Cerebrovascular Patients Research Articles

A Study Protocol for Estimating the Association of De Ritis ratio (AST/ALT) with Outcomes in Patients of Acute Ischemic Stroke

Background: One of the clinical endpoints of atherosclerosis is stroke, the most prominent clinical manifestation of cerebrovascular disease. It is a cerebral blood vessel disease that nourishes the brain. A global health concern is stroke. It is the second most prevalent cause of death worldwide and the fourth leading cause of disability. The underlying pathophysiology in most ischemic strokes is atherosclerosis. Few studies have shown that high AST/ALT ratio was independently corelated with the increased danger of complication and death in cerebrovascular event patients. This research aims to assess the correlation of De Ritis ratio in cases of acute ischaemic stroke at admission and their prognosis at 3 months.
 Methodology: This will be a observational cross sectional study. About 65 patients with signs suggestive of acute ischemic will be examined. A comprehensive laboratory examination will be carried out. For confirmation of the diagnosis, all patients will undergo CT SCAN or MRI assessment. The primary results of stroke severity on admission will be obtained according to the NIHSS scale. The ranking for NIHSS would be dichotomized to less than 5 and more than 5. For all cases diagnosed with acute ischemic stroke, AST/ALT RATIO will be computed. Data will be analysed with relevant statistical tests.
 Results Expected: We expect a significant correlation between serum de-Ritis ratio and prognosis of acute ischaemic stroke.

Genotypic stratification of risk of acute cerebral circulation disorder

Genotypic stratification of risk of acute cerebral circulation disorder

Effect of enteral nutrition with eicosapentaenoic acids for prevention of bedsores in cerebrovascular disease patients

Rationale: In cases with severely impaired consciousness due to cerebrovascular diseases, patients must go through therapy under hospitalization for several days, and are at risk of bedsores due to long-term bed rest during thrapeutical period. If bedsores could be prevented by feeding an enteral diet enriched with EPA, it can be supposed that this diet therapy might make a contribution to improvement of aspects of clinical care and reduction of clinical costs.

Cost Control of Treatment for Cerebrovascular Patients Using a Machine Learning Model in Western China.

Background Cerebrovascular disease has been the leading cause of death in China since 2017, and the control of medical expenses for these diseases is an urgent issue. Diagnosis-related groups (DRG) are increasingly being used to decrease the costs of healthcare worldwide. However, the classification variables and rules used vary from region to region. Of these variables, the question of whether the length of stay (LOS) should be used as a grouping variable is controversial. Aim To identify the factors influencing inpatient medical expenditure in cerebrovascular disease patients. The performance of two sets of classification rules, and the effects of the extent of control of unreasonable medical treatment, were compared, to investigate whether the classification variables should include LOS. Methods Data from 45,575 inpatients from a Healthcare Security Administration of a city in western China were used. Kruskal–Wallis H tests were used for single-factor analysis, and multiple linear stepwise regression was used to determine the main factors. A chi-squared automatic interaction detector (CHAID) algorithm was built as a decision tree model for grouping related data. The intensity of oversupply of service was controlled step by step from 10% to 100%, and the performance was calculated for each group. Results The average hospitalization cost was 1,284 US dollars, and the total was 51.17 million US dollars. Of this, 43.42 million were paid by the government, and 7.75 million were paid by individuals. Factors including gender, age, type of insurance, level of hospital, LOS, surgery, therapeutic outcomes, main concomitant disease, and hypertension significantly influenced inpatient expenditure (P < 0.05). Incorporating LOS, the patients were divided into seven DRG groups, while without LOS, the patients were divided into eight DRG groups. More clinical variables were needed to achieve good results without LOS. Of the two rule sets, smaller coefficient of variation (CV) and a lower upper limit for patient costs were found in the group including LOS. Using this type of economic control, 3.35 million US dollars could be saved in one year.

Clinical Profile of Acute Cerebrovascular Accidents

Background: Acute cerebrovascular disease or stroke is one of the most leading causes of morbidity and mortality. Due to change in dietary habits and life style factors, there is increase in co-morbid conditions like diabetes and hypertension. This in turn increases the risk for developing stroke.&#x0D; Aim: To study the cerebrovascular accident patients by analyzing and comparing their clinical profile.&#x0D; Materials and Methods: A prospective study was conducted in a tertiary care hospital in stroke patients. The type of stroke, associated risk factors and prognosis of the patients were studied.&#x0D; Results: A total of 50 patients were included in the study, for a period of 4 months from January 1, 2021 to April 30, 2021. Both male and female were included in the study. The mean age of the patients was 56.86 years. Thrombotic stroke was the most common (50%) followed by embolic and hemorrhagic stroke. Hypertension was the most commonly associated risk factor (80%), followed by diabetes (60%), smoking (52%), dyslipidemia (34%) and alcohol (28%). The comparatively higher incidence of cerebrovascular accidents in age less than 60 years is attributed to the rise in risk factors in the young age (P&lt;0.05). The average duration of hospitalization was 6.58 days. There is no in-hospital mortality.&#x0D; Conclusion: With prevalence of risk factors on rise, younger individuals are also affected. Proper risk factor management will help in preventing stroke and its recurrence.

A PROSPECTIVE OBSERVATIONAL STUDY ON THE ASSESSMENT OF POTENTIAL DRUG-DRUG INTERACTIONS AND MANAGEMENT OF POST-COMPLICATIONS IN STROKE PATIENTS AT A TERTIARY CARE TEACHING HOSPITAL

Objective: The objective of the study is to determine the occurrence, frequency, and severity of significant drug-drug interactions in stroke patients, with an emphasis on post complications and their symptomatic management. Methods: A prospective observational study was carried out for 6 mo at Osmania General Hospital, a Tertiary Care Teaching Hospital. The prescriptions taken by stroke patients throughout their hospital stay were analyzed for possible interactions using-Micromedex-2 (Thomson Reuters) × 2.0. Results: A total of 130 prescriptions was analyzed in the study in which 141 drug-drug interactions were found with a male predominance of 85.4%. The majority of interactions were of moderate severity (74.46%) and pharmacokinetics (67.37%) in nature. Among the clinical consequences, decreased atorvastatin efficacy (49.10%) was found to be the highest. The class of drugs most commonly involved in drug-drug interactions was found to be anti-epileptics and statins. 60.15% of the study population were identified with one complication, among which seizures account for 15% of patients. All the complications allied with the condition were treated with drug classes in the study population. Conclusion: This study highlighted the exigency for screening prescriptions of cerebrovascular accident patients for potential drug-drug interactions (pDDIs). Brain edema and seizure were the most accountable complications identified in the study population. The early detection of these problems can improve stroke outcomes and can reduce the mortality or disability rate.

Fabry-Stroke Italian Registry (FSIR): a nationwide, prospective, observational study about incidence and characteristics of Fabry-related stroke in young-adults. Presentation of the study protocol

BackgroundTIA and stroke, both ischemic and hemorrhagic, may complicate Fabry disease at young-adult age and be the first manifestation that comes to the clinician’s attention. No definite indications have yet been elaborated to guide neurologists in Fabry disease diagnostics. In current practice, it is usually sought in case of cryptogenic strokes (while Fabry-related strokes can also occur by classical pathogenic mechanisms) or through screening programs in young cerebrovascular populations. Data on recurrence and secondary prevention of Fabry’s stroke are scanty.MethodsThe study had a prospective observational design involving 33 Italian neurological Stroke Units. Considering the incidence of TIA/stroke in the European population aged < 60 years and the frequency of Fabry disease in this category (as foreseen by a pilot study held at the Careggi University-Hospital, Florence), we planned to screen for Fabry disease a total of 1740 < 60-year-old individuals hospitalized for TIA, ischemic, or hemorrhagic stroke. We investigated TIA and stroke pathogenesis through internationally validated scales and we gathered information on possible early signs of Fabry disease among all cerebrovascular patients. Every patient was tested for Fabry disease through dried blood spot analysis. Patients who received Fabry disease diagnosis underwent a 12-month follow-up to monitor stroke recurrence and multi-system progression after the cerebrovascular event.DiscussionThe potential implications of this study are as follows: (i) to add information about the yield of systematic screening for Fabry disease in a prospective large cohort of acute cerebrovascular patients; (ii) to deepen knowledge of clinical, pathophysiological, and prognostic characteristics of Fabry-related stroke.

Immediate Glucose-Lowering Effect After the First Administration of Dulaglutide: A Retrospective, Single-Center, Observational Study

IntroductionDulaglutide is a long-acting glucagon-like peptide 1 receptor agonist that is administered once weekly for the treatment of type 2 diabetes. However, the immediate glucose-lowering effect of dulaglutide after the first administration and the factors affecting the efficacy of the drug remain unclear.MethodsThis study was a retrospective and observational study of 80 subjects with type 2 diabetes conducted in a hospitalized setting. The changes (Δ) in the blood glucose (BG) levels at six time points (6-point BG levels) from the baseline (day − 1) to the day after the first administration of 0.75 mg of dulaglutide (day 1) were evaluated. The associations of the Δ 6-point BG levels with the patients’ characteristics and laboratory data were also analyzed.ResultsSignificant reduction of the fasting BG, preprandial BG, postprandial BG, and standard deviation (SD) of the 6-point BG levels was observed on day 1 as compared to day − 1 (P < 0.0001) and the reduced BG levels were maintained throughout the remaining observation period of 5 days. The baseline serum hemoglobin A1c and glycoalbumin levels were positively correlated with the reduction of the fasting BG. The Δ BG levels were not related to the parameters of insulin-secreting capacity. Insulin treatment was positively associated with the reduction of the 6-point BG levels. Patients without cerebrovascular disease and patients without diabetic retinopathy showed greater improvements of the fasting BG and SD of the 6-point BG levels, respectively. Urinary microalbumin level was positively correlated with improvements of the 6-point BG levels. Dulaglutide reduced the BG levels, irrespective of the previously used class of antidiabetic medication(s).ConclusionDulaglutide achieved reduction in glucose level within 24 h of the first injection. The improvement in the BG levels remained stable for a week in the hospitalized clinical setting.

Are there consistent abnormalities in event-related EEG oscillations in patients with Alzheimer's disease compared to other diseases belonging to dementia?

Cerebrospinal and structural-molecular neuroimaging in-vivo biomarkers are recommended for diagnostic purposes in Alzheimer's disease (AD) and other dementias; however, they do not explain the effects of AD neuropathology on neurophysiological mechanisms underpinning cognitive processes. Here, an Expert Panel from the Electrophysiology Professional Interest Area of the Alzheimer's Association reviewed the field literature and reached consensus on the event-related electroencephalographic oscillations (EROs) that show consistent abnormalities in patients with significant cognitive deficits due to Alzheimer's, Parkinson's (PD), Lewy body (LBD), and cerebrovascular diseases. Converging evidence from oddball paradigms showed that, as compared to cognitively unimpaired (CU) older adults, AD patients had lower amplitude in widespread delta (>4Hz) and theta (4-7Hz) phase-locked EROs as a function of disease severity. Similar effects were also observed in PD, LBD, and/or cerebrovascular cognitive impairment patients. Non-phase-locked alpha (8-12Hz) and beta (13-30Hz) oscillations were abnormally reduced (event-related desynchronization, ERD) in AD patients relative to CU. However, studies on patients with other dementias remain lacking. Delta and theta phase-locked EROs during oddball tasks may be useful neurophysiological biomarkers of cognitive systems at work in heuristic and intervention clinical trials performed in AD patients, but more research is needed regarding their potential role for other dementias.

Serum uric acid, lipid profile and alkaline phosphatase levels in ischemic cerebrovascular accident patients

Background: Stroke or cerebrovascular accident (CVA) is noted as the second cause of mortality, especially in the elderly population. Recent studies indicated that higher concentrations of uric acid are involved in various vascular diseases. The findings of previous investigations suggest that, elevated serum alkaline phosphatase (ALP) levels may have a pathophysiological character in the occurrence of atherosclerotic vascular disease (AVD) of the heart and brain. This study evaluated the association between serum uric acid (SUA) levels, serum lipid levels, serum alkaline phosphatase (ALP) levels, and changes in ischemic cerebrovascular accident patients.Methods: All patients with Ischemic cerebrovascular accident age &gt;50 years were included based on their clinical, laboratory, and radiological findings (including computed tomography (CT)/magnetic resonance imaging (MRI)) those admitted in our hospital. As control group 200 healthy individuals matched for sex and age were recruited from the same demographic area.Result: Multiple logistic regression analysis findings proposed four components as significant predictors in ischemic cerebrovascular accident (serum uric acid, serum ALP, LDL and HDL. In this study, it was found, that patients with ischemic cerebrovascular accident had significant difference (p&lt;0.001) in serum uric acid and serum ALP than normal patients (non-ischemic cerebrovascular accident patients).Conclusions: Patients with ischemic cerebrovascular accident had significant difference (p&lt;0.001) in SUA and serum ALP than normal patients (non-ischemic cerebrovascular accident patients). High SUA levels were observed to be associated significantly with ischemic stroke. On the basis of our study design, we cannot clarify that the elevated levels are the risk of ischemic stroke and it requires further studies.

Paroxysmal atrial fibrillation incidence in acute ischemic stroke or transient ischemic attacks detected by 48-h Holter monitoring

Objective To examine the feasibility of early use of 48-h Holter monitoring to detect the incidence of paroxysmal atrial fibrillation (AF) in patients presenting with acute stroke or transient ischemic attack (TIA) and without present evidence of AF in the Neurology Department (MUST University). Background Many ischemic stroke patients have undiagnosed paroxysmal AF. Paroxysmal AF diagnosis is relevant in individuals who present with cerebral stroke and without AF on admission. Diagnosis of paroxysmal AF is essential because it is a strong risk factor for stroke recurrence and also because oral anticoagulation has an advantage over antiplatelet treatment. Patients and methods The study included 200 consecutive patients who had acute ischemic stroke or TIA symptoms. Each of them had no evidence of AF at the time of presentation, and within 1 week, they performed Holter monitoring for 48 h. Results Two-hundred patients with mean age 65.27 ± 13.61 years old with TIA and acute ischemic stroke were found in 41 (20.5%) patients and 159 (79.5%) patients, respectively. All 200 patients were monitored by 48-h Holter. Among 200 cases, 13 (6.5%) patients had paroxysmal AF. All 13 patients had acute stroke and were older than age 60 years. It represented 8.17% of patients with acute cerebrovascular stroke (13 patients out of 159 patients with acute cerebrovascular stroke). The only factor related to an increased risk of paroxysmal AF was stroke type. AF was responsible for 50% of clinically suspected cardiac embolic stroke cases. Conclusion Paroxysmal AF was diagnosed in ~ 6.5% of acute-stroke or TIA patients having normal ECG rhythm by early use of 48-h Holter monitoring. In acute cerebrovascular stroke patients, AF represented 8.17%. Holter monitoring is a feasible and simple tool for paroxysmal AF diagnosis in TIA or acute-stroke patients, thus allowing proper treatment and better secondary prevention.

Diagnostic accuracy of MicroRNA 208b level with respect to different types of atrial fibrillation

MicroRNAs (miRNA) are prerequisite for cardiovascular functions. miRNA miR-208 b is a cardio-specific miRNA with tissue (atrial) levels elevated in atrial fibrillation (AFib) and blood levels significantly elevated in myocardial infarction. We calculated serum levels of miR-208 b in paroxysmal and persistent AFib, embolic cerebrovascular accident patients with AFib as possible etiology and controls. There was a statistically significant change of miR-208 b levels in paroxysmal (p = 0.044) and persistent (p = 0.040) AFib patients, but not for embolic CVA patients. miR-208 b could serve as a new serum marker for paroxysmal AFib.

Study of electrocardiographic changes in patients with acute cerebrovascular accidents

Background: Stroke is “a focal (or at times global) neurological impairment of sudden onset, and lasting more than 24 hours (or leading to death), and of presumed vascular origin. A variety of cardiovascular events like cardiac arrest, arrhythmias, and severe hypotension can be seen in stroke victims. The purpose of this study is to investigate the prevalence and characterization of ECG abnormalities in patients of cerebrovascular accidents.Methods: Study was carried out in Dr. PDMMC and tertiary care hospital Amravati, Maharashtra, India. All acute cerebrovascular accidents patients were the study subjects. The diagnosis of ischemic stroke was confirmed by CT scanning. Pre-validated questionnaire was used for data collection. At the end of the study all the ECG were compared to approach towards the result. Study was carried out over a period of three months from October to December 2020.Results: We have recruited 90 stroke patients, most of them were males. Major type was ischemic stroke. In total 62 (68.89%) stroke patients had some form of ECG change. Majority i.e. 35 (38.89%) patients had QTc prolongation followed by 32 (35.56%) patients had T wave changes. QTc prolongation and Atrial fibrillation were significantly more among hemorrhagic stroke patients (p&lt;0.05) and T wave changes and ST changes (elevation or depression) were significantly more among ischemic stroke patients (p&lt;0.05).Conclusions: Prevalence of ECG abnormalities among stroke patients was more i.e. 68.89%. QTc prolongation and T wave changes were the commonest ECG abnormalities.

An evaluation of efficacy of addition of dexmedetomidine /clonidine to fentanyl in attenuation of pressor response of laryngoscopy and intubation: A prospective double blind randomized controlled trial

Laryngoscopy and intubation have been associated with increased sympathetic responses such as hypertension, tachycardia, arrhythmias, and myocardial infarction. This response is usually transient and variable but might be life threatening in cardiovascular and cerebrovascular compromised patients. So controlling this response is utmost goal of anaesthesia. We evaluated the effectiveness of dexemedetomidine/clonidine to attenuate pressor response.Evaluation of efficacy of addition of Dexemedetomidine/ clonidine to fentanyl in attenuation of pressor response of laryngoscopy and intubation.96 patients were enrolled and randomly divided in three groups having 32 patients each. Group NS received 10 ml normal saline, Group CL received 2mcg/kg Inj. Clonidine and Group DE received 1mcg/kg Inj. Dexemedetomidine infusion over 10 min before laryngoscopy. Heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure were studied immediately after premedication, 10 min after study drug infusion and then at 1, 2,3,4,5 and 10 min intervals. : There was significant fall in mean HR and mean MAP after 10 min of study drug infusion. Clonidine and dexemedetomidine groups had significantly less rise in heart rate and mean arterial pressure after intubation and then at 1,2,3,4,5 and 10 min time intervals compared to placebo group. No significant side effects were observed.: Use of dexemedetomidine 10 min before laryngoscopy was associated with significantly less rise in pressor response compared to placebo group. Dexemedetomidine better attenuates the pressor response compared to clonidine but the difference was statistically insignificant.

Cost-effectiveness of a cardiovascular polypill strategy (aspirin, atorvastatin, ramipril) for the secondary prevention of cardiovascular disease based on real life improvement in risk factor control

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Ferrer Internacional Background The cardiovascular (CV) polypill has consistently demonstrated cost-effectives in decreasing the risk of CV disease in patients in secondary prevention. Previous pharmacoeconomic studies addressed improvements in adherence as a driver of health gains. This economic assessment focuses on the implications of improved control of risk factors with the polypill as observed in clinical practice. Purpose To assess the cost-effectiveness of a fixed-dose combination polypill (ASA 100mg, atorvastatin 20/40mg, ramipril 2.5/5/10mg) strategy for the secondary prevention of CV and cerebrovascular events in adults with a history of coronary heart disease (CHD) or stroke compared to usual care with monocomponents. Methods A Markov cost-effectiveness model (1-year cycles; 4 health states: stable disease, subsequent CHD, subsequent stroke, death; payer perspective; direct medical costs; lifetime horizon; 4% discount rate) based on changes in CV risk factors (total cholesterol, 18.3% reduction; high density lipoprotein cholesterol, 2.1% increment; systolic blood pressure, 11.46% reduction) obtained from a real-life effectiveness study was set for Portugal. The probability of transition between health states was based on the SMART risk equation. Cost-effectiveness was calculated for two cohorts (n = 1,000) of secondary prevention patients with previous CHD or stroke. Systematic reviews, Portuguese registries, mortality tables and official reports were searched to identify effectiveness, epidemiological, costs and utility data. Outcomes were costs (€, 2020) per life year (LY) and Quality Adjusted LY (QALY) gained. One-way (OWA) and probabilistic (PSA) sensitivity analyses tested consistency. Assumptions were validated by experts. Results In the CHD cohort, the incremental cost-effectiveness ratio for the polypill strategy (ICER) is 2,402 €/LY and the incremental cost-utility ratio (ICUR) is 2,328 €/QALY. Incremental cost reaches 278,927 € (polypill, 13,198,506 €; monocomponents: 12,919,579 €) with less subsequent CV events (552.31 vs 641.88) and CV deaths (102.4 vs 118.68). Assuming a willingness-to-pay (WTP) threshold of 30.000 €/QALY gained, the PSA shows a 81.4% probability for the polypill to be cost-effective and 39.1% chances to be costs saving compared to usual care. In the stroke cohort, the ICER is 386 €/LY and the ICUR is 553 €/QALY. Incremental costs are 34,178 € (polypill, 10,138,807 €; monocomponents: 10,104,629 €) with less subsequent CV events (481.99 vs 564.50) and CV deaths (101.00 vs. 117.23) with the polypill. There is a 75.9% probability for the polypill to be cost-effective and 49.5% chances to be costs saving. Conclusion The CV polypill is a cost-effective secondary prevention strategy compared to usual care with monocomponents. Its ICER is well below acceptable thresholds in both CV and cerebrovascular disease patients. It reduces the number of recurrent events at a moderately higher cost compared to monocomponents.

MRI-visible perivascular space volumes, sleep duration and daytime dysfunction in adults with cerebrovascular disease

ObjectivesRecent studies suggest that interindividual genetic differences in glial-dependent CSF flow through the brain parenchyma, known as glymphatic flow, may trigger compensatory changes in human sleep physiology. In animal models, brain perivascular spaces are a critical conduit for glymphatic flow. We tested the hypothesis that MRI-visible PVS volumes, a putative marker of perivascular dysfunction, are associated with compensatory differences in real-world human sleep behavior. MethodsWe analyzed data from 152 cerebrovascular disease patients from the Ontario Neurodegenerative Disease Research Initiative (ONDRI). PVS volumes were measured using 3T-MRI. Self-reported total sleep time, time in bed, and daytime dysfunction were extracted from the Pittsburgh Sleep Quality Index. ResultsIndividuals with greater PVS volumes reported longer time in bed (+0.85 h per log10 proportion of intracranial volume (ICV) occupied by PVS, SE = 0.30, p = 0.006) and longer total sleep times (+0.70 h per log10 proportion of ICV occupied by PVS volume, SE = 0.33, p = 0.04), independent of vascular risk factors, sleep apnea, nocturnal sleep disturbance, depression, and global cognitive status. Further analyses suggested that the positive association between PVS volumes and total sleep time was mediated by greater time in bed. Moreover, despite having on average greater total sleep times, individuals with greater basal ganglia PVS volumes were more likely to report daytime dysfunction (OR 5.63 per log10 proportion of ICV occupied by PVS, 95% CI: 1.38–22.26, p = 0.018). ConclusionsIndividuals with greater PVS volumes spend more time in bed, resulting in greater total sleep time, which may represent a behavioral compensatory response to perivascular space dysfunction.

Effectiveness of Chest Physiotherapy in Cerebrovascular Accident Patients With Aspiration Pneumonia

Effectiveness of Chest Physiotherapy in Cerebrovascular Accident Patients With Aspiration Pneumonia

Assessment of Dietary Habits Using the Diet Quality Index-International in Cerebrovascular and Cardiovascular Disease Patients.

Improvement of dietary habits is recommended for the management of cerebrovascular and cardiovascular diseases (CCVD). This study aimed to evaluate the dietary habits of CCVD patients and compare them with the general population by using the Diet Quality Index—International (DQI-I). Data from the Korean National Health and Nutrition Examination Surveys (2013–2016) were used. Cardiovascular diseases included myocardial infarction, angina pectoris, and heart failure; and cerebrovascular diseases included stroke, cerebral infarction, and hemorrhage. In total, 12,683 subjects over 20 years old were included, comprising 718 CCVD patients and 11,965 non-CCVD subjects. Survey-weighted multiple linear regression analyses with adjustment for covariates were used to compare DQI-I scores. The mean total DQI-I scores for the CCVD and non-CCVD groups were 66.7 ± 9.2 and 67.8 ± 9.2, respectively. After adjusting for covariates, the CCVD group had DQI-I scores significantly lower than the non-CCVD group (coefficient −1.13, p-value = 0.011). In the analysis of each DQI-I component, the CCVD group had lower scores for variety (coefficient −0.54, p-value = 0.004) and adequacy (coefficient −0.86, p-value = 0.001). In this study, using nationally representative data, dietary habits of CCVD patients were shown to be lower in quality than non-CCVD subjects. Therefore, evaluation and education of adequate dietary habits are needed in the management of CCVD patients.

Prognostic Indicators and Outcomes of Hospitalised COVID-19 Patients with Neurological Disease: A Systematic Review and Individual Patient Data Meta-Analysis

Background: Neurological COVID-19 disease has been reported widely, but often without using standard case definitions or detailed diagnostic work up. Several meta-analyses, based on such reports, describe the neurological diagnoses but give little information on outcomes and risk factors.Methods: We conducted an individual patient data meta-analysis of hospitalised patients with neurological COVID-19 disease, using standard case definitions. We invited authors of studies from the first pandemic wave, plus clinicians in the Global COVID-Neuro Network with unpublished data, to contribute, and extracted aggregate data from published reports. We analysed features associated with poor outcome (moderate to severe sequelae or death, 3-6, on the modified Rankin scale) using multivariable models. Findings: We identified 381 studies (31 unpublished) describing 4443 patients with COVID-19 and neurological disease: 83 of these provided IPD for 1979 (45%) patients. Encephalopathy (978 [49%]) and cerebrovascular events (506 [26%]), were the most common diagnoses in the IPD database and aggregate data. Respiratory and systemic symptoms preceded neurological features in 93% of patients; one third developed neurological disease after hospital admission. A poor outcome was more common in patients with cerebrovascular events (76% [95% CI 67-82]), than encephalopathy (54% [42-65]). Intensive care use was high (38% [35-41] overall), and also greater in the cerebrovascular patients. In the cerebrovascular, but not encephalopathic patients, risk factors for poor outcome included breathlessness on admission and elevated D-Dimer. Overall, 30-day mortality was 30% (27-32). The hazard of death was reduced for patients in the WHO European region, but increased in low- and lower-middle-income countries. Interpretation: Neurological COVID-19 disease poses a considerable burden in terms of disease outcomes and use of hospital resources. The different risk factors for encephalopathy and stroke suggest different disease mechanisms which may be amenable to intervention, especially in those who develop neurological symptoms after hospital admission. Funding This study was funded by the UK Medical Research Council’s Global Effort on COVID-19 Programme (MR/V033441/1); UK National Institute for Health Research (NIHR)-funded Global Health Research Group on Acute Brain Infections (17/63/110); and the NIHR Health Protection Research Unit in Emerging and Zoonotic Infections (NIHR200907), at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine and the University of Oxford (Grant Nos. IS-HPU-1112-10117 and NIHR200907).Declaration of Interests: BS reports a grant from UKRI/DHSC Global Effort on COVID-19 Research (Medical Research Council) and non-financial support from UK National Institute for Health Research Global Health Research Group on Brain Infections. SL and TS are supported by a grant from the EU Zika Preparedness Latin American Network consortium (ZikaPLAN). ZikaPLAN has received funding from the EU's Horizon 2020 research and innovation programme under grant agreement number 734584. LCG reports non-financial support from Pfizer, non-financial support from Gilead. LB reports grants from GlaxoSmithKline, Research England and Wellcome Trust. AMBM reports grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico CNPq/Brazil, and São Paulo Research Foundation FAPESP/Brazil. AP reports personal fees from ZAMBON, UCB , BIOMARIN, and ABBvie pharma. TS was an adviser to the GlaxoSmithKline Ebola Vaccine programme, chaired a Siemens Diagnostics clinical advisory board, and advises the WHO Brain Health Unit Forum on Neurology and COVID-19; TS has also previously filed a patent for a test for bacterial meningitis based on a blood test (GB 1606537.7, April 14, 2016), and has grants from the UK Medical Research Council and National Institute for Health Research. All other authors declare no conflict of interest

Effectiveness of Shaker’s exercise in improving swallowing ability among cerebrovascular accidents patients with dysphagia

Effectiveness of Shaker’s exercise in improving swallowing ability among cerebrovascular accidents patients with dysphagia