Publications by authors named "John Y Choi"

23 Publications

  • Page 1 of 1

Regulatory T cells engineered with TCR signaling-responsive IL-2 nanogels suppress alloimmunity in sites of antigen encounter.

Sci Transl Med 2020 11;12(569)

Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.

Adoptive cell transfer of ex vivo expanded regulatory T cells (T) has shown immense potential in animal models of auto- and alloimmunity. However, the effective translation of such T therapies to the clinic has been slow. Because T homeostasis is known to require continuous T cell receptor (TCR) ligation and exogenous interleukin-2 (IL-2), some investigators have explored the use of low-dose IL-2 injections to increase endogenous T responses. Systemic IL-2 immunotherapy, however, can also lead to the activation of cytotoxic T lymphocytes and natural killer cells, causing adverse therapeutic outcomes. Here, we describe a drug delivery platform, which can be engineered to autostimulate T with IL-2 in response to TCR-dependent activation, and thus activate these cells in sites of antigen encounter. To this end, protein nanogels (NGs) were synthesized with cleavable bis(-hydroxysuccinimide) cross-linkers and IL-2/Fc fusion (IL-2) proteins to form particles that release IL-2 under reducing conditions, as found at the surface of T cells receiving stimulation through the TCR. T surface-conjugated with IL-2 NGs were found to have preferential, allograft-protective effects relative to unmodified T or T stimulated with systemic IL-2. We demonstrate that murine and human NG-modified T carrying an IL-2 cargo perform better than conventional T in suppressing alloimmunity in murine and humanized mouse allotransplantation models. In all, the technology presented in this study has the potential to improve T transfer therapy by enabling the regulated spatiotemporal provision of IL-2 to antigen-primed T.
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http://dx.doi.org/10.1126/scitranslmed.aaw4744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8519505PMC
November 2020

Donor myeloid derived suppressor cells (MDSCs) prolong allogeneic cardiac graft survival through programming of recipient myeloid cells in vivo.

Sci Rep 2020 08 28;10(1):14249. Epub 2020 Aug 28.

Renal Division, Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA, 02115, USA.

Solid organ transplantation is a lifesaving therapy for patients with end-organ disease. Current immunosuppression protocols are not designed to target antigen-specific alloimmunity and are uncapable of preventing chronic allograft injury. As myeloid-derived suppressor cells (MDSCs) are potent immunoregulatory cells, we tested whether donor-derived MDSCs can protect heart transplant allografts in an antigen-specific manner. C57BL/6 (H2K, I-A) recipients pre-treated with BALB/c MDSCs were transplanted with either donor-type (BALB/c, H2K, I-A) or third-party (C3H, H2K, I-A) cardiac grafts. Spleens and allografts from C57BL/6 recipients were harvested for immune phenotyping, transcriptomic profiling and functional assays. Single injection of donor-derived MDSCs significantly prolonged the fully MHC mismatched allogeneic cardiac graft survival in a donor-specific fashion. Transcriptomic analysis of allografts harvested from donor-derived MDSCs treated recipients showed down-regulated proinflammatory cytokines. Immune phenotyping showed that the donor MDSCs administration suppressed effector T cells in recipients. Interestingly, significant increase in recipient endogenous CD11bGr1 MDSC population was observed in the group treated with donor-derived MDSCs compared to the control groups. Depletion of this endogenous MDSCs with anti-Gr1 antibody reversed donor MDSCs-mediated allograft protection. Furthermore, we observed that the allogeneic mixed lymphocytes reaction was suppressed in the presence of CD11bGr1 MDSCs in a donor-specific manner. Donor-derived MDSCs prolong cardiac allograft survival in a donor-specific manner via induction of recipient's endogenous MDSCs.
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http://dx.doi.org/10.1038/s41598-020-71289-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7455707PMC
August 2020

Regulatory CD8 T cells that recognize Qa-1 expressed by CD4 T-helper cells inhibit rejection of heart allografts.

Proc Natl Acad Sci U S A 2020 03 28;117(11):6042-6046. Epub 2020 Feb 28.

Division of Renal Medicine, Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115;

Induction of longstanding immunologic tolerance is essential for survival of transplanted organs and tissues. Despite recent advances in immunosuppression protocols, allograft damage inflicted by antibody specific for donor organs continues to represent a major obstacle to graft survival. Here we report that activation of regulatory CD8 T cells (CD8 Treg) that recognize the Qa-1 class Ib major histocompatibility complex (MHC), a mouse homolog of human leukocyte antigen-E (HLA-E), inhibits antibody-mediated immune rejection of heart allografts. We analyzed this response using a mouse model that harbors a point mutation in the class Ib MHC molecule Qa-1, which disrupts Qa-1 binding to the T cell receptor (TCR)-CD8 complex and impairs the CD8 Treg response. Despite administration of cytotoxic T lymphocyte antigen 4 (CTLA-4) immunoglobulin (Ig), Qa-1 mutant mice developed robust donor-specific antibody responses and accelerated heart graft rejection. We show that these allo-antibody responses reflect diminished Qa-1-restricted CD8 Treg-mediated suppression of host follicular helper T cell-dependent antibody production. These findings underscore the critical contribution of this Qa-1/HLA-E-dependent regulatory pathway to maintenance of transplanted organs and suggest therapeutic approaches to ameliorate allograft rejection.
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http://dx.doi.org/10.1073/pnas.1918950117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7084119PMC
March 2020

Crystalline light chain proximal tubulopathy and podocytopathy: a case report.

J Bras Nefrol 2020 Mar 2;42(1):99-105. Epub 2019 Dec 2.

Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, EUA.

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http://dx.doi.org/10.1590/2175-8239-JBN-2019-0086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213934PMC
March 2020

Effect of Facility IAC-Accreditation on CT Dose Awareness and Reduction.

Radiol Technol 2017 May;88(5):472-480

Purpose: To assess characteristics of computed tomography (CT) facilities accredited by the Intersocietal Accreditation Commission (IAC) and evaluate the perceived effect of accreditation on CT radiation dose awareness and reduction.

Methods: IAC-accredited CT facilities were sent a survey in April 2016, which included 20 questions categorized into 5 groups: equipment and facility (7), patient safety/practice (5), protocols (2), dose reduction practice (3), and quality improvement (3).

Results: The response rate was 20.7% (N = 607). A majority of facilities (80%) reported that radiation dose was adjusted based on patient size. Before undergoing accreditation, 79% of facilities reported annual review of CT protocols and radiation exposure. Following accreditation, that number increased to 93%. A majority (77%) of respondents indicated that the accreditation process, along with the , increased awareness of radiation exposure; in addition, 36% indicated that radiation doses were lower after undertaking accreditation.

Discussion: This study demonstrated that most IAC-accredited facilities followed recommended radiation safety practices by adjusting radiation dose based on patient size, reviewing protocols annually, and participating in quality improvement activities that focus on patient radiation exposure.

Conclusion: IAC-accredited facilities reported that the accreditation process had a positive effect on radiation dose awareness and reduced dose associated with CT examinations.
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May 2017

Characteristics of Accredited Transcranial Doppler Ultrasound Laboratories in the United States.

J Neuroimaging 2017 03 9;27(2):210-216. Epub 2016 Dec 9.

Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA.

Purpose: The aim of this study was to describe in detail the characteristics and accreditation compliance of laboratories in the United States applying for Intersocietal Accreditation Commission (IAC) transcranial Doppler (TCD) accreditation.

Methods: This was a retrospective study of all applicant laboratories from 2012 to 2015. We used the IAC database to extract laboratory characteristics and guideline compliance metrics.

Results: Evaluation of 97 laboratories demonstrated that 67% were hospital-based and located in the South (43.3%), corresponding to the location of "Stroke Belt" states. Cases from 186 interpreting physicians, of which 110 (59%) were neurologists, were evaluated during the accreditation process. Established practice was the most common training pathway (54.8%), and a majority had not obtained an additional vascular interpretation credential (72.6%). From 318 case studies, the most frequent indications were subarachnoid hemorrhage (31.0%), stroke (17.0%), and carotid stenosis (14.3%). Although most laboratories had been previously accredited, accreditation was delayed for 77.3% due to incomplete studies (33.0%), discrepant findings between the report and the laboratory's diagnostic criteria (23.7%), and discrepant findings between the report and the waveforms/images (17.5%).

Conclusions: The results suggest that there are significant differences between IAC applicant laboratories and laboratories represented by Centers for Medicaid and Medicare Services (CMS) claims data. In addition, accurate study reporting, physician training, and ongoing quality improvement activities may not be optimized in laboratories applying for accreditation. With the information learned from this study, educational strategies by professional organizations, including the IAC, can be tailored to help improve TCD practice.
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http://dx.doi.org/10.1111/jon.12415DOI Listing
March 2017

How Do Noninvasive Imaging Facilities Perceive the Accreditation Process? Results of an Intersocietal Accreditation Commission Survey.

Clin Cardiol 2015 Jul 13;38(7):401-6. Epub 2015 Jun 13.

Intersocietal Accreditation Commission, Columbia, Maryland.

The Intersocietal Accreditation Commission (IAC) accredits vascular, echocardiography, nuclear medicine, computed tomography, and magnetic resonance imaging laboratories. How facilities involved in the accreditation process view accreditation is unknown. The objective of this study was to examine the perception of laboratory accreditation from those who had undergone the process. An electronic survey request was sent to all facilities that had received IAC accreditation at least once. Demographic information, as well as opinions on the perceived value of accreditation as it relates to 15 quality metrics was acquired. Responses were obtained from 2782 facilities. Of the 15 quality metrics examined, the process was perceived as leading to improvements by a majority of respondents for 10 (67%) metrics including: report standardization, adherence to guidelines, test standardization, report completeness, identification of deficiencies, improved staff knowledge, report timeliness, distinguished facility, correction of deficiencies, and image quality. Overall, the perceived improvement was greater for hospital-based facilities (global 66% vs 59%; P < 0.001). Survey data demonstrate that the accreditation process has a positive perceived impact on the majority of examined metrics. These findings suggest that those undergoing the process find value in accreditation.
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http://dx.doi.org/10.1002/clc.22408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6711094PMC
July 2015

Facility perception of nuclear cardiology accreditation: Results of an Intersocietal Accreditation Commission (IAC) survey.

J Nucl Cardiol 2015 Jun 29;22(3):496-503. Epub 2014 Oct 29.

University of Maryland School of Medicine, 295 Stoner Ave, #103, Baltimore, MD, 21157, USA,

Background: The Medicare Improvements for Patients and Providers Act requires accreditation for all non-hospital suppliers of nuclear cardiology, nuclear medicine, and positron emission tomography (PET) studies as a condition of reimbursement. The perceptions of these facilities regarding the value and impact of the accreditation process are unknown. We conducted an electronic survey to assess the value of nuclear cardiology accreditation.

Methods: A request to participate in an electronic survey was sent to the medical and technical directors (n = 5,721) of all facilities who had received Intersocietal Accreditation Commission (IAC) Nuclear/PET accreditation. Demographic information, as well as, opinions on the value of accreditation as it relates to 16 quality metrics was obtained.

Results: There were 664 (11.6%) respondents familiar with the accreditation process of which 26% were hospital-based and 74% were nonhospital-based. Of the quality metrics examined, the process was perceived as leading to improvements by a majority of all respondents for 10 (59%) metrics including report standardization, report completeness, guideline adherence, deficiency identification, report timeliness, staff knowledge, facility distinction, deficiency correction, acquisition standardization, and image quality. Overall, the global perceived improvement was greater for hospital-based facilities (63% vs 57%; P < .001). Ninety-five percent of respondents felt that accreditation was important. Hospital-based facilities were more likely to feel that accreditation demonstrates a commitment to quality (43% vs 33%, P = .029), while nonhospital-based facilities were more likely to feel accreditation is important for reimbursement (50% vs 29%, P≤ .001).

Conclusion: Although the accreditation process is demanding, the results of the IAC survey indicate that the accreditation process has a positive perceived impact for the majority of examined quality metrics, suggesting the facilities find the process to be valuable.
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http://dx.doi.org/10.1007/s12350-014-0011-5DOI Listing
June 2015

Pars plana vitrectomy versus immunomodulatory therapy for intermediate uveitis: a prospective, randomized pilot study.

Ocul Immunol Inflamm 2010 Oct;18(5):411-7

Massachusetts Eye Research and Surgery Institution, Cambridge, MA, USA.

Purpose: Comparison of pars plana vitrectomy (PPV) with immunomodulatory therapy (IMT) for patients with intermediate uveitis (IU).

Methods: A prospective, randomized pilot study was performed on patients with recalcitrant IU associated with degradation of visual acuity (VA) despite standard treatment. Outcome measures (VA, intraocular pressure, anterior chamber and vitreous cellular infiltrate) were collected.

Results: Sixteen patients (18 eyes) were randomized to the PPV IMT group. Nine of 11 eyes (82%) treated with PPV showed resolution of inflammation at follow-up, at 5.93 years. Four of 7 eyes (57%) given IMT had persistent inflammation requiring subsequent PPV. PPV patients showed greater improvement in Snellen line, IOP, and vitreous cell reduction. Three PPV patients had cystoid macular edema (CME) initially; all resolved postoperatively. CME improved in 2 of 3 eyes using IMT.

Conclusions: A higher percentage of patients treated with PPV had improvement of uveitis compared to those given IMT. A multicentered clinical trial is needed to confirm and statistically validate these conclusions.
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http://dx.doi.org/10.3109/09273948.2010.501132DOI Listing
October 2010

Sclerochoroidal calcification in a patient with chronic hypercalcemia from undiagnosed parathyroid adenoma.

Retin Cases Brief Rep 2009 ;3(4):431-3

From *The National Retina Institute, Towson, Maryland; and †Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania.

Purpose: To describe a case of sclerochoroidal calcification in a patient with hypercalcemia from undiagnosed parathyroid adenoma.

Methods: A 66-year-old white woman was found to have asymptomatic bilateral yellow choroidal tumors characteristic of sclerochoroidal calcification. The calcified tumors were echogenic on ultrasonography.

Results: Systemic evaluation disclosed hypercalcemia, and there was no abnormality of the parathyroid glands with hormone levels or nuclear medicine scans. After 4 years, the hypercalcemia persisted, prompting surgical exploration of the parathyroid glands that revealed an adenoma. After resection of the glands, the serum calcium reverted to normal.

Discussion: Sclerochoroidal calcification can be associated with systemic hypercalcemia. A search for the cause is warranted, and in this case, a subclinical adenoma was the source of the hypercalcemia.
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http://dx.doi.org/10.1097/ICB.0b013e31818ba944DOI Listing
November 2014

Abdominal compartment syndrome after ruptured abdominal aortic aneurysm.

ANZ J Surg 2008 Aug;78(8):648-53

Department of Surgery, Alfred Hospital, Melbourne, Victoria, Australia.

Abdominal Compartment Syndrome (ACS) is an increasingly recognized syndrome of intra-abdominal hypertension and generalized physiological dysfunction in critically ill patients. Patients suffering a ruptured abdominal aortic aneurysm (rAAA) are at risk of developing ACS. The objective of the study was to compare the current views on the importance, prevalence and management of ACS after rAAA among Australian vascular surgeons and intensivists. A questionnaire was mailed to 116 registered vascular fellows from the Royal Australasian College of Surgeons and 314 registered fellows of the Joint Faculty of Intensive Care Medicine. Data were collected on the prevalence and importance of ACS after rAAA and whether prophylactic measures were or should be taken to prevent ACS. Hypothetical clinical scenarios representing a range of ACS after rAAA were also presented. The responses were compared using chi(2)-test and t-test. Sixty-seven per cent (78 of 116) of surgeons and 39% (122 of 314) of intensivists responded. Both groups estimated the prevalence of ACS after rAAA as between 10 and 30% and considered it an important entity. Only 30% of surgeons and 50% of intensivists suggested routine intra-abdominal pressure (IAP) monitoring. In patients with borderline IAP (18 mmHg), both groups believed that surgical intervention was unnecessary. Intensivists were more inclined to suggest surgical intervention for clinically deteriorating patients with an increased IAP (30 mmHg) compared with surgeons. Forty-three per cent of intensivists and 17% of surgeons suggested prophylactic (leaving the abdomen open) measures to prevent ACS in high-risk patients. Surgeons and intensivists have similar views on the prevalence and clinical importance of ACS after rAAA. Intensivists more frequently monitored IAP and suggested both early prophylactic and therapeutic intervention for ACS based on physiological and IAP findings.
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http://dx.doi.org/10.1111/j.1445-2197.2008.04466.xDOI Listing
August 2008

Octreotide as a treatment for uveitic cystoid macular edema.

Arch Ophthalmol 2006 Sep;124(9):1353-5

Ocular Immunology and Uveitis Foundation, 348 Glen Road, Weston, MA 02114, USA.

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http://dx.doi.org/10.1001/archopht.124.9.1353DOI Listing
September 2006

Primary intraocular lymphoma: A review.

Semin Ophthalmol 2006 Jul-Sep;21(3):125-33

Retina Specialists of Boston, Cambridge, MA, USA.

Primary intraocular lymphoma (PIOL) is a type of primary central nervous system lymphoma (PCNSL). It is the most common neoplastic masquerade syndrome involving the eye. Its protean ocular manifestations, plus in many cases the initial positive response to corticosteroid therapy for presumed uveitis, delay accurate diagnosis. A high index of suspicion is essential, followed by tissue biopsy with cytology and ancillary studies. Current treatment is based on chemotherapy featuring high-dose methotrexate and radiation therapy. Prognosis is poor due to CNS involvement, but newer therapies have had some success in prolonging survival.
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http://dx.doi.org/10.1080/08820530500350498DOI Listing
November 2006

Does clinical-CT 'mismatch' predict early response to treatment with recombinant tissue plasminogen activator?

Cerebrovasc Dis 2006 4;22(5-6):384-8. Epub 2006 Aug 4.

Stroke Program, University of Texas-Houston Medical School, Houston, TX 77030, USA.

Background: We hypothesized that patients with clinically severe strokes but less severe early ischemic changes on brain CT (i.e., clinical-CT mismatch) may respond better to intravenous recombinant tissue plasminogen activator (i.v. rt-PA) within 3 h of symptom onset.

Methods: In this secondary analysis of the CLOTBUST data, patients with middle cerebral artery occlusions on transcranial Doppler (TCD) were treated with i.v. rt-PA. Alberta Stroke Program Early CT Scores were obtained with raters blinded to the NIH Stroke Scale and TCD results. Two mismatch criteria and three criteria of response to therapy were explored.

Results: Of 126 patients, 67% had a mismatch type 1 and 74% had a mismatch type 2. The presence of clinical-CT mismatch by either definition did not correlate with any of the three criteria of response to rt-PA. Recanalization was a strong determinant of response, whether or not mismatch was present.

Conclusions: Mismatch between severity of neurological deficit and CT findings is common but does not predict response to rt-PA therapy given within 3 h.
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http://dx.doi.org/10.1159/000094856DOI Listing
January 2007

Using telemedicine to facilitate thrombolytic therapy for patients with acute stroke.

Jt Comm J Qual Patient Saf 2006 Apr;32(4):199-205

Department of Neurology, University of Texas Health Science Center, Houston, USA.

Background: Recent stroke-care requirements state that all stroke patients should be screened for intravenous recombinant tissue plasminogen activator (rt-PA) and treated, if the appropriate inclusion and exclusion criteria are met. Two community hospitals 90-130 miles east of Houston deployed telemedicine (videoteleconferencing) to provide acute stroke consultative services. DEVELOPING A TELEMEDICINE CAPACITY: According to the Brain Attack Coalition's recommendations, neurosurgical services need to be accessible within two hours. Given their incomplete neurology coverage, the remote-site hospitals identified telemedicine as the best option, with the University of Texas Health Science Center at Houston stroke team as the provider of expertise.

Results: In the 13 months preceding the telemedicine project (January 2003-March 2004), 2 (.8%) of 327 patients received rt-PA, compared with 14 (4.3%) of 328 patients during the telemedicine project (April 2004-May 2005), p < .001). Seven patients had > or = 4 points improvement in a stroke scale at 24 hours posttreatment. Three patients worsened during the 24-hour assessment. No intracerebral hemorrhages occurred. Door-to-needle median time was 85 minutes (range, 27-165 minutes).

Discussion: Telemedicine facilitated thrombolytic therapy for acute stroke patients and is intended not to replace care provided by remote-site providers but rather to address a time- and spatially related emergency need.
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http://dx.doi.org/10.1016/s1553-7250(06)32025-9DOI Listing
April 2006

Natural course of ocular function in pigmented paravenous retinochoroidal atrophy.

Am J Ophthalmol 2006 Apr;141(4):763-5

Berman-Gund Laboratory for the Study of Retinal Degenerations, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.

Purpose: To estimate mean rates of change of ocular function in patients with pigmented paravenous retinochoroidal atrophy (PPRCA).

Design: Retrospective observational case series.

Methods: Fifteen patients aged 8 to 67 years with PPRCA were followed for 3 to 35 years (average follow-up time, 13 years) with measures of visual acuity, visual field area, and full-field electroretinogram amplitude. Mean annual exponential rates of change were quantified by repeated measures longitudinal regression.

Results: Estimated mean annual rates of change were -2.0% for visual acuity, +0.3% for visual field area, and -3.4% and -6.7% for 0.5 Hz and 30 Hz electroretinogram amplitudes, respectively.

Conclusion: Patients with PPRCA have a slowly progressive disease with respect to the loss of peripheral vision.
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http://dx.doi.org/10.1016/j.ajo.2005.11.009DOI Listing
April 2006

Telemedicine-guided carotid and transcranial ultrasound: a pilot feasibility study.

Stroke 2006 Jan 8;37(1):229-30. Epub 2005 Dec 8.

Department of Neurology, University of Texas Health Science Center, Houston, TX 77030, USA.

Background And Purpose: Transcranial Doppler (TCD) and carotid duplex (CD) provide rapid and safe screening for stroke patients but are highly operator dependent. We explored the feasibility of telemedicine (TM)-guided TCD/CD administered by a health care provider inexperienced with ultrasound.

Methods: Dual video screens transmitted real-time TCD/CD images and sound to a neurosonographer. TM TCD/CD characteristics were compared with an in-person (IP) examination independently obtained on the same patient. We compared carotid stenosis, thrombolysis in brain ischemia (TIBI) flow grades, and the time spent on testing.

Results: We examined 8 subjects with a median age of 51 (31 to 63 range). IP and TM successfully examined 100% of internal carotid and middle cerebral arteries, 50% versus 44% of anterior cerebral artery, and 100% versus 88% of the basilar arteries, respectively. The median time in minutes IP versus TM was 15 (range 10 to 35) and 30 (15 to 50) for CD (P=0.07) and 18 (15 to 30) and 45 (30 to 55) for TCD (P=0.002), respectively. TM correctly identified all normal CD/TCD examinations in 7 subjects. In 1 patient, TM identified carotid occlusion but misread TIBI flow grades in both middle cerebral arteries.

Conclusions: Our pilot study showed the feasibility of TCD/CD by an inexperienced health professional guided by a sonographer via TM. Tests were completed within times comparable to outpatient setting in a vascular laboratory.
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http://dx.doi.org/10.1161/01.STR.0000196988.45318.97DOI Listing
January 2006

Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary.

Stroke 2005 Sep;36(9):2049-56

Background: A panel of experts developed stroke rehabilitation guidelines for the Veterans Health Administration and Department of Defense Medical Systems.

Methods: Starting from previously established guidelines, the panel evaluated published literature through 2002, using criteria developed by the US Preventive Services Task Force. Recommendations were based on evidence from randomized clinical trials, uncontrolled studies, or consensus expert opinion if definitive data were lacking.

Results: Recommendations with Level I evidence include the delivery of poststroke care in a multidisciplinary rehabilitation setting or stroke unit, early patient assessment via the NIH Stroke Scale, early initiation of rehabilitation therapies, swallow screening testing for dysphagia, an active secondary stroke prevention program, and proactive prevention of venous thrombi. Standardized assessment tools should be used to develop a comprehensive treatment plan appropriate to each patient's deficits and needs. Medical therapy for depression or emotional lability is strongly recommended. A speech and language pathologist should evaluate communication and related cognitive disorders and provide treatment when indicated. The patient, caregiver, and family are essential members of the rehabilitation team and should be involved in all phases of the rehabilitation process. These recommendations are available in their entirety at http://stroke.ahajournals.org/cgi/content/full/36/9/e100. Evidence tables for each of the recommendations are also in the full document.

Conclusions: These recommendations should be equally applicable to stroke patients receiving rehabilitation in all medical system settings and are not based on clinical problems or resources unique to the Federal Medical System.
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http://dx.doi.org/10.1161/01.STR.0000180432.73724.ADDOI Listing
September 2005

Stroke and seizure following a recent laparoscopic Roux-en-Y gastric bypass.

Obes Surg 2004 Jun-Jul;14(6):857-60

Department of Neurology, University of Texas Health Science Center, 6431 Fannin, Houston, TX 77030, USA.

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been an available operation for weight loss for the past decade, and bariatric surgery is increasing in the United States. Careful patient screening and follow-up have been the cornerstone for success against the complexities of morbid obesity. Neurologic complications have occurred, such as polyneuropathy and Wernicke-Korsakoff syndrome. We report an 18-year-old female with morbid obesity, steatohepatitis, tobacco, recreational drug, and oral contraceptive use who at 4 months after LRYGBP experienced a generalized seizure and stroke. She was diagnosed with an acute ischemic stroke, possibly venous infarction. Her postoperative course had been complicated by malnutrition and dehydration, apparently related to nausea from chronic cholecystitis. She had a possible protein-S deficiency. Rare neurologic complications emphasize the importance of postoperative surveillance in these patients.
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http://dx.doi.org/10.1381/0960892041590890DOI Listing
October 2004

Telemedicine physician providers: augmented acute stroke care delivery in rural Texas: an initial experience.

Telemed J E Health 2004 ;10 Suppl 2:S-90-4

University of Texas Health Science Center at Houston, Houston, Texas 77030, USA.

We describe the first report of intravenous thrombolytic therapy for acute ischemic stroke given by a rurally based advanced practice nurse (APN) with a telemedicine team of an emergency physician and stroke specialists. A three-way T1 connection between the APN in Dickerson Memorial Hospital in Jasper, TX, the Houston, TX-based Emtel emergency physician, and the University of Texas-Houston Stroke Team physicians facilitated tissue plasminogen activator treatment 80 min into the patient's ischemic stroke, which was manifested by dysarthria, facial palsy, and near-total left-body hemiplegia (NIH Stroke Scale = 9). She was transferred to Memorial Hermann Hospital in Houston for further care. Within 24 h, her neurologic deficits resolved (NIH Stroke Scale = 0), and she was discharged home within 3 days. This represents successful acute stroke care given by an APN under supervision of a telemedicine physician team and may be an option for underserved areas. Educational training of health care providers remains the key for acute stroke care delivery. This case report illustrates a model for telemedicine that has been cost-effective for rural medical care.
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July 2013

Transient neurologic deficits associated with carbamazepine-induced hypertension.

Clin Neuropharmacol 2003 Jul-Aug;26(4):174-6

Department of Neurology and Neuroscience, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.

Carbamazepine is a well-established, effective treatment of complex partial seizures and is well tolerated in most patients. The adverse effects of carbamazepine include aplastic anemia, agranulocytosis, pancytopenia, bone marrow depression, thrombocytopenia, cardiac conduction abnormalities, congestive heart failure, and peripheral edema. Hypertension or hypotension has also rarely been documented in patients with either therapeutic or toxic blood levels of carbamazepine. It is possible that carbamazepine-induced hypertension in those with therapeutic blood levels is rarely seen because most of the patients who begin treatment are young and do not have baseline hypertension. The authors describe a patient of African-American descent with a history of controlled essential hypertension who developed severe uncontrolled hypertension when started on carbamazepine. Treatment with additional antihypertensive medications did not reduce his blood pressure. In addition, he developed two episodes of transient neurologic deficits, the symptoms of which consisted of dysarthria, vertigo, and unstable gait. A substantial reduction of his carbamazepine dose resulted in the control of his blood pressure and no recurrence of his symptoms.
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http://dx.doi.org/10.1097/00002826-200307000-00003DOI Listing
September 2003
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