Deans' stroke musings

Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 481 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:http://oc1dean.blogspot.com/2010/11/my-background-story_8.html

Friday, April 29, 2016

Features and Determinants of Lacune Shape

Just in case your doctor doesn't define a lacune. It is a type of stroke. My doctor never even explained what a CVA was, didn't use the word stroke.

Lacunes: Small, deep cerebral infarcts

http://stroke.ahajournals.org/content/47/5/1258.abstract 

Relationship With Fiber Tracts and Perforating Arteries

  1. Martin Dichgans, MD*
+ Author Affiliations
  1. From the Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich, Germany (B.G., M. Duering, M. Dichgans); Neurospin, CEA Saclay, Paris, France (E.D., J.-F.M.); Department of Neurology, DHU NeuroVasc, Hopital Lariboisiere, APHP, Paris, France (E.J., H.C.); Department of Neurology, Medical University of Graz, Austria (R.S.); Munich Cluster for Systems Neurology (SyNergy), Munich, Germany (M. Dichgans); and German Center for Neurodegenerative Diseases (DZNE), Munich, Germany (M. Dichgans).
  1. Correspondence to Martin Dichgans, MD, Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Feodor-Lynen St 17, D-81377 München, Germany. E-mail martin.dichgans@med.uni-muenchen.de
  1. * Drs Duering and Dichgans contributed equally and are joint senior authors.

Abstract

Background and Purpose—Lacunes are a major manifestation of cerebral small vessel disease. Although still debated, the morphological features of lacunes may offer mechanistic insights. We systematically analyzed the shape of incident lacunes in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, a genetically defined small vessel disease.
Methods—A total of 88 incident lacunes from 57 patients were segmented from 3-dimensional T1 magnetic resonance images and 3 dimensionally reconstructed. Anatomic location, diameter, volume, surface area, and compactness of lacunes were assessed. The shape was analyzed using a size, orientation, and position invariant spectral shape descriptor. We further investigated the relationship with perforating arteries and fiber tracts.
Results—Lacunes were most abundant in the centrum semiovale and the basal ganglia. Diameter, volume, and surface area of lacunes in the basal ganglia and centrum semiovale were larger than in other brain regions. The spectral shape descriptor revealed a continuum of shapes with no evidence for distinct classes of lacunes. Shapes varied mostly in elongation and planarity. The main axis and plane of lacunes were found to align with the orientation of perforating arteries but not with fiber tracts.
Conclusions—Elongation and planarity are the primary shape principles of lacunes. Their main axis and plane align with perforating arteries. Our findings add to current concepts on the mechanisms of lacunes.

 

Black Raspberry Extract Increased Circulating Endothelial Progenitor Cells and Improved Arterial Stiffness in Patients with Metabolic Syndrome: A Randomized Controlled Trial

Not to be followed unless your doctor prescribes this. You know how dangerous this stuff can be.
Interesting that no changes in blood pressure were seen  but other markers were better that your doctor can explain to you.
http://online.liebertpub.com/doi/full/10.1089/jmf.2015.3563
To cite this article:
Jeong Han Saem, Kim Sohyeon, Hong Soon Jun, Choi Seung Cheol, Choi Ji-Hyun, Kim Jong-Ho, Park Chi-Yeon, Cho Jae Young, Lee Tae-Bum, Kwon Ji-Wung, Joo Hyung Joon, Park Jae Hyoung, Yu Cheol Woong, and Lim Do-Sun. Journal of Medicinal Food. April 2016, 19(4): 346-352. doi:10.1089/jmf.2015.3563.
Published in Volume: 19 Issue 4: April 13, 2016
Online Ahead of Print: February 18, 2016

Author information

Han Saem Jeong,1,* Sohyeon Kim,1,* Soon Jun Hong,1 Seung Cheol Choi,1 Ji-Hyun Choi,1 Jong-Ho Kim,1 Chi-Yeon Park,1 Jae Young Cho,1 Tae-Bum Lee,2 Ji-Wung Kwon,2 Hyung Joon Joo,1 Jae Hyoung Park,1 Cheol Woong Yu,1 and Do-Sun Lim1
1Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea.
2Gochang Black Raspberry Research Institute, Gochang, Korea.
*These authors contributed equally to this work.
Address correspondence to: Soon Jun Hong, MD, PhD, Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, 126-1, 5ka, Anam-dong, Sungbuk-ku, Seoul 136-705, Republic of Korea, E-mail:
Manuscript received 22 July 2015
Revision accepted 14 January 2016

ABSTRACT

Administration of black raspberry (Rubus occidentalis) is known to improve vascular endothelial function in patients at a high risk for cardiovascular (CV) disease. We investigated short-term effects of black raspberry on circulating endothelial progenitor cells (EPCs) and arterial stiffness in patients with metabolic syndrome. Patients with metabolic syndrome (n = 51) were prospectively randomized into the black raspberry group (n = 26, 750 mg/day) and placebo group (n = 25) during the 12-week follow-up. Central blood pressure, augmentation index, and EPCs, such as CD34/KDR+, CD34/CD117+, and CD34/CD133+, were measured at baseline and at 12-week follow-up. Radial augmentation indexes were significantly decreased in the black raspberry group compared to the placebo group (−5% ± 10% vs. 3% ± 14%, P < .05). CD34/CD133+ cells at 12-week follow-up were significantly higher in the black raspberry group compared to the placebo group (19 ± 109/μL vs. −28 ± 57/μL, P < .05). Decreases from the baseline in interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) were significantly greater in the black raspberry group compared to the placebo group (−0.5 ± 1.4 pg/mL vs. −0.1 ± 1.1 pg/mL, P < .05 and −5.4 ± 4.5 pg/mL vs. −0.8 ± 4.0 pg/mL, P < .05, respectively). Increases from the baseline in adiponectin levels (2.9 ± 2.1 μg/mL vs. −0.2 ± 2.5 μg/mL, P  < .05) were significant in the black raspberry group. The use of black raspberry significantly lowered the augmentation index and increased circulating EPCs, thereby improving CV risks in patients with metabolic syndrome during the 12-week follow-up.

Introduction

Black raspberry (Rubus occidentalis) has long been used in traditional alternative medicine in Korea because of its potential to improve vascular function. The components of black raspberry include flavonoids, tannins, phenolic acids, tyrosol, ellagitannins, and resveratrol.1–4 These components have well-documented anti-inflammatory, antioxidative, and antiatherosclerotic effects.5–7 Antioxidant compounds of black raspberry reduce blood pressure and improve arterial stiffness.8 Some studies have demonstrated that black raspberry improves blood pressure, lipid profiles, and vascular function.9–11
Metabolic syndrome is a cluster of cardiovascular (CV) risk factors. As CV events are higher in patients with metabolic syndrome compared to the general population, it is important to manage individual CV risk parameters such as central blood pressure, radial artery augmentation index, and systemic inflammation.12,13 Central blood pressure is more related to CV risk than peripheral blood pressure.14 Arterial stiffness is included in the European Society of Hypertension/European Society of Cardiology guidelines for the assessment of CV risk.15 Obesity, hypertension, dyslipidemia, and insulin resistance are all components of the metabolic syndrome and these factors are known to be associated with arterial stiffness.16 Arterial stiffness is not just an aging process, but a consequence of pathophysiological alterations of endothelial cells, vascular smooth muscle cells, and the extracellular matrix.17,18 Especially, increased vascular stiffness is important in predicting CV disease in obese and insulin-resistant patients.19 The number of circulating endothelial progenitor cells (EPCs) promoting regeneration in damaged vascular endothelium and ischemic tissues is an emerging marker in CV diseases in recent years.20 Inverse correlation between the number of circulating EPCs and CV risk factors has been reported.21 Oxidative stress results in downregulation of nitric oxide (NO), thereby leading to endothelial dysfunction, which promotes vasoconstriction, platelet activation, vascular inflammation, and arterial stiffness.22 Thus, the key clinical implication in managing metabolic syndrome is to block the subsequent complications of metabolic syndrome.
Management of metabolic syndrome encompasses lifestyle modification and lowering individual CV risks by treatment of hypertension, glycemic control, and lowering of serum cholesterol. In our previous in vitro and in vivo studies, administration of black raspberry extracts lowered blood pressure in rats and improved lipid profiles and vascular endothelial function in patients with metabolic syndrome. Some other studies have shown that black raspberry improves endothelial cell function and the process of atherosclerosis.7–9 Anti-inflammatory and antioxidant properties of black raspberry could improve endothelial function and eventually increase circulating EPCs and decrease arterial stiffness. We hypothesized that administering black raspberry extract could have favorable effects on blood pressure, vascular endothelial function, and circulating EPCs. Therefore, we performed a prospective randomized study investigating the short-term effects of black raspberry on the circulating numbers of EPCs, central blood pressure, augmentation index, and inflammatory markers in patients with metabolic syndrome.

Materials and Methods

Study patients Patients were eligible for this study if they were between 18 and 75 years old with metabolic syndrome. For patients to meet the diagnostic criteria for metabolic syndrome, ≥3 of the following measurements had to be fulfilled: abdominal circumference ≥90 cm in men or ≥85 cm in women, triglyceride level ≥150 mg/dL, high-density lipoprotein cholesterol <40 mg/dL in men or <50 mg/dL in women, systolic blood pressure (SBP) of ≥130 mmHg, diastolic blood pressure (DBP) ≥85 mmHg, and fasting blood glucose of ≥100 mg/dL.23,24 Participants underwent randomization at a 1:1 ratio to receive placebo or black raspberry extract for 12 weeks (Supplementary Table S1).
A total of 116 patients with metabolic syndrome were screened for inclusion in the study at Korea University Anam Hospital Cardiovascular Center from August 2013 to November 2013 (Fig. 1). Exclusion criteria were (i) patients who did not fulfill the inclusion criteria (n = 5), (ii) who did not provide informed consent (n  = 48), (iii) familial hypercholesterolemia, (iv) hepatic dysfunction (aspartate aminotransferase or alanine aminotransferase>twice the upper limit), (v) gastrointestinal disorder such as Crohn's disease or history of surgery, (vi) alcohol abuse, (vii) steroid or hormone replacement therapy, (viii) serum creatinine >2.0 mg/dL, and (ix) expected life expectancy of <1 year. Patients who had CV or cerebrovascular disease, such as coronary artery disease, heart failure, and stroke, were eligible for this study. Eligible patients (n = 51) were prospectively randomized into the black raspberry group (n = 26, 750 mg/day equivalent of 4 capsules/day) or placebo group (n  = 25) during the 12-week follow-up. Dried unripe black raspberries were made into capsules containing black raspberry powder under good manufacturing practices, and each black raspberry capsule contained 187.5 mg of dried unripe black raspberry powder. The participants were told to take a total of four black raspberry capsules each day or placebo during the 12-week follow-up.
Complete clinical workup was scheduled at baseline and at a 12-week follow-up. Central blood pressure, radial artery augmentation index, and the circulating number of EPCs were compared between the two groups during the follow-up. The primary endpoints of the study were to compare the short-term effects of black raspberry on the radial artery augmentation index and the circulating number of EPCs in patients with metabolic syndrome during the 12-week follow-up. Patients received randomization numbers sequentially from a secret randomization list that was computer generated in blocks of three by individuals who had no contact with the persons who assigned patients to study groups or performed any assessments on patients. The clinical research center was given a single-sealed opaque envelope for each patient that contained the treatment code and it was to be opened only in a medical emergency. Investigators and participants were unaware of the randomization assignments until the final data were obtained. All participants were instructed to follow a diet based on “Dietary Approaches to Stop Hypertension” (DASH) diet for controlling metabolic syndrome and were instructed not to consume any berry species. Telephone interviews were conducted to check adherence to the intervention by counting the remaining black raspberry pills biweekly. Remaining black raspberry capsules were counted during the follow-up, and patients who took more than 85% of the black raspberry capsules were considered compliant. The study was approved by the University Hospital Institute Review Board, and written informed consent was obtained from all participants or their legal guardians.
Preparation of unripe R. occidentalis extract
The unripe fruits of R. occidentalis were collected from the Gochang (Jeollabuk-Do) area in South Korea. In brief, fruits were extracted twice with tap water at 100°C using a reflux condenser. Black raspberry was extracted with a reflux condenser device by adding 10-fold solvent volume of the unripe black raspberries (water, 25%, 50%, and 75% ethanol) for 2 h. The extracts were filtered and concentrated, and the concentrates were lyophilized in a freeze dryer (PVTFD10R; Ilshinbiobase, Dongducheon, Korea). Total polyphenol content was measured by the Folin–Denis method, and the total flavonoid content was measured by the Davis method. Ellagic acid was used as a marker compound to develop suitable identification test for raw materials.25 Ellagic acid (analytical standard, purity 95%; Sigma Co. St. Louis, MO, USA) was diluted with methanol. Ellagic acid was assayed by high-performance liquid chromatography (ACQUITY H-class; Waters, Co., Milford, MA, USA). One capsule of the black raspberry extract consisted of black raspberry powder (62.5%), magnesium stearate (1.5%), silica (1.5%), and isomaltose (34.5%). Placebo capsules had the same appearance, but contained isomaltose (97.0%), magnesium stearate (1.5%), and silica (1.5%). Isomaltose was made from corn powder. The nutrient composition in 100 g black raspberry was 9.6 g carbohydrate, 5.3 g fiber, 4.9 g sugar, 1.4 g protein, 0.5 g lipid, 29 mg calcium, 0.62 mg iron, 20 mg magnesium, 22 mg phosphorus, 21 mg vitamin C, 0.02 mg thiamin, 0.03 mg riboflavin, 0.6 mg niacin, 25 μg folate, 11 μg vitamin A, 128 μg β-carotene, 214 IU vitamin A, 1.17 mg vitamin E, 1.34 mg γ-tocopherol, 100 mg cyanidin, 0.4 mg pelargonidin, 37.1 mg catechin, 4.7 mg epicatechin, 3.6 mg quercetin, 0.7 mg myricetin, and 19.5 mg proanthocyanidins (USDA National Nutrient Database 2015). Further details of manufacture and characteristics of black raspberry powder were discussed in a previous study.11
Measurements of circulating EPCs
Peripheral blood samples (4 mL) were drawn into heparinized tubes in the morning after an overnight fast. Peripheral blood mononuclear cells were isolated within 1 h by density gradient centrifugation using Ficoll-Paque Plus (17-1440-03; Amersham Biosciences, Piscataway, NJ, USA) and stored at 4°C until the cells were analyzed. For flow cytometry analysis, the cells were washed with phosphate-buffered saline (PBS) containing 2% fetal bovine serum (FBS) and were double stained with anti-CD34-FITC (348053; BD Pharmingen, San Diego, CA, USA) and anti-KDR-PE (FAB357P; R&D Systems, Minneapolis, MN, USA) or anti-CD34-FITC and anti-CD117-PE (555714; BD Pharmingen) or anti-CD34-FITC and anti-CD133-PE (130-080-801; Miltenyi Biotec, Bergisch Gladbach, Germany) monoclonal antibodies diluted 1:100 in PBS containing 2% FBS for 20 min at 4°C. A negative control was also stained with FITC mouse IgG1 isotype control (555909; BD Pharmingen) and PE mouse IgG1 isotype control (349043; BD Pharmingen) antibodies. After washing with PBS containing 2% FBS, the cells were resuspended and analyzed by flow cytometry. For double-staining experiments, the interference of two fluorescence channels was adjusted by compensation. Three thousand cells per sample were analyzed on a FACS Vantage SE flow sorter (BD Biosciences, San Jose, CA, USA). Dead cells and debris were gated out using scatter properties of the cells. Data were analyzed by using CellQuest Pro software (BD Biosciences). CD34+KDR+ or CD34+CD117+ or CD34+CD133+ double-positive cells were defined as circulating EPCs after gating on lymphocyte population. The number of positive cells was calculated on the basis of absolute leukocyte count × percentage (%) of positive cells and expressed as the absolute number of cells per 1 mL of whole blood (Supplementary Fig. S1; Supplementary Data are available online at www.liebertpub.com/jmf).
Measurements of central blood pressure and augmentation index
Central pressure recordings were obtained using an Omron HEM-9000AI (cSBP-Omron) as described by the manufacturer's user manual. Blood pressure measurement was obtained through the digital oscillometric method using a blood pressure cuff. Accompanying augmentation index calculations were made based on the patient‘s pressure waveforms calibrated using brachial SBP and DBP. The augmentation index is determined by the change in pressure between the first and second peaks divided by the pulse pressure (augmentation index = ΔP/PP). The first peak is obtained when blood is ejected from the aorta. The second pressure peak occurs when blood is reflected at the aortic bifurcation. The pulse pressure is the overall peak pressure. All data were stored and analyzed offline after completion of testing.
Laboratory analysis
Inflammatory markers such as high-sensitive C-reactive protein (hsCRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) were measured for both groups at the beginning of the study and at the 12-week follow-up visit. Venous blood samples were drawn from each patient after 8 h or overnight fasting. Blood samples were centrifuged to obtain plasma, which was stored at −80°C. TNF-α was measured by a sandwich enzyme-linked immunosorbent assay (ELISA) with a minimum detectable level of 0.5 pg/mL (ALPCO Diagnostics, Salem, NH, USA). Undetectable TNF-α values were recorded as 0.4 pg/mL. High-sensitivity IL-6 was measured by a sandwich ELISA with a minimum detectable level of 0.16 pg/mL (ALPCO Diagnostics). hsCRP concentration was quantified using the latex nephelometer II (Dade Behring, Inc., Newark, DE, USA). The plasma adiponectin concentration was assessed by the radioimmunoassay (Linco Research, Inc., St. Charles, MO, USA). The sensitivity of this assay was 0.78 ng/mL. The coefficient of variation for intra- and interassay was 9.3% and 15.3%, respectively. In addition, sICAM-1 and sVCAM-1 were measured using ELISA according to the manufacturer's instructions (R&D Systems).
Statistical analyses
Data are expressed as means for continuous variables, and data for the categorical variables are expressed as the number and the percentage of patients. Chi-square tests were used for categorical variables. The change from baseline was calculated as the value obtained at the end of the treatment subtracted from the value obtained at the beginning of the study. The results between two groups were compared by an unpaired Student's t-test, and the comparisons between before and after treatment were analyzed by a paired t-test. Using a two-sided test for differences in independent binomial proportions with an α level of 0.05, we calculated that 46 patients (23 patients for each group) would have to undergo randomization for the study to have 80% power to detect a difference in the circulating number of EPCs between the two groups; therefore, we enrolled 51 patients to account for 10% loss in the 12-week follow-up. Variables that did not show normal distribution were log transformed in subsequent analysis. P-value <.05 was considered statistically significant. SPSS software (version 20.0) was used for the analyses.

Results

Study patients characteristics Of the 116 patients that underwent actual screening, the eligible patients (n = 51) were prospectively randomized into the black raspberry group (n = 26, 750 mg/day equivalent of 4 capsules/day) and placebo group (n  = 25) and were followed for the 12-week study period at Korea University Anam Hospital Cardiovascular Center from August 2013 to November 2013. Baseline patient characteristics such as mean ages and body mass indexes were similar between the two groups (Table 1). Risk factors such as hypertension, diabetes, hyperlipidemia, and current smoking were not significantly different between the two groups. There were no patients who had coronary artery diseases or cerebrovascular diseases in this study. Moreover, medications at baseline did not differ significantly between the two groups. During the intervention, none of the patients dropped out. No adverse event was reported.
Data table
Table 1. Baseline Patient Characteristics
Changes in central blood pressure and augmentation index There were no significant changes in SBP, DBP, or central systolic blood pressure. However, the radial artery augmentation index decreased significantly in the black raspberry group when compared to the placebo group (−5% ± 10% vs. 3% ± 14%, P < .05) (Table 2). The radial artery augmentation index decreased significantly even after adjusting for age (P = .005). In subgroup analysis, sex did not significantly impact the augmentation index (P = .066).
Data table
Table 2. Changes in Central Blood Pressure and Radial Augmentation Index
Circulating EPCs and inflammatory parameters during the 12-week follow-up Counts of circulating EPCs at baseline were similar between the two groups in CD34/KDR+, CD34/CD117+, and CD34/CD133+ cells. However, increases in CD34/CD133+ cells at 12-week follow-up were significantly greater in the black raspberry group when compared to the placebo group (19 ± 109/μL vs. −28 ± 57/μL, P < .05) (Table 3). Decreases from the baseline in IL-6 and TNF-α were significantly greater in the black raspberry group than in the placebo group (−0.5 ± 1.4 pg/mL vs. −0.1 ± 1.1 pg/mL, P < .05, and −5.4 ± 4.5 pg/mL vs. −0.8 ± 4.0 pg/mL, P < .05, respectively). Increases from the baseline in adiponectin levels (2.9 ± 2.1 μg/mL vs. −0.2 ± 2.5 μg/mL, P < .05) were significantly greater in the black raspberry group.
Data table
Table 3. Changes in Circulating Endothelial Progenitor Cells and Inflammatory Parameters During 12-Week Follow-Up

Discussion

This is the first prospective randomized double-blind study to investigate the effect of black raspberry on circulating EPCs and on arterial stiffness. Administering black raspberry (R. occidentalis) extract, 750 mg/day for 12 weeks, significantly lowered the radial artery augmentation index compared to the placebo group and significantly increased the circulating numbers of CD34/CD133+ cells during the follow-up.
The augmentation index is defined as the percentage of central pulse pressure attributed to reflected wave overlap in systole and is related with CV outcomes.26,27 When arteries are stiff, the reflected wave overlaps earlier with incident wave, resulting in increased pulse pressure and higher augmentation index.28 Arterial stiffness is a result of endothelial damage since endothelial dysfunction causes decreased production and function of NO and reduces arterial compliance.29 Increased oxidative stress and inflammation also exacerbate arteriolar remodeling.30,31 Although central blood pressure did not change in this study, the decreases in augmentation index were observed only in the black raspberry group, which could be explained by the improvement in vascular endothelial function in the black raspberry group from our previous study.10 The endothelium regulates vascular reactivity through the dilator-associated mediators including NO and prostaglandins.32,33 Flavonoids, major components of the black raspberry, are a well-known element that improves vascular function through the endothelium-dependent flow-mediated vasodilation and reduces CV risks in patients with endothelial dysfunction.10,34 Flavonoids increase bioavailability of NO and endothelial nitric oxide synthase (eNOS).35,36 Moreover, an experimental study shows that polyphenolic compounds can induce the endothelium-NO-dependent relaxation of coronary arteries.37 In particular, anthocyanin, one of the phenolic compounds, possesses anti-inflammatory and antioxidant capacity and improves vascular function by upregulating NO and eNOS.38–40 A study has shown that administration of anthocyanins improves arterial stiffness such as the augmentation index and pulse wave velocity, arterial systolic pressure, and central blood pressure,41,42 leading to the assumption that anthocyanins reduce the risks of CV disease-related mortality.43 The improvement of augmentation index in this study might have been mediated by the vasodilating and anti-inflammatory effects of black raspberry.
Decrease of the augmentation index is presumably associated with the circulating number of EPCs. EPCs are bone marrow-derived stem cells that are mobilized into peripheral circulation. These cells stimulate neoangiogenesis and repair the damaged vascular endothelium.44 EPCs home into the injury site to replicate endothelial cells and activate the endogenous repair system.45 EPCs represented with circulating CD34+ and CD133+ cells express vascular endothelial growth factor receptor 2 (VEGFR-2) and eNOS.46 CD34+ cells also stimulate subject angiogenic cytokines.47 Some studies have demonstrated that EPCs restore ischemic damage in vivo and improve clinical outcomes.48,49 The number of circulating EPCs inversely correlates with CV risk factors, suggesting that the circulating number of EPCs is lower in patients with CV diseases.21,50 Moreover, patients with increased numbers of circulating EPCs have preserved endothelial function and show better arterial stiffness profiles regardless of the risk factors.21 Increases in circulating EPCs during the 12-week follow-up in this study suggest rapid restoration to the damaged endothelium, thereby contributing to the improvement of arterial stiffness and the augmentation index. Other randomized clinical trials of cranberry juice and blueberry drink did not show significant changes in the augmentation index.51,52 However, administering black raspberry contributed to the increases in the numbers of circulating EPCs, which presumably improved endothelial dysfunction and upregulated eNOS and NO expression, thereby improving arterial stiffness and the augmentation index in patients with metabolic syndrome in this study.
Our study had a few limitations. The total number of study participants was relatively small for evaluating clinical CV events. Black raspberry contains various types of beneficial natural compounds, including polyphenolic compounds; however, exact mechanisms about the relationship between the beneficial compounds in black raspberry and favorable effects on circulating number of EPCs and arterial stiffness need to be further investigated.
In conclusion, the use of black raspberry significantly lowered the augmentation index and increased circulating EPCs, thereby improving CV risks in patients with metabolic syndrome during the 12-week intervention.

Black Raspberry Improves Cardiovascular Risk in Metabolic Syndrome

The arterial stiffness improvement should excite your doctor but I bet this will not change your stroke diet protocol. I bet you don't even have a diet protocol.
http://www.alphagalileo.org/ViewItem.aspx?ItemId=163627&CultureCode=en
A new study shows that black raspberry extract can significantly lower a key measure of arterial stiffness-an indicator of cardiovascular disease. Black raspberry intake was also associated with increased levels of circulating endothelial progenitor cells (EPCs), which help repair and regenerate damaged arteries, according to the study published in Journal of Medicinal Food, a peer-reviewed journal from Mary Ann Liebert, Inc., publishers (http://www.liebertpub..com/). The article is available free on the Journal of Medicinal Food (http://online.liebertpub.com/doi/full/10.1089/jmf.2015.3563) website until May 28, 2016.

Han Saem Jeong, Sohyeon Kim, and coauthors from Korea University Anam Hospital (Seoul) and Gochang Black Raspberry Research Institute (Korea), describe the results of a randomized controlled trial in which they compared two groups of patients with metabolic syndrome. One group received 750 mg/day of black raspberry extract, and the other received a placebo for 12 weeks.

In the article "Black Raspberry Extract Increased Circulating Endothelial Progenitor Cells and Improved Arterial Stiffness in Patients with Metabolic Syndrome: A Randomized Controlled Trial (http://online.liebertpub.com/doi/full/10.1089/jmf.2015.3563)," the researchers present the changes recorded in the radial augmentation index (a measure of arterial stiffness), blood pressure, circulating EPCs, and various markers of inflammation for the two groups of patients.

Attached files

Journal of Medicinal Food

Harsh Out of Necessity - MS "moral cognition" of patients

Your doctor and psychologist should be informing you of this problem since it likely also occurs in stroke survivors and caregivers.
http://www.alphagalileo.org/ViewItem.aspx?ItemId=163588&CultureCode=en
To cope with Multiple Sclerosis, patients become morally stricter.
Multiple sclerosis (MS) can have a strong impact on the life of patients. Not only must they address the unpleasant symptoms, they are also subject to unpredictable relapses after more or less long periods of remission (which are irregular in duration), a condition that can cause anxiety and stress. As noted in a new study carried out by SISSA of Trieste in collaboration with the Medical University of South Carolina (and other international institutions), this condition has consequences for the "moral cognition" of patients, who become particularly intransigent in moral judgments of third parties. This ”moral inflexibility” results from cognitive styles adopted to overcome the inconveniences of the disease. Understanding their causes, explain the authors of the recently published study in Social Neuroscience, has important ramifications for the social wellbeing of patients.
Multiple Sclerosis affects nearly 2 and a half million people worldwide. It is a highly debilitating autoimmune disease: the condition severely reduces patients’ quality of life through symptoms which disrupt motor, cognitive, and sensory systems. The disease, which in its most typical form is characterized by irregular remissions and acute attacks can create a state of increased anxiety in patients, and, according to scientists, can have negative cognitive/emotional effects as well, even influencing moral cognition in patients, as was observed in the recent study.
Indrajeet Patil, a researcher at the International School for Advanced Studies (SISSA) of Trieste, and first author of the study, and his colleagues, subjected a group of patients to third-person "moral dilemmas."  The moral dilemma is a common test for measuring moral cognition, but it is usually used in the first person. In this case, subjects had to judge others’ actions, as if they were jury members in a trial. For this specific study, manslaughter (accidental killings, i.e.) and attempted murder were considered. Subjects evaluated the appropriateness of and punishment for a variety of third-party moral behaviors that varied on two key dimensions: intent to harm and harmful consequence. That is, the agents in these scenarios either acted with an intent to harm or not and consequently either produced or did not produce a harmful outcome.
"These conditions are important because we know that two main criteria come into play in judgments of this kind," says Patil. "We take into account both the intention, and the seriousness of the consequences. We tend to be more forgiving in cases of manslaughter, where intentions are innocent but consequences are serious, and to punish an attempted murder, whose intention is bad but the consequences are not serious. "
It is well known that certain pathological conditions alter this kind of judgment: if there are alterations in the Theory of mind (the ability to attribute mental states to others), as happens in autism, for example, it is difficult to evaluate intentions, so manslaughter is judged severely, because of the serious consequences. Psychopaths tend instead to forgive culpable homicide more easily, not so much because they do not have a correct assessment of intentions, but rather because of reduced empathy towards the victims.
Surprising results
In MS patients, Patil and colleagues were expecting a greater tendency for forgiveness, because of difficulty with Theory of mind that has been described in some of these patients, as well as a decrease in empathic response. "The results, however, were surprising: subjects’ answers were more severe than average in all conditions. They also proved overly confident about the validity of their own judgment, much more so than in healthy subjects, declaring they were sure that anyone would respond as they did."
Further tests have allowed the authors to develop a hypothesis for this unexpected attitude. "We believe that these severe responses are connected to a type of emotional/general cognitive strategy used by MS patients, possibly emerging as a mechanism to cope with their medical condition and the many challenges that are associated with it," says Ezequiel Gleichgerrcht, a neurologist and researcher at the Medical University of South Carolina. "The constant stress they face can elicit persistently negative emotions. In the long run, this state can induce cognitive strategies that help them minimize the damage. Neuroscientists have coined the term ‘externally oriented thinking’ to refer to this phenomenon  which is characterized by the tendency to orient thoughts on the external events rather than introspecting on our inner experiences and feelings."
"It is a common strategy, resulting in an inability to properly reflect and identify emotions," says Patil. "In situations of moral judgment like those in the study, there is an inability to identify the real cause of their negative emotional state, attributing it to external causes, and not to the medical condition."
Put simply, during the experiments, the MS patients tended to attribute their negative emotions to what they read in the dilemma. Whether the consequences were the result of an accident as in the manslaughter situation, or bad intentions as in the attempted murder, mattered little. "The patient believed that these situations led to the negative affect they felt and therefore judged the third-party actors more severely. This explains why we observed more harsh judgments even in neutral conditions where there was neither bad intent nor outcome," says Patil.
"Knowing that MS patients tend to adopt this cognitive strategy, along with their nearly constant state of emotional stress, is important," he concludes. “On one hand, it helps healthcare providers working with them to objectively read their behavior, and improve interpersonal relationships, which are vital in this type of care. On the other hand, knowing this 'dark' side can also help us develop cognitive/behavioral treatment for helping patients improve their emotional response."
https://www.sissa.it/news/harsh-out-necessity

Poo transplants better understood

Since you might be a candidate for this your doctor needs to understand this more fully. Do you trust your doctor to be up-to-date on research? I wouldn't.

Restoring gut bacteria to youthful age linked to improved stroke recovery in mice


Transfer of gut bacteria affects brain function and nerve fiber insulation


Poo transplants better understood
For the first time, scientists studying stool transplants have been able to track which strains of bacteria from a donor take hold in a patient’s gut after a transplant. The team, led by EMBL with collaborators at Wageningen University and the Academic Medical Centre, both in the Netherlands, and the University of Helsinki, Finland found that compatibility between donor and patient likely plays a bigger role in these transplants than previously thought. The study, published today in Science, could help make stool transplants a valid treatment option for more conditions than they are currently applied to.
“Ultimately, the goal is to move from a stool transplant to something more manageable, such as a pill,” says Simone Li, who carried out the work at EMBL. “Our work shows that this is likely going to be a personalised bacterial cocktail, rather than a one-size-fits-all solution.”
Stool transplants – also known as faecal microbiota transplants – involve taking microbes from the poo of a healthy donor and transferring them to the patient’s gut. The hope is that this will help to restore health to patients suffering from conditions where the normal balance of microbes in the gut gets skewed. The approach has been very successful for treating recurrent Clostridium difficile (C. diff) infections – which can cause life-threatening cases of diarrhoea, and are becoming a serious problem in hospitals and healthcare institutes. But for other conditions, like ulcerative colitis, stool transplants have proven much less effective. The current study, led by Peer Bork and Shinichi Sunagawa at EMBL, could help improve those odds. The trick, the scientists say, is to look beyond what species of microbes are in a person’s gut, to what strains of each species.
Most people have E. coli in their gut, for instance, but different people have different strains of this species – and some of those strains can cause health issues. By distinguishing between different strains, the EMBL scientists were able to track if the microbes in a patient’s gut after the treatment were their own or came from the donor.
They found that after a stool transplant, new strains of microbes from the donor were more likely to colonise a patient’s gut if the patient already had that species. This implies that if doctors can match donors to patients, the chances of the treatment being a success could improve considerably. Looking at strains rather than species of bacteria could also make the therapy effective in conditions where it isn’t currently working.
“With this method, we can really see if, for example, an antibiotic-resistant strain is replaced by a non-resistant one,” says microbiologist Willem de Vos, who led the work at Wageningen University and the University of Helsinki, “so it could help to design stool transplants to work in other conditions beyond C. diff.”
The study builds on a clinical trial that looked into the use of stool transplants as a treatment for metabolic syndrome, run by Max Nieuwdorp at the Academic Medical Centre in Amsterdam. Although based on data from only 10 people, the work already provides strong indications that donor-patient compatibility is more important than assumed: transplants from one donor led to very different outcomes in three different patients.
http://s.embl.org/pr280416

Evolving Treatments for Acute Ischemic Stroke

You will have to send your doctor after this to see if any protocols are proposed for the hyperacute period. See if they are treating any of the 5 causes of the neuronal cascade of death? Do they mention any of the 1000+ failed neuroprotective research trials that Dr. Michael Tymianski, of the Toronto Western Hospital Research Institute in Canada  talks about? Anything on my 31 ideas on hyperacute therapy I'm going to insist my doctor give me during the first week?
Which of these 177 hyperacute therapies that need more research did they study?
Did anything here advance knowledge in helping survivors recover?
I bet nothing useful comes from this, your doctor can email them asking what they did to advance the stroke strategy.
http://circres.ahajournals.org/content/118/9/1425.abstract?etoc 
  1. Michael D. Hill
+ Author Affiliations
  1. From the Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.
  1. Correspondence to Michael D. Hill, MD, MSc, Calgary Stroke Program, Department Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Health Sciences Centre, 3300 Hospital Dr NW Calgary, AB T2N 4N1, Canada. E-mail michael.hill@ucalgary.ca
  1. * Drs Zerna and Hegedus jointly wrote and are considered co-first authors of this article.
  2. Dr Hill provided oversight and senior authorship.

Abstract

The purpose of this article is to review advances in stroke treatment in the hyperacute period. With recent evolutions of technology in the fields of imaging, thrombectomy devices, and emergency room workflow management, as well as improvement in statistical methods and study design, there have been ground breaking changes in the treatment of acute ischemic stroke. We describe how stroke presents as a clinical syndrome and how imaging as the most important biomarker will help differentiate between stroke subtypes and treatment eligibility. The evolution of hyperacute treatment has led to the current standard of care: intravenous thrombolysis with tissue-type plasminogen activator and endovascular treatment for proximal vessel occlusion in the anterior cerebral circulation. All patients with acute ischemic stroke are in need of hyperacute secondary prevention because the risk of recurrence is highest closest to the index event. The dominant themes of modern stroke care are the use of neurovascular imaging and speed of diagnosis and treatment.

Thursday, April 28, 2016

Arm rehab possibilities while driving

You can't let any time go to waste. None of these have any clinical studies to back them up. Don't do them.

1. Drive with the left hand at the 1 o'clock position. This only works on straight or slightly curving roads. I can only do it for 15-20 minutes before spasticity tires it out. I then use my right arm to hold the left hand in position at 1 o'clock.
2.  Roll the window down and lift the left arm on the sill so the lower arm will hang out the window. This provides massive amounts of necessary stimulation. Even better when it rains and it feels like needles entering your skin.
3. Hang the arm down between the seat and the door. This requires using the right am to push the left arm into place. Spasticity rears its ugly head and unless I wedge it properly it will crawl back up into my lap.  Trying to stop my spasticity with this therapy.
4.  Put left elbow on arm rest, hand at 7 o'clock position. This is to quiet the spasticity that tries to pull the elbow to my body and get some grasping with my fingers.
5.  Put my left hand between my legs, left thumb on seat but under right leg, fingers trying to dangle below. This causes staining on my car seat.
There is never enough driving time to get these all accomplished. Number 2, 3 and 4 require doing this while stopped.I really do expect my therapists to know how many repetitions and time is needed to recover these functions.
At least now while doing #1 and on cruise control I can drink coffee using a straw or change CDs.

Terry Lifestyle Home Lift - Home Elevator - Residential Elevator by Terry Lifts

See if your doctor or therapists recommend this as a home modification. Much better than the chair up the stairs in my opinion.
https://www.youtube.com/watch?v=QUDuPmVUvig

First-time stroke survivors and caregivers’ perceptions of being engaged in rehabilitation

Ten years ago I was told absolutely nothing about my stroke or rehabilitation.
http://onlinelibrary.wiley.com/doi/10.1111/jan.12819/full

  1. Langduo Chen MNg RN Clinical Services Coordinator,
  2. Lily Dongxia Xiao PhD RN Associate Professor* and
  3. Anita De Bellis PhD RN Senior Lecturer
Article first published online: 24 SEP 2015
DOI: 10.1111/jan.12819
Journal of Advanced Nursing

Journal of Advanced Nursing

Volume 72, Issue 1, pages 73–84, January 2016

SEARCH

Keywords:

  • discharge planning;
  • family caregivers;
  • interpretive study;
  • rehabilitation nurses;
  • stroke survivors

Abstract

Aim

To explore community-dwelling first-time stroke survivors and family caregivers’ perceptions of being engaged in stroke rehabilitation.

Background

Stroke is recognized as a worldwide common healthcare problem and the leading cause of adult disability. An holistic approach to rehabilitation can only be achieved by engaging stroke survivors and caregivers in all stages of recovery and by providing ongoing coordinated rehabilitation programmes.

Design

An interpretive study design was applied to the study.

Method

In-depth semi-structured interviews with 22 community-dwelling first-time stroke survivors and caregivers were conducted in 2013. The interviews were audiotaped, transcribed and analysed using a thematic analysis.

Findings

Four major themes were identified. First, participants demonstrated low health literacy in stroke and their needs to learn about the disease and rehabilitation were usually ignored in busy clinical settings prior to discharge from hospital. Second, there was a lack of communication and continuity of treatment when the stroke survivors were transferred from one institution to another. Third, challenged with fragmented post-discharge rehabilitation services, the participants perceived that nurse-led coordination of rehabilitation was desirable. Fourth, participants perceived ongoing changing of rehabilitation goals in different stages of recovery. They expected to be engaged in ongoing rehabilitation planning and programmes.

Conclusion

The findings of this study challenge service providers to realize a true partnership with stroke survivors and caregivers by working with them as one team that is led by nurses. Making the necessary changes requires mutual effort at both the systemic and individual levels with rehabilitation nurse-led coordination of rehabilitation programmes.

National Stroke Association - Where the money goes

This in a nutshell points out the whole problem with our stroke associations. Awareness NOT finding solutions to all the problems in stroke. This is so simple to solve;
1. Create and follow a stroke strategy to solve stroke problems. BHAGs (Big Hairy Audacious Goals)  Like repeatable neuroplasticity, repeatable neurogenesis, fatigue, spasticity, aphasia. And since we have no National Stroke Plan or strategy nothing will get done in stroke from the NSA that actually helps survivors.
2. Put out RFPs(Request for Proposals) to researchers to solve those problems.
3. Apply for grant money to fund those research projects.
4. Broadcast the success stories to generate enthusiasm and more foundations that want to get on a successful stroke strategy train. Hit the tipping point for stroke so each stroke success is met with breathless anticipation and media stories.
http://www.stroke.org/

Where the Money Goes


Total Expenses: $3,339,663

  • Administrative: $313,110 - 9%
  • Fundraising: $515,266 - 15%
  • Stroke Education: $2,511,287 - 74%

pie chart

Association of Get With The Guidelines-Stroke Program Participation and Clinical Outcomes for Medicare Beneficiaries With Ischemic Stroke

This is completely and totally fucking worthless. By measuring guidelines instead of results you are insuring that improvements will not occur on a regular basis. 
http://stroke.ahajournals.org/content/early/2016/04/13/STROKEAHA.115.011874.abstract

  1. Jeffrey L. Saver, MD
+ Author Affiliations
  1. From the Department of Neurology, Rush University Medical Center, Chicago, IL (S.S.); Departments of Cardiology (G.C.F.) and Neurology (J.L.S.), University of California, Los Angeles; Department of Neurology, University of Texas-Southwestern, Dallas (D.M.O.); Departments of Biostatistics and Bioinformatics (L.L., P.J.S.) and Cardiology (A.F.H., E.D.P.), Duke University, Durham, NC; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
  1. Correspondence to Sarah Song, MD, MPH, Department of Neurology, Rush University Medical Center, 1725 W Harrison St, Suite 1121, Chicago, IL 60612. E-mail sarah_song@rush.edu

Abstract

Background and Purpose—Get With The Guidelines (GWTG)-Stroke is a national, hospital-based quality improvement program developed by the American Heart Association. Although studies have suggested improved processes of care in GWTG-Stroke–participating hospitals, it is not known whether this improved care translates into improved clinical outcomes compared with nonparticipating hospitals.(You can't compare GWTG hospitals against each other)
Methods—From all acute care US hospitals caring for Medicare beneficiaries with acute stroke between April 2003 and December 2008, we matched hospitals that joined the GWTG-Stroke program with similar hospitals that did not. Using a difference-in-differences design, we analyzed whether hospital participation in GWTG-Stroke was associated with a greater improvement in clinical outcomes compared with the underlying secular change.
Results—The matching algorithm identified 366 GWTG-Stroke–adopting hospitals that cared for 88 584 acute ischemic stroke admissions and 366 non–GWTG-Stroke hospitals that cared for 85 401 acute ischemic stroke admissions. Compared with the Pre period (18–6 months before program implementation), in the Early period (0–6 months after program implementation), GWTG-Stroke hospitals had accelerated increases in discharge to home and reduced mortality at 30 days and 1 year. In the Sustained period (6–18 months after program implementation), the accelerated reduction in mortality at 1 year was sustained, with a trend toward sustained accelerated increase in discharge home.
Conclusions—Hospital adoption of the GWTG-Stroke program was associated with improved functional outcomes at discharge and reduced postdischarge mortality.

MORE THAN A BLACK BOX OF REHABILITATION: CHARACTERIZING THERAPY PROGRAMMES FOLLOWING BOTULINUM TOXIN INJECTIONS FOR SPASTICITY IN ADULTS WITH STROKE

See if your doctor can make any use of this.

More Than a Black Box of Rehabilitation: Characterizing Therapy Programmes Following Botulinum Toxin Injections for Spasticity in Adults with Stroke

Objectives: To describe ambulatory rehabilitation programmes (physical and occupational therapy activities and interventions) following botulinum toxin injections for poststroke spasticity using a stroke rehabilitation taxonomy. To explore the relationship between therapy provided and injected limb/s and treatment goals. 

Design: Prospective, observational cohort study. Participants: Stroke survivors (n = 47) participating in ambulatory rehabilitation programmes following botulinum toxin injections for upper limb, lower limb or upper and lower limb spasticity. 

Methods: Standardized therapy documentation forms were completed prospectively for each occupational and physical therapy session. Main outcomes were the proportion of: total therapy time spent in various therapeutic activities; total sessions during which each intervention was used to facilitate the activities most time was spent in; and goals related to each activity category. Sub-analysis was carried out for participants, based on limb/s injected. 

Results: Most time was spent in “upper extremity control” activities as the upper limb was more often injected. A large proportion of therapy time was spent in activities remediating “performance skills or body structure and function impairments”. In the upper and lower limb, and upper limb groups 38.7% and 46.2% of goals, respectively, related to this activity category, but less than 10% in the lower limb group. Little time was spent in community participation and leisure activities, whilst over one-third of lower limb group goals related to this category. 

Conclusion: Ambulatory rehabilitation programmes following botulinum toxin injections for post-stroke spasticity varied depending on limb/s injected and reflected treatment goals to some extent.

Upper limb rehabilitation following stroke - free online taster course - Nicky Snowdon University Lecturer in physiotherapy at Sheffield Hallam University

Free course, designed for therapists but survivors should crash it to make it real for them. Don't be polite, call them out on their total lack of knowledge.  Have at it, I'm going to compare it to what I've already written about.
https://www.linkedin.com/groups/1774685/1774685-6130392829639344132
Go to http://bit.ly/ulshooc to learn more and just visit the same page again on the 25th May to see the course materials.
This online taster course is designed for therapists who are considering joining our MSc in Advancing Physiotherapy Practice as a distance learning student. It will give you a taste of what it is like to study online. The course commences on the 25th May and runs for two weeks.

Free open access online taster course

The course will focus on rehabilitation of the upper limb following stroke. We will discuss current issues in practice and how these challenge us to achieve an active, evidence informed approach to rehabilitation, which is engaging for stroke survivors and produces results. We hope that by the end of the short course, you will be confident in applying current evidence around upper limb rehabilitation to your practice.
Week 1 - starts 25th May 2016 - What are the ingredients of good upper limb rehabilitation?

Week 2 - starts 1st June 2016 - Assessment of the upper limb following stroke.
The course will involve several interactive aspects to model the types of activities you would do as part of an online Master's course. Our online learning provision at SHU is characterised by - conversation with other learners (including the tutors), structured learning, practical relevance and multi-media resources.

You do not need to register to join the course. Simply revisit this web page after 25th May and the whole course will appear. You can either work through the course at the recommended rate to get the most out of interactivity with others or you can work through the course at your own pace.


To gain a certificate of completion, we ask you to:
1. Engage in each of the interactive activities, posting at least one comment in each week.
2. E-mail a short, reflective piece to us before the 22nd June 2016.