Association between cardiac autonomic control and cognitive performance among patients post stroke and age-matched healthy controls-an exploratory pilot study.

Associations between autonomic nervous system health and cognitive performance have been described in different populations. Autonomic disturbances are a common phenomenon in patients post stroke. Little is known about the relationship between post stroke disturbances of the autonomic nervous system and the commonly occurring disturbances of cognitive functions revealed by victims of stroke. To assess the association between heart rate variability (HRV) and cognitive performance among patients post ischemic stroke and healthy age-matched controls, 13 patients post first-ever ischemic stroke aged 40-80 years and 15 age-matched healthy controls were evaluated. HRV was monitored during sustained handgrip, while breathing at a rate of six breaths per minute, while performing the serial-3 subtraction task sitting at rest, and while cycling. Patients post stroke had greater error rate in the serial-3 subtraction task, and lower HRV (both at rest and during task performance) relative to healthy controls (at rest 26 ms [10-53] vs. 43 ms [29-88]). The HRV of stroke patients showed less sensitivity to changes in testing conditions, and also failed to show the correlation with cognitive performance exhibited by the healthy subjects. Stroke patients experience autonomic nervous system dysfunction in parallel to their motor and cognitive impairments. Too often only the latter receive appropriate treatment consideration in the rehabilitation setting. The current results, and earlier research, point to the importance of focusing clinical attention to the status of the autonomic nervous system, as amelioration of its functioning is likely to enhance motor and cognitive functioning as well.

Hospital disposition after stroke in a national survey of acute cerebrovascular diseases in Israel.

OBJECTIVE: To investigate predictive factors for disposition after acute stroke. DESIGN: A nationwide survey (2004 National Acute Stroke Israeli Survey). SETTING: All 28 primary general medical centers operating in Israel. PARTICIPANTS: Acute stroke patients (n=1583) admitted during February and March 2004 and discharged from the primary hospital. INTERVENTIONS: Data collected on baseline characteristics, stroke presentation, type and severity, in-hospital investigation and complications, discharge disability, acute hospital disposition, and mortality follow-up. MAIN OUTCOME MEASURE: Hospital disposition to home, acute rehabilitation, or nursing facility. RESULTS: Among patients, 58.9% (n=932) were discharged home, 33.7% (n=534) to rehabilitation departments, and only 7.4% (n=117) to nursing facilities. Admission neurologic status was a good predictor of hospital disposition. Patients with severe strokes were mostly discharged to rehabilitation facilities. Patients with significant functional decline before the index stroke, resulting from a previous stroke or another cause, were sent to inpatient rehabilitation less frequently. Disability level at discharge from acute hospitalization had high predictive value in hospital disposition after stroke. In the northern region of Israel, a higher proportion of patients were sent home and a lower proportion to rehabilitation and nursing facilities, probably because of lower availability of rehabilitation care in this region of Israel. CONCLUSIONS: This nationwide survey shows that most stroke survivors in Israel are discharged home from the acute primary hospital. Good functional status before the index stroke is an important predictor for being sent to acute inpatient rehabilitation. Severity of neurologic impairment and level of disability after the stroke at discharge from the primary hospital are strong predictors for disposition after stroke in Israel. Our data may be useful in discharge planning for stroke patients by policy-makers and health care providers in Israel.

The cardiac autonomic nervous system response to different daily demands among patients at the sub-acute phase post ischemic stroke and healthy controls.

BACKGROUND: Autonomic disturbances are a common phenomenon in patients' post-stroke, characterized by hypo function of the para-sympathetic and/or overactive sympathetic system. The impact of autonomic disturbances on physical therapy tasks during the rehabilitation period has not yet been assessed. OBJECTIVE: To describe the response of the cardiac autonomic nervous system during different tasks, among patients and age-matched healthy controls. METHODS: Nineteen patients in the subacute phase post first-ever ischemic stroke, and 16 controls. The Polar advanced heart rate monitor (RS800CX) was used to record RR intervals at rest, during paced breathing exercise, while performing different types of muscle contractions, and during single and dual task conditions. RESULTS: RR intervals and heart-rate variability (HRV) parameters were significantly lower among patients post stroke, both at rest and during most of the activities tested. Among the control group a significant autonomic adaptation was seen in the form of reduced RR intervals and HRV during muscle contraction and a significant increase in these parameters during slow breathing, no significant changes were observed among patients post stroke. CONCLUSION: Patients post-stroke experience hyper sympathetic function at rest and less adaptive cardiac autonomic control during different activities, which all may have an impact on rehabilitation outcomes.

Lack of significant effect of low doses of aspirin on the concentrations of C-reactive protein in a group of individuals with atherothrombotic risk factors and vascular events.

Atherothrombosis is associated with the presence of a microinflammatory response, usually monitored by the use of C-reactive protein (CRP) measurements. In the Physician Health Study it was suggested that individuals who benefit most from the treatment are those who have enhanced concentrations of this biomarker. The possibility was suggested that one of the mechanisms of action of aspirin in thrombotic prevention is through its anti-inflammatory properties in terms of reducing the concentration of CRP. We conducted a regression analysis in a cohort of 3888 apparently healthy individuals and those with atherothrombotic risk factors and vascular events, 370 of whom were under the treatment of low doses (

Methods of detecting potential causes of vascular cognitive impairment after coronary artery bypass grafting.

Coronary artery bypass grafting (CABG) is the most common major surgical procedure performed worldwide. Neuropsychological deficits are frequent following CABG occurring in up to 80% in the early postoperative period, 20-50% at 6 weeks and 10-30% of patients at 6 months. Transcranial Doppler monitoring is well suited for monitoring the brain during surgery. It has been shown that both solid and gaseous microemboli are frequent during, surgery especially during clamping and declamping of the aorta. This method can also monitor cerebral hemodynamics during surgery and alert the surgical team when a fall in perfusion pressure occurs. Magnetic resonance imaging (MRI) studies have found evidence which suggests increased water content in the brain following "on-pump" CABG. New postoperative cerebral lesions have also been found in many patients using diffusion-weighted MRI.

Inflammation-sensitive proteins and erythrocyte aggregation in atherothrombosis.

OBJECTIVE: To find the relative contribution of various inflammation-sensitive proteins including fibrinogen, immunoglobulins (IgG, IgM and IgA), ceruloplasmin and high sensitivity C-reactive protein (hs-CRP) to the induction and/or maintenance of enhanced erythrocyte adhesiveness/aggregation in the peripheral blood of individuals with atherothrombotic risk factors. METHODS: The degree of erythrocyte adhesiveness/aggregation was determined by a simple slide test and image analysis. In addition, we measured various inflammation-sensitive protein levels including fibrinogen, ceruloplasmin, immunoglobulins and hs-CRP in a group of 234 individuals with atherothrombotic risk factors and healthy ones. Pearson partial correlations and multiple linear regression analysis were performed. RESULTS: Fibrinogen was found to be the major protein contributing to the enhanced erythrocyte adhesiveness/aggregation, explaining 30% of the model. Fibrinogen and IgG together explained 32.4% of the model. Other inflammation-sensitive proteins did not reach statistical significance and were excluded from the model. CONCLUSIONS: Among inflammation-sensitive proteins measured in our cohort, fibrinogen is the dominant contributor to erythrocyte adhesiveness/aggregation in the peripheral blood of individuals with atherothrombotic risk factors and healthy ones. These findings may pave the way for the development of therapeutic strategies directed at the attenuation of erythrocyte aggregability in individuals with atherothrombosis.

The usefulness of an inflammation meter to detect the presence of infection/inflammation in elderly patients.

BACKGROUND: Medical personnel who work in small geriatric institutions most frequently do not have access to realtime laboratory facilities. METHODS: In order to present a new method to determine the presence of an inflammatory response and for the assessment of its intensity, 118 patients aged 77 +/- 6 years with various bacterial infections were evaluated as well as 129 elderly individuals with various stressful conditions but no acute infections who served as controls. The leukocyte and erythrocyte adhesiveness/aggregation tests were performed by using a simple slide test and image analysis. The availability of the CD11b/CD18 and CD62L antigen on the leukocytes' surface was measured by whole blood flow cytometry, and the quantitative C-reactive protein by using laser nephelometry and specific antihuman C-reactive protein antibodies. RESULTS: A significant difference was noted between patients and controls for all variables obtained by the slide test and image analysis. In addition, a highly significant correlation was noted between the number of leukocytes counted on the slides and white blood cell count, between the leukocyte adhesiveness/aggregation test and quantitative C-reactive protein, and between the degree of erythrocyte adhesiveness/aggregation and either the Westergren sedimentation or fibrinogen concentration. CONCLUSIONS: By using our low-cost and real-time slide test, any medical or paramedical personnel can get relevant information regarding the presence of an acute phase response at the point of care.

Recommendations for diabetic polyneuropathy treatment.

Diabetes is a chronic disease that requires continual medical care and patient self-management education in order to prevent acute complications and to reduce the risk of long-term complications. Diabetes is the leading known cause of neuropathy in developed countries, and neuropathy is the most common complication and the leading source of morbidity and mortality in diabetes patients. Diabetic polyneuropathy is primarily symmetric sensory neuropathy, initially affecting distal lower extremities. Patients have evidence of nerve damage at the time their diabetes is diagnosed in 10%-18% of cases, suggesting that even early impairment of glucose handling, classified as prediabetes, is associated with neuropathy. It is important to appreciate that there are other causes of neuropathy; these should be considered if there is any aspect of the history or clinical presentation suggesting features atypical of diabetic neuropathy. Diagnosis of diabetic neuropathy should be established according to clinical manifestations of the disease, laboratory findings (altered glucose metabolism) and results of electrophysiological examinations. Treatment of painful diabetic polyneuropathy rests on a two-pronged approach: modification of the underlying disease and control of pain symptoms. The goals of painful diabetic polyneuropathy pharmacotherapy should be reduction of pain for maximum relief commensurate with acceptable side effects and restoration/ improvement in functional measures and quality of life.

Anticoagulation remains underused in prevention of stroke associated with atrial fibrillation: insights from two consecutive national surveys.

BACKGROUND: Atrial fibrillation (AF) is a major risk factor of ischemic stroke. We tested whether the adoption of the CHADS(2) score in clinical guidelines has impacted treatment strategies for stroke prevention, and examined how AF affects stroke outcome. METHODS: In the setting of two national surveys [National Acute Stroke Israeli Surveys; all patients hospitalized for stroke in Israel during February-March 2004, and March-April 2007] data of patients with and without AF were analyzed with respect to patient characteristics, use of anticoagulation, stroke severity, clinical course, and long-term outcome. RESULTS: Of 3040 patients with acute ischemic stroke, 586 patients (19%) had a history of AF. Severe strokes on admission were significantly more frequent in patients with AF, as was the proportion of total anterior circulation strokes. Ischemic stroke associated with AF predicted poor outcome at discharge (adjusted OR 1.56; 95%CI 1.24-1.96) and higher mortality rates throughout follow-up. Among patients with a CHADS(2) score ≥ 2 prior to the index stroke and without known contraindications, 41% received anticoagulation. This proportion increased to only 62% after the index stroke, even after excluding patients with severe disability and no significant increase between 2004 and 2007 was detectable. Increasing age, in-hospital infectious complications, and unfavorable functional status at discharge were independently associated with decreased likelihood of receiving anticoagulation. CONCLUSIONS: In deviation from current recommendations and in spite of the introduction of CHADS(2) criteria, anticoagulation for stroke prevention remains underutilized, despite the particularly poor outcome of strokes associated with AF.

Menopause and ischaemic stroke: basic, clinical and epidemiological considerations. The role of hormone replacement.

Stroke is a leading cause of disability and death in women, despite progress in its prevention and treatment. As with coronary artery disease, the incidence of stroke rises after the menopause, in parallel with metabolic changes that add up to create an unfavourable risk factor profile for cardiovascular disease. The menopause metabolic syndrome, which includes weight gain and changes in lipids, insulin resistance, endothelial dysfunction, increased levels of homocysteine, lipoprotein (a) and several coagulation factors, may in part be attributable to estrogen deficiency, and may be reversible with hormone replacement therapy (HRT). As for blood pressure, a major detrimental risk factor for stroke, it is probably not affected by either the menopause per se or by HRT. Abundant experimental data exist indicating that estrogens have both anti-atherosclerotic and neuroprotective effects. The width or thickness of the carotid wall is a good indicator of carotid atherosclerosis; it increases after the menopause transition, and decreases with HRT. Estrogens may enhance cerebral blood flow and reduce vascular resistance. In animal models of stroke, estrogen induced anti-ischaemic effects. Several large-scale epidemiological studies have verified the concept of primary protection of stroke by HRT, though others have failed to do so. In light of these contradictory data, several recent reports were highly significant (Nurses' Health Study, HERS Study, Cancer Prevention II Trial, WEST Trial). Despite the known neural and vascular benefits of estrogen, it is uncertain whether HRT is associated with stroke protection. At present, prevention of stroke should involve proven risk reduction strategies.