Science.gov

Sample records for preventing stroke recurrence

  1. Telmisartan to Prevent Recurrent Stroke and Cardiovascular Events

    PubMed Central

    Yusuf, Salim; Diener, Hans-Christoph; Sacco, Ralph L.; Cotton, Daniel; Ôunpuu, Stephanie; Lawton, William A.; Palesch, Yuko; Martin, Reneé H.; Albers, Gregory W.; Bath, Philip; Bornstein, Natan; Chan, Bernard P.L.; Chen, Sien-Tsong; Cunha, Luis; Dahlöf, Björn; De Keyser, Jacques; Donnan, Geoffrey A.; Estol, Conrado; Gorelick, Philip; Gu, Vivian; Hermansson, Karin; Hilbrich, Lutz; Kaste, Markku; Lu, Chuanzhen; Machnig, Thomas; Pais, Prem; Roberts, Robin; Skvortsova, Veronika; Teal, Philip; Toni, Danilo; VanderMaelen, Cam; Voigt, Thor; Weber, Michael; Yoon, Byung-Woo

    2009-01-01

    BACKGROUND Prolonged lowering of blood pressure after a stroke reduces the risk of recurrent stroke. In addition, inhibition of the renin–angiotensin system in high-risk patients reduces the rate of subsequent cardiovascular events, including stroke. However, the effect of lowering of blood pressure with a renin–angiotensin system inhibitor soon after a stroke has not been clearly established. We evaluated the effects of therapy with an angiotensin-receptor blocker, telmisartan, initiated early after a stroke. METHODS In a multicenter trial involving 20,332 patients who recently had an ischemic stroke, we randomly assigned 10,146 to receive telmisartan (80 mg daily) and 10,186 to receive placebo. The primary outcome was recurrent stroke. Secondary outcomes were major cardiovascular events (death from cardiovascular causes, recurrent stroke, myocardial infarction, or new or worsening heart failure) and new-onset diabetes. RESULTS The median interval from stroke to randomization was 15 days. During a mean followup of 2.5 years, the mean blood pressure was 3.8/2.0 mm Hg lower in the telmisartan group than in the placebo group. A total of 880 patients (8.7%) in the telmisartan group and 934 patients (9.2%) in the placebo group had a subsequent stroke (hazard ratio in the telmisartan group, 0.95; 95% confidence interval [CI], 0.86 to 1.04; P = 0.23). Major cardiovascular events occurred in 1367 patients (13.5%) in the telmisartan group and 1463 patients (14.4%) in the placebo group (hazard ratio, 0.94; 95% CI, 0.87 to 1.01; P = 0.11). New-onset diabetes occurred in 1.7% of the telmisartan group and 2.1% of the placebo group (hazard ratio, 0.82; 95% CI, 0.65 to 1.04; P = 0.10). CONCLUSIONS Therapy with telmisartan initiated soon after an ischemic stroke and continued for 2.5 years did not significantly lower the rate of recurrent stroke, major cardiovascular events, or diabetes. (ClinicalTrials.gov number, NCT00153062.) PMID:18753639

  2. Effects of a Web-Based Stroke Education Program on Recurrence Prevention Behaviors among Stroke Patients: A Pilot Study

    ERIC Educational Resources Information Center

    Kim, Jae-Il; Lee, Sook; Kim, Jung-Hee

    2013-01-01

    The effectiveness of methods to prevent stroke recurrence and of education focusing on learners' needs has not been fully explored. The aims of this study were to assess the effects of such interventions among stroke patients and their primary caregivers and to evaluate the feasibility of a web-based stroke education program. The participants were…

  3. Recurrent Ischemic Stroke Characteristics and Assessment of Sufficiency of Secondary Stroke Prevention

    PubMed Central

    KOCAMAN, Gülşen; DÜRÜYEN, Hümeyra; KOÇER, Abdulkadir; ASİL, Talip

    2015-01-01

    Introduction Disabilities due to stroke lead to a serious individual and socioeconomic burden. In this presented hospital-based study, we aimed to evaluate recurrent ischemic stroke (RIS) characteristics and the sufficiency of secondary prevention regarding the most common modifiable risk factors. Methods The records of patients with a diagnosis of ischemic stroke between November 2009 and November 2011 in our unit were retrospectively investigated. Results Ninety-one (18%) out of 500 patients with ischemic stroke had RIS. Hypertension, diabetes mellitus, ischemic heart disease, hyperlipidemia, atrial fibrillation, and smoking were found in 88%, 43%, 36%, 30%, 11%, and 14% of the patients, respectively. Thirty-eight percent of the patients had more than two risk factors. While 14% of the hypertensive patients did not use antihypertensive medications, antihypertensive treatment was insufficient in 39% of those who already used antihypertensive medications. Twenty-three percent of the patients received no prophylactic agents. Sixty percent of the patients with a history of atrial fibrillation were on oral anticoagulant therapy (warfarin), and the international normalized ratio was <2.0 in 73% of them. Of the diabetic patients, 87% had an HgbA1C level above 6%. The LDL level was higher than 100 mg/dL in 72% of the patients. Conclusion The incidence of RIS and risk factors in our retrospective study was compatible with the results of those in literature. Secondary prophylactic treatment and modification of risk factors in the stroke patients were not satisfactory. The improvement of the patients’ adherence to treatment is also very important in addition to the optimal treatment and follow-up strategy for decreasing the incidence of RIS. A multidisciplinary outpatient model of stroke care may be beneficial for decreasing the incidence of RIS.

  4. Filling the gap between science & clinical practice: prevention of stroke recurrence.

    PubMed

    Russolillo, Anna; Di Minno, Matteo Nicola Dario; Tufano, Antonella; Prisco, Domenico; Di Minno, Giovanni

    2012-01-01

    Because of its high recurrence rate, active secondary prevention is mandatory once an episode of stroke has occurred. In non-cardioembolic stroke, in addition to lifestyle changes and to targeted treatments, current guidelines recommend aspirin, clopidogrel or aspirin+extended-release dipyridamole. In cardioembolic stroke (due to atrial fibrillation or flutter [AF]), vitamin K antagonists (VKAs) are recommended in most of patients. A favorable risk/benefit ratio of these treatments has been demonstrated also in elderly patients. However, registry data emphasize that such interventions are often under-used, especially in AF patients. A poor knowledge of current guidelines may play a role in hampering their application in clinical practice. The risk of major bleeding associated with antithrombotic drugs, their inherent limitations, such as socio-demographic (age >80 years, living alone) and clinical (previous or recent bleeding, trauma, cancer, dementia) features, may account for the gap between current guidelines for stroke/TIA prevention and clinical practice. The objective of the present report is to evaluate the gap between current recommendations/guidelines for stroke/TIA prevention and clinical practice (registry findings). In our opinion new antithrombotic drugs and detailed educational programs (especially devoted to general practitioners and to some medical specialists), concerning efficacy, safety and limitations of these strategies, are needed to better manage stroke epidemics in the third millennium.

  5. Secondary stroke prevention.

    PubMed

    Hankey, Graeme J

    2014-02-01

    Survivors of stroke and transient ischaemic attacks are at risk of a recurrent stroke, which is often more severe and disabling than the index event. Optimum secondary prevention of recurrent stroke needs rapid diagnosis and treatment and prompt identification of the underlying cardiovascular cause. Effective treatments include organised acute assessment and intervention with antithrombotic therapy, carotid revascularisation, and control of causal risk factors, as appropriate. However, effective treatments are not implemented optimally in clinical practice. Recurrent strokes continue to account for 25-30% of all strokes and represent unsuccessful secondary prevention. Immediate and sustained implementation of effective and appropriate secondary prevention strategies in patients with first-ever stroke or transient ischaemic attack has the potential to reduce the burden of stroke by up to a quarter.

  6. Peer education for secondary stroke prevention in inner-city minorities: Design and methods of the Prevent Recurrence of All Inner-city Strokes through Education randomized controlled trial

    PubMed Central

    Goldfinger, Judith Z.; Kronish, Ian M.; Fei, Kezhen; Graciani, Albert; Rosenfeld, Peri; Lorig, Kate; Horowitz, Carol R.

    2012-01-01

    Background The highest risk for stroke is among survivors of strokes or transient ischemic attacks (TIA). However, use of proven-effective cardiovascular medications to control stroke risk is suboptimal, particularly among the Black and Latino populations disproportionately impacted by stroke. Methods A partnership of Harlem and Bronx community representatives, stroke survivors, researchers, clinicians, outreach workers and patient educators used community-based participatory research to conceive and develop the Prevent Recurrence of All Inner-city Strokes through Education (PRAISE) trial. Using data from focus groups with stroke survivors, they tailored a peer-led, community-based chronic disease self-management program to address stroke risk factors. PRAISE will test, in a randomized controlled trial, whether this stroke education intervention improves blood pressure control and a composite outcome of blood pressure control, lipid control, and use of antithrombotic medications. Results Of the 582 survivors of stroke and TIA enrolled thus far, 81% are Black or Latino and 56% have an annual income less than $15,000. Many (33%) do not have blood pressures in the target range, and most (66%) do not have control of all three major stroke risk factors. Conclusions Rates of stroke recurrence risk factors remain suboptimal in the high risk, urban, predominantly minority communities studied. With a community-partnered approach, PRAISE has recruited a large number of stroke and TIA survivors to date, and may prove successful in engaging those at highest risk for stroke and reducing disparities in stroke outcomes in inner-city communities. PMID:22710563

  7. Recovery After Stroke: Recurrent Stroke

    MedlinePlus

    ... blood pressure  Find out if you have atrial fibrillation (an irregular heartbeat which allows blood to pool ... your stroke risk. One form  known as atrial fibrillation or AF  causes blood to form clots that ...

  8. Advantages of isovolemic hemodilution-red cell exchange therapy to prevent recurrent stroke in sickle cell anemia patients.

    PubMed

    Sarode, Ravi; Matevosyan, Karén; Rogers, Zora R; Burner, James D; Rutherford, Cynthia

    2011-01-01

    Chronic simple hypertransfusion (every 3 to 4 weeks) effectively prevents secondary stroke in children with sickle cell anemia but leads to iron overload despite chelation therapy. Conventional red blood cell exchange (C-RBCx) has advantages over simple transfusion: no net iron gain and less frequent hospital visits. However, C-RBCx requires more red blood cell units, an apheresis instrument and skilled personnel; it is also more expensive. We developed a modified procedure where isovolemic hemodilution precedes RBCx (IHD-RBCx) to decrease RBC units required and to increase the interval between procedures. Twenty patients underwent IHD-RBCx over a period of 7 years. IHD-RBCx required 11% fewer RBC units and increased inter-procedure interval from 37 to 53 days compared to C-RBCx. The median number of annual procedures decreased from 9.8 to 7.0 per patient, resulting in estimated savings of more than $4.5 million over 10 years for 20 patients while providing improved care. Five patients have discontinued chelation therapy; three while on C-RBCx and two while on IHD-RBCx. No adverse events occurred related to the isovolemic hemodilution phase and no patients had recurrent stroke. IHD-RBCx is a safe, efficient, and cost effective therapy for secondary prevention of stroke in patients with sickle cell anemia.

  9. Risk Factors and Treatment at Recurrent Stroke Onset: Results from the Recurrent Stroke Quality and Epidemiology (RESQUE) Study

    PubMed Central

    Leoo, T.; Lindgren, A.; Petersson, J.; von Arbin, M.

    2008-01-01

    Background Much effort has been made to study first-ever stroke patients. However, recurrent stroke has not been investigated as extensively. It is unclear which risk factors dominate, and whether adequate secondary prevention has been provided to patients who suffer from recurrent stroke. Also, the different types of recurrent stroke need further evaluation. Methods The study included patients with recurrent stroke admitted to twenty-three Swedish stroke centers. The type of previous and recurrent stroke was determined, as well as evaluation (when applicable) of recurrent ischemic stroke according to the TOAST classification. Presence of vascular risk factors was registered and compared to the type of stroke. Also assessed was ongoing secondary prevention treatment at recurrent stroke onset. Results A total of 889 patients with recurrent stroke (mean age 77) were included in the study. Of these, 805 (91%) had ischemic stroke, 78 (9%) had intracerebral hemorrhage and 6 (<1%) stroke of unknown origin. The most frequent vascular risk factors were hypertension (75%) and hyperlipidemia (56%). Among the 889 patients, 29% had atrial fibrillation. Of the patients in the ischemic group with cardiac embolism, only 21% were on anticoagulation treatment. The majority of the patients (75%) had their most recent previous stroke >12 months before admission. Conclusions Few patients had a recurrent stroke shortly after the previous stroke in this study. This indicates that it is meaningful to prevent a second event with an adequate long-term treatment strategy for secondary prevention after first-ever stroke. There also seems to be a clear potential for improving secondary prevention after stroke. PMID:18216468

  10. Preventing stroke

    MedlinePlus

    ... risk of stroke. Diseases such as cancer, chronic kidney disease , and some autoimmune diseases . Weak areas in an artery wall or abnormal arteries and veins . Pregnancy, both during and in the weeks right after ...

  11. Heart Disease and Stroke Prevention

    MedlinePlus

    ... Heart disease and stroke prevention Heart Health and Stroke Heart disease and stroke prevention Related information Learn more about healthy eating ... to top More information on Heart disease and stroke prevention Read more from womenshealth.gov A Lifetime ...

  12. [A case of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) in which lomerizine hydrochloride was suggested to prevent recurrent stroke].

    PubMed

    Shimizu, Hisao; Nagami, Shuhei; Takahashi, Nobuyuki

    2014-01-01

    A 60-year-old man visited our hospital because of left hemiparesis in September 2006. Magnetic resonance imaging (MRI) revealed a high-intensity lesions in the right corona radiata on diffusion-weighted images and a high-intensity lesions in the basal ganglia and deep white matter on T2-weighted images. He recovered with no sequelae. Antithrombotic agents such as aspirin were given to prevent stroke, but stroke recurred three times over the course of 3 years. In February 2009, neurological examination revealed right hemiparalysis and dysarthria. Dysphagia and cognitive decline had been progressing gradually. We suspected cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) on the basis of the clinical and family history. An Arg75Pro mutation in the Notch3 gene was found, but did not involve a cysteine residue. Antithrombotic agents were ineffective. We tried lomerizine hydrochloride, which was reported to prevent stroke in a patient with CADASIL. In Japan, lomerizine hydrochloride is used to prevent migraine and to selectively inhibit cerebral artery contraction. During treatment with lomerizine hydrochloride (5 mg/day) for more than 3 years, there was no recurrence of cerebral infarction and no further deterioration of cognitive function or MRI findings. There is no evidence supporting the efficacy of antithrombotic agents in CADASIL patients. Moreover, antithrombotic agents have been reported to increase the frequency of clinically silent microbleeds on MRI in CADASIL. Lomerizine hydrochloride might therefore be one option for the treatment of CADASIL.

  13. Recurrent ischaemic stroke unveils polycythaemia vera

    PubMed Central

    Abdel-Rahman, Islam; Murphy, Christie

    2015-01-01

    Polycythaemia vera is a recognised cause of ischaemic stroke. If not treated, this condition may result in recurrent strokes. This is a case of a 61-year-old Caucasian man presenting with the inability to ambulate for 3 days. Brain imaging revealed acute and chronic infarctions in the brain stem and the cerebrum. Polycythaemia vera was diagnosed and treated during the admission. The unique mechanisms and management issues of ischaemic stroke associated with polycythaemia vera are discussed. PMID:25754163

  14. Effects of aspirin plus extended-release dipyridamole versus clopidogrel and telmisartan on disability and cognitive function after recurrent stroke in patients with ischaemic stroke in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial: a double-blind, active and placebo-controlled study

    PubMed Central

    Diener, Hans-Christoph; Sacco, Ralph L; Yusuf, Salim; Cotton, Daniel; Ôunpuu, Stephanie; Lawton, William A; Palesch, Yuko; Martin, Reneé H; Albers, Gregory W; Bath, Philip; Bornstein, Natan; Chan, Bernard P L; Chen, Sien-Tsong; Cunha, Luis; Dahlöf, Björn; Keyser, Jacques De; Donnan, Geoffrey A; Estol, Conrado; Gorelick, Philip; Gu, Vivian; Hermansson, Karin; Hilbrich, Lutz; Kaste, Markku; Lu, Chuanzhen; Machnig, Thomas; Pais, Prem; Roberts, Robin; Skvortsova, Veronika; Teal, Philip; Toni, Danilo; VanderMaelen, Cam; Voigt, Thor; Weber, Michael; Yoon, Byung-Woo

    2009-01-01

    Summary Background The treatment of ischaemic stroke with neuroprotective drugs has been unsuccessful, and whether these compounds can be used to reduce disability after recurrent stroke is unknown. The putative neuroprotective effects of antiplatelet compounds and the angiotensin II receptor antagonist telmisartan were investigated in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial. Methods Patients who had had an ischaemic stroke were randomly assigned in a two by two factorial design to receive either 25 mg aspirin (ASA) and 200 mg extended-release dipyridamole (ER-DP) twice a day or 75 mg clopidogrel once a day, and either 80 mg telmisartan or placebo once per day. The predefined endpoints for this substudy were disability after a recurrent stroke, assessed with the modified Rankin scale (mRS) and Barthel index at 3 months, and cognitive function, assessed with the mini-mental state examination (MMSE) score at 4 weeks after randomisation and at the penultimate visit. Analysis was by intention to treat. The study was registered with ClinicalTrials.gov, number NTC00153062. Findings 20 332 patients (mean age 66 years) were randomised and followed-up for a median of 2·4 years. Recurrent strokes occurred in 916 (9%) patients randomly assigned to ASA with ER-DP and 898 (9%) patients randomly assigned to clopidogrel; 880 (9%) patients randomly assigned to telmisartan and 934 (9%) patients given placebo had recurrent strokes. mRS scores were not statistically different in patients with recurrent stroke who were treated with ASA and ER-DP versus clopidogrel (p=0·38), or with telmisartan versus placebo (p=0·61). There was no significant difference in the proportion of patients with recurrent stroke with a good outcome, as measured with the Barthel index, across all treatment groups. Additionally, there was no significant difference in the median MMSE scores, the percentage of patients with an MMSE score of 24 points or less, the

  15. Incidence of Recurrence in Posterior Circulation Childhood Arterial Ischemic Stroke

    PubMed Central

    Uohara, Michael Y.; Beslow, Lauren A.; Billinghurst, Lori; Jones, Brianna M.; Kessler, Sudha K.; Licht, Daniel J.; Ichord, Rebecca N.

    2017-01-01

    stroke may account for this difference. Children with PCAIS may warrant increased monitoring. This study highlights the necessity for further research focused on recurrence prevention. PMID:28114639

  16. Secondary prevention of stroke--results from the Southern Africa Stroke Prevention Initiative (SASPI) study.

    PubMed Central

    Thorogood, M.; Connor, M. D.; Lewando-Hundt, G.; Tollman, S.; Ngoma, B.

    2004-01-01

    OBJECTIVE: To describe the prevalence of risk factors and experience of preventive interventions in stroke survivors, and identilfy barriers to secondary prevention in rural South Africa. METHODS: A clinician visited individuals in the Agincourt field site (in South Africa's rural north east) who were identified in a census as possible stroke victims to confirm the diagnosis of stroke. We explored the impact of stroke on the individual's family, and health-seeking behaviour following stroke by conducting in-depth interviews in the households of 35 stroke survivors. We held two workshops to understand the knowledge, experience, and views of primary care nurses, who provide the bulk of professional health care. FINDINGS :We identified 103 stroke survivors (37 men), 73 (71%) of whom had hypertension, but only 8 (8%) were taking anti-hypertensive treatment. Smoking was uncommon; 8 men and 1 woman smoked a maximum of ten cigarettes daily. 94 (91%) stroke survivors had sought help, which involved allopathic health care for most of them (81; 79%). 42 had also sought help from traditional healers and churches, while another 13 people had sought help only from those sources. Of the 35 survivors who were interviewed, 29 reported having been prescribed anti-hypertensive pills after their stroke. Barriers to secondary prevention included cost of treatment, reluctance to use pills, difficulties with access to drugs, and lack of equipment to measure blood pressure. A negative attitude to allopathic care was not an important factor. CONCLUSION: In this rural area hypertension is the most important modifiable risk factor in stroke survivors. Effective secondary prevention may reduce the incidence of recurrent strokes, but there is no system to deliver such care. New strategies for care are needed involving both allopathic and non-allopathic-health care providers. PMID:15500283

  17. Stroke Prevention in Atrial Fibrillation

    MedlinePlus

    ... Association Cardiology Patient Page Stroke Prevention in Atrial Fibrillation Christian T. Ruff Download PDF https://doi.org/ ... an irregular and fast heartbeat. What Causes Atrial Fibrillation? Several factors and medical conditions make it more ...

  18. Twenty four hour pulse pressure predicts long term recurrence in acute stroke patients

    PubMed Central

    Tsivgoulis, G; Spengos, K; Zakopoulos, N; Manios, E; Xinos, K; Vassilopoulos, D; Vemmos, K

    2005-01-01

    Objectives: The impact of different blood pressure (BP) components during the acute stage of stroke on the risk of recurrent stroke is controversial. The present study aimed to investigate by 24 hour BP monitoring a possible association between acute BP values and long term recurrence. Methods: A total of 339 consecutive patients with first ever acute stroke underwent 24 hour BP monitoring within 24 hours of ictus. Known stroke risk factors and clinical findings on admission were documented. Patients given antihypertensive medication during BP monitoring were excluded. The outcome of interest during the one year follow up was recurrent stroke. The Cox proportional hazard model was used to analyse association of casual and 24 hour BP recordings with one year recurrence after adjusting for stroke risk factors, baseline clinical characteristics, and secondary prevention therapies. Results: The cumulative one year recurrence rate was 9.2% (95% CI 5.9% to 12.3%). Multivariate Cox regression analyses revealed age, diabetes mellitus, and 24 hour pulse pressure (PP) as the only significant predictors for stroke recurrence. The relative risk for one year recurrence associated with every 10 mm Hg increase in 24 hour PP was 1.323 (95% CI 1.019 to 1.718, p = 0.036). Higher casual PP levels were significantly related to an increased risk of one year recurrence on univariate analysis, but not in the multivariate Cox regression model. Conclusions: Elevated 24 hour PP levels in patients with acute stroke are independently associated with higher risk of long term recurrence. Further research is required to investigate whether the risk of recurrent stroke can be reduced to a greater extent by decreasing the pulsatile component of BP in patients with acute stroke. PMID:16170077

  19. Mexican Americans with Atrial Fibrillation have More Recurrent Strokes than Non-Hispanic Whites

    PubMed Central

    Simpson, J.R.; Zahuranec, D.B.; Lisabeth, L.D.; Sánchez, B.N.; Skolarus, L.E.; Mendizabal, J.E.; Smith, M.A.; Garcia, N.M.; Morgenstern, L.B.

    2010-01-01

    Background and Purpose Atrial fibrillation is a common cause of stroke with a known preventative treatment. We compared post-stroke recurrence and survival in Mexican Americans (MAs) and non-Hispanic whites (NHWs) with atrial fibrillation in a population-based study. Methods Using surveillance methods from the Brain Attack Surveillance in Corpus Christi (BASIC) Project, cases of ischemic stroke/TIA with atrial fibrillation were prospectively identified January 2000-June 2008. Recurrent stroke and all-cause mortality were compared by ethnicity with survival analysis methods. Results A total of 236 patients were available (88 MA, 148 NHW). MAs were younger than NHWs, with no ethnic differences in severity of the first stroke or proportion discharged on warfarin. MAs had a higher risk of stroke recurrence than NHWs (Kaplan Meier estimates of survival free of stroke recurrence risk at 28-days and 1-year were 0.99 and 0.85 in MAs and 0.98 and 0.96 in NHWs; p=0.01, log-rank test), which persisted despite adjustment for age and gender (hazard ratio 2.46, 95% CI: 1.19, 5.11). Severity of the recurrent stroke was higher in MAs than in NHWs (p=0.02). There was no ethnic difference in survival after stroke in unadjusted analysis or after adjusting for demographics and clinical factors (hazard ratio 1.03, 95% CI: 0.63–1.67). Conclusions MAs with atrial fibrillation have a higher stroke recurrence risk and more severe recurrences than NHWs, but no difference in all-cause mortality. Aggressive stroke prevention measures focused on MAs are warranted. PMID:20829515

  20. Blood pressure control versus atrial fibrillation management in stroke prevention.

    PubMed

    Savoia, Carmine; Sada, Lidia; Volpe, Massimo

    2015-06-01

    Hypertension is one of the major risk factors for atrial fibrillation which in turn is the most prevalent concomitant condition in hypertensive patients. While both these pathological conditions are independent risk factors for stroke, the association of hypertension and atrial fibrillation increases the incidence of disabling strokes. Moreover, documented or silent atrial fibrillation doubles the rate of cardiovascular death. Lowering blood pressure is strongly recommended, particularly for primary stroke prevention. However, a relatively small percentage of hypertensive patients still achieve the recommended blood pressure goals. The management of atrial fibrillation with respect to stroke prevention is changing. New oral anticoagulants represent a major advancement in long-term anticoagulation therapy in non valvular atrial fibrillation. They have several benefits over warfarin, including improved adherence to the anticoagulation therapy. This is an important issue since non-adherence to stroke prevention medications is a risk factor for first and recurrent strokes.

  1. Plasma desmoplakin I biomarker of vascular recurrence after ischemic stroke.

    PubMed

    López-Farré, Antonio J; Zamorano-León, José J; Segura, Antonio; Mateos-Cáceres, Petra J; Modrego, Javier; Rodríguez-Sierra, Pablo; Calatrava, Laura; Tamargo, Juan; Macaya, Carlos

    2012-04-01

    Stroke patients have a high risk of vascular recurrence. Biomarkers related to vascular recurrence, however, remain to be identified. The aim of the study was to identify, through proteomic analysis, plasma biomarkers associated with vascular recurrence within one year after the first ischemic stroke. This is a substudy (n = 134) of a large prospective multicenter study of post-stroke patients with an ischemic stroke. Plasma samples were obtained at inclusion. Among the identified proteins, only plasma levels of desmoplakin I were associated with protection against a new vascular event (Odds ratio: 0.64; 95% CI: 0.46-0.89; p = 0.009) after adjustment for hypercholesterolemia, statins and previous atherothrombotic stroke subtype. A greater number of patients without vascular recurrence had been treated with statins within three months of the recent ischemic stroke. Only patients who had been taking statins for 3 months after the ischemic stroke and did not suffer vascular recurrence over a follow-up year, have higher levels of desmoplakin I at the time of inclusion (Odds ratio 0.49; 95% CI: 0.28-0.86; p = 0.013). Increased desmoplakin I levels, determined within 1-3 months of the first ischemic stroke, could be a biomarker for statin responsiveness against a new vascular event in post-ischemic stroke patients taking statins early (1-3 months) after the ischemic stroke.

  2. Stroke

    MedlinePlus

    ... version of this page please turn Javascript on. Stroke About Stroke Stroke -- A Serious Event A stroke is serious, just ... lifestyle can help you prevent stroke. What Is Stroke? A stroke is sometimes called a "brain attack." ...

  3. The Secondary Prevention of Small Subcortical Strokes (SPS3) study

    PubMed Central

    Benavente, Oscar R.; White, Carole L.; Pearce, Lesly; Pergola, Pablo; Roldan, Ana; Benavente, Marie-France; Coffey, Christopher; McClure, Leslie A.; Szychowski, Jeff M.; Conwit, Robin; Heberling, Patricia A.; Howard, George; Bazan, Carlos; Vidal-Pergola, Gabriela; Talbert, Robert; Hart, Robert G.

    2014-01-01

    Background Small subcortical strokes, also known as lacunar strokes, comprise more than 25% of brain infarcts, and the underlying vasculopathy is the most common cause of vascular cognitive impairment. How to optimally prevent stroke recurrence and cognitive decline in S3 patients is unclear. The aim of the Secondary Prevention of Small Subcortical Strokes study (Trial registration: NCT00059306) is to define strategies for reducing stroke recurrence, cognitive decline, and major vascular events. Methods Secondary Prevention of Small Subcortical Strokes is a randomised, multicentre clinical trial (n = 3000) being conducted in seven countries, and sponsored by the US NINDS/NIH. Patients with symptomatic small subcortical strokes in the six-months before and an eligible lesion on magnetic resonance imaging are simultaneously randomised, in a 2 × 2 factorial design, to antiplatelet therapy – 325 mg aspirin daily plus 75 mg clopidogrel daily, vs. 325 mg aspirin daily plus placebo, double-blind – and to one of two levels of systolic blood pressure targets –‘intensive’ (<130 mmHg) vs. ‘usual’ (130–149 mmHg). Participants are followed for an average of four-years. Time to recurrent stroke (ischaemic or haemorrhagic) is the primary outcome and will be analysed separately for each intervention. The secondary outcomes are the rate of cognitive decline and major vascular events. The primary and most secondary outcomes are adjudicated centrally by those unaware of treatment assignment. Conclusions Secondary Prevention of Small Subcortical Strokes will address several important clinical and scientific questions by testing two interventions in patients with recent magnetic resonance imaging-defined lacunar infarcts, which are likely due to small vessel disease. The results will inform the management of millions of patients with this common vascular disorder. PMID:21371282

  4. Definition and Implications of the Preventable Stroke

    PubMed Central

    Fisher, Mark; Moores, Lisa; Alsharif, Mohamad N.; Paganini-Hill, Annlia

    2016-01-01

    IMPORTANCE Although patients with acute stroke are routinely evaluated for potential treatment (ie, treatability of the stroke), preventability of the presenting stroke is generally not seriously considered. OBJECTIVE To systematically analyze stroke preventability. DESIGN, SETTING, AND PARTICIPANTS We evaluated medical records of 274 consecutive patients discharged with a diagnosis of ischemic stroke between December 2, 2010, and June 11, 2012, at the University of California Irvine Medical Center. Mean (SE) patient age was 67.2 (0.8) years. Data analysis was conducted from July 3, 2014, to August 4, 2015. EXPOSURES Medical records were systematically examined for demographic information, stroke risk factors, stroke severity, and acute stroke treatment. MAIN OUTCOMES AND MEASURES We defined stroke preventability as the degree to which the patient’s presenting stroke was preventable. Using variables easily determined at onset of stroke, we developed a 10-point scale (0, not preventable; 10, most preventable) to classify the degree of stroke preventability. Our focus was effectiveness of treatment of hypertension (0–2 points), hyperlipidemia (0–2 points), and atrial fibrillation (0–4 points), as well as use of antithrombotic treatment for known prior cerebrovascular and cardiovascular disease (0–2 points). RESULTS Total risk scores ranged from 0 to 8 (mean [SE], 2.2 [0.1]), with 207 patients (75.5%) exhibiting some degree of preventability (score of 1 or higher). Seventy-one patients (25.9%) had scores of 4 or higher, indicating that the stroke was highly preventable. Severity of stroke as determined by the National Institutes of Health Stroke Scale score was not related to preventability of stroke. However, 21 of 71 patients (29.6%) whose stroke was highly preventable were treated with intravenous or intra-arterial acute stroke therapy while these treatments were provided for only 13 of 67 patients (19.4%) with scores of 0 (no preventability) and 19 of

  5. Shared genetic susceptibility of vascular-related biomarkers with ischemic and recurrent stroke

    PubMed Central

    Williams, Stephen R.; Hsu, Fang-Chi; Keene, Keith L.; Chen, Wei-Min; Nelson, Sarah; Southerland, Andrew M.; Madden, Ebony B.; Coull, Bruce; Gogarten, Stephanie M.; Furie, Karen L.; Dzhivhuho, Godfrey; Rowles, Joe L.; Mehndiratta, Prachi; Malik, Rainer; Dupuis, Josée; Lin, Honghuang; Seshadri, Sudha; Rich, Stephen S.; Sale, Michèle M.

    2016-01-01

    Objective: To investigate the genetic contributors to cerebrovascular disease and variation in biomarkers of ischemic stroke. Methods: The Vitamin Intervention for Stroke Prevention Trial (VISP) was a randomized, controlled clinical trial of B vitamin supplementation to prevent recurrent stroke, myocardial infarction, or death. VISP collected baseline measures of C-reactive protein (CRP), fibrinogen, creatinine, prothrombin fragments F1+2, thrombin-antithrombin complex, and thrombomodulin prior to treatment initiation. Genome-wide association scans were conducted for these traits and follow-up replication analyses were performed. Results: We detected an association between CRP single nucleotide polymorphisms (SNPs) and circulating CRP levels (most associated SNP, rs2592902, p = 1.14 × 10−9) in 2,100 VISP participants. We discovered a novel association for CRP level in the AKR1D1 locus (rs2589998, p = 7.3 × 10−8, approaching genome-wide significance) that also is an expression quantitative trait locus for CRP gene expression. We replicated previously identified associations of fibrinogen with SNPs in the FGB and LEPR loci. CRP-associated SNPs and CRP levels were significantly associated with risk of ischemic stroke and recurrent stroke in VISP as well as specific stroke subtypes in METASTROKE. Fibrinogen levels but not fibrinogen-associated SNPs were also found to be associated with recurrent stroke in VISP. Conclusions: Our data identify a genetic contribution to inflammatory and hemostatic biomarkers in a stroke population. Additionally, our results suggest shared genetic contributions to circulating CRP levels measured poststroke and risk for incident and recurrent ischemic stroke. These data broaden our understanding of genetic contributors to biomarker variation and ischemic stroke risk, which should be useful in clinical risk evaluation. PMID:26718567

  6. Strokes in young adults: epidemiology and prevention.

    PubMed

    Smajlović, Dževdet

    2015-01-01

    Strokes in young adults are reported as being uncommon, comprising 10%-15% of all stroke patients. However, compared with stroke in older adults, stroke in the young has a disproportionately large economic impact by leaving victims disabled before their most productive years. Recent publications report an increased incidence of stroke in young adults. This is important given the fact that younger stroke patients have a clearly increased risk of death compared with the general population. The prevalence of standard modifiable vascular risk factors in young stroke patients is different from that in older patients. Modifiable risk factors for stroke, such as dyslipidemia, smoking, and hypertension, are highly prevalent in the young stroke population, with no significant difference in geographic, climatic, nutritional, lifestyle, or genetic diversity. The list of potential stroke etiologies among young adults is extensive. Strokes of undetermined and of other determined etiology are the most common types among young patients according to TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Prevention is the primary treatment strategy aimed at reducing morbidity and mortality related to stroke. Therefore, primary prevention is very important with regard to stroke in young adults, and aggressive treatment of risk factors for stroke, such as hypertension, smoking, and dyslipidemia, is essential. The best form of secondary stroke prevention is directed toward stroke etiology as well as treatment of additional risk factors. However, there is a lack of specific recommendations and guidelines for stroke management in young adults. In conclusion, strokes in young adults are a major public health problem and further research, with standardized methodology, is needed in order to give us more precise epidemiologic data. Given the increasing incidence of stroke in the young, there is an objective need for more research in order to reduce this burden.

  7. Guidelines for the Primary Prevention of Stroke

    PubMed Central

    Meschia, James F.; Bushnell, Cheryl; Boden-Albala, Bernadette; Braun, Lynne T.; Bravata, Dawn M.; Chaturvedi, Seemant; Creager, Mark A.; Eckel, Robert H.; Elkind, Mitchell S.V.; Fornage, Myriam; Goldstein, Larry B.; Greenberg, Steven M.; Horvath, Susanna E.; Iadecola, Costantino; Jauch, Edward C.; Moore, Wesley S.; Wilson, John A.

    2016-01-01

    The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale. PMID:25355838

  8. Risk of First and Recurrent Stroke in Childhood Cancer Survivors Treated With Cranial and Cervical Radiation Therapy

    SciTech Connect

    Mueller, Sabine; Sear, Katherine; Hills, Nancy K.; Chettout, Nassim; Afghani, Shervin; Gastelum, Erica; Haas-Kogan, Daphne; Fullerton, Heather J.

    2013-07-15

    Purpose: To assess, in a retrospective cohort study, rates and predictors of first and recurrent stroke in patients treated with cranial irradiation (CRT) and/or cervical irradiation at ≤18 years of age. Methods and Materials: We performed chart abstraction (n=383) and phone interviews (n=104) to measure first and recurrent stroke in 383 patients who received CRT and/or cervical radiation at a single institution between 1980 and 2009. Stroke was defined as a physician diagnosis and symptoms consistent with stroke. Incidence of first stroke was number of first strokes per person-years of observation after radiation. We used survival analysis techniques to determine cumulative incidence of first and recurrent stroke. Results: Among 325 subjects with sufficient follow-up data, we identified 19 first strokes (13 ischemic, 4 hemorrhagic, 2 unknown subtype) occurring at a median age of 24 years (interquartile range 17-33 years) in patients treated with CRT. Imaging was reviewed when available (n=13), and the stroke was confirmed in 12. Overall rate of first stroke was 625 (95% confidence interval [CI] 378-977) per 100,000 person-years. The cumulative incidence of first stroke was 2% (95% CI 0.01%-5.3%) at 5 years and 4% (95% CI 2.0%-8.4%) at 10 years after irradiation. With each 100-cGy increase in the radiation dose, the stroke hazard increased by 5% (hazard ratio 1.05; 95% CI 1.01-1.09; P=.02). We identified 6 recurrent strokes; 5 had available imaging that confirmed the stroke. Median time to recurrence was 15 months (interquartile range 6 months-3.2 years) after first stroke. The cumulative incidence of recurrent stroke was 38% (95% CI 17%-69%) at 5 years and 59% (95% CI 27%-92%) at 10 years after first stroke. Conclusion: Cranial irradiation puts childhood cancer survivors at high risk of both first and recurrent stroke. Stroke prevention strategies for these survivors are needed.

  9. Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials

    PubMed Central

    Rothwell, Peter M; Algra, Ale; Chen, Zhengming; Diener, Hans-Christoph; Norrving, Bo; Mehta, Ziyah

    2017-01-01

    Background Aspirin is recommended for secondary prevention after transient ischaemic attack (TIA) and ischaemic stroke based on trials showing about a 13% reduction in long-term risk of recurrent stroke. However, the risk of major stroke is very high for only the first few days after TIA and minor ischaemic stroke and observational studies show substantially greater benefits of early medical treatment in the acute phase. We hypothesised that the short-term benefits of early aspirin have been underestimated. Methods Using individual patient data from all randomised trials of aspirin vs placebo in secondary prevention after TIA or ischaemic stroke, we studied the time-course of effects on risk and severity (modified Rankin score - mRS) of recurrent stroke and myocardial infarction. To more reliably determine the very early time-course of effect of aspirin on risk of recurrent ischaemic stroke, we also studied trials in treatment of acute stroke stratified by severity of baseline neurological deficit. To understand possible mechanisms of action, we also studied the time-course of the interaction between effects of aspirin and dipyridamole in secondary prevention of stroke. Results Among 15,778 patients in 12 trials of aspirin vs. control in secondary prevention, aspirin reduced the 6-week risk of major ischaemic vascular events by 70-80% (disabling or fatal ischaemic stroke - HR=0.29,0.20-0.43, p<0.0001; acute myocardial infarction - HR=0.22, 0.09-0.53, p=0.0008), with greatest benefit in patients with TIA or minor stroke (disabling or fatal ischaemic stroke: 0-2 weeks-HR=0.07,0.02-0.31,p=0.0004; 0-6 weeks-HR=0.19,0.11-0.34,p<0.0001). The effect of aspirin on early recurrent ischaemic stroke was due partly to a substantial reduction in severity (mRS shift analysis: OR=0.43,0.26-0.72,p=0.001). These effects were independent of dose, patient characteristics or aetiology of TIA or stroke. Some further reduction in risk of ischaemic stroke on aspirin only vs control

  10. Prevention of stroke: a strategic global imperative.

    PubMed

    Feigin, Valery L; Norrving, Bo; George, Mary G; Foltz, Jennifer L; Roth, Gregory A; Mensah, George A

    2016-09-01

    The increasing global stroke burden strongly suggests that currently implemented primary stroke prevention strategies are not sufficiently effective, and new primary prevention strategies with larger effect sizes are needed. Here, we review the latest stroke epidemiology literature, with an emphasis on the recently published Global Burden of Disease 2013 Study estimates; highlight the problems with current primary stroke and cardiovascular disease (CVD) prevention strategies; and outline new developments in primary stroke and CVD prevention. We also suggest key priorities for the future, including comprehensive prevention strategies that target people at all levels of CVD risk; implementation of an integrated approach to promote healthy behaviours and reduce health disparities; capitalizing on information technology to advance prevention approaches and techniques; and incorporation of culturally appropriate education about healthy lifestyles into standard education curricula early in life. Given the already immense and fast-increasing burden of stroke and other major noncommunicable diseases (NCDs), which threatens worldwide sustainability, governments of all countries should develop and implement an emergency action plan addressing the primary prevention of NCDs, possibly including taxation strategies to tackle unhealthy behaviours that increase the risk of stroke and other NCDs.

  11. Intrapulmonary arteriovenous malformation causing recurrent strokes

    PubMed Central

    Abed, Kareem; Premachandra, Lalith; Vankawala, Viren; Sun, Qi

    2015-01-01

    This case reveals a left pulmonary arteriovenous malformation (PAVM) as a cause of recurrent cerebral and cerebellar emboli. Extensive workup excluded other etiologies of emboli formation, and the patient was transferred to a tertiary care center for percutaneous embolotherapy. In the absence of a clear etiology, PAVM should be considered as a potential cause of recurrent cerebral emboli, especially in the absence of carotid disease, intracardiac thrombus, atrial septal defect, and patent foramen ovale. Diagnostic work-up for the PAVM can be cost effective and expedited by utilization of agitated saline contrast echocardiography, as noted in our case. PMID:26486114

  12. Recurrent stroke after transient ischaemic attack or minor ischaemic stroke: does the distinction between small and large vessel disease remain true to type? Dutch TIA Trial Study Group.

    PubMed Central

    Kappelle, L J; van Latum, J C; van Swieten, J C; Algra, A; Koudstaal, P J; van Gijn, J

    1995-01-01

    The incidence and vascular type of recurrent ischaemic stroke was studied in patients with supratentorial transient ischaemic attacks or non-disabling ischaemic strokes, who were treated with aspirin (30 or 283 mg). Patients were divided into groups with small vessel disease (SVD) (n = 1216) or large vessel disease (LVD) (n = 1221) on the grounds of their clinical features and CT at baseline. Patients with evidence of both SVD and LVD (n = 180) were excluded from further analyses. During follow up (mean 2.6 years) annual stroke rate was 3.6% in both groups. Of the 107 patients with SVD at baseline who had recurrent strokes, 83 proved to have an identifiable infarct: 30 (28%) again had a small vessel infarct, 39 (36%) had a large vessel ischaemic stroke and in 14 (13%) the recurrent ischaemic stroke was in the posterior fossa. Of the 110 patients with LVD at baseline and recurrent stroke, 91 had an identifiable infarct: 67 (61%) again had a large vessel ischaemic stroke, 16 (15%) had a small vessel ischaemic stroke, and eight (7%) had the recurrent ischaemic stroke in the posterior fossa. Thus patients with a transient ischaemic attack or non-disabling ischaemic stroke caused by LVD were more likely to have an ischaemic stroke of the same vessel type during follow up than patients with SVD (relative risk 2.2; 95% confidence interval 1.5-3.4). Possible explanations for this difference are: (1) patients with a small vessel ischaemic stroke at baseline had both SVD and LVD or were misdiagnosed; (2) recurrent small vessel ischaemic stroke may have occurred more often than reported, because they were silent or only minimally disabling; (3) recurring large vessel ischaemic strokes occurring in patients initially diagnosed as having SVD might have been related to potential cardiac sources of emboli that had not been previously recognized; (4) the antiplatelet drug aspirin (30 or 283 mg) prescribed in this patient group may have prevented thrombosis in small vessels better

  13. The PRoFESS trial: future impact on secondary stroke prevention.

    PubMed

    Diener, Hans-Christoph

    2007-09-01

    Patients with transient ischemic attack and ischemic stroke have a high risk of recurrent stroke and death. While aspirin is accepted as standard therapy in these patients, recent trials demonstrate that a combination of aspirin and extended-release dipyridamole or clopidogrel is superior to aspirin monotherapy. Blockade of the renin-angiotensin system with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers may also reduce recurrent stroke. The ongoing Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial is designed to evaluate whether extended-release dipyridamole plus aspirin compared with clopidogrel, and whether telmisartan in addition to usual care, in individuals after a stroke, will reduce the risk of further strokes. PRoFESS is a multicenter, randomized, double-blind trial involving 695 sites from 35 countries or regions. The primary outcome for the trial is recurrent stroke, using a time-to-event analysis. Safety is evaluated by assessing the risk of major hemorrhagic and other serious adverse events. With over 20,000 patients randomized, and utilizing a 2 x 2 factorial design, PRoFESS is the largest stroke trial to investigate the prevention of recurrent stroke.

  14. Aspirin and Extended-Release Dipyridamole versus Clopidogrel for Recurrent Stroke

    PubMed Central

    Sacco, Ralph L.; Diener, Hans-Christoph; Yusuf, Salim; Cotton, Daniel; Ôunpuu, Stephanie; Lawton, William A.; Palesch, Yuko; Martin, Reneé H.; Albers, Gregory W.; Bath, Philip; Bornstein, Natan; Chan, Bernard P.L.; Chen, Sien-Tsong; Cunha, Luis; Dahlöf, Björn; De Keyser, Jacques; Donnan, Geoffrey A.; Estol, Conrado; Gorelick, Philip; Gu, Vivian; Hermansson, Karin; Hilbrich, Lutz; Kaste, Markku; Lu, Chuanzhen; Machnig, Thomas; Pais, Prem; Roberts, Robin; Skvortsova, Veronika; Teal, Philip; Toni, Danilo; VanderMaelen, Cam; Voigt, Thor; Weber, Michael; Yoon, Byung-Woo

    2009-01-01

    BACKGROUND Recurrent stroke is a frequent, disabling event after ischemic stroke. This study compared the efficacy and safety of two antiplatelet regimens — aspirin plus extendedrelease dipyridamole (ASA–ERDP) versus clopidogrel. METHODS In this double-blind, 2-by-2 factorial trial, we randomly assigned patients to receive 25 mg of aspirin plus 200 mg of extended-release dipyridamole twice daily or to receive 75 mg of clopidogrel daily. The primary outcome was first recurrence of stroke. The secondary outcome was a composite of stroke, myocardial infarction, or death from vascular causes. Sequential statistical testing of noninferiority (margin of 1.075), followed by superiority testing, was planned. RESULTS A total of 20,332 patients were followed for a mean of 2.5 years. Recurrent stroke occurred in 916 patients (9.0%) receiving ASA–ERDP and in 898 patients (8.8%) receiving clopidogrel (hazard ratio, 1.01; 95% confidence interval [CI], 0.92 to 1.11). The secondary outcome occurred in 1333 patients (13.1%) in each group (hazard ratio for ASA–ERDP, 0.99; 95% CI, 0.92 to 1.07). There were more major hemorrhagic events among ASA–ERDP recipients (419 [4.1%]) than among clopidogrel recipients (365 [3.6%]) (hazard ratio, 1.15; 95% CI, 1.00 to 1.32), including intracranial hemorrhage (hazard ratio, 1.42; 95% CI, 1.11 to 1.83). The net risk of recurrent stroke or major hemorrhagic event was similar in the two groups (1194 ASA–ERDP recipients [11.7%], vs. 1156 clopidogrel recipients [11.4%]; hazard ratio, 1.03; 95% CI, 0.95 to 1.11). CONCLUSIONS The trial did not meet the predefined criteria for noninferiority but showed similar rates of recurrent stroke with ASA–ERDP and with clopidogrel. There is no evidence that either of the two treatments was superior to the other in the prevention of recurrent stroke. PMID:18753638

  15. Comparison of Functional Outcome and Stroke Recurrence in Patients with Embolic Stroke of Undetermined Source (ESUS) vs. Cardioembolic Stroke Patients

    PubMed Central

    Arauz, Antonio; Morelos, Eugenia; Colín, Jonathan; Roldán, Javier

    2016-01-01

    Background Embolic stroke of undetermined source (ESUS) recurrence and functional outcome from long-term follow-up is not well delineated. The purpose of this study is to compare these functional variables between ESUS vs. cardioembolic stroke (CS) patients. Methods We analyzed data of consecutive ESUS and CS patients from our institutional database, from January 2003 until April 2015. The endpoints were stroke recurrence, mortality and poor clinical outcome (Modified Rankin Score 3–6), at discharge, 6 months and final follow-up. Adjusted multivariate Cox analysis and Kaplan-Meier curves were used to estimate the probability of recurrence and death. Results 149 ESUS (median age 44 years) and 235 CS (median age 66 years) consecutive patients were included in the study. Median follow-up period for the entire sample was 19 months (interquartile range 6.0–45.0 months). Stroke recurrence was similar between ESUS and CS patients (5.4% vs. 9.8% respectively, p = 0.12). Death occurred in 30 CS cases (12.8%), with a cumulative probability of survival of 77%. Poor functional outcome was present in 58.3%, 54.0% and 54.9% at discharge, 6 months and final follow-up respectively in CS patients, significantly worst compared to ESUS cases (HR 3.1; CI 95% 1.96–4.68). Oral anticoagulation presents with a HR 8.01 for recurrence, and antiplatelet therapy had the highest risk for recurrence for both groups (HR 24.3). Conclusion ESUS patients are substantially younger than CS patients but have a stroke recurrence rate similar to CS patients, with a lower mortality rate, and better functional outcome on long-term follow-up. PMID:27832136

  16. Aspirin to Prevent a First Heart Attack or Stroke

    MedlinePlus

    ... NHLBI on Twitter. Aspirin to Prevent a First Heart Attack or Stroke Also known as aspirin primary prevention. ... if I’m taking aspirin to prevent another heart attack or stroke? The information discussed in Who may ...

  17. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association.

    PubMed

    Furie, Karen L; Kasner, Scott E; Adams, Robert J; Albers, Gregory W; Bush, Ruth L; Fagan, Susan C; Halperin, Jonathan L; Johnston, S Claiborne; Katzan, Irene; Kernan, Walter N; Mitchell, Pamela H; Ovbiagele, Bruce; Palesch, Yuko Y; Sacco, Ralph L; Schwamm, Lee H; Wassertheil-Smoller, Sylvia; Turan, Tanya N; Wentworth, Deidre

    2011-01-01

    The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches to the implementation of guidelines and their use in high-risk populations.

  18. Intensive risk factor control in stroke prevention

    PubMed Central

    2013-01-01

    Stroke prevention is an urgent priority because of the aging of the population and the steep association of age and risk of stroke. Direct costs of stroke are expected to more than double in the US between 2012 and 2030. By getting everything right, patients can reduce the risk of stroke by 80% or more; however, getting everything right is a tall order. Roughly in order of importance, this requires smoking cessation, maintenance of a healthy weight, a Cretan Mediterranean diet, blood pressure control, lipid-lowering drugs, appropriate use of antiplatelet agents and anticoagulants, and appropriate carotid endarterectomy and stenting. A new approach called “treating arteries instead of targeting risk factors” appears promising but requires validation in randomized trials. PMID:24167723

  19. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.

    PubMed

    Kernan, Walter N; Ovbiagele, Bruce; Black, Henry R; Bravata, Dawn M; Chimowitz, Marc I; Ezekowitz, Michael D; Fang, Margaret C; Fisher, Marc; Furie, Karen L; Heck, Donald V; Johnston, S Claiborne Clay; Kasner, Scott E; Kittner, Steven J; Mitchell, Pamela H; Rich, Michael W; Richardson, DeJuran; Schwamm, Lee H; Wilson, John A

    2014-07-01

    The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.

  20. Newer Oral Anticoagulants: Stroke Prevention and Pitfalls

    PubMed Central

    Patel, Anand; Goddeau Jr, Richard P.; Henninger, Nils

    2016-01-01

    Warfarin is very effective in preventing stroke in patients with atrial fibrillation. However, its use is limited due to fear of hemorrhagic complications, unpredictable anticoagulant effects related to multiple drug interactions and dietary restrictions, a narrow therapeutic window, frequent difficulty maintaining the anticoagulant effect within a narrow therapeutic window, and the need for inconvenient monitoring. Several newer oral anticoagulants have been approved for primary and secondary prevention of stroke in patients with non-valvular atrial fibrillation. These agents have several advantages relative to warfarin therapy. As a group, these direct oral anticoagulants (DOAC), which include the direct thrombin inhibitor, dabigatran, and the factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban), are more effective than dose adjusted warfarin for prevention of all-cause stroke (including both ischemic and hemorrhagic stroke), and have an overall more favorable safety profile. Nevertheless, an increased risk of gastrointestinal bleeding (with the exception of apixaban), increased risk for thrombotic complication with sudden discontinuation, and inability to accurately assess and reverse anticoagulant effect require consideration prior to therapy initiation, and pose a challenge for decision making in acute stroke therapy. PMID:27347226

  1. Recurrent stroke as a presenting feature of acquired partial lipodystrophy

    PubMed Central

    Prasad, Namburi R.; Reddy, Ponnala A.; Menon, Bindu; Karthik, T. S.; Ahmed, Faizal; Chakravarthy, Mithun

    2012-01-01

    Acquired partial lipodystrophy (PL) (Barraquer–Simons syndrome) is a rare condition with onset in childhood, and it is characterized by progressive loss of subcutaneous fat in a cephalocaudal fashion. This report describes a case of acquired PL in a 16-year-old girl, who had progressive loss of facial fat since 3 years. Systemic lupus erythematosus (SLE), anticardiolipin antibody, primary hypothyroidism, diabetes, and dyslipidemia may antedate the development of complications such as cerebrovascular stroke and cardiovascular disease. The girl had developed recurrent left hemiparesis, and withdrawn from school due to poor performance. PMID:23565465

  2. Preventing venous ulcer recurrence: a review.

    PubMed

    Vowden, Kathryn R; Vowden, Peter

    2006-03-01

    This review article examines the available evidence on both the primary and secondary prevention of venous ulceration, exploring both the individual, social and financial implications of system failures that allow patients to remain at increased risk of recurrent ulceration. The role of both venous disease assessment and corrective superficial venous surgery are discussed in the light of recently published randomised controlled studies on the role of superficial venous surgery as both an adjunct to ulcer healing and ulcer prevention.

  3. Recurrent Cellulitis: How Can I Prevent It?

    MedlinePlus

    ... M.D. To help prevent recurrent episodes of cellulitis — a bacterial infection in the deepest layer of skin — keep skin ... www.merckmanuals.com/professional/dermatologic_disorders/bacterial_skin_infections/cellulitis.html?qt=cellulitis&alt=sh. Accessed Dec. 20, ...

  4. Prevention of Recurrent Staphylococcal Skin Infections

    PubMed Central

    Creech, C. Buddy; Al-Zubeidi, Duha N.; Fritz, Stephanie A.

    2015-01-01

    Synopsis Staphylococcus aureus infections pose a significant health burden. The emergence of community-associated methicillin-resistant S. aureus has resulted in an epidemic of skin and soft tissue infections (SSTI), and many patients experience recurrent SSTI. As S. aureus colonization is associated with subsequent infection, decolonization is recommended for patients with recurrent SSTI or in settings of ongoing transmission. S. aureus infections often cluster within households and asymptomatic carriers serve as reservoirs for transmission; therefore, a household approach to decolonization is more effective than measures performed by individuals alone. Other factors, such as environmental surface contamination, may also be considered. Novel strategies for the prevention of recurrent SSTI are needed. PMID:26311356

  5. Preventing recurrence of severe morning sickness

    PubMed Central

    Koren, Gideon; Maltepe, Caroline

    2006-01-01

    QUESTION A recent Motherisk article showed that initiating antinauseants even before symptoms start could prevent recurrence of severe morning sickness. In the study described, however, different physicians used different drugs. How can one be sure which drugs work? ANSWER The study of 26 women who had had severe morning sickness during previous pregnancies showed that using antiemetics before symptoms of morning sickness started appeared to prevent recurrence of severe morning sickness in subsequent pregnancies. Physicians in the United States used various antinauseant drugs. Physicians in Canada administered only one drug, the combination of doxylamine-pyridoxine (Diclectin®), to 12 women. Subanalysis of these 12 women revealed that pre-emptive use of doxylamine-pyridoxine significantly decreased the likelihood that severe morning sickness would recur. PMID:17279232

  6. Blood Pressure After Recent Stroke: Baseline Findings From the Secondary Prevention of Small Subcortical Strokes Trial

    PubMed Central

    White, Carole L.; Pergola, Pablo E.; Szychowski, Jeff M.; Talbert, Robert; Benavente, Oscar R.

    2013-01-01

    BACKGROUND Hypertension is the most powerful risk factor for stroke. The aim of this study was to characterize baseline blood pressure in participants in the Secondary Prevention of Small Subcortical Strokes trial. METHODS For this cross-sectional analysis, participants were categorized by baseline systolic blood pressure (SBP) < 120, 120–139, 140–159, 160–179, and ≥ 180mm Hg and compared on demographic and clinical characteristics. Predictors of SBP < 140mm Hg were examined. RESULTS Mean SBP was 143±19mm Hg while receiving an average of 1.7 antihypertensive medications; SBP ≥ 140mm Hg for 53% and ≥ 160 mm Hg for 18% of the 3,020 participants. Higher SBP was associated with a history of hypertension and hypertension for longer duration (both P < 0.0001). Higher SBPs were associated with more extensive white matter disease on magnetic resonance imaging (P < 0.0001). There were significant differences in entry-level SBP when participants were categorized by race and region (both P < 0.0001). Black participants were more likely to have SBP ≥ 140mm Hg. Multivariable logistic regression showed an independent effect for region with those from Canada more likely (odds ratio = 1.7; 95% confidence interval, 1.29, 2.32) to have SBP < 140mm Hg compared with participants from United States. CONCLUSIONS In this cohort with symptomatic lacunar stroke, more than half had uncontrolled hypertension at approximately 2.5 months after stroke. Regional, racial, and clinical differences should be considered to improve control and prevent recurrent stroke. CLINICAL TRIALS REGISTRATION Trial Number NCT00059306 PMID:23736109

  7. Daily Aspirin May Help Prevent Some Recurrent Miscarriages

    MedlinePlus

    ... https://medlineplus.gov/news/fullstory_163515.html Daily Aspirin May Help Prevent Some Recurrent Miscarriages Approach seemed ... as simple as taking a daily low-dose aspirin could help prevent a recurrence. The intervention appears ...

  8. Bilateral atherosclerotic internal carotid artery occlusion and recurrent ischaemic stroke.

    PubMed

    Amin, Osama S M

    2015-06-08

    Bilateral internal carotid artery occlusion (BICAO) is a rare disease that carries a gloomy prognosis. We report a case of a 52-year-old man who developed ischaemic infarction at the region of the right middle cerebral artery; he was found to have atherosclerotic occlusion of both internal carotid arteries on Doppler-duplex examination. He received medical treatment only. After 1 year, he developed a new infarction at the region of the left middle cerebral artery. Conventional angiography revealed bilateral occlusion of internal carotid arteries at their origin, approximately 50% stenosis of the common carotid bulbs and mild stenosis of the origin of external carotid arteries. The patient did not undergo any form of surgical revascularisation procedures and died of severe aspiration pneumonia approximately 2 months after the second stroke. BICAO portends a poor outcome and carries a risk of recurrent ischaemic events. The best management strategy for this vascular occlusion remains unclear.

  9. Clinical Neuroprotective Drugs for Treatment and Prevention of Stroke

    PubMed Central

    Kikuchi, Kiyoshi; Uchikado, Hisaaki; Morioka, Motohiro; Murai, Yoshinaka; Tanaka, Eiichiro

    2012-01-01

    Stroke is an enormous public health problem with an imperative need for more effective therapies. In therapies for ischemic stroke, tissue plasminogen activators, antiplatelet agents and anticoagulants are used mainly for their antithrombotic effects. However, free radical scavengers, minocycline and growth factors have shown neuroprotective effects in the treatment of stroke, while antihypertensive drugs, lipid-lowering drugs and hypoglycemic drugs have shown beneficial effects for the prevention of stroke. In the present review, we evaluate the treatment and prevention of stroke in light of clinical studies and discuss new anti-stroke effects other than the main effects of drugs, focusing on optimal pharmacotherapy. PMID:22837724

  10. [Statins in the secondary prevention of stroke: New evidence from the SPARCL Study].

    PubMed

    Castilla-Guerra, Luis; Fernández-Moreno, María Del Carmen; López-Chozas, José Manuel

    2016-01-01

    Until recently there was little evidence that statin therapy reduced the risk of stroke recurrence. The SPARCL trial, published in 2006, was the first trial to show the benefits of statin therapy in preventing recurrent stroke. The SPARCL trial showed that treatment with atorvastatin 80mg/day reduced recurrent stroke in patients with a recent stroke or transient ischemic attack (TIA). Several post hoc analyses of different subgroups followed the SPARCL trial. They have not revealed any significant differences when patients were grouped by age, sex or type of stroke. The SPARCL trial has also helped to identify patients who may have a greater benefit from statins: Patients with carotid stenosis, with more intense lipid lowering, and those who achieve optimal levels of LDL-C, HDL-C, triglycerides, and blood pressure. The trial has also helped to identify individuals at high risk of new vascular events. Clearly there is a before and after in stroke prevention since the SPARCL trial was published.

  11. Changes in pre-hospital management of vascular risk factors among patients admitted due to recurrent stroke in Poland from 1995 to 2013

    PubMed Central

    Bembenek, Jan P.; Karlinski, Michał; Kurkowska-Jastrzebska, Iwona

    2016-01-01

    Introduction The aim of this study was to investigate long-term trends in secondary stroke prevention through management of vascular risk factors directly before hospital admission for recurrent stroke. Material and methods This is a retrospective registry-based analysis of consecutive recurrent acute stroke patients from a highly urbanized area (Warsaw, Poland) admitted to a single stroke center between 1995 and 2013 with previous ischemic stroke. We compared between four consecutive time periods: 1995–1999, 2000–2004, 2005–2009 and 2010–2013. Results During the study period, 894 patients with recurrent strokes were admitted (18% of all strokes), including 867 with previous ischemic stroke (our study group). Among those patients, the proportion of recurrent ischemic strokes (88.1% to 93.9%) (p = 0.319) and males (44% to 49.7%) (p = 0.5) remained stable. However, there was a rising trend in patients’ age (median age of 73, 74, 76 and 77 years, respectively). There was also an increase in the use of antihypertensives (from 70.2% to 83.8%) (p = 0.013), vitamin K antagonists (from 4.8% to 15.6%) (p = 0.012) and statins (from 32.5% to 59.4%) (p < 0.001). Nonetheless, 21% of patients did not receive any antithrombotic prophylaxis. Tobacco smoking pattern remained unchanged. Conclusions Our data indicate a clear overall improvement of secondary stroke prevention. However, persistent use of antithrombotic drugs and tobacco smoking after the first ischemic stroke is constantly suboptimal. PMID:27482236

  12. Personalized medicine and stroke prevention: where are we?

    PubMed

    Kim, Joosup; Thrift, Amanda G; Nelson, Mark R; Bladin, Christopher F; Cadilhac, Dominique A

    2015-01-01

    There are many recommended pharmacological and non-pharmacological therapies for the prevention of stroke, and an ongoing challenge is to improve their uptake. Personalized medicine is seen as a possible solution to this challenge. Although the use of genetic information to guide health care could be considered as the apex of personalized medicine, genetics is not yet routinely used to guide prevention of stroke. Currently personalized aspects of prevention of stroke include tailoring interventions based on global risk, the utilization of individualized management plans within a model of organized care, and patient education. In this review we discuss the progress made in these aspects of prevention of stroke and present a case study to illustrate the issues faced by health care providers and patients with stroke that could be overcome with a personalized approach to the prevention of stroke.

  13. Population-based study of blood biomarkers in prediction of sub-acute recurrent stroke

    PubMed Central

    Segal, Helen C; Burgess, Annette I; Poole, Debbie L; Mehta, Ziyah; Silver, Louise E; Rothwell, Peter M

    2017-01-01

    Background and purpose Risk of recurrent stroke is high in the first few weeks after TIA or stroke and clinic risk prediction tools have only limited accuracy, particularly after the hyper-acute phase. Previous studies of the predictive value of biomarkers have been small, been done in selected populations and have not concentrated on the acute phase or on intensively treated populations. We aimed to determine the predictive value of a panel of blood biomarkers in intensively treated patients early after TIA and stroke. Methods We studied 14 blood biomarkers related to inflammation, thrombosis, atherogenesis and cardiac or neuronal cell damage in early TIA or ischaemic stroke in a population-based study (Oxford Vascular Study). Biomarker levels were related to 90-day risk of recurrent stroke as Hazard Ratio (95%CI) per decile increase, adjusted for age and sex. Results Among 1292 eligible patients there were 53 recurrent ischaemic strokes within 90 days. There were moderate correlations (r>0.40; p<0001) between the inflammatory biomarkers and between the cell damage and thrombotic subsets. However, associations with risk of early recurrent stroke were weak, with significant associations limited to Interleukin-6 (HR=1.12, 1.01-1.24; p=0.035) and C-reactive protein (1.16, 1.02-1.30; p=0.019). When stratified by type of presenting event, P-selectin predicted stroke after TIA (1.31, 1.03-1.66; p=0.028) and C-reactive protein predicted stroke after stroke (1.16, 1.01-1.34; p=0.042). These associations remained after fully adjusting for other vascular risk factors. Conclusion In the largest study to date, we found very limited predictive utility for early recurrent stroke for a panel of inflammatory, thrombotic and cell damage biomarkers. PMID:25158774

  14. Novel preventive and therapuetic strategy for post-stroke pneumonia.

    PubMed

    Teramoto, Shinji

    2009-08-01

    Pneumonia is a significant complication of ischemic stroke that increases mortality. Post-stroke pneumonia is defined as newly developed pneumonia following stroke onset. Clinically and chronologically, post-stroke pneumonia is divided into two types of aspiration pneumonia. First, acute-onset post-stroke pneumonia occurs within 1 month after stroke. Second, insidious or chronic-onset post-stroke pneumonia occurs 1 month after the stroke. The mechanisms of pneumonia are apparent aspiration and dysphagia-associated microaspiration. Stroke and the post-stroke state are the most significant risk factors for aspiration pneumonia. The preventive and therapeutic strategies have been developed thoroughly and appropriate antibiotic use, and both pharmacological and nonpharmacological approaches for the treatment of post-stroke pneumonia have been studied rigorously. Increases in substance P levels, oral care, and swallowing rehabilitation are necessary to improve swallowing function in post-stroke patients, resulting in a reduction in the incidence of post-stroke pneumonia in a chronic stage. The stroke must be a cause of aspiration pneumonia.

  15. Systems Pharmacology Dissection of Multi-Scale Mechanisms of Action for Herbal Medicines in Stroke Treatment and Prevention

    PubMed Central

    Zhang, Jingxiao; Li, Yan; Chen, Xuetong; Pan, Yanqiu; Zhang, Shuwei; Wang, Yonghua

    2014-01-01

    Annually, tens of millions of first-ever strokes occur in the world; however, currently there is lack of effective and widely applicable pharmacological treatments for stroke patients. Herbal medicines, characterized as multi-constituent, multi-target and multi-effect, have been acknowledged with conspicuous effects in treating stroke, and attract extensive interest of researchers although the mechanism of action is yet unclear. In this work, we introduce an innovative systems-pharmacology method that combines pharmacokinetic prescreening, target fishing and network analysis to decipher the mechanisms of action of 10 herbal medicines like Salvia miltiorrhizae, Ginkgo biloba and Ephedrae herba which are efficient in stroke treatment and prevention. Our systematic analysis results display that, in these anti-stroke herbal medicines, 168 out of 1285 constituents with the favorable pharmacokinetic profiles might be implicated in stroke therapy, and the systematic use of these compounds probably acts through multiple mechanisms to synergistically benefit patients with stroke, which can roughly be classified as preventing ischemic inflammatory response, scavenging free radicals and inhibiting neuronal apoptosis against ischemic cerebral damage, as well as exhibiting lipid-lowering, anti-diabetic, anti-thrombotic and antiplatelet effects to decrease recurrent strokes. Relying on systems biology-based analysis, we speculate that herbal medicines, being characterized as the classical combination therapies, might be not only engaged in multiple mechanisms of action to synergistically improve the stroke outcomes, but also might be participated in reducing the risk factors for recurrent strokes. PMID:25093322

  16. Systems pharmacology dissection of multi-scale mechanisms of action for herbal medicines in stroke treatment and prevention.

    PubMed

    Zhang, Jingxiao; Li, Yan; Chen, Xuetong; Pan, Yanqiu; Zhang, Shuwei; Wang, Yonghua

    2014-01-01

    Annually, tens of millions of first-ever strokes occur in the world; however, currently there is lack of effective and widely applicable pharmacological treatments for stroke patients. Herbal medicines, characterized as multi-constituent, multi-target and multi-effect, have been acknowledged with conspicuous effects in treating stroke, and attract extensive interest of researchers although the mechanism of action is yet unclear. In this work, we introduce an innovative systems-pharmacology method that combines pharmacokinetic prescreening, target fishing and network analysis to decipher the mechanisms of action of 10 herbal medicines like Salvia miltiorrhizae, Ginkgo biloba and Ephedrae herba which are efficient in stroke treatment and prevention. Our systematic analysis results display that, in these anti-stroke herbal medicines, 168 out of 1285 constituents with the favorable pharmacokinetic profiles might be implicated in stroke therapy, and the systematic use of these compounds probably acts through multiple mechanisms to synergistically benefit patients with stroke, which can roughly be classified as preventing ischemic inflammatory response, scavenging free radicals and inhibiting neuronal apoptosis against ischemic cerebral damage, as well as exhibiting lipid-lowering, anti-diabetic, anti-thrombotic and antiplatelet effects to decrease recurrent strokes. Relying on systems biology-based analysis, we speculate that herbal medicines, being characterized as the classical combination therapies, might be not only engaged in multiple mechanisms of action to synergistically improve the stroke outcomes, but also might be participated in reducing the risk factors for recurrent strokes.

  17. Seizure Outcomes and Predictors of Recurrent Post-Stroke Seizure: A Retrospective Observational Cohort Study

    PubMed Central

    Motoyama, Rie; Fukuma, Kazuki; Miyagi, Tetsuya; Nishimura, Kazutaka; Toyoda, Kazunori; Nagatsuka, Kazuyuki

    2015-01-01

    Background Seizure is a common complication after stroke (termed “post-stroke seizure,” PSS). Although many studies have assessed outcomes and risk factors of PSS, no reliable predictors are currently available to determine PSS recurrence. We compared baseline clinical characteristics and post-stroke treatment regimens between recurrent and non-recurrent PSS patients to identify factors predictive of recurrence. Methods Consecutive PSS patients admitted to our stroke center between January 2011 and July 2013 were monitored until February 2014 (median 357 days; IQR, 160–552) and retrospectively evaluated for baseline clinical characteristics and PSS recurrence. Cumulative recurrence rates at 90, 180, and 360 days post-stroke were estimated by Kaplan—Meier analysis. Independent predictors of recurrent PSS were identified by Cox proportional-hazards analysis. Results A total of 104 patients (71 men; mean age, 72.1 ± 11.2 years) were analyzed. PSS recurred in 31 patients (30%) during the follow-up. Factors significantly associated with PSS recurrence by log-rank analysis included previous PSS, valproic acid (VPA) monotherapy, polytherapy with antiepileptic drugs (AEDs), frontal cortical lesion, and higher modified Rankin Scale score at discharge (all p < 0.05). Independent predictors of recurrent PSS were age <74 years (HR 2.38, 95% CI 1.02–5.90), VPA monotherapy (HR 3.86, 95% CI 1.30–12.62), and convulsions on admission (HR 3.87, 95% CI 1.35–12.76). Conclusions Approximately one-third of PSS patients experienced seizure recurrence within one year. The predictors of recurrent PSS were younger age, presence of convulsions and VPA monotherapy. Our findings should be interpreted cautiously in countries where monotherapy with second-generation AEDs has been approved because this study was conducted while second-generation AEDs had not been officially approved for monotherapy in Japan. PMID:26309124

  18. Preventing Relapse/Recurrence in Recurrent Depression With Cognitive Therapy: A Randomized Controlled Trial

    ERIC Educational Resources Information Center

    Bockting, Claudi L. H.; Schene, Aart H.; Spinhoven, Philip; Koeter, Maarten W. J.; Wouters, Luuk F.; Huyser, Jochanan; Kamphuis, Jan H.

    2005-01-01

    This article reports on the outcome of a randomized controlled trial of cognitive group therapy (CT) to prevent relapse/recurrence in a group of high-risk patients diagnosed with recurrent depression. Recurrently depressed patients (N = 187) currently in remission following various types of treatment were randomized to treatment as usual,…

  19. Suicide in stroke survivors: epidemiology and prevention.

    PubMed

    Pompili, Maurizio; Venturini, Paola; Lamis, Dorian A; Giordano, Gloria; Serafini, Gianluca; Belvederi Murri, Martino; Amore, Mario; Girardi, Paolo

    2015-01-01

    Stroke is a dramatic event and is associated with potentially severe consequences, including disability, mortality, and social costs. Stroke may occur at any age; however, most strokes occur in individuals aged 65 years and older. Previous research has found that stroke increases suicide risk, especially among women and younger patients. The aim of the current review is to investigate the relationship between suicide and stroke in order to determine which stroke patients are at elevated risk for suicide. Moreover, we review the literature in order to provide pharmacological treatment strategies for stroke patients at high risk of suicide. We performed a careful search to identify articles and book chapters focused on this issue, selecting only English-language articles published from 1990 to 2014 that addressed the issue of suicide after stroke and its pharmacological management. We found 12 clinical trials that explored the relationship between stroke and suicidal ideation and/or suicidal plans and 11 investigating suicide as the cause of death after stroke. We identified stroke as a significant risk factor for both suicide and suicidal ideation, especially among younger adult depressed patients in all articles, providing further support for the association between post-stroke and suicidality. Suicide risk is particularly high in the first 5 years following stroke. Depression, previous mood disorder, prior history of stroke, and cognitive impairment were found to be the most important risk factors for suicide. Selective serotonin reuptake inhibitors (SSRIs) represent the treatment of choice for stroke survivors with suicide risk, and studies in rats have suggested that carbolithium is a promising treatment in these patients. Early identification and treatment of post-stroke depression may significantly reduce suicide risk in stroke patients.

  20. Prevention and management of stroke in women.

    PubMed

    Howe, Matthew D; McCullough, Louise D

    2015-04-01

    Stroke is the leading cause of acquired disability and the third leading cause of death in women worldwide. Sex differences in risk factors, treatment response and quality of life after stroke complicate stroke management in women. Women have an increased lifetime incidence of stroke compared to men, largely due to a sharp increase in stroke risk in older postmenopausal women. Women also have an increased lifetime prevalence of stroke risk factors, including hypertension and atrial fibrillation in postmenopausal women, as well as abdominal obesity and metabolic syndrome in middle-aged women. Controversy continues over the risks of oral contraceptives, hormone therapy and surgical intervention for carotid stenosis in women. Pregnancy and the postpartum period represent a time of increased risk, presenting challenges to stroke management. Recognition of these issues is critical to improving acute care and functional recovery after stroke in women.

  1. Emerging Tools for Stroke Prevention in Atrial Fibrillation.

    PubMed

    Voukalis, Christos; Lip, Gregory Y H; Shantsila, Eduard

    2016-02-01

    Ischaemic strokes resulting from atrial fibrillation (AF) constitute a devastating condition for patients and their carers with huge burden on health care systems. Prophylactic treatment against systemic embolization and ischaemic strokes is the cornerstone for the management of AF. Effective stroke prevention requires the use of the vitamin K antagonists or non-vitamin K oral anticoagulants (NOACs). This article summarises the latest developments in the field of stroke prevention in AF and aims to assist physicians with the choice of oral anticoagulant for patients with non-valvular AF with different risk factor profile.

  2. Emerging Tools for Stroke Prevention in Atrial Fibrillation

    PubMed Central

    Voukalis, Christos; Lip, Gregory Y.H.; Shantsila, Eduard

    2016-01-01

    Ischaemic strokes resulting from atrial fibrillation (AF) constitute a devastating condition for patients and their carers with huge burden on health care systems. Prophylactic treatment against systemic embolization and ischaemic strokes is the cornerstone for the management of AF. Effective stroke prevention requires the use of the vitamin K antagonists or non-vitamin K oral anticoagulants (NOACs). This article summarises the latest developments in the field of stroke prevention in AF and aims to assist physicians with the choice of oral anticoagulant for patients with non-valvular AF with different risk factor profile. PMID:26981569

  3. Preventing stroke: the PRoFESS, ONTARGET, and TRANSCEND trial programs.

    PubMed

    Diener, Hans-Christoph

    2009-07-01

    Renin-angiotensin system blockers have been shown to reduce stroke risk, partly independent of their blood pressure-lowering effect. The PReventiOn regimen For Effectively avoiding Second Strokes (PRoFESS) trial, ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and Telmisartan Randomized AssessmeNt Study in aCE-iNtolerant subjects with cardiovascular Disease (TRANSCEND) recently showed potential benefits of the angiotensin II receptor blocker, telmisartan, in reducing secondary strokes. In PRoFESS, 20 332 ischemic stroke patients were randomized to telmisartan 80 mg versus placebo and to two antiplatelets in a 2 x 2 factorial design. After a mean exposure of 2 years, telmisartan showed a nonsignificant lower rate of recurrent stroke versus placebo [880 versus 934; hazard ratio 0.95; 95% confidence interval (CI) 0.86-1.04]. In a post-hoc analysis, from 6 months, telmisartan significantly reduced the number of strokes versus placebo (533 versus 608; hazard ratio 0.88; 95% CI 0.78-0.99; P = 0.042). In the stroke subgroup of ONTARGET, telmisartan 80 mg showed a trend toward reducing recurrent stroke versus ramipril 10 mg (hazard ratio 0.91; 95% CI 0.79-1.05). In the TRANSCEND study, 5926 patients who were intolerant to angiotensin-converting enzyme inhibitors were treated with 80 mg telmisartan or placebo. In a combined analysis of PRoFESS and TRANSCEND, the incidence of the composite of stroke, myocardial infarction, or vascular death was 12.8% for telmisartan versus 13.8% for placebo (hazard ratio 0.91; 95% CI 0.85-0.98; P = 0.013).

  4. Recurrence of spinal schwannoma: Is it preventable?

    PubMed Central

    Senapati, Satya B.; Mishra, Sudhansu S.; Dhir, Manmath K.; Patnaik, Ashis; Panigrahi, Souvagya

    2016-01-01

    Spinal schwannomas account for about 25% of primary intradural spinal cord tumors in adult. The prognosis for spinal schwannomas is excellent in most cases. Complete resection is curative. However following subtotal removal, recurrence develops after several years. We describe a case of recurrent spinal schwannoma who had been operated twice before for same disease. The possible cause of recurrence and difficulties in reoperation are discussed. PMID:27695564

  5. Recurrent Embolic Strokes of Undetermined Source in a Patient with Extreme Lipoprotein(a) Levels.

    PubMed

    Bulwa, Zachary; Kim, Audrey; Singh, Karandeep; Kantorovich, Alexander; Suhail, Faten

    2016-01-01

    Lipoprotein(a) is a plasma lipoprotein and known cardiovascular risk factor, most recently implicated in the development of high-risk carotid atherosclerotic plaques without significant carotid stenosis. We present a case of a young African-American female with recurrent embolic strokes of undetermined source. After our thorough investigation, we identified the link between a small, irregular plaque in the right internal carotid artery, and an extremely elevated plasma level of lipoprotein(a) as the source of her embolic strokes.

  6. Antiplatelet therapy for preventing stroke in patients with chronic kidney disease.

    PubMed

    Kim, Suk Jae; Bang, Oh Young

    2013-01-01

    Chronic kidney disease (CKD), defined as reduced glomerular filtration rate and/or proteinuria, is a serious worldwide health problem. The incidence and prevalence of CKD are increasing with age, and patients with CKD are a population at very high risk for developing stroke. CKD may increase the risk for incident stroke independent of conventional stroke risk factors. A common pathological process including anemia, homocysteine, nitric oxide, oxidative stress, inflammation, and conditions promoting coagulation may be related to the development of stroke in the course of CKD. CKD can also serve as a marker of brain injury, because the cerebral microvascular system has similar hemodynamic features with the vascular beds of the kidney. CKD has been linked with markers of cerebral small artery disease including white matter lesions, lacunar infarctions, and cerebral microbleeds. CKD has been implicated with neurological deterioration during hospitalization, poor functional outcome, and hemorrhagic transformation in patients with acute stroke. Recurrence of stroke may also be higher in CKD patients compared with those having normal kidney function. However, there have been no specific recommendations for antiplatelet therapy in patients with ischemic stroke plus CKD. As CKD patients have distinct characteristics including high bleeding complications and poor response to antiplatelet agents, selecting and adjusting platelet aggregation inhibitors should be individualized. In addition, it should be noted that aspirin may aggravate renal dysfunction. Phosphodiesterase inhibitors restore endothelial dysfunction and may serve as a target for preventing stroke in CKD patients. Aside from antiplatelet therapy, other treatments including lipid control, blood pressure lowering, and renal transplantation are also important. Further studies are warranted for optimal treatment in stroke prevention in CKD patients.

  7. Recurrent Stroke with Rapid Development of Intracranial Stenoses in Polycythemia Vera.

    PubMed

    Crespo, Ane M; Abraira, Laura; Guanyabens, Nicolau; Millán, Mónica; Munuera, Josep; Dávalos, Antoni; López-Cancio, Elena

    2016-04-01

    Polycythemia vera (PV) is a blood disorder in which the first expression may be an ischemic stroke. Stroke mechanism in PV is usually attributed to a hypercoagulability state and blood stasis. We report a case of a patient with PV presenting with recurrent ischemic stroke associated with the development of large intracranial stenosis in a period of 1 month. Stenosis was associated with microembolic signals detected by transcranial Doppler. One year later and after hematocrit control, stenosis persisted but microembolic signals disappeared. We discuss similar reports in the literature and the possible pathophysiological mechanism of large-vessel damage in these patients.

  8. Apixaban for the prevention of stroke in atrial fibrillation.

    PubMed

    Littrell, Rachel; Flaker, Greg

    2012-02-01

    Until recently, pharmaceutical options for stroke prevention in atrial fibrillation were restricted to aspirin or vitamin K antagonist therapy. In recent years development has been underway for alternatives. Apixaban, a direct Factor Xa inhibitor, is orally dosed, target selective and has few known drug or food interactions. As such, it is a member of a new generation of anticoagulants expected to revolutionize the way we approach anticoagulation for stroke prevention in atrial fibrillation. Apixaban has been studied in Phase II and Phase III trials for a variety of indications. The AVERROES trial established apixaban as superior to aspirin for stroke reduction in patients with atrial fibrillation for whom vitamin K antagonist therapy is unsuitable. The recent ARISTOTLE trial found apixaban to be superior to warfarin for stroke prevention in a wide range of patients with atrial fibrillation, with significantly lower bleeding risk, and lower risk of all-cause mortality.

  9. Diabetes - preventing heart attack and stroke

    MedlinePlus

    Diabetes complications - heart; Coronary artery disease - diabetes; CAD - diabetes; Cerebrovascular disease - diabetes ... People with diabetes have a higher chance of having heart attacks and strokes. Smoking and having high blood pressure and high ...

  10. A Practical Approach to Preventing Postoperative Recurrence in Crohn's Disease.

    PubMed

    Hashash, Jana G; Regueiro, Miguel

    2016-05-01

    Postoperative Crohn's disease recurrence remains common, and preventing additional surgery remains a challenge. A critical step to postoperative management of Crohn's disease is being able to identify patients who should receive immediate postoperative therapy from the patients who can wait for recurrence prior to starting medications. All patients, regardless of their risk for recurrence, are advised to undergo a colonoscopy at 6 to 12 months after surgery to evaluate for endoscopic evidence of Crohn's disease. Further management of patients depends on symptoms and the presence or absence of endoscopic recurrence.

  11. Prevention strategies for cardioembolic stroke: present and future perspectives.

    PubMed

    Giacalone, Giacomo; Abbas, Mohammed Abballa; Corea, Francesco

    2010-06-15

    Atrial fibrillation (AF) is the most common cause of cardioembolism. An update on secondary prevention strategies, used to protect patients from the risk of stroke in many common cardiac conditions, is presented in the paper. The main line of actions of stroke prevention in cardioembolism is mostly connected with antithrombotic drugs, but also other, more invasive, techniques are quickly emerging. Also the classic pharmacological prevention with coumarins may soon be overcome by new generation anticoagulants. Is an aggressive treatment of Patent Foramen Ovale (PFO) always recommended? One of the main challenges of the future years will be to understand competitiveness between old and new preventive strategies.

  12. Can Blood Pressure Be Lowered Safely in Older Adults with Lacunar Stroke? The Secondary Prevention of Small Subcortical Strokes Study Experience

    PubMed Central

    White, Carole L.; Szychowski, Jeff M.; Pergola, Pablo E.; Field, Thalia S.; Talbert, Robert; Lau, Helena; Peri, Kalyani; Benavente, Oscar R.

    2015-01-01

    OBJECTIVES To determine safety and tolerability of lowering blood pressure in older adults with lacunar stroke. DESIGN Cohort study. SETTING The Secondary Prevention of Small Subcortical Strokes (SPS3) Trial, which compared the efficacy of two systolic blood pressure (SBP) targets (<130 mmHg and 130–149 mmHg) for secondary stroke prevention. PARTICIPANTS Of 3,020 SPS3 participants, 494 aged 75 and older at baseline were used in these analyses. MEASUREMENTS Rates of side effects related to lowering SBP and clinical outcomes, including stroke recurrence and vascular death, were examined. RESULTS Older participants achieved SBP levels similar to those of younger participants (mean SBP of 125 mmHg and 137 mmHg in lower and higher SBP target groups, respectively). At least once during the approximately 3.5 years of follow-up, 21% reported dizziness, and 15% reported lightheadedness when standing; the only significant difference between the younger and older groups was unsteadiness when standing (23% vs 32% respectively, P < .001). There was no difference according to treatment group. In younger adults, recurrent stroke was less likely in the lower than the higher SBP group (hazard ratio (HR) = 0.77, 95% confidence interval (CI) = 0.59–1.01) but not in older participants (HR = 1.01, 95% CI = 0.59– 1.73), although the interaction was not significant (P = .39). The lower SBP target was associated with a significant reduction in vascular death in older participants (HR = 0.42, 95% CI = 0.18–0.98), with a significant interaction between age and SBP group (P = .049). CONCLUSION Except for unsteadiness when standing, there was no difference according to age in individuals with lacunar stroke with respect to side effects potentially related to lowering blood pressure. Although the lower SBP target was not associated with lower likelihood of recurrent stroke, these exploratory analyses suggested a possible benefit related to vascular death. PMID:25850462

  13. Antiplatelet therapy for secondary prevention of noncardioembolic ischemic stroke: a critical review.

    PubMed

    O'Donnell, Martin J; Hankey, Graeme J; Eikelboom, John W

    2008-05-01

    For patients with ischemic stroke or transient ischemic attack caused by atherothromboembolism, immediate and long-term aspirin reduces the relative risk of recurrent stroke, MI, and death attributable to vascular causes. Oral anticoagulation is not more effective than aspirin. Long-term clopidogrel reduces the relative risk of stroke, MI, or vascular death by about 9% (0.3% to 16.5%) compared with aspirin. Any long-term benefits of clopidogrel combined with aspirin, compared with aspirin or clopidogrel alone, appear to be offset by increased major bleeding. The combination of aspirin and extended-release dipyridamole reduces the relative odds of stroke, MI, or vascular death by about 18% (odds ratio 0.82, 0.74 to 0.91) compared with aspirin alone without causing more bleeding. Cilostazole reduces the risk of stroke, MI, or vascular death by 39% compared to placebo. A large clinical trial comparing clopidogrel with the combination of aspirin and dipyridamole, in >20 000 patients with recent (<120 days) atherothrombotic ischemic stroke, is expected to report in 2008. Emerging antiplatelet therapies presently being evaluated for secondary prevention of atherothromboembolism include other P(2)Y(12) ADP receptor antagonists (prasugrel, cangrelor, AZD 6140), thromboxane receptor antagonists (eg, S18886 - terutroban), and thrombin receptor (PAR-1) antagonists (eg, SCH530348).

  14. Barriers to medication adherence for the secondary prevention of stroke: a qualitative interview study in primary care

    PubMed Central

    Jamison, James; Graffy, Jonathan; Mullis, Ricky; Mant, Jonathan; Sutton, Stephen

    2016-01-01

    Background Medications are highly effective at reducing risk of recurrent stroke, but success is influenced by adherence to treatment. Among survivors of stroke and transient ischaemic attack (TIA), adherence to medication is known to be suboptimal. Aim To identify and report barriers to medication adherence for the secondary prevention of stroke/TIA. Design and setting A qualitative interview study was conducted within general practice surgeries in the East of England, UK. Method Patients were approached by letter and invited to take part in a qualitative research study. Semi-structured interviews were undertaken with survivors of stroke, caregivers, and GPs to explore their perspectives and views around secondary prevention and perceived barriers to medication adherence. Key themes were identified using a grounded theory approach. Verbatim quotes describing the themes are presented here. Results In total, 28 survivors of stroke, including 14 accompanying caregivers and five GPs, were interviewed. Two key themes were identified. Patient level barriers included ability to self-care, the importance people attach to a stroke event, and knowledge of stroke and medication. Medication level barriers included beliefs about medication and beliefs about how pills work, medication routines, changing medications, and regimen complexity and burden of treatment. Conclusion Patients who have had a stroke are faced with multiple barriers to taking secondary prevention medications in UK general practice. This research suggests that a collaborative approach between caregivers, survivors, and healthcare professionals is needed to address these barriers and facilitate medication-taking behaviour. PMID:27215572

  15. What Is the Future of Stroke Prevention?

    PubMed Central

    Kernan, Walter N.; Launer, Lenore J.; Goldstein, Larry B.

    2016-01-01

    Background and Purpose The control of stroke risk factors remains challenging. The “polypill” concept represents a novel approach for reducing stroke and cardiovascular risk factors in the entire population. The polypill would include several components and be provided without prescription to all adults of a certain age. Results A polypill aimed at lowering blood pressure and cholesterol levels is estimated to potentially reduce the risk of a first ischemic stroke by 53%; this would translate to about 400 000 fewer strokes each year in the United States alone. Recommending a polypill for the entire older adult population would, however, include many individuals without the multiple risk factors targeted by its components, putting them at risk for drug-related side effects and responsible for the costs of a medication from which they would not derive benefit. Additional arguments for and against the polypill approach are discussed. Conclusions Only clinical trials can provide the evidence needed to determine the usefulness of the polypill approach. Issues related to defining the components of the polypill, evaluating the pharmacodynamics and pharmacokinetics of a multiple-component formulation, and establishing safety and cost-effectiveness when given to large populations, however, are not trivial. PMID:20876501

  16. Treatment Challenges of a Primary Vertebral Artery Aneurysm Causing Recurrent Ischemic Strokes

    PubMed Central

    Peruzzotti-Jametti, Luca; Fanelli, Giovanna; Simionato, Franco; Chiesa, Roberto; Rinaldi, Enrico; Comi, Giancarlo; Sessa, Maria

    2017-01-01

    Background. Extracranial vertebral artery aneurysms are a rare cause of embolic stroke; surgical and endovascular therapy options are debated and long-term complication may occur. Case Report. A 53-year-old man affected by neurofibromatosis type 1 (NF1) came to our attention for recurrent vertebrobasilar embolic strokes, caused by a primary giant, partially thrombosed, fusiform aneurysm of the left extracranial vertebral artery. The aneurysm was treated by endovascular approach through deposition of Guglielmi Detachable Coils in the proximal segment of the left vertebral artery. Six years later the patient presented stroke recurrence. Cerebral angiography and Color Doppler Ultrasound well characterized the unique hemodynamic condition developed over the years responsible for the new embolic event: the aneurysm had been revascularized from its distal portion by reverse blood flow coming from the patent vertebrobasilar axis. A biphasic Doppler signal in the left vertebral artery revealed a peculiar behavior of the blood flow, alternately directed to the aneurysm and backwards to the basilar artery. Surgical ligation of the distal left vertebral artery and excision of the aneurysm were thus performed. Conclusion. This is the first described case of NF1-associated extracranial vertebral artery aneurysm presenting with recurrent embolic stroke. Complete exclusion of the aneurysm from the blood circulation is advisable to achieve full resolution of the embolic source. PMID:28168068

  17. Update on Antithrombotic Therapy for Stroke Prevention in Atrial Fibrillation

    PubMed Central

    Ovbiagele, Bruce

    2010-01-01

    Opinion statement Atrial fibrillation (AF) is the most common cardiac arrhythmia in the elderly, affecting 1 in 20 adults over the age of 70 years. Stroke is a major yet highly preventable complication of AF, and the strokes related to AF often are disabling and fatal. Warfarin is the treatment of choice in high-risk patients with AF, and its superior efficacy over aspirin for preventing stroke in these patients is widely recognized. However, several eligible patients with AF are not being treated with warfarin or are being treated inadequately, largely because of concerns regarding the attendant strict monitoring, drug interactions, and risk of major bleeding. As such, alternative antithrombotic therapies that can rival or exceed the efficacy of warfarin, yet compare favorably with its administration and side effect profile, are being sought. One such strategy, the use of a combination antiplatelet regimen, for stroke prevention in high-risk patients with nonvalvular AF was investigated recently in two clinical trials. This article reviews the role of combination antiplatelet regimens in stroke prevention for patients with AF. Other therapies discussed include oral anticoagulation, single antiplatelet therapies, oral anticoagulation plus antiplatelet treatment, direct thrombin inhibitors, and factor Xa inhibitors. PMID:20461116

  18. Diagnosis, prevention and treatment of postoperative Crohn's disease recurrence.

    PubMed

    Buisson, Anthony; Chevaux, Jean-Baptiste; Bommelaer, Gilles; Peyrin-Biroulet, Laurent

    2012-06-01

    Ileocolonoscopy remains the gold standard in diagnosing postoperative recurrence. After excluding stricture, wireless capsule endoscopy seemed accurate in small series, but no validated score is available. Ultrasonography is a non-invasive diagnostic method reducing radiation exposure and emerging as an alternative tool for identifying post-operative recurrence. Computed tomography enteroclysis yields objective morphologic criteria that help differentiate between recurrent disease and fibrostenosis at the anastomotic site, but ionising radiation exposure limits its use. Magnetic resonance imaging may be as powerful as ileocolonoscopy in diagnosing postoperative recurrence and in predicting the clinical outcome using specific MR-scores. Biomarkers such as faecal calprotectin and faecal lactoferrin showed promising results, but their specificity in the postoperative period will require further investigation. Numerous medications have been tested to prevent and/or to treat postoperative recurrence. Efficacy of mesalamine is very low and comparable to placebo in most series. Thiopurines have modest efficacy in the postoperative setting and are associated with a high rate of adverse events leading to drug withdrawal. Antibiotics such as metronidazole or ornidazole may be effective, but toxicity and drug resistance prevent their long-term use. Anti-Tumour Necrosis Factor therapy is the most potent drug class to prevent and to treat postoperative recurrence in Crohn's disease.

  19. Addressing Disparities in Stroke Prevention for Atrial Fibrillation: Educational Opportunities.

    PubMed

    Karcher, Rachel; Berman, Adam E; Gross, Hartmut; Hess, David C; Jauch, Edward C; Viser, Paul E; Solenski, Nina J; Wolf, Andrew M D

    2016-07-01

    Disparities in atrial fibrillation (AF)-related stroke and mortality persist, especially racial disparities, within the US "Stroke Belt." This study identified barriers to optimal stroke prevention to develop a framework for clinician education. A comprehensive educational needs assessment was developed focusing on clinicians within the Stroke Belt. The mixed qualitative-quantitative approach included regional surveys and one-on-one clinician interviews. Identified contributors to disparities included implicit racial biases, lack of awareness of racial disparities in AF stroke risk, and lack of effective multicultural awareness and training. Additional barriers affecting disparities included patient medical mistrust and clinician-patient communication challenges. General barriers included lack of consistency in assessing stroke and anticoagulant-related bleeding risk, underuse of standardized risk assessment tools, discomfort with novel anticoagulants, and patient education deficiencies. Effective cultural competency training is one strategy to reduce disparities in AF-related stroke and mortality by improving implicit clinician bias, addressing medical mistrust, and improving clinician-patient communication.

  20. Orthopantomography contribution to prevent isquemic stroke

    PubMed Central

    Chimenos-Küstner, Eduardo; López-López, osé

    2014-01-01

    Objectives: The ortopantomography (OPG) can be a valuable way for an early detection of calcified atheroma plaques, thus contributing for a preliminary stroke risk evaluation. The study looks for the existence of calcified atheroma plates through the use of OPG, comparing the results with the stenosis percentage found through eco-doppler. It has been analyzed the correlation of the number of years as a smoker, arterial hypertension and body mass index, against the risk of having calcified atheroma plaques. Study Design: Observational, transversal and prospective study with 84 patients from the Dental Center of Hospital Particular de Lisboa. First the patients answered to an inquiry and them they were submitted to an OPG and an eco-doppler. Results and Conclusions: It is possible to detect calcified atheroma plaques in the carotid artery through an OPG and patients who have them have got a fifteen fold greater risk of suffering from carotid stenosis. In this study, it has been confirmed the increase in carotid stenosis for long term smokers (OR = 1,033, n=18, 42,9%). The study results show that hypertension patients have a probability 5,426 greater than normal of developing atheroma plaques (with sig=0,049). Amid analyzed patients, the correlation between obesity and the existence of carotid atheroma plaques was significant, although negative (sig=0,047). OPG can help find patients with higher risk of isquemic stroke. Key words:Orthopantomography, Stroke, Carotid disease, Calcified atheroma. PMID:24790711

  1. Homocysteine-lowering therapy: a role in stroke prevention?

    PubMed

    Spence, J David

    2007-09-01

    On the basis of the results of several recent clinical trials, many researchers have concluded that vitamin therapy designed to lower total homocysteine concentrations is not effective in reducing the risk of cardiovascular events. However, whereas almost all myocardial infarctions are due to plaque rupture, stroke has many more pathophysiological mechanisms, and thrombosis-which is increased by raised total homocysteine concentrations-has an important role in many of these processes. Thus, stroke and myocardial infarction could respond differently to vitamin therapy. A detailed assessment of the results of the recent HOPE-2 trial and a reanalysis of the VISP trial restricted to patients capable of responding to vitamin therapy suggest that higher doses of vitamin B12 and perhaps new approaches to lowering total homocysteine besides routine vitamin therapy with folate, vitamin B6, and vitamin B12 could reduce the risk of stroke. Thus, therapy to lower homocysteine could still help to prevent stroke, if not other vascular outcomes.

  2. Prevention and Treatment of Recurrent Hepatitis B after Liver Transplantation

    PubMed Central

    Maiwall, Rakhi; Kumar, Manoj

    2016-01-01

    Chronic hepatitis B is a global health problem that leads to development of various complications, such as cirrhosis, liver cancer, and liver failure requiring liver transplantation. The recurrence of hepatitis B virus (HBV) post-liver transplantation is a major cause of allograft dysfunction, cirrhosis of the allograft, and graft failure. Patients with high viral load at the time of transplantation, hepatitis B e antigen (HBeAg) positivity, or those with a history of anti-viral drug resistance are considered as high-risk for recurrent HBV post-liver transplantation, while patients with low viral load, including HBeAg negative status, acute liver failure, and hepatitis D virus (HDV) co-infection are considered to be at low-risk for recurrent HBV post-liver transplantation. Antivirals for patients awaiting liver transplantation(LT) cause suppression of HBV replication and reduce the risk of recurrent HBV infection of the allograft and, therefore, all HBV patients with decompensated cirrhosis should be treated with potent antivirals with high genetic barrier to resistance (entecavir or tenofovir) prior to liver transplantation. Prevention of post-liver transplantation recurrence should be done using a combination of hepatitis B immunoglobulin (HBIG) and antivirals in patients at high risk of recurrence. Low dose HBIG, HBIG-free protocols, and monoprophylaxis with high potency antivirals can still be considered in patients at low risk of recurrence. Even, marginal grafts from anti-HBc positive donors can be safely used in hepatitis B surface antigen (HBsAg) negative, preferably in anti-hepatitis B core (HBc)/anti-hepatitis B surface (HBs) positive recipients. In this article, we aim to review the mechanisms and risk factors of HBV recurrence post-LT in addition to the various treatment strategies proposed for the prevention of recurrent HBV infection PMID:27047773

  3. Stroke Prevention in Atrial Fibrillation: Focus on Latin America

    PubMed Central

    Massaro, Ayrton R.; Lippp, Gregory Y. H.

    2016-01-01

    Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with an estimated prevalence of 1-2% in North America and Europe. The increased prevalence of AF in Latin America is associated with an ageing general population, along with poor control of key risk factors, including hypertension. As a result, stroke prevalence and associated mortality have increased dramatically in the region. Therefore, the need for effective anticoagulation strategies in Latin America is clear. The aim of this review is to provide a contemporary overview of anticoagulants for stroke prevention. The use of vitamin K antagonists (VKAs, eg, warfarin) and aspirin in the prevention of stroke in patients with AF in Latin America remains common, although around one fifth of all AF patients receive no anticoagulation. Warfarin use is complicated by a lack of access to effective monitoring services coupled with an unpredictable pharmacokinetic profile. The overuse of aspirin is associated with significant bleeding risks and reduced efficacy for stroke prevention in this patient group. The non-VKA oral anticoagulants (NOACbs) represent a potential means of overcoming many limitations associated with VKA and aspirin use, including a reduction in the need for monitoring and a reduced risk of hemorrhagic events. The ultimate decision of which anticoagulant drug to utilize in AF patients depends on a multitude of factors. More research is needed to appreciate the impact of these factors in the Latin American population and thereby reduce the burden of AF-associated stroke in this region. PMID:27533256

  4. Novel oral anticoagulants in secondary prevention of stroke.

    PubMed

    Diener, H C; Easton, J D; Hankey, G J; Hart, R G

    2013-06-01

    In patients with atrial fibrillation (AF) oral anticoagulation with vitamin-K antagonists (warfarin, phenprocoumon) is effective both for primary and secondary stroke prevention yielding a 60-70% relative reduction in stroke risk compared with placebo, as well as a mortality reduction of 26 percent. Vitamin-K antagonists have a number of well documented shortcomings. Recently the results of randomised trials for three new oral anticoagulants that do not exhibit the limitations of vitamin-K antagonists have been published. These include direct factor Xa inhibitors (rivaroxaban and apixaban) and a direct thrombin inhibitor (dabigatran). The studies (RE-LY, ROCKET-AF, ARISTOTLE, AVERROES) provide promising results for the new agents, including higher efficacy and a significantly lower incidence of intracranial bleeds compared with warfarin or aspirin. The new drugs show similar results in secondary as well as in primary stroke prevention in patients with AF. Apixaban was demonstrated to be clearly superior to aspirin and had the same rate of major bleeding complications. Meta-analyses show that the novel anticoagulants are superior to warfarin for the reduction of stroke, major bleeding and intracranial bleeds. New anticoagulants add to the therapeutic options for patients with AF, and offer a number of advantages over warfarin, for both the clinician and patient, including a favorable bleeding profile and convenience of use. Aspirin is no longer an option in secondary stroke prevention in patients with atrial fibrillation. Consideration of these new anticoagulants will improve clinical decision making.

  5. Free Floating Thrombus in Carotid Artery in a Patient with Recurrent Strokes.

    PubMed

    Roy, Moni; Roy, Ashish Kumar; DeSanto, Jeffrey R; Abdelsalam, Murad

    2017-01-01

    We present a case of 72-year-old male with reported past medical history of recurrent transient ischemic attacks (TIAs) presenting with myriad of neurological symptoms. Patient was transferred from outlying hospital with complaints of right sided facial droop and dysarthria. Computed tomography angiography (CTA) showed high grade proximal left internal carotid artery (ICA) stenosis along with interesting finding of a free floating thrombus (FFT) in the left ICA. After discussion with the neurosurgical team, our case was treated conservatively with combination of antiplatelet therapy with Aspirin and anticoagulation with Warfarin without recurrence of TIAs or strokes on six-month follow-up.

  6. Bilateral Vertebral Artery Aneurysms at the Atlantoaxial Joint Level Causing Recurrent Stroke

    PubMed Central

    Komatsu, Kenichi; Ozaki, Akihiko; Iwasaki, Koichi; Matsumoto, Sadayuki

    2016-01-01

    Vertebral arteries (VAs) are vulnerable to mechanical stress between the atlas and axis, and subsequent VA dissection can cause posterior circulation infarction. We herein present a rare but informative case of bilateral VA aneurysms that caused recurrent stroke. The localization of the aneurysms and dynamic angiography with neck movement suggested a pathogenesis related to chronic mechanical injury of the VAs, though no skeletal abnormality was detected. The recurrences stopped and both aneurysms shrank after neck collar fixation and after the combination use of antithrombotics. For patients with posterior circulation infarction of unknown origin, a careful evaluation of VAs with physicians paying special attention to the atlantoaxial joint level is therefore recommended. PMID:27853085

  7. Free Floating Thrombus in Carotid Artery in a Patient with Recurrent Strokes

    PubMed Central

    Roy, Ashish Kumar; DeSanto, Jeffrey R.

    2017-01-01

    We present a case of 72-year-old male with reported past medical history of recurrent transient ischemic attacks (TIAs) presenting with myriad of neurological symptoms. Patient was transferred from outlying hospital with complaints of right sided facial droop and dysarthria. Computed tomography angiography (CTA) showed high grade proximal left internal carotid artery (ICA) stenosis along with interesting finding of a free floating thrombus (FFT) in the left ICA. After discussion with the neurosurgical team, our case was treated conservatively with combination of antiplatelet therapy with Aspirin and anticoagulation with Warfarin without recurrence of TIAs or strokes on six-month follow-up. PMID:28163720

  8. Patent Foramen Ovale Closure and Medical Treatments for Secondary Stroke Prevention A Systematic Review of Observational and Randomized Evidence

    PubMed Central

    Kitsios, Georgios D.; Dahabreh, Issa J.; Abu Dabrh, Abd Moain; Thaler, David E.; Kent, David M.

    2012-01-01

    Background and Purpose Patients discovered to have a patent foramen ovale in the setting of a cryptogenic stroke may be treated with percutaneous closure, antiplatelet therapy, or anticoagulants. A recent randomized trial (CLOSURE I) did not detect any benefit of closure over medical treatment alone; the optimal medical therapy is also unknown. We synthesized the available evidence on secondary stroke prevention in patients with patent foramen ovale and cryptogenic stroke. Methods A MEDLINE search was performed for finding longitudinal studies investigating medical treatment or closure, meta-analysis of incidence rates (IR), and IR ratios of recurrent cerebrovascular events. Results Fifty-two single-arm studies and 7 comparative nonrandomized studies and the CLOSURE I trial were reviewed. The summary IR of recurrent stroke was 0.36 events (95% CI, 0.24–0.56) per 100 person-years with closure versus 2.53 events (95% CI, 1.91–3.35) per 100 person-years with medical therapy. In comparative observational studies, closure was superior to medical therapy (IR ratio=0.19; 95% CI, 0.07–0.54). The IR for the closure arm of the CLOSURE I trial was higher than the summary estimate from observational studies; there was no significant benefit of closure over medical treatment (P=0.002 comparing efficacy estimates between observational studies and the trial). Observational and randomized data (9 studies) comparing medical therapies were consistent and suggested that anticoagulants are superior to antiplatelets for preventing stroke recurrence (IR ratio=0.42; 95% CI, 0.18–0.98). Conclusions Although further randomized trial data are needed to precisely determine the effects of closure on stroke recurrence, the results of CLOSURE I challenge the credibility of a substantial body of observational evidence strongly favoring mechanical closure over medical therapy. PMID:22180252

  9. Recurrent Stroke Due to Metastatic Pulmonary Tumor Emboli as an Important Clinical Entity.

    PubMed

    Takasugi, Junji; Sakaguchi, Manabu; Oyama, Naoki; Gon, Yasufumi; Terasaki, Yasukazu; Sasaki, Tsutomu; Nakahara, Susumu; Ohshima, Kenji; Hori, Yumiko; Morii, Eiichi; Mochizuki, Hideki

    2017-03-30

    We present an autopsy case of repetitive stroke due to tumor emboli, indistinguishable from thromboembolism with a hypercoagulable state in its clinical course. A 72-year-old man diagnosed with stage IVA oropharyngeal squamous cell carcinoma received chemoradiotherapy. Follow-up imaging revealed mediastinal lymph nodes and pulmonary metastasis. One year later, the patient experienced right arm weakness, and brain magnetic resonance imaging showed acute ischemic lesions in multiple vascular territories. He was diagnosed with paradoxical cerebral embolism due to cancer-associated venous thrombosis and treated with rivaroxaban. However, newly developed cerebral infarcts were confirmed 1 month later. Then, rivaroxaban treatment was switched to subcutaneous unfractionated heparin injection. He was admitted again for stroke recurrence and died of respiratory failure 8 days after admission. Autopsy demonstrated pulmonary metastasis invading the veins and tumor emboli in the culprit cerebral arteries. D-dimer was kept constant at a slightly higher level, ranging from 1 to 3 µg/mL during the course of recurrence. We should consider tumor embolism in the differential diagnosis of recurrent stroke along with pulmonary tumor and resistance to heparin preparations with unchanged D-dimer levels.

  10. An 18-year-old man with fenestrated vertebral arteries, recurrent stroke and successful angiographic coiling

    PubMed Central

    Bernard, Timothy J.; Mull, Brendan R.; Handler, Michael H.; Harned, Roger K.; Filley, Christopher M.; Kumpe, David A.; Tseng, Brian S.

    2010-01-01

    Fenestration of vertebral arteries has been reported in association with thromboembolic brain infarctions. However, few cases have been reported in which recurrent infarction occurred in spite of adequate anticoagulation. We report a young man with fenestrated vertebral arteries and stroke who failed to respond to standard anticoagulation therapy but did well with angiographic coil obliteration of an abnormal vertebral segment. An 18-year-old left-handed man presented with acute onset of dizziness and headache. No trauma or other stroke risk factors were identified. Left cerebellar infarction was seen on CT, but the cause could not be identified by brain and neck MRI, MRA, or CTA. Bilateral fenestrated vertebral arteries were identified with conventional angiography. Although the patient recovered fully and was treated with anticoagulation, he suffered a recurrent stroke 1 month later involving the right cerebellum while he was on a therapeutic dose of warfarin. Repeat arteriography showed a spontaneous dissection within one of the fenestrated vertebral segments. Since receiving angiographic coil obliteration of the pathologic segment, he has been free of all symptoms. We conclude that the patient sustained recurrent thromboembolic events in his posterior circulation due to spontaneous dissection within a fenestrated vertebral artery segment. Conventional angiography and emergent interventional embolization were essential to his diagnostic evaluation and therapeutic intervention. PMID:17568613

  11. [New anticoagulants for stroke prevention in atrial fibrillation].

    PubMed

    Diener, H C; Hajjar, K; Frank, B; Perrey, M

    2012-06-01

    Oral anticoagulation with vitamin K antagonists (warfarin, phenprocoumon) is successful in both primary and secondary stroke prevention for patients with atrial fibrillation (AF), yielding a 60-70% relative reduction in stroke risk compared with placebo and a mortality reduction of 26%. However, these agents have a number of well documented shortcomings. This review describes the current landscape and developments in stroke prevention in patients with AF with special reference to secondary prevention. A number of new drugs for oral anticoagulation that do not exhibit the limitations of vitamin K antagonists are under investigation. These include direct factor Xa inhibitors and direct thrombin inhibitors. Recent studies (RE-LY, ROCKET-AF, AVERROES, ARISTOTLE) provide promising results for these new agents including higher efficacy and significantly lower incidences of intracranial bleeding compared with warfarin. The new substances show similar results in secondary as well as in primary stroke prevention in patients with AF. The new anticoagulants add to the therapeutic options for patients with AF and offer a number of advantages over warfarin for both clinician and patient, including a favorable bleeding profile and convenience of use. Consideration of these new anticoagulants will improve clinical decision-making.

  12. Eyeglass frame allergic contact dermatitis: does tacrolimus prevent recurrences?

    PubMed

    Nakada, Tokio; Iijima, Masafumi; Maibach, Howard I

    2005-10-01

    A 35-year-old man developed well-demarcated, oedematous and erosive erythematous lesions on the nasal bridge and retroauricular regions bilaterally. His eyeglass frame was repaired by an optician 2 weeks prior to symptom onset. Patch testing revealed a positive reaction to scrapings of nose pads and temples of the frame in petrolatum. Because the patient did not take our exhortation to change eyeglass frames, we advised him to cover their nose pads and temples with vinyl tape to prevent direct skin contact. Although topical corticosteroid therapy produced clinical resolution temporally, recurrences were not prevented. After starting tacrolimus ointment therapy, recurrence has not occurred for 9 months. Tacrolimus may be effective for allergic contact dermatitis patients who cannot avoid repeated allergen exposure, as it may not only reduce inflammation but inhibit recurrences.

  13. Cost considerations in the pharmacological prevention and treatment of stroke.

    PubMed

    Alexandrov, A V; Smurawska, L T; Bartle, W; Oh, P

    1997-05-01

    Stroke remains the leading cause of neurological disability and the third leading cause of death worldwide, consuming a large share of total healthcare expenditures. In this review, we discuss the cost effectiveness of stroke prevention for various risk factor-modification programmes and pharmacological interventions with aspirin (acetylsalicylic acid), ticlopidine and warfarin. Cost considerations and potential cost savings resulting from acute treatment are discussed for parenterally administered anticoagulants, such as heparin and nadroparin, and for intravenous thrombolysis with alteplase (recombinant tissue plasminogen activator; r-tPA). Patients with multiple risk factors for stroke require more aggressive prevention strategies which are associated with a greater risk of complications. The rates of complications, particularly intracerebral haemorrhage, should be kept low to achieve cost benefits for warfarin and alteplase. Reduced hospital length of stay is the key factor in the implementation of cost-effective stroke therapies. The analysis of future clinical trials of new stroke therapies should also include economic parameters, such as length of hospital stay and intensity of resource usage, to help guide formulary and therapeutic decision.

  14. Recurrent Strokes due to Transient Vasospasms of the Extracranial Internal Carotid Artery

    PubMed Central

    Wöpking, Sigrid; Kastrup, Andreas; Lentschig, Markus; Brunner, Freimuth

    2013-01-01

    Vasospasms of the intracranial arteries are a well-known complication of subarachnoid hemorrhage and are also frequently encountered in other disorders such as migraine, cerebral vasculitis or reversible cerebral vasoconstriction syndrome. In contrast, recurrent spontaneous vasospasms of the extracranial circulation appear to be extremely rare and have most often been associated with migraine. We present a patient with recurrent strokes due to spontaneous transient vasospastic occlusions of the internal carotid artery (ICA) without migraine over a time period of at least 13 years. Initially, the patient had presented with a bilateral ICA occlusion and a cerebral infarct on the right side. While the right ICA remained occluded, a reopening of the left ICA could be detected 3 days after this initial event. In subsequent years, both duplex sonography and magnetic resonance angiography revealed recurrent occlusions of the left ICA, which resolved spontaneously within days. This case and other rare previous reports indicate that recurrent non-migrainous vasospasms of the extracranial carotid artery likely reflect a distinct entity which can cause ischemic strokes. PMID:24052791

  15. Secondary prevention and cognitive function after stroke: a study protocol for a 5-year follow-up of the ASPIRE-S cohort

    PubMed Central

    Williams, David; Gaynor, Eva; Bennett, Kathleen; Dolan, Eamon; Callaly, Elizabeth; Large, Margaret; Hickey, Anne

    2017-01-01

    Introduction Cognitive impairment is common following stroke and can increase disability and levels of dependency of patients, potentially leading to greater burden on carers and the healthcare system. Effective cardiovascular risk factor control through secondary preventive medications may reduce the risk of cognitive decline. However, adherence to medications is often poor and can be adversely affected by cognitive deficits. Suboptimal medication adherence negatively impacts secondary prevention targets, increasing the risk of recurrent stroke and further cognitive decline. The aim of this study is to profile cognitive function and secondary prevention, including adherence to secondary preventive medications and healthcare usage, 5 years post-stroke. The prospective associations between cognition, cardiovascular risk factors, adherence to secondary preventive medications, and rates of recurrent stroke or other cardiovascular events will also be explored. Methods and analysis This is a 5-year follow-up of a prospective study of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) cohort of patients with stroke. This cohort will have a detailed assessment of cognitive function, adherence to secondary preventive medications and cardiovascular risk factor control. Ethics and dissemination Ethical approval for this study was granted by the Research Ethics Committees at Beaumont Hospital, Dublin and Connolly Hospital, Dublin, Mater Misericordiae University Hospital, Dublin, and the Royal College of Surgeons in Ireland. Findings will be disseminated through presentations and peer-reviewed publications. PMID:28348196

  16. Secondary preventive medication persistence and adherence 1 year after stroke

    PubMed Central

    Olson, D.M.; Zhao, X.; Pan, W.; Zimmer, L.O.; Goldstein, L.B.; Alberts, M.J.; Fagan, S.C.; Fonarow, G.C.; Johnston, S.C.; Kidwell, C.; LaBresh, K.A.; Ovbiagele, B.; Schwamm, L.; Peterson, E.D.

    2011-01-01

    Objective: Data on long-term use of secondary prevention medications following stroke are limited. The Adherence eValuation After Ischemic stroke–Longitudinal (AVAIL) Registry assessed patient, provider, and system-level factors influencing continuation of prevention medications for 1 year following stroke hospitalization discharge. Methods: Patients with ischemic stroke or TIA discharged from 106 hospitals participating in the American Heart Association Get With The Guidelines–Stroke program were surveyed to determine their use of warfarin, antiplatelet, antihypertensive, lipid-lowering, and diabetes medications from discharge to 12 months. Reasons for stopping medications were ascertained. Persistence was defined as continuation of all secondary preventive medications prescribed at hospital discharge, and adherence as continuation of prescribed medications except those stopped according to health care provider instructions. Results: Of the 2,880 patients enrolled in AVAIL, 88.4% (2,457 patients) completed 1-year interviews. Of these, 65.9% were regimen persistent and 86.6% were regimen adherent. Independent predictors of 1-year medication persistence included fewer medications prescribed at discharge, having an adequate income, having an appointment with a primary care provider, and greater understanding of why medications were prescribed and their side effects. Independent predictors of adherence were similar to those for persistence. Conclusions: Although up to one-third of stroke patients discontinued one or more secondary prevention medications within 1 year of hospital discharge, self-discontinuation of these medications is uncommon. Several potentially modifiable patient, provider, and system-level factors associated with persistence and adherence may be targets for future interventions. PMID:21900638

  17. Imaging Parameters and Recurrent Cerebrovascular Events in Patients With Minor Stroke or Transient Ischemic Attack

    PubMed Central

    Yaghi, Shadi; Rostanski, Sara K.; Boehme, Amelia K.; Martin-Schild, Sheryl; Samai, Alyana; Silver, Brian; Blum, Christina A.; Jayaraman, Mahesh V.; Siket, Matthew S.; Khan, Muhib; Furie, Karen L.; Elkind, Mitchell S. V.; Marshall, Randolph S.; Willey, Joshua Z.

    2016-01-01

    IMPORTANCE Neurological worsening and recurrent stroke contribute substantially to morbidity associated with transient ischemic attacks and strokes (TIA-S). OBJECTIVE To determine predictors of early recurrent cerebrovascular events (RCVEs) among patients with TIA-S and National Institutes of Health Stroke Scale scores of 0 to 3. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted at 2 tertiary care centers (Columbia University Medical Center, New York, New York, and Tulane University Medical Center, New Orleans, Louisiana) between January 1, 2010, and December 31, 2014. All patients with neurologist-diagnosed TIA-S with a National Institutes of Health Stroke Scale score of 0 to 3 who presented to the emergency department were included. MAIN OUTCOMES AND MEASURES The primary outcome (adjudicated by 3 vascular neurologists) was RCVE: neurological deterioration in the absence of a medical explanation or recurrent TIA-S during hospitalization. RESULTS Of the 1258 total patients, 1187 had no RCVEs and 71 had RCVEs; of this group, 750 patients (63.2%) and 39 patients (54.9%), respectively, were aged 60 years or older. There were 505 patients with TIA-S at Columbia University; 31 (6.1%) had RCVEs (15 patients had neurological deterioration only, 11 had recurrent TIA-S only, and 5 had both). The validation cohort at Tulane University consisted of 753 patients; 40 (5.3%) had RCVEs (24 patients had neurological deterioration only and 16 had both). Predictors of RCVE in multivariate models in both cohorts were infarct on neuroimaging (computed tomographic scan or diffusion-weighted imaging sequences on magnetic resonance imaging) (Columbia University: not applicable and Tulane University: odds ratio, 1.75; 95% CI, 0.82–3.74; P = .15) and large-vessel disease etiology (Columbia University: odds ratio, 6.69; 95% CI, 3.10–14.50 and Tulane University: odds ratio, 8.13; 95% CI, 3.86–17.12; P < .001). There was an increase in the percentage of

  18. A Total Pleural Covering for Lymphangioleiomyomatosis Prevents Pneumothorax Recurrence

    PubMed Central

    Kurihara, Masatoshi; Mizobuchi, Teruaki; Kataoka, Hideyuki; Sato, Teruhiko; Kumasaka, Toshio; Ebana, Hiroki; Yamanaka, Sumitaka; Endo, Reina; Miyahashira, Sumika; Shinya, Noriko; Seyama, Kuniaki

    2016-01-01

    Background Spontaneous pneumothorax is a major and frequently recurrent complication of lymphangioleiomyomatosis (LAM). Despite the customary use of pleurodesis to manage pnenumothorax, the recurrence rate remains high, and accompanying pleural adhesions cause serious bleeding during subsequent lung transplantation. Therefore, we have developed a technique of total pleural covering (TPC) for LAM to wrap the entire visceral pleura with sheets of oxidized regenerated cellulose (ORC) mesh, thereby reinforcing the affected visceral pleura and preventing recurrence. Methods Since January 2003, TPC has been applied during video-assisted thoracoscopic surgery for the treatment of LAM. The medical records of LAM patients who had TPC since that time and until August 2014 are reviewed. Results TPC was performed in 43 LAM patients (54 hemithoraces), 11 of whom required TPC bilaterally. Pneumothorax recurred in 14 hemithoraces (25.9%) from 11 patients (25.6%) after TPC. Kaplan-Meier estimates of recurrence-free hemithorax were 80.8% at 2.5 years, 71.7% at 5 years, 71.7% at 7.5 years, and 61.4% at 9 years. The recurrence-free probability was significantly better when 10 or more sheets of ORC mesh were utilized for TPC (P = 0.0018). TPC significantly reduced the frequency of pneumothorax: 0.544 ± 0.606 episode/month (mean ± SD) before TPC vs. 0.008 ± 0.019 after TPC (P<0.0001). Grade IIIa postoperative complications were found in 13 TPC surgeries (24.1%). Conclusions TPC successfully prevented the recurrence of pneumothorax in LAM, was minimally invasive and rarely caused restrictive ventilatory impairment. PMID:27658250

  19. Preeclampsia: Reflections on How to Counsel About Preventing Recurrence.

    PubMed

    Costa, Maria Laura

    2015-10-01

    Preeclampsia is one of the most challenging diseases of pregnancy, with unclear etiology, no specific marker for prediction, and no precise treatment besides delivery of the placenta. Many risk factors have been identified, and diagnostic and management tools have improved in recent years. However, this disease remains one of the leading causes of maternal morbidity and mortality worldwide, especially in under-resourced settings. A history of previous preeclampsia is a known risk factor for a new event in a future pregnancy, with recurrence rates varying from less than 10% to 65%, depending on the population or methodology considered. A recent review that performed an individual participant data meta-analysis on the recurrence of hypertensive disorders of pregnancy in over 99 000 women showed an overall recurrence rate of 20.7%; when specifically considering preeclampsia, it was 13.8%, with milder disease upon recurrence. Prevention of recurrent preeclampsia has been attempted by changes in lifestyle, dietary supplementation, antihypertensive drugs, antithrombotic agents, and others, with much uncertainty about benefit. It is always challenging to treat and counsel a woman with a previous history of preeclampsia; this review will be based on hypothetical clinical cases, using common scenarios in obstetrical practice to consider the available evidence on how to counsel each woman during pre-conception and prenatal consultations.

  20. Stroke prevention by direct revascularization for patients with adult-onset moyamoya disease presenting with ischemia.

    PubMed

    Kim, Tackeun; Oh, Chang Wan; Kwon, O-Ki; Hwang, Gyojun; Kim, Jeong Eun; Kang, Hyun-Seung; Cho, Won-Sang; Bang, Jae Seung

    2016-06-01

    OBJECT Moyamoya disease (MMD) is a progressive disease that can cause recurrent stroke. The authors undertook this retrospective case-control study with a large sample size in an attempt to assess the efficacy of direct or combined revascularization surgery for ischemia in adults with MMD. METHODS The authors investigated cases involving patients with moyamoya disease presenting with ischemia who visited Seoul National University Bundang Hospital and Seoul National University Hospital between 2000 and 2014. Among 441 eligible patients, 301 underwent revascularization surgery and 140 were treated conservatively. Variables evaluated included age at diagnosis, sex, surgical record, Suzuki stage, and occurrence of stroke. Patients were stratified into 2 groups based on whether or not they had undergone revascularization surgery. Actuarial 1-, 5-, and 10-year stroke rates were calculated using the life table method. Risk factor analysis for 5-year stroke occurrence was conducted with multivariate regression. RESULTS Of the 441 patients, 301 had been surgically treated (revascularization group) and 140 had not (control group). The mean follow-up durations were 45 and 77 months, respectively. The actuarial 10-year cumulative incidence rate for any kind of stroke was significantly lower in the revascularization group (9.4%) than in the control group (19.6%) (p = 0.041); the relative risk reduction (RRR) was also superior (52.0%) in the revascularization group, and the number needed to treat was 10. The 10-year rate of ischemic stroke was greater (13.3%) in the control group than in the revascularization group (3.9%) (p = 0.019). The RRR for ischemic stroke in the revascularization group was 70.7%, and the number needed to treat was 11. However, the actuarial 1- and 5-year rates of ischemic stroke did not significantly differently between the groups. Overall, revascularization surgery was shown to be an independent protective factor, as revealed by multivariate analysis

  1. Unusual case of recurrent SMART (stroke-like migraine attacks after radiation therapy) syndrome.

    PubMed

    Ramanathan, Ramnath Santosh; Sreedher, Gayathri; Malhotra, Konark; Guduru, Zain; Agarwal, Deeksha; Flaherty, Mary; Leichliter, Timothy; Rana, Sandeep

    2016-01-01

    Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare delayed complication of cerebral radiation therapy. A 53-year-old female initially presented with headache, confusion and left homonymous hemianopia. Her medical history was notable for cerebellar hemangioblastoma, which was treated with radiation in 1987. Her initial brain MRI (magnetic resonance imaging) revealed cortical enhancement in the right temporo-parieto-occipital region. She improved spontaneously in 2 weeks and follow-up scan at 4 weeks revealed no residual enhancement or encephalomalacia. She presented 6 weeks later with aphasia. Her MRI brain revealed similar contrast-enhancing cortical lesion but on the left side. Repeat CSF studies was again negative other than elevated protein. She was treated conservatively and recovered completely within a week. Before diagnosing SMART syndrome, it is important to rule out tumor recurrence, encephalitis, posterior reversible encephalopathy syndrome (PRES) and stroke. Typically the condition is self-limiting, and gradually resolves.

  2. Edoxaban in venous thromboembolism and stroke prevention: an appraisal

    PubMed Central

    Proietti, Marco; Lip, Gregory YH

    2016-01-01

    Oral anticoagulation is the therapeutic cornerstone in preventing thromboembolic risk in both atrial fibrillation (AF) and venous thromboembolism (VTE). After decades of the sole therapeutic oral anticoagulation option being warfarin, the introduction of non-vitamin K antagonist oral anticoagulants has heralded a new era. Edoxaban is the latest addition to these available for clinical use. Edoxaban was as effective and safer than warfarin in preventing thromboembolic risk in AF patients. Similarly, edoxaban effectiveness and safety was evident when treating VTE patients to prevent recurrent VTE or VTE-related death. Therefore, edoxaban represents a valuable alternative in treating thromboembolic risk for AF and VTE patients. PMID:27013883

  3. Mediterranean diet in healthy lifestyle and prevention of stroke.

    PubMed

    Demarin, Vida; Lisak, Marijana; Morović, Sandra

    2011-03-01

    Several studies demonstrated the beneficial and preventive role of Mediterranean diet in the occurrence of cardiovascular diseases, chronic neurodegenerative diseases and neoplasms, obesity and diabetes. In randomized intervention trials, Mediterranean diet improved endothelial function and significantly reduced waist circumference, plasma glucose, serum insulin and homeostasis model assessment score in metabolic syndrome. Several studies support favorable effects of Mediterranean diet on plasma lipid profile: reduction of total and plasma LDL cholesterol levels, plasma triglyceride levels, and apo-B and VLDL concentrations, and an increase in plasma HDL cholesterol levels. This effect is associated with increased plasma antioxidant capacity, improved endothelial function, reduced insulin resistance, and reduced incidence of the metabolic syndrome. The beneficial impact of fish consumption on the risk of cardiovascular diseases is the result of synergistic effects of nutrients in fish. Fish is considered an excellent source of protein with low saturated fat, nutritious trace elements, long-chain omega-3 polyunsaturated fatty acids (LCn3PUFAs), and vitamins D and B. Fish consumption may be inversely associated with ischemic stroke but not with hemorrhagic stroke because of the potential antiplatelet aggregation property of LCn3PUFAs. Total stroke risk reduction was statistically significant for fish intake once per week, while the risk of stroke was lowered by 31% in individuals who ate fish 5 times or more per week. In the elderly, moderate consumption of tuna/other fish, but not fried fish, was associated with lower prevalence of subclinical infarcts and white matter abnormalities on MRI examination. Dietary intake of omega-3 fatty acids in a moderate-to-high range does not appear to be associated with reduced plaque, but is negatively associated with carotid artery intima-media thickness. Greater adherence to Mediterranean diet is associated with significant

  4. Stroke prevention in atrial fibrillation: pharmacological rate versus rhythm control.

    PubMed

    Sherman, David G

    2007-02-01

    Atrial fibrillation is a common arrhythmia associated with increased risk for embolic stroke. Restoration of sinus rhythm in patients with atrial fibrillation is a logical strategy to prevent the cardiovascular and thromboembolic complications of this dysrhythmia. The most common strategy for restoration of sinus rhythm is pharmacological antiarrhythmic therapy with or without electrical cardioversion. Five randomized clinical trials compared rhythm to rate-control strategies in patients with atrial fibrillation. These trials examined mortality, thromboembolic complications, exercise tolerance, quality of life, hospital admissions and drug-related adverse reactions. Mortality ranged from 2.9% to 23.8% among the trial subjects randomized to rhythm control versus 1.0% to 21.3% in the rate control subjects. The risk of thromboemboli was greater: 2.9% to 7.9% in the rhythm-control subjects compared with 0% to 5.5% in the rate control subjects. Hospital admissions and drug-related adverse events were increased in the rhythm-control subjects. Stroke and systemic emboli occurred more often in the rhythm-control subjects many of whom had been withdrawn from anticoagulation. Rhythm-control offered no advantage compared with rate control for patients with atrial fibrillation at increased risk for stroke. One explanation for this finding is that those patients thought to have been successfully converted to sinus rhythm in fact had asymptomatic paroxysmal episodes of atrial fibrillation increasing their risk of stroke because they were unprotected by anticoagulation. Pharmacological attempts to restore atrial fibrillation to sinus rhythm do not improve mortality or reduce thromboembolic events. All patients with atrial fibrillation at increased risk for stroke should be continued on long-term anticoagulation even if they appear to have been successfully restored to sinus rhythm.

  5. Sulodexide for the Prevention of Recurrent Venous Thromboembolism

    PubMed Central

    Bignamini, Angelo A.; Davì, Giovanni; Palareti, Gualtiero; Matuška, Jiří; Holý, Martin; Pawlaczyk-Gabriel, Katarzyna; Džupina, Andrej; Sokurenko, German Y.; Didenko, Yury P.; Andrei, Laurentia D.; Lessiani, Gianfranco; Visonà, Adriana

    2015-01-01

    Background— Patients with a first episode of unprovoked venous thromboembolism have a high risk of recurrence after discontinuation of anticoagulant therapy. Extending anticoagulation reduces the risk of recurrence but is associated with increased bleeding. Sulodexide, a glycosaminoglycan, exerts antithrombotic and profibrinolytic actions with a low bleeding risk when administered orally, but its benefit for preventing recurrent venous thromboembolism is not well known. Methods and Results— In this multicenter, double-blind study, 615 patients with first-ever unprovoked venous thromboembolism who had completed 3 to 12 months of oral anticoagulant treatment were randomly assigned to sulodexide 500 lipasemic units twice daily or placebo for 2 years, in addition to elastic stockings. The primary efficacy outcome was recurrence of venous thromboembolism. Major or clinically relevant bleeding was the primary safety outcome. Venous thromboembolism recurred in 15 of the 307 patients who received sulodexide and in 30 of the 308 patients who received placebo (hazard ratio, 0.49; 95% confidence interval [CI], 0.27–0.92; P=0.02). The analysis in which lost to follow-up was assigned to failure yielded a risk ratio among treated versus control subjects of 0.54 (95% confidence interval, 0.35–0.85; P=0.009). No major bleeding episodes occurred; 2 patients in each treatment group had a clinically relevant bleeding episode. Adverse events were similar in the 2 groups. Conclusion— Sulodexide given after discontinuation of anticoagulant treatment reduced the risk of recurrence in patients with unprovoked venous thromboembolism, with no apparent increase of bleeding risk. Clinical Trial Registration— URL: https://www.clinicaltrialsregister.eu/. Identifier: EudraCT number 2009-016923-77. PMID:26408273

  6. Environmental vascular risk factors: new perspectives for stroke prevention.

    PubMed

    Bernal-Pacheco, Oscar; Román, Gustavo C

    2007-11-15

    Despite intensive evaluation of acute stroke patients, perhaps only half of the attributable stroke risk is usually identified. In addition to traditional and non-traditional vascular risk factors-including most recently homocysteine, inflammation, and alterations of coagulation-a number of environmental risk factors for stroke have been identified in the last decade. In this update we review the following: lower education and poor socioeconomic status (probable surrogates for exposure to traditional high-risk behaviors such as smoking, poor nutrition, lack of prenatal control, absence of preventive medical and dental care, and non-compliance of treatment of conditions such as hypertension); depression, stress and affective disorders; obstructive sleep apnea; passive smoking and environmental pollution; infections, in particular periodontal diseases that increase C-reactive protein (CRP); raised body mass index (obesity); exercise, and diet. The possible role of high-fructose corn syrup in the epidemic of obesity in the USA is reviewed. Protective diets include higher consumption of fish, olive oil, grains, fruits and vegetables (Mediterranean diet), as well as probiotic bacteria in yogurt and dairy products. Careful attention should be given to the patient's environment looking for modifiable factors. The effects of clean environmental air and water, adequate diet and appropriate nutrition, healthy teeth, exercise, and refreshing sleep in the prevention of stroke and cardiovascular disease appear to be quite compelling. Although some of these modifiable risk factors lack evidence-based information, judicious clinical sense should be used to counteract the potentially damaging effects of adverse environmental vascular risk factors.

  7. Healing ulcers and preventing their recurrences in the diabetic foot

    PubMed Central

    Sabapathy, S. Raja; Periasamy, Madhu

    2016-01-01

    Fifteen percent of people with diabetes develop an ulcer in the course of their lifetime. Eighty-five percent of the major amputations in diabetes mellitus are preceded by an ulcer. Management of ulcers and preventing their recurrence is important for the quality of life of the individual and reducing the cost of care of treatment. The main causative factors of ulceration are neuropathy, vasculopathy and limited joint mobility. Altered bio-mechanics due to the deformities secondary to neuropathy and limited joint mobility leads to focal points of increased pressure, which compromises circulation leading to ulcers. Ulcer management must not only address the healing of ulcers but also should correct the altered bio-mechanics to reduce the focal pressure points and prevent recurrence. An analysis of 700 patients presenting with foot problems to the Diabetic Clinic of Ganga Hospital led to the stratification of these patients into four classes of incremental severity. Class 1 – the foot at risk, Class 2 – superficial ulcers without infection, Class 3 – the crippled foot and Class 4 – the critical foot. Almost 77.5% presented in either Class 3 or 4 with complicated foot ulcers requiring major reconstruction or amputation. Class 1 foot can be managed conservatively with foot care and appropriate foot wear. Class 2 in addition to measures for ulcer healing would need surgery to correct the altered bio-mechanics to prevent the recurrence. The procedures called surgical offloading would depend on the site of the ulcer and would need an in-depth clinical study of the foot. Class 3 would need major reconstructive procedures and Class 4 would need amputation since it may be life-threatening. As clinicians, our main efforts must be focused towards identifying patients in Class 1 and offer advice on foot care and Class 2 where appropriate surgical offloading procedure would help preserve the foot. PMID:28216809

  8. Secondary prevention of cardioembolic stroke: oldest and newest promises.

    PubMed

    Corea, F; Spinelli, M; Tambasco, N; Silvestrelli, G; Parnetti, L

    2006-01-01

    Atrial fibrillation (AF) is the most common cause of cardioembolism. An update on secondary prevention strategies used to protect from the risk of stroke AF patients is presented. The main line of actions of stroke prevention in AF are antithrombotics (anticoagulant or antiplatelet), antiarrhythmics (for rate control and sinus rhythm restore), mechanical means (for occlusion of the left atrial appendage or protection of the internal carotid artery from emboli). Classic pharmacological prevention with K vitamin Kantagonists such as warfarin may be overcome by direct thrombin inhibitors like ximelagatran and melagatran. New ablation technologies promise to cure, at least a part of Nonvalvolae AF in the community, restoring sinus rhythm. Recent achievements on endovascular procedures deploying carotid artery implants provide an opportunity to divert emboli to nonhazardous locations, whereas cardiac devices can seal left atrial appendages and avoid risk of clot migration in the blood stream. In the next decade, the challenge will be to understand competitiveness between old and new drugs with endovascular implants.

  9. SY 08-2 HYPERTENSION MANAGEMENT FOR SECONDARY PREVENTION OF STROKE.

    PubMed

    Shimada, Kazuyuki

    2016-09-01

    Stroke is known to frequently recur in patients with a history of cerebrovascular disease, and the control of hypertension is extremely important for the treatment of those patients. The robust relationship between the recurrent cerebrovascular disease and blood pressure control has been demonstrated in large-scale clinical studies. The antihypertensive drug therapy significantly reduces the recurrence rate of all types of cerebrovascular disease, incidences of myocardial infarction and all vascular events. Evidence suggests that any class of antihypertensive drugs including diuretics, Ca channel blockers, ARBs, and ACE inhibitors are shown to be similarly effective for the secondary prevention of stroke, except in some small study such as MOSES. Thus, most of the benefit obtained from drugs can be ascribed to a decrease in blood pressure.Then, how far should blood pressure be lowered? Target of blood pressure control has been somewhat controversial, since an excessive reduction of blood pressure might exacerbate cerebral ischemia in the area perfused by cerebral artery with a significant stenosis. In fact, some Japanese clinical study has shown that in patients with impaired perfusion demonstrated by PET-CT, the risk of recurrent stroke was high when the systolic blood pressure was <130 mmHg. In those without impaired perfusion, this risk may be high at a high blood pressure level. In the study involving patients with carotid artery stenosis, the risk of cerebrovascular disease significantly increased in a group in which the systolic blood pressure decreased to 140 mmHg among patients with symptomatic, 70% or greater stenosis of the bilateral carotid arteries (accounting for 2 to 3%), whereas there was no increase in this risk even when the systolic blood pressure decreased to 140 mmHg in patients with 70% or greater unilateral carotid artery stenosis. In the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) Study, among patients with symptomatic

  10. Preventive Ceftriaxone in Patients with Stroke Treated with Intravenous Thrombolysis: Post Hoc Analysis of the Preventive Antibiotics in Stroke Study

    PubMed Central

    Vermeij, Jan-Dirk; Westendorp, Willeke F.; Roos, Yvo B.; Brouwer, Matthijs C.; van de Beek, Diederik; Nederkoorn, Paul J.

    2016-01-01

    Background The Preventive Antibiotics in Stroke Study (PASS), a randomized open-label masked endpoint trial, showed that preventive ceftriaxone did not improve functional outcome at 3 months in patients with acute stroke (adjusted common OR 0.95; 95% CI 0.82-1.09). Post-hoc analyses showed that among patients who received intravenous thrombolysis (IVT), patients who received ceftriaxone had a significantly better outcome as compared with the control group. This study aimed to gain more insight into the characteristics of these patients. Methods In PASS, 2,550 patients were randomly assigned to preventive antibiotic treatment with ceftriaxone or standard care. In current post-hoc analysis, 836 patients who received IVT were included. Primary outcome included functional status on the modified Rankin Scale, analyzed with adjusted ordinal regression. Secondary outcomes included infection rate and symptomatic intracerebral hemorrhage (sICH) rate. Results For all patients in PASS, the p value for the interaction between IVT and preventive ceftriaxone regarding functional outcome was 0.03. Of the 836 IVT-treated patients, 437 were administered ceftriaxone and 399 were allocated to the control group. Baseline characteristics were similar. In the IVT subgroup, preventive ceftriaxone was associated with a significant reduction in unfavorable outcome (adjusted common OR 0.77; 95% CI 0.61-0.99; p = 0.04). Mortality at 3 months was similar (OR 0.75; 95% CI 0.48-1.18). Preventive ceftriaxone was associated with a reduction in infections (OR 0.43; 95% CI 0.28-0.66), and a trend towards an increased risk for sICH (OR 3.09; 95% CI 0.85-11.31). Timing of ceftriaxone administration did not influence the outcome (aOR 1.00; 95% CI 0.98-1.03; p = 0.85). Conclusions According to the post-hoc analysis of PASS, preventive ceftriaxone may improve the functional outcome in IVT-treated patients with acute stroke, despite a trend towards an increased rate of post-IVT-sICH. PMID:27336314

  11. Prevention

    MedlinePlus

    ... Is Strong Error processing SSI file About Heart Disease & Stroke Prevention Heart disease and stroke are an epidemic in ... to avoid secondhand smoke. Barriers to Effective Heart Disease & Stroke Prevention Many people with key risk factors for heart ...

  12. Use of antiplatelet agents to prevent stroke: what is the role for combinations of medications?

    PubMed

    Schwartz, Neil E; Albers, Gregory W

    2008-01-01

    Antiplatelet agents are the medications of choice for preventing non-cardioembolic strokes. The diverse pathways involved in platelet function suggest the possibility of synergistic effects by combining various agents. In heart disease and in the setting of coronary artery stents, antiplatelet therapy with clopidogrel and aspirin has established benefits. Although it is tempting to extrapolate the benefits of this combination for stroke prevention, recent clinical trials have not borne this out. Unacceptable bleeding risks without additional efficacy weigh against the routine use of clopidogrel with aspirin for stroke prophylaxis. The combination of aspirin and extended-release dipyridamole has demonstrated superiority over aspirin in two large secondary stroke prevention trials.

  13. Relation of Candidate Genes that Encode for Endothelial Function to Migraine and Stroke: The Stroke Prevention in Young Women Study

    PubMed Central

    MacClellan, Leah R.; Howard, Timothy D.; Cole, John W.; Stine, O. Colin; Giles, Wayne H.; O’Connell, Jeffery R.; Wozniak, Marcella A.; Stern, Barney J.; Mitchell, Braxton D.; Kittner, Steven J.

    2009-01-01

    Background and Purpose Migraine with aura is a risk factor for ischemic stroke but the mechanism by which these disorders are associated remains unclear. Both disorders exhibit familial clustering, which may imply a genetic influence on migraine and stroke risk. Genes encoding for endothelial function are promising candidate genes for migraine and stroke susceptibility because of the importance of endothelial function in regulating vascular tone and cerebral blood flow. Methods Using data from the Stroke Prevention in Young Women (SPYW) study, a population-based case-control study including 297 women aged 15–49 years with ischemic stroke and 422 women without stroke, we evaluated whether polymorphisms in genes regulating endothelial function, including endothelin-1 (EDN), endothelin receptor type B (EDNRB), and nitric oxide synthase-3 (NOS3), confer susceptibility to migraine and stroke. Results EDN SNPs rs1800542 and rs10478723 were associated with increased stroke susceptibility in Caucasians, (OR = 2.1 (95% CI, 1.1 to 4.2) and OR = 2.2 (95% CI, 1.1 to 4.4); p = 0.02 and 0.02, respectively) as were EDNRB SNPs rs4885493 and rs10507875, (OR = 1.7 (95% CI, 1.1 to 2.7) and OR = 2.4 (95% CI, 1.4 to 4.3); p = 0.01 and 0.002, respectively). Only one of the tested SNPs (NOS3 - rs3918166) was associated with both migraine and stroke. Conclusions In our study population, variants in EDN and EDNRB were associated with stroke susceptibility in Caucasian but not in African-American women. We found no evidence that these genes mediate the association between migraine and stroke. PMID:19661472

  14. Stroke Prevention in Atrial Fibrillation: Focus on Latin America.

    PubMed

    Massaro, Ayrton R; Lip, Gregory Y H

    2016-08-11

    Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with an estimated prevalence of 1-2% in North America and Europe. The increased prevalence of AF in Latin America is associated with an ageing general population, along with poor control of key risk factors, including hypertension. As a result, stroke prevalence and associated mortality have increased dramatically in the region. Therefore, the need for effective anticoagulation strategies in Latin America is clear. The aim of this review is to provide a contemporary overview of anticoagulants for stroke prevention. The use of vitamin K antagonists (VKAs, eg, warfarin) and aspirin in the prevention of stroke in patients with AF in Latin America remains common, although around one fifth of all AF patients receive no anticoagulation. Warfarin use is complicated by a lack of access to effective monitoring services coupled with an unpredictable pharmacokinetic profile. The overuse of aspirin is associated with significant bleeding risks and reduced efficacy for stroke prevention in this patient group. The non-VKA oral anticoagulants (NOACbs) represent a potential means of overcoming many limitations associated with VKA and aspirin use, including a reduction in the need for monitoring and a reduced risk of hemorrhagic events. The ultimate decision of which anticoagulant drug to utilize in AF patients depends on a multitude of factors. More research is needed to appreciate the impact of these factors in the Latin American population and thereby reduce the burden of AF-associated stroke in this region. Resumo A fibrilação atrial (FA) é a arritmia cardíaca sustentada mais comum, com uma prevalência estimada de 1-2% na América do Norte e Europa. O aumento da prevalência da FA na América Latina está associado com o envelhecimento da população geral, juntamente com um mal controle dos principais fatores de risco, incluindo a hipertensão arterial. Como resultado, a prevalência do acidente

  15. A Community Engagement Symposium to Prevent and Improve Stroke Outcomes in Diverse Communities

    PubMed Central

    Bharmal, Nazleen; Lucas-Wright, Anna “Aziza”; Vassar, Stefanie D.; Jones, Felica; Jones, Loretta; Wells, Rebekah; Cienega, Jason; Brown, Arleen F.

    2016-01-01

    Background Racial/ethnic minorities have a higher burden of stroke, but lower awareness and understanding of stroke and its risk factors. Our community–academic collaborative hosted a symposium in South Los Angeles to increase awareness about stroke, provide information on the Los Angeles Stroke Intervention and Research Program (SPIRP), and facilitate bidirectional communication between researchers and community stakeholders. Objectives We discuss our partnered approach to increase stroke awareness, elicit community perspectives and perceptions about stroke prevention and research participation, and increase community involvement in research using a community engagement symposium (CES). Methods We used a community-partnered participatory research (CPPR) conference framework to guide symposium planning, implementation and analysis. The morning session included clinical lectures, a panel of researchers describing LA SPIRP, and a panel presentation by stroke caregivers and survivors. In afternoon breakout sessions, attendees identified 1) community-based strategies to prevent stroke and 2) methods to increase recruitment of diverse populations in stroke research studies. Attendees were surveyed about stroke knowledge before and after the morning session. Data from breakout sessions were analyzed using content analysis and pile sorting to identify themes. Conclusions We found that the CES based on CPPR principles was effective method to increase short-term stroke awareness and stimulate discussion about stroke research among community members and community stakeholders who serve racial/ethnic minorities. PMID:27018364

  16. Physical activity in the prevention of ischemic stroke and improvement of outcomes: a narrative review.

    PubMed

    Middleton, Laura E; Corbett, Dale; Brooks, Dina; Sage, Michael D; Macintosh, Bradley J; McIlroy, William E; Black, Sandra E

    2013-02-01

    Physical activity is an integral component of stroke prevention. Although approximately 80% of strokes are due to cerebral ischemia, the mechanisms linking physical activity to the incidence of and recovery from ischemic stroke are not completely understood. This review summarizes evidence from human and animal studies regarding physical activity in the prevention of overt and covert ischemic stroke and associated injury. In cohort studies, people who are physically active have reduced rates of overt ischemic stroke and ischemic stroke mortality. However, few human studies have examined physical activity and the incidence of covert stroke. Evidence from animal models of ischemic stroke indicates that physical activity reduces injury after ischemic stroke by reducing infarct size and apoptotic cell death. Accordingly, physical activity may reduce the magnitude of injury from ischemic stroke so that there are fewer or less severe symptoms. Future research should investigate physical activity and incidence of covert stroke prospectively, ascertain the optimal dose and type of exercise to prevent ischemic injury, and identify the underlying neuroprotective mechanisms.

  17. Multimodal Secondary Prevention Behavioral Interventions for TIA and Stroke: A Systematic Review and Meta-Analysis

    PubMed Central

    Lawrence, Maggie; Pringle, Jan; Kerr, Susan; Booth, Joanne; Govan, Lindsay; Roberts, Nicola J.

    2015-01-01

    Background Guidelines recommend implementation of multimodal interventions to help prevent recurrent TIA/stroke. We undertook a systematic review to assess the effectiveness of behavioral secondary prevention interventions. Strategy Searches were conducted in 14 databases, including MEDLINE (1980-January 2014). We included randomized controlled trials (RCTs) testing multimodal interventions against usual care/modified usual care. All review processes were conducted in accordance with Cochrane guidelines. Results Twenty-three papers reporting 20 RCTs (6,373 participants) of a range of multimodal behavioral interventions were included. Methodological quality was generally low. Meta-analyses were possible for physiological, lifestyle, psychosocial and mortality/recurrence outcomes. Note: all reported confidence intervals are 95%. Systolic blood pressure was reduced by 4.21 mmHg (mean) (−6.24 to −2.18, P = 0.01 I2 = 58%, 1,407 participants); diastolic blood pressure by 2.03 mmHg (mean) (−3.19 to −0.87, P = 0.004, I2 = 52%, 1,407 participants). No significant changes were found for HDL, LDL, total cholesterol, fasting blood glucose, high sensitivity-CR, BMI, weight or waist:hip ratio, although there was a significant reduction in waist circumference (−6.69 cm, −11.44 to −1.93, P = 0.006, I2 = 0%, 96 participants). There was no significant difference in smoking continuance, or improved fruit and vegetable consumption. There was a significant difference in compliance with antithrombotic medication (OR 1.45, 1.21 to 1.75, P<0.0001, I2 = 0%, 2,792 participants) and with statins (OR 2.53, 2.15 to 2.97, P< 0.00001, I2 = 0%, 2,636 participants); however, there was no significant difference in compliance with antihypertensives. There was a significant reduction in anxiety (−1.20, −1.77 to −0.63, P<0.0001, I2 = 85%, 143 participants). Although there was no significant difference in odds of death or recurrent TIA/stroke, there was a significant reduction in

  18. Talk With Your Health Care Provider About Taking Aspirin to Prevent Strokes

    MedlinePlus

    ... Heart and Circulation For Women Talk With Your Health Care Provider About Taking Aspirin to Prevent Strokes Did ... attacks. Please see the brochure Talk with Your Health Care Provider About Taking Aspirin to Prevent Heart Attacks ...

  19. Stroke survivors', caregivers' and GPs' attitudes towards a polypill for the secondary prevention of stroke: a qualitative interview study

    PubMed Central

    Jamison, James; Graffy, Jonathan; Mullis, Ricky; Mant, Jonathan; Sutton, Stephen

    2016-01-01

    Objectives To understand the perspectives of stroke survivors, caregivers and general practitioners (GPs) on a polypill approach, consisting of blood pressure and cholesterol-lowering therapies, with or without aspirin, for the secondary prevention of stroke. Methods A qualitative interview study was undertaken in 5 GP surgeries in the East of England. 28 survivors of stroke/transient ischaemic attack (TIA) were interviewed, 14 of them with a caregiver present, along with a convenience sample of 5 GPs, to assess attitudes towards a polypill and future use. Topic guides explored participants attitudes, potential uptake and long-term use, management of polypill medication and factors influencing the decision to prescribe. Data were analysed using a grounded theory approach. Key themes are presented and illustrated with verbatim quotes. Results The analysis identified 3 key themes: polypill benefits, polypill concerns and polypill lessons for implementation. Stroke/TIA survivors were positive about the polypill concept and considered it acceptable in the secondary prevention of stroke. Perceived benefits of a polypill included convenience resulting in improved adherence and reduced burden of treatment. Caregivers felt that a polypill would improve medication-taking practices, and GPs were open to prescribing it to those at increased cardiovascular risk. However, concerns raised included whether a polypill provided equivalent therapeutic benefit, side effects through combining medications, consequences of non-adherence, lack of flexibility in regulating dosage, disruption to current treatment and suitability to the wider stroke population. Conclusions Participants acknowledged potential advantages in a polypill approach for secondary prevention of stroke; however, significant concerns remain. Further research on the efficacy of a polypill is needed to reassure practitioners whose concerns around inflexibility and treatment suitability are likely to influence the

  20. Microalgae for the prevention of cardiovascular disease and stroke.

    PubMed

    Raposo, Maria Filomena de Jesus; de Morais, Alcina Maria Miranda Bernardo

    2015-03-15

    This review focuses on and discusses the primary phytochemicals present in microalgal biomass - carotenoids, phenolic compounds, antioxidant vitamins, sterols, and polyunsaturated fatty acids - and also on the exopolysaccharides, which are produced by some types of microalgae and may play a significant role in the prevention of cardiovascular diseases (CVD) and strokes. We have listed several preclinical trials and clinical studies supporting the health benefits that most of these compounds may provide. Microalgae are very easy to grow and are not vulnerable to contaminants when grown under controlled conditions. Proper handling and growth conditions may improve the production of phytochemicals. Therefore, they may represent an excellent source of nutraceuticals and food supplements once their safety as a food supplement has been confirmed.

  1. Extracorporeal abdominal massage may help prevent recurrent bile duct stones after endoscopic sphincterotomy

    PubMed Central

    Uchida, Naohito; Hamaya, Sae; Tatsuta, Miwa; Nakatsu, Toshiaki

    2016-01-01

    Background and study aims: Endoscopic sphincterotomy (EST) is effective, but recurrent bile duct stones are a common late complication. Because there are still no effective therapies for preventing this complication, some patients have experienced bile duct stone recurrence many times. We describe herein a method of abdominal massage to treat patients with prior cholecystectomy who have experienced recurrence of bile duct stones. PMID:27540575

  2. Routine exposure of recurrent laryngeal nerve in thyroid surgery can prevent nerve injury★

    PubMed Central

    Shen, Chenling; Xiang, Mingliang; Wu, Hao; Ma, Yan; Chen, Li; Cheng, Lan

    2013-01-01

    To determine the value of dissecting the recurrent laryngeal nerve during thyroid surgery with respect to preventing recurrent laryngeal nerve injury, we retrospectively analyzed clinical data from 5 344 patients undergoing thyroidectomy. Among these cases, 548 underwent dissection of the recurrent laryngeal nerve, while 4 796 did not. There were 12 cases of recurrent laryngeal nerve injury following recurrent laryngeal nerve dissection (injury rate of 2.2%) and 512 cases of recurrent laryngeal nerve injury in those not undergoing nerve dissection (injury rate of 10.7%). This difference remained statistically significant between the two groups in terms of type of thyroid disease, type of surgery, and number of surgeries. Among the 548 cases undergoing recurrent laryngeal nerve dissection, 128 developed anatomical variations of the recurrent laryngeal nerve (incidence rate of 23.4%), but no recurrent laryngeal nerve injury was found. In addition, the incidence of recurrent laryngeal nerve injury was significantly lower in patients with the inferior parathyroid gland and middle thyroid veins used as landmarks for locating the recurrent laryngeal nerve compared with those with the entry of the recurrent laryngeal nerve into the larynx as a landmark. These findings indicate that anatomical variations of the recurrent laryngeal nerve are common, and that dissecting the recurrent laryngeal nerve during thyroid surgery is an effective means of preventing nerve injury. PMID:25206452

  3. Questions and Answers about Treating Arterial Stenosis and Preventing Stroke

    MedlinePlus

    ... context of stroke, “stenosis” is usually caused by atherosclerosis, a condition where a blood vessel supplying blood ... high cholesterol. How does stenosis contribute to stroke? Atherosclerosis can activate cells involved in blood clotting. As ...

  4. Could Stroke Trigger Be Prevented by Healthy Family Relationships?

    ERIC Educational Resources Information Center

    Rochette, Annie; Gaulin, Philippe; Tellier, Myriam

    2009-01-01

    Although major stroke risk factors are well documented, little is known about which life circumstances are perceived to be related to the actual triggering of a first stroke. The purpose was to explore self-perceived spontaneously related life circumstances surrounding the trigger of a first stroke. A qualitative design with a phenomenological…

  5. Preventive Antibacterial Therapy in Acute Ischemic Stroke: A Randomized Controlled Trial

    PubMed Central

    Klehmet, Juliane; Rogge, Witold; Drenckhahn, Christoph; Göhler, Jos; Bereswill, Stefan; Göbel, Ulf; Wernecke, Klaus Dieter; Wolf, Tilo; Arnold, Guy; Halle, Elke; Volk, Hans-Dieter; Dirnagl, Ulrich; Meisel, Andreas

    2008-01-01

    Background Pneumonia is a major risk factor of death after acute stroke. In a mouse model, preventive antibacterial therapy with moxifloxacin not only prevents the development of post-stroke infections, it also reduces mortality, and improves neurological outcome significantly. In this study we investigate whether this approach is effective in stroke patients. Methods Preventive ANtibacterial THERapy in acute Ischemic Stroke (PANTHERIS) is a randomized, double-blind, placebo-controlled trial in 80 patients with severe, non-lacunar, ischemic stroke (NIHSS>11) in the middle cerebral artery (MCA) territory. Patients received either intravenous moxifloxacin (400 mg daily) or placebo for 5 days starting within 36 hours after stroke onset. Primary endpoint was infection within 11 days. Secondary endpoints included neurological outcome, survival, development of stroke-induced immunodepression, and induction of bacterial resistance. Findings On intention-to treat analysis (79 patients), the infection rate at day 11 in the moxifloxacin treated group was 15.4% compared to 32.5% in the placebo treated group (p = 0.114). On per protocol analysis (n = 66), moxifloxacin significantly reduced infection rate from 41.9% to 17.1% (p = 0.032). Stroke associated infections were associated with a lower survival rate. In this study, neurological outcome and survival were not significantly influenced by treatment with moxifloxacin. Frequency of fluoroquinolone resistance in both treatment groups did not differ. On logistic regression analysis, treatment arm as well as the interaction between treatment arm and monocytic HLA-DR expression (a marker for immunodepression) at day 1 after stroke onset was independently and highly predictive for post-stroke infections. Interpretation PANTHERIS suggests that preventive administration of moxifloxacin is superior in reducing infections after severe non-lacunar ischemic stroke compared to placebo. In addition, the results emphasize the

  6. Aspiration Pneumonia After Stroke

    PubMed Central

    Armstrong, John R.; Mosher, Benjamin D.

    2011-01-01

    Fifteen million strokes occur worldwide each year with 5 million associated deaths and an additional 5 million people left permanently disabled. In the United States, about 780 000 people suffer a new or recurrent stroke each year. There were an estimated total 5.8 million stroke survivors as of 2008. Mortality from stroke is the third leading cause of death in America following heart disease and cancer. Chest infection may affect up to as many as one-third of stroke patients. This increases the morbidity and mortality of this patient population. Pneumonia causes the highest attributable mortality of all medical complications following stroke. A comprehensive multidisciplinary team approach is required at the hospital level. This requires active administrative commitment and participation. Implementation of evidence-based management strategies can improve outcomes and reduce costs. We sought to review the problem of post-stroke pneumonia and discuss strategies for prevention and intervention. PMID:23983842

  7. Evaluation of patients' attitudes towards stroke prevention and bleeding risk in atrial fibrillation.

    PubMed

    Lahaye, S; Regpala, S; Lacombe, S; Sharma, M; Gibbens, S; Ball, D; Francis, K

    2014-03-03

    Patient's values and preferences regarding the relative importance of preventing strokes and avoiding bleeding are now recognised to be of great importance in deciding on therapy for the prevention of stroke due to atrial fibrillation (SPAF). We used an iPad questionnaire to determine the minimal clinically important difference (Treatment Threshold) and the maximum number of major bleeding events that a patient would be willing to endure in order to prevent one stroke (Bleeding Ratio) for the initiation of antithrombotic therapy in 172 hospital in-patients with documented non-valvular atrial fibrillation in whom anticoagulant therapy was being considered. Patients expressed strong opinions regarding SPAF. We found that 12% of patients were "medication averse" and were not willing to consider antithrombotic therapy; even if it was 100% effective in preventing strokes. Of those patients who were willing to consider antithrombotic therapy, 42% were identified as "risk averse" and 15% were "risk tolerant". Patients required at least a 0.8% (NNT=125) annual absolute risk reduction and 15% relative risk reduction in the risk of stroke in order to agree to initiate antithrombotic therapy, and patients were willing to endure 4.4 major bleeds in order to prevent one stroke. In conclusion, there was a substantial amount of inter-patient variability, and often extreme differences in opinion regarding tolerance of bleeding risk in the context of stroke prevention in atrial fibrillation. These findings highlight the importance of considering patient preferences when deciding on SPAF therapy.

  8. Novel oral anticoagulants for stroke prevention in atrial fibrillation: focus on apixaban.

    PubMed

    Potpara, Tatjana S; Polovina, Marija M; Licina, Marina M; Stojanovic, Radan M; Prostran, Milica S; Lip, Gregory Y H

    2012-06-01

    Stroke prevention in atrial fibrillation (AF) has been challenging over decades, mostly due to a number of difficulties associated with oral vitamin K antagonists (VKAs), which have been the most effective stroke prevention treatment for a long time. The oral direct thrombin inhibitors (e.g., dabigatran) and oral direct inhibitors of factor Xa (e.g., rivaroxaban, apixaban) have emerged recently as an alternative to VKAs for stroke prevention in AF. These drugs act rapidly, and have a predictable and stable dose-related anticoagulant effect with a few clinically relevant drug-drug interactions. The novel oral anticoagulants are used in fixed doses with no need for regular laboratory monitoring of anticoagulation intensity. However, each of these drugs has distinct pharmacological properties that could influence optimal use in clinical practice. The following phase 3 randomized trials with novel oral anticoagulants versus warfarin for stroke prevention in AF have been completed: the Randomized Evaluation of Long-term Anticoagulant therapy (RE-LY) trial with dabigatran, the Rivaroxaban Once daily oral direct Factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation (ROCKET-AF) trial with rivaroxaban, and the Apixaban for Reduction of Stroke and Other Thromboembolism Events in Atrial Fibrillation (ARISTOTLE) trial with apixaban. Moreover, the Apixaban Versus Acetylsalicylic Acid to prevent Strokes (AVERROES) trial included patients with AF who have failed or were unsuitable for warfarin, and compared apixaban versus aspirin for stroke prevention in AF. Overall, apixaban has two large trials for stroke prevention in AF showing benefits not only over warfarin, but also over aspirin among those patients who have failed or refused warfarin. In the ARISTOTLE trial, apixaban was superior to warfarin in the reduction of stroke or systemic embolism, major bleeding, intracranial hemorrhage, and all-cause mortality

  9. Stroke Prevention Trial in Sickle Cell Anemia (STOP): extended follow-up and final results.

    PubMed

    Lee, Margaret T; Piomelli, Sergio; Granger, Suzanne; Miller, Scott T; Harkness, Shannon; Brambilla, Donald J; Adams, Robert J

    2006-08-01

    The Stroke Prevention Trial in Sickle Cell Anemia (STOP) was a randomized trial to evaluate whether chronic transfusion could prevent initial stroke in children with sickle-cell anemia at high risk as determined by transcranial Doppler (TCD). The trial demonstrated a large benefit of transfusion and was halted early. After termination of the trial, patients participated in a post-trial follow-up study. More patients in the transfusion group (70%) elected transfusion for primary stroke prevention compared with those on standard care (45%). Six patients with persistently abnormal TCD results developed stroke. A minority with initially abnormal TCD results remained stroke-free without transfusion. Except for lower baseline and follow-up TCD velocities compared with those with stroke, no predictive features of this apparent lower-risk subgroup could be determined. TCD results at last testing in 108 patients that did not have stroke were: normal (44.4%), conditional (26.9%), abnormal (22.2%), and inadequate (6.5%). Patients on transfusion were more likely to have normal TCD results. Transfusion resulted in iron overload and alloimmunization, but no infection. The study provides new information on acceptance rates and long-term effects of transfusion. Persistent TCD elevation signals ongoing stroke risk. Reduction in TCD results over time without transfusion is observed in some patients and requires further study.

  10. Pre-Stroke Use of Beta-Blockers Does Not Lower Post-Stroke Infection Rate: An Exploratory Analysis of the Preventive Antibiotics in Stroke Study

    PubMed Central

    Westendorp, Willeke F.; Vermeij, Jan-Dirk; Brouwer, Matthijs C.; Roos, Y.B.W.E.M.; Nederkoorn, Paul J.; van de Beek, Diederik

    2016-01-01

    Background Stroke-associated infections occur frequently and are associated with unfavorable outcome. Previous cohort studies suggest a protective effect of beta-blockers (BBs) against infections. A sympathetic drive may increase immune suppression and infections. Aim This study is aimed at investigating the association between BB treatment at baseline and post-stroke infection in the Preventive Antibiotics in Stroke Study (PASS), a prospective clinical trial. Methods We performed an exploratory analysis in PASS, 2,538 patients with acute phase of stroke (24 h after onset) were randomized to ceftriaxone (intravenous, 2 g per day for 4 days) in addition to stroke unit care, or standard stroke unit care without preventive antibiotic treatment. All clinical data, including use of BBs, was prospectively collected. Infection was diagnosed by the treating physician, and independently by an expert panel blinded for all other data. Multivariable analysis was performed to investigate the relation between BB treatment and infection rate. Results Infection, as defined by the physician, occurred in 348 of 2,538 patients (14%). Multivariable analysis showed that the use of BBs at baseline was associated with the development of infection during clinical course (adjusted OR (aOR) 1.61, 95% CI 1.19-2.18; p < 0.01). BB use at baseline was also associated with the development of pneumonia (aOR 1.56, 95% CI 1.05-2.30; p = 0.03). Baseline BB use was not associated with mortality (aOR 1.14, 95% CI 0.84-1.53; p = 0.41) or unfavorable outcome at 3 months (aOR 1.10, 95% CI 0.89-1.35; p = 0.39). Conclusions Patients treated with BBs prior to stroke have a higher rate of infection and pneumonia. PMID:27701170

  11. Oral anticoagulation in elderly patients as secondary prevention of cardioembolic strokes

    PubMed Central

    2010-01-01

    Background Stroke incidence increases with age. Atrial fibrillation (AF) is an important risk factor for ischemic stroke and its incidence also increases with age. However oral anticoagulant therapy (OAT) tends to be underused in the elderly population. Methods Elderly patients (> = 80 years) with an ischemic stroke admitted in our department between 1/7/2003 and 31/6/2005 were prospectively evaluated. Baseline characteristics, risk factors, treatment and etiology according to TOAST criteria were recorded. Patients treated with OAT were followed up in order to assess any side effect and stroke recurrence. Mean follow-up was of 19.5 months (7-45) from discharge. Results Sixty four out of a hundred and fifty nine elderly patients (40.25%) were classified as cardioembolic; mean age was 84.5 years (80-97) and 64.6% were women. AF had been previously identified in 60% of them (16.9% were on OAT and 40.6% on antiplatelet therapy). At discharge, 32 patients (49.2%) were on OAT. In the follow-up 4 patients (12.5%) suffered systemic haemorrhages (3 urinary, 1 gastrointestinal bleeding), with no change in their functional status. Mean INR in this group was 5.9 [3-11] and, in 3 of them, OAT was cancelled. No brain haemorrhages were recorded. Ischemic stroke recurred in 4 patients (INR < 1.8 in 3 of them; the other, INR 2.35). Three patients had died at the end of the follow-up, one of them as a consequence of ischemic stroke recurrence. Discussion Twenty eight point eight of stroke patients admitted in the period of study were >80 years. The high proportion of cardioembolic strokes in this age segment contrasts with the general underuse of OAT as antithrombotic prophylaxis. Our study suggests that OAT is a safe strategy when carefully prescribed, even for elderly patients. PMID:20525389

  12. Stroke

    MedlinePlus

    ... emergency. Strokes happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds ... blocks or plugs a blood vessel in the brain. The other kind, called hemorrhagic stroke, is caused ...

  13. Direct oral anticoagulants: key considerations for use to prevent stroke in patients with nonvalvular atrial fibrillation

    PubMed Central

    Ment, Jerome

    2015-01-01

    Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide. Strokes that occur as a complication of AF are usually more severe and associated with a higher disability or morbidity and mortality rate compared with non-AF-related strokes. The risk of stroke in AF is dependent on several risk factors; AF itself acts as an independent risk factor for stroke. The combination of effective anticoagulation therapy, risk stratification (based on stroke risk scores, such as CHADS2 and CHA2DS2-VASc), and recommendations provided by guidelines is essential for decreasing the risk of stroke in patients with AF. Although effective in preventing the occurrence of stroke, vitamin K antagonists (VKAs; eg, warfarin) are associated with several limitations. Therefore, direct oral anticoagulants, such as apixaban, dabigatran etexilate, edoxaban, and rivaroxaban, have emerged as an alternative to the VKAs for stroke prevention in patients with nonvalvular AF. Compared with the VKAs, these agents have more favorable pharmacological characteristics and, unlike the VKAs, they are given at fixed doses without the need for routine coagulation monitoring. It remains important that physicians use these direct oral anticoagulants responsibly to ensure optimal safety and effectiveness. This article provides an overview of the existing data on the direct oral anticoagulants, focusing on management protocols for aiding physicians to optimize anticoagulant therapy in patients with nonvalvular AF, particularly in special patient populations (eg, those with renal impairment) and other specific clinical situations. PMID:26089678

  14. Direct oral anticoagulants: key considerations for use to prevent stroke in patients with nonvalvular atrial fibrillation.

    PubMed

    Ment, Jerome

    2015-01-01

    Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide. Strokes that occur as a complication of AF are usually more severe and associated with a higher disability or morbidity and mortality rate compared with non-AF-related strokes. The risk of stroke in AF is dependent on several risk factors; AF itself acts as an independent risk factor for stroke. The combination of effective anticoagulation therapy, risk stratification (based on stroke risk scores, such as CHADS2 and CHA2DS2-VASc), and recommendations provided by guidelines is essential for decreasing the risk of stroke in patients with AF. Although effective in preventing the occurrence of stroke, vitamin K antagonists (VKAs; e.g., warfarin) are associated with several limitations. Therefore, direct oral anticoagulants, such as apixaban, dabigatran etexilate, edoxaban, and rivaroxaban, have emerged as an alternative to the VKAs for stroke prevention in patients with nonvalvular AF. Compared with the VKAs, these agents have more favorable pharmacological characteristics and, unlike the VKAs, they are given at fixed doses without the need for routine coagulation monitoring. It remains important that physicians use these direct oral anticoagulants responsibly to ensure optimal safety and effectiveness. This article provides an overview of the existing data on the direct oral anticoagulants, focusing on management protocols for aiding physicians to optimize anticoagulant therapy in patients with nonvalvular AF, particularly in special patient populations (e.g., those with renal impairment) and other specific clinical situations.

  15. Bezlotoxumab for Prevention of Recurrent Clostridium difficile Infection.

    PubMed

    Wilcox, Mark H; Gerding, Dale N; Poxton, Ian R; Kelly, Ciaran; Nathan, Richard; Birch, Thomas; Cornely, Oliver A; Rahav, Galia; Bouza, Emilio; Lee, Christine; Jenkin, Grant; Jensen, Werner; Kim, You-Sun; Yoshida, Junichi; Gabryelski, Lori; Pedley, Alison; Eves, Karen; Tipping, Robert; Guris, Dalya; Kartsonis, Nicholas; Dorr, Mary-Beth

    2017-01-26

    Background Clostridium difficile is the most common cause of infectious diarrhea in hospitalized patients. Recurrences are common after antibiotic therapy. Actoxumab and bezlotoxumab are human monoclonal antibodies against C. difficile toxins A and B, respectively. Methods We conducted two double-blind, randomized, placebo-controlled, phase 3 trials, MODIFY I and MODIFY II, involving 2655 adults receiving oral standard-of-care antibiotics for primary or recurrent C. difficile infection. Participants received an infusion of bezlotoxumab (10 mg per kilogram of body weight), actoxumab plus bezlotoxumab (10 mg per kilogram each), or placebo; actoxumab alone (10 mg per kilogram) was given in MODIFY I but discontinued after a planned interim analysis. The primary end point was recurrent infection (new episode after initial clinical cure) within 12 weeks after infusion in the modified intention-to-treat population. Results In both trials, the rate of recurrent C. difficile infection was significantly lower with bezlotoxumab alone than with placebo (MODIFY I: 17% [67 of 386] vs. 28% [109 of 395]; adjusted difference, -10.1 percentage points; 95% confidence interval [CI], -15.9 to -4.3; P<0.001; MODIFY II: 16% [62 of 395] vs. 26% [97 of 378]; adjusted difference, -9.9 percentage points; 95% CI, -15.5 to -4.3; P<0.001) and was significantly lower with actoxumab plus bezlotoxumab than with placebo (MODIFY I: 16% [61 of 383] vs. 28% [109 of 395]; adjusted difference, -11.6 percentage points; 95% CI, -17.4 to -5.9; P<0.001; MODIFY II: 15% [58 of 390] vs. 26% [97 of 378]; adjusted difference, -10.7 percentage points; 95% CI, -16.4 to -5.1; P<0.001). In prespecified subgroup analyses (combined data set), rates of recurrent infection were lower in both groups that received bezlotoxumab than in the placebo group in subpopulations at high risk for recurrent infection or for an adverse outcome. The rates of initial clinical cure were 80% with bezlotoxumab alone, 73% with actoxumab

  16. Cardiac procedures to prevent stroke: patent foramen ovale closure/left atrial appendage occlusion.

    PubMed

    Freixa, Xavier; Arzamendi, Dabit; Tzikas, Apostolos; Noble, Stephane; Basmadjian, Arsene; Garceau, Patrick; Ibrahim, Réda

    2014-01-01

    Stroke is a major contributor to population morbidity and mortality. Cardiac thromboembolic sources are an important potential cause of stroke. Left atrial appendage (LAA) thromboembolism in association with atrial fibrillation is a major contributor to stroke occurrence, particularly in elderly individuals. Patent foramen ovale (PFO) acts as a potential conduit from the right-sided circulation to the brain, and has been suggested to be an important factor in cryptogenic stroke in the young patients. Advances in interventional cardiology have made it possible to deal with these potential stroke sources (LAA and PFO), but the available methods have intrinsic limitations that must be recognized. Furthermore, the potential value of LAA and PFO closure depends on our ability to identify when the target structure is importantly involved in stroke risk; this is particularly challenging for PFO. This article addresses the clinical use of PFO and LAA closure in stroke prevention. We discuss technical aspects of closure devices and methods, questions of patient selection, and clinical trials evidence. We conclude that for PFO closure, the clinical trials evidence is thus far negative in the broad cryptogenic stroke population, but closure might nevertheless be indicated for selected high-risk patients. LAA closure has an acceptable balance between safety and efficacy for atrial fibrillation patients with high stroke risk and important contraindications to oral anticoagulation. Much more work needs to be done to optimize the devices and techniques, and better define patient selection for these potentially valuable procedures.

  17. Urethral recurrence after cystectomy: current preventative measures, diagnosis and management.

    PubMed

    Chan, Yvonne; Fisher, Patrick; Tilki, Derya; Evans, Christopher P

    2016-04-01

    To summarise the current literature on the diagnosis and management of urethral recurrence (UR) after radical cystectomy (RC), as UR after RC is rare but associated with high mortality. With the recently increased use of orthotopic bladder substitution and the questionable benefit of prophylactic urethrectomy, identification of patients at high risk of UR, management of the remnant urethra, and treatment of UR become critical questions. A review of the PubMed database from 1980 to 2014 was performed to identify studies evaluating recurrent urothelial cancer of the urethra after RC. The search terms used included 'urethral recurrence', 'cystectomy' or 'cystoprostatectomy'. Selected studies provided information on the type of urinary diversion performed, the incidence of UR, and the time to UR. Incidence of UR after RC ranges from 1% to 8% with most recurrences occurring within the first 2 years after surgery. Increased risk of UR is associated with involvement of the prostate, tumour multifocality, bladder neck involvement, and cutaneous diversion. The median overall survival after UR ranges from 6 to 54 months and the 5-year disease-specific survival after UR is reported to be between zero and 83%. UR remains a relatively rare event. Current literature suggests that urethral wash cytology may be useful in patients with intermediate- to high-risk of recurrence to enable early detection of non-invasive disease, which may be amenable to conservative therapy before urethrectomy.

  18. Effects of a Stroke Primary Prevention Program on Risk Factors for At-Home Elderly.

    PubMed

    Jeon, Mi Yang; Jeong, HyeonCheol

    2015-11-28

    BACKGROUND To prevent stroke from occurring, stroke risk factors in at-risk subjects should be controlled and the diseases causing stroke should be managed. This study evaluated a nursing intervention to prevent stroke in at-risk elderly living at home. The program consisted of stroke and nutrition education as well as exercise guidance. MATERIAL AND METHODS This study targeted 93 elderly people living at home residing in E province with 1 or more stroke risk factors, including high blood pressure, diabetes, hyperlipidemia, obesity, smoking, or drinking alcohol. The 12-week program included a stroke education class once a week, a nutrition management class once a week, and exercise guidance 3 times a week. Each session lasted 50-70 min. Each disease education and nutrition management session lasted for 20 min and each exercise session lasted for 30-50 min. RESULTS The experimental group's body mass index (BMI) (t=8.27, p<.001), systolic blood pressure (t=2.39, p=.021), fasting blood sugar (t=0.39, p=.700), total cholesterol (t=4.18, p<.001), triglyceride levels (t=2.50, p=.016), and depression scores (t=5.48, p<.001) were significantly reduced and high-density phospholipid protein levels increased significantly by the end of the program (t=-2.94, p=.005). CONCLUSIONS Based on the results of this study, participating in a stroke prevention program enabled at-risk elderly participants who lived at home in rural areas to perform health-promoting behaviors. This program may reduce the incidence of stroke by reducing risk factors and managing stroke precursor diseases.

  19. Status and costs of primary prevention for ischemic stroke in China.

    PubMed

    Zhao, J J; He, G Q; Gong, S Y; He, L

    2013-10-01

    Despite the benefits in reducing the risk of stroke, primary prevention is not well translated into practice. We sought to evaluate patient compliance with guidelines and the cost of primary stroke prevention in southwest China. We consecutively enrolled 305 patients with headaches and/or dizziness who were at high risk of stroke from our hospital. We retrospectively obtained their information, including the extent of their knowledge of stroke risk factors, adherence to guidelines, medications taken, and costs of primary prevention for stroke within the past year. Only 45.9% of patients had any knowledge of primary prevention, and only 17.0% had completely followed guidelines. Moreover, 79.0% of the patients were using medications, but only 39.3% took their medication as recommended. In patients who took medication, 89.6% were prescribed by physicians. The annual costs of primary prevention were estimated to be US$517.8 per capita, which included direct medical costs (US$435.4), direct non-medical costs (US$18.1), and indirect costs (US$64.3). Costs in the hypertension group were less than those reported by a similar international study. Although our population sample may not be representative of the population at high risk of stroke in China, it is appropriate for the evaluation of our primary prevention system. Primary prevention for stroke in southwest China is very challenging, with few medical resource investments. There is a current urgency to improve patient knowledge of primary prevention, which would bridge the gaps between guidelines and practice and increase medical resource investments.

  20. Is it possible to apply secondary stroke prevention guidelines to very old populations?

    PubMed

    Brescacín, Laura

    2011-03-01

    The aging population is an undeniable reality which must be faced by all health systems all over the world. Among people over 80 years old, increase in stroke incidence, high mortality rates and adverse outcomes are problems of major public concern. Lack of evidence-based data to guide rational decision making on vascular risk factors management to avoid recurrence in elderly stroke patients increases the areas of uncertainty, and sometimes favors medical inertia at the time of taking care of this growing elderly population.

  1. RECURRENT STROKE IN THE WARFARIN VERSUS ASPIRIN IN REDUCED EJECTION FRACTION (WARCEF) TRIAL

    PubMed Central

    Pullicino, Patrick M.; Qian, Min; Sacco, Ralph L.; Freudenberger, Ron; Graham, Susan; Teerlink, John R.; Mann, Douglas; Di Tullio, Marco R.; Ponikowski, Piotr; Lok, Dirk J.; Anker, Stefan D.; Lip, Gregory Y.H.; Estol, Conrado J.; Levin, Bruce; Mohr, J.P.; Thompson, John L. P.; Homma, Shunichi

    2014-01-01

    Background and Purpose WARCEF randomized 2305 patients in sinus rhythm with ejection fraction (EF) ≤35% to warfarin (INR 2.0–3.5) or aspirin 325 mg. Warfarin reduced the incident ischemic stroke (IIS) hazard rate by 48% over aspirin in a secondary analysis. The IIS rate in heart failure (HF) is too low to warrant routine anticoagulation but epidemiologic studies show that prior stroke increases the stroke risk in HF. We here explore IIS rates in WARCEF patients with and without baseline stroke to look for risk factors for IIS and determine if a subgroup with an IIS rate high enough to give a clinically relevant stroke risk reduction can be identified. Methods We compared potential stroke risk factors between patients with baseline stroke and those without using the exact conditional score test for Poisson variables. We looked for risk factors for IIS, by comparing IIS rates between different risk factors. For EF we tried cutoff points of 10%, 15% and 20%. 15% was used as it was the highest EF that was associated with a significant increase in IIS rate. IIS and EF strata were balanced as to warfarin/aspirin assignment by the stratified randomized design. A multiple Poisson regression examined the simultaneous effects of all risk factors on IIS rate. IIS rates per hundred patient years (/100PY) were calculated in patient groups with significant risk factors. Missing values were assigned the modal value. Results Twenty of 248 (8.1%) patients with baseline stroke and 64 of 2048 (3.1%) without had IIS. IIS rate in patients with baseline stroke (2.37/100PY) was greater than patients without (0.89/100PY)(rate ratio 2.68, p<0.001). Fourteen of 219 (6.4%) patients with ejection fraction (EF)<15% and 70 of 2079 (3.4%) with EF ≥15% had IIS. In the multiple regression analysis stroke at baseline (p<0.001) and EF<15% vs. ≥15% (p=.005) remained significant predictors of IIS. IIS rate was 2.04/100PY in patients with EF<15% and 0.95/100PY in patients with EF ≥15% (p=0

  2. Cost-benefit analysis of the polypill in the primary prevention of myocardial infarction and stroke.

    PubMed

    Wald, Nicholas J; Luteijn, Johannes Michiel; Morris, Joan K; Taylor, David; Oppenheimer, Peter

    2016-04-01

    The primary prevention of cardiovascular disease is a public health priority. To assess the costs and benefits of a Polypill Prevention Programme using a daily 4-component polypill from age 50 in the UK, we determined the life years gained without a first myocardial infarction (MI) or stroke, together with the total service cost (or saving) and the net cost (or saving) per year of life gained without a first MI or stroke. This was estimated on the basis of a 50 % uptake and a previously published 83 % treatment adherence. The total years of life gained without a first MI or stroke in a mature programme is 990,000 each year in the UK. If the cost of the Polypill Prevention Programme were £1 per person per day, the total cost would be £4.76 bn and, given the savings (at 2014 prices) of £2.65 bn arising from the disease prevented, there would be a net cost of £2.11 bn representing a net cost per year of life gained without a first MI or stroke of £2120. The results are robust to sensitivity analyses. A national Polypill Prevention Programme would have a substantial effect in preventing MIs and strokes and be cost-effective.

  3. Compression for Primary Prevention, Treatment, and Prevention of Recurrence of Venous Leg Ulcers

    PubMed Central

    Yates, Stephanie; McNichol, Laurie; Gray, Mikel

    2016-01-01

    Chronic venous insufficiency is a prevalent disease that frequently leads to development of venous leg ulcers. While a number of evidence-based clinical practice guidelines have been developed that provide guidance for clinicians when caring for patients with chronic venous insufficiency, they lack adequate detail concerning selection and application of compression for prevention and management of venous leg ulcers. In order to address this need, the WOCN Society appointed a task force to develop an algorithm for compression for primary prevention, treatment, and prevention of recurrent venous leg ulcers in persons with chronic venous insufficiency. The task force used findings from a scoping literature review to identify current best evidence needed to support decision points and pathways within the algorithm. In addition, the task force convened a panel of 20 clinicians and researchers with expertise in lower extremity venous disorders in order to establish consensus around pathways and decision points within the algorithm lacking robust evidence. Following initial construction of the algorithm, a second interdisciplinary group of expert clinicians established content validity and provided additional qualitative feedback used to complete final revisions of the algorithm. This article reviews the process used to create this landmark algorithm, including generation of the evidence- and consensus-based statements used in its construction, the various pathways, and rich supplemental materials embedded within the algorithm, and the process used to establish content validity. PMID:27163774

  4. Prevention of Stroke in Patients With Silent Cerebrovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.

    PubMed

    Smith, Eric E; Saposnik, Gustavo; Biessels, Geert Jan; Doubal, Fergus N; Fornage, Myriam; Gorelick, Philip B; Greenberg, Steven M; Higashida, Randall T; Kasner, Scott E; Seshadri, Sudha

    2017-02-01

    Two decades of epidemiological research shows that silent cerebrovascular disease is common and is associated with future risk for stroke and dementia. It is the most common incidental finding on brain scans. To summarize evidence on the diagnosis and management of silent cerebrovascular disease to prevent stroke, the Stroke Council of the American Heart Association convened a writing committee to evaluate existing evidence, to discuss clinical considerations, and to offer suggestions for future research on stroke prevention in patients with 3 cardinal manifestations of silent cerebrovascular disease: silent brain infarcts, magnetic resonance imaging white matter hyperintensities of presumed vascular origin, and cerebral microbleeds. The writing committee found strong evidence that silent cerebrovascular disease is a common problem of aging and that silent brain infarcts and white matter hyperintensities are associated with future symptomatic stroke risk independently of other vascular risk factors. In patients with cerebral microbleeds, there was evidence of a modestly increased risk of symptomatic intracranial hemorrhage in patients treated with thrombolysis for acute ischemic stroke but little prospective evidence on the risk of symptomatic hemorrhage in patients on anticoagulation. There were no randomized controlled trials targeted specifically to participants with silent cerebrovascular disease to prevent stroke. Primary stroke prevention is indicated in patients with silent brain infarcts, white matter hyperintensities, or microbleeds. Adoption of standard terms and definitions for silent cerebrovascular disease, as provided by prior American Heart Association/American Stroke Association statements and by a consensus group, may facilitate diagnosis and communication of findings from radiologists to clinicians.

  5. Recent advances in the understanding and management of atrial fibrillation: a focus on stroke prevention

    PubMed Central

    Shahid, Farhan; Shantsila, Eduard; Lip, Gregory Y. H.

    2016-01-01

    Atrial fibrillation (AF) is associated with an increased risk of stroke compared with the general population. It is anticipated that by 2030 an estimated 14–17 million patients will be diagnosed with this most prevalent arrhythmia within the European Union. AF-related stroke confers a higher mortality and morbidity risk, and thus early detection and assessment for the initiation of effective stroke prevention with oral anticoagulation (OAC) is crucial. Recent guidelines point to the use of non-vitamin K antagonist OACs (NOACs) where appropriate in stroke prevention of patients with non-valvular AF. At present, there are four NOACS available, with no direct head-to-head comparisons to suggest the superiority of one drug over another. Simple and practical risk assessment tools have evolved over the years to facilitate stroke and bleeding risk assessment in busy clinics and wards to aid decision-making. At present, the CHA 2DS 2VASc (congestive heart failure, hypertension, age 65–74/>75, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, female sex) score is recommended by many international guidelines as a simple and practical method of assessing stroke risk in such patients. Alongside this, use of the HAS BLED (hypertension systolic blood pressure >160 mmHg, abnormal liver/renal function [with creatinine ≥200 μmol/L], stroke, bleeding history or predisposition, labile international normalized ratio [range <60% of the time], elderly [>65], concomitant drugs/alcohol) score aims to identify patients at high risk of bleeding for more regular review and follow-up and draws attention to potentially reversible bleeding risk factors. The aim of this review article is to provide an overview of recent advances in the understanding and management of AF with a focus on stroke prevention. PMID:28105320

  6. A review of apixaban for stroke prevention in atrial fibrillation: insights from ARISTOTLE.

    PubMed

    Hess, Connie N; Al-Khatib, Sana M; Granger, Christopher B; Lopes, Renato

    2013-09-01

    Atrial fibrillation (AF) is associated with significant mortality and morbidity, and stroke represents the most-feared complication. Consequently, AF treatment has focused on thromboprophylaxis, with warfarin as the mainstay of therapy. However, concerns over ease of use and safety have limited its use. Three novel oral anticoagulants have been approved for use in stroke prevention in AF based on randomized data: 1) dabigatran, studied in Randomized Evaluation of Long-term Anticoagulation Therapy (RE-LY); 2) rivaroxaban, studied in Rivaroxaban Once-daily, Oral, Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF); and 3) apixaban, studied in Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE). In this review, we focus on apixaban and discuss subgroup analyses that have been performed in the three trials comparing novel oral anticoagulants with warfarin. We conclude with recommendations regarding further investigations.

  7. Detection of multiple annexin autoantibodies in a patient with recurrent miscarriages, fulminant stroke and seronegative antiphospholipid syndrome.

    PubMed

    Scholz, Philipp; Auler, Markus; Brachvogel, Bent; Benzing, Thomas; Mallman, Peter; Streichert, Thomas; Klatt, Andreas R

    2016-01-01

    Anti-phospholipid syndrome (APS) is one of the main causes for recurrent miscarriages. The diagnosis of APS is based on the occurrence of clinical symptoms such as thrombotic events or obstetric complications as well as the detection of antiphospholipid antibodies directed against β2-glycoprotein I and cardiolipin, or a positive lupus anticoagulant assay. However, there is a subpopulation of patients with clinical symptoms of APS, but the lack of serological markers (seronegative APS). In addition, a large proportion of patients with unexplained recurrent miscarriages exist. These cases may be attributed, at least in part, to a seronegative APS.
The presence of autoantibodies against annexins is potentially associated with APS. Here we used immunoassays and immunoblots to detect autoantibodies directed against annexin A1-5, and A8, respectively, in a patient with a seronegative APS and a history of six recurrent pregnancy losses and fulminant stroke. We found strong IgM isotype antibody reactivity directed against annexin A2 and annexin A8, and moderate to weak IgM isotype antibody reactivity directed against annexin A1, A3, and A5. Further studies will evaluate the diagnostic value of IgM isotype antibodies against annexin A1-A5, and A8 for seronegative APS and recurrent miscarriages.

  8. How French general practitioners manage and prevent recurrent respiratory tract infections in children: the SOURIRRE survey

    PubMed Central

    Chicoulaa, Bruno; Haas, Hervé; Viala, Jérôme; Salvetat, Maryline; Olives, Jean-Pierre

    2017-01-01

    Background Recurrent respiratory tract infections (RRTIs) are the most common reason for children’s visits to primary care physicians in France; however, little is known about general practitioners’ (GPs) opinions and expectations concerning the management and prevention of these common and recurrent pathologies. Purpose To describe French GPs’ daily practice in the management of respiratory infections and the prevention of their recurrence in children. Methods A sample group of French GPs answered a structured questionnaire on risk factors, RRTI management, antibiotic use and prevention measures. Results A total of 358 GPs participated in the survey. Rhinopharyngitis, the most frequent respiratory infection, was considered to be recurrent if six or more episodes occurred in a year. Four risk factors were acknowledged as substantial: living in communities, passive smoking, pollution and allergies. Around 63% of GPs said that RRTIs are too often treated with antibiotics. More than 85% thought that prevention of RRTIs is possible. Smoking cessation, vaccination, allergen avoidance and hygiene were identified as the main preventive measures. A large majority of GPs (84%) prescribed products for prevention and ~90% would prescribe a product stimulating immunity if the efficacy and tolerability of these agents was proven and confirmed in their daily practice. Conclusions French GPs are well aware of the health and socioeconomic burdens resulting from RRTIs, as well as the risk of antibiotic overuse. They have a prevention-oriented approach, implement preventive measures when possible and prescribe products for prevention. PMID:28293116

  9. Tissue plasminogen activator prevents white matter damage following stroke

    PubMed Central

    Correa, Fernando; Gauberti, Maxime; Parcq, Jérôme; Macrez, Richard; Hommet, Yannick; Obiang, Pauline; Hernangómez, Miriam; Montagne, Axel; Liot, Géraldine; Guaza, Carmen; Maubert, Eric; Ali, Carine; Vivien, Denis

    2011-01-01

    Tissue plasminogen activator (tPA) is the only available treatment for acute stroke. In addition to its vascular fibrinolytic action, tPA exerts various effects within the brain, ranging from synaptic plasticity to control of cell fate. To date, the influence of tPA in the ischemic brain has only been investigated on neuronal, microglial, and endothelial fate. We addressed the mechanism of action of tPA on oligodendrocyte (OL) survival and on the extent of white matter lesions in stroke. We also investigated the impact of aging on these processes. We observed that, in parallel to reduced levels of tPA in OLs, white matter gets more susceptible to ischemia in old mice. Interestingly, tPA protects murine and human OLs from apoptosis through an unexpected cytokine-like effect by the virtue of its epidermal growth factor–like domain. When injected into aged animals, tPA, although toxic to the gray matter, rescues white matter from ischemia independently of its proteolytic activity. These studies reveal a novel mechanism of action of tPA and unveil OL as a target cell for cytokine effects of tPA in brain diseases. They show overall that tPA protects white matter from stroke-induced lesions, an effect which may contribute to the global benefit of tPA-based stroke treatment. PMID:21576385

  10. Graduated compression stockings to prevent venous thromboembolism in hospital: evidence from patients with acute stroke.

    PubMed

    Kearon, Clive; O'Donnell, Martin

    2011-01-01

    Pulmonary embolism is the most common preventable cause of death in hospital patients and prevention of venous thromboembolism (VTE) is cost-saving in high-risk patients. Low-dose anticoagulation is very effective at preventing VTE but increases bleeding. Graduated compression stockings and intermittent pneumatic compression devices are also used to prevent VTE and do not increase bleeding, which makes their use appealing in patients who cannot tolerate bleeding, such as patients with acute stroke. Studies that evaluated mechanical methods of preventing VTE were small and mainly used asymptomatic deep vein thrombosis (DVT), detected using screening tests, as the study outcome. The recently published CLOTS Trial 1 (Clots in Legs Or sTockings after Stroke) compared thigh-level compression stockings with no stockings in about 2500 patients with stroke and immobility, and found that thigh-level stockings were not effective. Indirectly, the findings of this study question the ability of stockings to prevent VTE in other patient groups, including those after surgery. CLOTS 1 compared thigh-level and below-knee stockings in about 3000 patients with acute stroke. Given that thigh-level stockings were ineffective in CLOTS 1, it is surprising that they were more effective than below-knee stockings in CLOTS Trial 2. A possible explanation is that below-knee stockings increase DVT, although this seems unlikely. CLOTS 1 and CLOTS 2 question whether graduated compression stockings prevent VTE and suggest the need for further trials evaluating their efficacy in medical and surgical patients.

  11. Adjuvant Chinese Herbal Products for Preventing Ischemic Stroke in Patients with Atrial Fibrillation

    PubMed Central

    Muo, Chih-Hsin; Chiu, Hsienhsueh Elley; Liu, Chun-Ting

    2016-01-01

    Objective Chinese herbal products (CHPs) are widely used for atrial fibrillation (AF) in Taiwan. We investigated the effect of adjuvant CHPs in preventing ischemic stroke in patients with AF. Methods Taiwanese patients in the Health Insurance Database newly diagnosed with AF during 2000–2011 were enrolled. Medication treatment with/without CHPs was administered within 7 days after the AF diagnosis. The clinical endpoint was an ischemic stroke. The Chi-square test, Fisher’s exact test, and Student t test were used to examine differences between the traditional Chinese medicine (TCM) and non-TCM cohorts. Cox proportional hazard regression was used to assess the risk for ischemic stroke between two cohorts. Results Three hundred and eleven patients underwent TCM treatment and 1715 patients did not. Compared to non-TCM users, TCM users had a lower incidence of stroke (12.59% vs. 1.93%, respectively) and lower risk of stroke [CHA2DS2-VASc score = 0–2 (hazard ratio = 0.20; 95% confidence interval = 0.06–0.65)]. Compared to non-TCM users, the stroke risk was significantly lower in TCM users with AF who were female or younger than 65 years, but not in males, people more than 65 years old, or people with comorbidities. Compared to TCM users, non-TCM users who received conventional treatment had a higher ischemic stroke risk. The risk for AF-related hospitalization was significantly lower in TCM users (0.64%) than in non-TCM users (38.1%). Conclusions Users of TCM with AF have a lower risk of new-onset ischemic stroke. Therefore, adjuvant CHP therapy may have a protective effect and may be used in AF patients to prevent ischemic stroke. PMID:27428543

  12. Role of dexamethasone in the prevention of migraine recurrence in the acute care setting: a review.

    PubMed

    Giuliano, Christopher; Smalligan, Roger D; Mitchon, Greg; Chua, Matt

    2012-05-01

    Patients with migraine headaches are commonly encountered by clinicians both in the clinic and in the emergency department. Migraines impose a significant financial burden on patients, caregivers, and society. Up to 49% of patients treated acutely for migraine headache will have a recurrence within 72 hours. Recurrence of migraines is dependent on a number of factors, including the choice of abortive agent, age, sex, and initial severity of the migraine. Dexamethasone has been proposed and studied as a medication that may decrease the frequency of such recurrences of migraine headaches in affected patients. Dexamethasone is a corticosteroid that has been proposed to prevent recurrence of migraines through its prevention of neurogenic inflammation. Initial trials, with less-than-ideal methodology, showed large decreases in the number of patients experiencing recurrent migraines. Later randomized controlled trials revealed mixed results, with subsequent meta-analyses showing an overall benefit in the prevention of recurrence of migraines. These meta-analyses suggest that dexamethasone will prevent recurrence in about 10% of patients, although trials that used higher doses of dexamethasone and followed patients for ≥ 72 hours showed a larger benefit. Very few adverse events were reported in the randomized controlled trials following a single dose of dexamethasone. Given the benign side effect profile and wide tolerability to a single high dose of dexamethasone, it appears to be a safe and modestly effective addition to standard migraine abortive therapy for the prevention of migraine recurrence. Dexamethasone should not be used in patients with non-migraine headaches or contraindications to steroids. Further studies should help delineate if dexamethasone can be tailored to specific patient populations and hence enhance its therapeutic effectiveness.

  13. Systematic review and network meta-analysis of stroke prevention treatments in patients with atrial fibrillation

    PubMed Central

    Tawfik, Amy; Bielecki, Joanna M; Krahn, Murray; Dorian, Paul; Hoch, Jeffrey S; Boon, Heather; Husereau, Don; Pechlivanoglou, Petros

    2016-01-01

    Background In the last 4 years, four novel oral anticoagulants have been developed as alternatives to warfarin and antiplatelet agents for stroke prevention in atrial fibrillation (AF) patients. The objective of this review was to estimate the comparative effectiveness of all antithrombotic treatments for AF patients. Materials and methods Data sources were Medline Ovid (1946 to October 2015), Embase Ovid (1980 to October 2015), and the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 9, 2015). Randomized controlled trials of AF patients were selected if they compared at least two of the following: placebo, aspirin, aspirin and clopidogrel combination therapy, adjusted-dose warfarin (target international normalized ratio 2.0–3.0), dabigatran, rivaroxaban, apixaban, and edoxaban. Bayesian network meta-analyses were conducted for outcomes of interest (all stroke, ischemic stroke, myocardial infarction, overall mortality, major bleeding, and intracranial hemorrhage). Results Based on 16 randomized controlled trials of 96,826 patients, all oral anticoagulants were more effective than antiplatelet agents at reducing the risk of ischemic stroke and all strokes. Compared to warfarin, dabigatran 150 mg (rate ratio 0.65, 95% credible interval 0.52–0.82) and apixaban (rate ratio 0.82, 95% credible interval 0.69–0.97) reduced the risk of all strokes. Dabigatran 150 mg was also more effective than warfarin at reducing ischemic stroke risk (rate ratio 0.76, 95% credible interval 0.59–0.99). Aspirin, apixaban, dabigatran 110 mg, and edoxaban were associated with less major bleeding than warfarin. Conclusion All oral anticoagulants reduce the risk of stroke in AF patients. Some novel oral anticoagulants are associated with a lower stroke and/or major bleeding risk than warfarin. In addition to the safety and effectiveness of drug therapy, as reported in this study, individual treatment recommendations should also consider the patient’s underlying stroke

  14. Concepts in Onychomycosis Treatment and Recurrence Prevention: An Update.

    PubMed

    Rosen, Theodore

    2016-03-01

    In considering therapy for onychomycosis, the most important factor to take into account is patient selection rather than treatment selection. Patients should be screened and evaluated for the extent of nail involvement, the amount of subungual debris, the degree of dystrophy, their ability and willingness to follow the regimen, and whether comorbidities are present that may affect the efficacy and/or safety of one or more therapies. Onychomycosis is a chronic disease with a high recurrence rate. Commonsense measures to reduce the risk for reinfection include patient education and a clinician-patient team approach to long-term management.

  15. Stroke

    MedlinePlus

    ... Is a Stroke? A stroke occurs if the flow of oxygen-rich blood to a portion of the brain ... pressure from the leaked blood damages brain cells. High blood pressure and ... A TIA occurs if blood flow to a portion of the brain is blocked ...

  16. [Stroke prevention in sickle-cell disease: results, hurdles and future perspectives].

    PubMed

    Bernaudin, Françoise; Verlhac, Suzanne

    2008-10-01

    Sickle cell disease (SCD) is the most frequent cause of stroke during infancy, and stroke is the most serious complication of SCD in children. Sludge-induced distal vasculopathy explains 25% of strokes in SCD, while proximal vasculopathy is responsible for 75% of cases. The stenoses observed in SCD-related proximal vasculopathy are progressive and can be detected by transcranial Doppler (TCD), a reliable, non-invasive and low-cost imaging method. High velocities (> 2 mls) are associated with a 40% risk of stroke within 36 months, but initiation of a transfusion program maintaining the HbS level under 30% reduces the risk to less than 2%. TCD must be performed in all children at 12-18 months of age to detect cerebral vasculopathy and prevent stroke. This approach has been adopted in our institution, based on a cohort of SCD newborns screened at birth: the risk of stroke was reduced from the expected 11% to less than 2% at 18 years. Genoidentical stem cell transplantation, which safely obviates the need for transfusion programs and provides a 95% chance of cure, should be offered early to patients at risk of stroke. When possible, sibling cord blood cryopreservation is recommended

  17. Stroke in Latin America: Burden of Disease and Opportunities for Prevention.

    PubMed

    Avezum, Álvaro; Costa-Filho, Francisco F; Pieri, Alexandre; Martins, Sheila O; Marin-Neto, José A

    2015-12-01

    The epidemiological transition in Latin America toward older urban dwelling adults has led to the rise in cardiovascular risk factors and an increase in morbidity and mortality rates related to both stroke and myocardial infarction. As a result, there is an immediate need for effective actions resulting in better detection and control of cardiovascular risk factors that will ultimately reduce cardiovascular disease burden. Data from case-control studies have identified the following risk factors associated with stroke: hypertension; smoking; abdominal obesity; diet; physical activity; diabetes; alcohol intake; psychosocial factors; cardiac causes; and dyslipidemia. In addition to its high mortality, patients who survive after a stroke present quite frequently with marked physical and functional disability. Because stroke is the leading cause of death in most Latin American countries and also because it is a clearly preventable cause of death and disability, simple, affordable, and efficient strategies must be urgently implemented in Latin America.

  18. Sex differences in ischaemic stroke: potential cellular mechanisms.

    PubMed

    Chauhan, Anjali; Moser, Hope; McCullough, Louise D

    2017-04-01

    Stroke remains a leading cause of mortality and disability worldwide. More women than men have strokes each year, in part because women live longer. Women have poorer functional outcomes, are more likely to need nursing home care and have higher rates of recurrent stroke compared with men. Despite continued advancements in primary prevention, innovative acute therapies and ongoing developments in neurorehabilitation, stroke incidence and mortality continue to increase due to the aging of the U.S.

  19. Apixaban for stroke prevention in atrial fibrillation: a review of the clinical trial evidence.

    PubMed

    Yates, Scott W

    2011-10-01

    The objective of this review is to summarize data from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) and Apixaban Versus Acetylsalicylic Acid to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment (AVERROES) trials of apixaban for stroke prevention in patients with atrial fibrillation (AF). The ARISTOTLE trial compared apixaban with warfarin in 18 201 patients with AF and ≥ 1 additional risk factor for stroke. The AVERROES trial compared apixaban with aspirin in 5599 patients with AF who were at increased risk of stroke and for whom vitamin K antagonists were unsuitable. In ARISTOTLE, apixaban reduced the risk of stroke or systemic embolism by 21% compared with warfarin (1.27% vs 1.60% per year; hazard ratio, 0.79; 95% confidence interval, 0.66-0.95). The reduction was significant and demonstrated the superiority of apixaban over warfarin for the primary outcome of preventing stroke or systemic embolism (P = 0.01 for superiority). Apixaban also reduced all-cause mortality by 11% (P = 0.047) and major bleeding by 31% (P < 0.001) compared with warfarin. The benefits of apixaban observed in ARISTOTLE are further supported by the results from AVERROES, which demonstrated a 55% reduction in the risk of stroke or systemic embolism compared with aspirin. Risk of major bleeding was not significantly different between apixaban and aspirin. Subgroup analyses in both trials demonstrated that the effects of apixaban are highly consistent across various patient subpopulations. Discontinuation of study medication was significantly lower with apixaban than with either warfarin in ARISTOTLE or aspirin in AVERROES. Apixaban is the first new oral anticoagulant that has been shown to be superior to warfarin in reducing stroke or systemic embolism, all-cause mortality, and major bleeding in patients with AF. Moreover, in patients with AF who are considered

  20. Do thiazides prevent recurrent idiopathic renal calcium oxalate stones?

    PubMed

    Wolf, H; Brocks, P; Dahl, C

    1983-01-01

    In a double-blind controlled clinical trial 62 patients with recurrent idiopathic renal calcium oxalate stone formation were allocated either to treatment with bendroflumethiazide, 2.5 mg three times a day, or placebo. In each group the rate of stone formation during medication (average follow-up period 36 months) was compared with the rate of stone formation before medication (average control period 36 months). In both groups a similar striking fall in the rate of stone formation was found, indicating that thiazides in this study did not alter the spontaneous course of idiopathic renal calcium oxalate stone formation. It is doubtful whether life-long prophylaxis with thiazide is justified in patients with a moderate rate of stone formation.

  1. Management and prevention of recurrent herpes labialis in immunocompetent patients.

    PubMed

    Gilbert, Stanley C

    2007-12-01

    A range of topical and systemic therapies exists for treating recurrent herpes labialis. Among the topical agents, aciclovir and its derivatives can lessen the symptoms and duration of disease if applied frequently in the proper vehicle and started during the prodromal phase. Delivering these agents to the lesion via novel devices or vehicles may enhance their topical efficacy in the future. Among the systemic agents, new high-dose, 1-day regimens using either famciclovir or valaciclovir offer greater convenience and cost-effectiveness compared with traditional 5-7-day therapy. Combining either topical or systemic antinucleoside agents with topical anti-inflammatories such as corticosteroids may also lead to enhanced efficacy. Novel agents such as docosanol, toll-like receptor agonists, and viral ribonucleoside reductase inhibitors may also play a larger role in the future.

  2. Role of Endovascular Closure of the Left Atrial Appendage in Stroke Prevention for Atrial Fibrillation.

    PubMed

    Kiani, Jawad; Holmes, David R

    2015-11-01

    The pathophysiologic mechanism of thromboembolic stroke in the setting of non-valvular atrial fibrillation (AF) resides in the left atrial appendage (LAA). In this setting, approximately 90 % of all strokes originate from this structure. Percutaneous left atrial appendage occlusion (LAAO) therapy has recently emerged as an important strategy for prevention of stroke and systemic embolism in patients with non-valvular AF. Systemic anticoagulation therapy in this AF population, while effective, is associated with a significant bleeding risk, drug compliance issues, and limited reversal strategies. In this manuscript, we will review the percutaneous devices and techniques that allow endovascular closure of the LAA, including their efficacy in stroke prevention, the safety profile of these local site-specific therapies, comparison of the multiple approaches being studied, the index patient populations involved, and long-term follow-up in comparison with systemic anticoagulation therapy. The percutaneous LAAO approach indeed represents an exciting and revolutionary advance in the field of stroke prevention in AF.

  3. Secondary prevention of stroke with antiplatelet agents in patients with diabetes mellitus.

    PubMed

    Piechowski-Jozwiak, Bartlomiej; Maulaz, Alexander; Bogousslavsky, Julien

    2005-01-01

    The prevalence of diabetes mellitus (DM) varies from 1.2 to 13.3% in the general population. The most frequent is type 2 (non-insulin-dependent) DM, which constitutes 90-95% of all cases. DM increases the risk of cardiac disease, stroke, retinopathy, nephropathy, neuropathy and gangrene, and the disease is associated with an increased prevalence of other cardiovascular risk factors such as hypertension, hypercholesterolaemia, asymptomatic carotid artery disease, and obesity. The risk of stroke may be directly and indirectly increased by the presence of DM. Epidemiological data show that DM independently amplifies the risk of ischaemic stroke from 1.8- up to 6-fold, so that prevention of cardiovascular risk in diabetics is of utmost importance. The main goal is to control glycaemia, although it has never been shown to be beneficial in stroke patients. Other preventive strategies include antiplatelet treatment. The open-label Primary Prevention Project trial tested the efficacy of low-dose acetylsalicylic acid (ASA) in prevention of ischaemic events in high-risk patients, but failed to demonstrate a significant benefit of ASA in diabetic patients. However, in the CAPRIE trial, the benefit of clopidogrel was amplified in patients with DM versus those without DM in preventing ischaemic events. This difference was even more striking when comparing patients treated with insulin versus non-diabetics. Another trial -- MATCH -- tested the benefit of adding ASA to clopidogrel versus clopidogrel alone in the prevention of ischaemic events in high-risk cerebrovascular patients, two-thirds of whom had DM. Further research is needed to clarify the effects of different antiplatelet regimens in stroke prevention in diabetic patients, who should be considered as high vascular-risk patients.

  4. Using behavioral risk factor surveillance data for heart disease and stroke prevention programs.

    PubMed

    Greenlund, Kurt J; Denny, Clark H; Mokdad, Ali H; Watkins, Nancy; Croft, Janet B; Mensah, George A

    2005-12-01

    An effective state heart disease and stroke prevention program must be able to monitor changes in heart disease and stroke risk factors of the state population. The Behavioral Risk Factor Surveillance System (BRFSS), a state-based telephone survey, has been an important source for monitoring health-related factors and evaluating the success of programs. The BRFSS currently includes modules on hypertension and cholesterol screening and awareness, cardiovascular disease preventive practices, and recognition of the signs and symptoms of heart attack and stroke as well as relevant modules on fruit and vegetable intake, physical activity, tobacco use, and diabetes. Publication topics included monitoring risk factors and clinical services, assessing progress toward national goals, assessing health disparities, and health status and health-related quality of life issues. States have used the BRFSS data for monitoring health risks in the state, assessing state and national health objectives, determining and providing data for public health campaigns, providing information for legislative proposals, and providing information that helps to initiate collaboration. Major methodologic issues involve validating self-reported data against direct measurement and assessing the effects of changes in telecommunications. As Centers for Disease Control's (CDC) national heart disease and stroke prevention program and each state health department program develop, state and even local level data will become more important to measure the burden of disease and program impact. State heart disease and stroke prevention programs are encouraged to work closely with state BRFSS coordinators to obtain vital information to measure the burden of heart disease and stroke in their state and to be able to measure program impact on addressing the first and third leading causes of death in the U.S.

  5. [Postoperative recurrence of Crohn's disease, and its prevention].

    PubMed

    Lakatos, László; Lakatos, Péter László

    2010-05-23

    Crohn's disease is a chronic, progressive disabling condition ultimately leading to stricturing and/or penetrating complications. The need for surgery may be as high as 70% in patients with severe active disease or complications. However, relapse may develop in a significant proportion of the patients after surgery leading to frequent re-operations. Despite emerging data, postoperative prevention is still controversial. After careful evaluation of the individual risk a tailored therapy should be considered. In patients with small risk for relapse mesalazine or in selected cases no-treatment may be an option. In patients with a moderate-to-high risk azathioprine should be considered together with metronidazole in the three months. Follow-up ileocolonoscopy 6-12 months after the surgery is helpful in the determination of endoscopic severity and may assist in the optimization of the therapy. In most severe cases anti-TNF agents may be appropriate for postoperative prevention and therapy.

  6. Vaginal delivery of carboplatin-loaded thermosensitive hydrogel to prevent local cervical cancer recurrence in mice.

    PubMed

    Wang, Xue; Wang, Jin; Wu, Wenbin; Li, Hongjun

    2016-11-01

    Local tumor recurrence after cervical cancer surgery remains a clinical problem. Vaginal delivery of thermosensitive hydrogel may be suited to reduce tumor relapse rate with more efficacy and safety. A pilot study was carried out to evaluate the efficacy of carboplatin-loaded poloxamer hydrogel to prevent local recurrence of cervical cancer after surgery. In vivo vaginal retention evaluation of 27% poloxamer hydrogel in mice was proven to be a suitable vaginal drug delivery formulation due to its low gelation temperature. A mimic orthotopic cervical/vaginal cancer recurrence model after surgery was established by injecting murine cervical cancer cell line U14 into the vaginal submucosa to simulate the residual tumor cells infiltrated in the surgical site, followed by drug administration 24 h later to interfere with the formation/recurrence of the tumor. By infusing fluorescein sodium-loaded hydrogel into the vagina of mice, a maximized accumulation of fluorescein sodium (Flu) in the vagina was achieved and few signals were observed in other organs. When used in the prevention of the cervical cancer formation/recurrence in mice, the carboplatin-loaded poloxamer hydrogel exhibited great efficacy and systemic safety. In conclusion, thermosensitive hydrogel presents a simple, practical approach for the local drug delivery via vagina against cervical cancer recurrence.

  7. Long-term prehypertension treatment with losartan effectively prevents brain damage and stroke in stroke-prone spontaneously hypertensive rats.

    PubMed

    He, De-Hua; Zhang, Liang-Min; Lin, Li-Ming; Ning, Ruo-Bing; Wang, Hua-Jun; Xu, Chang-Sheng; Lin, Jin-Xiu

    2014-02-01

    Prehypertension has been associated with adverse cerebrovascular events and brain damage. The aims of this study were to investigate ⅰ) whether short‑ and long-term treatments with losartan or amlodipine for prehypertension were able to prevent blood pressure (BP)-linked brain damage, and ⅱ) whether there is a difference in the effectiveness of treatment with losartan and amlodipine in protecting BP-linked brain damage. In the present study, prehypertensive treatment with losartan and amlodipine (6 and 16 weeks treatment with each drug) was performed on 4-week‑old stroke-prone spontaneously hypertensive rats (SHRSP). The results showed that long-term (16 weeks) treatment with losartan is the most effective in lowering systolic blood pressure in the long term (up to 40 weeks follow-up). Additionally, compared with the amlodipine treatment groups, the short‑ and long-term losartan treatments protected SHRSP from stroke and improved their brains structurally and functionally more effectively, with the long-term treatment having more benefits. Mechanistically, the short‑ and long-term treatments with losartan reduced the activity of the local renin-angiotensin-aldosterone system (RAAS) in a time-dependent manner and more effectively than their respective counterpart amlodipine treatment group mainly by decreasing AT1R levels and increasing AT2R levels in the cerebral cortex. By contrast, the amlodipine treatment groups inhibited brain cell apoptosis more effectively as compared with the losartan treatment groups mainly through the suppression of local oxidative stress. Taken together, the results suggest that long-term losartan treatment for prehypertension effectively protects SHRSP from stroke-induced brain damage, and this protection is associated with reduced local RAAS activity than with brain cell apoptosis. Thus, the AT1R receptor blocker losartan is a good candidate drug that may be used in the clinic for long-term treatment on prehypertensive

  8. Metabolic vitamin B12 deficiency: a missed opportunity to prevent dementia and stroke.

    PubMed

    Spence, J David

    2016-02-01

    The purpose of this narrative review is to highlight insights into the importance and frequency of metabolic vitamin B12 (B12) deficiency, reasons why it is commonly missed, and reasons for the widespread but mistaken belief that treatment of B12 deficiency does not prevent stroke or improve cognitive function. Metabolic B12 deficiency is common, being present in 10%-40% of the population; is frequently missed; is easily treated; and contributes importantly to cognitive decline and stroke in older people. Measuring serum B12 alone is not sufficient for diagnosis; it is necessary to measure holotranscobalamin or functional markers of B12 adequacy such as methylmalonic acid or plasma total homocysteine. B-vitamin therapy with cyanocobalamin reduces the risk of stroke in patients with normal renal function but is harmful (perhaps because of thiocyanate accumulation from cyanide in cyanocobalamin) in patients with renal impairment. Methylcobalamin may be preferable in renal impairment. B12 therapy slowed gray matter atrophy and cognitive decline in the Homocysteine and B Vitamins in Cognitive Impairment Trial. Undiagnosed metabolic B12 deficiency may be an important missed opportunity for prevention of dementia and stroke; in patients with metabolic B12 deficiency, it would be prudent to offer inexpensive and nontoxic supplements of oral B12, preferably methylcobalamin or hydroxycobalamin. Future research is needed to distinguish the effects of thiocyanate from cyanocobalamin on hydrogen sulfide, and effects of treatment with methylcobalamin on cognitive function and stroke, particularly in patients with renal failure.

  9. [A case of Behçet disease developing recurrent ischemic stroke with fever and scrotal ulcers].

    PubMed

    Koike, Yuka; Sakai, Naoko; Umeda, Yoshitaka; Umeda, Maiko; Oyake, Mutsuo; Fujita, Nobuya

    2015-01-01

    A 30-year-old man, who was diagnosed with Behçet disease at 10 years of age, was hospitalized because of transient right hemiparesis after presenting with high fever and scrotal ulcers. Brain MRI revealed ischemic lesions in the area supplied by the anterior cerebral arteries. Analysis of cerebrospinal fluid (CSF) showed pleocytosis and a high interleukin-6 (IL-6) concentration (668 pg/ml). The patient was diagnosed with acute ischemic stroke associated with exacerbation of Behçet disease. After initiation of corticosteroid therapy, his clinical symptoms improved, and the CSF IL-6 concentration decreased. One year later, the patient developed high fever and scrotal ulcers after the onset of transient left upper limb plegia. Brain MRI showed an acute ischemic lesion in the right putamen, and CSF analysis showed an elevated IL-6 concentration (287 pg/ml). Brain CT angiography revealed stenosis of the left anterior cerebral artery and occlusion of the right anterior cerebral artery, which had been well visualized one year previously. Involvement of the intracranial cerebral arteries in Behçet disease is extremely rare. To the best of our knowledge, this is the first case report of a patient with recurrent symptomatic ischemic stroke associated with high fever and scrotal ulcers, which suggests exacerbation of Behçet disease.

  10. New anticoagulants for the prevention of stroke in atrial fibrillation.

    PubMed

    Höchtl, Thomas; Huber, Kurt

    2012-02-01

    Oral anticoagulation in atrial fibrillation is obligatory to lower the risk of spontaneous cerebrovascular and systemic thromboembolism. For this purpose, vitamin K antagonists (coumarins) have been recommended as the most effective drugs for a long time. However, problems with the practical use of these agents, e.g. the need for frequent and regular coagulation controls, the inter-individual differences in maintaining a stable therapeutic range, as well as drug or food interactions, have led to the search and investigation of alternative compounds characterized by a more simple use (e.g. without regular controls of therapeutic levels), high efficacy, as well as low risk of bleeding. The direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban and apixaban have recently been investigated to prove whether they fulfill the high expectancy of an ideal anticoagulant with respect to a more favorable efficacy/safety profile and without the need for coagulation controls, thereby improving quality of life. Dabigatran (RE-LY) achieved an impressive reduction in stroke and non-central nervous system (non-CNS) embolism (110 mg: 1.5%/year; 150 mg: 1.1%/year) in contrast to warfarin (1.7%/year; P = 0.34 and P < 0.001) with a favorable action on bleeding hazards. The results of rivaroxaban which were obtained in the ROCKET AF study (on treatment analysis: stroke and non-CNS embolism: 1.7%/year vs. 2.15%/year with warfarin; P = 0.015; primary safety endpoint major and minor bleeding: 14.91 vs. 14.52%; P = 0.442) point in the same direction. And finally, compared to aspirin, apixaban reduced the combined primary efficacy endpoint by 52% with comparable rates of bleeding (AVERROES). This review gives a summary of the current knowledge about these agents and their potential future importance.

  11. Methenamine: a forgotten drug for preventing recurrent urinary tract infection in a multidrug resistance era.

    PubMed

    Lo, Tze Shien; Hammer, Kimberly D P; Zegarra, Milagros; Cho, William C S

    2014-05-01

    In the era of multidrug resistance, it is critical to utilize antibiotics in an appropriate manner and to identify new treatments or revisit the use of 'forgotten' drugs. Because urinary tract infections (UTIs) are common, particularly in an increasing elderly population, the 'forgotten' drug, methenamine, may become important as a preventive therapy for recurrent UTIs. Methenamine, a urinary antibacterial agent, can be used as methenamine hippurate or methenamine mandelate preparations and is United States Food and Drug Administration-approved. This article discusses the place of preventive therapy for recurrent UTIs, chemistry, mechanism of action, pharmacology, clinical uses, dosage, adverse reactions and safety, and drug interactions of methenamine. Because of its unique antiseptic property, the authors suggest that methenamine should be considered when more commonly used antibiotics fail to suppress recurrent UTIs.

  12. Genetic Associations with Plasma B12, B6, and Folate Levels in an Ischemic Stroke Population from the Vitamin Intervention for Stroke Prevention (VISP) Trial

    PubMed Central

    Keene, Keith L.; Chen, Wei-Min; Chen, Fang; Williams, Stephen R.; Elkhatib, Stacey D.; Hsu, Fang-Chi; Mychaleckyj, Josyf C.; Doheny, Kimberly F.; Pugh, Elizabeth W.; Ling, Hua; Laurie, Cathy C.; Gogarten, Stephanie M.; Madden, Ebony B.; Worrall, Bradford B.; Sale, Michele M.

    2014-01-01

    Background: B vitamins play an important role in homocysteine metabolism, with vitamin deficiencies resulting in increased levels of homocysteine and increased risk for stroke. We performed a genome-wide association study (GWAS) in 2,100 stroke patients from the Vitamin Intervention for Stroke Prevention (VISP) trial, a clinical trial designed to determine whether the daily intake of high-dose folic acid, vitamins B6, and B12 reduce recurrent cerebral infarction. Methods: Extensive quality control (QC) measures resulted in a total of 737,081 SNPs for analysis. Genome-wide association analyses for baseline quantitative measures of folate, Vitamins B12, and B6 were completed using linear regression approaches, implemented in PLINK. Results: Six associations met or exceeded genome-wide significance (P ≤ 5 × 10−08). For baseline Vitamin B12, the strongest association was observed with a non-synonymous SNP (nsSNP) located in the CUBN gene (P = 1.76 × 10−13). Two additional CUBN intronic SNPs demonstrated strong associations with B12 (P = 2.92 × 10−10 and 4.11 × 10−10), while a second nsSNP, located in the TCN1 gene, also reached genome-wide significance (P = 5.14 × 10−11). For baseline measures of Vitamin B6, we identified genome-wide significant associations for SNPs at the ALPL locus (rs1697421; P = 7.06 × 10−10 and rs1780316; P = 2.25 × 10−08). In addition to the six genome-wide significant associations, nine SNPs (two for Vitamin B6, six for Vitamin B12, and one for folate measures) provided suggestive evidence for association (P ≤ 10−07). Conclusion: Our GWAS study has identified six genome-wide significant associations, nine suggestive associations, and successfully replicated 5 of 16 SNPs previously reported to be associated with measures of B vitamins. The six genome-wide significant associations are located in gene regions that have shown previous associations with measures of B

  13. Telestroke in stroke survivors.

    PubMed

    Joubert, Jacques; Joubert, Lynette B; de Bustos, Elizabeth Medeiros; Ware, Dallas; Jackson, David; Harrison, Terrence; Cadilhac, Dominique

    2009-01-01

    Stroke is a high-frequency disorder placing a significant burden on the health care systems, being the foremost cause of complex chronic disability in adults. Devising systems that can enhance the prevention of stroke recurrence is an important priority and challenge in both the developed and the developing world. The potential for recurrent stroke can be substantially reduced by effective management of vascular risk factors. Telestroke is a tool with potential application to improve risk management of stroke survivors. Lack of acknowledgment of existing practices as well as lack of awareness of potential financial barriers to diffusion of telestroke can lead to limited implementation. Telestroke offers service providers the opportunity to access large numbers of stroke survivors targeting secondary prevention. The ideal 'telestroke model' provides service support, education for the patient and caregiver, as well as integration of specialist and primary care services. Effective use of technological advances, with adequate recognition of the importance of human interaction in the long-term management of a largely elderly population of stroke survivors is challenging but possible. Telestroke should be systems- and not technology-driven. Barriers in the implementation of telestroke have been identified as insufficient planning of IT infrastructure, lack of long-term vision for sustainability, a lack of contextual perspective as well as poor communication across domains. Future telestroke models should provide effective action in an integrated model of care recognizing and involving all existing players and practices.

  14. Relapse and Recurrence Prevention in the Treatment for Adolescents with Depression Study

    ERIC Educational Resources Information Center

    Simons, Anne D.; Rohde, Paul; Kennard, Betsy D.; Robins, Michele

    2005-01-01

    Relapse and recurrence in adolescent depression are important problems. Much less is known about relapse prevention compared to the acute treatment of depression in adolescents. Based on previous research, theoretical predictions, and clinical experience, the Treatment for Adolescents With Depression Study (TADS) protocol was designed to determine…

  15. [Heat stroke related to the use of topiramate. The importance of prevention].

    PubMed

    Rosich Del Cacho, M; Pareja Grande, J; Martínez Jiménez, M D; Latorre Latorre, J F; Bejarano Ramírez, N; López-Menchero Oliva, C

    2014-09-01

    Heat stroke is the most severe pathology related to heat. It is defined as an increase in core body temperature accompanied by signs of neurological dysfunction. In the absence of an early treatment, it has a very high mortality rate. Topiramate is a well known drug widely used in epilepsy treatment and migraine prevention. Oligohydrosis has been described amongst topiramate side effects, favouring the risk of hyperthermia and heatstroke. We present the case of a patient who developed heat stroke due to physical exercise while under topiramate treatment.

  16. Prevention of post-operative recurrence of Crohn’s disease

    PubMed Central

    Vaughn, Byron Philip; Moss, Alan Colm

    2014-01-01

    Endoscopic and clinical recurrence of Crohn’s disease (CD) is a common occurrence after surgical resection. Smokers, those with perforating disease, and those with myenteric plexitis are all at higher risk of recurrence. A number of medical therapies have been shown to reduce this risk in clinical trials. Metronidazole, thiopurines and anti-tumour necrosis factors (TNFs) are all effective in reducing the risk of endoscopic or clinical recurrence of CD. Since these are preventative agents, the benefits of prophylaxis need to be weighed-against the risk of adverse events from, and costs of, therapy. Patients who are high risk for post-operative recurrence should be considered for early medical prophylaxis with an anti-TNF. Patients who have few to no risk factors are likely best served by a three-month course of antibiotics followed by tailored therapy based on endoscopy at one year. Clinical recurrence rates are variable, and methods to stratify patients into high and low risk populations combined with prophylaxis tailored to endoscopic recurrence would be an effective strategy in treating these patients. PMID:24574791

  17. Stroke Prevention in Atrial Fibrillation and Valvular Heart Disease.

    PubMed

    Ahmad, Saad; Wilt, Heath

    2016-01-01

    There is a clinically staggering burden of disease stemming from cerebrovascular events, of which a majority are ischemic in nature and many are precipitated by atrial fibrillation (AF). AF can occur in isolation or in association with myocardial or structural heart disease. In the latter case, and when considering health at an international level, congenital and acquired valve-related diseases are frequent contributors to the current pandemic of AF and its clinical impact. Guidelines crafted by the American Heart Association, American College of Cardiology, European Society of Cardiology and Heart Rhythm Society underscore the use of vitamin K antagonists (VKAs) among patients with valvular heart disease, particularly in the presence of concomitant AF, to reduce the risk of ischemic stroke of cardioembolic origin; however, the non-VKAs, also referred to as direct, target-specific or new oral anticoagulants (NOACs), have not been actively studied in this particular population. In fact, each of the new agents is approved in patients with AF not caused by a valve problem. The aim of our review is to carefully examine the available evidence from pivotal phase 3 clinical trials of NOACs and determine how they might perform in patients with AF and concomitant valvular heart disease.

  18. Stroke Prevention in Atrial Fibrillation and Valvular Heart Disease

    PubMed Central

    Ahmad, Saad; Wilt, Heath

    2016-01-01

    There is a clinically staggering burden of disease stemming from cerebrovascular events, of which a majority are ischemic in nature and many are precipitated by atrial fibrillation (AF). AF can occur in isolation or in association with myocardial or structural heart disease. In the latter case, and when considering health at an international level, congenital and acquired valve-related diseases are frequent contributors to the current pandemic of AF and its clinical impact. Guidelines crafted by the American Heart Association, American College of Cardiology, European Society of Cardiology and Heart Rhythm Society underscore the use of vitamin K antagonists (VKAs) among patients with valvular heart disease, particularly in the presence of concomitant AF, to reduce the risk of ischemic stroke of cardioembolic origin; however, the non-VKAs, also referred to as direct, target-specific or new oral anticoagulants (NOACs), have not been actively studied in this particular population. In fact, each of the new agents is approved in patients with AF not caused by a valve problem. The aim of our review is to carefully examine the available evidence from pivotal phase 3 clinical trials of NOACs and determine how they might perform in patients with AF and concomitant valvular heart disease. PMID:27347228

  19. Recurrent urinary tract infections in children: Preventive interventions other than prophylactic antibiotics

    PubMed Central

    Tewary, Kishor; Narchi, Hassib

    2015-01-01

    Urinary tract infection (UTI) is one of the most common childhood infections. Permanent renal cortical scarring may occur in affected children, especially with recurrent UTIs, leading to long-term complications such as hypertension and chronic renal failure. To prevent such damage, several interventions to prevent UTI recurrences have been tried. The most established and accepted prevention at present is low dose long-term antibiotic prophylaxis. However it has a risk of break through infections, adverse drug reactions and also the risk of developing antibiotic resistance. The search is therefore on-going to find a safer, effective and acceptable alternative. A recent meta-analysis did not support routine circumcision for normal boys with no risk factors. Vaccinium Macrocarpon (cranberry), commonly used against UTI in adult women, is also effective in reducing the number of recurrences and related antimicrobial use in children. Sodium pentosanpolysulfate, which prevents bacterial adherence to the uroepithelial cells in animal models, has shown conflicting results in human trials. When combined with antibiotic, Lactobacillus acidophilus (LA-5) and Bifidobacterium, by blocking the in vitro attachment of uropathogenic bacteria to uroepithelial cells, significantly reduce in the incidence of febrile UTIs. Deliberate colonization of the human urinary tract of patients with recurrent UTI with Escherichia-coli (E. coli) 83972 has resulted in subjective benefit and less UTI requiring treatment. The non-pathogenic E. coli isolate NU14 DeltawaaL is a candidate to develop live-attenuated vaccine for the treatment and prevention of acute and recurrent UTI. Diagnosing and treating dysfunctional elimination syndromes decrease the incidence of recurrent UTI. A meta-analysis found the lack of robust prospective randomized controlled trials limited the strength of the established guidelines for surgical management of vesicoureteral reflux. In conclusion, several interventions

  20. Final Results of Cilostazol-Aspirin Therapy against Recurrent Stroke with Intracranial Artery Stenosis (CATHARSIS)

    PubMed Central

    Uchiyama, Shinichiro; Sakai, Nobuyuki; Toi, Sono; Ezura, Masayuki; Okada, Yasushi; Takagi, Makoto; Nagai, Yoji; Matsubara, Yoshihiro; Minematsu, Kazuo; Suzuki, Norihiro; Tanahashi, Norio; Taki, Waro; Nagata, Izumi; Matsumoto, Masayasu

    2015-01-01

    Purpose To compare the effect of cilostazol plus aspirin versus aspirin alone on the progression of intracranial arterial stenosis (IAS), and to compare ischemic and hemorrhagic events in patients with symptomatic IAS, an investigator-driven, nationwide multicenter cooperative randomized controlled trial (CATHARSIS; ClinicalTrials.gov Identifier 00333164) was conducted. Methods 165 noncardioembolic ischemic stroke patients with >50% stenosis in the responsible intracranial artery after 2 weeks to 6 months from the onset were randomly allocated to receive either cilostazol 200 mg/day plus aspirin 100 mg/day (n = 83, CA group) or aspirin 100 mg/day alone (n = 82, A group). The primary endpoint was the progression of IAS on magnetic resonance angiography at 2 years after randomization. Secondary endpoints were any vascular events, any cause of death, serious adverse events, new silent brain infarcts, and worsening of the modified Rankin Scale score. Results Progression of IAS was observed in 9.6% of the CA group patients and in 5.6% of the A group patients, with no significant intergroup difference (p = 0.53). The incidence of the secondary endpoints tended to be lower in the CA group compared with the A group, although the differences were not significant. By using exploratory logistic regression analysis adjusted for patient background characteristics, it was shown that the risk for certain combinations of secondary endpoints was lower in the CA group than in the A group [all vascular events and silent brain infarcts: odds ratio (OR) = 0.37, p = 0.04; stroke and silent brain infarcts: OR = 0.34, p = 0.04; all vascular events, worsening of modified Rankin Scale scores and silent brain infracts: OR = 0.41, p = 0.03]. Major hemorrhage was observed in 4 patients of the CA group and in 3 of the A group. Conclusion Progression of IAS during the 2-year observation period appears to be less frequent than previously reported in stroke patients on antiplatelet agents after

  1. Is it possible to prevent recurrent vulvovaginitis? The role of Lactobacillus plantarum I1001 (CECT7504).

    PubMed

    Palacios, S; Espadaler, J; Fernández-Moya, J M; Prieto, C; Salas, N

    2016-10-01

    The purpose of this study was to prospectively evaluate the impact of the use of L. plantarum I1001 applied vaginally on Vulvovaginal Candidiasis (VVC) time-until-recurrence after treatment with single-dose vaginal clotrimazole. This was a clinical open-label, prospective study of two non-randomized parallel cohorts with symptomatic acute VVC: (1) 33 sexually active women 18-50 years old, prescribed a standard single-dose 500 mg vaginal tablet of clotrimazole followed by vaginal tablets with L. plantarum I1001 as adjuvant therapy, and (2) 22 women of similar characteristics but prescribed single-dose clotrimazole only. Use of the probiotic and factors that might influence recurrence risk (age, recurrent VVC within previous year, antibiotic prior to study enrolment, diaphragm or IUD contraception, among others) were included in a multivariate Cox regression model to adjust for potential between-cohort differences. Probiotic use was associated with a three-fold reduction in the adjusted risk of recurrence (HR [95 %CI]: 0.30 [0.10-0.91]; P = 0.033). Adjusted free-survival recurrence was 72.83 % and 34.88 % for the probiotic and control groups, respectively. A higher cumulative recurrence was also observed in cases with use of antibiotics prior to enrolment (HR [95 %CI]: 10.46 [2.18-50.12]; P = 0.003). Similar findings were found at six months after azole treatment in women with RVVC. Overall, good compliance with the probiotic was reported for 91.3 % of women. The study suggests that follow-up therapy with vaginal tablets with L. plantarum I1001 could increase the effectiveness of single-dose 500 mg clotrimazole at preventing recurrence of VVC, an effect that was also observed in women with recurrent vulvovaginal candidiasis (RVVC) after six months of azole treatment.

  2. A Randomized Controlled Trial of Celecoxib to Prevent Recurrence of Non-Muscle–Invasive Bladder Cancer

    PubMed Central

    Sabichi, Anita L.; Lee, J. Jack; Grossman, H. Barton; Liu, Suyu; Richmond, Ellen; Czerniak, Bogdan A.; De la Cerda, Jorge; Eagle, Craig; Viner, Jaye L.; Palmer, J. Lynn; Lerner, Seth P.

    2014-01-01

    Significant morbidity and expense result from frequent recurrences of non-muscle invasive bladder cancer (NMIBC) after standard treatment, and carcinoma in situ (Tis) is a poor prognostic factor. Predicated on observational and preclinical data strongly supporting cyclooxygenase-2 (COX-2) in the pathogenesis, and the activity of COX-2 inhibitors, in bladder cancer, we conducted a randomized, double-blind, placebo-controlled trial to determine if celecoxib could reduce the time-to-recurrence (TTR) in NMIBC patients at high risk for recurrence. 146 patients were randomized to celecoxib (200 mg) or placebo orally twice daily for at least 12 months. The average treatment duration was 1.25 years. Primary intent-to-treat analysis revealed celecoxib did not statistically significantly prolong TTR compared with placebo (P = 0.17, log-rank). With a median follow-up of 2.49 years the relative risk of recurrence in the celecoxib vs placebo arms was 0.64 (95% CI, 0.38, 1.17). The recurrence-free rate at 12 months with celecoxib was 88% (95% CI, 0.81,0.96) versus 78% (95% CI, 0.69, 0.89) with placebo. After controlling for covariates with Cox regression analysis, recurrence rates did not differ between the two study arms (HR = 0.69; 95% CI, 0.37,1.29). Celecoxib had a marginally significant effect on reducing metachronous recurrences (vs. placebo) with hazard ratio of 0.56 (95% CI, 0.3,1.06; P=0.075). Celecoxib was well tolerated, with similar adverse events and quality-of-life in both arms. Our clinical trial results do not show a clinical benefit for celecoxib in preventing NMIBC recurrence but further investigation of COX-2 inhibitors in this setting is warranted. PMID:21881030

  3. Stroke injury, cognitive impairment and vascular dementia☆

    PubMed Central

    Kalaria, Raj N.; Akinyemi, Rufus; Ihara, Masafumi

    2016-01-01

    The global burden of ischaemic strokes is almost 4-fold greater than haemorrhagic strokes. Current evidence suggests that 25–30% of ischaemic stroke survivors develop immediate or delayed vascular cognitive impairment (VCI) or vascular dementia (VaD). Dementia after stroke injury may encompass all types of cognitive disorders. States of cognitive dysfunction before the index stroke are described under the umbrella of pre-stroke dementia, which may entail vascular changes as well as insidious neurodegenerative processes. Risk factors for cognitive impairment and dementia after stroke are multifactorial including older age, family history, genetic variants, low educational status, vascular comorbidities, prior transient ischaemic attack or recurrent stroke and depressive illness. Neuroimaging determinants of dementia after stroke comprise silent brain infarcts, white matter changes, lacunar infarcts and medial temporal lobe atrophy. Until recently, the neuropathology of dementia after stroke was poorly defined. Most of post-stroke dementia is consistent with VaD involving multiple substrates. Microinfarction, microvascular changes related to blood–brain barrier damage, focal neuronal atrophy and low burden of co-existing neurodegenerative pathology appear key substrates of dementia after stroke injury. The elucidation of mechanisms of dementia after stroke injury will enable establishment of effective strategy for symptomatic relief and prevention. Controlling vascular disease risk factors is essential to reduce the burden of cognitive dysfunction after stroke. This article is part of a Special Issue entitled: Vascular Contributions to Cognitive Impairment and Dementia edited by M. Paul Murphy, Roderick A. Corriveau and Donna M. Wilcock. PMID:26806700

  4. Apixaban to prevent stroke in patients with atrial fibrillation: a review.

    PubMed

    Peterson, Benjamin E; Al-Khatib, Sana M; Granger, Christopher B

    2017-03-01

    Atrial fibrillation is a common, costly and morbid cardiovascular arrhythmia. Stroke prevention remains the mainstay of treatment for atrial fibrillation, and the recent advent of novel oral anticoagulants with direct factor IIa or factor Xa inhibition has significantly revolutionized this aspect of treatment for atrial fibrillation patients. This review focuses on the tolerability and efficacy of apixaban and tackles the generalizability of the findings with apixaban to broader patient populations than those primarily enrolled in the clinical trials, drawing from the AVERROES and ARISTOTLE trials and their subsequent secondary analyses. Taken together, findings from these trials show that apixaban is superior to warfarin in preventing stroke with a lower risk of major bleeding in the general population of patients with atrial fibrillation as well as in several key high-risk patient subgroups.

  5. Prevention of post-stroke generalized anxiety disorder, using escitalopram or problem-solving therapy.

    PubMed

    Mikami, Katsunaka; Jorge, Ricardo E; Moser, David J; Arndt, Stephan; Jang, Mijin; Solodkin, Ana; Small, Steven L; Fonzetti, Pasquale; Hegel, Mark T; Robinson, Robert G

    2014-01-01

    This study examined the efficacy of antidepressant treatment for preventing the onset of generalized anxiety disorder (GAD) among patients with recent stroke. Of 799 patients assessed, 176 were randomized, and 149 patients without evidence of GAD at the initial visit were included in this double-blind treatment with escitalopram (N=47) or placebo (N=49) or non-blinded problem-solving therapy (PST; 12 total sessions; N=53). Participants given placebo over 12 months were 4.95 times more likely to develop GAD than patients given escitalopram and 4.00 times more likely to develop GAD than patients given PST. Although these results should be considered preliminary, the authors found that both escitalopram and PST were effective in preventing new onset of post-stroke GAD.

  6. Left atrial appendage exclusion for prevention of stroke in atrial fibrillation: review of minimally invasive approaches.

    PubMed

    Moss, Joshua D

    2014-02-01

    Stroke prevention is of vital importance in the management of atrial fibrillation (AF), though the proven strategy of systemic anticoagulation for thromboembolic prophylaxis is underutilized for a variety of reasons. The left atrial appendage (LAA) has long been suspected as the principal source of arterial emboli, particularly in nonvalvular AF, and a variety of techniques for its exclusion from the circulation have been developed. This review highlights the history of the LAA as a target of intervention, and the parallel advances in three minimally invasive strategies for its exclusion: percutaneous occlusion of the LAA orifice from within the left atrium, closed-chest ligation via a percutaneous pericardial approach, and minimally invasive thoracoscopic surgery. While further study is necessary, available evidence suggests that effective LAA exclusion is becoming a viable alternative to anticoagulation for stroke prevention in nonvalvular AF.

  7. [Evaluation of treatment and preventive care for recurrent urolithiasis in children].

    PubMed

    Gołabek, B; Słowik, M; Grabowska, M; Kowalska, B; Nowakowska, K; Nowaczewska, I

    1999-01-01

    Among 425 children with urolithiasis treated in the Paediatric Clinical Department of the National Research Institute of Mother and Child in Warsaw between 1976-1997, 50 of them i.e. 11.7% (26 boys and 24 girls) had recurrent urolithiasis. Patients' age was from 10 months to 16 years and 5 months. The number of recurrences of uroliothiasis before treatment in the Institute was from 1 to 8. Most of the children had numerous surgical operations, some of them excreted stones spontaneously. The etiology was determined in all cases. A metabolic cause of urolithiasis was found in 34 cases, i.e. 68% of the analysed group. They were as follows: idiopathic hypercalcuria--24 cases, uric acid urolithiasis--5 cases, cystynuria--4 cases, and incomplete distal renal tubular acidosis--1 case. Other reasons for urolithiasis were: infection--7 cases, idiopathic urolithiasis--8 cases, ren spongiosum--1 case. Prevention of recurrences depending on the etiology was successful. In 45 cases no recurrences were found. Recurrent urolithiasis was observed in 4 cases of cystynuria and in one case of incomplete tubular acidosis. The observation period was from 3-19 years.

  8. XANTUS: rationale and design of a noninterventional study of rivaroxaban for the prevention of stroke in patients with atrial fibrillation.

    PubMed

    Camm, A John; Amarenco, Pierre; Haas, Sylvia; Hess, Susanne; Kirchhof, Paulus; van Eickels, Martin; Turpie, Alexander G G

    2014-01-01

    Atrial fibrillation (AF) is associated with a fivefold increase in the risk of stroke. The Phase III ROCKET AF (Rivaroxaban Once-Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation) trial showed that rivaroxaban, an oral, direct Factor Xa inhibitor, was noninferior to warfarin for the reduction of stroke or systemic embolism in patients with AF. Compared with warfarin, rivaroxaban significantly reduced rates of intracranial and fatal hemorrhages, although not rates of bleeding overall. XANTUS (Xarelto(®) for Prevention of Stroke in Patients with Atrial Fibrillation) is a prospective, international, observational, postauthorization, noninterventional study designed to collect safety and efficacy data on the use of rivaroxaban for stroke prevention in AF in routine clinical practice. The key goal is to determine whether the safety profile of rivaroxaban established in ROCKET AF is also observed in routine clinical practice. XANTUS is designed as a single-arm cohort study to minimize selection bias, and will enroll approximately 6,000 patients (mostly from Europe) with nonvalvular AF prescribed rivaroxaban, irrespective of their level of stroke risk. Overall duration of follow-up will be 1 year; the first patient was enrolled in June 2012. Similar studies (XANTUS-EL [Xarelto(®) for Prevention of Stroke in Patients with Nonvalvular Atrial Fibrillation, Eastern Europe, Middle East, Africa and Latin America] and XANAP [Xarelto(®) for Prevention of Stroke in Patients with Atrial Fibrillation in Asia-Pacific]) are ongoing in Latin America and Asia-Pacific. Data from these studies will supplement those from ROCKET AF and provide practical information concerning the use of rivaroxaban for stroke prevention in AF.

  9. Outcome of overt stroke in sickle cell anaemia, a single institution's experience.

    PubMed

    Majumdar, Suvankar; Miller, Morgan; Khan, Majid; Gordon, Catherine; Forsythe, Amy; Smith, Mary G; Megason, Gail; Iyer, Rathi

    2014-06-01

    Stroke is a traumatic complication in sickle cell anaemia (SCA) that is associated with significant morbidity and a risk of recurrent overt stroke of 2·2-6·4 events per 100 patient-years. A retrospective study was performed on all paediatric SCA patients diagnosed with a history of overt stroke between 1997 and 2010. A total of 31 children with SCA had new onset overt stroke. The mean age of the active patients (n = 27) was 17·9 years (range 6·8-27·6 years) with a total period of observation of 305 patient-years. Twenty-two of 27 (81%) were receiving long term red blood cell transfusions and 16 (59%) were taking the anti-platelet agent, aspirin, since diagnosis of the stroke. Two of 27 (7%) patients had a second overt stroke with an overall risk of recurrent stroke of 0·66/100 patient-years (one stroke was ischaemic and the other haemorrhagic). In patients taking aspirin with 180 patient-years of follow up, the recurrence rate of haemorrhagic stroke was 0·58/100 patient-years. We have an excellent outcome for overt stroke in paediatric SCA patients with a low rate of recurrent stroke. Further studies are needed to determine the risk-benefit ratio of aspirin therapy in the prevention of recurrent stroke in paediatric SCA.

  10. Valacyclovir for prevention of recurrent herpes labialis: 2 double-blind, placebo-controlled studies.

    PubMed

    Baker, David; Eisen, Drore

    2003-03-01

    The oral antiviral valacyclovir, which is 3 to 5 times more bioavailable than its parent compound acyclovir, is a good candidate for effective therapy to suppress recurrent herpes labialis lesions. The efficacy of oral valacyclovir in the suppression of herpes labialis has not previously been reported. Two identical, randomized, double-blind, parallel-group studies were conducted to evaluate the efficacy of oral valacyclovir 500 mg (n=49) versus placebo (n=49) once daily for 16 weeks in the suppression of herpes labialis among patients with a history of 4 or more recurrent lesions in the previous year. Data from the studies were pooled for analysis. Twenty-eight patients (60%) in the valacyclovir group compared with only 18 patients (38%) in the placebo group were recurrence-free throughout the 4-month treatment period (P=.041). The mean time to first recurrence was significantly longer with valacyclovir (13.1 weeks) compared with placebo (9.6 weeks) (P=.016). The total number of recurrences in patients using valacyclovir was 24 compared with 41 in patients using placebo. The incidence of adverse events during the 4-month treatment period was slightly lower in the valacyclovir group (22 events, 33% of patients) compared with the placebo group (29 events, 39% of patients). The results of these small double-blind, placebo-controlled studies suggest that oral valacyclovir 500 mg once daily for 4 months is effective and well tolerated for the prevention of recurrent herpes labialis. More research with larger patient numbers is warranted to corroborate and extend these findings.

  11. [Surgical prevention of stroke in patients with carotid stenosis].

    PubMed

    Pyshkina, L I; Khatagova, D T; Kabanov, A A; Darvish, N A; Alibekova, Zh M

    2014-01-01

    Objectives. To study the cerebral and central hemodynamics in patients with stenotic lesions of inner carotid arteries (ICA) before and after reconstructive surgery. Material and methods. Fifty-nine patients, aged from 46 to 78 years, with >50% atherosclerotic stenosis of ICA who underwent preventive carotid endarterectomy (CEAE) were examined. The isolate stenosis of ICA was identified in 13.6% of patients, concomitant lesions of brachiocephalic arteries in 86.4%. Atherosclerotic lesions of coronary arteries were found in 91.1% of patients and those of arteries of lower extremities in 45.8%. In 25.5% of patients, the heart surgery was performed before the current hospitalization. Heterogeneous atherosclerotic plaques with dense or hyperdense components were more frequents in symptomatic stenosis (63.3%). The maximal stenosis was identified in heterogeneous hyperechogenic plaques, the minimal ones in homogenous hypoechogenic plaques. Parameters of central hemodynamics were better in patients with 2nd stage of reconstructive surgeries. The emission fraction decreased proportionally to the degree of stenosis. The parameters of cerebral hemodynamics were significantly decreased in ICA stenosis and improved in the early post-surgery period. Results. CEAE promoted the improvement of cognitive functions and the recovery of motor functions. The best positive dynamics was recorded in asymptomatic ICA stenosis. Poor outcome (transitory ischemic attacks, urgent surgery, restenosis) was found in patients with low levels of central and cerebral hemodynamics 12-24 months after the discharge. Moreover, smoking and the degree of stenosis predicted poor outcome. Conclusions. Surgical treatment in combination with the complex pharmacotherapy (hypotensive drugs, antiaggregants and statins) had the maximal effect, including the remote period.

  12. Clinical Features and Racial/Ethnic Differences among the 3020 Participants in the Secondary Prevention of Small Subcortical Strokes (SPS3) Trial

    PubMed Central

    White, Carole L.; Szychowski, Jeff M.; Roldan, Ana; Benavente, Marie-France; Pretell, Edwin J.; Del Brutto, Oscar H.; Kase, Carlos S.; Arauz, Antonio; Meyer, Brett C.; Meissner, Irene; Demaerschalk, Bart M.; McClure, Leslie A.; Coffey, Christopher S.; Pearce, Lesly A.; Conwit, Robin; Irby, Lisa H.; Peri, Kalyani; Pergola, Pablo E.; Hart, Robert G.; Benavente, Oscar R.

    2012-01-01

    AIM To describe the baseline characteristics, racial/ethnic differences, and geographic differences among participants in the Secondary Prevention of Small Subcortical Strokes (SPS3) study. METHODS The SPS3 trial enrolled patients with a symptomatic small subcortical stroke (lacunar stroke) within the prior 6 months and an eligible lesion on MRI, who were randomized, in a factorial design, to antiplatelet therapy (aspirin 325 mg daily plus clopidogrel 75 mg daily vs. aspirin 325 mg daily plus placebo) and to one of two levels of systolic blood pressure targets (“intensive” (<130 mmHg) vs. “usual” (130–149 mmHg)). RESULTS Among the 3020 participants recruited from 81 clinical sites in 8 countries, the mean age was 63 years, 63% were men, 75% had a history of hypertension, and 37% were diabetic. Fifty-one percent were White, 30% Hispanic, and 16% Black. Black participants were younger (mean age 58 years vs. 64 years, p<0.001) and more often had hypertension (95% vs. 89%, p<0.001) than White participants. Hispanic and Black participants more often had diabetes than White participants (42%, 40% vs. 32% respectively, both p<0.001). Tobacco smoking at the time of qualifying stroke was much more frequent among Spanish participants (32%) than those from North America (22%) or Latin America (8%) (p<0.001); systolic blood pressure at study entry was 5 mmHg lower among Spanish vs. North American participants (p<0.01). CONCLUSIONS The SPS3 cohort is the largest MRI-defined series of patients with S3. Among the racially/ethnically diverse SPS3 participants, there are important differences in patient features and vascular risk factors could influence prognosis for recurrent stroke and response to interventions. Clinical Trial Registration Information The SPS3 study is registered on www.clinicaltrials.gov (NCT00059306). PMID:22516427

  13. [Stroke and Cancer: Are Cryptogenic Strokes a Paraneoplastic Syndrome?].

    PubMed

    Eschle, Daniel

    2015-07-22

    Cancer is an independent risk factor for ischemic stroke, and stroke can precede tumour diagnosis by many months. A paraneoplastic hypercoagulability has been implicated. Overall, cancer is a rare cause, but should be suspected in cases of cryptogenic stroke. In patients with cryptogenic stroke, two criteria – ischemic lesions in multiple vascular territories and D-dimer values >2,15 µg/ml – predict cancer with 100% specificity according to one relevant study. An adenocarcinoma at an advanced stage is identified in many cases, the risk of stroke-recurrence is high. There is a lack of evidence-based recommendations regarding secondary prevention in these cases. In analogy to the guidelines for venous thromboembolism in cancer patients, low molecular weight heparins might be more efficient compared to other anti-clotting agents.

  14. Stroke prevention following modified endoscopic ablation and appendectomy for atrial fibrillation.

    PubMed

    Ma, Nan; Jiang, Zhaolei; Chen, Fei; Yin, Hang; Ding, Fangbao; Mei, Ju

    2016-09-01

    We reported the results of stroke prevention following modified endoscopic procedure for atrial fibrillation. 82 patients underwent modified endoscopic procedure for atrial fibrillation (AF), in whom 47 had paroxysmal, 28 had persistent, and 7 had long-standing atrial fibrillation. CHA2DS2VASC median score was 3 (range from 0 to 8). The procedure was performed on the beating heart, through 3 ports on the left chest wall. Pulmonary vein isolation and ablation of the left atrium were achieved by bipolar radiofrequency ablation. Left atrial appendage (LAA) was excluded by stapler. Brain CT, cardiac CT and 24-h Holter monitoring were performed following the procedure. The procedure was successfully completed for all patients. The mean duration was 122 ± 40.1 min. LAA was excluded after appendectomy and checked by intraoperative transesophageal echocardiography. The mean follow-up duration was 24.3 ± 3.5 months. No patients showed signs and symptoms of transient ischemic attack or stroke. No new positive findings were demonstrated by recurring brain CT scan performed after the procedure. Cardiac CT confirmed the absence of LAA and thrombosis in the left atrium. 87.8 % (72/82) of all patients were in sinus rhythm. Our results demonstrate that the modified endoscopic procedure is a safe, effective, and appropriate treatment for AF, which restores sinus rhythm and may be associated with the prevention of AF-related stroke.

  15. Prevention of Lung Cancer Recurrence Using Cisplatin-Loaded Superhydrophobic Nanofiber Meshes

    PubMed Central

    Kaplan, Jonah A.; Liu, Rong; Freedman, Jonathan D.; Padera, Robert; Schwartz, John; Colson, Yolonda L.; Grinstaff, Mark W.

    2016-01-01

    For early stage lung cancer patients, local cancer recurrence after surgical resection is a significant concern and stems from microscopic disease left behind after surgery. Here we apply a local drug delivery strategy to combat local lung cancer recurrence after resection using non-woven, biodegradable nanofiber meshes loaded with cisplatin. The meshes are fabricated using a scalable electrospinning process from two biocompatible polymers—polycaprolactone and poly(glycerol monostearate-co-caprolactone)—to afford favorable mechanical properties for use in a dynamic tissue such as the lung. Owing to their rough nanostructure and hydrophobic polymer composition, these meshes exhibit superhydrophobicity, and it is this non-wetting nature that sustains the release of cisplatin in a linear fashion over ~90 days, with anti-cancer efficacy demonstrated using an in vitro Lewis Lung carcinoma (LLC) cell assay. The in vivo evaluation of cisplatin-loaded superhydrophobic meshes in the prevention of local cancer recurrence in a murine model of LLC surgical resection demonstrated a statistically significant increase (p = 0.0006) in median recurrence-free survival to >23 days, compared to standard intraperitoneal cisplatin therapy of equivalent dose. These results emphasize the importance of supplementing cytoreductive surgery with local drug delivery strategies to improve prognosis for lung cancer patients undergoing tumor resection. PMID:26547283

  16. Hypertension and stroke in Asia: prevalence, control and strategies in developing countries for prevention.

    PubMed

    Singh, R B; Suh, I L; Singh, V P; Chaithiraphan, S; Laothavorn, P; Sy, R G; Babilonia, N A; Rahman, A R; Sheikh, S; Tomlinson, B; Sarraf-Zadigan, N

    2000-01-01

    Reliable statistics related to the prevalence, incidence and mortality of hypertension and stroke are not available from Asia. The data may be in national or institutional reports or journals published in the local language only. The mortality rate for stroke has been on the decline since the mid 1960s in the developed countries of Asia, such as Australia, New Zealand, and Japan, with some improvement in Singapore, Taiwan and Hong Kong, some areas of China and Malaysia about 15 years later. In India, China, Philippines, Thailand, Sri Lanka, Iran, Pakistan, Nepal, there has been a rapid increase in stroke mortality and prevalence of hypertension. The prevalence of hypertension according to new criteria (>140/90 mm Hg) varies between 15-35% in urban adult populations of Asia. In rural populations, the prevalence is two to three times lower than in urban subjects. Hypertension and stroke occur at a relatively younger age in Asians and the risk of hypertension increases at lower levels of body mass index of 23-25 kg/m2. Overweight, sedentary behaviour, alcohol, higher social class, salt intake, diabetes mellitus and smoking are risk factors for hypertension in most of the countries of Asia. In Australia, New Zealand and Japan, lower social class is a risk factor for hypertension and stroke. Population-based long-term follow-up studies are urgently needed to demonstrate the association of risk factors with hypertension in Asia. However prevention programmes should be started based on cross-sectional surveys and case studies without waiting for the cohort studies.

  17. Decision-making around antithrombotics for stroke prevention in atrial fibrillation: the health professionals' views.

    PubMed

    Wang, Yishen; Bajorek, Beata

    2016-08-01

    Background For stroke prevention in patients with atrial fibrillation (AF), the decision-making around antithrombotic therapy has been complicated by older age, multiple comorbidities, polypharmacy and the different pharmacological properties of warfarin and the nonvitamin K antagonist oral anticoagulants (NOACs). The complexity of decision-making has been associated with a reluctance by health professionals to use antithrombotic therapy, leading to poor clinical outcomes. In order to improve stroke prevention in patients with AF, the contemporary perspectives of health professionals on the decision-making around antithrombotic therapy needs exploration. Objective To elicit emerging themes describing health professionals' perspectives on the decision-making around antithrombotic therapy for stroke prevention in patients with AF. Setting Sydney metropolitan area of New South Wales, Australia. Method A qualitative study based on face-to-face interviews was conducted from August to October 2014. Seven pharmacists, seven specialists, six general practitioners and six nurses practising in the Sydney metropolitan area and managing antithrombotic therapy for AF were interviewed until theme saturation was achieved in each subgroup. Interview transcripts were analysed using manual inductive coding. Main outcome measure Emerging themes describing health professionals' perspectives on the decision-making around antithrombotic therapy for stroke prevention in patients with AF. Results Three overarching themes emerged. (1) Comprehensive assessment is necessary for decision-making but is not always implemented. Health professionals mostly focused on stroke risk assessment, not on the bleeding risk and medication safety issues. (2) Health professionals from different disciplines have different preferences for antithrombotic therapies. Although the majority of health professionals considered warfarin as the first-line therapy, NOACs were preferred by neurologists and

  18. Analysis of the Cochrane Review: Fibrates for secondary prevention of cardiovascular disease and stroke.

    PubMed

    Pires da Rosa, Gilberto; Libânio, Diogo; Filipe Azevedo, Luís

    2017-01-01

    The influence of fibrates on cardiovascular risk has been the focus of several clinical trials. This Cochrane Collaboration Systematic Review evaluated the efficacy of fibrates for secondary prevention of cardiovascular events and stroke, analyzing 13 randomized controlled trials, in a total of 16 112 participants with a history of cardiovascular disease. Fibrates showed a protective effect for the composite outcome of non-fatal stroke, non-fatal myocardial infarction (MI) and vascular death, mainly due to reduction in the risk of non-fatal or fatal MI. Nonetheless, these results largely relied on studies including clofibrate, a drug withdrawn from the market in 2002. No statistically significant differences regarding adverse events were found between fibrates and placebo. Although insufficient to support the routine prescription of fibrates in this setting, this evidence should be taken into account when deciding on lipid-modifying therapy in dyslipidemic patients with a history of cardiovascular disease.

  19. Left atrial appendage occlusion with the WATCHMAN™ for stroke prevention in atrial fibrillation.

    PubMed

    Price, Matthew J

    2014-01-01

    Atrial fibrillation (AF) is a major cause of stroke and systemic embolism. Although warfarin and the novel oral anticoagulants reduce thromboembolic risk, they are associated with an ongoing bleeding hazard, in addition to other limitations that deter their use. The left atrial appendage (LAA) appears to be the primary source of thrombus in AF; therefore, LAA closure represents a mechanical strategy for stroke prevention in these patients. The WATCHMAN™ LAA closure device (Boston Scientific, Natick, MA) is a nitinol-framed occluder that is implanted percutaneously under echocardiographic and fluoroscopic guidance. Data from two randomized clinical trials support the clinical efficacy of transcatheter LAA occlusion with the WATCHMAN and demonstrate that procedural safety has improved significantly since initial experience. This article summarizes the rationale, procedural technique, safety, and clinical efficacy of the WATCHMAN device in patients with AF at high risk for thromboembolic events.

  20. Under-prescribing of Prevention Drugs and Primary Prevention of Stroke and Transient Ischaemic Attack in UK General Practice: A Retrospective Analysis

    PubMed Central

    Fitzmaurice, David; Cheng, K. K.; Marshall, Tom

    2016-01-01

    Background Stroke is a leading cause of death and disability; worldwide it is estimated that 16.9 million people have a first stroke each year. Lipid-lowering, anticoagulant, and antihypertensive drugs can prevent strokes, but may be underused. Methods and Findings We analysed anonymised electronic primary care records from a United Kingdom (UK) primary care database that covers approximately 6% of the UK population. Patients with first-ever stroke/transient ischaemic attack (TIA), ≥18 y, with diagnosis between 1 January 2009 and 31 December 2013, were included. Drugs were considered under-prescribed when lipid-lowering, anticoagulant, or antihypertensive drugs were clinically indicated but were not prescribed prior to the time of stroke or TIA. The proportions of strokes or TIAs with prevention drugs under-prescribed, when clinically indicated, were calculated. In all, 29,043 stroke/TIA patients met the inclusion criteria; 17,680 had ≥1 prevention drug clinically indicated: 16,028 had lipid-lowering drugs indicated, 3,194 anticoagulant drugs, and 7,008 antihypertensive drugs. At least one prevention drug was not prescribed when clinically indicated in 54% (9,579/17,680) of stroke/TIA patients: 49% (7,836/16,028) were not prescribed lipid-lowering drugs, 52% (1,647/3,194) were not prescribed anticoagulant drugs, and 25% (1,740/7,008) were not prescribed antihypertensive drugs. The limitations of our study are that our definition of under-prescribing of drugs for stroke/TIA prevention did not address patients’ adherence to medication or medication targets, such as blood pressure levels. Conclusions In our study, over half of people eligible for lipid-lowering, anticoagulant, or antihypertensive drugs were not prescribed them prior to first stroke/TIA. We estimate that approximately 12,000 first strokes could potentially be prevented annually in the UK through optimal prescribing of these drugs. Improving prescription of lipid-lowering, anticoagulant, and

  1. Comparative Study of Different {beta}-Radiation Doses for Preventing Pterygium Recurrence

    SciTech Connect

    Yamada, Takayuki; Mochizuki, Hideki; Ue, Takahiro; Kiuchi, Yoshiaki; Takahashi, Yasuhiro; Oinaka, Matsuyoshi

    2011-12-01

    Purpose: To compare the pterygium recurrence rates after treatment with two different {beta}-radiation doses. Methods and Materials: A total of 84 patients with a mean age of 63.0 {+-} 10.3 years (men, 48 eyes, and women, 47 eyes) and initially treated with {beta}-radiation after pterygium excision were recruited. The mean follow-up period was 49.9 {+-} 51.3 months. The patients were assigned to two dose groups: a high-dose (40 Gy) or a low-dose (20 Gy) group. The statistical significance of differences in patient age, pterygium size, and interval between surgery and radiotherapy were analyzed in the 20-Gy group using the Cox proportional hazard model at p < .05. Results: The high- and low-dose groups included 28 and 67 eyes, respectively. Pterygia recurred in 11 eyes, all in the low-dose group. The interval between surgery and radiotherapy was not a significant predictor of recurrence. Smaller pterygia had a lower risk of recurrence than pterygia that had encroached the pupillary area (pterygium located within one-third of the corneal radius from the limbus, corrected hazard ratio [HR], 0.069; 95% confidence interval [CI], 0.006-0.766; p = .030; pterygium extending beyond one-third of the corneal radius, corrected HR, 0.188; 95% CI, 0.018-0.696; p = 0.019; and pterygium reaching the pupillary area, corrected HR, 0.184; 95% CI, 0.036-0.929; p = .040). Older age was marginally significant as a negative predictor of recurrence (HR, 0.943; 95% CI, 0.887-1.003; p = .061). No scleromalacia developed during the follow-up period. Conclusions: {beta}-Radiation at 40 Gy was more efficacious than at 20 Gy in preventing pterygium recurrence without scleromalacia development, particularly for large-size pterygia and those in young patients.

  2. Blood transfusion for preventing primary and secondary stroke in people with sickle cell disease.

    PubMed

    Estcourt, Lise J; Fortin, Patricia M; Hopewell, Sally; Trivella, Marialena; Wang, Winfred C

    2017-01-17

    BACKGROUND: Sickle cell disease is one of the commonest severe monogenic disorders in the world, due to the inheritance of two abnormal haemoglobin (beta globin) genes. Sickle cell disease can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Stroke affects around 10% of children with sickle cell anaemia (HbSS). Chronic blood transfusions may reduce the risk of vaso-occlusion and stroke by diluting the proportion of sickled cells in the circulation.This is an update of a Cochrane Review first published in 2002, and last updated in 2013. OBJECTIVES: To assess risks and benefits of chronic blood transfusion regimens in people with sickle cell disease for primary and secondary stroke prevention (excluding silent cerebral infarcts). SEARCH METHODS: We searched for relevant trials in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1980), and ongoing trial databases; all searches current to 04 April 2016.We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register: 25 April 2016. SELECTION CRITERIA: Randomised controlled trials comparing red blood cell transfusions as prophylaxis for stroke in people with sickle cell disease to alternative or standard treatment. There were no restrictions by outcomes examined, language or publication status. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial eligibility and the risk of bias and extracted data. MAIN RESULTS: We included five trials (660 participants) published between 1998 and 2016. Four of these trials were terminated early. The vast majority of participants had the haemoglobin (Hb)SS form of sickle cell disease.Three trials compared regular red cell transfusions to standard care in primary prevention of stroke: two in children with no previous long-term transfusions; and one in children and adolescents on long-term transfusion.Two trials compared the drug

  3. Blood transfusion for preventing primary and secondary stroke in people with sickle cell disease

    PubMed Central

    Estcourt, Lise J; Fortin, Patricia M; Hopewell, Sally; Trivella, Marialena; Wang, Winfred C

    2017-01-01

    Background Sickle cell disease is one of the commonest severe monogenic disorders in the world, due to the inheritance of two abnormal haemoglobin (beta globin) genes. Sickle cell disease can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Stroke affects around 10% of children with sickle cell anaemia (HbSS). Chronic blood transfusions may reduce the risk of vaso-occlusion and stroke by diluting the proportion of sickled cells in the circulation. This is an update of a Cochrane Review first published in 2002, and last updated in 2013. Objectives To assess risks and benefits of chronic blood transfusion regimens in people with sickle cell disease for primary and secondary stroke prevention (excluding silent cerebral infarcts). Search methods We searched for relevant trials in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1980), and ongoing trial databases; all searches current to 04 April 2016. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register: 25 April 2016. Selection criteria Randomised controlled trials comparing red blood cell transfusions as prophylaxis for stroke in people with sickle cell disease to alternative or standard treatment. There were no restrictions by outcomes examined, language or publication status. Data collection and analysis Two authors independently assessed trial eligibility and the risk of bias and extracted data. Main results We included five trials (660 participants) published between 1998 and 2016. Four of these trials were terminated early. The vast majority of participants had the haemoglobin (Hb)SS form of sickle cell disease. Three trials compared regular red cell transfusions to standard care in primary prevention of stroke: two in children with no previous long-term transfusions; and one in children and adolescents on long-term transfusion. Two trials compared the drug

  4. The Benefit and Safety of Aspirin for Primary Prevention of Ischemic Stroke: A Meta-Analysis of Randomized Trials

    PubMed Central

    Lei, Hong; Gao, Qian; Liu, Shan-Rong; Xu, Jian

    2016-01-01

    Background: Although aspirin is effective in the secondary prevention of stroke among men and women, its use in primary prevention remains controversial. We conducted a meta-analysis of randomized trials to evaluate the benefit and safety of aspirin for the primary prevention of ischemic stroke. Methods: We searched three electronic databases (Medline, the Cochrane Central Register of Controlled Trials, and Embase) for articles published before August 1st, 2016. Randomized trials reporting the effect of aspirin on the primary prevention of ischemic stroke and its side effects (hemorrhagic stroke and severe gastrointestinal bleeding) were included. We used a fixed-effect model to quantify the effect of aspirin on the primary prevention of stroke when the heterogeneity was low, or else applied the random-effect model. Results: Fourteen randomized trials were included. Overall, aspirin use was associated with a decreased risk of ischemic stroke compared with non-aspirin use (OR: 0.83, 95% CI: 0.74–0.93, P = 0.45). In subgroup analyses, the effect of aspirin on ischemic stroke in apparently healthy adults remained significant (OR: 0.83, 95% confidence interval: 0.74–0.94, I2 = 22%, P = 0.28); while in patients with cardiovascular diseases there was no difference in the risk of ischemic stroke between aspirin and non-aspirin groups (OR: 0.75, 95% confidence interval: 0.44–1.29, P = 0.46). As for adverse effects, the prophylactic use of aspirin potentially increased the risk of serious bleeding events in a population of apparently healthy individuals and in patients with previous cardiovascular diseases. Conclusion: This meta-analysis of randomized trials indicated that both the apparently healthy adults and patients with cardiovascular diseases will derive little protective benefit from aspirin considering the increased risk of severe bleeding events. PMID:27917124

  5. Stepping towards prevention of bone loss after stroke: a systematic review of the skeletal effects of physical activity after stroke.

    PubMed

    Borschmann, Karen; Pang, Marco Y C; Bernhardt, Julie; Iuliano-Burns, Sandra

    2012-06-01

    Bone loss after stroke is pronounced, and contributes to increased fracture risk. People who fracture after stroke experience reduced mobility and increased mortality. Physical activity can maintain or improve bone mineral density and structure in healthy older adults, likely reducing fracture risk. The purpose of this systematic review was to investigate the skeletal effects of physical activity in adults affected by stroke. A search of electronic databases was undertaken. Selection criteria of trials were • prospective and controlled • physical activity-based intervention • participants with history of stroke, and • bone-related outcome measures. Effect sizes were calculated for outcomes of paretic and nonparetic limbs. Three of 349 identified records met the inclusion criteria. Small effect sizes were found in favor of physical activity in adults with chronic stroke (n=95, 40% female, average age 63·8 years, more than one-year poststroke). Patients in intervention groups had significantly higher changes in femoral neck bone mineral density, tibial cortical thickness and trabecular bone mineral content of the paretic limb, compared with controls (P<0·05). It is not known whether these benefits reduced fracture risk. There are limited studies investigating the skeletal effect of physical activity for adults poststroke. Given the increased risk of, and poor outcomes following a fracture after stroke, randomized trials are warranted to investigate the benefits of physical activity on bone, after stroke. Interventions are likely to be beneficial if implemented soon after stroke, when bone loss appears to be rapid and pronounced.

  6. Prospects for primary stroke prevention in children with sickle cell anaemia.

    PubMed

    Jordan, Lori C; Casella, James F; DeBaun, Michael R

    2012-04-01

    This review will focus on the strengths and limitations associated with the current standard of care for primary prevention of ischaemic strokes in children with sickle cell anaemia (SCA) - transcranial Doppler ultrasound (TCD) screening followed by regular blood transfusion therapy when TCD measurement is above a threshold defined by a randomized clinical trial (RCT). The theoretical basis for potential alternative strategies for primary prevention of neurological injury in SCA is also discussed. These strategies will include, but will not be limited to: immunizations to prevent bacterial infections, particularly in low income countries; management of elevated blood pressure; and targeted strategies to increase baseline haemoglobin levels with therapies such as hyroxycarbamide or potentially definitive haematopoietic stem cell transplant.

  7. Minimizing bleeding risk in patients receiving direct oral anticoagulants for stroke prevention

    PubMed Central

    Habert, Jeffrey Steven

    2016-01-01

    Many primary care physicians are wary about using direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (AF). Factors such as comorbidities, concomitant medications, and alcohol misuse increase concerns over bleeding risk, especially in elderly and frail patients with AF. This article discusses strategies to minimize the risk of major bleeding events in patients with AF who may benefit from oral anticoagulant therapy for stroke prevention. The potential benefits of the DOACs compared with vitamin K antagonists, in terms of a lower risk of intracranial hemorrhage, are discussed, together with the identification of reversible risk factors for bleeding and correct dose selection of the DOACs based on a patient’s characteristics and concomitant medications. Current bleeding management strategies, including the new reversal agents for the DOACs and the prevention of bleeding during preoperative anticoagulation treatment, in addition to health care resource use associated with anticoagulation treatment and bleeding, are also discussed. Implementing a structured approach at an individual patient level will minimize the overall risk of bleeding and should increase physician confidence in using the DOACs for stroke prevention in their patients with nonvalvular AF. PMID:27785089

  8. Rosuvastatin Treatment Prevents Progressive Kidney Inflammation and Fibrosis in Stroke-Prone Rats

    PubMed Central

    Gianella, Anita; Nobili, Elena; Abbate, Mauro; Zoja, Carla; Gelosa, Paolo; Mussoni, Luciana; Bellosta, Stefano; Canavesi, Monica; Rottoli, Daniela; Guerrini, Uliano; Brioschi, Maura; Banfi, Cristina; Tremoli, Elena; Remuzzi, Giuseppe; Sironi, Luigi

    2007-01-01

    Salt-loaded, spontaneously hypertensive stroke-prone rats show progressive increases in blood pressure and proteinuria and accumulate acute-phase proteins in body fluids, modeling events during renal damage. The aim of this study was to assess the pathological events occurring in the kidney of spontaneously hypertensive stroke-prone rats over time and evaluate the effects of statin treatment, which is known to improve renal and cardiovascular outcomes. Kidneys of male spontaneously hypertensive stroke-prone rats euthanized at different stages of proteinuria showed progressive inflammatory cell infiltration, the accumulation of α-smooth muscle actin-positive cells, degenerative changes in podocytes, and severe fibrosis. These were accompanied by an imbalance in the plasminogen/plasmin and metalloprotease systems characterized by the increased renal expression of plasminogen activator inhibitor-1, tissue plasminogen activator, and urokinase plasminogen activator; the net result was an increase in plasmin and matrix metalloproteinase (MMP)-2 and a reduction in MMP-9 activity. Chronic treatment with the hydrophilic rosuvastatin had renoprotective effects in terms of morphology and inflammation and prevented the changes in plasmin, MMP-2, and MMP-9 activity. These effects were independent of the changes in blood pressure and plasma lipid levels. Treatment with the lipophilic simvastatin was not renoprotective. These data suggest that rosuvastatin may have potential utility as a therapeutic option in renal diseases that are characterized by inflammation and fibrosis. PMID:17392157

  9. Novel oral anticoagulants for stroke prevention in patients with atrial fibrillation: dawn of a new era.

    PubMed

    Contractor, Tahmeed; Levin, Vadim; Martinez, Matthew W; Marchlinski, Francis E

    2013-01-01

    Atrial fibrillation (AF) is an important cause of ischemic stroke and is the underlying cause of > 20% of all strokes, with increasing age being a risk factor. Until recently, warfarin was the only available oral anticoagulant used to decrease this risk in patients with AF. However, there are several disadvantages of warfarin use, such as the requirement for monitoring the international normalized ratio, its wide range of drug-food interactions, and its narrow therapeutic index. Thus, there has been a strong impetus for the development of newer oral anticoagulants with predictable pharmacokinetics that obviate the need for monitoring the international normalized ratio. The US Food and Drug Administration has approved a direct thrombin inhibitor (dabigatran) and 2 factor Xa inhibitors (rivaroxaban and apixaban) for stroke prevention in patients with nonvalvular AF. There are several other new oral anticoagulant agents on the horizon, including the factor Xa inhibitor edoxaban. This review article discusses the pharmacological properties, clinical trial data, and practical issues associated with the use of these novel oral anticoagulants.

  10. Development of apixaban: a novel anticoagulant for prevention of stroke in patients with atrial fibrillation.

    PubMed

    Hanna, Michael S; Mohan, Puneet; Knabb, Robert; Gupta, Elora; Frost, Charles; Lawrence, John H

    2014-11-01

    The factor Xa inhibitor apixaban is one of the novel anticoagulants to emerge as alternatives to long-standing standards of care that include low-molecular-weight heparin and warfarin. The development of apixaban reflects a strategy to optimize the clinical pharmacology profile, dosing posology, trial designs, and statistical analyses across multiple indications, and to seek alignment with global health authorities. The primary objective of dose selection was to maintain balance between efficacy and bleeding risk. Twice-daily dosing of apixaban, rather than once daily, was chosen to lower peak concentrations and reduce fluctuations between peak and trough levels. Our discussion here focuses on the use of apixaban for stroke prevention in nonvalvular atrial fibrillation (NVAF). Supporting this indication, a pair of registrational trials was conducted that enrolled the full spectrum of patients who, by guidelines, were eligible for anticoagulation. In the AVERROES study of patients who were unsuitable for warfarin therapy, apixaban was superior to aspirin in reducing the risk of stroke or systemic embolism (SSE), without a significant increase in major bleeding (MB). In the ARISTOTLE (Apixaban for Reduction In STroke and Other ThromboemboLic Events in Atrial Fibrillation) study, apixaban was superior to warfarin on the rates of SSE, MB, and all-cause mortality. Overall, these studies have demonstrated a substantially favorable benefit-risk profile for apixaban over warfarin and aspirin in NVAF.

  11. Concerns Regarding the Use of Dabigatran for Stroke Prevention in Atrial Fibrillation

    PubMed Central

    Stöllberger, Claudia; Finsterer, Josef

    2012-01-01

    Dabigatran is an oral thrombin inhibitor which has been approved in several countries as an alternative to vitamin-K-antagonists for the prevention of stroke or embolism in atrial fibrillation patients. Dabigatran is introduced into clinical practice, although many issues regarding this drug are still unclear, like laboratory monitoring, use in elderly patients, drug- and food-interactions and use in patients with renal insufficiency. Additionally, there is no antidote for dabigatran. Thus, aim of the present review is to give an overview of concerns and unresolved issues concerning dabigatran. PMID:24288086

  12. Blood pressure control and primary prevention of stroke: summary of the recent clinical trial data and meta-analyses.

    PubMed

    Gaciong, Zbigniew; Siński, Maciej; Lewandowski, Jacek

    2013-12-01

    Stroke is the second most common cause of death worldwide and of adult disability, but in the near future the global burden of cerebrovascular diseases will rise due to ageing and adverse lifestyle changes in populations worldwide. The risk of stroke increases at blood pressure levels above 115/75 mm Hg and high blood pressure (BP) is the most important modifiable risk factor for stroke, associated with 54 % episodes of stroke worldwide. There is strong evidence from clinical trials that antihypertensive therapy reduces substantially the risk of any type of stroke, as well as stroke-related death and disability. The risk attributed to BP is associated not only with absolute values but also with certain parameters describing BP diurnal pattern as well as short-term and long-term variability. Many studies reported that certain features of BP like nocturnal hypertension, morning surge or increased variability predict an increased stroke risk. However, there is no accepted effective modality for correction of these disturbances (chronotherapy, certain classes of antihypertensive drugs). In the elderly, who are mostly affected by stroke, the primary prevention guidelines recommend treatment with diuretics and calcium channel blockers to lower blood pressure to the standard level.

  13. Detection of previously undiagnosed atrial fibrillation in patients with stroke risk factors and usefulness of continuous monitoring in primary stroke prevention.

    PubMed

    Ziegler, Paul D; Glotzer, Taya V; Daoud, Emile G; Singer, Daniel E; Ezekowitz, Michael D; Hoyt, Robert H; Koehler, Jodi L; Coles, James; Wyse, D George

    2012-11-01

    The detection of undiagnosed atrial tachycardia/atrial fibrillation (AT/AF) among patients with stroke risk factors could be useful for primary stroke prevention. We analyzed newly detected AT/AF (NDAF) using continuous monitoring in patients with stroke risk factors but without previous stroke or evidence of AT/AF. NDAF (AT/AF >5 minutes on any day) was determined in patients with implantable cardiac rhythm devices and ≥1 stroke risk factors (congestive heart failure, hypertension, age ≥75 years, or diabetes). All devices were capable of continuously monitoring the daily cumulative time in AT/AF. Of 1,368 eligible patients, NDAF was identified in 416 (30%) during a follow-up of 1.1 ± 0.7 years and was unrelated to the CHADS(2) score (congestive heart failure, hypertension [blood pressure consistently >140/90 mm Hg or hypertension treated with medication], age ≥75 years, diabetes mellitus, previous stroke or transient ischemic attack). The presence of AT/AF >6 hours on ≥1 day increased significantly with increased CHADS(2) scores and was present in 158 (54%) of 294 patients with NDAF and a CHADS(2) score of ≥2. NDAF was sporadic, and 78% of patients with a CHADS(2) score of ≥2 with NDAF experienced AT/AF on <10% of the follow-up days. The median interval to NDAF detection in these higher risk patients was 72 days (interquartile range 13 to 177). In conclusion, continuous monitoring identified NDAF in 30% of patients with stroke risk factors. In patients with NDAF, AT/AF occurred sporadically, highlighting the difficulty in detecting paroxysmal AT/AF using traditional monitoring methods. However, AT/AF also persisted for >6 hours on ≥1 days in most patients with NDAF and multiple stroke risk factors. Whether patients with CHADS(2) risk factors but without a history of AF might benefit from implantable monitors for the selection and administration of anticoagulation for primary stroke prevention merits additional investigation.

  14. Exploratory Network Meta Regression Analysis of Stroke Prevention in Atrial Fibrillation Fails to Identify Any Interactions with Treatment Effect

    PubMed Central

    Batson, Sarah; Sutton, Alex; Abrams, Keith

    2016-01-01

    Background Patients with atrial fibrillation are at a greater risk of stroke and therefore the main goal for treatment of patients with atrial fibrillation is to prevent stroke from occurring. There are a number of different stroke prevention treatments available to include warfarin and novel oral anticoagulants. Previous network meta-analyses of novel oral anticoagulants for stroke prevention in atrial fibrillation acknowledge the limitation of heterogeneity across the included trials but have not explored the impact of potentially important treatment modifying covariates. Objectives To explore potentially important treatment modifying covariates using network meta-regression analyses for stroke prevention in atrial fibrillation. Methods We performed a network meta-analysis for the outcome of ischaemic stroke and conducted an exploratory regression analysis considering potentially important treatment modifying covariates. These covariates included the proportion of patients with a previous stroke, proportion of males, mean age, the duration of study follow-up and the patients underlying risk of ischaemic stroke. Results None of the covariates explored impacted relative treatment effects relative to placebo. Notably, the exploration of ‘study follow-up’ as a covariate supported the assumption that difference in trial durations is unimportant in this indication despite the variation across trials in the network. Conclusion This study is limited by the quantity of data available. Further investigation is warranted, and, as justifying further trials may be difficult, it would be desirable to obtain individual patient level data (IPD) to facilitate an effort to relate treatment effects to IPD covariates in order to investigate heterogeneity. Observational data could also be examined to establish if there are potential trends elsewhere. The approach and methods presented have potentially wide applications within any indication as to highlight the potential benefit

  15. Mycophenolate mofetil prevents cerebrovascular injury in stroke-prone spontaneously hypertensive rats.

    PubMed

    Dhande, Isha S; Zhu, Yaming; Braun, Michael C; Hicks, M John; Wenderfer, Scott E; Doris, Peter A

    2017-03-01

    Stroke-prone spontaneously hypertensive rats (SHR-A3) develop strokes and progressive kidney disease as a result of naturally occurring genetic variations. We recently identified genetic variants in immune signaling pathways that contribute to end-organ injury. The present study was designed to test the hypothesis that a dysregulated immune response promotes stroke susceptibility. We salt-loaded 20 wk old male SHR-A3 rats and treated them with the immunosuppressant mycophenolate mofetil (MMF, 25 mg/kg/day po) (n = 8) or vehicle (saline) (n = 9) for 8 wk. Blood pressure (BP) was measured weekly by telemetry. Compared with vehicle-treated controls, MMF-treated SHR-A3 rats had improved survival and lower neurological deficit scores (1.44 vs. 0.125; P < 0.02). Gross morphology of the brain revealed cerebral edema in 8 of 9, and microbleeds and hemorrhages in 5 of 9 vehicle-treated rats. These lesions were absent in MMF-treated rats. Brain CD68 expression, indicating macrophage/microglial activation, was upregulated in vehicle-treated rats with microbleeds and hemorrhages but was undetectable in the brains of MMF-treated rats. MMF also prevented renal injury in SHR-A3 rats, evidenced by reduced proteinuria (albumin:creatinine) from 7.52 to 1.05 mg/mg (P < 0.03) and lower tubulointerstitial injury scores (2.46 vs. 1.43; P < 0.01). Salt loading resulted in a progressive increase in BP, which was blunted in rats receiving MMF. Our findings provide evidence that abnormal immune activation predisposes to cerebrovascular and renal injury in stroke-prone SHR-A3 rats.

  16. Effect of secondary preventive therapy on recurrence of tuberculosis in HIV-infected individuals: a systematic review.

    PubMed

    Bruins, Wassilis Sc; van Leth, Frank

    2017-03-01

    Human immunodeficiency virus (HIV)-infected individuals successfully treated for tuberculosis (TB) remain at risk of recurrence of the disease, especially in high TB incidence settings. We performed a systematic review, investigating whether secondary preventive therapy (sPT) with anti-TB drugs (preventive therapy in former TB patients with treatment success) is an effective strategy to prevent recurrence of TB in this patient group. We searched the databases PubMed, Cochrane Library, EMBASE, Web of Science and Google Scholar using the keywords HIV-infections, HIV, human immunodeficiency virus, AIDS, isoniazid, isoniazid preventive therapy (IPT), tuberculosis, TB, recurrence and recurrent disease, resulting in 253 potential publications. We identified eight publications for full text assessment, after which four articles qualified for inclusion in this systematic review. The quality of the included articles was rated using the GRADE system. All but one study were rated as having a high quality. In all included studies, sPT significantly decreased the incidence of recurrent TB in HIV-infected individuals to a substantial degree in comparison to non-treatment or placebo. Relative reductions varied from 55.0% to 82.1%. These data showed that the use of sPT to prevent recurrent TB in HIV-infected individuals was highly beneficial. These findings need to be confirmed in prospective studies with an adequate assessment of the effect of antiretroviral therapy (ART) and the occurrence of drug resistance.

  17. Cystoman® and calculi: a good alternative to standard therapies in preventing stone recurrence.

    PubMed

    Proietti, S; Giannantoni, A; Luciani, L G; Sortino, G; Graziotti, P; Giusti, G

    2014-08-01

    To assess the efficacy and tolerability of D-mannose-containing product (Cystoman(®)) in preventing recurrence in patients who underwent surgical treatment for infection related urinary stones. From January 2011 to February 2013 we have enrolled all consecutive patients affected by staghorn calculi and recurrent urinary tract infections (UTIs). All patients recommended for surgery were scheduled for percutaneous nephrolithotomy. The study agent was administered daily for 5 months after surgical procedure. At baseline and 5-month follow-up all patients underwent abdominal Computed Tomography (CT) scan and they also completed Medical Outcomes Study short-form, 36-item questionnaire (SF-36). They performed urine and urine culture monthly. The primary endpoints were the assessment of the efficacy with regard to infection-related urinary stone recurrence and the tolerability of Cystoman(®). The secondary endpoint was the evaluation of quality-of-life symptoms. During the study period, a total of 27 patients were included in the study. The data from 25 patients were analyzable. Seventeen patients (68%) did not report UTIs during follow-up. Eight patients (32%) remained infected and the average number of UTIs was 2.6 ± 1.6 in 5 months. At 5-month follow-up 17 (68%) patients were free from stones recurrence; in 8 (32%) cases CT scan revealed stone recurrence with an average stone diameter of 1.1 ± 0.4 cm. In nonrecurring patients, 2 (11.7%) reported an average of 1.5 ± 0.7 UTIs episodes; in recurring patients, 6 (75%) showed 3 ± 1.67 of UTIs episodes. Statistically significant differences were seen in the occurrence of UTIs episodes were detected between nonrecurring stone patients and recurring patients (p < 0.05). Moreover, statistically significant changes were detected in SF-36 scores from baseline to month 5 in the categories of physical functioning and energy/fatigue (p < 0.05). Cystoman(®) is effective in preventing infection-related urinary stones.

  18. Inhibition of vasculogenesis, but not angiogenesis, prevents the recurrence of glioblastoma after irradiation in mice.

    PubMed

    Kioi, Mitomu; Vogel, Hannes; Schultz, Geoffrey; Hoffman, Robert M; Harsh, Griffith R; Brown, J Martin

    2010-03-01

    Despite the high doses of radiation delivered in the treatment of patients with glioblastoma multiforme (GBM), the tumors invariably recur within the irradiation field, resulting in a low cure rate. Understanding the mechanism of such recurrence is therefore important. Here we have shown in an intracranial GBM xenograft model that irradiation induces recruitment of bone marrow-derived cells (BMDCs) into the tumors, restoring the radiation-damaged vasculature by vasculogenesis and thereby allowing the growth of surviving tumor cells. BMDC influx was initiated by induction of HIF-1 in the irradiated tumors, and blocking this influx prevented tumor recurrence. Previous studies have indicated that BMDCs are recruited to tumors in part through the interaction between the HIF-1-dependent stromal cell-derived factor-1 (SDF-1) and its receptor, CXCR4. Pharmacologic inhibition of HIF-1 or of the SDF-1/CXCR4 interaction prevented the influx of BMDCs, primarily CD11b+ myelomonocytes, and the postirradiation development of functional tumor vasculature, resulting in abrogation of tumor regrowth. Similar results were found using neutralizing antibodies against CXCR4. Our data therefore suggest a novel approach for the treatment of GBM: in addition to radiotherapy, the vasculogenesis pathway needs to be blocked, and this can be accomplished using the clinically approved drug AMD3100, a small molecule inhibitor of SDF-1/CXCR4 interactions.

  19. Pharmaceutical treatments to prevent recurrence of endometriosis following surgery: a model-based economic evaluation

    PubMed Central

    Sanghera, Sabina; Barton, Pelham; Bhattacharya, Siladitya; Horne, Andrew W; Roberts, Tracy Elizabeth

    2016-01-01

    Objective Conduct an economic evaluation based on best currently available evidence comparing alternative treatments levonorgestrel-releasing intrauterine system, depot-medroxyprogesterone acetate, combined oral contraceptive pill (COCP) and ‘no treatment’ to prevent recurrence of endometriosis after conservative surgery in primary care, and to inform the design of a planned trial-based economic evaluation. Methods We developed a state transition (Markov) model with a 36-month follow-up. The model structure was informed by a pragmatic review and clinical experts. The economic evaluation adopted a UK National Health Service perspective and was based on an outcome of incremental cost per quality-adjusted life year (QALY). As available data were limited, intentionally wide distributions were assigned around model inputs, and the average costs and outcome of the probabilistic sensitivity analyses were reported. Results On average, all strategies were more expensive and generated fewer QALYs compared to no treatment. However, uncertainty attributing to the transition probabilities affected the results. Inputs relating to effectiveness, changes in treatment and the time at which the change is made were the main causes of uncertainty, illustrating areas where robust and specific data collection is required. Conclusions There is currently no evidence to support any treatment being recommended to prevent the recurrence of endometriosis following conservative surgery. The study highlights the importance of developing decision models at the outset of a trial to identify data requirements to conduct a robust post-trial analysis. PMID:27084280

  20. Are High Proanthocyanidins Key to Cranberry Efficacy in the Prevention of Recurrent Urinary Tract Infection?

    PubMed

    Vostalova, Jitka; Vidlar, Ales; Simanek, Vilim; Galandakova, Adela; Kosina, Pavel; Vacek, Jan; Vrbkova, Jana; Zimmermann, Benno F; Ulrichova, Jitka; Student, Vladimir

    2015-10-01

    Most research on American cranberry in the prevention of urinary tract infection (UTI) has used juices. The spectrum of components in juice is limited. This study tested whether whole cranberry fruit powder (proanthocyanidin content 0.56%) could prevent recurrent UTI in 182 women with two or more UTI episodes in the last year. Participants were randomized to a cranberry (n = 89) or a placebo group (n = 93) and received daily 500 mg of cranberry for 6 months. The number of UTI diagnoses was counted. The intent-to-treat analyses showed that in the cranberry group, the UTIs were significantly fewer [10.8% vs. 25.8%, p = 0.04, with an age-standardized 12-month UTI history (p = 0.01)]. The Kaplan-Meier survival curves showed that the cranberry group experienced a longer time to first UTI than the placebo group (p = 0.04). Biochemical parameters were normal, and there was no significant difference in urinary phenolics between the groups at baseline or on day180. The results show that cranberry fruit powder (peel, seeds, pulp) may reduce the risk of symptomatic UTI in women with a history of recurrent UTIs.

  1. Safe use of antithrombotics for stroke prevention in atrial fibrillation: consideration of risk assessment tools to support decision-making

    PubMed Central

    Bajorek, Beata

    2014-01-01

    Clinical guidelines advocate stroke prevention therapy in atrial fibrillation (AF) patients, specifically anticoagulation. However, the decision to initiate treatment is based on the risk (bleeding) versus benefit (prevention of stroke) of therapy, which is often difficult to assess. This review identifies available risk assessment tools to facilitate the safe and optimal use of antithrombotic therapy for stroke prevention in AF. Using key databases and online clinical resources to search the literature (1992–2012), 19 tools have been identified and published to date: 11 addressing stroke risk, 7 addressing bleeding risk and 1 integrating both risk assessments. The stroke risk assessment tools (e.g. CHADS2, CHA2DS2-VASc) share common risk factors: age, hypertension, previous cerebrovascular attack. The bleeding risk assessment tools (e.g. HEMORR2HAGES, HAS-BLED) share common risk factors: age, previous bleeding, renal and liver impairment. In terms of their development, six of the stroke risk assessment tools have been derived from clinical studies, whilst five are based on refinement of existing tools or expert consensus. Many have been evaluated by prospective application to data from real patient cohorts. Bleeding risk assessment tools have been derived from trials, or generated from patient data and then validated via further studies. One identified tool (i.e. Computerised Antithrombotic Risk Assessment Tool [CARAT]) integrates both stroke and bleeding, and specifically considers other key factors in decision-making regarding antithrombotic therapy, particularly those increasing the risk of medication misadventure with treatment (e.g. function, drug interactions, medication adherence). This highlights that whilst separate tools are available to assess stroke and bleeding risk, they do not estimate the relative risk versus benefit of treatment in an individual patient nor consider key medication safety aspects. More effort is needed to synthesize these

  2. An open trial of mindfulness-based cognitive therapy for the prevention of perinatal depressive relapse/recurrence.

    PubMed

    Dimidjian, Sona; Goodman, Sherryl H; Felder, Jennifer N; Gallop, Robert; Brown, Amanda P; Beck, Arne

    2015-02-01

    Pregnant women with histories of depression are at high risk of depressive relapse/recurrence during the perinatal period, and options for relapse/recurrence prevention are limited. Mindfulness-based cognitive therapy (MBCT) has strong evidence among general populations but has not been studied among at-risk pregnant women to prevent depression. We examined the feasibility, acceptability, and clinical outcomes of depression symptom severity and relapse/recurrence associated with MBCT adapted for perinatal women (MBCT-PD). Pregnant women with depression histories were recruited from obstetrics clinics in a large health maintenance organization at two sites and enrolled in MBCT-PD (N = 49). Self-reported depressive symptoms and interview-based assessments of depression relapse/recurrence status were measured at baseline, during MBCT-PD, and through 6-months postpartum. Pregnant women reported interest, engagement, and satisfaction with the program. Retention rates were high, as were rates of completion of daily homework practices. Intent to treat analyses indicated a significant improvement in depression symptom levels and an 18 % rate of relapse/recurrence through 6 months postpartum. MBCT-PD shows promise as an acceptable, feasible, and clinically beneficial brief psychosocial prevention option for pregnant women with histories of depression. Randomized controlled trials are needed to examine the efficacy of MBCT-PD for the prevention of depressive relapse/recurrence during pregnancy and postpartum.

  3. Are there differences in risk factor profiles and frequency of CT/MRI-based infarcts among African American stroke patients with and without hypertension? A report from the African American Antiplatelet Stroke Prevention Study (AAASPS).

    PubMed Central

    Whittley, Chandra Y.; Gorelick, Philip B.; Raman, Rema; Harris, Jeffrey; Richardson, DeJuran

    2003-01-01

    BACKGROUND; African Americans (AAs) have a high risk of stroke and a high prevalence of cardiovascular risk factors. Little is known about stroke risk profiles among non-hypertensive AAs. METHODS: African American Antiplatelet Stroke Prevention Study (AAASPS) enrollees with a history of hypertension (htn) were compared to those without htn for history of traditional cardiovascular risk factors and number and distribution of CT/MRI infarcts. Estimated odds ratios are presented describing the association between selected risk factors and htn status. The estimated odds ratios and 95% confidence intervals (CI) were obtained using multivariate logistic regression. RESULTS: The database for this analysis included 1012 patients with htn and 74 patients without htn. When compared to those with htn, those without htn were more commonly men (59% vs. 46%; p = 0.030), current cigarette smokers (55% vs. 37%; p = 0.001), were younger (median age: 59 years vs. 62 years; p = 0.064), had higher education (11.7 +/- 2.9 vs. 11.1 +/- 3.1; p = 0.024), had a higher number of acute strokes of unknown cause (23% vs. 13%; p=0.060), and less commonly had a history of diabetes (25% vs. 41%; p = 0.007). Those without htn had a lower mean number of old infarcts on MRI (0.94 +/- 1.40 vs. 1.45 +/- 1.60; p = 0.045), and a higher number of mean recent infarcts on CT (1.30 +/- 1.15 vs. 0.93 +/- 1.01; p = 0.031). Multivariate analysis to predict those without htn showed that these patients were more likely to be current cigarette smokers (OR = 2.89; CI = 1.60,5.49) and have higher education (OR = 1.08, CI = 0.996,1.17), and were less likely to have old CT/MRI-based infarcts (OR = 0.46; CI = 0.26,0.76). CONCLUSIONS: AAs without htn may have a different cardiovascular risk factor profile and CT/MRI profile than AAs with htn. This baseline profile among AAs without htn may predict lower stroke recurrence rates in this ongoing trial. PMID:12856908

  4. Safety and Effectiveness of Statins for Prevention of Recurrent Myocardial Infarction in 12 156 Typical Older Patients: A Quasi-Experimental Study

    PubMed Central

    Hughes, Peter M.; Delgado, Joao; Masoli, Jane A.; Bowman, Kirsty; Zirk-Sadowski, Jan; Mujica Mota, Ruben E.; Henley, William E.; Melzer, David

    2017-01-01

    Background: There is limited evidence on statin risk and effectiveness for patients aged 80+. We estimated risk of recurrent myocardial infarction, muscle-related and other adverse events, and statin-related incremental costs in “real-world” older patients treated with statins versus no statins. Methods: We used primary care electronic medical records from the UK Clinical Practice Research Datalink. Subhazard ratios (competing risk of death) for myocardial infarction recurrence (primary end point), falls, fractures, ischemic stroke, and dementia, and hazard ratios (Cox) for all-cause mortality were used to compare older (60+) statin users and 1:1 propensity-score-matched controls (n = 12,156). Participants were followed-up for 10 years. Results: Mean age was 76.5±9.2 years; 45.5% were women. Statins were associated with near significant reduction in myocardial infarction recurrence (subhazard ratio = 0.84, 0.69–1.02, p = .073), with protective effect in the 60–79 age group (0.73, 0.57–0.94) but a nonsignificant result in the 80+ group (1.06, 0.78–1.44; age interaction p = .094). No significant associations were found for stroke or dementia. Data suggest an increased risk of falls (1.36, 1.17–1.60) and fractures (1.33, 1.04–1.69) in the first 2 years of treatment, particularly in the 80+ group. Treatment was associated with lower all-cause mortality. Statin use was associated with health care cost savings in the 60–79 group but higher costs in the 80+ group. Conclusions: Estimates of statin effectiveness for the prevention of recurrent myocardial infarction in patients aged 60–79 years were similar to trial results, but more evidence is needed in the older group. There may be an excess of falls and fractures in very old patients, which deserves further investigation. PMID:27146371

  5. Comparison of the efficacy and safety of intensive-dose and standard-dose statin treatment for stroke prevention

    PubMed Central

    Wang, Juan; Chen, Dan; Li, Da-Bing; Yu, Xin; Shi, Guo-Bing

    2016-01-01

    Abstract Background: Previous study indicated that high-dose statin treatment might increase the risk of hemorrhagic stroke and adverse reactions. We aim to compare the efficacy and safety of intensive-dose and standard-dose statin treatment for preventing stroke in high-risk patients. Methods: A thorough search was performed of multiple databases for publications from 1990 to June 2015. We selected the randomized clinical trials comparing standard-dose statin with placebo and intensive-dose statin with standard-dose statin or placebo for the prevention of stroke events in patients. Duplicate independent data extraction and bias assessments were performed. Data were pooled using a fixed-effects model or a random-effects model if significant heterogeneity was present. Results: For the all stroke incidences, intensive-dose statin treatment compared with placebo treatment and standard-dose statin treatment compared with placebo treatment showed a significant 21% reduction in relative risk (RR) (RR 0.79, 95% confidence interval (CI) [0.71, 0.87], P < 0.00001) and an 18% reduction in RR (RR 0.82, 95% CI [0.73, 0.93], P = 0.002) in the subgroup without renal transplant recipients and patients undergoing regular hemodialysis separately. For the fatal stroke incidences, intensive-dose statin treatment compared with standard dose or placebo was effective reducing fatal stroke (RR 0.61, 95% CI [0.39, 0.96], P = 0.03) and the RR was 1.01 (95% CI [0.85, 1.20], P = 0.90) in standard-dose statin treatment compared with placebo. Conclusion: The results of this meta-analysis suggest that intensive-dose statin treatment might be more favorable for reducing the incidences of all strokes than standard-dose statin treatment, especially for patients older than 65 years in reducing the incidences of all stroke incidences. PMID:27684837

  6. Future of polypill use for the prevention of cardiovascular disease and strokes.

    PubMed

    Chrysant, Steven G; Chrysant, George S

    2014-08-15

    Cardiovascular disease (CVD) remains still the leading cause of death in the United States, and it is estimated to be the leading cause of death in the developing countries by 2020. In addition, the modifiable cardiovascular risk factors (CVRFs), hypertension, hypercholesterolemia, diabetes, and obesity, have increased significantly and by 2020 will account for 80% of all CVD deaths worldwide. Because the CVD and stroke risk increases significantly for subjects aged >50 years, it has been proposed to treat these subjects with a polypill containing 4 to 5 drugs, which is known to reduce the CVRFs for all subjects aged ≥55 years with an estimated reduction of CVD and stroke by 80%. However, this proposal is neither practical nor cost-effective, because it will involve a large number of subjects. Some investigators suggest to incorporate the coronary artery calcium score (CACS) with the Framingham Risk Score (FRS) to reduce the number of subjects who will benefit from the polypill. They have shown that patients with a CACS = 0 at age 50 years will derive no benefit from the polypill regardless of existing CVRFs, whereas those with a CACS of >100 will derive the best benefit. This strategy will reduce the number of qualified subjects for treatment with the polypill by 60%. Greater benefits will be derived with the combination of CACS and FRS. Additionally, other issues will have to be considered before approval of a polypill, and these issues will be discussed in this concise review. In conclusion, a polypill treatment strategy may be effective in the prevention of CVD and stroke, but, to be cost-effective, it may be reasonable to target patients with a high CACS and FRS.

  7. Anticoagulants to prevent recurrent placenta-mediated pregnancy complications: Is it time to put the needles away?

    PubMed

    Skeith, Leslie; Rodger, Marc

    2017-03-01

    Placenta-mediated pregnancy complications, such as pre-eclampsia, placental abruption, birth of a small-for-gestational age infant and late pregnancy loss, are common and carry significant morbidity and mortality. The etiology of placenta-mediated pregnancy complications is likely multifactorial and may include abnormal coagulation activation of the maternal-fetal interface. The use of antepartum low-molecular-weight heparin (LMWH) prophylaxis to prevent recurrent placenta-mediated pregnancy complications has become common practice despite limited and conflicting evidence to support its use. This paper reviews the evidence, including recently published data from an individual patient level meta-analysis, which challenges the role of LMWH in preventing recurrent placenta-mediated pregnancy complications. Incorporating this recent evidence, we recommend against the use of LMWH to prevent recurrent placenta-mediated pregnancy complications in women with and without inherited thrombophilia.

  8. Deliberate Establishment of Asymptomatic Bacteriuria—A Novel Strategy to Prevent Recurrent UTI

    PubMed Central

    Wullt, Björn; Svanborg, Catharina

    2016-01-01

    We have established a novel strategy to reduce the risk for recurrent urinary tract infection (UTI), where rapidly increasing antibiotic resistance poses a major threat. Epidemiologic studies have demonstrated that asymptomatic bacteriuria (ABU) protects the host against symptomatic infections with more virulent strains. To mimic this protective effect, we deliberately establish ABU in UTI-prone patients, who are refractory to conventional therapy. The patients are inoculated with Escherichia coli (E. coli) 83972, now widely used as a prototype ABU strain. Therapeutic efficacy has been demonstrated in a placebo-controlled trial, supporting the feasibility of using E. coli 83972 as a tool to prevent recurrent UTI and, potentially, to outcompete antibiotic-resistant strains from the human urinary tract. In addition, the human inoculation protocol offers unique opportunities to study host-parasite interaction in vivo in the human urinary tract. Here, we review the clinical evidence for protection using this approach as well as some molecular insights into the pathogenesis of UTI that have been gained during these studies. PMID:27483325

  9. Life style prevention of cancer recurrence: the yin and the yang.

    PubMed

    Berrino, Franco

    2014-01-01

    There is increasing evidence that lifestyle after the diagnosis of cancer may affect prognosis. Several studies have shown that a Western dietary pattern, obesity, weight gain, a sedentary lifestyle, metabolic syndrome, high serum levels of insulin, growth factors, and inflammatory cytokines after the diagnosis of cancer are associated with an increased incidence of recurrences. Most studies have been on breast and colon cancer. However, in the clinical management of cancer, little attention is presently paid to improving lifestyle and controlling body weight. Lifestyle intervention trials are needed to corroborate or confute the observational results on cancer recurrences, but, even now, there is no contraindication to promoting moderate physical exercise, moderate calorie restriction (CR), and a Mediterranean dietary pattern. In fact, the AICR/WCRF 2007 systematic literature review recommends cancer patients to adopt the lifestyle recommended for the prevention of cancer. Interestingly, the evidence-based AICR/WCRF recommendations coincide with traditional rules, based on far Eastern philosophy, of avoiding extremely yin food, such as sugared beverages and calorie-dense foods, and extremely yang food, such as processed meat, and relying on the equilibrium of slightly yang food, such as whole-grain unprocessed cereals, eaten with slightly yin food, such as legumes and vegetables.

  10. Prevention of ulcerative lesions by episodic treatment of recurrent herpes labialis: A literature review.

    PubMed

    Harmenberg, Johan; Oberg, Bo; Spruance, Spotwood

    2010-03-01

    There are substantial difficulties involved in carrying out clinical studies of recurrent herpes labialis, since the disease has a rapid onset, short-lasting viral shedding period and is rapidly self-healing. The aim of this paper was to critically assess published reports of episodic treatment of herpes labialis and to review biological and methodological problems involved in such studies. Limited, but statistically significant, results have been shown with topical antivirals, such as acyclovir and penciclovir, improving healing times by approximately 10%. Orally administrated antivirals, such as valaciclovir and famciclovir, have subsequently found clinical use. However, these two oral medications have different profiles in phase 3 studies. Famciclovir showed additional improvement of efficacy in terms of lesion healing time, but no effect on prevention of ulcerative lesions, while valaciclovir appeared to have similar efficacy to that of acyclovir cream on lesion healing, but some additional efficacy with respect to prevention of ulcerative lesions. A formulation of acyclovir/hydrocortisone showed further improvement in prevention of ulcerative lesions, while retaining efficacy with respect to lesion healing.

  11. Identifying the Non-recurrent Laryngeal Nerve: Preventing a Major Risk of Morbidity During Thyroidectomy

    PubMed Central

    Mahmodlou, Rahim; Aghasi, Mohammad Reza; Sepehrvand, Nariman

    2013-01-01

    Non-recurrent laryngeal nerve (NRLN) is a rare anomaly which is reported in 0.3%-0.8% of people on the right side and in 0.004% (extremely rare) on the left side. Damage to this nerve during the surgical procedure may lead to severe iatrogenic morbidity and should therefore be prevented from being damaged. The best way to avoid this damage to the nerve is to identify the nerve with a systematic diligent dissection based on usual anatomical landmarks and awareness about the possibility of their existence. Hereby, we are going to present a 26-year-old woman, a case of NRLN on the right side which was identified during thyroidectomy. The nervous anomaly was accompanied with vascular abnormality which was confirmed by computerized tomography (CT) angiography, post-operatively. PMID:23543847

  12. Prevention of recurrent deep venous thrombosis with sulodexide: the SanVal registry.

    PubMed

    Errichi, B M; Cesarone, M R; Belcaro, G; Marinucci, R; Ricci, A; Ippolito, A; Brandolini, R; Vinciguerra, G; Dugall, M; Felicita, A; Pellegrini, L; Gizzi, G; Ruffini, M; Acerbi, G; Bavera, P; Renzo, A Di; Corsi, M; Scoccianti, M; Hosoi, M; Lania, M

    2004-01-01

    The aim of this study was to evaluate the prevention of recurrent deep vein thrombosis (R-DVT) with an oral antithrombotic agent (sulodexide) in moderate to high-risk subjects. A group of 405 patients was included into the multicenter registry. Both compression and an exercise program were used as well as a risk-factors control plan. After diagnosis of DVT, patients were treated with oral anticoagulants for 6 months. At the end of this period a coagulation study was made and patients started treatment with oral sulodexide capsules for a period of 24 months. The femoral, popliteal, tibial, and superficial veins were scanned with high-resolution ultrasound at inclusion;scans were repeated at 6, 12, 18, and 24 months. Of the 405 subjects included into the registry 178 in the control group (mean age 52.2; SD 11; M:F=90:88) and 189 in the treatment group (mean age 53.2; SD 10.3; M:F=93:96) completed the analysis period of 24 months. At 6 and 12 months the incidence of R-DVT was lower (p<0.05) in the treatment group. At 24 months the global incidence of R-DVT was 17.9% in the control group and 7.4% in the sulodexide group (p<0.05), 2.42 times lower than in controls. The 2 groups were comparable for age and sex distribution and for the localization of the thrombi at inclusion. Also the 2 groups of dropouts were comparable. In the control group there were 32 recurrent DVTs and 24 subjects lost to follow-up (total of 56) of 202 included subjects (27.7%) in comparison with 28 failures (14 recurrent DVTs and 14 lost subjects) of 203 subjects (13.8%) in the treatment group. This difference was statistically significant. In this analysis the incidence of DVT in controls was 2.07 times higher than in the treatment group subjects. In conclusion sulodexide was effective in reducing recurrent thrombotic events in high-risk subjects.

  13. Retrospective Cross-Sectional Pilot Study of Rifaximin Dosing for the Prevention of Recurrent Hepatic Encephalopathy.

    PubMed

    Lyon, Kelsey C; Likar, Eric; Martello, Jay L; Regier, Michael

    2017-02-08

    Standard treatment for hepatic encephalopathy (HE) includes medications that reduce ammonia and bacterial translocation in the gut. Rifaximin can be used off-label for the reduction of overt HE. The study purpose was to determine efficacy of traditional rifaximin dosing (400 mg three times daily) compared to newer dosing (550 mg twice daily) via readmission rates for the prevention of recurrent HE. This was a retrospective, observational, cross-sectional pilot study conducted in a tertiary medical center. A total of 226 patients 18-89 years of age with documentation of HE via ICD-9 code who started rifaximin therapy while inpatient between April 2009 and June 2014 were evaluated. Data collected included rifaximin dosing, other medications used to treat HE, duration of therapy, time to readmission, and various laboratory values. There were no differences in readmission rates at 30 days, 60 days, or 6 months between treatment groups. Additionally, there was no difference in the odds of readmission between the treatment groups (OR = 0.77, 95% CI: (0.201, 4.365), p = 0.718). Patients had a low overall probability of readmission over the observational period. Based on average wholesale price (AWP) data, the cost for a 9 day supply of rifaximin for the 400 mg dosing regimen is $952.56 versus $605.16 for the 550 mg dosing regimen. The rifaximin 550 mg dosing strategy should be utilized in hospitalized patients for the prevention of recurrent HE as there was no difference in readmission rate or time to readmission between dosing groups. The 550 mg regimen had a lower acquisition cost for a 9-day duration of treatment in the studied institution.

  14. An evidence-based review of edoxaban and its role in stroke prevention in patients with nonvalvular atrial fibrillation

    PubMed Central

    Acharya, Tushar; Deedwania, Prakash

    2015-01-01

    Atrial fibrillation is the most common arrhythmia in the elderly. It is responsible for significant morbidity and mortality from cardioembolic complications like stroke. As a result, atrial fibrillation patients are risk-stratified using the CHADS2 or CHA2DS2-VASc scoring systems. Those at intermediate-to-high risk have traditionally been treated with therapeutic anticoagulation with warfarin for stroke prevention. Although effective, warfarin use is fraught with multiple concerns, such as a narrow therapeutic window, drug–drug and drug–food interactions, and excessive bleeding. Novel oral anticoagulant agents have recently become available as viable alternatives for warfarin therapy. Direct thrombin inhibitor dabigatran and factor Xa inhibitors like rivaroxaban and apixaban have already been approved by the US Food and Drug Administration (FDA) for stroke prevention in patients with nonvalvular atrial fibrillation. Edoxaban is the latest oral direct factor Xa inhibitor studied in the largest novel oral anticoagulant trial so far: ENGAGE AF-TIMI 48. Treatment with a 30 mg or 60 mg daily dose of edoxaban was found to be noninferior to dose-adjusted warfarin in reducing the rate of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, with a lower incidence of bleeding complications and cardiovascular deaths. Edoxaban was recently reviewed by an FDA advisory committee and recommended as a stroke-prophylaxis agent. Once approved, it promises to provide another useful alternative to warfarin therapy. PMID:26019695

  15. An evidence-based review of apixaban and its potential in the prevention of stroke in patients with atrial fibrillation.

    PubMed

    Deedwania, Prakash; Huang, Grace W

    2012-01-01

    Atrial fibrillation (AF) is a common cardiac arrhythmia, especially in the elderly population. It is associated with cardioembolic complications, particularly strokes, resulting in severe functional deficit or death. AF patients are first stratified into low, intermediate, and high risk for thromboembolic events using the CHADS(2) and CHA(2)DS(2)-VASc score systems. Depending on their risks, patients are treated with either therapeutic anticoagulation with warfarin or acetylsalicylic acid for stroke prevention. Although warfarin is the recommended therapy, it is underutilized clinically due to concern for narrow therapeutic window, drug-to-drug and drug-to-food interactions, and hemorrhagic complications. Newer anticoagulant agents such as dabigatran (a direct thrombin inhibitor) and rivaroxaban (a direct factor Xa inhibitor) have already been approved by US Food and Drug Administration for stroke prevention in patients with nonvalvular atrial fibrillation. Apixaban is the newest oral direct factor Xa inhibitor and it has been extensively studied in the AVERROES and ARISTOTLE trials. Apixaban demonstrated reduced incidence of primary outcome of stroke and bleeding events when compared with warfarin. Apixaban is currently being reviewed by the Food and Drug Administration as a stroke prophylactic agent. In addition, there are several other indirect factor Xa inhibitors and vitamin K antagonists under study presently. Results from these studies will provide us with information about possible alternatives to warfarin.

  16. Stroke: current concepts.

    PubMed

    Albertson, Megan; Sharma, Jitendra

    2014-11-01

    , but so far they are only experimental treatment options. The best preventative measures for first time or recurrent stroke are: starting or switching antiplatelet therapy, treatment of cardiovascular risk factors (atrial fibrillation and carotid stenosis), optimization of hypertension, dyslipidemia and diabetes mellitus management, and smoking cessation.

  17. High dry bean intake and reduced risk of advanced colorectal adenoma recurrence among participants in the polyp prevention trial.

    PubMed

    Lanza, Elaine; Hartman, Terryl J; Albert, Paul S; Shields, Rusty; Slattery, Martha; Caan, Bette; Paskett, Electra; Iber, Frank; Kikendall, James Walter; Lance, Peter; Daston, Cassandra; Schatzkin, Arthur

    2006-07-01

    Adequate fruit and vegetable intake was suggested to protect against colorectal cancer and colorectal adenomas; however, several recent prospective studies reported no association. We examined the association between fruits and vegetables and adenomatous polyp recurrence in the Polyp Prevention Trial (PPT). The PPT was a low-fat, high-fiber, high-fruit, and vegetable dietary intervention trial of adenoma recurrence, in which there were no differences in the rate of adenoma recurrence in participants in the intervention and control arms of the trial. In this analysis of the entire PPT trial-based cohort, multiple logistic regression analysis was used to estimate the odds ratio (OR) of advanced and nonadvanced adenoma recurrence within quartiles of baseline and change (baseline minus the mean over 3 y) in fruit and vegetable intake, after adjustment for age, total energyy intake, use of nonsteroidal anti-inflammatory drugs, BMI, and gender. There were no significant associations between nonadvanced adenoma recurrence and overall change in fruit and vegetable consumption; however, those in the highest quartile of change in dry bean intake (greatest increase) compared with those in the lowest had a significantly reduced OR for advanced adenoma recurrence (OR = 0.35; 95% CI, 0.18-0.69; P for trend = 0.001). The median in the highest quartile of change in dry bean intake was 370% higher than the baseline intake. The PPT trial-based cohort provides evidence that dry beans may be inversely associated with advanced adenoma recurrence.

  18. Omega-3 fatty acid is a potential preventive agent for recurrent colon cancer

    PubMed Central

    Vasudevan, Anita; Yu, Yingjie; Banerjee, Sanjeev; Woods, James; Farhana, Lulu; Rajendra, Sindhu G.; Patel, Aamil; Dyson, Gregory; Levi, Edi; Maddipati, Krishna Rao; Majumdar, Adhip P.N.; Nangia-Makker, Pratima

    2014-01-01

    Increasing evidence supports the contention that many malignancies, including sporadic colorectal cancer (CRC), are driven by the self-renewing, chemotherapy-resistant cancer stem/stem-like cells (CSCs/CSLCs) underscoring the need for improved preventive and therapeutic strategies targeting CSCs/CSLCs. Omega-3 polyunsaturated fatty acids (ω-3 PUFA), have been reported to inhibit the growth of primary tumors, but their potential as a preventive agent for recurring cancers is un-explored. The primary objectives of this investigation are to examine whether eicosapentaenoic acid (EPA; one of the ω-3 PUFA) synergizes with FuOx (5-FU+Oxaliplatin), the backbone of colon cancer chemotherapy, and (b) whether EPA by itself or in combination with conventional chemotherapy prevents the recurrence of colon cancer via eliminating/suppressing CSCs/CSLCs. FuOx-resistant (chemo-resistant; CR) colon cancer cells, highly enriched in CSCs, were utilized for this study. While EPA alone was effective, combination of EPA and FuOx was more potent in (a) inhibiting cell growth, colonosphere formation and sphere-forming frequency, (b) increasing sphere disintegration, (c) suppressing the growth of SCID mice xenografts of CR colon cancer cells, and (d) decreasing pro-inflammatory metabolites in mice. Additionally, EPA + FuOx caused a reduction in CSC/CSLC population. The growth reduction by this regimen is the result of increased apoptosis as evidenced by PARP cleavage. Furthermore, increased pPTEN, decreased pAkt, normalization of β-catenin expression, localization and transcriptional activity by EPA suggests a role for PTEN/Akt axis and Wnt signaling in regulating this process. Our data suggest that EPA by itself or in combination with FuOx could be an effective preventive strategy for recurring CRC. PMID:25193342

  19. Omega-3 fatty acid is a potential preventive agent for recurrent colon cancer.

    PubMed

    Vasudevan, Anita; Yu, Yingjie; Banerjee, Sanjeev; Woods, James; Farhana, Lulu; Rajendra, Sindhu G; Patel, Aamil; Dyson, Gregory; Levi, Edi; Maddipati, Krishna Rao; Majumdar, Adhip P N; Nangia-Makker, Pratima

    2014-11-01

    Increasing evidence supports the contention that many malignancies, including sporadic colorectal cancer, are driven by the self-renewing, chemotherapy-resistant cancer stem/stem-like cells (CSC/CSLC), underscoring the need for improved preventive and therapeutic strategies targeting CSCs/CSLCs. Omega-3 polyunsaturated fatty acids (ω-3 PUFA), have been reported to inhibit the growth of primary tumors, but their potential as a preventive agent for recurring cancers is unexplored. The primary objectives of this investigation are (i) to examine whether eicosapentaenoic acid (EPA; one of the ω-3 PUFA) synergizes with FuOx (5-FU+Oxaliplatin), the backbone of colon cancer chemotherapy, and (ii) whether EPA by itself or in combination with conventional chemotherapy prevents the recurrence of colon cancer via eliminating/suppressing CSCs/CSLCs. FuOx-resistant (chemoresistant; CR) colon cancer cells, highly enriched in CSCs, were used for this study. Although EPA alone was effective, combination of EPA and FuOx was more potent in (i) inhibiting cell growth, colonosphere formation, and sphere-forming frequency, (ii) increasing sphere disintegration, (iii) suppressing the growth of SCID mice xenografts of CR colon cancer cells, and (iv) decreasing proinflammatory metabolites in mice. In addition, EPA + FuOx caused a reduction in CSC/CSLC population. The growth reduction by this regimen is the result of increased apoptosis as evidenced by PARP cleavage. Furthermore, increased pPTEN, decreased pAkt, normalization of β-catenin expression, localization, and transcriptional activity by EPA suggests a role for the PTEN-Akt axis and Wnt signaling in regulating this process. Our data suggest that EPA by itself or in combination with FuOx could be an effective preventive strategy for recurring colorectal cancer.

  20. C-reactive Protein as a Prognostic Marker after Lacunar Stroke: The Levels of Inflammatory Markers in the Treatment of Stroke (LIMITS) Study

    PubMed Central

    Elkind, Mitchell S. V.; Luna, Jorge M.; McClure, Leslie A.; Zhang, Yu; Coffey, Christopher S.; Roldan, Ana; Del Brutto, Oscar H.; Pretell, Edwin Javier; Pettigrew, L. Creed; Meyer, Brett C.; Tapia, Jorge; White, Carole; Benavente, Oscar R.

    2014-01-01

    Background and Purpose Inflammatory biomarkers predict incident and recurrent cardiac events, but their relationship to stroke prognosis is uncertain. We hypothesized that high-sensitivity C-reactive protein (hsCRP) predicts recurrent ischemic stroke after recent lacunar stroke. Methods Levels of Inflammatory Markers in the Treatment of Stroke (LIMITS) was an international, multicenter, prospective ancillary biomarker study nested within Secondary Prevention of Small Subcortical Strokes (SPS3), a Phase III trial in patients with recent lacunar stroke. Patients were assigned in factorial design to aspirin versus aspirin plus clopidogrel, and higher versus lower blood pressure targets. Patients had blood samples collected at enrollment, and hsCRP measured using nephelometry at a central laboratory. Cox proportional hazards models were used to calculate hazard ratios and 95% confidence intervals (HR, 95%CI) for recurrence risks before and after adjusting for demographics, comorbidities, and statin use. Results Among 1244 lacunar stroke patients (mean 63.3 ± 10.8 years), median hsCRP was 2.16 mg/L. There were 83 recurrent ischemic strokes (including 45 lacunes), and 115 major vascular events (stroke, myocardial infarction, vascular death). Compared with the bottom quartile, those in the top quartile (hsCRP >4.86 mg/L) were at increased risk of recurrent ischemic stroke (unadjusted HR 2.54, 95%CI 1.30–4.96), even after adjusting for demographics and risk factors (adjusted HR 2.32, 95%CI 1.15–4.68). HsCRP predicted increased risk of major vascular events (top quartile adjusted HR 2.04, 95%CI 1.14–3.67). There was no interaction with randomized antiplatelet treatment. Conclusions Among recent lacunar stroke patients, hsCRP levels predict risk of recurrent strokes and other vascular events. HsCRP did not predict response to dual antiplatelets. PMID:24523037

  1. Stroke prevention in the elderly atrial fibrillation patient with comorbid conditions: focus on non-vitamin K antagonist oral anticoagulants

    PubMed Central

    Turagam, Mohit K; Velagapudi, Poonam; Flaker, Greg C

    2015-01-01

    Stroke prevention in elderly atrial fibrillation patients remains a challenge. There is a high risk of stroke and systemic thromboembolism but also a high risk of bleeding if anticoagulants are prescribed. The elderly have increased chronic kidney disease, coronary artery disease, polypharmacy, and overall frailty. For all these reasons, anticoagulant use is underutilized in the elderly. In this manuscript, the benefits of non-vitamin K antagonist oral anticoagulants compared with warfarin in the elderly patient population with multiple comorbid conditions are reviewed. PMID:26366064

  2. Predictors of Response to 17-alpha hydroxyprogesterone caproate for Prevention of Recurrent Spontaneous Preterm Birth

    PubMed Central

    MANUCK, Tracy A.; ESPLIN, M. Sean; BIGGIO, Joseph; BUKOWSKI, Radek; PARRY, Samuel; ZHANG, Heping; HUANG, Hao; VARNER, Michael W.; ANDREWS, William; SAADE, George; SADOVSKY, Yoel; REDDY, Uma M.; ILEKIS, John

    2016-01-01

    Background Prematurity is the leading cause of neonatal morbidity and mortality amongst non-anomalous neonates in the United States. Intramuscular 17-alpha hydroxyprogesterone caproate (17OHP-C) injections reduce the risk of recurrent prematurity by approximately one third. Unfortunately, prophylactic 17OHP-C is not always effective, and one-third of high-risk women will have a recurrent PTB despite 17OHP-C therapy. The reasons for this variability in response are unknown. Previous investigators have examined the influence of a variety of factors on 17OHP-C response, but have analyzed data used a fixed outcome of ‘term’ delivery to define progesterone response. Objective We hypothesized that the demographics, history, and pregnancy course among women who deliver at a similar gestational age with 17-alpha hydroxyprogesterone caproate (17OHP-C) for recurrent spontaneous preterm birth (SPTB) prevention differs when compared to those women who deliver later with 17OHP-C, and that these associations could be refined by using a contemporary definition of 17OHP-C ‘responder.’ Study Design This was a planned secondary analysis of a prospective, multi-center, longitudinal study of women with ≥ 1 prior documented singleton SPTB <37 weeks gestation. Data were collected at 3 pre-specified gestational age epochs during pregnancy. All women included in this analysis received 17OHP-C during the studied pregnancy. We classified women as a 17OHP-C responder or non-responder by calculating the difference in delivery gestational age between the 17OHP-C treated pregnancy and her earliest SPTB. Responders were defined as those with pregnancy extending ≥3 weeks later with 17OHP-C compared to the delivery gestational age of their earliest prior SPTB. Data were analyzed using chi-square, t-test, and logistic regression. Results 155 women met inclusion criteria. The 118 responders delivered later on average (37.7 weeks) than the 37 non-responders (33.5 weeks), p<0.001. Among

  3. Non-Recurrence Complications of Fibrin Glue Use in Pterygium Surgery: Prevention and Management

    PubMed Central

    Hüseyin Cagatay, Halil; Gökçe, Gökçen; Mete, Alper; Koban, Yaran; Ekinci, Metin

    2015-01-01

    Purpose : To present complications of using fibrin glue in conjunctival-limbal autografting in pterygium surgeries other than recurrences and discuss their prevention and management strategies. Materials and Methodology: The charts of all patients who underwent fibrin glue assisted pterygium excision surgery with conjunctival-limbal autograft transplantation from 2010 to 2013 were reviewed. Patients who developed complications except recurrence postoperatively were included in this study. Results : Sixteen (17.39%) of the 92 patients were detected with a complication. Graft dehiscence was diagnosed in 7 (7.6%) patients with 5 of them treated conservatively and 2 patients requiring suturing. Five (5.43%) patients were diagnosed with cyst formation between the graft and conjunctiva or in the graft-removal area; these cysts were primarily excised and no additional problems occurred. Corneal dellen developed in 3 (3.26%) patients and 2 of them regressed after cessation of topical steroids and application of lubricant therapy while one was treated with amniotic membrane transplantation. Residual fibrin glue particles had stiffened on the ocular surface, which resulted in intensive pain and irritation in one (1.08%) patient on the same day of the surgery. The patient’s complaints were reduced by removing these particles from the ocular surface under topical anesthesia. Conclusion : Complications in fibrin glue assisted pterygium surgery are relatively different from other techniques. To avoid potential complications of fibrin glue in pterygium surgery, peroperatively ophthalmologists should ensure the conjunctival autograft and conjunctiva are properly adhered, fibrin glue remnants are completely removed from the ocular surface, and no Tenon’s capsule remains between the graft and the conjunctiva. PMID:26862358

  4. MELAS, an important consideration in the adult population presenting with unusual and recurrent stroke-like episodes

    PubMed Central

    Corr, Alison; Gaughan, Maria; Moroney, Joan; Looby, Seamus

    2014-01-01

    A 48-year-old man was admitted for workup of stroke-like symptoms and generalised tonic–clonic seizures. History and examination revealed that the patient had background diagnoses of type 2 diabetes mellitus, epilepsy and had suffered a temporal lobe infarct 3 years ago. The unusual presentation and physical findings, along with subsequent MRI findings led to a diagnosis of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS). MELAS is a mitochondrial disorder typified by the aforementioned symptoms, and is typically diagnosed in the first two decades of life. PMID:24473421

  5. Extracranial-Intracranial Bypass Surgery for Stroke Prevention in Hemodynamic Cerebral Ischemia: The Carotid Occlusion Surgery Study: A Randomized Trial

    PubMed Central

    Powers, William J.; Clarke, William R.; Grubb, Robert L.; Videen, Tom O; Adams, Harold P.; Derdeyn, Colin P.

    2013-01-01

    and 22.7% (95% CI, 13.9% to 31.6%; 20 events) for the nonsurgical group (p=0.78, z-test); difference = 1.7% (95% CI, −10.4% to 13.8%). Thirty-day rates for ipsilateral ischemic stroke were 14.3% (14/97) in the surgical group and 2.0% (2/98) in the nonsurgical group; difference = (95% CI, 4.9% to 19.9%) Conclusions Among participants with recently symptomatic AICAO and hemodynamic cerebral ischemia, EC-IC bypass surgery plus medical therapy compared to medical therapy alone did not reduce the risk of recurrent ipsilateral ischemic stroke at 2 years. PMID:22068990

  6. Effects of a multifactorial fall prevention program on balance, gait, and fear of falling in post-stroke inpatients

    PubMed Central

    Jung, Younuk; Lee, Kyeongbong; Shin, Seonhae; Lee, Wanhee

    2015-01-01

    [Purpose] This study investigated the effects of a multifactorial fall prevention program on balance, gait, and fear of falling in stroke patients. [Subjects] Twenty-five stroke patients were divided randomly into multifactorial fall prevention program group (n=15) and control treadmill group (n=10). [Methods] All interventions were applied for 30 min, five times per week, for five weeks. The fall prevention program included interventions based on the “Step Up to Stop Falls” initiative and educational interventions based on the Department of Health guidelines. For those in the treadmill group, the speed was increased gradually. The Korean falls efficacy scale and Korean activities-specific balance confidence scale were used to assess fear of falling. To assess balance and walking ability, the Korean performance-oriented mobility assessment scale and the 10-m and 6-minute walk tests were used. [Results] The fall prevention program interventions were found to be very effective at improving gait, balance, and fear of falling compared with the treadmill intervention and therefore seem appropriate for stroke patients. [Conclusion] A multifactorial fall prevention program is effective at improving balance, gait ability, and fear of falling. It is a more specific and broad intervention for reducing falls among inpatients in facilities and hospitals. PMID:26180337

  7. Meta-analysis of low-molecular-weight heparin to prevent recurrent placenta-mediated pregnancy complications.

    PubMed

    Rodger, Marc A; Carrier, Marc; Le Gal, Grégoire; Martinelli, Ida; Perna, Annalisa; Rey, Evelyne; de Vries, J I P; Gris, Jean-Christophe

    2014-02-06

    A 35-year-old woman with recurrent severe placenta-mediated pregnancy complications in her 2 pregnancies asks: Will low-molecular-weight heparin help prevent recurrent placenta-mediated pregnancy complications in my next pregnancy? We performed a meta-analysis of randomized controlled trials (RCTs) comparing low-molecular-weight heparin (LMWH) vs no LMWH for the prevention of recurrent placenta-mediated pregnancy complications. We identified six RCTs that included a total of 848 pregnant women with prior placenta-mediated pregnancy complications. The primary outcome was a composite of pre-eclampsia (PE), birth of a small-for-gestational-age (SGA) newborn (<10th percentile), placental abruption, or pregnancy loss >20 weeks. Overall, 67 (18.7%) of 358 of women being given prophylactic LMWH had recurrent severe placenta-mediated pregnancy complications compared with 127 (42.9%) of 296 women with no LMWH (relative risk reduction, 0.52; 95% CI, 0.32 to 0.86; P = .01; I(2), 69%, indicating moderate heterogeneity). We identified similar relative risk reductions with LMWH for individual outcomes, including any PE, severe PE, SGA <10th percentile, SGA <5th percentile, preterm delivery <37 weeks, and preterm delivery <34 weeks with minimal heterogeneity. LMWH may be a promising therapy for recurrent, especially severe, placenta-mediated pregnancy complications, but further research is required.

  8. Economic Evaluation of Apixaban for the Prevention of Stroke in Non-Valvular Atrial Fibrillation in the Netherlands

    PubMed Central

    Stevanović, Jelena; Pompen, Marjolein; Le, Hoa H.; Rozenbaum, Mark H.; Tieleman, Robert G.; Postma, Maarten J.

    2014-01-01

    Background Stroke prevention is the main goal of treating patients with atrial fibrillation (AF). Vitamin-K antagonists (VKAs) present an effective treatment in stroke prevention, however, the risk of bleeding and the requirement for regular coagulation monitoring are limiting their use. Apixaban is a novel oral anticoagulant associated with significantly lower hazard rates for stroke, major bleedings and treatment discontinuations, compared to VKAs. Objective To estimate the cost-effectiveness of apixaban compared to VKAs in non-valvular AF patients in the Netherlands. Methods Previously published lifetime Markov model using efficacy data from the ARISTOTLE and the AVERROES trial was modified to reflect the use of oral anticoagulants in the Netherlands. Dutch specific costs, baseline population stroke risk and coagulation monitoring levels were incorporated. Univariate, probabilistic sensitivity and scenario analyses on the impact of different coagulation monitoring levels were performed on the incremental cost-effectiveness ratio (ICER). Results Treatment with apixaban compared to VKAs resulted in an ICER of €10,576 per quality adjusted life year (QALY). Those findings correspond with lower number of strokes and bleedings associated with the use of apixaban compared to VKAs. Univariate sensitivity analyses revealed model sensitivity to the absolute stroke risk with apixaban and treatment discontinuations risks with apixaban and VKAs. The probability that apixaban is cost-effective at a willingness-to-pay threshold of €20,000/QALY was 68%. Results of the scenario analyses on the impact of different coagulation monitoring levels were quite robust. Conclusions In patients with non-valvular AF, apixaban is likely to be a cost-effective alternative to VKAs in the Netherlands. PMID:25093723

  9. Physical Exercise as a Diagnostic, Rehabilitation, and Preventive Tool: Influence on Neuroplasticity and Motor Recovery after Stroke.

    PubMed

    Pin-Barre, Caroline; Laurin, Jérôme

    2015-01-01

    Stroke remains a leading cause of adult motor disabilities in the world and accounts for the greatest number of hospitalizations for neurological disease. Stroke treatments/therapies need to promote neuroplasticity to improve motor function. Physical exercise is considered as a major candidate for ultimately promoting neural plasticity and could be used for different purposes in human and animal experiments. First, acute exercise could be used as a diagnostic tool to understand new neural mechanisms underlying stroke physiopathology. Indeed, better knowledge of stroke mechanisms that affect movements is crucial for enhancing treatment/rehabilitation effectiveness. Secondly, it is well established that physical exercise training is advised as an effective rehabilitation tool. Indeed, it reduces inflammatory processes and apoptotic marker expression, promotes brain angiogenesis and expression of some growth factors, and improves the activation of affected muscles during exercise. Nevertheless, exercise training might also aggravate sensorimotor deficits and brain injury depending on the chosen exercise parameters. For the last few years, physical training has been combined with pharmacological treatments to accentuate and/or accelerate beneficial neural and motor effects. Finally, physical exercise might also be considered as a major nonpharmacological preventive strategy that provides neuroprotective effects reducing adverse effects of brain ischemia. Therefore, prestroke regular physical activity may also decrease the motor outcome severity of stroke.

  10. Physical Exercise as a Diagnostic, Rehabilitation, and Preventive Tool: Influence on Neuroplasticity and Motor Recovery after Stroke

    PubMed Central

    Pin-Barre, Caroline; Laurin, Jérôme

    2015-01-01

    Stroke remains a leading cause of adult motor disabilities in the world and accounts for the greatest number of hospitalizations for neurological disease. Stroke treatments/therapies need to promote neuroplasticity to improve motor function. Physical exercise is considered as a major candidate for ultimately promoting neural plasticity and could be used for different purposes in human and animal experiments. First, acute exercise could be used as a diagnostic tool to understand new neural mechanisms underlying stroke physiopathology. Indeed, better knowledge of stroke mechanisms that affect movements is crucial for enhancing treatment/rehabilitation effectiveness. Secondly, it is well established that physical exercise training is advised as an effective rehabilitation tool. Indeed, it reduces inflammatory processes and apoptotic marker expression, promotes brain angiogenesis and expression of some growth factors, and improves the activation of affected muscles during exercise. Nevertheless, exercise training might also aggravate sensorimotor deficits and brain injury depending on the chosen exercise parameters. For the last few years, physical training has been combined with pharmacological treatments to accentuate and/or accelerate beneficial neural and motor effects. Finally, physical exercise might also be considered as a major nonpharmacological preventive strategy that provides neuroprotective effects reducing adverse effects of brain ischemia. Therefore, prestroke regular physical activity may also decrease the motor outcome severity of stroke. PMID:26682073

  11. Predictors of 30-day mortality and the risk of recurrent systemic thromboembolism in cancer patients suffering acute ischemic stroke

    PubMed Central

    Kim, Tae Jung; An, Sang Joon; Oh, Kyungmi; Mo, Heejung; Kang, Min Kyoung; Han, Moon-Ku; Demchuk, Andrew M.; Ko, Sang-Bae; Yoon, Byung-Woo

    2017-01-01

    Background Stroke in cancer patients is not rare but is a devastating event with high mortality. However, the predictors of mortality in stroke patients with cancer have not been well addressed. D-dimer could be a useful predictor because it can reflect both thromboembolic events and advanced stages of cancer. Aim In this study, we evaluate the possibility of D-dimer as a predictor of 30-day mortality in stroke patients with active cancer. Methods We included 210 ischemic stroke patients with active cancer. The 30-day mortality data were collected by reviewing medical records. We also collected follow-up D-dimer levels in 106 (50%) participants to evaluate the effects of treatment response on D-dimer levels. Results Of the 210 participants, 30-day mortality occurred in 28 (13%) patients. Higher initial NIHSS scores, D-dimer levels, and CRP levels as well as frequent cryptogenic mechanism, systemic metastasis, multiple vascular territory lesion, hemorrhagic transformation, and larger infarct volume were related to 30-day mortality. In the multivariate analysis, D-dimer [adjusted OR (aOR) = 2.19; 95% CI, 1.46–3.28, P < 0.001] predicted 30-day mortality after adjusting for confounders. The initial NIHSS score (aOR = 1.07; 95% CI, 1.00–1.14, P = 0.043) and hemorrhagic transformation (aOR = 3.02; 95% CI, 1.10–8.29, P = 0.032) were also significant independent of D-dimer levels. In the analysis of D-dimer changes after treatment, the mortality group showed no significant decrease in D-dimer levels, despite treatment, while the survivor group showed the opposite response. Conclusions D-dimer levels may predict 30-day mortality in acute ischemic stroke patients with active cancer. PMID:28282388

  12. Awareness, Treatment, and Control of Vascular Risk Factors Among Stroke Survivors

    PubMed Central

    Brenner, D. A.; Zweifler, R. M.; Gomez, C.R.; Kissela, B.M.; Levine, D.; Howard, G.; Coull, B.; Howard, V. J.

    2013-01-01

    Introduction Stroke survivors should recognize and control vascular risk factors to prevent recurrent strokes. We therefore assessed the prevalence, treatment and control of hypertension, diabetes, and dyslipidemia among stroke survivors versus stroke-free controls. Methods Cross-sectional analysis from the Reasons for Geographic And Racial Differences in Stroke (REGARDS) Study cohort, which includes oversampling from the Stroke Belt and African Americans. Patients were interviewed by telephone then visited for blood pressure, glucose, and lipid measurements. There were 2,830 participants reporting a past stroke or TIA (“stroke survivors”) and 24,886 participants without past stroke or TIA (controls). Outcome measures included the recognition, treatment, and control of hypertension, diabetes, and dyslipidemia. Results Stroke survivors more likely had unrecognized hypertension (18.7% vs. 13.5%, p<0.0003), unrecognized Stage 2 hypertension (4.4% vs. 2.2%, p<0.0006), and unrecognized diabetes (4.2% vs. 3.2%, p<0.026) versus controls. Stroke survivors were more likely treated for hypertension (92.4% vs. 89.0%, p<0.0001), diabetes (88.3% vs. 81.4%, p<0.0001), and dyslipidemia (76.3% vs. 61.9%, p<0.0001). However despite treatment, stroke survivors were more likely to have hypertension (33.3% vs. 30.4%, p=0.0074) and Stage 2 hypertension (9.1 % vs. 7.6%, p=0.017). Predictors of unrecognized and undertreated risk factors in stroke survivors include increasing BMI, black race, and lower education. Discussion Despite having a past stroke or TIA, stroke survivors had higher rates of unrecognized hypertension, unrecognized diabetes, and undertreated hypertension. Better efforts are needed to help stroke survivors recognize and control vascular risk factor to prevent recurrent stroke. PMID:20472464

  13. Valacyclovir for the prevention of recurrent herpes simplex virus eye disease after excimer laser photokeratectomy.

    PubMed Central

    Asbell, P A

    2000-01-01

    PURPOSE: A variety of factors have been reported as inducing the reactivation of latent herpes simplex virus (HSV), among them stress, trauma, and UV radiation. Excimer laser photorefractive keratectomy (PRK) is a surgical procedure utilizing a 193 nm ultraviolet light to alter the curvature of the cornea and hence correct vision. Reactivation of ocular herpes simplex keratitis following such excimer laser PRK has been reported. All published cases of HSV reactivation following excimer laser treatment in humans are reviewed. The present study evaluates whether stress, trauma of the corneal de-epithelialization prior to the laser, or the excimer laser treatment itself to the stromal bed induces this ocular reactivation of the latent HSV, and whether a systemic antiviral agent, valacyclovir, would prevent such laser PRK-induced reactivation of the HSV. METHODS: Forty-three normal 1.5- to 2.5-kg New Zealand white rabbits were infected on the surface of the cornea with HSV-1, strain RE. The animals were monitored until resolution, and then all animals were divided into 5 treatment groups: (1) de-epithelialization only, intraperitoneal (i.p.) saline for 14 days; (2) de-epithelialization plus laser, i.p. saline for 14 days; (3) de-epithelialization plus laser, valacyclovir 50 mg/kg per day i.p. for 14 days; (4) de-epithelialization plus laser, valacyclovir 100 mg/kg per day i.p. for 14 days; (5) de-epithelialization plus laser, valacyclovir 150 mg/kg per day i.p. for 14 days. Animals were evaluated in a masked fashion by clinical examination biweekly and viral cultures biweekly through day 28. RESULTS: The reactivation rates were as follows: group 1, 0%; group 2, 67%; group 3, 50%; group 4, 17%; and group 5, 0%. Viral titers were negative in animals that had no reactivation but persistently positive in those that had reactivation (day 6 through day 28). CONCLUSIONS: Excimer laser (193 nm) treatment can trigger reactivation of ocular herpes disease (67%) and viral

  14. PRIMARY STROKE PREVENTION IN CHILDREN WITH SICKLE CELL ANEMIA LIVING IN AFRICA: THE FALSE CHOICE BETWEEN PATIENT-ORIENTED RESEARCH AND HUMANITARIAN SERVICE

    PubMed Central

    DEBAUN, MICHAEL R.; GALADANCI, NAJIBAH A.; KASSIM, ADETOLA A.; JORDAN, LORI C.; PHILLIPS, SHARON; ALIYU, MUKTAR H.

    2016-01-01

    In the United States, primary stroke prevention in children with sickle cell anemia (SCA) is now the standard of care and includes annual transcranial Doppler ultrasound evaluation to detect elevated intracranial velocities; and for those at risk, monthly blood transfusion therapy for at least a year followed by the option of hydroxyurea therapy. This strategy has decreased stroke prevalence in children with SCA from approximately 11% to 1%. In Africa, where 80% of all children with SCA are born, no systematic approach exists for primary stroke prevention. The two main challenges for primary stroke prevention in children with SCA in Africa include: 1) identifying an alternative to blood transfusion therapy, because safe monthly blood transfusion therapy is not feasible; and 2) assembling a health care team to implement and expand this effort. We will emphasize early triumphs and challenges to decreasing the incidence of strokes in African children with SCA. PMID:28066035

  15. [Ischemic stroke in the young adult].

    PubMed

    Calvet, D

    2016-01-01

    Ischemic stroke is not rare in young adults since one in ten stroke patients are less than 50 years old. This incidence increased over the past last years, mainly due to the rise in the prevalence of traditional vascular risk factors in this sub-group of age but also of illegal drug use. Even though both survival and functional outcome of young stroke patients are better than those observed in older patients, socio-economic and quality of life consequences make this disease a main objective in terms of primary and secondary prevention. Identifying the cause of ischemic stroke in young adults is of major importance to prevent stroke recurrence. However, given the wide variety of potential underlying causes, the etiologic work-up of stroke in young adults requires a different approach from that in the elderly. In this context, a sequential diagnostic work-up is needed in order to optimize the yield of diagnostic tests, to reduce their cost and risks for the patient. Arterial dissection is the most frequent cause of stroke in young adults but other less frequent causes are numerous. Despite a comprehensive work-up, about one third of cases remains unexplained leading to the diagnosis of cryptogenic ischemic stroke.

  16. A dietary polyphenol resveratrol acts to provide neuroprotection in recurrent stroke models by regulating AMPK and SIRT1 signaling, thereby reducing energy requirements during ischemia.

    PubMed

    2016-04-01

    The above article from European Journal of Neuroscience, published online on 5 March 2013 in Wiley Online Library (http://onlinelibrary.wiley.com/doi/10.1111/ejn.12162/full), has been retracted by agreement between the Editors-in-Chief, Paul Bolam and John Foxe, the authors and John Wiley & Sons Ltd. The retraction has been agreed as Dr Phillip Barber has informed the publisher that he had seen neither the original data nor any version of the manuscript, and had not been involved in the work reported. A subsequent Institutional investigation found evidence of misconduct on the part of the submitting author. Reference Wang, L.-M., Wang, Y.-J., Cui, M., Luo, W.-J., Wang, X.-J., Barber, P.A. & Chen, Z.-Y. (2013) A dietary polyphenol resveratrol acts to provide neuroprotection in recurrent stroke models by regulating AMPK and SIRT1 signaling, thereby reducing energy requirements during ischemia.

  17. Role of Intraoperative Nerve Monitoring During Parathyroidectomy to Prevent Recurrent Laryngeal Nerve Injury

    PubMed Central

    Assad, Salman; Assad, Shuja

    2016-01-01

    Injury to the recurrent laryngeal nerve (RLN) is a well known, though less frequent, complication of parathyroid surgery. In recent years, the use of intraoperative nerve monitoring (IONM) has gained popularity amongst surgeons when operating on thyroid gland; however, its utilization in parathyroid surgery is not established. This trend continues to rise, despite multiple studies documenting no statistically significant difference that IONM decreases the incidence of RLN injury. Most surgeons use this technology as an adjunct to visualization alone for identification of RLN. The purpose of this review is to discuss the possible role of IONM in parathyroid surgery with regards to the accuracy, efficacy, and recent trends in the utilization of this technology. There is insufficient evidence that IONM reduces the risk of RLN injury in parathyroidectomy. Although IONM may decrease the likelihood of nerve injury by helping to identify and map the RLN during thyroidectomy, we did not find studies exclusive to parathyroid surgery to see if its use can be supported for parathyroidectomy. Despite this lack of evidence, we believe that IONM is a promising adjunct to visualization alone in detecting nerve structures during neck dissection, but more clinical trials are warranted to establish its role in preventing nerve injury in parathyroid surgery. PMID:28003944

  18. Primary prevention of stroke by a healthy lifestyle in a high-risk group

    PubMed Central

    Åkesson, Agneta; Wolk, Alicja

    2015-01-01

    Objective: To examine the impact of a healthy lifestyle on stroke risk in men at higher risk of stroke because of other cardiovascular diseases or conditions. Methods: Our study population comprised 11,450 men in the Cohort of Swedish Men who had a history of hypertension, high cholesterol levels, diabetes, heart failure, or atrial fibrillation. Participants had completed a questionnaire about diet and lifestyle and were free from stroke and ischemic heart disease at baseline (January 1, 1998). We defined a healthy lifestyle as a low-risk diet (≥5 servings/d of fruits and vegetables and <30 g/d of processed meat), not smoking, ≥150 min/wk of physical activity, body mass index of 18.5 to 25 kg/m2, and low to moderate alcohol consumption (>0 to ≤30 g/d). Ascertainment of stroke cases was accomplished through linkage with the National Inpatient Register and the Swedish Cause of Death Register. Results: During a mean follow-up of 9.8 years, we ascertained 1,062 incident stroke cases. The risk of total stroke and stroke types decreased with increasing number of healthy lifestyle factors. The multivariable relative risk of total stroke for men who achieved all 5 healthy lifestyle factors compared with men who achieved 0 or 1 factor was 0.28 (95% confidence interval 0.14–0.55). The corresponding relative risks (95% confidence interval) were 0.31 (0.15–0.66) for ischemic stroke and 0.32 (0.04–2.51) for hemorrhagic stroke. Conclusions: A healthy lifestyle is associated with a substantially reduced risk of stroke in men at higher risk of stroke. PMID:25934859

  19. Transfusional iron overload in children with sickle cell anemia on chronic transfusion therapy for secondary stroke prevention.

    PubMed

    Kwiatkowski, Janet L; Cohen, Alan R; Garro, Julian; Alvarez, Ofelia; Nagasubramanian, Ramamorrthy; Sarnaik, Sharada; Thompson, Alexis; Woods, Gerald M; Schultz, William; Mortier, Nicole; Lane, Peter; Mueller, Brigitta; Yovetich, Nancy; Ware, Russell E

    2012-02-01

    Chronic transfusion reduces the risk of recurrent stroke in children with sickle cell anemia (SCA) but leads to iron loading. Management of transfusional iron overload in SCA has been reported as suboptimal [1], but studies characterizing monitoring and treatment practices for iron overload in children with SCA, particularly in recent years with the expansion of chelator options, are lacking. We investigated the degree of iron loading and treatment practices of 161 children with SCA receiving transfusions for a history of stroke who participated in the Stroke with Transfusions Changing to Hydroxyurea (SWiTCH) trial. Data obtained during screening, including past and entry liver iron concentration (LIC) measurements, ferritin values, and chelation were analyzed. The mean age at enrollment was 12.9 ± 4 years and the mean duration of transfusion was 7 ± 3.8 years. Baseline LIC (median 12.94 mg/g dw) and serum ferritin (median 3,164 ng/mL) were elevated. Chelation therapy was initiated after a mean of 2.6 years of transfusions. At study entry, 137 were receiving chelation, most of whom (90%) were receiving deferasirox. This study underscores the need for better monitoring of iron burden with timely treatment adjustments in chronically transfused children with SCA.

  20. [Edoxaban for stroke prevention in atrial fibrillation and treatment of venous thromboembolism: an expert position paper].

    PubMed

    Weiss, Thomas W; Rohla, Miklos; Dieplinger, Benjamin; Domanovits, Hans; Fries, Dietmar; Vosko, Milan R; Gary, Thomas; Ay, Cihan

    2017-02-24

    Edoxaban is the most recent available representative of the Non-Vitamin K antagonist oral anticoagulants (NOAC). The approval was based on the largest phase III trials of NOACs for stroke prevention in patients with non-valvular atrial fibrillation (AF, ENGAGE-AF), and for the treatment of venous thromboembolism (VTE, HOKUSAI-VTE). In both trials, edoxaban was associated with similar efficacy and a significant reduction in bleeding events with respect to the pre-defined primary safety endpoints, as compared to warfarin.Additionally, the once daily dosing of edoxaban, the clinically investigated strategy for dose-reduction based on clearly defined criteria and the favorable pharmacokinetic profile might further support the clinical applicability of the substance.In the light of recent data, this expert consensus document aims to summarize the latest clinical trial results while providing a concise overview of current guideline recommendations on the management of patients with non-valvular AF and VTE.

  1. [Stroke - lifestyle and environment].

    PubMed

    Gerischer, L M; Flöel, A; Endres, M

    2015-08-01

    Lifestyle modifications and environmental factors are important for stroke prevention and rehabilitation after stroke. The individual stroke risk may be modified by factors like physical activity, body weight and nutrition, special dietary supplements such as vitamins, smoking, consumption of tea, coffee and alcohol, psychological factors and by keeping a pet. The focus of this article lies on measures for stroke prevention. For certain topics, it also comments on factors that are important during rehabilitation after stroke.

  2. Economic evaluation of rivaroxaban in stroke prevention for patients with atrial fibrillation in Greece

    PubMed Central

    2014-01-01

    Background To undertake an economic evaluation of rivaroxaban relative to the standard of care for stroke prevention in patients with non-valvular atrial fibrillation (AF) in Greece. Methods An existing Markov model designed to reflect the natural progression of AF patients through different health states, in the course of three month cycles, was adapted to the Greek setting. The analysis was undertaken from a payer perspective. Baseline event rates and efficacy data were obtained from the ROCKET-AF trial for rivaroxaban and vitamin-K-antagonists (VKAs). Utility values for events were based on literature. A treatment-related disutility of 0.05 was applied to the VKA arm. Costs assigned to each health state reflect the year 2013. An incremental cost effectiveness ratio (ICER) was calculated where the outcome was quality-adjusted-life year (QALY) and life-years gained. Probabilistic analysis was undertaken to deal with uncertainty. The horizon of analysis was over patient life time and both cost and outcomes were discounted at 3.5%. Results Based on safety-on-treatment data, rivaroxaban was associated with a 0.22 increment in QALYs compared to VKA. The average total lifetime cost of rivaroxaban-treated patients was €239 lower compared to VKA. Rivaroxaban was associated with additional drug acquisition cost (€4,033) and reduced monitoring cost (-€3,929). Therefore, rivaroxaban was a dominant alternative over VKA. Probabilistic analysis revealed that there is a 100% probability of rivaroxaban being cost-effective versus VKA at a willingness to pay threshold of €30,000/QALY gained. Conclusion Rivaroxaban may represent for payers a dominant option for the prevention of thromboembolic events in moderate to high risk AF patients in Greece. PMID:24512351

  3. Stroke Risk Factor Profiles in African American Women

    PubMed Central

    Worrall, Bradford B.; Johnston, Karen C.; Kongable, Gail; Hung, Elena; Richardson, DeJuran; Gorelick, Philip B.

    2008-01-01

    Background and Purpose If sex differences in stroke risk factor profiles exist among African Americans in the United States, prevention strategies will need to reflect those differences. African Americans and women have been underrepresented in stroke prevention studies. The purpose of this study was to determine whether medical and lifestyle factors differ among women and men who have enrolled in the African-American Antiplatelet Stroke Prevention Study (AAASPS). Methods We performed a planned exploratory analysis of differences in baseline characteristics and risk factors between women and men enrolled in AAASPS, a double-blind, randomized, multicenter, controlled trial. Frequencies of vascular risk factors and related conditions, medical therapies, stroke subtypes, and vascular territories were compared between women and men by 1-way ANOVA and Fisher’s exact test where appropriate. Results A total of 1087 African American patients (574 women, 513 men) enrolled between December 1995 and June 1999. Women had higher rates of hypertension, diabetes, family history of stroke, and no reported leisure exercise. Men had higher rates of smoking and heavy alcohol use. Few differences were noted in proportions of stroke subtype or proportions receiving preventive therapy. Conclusions AAASPS represents the largest enrollment of African American women in a recurrent stroke prevention study. Our data suggest that African American women in a clinical trial differ from men in the frequency of key vascular risk factors. Although limited, these data provide an important first characterization of sex differences in African Americans with stroke. PMID:11935036

  4. Novel nonpharmacologic approaches for stroke prevention in atrial fibrillation: results from clinical trials

    PubMed Central

    Proietti, Riccardo; Joza, Jacqueline; Arensi, Andrea; Levi, Michael; Russo, Vincenzo; Tzikas, Apostolos; Danna, Paolo; Sagone, Antonio; Viecca, Maurizio; Essebag, Vidal

    2015-01-01

    Atrial fibrillation (AF), the most common cardiac arrhythmia, confers a 5-fold risk of stroke that increases to 17-fold when associated with mitral stenosis. At this time, the most effective long-term solution to protect patients from stroke and thromboembolism is oral anticoagulation, either with vitamin K antagonists (VKAs) or a novel oral anticoagulant (NOAC). Despite the significant benefits they confer, both VKAs and NOACs are underused because of their increased potential for bleeding, and VKAs are underused because of their narrow therapeutic range, need for regular international normalized ratio checks, and interactions with food or medications. In patients with nonvalvular AF, approximately 90% of strokes originate from the left atrial appendage (LAA); in patients with rheumatic mitral valve disease, many patients (60%) have strokes that originate from the left atrium itself. Surgical LAA amputation or closure, although widely used to reduce stroke risk in association with cardiac surgery, is not currently performed as a stand-alone operation for stroke risk reduction because of its invasiveness. Percutaneous LAA closure, as an alternative to anticoagulation, has been increasingly used during the last decade in an effort to reduce stroke risk in nonvalvular AF. Several devices have been introduced during this time, of which one has demonstrated noninferiority compared with warfarin in a randomized controlled trial. This review describes the available technologies for percutaneous LAA closure, as well as a summary of the published trials concerning their safety and efficacy in reducing stroke risk in AF. PMID:25678828

  5. Executive function is independently associated with performances of balance and mobility in community-dwelling older adults after mild stroke: implications for falls prevention

    PubMed Central

    Liu-Ambrose, Teresa; Pang, Marco; Eng, Janice J

    2015-01-01

    Background Stroke survivors have a high incidence of falls. Impaired executive-controlled processes are frequent in stroke survivors and are associated with falls in this population. Better understanding of the independent association between executive-controlled processes and physiological fall risk (i.e. performances of balance and mobility) could enhance future interventions that aim to prevent falls and to promote an independent lifestyle among stroke survivors. Methods Cross-sectional analysis of 63 adults who suffered a mild stroke >1 year prior to the study, aged > or =50 years. Results Cognitive flexibility was independently associated with performances of balance and mobility in community-dwelling older adults after mild stroke, after accounting for age, quadriceps strength of the paretic side and current physical activity level. Conclusions Clinicians may need to consider cognitive function when assessing and treating impaired balance and mobility in community-dwelling older adults after mild stroke. PMID:17143004

  6. Prototype to practice: Developing and testing a clinical decision support system for secondary stroke prevention in a veterans healthcare facility.

    PubMed

    Anderson, Jane A; Willson, Pamela; Peterson, Nancy J; Murphy, Chris; Kent, Thomas A

    2010-01-01

    A clinical decision support system that guides nurse practitioners and other healthcare providers in secondary stroke prevention was developed by a multidisciplinary team with funding received from the Veterans Health Administration Office of Nursing Services. This article presents alpha-testing results obtained while using an integrated model for clinical decision support system development that emphasizes end-user perspectives throughout the development process. Before-after and descriptive methods were utilized to evaluate functionality and usability of the prototype among a sample of multidisciplinary clinicians. The predominant functionality feature of the tool is automated prompting and documentation of secondary stroke prevention guidelines in the electronic medical record. Documentation of guidelines was compared among multidisciplinary providers (N = 15) using test case scenarios and two documentation systems, standard versus the prototype. Usability was evaluated with an investigator-developed questionnaire and one open-ended question. The prototype prompted a significant increase (P < .05) in provider documentation for six of 11 guidelines as compared with baseline documentation while using the standard system. Of a possible 56 points, usability was scored high (mean, 48.9 [SD, 6.8]). These results support that guideline prompting has been successfully engineered to produce a usable and useful clinical decision support system for secondary stroke prevention.

  7. Verapamil is Less Effective than Triamcinolone for Prevention of Keloid Scar Recurrence After Excision in a Randomized Controlled Trial.

    PubMed

    Danielsen, Patricia L; Rea, Suzanne M; Wood, Fiona M; Fear, Mark W; Viola, Helena M; Hool, Livia C; Gankande, Thilanee U; Alghamdi, Mansour; Stevenson, Andrew W; Manzur, Mitali; Wallace, Hilary J

    2016-08-23

    A double-blind randomized controlled trial with a paired split-scar design compared verapamil, an L-type Ca2+ channel antagonist, and triamcinolone for prevention of keloid recurrence after excision. Ca2+ channel blocking activity of verapamil in keloid cells was explored. One keloid was excised per subject and each wound half randomized to receive intralesional injections of triamcinolone (10 mg/ml) or verapamil (2.5 mg/ml) at monthly intervals (4 doses). Interim analysis was performed after 14 subjects were completed. Survival analysis demonstrated significantly higher keloid recurrence with verapamil compared to triamcinolone 12 months post-surgery (log-rank test, p = 0.01) and higher overall risk of recurrence with verapamil (hazard ratio 8.44, 95% CI 1.62-44.05). The study was terminated early according to the stopping guideline (p < 0.05). Verapamil is safe but not as effective as triamcinolone in preventing keloid recurrence after excision. Further study is necessary to determine if clinical response to verapamil is linked to modulation of intracellular Ca2+.

  8. Intracranial pressure elevation after ischemic stroke in rats: cerebral edema is not the only cause, and short-duration mild hypothermia is a highly effective preventive therapy

    PubMed Central

    Murtha, Lucy A; McLeod, Damian D; Pepperall, Debbie; McCann, Sarah K; Beard, Daniel J; Tomkins, Amelia J; Holmes, William M; McCabe, Christopher; Macrae, I Mhairi; Spratt, Neil J

    2015-01-01

    In both the human and animal literature, it has largely been assumed that edema is the primary cause of intracranial pressure (ICP) elevation after stroke and that more edema equates to higher ICP. We recently demonstrated a dramatic ICP elevation 24 hours after small ischemic strokes in rats, with minimal edema. This ICP elevation was completely prevented by short-duration moderate hypothermia soon after stroke. Here, our aims were to determine the importance of edema in ICP elevation after stroke and whether mild hypothermia could prevent the ICP rise. Experimental stroke was performed in rats. ICP was monitored and short-duration mild (35 °C) or moderate (32.5 °C) hypothermia, or normothermia (37 °C) was induced after stroke onset. Edema was measured in three studies, using wet–dry weight calculations, T2-weighted magnetic resonance imaging, or histology. ICP increased 24 hours after stroke onset in all normothermic animals. Short-duration mild or moderate hypothermia prevented this rise. No correlation was seen between ΔICP and edema or infarct volumes. Calculated rates of edema growth were orders of magnitude less than normal cerebrospinal fluid production rates. These data challenge current concepts and suggest that factors other than cerebral edema are the primary cause of the ICP elevation 24 hours after stroke onset. PMID:25515213

  9. Low Hemoglobin and Recurrent Falls in U.S. Men and Women: Prospective findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) Cohort

    PubMed Central

    Bowling, C. Barrett; Muntner, Paul; Bradbury, Brian D.; Kilpatrick, Ryan D.; Isitt, John J.; Warriner, Amy H.; Curtis, Jeffrey R.; Judd, Suzanne; Brown, Cynthia J.; Allman, Richard M.; Warnock, David Gene; McClellan, William

    2012-01-01

    Background There are few data available on low hemoglobin levels and incident falls in the general U.S. population. Methods Of 30,239 Black and white U.S. adults ≥ 45 years old in the population-based REasons for Geographic and Racial Differences in Stroke (REGARDS) study, 16,782 had hemoglobin measured at baseline and follow-up data on falls. Hemoglobin was categorized by 1.0 g/dL increments relative to the World Health Organization cut-point for anemia (13.0 g/dL for men, 12.0 g/dL for women). Recurrent falls, defined as ≥2 falls in the 6 months following baseline were assessed during a telephone interview. Results Recurrent falls occurred in 3.9% of men and 4.8% of women. Compared to those with a hemoglobin 1 to 2 g/dL above the anemia cut-point the multivariable adjusted odds ratios (OR; 95% confidence interval [CI]) for recurrent falls associated with hemoglobin levels ≥ 3g/dL, 2 to <3 g/dL, and 0 to 1 g/dL above the cut-point, and 0 to <1 g/dL and ≥1 g/dL below the cut-point were 0.73 (0.45–1.19), 0.84 (0.57–1.24), 1.29 (0.88–1.90), 1.32 (0.0.80–1.2.18) and 2.12 (1.23–3.63), respectively, among men (linear trend p<0.001) and 1.59 (1.10–2.3), 1.24 (0.95–1.62), 1.42(1.11–1.81), 1.28 (0.91–1.80) and 1.76 (1.13–2.74), respectively, among women (linear trend p=0.45; quadratic trend p=0.016). Conclusions Among men, lower hemoglobin was associated with an increased risk for recurrent falls. While our findings suggest an increased risk for recurrent falls at both lower and higher hemoglobin levels among women, these findings should be confirmed in subsequent studies. PMID:23328832

  10. Building bridges: a partnership between professional nursing and the Centers for Disease Control and Prevention to reduce the burden of heart disease and stroke.

    PubMed

    Dunbar, Sandra B; Mensah, George A; Labarthe, Darwin R

    2005-12-01

    The escalating burden of heart disease and stroke in the United States, coupled with the complexity of public health goals to prevent and control chronic diseases, warrant new strategies and partners. The 2.7 million nurses in the United States represent the nation's largest healthcare profession and, through their professional organizations, constitute a strategic partner for the Centers for Disease Control and Prevention (CDC) Heart Disease and Stroke Programs. In addition, because heart disease and stroke rank first and third among leading causes of death in women in the United States, and 95% of nurses are women, nurses represent an important population to target with preventive cardiovascular health approaches. The authors describe a proposed CDC strategic partnership with professional nursing organizations, including goals aimed at improving the capacity of nurses as change agents in the area of heart disease and stroke, as well as promoting change among the change agents to reduce nurses' risk for cardiovascular disease. The primary goals of the partnership between key professional nursing organizations and the CDC Cardiovascular Health (CVH) Programs follow: (1) share information and develop effective communication; (2) link with key professional and community organizations; (3) assess capabilities and expertise that nursing organizations can add to CDC's internal and external partnerships, including the Public Health Action Plan; (4) explore possible linkages with the CDC-funded state-level heart disease and stroke prevention programs and emerging CDC stroke networks; (5) develop, disseminate, and apply evidence-based guidelines to improve outcomes of care; and (6) develop policy and environment strategies in work-site settings to prevent heart disease and stroke in women and among the membership of professional nursing organizations. The development and implementation of a CDC CVH Program Professional Nurse Partnership have strong potential for enhancing

  11. Mindfulness-Based Cognitive Therapy for Preventing Relapse in Recurrent Depression: A Randomized Dismantling Trial

    PubMed Central

    2013-01-01

    Objective: We compared mindfulness-based cognitive therapy (MBCT) with both cognitive psychological education (CPE) and treatment as usual (TAU) in preventing relapse to major depressive disorder (MDD) in people currently in remission following at least 3 previous episodes. Method: A randomized controlled trial in which 274 participants were allocated in the ratio 2:2:1 to MBCT plus TAU, CPE plus TAU, and TAU alone, and data were analyzed for the 255 (93%; MBCT = 99, CPE = 103, TAU = 53) retained to follow-up. MBCT was delivered in accordance with its published manual, modified to address suicidal cognitions; CPE was modeled on MBCT, but without training in meditation. Both treatments were delivered through 8 weekly classes. Results: Allocated treatment had no significant effect on risk of relapse to MDD over 12 months follow-up, hazard ratio for MBCT vs. CPE = 0.88, 95% CI [0.58, 1.35]; for MBCT vs. TAU = 0.69, 95% CI [0.42, 1.12]. However, severity of childhood trauma affected relapse, hazard ratio for increase of 1 standard deviation = 1.26 (95% CI [1.05, 1.50]), and significantly interacted with allocated treatment. Among participants above median severity, the hazard ratio was 0.61, 95% CI [0.34, 1.09], for MBCT vs. CPE, and 0.43, 95% CI [0.22, 0.87], for MBCT vs. TAU. For those below median severity, there were no such differences between treatment groups. Conclusion: MBCT provided significant protection against relapse for participants with increased vulnerability due to history of childhood trauma, but showed no significant advantage in comparison to an active control treatment and usual care over the whole group of patients with recurrent depression. PMID:24294837

  12. Pro-atrial natriuretic peptide and prediction of atrial fibrillation and stroke: The Malmö Preventive Project.

    PubMed

    Berntsson, John; Smith, J Gustav; Nilsson, Peter M; Hedblad, Bo; Melander, Olle; Engström, Gunnar

    2017-01-01

    Background The increasing prevalence of atrial fibrillation and novel therapeutic tools to prevent cardioembolic stroke has increased the need for risk markers. Objectives This study explored the relationship between the midregional sequence of pro-atrial natriuretic peptide (MR-proANP) levels with the risk of atrial fibrillation and stroke, and whether measurement of MR-proANP improves the prediction of these outcomes. Methods MR-proANP was measured in fasting blood samples of 5130 subjects (69% men, mean age 69.2 ± 6.2 years) without a history of atrial fibrillation or stroke from the general population. The incidence of atrial fibrillation and stroke was monitored over a median follow-up of 5.6 years. C-statistics and net reclassification improvement was used to assess the predictive ability of MR-proANP in addition to conventional risk factors. Results Log-normalized MR-proANP was significantly associated with the incidence of atrial fibrillation ( n = 362; hazard ratio (HR); 95% confidence interval (CI) per 1 standard deviation (SD) 2.05, 1.86-2.27) and stroke from all causes ( n = 195; HR 1.30; 95% CI 1.12-1.50). The HR for stroke events related to atrial fibrillation was 1.79 (95% CI 1.25-2.58) per 1 SD. MR-proANP significantly improved the prediction of atrial fibrillation when added to a risk score of conventional risk factors (C statistic 0.69 vs. 0.75), mainly by down-classifying subjects who did not develop atrial fibrillation. A smaller improvement in predictive ability was observed for stroke (C statistic 0.66 vs. 0.68). Conclusion High plasma levels of MR-proANP are associated with the incidence of atrial fibrillation and stroke in the middle-aged and elderly population. MR-proANP may be useful to identify individuals with an increased risk of atrial fibrillation.

  13. Antiplatelet resistance in stroke

    PubMed Central

    Topçuoglu, Mehmet Akif; Arsava, Ethem Murat; Ay, Hakan

    2011-01-01

    Although the exact prevalence of antiplatelet resistance in ischemic stroke is not known, estimates about the two most widely used antiplatelet agents – aspirin and clopidogrel – suggest that the resistance rate is high, irrespective of the definition used and parameters measured. Inadequate antiplatelet responsiveness correlates with an increased risk of recurrent ischemic vascular events in patients with stroke and acute coronary syndrome. It is not currently known whether tailoring antiplatelet therapy based on platelet function test results translates into a more effective strategy to prevent secondary vascular events after stroke. Large-scale clinical trials using a universally accepted definition and standardized measurement techniques for antiplatelet resistance are needed to demonstrate whether a ‘platelet-function test-guided antiplatelet treatment’ strategy translates into improved stroke care. This article gives an overview of the clinical importance of laboratory antiplatelet resistance, describes the challenges for platelet-function test-guided antiplatelet treatment and discusses practical issues about the management of patients with aspirin and/or clopidogrel resistance. PMID:21306212

  14. Barriers and facilitators to exercise among stroke survivors.

    PubMed

    Damush, Teresa M; Plue, Laurie; Bakas, Tamilyn; Schmid, Arlene; Williams, Linda S

    2007-01-01

    Physical activity after stroke may prevent disability and stroke recurrence; yet, physical impairments may inhibit poststroke exercise and subsequently limit recovery. The goal of this study was to elicit barriers to and facilitators of exercise after stroke. We conducted three focus groups and achieved content saturation from 13 stroke survivors--eight men and five women--85% of whom were African American and 15% White, with a mean age of 59 years. We coded and analyzed the transcripts from the focus groups for common themes. Participants across groups reported three barriers (physical impairments from stroke, lack of motivation, and environmental factors) and three facilitators (motivation, social support, and planned activities to fill empty schedule) to exercise after stroke. Exercise activity can provide a purpose and structure to a stroke survivor's daily schedule, which may be interrupted after stroke. In addition, receiving social support from peers and providers, as well as offering stroke-specific exercise programming, may enhance physical activity of stroke survivors including those with disabilities. We intend to incorporate these findings into a post-stroke self-management exercise program.

  15. Global Burden of Stroke.

    PubMed

    Feigin, Valery L; Norrving, Bo; Mensah, George A

    2017-02-03

    On the basis of the GBD (Global Burden of Disease) 2013 Study, this article provides an overview of the global, regional, and country-specific burden of stroke by sex and age groups, including trends in stroke burden from 1990 to 2013, and outlines recommended measures to reduce stroke burden. It shows that although stroke incidence, prevalence, mortality, and disability-adjusted life-years rates tend to decline from 1990 to 2013, the overall stroke burden in terms of absolute number of people affected by, or who remained disabled from, stroke has increased across the globe in both men and women of all ages. This provides a strong argument that "business as usual" for primary stroke prevention is not sufficiently effective. Although prevention of stroke is a complex medical and political issue, there is strong evidence that substantial prevention of stroke is feasible in practice. The need to scale-up the primary prevention actions is urgent.

  16. Burden of upper gastrointestinal symptoms in patients prescribed dabigatran for stroke prevention

    PubMed Central

    Chan, Pak-Hei; Hai, Jo-Jo; Huang, Duo; Ho, Mei-Han; Chan, Esther W; Cheung, Bernard Man-Yung; Chan, Annie On-On; Wong, Ian Chi-Kei; Tse, Hung-Fat; Hung, Ivan Fan-Ngai; Siu, Chung-Wah

    2016-01-01

    Background: Dabigatran, a non-vitamin K antagonist oral anticoagulant, has been shown to prevent stroke in patients with non-valvular atrial fibrillation. Nonetheless, studies show that 10%–30% of those prescribed dabigatran experience dyspepsia that may eventually lead to discontinuation of therapy and loss of clinical benefit. Aim: To evaluate the gastrointestinal tolerability of dabigatran utilizing a validated questionnaire, as well as determining subsequent non-compliance and drug discontinuation. Method: This is an observational study. All patients were assessed by a validated questionnaire, Hong Kong dyspepsia index, prior to drug prescription and again 4 weeks later. Results: In this study, 115 patients with non-valvular atrial fibrillation (mean age: 74.6 ± 11.4 years; mean CHA2DS2-VASc score was 3.39 ± 1.59) were prescribed dabigatran. At baseline, the mean Hong Kong dyspepsia index was 12.9 ± 1.6 and nine patients had significant dyspepsia (Hong Kong dyspepsia index ⩾ 16). After 4 weeks, the mean Hong Kong dyspepsia index was similar at 12.6 ± 1.9 (p = 0.23). There was no change in Hong Kong dyspepsia index after initiation of dabigatran in 59 (51.3%) patients, and improvement in 37 (32.2%). Only 19 (16.5%) patients had worsening of Hong Kong dyspepsia index, and among these 19 patients, only 1 patient (0.9%) discontinued dabigatran due to significant dyspepsia. Conclusion: Worsening of dyspepsia with dabigatran 110 mg twice daily was uncommon with correct drug administration and clear instructions provided. Systematic assessment of dyspeptic symptoms using a validated questionnaire (i.e. Hong Kong dyspepsia index) before and after treatment initiation allows a more objective comparison of dyspeptic symptoms. PMID:27551422

  17. Interleukin-6 as a Potential Indicator for Prevention of High Risk Adenoma Recurrence by Dietary Flavonols in the Polyp Prevention Trial

    PubMed Central

    Bobe, Gerd; Albert, Paul S.; Sansbury, Leah B.; Lanza, Elaine; Schatzkin, Arthur; Colburn, Nancy H.; Cross, Amanda J.

    2010-01-01

    Serum interleukin (IL)-6, a pro-inflammatory cytokine, is considered an indicator of inflammation and may be an indicator of colorectal carcinogenesis given that inflammation can promote carcinogenesis. Flavonols, which can be found in fruits and vegetables, may inhibit colorectal carcinogenesis partly by inhibiting inflammation. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) to determine whether serum IL-6 was associated with colorectal adenoma recurrence and flavonol intake and, thus may serve as a risk indicator and as a response indicator to dietary flavonols. Serum IL-6 concentrations at baseline, year 1 and 3 were measured in 872 participants from the intervention arm of the Polyp Prevention Trial, a 4-year trial that examined the effectiveness of a low-fat, high-fiber, high-fruit and vegetable diet on adenoma recurrence. Intake of flavonols, especially of isorhamnetin, kaempferol, and quercetin, was inversely associated with serum IL-6 concentrations (highest vs. lowest flavonol intake quartile, 1.80 vs. 2.20 pg/mL) and high risk (OR = 0.51, 95% CI: 0.26–0.98) and advanced adenoma recurrence (OR = 0.17, 95% CI: 0.06–0.50). A decrease in IL-6 concentration during the trial was inversely associated with high risk (OR = 0.44, 95% CI: 0.23–0.84) and advanced adenoma recurrence (OR = 0.47, 95% CI: 0.19–1.18). Individuals with above median flavonol intake and equal or below median IL-6 change after baseline had the lowest risk of recurrence of high risk and advanced adenoma. Our results suggest that serum IL-6 may serve as a risk indicator and as a response indicator to dietary flavonols for colorectal cancer prevention. PMID:20484173

  18. A Surgeon's View on Endarterectomy and Stenting in 2011: Lest We Forget, It's All About Preventing Stroke

    SciTech Connect

    Naylor, A. Ross

    2012-04-15

    It has been nearly 60 years since Felix Eastcott published his seminal paper on carotid reconstruction, which paved the way for carotid endarterectomy (CEA) and then carotid artery stenting (CAS) to assume prominent roles in the prevention of stroke. Yet the ensuing 60 years has witnessed repeated cycles of challenges to practice, professional mistrust, conflicts of interest, dogmatic retention of traditional management strategies, inappropriate corporate interventions, and a general failure to adapt to new evidence. Even the performance of large-scale randomised trials has been associated with rancour and a lack of consensus. This article reviews the history of invasive interventions in the treatment of carotid disease and makes a plea to both the surgical and interventional communities that the fundamental priority must always be the prevention of stroke. It concludes with an appeal for colleagues to collaborate to determine how best to treat patients during the hyperacute period after the onset of symptoms and to identify a smaller cohort of asymptomatic patients who are truly at high risk for stroke in whom to target CAS or CEA.

  19. Emerging Treatments for Motor Rehabilitation After Stroke

    PubMed Central

    Krishnan, Chandramouli; Khot, Sandeep P.

    2015-01-01

    Although numerous treatments are available to improve cerebral perfusion after acute stroke and prevent recurrent stroke, few rehabilitation treatments have been conclusively shown to improve neurologic recovery. The majority of stroke survivors with motor impairment do not recover to their functional baseline, and there remains a need for novel neurorehabilitation treatments to minimize long-term disability, maximize quality of life, and optimize psychosocial outcomes. In recent years, several novel therapies have emerged to restore motor function after stroke, and additional investigational treatments have also shown promise. Here, we familiarize the neurohospitalist with emerging treatments for poststroke motor rehabilitation. The rehabilitation treatments covered in this review will include selective serotonin reuptake inhibitor medications, constraint-induced movement therapy, noninvasive brain stimulation, mirror therapy, and motor imagery or mental practice. PMID:25829989

  20. Cost-effectiveness of edoxaban versus rivaroxaban for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF) in the US

    PubMed Central

    Miller, Jeffrey D; Ye, Xin; Lenhart, Gregory M; Farr, Amanda M; Tran, Oth V; Kwong, W Jackie; Magnuson, Elizabeth A; Weintraub, William S

    2016-01-01

    Background Understanding the value of new anticoagulation therapies compared with existing therapies is of paramount importance in today’s cost-conscious and efficiency-driven health care environment. Edoxaban and rivaroxaban for stroke prevention in nonvalvular atrial fibrillation (NVAF) patients with CHADS2 scores ≥2 have been evaluated in pivotal trials versus warfarin. The relative value of edoxaban versus rivaroxaban would be of interest to health care stakeholders and patients who prefer a once-daily treatment option for long-term stroke prevention in NVAF. Objective To evaluate the relative cost-effectiveness of two once-daily regimens of novel oral anticoagulation therapy – edoxaban (60 mg/30 mg dose-reduced) versus rivaroxaban (20 mg/15 mg dose-reduced) – for stroke prevention in NVAF patients from a US health-plan perspective. Materials and methods A Markov model simulated lifetime risk and treatment of stroke, systemic embolism, major bleeding, clinically relevant nonmajor bleeding, myocardial infarction, and death in NVAF patients treated with edoxaban or rivaroxaban. Efficacy and safety data were derived from a network meta-analysis that utilized data from patients enrolled in ENGAGE AF-TIMI 48 and ROCKET-AF. Health care cost and utility data were obtained from published sources. Incremental cost-effectiveness ratios of $150,000 per quality-adjusted life year (QALY) gained were used as thresholds for “highly cost-effective”, “cost-effective”, and “not cost-effective” treatment options, respectively, as per American Heart Association/American College of Cardiology guidelines. Results Edoxaban was dominant relative to rivaroxaban, such that it was associated with lower total health care costs and better effectiveness in terms of QALYs in the base-case analysis. Results were supported by probabilistic sensitivity analyses that showed edoxaban as either dominant or a highly cost-effective alternative

  1. Primary prevention for risk factors of ischemic stroke with Baduanjin exercise intervention in the community elder population: study protocol for a randomized controlled trial

    PubMed Central

    2014-01-01

    Background Stroke is a major cause of death and disability in the world, and the prevalence of stroke tends to increase with age. Despite advances in acute care and secondary preventive strategies, primary prevention should play the most significant role in the reduction of the burden of stroke. As an important component of traditional Chinese Qigong, Baduanjin exercise is a simple, safe exercise, especially suitable for older adults. However, current evidence is insufficient to inform the use of Baduanjin exercise in the prevention of stroke. The aim of this trail is to systematically evaluate the prevention effect of Baduanjin exercise on ischemic stroke in the community elder population with high risk factors. Methods A total of 170 eligible participants from the community elder population will be randomly allocated into the Baduanjin exercise group and usual physical activity control group in a 1:1 ratio. Besides usual physical activity, participants in the Baduanjin exercise group will accept a 12-week Baduanjin exercise training with a frequency of five days a week and 40 minutes a day. Primary and secondary outcomes will be measured at baseline, 13 weeks (at end of intervention) and 25 weeks (after additional 12-week follow-up period). Discussion This study will be the randomized trial to evaluate the effectiveness of Baduanjin exercise for primary prevention of stroke in community elder population with high risk factors of stroke. The results of this trial will help to establish the optimal approach for primary prevention of stroke. Trial registration Chinese Clinical Trial Registry: ChiCTR-TRC-13003588. Registration date: 24 July, 2013. PMID:24712684

  2. The recruitment triangle: reasons why African Americans enroll, refuse to enroll, or voluntarily withdraw from a clinical trial. An interim report from the African-American Antiplatelet Stroke Prevention Study (AAASPS).

    PubMed Central

    Gorelick, P. B.; Harris, Y.; Burnett, B.; Bonecutter, F. J.

    1998-01-01

    Recruitment and retention of study subjects are key to the success of a clinical trial. In the case of minority patients, this may be challenging as minority patients have been underserved by the medical health-care system. Furthermore, minority patients are more likely to experience barriers to entry into a clinical trial such as mistrust of the medical system, economic disadvantages, lack of awareness of study programs, and communication barriers. An open-ended questionnaire was used to determine reasons why subjects in the African-American Antiplatelet Stroke Prevention Study (AAASPS) remained in the study or voluntarily withdrew in the absence of an adverse event. Potential enrollees who refused to participate in the AAASPS also were queried. Enrollees who remained in the program consistently stated that they participated to reduce the risk of stroke recurrence and to help others by finding a "cure" for stroke. Those who withdrew or refused to participate consistently stated that they were afraid of being used as "guinea pigs." A "recruitment triangle" emerged that might predict a patient's likelihood of participation in a clinical trial. The sides of the triangle include the patient, key family members and friends, and the primary medical doctor and other medical personnel. The organizers of a clinical trial need to be aware of the "recruitment triangle" and establish strategies to heighten and maintain its integrity. PMID:9549977

  3. The recruitment triangle: reasons why African Americans enroll, refuse to enroll, or voluntarily withdraw from a clinical trial. An interim report from the African-American Antiplatelet Stroke Prevention Study (AAASPS).

    PubMed

    Gorelick, P B; Harris, Y; Burnett, B; Bonecutter, F J

    1998-03-01

    Recruitment and retention of study subjects are key to the success of a clinical trial. In the case of minority patients, this may be challenging as minority patients have been underserved by the medical health-care system. Furthermore, minority patients are more likely to experience barriers to entry into a clinical trial such as mistrust of the medical system, economic disadvantages, lack of awareness of study programs, and communication barriers. An open-ended questionnaire was used to determine reasons why subjects in the African-American Antiplatelet Stroke Prevention Study (AAASPS) remained in the study or voluntarily withdrew in the absence of an adverse event. Potential enrollees who refused to participate in the AAASPS also were queried. Enrollees who remained in the program consistently stated that they participated to reduce the risk of stroke recurrence and to help others by finding a "cure" for stroke. Those who withdrew or refused to participate consistently stated that they were afraid of being used as "guinea pigs." A "recruitment triangle" emerged that might predict a patient's likelihood of participation in a clinical trial. The sides of the triangle include the patient, key family members and friends, and the primary medical doctor and other medical personnel. The organizers of a clinical trial need to be aware of the "recruitment triangle" and establish strategies to heighten and maintain its integrity.

  4. Cardioembolic Stroke: Clinical Features, Specific Cardiac Disorders and Prognosis

    PubMed Central

    Arboix, Adrià; Alió, Josefina

    2010-01-01

    This article provides the reader with an overview and up-date of clinical features, specific cardiac disorders and prognosis of cardioembolic stroke. Cardioembolic stroke accounts for 14-30% of ischemic strokes and, in general, is a severe condition; patients with cardioembolic infarction are prone to early and long-term stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of cardioembolic infarction, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke’s aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at the time of stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a lacunar infarct and especially multiple lacunar infarcts, make cardioembolic origin unlikely. The more common high risk cardioembolic conditions are atrial fibrillation, recent myocardial infarction, mechanical prosthetic valve, dilated myocardiopathy, and mitral rheumatic stenosis. Transthoracic and transesophageal echocardiogram can disclose structural heart diseases. Paroxysmal atrial dysrhyhtmia can be detected by Holter monitoring. In-hospital mortality in cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of cerebral infarction. In our experience, in-hospital mortality in patients with early embolic recurrence (within the first 7 days) was 77%. Patients with alcohol abuse, hypertension, valvular heart disease, nausea and vomiting, and previous cerebral infarction are at increased risk of early recurrent systemic embolization. Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent. PMID:21804774

  5. Proposal of a skin tests based approach for the prevention of recurrent hypersensitivity reactions to iodinated contrast media.

    PubMed

    Della-Torre, E; Berti, A; Yacoub, M R; Guglielmi, B; Tombetti, E; Sabbadini, M G; Voltolini, S; Colombo, G

    2015-05-01

    The purpose of the present work is to evaluate the efficacy of an approach that combines clinical history, skin tests results, and premedication, in preventing recurrent hypersensitivity reactions to iodinated contrast media (ICM). Skin Prick tests, Intradermal tests, and Patch tests were performed in 36 patients with a previous reaction to ICM. All patients underwent a second contrast enhanced radiological procedure with an alternative ICM selected on the basis of the proposed approach. After alternative ICM re-injection, only one patient presented a mild NIR. The proposed algorithm, validated in clinical settings where repeated radiological exams are needed, offers a safe and practical approach for protecting patients from recurrent hypersensitivity reactions to ICM.

  6. Dabigatran etexilate: a review of its use in the treatment of acute venous thromboembolism and prevention of venous thromboembolism recurrence.

    PubMed

    Greig, Sarah L; McKeage, Kate

    2014-10-01

    Dabigatran etexilate (Pradaxa(®), Prazaxa(®)) has recently been approved for the treatment of acute venous thromboembolism (VTE) and prevention of VTE recurrence. Dabigatran etexilate is an oral prodrug of dabigatran, a selective, reversible, competitive, direct thrombin inhibitor. Dabigatran etexilate has a wide therapeutic range that allows for fixed-dose administration without the need for routine monitoring, a requirement of standard vitamin K antagonist (VKA) therapy. In randomized phase III trials in patients with acute VTE (RE-COVER and RE-COVER II), long-term treatment with oral dabigatran etexilate 150 mg twice daily for 6 months after initial parenteral anticoagulation was noninferior to dose-adjusted warfarin with regard to the incidence of recurrent symptomatic VTE or related death. In randomized trials of patients with previously treated VTE, extended dabigatran etexilate treatment was noninferior to warfarin (RE-MEDY) and significantly more effective than placebo (RE-SONATE) with regard to the incidence of recurrent VTE or related death. Dabigatran etexilate was generally well tolerated, with a similar incidence of major bleeding to that with warfarin in individual studies (although pooled data showed a significantly lower incidence in patients with acute VTE), and significantly lower incidences of the combined endpoint of major or clinically relevant nonmajor bleeding and of any bleeding than with warfarin. However, in the RE-SONATE trial, dabigatran etexilate was associated with a higher risk of bleeding than placebo. In conclusion, dabigatran etexilate is a valuable treatment option for acute VTE and prevention of VTE recurrence, providing an effective and convenient alternative to standard VKA therapy with the potential for a lower overall rate of bleeding.

  7. High-Dose Viscum album Extract Treatment in the Prevention of Recurrent Bladder Cancer: A Retrospective Case Series

    PubMed Central

    von Schoen-Angerer, Tido; Wilkens, Johannes; Kienle, Gunver S; Kiene, Helmut; Vagedes, Jan

    2015-01-01

    Introduction: Viscum album extract (European mistletoe), containing immuno-active compounds with dose-dependent cytotoxic activity, is being used as an adjuvant cancer treatment in Europe. Few studies have yet been done with high-dose, fever-inducing Viscum album treatment. Objective: To explore whether subcutaneous injections of high-dose Viscum album have a preventive effect on risk of recurrence of bladder cancer. Methods: We retrospectively analyzed the case records of patients with resectable bladder cancer who underwent initiation of high-dose Viscum album treatment at our clinic between January 2006 and December 2012. Main Outcome Measures: We calculated tumor recurrence and progression risk and explored case records to assess whether treatment had a likely, possible, or unlikely beneficial effect. Results: Eight patients were identified, 7 of whom had nonmuscle-invasive bladder cancer and 1 with muscle-invasive cancer. Four patients had frequently recurring tumors before treatment. Among the 8 patients, 28 episodes of recurrence were observed. Median tumor-free follow-up duration was 48.5 months. High-dose Viscum album showed a possible beneficial effect in 5 of 8 patients, could not be assessed in 2 patients, and had an uncertain effect in 1 patient. No tumor progression was observed. Treatment was generally well tolerated and no patient stopped treatment because of side effects. Conclusion: High-dose Viscum album treatment may have interrupted frequently recurring tumors in individual patients with recurrent bladder cancer. Prospective studies are needed to assess whether this treatment offers an additional, bladder-sparing preventive option for patients with intermediate- to high-risk nonmuscleinvasive bladder cancer. PMID:26517439

  8. Therapeutic Potential of Natural Product-Based Oral Nanomedicines for Stroke Prevention.

    PubMed

    Mutoh, Tatsushi; Mutoh, Tomoko; Taki, Yasuyuki; Ishikawa, Tatsuya

    2016-06-01

    Cerebral stroke is the leading cause of death and permanent disability in elderly persons. The impaired glucose and oxygen transport to the brain during ischemia causes bioenergetic failure, leading to oxidative stress, inflammation, blood-brain barrier dysfunction, and eventually cell death. However, the development of effective therapies against stroke has been hampered by insufficient oral absorption of pharmaceuticals and subsequent delivery to the brain. Nanotechnology has emerged as a new method of treating cerebral diseases, with the potential to fundamentally change currently available therapeutic approaches using compounds with low bioavailability. This perspective review provides an overview of the therapeutic potential of oral nanomedicines for stroke, focusing on novel natural product-loaded delivery system with potent antioxidant and anti-inflammatory effects.

  9. Maintenance therapy with unprocessed bran in the prevention of acute anal fissure recurrence.

    PubMed Central

    Jensen, S L

    1987-01-01

    The effect of unprocessed bran in a dose of 5 g three times daily and a dose of 2.5 g three times daily for one year on the recurrence rate of anal fissures was studied in a double-blind, placebo-controlled trial in 90 patients with recently healed acute posterior anal fissures. Fifteen patients (16.6%) were withdrawn before the code was broken due to failure to follow the trial protocol for various reasons. Significantly fewer recurrences occurred in patients receiving bran 5 g three times daily (recurrence rate 16%, 95% confidence limits, 4.54 to 36.08) when compared with patients receiving bran 2.5 g three times daily (60%; 38.67 to 78.87) (P less than 0.01) and with patients receiving placebo three times daily (68%; 46.50 to 85.05) (P less than 0.01). No significant difference in recurrences was found between patients on bran 2.5 g and those on placebo. PMID:3039130

  10. Mindfulness-Based Cognitive Therapy to Prevent Relapse in Recurrent Depression

    ERIC Educational Resources Information Center

    Kuyken, Willem; Byford, Sarah; Taylor, Rod S.; Watkins, Ed; Holden, Emily; White, Kat; Barrett, Barbara; Byng, Richard; Evans, Alison; Mullan, Eugene; Teasdale, John D.

    2008-01-01

    For people at risk of depressive relapse, mindfulness-based cognitive therapy (MBCT) has an additive benefit to usual care (H. F. Coelho, P. H. Canter, & E. Ernst, 2007). This study asked if, among patients with recurrent depression who are treated with antidepressant medication (ADM), MBCT is comparable to treatment with maintenance ADM (m-ADM)…

  11. Evidence-Based Carotid Interventions for Stroke Prevention: State-of-the-art Review.

    PubMed

    Morris, Dylan R; Ayabe, Kengo; Inoue, Takashi; Sakai, Nobuyuki; Bulbulia, Richard; Halliday, Alison; Goto, Shinya

    2017-04-03

    Carotid artery stenosis is responsible for between 10-20% of all ischaemic strokes. Interventions, such as carotid endarterectomy and carotid stenting, effectively reduce the risk of stroke in selected individuals. This review describes the history of carotid interventions, and summarises reliable evidence on the safety and efficacy of these interventions gained from large randomised clinical trials.Early trials comparing carotid endarterectomy to medical therapy alone in symptomatic patients, and asymptomatic patients, demonstrated that endarterectomy halved the risk of stroke and perioperative death in these two unique populations. The absolute risk reduction was smaller in the asymptomatic carotid trials, consistent with their lower absolute stroke risk. More recent trials in symptomatic patients, suggest that carotid stenting has similar long term durability to carotid endarterectomy, but possibly has higher procedural hazards dominated by non-disabling strokes. The Asymptomatic Carotid Surgery Trial-2, along with individual patient data meta-analysis of all asymptomatic trials, will provide reliable evidence for the choice of intervention in asymptomatic patients in whom a decision has been made for carotid revascularisation. Given improvements in effective cardiovascular medical therapy, in particular lipid-lowering medications, there is renewed uncertainty as to whether carotid interventions still provide meaningful net reductions in stroke risk in asymptomatic populations. Four large trials in Europe and the US are currently underway, and are expected to report long-term results in the next decade.It is essential that surgeons, interventionalists, and physicians continue to randomise large numbers of patients from around the world to clarify current uncertainty around the management of asymptomatic carotid stenosis.

  12. Prevention of Relapse and Recurrence in Adults with Major Depressive Disorder: Systematic Review and Meta-Analyses of Controlled Trials

    PubMed Central

    Lau, Wai Keat; Sim, Jordan; Sum, Min Yi; Baldessarini, Ross J.

    2016-01-01

    Background: Findings of substantial remaining morbidity in treated major depressive disorder (MDD) led us to review controlled trials of treatments aimed at preventing early relapses or later recurrences in adults diagnosed with MDD to summarize available data and to guide further research. Methods: Reports (n = 97) were identified through systematic, computerized literature searching up to February 2015. Treatment versus control outcomes were summarized by random-effects meta-analyses. Results: In 45 reports of 72 trials (n = 14 450 subjects) lasting 33.4 weeks, antidepressants were more effective than placebos in preventing relapses (response rates [RR] = 1.90, confidence interval [CI]: 1.73–2.08; NNT = 4.4; p < 0.0001). In 35 reports of 37 trials (n = 7253) lasting 27.0 months, antidepressants were effective in preventing recurrences (RR = 2.03, CI 1.80–2.28; NNT = 3.8; p < 0.0001), with minor differences among drug types. In 17 reports of 22 trials (n = 1 969) lasting 23.7 months, psychosocial interventions yielded inconsistent or inconclusive results. Conclusions: Despite evidence of the efficacy of drug treatment compared to placebos or other controls, the findings further underscore the substantial, unresolved morbidity in treated MDD patients and strongly encourage further evaluations of specific, improved individual and combination therapies (pharmacological and psychological) conducted over longer times, as well as identifying clinical predictors of positive or unfavorable responses and of intolerability of long-term treatments in MDD. PMID:26152228

  13. Trends in the treatment of risk factors for stroke in a Czech stroke unit

    PubMed Central

    Simunek, Libor; Krajickova, Dagmar; Vysata, Oldrich; Valis, Martin

    2015-01-01

    The goal of this study is to evaluate therapeutic trends for several diseases that represent risk factors for stroke. The relative frequency of therapy with compounds that influence the risk factors for stroke was monitored in a group of 3,290 patients who were hospitalised in the Stroke Unit at the University Hospital in Hradec Kralove between 2005 and 2012. For most drugs monitored, the reasons for the significant decrease or increase in use were causes other than the reduction of stroke risk. Despite this finding, the majority of statistically significant changes had, according to review of comparative studies, a positive effect on prevention of stroke. Motivation to change treatment of stroke risk factors, such as hypertension, diabetes mellitus and hypercholesterolemia, was mainly aimed at sufficient disease management with a minimum of adverse effects. On the other hand, optimization of stroke recurrence and economic factors were motivations to treatment changes in prevention with antiplatelets. Antidiabetics were associated with an increase in metformin use and reduction in insulin use. For antihypertensives, the most significant reduction was associated with the use of diuretics, although calcium channel blockers and beta-blockers are also less used. Additionally, the use of the ACE inhibitor ramipril increased PMID:28352720

  14. Unanswered questions and research priorities to optimise stroke prevention in atrial fibrillation with the new oral anticoagulants.

    PubMed

    Hankey, Graeme J

    2014-05-05

    This review article discusses the following, as yet unanswered, questions and research priorities to optimise patient management and stroke prevention in atrial fibrillation with the new direct oral anticoagulants (NOACs): 1. In patients prescribed a NOAC, can the anticoagulant effects or plasma concentrations of the NOACs be measured rapidly and reliably and, if so, can "cut-off points" between which anticoagulation is therapeutic (i.e. the "therapeutic range") be defined? 2. In patients who are taking a NOAC and bleeding (e.g. intracerebral haemorrhage), can the anticoagulant effects of the direct NOACs be reversed rapidly and, if so, can NOAC-associated bleeding and complications be minimised and patient outcome improved? 3. In patients taking a NOAC who experience an acute ischaemic stroke, to what degree of anticoagulation or plasma concentration of NOAC, if any, can thrombolysis be administered safely and effectively? 4. In patients with a recent cardioembolic ischaemic stroke, what is the optimal time to start (or re-start) anticoagulation with a NOAC (or warfarin)? 5. In anticoagulated patients who experience an intracranial haemorrhage, can anticoagulation with a NOAC be re-started safely and effectively, and if so when? 6. Are the NOACs effective and safe in multimorbid geriatric people (who commonly have atrial fibrillation and are at high risk of stroke but also bleeding)? 7. Can dose-adjusted NOAC therapy augment the established safety and efficacy of fixed-dose unmonitored NOAC therapy? 8. Is there a dose or dosing regimen for each NOAC that is as effective and safe as adjusted-dose warfarin for patients with atrial fibrillation who have mechanical prosthetic heart valves? 9. What is the long-term safety of the NOACs?

  15. Achieved Blood Pressures in the Secondary Prevention of Small Subcortical Strokes (SPS3) Study: Challenges and Lessons Learned

    PubMed Central

    Pergola, Pablo E.; Szychowski, Jeff M.; Talbert, Robert; del Brutto, Oscar; Castellanos, Mar; Graves, John W.; Matamala, Gonzalo; Pretell, Edwin Javier; Yee, Jerry; Rebello, Rosario; Zhang, Yu; Benavente, Oscar R.

    2014-01-01

    BACKGROUND Lowering blood pressure (BP) after stroke remains a challenge, even in the context of clinical trials. The Secondary Prevention of Small Subcortical Strokes (SPS3) BP protocol, BP management during the study, and achieved BPs are described here. METHODS Patients with recent symptomatic lacunar stroke were randomized to 1 of 2 levels of systolic BP (SBP) targets: lower: <130mm Hg, or higher: 130–149mm Hg. SBP management over the course of the trial was examined by race/ethnicity and other baseline conditions. RESULTS Mean SBP decreased for both groups from baseline to the last follow-up, from 142.4 to 126.7mm Hg for the lower SBP target group and from 143.6 to 137.4mm Hg for the higher SBP target group. At baseline, participants in both groups used an average of 1.7±1.2 antihypertensive medications, which increased to a mean of 2.4±1.4 (lower group) and 1.8±1.4 (higher group) by the end-study visit. It took an average of 6 months for patients to reach their SBP target, sustained to the last follow-up. Black participants had the highest proportion of SBP ≥150mm Hg at both study entry (40%) and end-study visit (17%), as compared with whites (9%) and Hispanics (11%). CONCLUSIONS These results show that it is possible to safely lower BP even to a SBP goal <130mm Hg in a variety of patients and settings, including private and academic centers in multiple countries. This provides further support for protocol-driven care in lowering BP and consequently reducing the burden of stroke. PMID:24610884

  16. Potential of the angiotensin receptor blockers (ARBs) telmisartan, irbesartan, and candesartan for inhibiting the HMGB1/RAGE axis in prevention and acute treatment of stroke.

    PubMed

    Kikuchi, Kiyoshi; Tancharoen, Salunya; Ito, Takashi; Morimoto-Yamashita, Yoko; Miura, Naoki; Kawahara, Ko-ichi; Maruyama, Ikuro; Murai, Yoshinaka; Tanaka, Eiichiro

    2013-09-13

    Stroke is a major cause of mortality and disability worldwide. The main cause of stroke is atherosclerosis, and the most common risk factor for atherosclerosis is hypertension. Therefore, antihypertensive treatments are recommended for the prevention of stroke. Three angiotensin receptor blockers (ARBs), telmisartan, irbesartan and candesartan, inhibit the expression of the receptor for advanced glycation end-products (RAGE), which is one of the pleiotropic effects of these drugs. High mobility group box 1 (HMGB1) is the ligand of RAGE, and has been recently identified as a lethal mediator of severe sepsis. HMGB1 is an intracellular protein, which acts as an inflammatory cytokine when released into the extracellular milieu. Extracellular HMGB1 causes multiple organ failure and contributes to the pathogenesis of hypertension, hyperlipidemia, diabetes mellitus, atherosclerosis, thrombosis, and stroke. This is the first review of the literature evaluating the potential of three ARBs for the HMGB1-RAGE axis on stroke therapy, including prevention and acute treatment. This review covers clinical and experimental studies conducted between 1976 and 2013. We propose that ARBs, which inhibit the HMGB1/RAGE axis, may offer a novel option for prevention and acute treatment of stroke. However, additional clinical studies are necessary to verify the efficacy of ARBs.

  17. Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 2.

    PubMed

    Diener, Hans-Christoph; Aisenberg, James; Ansell, Jack; Atar, Dan; Breithardt, Günter; Eikelboom, John; Ezekowitz, Michael D; Granger, Christopher B; Halperin, Jonathan L; Hohnloser, Stefan H; Hylek, Elaine M; Kirchhof, Paulus; Lane, Deirdre A; Verheugt, Freek W A; Veltkamp, Roland; Lip, Gregory Y H

    2016-02-04

    The choice of oral anticoagulant (OAC) for patients with atrial fibrillation (AF) may be influenced by individual clinical features or by patterns of risk factors and comorbidities. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. non-vitamin K oral anticoagulants (NOACs) for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In addition, we discuss the timing of initiation of anticoagulation. In the second of a two-part review, we discuss the use of NOAC for stroke prevention in the following subgroups of patients with AF: (vii) secondary stroke prevention in patients after stroke or transient ischaemic attack (TIA), (viii) patients with acute stroke requiring thrombolysis or thrombectomy, (ix) those initiating or restarting OAC treatment after stroke or TIA, (x) those with renal impairment on dialysis, (xi) the elderly, (xii) those at high risk of gastrointestinal bleeding, and (xiii) those with hypertension. In addition, we discuss adherence and compliance. Finally, we present a summary of treatment suggestions. In specific subgroups of patients with AF, evidence supports the use of particular NOACs and/or particular doses of anticoagulant. The appropriate choice of treatment for these subgroups will help to promote optimal clinical outcomes.

  18. Similar Secondary Stroke Prevention and Medication Persistence Rates among Rural and Urban Patients

    ERIC Educational Resources Information Center

    Rodriguez, Daniel; Cox, Margueritte; Zimmer, Louise O.; Olson, DaiWai M.; Goldstein, Larry B.; Drew, Laura; Peterson, Eric D.; Bushnell, Cheryl D.

    2011-01-01

    Purpose: Rural residents are less likely to obtain optimal care for many serious conditions and have poorer health outcomes than those residing in more urban areas. We determined whether rural vs urban residence affected postdischarge medication persistence and 1 year outcomes after stroke. Methods: The Adherence eValuation After Ischemic…

  19. Feasibility, safety and cost of outpatient management of acute minor ischaemic stroke: a population-based study

    PubMed Central

    Paul, Nicola L M; Koton, Silvia; Simoni, Michela; Geraghty, Olivia C; Luengo-Fernandez, Ramon; Rothwell, Peter M

    2017-01-01

    Background Outpatient management is safe and effective in preventing early recurrent stroke after TIA, but this approach may not be safe in patients with acute minor stroke. Methods We studied outcomes of clinic and hospital-referred patients with TIA or minor stroke (NIHSS≤3) in a prospective, population-based study (Oxford Vascular Study). Results Of 845 patients with TIA/stroke, 587 (67%) were referred directly to outpatient clinics and 258 (30%) directly to inpatient services. Of the 250 clinic-referred minor strokes (mean age=72.7 years), 237 (95%) were investigated, treated and discharged on the same day, of whom 16 (6.8%) were subsequently admitted to hospital within 30 days for recurrent stroke (n=6), sepsis (n=3), falls (n=3), bleeding (n=2), angina (n=1), and nursing care (n=1). The 150 patients (mean age=74.8 years) with minor stroke referred directly to hospital (median length-of-stay=9 days) had a similar 30-day-readmission rate (9/150;6.3%;p=0.83) after initial discharge and a similar 30-day risk of recurrent stroke (9/237 in clinic patients vs 8/150, OR=0.70,0.27-1.80,p=0.61). Rates of prescription of secondary prevention medication after initial clinic/hospital discharge were higher in clinic versus hospital-referred patients for antiplatelets/anticoagulants (p<0.05) and lipid lowering (p<0.001) and were maintained at one-year follow-up. The mean (SD) secondary care cost was £8323 (13,133) for hospital-referred minor stroke versus £743 (1794) for clinic-referred cases. Conclusion Outpatient management of clinic-referred minor stroke is feasible and may be as safe as inpatient care. Rates of early hospital admission and recurrent stroke were low and uptake and maintenance of secondary prevention was high. PMID:23172867

  20. Understanding Stroke - Know Stroke • Know the Signs • Act in Time

    MedlinePlus

    ... Home Current Issue Past Issues Special Section Understanding Stroke Know Stroke • Know the Signs • Act in Time Past Issues / ... Julie Harris, and motivational speaker David Layton. Preventing Stroke "Until I had my stroke, I didn't ...

  1. [Prevention of brain infarction in patients with atrial fibrillation].

    PubMed

    Ogata, Toshiyasu; Yasaka, Masahiro

    2007-01-01

    The patients with cardioembolic stroke sometimes suffer from severe neurological deficit and from recurrent strokes. Since atrial fibrillation, especially non-valvular atrial fibrillation (NVAF) is associated with over half of the cardioembolic strokes, the prevention of cardioembolic stroke in patients with NVAF is important. There have been some reports about how to prevent stroke. They have indicated that the best medication for preventing from stroke was anticoagulation by warfarin. Therefore, the guidelines recommended the patients with NVAF to take warfarin. In case with the older patients under 70 years, prothrombin international normalized ratio (PT-INR) should be kept from 2.0 to 3.0. On the other hand, if the patients with NVAF are over 70 years, PT-INR has to be controlled from 1.6 to 2.6. Before extraction of a tooth, anticoagulation should not be call off.

  2. Therapeutic Inhibition of the MDM2-p53 Interaction Prevents Recurrence of Adenoid Cystic Carcinomas.

    PubMed

    Nör, Felipe; Warner, Kristy A; Zhang, Zhaocheng; Acasigua, Gerson A; Pearson, Alexander T; Kerk, Samuel A; Helman, Joseph I; Sant'Ana Filho, Manoel; Wang, Shaomeng; Nör, Jacques E

    2017-02-15

    Purpose: Conventional chemotherapy has modest efficacy in advanced adenoid cystic carcinomas (ACC). Tumor recurrence is a major challenge in the management of ACC patients. Here, we evaluated the antitumor effect of a novel small-molecule inhibitor of the MDM2-p53 interaction (MI-773) combined with cisplatin in patient-derived xenograft (PDX) ACC tumors.Experimental Design: Therapeutic strategies with MI-773 and/or cisplatin were evaluated in SCID mice harboring PDX ACC tumors (UM-PDX-HACC-5) and in low passage primary human ACC cells (UM-HACC-2A, -2B, -5, -6) in vitro The effect of therapy on the fraction of cancer stem cells (CSC) was determined by flow cytometry for ALDH activity and CD44 expression.Results: Combined therapy with MI-773 with cisplatin caused p53 activation, induction of apoptosis, and regression of ACC PDX tumors. Western blots revealed induction of MDM2, p53 and downstream p21 expression, and regulation of apoptosis-related proteins PUMA, BAX, Bcl-2, Bcl-xL, and active caspase-9 upon MI-773 treatment. Both single-agent MI-773 and MI-773 combined with cisplatin decreased the fraction of CSCs in PDX ACC tumors. Notably, neoadjuvant MI-773 and surgery eliminated tumor recurrences during a postsurgical follow-up of more than 300 days. In contrast, 62.5% of mice that received vehicle control presented with palpable tumor recurrences within this time period (P = 0.0097).Conclusions: Collectively, these data demonstrate that therapeutic inhibition of MDM2-p53 interaction by MI-773 decreased the CSC fraction, sensitized ACC xenograft tumors to cisplatin, and eliminated tumor recurrence. These results suggest that patients with ACC might benefit from the therapeutic inhibition of the MDM2-p53 interaction. Clin Cancer Res; 23(4); 1036-48. ©2016 AACR.

  3. Establishing the Mineral Apposition Rate of Heterotopic Ossification for Prevention of Recurrence

    DTIC Science & Technology

    2015-12-01

    clinical factors are needed to refine this model. A follow-up HO grant awarded using this data as a benchmark for developing a translatable animal model...evidence of ectopic bone growth . Further assessment may lead to improved surgical planning to reduce recurrence and help explain the etiology of this...took oxytetracycline on four scheduled days prior to HO resection to determine the mineral apposition rate (MAR; i.e., bone growth rate). Results

  4. Role of Virechana Karma in cure and prevention of recurrence of Vicharchika (Eczema)

    PubMed Central

    Kaur, Mandip; Chandola, Harimohan

    2012-01-01

    Mandip and Chandola reported that administration of Rasayana (Guduchi and Bhringaraja) after Koshtha Shuddhi with Aragvadha Hima and simultaneous giving of Shirishadi decoction orally and applying of Snuhyadi Lepa externally provided complete remission to 22.6% patients of Vicharchika (Eczema) and checked the recurrences of the disease in the 89.5% patients. As in this group, cure rate was not up to the expectation; therefore, it was thought desirable to see whether performing of Virechana Karma instead of Koshtha Shuddhi prior to the administration of the above drugs enhances the cure rate for the Vicharchika (Eczema) patients. For the present study, 39 patients of Vicharchika (Eczema) were registered, of which 32 patients completed the full course of the treatment. These patients were given Virechana after preparing with the proper internal Snehana, Abhyanga, and Svedana as per classical method. After the Samsarjana Krama, they were administered the Shirishadi decoction and Guduchi-Bhringraja Rasayana powder orally with simultaneous local application of Snuhyadi Lepa on the eczematous lesions. The results of this study showed that when Virechana Karma was performed prior to the administration of Guduchi-Bhringaraja Rasayana and Shirishadi decoction orally and SnuhyadiLepa externally, it not only increased the cure rate to 81.3% in the patients of Vicharchika (Eczema) but also checked the recurrences to great extent as only negligible number of the patients reported the recurrence. PMID:23723667

  5. Aspirin in Preventing Disease Recurrence in Patients With Barrett Esophagus After Successful Elimination by Radiofrequency Ablation | Division of Cancer Prevention

    Cancer.gov

    This randomized phase II trial studies the safety of and how well aspirin works in preventing Barrett's esophagus from returning after it has been successfully eliminated by radiofrequency ablation. Studying samples of tissue from patients with Barrett's esophagus for the levels of a specific protein that is linked to developing Barrett's esophagus may help doctors learn whether aspirin can prevent it from returning after it has been successfully treated. |

  6. European Stroke Prevention Study 2: A study of low-dose acetylsalicylic acid and of high dose dipyridamole in secondary prevention of cerebro-vascular accidents.

    PubMed

    1995-11-01

    In spite of some data being added to our knowledge of the effect of antiplatelets in secondary prevention of brain ischemic lesion in recent years, the main reasons to perform a second European Stroke Prevention Study (ESPS 2), which started in 1987-1988, were: (a) clarify the relative roles of aspirin (ASA) and dipyridamole (DP) alone or in combination; (b) confirm the efficacy of small doses of ASA and, so doing, decrease the number of drop-outs due to ASA side effects; (c) join information to the effect of antiplatelets in complete stroke. General characteristics of the sample of 6602 patients are presented and compared with other major trials and series. The patients in the four treatment arms (aspirin, dipyridamole, aspirin + dipyridamole and placebo) are compared. The more relevant features and risk factors known to influence long term prognosis are described and discussed. The small proportion of patients included with TIA (23.7%) and the comparability among treatment groups are stressed. No relevant differences have been found, among groups, on the sex or age distribution, prevalence of hypertension, diabetes, previous vascular events or atrial fibrillation, nor in the characteristics of the accident leading to the inclusion in trial.

  7. Use of aspirin and statins for the primary prevention of myocardial infarction and stroke in patients with human immunodeficiency virus infection.

    PubMed

    Park, Tae Eun; Yusuff, Jameela; Sharma, Roopali

    2016-05-01

    This retrospective, cross-sectional study evaluated whether HIV-infected patients received aspirin and statins for the primary prevention of myocardial infarction and stroke. Among the 258 patients included, 50.4% (n = 130/258) of the patients had a high risk of myocardial infarction and 14% (n = 36/258) of stroke. Overall, 43.1% (n = 56/130) and 50% (n = 18/36) of the patients were prescribed aspirin for the primary prevention of myocardial infarction and stroke, respectively. Among the patients who required statin therapy, 42.5% (n = 34/80) and 37.1% (n = 13/35) of patients received it for the primary prevention of myocardial infarction and stroke, respectively. The patients who had hypertension (odds ratio 3.8, 95% confidence interval 1.5-10.9) and diabetes mellitus (odds ratio 5.6, 95% confidence interval 2.6-12.4) were more likely to receive aspirin. Interventions are needed to improve provider awareness of the use of aspirin and statins in the primary prevention of myocardial infarction and stroke in HIV-infected patients.

  8. Bipolar disorder recurrence prevention using self-monitoring daily mood charts: case reports from a 5 year period

    PubMed Central

    Yasui-Furukori, Norio; Nakamura, Kazuhiko

    2017-01-01

    Mood symptoms in bipolar disorders are significantly related to psychosocial events, and the personalized identification of symptom triggers is important. Ecological momentary assessments have been used in paper-and-pencil form to explore emotional reactivity to daily life stress in patients with bipolar disorder. However, there are few data on long-term recurrence prevention effects using ecological momentary assessments. Subjects were three outpatients with bipolar disorder who had a history of at least one admission. They recorded self-monitoring daily mood charts using a 5-point Likert scale. Paper-and-pencil mood charts included mood, motivation, thinking speed, and impulsivity. Additionally, they recorded waking time, bedtime, and medication compliance. Fewer manic or depressive episodes including admissions occurred after self-monitoring daily mood charts compared to patients’ admissions in the past 3 years. This study suggests that self-monitoring daily mood in addition to mood stabilizing medication has some effect on recurrence prevention in follow-up periods of at least 5 years. Further studies with rigorous designs and large sample sizes are needed. PMID:28331323

  9. Trials of Novel Oral Anticoagulants for Stroke Prevention In Patients with Non-valvular Atrial Fibrillation

    PubMed Central

    Halperin, Jonathan L; Dorian, Paul

    2014-01-01

    Patients with non-valvular atrial fibrillation (AF) face an increased risk of stroke compared with those in normal sinus rhythm. The vitamin K antagonist warfarin, available for over half a century, is highly effective in reducing the risk of stroke in patients with AF, but it is a difficult drug to use properly. As a result, it is challenging to keep the anticoagulant effect of warfarin in the desired range. Newer oral anticoagulants (NOACs) that directly inhibit Factor IIa (thrombin) or Factor Xa provide reliable anticoagulation when administer in fixed oral doses without routine coagulation monitoring. This manuscript will review in detail the pivotal trials of these NOACs that led to their approval as well as comment on the factors that should influence their selection. PMID:24821657

  10. Accessibility, usability, and usefulness of a Web-based clinical decision support tool to enhance provider-patient communication around Self-management TO Prevent (STOP) Stroke.

    PubMed

    Anderson, Jane A; Godwin, Kyler M; Saleem, Jason J; Russell, Scott; Robinson, Joshua J; Kimmel, Barbara

    2014-12-01

    This article reports redesign strategies identified to create a Web-based user-interface for the Self-management TO Prevent (STOP) Stroke Tool. Members of a Stroke Quality Improvement Network (N = 12) viewed a visualization video of a proposed prototype and provided feedback on implementation barriers/facilitators. Stroke-care providers (N = 10) tested the Web-based prototype in think-aloud sessions of simulated clinic visits. Participants' dialogues were coded into themes. Access to comprehensive information and the automated features/systematized processes were the primary accessibility and usability facilitator themes. The need for training, time to complete the tool, and computer-centric care were identified as possible usability barriers. Patient accountability, reminders for best practice, goal-focused care, and communication/counseling themes indicate that the STOP Stroke Tool supports the paradigm of patient-centered care. The STOP Stroke Tool was found to prompt clinicians on secondary stroke-prevention clinical-practice guidelines, facilitate comprehensive documentation of evidence-based care, and support clinicians in providing patient-centered care through the shared decision-making process that occurred while using the action-planning/goal-setting feature of the tool.

  11. GPs have pivotal role in care of stroke patients.

    PubMed

    Best, Catherine; Mead, Gillian

    2010-02-01

    Stroke is a major cause of mortality in the community and the most common cause of disability. At one year, a third of patients who have had a stroke have died, and 37% of survivors are dependent. In the acute phase of ischaemic stroke, patients should receive thrombolysis (within 4.5 hours of stroke onset), aspirin (within 48 hours of onset), and early access to a stroke unit. Care in a stroke unit significantly reduces the risk of death or dependency irrespective of stroke severity. A multidisciplinary team to manage the range of problems after stroke (e.g. swallowing difficulties, communication problems, mobility) is central to rehabilitation. Much rehabilitation is orientated toward physical function whereas returning to their social roles is more important to patients. While the emphasis of rehabilitation is on targeted therapy interventions to improve function and finding compensatory strategies to increase independence--the goal of community exercise is to improve general physical fitness and activity levels. The marked loss of physical fitness evident in stroke survivors can be at least partly reversed by physical fitness training, and leads to improvements in physical function. Group exercise also improves self-confidence and social integration. Pharmacological therapies play a key role in secondary prevention, and must be started as soon as possible to reduce the risk of early recurrence.

  12. The impact of surgical left atrial appendage amputation/ligation on stroke prevention in patients undergoing off-pump coronary artery bypass grafting.

    PubMed

    Endo, Daisuke; Kato, Tomoko S; Iwamura, Tai; Oishi, Atsumi; Yokoyama, Yasutaka; Kuwaki, Kenji; Inaba, Hirotaka; Amano, Atsushi

    2016-11-09

    Stroke is a major adverse event in patients developing atrial fibrillation (AF) after cardiac surgery. Surgical left atrial appendage amputation/ligation (LAA-A/L) during off-pump coronary artery bypass grafting (OPCAB) is routinely performed in our institution. We analyzed 578 consecutive patients (mean age 69 years, male 82%) undergoing OPCAB with or without concomitant LAA-A/L from 2011 to 2014 at our institution in a prospective observational manner. The safety and efficacy of the concomitant LAA-A/L on preventing early (<30 days) and overall postoperative stroke were examined. A total of 193 patients (33.4%) underwent LAA-A/L, consisting of amputation in 154 and ligation in 39 patients (80 and 20% of the cases, respectively). Preoperative characteristics, operative time, requirement of blood transfusion, and 30-day mortality were not significantly different between those with and without LAA-A/L. The incidences of postoperative AF and early and overall stroke were not significantly different between the groups in the analysis based on a total cohort. In a subanalysis of patients without LAA-A/L, early and overall stroke occurred more frequently in those developing postoperative AF than those without AF (2.8 vs. 0%; p = 0.005, 6.2 vs. 1.5%; p = 0.017, respectively), while in patients receiving LAA-A/L, stroke incidences did not differ between those with and without AF. Multivariate logistic regression showed postoperative AF without LAA-A/L as the only independent positive predictor of overall stroke (OR 3.69, p = 0.03). Concomitant LAA-A/L with OPCAB can safely prevent postoperative stroke occurrence in case patients develop AF, the most common arrhythmia associated with stroke.

  13. Effectiveness and safety of warfarin and anti-platelet drugs for the primary prevention of stroke in patients with non-valvular atrial fibrillation: a meta-analysis

    PubMed Central

    Shi, Xin-Xiu; Ren, Guang-Hao; Wang, Jie; Zhang, Ni; Yu, Ming-Zhu; Wang, Yan-Qiu; Shao, Yan-Kun

    2015-01-01

    Objective: To evaluate the effectiveness and safety of warfarin and anti-platelet drugs as the primary approach to the prevention of stroke in patients with non-valvular atrial fibrillation (NVAF). Methods: Three English databases (the Cochrane library, Embase, and Medline), and three Chinese databases (the Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure, and Chinese Periodical Full-text Database of Science and Technology) were searched to select potentially eligible studies published before May, 2014. The studies were randomized controlled trials (RCTs) that investigated the effectiveness and safety of using warfarin and anti-platelet drugs in preventing stroke in NVAF patients; The statistical analysis was performed using the Review Manager 5.2 software provided by the Cochrane Collaboration. Results: nine articles were finally included. Compared with antiplatelet drugs, warfarin treatment significantly reduced the risk of stroke (OR = 0.62, 95% CI 0.50-05.77), systemic embolism events (OR = 0.49, 95% CI 0.31-0.77), ischemic stroke events (OR = 0.46, 95% CI 0.36-0.59), stroke-related disability or death events (OR = 0.66, 95% CI 0.52-0.84). Warfarin did not increase the incidence of All-cause death events (OR = 0.92, 95% CI 0.78-1.08), intracranial hemorrhage events (OR = 1.28, 95% CI 0.85-1.93), major hemorrhage events (OR = 1.01, 95% CI 0.79-1.29). Conclusions: This meta-analysis found that compared with antiplatelet drugs, warfarin treatment significantly reduced the risk of stroke, systemic embolism events, ischemic stroke events, stroke-related disability or death events. And warfarin did not increase the incidence of All-cause death events, intracranial hemorrhage events, major hemorrhage events. PMID:26309492

  14. Pediatric Stroke

    MedlinePlus

    ... News About Neurology Image Library Search The Internet Stroke Center Patients & Families About Stroke Stroke Diagnosis Stroke ... communicate with your child’s doctor. Symptoms of a Stroke Stroke is an injury to part of the ...

  15. Secondary prevention lifestyle interventions initiated within 90 days after TIA or ‘minor’ stroke: a systematic review and meta-analysis of rehabilitation programmes

    PubMed Central

    Heron, Neil; Kee, Frank; Cardwell, Christopher; Tully, Mark A; Donnelly, Michael; Cupples, Margaret E

    2017-01-01

    Background Strokes are often preceded by a transient ischaemic attack (TIA) or ‘minor’ stroke. The immediate period after a TIA/minor stroke is a crucial time to initiate secondary prevention. However, the optimal approach to prevention, including non-pharmacological measures, after TIA is not clear. Aim To systematically review evidence about the effectiveness of delivering secondary prevention, with lifestyle interventions, in comprehensive rehabilitation programmes, initiated within 90 days of a TIA/minor stroke. Also, to categorise the specific behaviour change techniques used. Design and setting The review identified randomised controlled trials by searching the Cochrane Library, Ovid MEDLINE, Ovid EMBASE, Web of Science, EBSCO CINAHL and Ovid PsycINFO. Method Two review authors independently screened titles and abstracts for eligibility (programmes initiated within 90 days of event; outcomes reported for TIA/minor stroke) and extracted relevant data from appraised studies; a meta-analysis was used to synthesise the results. Results A total of 31 potentially eligible papers were identified and four studies, comprising 774 patients post-TIA or minor stroke, met the inclusion criteria; two had poor methodological quality. Individual studies reported increased aerobic capacity but meta-analysis found no significant change in resting and peak systolic blood pressure, resting heart rate, aerobic capacity, falls, or mortality. The main behaviour change techniques were goal setting and instructions about how to perform given behaviours. Conclusion There is limited evidence of the effectiveness of early post-TIA rehabilitation programmes with preventive lifestyle interventions. Further robust randomised controlled trials of comprehensive rehabilitation programmes that promote secondary prevention and lifestyle modification immediately after a TIA are needed. PMID:27919935

  16. Balancing efficacy and bleeding risk in the prevention of stroke due to atrial fibrillation with newer oral anticoagulants.

    PubMed

    Agarwal, M B; Verma, Subhash; Mahapatra, Manoranjan; Tripathi, A K; Bhave, Abhay; Deshpande, Anand; Vora, Amit; Dalal, Jamshed J; Shah, A B; Bichu, S

    2012-09-01

    With the evaluation and approval of newer oral anticoagulants such as the factor IIa inhibitor, dabigatran etexilate and the factor Xa inhibitors, rivaroxaban and apixaban, strategies for stroke prevention in atrial fibrillation need a thorough re-evaluation of current options. Clinicians are naturally excited about the imminent introduction of these newer drugs that do not need international normalized ratio (INR) monitoring, besides having no drug-food and minimal drug-drug interactions. However, as with all new drugs, it is always prudent to use these judiciously so that they stay in our therapeutic armamentarium for a long time. More than 56 years after the introduction of warfarin we now have three drugs, viz., dabigatran 150 mg bid, rivaroxaban 20 mg od, and apixaban 5 mg bid which were effective in comparison with warfarin in reducing the risk of stroke and bleeding in the landmark trials, RE-LY, ROCKET-AF, and ARISTOTLE respectively. There is a thin dividing line between physiological hemostasis and pathological thrombosis. Routine INR monitoring may not be required but in special situations, such as prior to major surgery, overdose, non-compliance or stroke while on the anticoagulant, one may wish to know whether there are any laboratory measures of efficacy or means of reversal of over anticoagulation. Similar questions may be raised about other situations such as renal dysfunction, cardioversion, ablation procedures, post-stenting, or switch to and from warfarin, heparin or LMWH? This document is an attempt to address these concerns based on available evidence and give physicians a perspective and practice guidelines on how best to use these agents, both old and new, for optimal patient outcomes, maximizing efficacy and minimizing risk.

  17. Intracytoplasmic sperm injection combined with preimplantation genetic diagnosis for the prevention of recurrent gestational trophoblastic disease.

    PubMed

    Reubinoff, B E; Lewin, A; Verner, M; Safran, A; Schenker, J G; Abeliovich, D

    1997-04-01

    A strategy for the prevention of repeated molar pregnancies by using intracytoplasmic sperm injection (ICSI) coupled with preimplantation genetic diagnosis (PGD) with fluorescence in-situ hybridization (FISH) was developed. In this approach, complete moles which arise from dispermic fertilization are avoided by the use of ICSI. ICSI is followed by preimplantation selection against the transfer of 46,XX embryos, thus preventing complete moles resulting from a fertilization of an inactive oocyte, by a haploid X-bearing spermatozoon which subsequently duplicates. Triploid partial moles which arise mainly from dispermic fertilization may also be prevented by ICSI. The preimplantation confirmation of diploidy by FISH guards against triploid partial moles which may result from mechanisms other than dispermic fertilization. The employment of this strategy in an attempt to prevent a repeated event of molar pregnancy in a patient with a history of two previous episodes of gestational trophoblastic disease is reported.

  18. Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 1.

    PubMed

    Diener, Hans-Christoph; Aisenberg, James; Ansell, Jack; Atar, Dan; Breithardt, Günter; Eikelboom, John; Ezekowitz, Michael D; Granger, Christopher B; Halperin, Jonathan L; Hohnloser, Stefan H; Hylek, Elaine M; Kirchhof, Paulus; Lane, Deirdre A; Verheugt, Freek W A; Veltkamp, Roland; Lip, Gregory Y H

    2016-02-04

    Patients with atrial fibrillation (AF) have a high risk of stroke and mortality, which can be considerably reduced by oral anticoagulants (OAC). Recently, four non-vitamin-K oral anticoagulants (NOACs) were compared with warfarin in large randomized trials for the prevention of stroke and systemic embolism. Today's clinician is faced with the difficult task of selecting a suitable OAC for a patient with a particular clinical profile or a particular pattern of risk factors and concomitant diseases. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. NOACs for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In the first of a two-part review, we discuss the choice of NOAC for stroke prevention in the following subgroups of patients with AF: (i) stable coronary artery disease or peripheral artery disease, including percutaneous coronary intervention with stenting and triple therapy; (ii) cardioversion, ablation and anti-arrhythmic drug therapy; (iii) mechanical valves and rheumatic valve disease, (iv) patients with time in therapeutic range of >70% on warfarin; (v) patients with a single stroke risk factor (CHA2DS2VASc score of 1 in males, 2 in females); and (vi) patients with a single first episode of paroxysmal AF. Although there are no major differences in terms of efficacy and safety between the NOACs for some clinical scenarios, in others we are able to suggest that particular drugs and/or doses be prioritized for anticoagulation.

  19. [Comparative efficacy and tolerability of paroxetine and amitriptiline in long-term therapy preventing depressive recurrences].

    PubMed

    Mosolov, S N; Kostiukova, E G; Gorodnichev, A V; Timofeev, I V

    2005-01-01

    An open comparative randomized study of paroxetine (selective inhibitor of serotonin re-uptake) and tricyclic antidepressant amitriptiline has been conducted. These drugs were used for the treatment of 43 patients with recurrent depression (RD) with frequent relapses (ICD-10 F33.0-F33.2) during 12 months. There were 2 groups matched for demographic and clinical data, one included 21 patients treated by paroxetine and the other 22 patients switched to amitriptiline. Basing on clinical records and scores on a number of scales, i.e. HAM-D, CGI, quality of life, high efficacy of the drugs was confirmed, being estimated as 90,5% responders in the paroxetine group and 69,2% in the amitriptiline one, with the marked advantage of the former medication. The better tolerability, possibility of single intake and absence of severe side-effects argue for preferable use of paroxetine during long-term therapy in RD patients with frequent relapses.

  20. Optimal Stroke Prevention in the Geriatric Patient with Atrial Fibrillation: Position Paper of an Interdisciplinary Expert Panel.

    PubMed

    Bahrmann, P; Wehling, M; Ropers, D; Flohr, J; Leischker, A; Röther, J

    2015-10-01

    The present position paper summarises the outcomes of an expert panel discussion held by hospital-based and office-based physicians with ample experience in the treatment of geriatric patients. The optimal approach to stroke prevention in geriatric patients with atrial fibrillation (AF) has not been adequately clarified. Despite their high risk of stroke and clear indication for anticoagulation according to established risk scores, in practice geriatric AF patients often are withheld treatment because of comorbidities and comedications, concerns about low treatment adherence or fear of bleeding events, in particular due to falls. The panel agreed that geriatric patients should receive oral anticoagulation as a rule, unless a comprehensive neurological and geriatric assessment (including clinical examination, gait tests and validated instruments such as Modified Rankin Scale, Mini-mental state examination or Timed Test of Money Counting) provides sound reasons for refraining from treatment. All patients with a history of falls should be thoroughly evaluated for further evaluation of the causes. Patients with CHADS2 score ≥ 2 should receive anticoagulation even if at high risk for falls. The novel oral anticoagulants (NOAC) facilitate management in the geriatric population with AF (no INR monitoring needed, easier bridging during interventions) and have, based on available data, an improved benefit-risk ratio compared to vitamin K antagonists. Drugs with predominantly non-renal elimination are safer in geriatric patients and should be preferred.

  1. The Indian consensus guidance on stroke prevention in atrial fibrillation: An emphasis on practical use of nonvitamin K oral anticoagulants☆

    PubMed Central

    Dalal, Jamshed; Bhave, Abhay; Oomman, Abraham; Vora, Amit; Saxena, Anil; Kahali, Dhiman; Poncha, Fali; Gambhir, D.S.; Chaudhuri, Jaydip Ray; Sinha, Nakul; Ray, Saumitra; Iyengar, S.S.; Banerjee, Suvro; Kaul, Upendra

    2015-01-01

    The last ten years have seen rapid strides in the evolution of nonvitamin K oral anticoagulants (NOACs) for stroke prevention in patients with atrial fibrillation (AF). For the preparation of this consensus, a comprehensive literature search was performed and data on available trials, subpopulation analyses, and case reports were analyzed. This Indian consensus document intends to provide guidance on selecting the right NOAC for the right patients by formulating expert opinions based on the available trials and Asian/Indian subpopulation analyses of these trials. A section has been dedicated to the current evidence of NOACs in the Asian population. Practical suggestions have been formulated in the following clinical situations: (i) Dose recommendations of the NOACs in different clinical scenarios; (ii) NOACs in patients with rheumatic heart disease (RHD); (iii) Monitoring anticoagulant effect of the NOACs; (iv) Overdose of NOACs; (v) Antidotes to NOACs; (vi) Treatment of hypertrophic cardiomyopathy (HCM) with AF using NOACs; (vii) NOACs dose in elderly, (viii) Switching between NOACs and vitamin K antagonists (VKA); (ix) Cardioversion or ablation in NOAC-treated patients; (x) Planned/emergency surgical interventions in patients currently on NOACs; (xi) Management of bleeding complications of NOACs; (xii) Management of acute coronary syndrome (ACS) in AF with NOACs; (xiii) Management of acute ischemic stroke while on NOACs. PMID:26688149

  2. Efficacy and Safety of the WATCHMAN Left Atrial Appendage System for Stroke Prevention in Chinese Patients with Nonvalvular Atrial Fibrillation: A Single-center, Prospective, Observational Study

    PubMed Central

    Huang, Wei-Ping; Zhang, Yong-Hua; He, Lei; Su, Xi; Yang, Xin-Wei; Guo, Zai-Xiong

    2017-01-01

    Background: In patients with nonvalvular atrial fibrillation (NVAF), embolic stroke is thought to be associated with left atrial appendage (LAA) thrombi. The WATCHMAN LAA Occlusion Device has been shown to be noninferior to conventional oral anticoagulation with warfarin for stroke prevention in patients with NVAF. This study aimed to evaluate the procedural feasibility, safety and 12-month outcomes of the WATCHMAN LAA Occlusion Device in NVAF patients with high risk for stroke in China. Methods: The clinical data of 106 NVAF patients, who were consecutively underwent LAA closure with the WATCHMAN Device between April 2014 and May 2015, were collected. Patients were followed up at 1, 3, 6, and 12 months after discharge. A transesophageal echocardiograph was performed at 45 days after implantation and repeated in case of an unexpected event during the follow-up period. Results: This study included 106 NVAF patients with a mean age of 64.2 ± 8.6 years (ranging from 50 to 88 years), and the mean CHA2DS2-VASc score of all patients was 3.6 ± 1.6 (ranging from 2 to 9). Among those 106 NVAF patients, 100 (94.3%) patients were implanted with the device successfully. The procedural success rate was 94.3% (100/106), and the occlusion rate was 100.0% (100/100). There were one tamponade, one ischemic stroke, and eight minor pericardial effusions during hospitalization. During 12-month follow-up period, two patients developed a thrombus layer on the device that resolved with additional anticoagulation: one with visible device-thrombus experienced transient ischemic stroke, and one had a hemorrhagic stroke. There were no deaths in this study. The overall survival rate was 100.0%, and nonmajor adverse event rate was 95.0% (95/100). In this study, the expected annual rate of ischemic stroke risk in these patients according to the CHA2DS2-VASc score was 4.0%, while the observed ischemic stroke rate was 2.0% per year. Conclusions: LAA closure with the WATCHMAN Device was feasible

  3. Educational approach on stroke training in Europe.

    PubMed

    Corea, F; Gunther, A; Kwan, J; Petzold, A; Debette, S; Sessa, M; Silvestrelli, G; Parnetti, L; Tambasco, N

    2006-01-01

    According to the European Stroke Initiative (EUSI), stroke care is best delivered within a stroke unit by a specialized multidisciplinary stroke team led by stroke specialists. At present, there is no guideline or consensus regarding training requirements or clinical standards that stroke specialists should achieve. It is envisaged that stroke specialists in training would need to acquire adequate knowledge and competency across three major areas of stroke care: acute stroke, stroke rehabilitation, and stroke prevention. With an EUSI document, the European Association of Young Neurologists and Trainees Stroke Subspeciality Group aims to promote discussion on the many aspects of stroke training and the requirements to be a stroke specialist in the European community. The ultimate purpose is to agree on common standards to promote good clinical care and effective stroke prevention across Europe. In the future, this may be translated into better patient outcome and a reduction in the global burden of this condition.

  4. Recurrent Issues in Efforts to Prevent Homicidal Youth Violence in Schools: Expert Opinions

    ERIC Educational Resources Information Center

    Dill, Karen E.; Redding, Richard E.; Smith, Peter K.; Surette, Ray; Cornell, Dewey G.

    2011-01-01

    Developmental research on social influences on adolescents can guide practices aimed to prevent homicidal youth violence. School shootings have repeatedly raised questions about the contributory role of bullying and entertainment violence, how news media publicity might produce copycat crimes, and whether stiffer criminal sanctions might have a…

  5. Dabigatran for the prevention of stroke and systemic embolism in atrial fibrillation: A NICE single technology appraisal.

    PubMed

    Faria, Rita; Spackman, Eldon; Burch, Jane; Corbacho, Belen; Todd, Derick; Pepper, Chris; Woolacott, Nerys; Palmer, Stephen

    2013-07-01

    The National Institute for Health and Clinical Excellence (NICE) invited the manufacturer of dabigatran etexilate (Boehringer Ingelheim Ltd, UK) to submit evidence for the clinical and cost-effectiveness of this drug for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF) as part of the NICE single technology appraisal process. The Centre for Reviews and Dissemination and the Centre for Health Economics at the University of York were commissioned to act as the evidence review group (ERG). This article presents a summary of the manufacturer's submission, the ERG report and the subsequent development of NICE guidance for the use of dabigatran within the UK National Health Service. Dabigatran was granted marketing authorisation by the European Medicines Agency for a sequential dosing regimen (DBG sequential), in which patients under 80 years are treated with dabigatran 150 mg twice daily (DBG150) and patients 80 years and over are given dabigatran 110 mg twice daily (DBG110). NICE decisions are bound by the marketing authorisation; therefore, the decision problem faced by the committee was whether the DBG sequential regimen was effective and cost-effective compared with warfarin or aspirin for patients with non-valvular AF and one or more risk factors. The RE-LY trial, a large multi-centre non-inferiority randomised clinical trial, was the primary source of clinical evidence. DBG150 was shown to be non-inferior, and subsequently superior to warfarin, for the primary outcome of all stroke/systemic embolism. DBG110 was found to be non-inferior to warfarin. Results were presented for a post hoc subgroup analysis for patients under and over 80 years of age, where DBG110 showed a statistically significant reduction of haemorrhagic stroke and intracranial haemorrhage in comparison to warfarin in patients over 80 years of age. This post hoc subgroup analysis by age was the basis for the licensed DBG sequential regimen

  6. Compression for Primary Prevention, Treatment, and Prevention of Recurrence of Venous Leg Ulcers: An Evidence-and Consensus-Based Algorithm for Care Across the Continuum.

    PubMed

    Ratliff, Catherine R; Yates, Stephanie; McNichol, Laurie; Gray, Mikel

    2016-01-01

    Chronic venous insufficiency is a prevalent disease that frequently leads to development of venous leg ulcers. While a number of evidence-based clinical practice guidelines have been developed that provide guidance for clinicians when caring for patients with chronic venous insufficiency, they lack adequate detail concerning selection and application of compression for prevention and management of venous leg ulcers. In order to address this need, the WOCN Society appointed a task force to develop an algorithm for compression for primary prevention, treatment, and prevention of recurrent venous leg ulcers in persons with chronic venous insufficiency. The task force used findings from a scoping literature review to identify current best evidence needed to support decision points and pathways within the algorithm. In addition, the task force convened a panel of 20 clinicians and researchers with expertise in lower extremity venous disorders in order to establish consensus around pathways and decision points within the algorithm lacking robust evidence. Following initial construction of the algorithm, a second interdisciplinary group of expert clinicians established content validity and provided additional qualitative feedback used to complete final revisions of the algorithm. This article reviews the process used to create this landmark algorithm, including generation of the evidence- and consensus-based statements used in its construction, the various pathways, and rich supplemental materials embedded within the algorithm, and the process used to establish content validity.

  7. Efficacy and safety of the target-specific oral anticoagulants for stroke prevention in atrial fibrillation: the real-life evidence

    PubMed Central

    Russo, Vincenzo; Rago, Anna; Proietti, Riccardo; Di Meo, Federica; Antonio Papa, Andrea; Calabrò, Paolo; D’Onofrio, Antonio; Nigro, Gerardo; AlTurki, Ahmed

    2016-01-01

    The aim of our article is to provide a concise review for clinicians entailing the main studies that evaluated the efficacy and safety of target-specific oral anticoagulants (TSOAs) for thromboembolic stroke prevention in the real-world setting. Atrial fibrillation (AF) is one of the most common supraventricular arrhythmias that requires anticoagulation therapy to prevent stroke and systemic embolism. TSOAs, dabigatran, apixaban and rivaroxaban have become available as an alternative to warfarin anticoagulation in nonvalvular atrial fibrillation (NVAF). Randomized clinical trials showed non-inferior or superior results in efficacy and safety of the TSOAs compared with warfarin for stroke prevention in NVAF patients. For this reason, the 2012 update to the European Society of Cardiology guidelines for the management of AF recommends TSOAs as broadly preferable to vitamin K antagonists (VKAs) in the vast majority of patients with NVAF [Camm et al. 2012]. Although the clinical trial results and the guideline’s indications, there is a need for safety and efficacy data from unselected patients in everyday clinical practice. Recently, a large number of studies testing the efficacy and the safety of TSOAs in clinical practice have been published. The aim of our article is to provide a concise review for clinicians, outlining the main studies that evaluated the efficacy and safety of TSOAs for thromboembolic stroke prevention in the real-world setting. PMID:28255434

  8. Impact of nutritional status and dietary quality on stroke: do we need specific recommendations?

    PubMed

    Lim, H; Choue, R

    2013-05-01

    Stroke, one of the most prevalent geriatric diseases, is a leading cause of death worldwide that often results in permanent physical disability and decreased quality of life, and can have a negative impact on families both financially and emotionally. Although many previous studies have shown relationships between the risk of stroke and nutritional factors, clear dietary recommendations for the prevention and reduction of stroke recurrence have not been established. Several factors should be considered to control and manage stroke. For example, a considerable number of patients with stroke are poorly nourished, have several comorbidities and undesirable health-related behaviors may be present. Stroke patients are less likely to consume beneficial foods, have poorer eating habits and have impoverished dietary quality. In addition, psychological factors such as depression must also be considered in stroke management. Given these factors, dietary recommendations for stroke patients should be established. In this article, we summarized the nutritional status and dietary quality of stroke patients. We also suggested some nutritional guidelines for stroke patients and for those who are at risk for stroke.

  9. Development and description of a decision analysis based decision support tool for stroke prevention in atrial fibrillation

    PubMed Central

    Thomson, R.; Robinson, A.; Greenaway, J.; Lowe, P.

    2002-01-01

    Background: There is an increasing move towards clinical decision making that engages the patient, which has led to the development and use of decision aids to support better decisions. The treatment of patients in atrial fibrillation (AF) with warfarin to prevent stroke is a decision that is sensitive to patient preferences as shown by a previous decision analysis. Aim: To develop a computerised decision support tool, building upon a previous decision analysis, which would engage individual patient preferences in reaching a shared decision on whether to take warfarin to prevent stroke. Methods: The development process had two main phases: (1) the development phase which employed focus groups and repeated interviews with GPs/practice nurses and patients alongside an iterative development of a computerised tool; (2) the training and testing phase in which GPs and practice nurses underwent training in the use of the tool, including the use of simulated patients. The tool was then used in a feasibility study in a small number of patients with AF to inform the design of a subsequent randomised controlled trial. Results: The prototype tool had three components: (1) derivation of an individual patient's values for relevant health states using a standard gamble; (2) presentation/discussion of a patient's risks of stroke using the Framingham equation and the benefits/risks of warfarin from a systematic literature review; and (3) decision making component incorporating the outcome of a Markov decision analysis model. Older patients could be taken through the decision analysis based computerised tool, and patients and clinicians welcomed information on risks and benefits of treatments. The tool required time and training to use. Patients' decisions in the feasibility phase did not necessarily coincide with the output of the decision analysis model, but decision conflict appeared to be reduced and both patients and GPs were satisfied with the process. Conclusions: It is

  10. Bacterial lysate in the prevention of acute exacerbation of COPD and in respiratory recurrent infections

    PubMed Central

    Braido, F; Tarantini, F; Ghiglione, V; Melioli, G; Canonica, G W

    2007-01-01

    Respiratory tract infections (RTIs) represent a serious problem because they are one of the most common cause of human death by infection. The search for the treatment of those diseases has therefore a great importance. In this study we provide an overview of the currently available treatments for RTIs with particular attention to chronic obstructive pulmonary diseases exacerbations and recurrent respiratory infections therapy and a description of bacterial lysate action, in particular making reference to the medical literature dealing with its clinical efficacy. Those studies are based on a very large number of clinical trials aimed to evaluate the effects of this drug in maintaining the immune system in a state of alert, and in increasing the defences against microbial infections. From this analysis it comes out that bacterial lysates have a protective effect, which induce a significant reduction of the symptoms related to respiratory infections. Those results could be very interesting also from an economic point of view, because they envisage a reduction in the number of acute exacerbations and a shorter duration of hospitalization. The use of bacterial lysate could therefore represent an important means to achieve an extension of life duration in patients affected by respiratory diseases. PMID:18229572

  11. Induction of thymic tolerance as possibility in prevention of recurrent spontaneous abortion.

    PubMed

    Bubanovic, I V

    2003-04-01

    A major process through which the immune system becomes tolerant to self-proteins involves the deletion of self-reactive cells in the thymus and/or inhibition of specific Th(1) cells clones. Deletion process includes two selection mechanisms in which the thymus eliminates unwanted thymocytes are known as positive selection and negative selection. The thymus is an antigenically privileged site, mainly for it is discrete by blood-thymus barrier. Many researches were shown that intrathymic inoculation of any antigen resulted in specific tolerance induction. The embryo/fetus and placenta are an allograft to which the mother must remain immunologically tolerant in order for the fetus to survive. Today, there is much interest focused on the immunology of recurrent spontaneous abortion (RSA). Up to 50% of RSA may be mediated by the immune system via inadequate maternal anti-paternal response. Nature of this maternal-fetal disturbance represents disbalance in Th(1)/Th(2) activity. Contra-shift in Th(1)/Th(2) activity is the basis for immunotherapy with paternal leukocyte immunization (PLI). PLI induce some kind of peripheral tolerance on embryonic/fetal/trophoblast antigens, but problems of central tolerance are still open. Intrathymic inoculation of fetal or paternal cells (like leukocyte, thymic dendritic cells, trophoblast cells) or paternal set of MHC molecules may cause central specific tolerance and may be a new possibility for immunotherapy in RSA patients.

  12. Recurrent bilateral occipital infarct with cortical blindness and anton syndrome.

    PubMed

    Kwong Yew, Kiu; Abdul Halim, Sanihah; Liza-Sharmini, Ahmad Tajudin; Tharakan, John

    2014-01-01

    Bilateral cortical blindness and Anton syndrome, are most commonly caused by ischaemic stroke. In this condition, patients have loss of vision but deny their blindness despite objective evidence of visual loss. We report a case of a patient with multiple cardiovascular risk factors who developed recurrent bilateral occipital lobe infarct with Anton syndrome. A suspicion of this condition should be raised when the patient has denial of blindness in the presence of clinical and radiological evidence of occipital lobe injury. Management of this condition should focus on the underlying cause, in which our patient requires secondary stroke prevention and rehabilitation.

  13. The case for an elderly targeted stroke management.

    PubMed

    Fustinoni, Osvaldo

    2011-01-01

    Stroke is a leading cause of death and disability worldwide. The elderly, in whom atrial fibrillation (AF) is most prevalent, carry the greatest risk, undergoing more recurrent, deadlier strokes, with bigger deficits, slower recoveries, and more comorbidities. Evidence-based data on advanced age stroke management are scarce. Age-related cerebral changes might undermine the benefit of established stroke treatments. Nevertheless, the elderly should probably also undergo thrombolysis for ischemic stroke: they do not bleed more, and die not because of hemorrhage but of concomitant illnesses. Beyond natural bleeding risks, AF in advanced age has a high embolic potential if not anticoagulated. Standard or lower intensity warfarin anticoagulation prevents embolic stroke in the elderly with a hemorrhage risk even lower than aspirin. In fact, adverse effects seem to occur more often with aspirin. Excess anticoagulation hazards are prevented with lower starting doses, stricter corrections, more frequent International Normalized Ratio monitoring, and longer adjustment intervals. Validated prognostic scores such as CHADS(2) help minimize bleeds. Direct inhibitors have recently shown a benefit similar to warfarin with fewer hemorrhages. Carefully tailoring antithrombotics to this age group is therefore useful. Antihypertensives probably help 80-plus stroke patients as well, but the risk/benefit of lowering blood pressure in secondary stroke prevention at that age is uncertain. Evidence-based data on diabetes management and use of lipid-lowering drugs are still lacking in this age group. In summary, emerging data suggest that stroke management should be specifically targeted to the elderly to better prevent its devastating consequences in the population at the highest risk.

  14. The Case for an Elderly Targeted Stroke Management

    PubMed Central

    Fustinoni, Osvaldo

    2011-01-01

    Stroke is a leading cause of death and disability worldwide. The elderly, in whom atrial fibrillation (AF) is most prevalent, carry the greatest risk, undergoing more recurrent, deadlier strokes, with bigger deficits, slower recoveries, and more comorbidities. Evidence-based data on advanced age stroke management are scarce. Age-related cerebral changes might undermine the benefit of established stroke treatments. Nevertheless, the elderly should probably also undergo thrombolysis for ischemic stroke: they do not bleed more, and die not because of hemorrhage but of concomitant illnesses. Beyond natural bleeding risks, AF in advanced age has a high embolic potential if not anticoagulated. Standard or lower intensity warfarin anticoagulation prevents embolic stroke in the elderly with a hemorrhage risk even lower than aspirin. In fact, adverse effects seem to occur more often with aspirin. Excess anticoagulation hazards are prevented with lower starting doses, stricter corrections, more frequent International Normalized Ratio monitoring, and longer adjustment intervals. Validated prognostic scores such as CHADS2 help minimize bleeds. Direct inhibitors have recently shown a benefit similar to warfarin with fewer hemorrhages. Carefully tailoring antithrombotics to this age group is therefore useful. Antihypertensives probably help 80-plus stroke patients as well, but the risk/benefit of lowering blood pressure in secondary stroke prevention at that age is uncertain. Evidence-based data on diabetes management and use of lipid-lowering drugs are still lacking in this age group. In summary, emerging data suggest that stroke management should be specifically targeted to the elderly to better prevent its devastating consequences in the population at the highest risk. PMID:22232616

  15. Recurrent issues in efforts to prevent homicidal youth violence in schools: expert opinions.

    PubMed

    Dill, Karen E; Redding, Richard E; Smith, Peter K; Surette, Ray; Cornell, Dewey G

    2011-01-01

    Developmental research on social influences on adolescents can guide practices aimed to prevent homicidal youth violence. School shootings have repeatedly raised questions about the contributory role of bullying and entertainment violence, how news media publicity might produce copycat crimes, and whether stiffer criminal sanctions might have a deterrent effect. This article presents the thoughts and recommendations of a group of experts on these topics summarizing the current knowledge base. In brief, bullying reduction programs may be a useful early prevention effort. Television and video games with violent themes can encourage aggressive behavior, but these media can be used to teach more prosocial behavior as well. The potential copycat effects of highly publicized crimes might be diminished with more restrained reporting, although more research is needed. Finally, there is substantial evidence that increased criminal sanctions for youthful offenders have not had a deterrent effect.

  16. Getting on Target with Community Health Advisors (GOTCHA): an innovative stroke prevention project.

    PubMed

    Story, Lachel; Mayfield-Johnson, Susan; Downey, Laura H; Anderson-Lewis, Charkarra; Young, Rebekah; Day, Pearlean

    2010-12-01

    Health disparities along with insufficient numbers of healthcare providers and resources have created a need for effective and efficient grassroots approaches to improve community health. Community-based participatory research (CBPR), more specifically the utilization of community health advisors (CHAs), is one such strategy. The Getting on Target with Community Health Advisors (GOTCHA) project convened an interdisciplinary team to answer the call from 10 counties in the rural Mississippi Delta area of 'The Stroke Belt' to meet the region's identified health needs, and to impact the health of a disparaged state. This article explores this CBPR project including the community involvement strategies, innovative CHA training curriculum, evaluation plan, and implications to healthcare professionals, particularly nurses.

  17. Stroke prevention in patients with atrial fibrillation: The diagnosis and management of hypertension by specialists

    PubMed Central

    Healey, Jeff S; Wharton, Sean; Al-Kaabi, Saif; Pai, Menaka; Ravandi, Amir; Nair, Girish; Morillo, Carlos A; Connolly, Stuart J

    2006-01-01

    BACKGROUND Hypertension is common in patients with atrial fibrillation (AF) and is an important cause of stroke. OBJECTIVES To determine how effectively hypertension is managed among specialist-treated outpatients with AF. METHODS Investigators reviewed the charts of patients with a diagnosis of AF cared for by medical specialists to determine the change in blood pressure, patterns of antihypertensive drug use and the role of the specialist in the management of hypertension. RESULTS Of 209 patients with AF, 118 had a history of hypertension or an office blood pressure greater than 140/90 mmHg. Blood pressure was measured at 73% of all visits. Hypertension was identified as an important problem in 57% of patients and antihypertensive therapy was either initiated or suggested in 77%. One year after the initial specialist visit, systolic blood pressure was significantly lower (140±20 mmHg at one year versus 148±23 mmHg initially; P=0.015); however, there was no change in diastolic blood pressure (80±12 mmHg at one year versus 81±16 mmHg initially; P=0.602) and only 50% of patients had a blood pressure less than 140/90 mmHg. In contrast, the percentage of patients receiving warfarin increased from 46% to 78% (P=0.0001). CONCLUSIONS In patients treated by specialists for AF, systolic blood pressure is significantly reduced during follow-up; however, 50% of patients continue to have suboptimal blood pressure control. In many patients, hypertension is not identified as an important comorbid illness and antihypertensive therapy is neither recommended nor initiated by the specialist. Greater specialist involvement in the identification and treatment of hypertension in patients with AF could lead to an important, additional reduction in stroke. PMID:16685312

  18. The Efficacy of Surgical Treatment for the Secondary Prevention of Stroke in Symptomatic Moyamoya Disease

    PubMed Central

    Qian, Cong; Yu, Xiaobo; Li, Jianru; Chen, Jingyin; Wang, Lin; Chen, Gao

    2015-01-01

    Abstract The treatment of moyamoya disease (MMD) is controversial and often depends on the doctor's experience. In addition, the choice of surgical procedure to treat MMD can differ in many ways. In this study, we performed a meta-analysis to determine whether surgical treatment of MMD is superior to conservative treatment and to provide evidence for the selection of an appropriate surgical treatment. The human case–control studies regarding the association of MMD treatment were systematically identified through online databases (PubMed, Web of Science, Elsevier Science Direct, and Springer Link). Inclusion and exclusion criteria were defined for the eligible studies. The fixed-effects model was performed when homogeneity was indicated. Alternatively, the random-effects model was utilized. This meta-analysis included 16 studies. Surgical treatment significantly reduced the risk of stroke (odds ratio (OR) of 0.17, 95% confidence interval (CI), 0.12–0.26, P < 0.01). A subgroup analysis showed that surgical treatment was more beneficial to hemorrhagic MMD (OR of 0.23, 95% CI, 0.15–0.38, P < 0.01), but there was no significant difference between surgical treatment and conservative treatment on ischemic MMD treatment (OR of 0.45, 95% CI, 0.15–1.29, P = 0.14). Further analysis indicated that compared to direct bypass surgery, indirect bypass surgery had a lower efficacy on secondary stroke risk reduction (OR of 1.79, 95% CI, 1.14–2.82, P = 0.01), while no significant difference was detected for perioperative complications. Surgery is an effective treatment for symptomatic MMD patients, and direct bypass surgery may bring more benefits for these patients. PMID:26656359

  19. Citicoline in vascular cognitive impairment and vascular dementia after stroke.

    PubMed

    Alvarez-Sabín, Jose; Román, Gustavo C

    2011-01-01

    Cognitive decline after stroke is more common than stroke recurrence. Stroke doubles the risk of dementia and is a major contributor to vascular cognitive impairment and vascular dementia. Neuropathological studies in most cases of dementia in the elderly reveal a large load of vascular ischemic brain lesions mixed with a lesser contribution of neurodegenerative lesions of Alzheimer disease. Nonetheless, few pharmacological studies have addressed vascular cognitive impairment and vascular dementia after stroke. Citicoline has demonstrated neuroprotective effects in acute stroke and has been shown to improve cognition in patients with chronic cerebrovascular disease and in some patients with Alzheimer disease. A recent trial lasting 6 months in patients with first-ever ischemic stroke showed that citicoline prevented cognitive decline after stroke with significant improvement of temporal orientation, attention, and executive function. Experimentally, citicoline exhibits neuroprotective effects and enhances neural repair. Citicoline appears to be a safe and promising alternative to improve stroke recovery and could be indicated in patients with vascular cognitive impairment, vascular dementia, and Alzheimer disease with significant cerebrovascular disease.

  20. Ovarian Cancer: Prevention, Detection and Treatment of the Disease and Its Recurrence. Molecular Mechanisms and Personalized Medicine Meeting Report

    PubMed Central

    Modugno, Francesmary; Edwards, Robert P.

    2012-01-01

    Objective To review the current understanding of the underlying molecular, biologic and genetic mechanisms involved in ovarian cancer development and how these mechanisms can be targets for prevention, detection and treatment of the disease and its recurrence. Methods In May 2012, we convened a meeting of researchers, clinicians and consumer advocates to review the state of current knowledge on molecular mechanisms and identify fruitful areas for further investigations. Results The meeting consisted of seven scientific sessions, ranging from Epidemiology, Early Detection, and Biology to Therapeutics and Quality of Life. Sessions consisted of talks and panel discussions by international leaders in ovarian cancer research. A special career-development session by the CDMRP Department of Defense Ovarian Cancer Academy as well as an oral abstract and poster session showcased promising new research by junior scientists. Conclusions Technological advances in the last decade have increased our knowledge of the molecular mechanisms involved in a host of biological activities related to ovarian cancer. Understanding the role these mechanisms play in cancer initiation and progression will help lead to the development of prevention and treatment modalities that can be personalized to each patient, thereby helping to overcome this highly-fatal malignancy. PMID:23013733

  1. Prognostic value of trans-thoracic echocardiography in patients with acute stroke and atrial fibrillation: findings from the RAF study.

    PubMed

    Paciaroni, Maurizio; Agnelli, Giancarlo; Falocci, Nicola; Caso, Valeria; Becattini, Cecilia; Marcheselli, Simona; Rueckert, Christina; Pezzini, Alessandro; Poli, Loris; Padovani, Alessandro; Csiba, Laszló; Szabó, Lilla; Sohn, Sung-Il; Tassinari, Tiziana; Abdul-Rahim, Azmil H; Michel, Patrik; Cordier, Maria; Vanacker, Peter; Remillard, Suzette; Alberti, Andrea; Venti, Michele; Acciarresi, Monica; D'Amore, Cataldo; Mosconi, Maria Giulia; Scoditti, Umberto; Denti, Licia; Orlandi, Giovanni; Chiti, Alberto; Gialdini, Gino; Bovi, Paolo; Carletti, Monica; Rigatelli, Alberto; Putaala, Jukka; Tatlisumak, Turgut; Masotti, Luca; Lorenzini, Gianni; Tassi, Rossana; Guideri, Francesca; Martini, Giuseppe; Tsivgoulis, Georgios; Vadikolias, Kostantinos; Liantinioti, Chrissoula; Corea, Francesco; Del Sette, Massimo; Ageno, Walter; De Lodovici, Maria Luisa; Bono, Giorgio; Baldi, Antonio; D'Anna, Sebastiano; Sacco, Simona; Carolei, Antonio; Tiseo, Cindy; Imberti, Davide; Zabzuni, Dorjan; Doronin, Boris; Volodina, Vera; Consoli, Domenico; Galati, Franco; Pieroni, Alessio; Toni, Danilo; Monaco, Serena; Baronello, Mario Maimone; Barlinn, Kristian; Pallesen, Lars-Peder; Kepplinger, Jessica; Bodechtel, Ulf; Gerber, Johannes; Deleu, Dirk; Melikyan, Gayane; Ibrahim, Faisal; Akhtar, Naveed; Lees, Kennedy R

    2016-02-01

    Anticoagulant therapy is recommended for the secondary prevention of stroke in patients with atrial fibrillation (AF). T he identification of patients at high risk for early recurrence, which are potential candidates to prompt anticoagulation, is crucial to justify the risk of bleeding associated with early anticoagulant treatment. The aim of this study was to evaluate in patients with acute ischemic stroke and AF the association between findings at trans-thoracic echocardiography (TTE) and 90 days recurrence. In consecutive patients with acute ischemic stroke and AF, TTE was performed within 7 days from hospital admission. Study outcomes were recurrent ischemic cerebrovascular events (stroke or TIA) and systemic embolism. 854 patients (mean age 76.3 ± 9.5 years) underwent a TTE evaluation; 63 patients (7.4%) had at least a study outcome event. Left atrial thrombosis was present in 11 patients (1.3%) among whom 1 had recurrent ischemic event. Left atrial enlargement was present in 548 patients (64.2%) among whom 51 (9.3%) had recurrent ischemic events. The recurrence rate in the 197 patients with severe left atrial enlargement was 11.7%. On multivariate analysis, the presence of atrial enlargement (OR 2.13; 95% CI 1.06-4.29, p = 0.033) and CHA2DS2-VASc score (OR 1.22; 95% CI 1.04-1.45, p = 0.018, for each point increase) were correlated with ischemic recurrences. In patients with AF-associated acute stroke, left atrial enlargement is an independent marker of recurrent stroke and systemic embolism. The risk of recurrence is accounted for by severe atrial enlargement. TTE-detected left atrial thrombosis is relatively uncommon.

  2. Effectiveness and usage of a decision support system to improve stroke prevention in general practice: A cluster randomized controlled trial

    PubMed Central

    2017-01-01

    Background Adherence to guidelines pertaining to stroke prevention in patients with atrial fibrillation is poor. Decision support systems have shown promise in increasing guideline adherence. Aims To improve guideline adherence with a non-obtrusive clinical decision support system integrated in the workflow. Secondly, we seek to capture reasons for guideline non-adherence. Design and setting A cluster randomized controlled trial in Dutch general practices. Method A decision support system was developed that implemented properties positively associated with effectiveness: real-time, non-interruptive and based on data from electronic health records. Recommendations were based on the Dutch general practitioners guideline for atrial fibrillation that uses the CHA2DS2-VAsc for stroke risk stratification. Usage data and responses to the recommendations were logged. Effectiveness was measured as adherence to the guideline. We used a chi square to test for group differences and a mixed effects model to correct for clustering and baseline adherence. Results Our analyses included 781 patients. Usage of the system was low (5%) and declined over time. In total, 76 notifications received a response: 58% dismissal and 42% acceptance. At the end of the study, both groups had improved, by 8% and 5% respectively. There was no statistically significant difference between groups (Control: 50%, Intervention: 55% P = 0.23). Clustered analysis revealed similar results. Only one usable reasons for non-adherence was captured. Conclusion Our study could not demonstrate the effectiveness of a decision support system in general practice, which was likely due to lack of use. Our findings should be used to develop next generation decision support systems that are effective in the challenging setting of general practice. PMID:28245247

  3. Stroke prevention in atrial fibrillation: established oral anticoagulants versus novel anticoagulants-translating clinical trial data into practice.

    PubMed

    Ezekowitz, Michael D; Spahr, Judy; Ghosh, Pradeepto; Corelli, Kathryn

    2014-09-01

    Anticoagulation for stroke prevention in atrial fibrillation (AF) is effective. Pivotal trials RE-LY, ROCKET AF, ARISTOTLE, and ENGAGE-AF TIMI 48 tested novel agents against warfarin (W). In RE-LY, an open-label trial, dabigatran 150 mg BID (D150) was superior (35%) and 110 mg BID (D110) was noninferior to W. D150 reduced ischemic strokes by 25% and intracerebral bleeds by 74%, but increased major GI bleeds by 0.5 % per year. In ROCKET AF, a double-blind study, rivaroxaban 20 mg daily, downtitrated to 15 mg daily (if CrCl was <49) was noninferior for efficacy and safety, with an increase in GI bleeds. In ARISTOTLE, a double-blind study, apixaban 5 mg BID (downtitrated to 2.5 mg BID if two of the following were present: age, >80; weight, <60 kg; or serum creatinine, >1.5 mg) was superior for safety (31%), efficacy (21%), and all-cause mortality (11%). In ENGAGE-AF TIMI 48, edoxaban 60 mg once daily (30 mg once daily if CrCl 30-50 ml/min, weight <60 kg, or concomitant verapamil or quinidine) was noninferior to W for efficacy, but reduced major bleeding (20%). To translate clinical trials to practice, understanding the disease and each anticoagulant is essential. For all novel agents, rapid anticoagulation, absence of monitoring, and a short half-life differentiate them from W. Bleed rates were either noninferior or lower than for W, without an antidote. Patient compliance is critical. Knowledge of renal function is essential and maintaining patients on therapy is key.

  4. Is an adjunctive subvalvular repair during mitral annuloplasty for secondary mitral regurgitation effective in preventing recurrent regurgitation?

    PubMed

    Mihos, Christos G; Santana, Orlando

    2016-02-01

    A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Is an adjunctive subvalvular repair during mitral annuloplasty for secondary mitral regurgitation effective in preventing recurrent regurgitation? Altogether, 353 studies were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. The best evidence regarding adjunctive subvalvular repair during mitral annuloplasty for secondary mitral regurgitation was from retrospective analyses. The studies reported outcomes of mitral valve repair (MVr) with annuloplasty alone (ring MVr) versus adjunctive papillary muscle approximation (PMA; n = 3), papillary muscle relocation (PMR; n = 3), secondary chordal cutting (n = 2) and PMA + PMR (n = 1). All but one study included concomitant coronary artery bypass grafting, whereas additional ventriculoplasty was performed in three studies. Follow-up ranged from 1 month to 5 years. The performance of PMA was associated with a lower mitral regurgitation (MR) grade when combined with ventriculoplasty in one study, whereas a greater improvement in left ventricular end-diastolic diameter and left ventricular ejection fraction at follow-up was observed with PMA alone in a separate study. Three studies of ring + PMR reported a reduction in ≥ 2+ recurrent MR, whereas two studies also observed a greater reduction in left ventricular end-diastolic diameter. The two studies on secondary chordal cutting reported a lower MR grade, lower recurrence of ≥ 2+ MR and a greater left ventricular ejection fraction at follow-up. Combining PMA + PMR + ventriculoplasty significantly reduced left ventricular end-systolic volume index at short-term follow-up in one study. Finally, none of the studies reported a significant difference in

  5. From efficacy in trials to effectiveness in clinical practice: The Swedish Stroke Prevention Study.

    PubMed

    Brunström, Mattias; Dahlström, John; Lindholm, Lars Hjalmar; Lönnberg, Göran; Hallström, Sara; Norberg, Margareta; Nyström, Lennarth; Persson, Mats; Weinehall, Lars; Carlberg, Bo

    2016-08-01

    Blood pressure treatment has shown great efficacy in reducing cardiovascular events in randomized controlled trials. If this is effective in reducing cardiovascular disease in the general population, is less studied. Between 2001 and 2009 we performed an intervention to improve blood pressure control in the county of Västerbotten, using Södermanland County as a control. The intervention was directed towards primary care physicians and included lectures on blood pressure treatment, a computerized decision support system with treatment recommendations, and yearly feed back on hypertension control. Each county had approximately 255 000 inhabitants. Differences in age and incidence of cardiovascular disease were small. During follow-up, more than 400 000 patients had their blood pressure recorded. The mean number of measurements was eight per patient, yielding a total of 3.4 million blood pressure recordings. The effect of the intervention will be estimated combining the blood pressure data collected from the electronic medical records, with data on stroke, myocardial infarction and mortality from Swedish health registers. Additional variables, from health registers and Statistics Sweden, will be collected to address for confounders. The blood pressure data collected within this study will be an important asset for future epidemiological studies within the field of hypertension.

  6. Heart Failure in Acute Ischemic Stroke

    PubMed Central

    Cuadrado-Godia, Elisa; Ois, Angel; Roquer, Jaume

    2010-01-01

    Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Due to the aging of the population it has become a growing public health problem in recent decades. Diagnosis of HF is clinical and there is no diagnostic test, although some basic complementary testing should be performed in all patients. Depending on the ejection fraction (EF), the syndrome is classified as HF with low EF or HF with normal EF (HFNEF). Although prognosis in HF is poor, HFNEF seems to be more benign. HF and ischemic stroke (IS) share vascular risk factors such as age, hypertension, diabetes mellitus, coronary artery disease and atrial fibrillation. Persons with HF have higher incidence of IS, varying from 1.7% to 10.4% per year across various cohort studies. The stroke rate increases with length of follow-up. Reduced EF, independent of severity, is associated with higher risk of stroke. Left ventricular mass and geometry are also related with stroke incidence, with concentric hypertrophy carrying the greatest risk. In HF with low EF, the stroke mechanism may be embolism, cerebral hypoperfusion or both, whereas in HFNEF the mechanism is more typically associated with chronic endothelial damage of the small vessels. Stroke in patients with HF is more severe and is associated with a higher rate of recurrence, dependency, and short term and long term mortality. Cardiac morbidity and mortality is also high in these patients. Acute stroke treatment in HF includes all the current therapeutic options to more carefully control blood pressure. For secondary prevention, optimal control of all vascular risk factors is essential. Antithrombotic therapy is mandatory, although the choice of a platelet inhibitor or anticoagulant drug depends on the cardiac disease. Trials are ongoing to evaluate anticoagulant therapy for prevention of embolism in patients with low EF who are at

  7. Epidemiology of stroke in Europe and trends for the 21st century.

    PubMed

    Béjot, Yannick; Bailly, Henri; Durier, Jérôme; Giroud, Maurice

    2016-12-01

    Despite major improvements in primary prevention and acute treatment over the last decades, stroke is still a devastating disease. At the beginning of the 21st century, the age-standardized incidence of stroke in Europe ranged from 95 to 290/100,000 per year, with one-month case-fatality rates ranging from 13 to 35%. Approximately 1.1 million inhabitants of Europe suffered a stroke each year, and ischemic stroke accounted for approximately 80% of cases. Although global stroke incidence is declining, rates observed in young adults are on the rise, thus suggesting a need for strategies to improve prevention. In addition, because of the ageing population, the absolute number of stroke is expected to dramatically increase in coming years: by 2025, 1.5 million European people will suffer a stroke each year. Beyond vital prognosis, stroke patients are also at increased risk of poor outcome within the first year of the event including re-hospitalisation (33%), recurrent event (7 to 13%), dementia (7 to 23%) mild cognitive disorder (35 to 47%), depression (30 to 50%), and fatigue (35% to 92%), all of them contributing to affect health related quality of life. Given these observations, an urgent development of acute care provision, as well as resources for post-stroke therapeutic strategies, is needed.

  8. Cost and Outcome in Pediatric Ischemic Stroke.

    PubMed

    Hamilton, William; Huang, Haijuan; Seiber, Eric; Lo, Warren

    2015-10-01

    The cost of childhood stroke receives little notice. The authors examined potential drivers of cost and outcome to test whether (1) neonatal strokes cost less than childhood strokes, (2) associated diseases influence cost, (3) arterial ischemic stroke is more costly than sinovenous thrombosis, and (4) cost correlates with outcome. The authors reviewed records of 111 children who sustained arterial ischemic stroke or sinovenous thrombosis between 2005 and 2010 to identify costs for the following year. They assessed outcomes in 46 with the Recovery and Recurrence Questionnaire and the Pediatric Quality of Life Inventory. Neonatal strokes cost less than childhood stroke. Strokes associated with congenital heart disease or vasculopathy cost the most, while perinatal or idiopathic strokes cost the least. Higher costs are correlated with worse impairment and poorer quality of life. Stroke etiology significantly influences the cost of pediatric stroke. Future cost-benefit studies must consider etiology when estimating the incremental costs associated with stroke.

  9. [Good practice in occupational health services--Certification of stroke as an accident at work. Need for secondary prevention in people returning to work after acute cerebrovascular events].

    PubMed

    Marcinkiewicz, Andrzej; Walusiak-Skorupa, Jolanta

    2015-01-01

    The classification of an acute vascular episode, both heart infarct and stroke, as an accident at work poses difficulties not only for post accidental teams, but also to occupational health professionals, experts and judges at labor and social insurance courts. This article presents the case of a 41-year-old office worker, whose job involved client services. While attending a very aggressive customer she developed solid stress that resulted in symptoms of the central nervous system (headache, speech disturbances). During her hospitalisation at the neurological unit ischemic stroke with transient mixed type aphasia was diagnosed. Magnetic resonance imaging (MRI) scan of the head revealed subacute ischemia. After an analysis of the accident circumstances, the employer's post accidental team decided that ischemic stroke had been an accident at work, because it was a sudden incident due to an external cause inducing work-related traumatic stroke. As a primary cause tough stress and emotional strain due to the situation developed while attending the customer were acknowledged. During control medical check up after 5 months the patient was found to be fit for work, so she could return to work. However, it should be noted that such a check up examination of subjects returning to work after stroke must be holistic, including the evaluation of job predispositions and health education aimed at secondary prevention of heart and vascular diseases with special reference to their risk factors.

  10. Poor stroke-related risk factor control even after stroke: an opportunity for rehabilitation professionals.

    PubMed

    Ellis, Charles; Breland, Hazel L

    2014-01-01

    The burden of chronic disease worldwide is substantial. Unfortunately, risk factor control for most chronic diseases remains poor even after diagnoses. This is a major concern because poor risk factor control often leads to secondary consequences of the disease and the development of co-existing diseases. Stroke is a chronic condition that frequently requires the services of rehabilitation professionals who can also play an important role in risk factor management to reduce recurrent stroke. Approaches to the management of stroke risk factors in stroke survivors vary greatly and consequently outcomes vary in a similar fashion. The current literature suggests that uniform offering of structured risk factor control programs over time to individuals with chronic disease can improve knowledge of stroke risk factors, knowledge of action to control risk factors and in turn facilitate self-management practices that reduce the negative consequences of chronic diseases. Rehabilitation professionals can play a vital role in the management and secondary prevention of chronic diseases during the rehabilitation process via patient education and training. Implications for Rehabilitation Evidence suggests that risk factor control remains poor in many individuals with chronic conditions such as stroke. Rehabilitation professionals can play a key role in programs designed to improve risk factor control in chronic conditions. Future risk factor control programs can be structured and implemented over time to include rehabilitation professionals.

  11. Oral anticoagulants for primary prevention, treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis.

    PubMed Central

    Sterne, Jonathan Ac; Bodalia, Pritesh N; Bryden, Peter A; Davies, Philippa A; López-López, Jose A; Okoli, George N; Thom, Howard Hz; Caldwell, Deborah M; Dias, Sofia; Eaton, Diane; Higgins, Julian Pt; Hollingworth, Will; Salisbury, Chris; Savović, Jelena; Sofat, Reecha; Stephens-Boal, Annya; Welton, Nicky J; Hingorani, Aroon D

    2017-01-01

    BACKGROUND Warfarin is effective for stroke prevention in atrial fibrillation (AF), but anticoagulation is underused in clinical care. The risk of venous thromboembolic disease during hospitalisation can be reduced by low-molecular-weight heparin (LMWH): warfarin is the most frequently prescribed anticoagulant for treatment and secondary prevention of venous thromboembolism (VTE). Warfarin-related bleeding is a major reason for hospitalisation for adverse drug effects. Warfarin is cheap but therapeutic monitoring increases treatment costs. Novel oral anticoagulants (NOACs) have more rapid onset and offset of action than warfarin, and more predictable dosing requirements. OBJECTIVE To determine the best oral anticoagulant/s for prevention of stroke in AF and for primary prevention, treatment and secondary prevention of VTE. DESIGN Four systematic reviews, network meta-analyses (NMAs) and cost-effectiveness analyses (CEAs) of randomised controlled trials. SETTING Hospital (VTE primary prevention and acute treatment) and primary care/anticoagulation clinics (AF and VTE secondary prevention). PARTICIPANTS Patients eligible for anticoagulation with warfarin (stroke prevention in AF, acute treatment or secondary prevention of VTE) or LMWH (primary prevention of VTE). INTERVENTIONS NOACs, warfarin and LMWH, together with other interventions (antiplatelet therapy, placebo) evaluated in the evidence network. MAIN OUTCOME MEASURES Efficacy Stroke, symptomatic VTE, symptomatic deep-vein thrombosis and symptomatic pulmonary embolism. Safety Major bleeding, clinically relevant bleeding and intracranial haemorrhage. We also considered myocardial infarction and all-cause mortality and evaluated cost-effectiveness. DATA SOURCES MEDLINE and PREMEDLINE In-Process & Other Non-Indexed Citations, EMBASE and The Cochrane Library, reference lists of published NMAs and trial registries. We searched MEDLINE and PREMEDLINE In-Process & Other Non-Indexed Citations, EMBASE and The

  12. Psychoneuroimmunology of stroke.

    PubMed

    Skinner, Robert; Georgiou, Rachel; Thornton, Peter; Rothwell, Nancy

    2009-05-01

    Stroke is the major cause of disability in the Western world and is the third greatest cause of death, but there are no widely effective treatments to prevent the devastating effects of stroke. Extensive and growing evidence implicates inflammatory and immune processes in the occurrence of stroke and particularly in the subsequent injury. Several inflammatory mediators have been identified in the pathogenesis of stroke including specific cytokines, adhesion molecules, matrix metalloproteinases, and eicosanoids. An early clinical trial suggests that inhibiting interleukin-1 may be of benefit in the treatment of acute stroke.

  13. Radiation therapy for favorable histology Wilms tumor: Prevention of flank recurrence did not improve survival on National Wilms Tumor Studies 3 and 4

    SciTech Connect

    Breslow, Norman E. . E-mail: norm@u.washington.edu; Beckwith, J. Bruce; Haase, Gerald M.; Kalapurakal, John A.; Ritchey, Michael L.; Shamberger, Robert C.; Thomas, Patrick; D'Angio, Giulio J.; Green, Daniel M.

    2006-05-01

    Purpose: To determine whether radiation therapy (RT) of patients with Wilms tumor of favorable histology prevented flank recurrence and thereby improved the survival outcomes. Methods and Materials: Recurrence and mortality risks were compared among groups of patients with Stage I-IV/favorable histology Wilms tumor enrolled in the third (n = 1,640) and fourth (n = 2,066) National Wilms Tumor Study Group studies. Results: Proportions of patients with flank recurrence were 0 of 513 = 0.0% for 20 Gy, 12 of 805 = 1.5% for 10 Gy, and 44 of 2,388 = 1.8% for no flank RT (p trend 0.001 adjusted for stage and doxorubicin); for intra-abdominal (including flank) recurrence they were 5 of 513 = 1.0%, 30 of 805 = 3.7%, and 58 of 2,388 = 2.4%, respectively (p trend = 0.02 adjusted). Survival percentages at 8 years after intra-abdominal recurrence were 0 of 5 = 0% for 20 Gy, 10 of 30 = 33% for 10 Gy, and 34 of 58 = 56% for no RT (p trend = 0.0001). NWTS-4 discontinued use of 20 Gy RT, and the 8-year flank recurrence risk increased to 2.1% from 1.0% on NWTS-3 (p = 0.013). However, event-free survival was unaltered (88% vs. 86%, p = 0.39), and overall survival was better (93.8% vs. 90.8%, p = 0.036) on NWTS-4. Conclusions: Partly because of lower postrecurrence mortality among nonirradiated patients, prevention of flank recurrence by RT did not improve survival. It is important to evaluate entire treatment policies with regard to long-term outcomes.

  14. Preventing stroke: a narrative review of community interventions for improving hypertension control in black adults.

    PubMed

    Connell, Patricia; Wolfe, Charles; McKevitt, Christopher

    2008-03-01

    Incidence rates for stroke and hypertension are higher in black ethnic groups of African descent in the USA and UK than in white groups, suggesting a need for targeted intervention. We conduct a narrative review of published research evidence on community interventions to manage hypertension among black ethnic groups, and explore the concept of cultural sensitivity in these interventions. Data sources comprised computer-aided searches of published studies over the years 1981 to March 2006, on community strategies for improving hypertension control targeting black groups, and further references from these articles. Twenty-seven relevant studies were identified. Health education was associated with improvements in knowledge about hypertension, while education combined with individualised support for patients to self-manage hypertension, including goal setting and monitoring to enhance patient self-management of hypertension, and family support in managing hypertension were associated with reductions in blood pressure levels and improvements in blood pressure control. Collaboration with black communities, using local or minority ethnic staff, conducting preliminary research with target groups to investigate perceptions and canvass ideas for the intervention design were common methods assumed to achieve cultural sensitivity. Studies, however, provided insufficient robust evidence of the effectiveness of these strategies in terms of quantifiable outcomes, although this criterion is contested, with social justice arguments being offered instead. Implicit assumptions about homogeneity and shared interests within the 'community', and representation of 'community' views have implications for the effectiveness of interventions. These findings highlight areas for the future development of interventions to reduce hypertension rates in black groups, and factors that need to be robustly investigated and explicitly addressed in intervention design.

  15. Rivaroxaban in the Prevention of Stroke and Systemic Embolism in Patients with Non-Valvular Atrial Fibrillation: Clinical Implications of the ROCKET AF Trial and Its Subanalyses.

    PubMed

    Spencer, Ryan J; Amerena, John V

    2015-12-01

    Atrial fibrillation (AF) is an increasingly common cause of stroke and systemic embolism. While warfarin has been the mainstay of stroke prevention in patients with AF, newer novel oral anticoagulant medications are now available. Rivaroxaban, a direct factor Xa inhibitor with a rapid onset and offset after oral administration, offers potential advantages over warfarin, predominantly due to its predictable pharmacokinetics across wide patient populations. It requires no coagulation monitoring, and only two different doses are needed (20 mg daily for patients with normal renal function and 15 mg daily in those with reduced renal function). A large randomized trial (ROCKET AF) has shown non-inferiority to warfarin for preventing stroke or systemic embolism in the per-protocol population and superiority to warfarin in the on-treatment safety population. Several subanalyses confirm that the treatment effect of rivaroxaban is consistent across different patient subgroups, including those with reduced renal function. The tolerability of rivaroxaban appears similar to that of warfarin, with comparable overall bleeding rates in clinical trials. In ROCKET AF, significantly lower rates of fatal and intracranial bleeding were seen with rivaroxaban, while lower rates of gastrointestinal bleeding were seen with warfarin. Important contraindications to rivaroxaban include valvular AF, the presence of a prosthetic valve (mechanical or bioprosthetic) or valve repair, the need for concurrent dual antiplatelet therapy, and creatinine clearance <30 ml/min. Once-daily dosing and the lack of coagulation monitoring may increase utilization and adherence compared with warfarin, potentially decreasing the large burden of care associated with stroke secondary to AF. Overall, rivaroxaban offers a useful alternative to warfarin for stroke prevention in patients with AF.

  16. Effects of Blood Pressure Targets in Patients with Recent Lacunar Stroke

    PubMed Central

    2014-01-01

    BACKGROUND Lowering blood pressure (BP) prevents stroke, however optimal target levels of blood reduction to prevent stroke recurrence are lacking. We hypothesized that targeting systolic BP of <130 mmHg would reduce stroke recurrence in patients with recent lacunar stroke. METHODS The Secondary Prevention of Small Subcortical Strokes (SPS3) was a multi-center international trial, involving 3020 patients with recent symptomatic MRI-defined lacunar infarcts randomized to two target levels of systolic BP: a) higher group 130–149 mm Hg vs. b) lower group <130 mm Hg, and followed for a mean of 3.7 years. The primary outcome was all recurrent stroke (including ischemic strokes and intracranial hemorrhages). The study is registered, NCT 00059306. FINDINGS Mean participant age was 63 years; after 1 year mean systolic BP was 138 mm Hg (95% CI 137 to 139) in the higher group and 127 mm Hg (95% CI, 126 to 128) in the lower group. At last study visit, the difference in systolic BP between groups averaged 11 mm Hg (±SD 16). The annualized rate of recurrent stroke in the higher target group was 2.77% (n=152) compared with 2.25% (n=125) in the lower target group (HR 0.81, 95% CI 0.64, 1.03, p-value 0.08). Similar trends were observed for reductions in disabling/fatal stroke (HR 0.81, 95%CI 0.53, 1.23, p-value 0.32) and in the composite outcome of stroke, myocardial infarct or vascular death (HR 0.84, 95%CI 0.68,1.01, p-value 0.10). Intracerebral hemorrhage was reduced by 63% in those assigned to the lower target group (HR 0.37 95% CI, 0.14, 0.89, p-value 0.03). Serious complications of BP lowering were in frequent, and not significantly different in frequency between groups. INTERPRETATION In patients with recent lacunar stroke, targeting asystolic BP of< 130 mm Hg did not significantly reduce all stroke, but markedly reduced intracerebral hemorrhage. The lower target was safe and well tolerated. PMID:23726159

  17. Short-term green tea supplementation prevents recognition memory deficits and ameliorates hippocampal oxidative stress induced by different stroke models in rats.

    PubMed

    Altermann, Caroline Dalla Colletta; Souza, Mauren Assis; Schimidt, Helen L; Izaguirry, Aryele Pinto; Martins, Alexandre; Garcia, Alexandre; Santos, Francielli W; Mello-Carpes, Pâmela B

    2017-03-19

    This study investigated the effect of green tea (GT) on short and long term declarative memory and oxidative damage induced by transient ischemia-reperfusion (IR) and intracerebral hemorrhage (ICH) in rats. Male Wistar rats were divided into 8 groups of 10 according the stroke type induced: Sham IR, Sham IR+GT, IR, IR+GT, Sham ICH, Sham ICH+GT, ICH, ICH+GT. Supplementation with GT was initiated 10days before stroke surgery and continuous for 6days after (GT dose 400mg/kg). Short (STM) and long term memory (LTM) we evaluated with object recognition task (OR) and hippocampus were used to evaluate parameters related to oxidative stress (ROS, lipid peroxidation and total antioxidant capacity). The rats subjected to IR and ICH showed STM and LTM deficits and GT intervention prevented it in both stroke models. IR and ICH induced increase on ROS levels in hippocampus. ICH increased the lipid peroxidation in hippocampus and the GT supplementation avoided it. IR induced decrease on total antioxidant capacity and GT prevented it. These results reveal that GT supplementation presents a neuroprotective role, attenuates redox imbalance and might have a beneficial impact on cognitive function after stroke.

  18. The Migraine–Stroke Connection

    PubMed Central

    Lee, Mi Ji; Lee, Chungbin; Chung, Chin-Sang

    2016-01-01

    Migraine and stroke are common neurovascular disorders which share underlying physiological processes. Increased risks of ischemic stroke, hemorrhagic stroke, and subclinical ischemic lesions have been consistently found in migraineurs. Three possible associations are suggested. One is that underlying pathophysiology of migraine can lead to ischemic stroke. Second, common comorbidities between migraine and stroke can be present. Lastly, some syndromes can manifest with both migraine-like headache and cerebrovascular disease. Future studies should be targeted on bidirectional influence of migraine on different stroke mechanisms and optimal prevention of stroke in migraine patients. PMID:27283278

  19. Efficacy of Bacillus clausii spores in the prevention of recurrent respiratory infections in children: a pilot study.

    PubMed

    Marseglia, Gian Luigi; Tosca, Mariangela; Cirillo, Ignazio; Licari, Amelia; Leone, Maddalena; Marseglia, Alessia; Castellazzi, Anna Maria; Ciprandi, Giorgio

    2007-03-01

    Probiotic milk has been previously demonstrated to reduce the number of respiratory infections (RI) among children attending day care centres. Thus, this pilot study was aimed to assess the efficacy and the safety of 3 month treatment with Bacillus clausii in the prevention of recurrent respiratory infections (RRI) in children. Eighty children with RRI were studied: 40 of them were randomly treated with B. clausii for 3 months, and followed up for further 3 months; 40 were included in the control group during the same period. Children treated with B. clausii had shorter duration of RI in comparison with the control group both during the treatment phase (mean 11.7 days vs 14.37; p=0.037) and the follow-up period (mean 6.6 days vs 10.92; p=0.049). This effect was evident also in allergic children during the follow-up. In conclusion, this pilot study provides the first preliminary evidence that B. clausii may exert a significant and persistent impact on RI in children and is safe and well tolerated.

  20. Therapy with the Combination of Amlodipine and Irbesartan Has Persistent Preventative Effects on Stroke Onset Associated with BDNF Preservation on Cerebral Vessels in Hypertensive Rats.

    PubMed

    Hasegawa, Yu; Nakagawa, Takashi; Uekawa, Ken; Ma, Mingjie; Lin, Bowen; Kusaka, Hiroaki; Katayama, Tetsuji; Sueta, Daisuke; Toyama, Kensuke; Koibuchi, Nobutaka; Kim-Mitsuyama, Shokei

    2016-02-01

    Although calcium channel blockers, angiotensin II receptor blockers, and combination therapy are effective for hypertensive patients, the significant differences among them against stroke onset are undetermined. In this study, we investigated the significant beneficial effects of the combination therapy using amlodipine and irbesartan against stroke onset in hypertensive rats. The animals were fed an 8% sodium diet and assigned to (1) vehicle, (2) amlodipine (2 mg/kg/day), (3) irbesartan (20 mg/kg/day), and (4) amlodipine + irbesartan groups. The drugs were given orally until 35 days, and incidences of stroke-related signs and mortality and blood pressure (BP) were monitored. Cerebral blood flow (CBF), brain water content, weight of the brain and left ventricle, and histological evaluations were conducted for the treated groups at 42 days after the start of the high-salt diet. Amlodipine and the combination therapy significantly reduced BP compared with the vehicle. Although the rates of stroke-related signs and mortality were high in the vehicle group, the rats in the treatment groups were mostly healthy until 35 days. After all drugs were discontinued, stroke onset was frequently seen in the monotherapy groups until 42 days, but no signs were observed in the combination therapy group. Although there were no significant differences in CBF or brain edema, the combination therapy reduced blood-brain barrier disruption, white matter injury, and reactive astrocytes compared with irbesartan, and the combination also inhibited left ventricular hypertrophy and preserved brain-derived neurotrophic factor (BDNF) expression on cerebral vessels compared to the monotherapies. These data suggest that the combination therapy had a persistent preventive effect on stroke onset in hypertensive rats, and the effects might be associated with BDNF preservation on cerebral vessels.

  1. Atrial Fibrillation Identified During Echocardiography in a Patient with Recurrent Cardioembolic Events: A Case Report

    PubMed Central

    Christia, Panagiota; Katsa, Ioanna; Ocava, Lenore; Faillace, Robert

    2016-01-01

    Patient: Female, 80 Final Diagnosis: Stroke Symptoms: Weakness • left sided Medication: — Clinical Procedure: Echocardiogram Specialty: Naurology Objective: Unusual clinical course Background: Stroke is the major cause of disability and the fifth leading cause of death in the United States. In 30–40% of strokes the etiology remains uncertain or unknown. Identifying the cause of a cerebrovascular event offers the opportunity for an intervention that may decrease the risk of future stroke and thus prevent the resultant impairment. Case Report: We report the case of an 80-year-old African American woman with a prior right middle cerebral artery stroke, who presented to the hospital with new left-sided weakness and was found to have a new right-sided frontal lobe infarct. Twenty-four hour Holter monitoring performed during this hospitalization and prior 24-h electrocardiogram (ECG) recording did not reveal an arrhythmia. However, the patient was found to have an isolated episode of atrial fibrillation (AF) during an echocardiogram as part of the evaluation for stroke etiology. Conclusions: AF is an important and treatable cause of recurrent stroke and needs to be ruled out by thorough evaluation before the diagnosis of cryptogenic stroke is assigned. Despite meticulous diagnostic work-up, many strokes caused by paroxysmal AF remain undetected and longer ECG monitoring (>24 h) may be required. PMID:26932564

  2. Randomized, Placebo-Controlled Phase 2 Trial of a Lactobacillus crispatus Probiotic Given Intravaginally for Prevention of Recurrent Urinary Tract Infection

    PubMed Central

    Au-Yeung, Melissa; Hooton, Thomas M.; Fredricks, David N.; Roberts, Pacita L.; Czaja, Christopher A.; Yarova-Yarovaya, Yuliya; Fiedler, Tina; Cox, Marsha; Stamm, Walter E.

    2011-01-01

    Background. Urinary tract infections (UTIs) are common among women and frequently recur. Depletion of vaginal lactobacilli is associated with UTI risk, which suggests that repletion may be beneficial. We conducted a double-blind placebo-controlled trial of a Lactobacillus crispatus intravaginal suppository probiotic (Lactin-V; Osel) for prevention of recurrent UTI in premenopausal women. Methods. One hundred young women with a history of recurrent UTI received antimicrobials for acute UTI and then were randomized to receive either Lactin-V or placebo daily for 5 d, then once weekly for 10 weeks. Participants were followed up at 1 week and 10 weeks after intervention and for UTIs; urine samples for culture and vaginal swabs for real-time quantitative 16S ribosomal RNA gene polymerase chain reaction for L. crispatus were collected. Results. Recurrent UTI occurred in 7/48 15% of women receiving Lactin-V compared with 13/48 27% of women receiving placebo (relative risk [RR], .5; 95% confidence interval, .2–1.2). High-level vaginal colonization with L. crispatus (≥106 16S RNA gene copies per swab) throughout follow-up was associated with a significant reduction in recurrent UTI only for Lactin-V (RR for Lactin-V, .07; RR for placebo, 1.1; P < .01). Conclusions. Lactin-V after treatment for cystitis is associated with a reduction in recurrent UTI. Larger efficacy trials of this novel preventive method for recurrent UTI are warranted. Clinical Trials Registration. NCT00305227. PMID:21498386

  3. [THE IMPORTANCE OF ANTICOAGULANT THERAPY IN PATIENTS WITH ARTIAL FIBRILLATION IN STROKE PREVENTION--SUMMARY OF INTERNATIONAL DATA AND NOVEL THERAPEUTIC MODALITIES].

    PubMed

    Mirolovics, Ágnes; Papp, Csaba; Zsuga, Judit; Bereczki, Dániel

    2016-03-30

    The most common cardiogenic cause of ischaemic stroke is atrial fibrillation which increases the probability of stroke five-fold and doubles case fatality. Based on international data the incidence of atrial fibrillation is approx. 2% however this rapidly increases with age. The necessity of using oral anticoagulants in the prevention of non-valvular atrial fibrillation related stroke is decided based on estimated stroke risk. The CHADS2 and the more predictive CHA2DS2-VASc scales are used for this purpose while the bleeding risk of patients treated with anticoagulant may be estimated by the HAS-BLED scoring scale. For decades oral anticoagulation meant using vitamin-K antagonists. Based on international data we can see that rate of anticoagulation is unacceptably low, furthermore most of the anticoagulated patients aren't within the therapeutic range of INR (INR: 2-3). A lot of disadvantages of vitamin-K antagonists are known (e.g. food-drug interaction, need for regular coagulation monitoring, increased risk of bleeding), therefore compounds with new therapeutic target have been developed. The novel oral anticoagulants (NOAC) can be divided in two major subgroups: direct thrombin inhibitors (dabigatran etexilate) and Xa-factor inhibitors (rivaroxaban, apixaban, edoxaban). These products are administered in fix doses, they less frequently interact with other medications or food, and regular coagulation monitoring is not needed when using these drugs. Moreover several studies have shown that they are at least as effective in the prevention of ischaemic stroke than the vitamin-K antagonists, with no more haemorrhagic complications.

  4. Train the vessel, gain the brain: physical activity and vessel function and the impact on stroke prevention and outcome in cerebrovascular disease.

    PubMed

    Schmidt, Wolf; Endres, Matthias; Dimeo, Fernando; Jungehulsing, Gerhard J

    2013-01-01

    The burden of cerebrovascular disease (CVD) is huge and therapeutic options are limited. Physical activity is effective in preventing coronary heart and peripheral artery disease both experimentally and clinically. It is likely that the protective effects of exercise can be extended to both CVD and cognitive impairment. The pleiotropic protective and preventive mechanisms induced by physical activity include increased perfusion as well as mechanisms of collateral recruitment and neovascularization mediated by arterio- and angiogenesis. Physical activity increases the bioavailability of nitric oxide, bone marrow-derived CD34+ cells and growth factors, all of which promote neovascularization. Additionally, shear stress is discussed as a potential mechanism for vessel growth. Moreover, physical activity plays a role in endothelial function and cerebral autoregulation in small- and large-artery CVD. The vascular niche hypothesis highlights the complex interactions of neuro- and angiogenesis for regenerative and repair mechanisms in the human brain. Experimental and clinical studies demonstrate the positive impact of prior physical activity on stroke lesion size and on outcome after stroke. Clinical trials are necessary to further address the impact of physical activity on primary and secondary stroke prevention, outcome and cognitive function.

  5. Stroke: New Developments and Their Application in Clinical Practice.

    PubMed

    Kelly, Peter J; Kavanagh, Eoin; Murphy, Sean

    2016-08-01

    Significant advances have been made in recent years in primary stroke prevention, improved stroke outcomes in high-income populations, emergency stroke therapy, and stroke prevention. In this article, we review recent trends in stroke epidemiology, improvements in delivery of intravenous thrombolysis (via stroke system-wide approaches, application of 'Lean Principles' to improve workflow processes, and re-evaluation of exclusion criteria), recent stroke thrombectomy trials, and new developments in stroke prevention, with emphasis on risk prediction in transient ischemic attack, choice and timing of anticoagulation therapy for secondary stroke prevention, and emerging concepts in risk stratification for management of symptomatic carotid stenosis.

  6. Two doses of rivaroxaban versus aspirin for prevention of recurrent venous thromboembolism. Rationale for and design of the EINSTEIN CHOICE study.

    PubMed

    Weitz, Jeffrey I; Bauersachs, Rupert; Beyer-Westendorf, Jan; Bounameaux, Henri; Brighton, Timothy A; Cohen, Alexander T; Davidson, Bruce L; Holberg, Gerlind; Kakkar, Ajay; Lensing, Anthonie W A; Prins, Martin; Haskell, Lloyd; van Bellen, Bonno; Verhamme, Peter; Wells, Philip S; Prandoni, Paolo

    2015-08-31

    Patients with unprovoked venous thromboembolism (VTE) are at high risk for recurrence. Although rivaroxaban is effective for extended VTE treatment at a dose of 20 mg once daily, use of the 10 mg dose may further improve its benefit-to-risk ratio. Low-dose aspirin also reduces rates of recurrent VTE, but has not been compared with anticoagulant therapy. The EINSTEIN CHOICE study is a multicentre, randomised, double-blind, active-controlled, event-driven study comparing the efficacy and safety of two once daily doses of rivaroxaban (20 and 10 mg) with aspirin (100 mg daily) for the prevention of recurrent VTE in patients who completed 6-12 months of anticoagulant therapy for their index acute VTE event. All treatments will be given for 12 months. The primary efficacy objective is to determine whether both doses of rivaroxaban are superior to aspirin for the prevention of symptomatic recurrent VTE, while the principal safety outcome is the incidence of major bleeding. The trial is anticipated to enrol 2,850 patients from 230 sites in 31 countries over a period of 27 months. In conclusion, the EINSTEIN CHOICE study will provide new insights into the optimal antithrombotic strategy for extended VTE treatment by comparing two doses of rivaroxaban with aspirin (clinicaltrials.gov NCT02064439).

  7. Antifibrotic medication using a combination of N-acetyl-L-cystein (NAC) and ACE inhibitors can prevent the recurrence of Dupuytren's disease.

    PubMed

    Knobloch, Karsten; Redeker, Joern; Vogt, Peter M

    2009-11-01

    Dupuytren's disease is a progress fibromatosis of unknown origin first described in 1831. Nonoperative treatment options have been suggested involving radiation therapy, vitamin E, local injection therapy suing calcium channel blockers, interferon, corticosteroids or collagenase. Transforming growth factor-beta1 (TGF-beta1) and its downstream Smad signalling system is well established as a key player during fibrogenesis. A number of in vitro experiments have been assessed the blockade of TGF-beta1 and TGF-beta 2. Clinically, a number of antifibrotic agents are available such as N-acetyl-L-cysteins (NAC) as well as angiotensin-converting enzyme (ACE) inhibitors or AT II antagonists. However, to date none of the well known substances has been tested clinically in fibromatosis such as Dupuytren's disease especially to prevent recurrences after surgical release. Antifibrotic medication using a combination of N-acetyl-L-cystein (NAC) and ACE inhibitor can prevent the recurrence of Dupyutren's disease. Given the fact that recurrence rate in Dupuytren's disease is high and unpredictable after surgical release, an antifibrotic intervention might be worthwhile to consider in the clinical setting. Antifibrotic agents inhibit TGF-beta1, which play a key role in fibromatosis. Thus, antifibrotic medication might reduce the recurrence rate in fibromatosis such as Dupuytren's disease in a clinical significant way.

  8. Fungus Infections: Preventing Recurrence

    MedlinePlus

    ... place for these spores to collect is in shoes. Therefore, after effective treatment, a fungus may recur ... feet clean, cool and dry. Change socks. Wear shoes that "breathe" like leather, rather than plastic. Make ...

  9. Ischemic Stroke

    MedlinePlus

    A stroke is a medical emergency. There are two types - ischemic and hemorrhagic. Ischemic stroke is the most common type. It is usually ... are at risk for having a more serious stroke. Symptoms of stroke are Sudden numbness or weakness ...

  10. Primary stroke prevention for sickle cell disease in north-east Italy: the role of ethnic issues in establishing a Transcranial Doppler screening program

    PubMed Central

    Colombatti, Raffaella; Meneghetti, Giorgio; Ermani, Mario; Pierobon, Marta; Sainati, Laura

    2009-01-01

    Background Stroke is a serious complication of sickle cell disease (SCD) in children. Transcranic Doppler (TCD) is a well-established predictor of future cerebrovascular symptoms: a blood flow velocity >200 cm/sec in the Middle Cerebral Artery (MCA) correlates with a high risk of stroke in cohorts of African-american HbS/HbS patients. In North-East Italy the recent increase in SCD patients is mainly due to immigration from Africa. A comprehensive care program for children with SCD was established in our Center since 2004, but a wide and routine screening for Primary stroke prevention needs to be developed. Methods In order to verify the feasibility of TCD and Transcranial color coded Sonography (TCCS) screening in our setting and the applicability of international reference values of blood velocities to our population of African immigrants with HbS/HbS SCD, we performed TCD and TCCD in 12 HbS/HbS African children and two groups of age-matched controls of Caucasian and African origin respectively. TCD and TCCS were performed on the same day of the scheduled routine hematologic visit after parental education. Results All parents accepted to perform the sonography to their children. TCD and TCCD were performed in all patients and an adequate temporal window could be obtained in all of them. Pulsatility index and depth values in both the MCA and the Basilar Artery (BA) were similar at TCD and TCCS evaluation in the three groups while time-average maximum velocities (TAMM), peak systolic velocity and diastolic velocity in the MCA and BA were higher in the patients' group on both TCD and TCCS evaluation. African and Caucasian healthy controls had similar lower values. Conclusion Our preliminary data set the base to further evaluate the implementation of a primary stroke prevention program in our setting of HbS/HbS African immigrants and HbS/beta thalassemia Italians. Parental education-preferably in the native language- on stroke risk and prevention in SCD increases

  11. Prevention of Recurrent Foot Ulcers With Plantar Pressure–Based In-Shoe Orthoses: The CareFUL Prevention Multicenter Randomized Controlled Trial

    PubMed Central

    Ulbrecht, Jan S.; Hurley, Timothy; Mauger, David T.

    2014-01-01

    OBJECTIVE To assess the efficacy of in-shoe orthoses that were designed based on shape and barefoot plantar pressure in reducing the incidence of submetatarsal head plantar ulcers in people with diabetes, peripheral neuropathy, and a history of similar prior ulceration. RESEARCH DESIGN AND METHODS Single-blinded multicenter randomized controlled trial with subjects randomized to wear shape- and pressure-based orthoses (experimental, n = 66) or standard-of-care A5513 orthoses (control, n = 64). Patients were followed for 15 months, until a study end point (forefoot plantar ulcer or nonulcerative plantar forefoot lesion) or to study termination. Proportional hazards regression was used for analysis. RESULTS There was a trend in the composite primary end point (both ulcers and nonulcerative lesions) across the full follow-up period (P = 0.13) in favor of the experimental orthoses. This trend was due to a marked difference in ulcer occurrence (P = 0.007) but no difference in the rate of nonulcerative lesions (P = 0.76). At 180 days, the ulcer prevention effect of the experimental orthoses was already significant (P = 0.003) when compared with control, and the benefit of the experimental orthoses with respect to the composite end point was also significant (P = 0.042). The hazard ratio was 3.4 (95% CI 1.3–8.7) for the occurrence of a submetatarsal head plantar ulcer in the control compared with experimental arm over the duration of the study. CONCLUSIONS We conclude that shape- and barefoot plantar pressure–based orthoses were more effective in reducing submetatarsal head plantar ulcer recurrence than current standard-of-care orthoses, but they did not significantly reduce nonulcerative lesions. PMID:24760263

  12. Optical probes for molecular-guided surgery: Using photomedicine to prevent recurrence in the surgical bed (Conference Presentation)

    NASA Astrophysics Data System (ADS)

    Spring, Bryan Q.; Sears, R. Bryan; Zheng, Lei Z.; Mai, Zhiming; Watanabe, Reika; Villa, Elizabeth; Hasan, Tayyaba

    2016-03-01

    Residual tumor deposits missed by conventional treatments frequently seed local and distal recurrence utilizing a network of molecular signaling mechanisms. Beyond providing contrast for molecular-guided surgery, this talk will highlight new concepts in phototherapy to address residual cancer cells in danger zones of recurrence, including selective treatment of microscopic disease using molecular-targeted, activatable immunoconjugates, and photo-initiated release of multikinase inhibitors that suppress multiple modes of tumor escape using optically active nanoparticles. These new approaches support an expanded role for the use of light in fluorescence-guided surgery—for phototherapy and for focused drug release to maximize tumor debulking with suppression of disease recurrence.

  13. Efficacy and harms of direct oral anticoagulants in the elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: systematic review and meta-analysis

    PubMed Central

    Sharma, Manuj; Cornelius, Victoria R; Patel, Jignesh P; Davies, J Graham; Molokhia, Mariam

    2016-01-01

    Background Evidence regarding use of direct oral anticoagulants (DOACs) in the elderly, particularly bleeding risks, is unclear despite the presence of greater comorbidities, polypharmacy and altered pharmacokinetics in this age group. Methods and Results We performed a systematic review and meta-analysis of randomised trials of DOACs (dabigatran, apixaban, rivaroxaban, edoxaban) for efficacy and bleeding outcomes compared to VKA (vitamin k antagonists) in elderly participants (aged ≥75 years) treated for acute venous thromboembolism or stroke prevention in atrial fibrillation. Nineteen studies were eligible for inclusion but only 11 reported data specifically for elderly participants. Efficacy in managing thrombotic risks for each DOAC was similar or superior to VKA in the elderly. A non-significantly, higher risk of major bleeding than VKA was observed with dabigatran 150mg (Odds Ratio 1.18, 95% confidence interval 0.97-1.44) but not with the 110mg dose. Significantly higher gastrointestinal bleeding risks with dabigatran 150mg (1.78, 1.35-2.35) and 110mg (1.40, 1.04-1.90) and lower intracranial bleeding risks than VKA for dabigatran 150mg (0.43, 0.26-0.72) and dabigatran 110mg (0.36, 0.22-0.61) were also observed. A significantly lower major bleeding risk compared to VKA was observed for apixaban (0.63, 0.51-0.77), edoxaban 60mg (0.81, 0.67-0.98) and 30mg (0.46, 0.38-0.57) while rivaroxaban showed similar risk. Conclusion DOACs demonstrated at least equal efficacy to VKA in managing thrombotic risks in the elderly however bleeding patterns were distinct. In particular, dabigatran was associated with a higher risk of gastrointestinal bleeding than VKA. Insufficient published data for apixaban, edoxaban and rivaroxaban indicates further work is needed to clarify their bleeding risks in the elderly. PMID:25995317

  14. Modern strategies to prevent coronary sequelae and stroke in hypertensive patients differ from the JNC V Consensus Guidelines.

    PubMed

    Tobian, L; Brunner, H R; Cohn, J N; Gavras, H; Laragh, J H; Materson, B J; Weber, M A

    1994-10-01

    In recent years, government agencies of many countries have established consensus guidelines for the evaluation and treatment of hypertension. Once published, guidelines tend to be perceived as directives by a variety of health care providers. Unfortunately, these guidelines often do not reflect the practices of most hypertension experts. This report summarizes the opinions of seven hypertension experts concerning the impact of "official" guidelines on clinical practice. In addition, the individual therapeutic recommendations of these panel members are summarized. Their different treatment strategies reflect the diversity of first rate treatment plans that aim to reduce the cardiovascular sequelae in individual patients with essential hypertension. Most importantly, not one of these seven treatment strategies followed the "preferred" treatment of the U.S. guidelines, which recommend diuretics and beta-blockers as first-line therapy. The present authors approach the treatment of hypertension as a means to reduce cardiovascular events. Thus, reduction of blood pressure is not the most important therapeutic endpoint. The panel believes that whereas many different drugs can produce effective blood pressure reduction, the modern primary goal of antihypertensive drug therapy is to select a regimen most likely to prolong the quality and duration of life. In real terms, this means that the primary goal of treatment is the prevention of the major vascular sequelae of hypertension (heart attack, ventricular remodeling, hypertrophy, heart failure, and stroke) that shorten useful life. There are a number of effective hypertensive treatments, which can be selected based on individual patient requirements. However, many consensus guidelines do not allow the flexibility required to optimize individual patient treatment. As a result, health care providers should not feel compelled to regard the preferences of "official" guidelines as the best, modern, state-of-the-art therapy for

  15. Stroke prevention in atrial fibrillation and 'real world' adherence to guidelines in the Balkan Region: The BALKAN-AF Survey.

    PubMed

    Potpara, Tatjana S; Dan, Gheorghe-Andrei; Trendafilova, Elina; Goda, Artan; Kusljugic, Zumreta; Manola, Sime; Music, Ljilja; Musetescu, Rodica; Badila, Elisabeta; Mitic, Gorana; Paparisto, Vilma; Dimitrova, Elena S; Polovina, Marija M; Petranov, Stanislav L; Djergo, Hortensia; Loncar, Daniela; Bijedic, Amira; Brusich, Sandro; Lip, Gregory Y H

    2016-02-12

    Data on the management of atrial fibrillation (AF) in the Balkan Region are limited. The Serbian AF Association (SAFA) prospectively investigated contemporary 'real-world' AF management in clinical practice in Albania, Bosnia&Herzegovina, Bulgaria, Croatia, Montenegro, Romania and Serbia through a 14-week (December 2014-February 2015) prospective, multicentre survey of consecutive AF patients. We report the results pertinent to stroke prevention strategies. Of 2712 enrolled patients, 2663 (98.2%) with complete data were included in this analysis (mean age 69.1 ± 10.9 years, female 44.6%). Overall, 1960 patients (73.6%) received oral anticoagulants (OAC) and 762 (28.6%) received antiplatelet drugs. Of patients given OAC, 17.2% received non-vitamin K antagonist oral anticoagulants (NOACs). CHA2DS2-VASc score was not significantly associated with OAC use. Of the 'truly low-risk' patients (CHA2DS2-VASc = 0 [males], or 1 [females]) 56.5% received OAC. Time in Therapeutic Range (TTR) was available in only 18.7% of patients (mean TTR: 49.5% ± 22.3%). Age ≥ 80 years, prior myocardial infarction and paroxysmal AF were independent predictors of OAC non-use. Our survey shows a relatively high overall use of OAC in AF patients, but with low quality of vitamin K antagonist therapy and insufficient adherence to AF guidelines. Additional efforts are needed to improve AF-related thromboprophylaxis in clinical practice in the Balkan Region.

  16. Multifaceted implementation of stroke prevention guidelines in primary care: cluster‐randomised evaluation of clinical and cost effectiveness

    PubMed Central

    Wright, John; Bibby, John; Eastham, Joe; Harrison, Stephen; McGeorge, Maureen; Patterson, Chris; Price, Nick; Russell, Daphne; Russell, Ian; Small, Neil; Walsh, Matt; Young, John

    2007-01-01

    Objective To evaluate clinical and cost effectiveness of implementing evidence‐based guidelines for the prevention of stroke. Design Cluster‐randomised trial Setting Three primary care organisations in the North of England covering a population of 400 000. Participants Seventy six primary care teams in four clusters: North, South & West, City I and City II. Intervention Guidelines for the management of patients with atrial fibrillation and transient ischaemic attack (TIA) were developed and implemented using a multifaceted approach including evidence‐based recommendations, audit and feedback, interactive educational sessions, patient prompts and outreach visits. Outcomes Identification and appropriate treatment of patients with atrial fibrillation or TIA, and cost effectiveness. Results Implementation led to 36% increase (95% CI 4% to 78%) in diagnosis of atrial fibrillation, and improved treatment of TIA (odds ratio of complying with guidelines 1.8; 95% CI 1.1 to 2.8). Combined analysis of atrial fibrillation and TIA estimates that compliance was significantly greater (OR 1.46 95% CI 1.10 to 1.94) in the condition for which practices had received the implementation programme. The development and implementation of guidelines cost less than £1500 per practice. The estimated costs per quality‐adjusted life year gained by patients with atrial fibrillation or TIA were both less than £2000, very much less than the usual criterion for cost effectiveness. Conclusions Implementation of evidence‐based guidelines improved the quality of primary care for atrial fibrillation and TIA. The intervention was feasible and very cost effective. Key components of the model include contextual analysis, strong professional support, clear recommendations based on robust evidence, simplicity of adoption, good communication and use of established networks and opinion leaders. PMID:17301206

  17. Prevention of poststroke depression with milnacipran in patients with acute ischemic stroke: a double-blind randomized placebo-controlled trial.

    PubMed

    Tsai, Ching-Shu; Wu, Chen-Long; Chou, Shih-Yong; Tsang, Hin-Yeung; Hung, Tai-Hsin; Su, Jian-An

    2011-09-01

    Poststroke depression (PSD) is one of the most frequent neuropsychiatric consequences of stroke. It has been shown to be associated with both impaired recovery and increased mortality. The purpose of this study is to investigate the prophylactic effect of milnacipran in PSD. Ninety-two patients were enrolled in the 12 months of this double-blind randomized placebo-controlled trial. The assessment was performed at baseline, and at the first, third, sixth, ninth and 12th month after enrollment. The definition of PSD was in accordance with the diagnostic criteria of major depressive episode based on the Diagnostic and Statistical Manual, fourth edition. Forty-six patients were randomized to the treatment group with milnacipran and another 46 patients to the placebo group. No significant differences were found between the two groups in terms of sex (P=0.83), age (P=0.08), marital status (P=0.66), occupation (P=0.22), educational level (P=0.29), and drug side-effects (P=0.73). The incidence of depression in the two groups was 2.22% and 15.22%, respectively. Milnacipran was proved to have a statistically significant advantage in preventing PSD (P<0.05). In conclusion, milnacipran could prevent the development of depression in the first year following a stroke and is safe to use without significant adverse effects in stroke patients.

  18. Booster Vaccination in Preventing Disease Recurrence in Previously Vaccinated Patients With Melanoma That Has Been Removed By Surgery

    ClinicalTrials.gov

    2015-01-23

    Recurrent Melanoma; Stage IA Skin Melanoma; Stage IB Skin Melanoma; Stage IIA Skin Melanoma; Stage IIB Skin Melanoma; Stage IIC Skin Melanoma; Stage IIIA Skin Melanoma; Stage IIIB Skin Melanoma; Stage IIIC Skin Melanoma; Stage IV Skin Melanoma

  19. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial

    PubMed Central

    Halliday, Alison; Harrison, Michael; Hayter, Elizabeth; Kong, Xiangling; Mansfield, Averil; Marro, Joanna; Pan, Hongchao; Peto, Richard; Potter, John; Rahimi, Kazem; Rau, Angela; Robertson, Steven; Streifler, Jonathan; Thomas, Dafydd

    2010-01-01

    Summary Background If carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA. Methods Between 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3–2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6–11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392. Findings 1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7% versus 4·8% at 1 year (and 92·1% vs 16·5% at 5 years). Perioperative risk of stroke or death within 30 days was 3·0% (95% CI 2·4–3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1% versus 10·0% at 5 years (gain 5·9%, 95% CI 4·0–7·8) and 10·8% versus 16·9% at 10 years (gain 6·1%, 2·7–9·4); ratio of stroke incidence rates 0·54, 95% CI 0·43–0·68, p<0·0001. 62 versus 104 had a disabling or fatal stroke, and 37 versus 84 others had a non-disabling stroke. Combining perioperative events and strokes, net risks were 6·9% versus 10·9% at 5 years (gain 4·1%, 2·0–6·2) and 13·4% versus 17·9% at 10 years (gain 4·6%, 1·2–7·9). Medication was similar in both groups; throughout the study, most were on antithrombotic and antihypertensive therapy. Net benefits

  20. World Stroke Organization global stroke services guidelines and action plan.

    PubMed

    Lindsay, Patrice; Furie, Karen L; Davis, Stephen M; Donnan, Geoffrey A; Norrving, Bo

    2014-10-01

    Every two seconds, someone across the globe suffers a symptomatic stroke. 'Silent' cerebrovascular disease insidiously contributes to worldwide disability by causing cognitive impairment in the elderly. The risk of cerebrovascular disease is disproportionately higher in low to middle income countries where there may be barriers to stroke care. The last two decades have seen a major transformation in the stroke field with the emergence of evidence-based approaches to stroke prevention, acute stroke management, and stroke recovery. The current challenge lies in implementing these interventions, particularly in regions with high incidences of stroke and limited healthcare resources. The Global Stroke Services Action Plan was conceived as a tool to identifying key elements in stroke care across a continuum of health models. At the minimal level of resource availability, stroke care delivery is based at a local clinic staffed predominantly by non-physicians. In this environment, laboratory tests and diagnostic studies are scarce, and much of the emphasis is placed on bedside clinical skills, teaching, and prevention. The essential services level offers access to a CT scan, physicians, and the potential for acute thrombolytic therapy, however stroke expertise may still be difficult to access. At the advanced stroke services level, multidisciplinary stroke expertise, multimodal imaging, and comprehensive therapies are available. A national plan for stroke care should incorporate local and regional strengths and build upon them. This clinical practice guideline is a synopsis of the core recommendations and quality indicators adapted from ten high quality multinational stroke guidelines. It can be used to establish the current level of stroke services, target goals for expanding stroke resources, and ensuring that all stages of stroke care are being adequately addressed, even at the advanced stroke services level. This document is a start, but there is more to be done

  1. The implantation of non-cell-based materials to prevent the recurrent disc herniation: an in vivo porcine model using quantitative discomanometry examination

    PubMed Central

    Wang, Yao-Hung; Kuo, Tzong-Fu

    2007-01-01

    Recurrent disc herniation is frequently observed due to leakage of nucleus pulposus through injured anulus fibrosus. There is no effective treatment to prevent recurrent disc herniation yet. In this study, we proposed to implant non-cell-based materials into the porcine disc to stimulate the growth of fibrous tissue and thereby increase the disc functional integrity. The disc herniation was simulated by anular punctures using the spinal needles. Four clinically used implantation materials, i.e., gelfoam, platinum coil, bone cement and tissue glue, were delivered into the discs via percutaneous spinal needles. Two months after the surgery, the swine were killed. The degree of disc integrity of intact, naturally healed and implanted discs, was examined by quantitative discomanometry apparatus. We found the disc injury could not recover after 2 months of healing, and the disc implantation affected the degree of disc integrity. The disc integrity of gelfoam-implanted discs was better than that of coil-, bone cement-, and glue-implanted discs. The implantation of non-cell-based material was proved to be a potentially clinically applicable method to recover the integrity of injured discs and to prevent recurrent disc herniation. PMID:17252217

  2. [The perioperative period in cancer surgery: a critical moment! Is there a role for regional anesthesia in preventing cancer recurrence?].

    PubMed

    Beloeil, H; Nouette-Gaulain, K

    2012-06-01

    Surgical treatment of cancer is usually necessary but it can paradoxically aggravate the patient outcome by increasing the risk of recurrence. Many perioperative factors have been shown to contribute to the dissemination of the tumor: surgery itself, stress, inflammation, pain, anaesthetic drugs, blood transfusion, etc. The type of anaesthesia chosen in the cancer patient could then be crucial and influence the evolution of the disease. Experimental, preclinical and retrospective studies have suggested that a regional anesthesia associated or not with a general anesthesia for carcinologic surgery might reduce the risk of cancer recurrence. This text reviews the factors promoting the recurrence of tumors after carcinologic surgery and the potential possibilities of protection associated with the type of anaesthesia chosen.

  3. Brain Basics: Preventing Stroke

    MedlinePlus

    ... been linked to the buildup of fatty substances (atherosclerosis) in the carotid artery, the main neck artery ... disability. The most common blood vessel disease is atherosclerosis. Hypertension promotes atherosclerosis and causes mechanical damage to ...

  4. Recurrent recurrent gallstone ileus.

    PubMed

    Hussain, Z; Ahmed, M S; Alexander, D J; Miller, G V; Chintapatla, S

    2010-07-01

    We describe the second reported case of three consecutive episodes of gallstone ileus and ask the question whether recurrent gallstone ileus justifies definitive surgery to the fistula itself or can be safely managed by repeated enterotomies.

  5. Adenoviral targeting of malignant melanoma for fluorescence-guided surgery prevents recurrence in orthotopic nude-mouse models

    PubMed Central

    Yano, Shuya; Takehara, Kiyoto; Kishimoto, Hiroyuki; Urata, Yasuo; Kagawa, Shunsuke; Bouvet, Michael; Fujiwara, Toshiyoshi; Hoffman, Robert M.

    2016-01-01

    Malignant melanoma requires precise resection in order to avoid metastatic recurrence. We report here that the telomerase-dependent, green fluorescent protein (GFP)-containing adenovirus OBP-401 could label malignant melanoma with GFP in situ in orthotopic mouse models. OBP-401-based fluorescence-guided surgery (FGS) resulted in the complete resection of malignant melanoma in the orthotopic models, where conventional bright-light surgery (BLS) could not. High-dose administration of OBP-401 enabled FGS without residual cancer cells or recurrence, due to its dual effect of cancer-cell labeling with GFP and killing. PMID:26701857

  6. Rivaroxaban: a review of its use in the treatment of deep vein thrombosis or pulmonary embolism and the prevention of recurrent venous thromboembolism.

    PubMed

    Burness, Celeste B; Perry, Caroline M

    2014-02-01

    Rivaroxaban (Xarelto(®)), an oral direct factor Xa inhibitor, is approved for the initial treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as the prevention of recurrent DVT and PE. It is administered at a fixed oral dose and does not require routine coagulation monitoring. In the EINSTEIN-DVT and EINSTEIN-PE trials, in over 8,000 patients with DVT and/or PE, a single-drug approach with rivaroxaban was shown to be noninferior to standard therapy consisting of subcutaneous enoxaparin sodium overlapping with and followed by an oral dose-adjusted vitamin K antagonist (enoxaparin-VKA) with regard to the incidence of symptomatic recurrent venous thromboembolism (VTE) after 3, 6 or 12 months of treatment. Rivaroxaban was generally well tolerated in patients with DVT or PE, with no significant between-group differences in clinically relevant bleeding between the rivaroxaban and enoxaparin-VKA groups. Notably, rivaroxaban was associated with a significantly lower rate of major bleeding compared with enoxaparin-VKA when EINSTEIN-DVT and EINSTEIN-PE data were pooled. Pharmacoeconomic analyses indicated that rivaroxaban may be a cost-effective alternative to enoxaparin-VKA for the treatment of DVT or PE and prevention of recurrent VTE. Extended prophylaxis with rivaroxaban reduced the incidence of symptomatic recurrent VTE to a greater extent than placebo in the EINSTEIN-Extension trial, but was associated with a non-significant increase in the risk of clinically relevant bleeding compared with placebo. In conclusion, rivaroxaban is a reasonable alternative to standard therapy for the treatment of DVT and PE, and as extended thromboprophylaxis.

  7. Recurrent Urinary Tract Infections Among Women: Comparative Effectiveness of 5 Prevention and Management Strategies Using a Markov Chain Monte Carlo Model

    PubMed Central

    Eells, Samantha J.; Bharadwa, Kiran; McKinnell, James A.; Miller, Loren G.

    2014-01-01

    Background. Recurrent urinary tract infections (UTIs) are a common problem among women. However, comparative effectiveness strategies for managing recurrent UTIs are lacking. Methods. We performed a systematic literature review of management of women experiencing ≥3 UTIs per year. We then developed a Markov chain Monte Carlo model of recurrent UTI for each management strategy with ≥2 adequate trials published. We simulated a cohort that experienced 3 UTIs/year and a secondary cohort that experienced 8 UTIs/year. Model outcomes were treatment efficacy, patient and payer cost, and health-related quality of life. Results. Five strategies had ≥2 clinical trials published: (1) daily antibiotic (nitrofurantoin) prophylaxis; (2) daily estrogen prophylaxis; (3) daily cranberry prophylaxis; (4) acupuncture prophylaxis; and (5) symptomatic self-treatment. In the 3 UTIs/year model, nitrofurantoin prophylaxis was most effective, reducing the UTI rate to 0.4 UTIs/year, and the most expensive to the payer ($821/year). All other strategies resulted in payer cost savings but were less efficacious. Symptomatic self-treatment was the only strategy that resulted in patient cost savings, and was the most favorable strategy in term of cost per quality-adjusted life-year (QALY) gained. Conclusions. Daily antibiotic use is the most effective strategy for recurrent UTI prevention compared to daily cranberry pills, daily estrogen therapy, and acupuncture. Cost savings to payers and patients were seen for most regimens, and improvement in QALYs were seen with all. Our findings provide clinically meaningful data to guide the physician–patient partnership in determining a preferred method of prevention for this common clinical problem. PMID:24065333

  8. Antioxidants prevent depletion of [Mg2+]i induced by alcohol in cultured canine cerebral vascular smooth muscle cells: possible relationship to alcohol-induced stroke.

    PubMed

    Li, W; Zheng, T; Altura, B T; Altura, B M

    2001-07-01

    Low serum concentrations of Mg(2+) ions have been reported, recently, in patients with coronary disease, atherosclerosis, and stroke as well as in patients with cerebral hemorrhage. The aim of the present study was to determine whether potent antioxidants [alpha-tocopherol and pyrrolidine dithiocarbamate (PDTC)] can prevent or ameliorate intracellular Mg(2+) ([Mg(2+)](i)) depletion associated with cerebral vascular injury induced by alcohol. Exposure of cultured canine cerebral vascular smooth muscle cells to alcohol (10-100 mM) for 24 h induced marked depletion in [Mg(2+)](i) (i.e., approximately 30-65%, depending upon alcohol concentration). Treatment of the cultured cells with either PDTC (0.1 microM) or alpha-tocopherol (15 microM) for 24 h, alone, failed to interfere with basal [Mg(2+)](i) levels. However, preincubation of the cells with either alpha-tocopherol or PDTC for 24 h completely inhibited the depletion of [Mg(2+)](i) induced by exposure to 10-100 mM ethanol. These results indicate that alpha-tocopherol and PDTC prevent decreases in [Mg(2+)](i) produced by ethanol. Moreover, these new results suggest that such protective effects of alpha-tocopherol and PDTC on cerebral vascular cells might be useful therapeutic tools in prevention and amelioration of cerebral vascular injury and stroke in alcoholics.

  9. Preventing Depressive Relapse and Recurrence in Higher Risk Cognitive Therapy Responders: A Randomized Trial of Continuation Phase Cognitive Therapy, Fluoxetine, or Matched Pill Placebo

    PubMed Central

    Jarrett, Robin B.; Minhajuddin, Abu; Gershenfeld, Howard; Friedman, Edward S.; Thase, Michael E.

    2014-01-01

    Context Strategies to improve the course of recurrent major depressive disorder (MDD) have great public health relevance. To reduce the risk of relapse/recurrence after acute phase Cognitive Therapy (CT), a continuation phase model of therapy (C-CT) may improve outcomes. Objectives To test the efficacy of C-CT and fluoxetine (FLX) for relapse prevention in a placebo (PBO) controlled randomized trial and compare the durability of prophylaxis after discontinuation of treatments. Design A sequential, three stage design with: acute phase (all patients received 12 weeks of CT), 8 month experimental phase (responders at higher risk were randomized to C-CT, FLX, or PBO), and 24 months of longitudinal, post-treatment follow-up. Setting Two university-based specialty clinics. Patients 523 adults with recurrent MDD began acute phase CT, of which 241 “higher risk” responders were randomized and 181 subsequently entered the follow-up. Interventions CT responders at higher risk for relapse were randomized to receive 8 months of C-CT (n = 86), FLX (n = 86) or PBO (n = 69). Main Outcome Measures Survival analyses of relapse/recurrence rates, as determined by “blinded” evaluators using DSM-IV criteria and the LIFE interview. Results As predicted, the C-CT or FLX groups were significantly less likely to relapse than the PBO group across 8 months. Relapse/recurrence rates for C-CT and FLX were nearly identical during the 8 months of treatment, although C-CT patients were more likely to accept randomization, stayed in treatment longer, and attended more sessions than those in FLX/PBO. Contrary to prediction, relapse/recurrence rates following the discontinuation of C-CT and FLX did not differ. Conclusions Relapse risk was reduced by both C-CT and FLX in an “enriched” randomization sampling only CT responders. The preventive effects of C-CT were not significantly more ‘durable’ than those of FLX after treatment was stopped, suggesting that some higher risk patients may

  10. Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study.

    PubMed

    Lowres, Nicole; Neubeck, Lis; Salkeld, Glenn; Krass, Ines; McLachlan, Andrew J; Redfern, Julie; Bennett, Alexandra A; Briffa, Tom; Bauman, Adrian; Martinez, Carlos; Wallenhorst, Christopher; Lau, Jerrett K; Brieger, David B; Sy, Raymond W; Freedman, S Ben

    2014-06-01

    Atrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy.Pharmacists performedpulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8-2.5%); mean age 79 ± 6 years; all had CHA2DS2-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92-100%) sensitivity for AF detection and 91.4% (CI, 89-93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be $AUD5,988 (€3,142; $USD4,066) per Quality Adjusted Life Year gained and $AUD30,481 (€15,993; $USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence.Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered.

  11. Illustration of Cost Saving Implications of Lower Extremity Nerve Decompression to Prevent Recurrence of Diabetic Foot Ulceration

    PubMed Central

    Rankin, Timothy M.; Miller, John D.; Gruessner, Angelika C.; Nickerson, D. Scott

    2015-01-01

    The US diabetic foot ulcer (DFU) incidence is 3-4% of 22.3 million diagnosed diabetes cases plus 6.3 million undiagnosed, 858 000 cases total. Risk of recurrence after healing is 30% annually. Lower extremity multiple nerve decompression (ND) surgery reduces neuropathic DFU (nDFU) recurrence risk by >80%. Cost effectiveness of hypothetical ND implementation to minimize nDFU recurrence is compared to the current $6.171 billion annual nDFU expense. A literature review identified best estimates of annual incidence, recurrence risk, medical management expense, and noneconomic costs for DFU. Illustrative cost/benefit calculations were performed assuming widespread application of bilateral ND after wound healing to the nDFU problem, using Center for Medicare Services mean expense data of $1143/case for unilateral lower extremity ND. Calculations use conservative, evidence-based cost figures, which are contemporary (2012) or adjusted for inflation. Widespread adoption of ND after nDFU healing could reduce annual DFU occurrences by at least 21% in the third year and 24% by year 5, representing calculated cost savings of $1.296 billion (year 3) to $1.481 billion (year 5). This scenario proffers significant expense reduction and societal benefit, and represents a minimum 1.9× return on the investment cost for surgical treatment. Further large cost savings would require reductions in initial DFU incidence, which ND might achieve by selective application to advanced diabetic sensorimotor polyneuropathy (DSPN). By minimizing the contribution of recurrences to yearly nDFU incidence, ND has potential to reduce by nearly $1 billion the annual cost of DFU treatment in the United States. PMID:26055081

  12. Ischemic Stroke

    MedlinePlus

    ... Spread the Word Advocate Share Spread the Word Contact Us Contact Us 1-800-STROKES (787-6537) 9707 E. ... Stroke En Espanol Stroke Facts Come Back Strong Contact Us 1-800-787-6537 9707 E. Easter ...

  13. Stroke Rehabilitation

    MedlinePlus

    A stroke can cause lasting brain damage. People who survive a stroke need to relearn skills they lost because of ... them relearn those skills. The effects of a stroke depend on which area of the brain was ...

  14. Hemorrhagic Stroke

    MedlinePlus

    A stroke is a medical emergency. There are two types - ischemic and hemorrhagic. Hemorrhagic stroke is the less common type. It happens when ... an artery wall that breaks open. Symptoms of stroke are Sudden numbness or weakness of the face, ...

  15. What Are Some Common Outcomes of Stroke and Some Common Treatments for These Outcomes?

    MedlinePlus

    ... and Publications What are some common outcomes of stroke & some common treatments for these outcomes? Skip sharing ... and temperature changes Depression Types of Treatment for Stroke Stroke treatment includes: Emergency treatment Preventing another stroke ...

  16. Dehydration, Heat Stroke, or Hyponatremia? The Recognition, Treatment, and Prevention of Hyponatremia Caused by High Exercise Outdoor Activities.

    ERIC Educational Resources Information Center

    Cochran, Brent

    Hyponatremia (severe sodium depletion) has symptoms similar to heat exhaustion and heat stroke and can easily be misdiagnosed. The number of wilderness users and extreme adventure activities has increased in recent years, and more cases are being diagnosed. Given that a 1993 study found that 1 in 10 cases of heat-related illnesses were…

  17. Assessing Rates and Predictors of Tachyphylaxis During the Prevention of Recurrent Episodes of Depression With Venlafaxine ER for Two Years (PREVENT) Study

    PubMed Central

    Rothschild, Anthony J.; Dunlop, Boadie W.; Dunner, David L.; Friedman, Edward S.; Gelenberg, Alan; Holland, Peter; Kocsis, James H.; Kornstein, Susan G.; Shelton, Richard; Trivedi, Madhukar H.; Zajecka, John M.; Goldstein, Corey; Thase, Michael E.; Pedersen, Ron; Keller, Martin B.

    2013-01-01

    Background Antidepressant tachyphylaxis describes the return of apathetic depressive symptoms, such as fatigue and decreased motivation, despite continued use of a previously effective treatment. Methods Data were collected from a multiphase, double-blind, placebo-controlled study that assessed the efficacy of venlafaxine extended release (ER) during 2 sequential 1-year maintenance phases (A and B) in patients with recurrent major depressive disorder (MDD). The primary outcome was the cumulative probability of tachyphylaxis in patients receiving venlafaxine ER, fluoxetine, or placebo. Tachyphylaxis was defined as Rothschild Scale for Antidepressant Tachyphylaxis (RSAT) scored ≥ 7 in patients with prior satisfactory therapeutic response. A Kaplan-Meier estimate of the cumulative probability of not experiencing tachyphylaxis, and a 2-sided Fisher exact test was used to assess the relationship between tachyphylaxis and recurrence. Results The maintenance phase A population was comprised of 337 patients (venlafaxine ER [n = 129], fluoxetine [n = 79], placebo [n = 129]), whereas 128 patients (venlafaxine ER [n = 43], fluoxetine [n = 45], placebo [n = 40]) were treated during maintenance phase B. No difference in the probability of experiencing tachyphylaxis were observed between the active treatment groups during either maintenance phase; however, a significant difference between venlafaxine ER and placebo was observed at the completion of maintenance phase A. A significant relationship between tachyphylaxis and recurrence was observed. Limitations Despite demonstrating psychometric validity and reliability, the current definition of tachyphylaxis has not been widely studied Conclusions Although no significant differences were observed in the probability of tachyphylaxis among patients receiving active treatment, the relationship between tachyphylaxis and recurrence suggests that tachyphylaxis may be a predrome of recurrence. PMID:19752838

  18. Direct oral anticoagulants in the secondary prevention of stroke and transient ischemic attack in patients with atrial fibrillation.

    PubMed

    Arnao, Valentina; Agnelli, Giancarlo; Paciaroni, Maurizio

    2015-08-01

    In patients with non-valvular atrial fibrillation (NVAF) and history of transient ischemic attack (TIA) or stroke, the rate of vascular events is higher in comparison to patients without history of stroke or TIA. A meta-analysis of direct oral anticoagulants (DOACs) studies, including only patients with history of stroke or TIA, report a significant reduction of 15 % in the rates of composite of stroke and systemic embolism in patients treated with DOACs, compared to those treated with warfarin. Furthermore, a reduction of 14 % for major bleeding, as well as a 56 % reduction for hemorrhagic stroke over a median follow-up of 1.8-2.0 years is reported. The combination of DOACs and antiplatelet agents carries the potential of additive benefits in patients with NVAF and other vascular diseases. However, the rate of major bleeding is higher among patients who receive concomitantly antiplatelet agents, compared to those taking only a single drug category. The risk of major bleeding seems to be higher among patients receiving dual antiplatelet agents, compared to those receiving a single antiplatelet drug. When NVAF is associated with an acute coronary syndrome requiring dual antiplatelet therapy (e.g. coronary angioplasty and stenting), DOACs plus this therapy should be considered. However, this therapy has to be administered for the shortest possible time, according to the patient's haemorrhagic and thrombotic risks, and stent type. When NVAF is associated with carotid stenosis, a single antiplatelet therapy should be considered. Regarding carotid revascularization, it seems preferable to treat these patients with endarterectomy, so to avoid dual antiplatelet therapy, which is generally administered after stenting.

  19. Non-Vitamin K Antagonist Oral Anticoagulants and Antiplatelet Therapy for Stroke Prevention in Patients With Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials.

    PubMed

    Kumar, Shashi; Danik, Stephan B; Altman, Robert K; Barrett, Conor D; Lip, Gregory Y H; Chatterjee, Saurav; Roubin, Gary S; Natale, Andrea; Danik, Jacqueline S

    2016-01-01

    Non-vitamin K antagonist oral anticoagulants (NOACs) are frequently used to prevent stroke in patients with atrial fibrillation. These patients are often also on aspirin or other antiplatelet agents. It is possible that treatment with both NOACs and aspirin or other antiplatelet drug may be effective in decreasing stroke, but data are sparse regarding the efficacy and safety of using both agents for stroke prevention. To address these issues, data were pooled from the 4 recent randomized, controlled trials of NOACs: apixaban, rivaroxaban, dabigatran, and edoxaban, which included 42,411 patients; 14,148 (33.4%) were also on aspirin or other antiplatelet drug. The number of thromboembolic events among participants on NOAC and aspirin/antiplatelet was compared with the number of events in patients on NOAC alone. Bleeding rates were also compared between those on NOAC + aspirin/antiplatelet and on NOAC alone. These results were compared with thromboembolic and bleeding events in the warfarin + aspirin/antiplatelet versus warfarin alone. No greater risk for thromboembolism was seen in patients on NOACs compared with patients on both NOACs and aspirin/antiplatelet drug. In this nonrandomized comparison, there was initially a signal toward higher thromboembolic rates among NOAC users also on aspirin/antiplatelet drugs (relative risk, 1.16; 95% confidence intervals, 1.05, 1.29) when compared with NOAC alone. This likely reflected the higher CHADS2 scores of those on aspirin/antiplatelet drugs. When the analysis was limited to studies that included aspirin rather than other antiplatelet drugs, no difference was seen for thromboembolic rates comparing dual therapy to NOAC alone (relative risk, 1.02; 95% confidence intervals, 0.90, 1.15). Higher rates of bleeding were seen with aspirin/antiplatelet drug in conjunction with NOAC. In this meta-analysis and nonrandomized comparison of aspirin/antiplatelet users and nonusers also on anticoagulation, there was no additional

  20. The complexity of atrial fibrillation newly diagnosed after ischemic stroke and transient ischemic attack: advances and uncertainties

    PubMed Central

    Cerasuolo, Joshua O.; Cipriano, Lauren E.; Sposato, Luciano A.

    2017-01-01

    Purpose of review Atrial fibrillation is being increasingly diagnosed after ischemic stroke and transient ischemic attack (TIA). Patient characteristics, frequency and duration of paroxysms, and the risk of recurrent ischemic stroke associated with atrial fibrillation detected after stroke and TIA (AFDAS) may differ from atrial fibrillation already known before stroke occurrence. We aim to summarize major recent advances in the field, in the context of prior evidence, and to identify areas of uncertainty to be addressed in future research. Recent findings Half of all atrial fibrillations in ischemic stroke and TIA patients are AFDAS, and most of them are asymptomatic. Over 50% of AFDAS paroxysms last less than 30 s. The rapid initiation of cardiac monitoring and its duration are crucial for its timely and effective detection. AFDAS comprises a heterogeneous mix of atrial fibrillation, possibly including cardiogenic and neurogenic types, and a mix of both. Over 25 single markers and at least 10 scores have been proposed as predictors of AFDAS. However, there are considerable inconsistencies across studies. The role of AFDAS burden and its associated risk of stroke recurrence have not yet been investigated. Summary AFDAS may differ from atrial fibrillation known before stroke in several clinical dimensions, which are important for optimal patient care strategies. Many questions remain unanswered. Neurogenic and cardiogenic AFDAS need to be characterized, as it may be possible to avoid some neurogenic cases by initiating timely preventive treatments. AFDAS burden may differ in ischemic stroke and TIA patients, with distinctive diagnostic and treatment implications. The prognosis of AFDAS and its risk of recurrent stroke are still unknown; therefore, it is uncertain whether AFDAS patients should be treated with oral anticoagulants. PMID:27984303

  1. Study protocol for a randomized controlled trial comparing mindfulness-based cognitive therapy with maintenance anti-depressant treatment in the prevention of depressive relapse/recurrence: the PREVENT trial

    PubMed Central

    2010-01-01

    Background Depression is a common and distressing mental health problem that is responsible for significant individual disability and cost to society. Medication and psychological therapies are effective for treating depression and maintenance anti-depressants (m-ADM) can prevent relapse. However, individuals with depression often express a wish for psychological help that can help them recover from depression in the long-term. We need to develop psychological therapies that prevent depressive relapse/recurrence. A recently developed treatment, Mindfulness-based Cognitive Therapy (MBCT, see http://www.mbct.co.uk) shows potential as a brief group programme for people with recurring depression. In two studies it has been shown to halve the rates of depression recurring compared to usual care. This trial asks the policy research question, is MBCT superior to m-ADM in terms of: a primary outcome of preventing depressive relapse/recurrence over 24 months; and, secondary outcomes of (a) depression free days, (b) residual depressive symptoms, (c) antidepressant (ADM) usage, (d) psychiatric and medical co-morbidity, (e) quality of life, and (f) cost effectiveness? An explanatory research question asks is an increase in mindfulness skills the key mechanism of change? Methods/Design The design is a single blind, parallel RCT examining MBCT vs. m-ADM with an embedded process study. To answer the main policy research question the proposed trial compares MBCT plus ADM-tapering with m-ADM for patients with recurrent depression. Four hundred and twenty patients with recurrent major depressive disorder in full or partial remission will be recruited through primary care. Depressive relapse/recurrence over two years is the primary outcome variable. The explanatory question will be addressed in two mutually informative ways: quantitative measurement of potential mediating variables pre/post-treatment and a qualitative study of service users' views and experiences. Discussion If the

  2. Peroxisome proliferator-activated receptor {alpha} agonism prevents renal damage and the oxidative stress and inflammatory processes affecting the brains of stroke-prone rats.

    PubMed

    Gelosa, Paolo; Banfi, Cristina; Gianella, Anita; Brioschi, Maura; Pignieri, Alice; Nobili, Elena; Castiglioni, Laura; Cimino, Mauro; Tremoli, Elena; Sironi, Luigi

    2010-11-01

    A growing body of evidence suggests that chronic kidney disease is a significant risk for cardiovascular events and stroke regardless of traditional risk factors. The aim of this study was to examine the effects of peroxisome proliferator-activated receptor (PPAR) agonists on the tissue damage affecting salt-loaded spontaneously hypertensive stroke-prone rats ( SHRSPs), an animal model that develops a complex pathology characterized by systemic inflammation, hypertension, and proteinuria and leads to end-organ injury (initially renal and subsequently cerebral). Compared with the PPARγ agonist rosiglitazone, the PPARα ligands fenofibrate and clofibrate significantly increased survival (p < 0.001) by delaying the occurrence of brain lesions monitored by magnetic resonance imaging (p < 0.001) and delaying increased proteinuria (p < 0.001). Fenofibrate completely prevented the renal disorder characterized by severe vascular lesions, tubular damage, and glomerular sclerosis, reduced the number of ED-1-positive cells and collagen accumulation, and decreased the renal expression of interleukin-1β, transforming growth factor β, and monocyte chemoattractant protein 1. It also prevented the plasma and urine accumulation of acute-phase and oxidized proteins, suggesting that the protection induced by PPARα agonists was at least partially caused by their anti-inflammatory and antioxidative properties. The results of this study demonstrate that PPAR agonism has beneficial effects on spontaneous brain and renal damage in SHRSPs by inhibiting systemic inflammation and oxidative stress, and they support carrying out future studies aimed at evaluating the effect of PPARα agonists on proteinuria and clinical outcomes in hypertensive patients with renal disease at increased risk of stroke.

  3. [Professionalizing the management of strokes].

    PubMed

    Jonniaux, Sandrine; Simon, Josette; Haouisée, Jocelyne

    2016-01-01

    A stroke is a life threatening emergency requiring fast access to medical care and to a technical support centre. Health professionals are trained in the complexity of this care. Preventive care and educational activities are developed in emergency departments, notably in neurovascular units, thereby contributing to the prevention of complications and the risk of repeat strokes.

  4. Local triple-combination therapy results in tumour regression and prevents recurrence in a colon cancer model

    NASA Astrophysics Data System (ADS)

    Conde, João; Oliva, Nuria; Zhang, Yi; Artzi, Natalie

    2016-10-01

    Conventional cancer therapies involve the systemic delivery of anticancer agents that neither discriminate between cancer and normal cells nor eliminate the risk of cancer recurrence. Here, we demonstrate that the combination of gene, drug and phototherapy delivered through a prophylactic hydrogel patch leads, in a colon cancer mouse model, to complete tumour remission when applied to non-resected tumours and to the absence of tumour recurrence when applied following tumour resection. The adhesive hydrogel patch enhanced the stability and provided local delivery of embedded nanoparticles. Spherical gold nanoparticles were used as a first wave of treatment to deliver siRNAs against Kras, a key oncogene driver, and rod-shaped gold nanoparticles mediated the conversion of near-infrared radiation into heat, causing the release of a chemotherapeutic as well as thermally induced cell damage. This local, triple-combination therapy can be adapted to other cancer cell types and to molecular targets associated with disease progression.

  5. High Blood Cholesterol Prevention

    MedlinePlus

    ... this? Submit What's this? Submit Button Related CDC Web Sites Division for Heart Disease and Stroke Prevention ... this? Submit What's this? Submit Button Related CDC Web Sites Division for Heart Disease and Stroke Prevention ...

  6. Preventing High Blood Pressure

    MedlinePlus

    ... this? Submit What's this? Submit Button Related CDC Web Sites Division for Heart Disease and Stroke Prevention ... this? Submit What's this? Submit Button Related CDC Web Sites Division for Heart Disease and Stroke Prevention ...

  7. The effect of serum vitamin D normalization in preventing recurrences of benign paroxysmal positional vertigo: A case-control study

    PubMed Central

    Sheikhzadeh, Mahboobeh; Lotfi, Yones; Mousavi, Abdollah; Heidari, Behzad; Bakhshi, Enyatollah

    2016-01-01

    Background: Benign paroxysmal positional vertigo (BPPV) is a condition with recurrent attacks in a significant proportion of patients. The present case- control study was conducted to assess the influence of serum vitamin D normalization on recurrent attacks of vitamin D deficient patients. Methods: Diagnosis of BPPV was made based on history and clinical examination and exclusion of other conditions. Serum 25-hydroxy vitamin D (25-OHD) was measured using ELISA method and a levels of < 20 ng/ml was considered a deficiency of vitamin D. Inclusion criteria were as follows: history of recurrent attacks and serum 25-OHD<20.ng/ml. While the patients with history of trauma, surgery and chronic systemic diseases were excluded. The patients were classified into two groups: treatment and control, intermittently. Both groups received Epley rehabilitation therapy one session per week for 4 weeks but the treatment group received an additional supplement of 50.000 IU of vitamin D (cholecalciferol) weekly for two months to achieve serum 25-OHD ≥ 30 ng/ml and the study patients were followed-up for 6 months. Results: Twenty-seven patients were allocated to each group. At baseline, serum 25-OHD was similar (10.7±2.3 vs 11.41±1.9, P=0.23). At month 2, serum 25-OHD in the treatment group increased significantly to ≥ 30 ng/ ml, whereas serum 25-OHD in the control group remained unchanged (34.2±3.3 vs 10.6 10.6±2.2 ng/ml, P=0.001). During the follow-up period, attacks of BPPV in the treatment group decreased significantly compared with the control group (14.8% vs 96.3% OR= 0.18, P=0.001). Conclusion: The findings of this study indicate that the normalization of serum vitamin D significantly reduces BPPV recurrences. PMID:27757201

  8. Rosuvastatin reduces microglia in the brain of wild type and ApoE knockout mice on a high cholesterol diet; implications for prevention of stroke and AD.

    PubMed

    Famer, D; Wahlund, L-O; Crisby, M

    2010-11-12

    We have previously shown that a high cholesterol (HC) diet results in increases in microglia load and levels of the pro-inflammatory cytokine interleukin-6 (IL-6) in the brains of wild type (WT) and apolipoprotein E knockout (ApoE-/-) mice. In the present investigation, we analyzed whether treatment with rosuvastatin, an inhibitor of the enzyme 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, would prevent the increases in inflammatory microglia and IL-6 levels in the brain and plasma of WT and ApoE-/- mice. We report that a HC diet resulted in an increased microglia load in the brains of WT and ApoE-/- mice, in support of our previous study. Treatment with rosuvastatin significantly decreased the microglia load in the brains of WT and ApoE-/- mice on a HC diet. Rosuvastatin treatment resulted in lowered plasma IL-6 levels in WT mice on a HC diet. However, in the present study the number of IL-6 positive cells in the brain was not significantly affected by a HC diet. A recent clinical study has shown that rosuvastatin reduces risk of ischemic stroke in patients with high plasma levels of the inflammatory marker C-reactive protein by 50%. The results from our study show that rosuvastatin reduces inflammatory cells in the brain. This finding is essential for furthering the prevention and treatment of neurodegenerative diseases such as Alzheimer's disease (AD) and stroke.

  9. Preventing relapse in recurrent depression using mindfulness-based cognitive therapy, antidepressant medication or the combination: trial design and protocol of the MOMENT study

    PubMed Central

    2012-01-01

    Background Depression is a common psychiatric disorder characterized by a high rate of relapse and recurrence. The most commonly used strategy to prevent relapse/recurrence is maintenance treatment with antidepressant medication (mADM). Recently, it has been shown that Mindfulness-Based Cognitive Therapy (MBCT) is at least as effective as mADM in reducing the relapse/recurrence risk. However, it is not yet known whether combination treatment of MBCT and mADM is more effective than either of these treatments alone. Given the fact that most patients have a preference for either mADM or for MBCT, the aim of the present study is to answer the following questions. First, what is the effectiveness of MBCT in addition to mADM? Second, how large is the risk of relapse/recurrence in patients withdrawing from mADM after participating in MBCT, compared to those who continue to use mADM after MBCT? Methods/design Two parallel-group, multi-center randomized controlled trials are conducted. Adult patients with a history of depression (3 or more episodes), currently either in full or partial remission and currently treated with mADM (6 months or longer) are recruited. In the first trial, we compare mADM on its own with mADM plus MBCT. In the second trial, we compare MBCT on its own, including tapering of mADM, with mADM plus MBCT. Follow-up assessments are administered at 3-month intervals for 15 months. Primary outcome is relapse/recurrence. Secondary outcomes are time to, duration and severity of relapse/recurrence, quality of life, personality, several process variables, and incremental cost-effectiveness ratio. Discussion Taking into account patient preferences, this study will provide information about a) the clinical and cost-effectiveness of mADM only compared with mADM plus MBCT, in patients with a preference for mADM, and b) the clinical and cost-effectiveness of withdrawing from mADM after MBCT, compared with mADM plus MBCT, in patients with a preference for MBCT

  10. Knowledge of Stroke Risk Factors among Stroke Survivors in Nigeria

    PubMed Central

    Moses, Taritei

    2016-01-01

    Background. Knowledge of stroke risk factors is expected to reduce the incidence of stroke—whether first-ever or recurrent. This study examined knowledge of stroke risk factors and its determinants among stroke survivors. Methods. A cross-sectional survey of consenting stroke survivors at two physiotherapy facilities in Nigeria was carried out. Sociodemographic and clinical data were obtained and knowledge of stroke risk factors (defined as the ability to mention at least one correct risk factor) was assessed using open-ended questionnaire. Data were treated with descriptive statistics and logistic regression analysis. Results. Sixty-nine stroke survivors (male = 72.5%; mean ± SD age = 49.7 ± 10.6 years) participated in the study. Thirty-four (49.4%) participants had knowledge of stroke risk factors. Only educational level was significantly associated with knowledge and participants with tertiary educational qualification were about 48 times (odds ratio = 48.5; CI = 7.6–309.8; P < 0.0001) more likely to be knowledgeable than those with no education. Conclusion. Less than half of the participants had knowledge of stroke risk factors. Participants with tertiary education were significantly more knowledgeable than those with lower educational qualifications. Effective means of educating stroke survivors on stroke risk factors should be identified and adopted. PMID:27882262

  11. Fluorescence-guided surgery of a highly-metastatic variant of human triple-negative breast cancer targeted with a cancer-specific GFP adenovirus prevents recurrence

    PubMed Central

    Yano, Shuya; Takehara, Kiyoto; Miwa, Shinji; Kishimoto, Hiroyuki; Tazawa, Hiroshi; Urata, Yasuo; Kagawa, Shunsuke; Bouvet, Michael; Fujiwara, Toshiyoshi; Hoffman, Robert M.

    2016-01-01

    We have previously developed a genetically-engineered GFP-expressing telomerase-dependent adenovirus, OBP-401, which can selectively illuminate cancer cells. In the present report, we demonstrate that targeting a triple-negative high-invasive human breast cancer, orthotopically-growing in nude mice, with OBP-401 enables curative fluorescence-guided surgery (FGS). OBP-401 enabled complete resection and prevented local recurrence and greatly inhibited lymph-node metastasis due to the ability of the virus to selectively label and subsequently kill cancer cells. In contrast, residual breast cancer cells become more aggressive after bright (white)-light surgery (BLS). OBP-401-based FGS also improved the overall survival compared with conventional BLS. Thus, metastasis from a highly-aggressive triple-negative breast cancer can be prevented by FGS in a clinically-relevant mouse model. PMID:27689331

  12. Acetyl-L-Carnitine Hydrochloride in Preventing Peripheral Neuropathy in Patients With Recurrent Ovarian Epithelial Cancer, Primary Peritoneal Cavity Cancer, or Fallopian Tube Cancer Undergoing Chemotherapy

    ClinicalTrials.gov

    2014-12-29

    Fatigue; Malignant Ovarian Mixed Epithelial Tumor; Neuropathy; Neurotoxicity Syndrome; Ovarian Brenner Tumor; Ovarian Clear Cell Cystadenocarcinoma; Ovarian Endometrioid Adenocarcinoma; Ovarian Mucinous Cystadenocarcinoma; Ovarian Serous Cystadenocarcinoma; Pain; Recurrent Fallopian Tube Carcinoma; Recurrent Ovarian Carcinoma; Recurrent Primary Peritoneal Carcinoma

  13. Diagnosis of deep vein thrombosis, and prevention of deep vein thrombosis recurrence and the post-thrombotic syndrome in the primary care medicine setting anno 2014.

    PubMed

    Michiels, Jan Jacques; Michiels, Janneke Maria; Moossdorff, Wim; Lao, Mildred; Maasland, Hanny; Palareti, Gualtiero

    2015-02-04

    -term compression stocking therapy to prevent PTS after the initial anticoagulant treatment in the acute phase of DVT? Is 3 mo the appropriate point in time to determine candidates at risk to develop DVT recurrence and PTS? Which high risk symptomatic PTS patients need extended anticoagulant treatment?

  14. Clinical presentation and imaging characteristics of occult lung cancer associated ischemic stroke.

    PubMed

    Mai, Hui; Xia, Jun; Wu, Yongjun; Ke, Junlong; Li, Junliang; Pan, Jiangang; Chen, Wubiao; Shao, Yiming; Yang, Zhi; Luo, Saihua; Sun, Yonghua; Zhao, Bin; Li, Longxuan

    2015-02-01

    We investigated the clinical and imaging characteristics of initial and recurrent strokes in patients with occult lung cancer associated ischemic stroke (OLCA-stroke). A retrospective review of all ischemic stroke patients with occult lung cancer in the absence of conventional stroke etiologies between 2005 and 2013 was conducted. We compared the initial and recurrent lesion patterns on diffusion-weighted MRI in patients with OLCA-stroke, with respect to vascular territory involved, number and size of lesions, clinical presentation, cancer subtypes, recurrences and fatalities, and outcome of survivors. Thirteen patients with confirmed OLCA-stroke were identified. All had elevated D-dimer levels, six had central lung cancer and seven had peripheral lung cancer. Eight (62%) had adenocarcinoma, and nine (69%) had metastasis. Ten (77%) patients had multiple lesions in multiple vascular territories. Twelve (92%) patients suffered recurrent strokes. Multiple small and large disseminated lesions in multiple vascular territories were more frequent in recurrent strokes in comparison with initial strokes. The middle cerebral artery was most frequently involved in recurrent strokes, followed by the posterior circulation territory and anterior cerebral artery, which were of similar frequency as initial strokes. Overall, 58% of patients had their first recurrent stroke within the first month, and 69% had a poor outcome, especially for those with multiple recurrent strokes and metastases. Occult cancer should be considered in the setting of multiple and recurrent embolic strokes within the short term in the absence of conventional stroke etiologies. The severity of malignancy and cancer treatments and stroke influenced the recurrences and outcome.

  15. Dalteparin versus vitamin K antagonists for the prevention of recurrent venous thromboembolism in patients with cancer and renal impairment: a Canadian pharmacoeconomic analysis

    PubMed Central

    Dranitsaris, George; Shane, Lesley G; Crowther, Mark; Feugere, Guillaume; Woodruff, Seth

    2017-01-01

    Background Patients with cancer are at increased risk of venous thromboembolism (VTE) and the risk is further elevated after a primary VTE. To reduce the risk of recurrent events, extended prophylaxis with vitamin K antagonists (VKA) is available for use. However, in a large randomized trial (Comparison of Low-Molecular-Weight Heparin versus Oral Anticoagulant Therapy for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer [CLOT]; Lee et al), extended duration dalteparin reduced the relative risk of recurrent VTE by 52% compared to VKA (p=0.002). A recent subgroup analysis of patients with moderate-to-severe renal impairment also revealed lower absolute VTE rates with dalteparin (3% vs. 17%; p=0.011). To measure the economic value of dalteparin as an alternative to VKA, a patient-level cost utility analysis was conducted from a Canadian perspective. Methods Resource use data captured during the CLOT trial were extracted and linked to 2015 Canadian unit cost estimates. Health state utilities were then measured using the Time-Trade-Off technique in 24 randomly selected members of the general Canadian public to estimate the gains in quality-adjusted life years (QALYs). Results For the entire CLOT trial population (n=676), the dalteparin group had significantly higher mean costs compared to the VKA group ($Can5,771 vs. $Can2,569; p<0.001). However, the utility assessment revealed that 21 of 24 respondents (88%) selected dalteparin over VKA, with an associated gain of 0.14 (95% confidence interval [CI]: 0.10–0.18) QALYs. When the incremental cost of dalteparin was combined with the QALY gain, dalteparin had a cost of $Can23,100 (95% CI: $Can19,200–$Can25,800) per QALY gained. The analysis in patients with renal impairment suggested even better economic value with the cost per QALY gained being <$14,000. Conclusion Extended duration dalteparin is a cost-effective alternative to VKA for the prevention of recurrent VTE in patients with cancer

  16. Antihypertensive treatment with cerebral hemodynamics monitoring by ultrasonography in elderly hypertensives without a history of stroke may prevent or slow down cognitive decline. A pending issue.

    PubMed

    Hadjiev, Dimiter I; Mineva, Petya P

    2011-03-01

    The role of the antihypertensive therapy in preventing cognitive disorders in elderly persons without a history of stroke is still a matter of debate. This article focuses on the pathogenesis of vascular cognitive disorders in hypertension and on the impact of antihypertensive treatment in their prevention. Cerebral white matter lesions, caused by small vessel disease and cerebral hypoperfusion, have been found in the majority of elderly hypertensives. They correlate with cognitive disorders, particularly impairments of attention and executive functions. Excessive blood pressure lowering in elderly patients with long-standing hypertension below a certain critical level, may increase the risk of further cerebral hypoperfusion because of disrupted cerebral blood flow autoregulation. As a result, worsening of the cognitive functions could occur, especially in cases with additional vascular risk factors. Five randomized, placebo-controlled trials have focused on the efficacy of antihypertensive treatments in preventing cognitive impairments in elderly patients without a prior cerebrovascular disease. Four of them have not found positive effects. We suggest that repeated neuropsychological assessments and ultrasonography for evaluation of carotid atherosclerosis, as well as cerebral hemodynamics monitoring could adjust the antihypertensive therapy with the aim to decrease the risk of cerebral hypoperfusion and prevent or slow down cognitive decline in elderly hypertensives. Prospective studies are needed to confirm such a treatment strategy.

  17. Cardioembolic Stroke Diagnosis Using Blood Biomarkers

    PubMed Central

    Llombart, VÍctor; GarcÍa-Berrocoso, Teresa; Bustamante, Alejandro; Fernández-Cadenas, Israel; Montaner, Joan

    2013-01-01

    Stroke is one of the main causes of death and disability in the world. Cardioembolic etiology accounts for approximately one fifth of all ischemic strokes whereas 25-30% remains undetermined even after an advanced diagnostic workup. Despite there is not any biomarker currently approved to distinguish cardioembolic stroke among other etiologies in clinical practice the use of biomarkers represents a promising valuable complement to determine stroke etiology reducing the number of cryptogenic strokes and aiding in the prescription of the most appropriated primary and secondary treatments in order to minimize therapeutic risks and to avoid recurrences. In this review we present an update about specific cardioembolic stroke-related biomarkers at a protein, transcriptomic and genetic level. Finally, we also focused on reported biomarkers associated with atrial fibrillation (a cardiac illness strongly related with cardioembolic stroke subtype) thus with a potential to become biomarkers to detect cardioembolic stroke in the future. PMID:24527683

  18. Recurrent Bleeding in Hemorrhagic Moyamoya Disease : Prognostic Implications of the Perfusion Status

    PubMed Central

    Jo, Kyung-Il; Kim, Min Soo; Yeon, Je Young; Kim, Jong-Soo

    2016-01-01

    Objective Hemorrhagic moyamoya disease (hMMD) is associated with a poor clinical course. Furthermore, poorer clinical outcomes occur in cases of recurrent bleeding. However, the effect of hemodynamic insufficiency on rebleeding risk has not been investigated yet. This study evaluated the prognostic implications of the perfusion status during the clinical course of adult hMMD. Methods This retrospective study enrolled 52 adult hMMD patients between April 1995 and October 2010 from a single institute. Demographic data, clinical and radiologic characteristics, including hemodynamic status using single photon emission computed tomography (SPECT), and follow up data were obtained via a retrospective review of medical charts and imaging. Statistical analyses were performed to explore potential prognostic factors. Results Hemodynamic abnormality was identified in 44 (84.6%) patients. Subsequent revascularization surgery was performed in 22 (42.3%) patients. During a 58-month (median, range 3–160) follow-up assessment period, 17 showed subsequent stroke (hemorrhagic n=12, ischemic n=5, Actuarial stroke rate 5.8±1.4%/year). Recurrent hemorrhage was associated with decreased basal perfusion (HR 19.872; 95% CI=1.196–294.117) and omission of revascularization (10.218; 95%; CI=1.532–68.136). Conclusion Decreased basal perfusion seems to be associated with recurrent bleeding. Revascularization might prevent recurrent stroke in hMMD by rectifying the perfusion abnormality. A larger-sized, controlled study is required to address this issue. PMID:26962416

  19. Optimal Combination Treatment and Vascular Outcomes in Recent Ischemic Stroke Patients by Premorbid Risk Level

    PubMed Central

    Park, Jong-Ho; Ovbiagele, Bruce

    2015-01-01

    Background Optimal combination of secondary stroke prevention treatment including antihypertensives, antithrombotic agents, and lipid modifiers is associated with reduced recurrent vascular risk including stroke. It is unclear whether optimal combination treatment has a differential impact on stroke patients based on level of vascular risk. Methods We analyzed a clinical trial dataset comprising 3680 recent non-cardioembolic stroke patients aged ≥35 years and followed for 2 years. Patients were categorized by appropriateness level 0 to III depending on the number of the drugs prescribed divided by the number of drugs potentially indicated for each patient (0=none of the indicated medications prescribed and III=all indicated medications prescribed [optimal combination treatment]). High-risk was defined as having a history of stroke or coronary heart disease (CHD) prior to the index stroke event. Independent associations of medication appropriateness level with a major vascular event (stroke, CHD, or vascular death), ischemic stroke, and all-cause death were analyzed. Results Compared with level 0, for major vascular events, the HR of level III in the low-risk group was 0.51 (95% CI: 0.20–1.28) and 0.32 (0.14–0.70) in the high-risk group; for stroke, the HR of level III in the low-risk group was 0.54 (0.16–1.77) and 0.25 (0.08–0.85) in the high-risk group; and for all-cause death, the HR of level III in the low-risk group was 0.66 (0.09–5.00) and 0.22 (0.06–0.78) in the high-risk group. Conclusion Optimal combination treatment is related to a significantly lower risk of future vascular events and death among high-risk patients after a recent non-cardioembolic stroke. PMID:26044963

  20. Evaluating the Primary Prevention of Ischemic Stroke of Oral Antithrombotic Therapy in Head and Neck Cancer Patients with Radiation Therapy

    PubMed Central

    Hsu, Chin-Wei

    2016-01-01

    Although previous studies demonstrated the risk of ischemic stroke (IS) in patients with head and neck cancer (HNC), the impact of oral antithrombotic therapy (OAT) on this risk has not yet been assessed. We aimed to evaluate the effectiveness and safety of OAT in patients with HNC treated with RT. This retrospective cohort study was performed using the National Health Insurance Research Database of Taiwan. A total of 37,638 patients diagnosed with HNC included in the study were classified as users and nonusers of OAT. Primary outcome was IS or transient ischemic attack (TIA), and secondary outcomes were death and major bleeding. The Cox proportional hazards model was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). There was no significant difference in the risk of IS or TIA between patients on continuous OAT and nonusers (adjusted HR, 0.812; 95% CI, 0.199–3.309). The risk of major bleeding was not significantly different between the groups. From a national population database, we did not find an association between OAT and decreasing risk of ischemic stroke/TIA or increasing hazard of major bleeding. PMID:27990433

  1. Factors influencing the participation of middle-aged and older Latin-American women in physical activity: a stroke-prevention behavior.

    PubMed

    Vaughn, Stephanie

    2009-01-01

    Despite the known benefits of regular physical activity for preventing stroke and cardiovascular disease, middle-aged and older Latin-American women continue to be physically inactive and demonstrate a high incidence of obesity. Ethnographic methodology was used to explore factors that influenced this health behavior in 25 Latin-American women. Perceptions of health, the health activities in which they engaged, and the factors that influenced their participation in physical activity comprised the three categories of responses. Facilitators and barriers were identified as the two primary categories and were further sorted into intrinsic or extrinsic factors. Conclusions of this study were that these Latin American women, despite multiple role demands and other barriers, participated in some form of physical activity; however, culturally sensitive strategies are needed to promote sustained physical activity in this population.

  2. CD4+FOXP3+ regulatory T cell depletion by low-dose cyclophosphamide prevents recurrence in patients with large condylomata acuminata after laser therapy.

    PubMed

    Cao, Yuchun; Zhao, Jie; Yang, Zhuoshun; Cai, Zaisheng; Zhang, Biao; Zhou, Yu; Shen, Guan-Xin; Chen, Xingping; Li, Shenqiu; Huang, Bo

    2010-07-01

    Condylomata acuminata (CA) caused by human papillomavirus (HPV) is a common sexually transmitted disease with half a million new cases diagnosed in the United States per year and the annual increase in incidence in China. Recurrence is a major challenge for CA treatment. Recently, we demonstrated that FOXP3(+) regulatory T (Treg) cells mediate the immunosuppression in large genital warts. Here, we further report that low-dose cyclophosphamide (CY), a conventional chemotherapy drug, can effectively prevent the recurrence of large CA in clinical patients after laser therapy. Surprisingly, although 9 out of 52 patients recur six weeks after the combination treatment, the re-administration of low-dose CY alone completely eliminates most recurred lesions. We provide evidence that low-dose CY not only depletes patients' Treg cells and enhances function of HPV-specific T cells and NK cells in the periphery, but also ameliorates the immune milieu of the lesion site, leading to the elimination of remnant viruses. These findings have important clinical significance, and potentially lead to a therapeutic breakthrough for the treatment of CA.

  3. Therapeutic application of injectable thermosensitive hydrogel in preventing local breast cancer recurrence and improving incision wound healing in a mouse model.

    PubMed

    Lei, Na; Gong, ChangYang; Qian, ZhiYong; Luo, Feng; Wang, Cheng; Wang, HeLan; Wei, YuQuan

    2012-09-21

    Many drug delivery systems (DDSs) have been investigated for local targeting of malignant disease with the intention of increasing anti-tumor activity and minimizing systemic toxicity. An injectable thermosensitive hydrogel was applied to prevent locoregional recurrence of 4T1 breast cancer in a mouse model. The presented hydrogel, which is based on poly(ethyleneglycol)-poly(ε-caprolactone)-poly(ethylene glycol) (PEG-PCL-PEG, PECE), flows freely at normal temperature, forms a gel within seconds in situ at body temperature, and eventually releases the drug in a consistent and sustained fashion as it gradually biodegrades. Locoregional recurrence after primary tumor removal was significantly inhibited in mice treated with the paclitaxel (PTX)-loaded PECE hydrogel subcutaneously (9.1%) administered, compared with the blank hydrogel (80.0%), systemic (77.8%) and locally (75.0%) administered PTX, and the control group (100%) (P < 0.01). In addition, tensile strength measurements of the surgical incisions showed that the PECE hydrogel accelerates wound healing at postoperative day 7 (P < 0.05), and days 4 and 14 (P > 0.05), in agreement with histopathological examinations. This novel DDSs represents a promising approach for local adjuvant therapy in malignant disease.

  4. Stroke rehabilitation

    PubMed Central

    Bindawas, Saad M.; Vennu, Vishal S.

    2016-01-01

    Stroke is a major cause of death and other complications worldwide. In Saudi Arabia, stroke has become an emerging health issue leading to disability and death. However, stroke care including rehabilitation services, in Saudi Arabia lags behind developed countries. Stroke rehabilitation is an essential recovery option after stroke and should start as early as possible to avoid potential complications. The growing evidence on stroke rehabilitation effectiveness in different health care settings and outcome measures used widely are reviewed in this call to action paper. PMID:27744457

  5. Stroke: advances in medical therapy and acute stroke intervention.

    PubMed

    Barrett, Kevin M; Lal, Brajesh K; Meschia, James F

    2015-10-01

    Evidence-based therapeutic options for stroke continue to emerge based on results from well-designed clinical studies. Ischemic stroke far exceeds hemorrhagic stroke in terms of prevalence and incidence, both in the USA and worldwide. The public health effect of reducing death and disability related to ischemic stroke justifies the resources that have been invested in identifying safe and effective treatments. The emergence of novel oral anticoagulants for ischemic stroke prevention in atrial fibrillation has introduced complexity to clinical decision making for patients with this common cardiac arrhythmia. Some accepted ischemic stroke preventative strategies, such as carotid revascularization for asymptomatic carotid stenosis, require reassessment, given advances in risk factor management, antithrombotic therapy, and surgical techniques. Intra-arterial therapy, particularly with stent retrievers after intravenous tissue plasminogen activator, has recently been demonstrated to improve functional outcomes and will require investment in system-based care models to ensure that effective treatments are received by patients in a timely fashion. The purpose of this review is to describe recent advances in medical and surgical approaches to ischemic stroke prevention and acute treatment. Results from recently published clinical trials will be highlighted along with ongoing clinical trials addressing key questions in ischemic stroke management and prevention where equipoise remains.

  6. Comparison of mitomycin C and limbal-conjunctival autograft in the prevention of pterygial recurrence in Turkish patients: A one-year, randomized, assessor-masked, controlled trial

    PubMed Central

    Ari, Şeyhmus; Çaca, Îhsan; Yildiz, Zennure Özdemir; Şakalar, Yildirim Bayezit; Dogan, Eyüp

    2009-01-01

    Background: A pterygium is a fibrovascular overgrowth of degenerative bulbar conjunctival tissue that grows over the limbus onto the cornea. Although various approaches have been proposed for the treatment of pterygium, the common problem after these treatments is recurrence. Objectives: The goals of this study were to compare the efficacy of mitomycin C (MMC) and limbal-conjunctival autograft (LCAU) in preventing recurrence of primary pterygia and to monitor long-term adverse effects (AEs). Methods: Patients undergoing pterygium surgery between February 2006 and May 2007 were assessed prospectively and randomly divided into 2 groups using a random number table. The MMC group underwent pterygium excision and received 0.02% MMC intraoperatively for 2 minutes. The LCAU group underwent pterygium excision and LCAU. Recurrence and AE rates of the 2 treatments were compared during the 1-year follow-up period. Assessors for pterygial recurrence were masked to treatment group. Results: One hundred thirteen eyes (57 patients in the MMC group and 56 patients in the LCAU group) were included in the study. Thirteen of the patients (7 in the MMC group and 6 in the LCAU group) were withdrawn due to irregular attendance at follow-up visits or lack of sufficient dose and duration for postoperative topical antibiotic and steroid administration; their data were excluded from analysis. Fifty patients (MMC group: 26 men, 24 women; mean [SD] age, 48.0 [12.3] years; age range, 30–73 years; LCAU group: 27 men, 23 women; mean age, 49.0 [12.6] years; age range, 28–71 years) in each group completed the study. The mean (SD) length of the pterygium across the limbus was similar in the MMC group and the LCAU group (4.18 [1.27] vs 4.07 [1.24] mm). The mean follow-up period was also similar in the 2 groups (16.0 [1.9] vs 15.0 [1.7] months). The rate of recurrence was significantly greater in the MMC group than in the LCAU group (10 [20.0%] vs 2 [4.0%] patients; P=0.035). Seven patients (14

  7. The Efficacy of Surgical Treatment for the Secondary Prevention of Stroke in Symptomatic Moyamoya Disease: A Meta-Analysis.

    PubMed

    Qian, Cong; Yu, Xiaobo; Li, Jianru; Chen, Jingyin; Wang, Lin; Chen, Gao

    2015-12-01

    The treatment of moyamoya disease (MMD) is controversial and often depends on the doctor's experience. In addition, the choice of surgical procedure to treat MMD can differ in many ways. In this study, we performed a meta-analysis to determine whether surgical treatment of MMD is superior to conservative treatment and to provide evidence for the selection of an appropriate surgical treatment.The human case-control studies regarding the association of MMD treatment were systematically identified through online databases (PubMed, Web of Science, Elsevier Science Direct, and Springer Link). Inclusion and exclusion criteria were defined for the eligible studies. The fixed-effects model was performed when homogeneity was indicated. Alternatively, the random-effects model was utilized.This meta-analysis included 16 studies. Surgical treatment significantly reduced the risk of stroke (odds ratio (OR) of 0.17, 95% confidence interval (CI), 0.12-0.26, P < 0.01). A subgroup analysis showed that surgical treatment was more beneficial to hemorrhagic MMD (OR of 0.23, 95% CI, 0.15-0.38, P < 0.01), but there was no significant difference between surgical treatment and conservative treatment on ischemic MMD treatment (OR of 0.45, 95% CI, 0.15-1.29, P = 0.14). Further analysis indicated that compared to direct bypass surgery, indirect bypass surgery had a lower efficacy on secondary stroke risk reduction (OR of 1.79, 95% CI, 1.14-2.82, P = 0.01), while no significant difference was detected for perioperative complications.Surgery is an effective treatment for symptomatic MMD patients, and direct bypass surgery may bring more benefits for these patients.

  8. Know Stroke

    MedlinePlus

    ... Home Current Issue Past Issues Special Section Know Stroke Past Issues / Summer 2007 Table of Contents For ... D. Director, National Institute of Neurological Disorders and Stroke Photo courtesy of NIH/NINDS Welcome to this ...

  9. Controversies in Cardioembolic Stroke

    PubMed Central

    Wessler, Benjamin S.; Kent, David M

    2015-01-01

    Opinion statement Cardioembolic (CE) stroke mechanisms account for a significant number of ischemic strokes however the true burden is likely underestimated. It is critically important to identify patients with CE strokes since these individuals have high recurrence rates and represent a subgroup of patients who may benefit from targeted therapy in the form of anticoagulation or device based treatments. Current guidelines offer recommendations for diagnosis and treatment of these patients however important questions remain. Appropriate cardiac testing in the setting of CE must be individualized and the optimal duration of electrocardiographic monitoring to rule out atrial fibrillation (AF) is unclear. So too, risk stratification tools for AF remain understudied and there is controversy about which anticoagulant agents are most appropriate. Lastly, important potential CE sources of stroke such as PFO have garnered significant attention recently and debate regarding how to treat these patients remains. In this review we discuss some of the important controversies in diagnosing and treating patients with possible CE stroke, pointing to areas where future research might be particularly valuable. PMID:25398426

  10. Ischemic Strokes (Clots)

    MedlinePlus

    ... Quiz 5 Things to Know About Stroke Ischemic Strokes (Clots) Updated:Nov 9,2016 Ischemic stroke accounts ... strokes. Read more about silent strokes . TIA and Stroke: Medical Emergencies When someone has shown symptoms of ...

  11. Recovering after stroke

    MedlinePlus

    Stroke rehabilitation; Cerebrovascular accident - rehabilitation; Recovery from stroke; Stroke - recovery; CVA - recovery ... WHERE TO LIVE AFTER A STROKE Most people will need stroke ... after they leave the hospital. Stroke rehab will help you ...

  12. Prevention of dementia and cerebroprotection with antihypertensive drugs.

    PubMed

    Hanon, Olivier; Seux, Marie Laure; Lenoir, Hermine; Rigaud, Anne Sophie; Forette, Françoise

    2004-06-01

    High blood pressure is a major risk factor for stroke and is also closely correlated with cognitive decline and dementia. Indeed, most longitudinal studies showed that cognitive functioning is often inversely proportional to blood pressure values measured 15 or 20 years previously. Because of the aging of the population, the frequency of stroke and dementia will dramatically increase in the coming years. Therefore, the prevention of cerebrovascular and cognitive disorders represents a major challenge. Antihypertensive drugs have shown clinical benefits in both primary and secondary prevention of strokes. Consensus is generally that blood-pressure lowering represents the major determinant of the benefit conferred by the antihypertensive treatment for stroke prevention; however, recent studies have suggested some differences between classes of antihypertensive drugs. The results of therapeutic trials (Systolic Hypertension in Europe, Perindopril Protection Against Recurrent Stroke Study [PROGRESS]) open the way to the prevention of dementia (vascular or Alzheimer's type) by antihypertensive treatments. These two studies suggest different mechanisms for the prevention of cognitive decline using antihypertensive drugs. In this context, reduced incidence of dementia should be the primary outcome of future trials comparing different classes of antihypertensive drugs.

  13. Effective components of nurse-coordinated care to prevent recurrent coronary events: a systematic review and meta-analysis.

    PubMed

    Snaterse, Marjolein; Dobber, Jos; Jepma, Patricia; Peters, Ron J G; Ter Riet, Gerben; Boekholdt, S Matthijs; Buurman, Bianca M; Scholte op Reimer, Wilma J M

    2016-01-01

    Current guidelines on secondary prevention of cardiovascular disease recommend nurse-coordinated care (NCC) as an effective intervention. However, NCC programmes differ widely and the efficacy of NCC components has not been studied. To investigate the efficacy of NCC and its components in secondary prevention of coronary heart disease by means of a systematic review and meta-analysis of randomised controlled trials. 18 randomised trials (11 195 patients in total) using 15 components of NCC met the predefined inclusion criteria. These components were placed into three main intervention strategies: (1) risk factor management (13 studies); (2) multidisciplinary consultation (11 studies) and (3) shared decision making (10 studies). Six trials combined NCC components from all three strategies. In total, 30 outcomes were observed. We summarised observed outcomes in four outcome categories: (1) risk factor levels (16 studies); (2) clinical events (7 studies); (3) patient-perceived health (7 studies) and (4) guideline adherence (3 studies). Compared with usual care, NCC lowered systolic blood pressure (weighted mean difference (WMD) 2.96 mm Hg; 95% CI 1.53 to 4.40 mm Hg) and low-density lipoprotein cholesterol (WMD 0.23 mmol/L; 95% CI 0.10 to 0.36 mmol/L). NCC also improved smoking cessation rates by 25% (risk ratio 1.25; 95% CI 1.08 to 1.43). NCC demonstrated to have an effect on a small number of outcomes. NCC that incorporated blood pressure monitoring, cholesterol control and smoking cessation has an impact on the improvement of secondary prevention. Additionally, NCC is a heterogeneous concept. A shared definition of NCC may facilitate better comparisons of NCC content and outcomes.

  14. Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.

    PubMed

    Towfighi, Amytis; Ovbiagele, Bruce; El Husseini, Nada; Hackett, Maree L; Jorge, Ricardo E; Kissela, Brett M; Mitchell, Pamela H; Skolarus, Lesli E; Whooley, Mary A; Williams, Linda S

    2017-02-01

    Poststroke depression (PSD) is common, affecting approximately one third of stroke survivors at any one time after stroke. Individuals with PSD are at a higher risk for suboptimal recovery, recurrent vascular events, poor quality of life, and mortality. Although PSD is prevalent, uncertainty remains regarding predisposing risk factors and optimal strategies for prevention and treatment. This is the first scientific statement from the American Heart Association on the topic of PSD. Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion. This multispecialty statement provides a comprehensive review of the current evidence and gaps in current knowledge of the epidemiology, pathophysiology, outcomes, management, and prevention of PSD, and provides implications for clinical practice.

  15. SLAP/SLAP2 prevent excessive platelet (hem)ITAM signaling in thrombosis and ischemic stroke in mice.

    PubMed

    Cherpokova, Deya; Bender, Markus; Morowski, Martina; Kraft, Peter; Schuhmann, Michael K; Akbar, Sarah M; Sultan, Cheryl S; Hughes, Craig E; Kleinschnitz, Christoph; Stoll, Guido; Dragone, Leonard L; Watson, Steve P; Tomlinson, Michael G; Nieswandt, Bernhard

    2015-01-01

    Glycoprotein VI and C-type lectin-like receptor 2 are essential platelet activating receptors in hemostasis and thrombo-inflammatory disease, which signal through a (hem)immunoreceptor tyrosine-based activation motif (ITAM)-dependent pathway. The adapter molecules Src-like adapter proteins (SLAP and SLAP2) are involved in the regulation of immune cell surface expression and signaling, but their function in platelets is unknown. In this study, we show that platelets expressed both SLAP isoforms and that overexpression of either protein in a heterologous cell line almost completely inhibited glycoprotein VI and C-type lectin-like receptor 2 signaling. In mice, single deficiency of SLAP or SLAP2 had only moderate effects on platelet function, whereas double deficiency of both adapters resulted in markedly increased signal transduction, integrin activation, granule release, aggregation, procoagulant activity, and thrombin generation in response to (hem)ITAM-coupled, but not G protein-coupled, receptor activation. In vivo, constitutive SLAP/SLAP2 knockout mice displayed accelerated occlusive arterial thrombus formation and a dramatically worsened outcome after focal cerebral ischemia. This was attributed to the absence of both adapter proteins in platelets, as demonstrated by adoptive transfer of Slap(-/-)/Slap2(-/-) platelets into wild-type mice. Our results establish SLAP and SLAP2 as critical inhibitors of platelet (hem)ITAM signaling in the setting of arterial thrombosis and ischemic stroke.

  16. Prevention: What You Can Do

    MedlinePlus

    ... this? Submit What's this? Submit Button Related CDC Web Sites Division for Heart Disease and Stroke Prevention ... this? Submit What's this? Submit Button Related CDC Web Sites Division for Heart Disease and Stroke Prevention ...

  17. Use of microencapsulated iron(II) fumarate sprinkles to prevent recurrence of anaemia in infants and young children at high risk.

    PubMed Central

    Zlotkin, Stanley; Antwi, Kojo Yeboah; Schauer, Claudia; Yeung, George

    2003-01-01

    OBJECTIVE: To compare the effectiveness of microencapsulated iron(II) fumarate sprinkles (with and without vitamin A), iron(II) sulfate drops, and placebo sprinkles in preventing recurrence of anaemia and to determine the long-term haematological outcomes in children at high risk of recurrence of anaemia 12 months after the end of supplementation. METHODS: A prospective, randomized, placebo-controlled design was used to study 437 Ghanaian children aged 8-20 months who were not anaemic (haemoglobin > or = 100 g/l). Four groups were given microencapsulated iron(II) fumarate sprinkles, microencapsulated iron(II) fumarate sprinkles with vitamin A, iron(II) sulfate drops or placebo sprinkles daily for six months. Primary outcome measures were change in haemoglobin and anaemic status at baseline and study end. Non-anaemic children at the end of the supplementation period were reassessed 12 months after supplementation ended. FINDINGS: Overall, 324 children completed the supplementation period. Among the four groups, no significant changes were seen in mean haemoglobin, ferritin or serum retinol values from baseline to the end of the supplementation period. During the trial, 82.4% (267/324) of children maintained their non-anaemic status. Sprinkles were well accepted without complications. At 12 months post-supplementation, 77.1% (162/210) of children with no intervention remained non-anaemic. This proportion was similar for children among the four groups. CONCLUSION: In most children previously treated for anaemia, further supplementation was not needed to maintain their non-anaemic status. These results may have important implications for community intervention programmes in which initial high-dose treatment is needed because of a high prevalence of anaemia. PMID:12756979

  18. Catalase prevents elevation of [Ca(2+)](i) induced by alcohol in cultured canine cerebral vascular smooth muscle cells: Possible relationship to alcohol-induced stroke and brain pathology.

    PubMed

    Li, Wenyan; Liu, Weimin; Altura, Bella T; Altura, Burton M

    2003-01-15

    Several studies have suggested that alcohol-induced brain injury is associated with generation of reactive oxygen species (ROS). The recent findings, that antioxidants (Vitamin E and pyrrolidine dithiocarbamate (PDTC)) prevent intracellular Ca(2+) ([Ca(2+)](i)) overload in cerebral vascular smooth muscle cells, induced by alcohol, demonstrate indirectly that ROS formation is related to cerebral vascular injury. The present experiments were designed to test the hypothesis that catalase, an hydrogen peroxide (H(2)O(2)) scavenging enzyme, can prevent or ameliorate alcohol-induced elevation of [Ca(2+)](i). Preincubation of cultured canine cerebral vascular smooth muscle cells with catalase (20-1000 units/ml) didn't produce any apparent changes from controls in resting levels of [Ca(2+)](i) after 1-3 days. Exposure of the cerebral vascular cells to culture media containing 10-100mM ethanol resulted in significant rises in [Ca(2+)](i) (p<0.01). Although exposure of these cells to a low concentration of catalase (20 units/ml) failed to prevent the increased level of [Ca(2+)](i) induced by ethanol, concomitant addition of higher concentrations of catalase (100-1000 units/ml) and ethanol (10-100mM) inhibited or ameliorated the rises of [Ca(2+)](i) induced by ethanol either at 24h or at 3 days, in a concentration-dependent manner. Catalase, in the range of 100-200 units/ml, inhibited approximately 50% of the [Ca(2+)](i) increases caused by ethanol in the first 24h. Catalase at a concentration of 1000 units/ml inhibited completely excessive [Ca(2+)](i) accumulation. The present results when viewed in light of other recently published data suggest that H(2)O(2) generation may be one of the earliest events triggered by alcohol in alcohol-induced brain-vascular damage, neurobehavioral actions and stroke.

  19. Recurrent facial urticaria following herpes simplex labialis.

    PubMed

    Zawar, Vijay; Godse, Kiran

    2012-03-01

    We describe recurrent acute right-sided facial urticaria associated with herpes labialis infection in a middle-aged female patient. Antiviral medications and antihistamines not only successfully cleared the herpes infection and urticaria but also prevented further recurrences.

  20. Anticoagulation for the prevention of stroke in non-valvular AF in general practice: room for improvement

    PubMed Central

    Ioannou, Adam; Metaxa, Sofia; Kassianos, George; Missouris, Constantinos G.

    2016-01-01

    Objective: Our aim was to assess whether the recommendations and guidelines for thromboprophylaxis in patients with atrial fibrillation (AF) have been adopted in general practice (GP). Methods: We conducted a retrospective study using the GP computer database (Hatfield, UK) on all 9400 patients to assess the quality of anticoagulation in patients with a recorded diagnosis of AF. Results: Of the 180 patients with a diagnosis of AF, 107 (59.4%) were treated with warfarin, 19 (10.6%) with a novel oral anticoagulant (NOAC), 31 (17.2%) with aspirin or clopidogrel, and 23 (12.8%) received none. Thirty-seven patients (34.6%) who were taking warfarin had a time in the therapeutic range (TTR) of less than 65%. Forty-five (27.6%) of the 163 patients who had a CHA2DS2VASc score of two or more were not prescribed a vitamin K antagonist (VKA) or a NOAC. None had a HAS-BLED greater than the CHA2DS2VASc score. Conclusion: Our study demonstrates that one in four patients with non-valvular AF, at risk of a stroke, is not being adequately treated with an oral anticoagulant in primary care. The majority were treated with warfarin, a third of which had a low TTR. A high proportion of patients are prescribed antiplatelet therapy instead. This is despite overwhelming evidence that VKAs and NOACs, and not aspirin or clopidogrel, improve outcome in patients with non-valvular AF. We suggest that a review of GP practice databases should be considered to identify patients with non-valvular AF, at risk of a disabling or fatal event, and measures taken to initiate anticoagulant therapy. PMID:27403193

  1. [Oral loading dose of phenytoin in the treatment of serial seizures, prevention of seizure recurrence and rapid drug substitution].

    PubMed

    Sokić, D; Janković, S M

    1994-01-01

    Over a period of nine months twenty-five epileptic patients were treated with the oral loading dose of phenytoin. The dose ranged from 12 to 23 mg/kg body weight during 1 to 12 hours. In 20 patients with serial seizures or intolerance to other antiepileptic drugs this treatment was effective. Seizures also stopped in 2 of 4 patients with serial partial motor seizures. These 2 patients required both higher loading dose and faster rate of administration than the other patients. A patient with epilepsia partialis continua failed to respond to the treatment. Patients that received phenytoin through the naso-gastric tube, in respect to oral administration, required higher doses to obtain therapeutic plasma levels of phenytoin. One patient had mild nausea, 3 mild dizziness, and 1 tinitus on the first day of the treatment. There was no correlation between a given dose and the achieved phenytoin plasma levels. In our opinion the therapy with oral loading dose of phenytoin is highly effective in the treatment of serial generalized seizures and rapid antiepileptic drug substitution, and partially effective in the prevention of partial motor seizures. It produces only mild and transient side-effects.

  2. Urinary Metabolites of Prostanoids and Risk of Recurrent Colorectal Adenomas in the Aspirin/Folate Polyp Prevention Study (AFPPS)

    PubMed Central

    Fedirko, Veronika; Bradshaw, Patrick T.; Figueiredo, Jane C.; Sandler, Robert S.; Barry, Elizabeth L.; Ahnen, Dennis J.; Milne, Ginger L.; Bresalier, Robert; Baron, John A.

    2015-01-01

    Aspirin has been shown to protect against colorectal neoplasms, however the optimal chemopreventive dose and underlying mechanisms are unclear. We aimed to study the relationship between prostanoid metabolites and aspirin’s effect on adenoma occurrence. We used data from the Aspirin/Folate Polyp Prevention Study, in which 1,121 participants with a recent adenoma were randomized to placebo or two doses of aspirin (81 or 325 mg/d) to be taken until the next surveillance colonoscopy, anticipated about 3 years later. Urinary metabolites of prostanoids (PGE-M, PGI-M, and dTxB2) were measured using LC/MS or GC/NICI-MS in 876 participants near the end of treatment follow-up. Poisson regression with a robust error variance was used to calculate relative risks and 95% confidence intervals. PGE-M, PGI-M, and dTxB2 levels were 28%, 37%, and 60% proportionately lower, respectively, in individuals who took 325 mg of aspirin compared to individuals who took placebo (all P<0.001). Similarly, among individuals who took 81 mg of aspirin, PGE-M, PGI-M, and dTxB2 were, respectively, 18%, 30%, and 57% proportionally lower compared to placebo (all P<0.005). None of the metabolites or their ratios were statistically significantly associated with the risk of adenoma occurrence. The effect of aspirin in reducing adenoma risk was independent of prostanoid levels. Aspirin use is associated with lower levels of urinary prostanoid metabolites. However, our findings do not support the hypothesis that these metabolites are associated with adenoma occurrence, suggesting that COX-dependent mechanisms may not completely explain the chemopreventive effect of aspirin on colorectal neoplasms. PMID:26304466

  3. Recurrent MRSA skin infections in atopic dermati