Rationale and design of a randomized, double-blind, parallel-group study of terutroban 30 mg/day versus aspirin 100 mg/day in stroke patients: the prevention of cerebrovascular and cardiovascular events of ischemic origin with terutroban in patients with a history of ischemic stroke or transient ischemic attack (PERFORM) study.

BACKGROUND: Ischemic stroke is the leading cause of mortality worldwide and a major contributor to neurological disability and dementia. Terutroban is a specific TP receptor antagonist with antithrombotic, antivasoconstrictive, and antiatherosclerotic properties, which may be of interest for the secondary prevention of ischemic stroke. This article describes the rationale and design of the Prevention of cerebrovascular and cardiovascular Events of ischemic origin with teRutroban in patients with a history oF ischemic strOke or tRansient ischeMic Attack (PERFORM) Study, which aims to demonstrate the superiority of the efficacy of terutroban versus aspirin in secondary prevention of cerebrovascular and cardiovascular events. METHODS AND RESULTS: The PERFORM Study is a multicenter, randomized, double-blind, parallel-group study being carried out in 802 centers in 46 countries. The study population includes patients aged > or =55 years, having suffered an ischemic stroke (< or =3 months) or a transient ischemic attack (< or =8 days). Participants are randomly allocated to terutroban (30 mg/day) or aspirin (100 mg/day). The primary efficacy endpoint is a composite of ischemic stroke (fatal or nonfatal), myocardial infarction (fatal or nonfatal), or other vascular death (excluding hemorrhagic death of any origin). Safety is being evaluated by assessing hemorrhagic events. Follow-up is expected to last for 2-4 years. Assuming a relative risk reduction of 13%, the expected number of primary events is 2,340. To obtain statistical power of 90%, this requires inclusion of at least 18,000 patients in this event-driven trial. The first patient was randomized in February 2006. CONCLUSIONS: The PERFORM Study will explore the benefits and safety of terutroban in secondary cardiovascular prevention after a cerebral ischemic event.

AltitudeOmics: enhanced cerebrovascular reactivity and ventilatory response to CO2 with high-altitude acclimatization and reexposure.

The present study is the first to examine the effect of high-altitude acclimatization and reexposure on the responses of cerebral blood flow and ventilation to CO2. We also compared the steady-state estimates of these parameters during acclimatization with the modified rebreathing method. We assessed changes in steady-state responses of middle cerebral artery velocity (MCAv), cerebrovascular conductance index (CVCi), and ventilation (V(E)) to varied levels of CO2 in 21 lowlanders (9 women; 21 ± 1 years of age) at sea level (SL), during initial exposure to 5,260 m (ALT1), after 16 days of acclimatization (ALT16), and upon reexposure to altitude following either 7 (POST7) or 21 days (POST21) at low altitude (1,525 m). In the nonacclimatized state (ALT1), MCAv and V(E) responses to CO2 were elevated compared with those at SL (by 79 ± 75% and 14.8 ± 12.3 l/min, respectively; P = 0.004 and P = 0.011). Acclimatization at ALT16 further elevated both MCAv and Ve responses to CO2 compared with ALT1 (by 89 ± 70% and 48.3 ± 32.0 l/min, respectively; P < 0.001). The acclimatization gained for V(E) responses to CO2 at ALT16 was retained by 38% upon reexposure to altitude at POST7 (P = 0.004 vs. ALT1), whereas no retention was observed for the MCAv responses (P > 0.05). We found good agreement between steady-state and modified rebreathing estimates of MCAv and V(E) responses to CO2 across all three time points (P < 0.001, pooled data). Regardless of the method of assessment, altitude acclimatization elevates both the cerebrovascular and ventilatory responsiveness to CO2. Our data further demonstrate that this enhanced ventilatory CO2 response is partly retained after 7 days at low altitude.

[Archives de la parole]. , [Conversation dialoguée] / [Ferdinand Brunot], collecteur ; [Jean Ducroc, 51 ans, cultivateur], voix ; [Sylvain Robin, 56 ans, cultivateur], voix. [Allons, mon Toène, allons...] : [chanson] / [Henri Viaud, 20 ans, cultivateur], chant. [Briolée aux bœufs] : [chanson] / [Ferdinand Brunot], collecteur ; [Henri Viaud, 20 ans, cultivateur], chant. [Chanson de l'Empereur] / [Ferdinand Brunot], collecteur ; [Mme Rivière, 78 ans, cultivatrice], chant

[Traditions. France. Berry]

[Archives de la parole]. , [Allons, mon Toène, allons...] : [chanson] ; [Briolée aux boeufs] : [chanson] / [Ferdinand Brunot], collecteur ; [Henri Viaud, 20 ans, cultivateur], chant. [Chanson de l'Empereur] / [Ferdinand Brunot], collecteur ; [Mme Rivière, 78 ans, cultivatrice], chant

[Traditions. France. Berry]

Systematic surgical closure of patent foramen ovale in selected patients with cerebrovascular events due to paradoxical embolism. Early results of a preliminary study.

OBJECTIVE: To define therapeutic strategy for management of patients with ischemic stroke due to a high probability of paradoxical embolism through a Patent Foramen Ovale (PFO). METHODS: Since 1988 all consecutive patients with cerebrovascular events and PFO from the Stroke Registry of our population-based primary-care center are prospectively studied and followed. Since 1992, among 118 patients with cryptogenic embolic brain infarct or transient ischemic attack (TIA) and PFO, 32 consecutive patients younger than 60 years who presented at least two of the following criteria were admitted for surgery: history of Valsalva strain before stroke (11); multiple clinical events (13); multiple infarcts on brain Magnetic Resonance Imaging (MRI) (15); atrial septal aneurysm (ASA) (16); large right-to-left shunt (> 50 microbubbles) (12). RESULTS: Operative time 135' +/- 33'. CPB time 34' +/- 14'. Aortic crossclamping time 16' +/- 6'. Post-operative bleeding 485 +/- 170 ml. No homologous blood transfusion required. No neurological, cardiac or renal complications. All patients were followed-up corresponding to a cumulative time of 601 patient-months. This revealed no recurrent vascular events nor silent new brain lesions on brain MRI. Systematic simultaneous contrast Trans Esophageal Echocardiography (TEE)-Trans Cranial Doppler showed a small residual interatrial shunt in two patients. CONCLUSION: Surgical closure of a patent foramen ovale can be accomplished with very low morbidity and reduce efficiently the risk of stroke recurrence. It seems to be the option of choice in selected patients with a higher (> 1.5%/year) risk of stroke recurrence.

Acute ischemic cerebrovascular events on antiplatelet therapy: what is the optimal prevention strategy?

Even though patients who develop ischemic stroke despite taking antiplatelet drugs represent a considerable proportion of stroke hospital admissions, there is a paucity of data from investigational studies regarding the most suitable therapeutic intervention. There have been no clinical trials to test whether increasing the dose or switching antiplatelet agents reduces the risk for subsequent events. Certain issues have to be considered in patients managed for a first or recurrent stroke while receiving antiplatelet agents. Therapeutic failure may be due to either poor adherence to treatment, associated co-morbid conditions and diminished antiplatelet effects (resistance to treatment). A diagnostic work up is warranted to identify the etiology and underlying mechanism of stroke, thereby guiding further management. Risk factors (including hypertension, dyslipidemia and diabetes) should be treated according to current guidelines. Aspirin or aspirin plus clopidogrel may be used in the acute and early phase of ischemic stroke, whereas in the long-term, antiplatelet treatment should be continued with aspirin, aspirin/extended release dipyridamole or clopidogrel monotherapy taking into account tolerance, safety, adherence and cost issues. Secondary measures to educate patients about stroke, the importance of adherence to medication, behavioral modification relating to tobacco use, physical activity, alcohol consumption and diet to control excess weight should also be implemented.

Reeducación del equilibrio en pacientes con accidente cerebrovascular crónico en medio acuático y terrestre.

Pacientes: Participación de dos grupos experimentales de pacientes diagnosticados de Accidente cerebrovascular crónico (ACV), sometidos aleatorizadamente a un tratamiento acuático o terrestre de 24 semanas. Intervención: El tratamiento tanto acuático como terrestre tendrá una duración de 60 minutos y se realizará tres veces por semana, consistiendo principalmente en la realización de ejercicios diseñados específicamente para mejorar el equilibrio y secundariamente otras capacidades físicas básicas.Comparación: Se compararan las mejoras del equilibrio medidas en el grupo que realiza ejercicio físico en un medio terrestre con el grupo que lo realiza en un medio acuático. Objetivo: Evaluar los beneficios del ejercicio físico acuático en comparación con los realizados en un medio terrestre, en la reeducación del equilibrio en pacientes con ACV. Metodología: Los sujetos serán seleccionados de forma aleatorizada en dos grupos, ambos experimentales, distinguiendo un grupo de tratamiento acuático y un grupo de tratamiento terrestre. Ambos grupos recibirán un tratamiento de 72 sesiones y serán evaluados utilizando diferentes instrumentos de medida como; la escala del equilibrio de Berg, Time Up and Go test, índice de Barthel, escala especifica de Calidad de vida, Falls-Related Efficacy Scale, Tinetti test y Cognitive Impairment Test.

Thromboxane prostaglandin receptor antagonist and carotid atherosclerosis progression in patients with cerebrovascular disease of ischemic origin: a randomized controlled trial.

BACKGROUND AND PURPOSE: Thromboxane prostaglandin receptors have been implicated to be involved in the atherosclerotic process. We assessed whether Terutroban, a thromboxane prostaglandin receptor antagonist, affects the progression of atherosclerosis, as measured by common carotid intima-media thickness and carotid plaques. METHODS: A substudy was performed among 1141 participants of the aspirin-controlled Prevention of Cerebrovascular and Cardiovascular Events of Ischemic Origin with Terutroban in Patients with a History of Ischemic Stroke or Transient Ischemic Attack (PERFORM) trial. Common carotid intima-media thickness and carotid plaque occurrence was measured during a 3-year period. RESULTS: Baseline characteristics did not differ between Terutroban (n=592) and aspirin (n=549) treated patients and were similar as in the main study. Mean study and treatment duration were similar (28 and 25 months, respectively). In the Terutroban group, the annualized rate of change in common carotid intima-media thickness was 0.006 mm per year (95% confidence interval, -0.004 to 0.016) and -0.005 mm per year (95% confidence interval, -0.015 to 0.005) in the aspirin group. There was no statistically significant difference between the groups in the annualized rate of change of common carotid intima-media thickness (0.011 mm per year; 95% confidence interval, -0.003 to 0.025). At 12 months of follow-up, 66% of Terutroban patients had no emergent plaques, 31% had 1 to 2 emergent plaques, and 3% had ≥3 emergent plaques. In the aspirin group, the corresponding percentages were 64%, 32%, and 4%. Over time, there was no statistically significant difference in the number of emergent carotid plaques between treatment modalities (rate ratio, 0.91; 95% confidence interval, 0.77-1.07). CONCLUSIONS: Compared with aspirin, Terutroban did not beneficially affect progression of carotid atherosclerosis among well-treated patients with a history of ischemic stroke or transient ischemic attacks with an internal carotid stenosis <70%. CLINICAL TRIAL REGISTRATION URL: http://www.controlled-trials.com. Unique identifier: ISRCTN66157730.

Telerehabilitació en pacients amb accidents cerebrovascular: revisió bibliogràfica.

L’ ictus és una alteració brusca de la circulació de la sang al cervell, sent la segona causa de mort al món i la primera en discapacitat. Objectius. Examinar si la telerehabilitació i la realitat virtual poden millorar l'estat físic i psíquic dels pacients amb accident cerebrovascular i avaluar l’impacte en les activitats de la vida diària. Conclusió. Els resultats indiquen que la fisioteràpia convencional i un programa combinat de telerehabilitació o realitat virtual amb fisioteràpia, milloren les capacitats físiques dels pacients, no obstant, el tractament combinat obté millores significativament superiors al tractament convencional. La tecnologia en l’àmbit de la rehabilitació pot ser una alternativa segura per promoure la recuperació motora després d'un accident cerebrovascular.

Tómese unos minutos para revisar sus conocimientos sobre: Enfermedad cerebrovascular/circulación cerebral

1. ¿Cuál de las siguientes arterias no forma parte del territorio carotídeo? a. Arteria cerebral posterior, b. Carótida interna, c. Arteria cerebral media, d. Arteria ...

Revisión actualizada sobre enfermedad cerebrovascular: estudio de un caso

La enfermedad cerebrovascular (ECV), también denominada accidente cerebrovascular (ACV)o ictus, representa el 90% de las enfermedades neurológicas y constituye la tercera causa de muerte en la mayoría de los países desarrollados; en España representa la primera causa de muerte en mujeres de 75 años o más de edad.

AltitudeOmics : Resetting of Cerebrovascular CO2 Reactivity Following Acclimatization to High Altitude.

Previous studies reported enhanced cerebrovascular CO2 reactivity upon ascent to high altitude using linear models. However, there is evidence that this response may be sigmoidal in nature. Moreover, it was speculated that these changes at high altitude are mediated by alterations in acid-base buffering. Accordingly, we reanalyzed previously published data to assess middle cerebral blood flow velocity (MCAv) responses to modified rebreathing at sea level (SL), upon ascent (ALT1) and following 16 days of acclimatization (ALT16) to 5260 m in 21 lowlanders. Using sigmoid curve fitting of the MCAv responses to CO2, we found the amplitude (95 vs. 129%, SL vs. ALT1, 95% confidence intervals (CI) [77, 112], [111, 145], respectively, P = 0.024) and the slope of the sigmoid response (4.5 vs. 7.5%/mmHg, SL vs. ALT1, 95% CIs [3.1, 5.9], [6.0, 9.0], respectively, P = 0.026) to be enhanced at ALT1, which persisted with acclimatization at ALT16 (amplitude: 177, 95% CI [139, 215], P < 0.001; slope: 10.3%/mmHg, 95% CI [8.2, 12.5], P = 0.003) compared to SL. Meanwhile, the sigmoidal response midpoint was unchanged at ALT1 (SL: 36.5 mmHg; ALT1: 35.4 mmHg, 95% CIs [34.0, 39.0], [33.1, 37.7], respectively, P = 0.982), while it was reduced by ~7 mmHg at ALT16 (28.6 mmHg, 95% CI [26.4, 30.8], P = 0.001 vs. SL), indicating leftward shift of the cerebrovascular CO2 response to a lower arterial partial pressure of CO2 (PaCO2) following acclimatization to altitude. Sigmoid fitting revealed a leftward shift in the midpoint of the cerebrovascular response curve which could not be observed with linear fitting. These findings demonstrate that there is resetting of the cerebrovascular CO2 reactivity operating point to a lower PaCO2 following acclimatization to high altitude. This cerebrovascular resetting is likely the result of an altered acid-base buffer status resulting from prolonged exposure to the severe hypocapnia associated with ventilatory acclimatization to high altitude.

Estudio piloto de la relación entre el aumento de la velocidad de onda del pulso en arteria carótida común medida por resonancia magnética y los factores de riesgo vasculares clásicos en sujetos con sospecha de lesión cerebrovascular isquémica

Arterial stiffness assessed by carotid-femoral pulse wave velocity (cfPWV) measurement is now well accepted as an independent predictor of vascular mortality and morbidity. However, the value of cfPWV has been considered to be limited for risk classification in patients with several vascular risk factors. Magnetic resonance (MR) allows measurement of PWV between two points, though to date mainly used to study the aorta. To assess the common carotid artery pulse wave velocity by magnetic resonance, determine their association with classical vascular risk factors and ischemic brain injury burden in patients with suspected ischemic cerebrovascular disease

Savnets tone i ensomhetens melodi : ensomhet hos aleneboende personer med alvorlig psykisk lidelse

Studiens overordnede hensikt er å bestemme begrepet ensomhet i et vårdvitenskapelig perspektiv. Avhandlingen er en monografisk eksplorativ hermeneutisk studie og oppbygget i fire større helheter, der første hoveddel starter med en inntreden i den hermeneutiske spiral, og hvor paradigme, ontologiske, epistemologiske og metodologiske overveielser angir studiens videre retning. Andre hoveddel anses som studiens teoretiske substans og belyser ensomhetens `Hva´ gjennom ulike teoretiske perspektiv og begrepsanalyse av ensom. I belysningen framkommer ensomhet både som lidelse og som meningsfullt for eksistensen. Første hoveddel avsluttes med en bestemmelse av ensomhet som substanskunnskap innenfor vårdvitenskapens helse-og lidelsesforhold som utgjør ulike nivåer av gjørende, værende og vardende. Tredje hoveddel er en empiriskstudie med deltagende observasjon, forskersamtaler og kvalitative intervjuer i samtaleform. Informantene var åtte aleneboende personer med alvorlig psykisk lidelse i en storby og foregikk over ca. ett år. I tolkningsprosessen søkes en gradvis fordypende forståelse av den enkelte informants ensomhet i relasjon til vårdvitenskapens livs-, sykdoms- og vårdlidelse. Tolkningsrammen er i det vesentligefra første teoridel, samtidig som nye tolkningsteoretikere innlemmes som opplysende "lamper". Forståelsens tolkningsresultater framkommer gjennom en sammenfattende diskusjon, der livsberettelsens felles skjebne synliggjør savn som ideografisk invarians. Fjerde hoveddel er en vårdvitenskapelig filosofisk belysning av forholdet ensomhet og savn, hvor Levinas' fundamentaletikk utgjør tolkningsrammen. Studien avsluttes med en horisontsammensmeltning av forholdet ensomhet og savngjennom fellesskap og oppfyllelse i tid og rom. Horisontsammensmeltningen viserat ensomhet og savn i sin dybdestruktur forholder seg til hverandre i en dialektikk til motsetningene: fellesskap og oppfyllelse. Det nedfelles fem teser som ansatser til vårdvitenskapelig teori. Resultatene får implikasjoner for så vel pedagogikk som vårdpraksis.