Simultaneous Monitoring of the Middle Cerebral and Basilar Arteries to Detect Right-to-Left Shunts Using Transcranial Doppler by Agitated Saline Administration

Abstract Transcranial Doppler (TCD) is an easy, non-invasive, and real-time monitoring device for detecting right-to-left shunts (RLS). Nonetheless, it has limited benefits in patients with poor temporal windows. Therefore, we aimed to investigate whether the basilar artery (BA) window was as effective as the middle cerebral artery (MCA) in detecting RLS during TCD monitoring. Overall, we enrolled 344 patients with stroke, transient ischemic attack, headache, or dizziness. MCA and BA were monitored using a modified headset. To investigate the feasibility of the suboccipital window in detecting RLS, we instituted an evaluation tool with three tiers to evaluate microembolic signals (MESs) during TCD monitoring. Tier 1: TCD monitoring of the MCA (bilaterally) in the resting state, tier 2: TCD monitoring of the MCA (bilaterally) while performing the Valsalva maneuver, and tier 3: TCD monitoring of the index MCA and BA while performing the Valsalva maneuver. In tiers 2 and 3, a high agreement rate of 0.8076 and 0.8068 (p<0.001), respectively, on the weighted kappa index, and a high intra-class correlation coefficient of 0.9822 and 0.9860 (p<0.001), respectively, were observed on detecting MESs. Our data suggests that the BA window is as effective as the MCA window for detecting RLS on TCD.

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A Comparison of Transcranial Doppler and Transesophageal Echocardiography (with Conscious Sedation) in the Detection of Right-to-Left Cardiac Shunts

Journal for Vascular Ultrasound ◽

10.1177/154431670903300306 ◽

2009 ◽

Vol 33 (3) ◽

pp. 147-149

Author(s):

Thomas H. Alexander ◽

Lester B. Collins

Keyword(s):

Transesophageal Echocardiography ◽

Transcranial Doppler ◽

Conscious Sedation ◽

Valsalva Maneuver ◽

Cryptogenic Stroke ◽

Intravenous Sedation ◽

East Texas ◽

Alternative Test ◽

Ischemic Attack ◽

Therapeutic Alternatives

Background and Purpose Transesophageal echocardiography (TEE) is used and accepted as a method for detecting right-to-left cardiac shunts, most commonly caused by patent foramen ovale (PFO). Transcranial Doppler (TCD) is an accepted alternative test involving the injection of agitated saline with a timed and gauged Valsalva maneuver. Controversy exists about the exact role of PFO in patients with cryptogenic stroke and the resultant therapeutic alternatives; however, there is no controversy about the need to accurately detect the PFO. Methods We reviewed the records of 264 consecutive patients referred for TCD with the diagnosis of cryptogenic stroke or transient ischemic attack. Results A total of 89 (33.7%) patients had a positive TCD test for PFO; 39 went on to have TEE studies. A total of 19 of the TEE results failed to confirm the PFO (48.7%). TEE in the East Texas Region is routinely performed by the use of conscious sedation, which requires the supervising cardiologist to compress the abdomen to simulate Valsalva. Conclusion In the East Texas region, transcranial Doppler is superior to transesophageal echocardiography for the detection of right-to-left shunt in stroke patients, presumably because of the Valsalva limiting effect of intravenous sedation routinely given during the latter procedure.

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Comparison of the Mayo Endoscopy Score and the Ulcerative Colitis Endoscopy Index of Severity and the Ulcerative Colitis Colonoscopy Index of Severity

Endoscopy International Open ◽

10.1055/a-1313-6968 ◽

2021 ◽

Vol 09 (02) ◽

pp. E130-E136

Author(s):

María Belvis Jiménez ◽

Pedro Hergueta-Delgado ◽

Blas Gómez Rodríguez ◽

Belén Maldonado Pérez ◽

Luisa Castro Laria ◽

...

Keyword(s):

Ulcerative Colitis ◽

Interobserver Variability ◽

Intraclass Correlation ◽

Weighted Kappa ◽

Clinical Situation ◽

Kappa Index ◽

Perfect Correlation ◽

Index Of Severity ◽

Severity Of The Disease ◽

Normal Clinical Practice

Abstract Background and study aims: Endoscopy plays an essential role in managing patients with ulcerative colitis (UC), as it allows us to visualize and assess the severity of the disease. As such assessments are not always objective, different scores have been devised to standardize the findings. The main aim of this study was to assess the interobserver variability between the Mayo Endoscopy Score (MES), Ulcerative Colitis Endoscopy Index of Severity (UCEIS) and Ulcerative Colitis Colonoscopy Index of Severity (UCCIS) analyzing the severity of the endoscopic lesions in patients with ulcerative colitis. Patients and methods: This was a single-cohort observational study in which a colonoscopy was carried out on patients with UC, as normal clinical practice, and a video was recorded. The results from the video were classified according to the MES, UCEIS and UCCIS by three endoscopic specialists independently, and they were compared to each other. The Mayo Endoscopy Score (MES) was used to assess the clinical situation of the patient. The therapeutic impact was analyzed after colonoscopy was carried out. Results: Sixty-seven patients were included in the study. The average age was 51 (SD ± 16.7) and the average MES was 3.07 (SD ± 2.54). The weighted Kappa index between endoscopists A and B for the MES was 0.8; between A and C 0.52; and between B and C 0.49. The intraclass correlation coefficient for UCEIS was 0.92 among the three endoscopists (CI 95 %: 0.83–0.96) and 0.96 for UCCIS among the three endoscopists (CI 95 % 0.94–0.97). A change in treatment for 34.3 % of the patients was implemented on seeing the results of the colonoscopy. Conclusions: There was an adequate, but not perfect, correlation between the different endoscopists for MES, UCEIS, UCCIS. This was higher with the last two scores. Thus, there is still some subjectivity to be minimized through special training, on assessing the seriousness of the endoscopic lesions in patients with UC.

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Optimal Timing for Launching Installation of Tier 2 and 3 Systems of School-Wide Positive Behavioral Interventions and Supports

Journal of Positive Behavior Interventions ◽

10.1177/1098300721996084 ◽

2021 ◽

pp. 109830072199608

Author(s):

Angus Kittelman ◽

Sterett H. Mercer ◽

Kent McIntosh ◽

Robert Hoselton

Keyword(s):

Longitudinal Study ◽

Behavioral Interventions ◽

Structural Equation ◽

Equation Modeling ◽

Optimal Timing ◽

First Year ◽

Tier 2 ◽

Positive Behavioral Interventions ◽

Tier 1 ◽

Tier 3

The purpose of this longitudinal study was to examine patterns in implementation of Tier 2 and 3 school-wide positive behavioral interventions and supports (SWPBIS) systems to identify timings of installation that led to higher implementation of advanced tiers. Extant data from 776 schools in 27 states reporting on the first 3 years of Tier 2 implementation and 359 schools in 23 states reporting on the first year of Tier 3 implementation were analyzed. Using structural equation modeling, we found that higher Tier 1 implementation predicted subsequent Tier 2 and Tier 3 implementation. In addition, waiting 2 or 3 years after initial Tier 1 implementation to launch Tier 2 systems predicted higher initial Tier 2 implementation (compared with implementing the next year). Finally, we found that launching Tier 3 systems after Tier 2 systems, compared with launching both tiers simultaneously, predicted higher Tier 2 implementation in the second and third year, so long as Tier 3 systems were launched within 3 years of Tier 2 systems. These findings provide empirical guidance for when to launch Tier 2 and 3 systems; however, we emphasize that delays in launching advanced systems should not equate to delays in more intensive supports for students.

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Correction to: Transient ischemic attack presenting as recurrent migratory numbness by seconds: a rare case confirmed by transcranial Doppler micro-emboli monitoring

BMC Neurology ◽

10.1186/s12883-020-02026-2 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Xianyue Liu ◽

Ke Han ◽

Mingyi Hu ◽

Huanquan Liao ◽

Qinghua Hou

Keyword(s):

Transient Ischemic Attack ◽

Transcranial Doppler ◽

Rare Case ◽

Ischemic Attack

An amendment to this paper has been published and can be accessed via the original article.

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High-Grade Stenosis of a Traumatic Brachiocephalic Pseudoaneurysm and the Change in Cerebral Blood Flow Assessed With Transcranial Doppler Ultrasound

Journal for Vascular Ultrasound ◽

10.1177/15443167211002315 ◽

2021 ◽

pp. 154431672110023

Author(s):

Winnie Nguyen ◽

Tammy Albanese ◽

Vanessa Tran ◽

Anne Moore ◽

Laligam Sekhar

Keyword(s):

Doppler Ultrasound ◽

Transcranial Doppler ◽

Transcranial Doppler Ultrasound ◽

Computed Tomographic Angiography ◽

Computed Tomographic ◽

Vertebral Arteries ◽

Luminal Narrowing ◽

Basilar Arteries ◽

The Right ◽

Tomographic Angiography

This is a case report of a 35-year-old female pedestrian struck by a semi-truck. computed tomographic angiography (CTA) revealed a pseudoaneurysm at the proximal brachiocephalic artery measuring 1.8 cm in cranio-caudal length and 1.2 × 0.6 cm transverse. Just distal to the pseudoaneurysm, there was severe luminal narrowing caused by either a dissection flap or mural thrombus. Due to profound left-sided weakness, transcranial Doppler ultrasound was performed which demonstrated “hesitant” waveforms in the right middle cerebral and right vertebral arteries secondary to proximal obstruction. Hesitant waveforms display mid-systolic velocity deceleration and may also be referred to as the “bunny” waveform. Emboli monitoring of the right middle cerebral and basilar arteries were positive for active embolization

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Global Inland Capture and Culture Finfisheries Follow Different Trends When Evaluated by the Human Development Index

Sustainability ◽

10.3390/su13158420 ◽

2021 ◽

Vol 13 (15) ◽

pp. 8420

Author(s):

Peter W. Sorensen ◽

Maria Lourdes D. Palomares

Keyword(s):

Socioeconomic Factors ◽

Human Development ◽

Human Development Index ◽

Developed Countries ◽

Global Scale ◽

Tier 2 ◽

Development Index ◽

Tier 1 ◽

Catch Reconstruction ◽

Tier 3

To assess whether and how socioeconomic factors might be influencing global freshwater finfisheries, inland fishery data reported to the FAO between 1950 and 2015 were grouped by capture and culture, country human development index, plotted, and compared. We found that while capture inland finfishes have greatly increased on a global scale, this trend is being driven almost entirely by poorly developed (Tier-3) countries which also identify only 17% of their catch. In contrast, capture finfisheries have recently plateaued in moderately-developed (Tier-2) countries which are also identifying 16% of their catch but are dominated by a single country, China. In contrast, reported capture finfisheries are declining in well-developed (Tier-1) countries which identify nearly all (78%) of their fishes. Simultaneously, aquacultural activity has been increasing rapidly in both Tier-2 and Tier-3 countries, but only slowly in Tier-1 countries; remarkably, nearly all cultured species are being identified by all tier groups. These distinctly different trends suggest that socioeconomic factors influence how countries report and conduct capture finfisheries. Reported rapid increases in capture fisheries are worrisome in poorly developed countries because they cannot be explained and thus these fisheries cannot be managed meaningfully even though they depend on them for food. Our descriptive, proof-of-concept study suggests that socioeconomic factors should be considered in future, more sophisticated efforts to understand global freshwater fisheries which might include catch reconstruction.

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23. Regional Variation in Outpatient Antibiotic Prescribing in a Commercially-insured Population, United States, 2017

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa417.022 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S12-S12

Author(s):

Destani J Bizune ◽

Danielle Palms ◽

Laura M King ◽

Monina Bartoces ◽

Ruth Link-Gelles ◽

...

Keyword(s):

United States ◽

Otitis Media ◽

Acute Otitis Media ◽

Urgent Care ◽

Antibiotic Prescribing ◽

Tier 2 ◽

Regional Variability ◽

Patient Age ◽

Patient Âgé ◽

Tier 3

Abstract Background Studies have shown that the Southern United States has higher rates of outpatient antibiotic prescribing compared to other regions in the country, but reasons for this variation are unclear. We aimed to determine whether the regional variability in outpatient antibiotic prescribing for respiratory diagnoses can be explained by differences in patient age, care setting, comorbidities, and diagnosis in a commercially-insured population. Methods We analyzed the 2017 IBM® MarketScan® Commercial Database of commercially-insured individuals aged < 65 years. We included visits with acute respiratory tract infection (ARTI) diagnoses from retail clinics, urgent care centers, emergency departments, and physician offices. ARTI diagnoses were categorized as: Tier 1, antibiotics are almost always indicated (pneumonia); Tier 2, antibiotics are sometimes indicated (sinusitis, acute otitis media, pharyngitis); and Tier 3, antibiotics are not indicated (asthma, allergy, bronchitis, bronchiolitis, influenza, nonsuppurative otitis media, viral upper respiratory infections, viral pneumonia). We calculated risk ratios and 95% confidence intervals (CI) stratified by US Census region and ARTI tier using log-binomial models controlling for patient age, comorbidities (Elixhauser and Complex Chronic Conditions for Children), and setting of care, with Tier 3 visits in the West, the strata with the lowest antibiotic prescription rate, as the reference for all strata. Results A total of 100,104,860 visits were analyzed. In multivariable modeling, ARTI visits in the South and Midwest were highly associated with receiving an antibiotic for Tier 2 conditions vs. patients in other regions (Figure 1). Figure 1. Multivariable model comparing risk of receiving an antibiotic for an ARTI by region and diagnostic tier in urgent care, retail health, emergency department, and office visits, MarketScan® 2017, United States Conclusion Regional variability in outpatient antibiotic prescribing for Tier 2 and 3 ARTIs remained even after controlling for patient age, comorbidities, and setting of care. It is likely that this variability is in part due to non-clinical factors such as regional differences in clinicians’ prescribing habits and patient expectations. Targeted and enhanced public health stewardship interventions are needed to address cultural factors that affect antibiotic prescribing in outpatient settings. Disclosures All Authors: No reported disclosures

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Incorporation of plasma-based next-generation sequencing to improve guideline-concordant molecular testing in patients with newly diagnosed metastatic nonsquamous non-small cell lung cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2020.39.28_suppl.14 ◽

2021 ◽

Vol 39 (28_suppl) ◽

pp. 14-14

Author(s):

Charu Aggarwal ◽

Melina Elpi Marmarelis ◽

Wei-Ting Hwang ◽

Dylan G. Scholes ◽

Aditi Puri Singh ◽

...

Keyword(s):

Clinical Practice ◽

Practice Change ◽

Molecular Testing ◽

Tier 2 ◽

Newly Diagnosed ◽

Next Generation ◽

First Line ◽

Tier 1 ◽

Tier 3 ◽

The Impact

14 Background: Current NCCN guidelines recommend comprehensive molecular profiling for all newly diagnosed patients with metastatic non-squamous NSCLC to enable the delivery of personalized medicine. We have previously demonstrated that incorporation of plasma based next-generation gene sequencing (NGS) improves detection of clinically actionable mutations in patients with advanced NSCLC (Aggarwal et al, JAMA Oncology, 2018). To increase rates of comprehensive molecular testing at our institution, we adapted our clinical practice to include concurrent use of plasma (P) and tissue (T) based NGS upon initial diagnosis. P NGS testing was performed using a commercial 74 gene assay. We analyzed the impact of this practice change on guideline concordant molecular testing at our institution. Methods: A retrospective cohort study of patients with newly diagnosed metastatic non-squamous NSCLC following the implementation of this practice change in 12/2018 was performed. Tiers of NCCN guideline concordant testing were defined, Tier 1: complete EGFR, ALK, BRAF, ROS1, MET, RET, NTRK testing, Tier 2: included above, but with incomplete NTRK testing, Tier 3: > 2 genes tested, Tier 4: single gene testing, Tier 5: no testing. Proportion of patients with comprehensive molecular testing by modality (T NGS vs. T+P NGS) were compared using one-sided Fisher’s exact test. Results: Between 01/2019, and 12/2019, 170 patients with newly diagnosed metastatic non-Sq NSCLC were treated at our institution. Overall, 98.2% (167/170) patients underwent molecular testing, Tier 1: n = 100 (59%), Tier 2: n = 39 (23%), Tier 3/4: n = 28 (16.5%), Tier 5: n = 3 (2%). Amongst these patients, 43.1% (72/167) were tested with T NGS alone, 8% (15/167) with P NGS alone, and 47.9% (80/167) with T+P NGS. A higher proportion of patients underwent comprehensive molecular testing (Tiers 1+2) using T+P NGS: 95.7% (79/80) compared to T alone: 62.5% (45/72), p < 0.0005. Prior to the initiation of first line treatment, 72.4% (123/170) patients underwent molecular testing, Tier 1: n = 73 (59%), Tier 2: n = 27 (22%) and Tier 3/4: n = 23 (18%). Amongst these, 39% (48/123) were tested with T NGS alone, 7% (9/123) with P NGS alone and 53.6% (66/123) with T+P NGS. A higher proportion of patients underwent comprehensive molecular testing (Tiers 1+2) using T+P NGS, 100% (66/66) compared to 52% (25/48) with T NGS alone (p < 0.0005). Conclusions: Incorporation of concurrent T+P NGS testing in treatment naïve metastatic non-Sq NSCLC significantly increased the proportion of patients undergoing guideline concordant molecular testing, including prior to initiation of first-line therapy at our institution. Concurrent T+P NGS should be adopted into institutional pathways and routine clinical practice.

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Initial Experience in Predicting the Risk of Hospitalization of 496 Outpatients with COVID-19 Using a Telemedicine Risk Assessment Tool

10.1101/2020.07.21.20159384 ◽

2020 ◽

Cited By ~ 1

Author(s):

James B O'Keefe ◽

Elizabeth J Tong ◽

Thomas H Taylor ◽

Ghazala D Datoo O'Keefe ◽

David C Tong

Keyword(s):

Risk Assessment ◽

Assessment Tool ◽

Cox Regression ◽

Risk Assessment Tool ◽

Individual Risk ◽

Tier 2 ◽

Tier 1 ◽

Risk Patients ◽

Tier 3

Objective: To determine whether a risk prediction tool developed and implemented in March 2020 accurately predicts subsequent hospitalizations. Design: Retrospective cohort study, enrollment from March 24 to May 26, 2020 with follow-up calls until hospitalization or clinical improvement (final calls until June 19, 2020) Setting: Single center telemedicine program managing outpatients from a large medical system in Atlanta, Georgia Participants: 496 patients with laboratory-confirmed COVID-19 in isolation at home. Exclusion criteria included: (1) hospitalization prior to telemedicine program enrollment, (2) immediate discharge with no follow-up calls due to resolution. Exposure: Acute COVID-19 illness Main Outcome and Measures: Hospitalization was the outcome. Days to hospitalization was the metric. Survival analysis using Cox regression was used to determine factors associated with hospitalization. Results: The risk-assessment rubric assigned 496 outpatients to risk tiers as follows: Tier 1, 237 (47.8%); Tier 2, 185 (37.3%); Tier 3, 74 (14.9%). Subsequent hospitalizations numbered 3 (1%), 15 (7%), and 17 (23%) and for Tiers 1-3, respectively. From a Cox regression model with age ≥ 60, gender, and self-reported obesity as covariates, the adjusted hazard ratios using Tier 1 as reference were: Tier 2 HR=3.74 (95% CI, 1.06-13.27; P=0.041); Tier 3 HR=10.87 (95% CI, 3.09-38.27; P<0.001). Tier was the strongest predictor of time to hospitalization. Conclusions and Relevance: A telemedicine risk assessment tool prospectively applied to an outpatient population with COVID-19 identified both low-risk and high-risk patients with better performance than individual risk factors alone. This approach may be appropriate for optimum allocation of resources.

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