The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for ...use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.
Falls are a major cause of injury and death annually for millions of individuals 65 and older. Older adults are at risk for falls for a variety of reasons regardless of where they live. Falls are ...defined as any sudden drop from one surface to a lower surface. The purpose of this fall prevention evidence-based practice guideline is to describe strategies that can identify individuals at risk for falls. A 10-step protocol including screening for falls, comprehensive fall assessment, gait and balance screening when necessary, and an individualized fall intervention program addressing specific fall risks is presented. Reassessing fall risk and fall prevention programs will ensure a proactive approach to reducing falls in the aging population. Journal of Gerontological Nursing, 43(11), 15-21..
Multimodal CT in Acute Stroke Wannamaker, R.; Buck, B.; Butcher, K.
Current neurology and neuroscience reports,
09/2019, Letnik:
19, Številka:
9
Journal Article
Recenzirano
Purpose of Review
Multimodal CT imaging (non-contrast CT, NCCT; CT angiography, CTA; and CT Perfusion, CTP) is central to acute ischemic stroke diagnosis and treatment. We reviewed the purpose and ...interpretation of each component of multimodal CT, as well as the evidence for use in routine care.
Recent Findings
Acute stroke thrombolysis can be administered immediately following NCCT in acute ischemic stroke patients assessed within 4.5 h of symptom onset. Definitive identification of a large vessel occlusion (LVO) requires vascular imaging, which is easily achieved with CTA. This is critical, as the standard of care for LVO within 6 h of onset is now endovascular thrombectomy (EVT). CTA source images can also be used to estimate the efficacy of collateral flow in LVO patients. The final component (CTP) permits a more accurate assessment of the extent of the ischemic penumbra. Complete multimodal CT, including objective penumbral measurement with CTP, has been used to extend the EVT window to 24 h. There is also randomized controlled trial evidence for extension of the IV thrombolysis window to 9 h with multimodal CT. Although there have been attempts to assess for responders to reperfusion strategies beyond 6 h (“late window”) using collateral grades, the only evidence for treatment of this group of patients is based on selection using multimodal CT including CTP. The development of fully automated software providing quantitative ischemic penumbral and core volumes has facilitated the adoption of CTP and complete multimodal CT into routine clinical use.
Summary
Multimodal CT is a powerful imaging algorithm that is central to current ischemic stroke patient care.
Tolerance is a long-recognized property of macrophages that leads to an altered response to repeated or chronic exposure to endotoxin. The physiological role of tolerance is to limit the potential ...damage to host tissue that may otherwise result from prolonged production of pro-inflammatory cytokines. Tolerance is induced by all toll-like receptor (TLR) ligands tested to date, however, tolerance induced by the TLR4 ligand lipopolysaccharide (LPS) is by far the best studied. LPS tolerance involves a global transcriptional shift from a pro-inflammatory response toward one characterized by the expression of anti-inflammatory and pro-resolution factors. Although largely reversible, LPS-tolerance leads to a hybrid macrophage activation state that is pro-inflammatory in nature, but possesses distinct regulatory anti-inflammatory features. Remarkably, a comparative transcriptomic analysis of tolerance induced by different TLR ligands has not previously been reported. Here, we describe the transcriptomic profiles of mouse macrophages tolerized with ligands for TLR2, TLR3, TLR4 and TLR 9. While we identified TLR-specific transcriptional profiles in macrophages tolerized with each ligand, tolerance induced by TLR4 represented an archetype pattern, such that each gene tolerized by any of the TLRs tested was also found to be tolerized by TLR4. Pro-inflammatory cytokines are not universally suppressed in all tolerant cells, but distinct patterns of cytokine expression distinguished TLR-specific tolerance. Analysis of gene regulatory regions revealed specific DNA sequence motifs associated with distinct states of TLR tolerance, implicating previously identified as well as novel transcriptional regulators of tolerance in macrophages. These data provide a basis for the future exploitation of TLR-specific tolerant states to achieve therapeutic re-programming of the innate immune response.
The Echoplanar Imaging Thrombolysis Evaluation Trial (EPITHET) tests the hypothesis that perfusion-weighted imaging (PWI)-diffusion-weighted imaging (DWI) mismatch predicts the response to ...thrombolysis. There is no accepted standardized definition of PWI-DWI mismatch. We compared common mismatch definitions in the initial 40 EPITHET patients.
Raw perfusion images were used to generate maps of time to peak (TTP), mean transit time (MTT), time to peak of the impulse response (Tmax) and first moment transit time (FMT). DWI, apparent diffusion coefficient (ADC), and PWI volumes were measured with planimetric and thresholding techniques. Correlations between mismatch volume (PWIvol-DWIvol) and DWI expansion (T2(Day 90-vol)-DWI(Acute-vol)) were also assessed.
Mean age was 68+/-11, time to MRI 4.5+/-0.7 hours, and median National Institutes of Health Stroke Scale (NIHSS) score 11 (range 4 to 23). Tmax and MTT hypoperfusion volumes were significantly lower than those calculated with TTP and FMT maps (P<0.001). Mismatch > or =20% was observed in 89% (Tmax) to 92% (TTP/FMT/MTT) of patients. Application of a +4s (relative to the contralateral hemisphere) PWI threshold reduced the frequency of positive mismatch volumes (TTP 73%/FMT 68%/Tmax 54%/MTT 43%). Mismatch was not significantly different when assessed with ADC maps. Mismatch volume, calculated with all parameters and thresholds, was not significantly correlated with DWI expansion. In contrast, reperfusion was correlated inversely with infarct growth (R=-0.51; P=0.009).
Deconvolution and application of PWI thresholds provide more conservative estimates of tissue at risk and decrease the frequency of mismatch accordingly. The precise definition may not be critical; however, because reperfusion alters tissue fate irrespective of mismatch.
Background and Purpose- Observational data suggest that antiplatelet therapy after intracerebral hemorrhage (ICH) alleviates thromboembolic risk without increasing the risk of recurrent ICH. Given ...the paucity of data on the relationship between antiplatelet therapy after ICH and functional outcomes, we aimed to study this association in a multicenter cohort. Methods- We meta-analyzed data from (1) the Massachusetts General Hospital ICH registry (n=1854), (2) the Virtual International Stroke Trials Archive database (n=762), and (3) the Yale stroke registry (n=185). Our exposure was antiplatelet therapy after ICH, which was modeled as a time-varying covariate. Our primary outcomes were all-cause mortality and a composite of major disability or death (modified Rankin Scale score 4-6). We used Cox proportional regression analyses to estimate the hazard ratio of death or poor functional outcome as a function of antiplatelet therapy and random-effects meta-analysis to pool the estimated HRs across studies. Additional analyses stratified by hematoma location (lobar and deep ICH) were performed. Results- We included a total of 2801 ICH patients, of whom 288 (10.3%) were started on antiplatelet medications after ICH. Median times to antiplatelet therapy ranged from 7 to 39 days. Antiplatelet therapy after ICH was not associated with mortality (hazard ratio, 0.85; 95% CI, 0.66-1.09), or death or major disability (hazard ratio, 0.83; 95% CI, 0.59-1.16) compared with patients not started on antiplatelet therapy. Similar results were obtained in additional analyses stratified by hematoma location. Conclusions- Antiplatelet therapy after ICH appeared safe and was not associated with all-cause mortality or functional outcome, regardless of hematoma location. Randomized clinical trials are needed to determine the effects and harms of antiplatelet therapy after ICH.
Elderly humans are more susceptible to bacterial infections because of declining immune status. We have investigated the effect of aging on neutrophil bactericidal responses, comparing neutrophil ...function in healthy, young (23-35 years) and elderly (>65 years) volunteers. Superoxide generation in response to fMLP was slightly increased in neutrophils from elderly donors, and serum from the elderly was able to opsonize E. coli efficiently. In contrast, phagocytic index was significantly lower in neutrophils from the elderly, compared with young donors (P<0.005). CD11a and CD11b expression was not affected by age, but CD16 was significantly reduced in neutrophils from elderly donors (P<0.0001). CD16 expression and phagocytic index were measured in the same neutrophils using FITC-labeled E. coli, PE-conjugated anti-CD16 antibody, and CD16 expression correlated with phagocytic index (r=0.83; P<0.05). In elderly patients with bacterial infection, CD16 expression remained low. We propose that reduced neutrophil CD16 expression and phagocytosis contribute to human immunesenescence.
The purpose of this article is to reintroduce and describe the processes and phases of heuristic inquiry and to illustrate how the method can advance nursing science. Heuristic inquiry is a rigorous, ...systematic, phenomenologically orientated research method developed by Clark Moustakas for investigating, discovering, and understanding the nature and meaning of living experiences. Heuristic inquiry invites the inclusion of the researcher’s autobiographical living of experience being investigated honoring the personal experiences of the phenomenon from self and each participant in the research study. The author proposes that heuristic inquiry be used in nursing science by including a theoretical interpretive process connecting the thematic essences of the nursing conceptual framework guiding the study. Nursing theory-guided heuristic research advances the study of caring for persons experiencing human-environmental-health transitions to enhance human betterment and wellbecoming.
Summary
Evolutionary pressure has selected individuals with traits that allow them to survive to reproduction, without consideration of the consequences for the post‐child rearing years and old age. ...In the 21st century, society is populated increasingly by the elderly and with the falling birth rate and improved health care this trend is set to continue for the foreseeable future. To minimize the potential burden on health services one would hope that ‘growing old gracefully’ should also mean ‘growing old healthily’. However, for too many the aging process is accompanied by increasing physical and mental frailty producing an elevated risk of physical and psychological stress in old age. Stress is a potent modulator of immune function, which in youth can be compensated for by the presence of an optimal immune response. In the elderly the immune response is blunted as a result of the decline in several components of the immune system (immune senescence) and a shifting to a chronic pro‐inflammatory status (the so‐called ‘inflamm‐aging’ effect). We discuss here what is known of the effects of both stress and aging upon the innate immune system, focusing in particular upon the age‐related alterations in the hypopituitary–adrenal axis. We propose a double hit model for age and stress in which the age‐related increase in the cortisol/sulphated dehydroepiandrosterone ratio synergizes with elevated cortisol during stress to reduce immunity in the elderly significantly.
All phenomenological research, including descriptive phenomenological methods, are theory based. The knowledge in a discipline is built using discipline-specific methods. The purpose of this article ...is to develop and describe the processes of a mode of inquiry specific to caring in nursing theories housed within the unitary caring paradigm. Morgan’s practical framework examining ontological-epistemological-methodological linkages was used to develop the unitary-caring hermeneutic phenomenological research method The method is specific to conducting hermeneutic phenomenological research within Watson’s unitary caring science and Smith’s theory of unitary caring. The method includes a process of linking and interpreting themes generated from the textual analysis of participant descriptions of the caring phenomena to concepts in the specific unitary caring theory that informs the researcher’s a priori theoretical perspective to develop a theoretical understanding of the experience and contribute to the development of unitary caring nursing science.
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