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Biomedical subjects

Larry B Goldstein

Publications and source records attributed to Larry B Goldstein.

At least 55 records · Page 3Linked to original sources
PubMed2003

Statewide assessment of hospital-based stroke prevention and treatment services in North Carolina: changes over the last 5 years.

BACKGROUND AND PURPOSE: The first published statewide assessment of stroke prevention and treatment services in the United States was carried out in North Carolina in 1998. The purpose of the present study was to measure changes in these services that may have occurred over the last 5 years. METHODS: A 1-page questionnaire was sent to each facility in the state in February 2003. RESULTS: Complete responses were obtained from each of the state's 128 facilities. The proportions of hospitals providing CT angiography (35% versus 55%, P<or=0.01), diffusion-weighted MRI (20% versus 45%, P<or=0.01), transesophageal echocardiography (45% versus 59%, P<or=0.02), and inpatient rehabilitation services (25% versus 43%, P<or=0.01) increased over the 5 years. There was a trend toward more facilities having tissue plasminogen activator protocols (43% versus 54%, P<or=0.09) but a decrease in the proportion of hospitals with interventional radiologists (23% versus 15%, P<0.01). There was no change in the proportion of the state's population living in a county with a basic stroke prevention and treatment center, with the proportion residing in a county with an advanced center increasing by 12%. Entire regions of the state lacked either type of center, and only 14% had even the essential infrastructure recommended for a Brain Attack Coalition-type primary stroke center. There was no difference in the proportions of hospitals with organized stroke teams, those having a stroke acute care unit, those using stroke care maps, or hospitals having community awareness programs. CONCLUSIONS: Certain technologies have become more widely available, but hospital investments in stroke-related programs have not appreciably increased.

Diagnostic Imaging↗
PubMed2003

Extracranial carotid artery stenosis.

BACKGROUND: Carotid endarterectomy is the most common surgical procedure used to treat stenosis of the extracranial precerebral carotid artery. Data from several randomized controlled trials are available to help guide its use in specific patient subgroups. Carotid angioplasty with stenting is also being performed, and clinical trials comparing this procedure with carotid endarterectomy are in progress. SUMMARY OF REPORT: For patients with symptomatic high-grade (ie, 70% to 99%) stenosis, carotid endarterectomy is associated with an overall benefit (risk ratio estimate for the combined end point of nonfatal stroke, nonfatal myocardial infarction, or death, 0.67; 95% CI, 0.54 to 0.83). The benefit is more modest for patients with less severe stenosis (ie, 50% to 69%) and may vary with specific patient characteristics. Selected patients with asymptomatic carotid stenosis may also benefit from the operation, but it needs to be performed with very low complication rates, which can be difficult to achieve in clinical practice. Several studies of angioplasty, angioplasty with stenting, and more recently angioplasty with stenting and a so-called distal protection device have also been performed. The technology involved continues to evolve rapidly, presenting a challenge for the design and conduct of clinical trials. CONCLUSIONS: Surgical intervention for extracranial carotid stenosis remains a major potential therapeutic modality for the prevention of stroke in selected patients. Endovascular approaches continue to be evaluated in ongoing trials.

Angioplasty↗
PubMed2003

Medicine. Stroke--tPA and the clinic.

Clinical trial results are not always rapidly incorporated into routine medical practice. This Policy Forum describes a variety of barriers that have impeded the more widespread use of thrombolytic therapy (tPA, tissue plasminogen activator) for selected patients with acute ischemic stroke. These barriers are not insurmountable but will require a concerted effort to overcome.

Animals↗
PubMed2003

Sensorimotor deficits and increased brain nicotinic acetylcholine receptors following exposure to chlorpyrifos and/or nicotine in rats.

Despite well-known adverse effects associated with cigarette smoking, approximately 20% of the US population continues to smoke and many more are exposed to environmental tobacco smoke. Many of the same individuals are also exposed to environmental neurotoxic chemicals such as the organophosphorus insecticide chlorpyrifos. In the present study, the effects of exposure to low doses of nicotine and chlorpyrifos alone and in combination, were studied on the central cholinergic system and sensorimotor performance in rats. Male Sprague-Dawley rats (250-300 g) were treated with nicotine (1 mg/kg s.c., in normal saline), chlorpyrifos (0.1 mg/kg dermally, in 0.1 ml 70% ethanol), or a combination of both, daily for 30 days. Control rats were treated with saline and dermally with ethanol. Sensorimotor behavior was evaluated 24 h following the last dose using a battery of tests. There was a significant deficit in incline plane performance, beam-walk score and beam-walk time following exposure to each chemical, alone or in combination. The deficit in incline plane performance was greater when the two chemicals were given in combination than with either compound alone. Biochemical analysis showed a decrease in cerebellar and an increase in midbrain acetylcholinesterase (AChE) activity following combined exposure. Exposure to nicotine alone resulted in a significant increase in AChE activity in brainstem and midbrain, whereas there was no significant change after exposure to chlorpyrifos, alone. A significant increase in ligand binding to nicotinic acetylcholine receptors (nAChR) was observed in brainstem and cortex following exposure to nicotine or chlorpyrifos. This was further augmented with combined exposure, which caused a modest but significant increase in m2 muscarinic acetylcholine receptors (m2-mAChR) ligand binding in the cortex. These data suggest that exposure to either nicotine or chlorpyrifos or a combination of the two may impair neurobehavioral performance and affect the central nervous system cholinergic pathways.

Acetylcholine↗
PubMed2003

Veterans Administration Acute Stroke (VASt) Study: lack of race/ethnic-based differences in utilization of stroke-related procedures or services.

BACKGROUND AND PURPOSE: Race/ethnic-based disparities in the utilization of health-related services have been reported. Data collected as part of the Veterans Administration Acute Stroke Study (VASt) were analyzed to determine whether similar differences were present in patients admitted to Veterans Administration (VA) hospitals with acute ischemic stroke. METHODS: VASt prospectively identified stroke patients admitted to 9 geographically separated VA hospitals between April 1995 and March 1997. Demographic characteristics and all inpatient diagnostic tests/procedures were recorded. Frequencies were compared with chi2 tests. RESULTS: Of 1073 enrolled patients, 775 (white, n=520; nonwhite, n=255, including 226 blacks and 28 Hispanic-Americans) with ischemic stroke were admitted from home. Mean ages (71.0+/-0.6 versus 71.9+/-0.4 years; P=0.25) and Trial of ORG 10172 in Acute Stroke Treatment (TOAST) stroke types (atherothrombotic, 12.9% versus 13.3%; cardioembolic, 16.5% versus 18.0%; lacunar, 26.4% versus 27.1%; other, 1.4% versus 2.0%; unclassified, 42.9% versus 39.6%; P=0.89) for whites versus nonwhites were similar. There were no race/ethnic-based differences in the utilization of brain CT (91.0% versus 92.2%; P=0.58), MRI (36.2% versus 41.6%; P=0.14), transthoracic (52.5% versus 53.7%; P=0.75) or transesophageal echocardiography (10.2% versus 10.6%; P=0.86), 24-hour ECG (3.3% versus 1.6%; P=0.17), carotid ultrasound (64.0% versus 62.0%; P=0.57), carotid endarterectomy (1.5% versus 0.8%; P=0.38), rehabilitation evaluations (71.0% versus 76.5%; P=0.11), speech therapy (9.6% versus 12.6%; P=0.21), recreational therapy (3.1% versus 2.0%; P=0.37), or occupational therapy (16.0% versus 19.6%; P=0.20) for whites versus nonwhites, respectively. Angiography was performed less frequently (3.1% versus 8.5%; P=0.01) and ECG more frequently (81.6% versus 73.5%; P=0.01) in nonwhites. The proportions of patients discharged functionally independent were also similar (52% of whites and 50% of nonwhites had discharge Rankin Scale scores of 0, 1, or 2; P=0.63). CONCLUSIONS: Aside from cerebral angiography and ECG, there were no race/ethnic-based disparities in the utilization of a variety of stroke-related procedures and services. The difference in the use of angiography is unlikely to be related to a difference in screening for carotid endarterectomy because there was no difference in the frequency of carotid ultrasonography. The reason ECG was obtained more frequently in nonwhites is uncertain.

Acute Disease↗
PubMed2003

Screening for hypercoagulable syndromes following stroke.

Patients with ischemic stroke of unclear etiology are often screened for hypercoagulable syndromes or thrombophilias. These have been recognized to cause venous thrombosis, and include hereditary deficiencies of coagulation factors, genetic mutations, or acquired disorders. However, the majority of coagulation disorders are only rarely associated with ischemic stroke. The tests most commonly used to screen for thrombophilias comprise a complex array of assays that may be unreliable in various settings, including acute thrombosis, inflammation, and uses of medications such as anticoagulants. The diagnostic yield of thrombophilia tests in unselected stroke patients is very low, but may improve with careful selection of younger patients who have an otherwise undetermined cause of stroke or a history of venous thrombosis or multiple miscarriages. Various strategies have been developed that can guide the selection of patients (based on specific characteristics) and tests in the evaluation of thrombophilias. Although the diagnosis of thrombophilia aids in the potential explanation of stroke etiology, the best regimen for secondary prevention treatment for the majority of thrombophilias is still unknown.

Humans↗
PubMed2003

Amphetamines and related drugs in motor recovery after stroke.

Studies in laboratory animals indicate that the rate and extent of functional recovery after focal brain injury can be modulated by drugs affecting specific central neurotransmitters. Preliminary clinical studies suggest that similar drug effects may occur in humans recovering from stroke. Combined with principles derived from the laboratory, these clinical studies provide important insights to guide the rational design of trials aimed at determining the clinical use of this approach to improving poststroke recovery.

Central Nervous System Stimulants↗
PubMed2003

Neuropharmacology of TBI-induced plasticity.

PRIMARY OBJECTIVE: The purpose of this report is to review both fundamental studies in laboratory animals and preliminary clinical data suggesting that certain drugs may affect behavioural recovery after brain injury. MAIN OUTCOMES AND RESULTS: Laboratory studies show that systemically-administered drugs that affect specific central neurotransmitters including norepinephrine and GABA influence affect recovery in a predictable manner. Although some drugs such as d-amphetamine have the potential to enhance recovery, others such as neuroleptics and other central dopamine receptor antagonists, benzodiazepines and the anti-convulsants phenytoin and phenobarbital may be detrimental. In one study, 72% of patients with traumatic brain injury received one or a combination of the drugs that may impair recovery based on both animal experiments and studies in recovering stroke patients. CONCLUSIONS: Until the true impact of these classes of drugs are better understood, care should be exercised in the use of medications that may interfere with the recovery process in patients with traumatic brain injury. Additional research needs to be completed before the clinical efficacy of drugs that may enhance recovery can be established.

Amphetamines↗
PubMed2003

Model of recovery of locomotor ability after sensorimotor cortex injury in rats.

Animal models of locomotor recovery after brain injury provide tools for understanding the basic neurobiological processes that may underlie recovery after stroke in humans. Measurement of the ability of rats to traverse a narrow elevated beam has proven to be a particularly useful test of locomotor function. Repeated measurement of this behavior over time provides a simple method for quantifying the rate and degree of a rat's locomotor recovery after sensorimotor cortex injury and constitutes a tool for studying its mechanisms and possible treatment strategies. The model has proven particularly useful in predicting the effects of drugs on poststroke recovery in humans.

Animals↗
PubMed2002

Homocysteine testing in patients with acute ischemic stroke.

OBJECTIVE: To determine pretesting factors associated with elevated total homocysteine (tHcy) levels in a cohort of patients with acute ischemic stroke and to identify patient characteristics associated with physicians' decisions to obtain tHcy levels in routine clinical practice. METHODS: Patient demographics, traditional stroke risk factors, and the results of tHcy tests were recorded for a consecutive series of adult patients with ischemic stroke admitted to an academic medical center from January 1997 to December 1999 (n = 674). Stroke subtype was classified using the TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Univariate analyses were used to identify patient characteristics associated with elevated tHcy levels and factors associated with tHcy testing. Multivariable stepwise logistic regression analyses were then used to identify the independent associations of univariately significant variables with tHcy testing. RESULTS: Of 674 patients, 131 (19.4%) were tested for tHcy. There were no associations between age, sex, stroke subtype, or the presence of other stroke risk factors and tHcy levels. Younger age (odds ratio [OR] = 0.54/decade, 95% CI = 0.46 to 0.62), the presence of hyperlipidemia (OR = 1.9, 95% CI = 1.2 to 2.9), diabetes (OR = 0.47, 95% CI = 0.29 to 0.78), and cardioembolic (OR = 0.47, 95% CI = 0.23 to 0.95) and small-vessel (OR = 0.43, 95% CI = 0.22 to 0.83) stroke subtypes were independently associated with tHcy testing. CONCLUSIONS: Elevated tHcy levels were not associated with any of the studied characteristics of ischemic stroke patients. More research is needed to determine factors that aid in selecting patients for tHcy testing and improving diagnostic yield.

Acute Disease↗