Management of acute stroke. Specific nursing care and treatments in the stroke unit

OBJECTIVE

This study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres' internal protocols, serving as a reference for nursing care.

METHODS

We review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification.

RESULTS

The study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital.

CONCLUSIONS

These guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.

Management of acute stroke. Specific nursing care and treatments in the stroke unit

OBJECTIVE

This study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres' internal protocols, serving as a reference for nursing care.

METHODS

We review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification.

RESULTS

The study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital.

CONCLUSIONS

These guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.

Use of quantitative real-time PCR to assess the in vitro survival of specific DNA gene sequences of rumen microbes under simulated abomasal conditions

The use of specific DNA sequences (DS) as a microbial marker in post-rumen digesta requires their persistence and integrity throughout gastric digestion. The aim of this study was to evaluate in vitro the survival of microbial DS during gastric digestion and the factors involved. Gastric pH had a highly significant effect on the integrity of DS. pH 4.2 allows for a significant growth of microbes in the medium, but at pH 1.2, almost all of the DS were hydrolysed. In the presence of carboxymethylcellulose, the effect of pH was reduced, pepsin activity was inhibited and gene survival increased considerably. In the simulated abomasal conditions (pH = 2.3, 2 g/l of carboxymethylcellulose, and 40-min retention time), almost all of the bacterial genes and around 78% of the protozoa gene sequences retained their molecular integrity throughout gastric digestion, although factors such as acidity and viscera retention time might compromise the utilisation of DS as a microbial marker.

Effects of high-fat, low-cholesterol diets on hepatic lipid peroxidation and antioxidants in apolipoprotein E-deficient mice

The present study describes the effects of several high-fat low-cholesterol antiatherogenic diets on the hepatic lipid peroxidation and hepatic antioxidant systems in apolipoprotein E-deficient mice. Eighty mice were distributed into five groups and fed with regular mouse chow or chow supplemented with coconut, palm, olive and sunflower seed oils. After ten weeks, they were sacrificed and the livers were removed so that lipid peroxidation and alpha-tocopherol concentrations, and superoxide dismutase, glutathione peroxidase and glutathione reductase activities could be measured. The size of the atherosclerotic lesions in the aortas was also measured. Results showed that the diets supplemented with olive oil, palm oil or sunflower seed oil significantly decreased the size of the lesion. However, there was an association between those mice that were on diets supplemented with palm or coconut oils and a significant increase in hepatic lipid peroxidation. This association was not found in animals fed with olive or sunflower seed oils, the diets with the highest content of vitamin E. The dietary content of vitamin E was significantly correlated (r = 0.98; p < 0.05) with the hepatic concentration of this compound. Our study suggests that the high content of vitamin E in olive oil or sunflower seed oil may protect from the undesirable hepatotoxic effects of high-fat diets in apo E-deficient mice and that this should be taken into account when these diets are used to prevent atherosclerosis.

Supplementation with vitamin E and/or zinc does not attenuate atherosclerosis in apolipoprotein E-deficient mice fed a high-fat, high-cholesterol diet

Ever since oxidation has been known to be involved in atherogenesis, antioxidants have received considerable attention as potential antiatherogenic agents. The lipid-soluble vitamin E is the main antioxidant carried by lipoproteins. Zinc is a water-soluble trace element that acts as a cofactor of superoxide dismutase (SOD) and has an antioxidant role in several oxidative processes. To test the hypothesis that zinc could adjuvate the antioxidant activity of vitamin E and diminish atherogenesis, we explored how supplementing diet with vitamin E and/or zinc would affect an atherosclerosis-prone animal like Apo E-deficient mice. The increased plasma concentrations of both vitamin E and zinc showed that absorption was high. They had a significant hypolipidemic effect and the supplemented animals had 25% less plasma cholesterol and triglyceride than controls. The SOD activity was significantly higher in washed erythrocytes from mice supplemented with zinc. The plasma of supplemented animals was also significantly more resistant to oxidation. The size of lesions in the proximal aortic region did not differ among groups. Therefore, dietary supplementation resulted in the expected antioxidant effects but there was no substantial attenuation of atherosclerosis in this particular model.

The continuous administration of aspirin attenuates atherosclerosis in apolipoprotein E-deficient mice

Aspirin reduces the incidence of thrombotic occlusive events. Classically this has been thought to be due to the platelet inhibitory action of aspirin but it has recently been shown that inflammation plays a predominant role in the initiation and progression of lesions in atherosclerosis. In humans, treatment with aspirin reduces cardiovascular risk and slows carotid plaque growth in a dose-dependent fashion. We have explored this issue in Apo E-deficient mice on a high-fat, high cholesterol diet which provided these animals with a continuous administration of 500 microg/day of acetylsalicylic acid in the drinking water. After 10 weeks of treatment, the size of the atherosclerotic lesion at the aortic sinus had reduced by 35%. At the end of the trial there were no significant changes in either plasma lipids or in the quantitative distribution among lipoproteins. Likewise, the total antioxidant status and the resistance of plasma to oxidation in vitro was similar and there was no change in the distribution of iron deposits and in the relative composition of plasma pro-oxidants and antioxidants, or in the concentration of plasma in ferritin. Therefore, it is our hypothesis that the antiinflammatory effect is responsible for the reduction in lesion size. We propose that antiinflammatory molecules which do not cause gastrointestinal complications should be tested in humans to determine long-term efficacy in the attenuation of atherosclerosis.

Effects of dietary fat amount and saturation on the regulation of hepatic mRNA and plasma apolipoprotein A-I in rats

The effects of the amount of dietary fat and saturation together with cholesterol both on hepatic apolipoprotein A-I gene mRNA levels and on plasma levels of this apolipoprotein were studied in male rats. To achieve these goals, seven groups of male Wistar rats were established: control group (n=5) consuming chow diet; cholesterol group (n=4) fed on a chow diet containing 0.1% (w/w) cholesterol; coco group (n=5) fed on a chow diet containing 0.1% (w/w) cholesterol and 40% coconut oil; corn group (n=5) fed on a chow diet containing 0.1% (w/w) cholesterol and 40% corn oil; and three olive groups consuming a chow diet containing 0.1% (w/w) cholesterol and percentages of 5 (n=5), 10 (n=4) and 40% (n=5), respectively, of olive oil. Animals were kept on these diets for 2 months and then sacrificed for lipoprotein, apolipoprotein and hepatic mRNA analysis. Dietary cholesterol by itself was hypercholesterolemic when compared to chow diet, an effect that was mainly due to an increase in LDL-cholesterol. Corn oil had a hypocholesterolemic action, whether compared to chow or to cholesterol diet, due to a reduction in HDL-cholesterol as well as LDL-cholesterol. HDL-cholesterol levels of 40% olive oil diet were lower than those corresponding to coconut oil and higher than those found in corn oil diet. When compared to control or cholesterol diets, plasma apoA-I concentration appeared significantly increased in coconut and 40% olive oil diets. Coconut oil or corn oil diets did not induce any significant change in apoA-I mRNA compared to control or cholesterol diets. Compared to cholesterol diet, 40 and 10% olive oil diets induced a significant increase in the expression of this message. A positive and significant (r=0.97, P<0.01) correlation between plasma apolipoprotein A-I concentration and its hepatic mRNA, was observed when the amount of dietary olive oil was 40% (w/w). A significant negative (r=-0.97, P<0.01) correlation was found in the corn oil group and no significant association was observed in the remaining groups. Based on the increased plasma levels in coconut oil and in high percentage olive oil diets, and the differences between these two diets for mRNA expression, it can be concluded that different fatty acid containing diets regulate apolipoprotein A-I through different mechanisms, and these mechanisms could be modulated by the fat intake.

Reduced progression of atherosclerosis in apolipoprotein E-deficient mice with phenylhydrazine-induced anemia

Epidemiological and experimental studies suggest that circulating erythrocytes play a role in the incidence of coronary heart disease. We investigated the influence of phenylhydrazine (PHZ)-induced anemia on the formation of atherosclerotic lesions in apo E-deficient mice on regular chow and on a high-fat, high-cholesterol diet during 10 weeks. The repeated doses of PHZ caused sustained anemia throughout the study, changes in the physical characteristics of erythrocytes and increased reticulocyte count. The lesions of the anemic animals were smaller than in the controls and this was even more evident in mice fed with the atherogenic diet. A positive correlation was found between circulating red blood cells at the end of the experiment and the area of aortic lesion. There was also a negative association between the lesion and the reticulocyte count. This reduced progression of atherosclerotic lesions is independent of nutritional status or the lipoprotein cholesterol distribution. The results suggest that mechanisms related to the number of circulating red blood cells may have a significant influence on the development of atherosclerosis.

Low-cholesterol and high-fat diets reduce atherosclerotic lesion development in ApoE-knockout mice

We have investigated the effect of most common oils used in human nutrition on the development of atherosclerosis in apoE-knockout mice. Seven groups of animals, separated according to sex, were fed for 10 weeks either chow diet or the chow diet 10% (wt/wt) enriched with different oils (palm, coconut, 2 types of olive oil, and 2 types of sunflower oil) without addition of cholesterol. At the end of this period, plasma lipid parameters were measured and vascular lesions scored. None of the diets induced changes in plasma cholesterol concentrations, whereas plasma triglycerides were uniformly reduced in all diet groups. Some diets caused significant reductions in the size of atherosclerotic lesions in males and others in females; males responded most to sunflower oils and females to palm oil and one olive oil (II). The lesion reduction in males consuming sunflower oils was associated with the decrease of triglycerides in triglyceride-rich lipoproteins, whereas the decrease in females consuming olive oil II or palm oil was accompanied by an increase in plasma apoA-I. The increase in plasma apoA-I in the latter condition, is mainly due to overexpression of hepatic message elicited by a mechanism independent of apoE ligand. The data suggest that the different diets modulate lesion development in a gender specific manner and by different mechanisms and that the development of atherosclerosis, due to genetic deficiencies, may be modulated by nutritional maneuvers that may be implemented in human nutrition.