Recent research has shown that neuroinflammation progresses rapidly within a few hours after stroke; however, the relationship between its progression and clinical outcomes remains unclear. Therefore, this study aimed to investigate the effect of neuroinflammation, measured by serum GFAP (glial fibrillary acidic protein), on patient outcomes, as well as the influence of baseline peripheral inflammation on the progression of neuroinflammation. This prospective cohort study enrolled patients with acute ischemic stroke who received intravenous thrombolysis (IVT) between September 2016 and April 2023 across 16 centers in China. Serum GFAP levels were measured before (baseline, within 4.5 hours of onset) and at 24 hours after IVT. GFAP changes were determined by subtracting baseline levels from those measured 24 hours post-IVT. Outcome measures included final infarct volume during hospitalization, National Institutes of Health Stroke Scale scores at 24 hours and 7 days post-IVT, early neurological deterioration within 24 hours, delayed neurological deterioration within 7 days, and 3-month modified Rankin Scale scores. A modified Rankin Scale score of ≥2 was classified as an unfavorable outcome. Peripheral inflammation indicators were measured at baseline. Binary logistic and linear regressions were used as the main statistical methods. Overall, 743 patients were included. A significant increase in GFAP levels was observed, indicating progression of neuroinflammation. Regression analyses revealed that increased GFAP after IVT was independently associated with larger infarct volume (β, 30.965 [95% CI, 19.185-42.745]; P<0.001), higher 24-hour and 7-day National Institutes of Health Stroke Scale scores (24-hour: β, 2.632 [95% CI, 1.644-3.620]; P<0.001; 7-day: β, 3.298 [95% CI, 2.179-4.417]; P<0.001), and unfavorable outcomes (odds ratio, 3.631, [95% CI, 2.159-6.106]; P<0.001). Furthermore, baseline peripheral inflammation, assessed using peripheral inflammation indicators, was significantly associated with elevated GFAP levels. The increase in GFAP levels over the first 24 hours after IVT is independently associated with clinical outcomes, with higher baseline peripheral inflammation correlating with greater GFAP elevation during that period.

Loberamisal, a novel agent that dissociates the post-synaptic density protein 95/neuronal nitric oxide synthase complex and potentiates the α2-containing γ-aminobutyric acid type A receptors, is a potential neuroprotectant that is effective in preclinical studies for acute ischaemic stroke. This trial aims to demonstrate the efficacy and safety of intravenous loberamisal in patients with acute ischaemic stroke (AIS) within 48 hours of onset. The LAIS (Loberamisal for Acute Ischaemic Stroke) trial is a multicentre, prospective, randomised, double-blind, placebo-controlled phase 3 trial. A total of 998 eligible patients will be randomly assigned to receive either loberamisal or placebo in a 1:1 ratio. The primary efficacy outcome is proportion of individuals achieving an excellent functional outcome, defined as modified Rankin Scale (mRS) 0-1 at 90 days. Secondary efficacy outcomes include favourable functional outcome (defined as an mRS score of 0 in patients with a baseline NIHSS score of 4 to 7; an mRS score of 0 to 1 in patients with a baseline NIHSS score of 8 to 14; and an mRS score of 0 to 2 in patients with a baseline NIHSS score of 15 to 25), distribution of mRS at 90 days, patients with ≥4 points reduction in National Institutes of Health Stroke Scale score from baseline at 10 days and 30 days, and Barthel Index ≥95 at 90 days. Safety outcomes were adverse events. Exploratory outcomes include the incidence of depressive and anxiety symptoms at 90 days. The LAIS trial will evaluate the potential of loberamisal as a novel neuroprotectant in acute ischaemic stroke. NCT06517173.

To assess the efficacy and safety of tenecteplase in patients presenting within 24 hours of symptom onset with a large vessel occlusion and target mismatch on perfusion computed tomography. ETERNAL-LVO (Extending the Time Window for Tenecteplase by Effective Reperfusion in Patients With Large Vessel Occlusion) was a prospective, randomized, open-label, blinded end point, phase 3, superiority trial where adult participants with a large vessel occlusion, presenting within 24 hours of onset with salvageable tissue on computed tomography perfusion, were randomized to tenecteplase 0.25 mg/kg or standard care across 11 primary and comprehensive stroke centers in Australia. The primary outcome was the modified Rankin Scale score of 0 to 1 or return to baseline at 90 days via a modified Poisson regression model. Secondary outcomes include the modified Rankin Scale, considered as an ordinal variable, and symptomatic intracerebral hemorrhage. Following trial initiation, a supply shortage of the investigational product hindered recruitment. When supply resumed, phase 3 evidence had emerged supporting tenecteplase use within 4.5 hours of stroke onset, including large vessel occlusion. ETERNAL-LVO was, therefore, terminated early. Two hundred forty-two participants (median age: 73 years, 43% female, 79% undergoing EVT) were included in the modified intention-to-treat analysis; 120 received tenecteplase and 122 received standard care. No difference in the primary outcome was observed between the tenecteplase (n=44, 37%) and standard care (n=52, 43%; adjusted risk ratio, 0.90 [95% CI, 0.66-1.21]; P=0.48). No significant differences in an ordinal analysis of the modified Rankin Scale were observed between the 2 treatment groups. In a planned per-protocol analysis, the odds of improvement by 1 point in the modified Rankin Scale were doubled in the tenecteplase-treated transfer subgroup compared with standard care transfer patients (odds ratio, 2.61 [95% CI, 1.07-6.40]). Symptomatic intracerebral hemorrhage occurred in 5 (4%) participants assigned to tenecteplase and was present in 1 (1%) participant assigned to standard care. Treatment with tenecteplase did not increase the likelihood of a favorable functional outcome, but early stoppage of the study prevents definitive conclusions from being drawn. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04454788.

Elevated Baseline High-Sensitivity Cardiac Troponin T Associates with Early Neurological Deterioration After Thrombectomy for Acute Ischemic Stroke.

A 10-year-old girl was admitted with a 38-hour history of widespread subcutaneous petechiae and hematuria and a 6-hour history of jaundice and oliguria. Physical examination revealed widespread subcutaneous petechiae and jaundice of the skin and sclera. Laboratory tests showed anemia, thrombocytopenia, acute kidney injury, and markedly elevated lactate dehydrogenase. Thrombotic microangiopathy was initially diagnosed, with a high suspicion of atypical hemolytic uremic syndrome (aHUS). Eculizumab was initiated within 9 hours of admission (within 48 hours of onset). After the first infusion, hemolysis rapidly ceased, and the platelet count and renal function gradually returned to normal. Whole-exome sequencing identified homozygous deletions of CFHR1 exon 2 and CFHR4 exon 1. aHUS typically has abrupt onset and rapid progression. Clinicians should maintain high suspicion for aHUS when the triad of thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury is present. Ultra-early eculizumab (within 48 hours of onset) rapidly blocks complement-mediated thrombotic microangiopathy, reverses organ injury, and improves long-term prognosis. Additionally, complement-related genetic testing is important for etiological clarification and individualized determination of eculizumab treatment duration.

Background: Acute stroke is a leading neurological emergency, and rapid identification of underlying pathology is essential for appropriate management. Subarachnoid hemorrhage (SAH) is a less common but life-threatening cause of acute stroke, requiring urgent diagnosis and intervention. Evaluating its frequency in stroke presentations can support early detection and improved outcomes. Objective: To determine the frequency of subarachnoid hemorrhage in patients presenting with acute stroke. Study Design: Cross-sectional study. Setting: Department of General Medicine, DHQ Teaching Hospital, Dera Ismail Khan, Pakistan. Duration of Study: From January 2025 to July 2025. Methods: A total of 203 patients aged 40 years or older of either gender presenting with acute stroke within 48 hours of onset were enrolled. SAH was diagnosed based on radiological confirmation of blood in the subarachnoid space on CT scan and classified using the Fisher scale. Data were analyzed using SPSS version 25. Descriptive statistics were applied to determine SAH frequency and grading distribution. Results: The mean age of patients was 52.96 ± 9.62 years, with 58.1% males and 41.9% females. Subarachnoid hemorrhage was identified in 12 patients (5.9%). Among SAH cases, Fisher grade I was observed in 1 patient (8.3%), grade II in 3 patients (25%), grade III in 4 patients (33.3%), and grade IV in 4 patients (33.3%). Conclusion: SAH accounted for 5.9% of acute stroke presentations in the studied population. Most cases were categorized as Fisher grade III and IV, highlighting the importance of immediate radiological evaluation for severe SAH to guide timely management and improve patient outcomes.

IV thrombolysis only (IVT-O) is the primary reperfusion therapy for most stroke patients. At least 50% of IVT-O patients remain disabled. We assessed 2 therapies added to IVT-O aimed at increasing clot lysis or preventing arterial reocclusion. This 3-arm, adaptive, single-blinded, randomized controlled phase III clinical trial was conducted at 57 US sites. Patients with acute ischemic stroke (AIS) within 3 hours of onset receiving IV tissue plasminogen activator or tenecteplase were randomized to argatroban (100 μg/kg bolus and 12-hour infusion at 3 μg/kg/min), eptifibatide (135 μg/kg bolus and 2-hour infusion at 0.75 μg/kg/min), or placebo (bolus and 12-hour infusion). The primary end point was utility-weighted 90-day modified Rankin Scale score (uwmRS score; worst = 0, best = 10). This prespecified secondary analysis was conducted on the intent-to-treat population in the IVT-O cohort using a Bayesian normal dynamic linear model. Of 514 patients enrolled into Multi-arm Optimization of Stroke Thrombolysis (MOST) before the study was stopped for futility, 260 were in the IVT-O cohort (118 treated with placebo, 114 with eptifibatide, and 28 with argatroban; mean age 66 years, 46.9% female). Baseline variables were similar across groups (median NIH Stroke Scale score 8, mean time from symptom onset to IVT 105 minutes, mean time from IVT bolus to study drug start 62 minutes). A clot was visible in 30.8% of patients. There was only a 1% or 2.5% chance that argatroban or eptifibatide, respectively, was superior to placebo for the primary outcome (mean uwmRS scores [SD] of 5.5 [3.6], 6.6 [3.2], and 7.4 [2.6] for argatroban, eptifibatide, and placebo, respectively). No secondary outcomes favored either treatment group. The risk difference for symptomatic hemorrhage between the argatroban and eptifibatide arms vs placebo was -0.8% (p = 0.82) and 1.8% (p = 0.36). Mortality was 3.4% with placebo, 14.3% for argatroban (p = 0.03), and 11.4% for eptifibatide (p = 0.02). There was no benefit in any subgroup. Outcomes in patients treated with IVT-O were not improved by adding either argatroban or eptifibatide. Increased bleeding was not observed, but mortality was higher in both investigational arms. Limitations included small sample size in the argatroban subgroup. This study was registered on ClinicalTrials.gov (registration number: NCT03735979) on November 8, 2018. The first patient was enrolled on October 15, 2019. This study provides Class II evidence that in patients with AIS treated with IVT within 3 hours of onset, argatroban or eptifibatide does not improve outcomes vs thrombolysis alone but does increase mortality.

Intravenous diphenhydramine is commonly used to treat acute peripheral vertigo but may cause sedation. Sodium bicarbonate, an alternative therapy used in Eastern countries, may relieve vertigo symptoms without lethargy. However, comparative evidence is limited. To evaluate the efficacy and safety of diphenhydramine, sodium bicarbonate, and their combination in treating acute peripheral vertigo among emergency department (ED) patients. A triple-arm, double-blind, randomized clinical trial was conducted at the National Taiwan University Hospital, Yunlin Branch ED, from January 17 to November 14, 2023. Adults with peripheral vertigo within 24 hours of onset were enrolled. Exclusion criteria included refusal, pregnancy, prior antivertigo medication use, symptom duration of more than 24 hours, heart failure, chronic kidney disease, or drug allergy. Patients were randomized in a 1:1:1 ratio to receive 30 mg of intravenous diphenhydramine (group A), 66.4 mEq (approximately 1 mEq/kg) of sodium bicarbonate (group B), or both agents (group C). The primary outcome was change in vertigo severity using a 10-point visual analog scale (VAS) at 60 minutes after treatment. Key secondary outcomes included change in nausea severity using a 10-point VAS, rescue medication use, ED length of stay, and adverse effects. Analysis was performed on a modified intention-to-treat basis. Among 222 patients (mean [SD] age, 57.9 [17.6] years; 150 women [67.6%%]), group C had greater improvement in vertigo severity than group A (mean [SD] VAS score, -5.6 [2.1] vs -4.4 [2.7]; P = .01), with the treatment effect most pronounced among younger male patients without a history of vertigo. Group B showed similar VAS improvement compared with group A (mean [SD] VAS score, -5.1 [2.2] vs -4.4 [2.7]; P = .34). Rescue therapy was used less frequently in group C (17.8% [13 of 73]) than in group A (46.7% [35 of 75]; P < .001). No differences were observed between groups in nausea scores or ED length of stay. Lethargy was more common in diphenhydramine groups than in the sodium bicarbonate group (moderate lethargy: group A, 38.7% [29 of 75] and group C, 30.1% [22 of 73] vs group B, 8.1% [6 of 74]; P < .001). Injection discomfort was more common with sodium bicarbonate (group A, 8.0% [6 of 75]; group B, 17.6% [13 of 74]; group C, 28.8% [21 of 73]; P = .004). In this randomized clinical trial of patients with acute peripheral vertigo, combination therapy provided better symptom relief than diphenhydramine alone. Further studies should focus on the determination of peripheral vertigo types that can benefit from sodium bicarbonate and the underlying mechanisms. ClinicalTrials.gov Identifier: NCT05676216.

Application of Glasgow Outcome Scale score combined with neutrophil-to-lymphocyte ratio in predicting prognosis of aneurysmal subarachnoid hemorrhage.

Early diagnostic utility of BNP and NT-proBNP for cardioembolic stroke: A head-to-head comparison in the hyperacute and early acute phase.

To compare six machine learning models for predicting early neurological deterioration (END) after intravenous rt-PA thrombolysis in acute ischaemic stroke, and to develop an interpretable clinical tool. Observational study. Place and Duration of the Study: Department of Neurology, Benxi Central Hospital, Benxi, China, from January 2021 to December 2023. All consecutive adults receiving standard-dose rt-PA within 4.5 hours of onset were screened. END was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score of ≥4 or death within 24 hours. Thirty-two baseline variables were collected; those showing p <0.10 on univariate analysis (NIHSS, age, fibrinogen, and hypertension) entered model construction. An 80:20 stratified split produced training and validation cohorts. Decision tree, random forest, XGBoost, support vector classifier, multilayer perceptron, and logistic regression were tuned by grid search with fivefold cross-validation. Discrimination (area under the ROC curve and AUC), accuracy, sensitivity, specificity, and F1 score were calculated on the hold-out set. The best model underwent SHapley Additive exPlanation (SHAP) analysis to visualise feature important and protective or harmful thresholds. Internal robustness was confirmed with 1,000 bootstrap resamples. Among 209 eligible patients (END = 16, 7.7%), the XGBoost model achieved the highest discrimination (AUC 0.966), perfect sensitivity (1.000), accuracy (0.905), and specificity (0.897). The decision tree produced the top F1 score (0.750) but lower AUC (0.957). SHAP plots identified admission NIHSS, hypertension, age ≥72 years, and fibrinogen >3.2 g/L as the principal drivers of risk, together accounting for 85 % of model weight. A concise, four-variable XGBoost model reliably stratifies END risk after rt-PA, offering a transparent decision aid for clinicians to allocate intensified monitoring or adjunctive therapy. Machine learning, Stroke, Intravenous thrombolysis, rt‑PA, Early neurological deterioration.

ABSTRACTIn this article, we report the case of a 57‐year‐old hypertensive man with a prosthetic valve and a pacemaker who presented after many hours of onset of left‐sided hemiplegia, left facial drop and dysarthria. Computed tomography of the brain revealed an ischemic stroke, and after an extensive workup the diagnosis of an embolic stroke induced by a Streptococcus gordonii endocarditis was established. This organism is considered to be a rare cause of endocarditis as only a dozen cases were previously reported in the literature. We describe the clinical interventions used, expose the diagnostic approach and challenges faced. To the best of our knowledge, this is the first Streptococcus gordonii‐associated endocarditis that is reported in Lebanon and, as such, it widens the geographical setting in which it had been reported and helps gain a better understanding of its epidemiology and strain resistance. Furthermore, it highlights the need to include in the differential diagnosis of endocarditis unusual causative and infectious agents, and as such, it urges clinicians to maintain vigilance towards them and take timely intervention against them in order to ameliorate patients' prognosis. We also provide updates in this article on recent research findings and prevention strategies that may be used in the future against infectious endocarditis.

Background:The relationship between adjunctive traditional Chinese medicine therapy and symptom resolution in viral influenza has not been thoroughly examined. This study aimed to evaluate whether the addition of Mahuang Fuzi Xixin (MFX) decoction to standard antiviral therapy improves clinical outcomes in patients with early-stage viral influenza.Methods:We conducted a randomized controlled study involving 61 patients with viral influenza symptoms presenting within 48 hours of onset. Participants were assigned based on disease severity, age, and sex in a 1:1 ratio to either the MFXD plus antiviral drugs group (MFXD group, n = 31) or the antiviral drugs alone group (control group, n = 30). Fever duration and virological clearance were compared between groups during and after treatment.Results:After 5 days, the MFXD group exhibited a significantly shorter fever duration (27.4 ± 11.1 hours) compared to the control group (60.9 ± 21.6 hours; P < .01). By day 3, 22 of 35 patients (62.9%) in the MFXD group had become afebrile, compared with 12 of 33 (36.4%) in the control group (P = .028). By day 5, fever resolution was achieved in 30 of 31 evaluable patients (96.8%) in the MFXD group versus 19 of 30 (63.3%) in the control group (P = .002). Additionally, at the end of treatment, 23 patients (74.2%) in the MFXD group tested negative for influenza viruses, adenovirus, or mycoplasma pneumoniae, compared with 13 patients (43.3%) in the control group (P = .029).Conclusion:The early combined use of MFXD and antiviral drugs accelerates symptom resolution and virological clearance. MFXD may be a beneficial adjunctive treatment for elderly patients with viral influenza.

BackgroundTimely differentiation between ischemic stroke (IS) and intracerebral hemorrhage (ICH) is critical for guiding appropriate acute management strategies. While neuroimaging is the diagnostic gold standard, its accessibility is often limited in urgent clinical settings. Blood biomarkers offer a promising, scalable diagnostic alternative; however, no validated panel is yet available for distinguishing stroke subtypes during the hyperacute phase.MethodsIn a multicenter study, plasma samples were collected within 6 h of symptom onset. A total of 3,072 proteins were measured using Olink® proximity extension assays. We applied differential expression analysis, principal component analysis (PCA), partial least squares discriminant analysis (PLS-DA), and receiver operating characteristic (ROC) curve evaluation. To interpret the biological relevance of the findings, we conducted functional enrichment and protein–protein interaction (PPI) analyses.ResultsAmong the 388 patients (344 IS, 44 ICH), 2,531 proteins were retained; 878 reached nominal significance (p < 0.05), and 67 remained significant after multiple-testing correction (FDR-adjusted p < 0.05). Of these, 844 were overexpressed in ICH and 34 in IS. GFAP, a glial marker, emerged as the most discriminative biomarker for ICH versus IS (AUC = 0.887; sensitivity: 80%, specificity: 90%), followed by BCAN (AUC = 0.820), SNAP25 (AUC = 0.797), and SPOCK1 (AUC = 0.786). For IS, S100A12 (AUC = 0.677) and MNDA (AUC = 0.657) showed the best performance. Multivariate analyses confirmed the presence of distinct proteomic patterns, with enrichment revealing a significant overrepresentation of neurodevelopmental and synaptic pathways. In PPI networks, GFAP and LYN emerged as central hubs.ConclusionThis study reveals a robust plasma proteomic signature distinguishing IS from ICH within hours of onset. These results lay the groundwork for scalable, blood-based diagnostics to guide early stroke management when imaging is delayed or unavailable.Supplementary InformationThe online version contains supplementary material available at 10.1186/s40364-025-00848-1.

Outcomes following intravenous thrombolysis for minor ischemic stroke may vary based on the presence of disabling deficits. To determine whether intravenous tenecteplase improves outcomes according to US National Institutes of Health Stroke Scale (NIHSS) score-based definitions of pretreatment disabling deficits. This is a secondary analysis of the TEMPO-2 (Tenecteplase vs Standard of Care for Minor Ischemic Stroke With Proven Occlusion) randomized clinical trial, conducted between April 27, 2015, and January 19, 2024. Patients were followed up for 90 days. The TEMPO-2 trial was conducted across 48 sites globally among patients with minor ischemic stroke (NIHSS 0-5) and proven intracranial occlusion within 12 hours of onset. Patients were divided into having nondisabling vs disabling syndromes at presentation as per the TREAT Task Force consensus. Other established definitions of disabling stroke from the ARAMIS trial and the National Institute of Neurological Disorders and Stroke trial were explored. Data analysis was completed from July 2024 to September 2024. Intravenous tenecteplase (0.25 mg/kg) vs nonthrombolytic standard of care. The primary outcome was a return to baseline modified Rankin scale score at 90 days. Among 886 enrolled patients, 2 withdrew consent and 884 were included in the secondary analysis. Among 884 patients analyzed (369 women [41.7%]; median [IQR] age, 72 [61-80] years), 100 (11.3%) had disabling and 784 (88.7%) had nondisabling deficits. Patients with disabling deficits had higher median (IQR) baseline NIHSS scores (4 [3-5] vs 2 [1-3]), later presentations (onset to hospital arrival time: 288 [153-412] minutes vs 133 [70-310] minutes), and longer onset to treatment time (411 [307-560] minutes vs 278 [170-462] minutes) than those with nondisabling deficits. In the disabling group, the primary outcome following tenecteplase, compared with standard of care, occurred in 29 patients (54.7%) vs 32 patients (68.1%) (adjusted risk ratio [aRR], 0.81; 95% CI, 0.60-1.10). This neutral treatment effect was consistent in patients without disabling deficits (280 [73.9%] vs 306 [75.6%]; aRR, 0.98; 95% CI, 0.91-1.07; P for interaction = .32). In this secondary analysis of the TEMPO-2 randomized clinical trial, current definitions of disabling symptoms based on NIHSS score at baseline did not modify the neutral treatment effect of intravenous tenecteplase in patients with minor stroke and intracranial occlusion. Together with converging evidence comparing intravenous thrombolysis to nonthrombolytic standard of care, this analysis suggests the need to reevaluate thrombolysis in minor disabling stroke. ClinicalTrials.gov Identifier: NCT02398656.

ObjectiveTo explore the predictive value of liver/spleen CT Value, bedside index for severity in acute pancreatitis (BISAP) score combined with serum soluble programmed death ligand 1 (sPD-L1) within 24 hours of onset for the severity tendency of hyperlipidemic acute pancreatitis (HTG-AP).MethodsA retrospective study was conducted on the clinical data of 102 patients with mild to moderate HTG-AP. These patients were divided into the progression group (24 cases) and the stable group (78 cases) based on whether they progressed to severe HTG-AP. The liver/spleen CT values, BISAP scores, serum sPD-L1 levels and blood urea nitrogen (BUN) levels were compared within 24 hours of onset in the two groups. The COX regression model was used to analyze the influencing factors of the tendency of HTG-AP severity. The predictive efficacy of each indicator was evaluated through the Receiver operating characteristic curves (ROC).ResultsThe BUN, BISAP score, serum sPD-L1 levels, and the proportion of moderate HTG-AP in the progression group were all higher than those in the stable group, while the liver/spleen CT values were lower than the stable group (all P<0.05). Liver/spleen CT values were protective factors (HR=0.245, 95% CI: 0.098–0.613) for the tendency towards severe HTG-AP, while BISAP scores (HR=4.536) and serum sPD-L1 (HR=4.345) were risk factors (all P<0.05). The combined prediction of the three indicators for the severity of HTG-AP had an AUC of 0.826, with a sensitivity of 0.89 and a specificity of 0.79, and the efficacy was superior to that of a single indicator (all P<0.05).ConclusionLiver/spleen CT values, BISAP scores and serum sPD-L1 have certain predictive value for the tendency of severe deterioration in patients with HTG-AP within 24 hours of onset. When these three factors are combined, the predictive efficacy is even better.

Postpartum haemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide. While coagulation disorders are seldom the primary cause of PPH and are rare early in PPH, the incidence of coagulation abnormalities increases when blood loss escalates. Acute obstetric coagulopathy (AOC), with an incidence of one in 1000 deliveries, has emerged as a distinct coagulopathy in PPH, highlighting the need for timely coagulation testing and intervention. This narrative review examines the current evidence on the use of visco-elastic haemostatic assays (VHAs) to guide treatment in PPH, and further explores the prophylactic and therapeutic roles of fibrinogen and tranexamic acid (TXA). VHAs have shown potential in PPH management, with large prospective and retrospective cohort studies demonstrating reductions in transfusions and transfusion-related complications. However, these findings have not been consistently replicated, possibly due to variations in study design and statistical power. This review explores the benefits and limitations of VHAs in the context of PPH management. Until large, well designed studies suggest otherwise, women with PPH might benefit from access to VHAs, given their potential to improve clinical outcomes in large cohorts without evidence of associated harm. Fibrinogen replacement is essential in PPH management. VHAs have been shown to be as effective as the Clauss fibrinogen assay in guiding fibrinogen substitution during PPH. Recent updates to ROTEM Sigma cartridges have led to new FIBTEM A5 thresholds, with the Obstetric Bleeding Strategy (OBS) group of Wales proposing a FIBTEM A5 of 8 mm or less as the new trigger for fibrinogen replacement in PPH. Fibrinogen concentrate offers advantages over cryoprecipitate and may be preferred when both are available. Effective fibrinogen substitution not only corrects VHA results but also helps to control bleeding. TXA is a cornerstone in the treatment of PPH and should be administered promptly at a dose of 1 g as soon as PPH is diagnosed, regardless of VHA results, and always within three hours of onset. A second dose may be given if bleeding persists or recurs. However, high-quality randomised trials have consistently shown no benefit from prophylactic TXA in low-risk caesarean section or in vaginal births across all risk groups. Data on the prophylactic use of TXA in high-risk caesarean section are limited and its use in these cases should be based on clinical judgement and individual risk assessment.

BACKGROUND: Anaphylaxis is a severe, life-threatening systemic allergic reaction. Currently, the only biomarker of anaphylaxis recommended for use in Russian and international consensus documents is tryptase, with very limited data on the efficacy of its use in real clinical practice in children. AIMS: To determine the frequency of measurement and diagnostic significance of tryptase level estimation in children with anaphylaxis within the recommended time frame in real clinical practice, as well as its relationship with the age of patients and the severity of symptoms. METHODS: The observational single-center prospective study included 128 patients aged 0 to 18 years who were hospitalized urgently in the State Budgetary Institution “Morozov Children's Hospital of Moscow” due to an episode of anaphylaxis in the period from May 2022 to April 2025 and were included in the Pediatric Moscow Anaphylaxis Register. The diagnosis of anaphylaxis was verified by an expert allergist-immunologist based on clinical criteria for anaphylaxis. Serum tryptase levels were measured in patients admitted to the hospital within 3 hours of the onset of symptoms of acute allergic reaction. The patients' clinical and laboratory parameters were entered into an online registry questionnaire and processed using a computer program, which is a system for data recording and analysis. RESULTS: Of the 128 children, 52 (40.6%) had their tryptase levels measured within 3 hours of symptom onset. Among these, 15 (28.8%) showed elevated tryptase levels. For the 76 children who were not assessed (due to delayed hospitalization), a higher frequency of mild anaphylaxis was observed compared to those assessed for tryptase levels (31.6% vs 15.4%, p=0.037). No correlation was found between age and tryptase levels, though there was a trend toward older patients (median 12 years vs. 10 years, p=0.052) being within the timeframe for tryptase measurement. Severity of reaction did not affect tryptase concentrations. CONCLUSIONS: In clinical practice, tryptase levels can be measured within 3 hours of symptom onset in less than half of patients, with only one third showing elevated levels. Delayed hospital arrival in patients with mild anaphylaxis is likely to delay diagnosis and treatment.

BackgroundAcute ischemic stroke (AIS) triggers activation of the hypothalamic-pituitary-adrenal (HPA) axis, resulting in elevated cortisol levels. Cortisol influences glucose mobilization, cardiovascular output, and metabolic responses. This study aimed to evaluate the relationship between serum cortisol levels and outcomes in patients with AIS.MethodsThis prospective analytical study was conducted in the Department of Internal Medicine, Sree Balaji Medical College and Hospital, Chennai, over 12 months (April 2023-March 2024). A total of 75 patients presenting with AIS within 72 hours of onset were included. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and serum cortisol levels were measured on admission. Functional outcome was evaluated using the Modified Rankin Scale (mRS) at 15 days. Statistical analysis included Student’s t-test, ANOVA, Mann-Whitney test, and Pearson correlation.ResultsThe mean age of participants was 59.2 ± 16.4 years, with a male predominance (57.3%). Common comorbidities included hypertension (37.3%), diabetes mellitus (26.7%), and coronary artery disease (34.7%). The average NIHSS score was 10.61, indicating moderate stroke severity. Elevated cortisol levels were strongly correlated with higher NIHSS and worse mRS scores. Patients with cortisol levels >690 nmol/L had more severe strokes, poorer functional outcomes, and higher mortality. Non-survivors demonstrated significantly higher mean cortisol levels (985.8 nmol/L) compared to survivors (726.5 nmol/L). Cortisol elevation also showed associations with hyperglycemia and hypercholesterolemia.ConclusionSerum cortisol is a reliable prognostic marker in AIS, closely linked to stroke severity, functional outcome, and mortality. Incorporating cortisol measurement into routine evaluation may improve prognostic accuracy and help guide management strategies for better patient care.

Background: Stroke-associated pneumonia (SAP) is a commonly encountered complication in patients with acute ischemic stroke (AIS) and is generally manifested within the first week following stroke onset.Aims: The objectives of this study were to determine the association of the fibrinogen-to-albumin ratio (FAR) with SAP in AIS and to examine the predictive and prognostic utility of FAR for the development of SAP.Methods: We performed a prospective cohort study involving 44 men with AIS admitted to the stroke unit within 24 hours of onset and followed up for two weeks. Based on clinical outcomes, individual patients were classified into SAP and non-SAP groups, in addition to another 22 age-matched healthy controls. Clinical characteristics, laboratory data, and outcomes were compared for differences, and receiver operating characteristic (ROC) curves were also constructed to observe the predictive capacity of FAR.Results: FAR uniquely distinguished the SAP group from controls with a 95.5% sensitivity and a 100% specificity at a cutoff of 0.079 (area under the curve (AUC)=0.997; p<0.001). FAR also distinguished AIS-only patients from controls with an 81.8% sensitivity and a 95.5% specificity at a cutoff of 0.072 (AUC=0.946; p<0.001).Conclusion: FAR is a simple, robust biomarker and may independently predict the risk of SAP in AIS patients. Its very high discriminative accuracy for distinguishing SAP from both non-SAP stroke and healthy controls supports its rationale in early risk stratification and prediction. Usage of FAR in clinical assessment could facilitate the early detection of such patients, allow scope for therapeutic intervention based on individual risk, and reduce SAP-related morbidity.