Narrative: Stroke is a devastating condition that leaves most survivors with permanent neurological disability. Worldwide, stroke is the second leading cause of death and has a declining age-adjusted incidence in high-income countries but a rapidly rising incidence and impact in lower- and middle-income countries. Ischemic stroke is the most common stroke type, accounting for roughly 85% of all strokes. Ischemic stroke is caused by an acute occlusion of an intracranial artery or one of four extracranial cervical arteries leading to the brain. Treatment with thrombolytic drugs targets the occlusion and is designed to restore blood flow to the brain. Thrombolytic drugs are effective in recanalizing occluded brain arteries only some of the time. Large proximal artery occlusions (e.g. carotid artery or middle cerebral artery stem) are opened 10-35% of the time, and smaller more distal arteries, up to 60-80% of the time. Large proximal artery occlusions are best treated with a combination of thrombolysis and endovascular thrombectomy.1, 2Initial thrombolytic trials, which assessed streptokinase, were uniformly negative; streptokinase was shown to be harmful, resulting in a higher rate of fatal intracranial hemorrhage and overall greater mortality compared to placebo. As a consequence, streptokinase has been abandoned and should no longer be considered for stroke. Individual trials of alteplase have been both positive and neutral. Treatment efficacy is highly time-dependent, while treatment harm is independent of time, within a 6-hour treatment window. The therapeutic index (i.e, benefit vs harm) is therefore much larger when treatment is administered quickly after stroke onset, and much smaller when given at later times. More recent trials have examined comparisons of alteplase dose (0.6mg/kg vs. 0.9mg/kg) and the use of advanced brain imaging to select patients for treatment who fall outside the usual time-based rules.3, 4, 5Stroke outcomes are assessed using a global outcome which includes both efficacy (good neurological functional outcome) and harm (death, fatal ICH and ICH leading to poor functional neurological status) outcomes in a single composite measure. The modified Rankin Scale assesses neurologic functional outcome on a 7-point scale from 0 (no symptoms at all) to 5 (bedbound) and 6 (death). Outcome is typically assessed at 90-180 days after stroke onset. The outcome is validated and reproducible. The score is commonly characterized and evaluated statistically as follows: mRS 0-1 = excellent functional outcome; mRS 0-2 = independent functional outcome; mRS 3-6 = dependency or death. This review summarizes the pooled individual-patient meta-analysis of randomized phase-3 trials comparing alteplase to placebo, comprising 6756 patients.6 Assessments of streptokinase or other thrombolytic agents are not included because they are known to be harmful. The treatment benefit is most pronounced when treatment is delivered rapidly after stroke onset (NNT = 10 for treatment within 3 hours of stroke onset). Beyond 4.5 hours from stroke onset, there is no average benefit. With increasing awareness of the importance of rapid evaluation and treatment and the establishment of acute stroke teams that include emergency physicians and specialist stroke physicians, door-to-treatment times of under 30 minutes can be routinely achieved. Treatment of ischemic stroke due to large vessel occlusion within 30 minutes of hospital arrival, as compared to >30 minutes after hospital arrival, is associated with a NNT of 5; for every 5 patients with large vessel occlusion treated with intravenous alteplase within 30 minutes of hospital arrival, one additional patients will have an independent functional outcome (mRS 0-2). However, only one third of stroke patients achieve an excellent neurologic outcome with thrombolysis; thus, a majority still fare poorly with only alteplase treatment. [Note that the rising proportion of patients with a good outcome in the control group in later time windows reflects that fact that stroke severity is lower at later time points; more severe stroke presents early.] The combination of alteplase plus endovascular thrombectomy for severe strokes due to proximal large vessel occlusion improves the proportion of patients with independent functional outcome to 50%.1Stroke treatment with alteplase is associated with an increased risk of fatal intracranial hemorrhage (2.7% vs. 0.4%) in the first 7 days (SITS-MOST criteria type 2 parenchymal hemorrhage - which defines clinical symptomatic and large radiological ICH). The absolute risk increase is 2.0-2.5% (NNH = 40-50).6 Additional non-fatal symptomatic hemorrhage in the first 7 days (SITS-MOST criteria type 2 parenchymal hemorrhage) is increased (1.0% vs 0.2%). The absolute increase is 0.8% (NNH = 125). When hemorrhage is defined radiologically only as PH-2 type hemorrhage (including all fatal, symptomatic and asymptomatic large parenchymal hematoma), there is an absolute increase of PH-2 type hemorrhage in the first 7 days of 5.5% (6.8% vs 1.3%). In addition, the natural history of ischemic stroke is to evolve some degree of asymptomatic (usually petechial) hemorrhage. Asymptomatic hemorrhage can be detected by magnetic resonance imaging in nearly all ischemic strokes, with and without thrombolysis treatment, and is not associated with poorer outcome. Poor outcomes (death or disability) due to hemorrhage are included in the global outcome assessment using the mRS. It is important not to conflate acute hemorrhage with poor outcome at 90 days. While acute hemorrhage is often serious and even fatal (50% of symptomatic ICH is fatal), it is not necessarily the dominant cause of poorer long-term outcomes; overall, the major prevalent cause of poor outcomes is large ischemic stroke, which are reduced with thrombolysis. The NNH for all-cause mortality is 71.6 There is a tradeoff involved in stroke thrombolysis. Treatment, particularly fast treatment, results in a greater number of patients with independent neurologic functional outcome, but with a small risk of early death due to fatal intracranial hemorrhage.
Elastic Network Adapter (ENA) - The Elastic Network Adapter (ENA) supports network speeds of up to 200 Gbps for supported instance types. The instances listed as current generation use ENA for enhanced networking, with the exception of C4, D2, and M4 instances smaller than m4.16xlarge. Q: What does it mean to have multiple network cards for an EC2 instance? Why is it needed? Newer generation EC2 instances use Nitro network cards for VPC data-plane offloading. To provide higher network bandwidth and improved packet rate performance, select EC2 instances can be configured to use multiple network cards for packet processing ultimately increasing overall system performance. Q: What instance types support multiple Network cards? Multiple network cards are supported on accelerated instances such as p4d.24xlarge and network optimized instances such as c6in.32xlarge. For a full list of instances supporting multiple network cards, refer to the Elastic network interfaces page. Q: What is the default number of network interfaces a multiple card instance can launch with? This depends on the instance type. Accelerated instances such as p4 scale up to 15 network interfaces per network card. High network instances such as the recently launched c6in instances support an aggregate 14 network interfaces split evenly (7 and 7) across the two network cards. Network interface scale per network card is available in the Network cards section of Elastic network interfaces page.
Windows 10 Permanent Activator Ultimate 2019 2.8 [Full]
The extension currently has three primary design modes: Framing On, Framing Off and 2D. With the 2D option the walls and windows are simply represented as planar faces and lines while still allowing the user to fully manipulate the wall panels and layout of openings. This mode is intended to be a very lightweight design mode and should allow the designer to quickly put together preliminary designs.
The permanent license or version of the extension is an unrestricted, full, and permanent license for both commercial and personal use. The number of installations per licensed copy is not limited, however the license can only be concurrently utilized on up to (3) separate machines.
The LT version includes only the 2D and 3D (framing off) modes. The LT version does not include the 3D (framing on) mode with all of the associated wall framing. It also does not include estimating and engineering features found in the full extension. This version is intended for designers who are primarily concerned only with the layout (of walls, windows and doors) and exterior aesthetics of a structure.
The mdkBIM suite combines all three extensions (Wall, Truss and Foundation) into one convenient package that can be purchased at a fairly sizable discount.The mdkBIM suite includes the full permanent version of all three extensions and will also include any future add-on plugins or modules.
You have 14 days from the date of purchase to request a refund for your Medeek subscription or permanent license. After 14 days, you cannot obtain a full or partial refund. All refunds are subject to a 5% restocking (transaction) fee.
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