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Background Stenting extracranial internal carotid artery (ICA) lesions in acute ischemic stroke with tandem lesions is technically challenging. Its safety is highly debated because of the requirement of dual‐antiplatelet therapy. The optimal stenting device, timing, and periprocedural antiplatelet therapy for extracranial ICA stenting in the setting of acute tandem occlusion are still unclear. Methods We performed a retrospective study of patients with acute ischemic stroke attributable to tandem lesions who underwent endovascular treatment during a 5‐year period receiving either conventional self‐expanding carotid stents (SX) or balloon‐expandable carotid stent (BX). BX stents were restented with an SX in the subacute phase. Primary outcomes of interest were extracranial ICA patency at follow‐up and symptomatic intracranial hemorrhage. Results A total of 112 patients admitted from April 2016 to April 2021 were included. Dual‐antiplatelet therapy immediately following endovascular treatment was more frequently administered in the SX group (35/39 [89.7%]) compared with the BX group (20/73 [27.4%]) (P

Background Our goal is to evaluate whether the administration of thrombolytic treatment has varying effects on clinical and radiological outcomes in patients with large‐vessel occlusion stroke, based on the type of stroke center where the treatment was given (thrombectomy‐capable center versus local stroke center). Methods We included patients with an acute ischemic large‐vessel occlusion stroke who were directly admitted to thrombectomy‐capable centers and treated with endovascular thrombectomy, or were transferred from local stroke centers as thrombectomy candidates, in Catalonia, Spain, between 2017 and 2021. The primary outcome was the shift analysis on the modified Rankin scale score at 90 days. Secondary outcomes included death at 90 days and the rate of parenchymal hemorrhage and successful reperfusion. Inverse‐probability weighting clustered at the type of stroke center was used to estimate the effects. Results The analysis included 2268 patients directly admitted to thrombectomy‐capable centers, of whom 975 (49%) were treated with thrombolysis, and 938 patients transferred from local stroke centers, of whom 580 (66%) were treated with thrombolysis and 616 (67%) were treated with thrombectomy. Mean age was 72 (SD ±13) years, median National Institute of Health Stroke Scale score was 17 (interquartile range, 12–21), and 1363 patients were women (48%). Patients treated with intravenous thrombolysis were younger, had shorter time from onset to first image, higher Alberta Stroke Program Early Computed Tomography Score, and lower rates of wake‐up stroke, atrial fibrillation, and anticoagulation intake. Patients treated with thrombolysis had better functional outcome at 90 days, with no difference between patients directly admitted to thrombectomy‐capable centers (adjusted common odds ratio [acOR], 1.50 [95% CI, 1.24–1.81]) and patients transferred from local stroke centers (acOR, 1.44 [95% CI, 1.04–2.01]). Patients treated with intravenous thrombolysis had lower death rate, higher rate of parenchymal hematoma, and similar rate of successful reperfusion, with no difference according to type of center (Pinteraction>0.1). Conclusion Administration of intravenous thrombolysis in patients with a large‐vessel stroke with intention of thrombectomy was associated with lower degrees of disability, lower death rate, and higher rates of parenchymal hematoma both in thrombectomy‐capable centers and in local stroke centers.

IntroductionUric acid has gained considerable attention as a potential neuroprotective agent in stroke during the last decades, however, its role in the pathophysiology of ischemic stroke remains poorly understood. A serial evaluation of uric acid levels during the acute phase of stroke and its association with infarct size on magnetic resonance imaging is lacking.MethodsWe present a cohort study of 31 patients with ischemic stroke who were not candidates for thrombolysis according to current criteria at the time. We performed daily measurements of serum uric acid and total antioxidant capacity of plasma during the first week after symptoms onset and 30 days after. Infarct size was determined in the acute phase by a DWI sequence and the final infarct size with a control MRI (FLAIR) at day 30.ResultsUric acid significantly decreases between days 2 to 6 compared to day 1, after adjustment by sex, age and DWI at diagnosis, with a nadir value at 72h. A mixed model analysis showed a negative association between DWI at diagnosis and uric acid evolution during the first week after stroke. Moreover, multivariable linear regression of uric acid values during follow up on DWI volumes demonstrated that DWI volume at diagnosis is negatively associated with uric acid levels at day 3 and 4. There were no significant associations between total antioxidant capacity of plasma and DWI at diagnosis, or FLAIR at any point.DiscussionPatients with larger infarcts exhibited a significant decrease in serum uric acid levels, accounting for a more prominent reactive oxygen species scavenging activity with subsequent consumption and decay of this antioxidant. The different kinetics of total antioxidant capacity of plasma and serum uric acid levels suggests a specific role of uric acid in the antioxidant response in ischemic stroke.

Rationale: In-stent reocclusion after endovascular therapy has a negative impact on outcomes in acute ischemic stroke (AIS) due to tandem lesions (TL). Optimal antiplatelet therapy approach in these patients to avoid in-stent reocclusion is yet to be elucidated., Aims: To assess efficacy and safety of intravenous tirofiban versus intravenous aspirin in patients undergoing MT plus carotid stenting in the setting of AIS due to TL., Sample Size Estimates: Two hundred forty patients will be enrolled, 120 in every treatment arm., Methods and Design: A multicenter, prospective, randomized, controlled (aspirin group), assessor-blinded clinical trial will be conducted. Patients fulfilling the inclusion criteria will be randomized at MT onset to the experimental or control group (1:1). Intravenous aspirin will be administered at a 500-mg single dose and tirofiban at a 500-mcg bolus followed by a 200-mcg/h infusion during the first 24 h. All patients will be followed for up to 3 months., Study Outcomes: Primary efficacy outcome will be the proportion of patients with carotid in-stent thrombosis within the first 24 h after MT. Primary safety outcome will be the rate of symptomatic intracranial hemorrhage., Discussion: This will be the first clinical trial to assess the best antiplatelet therapy to avoid in-stent thrombosis after MT in patients with TL., Trial Registration: The trial is registered as NCT05225961. February, 7th, 2022., (© 2024. The Author(s).)

Background: In-stent thrombosis after mechanical thrombectomy (MT) worsen outcomes in acute ischemic stroke (AIS) due to tandem lesions (TL). Although an optimal antiplatelet therapy is needed, the best approach to avoid in-stent thrombosis is yet to be elucidated., Hypothesis: Low-dose intravenous tirofiban is superior to intravenous aspirin in avoiding in-stent thrombosis in patients undergoing MT plus carotid stenting in the setting of AIS due to TL., Methods: The ATILA-trial is a multicenter, prospective, phase IV, randomized, controlled (aspirin group as control), assessor-blinded clinical trial. Patients fulfilling inclusion criteria (AIS due to TL, ASPECTS ⩾ 6, pre-stroke modified Rankin Scale ⩽2 and onset <24 h) will be randomized (1:1) at MT onset to experimental (intravenous tirofiban) or control group (intravenous aspirin). Intravenous aspirin will be administered at a 500 mg single dose and tirofiban at a 500 µg bolus followed by a 200 µg/h infusion during first 22 h. All patients will be followed up to 3 months. Sample size estimated is 240 patients., Outcomes: The primary efficacy outcome is the proportion of patients with carotid in-stent thrombosis within the first 24 h after MT. The primary safety outcome is the rate of symptomatic intracranial hemorrhage. Secondary outcomes include functional independence defined as modified Rankin Scale 0-2, proportion of patients undergoing rescue therapy due to in-stent aggregation during MT and carotid reocclusion at 30 days., Discussion: ATILA-trial will be the first clinical trial regarding the best antiplatelet therapy to avoid in-stent thrombosis after MT in patients with TL., Trial Registration: NCT0522596., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© European Stroke Organisation 2022.)

Appropriative water rights allocate surface water to competing users based on seniority. Often water rights vary seasonally with spring runoff, irrigation schedules, or other non-uniform supply and demand. Downscaled monthly Coupled Model Intercomparison Project multi-model, multi-emissions scenario hydroclimate data evaluate water allocation reliability and variability with anticipated hydroclimate change. California's Tuolumne watershed is a study basin, chosen because water rights are well-defined, simple, and include competing environmental, agricultural, and urban water uses representative of most basins. We assume that dedicated environmental flows receive first priority when mandated by federal law like the Endangered Species Act or hydropower relicensing, followed by senior agricultural water rights, and finally junior urban water rights. Environmental flows vary by water year and include April pulse flows, and senior agricultural water rights are 68% larger during historical spring runoff from April through June. Results show that senior water right holders receive the largest climate-driven reductions in allocated water when peak streamflow shifts from snowmelt-dominated spring runoff to mixed snowmelt- and rainfall-dominated winter runoff. Junior water right holders have higher uncertainty from inter-annual variability. These findings challenge conventional wisdom that water shortages are absorbed by junior water users and suggest that aquatic ecosystems may be disproportionally impaired by hydroclimate change, even when environmental flows receive priority., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Even after the introduction of the Patient Protection and Affordable Care Act (ACA), uninsured visits remain high, especially in states that opted out of Medicaid expansion. Since the ACA does not provide universal coverage, free clinics serve as safety nets for the un- or under-insured, and will likely continue serving underserved populations. The purpose of this study is to examine factors influencing intentions to not apply for health insurance via the ACA among uninsured free clinic patients in a state not expanding Medicaid. Uninsured primary care patients utilizing a free clinic (N = 551) completed a self-administered survey in May and June 2015. Difficulty obtaining information, lack of instruction to apply, and cost, are major factors influencing intention not to apply for health insurance through the ACA. US born English speakers, non-US born English speakers, and Spanish speakers reported different kinds of perceived barriers to applying for health insurance through the ACA. Age is an important factor impacting individuals' intentions not to apply for health insurance through the ACA, as older patients in particular need assistance to obtain relevant information about the ACA and other resources. A number of unchangeable factors limit the free clinics' ability to promote enrollment of health insurance through the ACA. Yet free clinics could be able to provide some educational programs or the information of resources to patients. In particular, non-US born English speakers, Spanish speakers, and older adults need specific assistance to better understand health insurance options available to them.

Objectives: This study examined the impact of neighborhood environments on health consciousness, information seeking, and attitudes among uninsured free clinic patients to better understand the specific needs of the population for health promotion and prevention efforts., Methods: US-born English-speaking, non-US-born English-speaking, and Spanish-speaking free clinic patients completed a self-administered survey using reliable measures in autumn 2014 (N = 769)., Results: The results of this study suggest that social cohesion is positively associated with health consciousness, information seeking, and attitudes. Lower levels of available healthy food in the community were associated with higher levels of health consciousness. Although Spanish speakers reported lower levels of the availability of healthy food, social cohesion, and access to the Internet or text messaging compared with US-born or non-US-born English speakers, they were more likely to be health conscious and have higher levels of health information seeking. Spanish speakers as well as non-US-born English speakers, were more likely to attend health education classes compared with US-born English speakers., Conclusions: Health education programs for free clinic patients should include strategies to increase social cohesion. Health education programs should consider the diverse needs of these individual populations to maximize the effectiveness of the programs for free clinic patients.

The prevalence of Toxoplasma gondii in free range chickens is a good indicator of the prevalence of T. gondii oocysts in the environment because chickens feed from the ground. In the present study, prevalence of T. gondii in 40 free range chickens (Gallus domesticus) from a rural area surrounding Paraná, Brazil was assessed. Blood, heart, and brain from each chicken were examined for T. gondii infection. Antibodies to T. gondii, assayed with the modified agglutination test (MAT> or =1:5) were found in 16 chickens. Hearts and brains of seropositive (MAT> or =1:5) chickens were bioassayed in mice. Additionally, hearts and brains of seronegative (MAT<1:5) chickens were bioassayed in two T. gondii-free cats (12 chickens per cat). T. gondii was isolated from 13 of 16 (81%) seropositive chickens. Of the two cats fed tissues pooled form seronegative chickens, one shed T. gondii oocysts. Nine of the 13 T. gondii isolates killed 100% of infected mice. The T. gondii isolate from the cat was also virulent for mice. Genotyping of 13 chicken isolates of T. gondii using the SAG2 locus indicated that seven isolates were type I and six were type III; three of these type III isolates killed all infected mice suggesting that all strains virulent for mice are not type I. The isolate from the feces of the cat fed chicken tissues was type I.

Purpose: To study the angiographic anatomy of human coronary veins and the possibility of epicardial venous mapping through microelectrode catheters., Methods: We evaluated 30 patients with sustained ventricular tachycardia using a catheter which provided occlusion of the coronary sinus ostium during venous angiography. They were 25 males, 5 females, ages ranging from 24 to 76 years (mean = 52.7). The veins were studied according to their number, caliber and distribution in the anterior and posterior wall of the left ventricle., Results: Coronary sinus was catheterized in all patients. No discomfort or complication were observed. The number of veins from posterior wall of the left ventricle was 3.1 and anterior wall, 1.9, p < 0.05. The caliber of the coronary veins were: anterior interventricular vein (distal segment = 1.19 +/- 0.22 mm, middle segment = 1.65 +/- 0.35 mm), posterior interventricular vein (distal segment = 1.83 +/- 0.47 mm, middle segment = 2.00 +/- 0.52 mm), left posterior vein (distal segment = 1.45 +/- 0.25 mm, middle segment = 2.49 +/- 0.92 mm); p < 0.05., Conclusion: The balloon occlusion technique for coronary venous angiography is feasible and safe. The number and the caliber (distal and middle) of the veins from the posterior wall of the left ventricle were significantly greater than those from the anterior wall. Anatomic conditions for venous epicardial mapping are more adequate in the posterior wall of the left ventricle.