Ethical Issues in Vascular Neurology.

There are ethical aspects to each of the three phases of cerebrovascular disease: hyperacute management, acute prognostication and management of early complications, and long-term recovery and reintegration with the community. This article addresses ethical concerns pertinent to each phase. First, we discuss ethical issues regarding consent for thrombolysis and endovascular treatment for acute ischemic stroke, including a review of considerations regarding the provision of acute stroke treatment advice over the telephone. Next, we discuss capacity for consent and prognostication after ischemic stroke and intracranial hemorrhage, with a focus on the problems of the self-fulfilling prophecy. Finally, we discuss residual disability and patients' return to driving. Consideration of these ethical dimensions of cerebrovascular disease will assist neurologists in caring for patients and families suffering from this complex condition.

Reach Out Churches: A Community-Based Participatory Research Pilot Trial to Assess the Feasibility of a Mobile Health Technology Intervention to Reduce Blood Pressure Among African Americans.

Innovative strategies are needed to reduce the hypertension epidemic among African Americans. Reach Out was a faith-collaborative, mobile health, randomized, pilot intervention trial of four mobile health components to reduce high blood pressure (BP) compared to usual care. It was designed and tested within a community-based participatory research framework among African Americans recruited and randomized from churches in Flint, Michigan. The purpose of this pilot study was to assess the feasibility of the Reach Out processes. Feasibility was assessed by willingness to consent (acceptance of randomization), proportion of weeks participants texted their BP readings (intervention use), number lost to follow-up (retention), and responses to postintervention surveys and focus groups (acceptance of intervention). Of the 425 church members who underwent BP screening, 94 enrolled in the study and 73 (78%) completed the 6-month outcome assessment. Median age was 58 years, and 79% were women. Participants responded with their BPs on an average of 13.7 (SD = 10.7) weeks out of 26 weeks that the BP prompts were sent. All participants reported satisfaction with the intervention. Reach Out, a faith-collaborative, mobile health intervention was feasible. Further study of the efficacy of the intervention and additional mobile health strategies should be considered.

Self-Administered Gerocognitive Examination: longitudinal cohort testing for the early detection of dementia conversion.

BACKGROUND: Significant cognitive changes as individuals' age are not being identified in a timely manner, delaying diagnosis and treatments. Use of brief, multi-domain, self-administered, objective cognitive assessment tools may remove some barriers in assessing and identifying cognitive changes. We compared longitudinal Self-Administered Gerocognitive Examination (SAGE) test scores to non-self-administered Mini-Mental State Examination (MMSE) scores in 5 different diagnostic subgroups. METHODS: A cohort study evaluating annual rates of change was performed on 665 consecutive patients from Ohio State University Memory Disorders Clinic. Patients with at least two visits 6 months apart evaluated with SAGE and MMSE and classified according to standard clinical criteria as subjective cognitive decline (SCD), mild cognitive impairment (MCI), or Alzheimer's disease (AD) dementia were included. The pattern of change in SAGE scores was compared to MMSE. One way and repeated measures ANOVA and linear regression models were used. RESULTS: Four hundred twenty-four individuals (40 SCD, 94 MCI non-converters to dementia, 70 MCI converters to dementia (49 to AD dementia and 21 to non-AD dementia), 220 AD dementia) met inclusion criteria. SAGE and MMSE scores declined respectively at annual rates of 1.91 points/year (p < 0.0001) and 1.68 points/year (p < 0.0001) for MCI converters to AD dementia, and 1.82 points/year (p < 0.0001) and 2.38 points/year (p < 0.0001) for AD dementia subjects. SAGE and MMSE scores remained stable for SCD and MCI non-converters. Statistically significant decline from baseline scores in SAGE occurred at least 6 months earlier than MMSE for MCI converters to AD dementia (14.4 vs. 20.4 months), MCI converters to non-AD dementia (14.4 vs. 32.9 months), and AD dementia individuals (8.3 vs. 14.4 months). CONCLUSIONS: SAGE detects MCI conversion to dementia at least 6 months sooner than MMSE. Being self-administered, SAGE also addresses a critical need of removing some barriers in performing cognitive assessments. Limitations of our single-site cohort study include potential referral and sampling biases. Repetitively administering SAGE and identifying stability or decline may provide clinicians with an objective cognitive biomarker impacting evaluation and management choices.

Expiratory Positive Airway Pressure for Sleep Apnea after Stroke: A Randomized, Crossover Trial.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is common after stroke and predicts poor outcomes. Continuous positive airway pressure (CPAP) treats OSA but is generally poorly tolerated by stroke patients. We assessed whether nasal expiratory positive airway pressure (EPAP), an alternative to CPAP, may be an effective option after acute stroke. METHODS: We conducted a randomized, controlled, two-period crossover study in which each acute ischemic stroke patient received 1 night of EPAP and 1 night without EPAP while OSA was monitored with a validated device, the Watch-PAT 200. Linear repeated- measures analyses were conducted. Sample size calculations indicated that 18 subjects would be required to detect a 10-point or larger average reduction in the apnea-hypopnea index (AHI, the primary outcome), with use of EPAP, with power ≥ 80% and α = 0.05. RESULTS: Among the 19 subjects who completed the protocol, nasal EPAP treatment was associated with a nonsignificant absolute difference in AHI of -5.73 events/h in the primary analysis (p = 0.183, 95% confidence interval -14.4, 2.97) and a nonsignificant absolute difference in AHI of -5.43 events/h in the subgroup of patients who used nasal EPAP for ≥ 3 h (p = 0.314, 95% confidence interval -16.6, 5.76). CONCLUSIONS: This study suggests that EPAP is not an effective alternative to CPAP in acute stroke patients with OSA. Further work is needed to identify other more effective alternatives. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT01703663.