Informed Consent: The Rate-Limiting Step in Acute Stroke Trials

Successful implementation of a randomized clinical trial (RCT) for neuro-vascular emergencies such as cerebral infarction, intracerebral hemorrhage, or subarachnoid hemorrhage is extraordinarily challenging. Besides establishing an accurate, hyper-expedited diagnosis among many mimics in a person with acute neurological deficits, informed consent must be obtained from this vulnerable group of patients who may be unable to convey their own wishes, grasp the gravity of their situation, or give a complete history or examination. We review the influences, barriers, and factors investigators encounter when providing established and putative stroke therapies, and focus on informed consent, the most important research protector of human subjects, as the rate-limiting step for enrollment into acute stroke RCTs. The informed consent process has received relatively little attention in the stroke literature, but is especially important for stroke victims with acute cognitive, aural, lingual, motor, or visual impairments. Consent by a surrogate may not accurately reflect the patient’s wishes. Further, confusion about trial methodology, negative opinions of placebo-controlled studies, and therapeutic misconception by patients or surrogates may impede trial enrollment and requires further study. Exception from informed consent offers an opportunity that is rarely if ever utilized for stroke RCTs. Ultimately, advancing the knowledge base and treatment paradigms for acute stroke is essential but autonomy, beneficence (non-malfeasance), and justice must also be carefully interwoven into any well-designed RCT

Restricted Diffusion of Pus in the Subarachnoid Space: MRSA Meningo-Vasculitis and Progressive Brainstem Ischemic Strokes – A Case Report

Extra-axial restriction on diffusion weighted imaging (DWI) is an unusual finding on brain magnetic resonance imaging (MRI). Intra-axial restriction on DWI, however, is common, and can represent brain parenchymal infarction, tumor, abscess, or toxic-metabolic process. The infrequency of extra-axial DWI restriction and the paucity of clinico-pathological correlation in the literature limit its differential diagnosis. Scant case reports suggest that extra-axial DWI restriction could be a lymphoma, neurenteric cyst, or, in one patient, subdural empyema [1,2,3]. We postulate that pus formation must be excluded first, because it can provoke an aggressive meningo-vasculitis with rapidly fatal, intra-axial infarctions. Our patient was a 45-year-old man, presenting to our hospital with left facial droop and right (contralateral) arm and leg weakness. Initial MRI revealed DWI restriction in the left lateral pons, consistent with a classic Millard-Gubler stroke. Also noted was a subtle, extra-axial area of curvilinear diffusion restriction in the left cerebellar-pontine angle's subarachnoid space. Days later, the patient had a headache, and repeat MRI revealed extension of the two DWI lesions – both the intra-axial pontine infarction and the extra-axial area of restricted diffusion in the subarachnoid space. The patient became comatose, a third MRI revealed more extensive DWI restrictions, and he expired despite aggressive care. Autopsy revealed massive brainstem infarcts, a thick lymphoplasmacytic infiltrate, copious Gram-Positive cocci (likely MRSA) and arteries partially occluded with fibrointimal proliferation. This emphasizes the concept that extra-axial DWI restriction can represent pus development in the subarachnoid space – a radiographic marker to identify a patient at risk for demise due to septic, meningo-vasculitic infarctions

Medial Temporal Lobe Volume Predicts Elders’ Everyday Memory

Deficits in memory for everyday activities are common complaints among healthy and demented older adults. The medial temporal lobes and dorsolateral prefrontal cortex are both affected by aging and early-stage Alzheimer’s disease, and are known to influence performance on laboratory memory tasks. We investigated whether the volume of these structures predicts everyday memory. Cognitively healthy older adults and older adults with mild Alzheimer’s-type dementia watched movies of everyday activities and completed memory tests on the activities. Structural MRI was used to measure brain volume. Medial temporal but not prefrontal volume strongly predicted subsequent memory. Everyday memory depends on segmenting activity into discrete events during perception, and medial temporal volume partially accounted for the relationship between performance on the memory tests and performance on an event-segmentation task. The everyday-memory measures used in this study involve retrieval of episodic and semantic information as well as working memory updating. Thus, the current findings suggest that during perception, the medial temporal lobes support the construction of event representations that determine subsequent memory

Building partnerships towards strengthening Makerere University College of Health Sciences: a stakeholder and sustainability analysis

<p>Abstract</p> <p>Background</p> <p>Partnerships and networking are important for an institution of higher learning like Makerere University College of Health Sciences (MakCHS) to be competitive and sustainable.</p> <p>Methods</p> <p>A stakeholder and sustainability analysis of 25 key informant interviews was conducted among past, current and potential stakeholders of MakCHS to obtain their perspectives and contributions to sustainability of the College in its role to improve health outcomes.</p> <p>Results</p> <p>The College has multiple internal and external stakeholders. Stakeholders from Uganda wanted the College to use its enormous academic capacity to fulfil its vision, take initiative, and be innovative in conducting more research and training relevant to the country’s health needs. Many stakeholders felt that the initiative for collaboration currently came more from the stakeholders than the College. External stakeholders felt that MakCHS was insufficiently marketing itself and not directly engaging the private sector or Parliament. Stakeholders also identified the opportunity for MakCHS to embrace information technology in research, learning and training, and many also wanted MakCHS to start leadership and management training programmes in health systems. The need for MakCHS to be more vigorous in training to enhance professionalism and ethical conduct was also identified.</p> <p>Discussion</p> <p>As a constituent of a public university, MakCHS has relied on public funding, which has been inadequate to fulfill its mission. Broader networking, marketing to mobilize resources, and providing strong leadership and management support to inspire confidence among its current and potential stakeholders will be essential to MakCHS’ further growth. MakCHS’ relevance is hinged on generating research knowledge for solving the country’s contemporary health problems and starting relevant programs and embracing technologies. It should share new knowledge widely through publications and other forms of dissemination. Whether institutional leadership is best in the hands of academicians or professional managers is a debatable matter.</p> <p>Conclusions</p> <p>This study points towards the need for MakCHS and other African public universities to build a broad network of partnerships to strengthen their operations, relevance, and sustainability. Conducting stakeholder and sustainability analyses are instructive toward this end, and have provided information and perspectives on how to make long-range informed choices for success.</p

Validation of a Dynamic Measure of Current Cognitive Reserve in a Longitudinally Assessed Sample of Healthy Older Adults.

Cognitive reserve (CR) is a theoretical construct describing the underlying cognitive capacity of an individual that confers differential levels of resistance to, and recovery from, brain injuries of various types. To date, estimates of an individual's level of CR have been based on single proxy measures that are retrospective and static in nature. To develop a measure of dynamic change in CR across a lifetime, we previously identified a latent factor, derived from an exploratory factor analysis of a large sample of healthy older adults, as current CR (cCR). In the present study, we examined the longitudinal results of a sample of 272 older adults enrolled in the Tasmanian Healthy Brain Project. Using results from 12-month and 24-month reassessments, we examined the longitudinal validity of the cCR factor using confirmatory factor analyses. The results of these analyses indicate that the cCR factor structure is longitudinally stable. These results, in conjunction with recent results from our group demonstrating dynamic increases in cCR over time in older adults undertaking further education, lend weight to this cCR measure being a valid estimate of dynamic change in CR over time

Structural Transitions and Global Minima of Sodium Chloride Clusters

In recent experiments on sodium chloride clusters structural transitions between nanocrystals with different cuboidal shapes were detected. Here we determine reaction pathways between the low energy isomers of one of these clusters, (NaCl)35Cl-. The key process in these structural transitions is a highly cooperative rearrangement in which two parts of the nanocrystal slip past one another on a {110} plane in a direction. In this way the nanocrystals can plastically deform, in contrast to the brittle behaviour of bulk sodium chloride crystals at the same temperatures; the nanocrystals have mechanical properties which are a unique feature of their finite size. We also report and compare the global potential energy minima for (NaCl)NCl- using two empirical potentials, and comment on the effect of polarization.Comment: extended version, 13 pages, 8 figures, revte

Social Value of Marine and Coastal Protected Areas in England and Wales.

The U.K. government is committed to establishing a coherent network of marine protected areas by 2012 and the recentMarine and Coastal Access Act, 2009 will designate marine conservation zones and provide wider access rights to the coast. To fulfill these goals, this article argues the need for a clearer, shared understanding of the social value of protected areas in creating new designations and managing existing ones. Although marine and coastal environments attract many people and are vitally important in terms of realized and potential social value, the majority of the public in the United Kingdom lacks understanding and awareness regarding them. Combined with this, the social value of marine and coastal protected areas (MCPAs) have been largely ignored relative to conservation and economics, with the latter invariably taking precedence in environmental policymaking. Social value reflects the complex, individual responses that people experience in a given place. Many reasons determine why one area is valued above another, and this research investigates the social value of MCPAs from a practitioner’s perspective through a series of interviews. Understanding why we “socially” value MCPAs will ultimately equip managers with an informed understanding of these spaces, influence management decisions, and, potentially, policymaking. This article defines social value in the context of MCPAs in England and Wales from a practitioner perspective, explores key concepts, and suggests possible improvements in decision-making

Class talk: habitus and class in parental narratives of school choice

© 2016 Westburn Publishers Ltd. This article explores how social class is linguistically negotiated and contested in parental narratives of school choice in the British education marketplace. Our study reveals prevalent yet obscured vestiges of ‘class talk’, and in doing so, unmasks ‘micro-political’ acts of status claiming. Using interactional narrative interviewing with 30 parents, we explore how inter- and intra-class differences are emotionally expressed, thus exposing the embodied dispositions of parents’ habitus and its’ subtle influence on school choice. The parental narratives also unveil a moral and political tension between the neoliberal ideal of entrepreneurial self-advancement and an egalitarian sentiment for social equality. Our study therefore challenges the neoliberal educational policy of market choice in closing the attainment gap

Dengue vector habitats in Ouagadougou, Burkina Faso, 2020: an unintended consequence of the installation of public handwashing stations for COVID-19 prevention

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Racial-Ethnic Disparities in Acute Stroke Care in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study

Background-Racial-ethnic disparities in acute stroke care can contribute to inequality in stroke outcomes. We examined raceethnic disparities in acute stroke performance metrics in a voluntary stroke registry among Florida and Puerto Rico Get With the Guidelines-Stroke hospitals. Methods and Results-Seventy-five sites in the Florida Puerto Rico Stroke Registry (66 Florida and 9 Puerto Rico) recorded 58 864 ischemic stroke cases (2010-2014). Logistic regression models examined racial-ethnic differences in acute stroke performance measures and defect-free care (intravenous tissue plasminogen activator treatment, in-hospital antithrombotic therapy, deep vein thrombosis prophylaxis, discharge antithrombotic therapy, appropriate anticoagulation therapy, statin use, smoking cessation counseling) and temporal trends. Among ischemic stroke cases, 63% were non-Hispanic white (NHW), 18% were non-Hispanic black (NHB), 14% were Hispanic living in Florida, and 6% were Hispanic living in Puerto Rico. NHW patients were the oldest, followed by Hispanics, and NHBs. Defect-free care was greatest among NHBs (81%), followed by NHWs (79%) and Florida Hispanics (79%), then Puerto Rico Hispanics (57%) (P \u3c 0.0001). Puerto Rico Hispanics were less likely than Florida whites to meet any stroke care performance metric other than anticoagulation. Defect-free care improved for all groups during 2010-2014, but the disparity in Puerto Rico persisted (2010: NHWs=63%, NHBs=65%, Florida Hispanics=59%, Puerto Rico Hispanics=31%; 2014: NHWs=93%, NHBs=94%, Florida Hispanics=94%, Puerto Rico Hispanics=63%). Conclusions-Racial-ethnic/geographic disparities were observed for acute stroke care performance metrics. Adoption of a quality improvement program improved stroke care from 2010 to 2014 in Puerto Rico and all Florida racial-ethnic groups. However, stroke care quality delivered in Puerto Rico is lower than in Florida. Sustained support of evidence-based acute stroke quality improvement programs is required to improve stroke care and minimize racial-ethnic disparities, particularly in resource-strained Puerto Rico