Mechanical Thrombectomy in Patients With Milder Strokes and Large Vessel Occlusions A Multicenter Matched Analysis

Background and Purpose-We aimed to describe the safety and efficacy of immediate mechanical thrombectomy (MT) in patients with large vessel occlusions and low National Institutes of Health Stroke Scale (NIHSS) versus best medical management. Methods-Patients from prospectively collected databases of 6 international comprehensive stroke centers with large vessel occlusions (distal intracranial internal carotid, middle cerebral artery-M1 and M2 segments, or basilar artery with or without tandem occlusions) and NIHSS 0 to 5 were identified and divided into 2 groups for analysis: immediate MT or initial best medical management which included rescue MT after neurological deterioration (best medical management-MT). Uni- and multivariate analyses and patient-level matching for age, baseline NIHSS, and occlusion site were performed to compare baseline and outcome variables across the 2 groups. The primary outcome was defined as good outcome (modified Rankin Scale score, 0-2) at day 90. Safety outcome was symptomatic intracranial hemorrhage as defined by the ECASS (European Cooperative Acute Stroke Study) II and mortality at day 90. Results: Compared with best medical management-MT (n=220), patients with immediate MT (n=80) were younger (65.3 +/- 13.5 versus 69.5 +/- 14.1;P=0.021), had more often atrial fibrillation (44.8% versus 28.2%;P=0.012), higher baseline NIHSS (4, 0-5 versus 3, 0-5;P=0.005), higher Alberta Stroke Program Early CT Score (10, 7-10 versus 10, 5-10;P=0.023), more middle cerebral artery-M1, and less middle cerebral artery-M2 (41.3% versus 21.9% and 28.8% versus 49.3%;P=0.016) occlusions. The adjusted odds ratio for good outcome was 3.1 (95% CI, 1.4-6.9) favoring immediate MT. In the matched analysis, there was a 14.4% absolute difference in good outcome (84.4% versus 70.1%;P=0.03) at day 90 favoring immediate MT. There were no safety concerns. Conclusions: Our retrospective, pilot analysis suggests that immediate thrombectomy in large vessel occlusions patients with low NIHSS on presentation may be safe and has the potential to result in improved outcomes. Randomized clinical trials are warranted to establish the optimal management for this patient population

Adenovirus types 2, 8, and 37 associated with genital infections in patients attending a sexually transmitted disease clinic

Adenoviruses (Ads) are an important cause of respiratory illness, conjunctivitis, and gastroenteritis, but they are seldom recognized as a potential cause of sexually transmitted disease. We performed virus cultures on approximately 7,000 patients attending a sexually transmitted disease clinic or other health department clinics for the evaluation of genital ulcers, urethritis, or conjunctivitis. Ads were isolated from genital or conjunctival specimens obtained from 23 (0.33%) patients. Among the 20 Ad-positive men, 15 (75%) had urethritis, 12 (60%) had conjunctivitis, and 10 (50%) had both. All three Ad-positive women had vaginal discharge and genital ulcers or fissures. Ad isolates from 17 patients were available for serotyping. Ad type 37 was isolated from 14 patients, Ad type 8 was isolated from 2 patients, and Ad type 2 was isolated from 1 patient. In three of the Ad type 37 cases, Ad was recovered from both urethral and conjunctival specimens. One of the Ad type 8 cases had conjunctivitis, but the Ad type 2 case did not. Ads, particularly type 37, may be a sexually transmissible cause of genital ulcers, urethritis, and conjunctivitis.</jats:p

Incidence of Nongonococcal Urethritis in Men Who Have Sex With Women and Associated Risk Factors

BACKGROUND: Incidence and risk factors for nongonococcal urethritis (NGU) remain poorly defined. We conducted a cohort study to estimate the incidence of NGU and identify risk factors in men who have sex with women. METHODS: We enrolled cisgender male STD clinic attendees age ≥16 who reported exclusively female partners. At enrollment and six monthly follow-up visits, men underwent a clinical exam, provided urethral swab and urine specimens, completed a sexual behavior survey and bi-weekly diaries, and were tested for Chlamydia trachomatis (CT) and Mycoplasma genitalium (MG) using Aptima assays (Hologic, Inc.). NGU was defined as ≥5 polymorphonuclear leukocytes per high-power field plus either urethral symptoms or visible discharge. We estimated incidence of NGU overall, asymptomatic and symptomatic NGU, non-CT/non-MG NGU and CT/MG-associated NGU using Poisson regression for clustered outcomes. We performed relative risk binomial regression for clustered data to identify characteristics associated with incident NGU. RESULTS: From 08/2014–07/2018, 307 participants contributed 109.4 person-years at risk of NGU. Median age was 32 years and 52% were White. At enrollment, 107 men had NGU; of these 88% were symptomatic, 27% had CT and 22% had MG. Fifty men had 60 cases of incident NGU (incidence rate (IR)=56 per 100 person-years [95% confidence interval (CI)=43–74]). Unlike prevalent NGU at enrollment, CT/MG-associated incident NGU was rare (IR=7 [95% CI 4–15]) and most (78%) incident NGU was asymptomatic. Risk factors for incident NGU were ≤high school education (adjusted rate ratio (ARR)=2.45; 1.19–5.00), history of CT (ARR=2.15; 1.08–4.27), history of NGU (ARR=2.67; 1.27–5.62), and NGU at enrollment (ARR=2.03; 1.04–3.98). Neither condom use nor having a new partner were associated with incident NGU; Black race was only associated with incident symptomatic and non-CT/non-MG NGU. CONCLUSION: Incidence of NGU was high, predominantly non-CT/non-MG and asymptomatic. Future studies should investigate the etiology and clinical significance of asymptomatic NGU

Stroke Etiology Modifies the Effect of Endovascular Treatment in Acute Stroke

Background and Purpose— Stroke etiology drives thrombus composition. We thus hypothesized that endovascular treatment shows different efficacy in cardioembolic versus noncardioembolic large-vessel occlusions (LVOs). Methods— Procedural characteristics, grade of reperfusion, and functional outcome at discharge and 90 days were compared between patients with cardioembolic versus noncardioembolic LVO from the GSR-ET (German Stroke Registry–Endovascular Treatment; n=2589). To determine associations with functional outcome, adjusted odds ratios and 95% CIs were calculated using ordinal multivariable logistic regression models adjusting for potential baseline confounder variables. Results— Endovascular treatment of cardioembolic LVO had a higher rate of successful reperfusion (85.6% versus 81.0%; P =0.002) and a higher rate of complete reperfusion after a single thrombectomy pass (45.7% versus 38.1%; P &lt;0.001) compared with noncardioembolic LVO. Cardioembolic LVO was associated with better functional outcome at discharge (adjusted odds ratio, 1.61 [95% CI, 1.37–1.88]) and 90 days (adjusted odds ratio, 1.29 [95% CI, 1.09–1.53]). In mediation analysis, reperfusion explained 47% of the effect of etiology on functional outcome at discharge. Conclusions— These results provide evidence for higher efficacy of endovascular treatment in cardioembolic LVO compared with noncardioembolic LVO. </jats:sec