. 3: P = 0.003). Conclusions Zero-degree head of bed positioning in the first 24 h following an acute ischemic stroke treated with IV-tPA was associated with acceptable rates of pneumonia. Rates for pneumonia may be further reduced by eliminating use of a 0° protocol in intubated/mechanically ventilated patients.

In the recent years, classical vascular risk factors have been suggested to play a role also in the development of degenerative dementia. Arterial hypertension has been implicated in the pathogenesis of dementia but no conclusive results have been produced yet; more recently, blood pressure variability (BPV) has been suggested as a more important risk factor for both silent brain vascular lesions and the development of dementia. Blood pressure variability is defined as the variation in blood pressure over time, measured on different time spans and in different ways. We reviewed current scientific literature about the role of BPV in the pathogenesis of dementia, and about the association of abnormal BPV patterns and different forms of dementia. We also suggested some hypothetical pathogenic mechanisms.

Allergens are proteins or glycoproteins that are recognized by IgE produced by the immune system of allergic individuals. Until now around 1,500 allergenic structures have been identified and this number seems not have reached a plateau after 3-4 decades of research and the advent of molecular biology. Several allergen databases are available on Internet. Different aims and philosophies lead to different products. Here we report about main feature of web sites dedicated to allergens and we describe in more details our current work on the Allergome platform. The web server Allergome (www.allergome.org) represent a free independent open resource whose goal is to provide an exhaustive repository of data related to all the IgE-binding compounds. The main purpose of Allergome is to collect a list of allergenic sources and molecules by using the widest selection criteria and sources. A further development of the Allergome platform has been represented by the Real Time Monitoring of IgE sensitization module (ReTiME) that allows uploading of raw data from both in vivo and in vitro testing, thus representing the first attempt to have IT applied to allergy data mining. More recently, a new module (RefArray) representing a tool for literature mining has been released.

We present a case of a man presenting with vertigo and nausea who was found to have multifocal infarcts in the posterior circulation on magnetic resonance imaging (MRI). An magnetic resonance angiography (MRA) demonstrated focal widening and central signal dropout in the distal vertebral artery consistent with arterial fenestration. Transcranial Doppler ultrasonography showed turbulent flow and a spike waveform suggestive of an intra-luminal thrombus. This was confirmed by computed tomography (CT) angiography. Following the initiation of dual antiplatelet therapy, the signal abnormalities on transcranial doppler (TCD) resolved suggesting dissolution of the thrombus. This case highlights the diagnostic pitfalls that may arise when relying on only one modality for assessing intracranial vasculature and the importance of clarifying the diagnosis of basilar thrombosis or fenestration.

Background: Over time, exposure to cerebrovascular risk factors and carotid artery disease may cause multiple asymptomatic brain cortical and subcortical microinfarcts, which are commonly found at brain autopsy. So far, lack of convenient neuroimaging tools limited the investigation of grey matter ischemic damage in vivo. We applied the Double Inversion Recovery (DIR) sequence to explore the impact of carotid artery disease on intracortical ischemic lesion load in vivo, taking into account the impact of demographic characteristics and vascular risk factors. Methods: DIR was acquired in 62 patients with common cerebrovascular risk factors stratified in three groups according to carotid artery disease severity. Intracortical lesions scored on DIR (DIRlns) were classified by vascular territory, lobe and hemisphere. White matter hyperintensities (WMHs) volume was also quantified on Fluid Attenuated Inversion Recovery sequence (FLAIR). Results: Among demographic characteristics and cerebrovascular risk variables explored, General Linear Model indicated that age and carotid artery disease were significantly associated to DIRlns. After correcting for age, DIRlns load was found to be significantly dependent on carotid artery stenosis severity (F(2, 58) = 5.56, p = 0.006). A linear positive correlation between DIRlns and WMHs was found after correcting for age (p = 0.003). Conclusions: Carotid disease severity is associated with DIRlns accrual. Microembolism and impaired cerebral hemodynamics may act as physiopathological mechanisms underlying cortical ischemic damage. The role of other factors, such as small vessel disease and the possible interaction with carotid disease, remains to be further explored.

Background Growing evidence suggests that the endocannabinoid system is involved in the pathogenesis of Alzheimer's disease (AD) and atherosclerosis. Objective The purpose of this study was to investigate the activation of the endocannabinoid system in AD in vivo and the possible intermediate role of atherosclerosis. Methods We enrolled 41 patients with probable AD, and 30 age- and gender-matched controls. All subjects underwent: ultrasound examination of cerebral and neck vessels (including intima-media thickness and plaque stenosis evaluation); blood sampling to measure levels of endocannabinoid [anandamide (AEA), 2-arachidonoylglycerol (2-AG)] and endogenous AEA analogues [N-palmitoyl-ethanolamide (PEA); N-oleoyl-ethanolamide]; neuropsychological evaluation and brain MRI (atrophy, white matter hyperintensity volume). Results 2-AG levels were higher in AD patients compared to controls (Mann-Whitney test p = 0.021). In the AD group, 2-AG correlated to white matter hyperintensity volume (r = 0.415, p = 0.015) and was higher in patients with chronic heart ischemic disease (p = 0.023). In AD patients, 2-AG was also positively related to memory (r = 0.334, p = 0.05) and attention (r = 0.423, p = 0.018) performances. Constructional praxia test scores were lower in patients with higher levels of PEA (r =-0.389, p = 0.019). Conclusion AD patients present high plasma 2-AG levels, also in relation to heart ischemic disease and cerebral leukoaraiosis. This may be a protective mechanism hindering neurodegeneration, but it may also play an ambivalent role on cerebrovascular circulation. The increase in 2-AG and PEA levels observed with ongoing pathological processes may differently modulate cognitive performances.

A 54-year-old woman started to loose vision 2 days prior to admission and also experienced left-sided headache, nausea, emesis, and disorientation. Magnetic resonance imaging (MRI) revealed bilateral posterior cerebral artery and cerebellar infarctions. Transcranial power motion Doppler (PMD-TCD) showed blunted flow signal in the proximal basilar artery (BA) suggestive for a high-grade stenosis also seen on magnetic resonance angiography (MRA). Dual antiplatelet therapy with aspirin and clopidogrel was started. Catheter angiography confirmed the proximal high-grade BA stenosis. After angiography, the patient experienced hypertensive crisis with severe headache. Blood pressure was lowered and headache resolved. One hour later she developed fluctuating level of consciousness and motor symptoms. PMD-TCD findings were suggestive for an intraluminal thrombus that moved from the proximal to the distal basilar artery, presumably further contributing to brain stem hypoperfusion and neurological deterioration. To achieve a compromise between lower blood pressure and maintenance of brain perfusion, hypervolemic hemodilution with intravenous dextran-40 was initiated. Patient's symptoms resolved to baseline and MRI showed no new parenchymal lesions.