Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics.

BACKGROUND: Current guidelines for the treatment of acute ischemic stroke are mainly based on the time between symptom onset and initiation of treatment. This time is unknown in patients with wake-up stroke (WUS). We investigated clinical and multimodality CT imaging characteristics on admission in patients with WUS and in patients with a stroke with a known onset time. METHODS: All patients were selected from a large prospective cohort study (Dutch acute stroke study). WUS patients last seen well > 4.5 and ≤4.5 h were separately compared to patients with a known onset time ≤4.5 h. In addition, WUS patients with a proximal occlusion of the anterior circulation last seen well > 6 and ≤6 h were separately compared to patients with a known onset time ≤6 h and a proximal occlusion. National Institute of Health Stroke Score, age, gender, history of atrial fibrillation, non-contrast CT (NCCT) Alberta Stroke Program Early CT Score (ASPECTS), CT-perfusion abnormalities, proximal occlusions, and collateral filling on CT angiography were compared between groups using the Mann-Whitney U test and Fisher's exact test. RESULTS: WUS occurred in 149/1,393 (10.7%) patients. Admission clinical and imaging characteristics of WUS patients last seen well > 4.5 h (n = 81) were not different from WUS patients last seen well ≤4.5 h (n = 68). Although WUS patients last seen well > 4.5 h had a significantly lower NCCT ASPECTS than patients with a known time of stroke symptom onset of ≤4.5 h (n = 1,026), 85.2% had an NCCT ASPECTS > 7 and 75% had a combination of favorable ASPECTS > 7 and good collateral filling. There were no statistically significant differences between the admission clinical and imaging characteristics of WUS patients with proximal occlusions last seen well > 6 h (n = 23), last seen well ≤6 h (n = 40), and patients with a known time to stroke symptom onset ≤6 h (n = 399). Of all WUS patients with proximal occlusions last seen well > 6 h, only 4.3% had severe ischemia (ASPECTS < 5), 13 (56.5%) had ASPECTS > 7 and good collateral filling. CONCLUSIONS: There are only minor differences between clinical and imaging characteristics of WUS patients and patients who arrive in the hospital within the time criteria for intravenous or endovascular treatment. Therefore, CT imaging may help to identify WUS patients who would benefit from treatment and rule out those patients with severe ischemia and poor collaterals.

International military leaders' survey on operational stress.

Despite the importance of military leaders in moderating the impact of deployment stressors on unit members, little attention has focused on the training leaders receive in managing unit stress. As part of a NATO Research Panel (Human Factors and Medicine (HFM)-081/Research and Technology Organization Task Group (RTG)), 16 nations participated in a needs assessment survey of military leaders who had returned from an operation within the previous 2 years. Findings from 172 leaders emphasized the lack of training specifically geared for leaders to address operational stress issues for unit members and their families and the need for integrated mental health support across the deployment cycle. In general, most leaders regarded stress-related mental health problems as normal and were supportive of help-seeking. The information obtained here was used to develop a Human Factors and Medicine -081/RTG Leader's Guide on operational stress.

"Pumped-up propulsion" during front crawl swimming.

PURPOSE: It is currently held that propulsion in human front crawl swimming is achieved by lift and drag forces predominantly generated by the hands. Calculation of these propulsive forces relies on the quasi-steady assumption that the fluid dynamic behavior of a hand model in a flow channel (constant velocity and orientation) is similar to that of a hand of a real swimmer. However, both experimental and theoretical analyses suggest that this assumption is questionable and that unsteady and rotational propulsion mechanisms play a significant role. Theoretical considerations suggest that arm rotation could lead to a proximodistal pressure gradient, which would induce significant axial flow along the arm toward the hand. METHODS: To gain insight into such mechanisms, we used tufts to study the flow directions around the arm and hand during the front crawl, which consists of a glide, an insweep, and an outsweep phase. In a second experiment, we measured pressure during the stroke at various points along the arm and hand. RESULTS: It was observed that 1) the flow during insweep and part of the outsweep was highly unsteady; 2) the arm movements were largely rotational; 3) a clear axial flow component, not in the direction of the arm movement, was observed during insweep and outsweep; and 4) both the V-shaped "contracting" arrangement of the tufts during the outsweep and pressure recordings point to a pressure gradient along the direction of the arm during the outsweep, as predicted on theoretical grounds. CONCLUSION: Our results demonstrate the reality of the predicted rotational and unsteady effects during front crawl swimming. We hypothesize that the axial flow observed during the outsweep has a propulsion-enhancing effect by increasing the pressure difference over the hand. Further investigation is required to establish more accurately the role of axial flow on propulsion.