Summary Background Intravenous thrombolysis with alteplase alone cannot reperfuse most large-artery strokes. We aimed to determine whether mechanical thrombectomy in addition to intravenous ...thrombolysis improves clinical outcome in patients with acute ischaemic stroke. Methods THRACE is a randomised controlled trial done in 26 centres in France. Patients aged 18–80 years with acute ischaemic stroke and proximal cerebral artery occlusion were randomly assigned to receive either intravenous thrombolysis alone (IVT group) or intravenous thrombolysis plus mechanical thrombectomy (IVTMT group). Intravenous thrombolysis (alteplase 0·9 mg/kg maximum 90 mg, with an initial bolus of 10% of the total dose followed by infusion of the remaining dose over 60 min) had to be started within 4 h and thrombectomy within 5 h of symptom onset. Occlusions had to be confirmed by CT or magnetic resonance angiography. Randomisation was done centrally with a computer-generated sequential minimisation method and was stratified by centre. The primary outcome was the proportion of patients achieving functional independence at 3 months, defined by a score of 0–2 on the modified Rankin scale, assessed in the modified intention-to-treat population (ie, patients lost to follow-up and those with missing data were excluded). Safety outcomes were analysed in the per-protocol population (ie, all patients who did not follow the protocol of their randomisation group precisely were excluded from the analysis). THRACE is registered with ClinicalTrials.gov , NCT01062698. Findings Between June 1, 2010, and Feb 22, 2015, 414 patients were randomly assigned to the IVT group (n=208) or the IVTMT group (n=204). Four patients (two in each group) lost to follow-up and six (four in the IVT group and two in the IVTMT group) with missing data were excluded. 85 (42%) of 202 patients in the IVT group and 106 (53%) of 200 patients in the IVTMT group achieved functional independence at 3 months (odds ratio 1·55, 95% CI 1·05–2·30; p=0·028). The two groups had no significant differences in mortality at 3 months (24 12% deaths of 202 patients vs 27 13% of 206; p=0·70) or symptomatic intracranial haemorrhage at 24 h (four 2% of 185 vs three 2% of 192; p=0·71). Common adverse events related to thrombectomy were vasospasm (33 23% patients) and embolisation in a new territory (nine 6%). Interpretation Mechanical thrombectomy combined with standard intravenous thrombolysis improves functional independence in patients with acute cerebral ischaemia, with no evidence of increased mortality. Bridging therapy should be considered for patients with large-vessel occlusions of the anterior circulation. Funding French Ministry for Health.
•Determining reproducibility is necessary to interpret gait changes after treatment.•The outcome measurements were highly reliable over a one-week period.•The MDC95 should be used as a cut-off rather ...than MICD values.
Gait limitation is one of the most common disabilities in people with multiple sclerosis (MS). Several studies have used gait parameters to determine the effects of different therapies. However, few studies have determined their reproducibility, also the therapeutic effects could be overestimated.
To examine the reproducibility in gait measurements during short and long distances.
In this cross-sectional study we recruited a group of MS patients and compare it to a control group. The participants performed the following tests in a fixed order: a 25-foot walk at a comfortable speed, at a fast speed and during a dual task, a timed up-and-go test (TUG) and a six- minute walk test (6MWT). Two measurements were conducted a week apart. Systematic error was evaluated by the Student t-test, reliability by the intra-class correlation coefficients (ICC) and agreement by the minimum detectable change (MDC95).
A total of 58 people with MS and 19 healthy people were included. The absence of systematic error was only found for the fast speed condition. The reliability of the gait parameters had moderate to high ICC values (ICC > 0.7) except for the dual task cost (DTC) which was 0.45. The MDC95 was higher in people with MS compared to healthy people, and it was higher in people with MS for gait speeds in all conditions (> 34%). For the TUG and 6MWT, the MDC95 were 51.5% and 31.7% respectively. For people with MS the smallest MDC95 was found for the stance time for all conditions (6.8%), whereas the highest was found for the dual task cost (158.7%).
The MDC95 values were higher than the cut-off point based on the minimally important clinical difference (MICD) proposed in previous studies. Thus, the MDC95 should be used as a cut-off rather than MICD values.
The assessment of the functional performance status of persons with multiple sclerosis (PwMS) is a useful tool to optimize healthcare. This concept does not seem to be extensively explored in this ...population. This study aimed to determine the level of activity of PwMS during weekdays and weekends, and to establish associations between clinical parameters. Forty-one PwMS and 16 healthy persons participated in this study. Their physical activity in real-life conditions was assessed with an accelerometer. For the clinical evaluations, the quality of life, fatigue, gait, and balance were assessed. The level of activity between PwMS for weekdays, weekends, Saturdays, and Sundays was significantly reduced compared with the reference group (p = 0.001–0.00001, d = 0.95–1.76). PwMS had a constant level of activity throughout the week, whereas the reference group increased its level of activity on Saturdays (p = 0.04, d = 0.69). The level of activity was correlated in descending order with multiple sclerosis disability, body mass index, gait velocity, six-minute walk test, and timed up and go test. This study showed that PwMS had a stable level of activity throughout the week, contrary to healthy persons. It could be necessary to develop programs to facilitate physical activity and participation during the weekdays, but especially during weekends.
Intracranial hemorrhage is one of the most feared complications following brain infarct. Ischemic tissues have a natural tendency to bleed. Moreover, the first recanalization trials using intravenous ...thrombolysis have shown an increase in mild to severe intracranial hemorrhage. Symptomatic intracerebral hemorrhage is strongly associated with poor outcomes and is an important factor in recanalization decisions. Stroke physicians have to weigh the potential benefit of recanalization therapies, first, with different risks of intracranial hemorrhage described in randomized controlled trials, and second with numerous risk markers that have been found to be associated with intracranial hemorrhage in retrospective series. These decisions have become quite complex with different intravenous thrombolytics and mechanical thrombectomy. This review aims to outline some elements of the pathophysiological mechanisms and classifications, describe most of the risk factors identified for each reperfusion therapy, and finally suggest future research directions that could help physicians dealing with these complications.
Summary Background Hemiplegia and hemiparesis are the most common deficits caused by stroke. A few small clinical trials suggest that fluoxetine enhances motor recovery but its clinical efficacy is ...unknown. We therefore aimed to investigate whether fluoxetine would enhance motor recovery if given soon after an ischaemic stroke to patients who have motor deficits. Methods In this double-blind, placebo-controlled trial, patients from nine stroke centres in France who had ischaemic stroke and hemiplegia or hemiparesis, had Fugl-Meyer motor scale (FMMS) scores of 55 or less, and were aged between 18 years and 85 years were eligible for inclusion. Patients were randomly assigned, using a computer random-number generator, in a 1:1 ratio to fluoxetine (20 mg once per day, orally) or placebo for 3 months starting 5–10 days after the onset of stroke. All patients had physiotherapy. The primary outcome measure was the change on the FMMS between day 0 and day 90 after the start of the study drug. Participants, carers, and physicians assessing the outcome were masked to group assignment. Analysis was of all patients for whom data were available (full analysis set). This trial is registered with ClinicalTrials.gov , number NCT00657163. Findings 118 patients were randomly assigned to fluoxetine (n=59) or placebo (n=59), and 113 were included in the analysis (57 in the fluoxetine group and 56 in the placebo group). Two patients died before day 90 and three withdrew from the study. FMMS improvement at day 90 was significantly greater in the fluoxetine group (adjusted mean 34·0 points 95% CI 29·7–38·4) than in the placebo group (24·3 points 19·9–28·7; p=0·003). The main adverse events in the fluoxetine and placebo groups were hyponatraemia (two 4% vs two 4%), transient digestive disorders including nausea, diarrhoea, and abdominal pain (14 25% vs six 11%), hepatic enzyme disorders (five 9% vs ten 18%), psychiatric disorders (three 5% vs four 7%), insomnia (19 33% vs 20 36%), and partial seizure (one <1% vs 0). Interpretation In patients with ischaemic stroke and moderate to severe motor deficit, the early prescription of fluoxetine with physiotherapy enhanced motor recovery after 3 months. Modulation of spontaneous brain plasticity by drugs is a promising pathway for treatment of patients with ischaemic stroke and moderate to severe motor deficit. Funding Public French National Programme for Clinical Research.
Telemedicine is a remote medical practice that is progressively expanding in France. In 2018, regulatory changes authorised telemedicine to become part of daily clinical practice. Telemedicine ...education and training (ET), however, has not been widespread, despite its integration in the medical curriculum since 2009. The objective of this study was to examine the self-perceived knowledge, attitudes and practices (KAP) and ET of telemedicine ET from medical students and residents in France.
A national survey was distributed online (15 December 2018 to 3 March 2019) to approximately 135,000 medical students and residents in medical schools (
= 38). The survey consisted of a total of 24 binary and Likert-scale questions covering telemedicine ET and KAP.
In total, 3,312 medical students and residents completed the survey. Synchronous video consultation was the most well-known telemedicine activity (86.9%); asynchronous tele-expertise was the least recognised (40.3%). Most respondents (84.8%) stated they were not familiar with telemedicine regulations. The relevance of telemedicine for improving access to care was acknowledged by 82.8% of students and residents; 14% of respondents stated they had previously practised telemedicine during their studies; 14.5% stated they had received telemedicine ET; however, 97.9% stated they were not sufficiently trained.
This is the first national scale study on telemedecine ET by medical students and residents, to date. Despite positive attitudes, participants were found to have limited telemedicine ET, knowledge and practices. The demand for telemedicine ET is increasing. Such studies that incorporate the perspectives of medical students and residents may strengthen the implementation of telemedicine ET in the future.
Since the beginning of the 20th century, electroencephalography (EEG) has been used in a wide variety of applications, both for medical needs and for the study of various cerebral processes. With the ...rapid development of the technique, more and more precise and advanced tools have emerged for research purposes. However, the main constraints of these devices have often been the high price and, for some devices the low transportability and the long set-up time. Nevertheless, a broad range of wireless EEG devices have emerged on the market without these constraints, but with a lower signal quality. The development of EEG recording on multiple participants simultaneously, and new technological solutions provides further possibilities to understand the cerebral emotional dynamics of a group. A great number of studies have compared and tested many mobile devices, but have provided contradictory results. It is therefore important to test the reliability of specific wireless devices in a specific research context before developing a large-scale study. The aim of this study was to assess the reliability of two wireless devices (g.tech Nautilus SAHARA electrodes and Emotiv™ Epoc +) for the detection of musical emotions, in comparison with a gold standard EEG device. Sixteen participants reported feeling emotional pleasure (from low pleasure up to musical chills) when listening to their favorite chill-inducing musical excerpts. In terms of emotion detection, our results show statistically significant concordance between Epoc + and the gold standard device in the left prefrontal and left temporal areas in the alpha frequency band. We validated the use of the Emotiv™ Epoc + for research into musical emotion. We did not find any significant concordance between g.tech and the gold standard. This suggests that Emotiv Epoc is more appropriate for musical emotion investigations in natural settings.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Some students have neurodevelopmental disorders that might affect their academic and professional careers if they are not identified and addressed by specific pedagogic adaptations. The objective of ...this work was to describe medical teachers' opinions of students with neurodevelopmental disorders and their management of these students.
An anonymous cross-sectional electronic survey was performed to describe medical teachers' opinions about the impact of neurodevelopmental disorders on the student's life and on the medical teachers' management. aThe survey was created, including visual analogic scales and free text, to assess teachers' opinions from identification and assessment of neurodevelopemental burden on students and teachers, to their own knowledge about neurodevelopemental disorders and the specific pedagogic management available. The survey was sent to 175 medical teachers in 2019, of whom 67 responded. Quantitative descriptive statistics and qualitative analysis of free text were reported.
Many medical teachers report having encountered students who might have had neurodevelopmental disorders (dyspraxia 33%; dyslexia 46%; autism spectrum disorders 68%; attention deficit hyperactivity disorders 75%). Impact on students and on teachers was considered as important (mean VAS score for impact over 60/100 for all syndromes except for dyspraxia). Medical teachers' self-reported knowledge about neurodevelopmental disorders (mean VAS score 43.9/100) and available pedagogical adaptations (mean VAS score 19.0/100) was limited. The teachers were concerned about ethical issues (mean VAS score 72.2/100) but were interested in receiving specialized training (mean VAS score 64.4/100).
Medical teachers feel unprepared to manage students with neurodevelopmental disorders. They would be interested in specific training and procedures about the pedagogic management of these students.
Music has the capacity to elicit strong positive feelings in humans by activating the brain’s reward system. Since group’s emotional dynamics is a central concern of social neurosciences, the study ...of emotion in natural/ecological conditions gain interest. This study aimed to show that High Density EEG (HD-EEG) is able to reveal patterns of cerebral activities previously identified by fMRI or PET scans when the subject experiences pleasurable musical chills. Participants (11 female, 7 male) were recorded by HD-EEG while listening to their favourite pleasurable chill-inducing musical excerpt; they reported their subjective emotional state from low pleasure up to chills. HD-EEG results showed an increase of theta activity in the prefrontal cortex when arousal and emotional ratings increased, which are associated with orbitofrontal cortex activation localised using source localisation algorithms. In addition, two specific pattern of chills has been identified; a decreased theta activity in the right central region could reflect supplementary motor area (SMA) activation during chills, may be related to rhythmic anticipation processing. A decreased theta activity in the right temporal region may be related to musical appreciation. The alpha frontal/prefrontal asymmetry did not reflect the felt emotional pleasure but the increased arousal (frontal beta/alpha ratio) corresponded to increased emotional ratings. These results correspond with fMRI and PET findings, thus confirming that EEG is a reliable method and a promising tool for the investigation of group musical pleasure through musical reward processing.
The presence of a Susceptibility Vessel Sign (SVS) in the acute phase of proximal occlusion ischemic stroke indicates the presence of deoxyhemoglobin in the thrombus. Thrombi composition changes over ...time. The aim of this study was to investigate whether the absence of SVS is associated with a shorter symptom onset to imaging time.
We retrospectively analyzed all patients referred for mechanical thrombectomy at Besançon University Hospital between 1 January 2015 and 31 December 2020 for whom readable T2
-weighted imaging was available. We compared patient characteristics according to the presence or absence of an SVS. We also studied the subgroup for whom the exact symptom onset time was known. We performed a univariate statistical analysis, then a multivariate analysis on the variables that were statistically significant in the univariate analysis.
Of the 389 patients included, 309 (79.4%) were SVS+. We found no significant relationship between SVS- and the time between symptom onset and imaging in the whole cohort. In the multivariate analysis, SVS- was associated with anticoagulant treatment (
< 0.01), and SVS+ with age (
= 0.023) and carotid terminus occlusion (
= 0.042). In the known symptom onset subgroup, SVS- was significantly associated with a shorter symptom onset -imaging time (
< 0.001), and this was confirmed in the multivariate analysis (
= 0.011; OR 0.911; 95% CI 0.844; 0.972).
In the acute phase of proximal occlusion ischemic stroke, absence of SVS was associated with a shorter symptom onset-imaging time for patients with a known symptom onset time.
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