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Background: We aim to assess whether time of day modified the treatment effect in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion Trial), a cluster-randomized trial that did not demonstrate the benefit of direct transportation to a thrombectomy-capable center versus nearest local stroke center for patients with a suspected large vessel stroke triaged in nonurban Catalonia between March 2017 and June 2020. Methods: We performed a post hoc analysis of RACECAT to evaluate if the association between initial transport routing and functional outcome differed according to trial enrollment time: daytime (8:00 am –8:59 pm ) and nighttime (9:00 pm –7:59 am ). Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with ischemic stroke. Subgroup analyses according to stroke subtype were evaluated. Results: We included 949 patients with an ischemic stroke, of whom 258 patients(27%) were enrolled during nighttime. Among patients enrolled during nighttime, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days (adjusted common odds ratio [acOR], 1.620 [95% CI, 1.020–2.551]); no significant difference between trial groups was present during daytime (acOR, 0.890 [95% CI, 0.680–1.163]; P interaction =0.014). Influence of nighttime on the treatment effect was only evident in patients with large vessel occlusion(daytime, acOR 0.766 [95% CI, 0.548–1.072]; nighttime, acOR, 1.785 [95% CI, 1.024–3.112] ; P interaction P interaction >0.1 for all comparisons). We observed longer delays in alteplase administration, interhospital transfers, and mechanical thrombectomy initiation during nighttime in patients allocated to local stroke centers. Conclusions: Among patients evaluated during nighttime for a suspected acute severe stroke in non-urban areas of Catalonia, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days. This association was only evident in patients with confirmed large vessel occlusion on vascular imaging. Time delays in alteplase administration and interhospital transfers might mediate the observed differences in clinical outcome. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02795962.

Resumen Introduccion La puncion retrograda se puede realizar guiada mediante fluoroscopia o ecografia. Nuestro objetivo fue analizar la utilidad de la ecografia en la puncion retrograda distal de las extremidades inferiores. Metodos Estudio analitico observacional de diciembre del 2013 a junio del 2019. Se incluyeron todos los accesos retrogrados distales que fueron realizados guiados ecograficamente. Se analizaron datos demograficos y clinicos, vaso utilizado como acceso retrogrado, procedimiento efectuado, cantidad de contraste usada y tiempo de escopia, fallo en el acceso y complicaciones locales. Resultados De 715 procedimientos, se utilizo el acceso retrogrado ecoguiado en 25 pacientes (64% hombres). La edad media fue de 74,8 anos (45 a 90), con un 92% de diabeticos y un 32% de insuficiencia renal cronica. La clinica inicial era estadio 4 de Rutherford en dos pacientes y estadios 5-6 en los restantes 23. En 24 (96%) pacientes la puncion ecoguiada fue satisfactoria, mientras que en un caso (4%) no se consiguio entrar en el vaso diana. Posteriormente a la puncion, el exito tecnico de la revascularizacion fue conseguido en 19 (79,2%) pacientes, con cinco (20,8%) en los que no se consiguio superar la lesion. Las arterias utilizadas como acceso retrogrado fueron: tibial anterior 11, tibial posterior 10 y peronea en cuatro. Se utilizo una media de 63mL (9 a 100 mL) de contraste con un tiempo medio de escopia de 43 minutos (15 a 76 min). No se observaron complicaciones relacionadas con el acceso retrogrado. Conclusiones El acceso retrogrado distal ecoguiado es un metodo seguro y efectivo, que supone un buen recurso en aquellos procedimientos endovasculares en los que no es posible su realizacion via anterograda.

Cannabidiol causes inhibitory effects on sodium channels, but its action on nerve impulses is not understood. Lamotrigine blocks the nerve impulses, however, it is not known if this action is of extracellular or intracellular origin. With the use of nerve chambers, we are hoping to elucidate this unknown mechanism. We hypothesize that these two chemicals may modify components of action potentials of nerve fibers in frogs. Action potential recording was made possible by the IWorx Data Quest system and a nerve chamber. Action potential data was analyzed by looking at two different components—the peaks of depolarization and the difference between the peak of depolarization and the nadir of repolarization. For every 50 minutes of recording, the data was divided into three clusters—before chemicals, after 10 minutes of treatment, and 30 minutes after treatment. In frogs, we found the high dosage (1.0 milligram/milliliter (mg/mL)) of cannabidiol had no effect on the maximum amplitude of depolarization among the three data clusters—saline, 10 minutes after cannabidiol, and 30 minutes after cannabidiol. The high dosage of cannabidiol also had no effect on the repolarization of action potentials when compared among the above three data clusters. In addition, in frogs we found the low dosage (0.1 mg/mL) of cannabidiol showed a significant difference in the maximum amplitude of depolarization when the saline data cluster was compared to the 10-minute cluster after cannabidiol cluster. Likewise, there was a significant difference on the repolarization of action potentials when the saline data cluster was compared to the 10-minute cluster after cannabidiol cluster and when the 10-minute cluster was compared to the 30-minute cluster after cannabidiol cluster. High dosage of lamotrigine showed a significant difference on the maximum amplitude of depolarization when the saline cluster was compared to the 10-minute cluster after lamotrigine on action potentials. Low dosage of lamotrigine data is currently being collected to be analyzed and presented cumulatively with all the data. This research is being supported and funded by the Department of the Biological Sciences at the University of Tennessee at Martin. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Objective: To assess whether the effect of intravenous thrombolysis in patients with large-vessel occlusion differed between patients directly admitted to thrombectomy-capable centers and patients transferred from local stroke centers without thrombectomy capabilities. Methods: We included 3206 patients with an acute ischemic large-vessel stroke with first imaging within 7 hours after onset that were directly admitted to thrombectomy-capable centers and treated with thrombectomy, or transferred from local stroke centers for thrombectomy evaluation, between 2017 and 2021 in Catalonia, Spain. Primary outcome was the degree of disability at 90 days, as evaluated by the shift analysis on the mRs score. Secondary outcomes included mortality 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 (975[49%] treated with thrombolysis) directly admitted to thrombectomy-capable centers and 938 patients (580[66%] treated with thrombolysis and 616[67%] treated with thrombectomy) transferred from local stroke centers (mean age 72±13 years, median NIHSS score 17[IQR 12-21], 1363 female[48%]). Patients treated with intravenous thrombolysis were younger, had shorter time from onset to first image acquisition, and higher rates of wake-up stroke, atrial fibrillation and anticoagulation intake. The effect of intravenous thrombolysis on the primary outcome was similar in patients directly admitted to thrombectomy-capable centers (acOR 1.50, 95% CI 1.24-1.81) and patients transferred from local stroke centers (acOR 1.44, 95% CI 1.04 to 2.01)(p interaction =0.68). Patients treated with intravenous thrombolysis had lower mortality rate, higher rate of parenchymal hematoma and similar rate of successful reperfusion, with no difference according to type of center (p interaction >0.1). Conclusion: Administration of intravenous thrombolysis in patients with a large-vessel stroke with intention to thrombectomy was associated with higher odds of good functional outcome and higher rates of parenchymal hematoma, independently of the type of stroke center were it was administered.

Background: Hospital at home (HaH), either admission avoidance (AA) or early supported discharge (ESD), was increasingly implemented in Catalonia (7.7 M, Spain) for selected patients, achieving regional adoption within the 2011-2015 Health Plan. This study aimed to assess population-wide HaH outcomes over five years (2015-2019) in a consolidated regional HaH program and provide context-independent recommendations for service quality assurance. Methods: A mixed-methods approach was adopted, combining population-based retrospective analyses of registry information with qualitative research. AA and ESD were separately compared with conventional hospitalization groups using propensity score matching techniques. In the analysis, we evaluated the 12-month period before the acute episode, the admission, and use of healthcare resources at 30 and 90 days after discharge. A panel of experts discussed the results and provided recommendations for monitoring HaH services. Results: The adoption of AA steadily increased from 5,185 to 8,086 episodes/year (total episodes 31,901; mean age 73 (SD 17) years; 79% high-risk patients), whereas ESD remained stable over the study period, averaging 5,329 episodes per year (total episodes 26,646; mean age 68 (SD 16) years; 71% high-risk patients). Mortality rates were similar in HaH and conventional hospitalization within the episode (AA: 0.31% vs. 0.45%; ESD: 0.18% vs. 0.45%) and at 30-days (AA: 3.94% vs. 3.24%; ESD: 4.50% vs. 4.07%). Likewise, the frequency of patients requiring hospital re-admissions or ER visits 30 days after discharge was similar in HaH (AA and ESD) and the corresponding controls. The 27 healthcare providers assessed showed high variability in patients age, multimorbidity, severity of episodes, recurrences, and length of stay of AA episodes. Recommendations aiming at enhancing service delivery were produced. Conclusions: Besides confirming safety and value generation of AA, we found that this service is delivered in a case-mix of diferent scenarios, encouraging provider-profiled monitoring of the service, particularly for ESD modalities. Keywords: Hospital at Home, Admission Avoidance, Early Supported Discharge, Implementation Science, Integrated Care.

Wire arc additive manufacturing (WAAM) is an energy-efficient manufacturing technique used for near-net-shape production of functional industrial components. However, heat accumulation during deposition and the associated mechanical and metallurgical changes result in complex residual stress profiles across the cross section of the fabricated components. These residual stresses are detrimental to the service life of the components. In this study, sequentially coupled thermomechanical analysis of WAAM B91 steel is conducted to quantify the residual stress variation across the component. The thermomechanical analysis includes a transient heat transfer model and a static stress model that incorporates the transformation-induced plasticity due to martensitic phase transformation. The experimentally calibrated heat transfer model mirrors the temperature variation of the system during the deposition. The results from the stress model are validated via x-ray diffraction measurements, and the numerical results are in good agreement with the experimental data.

Objective Our goal was to analyze the utility of the age-adjusted D-dimer cutoff value in patients with clinically suspected deep venous thrombosis (DVT) in an ambulatory care setting, including distal DVTs. Methods This was an observational cohort study of 606 outpatients older than 18 years presenting with low or moderate clinical suspicion of lower limb DVT (measured by Wells scale). D-dimer levels were obtained, and duplex ultrasound was performed (including femoropopliteal and below-knee veins). We calculated sensitivity, specificity, and positive and negative predictive D-dimer values and when to apply the age-adjusted D-dimer cutoff value (D-dimer threshold = age × 10 μg/L). We split patients older than 50 years into 10-year age groups. We constructed receiver operating characteristic curves of the D-dimer test for each group to find the best threshold (defined as the value of D-dimer that gives more specificity, maintaining the maximum possible sensitivity). Results There were 249 men and 357 women with a mean age of 69.3 years; 41 patients were diagnosed with DVT. At a D-dimer threshold of 250 μg/L, sensitivity was 93%, specificity was 8%, positive predictive value was 7%, and negative predictive value was 94%. When the age-adjusted cutoff level was applied, global sensitivity was 76% and specificity 61%; positive predictive value was 12%, and negative predictive value was 97%. False-negative rate was 24%. We split patients older than 50 years into 10-year age groups: 50 to 60 years, 60 to 70 years, 70 to 80 years, and >80 years. The optimum thresholds were, respectively, 526 μg/L, 442.5 μg/L, 475 μg/L, and 549. μg/L. Conclusions In our series, the age-adjusted D-dimer cutoff level is not useful in the diagnostic algorithm of DVT.

Introduction Current recommendations for regional stroke destination suggest that patients with severe acute stroke in non-urban areas should be triaged based on the estimated transport time to a referral thrombectomy-capable center. Methods We performed a post hoc analysis to evaluate the association of pre-hospital workflow times with neurological outcomes in patients included in the RACECAT trial. Workflow times evaluated were known or could be estimated before transport allocation. Primary outcome was the shift analysis on the modified Rankin score at 90 days. Results Among the 1,369 patients included, the median time from onset to emergency medical service (EMS) evaluation, the estimated transport time to a thrombectomy-capable center and local stroke center, and the estimated transfer time between centers were 65 minutes (interquartile ratio [IQR] = 43-138), 61 minutes (IQR = 36-80), 17 minutes (IQR = 9-27), and 62 minutes (IQR = 36-73), respectively. Longer time intervals from stroke onset to EMS evaluation were associated with higher odds of disability at 90 days in the local stroke center group (adjusted common odds ratio (acOR) for each 30-minute increment = 1.03, 95% confidence interval [CI] = 1.01-1.06), with no association in the thrombectomy-capable center group (acOR for each 30-minute increment = 1.01, 95% CI = 0.98-1.01, p(interaction) = 0.021). No significant interaction was found for other pre-hospital workflow times. In patients evaluated by EMS later than 120 minutes after stroke onset, direct transport to a thrombectomy-capable center was associated with better disability outcomes (acOR = 1.49, 95% CI = 1.03-2.17). Conclusion We found a significant heterogeneity in the association between initial transport destination and neurological outcomes according to the elapse of time between the stroke onset and the EMS evaluation (: NCT02795962). ANN NEUROL 2022

To enable the advancement of large-scale additive manufacturing processes, it is necessary to establish and standardize methodologies to characterize the mechanical properties of printed test coupons. Due to the large size of the print beads, conventional test standards are inadequate. The focus of this study was to determine the feasibility of using Digital image correlation (DIC) technology as a key enabler for robust data collection of strain measurements of large 3D printed parts. To incorporate the DIC measurements, a novel method was developed to prepare large 20% (by wt.) glass filled ABS test coupons for adequate contrast. Through this technique, Poisson's ratio and elastic modulus were measured and stress strain curves were generated. The data produced by DIC correlated well with failure analysis performed on spent test coupons. Additionally, fracture surface analysis of the specimens revealed poor adhesion among the ABS matrix and glass fibers. This matrix/fiber debonding demonstrated the need for improved printing parameters to maximize tensile strength. Finally, critical length analysis of the fibers revealed them to be dimensionally inadequate.

Catatonia is a complex neuropsychiatric syndrome that can be associated with several underlying etiologies including primary psychiatric and autoimmune disorders. Anti-N-methyl-D-aspartate receptor encephalitis is an autoimmune disorder typically characterized by seizures, movement abnormalities, and behavioral changes. Anti-N-methyl-D-aspartate can present with complex neuropsychiatric symptoms including catatonia which can be challenging for clinicians to identify as excited catatonia can mimic delirium and psychiatric disorders such as psychosis and mania.To identify and present cases of anti-N-methyl-D-aspartate receptor encephalitis where excited catatonia is the presenting symptom.We present 2 case studies of agitation and disinhibition in an adolescent and young adult that were ultimately found to be secondary to autoimmune receptor encephalitis, in both cases, confirmed by cerebrospinal fluid analysis to be due to anti-N-methyl-D-aspartate receptor antibodies.Excited catatonia was suspected and initially treated with immunological therapy and high doses of lorazepam. As the severity of catatonia progressed with limited improvement with lorazepam, both cases were ultimately effectively treated with electroconvulsive therapy.Excited catatonia should be considered with presentations of bizarre behavior, agitation, disinhibition, and other psychotic symptoms in patients with no prior psychiatric history. Although the primary treatment for catatonia associated with anti-N-methyl-D-aspartate receptor encephalitis is immunomodulatory therapy paired with benzodiazepines, electroconvulsive therapy has been shown to be an effective and safe adjuvant treatment that is especially useful for management of excited catatonia.

BACKGROUND: Venous thromboembolic events have been one of the main causes of mortality among hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia. The aim of our study was to describe the prevalence of deep vein thrombosis (DVT) in non-critically ill patients with COVID-19 pneumonia and correlate such observations with the thromboprophylaxis received. METHODS: We performed a prospective cohort study of 67 patients admitted to the hospital for COVID-19 pneumonia. The diagnosis was confirmed using polymerase chain reaction testing of nasopharyngeal specimens. The deep veins were examined using compression duplex ultrasonography with the transducer on B-mode. The patients were separated into two groups for statistical analysis: those receiving low-molecular-weight heparin prophylaxis and those receiving intermediate or complete anticoagulation treatment. Risk analysis and logistic regression were performed. RESULTS: Of the 67 patients, 57 were included in the present study after applying the inclusion and exclusion criteria; 49.1% were women, and the patient mean age was 71.3 years. All 57 patients had undergone compression duplex ultrasonography. Of these 57 patients, 6 were diagnosed with DVT, for an in-hospital rate of DVT in patients with COVID-19 pneumonia of 10.5%. All the patients who had presented with DVT had been receiving low-molecular-weight heparin prophylaxis. The patients receiving prophylactic anticoagulation treatment had a greater risk of DVT (16.21%; 95% confidence interval, 0.04-0.28; P = .056) compared with those receiving intermediate or complete anticoagulation treatment. We also found a protective factor for DVT in the intermediate or complete anticoagulation treatment group (odds ratio, 0.19; 95% confidence interval, 0.08-0.46; P < .05). CONCLUSIONS: Non-critically ill, hospitalized patients with COVID-19 pneumonia have a high risk of DVT despite receipt of correct, standard thromboprophylaxis.

Laser powder bed fusion (L-PBF) has emerged as one of the mainstream additive manufacturing approaches for fabricating metal parts with complex geometries and intricate internal structures. However, large deformation associated with rapid heating and cooling can lead to build failure and requires post-processing which may increase manufacturing cost and prolong the production period. In this work, an island scanning pattern design method is proposed to optimize the scanning direction of each island in order to reduce part deformation after cutting off the build platform. The objective of this optimization is to minimize the upward bending of the part after sectioning, which allows the part deformation to satisfy the tolerance requirement or reduce the post heat treatment time. Inherent strain method is employed in the sequential finite element analysis consisting of layer-by-layer activations and sectioning for fast residual distortion prediction. Full sequential sensitivity analysis for the formulated optimization is provided to update the island scanning directions. To show the feasibility and effectiveness of the proposed method, the scanning patterns of a block structure and a connecting rod were designed and parts were fabricated using an open architecture L-PBF machine. The fabrication experiments demonstrated that the residual deformation of both parts fabricated by optimized scanning pattern can be reduced by over 50% compared to the initial scanning patterns, which demonstrate the effectiveness of the proposed method.

Bupropion is an atypical antidepressant that is structurally similar to amphetamines. Its primary toxic effects include seizure, sinus tachycardia, hypertension, and agitation; however, at higher amounts of ingestion, paradoxical cardiac effects are seen. We report the case of a 21-year-old woman who ingested 13.5 g of bupropion, a dose higher than any other previously reported. The patient presented with seizure, sinus tachycardia with prolonged QTc and QRS intervals, dilated pupils, and agitation. Four days after overdose, the patient's sinus tachycardia and prolonged QTc and QRS intervals resolved with symptomatic management, but she soon developed sinus bradycardia, hypotension, and mild transaminitis. With continued conservative management and close monitoring, her sinus bradycardia resolved 8 days after the overdose. The transaminitis resolved 12 days after the overdose. Our findings are consistent with previously reported toxic effects associated with common overdose amounts of bupropion. In addition, we have observed transient cardiotoxicity manifesting as sinus bradycardia associated with massive bupropion overdose. These findings are less frequently reported and must be considered when managing patients with massive bupropion overdose. We review the psychopharmacologic implications of this and comment on previous literature.

Accurate measurement of very low cerebrospinal fluid (CSF) white blood cell (WBC) concentration is key to the diagnosis of bacterial meningitis, lethal if not promptly treated. Here we show that high frequency ultrasound (HFUS) can detect CSF WBC in vitro in concentrations relevant to meningitis diagnosis with a much finer precision than gold standard manual counting in a Fuchs-Rosenthal chamber. WBC concentrations in a mock CSF model, in the range 0-50 WBC/μL, have been tested and compared to gold standard ground truth. In this range, excellent agreement (Cohen's kappa [κ] = 0.78-90) (Cohen 1960) was observed between HFUS and the gold standard method. The presented experimental set-up allowed us to detect WBC concentrations as low as 2 cells/μL. HFUS shows promise as a low-cost, reliable and automated technology to measure very low CSF WBC concentrations for the diagnosis of early meningitis.

In large area pellet extrusion additive manufacturing, the temperature of the substrate just before the deposition of a new subsequent layer affects the overall structure of the part. Warping and cracking occur if the substrate temperature is below a material-specific threshold, and deformation and deposition adhesion failure occur if the substrate temperature is above a different threshold. Currently, Big Area Additive Manufacturing (BAAM) machine users mitigate this problem by trial and error, which is costly and may result in decreased mechanical properties, monetary losses and time inefficiencies. Through thermal imaging, the range of temperatures present during the printing of a 20 wt. % carbon fiber reinforced acrylonitrile butadiene styrene (ABS-20CF) single-bead vertical wall via the BAAM machine was measured. Compression tests were performed to understand the material behavior at those temperatures. Optical imaging was performed to identify a relationship between porosity in the printed bead and plateau regions in the compression curves at temperatures of 170 °C and below. From the thermal imaging and compressive testing, it was concluded that if the substrate temperature is above 200 °C, it will not be able to withstand the load exerted by the deposition of a new layer without experiencing deformation. This behavior was attributed to the experimentally obtained low compressive strength of ABS-20CF observed at temperatures above 200 °C.

Endovascular surgery has become the initial treatment for most patients with chronic ischemia of the lower limbs. Few studies support ultrasound surveillance (US) of this kind of procedures. The purpose of this study was to evaluate the initial efficacy of duplex ultrasound as a surveillance method in endovascular treatment in symptomatic peripheral arterial disease patients in our center.A total of 113 endovascular procedures performed in 106 patients between February 2013 and June 2015 were included. Follow-up included clinical assessment, physical examination, ankle-brachial index (ABI), plethysmography, and ultrasound at 1, 3, 6, 12, 18, and 24 months after surgery. Patients without a minimum follow-up of two controls were excluded. Worsening was defined as follows: (1) in ultrasound, a restenosis70%; (2) from ABI, a decrease0.15; (3) clinically, a decrease in claudication distance, reappearance rest pain, or worsening injuries; (4) in plethysmography, flattening in the curve.The average age was 68.3 years, with 72% being men. Twenty-two percent of treated lesions were iliac, 57% were femoropopliteal, and 21% were distal. There were 329 visits, with a mean follow-up of 13.5 months (3-31). The US detected permeability or moderate stenosis in 66 patients (58.4%) and restenosis or occlusion in 47 (41.6%). When compared with clinical status, there was a noncorrelation in 23% and a discrepancy with respect to the ABI of 27% and of 39% with plethysmography. All these differences were statistically significant (P 0.001). Twenty-one reinterventions were performed (18.6%), six patients died (5.3%), and 11 required major amputation (9.7%).Clinical status and hemodynamics can detect restenosis or occlusion of the procedure in a large part of the cases, but it can omit more than 20% of these that were only detected by US. The ultrasound follow-up is of great help to increase the reliability of the control in patients with endovascular revascularization of lower limbs.