Deans' stroke musings

Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 493 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:http://oc1dean.blogspot.com/2010/11/my-background-story_8.html

Friday, November 24, 2017

Thousands of deaths and disabilities caused by strokes in Australia could have been avoided with better care and facilities, according to a new audit by the Stroke Foundation

You don't need best practices or 'care', you need protocols with defined efficacy ratings. That will give you RESULTS, not just better care. Ask for the correct intervention, not the lazy response of better care. YOU have to tell these hospitals they don't know a fucking thing about getting survivors to 100% recovery. That is the only goal, NOT BETTER CARE! 
https://tenplay.com.au/news/national/november-2017/disappointing-care-failing-thousands-of-stroke-patients
The study surveyed more than 30,000 stroke admissions to more than 120 hospitals in 2016 and found many patients were “denied best practice.”
Only 36 percent of stroke victims are reaching hospital within the crucial 4.5-hour window in order to receive essential ‘clot-busting’ medication, and just 30 percent received the medication within an hour of arriving at hospital - compared with 59 percent in the US and 62 percent in the UK. 
The medication, called thrombolysis, acts by dissolving clots of blood disrupting blood flow to the brain. The sooner it is administered after a stroke, the better the chances of recovery.
But the audit found the potentially life-saving medication is only being used in 13 percent of eligible cases Australia-wide - although this is up from seven percent in 2015.
This is despite it being available in more than 70 percent of hospitals in the country.
The report also found a “significant disparity” between regional and metro areas, with less than half of regional victims receiving care from a dedicated stroke unit, compared to more than 75 percent in metro areas.
Australians in regional areas were 19 percent more likely to suffer a stroke than city-dwellers, according to the audit.
Sharon McGowan, CEO of the Stroke Foundation, said there is a lot of work to be done to achieve best practice.
“Surviving and living well after stroke should not be determined by your post code,” she said.
“Australia has one of the most advanced trauma systems in the world, we need to apply the same thinking to emergency stroke treatment to ensure people living in regional and rural Australia have the best chance(Weasel words, You expect results) of making a meaningful recovery after a stroke.”
But there’s a silver lining: the report found the number of stroke units Australia-wide had increased from 87 in 2015 to 95 this year, and the use of thrombolysis increased from only 7 percent in 2015.
Ms McGowan says improvements to stroke care can be achieved.
“Stroke is a serious medical emergency which requires urgent attention, but with the right treatment at the right time many people are able to recover,” she said.
“We [must] ensure every patient with a stroke has a clear pathway to stroke treatment, whether that be at the regional hospital, utilising telehealth, or transported to the nearest comprehensive stroke service.
“This means clear processes between ambulances, emergency departments and stroke units enabling patients to be diagnosed and provided with appropriate treatment quickly,” she said.

Inactive lifestyles and sedentary behavior in persons with chronic aneurysmal subarachnoid hemorrhage: evidence from accelerometer-based activity monitoring

Totally wrong conclusion. You should target your doctors for not solving the neuronal cascade of death resulting in fewer dead and damaged neurons. But it is so much easier to blame the patient you lazy bastards.
https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-017-0331-1

  • Wouter J. HarmsenEmail author,
  • Gerard M. Ribbers,
  • Majanka H. Heijenbrok-Kal,
  • Johannes B. J. Bussmann,
  • Emiel M. Sneekes,
  • Ladbon Khajeh,
  • Fop van Kooten,
  • Sebastian J. C. M. M. Neggers and
  • Rita J. van den Berg-Emons
Journal of NeuroEngineering and Rehabilitation201714:120
Received: 7 November 2016
Accepted: 31 October 2017
Published: 23 November 2017

Abstract

Background

Aneurysmal subarachnoid hemorrhage (a-SAH) is a potential life-threatening stroke. Because survivors may be at increased risk for inactive and sedentary lifestyles, this study evaluates physical activity (PA) and sedentary behavior (SB) in the chronic phase after a-SAH.

Methods

PA and SB were objectively measured at six months post a-SAH with an accelerometer-based activity monitor, with the aim to cover three consecutive weekdays. Total time spent in PA (comprising walking, cycling, running and non-cyclic movement) and SB (comprising sitting and lying) was determined. Also, in-depth analyses were performed to determine the accumulation and distribution of PA and SB throughout the day. Binary time series were created to determine the mean bout length and the fragmentation index. Measures of PA and SB in persons with a-SAH were compared to those in sex- and age-matched healthy controls.

Results

The 51 participants comprised 33 persons with a-SAH and 18 controls. None of the participants had signs of paresis or spasticity. Persons with a-SAH spent 105 min/24 h being physically active, which was 35 min/24 h less than healthy controls (p = 0.005). For PA, compared with healthy controls, the mean bout length was shorter in those with a-SAH (12.0 vs. 13.5 s, p = 0.006) and the fragmentation index was higher (0.053 vs. 0.041, p < 0.001). Total sedentary time during waking hours showed no significant difference between groups (514 min vs. 474 min, p = 0.291). For SB, the mean bout length was longer in persons with a-SAH (122.3 vs. 80.5 s, p = 0.024), whereas there was no difference in fragmentation index between groups (0.0032 vs 0.0036, p = 0.396).

Conclusions

Persons with a-SAH are less physically active, they break PA time into shorter periods, and SB periods last longer compared to healthy controls. Since inactive lifestyles and prolonged uninterrupted periods of SB are independent risk factors for poor cardiovascular health, interventions seem necessary and should target both PA and SB.

Study registration

Dutch registry number: NTR 2085.

Coffee: No Harm, No Foul If Only 4 Cups Daily

I bet your incompetent stroke hospital will not create a 24 hour a day coffee station. And if you are not catheterized this is great therapy for walking to the bathroom in time. There are NO excuses for such incompetence.
https://www.medpagetoday.com/primarycare/dietnutrition/69484?
However, link seen between coffee drinking and fracture risk in women
by Alexandria Bachert MPH, Staff Writer, MedPage Today
November 22, 2017
Daily consumption of coffee is safe within usual patterns of intake and more likely to benefit health than to harm it, British researchers concluded.
Analysis of more than 200 studies found that drinking three to four cups of coffee a day (400 mg/day) was associated with a reduced risk of all cause mortality (relative risk 0.83, 95% CI 0.83-0.88), cardiovascular mortality (0.81, 95% CI 0.72-0.90), and cardiovascular disease (0.85, 95% CI 0.80-0.90), reported Robin Poole, MD, of the University of Southampton in England, and colleagues.
Increasing consumption to more than three cups a day was not linked to harmful effects, but the benefit was less pronounced, they wrote online in BMJ.
Poole's group searched PubMed, Embase, CINAHL, and the Cochrane Database of Systematic Reviews for meta-analyses of observational or interventional studies that investigated the link between coffee consumption and any health outcome. Searching for "coffee OR caffeine" and "systematic review OR meta-analysis," they found 201 meta-analyses of observational research with 67 unique outcomes and 17 meta-analyses of randomized controlled trials with nine unique outcomes.
A meta-analysis of 40 cohort studies showed a lower incidence of cancer for high versus low coffee consumption (relative risk 0.82, 95% CI 0.74 to 0.89), any versus no consumption (RR 0.87, 95% CI 0.82-0.92), and one additional cup per day (RR 0.97, 95% CI 0.96-0.98), they reported.
Any versus no coffee consumption was associated with a 29% lower risk of non-alcoholic fatty liver disease (relative risk 0.71, 95% CI 0.60-0.85), a 27% lower risk for liver fibrosis (odds ratio 0.73, 95% CI 0.56-0.94), and a 39% lower risk for liver cirrhosis (OR 0.61, 95% CI 0.45-0.84), as well as a lower risk of cirrhosis with high versus low consumption (OR 0.69, 95% CI 0.44-1.07).
Additionally, coffee consumption was consistently associated with a lower risk of type 2 diabetes for high versus low consumption (RR 0.70, 95% CI 0.65-0.75) and Alzheimer's disease (RR 0.73, 95% CI 0.55-0.97).
Poole's group didn't find any consistent evidence of harmful associations between coffee consumption and health outcomes except for those related to pregnancy and risk of fracture in women. After adjustment for smoking, consumption in pregnancy was associated with harmful outcomes related to low birth weight (OR 1.31, 95% CI 1.03-1.67), preterm birth in the first trimester (OR 1.22, 95% CI 1.00-1.49), and second trimester (OR 1.12, 95% CI 1.02-1.22), and pregnancy loss (OR 1.46, 95% CI 1.06-1.99).
A research limitation was that much of the evidence was low quality and came from observational studies which may include residual confounding. However, the researchers noted that "the analysis indicates that future randomised controlled trials in which the intervention is increasing coffee consumption, within usual levels of intake, possibly optimised at three to four cups a day, would be unlikely to result in significant harm to participants."
In an accompanying editorial, Eliseo Guallar, MD, of Johns Hopkins Bloomberg School of Public Health in Baltimore, agreed but cited several suggestions regarding future research. "Poole and colleagues argue that randomised clinical trials are needed, although the complexity of long term trials of behavioural interventions, the large sample size required, and the high cost complicate the feasibility of trials prospectively testing the effect of coffee on clinical endpoints."
"Mendelian randomisation analyses may also help, but their power is limited if genetic traits explain only a small fraction of coffee intake patterns, and their interpretation is complicated by the pleiotropic effects of the genes involved in metabolising caffeine," Guallar noted.
Poole and co-authors disclosed no relevant relationships with industry.
Primary Source
BMJ
Source Reference: Guallar E "Coffee gets a clean bill of health" BMJ 2017; DOI: 10.1136/bmj.j5356.
Secondary Source
BMJ
Source Reference: Poole R, et al "Coffee consumption and health: umbrella review of meta-analyses of multiple health outcomes" BMJ 2017; DOI: 10.1136/bmj.j5024.

How providers, payers and pharma can work together to drive the transition to value-based care

When we get to value based care(paying for results), it is likely you will have to pay nothing for your stroke recovery if it is less than 100%. That might be the only way the stroke medical world might focus and solve all the problems in stroke.
https://www.fiercehealthcare.com/healthcare/how-providers-payers-and-pharma-can-drive-value-based-care?
by Paige Minemyer |

WASHINGTON—As the healthcare industry continues its transition away from traditional fee-for-service models, policymakers and other stakeholders can take steps to ease the growing pains.

On Friday, the Healthcare Leadership Council convened a panel of leaders in the provider, payer and pharmaceutical space to discuss the challenges these three groups face in the transformation to value-based care models and how each would like to see those changes continue to progress.
Andrew Baskin, M.D., national medical director for clinical quality and policy at Aetna, said it ultimately comes down to effective payer-provider collaboration. High-level alternative payment models, like accountable care organizations, operate more effectively when these two groups can bring their strengths together to achieve shared goals.
Providers bring a strong community presence and have preexisting relationships with individuals, while payers can provide a more population-based viewpoint and have experience in financial risk management. When those viewpoints are aligned, accountable care is at its most effective, he said.

“These relationships have been evolving over time,” Baskin said, but accelerated far more rapidly under the Affordable Care Act.
The main challenges, according to Baskin, lie in unclear or inflexible regulations; for instance, programs like the 340B drug discount program can discourage insurers from embracing value-based frameworks. Some discounts in value-based care contracts could be construed as kickbacks, and guidance on data-sharing is often unclear, he said.
Helen Macfie, chief transformation officer for the Los Angeles-based MemorialCare Health System, stressed the value of continued support for innovation and sharing best practices in value-based care, particularly through the Center for Medicare & Medicaid Innovation.
She said that MemorialCare, which operates ACOs and other value-based programs, is “bullish” on bundled payments and has seen the benefits of such programs by voluntarily deploying them. Other providers view value-based care programs similarly.
“[Bundled payments] get specialists together with providers to do something really cool,” she said.
But Macfie agreed with Baskin that certain regulations can hinder provider performance in value-based programs. For example, the 3-Day Rule for skilled nursing facilities—which requires Medicare beneficiaries to undergo a hospital stay of at least three days in order to get coverage for their SNF stay—is significant barrier.
The continued evolution of the Medicare Access and CHIP Reauthorization Act (MACRA) will also play a role in this issue, and Macfie said she and other providers hope that it stimulates the development of further advanced payment models.
For pharmaceutical manufacturers, the concern is how they can best interact with patients and providers in these value-based models, said Mitch Higashi, Ph.D, vice president for health economics and outcomes research at Bristol-Myers Squibb. Higashi said that pharma companies would be able to take on some of the financial risk, but doing so could be inappropriate.
He offered an example of a program where a drugmaker would offer patients rebates for medications or treatments that were ineffective. However, he said the rebates could set the drug pricing floor too low and could appear to be a kickback to encourage prescriptions. The Department of Health and Human Services Office of Inspector General, he said, could provide guidance on how these relationships would work.
Value-based care programs also must be analyzed more closely with regard to how they affect patient-centered quality measures, he said. This is especially key as value assessments need to keep pace with innovation.
“Patients are necessary partners in developing measures of value,” Higashi said.

Effects of Female Sex Steroids Administration on Pathophysiologic Mechanisms in Traumatic Brain Injury

8 posts on estrogen all the way back to Jan. 2012 just to show you how fucking incompetent your stroke medical world is. 9 posts on progesterone back to Jan. 2012 show the same incompetence. You doctor can explain why nothing has been done. 
https://link.springer.com/article/10.1007/s12975-017-0588-5

  • Mohammad Khaksari
  • Zahra Soltani
  • Nader Shahrokhi
  1. 1.Physiology Research Center, Institute of NeuropharmacologyKerman University of Medical SciencesKermanIran
  2. 2.Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology SciencesKerman University of Medical SciencesKermanIran
  3. 3.Neuroscience Research Center, Institute of NeuropharmacologyKerman University of Medical SciencesKermanIran
Review




Abstract

Secondary brain damage following initial brain damage in traumatic brain injury (TBI) is a major cause of adverse outcomes. There are many gaps in TBI research and a lack of therapy to limit debilitating outcomes in TBI or enhance the neurogenesis, despite pre-clinical and clinical research performed in TBI. Females show harmful outcomes against brain damage including TBI less than males, independent of different TBI occurrence. A significant reduction in secondary brain damage and improvement in neurologic outcome post-TBI has been reported following the use of progesterone and estrogen in many experimental studies. Although useful features of sex steroids including progesterone have been identified in TBI clinical trials I and II, clinical trials III have been unsuccessful. This review article focuses on evidence of secondary injury mechanisms and neuroprotective effects of estrogen and progesterone in TBI. Understanding these mechanisms may enable researchers to achieve greater success in TBI clinical studies. It seems that the design of clinical studies should be revised due to translation loss of animal studies to clinical studies. The heterogeneous and complex nature of TBI, the endogenous levels of sex hormones at the time of taking these hormones, the therapeutic window of the drug, the dosage of the drug, the selection of appropriate targets in evaluation, the determination of responsive population, gender and age based on animal studies should be considered in the design of TBI human studies in future.

Scientists reveal breakthrough in brain cell repair around Parkinson’s disease

But are these other models for getting stem cells into the brain better? DEMAND your doctor answer that simple question.  WHOM is testing all these for stroke recovery? Does anyone have any fucking idea what they are doing in stroke other than flailing away?


Peptide-Based Scaffolds Support Human Cortical Progenitor Graft Integration to Reduce Atrophy and Promote Functional Repair in a Model of Stroke  Aug. 2017


Or nanofibers?


Nanofibrous scaffolds supporting optimal central nervous system regeneration: an evidence-based review  Dec. 2015


Or any better than this?

Thick collagen-based 3D matrices including growth factors to induce neurite outgrowth.
Nov. 2012


 The latest here:

Scientists reveal breakthrough in brain cell repair around Parkinson’s disease

Neuroscientists at NUI Galway have made a breakthrough in regenerative medicine approaches to the neurodegenerative condition Parkinson’s disease. The research was published today in the Nature journal, Scientific Reports.Parkinson’s is a condition that primarily affects a person’s ability to control movement leading to a progressive deterioration in ability. The symptoms of the condition are caused by the degeneration and death of brain cells that regulate movement.Brain repair for Parkinson’s involves replacing the dead cells by transplanting healthy brain cells back into the brain, but the widespread roll-out of this therapy has been hindered by the poor survival of the implanted cells.The research, carried out by a team at the Galway Neuroscience Centre and CÚRAM, the Science Foundation Ireland Centre for Research in Medical Devices, based at NUI Galway, has shown that the survival of the transplanted cells is dramatically improved if they are implanted within a supportive matrix made from the natural material collagen. Commenting on the research, lead author of the research paper, Dr Eilis Dowd at NUI Galway, said: “The collagen provides the cells with a nurturing, supportive environment in the brain and helps them to survive the aversive transplant process.”The work will be presented at the upcoming Network for European CNS Transplantation and Restoration (NECTAR) conference which is being hosted by Dr Dowd in Dublin from the 6–8 December 2017. The event will feature leading scientists from the US, Canada, Australia, Belgium, Denmark, France, Ireland, Sweden, Switzerland and the UK, who will present their latest research on brain repair for Parkinson’s, Huntington’s and Alzheimer’s.This NUI Galway research was also presented recently at the International Neural Transplantation and Repair (INTR) conference in Port Douglas, Australia by Niamh Moriarty, the PhD student working on the project. Niamh was awarded a highly competitive Travel Award from the Campaign for Alzheimer’s Research in Europe which enabled her to present her work at this leading international event. The research was recently featured in the short documentary Feats of Modest Valour, produced through CÚRAM’s Science on Screen programme. The film won the coveted Scientist Award at the Imagine Science Film Festival in New York in October, and was screened on RTÉ One for Science Week 2017. The documentary is available to watch on the RTÉ Player until 11 December 2017.This research was funded by Science Foundation Ireland and a Government of Ireland Irish Research Council PhD Scholarship to Niamh Moriarty.