Ind. stroke survivor, considered intoxicated by police, pushes awareness for first responders

 It is YOUR RESPONSIBILITY  to have the proper stroke indicators(drooping smile, inability to lift arm). You can't do the slurred speech or dizziness one either.

 What is your stroke hospital misdiagnosis rate on strokes?

Have they prevented these problems from happening?

Auckland man dies from stroke after being misdiagnosed with a migraine

 

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

 

Factors Associated With Misdiagnosis of Acute Stroke in Young Adults

 

Pediatric Stroke Often Misdiagnosed, Treatment Delayed

 

Younger Stroke Patients Often Misdiagnosed

 

 Among 821 consecutive patients admitted to an acute stroke unit, the initial diagnosis of stroke proved incorrect in 108 (13%)

 

The latest here:

Ind. stroke survivor, considered intoxicated by police, pushes awareness for first responders

VALPARAISO, Ind. — Pat Ingram remembers leaving a Valparaiso Noon Kiwanis meeting held at First Christian Church a little more than a year ago but after that, things got fuzzy.

The Valparaiso woman, 67, has vague memories of someone tapping on the window of her car, which she pulled into a snow bank in the parking lot of a pediatrician’s office a few blocks west of the church. She recalls the cold of metal handcuffs around her wrists and seeing her husband Steve and son Aaron when she was placed in an ambulance.

And Ingram remembers waking up hours later, early the morning of Jan. 18, 2024, at Community Hospital in Munster and subsequently finding out that she had had a stroke and undergone emergency brain surgery.

For the most part, Ingram has recovered from the stroke and has been able to piece together what happened on Jan. 17 of last year. What she and her husband Steve are still unable to understand is why Valparaiso Police officers who responded to the scene spent so much time focusing on whether she was intoxicated without evaluating her for a stroke.

“We would have loved to meet with the city two weeks after this happened,” Steve Ingram said, adding they would have liked an apology and assurance from officials that police were properly trained to recognize the symptoms of a stroke.

Per an email from Patrick Lyp, Valparaiso’s city attorney, all of the city’s police officers receive “general first aid training and basic life support as part of their initial recruitment and basic training instruction,” as well as training on CPR, the use of AEDs and the administration of the opioid antidote naloxone, and other measures.

“Many officers decide to extend their basic medical response knowledge, to include the certifications of Emergency Medical Responder (EMR) or Emergency Medical Technician (EMT). The Valparaiso Police Department currently has 16 EMR-certified officers and three EMT-certified officers,” Lyp said in the email. The training, which ranges from 80 to 160 hours depending on the level of certification, addresses patients suffering from strokes.

“Within the past year, the Valparaiso Police Department has completed refresher training in medical response, to include CPR, AED, and patient assessment,” Lyp said in the email. “Additional officers have been added to the Emergency Medical Response team, as certification in this area is extremely important to the well-being of our community. VPD continues to offer training courses biennially to increase the number of officers who have this expertise.”

Police officers in Indiana are required to have training in Basic Life Support and Basic First Aid as part of their initial training, Lyp said, adding that training is set forth by department and may include specialty training and/or refresher training in those basic skills.

“VPD was the first law enforcement agency in Porter County to incorporate an emergency medical specialty, starting the program in 2020,” Lyp said.

Because Pat Ingram filed a tort claim notice, indicating the possible filing of a lawsuit, Lyp said there were limitations on how the city could respond to media questions.

Attorney Jessica Smithey filed the tort claim notice on June 4.

“Patricia’s No. 1 goal has always been to have a conversation about what occurred and what she went through,” Smithey said, adding she filed a notice of tort claim act “to preserve Patricia’s rights moving forward.”

The Ingrams note that Pat’s car came to rest in a physician’s parking lot and the Valparaiso Medical Center, a facility that’s part of the Northwest Health system, was directly across the street.

“This would have turned out differently if a firefighter had pulled up instead of a cop,” Steve Ingram said.

The Ingrams have lived in Valparaiso since 1987 and have long been active in the community.

“I dislike doing this because I love this city,” Pat Ingram said.

Ingram’s ordeal was captured on police body and squad car cameras; the couple paid the requisite fee of $150 per video, for a total of $750, per the invoice, to the police department to get the footage a week after she had the stroke.

One of those videos is about an hour long and begins as an officer is on his way to the parking lot of Associated Pediatricians at 1111 E. Glendale Boulevard for a call of “a possibly intoxicated subject,” according to the police report, and ends when she is placed in an ambulance headed to Northwest Health-Porter. She was later transported by medical helicopter to Munster .

Throughout much of the video, Pat Ingram speaks so softly that when she speaks at all, she is difficult to hear or understand. She appears confused by instructions she receives from police to lower her car radio and step out of her car, and is unsteady on her feet.

When police transport her to the sallyport at the police station and take her out of the squad car to again try to assess what’s going on, an officer hands her a pad of paper and a pen to write down where she had been before she crashed into the snowbank on but Ingram is unable to hold the objects in her right hand. Sometimes, she sighs and closes her eyes instead of responding to officers.

They ask her numerous times if she’s had a drink; she answers yes then later says no. They ask if she’s on any medication and she says no, unable to communicate that, according to her and her husband, she’s on an assortment of medications for various health issues. Police ask if Pat Ingram is diabetic; again, she is not able to articulate what’s going on.

Police appear genuinely puzzled by her condition. Once they make contact with Steve Ingram and call for an ambulance while they’re in the police department’s sallyport, first responders deduce she’s having a stroke.

Pat Ingram told her husband she was getting groceries ahead of a predicted snowstorm after the Kiwanis meeting, which wrapped up around 1:15 p.m. or so. When Steve Ingram couldn’t reach her on her cellphone after repeated attempts, he called their son.

TESLA Trial: Does Timing Make or Break Thrombectomy for Large-Core Strokes?

Nothing here makes a damn bit of difference on your doctor and hospital responsibility. They are still required to have 100% recovery protocols regardless of this timing. THERE ARE NO EXCUSES ALLOWED! Your doctor and hospital have known of the need of 100% recovery protocols for decades! If they have done nothing, THEY ARE TOTALLY FUCKING INCOMPETENT!

Send me hate mail on this: oc1dean@gmail.com. I'll print your complete statement with your name and my response in my blog. Or are you afraid to engage with my stroke-addled mind? Your patients need an explanation of why you haven't already created 100% recovery protocols. Looking forward to your responses.

 

TESLA Trial: Does Timing Make or Break Thrombectomy for Large-Core Strokes?

Trial results deemed "neutral" for endovascular therapy in contrast with other recent studies

by Nicole Lou, Senior Staff Writer, MedPage Today September 23, 2024

The TESLA trial was unable to support a benefit to thrombectomy for stroke patients with large-core infarcts identified on noncontrast CT within 24 hours.

Unlike other studies, endovascular therapy in TESLA conferred no significantly better improvement in 90-day functional outcome based on the mean utility-weighted modified Rankin Scale (mRS). With a score of 0 indicating death or severe disability and 10 zero symptoms on this scale, treatment and control arms of the trial scored a mean 2.93 versus 2.27, respectively (adjusted difference of 0.63, 95% credible interval -0.09 to 1.34).

"But the width of the credible interval around the effect estimate includes the possibility of both no important effect and a clinically relevant benefit, so the potential role of thrombectomy with this imaging approach and time window will likely require additional study," stated Osama Zaidat, MD, MS, of St. Vincent Medical Center-Bon Secours Mercy Health Medical Center in Toledo, Ohio, and colleagues in JAMAopens in a new tab or window.

The investigators highlighted the relatively long median 11.5 hours from stroke onset to randomization in TESLA. This, they suggested, is one way it stands apart from the more positive studies on endovascular thrombectomy for large-core strokes, like the ANGEL-ASPECT (sub-8 hours) and SELECT2 trial (sub-10 hours)opens in a new tab or window from last year, and the more recent TENSION trialopens in a new tab or window that capped patient eligibility outright after 11 hours.

Also notable was TESLA's lack of advanced stroke imaging criteria for study entry.

Thus, although the present "neutral" findings may not mirror that of the other studies, and the trial was likely underpowered, "the results of TESLA complement and extend those of the recent prior trials," according to an accompanying editorial by Tudor Jovin, MD, and colleagues of Cooper University Health Care in Camden, New Jersey.

"Compared with earlier trials, TESLA had broader, more pragmatic entry criteria. It was the only trial to extend the enrollment window to 24 hours while requiring only noncontrast CT for infarct size estimation and CT angiography for diagnosis of target vessel occlusion without more advanced imaging techniques to identify patients for entry," the editorialists wrote.

American guidelines currently recommend certain advanced imaging criteria for mechanical thrombectomy in selected patients with acute ischemic stroke with large vessel occlusion in the anterior circulation.

"Removing the requirement for advanced imaging as a selection tool for thrombectomy in the extended time window would significantly reduce barriers in access to thrombectomy worldwide," Jovin's group surmised. However, the editorialists said that yet more research needs to be done, including on how thrombectomy would fare when used on late-presenting stroke patients with large infarcts.

TESLA was a phase III open-label trial conducted at 47 stroke thrombectomy centers in the U.S. from 2019 to 2022.

Participants were 300 people with large infarcts identified on noncontrast CT. Eligibility criteria included an anterior-circulation proximal artery occlusion, a time window of 0 to 24 hours from last seen well, age younger than 85, an NIH Stroke Scale (NIHSS) score of 6 or higher, and Alberta Stroke Program Early CT Scores (ASPECTS) of 2 to 5 -- therefore excluding people with the largest of the large infarcts.

The cohort randomized to thrombectomy or usual care was 46% women and had a median age of 67. The median baseline NIHSS score was 19. Of note, there was some disagreement between site and the core laboratory over ASPECTS, so over 10% of people were ultimately judged to have had baseline ASPECTS >5 by core laboratory.

One in five people received IV alteplase under the recommended early time window.

Ultimately, 90-day mortality rates were 35.3% with thrombectomy versus 33.3% with usual care. Symptomatic intracranial hemorrhage in 24 hours reached 4.0% versus 1.3%, respectively, indicating some excess risk in the intervention arm.

"Given the higher incidence of hemorrhagic complications seen with thrombectomy across these trials and the limited benefit of thrombolysis prior to thrombectomy beyond the ultra-early time window, investigating the benefit and safety of bridging intravenous thrombolysis prior to thrombectomy in patients with a large-core is necessary," Jovin's group commented.

Meanwhile, the secondary endpoint of proportion of 90-day mRS score range of 0 to 2 favored the thrombectomy arm (14.6% vs 8.9%).

Zaidat and colleagues reported a higher point estimate of benefit when the intervention was performed in the 0- to 6-hour time window, but they could not back this up with evidence of a significant treatment effect modification by presentation time on post hoc analysis.

The main results of TESLA were initially reported at the 2023 European Stroke Organisation meeting.

• 

  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

The TESLA trial was funded by Medtronic, Cerenovus, Penumbra, Stryker, and Genentech.

Zaidat reported receiving personal fees for serving as a consultant for Cerenovus, Medtronic, Stryker, and Penumbra; and having a patent for system and device for engulfing thrombi.

Jovin reported serving as an investor-advisor to Anaconda, FreeOx Biotech, Route 92, Viz.ai, Methinks, Galaxy, StataDX, Kandu, and Gravity; personal fees for serving on the data and safety monitoring board for Cerenovus and on the advisory board of Contego Medical; and receiving grants from Stryker and Medtronic.

Primary Source

JAMA

Source Reference: Yoo AJ, et al "Thrombectomy for stroke with large infarct on noncontrast CT: the TESLA randomized clinical trial" JAMA 2024; DOI: 10.1001/jama.2024.13933.

Secondary Source

JAMA

Source Reference: Khalife J, et al "CT-guided thrombectomy for large core stroke up to 24 hours -- another piece in a complex puzzle" JAMA 2024; DOI: 10.1001/jama.2024.15670.

Celebration as Margate stroke rehab unit marks first anniversary

 Nothing here on celebrating 100% recovery! So in my opinion this is a failed stroke unit! You should expect 100% recovery from all stroke hospitals if they are any good at all!

Celebration as Margate stroke rehab unit marks first anniversary

Patients at a specialist stroke rehab unit in Margate have thanked the team which ‘gave them their life back’ as they celebrated the unit’s first anniversary

At an afternoon tea party to mark the anniversary, patients spoke about how they had been helped to walk again, become independent and get back to the things they love. They celebrated recoveries and wrote  thank yous and recollections in a memory book.

The unit at Westbrook House, which is run by Kent Community Health NHS Foundation Trust, offers round the clock care and rehabilitation, seven-days-a-week.

Former stroke patient Paul Robbins, 67, from Sholden, near Deal, cut the cake and gave a heartfelt thank you to the ward team, saying: “To the people who gave me life back… I love you all. The NHS saved my life.”

Paul Robbins, his wife Jacqueline and Stroke Team Therapy Lead Vicki Pout cutting the cake

Therapy and care plans are tailored to what each individual wants to work towards, with exercises and activities that will help them get home and back to doing the things they love.

Therapy Lead Vicki Pout said: “Our first year has been fantastic. It has been a privilege to work with the patients and team over the past year. Our patients have been receptive to the therapy and the team has always been willing to try new things. It is the best place I have ever worked.”

KCHFT’s Deputy Chief Executive Pauline Butterworth was among the guests. She said: “This is a new model of care for us which is very focussed on the patient and their individual needs. It is about patients becoming independent and being confident when they go home. It’s exciting to try something new and it has been very successful.”

Guests included former patients, those currently receiving care on the unit, their families, carers and colleagues.

James Linsley, 76, from Broadstairs, was a patient for six weeks. He said: “They took very good care of me and the physios told me what I needed to do. I came back to see the people who were on the ward with me and the staff. I wanted them to see how well I’m doing. I don’t even use a walking stick now.”

June Finch-Hawkes, 80, from Birchington was at the unit for four weeks, after having a stroke while walking back from a trip to the shops. She said: “Being at the unit gave me a chance to recover. I needed help to walk. I had a lot of physiotherapy and the physiotherapist was lovely.”

Andrew Killian and wife Shirley from Folkestone

Former patient Andrew Killian, 67, from Folkestone, went along with his wife Shirley. He said: “They helped me get back on my feet and to walk again. They got me doing physio and socialising and doing more things for myself. The staff are kind, helpful and go beyond what you would expect.”

Jessica and Fay Woodward and their mum Linda Broadbridge, who all work on the ward as domestics, enjoyed chatting with former patients at the party. Jessica said: “We tidy patient rooms and sit and talk with them. It’s a rewarding job as we get to be part of their journey and we see the progress they make.”

Sisters Jessica Woodward, left and Fay Woodward right, with mum Linda Broadbridge, centre, from the unit’s domestic team

The ward has a multi-disciplinary team which includes nurses, physiotherapists, occupational therapists and dietitians, helping people to regain their independence after a stroke. Patients arrive at the ward from acute hospitals and the community. Patients eat their meals together and there are group therapy sessions, where they encourage and support each other.

The community made donations towards the party. As well as support from KCHFT’s i care charity, there were also donations from local accountant Ian Broughton, from Gross Margin, Paige Featherstone, from Marvellous Home And Party Glam and Maya’s Community Support Centre.

The unit is raising money for more specialist gym equipment and an interactive motion activated projector, to encourage patients to move more. To give support, visit the Westbrook House Stroke Rehabilitation Unit Just Giving page.

Anticoagulants versus Antiplatelet Treatment in the Medical Management of Carotid Floating Thrombus

You might want to make sure your hospital has this written into protocols and training done so when you show up with this your doctors aren't 'winging it'.

Anticoagulants versus Antiplatelet Treatment in the Medical Management of Carotid Floating Thrombus

• Hassan Aboul-Nour, MD
• Qasem Alshaer, MD
• Fatima Chughtai Khalid, MD
• 
  
• Mahmoud H. Mohammaden, MD, MSc, PhD
• Diogo C. Haussen, MD
• Jaydevsinh N. Dolia, MD
• Show all authors

Published:May 06, 2024DOI:https://doi.org/10.1016/j.jstrokecerebrovasdis.2024.107760

ABSTRACT

BACKGROUND

Carotid free-floating thrombus (CFT) is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by flow on vascular imaging. Unfortunately, there is no clear consensus among experts on the ideal treatment for this pathology.

METHODS

Retrospective analysis of acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients diagnosed with CFT on computed tomography angiogram (CTA) between January 2015-March 2023. We aimed to compare two treatment regimens: anticoagulation (ACT) and antiplatelet (APT) in the treatment of CFT. APT regimens included the use of dual or single antiplatelets (DAPT or SAPT; aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin +/- ASA. Patients that underwent mechanical thrombectomy were excluded.

RESULTS

During study time there were 8252 acute ischemic stroke hospitalizations, of which 135 (1.63 %) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.41years ± 12.82;p < 0.01). Other demographic variables were similar between ACT and APT groups. Complete CFT resolution on repeat vascular imaging was numerically higher at 30 days (58.8 vs 31.6 %, respectively; p = 0.1) and at latest follow-up (70.8 vs 50 %; p = 0.1) on ACT vs APT, respectively without reaching statistical significance. Similarly, there was numerically higher rates of any ICH with ACT compared to APT but it did not achieve statistical significance (27.6 % vs 13.5 %; p = 0.5). There were similar rates of PH1/2 hemorrhagic transformation, independence at discharge and similar hospital length of stay between ACT and APT groups. Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5 vs 55.2 %; p < 0.001). The rate of 30-day recurrent stroke was comparable among ACT and APT at 30 days (3.4 vs 0 %; p = 0.1, respectively). Subgroup analysis comparing exclusive ACT vs Dual APT lead to similar results.

CONCLUSION

Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed medically with ACT vs APT. Larger prospective studies are needed.

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The use of frailty questionnaires in inpatients in two neurorehabilitation units in the East Midlands – A cross-sectional cohort study with follow-up to 1-year after discharge from inpatient rehabilitation

 Is your hospital ready with protocols to get frail stroke survivors to 100% recovery or not? If not, find someplace that is competent in that!

The use of frailty questionnaires in inpatients in two neurorehabilitation units in the East Midlands – A cross-sectional cohort study with follow-up to 1-year after discharge from inpatient rehabilitation

Laura Edwards https://orcid.org/0000-0003-1392-2648 laura.edwards@nottingham.ac.uk, Vina Tesorero, […], and Adam L Gordon+3View all authors and affiliations

OnlineFirst

https://doi.org/10.1177/14782715241242509

• 
  

• • Abstract
  • Introduction
  • Methods
  • Results
  • Discussion
  • Acknowledgments
  • Declaration of conflicting interests
  • Funding
  • ORCID iD
  • References
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Abstract

Background:

Frailty correlates with poor clinical outcomes and is not routinely assessed in neurorehabilitation inpatient settings.

Methods:

We recruited adults from two neurorehabilitation units. We administered six validated tools for assessing frailty and collected data around length of stay, discharge, readmission and change in rehabilitation outcome measures.

Results:

Seventy-eight participants aged between 31 and 84 years were recruited with a range of neurological diagnoses. Frailty prevalence ranged between 23% and 46%, depending on the scale used, with little agreement between tools. Frailty status did not correlate with age, gender, length of stay, discharge destination and rehabilitation outcome measures. One-year readmission was higher in participants rated as frail by the Frail-Non-Disabled Questionnaire, the FRESH-screening questionnaire and the Clinical Frailty Scale.

Discussion:

Frailty ascertainment was variable depending on the tool used. Three frailty indices predicted readmission rate at 1 year but no other outcome measures. Therefore, frailty tools may have limited utility in this clinical population.

Introduction

Frailty describes loss of physiological reserve and vulnerability to adverse events. It was initially described in older people because it increases in prevalence with age and has explanatory value in understanding how older people respond differentially to acute illness.¹ Frailty is associated with adverse outcomes regardless of age.² The term ‘frailty’ should not be used in populations with life-long impairments but may help understand other patient groups with acquired disabilities who deteriorate physiologically in response to acute insults.

Prognostication in neurorehabilitation is difficult because of multiple complex interacting exposures that determine outcomes.³ Identifying (and addressing) frailty may improve outcomes or help to inform discussions around prognosis and treatment planning.

Two main paradigms describe and measure frailty. The first describes a cascade of homeostatic decompensation and is measured by the presence or absence of physiological parameters (phenotypic frailty).⁴ The second counts deficits across a number of domains and expresses severity of frailty as a ratio of deficits present to potential deficits (accumulation of deficits).⁵ Both models select different individuals as being frail but predict adverse outcomes equally well and consensus papers⁶ have suggested that frailty indices should be selected based upon feasibility and utility in a given clinical context. Most frailty indices have been designed and are primarily used in older populations, and caution should be used when applying them to younger populations.⁷

Against this background, we set out to evaluate frailty indices in inpatients undergoing neurorehabilitation with the following objectives:

•

To compare the prevalence of frailty as measured by different frailty measures

•

To assess differences in frailty between different diagnoses and ages

•

To assess whether frailty status impacted rehabilitation outcomes

•

To assess feasibility of assessing frailty using questionnaires during inpatient neurorehabilitation

•

To assess ease of use of commonly used questionnaires either with patient or next of kin

Methods

This was a two-site study in the East Midlands of England. The sites comprised a 19-bedded level 2b unit and a 25-bedded level 2a unit based within large NHS acute provider trusts.

The study was sponsored by the University of Nottingham and received ethical approval from Yorkshire and The Humber – Leeds East Research Ethics Committee (ref: 18/YH/0361).

Participants were recruited between February 2019 and December 2020, with a hiatus between March and July 2020 (Derby) and March and September 2020 (Nottingham) due to the COVID-19 pandemic.

Patients were eligible for inclusion if they were inpatients in participating units for purposes of neurorehabilitation and aged 18 years or older. They were excluded if they or a consultee were unable or unwilling to give consent.

Potential participants who had capacity to consent to participate in the study gave written informed consent. Participants who lacked capacity and could not give consent were recruited following a discussion with a relevant consultee, such as a family member or friend, in keeping with the provisions of the Mental Capacity Act 2005.⁸

Baseline constituted the date of admission to the rehabilitation unit. Data collection at baseline comprised participant demographic and clinical details, including diagnosis, comorbidities, age, gender, date of admission to rehabilitation unit and frailty status.

We selected frailty assessment tools which:

•

Asked about the period of time before the hospital admission as being representative of a patient’s baseline function

•

Did not require invasive testing for example, blood tests/muscle biopsies

•

Did not rely on tests which could have been altered by recent inpatient stay or intercurrent illness (e.g. serum albumin)

•

Could be answered by next of kin/consultee if the participant was cognitively impaired and unable

•

Could be carried out quickly and simply on an inpatient unit, with minimal disruption to daily care

•

Had been used and validated in clinical settings

•

Required no special training to perform

On this basis we recorded:

•

The Clinical Frailty Scale (CFS) – uses a nine-item scale to categorise individuals on the spectrum of ‘very fit’ to ‘terminally ill’⁹

•

Fatigue/Resistance/Ambulation/Illness/Loss of weight scale (FRAIL) – a five-item questionnaire (covers fatigue/resistance/ambulation/illnesses/loss of weight); individuals are divided into ‘frail’, ‘pre-frail’ or ‘robust’ depending on their score¹⁰

•

Frail non-disabled questionnaire (FIND) – a brief, five item questionnaire which asks about walking, climbing stairs, weight loss, fatigue and physical activity; it categorises respondents into ‘robust/disabled/frail/frail and disabled’¹¹

•

FRESH-screening instrument – a four-question tool (around mobility/fatigue/falls/assistance); individuals are characterised as ‘normal’ or ‘frail’¹²

•

Groningen Frailty Index (GFI) – a 15-question questionnaire that covers the domains of mobility, vision, hearing, nutrition, comorbidity, cognition, psychosocial and physical fitness, with the total score dividing respondents into ‘frail’ or ‘non-frail’¹³

•

Modified Reported Edmonton Frail Scale (m-REFS) – removes the question which asks the patient to draw a clock and instead replaces it with a question around a history of cognitive impairment, shown to be equivalent to the Reported Edmonton Frail Scale in a prospective cohort study.¹⁴ The original Edmonton frail scale is valid and reliable¹⁵; this had been modified slightly to allow it to be answered by next of kin and trialled successfully. Respondents are classified as ‘not frail’/‘apparently vulnerable’/ ‘mildly frail’/‘moderately frail’/‘severely frail’.¹⁴

For the sake of simplicity, the scores were divided into ‘frail’ and ‘non-frail’/‘robust’ as shown in Table 1:

Tiny plastics in carotid plaque tied to elevated risk for heart attack, stroke, death

It is your doctor's and hospital's responsibility to contact stroke leadership and get research done to alleviate this problem. But I guess that is impossible since there is NO STROKE LEADERSHIP! So you're screwed.

Tiny plastics in carotid plaque tied to elevated risk for heart attack, stroke, death

Key takeaways:

• Patients who had microplastics or nanoplastics in their carotid plaque were more likely to die or have a heart attack or stroke than those who did not.
• The findings confirm prior in vitro and animal studies.

Perspective from Larry B. Goldstein, MD, FAAN, FANA, FAHA

Among patients with asymptomatic carotid artery disease who had carotid endarterectomy, those whose atheromas contained microplastics and/or nanoplastics had worse outcomes than those whose atheromas did not, researchers reported.

Risk for heart attack, stroke or all-cause death at nearly 3 years was more than fourfold higher in patients with carotid atheromas containing microplastics and/or nanoplastics (MNPs) than in those with no evidence of MNPs, the researchers wrote in The New England Journal of Medicine.

Data were derived from Marfella R, et al. N Engl J Med. 2024;doi:10.1056/NEJMoa2309822.

“Recent studies performed in preclinical models have led to the suggestion of MNPs as a new risk factor for cardiovascular diseases,” Raffaele Marfella, MD, PhD, from the department of advanced medical and surgical sciences at the University of Campania “Luigi Vanvitelli,” Naples, Italy, and colleagues wrote. “However, the clinical relevance of these findings is unknown. Evidence is lacking to show that MNPs infiltrate vascular lesions in humans or to support an association between the burden of MNPs and cardiovascular disease. To explore whether MNPs are detectable within atherosclerotic plaque and whether the burden of MNPs is associated with cardiovascular disease, we assessed the presence of these substances in surgically excised carotid artery plaque by means of pyrolysis-gas chromatography-mass spectrometry, stable isotope analysis and electronic microscopy. We then determined whether the presence of MNPs was associated with a composite endpoint of myocardial infarction, stroke or death from any cause.”

The researchers enrolled 304 patients with asymptomatic carotid artery disease undergoing carotid endarterectomy, of whom 257 completed follow-up of a mean of 33.7 months.

Marfella and colleagues detected polyethylene in the atheromas of 58.4% of patients (mean level, 21.7 g/mg of plaque) and found that 12.1% of those patients also had measurable amounts of polyvinyl chloride in their atheromas (mean level, 5.2 g/mg of plaque). In those with MNPs, the mean age was 71 years and 77.3% were men. In those without MNPs, the mean age was 73 years and 73.8% were men.

Electron microscopy showed “visible, jagged-edged foreign particles” in plaque macrophages and scattered in external debris, and X-rays revealed that some of these particles also contained chlorine, the researchers wrote.

Compared with those who had no MNPs detected, patients who had MNPs detected were at more than fourfold risk for MI, stroke or death during follow-up (20% vs. 7.5%; HR = 4.53; 95% CI, 2-10.27; P < .001), according to the researchers.

“Our findings suggest that nanoplastics, rather than microplastics, might accumulate in sites of atherosclerosis,” the researchers wrote. “Indeed, the large majority of particles detected in the current study were also below the 200 nm threshold suggested for gut and other barriers and were visible in the extracellular space as scattered debris, which aligns with the notion that the absorption and distribution of MNPs increase as particle size decreases.”

Perspective

Back to Top

Larry B. Goldstein, MD, FAAN, FANA, FAHA

This is an important initial study showing an association between MNPs and cardiovascular outcomes. The primary finding is that patients with evidence of MNPs within atherosclerotic carotid artery plaques in asymptomatic persons were at higher risk of subsequent CV events. As pointed out by the authors, this does not necessarily mean that the two are causally linked because of the possibility of other unmeasured factors that could differ between those with and without MNPs. Preclinical data, however, provide some evidence of vascular effects of MNPs.

At this point, it is unclear what we can do to prevent events related to MNPs. MNPs are fairly ubiquitous. Because there appeared to be a relationship between the amount of MNPs and vascular events, developing strategies to reduce exposure on a population level may need to be considered.

This study was limited to patients who were treated for asymptomatic carotid artery atherosclerotic disease. Extending the observation to other populations would further support the association.

Larry B. Goldstein, MD, FAAN, FANA, FAHA

Healio | Cardiology Today Editorial Board Member

Ruth L. Works Professor and Chair, Department of Neurology

Associate Dean for Clinical Research, College of Medicine

Co-Director, Kentucky Neuroscience Institute

Co-Director, UK Neuroscience Research Priority Area

Interim Director, UK-Norton Stroke Care Network

KY Clinic - University of Kentucky

Disclosures: Goldstein reports no relevant financial disclosures.

Published by:

Sources/Disclosures

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Source:

Marfella R, et al. N Engl J Med. 2024;doi:10.1056/NEJMoa2309822.

Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke

 How long before this is implemented in your hospital? If you don't ask it will probably never get there since I'm sure your hospital doesn't have a research analyst whose only job is to keep up with stroke research and get it implemented in the hospital.

Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke

List of authors.

• Ying Gao, M.D.,
• Weiqi Chen, M.D.,
• Yuesong Pan, Ph.D.,
• Jing Jing, M.D., Ph.D.,
• Chunjuan Wang, M.D., Ph.D.,
• S. Claiborne Johnston, M.D., Ph.D.,
• Pierre Amarenco, M.D.,
• Philip M. Bath, D.Sc.,
• Lingling Jiang, Ph.D.,
• Yingying Yang, M.D.,
• Tingting Wang, M.D.,
• Shangrong Han, M.D.,
• Xia Meng, M.D., Ph.D.,
• Jinxi Lin, M.D., Ph.D.,
• Xingquan Zhao, M.D., Ph.D.,
• Liping Liu, M.D., Ph.D.,
• Jinguo Zhao, M.D.,
• Ying Li, M.D.,
• Yingzhuo Zang, M.D.,
• Shuo Zhang, M.D.,
• Hongqin Yang, M.D.,
• Jianbo Yang, M.D.,
• Yuanwei Wang, M.D.,
• Dali Li, M.D.,
• Yanxia Wang, M.D.,
• Dongqi Liu, M.D.,
• Guangming Kang, M.D.,
• Yongjun Wang, M.D.,
• and Yilong Wang, M.D., Ph.D.
• 
  

• for the INSPIRES Investigators^*

Abstract

Background

Dual antiplatelet treatment has been shown to lower the risk of recurrent stroke as compared with aspirin alone when treatment is initiated early (≤24 hours) after an acute mild stroke. The effect of clopidogrel plus aspirin as compared with aspirin alone administered within 72 hours after the onset of acute cerebral ischemia from atherosclerosis has not been well studied.

Methods

In 222 hospitals in China, we conducted a double-blind, randomized, placebo-controlled, two-by-two factorial trial involving patients with mild ischemic stroke or high-risk transient ischemic attack (TIA) of presumed atherosclerotic cause who had not undergone thrombolysis or thrombectomy. Patients were randomly assigned, in a 1:1 ratio, within 72 hours after symptom onset to receive clopidogrel (300 mg on day 1 and 75 mg daily on days 2 to 90) plus aspirin (100 to 300 mg on day 1 and 100 mg daily on days 2 to 21) or matching clopidogrel placebo plus aspirin (100 to 300 mg on day 1 and 100 mg daily on days 2 to 90). There was no interaction between this component of the factorial trial design and a second part that compared immediate with delayed statin treatment (not reported here). The primary efficacy outcome was new stroke, and the primary safety outcome was moderate-to-severe bleeding — both assessed within 90 days.

Results

A total of 6100 patients were enrolled, with 3050 assigned to each trial group. TIA was the qualifying event for enrollment in 13.1% of the patients. A total of 12.8% of the patients were assigned to a treatment group no more than 24 hours after stroke onset, and 87.2% were assigned after 24 hours and no more than 72 hours after stroke onset. A new stroke occurred in 222 patients (7.3%) in the clopidogrel–aspirin group and in 279 (9.2%) in the aspirin group (hazard ratio, 0.79; 95% confidence interval [CI], 0.66 to 0.94; P=0.008). Moderate-to-severe bleeding occurred in 27 patients (0.9%) in the clopidogrel–aspirin group and in 13 (0.4%) in the aspirin group (hazard ratio, 2.08; 95% CI, 1.07 to 4.04; P=0.03).

Conclusions

Among patients with mild ischemic stroke or high-risk TIA of presumed atherosclerotic cause, combined clopidogrel–aspirin therapy initiated within 72 hours after stroke onset led to a lower risk of new stroke at 90 days than aspirin therapy alone but was associated with a low but higher risk of moderate-to-severe bleeding. (Funded by the National Natural Science Foundation of China and others; INSPIRES ClinicalTrials.gov number, NCT03635749. opens in new tab.)

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Development of a whole arm wearable robotic exoskeleton for rehabilitation and to assist upper limb movements

 

10 years, what happened with this? And doing this with healthy subjects is useless.

Do you prefer your hospital incompetence NOT KNOWING? OR NOT DOING?

Development of a whole arm wearable robotic exoskeleton for rehabilitation and to assist upper limb movements

Published online by Cambridge University Press:  28 January 2014

M. H. Rahman ,

M. J. Rahman ,

O. L. Cristobal ,

M. Saad ,

J. P. Kenné  and

P. S. Archambault

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Summary

To assist physically disabled people with impaired upper limb function, we have developed a new 7-DOF exoskeleton-type robot named Motion Assistive Robotic-Exoskeleton for Superior Extremity (ETS-MARSE) to ease daily upper limb movements and to provide effective rehabilitation therapy to the superior extremity. The ETS-MARSE comprises a shoulder motion support part, an elbow and forearm motion support part, and a wrist motion support part. It is designed to be worn on the lateral side of the upper limb in order to provide naturalistic movements of the shoulder (vertical and horizontal flexion/extension and internal/external rotation), elbow (flexion/extension), forearm (pronation/supination), and wrist joint (radial/ulnar deviation and flexion/extension). This paper focuses on the modeling, design, development, and control of the ETS-MARSE. Experiments were carried out with healthy male human subjects in whom trajectory tracking in the form of passive rehabilitation exercises (i.e., pre-programmed trajectories recommended by a therapist/clinician) were carried out. Experimental results show that the ETS-MARSE can efficiently perform passive rehabilitation therapy.

CD13 facilitates immune cell migration and aggravates acute injury but promotes chronic post-stroke recovery

 So the research was incomplete, since nothing tells us how this gets us recovered. Further research needed that your doctors and hospital should initiate. NO EXCUSES!

CD13 facilitates immune cell migration and aggravates acute injury but promotes chronic post-stroke recovery

• Justin N. Nguyen,
• Eric C. Mohan,
• Gargee Pandya,
• Uzma Ali,
• Chunfeng Tan,
• Julia K. Kofler,
• Linda Shapiro,
• Sean P. Marrelli &
• Anjali Chauhan 

Journal of Neuroinflammation volume 20, Article number: 232 (2023) Cite this article

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Abstract

Introduction

Acute stroke leads to the activation of myeloid cells. These cells express adhesion molecules and transmigrate to the brain, thereby aggravating injury. Chronically after stroke, repair processes, including angiogenesis, are activated and enhance post-stroke recovery. Activated myeloid cells express CD13, which facilitates their migration into the site of injury. However, angiogenic blood vessels which play a role in recovery also express CD13. Overall, the specific contribution of CD13 to acute and chronic stroke outcomes is unknown.

Methods

CD13 expression was estimated in both mice and humans after the ischemic stroke. Young (8–12 weeks) male wild-type and global CD13 knockout (KO) mice were used for this study. Mice underwent 60 min of middle cerebral artery occlusion (MCAO) followed by reperfusion. For acute studies, the mice were euthanized at either 24- or 72 h post-stroke. For chronic studies, the Y-maze, Barnes maze, and the open field were performed on day 7 and day 28 post-stroke. Mice were euthanized at day 30 post-stroke and the brains were collected for assessment of inflammation, white matter injury, tissue loss, and angiogenesis. Flow cytometry was performed on days 3 and 7 post-stroke to quantify infiltrated monocytes and neutrophils and CXCL12/CXCR4 signaling.

Results

Brain CD13 expression and infiltrated CD13⁺ monocytes and neutrophils increased acutely after the stroke. The brain CD13⁺lectin⁺ blood vessels increased on day 15 after the stroke. Similarly, an increase in the percentage area CD13 was observed in human stroke patients at the subacute time after stroke. Deletion of CD13 resulted in reduced infarct volume and improved neurological recovery after acute stroke. However, CD13KO mice had significantly worse memory deficits, amplified gliosis, and white matter damage compared to wild-type animals at chronic time points. CD13-deficient mice had an increased percentage of CXCL12⁺cells but a reduced percentage of CXCR4⁺cells and decreased angiogenesis at day 30 post-stroke.

Conclusions

CD13 is involved in the trans-migration of monocytes and neutrophils after stroke, and acutely, led to decreased infarct size and improved behavioral outcomes. However, loss of CD13 led to reductions in post-stroke angiogenesis by reducing CXCL12/CXCR4 signaling.