Mount Sinai Rehabilitation Hospital

BackgroundCangrelor, an intravenous P2Y12-receptor inhibitor, is a reversible and short-acting antithrombotic medication non-inferior to irreversible Glycoprotein IIb-IIIa inhibitors (GPI) like eptifibatide. However, there is insufficient data to compare the medications in endovascular thrombectomy (EVT) cases requiring emergent platelet inhibition. This study reviews our experience with cangrelor in EVT and compares its safety and efficacy against GPIs.MethodsA large healthcare system retrospective review identified all patients who received cangrelor or eptifibatide intraoperatively during EVT from December 2018 to March 2023 for a cohort study. Clinical data was reviewed. Functional status was defined by the modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) at multiple time points. Binary variables were tested with Pearson χ2 tests or Fisher’s exact tests. Continuous variables were tested with two-tailed t-tests or Wilcoxon tests.ResultsOf 1,010 EVT patients, 36 cangrelor and 104 eptifibatide patients were selected. There were no significant differences in baseline functional status or presentations. Cangrelor was most frequently administered for stenting tandem occlusions (n=16, 44.4%) and successful reperfusion occurred in 93.3% of patients (n=30). On multivariate analysis, cangrelor usage was associated with decreased odds of hemorrhagic conversion (adjusted odds ratio (AOR) 0.76, p=0.004) and symptomatic hemorrhage (AOR 0.86, p=0.021). There were no significant differences in thrombotic re-occlusion. Cangrelor was associated with lower 24-hour NIHSS (7.0 vs. 12.0, p=0.013) and discharge NIHSS scores (3.0 vs 9.0, p=0.009). There were no significant differences in in-hospital mortality or length of stay. Cangrelor was associated with improved odds of favorable outcome, defined as mRS 0-2, at discharge (AOR 2.69, p=0.001) and on 90-day follow-up (AOR 2.23, p=0.031).ConclusionCangrelor was associated with a decreased risk of hemorrhagic conversion and may lead to favorable functional outcomes for patients during hospitalization when compared to GPIs. Future prospective studies are warranted to investigate its use in EVT.Previous PresentationsThis abstract was previous presented as a podium presentation at the Society of Neurointerventional Surgery’s 20thAnnual Meeting in San Diego, CA from July 31st- August 4th, 2023.

Cognitive impairment, difficulty performing basic activities of daily living (ADLs) and instrumental ADLs (IADLs), depression, and fatigue are common among individuals with multiple sclerosis (MS). Some associations between these symptoms are known; however, many of their relationships remain unclear. This study investigated the contributions of subjective and objective cognition, depressive symptom severity, and fatigue on ADLs and IADLs. Participants (N = 217) were individuals with MS from a comprehensive MS center, participating in a larger study characterizing upper extremity function in MS. Outcome measures of ADL and IADL abilities were the Functional Status Index-Assistance (FSI-A) and Functional Status Index-Difficulty (FSI-D) and the Test D'évaluation Des Membres Supérieurs de Personnes Âgées (TEMPA). Predictors were objective cognition (Symbol Digit Modalities Test; SDMT), subjective cognition (Performance Scales©-Cognition; PS-C), depressive symptom severity (Center for Epidemiologic Studies Depression Scale; CES-D-10), and fatigue (Modified Fatigue Impact Scale; MFIS-5). Correlations were conducted, followed by hierarchal linear regressions. The SDMT and PS-C were entered into separate models. After controlling for demographics, the SDMT significantly predicted the TEMPA and FSI-A, while the PS-C predicted only the FSI-D. The CES-D-10 predicted the FSI-D even after accounting for PS-C and SDMT, while the MFIS-5 only predicted the FSI-D when the SDMT was included. Neither the CES-D-10 nor MFIS-5 significantly predicted the FSI-A or TEMPA. The way an individual with MS perceived their symptoms significantly contributed to their reported difficulty with functional tasks, while only their objective cognitive functioning predicted ADL and IADL performance and the level of assistance they would require.

Objectives: Difficulties with prospective memory (PM) are not routinely assessed in persons with multiple sclerosis (MS) even though they can impact daily functioning. This study aimed to examine the preliminary criterion and ecological validity of a highly abbreviated Memory for Intentions Test (MIST) intended to serve as an initial screening of PM in persons with MS. Methods: Participants (n = 112) were classified as impaired if they performed 1.5 standard deviations below the normative mean on the MIST. Individual MIST trials with adequate difficulty and discriminability were examined using receiver operating characteristic analyses, with their classification accuracies, sensitivities, and specificities compared to each other. Regressions were run to evaluate their ecological validity, with appointment attendance and employment as the outcomes. Results: Two trials had a classification accuracy of ≥80%: Trial 3 (79% sensitivity, 84% specificity) and Trial 4 (57% sensitivity, 91% specificity). These two trials had comparable specificity (p=.127), with Trial 3 having slightly higher sensitivity (p=.083). Only Trial 4 was significantly associated with appointment attendance (b = 1.63, p=.047) and unemployment (aOR = 11.20, p=.027). Discussion:Trial 4 of the MIST, a verbal task with a time-based cue that requires participants to complete a pre-specified response after a 15-minute delay, has the potential to be a screener for PM.

The anterior optic pathway is one of the preferential sites of involvement in CNS inflammatory demyelinating diseases, such as multiple sclerosis and neuromyelitis optica, with optic neuritis being a common presenting symptom. What is more, optic nerve involvement in these diseases is often subclinical, with optical coherence tomography demonstrating progressive neuroretinal thinning in the absence of optic neuritis. The pathological substrate for these findings is poorly understood and requires investigation. We had access to post-mortem tissue samples of optic nerves, chiasms and tracts from 29 multiple sclerosis (mean age 59.5, range 25-84 years; 73 samples), six neuromyelitis optica spectrum disorders (mean age 56, range 18-84 years; 22 samples), six acute disseminated encephalomyelitis (mean age 25, range 10-39 years; 12 samples) cases and five non-neurological controls (mean age 55.2, range 44-64 years; 16 samples). Formalin-fixed paraffin-embedded samples were immunolabelled for myelin, inflammation (microglial/macrophage, T- and B-cells, complement), acute axonal injury and astrocytes. We assessed the extent and distribution of these markers along the anterior optic pathway for each case in all compartments (i.e. parenchymal, perivascular and meningeal), where relevant. Demyelinated plaques were classified as active based on established criteria. In multiple sclerosis, demyelination was present in 82.8% of cases, of which 75% showed activity. Microglia/macrophage and lymphocyte inflammation were frequently found both in the parenchymal and meningeal compartments in non-demyelinated regions. Acute axonal injury affected 41.4% of cases and correlated with extent of inflammatory activity in each compartment, even in cases that died at advanced age with over 20 years of disease duration. An antero-posterior gradient of anterior optic pathway involvement was observed with optic nerves being most severely affected by inflammation and acute axonal injury compared with the optic tract, where a higher proportion of remyelinated plaques were seen. In neuromyelitis optica spectrum disorder, cases with a history of optic neuritis had extensive demyelination and lost aquaporin-4 reactivity. In contrast, those without prior optic neuritis did not have demyelination but rather diffuse microglial/macrophage, T- and B-lymphocyte inflammation in both parenchymal and meningeal compartments, and acute axonal injury was present in 75% of cases. Acute demyelinating encephalomyelitis featured intense inflammation, and perivenular demyelination in 33% of cases. Our findings suggest that chronic inflammation is frequent and leads to neurodegeneration in multiple sclerosis and neuromyelitis optica, regardless of disease stage. The chronic inflammation and subsequent neurodegeneration occurring along the optic pathway broadens the plaque-centred view of these diseases and partly explains the progressive neuroretinal changes observed in optic coherence tomography studies.

Multiple sclerosis (MS) is a degenerative neurological condition that results in impairments in multiple domains including cognition, fatigue, and mood. Dalfampridine-extended release (D-ER) has been approved to improve walking in persons with MS. It is plausible that D-ER could improve cognition, fatigue, and mood through the same mechanisms. We aim to examine effects of D-ER on cognition, depression, mood, and fatigue and to describe how these associations differ among those with and without D-ER related improvements in walking speed. Patients with MS at the Mandell Center who were newly prescribed D-ER as part of their standard MS care were invited to participate in this observational pre-post study. Thirty-nine participants with MS were observed for 14 weeks; 31 remained on D-ER for 14 weeks or longer. Of these, 28 were then subdivided based on walk responder status. Cognition was assessed using the SDMT; depression was measured with the CESD. Self-reported cognition, mood, and fatigue were also measured using subscales of the Performance Scales (PS). Among those on drug through 14 weeks, there was significant improvement in the SDMT (P < 0.001) and the PS Fatigue score (P = 0.04). Among those who discontinued drug before 14 weeks, PS Cognition and PS Mood scores significantly improved (P = 0.02). Timed walk responders had significant improvements in SDMT (P < 0.001) and PS Fatigue (P = 0.046) from baseline to week 14. Among timed walk nonresponders, none of the measures significantly changed. Dalfampridine-extended release may improve cognition and fatigue in persons with MS, especially among timed walk responders.

Streptococcus salivarius is a normal inhabitant of the oral cavity. When isolated from blood cultures, this viridans streptococcus is often disregarded as a contaminant. Viridans streptococci, although a common cause of endocarditis, are rarely associated with bacterial meningitis and account for less than 1% of all cases of purulent meningitis. We report a case of bacteremia and meningitis due to S. salivarius that occurred in a patient who underwent upper gastrointestinal endoscopy and cauterization for control of gastric bleeding. Although bacteremia following gastrointestinal procedures has been well documented, its incidence is low (ranging from 2% to 10%), and its course is usually transient without major clinical sequelae. This case is unique with respect to the pathogen isolated, the length of bacteremia, and the meningitis that subsequently developed following a gastroesophageal procedure.

Vibrio hollisae was recovered from the bloodstream of a 36-year-old man with chronic active hepatitis who was admitted to the hospital with signs of gastrointestinal illness. V. hollisae is an infrequent human pathogen associated with seafood ingestion. No etiologic link to seafood was demonstrated in this case report.

The identification of coagulase-negative staphylococci to the species level was achieved by adapting 12 conventional biochemical test procedures to a microtiter plate format. The tests included production of urease and phosphatase, reduction of nitrate to nitrite, and acid production from nine carbohydrates. There were separate assessments of susceptibility to novobiocin and capability for beta hemolysis. This technique yielded consistent biochemical reactions for all 33 stock strains used for quality control, although one of the strains may have been incorrectly identified. In addition, 110 of 113 clinical isolates of coagulase-negative staphylococci could be identified.