Pathophysiology and Risk of Atrial Fibrillation Detected after Ischemic Stroke (PARADISE): A Translational, Integrated, and Transdisciplinary Approach.

BACKGROUND: It has been hypothesized that ischemic stroke can cause atrial fibrillation. By elucidating the mechanisms of neurogenically mediated paroxysmal atrial fibrillation, novel therapeutic strategies could be developed to prevent atrial fibrillation occurrence and perpetuation after stroke. This could result in fewer recurrent strokes and deaths, a reduction or delay in dementia onset, and in the lessening of the functional, structural, and metabolic consequences of atrial fibrillation on the heart. METHODS: The Pathophysiology and Risk of Atrial Fibrillation Detected after Ischemic Stroke (PARADISE) study is an investigator-driven, translational, integrated, and transdisciplinary initiative. It comprises 3 complementary research streams that focus on atrial fibrillation detected after stroke: experimental, clinical, and epidemiological. The experimental stream will assess pre- and poststroke electrocardiographic, autonomic, anatomic (brain and heart pathology), and inflammatory trajectories in an animal model of selective insular cortex ischemic stroke. The clinical stream will prospectively investigate autonomic, inflammatory, and neurocognitive changes among patients diagnosed with atrial fibrillation detected after stroke by employing comprehensive and validated instruments. The epidemiological stream will focus on the demographics, clinical characteristics, and outcomes of atrial fibrillation detected after stroke at the population level by means of the Ontario Stroke Registry, a prospective clinical database that comprises over 23,000 patients with ischemic stroke. CONCLUSIONS: PARADISE is a translational research initiative comprising experimental, clinical, and epidemiological research aimed at characterizing clinical features, the pathophysiology, and outcomes of neurogenic atrial fibrillation detected after stroke.

Pre-Procedure Blood Sugar Levels in Diabetic and High-Risk Patients Visiting King Abdulaziz University Dental Hospital: The Role of the Dentist in Diabetes Screening.

Aim: Diabetes mellitus (DM) is a widespread problem. Satisfactory control of DM is essential for maintaining oral health and optimizing the outcomes of dental treatment; DM patients with poor glycaemic control have a high risk of dental treatment-related complications. Furthermore, the dentist and dental office can play an important role in DM screening. Therefore, this study aimed at measuring random blood glucose (RBG) levels in patients with established DM or high risk of DM seeking dental treatment at the King Abdulaziz University Dental Hospital to avoid treatment complications and execute an immediate physician referral. Methods and Material: This cross-sectional study included patients presenting to our institution for dental treatment, who were categorized as diabetic (established diagnosis) or at high risk of DM according to the American Diabetes Association criteria. Participants' pre-procedure RBG level was assessed via a glucometer. High-risk participants were classified as per their blood glucose level into two groups (<200 mg/dL and >200 mg/dL), while the diabetic participants were placed into four groups (<140 mg/dL; 140 to <200 mg/dL; 200-300 mg/dL; and >300 mg/dL). Results: This study included 695 patients (361 females and 334 males), of which 354 (52%) had established DM and 341 (48%) were high-risk patients. Around 31% of patients in the high-risk group were potentially diabetic but unaware of it; 46% of the diabetic patients had RBG levels >200 mg/dL. For the high-risk participants, age had a statistically significant association (P-value 0.03) with the RBG level. Conclusion: Pre-procedure RBG measurement in diabetic and high-risk patients undergoing dental treatment is crucial for the prevention of DM-related complications. Dental health-care professionals have a vital role in screening, early detection, and referral of these patients.

Upgoing thumb sign: A sensitive indicator of brain involvement?

OBJECTIVE: To assess the frequency of this finding in patients with minor stroke and TIAs compared to those with stroke mimics and to evaluate the level of agreement between examiners to detect an upgoing thumb sign. METHODS: We previously reported an upgoing thumb sign as a subtle clinical finding in patients with transient ischemic attacks or minor stroke. In this study conducted between March 2016 and October 2016 at the Stroke Prevention Clinic at University Hospital, University of Western Ontario, London, Canada, participants were examined independently by stroke faculty and fellows who were blinded to each other's findings. The frequency of the upgoing thumb sign in patients with minor or threatened stroke was compared to that in patients with stroke mimics, and the level of agreement between examiners and clinical findings was assessed with the Cohen κ test. RESULTS: The upgoing thumb sign was observed more frequently in those with minor stroke/TIA than in those with stroke mimics (p = 0.001). A substantial level of agreement between examiners was recorded in the detection of the thumb sign (κ: right 0.71, left 0.78). In addition, an upgoing thumb sign showed a substantial level of agreement with the patient's symptoms (examiner 1: κ = 0.65, p < 0.01; examiner 2: κ = 0.64; p < 0.01). CONCLUSIONS: An upgoing thumb sign is a sensitive and reliable indicator of brain involvement. This examination is noninvasive, easy, reliable, and highly compatible with and confirmatory of the patient's symptoms.

Time is brain: Balancing risk in the treatment of presumed cardioembolic stroke.

OBJECTIVE: To assess whether clinical criteria can differentiate between presumed embolic strokes and non-embolic strokes before the full etiologic workup. METHODS: Between January 1, 2014 to December 30, 2015, patients with a diagnosis of stroke or transient ischemic attack were first classified clinically (without access to a cardiac assessment) as: 1. presumed embolic stroke defined as a combination of definite cardioembolic stroke and likely to be embolic stroke (no evidence of large/small artery atherosclerosis); 2. non-embolic strokes; i.e. small/large artery diseases and stroke due to other causes. Stroke etiology was reassessed after investigations and concordances between the early diagnosis and final classifications were analyzed. RESULTS: 77 patients with early diagnosis of presumed embolic strokes and 45 cases with non-embolic stroke (selected randomly) were enrolled. We were able to differentiate between presumed embolic strokes and non-embolic strokes with a high level of accuracy (sensitivity 81.40%, 95% CI: 71.55%-88.98%; specificity 80.56%, 95% CI: 63.98%-91.81%). A moderate level of agreement between initial and final diagnosis of embolic/non-embolic strokes (kappa 0.58, SE 0.08, p≤0.01) was observed. The results of carotid imaging improved the specificity and positive likelihood ratio of correct differentiation. CONCLUSIONS: Those at high risk of embolism can be diagnosed clinically even before the completion of tests. This is a practical approach to distinguish patients at risk and help balance early risks of recurrence with those of short-term anticoagulation.

Inhibition of the primary motor cortex and the upgoing thumb sign.

BACKGROUND: The upgoing thumb sign has been frequently observed in patients with minor strokes and transient ischemic attacks as an indicator of brain involvement. We assessed the effect of primary motor cortex (M1) inhibition in the development of the upgoing thumb sign. METHODS: Used repetitive Transcranial Magnetic Stimulation (rTMS, 1 Hz frequency for 15 min, 1s ISI, 900 pulses) at 60% of resting motor threshold to inhibit the right or left primary motor cortex of 10 healthy individuals. Participants were examined before and after rTMS by a neurologist who was blind to the site of motor cortex inhibition. RESULTS: 10 neurological intact participants (5 women/5 men) were recruited for this study. 2 cases were excluded due to pre-existing possible thumb signs. After the inhibition of the primary motor cortex, in 6 subjects out of 8, we observed a thumb sign contralateral to the site of primary motor cortex inhibition. In one subject an ipsilateral thumbs sign was noted. In another case, we did not find an upgoing thumb sign. CONCLUSION: The upgoing thumb sign is a subtle neurological finding that may be related to the primary motor cortex or corticospinal pathways involvements.