Comprehensive portrait of stroke fellowship training in Brazil: A national survey study.

BACKGROUND AND OBJECTIVES: The field of vascular neurology has undergone significant advances over the last decade, and care has become more complex. However, vascular neurology training programs remain underdeveloped in many countries, despite stroke impact on health care. There are efforts towards building a nationally regulated curricula in some countries. Still, comprehensive planning and implementation of these programs may be needed on a global scale, especially in countries where stroke treatment is not fully implemented. We aim to comprehensively analyze vascular neurology trainees' profiles in Brazil to describe training program contents from trainees and program directors' perspectives. METHODS: We performed an observational, cross-sectional, web-based survey study to describe trainee and program-specific characteristics at vascular neurology fellowship training programs in Brazil. The study was conducted from June to September 2023 using a secure web-based survey sent to active fellows and program directors from all known vascular neurology fellowship programs in the country. All respondents were required to provide informed consent. RESULTS: We obtained a 100 % response rate of a total of 12 programs distributed in 7 federal states. Notably, 57 % of the 28 surveyed fellows were women, 60 % were aged 25-30, and 70 % self-identified as White. All fellows had prior neurology training, and 60 % engaged in the program just following residency. Exposure to various training experiences was favorable, except for simulation-based learning and telestroke training. Program directors perceived exposure to be sufficient for most components but similarly found deficiencies in telestroke and simulation-based learning. Scientific productivity was low, with about two-thirds of fellows having no publications or abstracts. Most fellows (92.6 %) reported performing non-fellowship medical activities to supplement their incomes. DISCUSSION: In conclusion, the number of vascular neurology training programs and trainees in Brazil is currently insufficient and exhibits an uneven geographic distribution. Despite this, the clinical training provided is extensive, and there is generally some funding available for fellows. These insights highlight the need for strategic improvements in Brazil's stroke education and could inform similar developments in other nations.

Future Exploration of the Outer Heliosphere and Very Local Interstellar Medium by Interstellar Probe.

A detailed overview of the knowledge gaps in our understanding of the heliospheric interaction with the largely unexplored Very Local Interstellar Medium (VLISM) are provided along with predictions of with the scientific discoveries that await. The new measurements required to make progress in this expanding frontier of space physics are discussed and include in-situ plasma and pick-up ion measurements throughout the heliosheath, direct sampling of the VLISM properties such as elemental and isotopic composition, densities, flows, and temperatures of neutral gas, dust and plasma, and remote energetic neutral atom (ENA) and Lyman-alpha (LYA) imaging from vantage points that can uniquely discern the heliospheric shape and bring new information on the interaction with interstellar hydrogen. The implementation of a pragmatic Interstellar Probe mission with a nominal design life to reach 375 Astronomical Units (au) with likely operation out to 550 au are reported as a result of a 4-year NASA funded mission study.

Successful Reperfusion is Associated with Favorable Functional Outcome despite Vessel Perforation during Thrombectomy: A Case Series and Systematic Review.

BACKGROUND: Arterial perforation is a potentially serious complication during endovascular thrombectomy. PURPOSE: Our aim was to describe interventional approaches after arterial perforation during endovascular thrombectomy and to determine whether reperfusion remains associated with favorable outcome despite this complication. DATA SOURCES: Data from consecutive patients with acute stroke undergoing endovascular thrombectomy were retrospectively collected between 2015 to 2020 from a single-center cohort, and a systematic review was performed using PubMed, EMBASE, and Ovid MEDLINE up to June 2020. STUDY SELECTION: Articles reporting functional outcome after arterial perforation during endovascular thrombectomy were selected. DATA ANALYSIS: Functional outcomes of patients achieving successful reperfusion (TICI 2b/3) were compared with outcomes of those with unsuccessful reperfusion in our single-center cohort. We then summarized the literature review to describe interventional approaches and outcomes after arterial perforation during endovascular thrombectomy. DATA SYNTHESIS: In our single-center cohort, 1419 patients underwent endovascular thrombectomy, among whom 32 (2.3%) had vessel perforation and were included in the analysis. The most common hemostatic strategy was watchful waiting (71% of cases). Patients with successful reperfusion had a higher proportion of favorable 90-day mRS scores (60% versus 12.5%; P = .006) and a lower mortality rate (13.3% versus 56.3%, P = .01) than patients without successful reperfusion. Thirteen articles were included in the systematic review. Successful reperfusion also appeared to be associated with better outcomes. LIMITATIONS: Given the low number of published reports, we performed only a descriptive analysis. CONCLUSIONS: Arterial perforation during endovascular thrombectomy is rare but is associated with high mortality rates and poor outcome. However, successful reperfusion remains correlated with favorable outcome in these patients.

Water-Group Pickup Ions From Europa-Genic Neutrals Orbiting Jupiter.

Water-group gas continuously escapes from Jupiter's icy moons to form co-orbiting populations of particles or neutral toroidal clouds. These clouds provide insights into their source moons as they reveal loss processes and compositions of their parent bodies, alter local plasma composition, and act as sources and sinks for magnetospheric particles. We report the first observations of H2 + pickup ions in Jupiter's magnetosphere from 13 to 18 Jovian radii and find a density ratio of H2 +/H+ = 8 ± 4%, confirming the presence of a neutral H2 toroidal cloud. Pickup ion densities monotonically decrease radially beyond 13 R J consistent with an advecting Europa-genic toroidal cloud source. From these observations, we derive a total H2 neutral loss rate from Europa of 1.2 ± 0.7 kg s-1. This provides the most direct estimate of Europa's H2 neutral loss rate to date and underscores the importance of both ion composition and neutral toroidal clouds in understanding satellite-magnetosphere interactions.

Ion Dynamics at the Magnetopause of Ganymede.

We study the dynamics of the thermal O+ and H+ ions at Ganymede's magnetopause when Ganymede is inside and outside of the Jovian plasma sheet using a three-dimensional hybrid model of plasma (kinetic ions, fluid electrons). We present the global structure of the electric fields and power density (E â‹… J) in the magnetosphere of Ganymede and show that the power density at the magnetopause is mainly positive and on average is +0.95 and +0.75 nW/m3 when Ganymede is inside and outside the Jovian plasma sheet, respectively, but locally it reaches over +20 nW/m3. Our kinetic simulations show that ion velocity distributions at the vicinity of the upstream magnetopause of Ganymede are highly non-Maxwellian. We investigate the energization of the ions interacting with the magnetopause and find that the energy of those particles on average increases by a factor of 8 and 30 for the O+ and H+ ions, respectively. The energy of these ions is mostly within 1-100 keV for both species after interaction with the magnetopause, but a few percentages reach to 0.1-1 MeV. Our kinetic simulations show that a small fraction ( < 25%) of the corotating Jovian plasma reach the magnetopause, but among those >50% cross the high-power density regions at the magnetopause and gain energy. Finally, we compare our simulation results with Galileo observations of Ganymede's magnetopause crossings (i.e., G8 and G28 flybys). There is an excellent agreement between our simulations and observations, particularly our simulations fully capture the size and structure of the magnetosphere.

Strength of Association between Infarct Volume and Clinical Outcome Depends on the Magnitude of Infarct Size: Results from the ESCAPE-NA1 Trial.

BACKGROUND AND PURPOSE: Infarct volume is an important predictor of clinical outcome in acute stroke. We hypothesized that the association of infarct volume and clinical outcome changes with the magnitude of infarct size. MATERIALS AND METHODS: Data were derived from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, in which patients with acute stroke with large-vessel occlusion were randomized to endovascular treatment plus either nerinetide or a placebo. Infarct volume was manually segmented on 24-hour noncontrast CT or DWI. The relationship between infarct volume and good outcome, defined as mRS 0-2 at 90 days, was plotted. Patients were categorized on the basis of visual grouping at the curve shoulders of the infarct volume/outcome plot. The relationship between infarct volume and adjusted probability of good outcome was fitted with linear or polynomial functions as appropriate in each group. RESULTS: We included 1099 individuals in the study. Median infarct volume at 24 hours was 24.9 mL (interquartile range [IQR] = 6.6-92.2 mL). On the basis of the infarct volume/outcome plot, 4 infarct volume groups were defined (IQR = 0-15 mL, 15.1-70 mL, 70.1-200 mL, >200 mL). Proportions of good outcome in the 4 groups were 359/431 (83.3%), 219/337 (65.0%), 71/201 (35.3%), and 16/130 (12.3%), respectively. In small infarcts (IQR = 0-15 mL), no relationship with outcome was appreciated. In patients with intermediate infarct volume (IQR = 15-200 mL), there was progressive importance of volume as an outcome predictor. In infarcts of > 200 mL, outcomes were overall poor. CONCLUSIONS: The relationship between infarct volume and clinical outcome varies nonlinearly with the magnitude of infarct size. Infarct volume was linearly associated with decreased chances of achieving good outcome in patients with moderate-to-large infarcts, but not in those with small infarcts. In very large infarcts, a near-deterministic association with poor outcome was seen.

Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions.

Approximately 15% of patients undergoing endovascular thrombectomy for anterior circulation acute ischemic stroke have a tandem lesion, defined as a severe stenosis or occlusion of the cervical internal carotid artery ipsilateral to its intracranial occlusion. Patients with tandem lesions have worse outcomes than patients with isolated intracranial occlusions, but the optimal management of their carotid lesions during endovascular thrombectomy remains controversial. The main options commonly used in current practice include acute stent placement in the carotid lesion versus thrombectomy alone without definitive revascularization of the carotid artery. While treatment decisions for these patients are often complex and strategies vary according to clinical, anatomic, and technical considerations, only results from randomized trials comparing these approaches are likely to strengthen current recommendations and optimize patient care.

Exophthalmos following mechanical thrombectomy for anterior circulation stroke: A retrospective study and review of literature.

BACKGROUND: Anecdotal cases of exophthalmos after acute mechanical thrombectomy have been described. We sought to estimate the incidence in a large cohort of patients with acute anterior circulation stroke treated with mechanical thrombectomy. Secondarily, we aimed to evaluate the underlying mechanism and to differentiate it on imaging from other pathology with similar clinical orbital features. METHODS: Between November 2016 and November 2018, we performed a retrospective single-center study of 250 patients who underwent anterior circulation mechanical thrombectomy. Development of exophthalmos was independently evaluated by two readers on preprocedure and 24-h postprocedure non-contrast cerebral CT. RESULTS: In the mechanical thrombectomy cohort, six individuals (2.4%) developed interval ipsilateral exophthalmos at 24 h. Of these, at least two patients developed clinical symptoms. There was almost perfect agreement between assessments of the two readers (Cohen's kappa = 0.907 (95% confidence interval: 0.726, 1.000)). In two patients, there was delayed ophthalmic artery filling on digital subtraction angiography. None of the patients had features of a direct carotid-cavernous fistula. CONCLUSIONS: Exophthalmos is not uncommon after mechanical thrombectomy (2.4%). The underlying mechanism is difficult to confirm, but it is most likely due to orbital ischemia from hypoperfusion or distal emboli.

Effects of health at every size® interventions on health-related outcomes of people with overweight and obesity: a systematic review.

CONTEXT: The growing use of interventions based on the Health at Every Size® (HAES®) in obesity management. OBJECTIVE: This study aimed to summarize the health-related effects of HAES®-based interventions on people with overweight and obesity. DATA SOURCES: MEDLINE (via PubMed), EMBASE, Cochrane Library, LILACS, Google Scholar, OpenGrey and Grey Literature Report. STUDY SELECTION: A systematic review of studies published until January 2017 reporting on HAES®-based randomized and non-randomized controlled trials in people with overweight and/or obesity. DATA EXTRACTION: Fourteen papers met the inclusion criteria. The assessed studies included the following tests: blood profile, blood pressure, anthropometry, eating behaviour, energy intake, diet quality, psychological and qualitative evaluations. RESULTS: The HAES® interventions benefited both the psychological and physical activity outcomes, besides promoting behavioural and qualitative changes in eating habits. On the other hand, the results regarding cardiovascular responses, body-image perception and total energy intake were inconsistent. CONCLUSIONS: Despite improving the cardiovascular status, eating behaviours, quality of life and psychological well-being in participants, other large long-term clinical trials should be performed to establish the effectiveness of HAES®-based interventions in improving health for people with overweight and obesity. PROSPERO registration 2017: CRD42017054857.

Breast cancer subtype and survival by parity and time since last birth.

BACKGROUND: Pregnancy affects breast cancer risk but how it affects the subtype and prognosis remain controversial. We studied the effect of parity and time since last birth on breast cancer subtype and outcome. PATIENTS AND METHODS: We conducted a retrospective multivariate cohort study including all premenopausal women with early breast cancer aged ≤ 50 years (N = 1306) at diagnosis at the University Hospitals Leuven (Jan. 2000-Dec. 2009). Primary study endpoints were the breast cancer subtype, disease-free survival, and distant disease-free survival by parity and time since last birth. Statistical methods used were baseline-category logits models and Cox proportional hazard models. Multivariable models were used to correct for possible confounders. RESULTS: Breast cancer subtypes did not differ between nulliparous (N = 266) and parous women (N = 1040) but subtypes differed significantly in parous women by time since last birth (p < 0.001). Tumors within 5 years of last birth were proportionally more likely triple negative and HER-2 like, even when corrected for age at diagnosis. After a mean follow-up period of 10 years, parous women had a better disease-free survival compared to nulliparous women (HR 0.733; CI 0.560-0.961; p = 0.025, HR 0.738; CI 0.559-0.974; p = 0.032 before and after correction for known prognostic factors, respectively). In parous women, a longer time since last birth was correlated with a longer disease-free survival compared to patients with a recent pregnancy (HR 0.976; CI 0.957-0.996; p = 0.018). However, after correction, this association completely disappeared (HR 1.010; CI 0.982-1.040; p = 0.480). CONCLUSION: We observed a better disease-free survival for parous than nulliparous women. The influence of recent birth on disease-free survival is probably due to tumor and patient characteristics, as recent birth is associated with more aggressive subtypes.

A Tenuous Lunar Ionosphere in the Geomagnetic Tail.

We utilize measurements of electron plasma frequency oscillations made by the two-probe Acceleration, Reconnection, Turbulence, and Electrodynamics of Moon's Interaction with the Sun mission to investigate the charged particle density in the lunar environment as the Moon passes through the Earth's geomagnetic tail. We find that the Moon possesses a tenuous ionosphere with an average density of ~0.1-0.3 cm-3, present at least 50% of the time in the geomagnetic tail, primarily confined to within a few thousand kilometers of the dayside of the Moon. The day-night asymmetry and dawn-dusk symmetry of the observed plasma suggests that photoionization of a neutral exosphere with dawn-dusk symmetry produces the majority of the lunar-derived plasma. The lunar plasma density commonly exceeds the ambient plasma density in the tail, allowing the presence of the lunar ionosphere to appreciably perturb the local plasma environment.

ARTEMIS Observations of Solar Wind Proton Scattering off the Lunar Surface.

We study the scattering of solar wind protons off the lunar surface, using ion observations collected over 6 years by the ARTEMIS satellites at the Moon. We show the average scattered proton energy spectra, directional scattering distributions, and scattering efficiency, for different solar wind incidence angles and impact speeds. We find that the protons have a scattering distribution that is similar to existing empirical models for scattered hydrogen energetic neutral atoms, with a peak in the backward direction (toward the Sun). We provide a revised model for the scattered proton energy spectrum. We evaluate the positive to neutral charge state ratio by comparing the proton spectrum with existing models for scattered hydrogen. The positive to neutral ratio increases with increasing exit speed from the surface but decreases with increasing impact speed. Combined, these counteracting effects result in a scattering efficiency that decreases from ~0.5% at 300 km/s solar wind speed to ~0.3% at 600 km/s solar wind speed.

Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial.

BACKGROUND AND PURPOSE: The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial. MATERIALS AND METHODS: Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0-2, mRS 0-1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses. RESULTS: There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0-2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage. CONCLUSIONS: Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.

Photoemission and electrostatic potentials on the dayside lunar surface in the terrestrial magnetotail lobes.

Despite the need to accurately predict and assess the lunar electrostatic environment in all ambient conditions that the Moon encounters, photoemission and electrostatic potentials on the dayside lunar surface in the terrestrial magnetotail lobes remain poorly characterized. We study characteristics and variabilities of lunar photoelectron energy spectra by utilizing Acceleration, Reconnection, Turbulence, and Electrodynamics of the Moon's Interaction with the Sun (ARTEMIS) and Apollo measurements in combination with the Flare Irradiance Spectral Model (FISM). We confirm that the photoelectron spectral shapes are consistent between ARTEMIS and Apollo and that the photoelectron flux is linearly correlated with the FISM solar photon flux. We develop an observation-based model of lunar photoelectron energy distributions, thereby deriving the current balance surface potential. The model predicts that dayside lunar surface potentials in the tail lobes (typically tens of volts) could increase by a factor of 2 - 3 during strong solar flares.

ARTEMIS observations of the solar wind proton scattering function from lunar crustal magnetic anomalies.

Despite their small scales, lunar crustal magnetic fields are routinely associated with observations of reflected and/or backstreaming populations of solar wind protons. Solar wind proton reflection locally reduces the rate of space weathering of the lunar regolith, depresses local sputtering rates of neutrals into the lunar exosphere, and can trigger electromagnetic waves and small-scale collisionless shocks in the near-lunar space plasma environment. Thus, knowledge of both the magnitude and scattering function of solar wind protons from magnetic anomalies is crucial in understanding a wide variety of planetary phenomena at the Moon. We have compiled 5.5 years of ARTEMIS (Acceleration, Reconnection, Turbulence and Electrodynamics of the Moon's Interaction with the Sun) observations of reflected protons at the Moon and used a Liouville tracing method to ascertain each proton's reflection location and scattering angles. We find that solar wind proton reflection is largely correlated with crustal magnetic field strength, with anomalies such as South Pole/Aitken Basin (SPA), Mare Marginis, and Gerasimovich reflecting on average 5-12% of the solar wind flux while the unmagnetized surface reflects between 0.1 and 1% in charged form. We present the scattering function of solar wind protons off of the SPA anomaly, showing that the scattering transitions from isotropic at low solar zenith angles to strongly forward scattering at solar zenith angles near 90°. Such scattering is consistent with simulations that have suggested electrostatic fields as the primary mechanism for solar wind proton reflection from crustal magnetic anomalies.

Distribution and solar wind control of compressional solar wind-magnetic anomaly interactions observed at the Moon by ARTEMIS.

A statistical investigation of 5 years of observations from the two-probe Acceleration, Reconnection, Turbulence, and Electrodynamics of Moon's Interaction with the Sun (ARTEMIS) mission reveals that strong compressional interactions occur infrequently at high altitudes near the ecliptic but can form in a wide range of solar wind conditions and can occur up to two lunar radii downstream from the lunar limb. The compressional events, some of which may represent small-scale collisionless shocks ("limb shocks"), occur in both steady and variable interplanetary magnetic field (IMF) conditions, with those forming in steady IMF well organized by the location of lunar remanent crustal magnetization. The events observed by ARTEMIS have similarities to ion foreshock phenomena, and those observed in variable IMF conditions may result from either local lunar interactions or distant terrestrial foreshock interactions. Observed velocity deflections associated with compressional events are always outward from the lunar wake, regardless of location and solar wind conditions. However, events for which the observed velocity deflection is parallel to the upstream motional electric field form in distinctly different solar wind conditions and locations than events with antiparallel deflections. Consideration of the momentum transfer between incoming and reflected solar wind populations helps explain the observed characteristics of the different groups of events.

Pluto's interaction with its space environment: Solar wind, energetic particles, and dust.

The New Horizons spacecraft carried three instruments that measured the space environment near Pluto as it flew by on 14 July 2015. The Solar Wind Around Pluto (SWAP) instrument revealed an interaction region confined sunward of Pluto to within about 6 Pluto radii. The region's surprisingly small size is consistent with a reduced atmospheric escape rate, as well as a particularly high solar wind flux. Observations from the Pluto Energetic Particle Spectrometer Science Investigation (PEPSSI) instrument suggest that ions are accelerated and/or deflected around Pluto. In the wake of the interaction region, PEPSSI observed suprathermal particle fluxes equal to about 1/10 of the flux in the interplanetary medium and increasing with distance downstream. The Venetia Burney Student Dust Counter, which measures grains with radii larger than 1.4 micrometers, detected one candidate impact in ±5 days around New Horizons' closest approach, indicating an upper limit of <4.6 kilometers(-3) for the dust density in the Pluto system.

Structure and composition of the distant lunar exosphere: Constraints from ARTEMIS observations of ion acceleration in time-varying fields.

By analyzing the trajectories of ionized constituents of the lunar exosphere in time-varying electromagnetic fields, we can place constraints on the composition, structure, and dynamics of the lunar exosphere. Heavy ions travel slower than light ions in the same fields, so by observing the lag between field rotations and the response of ions from the lunar exosphere, we can place constraints on the composition of the ions. Acceleration, Reconnection, Turbulence, and Electrodynamics of Moon's Interaction with the Sun (ARTEMIS) provides an ideal platform to utilize such an analysis, since its two-probe vantage allows precise timing of the propagation of field discontinuities in the solar wind, and its sensitive plasma instruments can detect the ion response. We demonstrate the utility of this technique by using fully time-dependent charged particle tracing to analyze several minutes of ion observations taken by the two ARTEMIS probes ~3000-5000 km above the dusk terminator on 25 January 2014. The observations from this time period allow us to reach several interesting conclusions. The ion production at altitudes of a few hundred kilometers above the sunlit surface of the Moon has an unexpectedly significant contribution from species with masses of 40 amu or greater. The inferred distribution of the neutral source population has a large scale height, suggesting that micrometeorite impact vaporization and/or sputtering play an important role in the production of neutrals from the surface. Our observations also suggest an asymmetry in ion production, consistent with either a compositional variation in neutral vapor production or a local reduction in solar wind sputtering in magnetic regions of the surface.

The electrostatic plasma environment of a small airless body under non-aligned plasma flow and UV conditions.

Airless bodies interact with a wide variety of plasma environments throughout the solar system. For many objects, incident plasma is nearly co-aligned with solar ultraviolet radiation leading to the development of a positively charged dayside photoelectron sheath and a negatively charged nightside plasma sheath. Other objects, however, are present in environments where the plasma flow and solar UV radiation may not co-align. These environments include, for example, the moons of Mars as they pass through the deflected Martian magnetosheath, and many of the moons of the outer planets, which are embedded in co-rotating planetary magnetospheres. The decoupling of the plasma flow and UV incidence vectors opens up a wide range of possible surface charging and near-object plasma conditions as a function of the relative plasma-UV incidence angle. Here, we report on a series of simulations of the plasma interaction of a small body (effectively smaller than both electron and ion gyroradii) with both flowing plasma and UV radiation for different plasma-UV incidence angles using an electrostatic treecode model. We describe the plasma and electric field environment both on the object surface and in the interaction region surrounding the object, including complex surface charge and electric field distributions, interactions between surface-generated photoelectrons and ambient plasma electrons, and complex potential distributions, all of which vary as a function of the relative plasma flow-UV angle. We also show that in certain conditions, non-monotonic potential structures may exist around such objects, partially similar to those found at Earth's Moon.