There Is Selective Increase in Pro-thrombotic Circulating Extracellular Vesicles in Acute Ischemic Stroke and Transient Ischemic Attack: A Study of Patients From the Middle East and Southeast Asia.

Stroke attacks were found to be present at a younger age in patients from Southeast Asia (SE) and the Middle East (ME) resident in the state of Qatar. Extracellular vesicles (EVs), which are small membrane vesicles with pro-thrombotic properties, may contribute to the high risk of stroke in this population. Thus, total and cell-specific medium size EVs were counted by flow cytometry in platelet-free plasma from healthy volunteers and patients with transient ischemic attacks (TIA) and acute ischemic stroke (AIS) from SE and ME. Acutely, within 48 h of attacks, there was an increase in total endothelial EVs in TIA (6.73 ± 1.77; = 0.0156; = 21) and AIS (11.23 ± 1.95; = 0.0007; = 66) patients compared to controls (2.04 ± 0.78; = 24). Similar increases were also evident in EVs originating from platelets, erythrocytes, granulocytes, and leukocytes. Compared to controls, there was also an increase in EVs derived from activated endothelial cells, platelets, granulocytes, leukocytes, and pro-coagulant EVs (Annexin V) at 5 and 30-days following the acute events, while a decrease was observed in erythrocyte-derived EVs. This is the first study characterizing EVs in TIA and AIS patients from ME and SE showing an increase in EVs associated with endothelial and platelet cell activation, which may contribute to the elevated risk of stroke at a younger age in this population.Qatar University high collaborative grant (QUCG-CPH-2018\2019-2

Klippel-Trénaunay Syndrome with Intracranial Arteriovenous Malformation: A Rare Presentation

Klippel-Trénaunay syndrome (KTS) is a rare vascular congenital anomaly affecting less than 200,000 people in the United States. Vascular malformations associated with KTS tend to affect slow flow systems: venous, capillary, and lymphatic systems. The nature of the syndrome leads to a higher risk for the development of arteriovenous malformations. Our case presentation describes a patient with KTS and an associated rare presentation of intraventricular arteriovenous malformation (AVM)

An efficient algorithm to calculate intrinsic thermoelectric parameters based on Landauer approach

The Landauer approach provides a conceptually simple way to calculate the intrinsic thermoelectric (TE) parameters of materials from the ballistic to the diffusive transport regime. This method relies on the calculation of the number of propagating modes and the scattering rate for each mode. The modes are calculated from the energy dispersion (E(k)) of the materials which require heavy computation and often supply energy relation on sparse momentum (k) grids. Here an efficient method to calculate the distribution of modes (DOM) from a given E(k) relationship is presented. The main features of this algorithm are, (i) its ability to work on sparse dispersion data, and (ii) creation of an energy grid for the DOM that is almost independent of the dispersion data therefore allowing for efficient and fast calculation of TE parameters. The inclusion of scattering effects is also straight forward. The effect of k-grid sparsity on the compute time for DOM and on the sensitivity of the calculated TE results are provided. The algorithm calculates the TE parameters within 5% accuracy when the K-grid sparsity is increased up to 60% for all the dimensions (3D, 2D and 1D). The time taken for the DOM calculation is strongly influenced by the transverse K density (K perpendicular to transport direction) but is almost independent of the transport K density (along the transport direction). The DOM and TE results from the algorithm are bench-marked with, (i) analytical calculations for parabolic bands, and (ii) realistic electronic and phonon results for $Bi_{2}Te_{3}$.Comment: 16 Figures, 3 Tables, submitted to Journal of Computational electronic

Epidemiological profile of the Ebola virus disease outbreak in Nigeria, July-September 2014

Introduction: In July 2014, Nigeria experienced an outbreak of Ebola virus disease following the introduction of the disease by an ill Liberian Traveler. The Government of Nigeria with the support of Technical and Development Partners responded quickly and effectively to contain the outbreak. The epidemiological profile of the outbreak that majorly affected two States in the country in terms of person, place and time characteristics of the cases identified is hereby described. Methods: Using field  investigation technique, all confirmed and probable cases were identified, line-listed and analysed using Microsoft Excel 2007 by persons, time and place. Results: A total of 20 confirmed and probable cases; 16 in Lagos (including the index case from Liberia) and 4 in Port Harcourt were  identified. The mean age was 39.5 ± 12.4 years with over 40% within the age group 30-39 years. The most frequent exposure type was direct physical contact in 70% of all cases and 73% among health care workers. The total case-fatality was 40%; higher among healthcare workers (46%) compared with non-healthcare workers (22%). The epidemic curve initially shows a typical common source outbreak, followed by a propagated pattern. Conclusion: Investigation revealed the size and spread of the outbreak and provided information on the characteristics of persons, time and place. Enhanced surveillance measures, including contact tracing and follow-up proved very useful in early case detection and containment of the outbreak

Characteristics of Recurrent Ischemic Stroke after Embolic Stroke of Undetermined Source: Secondary Analysis of a Randomized Clinical Trial

Importance: The concept of embolic stroke of undetermined source (ESUS) unifies a subgroup of cryptogenic strokes based on neuroimaging, a defined minimum set of diagnostic tests, and exclusion of certain causes. Despite an annual stroke recurrence rate of 5%, little is known about the etiology underlying recurrent stroke after ESUS. Objective: To identify the stroke subtype of recurrent ischemic strokes after ESUS, to explore the interaction with treatment assignment in each category, and to examine the consistency of cerebral location of qualifying ESUS and recurrent ischemic stroke. Design, Setting, and Participants: The NAVIGATE-ESUS trial was a randomized clinical trial conducted from December 23, 2014, to October 5, 2017. The trial compared the efficacy and safety of rivaroxaban and aspirin in patients with recent ESUS (n = 7213). Ischemic stroke was validated in 309 of the 7213 patients by adjudicators blinded to treatment assignment and classified by local investigators into the categories ESUS or non-ESUS (ie, cardioembolic, atherosclerotic, lacunar, other determined cause, or insufficient testing). Five patients with recurrent strokes that could not be defined as ischemic or hemorrhagic in absence of neuroimaging or autopsy were excluded. Data for this secondary post hoc analysis were analyzed from March to June 2019. Interventions: Patients were randomly assigned to receive rivaroxaban, 15 mg/d, or aspirin, 100 mg/d. Main Outcomes and Measures: Association of recurrent ESUS with stroke characteristics. Results: A total of 309 patients (205 men [66%]; mean [SD] age, 68 [10] years) had ischemic stroke identified during the median follow-up of 11 (interquartile range [IQR], 12) months (annualized rate, 4.6%). Diagnostic testing was insufficient for etiological classification in 39 patients (13%). Of 270 classifiable ischemic strokes, 156 (58%) were ESUS and 114 (42%) were non-ESUS (37 [32%] cardioembolic, 26 [23%] atherosclerotic, 35 [31%] lacunar, and 16 [14%] other determined cause). Atrial fibrillation was found in 27 patients (9%) with recurrent ischemic stroke and was associated with higher morbidity (median change in modified Rankin scale score 2 [IQR, 3] vs 0 (IQR, 1]) and mortality (15% vs 1%) than other causes. Risk of recurrence did not differ significantly by subtype between treatment groups. For both the qualifying and recurrent strokes, location of infarct was more often in the left (46% and 54%, respectively) than right hemisphere (40% and 37%, respectively) or brainstem or cerebellum (14% and 9%, respectively). Conclusions and Relevance: In this secondary analysis of randomized clinical trial data, most recurrent strokes after ESUS were embolic and of undetermined source. Recurrences associated with atrial fibrillation were a minority but were more often disabling and fatal. More extensive investigation to identify the embolic source is important toward an effective antithrombotic strategy. Trial Registration: ClinicalTrials.gov Identifier: NCT02313909

Evaluation of health workforce competence in maternal and neonatal issues in public health sector of Pakistan: an Assessment of their training needs

<p>Abstract</p> <p>Background</p> <p>More than 450 newborns die every hour worldwide, before they reach the age of four weeks (neonatal period) and over 500,000 women die from complications related to childbirth. The major direct causes of neonatal death are infections (36%), Prematurity (28%) and Asphyxia (23%). Pakistan has one of the highest perinatal and neonatal mortality rates in the region and contributes significantly to global neonatal mortality. The high mortality rates are partially attributable to scarcity of trained skilled birth attendants and paucity of resources. Empowerment of health care providers with adequate knowledge and skills can serve as instrument of change.</p> <p>Methods</p> <p>We carried out training needs assessment analysis in the public health sector of Pakistan to recognize gaps in the processes and quality of MNCH care provided. An assessment of Knowledge, Attitude, and Practices of Health Care Providers on key aspects was evaluated through a standardized pragmatic approach. Meticulously designed tools were tested on three tiers of health care personnel providing MNCH in the community and across the public health care system. The Lady Health Workers (LHWs) form the first tier of trained cadre that provides MNCH at primary care level (BHU) and in the community. The Lady Health Visitor (LHVs), Nurses, midwives) cadre follow next and provide facility based MNCH care at secondary and tertiary level (RHCs, Taluka/Tehsil, and DHQ Hospitals). The physician/doctor is the specialized cadre that forms the third tier of health care providers positioned in secondary and tertiary care hospitals (Taluka/Tehsil and DHQ Hospitals). The evaluation tools were designed to provide quantitative estimates across various domains of knowledge and skills. A priori thresholds were established for performance rating.</p> <p>Results</p> <p>The performance of LHWs in knowledge of MNCH was good with 30% scoring more than 70%. The Medical officers (MOs), in comparison, performed poorly in their knowledge of MNCH with only 6% scoring more than 70%. All three cadres of health care providers performed poorly in the resuscitation skill and only 50% were able to demonstrate steps of immediate newborn care. The MOs performed far better in counselling skills compare to the LHWs. Only 50 per cent of LHWs could secure competency scale in this critical component of skills assessment.</p> <p>Conclusions</p> <p>All three cadres of health care providers performed well below competency levels for MNCH knowledge and skills. Standardized training and counselling modules, tailored to the needs and resources at district level need to be developed and implemented. This evaluation highlighted the need for periodic assessment of health worker training and skills to address gaps and develop targeted continuing education modules. To achieve MDG4 and 5 goals, it is imperative that such deficiencies are identified and addressed.</p

Health workforce and governance: the crisis in Nigeria

Background In Nigeria, several challenges have been reported within the health sector, especially in training, funding, employment, and deployment of the health workforce. We aimed to review recent health workforce crises in the Nigerian health sector to identify key underlying causes and provide recommendations toward preventing and/or managing potential future crises in Nigeria. Methods We conducted a scoping literature search of PubMed to identify studies on health workforce and health governance in Nigeria. A critical analysis, with extended commentary, on recent health workforce crises (2010–2016) and the health system in Nigeria was conducted. Results The Nigerian health system is relatively weak, and there is yet a coordinated response across the country. A number of health workforce crises have been reported in recent times due to several months’ salaries owed, poor welfare, lack of appropriate health facilities and emerging factions among health workers. Poor administration and response across different levels of government have played contributory roles to further internal crises among health workers, with different factions engaged in protracted supremacy challenge. These crises have consequently prevented optimal healthcare delivery to the Nigerian population. Conclusions An encompassing stakeholders’ forum in the Nigerian health sector remain essential. The national health system needs a solid administrative policy foundation that allows coordination of priorities and partnerships in the health workforce and among various stakeholders. It is hoped that this paper may prompt relevant reforms in health workforce and governance in Nigeria toward better health service delivery in the country