Comparison of preventive effects of combined furosemide and mannitol versus single diuretics, furosemide or mannitol, on cisplatin-induced nephrotoxicity

Cisplatin (CDDP)-induced nephrotoxicity is a common dose-limiting toxicity, and diuretics are often administered to prevent nephrotoxicity. However, the efficacy and optimal administration of diuretics in preventing CDDP-induced nephrotoxicity remain to be established. This study aimed to evaluate the efficacy of combining furosemide and mannitol to prevent CDDP-induced nephrotoxicity. This was a post-hoc analysis of pooled data from a multicenter, retrospective, observational study, including 396 patients who received one or two diuretics for CDDP-based chemotherapy, compared using propensity score matching. Multivariate logistic regression analyses were used to identify risk factors for nephrotoxicity. There was no significant difference in the incidence of nephrotoxicity between the two groups (22.2% vs. 28.3%, P = 0.416). Hypertension, CDDP dose ≥ 75 mg/m2, and no magnesium supplementation were identified as risk factors for nephrotoxicity, whereas the use of diuretics was not found to be a risk factor. The combination of furosemide and mannitol showed no advantage over a single diuretic in preventing CDDP-induced nephrotoxicity. The renal function of patients receiving CDDP-based chemotherapy (≥ 75 mg/m2) and that of those with hypertension should be carefully monitored. Magnesium supplementation is important for these patients.

Effect of outpatient cardiac rehabilitation on motor function and health-related quality of life in stroke survivors

BACKGROUND

Outpatient cardiac rehabilitation (CR) is a promising tool for improving functional outcome in stroke survivors, however, evidence for improving emotional health is limited. We aimed to clarify the effects of outpatient CR following in-hospital stroke rehabilitation on health-related quality of life (HRQOL) and motor function.

METHODS

Patients with acute ischemic stroke or transient ischemic attack discharged directly home were recruited, and 128 patients who fulfilled criteria for insurance coverage of CR were divided into the CR (+) group (n = 46) and CR (-) group (n = 82). All patients underwent in-hospital stroke rehabilitation, and within 2 months after stroke onset, patients in the CR (+) group started a 3-month outpatient CR program of supervised sessions. Changes of motor function and HRQOL assessed by the short form-36 version 2 (SF-36) from discharge to 3 months post-discharge were compared between the two groups.

RESULTS

Twenty-six patients in the CR (+) group completed the program and 66 patients in the CR (-) group were followed up at a 3-month examination. Least-square mean changes in 6-minute walk distance and isometric knee extension muscle strength were significantly higher in the CR (+) group than the CR (-) group (52.6 vs. 16.3 m; 10.1 vs. 3.50 kgf/kg). Improvement of HRQOL at 3 months was not observed in the CR (+) group.

CONCLUSIONS

Outpatient CR following in-hospital stroke rehabilitation within 2 months after stroke onset improved exercise tolerance and functional strength but not HRQOL assessed by the SF-36 after completion of CR in the present cohort.

Pre-existing sarcopenia and swallowing outcomes in acute stroke patients

BACKGROUND & AIMS

This study aimed to investigate the associations of pre-existing sarcopenia with swallowing function, oral intake level, and aspiration pneumonia in patients with acute stroke.

METHODS

This observational study included patients (≥60 years of age) with acute ischemic stroke or intracerebral hemorrhage within 7 days of onset who were screened for sarcopenia, malnutrition, and swallowing difficulties in a stroke-care unit within 48 h of admission. Sarcopenia was defined by the Asian Working Group on Sarcopenia 2019 as having a low calf circumference, handgrip strength, and appendicular muscle mass index. The primary outcome was impaired oral intake (functional oral intake scale <5 points) at 3, 7, and 14 days after admission, and the secondary outcome was aspiration pneumonia during hospitalization.

RESULTS

We enrolled 350 patients (median age of 77 years; 63% males) who underwent the aforementioned screening. Sarcopenia was diagnosed in 34% of patients, and malnutrition was found in 66% of patients with sarcopenia. When compared with the comparison group (defined as patients with either or both normal calf circumference and handgrip strength), the sarcopenia group had significantly lower tongue pressure and a higher prevalence of dysphagia. Sarcopenia was associated with functional oral intake scale <5 at 7 days (adjusted odds ratio [OR], 4.72; 95% confidence interval [CI], 1.91-11.71); p = 0.002) and 14 days (adjusted OR, 3.93; 95% CI, 1.47-10.53; p = 0.006) and with aspiration pneumonia during hospitalization (adjusted OR, 6.12; 95% CI, 1.63-22.94; p = 0.007).

CONCLUSION

Acute stroke patients with sarcopenia may have weakness of the swallowing-related muscles which may lead to impaired oral intake and aspiration pneumonia.

Dynamic changes of the direction and angle of radiographic ocular lateral deviation in patients with lateropulsion after stroke onset

OBJECTIVE

To examine if radiographic ocular lateral deviation (rOLD) could be provoked in stroke patients with mild-to-moderate lateropulsion according to vertical perception.

METHODS

In this single-center, retrospective study, acute stroke patients with mild-to-moderate lateropulsion assessed by the Scale for Contraversive Pushing were enrolled. Computed tomography or magnetic resonance imaging was performed on all patients on admission and then according to their conditions. The direction and angle of rOLD were compared among three groups according to the responsible lesion: lateral medullary (LM), pontine (P), and hemispheric (H).

RESULTS

Sixty-six patients (male, 47; average age, 67 years) were enrolled and divided into the LM (n = 37), P (n = 8), and H (n = 21) groups. All patients had body tilt. Patients in the LM group showed body tilt to the ipsilesional side during hospitalization, while those in the P and H groups tilted to the contralesional side. All patients had rOLD at the final assessment at an average of 13 days after onset; patients in the P and H groups showed contralateral rOLD, while those in the LM group showed ipsilateral rOLD if they did not have cerebellar or pontine lesions. Significant decreases in the angle and changes in direction of rOLD according to lesion site were observed during hospitalization.

CONCLUSION

Serial changes in rOLD findings after stroke onset are different according to the responsible lesion. The direction of rOLD in most patients is in accordance with vertical perception after the acute stage of stroke.

Effect of cyborg-type robot Hybrid Assistive Limb on patients with severe walking disability in acute stroke: A randomized controlled study

OBJECTIVES

To investigate whether early gait training using Hybrid Assistive Limb (HAL) is feasible and improves walking and independency compared with conventional physical therapy (CPT) in patients with severe walking disability after stroke.

METHODS

We conducted a single-center, randomized controlled study. Patients with first-ever stroke who had severe walking disability were included. All patients started gait training within 10 days post-stroke onset. Twenty-four patients were randomly assigned into HAL or CPT groups. Outcome measures were collected at three time points, at baseline, completion of 20 sessions of gait training (second assessment), and 3 months after the initiation of gait training. The primary outcomes were changes in motor sub-scores of the Functional Independence Measure or Functional Ambulation Category at the completion of the second assessment from baseline.

RESULTS

Twenty-two patients (median age, 68 years; 12 patients in the HAL group and 10 patients in the CPT group) completed the study. There were no significant differences in primary outcomes. Apathy scale, one of the secondary outcomes, showed a decreasing trend in the HAL group (mean change of -3.8, 95% CI -8.14 to 0.475), and a slight increasing trend in the CPT group (mean change of 1.2, 95% CI -2.66 to 5.06) at the second assessment. Patients in the HAL group experienced no adverse events.

CONCLUSIONS

Early gait training in patients with severe walking disability after stroke using HAL was feasible. Walking ability and independency were not improved at the completion of 20 sessions of gait training.

Preventive effect of 20 mEq and 8 mEq magnesium supplementation on cisplatin-induced nephrotoxicity: a propensity score-matched analysis

PURPOSE

The protective effect of magnesium (Mg) supplementation against cisplatin (CDDP)-induced nephrotoxicity has been widely described; however, the optimal dose of Mg supplementation is unclear. The aim of this study was to investigate whether 20 mEq of Mg supplementation is more effective than 8 mEq Mg in preventing CDDP-induced nephrotoxicity, as well as the associated risk factors, in cancer patients treated with CDDP-based chemotherapy.

METHODS

Pooled data of 272 patients receiving 20 mEq or 8 mEq Mg supplementation to CDDP-based chemotherapy from a multicenter, retrospective, observational study were compared using propensity score matching. Separate multivariate logistic regression analyses were used to identify the risk factors for renal failure induced by each treatment dose.

RESULTS

There was no significant difference in the incidence of nephrotoxicity between the 8 mEq and 20 mEq groups (P = 0.926). There was also no significant difference in the severity of nephrotoxicity, elevated serum creatinine levels, and decreased estimated creatinine clearance levels between the two groups. Cardiac disease and albumin levels were identified as independent risk factors for CDDP-induced nephrotoxicity.

CONCLUSION

We did not find an advantage of 20 mEq over 8 mEq Mg supplementation in terms of a preventive effect against CDDP-induced nephrotoxicity. The optimal dose of Mg supplementation for the prevention of CDDP-induced nephrotoxicity remains unknown, and further studies are warranted.

Analysis of Skin Deformation Differences on the Upper Arm Between Active and Passive Movements During Elbow Flexion and Extension

The motion ability of patients in the acute phase of stroke is difficult to define with existing indexes such as the Brunnstrom stage. Hence, for designing a novel evaluation index for stroke rehabilitation in the acute phase, we focused on the differences between the skin deformations in active and passive movements. Skin deformation reflects the activities of body tissues that are related to motion ability. We measured skin deformations on the upper arm in active and passive movements during elbow flexion and extension and extracted features from these deformations. For practical rehabilitation applications, we developed a novel flexible distance sensor array to reduce the time needed for attaching sensors to patients. Using principal component analysis (PCA), the skin deformation could be decomposed into joint movements and activeness of movements as the first two components (PC1 and PC2). The joint angle and PC1 exhibited a high correlation, and the standard deviation (SD) of PC2 indicated a significant difference in the types of movements. From the above results, we concluded that the SD ratio between PC2 and PC1 may be used to evaluate motion ability considering the inherent biomechanical characteristics.

Risk Factors for Cisplatin-Induced Nephrotoxicity: A Multicenter Retrospective Study

INTRODUCTION

Cisplatin (CDDP)-induced nephrotoxicity is a concern in CDDP-based chemotherapy. The goal of this multicenter retrospective study was to identify potential risk factors for CDDP nephrotoxicity.

METHODS

Clinical data were reviewed for 762 patients who underwent chemotherapy including CDDP ≥60 mg/m2 per day from Spring 2014 to September 2016. CDDP nephrotoxicity was defined according to the National Cancer Institute Common Terminology Criteria for Adverse Events for acute kidney injury. Univariate and multivariate logistic regression analyses were performed to identify risk factors for CDDP nephrotoxicity.

RESULTS

CDDP nephrotoxicity was observed in 165 patients (21.7%). Multivariate analysis showed a significantly higher rate of CDDP nephrotoxicity in patients with cardiac disease (odds ratio [OR]: 2.05, 95% confidence interval [CI]: 1.07-3.93, p = 0.03), hypertension (OR: 1.57, 95% CI: 1.06-2.32, p = 0.02), and high-dose CDDP therapy (OR: 2.15, 95% CI: 1.50-3.07, p < 0.01). Magnesium (Mg) supplementation (OR: 0.65, 95% CI: 0.45-0.93, p = 0.02) and diuretic use (OR: 0.22, 95% CI: 0.08-0.63, p < 0.01) were also independent risk factors for CDDP nephrotoxicity.

CONCLUSIONS

Our results suggest that high-dose CDDP and comorbidities of cardiac disease and hypertension are independent risk factors for CDDP nephrotoxicity. Therefore, close monitoring of serum creatinine values during CDDP treatment is recommended for patients with these risk factors. In addition, Mg supplementation and administration of diuretics might be effective for prevention of CDDP nephrotoxicity.

Microstructural white matter changes following gait training with Hybrid Assistive Limb initiated within 1 week of stroke onset

The early initiation of robot-assisted gait training in patients with acute stroke could promote neuroplasticity. The aim of this study was to clarify the microstructural changes of white matter associated with gait training using Hybrid Assistive Limb (HAL) by diffusion tensor imaging (DTI). Patients with first-ever stroke and requiring a walking aid started gait training within 1 week of stroke onset. The patients were quasi-randomly assigned either to the conventional physical therapy (CPT) group or gait training using HAL (HAL) group. Motor function and DTI were examined at baseline and after 3-5 months. Voxel-based statistical analyses of fractional anisotropy (FA) images were performed using diffusion metric voxel-wise analyses. Volume of interest (VOI)-based analyses were used to assess changes in FA (ΔFA). Twenty-seven patients (17 in the CPT group and 10 in the HAL group) completed the study. There were improvements in motor function and independency in the CPT and HAL groups (p < .001). Compared to baseline, there were decreases in FA in the ipsi-lesional cerebral peduncle in the CPT group (p < .001) and increases in the contra-lesional rostrum of the corpus callosum in the HAL group (p < .001) at the second assessment, consistent with the mean ΔFA in each group from VOI analysis (CPT/HAL: cerebral peduncle, -0.066/-0.027, p = .027; corpus callosum, 0.002/0.042, p < .001). Gait training using HAL initiated within 1 week after stroke onset facilitated the recovery of inter-hemispheric communication and prevented the progression of Wallerian degeneration of the affected pyramidal tract.

Visually-Rated Medial Temporal Lobe Atrophy with Lower Educational History as a Quick Indicator of Amnestic Cognitive Impairment after Stroke

BACKGROUND

Time and resource limitations prevent cognitive assessment in acute-to-subacute settings, even in comprehensive stroke centers.

OBJECTIVE

To assess cognitive function in acute stroke patients undergoing routine clinical, laboratory, and radiological investigations, with a view to improving post-stroke care and treatment.

METHODS

Sixty-nine patients (72.6±11.1 years; 65% male) were prospectively enrolled within 14 days of acute ischemic stroke. Patients with altered consciousness, aphasia, or dysarthria were excluded. Clinical features including modified Rankin and NIH stroke scales, and vascular risk factors were assessed, as well as neuroimaging parameters by semi-quantitative evaluation of medial temporal lobe atrophy (MTLA) using MRA source images, FLAIR images for white matter changes (Fazekas scores), and T2∗ images for cerebral microbleeds. Neuropsychological screening was conducted using the Montreal Cognitive Assessment (MoCA) test. Univariate and multivariate analyses were used to evaluate the influence of variables on MoCA total and subscale scores.

RESULTS

Lower MoCA scores of 22 or less were associated with MTLA [OR (95% CI), 5.3 (1.0-27.5); p = 0.045], education years [OR (95% CI), 0.71 (0.55-0.91); p = 0.007], and modified Rankin scale at discharge [OR (95% CI), 2.4 (1.3-4.5); p = 0.007]. The delayed recall MoCA score was correlated with MTLA (r = - 0.452, p < 0.001), periventricular (r = - 0.273, p = 0.024), and deep (r = - 0.242, p = 0.046), white matter changes.

CONCLUSIONS

MTLA, together with lower educational history, are quick indicators of amnestic cognitive impairment after stroke. The association between cognitive impairment and physical disability at discharge may signify the importance of earlier cognitive assessment.

Acute stroke rehabilitation for gait training with cyborg type robot Hybrid Assistive Limb: A pilot study

Robot-assisted gait training following acute stroke could allow patients with severe disability to receive a high dosage and intensity of gait training compared with conventional physical therapy (CP). However, given the limited data on gauging the efficacy of Hybrid Assistive Limb (HAL) on gait training in patients with acute stroke, we aimed to evaluate several outcome measures following gait training with HAL. Patients with first-ever stroke, who required a walking aid and were able to start gait training within 1 week of stroke onset were included in the current study. Patients were assigned to either the CP or HAL group. Outcome measures were collected at baseline, and at the 2nd (at 2-6 weeks), and 3rd (at 3-5 months) assessments. All patients underwent physical therapy until the 3rd assessment; patients in the HAL group underwent gait training using HAL until the 2nd assessment. Thirty-seven patients (19 from CP and 18 from HAL, median age = 69 years) completed the study. At the 2nd assessment, the total Functional Independence Measure (FIM) score was higher in the HAL group than in the CP group (90.1 vs. 79.0, p = 0.042). In conclusion, the FIM scale could be used to identify responsiveness to acute stroke rehabilitation using HAL.

Dendrite complexity of the posterior cingulate cortex as a substrate for recovery from post-stroke depression: A pilot study

The neural basis of recovery from a depressive state remains poorly understood. The main purpose of this study was to determine the neural basis of vulnerability/resilience to depression in stroke patients in terms of changes in regional microstructure. The study included 20 individuals with acute ischaemic stroke. Symptoms of depression were assessed, and the intraneurite volume fraction and neurite orientation-dispersion index (ODI) were evaluated by a multi-shell diffusion imaging and neurite-orientation dispersion and density imaging model. Patients underwent follow-up examinations after 2 months and were classified into depression improvement and depression deterioration groups. A significant interaction effect of group × time on the ODI was shown by voxel-based analysis in the posterior cingulate cortex (PCC). The ODI change in the PCC was negatively correlated with the change in the depression scale scores at the 2-month time point. The increase in ODI in the PCC that occurred during the 2-month interval was thought to be associated with decreased depressive symptom scores. As the ODI represents the pattern of sprawling dendrite progression, our findings indicate that the dendritic complexity of the PCC is a substrate for recovery in individuals who experienced post-stroke psychosocial and biological stress.

Fluorescent molecular spring that visualizes the extension and contraction motions of a double-stranded helicate bearing terminal pyrene units triggered by release and binding of alkali metal ions

A unique springlike motion of a fluorescent pyrene-terminated double-stranded helicate is visualized by the catch and release of alkali metal ions.

Risk factors for delayed chemotherapy-induced nausea and vomiting with low-emetic-risk chemotherapy: a prospective, observational, multicenter study

Purpose

Improvement in the control of delayed chemotherapy-induced nausea and vomiting (CINV) is needed. There is limited information on antiemetic prophylaxis for patients undergoing low-emetic-risk chemotherapy (LEC), and the optimal antiemetic treatment is not well understood. Therefore, we analyzed the risk factors for delayed CINV to aid in the development of individualized treatments.

Patients and methods

This prospective multicenter study was conducted in 13 hospitals and included patients with solid cancers undergoing LEC. A total of 222 patients were enrolled between September 2013 and November 2014. The participants completed a daily diary for 5 days after the commencement of the first cycle of LEC to describe the daily incidence of CINV (yes/no). Furthermore, the participants described the severity of nausea and the amount of food intake with the help of VAS.

Results

Two hundred and ten patients provided their data that were analyzed using multivariate logistic regression to examine the risk factors for delayed CINV. History of CINV, Eastern Cooperative Oncology Group performance status score ≥1, acute CINV, and single-day antiemetic prophylaxis were identified as independent risk factors for delayed CINV.

Conclusion

The current use of antiemetic prophylaxis according to the recommended guideline appears to effectively control delayed CINV in patients undergoing LEC. Therefore, patients with the abovementioned risk factors should be carefully observed, and their treatment should be adjusted according to their symptoms. The use of multiple-day dexamethasone may be beneficial for those patients who develop acute CINV, especially when it is accompanied by anorexia.

Reversible Cerebral Vasoconstriction Syndrome After Heart Transplantation: A Case Report

BACKGROUND

Reversible cerebral vasoconstriction syndrome (RCVS) is a transient cerebrovascular disorder putatively caused by some immunosuppressive agents.

CASE REPORT

We recently encountered a 47-year-old female patient diagnosed with dilated cardiomyopathy who developed RCVS after heart transplantation. A triple-drug regimen consisting of tacrolimus, mycophenolate mofetil, and a corticosteroid was started after surgery. On postoperative day (POD) 11, the patient developed a severe headache, although computed tomography of the head demonstrated no signs of hemorrhage or infarction. At first, both a painkiller and migraine drugs were regularly administered to the patient. On POD 21, however, she developed an unbearable headache with a visual field defect and mild hemiparesis of the right hand. Magnetic resonance imaging (MRI) of the brain revealed a cerebral infarction in the left occipital lobe with diffuse vasoconstriction of both the middle and posterior cerebral arteries. A diagnosis of RCVS was made and tacrolimus, a drug suspected to cause RCVS, was discontinued. In its place, two doses of basiliximab followed by everolimus, both of which are alternatives for tacrolimus, were given. The corticosteroid dose was also increased. Furthermore, to release vasoconstriction, both verapamil and diltiazem were administered. On POD 27, cerebrovascular constrictions were shown to be relieved on brain MRI and the patient's neurological symptoms subsequently almost completely diminished.

CONCLUSION

RCVS should always be considered as a cause of headache in heart transplant recipients because tacrolimus, an immunosuppressive agent, may trigger RCVS. This will allow rapid intervention that is essential for avoiding irreversible neurological deficits.

Seasonal Variations in Neurological Severity and Outcomes of Ischemic Stroke - 5-Year Single-Center Observational Study

BACKGROUND

Seasonal variations in the severity and outcomes of stroke remain unclarified.Methods and Results:A total of 2,965 acute ischemic stroke patients from a single-center prospective registry were studied. Among the total patients, stroke onset did not vary by season, though it varied with a peak in winter when limited to patients >75 years old (P=0.026), when limited to patients with moderate-to-severe initial neurological deficits (National Institutes of Health Stroke Scale Score ≥10, P=0.014), and when limited to those with cardioembolic stroke (n=1,031, P=0.010). In 1,934 patients with noncardioembolic stroke, stroke onset did not vary by season. After multivariable adjustment, moderate-to-severe neurological deficits were more common in winter (odds ratio 1.37, 95% confidence interval 1.10-1.72) and spring (1.27, 1.01-1.60), and death at 1 year was more common in summer than in fall (1.55, 1.03-2.36); death or dependency (modified Rankin Scale score 3-6) and death or bedridden (score of 5-6) were not differently common among the seasons.

CONCLUSIONS

Overall ischemic stroke showed a fairly even distribution among the 4 seasons. Cardioembolic stroke was more common in winter. Ischemic stroke patients had more moderate-to-severe initial neurological deficits in winter and spring. Poor clinical outcomes at 1 year were generally similar among the seasons. Ischemic stroke is not necessarily a winter-dominant disease.

Spreading Awareness of Stroke through School-Based Education: A Pooled Analysis of Three Community-Based Studies

BACKGROUND

Advancing school-based education is a promising means to spread knowledge pertaining to stroke. The aim of the current study was to clarify whether stroke lessons provided by schoolteachers could deliver stroke knowledge to children (aged 9-11 years) and their parents, at a similar level to when taught by medical staff.

METHODS

Schoolteachers conducted lessons on stroke for school children using the educational materials we prepared (i.e., the teacher group; 1051 children and 719 parents). This was compared with our previous data from Akashi city and Tochigi prefecture, in which the stroke lessons were conducted by medical staff (i.e., the medical group; 1031 children and 756 parents). Three campaigns were conducted between September 2014 and May 2016. Each child was given education materials to take home to discuss stroke with their parents. The children and their parents answered questionnaires on stroke knowledge, at baseline, immediately after the lesson, and at 3 months after the lesson.

RESULTS

Compared with the time point before the lesson, both children and parents instructed by the teacher group showed significant increases in the scores about stroke symptoms and risk factors, immediately and at 3 months after the lesson (P < .001). The combined analysis for the group instructed by medical personnel showed no significant differences in the stroke knowledge scores between the 2 groups at 3 months.

CONCLUSIONS

Teacher-led lessons, using our educational material, adequately delivered knowledge of stroke to children and parents, in a manner that was similar to when medical staff delivered this information.

Effects of a school-based stroke education program on stroke-related knowledge and behaviour modification-school class based intervention study for elementary school students and parental guardians in a Japanese rural area

OBJECTIVES

This study aimed to determine the effect of a stroke education programme on elementary school students and their parental guardians in a rural area in Japan that has high stroke mortality.

DESIGN

School class based intervention study.

SETTING

Eleven public elementary schools in Tochigi Prefecture, Japan.

PARTICIPANTS

268 students aged 11-12 years and 267 parental guardians.

INTERVENTIONS

Students received lessons about stroke featuring animated cartoons and were instructed to communicate their knowledge about stroke to their parental guardians using material (comic books) distributed in the lessons. Stroke knowledge (symptoms, risk factors and attitude towards stroke) and behavioural change for risk factors were assessed at baseline, immediately after the programme and at 3 months. We also evaluated behavioural change for risk factors among parental guardians.

RESULTS

The percentage of students with all correct answers for stroke symptoms, risk factors and the recommended response to stroke was significantly increased at 3 months P<0.001). We observed a significant increase in the percentage of guardians who chose all correct symptoms (P<0.001: 61.0% vs 85.4%) and risk factors (P<0.001: 41.2% vs 59.9%) at 3 months compared with baseline. The percentage of parental guardians with a high behavioural response to improving risk factors was significantly increased at 3 months compared with baseline (P<0.001).

CONCLUSIONS

In a rural population with high stroke mortality, stroke education can improve knowledge about stroke in elementary school students and their parental guardians.

ETHICS AND DISSEMINATION

We conducted the intervention as a part of compulsory education; this study was not a clinical trial. This study was approved by the Ethics Committee of the National Cerebral and Cardiovascular Center (M27-026).

Embolic Stroke due to Carotidynia Potentially Associated with Moving Carotid Artery Caused by Swallowing

A 63-year-old woman with end-stage renal disease on maintenance hemodialysis discontinued her medication for rheumatoid arthritis with prednisolone and azathioprine. One month later, she was admitted because of consciousness disturbance and right hemiparesis. Diffusion-weighted brain magnetic resonance imaging (MRI) revealed multiple hyperintensities in her left frontal and parietal lobes. She also developed high fever and left neck pain. Carotid ultrasonography showed calcified plaque with vessel wall swelling at the bifurcation of the left common carotid artery (LCCA) and surrounding hypoechoic soft tissue. The tissue was identified as an isodense lesion on noncontrast computed tomography (CT) and as a high-intensity lesion on fat-saturated T2-weighted MRI. From her symptoms and radiological findings, she was diagnosed with carotidynia. Cervical MRI also showed that the LCCA was transposed to a retropharyngeal location, suggesting a moving carotid artery. Carotid ultrasonography revealed that the LCCA moved to and from the retropharyngeal position with swallowing and was thus being compressed by the hyoid bone. After corticosteroid therapy was initiated with 30 mg of prednisolone, her symptoms and radiological findings improved. To our knowledge, this is the first report of a case of cerebral embolism due to carotidynia. The repetitive compressions by the hyoid bone during swallowing were presumed to have provoked shear stress and inflammation of the carotid vessel wall, which was aggravated by discontinuation of steroid therapy in our case. These mechanical and inflammatory stresses might cause dysfunction of endothelial cells, hypercoagulation, platelet hyperaggregation, and vulnerability and rupture of carotid plaques, and may subsequently result in embolic strokes.

Effects of school-based intervention by emergency medical technicians on students and their parents: a community-based prospective study of the Akashi project

OBJECTIVE

Stroke lessons for youth provided by emergency medical technicians (EMTs) may be an effective strategy to facilitate early intervention for patients with stroke. The aim of this study was to examine how effective EMT-led lessons on stroke awareness for schoolchildren were at disseminating stroke information.

SETTING, PARTICIPANTS AND OUTCOME MEASURES

The study was performed in the city of Akashi, Hyogo, Japan (Akashi project). Children (aged 9-10 years old) at 11 public elementary schools and their parents were enrolled in this study. EMTs from the firefighting headquarters provided lessons on stroke to the children using our educational materials between September 2014 and October 2015. Each child was given our educational materials to take home and discuss stroke with their parents. The children and their parents answered questionnaires on stroke knowledge before, immediately and at 3 months after the lesson.

RESULTS

A total of 763 children and 489 parents were enrolled (ie, 64% of children). The scores of either stroke symptoms or risk factors were significantly higher immediately and at 3 months after the lesson, compared with before the lesson, both in children and the parents (p<0.01). Compared with the baseline in both groups (58% in children, 83% in parents), the meaning of the FAST mnemonic at 3 months (88%, 94%), as well as at immediately after the lesson (90%, 89%), was significantly higher (p<0.001).

CONCLUSION

Stroke education by EMTs was effective in increasing stroke awareness in elementary school children, as well as their parents.

Binding of 11C-Pittsburgh compound-B correlated with white matter injury in hypertensive small vessel disease

OBJECTIVE

¹¹C-Pittsburgh compound-B (¹¹C-PIB) positron emission tomography (PET) is used to visualize and quantify amyloid deposition in the brain cortex in pathological conditions such as Alzheimer's disease (AD). Intense ¹¹C-PIB retention is also observed in the white matter (WM) of both healthy individuals and AD patients. However, the clinical implications of this retention in brain WM have not been clarified. We investigated the relationship between the extent of white matter lesions (WMLs) and the binding potential of ¹¹C-PIB (BP_ND) in the WM in patients with hypertensive small vessel disease. We further examined the relationship between the extent of WMLs and BP_ND in WML and in normal-appearing white matter (NAWM).

METHODS

Twenty-one hypertensive vasculopathy patients, without AD and major cerebral arterial stenosis and/or occlusion, were enrolled (9 women, 68 ± 7 years). Regions of WML and NAWM were extracted using magnetization-prepared rapid gradient-echo and fluid-attenuated inversion recovery of magnetic resonance images. Volumes of interest (VOIs) were set in the cortex-subcortex, basal ganglia, and centrum semiovale (CS). BP_ND in the cortex-subcortex, basal ganglia, CS, WML, and NAWM were estimated on ¹¹C-PIB PET using Logan graphical analysis with cerebellar regions as references. The relationships between WML volume and BP_ND in each region were examined by linear regression analysis.

RESULTS

BP_ND was higher in the CS and basal ganglia than in the cortex-subcortex regions. WML volume had a significant inverse correlation with BP_ND in the CS (Slope = -0.0042, R ²  = 0.44, P < 0.01). For intra WM comparison, BP_ND in NAWM was significantly higher than that in WML. In addition, although there were no correlations between WML volume and BP_ND in WML, WML volume was significantly correlated inversely with BP_ND in NAWM (Slope = -0.0017, R ²  = 0.26, P = 0.02).

CONCLUSIONS

¹¹C-PIB could be a marker of not only cortical amyloid-β deposition but also WM injury accompanying the development of WMLs in hypertensive small vessel disease.

Delivering Knowledge of Stroke to Parents Through Their Children Using a Manga for Stroke Education in Elementary School

BACKGROUND

School-based intervention would be promising to spread stroke knowledge widely. This study aimed to clarify the effectiveness of our new educational aids that were developed for elementary school children to impart information about stroke to children and their parents in 2 different ways: with or without stroke lessons by a neurologist.

METHODS

We enrolled 562 children (aged 11 to 12 years) and their parents (n = 485). The students were divided into 2 groups: 323 received a lesson on stroke by a stroke neurologist without watching an animated cartoon (Group I), and 239 watched an animated cartoon without the lesson (Group II). All of the children took the manga home, and talked about stroke with their parents. Questionnaires on stroke knowledge were administered at baseline (BL), immediately after the lesson (IL), and 3 months (3M) after the lesson.

RESULTS

There were significant increases in the adjusted mean scores for risk factors as well as stroke symptoms at 3M in both groups compared with BL scores, although the children in Group I scored significantly better than those in Group II at IL and 3M (P < .05). In both children and parents, the correct answer rates of the FAST mnemonic at 3M were around 90%, with no significant differences between groups.

CONCLUSIONS

Stroke education for elementary school children using our educational aids provided knowledge of stroke symptoms to the children as well as their parents even without lessons on stroke, although a better understanding of stroke was obtained from lessons led by stroke neurologists.

Comparison of Characteristics of Stroke-Associated Pneumonia in Stroke Care Units in Indonesia and Japan

BACKGROUND

Pneumonia is one of the most common medical complications after stroke. Incidence and risk factor analyses of stroke-associated pneumonia (SAP) in stroke care units (SCUs) are limited. SAP incidence comparisons across countries can identify the most effective treatment to reduce this incidence.

METHODS

This was a retrospective study including consecutive patients with acute stroke in SCUs in 2 hospitals: 105 patients (mean age 78.2 ± 5.8) from the National Cerebral and Cardiovascular Center (NCVC) in Osaka, Japan (from July to August 2015), and 105 patients (mean age 60 ± 5.8) from the National Brain Centre (NBC) Hospital in Jakarta, Indonesia (from May to September 2015). We used descriptive statistics and a logistic regression model for statistical analysis.

RESULTS

The incidence of SAP in the SCU NBC Hospital was higher than that in the SCU NCVC (22.9% versus 12.4%, P = .0466). In the SCU NBC Hospital, dysphagia (odds ratio [OR] 15.20, 95% confidence interval [CI] 1.77-130.73) and severe neurological deficits on admission (OR 5.31, 95% CI 1.60-17.60) were significantly associated with SAP, whereas in the SCU NCVC, dysphagia (OR 14.42, 95% CI 2.34-88.98) and diabetes mellitus (OR 7.16, 95% CI 1.27-40.18) were the risk factors. When the patients of both hospitals were analyzed together, severe neurological deficits on admission (OR 3.36, 95% CI 1.31-8.64) and dysphagia (OR 12.62, 95% CI 3.75-42.45) were significant determinants for developing SAP.

CONCLUSIONS

The incidence of SAP was higher in the Indonesian hospital than in the Japanese one. Our findings support other epidemiological data of a high incidence of SAP with severe neurological deficits on admission and dysphagia in an SCU setting.

Cerebral blood flow and metabolism associated with cerebral microbleeds in small vessel disease

OBJECTIVE

Cerebral microbleeds (CMBs), probably reflecting microangiopathy, have not yet sufficiently been examined in association with cerebral blood flow (CBF) and metabolism. We investigated the relationships between CMBs, and CBF and metabolism in symptomatic small vessel disease.

METHODS

We enrolled 22 patients with symptomatic small vessel disease without severe stenosis (>50 %) in major cerebral arteries. Volumes of white matter lesions (WMLs) and number of CMBs were assessed on images of fluid-attenuated inversion recovery and gradient-echo T2*-weighted magnetic resonance imaging, respectively. Patients were divided into two groups according to the median number of CMBs (group I <5, n = 10; group II ≥5, n = 12). Parametric images of CBF, cerebral metabolic rate of oxygen (CMRO2), oxygen extraction fraction and cerebral blood volume were estimated using positron emission tomography and (15)O-labeled gases. The functional values in the cortex-subcortex, basal ganglia, and centrum semiovale were compared between the two groups.

RESULTS

Volumes of WMLs of group II were larger than those of group I (median: 38.4; range: 25.1-91.5 mL vs. median: 11.3; range: 4.2-73.4 mL, p = 0.01). In the centrum semiovale, the mean CBF of group II was significantly lower than that of group I (12.6 ± 2.6 vs. 15.6 ± 3.3 mL/100 g/min, p = 0.04). In the other regions, there were no significant differences in either CBF or CMRO2 between the two groups.

CONCLUSIONS

Our study indicated that increases in the number of CMBs with larger volumes of WMLs were associated with cerebral ischemia in the deep white matter in patients with symptomatic small vessel disease.

High Levels of Soluble Lectin-Like Oxidized Low-Density Lipoprotein Receptor-1 in Acute Stroke: An Age- and Sex-Matched Cross-Sectional Study

AIM

Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is known to be a key molecule in the pathogenesis of atherosclerosis. Although high levels of serum soluble LOX-1 (sLOX-1) were demonstrated in patients with acute coronary syndrome, there are no reports about acute stroke patients. The aim of the present study was to evaluate the levels of sLOX-1 in acute stroke patients according to different stroke subtypes.

METHODS

We enrolled a total of 377 patients with a stroke (men/women: 251/126; age: 40-79 years), 250 with ischemic stroke and 127 with intracerebral hemorrhage (ICH). Patients were admitted to our hospital within 3 days after the onset of stroke. As controls, we randomly selected age- and sex-matched subjects without a past history of cardiovascular disease according to stroke subtype from the community-based cohort of the Suita study. Serum LOX-1 levels were compared between stroke patients and healthy controls according to stroke subtype.

RESULTS

Median values of serum sLOX-1 in stroke patients were significantly higher than those in controls (526 vs. 486 ng/L in ischemic stroke and 720 vs. 513 ng/L in ICH, respectively). Among subtypes of ischemic stroke, median sLOX-1 levels in atherothrombotic brain infarction (641 ng/L) only were significantly higher than those in controls (496 ng/L). Ischemic stroke [odds ratio (OR), 3.80; 95% confidence interval (CI), 1.86-7.74] and ICH (OR, 5.97; 95% CI, 2.13-16.77) were independently associated with high levels of sLOX-1 by multivariate logistic regression analysis.

CONCLUSIONS

Higher levels of sLOX-1 were observed in patients with acute stoke than in controls. High levels of sLOX-1 can be useful as biomarker for acute stroke.

The Japan Statin Treatment Against Recurrent Stroke (J-STARS): A Multicenter, Randomized, Open-label, Parallel-group Study

Background

Although statin therapy is beneficial for the prevention of initial stroke, the benefit for recurrent stroke and its subtypes remains to be determined in Asian, in whom stroke profiles are different from Caucasian. This study examined whether treatment with low-dose pravastatin prevents stroke recurrence in ischemic stroke patients.

Methods

This is a multicenter, randomized, open-label, blinded-endpoint, parallel-group study of patients who experienced non-cardioembolic ischemic stroke. All patients had a total cholesterol level between 4.65 and 6.21 mmol/L at enrollment, without the use of statins. The pravastatin group patients received 10 mg of pravastatin/day; the control group patients received no statins. The primary endpoint was the occurrence of stroke and transient ischemic attack (TIA), with the onset of each stroke subtype set to be one of the secondary endpoints.

Finding

Although 3000 patients were targeted, 1578 patients (491 female, age 66.2 years) were recruited and randomly assigned to pravastatin group or control group. During the follow-up of 4.9 ± 1.4 years, although total stroke and TIA similarly occurred in both groups (2.56 vs. 2.65%/year), onset of atherothrombotic infarction was less frequent in pravastatin group (0.21 vs. 0.64%/year, p = 0.0047, adjusted hazard ratio 0.33 [95%CI 0.15 to 0.74]). No significant intergroup difference was found for the onset of other stroke subtypes, and for the occurrence of adverse events.

Interpretation

Although whether low-dose pravastatin prevents recurrence of total stroke or TIA still needs to be examined in Asian, this study has generated a hypothesis that it may reduce occurrence of stroke due to larger artery atherosclerosis.

Funding

This study was initially supported by a grant from the Ministry of Health, Labour and Welfare, Japan. After the governmental support expired, it was conducted in collaboration between Hiroshima University and the Foundation for Biomedical Research and Innovation.

•

1578 patients with non-cardioembolic ischemic stroke were randomly assigned to pravastatin group or control group.

•

Total stroke and TIA similarly occurred in both groups (2.56 vs. 2.65%/year).

•

Atherothrombotic infarction onset was less in pravastatin group (0.21 vs. 0.64%/year, adjusted hazard ratio 0.33).

Although statin therapy is beneficial for the prevention of initial stroke, the benefit for recurrent stroke and its subtypes remains to be determined. This study examined stroke preventive effect of statin on 1578 patients who were assigned to pravastatin group (10 mg/day) or to control group. After 4.9 years of follow-up, although occurrence of total stroke and TIA was not different by the use of pravastatin, occurrence of atherothrombotic infarction was suppressed in the pravastatin group, raising a hypothesis that statins may reduce occurrence of stroke due to larger artery atherosclerosis.

Effective Education Materials to Advance Stroke Awareness Without Teacher Participation in Junior High School Students

BACKGROUND

Youth stroke education is promising for the spread of stroke awareness. The aim of this study was to examine whether our stroke awareness teaching materials without teacher's participation can increase student awareness to act fast on suspected stroke signs.

METHODS

We used the face, arm, speech, and time (FAST) mnemonic derived from the Cincinnati Prehospital Stroke Scale. Seventy-three students of the second grade and 72 students of the third grade (age range, 13-15 years) in a junior high school were enrolled in the study. The students were divided into 2 groups: students who received a teacher's lesson (group I) and those who did not receive a teacher's lesson (group II). Students in group II watched an animated cartoon and read a Manga comic in class. All students took the educational aids home, including the Manga comic and magnetic posters printed with the FAST message. Questionnaires on stroke knowledge were examined at baseline and immediately and 3 months after receiving the intervention.

RESULTS

At 3 months after the intervention, a significant improvement in understanding the FAST message was confirmed in both the groups (group I, 85%; group II, 94%). Significant increases in the knowledge of risk factors were not observed in each group.

CONCLUSIONS

Our education materials include a Manga comic, an animated cartoon, and a magnetic poster, without an accompanying teacher's lesson can increase stroke awareness, including the FAST message, in junior high school students.

Abstract T P178: Cerebral Blood Flow and Metabolism Associated with Cerebral Microbleeds in Patients with Non-cardioembolic Stroke Without Major Cerebral Arterial Stenosis

Background and Purpose: Cerebral microbleeds (CMBs) are associated with not only higher age but also extensive white matter lesions (WMLs), indicating that CMBs could be a reflection of microangiopathy. CMBs have not yet been examined in association with cerebral blood flow (CBF) and metabolism. The purpose of this study was to clarify the relationships of CMBs with WMLs volume, and CBF and metabolism in patients with ischemic stroke.

Methods: We enrolled 19 patients who had past history of non-cardioembolic stroke without severe stenosis (>50%) in major cerebral arteries (69±7 years, 9 women). We measured WMLs volume and counted the number of CMBs on a 1.5-T magnetic resonance imaging (MRI) scanner. CBF, cerebral blood volume, oxygen extraction fraction and cerebral metabolic rate of oxygen were measured with 15 O-labeled gas positron emission tomography (PET). We set 36 regions of interest (ROIs) in the cortex-subcortex regions, basal ganglia and centra semiovale in each patient on MRI. MRI was superimposed on PET images and 4 parameters of each ROI were calculated.

Results: CMBs existed in 14 out of 19 patients (median 5; range 0-39). Patients were divided into 2 groups according to the number of CMBs; less than 5 as the group I (n=9) and 5 or more as the group II (n=10). WMLs volume of the group II was larger than that of the group I (median 38.4 with range of 25.1-91.5 vs. 10.0 with 4.2-73.4 ml, p=0.020). In the centra semiovale, CBF of the group II was significantly lower than that of the group I (12.5±2.5 vs. 15.7±3.5 ml/100g/min, p=0.031). In the other regions, there were no significant differences in all 4 parameters of PET between the 2 groups.

Conclusions: We showed that the increases in the number of CMBs could indicate cerebral ischemia in the deep white matter of patients with non-cardioembolic stroke without major cerebral arterial stenosis.

Effects of Stroke Education of Junior High School Students on Stroke Knowledge of Their Parents

Background and purpose—

Educating the youth about stroke is a promising approach for spreading stroke knowledge. The aim of this study was to verify communication of stroke knowledge to parents by educating junior high school students about stroke.

Methods—

We enrolled 1127 junior high school students (age, 13–15 years) and their parents in the Tochigi prefecture, Japan. All students received a stroke lesson, watched an animated cartoon, and read the related Manga comic as educational aids. The students took back home the Manga and discussed what they learned with their parents. Questionnaires on stroke knowledge were given to all at baseline and immediately after the lesson.

Results—

A total of 1125 students and 915 parents answered the questionnaires. In the students, the frequency of correct answers increased significantly for all questions on stroke symptoms except for headache, and for all questions on risk factors after the lesson. In the parents, the correct answer rates increased for stroke symptoms except for headache and numbness in one side of the body, and for all questions on risk factors except for hypertension. Ninety-one percent of students and 92.7% of parents correctly understood the Face, Arm, Speech, and Time (FAST) mnemonic after the lesson.

Conclusions—

Improvement of stroke knowledge immediately after the stroke lesson was observed in parents as well as their children, which indicated that our teaching materials using the Manga was effective in delivering the stroke knowledge to parents through their children.

Stroke education for multidisciplinary medical personnel in a rural area of Japan for promotion of hospital visit of acute stroke patients

BACKGROUND

There are few studies of stroke education suitable for multidisciplinary medical personnel. A reorganization of the management of acute stroke and stroke education for multidisciplinary medical personnel started since 2013 in our hospital located in a rural area of Japan. This study aimed to examine the effect of our stroke education on changing the number of visits of acute stroke patients to our hospital and to test the stroke knowledge of medical personnel.

METHODS

The stroke education, composed of a 20-minute lecture, was given by a stroke neurologist to 217 medical personnel (age, 49 ± 10 years; male, 70%). Posters printed with the FAST message were given to the participants at the end of the lesson: F, facial drooping; A, arm numbness or weakness; S, slurred speech or difficulty speaking or understanding; T, a time to call an ambulance. Participants completed questionnaires on stroke knowledge at baseline and 3 months after the lesson.

RESULTS

The number of participants who remembered correctly the FAST mnemonic at 3 months was significantly higher than at baseline (78 vs. 90%, P = .006). The correct answer rate for stroke symptoms other than FAST such as vision loss was approximately 50% at 3 months. The number of visits of acute stroke patients to our hospital, particularly patients with transient ischemic attack, increased significantly compared with that before the stroke education.

CONCLUSIONS

Our stroke education method using the FAST mnemonic designed for multidisciplinary medical personnel improved their stroke knowledge. Reorganization of the management of acute stroke and greater stroke knowledge for medical staff are necessary to increase the visits of acute stroke patients in the rural areas.

Effects of stroke education using an animated cartoon and a manga on elementary school children

BACKGROUND

Stroke education for the youth is expected to reduce prehospital delay by informing the bystander of appropriate action to take and providing knowledge to prevent onset of stroke in future. Previously, we developed effective teaching materials consisting of an animated cartoon and a Manga for junior high school students. The aim of this study was to evaluate the feasibility and effectiveness of our educational materials for stroke education taught by schoolteachers to elementary school children.

METHODS

Using our teaching materials, a 30-minute lesson was given by trained general schoolteachers. Questionnaires on stroke knowledge (symptoms and risk factors) and action to take on identification of suspected stroke symptoms were filled out by school children before, immediately after, and at 3 months after completion of the lesson.

RESULTS

A total of 219 children (aged 10 or 11 years) received the stroke lesson. Stroke knowledge significantly increased immediately after the lesson compared with before (symptoms, P < .001; risk factors, P < .001); however, correct answer rates decreased at 3 months immediately after completion of the lesson (symptoms, P = .002; risk factors, P = .045). The proportion of the number of children calling emergency medical service on identifying stroke symptoms was higher immediately after the lesson than baseline (P = .007) but returned to the baseline at 3 months after the lesson.

CONCLUSIONS

Stroke lesson by schoolteachers using our teaching materials consisting of an animated cartoon and a Manga that was previously used for junior high school students was feasible for elementary school children. However, revision of the materials is required for better retention of stroke knowledge for children.

Stroke education using an animated cartoon and a manga for junior high school students

BACKGROUND

We investigated whether junior high school students could be educated regarding stroke with an animated cartoon and a Manga that we produced for the purpose of dissemination of this knowledge.

METHODS

We produced a 10-minute animated cartoon and a Manga that provided information regarding stroke risk factors, stroke signs and symptoms, and awareness to immediately contact emergent medical service (EMS) on identification of stroke signs and symptoms. From December 2011 to March 2012, 493 students in 15 classes of the first grade (age 12-13 years) of 3 junior high schools were enrolled in the study. Each subject watched the animated cartoon and read the Manga; this was referred to as "training." Lessons about stroke were not given. Questionnaires on stroke knowledge were evaluated at baseline, immediately after the training, and 3 months after the training.

RESULTS

The proportion of correct answers given immediately after the training was higher for all questions, except those related to arrhythmia, compared with baseline. Percentage of correct answers given at 3 months was higher than that at baseline in questions related to facial palsy (75% versus 33%), speech disturbance (91% versus 60%), hemiplegia (79% versus 52%), numbness of 1 side (58% versus 51%), calling for EMS (90% versus 85%), alcohol intake (96% versus 72%), and smoking (69% versus 54%). At 3 months after the training, 56% of students answered the FAST (facial droop, arm weakness, speech disturbance, time to call for EMS) mnemonic correctly.

CONCLUSIONS

Stroke education using these teaching aids of the animated cartoon and the Manga improved stroke knowledge in junior high school students.

Abstract W P356: The Effectiveness of the Stroke Educational Activities for Junior High School Students: The Tochigi Project

Background and Purpose: Bringing stroke lessons into the compulsory education is promising for spreading of stroke knowledge nationwide. We produced stroke teaching materials using the FAST mnemonic. The aim of this study is to verify the effectiveness of a stroke education project using our teaching materials for stroke enlightenment, the Tochigi project.

Methods: The subjects were 10,227 students of the 1 st to 3 rd grade (13-15 y.o.) in 53 public junior high schools in Tochigi prefecture, Japan. They were divided into 2 groups; 1,127 students in 9 schools received a 20-minute stroke lesson by their teachers and then watched our 10-minute animated cartoon and read our comic book for 10 minutes (group [[Unable to Display Character: &#1030;]]). The remaining 9,100 students in 44 schools had no teacher's lesson, but watched the animated cartoon and read the comic book (group II). Questionnaires on stroke knowledge were examined for all the students at baseline and immediately after the intervention.

Results: The numbers of questionnaires collected at immediately after the intervention were 1,125 (99.8%) in the group I, and 9,067 (99.6%) in the group II, respectively. In the group I, frequencies of the correct answers increased for all questionnaires except for headache (68.3 vs. 68.0%, p=0.87) as a symptom after the intervention. In the group II, the correct answer rates decreased for the questions of headache (70.9 vs. 32.5%, P<0.0001) and hemi-sensory disturbance (58.1 vs. 56.5%, P<0.05) and increased significantly for those of the other symptoms after the intervention. The correct answer rates increased significantly for questions except for arrhythmia (47.6 vs. 40.6%, P<0.0001) as risk factors after the intervention. Ninety-one % of students understood correctly the “FAST” mnemonic immediately after the intervention in the group I, being higher than the rate of 76% in the group II (p<0.001).

Conclusion: Our teaching materials of stroke enlightenment would be promising for conducting the FAST message to junior high school students.

Abstract W P340: Effects of Stroke Enlightenment on Guardians by Educating Junior High Students: the Tochigi Project

Background and Purpose: School-based interventions of stroke enlightenment are not only beneficial for students but also expected to deliver stroke message effectively to their parents. We produced stroke teaching materials using FAST mnemonic. The aim of this study is to verify the effectiveness of stroke education project (the Tochigi project) for delivering stroke message to their parents through their children, using our teaching materials of stroke enlightenment.

Methods: Subjects were guardians of 1,125 students (13-15 y.o.) in 9 public junior high schools in Tochigi prefecture, Japan. All students received a 20-minute stroke lesson by their teacher using the FAST mnemonic, and then watched a 10-minute animated cartoon and read the comic book. At the close of the lesson, the teacher asked the students to take back the comic book and talk about stroke with their guardians while showing the comic book. Questionnaires on stroke knowledge were examined for all the guardians before and immediately after the conversation about stroke with their children.

Results: There were 915 guardians (81.3%, 94%; parents) participated in the present study. Correct answer rates for the questions of headache (81.1 vs. 72.8%, p<0.0001) and hemi-sensory disturbance (69.3 vs. 72.5%, p=0.14) after the conversation were not improved compared with those before. Frequencies of correct answers increased for the other questionnaires of symptoms and risk factors except hypertension after the conversation. The rate of correct answer for hypertension was high before and after the conversation (91.0 vs. 91.7%). The number of the guardians with correct answer for the meaning of the “FAST” mnemonic was as same as that of students (92.7 vs. 91.0%).

Conclusions: Our teaching materials of stroke enlightenment for junior high school students would be promising means of delivering the stroke message effectively to their guardians.

Stroke education program of act FAST for junior high school students and their parents

BACKGROUND

We produced a stroke education program using the FAST (facial droop, arm weakness, speech disturbance, time to call an ambulance) mnemonic.

AIMS

The aim of this study is to examine efficacy of our education program for junior high school students and their parents.

METHODS

One hundred ninety students of 3 junior high schools (aged 12-13 years) and their parents were enrolled. Students received a 45-minute lesson of stroke enlightenment using the FAST mnemonic. Enlightenment items, such as a magnet poster, were distributed. Parents were educated indirectly from their child. Surveys of stroke knowledge were examined at baseline, immediately after the lesson, and at 3 months after the lesson.

RESULTS

For the students, correct answers at 3 months were significantly higher than those at baseline in questions of facial palsy (98% versus 33%), speech disturbance (98% versus 54%), numbness on one side (64% versus 42%), weakness on one side (80% versus 51%), calling an ambulance (88% versus 60%), alcohol drinking (85% versus 65%), smoking (70% versus 43%), dyslipidemia (58% versus 46%), hyperglycemia (59% versus 48%), and obesity (47% versus 23%). At 3 months, the parents answered more correctly questions of facial palsy (93% versus 66%), calling an ambulance (95% versus 88%), and alcohol drinking (65% versus 51%) than at baseline. At 3 months, 96% of students and 78% of parents answered the FAST mnemonic correctly.

CONCLUSIONS

Our stroke education program improved stroke knowledge, especially the FAST message, for junior high school students and their parents.

Association of geographical factors with administration of tissue plasminogen activator for acute ischemic stroke

BACKGROUND

Intravenous tissue plasminogen activator (tPA) is an effective treatment for acute ischemic stroke if administered within a few hours of stroke onset. Because of this time restriction, tPA administration remains infrequent. Ambulance use is an effective strategy for increasing tPA administration but may be influenced by geographical factors. The objectives of this study are to investigate the relationship between tPA administration and ambulance use and to examine how patient travel distance and population density affect tPA utilization.

METHODS AND RESULTS

We analyzed administrative claims data from 114,194 acute ischemic stroke cases admitted to 603 hospitals between July 2010 and March 2012. Mixed-effects logistic regression models of patients nested within hospitals with a random intercept were generated to analyze possible predictive factors (including patient characteristics, ambulance use, and driving time from home to hospital) of tPA administration for different population density categories to investigate differences in these factors in various regional backgrounds. Approximately 5.1% (5797/114,194) of patients received tPA. The composition of baseline characteristics varied among the population density categories, but adjustment for covariates resulted in all factors having similar associations with tPA administration in every category. The administration of tPA was associated with patient age and severity of stroke symptoms, but driving time showed no association. Ambulance use was significantly associated with tPA administration even after adjustment for covariates.

CONCLUSION

The association between ambulance use and tPA administration suggests the importance of calling an ambulance for suspected stroke. Promoting ambulance use for acute ischemic stroke patients may increase tPA use.

Rationale, design, and baseline features of a randomized controlled trial to assess the effects of statin for the secondary prevention of stroke: the Japan Statin Treatment Against Recurrent Stroke (J-STARS)

BACKGROUND

Although statin therapy is beneficial for preventing first strokes, the benefit for recurrent stroke and its sub-types remains unknown in Asian populations. The aim of this study is to examine the role of pravastatin in the secondary prevention of stroke in Japanese patients.

METHODS

This is a multicenter, randomized, open-label, parallel group study of patients with noncardioembolic ischemic stroke (atherothrombotic infarction, lacunar infarction, and infarction of undetermined etiology). All patients were diagnosed with hyperlipidemia and with a total cholesterol level between 180 and 240 mg/dl at enrollment. Patients in the treatment group receive 10 mg/day of pravastatin, and those in the control group receive no statin treatment. The primary end-point is the recurrence of stroke, including transient ischemic attack. The secondary end-points include the onset of respective stroke sub-types and functional outcomes related to stroke. The patients were enrolled for five-years and will be followed up for five-years.

RESULTS

A total of 1578 eligible patients (age: 66·2 years, men: 68·8%), including 64·2% with lacunar infarction, 25·4% with atherothrombotic infarction, and 10·4% with infarction of undetermined etiology were included in this study. Lipid levels were generally well controlled (total cholesterol: 210·0 mg/dl, low density lipoprotein cholesterol: 129·5 mg/dl) at baseline. In addition, the disability of patients was relatively mild, and cognitive function was preserved in the majority of patients.

CONCLUSION

This article reports the rationale, design, and baseline features of a randomized controlled trial to assess the effects of statin for the secondary prevention of stroke. Follow-ups of patients are in progress and will end in 2014.

Factors associated with the administration of tissue plasminogen activator for acute ischemic stroke

BACKGROUND

The use of intravenous tissue plasminogen activator (t-PA) can be an effective treatment for acute ischemic stroke if administered promptly. Despite its clinical effectiveness, overall use in Japan remains low, and regional variations have been reported. Factors such as ambulance utilization and geographical distance from patients' residences to hospitals may influence t-PA administration rates. The aim of this study is to identify factors associated with the administration of t-PA for acute ischemic stroke while adjusting for casemix using a large-scale administrative database in Japan.

METHODS

We analyzed acute ischemic stroke patients admitted to acute care hospitals between July 2010 and March 2011 using a nationwide database. A logistic regression model was used to analyze the factors influencing t-PA administration. Candidate factors included patient gender, age, stroke severity, direct distance between each patient's residence and admitting hospital, and ambulance utilization.

RESULTS

Of the 10,615 ischemic stroke patients from 89 hospitals analyzed, 557 (5.2%) received t-PA treatment. Patients aged 75 years and older were found to be associated with decreased t-PA administration. In contrast, severe stroke and ambulance utilization were associated with increased t-PA administration. Distance was not significantly associated with the use of t-PA.

CONCLUSIONS

Our findings suggest that ambulance utilization is an important factor for improving the likelihood of t-PA administration in patients with stroke and may underline a need for educational programs to the general public that promote the use of ambulances for suspected stroke patients.

Abstract TP173: Stroke Education by Using a Comic Book and Animated Cartoon Improve Stroke Knowledge among Junior High School Students

Background and Purpose: We have reported that stroke lesson by stroke neurologists for junior high school students improved their stroke knowledge. For the next step, we investigated whether junior high school students could get the knowledge only by stroke education with a comic book and animated cartoon, which we produced to spread the stroke knowledge widely.

Methods: We produce a comic book and a 10-minutes animated cartoon instructing stroke risk factors, stroke sign and symptoms, and encouraging immediate calling for emergent medical service (EMS) on identification of stroke signs and symptoms (the FAST message). Three stories were involved in this comic book and animated cartoon. The first one was a case of acute ischemic stroke treated successfully with hyperacute thrombolytic therapy. The remaining 2 stories were cases of transient ischemic attack; a case of preventing stroke successfully with an appropriate action of his family, but the other case of suffering from a completed stroke with delay of the hospital visit due to the lack of stroke symptom knowledge. From December 2011 to March 2012, 493 students in 15 classes of the 1 st grade (12 - 13 years old) of 3 junior high schools were enrolled. Each subject was distributed the comic book and watched the animated cartoon. Stroke lessons were not performed. Questionnaires on stroke knowledge were examined before, immediately after, and 3 months after the intervention.

Results: Proportions of correct answer in all questions except arrhythmia were significantly higher immediately after the intervention than at baseline. At 3 month, higher proportions of correct answer for facial palsy, speech disturbance, hemiplegia, numbness of one side, calling 119 for stroke, alcohol drinking, smoking, and obesity were preserved as compared with those at baseline;75% vs. 33%, 91% vs. 60%, 79% vs. 52%, 58% vs. 51%, 79% vs. 52%, 90% vs. 85%, 96% vs.72%, 69% vs.54%, 35% vs.22%, respectively (p<0.05). Fifty six percentages of students answered correctly the FAST message.

Conclusions: Stroke education by using our homemade comic book and animated cartoon improved knowledge about stroke among junior high school students.

Abstract WP179: Effects of Stroke Lesson Using A Comic Book and Animated Cartoon on Elementary School Children

Background and purpose: Efforts to increase the knowledge of stroke risk factors and warning signs for youth are expected to reduce the time from stroke onset to hospital and to be effective in stroke prevention. Although there were a few studies about stroke enlightenments for younger individuals, the effective means of stroke enlightenments for elementary school children have not been clarified. The aim of this study is to evaluate the effectiveness of stroke lesson which we developed for elementary school children using a comic book and animated cartoon.

Methods: We developed a comic book and a 10-minutes animated cartoon introducing stroke risk factors, stroke sign and symptoms, and encouraging immediate calling for emergent medical service (EMS) on identification of stroke signs and symptoms. Using these materials, a 30-minutes lesson was performed by the school teacher for school children. Questionnaires on stroke knowledge (including a total of 7 correct items for risk factors and 6 for stroke signs and symptoms), consisted of multiple-choice and closed type questions, were filled out by school children before, immediately after, and 3 months after the lesson. The score was calculated as total numbers of correct answers in assessing stroke knowledge.

Results: A total of 219 school children (10 or 11 years old) in 2 public elementary schools were received the stroke lesson. The knowledge about stroke risk factors at the point of immediately after the lesson increased significantly compared with that of before the lesson (mean ± standard deviation, 4.75±1.40 vs. 4.25±1.51, p<0.001), and it preserved at the points of 3 months after the lesson (4.55±1.55). Correct answers for stroke symptoms immediately after the lesson also improved significantly compared with that before the lesson (3.48±1.00 vs. 2.96±1.21, p<0.001), and it conserved at 3 months after the lesson (3.35±1.06). The proportion of calling EMS on identifying stroke signs and symptoms immediately after the lesson were significantly higher than that before the lesson (97% vs. 91%, p=0.007).

Conclusion: Stroke lesson by a school teacher using a comic book and animated cartoon which we developed was effective on the stroke enlightenments for elementary school children.