Anemia and stroke: Where do we stand?

Implementation of School Nutrition Policies to Address Noncommunicable Diseases in Uzbekistan and Kyrgyzstan

Noncommunicable diseases (NCDs), including cardiovascular diseases, cancer, and diabetes, account for over 80% of mortality in Uzbekistan and Kyrgyzstan in 2019, and unhealthy dietary behaviors are a major risk factor for NCDs in both countries. In 2021, national stakeholders, in consultation with the World Health Organization, identified school nutrition policies (SNPs) as a major approach to reducing the burden of NCDs in both countries. The SNPs included interventions implemented through a multistakeholder and multisectoral arrangement that aimed to improve the health and nutrition status of children and young people by providing healthy food/beverages and restricting unhealthy foods or beverages in schools. We used a multimethod approach of document review, participatory workshops, and key informant interviews to generate theories of change for the large-scale implementation of SNPs and describe the implementation processes to date, including key implementation and health system challenges, salient implementation strategies, and implementation outcomes in both countries. Multiple pathways for enacting and implementing SNPs successfully were identified. However, significant health system challenges, such as the lack of accountability for contracting and tender processes and coordination among different sectors, continue to hamper the large-scale implementation of these policies in both countries. The pathways, theories, and implementation outcomes identified will facilitate the development of implementation strategies and systematic learning and evaluation around SNPs for NCD prevention and control programs in the Central Asian region and other low- and middle-income countries more broadly.

PRERISK: A Personalized, Artificial Intelligence-Based and Statistically-Based Stroke Recurrence Predictor for Recurrent Stroke

BACKGROUND

Predicting stroke recurrence for individual patients is difficult, but individualized prediction may improve stroke survivors' engagement in self-care. We developed PRERISK: a statistical and machine learning classifier to predict individual risk of stroke recurrence.

METHODS

We analyzed clinical and socioeconomic data from a prospectively collected public health care-based data set of 41 975 patients admitted with stroke diagnosis in 88 public health centers over 6 years (2014-2020) in Catalonia-Spain. A new stroke diagnosis at least 24 hours after the index event was considered as a recurrent stroke, which was considered as our outcome of interest. We trained several supervised machine learning models to provide individualized risk over time and compared them with a Cox regression model. Models were trained to predict early, late, and long-term recurrence risk, within 90, 91 to 365, and >365 days, respectively. C statistics and area under the receiver operating characteristic curve were used to assess the accuracy of the models.

RESULTS

Overall, 16.21% (5932 of 36 114) of patients had stroke recurrence during a median follow-up of 2.69 years. The most powerful predictors of stroke recurrence were time from previous stroke, Barthel Index, atrial fibrillation, dyslipidemia, age, diabetes, and sex, which were used to create a simplified model with similar performance, together with modifiable vascular risk factors (glycemia, body mass index, high blood pressure, cholesterol, tobacco dependence, and alcohol abuse). The areas under the receiver operating characteristic curve were 0.76 (95% CI, 0.74-0.77), 0.60 (95% CI, 0.58-0.61), and 0.71 (95% CI, 0.69-0.72) for early, late, and long-term recurrence risk, respectively. The areas under the receiver operating characteristic curve of the Cox risk class probability were 0.73 (95% CI, 0.72-0.75), 0.59 (95% CI, 0.57-0.61), and 0.67 (95% CI, 0.66-0.70); machine learning approaches (random forest and AdaBoost) showed statistically significant improvement (P<0.05) over the Cox model for the 3 recurrence time periods. Stroke recurrence curves can be simulated for each patient under different degrees of control of modifiable factors.

CONCLUSIONS

PRERISK is a novel approach that provides a personalized and fairly accurate risk prediction of stroke recurrence over time. The model has the potential to incorporate dynamic control of risk factors.

Association between baseline hemoglobin level and early neurological deterioration after intravenous thrombolysis in patients with acute ischemic stroke

OBJECTIVES

To investigate the association between baseline hemoglobin level and early neurologic deterioration (END) after intravenous thrombolysis in patients with acute ischemic stroke (AIS).

METHODS

Data of AIS patients who received intravenous thrombolytic therapy at multiple hospitals across the country between January 2017 and July 2020 were collected from the online database Acute Stroke Patients for Stroke Management Quality Evaluation (CASE-Ⅱ, NCT04487340). Binary logistic regression analysis was used to study the factors affecting the occurrence of END after intravenous thrombolytic therapy, and the correlation between baseline hemoglobin level and END was investigated by limiting cubic spline curve analysis.

RESULTS

A total of 8162 patients were included. Patients with END had lower baseline hemoglobin levels (136 and 140 g/L, P<0.01) and higher rates of anemia (24.2% and 16.9%, P<0.01) compared with non-END patients. Binary logistic regression analysis showed that baseline hemoglobin level (OR=0.995, 95%CI: 0.991-0.999, P<0.05) and anemia (OR=1.238, 95%CI: 1.055-1.454, P<0.01) were independently correlated with the occurrence of END after intravenous thrombolysis in AIS patients. Restricted cubic spline regression showed that there was a U-shaped relationship between hemoglobin level and the risk of END after intravenous thrombolysis in AIS patients (P<0.01), although this relationship was only significant in male patients (P<0.05) and not in female patients (P>0.05).

CONCLUSIONS

There is a correlation between baseline hemoglobin level and the risk of END in AIS patients after intravenous thrombolysis, especially in male patients, in whom both lower and higher hemoglobin level may increase the risk of END.

Role of Erythropoiesis-Stimulating Agents in Cardiovascular Protection in CKD Patients: Reappraisal of Their Impact and Mechanisms

Erythropoiesis-stimulating agents (ESAs) have markedly reduced the need for blood transfusion for renal anemia and are included in standard therapies for patients with chronic kidney disease (CKD). Various protective effects of ESAs on the cardiovascular system have been discovered through basic research, and the effects have received much attention because the rates of cardiovascular events and mortality are high in CKD patients. However, randomized clinical trials did not provide strong evidence that ESAs exert cardioprotection in humans, including CKD patients. It is difficult to assess the cardioprotective effects of ESAs in CKD patients through the clinical data that has been reported to date because the relationship between hemoglobin level rather than ESA dose and cardiovascular event rates was examined in most studies. Interestingly, recent studies using a rat model of CKD showed that the infarct size-limiting effect of an ESA was lost when its dose was increased to a level that normalized blood hemoglobin levels, suggesting that the optimal dose of an ESA for myocardial protection is less than the dose required to normalize hemoglobin levels. Furthermore, animal models of traditional coronary risk factors or comorbidities were resistant to the cardioprotective effects of ESAs because of interruptions in signal-mediated mechanisms downstream of erythropoietin receptors. In this review, we briefly discuss basic and clinical data on the impact of anemia on coronary and systemic circulation, the effects of CKD on the cardiovascular system, and the multiple pharmacological actions of ESAs to examine whether the ESAs that are prescribed for renal anemia exert any cardioprotection in patients with CKD.

Pulmonary embolism after diagnostic curettage in patient with adenomyosis and hysteromyoma: A case report and brief review of literature

RATIONALE

Pulmonary embolism (PE) is a common cause of cardiovascular death whose major acquired risk factors include postoperative states, pregnancy, malignancy, and age. We report a case of PE that occurred after diagnostic curettage for abnormal uterine bleeding, with a medical history of adenomyosis and hysteromyoma.

PATIENT CONCERNS AND DIAGNOSES

A 31-year-old Han Chinese female was referred to our hospital with menstrual disorders, increased menstrual flow, and severe anemia. After admission, the patient was treated with a blood transfusion, iron supplementation, and erythropoietin, and diagnostic curettage was performed the following day. On the first postoperative day, the patient developed pulmonary embolism with dyspnea and fever diagnosed by CT pulmonary angiography and significantly elevated D-dimer.

INTERVENTIONS AND OUTCOMES

Molecular weight heparin was administered for PE for 2 weeks, dyspnea was relieved significantly after 2 days of treatment and the uterine bleeding did not increase; and gonadotropin-releasing hormone agonists were administered for adenomyosis after 1 week of anticoagulant therapy to reduce bleeding. We followed up for 6 months, and the patient had no recurrence of thrombosis and uterine bleeding had improved.

CONCLUSION

We speculate that the occurrence of pulmonary embolism was closely related to adenomyosis, hysteromyoma, and curettage in this patient. Treating the presence of both menstrual bleeding and thromboembolism is challenging, and careful management is necessary to avoid therapeutic contradictions.

Associations of anaemia with bleeding and thrombotic complications in patients with atrial fibrillation treated with warfarin: a registry-based nested case-control study

OBJECTIVES

We studied association of laboratory testing beyond the international normalised ratio (INR) with bleeding and stroke/transient ischaemic attack (TIA) outcomes in patients with atrial fibrillation treated with warfarin.

DESIGN

This was a retrospective nested case-control study from the Finnish Warfarin in Atrial Fibrillation (FinWAF) registry (n=54 568), reporting the management and outcome in warfarin-anticoagulated patients. Associations of blood count test frequency and results were assessed together with risk of bleeding or stroke/TIA during 5-year follow-up.

SETTING

National FinWAF registry, with data from all six hospital districts. Follow-up period for complications was 1 January 2007-31 December 2011.

PARTICIPANTS

A total of 54 568 warfarin-anticoagulated patients.

RESULTS

The number of patients with bleeding was 4681 (9%) and stroke/TIA episodes, 4692 (9%). In patients with bleeds, lower haemoglobin (within 3 months) preceded the event compared with the controls (median 126 vs 135 g/L; IQR 111-141 g/L vs 123-147 g/L, p<0.001), while patients with stroke/TIA had only modestly lower INR (median 2.2 vs 2.3; 1.8-2.6 vs 2.1-2.7, p<0.001). When the last measured haemoglobin was below the reference value (130 g/L for men, 120 g/L for women), the OR for a bleeding complication was 2.9 and stroke/TIA, 1.5. If the haemoglobin level was below 100 g/L, the complication risk increased further by 10-fold. If haemoglobin values were repeatedly (more than five times) low during the preceding 3 months, future OR was for bleeds 2.3 and for stroke/TIA 2.4.

CONCLUSIONS

The deeper the anaemia, the higher the risk of bleeding and stroke/TIA. However, INR remained mainly at its target and only occasionally deviated, failing to detect the complication risk. Repeated low haemoglobin results, compatible with persistent anaemia, refer to suboptimal management and increased the complication risk in anticoagulated patients.

Brain BOLD and NIRS response to hyperoxic challenge in sickle cell disease and chronic anemias

PURPOSE

Congenital anemias, including sickle cell anemia and thalassemia, are associated with cerebral tissue hypoxia and heightened stroke risks. Recent works in sickle cell disease mouse models have suggested that hyperoxia respiratory challenges can identify regions of the brain having chronic tissue hypoxia. Therefore, this work investigated differences in hyperoxic response and regional cerebral oxygenation between anemic and healthy subjects.

METHODS

A cohort of 38 sickle cell disease subjects (age 22 ± 8 years, female 39%), 25 non-sickle anemic subjects (age 25 ± 11 years, female 52%), and 31 healthy controls (age 25 ± 10 years, female 68%) were examined. A hyperoxic gas challenge was performed with concurrent acquisition of blood oxygen level-dependent (BOLD) MRI and near-infrared spectroscopy (NIRS). In addition to hyperoxia-induced changes in BOLD and NIRS, global measurements of cerebral blood flow, oxygen delivery, and cerebral metabolic rate of oxygen were obtained and compared between the three groups.

RESULTS

Regional BOLD changes were not able to identify brain regions of flow limitation in chronically anemic patients. Higher blood oxygen content and tissue oxygenation were observed during hyperoxia gas challenge. Both control and anemic groups demonstrated lower blood flow, oxygen delivery, and metabolic rate compared to baseline, but the oxygen metabolism in anemic subjects were abnormally low during hyperoxic exposure.

CONCLUSION

These results indicated that hyperoxic respiratory challenge could not be used to identify chronically ischemic brain. Furthermore, the low hyperoxia-induced metabolic rate suggested potential negative effects of prolonged oxygen therapy and required further studies to evaluate the risk for hyperoxia-induced oxygen toxicity and cerebral dysfunction.

Rubrometabolic Syndrome

Metabolic syndrome (MS), a conglomeration of several conditions including obesity, type 2 diabetes mellitus (T2DM), insulin resistance, elevated blood pressure, and dyslipidemia is reaching epidemic proportions. Anemia is caused by iron deficiency or dysregulation of iron homeostasis, leading to tissue hypoxia. Coexistence of anemia and MS or its components has been reported in the literature. The term "rubrometabolic syndrome" acts as a unifying entity linking the importance of blood in health and anemia in MS; it justifies two principles - redness of blood and low-grade inflammation. Chronic low-grade inflammation in MS affects iron metabolism leading to anemia. Tissue hypoxia that results from the anemic condition seems to be a major causative factor for the exacerbation of several microvascular and macrovascular components of T2DM, which include diabetic neuropathy, nephropathy, retinopathy, and cardiovascular complications. In obesity, anemia leads to malabsorption of micronutrients and can complicate the management of the condition by bariatric surgery. Anemia interferes with the diagnosis and management of T2DM, obesity, dyslipidemia, or hypertension due to its effect on pathological tests as well as medications. Since anemia in MS is multifaceted, the management of anemia is challenging as overcorrection of anemia with erythropoietin-stimulating agents can cause detrimental effects. These limitations necessitate availability of an effective and safe therapy that can maintain and elevate the hemoglobin levels along with maintaining the physiological balance of other systems. This review discusses the physiological links between anemia and MS along with diagnosis and management strategies in patients with coexistence of anemia and MS.

Association between Anemia Severity and Ischemic Stroke Incidence: A Retrospective Cohort Study

Stroke patients presenting with anemia at the time of stroke onset had a higher risk of mortality and development of other cardiovascular diseases and comorbidities. The association between the severity of anemia and the risk of developing a stroke is still uncertain. This retrospective study aimed to evaluate the association between stroke incidence and anemia severity (by WHO criteria). A total of 71,787 patients were included, of whom 16,708 (23.27%) were identified as anemic and 55,079 patients were anemia-free. Female patients (62.98%) were more likely to have anemia than males (37.02%). The likelihood of having a stroke within eight years after anemia diagnosis was calculated using Cox proportional hazard regression. Patients with moderate anemia had a significant increase in stroke risk compared to the non-anemia group in univariate analyses (hazard ratios [HR] = 2.31, 95% confidence interval [CI], 1.97-2.71, p < 0.001) and in adjusted HRs (adj-HR = 1.20, 95% CI, 1.02-1.43, p = 0.032). The data reveal that patients with severe anemia received more anemia treatment, such as blood transfusion and nutritional supplementation, and maintaining blood homeostasis may be important to preventing stroke. Anemia is an important risk factor, but other risk factors, including diabetes and hyperlipidemia, also affect stroke development. There is a heightened awareness of anemia's severity and the increasing risk of stroke development.

Adenomyosis-Associated Ischemic Stroke: Pathophysiology, Detection and Management

Female-specific risk factors for stroke have gradually received attention. The relationship between ischemic stroke and adenomyosis, a benign uterine disorder commonly present in parous women, is underrecognized. We aimed to provide an overview of the epidemiology, pathophysiological mechanisms, clinical characteristics, diagnostic considerations, and potential therapeutic strategies of adenomyosis-associated ischemic stroke. We shared our experience with the diagnosis and management of a patient, and summarized current findings and knowledge gaps of this disease based on previous literature. The relevant studies were searched in English and Chinese databases up to April 2022 using the keywords "ischemic stroke", "cerebral infarction" and "adenomyosis". Then, we provided a narrative review of the retrieved articles. Finally, the data of 32 cases were analyzed. We found that increased levels of carbohydrate antigen 125 and D-dimer and decreased level of hemoglobin are biomarkers of adenomyosis-associated ischemic stroke. In addition, hypercoagulability might be a key mechanism leading to thromboembolism in the cerebrovascular system. Additional studies are needed to find optimal prevention strategies for the disease. A better understanding of this "rare" pathogenesis of ischemic stroke may inform a more precise diagnosis and effective prevention strategy in middle-aged women with embolic stroke of undetermined source.

Neurovascular Manifestations of Iron-Deficient Anemia: Narrative Review and Practical Reflections through a Teaching Case

Anemia is one of the most frequent diseases worldwide, affecting one-third of the general population. Anemia in general and in particular, iron-deficient anemia (IDA), has been associated to a higher risk of thrombotic manifestations, including ischemic stroke and cerebral venous thrombosis (CVT), as well as systemic extra-cerebral arterial and venous thrombosis. Despite these data, anemia is seldom considered as an etiological factor of stroke. An individual case encompassing all known neurovascular and systemic arterial and venous thrombotic manifestations related to IDA is presented with the focus on clinical reasoning issues in the diagnostic pathways, starting from the neuroradiological signs. The main questions have been identified and addressed in a narrative review of the most relevant data in the literature from a pragmatic and clinical viewpoint. The presented case concerns a 46-year-old man admitted to the Stroke Unit because of acute ischemic stroke with multiple thrombi in large intracranial and extracranial vessels, multifocal ischemic lesions in several arterial territories and the concurrent finding of asymptomatic CVT, pulmonary embolism with lung infarction and aortic thrombosis. An extended diagnostic work-up excluded the main etiologies (arterial dissection, cardiac embolism, genetic and acquired prothrombotic disorders, such as cancer and antiphospholipid syndrome), except for a severe IDA, such as to require blood transfusions followed by anticoagulant therapy for the several thrombotic manifestations. Neuroimaging and systemic vascular findings have been analyzed, and the main issues proposed by the case in the diagnostic pathway have been identified and discussed in a pragmatic clinical road map reviewing the data provided by the literature. Conclusions: IDA is a common but treatable condition that, independently or synergically, may increase the risk of thrombotic events. The diagnostic and therapeutic approach has not yet been defined, and each case should be individually addressed in a pragmatic clinical road map.

Anemia and risk of periprocedural cerebral injury detected by diffusion-weighted magnetic resonance imaging in patients undergoing transcatheter aortic valve replacement

BACKGROUND

Anemia is prevalent in patients undergoing transcatheter aortic valve replacement (TAVR) and has been linked to impaired outcomes after the procedure. Few studies have evaluated the impact of anemia and new ischemic lesions post TAVR.

METHODS

We prospectively enrolled 158 patients who received TAVR in our center. Anemia was defined according to the World Health Organization criteria as hemoglobin <12 g/dL in women and <13 g/dL in men. All patients underwent diffusion-weighted magnetic resonance imaging (DW-MRI) procedure before and within 4-7 days after TAVR.

RESULTS

Anemia was present in 85 (53.8%) patients who underwent TAVR, and 126 (79.7%) patients had 718 new DW-MRI positive lesions with a mean of 4.54±5.26 lesions per patient. The incidence of new ischemic lesions was 81.2% in patients with anemia versus 78.1% in patients without anemia (P=0.629). Moreover, anemic patients had bigger total volume/lesions in the anterior cerebral artery/middle cerebral artery (ACA/MCA) and MCA regions compared to the non-anemic patients (31.89±55.78 mm3 vs. 17.08±37.39 mm3, P=0.049; and 54.54±74.72 mm3 vs. 33.75±46.03 mm3, P=0.034). Anemia was independently associated with the volume/lesion in the ACA/MCA (β=16.796, 95% confidence interval [95% CI] 2.001 to 31.591, P=0.026) and in the MCA zone (β=0.020, 95% CI 0.001 to 0.040, P=0.041).

CONCLUSIONS

Patients with pre-procedural anemia may have bigger total volume/lesions in the ACA/MCA and MCA regions compared to the non-anemic patients. Whether the consequences of bigger total volume/lesions impact neurological and cognitive outcomes remains to be investigated.

Interactions Between Kidney Function and Cerebrovascular Disease: Vessel Pathology That Fires Together Wires Together

The kidney and the brain, as high-flow end organs relying on autoregulatory mechanisms, have unique anatomic and physiological hemodynamic properties. Similarly, the two organs share a common pattern of microvascular dysfunction as a result of aging and exposure to vascular risk factors (e.g., hypertension, diabetes and smoking) and therefore progress in parallel into a systemic condition known as small vessel disease (SVD). Many epidemiological studies have shown that even mild renal dysfunction is robustly associated with acute and chronic forms of cerebrovascular disease. Beyond ischemic SVD, kidney impairment increases the risk of acute cerebrovascular events related to different underlying pathologies, notably large artery stroke and intracerebral hemorrhage. Other chronic cerebral manifestations of SVD are variably associated with kidney disease. Observational data have suggested the hypothesis that kidney function influences cerebrovascular disease independently and adjunctively to the effect of known vascular risk factors, which affect both renal and cerebral microvasculature. In addition to confirming this independent association, recent large-scale human genetic studies have contributed to disentangling potentially causal associations from shared genetic predisposition and resolving the uncertainty around the direction of causality between kidney and cerebrovascular disease. Accelerated atherosclerosis, impaired cerebral autoregulation, remodeling of the cerebral vasculature, chronic inflammation and endothelial dysfunction can be proposed to explain the additive mechanisms through which renal dysfunction leads to cerebral SVD and other cerebrovascular events. Genetic epidemiology also can help identify new pathological pathways which wire kidney dysfunction and cerebral vascular pathology together. The need for identifying additional pathological mechanisms underlying kidney and cerebrovascular disease is attested to by the limited effect of current therapeutic options in preventing cerebrovascular disease in patients with kidney impairment.

Hemoglobin Concentration and Clinical Outcomes After Acute Ischemic Stroke or Transient Ischemic Attack

Background

Anemia or low hemoglobin can increase the risk of stroke. However, the association between hemoglobin and outcomes after stroke is uncertain. In this study, we aimed to investigate the association between hemoglobin and clinical outcomes, including mortality, poor functional outcome, stroke recurrence, and composite vascular events at 1 year.

Methods and Results

We included the patients diagnosed with acute ischemic stroke or transient ischemic attack from the Third China National Stroke Registry. We used the Cox model for mortality, stroke recurrence, and composite vascular events and the logistic model for the poor functional outcome to examine the relationship between hemoglobin and clinical outcomes. In addition, we used the restricted cubic spline to evaluate the nonlinear relationship. This study included 14 159 patients with acute ischemic stroke or transient ischemic attack. After adjusted for potential cofounders, both anemia and high hemoglobin were associated with the higher risk of mortality (hazard ratio [HR], 1.73; 95% CI, 1.39–2.15; HR, 2.71; 95% CI, 1.95–3.76) and poor functional outcome (odds ratio [OR], 1.36; 95% CI, 1.18–1.57; OR, 1.42; 95% CI, 1.07–1.87). High hemoglobin, but not anemia, increased the risk of stroke recurrence (HR, 1.37; 95% CI, 1.05–1.79) and composite vascular events (HR, 1.41; 95% CI, 1.08–1.83). There was a U‐shaped relationship between hemoglobin and mortality and poor functional outcome.

Conclusions

Abnormal hemoglobin was associated with a higher risk of all‐cause mortality, poor functional outcome, stroke recurrence, and composite vascular events. More well‐designed clinical studies are needed to confirm the relationship between hemoglobin and clinical outcomes after stroke.

Stroke Secondary to Iron Deficiency Anemia: A Case Report

Cerebrovascular accident is the fifth leading cause of death in the United States, with about 795,000 cases reported to the Centers for Disease Control and Prevention (CDC) each year. Several risk calculators for the development of stroke have been developed throughout the years, but none included iron deficiency anemia (IDA). We therefore would like to highlight the case of a 34-year-old female with severe iron deficiency anemia secondary to menorrhagia who had an ischemic stroke. An extensive workup was done and was negative. Given its significant presence with other comorbidities and various proposed pathogenesis, we propose that iron deficiency anemia be considered as a stroke factor. Studies in optimal hemoglobin or iron levels in patients with stroke to lower comorbidities and predict prognosis may also be beneficial.

L, Kariyappa M, Devadas S, Kumble D, Sajjan SV, Rangegowda RK, Patel AS. Acute Ischemic Stroke in a Young Child and Its Association with SARS-CoV-2 Infection

The coronavirus disease 2019 (COVID-19) in children has been shown to have lower morbidity and mortality in children as compared with adults. The neurological complications related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are increasingly reported in children, yet the cerebrovascular complications are rare. We report a case of a toddler who presented with right-sided hemiparesis and motor aphasia, with an antecedent history suggestive of COVID-19 infection. The child tested negative on the nasopharyngeal swab for real-time reverse transcription-polymerase chain reaction (RT-PCR), but the serology for anti-SARS-CoV-2 IgG assay was positive. The neuroimaging showed an acute infarct in the left middle cerebral artery territory. A detailed evaluation for causes of childhood stroke was unrevealing, except for the presence of severe iron deficiency anemia (IDA). The child was diagnosed as acute ischemic stroke (AIS) most probably secondary to mild COVID-19 infection. The objective of this case report is to explain the possibility of AIS after a mild COVID-19 infection, complicated by the underlying severe IDA. Therefore, an association between COVID-19 and stroke in children needs to be emphasized and RT-PCR for SARS-CoV-2 as well as serological assay must be included in the workup of stroke in the young.

Risk Prediction and Treatment of LE-DVT in Patients with Chronic Radiation Intestinal Injury: A Retrospective Case-Control Study

Background

Chronic radiation intestinal injury (CRII) is the most common complication after pelvic malignancy radiation. Once hemorrhagic CRII patients suffer from lower extremity deep venous thrombosis (LE-DVT), hemostasis and anticoagulation therapy will be adopted simultaneously, but the treatment strategy is a paradox, as the condition is extremely intractable and serious. The aim of this study was to investigate the prevalence of and risk factors for LE-DVT in CRII patients and explore the treatment of hemorrhagic CRII patients with LE-DVT.

Methods

This was a retrospective study, and a total of 608 hospitalized CRII patients after pelvic radiotherapy were included from November 2011 to October 2018. Univariate and multivariate analyses were conducted to investigate the potential risk factors for LE-DVT in CRII patients. Furthermore, the treatment of hemorrhagic CRII patients with LE-DVT was explored.

Results

Among the CRII patients, 94 (15.5%) were with suspicious symptoms of LE-DVT in the lower limbs, and 32 (5.3%) were diagnosed with LE-DVT. Among the patients with LE-DVT, 65.6% (21/32) had bleeding simultaneously, and 29 (90.6%) had anemia with 24 (75.0%) having moderate to severe anemia. Multivariate analysis showed that a recent surgical history (≤6 months) (OR = 5.761, 95% CI: 2.506~13.246, p < 0.001), tumor recurrence or metastasis (OR = 3.049, 95% CI: 1.398~6.648, p = 0.005) and the hemoglobin (Hb) level (OR = 0.960, 95% CI: 0.942~0.979, p < 0.001) were significantly associated with the development of LE-DVT. ROC curve analysis showed that the AUC of the merged risk score of the independent risk factors was 0.822 (95% CI: 0.789~0.852), and the optimal Hb cutoff was 82.5 g/L. After colostomy, obvious bleeding remission was rapidly found in 84.6% of hemorrhagic CRII patients with LE-DVT.

Conclusion

The prevalence of LE-DVT in hospitalized CRII patients was 5.3%. A recent surgical history, tumor recurrence or metastasis and a lower Hb level were independently associated with LE-DVT development in CRII patients. Colostomy could be a good choice for intractable hemorrhagic CRII patients with LE-DVT.

Both Ends of Values in the Hemoglobin Spectrum Are Associated with Adverse Stroke Outcomes

BACKGROUND AND PURPOSE

Existing studies on the association between hemoglobin values and stroke outcomes mostly focus on the lower side and mortality, often the only and primary endpoint. The current study was conducted to assess the association between hemoglobin concentration and a variety of poor stroke outcomes in patients with acute ischemic stroke.

METHODS

We studied 8,321 patients enrolled in the China National Stroke Registry (CNSR) between 2007 and 2008. Patients were divided into 7 groups, and a logistic regression model was used to evaluate the association. Endpoints of interest included 1-year all-cause mortality, stroke recurrence, combined endpoint, and stroke disability. Stroke disability was defined as a modified Rankin Scale of 2-6.

RESULTS

Patients with low and high hemoglobin values (≤11.6 g/dL and >16.1 g/dL) had higher proportion of poststroke adverse events than those in other groups. As compared with the fourth group of hemoglobin values of 13.5-14.2 g/dL, the adjusted odds ratios (ORs) with 95% confidence interval (CI) of low hemoglobin values (≤11.6 g/dL) were 2.25 (1.72-2.93) for all-cause mortality, 1.30 (1.04-1.61) for stroke recurrence, 1.63 (1.33-2.01) for combined endpoint, and 1.37 (1.12-1.67) for stroke disability, respectively. And, the ORs of high hemoglobin values (>16.1 g/dL) for adverse stroke outcomes were 1.72 (1.25-2.37), 1.43 (1.13-1.82), 1.43 (1.13-1.81), and 1.31 (1.06-1.63), respectively. Stratified analysis showed significant interactions between sex and categories of hemoglobin values for all-cause mortality (p = 0.05), stroke recurrence (p = 0.03), and combined endpoint (p = 0.01) but not for stroke disability (p = 0.24).

CONCLUSIONS

Our study found both low and high hemoglobin values were associated with adverse stroke outcomes including all-cause mortality, stroke recurrence, combined endpoint, and stroke disability, which showed a U-shaped association. And, significant interactions between sex and hemoglobin concentration on all-cause mortality and stroke recurrence were also identified.

Nutritional Supplements and Neuroprotective Diets and Their Potential Clinical Significance in Post-Stroke Rehabilitation

Nutrition and rehabilitation are crucial in post-stroke recovery, especially in the elderly. Since stroke is the leading cause of long-term disability, there is a need to promote special, individually tailored nutrition strategies targeting older patients with low motor ability. Chronic stroke survivors have higher risk of developing nutrition-related chronic diseases, such as sarcopenia, anemia, type 2 diabetes mellitus and osteoporosis. Moreover, reduced motor activity, cognitive impairment and depression might be aggravated by poor malnutrition status. Accumulated data suggest that nutritional supplements and neuroprotective diets can be associated with better effectiveness of post-stroke rehabilitation as well as brain recovery. Therefore, this review focuses on preventive strategies that can improve dietary intake and change dietary patterns. We highlight the importance of neuroprotective diets, the problem of dysphagia and the role of nutrition in rehabilitation. This article focuses on potential nutritional supplements and neuroprotective diets that may have an impact on functional recovery during and after rehabilitation. Moreover, a new approach to post-stroke neuroplasticity including the use of agents from marine sources such as fucoxanthin and tramiprosate as compounds that might be used as potential neuroprotectants with antioxidative and anti-inflammatory properties is introduced.

Cerebral venous thrombosis, neutropenia and iron-deficiency anemia in Huntington disease

Neurologic and nonneurologic manifestations have been shown for Huntington disease (HD) as a genetic neurodegenerative disorder. However, cerebral venous thrombosis (CVT), iron-deficiency anemia and neutropenia have not been reported as its presentations to date. We introduce the first case of a HD patient with CVT, iron-deficiency anemia and neutropenia. All transient and chronic risk factors for development of these manifestations were ruled out. According to the experimental evidences reviewed in this article, we suggest that HD itself could promote formation of CVT, iron-deficiency anemia and neutropenia through vascular and blood cell abnormalities.

Characteristics and functional outcomes of pediatric stroke survivors at a rehabilitation unit in Saudi Arabia

There is a lack of data regarding functional outcomes of comprehensive inpatient rehabilitation (IPR) in children with stroke in Saudi Arabia. The objective of this study was to analyze the effect of IPR on functional outcomes of pediatric stroke survivors. This retrospective cohort study included pediatric stroke survivors (n = 18) admitted to pediatric rehabilitation unit from January 2011 to December 2018. Data were obtained regarding functional status based on WeeFIM at the time of admission and discharge. Functional gain was compared within genders, age-groups, geographical regions, lesion characteristics, location of motor deficits, primary etiology, comorbidities, and risk factors. Improvement in self-care, mobility, and cognition was also compared. Results showed a delayed admission to IPR from the time of stroke; however, a significant gain was observed in overall WeeFIM score (p < 0.001), self-care, and mobility (both p = 0.001) but not in cognition (p = 0.13). WeeFIM gain was significantly better in hemorrhagic stroke survivors than ischemic stroke survivors (p = 0.027). Age-group, gender, geographical region, primary etiology, lesion characteristics, comorbidities, risk factors, and location of motor deficits did not affect the functional improvement. The association analysis of WeeFIM gain with age, duration from onset of stroke to IPR admission, WeeFIM score at admission, and length of stay did not yield any significant value. Self-care domain of WeeFIM had significantly better percentage gain than mobility and cognition (p = 0.01). In conclusion, functional outcomes among our cohort of Saudi pediatric stroke survivors improved significantly after IPR especially in self-care. Hemorrhagic strokes had better functional outcome than ischemic strokes.

Association between Anemia and Stroke in Females: A Nationwide, Population-Based Cohort Study in Taiwan

Optimal stroke prevention strategies for women should take into account specific sex-related stroke risk factors. Anemia is a common medical condition in females, particularly in women of reproductive age. This study investigated whether anemia is an independent risk factor for stroke in females in a population-based cohort study. We investigated newly diagnosed anemic female patients with no history of central nervous system disease, psychiatric disorders, traumatic brain injury, major operations or hemorrhagic diseases identified from the Taiwan National Health Insurance Research Database. Non-anemic matched controls (1:1) were selected based on a propensity score estimated using a logistic regression model that included demographic characteristics and comorbidities. A competing risk analysis was applied to estimate the stroke risk in anemic patients compared to that of their matched controls. In our study, the adjusted sub-distribution hazard ratios (aSHRs) of overall, hemorrhagic and ischemic stroke in anemic female patients aged <50 years were 1.35 (95% confidence interval (CI): 1.19-1.52, p < 0.001), 1.31 (95% CI, 1.09-1.56, p < 0.003), and 1.35 (95% CI, 1.15-1.58, p < 0.001), respectively, compared to non-anemic female controls. However, a positive association between anemia and stroke was not found for those aged ≥50 years. Similar results were observed when the follow-up age was limited to 50 years to reduce the potential effects of menopause on stroke. In conclusion, the present population-based cohort study found that anemia is a potential risk factor for overall, hemorrhagic and ischemic stroke in females of reproductive age.

Critical Care Society of Southern Africa adult patient blood management guidelines: 2019 Round-table meeting, CCSSA Congress, Durban, 2018

The CCSSA PBM Guidelines have been developed to improve patient blood management in critically ill patients in southern Africa. These consensus recommendations are based on a rigorous process by experts in the field of critical care who are also practicing in South Africa (SA). The process comprised a Delphi process, a round-table meeting (at the CCSSA National Congress, Durban, 2018), and a review of the best available evidence and international guidelines. The guidelines focus on the broader principles of patient blood management and incorporate transfusion medicine (transfusion guidelines), management of anaemia, optimisation of coagulopathy, and administrative and ethical considerations. There are a mix of low-middle and high-income healthcare structures within southern Africa. Blood products are, however, provided by the same not-for-profit non-governmental organisations to both private and public sectors. There are several challenges related to patient blood management in SA due most notably to a high incidence of anaemia, a frequent shortage of blood products, a small donor population, and a healthcare system under financial strain. The rational and equitable use of blood products is important to ensure best care for as many critically ill patients as possible. The summary of the recommendations provides key practice points for the day-to-day management of critically ill patients. A more detailed description of the evidence used to make these recommendations follows in the full clinical guidelines section.

Transient Hypoxia Model Revealed Cerebrovascular Impairment in Anemia Using BOLD MRI and Near-Infrared Spectroscopy

BACKGROUND

Obstructive sleep apnea and nocturnal oxygen desaturations, which are prevalent in sickle cell disease (SCD) and chronic anemia disorders, have been linked to risks of stroke and silent cerebral infarcts (SCI). Cerebrovascular response to intermittent desaturations has not been well studied and may identify patients at greatest risk.

PURPOSE

To investigate the cerebral dynamic response to induced desaturation in SCD patients with and without SCI, chronic anemia, and healthy subjects.

STUDY TYPE

Prospective.

SUBJECTS

Twenty-six SCD patients (age = 21 ± 8.2, female 46.2%), including 15 subjects without SCI and nine subjects with SCI, 15 nonsickle anemic patients (age = 22 ± 5.8, female 66.7%), and 31 controls (age = 28 ± 12.3, female 77.4%).

FIELD STRENGTH/SEQUENCE

3T, gradient-echo echo-planar imaging.

ASSESSMENT

A transient hypoxia challenge of five breaths of 100% nitrogen gas was performed with blood oxygen level-dependent (BOLD) MRI and near-infrared spectroscopy (NIRS) acquisitions. Hypoxia responses were characterized by desaturation depth, time-to-peak, return-to-baseline half-life, and posthypoxia recovery in the BOLD and NIRS time courses. SCI were documented by T₂ fluid-attenuation inversion recovery (FLAIR).

STATISTICAL TESTS

Univariate and multivariate regressions were performed between hypoxic parameters and anemia predictors. Voxelwise two-sample t-statistic maps were used to assess the regional difference in hypoxic responses between anemic and control groups.

RESULTS

Compared to controls, SCD and chronically anemic patients demonstrated significantly higher desaturation depth (P < 0.01) and shorter return-to-baseline timing response (P < 0.01). Patients having SCI had shorter time-to-peak (P < 0.01), return-to-baseline (P < 0.01), and larger desaturation depth (P < 0.01) in both white matter regions at risk and normal-appearing white matter than patients without infarcts. On multivariate analysis, desaturation depth and timing varied with age, sex, blood flow, white blood cells, and cell-free hemoglobin (r² = 0.25 for desaturation depth; r² = 0.18 for time-to-peak; r² = 0.37 for return-to-baseline).

DATA CONCLUSION

Transient hypoxia revealed global and regional response differences between anemic and healthy subjects. SCI was associated with extensive heterogeneity of desaturation dynamics, consistent with extensive underlying microvascular remodeling.

Acute cerebral infarction with adenomyosis in a patient with fever: a case report

Background

It is reported that acute cerebral infarction with adenomyosis is associated with elevated D-Dimer, elevated CA125, anemia and menstruation. However, previous reports did not notice infection known as fever, which may be a potential risk factor for developing acute cerebral infarction with adenomyosis.

Case presentation

We describe a 34-year-old woman who presented headache and fever (38 °C) for 4 days and left limb weakness for 1 day during her menstrual phase. Laboratory test data showed: Hemoglobin (HGB) (112 g/L, normal: 120–150 g/L), Carcinoembryonic antigen 125 (CA125) (937.70 U/ml, normal: 0–35 U/ml), D-Dimer (27.4 mg/L, normal: 0–1.5 mg/L). Magnetic resonance imaging (MRI) indicated acute cerebral infarction in right basal ganglia and subcortical region of right frontotemporal lobe. Further, brain computed tomography angiography (CTA) showed that the M1 segment of right middle cerebral artery was strictured and the distal branches of right middle cerebral artery were significantly less than those on the opposite side. No obvious abnormality was found in cranial magnetic resonance venogram (MRV). She had a 5-year history of adenomyosis. No tumors were found by whole body positron emission tomography-computed tomography (PET-CT). We treated this patient by using anti-infective therapy for 1 week and using anticoagulant therapy with low molecular weight heparin for 2 weeks. Subsequently, the anticoagulant therapy was discontinued and replaced by antiplatelet therapy with clopidogrel. We followed up this patient for 4 months, and no recurrence of cerebral infarction was found.

Conclusions

Acute cerebral infarction with adenomyosis may be related to elevated D-Dimer, elevated CA125, anemia and menstruation. Our report suggests that infection may be a potential risk factor for developing acute cerebral infarction with adenomyosis.

Anaemia at admission is associated with poor clinical outcome in cerebral venous thrombosis

Background and purpose

Anaemia is associated with poor clinical outcome after ischaemic and haemorrhagic stroke. The association between anaemia and outcome in patients with cerebral venous thrombosis (CVT) was examined.

Methods

Consecutive adult patients with CVT were included from seven centres. Anaemia at admission was scored according to World Health Organization definitions. Poor clinical outcome was defined as a modified Rankin Scale score 3–6 at last follow‐up. A multiple imputation procedure was applied for handling missing data in the multivariable analysis. Using binary logistic regression analysis, adjustments were made for age, sex, cancer and centre of recruitment (model 1). In a secondary analysis, adjustments were additionally made for coma, intracerebral haemorrhage, non‐haemorrhagic lesion and deep venous system thrombosis (model 2). In a sensitivity analysis, patients with cancer were excluded.

Results

Data for 952 patients with CVT were included, 22% of whom had anaemia at admission. Patients with anaemia more often had a history of cancer (17% vs. 7%, P < 0.001) than patients without anaemia. Poor clinical outcome (21% vs. 11%, P < 0.001) and mortality (11% vs. 6%, P = 0.07) were more common amongst patients with anaemia. After adjustment, anaemia at admission increased the risk of poor outcome [adjusted odds ratio (aOR) 2.4, 95% confidence interval (CI) 1.5–3.7, model 1]. Model 2 revealed comparable results (aOR 1.9, 95% CI 1.2–3.2), as did the sensitivity analysis excluding patients with cancer (aOR 2.3, 95% CI 1.3–3.8, model 1).

Conclusion

The risk of poor clinical outcome is doubled in CVT patients presenting with anaemia at admission.

An international consensus statement on the management of postoperative anaemia after major surgical procedures

Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.

"Recurrent multiple cerebral infarctions related to the progression of adenomyosis: a case report"

Background

Benign gynecologic tumor, such as uterine adenomyosis, has been suggested to develop hypercoagulability. Although some cases of cerebral infarction associated with adenomyosis have been reported, the mechanism of hypercoagulation initiated by adenomyosis is still not clear, and the therapeutic strategy is uncertain.

Case presentation

A 44-year-old woman was presented to our department with headache, left hand weakness, and gait disturbance during her menstrual phase. She had a history of adenomyosis and infertility treatment for 18 years and heavy menstrual bleeding. Magnetic resonance imaging on admission showed multiple hyperintense lesions in cortical and subcortical areas in the cerebrum and cerebellum on diffusion-weighted imaging. Transesophageal echocardiography showed neither embolic sources nor existence of foramen ovale. Her laboratory data revealed anemia, a high D-dimer level, and elevated levels of a mucinous tumor marker. She had adenomyosis and no malignancy was detected. Anticoagulation therapy with intravenous heparin followed by rivaroxaban did not prevent recurrence of cerebral infarction. We discontinued rivaroxaban, and started warfarin therapy with pseudomenopause treatment, which prevented recurrence for 6 months. Five months after her last pseudomenopause treatment, multiple cerebral infarctions occurred. Total hysterectomy was performed, which prevented recurrence of the multiple cerebral infarctions for 2 years without anticoagulation therapy.

Conclusions

Our findings reveal for the first time that anticoagulation therapy, including novel oral anticoagulants, had no preventive effect against cerebral infarctions associated with adenomyosis in a middle-aged woman. Although pseudomenopause treatment temporarily prevented recurrence, resection of the adenomyosis might be the most effective therapy in these cases.

Long-Term Outcomes in Patients with Anemia And Cerebral Venous Thrombosis

BACKGROUND

Anemia is associated with unfavorable functional outcome in ischemic and hemorrhagic stroke. However, the relationship between anemia and prognosis in patients with cerebral venous thrombosis (CVT) has not been studied.

METHODS

Consecutive CVT patients were retrospectively identified from November 2011, through January 2017. Anemia was defined according to the World Health Organization criteria (non-pregnant female hemoglobin level < 120 g/L, pregnant female < 110 g/L and male < 130 g/L), which was further classified as mild, moderate, and severe anemia according to hemoglobin concentration, and as microcytic, normocytic, and macrocytic anemia according to mean corpuscular volume. Unfavorable outcome was defined as modified Rankin Scale (mRS) of 3-6. Factors such as age, sex, coma, malignancy, intracerebral hemorrhage, and straight sinus and/or deep CVT involved, premorbid mRS were adjusted to evaluate the relationship between anemia and prognosis in CVT patients.

RESULTS

A total of 238 CVT patients were included, among whom 73 patients (30.67%) were diagnosed with anemia. Multivariate logistic regression analysis showed that patients with anemia had a higher risk of mRS of 3-6 (OR = 3.62; 95% CI, 1.45-9.01; P = 0.006) and mortality (OR = 5.46; 95% CI, 1.90-15.70; P = 0.002). Subgroup analysis showed that severe anemia was independently associated with mRS of 3-6 (OR = 8.80; 95% CI, 1.90-40.81; P = 0.005) and mortality (OR = 9.82; 95% CI, 1.81-53.25; P = 0.010). Similarly, microcytic anemia increased the risk of mRS of 3-6 (OR = 4.64; 95% CI, 1.48-14.52; P = 0.008) and mortality (OR = 9.68; 95% CI, 2.61-35.91; P = 0.001). In addition, our study also revealed that lower hemoglobin level, evaluated as a continuous variable, was inversely associated with mRS of 3-6 (OR = 0.98; 95% CI, 0.96-0.99; P = 0.007) and mortality (OR = 0.97; 95% CI, 0.95-0.99; P = 0.005).

CONCLUSIONS

Anemia was a significant and independent predictor of unfavorable functional outcome in patients with CVT.

Current misconceptions in diagnosis and management of iron deficiency

The prevention and treatment of iron deficiency is a major public health goal. Challenges in the treatment of iron deficiency include finding and addressing the underlying cause and the selection of an iron replacement product which meets the needs of the patient. However, there are a number of non-evidence-based misconceptions regarding the diagnosis and management of iron deficiency, with or without anaemia, as well as inconsistency of terminology and lack of clear guidance on clinical pathways. In particular, the pathogenesis of iron deficiency is still frequently not addressed and iron not replaced, with indiscriminate red cell transfusion used as a default therapy. In our experience, this imprudent practice continues to be endorsed by non-evidence-based misconceptions. The intent of the authors is to provide a consensus that effectively challenges these misconceptions, and to highlight evidence-based alternatives for appropriate management (referred to as key points). We believe that this approach to the management of iron deficiency may be beneficial for both patients and healthcare systems. We stress that this paper solely presents the Authors' independent opinions. No pharmaceutical company funded or influenced the conception, development or writing of the manuscript.

Early Postpartum Hemoglobin Less Than 10 g/dL Is Associated with Future Maternal Atherosclerotic Morbidity

OBJECTIVE

Anemia is associated with increased cardiovascular morbidity in the general population. Anemia is common during pregnancy. We examined the association between anemia at the very early postpartum period and long-term atherosclerotic-related morbidity.

PATIENTS AND METHODS

A retrospective study including women who gave birth between 1988 and 2013 was conducted. The women were divided into two groups according to hemoglobin (Hb) value on the first day after delivery: Hb <10 g/dL and Hb ≥10 g/dL. We examined the rates of hospitalization due to atherosclerotic-related morbidity, which were classified into minor and major events. The follow-up period was from the index birth until either hospitalization or the end of study period. Survival estimates were calculated by Kaplan-Meier survival analysis. Cox proportional hazards models were used to evaluate whether Hb <10 gr/dL is an independent risk factor for long-term atherosclerotic events.

RESULTS

The study population included 30,088 (37.40%) women with Hb <10 g/dL and 50,354 (63%) women with Hb ≥10 g/dL at the index birth. The hospitalization incidence density was higher in the Hb <10 g/dL group versus the Hb ≥10 g/dL group, for total atherosclerotic- related hospitalizations (4.35 vs. 3.76, p < 0.001), and hospitalization for major events (1.83 vs. 1.51, p < 0.001) and minor events (2.60 vs. 2.31, p < 0.001). In Cox proportional hazards models, it was demonstrated that Hb <10 g/dL was independently associated with total hospitalizations (HR 1.13; CI: 1.04-1.24 p = 0.004) and hospitalizations for major events (HR 1.16; CI: 1.01-1.34 p = 0.034) Conclusions: Hb <10 g/dL at the very early postpartum period might be a marker for long-term atherosclerotic-related morbidity.

Anemia in children: prevalence, causes, diagnostic work-up, and long-term consequences

INTRODUCTION

Anemia in children is a major public health problem throughout the world. It is often multifactorial, iron deficiency being the most frequent etiology. Consequences are diverse and largely under evaluated. Areas covered: This paper briefly reviews the main causes and focus on the potential consequences of acute and chronic anemia in children. Expert commentary: Anemia in children should never be trivialized. Even if iron deficiency is frequently involved, other potentially life-threatening causes are possible and should be looked for. The exact contribution of anemia to child mortality and morbidity is difficult to assess because of overlapping comorbidities. Chronic anemia may impair growth, cardiac function and cognitive development in infants but other consequences are rather poorly described and should be explored more thoroughly.