Time to consider health services dedicated for adults living with cerebral small vessel disease: Report of a ESO scientific seminar

PURPOSE

Cerebral small vessel disease (cSVD) is a highly prevalent disorder leading to physical, cognitive and functional decline. We report key barriers in the management of individuals with cSVD, the potential benefit of cSVD-dedicated health services, and evidence from existing models of care for adults with cSVD.

METHODS

We examined information from a scientific seminar developed between seven experts in cSVD during the eighth European Stroke Organisation Conference that discussed the optimal health care for adults with cSVD and what health services dedicated to cSVD should include.

FINDINGS

Barriers in cSVD care include unrecognised symptoms and modifiable risk factors, heterogeneity of clinical presentations, inefficient inter/intra-clinical services communication/organisation, and uncertainties regarding what assessments/treatments should be routinely done, when and by whom. However, existing health services and research studies suggest models of care in cSVD. Multi-step approaches can be used for identification and aetiological workup in individuals with cSVD, including basic and selected advanced evaluations, for example, monogenic cSVD testing. Although current guidelines for management of cSVD illlustrate limitations, there are recommendations on risk factors and lifestyle considerations, as well as pharmacological and non-pharmacological interventions for people with cSVD.

DISCUSSION AND CONCLUSION

Existing healthcare models do not provide optimal care for individuals with cSVD. Lack of awareness of heterogeneous clinical presentations and uncertainty in threshold of cSVD 'burden' for referral to specialist multidisciplinary services, are key challenges for health services to overcome. Creating cSVD-dedicated services may prevent underdiagnosing and achieve standardised holistic management to improve outcomes in people with cSVD. However, adequate prevention and early management should be offered at all levels of care.

Relationship between physical activity and depressive symptoms in stroke survivors: a cross-sectional study of 1,140 individuals

OBJECTIVES

To investigate the relationship between physical activity and depressive symptoms in stroke survivors.

DESIGN

A cross-sectional study utilizing National Health and Nutrition Examination Survey (NHANES) 2007-2018 data, employing propensity score matching to control for confounders.

PATIENTS

1,140 stroke survivors from NHANES, assessing depressive symptoms through the Patient Health Questionnaire-9 (PHQ-9) conducted via family interview or a mobile examination centre examination.

METHODS

PA was surveyed concurrently with the PHQ-9, categorized into vigorous, moderate, and moderate-to-vigorous intensities. Propensity score matching was used to match participants based on their activity levels, and the relationship between physical activity and depressive symptoms was analysed by logistic regression.

RESULTS

Among all the subjects, 225 individuals had significant depressive symptoms. If vigorous-intensity PA duration is longer than 75 min (odds ratio [OR] = 0.41, 95% CI 0.21-0.75) or longer than 150 min (OR = 0.42, 95% CI 0.19-0.85), and moderate-intensity physical activity duration is longer than 150 min (OR = 0.59, 95% CI 0.38-0.90) or between 150 and 300 min (OR = 0.36, 95% CI 0.15-0.77), and moderate-to-vigorous PA duration is greater than 150 min (OR = 0.61, 95% CI 0.40-0.91) or exceeding 300 min (OR = 0.50, 95% CI 0.31-0.78), this might be associated with lower depressive symptoms.

CONCLUSION

Regular physical activity, particularly of moderate or higher intensity, is associated with milder depressive symptoms in stroke survivors, suggesting the potential for non-pharmacological intervention.

Associations of reverse triiodothyronine serum levels with anxiety, depression, and health related quality of life after experiencing acute ischemic stroke

Aim

This study intended to explore associations of reverse triiodothyronine (rT3) with emotional disturbances and health-related quality of life (HRQoL) after experiencing acute ischemic stroke (AIS).

Materials and methods

Serum samples from individuals with AIS were collected on admission to three Lithuania stroke centers and investigated for free tetraiodothyronine, free triiodothyronine (fT3), rT3, and thyroid stimulating hormone levels. At discharge, emotional disturbance was evaluated using the Hospital Depression and Anxiety Scale (HADS), and HRQoL using the EQ-5D-5L scale.

Results

Analyses included 159 individuals (59.7% male and 40.3% female; mean (SD) aged 66.4 [10.3] years), 52.83% of which showed increased rT3 levels upon admission. After adjustment for age, sex, National Institutes of Health Stroke Scale scores, previous stroke, modified Rankin Scale before AIS ≤ 2, and diabetes mellitus, multivariable linear regression revealed negative associations of rT3 with HADS total score (β = -0.163; p = 0.046) and HADS-D subscale score (β = -0.187; p = 0.019). Analyses supported a positive relationship between the fT3 ratio to rT3 with HADS-D score (β = 0.157; p = 0.046) and rT3, rT3 × fT3 product with EQ-5D index score (β = 0.157; p = 0.044 and β = 0.179; p = 0.023, respectively).

Conclusion

We found that individuals who experienced AIS and had higher levels of rT3 at hospital admission had less emotional disturbance and better HRQoL when discharged.

Helicopter emergency medical services in Eastern Iran: a 4-year cross-sectional study of time intervals and mission profiles

BACKGROUND

Air medical transport services play a significant role in emergency situations by providing timely transfers of critically ill patients to medical facilities. This study aimed to investigate the mission characteristics of helicopter emergency medical services (HEMS) and the associated time intervals in a geographically remote region of eastern Iran. We also compared the prehospital times of HEMS and ground transportation to determine whether dispatching a helicopter is time-efficient.

METHODS

This retrospective cross-sectional study was conducted at the prehospital emergency medical center in Gonabad, a remote area in eastern Iran. Data were collected using standardized electronic forms developed by the Ministry of Health and Medical Education (MOHME) in Iran. We analyzed the mission profiles and prehospital time intervals for all Gonabad HEMS missions conducted between 2021 and 2024. The mean activation time was compared to the national benchmark of three minutes, and the prehospital time intervals of air ambulances were compared to those of ground ambulances.

RESULTS

From 2021 to 2024, there were 252 HEMS missions, transporting 265 patients. Of all 252 missions, 95 (37.7%) were primary missions, and 157 (62.3%) were secondary missions. The most frequent reasons for air ambulance dispatch were trauma, acute coronary syndrome, and strokes. The mean ± SD for HEMS activation time was 9.14 ± 3.63 min, significantly exceeding the national benchmark of three minutes. HEMS prehospital time was 49.73 ± 9.67 min. The comparison of prehospital time intervals indicated that air emergency services are more time-efficient than ground ambulances.

CONCLUSION

This study found that the mean activation time of air ambulances exceeded the national benchmark of three minutes. When comparing prehospital times for air ambulance and ground ambulance services, HEMS was faster than both ground scenarios. The current benchmark for helicopter activation time in Iran may need clarification and revision.

Association between the systemic immunity-inflammation index and stroke: a population-based study from NHANES (2015-2020)

Background The systemic immunity-inflammation index(SII) is a new indicator of composite inflammatory response. Inflammatory response is an important pathological process in stroke. Therefore, this study sought to investigate the association between SII and stroke. Methods We collected data on participants with SII and stroke from the 2015-2020 cycle of National Health and Nutrition Examination Survey (NHANES) for the cross-sectional investigation. Multivariate linear regression models were used to test the association between SII and stroke. Fitted smoothing curves and threshold effect analysis were applied to describe the nonlinear relationship. Results A total of 13,287 participants were included in our study, including 611 (4.598%) participants with stroke. In a multivariate linear regression analysis, we found a significant positive association between SII and stroke, and the odds ratio (OR) [95% CI] of SII associating with prevalence of stroke was [1.02 (1.01, 1.04)] (P < 0.01). In subgroup analysis and interaction experiments, we found that this positive relationship was not significantly correlated among different population settings such as age, gender, race, education level, smoking status, high blood pressure, diabetes and coronary heart disease (P for trend > 0.05). Moreover, we found an nonlinear relationship between SII and stroke with an inflection point of 740 (1,000 cells /µl) by using a two-segment linear regression model. Conclusions This study implies that increased SII levels are linked to stroke. To confirm our findings, more large-scale prospective investigations are needed.

Longitudinal changes in remnant cholesterol and the risk of cardiovascular disease

BACKGROUND AND AIM

The analyses of longitudinal changes in remnant cholesterol (RC) and cardiovascular disease (CVD) remains are limited. The objective of the study was to investigate the associations of longitudinal changes in RC with the risks of CVD and its subtypes (myocardial infarction [MI] and stroke).

METHODS AND RESULTS

The participants were enrolled in the Kailuan study. The RC short-term change pattern was defined by RC cutoff points according to equivalent percentiles for low-density lipoprotein cholesterol of 2.6 mmol/L at visits in 2006 and 2008. The RC long-term change pattern was defined as the RC trajectories from 2006 to 2010. Multivariate Cox proportion models were used to calculate hazard ratios (HRs) and their 95% confidence intervals (CIs). The cutoff values of RC were 0.52 mmol/L at the 2006 visit and 0.51 mmol/L at the 2008 visit. In the RC short-term change analysis, the participants in the high stable group had a 31% increased risk of CVD (HR 1.31; 95% CI 1.22-1.41), 73% increased risks of MI (HR 1.73; 95% CI 1.47-2.03), and 21% increased risks of stroke (HR 1.21; 95% CI 1.12-1.31) compared with participants in the low stable group. Three RC trajectories were employed in the RC long-term change analysis. Compared with the low stable group, the high stable group had a 1.34-fold risk of CVD (HR 1.34; 95% CI 1.17-1.53), 1.66-fold risk of MI (HR 1.66; 95% CI 1.24-2.21), and 1.22-fold risk of stroke (HR 1.22; 95% CI 1.05-1.42).

CONCLUSIONS

The stable high RC was associated with a higher risk of CVD. Maintaining optional RC levels could reduce the lifetime risk of CVD and prolong the year of life free from CVD.

Biomimetic Nanomotors for Deep Ischemia Penetration and Ferroptosis Inhibition in Neuroprotective Therapy of Ischemic Stroke

Nerve injury represents the primary reason of mortality and disability in ischemic stroke, but effective drug delivery to the region of cerebral ischemia and hypoxia poses a significant challenge in neuroprotective treatment. To address these clinical challenges, a biomimetic nanomotor, Pt@LF is designed, to facilitate deep delivery of neuroprotective agents and inhibit ferroptosis in ischemic stroke. Pt@LF traverses the blood-brain barrier (BBB) and penetrates into deep cerebral ischemic-hypoxic areas due to the active targeting capacity of apo-lactoferrin (Apo-LF) and the self-propelling motion properties of nanomotors. Subsequently, Pt@LF loosens thrombus and alleviates the "no reflow" phenomenon via mechanical thrombolysis. Thanks to the various enzyme-like abilities and multi-target ferroptosis inhibition capability, Pt@LF ameliorates the inflammatory microenvironment and rescues dying neurons. In conclusion, Pt@LF demonstrates efficiently deep penetration and neuroprotective effects in vitro and vivo. And this study provides a promising therapeutic platform for the treatment of ischemic stroke.

Cost evaluation of acute ischemic stroke in Latin America: a multicentric study

Background

Current literature highlights a gap in precise stroke cost data for Latin America. This study measures the real costs associated with acute ischemic stroke care in Latin America using Time-Driven Activity-Based Costing (TDABC). The findings aim to lay a solid foundation for adopting value-based healthcare (VBHC) strategies in the region.

Methods

The study is an observational, multicenter, international analysis of direct costs and outcomes for patients hospitalised with acute ischemic stroke from December 2021 to December 2022. Data from stroke centres in Argentina, Brazil, Chile, Colombia, Costa Rica, Mexico, Peru, and Uruguay were analysed. Costs were stratified by country. Factors such as favourable outcomes based on the modified Rankin Scale (mRS 0-2), clinical risk levels, and treatment interventions were considered for the analysis. Generalized Estimating Equation (GEE) models were utilised to assess the relationship of clinical variables with the total cost per patient.

Findings

A total of 1106 patients were included in the study. Among these patients, 74% received medical treatment alone, 18% received intravenous thrombolysis (IVT), 4% underwent mechanical thrombectomy (MT), and 3% received combined IVT plus MT. The mean cost per patient was I$ 12,203 (SD I$ 15,055), with 49% achieving a favourable functional outcome. Compared to medical treatment alone, MT incurred costs 3.1 times higher, with an incremental cost of I$ 20,418 per patient (p < 0.0001). Across all countries, costs increased according to patients' clinical risk and treatment options, with length of hospital stay emerging as the primary cost driver.

Interpretation

Our study highlights significant disparities in stroke costs across healthcare services in Latin America, influenced by variations in treatment accessibility, patient outcomes, and clinical risk profiles. These findings offer essential insights for shaping health policy decisions to enhance the long-term sustainability of stroke care in the region.

Funding

The project received funding from the World Stroke Organization and Boehringer Ingelheim (BI) IS 0135-0352.

Enhancing stroke-associated pneumonia prediction in ischemic stroke: An interpretable Bayesian network approach

Background

Stroke-associated pneumonia (SAP) is a major cause of mortality following ischemic stroke (IS). However, existing predictive models for SAP often lack transparency and interpretability, limiting their clinical utility. This study aims to develop an interpretable Bayesian network (BN) model for predicting SAP in IS patients, focusing on enhancing both predictive accuracy and clinical interpretability.

Methods

This retrospective study included patients diagnosed with IS and admitted to the Second Affiliated Hospital of Nanchang University between January and December 2019. Clinical data collected within 48 h of admission and SAP occurrences within 7 days were analyzed. Dimensionality reduction was performed using Least Absolute Shrinkage and Selection Operator regression, while data imbalances were addressed using synthetic minority oversampling technique. A BN model was trained using a hill-climbing algorithm and compared to logistic regression, decision trees, deep neural networks, and existing risk-scoring systems. Decision curve analysis was used to assess clinical usefulness.

Results

Of the 1252 patients, 165 (13.18%) patients had SAP within 7 days of admission. The BN model identified age, risk of pressure injury (PI), National Institutes of Health Stroke Scale (NIHSS) score, and C-reactive protein (CRP) as significant prognostic factors. The BN model achieved an area under the curve of 0.85(95% CI: 0.78-0.92) on the test set, outperforming other models and demonstrating a greater net benefit in clinical decision-making.

Conclusions

Age, risk of PI, NIHSS score, and CRP are significant predictors of SAP in IS patients. The interpretable BN model demonstrates superior predictive performance and interpretability, suggesting its potential as an effective and interpretable tool for clinical decision support in SAP risk assessment.

The Power of Advocacy in Global Neurosurgery

Advocacy, one of the five domains of global neurosurgery, represents a powerful avenue to influence public policy to expand access to safe, timely, and affordable neurosurgical care. In this manuscript, we characterize advocacy in global neurosurgery, describe specific neurosurgeon-led initiatives, and delineate how neurosurgeons can become involved in global neurosurgery advocacy efforts. Advocacy in global neurosurgery involves working together in organized neurosurgery with organizations focused on clinical provisions, training, and policy initiatives. Effective advocacy uses a data-driven approach with myriad facilitators, including collaboration and approach strategies for sharing information and a variety of contextual, ideological, and practical barriers. The main action fronts for global neurosurgery include identifying needs, broadening access, and assuring quality. Neurosurgery-led initiatives transforming public policy have occurred on regional and global scales and accelerated since 2019. Folate fortification of staple foods to prevent neural tube defects represents a recent and notably successful area of advocacy and remains in progress. Neurosurgeons who aspire to become involved in advocacy efforts must obtain competencies and skills distinct from, yet complementary to, the traditional neurosurgical training curriculum.

Self-advocacy positive perceptions and stage experiences in patients who had a stroke: a qualitative study in China

OBJECTIVES

This study explored the perceptions and experiences of self-advocacy among patients who had a stroke in China.

DESIGN

A descriptive phenomenological qualitative study was performed. Colaizzi's seven-step method was used to analyse the data.

SETTING

Two hospitals in Zhengzhou and Luoyang City, Henan Province, China.

PARTICIPANTS

19 patients who had a stroke were recruited and interviewed face-to-face between October 2023 and February 2024.

RESULTS

The findings revealed two categories: positive perceptions and stage experiences. Three themes of positive perceptions were extracted: 'accept the facts of illness while maintaining inner integrity' with three subthemes (disease cognition, firm faith and positive attitude); 'clarify one's own needs and strive for them' with four subthemes (self-care knowledge, effective communication, independent decision-making and power from relation); 'enhancing subjective initiative and maintaining healthy behaviours' with three subthemes (active participant in disease management, increased treatment compliance and increased initiative in rehabilitation exercises). Three stage experiences themes were motivation, response and stabilisation stage.

CONCLUSIONS

In this study, patients who had a stroke showed more positive perceptions of self-advocacy. Self-advocacy is a dynamic and progressive process of accepting their disease and actively participating in disease treatment. In addition, patients' health behaviours are improved and maintained when they engage in self-advocacy.

L, Heredia-Espín M, Arias-Intriago M, Izquierdo-Condoy JS. Pheochromocytoma: an updated scoping review from clinical presentation to management and treatment

Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors derived from chromaffin cells, with 80-85% originating in the adrenal medulla and 15-20% from extra-adrenal chromaffin tissues (paragangliomas). Approximately 30-40% of PPGLs have a hereditary component, making them one of the most genetically predisposed tumor types. Recent advances in genetic research have classified PPGLs into three molecular clusters: pseudohypoxia-related, kinase-signaling, and WNT-signaling pathway variants. Specifically, the detection of SDHB-related tumors indicates an increased risk of metastatic disease, which may impact decisions regarding functional imaging in patients with high suspicion of metastasis and influence targeted treatment strategies. Diagnosis of PPGLs primarily relies on biochemical testing, measuring catecholamines or their metabolites in plasma or urine. However, molecular testing, functional imaging, and targeted therapies have greatly enhanced diagnostic precision and management. Personalized treatment approaches based on genetic profiling are becoming integral to the clinical management of these tumors. In South American countries like Colombia, functional imaging techniques such as positron emission tomography/computed tomography (PET/CT) with tracers like 18F-DOPA, 18F-fluorodeoxyglucose (18F-FDG), and 68Ga-DOTA-conjugated somatostatin receptor-targeting peptides (68Ga-DOTA-SST) are used to guide follow-up and treatment strategies. Radionuclide therapy with lutetium-177 DOTATATE is employed for patients showing uptake in 68Ga-DOTA-SST PET/CT scans, while access to 131-MIBG therapy remains limited due to high costs and availability. Recent clinical trials have shown promise for systemic therapies such as sunitinib and cabozantinib, offering potential new options for patients with slow or moderate progression of PPGLs. These advancements underscore the potential of personalized and targeted therapies to improve outcomes in this challenging patient population.

Interleukin-6 and thyroid-stimulating hormone index predict plaque stability in carotid artery stenosis: analyses by lasso-logistic regression

Objective

To develop and validate a new prediction model based on the Lass-logistic regression with inflammatory serologic markers for the assessment of carotid plaque stability, providing clinicians with a reliable tool for risk stratification and decision-making in the management of carotid artery disease.

Methods

In this study, we retrospectively collected the data of the patients who underwent carotid endarterectomy (CEA) from 2019 to 2023 in Nanjing Drum Tower Hospital. Demographic characteristics, vascular risk factors, and the results of preoperative serum biochemistry were measured and collected. The risk factors for vulnerable carotid plaque were analyzed. A Lasso-logistic regression prediction model was developed and compared with traditional logistic regression models. The Akaike information criterion (AIC) and Bayesian information criterion (BIC) were used to evaluate the performance of three models.

Results

A total of 131 patients were collected in this study, including 66 (50.4%) in the vulnerable plaque group and 65 (49.6%) in the stable plaque group. The final Lasso-logistic regression model included 4 features:IL-6, TSH, TSHI, and TT4RI; AIC = 161.6376, BIC = 176.0136, both lower than the all-variable logistic regression model (AIC = 181.0881, BIC = 261.5936), and the BIC was smaller than the stepwise logistic regression model (AIC = 154.024, BIC = 179.9007). Finally, the prediction model was constructed based on the variables screened by the Lasso regression, and the model had favorable discrimination and calibration.

Conclusions

The noninvasive prediction model based on IL-6 and TSHI is a quantitative tool for predicting vulnerable carotid plaques. It has high diagnostic efficacy and is worth popularizing and applying.

Research on stroke patients' perception of recurrence risk: A scoping review protocol

INTRODUCTION

Stroke, a major global cause of death and disability, has a high recurrence rate that significantly affects patients' physical, psychological, and economic well-being. Despite the importance of health risk perception in preventive measures, most stroke patients struggle to accurately assess the risk of recurrence. Current research on stroke recurrence risk perception is still exploratory, with a lack of systematic understanding of the influencing factors. This study aims to comprehensively analyze the current state of stroke recurrence research and the factors that influenced recurrence and assess the effectiveness and limitations of various assessment tools to guide future research and intervention strategies.

METHODS AND ANALYSIS

This scoping review will follow Arksey and O'Malley's methodological framework as well as the updated scoping review methodology guidance by the Joanna Briggs Institute (JBI). Review results will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The search strategy will be developed via keywords, such as stroke, recurrence risk perception, and influencing factors. We will systematically search seven English databases, PubMed, CINAHL, Web of Science, Embase, Cochrane Library, PsycInfo, and MEDLINE, as well as four Chinese databases, CNKI, Wanfang, VIP, and the China National Knowledge Infrastructure for Biomedical Literature. Studies published in both English and Chinese will be included. Data will be extracted via a standardized form and summarized through quantitative (frequency) and qualitative analyses (narrative synthesis). Furthermore, the findings will be reported.

ETHICS AND DISSEMINATION

Since this review involves collecting data from existing literature and does not involve human participants, ethical approval is not required. Research findings will be disseminated through conference presentations and publications in peer-reviewed journals.

REGISTRATION DETAILS

This protocol has been registered on the Open Science Framework (OSF). Relevant materials and potential following updates are available at https://osf.io/7kq5t.

Buyang huanwu decoction improves synaptic plasticity of ischemic stroke by regulating the cAMP/PKA/CREB pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Ischemic stroke is an acute central nervous system disease that poses a threat to human health. It induces a series of severe pathological mechanisms, ultimately leading to neuronal cell death in the brain due to local ischemia and hypoxia. Buyang Huanwu decoction (BYHWD), as a representative formula for treating ischemic stroke, has shown good therapeutic effects in stroke patients.

AIM OF THE STUDY

This study aimed to explore the mechanism of BYHWD in promoting neural remodeling after ischemic stroke from the perspective of neuronal synaptic plasticity, based on the cAMP/PKA/CREB signaling pathway.

MATERIALS AND METHODS

A modified suture technique was employed to establish a rat model of MCAO. The rats were divided into sham, model, and BYHWD (20 g/kg) groups. After the corresponding intervention, rat brains from each group were collected. TMT quantitative proteomics technology was employed for the research. Following proteomics studies, we investigated the mechanism of BYHWD in the intervention of ischemic stroke through animal experiments and cell experiments. The experimental animals were divided into sham, model, and BYHWD (5 g/kg, 10 g/kg, and 20 g/kg) groups. Infarct volume and severity of brain injury were measured by TTC staining. HE staining was utilized to evaluate alterations in tissue morphology. The Golgi staining was used to observe changes in cell body, dendrites, and dendritic spines. Transmission electron microscopy was used to observe the ultrastructure of synapses in the cortex and hippocampus. TUNEL staining was conducted to identify apoptotic neurons. Meanwhile, a stable and reliable (OGD/R) SH-SY5Y cell model was established. The effect of BYHWD-containing serum on SH-SY5Y cell viability was measured by CCK-8 kit. The apoptosis situation of SH-SY5Y cells was determined by Annexin V-FITC/PI. Immunofluorescence was employed to measure the fluorescence intensity of synaptic-related factors Syt1, Psd95, and Syn1. Synaptic plasticity pathways were assessed by using RT-qPCR and Western blot to determine the expression levels of cAMP, Psd95, Prkacb, Creb1/p-Creb1, BDNF, Shank2, Syn1, Syt1, Bcl-2, Bcl-2/Bax mRNA and proteins.

RESULTS

After treatment with BYHWD, notable alterations were detected in the signaling pathways linked to synaptic plasticity and the cAMP signaling pathway-related targets among the intervention targets. This trend of change was also reflected in other bioinformatics analyses, indicating the important role of synaptic plasticity changes before and after modeling and drug intervention. The results of vivo and vitro experiments showed that BYHWD improved local pathological changes, and reduced cerebral infarct volume, and neurological function scores in MCAO rats. It increased dendritic spine density, improved synaptic structural plasticity, and had a certain neuroprotective effect. BYHWD increased the postsynaptic membrane thickness, synaptic interface curvature, and synaptic quantity. 10% BYHWD-containing serum was determined as the optimal concentration for treatment. 10% BYHWD-containing serum significantly reduced the overall apoptotic rate of (OGD/R) SH-SY5Y cells. Immunofluorescence experiments demonstrated that 10% BYHWD-containing serum could improve synaptic plasticity and increase the relative expression levels of synaptic-related proteins Syt1, Psd95, and Syn1. BYHWD and decoction-containing serum upregulated the mRNA and protein expression levels in (OGD/R) SH-SY5Y cells and MCAO rats, suggesting its ability to improve damaged neuronal synaptic plasticity and enhance transmission efficiency, which might be achieved through the regulation of the cAMP/PKA/CREB pathway.

CONCLUSIONS

This study may provide a basis for clinical medication by elucidating the underlying experimental evidence for the promotion of neural plasticity after ischemic stroke by BYHWD.

Mediation Analysis of Serum Fibroblast Growth Factor 20 and Poor Prognosis After Ischemic Stroke

BACKGROUND

We aimed to examine the relationship between serum FGF20 (fibroblast growth factor 20) levels and stroke prognosis in a multicenter cohort study.

METHODS AND RESULTS

Patients with ischemic stroke/transient ischemic attack were prospectively recruited from 5 participating centers and followed up at 3 months and 1 year. FGF20 levels were measured using the ELISA method. The primary outcome was poor stroke functional outcome (modified Rankin Scale score of 3-6), and secondary outcomes included death and composite vascular events. Multivariable logistic regression analysis or Cox proportional hazards regression analysis was employed to estimate the relationship between FGF20 and study outcomes. Mediation analysis was conducted to examine the mediating effects of traditional risk factors on the association between FGF20 and stroke outcomes. A total of 1011 patients with ischemic stroke were included in the study. After adjusting for potential confounding factors, an elevated serum FGF20 level was associated with a reduced risk of the poor outcome and death. Multivariable adjusted spline regression analysis demonstrated a linear correlation between serum FGF20 levels and the stroke outcomes. The incorporation of FGF20 alongside conventional risk factors marginally enhanced the reclassification of adverse outcomes. Renal function and white blood cell count partially mediated the relationship between FGF20 and the prognosis of ischemic stroke.

CONCLUSIONS

Elevated FGF20 level is associated with decreased risks of adverse outcomes after ischemic stroke, which was partially mediated by renal function and white blood cells with a modest amount, indicating that serum FGF20 might serve as a promising biomarker for predicting stroke prognosis.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2100051104.

Projections of the Stroke Burden at the Global, Regional, and National Levels up to 2050 Based on the Global Burden of Disease Study 2021

BACKGROUND

Stroke is a pressing public health issue worldwide. This study aimed to forecast the future temporal trends and distribution characteristics of the global stroke burden.

METHODS AND RESULTS

Global data on stroke incidence, prevalence, deaths, and disability-adjusted life years between 1990 and 2021 were obtained from the GBD (Global Burden of Disease) Study 2021. The temporal trends of stroke burden were estimated using various regression models. Gross domestic product per capita was adopted as a predictor in the model to consider the impact of economic development on stroke burden. Projections of stroke burden up to 2050 were generated using the optimal model selected based on the Akaike information criterion, encompassing global, World Bank income levels, national levels, and sex-age groups. In 2050, we projected 21.43 million stroke cases, 159.31 million survivors, 12.05 million deaths, and 224.86 million disability-adjusted life years due to stroke globally. From 2021 to 2050, there was a declining trend in the global age-adjusted stroke rates, with -7% in incidence, -4% in prevalence, -28% in deaths, and -28% in disability-adjusted life years. Upper-middle-income countries were projected to have the most severe stroke burden, followed by lower-middle-income countries, low-income countries, and high-income countries. The stroke burden in over half of the 204 countries and territories was expected to be alleviated from 2022 to 2050. Men and older women worldwide bear higher burden.

CONCLUSIONS

Stroke remains a serious global health challenge, especially in low-income and middle-income countries. Targeted implementation of prevention and interventions is imperative across diverse demographic groups.

The nitration of SIRT6 aggravates neuronal damage during cerebral ischemia-reperfusion in rat

Ischemic stroke is a major cause of death and disability. The activation of neuronal nitric oxide synthase (nNOS) and the resulting production of nitric oxide (NO) via NMDA receptor-mediated calcium influx play an exacerbating role in cerebral ischemia reperfusion injury. The NO rapidly reacts with superoxide (O2-) to form peroxynitrite (ONOO-), a toxic molecule may modify proteins through tyrosine residue nitration, ultimately worsening neuronal damage. SIRT6 has been proven to be crucial in regulating cell proliferation, death, and aging in various pathological settings. We have previous reported that human SIRT6 tyrosine nitration decreased its intrinsic catalytic activity in vitro. However, the exact role of SIRT6 function in the process of cerebral ischemia reperfusion injury is not yet fully elucidated. Herein, we demonstrated that an increase in the nitration of SIRT6 led to reduce its enzymatic activity and aggravated hippocampal neuronal damage in a rat model of four-artery cerebral ischemia reperfusion. In addition, reducing SIRT6 nitration resulted in increase the activity of SIRT6, alleviating hippocampal neuronal damage. Moreover, SIRT6 nitration affected its downstream molecule activity such as PARP1 and GCN5, promoting the process of neuronal ischemic injury in rat hippocampus. Additionally, treatment with NMDA receptor antagonist MK801, or nNOS inhibitor 7-NI, and resveratrol (an antioxidant) diminished SIRT6 nitration and the catalytic activity of downstream molecules like PARP1 and GCN5, thereby reducing neuronal damage. Finally, in the biochemical regulation of SIRT6 activity, tyrosine 257 was essential for its activity and susceptibility to nitration. Replacing tyrosine 257 with phenylalanine in rat SIRT6 attenuated the death of SH-SY5Y neurocytes under oxygen-glucose deprivation (OGD) conditions. These results may offer further understanding of SIRT6 function in the pathogenesis of cerebral ischemic diseases.

Baseline characteristics, reperfusion treatment secondary prevention and outcome after acute ischemic stroke in three different socioeconomic environments in Europe

INTRODUCTION

The differences in vascular risk factors' and stroke burden across Europe are notable, however there is limited understanding of the influence of socioeconomic environment on the quality of secondary prevention and outcome after acute ischemic stroke.

PATIENTS AND METHODS

In this observational multicenter cohort study, we analyzed baseline characteristics, reperfusion treatment, outcome and secondary prevention in patients with acute ischemic stroke from three tertiary-care teaching hospitals with similar service population size in different socioeconomic environments: Bern/CH/n = 293 (high-income), Gdansk/PL/n = 140 (high-income), and Lutsk/UA/n = 188 (lower-middle-income).

RESULTS

We analyzed 621 patients (43.2% women, median age = 71.4 years), admitted between 07 and 12/2019. Significant differences were observed in median BMI (CH = 26/PL = 27.7/UA = 27.8), stroke severity [(median NIHSS CH = 4(0-40)/PL = 11(0-33)/UA = 7(1-30)], initial neuroimaging (CT:CH = 21.6%/PL = 50.7%/UA = 71.3%), conservative treatment (CH = 34.1%/PL = 38.6%/UA = 95.2%) (each p < 0.001), in arterial hypertension (CH = 63.8%/PL = 72.6%/UA = 87.2%), atrial fibrillation (CH = 28.3%/PL = 41.4%/UA = 39.4%), hyperlipidemia (CH = 84.9%/PL = 76.4%/UA = 17%) (each p < 0.001) and active smoking (CH = 32.2%/PL = 27.3%/UA = 10.2%) (p < 0.007). Three-months favorable outcome (mRS = 0-2) was seen in CH = 63.1%/PL = 50%/UA = 59% (unadjusted-p = 0.01/adjusted-p CH-PL/CH-UA = 0.601/0.981), excellent outcome (mRS = 0-1) in CH = 48.5%/PL = 32.1%/UA = 27% (unadjusted-p < 0.001/adjusted-p CH-PL/CH-UA = 0.201/0.08 and adjusted-OR CH-UA = 2.09). Three-months mortality was similar between groups (CH = 17.2%/PL = 15.7%/UA = 4.8%) (unadjusted-p = 0.71/adjusted-p CH-PL/CH-UA = 0.087/0.24). Three-months recurrent stroke/TIA occurred in CH = 3.1%/PL = 10.7%/UA = 3.1%, adjusted-p/OR CH-PL = 0.04/0.32). Three-months follow-up medication intake rates were the same for antihypertensives. Statin/OAC intake was lowest in UA = 67.1%/25.5% (CH = 87.3%/39.2%/unadjusted-p < 0.001/adjusted-p CH-UA = 0.02/0.012/adjusted-OR CH-UA = 2.33/2.18). Oral intake of antidiabetics was lowest in CH = 10.8% (PL = 15.7%/UA = 16.1%/unadjusted-p = 0.245/adjusted-p CH-PL/CH-UA = 0.061/0.002/adjusted-OR CH-UA = 0.25). Smoking rates decreased in all groups during follow-up.

DISCUSSION AND CONCLUSION

Substantial differences in presentation, treatment and secondary prevention measures, are linked to a twofold difference in adjusted 3-months excellent outcome between Switzerland and Ukraine. This underscores the importance of socioeconomic factors that influence stroke outcomes, emphasizing the necessity for targeted interventions to address disparities in treatment and secondary prevention strategies.

Gamified Practice Improves Paretic Arm Motor Behavior in Individuals With Stroke

BACKGROUND

Stroke is a heterogeneous condition, making choice of treatment, and determination of how to structure rehabilitation outcomes difficult. Individualized goal-directed and repetitive physical practice is an important determinant of motor learning. Yet, many investigations of motor learning after stroke deliver task practice without consideration of individual capability of the learner.

OBJECTIVE

We developed a gamified arm rehabilitation task for people with stroke that is personalized to individual capacity for paretic arm movement, provides a high dose of practice, progresses through increasingly difficulty levels that are dependent on the performance of the individual, and is practiced in an engaging environment. The objectives of the current study were to determine if 10 days of gamified, object intercept training using the paretic arm would improve arm movement speed and clinical outcome measures of impairment or function.

METHODS

Individuals with chronic stroke and age-matched controls engaged in 10 days of gamified, skilled motor practice of a semi-immersive virtual reality-based intercept and release task. The paretic arm was assessed using the Fugl-Meyer Assessment (motor impairment) and Wolf Motor Function Test (motor function) before and after training.

RESULTS

Both groups showed faster arm movement speed with practice; individuals with stroke demonstrated reduced paretic arm motor impairment and increased function after the intervention. Age and sex (for both groups), and time post-stroke were not related to changes in movement speed.

CONCLUSIONS

Findings indicate that gamified motor training positively affects paretic arm motor behavior in individuals with mild to severe chronic stroke.

Prehospital stroke diagnostics using three different simulation methods: A pragmatic pilot study

INTRODUCTION

The optimal pathway for ultra-early diagnostics and treatment in patients with acute stroke remains uncertain. The aim of this study was to investigate how three different methods of simulated, rural prehospital computed tomography (CT) affected the time to prehospital treatment decision in acute stroke.

MATERIALS AND METHODS

In this pragmatic, simulation, pilot study of prehospital CT we investigated a conventional ambulance with transport to a standard care rural stationary CT machine managed by paramedics, a Mobile Stroke Unit (MSU), and a helicopter with a simulated CT machine. Each modality completed 20 real-life dispatches combined with simulation of predetermined animated patient cases with acute stroke symptoms and CT images. The primary endpoint of the study was the time from alarm to treatment decision.

RESULTS

Median time from alarm to the treatment decision differed significantly between the three groups (p = 0.0005), with 38 min for rural CT, 33 min for the MSU, and 30 min for the helicopter. There was no difference in time when comparing rural CT with MSU, nor when comparing the MSU with the helicopter. There was a difference in time to treatment decision between the rural CT and the helicopter (p < 0.0001). The helicopter had significantly lower estimated time from treatment decision to hospital (p = 0.001).

DISSCUSSION/CONCLUSION

Prehospital CT can be organized in several ways depending on geography, resources and need. Further research on paramedic run rural CT, MSU in rural areas, and helicopter CT is needed to find the optimal strategy.

Multi-omics combined to investigate potential druggable therapeutic targets for stroke: A systematic Mendelian randomization study and transcriptome verification

OBJECTIVE

Stroke is a highly prevalent and disabling disease whose disease mechanisms are not fully understood. The discovery of disease-associated proteins with genetic evidence of pathogenicity provides an opportunity to identify new therapeutic targets.

METHOD

We examined the observed and causal associations of thousands of plasma and inflammatory proteins that were measured using affinity-based proteomic assays. First, we pooled >3000 relevant proteins using a fixed-effects meta-analysis of 2 population-based studies involving 48,383 participants, then investigated the causal effects of stroke and its subtype-associated proteins by forward Mendelian randomization using cis-protein quantitative locus genetic tools identified from genome-wide association studies of these >48,000 individuals. To improve the accuracy of causal estimation, we implemented a systematic Mendelian randomization model that accounts for cascading imbalances between instruments and tested the robustness of causal estimation through multi-method analyses. To further validate the hypothesis that ginsenoside Rg1 monomer acts on the five protein targets screened for drug-targeted regulation, we conducted a comparative analysis of the mRNA (gene) expression levels of a limited number of genes in the brain tissues of different groups of SD rats. The druggability of the candidate proteins was investigated and the mechanism of action and potential targeting side effects were explored by Phenome-wide MR.

RESULTS

Six circulating proteins were identified to have a significant genetic association with stroke (PFDR < 0.05). For example, in patients with cardioembolic stroke, higher genetically predicted APRT was associated with a lower risk of cardioembolic stroke (ORivw [95 % CI] = 0.641 [0.517, 0.795]; P = 5.25 × 10-5, ORSMR [95 % CI] = 0.572, [0.397, 0.825], PSMR = 0.003). Mediation analyses suggested that atrial fibrillation, angina pectoris, and heart failure may mediate the association of CD40L, LIFR, and UPA with stroke. Molecular docking revealed promising interactions between the identified proteins and glycosides. Transcriptomic sequencing in animal models indicated that ginsenoside Rg1 may act through APRT, IL15RA, and VSIR pathways, with APRT showing significant variability in mRNA sequencing expression. Phenome-wide MR of the six target proteins showed an overwhelming predominance of PFDR > 0.05, indicating less toxicity.

CONCLUSIONS

The present study provides genetic evidence to support the potential efficacy of targeting the three druggable protein targets for the treatment of stroke. This is achieved by triangulating population genomic and proteomic data. Furthermore, the study validates the pathway mechanisms by which APRT, IL15RA, and VSIR dock ginsenoside Rg1 in animal models. This will help to prioritize stroke drug development.

The therapeutic effects of salvianolic acids on ischemic stroke: From molecular mechanisms to clinical applications

Ischemic stroke (IS), primarily caused by cerebrovascular occlusion, poses a significant public health challenge with limited effective therapeutic options. Evidence suggests that salvianolic acids (SAs), mainly from Salvia miltiorrhiza Bunge, have been formulated into injections and are widely used in clinical treatments for cardiovascular and cerebrovascular diseases, including stroke. The pharmacological properties of SAs include reducing neuroinflammation, alleviating oxidative stress injury, inhibiting cellular apoptosis, preserving endothelial function, maintaining blood-brain barrier integrity, and promoting angiogenesis. Salvianolic acids for injection (SAFI) serve as a safe and effective treatment option for cardiovascular and cerebrovascular conditions by influencing various signaling pathways and molecular targets associated with these diseases. In this review, we first discuss the pathogenesis of IS, then summarize the classification of SAs, elaborate detailed molecular mechanisms of their efficacy, and the related clinical applications of SAFI. We also emphasize the recent pharmacological advancements and therapeutic possibilities of this promising drug preparation derived from herbs for cerebrovascular conditions.

C-reactive protein-triglyceride glucose index predicts stroke incidence in a hypertensive population: a national cohort study

BACKGROUND

Both the triglyceride-glucose (TyG) index, a predictor of insulin resistance (IR), and inflammation are risk factors for stroke in hypertensive patients. However, only a handful of studies have coupled the TyG index and inflammation indices to predict stroke risk in hypertensive patients. The C-reactive protein-triglyceride-glucose index (CTI) is a novel marker that comprehensively assesses the severity of IR and inflammation. The present study explored the association between CTI and the risk of stroke in patients with hypertension.

METHODS

A total of 3,834 hypertensive patients without a history of stroke at baseline were recruited from the China Health and Retirement Longitudinal Study (CHARLS). Multivariate Cox regression and restricted cubic spline (RCS) analyses were employed to assess the relationship between CTI and stroke risk in hypertensive patients. Furthermore, the Boruta algorithm was applied to evaluate the importance of CTI and construct prediction models to forecast the incidence of stroke in the study cohort.

RESULTS

After 7 years of follow-up, the incidence of stroke in hypertensive patients was 9.6% (368 cases). Multivariate Cox regression analysis revealed a 21% increase in stroke risk with an increase in each CTI unit (hazard ratio (HR) = 1.21, 95% confidence interval (CI) = 1.08-1.37). The top quartile group was 66% more likely to have a stroke than the bottom quartile group (HR = 1.66, 95% CI = 1.23-2.25). RCS analysis confirmed a linear relationship between CTI and stroke risk. The Boruta algorithm validated CTI as a crucial indicator of stroke risk. The Support Vector Machine (SVM) survival model exhibited the best predictive performance for stroke risk in hypertensive patients, with an area under the curve (AUC) of 0.956.

CONCLUSIONS

An increase in CTI levels is associated with a higher risk of stroke in hypertensive patients. This study suggests that CTI may emerge as a unique predictive marker for stroke risk.

The Interrelation of Blood Urea Nitrogen-to-Albumin Ratio with Three-Month Clinical Outcomes in Acute Ischemic Stroke Cases: A Secondary Analytical Exploration Derived from a Prospective Cohort Study

Objective

This study targeted elucidating the intricate correlation of the blood urea nitrogen (BUN)-to-albumin (BUN/Alb) ratio with adverse outcomes (AOs) at 3-month in acute ischemic stroke (AIS) cases within a Korean cohort.

Methods

The cohort involved a comprehensive dataset of 1850 AIS cases from a South Korean hospital, spanning from January 2010 to December 2016. To discern the linear relationship of the BUN/Alb ratio with AOs in AIS cases, utilization of a binary logistic regression model (BLRM) was implemented. Additionally, it was attempted to utilize sophisticated statistical techniques, such as generalized additive models (GAMs) and smooth curve fitting methods, to unravel the nonlinear association of the BUN/Alb ratio with AOs in such patients.

Results

The incidence of AOs was determined to be 28.49%, with the median BUN/Alb ratio being 3.85. After adjusting for a number of covariates, the BLRM disclosed that the linear association of BUN/Alb ratio with the risk of AOs particularly in AIS cases did not achieve statistical significance. However, a noticeable nonlinear relationship emerged, with an inflection point identified at 2.86. To the left of this inflection point, the relationship is not statistically significant. On the right side of the inflection point, there was a remarkable 9.47% rise in the risk of AOs (odds ratio (OR) = 1.09, 95% confidence interval (CI): 1.00, 1.19, P = 0.04).

Conclusion

The outcomes illuminate the complex and nonlinear relationship of the BUN/Alb ratio with 3-month AOs in AIS cases. This study established a robust groundwork for the future research, underscoring the potential clinical utility of monitoring the BUN/Alb ratio to enhance the prognostic assessment and management of AIS cases.

Vanishing bile duct syndrome: a sequela of temozolomide and levetiracetam-induced cholestatic liver injury

Temozolomide (TMZ)-levetiracetam (LEV) combination therapy in glioblastoma management is gradually becoming a mainstay treatment given its superior effect compared with TMZ monotherapy. While there have been previous cases of hepatotoxicity, there are no prior reports of vanishing bile duct syndrome (VBDS) associated with TMZ-LEV combination use. This case report details a male in his 50s who had recently completed TMZ and LEV for right frontal lobe glioblastoma. He presented 3 days later with painless jaundice, dark urine and pale stools. Laboratory evaluation was remarkable for marked hyperbilirubinemia and transaminitis. Extensive work up for hepatic and extra-hepatic causes of jaundice was of no yield, thus necessitating a liver biopsy. Liver pathology showed a non-specific histomorphology pattern suggesting drug-induced liver injury and cholestasis with severe ductopenia. VBDS due to TMZ and LEV was diagnosed. The patient followed with the gastroenterology clinic over 6 months for persistently elevated liver function tests before suffering a fatal cardiac arrest.

Analysis of Stroke Burden in China from 1990 to 2021 and Projections for the Next Decade

INTRODUCTION

This study aimed to describe the temporal trends of stroke burden in different age and sex groups in China from 1990 to 2021, including incidence, prevalence, mortality, and disability-adjusted life years (DALYs), and to compare these data with global figures.

METHODS

Using data from the Global Burden of Disease database from 1990 to 2021, we analyzed changes in stroke burden in China and globally. The average annual percentage change (AAPC) was calculated using Joinpoint software to reflect trends. Stroke burden differences across various age groups and sexes were compared, and the ARIMA model was utilized for future projections.

RESULTS

Between 1990 and 2021, the age-standardized incidence rate (ASIR) of stroke in China decreased from 226.938 to 204.753 per 100,000, while the global ASIR decreased from 180.973 to 141.553 per 100,000. The age-standardized prevalence rate (ASPR) in China increased from 1,167.425 to 1,301.42 per 100,000, whereas the global ASPR decreased from 1,201.111 to 1,099.31 per 100,000. The age-standardized mortality rate (ASMR) in China fell from 242.18 to 138.029 per 100,000, while the global ASMR decreased from 144.313 to 87.454 per 100,000. China's age-standardized DALY rate (ASDR) declined from 4,834.791 to 2,648.025 per 100,000, whereas the global ASDR decreased from 3,078.952 to 1,886.196 per 100,000. The AAPCs for ASIR, ASPR, ASMR, and ASDR in China were -0.370%, 0.326%, -1.793%, and -1.933%, respectively, compared to -0.291%, -0.807%, -1.601%, and -1.570% globally from 1990 to 2021. Age and sex significantly influenced the stroke burden, with higher incidence and mortality rates in males than in females. Projections for the next decade indicate that stroke incidence in China will remain stable, with an expected rise in ASPR, and declines in ASMR and ASDR. Globally, ASIR is expected to decline, while ASPR will rise, and ASMR and ASDR will continue to decrease.

CONCLUSION

From 1990 to 2021, the incidence, mortality, and DALYs of stroke in China have decreased, while the prevalence has increased. Stroke burden is age-related, with higher prevalence in older adults and higher mortality in the elderly. Males are more susceptible to stroke and have a higher risk of death. Over the next decade, stroke prevalence in China is expected to rise, posing challenges due to population aging, even as mortality and disability rates decline. Sustained public health efforts will be necessary.

Building resilient surgical systems that can withstand external shocks

When surgical systems fail, there is the major collateral impact on patients, society and economies. While short-term impact on patient outcomes during periods of high system stress is easy to measure, the long-term repercussions of global crises are harder to quantify and require modelling studies with inherent uncertainty. When external stressors such as high-threat infectious disease, forced migration or climate-change-related events occur, there is a resulting surge in healthcare demand. This, directly and indirectly, affects perioperative pathways, increasing pressure on emergency, critical and operative care areas. While different stressors have different effects on healthcare systems, they share the common feature of exposing the weakest areas, at which point care pathways breakdown. Surgery has been identified as a highly vulnerable area for early failure. Despite efforts by the WHO to improve preparedness in the wake of the SARS-CoV-2 pandemic, measurement of healthcare investment and surgical preparedness metrics suggests that surgical care is not yet being prioritised by policy-makers. Investment in the 'response' phase of health system recovery without investment in the 'readiness' phase will not mitigate long-term health effects for patients as new stressors arise. This analysis aims to explore how surgical preparedness can be measured, identify emerging threats and explore their potential impact on surgical services. Finally, it aims to highlight the role of high-quality research in developing resilient surgical systems.

Health systems strengthening through surgical and perioperative care pathways: a changing paradigm

Global health has traditionally focused on the primary health development with disease-specific focus such as HIV, malaria and non-communicable diseases (NCDs). As such, surgery has traditionally been neglected in global health as investment in them is often expensive, relative to these other priorities. Therefore, efforts to improve surgical care have remained on the periphery of initiatives in health system strengthening. However, today, many would argue that global health should focus on universal health coverage with primary health and surgery and perioperative care integrated as a part of this. In this article, we discuss the past developments and future-looking solutions on how surgery can contribute to the delivery of effective and equitable healthcare across the world. These include bidirectional integration of surgical and chronic disease pathways and better understanding financing initiatives. Specifically, we focus on access to safe elective and emergency surgery for NCDs and an integrated approach towards the rising multimorbidity from chronic disease in the population. Underpinning these, data-driven solutions from high-quality research from clinical trials and cohort studies through established surgical research networks are needed. Although challenges will remain around financing, we propose that development of surgical services will strengthen and improve performance of whole health systems and contribute to improvement in population health across the world.

The RACE Scale for Large Vessel Stroke Diversion to a Comprehensive Stroke Center by Helicopter Air Ambulance: A Retrospective Cohort Study

OBJECTIVE

Acute ischemic stroke caused by large vessel occlusion (LVO) occurs frequently and benefits from endovascular therapies available at comprehensive stroke centers (CSCs). Prehospital stroke severity tools have been devised to detect LVO. The goal of this study was to assess the value of the Rapid Arterial Occlusion Evaluation (RACE) score in helicopter air ambulance (HAA) activation.

METHODS

A retrospective assessment of RACE scales > 4 performed by prehospital providers was used in order to activate HAAs. Descriptive statistics were obtained for patients transported, with the primary goal of determining the positive predictive values of the RACE scale for LVO occlusions. The secondary outcomes assessed if patients without LVO had other conditions requiring a CSC.

RESULTS

Data from 136 subjects were analyzed; 53 (39.0%) were true LVO cases as defined by computed tomographic imaging, computed tomography angiographic imaging, or magnetic resonance imaging. Mechanical thrombectomy occurred in 30 cases (22.1%), with 63 (46.4%) requiring a neurologic intervention. There were 83 (61%) false positives (no LVO on imaging). Of these false positives, 28 (20.6%) were non-LVO strokes, 22 (16.1%) were intracranial hemorrhages, and 8 (5.9%) had neurologic conditions requiring CSC care.

CONCLUSION

A RACE scale > 4 is an effective triage tool that delivers potential thrombectomy candidates to CSCs. When there is a false positive, the majority of patients require CSC care and benefit from direct transport from the scene.

Neuroprotective effects of Withania somnifera on ischemic stroke are mediated via anti-inflammatory response and modulation of neurotransmitter levels

The present study was designed to evaluate the beneficial effects of hydroalcoholic root extract of Withania somnifera (WS) on ischemia-reperfusion injury (IRI) induced by Middle Cerebral Artery Occlusion (MCAO). MCAO animals showed increase in IL-6, TNF-α and MCP-1 levels in terms of mRNA and protein levels. Concomitantly, mRNA and protein levels for astrocyte and microglial activation markers; GFAP and IBA-1, were increased in MCAO animals. COX-2 and NF-kβ protein levels were also increased in the brains of MCAO animals. The levels of neurotransmitters; glutamate and GABA were increased in the MCAO animals. On the contrary, levels of catecholamines; dopamine, norepinephrine and serotonin were reduced in the MCAO animals. Additionally, MCAO animals showed reduced locomotor activity. However, pre-supplementation with WS hydro-alcoholic root extract at a dose of 300 mg/kg, body weight to MCAO animals reduced the expression of IL-6, TNF-α and MCP-1. In addition, WS also reduced the number of GFAP and Iba-1 positive cells in comparison to MCAO animals. WS pre-supplementation was also observed to inhibit MCAO induced increase in COX-2; NF-kβ proteins and reduce the glutamate levels. The levels of GABA, dopamine, norepinephrine and serotonin were increased in WS pre-supplemented MCAO animals. WS pre-supplementation also prevented motor deficits in the MCAO animals. Taken together, these findings suggest that WS is effective in attenuating IRI induced neuroinflammation, neurochemical alterations and motor deficits in MCAO model of ischemic stroke thereby suggesting its ameliorative role in ischemia-reperfusion injury.

Assessment of large-scale imaging practices in patients with acute brain hemorrhage in French emergency departments: Emergency imaging practices in hemorrhagic stroke

OBJECTIVE

Intracerebral hemorrhage (ICH) is a life-threatening condition, where imaging plays a crucial role but remains poorly standardized. Our main objective was to analyze the imaging protocols used during the acute phase of ICH and ascertain the proportion of patients diagnosed with secondary hemorrhage.

PATIENTS AND METHODS

A multicenter retrospective observational study was conducted across over 100 French hospitals affiliated with a national tele-imaging network dedicated to emergency imaging. Among patients managed in the "Stroke Alert" pathway for suspected acute stroke from March 2021 to April 2023, those with ICH diagnosed within 24 h of symptoms onset were identified. Their imaging reports were reviewed to identify the imaging modality used and protocols performed and investigate whether a secondary cause was identified.

RESULTS

Of the 18,356 patients included in the "Stroke Alert" pathway, 662 cerebral hemorrhages were identified (3.6 %). Computed tomography (CT) was the most widely used imaging modality in the acute phase (71.8 % of examinations). Vascular imaging was performed in 78 % of patients with cerebral hemorrhage, most often CT angiography or TOF magnetic resonance angiography. A secondary cause was identified in 8.2 % (54/662) of cerebral hemorrhages, including vascular imaging in the vast majority of cases (92.6 %).

CONCLUSION

Optimization and standardization of imaging protocols in the acute phase of ICH is essential to improve the detection of its secondary causes, particularly vascular, requiring urgent treatment. Vascular imaging improves their early detection.

Mechanisms and causes of death after abdominal surgery in low-income and middle-income countries: a secondary analysis of the FALCON trial

BACKGROUND

Death after surgery is devasting for patients, families, and communities, but remains common in low-income and middle-income countries (LMICs). We aimed to use high-quality data from an existing global randomised trial to describe the causes and mechanisms of postoperative mortality in LMICs. To do so, we developed a novel framework, learning from both existing classification systems and emerging insights during data analysis.

METHODS

This study was a preplanned secondary analysis of the FALCON trial in 54 hospitals across seven LMICs (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). FALCON was a pragmatic, 2 × 2 factorial, randomised controlled trial that compared the effectiveness of two types of interventions for skin preparation (10% aqueous povidone-iodine vs 2% alcoholic chlorhexidine) and sutures (triclosan-coated vs uncoated). Patients who did not have surgery or were lost to follow-up were excluded (n=231). The primary outcomes of the present analysis were the mechanism and cause of death within 30-days of surgery, determined using a modified verbal autopsy strategy from serious adverse event reports. Factors associated with mortality were explored in a mixed-effects Cox proportional hazards model. The FALCON trial is registered with ClinicalTrials.gov, NCT03700749.

FINDINGS

This preplanned secondary analysis of the FALCON trial included 5558 patients who underwent abdominal surgery, of whom 4248 (76·4%) patients underwent surgery in tertiary, referral centres and 1310 (23·6%) underwent surgery in primary referral (ie, district or rural) hospitals. 3704 (66·7%) of 5558 surgeries were emergent. 306 (5·5%) of 5558 patients died within 30 days of surgery. 226 (74%) of 306 deaths were due to circulatory system failure, which included 173 (57%) deaths from sepsis and 29 (9%) deaths from hypovolaemic shock including bleeding. 47 (15%) deaths were due to respiratory failure. 60 (20%) of 306 patients died without a clear cause of death: 45 (15%) patients died with sepsis of unknown origin and 15 (5%) patients died of an unknown cause. 46 (15%) of 306 patients died within 24 h, 111 (36%) between 24 h and 72 h, 57 (19%) between >72 h and 168 h, and 92 (30%) more than 1 week after surgery. 248 (81%) of 306 patients died in hospital and 58 (19%) patients died out of hospital. The adjusted Cox regression model identified age (hazard ratio 1·01, 95% CI 1·01-1·02; p<0·0001), ASA grade III-V (4·93, 3·45-7·03; p<0·0001), presence of diabetes (1·47, 1·04-2·41; p=0·033), being an ex-smoker (1·59, 1·10-2·30; p=0·013), emergency surgery (2·08, 1·45-2·98; p<0·0001), cancer (1·98, 1·42-2·76; p<0·0001), and major surgery (3·94, 2·30-6·75; p<0·0001) as risk factors for postoperative mortality INTERPRETATION: Circulatory failure leads to most deaths after abdominal surgery, with sepsis accounting for almost two-thirds. Variability in timing of death highlights opportunities to intervene throughout the perioperative pathway, including after hospital discharge. A high proportion of patients without a clear cause of death reflects the need to improve capacity to rescue and cure by strengthening perioperative systems.

FUNDING

National Institute for Health and Care Research Global Health Research Unit.

APMCG-1 attenuates ischemic stroke injury by reducing oxidative stress and apoptosis and promoting angiogenesis via activating PI3K/AKT pathway

Ischemic stroke (IS) is a major cause of mortality and morbidity worldwide. Beyond thrombolysis, strategies targeting anti-oxidative apoptosis and angiogenesis are considered prospective therapeutic strategies. Nevertheless, existing natural and clinical remedies have limited efficacy in the management of IS. Moreover, despite their millennial legacy of IS remediation, natural remedies such as ginseng incur high production costs. The novel glycopeptide APMCG-1, extracted from mountain-cultivated ginseng dregs in our previous study, is a potent therapeutic candidate for IS. This study investigated APMCG-1's remedial mechanisms against IS injury using an H2O2-induced oxidative stress paradigm in human umbilical vein endothelial cells (HUVECs) emulating ischemic endothelial cells, in a ponatinib-induced zebrafish IS model, and in rat middle cerebral artery occlusion (MCAO) prototypes. Cellular assays confirmed the proficiency of APMCG-1 in preventing oxidative stress and cell death, fostering regeneration, and facilitating neovascularization within the H2O2-stressed HUVECs framework. Moreover, APMCG-1 augmented hemodynamic velocity, oxidative stress mitigation, apoptosis reduction, and motor enhancement in a zebrafish model of IS. In MCAO rats, APMCG-1 ameliorated neurological deficits and cerebral injury, as evidenced by increased neurological scores and diminished infarct dimensions. In cells and animal models, APMCG-1 activated the PI3K/AKT signaling pathway, modulating factors such as Nrf2, Bcl-2, Caspase 3, eNOS, and VEGFA, thereby ameliorating cellular oxidative distress and catalyzing angiogenesis. Collectively, these results demonstrate the potential protective effects of APMCG-1 in IS pharmacotherapy and its prospective utility as an herbal-derived IS treatment modality.

Effects of world stroke campaign on stroke literacy and knowledge in Taiwan

OBJECTIVES

Stroke is a leading cause of death in Taiwan. Poor public knowledge of stroke may lead to delays in prehospital arrival, resulting in unfavorable prognoses. Studies have investigated public knowledge of stroke and highlighted the importance of stroke education, however, few such studies have been conducted in Taiwan. This study assessed the changes in public knowledge of stroke between 2012 and 2020 by conducting a survey during two World Stroke Day events. Furthermore, this study identified areas where educational efforts may have been insufficient.

MATERIALS & METHODS

Questionnaires were distributed to the participants of 2012 and 2020 World Stroke Day events in Taiwan. In total, 328 and 336 questionnaires were completed, respectively. Stroke literacy and knowledge were analyzed between 2012 and 2020. Data were analyzed using the chi-square test or independent t-test. p < 0.05 indicates statistical significance.

RESULTS

Hypertension was the most recognized risk factor for stroke in both years (p < 0.001), and recognition of most of the given risk factors significantly increased. In addition, recognition of more than half of the stroke warning signs significantly increased, awareness of the correct acute stroke response also increased (p < 0.001), and overall stroke literacy in Taiwan increased (p = 0.001).

CONCLUSION

Stroke literacy and knowledge in Taiwan have improved significantly between 2012 and 2020, but many people still lack adequate stroke knowledge and awareness. Government health department must take this sort of intervention continually (campaigns) and novel approaches (e.g. board game…) to improve stroke literacy and knowledge in public health.

REGISTRATION ID

N202109072, approved by the Joint Institutional Review Board of Taipei Medical University on 2021/11/02.

Human Capital and Productivity in Surgery Research Across the Globe: A Big Data Analysis Using Artificial Intelligence

INTRODUCTION

No investigation of each nation's contribution to knowledge production and human capital in surgery currently exists. Previous studies explored country-level research productivity only in few surgical subspecialties. To identify current and future leaders in surgery research, we conduct a retrospective observational study of each country's human capital and research productivity.

METHODS

A web-scraping algorithm was deployed on PubMed to retrieve information on the first and senior author of every publication in all PubMed-indexed surgery outlets-a total of 388 journals-between 2010 and 2022, according to the SCImago classification. Each country's human capital is proxied by the number of first and senior authors.

RESULTS

A total of 665,668 publications from 110 countries were reviewed. The number of publications rises over time. The United States represents 30.78% and 31.32% of global publications based on first and senior authors, respectively. Other leading contributors include the United Kingdom (5.57% and 5.69% of global first and senior author publications, respectively), China (8.84% and 8.74%), Japan (7.14% and 7.10%), and Italy (4.54% and 4.46%). The number of publications per 100K people ranges between 0.04 and 86.01, suggesting widely varying levels of research productivity relative to the population.

CONCLUSIONS

Our findings underscore the US dominance in surgery research. Countries with a higher share of first or senior authors may have greater capacity to expand their future research output. As big data research expands, we expect studies deploying artificial intelligence methodologies, such as web scraping, on data repositories to guide healthcare provision and health policy decisions to become mainstream.

The association between C-reactive protein to albumin ratio and adverse outcomes in acute ischemic stroke patients: A study in the Korean population

Introduction

Our study aimed to explore the relationship between the C-reactive protein to albumin ratio (CAR) and adverse outcomes at 3 months in Korean patients with acute ischemic cerebral infarction.

Methods

This study focused on a sample of 1654 individuals with acute ischemic stroke (AIS), who received medical treatment at a reputable hospital in South Korea between January 2010 and December 2016. We used multivariate logistic regression models to show the effect of CAR admission on 3-month adverse outcomes in patients with AIS, as well as generalized additive modeling (GAM) and two-stage linear regression modeling to explore whether there was a linear relationship.

Results

A total of 1654 patients with acute ischemic cerebral infarction were enrolled in the study, and the CAR was determined to be associated with poor results for patients with AIS after 3 months. with correction for potential confounders (odds ratio [OR], 1.23; 95 % confidence interval [CI], 1.08-1; p < 0.001). A nonlinear relationship was found between the CAR and adverse outcomes at 3 months for patients with AIS, with a threshold of approximately 0.6. The effect sizes, CIs, and p-values above and below the threshold were 1.39 (1.25-1.55, p < 0.001) and 1.08 (0.81-1.43, p = 0.60).

Conclusions

The adverse outcomes of patients with AIS at three months were independently correlated with the CAR. In addition, there was a nonlinear relationship between adverse outcomes and the CAR, with the CAR increasing the risk of adverse outcomes at 3 months for patients with AIS when the CAR was less than 0.6.

Association of albumin-corrected anion gap with severe consciousness disorders and outcomes in ischemic stroke: a retrospective MIMIC analysis

The relationship between albumin-corrected anion gap (ACAG) and severe disorder of consciousness (SDOC), in-hospital mortality, and long-term mortality in patients with ischemic stroke (IS) remains unclear. This study investigates the association of ACAG with SDOC and other outcomes in IS using data from the MIMIC-IV database. A total of 2,379 IS patients were included, with a demographic breakdown showing 51% were male and an SDOC incidence of 16.4%. Analysis through Cox proportional hazards models indicated that ACAG is significantly associated with the risks of both SDOC and mortality. Additionally, restricted cubic spline(RCS) analysis suggested a nearly linear relationship between increasing ACAG levels and the incidence of SDOC. Kaplan-Meier curves demonstrated significant differences in the incidence rates of SDOC, in-hospital mortality, and long-term mortality across varying ACAG levels. The findings suggest that ACAG serves as an independent predictor for SDOC, in-hospital mortality, and long-term mortality in IS patients. Nonetheless, further prospective studies are needed to confirm these causal relationships.

The functions of apolipoproteins and lipoproteins in health and disease

Lipoproteins and apolipoproteins are crucial in lipid metabolism, functioning as essential mediators in the transport of cholesterol and triglycerides and being closely related to the pathogenesis of multiple systems, including cardiovascular. Lipoproteins a (Lp(a)), as a unique subclass of lipoproteins, is a low-density lipoprotein(LDL)-like particle with pro-atherosclerotic and pro-inflammatory properties, displaying high heritability. More and more strong evidence points to a possible link between high amounts of Lp(a) and cardiac conditions like atherosclerotic cardiovascular disease (ASCVD) and aortic stenosis (AS), making it a risk factor for heart diseases. In recent years, Lp(a)'s role in other diseases, including neurological disorders and cancer, has been increasingly recognized. Although therapies aimed at low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) have achieved significant success, elevated Lp(a) levels remain a significant clinical management problem. Despite the limited efficacy of current lipid-lowering therapies, major clinical advances in new Lp(a)-lowering therapies have significantly advanced the field. This review, grounded in the pathophysiology of lipoproteins, seeks to summarize the wide-ranging connections between lipoproteins (such as LDL-C and HDL-C) and various diseases, alongside the latest clinical developments, special emphasis is placed on the pivotal role of Lp(a) in cardiovascular disease, while also examining its future potential and mechanisms in other conditions. Furthermore, this review discusses Lp(a)-lowering therapies and highlights significant recent advances in emerging treatments, advocates for further exploration into Lp(a)'s pathogenic mechanisms and its potential as a therapeutic target, proposing new secondary prevention strategies for high-risk individuals.

Establishing Outcome Parameters for Helicopter Emergency Medical Services Research in The Netherlands: Results of a Mixed-Methods Delphi Consensus Study

OBJECTIVES

Physician staffed Helicopter Emergency Medical Services (P-HEMS) care in the Netherlands has transitioned from predominantly trauma management to handling a variety of medical conditions. Relevant outcome parameters for Dutch P-HEMS research have not been previously defined. National consensus was sought to identify relevant long term patient outcome parameters, process outcome parameters and performance outcome parameters for Dutch P-HEMS care.

METHODS

This was a mixed methods Delphi consensus study. A list of potentially relevant outcome parameters was identified using a systematic literature review. These parameters were subsequently surveyed in a Delphi consensus study. Helicopter Emergency Medical Services physicians and relevant stakeholders were invited to participate in this Delphi survey, where they were allowed to suggest additional outcome parameters. Descriptive analysis was performed on all data sets.

RESULTS

Forty-nine potential outcome parameters for Dutch P-HEMS care were surveyed. Of 71 invited participants, 53 (75%), 40 (56%), and 20 (28%) participated in the first, second, and third round of the Delphi study, respectively. Consensus was reached on 25 (51%) of 49 outcome parameters as being important. These consisted of seven long term patient related outcome parameters, four short term patient related outcome parameters, five process outcome parameters and nine performance outcome parameters.

CONCLUSIONS

In conclusion, this study identified 25 outcome parameters relevant for Dutch physician staffed HEMS care. These parameters should be considered when designing future studies and should be routinely collected for each dispatch if possible.

Worse cholecystectomy outcomes during the COVID-19 pandemic: were staff shortages or a change in patient case-mix the culprit?

BACKGROUND

The COVID-19 pandemic has profoundly impacted the field of surgery, mostly through infectious risks, staff shortages, reduced hospital capacities, and changed patient pathways. Prompted by an increase in wound complications, we performed an in-depth analysis of an example surgical procedure.

METHODS

A consecutive cohort of 195 patients undergoing laparoscopic cholecystectomy was studied retrospectively. Data of patients receiving cholecystectomy before, during, and after the peak of the pandemic were compared. The potential influence of patient characteristics, pandemic phase, and staffing level (surgeons and nurse assistants) was analyzed statistically. In the primary analyses, the composite measure of a 'textbook outcome' was examined, which was defined as no relevant complication, hospital stay < 5 days, and no readmission.

RESULTS

During the COVID-19 phase, acute biliary disease was more common than in the pre-COVID-19 phase (62% vs. 30%). In 35% of cases, no qualified operating room nurse was available. Intraoperative features and postoperative complication rates were increased (bile spillage in 46%, wound complications in 24%). A 59-year-old male admitted with acute cholecystitis during COVID-19 died of wound-related septic shock. Multivariate analysis confirmed the acuity of gallbladder inflammation (odds ratio 5.3) and old age (2.6) as risk factors for a non-textbook outcome. The absence of qualified nursing staff was clearly associated with a non-textbook outcome (odds ratio 3.3).

CONCLUSIONS

The fact that laparoscopic cholecystectomy outcomes were worse during COVID-19 can be partly attributed to a change in patient case-mix, but the shortage of qualified nursing staff in the operating room also had a strong negative influence.

Development of a behaviour change intervention for improving physical activity amongst stroke survivors with physical disabilities: a co-design approach

BACKGROUND

Stroke survivors face many barriers to physical activity (PA). Solving physical inactivity after stroke requires a "systems-based" approach. We aimed to develop a complex intervention targeted at improving PA after stroke in Singapore using behaviour change theory and a co-design approach involving multiple stakeholders.

METHODS

We carried out the intervention development in three phases: i. preparation phase, ii. co-design phase, and iii. intervention refinement phase. During the preparation phase, we conducted surveys (n = 38 stroke survivors, 71 physiotherapists and 35 exercise professionals) and interviews (n = 19 stroke survivors) to understand the factors influencing PA after stroke. The co-design phase consisted of two-co-design workshops held in August 2022 and were attended by 13 stroke survivors and 4 caregivers. Relevant domains of the Theoretical Domains Framework (TDF) and items in the Template for Intervention Description and Replication (TIDieR) checklist guided the discussion topics in the first co-design workshop. Solution prototypes such as exercise videos, arm and leg straps and information resources were shown in the second co-design workshop to gather feedback. In the intervention refinement phase, eight healthcare professionals from various sectors participated in two virtual Zoom meetings in August 2023, and used the Acceptability, Practicability, Effectiveness, Affordability, Spillover effects and Equity (APEASE) grid to rate the active ingredients in the complex intervention by considering the current healthcare landscape in terms of resources and manpower.

RESULTS

Stroke survivors and caregivers want a personalised PA program, stroke-specific PA opportunities and information resources, medical clearance, advice and help from healthcare professionals skilled in stroke care, face-to-face sessions at preferred exercise spaces, and access to adaptive equipment. A complex intervention consisting of 21 behaviour change techniques, 6 intervention functions and 8 options was developed.

CONCLUSIONS

Using behaviour change theory and a co-design approach involving multiple stakeholders, a complex intervention was developed to target physical inactivity after stroke. The intervention titled MOTIVATE is currently being tested in a type 1 hybrid effectiveness-implementation trial.

Activated sympathetic nerve post stroke downregulates Toll-like receptor 5 and disrupts the gut mucosal barrier

The gut permeability significantly increases after ischemic stroke, partly due to disrupted mucosal barrier, but the mechanism remains elusive. Here, we found that the mucus disruption starts at 2 h post stroke, whereas goblet cell functions remain intact. Meanwhile, the flagellated bacteria Helicobacter thrives and penetrates in the mucus layer. Elimination of the mucosal microbiota or transplantation of Helicobacter in germ-free mice reveals an important role of the mucosal microbiota in mucus disruption. The bacterial invasion is due to downregulated Toll-like receptor 5 (TLR5) and its downstream products flagellin-specific IgA and antimicrobial peptides. Knockdown of intestinal TLR5 increases the abundance of flagellated bacteria and exacerbates mucus injury. Intestinal TLR5 is downregulated by the activation of sympathetic nerve. Serum noradrenaline level is positively associated with flagellin level in patients with stroke and patients' prognosis. These findings reveal a neural pathway in which the sympathetic nerve disrupts the mucosal barrier, providing potential therapeutic targets for stroke injury.

Dipeptidyl peptidase 4 deficiency improves survival after focal cerebral ischemia in mice and ameliorates microglia activation and specific inflammatory markers

Dipeptidyl peptidase 4 (DPP4; CD26) is involved in the regulation of various metabolic, immunological, and neurobiological processes in healthy individuals. Observations based on epidemiological data indicate that DPP4 inhibition by gliptins, typically used in patients with diabetes, may reduce the risk for cerebral ischemia and may also improve related outcomes. However, as DPP4 inhibitor application is neither complete nor specific for suppression of DPP4 enzymatic activity and DPP4 has non-enzymatic functions as well, the variety of consequences is a matter of debate. Therefore, we here used DPP4 knock-out (KO) mice to analyze the specific contribution of DPP4 to cellular, immunological, and functional consequences of experimental focal cerebral ischemia. We observed a significantly higher survival rate of DPP4 KO mice after ischemia, which was accompanied by a lower abundance of the pro-inflammatory chemokine CCL2 and reduced activation of Iba1-positive microglia cells in brain tissue of DPP4 KO mice. In addition, after ischemia for 24 h to 72 h, decreased concentrations of CCL5 and CCL12 in plasma and of CCL17 in brain tissue of DPP4 KO mice were observed when compared to wild type mice. Other aspects analyzed, such as the functional Menzies score, astrocyte activation and chemokine levels in plasma and brain tissue were affected by ischemia but appeared to be unaffected by the DPP4 KO genotype. Taken together, experimental ablation of DPP4 functions in mice improves survival and ameliorates aspects of cellular and molecular inflammation after focal cerebral ischemia.

Predictive value of 8-year blood pressure measures in intracerebral haemorrhage risk over 5 years

AIMS

The relationships between long-term blood pressure (BP) measures and intracerebral haemorrhage (ICH), as well as their predictive ability on ICH, are unclear. In this study, we aim to investigate the independent associations of multiple BP measures with subsequent 5-year ICH risk, as well as the incremental value of these measures over a single-point BP measurement in ICH risk prediction.

METHODS AND RESULTS

We included 12 398 participants from the China Kadoorie Biobank (CKB) who completed three surveys every 4-5 years. The following long-term BP measures were calculated: mean, minimum, maximum, standard deviation, coefficient of variation, average real variability, and cumulative BP exposure (cumBP). Cox proportional hazard models were used to examine the associations between these measures and ICH. The potential incremental value of these measures in ICH risk prediction was assessed using Harrell's C statistics, continuous net reclassification improvement (cNRI), and relative integrated discrimination improvement (rIDI). The hazard ratios (95% confidence intervals) of incident ICH associated with per standard deviation increase in cumulative systolic BP and cumulative diastolic BP were 1.62 (1.25-2.10) and 1.59 (1.23-2.07), respectively. When cumBP was added to the conventional 5-year ICH risk prediction model, the C-statistic change was 0.009 (-0.001, 0.019), the cNRI was 0.267 (0.070-0.464), and the rIDI was 18.2% (5.8-30.7%). Further subgroup analyses revealed a consistent increase in cNRI and rIDI in men, rural residents, and participants without diabetes. Other long-term BP measures showed no statistically significant associations with incident ICH and generally did not improve model performance.

CONCLUSION

The nearly 10-year cumBP was positively associated with an increased 5-year risk of ICH and could significantly improve risk reclassification for the ICH risk prediction model that included single-point BP measurement.

Deep brain stimulation versus vagus nerve stimulation for the motor function of poststroke hemiplegia: study protocol for a multicentre randomised controlled trial

INTRODUCTION

Deep brain stimulation (DBS) and vagus nerve stimulation (VNS) can improve motor function in patients with poststroke hemiplegia. No comparison study exists.

METHODS AND ANALYSIS

This is a randomised, double-blind, controlled clinical trial involving 64 patients who had their first stroke at least 6 months ago and are experiencing poststroke limb dysfunction. These patients must receive necessary support at home and consent to participate. The aim is to evaluate the effectiveness and safety of DBS and VNS therapies. Patients are excluded if they have implantable devices that are sensitive to electrical currents, severe abnormalities in their lower limbs or are unable to comply with the trial procedures. The study has two parallel, distinct treatment arms: the Stimulation Group and the Sham Group. Initially, the Stimulation Group will undergo immediate electrical stimulation postsurgery, while the Sham Group will receive non-stimulation 1 month later. After 3 months, these groups will swap treatments, with the Stimulation Group discontinuing stimulation and the Sham Group initiating stimulation. Six months later, both groups will resume active stimulation. Our primary outcomes will meticulously assess motor function improvements, using the Fugl-Meyer Assessment, and safety, monitored by tracking adverse reaction rates. Furthermore, we will gain a comprehensive view of patient outcomes by evaluating secondary measures, including clinical improvement (National Institutes of Health Stroke Scale), surgical complications/side effects, quality of life (36-item Short Form Questionnaire) and mental health status (Hamilton Anxiety Rating Scale/Hamilton Depression Rating Scale). To ensure a thorough understanding of the long-term effects, we will conduct follow-ups at 9 and 12 months postsurgery, with additional long-term assessments at 15 and 18 months. These follow-ups will assess the sustained performance and durability of the treatment effects. The statistical analysis will uncover the optimal treatment strategy for poststroke hemiplegia, providing valuable insights for clinicians and patients alike.

ETHICS AND DISSEMINATION

This study was reviewed and approved by the Ethical Committee of Chinese PLA General Hospital (S2022-789-01). The findings will be submitted for publication in peer-reviewed journals with online accessibility, ensuring adherence to the conventional scientific publishing process while clarifying how the research outcomes will be disseminated and accessed.

TRIAL REGISTRATION NUMBER

NCT06121947.