Everyday Pain in Middle and Later Life: Associations with Daily and Momentary Present-Moment Awareness as One Key Facet of Mindfulness

This study investigated everyday associations between one key facet of mindfulness (allocating attention to the present moment) and pain. In Study 1, 89 community-dwelling adults (33-88 years; Mage = 68.6) who had experienced a stroke provided 14 daily end-of-day present-moment awareness and pain ratings. In Study 2, 100 adults (50-85 years; Mage = 67.0 years) provided momentary present-moment awareness and pain ratings three times daily for 10 days. Multi-level models showed that higher trait present-moment awareness was linked with lower overall pain (both studies). In Study 1, participants reported less pain on days on which they indicated higher present-moment awareness. In Study 2, only individuals with no post-secondary education reported less pain in moments when they indicated higher present-moment awareness. Findings add to previous research using global retrospective pain measures by showing that present-moment awareness might correlate with reduced pain experiences, assessed close in time to when they occur.

Microsatellite instability in pancreatic and ampullary carcinomas: histology, molecular pathology, and clinical implications

Microsatellite instability (MSI)/defective DNA mismatch repair (dMMR) represents an important molecular alteration with diagnostic, prognostic, and predictive value. The increasing interest toward this genetic alteration is given to the high response rate of MSI/dMMR tumors to immunotherapy. There are different cancers in the periampullary region that can harbor MSI/dMMR, and significant morphological-molecular correlates should be acknowledged in this district: (1) pancreatic ductal adenocarcinoma (PDAC): in this tumor category, the prevalence of MSI/dMMR is about 1-2%, and medullary and colloid variants are the most typically involved; (2) ampullary adenocarcinoma: here the prevalence of MSI/dMMR is up to 18%, and in this neoplastic group, MSI/dMMR is more commonly found in the intestinal subtype; (3) pancreatic acinar cell carcinoma: here the prevalence of MSI/dMMR is up to 14%; and (4) pancreatic and ampullary neuroendocrine carcinoma: in this tumor category, the prevalence of MSI/dMMR is up to 5-8%, and this molecular alteration should be assessed also in cases of mixed neuroendocrine-non-neuroendocrine neoplasms. Given the clinical importance of MSI/dMMR and its not-negligible prevalence among the different carcinomas arising in this district, its assessment should become part of the routine diagnostic workflow at least for the most typical histotypes. The test of choice is represented by immunohistochemistry for PDAC and ampullary carcinomas, and by direct molecular analyses including MSI-based polymerase chain reaction and next-generation sequencing for acinar cell and neuroendocrine carcinomas.

Rethinking Driving Against Medical Advice: The Situated Nature of Driving After Stroke

Background: As stroke can result in functional impairments that impact driving ability, many jurisdictions mandate a 30-day period of driving restriction post-stroke. However, between 26% and 38% of clients drive against medical advice during this period. Purpose: Informed by critical reflexivity of the literature and the first author's practice, this critical analysis paper (1) explicates and critiques how adherence to guidelines regarding driving after stroke in the first 30 days is conceptualized in individualistic, biomedically centred research and (2) argues for expanded understandings of driving based on a transactional occupational perspective. Key Issues: Individualistic, biomedical perspectives view driving against medical advice as an individually located phenomenon, generating partial understandings and individually focused solutions. Re-conceptualizing driving after stroke as a transactional occupational choice provides a productive basis for understanding and addressing driving within practice and research. Implications: Concepts from occupational science can generate new insights for research and client-centred practice regarding driving following stroke.

Self-Perceived ADL/IADL Function is Influenced by Residual Neurological Impairment, Aphasia, and Anxiety

BACKGROUND.

Self-perceptions of performance of activities of daily living (ADL) and instrumental activities of daily living (IADL) are reduced following stroke. Research investigating contributing factors is lacking.

PURPOSE.

We examined the extent to which aphasia status, neurological impairment and poststroke depression, and anxiety contribute to self-perceived ADL/IADL function.

METHOD.

Seventy-six community-dwelling individuals at least 6 months poststroke, 44 with and 32 without aphasia, participated in the cross-sectional study. The Stroke Impact Scale (SIS) ADL/IADL domain was the primary outcome measure with aphasia status, residual neurological impairment, depressive symptoms, and anxiety as predictor variables.

FINDINGS

Aphasia status, residual neurological impairment, and anxiety were independent predictors of self-perceived ADL/IADL function, together accounting for more than half the variance. Depression was not associated with ADL/IADL.

IMPLICATIONS.

Clinician awareness of the influence of anxiety on self-perceived ADL/IADL function, particularly for people with aphasia, may lead to future interventions that improve self-perceived ADL/IADL function.

[Strokein type 2 diabetic patients in the internal medicine department of the Teaching Hospital of Point G]

INTRODUCTION

Diabetes is a chronic hyperglycemia which can be discovered with specific organic complications particularly affecting the eyes, kidneys, nerves, heart and vessels. Globally, the prevalence of stroke in people with diabetes is approximately 10%.

OBJECTIVE

Study the epidemiological and clinical aspects of stroke in patients with type 2 diabetes.

METHODOLOGY

We made a descriptive and analytical study by a retrospective survey over a period of 10 years, in the department of internal medicine at the university Hospital ofPoint G. We focused on all hospitalized patients with type 2 diabetes, in whom the diagnosis of stroke was retained.

RESULTS

At the end of the study 24 patients out of 492 diabetes hospitalized in to the period met our inclusion criteria, representing a frequence of 4.9%. The mean age was 64.67 ± 13.409 years with a sex-ratio of 1.4. The reason for hospitalization was muscle weakness in 54.2% of patients. Eighty-seven point five percent (87.5%) of patients were already known to have diabetes before the weakness. Stroke was the mode of discovery of diabetes in 12.5%. Over 70% of our patients had hyperglycemia at the time of admission. Ischemic stroke was seen in 75% of patients.

CONCLUSION

Stroke is a great complication of diabetes witch, can be a way discovery of type 2 diabetes.

End-stage renal disease, calcification patterns and clinical outcomes after TAVI

BACKGROUND

Patients with chronic hemodialysis due to end-stage renal disease (ESRD) or severely impaired kidney function (CKD) constitute a relevant share of patients undergoing trans-catheter aortic valve implantation (TAVI). However, data on specific challenges and outcomes remain limited.

AIM

We aimed to characterize this patient population, evaluate clinical results and assess the significance of calcification patterns.

METHODS

This retrospective single-center analysis evaluated 2,712 TAVI procedures (2012-2019) according to baseline renal function: GFR < 30 ml/min/1.73m² (CKD; n = 210), chronic hemodialysis (ESRD; n = 119) and control (CTRL; n = 2383). Valvular and vascular calcification patterns were assessed from contrast-enhanced multi-detector computed tomography. Outcomes were evaluated in accordance with the VARC-2 definitions.

RESULTS

Operative risk was higher in ESRD and CKD vs. CTRL (STS-score 8.4% and 7.6% vs. 3.9%, p < 0.001) and patients with ESRD had more severe vascular calcifications (49.1% vs. 33.9% and 29.0%, p < 0.01). Immediate procedural results were similar but non-procedure-related major/life-threatening bleeding was higher in ESRD and CKD (5.0% and 5.3% vs. 1.6%, p < 0.01). 3-year survival was impaired in patients with ESRD and CKD (33.3% and 35.3% vs. 65.4%, p < 0.001). Multivariable analysis identified ESRD (HR 1.60), CKD (HR 1.79) and vascular calcifications (HR 1.29) as predictors for 3-year and vascular calcifications (HR 1.51) for 30-day mortality.

CONCLUSION

Patients with ESRD and CKD constitute a vulnerable patient group with extensive vascular calcifications. Immediate procedural results were largely unaffected by renal impairment, yielding TAVI a particularly valuable treatment option in these high-risk operative patients. Mid-term survival was determined by underlying renal disease, cardiovascular comorbidities, and vascular calcifications as a novel risk marker.

Sensory Modulation and Participation in Daily Occupations in Stroke Survivors

Background. Stroke may alter sensory modulation and restrict participation in daily occupations. Although studies highlight the relationship between altered sensory modulation and reduced participation, this relationship in stroke survivors has not been studied enough. Purpose. To examine the prevalence of altered sensory modulation among stroke survivors; to compare sensory modulation and participation between stroke survivors and healthy controls; to estimate the relationship between sensory modulation and participation among stroke survivors. Method. Thirty stroke survivors and 30 healthy controls, aged 18-70, completed the MoCA, the Adolescent-Adult Sensory Profile and the Activity Card Sort. Findings. Altered sensory modulation was more prevalent among stroke survivors. Their participation was significantly restricted as compared to healthy controls. Lower tendency to seek sensory input predicted lower participation in social activities. Implications. Occupational therapists should screen for altered sensory modulation in stroke survivors and understand their impacts on participation, in order to improve intervention outcomes.

[Pain induced during care, what non-drug treatment in post-stroke?]

At the neuro-vascular emergencies unit at the Pitié-Salpêtrière (AP-HP,Paris), a population that is mostly elderly and dependent is cared for daily by caregivers. With an average age of stroke of 74 years, these patients regularly suffer from neuropathic pain in post-stroke situations. Caregivers are very vigilant in preventing pain induced during care, particularly during mobilization, and are developing holistic pain management that includes non-drug approaches.

[Secondary blepharospasm, analysis and pathophysiology of blepharospasm. French translation of the article]

PURPOSE

To localize the brain structures involved in blepharospasm.

MATERIALS AND METHODS

This is a retrospective consecutive series of brain MRI's of patients with secondary blepharospasm whose immediate past medical history included cerebrovascular accident or head trauma.

RESULTS

Six patients, including 4 with CVA with ischemic or hemorrhagic lesions of the thalamus and caudate nuclei and 2 with head trauma with contusive sequellae to the tectal plate and frontal cortical and cerebellar atrophy.

CONCLUSION

According to the literature, brain lesions associated with blepharospasm involve mainly the thalamus, head of the caudate nucleus, corpus striatum, globus pallidus, internal capsule, cerebral cortex and cerebellum. This study demonstrates that blepharospasm is associated with a lesion of a complex neural network - cortex-thalamus-globus pallidus-cortex - and does not correspond to a single, unique lesion. This network is connected with ascending and descending sensory-motor pathways and motor nuclei.

[Stroke in type 2 diabetic patients in the internal medicine department of the Teaching Hospital of Point G]

INTRODUCTION

Diabetes is a chronic hyperglycemia which can be discovered with specific organic complications particularly affecting the eyes, kidneys, nerves, heart and vessels. Globally, the prevalence of stroke in people with diabetes is approximately 10%.

OBJECTIVE

Study the epidemiological and clinical aspects of stroke in patients with type 2 diabetes.

METHODOLOGY

We made a descriptive and analytical study by a retrospective survey over a period of 10 years, in the department of internal medicine at the university Hospital ofPoint G. We focused on all hospitalized patients with type 2 diabetes, in whom the diagnosis of stroke was retained.

RESULTS

At the end of the study 24 patients out of 492 diabetes hospitalized in to the period met our inclusion criteria, representing a frequence of 4.9%. The mean age was 64.67 ± 13.409 years with a sex-ratio of 1.4. The reason for hospitalization was muscle weakness in 54.2% of patients. Eighty-seven point five percent (87.5%) of patients were already known to have diabetes before the weakness. Stroke was the mode of discovery of diabetes in 12.5%. Over 70% of our patients had hyperglycemia at the time of admission. Ischemic stroke was seen in 75% of patients.

CONCLUSION

Stroke is a great complication of diabetes witch, can be a way discovery of type 2 diabetes.

Diabetes-related sex differences in the brain endothelin system following ischemia in vivo and in human brain endothelial cells in vitro

The endothelin (ET) system has been implicated to contribute to the pathophysiology of cognitive impairment and stroke in experimental diabetes. Our goals were to test the hypotheses that (1) circulating and (or) periinfarct ET-1 levels are elevated after stroke in both sexes and this increase is greater in diabetes, (2) ET receptors are differentially regulated in the diabetic brain, (3) brain microvascular endothelial cells (BMVEC) of female and male origin express the ETA receptor subtype, and (4) diabetes- and stroke-mimicking conditions increase ET-1 levels in BMVECs of both sexes. Control and diabetic rats were randomized to sham or stroke surgery. BMVECs of male (hBEC5i) and female (hCMEC/D3) origin, cultured under normal and diabetes-mimicking conditions, were exposed to normoxia or hypoxia. Circulating ET-1 levels were higher in diabetic animals and this was more pronounced in the male cohort. Stroke did not further increase plasma ET-1. Tissue ET-1 levels were increased after stroke only in males, whereas periinfarct ET-1 increased in both control and diabetic females. Male BMVECs secreted more ET-1 than female cells and hypoxia increased ET-1 levels in both cell types. There was sexually dimorphic regulation of ET receptors in both tissue and cell culture samples. There are sex differences in the stroke- and diabetes-mediated changes in the brain ET system at the endothelial and tissue levels.

Sovateltide (IRL-1620) affects neuronal progenitors and prevents cerebral tissue damage after ischemic stroke

Stimulation of endothelin B receptors by its agonist IRL-1620 (INN, sovateltide) provides neuroprotection and neurological and motor function improvement following cerebral ischemia. We investigated the effect of sovateltide on stem and progenitor cells mediated neural regeneration and its effect on the cerebral tissue repair and restoration of neurological and motor function. Sovateltide (5 μg/kg) was injected intravenously in permanent middle cerebral artery occluded (MCAO) rats at 4, 6, and 8 h at days 0, 3, and 6. Neurological and motor function tests were carried out pre-MCAO and at day 7 post-MCAO. At day 7, significantly reduced expression of neuronal differentiation markers HuC/HuD and NeuroD1 was seen in MCAO + vehicle than sham rats. Sovateltide treatment upregulated HuC/HuD and NeuroD1 compared to MCAO + vehicle and their expression was similar to sham. Expression of stem cell markers Oct 4 and Sox 2 was similar in rats of all of the groups. Significantly reduced infarct volume and DNA damage with recovery of neurological and motor function was observed in sovateltide-treated MCAO rats. These results indicate that sovateltide initiates a regenerative response by promoting differentiation of neuronal progenitors and maintaining stem cells in an equilibrium following cerebral ischemic stroke.

Hyperbaric oxygen and focused rehabilitation program: a feasibility study in improving upper limb motor function after stroke

Neuroplasticity and recovery after stroke can be enhanced by a rehabilitation program pertinent to upper limb motor function exercise and mental imagery (EMI) as well as hyperbaric oxygen therapy (HBOT). We assessed feasibility and safety of the combined approach utilizing both HBOT and EMI, and to derive preliminary estimates of its efficacy. In this randomized controlled trial, 27 patients with upper extremity hemiparesis at 3-48 months after stroke were randomized to receive either a complementary rehabilitation program of HBOT-EMI (intervention group), or EMI alone (control group). Feasibility and safety were assessed as total session attendance, duration of sessions, attrition rates, missing data, and intervention-related adverse events. Secondary clinical outcomes were assessed with both objective tools and self-reported measures at baseline, 8 weeks (end of treatment), and 12-weeks follow-up. Session attendance, duration, and attrition rate did not differ between the groups; there were no serious adverse events. Compared with baseline, there were significant sustained improvements of objective and subjective outcomes' measures in the intervention group, and a single improvement in an objective measure in the control group. Between-group outcome comparisons were not statistically significant. This study demonstrated that the combination HBOT-EMI was a safe and feasible approach in patients recovering from chronic stroke. There were also trends for improved motor function of the affected upper limb after the treatments. ClinicalTrials.gov registration no.: NCT02666469. Novelty HBOT combined with an upper limb exercise and mental imagery rehabilitation program is feasible and safe in chronic stroke patients. This combined approach showed trends for improved functional recovery.

Endothelin-1 (ET-1) promotes a proinflammatory microglia phenotype in diabetic conditions

Diabetes increases the risk and severity of cognitive impairment, especially after ischemic stroke. It is also known that the activation of the endothelin (ET) system is associated with cognitive impairment and microglia around the periinfarct area produce ET-1. However, little is known about the effect of ET-1 on microglial polarization, especially under diabetic conditions. We hypothesized that (i) ET-1 activates microglia to the proinflammatory M-1-like phenotype and (ii) hypoxia/ lipopolysaccharide (LPS) activates the microglial ET system and promotes microglial activation towards the M-1 phenotype in diabetic conditions. Microglial cells (C8B4) cultured under normal-glucose (25 mmol/L) conditions and diabetes-mimicking high-glucose (50 mmol/L) conditions for 48 h were stimulated with ET-1, cobalt chloride (200 μmol/L), or LPS (100 ng/mL) for 24 h. PPET-1, ET receptor subtypes, and M1/M2 marker gene mRNA expression were measured by RT-PCR. Secreted ET-1 was measured by ELISA. A high dose of ET-1 (1 μmol/L) increases the mRNA levels of ET receptors and activates the microglia towards the M1 phenotype. Hypoxia or LPS activates the ET system in microglial cells and shifts the microglia towards the M1 phenotype in diabetic conditions. These in vitro observations warrant further investigation into the role of ET-1-mediated activation of proinflammatory microglia in post-stroke cognitive impairment in diabetes.

[Neuroanatomical correlates between stroke lesions and urinary disorders: A narrative review]

CONTEXT

Stroke generates diverse urinary disorders, frequent but often under-diagnosed and thus untreated. Even though advances in the comprehension of the physiological voiding control and involved brain areas, the precise correspondence between lesion sites and observed urinary symptoms is not clearly established.

OBJECTIVE

This review aimed to update on this neuroanatomical correlates.

DOCUMENTARY SOURCES

The search focused on articles written in French or English, on PubMed, studying human beings or animals, published between the 1st of January 2000 and the 31st of August 2018 using the following keywords (stroke or hemiplegia) and (urinary incontinence or low urinary tract symptom or retention or overactive bladder or dysuria) and (anatomy or location or localization or area or lesion).

STUDIES SELECTION

The main author selected the most pertinent articles on abstracts and then on full text.

RESULTS

Twelve studies were included in our review. We could not fully confirm the neuroanatomical correlates based on the animal model. Frontoparietal lesions in urinary incontinence, role of the insula in the urinary retention, and systematic but different urinary symptoms in the brain stem lesions are the main findings.

LIMITS

Few studies were included, with varying methodologies and types of population.

CONCLUSION

A few cerebral areas damaged by stroke seem to be linked to certain urinary troubles, but new studies with a higher methodological quality are required to confirm this result.

HAND2 Target Gene Regulatory Networks Control Atrioventricular Canal and Cardiac Valve Development

The HAND2 transcriptional regulator controls cardiac development, and we uncover additional essential functions in the endothelial to mesenchymal transition (EMT) underlying cardiac cushion development in the atrioventricular canal (AVC). In Hand2-deficient mouse embryos, the EMT underlying AVC cardiac cushion formation is disrupted, and we combined ChIP-seq of embryonic hearts with transcriptome analysis of wild-type and mutants AVCs to identify the functionally relevant HAND2 target genes. The HAND2 target gene regulatory network (GRN) includes most genes with known functions in EMT processes and AVC cardiac cushion formation. One of these is Snai1, an EMT master regulator whose expression is lost from Hand2-deficient AVCs. Re-expression of Snai1 in mutant AVC explants partially restores this EMT and mesenchymal cell migration. Furthermore, the HAND2-interacting enhancers in the Snai1 genomic landscape are active in embryonic hearts and other Snai1-expressing tissues. These results show that HAND2 directly regulates the molecular cascades initiating AVC cardiac valve development.

[Multiple facets of ADA2 deficiency: Vasculitis, auto-inflammatory disease and immunodeficiency: A literature review of 135 cases from literature]

Deficiency of adenosine deaminase 2 (DADA2) is a recently described auto-inflammatory disorder. It is an autosomal recessive inherited disease, caused by mutations in the ADA2 gene (formerly known as CECR1) encoding ADA2 enzyme. Besides its role in the purine metabolism, it has been postulated that ADA2 may act as a growth factor for endothelial cells and in the differenciation of monocytes. Thus, deficiency of ADA2 would lead to endothelial damage and a skewing of monocytes into M1 pro-inflammatory macrophage, causing DADA2 manifestations. Three core clinical features have been described: inflammatory-vascular signs, hematologic abnormalities and immunodeficiency. Clinically, patients display intermittent fever, cutaneous vascular manifestations, such as livedo, ischemic strokes, arthralgia and abdominal pain crisis. Corticosteroids and immunosuppressive agents (i.e. cyclophosphamide, azathioprine, ciclosporin, methotrexate) appear to be poorly effective. Although the mechanism has not been elucidated, anti-TNF agents have been proven efficient in DADA2 and should therefore be used as first line therapy for vasculitis. Role of anti-platelet and anticoagulant therapies in stroke-prophylaxis remains to be discussed, as those patients display a high risk of intracranial bleeding.

Difference between individuals with left and right hemiparesis in the effect of gluteus medius vibration on body weight shifting

OBJECTIVE

To test the effect of gluteus medius (GM) vibration on the reduction of asymmetric body weight distribution in individuals with hemiparesis (HP) at two stages of postural recovery.

METHODS

The effects of GM vibration according to the shift of the body weight (%Shift) onto the paretic leg during GM vibration were registered while standing on a force-platform in 40 HP (19 left and 21 right; mean age 54.7±10.6years, mean time after stroke 2.0±1.3months), as soon as they could stand without assistance and 4 to 6 weeks later, and in 40 control subjects (mean age 54.7±10.5years).

RESULTS

Without vibration, baseline body weight (BW) distribution was characterized by underloading of the paretic limb (mean BW on the paretic limb 37.2%±13.1%). At the early stage of balance recovery, % shift toward the paretic limb induced by GM vibration differed significantly between left and right HP (P=0.049) and between left HP and controls (C) (P=0.022) and was related to BW asymmetry (r=0.437, P=0.004). Later, GM vibration reduced asymmetric BW distribution in most HP and no difference was found between left and right HP and between left and C.

CONCLUSION

At an advanced stage of postural recovery, GM vibration could help encourage HP to put weight on the affected limb. Interestingly, a behavioral difference was initially observed between right and left HP that could probably be explained by a different strategy due to the baseline severity of the BW asymmetry.

The effect of exercise preconditioning on stroke outcome in ovariectomized mice with permanent middle cerebral artery occlusion

Exercise preconditioning has been shown to be effective in improving behavioral and neuropathological indices after cerebral ischemia. We evaluated the effect of exercise preconditioning, 17β-estradiol, and their combination on stroke outcome using an experimental model of stroke in ovariectomized (OVX) mice. OVX mice were randomly assigned to 4 groups as follows: control (stroke), exercise (exercise and stroke), estradiol (17β-estradiol and stroke), and exercise+estradiol (exercise and 17β-estradiol and stroke). Exercise preconditioning was performed on a treadmill 5 days/week, 40 min/day, at a speed of 18 m/min for 4 weeks. 17β-estradiol was gavaged (40 μg/kg per day) for 4 weeks. Stroke was induced by permanent middle cerebral artery occlusion (pMCAO), and neurological deficits were evaluated 1, 2, and 7 days after stroke. Then, the serum concentrations of matrix metalloproteinase-9 (MMP-9) and interleukin-10 (IL-10) and infarct volumes were assessed. Exercise preconditioning and 17β-estradiol induced a better outcome compared with the control ischemic mice, which was manifested by decrease in MMP-9, increase in IL-10, diminished infarct volume, and improved neurological deficits. Concomitant administration of 17β-estradiol and exercise also significantly improved these parameters. Exercise preconditioning or administration of 17β-estradiol alone or in combination before pMCAO induced significant neuroprotection in OVX mice.

Runx2-I is an Early Regulator of Epithelial-Mesenchymal Cell Transition in the Chick Embryo

BACKGROUND

Although normally linked to bone and cartilage development, the Runt-related transcription factor, RUNX2, was reported in the mouse heart during development of the valves. We examined RUNX2 expression and function in the developing avian heart as it related to the epithelial-mesenchymal transition (EMT) in the atrioventricular canal. EMT can be separated into an activation stage involving hypertrophy and cell separation and an invasion stage where cells invade the extracellular matrix. The localization and activity of RUNX2 was explored in relation to these steps in the heart. As RUNX2 was also reported in cancer tissues, we examined its expression in the progression of esophageal cancer in staged tissues.

RESULTS

A specific isoform, RUNX2-I, is present and required for EMT by endothelia of the atrioventricular canal. Knockdown of RUNX2-I inhibits the cell-cell separation that is characteristic of initial activation of EMT. Loss of RUNX2-I altered expression of EMT markers to a greater extent during activation than during subsequent cell invasion. Transforming growth factor beta 2 (TGFβ2) mediates activation during cardiac endothelial EMT. Consistent with a role in activation, RUNX2-I is regulated by TGFβ2 and its activity is independent of similarly expressed Snai2 in regulation of EMT. Examination of RUNX2 expression in esophageal cancer showed its upregulation concomitant with the development of dysplasia and continued expression in adenocarcinoma.

CONCLUSIONS

These data introduce the RUNX2-I isoform as a critical early transcription factor mediating EMT in the developing heart after induction by TGFβ2. Its expression in tumor tissue suggests a similar role for RUNX2 in the EMT of metastasis. Developmental Dynamics 247:542-554, 2018. © 2017 Wiley Periodicals, Inc.

Ellagic acid protects against neuron damage in ischemic stroke through regulating the ratio of Bcl-2/Bax expression

An oxygen-glucose deprivation and reoxygenation model in primary cultured rat cortical neurons was developed for this study to investigate the effects of ellagic acid (EA), a low-molecular-weight polyphenol, on neuron cells and their function, and to evaluate whether EA can be safely utilized by humans as a functional food or therapeutic agent. Administration of EA significantly decreased the volume of cerebrum infarction and the neurological deficit scores of the rats; EA treatment also increased the number of Bcl-2-positive cells and the ratio of Bcl-2-positive to Bax-positive neurons in the semidarkness zone near the brain ischemic focus in the photothrombotic cerebral ischemia model. Treatment of EA resulted in increased neuron viability, cell nuclear integrity, and the ratio of Bcl-2/Bax expression in the primary cultured neuron model; EA treatment also lead to a decrease in the number of apoptotic cells. Our results therefore suggest a specific mechanism for the beneficial effects of EA, providing new insights into how it provides neuroprotection. To the best of our knowledge, these results represent new insights on the mechanisms of the brain cell protective activity of EA. Thus, EA may be used in functional foods or medicines to help treat nerve dysfunction, neurodegenerative disease, and aging.

[Factors associated with quality of life for patients with post-stroke aphasia in the Cotonou hospitals, Benin]

INTRODUCTION

The objective of this study was to determine the factors influencing quality of life for patients with post-stroke aphasia followed in Cotonou hospitals.

METHOD

A prospective descriptive and analytical cross-sectional study was conducted in CNHU-HKM (Cotonou, Benin) from October to December 2012; focusing on patients with at least six months of post-stroke aphasia. For each patient, a SIP-65 questionnaire was administered. The Epi Info 3.5 software was used for data analysis. A multivariate analysis was performed to determine factors associated with quality of life for patients with aphasia.

RESULTS

In total, 41 patients were included in this study with a sex ratio of 1.3. The average age was 55.3 ± 2.5 years. The average duration of the aphasia was 10 months. Broca's aphasia was predominant (68.3%). 60.8% of aphasia patients were able to preserve their quality of life. Multivariate analysis showed that age, family support, the type of stroke and aphasia and speech therapy were associated with quality of life.

CONCLUSION

The treatment of post-stroke aphasia must incorporate these factors associated with quality of life for a better recovery of patients.

[Problematics of subarachnoid hemorrhage in developing countries: The case of Togo]

OBJECTIVE

To analyze the diagnostic and therapeutic strategies as well as the results of the treatment of spontaneous subarachnoid hemorrhage (SAH) in Togo, before creating a neurosurgery department.

METHODS

We conducted a case series of subarachnoid hemorrhage collected from 30 June 2005 to 30 June 2010 in the Universities Hospital of Lomé. It involved patients older than 15 years of age hospitalized for subarachnoid hemorrhage with clinical and/or radiation confirmation.

RESULTS

Thirty-five cases of SAH were found and corresponded to 0.20 % of neurological emergencies. The average age was 48 years with a range of 22 to 78 years with a sex-ratio F/H 1.33. The consciousness disorders (48.57 %) and headaches (42.85 %) were the main reasons for admission. Seventeen patients (48.57 %) had hypertension and 14 (40 %) were ethylic. Lumbar puncture performed in 9 patients (25.71 %) and CT scan in 29 patients (82.86 %), respectively, had a sensitivity of 100 % and 93.10 %. Four cases of intracranial aneurysm were diagnosed. The admission average was 3.07±3.69 days. The treatment was mainly symptomatic. Mortality was 22.85 % and severe disability was observed in 8 patients (22.85 %).

CONCLUSION

The profile of the SAH in Lomé appeared to differ from the literature. Too low a proportion of aneurysm is diagnosed. The equipment of Hospital and neurosurgeons training would be needed to improve the management of this pathology.

Driving behaviour responses to a moose encounter, automatic speed camera, wildlife warning sign and radio message determined in a factorial simulator study

In a driving simulator study, driving behaviour responses (speed and deceleration) to encountering a moose, automatic speed camera, wildlife warning sign and radio message, with or without a wildlife fence and in dense forest or open landscape, were analysed. The study consisted of a factorial experiment that examined responses to factors singly and in combination over 9-km road stretches driven eight times by 25 participants (10 men, 15 women). The aims were to: determine the most effective animal-vehicle collision (AVC) countermeasures in reducing vehicle speed and test whether these are more effective in combination for reducing vehicle speed; identify the most effective countermeasures on encountering moose; and determine whether the driving responses to AVC countermeasures are affected by the presence of wildlife fences and landscape characteristics. The AVC countermeasures that proved most effective in reducing vehicle speed were a wildlife warning sign and radio message, while automatic speed cameras had a speed-increasing effect. There were no statistically significant interactions between different countermeasures and moose encounters. However, there was a tendency for a stronger speed-reducing effect from the radio message warning and from a combination of a radio message and wildlife warning sign in velocity profiles covering longer driving distances than the statistical tests. Encountering a moose during the drive had the overall strongest speed-reducing effect and gave the strongest deceleration, indicating that moose decoys or moose artwork might be useful as speed-reducing countermeasures. Furthermore, drivers reduced speed earlier on encountering a moose in open landscape and had lower velocity when driving past it. The presence of a wildlife fence on encountering the moose resulted in smaller deceleration.

Treating coronary artery disease in patients with a history of cerebrovascular disease

Patients with coronary artery disease and a history of stroke account for as many as one in eight of all patients with coronary artery disease, and they are at higher risk of ischaemic events than patients with 'lone' coronary artery disease. It is therefore tempting to increase the potency of antithrombotic treatment in this patient subset. However, these patients are also at greater risk of intracranial haemorrhage. In recent trials of new antithrombotic agents in acute coronary syndromes, patients with a history of cerebrovascular disease derived no clinical benefit from (and were even harmed by) the potent novel antithrombotic agents, with an increased risk of intracranial haemorrhage. However, this risk did not appear to be uniform: it was higher in patients with a history of stroke than in those with a history of transient ischaemic attack, and appeared to be largely confined to the first year after stroke/transient ischaemic attack. Specific strategies to optimize the benefit/risk ratio of antithrombotic agents in this relatively common patient group should be developed and evaluated.

[Vascular age and cardiovascular risk in patients suffering from stroke]

AIMS

To determine the vascular age of patients suffering from stroke and their cardiovascular risk at 10 years and to compare their vascular age to their real age.

MATERIAL AND METHODS

It was about a descriptive and retrospective study carried up from 1st January 2012 to 31st December 2013 at the neurologic clinic of the University teaching hospital Sylvanus Olympio of Lome from patients' files with a confirmed diagnostic of stroke according to the clinical examination and the scanner data.

RESULTS

One hundred and ninety-four patients were related to our study. They were shared-out into 101 men and 93 women equal to a sex-ratio (man/woman) of 1.08. The average real age was of 57.6 ± 13.7 years. High blood pressure was the main risk factor with a prevailing rate of 86.6%, followed by the total hypercholesterolemia (54.3%), the hypocholesterolemia HDL (22.7%), diabetes (10.8%) and nicotinism addiction (4.1%). The average vascular age for all patients was of 68.23 years. The average difference between the real age and the vascular age was of 10 years. The average cardiovascular risk at 10 years in our study was of 13.2%.

CONCLUSION

The vascular age of patients suffering from stroke at the University teaching hospital Sylvanus Olympio of Lome is 10 years higher than their real age. This condition considerably increases their risk of cardiovascular diseases. The screening and the early care about vascular risk factors appear therefore of utmost importance.

[Contribution of arterial spin labeling to the diagnosis of sudden and transient neurological deficit]

MRI is the gold standard exploration for sudden transient neurological events. If diffusion MRI is negative, there may be a diagnostic doubt between transient ischemic attack and other causes of transient neurological deficit. We illustrate how sequence arterial spin labeling (ASL), which evaluates cerebral perfusion, contributes to the exploration of transient neurological events. An ASL sequence was performed in seven patients with a normal diffusion MRI explored for a transient deficit. Cortical hyperperfusion not systematized to an arterial territory was found in three and hypoperfusion systematized to an arterial territory in four. ASL helped guide early management of these patients.

[Does upper limb robot-assisted rehabilitation contribute to improve the prognosis of post-stroke hemiparesis?]

INTRODUCTION

Upper limb robot-assisted rehabilitation is a novel physical treatment for neurological motor impairments. During the last decade, this rehabilitation option utilizing technological tools has been evaluated in hemiparetic patients, mostly after stroke.

STATE OF ART

Studies at acute and chronic stages suggested good tolerance and a significant and persistent reduction of motor impairment; a real impact on disability has been shown in acute/sub acute patients.

PERSPECTIVES

Improved access to rehabilitation robots and an optimal use will probably be associated with higher efficiency of rehabilitative work in the paretic upper limb.

CONCLUSIONS

Even if this treatment is still confined to a narrow circle of users, the device's biomechanical properties and clinical suggestions from the literature may show promise for the future of rehabilitation.

Cost-effectiveness of rivaroxaban for stroke prevention in atrial fibrillation in the Portuguese setting

INTRODUCTION AND AIMS

To project the long-term cost-effectiveness of treating non-valvular atrial fibrillation (AF) patients for stroke prevention with rivaroxaban compared to warfarin in Portugal.

METHODS

A Markov model was used that included health and treatment states describing the management and consequences of AF and its treatment. The model's time horizon was set at a patient's lifetime and each cycle at three months. The analysis was conducted from a societal perspective and a 5% discount rate was applied to both costs and outcomes. Treatment effect data were obtained from the pivotal phase III ROCKET AF trial. The model was also populated with utility values obtained from the literature and with cost data derived from official Portuguese sources. The outcomes of the model included life-years, quality-adjusted life-years (QALYs), incremental costs, and associated incremental cost-effectiveness ratios (ICERs). Extensive sensitivity analyses were undertaken to further assess the findings of the model. As there is evidence indicating underuse and underprescription of warfarin in Portugal, an additional analysis was performed using a mixed comparator composed of no treatment, aspirin, and warfarin, which better reflects real-world prescribing in Portugal.

RESULTS

This cost-effectiveness analysis produced an ICER of €3895/QALY for the base-case analysis (vs. warfarin) and of €6697/QALY for the real-world prescribing analysis (vs. mixed comparator). The findings were robust when tested in sensitivity analyses.

CONCLUSION

The results showed that rivaroxaban may be a cost-effective alternative compared with warfarin or real-world prescribing in Portugal.

Perceptual video quality assessment in H.264 video coding standard using objective modeling

Since usage of digital video is wide spread nowadays, quality considerations have become essential, and industry demand for video quality measurement is rising. This proposal provides a method of perceptual quality assessment in H.264 standard encoder using objective modeling. For this purpose, quality impairments are calculated and a model is developed to compute the perceptual video quality metric based on no reference method. Because of the shuttle difference between the original video and the encoded video the quality of the encoded picture gets degraded, this quality difference is introduced by the encoding process like Intra and Inter prediction. The proposed model takes into account of the artifacts introduced by these spatial and temporal activities in the hybrid block based coding methods and an objective modeling of these artifacts into subjective quality estimation is proposed. The proposed model calculates the objective quality metric using subjective impairments; blockiness, blur and jerkiness compared to the existing bitrate only calculation defined in the ITU G 1070 model. The accuracy of the proposed perceptual video quality metrics is compared against popular full reference objective methods as defined by VQEG.

Severe stroke: which medicine for which results?

In face of any severe stroke, the questions for health professionals in charge of the patient are: will the handicap be acceptable for the patient? But can we predict an acceptable handicap for the patient? For his family? When we know that the cognitive disorders, consequences of severe stroke often modify, in a major way, the behaviour of these patients? Given these difficulties for estimate vital and functional prognosis and even more the quality of life of patients with severe stroke, collective reflexions between physicians and nurses are essential, reflexions taking into account preferences and values of patients. Use of resuscitation resources for severe stroke patients implies to offer them the best rehabilitation. So, questions about health pathways for severe stroke are essential: which structures for these patients, which technologies, which medical, medico-social and social supports, which human accompaniment the society can propose to the patients and to their family, so that they have an acceptable quality of life.

[Gender and stroke in Brazzaville]

BACKGROUND

The relationship between gender and cerebrovascular disease is controversial. The aim of our study was to evaluate the relationship between gender and vascular risk factors, biological variables and the severity of the neurological deficit in stroke.

METHODS

This cross-sectional study, conducted from March to August 2011 in the department of neurology of the university hospital of Brazzaville which included all patients hospitalized for confirmed stroke. The study variables were: age, sex, vascular risk factors, NIHSS scores and Glasgow, blood pressure, and the biological exams and complications. Statistical analysis was performed on SPSS12.

RESULTS

Eighty patients were included. The mean age was 62.7 ± 11.2 years, with 58.8% of men. Alcohol intake and smoking were more frequent in men than women respectively P=0.005 and P=0.032. Psychosocial stress was more often declared by women than men (P=0.042). However there was no significant difference in biological variables, the severity of stroke and the occurrence of complications

CONCLUSION

Our study suggests that in the Congolese context, gender does not influence significantly most parameters during stroke, but men consume more alcohol and women are exposed to psychosocial stress.

Transcranial magnetic stimulation in brain injury

OBJECTIVES

Transcranial magnetic stimulations (TMS) have been used for many years as a diagnostic tool to explore changes in cortical excitability, and more recently as a tool for therapeutic neuromodulation. We are interested in their applications following brain injury: stroke, traumatic and anoxic brain injury.

DATA SYNTHESIS

Following brain injury, there is decreased cortical excitability and changes in interhemispheric interactions depending on the type, the severity, and the time-lapse between the injury and the treatment implemented. rTMS (repetitive TMS) is a therapeutic neuromodulation tool which restores the interhemispheric interactions following stroke by inhibiting the healthy cortex with frequencies ≤1Hz, or by exciting the lesioned cortex with frequencies between 3 and 50Hz. Results in motor recovery are promising and those in improving aphasia or visuospatial neglect are also encouraging. Finally, the use of TMS is mainly limited by the risk of seizure, and is therefore contraindicated for many patients.

CONCLUSION

TMS is a useful non-invasive brain stimulation tool to diagnose the effects of brain injury, to study the mechanisms of recovery and a non-invasive neuromodulation promising tool to influence the post-lesional recovery.

Association between cardiovascular disease and socioeconomic level in Portugal

INTRODUCTION

Cardiovascular disease is the leading cause of morbidity, mortality and disability in Portugal. Socioeconomic level is known to influence health status but there is scant evidence on socioeconomic inequalities in cardiovascular disease in Portugal.

AIM

To analyze the distribution of cardiovascular disease in the Portuguese population according to socioeconomic status.

METHODS

We conducted a cross-sectional study using data from the fourth National Health Survey on a representative sample of the Portuguese population. Socioeconomic inequalities in cardiovascular disease, risk factors and number of medical visits were analyzed using odds ratios according to socioeconomic status (household equivalent income) in the adult population (35-74 years). Comparisons focused on the top and bottom 50% and 10% of household income distribution.

RESULTS

Of the 21 807 individuals included, 53.3% were female, and mean age was 54 ± 11 years. Cardiovascular disease, stroke, ischemic heart disease, hypertension, diabetes, obesity and physical inactivity were associated with lower socioeconomic status, while smoking was associated with higher status; number of medical visits and psychological distress showed no association. When present, inequality was greater at the extremes of income distribution.

CONCLUSIONS

The results reveal an association between morbidity, lifestyle and socioeconomic status. They also suggest that besides improved access to effective medical intervention, there is a need for a comprehensive strategy for health promotion and disease prevention that takes account of individual, cultural and socioeconomic characteristics.

The complex nature of discordant severe calcified aortic valve disease grading: new insights from combined Doppler echocardiographic and computed tomographic study

OBJECTIVES

With concomitant Doppler echocardiography and multidetector computed tomography (MDCT) measuring aortic valve calcification (AVC) load, this study aimed at defining: 1) independent physiologic/structural determinants of aortic valve area (AVA)/mean gradient (MG) relationship; 2) AVC thresholds best associated with severe aortic stenosis (AS); and 3) whether, in AS with discordant MG, severe calcified aortic valve disease is generally detected.

BACKGROUND

Aortic stenosis with discordant markers of severity, AVA in severe range but low MG, is a conundrum, unresolved by outcome studies.

METHODS

Patients (n = 646) with normal left ventricular ejection fraction AS underwent Doppler echocardiography and AVC measurement by MDCT. On the basis of AVA-indexed-to-body surface area (AVAi) and MG, patients were categorized as concordant severity grading (CG) with moderate AS (AVAi >0.6 cm²/m², MG <40 mm Hg), severe AS (AVAi ≤0.6 cm²/m², MG ≥ 40 mm Hg), discordant-severity-grading (DG) with low-MG (AVAi ≤0.6 cm(2)/m(2), MG <40 mm Hg), or high-MG (AVAi >0.6 cm(2)/m(2), MG ≥40 mm Hg).

RESULTS

The MG (discordant in 29%) was strongly determined by AVA and flow but also independently and strongly influenced by AVC-load (p < 0.0001) and systemic arterial compliance (p < 0.0001). The AVC-load (median [interquartile range]) was similar within patients with DG (low-MG: 1,619 [965 to 2,528] arbitrary units [AU]; high-MG: 1,736 [1,209 to 2,894] AU; p = 0.49), higher than CG-moderate-AS (861 [427 to 1,519] AU; p < 0.0001) but lower than CG-severe-AS (2,931 [1,924 to 4,292] AU; p < 0.0001). The AVC-load thresholds separating severe/moderate AS were defined in CG-AS with normal flow (stroke-volume-index >35 ml/m(2)). The AVC-load, absolute or indexed, identified severe AS accurately (area under the curve ≥0.89, sensitivity ≥86%, specificity ≥79%) in men and women. Upon application of these criteria to DG-low MG, at least one-half of the patients were identified as severe calcified aortic valve disease, irrespective of flow.

CONCLUSIONS

Among patients with AS, MG is often discordant from AVA and is determined by multiple factors, valvular (AVC) and non-valvular (arterial compliance) independently of flow. The AVC-load by MDCT, strongly associated with AS severity, allows diagnosis of severe calcified aortic valve disease. At least one-half of the patients with discordant low gradient present with heavy AVC-load reflective of severe calcified aortic valve disease, emphasizing the clinical yield of AVC quantification by MDCT to diagnose and manage these complex patients.

[Ischemic stroke after cardioversion and atrial flutter ablation in a patient taking dabigatran]

This article reports an acute ischemic stroke after cardioversion and atrial flutter catheter ablation in a patient on treatment by dabigatran 110mg twice daily. Trans-esophageal echocardiography did not show any thrombi. Even if this event cannot be attributed to the treatment, this article indicates that prospective studies are necessary.

Vascular risk factors and cognitive disorders

Delaying the onset of dementia by just a few years could have a major impact on the prevalence of the disease at the population level. Vascular risk factors are modifiable and may offer an important opportunity for preventive approaches. Several studies have shown that diabetes, hypertension, obesity, and smoking are associated with an increased risk of cognitive decline and dementia, but other groups have not observed such a relation. Positive associations were observed mainly in studies where risk factors were assessed in midlife, suggesting that age is an important modulator in the relation between vascular risk factors and cognition. The population attributable risk of dementia is particularly high for hypertension. Associations of vascular risk factors with cognitive decline and dementia are probably mediated largely by cerebrovascular disease, including both stroke and covert vascular brain injury, which can have additive or synergistic effects with coexisting neurodegenerative lesions. To date, randomized trials have not convincingly demonstrated that treating vascular risk factors is associated with a reduction in cognitive decline or dementia risk. Of eight randomized trials testing the effect of antihypertensive agents on dementia risk, only one was positive, and another in a subgroup of individuals with recurrent stroke. In most trials, cognition and dementia were secondary outcomes, follow-up was short and treatment was initiated at an older age. No effect on cognitive decline or dementia could be demonstrated for statins and intensive glycemic control. Future areas of investigation could include differential class effects of antihypertensive drugs on cognitive outcomes and identification of high risk individuals as target population for clinical trials initiated in midlife.

Neuropsychological assessment and cerebral vascular disease: the new standards

Vascular cognitive impairment (VCI) includes vascular dementia (VaD), vascular mild cognitive impairment (VaMCI) and mixed dementia. In clinical practice, VCI concerns patients referred for clinical stroke or cognitive complaint. To improve the characterization of VCI and to refine its diagnostic criteria, an international group has elaborated a new standardized evaluation battery of clinical, cognitive, behavioral and neuroradiological data which now constitutes the reference battery. The adaption of the battery for French-speaking subjects is reported as well as preliminary results of the on-going validation study of the GRECOG-VASC group [Clinical Trial NCT01339195]. The diagnostic accuracy of various screening tests is reviewed and showed an overall sub-optimal sensitivity (<0.8). Thus, the general recommendation is to perform systematically a comprehensive assessment in stroke patients at risk of VCI. Furthermore,the use of a structured interview has been shown to increase the detection of dementia. In addition to the well known NINDS-AIREN criteria of VaD, criteria of VCI have been recently proposed which are based on the demonstration of a cognitive disorder by neuropsychological testing and either history of clinical stroke or presence of vascular lesion by neuroimaging suggestive of a link between cognitive impairment and vascular disease. A memory deficit is no longer required for the diagnosis of VaD as it is based on the cognitive decline concerning two or more domains that affect activities of daily living. Both VaMCI and VaD are classified as probable or possible. These new criteria have yet to be validated. Considerable uncertainties remain regarding the determinant of VCI, and especially the lesion amount inducing VCI and VaD. The interaction between lesion amount and its location is currently re-examined using recent techniques for the analysis of MRI data. The high frequency of associated Alzheimer pathology is now assessable in vivo using amyloid imaging. The first studies showed that about a third of patients with VaD due to small vessel disease or with poststroke dementia have amyloid PET imaging suggestive of AD. These new techniques will examine the interaction between vascular lesions and promotion of amyloid deposition. Although results of these on-going studies will be available in few years, these data indicate that efforts should be done in clinical practice to reduce underdiagnosis of VCI; VCI should be examined using a specific protocol which will be fully normalized soon for French-speaking patients; the sub-optimal sensitivity of screening tests prompts to use a structured interview to grade Rankin scale and to perform systematically a comprehensive assessment in stroke patients at risk of VCI; poststroke dementia occurring after 3 months poststroke may be preventable by treatment of modifiable vascular risk factors and secondary prevention of stroke recurrence according to recent recommendations.

RNA binding proteins in the regulation of heart development

In vivo, RNA molecules are constantly accompanied by RNA binding proteins (RBPs), which are intimately involved in every step of RNA biology, including transcription, editing, splicing, transport and localization, stability, and translation. RBPs therefore have opportunities to shape gene expression at multiple levels. This capacity is particularly important during development, when dynamic chemical and physical changes give rise to complex organs and tissues. This review discusses RBPs in the context of heart development. Since the targets and functions of most RBPs--in the heart and at large--are not fully understood, this review focuses on the expression and roles of RBPs that have been implicated in specific stages of heart development or developmental pathology. RBPs are involved in nearly every stage of cardiogenesis, including the formation, morphogenesis, and maturation of the heart. A fuller understanding of the roles and substrates of these proteins could ultimately provide attractive targets for the design of therapies for congenital heart defects, cardiovascular disease, or cardiac tissue repair.

Specific left ventricular twist-untwist mechanics during exercise in children

BACKGROUND

In adults, left ventricular (LV) systolic twist is an important factor that determines LV filling, both at rest and during exercise. In children, lower LV twist has been demonstrated at rest, but its adaptation during exercise and its functional consequences on LV filling are unknown.

METHODS

Using speckle-tracking echocardiography, LV twist-untwist mechanics were studied in 25 children (aged 10-12 years) and 20 young adults (aged 18-44 years) at rest and during three exercise workloads performed at 20%, 30%, and 40% of their maximal aerobic power.

RESULTS

At rest, LV twist was lower in children, because of a higher temporal dispersion of peak rotation between base and apex. During exercise, the increase of basal rotation was blunted in children compared with adults (-6.7 ± 2.7° vs -9.0 ± 2.0° at 40% of maximal aerobic power, P < .05). Consequently, LV twist increased to a lesser extent (13.0 ± 5.0° vs 15.8 ± 4.5° at 40% of maximal aerobic power, P < .05). The increase in LV untwisting rates during exercise was also lower in children, leading to a lower percentage of untwisting during early diastole (8 ± 8% vs 29 ± 20% at 40% of maximal aerobic power, P < .001). Consequently, during early diastole, the normal timing of diastolic events observed in young adults, with untwist occurring before radial displacement, was blunted in children. Nevertheless, children exhibited normal LV filling due to higher diastolic radial and longitudinal strain rates.

CONCLUSIONS

Twist-untwist mechanics may evolve with advancing age. In children, early diastolic LV untwisting appears to be less important than in adults. Their better LV intrinsic myocardial relaxation may ensure adequate LV filling during exercise without dependence on the additional effect of suction resulting from LV energy recoil.

[Economic evaluation of dabigatran for stroke prevention in patients with non-valvular atrial fibrillation]

INTRODUCTION AND OBJECTIVES

To estimate the cost-effectiveness and cost-utility of dabigatran in the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation in Portugal.

METHODOLOGY

A Markov model was used to simulate patients' clinical course, estimating the occurrence of ischemic and hemorrhagic stroke, transient ischemic attack, systemic embolism, myocardial infarction, and intra- and extracranial hemorrhage. The clinical parameters are based on the results of the RE-LY trial, which compared dabigatran with warfarin, and on a meta-analysis that estimated the risk of each event in patients treated with aspirin or with no antithrombotic therapy.

RESULTS

Dabigatran provides an increase of 0.331 life years and 0.354 quality-adjusted life years for each patient. From a societal perspective, these clinical gains entail an additional expenditure of 2978 euros. Thus, the incremental cost is 9006 euros per life year gained and 8409 euros per quality-adjusted life year.

CONCLUSIONS

The results show that dabigatran reduces the number of events, especially the most severe such as ischemic and hemorrhagic stroke, as well as their long-term sequelae. The expense of dabigatran is partially offset by lower event-related costs and by the fact that INR monitoring is unnecessary. It can thus be concluded that the use of dabigatran in clinical practice in Portugal is cost-effective.

Factors associated with the immune response to hepatitis A vaccination in HIV-infected patients in the era of highly active antiretroviral therapy

INTRODUCTION

HIV seropositivity is considered a risk factor for complications in hepatitis A virus (HAV) infection. HAV vaccination schedules are widely implemented in HIV-infected patients, but the immune response remains impaired.

METHODS

We analysed the response to vaccination (antiHAV titres ≥20IU/l) in 282 HIV-infected patients included in a standard (1440 Elisa Units (EU) at 0, 6 months) or rapidly accelerated schedule (720 EU at 0, 7, 21 days and 6 months) between 1997 and 2009. Factors associated with the response to vaccination were analysed using logistic regression.

RESULTS

The overall response rate was 73.4%. Male sex (OR: 0.16, 95% CI 0.05-0.51) and hepatitis C virus co-infection (OR: 0.30, 95% CI 0.14-0.74) were associated with a lower probability of response. Protective antibody response was associated with a higher CD4/CD8 ratio (OR: 3.69, 95% CI 1.3-10.5) and having received two doses of standard schedule (compared with patients receiving only one dose of the same schedule) (OR: 2.51, 95% CI 1.22-5.15). Three doses of the rapidly accelerated schedule were not more effective than a single dose of 1440 EU (OR: 1.32, 95% CI 0.48-3.63).

CONCLUSION

The low responses observed in patients receiving a single dose suggest the need to emphasize adhesion to vaccination protocols to avoid failure. The CD4/CD8 ratio may be considered as an immune status marker which could help to better choose the moment of vaccination. Our findings underscore the importance of identifying strategies that optimize the timing and effectiveness of hepatitis A vaccination in HIV-infected patients and of the need for further studies on individual factors such as sex and hepatitis C co-infection that may affect the response to vaccination. Likewise, the sub-optimal effectiveness of three doses of 720 EU in the rapidly accelerated schedule, if confirmed in future studies, might lead to a revision of the current schedule recommended for HIV-infected travellers.

[Modalities of stroke management in Mali (West Africa): a survey of practices]

The upsurge and the impact of stroke in terms of mortality and morbidity in Africa are well documented. But their current stroke management modalities remain to be evaluated.

METHODS

This study investigated the modalities of healthcare practitioners working in structures involved in stroke management in seven of the eight regions and the capital city of Bamako. A questionnaire was sent out to all potential participants identified in the designated areas, whereas the relevant medical personnel were systematically enrolled to take part. 149 practitioners (90%) including 68 general practitioners, 12 specialists, and 69 residents responded to the questionnaire. Six CT-scan, 15 echocardiographs, and 21 electrocardiographs were available. The team directly involved in patient management included six neurologists, seventeen cardiologists, six neurosurgeons, 86 physical therapists, three orthophonists, and two ergotherapists. Hemiplegia was the revealing symptom of stroke in 61.1% of cases. Almost all infrastructures and the personnel are located in a geographic area representing less than 10% of the country, where only 14 % of the population live. These findings emphasize the lack and unequal distribution of resources allocated to stroke management.

CONCLUSION

Problems related to stroke in Mali need a re-organization of patient management networks. An initial and continued training of health practitioners should be implemented.