Annals of the New York Academy of Sciences
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Ann. N. Y. Acad. Sci. · Mar 2013
ReviewPre- and postsynaptic inhibitory control in the spinal cord dorsal horn.
Sensory information transmitted to the spinal cord dorsal horn is modulated by a complex network of excitatory and inhibitory interneurons. The two main inhibitory transmitters, GABA and glycine, control the flow of sensory information mainly by regulating the excitability of dorsal horn neurons. A presynaptic action of GABA has also been proposed as an important modulatory mechanism of transmitter release from sensory primary afferent terminals. By inhibiting the release of glutamate from primary afferent terminals, activation of presynaptic GABA receptors could play an important role in nociceptive and tactile sensory coding, while changes in their expression or function could be involved in pathological pain conditions, such as allodynia.
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Ann. N. Y. Acad. Sci. · Sep 2012
ReviewHow baseline severity affects efficacy and safety outcomes in acute ischemic stroke intervention trials.
Baseline severity of stroke may be an important predictor of efficacy and safety outcomes in acute stroke intervention trials. This summary explores definitions of baseline variables and outcomes used to measure stroke severity, efficacy, and safety. In addition, the discussion here reviews select acute ischemic stroke intravenous thrombolytic studies, such as the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study and European Cooperative Acute Stroke Studies, select neuroprotectant and endovascular clot retrieval device studies, and large cooperative databases, such as the Virtual International Stroke Trials Archive and Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Registry, to explore relationships between baseline stroke severity and other possible factors associated with efficacy and safety outcomes. The NIH Stroke Scale and modified Rankin scale will be featured as major stroke outcome measures, based on frequency of use and reliability, familiarity, adaptability, and comparability.
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Hemorrhagic transformation (HT) associated with recombinant tissue plasminogen activator (rt-PA) complicates and limits its use in stroke. Here, we provide a focused review on the involvement of matrix metalloproteinase 9 (MMP-9) in rt-PA-associated HT in cerebral ischemia, and we review emerging evidence that the selective inhibitor of the sulfonylurea receptor 1 (Sur1), glibenclamide (U. ⋯ A retrospective clinical study comparing outcomes in diabetic patients with stroke treated with rt-PA showed that those who were previously on and were maintained on a sulfonylurea fared significantly better than those whose diabetes was managed without sulfonylureas. Inhibition of Sur1 with injectable glyburide holds promise for ameliorating rt-PA-associated HT in stroke.
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Ann. N. Y. Acad. Sci. · Sep 2012
ReviewImpact of regional pre-hospital emergency medical services in treatment of patients with acute ischemic stroke.
Stroke is a major public health concern afflicting an estimated 795,000 Americans annually. The associated morbidity and mortality is staggering. Early treatment with thrombolytics is beneficial. ⋯ Ambulance transport of stroke patients to the hospital has demonstrated improvements in key benchmarks such as door to physician evaluation, door to CT initiation, and increased thrombolytic treatment. Pre-hospital notification of the impending arrival of a stroke patient allows for vital preparation in the treating emergency department, and improving timely evaluation and treatment upon arrival of the stroke patient. EMS systems are a vital component of the management of stroke patients, and resources used to improve these systems are beneficial.
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Acute ischemic stroke is a time-critical emergency for which thrombolytic therapy is the only medical treatment. Many patients who would benefit from this treatment are deprived of it due to delays. Failure to call for help rapidly is the main obstacle, but even when the call is made in time, the prehospital evaluation, transportation, and emergency department (ED) diagnostics often take too long to treat the patient with thrombolysis. ⋯ The intersection of the pre- and in-hospital care is of special importance. With successful protocols and good communication between the emergency medical service and ED, delays can be significantly reduced. On the basis of our experience, 94% of patients can be treated within 60 min of arrival, based largely on using the prehospital time effectively.