Overview of Acute Ischemic Stroke Evaluation and Management.

Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.

Impact of Laws Regulating Pain Clinics on Opioid Prescribing and Opioid-Related Toxicity Among Texas Medicare Part D Beneficiaries.

BACKGROUND: Pain management clinics are major sources of prescription opioids. Texas government passed several laws regulating pain clinics between 2009 and 2011 to reduce opioid-related toxicity. Understanding the impact of these laws can inform policy geared toward making the laws more effective in curbing the growing epidemic of opioid overdose, especially among the elderly population. OBJECTIVES: To examine the longitudinal association of laws regulating pain clinics on opioid-prescribing and opioid-related toxicity among Texas Medicare recipients. METHODS: The 2007 to 2012 claims data for Texas Medicare Part D recipients were used to assess temporal trends in the percentage of patients filling any schedule II or schedule III opioid prescription, hospitalization for opioid toxicity, and their relationships to the 2009 to 2011 Texas laws regulating pain clinics. We excluded those with a cancer diagnosis. Join-point trend analysis with Bayesian Information Criterion selection methods were used to evaluate the change in monthly percentages of patients filling opioid prescriptions and hospitalization over time. RESULTS: There was a short-lived decline in the monthly percentages of patients who filled a schedule II or schedule III opioid prescription after the 2009 laws regulating pain clinics. The decline lasted about 3 months. Subsequent new laws had no effect on the percentages of patients who filled any opioid prescription or were hospitalized for potential opioid toxicity. Hospitalizations for opioid toxicity were highest in the winter and lowest in the summer. CONCLUSIONS: Changes in the percentages of opioid-prescribing or opioid-related hospitalizations over time were not associated with laws regulating pain clinics.

Trends in Opioid Prescriptions Among Part D Medicare Recipients From 2007 to 2012.

BACKGROUND: There is growing concern about potential overuse of, and toxicity from, opioid analgesics. No nationally representative study has examined inter-state variations in opioid use and impact of policy on opioid use among older adults. METHODS: We used national Medicare data from 2007-2012 to assess temporal and geographic trends in rates of opioid prescription and relationship to opioid toxicity and different state regulations in Part D Medicare recipients. We excluded those with a cancer diagnosis. Multilevel, multivariable regression analyses evaluated rates of prolonged prescriptions for schedule II, schedule III, and combination II/III opioid for each state, adjusting for patient characteristics. RESULTS: The percent of Part D recipients receiving prescriptions for combined schedule II/III opioid more than 90 days in a year increased from 4.62% in 2007 to 7.35% in 2012. Large variations existed among states in rates of opioid prescriptions: from 2.84% in New York to 10.93% in Utah, in 2012 data. The state variation was larger for schedule III than schedule II. Individual characteristics independently associated with prolonged use included older age, female gender, white race, low income, living in a lower-education area, and comorbidity of drug abuse, rheumatoid arthritis, and depression. Only state law regulating pain clinic was associated with reduction of schedule II opioid prescriptions. Prolonged opioid prescription use increased the odds of opioid overdose-related emergency room visits or hospitalization by 60%. CONCLUSIONS: Analyses of Medicare Part D data demonstrated a substantial growth in opioid prescriptions from 2007 to 2011 and large variation in opioid prescriptions across states.

Anorexia nervosa: a unified neurological perspective.

The roles of corticotrophin-releasing factor (CRF), opioid peptides, leptin and ghrelin in anorexia nervosa (AN) were discussed in this paper. CRF is the key mediator of the hypothalamo-pituitary-adrenal (HPA) axis and also acts at various other parts of the brain, such as the limbic system and the peripheral nervous system. CRF action is mediated through the CRF1 and CRF2 receptors, with both HPA axis-dependent and HPA axis-independent actions, where the latter shows nil involvement of the autonomic nervous system. CRF1 receptors mediate both the HPA axis-dependent and independent pathways through CRF, while the CRF2 receptors exclusively mediate the HPA axis-independent pathways through urocortin. Opioid peptides are involved in the adaptation and regulation of energy intake and utilization through reward-related behavior. Opioids play a role in the addictive component of AN, as described by the "auto-addiction opioids theory". Their interactions have demonstrated the psychological aspect of AN and have shown to prevent the functioning of the physiological homeostasis. Important opioids involved are ß-lipotropin, ß-endorphin and dynorphin, which interact with both µ and κ opioids receptors to regulate reward-mediated behavior and describe the higher incidence of AN seen in females. Moreover, ghrelin is known as the "hunger" hormone and helps stimulate growth hormone (GH) and hepatic insulin-like-growth-factor-1(IGF-1), maintaining anabolism and preserving a lean body mass. In AN, high levels of GH due to GH resistance along with low levels of IGF-1 are observed. Leptin plays a role in suppressing appetite through the inhibition of neuropeptide Y gene. Moreover, the CRF, opioid, leptin and ghrelin mechanisms operate collectively at the HPA axis and express the physiological and psychological components of AN. Fear conditioning is an intricate learning process occurring at the level of the hippocampus, amygdala, lateral septum and the dorsal raphe by involving three distinct pathways, the HPA axis-independent pathway, hypercortisolemia and ghrelin. Opioids mediate CRF through noradrenergic stimulation in association with the locus coeruleus. Furthermore, CRF's inhibitory effect on gonadotropin releasing hormone can be further explained by the direct relationship seen between CRF and opioids. Low levels of gonadotropin have been demonstrated in AN where only estrogen has shown to mediate energy intake. In addition, estrogen is involved in regulating µ receptor concentrations, but in turn both CRF and opioids regulate estrogen. Moreover, opioids and leptin are both an effect of AN, while many studies have demonstrated a causal relationship between CRF and anorexic behavior. Moreover, leptin, estrogen and ghrelin play a role as predictors of survival in starvation. Since both leptin and estrogen are associated with higher levels of bone marrow fat they represent a longer survival than those who favor the ghrelin pathway. Future studies should consider cohort studies involving prepubertal males and females with high CRF. This would help prevent the extrapolation of results from studies on mice and draw more meaningful conclusions in humans. Studies should also consider these mechanisms in post-AN patients, as well as look into what predisposes certain individuals to develop AN. Finally, due to its complex pathogenesis the treatment of AN should focus on both the pharmacological and behavioral perspectives.

Laugh yourself into a healthier person: a cross cultural analysis of the effects of varying levels of laughter on health.

This cross-cultural study explored along with various personality factors the relationship between laughter and disease prevalence. Previous studies have only determined the effect of laughter on various health dimensions, whereas, this study quantified the level of laughter that was beneficial or detrimental to health. There were a total of 730 participants between the ages of eighteen and thirty-nine years. 366 participants were from Aurangabad, India (AUR), and 364 participants were from Mississauga, Canada (MISS). The participants were provided a survey assessing demographics, laughter, lifestyle, subjective well-being, life satisfaction, emotional well-being and health dimensions. In AUR, a beneficial effect of laughter was mediated through moderate levels (level two) of laughter, whereas both low (level one) and high (level three) levels had no effect. Similarly, in MISS, the beneficial effect was mediated through level two, but a negative effect was also seen at level three. This could be attributable to a higher prevalence of bronchial asthma in western countries. Laughter was associated with emotional well-being in MISS and life satisfaction in AUR, providing cross cultural models to describe the interactions between laughter and disease. This study validated the correlation between emotional well-being and life satisfaction, with a stronger correlation seen in MISS, suggesting that individualists rely more on their emotional well-being to judge their life satisfaction. In conclusion, there is a benefit to clinicians to incorporate laughter history into their general medical history taking. Future research should consider developing mechanisms to explain the effects of level two, determine specific systemic effects and obtain more samples to generalize the cross cultural differences.