Dysphagia in acute stroke.

A prospective study was undertaken to define the incidence, duration, and consequences of dysphagia in an unselected group of 91 consecutive patients who had suffered acute stroke. The site of the present lesion and of any previous stroke was determined clinically and was confirmed by computed tomography of the brain or necropsy in 40 cases. Of 41 patients who had dysphagia on admission, 37 had had a stroke in one cerebral hemisphere. Only seven patients showed evidence of lesions in both hemispheres. Nineteen of 22 patients who survived a stroke in a hemisphere regained their ability to swallow within 14 days. Dysphagia in patients who had had a stroke in a cerebral hemisphere was associated in this study with a higher incidence of chest infections, dehydration, and death.     

Recurrent primary biliary cirrhosis after liver transplantation--the disease and its management

Primary biliary cirrhosis (PBC) is a chronic cholestatic liver disease characterized by the destruction of interlobular and septal bile ducts that can lead to fibrosis and cirrhosis. Orthotopic liver transplantation (OLT) remains the definitive treatment for decompensated liver disease secondary to PBC. An estimated 10% to 40% of patients develop clinical, biochemical, and histologic changes consistent with recurrent PBC after OLT. However, the presence of recurrent PBC does not appear to affect either graft or patient survival rates. There is conflicting evidence regarding the effect of specific immunosuppressant medications (eg, tacrolimus vs cyclosporine) on the risk of recurrent PBC. Most experts favor the use of ursodeoxycholic acid (UDCA) for recurrent PBC given its beneficial effect in patients with pretransplant PBC and its improvement of biochemical markers in the posttransplant setting. However, despite its potential benefit, there is no evidence that UDCA improves graft or patient survival in recurrent PBC.     

Case management for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial

Background:

Optimization of systolic blood pressure and lipid levels are essential for secondary prevention after ischemic stroke, but there are substantial gaps in care, which could be addressed by nurse- or pharmacist-led care. We compared 2 types of case management (active prescribing by pharmacists or nurse-led screening and feedback to primary care physicians) in addition to usual care.

Methods:

We performed a prospective randomized controlled trial involving adults with recent minor ischemic stroke or transient ischemic attack whose systolic blood pressure or lipid levels were above guideline targets. Participants in both groups had a monthly visit for 6 months with either a nurse or pharmacist. Nurses measured cardiovascular risk factors, counselled patients and faxed results to primary care physicians (active control). Pharmacists did all of the above as well as prescribed according to treatment algorithms (intervention).

Results:

Most of the 279 study participants (mean age 67.6 yr, mean systolic blood pressure 134 mm Hg, mean low-density lipoprotein [LDL] cholesterol 3.23 mmol/L) were already receiving treatment at baseline (antihypertensives: 78.1%; statins: 84.6%), but none met guideline targets (systolic blood pressure ≤ 140 mm Hg, fasting LDL cholesterol ≤ 2.0 mmol/L). Substantial improvements were observed in both groups after 6 months: 43.4% of participants in the pharmacist case manager group met both systolic blood pressure and LDL guideline targets compared with 30.9% in the nurse-led group (12.5% absolute difference; number needed to treat = 8, p = 0.03).

Interpretation:

Compared with nurse-led case management (risk factor evaluation, counselling and feedback to primary care providers), active case management by pharmacists substantially improved risk factor control at 6 months among patients who had experienced a stroke. Trial registration: ClinicalTrials.gov, no. {"type":"clinical-trial","attrs":{"text":"NCT00931788","term_id":"NCT00931788"}}NCT00931788The risk of cardiovascular events is high for patients who survive a stroke or transient ischemic attack.^1,2 Treatment of hypertension and dyslipidemia can substantially reduce this risk.^3–7 However, vascular risk factors are often suboptimally managed after stroke or transient ischemic attack, even among patients admitted to hospital or seen in specialized stroke prevention clinics.^8–10Multiple barriers are responsible for the suboptimal control of risk factors, and traditional means of educating practitioners and patients have limited effectiveness.¹¹ Although it has been suggested that “case managers” may be able to improve the management of risk factors, evidence is sparse and inconsistent between studies.^12–16 The most recent Cochrane review on this topic concluded that “nurse- or pharmacist-led care may be a promising way forward … but these interventions require further evaluation.”¹⁶ Thus, we designed this trial to evaluate whether a pharmacist case manager could improve risk factors among survivors of stroke or transient ischemic attack.¹⁷ Because we have previously shown that hypertension control can be improved by monthly evaluation by nurses (with patient counselling and faxing of blood pressure measurements with guideline recommendations to primary care physicians),¹⁸ and this is an alternate method of case management implemented in many health organizations, we used this approach as the active control group for this study. Thus, our study represents a controlled comparison of 2 modes of case management: active prescribing (pharmacist-led case management) versus screening and delegating to primary care physicians (nurse-led case management).     

Blood into brain after stroke

Using a bone-marrow transplantation chimera-model in mice, we have shown that after a cerebral infarction, bone marrow-derived cells differentiate into cerebral endothelial cells and NeuN-expressing cells