One-year risk of stroke after transient ischemic attack or minor stroke in Hunter New England, Australia (INSIST study)

Background: One-year risk of stroke in transient ischemic attack and minor stroke (TIAMS) managed in secondary care settings has been reported as 5-8%. However, evidence for the outcomes of TIAMS in community care settings is limited. Methods: The INternational comparison of Systems of care and patient outcomes In minor Stroke and TIA (INSIST) study was a prospective inception cohort community-based study of patients of 16 general practices in the Hunter–Manning region (New South Wales, Australia). Possible-TIAMS patients were recruited from 2012 to 2016 and followed-up for 12 months post-index event. Adjudication as TIAMS or TIAMS-mimics was by an expert panel. We established 7-day, 90-day, and one-year risk of stroke, TIA, myocardial infarction (MI), coronary or carotid revascularization procedure and death; and medications use at 24 hours post-event. Results: Of 613 participants (mean age; 70 ± 12 years), 298 (49%) were adjudicated as TIAMS. TIAMS-group participants had ischemic strokes at 7-days, 90-days, and one-year, at Kaplan-Meier (KM) rates of 1% (95% confidence interval; 0.3, 3.1), 2.1% (0.9, 4.6), and 3.2% (1.7, 6.1), respectively, compared to 0.3%, 0.3% and 0.6% of TIAMS-mimic-group participants. At one year, TIAMS-group-participants had twenty-five TIA events (KM rate: 8.8%), two MI events (0.6%), four coronary revascularization (1.5%), eleven carotid revascularization (3.9%) and three death (1.1%), compared to 1.6%, 0.6%, 1.0%, 0.3% and 0.6% of TIAMS-mimic-group participants. Of 167 TIAMS-group participants who commenced or received enhanced therapies, 95 (57%) were treated within 24 hours post-index event. For TIAMS-group participants who commenced or received enhanced therapies, time from symptom onset to treatment was median 9.5 hours [IQR 1.8-89.9]). Conclusion: One-year risk of stroke in TIAMS participants was lower than reported in previous studies. Early implementation of antiplatelet/anticoagulant therapies may have contributed to the low stroke recurrence

Human-centered Approach for Proper Functioning of LEED Criteria; A Case Study in Tehran

Buildings are rated in five main categories according to the LEED standard to receive an environment-friendly design certificate. Sustainability, water efficiency, material properties, energy consumption, and the quality of indoor spaces are main criteria which confirm the proper function of a building in terms of optimal energy consumption. However, the role of residents and behavioral aspects in the consumption of energy and the decent application of energy standards are neglected. It is beyond doubt that the residents’ behavior is one of the most important factors in performance-based building design. Moreover, the individual mistakes, which most of the times cause energy dissipation, cannot be ignored. This research proposes "Integrated Interactive System" as a human-centered approach with the aim of minimizing energy consumption. A survey is conducted, and this system is evaluated as a case study in Tehran

Impact of team-based learning on nursing students\' knowledge of cardiovascular system examination

Background & Objective: The use of team-based learning (TBL) as one of the active learning strategies in the education of nursing students is expanding. The purpose of this study was to investigate the effect of employing the TBL method on improving the knowledge of the cardiovascular system in nursing students. Materials & Methods: This semi-experimental study was conducted on nursing students of Hormozgan University of Medical Sciences, Hormozgan, Iran, in 2017. The students were divided into intervention (TBL method) and comparison (traditional lecture method) groups. The intervention group was taught by the TBL method, while the control group received teaching by the lecture method during three 2-hour sessions. Pre-test and post-test were administered to all students. The data were analyzed using SPSS23 software and the significance level was considered ≤ 0.05. Results: The results showed a significant difference among the students in the intervention group, whose mean score of knowledge increased from 12.45±5.22 before the test to 32.26±4.25 after the test (P<0.001). Moreover, the comparison of the post-test mean scores in the intervention (32.26±4.25) and control (17.33±4.05) indicated a significant difference between the two groups (P<0.03). Conclusion: The adoption of novel educational methods, such as TBL, in the education of nursing students can improve their knowledge

The influence of anterior cerebral artery flow diversion measured by transcranial Doppler on acute infarct volume and clinical outcome in anterior circulation stroke

Introduction: Anterior cerebral artery flow diversion, measured by transcranial Doppler ultrasound, is correlated with leptomeningeal collateral flow on digital subtraction angiography in the setting of middle cerebral artery occlusion. We aimed to assess the influence of flow diversion as a marker of leptomeningeal collateralization on infarct size and penumbral volume. Methods: We assessed consecutive patients presenting within six-hours of ischaemic stroke. Anterior cerebral artery flow diversion, defined as ipsilateral mean velocity of at least 30% greater than the contralateral artery, was used as the Doppler index of leptomeningeal collateralization. Multivariable regression analysis was performed to assess the impact of anterior cerebral artery flow diversion, controlling for other important clinical variables. Leptomeningeal collateralization was also graded on computed tomography angiography. Infarct core and penumbral volumes were defined using computed tomography perfusion thresholds of cerebral blood volume and mean transit time. Infarct volume, reperfusion, and vessel status were measured at 24 h using magnetic resonance techniques. Results: Fifty-three patients qualified for analysis. Anterior cerebral artery flow diversion was associated with good collateral flow on computed tomography angiography (P < 0·001) and was an independent predictor of admission infarct core volume (P < 0·001), and 24 h infarct volume (P < 0·001). The likelihood of a favourable outcome (modified Rankin Score 0–2) was higher (odds ratio = 27·5, P < 0·001) in those with flow diversion. Conclusions: Anterior cerebral artery flow diversion indicates effective leptomeningeal collateralization as measured by computed tomography angiography, and independently predicts acute infarct size and 90-day clinical outcome. Flow diversion appears to provide penumbral perfusion, offering some protection against infarct expansion. Acute bedside transcranial Doppler assessment of flow diversion aids prognostication and therapeutic decision making in anterior circulation stroke

One-Year Risk of Stroke After Transient Ischemic Attack or Minor Stroke in Hunter New England, Australia (INSIST Study)

10.3389/fneur.2021.791193FRONTIERS IN NEUROLOGY12

Rural versus metropolitan comparison of processes of care in the community based management of TIA and minor stroke in Australia (an analysis from the INSIST Study)

Objectives: To compare processes of care and clinical outcomes of community-based management of TIAs and minor strokes (TIAMS) between rural and metropolitan Australia. Design: Inception cohort study between 2012 and 2016 with 12 month follow up after index event (sub-study of INSIST). Setting: Hunter and Manning valley regions of New South Wales, within the referral territory of the comprehensive stroke centre’s Acute Neurovascular Clinic (ANC). Participants: Consecutive patients of 16 participating general practices, presenting with possible TIAMS to either primary or secondary care. Main Outcome measures: Processes of care (referrals, key management processes, time-based metrics) and clinical outcomes. Results: Of 613 participants with possible TIAMS who completed the baseline interview, 298 were adjudicated as having TIAMS (119 from rural, 179 from metropolitan). Mean age was 72.3 years (SD, 10.7) and 127 (43%) were women. Rural participants were more likely to be managed solely by a general practitioner (GP) than metropolitan participants (34% v 20%) and less likely to be referred to an ANC specialist (13% v 38%) or have brain magnetic resonance imaging (MRI) [24% v 51%]. Those rural participants who were referred, also waited longer (both p<0.001). Recurrent stroke, myocardial infarction and death at 12 months were not significantly different between rural and metropolitan participants. Conclusions: Although TIAMS prognosis in rural settings where solely-GP care is common is very good, the processes of care in such areas are inferior to metropolitan. This suggests there is further scope to support rural GPs to optimise care of TIAMS patient