This public health brief draws attention to the issue of ischemic heart disease that is currently plaguing Panama. Due largely to the dietary culture of the country, ischemic heart disease remains the number one health-related killer of Panamanians. Over the past few decades, there has been a stark increase in the amount of processed foods that are becoming a large part of the diets of western nations, and Panama has become no stranger to this trend. Although there have been great strides made in the treatment of ischemic heart disease, Panama still has a long road ahead of itself before the disease is eradicated. With joint efforts between the Panamanian government and its people, ischemic heart disease can soon become part of the country's history.
Health care costs continue to rise toward unsustainable levels that will affect our nation's ability to support other key funding priorities for education, military, and infrastructure. Changing the way we deliver health care is critical to mitigating this financial crisis. This review highlights opportunities for redesigning care of acute ischemic stroke and TIA to maintain quality while substantially lowering costs. The recent innovations described are (1) adopting teleneurology networks to improve access to thrombolysis for acute ischemic stroke; (2) improving efficiency of emergency care for acute ischemic stroke; and (3) providing alternatives to inpatient care for TIA. Applying such process innovations will enable us to achieve the goal of patients and the nation—high-quality care at an affordable cost.
Remote ischemic conditioning (RIC) is a promising therapeutic approach for ischemic stroke patients. It has been proven that RIC reduces infarct size and improves functional outcomes. RIC can be applied either before ischemia (pre-conditioning; RIPreC), during ischemia (per-conditioning; RIPerC) or after ischemia (post-conditioning; RIPostC). Our aim was to systematically determine the efficacy of RIC in reducing infarct volumes and define the cellular pathways involved in preclinical animal models of ischemic stroke. A systematic search in three databases yielded 50 peer-review articles. Data were analyzed using random effects models and results expressed as percentage of reduction in infarct size (95% CI). A meta-regression was also performed to evaluate the effects of covariates on the pooled effect-size. 95.3% of analyzed experiments were carried out in rodents. Thirty-nine out of the 64 experiments studied RIPostC (61%), sixteen examined RIPreC (25%) and nine tested RIPerC (14%). In all studies, RIC was shown to reduce infarct volume (− 38.36%; CI − 42.09 to − 34.62%) when compared to controls. There was a significant interaction caused by species. Short cycles in mice significantly reduces infarct volume while in rats the opposite occurs. RIPreC was shown to be the most effective strategy in mice. The present meta-analysis suggests that RIC is more efficient in transient ischemia, using a smaller number of RIC cycles, applying larger length of limb occlusion, and employing barbiturates anesthetics. There is a preclinical evidence for RIC, it is safe and effective. However, the exact cellular pathways and underlying mechanisms are still not fully determined, and its definition will be crucial for the understanding of RIC mechanism of action. ; This study was supported by the Government of Catalonia-Agència de Gestió d'Ajuts Universitaris i de Recerca (FP: 2017 SGR 1628), Instituto de Salud Carlos III and co-funded by European Union (ERDF/ESF, "Investing in your future") (FP: Project PI17-01725) and the INVICTUS plus Research Network (Carlos III Health Institute). C.T-Q. was supported by a Grant from Contratos predoctorales de formación en investigación en salud (PFIS; FI18/00319).
Rationale: Remote ischemic perconditioning during cerebral ischemia (RIPerC) refers to the application of brief episodes of transient limb ischemia commonly to a limb, it represents a new safe, simple and low-cost paradigm in neuroprotection. Aim and/or Hypothesis: To evaluate the effects of RIPerC on acute ischemic stroke (AIS) patients, applied in the ambulance, to improve functional outcomes compared with standard of care. Sample Size Estimates: A sample size of 286 patients in each arm achieves 80% power to detect treatment differences of 14% in the outcome, using a two-sided binomial test at significance level of 0.05, assuming that 40% of the control patients will experience good outcome and an initial misdiagnosis rate of 29%. Methods and Design: We aim to conduct a multicentre study of pre-hospital RIPerC application in AIS patients. A total of 572 adult patients diagnosed of suspected clinical stroke within 8 h of symptom onset and clinical deficit >0 according to prehospital rapid arterial occlusion evaluation (RACE) scale score will be randomized, in blocks of size 4, to RIPerC or sham. Patients will be stratified by RACE score scale. RIPerC will be started in the ambulance before hospital admission and continued in the hospital if necessary. It will consist of five cycles of electronic tourniquet inflation and deflation (5 min each). The cuff pressure for RIPerC will be 200 mmHg during inflation. Sham will only simulate vibration of the device. Study Outcome(s): The primary outcome will be the difference in the proportion of patients with good outcomes as defined by a mRS score of 2 or less at 90 days. Secondary outcomes to be monitored will include early neurological improvement rate, treatment related serious adverse event rates, size of the infarct volume, symptomatic intracranial hemorrhage, metabolomic and lipidomic response to RIPerC and Neuropsychological evaluation at 90 days. Discussion: Neuroprotective therapies could not only increase the benefits of available reperfusion therapies among AIS patients but also provide an option for patients who are not candidates for these treatments. REMOTE-CAT will investigate the clinical benefit of RIC as a new neuroprotective strategy in AIS. ; Aquest treball ha estat finançat per: l'Agència de Gestió d'Ajuts Universitaris i de Recerca de la Generalitat de Catalunya 2017 SGR 1628, Instituto de Salud Carlos III, European Union (EU) PI17-01725 i INVICTUS plus Research Network (Carlos III Health Institute)
Ischemic optic neuropathy is one of the major causes of severe impairment of vision often leading to blindness. It has varied etiopathogenesis with limited management options and very often result in poor outcome. Perioperative ischemic optic neuropathy is rare and particularly seen in elderly patients with multiple comorbidities undergoing cardiac or spine surgery. We present a case of young patient who developed ischemic optic neuropathy following craniotomy for recurrent meningioma.Keywords: Ischemic optic neuropathy; optic nerve vasculature; painless vision loss; perioperative complications; perioperative optic nerve ischemia
This updated second edition of "Acute Ischemic Stroke: Imaging and Intervention" provides a comprehensive account of the state of the art in the diagnosis and treatment of acute ischemic stroke. The basic format of the first edition has been retained, with sections on fundamentals such as pathophysiology and causes, imaging techniques and interventions. However, each chapter has been revised to reflect the important recent progress in advanced neuroimaging and the use of interventional tools. In addition, a new chapter is included on the classification instruments for ischemic stroke.
Ischemic stroke, caused by the interruption of blood flow to the brain and subsequent neuronal death, represents one of the main causes of disability in developed countries. Therapeutic methods such as recanalization approaches, neuroprotective drugs, or recovery strategies have been widely developed to improve the patient's outcome; however, important limitations such as a narrow therapeutic window, the ability to reach brain targets, or drug side effects constitute some of the main aspects that limit the clinical applicability of the current treatments. Nanotechnology has emerged as a promising tool to overcome many of these drug limitations and improve the efficacy of treatments for neurological diseases such as stroke. The use of nanoparticles as a contrast agent or as drug carriers to a specific target are some of the most common approaches developed in nanomedicine for stroke. Throughout this review, we have summarized our experience of using nanotechnology tools for the study of stroke and the search for novel therapies ; This project was supported by the FRQS, ISCIII (AC19/00031 and AC20/00041), and ANR under the framework of EuroNanoMed III_2020 (PLATMED_project); the European Union program FEDER and the European Regional Development Fund–ERDF; and the Xunta de Galicia (IN607D2020/03 and ED431G2019/03). E.P. and B.P acknowledge the AEI grants (PID2019-111218RB-I00 and RyC-2017-23457). Finally, F.C. thanks the ISCIII and Miguel Servet program (CPII19/00020) ; SI
Objective: Stroke is a major health problem, yet no studies on stroke have been reported from Palestine. This one-year, hospital-based study was conducted to determine the prevalence of risk factors and the in-hospital mortality rate in patients with ischemic stroke. Method: All patients admitted to Al-Watani government hospital and diagnosed with ischemic stroke between September 2006 and August 2007 were included in the study. Data were obtained by retrospective review of medical charts. Pearson Chi-square and independent t test were used in the univariate analysis. Multiple logistic regression analysis was used to determine the independent predictors of in-hospital mortality rates among the patients. Statistical testing and graphics were carried out using SPSS 15. Results: We identified 153 ischemic stroke patients (83 females and 70 males) of whom 92 were having a first-ever stroke (FES). Patients had several prevalent modifiable risk factors such as hypertension (HTN) (66%), diabetes mellitus (DM) (45.8%), and renal reduced renal function (crcl < 60 ml/ min) (33.9%). Twenty-six (17%) of the patients died during hospitalization. Four variables were significantly associated with in-hospital mortality: history of previous stroke (P= 0.004), crcl at admission (P = 0.004), number of post-stroke complications (P = 0.001), and age (P = 0.043). Multiple logistic regression analysis indicated that the number of post-stroke complications (P= 0.001) and previous stroke (P = 0.03) were significant independent predictors of in-hospital mortality. Conclusion: Screening and better control of risk factors, especially HTN, DM and renal dysfunction, are required to decrease the incidence and in-hospital mortality among patients with ischemic stroke.
Background: Remote ischemic conditioning during cerebral ischemia (remote ischemic perconditioning, RIPerC) refers to the application of several cycles of brief ischemia and reperfusion (I/R) commonly to a limb, and it represents a new paradigm in neuroprotection with multiple mechanisms of action in ischemic stroke (IS) patients during acute phase. Some clinical trials just finished, and a few others are still ongoing; gather the current knowledge and pull it down to influence the present and future studies was the goal of this paper. Methods: A systematic review of published research papers and/or registered clinical trials since 2000 was performed. Results: Nineteen studies were identified and only four studies were completed. All of them have demonstrated that RIPerC is safe, feasible and well tolerated in IS patients. However, a high heterogeneity of clinical trial characteristics was observed: five (26.3%) randomized clinical trials (RCTs) included only thrombolytic-treated patients, three (15.8%) RCTs only thrombectomy-treated patients, and five (26.3%) RCTs required radiological confirmation of IS. Temporal inclusion criteria vary from 4 h to 48 h. Most of the clinical trials used 4 cycles of RIPerC in the upper non-affected limb. Interestingly, only three (16.7%) RCTs applied RIPerC during the transportation in the ambulance. Neuroimaging outputs were the main endpoints when endovascular therapy was applied; functional outcome is also the main endpoint in large-medium size studies. Conclusions: This review summarizes the completed and ongoing clinical trials on RIPerC in IS patients, where RIPerC has been used alone or in combination with recanalization therapies. Ongoing clinical trials will provide new information on the best RIPerC intervention strategy and potentially improve the functional outcome of IS patients; definition of new RIPerC strategies would ideally aim at enhancing tissue preservation, promoting neurological recovery, and stratify patients to improve treatment feasibility. ; This study was supported by the Government of Catalonia-Agència de Gestió d'Ajuts Universitaris i de Recerca (FP: 2017 SGR 1628), Instituto de Salud Carlos III and co-funded by European Union (ERDF/ESF, "A way to make Europe") (FP: Project PI17–01725) and the INVICTUS plus Research Network (Carlos III Health Institute).
Transient-ischemic attacks (TIA) as precursors of cerebral strokes occupy an important place among all forms of cerebrovascular insufficiency. With regard to the epidemiology of transient ischemic attacks (TIA), most countries do not have accurate data. So, in the US, they carry up to 5 million adult citizens per year, with many TIAs remaining undiagnosed. These episodes of sudden and short-term neurological deficit were considered benign and harmless for a long time. Most general practitioners and patients incorrectly or insufficiently understand the nature and significance of TIA, perhaps this can explain the small interest of doctors and the lack of statistical data on this nosological unit. Transient ischemic attacks (TIA) are defined clinically as rapidly occurring focal and less commonly diffuse (cerebral) dysfunctions of the brain that are caused by local ischemia and disappear within one day (Gafurov: 2006). Over the past two decades, many views on TIA have changed significantly; approaches to the diagnosis and treatment of patients have become much more intense and more aggressive. Current knowledge of TIA is of great importance both for the proper organization of patient care and for educational programs among the population, the importance of which cannot be overestimated.
Background and objective: Anti-hypertensive medications are recommended for prevention of recurrent ischemic stroke in hypertensive and normotensive patients. The objective of this study was to analyze the use of anti-hypertensive therapy in acute ischemic stroke survivors.Methods: All ischemic stroke survivors discharged from Al-watani governmental hospital in Palestine from August 2006 until September 2007 were investigated. Demographic data, clinical characteristics, and different classes of anti-hypertensive medications prescribed to stroke survivors were analyzed using SPSS 15.Results: One hundred and twenty four ischemic stroke survivors were identified, of which 80 (64.5%) had a documented history of hypertension (HTN). Two thirds of the survivors (n = 82; 66.1%) were prescribed anti-hypertensive medications, mostly as mono-therapy, at discharge. Angiotensin-converting enzyme inhibitors (ACEI) 65 (45.6%), followed by diuretics 41 (34.5%) were the most common drug classes prescribed. ACEI were used in combination with diuretics in 29 (23.4%) survivors. Among survivors with a documented history of HTN, 70 (85.5%) were prescribed anti-hypertensive medications at discharge while 12 (8.5%) of survivors with no history of HTN were prescribed anti-hypertensive medications at discharge.Conclusion: In this study, the use of anti-hypertensive medications as a mono-therapy was common among those with a history of hypertension but not among those without a history of hypertension.
Background Several studies linked the use of levodopa to an increase in homocysteine level, which can lead eventually to ischemic heart disease (IHD) in Parkinson's disease (PD) patients. There is a lack of large population studies that have investigated the cardiovascular safety of levodopa.
Objectives The main objective of the study is to investigate the one-year risk of IHD hospitalisation, all-cardiovascular hospital hospitalisation, and all-cause mortality among users of L-dopa compared with users of Monoamine oxidase B (MAO-B) inhibitors (as a reference).
Methods A population-based study evaluated data obtained from the Secure Anonymised Information Linkage (SAIL) Databank of residents in Wales, aged 40 years or older, newly treated with PD medications between 2000 and 2016. The General Practice (GP) database was used to identify the PD diagnostic codes, PD medications, and other medications used by PD patients. Hospital data were used to identify the first hospitalisation event (IHD and other cardiovascular events). A fully adjusted propensity score multivariate Cox regression analysis was used to examine associations between levodopa and the study outcomes. The index date was set at the date of the first PD prescription in the newly diagnosed PD patients. Other variables included gender, comorbidities, social deprivation score and previous medications history were controlled for.
Findings There were 5,140 participants on levodopa and 494 on MAO-B inhibitors. L-dopa was not associated with IHD (p=0.561), other cardiovascular events (p=0.233), or all-cause mortality (p=0.334). For IHD, the lack of difference was seen also in the unadjusted model and in the age-only adjusted model.
Conclusion This study has shown that L-dopa does not increase the risk of IHD, cardiovascular risk, or all-cause mortality in the newly diagnosed PD patient within one year after the therapy initiation. This could contribute to the safety profile of L-dopa therapy. Future research with a longer follow up period is warranted.
Aquest treball ha estat finançat per: l'Agència de Gestió d'Ajuts Universitaris i de Recerca de la Generalitat de Catalunya 2017 SGR 1628, Instituto de Salud Carlos III, European Union (EU) PI17-01725 i PI14/01574, IRBLleida Biobank B.0000682, Plataforma Biobancos PT17/0015/0027
OBJECTIVE: Transesophageal echocardiography (TEE) is sometimes used to search for cardioembolic sources after ischemic stroke or transient ischemic attack (TIA). TEE visualizes some sources better than transthoracic echocardiography, but TEE is invasive and may cause aspiration. Few data exist on the risk of respiratory complications after TEE in patients who had stroke or TIA. Our objective was to determine whether TEE was associated with increased risk of respiratory failure in patients who had ischemic stroke or TIA. DESIGN: This is a retrospective cohort study using administrative data from inpatient and outpatient insurance claims collected by the US federal government's Centers for Medicare and Medicaid Services. SETTING: Hospitals and outpatient clinics throughout the USA. PARTICIPANTS: 99 081 patients ≥65 years old hospitalized for out-of-hospital ischemic stroke or TIA, defined by validated International Classification of Disease-9/10 diagnosis codes and present-on-admission codes, using claims data from 2008 to 2018 in a random 5% sample of Medicare beneficiaries. MAIN OUTCOME MEASURES: Acute respiratory failure, defined as endotracheal intubation and/or mechanical ventilation, starting on the first day after admission through 28 days afterward. RESULTS: Of 99 081 patients included in this analysis, 73 733 (74.4%) had an ischemic stroke and 25 348 (25.6%) a TIA. TEE was performed in 4677 (4.7%) patients and intubation and/or mechanical ventilation in 1403 (1.4%) patients. The 28-day cumulative risk of respiratory failure after TEE (1.4%; 95% CI 0.8% to 2.7%) was similar to that seen in those without TEE (1.4%; 95% CI 1.4% to 1.5%) (p=0.84). After adjustment for age, sex, race, Charlson comorbidities, diagnosis of stroke versus TIA, intravenous thrombolysis, and mechanical thrombectomy, TEE was not associated with an increased risk of respiratory failure (HR, 0.9; 95% CI 0.6 to 1.2). CONCLUSIONS: In a cohort of older patients who had ischemic stroke or TIA, TEE was not associated with an increased risk ...
