Long-term complications of stroke and secondary prevention: an overview for primary care physicians

Primary Health Care in transitional care of people with stroke

OBJECTIVES

to understand the role of Primary Health Care teams in caring for people with stroke after hospital discharge.

METHODS

single case study, with integrated units of analysis, with a qualitative approach. Data triangulation occurred through interviews with professionals and family caregivers involved in transition of care, in addition to direct observations in rounds and document analysis. For the analyses, the analytical strategies of theoretical propositions and construction of explanations were used, with the help of ATLAS.ti®.

RESULTS

the importance of counter-referral, the role of community health workers and the multidisciplinary team, health promotion, secondary prevention, home visits as a visceral attribute and nurses as care managers are evident.

FINAL CONSIDERATIONS

the high demand on teams and the Social Determinants of Health interfere with adequate continuity of care. Transitional care programs that enable continuity of care are recommended.

Effectiveness of an institution-based adapted physical activity programme versus a home-based self-management programme for chronic poststroke adults: protocol for a randomised controlled study

INTRODUCTION

Physical activity (PA) protects the cardiovascular system and reduces the risk of stroke recurrence. However, most stroke survivors have significantly lower daily PA levels than those recommended. Adapted PA programmes provide a useful means of increasing the daily PA levels of this population. PA programmes designed to encourage people walking have been found to be more effective than no intervention. Some programmes have been applied in institutional settings while others are done on an independent basis. The aim of this study will be to compare the two methods in terms of their impact on the daily walking rates of subjects with spastic hemiparesis following a chronic stroke. Secondary outcomes will include effects on walking ability, endurance, balance, quality of life and motivation for exercise.

METHODS AND ANALYSIS

This French single-centre randomised (1:1), controlled, two-arm, parallel, single-blind study will include 40 adults with chronic stroke spastic hemiparesis who are able to walk for 6 min. The primary outcome will be the participants' daily activity measured via the number of steps performed per day using a Stepwatch device. We expect to establish that the institution-based programme will be more effective than a self-managed programme as a means of increasing the PA of chronic stroke subjects.

ETHICS AND DISSEMINATION

The protocol was approved by an independent National Ethics Committee (Comité de Protection des personnes Est IV). Participants will be asked to provide their signed informed consent prior to the study. The results will be disseminated via publications in the scientific literature, oral and poster presentations by partners at international scientific meetings and associations of patients.

TRIAL REGISTRATION

NCT06061770.

Effect of Specific mode electroacupuncture stimulation combined with NGF during the ischaemic stroke: Study protocol for a randomized controlled trial

BACKGROUND

The emergence of the Nerve Growth Factor (NGF) has promoted the development of neuroprotective therapy; however, it has little effect on cerebral ischemia because of its poor Blood-Brain Barrier (BBB) permeability. Specific Mode Electroacupuncture Stimulation (SMES) can open BBB safely and effectively; however, it has shown inconclusive clinical effects and indirect clinical evidence in the recovery phase. Hence, the authors conducted a multicentre, randomized, placebo-controlled, assessor-blinded clinical trial to assess the effectiveness and safety of SMES combined with NGF treatment used during ischaemic stroke recovery.

METHODS

A total of 288 stroke patients from three hospitals will be recruited and randomly allocated to four groups: acupuncture + placebo, acupuncture + NGF, SMES + placebo, and SMES + NGF, in a 1:1:1:1 ratio. Assessment data will be collected at baseline, 2-weeks, and 4-weeks during the treatment period, as well as at the 4-week and 8-week follow-up after treatment completion. The primary outcome measure will be the basic cure rate. The secondary outcome measures include the simplified Modified Barthel Index, Timed Up and Go Test, Fugl-Meyer Assessment of Motor Function Score, Tinetti Performance Oriented Mobility Assessment, Montreal Cognitive Assessment, and Loewenstein Occupational Therapy Cognitive Assessment. Moreover, resting-state functional magnetic resonance imaging and Functional near-infrared spectroscopy can detect changes in cerebral blood flow and brain function and investigate the relationship between the clinical efficacy and mechanism of the prescribed interventions.

CONCLUSION

This study will provide clinical evidence for the efficacy and safety of SMES combined with NGF in the treatment of stroke patients.

Exploring the Poststroke Experiences and Needs of South Asian Communities Living in High-Income Countries: Findings from a Scoping Review

Despite the high prevalence of stroke among South Asian communities in high-income countries, a comprehensive understanding of their unique experiences and needs after stroke is lacking. This study aimed to synthesize the literature examining the experiences and needs of South Asian community members impacted by stroke and their family caregivers residing in high-income countries. A scoping review methodology was utilized. Data for this review were identified from seven databases and hand-searching reference lists of included studies. Study characteristics, purpose, methods, participant characteristics, results, limitations, recommendations, and conclusions were extracted. Data were analyzed using descriptive qualitative analysis. In addition, a consultative focus group exercise with six South Asian community members who had experienced a stroke and a program facilitator was conducted to inform the review interpretations. A total of 26 articles met the inclusion criteria and were analyzed. Qualitative analysis identified four descriptive categories: (1) rationale for studying the South Asian stroke population (e.g., increasing South Asian population and stroke prevalence), (2) stroke-related experiences (e.g., managing community support versus stigma and caregiving expectations), (3) stroke service challenges (e.g., language barriers), and (4) stroke service recommendations to address stroke service needs (e.g., continuity of care). Several cultural factors impacted participant experiences, including cultural beliefs about illness and caregiving. Focus group participants from our consultation activity agreed with our review findings. The clinical and research recommendations identified in this review support the need for culturally appropriate services for South Asian communities across the stroke care continuum; however, more research is necessary to inform the design and structure of culturally appropriate stroke service delivery models.

Association of depressive symptom severity and suicidal ideation with health-related quality of life among stroke survivors, NHANES 2005-2018

Stroke, a critical health issue in the US, not only has physical repercussions but also potentially affects the health-related quality of life (HRQoL) through neuropsychiatric outcomes like depressive symptoms and suicidal thoughts. This study utilized a nationally representative sample of 1302 US stroke survivors (age ≥ 20) from the US National Health and Nutrition Examination Survey (2005-2018) to assessed relationships between QoL via the CDC HRQOL-4 and evaluated depressive symptoms and suicidal ideation using the Patient Health Questionnaire-9 (PHQ-9). Participants (mean age: 64.4; 56.0 % female) showed that 40.7 % had at least mild depressive symptoms, and 18.8 % exhibited major depressive symptoms. Suicidal ideation was reported by 8.1 %. After sociodemographic and health condition adjustments, mild and major depressive symptoms, along with suicidal ideation, were associated with poorer general health status and more physically and mentally unhealthy days and activity limitation days. A dose-response relationship between PHQ-9 scores and HRQoL outcomes was evident (All P for trend <0.001). Stroke survivors with suicidal ideation also experienced more physically and mentally unhealthy days and activity limitation days. Depressive symptoms and suicidal ideation are associated with reduced HRQoL among US stroke survivors, underscoring the importance of thorough neuropsychiatric evaluations and interventions to bolster stroke survivors' well-being.

Effectiveness and tolerability of brivaracetam in patients with epilepsy stratified by comorbidities and etiology in the real world: 12-month subgroup data from the international EXPERIENCE pooled analysis

OBJECTIVE

To assess the effectiveness and tolerability of brivaracetam (BRV) in adults with epilepsy by specific comorbidities and epilepsy etiologies.

METHODS

EXPERIENCE/EPD332 was a pooled analysis of individual patient records from several non-interventional studies of patients with epilepsy initiating BRV in clinical practice. Outcomes included ≥ 50% reduction from baseline in seizure frequency, seizure freedom (no seizures within prior 3 months), continuous seizure freedom (no seizures since baseline), BRV discontinuation, and treatment-emergent adverse events (TEAEs) at 3, 6, and 12 months. Analyses were performed for all adult patients (≥ 16 years of age) and stratified by comorbidity and by etiology at baseline (patients with cognitive/learning disability [CLD], psychiatric comorbidity, post-stroke epilepsy, brain tumor-related epilepsy [BTRE], and traumatic brain injury-related epilepsy [TBIE]).

RESULTS

At 12 months, ≥ 50% seizure reduction was achieved in 35.6% (n = 264), 38.7% (n = 310), 41.7% (n = 24), 34.1% (n = 41), and 50.0% (n = 28) of patients with CLD, psychiatric comorbidity, post-stroke epilepsy, BTRE, and TBIE, respectively; and continuous seizure freedom was achieved in 5.7% (n = 318), 13.7% (n = 424), 29.4% (n = 34), 11.4% (n = 44), and 13.8% (n = 29), respectively. During the study follow-up, in patients with CLD, psychiatric comorbidity, post-stroke epilepsy, BTRE, and TBIE, 37.1% (n = 403), 30.7% (n = 605), 33.3% (n = 51), 39.7% (n = 68), and 27.1% (n = 49) of patients discontinued BRV, respectively; and TEAEs since prior visit at 12 months were reported in 11.3% (n = 283), 10.0% (n = 410), 16.7% (n = 36), 12.5% (n = 48), and 3.0% (n = 33), respectively.

CONCLUSIONS

BRV as prescribed in the real world is effective and well tolerated among patients with CLD, psychiatric comorbidity, post-stroke epilepsy, BTRE, and TBIE.

Seizure prediction in stroke survivors who experienced an infection at skilled nursing facilities-a machine learning approach

Background

Infections and seizures are some of the most common complications in stroke survivors. Infections are the most common risk factor for seizures and stroke survivors that experience an infection are at greater risk of experiencing seizures. A predictive model to determine which stroke survivors are at the greatest risk for a seizure after an infection can be used to help providers focus on prevention of seizures in higher risk residents that experience an infection.

Methods

A predictive model was generated from a retrospective study of the Long-Term Care Minimum Data Set (MDS) 3.0 (2014-2018, n = 262,301). Techniques included three data balancing methods (SMOTE for up sampling, ENN for down sampling, and SMOTEENN for up and down sampling) and three feature selection methods (LASSO, Recursive Feature Elimination, and Principal Component Analysis). One balancing and one feature selection technique was applied, and the resulting dataset was then trained on four machine learning models (Logistic Regression, Random Forest, XGBoost, and Neural Network). Model performance was evaluated with AUC and accuracy, and interpretation used SHapley Additive exPlanations.

Results

Using data balancing methods improved the prediction performances of the machine learning models, but feature selection did not remove any features and did not affect performance. With all models having a high accuracy (76.5%-99.9%), interpretation on all four models yielded the most holistic view. SHAP values indicated that therapy (speech, physical, occupational, and respiratory), independence (activities of daily living for walking, mobility, eating, dressing, and toilet use), and mood (severity score, anti-anxiety medications, antidepressants, and antipsychotics) features contributed the most. Meaning, stroke survivors who received fewer therapy hours, were less independent, had a worse overall mood were at a greater risk of having a seizure after an infection.

Conclusion

The development of a tool to predict seizure following an infection in stroke survivors can be interpreted by providers to guide treatment and prevent complications long term. This promotes individualized treatment plans that can increase the quality of resident care.

Exploring different stroke populations' information needs: a cross-sectional study in England

BACKGROUND

While tailored information might have the potential to motivate stroke survivors to make essential lifestyle changes and improve long-term outcomes, how this varies among different stroke populations is not yet fully understood.

METHOD

From November 2022 to May 2023, stroke survivors in the UK, who were clinically stable, participated in a community-based, descriptive cross-sectional study. Participants rated several information themes on a Likert scale from one to five, indicating the relevance of each information group to them. Data were analysed using Wilcoxon and chi-squared tests on SPSS. Descriptive statistics were employed for examining the preferred information delivery method, timing, personnel, and frequency.

RESULTS

Seventy survivors, with an average age of 67 ± 19 (61% males), were recruited. Survivors emphasised the importance of symptoms, risk factors, and recovery information during hospital stay, while medication and lifestyle change information were more significant in the community. Subgroup analysis revealed distinct patterns: First-time stroke survivors highlighted the importance of social and financial support (acute phase median Likert score 3, chronic phase median Likert score 4; p < 0.01), while those with prior strokes emphasised information on driving and working after stroke (acute phase median Likert score 4, chronic phase median Likert score 3; p < 0.05). Survivors recruited after six months of stroke prioritised knowledge of carer support in the community (acute phase median Likert score 3.5, chronic phase median Likert score 4; p < 0.01).

CONCLUSION

Survivors' information needs differ depending on factors such as the recovery phase, type of stroke, time since diagnosis, and the presence of a previous stroke. Considering these factors is essential when developing or providing information to stroke survivors.

Assistive Technology utilization among stroke survivors in Kano, Northwest Nigeria: A cross-sectional study

Mobility impairments and participation restrictions are common occurrences post-stroke, which may necessitate the need to utilize Assistive Technology (AT). This study investigated the prevalence, pattern, and satisfaction with AT utilization in stroke survivors (SS). The study was conducted in two hospitals in Kano, Nigeria. The QUBEC user evaluation of satisfaction with AT (QUEST) questionnaire and the Rivermead Mobility Index were used to assess satisfaction with AT utilization and mobility, respectively. Pearson correlation and independent t-test were used to determine the relationship and gender difference among the outcomes, respectively. A total of 280 SS participated; however, only 115 (41.07%) were AT users. The commonly used AT was wheelchair 84 (73%), while the least used was walking frame 3 (2.6%). About two-thirds of the participants were quite or very satisfied with their ATs. The duration of AT utilization is positively related to stroke duration (r = 0.940) but negatively related to mobility level (r = -0.246). There is no significant gender difference in duration and satisfaction with AT utilization. AT like wheelchairs seems uncommonly utilized among SS in Kano, Nigeria, likely due to patients' lack of knowledge of use, economic factors, and culture among others.

Virtual Reality Self Co-Embodiment: An Alternative to Mirror Therapy for Post-Stroke Upper Limb Rehabilitation

We present Virtual Reality Self Co-embodiment, a new method for post-stroke upper limb rehabilitation. It is inspired by mirror therapy, where the patient's healthy arm is involved in recovering the affected arm's motion. By tracking the user's head, wrists, and fingers' positions, our new approach allows the handicapped arm to control a digital avatar in order to pursue a reaching task. We apply the concept of virtual co-embodiment to use the information from the unaffected arm and complete the affected limb's impaired motion, which is our added unique feature. This requires users to mechanically involve the incapacitated area as much as possible, prioritizing actual movement rather than the sole imagination of it. As a result, subjects will see a seemingly normally functional virtual arm primarily controlled by their handicapped extremity, but with the constant support of their healthy limb's motion. Our experiment compares the task execution performance and embodiment perceived when interacting with both mirror therapy and our proposed technique. We found that our approach's provided sense of ownership is mildly impacted by users' motion planning response times, which mirror therapy does not exhibit. We also observed that mirror therapy's sense of ownership is moderately affected by the subject's proficiency while executing the assigned task, which our new method did not display. The results indicate that our proposed method provides similar embodiment and rehabilitation capabilities to those perceived from existing mirror therapy. This experiment was performed in healthy individuals to have an unbiased comparison of how mirror therapy's and VRSelfCo's task performance and degree of virtual embodiment compare, but future work explores the possibility of applying this new approach to actual post-stroke patients.

Red blood cell distribution width as a predictor of mortality and poor functional outcome after acute ischemic stroke: a meta-analysis and meta-regression

BACKGROUND

This study aimed to review evidence on the ability of red cell distribution width (RDW) to predict mortality and poor functional outcomes after acute ischemic stroke (AIS).

METHODS

Databases of PubMed, CENTRAL, Scopus, Embase, and Web of Science were searched online from inception to 25th Jul 2023 for all studies reporting the association between RDW and outcomes as adjusted ratios. A random-effects meta-analysis was done. Meta-regression was conducted using multiple moderators.

RESULTS

15 studies with 14,968 patients were included. Meta-analysis found that RDW, both as a categorical variable (OR: 2.10 95% CI: 1.74, 2.55 I2 = 42%) and continuous variable OR: 1.16 95% CI: 1.05, 1.28 I2 = 64%) was a significant predictor of mortality after AIS. Age and number of hypertensives were found to be significant moderators in the meta-regression. Also, high RDW, as a categorical variable (OR: 1.68 95% CI: 1.20, 2.35 I2 = 84%), was associated with significantly higher odds of poor functional outcomes after AIS, but not as a continuous variable (OR: 1.07 95% CI: 0.99, 1.16 I2 = 61%). Meta-regression showed that the association was stronger in small sample-sized studies.

CONCLUSION

RDW can be a useful, readily available, and cost-effective biomarker to rapidly stratify AIS patients at risk of poor outcomes. High RDW was consistently associated with an increased risk of mortality after AIS, however, its ability to predict poor functional outcomes needs to be verified by further studies.

The Effectiveness of Upper Extremity Orthotic Interventions on Performance Skills and Performance of Occupations for Adults after Stroke: A Scoping Review

The objective of this study was to determine the effectiveness of upper extremity orthoses on improving performance skills and performance of occupations after stroke. Databases searched included CINAHL, PubMed, and OT Seeker. Articles were included if published between 2012 to 2022, English, peer-reviewed, level of evidence IB, IIB, or IIIB, and included upper extremity orthoses, adults after a stroke, and performance skill and performance of occupation outcome measures; six studies meet inclusion criteria. Moderate strength of evidence supports the usage of dynamic upper extremity orthoses to improve performance skills, although they do not improve performance of occupations for adults after stroke. Evidence suggests practitioners should utilize dynamic orthoses concurrently with tasks that promote performance skills such as gripping, pinching, grasping, and reaching during interventions to promote upper extremity use after stroke. Additional research is needed to further justify the use of upper extremity orthoses for performance of occupations after stroke.

Management of ischaemic stroke survivors in primary care setting: the road to holistic care

The management of ischaemic stroke survivors is multidisciplinary, necessitating the collaboration of numerous medical professionals and rehabilitation specialists. However, due to the lack of comprehensive and holistic follow-up, their post-discharge management may be suboptimal. Achieving this holistic, patient-centred follow-up requires coordination and interaction of subspecialties, which general practitioners can provide as the first point of contact in healthcare systems. This approach can improve the management of stroke survivors by preventing recurrent stroke through an integrated post-stroke care, including appropriate Antithrombotic therapy, assisting them to have a Better functional and physiological status, early recognition and intervention of Comorbidities, and lifestyles. For such work to succeed, close interdisciplinary collaboration between primary care physicians and other medical specialists is required in a holistic or integrated way.

Characterization of Demographic, Clinical, and Laboratory Risk Factors for Stroke in a Tertiary Hospital in Riyadh, Saudi Arabia

Background Stroke is a major cause of death and long-term disability worldwide, with varying incidence and risk factors across different populations. This study aims to analyze demographic, clinical, and laboratory risk factors for stroke among the Saudi Arabian population to enhance the understanding of its behavior and associated mortality. Methods In this retrospective cohort study, we analyzed data from 3586 patients diagnosed with hemorrhagic or non-hemorrhagic stroke at King Fahad Medical City from January 1, 2020, to November 11, 2022. We collected data on demographic variables, past medical history, social history, nationality, and laboratory components. Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 27.0. (Armonk, NY: IBM Corp.), with significance set at p<0.05. Results The study population was predominantly male (57.86%) and within the age group of 51 to 80 years (58.8%). A significant portion of patients were Saudi nationals (99.6%), with hypertension (50.2%) and diabetes (40.4%) being the most common comorbidities. Laboratory abnormalities related to sodium and potassium levels were strongly linked to mortality rates. Notably, ischemic stroke was the most common type across all age groups, except for patients under age 16, where hemorrhagic stroke was more prevalent. Conclusions Our findings reveal significant associations between stroke risk factors and mortality within the Saudi Arabian population, highlighting the impact of hypertension, diabetes, and electrolyte imbalances. The study underscores the need for targeted stroke prevention and management strategies in Saudi Arabia, aligning with global trends to mitigate the burden of this disease.

The Role of Continuous Theta Burst Stimulation on Primary Motor Cortex in Improving Bladder Function in Post-stroke Patients: A Case Report

Neurogenic bladder (NB) is a frequently encountered post-stroke complication, characterized by symptoms, such as urinary incontinence, dysuria, increased frequency, and urgency. Here, we present a case of a 75-year-old male with urgent urination, frequent urination, urinary incontinence, conspicuous discomfort during urination, and an unpleasant smell in the urine following a stroke. By reviewing the patient's previous medical records of stroke and ruling out other potential causes for bladder dysfunction, a diagnosis of NB could be established. We implemented conventional physical therapy, pelvic floor muscle training with the electromyography biofeedback device, and continuous theta burst stimulation (cTBS) on the contralesional primary motor cortex area to manage bladder function. To the best of our knowledge, this is the first case report on cTBS applied to manage NB after stroke. Our treatment has demonstrated remarkable efficacy in enhancing bladder and kidney function, improving the overall quality of life, and alleviating anxiety and depression symptoms in this patient. This case study concludes that the noninvasive neuromodulation approach exhibits significant potential in the clinical field when addressing this specific patient population.

The efficacy of contralaterally controlled functional electrical stimulation compared to conventional neuromuscular electrical stimulation for recovery of limb function following a stroke: a systematic review and meta-analysis

Introduction

Limb paresis following a stroke is a common sequela that can impact patients' quality of life. Many rehabilitation strategies targeting the restoration of motor function exist. This systematic review and meta-analysis aim to evaluate the effects of contralaterally controlled functional electrical stimulation (CCFES) as a modality for limb rehabilitation. Unlike conventional neuromuscular electrical simulation (NMES), the contra-laterality in CCFES is achieved by two methods a bend angle sensor or an electromyographic bridge (EMGB) method, both of which targets signals from the unaffected limb.

Method

This review study was performed following the preferred reporting item for systematic review and meta-analysis (PRISMA) guidelines. Records that met the inclusion criteria were extracted from the following databases: Medline, Embase, and Cochrane Register of Controlled Trials (CENTRAL). Additional articles were also retrieved from clinicaltrials.gov and China/Asia on Demand (CAOD). Only randomized controlled studies (RCTs) were included.

Results

Sixteen RCTs met the inclusion criteria, and 14 of which were included in the quantitative analysis (meta-analysis). The results of the analysis show that when compared to conventional NMES, CCFES displayed a better improvement in the upper extremity Fugl-Meyer assessment (UEFMA) (SMD = 0.41, 95% CI: 0.21, 0.62, p-value <0.0001, I2 = 15%, GRADE: moderate), box and blocks test (BBT) (SMD = 0.48, 95% CI: 0.10, 0.86, p-value = 0.01, I2 = 0%, GRADE: very low), modified Barthel index (mBI) (SMD = 0.44, 95% CI: 0.16, 0.71, p-value = 0.002, I2 = 0%, GRADE: moderate), active range of motion (AROM) (SMD = 0.61, 95% CI: 0.29, 0.94, p-value = 0.0002, I2 = 23%, GRADE: moderate), and surface electromyography (sEMG) scores (SMD = 0.52, 95% CI: 0.14, 0.90, p-value = 0.008, I2 = 0%, GRADE: low). The results of the subgroup analysis for the type of sensor used in CCFES shows that an EMGB (SMD = 0.58, 95% CI: 0.33, 0.84, p-value <0.00001, I2 = 7%) is more effective than a bend angle sensor (SMD = 0.17, 95% CI: -0.12, 0.45, p-value = 0.25, I2 = 0%).

Conclusion

The results of this study provide strong evidence that shows CCFES being a better electrical stimulation modality compared to conventional NMES. This could be explained by the fact that CCFES is bilateral in nature which offers a platform for better neuroplasticity following a stroke. There is still a need for high-quality studies with a standardized approach comparing CCFES to other treatment modalities.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=342670, identifier CRD42022342670.

An machine learning model to predict quality of life subtypes of disabled stroke survivors

OBJECTIVE

Stroke causes serious physical disability with impaired quality of life (QoL) and heavy burden on health. The goal of this study is to explore the impaired QoL typologies and their predicting factors in physically disabled stroke survivors with machine learning approach.

METHODS

Non-negative matrix factorization (NMF) was applied to clustering 308 physically disabled stroke survivors in rural China based on their responses on the short form 36 (SF-36) assessment of quality of life. Principal component analysis (PCA) was conducted to differentiate the subtypes, and the Boruta algorithm was used to identify the variables relevant to the categorization of two subtypes. A gradient boosting machine(GBM) and local interpretable model-agnostic explanation (LIME) algorithms were used to apply to interpret the variables that drove subtype predictions.

RESULTS

Two distinct subtypes emerged, characterized by short form 36 (SF-36) domains. The feature difference between worsen QoL subtype and better QoL subtype was as follows: role-emotion (RE), body pain (BP) and general health (GH), but not physical function (PF); the most relevant predictors of worsen QoL subtypes were help from others, followed by opportunities for community activity and rehabilitation needs, rather than disability severity or duration since stroke.

INTERPRETATION

The results suggest that the rehabilitation programs should be tailored toward their QoL clustering feature; body pain and emotional-behavioral problems are more crucial than motor deficit; stroke survivors with worsen QoL subtype are most in need of social support, return to community, and rehabilitation.

Effects of the royal jelly consumption on post-stroke complications in patients with ischemic stroke: results of a randomized controlled trial

Aims

There is a paucity of evidence regarding the benefit of royal jelly (RJ) on post-stroke complications in patients with ischemic stroke. To address this knowledge gap, this randomized, triple-blind, placebo-controlled clinical trial was carried out to determine the effects of RJ consumption on post-stroke clinical outcomes.

Methods

Of 64 eligible ischemic stroke patients (45-80 years), 32 were randomized to the RJ and 32 to the placebo groups and completed a 12-week intervention. The intervention group was advised to receive 1,000 mg of RJ dragee daily after breakfast. Post-stroke complications including cognition, fatigue, mental health, and appetite, along with serum levels of brain-derived neurotrophic factor (BDNF), and mid-upper arm circumference (MUAC) were assessed in groups pre-and post-intervention.

Results

After 12 weeks of RJ consumption, cognitive function [adjusted mean difference, 4.71; 95% confidence interval (CI), 1.75 to 7.67], serum levels of BDNF (adjusted mean difference, 0.36; 95% CI, 0.05 to 0.67), stress (adjusted mean difference, -3.33; 95% CI, -6.50 to -0.17), and appetite (adjusted mean difference, 1.38; 95% CI, 0.19 to 2.56) were significantly improved. However, the findings for fatigue (adjusted mean difference, -4.32; 95% CI, -10.28 to 1.63), depression (adjusted mean difference, -1.71; 95% CI, -5.58 to 2.16), anxiety (adjusted mean difference, -2.50; 95% CI, -5.50 to 0.49), and MUAC (adjusted mean difference, 0.36; 95% CI, -0.11 to 0.84) were less favorable.

Conclusion

Findings support the benefits of RJ consumption in improving post-stroke complications and clinical outcomes.Clinical trial registration: https://www.irct.ir/trial/59275, Identifier IRCT20180818040827N4.

Alkaline phosphatase and mortality in stroke patients: a systematic review

Background

Increased plasma levels of alkaline phosphatase (ALP) have been associated to a worse prognosis in several types of diseases. In the present review, the authors aimed to study the relationship between plasma levels of ALP and overall mortality in patients with stroke.

Methods

A systematic review was carried out, searching two databases: Web of Science and Medline/PubMed.

Results

A total of nine studies that included data on overall mortality in stroke patients were selected. The selected studies were published between 2010 and 2022 and were predominantly from Asia. The articles reviewed quantified ALP levels through different methods: highest versus lowest quintiles of plasma ALP (three reports); highest versus lowest quartiles of plasma ALP (four reports); and plasma ALP levels in deceased versus in surviving patients (two reports). All selected studies showed an increased mortality associated to elevated ALP levels, irrespective of stroke type and length of follow-up, from a mean of 10 days to 2.5 years. The studies comparing the highest to the lowest ALP quintiles showed an aggregate value of 1.8 times greater risk of mortality for the former, when compared to the latter. Whereas, the studies comparing the highest to the lowest ALP quartiles showed an aggregate value of 2.4 times greater risk of mortality for the former, when compared to the latter.

Conclusions

Elevated ALP levels are associated with increased mortality in stroke patients and provide cost effective prognostic indicators of mortality in stroke.

Drivers of Chronic Pathology Following Ischemic Stroke: A Descriptive Review

Stroke is the third leading cause of death and long-term disability in the world. Considered largely a disease of aging, its global economic and healthcare burden is expected to rise as more people survive into advanced age. With recent advances in acute stroke management, including the expansion of time windows for treatment with intravenous thrombolysis and mechanical thrombectomy, we are likely to see an increase in survival rates. It is therefore critically important to understand the complete pathophysiology of ischemic stroke, both in the acute and subacute stages and during the chronic phase in the months and years following an ischemic event. One of the most clinically relevant aspects of the chronic sequelae of stroke is its extended negative effect on cognition. Cognitive impairment may be related to the deterioration and dysfunctional reorganization of white matter seen at later timepoints after stroke, as well as ongoing progressive neurodegeneration. The vasculature of the brain also undergoes significant insult and remodeling following stroke, undergoing changes which may further contribute to chronic stroke pathology. While inflammation and the immune response are well established drivers of acute stroke pathology, the chronicity and functional role of innate and adaptive immune responses in the post-ischemic brain and in the peripheral environment remain largely uncharacterized. In this review, we summarize the current literature on post-stroke injury progression, its chronic pathological features, and the putative secondary injury mechanisms underlying the development of cognitive impairment and dementia. We present findings from clinical and experimental studies and discuss the long-term effects of ischemic stroke on both brain anatomy and functional outcome. Identifying mechanisms that occur months to years after injury could lead to treatment strategies in the chronic phase of stroke to help mitigate stroke-associated cognitive decline in patients.

Social Support and Depression among Stroke Patients: A Topical Review

Research has shown a protective association between social support and depression, depression among stroke patients, and health impacts of depression. Despite this, not much is known about the effect of social support on depression among stroke patients. This review aims to summarize the current research examining the association between social support and depression among stroke patients. A literature search was performed in PubMed to find original peer-reviewed journal articles from 2016 to 12 March 2023 that examined the association between social support and depression among stroke patients. The search terms were depression and "social support" and stroke, which lead to 172 articles. After abstract review, seven observational studies that studied the target association among stroke patients were selected. One additional study was found using PsycINFO as a complementary source with the same search strategy and criteria. Overall, a negative association was found between social support and depression among stroke patients in eight studies, with more social support leading to lower rates of depression post-stroke. The other study did not find a statistically significant association. Overall, the results of recent studies suggest that social support is negatively associated with depression among stroke patients. In most studies, this association was statistically significant. The findings suggest the importance of improving social support perceived by stroke patients in the prevention of depression after the occurrence of stroke.

Effects of Virtual Reality Cognitive Training on Neuroplasticity: A Quasi-Randomized Clinical Trial in Patients with Stroke

Cognitive Rehabilitation (CR) is a therapeutic approach designed to improve cognitive functioning after a brain injury, including stroke. Two major categories of techniques, namely traditional and advanced (including virtual reality-VR), are widely used in CR for patients with various neurological disorders. More objective outcome measures are needed to better investigate cognitive recovery after a stroke. In the last ten years, the application of electroencephalography (EEG) as a non-invasive and portable neuroimaging method has been explored to extract the hallmarks of neuroplasticity induced by VR rehabilitation approaches, particularly within the chronic stroke population. The aim of this study is to investigate the neurophysiological effects of CR conducted in a virtual environment using the VRRS device. Thirty patients with moderate-to-severe ischemic stroke in the chronic phase (at least 6 months after the event), with a mean age of 58.13 (±8.33) for the experimental group and 57.33 (±11.06) for the control group, were enrolled. They were divided into two groups: an experimental group and a control group, receiving neurocognitive stimulation using VR and the same amount of conventional neurorehabilitation, respectively. To study neuroplasticity changes after the training, we focused on the power band spectra of theta, alpha, and beta EEG rhythms in both groups. We observed that when VR technology was employed to amplify the effects of treatments on cognitive recovery, significant EEG-related neural improvements were detected in the primary motor circuit in terms of power spectral density and time-frequency domains. Indeed, EEG analysis suggested that VR resulted in a significant increase in both the alpha band power in the occipital areas and the beta band power in the frontal areas, while no significant variations were observed in the theta band power. Our data suggest the potential effectiveness of a VR-based rehabilitation approach in promoting neuroplastic changes even in the chronic phase of ischemic stroke.

Exploring research trends and focal points in the application of transcranial magnetic stimulation for enhancing motor function in post-stroke patients: A bibliometric and content analytical approach

BACKGROUND

Motor impairment is a significant health concern among post-stroke patients. Transcranial magnetic stimulation (TMS) is considered as an emerging rehabilitation therapy for various neurological conditions, and the effects of excitatory TMS on post-stroke have received much attention in past decade. However, the future hotspots and content analysis on the growth trends have not been studied. This bibliometric and content analysis aimed to study the global developmental history and current status of TMS for motor function of post-stroke from January 2004 to July 2023.

METHODS

Literature published on Scopus database from January 2004 to July 2023 were searched. Extracted data was analysed using the R studio and VOS viewer for author's publication, institutions, sources, keyword co-occurrence and world network analysis. Keyword cluster analysis, co-citation analysis for references and content analysis were also performed. We screened top 10 most cited or collaborative areas for publications, institutions and sources in the field of TMS associated with motor function of post-stroke.

RESULTS

In this study, a comprehensive analysis of 267 publications was conducted, revealing a substantial surge in research output throughout 2022. China emerged as the leading contributor, with 409 publications, followed by the United States with 211 publications. Notably, Harvard Medical School stood out as one of the most prolific institutions, accounting for 34 publications (13.12 %). Among researchers, Abo M garnered the highest publication count, with 9 articles (14.5 %). The Word cloud showed that motor function, repetitive transcranial magnetic stimulation (rTMS) and upper limb have been the focus of recent attention. Burst keywords on thematic evolution and topic trend shows that quality of life scale, network parameters, cognition, lower limb motor function are the future trends.

CONCLUSION

This bibliometric study describes that TMS has shown promising results in improving motor function of upper extremity in stroke patients, the long-term effects and durability of these improvements are still being investigated. Future research might focus on understanding the optimal duration and frequency of TMS sessions for sustained motor recovery and exploring strategies to maintain gains achieved through TMS over extended periods of time. Future studies can investigate the changes in the lower limb motor function.

Lipid profiles and lifestyle habits of stroke survivors in the east coast region of peninsular Malaysia: Preliminary findings

Background: Stroke survivors are at high risk for recurrent cardiovascular events if no prevention strategies are undertaken. Aim: This study aimed to investigate the fasting serum lipid profiles and lifestyle habits in stroke survivors, and the factors associated with suboptimal lipid profiles. Methods: A cross-sectional retrospective study was conducted in three public hospitals in Malaysia. Stroke survivors' data regarding the socio-demographic characteristics, clinical profiles, fasting serum lipid profiles, dietary adherence, and physical activity levels were acquired. Binary logistic regression was used to examine the factors associated with suboptimal lipid goals. Results: A total of 104 stroke survivors were recruited from patients attending the neurology and rehabilitation departments. Only 22% of the stroke survivors attained the targeted low-density lipoprotein cholesterol level (LDL-C < 1.8 mmol/L). Meanwhile, more than two thirds of patients achieved the targeted total cholesterol, triglyceride, and high-density lipoprotein cholesterol goals. Patients with a longer stroke duration (Adjusted odds ratio, AOR 3.33, 95% confidence intervals, CI: 1.09, 10.13, p  =  0.034), elevated blood pressure (AOR 4.74, 95% CI: 1.65, 13.62, p  =  0.004), chronic kidney disease (AOR 3.30, 95% CI: 1.05, 10.34, p  =  0.041), abdominal obesity (AOR 3.14, 95% CI: 1.20, 8.21, p  =  0.020), excessive energy intake (AOR 2.72, 95% CI: 1.07, 6.91, p  =  0.036), and excessive saturated fatty acids intake (AOR 2.85, 95% CI: 1.02, 7.93, p  =  0.045) were significantly associated with suboptimal lipid profiles. Conclusion: The lipid goals attainment was low, particularly the LDL-C levels among Malaysian stroke survivors. Greater efforts are warranted to fully utilise the lipid-lowering therapy and the lifestyle changes in these high-risk patients.

Dietary Intake and Quality among Stroke Survivors: NHANES 1999-2018

BACKGROUND

Nutrition is an important modifiable risk factor for prevention and treatment of stroke. However, examination of nutrient intake and diet quality in stroke survivors is limited.

OBJECTIVES

The aim of the study was to estimate usual nutrient intake and diet quality in US adults with and without a history of self-reported stroke.

METHODS

Using US National Health and Nutrition Examination Survey (NHANES) 1999-2018, we analyzed demographics, health history, and dietary intake data in 1626 individuals with a history of stroke matched for age, gender, and survey cycle to respective controls (n=1621) with no history of stroke. A minimum of one 24-h dietary recall was used to assess dietary intake. Diet quality was determined using Healthy Eating Index 2015 (HEI-2015) scores. Adult food security was assessed based on responses to the US Department of Agriculture Household Food Security Survey Module. Physical and mental limitations were assessed from responses to the NHANES Physical Functioning Questionnaire. Estimates were reported as mean (standard error).

RESULTS

In comparison to controls, stroke survivors were more likely to be food insecure, experience poverty, and report physical and mental limitations (P < .001, all comparisons). Stroke survivors were more likely to report excessive (% > acceptable macronutrient distribution range) intake for total fat (50.9 [2.7]% vs. 40.4 [2.2]%, P < .001) and inadequate intake (% < estimated average requirement) for calcium (54.6 [1.8]% vs. 43.5 [2.4]%, P = .001) and magnesium (66 [1.8] vs. 53.6 [1.8]%, P < .001). In addition, stroke survivors reported lower HEI-2015 total scores than controls (49.8 vs. 51.9, P < .001). Finally, HEI-2015 total scores were lower in stroke survivors who were food insecure and those with a lower income-to-poverty ratio (< 185%) (P = .001).

CONCLUSIONS

Dietary intake in stroke survivors was nutritionally poor, with suboptimal nutrient intake and lower overall diet quality compared with age- and gender-matched controls. Furthermore, poverty and food insecurity were more prevalent in stroke survivors and associated with worse diet quality.

Effectiveness of a family-based program for post-stroke patients and families: A cluster randomized controlled trial

Objective

To examine the effectiveness of a family-based program for post-stroke patients and their families.

Methods

A cluster randomized controlled trial design was used. Participants were randomly selected in the experimental group (3 districts) and the comparison group (3 districts), with 62 families recruited. Sixty-two persons with new stroke and families (family caregivers and family members) who met the inclusion criteria were assigned to two groups, 31 in each group. Using the Neuman System Model as a framework, we implemented the stressors assessment and family-based intervention into the program. Participants in the comparison group received usual care, and those in the experimental group underwent a stressors assessment and received the family-based program. Measurement of functional status, depression, and complications in post-stroke patients and family function in family caregivers and family members, as well as caregiver burden and caregiver stress in family caregivers, were assessed at baseline, 4 weeks, and 12 weeks after enrollment. Data analysis included descriptive statistics, the chi-square test, Bonferroni test, and repeated measures analysis of variance.

Results

After participating in a 12-week family-based program, post-stroke patients in the experimental group showed statistically significant improvements in their functional status and decreased depression compared to the comparison group (P < 0.05). The family function of the experimental group was significantly improved, and caregivers' burden and stress were decreased compared to the comparison group (P < 0.05). Three patients in the experimental group and seven in the comparison group experienced complications.

Conclusions

The study findings suggest that the present family-based program improved family function in family caregivers and family members and decreased caregiver burden and stress in family caregivers. The program also improved functional status and reduced depression in post-stroke patients. It is suggested the duration of the program be extended to assess its sustainable effectiveness.

Long-term behavioural alterations in mice following transient cerebral ischemia

Ischemic stroke is one of the leading causes of disability and mortality worldwide. Acute and chronic post-stroke changes have variable effects on the functional outcomes of the disease. Therefore, it is imperative to identify what daily activities are altered after stroke and to what extent, keeping in mind that ischemic stroke patients often have long-term post-stroke complications. Translational studies in stroke have also been challenging due to inconsistent study design of animal experiments. The objective of this study was to clarify whether and to what extent mouse behaviour was altered during a 6 months period after cerebral stroke. Experimental stroke was induced in mice by intraluminal filament insertion into the middle cerebral artery (fMCAo). Neurological deficits, recovery rate, motor performance, and circadian activity were evaluated following ischemia. We observed severe neurological deficits, motor impairments, and delay in the recovery rate of mice during the first 14 days after fMCAo. Aberrant circadian activity and distorted space map were seen in fMCAo mice starting one month after ischemia, similarly to altered new and familiar cage activity and sucrose preference using the IntelliCage, and was still evident 60- and 180- days following stroke in the voluntary running wheel using the PhenoMaster system. A preference towards ipsilateral side turns was observed in fMCAo mice both acutely and chronically after the stroke induction. Overall, our study shows the importance of determining time-dependent differences in the long-term post-stroke recovery (over 180 days after fMCAo) using multiple behavioural assessments.

Payer formulary tier increases of apixaban: how patients respond and potential implications

OBJECTIVE

To assess potential impacts of formulary tier increases of apixaban-an efficacious oral anticoagulant (OAC) for preventing stroke in patients with atrial fibrillation (AF)-on patients' prescription drug plan (PDP) switching and OAC treatment patterns.

METHODS

Nationwide claims data for Medicare beneficiaries with Parts A, B, and D (100% sample) were used to assess apixaban-treated AF patients who faced a formulary tier increase for apixaban in 2017 by their Part D PDP. Patients' out-of-pocket (OOP) costs for apixaban were described, along with PDP switching and OAC treatment patterns.

RESULTS

Among 1845 included patients, 97.7% had apixaban on tier 3 of their plan's formulary in 2016 and faced its increase to tier 4 for 2017. Approximately 4% (N = 81) of patients pre-emptively switched to a different PDP for 2017 with almost all switching to plans with apixaban on a lower formulary tier and 85.2% continuing apixaban treatment. Among the 96% (N = 1764) of patients who remained on the same PDP for 2017, over half (57.5%) continued apixaban treatment, despite increased OOP costs ($54 vs. $135 for a 30-day supply in 2016 vs. 2017). Only 12.4% of those who remained on the same plan for 2017 switched to another OAC, while as much as 30.1% discontinued OACs. These discontinuers exhibited higher comorbidity burdens than patients continuing on any OAC.

CONCLUSION

The majority of patients continued on apixaban despite higher OOP cost, suggesting patients' reluctance to change treatment for non-medical reasons; however, 30% of patients discontinued OAC treatment after higher apixaban tier placement.

Pilot Study of Cytoprotective Mechanisms of Selenium Nanorods (SeNrs) under Ischemia-like Conditions on Cortical Astrocytes

The cytoprotective properties of the trace element selenium, its nanoparticles, and selenium nanocomplexes with active compounds are shown using a number of models. To date, some molecular mechanisms of the protective effect of spherical selenium nanoparticles under the action of ischemia/reoxygenation on brain cells have been studied. Among other things, the dependence of the effectiveness of the neuroprotective properties of nanoselenium on its diameter, pathways, and efficiency of penetration into astrocytes was established. In general, most research in the field of nanomedicine is focused on the preparation and study of spherical nanoparticles of various origins due to the ease of their preparation; in addition, spherical nanoparticles have a large specific surface area. However, obtaining and studying the mechanisms of action of nanoparticles of a new form are of great interest since nanorods, having all the positive properties of spherical nanoparticles, will also have a number of advantages. Using the laser ablation method, we managed to obtain and characterize selenium nanorods (SeNrs) with a length of 1 μm and a diameter of 100 nm. Using fluorescence microscopy and inhibitory analysis, we were able to show that selenium nanorods cause the generation of Ca2+ signals in cortical astrocytes in an acute experiment through the mobilization of Ca2+ ions from the thapsigargin-sensitive pool of the endoplasmic reticulum. Chronic use of SeNrs leads to a change in the expression pattern of genes encoding proteins that regulate cell fate and protect astrocytes from ischemia-like conditions and reoxygenation through the inhibition of a global increase in the concentration of cytosolic calcium ([Ca2+]i). An important component of the cytoprotective effect of SeNrs during ischemia/reoxygenation is the induction of reactive A2-type astrogliosis in astrocytes, leading to an increase in both baseline and ischemia/reoxygenation-induced phosphoinositide 3-kinase (PI3K) activity and suppression of necrosis and apoptosis. The key components of this cytoprotective action of SeNrs are the actin-dependent process of endocytosis of nanoparticles into cells and activation of the Ca2+ signaling system of astrocytes.

Current evidence, clinical applications, and future directions of transcranial magnetic stimulation as a treatment for ischemic stroke

Transcranial magnetic stimulation (TMS) is a non-invasive brain neurostimulation technique that can be used as one of the adjunctive treatment techniques for neurological recovery after stroke. Animal studies have shown that TMS treatment of rats with middle cerebral artery occlusion (MCAO) model reduced cerebral infarct volume and improved neurological dysfunction in model rats. In addition, clinical case reports have also shown that TMS treatment has positive neuroprotective effects in stroke patients, improving a variety of post-stroke neurological deficits such as motor function, swallowing, cognitive function, speech function, central post-stroke pain, spasticity, and other post-stroke sequelae. However, even though numerous studies have shown a neuroprotective effect of TMS in stroke patients, its possible neuroprotective mechanism is not clear. Therefore, in this review, we describe the potential mechanisms of TMS to improve neurological function in terms of neurogenesis, angiogenesis, anti-inflammation, antioxidant, and anti-apoptosis, and provide insight into the current clinical application of TMS in multiple neurological dysfunctions in stroke. Finally, some of the current challenges faced by TMS are summarized and some suggestions for its future research directions are made.

Stroke and molecular imaging: a focus on FDG-PET

Stroke is the leading cause of disability worldwide, the second most common cause of dementia and the third leading cause of death. Though the etiology of stroke has been explored extensively, there remains open questions in the scientific and clinical study of stroke. Traditional imaging techniques, such as magnetic resonance imaging and computed tomography, have been applied extensively and remain mainstays in clinical practice. Nevertheless, positron emission tomography has proven to be a powerful molecular imaging tool in exploring the scientific aspects of neurological disease, and stroke remains an area of great interest. This review article examines the role of positron emission tomography in the study of stroke including its contributions to elaborating related pathophysiology and delving into possible clinical applications.

Vagal Nerve Activity and Short-Term Clinical Outcomes after Stroke: What Is Left May Not Be Right

Stroke is a leading cause of death worldwide. Multiple factors influence the severity of stroke. Normal functional and biological differences seen between the hemispheres may also be related to stroke severity. In the present study, we examined the differences in the severity of stroke as a function of stroke side, and whether patients' vagal nerve activity moderated such differences. We included 87 patients with an ischemic stroke, whose medical records were retrospectively examined for background information (age, gender), stroke side and severity by NIHSS, length of stay in hospital, inflammation such as C-reactive protein, and vagal nerve activity. The vagal activity was indexed by patients' heart-rate variability (HRV), fluctuations in the intervals between normal heartbeats, derived from patients' ECG. Results revealed that patients with left-side stroke had significantly worse NIHSS scores (10.6) than those with right-sided stroke (7.6, p < 0.05). However, when dividing the sample into those with low versus high HRV (at the median), only when HRV was low, did patients with left-side stroke have a worse NIHSS score (10.9) compared to those with right-sided stroke (6.5, p < 0.05). In contrast, no differences in stroke severity were seen between left stroke (10.2) and right stoke (8.7, p > 0.05), when HRV was high. These results tended to remain the same when statistically controlling for age effects, which was related to NIHSS, but not to the stroke side. These findings suggest that patients with left-sided stroke may have more severe strokes than those with right-sided ones, but that adequate vagal nerve activity may protect against such differences. Possible mechanisms and suggestions for future directions are provided.

Role of Urological Botulinum Toxin-A Injection for Overactive Bladder and Voiding Dysfunction in Patients with Parkinson's Disease or Post-Stroke

Botulinum toxin A (BoNT-A) paralyzes muscle by blocking acetylcholine release at the synaptic junction. BoNT-A has shown its therapeutic effects in neurological disorders such as Parkinson's disease (PD) and post-stroke spasticity. A high proportion of patients with PD and post-stroke develop neurogenic detrusor overactivity (nDO) and then develop urinary incontinence and overactive bladder (OAB) symptoms. This study aimed to disclose the safety and efficacy of BoNT-A injection in treating bladder and voiding dysfunction in PD and post-stroke patients by reviewing the current evidence. At present, intradetrusor injection of BoNT-A is a Food and Drug Administration (FDA)-approved third-line therapy for nDO and idiopathic OAB. Although intradetrusor injection of onaBoNT-A 200 U is already approved for nDO treatment, most researchers would like to manage PD and post-stroke patients by using onaBoNT-A 100 U intradetrusor injection to achieve long-term efficacy and reduce adverse effects. However, in contrast to its inclusion in the International Continence Society guidelines for PD treatment, the clinical use of BoNT-A for post-stroke patients is limited to experimental use due to the development of urinary retention in about one-fifth of patients. For treating urethral pseudodyssynergia, half of patients may respond to onaBoNT-A 100 U urethral injection. However, refinement is needed to reduce unwanted urinary incontinence.

Astrocytosis, Inflammation, Axonal Damage and Myelin Impairment in the Internal Capsule following Striatal Ischemic Injury

Secondary degeneration is defined as a set of destructive events that damage cells and structures that were initially spared or only peripherally affected by the primary insult, constituting a key factor for functional impairment after traumatic brain injury or stroke. In the present study, we evaluated the patterns of astrocytosis, inflammatory response, axonal damage and oligodendrocytes/myelin impairment in the internal capsule following a focal injection of endothelin-1 (ET-1) into the dorsal striatum. Animals were perfused at 1, 3 and 7 post-lesion days (PLD), and tissue was processed to immunohistochemistry for neutrophils (MBS1), macrophages/microglia (ED1), astrocytes (GFAP), axonal lesion (βAPP), oligodendrocytes (Tau) and myelin (MBP). A significant number of neutrophils was observed at 1PLD, followed by intense recruitment/activation of macrophages/microglia at 3PLD and astrocytic reaction with a peak at 7PLD. Oligodendrocyte damage was pronounced at 3PLD, remaining at 7PLD. Progressive myelin impairment was observed, with reduction of immunoreactivity at 7PLD. Axonal lesion was also identified, mainly at 7PLD. Our results indicate that acute inflammatory response elicited by the ischemic insult in the striatum can be associated with the axonal impairment and damage of both oligodendrocytes and myelin sheath identified in the internal capsule, which may be related to loss of tissue functionality observed in secondary degeneration.

Short-Term Exposure to Ambient Air Pollution and Hospital Admissions for Sequelae of Stroke in Chinese Older Adults

Extensive evidence suggests that ambient air pollution contributes to a higher risk of hospital admissions for cerebrovascular diseases; however, its association with admissions for sequelae of stroke remains unclear. A time-stratified case-crossover study was conducted among 31,810 older adults who were admitted to hospital for sequelae of stroke in Guangzhou, China during 2016-2019. For each subject, daily residential exposure to fine particulate matter (PM_2.5), inhalable particulate matter (PM₁₀), sulfur dioxide (SO₂), nitrogen dioxide (NO₂), carbon monoxide (CO), and ozone (O₃) was extracted from a validated grid data set. Conditional logistic regression models were used for exposure-response analyses. In single-pollutant models, each interquartile range (IQR) increase of lag 04-day exposure to CO (IQR: 0.25 mg/m³) and lag 3-day exposure to O₃ (69.6 μg/m³) was significantly associated with a 4.53% (95% confidence interval: 1.67%, 7.47%) and 5.63% (1.92%, 9.48%) increase in odds of hospital admissions for sequelae of stroke, respectively. These associations did not significantly vary across age or sex. With further adjustment for each of the other pollutants in 2-pollutant models, the association for CO did not change significantly, while the association for O₃ disappeared. We estimated that 7.72% of the hospital admissions were attributable to CO exposures. No significant or consistent association was observed for exposure to PM_2.5, PM₁₀, SO₂, or NO₂. In conclusion, short-term exposure to ambient CO, even at levels below the WHO air quality guideline, was significantly associated with an increased odds of hospital admissions for sequelae of stroke, which may lead to considerable excess hospital admissions.

Design and implementation of a Stroke Rehabilitation Registry for the systematic assessment of processes and outcomes and the development of data-driven prediction models: The STRATEGY study protocol

BACKGROUND

Stroke represents the second preventable cause of death after cardiovascular disease and the third global cause of disability. In countries where national registries of the clinical quality of stroke care have been established, the publication and sharing of the collected data have led to an improvement in the quality of care and survival of patients. However, information on rehabilitation processes and outcomes is often lacking, and predictors of functional outcomes remain poorly explored. This paper describes a multicenter study protocol to implement a Stroke rehabilitation Registry, mainly based on a multidimensional assessment proposed by the Italian Society of Physical and Rehabilitation Medicine (PMIC2020), in a pilot Italian cohort of stroke survivors undergoing post-acute inpatient rehabilitation, to provide a systematic assessment of processes and outcomes and develop data-driven prediction models of functional outcomes.

METHODS

All patients with a diagnosis of ischemic or haemorrhagic stroke confirmed by clinical assessment, admitted to intensive rehabilitation units within 30 days from the acute event, aged 18+, and providing informed consent will be enrolled. Measures will be taken at admission (T0), at discharge (T1), and at follow-up, 3 months (T2) and 6 months (T3) after the stroke. Assessment variables include anamnestic data, clinical and nursing complexity information and measures of body structures and function, activity and participation (PMIC2020), rehabilitation interventions, adverse events and discharge data. The modified Barthel Index will be our primary outcome. In addition to classical biostatistical analysis, learning algorithms will be cross-validated to achieve data-driven prognosis prediction models.

CONCLUSIONS

This study will test the feasibility of a stroke rehabilitation registry in the Italian health context and provide a systematic assessment of processes and outcomes for quality assessment and benchmarking. By the development of data-driven prediction models in stroke rehabilitation, this study will pave the way for the development of decision support tools for patient-oriented therapy planning and rehabilitation outcomes maximization.

CLINICAL TIAL REGISTRATION

The registration on ClinicalTrials.gov is ongoing and under review. The identification number will be provided when the review process will be completed.

Repetitive transcranial magnetic stimulation of the primary motor cortex in stroke survivors-more than motor rehabilitation: A mini-review

Stroke is a leading cause of morbidity and mortality among elderly populations worldwide. During the early phase of stroke, restoring blood circulation is of utmost importance to protect neurons from further injury. Once the initial condition is stabilized, various rehabilitation techniques can be applied to help stroke survivors gradually regain their affected functions. Among these techniques, transcranial magnetic stimulation (TMS) has emerged as a novel method to assess and modulate cortical excitability non-invasively and aid stroke survivors in the rehabilitation process. Different cortical regions have been targeted using TMS based on the underlying pathology and distorted function. Despite the lack of a standard operational procedure, repetitive TMS (rTMS) of the primary motor cortex (M1) is considered a promising intervention for post-stroke motor rehabilitation. However, apart from the motor response, mounting evidence suggests that M1 stimulation can be employed to treat other symptoms such as dysphagia, speech impairments, central post-stroke pain, depression, and cognitive dysfunction. In this mini-review, we summarize the therapeutic uses of rTMS stimulation over M1 in stroke survivors and discuss the potential mechanistic rationale behind it.

Effectiveness and Safety of Acupoint Catgut Embedding for the Treatment of Poststroke Constipation: A Systematic Review and Meta-Analysis

Objectives

Acupoint catgut embedding therapy has shown effectiveness in treating functional constipation; however, relevant, high-quality clinical evidence is scarce. This study aimed to systematically assess the effectiveness and safety of acupoint catgut embedding in treating poststroke constipation.

Methods

Correlative randomized controlled trials were identified through a comprehensive literature search of PubMed, Cochrane Library/Cochrane Central Register of Controlled Trials, Web of Science, Embase, China National Knowledge Internet, Chinese Biomedical Literature Database, Wanfang, and VIP databases from inception until February 2022. Meta-analysis was performed using RevMan 5.3 software.

Results

Fifteen trials involving 1084 patients were identified. The meta-analysis revealed that the acupoint catgut embedding group was significantly superior to the non-catgut embedding group with regard to the efficacy rate (RR = 1.27, 95% CI (1.19, 1.37), P < 0.05), the first defecation time (MD = −3.08, 95% CI (−4.53, −1.63), P < 0.05), the defecation sensation score (MD = −0.44, 95% CI (−0.61, −0.26), P < 0.05), the degree of difficulty in defecation (MD = −0.73, 95% CI (−1.10, −0.37), P < 0.05), the PAC-QOL scale score (MD = −10.06, 95% CI (−13.47, −6.64), P < 0.05), and the symptom integral (MD = −3.15, 95% CI (−3.60, −2.71), P < 0.05). However, there was no significant difference in the stool property score (MD = 0.06, 95% CI (−0.39, 0.50), P > 0.05) as well as the incidence of adverse reactions (RD = 0.01, 95% CI (−0.01, 0.03), P > 0.05) between the two groups.

Conclusions

The results showed that acupoint catgut embedding is probably an effective and safe acupuncture treatment strategy for poststroke constipation. Nevertheless, more rigorously designed, standardized, large-sample, and multicenter randomized controlled designs are warranted to further verify the findings of this study.