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IncidenCe and predictOrs of heaRt fAiLure after acute coronarY Syndrome The CORALYS registry.

Previous studies investigating predictors of Heart Failure (HF) after acute coronary syndrome (ACS) were mostly conducted during fibrinolytic era or restricted to baseline characteristics and diagnoses prior to admission. We assessed the incidence and predictors of HF hospitalizations among patients treated with percutaneous coronary intervention (PCI) for ACS. CORALYS is a multicenter, retrospective, observational registry including consecutive patients treated with PCI for ACS. Patients with known history of HF or reduced left ventricular ejection fraction (LVEF) were excluded. Incidence of HF hospitalizations was the primary endpoint. The composite of HF hospitalization or cardiovascular death, and cardiovascular and all-cause death were the secondary endpoints. Predictors of HF hospitalizations and the impact of HF hospitalization on cardiovascular and all-cause death were assessed by means of multivariable Cox proportional hazards model.14699 patients were included. After 2.9 ± 1.8 years, the incidence of HF hospitalizations was 12.7%. Multivariable analysis identified age, diabetes, chronic kidney disease, previous myocardial infarction, atrial fibrillation, pulmonary disease, GRACE risk-score ≥ 141, peripheral artery disease, cardiogenic shock at admission and LVEF ≤40% as independently associated with HF hospitalizations. Complete revascularization was associated with a lower risk of HF (HR 0.46,95%CI 0.39-0.55). HF hospitalization was associated with higher risk of CV and all-cause death (HR 1.89,95%CI 1.5-2.39 and HR 1.85,95%CI 1.6-2.14, respectively). Incidence of HF hospitalizations among patients treated with PCI for ACS is not negligible and is associated with detrimental impact on patients prognosis. Several variables may help to assess the risk of HF after ACS.

The role of the hippocampus in statistical learning and language recovery in persons with post stroke aphasia.

Although several studies have aimed for accurate predictions of language recovery in post stroke aphasia, individual language outcomes remain hard to predict. Large-scale prediction models are built using data from patients mainly in the chronic phase after stroke, although it is clinically more relevant to consider data from the acute phase. Previous research has mainly focused on deficits, i.e., behavioral deficits or specific brain damage, rather than compensatory mechanisms, i.e., intact cognitive skills or undamaged brain regions. One such unexplored brain region that might support language (re)learning in aphasia is the hippocampus, a region that has commonly been associated with an individuals learning potential, including statistical learning. This refers to a set of mechanisms upon which we rely heavily in daily life to learn a range of regularities across cognitive domains. Against this background, thirty-three patients with aphasia (22 males and 11 females, M 69.76 years, SD 10.57 years) were followed for 1 year in the acute (1-2 weeks), subacute (3-6 months) and chronic phase (9-12 months) post stroke. We evaluated the unique predictive value of early structural hippocampal measures for short-term and long-term language outcomes (measured by the ANELT). In addition, we investigated whether statistical learning abilities were intact in patients with aphasia using three different tasks an auditory-linguistic and visual task based on the computation of transitional probabilities and a visuomotor serial reaction time task. Finally, we examined the association of individuals statistical learning potential with acute measures of hippocampal gray and white matter. Using Bayesian statistics, we found moderate evidence for the contribution of left hippocampal gray matter in the acute phase to the prediction of long-term language outcomes, over and above information on the lesion and the initial language deficit (measured by the ScreeLing). Non-linguistic statistical learning in patients with aphasia, measured in the subacute phase, was intact at the group level compared to 23 healthy older controls (8 males and 15 females, M 74.09 years, SD 6.76 years). Visuomotor statistical learning correlated with acute hippocampal gray and white matter. These findings reveal that particularly left hippocampal gray matter in the acute phase is a potential marker of language recovery after stroke, possibly through its statistical learning ability.

Lifestyle changes to prevent cardio- and cerebrovascular disease at midlife A systematic review.

Cardio- and cerebrovascular diseases are leading causes of death and morbidity in ageing populations. While numerous cohort studies show inverse associations of presumably healthy lifestyles and cardiovascular risk factors, the causal link to many modifiable behaviors is still insufficiently evidence-based. Because of bias of studies and heterogeneity of results, we performed a systematic review of meta-analyses of randomized controlled trials and observational studies on lifestyle patterns including nutrition, physical activity, smoking, and weight versus incidence and mortality of cardio- and cerebrovascular diseases. A search string retrieved 624 references in PubMed covering the last five years. Two researchers screened titles and abstracts independently but with equivalent results. Nineteen references met the inclusion criteria. Results affirm that high adherence to plant-based diets, including components such as fruits, vegetables, legumes, whole grains, low-fat dairy, olive oil, nuts, and low intake of sodium, sweetened beverages, alcohol, and red and processed meats, results in lower risk of vascular outcomes in a dose-dependent manner. Physical activity quantified as walking pace or cardiorespiratory fitness yielded an inverse effect on stroke. Health measures such as smoking status, BMI and increase in body weight are associated with substantial risk of the incidence of and mortality from cardio- and cerebrovascular diseases, while strong adherence to an overall prudent lifestyle lowered the risk of cardiovascular disease by 66 % and that stroke by 60 %. In summary, increasing numbers of and adherence to health behaviors may markedly lower the burden of cardio- and cerebrovascular diseases. However, future research should focus on randomized controlled trials to test for causal relationships.

Principles into Practice An Observational Study of Physiotherapists use of Motor Learning Principles in Stroke Rehabilitation.

To describe a) how motor learning principles are applied during post stroke physiotherapy, with a focus on lower limb rehabilitation and b) the context in which these principles are used, in relation to patient andor task characteristics. Direct non-participation observation of routine physiotherapy sessions, with data collected via video recording. A structured analysis matrix and pre-agreed definitions were used to identify, count and record type of activity repetitions instructional and feedback statements (frequency and type) strategies such as observational learning and augmented feedback. Data was visualised using scatter plots, and analysed descriptively. 6 UK Stroke Units PARTICIPANTS 89 therapy sessions were observed, involving 55 clinicians and 57 patients. Proportion of time spent active within each session ranged from 26% to 98% (mean 85, SD 19). The frequency of task repetition varied widely, with a median of 3.7 repetitions per minute (IQR 2.1-8.6). Coaching statements were common (mean 6.46 per minute), with 52% categorised as instructions, 14% as feedback, and 34% as verbal cuesmotivational statements. 13% of instructions and 6% of feedback statements were externally focussed. Examining the use of different coaching behaviours in relation to patient characteristics found no associations. Overall, practice varied widely across the dataset. To optimise the potential for motor skill learning, therapists must manipulate features of their coaching language (what they say, how much and when) and practice design (type, number, difficulty and variability of task). There is an opportunity to implement motor learning principles more consistently, to benefit motor skill recovery following stroke. Clinicaltrials.gov (NCT03792126). CONTRIBUTION OF THE PAPER.

Aging Is Associated With Lower Neuroactive Steroids and Worsened Outcomes Following Cerebral Ischemia in Male Mice.

Ischemic stroke is a leading cause of disability and death, and aging is the main nonmodifiable risk factor. Following ischemia, neuroactive steroids have been shown to play a key role in cerebroprotection. Thus, brain steroid concentrations at the time of injury as well as their regulation after stroke are key factors to consider. Here, we investigated the effects of age and cerebral ischemia on steroid levels, behavioral outcomes, and neuronal degeneration in 3- and 18-month-old C57BL6JRj male mice. Ischemia was induced by middle cerebral artery occlusion for 1 hour followed by reperfusion (MCAOR) and analyses were performed at 6 hours after MCAO. Extended steroid profiles established by gas chromatography coupled with tandem mass spectrometry revealed that (1) brain and plasma concentrations of the main 5α-reduced metabolites of progesterone, 11-deoxycorticosterone, and corticosterone were lower in old than in young mice (2) after MCAOR, brain concentrations of progesterone, 5α-dihydroprogesterone, and corticosterone increased in young mice and (3) after MCAOR, brain concentrations of 5α-reduced metabolites of progesterone, 3α5α-tetrahydrodeoxycorticosterone, and 3β5α-tetrahydrodeoxycorticosterone were lower in old than in young mice. After ischemia, old mice showed increased sensori-motor deficits and more degenerating neurons in the striatum than young mice. Altogether, these findings strongly suggest that the decreased capacity of old mice to metabolize steroids toward the 5α-reduction pathway comparatively to young mice may contribute to the worsening of their stroke outcomes.

Atrial Impairment as a Marker in Discriminating Between Takotsubo and Acute Myocarditis Using Cardiac Magnetic Resonance.

The purpose of this study was to comprehensively compare the left and right atrium strain and strain rate (SR) parameters by cardiac magnetic resonance (CMR) between patients with Takotsubo (TS) and patients with acute myocarditis (AM). We retrospectively enrolled 3 groups of patients TS (n18), AM (n14), and 11 healthy subjects. All the patients had complete CMR data for features tracking assessment.Differences in reservoir, conduit strain (εe), conduit strain rate (SRe), and booster phase of biatrial strain were analyzed between the groups using analysis of variance and multivariate analysis of covariance analyses. Intraobserver and interobserver reproducibility was assessed for all strain and SR parameters using intraclass correlation coefficients and Bland-Altman analysis. Atrial strain was feasible in all patients and controls. In TS, left atrium (LA) reservoir strain (εs), reservoir SR, εe, and SRe were significantly lower compared with the other groups (P0,001 for all). multivariate analysis of covariance analysis showed association of these parameters after correction for age and sex, while LA booster deformation (εa and SRa) strain parameters were preserved. LA SRe proved to have excellent sensitivity in differentiating patients with TS from those with AM (areas under the curves of 0.903, 95% confidence interval 0.81-0.99).Biatrial strain and SR parameters showed good (excellent) intraobserver and interobserver reproducibility (ranged between 0.61 to 0.96 and 0.50 to 0.90, respectively). Compared with AM, patients with TS showed significantly decreased LA reservoir, conduit strain, and SR parameters. Therefore, LA strain assessment may have a role in discriminating between TS and AM.

Decreased left atrial function in obesity patients without known cardiovascular disease.

Obesity is a risk factor for heart failure with preserved ejection fraction (HFpEF). We hypothesized that assessment of left atrial (LA) strain may be useful to reveal precursors of HFpEF in obesity patients. Echocardiograms of obesity patients without known cardiovascular disease who underwent bariatric surgery, and echocardiograms of age- and gender matched controls were analyzed. The echocardiogram was repeated 1 year after bariatric surgery. LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were measured. 77 Obesity patients were compared with 46 non-obese controls. Obesity patients showed a significantly decreased LA function compared with non-obese individuals (LASr 32.2% ± 8.8% vs. 39.6% ± 10.8%, p < 0.001 LAScd 20.1% ± 7.5% vs. 24.9% ± 8.3%, p 0.001 LASct 12.1% ± 3.6% vs. 14.5% ± 5.5%, p 0.005). There was no difference in prevalence of diastolic dysfunction between the obesity group and controls (9.1% vs. 2.2%, p 0.139). One year after bariatric surgery, LASr improved (32.1% ± 8.9% vs. 34.2% ± 8.7%, p 0.048). In the multivariable linear regression analysis, BMI was associated with LASr, LAScd, and LASct (β - 0.34, CI - 0.54 to - 0.13 β - 0.22, CI - 0.38 to - 0.06 β - 0.10, CI - 0.20 to - 0.004). Obesity patients without known cardiovascular disease have impairment in all phases of LA function. LA dysfunction in obesity may be an early sign of cardiac disease and may be a predictor for developing HFpEF. LASr improved 1 year after bariatric surgery, indicating potential reversibility of LA function in obesity.

Impact of body mass index and diabetes on myocardial fat content, interstitial fibrosis and function.

We hypothesize that both increased myocardial steatosis and interstitial fibrosis contributes to subclinical myocardial dysfunction in patients with increased body mass index and diabetes mellitus. Increased body weight and diabetes mellitus are both individually associated with a higher incidence of heart failure with preserved ejection fraction. However, it is unclear how increased myocardial steatosis and interstitial fibrosis interact to influence myocardial composition and function. A total of 100 subjects (27 healthy lean volunteers, 21 healthy but overweight volunteers, and 52 asymptomatic overweight patients with diabetes) were prospectively recruited to measure left ventricular (LV) myocardial steatosis (LV-myoFat) and interstitial fibrosis (by extracellular volume ECV) using magnetic resonance imaging, and then used to determine their combined impact on LV global longitudinal strain (GLS) analysis by 2-dimensional (2D) speckle tracking echocardiography on the same day. On multivariable analysis, both increased body mass index and diabetes were independently associated with increased LV-myoFat. In turn, increased LV-myoFat was independently associated with increased LV ECV. Both increased LV-myoFat and LV ECV were independently associated with impaired 2D LV GLS. Patients with increased body weight and patients with diabetes display excessive myocardial steatosis, which is related to a greater burden of myocardial interstitial fibrosis. LV myocardial contractile function was determined by both the extent of myocardial steatosis and interstitial fibrosis, and was independent of increasing age. Further study is warranted to determine how weight loss and improved diabetes management can improve myocardial composition and function.

Neuroprotective Effects of Carbonic Anhydrase Inhibition and Cyclic Adenosine Monophosphate Activation in Mouse Model of Transient Global Cerebral Ischemia and Reperfusion.

Cerebral ischemia is the primary basis of stroke, both sharing common pathogenic origins leading to irreversible brain damage if blood supply is not restored promptly. Existing evidence indicates that carbonic anhydrase (CA) inhibitors (CAIs) may impart therapeutic benefits against ischemia-reperfusion (IR) pathology via the adenylyl cyclase-cyclic adenosine monophosphate (cAMP) pathway. We hypothesize that CAI and cAMP activation may enhance the therapeutic outcome against IR conditions. In this investigation, the potential of dichlorphenamide (CAI) and the role of cAMP against ischemia-reperfusion injury were evaluated using a transient global cerebral IR (tGCIR) model. Swiss albino mice were subjected to bilateral common carotid artery occlusion (BCCAo) for 20 min and reperfusion (R) or sham surgery on day 1. Dichlorphenamide (DCPA, 20 mgkg) andor forskolin (cAMP agonist, 3 mgkg) was administered intraperitoneally (i.p.) after BCCAoR for 14 days. Results showed that tGCIR impaired neurocognitive functions and lowered brain levels of cAMP and protein kinase A (PKA) that were ameliorated by DCPA andor forskolin (FSK). DCPA andor FSK attenuated tGCIR-induced brain edema, blood-brain barrier dysfunction, oxidative-nitrosative stress, pro-inflammatory cytokines, acetylcholinesterase activity, cell death, and neurotransmitter imbalance (e.g., glutamate, γ-aminobutyric acid). The study showed that DCPA improved neurological and biochemical parameters against tGCIR injury via cAMP-PKA-mediated activation of protective mechanisms. However, DCPA and FSK in combination showed much enhanced therapeutic outcomes against tGCIR. Therefore, CA and cAMP present novel targets that may retard the progress of a transient ischemic attack to a full-blown stroke.

POU Domain Class 2 Transcription Factor 2 Inhibits Ferroptosis in Cerebral Ischemia Reperfusion Injury by Activating Sestrin2.

Cerebral ischemia reperfusion injury (CIRI) is the commonest cause of brain dysfunction. Up-regulation of POU domain class 2 transcription factor 2 (POU2F2) has been reported in patients with cerebral ischemia, while the role of POU2F2 in CIRI remains elusive. Middle cerebral artery occlusionreperfusion (MCAOR) in mice and oxygen and glucose deprivationreperfusion (OGDR) in mouse primary cortical neurons were used as models of CIRI injury in vivo and in vitro. Lentivirus-mediated POU2F2 knockdown further impaired CIRI induced by MCAOR in mice, which was accompanied by increased-neurological deficits, cerebral infarct volume and neuronal loss. Our evidence suggested that POU2F2 deficiency deteriorated oxidative stress and ferroptosis according to the phenomenon such as the abatement of SOD, GSH, glutathione peroxidase 4 (GPX4) activity and accumulation of ROS, lipid ROS, 4-hydroxynonenal (4-HNE) and MDA. In vivo, primary cortical neurons with POU2F2 knockdown also showed worse neuronal damage, oxidative stress and ferroptosis. Sestrin2 (Sesn2) was reported as a neuroprotection gene and involved in ferroptosis mechanism. Up-regulation of Sesn2 was observed in the ischemic penumbra and OGDR-induced neuronal cells. Further, we proved that POU2F2, as a transcription factor, could bind to Sesn2 promoter and positively regulate its expression. Sesn2 overexpression relieved oxidative stress and ferroptosis induced by POU2F2 knockdown in OGDR-treated neurons. This research demonstrated that CIRI induced a compensatory increase of POU2F2 and Sesn2. Down-regulated POU2F2 exacerbated CIRI through the acceleration of oxidative stress and ferroptosis possibly by decreasing Sesn2 expression, which offers new sights into therapeutic mechanisms for CIRI.

RCVS by clinicians for clinicians-a narrative review.

Reversible cerebral vasoconstriction syndrome may be underdiagnosed. It can be accompanied by various complications, mainly intracerebral hemorrhage and ischemic stroke. The clinical presentation of this condition varies according to its localization. The aims of this review are to raise awareness of the disease, especially in the presence of corresponding risk factors to connect its precipitating factors, pathophysiology, and complications and to compare various differential diagnoses of vasoconstriction. A review of the literature in PubMedMEDLINE and Google Scholar was conducted from May 1997 until May 2022. Reversible cerebral vasoconstriction syndrome, which is a clinical-radiological syndrome, is mainly characterized by the occurrence of thunderclap headache and widespread vasoconstriction. The most common precipitating factors are the use of vasoactive substances and postpartum status. The pathophysiology is currently assumed to include two mechanisms sympathetic overactivity and endothelial dysfunction. From these mechanisms, it is possible to derive potential complications as well as the most important differential diagnoses posterior reversible encephalopathy syndrome, convexity subarachnoid hemorrhage, ischemic and hemorrhagic stroke, and primary angiitis of the central nervous system. In general, the outcome of reversible cerebral vasoconstriction syndrome is very good. Vasospasm as well as thunderclap headache attacks can be fully reversible, and > 90% of patients are functionally independent at discharge.

Thrombolysis in central retinal artery occlusion a retrospective observational study.

There is no evidence-based therapy for non-arteritic central retinal artery occlusion (NA-CRAO). Intravenous thrombolysis (IVT) with alteplase in a time window < 4.5 h may lead to a favorable outcome. Purpose of this study was to investigate the feasibility, efficacy and safety of IVT in patients classified as functionally blind. We conducted a retrospective observational study of NA-CRAO-patients. All patients underwent an ophthalmological and neurological examination including cerebral magnetic resonance imaging (MRI) for assessment of additional stroke lesions. Patients were treated either conservatively or with IVT within 4.5 h. Visual acuity (VA) was evaluated in logMAR and a categorical analysis was performed. Thirty-seven patients were included in the study, 21 patients in the conservative treatment group (CTG) and 16 patients in the IVT group. The median logMAR visual acuity at admission and discharge was similar in both groups. The medium symptom to treatment time in the IVT group was 158.0 min. 3 patients (19%) of the IVT group showed a favorable outcome, all CTG patients remained at the level of functional blindness. No serious adverse events were observed after IVT. MRI showed additional acute stroke in over one-third of the patients (n 14). Early intravenous thrombolysis therapy according to the current stroke protocol n a time window up to 4.5 h after the onset of symptoms was feasible and might be a potential treatment option for NA-CRAO. Patients with NA-CRAO are at very high risk of ischemic stroke and MRI should be done in all patients for optimized treatment and secondary stroke prevention. A prospective randomized study is required.

Mechanisms of COVID-19-induced cerebellitis.

The COVID-19 pandemic caused by SARS-CoV2 has raised several important health concerns, not least increased mortality and morbidity. SARS-CoV2 can infect the central nervous system

Long-term outcomes of concomitant transcatheter aortic valve implantation and percutaneous coronary intervention.

The safety of concomitant percutaneous coronary intervention (PCI) during transcatheter aortic valve implantation (TAVI) setting is still highly debated. This study aimed to assess the safety and the effectiveness of TAVI and PCI performed in the same session compared with TAVI alone. Patients with severe aortic stenosis and coronary artery disease (CAD) (n786) who underwent TAVI from June 2007 to April 2021 were divided into two groups patients who underwent TAVI alone (n633) and patients treated with TAVI and concomitant PCI (n153). The propensity-score matching adjustment was used to account for baseline confounding variables. A total of 302 TAVI with CAD patients (151 matched pairs), undergoing either isolated TAVI or TAVIPCI were compared. In-hospital death (6% vs 4% p0.427), stroke (2% vs 0.7% p0.314), myocardial infarction (MI) (0% vs 0.7% p0.317), major and life-threatening bleeding (14.6% vs 15.9% p0.749), and acute kidney injury (9.3% vs 10.6% p0.700) were similar for both groups. At 3 years, the rates of all-cause death (25.2% vs 19.2% p0.615), the composite endpoints of all-cause death and MI (27.2% vs 21.2% p0.699) and all-cause death, MI, and stroke (28.5% vs 22.5% p0.739) were also comparable between the two groups. Achieving complete coronary revascularization in the TAVI setting did not impact on long-term mortality (p0.257). In patients with severe aortic stenosis and CAD, concomitant TAVI and PCI was as safe and effective as TAVI alone up to 3-year follow-up.

The prognostic role of advanced hemodynamic variables in patients with left ventricular assist devices.

Invasive hemodynamic variables obtained from right heart catheterization have been used for risk-stratifying patients with advanced heart failure (HF). However, there is a paucity of data on the prognostic value of invasive hemodynamic variables in patients with left ventricular assist devices (LVAD). We hypothesized that cardiac power output (CPO), cardiac power efficiency (CPE), and left ventricular stroke work index (LVSWI) can serve as prognostic markers in patients with LVADs. Baseline hemodynamic data from patients who had LVAD ramp studies at our institution from 42014 to 72018 were prospectively collected, from which advanced hemodynamic variables (CPO, CPE, and LVSWI) were retrospectively analyzed. Univariate and multivariable analyses were performed for hemocompatibility-related adverse events (HRAE), HF admissions, and mortality. Ninety-one participants (age 61 ± 11 years, 34% women, 40% Black or African American, and 38% ischemic cardiomyopathy) were analyzed. Low CPE was significantly associated with mortality (HR 2.42, 95% CI 1.02-5.74, p 0.045) in univariate analysis and Kaplan-Meier analysis (p 0.04). Low LVSWI was significantly associated with mortality (HR 2.13, 95% CI 1.09-4.17, p 0.03) in univariate analysis and Kaplan-Meier analysis (p 0.02). CPO was not associated with mortality. CPO, CPE, and LVSWI were not associated with HRAE or HF admissions. Advanced hemodynamic variables can serve as prognostic indicators for patients with LVADs. Low CPE and LVSWI are prognostic for higher mortality, but no variables were associated with HF admissions or HRAEs.

Cardiopulmonary function during exercise in heart failure with reduced ejection fraction following baroreflex activation therapy.

Baroreflex activation therapy has favorable effects in heart failure patients. We report the results of a single-center study of baroreflex activation therapy in heart failure with reduced ejection fraction including cardiopulmonary exercise testing for the first time to show the effect on exercise capacity. A total of 17 patients were treated with baroreflex activation therapy. Eligibility criteria were the New York Heart Association class ⩾III and ejection fraction ⩽35% on guideline-directed medical and device therapy. The New York Heart Association class, quality of life, and 6-min hall walk distance were assessed in all patients. Twelve patients underwent cardiopulmonary exercise testing before and 8.9 ± 6.4 months after initiation of baroreflex activation therapy. The New York Heart Association class and 6-min hall walk distance improved after baroreflex activation therapy, while quality of life remained stable. Weight-adapted peak oxygen uptake increased significantly from 10.1 (8.2-12.9) mlminkg to 12.1 (10.4-14.6) mlminkg ( Weight-adapted peak oxygen uptake improved after baroreflex activation therapy, pointing to an enhanced exercise capacity. Ventilatory efficiency and heart rate did not change, while oxygen pulse increased in patients with low oxygen pulse at baseline, indicating an improvement in circulatory efficiency, that is, a beneficial effect on stroke volume and peripheral oxygen extraction.

Development, implementation, and evaluation of the Australian Stroke Data Tool (AuSDaT) Comprehensive data capturing for multiple uses.

Historically, national programs for collecting stroke data in Australia required the use of multiple online tools. Clinicians were required to enter overlapping variables for the same patient in the different databases. From 2013 to 2016, the Australian Stroke Data Tool (AuSDaT) was built as an integrated data management solution. In this article, we have described the development, implementation, and evaluation phases of establishing the AuSDaT. In the development phase, a governance structure with representatives from different data collection programs was established. Harmonisation of data variables, drawn from six programs used in hospitals for monitoring stroke care, was facilitated through creating a National Stroke Data Dictionary. The implementation phase involved a staged deployment for two national programs over 12 months. The evaluation included an online survey of people who had used the AuSDaT between March 2018 and May 2018. By July 2016, data entered for an individual patient was, for the first time, shared between national programs. Overall, 119422 users (90% female, 61% aged 30-49 years, 57% nurses) completed the online evaluation survey. The two most positive features reported about the AuSDaT were (i) accessibility of the system (including simultaneous user access), and (ii) the ability to download reports to benchmark local data against peer hospitals or national performance. More than three quarters of respondents ( The AuSDaT reduces duplication and enables users from different national programs for stroke to enter standardised data into a single system. This example may assist others who seek to establish a harmonised data management solution for different disease areas where multiple programs of data collection exist. The importance of undertaking continuous evaluation of end-users to identify preferences and aspects of the tool that are not meeting current requirements were illustrated. We also highlighted the opportunities to increase interoperability, utility, and facilitate the exchange of accurate and meaningful data.

Catheter ablation improves cardiovascular outcomes in patients with atrial fibrillation and heart failure a meta-analysis of randomized controlled trials.

The effect of atrial fibrillation catheter ablation on cardiovascular outcomes in heart failure is an important outstanding research question. We undertook a meta-analysis of randomized controlled trials comparing ablation to medical therapy in patients with AF and heart failure. We systematically identified all trials comparing catheter ablation to medical therapy in patients with heart failure and atrial fibrillation. The pre-specified primary endpoint was all-cause mortality in trials with at least 2 years of follow-up. The secondary endpoint was heart failure hospitalization. Sensitivity analyses were performed for trials with any follow-up and trials deemed at low risk of bias. Eight trials (1390 patients) were included. Seven hundred and seven patients were randomized to catheter ablation and 683 to medical therapy. In the primary analysis (three trials, n 977), catheter ablation reduced mortality compared with medical therapy relative risk (RR) 0.61, 95% confidence interval (CI) 0.44 to 0.84, P 0.003. Catheter ablation also reduced heart failure hospitalizations compared with medical therapy (RR 0.60, 95% CI 0.49-0.74, P < 0.001). The effect on stroke was not statistically significant (RR 0.62, 95% CI 0.28-1.37, P 0.237). There was low heterogeneity between studies. Sensitivity analyses were consistent with the primary analyses. In patients with atrial fibrillation and heart failure, catheter ablation reduces mortality and the occurrence of heart failure hospitalizations.

Imaging spectrum of extracorporeal membrane oxygenation related neurologic events in children.

Extracorporeal membrane oxygenation (ECMO) can be associated with severe neurological complications increasing morbidity and mortality. We aimed to evaluate imaging findings in patients with neurological complications associated with ECMO. Children ( lt 18 years) who had ECMO support and received cross-sectional imaging (cranial CT and or MRI) were retrospectively evaluated. Age, gender, clinical and imaging findings were documented and the relation to ECMO duration and survival rates with imaging findings and imaging time (during ECMO or after weaning) were examined. Twenty children who had cranial CTMRI during (n6) ECMO and after weaning (n14) were included in the study. The median duration of ECMO was 12.5 days (IQR5-25 days) with a survival rate of 65%. Fourteen patients had positive imaging findings including ischemic stroke (n4), hemorrhagic stroke (n4), hypoxicischemic encephalopathy (n2), posterior reversible encephalopathy syndrome (PRES) (n3) and cerebral vein thrombosis (n1). The duration of ECMO and survival rates did not significantly differ between patients with positive and unremarkable imaging findings. However, the survival rate was significantly higher (p lt 0.001) and the duration of ECMO was significantly lower in patients scanned after weaning compared to patients imaged during ECMO support (p0.033). Our series revealed PRES in ECMO-related neurologic events in addition to commonly reported thrombotic and hemorrhagic stroke in the literature. Availability of cross-sectional imaging and awareness of radiologists to these complications during ECMO or after weaning help in prompt diagnosis and treatment.

The Dynamic Relationship Between Invasive Microvascular Function and Microvascular Injury Indicators, and Their Association With Left Ventricular Function and Infarct Size at 1-Month After Reperfused ST-Segment-Elevation Myocardial Infarction.

The invasive microvascular function indices, coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR), exhibit a dynamic pattern after ST-segment-elevation myocardial infarction. The effects of microvascular injury on the evolution of the microvascular function and the prognostic significance of the evolution of microvascular function are unknown. We investigated the relationship between the temporal changes of CFR and IMR, and cardiovascular magnetic resonance-derived microvascular injury characteristics in reperfused ST-segment-elevation myocardial infarction patients, and their association with 1-month left ventricular ejection fraction and infarct size (IS). In 109 ST-segment-elevation myocardial infarction patients who underwent angiography for primary percutaneous coronary intervention (PPCI) and at 1-month follow-up, invasive assessment of CFR and IMR were performed in the culprit artery during both procedures. Cardiovascular magnetic resonance was performed 2 to 7 days after PPCI and at 1 month and provided assessment of left ventricular ejection fraction, IS, microvascular obstruction, and intramyocardial hemorrhage. CFR and IMR significantly changed over 1 month (both, In reperfused ST-segment-elevation myocardial infarction patients, CFR and IMR significantly improved 1 month after PPCI the temporal change in IMR is closely related to the presenceabsence of microvascular damage and IS. ΔIMR exhibits a stronger association for 1-month functional outcome than post-PPCI CFR, IMR, or ΔCFR.

Therapeutic Benefits of Adropin in Aged Mice After Transient Ischemic Stroke via Reduction of Blood-Brain Barrier Damage.

Adropin is a peptide encoded by the energy homeostasis-associated gene ( Aged (18-24 months old) male mice were subjected to 30 minutes of middle cerebral artery occlusion followed by 48 hours or 14 days of reperfusion. Sensorimotor (weight grip test and open field) and cognitive tests (Y-maze and novel object recognition) were performed at defined time points. Infarct volume was quantified by 2,3,5-triphenyltetrazolium chloride staining at 48 hours or Cresyl violet staining at 14 days post-middle cerebral artery occlusion. Blood-brain barrier damage, tight junction proteins, and MMP-9 (matrix metalloproteinase-9) were assessed 48 hours after middle cerebral artery occlusion by ELISA and Western blots. Genetic deletion of These data unveil a promising neuroprotective role of adropin in the aged brain after transient ischemic stroke via reducing neurovascular damage. These findings suggest that poststroke adropin therapy is a potential strategy to minimize brain injury and improve functional recovery in ischemic stroke patients.

Notch Signaling Mediates Radiation-Induced Smooth Muscle Cell Hypermuscularization and Cerebral Vasculopathy.

Emerging evidence highlighted vascular injury in aggravating radiation-induced brain injury (RIBI), a common complication of radiotherapy. This study aimed to delineate the pathological feature of cerebral small vessel and investigate the functional roles of Notch signaling in RIBI. Brain tissue and functional MRI from RIBI patients were collected and analyzed for radiation-induced vasculopathy. A RIBI mouse model was induced by a single dose of 30-Gy cranial irradiation. Vascular morphology, pulsatility, and reactivity to pharmacological interventions, such as nimodipine and 20-hydroxyeicosa-6(Z),15(Z)-dienoic acid, were monitored by 2-photon imaging in mice at 6 weeks postirradiation. Western blot, real-time quantitative PCR, immunofluorescence staining, and behavioral tests were performed. The effect of N-N-(3, 5-difluorophenacetyl)-l-alanyl-s-phenylglycinet-butyl ester, a Notch inhibitor, was used to investigate the vascular pathogenesis of RIBI mouse model. Morphologically, radiation resulted in vascular malformation featured by focal contractile rings together with general stenosis. Functionally, radiation also led to hypoperfusion, attenuated vascular pulsatility, and decreased dilation to nimodipine and 20-hydroxyeicosa-6(Z),15(Z)-dienoic acid. Mechanically, Notch activation and increased expression of α-SMA protein were found in both surgical specimens of RIBI patients and the irradiated mice. Importantly, Notch inhibition by N-N-(3, 5-difluorophenacetyl)-l-alanyl-s-phenylglycinet-butyl ester significantly alleviated cerebral hypoperfusion, vasculopathy, and cognitive deficits in the RIBI mouse model. Radiation-induced cerebral vasculopathy showed bead-like shape and increased contractile state. Inhibition of Notch signaling by N-N-(3, 5-difluorophenacetyl)-l-alanyl-s-phenylglycinet-butyl ester effectively attenuated vasculopathy and relieved cognitive impairment, suggesting Notch signaling as a therapeutic target for the treatment of RIBI.

Not Available.

Overweight and diabetes (DM) result in premature cardiovascular disease. Even if unaccompanied by ischaemic heart disease, DM stiffens the circulation, which may result in heart failure with preserved ejection fraction. Magnetic resonance imaging studies have documented cardiac hypertrophy, myocardial vascular rarefaction, and myocardial fibrosis in patients with type 2 DM. All three phenotypical changes seem noteworthy targets for early intervention. Diabetic cardiomyopathy is years underway and hence early detection may be needed to secure adequate treatment of the metabolic syndrome.

Ischemic stroke in a patient with EGFR-mutated non-small-cell lung cancer after treatment with ramucirumab.

Vascular endothelial growth factor (VEGF) inhibitors have been widely investigated in the last 10 years, with particular attention paid to their adverse effects because of their efficacy in improving cancer patient survival. Previous research primarily focused on the monoclonal anti-vascular endothelial growth factor antibody bevacizumab and its adverse outcomes. Reports show a higher risk of ischemic stroke, one of the most concerning clinically relevant events, after treatment with bevacizumab. However, few studies have examined the relationship between anti-VEGF receptor 2 monoclonal antibody ramucirumab and its adverse events. This article presents the case of a non-small-cell lung cancer patient who experienced a new ischemic stroke after treatment with ramucirumab. The findings suggest that further studies may be necessary to investigate the relationship between ramucirumab and the risk of ischemic stroke.

Serum uric acid levels are associated with macula microvasculature changes in hypertensive white matter hyperintensity patients.

to characterize the macula microvasculature using fractal dimension (FD) in hypertensive white matter hyperintensity (WMH) participants and explore the association between the microvascular changes and serum uric acid levels. Thirty-eight WMH participants who were dementia and stroke-free and 37 healthy controls were enrolled. Optical coherence tomographic angiography (OCTA) was used to image the superficial vascular complex (SVC), deep vascular complex (DVC,), and inner vascular complex (IVC) in a 2.5-mm diameter concentric circle (excluding the foveal avascular zone, FAZ). A commercial algorithm was used to quantify the complexity and density of the three capillary layers by fractal analysis. WMH participants showed significantly lower FD value in the SVC (P 0.002), DVC (P < 0.001) and IVC (P 0.012) macula microvasculature compared with control group. After adjusting for risk factors (hypertension, diabetes, age and gender) SVC (P 0.035) and IVC (P 0.030) significantly correlated with serum uric acid. Serum uric acid levels are associated with the microvascular changes in WMH. Fractal dimension based on OCTA imaging could help in the quantitative characterization of the macula microvasculature changes in WMH and may be a potential screening tool to detect serum uric acid level changes.

Inverted U-shaped relationship between mean platelet volumeplatelet count ratio and post-thrombolytic early neurological deterioration in patients with mild and moderate stroke.

The objective of this study is to investigate the relationship between mean platelet volume (MPV)platelet count (PC) ratio and post-thrombolytic early neurological deterioration (END) in patients with mild and moderate stroke. Mild and moderate stroke patients treated with intravenous thrombolysis (IVT) at the Affiliated Changsha Central Hospital of the University of South China between January 2016 and March 2022 were prospectively and consecutively enrolled. END was defined as an increase in the total National Institutes of Health Stroke Scale (NIHSS) score of ≥4 points or an increase in the motor items of ≥1 point within 24 hours after IVT treatment. Logistic regression and restricted cubic spline models were used to estimate the relationship between MPVPC ratio and post-thrombolytic END. Among the 406 patients recruited, 64 (15.8%) patients developed END. Patients in the first quintile of MPVPC ratio (adjusted OR 0.27, 95% CI 0.11-0.66, p 0.004) and the fifth quintile (adjusted OR 0.26, 95% CI 0.10-0.69, p 0.007) had a significantly lower risk of END compared with those in the third quintile. Restricted cubic spline analysis revealed an inverted U-shaped relationship between MPVPC ratio and END (p for nonlinearity 0.016). MPVPC ratio cut-off value associated with the highest END risk was 51.0. An MPVPC ratio ≤ 51.0 was shown to be positively associated with END (adjusted OR 1.07, 95% CI 1.02-1.14, p 0.012), while an MPVPC ratio >51.0 was negatively associated with END (adjusted OR 0.94, 95% CI 0.88-1.00, p 0.040). A significant interaction existed between MPVPC ratio and age in the low MPVPC ratio group (p 0.012). MPVPC ratio was positively associated with END only in patients ≥ 60 years, whereas this association was insignificant in patients < 60 years. An inverted U-shaped relationship between MPVPC ratio on admission and post-thrombolytic END was identified in patients with mild and moderate stroke, with a threshold MPVPC ratio of 51.0. The MPVPC ratio closer to the threshold was associated with a higher risk of post-thrombolytic END.

The impact of initial admission department on the management and prognosis of retinal artery occlusion.

Retinal artery occlusion (RAO) is an emergency condition in both neurology and ophthalmology departments. However, the management and visual outcome of RAO in different initial departments remain unclear. Therefore, we aimed to investigate the impact of the initial department on the management and prognosis of RAO. Consecutive cases of RAO between January 2011 and December 2021 were retrospectively analyzed. The baseline characteristics, relevant evaluation, and treatment were compared between the neurology and ophthalmology departments. The primary outcome was the visual recovery rate. The secondary outcomes were newly diagnosed cardiovascular factors, concurrent stroke and new-onset cardiovascular events. A total of 74 RAO patients were included. The median age was 54 years, and 67.6% were male. There were 42 (56.8%) patients admitted to the neurology department and 32 (43.2%) in the ophthalmology department. The visual recovery rate was higher in the neurology department than in the ophthalmology department, although the difference did not reach statistical significance (27.8 vs. 12.5%, p 0.120). Risk factor evaluation and secondary prevention were taken more frequently in the neurology department (p < 0.001). Cardiovascular risk factors and concurrent stroke were all discovered in the neurology department. However, the incidence of new-onset cardiovascular events was similar between the two departments. The study demonstrated that the visual prognosis of RAO was devastating regardless of the neurology and ophthalmology department. Given the admission delay, inadequate management, and high risk of cardiovascular risk factors and stroke, stroke centers should be recommended as initial admission departments for RAO patients.

Primary results of mechanical thrombectomy for acute ischemic stroke The K-NET registry in the Japanese metropolitan area.

Endovascular treatment (EVT) for acute large vessel occlusion has proven to be effective in randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in a metropolitan area with a large number of comprehensive stroke centers and to compare it with the results of other registries and randomized controlled trials (RCTs). We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT andor intravenous tissue-type plasminogen activator (tPA). Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0-2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis. The median age was 77 years, and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 min. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Overall mortality was 12.6%. Significant predictors for a good outcome were as follows age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization. EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous studies, despite the high proportion of patients with older age, pretreatment mRS score of >2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.

Association between the Triglyceride-Glucose Index and the Risk of Large Artery Atherosclerotic Stroke.

The aim of this study is to evaluate the value of the triglyceride-glucose (TyG) index and the risk of large artery atherosclerotic (LAA) stroke. Information on general demographic and clinical characteristics, magnetic resonance angiography (MRA) examination, and blood biochemical index determination were obtained. Based on age stratification, three models to evaluate the odds ratio (OR) and the 95% confidence interval (95% CI) were employed to determine the correlation between the TyG index and the risk of LAA stroke. The most effective TyG index threshold in predicting a high risk of LAA stroke was identified using receiver operating characteristic (ROC) curve analysis. Logistic regression verified the association between the risk of LAA stroke and the TyG index. Both with and without age stratification, logistic regression analysis showed that the TyG index was a significant predictor of the occurrence of LAA stroke (

Wearable Sensors Improve Prediction of Post-Stroke Walking Function Following Inpatient Rehabilitation.

A primary goal of acute stroke rehabilitation is to maximize functional recovery and help patients reintegrate safely in the home and community. However, not all patients have the same potential for recovery, making it difficult to set realistic therapy goals and to anticipate future needs for short- or long-term care. The objective of this study was to test the value of high-resolution data from wireless, wearable motion sensors to predict post-stroke ambulation function following inpatient stroke rehabilitation. Supervised machine learning algorithms were trained to classify patients as either household or community ambulators at discharge based on information collected upon admission to the inpatient facility (N33-35). Inertial measurement unit (IMU) sensor data recorded from the ankles and the pelvis during a brief walking bout at admission (10 meters, or 60 seconds walking) improved the prediction of discharge ambulation ability over a traditional prediction model based on patient demographics, clinical information, and performance on standardized clinical assessments. Models incorporating IMU data were more sensitive to patients who changed ambulation category, improving the recall of community ambulators at discharge from 85% to 89-93%. This approach demonstrates significant potential for the early prediction of post-rehabilitation walking outcomes in patients with stroke using small amounts of data from three wearable motion sensors. Accurately predicting a patients functional recovery early in the rehabilitation process would transform our ability to design personalized care strategies in the clinic and beyond. This work contributes to the development of low-cost, clinically-implementable prognostic tools for data-driven stroke treatment.

Mole crab-inspired vertical self-burrowing.

We present EMBUR-

Understanding the Professional Care Experience of Patients with Stroke A Qualitative Study Using In-Depth Interviews.

Professional support and communication stimulates the professional-patient relationship and supports the recovery of stroke patients. To describe the perspectives of patients with stroke regarding communication, professional support, and their ability to participate in processes and integrated care with health providers. A qualitative study was conducted. A purposeful sampling and snowball-technique were used. Patients diagnosed with moderate or severe stroke in the post-acute or chronic stage of the disease were included. Data collection consisted of in-depth interviews and researcher field notes. A thematic analysis was performed. Thirty-one patients were included. Three themes were identified 1) Providing support, with four categories, professional behavior, personalized attention, the heart of the professional and building a bond with the patient 2) Facilitating communication, with three categories, the patient as the recipient, the content of the message and the channel, and the professional as the person that conveys the message and 3) Promoting participation, with two categories, barriers, and incentives to participate. When providing support, professionals should consider communicating information and encouraging the participation of stroke patients for integrated care.

Sex Differences in Stroke Risk Factors, Clinical Profiles, and In-Hospital Outcomes Among Stroke Patients Admitted to the Medical Ward of Dessie Comprehensive Specialized Hospital, Northeast Ethiopia.

A stroke is a vascular accident that affects both men and women. The threat of stroke and outcome status differ between the sexes. Such data are lacking in Ethiopia. Therefore, this study assessed sex differences in stroke risk factors, clinical profiles, and outcomes in the medical ward of Dessie comprehensive specialized hospital. A retrospective cross-sectional study was employed among stroke patients. Medical records with complete information and a confirmed diagnosis of stroke using imaging techniques were included in the study. Using simple random sampling, 344 medical records were selected, 312 of which fulfilled the inclusion criteria. Bivariate and multivariate logistic regression analyses and a chi-square test were employed. The frequency, percentage, and mean and standard deviation of the variables were described using descriptive statistics. Findings with a P-value <0.05 were considered statistically significant. Most of the patients were above or equal to 45 years old in both sexes. A significantly higher number of male than female patients were aged less than 45 years (p-value-0.001). Younger age (AOR 2.998, p 0.000), cigarette smoking (AOR 2.911, p 0.009), and Khat chewing (AOR 3.650, p 0.001) were risk factors for stroke in males. A higher number of males presented with hemiplegiahemiparesis 89 (28.5%), aphasia 45 (14.4%), and facial palsy 19 (6.1%). However, more females were unconscious (15.1%). Significant differences were not seen in the stroke outcomes. Furthermore, there were no apparent differences in risk factors for stroke-related mortality. Males developed stroke at a younger age. Women were older at the time of stroke onset and presented unconscious. More males experienced hemiplegiahemiparesis, aphasia, and facial palsy. Smoking, drinking, and khat chewing were risk factors for stroke in men. There were no gender differences in the stroke death rate. Therefore, educating the public about stroke risk factors, lifestyle modification, and conducting prospective research is required.

Assessment of Direct Oral Anticoagulant Use at a Community Teaching Hospital.

Direct oral anticoagulants (DOACs) have become popular choices for both the treatment and prevention of thromboembolic events. However, these agents pose additional risks to patients due to complex dosing, insufficient monitoring, and inconsistent patient compliance. This study evaluates the appropriateness of DOAC prescribing for patients who received an order for apixaban or rivaroxaban over a 6-month period. The primary outcome is percentage of inappropriately prescribed DOAC regimens. Secondary outcomes include an effectiveness endpoint of stroke or embolism and a safety endpoint of major bleeding documented during or within 60 days of the initial visit as well as number of pharmacist clinical interventions. DOAC orders were appropriate 73% of the time. Of the 27% of inappropriate orders, approximately half were apixaban and half were rivaroxaban. The most common reason for an inappropriate order for apixaban was due to atrial fibrillation dosing, and the most common reason for an inappropriate rivaroxaban order was due to dose-indication mismatch. There were 30 pharmacist clinical interventions on DOAC orders that were documented during the 6-month period, and the most common reason for a pharmacist intervention was duplication with another anticoagulant.

Ischemic Stroke Secondary to a Stab Wound to the Neck in a Young Adult.

Vertebral artery dissection is a common cause of stroke in young adults without predisposing risk factors for cerebrovascular disease. We describe the case of a 28-year-old patient who presented with an ischemic stroke secondary to a stab wound to the neck that affected the vertebral artery. A physical examination revealed neurological deterioration (Glasgow 815), a sutured neck wound, no palpable hematoma, no thrills, and no active bleeding. A computed tomography angiography revealed a left vertebral artery arteriovenous fistula with a component of a pseudoaneurysm, for which a neurointerventional consultation was carried out. Due to neurological compromise, the airway was secured, and because the case involved a posterior fossa infarction with compression of the fourth ventricle and obstructive secondary hydrocephalus, an external ventricular shunt was inserted by neurosurgery. A fistula occlusion was performed with five Axium coils and a vial of Squid 12 the vertebral artery was catheterized, and a craniotomy was performed to manage hydrocephalus with a 12-mm H

Screening for Obstructive Sleep Apnea in Adults An Evidence Review for the U.S. Preventive Services Task Force

To systematically review the evidence on screening and treating asymptomatic adults with obstructive sleep apnea (OSA) or those with unrecognized symptoms for OSA. PubMedMEDLINE, the Cochrane Library, Embase, and trial registries through August 23, 2021 reference lists of retrieved articles outside experts and reviewers, with surveillance of the literature through September 23, 2022. Two investigators independently selected English-language studies using a priori criteria. Eligible studies included randomized, controlled trials (RCTs) of screening for or treatment of OSA reporting on health outcomes, studies evaluating accuracy of screening questionnaires or clinical prediction tools in asymptomatic adults with OSA or persons with unrecognized symptoms of OSA, and systematic reviews of treatment reporting on changes in blood pressure (BP) and apnea-hypopnea index (AHI) scores. One investigator extracted data and a second checked accuracy. Two reviewers independently rated data quality for all included studies using predefined criteria. No reviewed RCT directly compared screening with no screening. In two studies (702 total participants), the screening accuracy measured as AUC of the Multivariable Apnea Prediction (MVAP) score followed by unattended home sleep testing for detecting severe OSA syndrome (AHI ≥30 and Epworth Sleepiness Scale ESS score >10) was 0.80 (95% confidence interval CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90), respectively. Studies evaluating the Snoring, Tiredness, Observed apnea, blood Pressure, Body mass index, Age, Neck circumference, Gender (STOP-BANG) Questionnaire (k4) and the Berlin Questionnaire (BQ) (k2) enrolled different populations and used different criteria for a positive screening test. Recent systematic reviews of positive airway pressure (PAP) and mandibular advancement devices (MADs) show an association between PAP and MAD and reduction in BP and AHI, however reduction in BP outcomes versus inactive control is relatively small (2 to 3 mm Hg). Meta-analysis found that PAP compared with any control was associated with a significantly larger reduction in ESS score change (pooled mean difference, −2.33 95% CI, −2.75 to −1.90 47 trials, 7,024 participants), modest improvement in sleep-related quality of life (QOL) (standardized mean difference, 0.30 95% CI, 0.19 to 0.42 18 trials, 3,083 participants), and improved general health-related QOL measured by the SF-36 mental health component summary score change (2.20 95% CI, 0.95 to 3.44 15 trials, 2,345 participants) and SF-36 physical health component summary score change (pooled mean difference, 1.53 95% CI, 0.29 to 2.77 13 trials, 2,031 participants). Meta-analysis also found that use of MADs was associated with a significantly larger ESS score change than controls (pooled mean difference, −1.67 95% CI, −2.09 to −1.25 10 trials, 1,540 participants). Reporting of other health outcomes was sparse no included trial found significant benefit associated with PAP or MAD on mortality, cardiovascular outcomes, stroke, or motor vehicle accidents. Common adverse effects of PAP and MADs included oral or nasal dryness, irritation, and pain, among others. Two studies assessing the accuracy of the MVAP score oversampled participants at high risk of OSA and those with OSA syndrome. No study prospectively evaluated screening tools to report calibration or clinical utility for improving health outcomes. Three studies assessing the accuracy of the STOP-BANG and two assessing the BQ enrolled different populations and used different criteria for positive screening tests. Most included trials assessing the benefit of PAP and MADs reported outcomes over a relatively short duration (12 weeks or less), and most pooled estimates showing improvement in excessive sleepiness or QOL (except benefit of PAP for improving ESS scores) fell short of the range considered to be a minimal clinically important difference. Populations enrolled in trials of treatment were referred for treatment no trial enrolled populations who were identified by screening in primary care. The accuracy and clinical utility of potential screening tools for OSA that could be used in primary care settings are uncertain. PAP and MADs reduce AHI, BP and ESS score. Trials of PAP have not established whether treatment reduces mortality or improves most other health outcomes, except for its modest improvement in sleep-related QOL and general health–related QOL.

Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons An Evidence Review for the U.S. Preventive Services Task Force

Hormone therapy plays an important role in the clinical management of menopausal symptoms. Because of an increased risk of harms, hormone therapy is currently not recommended for the primary prevention of chronic conditions. To update evidence on the effectiveness of hormone therapy in reducing risk of chronic conditions, its adverse effects, and differences among population subgroups for the U.S. Preventive Services Task Force. We searched MEDLINE, the Cochrane Library, and Embase for English-language articles (through October 12, 2021). We conducted searches for unpublished literature by searching ClinicalTrials.gov, HSRProj, the World Health Organization’s International Clinical Trials Registry Platform, and NIH RePORTER. In addition, we reviewed reference lists of pertinent review articles and studies meeting our inclusion criteria. We conducted surveillance of the literature through June 1, 2022. We dually reviewed the literature and included randomized, placebo-controlled trials and large controlled cohort studies that provided information on the primary prevention of chronic conditions with hormone therapy and reported health outcomes. We abstracted details about participants, study design, analysis, followup, and results study quality and strength of evidence were rated using established criteria. Twenty fair- or good-quality trials and three large controlled cohort studies met eligibility criteria. The Women’s Health Initiative was the largest study and most applicable to the target population. Results of our review indicate differences in the risk-benefit profile between treatment formulations. Women using estrogen only had statistically significantly lower risk (per 10,000 women over 6.8 to 7.2 years) of diabetes (134 fewer cases) and fractures (388 fewer cases) than women taking placebo. However, risk (per 10,000 women over 5.4 to 7.1 years) was statistically significantly increased for gallbladder disease (377 more cases), stroke (79 more cases), and venous thromboembolism (77 more cases). Women using estrogen plus progestin therapy experienced statistically significantly lower risk (per 10,000 women over 5.0 to 5.6 years) for colorectal cancer (34 fewer cases), diabetes (78 fewer cases), and fractures (230 fewer cases) than women taking placebo. Risk (per 10,000 women over 4 to 5.6 years) of invasive breast cancer (51 more cases), probable dementia (88 more cases), gallbladder disease (260 more cases), stroke (52 more cases), and venous thromboembolism (120 more cases) was statistically significantly increased compared with women taking placebo. The risk of urinary incontinence (562 more cases per 10,000 women) was increased during a followup of 1 year. Meta-analyses rendered no statistically significant differences in all-cause mortality between women receiving hormone therapy and those receiving placebo (over 2 to 7.2 years for estrogen-only therapy and over 3.2 to 5.6 years for estrogen plus progestin therapy). Few trials or subgroup analyses were powered for prevention outcomes. No comparative evidence on type, dose, and mode of delivery of hormone therapy is available. The applicability of results to younger women who initiate hormone therapy to manage menopausal symptoms and to women of non-White ethnic backgrounds might be limited. Women undergoing hormone therapy for the primary prevention of chronic conditions experience some beneficial effects but also an increased risk of harms.

StatPearls

The Berg Balance Scale is a test used to assess functional balance. It was created by Katherine Berg in 1989 to evaluate balance ability in the elderly, with the initial target population having an average age of 73. It evaluates both dynamic and static balance through 14 tasks regarding mobility. In the beginning, it was mostly used to assess stroke patients however, this test has shown high validity and reliability in various patient populations, including neurological conditions such as Parkinson disease, multiple sclerosis, traumatic brain injury, and acquired conditions as lower extremity amputees. The scale has been useful in predicting the risk of falls and outcomes and even assessing the length of stay at inpatient rehabilitation. It is a short test that can be performed relatively quickly under different environments.

StatPearls

Stroke is a major cause of death and disability worldwide, with a prevalence of about 2.5%. A stroke is called ischemic when caused by an interruption of the blood supply to the brain either through a blood clot called a thrombus or an embolus, which is a dislodged clot. At the onset of an acute ischemic stroke, lack of oxygen and other nutrients trigger a series of events causing electrophysiological, metabolic, and molecular damage, leading to irreversible brain tissue damage. The most proximal part of the arterio-vascular occlusion sustains maximal damage and is usually called an ischemic core. Between the ischemic core and normal brain tissue lies the penumbra, an area of mild to moderate hypoxia that may become irreversibly damaged lest blood flow is restored to normal levels within a critical time period. Without therapeutic interventions and continued ischemia, brain tissue death is quantified as a loss of 1.9 million neurons, 14 billion synapses, and 12 km of myelinated fibers every minute. In other words, one hour of ischemic brain damage can be compared to 3.6 years of normal brain aging. Acute stroke therapeutics aim to contain the tissue damage happening at the penumbra level and restore the penumbras functionality. Alteplase, a tissue plasminogen activator (tPA), is the only United States FDA (Food and Drug Administration) approved clot-busting medication used to recanalize the thrombosed occluded vasculature in an ischemic stroke. Many studies have consistently shown better outcomes in acute ischemic stroke patients who received tPA. Intervention with tPA, newer proven endovascular interventions like mechanical thrombectomy aimed at recanalizing thrombosed vessels paradoxically may lead to deleterious consequences in the ischemic tissue due to many complexly woven biochemical and pathological events. In a subacute context, procedures like carotid endarterectomy and stenting may also lead to reperfusion injury. Such functional, microscopic, and sometimes a macroscopic injury consequential to blood flow restoration is termed as ischemia-reperfusion (IR) injury.

StatPearls

Exploding head syndrome (EHS) is a benign parasomnia characterized by the perception of a loud sound while asleep, which leads to abrupt awakening. These events occur during the wake-sleepsleep-wake transition period and generally last less than a second. Events are often accompanied by flashes of light and patient distress, but there is no significant associated pain. The sounds have most commonly been described as explosions, gunshots, or thunder but can be almost any loud noise. The events occur with variable frequency, and there may be prolonged remission between episodes. EHS was first described in medical literature in 1876 by American neurologist Silas Weir Mitchell. He reported a case study of two patients, who experienced the nocturnal sensation of loud sounds he described as “sensory shocks.” Despite earlier descriptions and case reports of EHS, it was not classified as a sleep disorder until 2005, when it gained inclusion in the 2nd edition of International Classification of Sleep Disorders (ICSD-2). More recently, the term episodic cranial shock has been proposed to describe this phenomenon. The phenomenon is often frightening to those who are unaware of its benign nature. Patients may initially fear a more ominous cause is responsible for the sounds, such as a stroke, brain tumor, or brain hemorrhage. These concerns are the reasons many seek medical evaluations. It is an underdiagnosed and under-reported syndrome because patients may feel embarrassed about their symptoms, and healthcare providers may not be familiar with the diagnosis.