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Parental acquired communication disability has long-lasting impacts on children, including increased child stress and behavioural problems. However, speech-language pathologists’ (SLPs) current practice in providing information, education and counselling support to these children is unknown. Therefore, we explored SLPs’ perceived needs, current practices and barriers and facilitators to working with children of people with acquired communication disability (PwCD).
An online survey sought information on Australian SLPs’ current practices in providing education and counselling to children of PwCD. Perceived barriers and facilitators were mapped to the COM-B, a model that considers Capability, Opportunity and Motivation as domains that influence behaviour.
75% of participants (n = 76) perceived a need to provide both information and counselling, but ‘never’ or ‘rarely’ provided either aspect of care. Barriers relating to ‘Opportunity’ were most frequently identified, such as not having access to children in therapy and lack of parental support/engagement. Capability (e.g., knowledge and skills) and Motivation (e.g., confidence) barriers were also identified.
There is potential for SLPs to provide services to children of PwCD either directly through information and/or counselling-type interactions or indirectly through referral to other services. This study highlights the need for more research into these areas of practice.
This is an observational cohort study comparing 156 patients evaluated for acute stroke between March 30th and May 31st 2020 at a comprehensive stroke center with 138 patients evaluated during the corresponding time period in 2019. During the pandemic, the proportion of COVID- 19 positive patients was low (3%), the time from symptom-onset to hospital presentation was significantly longer, and a smaller proportion of patients underwent reperfusion therapy. Among patients directly evaluated at our institution, door-to-needle and door-to-recanalization metrics were significantly longer. Our findings support concerns that the current pandemic may have a negative impact on the management of acute stroke.
The design of proper antenna element (AE) for microwave-based head imaging or brain stroke detection is a crucial challenge in the development process of microwave imaging (MWI) systems. The main purpose of this paper was to design, fabricate, and experimentally verify the compact and dimensions-reduced H-slot antenna suitable for the new generation of multichannel MWI system for brain stroke detection. The slot antenna type was chosen based on the numerical study of three AEs available in the literature, i.e. bow tie, slot, and waveguide-based. The study was focused on the sensitivity of the antennae (change of magnitude and phase of S21) due to dielectric parameters change or type and diameter of inclusion in a head phantom representing a hemorrhagic (HEM) or ischemic (ISCH) stroke phantom, respectively. Further, the analysis of antenna radiation to lossy medium/air and its immunity against plane wave exposure was carried out. The H-slot antenna was fabricated and experimentally verified (measurements of reflection as well as transmission coefficients) using a liquid head phantom with inserted HEM stroke phantom (both prepared as a mixture of propylene glycol, water, and salt). The phantoms were filled inside the designed two-port test system. Numerical models were validated by comparing calculated and measured S-parameters. The sensitivity of the H-slot antenna to the presence of the HEM stroke phenomenon within the phantom of the head was also demonstrated. The main advantage of the proposed H-slot antenna is its small dimensions, easy, inexpensive, and repeatable fabrication as well as mechanical stability.
Guidelines are lacking for management of acute ischemic stroke and stroke prevention in patients with immune thrombocytopenia (ITP). Our aim is to highlight the dilemma inherent in managing patients with both significant bleeding and thrombotic risk factors. In this review, we present two patients with history of ITP who presented with acute ischemic stroke and received tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT), a rare management strategy in this patient population. In addition, we identified 27 case reports of ischemic stroke in patients with ITP; none of them received tPA or EVT. Furthermore, there are 92 patients with significant thrombocytopenia with no available data regarding the cause of thrombocytopenia, who were acutely treated with tPA or EVT. Conclusive evidence cannot be determined based on these limited number of cases. Future multicenter prospective cohort studies in patients with ITP are needed to provide better evidence-based treatment plans. At present, treatment of acute ischemic stroke in patients with ITP requires close collaboration between hematology and vascular neurology experts to find a balance between the benefit and risk of hemorrhagic complications.
Delusional infestation is a condition at the interface of tactile and visual hallucinations and delusions. Individuals with this condition hold the fixed and false belief that their body or their environment is infested with parasites, insects or other organisms.
There are no guidelines or publications detailing the psychological assessment, formulation, intervention and evaluation of this presentation. This paper aims to address this gap.
Single case experimental design methodology was employed to evaluate the use of cognitive behavioural therapy (CBT) for delusional infestation in a 70-year-old male who was intolerant of anti-psychotic medication. ‘Tom’ had a large, mature infarct in the middle cerebral artery territory as well as a left posterior parietal infarct post-stroke, which may have precipitated his symptoms. After a baseline period of 3 weeks, Tom received eight sessions of CBT based on the model by Collerton and Dudley (2004).
Post-intervention, there was a reliable improvement on clinical measures as well as a large reduction in distress levels, which was maintained at 3-month follow-up. The conviction in the belief that the infestation was real did not shift.
This case demonstrated the potential for the use of CBT to address distress related to delusional infestation. This work is discussed in relation to post-stroke psychosis, psychological therapies with older adults, and suggestions are made for future research.
Megalencephaly–capillary malformation–polymicrogyria (MCAP) syndrome (OMIM #602501) is characterized by megalencephaly, midline capillary malformations, and cortical malformations. This genetic overgrowth syndrome is associated with mosaic gain-of-function pathogenic PIK3CA variants (OMIM #171834).
Prospective memory (PM) is the memory used when intentions are to be carried out in the future. Little research has been conducted examining PM after stroke. This study aimed to determine if PM is impaired after stroke through comparison of individuals with stroke to healthy controls. Additionally, it aimed to explore the predictors of PM performance post-stroke.
Twenty-eight individuals with stroke and 27 neurologically healthy controls completed the Cambridge Prospective Memory Test (CAMPROMPT), 2 self-report PM questionnaires, and multiple cognitive measures.
Individuals with stroke performed significantly lower on both event- and time-based PM than controls on the CAMPROMPT, indicating PM impairment. Event-based PM after stroke was significantly predicted by age, retrospective memory (RM), and global cognitive function, whereas time-based PM was only predicted by the metacognitive skill of note-taking. Age and note-taking predicted time-based PM for controls, whereas only age predicted event-based PM for control participants.
The findings of this study have helped to confirm that PM impairment does exist after stroke, particularly when using a standardised PM measure. Furthermore, PM impairment may be predicted by variables, such as age, strategy use, RM, and cognitive ability.
Family care-givers are the backbone of the long-term support system for care receivers at home. Care for stroke survivors after rehabilitation primarily rests on the shoulders of family members, often of older age themselves. We report the outcomes of a new complex support programme, the Care-givers’ Guide, on both individual and system levels. Psycho-social support and personalised information were the main ingredients of this intervention. A two-level multi-methodological approach was needed, with two concurrent interconnected studies. Family care-givers reflected on outcomes at an individual level in a quant-QUAL study with a pre–post quantitative questionnaire and a post-intervention qualitative semi-structured interview. Practitioners participated in a QUAL-QUAL study ex post interview, reflecting on the outcomes on the care-givers and on their own stroke care system. Individual family care-givers showed an increase in health literacy and level of psycho-social health. Qualitative analysis revealed improvement in knowledge, capability to act and individual empowerment; and stabilisation of sense of certainty, life balance and emotional wellbeing. Practitioners observed an optimisation of the stroke support system by improving professionals’ daily routine, augmenting the institutional support offer, securing the quality of patient care and increasing inter-institutional co-operation attempts. Positive outcomes of the support programme were observed on both evaluation levels: family care-givers showed improved health literacy and psycho-social health, whereas the professionals noticed an optimisation of the support system.
Delayed presentation to the emergency department influences acute stroke care and can result in worse outcomes. Despite public health messaging, many young adults consider stroke as a disease of older people. We determined the differences in ambulance utilization and delays to hospital presentation between women and men as well as younger (18–44 years) versus older (≥45 years) patients with stroke.
We conducted a population-based retrospective study using national administrative health data from the Canadian Institute of Health Information databases and examined data between 2003 and 2016 to compare ambulance utilization and time to hospital presentation across sex and age.
Young adults account for 3.9% of 463,310 stroke/transient ischemic attack/hemorrhage admissions. They have a higher proportion of hemorrhage (37% vs. 15%) and fewer ischemic events (50% vs. 68%) compared with older patients. Younger patients are less likely to arrive by ambulance (62% vs. 66%, p < 0.001), with younger women least likely to use ambulance services (61%) and older women most likely (68%). Median stroke onset to hospital arrival times were 7 h for older patients and younger men, but 9 h in younger women. There has been no improvement among young women in ambulance utilization since 2003, whereas ambulance use increased in all other groups.
Younger adults, especially younger women, are less likely to use ambulance services, take longer to get to hospital, and have not improved in utilization of emergency services for stroke over 13 years. Targeted public health messaging is required to ensure younger adults seek emergency stroke care.
Damage to the corticospinal tract (CST) from stroke leads to motor deficits. The damage can be quantified as the amount of overlap between the stroke lesion and CST (CST Injury). Previous literature has shown that the degree of motor deficits post-stroke is related to the amount of CST Injury. These studies delineate the stroke lesion from structural T1-weighted magnetic resonance imaging (MRI) scans, often acquired for research. In Canada, computed tomography (CT) is the most common imaging modality used in routine acute stroke care. In this proof-of-principle study, we determine whether CST Injury, using lesions delineated from CT scans, significantly explains the variability in motor impairment in individuals with stroke.
Thirty-seven participants with stroke were included in this study. These individuals had a CT scan within the acute stage (7 days) of their stroke and underwent motor assessments. Brain images from CT scans were registered to MRI space. We performed a stepwise regression analysis to determine the contribution of CST injury and demographic variables in explaining motor impairment variability.
Using clinically available CT scans, we found modest evidence that CST Injury explains variability in motor impairment (R2adj = 0.12, p = 0.02). None of the participant demographic variables entered the model.
We show for the first time a relationship between CST Injury and motor impairment using CT scans. Further work is required to evaluate the utility of data derived from clinical CT scans as a biomarker of stroke motor recovery.
This chapter reviews both seminal and recent work on late-life depression (LLD), with an emphasis on the vascular depression subtype of LLD. We first describe the clinical features and symptom presentation of LLD, highlighting executive functioning deficits that are a core feature of the “depression with executive dysfunction” syndrome. We discuss both vascular and nonvascular etiological pathways to depression with executive dysfunction in older adults. We highlight recent findings on the association between vascular disease, altered structural and functional brain network connectivity, and clinical symptoms in LLD. Vascular depression is associated with nonresponse to standard pharmacologic treatment. As such, behavioral interventions offer promising avenues for treatment. Novel behavioral approaches encompass psychotherapy, noninvasive brain stimulation, and cognitive remediation that are targeted toward the specific neural circuitry dysfunctions that underlie both affective and cognitive symptoms in older adults. We review these approaches, as well as psychosocial, exercise, and lifestyle interventions.
A 43-year-old female presents to the emergency department (ED) after she woke up with the sensation that the room was spinning and vomited three times at home. She continues to have significant vertigo when she presents to the ED 4 hours later. Her symptoms are worsened by head movement. She has noticed some unsteadiness but is able to walk unaided. When you examine her, she has left-beating horizontal nystagmus with a slight rotatory component to the left.
Both clinically observable and subclinical hemispatial neglect are related to functional disability. The aim of the present study was to examine whether increasing task complexity improves sensitivity in assessment and whether it enables the identification of subclinical neglect.
We developed and compared two computerized dual-tasks, a simpler and a more complex one, and presented them on a large, 173 × 277 cm screen. Participants in the study included 40 patients with unilateral stroke in either the left hemisphere (LH patient group, n = 20) or the right hemisphere (RH patient group, n = 20) and 20 healthy controls. In addition to the large-screen tasks, all participants underwent a comprehensive neuropsychological assessment. The Bells Test was used as a traditional paper-and-pencil cancellation test to assess neglect.
RH patients made significantly more left hemifield omission errors than controls in both large-screen tasks. LH patients’ omissions did not differ significantly from those of the controls in either large-screen task. No significant group differences were observed in the Bells Test. All groups’ reaction times were significantly slower in the more complex large-screen task compared to the simpler one. The more complex large-screen task also produced significantly slower reactions to stimuli in the left than in the right hemifield in all groups.
The present results suggest that dual-tasks presented on a large screen sensitively reveal subclinical neglect in stroke. New, sensitive, and ecologically valid methods are needed to evaluate subclinical neglect.
We assessed the impact of the coronavirus disease 19 (COVID-19) pandemic on code stroke activations in the emergency department, stroke unit admissions, and referrals to the stroke prevention clinic at London’s regional stroke center, serving a population of 1.8 million in Ontario, Canada. We found a 20% drop in the number of code strokes in 2020 compared to 2019, immediately after the first cases of COVID-19 were officially confirmed. There were no changes in the number of stroke admissions and there was a 22% decrease in the number of clinic referrals, only after the provincial lockdown. Our findings suggest that the decrease in code strokes was mainly driven by patient-related factors such as fear to be exposed to the SARS-CoV-2, while the reduction in clinic referrals was largely explained by hospital policies and the Government lockdown.
Endovascular thrombectomy (EVT) is effective in reducing disability in selected patients with stroke and large vessel occlusion (LVO), but access to this treatment is suboptimal.
We examined the proportion of patients with LVO who did not receive EVT, the reasons for non-treatment, and the association between time from onset and probability of treatment.
We conducted a retrospective cohort study of consecutive patients with acute stroke and LVO presenting between January 2017 and June 2018. We used multivariable log-binomial models to determine the association between time and probability of treatment with and without adjustment for age, sex, dementia, active cancer, baseline disability, stroke severity, and evidence of ischemia on computerized tomography.
We identified 256 patients (51% female, median age 74 [interquartile range, IQR 63.5, 82.5]), of whom 59% did not receive EVT. The main reasons for not treating with EVT were related to occlusion characteristics or infarct size. The median time from onset to EVT center arrival was longer among non-treated patients (218 minutes [142, 302]) than those who were treated (180 minutes [104, 265], p = 0.03). Among patients presenting within 6 hours of onset, the relative risk (RR) of receiving EVT decreased by 3% with every 10-minute delay in arrival to EVT center (adjusted RR 0.97 CI95 [0.95, 0.99]). This association was not found in the overall cohort.
The proportion of patients with acute stroke and confirmed LVO who do not undergo EVT is substantial. Minimizing delays in arrival to EVT center may optimize the delivery of this treatment.
The purpose of the present study was to evaluate the efficacy and safety of (−)-OSU6162 in doses up to 30 mg b.i.d. in patients suffering from mental fatigue following stroke or traumatic brain injury (TBI).
This 4 + 4 weeks double-blind randomised cross-over study included 30 patients afflicted with mental fatigue following a stroke or head trauma occurring at least 12 months earlier. Efficacy was assessed using the Mental Fatigue Scale (MFS), the Self-rating Scale for Affective Syndromes [Comprehensive Psychopathological Rating Scale (CPRS)], the Frenchay Activity Index (FAI), and a battery of neuropsychological tests. Safety was evaluated by recording spontaneously reported adverse events (AEs).
There were significant differences on the patients’ total FAI scores (p = 0.0097), the subscale FAI outdoor scores (p = 0.0243), and on the trail making test (TMT-B) (p = 0.0325) in favour of (−)-OSU6162 treatment. Principal component analysis showed a clear overall positive treatment effect in 10 of 28 patients; those who responded best to treatment had their greatest improvements on the MFS. Reported AEs were mild or moderate in severity and did not differ between the (−)-OSU6162 and the placebo period.
The most obvious beneficial effects of (−)-OSU6162 were on the patients’ activity level, illustrated by the improvement on the FAI scale. Moreover, a subgroup of patients showed substantial improvements on the MFS. Based on these observed therapeutic effects, in conjunction with the good tolerability of (−)-OSU6162, this compound may offer promise for treating at least part of the symptomatology in patients suffering from stroke- or TBI-induced mental fatigue.
Estimation of intravascular volume status by clinical examination and static measurements such as central venous pressure and pulmonary capillary wedge pressure do not predict fluid responsiveness. Current evidence indicates that dynamic monitoring of arterial pressure and derived indices are the most sensitive and specific means of determining fluid responsiveness, especially in mechanically ventilated patients. Several monitors that automate and embellish this approach, a few of which are noninvasive, are now commercially available and they are gradually being incorporated into intensive and perioperative care practice. This chapter reviews the physiologic underpinnings of how and why the arterial pressure waveform can be used to determine fluid responsiveness and gives an overview of the devices incorporating these principles.
Introduction: Atrial Fibrillation (AF) is the most common arrhythmia seen in patients presenting to the emergency department (ED). AF increases the risk of ischemic stroke which can be mitigated by anticoagulant prescription. National guidelines advise that emergency physicians initiate anticoagulation when AF is first diagnosed. We aimed to evaluate the 90-day incidence of stroke and major bleeding among emergency patients discharged home with a new diagnosis of AF. Methods: This was a health records review of patients diagnosed with AF in two EDs. We included patients ≥ age 18, with a new diagnosis of AF who were discharged from the ED, between 1st May 2014 and 1st May 2017. Using a structure review we collected data on CHADS65 and CHADS2 scores, contraindications to direct oral anticoagulant (DOAC) prescription and initiation of anticoagulation in the ED. Patient charts were reviewed for the diagnosis of stroke, transient ischemic attack (TIA), ischemic gut, ischemic limb or other systemic embolism within 90 days of the index ED presentation. We extracted data on major bleeding events within 90 days, defined by the International Society of Thrombosis and Haemostasis criteria. All data were extracted in duplicate for validation. Results: We identified 399 patients fulfilling the inclusion criteria, median age 68 (IQR 57-79), 213 (53%) male. 11 patients were already prescribed an anticoagulant for another indication and 19 had a contraindication to prescription of a DOAC. 48/299 (16%) CHADS65 positive patients were initiated on an anticoagulant, 3 of whom had a contra-indication to initiation of anticoagulation in the ED (1 dual antiplatelet therapy, 2 liver cirrhosis). 1/100 CHADS65 negative patients was initiated on anticoagulation. The median CHADS2 score was 1 (IQR 0-2). Among the 49 patients initiated on anticoagulation, 3 patients had a stroke/TIA within 90 days, 6.1% (95% CI; 2.1-16.5%). There were no bleeding events 0.0% (95% CI; 0.0-7.3%). Among the 350 patients who were not initiated on anticoagulation in the ED, 4 patients had a stroke/TIA 1.1% (95% CI; 1.1-2.9%) within 90 days and 2 patients had a major bleeding event. Conclusion: Prescription of anticoagulation for new diagnoses of AF was under-utilized in these EDs. The 90-day stroke/TIA rate was high, even among those given an anticoagulant prescription in the ED. No patient had an anticoagulant-associated bleeding event.