Predictors of pneumonia in stroke patients with dysphagia: A Turkish study.

Background and purpose:

Dysphagia, characterized by difficulty in swallowing due to neurological deficits, stands out as the foremost contributor to stroke asso­ciated pneumonia (SAP) development. Recent investigations have explored the utility of blood tests, including parameters like neutrophil count, leukocyte count, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and the CRP to albumin ratio (CAR), at the time of admission as potential markers for predicting SAP development. This study is set out to assess predictors of SAP in patients with acute ischemic stroke and dysphagia. 

This retrospective cross-sectio­nal study, conducted at the University of Health Sciences, Neurology Department of Erenkoy Mental Health Neurological Disor­ders in Istanbul, Turkey, between January 2021 and January 2023, assessed 65 indivi­duals with acute ischemic stroke and dysphagia. Excluding specific criteria, clinical and laboratory data were collected. Patients were categorized into SAP and non-SAP groups based on diagnostic criteria. Results provide insights into risk factors of SAP.

In this study of 65 stroke patients with dysphagia, 27 (41.5%) developed SAP within the first week. No significant differences in age, gender, comorbidities, or infarct size were observed between the pneumonia-positive and pneumonia-negative groups (p > 0.05). HbA1c levels were significantly lower in the pneumonia-positive group (p = 0.02). Logistic regression revealed that NLR, CAR levels, and the presence of atrial fibrillation (AF) were significant predictors of pneumonia development (p < 0.001).

Dysphagia is considered one of the most significant risk factors for SAP. However not all ischemic stroke patients with dysphagia develop SAP; that is the reason we think NLR, CAR, and AF might be predictors of SAP in acute ischemic stroke patients with dysphagia.

A modified Delphi survey to build expert consensus on the structure and content of an enhanced care pathway for cognitive changes after stroke in the UK.

BACKGROUND: Enhancing long-term support for post-stroke cognitive impairment is a top research priority. Addressing current gaps in UK post-stroke cognitive care provision requires a pragmatic and scalable intervention that can be integrated within the existing stroke care pathway. This study aimed to develop consensus on an initial set of core features for a UK-based monitoring and psychoeducational intervention for cognitive changes after stroke. METHODS: An expert panel of UK healthcare professionals and researchers participated in an online modified Delphi survey. Candidate intervention features were identified from clinical guidelines, existing literature, research team/collaborator expertise, and PPI group lived experience. Survey participants indicated whether they agreed/disagreed/had no opinion about including each candidate feature in the intervention and free-text responses were invited. We analysed responses for consensus (≥ 75% agreement) using descriptive statistics, with items not reaching consensus carried into subsequent rounds. Template analysis was used to identify similarities/differences in viewpoints for items that did not reach consensus. RESULTS: Three survey rounds were completed by 36, 29 and 26 participants, respectively. Participants agreed reviews should include a stroke-specific cognitive screen (97% agree) and assessment of other psychological changes (low mood, anxiety, fatigue: 94%, 90%, 89% agree, respectively). They agreed stroke survivors should be offered at least one review, regardless of their cognitive profile in hospital. They agreed on the importance of various cognition-focused psychoeducation topics, and formal (100% agree) and informal (79% agree) training for those conducting reviews. Consensus was not reached on the review mode (in person/remote options: 67% agree), offering reviews one-year post-discharge to patients without acute cognitive impairments (68% disagree), or including a dementia screen (63% disagree) and/or neuropsychological assessment battery (58% disagree). However, there were similarities in participant viewpoints. For example, participants emphasised the importance of onwards referral where clinically indicated.   CONCLUSIONS: The UK-based post-stroke monitoring and psychoeducation intervention was originally conceptualised as a cognitive care pathway, but expert participants agreed on the importance of simultaneously addressing related psychological changes (e.g. low mood, anxiety). There was clear consensus on a minimum set of intervention features. Recommendations outlined here may usefully inform local service improvements.

Chronic stroke survivors underestimate their upper limb motor ability in a simple 2D motor task.

BACKGROUND: Stroke survivors can exhibit a mismatch between the actual motor ability of their affected upper limb and how much they use it in daily life. The resulting non-use of the affected upper limb has a negative impact on participation in neurorehabilitation and functional independence. The factors leading to non-use of the affected upper limb are poorly understood. One possibility is that non-use comes about through inappropriately low confidence in their own upper limb motor abilities. OBJECTIVE: We asked whether chronic stroke survivors underestimate the motor ability of their affected upper limb. METHODS: 20 chronic stroke survivors (Mean FM: 28.2 ± 10.5) completed a 2D reaching task using an exoskeleton robot. Target sizes were individually altered to ensure success rates were similar for both upper limbs. Prior to each reaching movement, participants rated their confidence about successfully hitting the target (estimated upper limb motor ability). RESULTS: Confidence ratings were significantly lower for the affected upper limb (estimated ability), even though it was equally successful in the reaching task in comparison to the less affected upper limb (actual ability). Furthermore, confidence ratings did not correlate with level of impairment. CONCLUSIONS: Our results demonstrate that chronic stroke survivors can underestimate the actual motor abilities of their affected upper limb, independent of impairment level. Low confidence in affected upper limb motor abilities should be considered as a therapeutic target to increase the incorporation of the affected upper limb into activities of daily living.

The dose effectiveness of extracorporeal shockwave on plantar flexor spasticity of ankle in stroke patients: a randomized controlled trial.

BACKGROUND: Extracorporeal shockwave therapy (ESWT) has been proven beneficial for post-stroke spasticity (PSS) of ankle plantar flexor muscles. This study aims to investigate the dose-response effectiveness of focused-ESWT and the duration of its effect on the treatment of ankle PSS in stroke patients. METHODS: In this double-blinded randomized controlled trial, stroke patients diagnosed with PSS in the ankle plantar flexor muscles were randomly assigned to two groups. The experimental group received double-dose ESWT (4000 pulses per session) targeting spastic calf muscles, while the control group received half the dose (2000 pulses per session). Both groups underwent four sessions over two weeks. The outcomes, including modified Ashworth Scale (MAS), modified Tardieu Scale (MTS), passive range of motion (PROM) of the ankle, Timed Up and Go (TUG) Test, Barthel index and strain elastography were evaluated at baseline, 1st, 4th, 12th, and 24th week after ESWT. RESULTS: Within-group analysis revealed significant improvements in MAS, PROM, TUG Test, and Barthel index for the double-dose ESWT group and improvements in Barthel index for the control group. Between-group analysis revealed greater improvements in TUG Test, Barthel Index and strain elastography for the double-dose ESWT group. Generalized estimating equations analysis indicated that the double-dose ESWT group achieved superior outcomes in the TUG Test, Barthel Index, and strain elastography across various time points and groups. CONCLUSIONS: Double-dose ESWT showed better functional improvement and elastography compared to the control group. ESWT demonstrated dose-response effectiveness for PSS of ankle-equinus. TRIAL REGISTRATION: NCT05878223.

Trajectory of Cognitive Decline Before and After Stroke in 14 Population Cohorts.

Importance: Poststroke cognitive impairment is common, but the cognitive trajectory following a first stroke, relative to prestroke cognitive function, remains unclear. Objective: To map the trajectory of cognitive function before any stroke and after stroke in global cognition and in 4 cognitive domains, as well as to compare the cognitive trajectory prestroke in stroke survivors with the trajectory of individuals without incident stroke over follow-up. Design, Setting, and Participants: The study used harmonized and pooled data from 14 population-based cohort studies included in the Cohort Studies of Memory in an International Consortium collaboration. These studies were conducted from 1993 to 2019 across 11 countries among community-dwelling older adults without a history of stroke or dementia. For this study, linear mixed-effects models were used to estimate trajectories of cognitive function poststroke relative to a stroke-free cognitive trajectory. The full model adjusted for demographic and vascular risk factors. Data were analyzed from July 2022 to March 2024. Exposure: Incident stroke. Main outcomes and measures: The primary outcome was global cognition, defined as the standardized average of 4 cognitive domains (language, memory, processing speed, and executive function). Cognitive domain scores were formed by selecting the most commonly administered test within each domain and standardizing the scores. Results: The study included 20 860 participants (12 261 [58.8%] female) with a mean (SD) age of 72.9 (8.0) years and follow-up of 7.51 (4.2) years. Incident stroke was associated with a substantial acute decline in global cognition (-0.25 SD; 95% CI, -0.33 to -0.17 SD), the Mini-Mental State Examination, and all cognitive domains (ranging from -0.17 SD to -0.22 SD), as well as accelerated decline in global cognition (-0.038 SD per year; 95% CI, -0.057 to -0.019 SD per year) and all domains except memory (ranging from -0.020 to -0.055 SD per year), relative to a stroke-free cognitive trajectory. There was no significant difference in prestroke slope in stroke survivors compared with the rate of decline in individuals without stroke in all cognitive measures. The mean rate of decline without a previous stroke was -0.049 SD per year (95% CI, -0.051 to -0.047 SD) in global cognition. Conclusions and relevance: In this cohort study using pooled data from 14 cohorts, incident stroke was associated with acute and accelerated long-term cognitive decline in older stroke survivors.

Validation of a laser visual feedback and core stability exercise programme to improve lateropulsion reduction and pushing intensity in stroke patients with pusher syndrome: A Delphi study.

BACKGROUND: The patient with pusher syndrome (PS) is characterized by showing postural control alterations due to a lack of perception of his own body in the space. It appears when the patient actively pushes with his unaffected limbs towards the injured side, reacting with resistance to passive straightening towards the midline. Between 10% and 50% of strokes present PS. Nowadays, there is no clearly defined treatment for PS. OBJECTIVE: To design and validate an exercise program using visual feedback and specific core stability exercises (FeViCoS) for the treatment of patients with PS. METHODS: Validation was conducted by expert consensus using the Delphi method. Thirteen neurorehabilitation experts participated in the process. An online questionnaire with 18 Likert-type questions was used to evaluate the designed program. Consensus was considered reached if there was convergence between the quartile 1 and 3 values (RIQ = Q1-Q3) or if the relative interquartile range (RIR) was less than 20%. The degree of agreement between experts was measured by calculating the Fleiss' kappa coefficient. RESULTS: A total of 2 rounds were required to achieve 97.44% consensus with 100% participation. The RIR was less than or equal to 20% for all questions. The Fleiss' kappa index (0.831) showed that the degree of agreement between experts was excellent. CONCLUSION: Neurorehabilitation experts considered FeViCoS valid for the therapeutic approach to patients with PS. Expert consensus suggests a novel strategy in physical therapy clinical practice to improve balance and postural orientation in patients with subacute stroke and PS.

Neuromodulation of Executive Dysfunction in Patients with Acute Stroke Using Transcranial Direct Current Stimulation: Study Protocol for a Triple-Blind, Randomized Sham-Controlled Trial.

Research on the benefits of non-invasive brain stimulation in stroke patients to improve executive functions is scarce. The objective of this study was to investigate the effectiveness of transcranial direct current stimulation (tDCS) in combination with cognitive training for the rehabilitation of executive functions in acute and subacute stroke patients as well as to explore the underlying physiological mechanisms. A triple-blinded, randomized-controlled clinical trial will be conducted involving 60 stroke patients with frontal or basal ganglia lesions and a Montreal Cognitive Assessment (MoCA) score less than 26. Participants will be randomly assigned to receive active tDCS (anode over the left dorsolateral prefrontal cortex, cathode at the right supraorbital region, 20 min at 2 mA) or sham tDCS in a 1:1 ratio for 10 sessions, followed by targeted executive function training. The primary efficacy outcome will be the MoCA score, while secondary outcomes will include the five-digit test (inhibitory control), the Digit Span Task (working memory), the abbreviated version of the Wisconsin Card Sorting test (cognitive flexibility), modified Rankin scale (functional state), Beck-II depression inventory, apathy evaluation scale, and the WHOQOL-BREF (quality of life), assessed immediately after the intervention and at 1, 3, 6, and 12 months post-intervention. Additionally, resting-state functional connectivity and blood biomarkers, such as neurotrophins, growth factors, and inflammatory molecules, will be evaluated before and after the intervention. This study will contribute to the investigation of the efficacy of tDCS in rehabilitating executive functions in acute and subacute stroke patients. The multidimensional approach utilized in this study, which includes analysis of resting-state connectivity and neuroplasticity-related blood biomarkers, is expected to provide insights into the underlying brain mechanisms involved in the rehabilitation of dysexecutive syndrome.

Urdu translation and cross-cultural validation of neurological fatigue index on post stroke.

BACKGROUND: The Neurological Fatigue Index (NFI) is the instrument used to evaluate stroke patients' fatigue. There was no Urdu version of NFI available officially. OBJECTIVE: This study aimed to translate the Neurological Fatigue Index into Urdu and to determine the validity and reliability of Urdu NFI among stroke patients. METHODOLOGY: It is a cross-cultural validation study. According to international guidelines in phase I, a process of translation was carried out. In phase II, using the sample of 120 participants, validity and reliability of the Urdu version of the Neurological Fatigue Index scale was conducted. The Urdu version's content validity, convergent/concurrent validity, test-retest reliability, and internal consistency were determined. The latest version of SPSS was used for the data analysis. RESULTS: The Urdu version of NFI was drafted after the expert's review. The content validity index was used to analyze the content validity. The reliability and validity of the Urdu version NFI were evaluated by calculating Cronbach's alpha (α = 0.86), and intra-class correlation coefficient (ICC = 0.823). Correlations with other scales were the fatigue Severity Scale (FSS) (r = 0.76), Mental Fatigue Scale (MFS) (r = 0.68), Beck Depression Inventory (BDI) (r = 0.53) and Epworth Sleepiness Scale (ESS) (r = 0.47). CONCLUSION: The Urdu Version was linguistically acceptable for the fatigue assessment in post-stroke patients. It showed good content validity, convergent/concurrent validity, internal consistency, and test-retest reliability.

Effects of ankle joint degree of freedom of knee-ankle-foot orthoses on loading patterns and triceps surae muscle activity on the paretic side in individuals with subacute severe hemiplegia: a retrospective study.

BACKGROUND: Individuals with subacute severe hemiplegia often undergo alternate gait training to overcome challenges in achieving walking independence. However, the ankle joint setting in a knee-ankle-foot orthosis (KAFO) depends on trunk function or paralysis stage for alternate gait training with a KAFO. The optimal degree of ankle joint freedom in a KAFO and the specific ankle joint conditions for effective rehabilitation remain unclear. Therefore, this study aimed to investigate the effects of different degrees of freedom of the ankle joint on center-of-pressure (CoP) parameters and muscle activity on the paretic side using a KAFO and to investigate the recommended setting of ankle joint angle in a KAFO depending on physical function. METHODS: This study included 14 participants with subacute stroke (67.4 ± 13.3 years). The CoP parameters and muscle activity of the gastrocnemius lateralis (GCL) and soleus muscles were compared using a linear mixed model (LMM) under two ankle joint conditions in the KAFO: fixed at 0° and free ankle dorsiflexion. We confirmed the relationship between changes in CoP parameters or muscle activity under different conditions and physical functional characteristics such as the Fugl-Meyer Assessment of Lower Extremity Synergy Score (FMAs) and Trunk Impairment Scale (TIS) using LMM. RESULTS: Anterior-posterior displacement of CoP (AP_CoP) (p = 0.011) and muscle activity of the GCL (p = 0.043) increased in the free condition of ankle dorsiflexion compared with that in the fixed condition. The FMAs (p = 0.004) and TIS (p = 0.008) demonstrated a positive relationship with AP_CoP. A positive relationship was also found between TIS and the percentage of medial forefoot loading time in the CoP (p < 0.001). CONCLUSIONS: For individuals with severe subacute hemiplegia, the ankle dorsiflexion induction in the KAFO, which did not impede the forward tilt of the shank, promotes anterior movement in the CoP and muscle activity of the GCL. This study suggests that adjusting the dorsiflexion mobility of the ankle joint in the KAFO according to improvement in physical function promotes loading of the CoP to the medial forefoot.

Clinical Efficacy of Electroacupuncture at Sacral Four Points Combined with Moxibustion at Abdominal Three Points for Treating Post-Stroke Urinary Incontinence: Observations on Urodynamics, Quality of Life, and Safety.

BACKGROUND: Urinary incontinence is a common complication following a stroke. No specific drugs are available in Western medicine, and surgical treatment is highly traumatic, limiting its clinical application. This study aimed to observe the clinical efficacy of electroacupuncture at the "Sacral Four Points" combined with moxibustion at the "Abdominal Three Points" on post-stroke urinary incontinence, exploring its impact on urodynamics and quality of life. METHODS: Patients with post-stroke urinary incontinence treated at our Hospital from January 2021 to December 2023 were recruited. The study included 117 patients: 57 in the electroacupuncture group and 60 in the combined group. Urodynamic parameters were measured, and scores from the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and the Incontinence Quality of Life Questionnaire (I-QOL) were recorded before, and after the first and third courses of treatment. Clinical efficacy and adverse reactions were evaluated post-treatment. RESULTS: The study found no significant differences in clinical characteristics between the groups (p > 0.05), providing a baseline for comparison. Both groups showed substantial decreases in leakage volume after one course of treatment (p < 0.05), with a reduction in the ICIQ-UI SF score (p < 0.05) and an increase in the I-QOL score (p < 0.05). After three courses of treatment, the leakage volume of patients in both groups significantly decreased (p < 0.05), the ICIQ-UI SF score decreased (p < 0.05), and the I-QOL score increased (p < 0.05). The combined group showed a lower leakage volume compared to the electroacupuncture group (p < 0.05), with lower ICIQ-UI SF scores (p = 0.027) and higher I-QOL scores (p = 0.048). Importantly, the total effective rate was significantly higher in the combined group (88.33% vs 64.91%, p = 0.037), demonstrating the safety and efficacy of the treatment. CONCLUSIONS: Electroacupuncture at the "Sacral Four Points" combined with moxibustion at the "Abdominal Three Points" improves the clinical symptoms and enhances the quality of life for patients with post-stroke urinary incontinence, showing superior results compared to electroacupuncture alone.

How to return? experiences of patients in working age after first Ischaemic stroke: an interpretative phenomenological analysis of patient´s perspective at 12 - 24 months post-stroke.

BACKGROUND: Limited evidence of young adult patient-reported outcomes and experiences after ischaemic stroke has been conducted. AIM: To investigate the meaning of the lived experiences of stroke patients in working age 12-24 months after their first IS. MATERIAL AND METHODS: The exploratory qualitative study used an interpretative phenomenological analysis (IPA) design. Nine ischaemic stroke patients (with age ranges from 41 to 50 years) took part in semi-structured qualitative interviews. RESULTS: Even with mild residual neurological deficit, IS negatively impacted the quality of life daily and social life. Six subthemes and three interconnected group experiential themes were generated: (i) From confusion to understanding (ii) Triggers for rebuilding; and (iii) Challenges and benefits. CONCLUSION: The study highlights the current gaps and limitations in supporting the needs of stroke patients in working age in long-term post-stroke care. The findings are crucial for healthcare professionals to develop improved age- and mild- impairment-appropriate strategies or tailor self-management interventions for stroke patients of working age.ClinicalTrials.gov: NCT04839887.

The effect of computerized cognitive training and transcranial direct current stimulation on working memory among post-stroke individuals: a systematic review with meta-analysis and meta-regression.

BACKGROUND: Working memory (WM) impairment is a common phenomenon after stroke; however, its management in rehabilitation is less researched. This systematic review and meta-analysis aimed to provide a quantitative synthesis of the impact of computerised cognitive training (CCT) and transcranial direct current stimulation (tDCS) on WM span in post-stroke individuals. METHODS: The literature search in PubMed, Embase, Scopus, and Cochrane Library focused on randomized controlled trials testing the effect of CCT and tDCS on treated stroke patients as compared to untreated controls. Neuropsychological instruments such as Digit Span Forward/Backward and Visual Span Forward Tests defined the outcome of WM span. After extracting study characteristics and quality assessment using the Cochrane Risk of Bias Tool, we conducted a meta-analysis and meta-regression using standardised mean differences. RESULTS: The search yielded 4142 articles, nine of which (N = 461) fulfilled the inclusion criteria. In the case of CCT, we found significant improvement in Digit Span Backward Test (Z = 2.65, P = 0.008; 95% CI [0.10, 0.67]) and Visual Span Forward Test performance (Z = 3.05, P = 0.002; 95% CI [0.15, 0.69]), while for tDCS, we could not find a sufficient number of studies for the analysis. Furthermore, no significant moderating factor was found in the meta-regression. CONCLUSIONS: In conclusion, CCT appears to be a suitable choice to enhance WM span performance after stroke. However, further research is needed to investigate the effect of tDCS due to the limited number of studies. TRIAL REGISTRATION: The meta-analysis was conducted according to PRISMA (Preferred Reporting of Systematic Reviews and Meta-Analyses) standards with a PROSPERO registration protocol (ID: CRD42023387182).

Logistic regression analysis and machine learning for predicting post-stroke gait independence: a retrospective study.

This study investigated whether machine learning (ML) has better predictive accuracy than logistic regression analysis (LR) for gait independence at discharge in subacute stroke patients (n = 843) who could not walk independently at admission. We developed prediction models using LR and five ML algorithms-specifically, the decision tree (DT), support vector machine, artificial neural network, ensemble learning, and k-nearest neighbor methods. Functional Independence Measure sub-items were used to evaluate the ability to walk independently. Model predictive accuracies were evaluated using areas under receiver operating characteristic curves (AUCs) as well as accuracy, precision, recall, F1 score, and specificity. The AUC for DT (0.812) was significantly lower than those for the other algorithms (p < 0.01); however, the AUC for LR (0.895) did not differ significantly from those for the other models (0.893-0.903). Other performance metrics showed no substantial differences between LR and ML algorithms. In conclusion, the DT algorithm had significantly low predictive accuracy, and LR showed no significant difference in predictive accuracy compared with the other ML algorithms. As its predictive accuracy is similar to that of ML, LR can continue to be used for predicting the prognosis of gait independence, with additional advantages of being easily understandable and manually computable.

Increased risk of depression and associated symptoms in poststroke aphasia.

Poststroke aphasia hinders patients' emotional processing and social adaptation. This study estimated the risks of depression and related symptoms in patients developing or not developing aphasia after various types of stroke. Using data from the US Collaborative Network within the TriNetX Diamond Network, we conducted a retrospective cohort study of adults experiencing their first stroke between 2013 and 2022. Diagnoses were confirmed using corresponding International Classification of Diseases, Tenth Revision, Clinical Modification codes. Patients were stratified by poststroke aphasia status and stroke type, with propensity score matching performed to control for confounders. The primary outcome was depression within one year post-stroke; secondary outcomes included anxiety, fatigue, agitation, emotional impact, and insomnia. Each matched group comprised 12,333 patients. The risk of depression was significantly higher in patients with poststroke aphasia (hazard ratio: 1.728; 95% CI 1.464-2.038; p < 0.001), especially those with post-hemorrhagic-stroke aphasia (hazard ratio: 2.321; 95% CI 1.814-2.970; p < 0.001). Patients with poststroke aphasia also had higher risks of fatigue, agitation, and emotional impact. Anxiety and insomnia risks were higher in those with post-hemorrhagic-stroke aphasia. Poststroke aphasia, particularly post-hemorrhagic-stroke aphasia, may increase the risks of depression and associated symptoms, indicating the need for comprehensive psychiatric assessments.

Establishing Quality Indicators and Implementation Priorities for Post-Stroke Aphasia Services Through End-User Involvement.

BACKGROUND: Currently, there are no agreed quality standards for post-stroke aphasia services. Therefore, it is unknown if care reflects best practices or meets the expectations of people living with aphasia. We aimed to (1) shortlist, (2) operationalise and (3) prioritise best practice recommendations for post-stroke aphasia care. METHODS: Three phases of research were conducted. In Phase 1, recommendations with strong evidence and/or known to be important to people with lived experience of aphasia were identified. People with lived experience and health professionals rated the importance of each recommendation through a two-round e-Delphi exercise. Recommendations were then ranked for importance and feasibility and analysed using a graph theory-based voting system. In Phase 2, shortlisted recommendations from Phase 1 were converted into quality indicators for appraisal and voting in consensus meetings. In Phase 3, priorities for implementation were established by people with lived experience and health professionals following discussion and anonymous voting. FINDINGS: In Phase 1, 23 best practice recommendations were identified and rated by people with lived experience (n = 26) and health professionals (n = 81). Ten recommendations were shortlisted. In Phase 2, people with lived experience (n = 4) and health professionals (n = 17) reached a consensus on 11 quality indicators, relating to assessment (n = 2), information provision (n = 3), communication partner training (n = 3), goal setting (n = 1), person and family-centred care (n = 1) and provision of treatment (n = 1). In Phase 3, people with lived experience (n = 5) and health professionals (n = 7) identified three implementation priorities: assessment of aphasia, provision of aphasia-friendly information and provision of therapy. INTERPRETATION: Our 11 quality indicators and 3 implementation priorities are the first step to enabling systematic, efficient and person-centred measurement and quality improvement in post-stroke aphasia services. Quality indicators will be embedded in routine data collection systems, and strategies will be developed to address implementation priorities. PATIENT AND PUBLIC CONTRIBUTION: Protocol development was informed by our previous research, which explored the perspectives of 23 people living with aphasia about best practice aphasia services. Individuals with lived experience of aphasia participated as expert panel members in our three consensus meetings. We received support from consumer advisory networks associated with the Centre for Research Excellence in Aphasia Rehabilitation and Recovery and the Queensland Aphasia Research Centre.

Suppression of neuronal CDK9/p53/VDAC signaling provides bioenergetic support and improves post-stroke neuropsychiatric outcomes.

Bioenergy decline occurs with reperfusion following acute ischemic stroke. However, the molecular mechanisms that limit energy metabolism and their impact on post-stroke cognitive and emotional complications are still unclear. In the present study, we demonstrate that the p53 transcriptional response is responsible for neuronal adenosine triphosphate (ATP) deficiency and progressively neuropsychiatric disturbances, involving the downregulation of mitochondrial voltage-dependent anion channels (VDACs). Neuronal p53 transactivated the promoter of microRNA-183 (miR-183) cluster, thereby upregulating biogenesis of miR-183-5p (miR-183), miR-96-5p (miR-96), and miR-182-5p. Both miR-183 and miR-96 directly targeted and post-transcriptionally suppressed VDACs. Neuronal ablation of p53 protected against ATP deficiency and neurological deficits, whereas post-stroke rescue of miR-183/VDAC signaling reversed these benefits. Interestingly, cyclin-dependent kinase 9 (CDK9) was found to be enriched in cortical neurons and upregulated the p53-induced transcription of the miR-183 cluster in neurons after ischemia. Post-treatment with the CDK9 inhibitor oroxylin A promoted neuronal ATP production mainly through suppressing the miR-183 cluster/VDAC axis, further improved long-term sensorimotor abilities and spatial memory, and alleviated depressive-like behaviors in mice following stroke. Our findings reveal an intrinsic CDK9/p53/VDAC pathway that drives neuronal bioenergy decline and underlies post-stroke cognitive impairment and depression, thus highlighting the therapeutic potential of oroxylin A for better outcomes.

Protocol for exploring pathways to equitable outcomes in post-stroke aphasia and dysphagia.

INTRODUCTION: Longstanding racial disparities in stroke-related outcomes have been well documented. However, the underlying causes of observed disparities have neither been clearly determined nor have strategies to mitigate disparities been developed. Evidence suggests that racial disparities may be partially explained by structural barriers that can arise from implicit and explicit provider biases, institutional practices, public policies, or characteristics of the community where patients reside and recover from their conditions. The objective of this study is to move beyond traditional measures of disparities by identifying the mechanisms that drive these observed disparities in aphasia and dysphagia across the continuum of care. In this study we will follow stroke survivors for 12 months post-discharge, which will allow us to examine the patient, provider, health system, and administrative factors that impact their aphasia and dysphagia recovery. METHODS: This study will utilize a 100% sample of Medicare fee-for-service claims data for persons hospitalized for stroke. Patients discharged from acute stroke care will be followed for at least 12 months to measure the timing of post-acute care transition(s) and post-acute care speech-language pathology (SLP) utilization. Functional communication and swallowing outcomes will be measured at initiation, conclusion of post-acute care treatment, and points in-between allowing us to link improvement of functional communication (i.e., aphasia) and swallowing ability (i.e., dysphagia) to aphasia/dysphagia treatments as patients transition through post-acute settings. Then, using regression decomposition methods, we will examine the relationships between race and: (a) where patients receive treatment, (b) the timing of transition between sites of care, and (c) the quality of care received. Decomposition methods will allow us to elucidate the multiple factors that contribute to underlying observed health disparities by quantifying the extent to which differences between the outcomes of two groups are explained by 1) differential endowments or characteristics, such as geographic access, education, risk factors, or insurance coverage; or 2) differences in decision-making, defined as between group differences in outcomes despite equal endowments or unmeasured differences. DISCUSSION: We hypothesize that racial disparities in aphasia and dysphagia outcomes will not only result from differences in the quantity and timing of services provided in the post-acute and community settings, but also structural differences at the community level. These findings will provide a more comprehensive understanding of healthcare use and outcomes.

Patent Foramen Ovale-Associated Stroke: A Neurologist's Perspective.

Paradoxic embolism through a patent foramen ovale (PFO) is a common cause of ischemic stroke, accounting for 1 in 20 of all ischemic strokes. Neurologists play the leading role in diagnosing PFO-associated stroke, determining that a cerebral infarct is embolic in distribution and excluding other potential stroke mechanisms. Among patients aged 18 to 60 years old with a PFO and an otherwise cryptogenic stroke, the PFO-Associated Stroke Causal Likelihood classification system should be used to identify the 85% of patients likely to benefit from PFO closure and the 15% of patients likely to be harmed by PFO closure.

Concurrent Acute Myocardial Infarction and Stroke: Challenges in Diagnosis and Treatment.

Acute myocardial infarction (MI) and stroke occurring simultaneously in one patient is a rare clinical event. These medical emergencies involve many diagnostic and treatment challenges due to different causes, treatment modalities, and shifting priorities. Presence and exacerbation of bronchiectasis has been considered as a risk factor for atherosclerotic cardiovascular and cerebrovascular diseases and can trigger a cardioembolic stroke. We describe a case of a 59-year-old male patient with bronchiectasis who was treated at our tertiary care center due to concurrent MI and stroke.