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Intravenous tenecteplase has been shown to be noninferior to alteplase, with a meta-analysis suggesting superiority, 1 and although tenecteplase has been used off label, it is replacing alteplase as the preferred thrombolytic agent for the treatment of acute stroke. Aside from the use of thrombolysis for stroke on awakening (which applies to a limited population of patients with restrictive use involving the immediate need for magnetic resonance imaging to assess for mismatch between findings on diffusion-weighted imaging and those on fluid-attenuated inversion recovery imaging), thrombolysis for the treatment of acute stroke has generally remained confined to the 4.5-hour time window after . . .

The phenomenon of grade inflation has been studied extensively at high school and undergraduate levels, yet little is known about its occurrence in graduate education. This study bridges this gap by examining graduate grade inflation using data from one U.S. research intensive university, covering two decades of admissions across 75 master’s programs ( N = 24,815) and 78 doctoral programs ( N = 15,701). Relying on both linear and ordinal multilevel models, we investigated the presence of grade inflation and potential variations by degree level and individual academic programs at the program level. Our findings provide preliminary evidence for the presence of graduate grade inflation and suggest that the magnitudes differ across individual academic programs. There is also evidence showing that the trend of grade inflation significantly differed across master’s and doctoral programs. This apparent inflation undermines the signaling value of grades for employers and admission decisions in the labor market and academic selection, as well as for research, feedback, and learning purposes. Future research should replicate our findings using multi-institutional samples and examine drivers of graduate grade inflation to more accurately estimate its magnitude.

OBJECTIVE:To investigate the comparative acute health effects associated with exposures to diesel and 75% biodiesel/25% diesel (B75) blend fuel emissions. METHODS:We analyzed multiple health endpoints in 48 healthy adults before and after exposures to diesel and B75 emissions in an underground mine setting—lung function, lung and systemic inflammation, novel biomarkers of exposure, and oxidative stress were assessed. RESULTS:B75 reduced respirable diesel particulate matter by 20%. Lung function declined significantly more after exposure to diesel emissions. Lung inflammatory cells along with sputum and plasma inflammatory mediators increased significantly to similar levels with both exposures. Urinary 8-hydroxydeoxyguanosine, a marker of oxidative stress, was not significantly changed after either exposure. CONCLUSIONS:Use of B75 lowered respirable diesel particulate matter exposure and some associated acute health effects, although lung and systemic inflammation were not reduced compared with diesel use.

BackgroundWe sought to determine the rate of early neurologic decline (END) in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) who presented with mild deficits and received intravenous tissue plasminogen activator (IVtPA).MethodsAmong 1022 patients with AIS who received IVtPA from 2014 to 2019, we identified 313 (30.6%) with LVO, of which 94 (30%) presented with National Institute of Health Stroke Scale (NIHSS) score ≤7. Thirteen patients were excluded, leaving 81 for analysis. END was defined as NIHSS worsening of ≥4 points within 24 hours.ResultsAmong 81 patients with LVO and low NIHSS score, the mean age was 65.8 years (range 25–93) and 41% were female. The mean time to IVtPA from last known well was 2.5 hours (range 0.8–7). LVO sites were as follows: 5 (6%) carotid, 23 (28%) M1, and 53 (65%) M2 occlusions. Among the 81 patients, 28 (34.6%) had END, and these patients were older (70.8 vs 63.2 years, p=0.036). The mean change in NIHSS score at 24 hours in those with END was 10.4 (range 4–22). Patients with END were less likely to be discharged home (25% vs 66%, p=0.004).ConclusionsAmong patients with LVO AIS who received IVtPA, 30% presented with initial mild deficits. END occurred in one-third of LVO patients with initial mild deficits despite receiving IVtPA. Clinicians should be aware that the natural history of LVO with initial mild deficits is not benign and these patients are eligible for rescue thrombectomy in the 24-hour window if they deteriorate.

Background: To determine a pattern of symptoms and/or risk factors that distinguishes transient ischemic attack (TIA) from nonischemic causes of transient neurologic attacks (NI-TNA). Methods: We reviewed demographic, clinical, and hospital data on 100 consecutive patients with transient focal neurologic episode(s) lasting less than 24 h and in whom the initial diagnosis was TIA. After inpatient evaluation and review, final diagnoses were made by two stroke neurologists. Using stepwise multivariable logistic regression, we estimated odds ratios (OR) for independent predictors of NI-TNA. p < 0.05 was considered significant. Results: Of the 100 patients, 40 were confirmed to have TIA and 60 NI-TNA. Compared to TIA patients, those with NI-TNA were less likely to be male and white but more likely to have a history of prior unexplained TNA, gradual symptom onset, associated nonspecific symptoms, longer symptom duration, and delayed presentation. Other variables were similar between the two groups. In a multivariable logistic regression model, gradual symptom onset (adjusted OR 6.7, p = 0.002), prior history of unexplained transient neurologic attack (adjusted OR 10.6, p = 0.031), and presence of nonspecific symptoms (adjusted OR 4.2, p = 0.008) were independent predictors of the final diagnosis of NI-TNA. Conclusions: Distinguishing TIA from nonischemic causes is difficult in the emergency room, with 60% of suspected TIA patients having nonischemic causes on inpatient evaluation. We found 3 clinical features that may be useful in the emergency room triage of transient neurologic attacks. Further study is needed to develop tools that can accurately diagnose TIA.

Background: Antibiotic prescription practices in primary care in Singapore have received little scholarly attention. In this study, we ascertained prescription prevalence and identified care gaps and predisposing factors. Methods: A retrospective study was conducted on adults (>21 years old) at six public primary care clinics in Singapore. Prescriptions >14 days were excluded. Descriptive statistics were used to showcase the prevalence data. We used chi-square and logistic regression analyses to identify the factors affecting care gaps. Results: A total of 141,944 (4.33%) oral and 108,357 (3.31%) topical antibiotics were prescribed for 3,278,562 visits from 2018 to 2021. There was a significant reduction in prescriptions (p < 0.01) before and after the pandemic, which was attributed to the 84% reduction in prescriptions for respiratory conditions. In 2020 to 2021, oral antibiotics were most prescribed for skin (37.7%), genitourinary (20.2%), and respiratory conditions (10.8%). Antibiotic use in the “Access” group (WHO AWaRe classification) improved from 85.6% (2018) to 92.1% (2021). Areas of improvement included a lack of documentation of reasons for antibiotic use, as well as inappropriate antibiotic prescription for skin conditions. Conclusion: There was a marked reduction in antibiotic prescriptions associated with the onset of the COVID-19 pandemic. Further studies could address the gaps identified here and evaluate private-sector primary care to inform antibiotic guidelines and the local development of stewardship programs.

Data on primary care antibiotic prescription practices for children in Singapore, which are essential for health care policy, are lacking. We aimed to address this gap and to benchmark prescription practices against international standards. A retrospective cohort database study on antibiotic prescriptions for children (aged < 18 years) who visited six public primary care clinics in Singapore between 2018 and 2021 was conducted. Data were categorised according to the World Health Organization’s Access, Watch, Reserve (WHO AWaRe) classification. Quality indicators from the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) and the National Institute for Health and Care Excellence (NICE) guidelines were used as a measure of appropriateness of antibiotic prescribing at the individual and overall patient level. In 831,669 polyclinic visits by children between 2018 and 2021, there was a significant reduction in mean antibiotics prescribed per month during pandemic years (2020–2021) compared to pre-pandemic (2018–2019) (MD 458.3, 95% CI 365.9–550.7). Most prescriptions (95.8%) for acute conditions fell within the WHO AWaRe “Access” group. Antibiotic prescription significantly exceeded (55.2%) the relevant quality indicator for otitis media (0–20%). The proportion of children receiving appropriate antibiotics for acute respiratory infections (n = 4506, 51.3%) and otitis media (n = 174, 49.4%) was low compared to the quality indicator (80–100%). There is a need to develop local evidence-based primary care antibiotic guidelines, as well as to support the development of stewardship programmes.

Background The intracerebral hemorrhage (ICH) score is a simple grading scale that can be used to stratify risk of 30 day mortality in ICH patients. A similar risk stratification scale for subarachnoid hemorrhage (SAH) is lacking. We sought to develop a risk stratification mortality score for SAH. Methods With approval from the Institutional Review Board, we retrospectively reviewed 400 consecutive SAH patients admitted to our institution from August 1, 2006 to March 1, 2011. The SAH score was developed from a multivariable logistic regression model which was validated with bootstrap method. A separate cohort of 302 SAH patients was used for evaluation of the score. Results Among 400 patients with SAH, the mean age was 56.9 ± 13.9 years (range, 21.5–96.2). Among the 366 patients with known causes of SAH, 292 (79.8 %) of patients had aneurysmal SAH, 65 (17.8 %) were angiogram negative, and 9 (2 %) were other vascular causes. The overall in-hospital mortality rate was 20 %. In multivariable analysis, the variables independently associated with the in-hospital mortality were Hunt and Hess score (HH) ( p  < 0.0001), age ( p  < 0.0001), intraventricular hemorrhage (IVH) ( p  = 0.049), and re-bleed ( p  = 0.01). The SAH score (0–8) was made by adding the following points: HH (HH1-3 = 0, HH4 = 1, HH5 = 4), age (<60 = 0, 60–80 = 1, ≥80 = 2), IVH (no = 0, yes = 1), and re-bleed within 24 h (no = 0, yes = 1). Using our model, the in-hospital mortality rates for patients with score of 0, 1, 2, 3, 4, 5, 6, and 7 were 0.9, 4.5, 9.1, 34.5, 52.9, 60, 82.1, and 83.3 % respectively. Validation analysis indicates good predictive performance of this model. Conclusion The SAH score allows a practical method of risk stratification of the in-hospital mortality. The in-hospital mortality increases with increasing SAH mortality score. Further investigation is warranted to validate these findings.

Objectives: Data on primary care antibiotic prescription practices for children in Southeast Asia, which are essential for policy, quality improvement and patient safety, are lacking. We aimed to describe this gap and to benchmark prescription practices against international standards. Methods: Antibiotic prescriptions for children (age <18 years) who visited six public primary care clinics in Singapore between 2018 and 2021 were extracted and categorized according to the World Health Organization Access, Watch, Reserve (WHO AWaRe) classification. Quality indicators from the European Surveillance of Antimicrobial Consumption Network (ESAC- Net) and National Institute for Health and Care Excellence (NICE) guidelines were used as a measure of appropriateness of antibiotic prescribing. Descriptive statistics and T-test was used to compare prescription rates pre- and post-COVID-19 pandemic. Results: 19,325 and 20,692 oral and topical antibiotics were prescribed for 831,669 visits, with a prescription rate of 2.3% and 2.5% respectively. Mean antibiotic prescriptions fell significantly post-pandemic (2020–2021), compared to pre-pandemic numbers (1062.8 to 604.5 prescriptions per month) ( p <0.001). The majority (95.8%) of prescriptions belonged to the Access group. Watch group antibiotics constituted 6.1% of the total antibiotics prescribed for respiratory conditions (n = 562). While prescriptions were low (4.1%) and well within EASC-Net quality indicator limits of 0-20% for respiratory infections, prescriptions for otitis media were significantly high (56.6%). Approximately 1 in 2 children received antibiotics as recommended by NICE guidelines for both respiratory infections (n=4,622, 51.5%) and otitis media (n=204, 51.8%). Conclusions: Primary care antibiotic prescriptions for children in Singapore decreased post- COVID-19. However, high rates of otitis media prescriptions and only 50% appropriateness for respiratory infections and otitis media emphasize the need for targeted improvements in these areas.

BackgroundThe rate of intravenous tissue plasminogen activator (IVtPA) administered to stroke mimics (SM) occurs in 24%–44% of telestroke series.MethodsWe reviewed 270 suspected acute ischaemic stroke (AIS) patients who were evaluated by telestroke and received IVtPA from 1 July 2016 to 30 September 2017 at our academic comprehensive stroke centre.ResultsAmong 270 AIS patients who received IVtPA via telestroke, 64 (23.7%) were diagnosed with SM. Compared with patients who had a stroke, the SM group was younger (mean age 56.4 vs 68.2, p<0.0001), more likely to be female (60.9% vs 45.6%, p=0.0324) and had longer door-to-needle times (85.3 vs 69.9, p=0.0008). The most common SM diagnoses were migraine 26 (40.6%), conversion disorder 12 (18.8%), encephalopathy 7 (10.9%) and unmasking (9.4%). Among the SM, migraine and conversion disorder were younger compared with the other subgroups (p<0.001). Functional exam elements were noted more frequently in conversion disorder (66.7%) and migraine (34.6%), but rare in other diagnoses (p=0.006). Among the SM, 23 (35.9%) had a history of a prior similar episodes, and 15 (23.4%) had a history of more than 5 spells.ConclusionsIn our telestroke programme, 23.7% of those administered thrombolysis had a final diagnosis of SM.