Long-term study of the cognitive profile of Moyamoya Disease in adults

Moyamoya Disease (MMD) is a rare cerebrovascular disorder which can have significant cognitive consequences. The aim of the current study was to describe comprehensively the domain-specific cognitive profile of adult patients with MMD and to assess whether this changes in the absence of recurrent stroke over long-term follow-up. Comprehensive neuropsychological assessment covering seven cognitive domains was conducted on 61 adult patients with MMD at baseline and then at up to 3 further time points during follow up (median=2.31, 4.87 and 7.12 years). Although 27 patients had had prior surgical revasculariation, none had surgery between neuropsychological assessments. Cognitive impairment was common. At baseline, impairment in executive functions was most frequent (57%), followed by performance IQ (36%), speed of information processing (31%) and visual memory (30%). We found that the neuropsychological profile remains broadly stable over long-term follow-up with no clear indication of improvement or significant decline. The pattern of impairment also did not differ depending on age of onset or whether there was a history of either prior stroke at presentation or revascularisation surgery at presentation

Variation in quality of acute stroke care by day and time of admission: prospective cohort study of weekday and weekend centralised hyperacute stroke unit care and non-centralised services.

OBJECTIVE: To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units compared with the rest of England. DESIGN: Prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. SETTING: Acute stroke services in London hyperacute stroke units and the rest of England. PARTICIPANTS: 68 239 patients with a primary diagnosis of stroke admitted between January and December 2014. INTERVENTIONS: Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards designed to deliver uniform access to high-quality hyperacute stroke unit care across the week. MAIN OUTCOME MEASURES: 16 indicators of quality of acute stroke care, mortality at 3 days after admission to the hospital, disability at the end of the inpatient spell, length of stay. RESULTS: There was no variation in quality of care by day and time of admission to the hospital across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor was there variation in 3-day mortality or disability at hospital discharge (all p values>0.05). Other quality of care measures significantly varied by day and time of admission across the week in London (all p values0.05). CONCLUSIONS: The London hyperacute stroke unit model achieved performance standards for 'front door' stroke care across the week. The same benefits were not achieved by other models of care in the rest of England. There was no weekend effect for mortality in London or the rest of the England. Other aspects of care were not constant across the week in London hyperacute stroke units, indicating some performance standards were perceived to be more important than others

Clinical presentation of strokes confined to the insula: a systematic review of literature

Background and purpose The insular cortex serves a wide variety of functions in humans, ranging from sensory and affective processing to high-level cognition. Hence, insular dysfunction may result in several different presentations. Ischemic strokes limited to the insular territory are rare and deserve a better characterization, to be quickly recognized and to receive the appropriate treatment (e.g. thrombolysis). Methods We reviewed studies on patients with a first-ever acute stroke restricted to the insula. We searched in the Medline database the keywords “insular stroke” and “insular infarction”, to identify previously published cases. Afterwards, the results were divided depending on the specific insular region affected by the stroke: anterior insular cortex (AIC), posterior insular cortex (PIC) or total insula cortex (TIC). Finally, a review of the clinical correlates associated with each region was performed. Results We identified 25 reports including a total of 49 patients (59.7 ± 15.5 years, 48% male) from systematic review of the literature. The most common clinical phenotypes were motor and somatosensory deficits, dysarthria, aphasia and a vestibular-like syndrome. Atypical presentations were also common and included dysphagia, awareness deficits, gustatory disturbances, dysautonomia, neuropsychiatric or auditory disturbances and headache. Conclusions The clinical presentation of insular strokes is heterogeneous; however, an insular stroke should be suspected when vestibular-like, somatosensory, speech or language disturbances are combined in the same patient. Further studies are needed to improve our understanding of more atypical presentations

Prehospital video triage of potential stroke patients in North Central London and East Kent: rapid mixed-methods service evaluation

Background In response to COVID-19, alongside other service changes, North Central London and East Kent implemented prehospital video triage: this involved stroke and ambulance clinicians communicating over FaceTime (Apple Inc., Cupertino, CA, USA) to assess suspected stroke patients while still on scene. Objective To evaluate the implementation, experience and impact of prehospital video triage in North Central London and East Kent. Design A rapid mixed-methods service evaluation (July 2020 to September 2021) using the following methods. (1) Evidence reviews: scoping review (15 reviews included) and rapid systematic review (47 papers included) on prehospital video triage for stroke, covering usability (audio-visual and signal quality); acceptability (whether or not clinicians want to use it); impact (on outcomes, safety, experience and cost-effectiveness); and factors influencing implementation. (2) Clinician views of prehospital video triage in North Central London and East Kent, covering usability, acceptability, patient safety and implementation: qualitative analysis of interviews with ambulance and stroke clinicians (n = 27), observations (n = 12) and documents (n = 23); a survey of ambulance clinicians (n = 233). (3) Impact on safety and quality: analysis of local ambulance conveyance times (n = 1400; April to September 2020). Analysis of national stroke audit data on ambulance conveyance and stroke unit delivery of clinical interventions in North Central London, East Kent and the rest of England (n = 137,650; July 2018 to December 2020). Results (1) Evidence: limited but growing, and sparse in UK settings. Prehospital video triage can be usable and acceptable, requiring clear network connection and audio-visual signal, clinician training and communication. Key knowledge gaps included impact on patient conveyance, patient outcomes and cost-effectiveness. (2) Clinician views. Usability – relied on stable Wi-Fi and audio-visual signals, and back-up processes for when signals failed. Clinicians described training as important for confidence in using prehospital video triage services, noting potential for ‘refresher’ courses and joint training events. Ambulance clinicians preferred more active training, as used in North Central London. Acceptability – most clinicians felt that prehospital video triage improved on previous processes and wanted it to continue or expand. Ambulance clinicians reported increased confidence in decisions. Stroke clinicians found doing assessments alongside their standard duties a source of pressure. Safety – clinical leaders monitored and managed potential patient safety issues; clinicians felt strongly that services were safe. Implementation – several factors enabled prehospital video triage at a system level (e.g. COVID-19) and more locally (e.g. facilitative governance, receptive clinicians). Clinical leaders reached across and beyond their organisations to engage clinicians, senior managers and the wider system. (3) Impact on safety and quality: we found no evidence of increased times from symptom onset to arrival at services or of stroke clinical interventions reducing in studied areas. We found several significant improvements relative to the rest of England (possibly resulting from other service changes). Limitations We could not interview patients and carers. Ambulance data had no historic or regional comparators. Stroke audit data were not at patient level. Several safety issues were not collected routinely. Our survey used a convenience sample. Conclusions Prehospital video triage was perceived as usable, acceptable and safe in both areas. Future research Qualitative research with patients, carers and other stakeholders and quantitative analysis of patient-level data on care delivery, outcomes and cost-effectiveness, using national controls. Focus on sustainability and roll-out of services. Study registration This study is registered as PROSPERO CRD42021254209. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 26. See the NIHR Journals Library website for further project information

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units.

OBJECTIVES: Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units (HASUs). DESIGN: Interview and observation study to explain patterns of variation in delivery and outcomes of care described in a quantitative partner paper (Melnychuk et al). SETTING: Eight HASUs in London. PARTICIPANTS: We interviewed HASU staff (n=76), including doctors, nurses, therapists and administrators. We also conducted non-participant observations of delivery of care at different times of the day and week (n=45; ~102 hours). We analysed the data for thematic content relating to the ability of staff to provide evidence-based interventions consistently at different times of the day and week. RESULTS: Staff were able to deliver 'front door' interventions consistently by taking on additional responsibilities out of hours (eg, deciding eligibility for thrombolysis); creating continuities between day and night (through, eg, governance processes and staggering rotas); building trusting relationships with, eg, Radiology and Emergency Departments and staff prioritisation of 'front door' interventions. Variations by time of day resulted from reduced staffing in HASUs and elsewhere in hospitals in the evenings and at the weekend. Variations by day of week (eg, weekend effect) resulted from lack of therapy input and difficulties repatriating patients at weekends, and associated increases in pressure on Fridays and Mondays. CONCLUSIONS: Evidence-based service standards can facilitate 7-day working in acute stroke services. Standards should ensure that the capacity and capabilities required for 'front door' interventions are available 24/7, while other services, for example, therapies are available every day of the week. The impact of standards is influenced by interdependencies between HASUs, other hospital services and social services

Prevalence, patterns, and predictors of patient-reported non-motor outcomes at 30 days after acute stroke: prospective observational hospital cohort study

Background: Adverse non-motor outcomes are common after acute stroke and likely to substantially affect quality of life, yet few studies have comprehensively assessed their prevalence, patterns, and predictors across multiple health domains.// Aims: We aim to identify the prevalence, patterns and the factors associated with non-motor outcomes 30 days after stroke.// Methods: This prospective observational hospital cohort study (Stroke Investigation in North and Central London (SIGNAL) identified patients with acute ischaemic stroke or intracerebral haemorrhage (ICH) admitted to the Hyperacute Stroke Unit (HASU) University College Hospital (UCH), London, between August 1st 2018 and August 31st 2019. We assessed non-motor outcomes (anxiety, depression, fatigue, sleep, participation in social roles and activities, pain, bowel, and bladder function) at 30-day follow-up using the Patient Reported Outcome Measurement Information System-Version 29 (PROMIS-29) scale and Barthel Index scale.// Results: We obtained follow-up data for 605/719 (84.1%) eligible patients (mean age 72.0 years; 48.3% female; 521 with ischaemic stroke, 84 with ICH). Anxiety (57.0%), fatigue (52.7%), bladder dysfunction (50.2%), reduced social participation (49.2%), and pain (47.9%) were the commonest adverse non-motor outcomes. The rates of adverse non-motor outcomes in ≥1, ≥2 and ≥3 domains were 89%, 66.3% and 45.8%, respectively; in adjusted analyses, stroke due to ICH (compared to ischaemic stroke) and admission stroke severity were the strongest and most consistent predictors. There were significant correlations between; bowel dysfunction and bladder dysfunction (κ= 0.908); reduced social participation and bladder dysfunction (κ= 0.844); and anxiety and fatigue (κ= 0.613). We did not identify correlation for other pairs of non-motor domains.// Conclusions: Adverse non-motor outcomes are very common at one month after stroke, affecting nearly 90% of evaluated patients in at least one health domain, about two-thirds in two or more domains, and almost 50% in three or more domains. Stroke due to ICH and admission stroke severity were the strongest and most consistent predictors. Adverse outcomes occur in pairs of domains such as with anxiety and fatigue.Our findings emphasise the importance of a multi-domain approach to effectively identify adverse non-motor outcomes after stroke to inform the development of more holistic patient recovery programs

Planet Hunters. VIII. Characterization of 41 Long-Period Exoplanet Candidates from Kepler Archival Data

The census of exoplanets is incomplete for orbital distances larger than 1 AU. Here, we present 41 long-period planet candidates in 38 systems identified by Planet Hunters based on Kepler archival data (Q0-Q17). Among them, 17 exhibit only one transit, 14 have two visible transits and 10 have more than three visible transits. For planet candidates with only one visible transit, we estimate their orbital periods based on transit duration and host star properties. The majority of the planet candidates in this work (75%) have orbital periods that correspond to distances of 1-3 AU from their host stars. We conduct follow-up imaging and spectroscopic observations to validate and characterize planet host stars. In total, we obtain adaptive optics images for 33 stars to search for possible blending sources. Six stars have stellar companions within 4". We obtain high-resolution spectra for 6 stars to determine their physical properties. Stellar properties for other stars are obtained from the NASA Exoplanet Archive and the Kepler Stellar Catalog by Huber et al. (2014). We validate 7 planet candidates that have planet confidence over 0.997 (3-{\sigma} level). These validated planets include 3 single-transit planets (KIC-3558849b, KIC-5951458b, and KIC-8540376c), 3 planets with double transits (KIC-8540376b, KIC-9663113b, and KIC-10525077b), and 1 planet with 4 transits (KIC-5437945b). This work provides assessment regarding the existence of planets at wide separations and the associated false positive rate for transiting observation (17%-33%). More than half of the long-period planets with at least three transits in this paper exhibit transit timing variations up to 41 hours, which suggest additional components that dynamically interact with the transiting planet candidates. The nature of these components can be determined by follow-up radial velocity and transit observations.Comment: Published on ApJ, 815, 127 Notations of validated planets are changed in accordance with naming convention of NASA Exoplanet Archiv

Integrated biorefinery approach to valorise Saccharina latissima biomass : Combined sustainable processing to produce biologically active fucoxanthin, mannitol, fucoidans and alginates

The feasibility of European seaweed farming depends on the valorisation of algal biomass harvested. In the present work we have combined sequential extraction processes from Saccharina latissima to produce a range of products, focusing on the extraction of fucoxanthin using supercritical CO2 followed by different valorisation routes. We optimised the conditions the for extraction of fucoxanthin (40 MPa, temperature has little impact on extraction) and the extracts obtained were tested on cancer cell cultures to determine the antiproliferative effects of this pigment. We established that the supercritical CO2 extracts have an antiproliferative effect similar to that of commercial fucoxanthin (concentrations 0.1–0.4 mg/mL) and showed that the active compound in the extracts is fucoxanthin. In order to integrate this process with a holistic valorisation of the algal biomass, we explored the extraction of mannitol using a microwave-assisted protocol (4.15 wt % yield). We also evaluated the potential extraction of fucoidans and alginates from the solids remaining after supercritical CO2 extraction (67.27 to 69.38 % of alginates). A life cycle analysis of the supercritical CO2 extraction proposed shows that the drying process of algal biomass and the energy used to compress the CO2 are the elements with the highest environmental impact (over 90% of CO2 eq/g of extract) in this the process, indicating routes for reducing the environmental footprint. Combining supercritical CO2 extraction and microwave-assisted extraction methods would enable European seaweed producers to obtain multiple marketable products from algal biomass