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The symptoms of postural orthostatic tachycardia syndrome, or POTS, can be as varied as they are confounding.

There can be fatigue, pain, bleeding disorders and anxiety. Heart palpitations and lightheadedness are common. Some patients experience gastrointestinal issues or brain fog. For the most severely affected, the simple act of standing up can send them crumpling into unconsciousness.

Though likely much more common than once thought, POTS remains something of a mystery. Many physicians have never heard of it. There's no lab test to confirm a diagnosis and no treatment to cure the condition.

That could all be changing, owed in large part to the persistence of researchers Dr. William Gunning and Dr. Blair Grubb from The University of Toledo.

"For a long time, people would question whether this disorder even existed," said Grubb, a cardiologist at The University of Toledo Medical Center and Distinguished University Professor in the UToledo College of Medicine and Life Sciences.

Grubb, who has been treating POTS patients and studying the condition for more than three decades, now believes he and his collaborators are increasingly close to proving a long-held theory that POTS is an autoimmune disorder.

He and Gunning, a professor of pathology in the UToledo College of Medicine and Life Sciences whose expertise is in platelet disorders, are collaborating on innovative research examining patients' plasma for autoantibodies and inflammatory markers.

In a retrospective study of 34 POTS patients, Gunning, Grubb and a team of UToledo scientists documented a significant elevation of five inflammatory markers characteristic of an innate immune condition.

"This is a tremendous step forward," Grubb said. "Not only does this work give additional credence to the existence of POTS, we have an idea of pathophysiology and would potentially have a very simple diagnostic test. We don't yet have that with POTS, but these studies suggest we are getting close."

The inflammatory markers identified in the research -- a mixture of specific cytokines and chemokines -- are similar to those seen in patients with other autoimmune disorders, including psoriasis, multiple sclerosis and rheumatoid arthritis.

The paper, published in the journal Clinical Medicine, builds on years of research led by Gunning and Grubb. In 2019, the duo published what was at the time the largest study of POTS patients to date, finding 89% of patients had elevated levels of autoantibodies against the adrenergic alpha 1 receptor.

Taken together, the two publications are among the strongest evidence yet that POTS is an autoimmune disorder.

Grubb and Gunning also have hypothesized that POTS may be initiated by a viral infection.

"There are a number of patients previously diagnosed with COVID-19 being labeled 'long-haulers.' They develop similar symptoms to POTS and many have even been diagnosed with POTS post-COVID," Gunning said. "We don't know whether POTS is acquired or inherited, but viral infections cannot be dismissed as an initiating event in the development of POTS."

While they have yet to test the theory, Grubb and Gunning have observed recent Epstein-Barr viral infections in many patients' medical histories.

"The development of POTS post-COVID is an additional piece of evidence that a viral infection might start a cascade of chemicals produced by the innate immune system in the development of autoantibodies," Gunning said.

While additional research is needed to further validate the study's findings on inflammatory markers and expand the investigation to additional markers, the implications of the study are significant.

Currently physicians are only able to treat the symptoms of POTS. If POTS is confirmed as an autoimmune disorder, knowing the specific inflammatory markers that are engaged could help to direct treatments for the underlying condition itself.

For Grubb, who has dedicated much of his career to caring for POTS patients and is recognized as one of the world's foremost experts in syncope and disorders of the autonomic nervous system, these new discoveries show the value of perseverance.

"The pace of POTS research has accelerated exponentially. Part of that is having new technology that allows us to do this research, but it's also a function of the collaboration we have at this institution," he said. "We have been on the forefront of new innovations and research in the POTS field, and we are making real progress."

PULLMAN, Wash. - People who talk with their doctors are more likely to get vaccinated during a pandemic, according to a study of evidence collected during the "swine flu," the last pandemic to hit the U.S. before COVID-19.

Researchers from Washington State University and University of Wisconsin-Madison surveyed patients about the vaccine for the H1N1 virus, also known as the swine flu, which was declared a pandemic by the World Health Organization in 2009. They found that doctor-patient communication helped build trust in physicians, which led to more positive attitudes toward the H1N1 vaccine--and it was more than just talk; it correlated to people actually getting vaccinated.

The study, recently published in the journal Health Communication, builds on previous research showing doctors can curb negative attitudes toward vaccinations in general, but this study specifically focuses on that role during a pandemic.

"A vaccine during a pandemic is definitely different from others, like the flu vaccine, which people already know about," said Porismita Borah, an associate professor in WSU's Murrow College of Communication and lead author on the study. "During a pandemic, it is a new vaccine for everybody. People may have more hesitancy and may be more worried about side effects. The doctor's office is one of the best sources of information for patients who have questions."

The researchers analyzed survey responses from more than 19,000 people nationwide on their attitudes toward doctors and their willingness to discuss vaccines with their physician as well as their willingness to get vaccinations--and ultimately whether or not they got the H1N1 vaccine. They found that the willingness to talk to doctors about the issue correlated with increased trust and receiving the vaccination.

The authors note that doctors often feel that they cannot ethically tell patients to take a certain vaccine. Instead they recommend physicians simply act as a resource, helping answer questions so patients can make better informed decisions. They do not, however, need to wait until patients come to them.

"Doctors could voluntarily reach out to patients, even by email, to let them know what the COVID-19 vaccine means," said Borah. "They can answer questions like how was the vaccine made? What should patients expect? Why are there two doses? I think there might be many questions people have which can be easily answered by primary care physicians who are usually well trusted by the general public."

Doctor communication with patients is particularly pressing now, Borah added, given that that one in five Americans showed an unwillingness to get the COVID-19 vaccine and the amount of misinformation around the pandemic.

"People have to be really careful about what they're seeing and what they're reading because there is so much misinformation circulating on social media," said Borah. "Sometimes this misinformation is circulated by friends and family members without any sort of bad intention--they just share it, so it's extremely important to get information from trusted sources."

Mantle cell lymphoma is a malignant disease in which intensive treatment can prolong life. In a new study, scientists from Uppsala University and other Swedish universities show that people with mantle cell lymphoma who were unmarried, and those who had low educational attainment, were less often treated with a stem-cell transplantation, which may result in poorer survival. The findings have been published in the scientific journal Blood Advances.

Patients diagnosed with a mantle cell lymphoma (MCL) where the disease has spread receive intensive treatment with cytotoxic drugs and stem-cell transplantation. In a new study, researchers looked at which people are more likely to be offered transplants, and compared survival between those selected for transplantation versus those not selected. The study showed that transplantation prolongs life, but that people who were unmarried or had a lower level of education received a transplant less often.

"We don't know exactly why the unmarried or less educated patients got transplants less often, but we can speculate that less social support, or inadequate information, may lead to a fear - in both the patient and doctor alike - of undergoing a very demanding treatment. If you have lots of other diseases, you can't tolerate a transplant," says Ingrid Glimelius, chief physician and researcher at the Department of Immunology, Genetics and Pathology, who led the study.

The study included 369 patients from all over Sweden, diagnosed with MCL between 2000 and 2014 and aged 18-65 at the time. Among them, 40 per cent did not undergo a transplant during the initial treatment. According to the researchers, this was a surprisingly high proportion.

"In some cases, you shouldn't do a transplant - for instance, if the disease is very indolent or if you're too ill to tolerate the treatment. But this study shows that the people who weren't selected for a transplant also had clearly lower survival. This suggests that transplantation is a very important component in the treatment," Glimelius says.

Mortality within 100 days after transplantation was low, which also indicates that it is a safe treatment that could probably have been considered more often in Sweden. For people who are still unable to undergo a transplant, the study suggests that, instead of cytotoxic drugs alone, the option of providing new, modern and targeted drugs should be considered.

"Studies of this kind are important because they can lead to certain groups in society being offered more support. They can also act as an eye-opener for patients, health professionals and politicians alike, showing that there's still a need for more equality in health care in Sweden," says Ingrid Glimelius.

A multiyear workplace health promotion program can slow down the increase in health risks for working-age people. A study by the Faculty of Sport and Health Sciences at the University of Jyväskylä followed what kind of changes happened among participants during an eight-year workplace health promotion program in smoking, minor exercise, high blood pressure, musculoskeletal disorders, and overweight. The results of the study were encouraging for health promotion.

According to earlier studies, a high number of health risks are connected to an increase in occupational health care costs, lower productivity at work, and the growing number of sickness absences. Multiyear preventive actions at workplaces have not yet been studied much, and no research results have previously been available for studying which changes in health risks can be achieved during several years of intervention.

"Earlier studies have indicated that prevention is possible, but most of the studied programs have lasted only from one to three years," states Antti Äikäs, a doctoral student at the University of Jyväskylä. "Our research showed that in the long run we can prevent people in the low- or moderate-level risk groups from transitioning into the group of high-level health risks."

According to the research results, the study group had fewer health risks than average Finnish working-age people. The health risk assessments showed that 50-60% of the male-dominated personnel were categorized to the low-level health risk group (0-1 risks), 30-35% to the moderate-level group (2-3 risks), and 9-11% to the high-level health risk group (more than 4 risks).

The study also compared changes between low-, moderate- and high-risk groups during the multiyear health promotion program, and found that most of the personnel remained at the same level, 13-15% improved their rating, while the rating deteriorated for only 12-21%.

Impacts of aging were delayed

Health risks tend to get more common as people age. However, this study showed no statistically significant growth in the total number of health risks in the target population.

"Our research team detected improvements as well as deterioration among the participants, which means that the overall change was minimal," Äikäs notes. "The results are encouraging for maintaining working ability and enhancing national health."

The study examined a multiyear workplace health promotion program that was carried out by a Finnish forest corporation (N = 523-651) and a Finnish wellness company 4event Ltd from 2010 to 2017. The average age of the participants was 43.8 years. Over 120 separate services were performed around Finland during the program. During the first four years, the services were focused to support the lifestyle change of the employees, and the last four years were focused on mental resources and workplace atmosphere. The incidence of health risks was surveyed through three different health risk assessments by carrying out physiological measurements and questionnaires in 2010-2011, 2013-2014, and 2016-2017.

(Philadelphia, PA) - About 6.2 million Americans suffer from heart failure, an incurable disease with a staggering mortality rate - some 40 percent of patients die within five years of diagnosis. Heart failure is one form of heart disease, for which new therapies are desperately needed.

Now, in new work, scientists at the Lewis Katz School of Medicine (LKSOM) at Temple University identify a path to a promising novel therapeutic strategy, taking aim at a molecule in the heart known as G protein-coupled receptor kinase 5 (GRK5). In a study published online in the journal Cardiovascular Research, the scientists show in mice that reducing GRK5 levels can significantly improve survival following heart attack.

"Previous studies had found that GRK5 is elevated in patients with heart failure," explained Claudio de Lucia, MD, PhD, an associate scientist in the Center for Translational Medicine at LKSOM and lead author on the new study. "Our new research, in mice that experienced myocardial infarction (heart attack), shows that GRK5 overexpression is associated with physiological changes in the heart that decrease cardiac function."

Too much GRK5 in the heart was further linked to increased recruitment of immune cells into damaged heart tissue and harmful inflammation. The combination of these factors - reduced heart function and an influx of immune cells and inflammation - ultimately contributed to increased mortality in mice after heart attack.

Dr. de Lucia and colleagues, working with Walter J. Koch, PhD, W.W. Smith Endowed Chair in Cardiovascular Medicine, Professor and Chair of the Department of Pharmacology, Director of the Center for Translational Medicine at LKSOM, and senior investigator on the new study, examined GRK5 levels in the heart eight weeks after mice experienced heart attack. By that time, animals had developed a condition known as post-ischemic heart failure, in which heart function declines over time owing to reduced blood supply. Tissue damage that impairs circulation in the heart ultimately starves heart cells of the oxygen and nutrients they need to keep the heart working.

After establishing a link between increased GRK5 expression, decreased heart function, and decreased survival in the weeks following heart attack, the researchers explored the effect of manipulating GRK5 to lower its levels in the heart. To do this, they developed a GRK5 knockout mouse model, in which GRK5 expression was eliminated specifically from heart cells.

"After heart attack, our GRK5 knockout mice had much better heart function and better survival curves compared to wild-type mice with normal GRK5," Dr. de Lucia explained. "This raises the possibility that GRK5 inhibition may be a viable therapeutic strategy in human patients, as well."

The team's future work will focus on GRK5 inhibitors and understanding their effects in animals with heart disease.

"Highly selective drugs that block GRK5 are already available," Dr. de Lucia said. "Our next step is to test these agents in animal models of heart failure in order to determine their effect on cardiac function and survival."

Dr. Koch added, "Targeting abnormal levels and activity of GRK5 would represent a totally new drug class [for heart failure] that we hope will add important and innovative value to our fight against heart disease."

ITHACA, N.Y. - A new Penn State and Cornell study describes an effort to produce the most comprehensive and high-resolution map yet of chromosome architecture and gene regulation in yeast, a major step toward improving understanding of development, evolution and environmental responses in higher organisms.

Specifically, the study mapped precise binding sites of more than 400 different chromosomal proteins in the yeast genome, most of which regulate the expression of genes.

Yeast cells provide a simple model system with 6,000 genes, most of which are found in other organisms, including humans, making them excellent candidates for studying fundamental genetics and complex biological pathways.

The paper, "A High-Resolution Protein Architecture of the Budding Yeast Genome," published March 10 in the journal Nature.

"It's a vastly more complex proposition, but like the sequencing of the yeast genome preceded the sequencing of the human, I'm sure we will be able to see the regulatory architecture of the human genome," said senior author B. Franklin Pugh '83, professor of molecular biology and genetics in the College of Arts and Sciences and a former professor at Pennsylvania State University, where he began this work. Matthew Rossi, a research assistant professor at Penn State, is the paper's first author.

The team used a technique called ChIP-exo to map the binding locations of about 400 different proteins that interact with the yeast genome, some at a few locations and others at thousands of locations.

The team performed more than 1,200 individual ChIP-exo experiments, producing billions of individual data points. Analysis of so much data required use of Penn State's supercomputing clusters and the development of several novel bioinformatic tools to identify patterns and reveal the organization of regulatory proteins in the yeast genome. The analysis revealed a surprisingly small number of unique protein assemblages that are used repeatedly across the yeast genome.

The study revealed two distinct gene regulatory architectures, expanding the traditional model of gene regulation. So-called constitutive genes - those that perform basic "housekeeping" functions and are nearly always active at low levels - required only a basic set of regulatory controls, whereas those activated by environmental signals, known as inducible genes, had a more specialized architecture.

The traditional model of gene regulation involves proteins called "transcription factors," which bind to specific DNA sequences to control the expression of a nearby gene. However, the researchers found that "housekeeping" genes - which comprise the majority of genes in yeast - lacked a protein-DNA architecture that would allow specific transcription factors to bind, a hallmark of inducible genes.

"The resolution and completeness of the data allowed us to identify 21 protein assemblages and also to identify the absence of specific regulatory control signals at housekeeping genes," said co-author Shaun Mahony, assistant professor of biochemistry and molecular biology at Penn State. "The computational methods that we've developed to analyze this data could serve as a jumping-off point for further development for gene regulatory studies in more complex organisms."

WINSTON-SALEM, NC - March 12, 2021 - The Wake Forest Institute for Regenerative Medicine is investigating how cats with chronic kidney disease could someday help inform treatment for humans.

In humans, treatment for chronic kidney disease -- a condition in which the kidneys are damaged and cannot filter blood as well as they should -- focuses on slowing the progression of the organ damage. The condition can progress to end-stage kidney failure, which is fatal without dialysis or a kidney transplant. An estimated 37 million people in the US suffer from chronic kidney disease, according to the Centers for Disease Control.

The American Veterinary Medical Association estimates there are about 58 million cats in the United States. Chronic kidney disease affects 30-50% of cats age 15 years or older. The fibrosis or scarring that occurs as a result of the disease is a common final pathway for kidney disease in both animals and people. For cats, end-stage kidney disease has no effective cure.

In a new study published online by Frontiers in Veterinary Science in the Veterinary Regenerative Medicine platform, the WFIRM research team set out to test the effects of a cell-derived molecular therapy to treat kidney fibrosis in cats. Regenerative therapies using stem cells and vascular fractions have been tested, but the collection of cells or cell fractions is expensive, time consuming, and requires advanced cell processing capabilities not available in most veterinary general practices.

Alternatively, "The use of cell-based molecules to treat kidney fibrosis may be a promising approach," said lead author Julie Bennington, DVM, a WFIRM research fellow and PhD candidate. "Current treatments include pharmaceutical therapies and dietary management to slow disease progression and increase longevity, and alternatives are needed."

In this study, authors used a cell-signaling chemokine -- CXCL12 -- that is produced by cells and stimulates tissue regeneration. Recombinant human CXCL12 is commercially available, inexpensive, and has been shown to reduce fibrosis in rodent models of chronic kidney disease.

The goal of this study was to test the safety, feasibility, and efficacy of ultrasound-guided intra-renal CXCL12 injection in cats with chronic kidney fibrosis, first in a preclinical cat model, and, then in a pilot study in cats that may have early kidney disease.

"Results of these studies together show that intra-renal injection of CXCL12 may be a potential new therapy to treat early kidney disease in cats with a capability for widespread use," said co-author Koudy Williams, DVM, also of WFIRM. "Further clinical evaluations are needed."

Piedmont Animal Health, the company that funded the research, is preparing to set up a clinical pilot study in the US, and Bennington will serve as a consultant.

WFIRM Director Anthony Atala, MD, said this research is a good example of "how a condition like chronic kidney disease, common to both dogs and cats, can be studied and potentially applied to the disease in humans."

Leesburg, VA, March 12, 2021--According to an open-access article in ARRS' American Journal of Roentgenology (AJR), compared with multi-target stool-DNA (mt-sDNA) and fecal immunochemical test (FIT), CT colonography (CTC) with 10 mm threshold most effectively targets advanced neoplasia (AN)--preserving detection while decreasing unnecessary colonoscopies.

"CTC performed with a polyp size threshold for colonoscopy referral set at 10 mm represents the most effective and efficient non-invasive screening test for colorectal cancer (CRC) prevention and detection," clarified first author Perry J. Pickhardt from the department of radiology at the University of Wisconsin School of Medicine & Public Health.

Because the relative performance characteristics of available noninvasive tests had not yet been adequately compared, Pickhardt's team systematically searched PubMed and Google Scholar, including 10 mt-sDNA, 27 CTC, and 88 FIT published screening studies involving 25,132, 33,4932, and 2,355,958 asymptomatic adults, respectively. To determine test-positivity rates (TPR) leading to optical colonoscopy (OC), as well as positive predictive value (PPV) and detection rate (DR) for both AN and CRC, meta-analysis with hierarchical Bayesian modeling was conducted, in accordance with Cochrane Collaboration and PRISMA guidelines.

Pickhardt and colleagues' results showed that CRC prevention via screen detection of AN was highest with CTC, followed by mt- sDNA, and lowest with FIT due to the differing TPR and PPV, although overlap existed in the 95% CIs when accounting for uncertainty. Compared with mt-sDNA and CTC6, FIT and CTC10 strategies yielded substantially lower colonoscopy resource utilization, while mt-sDNA performance appeared to be similar to FIT at low positivity thresholds.

Acknowledging that each CRC screening option has relative advantages and disadvantages that should be carefully considered and tailored to the individual, "in the end," the authors of this AJR article concluded, "the 'best' test may be the one that the patient is willing to undergo."

An electronic supplement to this article is available here: https://www.ajronline.org/doi/10.2214/AJR.20.25416

Astronomers have painted their best picture yet of an RV Tauri variable, a rare type of stellar binary where two stars - one approaching the end of its life - orbit within a sprawling disk of dust. Their 130-year dataset spans the widest range of light yet collected for one of these systems, from radio to X-rays.

"There are only about 300 known RV Tauri variables in the Milky Way galaxy," said Laura Vega, a recent doctoral recipient at Vanderbilt University in Nashville, Tennessee. "We focused our study on the second brightest, named U Monocerotis, which is now the first of these systems from which X-rays have been detected."

A paper describing the findings, led by Vega, was published in The Astrophysical Journal.

The system, called U Mon for short, lies around 3,600 light-years away in the constellation Monoceros. Its two stars circle each other about every six and a half years on an orbit tipped about 75 degrees from our perspective.

The primary star, an elderly yellow supergiant, has around twice the Sun's mass but has billowed to 100 times the Sun's size. A tug of war between pressure and temperature in its atmosphere causes it to regularly expand and contract, and these pulsations create predictable brightness changes with alternating deep and shallow dips in light - a hallmark of RV Tauri systems. Scientists know less about the companion star, but they think it's of similar mass and much younger than the primary.

The cool disk around both stars is composed of gas and dust ejected by the primary star as it evolved. Using radio observations from the Submillimeter Array on Maunakea, Hawai'i, Vega's team estimated that the disk is around 51 billion miles (82 billion kilometers) across. The binary orbits inside a central gap that the scientists think is comparable to the distance between the two stars at their maximum separation, when they're about 540 million miles (870 million kilometers) apart.

When the stars are farthest from each other, they're roughly aligned with our line of sight. The disk partially obscures the primary and creates another predictable fluctuation in the system's light. Vega and her colleagues think this is when one or both stars interact with the disk's inner edge, siphoning off streams of gas and dust. They suggest that the companion star funnels the gas into its own disk, which heats up and generates an X-ray-emitting outflow of gas. This model could explain X-rays detected in 2016 by the European Space Agency's XMM-Newton satellite.

"The XMM observations make U Mon the first RV Tauri variable detected in X-rays," said Kim Weaver, the XMM U.S. project scientist and an astrophysicist at NASA's Goddard Space Flight Center in Greenbelt, Maryland. "It's exciting to see ground- and space-based multiwavelength measurements come together to give us new insights into a long-studied system."

In their analysis of U Mon, Vega's team also incorporated 130 years of visible light observations.

The earliest available measurement of the system, collected on Dec. 25, 1888, came from the archives of the American Association of Variable Star Observers (AAVSO), an international network of amateur and professional astronomers headquartered in Cambridge, Massachusetts. AAVSO provided additional historical measurements ranging from the mid-1940s to the present.

The researchers also used archived images cataloged by the Digital Access to a Sky Century @ Harvard (DASCH), a program at the Harvard College Observatory in Cambridge dedicated to digitizing astronomical images from glass photographic plates made by ground-based telescopes between the 1880s and 1990s.

U Mon's light varies both because the primary star pulsates and because the disk partially obscures it every 6.5 years or so. The combined AAVSO and DASCH data allowed Vega and her colleagues to spot an even longer cycle, where the system's brightness rises and falls about every 60 years. They think a warp or clump in the disk, located about as far from the binary as Neptune is from the Sun, causes this extra variation as it orbits.

Vega completed her analysis of the U Mon system as a NASA Harriett G. Jenkins Predoctoral Fellow, a program funded by the NASA Office of STEM Engagement's Minority University Research and Education Project.

"For her doctoral dissertation, Laura used this historical dataset to detect a characteristic that would otherwise appear only once in an astronomer's career," said co-author Rodolfo Montez Jr., an astrophysicist at the Center for Astrophysics | Harvard & Smithsonian, also in Cambridge. "It's a testament to how our knowledge of the universe builds over time."

Co-author Keivan Stassun, an expert in star formation and Vega's doctoral advisor at Vanderbilt, notes that this evolved system has many features and behaviors in common with newly formed binaries. Both are embedded in disks of gas and dust, pull material from those disks, and produce outflows of gas. And in both cases, the disks can form warps or clumps. In young binaries, those might signal the beginnings of planet formation.

"We still have questions about the feature in U Mon's disk, which may be answered by future radio observations," Stassun said. "But otherwise, many of the same characteristics are there. It's fascinating how closely these two binary life stages mirror each other."

DALLAS, March 11, 2021 -- As integral members of stroke treatment teams, nurses coordinate patient assessment and collaborate care among multiple health care professionals to facilitate the best possible outcomes for patients with acute ischemic stroke. Nurses also advocate for patients and their caregivers to ensure they receive appropriate information and education to successfully navigate phases of treatment in the hospital and after discharge. A series of three new Scientific Statements, "Care of the Patient With Acute Ischemic Stroke," from the American Heart Association, published today in Stroke, a journal of the American Stroke Association, a division of the American Heart Association, provide the latest evidence-based guidance for nurses working in a variety of stroke care settings, including hyperacute settings, emergency departments, intensive care units and stroke care units.

Ischemic stroke occurs when a clot forms in a vessel supplying blood flow to the brain. On average, someone in the United States has a stroke every 40 seconds, and ischemic stroke is the fifth leading cause of death in the U.S. As assessment tools, treatment protocols and overall care for acute ischemic stroke have evolved in recent years, best practice in nursing for care of the patient with a stroke continue to be revised and updated. Stroke care is increasingly complex, and nurses who care for stroke patients are expected to maintain levels of competency in both the acute and recovery care phases of patient care.

Nursing during emergency medical services/emergency care (Prehospital and Acute Phase of Care), Susan Ashcraft et al.

Emergency care for a patient with a suspected stroke centers around the "time is brain" principle due to the importance of quickly identifying patients with a suspected ischemic stroke to prevent potentially irreversible damage to brain tissue. This scientific statement recognizes the importance of the nurse's role in recognition of typical and atypical symptoms of stroke and prompt activation of the stroke response system.

The "D's of Stroke Care" are identified as significant steps in the diagnosis and treatment of stroke. The steps outlining fundamental points where nurses facilitate time-sensitive care are:

Detection - Nurses are key to community education programs that teach risk factor awareness and recognition of early stroke warning signs. Events that target high-risk groups are especially important.

Dispatch - Emergency dispatch personnel are often the first point of contact for someone having a stroke or someone witnessing the stroke. Appropriate training will include recommended prehospital triage, including asking when the patient's "last known normal (LKN)" was. This critical variable indicates when the person was last known to be well and can help determine appropriate routing of the patient for urgent treatment.

Delivery - Comprehensive assessment of a suspected stroke patient by emergency services personnel, including vital signs, current medications list, family and witness contact information, enable emergency department staff to make treatment decisions more efficiently.

Door - Nurses are often the link between the prehospital personnel and the emergency department team. Communication is critical to establish appropriate triage and reduce the time it takes for a patient to receive treatment. Mobile stroke units, ambulances equipped with specially trained staff and tools to provide care while en route to the hospital, can improve patient outcomes due to the ability to perform prehospital imaging, diagnosis and treatment.

Data - The arrival time of a patient at the emergency department or the documented time of arrival of a mobile stroke unit is an important data point for tracking time-sensitive metrics to determine processes and options to treat a patient with ischemic stroke. Stroke screening and triage scoring systems conducted by triage nurses help quickly determine the severity of a patient's condition and the appropriate resources needed.

Decision - Updated AHA recommendations reflect a quicker patient evaluation timeframe; the goal is to begin stroke treatment within 30 minutes after arrival at the hospital. To facilitate such timing, activation of a stroke response team can be initiated by ambulance personnel or immediately after the triage assessment at the time of patient arrival.

Drug/Device - Treatment with clot dissolving medications, as well as appropriate patient monitoring during administering of the medications, are detailed.

Disposition - Nursing interventions during transitions, such as when a patient leaves the emergency department to be transferred to an intensive care unit or stroke care unit, can successfully improve stroke outcomes. An emergency department code stroke pathway chart illustrates the key nursing responsibilities and sequence of care during this acute phase.

"Stroke care has become increasingly complex as reperfusion dominates our treatment protocols, demonstrating the intensity of nursing responsibility and the expanded and critical role for nurses in providing stroke care," said Chair of the writing committee Susan Ashcraft, D.N.P., A.P.R.N., FAHA, a neurocritical care clinical nurse specialist at Novant Health in Charlotte, North Carolina. "Nurses are empowered leaders, facilitating change through designing and implementing improvements in the delivery of stroke care. In addition, our communities continue to demonstrate disparities affecting access to emergency stroke care, requiring nurses to take an active role at the local, state and regional levels to address these needs.

Statement co-authors are Susan E. Wilson, D.N.P., A.P.R.N.; Karin V. Nyström, M.S.N., A.P.R.N., FAHA; Wendy Dusenbury, D.N.P., A.P.R.N., FAHA; Charles R. Wira, M.D., FAHA; and Tamika M. Burrus, M.D. Author disclosures are listed in the manuscript.

Nursing care throughout endovascular and intensive care unit treatment (Endovascular/Intensive Care Unit-Postinterventional Therapy), Mary L. Rodgers, et al.

Nurses serve in a critical role during a patients' stroke treatment by providing communication and care prior to, during and after medical procedures. As stroke treatments and research have evolved, updated nursing procedures in this statement address current evidence, potential complications and clinical practice strategies to ensure positive patient outcomes during the procedural phase of care.

"Acute ischemic stroke patients are vulnerable, and communication among various disciplines in the treatment and care of this population is critical," said Mary L. Rodgers, D.H.A., A.N.P., C.N.S., R.N., chair of the statement writing committee, quality manager for the VA Western New York Healthcare System in Buffalo, New York, and a reviewer for The Joint Commission. "Critical assessments must be done to care for and intervene for this at-risk patient population. These can help to safeguard the patient and improve patient outcomes, thus increasing the opportunity to maintain quality of life after a stroke."

Treatment for ischemic stroke is clot removal so that blood flow may return to the section of the brain affected. Intravenous thrombolysis--administering medication through an IV to dissolve the clot--is the standard treatment, and in 2015, mechanical thrombectomy became an additional standard of care in the U.S. for some patients with strokes caused by large blood clots. During mechanical thrombectomy, which may or may not follow intravenous thrombolysis treatment, a stent retriever device is inserted via a catheter through an artery in the groin up to the blocked artery in the brain. Once in place, the stent opens and retrieves the clot.

"During treatment, the intradisciplinary team needs to know if the patient is improving, staying the same or decompensating," added Rodgers. "Nursing care and identification of patient changes is key during this time. Nursing assessments and interventions assist the team in critical decisions related to treatment efficacy and the needs of the patient."

Throughout stroke procedures, interventional nurses anticipate patient needs, identify any potential complications and maintain patient safety. Their responsibilities encompass all phases of treatment care:

* Prior to the procedure - While no standard currently exists for how frequently nurses should repeat vital sign and neurological assessments, it is reasonable to do so at least every 30 to 60 minutes prior to mechanical thrombectomy procedures, and more often when intravenous clot dissolving medication has been administered. Patient evaluation using the National Institutes of Health Stroke Scale score, a systematic assessment tool that measures stroke-related neurologic deficit, is indicated. Patients with a high score, decreased mental status, a stroke in the back area of the brain, and/or existing heart or lung disease are more likely to require extra support and intubation during the procedure.

* During the procedure - Using universal protocol, nurses monitor patients by assessing vital signs, pain and anxiety, and levels of consciousness. The statement authors note that goals for blood pressure levels during mechanical thrombectomy and the optimal range for good patient outcomes are topics of ongoing research.

* Post procedure - Upon completion of a mechanical thrombectomy procedure, nurses will closely monitor patients for any immediate concerns at the site of the catheter. Current evidence also supports nurses completing a repeat neurological assessment on a patient immediately following the procedure, and to repeat the assessment every 15 minutes for the first two hours; every 30 minutes for the following six hours; and every hour for the next 16 hours.

When a patient with an acute ischemic stroke is treated with intravenous clot dissolving medication, with or without mechanical thrombectomy, they are vulnerable to developing complications that could lead to secondary brain injury and therefore typically require intensive monitoring in an intensive care unit (ICU). Recognition of post-procedure complications is necessary, as are timely and continuing neurological assessments, cardiac monitoring, vital sign checks, blood sugar monitoring and swallowing tests.

Statement co-authors are Elizabeth Fox, M.S.N., A.C.N.S, A.G.-A.C.N.P., C.C.R.N., FAHA, co-chair; Tamer Abdelhak, M.D.; Lauren M. Franker, D.N.P., A.P.R.N., A.C.N.P.- B.C.; Brenda Joyce Johnson, D.N.P., C.R.N.P.-B.C., A.N.V.P., FAHA; Christina Kirchner-Sullivan, D.N.P., A.C.N.P.-B.C., A.N.P.-B.C., S.C.R.N.; Sarah L. Livesay, D.N.P., R.N., A.C.N.P.- B.C., FAHA; and Franklin A. Marden, M.D., FAHA. Author disclosures are listed in the manuscript.

Nursing care for the patient after the acute care phase (Posthyperacute and Prehospital Discharge), Theresa L. Green et al.

Through evidence-based best practices, nurses can positively impact patient outcomes, decrease patient length of stay, costs and the likelihood of additional strokes.

"We know that what we do as nurses is important and crucial to the care of patients and families living with stroke, and this statement strengthens and supports the knowledge and provision of evidence-informed nursing care that will enhance and promote recovery and reintegration for patients transitioning across care environments to home and within their community," said writing committee Chair Theresa L. Green, Ph.D., R.N., FAHA, professor of rehabilitation nursing research at the University of Queensland in Brisbane, Australia.

Research confirms stroke patients have better outcomes and lower mortality rates when the medical facility has a specialized stroke unit. Of note, however, is that the research has not used consistent methodology and follow-up measures to assess outcomes, so more studies are needed. In the absence of a stroke unit, patients care consistent with best practice is important. Necessary stroke care assessments, screening tools and interventions outlined in the statement integrate evidence-based guidance from international organizations.

Highlights of key guidance include:

It is important to assess the swallowing ability, temperature and blood glucose levels of a stroke patient as early after a stroke as possible. Between 40% and 78% of patients with stroke experience swallowing difficulties.

Glucose monitoring is necessary for patients who also have Type 2 diabetes, yet glucose monitoring is also important for patients who do not have Type 2 diabetes because patients with high blood sugar following a stroke have a three-fold higher risk of death.

Better patient outcomes result when strategies are in place for early recognition and management of potential complications, including swallowing difficulties, pneumonia, cardiac complications, falls, psychological and neurological issues. One large study indicated one fourth of patients with stroke experienced at least one medical complication while hospitalized, leading to higher risk of adverse outcomes.

Formal rehabilitation assessment by an expert is critical, and mobility rehabilitation is most beneficial at a level that considers the patient's anticipated benefits and tolerance.

The rehabilitation needs of a patient transitioning out of the hospital are best determined based upon neurological, cognitive and physical assessments, in tandem with family/caregiver support and capacity.

"There remains a lack of definition internationally about what specialized stroke nursing care entails," added Green. "There is also a lack of well-planned nursing research detailing the specific contribution nursing makes to patient and family outcomes following stroke, and whether it makes a difference to patient care and outcomes if nurses are certified in a subspecialty area such as stroke nursing. This statement provides much-needed guidance that can contribute to improved patient outcomes."

WINSTON-SALEM, N.C. - March 11, 2021- For people who are overweight or obese and have type 2 diabetes, the first line of treatment is usually lifestyle intervention, including weight loss and increased physical activity. While this approach has cardiovascular benefit for many, it can be detrimental for people who have poor blood sugar control, according to a study conducted by researchers at Wake Forest School of Medicine.

In the study, published in the current issue of the journal Diabetes Care, the researchers re-evaluated the National Institutes of Health Action for Health in Diabetes (Look AHEAD) study that found intensive lifestyle intervention (ILI) neither helped nor hurt people with diabetes.

"Contrary to the initial findings of Look AHEAD, our work found that lifestyle interventions reduced potential cardiovascular harm and optimized benefits for 85% of those in the trial," said the study's lead investigator, Michael P. Bancks, Ph.D., assistant professor of public health sciences at Wake Forest School of Medicine, part of Wake Forest Baptist Health.

"However, for those who had poor blood sugar control, lifestyle intervention increased the risk of major cardiovascular events. Based on our findings, doctors may want to consider alternative options, such as glucose-lowering drugs, before trying lifestyle modification for those people."

Look AHEAD randomized 5145 participants with type 2 diabetes (T2D) who were overweight or obese to 10 years of ILI or a control group that received diabetes support and education. ILI focused on weight loss through decreased caloric intake and increased physical activity.

In the Wake Forest School of Medicine study, the researchers divided the study participants into four subgroups: diabetes onset at older age, poor glycemic control, severe obesity and younger age at onset. These subgroups were determined based on diabetes diagnosis, body mass index, waist circumference, measure of blood sugar value (glycemic control) and the age of diabetes onset.

Bancks and his team examined each group's response to the intensive lifestyle intervention and its association with major cardiovascular events. In the subgroup with poor glycemic control, the intervention was associated with 85% higher risk of having a cardiovascular event as compared to the control group. Among the three other diabetes subgroups analyzed, ILI was not associated with an increased risk of fatal and non-fatal cardiovascular events.

"Although the interest in diabetes subgroups is growing, our study is one of the first to apply it to lifestyle intervention," Bancks said. "So for clinicians, determining which subgroup their patient most closely resembles should help them determine the best treatment option and reduce any potential harm for that individual."

These results provide support for further investigation into whether these findings apply to other diabetes complications, including cognitive issues, and to assess what interventions would be beneficial for those individuals, Bancks said.

A new model of aging takes into account not only genetics and environmental exposures but also the tiny changes that randomly arise at the cellular level.

University Professor Caleb Finch introduced the “Tripartite Phenotype of Aging” as a new conceptual model that addresses why lifespan varies so much, even among human identical twins who share the same genes. Only about 10 to 35 percent of longevity can be traced to genes inherited from our parents, Finch mentioned.

Finch authored the paper introducing the model with one of his former graduate students, Amin Haghani, who received his PhD in the Biology of Aging from the USC Leonard Davis School in 2020 and is now a postdoctoral researcher at UCLA. In the article, they propose that the limited heritability of aging patterns and longevity in humans is an outcome of gene-environment interactions, together with stochastic, or chance, variations in the body’s cells. These random changes can include cellular changes that happen during development, molecular damage that occurs later in life, and more.

“We wanted to introduce a conceptual map and some new terminology that will motivate a more comprehensive understanding of what the limitations of genetic determinants in aging are, how important it is to consider the genetic variance in relationship to the environment, and include this new domain of stochastic variations, which is very well recognized by different fields,” said Finch, who holds the ARCO/William F. Kieschnick Chair in the Neurobiology of Aging at the USC Leonard Davis School. “It hasn’t really been put in a formal context in which the complete package can be discussed, and that’s what I hope our article achieves.”

Expanding on the exposome

The new model is a natural extension of the idea of the exposome, which was first proposed by cancer epidemiologist Christopher Paul Wild in 2005 to draw attention to the need for more data on lifetime exposure to environmental carcinogens. The exposome concept illustrates how external factors, ranging from air pollution and socioeconomic status to individual diet and exercise patterns, interact with endogenous, or internal, factors such as the body’s microbiome and fat deposits.

The exposome is now a mainstream model, eclipsing previous characterizations of environmental factors as affecting risk “one by one.” Finch has previously expanded on the exposome concept with the introduction of the Alzheimer’s disease exposome. The gero-exposome now considers how genes and the environment interact over the lifespan to shape how we age.

The new model illustrates that cell-by-cell variations in gene expression, variations arising during development, random mutations, and epigenetic changes – turning genes “off” or “on” – should be explicitly considered apart from traditional genetic or environmental research regarding aging, Finch said. More detailed study into these chance processes has been enabled by cutting-edge research techniques, including the study of gene transcription within single cells as well as ChIP-sequencing, which can illustrate how individual proteins interact with DNA.

Effects of happenstance on health

In the paper, Finch and Haghani discussed several examples of how risks of age-related disease are poorly predicted by DNA alone but are heavily influenced by environmental exposures as well as the time and duration of the exposure, including during development or over the course of decades.

One well-known example of a gene that is associated with increased Alzheimer’s risk is ApoE-4; however, having the ApoE-4 gene doesn’t definitively mean someone will get Alzheimer’s. Studies in both mice and humans revealed that ApoE-4 and clusters of related genes interact with exposures such as air pollution or cigarette smoke to influence risk, and Alzheimer’s patients also show differences in their epigenetics as compared to individuals without the disease.

He added that the idea of environmental exposure can stretch farther than many people expect. Disease exposure earlier in life can affect health risks later in life – and across generations.

“The environment that we’re exposed to goes back to our grandmothers because the egg we came from was in our mother’s ovaries at the time of her birth,” he explained. “So that means, in my case, because my grandmother was born in 1878, I might very well carry some traces of the 19th century environment, which included much greater exposure to infectious disease because there were no antibiotics.”

Finch said that he hopes the more comprehensive model on how genes, environment, and random variations over time interact to influence aging prompt a new discussion of what the rapidly developing field of precision medicine needs to take into account to promote healthy aging.

“I think that there will be a much greater recognition in understanding individual patterns of aging,” he said. “We can only define it up to a certain point by knowing the genetic risks; we must have a more comprehensive understanding of the lifetime exposures, environments and lifestyles of an individual to have a better understanding of genetic risk for particular diseases.”

Researchers at Lund University in Sweden can now show that a new examination method identifies high-risk plaques in the blood vessels surrounding the heart, that cannot be seen solely with traditional angiograms. This type of plaque, rich in fat, could potentially cause recurring heart attacks in patients with heart disease. The study is published in the The Lancet.

"We have been working on this study for ten years. This creates a unique opportunity to treat plaques before they cause a heart attack", says David Erlinge, professor of cardiology at Lund University and Consultant in Interventional Cardiology at Skåne University Hospital, who together with researchers in New York led the study.

The results show that over fourteen percent of the treated patients had some form of heart disease recurrence within four years. In eight percent of the cases, the cause was high-risk plaque that was not detected in a previous angiogram.

Several autopsy studies have previously shown that vulnerable plaques are the underlying cause of most coronary heart disease. When a plaque ruptures and forms one or more clots, they cause the majority of heart attacks and infarction-related sudden death.

"This a major step forward for cardiology," said co-author James Muller, MD, of the Division of Cardiovascular Medicine at Brigham and Women's Hospital in Boston, Mass. "This study has demonstrated a superior way to quantify risk at the plaque level and to identify patients who are at increased risk of experiencing adverse cardiac events."

The new method, known as NIRS (Near-Infrared Spectroscopy) and IVUS (Intravascular Ultrasound), uses infrared light and ultrasound. The examination of the patient is typically performed with a catheter brought to the heart area via the wrist, and done in connection with an angiogram. The high-fat plaques can then be seen in yellow on a color-coded map.

"An angiogram only reveals a shadow of the vessel walls, not what is in the wall. With the new NIRS-IVUS method, we can see vulnerable plaque there as well", says David Erlinge.

The study included 898 patients from 16 hospitals in Sweden, Denmark and Norway. All had suffered a heart attack and were treated with balloon dilation and stents in the coronary arteries. 14.4 percent of the patients in the study experienced new issues within four years of the heart attack. In 8 percent of the patients, the direct cause was untreated plaque. A total of 3,629 untreated plaques were found, which is an average of about four per treated patient.

"The study shows that most of the subsequent cardiac events were caused by plaque not revealed in previous examinations using angiograms and physiological pressure measurements, which are the methods used clinically today", says David Erlinge.

The next big question is how to treat these plaques. The researchers included a small treatment study that showed that stenting of dangerous plaques opened up the vessel and halved the number of cardiac events. This needs to be confirmed by larger studies, however.

DALLAS, March 11, 2021 — The ongoing U.S. opioid epidemic may have led to an increase in the number of strokes due to more bacterial infections of the heart, or infective endocarditis, according to preliminary research to be presented at the American Stroke Association’s International Stroke Conference 2021. The virtual meeting is March 17-19, 2021 and is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

According to the most recent comprehensive data (January 2020) from the Centers for Disease Control and Prevention (CDC), stroke is the fifth leading cause of death in the United States and a major contributor to long-term disability. Typically each year in the United States, up to 47,000 people are treated in the hospital for endocarditis, which increases stroke risk. This serious, sometimes deadly infection occurs when bacteria in the bloodstream reach the heart lining, valves or blood vessels. While endocarditis is uncommon, people with certain heart conditions are at greater risk.

Another risk factor for endocarditis is intravenous (IV) drug use. During IV drug use, bacteria from the injection needle enter the blood stream. In light of the ongoing, two decades-long national opioid epidemic, researchers wanted to understand the risk of stroke among patients with endocarditis from IV drug use compared to patients with endocarditis due to other causes. They also measured the frequency of endocarditis related to IV drug use.

This study included 351 patients treated for endocarditis at Ohio State University’s Wexner Medical Center between January 1, 2014 and July 1, 2018. Nearly half of the patients had a history of IV drug use.

The researchers found:

Over the four-year study, the occurrence of endocarditis from IV drug use increased by 630%.
Patients with endocarditis due to IV drug use were much more likely (26%) than those with endocarditis from other causes (14%) to have a stroke.
Patients with endocarditis from IV drug use were more likely than other patients to be homeless, unemployed and uninsured.

“Patients who are known IV drug users who have endocarditis should be more carefully screened for symptoms of cardiovascular disease,” said the study’s corresponding author Shahid M. Nimjee, M.D., Ph.D., associate professor of neurosurgery and surgical director of the Comprehensive Stroke Center at Ohio State University Wexner Medical Center in Columbus, Ohio.

“The wider societal impact of the opioid epidemic is not well understood,” Nimjee said. “Our research suggests that the impact of the opioid epidemic is far-reaching and contributes to increased costs in the criminal justice, health care systems and the workplace. The increased costs can be particularly substantial for stroke care.”

Medical costs were more than two times higher among patients with endocarditis from IV drug use than among those with endocarditis from other causes. This translated into a difference of more than $100,000 in health care costs during admission per patient, Nimjee noted.

The study did not control for other factors that could have affected stroke risk, and it included patients from only one hospital, therefore, the findings may not apply to other groups of patients.

Patients suffering from dry eye disease symptoms have a lower quality of life compared to those without symptoms, a new study reports. The findings showed that patients with the condition reported negative effects on visual function, their ability to carry out daily activities and their work productivity.

Dry eye disease is a common condition and a frequent reason for patients to seek medical care. It can affect people of any age but is most prevalent in women and in older people. Symptoms include irritation and redness in the eyes, blurred vision, and a sensation of grittiness or a foreign body in the eye. It has been reported that up to a third of adults over 65 years old have the condition, although the actual number is likely to be higher as there is no established diagnostic test and people with mild symptoms are less likely to report them to their doctor.

Treatment often involves prescriptions of artificial tears, ocular lubricants and astringents, which come at a cost to the NHS; in 2014, 6.4 million items were prescribed at a cost of over £27 million.

This new study, led by the University of Southampton, set out to explore how dry eye disease affects the lives of adults in the UK through an online survey of one thousand patients with the condition and further one thousand without. Participants undertook a questionnaire from the National Eye Institute about their visual function and a EuroQol questionnaire on health-related quality of life. Those who declared that they experienced dry eye disease also answered further questions to assess the severity of their symptoms.

The results, published in the journal BMJ Open, showed that a higher proportion of participants with dry eye disease had problems with mobility and experienced more difficulties in their day-to-day activities than patients without the condition. The surveys also revealed they were more likely to suffer from anxiety and depression.

Those with the most severe symptoms we more likely to experience a negative impact on their social and emotional functioning as well work productivity, including missing more time from work as a result of their symptoms.

Dr Parwez Hossain, Associate Professor in Ophthalmology at the University of Southampton, led the study. He said: "This study provided some very useful information on the burden that dry eye disease places on patients. As well as confirming the impact on work and social lives we also discovered showed that the extent of the effects are consistent with the severity of symptoms. We also found that participants with dry eye disease symptoms were a lot more likely to suffer from other comorbidities, twice as many suffered from arthritis, hearing loss or irritable bowel disease compared to the cohort without symptoms.

"Whilst we cannot draw causal associations through this study, the presence of dry eye disease does appear to impact on an individual's health and vision related quality of life."

Although both groups reported similar levels of digital screen use and reading, the cohort with symptoms reported more exposure to environmental factors such as air conditioning, forced heating or air pollution. The research team believe that these factors could either contribute to dry eye disease, or be noticed more by sufferers.