Comparing Low- or Standard-Dose Alteplase in Endovascular Thrombectomy: Insights From a Nationwide Registry.

BACKGROUND: Timely intravenous thrombolysis and endovascular thrombectomy are the standard reperfusion treatments for large vessel occlusion stroke. Currently, it is unknown whether a low-dose thrombolytic agent (0.6 mg/kg alteplase) can offer similar efficacy to the standard dose (0.9 mg/kg alteplase). METHODS: We enrolled consecutive patients in the multicenter Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke who had received combined thrombolysis (within 4.5 hours of onset) and thrombectomy treatment from January 2019 to April 2023. The choice of low- or standard-dose alteplase was based on the physician's discretion. The outcomes included successful reperfusion (modified Thrombolysis in Cerebral Infarction score, 2b-3), symptomatic intracerebral hemorrhage, 90-day modified Rankin Scale score, and 90-day mortality. The outcomes between the 2 groups were compared using multivariable logistic regression and inverse probability of treatment weighting-adjusted analysis. RESULTS: Among the 2242 patients in the Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke, 734 (33%) received intravenous alteplase. Patients in the low-dose group (n=360) were older, had more women, more atrial fibrillation, and longer onset-to-needle time compared with the standard-dose group (n=374). In comparison to low-dose alteplase, standard-dose alteplase was associated with a lower rate of successful reperfusion (81% versus 87%; adjusted odds ratio, 0.63 [95% CI, 0.40-0.98]), a numerically higher incidence of symptomatic intracerebral hemorrhage (6.7% versus 3.9%; adjusted odds ratio, 1.81 [95% CI, 0.88-3.69]), but better 90-day modified Rankin Scale score (functional independence [modified Rankin Scale score, 0-2], 47% versus 31%; adjusted odds ratio, 1.91 [95% CI, 1.28-2.86]), and a numerically lower mortality rate (9% versus 15%; adjusted odds ratio, 0.73 [95% CI, 0.43-1.25]) after adjusting for covariates. Similar results were observed in the inverse probability of treatment weighting-adjusted models. The results were consistent across predefined subgroups and age strata. CONCLUSIONS: Despite the lower rate of successful reperfusion and higher risk of symptomatic intracerebral hemorrhage with standard-dose alteplase, standard-dose alteplase was associated with a better functional outcome in patients receiving combined thrombolysis and thrombectomy.

Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke.

BACKGROUND: The time to initiate intravenous thrombolysis for acute ischemic stroke is generally limited to within 4.5 hours after the onset of symptoms. Some trials have suggested that the treatment window may be extended in patients who are shown to have ischemic but not yet infarcted brain tissue on imaging. METHODS: We conducted a multicenter, randomized, placebo-controlled trial involving patients with ischemic stroke who had hypoperfused but salvageable regions of brain detected on automated perfusion imaging. The patients were randomly assigned to receive intravenous alteplase or placebo between 4.5 and 9.0 hours after the onset of stroke or on awakening with stroke (if within 9 hours from the midpoint of sleep). The primary outcome was a score of 0 or 1 on the modified Rankin scale, on which scores range from 0 (no symptoms) to 6 (death), at 90 days. The risk ratio for the primary outcome was adjusted for age and clinical severity at baseline. RESULTS: After 225 of the planned 310 patients had been enrolled, the trial was terminated because of a loss of equipoise after the publication of positive results from a previous trial. A total of 113 patients were randomly assigned to the alteplase group and 112 to the placebo group. The primary outcome occurred in 40 patients (35.4%) in the alteplase group and in 33 patients (29.5%) in the placebo group (adjusted risk ratio, 1.44; 95% confidence interval [CI], 1.01 to 2.06; P = 0.04). Symptomatic intracerebral hemorrhage occurred in 7 patients (6.2%) in the alteplase group and in 1 patient (0.9%) in the placebo group (adjusted risk ratio, 7.22; 95% CI, 0.97 to 53.5; P = 0.05). A secondary ordinal analysis of the distribution of scores on the modified Rankin scale did not show a significant between-group difference in functional improvement at 90 days. CONCLUSIONS: Among the patients in this trial who had ischemic stroke and salvageable brain tissue, the use of alteplase between 4.5 and 9.0 hours after stroke onset or at the time the patient awoke with stroke symptoms resulted in a higher percentage of patients with no or minor neurologic deficits than the use of placebo. There were more cases of symptomatic cerebral hemorrhage in the alteplase group than in the placebo group. (Funded by the Australian National Health and Medical Research Council and others; EXTEND ClinicalTrials.gov numbers, NCT00887328 and NCT01580839.).

Smoking Paradox in Stroke Survivors?: Uncovering the Truth by Interpreting 2 Sets of Data.

Background and Purpose- The observation that smokers with stroke could have better outcome than nonsmokers led to the term "smoking paradox." The controversy of such a complex claim has not been fully settled, even though different case mix was noted. Analyses were conducted on 2 independent data sets to evaluate and determine whether such a paradox truly exists. Methods- Taiwan Stroke Registry with 88 925 stroke cases, and MJ cohort with 541 047 adults participating in a medical screening program with 1630 stroke deaths developed during 15 years of follow-up (1994-2008). Primary outcome for stroke registry was functional independence at 3 months by modified Rankin Scale score ≤2, for individuals classified by National Institutes of Health Stroke Scale score at admission. For MJ cohort, mortality risk by smoking status or by stroke history was assessed by hazard ratio. Results- A >11-year age difference in stroke incidence was found between smokers and nonsmokers, with a median age of 60.2 years for current smokers and 71.6 years for nonsmokers. For smokers, favorable outcome in mortality and in functional assessment in 3 months with modified Rankin Scale score ≤2 stratified by the National Institutes of Health Stroke Scale score was present but disappeared when age and sex were matched. Smokers without stroke history had a ≈2-fold increase in stroke deaths (2.05 for ischemic stroke and 1.53 for hemorrhagic stroke) but smokers with stroke history, 7.83-fold increase, overshadowing smoking risk. Quitting smoking at earlier age reversed or improved outcome. Conclusions- "The more you smoke, the earlier you stroke, and the longer sufferings you have to cope." Smokers had 2-fold mortality from stroke but endured stroke disability 11 years longer. Quitting early reduced or reversed the harms.

Association between heavy metal levels and acute ischemic stroke.

BACKGROUND: Few studies have examined the relationship between the amounts of heavy metal and stroke incidence. The aim of this study was to explore the relationship between levels of heavy metals, including Pb, Hg, As, and Cd, in patients with acute ischemic stroke (AIS). METHODS: We selected patients with first-ever AIS onset within 1 week as our study group. Healthy controls were participants without a history of stroke or chronic disease, except hypertension. The serum levels of Pb, Hg, As, and Cd in participants in the experimental and control groups were determined. All participants received a 1-g infusion of edetate calcium disodium (EDTA). Urine specimens were collected for 24 h after EDTA infusion and measured for heavy metal levels. RESULTS: In total, 33 patients with AIS and 39 healthy controls were enrolled in this study. The major findings were as follows: (1) The stroke group had a significantly lower level of serum Hg (6.4 ± 4.3 µg/L vs. 9.8 ± 7.0 µg/L, P = 0.032, OR = 0.90, 95% CI = 0.81-0.99) and a lower level of urine Hg (0.7 ± 0.7 µg/L vs. 1.2 ± 0.6 µg/L, P = 0.006, OR = 0.27, 95% CI = 0.11-0.68) than the control group. (2) No significant difference in serum Pb (S-Pb), As (S-As), and Cd (S-Cd) levels and urine Pb (U-Pb), As (U-As) and Cd (U-Cd) levels was observed in either group. CONCLUSIONS: Our study found low levels of serum and urine Hg in first-ever patients with AIS, providing new evidence of dysregulated heavy metals in patients with AIS.

Laser acupuncture-induced analgesic effect and molecular alterations in an incision pain model: a comparison with electroacupuncture-induced effects.

Low-level laser acupuncture (LLLA) produces photobiomodulation through acupuncture point and is an alternative to low-level laser therapy. Although the analgesic effect of LLLA on chronic pain has been proven, its effect on acute postincisional pain has yet to be investigated. A plantar incision (PI) model was used to mimic human postsurgical pain. Male adult rats received GaAlAs laser irradiation at the right ST36 acupoint immediately after operation and on the following 4 days. Three laser treatment groups (two red laser groups with a 30- or 15-min treatment duration and one 30-min near-infrared laser group) were compared with sham LLLA and naive groups and an electroacupuncture (EA) group (separate study). Behavioral withdrawal thresholds of both hind paws were measured before and after incision. Expression of mitogen-activated protein kinases (p-ERK and p-p38), inducible nitric oxide synthase (iNOS), and tumor necrosis factor (TNF) in the spinal cord was analyzed. All three LLLA treatments attenuated post-PI tactile allodynia in the ipsilateral paw, but only the 30-min red laser treatment affected the contralateral paw and had similar efficacy to that of EA. All laser treatments barely reduced heat hyperalgesia in both hind paws. At 3 days after PI, the 30-min red laser group showed reversed increases of PI-induced p-ERK, p-p38, and iNOS but not TNF expression in the spinal cord. Repetitive LLLA treatments ameliorated PI-induced mechanical pain. The inhibition of multiple sensitization signals highlights the unique clinical role of LLLA. Thus, LLLA is an alternative to EA as an adjuvant for postoperative pain control.

Involvement of Endothelial Nitric Oxide Synthase Activation in Midkine-Mediated Central Hypotensive Effects.

The growth factor midkine (MK) has been implicated in various biologic and pathologic events. It has been shown that the peripheral influence of MK on cardiovascular regulation is due to an influence on the renin-angiotensin system (RAS). The nucleus tractus solitarii (NTS) is the primary integrative center for cardiovascular control and other autonomic functions in the central nervous system. However, the signaling mechanisms involved in MK-mediated cardiovascular effects in the NTS remain unclear. In this study, we investigated whether the RAS and/or N-methyl-D-aspartate (NMDA) receptor-calmodulin-endothelial nitric oxide synthase (eNOS) signaling pathways were both involved in MK-mediated blood pressure (BP) regulation in the NTS of Wistar-Kyoto (WKY) rats. Intra-NTS microinjection and immunoblot analysis were used to evaluate the signal pathway. WKY rats were anesthetized with urethane. Unilateral microinjection of MK (600 fmol) into the NTS produced a dose-dependent decrease in BP and heart rate (HR). The depressor effects were observed before and after microinjection of the angiotensin-converting enzyme (ACE) inhibitor lisinopril (2.4 fmol), or the angiotensin receptor blockers (ARB) inhibitor valsartan (7.5 pmol). However, lisinopril and valsartan did not diminish the MK-mediated cardiovascular effects in the NTS. Microinjection of the NMDA receptor antagonist MK801 (1 nmol) or the NOS inhibitor N-nitro l-arginine methyl ester (L-NAME), (33 nmol), into the NTS attenuated the MK-induced hypotensive effects. Pretreatment with an eNOS inhibitor N5-iminoethyl-l-ornithine (L-NIO) (6 nmol) attenuated the MK-induced hypotensive effects. In this study, the data showed that MK might play a role in central cardiovascular regulation in the NTS. These results suggest that MK decreased BP and HR in the NTS probably acting via the NMDA receptor-calmodulin-eNOS signaling pathway.

Derivation and validation of a discharge disposition predicting model after acute stroke.

BACKGROUND: Discharge disposition planning is vital for poststroke patients. We investigated clinical factors associated with discharging patients to nursing homes, using the Taiwan Stroke Registry data collected from 39 major hospitals. METHODS: We randomly assigned 21,575 stroke inpatients registered from 2006 to 2008 into derivation and validation groups at a 3-to-1 ratio. We used the derivation group to develop a prediction model by measuring cumulative risk scores associated with potential predictors: age, sex, hypertension, diabetes mellitus, heart diseases, stroke history, snoring, main caregivers, stroke types, and National Institutes of Health Stroke Scale (NIHSS). Probability of nursing home care and odds ratio (OR) of nursing home care relative to home care by cumulative risk scores were measured for the prediction. The area under the receiver operating characteristic curve (AUROC) was used to assess the model discrimination against the validation group. RESULTS: Except for hypertension, all remaining potential predictors were significant independent predictors associated with stroke patient disposition to nursing home care after discharge from hospitals. The risk sharply increased with age and NIHSS. Patients with a cumulative risk score of 15 or more had an OR of 86.4 for the nursing home disposition. The AUROC plots showed similar areas under curves for the derivation group (.86, 95% confidence interval [CI], .85-.87) and for the validation group (.84, 95% CI, .83-.86). CONCLUSIONS: The cumulative risk score is an easy-to-estimate tool for preparing stroke patients and their family for disposition on discharge.

Association of stress hormones and the risk of cardiovascular diseases systematic review and meta-analysis.

Background: The roles of endogenous stress hormones (norepinephrine, epinephrine, and cortisol) in cardiovascular diseases have been discussed. However, the higher versus lower level of stress hormones in relation to cardiovascular risks remained uncertain. Methods: We searched databases from their inception to 31, March 2023. We conducted a meta-analysis to estimate the effect of higher to lower level of stress hormones with random effect model. Subgroup and meta-regression analysis were done to clarify the heterogeneity. Results: In total, 33 studies involving 43641 participants were included. With regard to cardiovascular disease risks, a higher risk for individuals with higher level of all stress hormones (risk ratio (RR), 1.63; 95 % Confidence intervals (CIs): 1.36, 1.97) was noted compared with lower level of all stress hormones. The meta-regression showed that as the follow-up year increased per year, the impact of higher level of all stress hormones on the risk of cardiovascular disease declined significantly (RR, -0.09; 95 % CIs: 0.15, -0.03, p = 0.006). A significantly higher risk of cardiovascular diseases for individuals with higher level of norepinephrine (RR, 1.68; 95 % CIs: 1.37, 2.06), with higher level of epinephrine (RR, 1.58; 95 % CIs: 1.10, 2.26), and with higher level of cortisol (RR, 1.60; 95 % CIs: 1.04, 2.26) were noted compared with a lower level of each stress hormone. Conclusion: Higher levels of stress hormones were significantly associated with higher risks of cardiovascular diseases compared with lower levels of stress hormones.

Associations of diabetes status and glucose measures with outcomes after endovascular therapy in patients with acute ischemic stroke: an analysis of the nationwide TREAT-AIS registry.

Background: Hyperglycemia affects the outcomes of endovascular therapy (EVT) for acute ischemic stroke (AIS). This study compares the predictive ability of diabetes status and glucose measures on EVT outcomes using nationwide registry data. Methods: The study included 1,097 AIS patients who underwent EVT from the Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke. The variables analyzed included diabetes status, admission glucose, glycated hemoglobin (HbA1c), admission glucose-to-HbA1c ratio (GAR), and outcomes such as 90-day poor functional outcome (modified Rankin Scale score ≥ 2) and symptomatic intracranial hemorrhage (SICH). Multivariable analyses investigated the independent effects of diabetes status and glucose measures on outcomes. A receiver operating characteristic (ROC) analysis was performed to compare their predictive abilities. Results: The multivariable analysis showed that individuals with known diabetes had a higher likelihood of poor functional outcomes (odds ratios [ORs] 2.10 to 2.58) and SICH (ORs 3.28 to 4.30) compared to those without diabetes. Higher quartiles of admission glucose and GAR were associated with poor functional outcomes and SICH. Higher quartiles of HbA1c were significantly associated with poor functional outcomes. However, patients in the second HbA1c quartile (5.6-5.8%) showed a non-significant tendency toward good functional outcomes compared to those in the lowest quartile (<5.6%). The ROC analysis indicated that diabetes status and admission glucose had higher predictive abilities for poor functional outcomes, while admission glucose and GAR were better predictors for SICH. Conclusion: In AIS patients undergoing EVT, diabetes status, admission glucose, and GAR were associated with 90-day poor functional outcomes and SICH. Admission glucose was likely the most suitable glucose measure for predicting outcomes after EVT.

Predictive value of motor-evoked potentials for motor recovery in patients with hemiparesis secondary to acute ischemic stroke.

BACKGROUND: Motor recovery following a stroke is related to the initial stroke severity and corticospinal tract integrity. One of the outcomes representing corticospinal tract integrity is the motor evoked potential (MEP). This study aimed to investigate the predictive value of MEP for motor recovery in patients with acute ischemic stroke. PATIENTS AND METHODS: Patients with hemiparesis secondary to initial acute ischemic stroke were enrolled. MEPs of the upper limb were assessed as preserved (MEP+) or absent (MEP-) response ≤10 days post-stroke. Fugl-Meyer assessment (FMA) was performed at baseline and post-stroke at 30 and 90 days. A modified Rankin scale (mRS) was conducted at 90 days post-stroke. Patients were divided into two groups according to the highest FMA score of MEP- patients. Generalized estimating equations and logistic regression were used for our study analysis. RESULTS: Sixty-one participants were included in this study. The highest FMA score of MEP- patients ≤10 days after stroke was 38. Among patients with an initial FMA score ≤38, FMA scores at 30 and 90 days post-stroke were significantly higher in MEP + patients than in MEP- patients. Proportional recovery at 30 and 90 days post-stroke was significantly higher in MEP + patients than in MEP- patients. MEP + patients had a higher percentage of good functional outcomes than MEP- patients, without statistical difference. Among patients with initial FMA score >38, FMA scores were 60.4 ± 4.8 and 63.9 ± 2.9 and proportional recovery was 65.2 ± 27.0% and 83.7 ± 24.6% at 30 and 90 days post-stroke, respectively. CONCLUSIONS: Among patients with moderate-to-severe ischemic stroke, MEP + patients had better motor recoveries (approximately 70%) than MEP- patients at 90 days post-stroke. MEP + patients had better functional outcomes than MEP- patients.

Key MessagesAmong patients with moderate-to-severe ischemic stroke, those with positive motor-evoked potentials (MEPs) had better motor recovery than those with negative MEPs at 90 days post-stroke.Assessment of motor-evoked potentials is a reliable method for predicting motor recovery in patients with moderate-to-severe ischemic stroke.Corticospinal tract function of patients with acute ischemic stroke was tested with transcranial magnetic stimulation.

Evaluation of the Psychometric Properties of a Newly Developed Chinese Screening Tool for Speech Disorders in Patients With Parkinson's Disease.

The study aimed to analyze the psychometric properties of a newly developed Chinese screening tool, the Chinese Version of the Speech Disorders in Parkinson's Disease Questionnaire (SDPD-C). The SDPD-C contains a 24-item questionnaire with four assessment domains. Overall, 93 patients with idiopathic Parkinson's disease (PD) (age 70.1 ± 8.9 years) and 76 healthy older adults (age 67.2 ± 8.1 years) participated in the psychometric analysis study. The internal consistency of the SDPD-C was .91 (four dimensions: .69-.85), and test-retest reliability was .91 (four dimensions: .85-.88). The SDPD-C was highly correlated with the Voice Handicap Index-10 and Movement Disorder Society-Unified Parkinson's Disease Rating Scale II 2.1 (r = .83 and .78, respectively). The SDPD-C scores also differed significantly between stages 1 and 4 of the Hoehn and Yahr Scale (p < .05). The area under the receiver operating characteristic curve was .955 (95% confidence interval, .927-.983; asymptotic significance p < .001), and the optimal cut-off score of this study was 36, with a sensitivity of .849 and specificity of .947. The results indicate that SDPD-C showed good reliability, validity, accuracy, and discrimination. It can be used as a screening tool for speech disorders in patients with PD.

Upper gastrointestinal lesions in patients receiving clopidogrel anti-platelet therapy.

BACKGROUND/PURPOSE: Clopidogrel is associated with a high incidence of upper gastrointestinal bleeding in high-risk patients. However, the characteristic upper gastrointestinal lesions in symptomatic clopidogrel users remain unclear. The aims of this study were to investigate the characteristics of endoscopic findings in clopidogrel users undergoing endoscopy for upper gastrointestinal symptoms and to compare the clinical characteristics and upper gastrointestinal lesions between symptomatic clopidogrel and aspirin users. METHODS: This observational study included 215 consecutive patients receiving clopidogrel (n=106) or low-dose aspirin (n=109) therapy who underwent endoscopy for dyspeptic symptoms. The upper gastrointestinal lesions were carefully assessed, and a complete medical history was obtained by a standard questionnaire. RESULTS: The frequencies of hemorrhagic spots, erosions and peptic ulcers in the symptomatic clopidogrel users were 25%, 39% and 39%, respectively. Among the peptic ulcer patients on clopidogrel therapy, the distributions of ulcers were 78%, 5% and 17% in the stomach, duodenum and both, respectively. Compared with the aspirin group, the clopidogrel group was older and had higher frequencies of past ulcer history and past gastrointestinal bleeding history in their clinical characteristics. By contrast, the clopidogrel users had a lower prevalence of active Helicobacter pylori infection than aspirin users (17% vs. 35%, respectively, p=0.007). Regarding to the endoscopic findings, the clopidogrel users had higher frequencies of hemorrhagic spots (25% vs. 10%) and peptic ulcer (39% vs. 24%) than aspirin users (p=0.004 and 0.027, respectively). CONCLUSION: Most peptic ulcers in clopidogrel users are located in the stomach. The frequencies of hemorrhagic spots and peptic ulcers in symptomatic clopidogrel users are higher than those in symptomatic aspirin users.

Effects of heavy metals in acute ischemic stroke patients: A cross-sectional study.

ABSTRACT: Cerebrovascular disease is the second commonest cause of mortality globally and among the commonest causes of disability. However, research executed to probe the heavy metal exposure-stroke incidence relationship is scarce. Accordingly, we executed our study to probe the relationship of heavy metal concentrations (ie, concentrations of lead [Pb], mercury [Hg], cadmium [Cd], and arsenic) in the serum and urine of acute ischemic stroke (AIS) patients with several patient variables.For enrollment, we chose patients who had a first AIS within 7 days after the onset of a stroke. Thus, 33 newly diagnosed patients with AIS were recruited. We determined the aforementioned metals' concentrations by executing inductively coupled plasma mass spectrometry. We also gauged the association between such metal concentrations and patient variables by employing Spearman correlation coefficient. To examine the differences in metal concentrations between the different variables, we implemented an independent Mann-Whitney U test.In our cohort analysis, we noted serum Pb and Cd concentrations to be positively correlated with serum creatinine and hemoglobin. Serum and urine Cd concentrations had a negative correlation with impaired HbA1c in AIS patients. Urine Hg had a positive correlation with C-reactive protein in the participants. Participants who smoked or consumed alcohol had significantly higher Pb and Cd levels in serum than did those who neither smoked nor drank. Patients with AIS who smoked or consumed alcohol had high levels of serum Pb and serum Cd than did those who did not. Patients with AIS who consumed alcohol had significantly higher Pb and Hg urine concentrations than did those who did not.Our study indicated that serum Cd and Pb elevation increased the AIS risk in southern Taiwan patients.

Variations in intraocular pressure and visual parameters before and after using mobile virtual reality glasses and their effects on the eyes.

We examined the effects of using mobile devices with immersive virtual reality for a short period on the physiological parameters of both eyes. The average age of the 50 participants (23 men and 27 women) was 17.72 ± 1.48 years, and refractive error ranged from 0 D to - 5.00 D. All the participants wore + 3.00 D glasses and underwent a 5-min relaxation adjustment through the atomization method. The participants wore immersive virtual reality (VR) glasses to watch a movie on a roller coaster for 10 min. Their relevant physiological parameters of the eyes were measured both before and after using VR glasses. Compared with before VR use, no significant difference (P > 0.05) was observed in the near-horizontal vergence and refractive error but a significant difference (P < 0.05) was observed in the amplitude of accommodation, intraocular pressure, divergence/convergence, and stereopsis after VR use. The corneal elastic coefficient was > 0.2 MPa, and we used Friedenwald's eye rigidity relationship to obtain the K value (0.065-0.09). Approximately 10% of the participants experienced cybersickness symptoms such as nausea and dizziness. The use of VR to watch three-dimensional movies reduced intraocular pressure, which may help prevent or treat glaucoma. Moreover, the binocular convergence was higher when viewing near-field objects in VR than in the real world. Therefore, individuals with convergence excess may experience symptoms. Binocular parallax is the most likely cause of cybersickness symptoms. Thus, mobile VR devices with higher quality and comfort are necessary.

Predicting 30-Day Readmission for Stroke Using Machine Learning Algorithms: A Prospective Cohort Study.

Background: Machine learning algorithms for predicting 30-day stroke readmission are rarely discussed. The aims of this study were to identify significant predictors of 30-day readmission after stroke and to compare prediction accuracy and area under the receiver operating characteristic (AUROC) curve in five models: artificial neural network (ANN), K nearest neighbor (KNN), random forest (RF), support vector machine (SVM), naive Bayes classifier (NBC), and Cox regression (COX) models. Methods: The subjects of this prospective cohort study were 1,476 patients with a history of admission for stroke to one of six hospitals between March, 2014, and September, 2019. A training dataset (n = 1,033) was used for model development, and a testing dataset (n = 443) was used for internal validation. Another 167 patients with stroke recruited from October, to December, 2019, were enrolled in the dataset for external validation. A feature importance analysis was also performed to identify the significance of the selected input variables. Results: For predicting 30-day readmission after stroke, the ANN model had significantly (P < 0.001) higher performance indices compared to the other models. According to the ANN model results, the best predictor of 30-day readmission was PAC followed by nasogastric tube insertion and stroke type (P < 0.05). Using a machine learning ANN model to obtain an accurate estimate of 30-day readmission for stroke and to identify risk factors may improve the precision and efficacy of management for these patients. Conclusion: Using a machine-learning ANN model to obtain an accurate estimate of 30-day readmission for stroke and to identify risk factors may improve the precision and efficacy of management for these patients. For stroke patients who are candidates for PAC rehabilitation, these predictors have practical applications in educating patients in the expected course of recovery and health outcomes.

Cost Utility Analysis of Multidisciplinary Postacute Care for Stroke: A Prospective Six-Hospital Cohort Study.

Background: Few studies have compared the optimal duration and intensity of organized multidisciplinary neurological/rehabilitative care delivered in a regional/district hospital with the standard rehabilitative care delivered in the general neurology/rehabilitation ward of a medical center. This study measured functional outcomes and conducted cost-utility analysis of an organized multidisciplinary postacute care (PAC) project in secondary care compared with standard rehabilitative care delivered in tertiary care. Methods: This prospective cohort study enrolled 1,476 patients who had a stroke between March 2014 and March 2018 and had a modified Rankin scale score of 2-4. After exact matching for age ± 1 year, sex, year of stroke diagnosis, nasogastric tube, and Foley catheter and propensity score matching for the other covariates, we obtained 120 patients receiving PAC (the PAC group) from four regional/district hospitals and 120 patients not receiving PAC (the non-PAC group) from two medical centers. Results: At baseline, the non-PAC group showed significantly better functional outcomes than the PAC group, including EuroQol-5 dimensions (EQ-5D), Mini-Mental State Examination (MMSE) and Barthel index (BI). During weeks 7-12 of rehabilitation, improvements in all functional outcomes were significantly larger in the PAC group (P < 0.001) except for Functional Oral Intake Scale (FOIS). Cost-utility analysis revealed that the PAC group had a significantly lower mean (± standard deviation) of direct medical costs (US$3,480 ± $1,758 vs. US$3,785 ± $3,840, P < 0.001) and a significantly higher average gain of quality-adjusted life years (0.1993 vs. 0.1233, P < 0.001). The PAC project was an economically "dominant" strategy. Conclusions: The PAC project saved costs and significantly improved the functional outcomes of patients with stroke with slight to moderately severe disabilities. Randomized control trials are required to corroborate these results.

Neuroprotection effects of retained acupuncture in neurotoxin-induced Parkinson's disease mice.

The aim of this study was to investigate the role of retained acupuncture (RA) in neurotoxin-induced Parkinson's disease (PD) mice. Male C57BL/6 mice were injected with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) to induce the PD model. The mice were divided into four groups, namely, (1) normal; (2) MPTP+retained acupuncture (RA); (3) MPTP+electroacupuncture (EA); (4) MPTP+sham acupuncture (SA). After mice being manipulated with/without acupuncture at acupoints (Daling, PC 7), groups 2-4 were injected with MPTP (15 mg/kg/d). The mice were evaluated for behavioral changes, in terms of time of landing, after acupuncture treatment. The animals were sacrificed and their brains assayed for dopamine and its metabolites and tyrosine hydroxylase (TH) expression by using HPLC and immunohistochemistry/Western blotting, respectively. [(123)I] IBZM-SPECT imaging between SA and RA groups were compared. The results showed that the time of landing of the three groups with treatment was significant longer than group 1 (normal) (4.33±0.15 s). Nonetheless, group 2 (RA) (7.13±0.20 s) had a shorter time of landing than group 4 (SA) (7.89±0.46 s). The number of TH (+) neurons and the expression of TH proteins were significantly higher in the RA group than in the SA/EA groups. RA also increased the uptake of [(123)I] IBZM into the triatum compared to the SA group. We conclude that RA possibly attenuates neuronal damage in MPTP-induced PD mice, which suggests RA may be useful as a complementary strategy when treating human PD.

Effect of Low-Level Laser Irradiation on Accommodation and Visual Fatigue.

PURPOSE: This study used low-level laser irradiation on auricular points for the eyes of junior college teenagers with myopia to observe the changes in refractive errors and eye accommodation. According to the Sterner's study, we used the relationship between the amplitude and subjective symptoms to assess the degree of improvement in visual fatigue caused by changes in accommodation. METHODS: Participants were 49 healthy junior college teenagers, with an average age of 16.04±0.80 years old, and the refractive errors of both eyes were between -1.50 D and -5.00 D. All participants underwent refractive error tests before and after class and after a 30-min break. In a 30-min break, all participants underwent two tests of with (experimental group) and without (control group) low-level laser irradiation on the auricular points. Then, refractive error tests were conducted to evaluate the participants' eye accommodation. RESULTS: The results revealed that with treatment of the auricular points with and without low-level laser irradiation, the refractive error of the participants' binocular left and right eyes decreased by -0.12 D (-0.18 D) in the experimental grou and by -0.05 D (-0.02D) in the control group. For the amplitudes of accommodation (AA) examination, the AA of the participants' binocular in the experimental group became 7.98 ± 1.35 D (7.65 ± 1.37 D). The AA of participants' binocular can recover to the level before the class. CONCLUSION: The results indicated that low-level laser irradiation at auricular points restored the eye accommodation faster than did natural closing of the eyes.

Reducing the discomfort in viewing 3D video with a prism device modified eye convergence.

A prism device is utilized in this study for modifying the eye convergence to reduce eye accommodation and enhance the comfort in viewing 3D video. Without changing the contents of 3D films, it aims to apply the myosis, convergence, and accommodation visual triad of eyeballs viewing near distance to not change the eyeball pupillary distance when viewing 3D films. Without convergence, the discomfort caused by intraocular muscle contraction when viewing near distance is reduced. Such an effect of a small prism lens is also proven in this study. When viewing 3D films with 1.0△ lenses, the physiological accommodation reaction of eyes would reduce (the right eye decreases 65% and the left eye decreases 70%), revealing the decreasing tension of intraocular muscle. The subjective psychological evaluation result also shows that viewing 3D images with small prism lenses could enhance the comfort. The evaluation of optical simulation, physiological reaction, and mental fatigue proves that the small prism lens proposed in this study could actually improve the comfort in viewing 3D films.