Health Services Research: A Critical Need in Stroke Care

Evidence defining high-quality stroke care has improved dramatically in the past 20 years; however, the gap between evidence and practice persists in stroke prevention, treatment, and rehabilitation.1 Although clinical trials have been instrumental in advancing the science supporting evidence- based guidelines, research is needed to identify gaps and factors contributing to gaps in care and outcomes and to develop strategies that promote uptake of evidence-based treatment and services for stroke patients. This article discusses health services research (HSR) as a multidisciplinary field encompassing outcomes research, implementation science, and financial evaluations that can address critical evidence, practice and policy gaps in stroke care

A Large, First-Year, Introductory, Multi-Sectional Biological Concepts of Health Course Designed to Develop Skills and Enhance Deeper Learning

Large first-year biology classes, with their heavy emphasis on factual content, contribute to low student engagement and misrepresent the dynamic, interdisciplinary nature of biological science. We sought to redesign a course to deliver fundamental biology curriculum through the study of health, promote skills development, and encourage a deeper level of learning for a large, multi-section first-year class. We describe the Biological Concepts of Health course designed to encourage higher-order learning and teach oral communication and independent learning skills to large numbers of first-year students. We used the Blooming Biology Tool to determine the cognitive skills level assessed in the newly developed course and the courses it replaced. This evidence-based approach demonstrated that our new course design achieved the goal of encouraging a deeper level of cognition, and further, successfully introduced both oral communication and independent learning skills in large first-year classes.  En mettant l’emphase sur un contenu factuel, les grandes classes de biologie de première année contribuent au faible engagement des élèves et donnent une représentation imprécise de la nature dynamique et interdisciplinaire des sciences de la biologie. Afin d’offrir un programme fondamental en biologie par l’étude de la santé, de promouvoir le perfectionnement des compétences et d’encourager un niveau d’apprentissage marqué, nous avons repensé un cours pour une grande classe de première année contenant plusieurs sous-groupes. Nous décrivons le cours « Biological Concepts of Health » conçu pour encourager l’apprentissage supérieur, ainsi que pour enseigner la communication orale et les habiletés d’apprentissage individualisé à un grand nombre d’étudiants de première année. Pour déterminer le niveau d’habiletés cognitives évalué dans ce cours nouvellement conçu et les cours qu’il remplace, nous avons utilisé le « Blooming Biology Tool ». Cette approche éprouvée démontre que ce nouveau cours a atteint son but d’encourager l’approfondissement des connaissances et, par ailleurs, a réussi à introduire la communication orale, de même que les habiletés d’apprentissage individualisé aux grandes classes de première année

A novel approach using potable diagnostic ultrasound to inform treatment choices for hemiplegic shoulder pain – A case study

Introduction: Hemiplegic shoulder pain (HSP) has a reported incidence of up to 84% of patients. The purpose of this case study is to report findings from a patient with HSP who received problem specific treatment and underwent real-time scanning of shoulder region with a portable diagnostic ultrasound. Treatment was modified to address the problems. Methods/Case Description:The patient was a 45 year-old woman with right sided-hemiparesis resulting from a clot. Patient was undergoing rehabilitation in a private clinic and reported shoulder pain. Patient was undergoing rehabilitation (over-arm exercises, electrical stimulation, stretches, Saebo exercises) however, continued to complain of shoulder pain (VAS-7). Ultrasound scanning was undertaken and following observations were made on both affected (AF) and unaffected (UAF) shoulders. Acromion-greater tuberosity (AGT) distance (AF-3.35 cm, UAF-2.04 cm), diameter of supraspinatus in resting state (AF -1.16 cm, UAF-1.42cm) and contracted state (AF-1.14cm, UAF-1.63cm). Modified treatment included: 1) Isometric exercises to supraspinatus muscle 2) Trigger point release for trapezius 3) Electrical stimulation to lateral deltoid and supraspinatus 4) avoid over-arm activitiesResults: Ultrasound measurement suggested reduction in AGT immediately following treatment. 8 weeks later, VAS score was 3 and patient reported using her arm more for various functional tasks. Diameter of supraspinatus in resting state (AF -1.30 cm, UAF-1.45cm) and contracted state (AF-1.42cm, UAF-1.70cm) suggested some improvement.Conclusions: Real-time ultrasound has potential benefits as an assessment tool to inform treatment choices for HSP. Further studies are required in this area

CYP450 phenotyping and metabolite identification of quinine by accurate mass UPLC-MS analysis: a possible metabolic link to blackwater fever

BACKGROUND: The naturally occurring alkaloid drug, quinine is commonly used for the treatment of severe malaria. Despite centuries of use, its metabolism is still not fully understood, and may play a role in the haemolytic disorders associated with the drug. METHODS: Incubations of quinine with CYPs 1A2, 2C9, 2C19, 2D6, and 3A4 were conducted, and the metabolites were characterized by accurate mass UPLC-MS(E) analysis. Reactive oxygen species generation was also measured in human erythrocytes incubated in the presence of quinine with and without microsomes. RESULTS: The metabolites 3-hydroxyquinine, 2’-oxoquininone, and O-desmethylquinine were observed after incubation with CYPs 3A4 (3-hydroxyquinine and 2’-oxoquininone) and 2D6 (O-desmethylquinine). In addition, multiple hydroxylations were observed both on the quinoline core and the quinuclidine ring system. Of the five primary abundance CYPs tested, 3A4, 2D6, 2C9, and 2C19 all demonstrated activity toward quinine, while 1A2 did not. Further, quinine produced robust dose-dependent oxidative stress in human erythrocytes in the presence of microsomes. CONCLUSIONS: Taken in context, these data suggest a CYP-mediated link between quinine metabolism and the poorly understood haemolytic condition known as blackwater fever, often associated with quinine ingestion

Risks and Benefits Associated With Prestroke Antiplatelet Therapy Among Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator

IMPORTANCE: Intravenous tissue plasminogen activator (tPA) is known to improve outcomes in ischemic stroke; however, many patients may have been receiving antiplatelet therapy before acute ischemic stroke and could face an increased risk for bleeding when treated with tPA. OBJECTIVE: To assess the risks and benefits associated with prestroke antiplatelet therapy among patients with ischemic stroke who receive intravenous tPA. DESIGN, SETTING, AND PARTICIPANTS: This observational study used data from the American Heart Association and American Stroke Association Get With the Guidelines-Stroke registry, which included 85 072 adult patients with ischemic stroke who received intravenous tPA in 1545 registry hospitals from January 1, 2009, through March 31, 2015. Data were analyzed during the same period. EXPOSURES: Prestroke antiplatelet therapy before tPA administration for acute ischemic stroke. MAIN OUTCOMES AND MEASURES: Symptomatic intracranial hemorrhage (sICH), in-hospital mortality, discharge ambulatory status, and modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]). RESULTS: Of the 85 072 registry patients, 38 844 (45.7%) were receiving antiplatelet therapy before admission; 46 228 patients (54.3%) were not. Patients receiving antiplatelet therapy were older (median [25th-75th percentile] age, 76 [65-84] vs 68 [56-80] years) and had a higher prevalence of cardiovascular risk factors. The unadjusted rate of sICH was higher in patients receiving antiplatelet therapy (5.0% vs 3.7%). After risk adjustment, prior use of antiplatelet agents remained associated with higher odds of sICH compared with no use (adjusted odds ratio [AOR], 1.18 [95% CI, 1.10-1.28]; absolute difference, +0.68% [95% CI, 0.36%-1.01%]; number needed to harm [NNH], 147). Among patients enrolled on October 1, 2012, or later, the highest odds (95% CIs) of sICH were found in 15 116 patients receiving aspirin alone (AOR, 1.19 [1.06- 1.34]; absolute difference [95% CI], +0.68% [0.21%-1.20%]; NNH, 147) and 2397 patients receiving dual antiplatelet treatment of aspirin and clopidogrel (AOR, 1.47 [1.16-1.86]; absolute difference, +1.67% [0.58%-3.00%]; NNH, 60). The risk for in-hospital mortality was similar between those who were and were not receiving antiplatelet therapy after adjustment (8.0% vs 6.6%; AOR, 1.00 [0.94-1.06]; nonsignificant absolute difference, -0.01% [-0.37% to 0.36%]). However, patients receiving antiplatelet therapy had a greater risk-adjusted likelihood of independent ambulation (42.1% vs 46.6%; AOR, 1.13 [1.08-1.17]; absolute difference, +2.23% [1.55%-2.92%]; number needed to treat, 43) and better functional outcomes (modified Rankin Scale score, 0-1) at discharge (24.1% vs 27.8%; AOR, 1.14; 1.07-1.22; absolute difference, +1.99% [0.78%-3.22%]; number needed to treat, 50). CONCLUSIONS AND RELEVANCE: Among patients with an acute ischemic stroke treated with intravenous tPA, those receiving antiplatelet therapy before the stroke had a higher risk for sICH but better functional outcomes than those who were not receiving antiplatelet therapy

Interaction Between Marginal Zinc and High Fat Supply on Lipid Metabolism and Growth of Weanling Rats

The impact of a moderate Zn deficiency on growth and plasma and liver lipids was investigated in two 4-week experiments with male weanling rats fed fat-enriched diets. Semisynthetic, approximately isocaloric diets containing 3% soybean oil were supplemented with either 7 or 100 mg Zn/kg diet and with 22% beef tallow (BT) or sunflower oil (SF). In Experiment 1, which compared the dietary fat level and the fat source in a factorial design of treatments, all diets were fed ad libitum to 6 × 8 animals, whereas intake of the high-Zn BT and SF diets was restricted in Experiment 2 (5 × 6 rats) to the level of intake of the respective low-Zn diets. The low-Zn SF diet consistently depressed food intake and final live weights of the animals to a greater extent than the other low-Zn diets, while intake and growth were comparable among the animals fed the high-Zn diets. The marginal Zn deficit per se did not alter plasma triglyceride and cholesterol concentrations nor hepatic concentrations of triglyceride, cholesterol and phospholipids. The fatty acid pattern of liver phospholipids did not indicate that chain elongation and desaturation of fatty acids was impaired by a lack of zinc. It was concluded that dietary energy and fat intake, and fat source have a greater effect on plasma and liver lipids than a moderate Zn deficiency. Marginally Zn-deficient diets enriched with sunflower oil as a major energy source cause a greater growth retardation than diets rich in carbohydrates or beef tallow

Expanding access to rehabilitation using mobile health to address musculoskeletal pain and disability

Introduction Musculoskeletal (MSK) disorders such as low back pain and osteoarthritis are a leading cause of disability and the leading contributor to the need for rehabilitation services globally. This need has surpassed the availability of trained clinicians; even in urban areas where services and providers are thought to be more abundant, access can be challenged by transportation options and financial costs associated with travel, care and lost time from work. However, continuing standard of fully in-person rehabilitation care for MSK-associated pain and disability may no longer be necessary. With increased ownership or access to even a basic mobile phone device, and evidence for remote management by trained clinicians, some individuals with MSK disorders may be able to continue their rehabilitation regimen predominantly from home after initial evaluation in primary care or an outpatient clinic. Methods This manuscript describes application of a framework we used to culturally and contextually adapt an evidence-based approach for leveraging digital health technology using a mobile phone (mHealth) to expand access to rehabilitation services for MSK-associated pain and disability. We then conducted a multi-level analysis of policies related to the adapted approach for rehabilitation service delivery to identify opportunities to support sustainability. Results Our study was conducted in Tanzania, a lower-middle income country with their first National Rehabilitation Strategic Plan released in 2021. Lessons learned can be applied even to countries with greater infrastructure or fewer barriers. The seven-step adaptation framework used can be applied in other regions to improve the likelihood of local mHealth adoption and implementation. Our practice and policy assessment for Tanzania can be applied in other regions and used collaboratively with government officials in support of building or implementing a national rehabilitation strategic plan. Conclusion The work described, lessons learned and components of the plan are generalizable globally and can improve access to rehabilitation services using mHealth to address the significant and increasing burden of disability

The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial

Background: Patients discharged home after stroke face significant challenges managing residual neurological deficits, secondary prevention, and pre-existing chronic conditions. Post-discharge care is often fragmented leading to increased healthcare costs, readmissions, and sub-optimal utilization of rehabilitation and community services. The COMprehensive Post-Acute Stroke Services (COMPASS) Study is an ongoing cluster-randomized pragmatic trial to assess the effectiveness of a comprehensive, evidence-based, post-acute care model on patient-centered outcomes. Methods: Forty-one hospitals in North Carolina were randomized (as 40 units) to either implement the COMPASS care model or continue their usual care. The recruitment goal is 6000 patients (3000 per arm). Hospital staff ascertain and enroll patients discharged home with a clinical diagnosis of stroke or transient ischemic attack. Patients discharged from intervention hospitals receive 2-day telephone follow-up; a comprehensive clinic visit within 2 weeks that includes a neurological evaluation, assessments of social and functional determinants of health, and an individualized COMPASS Care PlanTM integrated with a community-specific resource database; and additional follow-up calls at 30 and 60 days post-stroke discharge. This model is consistent with the Centers for Medicare and Medicaid Services transitional care management services provided by physicians or advanced practice providers with support from a nurse to conduct patient assessments and coordinate follow-up services. Patients discharged from usual care hospitals represent the control group and receive the standard of care in place at that hospital. Patient-centered outcomes are collected from telephone surveys administered at 90 days. The primary endpoint is patient-reported functional status as measured by the Stroke Impact Scale 16. Secondary outcomes are: caregiver strain, all-cause readmissions, mortality, healthcare utilization, and medication adherence. The study engages patients, caregivers, and other stakeholders (including policymakers, advocacy groups, payers, and local community coalitions) to advise and support the design, implementation, and sustainability of the COMPASS care model. Discussion: Given the high societal and economic burden of stroke, identifying a care model to improve recovery, independence, and quality of life is critical for stroke survivors and their caregivers. The pragmatic trial design provides a real-world assessment of the COMPASS care model effectiveness and will facilitate rapid implementation into clinical practice if successful

A visual processing advantage for young-adolescent deaf observers: Evidence from face and object matching tasks

It is unresolved whether the permanent auditory deprivation that deaf people experience leads to the enhanced visual processing of faces. The current study explored this question with a matching task in which observers searched for a target face among a concurrent lineup of ten faces. This was compared with a control task in which the same stimuli were presented upside down, to disrupt typical face processing, and an object matching task. A sample of young-adolescent deaf observers performed with higher accuracy than hearing controls across all of these tasks. These results clarify previous findings and provide evidence for a general visual processing advantage in deaf observers rather than a face-specific effect

Longitudinal analysis of physical function in older adults: the effects of physical inactivity and exercise training

Lack of exercise contributes to systemic inflammation and is a major cause of chronic disease. The long-term impact of initiating and sustaining exercise in late life, as opposed to sustaining a sedentary lifestyle, on whole-body health measures such as physical performance is not well known. This is an exploratory study to compare changes in physical performance among older adults initiating exercise late in life versus inactive older adults. Data from two observational cohorts were included in this analysis, representing two activity groups. The Active group cohort comprises older adults (n = 318; age 72.5 ± 7.2 years) enrolled in a supervised exercise program, “Gerofit.” The inactive group comprises older adults (n = 146; age 74.5 ± 5.5 years) from the Italian study “Act on Ageing” (AOA) who self-reported being inactive. Participants in both groups completed physical performance battery at baseline and 1-year including: 6-min walk test, 30-s chair stand, and timed up-and-go. Two-sample t-tests measured differences between Gerofit and AOA at baseline and 1-year across all measures. Significant between-group effects were seen for all performance measures (ps = 0.001). The AOA group declined across all measures from baseline to 1 year (range −18% to −24% change). The Gerofit group experienced significant gains in function for all measures (range +10% to +31% change). Older adults who initiated routine, sustained exercise were protected from age-related declines in physical performance, while those who remained sedentary suffered cumulative deficits across strength, aerobic endurance, and mobility. Interventions to reduce sedentary behaviors and increase physical activity are both important to promote multi-system, whole-body health