Deans' stroke musings

Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 493 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:

Monday, October 23, 2017

The Role of Nutrition in the Risk and Burden of Stroke

Useless, nothing that refers to ANY type of diet protocol. For blood pressure reduction; for stroke recovery; for stroke prevention; for dementia prevention; for cognitive improvement; for cholesterol reduction; for plaque removal; for inflammation reduction. NOT the lazy prescription of the MIND or  Mediterranean diets.

An Update of the Evidence

Graeme J. Hankey
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Since last reviewed,1 several epidemiological studies have reported the substantial role of suboptimal nutrition in the risk and burden of stroke and illustrated the potential for dietary modification to reduce the global burden of stroke.

Search Strategy

I searched the Cochrane Library, PubMed, and MEDLINE using the search term stroke in combinations with the terms nutrition, diet, nutrients, foods, dietary patterns, risk, burden, epidemiology, randomised trial, systematic review, and meta-analysis for articles published between January 1, 2012, and June 1, 2017. I also searched the reference lists of articles identified by the search. I selected mainly articles published in the past 5 years but included older key publications.

The Role of Nutrition in the Risk of Stroke

Case–Control Studies

Diet quality was 1 of 10 potentially modifiable risk factors for stroke in the prospective INTERSTROKE study of 13 447 cases of acute first stroke and 13 472 age- and sex-matched controls with no history of stroke in 32 countries.2 Diet quality was derived from the modified Alternative Healthy Eating Index, which was based on daily servings of fruits, vegetables, nuts and soy protein, fish, meat, eggs, whole grain, and fried foods. Higher modified Alternative Healthy Eating Index scores have been associated with lower risk of cardiovascular disease in previous studies.3 In INTERSTROKE, individuals in the highest tertile for the modified Alternative Healthy Eating Index had a 40% lower odds of stroke (odds ratio, 0.60; 99% confidence interval [CI], 0.53–0.67), and individuals in the second tertile had a 23% lower odds of stroke (odds ratio, 0.77; 99% CI, 0.69–0.86), compared with those in the lowest tertile.2 Individuals in the lowest 2 tertiles contributed substantially to the population attributable risk of stroke (population attributable risk, 23.2%; CI, 18.2–28.9) compared with the highest tertile of modified Alternative Healthy Eating Index.2
Diet had a stronger association with stroke in individuals older than 55 years …
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Angus health facilities under threat - Dundee, Scotland

YOU have to change the discussion points from the lazy and incompetent 'model of care' to 'model of results' 
More health facilities in Angus are under threat of closure as a major review of inpatient services is under way.
Wards at Arbroath Infirmary, Montrose Infirmary, Stracathro Hospital and Whitehills Health and Community Care Centre as well as Brechin Infirmary – which has not been operational since October 2015 – are being assessed in the review.
The inpatient wards cover medicine for the elderly, psychiatry of old age, palliative care and stroke rehabilitation.
Health chiefs are assessing a variety of services as they seek to develop a new “Angus Care Model” with minor injury units and out of hours services also being examined.
A final report providing options and costs for a new model of care, as well as feedback from public engagement events, will be considered by the Angus Integration Joint Board in January.
The review is being carried out by the Angus Health and Social Care Partnership which is the body responsible for delivering the services in Angus.
An update to NHS staff, seen by The Courier, says there are a “range of challenges” in providing inpatient care under the current operating model.
Staffing challenges, an ageing workforce and an inefficient number of beds at each location were highlighted in the internal document.
It states: “Each of our inpatient sites operate with a relatively small bed base of nine to 22 beds.
“This impacts on efficiency and is vulnerable to short-term staffing challenges in terms of recruiting and retaining an appropriate workforce.
“The review into inpatient care services aims to ensure that future inpatient facilities and model of care meet the changing health care needs of the people of Angus.”
An audit of the number of occupied beds was carried out on a day last month and it found that 77 people were in an Angus hospital bed, leaving 39 beds empty.
The document states: “Data from the past year show us that this is a typical level of occupancy. On average 37 beds are unoccupied each day across Angus.
“The audit team considered that 49/77 patients could have benefitted from community intervention earlier in their patient journey, had appropriate services been available, which may have avoided the need for a hospital admission.”
The report also noted a high proportion of the nurses working at the Angus wards could retire over the next few years. 44% of the nurses working as part of inpatient services are aged over 50.
Angus Health and Social Care Partnership admitted its review would result in changes to the number of inpatient beds and facilities in the county.
A spokesperson said changes are required across a “range of service areas” in Angus.
The Partnership’s strategic plan aims to provide services that have a much greater emphasis on prevention, early intervention, self-management, supporting people in their own homes and communities and less unnecessary use of hospitals and care homes.
The spokesperson said the inpatient care review would examine their resources to make sure they are “configured” in the right way to meet future needs as it develops a new model of care.
“Information to date suggests we are already doing well with more than 90% of older people’s care being delivered in the community but there is still more to do for the whole adult population,” she said.
“We need to carry out this review because we face a number of challenges in delivering sustainable services.
“We have an ageing workforce and there are national shortages of health care staff which we must plan for.
“The facilities we deliver our services from must be able to support the delivery of modern health care.
“More people need support in our communities, including carers, and we have more inpatient beds than we need, with up to 35 inpatient beds per day in Angus not being required.
“Of course we must also ensure that we are using our resources in the most effective way and getting best value for our financial resources.”
Last week a series of drop-in information events were held in Angus for people to express their views.
These will be considered when a report on a new model of care is considered by the Angus Integration Joint Board in January.
“Bringing all of these developments together gives us a real opportunity to develop better local integrated services and to create an Angus Care Model,” the spokesperson continued.
“Changes are required across a range of service areas. Although this will result in changes to the number of inpatient beds and facilities in Angus, it will enable us to provide more integrated care in communities locally and this is what people tell us they want.”

Incorporating Nonphysician Stroke Specialists Into the Stroke Team

And they missed the most important needed member, a stroke survivor, needed to decipher the doctors pronouncements and give out positive impressions of stroke recovery.
Emily Anderson, Samuel Fernandez, Adam Ganzman, Eliza C. Miller
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Stroke care is team-based care, but trainees in neurology programs may have little experience in working directly with stroke specialists from other disciplines. Outside of an intensive care unit, nurses and physicians rarely round as a team, and stroke neurologists often have few interactions with prehospital care providers besides a quick handoff in the emergency room. However, nonphysician stroke specialists bring a broad base of expertise which overlaps with and complements the stroke neurologist’s knowledge. Increasingly, integrated stroke care is being provided by multidisciplinary teams. Team structures may vary from hospital to hospital and country to country, but often include integration of emergency medical services (EMS; particularly where mobile stroke treatment units are used); specialized nurses and nurse practitioners (NPs); and specialized therapy teams including speech and language pathologists, occupational therapists, and physical therapists with particular expertise in poststroke care.

Prehospital Care

The stroke chain of survival begins with the 911 call, yet even high-level paramedics receive little formal stroke training outside of standard Advanced Cardiac Life Support protocols. EMS providers are often the first point of contact for the stroke patient and have the opportunity to collect vital information about timing of symptoms and medication use. First responders to stroke 911 calls may be Basic Life Support or Advanced Cardiac Life Support level. EMS providers should be familiar with validated prehospital stroke scales such as the Cincinnati Prehospital Stroke Scale.1
EMS providers who have more experience with stroke, such as paramedics who staff mobile stroke treatment units, find stroke to be an exciting field because of the time-critical nature of the treatment. Therefore, it is imperative that stroke neurologists reach out to EMS providers to offer additional training in stroke care. A basic understanding of stroke syndromes is both fascinating and extremely useful to EMS providers, who are often eager …
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Occupational Therapy for Adults With Problems in Activities of Daily Living After Stroke

So no findings of occupational therapy being clinically proven to be helpful in stroke recovery?  Unless I'm reading this totally wrong.
Lynn A. Legg, Sharon R. Lewis, Oliver J. Schofield-Robinson, Avril Drummond, Peter Langhorne

All people carry out a daily set of home-based activities to maintain physical and mental health and to prepare body and mind for the next day’s demands. These activities are referred to as activities of daily living (ADL). The goal of occupational therapy is to improve ability to self-care after stroke. Interventions used by occupational therapists include assessment, treatment, adaptive techniques, assistive technology, and environmental adaptations.


To assess the effects of occupational therapy interventions compared with no intervention or standard care/practice, on the ability of adults with stroke to self-care.

Search Methods

For this update, we searched the Cochrane Stroke Group Trials Register (last searched January 30, 2017), the Cochrane Controlled Trials Register (The Cochrane Library, January 2017), MEDLINE (1946 to January 5, 2017), Embase (1974 to January 5, 2017), CINAHL (1937 to January 2017), PsycINFO (1806 to November 2, 2016), AMED (1985 to November 1, 2016), and Web of Science (1900 to January 6, 2017). We also searched grey literature and clinical trials registers.

Selection Criteria

We identified randomized controlled trials of an occupational therapy intervention (compared with no intervention or standard care/practice) where ADL was the therapeutic medium or the goal.

Data Collection and Analysis

Two review authors independently performed study selection, data collection, and risk of bias assessments. We also evaluated the quality of evidence using the GRADE approach. The primary outcomes were the proportion of participants who had deteriorated or were dependent in ADL and performance in ADL at the end of follow-up.

Main Results

In this update, we included 9 studies with 994 participants, comparing ADL-focused occupational therapy with no intervention or standard care/practice. We found low quality evidence (based on unclear risk of selection bias and an unavoidable high risk of performance and detection bias) that occupational therapy interventions increased ADL performance scores (standardized mean difference, 0.17; 95% confidence interval, 0.03–0.31; P=0.02; Figure), reduced the risk of poor outcome (death, deterioration, or dependency in ADL; odds ratio, 0.71; 95% confidence interval, 0.52–0.96; P=0.03), and increased extended ADL scores (odds ratio, 0.22; 95% confidence interval, 0.07–0.37) P=0.005). Occupational therapy did not influence mortality or reduce the combined odds of death and institutionalization or death and dependency. Occupational therapy did not improve mood or distress scores. There were insufficient data to determine the effects of occupational therapy on health-related quality of life. There were insufficient data to determine carer-related outcomes or participants’ and carers’ satisfaction with services.

One-Stop Management of Acute Stroke Patients Minimizing Door-to-Reperfusion Times

Still not fast enough. I expect stroke patients to be treated with tPA prior to getting to the hospital. Your goal is wrong.
Marios-Nikos Psychogios, Daniel Behme, Katharina Schregel, Ioannis Tsogkas, Ilko L. Maier, Johanna Rosemarie Leyhe, Antonia Zapf, Julia Tran, Mathias Bähr, Jan Liman, Michael Knauth
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Background and Purpose—Intrahospital time delays significantly affect the neurological outcome of stroke patients with large-vessel occlusion. This study was conducted to determine whether a one-stop management can reduce intrahospital times of patients with acute large-vessel occlusion.
Methods—In this observational study, we report the first 30 consecutive stroke patients imaged and treated in the same room. As part of our protocol, we transported patients with a National Institutes of Health Stroke Scale score of ≥10 directly to the angio suite, bypassing multidetector computed tomography (CT). Preinterventional imaging consisted of noncontrast flat detector CT and flat detector CT angiography, acquired with an angiography system. Patients with large-vessel occlusions remained on the angio table and were treated with mechanical thrombectomy; patients with small artery occlusions were treated with intravenous thrombolysis, whereas patients with an intracranial hemorrhage and stroke mimics were treated as per guidelines. Door-to-groin puncture times were recorded and compared with our past results.
Results—Thirty patients were transferred directly to our angio suite from June to December 2016. The time from symptom onset to admission was 105 minutes. Ischemic stroke was diagnosed in 22 of 30 (73%) patients, 4 of 30 (13.5%) had an intracranial hemorrhage, and 4 of 30 (13.5) were diagnosed with a Todd’s paresis. Time from admission to groin puncture was 20.5 minutes. Compared with 44 patients imaged with multidetector CT in the first 6 months of 2016, door-to-groin times were significantly reduced (54.5 minutes [95% confidence interval, 47–61] versus 20.5 minutes [95% confidence interval, 17–26]).
Conclusions—In this small series, a one-stop management protocol of selected stroke patients using latest generation flat detector CT led to a significant reduction of intrahospital times.

Incorporating Stroke Severity Into Hospital Measures of 30-Day Mortality After Ischemic Stroke Hospitalization

By using the NIHSS they still are not objectively reporting on stroke severity. You need 3d scans to do that. My god, the massive amount of incompetence out there in stroke land.
Jennifer Schwartz, Yongfei Wang, Li Qin, Lee H. Schwamm, Gregg C. Fonarow, Nicole Cormier, Karen Dorsey, Robert L. McNamara, Lisa G. Suter, Harlan M. Krumholz, Susannah M. Bernheim
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Background and Purpose—The Centers for Medicare & Medicaid Services publicly reports a hospital-level stroke mortality measure that lacks stroke severity risk adjustment. Our objective was to describe novel measures of stroke mortality suitable for public reporting that incorporate stroke severity into risk adjustment.
Methods—We linked data from the American Heart Association/American Stroke Association Get With The Guidelines-Stroke registry with Medicare fee-for-service claims data to develop the measures. We used logistic regression for variable selection in risk model development. We developed 3 risk-standardized mortality models for patients with acute ischemic stroke, all of which include the National Institutes of Health Stroke Scale score: one that includes other risk variables derived only from claims data (claims model); one that includes other risk variables derived from claims and clinical variables that could be obtained from electronic health record data (hybrid model); and one that includes other risk variables that could be derived only from electronic health record data (electronic health record model).
Results—The cohort used to develop and validate the risk models consisted of 188 975 hospital admissions at 1511 hospitals. The claims, hybrid, and electronic health record risk models included 20, 21, and 9 risk-adjustment variables, respectively; the C statistics were 0.81, 0.82, and 0.79, respectively (as compared with the current publicly reported model C statistic of 0.75); the risk-standardized mortality rates ranged from 10.7% to 19.0%, 10.7% to 19.1%, and 10.8% to 20.3%, respectively; the median risk-standardized mortality rate was 14.5% for all measures; and the odds of mortality for a high-mortality hospital (+1 SD) were 1.51, 1.52, and 1.52 times those for a low-mortality hospital (−1 SD), respectively.
Conclusions—We developed 3 quality measures that demonstrate better discrimination than the Centers for Medicare & Medicaid Services’ existing stroke mortality measure, adjust for stroke severity, and could be implemented in a variety of settings.

Dietary Sodium to Potassium Ratio and Risk of Stroke in a Multiethnic Urban Population

Now what should occur is followup research detailing exactly the amounts of specific foods on a daily basis per bodyweight and sex to provide this level of potassium in the blood. But we won't get that, we'll get this:

Why eat three bananas a day?    April 2012 

The Northern Manhattan Study

Joshua Willey, Hannah Gardener, Sandino Cespedes, Ying K. Cheung, Ralph L. Sacco, Mitchell S.V. Elkind
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Background and Purpose—There is growing evidence that increased dietary sodium (Na) intake increases the risk of vascular diseases, including stroke, at least in part via an increase in blood pressure. Higher dietary potassium (K), seen with increased intake of fruits and vegetables, is associated with lower blood pressure. The goal of this study was to determine the association of a dietary Na:K with risk of stroke in a multiethnic urban population.
Methods—Stroke-free participants from the Northern Manhattan Study, a population-based cohort study of stroke incidence, were followed-up for incident stroke. Baseline food frequency questionnaires were analyzed for Na and K intake. We estimated the hazard ratios and 95% confidence intervals for the association of Na:K with incident total stroke using multivariable Cox proportional hazards models.
Results—Among 2570 participants with dietary data (mean age, 69±10 years; 64% women; 21% white; 55% Hispanic; 24% black), the mean Na:K ratio was 1.22±0.43. Over a mean follow-up of 12 years, there were 274 strokes. In adjusted models, a higher Na:K ratio was associated with increased risk for stroke (hazard ratio, 1.6; 95% confidence interval, 1.2–2.1) and specifically ischemic stroke (hazard ratio, 1.6; 95% confidence interval, 1.2–2.1).
Conclusions—Na:K intake is an independent predictor of stroke risk. Further studies are required to understand the joint effect of Na and K intake on risk of cardiovascular disease.

Serum Potassium Is Positively Associated With Stroke and Mortality in the Large, Population-Based Malmö Preventive Project Cohort

Now what should occur is followup research detailing exactly the amounts of specific foods on a daily basis per bodyweight and sex to provide this level of potassium in the blood. But we won't get that, we'll get this:

Why eat three bananas a day?    April 2012

Serum Potassium Is Positively Associated With Stroke and Mortality in the Large, Population-Based Malmö Preventive Project Cohort

Linda S. Johnson, Nick Mattsson, Ahmad Sajadieh, Per Wollmer, Martin Söderholm

Minimal Clinically Important Difference for Safe and Simple Novel Acute Ischemic Stroke Therapies

No clue what this means but they talk about guidelines, NOT protocols so to me this is useless.  Until we get to protocols stroke survivors will never have a path to 100% recovery. Guidelines are fucking worthless and lazy ways to make it look like progress.
Jessica S. Cranston, Brett D. Kaplan, Jeffrey L. Saver


Background and Purpose—Determining the minimal clinically important difference (MCID) is essential for evaluating novel therapies. For acute ischemic stroke, expert surveys have yielded MCIDs that are substantially higher than the MCIDs observed in actual expert behavior in guideline writing and clinical practice, potentially because of anchoring bias.
Methods—We administered a structured, internet-based survey to a cross-section of academic stroke neurologists in the United States. Survey responses assessed demographic and clinical experience, and expert judgment of the MCID of the absolute increase needed in the proportion of patients achieving functional independence at 3 months to consider a novel, safe neuroprotective agent as clinically worthwhile. To mitigate anchoring bias, the survey response framework used a base 1000 rather than base 100 patient framework.
Results—Survey responses were received from 122 of 333 academic stroke neurologists, there were 23% women, 72.8% had ≥6 years of practice experience, and neurovascular disease accounted for more than half of practice time in >70%. Responder–nonresponder and continuum of resistance tests indicated that responders were representative of the full expert population. Among respondents, the median MCID was 1.3% (interquartile range, 0.8% to >2%).
Conclusions—Stroke expert responses to MCID surveys are affected by anchoring and centrality bias. When survey design takes these into account, the expert-derived MCID for a safe acute ischemic stroke treatment is 1.1% to 1.5%, in accord with actual physician behavior in guideline writing and clinical practice. This revised MCID value can guide clinical trial design and grant-funding and regulatory agency decisions.


The minimal clinically important difference (MCID) is the smallest change in a treatment outcome that a patient, a care provider, or both would consider worthwhile.1
Establishing the MCID for a disease state is an essential prerequisite for clinical trial sample size calculation and informs funding decisions by the National Institutes of Health and other sponsors and drug or device approval decisions by the Food and Drug Administration and other regulatory agencies. For superiority trials, declarations that a novel treatment is clinically superior to standard therapy require that the improved outcome rate exceeds the MCID. For equivalence and noninferiority trials, declarations that 2 treatments are of equal clinical efficacy require that their outcome rates fall within the MCID. The smaller the MCID, the larger the sample size needed for a randomized trial to ensure that the study is adequately powered to detect or exclude a treatment benefit of clinical relevance.
Approaches to establishing the MCID for a particular disease or symptom fall into 3 categories: distribution-based, anchor-based, and Delphi expert–based approaches. Distribution-based approaches statistically derive an MCID from the distribution of outcome data, such as using one half the SD of an end point. They have the advantage of direct calculation from outcome data sets, but the drawback of not clearly correlating with clinically important change.
Anchor-based approaches compare change in end point scores with an external anchor, most commonly a patient global impression of change. Patient judgments that a change has been meaningful are relatively straightforward to elicit for treatments that are applied to patients with a previously stable disease-related health state. When interventions move patients from one to another long-lasting disease–related health state, patients can draw on their personal experience of both the before and the after states to render assessments comparing the 2. However, patient judgments that a change has been meaningful are challenging to derive for treatments that are applied to patients with an abrupt onset new condition, such as acute ischemic stroke. With acute onset conditions, patients can draw on their personal experience of only 1 stable disease-related health state, their own final outcome, and cannot compare this state to any alternative, personally experienced outcome state.
Given the limitations of the distribution- and anchor-based approaches for acute stroke, the survey methods have been the leading technique for determining what is a minimally important change in stroke outcomes. Surveys are administered to physicians, nurses, and other healthcare providers about the worth of different outcome states. Because healthcare providers have direct observational familiarity with a range of stroke outcomes, they are able to knowledgeably make comparative judgments of the value of alternative disease-related health states. But, for simple and safe therapies for acute ischemic stroke, MCIDs derived from expert judgment (5%–10%)2 have been higher than MCIDs derived from econometric modeling (2%–3%)3 and higher than MCIDs derived from observations of actual physician behavior and medical guidelines (1%–1.5%).47 These elevated expert-derived MICD values have been highlighted in European and American consensus statements on acute ischemic stroke clinical trial design.2,8
Recent studies of both nonexperts and experts have shown that human judgment in a wide variety of settings is prone to cognitive biases—systematic deviations from rationality. Notably, the architecture of questions used to elicit expert opinion may bias the resulting responses.9 Investigations of expert judgment of acute stroke MCID have generally used multiple choice questions, which are subject to anchoring and centrality bias. We sought to determine whether altering the question anchor framework would yield expert-derived MCIDs for acute stroke that better accord with actual expert behavior.

More at link.

National Trends in Patients Hospitalized for Stroke and Stroke Mortality in France, 2008 to 2014

But NO mention made of disability rates from stroke dropping due to better stroke interventions and rehab protocols.  You will have to ask if the National Stroke Action Plan contains ANYTHING AT ALL about stroke rehabilitation and 100% recovery.
Camille Lecoffre, Christine de Peretti, Amélie Gabet, Olivier Grimaud, France Woimant, Maurice Giroud, Yannick Béjot, Valérie Olié
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Background and Purpose—Stroke is the leading cause of death in women and the third leading cause in men in France. In young adults (ie, <65 years old), an increase in the incidence of ischemic stroke was observed at a local scale between 1985 and 2011. After the implementation of the 2010 to 2014 National Stroke Action Plan, this study investigates national trends in patients hospitalized by stroke subtypes, in-hospital mortality, and stroke mortality between 2008 and 2014.
Methods—Hospitalization data were extracted from the French national hospital discharge databases and mortality data from the French national medical causes of death database. Time trends were tested using a Poisson regression model.
Results—From 2008 to 2014, the age-standardized rates of patients hospitalized for ischemic stroke increased by 14.3% in patients <65 years old and decreased by 1.5% in those aged ≥65 years. The rate of patients hospitalized for hemorrhagic stroke was stable (+2.0%), irrespective of age and sex. The proportion of patients hospitalized in stroke units substantially increased. In-hospital mortality decreased by 17.1% in patients with ischemic stroke. From 2008 to 2013, stroke mortality decreased, except for women between 45 and 64 years old and for people aged ≥85 years.
Conclusions—An increase in cardiovascular risk factors and improved stroke management may explain the increase in the rates of patients hospitalized for ischemic stroke. The decrease observed for in-hospital stroke mortality may be because of recent improvements in acute-phase management.

Increase of Stroke Incidence in Young Adults in a Middle-Income Country

Well the first problem you need to solve is accurately identifying strokes in young persons, not prevention.

Pediatric Stroke Often Misdiagnosed, Treatment Delayed


Doctors tell boy, 15, he had a migraine after rugby tackle - but he was actually suffering a paralyzing stroke which nearly killed him


Factors Associated With Misdiagnosis of Acute Stroke in Young Adults


Amy on her 36 hour wait for a diagnosis.

But the prevention focus is here.

Increase of Stroke Incidence in Young Adults in a Middle-Income Country

A 10-Year Population-Based Study

Norberto Luiz Cabral, Aracélli Tavares Freire, Adriana Bastos Conforto, Nayara dos Santos, Felipe Ibiapina Reis, Vivian Nagel, Vanessa V. Guesser, Juliana Safanelli, Alexandre L. Longo
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Background and Purpose—The incidence of stroke is on the rise in young adults in high-income countries. However, there is a gap of knowledge about trends in stroke incidence in young adults from low- and middle-income countries. We aimed to measure trends in incidence of ischemic stroke (IS) and intracerebral hemorrhage (IH) in young people from 2005 to 2015 in Joinville, Brazil.
Methods—We retrospectively ascertained all first-ever IS subtypes and IH that occurred in Joinville in the periods of 2005 to 2006, 2010 to 2011, and 2014 to 2015. Poisson regression was used to calculate incidence rate ratios of all strokes, IS, and IH. We also compared the prevalence of risk factors and extension of diagnostic work-up across the 3 periods.
Results—For 10 years, we registered 2483 patients (7.5% aged <45 years). From 2005 to 2006 to 2014 to 2015, overall stroke incidence significantly increased by 62% (incidence rate ratios, 1.62; 95% confidence interval, 1.10–2.40) in subjects <45 years and by 29% in those <55 years (incidence rate ratios, 1.29; 95% confidence interval, 1.04–1.60). Incidence of IS increased by 66% (incidence rate ratios, 1.66; 95% confidence interval, 1.09–2.54), but there was no significant change in incidence of IH in subjects <45 years. Smoking rates decreased by 71% (odds ratio, 0.29; 95% confidence interval, 0.12–0.68).
Conclusions—Stroke incidence is rising in young adults in Joinville, Brazil, because of increase in rates of ischemic but not hemorrhagic strokes. We urgently need better policies of cardiovascular prevention in the young.

Gut microbes associated with CV risk

You'll have to have your doctor explain this one to you and provide intervention protocols.

“Our largest environmental exposure is what we eat, and that is all perceived through the filter of our gut microbiome,” Stanley L. Hazen, MD, PhD, chair of the department of cellular and molecular medicine, section head of preventive cardiology and rehabilitation and director of the Center for Microbiome and Human Health at Cleveland Clinic, said in the presentation. “The gut microbiome is an active participant in many facets of cardiovascular disease and thrombosis.”

The initial discovery and structural identification of gut microbe-derived metabolites that are associated with CVD risk occurred nearly a decade ago with untargeted metabolomics, according to the presentation. Data from healthy patients were reviewed for the development of CVD over a period of time. Patients’ serum levels were analyzed for the chemical signatures that predicted future CVD risk, and of the metabolites that predicted risks, a third of them are linked to gut microbes, Hazen said.

A study published in Nature in 2011 found that three compounds linked to phosphatidylcholine metabolism, also termed lecithin, suggested a common pathway: choline, betaine and trimethylamine N-oxide (TMAO).

Diet and intestinal microbes are mechanically linked to atherosclerotic heart disease. A diet rich in phosphatidylcholine, a Western diet, also feeds the gut microbes. The microbes generate trimethylamine (TMA) as a waste product of dietary lecithin. After the TMA leaves the gut, it goes into the liver where it is converted to TMAO. In animal studies, TMAO accelerated heart disease development.

The clinical relevance of this was validated in a study published in Nature in 2011, which found that choline, betaine and TMAO dose-dependently track CV events. Beyond association, the study proved causation because a diet rich in choline led to TMAO generation and accelerated atherosclerosis, Hazen said.

“The relationship between plasma TMAO levels and incident CVD and mortality risks in subjects is a steeper curve than what you see with LDL cholesterol, triglycerides or C-reactive protein, for example,” Hazen said.

2 more pages at link.

Skipping breakfast linked to increased CV risk

Correlation, but WHAT IS THE REAL CAUSE? Do some research to find out. I could just as easily speculate that those who are skipping breakfast are already obese/overweight and are skipping breakfast to lose weight.  The cause is their pre-existing obesity and not skipping breakfast.  Bad research conclusion.

According to the study, the number and quality of eating occasions are included among potential targets for primary prevention strategies that have a large effect on CV health.
“Eating patterns are highly dependent on cultural, social and psychological determinants, as people integrate them into their daily life routines,” Irina Uzhova, MSc, from the Centro Nacional de Investigaciones Cardiovasculares Carlos III in Madrid, and colleagues wrote. “A particular habit that might have a significant effect on CV health is breakfast consumption, as it is associated with factors such as satiety, daily energy intake, metabolic efficiency on the diet and appetite regulation.”

To assess the association between breakfast patterns and CVD risk factors, Uzhova and colleagues performed a cross-sectional analysis of the PESA study, which included asymptomatic adults aged 40 to 54 years.
The study collected lifestyle and multivascular imaging data and clinical covariates from 4,052 patients (mean age, 46 years) and analyzed the data using multivariate logistic regression models.
The researchers studied three patterns of breakfast consumption:
  • high-energy breakfast, contributing to > 20% of total daily energy intake (27% of the cohort);
  • low-energy breakfast, contributing between 5% and 20% of total daily energy intake (70% of the cohort); and
  • skipping breakfast, consuming < 5% of total daily energy (3% of thecohort).
Independent of the presence of traditional and dietary CV risk factors, compared with high-energy breakfast, frequent skipping of breakfast was linked to higher rates of noncoronary (OR = 1.55; 95% CI, 0.97-2.46) and generalized (OR = 2.57; 95% CI, 1.54-4.31) atherosclerosis risk.
“Considering the importance of regular breakfast consumption for primary CVD prevention, our findings are important for health professionals and might be used as an important key and simple message for lifestyle-based interventions and public health strategies, as well as informing dietary recommendations and guidelines,” the researchers wrote.
According to a related editorial from Prakash Deedwania, MD, from the University of California, San Francisco, and Tushar Acharya, MD, from Advanced Cardiovascular Imaging, NHLBI, the need for corrective public health measures to curb the global epidemic of obesity is urgent.
“Given the emerging evidence of association between altered dietary patterns and increased risk of obesity, metabolic syndrome, diabetes, subclinical atherosclerosis and clinical CV events, it seems prudent to pay attention to diet and educate the public to implement simple lifestyle changes that include emphasis on a regular, hearty and nutritious breakfast,” they wrote. “These easy and economical public health measures can curb the oncoming tsunami of diabetes and CV disorders. Indeed, the wisdom of the ages that breakfast is the most important meal of the day has been proven.” – by Dave Quaile