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Objective To determine factors associated with patients refusing IV t-PA for suspected acute ischemic stroke (AIS), and to compare the outcomes of patients who refused t-PA (RT) with those treated with t-PA. Methods Patients who were treated with and refused t-PA at our stroke center were identified retrospectively. Demographics, clinical presentation, and outcome measures were collected and compared. Clinical outcome was defined as excellent (mRS: 0–1), good (mRS: 0–2), and poor (mRS: 3–6). Results Over 7.5 years, thirty (4.2%) patients refused t-PA. There were no demographic differences between the treated and RT groups. The rate of RT decreased over time (OR 0.63, 95% CI 0.50 – 0.79). Factors associated with refusal included a later symptom onset to emergency department presentation time (OR 1.02, 95% CI 1.01 – 1.03), lower NIHSS (OR 1.11, 95% CI 1.03 – 1.18), a higher proportion of stroke mimics (OR 17.61, 95% CI 6.20 – 50.02) and shorter hospital stay (OR 1.32, 95% CI 1.09 – 1.61). Among patients who were subsequently diagnosed with ischemic stroke, only length of stay was significantly shorter for refusal patients (OR 1.37, 95% CI 1.06 – 1.78). After controlling for mild strokes and stroke mimics, clinical outcome was not different between the groups (OR 1.61, 95% CI 0.69 – 3.73). Conclusion The incidence of patients refusing t-PA has decreased over time, yet it may be a cause for t-PA under-utilization. Patients with milder symptoms were more likely to refuse t-PA. Refusal patients presented later to the hospital and had shorter hospital stays. One out six refusal patients (16.6%) had a stroke mimic.

Background Awake prone positioning has been recommended as an adjunctive measure in spontaneously breathing patients with hypoxemic respiratory failure during the COVID-19 pandemic. It remains uncertain as to how long this should be implemented, what variables to follow and who would be the ideal candidates for this adjunctive therapy. Methods A retrospective chart review of patients admitted from April to August 2020 within our institution with multifocal pneumonia and hypoxemic respiratory failure secondary to COVID-19 who underwent awake-proning for at least 3 hours was conducted. Results Improvement in respiratory parameters including ROX (SpO2/Fio2/ Respiratory Rate) indices and inflammatory markers within 4 days of institution of awake proning predicted a higher chance for success of this strategy in preventing need for mechanical ventilation. Moreover, benefits of awake proning were limited to patients with mild to moderate ARDS. Conclusions Awake prone positioning can be safely performed with improvement in oxygenation. However, its institution may be beneficial only in patients with mild to moderate ARDS and requires careful evaluation of respiratory parameters and serum inflammatory markers to avoid a delay in endotracheal intubation and consequent increase in mortality rates.

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The huge data on the websites due to rapid use of cloud computing increase the security concern. Cloud computing provides various services such as storage, scalable transactions, sharing and downloading. There are many techniques which provides security of these services but these are dynamic in nature and leads to overload the memory. In this paper, a novel framework has been presented based on data partitioning technique which avoids the data duplication and provides scalable consistent data with enhanced security. The proposed work divided into three parts in which Dice Coefficient and Cosine Similarity has been used to secure the similar data. The data has been further encrypted using the encryption system to enhance the data integrity and security level. The encrypted data further consider as input for the data partition techniques in which different algorithms has been developed to partition the data in blocks. The proposed work further optimized using the Artificial Bee Colony algorithm to optimize the partitioned data. The obtained results further cross validated using the classification technique Artificial Neural Network (ANN) in which data has been trained and tested to check the effectiveness of the proposed work. The experimental results finally validated by measuring the True Positive Value (TP), False Negative Value (FN), True Negative Value, and False Positive value. The good TP and bad FN shows that proposed framework efficiently partitioned the data in an effective and scalable way.

Objective: Stringent selection criteria pose challenges to recruiting patients into clinical trials testing potential novel therapies for stroke. We conducted a pilot study, Safety of Intravenous Mononuclear Cells for Acute Stroke (SIMVAS) trial involving autologous bone marrow cell administration in patients with middle cerebral artery (MCA) territory stroke within 72 hours of symptom onset. Given the stringent selection criteria for initial cell therapy clinical trials in stroke, we analyzed reasons for patient ineligibility into the SIVMAS trial to assess feasibility of recruitment. Methods: We retrospectively collected ischemic stroke patients from our stroke registry admitted from March 2009 to June 2010, the recruitment period of SIVMAS, and identified which of the selection criteria the patients did not meet. Results: Of a total of 534 MCA territory stroke patients, 25 met all the selection criteria. Ten patients were enrolled as planned over the 15 month period, 3 declined enrollment, 2 were excluded due to pending DSMB review on previously enrolled patients, and the rest did not have an adequate time window between bone marrow aspiration and dosing. A total of 1,943 exclusions were recorded; major reasons were NIHSS (15.3%) and infarct sizes above or below the selection criteria (12.4%). The table summarizes the patient exclusion frequency based on selection criteria. Among ineligible patients (n=509), 47 (9.2%) had a single exclusion, 81 (15.9%) had two exclusions and 108 (21.2%) had three exclusions. The figure presents a CONSORT flow diagram of the entire recruitment. Conclusion: This is the first study to assess recruitment of patients with acute ischemic stroke into a pilot cell therapy clinical trial. Among eligible patients, there was a low refusal rate. Among excluded patients, stroke severity and infarct size were major reasons for exclusion from SIVMAS. It is hoped that the data from this study may help facilitate the design of future clinical trials testing new cell-based therapies for ischemic stroke. We encourage investigators to choose selection criteria that will provide scientifically meaningful data but are not overly rigid in selecting potential research candidates.