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Although age-standardized stroke occurrence has been decreasing, the absolute number of stroke events globally, and in Canada, is increasing. Stroke surveillance is necessary for health services planning, informing research design, and public health messaging. We used administrative data to estimate the number of stroke events resulting in hospital or emergency department presentation across Canada in the 2017–18 fiscal year.
Methods:
Hospitalization data were obtained from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database and the Ministry of Health and Social Services in Quebec. Emergency department data were obtained from the CIHI National Ambulatory Care Reporting System (Alberta and Ontario). Stroke events were identified using ICD-10 coding. Data were linked into episodes of care to account for readmissions and interfacility transfers. Projections for emergency department visits for provinces/territories outside of Alberta and Ontario were generated based upon age and sex-standardized estimates from Alberta and Ontario.
Results:
In the 2017–18 fiscal year, there were 108,707 stroke events resulting in hospital or emergency department presentation across the country. This was made up of 54,357 events resulting in hospital admission and 54,350 events resulting in only emergency department presentation. The events resulting in only emergency department presentation consisted of 25,941 events observed in Alberta and Ontario and a projection of 28,409 events across the rest of the country.
Conclusions:
We estimate a stroke event resulting in hospital or emergency department presentation occurs every 5 minutes in Canada.
Despite the high proportion of stroke patients with a pre-existing impairment, patients with disabilities are often excluded from stroke treatment trials. Trials are designed for “perfect patients”: patients who are functionally independent and thus generally younger with fewer comorbidities; ironically, such patients are less likely to experience stroke than those with premorbid disability. Exclusionary practices in trials may translate into disparities in stroke care in practice. Through a review of literature, our purpose is to illuminate how people with disabilities are treated across the care continuum following a stroke.
Methods:
We completed a qualitative systematized review of articles pertaining to the care of patients with premorbid disability and stroke and their outcomes. Using a critical disability studies' theoretical lens, we analyzed inequity across the stroke care continuum.
Findings:
Among 24 included studies, we found evidence that people with disabilities did not receive equitable access to treatment ranging from being admitted to stroke units to receiving post-stroke rehabilitation. However, observational studies suggest that stroke therapies may be beneficial in selected patients with disabilities when measures of success are framed more achievable (e.g. return to pre-stroke status). This leaves us concerned about how people with pre-existing impairments might be structurally disabled within current systems of stroke care.
Conclusion:
We use our critical disability studies' theoretical lens to argue that an intersectional approach to stroke treatment is much needed if we are to remedy structural inequities embedded throughout the care continuum.
We examine the translation of a sphere in a stratified ambient in the limit of small Reynolds numbers ($Re \ll 1$) and viscous Richardson numbers ($Ri_v \ll 1$); here, $Re = {\rho Ua}/{\mu }$ and $Ri_v = {\gamma a^3 g}/{\mu U}$, with $a$ being the sphere radius, $U$ the translation speed, $\rho$ and $\mu$ the density and viscosity of the stratified ambient, $g$ the acceleration due to gravity, and $\gamma$ the density gradient characterizing the ambient stratification. In contrast to most earlier efforts, our study considers the convection-dominant limit corresponding to $Pe = {Ua}/{D} \gg 1$, $D$ being the diffusivity of the stratifying agent. We characterize in detail the velocity and density fields around the particle in what we term the Stokes stratification regime, defined by $Re \ll Ri_v^{{1}/{3}} \ll 1$, and corresponding to the dominance of buoyancy over inertial forces. Buoyancy forces associated with the perturbed stratification fundamentally alter the viscously dominated fluid motion at large distances of order the stratification screening length that scales as $a\,Ri_v^{-{1}/{3}}$. The motion at these distances transforms from the familiar fore–aft symmetric Stokesian form to a fore–aft asymmetric pattern of recirculating cells with primarily horizontal motion within, except in the vicinity of the rear stagnation streamline. At larger distances, the motion is vanishingly small except within (a) an axisymmetric horizontal wake whose vertical extent grows as $O(r_t^{{2}/{5}})$, $r_t$ being the distance in the plane perpendicular to translation, and (b) a buoyant reverse jet behind the particle that narrows as the inverse square root of distance downstream. As a result, for $Pe = \infty$, the motion close to the rear stagnation streamline starts off pointing in the direction of translation, in the inner region, and decaying as the inverse of the downstream distance; the motion reverses beyond distance $1.15a\,Ri_v^{-{1}/{3}}$, with the eventual reverse flow in the far-field buoyant jet again decaying as the inverse of the distance downstream. For large but finite $Pe$, the narrowing jet is smeared out beyond a distance of $O(a\,Ri_v^{-{1}/{2}}\, Pe^{{1}/{2}})$, leading to an exponential decay of the aforementioned reverse flow.
This paper examines the shape dynamics of deformable elastic and viscoelastic particles in an ambient Newtonian fluid subjected to simple shear. The particles are allowed to undergo large deformation, with the elastic stress determined using the neo-Hookean constitutive relation. We first present a method to determine the shape dynamics of initially ellipsoidal particles that is an extension of the method of Roscoe (J. Fluid Mech., vol. 28, issue 2, 1967, pp. 273–293), originally used to determine the shape at steady state of an initially spherical particle. We show that our method recovers earlier results for the in-plane trembling and tumbling dynamics of initially prolate spheroids in simple shear flow, obtained by a different approach. We then examine the in-plane dynamics of oblate spheroids and triaxial ellipsoids in simple shear flow, and show that they too, like prolate spheroids, exhibit time-periodic tumbling or trembling dynamics, depending on the initial aspect ratios of the particle and the elastic capillary number $G \equiv \mu \dot {\gamma }/\eta$, where $\mu$ is the viscosity of the fluid, $\eta$ is the elastic shear modulus of the particle and $\dot {\gamma }$ is the shear rate. In addition, we find a novel state wherein the particle extends indefinitely in time and asymptotically aligns with the flow axis. We demarcate all the dynamical regimes in the parameter space comprising $G$ and the initial particle aspect ratios. When the particles are viscoelastic, damped oscillatory dynamics is observed for initially spherical particles, and the tumbling–trembling boundary is altered for initially prolate spheroids so as to favour tumbling.
In newborns with hypoxic-ischaemic encephalopathy, more profound altered right and left ventricular function has been associated with mortality or brain injury. Mechanisms underlying cardiac dysfunction in this population are thought to be related to the persistence of increased pulmonary vascular resistance and myocardial ischaemia. We sought to compare cardiac function in newborns with hypoxic-ischaemic encephalopathy to controls using echocardiography.
Methods:
We did a retrospective case–control study with moderate or severe hypoxic-ischaemic encephalopathy between 2008 and 2017. Conventional and speckle-tracking echocardiography measures were extracted to quantify right and left ventricular systolic and diastolic function. Fifty-five newborns with hypoxic-ischaemic encephalopathy were compared to 28 controls.
Results:
Hypoxic-ischaemic encephalopathy newborns had higher estimated systolic pulmonary pressure (62.5 ± 15.0 versus 43.8 ± 17.3 mmHg, p < 0.0001) and higher systolic pulmonary artery pressure/systolic blood pressure ratio [101 ± 16 (iso-systemic) versus 71 ± 27 (2/3 systemic range) %, p < 0.0001]. Tricuspid annular plane systolic excursion was decreased (7.5 ± 2.2 versus 9.0 ± 1.4 mm, p = 0.002), E/e’ increased (7.9 ± 3.3 versus 5.8 ± 2.0, p = 0.01), and right ventricle-myocardial performance index increased (68.1 ± 21.5 versus 47.8 ± 9.5, p = 0.0001) in hypoxic-ischaemic encephalopathy. Conventional markers of left ventricle systolic function were similar, but e’ velocity (0.059 ± 0.019 versus 0.070 ± 0.01, p = 0.03) and left ventricle-myocardial performance index were statistically different (77.9 ± 26.2 versus 57.9 ± 11.2, p = 0.001). The hypoxic-ischaemic encephalopathy group had significantly altered right and left ventricular deformation parameters by speckle-tracking echocardiography. Those with decreased right ventricle-peak longitudinal strain were more likely to have depressed left ventricle-peak longitudinal strain.
Conclusion:
Newborns with hypoxic-ischaemic encephalopathy have signs of increased pulmonary pressures and altered biventricular systolic and diastolic function.
Background: There are uncertainties regarding the optimal management of acutely symptomatic carotid stenosis (“hot carotids”). We sought to explore the approaches of stroke physicians to anti-thrombotic management, imaging, and revascularization in patients with “hot carotids”. Methods: We used a qualitative descriptive methodology to examine decision-making approaches of physicians regarding the management of hot carotids. We conducted semi-structured interviews with 22 stroke physicians from various specialties in 16 centers across 4 continents. Results: Important themes regarding anti-thrombotic included limitations of existing clinical trial evidence, competing physician preferences, antiplatelet therapy while awaiting revascularization and various regional differences. Timely imaging availability, breadth of information gained, and surgeon/interventionalist preferences were important themes influencing the choice of imaging modality. The choice of revascularization intervention was influenced by healthcare system factors such as use of multidisciplinary review and operating room/angiography suite availability, and patient factors like age and infarct size. Many themes related to uncertainties in the management of hot carotids were also discussed. Conclusions: Our study revealed themes that are important to international stroke experts. We highlight common and divergent practices while underscoring important areas of clinical equipoise and uncertainty. Teams designing international carotid trials may wish to accommodate identified variations in practice patterns and areas of uncertainty.
Background: Randomized-controlled trials of thrombolysis in ischemic stroke have poorly represented patients with pre-stroke disability and the benefit of thrombolysis in this population remains uncertain. We performed a systematic review and meta-analysis to examine the outcomes of thrombolysis in patients with pre-morbid disability. Methods: In accordance with MOOSE guidelines, we retrieved studies reporting intravenous thrombolysis (IVT) in patients with pre-stroke disability (mRS=3-5) with ischemic stroke, either compared to untreated patients or to treated patients without pre-morbid disability. Primary outcome was the return to pre-morbid disability at 90-days. Results: 8 articles were included involving 103,988 patients. Patients with disability treated with IVT had better odds of returning to baseline function compared to those who did not receive IVT (OR=7.26, 95%CI=2.51-21.02). Mortality and sICH were not significantly different between patients with disability receiving IVT or not. Favourable outcomes (mRS=0-2 or return to pre-morbid mRS) and sICH were not significantly different between patients with and without disability. Mortality was three times higher in those with pre-morbid disability treated with IVT (38.2% versus 12.6%). Conclusions: Thrombolysis in patients with disability was associated with better outcomes compared to patients not receiving IVT. High-quality data comparing treated versus untreated patients with pre-morbid disability is needed to clarify this issue.
Background: Trials of endovascular thrombectomy (EVT) for acute stroke have excluded patients with pre-morbid disability. We performed a meta-analysis to assess the effectiveness and safety of EVT in patients with pre-morbid disability. Methods: According to PRISMA guidelines, we searched for studies describing outcomes in patients with pre-morbid disability (modified Rankin Scale [mRS] 2-5), treated with EVT or medical management (MM). Random-effects meta-analysis was used to pool outcomes including return to baseline mRS at 90 days, symptomatic ICH (sICH), and 90-day mortality. Results: We analyzed 14 studies of patients with pre-morbid disability (mRS2-5: EVT=1,373, MM=253). Compared to medical therapy, EVT was associated with higher likelihood of return to baseline mRS (OR=2.37, 95%CI:1.39-4.04) and a trend towards lower mortality (OR=0.68, 95%CI:0.46-1.02), with similar odds of sICH (OR 1.01, 95%CI:0.49-2.08). In studies comparing patients with vs. without pre-morbid disability treated with EVT, similar results were found except that pre-morbid disability, when defined more strictly as mRS 3-5, was associated with mortality (OR 3.49, p<0.001). Conclusions: In patients with pre-morbid disability, EVT carries a higher chance of return to baseline mRS compared to patients treated with MM or without pre-morbid disability, although with higher mortality than patients without pre-morbid disability. These findings merit validation with randomized controlled trials.
Background: Pandemics may promote hospital avoidance among patients with emergencies, and added precautions may exacerbate treatment delays. Methods: We used linked administrative data and data from the Quality Improvement and Clinical Research Alberta Stroke Program – a registry capturing stroke-related data on the entire Albertan population (4.3 million) – to identify all patients hospitalized with stroke in the pre-pandemic (01/01/2016-27/02/2020) and COVID-19 pandemic (28/02/2020-30/08/2020) periods. We examined changes in stroke presentation rates and use of thrombolysis and endovascular therapy (EVT), adjusted for age, sex, comorbidities, and pre-admission care needs; and in workflow, stroke severity (National Institutes of Health Stroke Scale/NIHSS), and in-hospital outcomes. Results: We analyzed 19,531 patients with ischemic stroke pre-pandemic versus 2,255 during the pandemic. Hospitalizations/presentations dropped (weekly adjusted-incidence-rate-ratio[aIRR]:0.48,95%CI:0.46-0.50), as did population-level incidence of thrombolysis (aIRR:0.49,0.44-0.56) or EVT (aIRR:0.59,0.49-0.69). However, proportions of presenting patients receiving thrombolysis/EVT did not decline (thrombolysis:11.7% pre-pandemic vs 13.1% during-pandemic, aOR:1.02,0.75-1.38). For out-of-hospital strokes, onset-to-door times were prolonged(adjusted-coefficient:37.0-minutes, 95%CI:16.5-57.5), and EVT recipients experienced greater door-to-reperfusion delays (adjusted-coefficient:18.7-minutes,1.45-36.0). NIHSS scores and in-hospital mortality did not differ. Conclusions: The first COVID-19 wave was associated with a halving of presentations and acute therapy utilization for ischemic stroke at a population level, and greater pre-/in-hospital treatment delays. Our data can inform public health messaging and stroke care in future pandemic waves.
A spacecraft during mission typically switches from chemical propulsion to electric propulsion once it lifts out of the Earth's gravity as the thrust requirement to drive it reduces substantially. Consequently, electric propulsion technology is commonly used for deep space mission, satellite orbit keeping and orbit correction. In the last few decades, the amount of man-made space junk (space debris) has increased enormously and has become a potential danger for space stations, space shuttles and other live satellites. A bi-directional plasma thruster, mounted on a satellite, can be used to remove space debris during satellite operation (Takahashi et al., Sci. Rep., vol. 8, 2018, p. 14417). A directed ion beam ejected from a plasma thruster imparts a net force on space debris to decelerate and facilitates manoeuvring and re-entry of space debris into the Earth's atmosphere where it can burn out. We present a detailed 1D3V PIC-MCC (particle in cell-Monte Carlo collision) simulation of a bi- directional plasma thruster. To this end, a PIC-MCC solver which resolves thruster axial direction and all three velocity dimensions is used to study a magnetic nozzle plasma thruster with both ends open (bi-directional plasma thruster). We show that such a bi-directional plasma thruster can be used to accelerate–decelerate a live satellite and also to remove space debris by altering the magnetic field spatial profile in the plasma expansion region. A detailed study is presented.
Parkinson’s disease (PD) is traditionally characterized by its motor symptoms of tremors, bradykinesia, rigidity, and postural instability [1]. However, it is now recognized that non-motor symptoms including neuropsychiatric manifestations are frequently present in PD, and their onset not only could precede motor symptoms but is also associated with increased dysfunction and reduced quality of life [2–4]. This chapter focuses on depression, the most commonly seen mood disorder in PD, and provides an overview of the epidemiology, clinical symptoms, proposed pathophysiology, diagnostic tools, and treatment options available for depression in PD.
We analyse the instability of a vortex column in a dilute polymer solution at large ${{Re}}$ and ${{De}}$ with ${{El}} = {{De}}/{{Re}}$, the elasticity number, being finite. Here, ${{Re}} = \varOmega _0 a^2/\nu$ and ${{De}} = \varOmega _0 \tau$ are, respectively, the Reynolds and Deborah numbers based on the core angular velocity ($\varOmega _0$), the radius of the column ($a$), the total (solvent plus polymer) kinematic viscosity ($\nu = (\mu _s +\mu _p)/\rho$ with $\mu _s$ and $\mu _p$ being the solvent and polymer contributions to the viscosity) and the polymeric relaxation time ($\tau$). The stability of small-amplitude perturbations in this distinguished limit is governed by the elastic Rayleigh equation whose spectrum is parameterized by ${E} = {{El}}(1-\beta )$, $\beta$ being the ratio of the solvent to the solution viscosity. The neglect of the relaxation terms, in the said limit, implies that the polymer solution supports undamped elastic shear waves propagating relative to the base-state flow. Unlike the neutrally stable inviscid case, an instability of the vortex column arises for finite ${E}$ due to a pair of elastic shear waves being driven into a resonant interaction under the differential convection by the irrotational shearing flow outside the core. An asymptotic analysis for the Rankine profile shows the absence of an elastic threshold for this instability. The growth rate is $O(\varOmega _0)$ for order unity $E$, although it becomes transcendentally small for ${E} \ll 1$, being $O(\varOmega _0 {E}^2{\rm e}^{-1/{E}^{{1}/{2}}})$. An accompanying numerical investigation shows that the instability persists for smooth monotonically decreasing vorticity profiles, provided the radial extent of the transition region (from the rotational core to the irrotational exterior) is less than a certain ${E}$-dependent threshold.
We revisit the somewhat classical problem of the linear stability of a rigidly rotating liquid column in this article. Although the literature pertaining to this problem dates back to 1959, the relation between inviscid and viscous stability criteria has not yet been clarified. While the viscous criterion for stability, given by $We < n^2 + k^2 -1$, is both necessary and sufficient, this relation has only been shown to be sufficient in the inviscid case. Here, $We = \rho \varOmega ^2 a^3 / \gamma$ is the Weber number and measures the relative magnitudes of the centrifugal and surface tension forces, with $\varOmega$ being the angular velocity of the rigidly rotating column, $a$ the column radius, $\rho$ the density of the fluid and $\gamma$ the surface tension coefficient; $k$ and $n$ denote the axial and azimuthal wavenumbers of the imposed perturbation. We show that the subtle difference between the inviscid and viscous criteria arises from the surprisingly complicated picture of inviscid stability in the $We$–$k$ plane. For all $n > 1$, the viscously unstable region, corresponding to $We > n^2 + k^2-1$, contains an infinite hierarchy of inviscidly stable islands ending in cusps, with a dominant leading island. Only the dominant island, now infinite in extent along the $We$ axis, persists for $n=1$. This picture may be understood, based on the underlying eigenspectrum, as arising from the cascade of coalescences between a retrograde mode, that is the continuation of the cograde surface-tension-driven mode across the zero Doppler frequency point, and successive retrograde Coriolis modes constituting an infinite hierarchy.
Background: Some patients do poorly despite small infarcts after endovascular therapy(EVT) whilst others with large infarcts do well. We validated exploratory findings from the ESCAPE trial regarding factors associated with such discrepancies, in the ESCAPE-NA1 trial(NCT02930018). Methods: We identified “discrepant cases” with modified Rankin Scale(mRS)≥3 despite small follow-up infarct volume(FIV≤25th-percentile) on 24-hour CT/MRI or mRS≤2 despite large FIV(volume≥75th-percentile). We compared area-under-the-curve(AUC) of pre-specified logistic models containing (a)pre-treatment factors(age/cancer/vascular risk-factors) and (b)treatment-related/post-treatment factors(serious adverse events/SAEs) in identifying small-FIV/mRS≥3 and large-FIV/mRS≤2, with stepwise regression-derived models. Results: Among 1,091 patients, 42/287(14.6%) with FIV≤7mL(25th-percentile) had mRS≥3; 65/275(23.6%) with FIV≥92mL(75th-percentile) had mRS≤2. Pre-specified pre-treatment factors(age/cancer/vascular risk-factors) were associated with FIV≤7mL/mRS≥3; stepwise models selected similar variables(similar AUCs:0.92-0.93,p=0.42). SAEs(infarct-in-new-territory/recurrent stroke/pneumonia/heart failure) were strongly associated with FIV≤7mL/mRS≥3; stepwise models also identified onset-to-needle time and hemoglobin(24-hours) as treatment-related/post-treatment factors(similar AUCs:0.92-0.94,p=0.14). Younger age was associated with FIV≥92mL/mRS≤2; stepwise models also selected diabetes absence and baseline hemoglobin(similar AUCs:0.76-0.77,p=0.82). Absence of SAEs(stroke progression/pneumonia/intracerebral hemorrhage) was strongly associated with FIV≥92mL/mRS≤2; stepwise models also identified 24-hour hemoglobin, glucose, and BP(similar AUCs:0.79-0.80,p=0.030). Conclusions: FIV-mRS discrepancies are associated with pre-treatment factors like age/comorbidities; and post-treatment complications related to stroke evolution, secondary prevention, and post-acute care quality. Optimizing thrombolysis speed, BP, glucose, and hemoglobin are modifiable factors meriting further study.
Background: We aimed to evaluate the association between hypertensive disorders in pregnancy (HDP) and future risk of cognitive impairment and dementia. Methods: Systematic searches were performed in MEDLINE and EMBASE up to April 27th, 2020. Exposure of interest included the different types of HDP. Outcomes of interest included dementia incidence, dementia subtype, and cognitive testing. Results: On qualitative review, 4/9 studies showed impaired memory, visual motor processing speed, executive function, and verbal testing in previously preeclamptic women. 2/4 studies showed impaired visual motor processing and subjective cognitive complaints in previously eclamptic women. Six cohort studies involving >2.6 million women were included in the meta-analysis. Pooled hazard ratios (aHR) with 95% confidence intervals were generally adjusted for age at delivery ethnicity, and vascular risk factors. Women with a history of gestational hypertension were more likely to develop vascular dementia (aHR 2.02 [1.45-2.83],I2:0%), but not Alzheimer disease (1.24 [0.93-1.66],single-study). Women with a history of preeclampsia were also more likely to develop vascular dementia (2.17 [1.20-3.91],I2:61.1%), but not Alzheimer dementia (1.19 [0.83-1.69],I2:69.9%).
Conclusions: Whereas studies of neuropsychological testing in previously preeclamptic and eclamptic women have been heterogeneous, a history of HDP is associated with developing vascular dementia in later life.