Stroke Victims Research Articles

The Role of Skeletal Muscles in Exertional Heat Stroke Pathophysiology

The active participation of skeletal muscles is a unique characteristic of exertional heat stroke. Nevertheless, the only well-documented link between skeletal muscle activities and exertional heat stroke pathophysiology is the extensive muscle damage (e. g., rhabdomyolysis) and subsequent leakage of intramuscular content into the circulation of exertional heat stroke victims. Here, we will present and discuss rarely explored roles of skeletal muscles in the context of exertional heat stroke pathophysiology and recovery. This includes an overview of heat production that contributes to severe hyperthermia and the synthesis and secretion of bioactive molecules, such as cytokines, chemokines and acute phase proteins. These molecules can alter the overall inflammatory status from pro- to anti-inflammatory, affecting other organ systems and influencing recovery. The activation of innate immunity can determine whether a victim is ready to return to physical activity or experiences a prolonged convalescence. We also provide a brief discussion on whether heat acclimation can shift skeletal muscle secretory phenotype to prevent or aid recovery from exertional heat stroke. We conclude that skeletal muscles should be considered as a key organ system in exertional heat stroke pathophysiology.

Delayed Administration of Angiotensin Receptor (AT2R) Agonist C21 Improves Survival and Preserves Sensorimotor Outcomes in Female Diabetic Rats Post-Stroke through Modulation of Microglial Activation.

About 70% of stroke victims present with comorbid diseases such as diabetes and hypertension. The integration of comorbidities in pre-clinical experimental design is important in understanding the mechanisms involved in the development of stroke injury and recovery. We recently showed that administration of compound C21, an angiotensin II type 2 receptor agonist, at day 3 post-stroke improved sensorimotor outcomes by lowering neuroinflammation in diabetic male animals. In the current study, we hypothesized that a delayed administration of C21 would also lower chronic inflammation post-stroke in diabetic female animals. Young female diabetic rats were subjected to 1 h of middle cerebral artery occlusion (MCAO). Three days post-stroke, rats were administered C21 or vehicle in drinking water at a dose of 0.12 mg/kg/day for 4 weeks. The impact of C21 on microglial polarization was analyzed by flow cytometry in vivo and in vitro. Compound 21 treatment improved fine motor skills after MCAO through modulation of the microglia/macrophage inflammatory properties. In addition, C21 increased M2 polarization and reduced the M1:M2 ratio in vitro. In conclusion, delayed administration of C21 downregulates post-stroke inflammation in female diabetic animals. C21 may be a useful therapeutic option to lower neuro-inflammation and improve the post-stroke recovery in diabetes.

Pelargonidin ameliorates MCAO-induced cerebral ischemia/reperfusion injury in rats by the action on the Nrf2/HO-1 pathway.

BackgroundMorbidity and mortality remain high for ischemic stroke victims, and at present these patients lack effective neuroprotective agents, which improve the cure rate. In recent years, studies have shown that pelargonidin has many biological actions. However, few studies are available regarding the pelargonidin treatment of cerebral ischemia.MethodsThe rat middle cerebral artery occlusion (MCAO) model was established to investigate the neuroprotective effect of pelargonidin on cerebral ischemia/reperfusion injury. Reperfusion was performed 2 h after ischemia; magnetic resonance imaging (MRI) and 2, 3, 5-triphenyltetrazolium chloride (TTC) staining were used to measure the volume of cerebral ischemia. Both modified neurological severity scores (mNSSs) and Morris water maze test were used to assess the neurological functions. ELISA was applied to determine the levels of TNF-α, TGF-β, IL-6, IL-10, MDA, and SOD. The expression of Nuclear factor-E2-related factor 2 (Nrf2) and heme oxygenase 1 (HO-1) protein in brain tissue was measured by immunofluorescence and Western blot assays.ResultsThe results showed that pelargonidin could effectively reduce the volume of cerebral ischemia and improve the neurological function in MCAO rats, thereby improving memory and learning ability. With the corresponding decreases in the expression of TNF-α, TGF-β, IL-6, and MDA, the level of IL-10 and SOD increased and also promoted the nuclear metastasis of Nrf2 and the expression of HO-1 in ischemic brain tissues.ConclusionsOur data demonstrated that pelargonidin ameliorated neurological function deficits in MCAO rats, and its potential mechanism of action was associated with overexpression of the Nrf2/HO-1-signaling pathway. This study will provide a new approach to treat cerebral ischemia/reperfusion injury.

Factors associated with social support for family members who care for stroke survivors.

IntroductionVascular strokes are a primary cause of long-term disability for adults, with many social consequences for the patient, the family and healthcare systems worldwide.AimTo investigate the relation between patients' and caregivers' characteristics, as well as burden and depression, and the social support received by carers for stroke victims in Greece.MethodPatients and caregivers were recruited from community settings in the Attica region of Greece, using purposive sampling. They completed a set of questionnaires during face-to-face interviews. Correlational and multiple regression analyses were performed to identify factors associated with caregivers' perceptions of social support.ResultsIn total, 109 dyads of patients and their respective caregivers were recruited. The patients' mean age was 69.3 years, while caregivers' mean age was 58.0 years; 51.4% of patients were males, whereas 67.9% of the caregivers were females. The majority of both patients and caregivers were married, with an annual family income less than €10,000. The level of perceived social support was significantly associated with patients' or caregivers' annual family income, caregivers' working status and the daily caring hours (p < 0.01). Greater perceived support was significantly associated with a lower care burden BCOS (r = 0.29, p < 0.01) and female gender (p = 0.023), but not with the patient's functional level nor with depression (p > 0.05).

Interdisciplinary management of acute ischaemic stroke - current evidence on training requirements for endovascular stroke treatment. Position Paper from the ESC Council on Stroke and the European Association for Percutaneous Cardiovascular Interventions with the support of the European Board of Neurointervention: A step forward.

Stroke, a vascular disease of the brain, is the #1 cause of disability and a major cause of death worldwide. Stroke has a major negative impact on the life of stroke-affected individuals, their families and the society. A significant proportion of stroke victims indicate that would have preferred death over their after-stroke quality of life. Mechanical thrombectomy (MT), opening the occluded artery using mechanical aspiration or a thrombus-entrapment device, is a guideline-mandated (class I, level of evidence A) treatment modality in patients with large vessel occlusion stroke. MT clinical benefit magnitude indicates that a universal access to this treatment strategy should be the standard of care. Today there is a substantial geographic variation in MT deliverability, with large-scale disparities in MT implementation. In many countries effective access to MT remains severely limited. In addition, many of the MT-treated patients are treated too late for a good functional outcome because of logistic delays that include transportations to remotely located, scarce, comprehensive stroke centres. Position Paper from the European Society of Cardiology Council on Stroke and European Association for Percutaneous Cardiovascular Interventions on interdisciplinary management of acute ischaemic stroke, developed with the support of the European Board of Neurointervention fills an important gap in systematically enabling interventional cardiologists to support stroke intervention in the geographic areas of unmet needs in particular. We review strengths and weaknesses of the document, and suggest directions for the next steps that are swiftly needed to deliver MT to stroke patients more effectively.

Perspectives offered by advanced nursing practice with stroke victims in France in 2021

30% more strokes are expected by 2030. To face this incoming huge public health challenge, large-scale projects for primary, secondary and tertiary prevention of neurovascular risk have to be developed. French new advanced nursing practices will be most promising if they are based on the timeliness of pathology follow-up but also on leadership in training, research and innovation in the care pathway for stroke victims.

Heart-attack: Causes and Preventions

Every year, around 12 million people die from a heart attack or stroke throughout the world. Both the rich and the poor are affected by these illnesses. The majority of people believe these are illnesses that affect middle-aged males. The fact is that heart attacks and strokes strike both men and women. After menopause, women are significantly more vulnerable. Although the human heart is only the size of a fist, it is the body's strongest muscle. The heart pumps blood to all areas of the body with each beat, bringing oxygen and nutrients. At rest, a person's heart beats around 70 times each minute. When we are active or experience intense emotions, our heart rate rises. Coronary arteries are blood channels that supply oxygen and nourishment to the heart. When the heart's blood supply is cut off, the lack of oxygen and nutrients can cause long-term harm to this important organ. A heart attack occurs when the blockage occurs suddenly. If the blockage is just partial and blood supply to the heart is reduced, chest discomfort known as angina might result. Although it may not create long-term damage to the heart muscle, it is an indication that a person is at risk of having a severe heart attack. Cause A blockage that stops blood from flowing to the heart or the brain is the major cause of heart attacks and strokes. A build-up of fatty deposits on the inner walls of the blood arteries that supply the heart or the brain is the most prevalent cause. The blood vessels become smaller and less flexible as a result of this. Atherosclerosis, or artery stiffening, is another name for it. Blood clots are more prone to clog the blood arteries as a result. When this happens, the blood arteries that provide blood to the heart and brain get blocked, causing damage to the heart and brain. A cerebral blood artery can break and haemorrhage, causing brain tissue damage. Intracerebral haemorrhage is the medical term for this. High blood pressure is a significant contributor to this. Preventions Almost two-thirds of people who have a heart attack die before reaching medical help. Despite having access to contemporary, advanced therapy, 60% of stroke victims die or become handicapped. As a result, it's critical to recognise the warning signals and respond quickly. But it's much better to avoid having a heart attack or stroke in the first place. Most heart attacks and strokes may be avoided, thus prevention is always preferable than therapy. According to research, a lot of factors increase our chances of having a heart attack or stroke. These are referred to as risk factors. Some risk factors are connected to the lifestyle choices we make. The three most important lifestyle variables are: • Tobacco usage • A poor diet and • Insufficient physical activity Tobacco usage is increasing in several countries across the world. In many nations, people are growing overweight as a result of less physical activity and increased consumption of high-fat, high-sugar foods. Obesity is causing an increasing number of young adults and children to get diabetes. We owe it to our children to alter our habits.

Adequate Knowledge of Stroke Symptoms, Risk Factors, and Necessary Actions in the General Population of Southern Poland.

Background and objectives: Stroke is the third most common cause of mortality in developed countries and the primary cause of neurological disability in adults. Recombinant tissue plasminogen activator administered intravenously within 4.5 h from the onset of symptoms constitutes a gold standard in the treatment of acute ischemic stroke. Prompt hospital admission is the prerequisite of effective thrombolysis. Therefore, stroke awareness in the general population is the key factor in timely recognition of the acute stroke victims and determines proper actions. Therefore, the purpose of this study was to determine the awareness of stroke in the general population of the Silesian voivodeship, the most populated region of Poland. We assessed also the “adequate knowledge of stroke”, a combined measure of the optimal level of stroke awareness, as a prerequisite for effective stroke management, and aimed to identify most impacting factor for adequate stoke knowledge, to help shaping education strategies. Materials and Methods: A proprietary anonymous questionnaire consisting of 15 items related to stroke was used in this research. A total of 1134 individuals were surveyed. Additionally to the knowledge of individual aspects of stroke, we assessed “adequate knowledge of stroke”, which was combined measure of risk factors, symptoms, and actions in the case of acute stroke. Results: The accurate definition of stroke was selected by 834 participants (73.5%). The vast majority of them indicated that a stroke is an emergency (92.8%) and medical assistance is required (97.5%). However, 42.4% of respondents did not know any specific symptom of stroke and only 38.6% participants were able to list two or more risk factors, which resulted in only 36.3% of individuals with adequate knowledge of stroke. Education duration, previous occurrence of stroke in relatives or friends, gender and place of residence were identified as independent predictors of adequate knowledge of stroke. Conclusions: 1. Knowledge of stroke in the population of southern Poland is low and may be considered insufficient to address the needs of timely management in the action chain. 2. Previous occurrence of stroke in the relatives or friends is the most impacting factor for adequate knowledge of stroke.

Stroke Recognition for First Aid Providers: A Systematic Review and Meta-Analysis.

AimTo perform a systematic review of the literature on the effectiveness of existing stroke recognition scales used in a prehospital setting and suitable for use by first aid providers. The systematic review will be used to inform an update of international first aid guidelines.MethodsWe followed the Cochrane Handbook for Systematic Reviews of Interventions methodology and report results according to PRISMA guidelines. We searched Medline, Embase and CENTRAL on May 25, 2020 for studies of stroke recognition scales used by first aid providers, paramedics and nurses for adults with suspected acute stroke in a prehospital setting. Outcomes included change in time to treatment, initial recognition of stroke, survival and discharge with favorable neurologic status, and increased layperson recognition of the signs of stroke. Two investigators reviewed abstracts, extracted and assessed the data for risk of bias. The certainty of evidence was evaluated using GRADE methodology.ResultsWe included 24 observational studies with 10,446 patients evaluating 10 stroke scales (SS). All evidence was of moderate to very low certainty. Use of the Kurashiki Prehospital SS (KPSS), Ontario Prehospital SS (OPSS) and Face Arm Speech Time SS (FAST) was associated with an increased number of suspected stroke patients arriving to a hospital within three hours and, for OPSS, a higher rate of thrombolytic therapy. The KPSS was associated with a decreased time from symptom onset to hospital arrival. Use of FAST Emergency Response (FASTER) was associated with decreased time from door to tomography and from symptom onset to treatment. The Los Angeles Prehospital Stroke Scale (LAPSS) was associated with an increased number of correct initial diagnoses. Meta-analysis found the summary estimate sensitivity of four scales ranged from 0.78 to 0.86. The FAST and Cincinnati Prehospital Stroke Scale (CPSS) were found to have a summary estimated sensitivity of 0.86, 95% CI [0.69-0.94] and 0.81, 95% CI [0.70-0.89], respectively.ConclusionStroke recognition scales used in the prehospital first aid setting improves the recognition and diagnosis of stroke, thereby aiding the emergency services to triage stroke victims directly down an appropriate stroke care pathway. Of those prehospital scales evaluated by more than a single study, FAST and Melbourne Ambulance Stroke Screen (MASS) were found to be the most sensitive for stroke recognition, while the CPSS had higher specificity. When blood glucose cannot be measured, the simplicity of FAST and CPSS makes these particular stroke scales appropriate for non-medical first aid providers.

Development of an IoT-Based Solution Incorporating Biofeedback and Fuzzy Logic Control for Elbow Rehabilitation

The last few years have seen significant advances in neuromotor rehabilitation technologies, such as robotics and virtual reality. Rehabilitation robotics primarily focuses on devices, control strategies, scenarios and protocols aimed at recovering sensory, motor and cognitive impairments often experienced by stroke victims. Remote rehabilitation can be adopted to relieve stress in healthcare facilities by limiting the movement of patients to clinics, mainly in the current COVID-19 pandemic. In this context, we have developed a remote controlled intelligent robot for elbow rehabilitation. The proposed system offers real-time monitoring and ultimately provides an electronic health record (EHR). Rehabilitation is an area of medical practice that treats patients with pain. However, this pain can prevent a person from positively interacting with therapy. To cope with this matter, the proposed solution incorporates a cascading fuzzy decision system to estimate patient pain. Indeed, as a safety measure, when the pain exceeds a certain threshold, the robot must stop the action even if the desired angle has not yet been reached. A fusion of sensors incorporating an electromyography (EMG) signal, feedback from the current sensor and feedback from the position encoder provides the fuzzy controller with the data needed to estimate pain. This measured pain is fed back into the control loop and processed to generate safe robot actions. The main contribution was to integrate vision-based gesture control, a cascade fuzzy logic-based decision system and IoT (Internet of Things) to help therapists remotely take care of patients efficiently and reliably. Tests carried out on three different subjects showed encouraging results.

Why Me?: A Qualitative Study on the Experiences of Young Stroke Survivors in the Accra Metropolis of Ghana, West Africa.

Young stroke survivors are affected gravely when diagnosed with stroke between the ages of 18 to 45 years. The psychological and social effects of young stroke require stringent coping factors geared toward recovery and regeneration of self. A qualitative exploratory design was used to explore coping experiences and purposive sampling technique was employed to recruit 10 participants. Data were collected using tape recorded interviews which lasted between 45 minutes to 1 hour 30 minutes and guided by a semistructured interview guide which was informed by the research objectives and literature review. Thematic content analysis was used to analyze the transcribed data and 6 themes namely: psychological disruption, disruption to social identity, spiritual practices and beliefs, self-determination, support, and herbal medicine were derived. These themes gave insight into how these young stroke victims experienced and coped with physical signs and symptoms which negatively impacted their activities of daily living and resulted in social isolation, fear, anxiety, depression, guilt, and suicidal ideations. Provision of continuity of care for young adults living with stroke is highly recommended.

Meta-Analysis of Perioperative Stroke and Mortality in CABG Patients With Carotid Stenosis.

Coronary artery bypass grafting (CABG) is a proven approach in the treatment of coronary heart disease, but the surgery has several complications, including stroke and death. Though it has been established that perioperative stroke is associated with higher rates of long-term mortality, the relationship between stroke and mortality in the perioperative period has not yet been systematically examined. Online databases of peer-reviewed literature were searched to retrieve articles concerning mortality and stroke after CABG in patients with carotid stenosis. Six studies (n=3786) were included for analysis. This study was conducted at a single University hospital system, University of Pittsburgh Medical Center, on patients who underwent CABG. The data obtained from peer-reviewed literature originated from several sources, primarily single institution hospitals. Consistent with current literature, the incidence of stroke in CABG patients with significant carotid stenosis was 2.1%. Data were further analyzed to generate a summary odds ratio of stroke-related mortality after CABG, which showed that patients who died within 30 days of CABG were 7.3 times more likely to have had a perioperative stroke (95% confidence interval, 4.1-13.2). The 30-day mortality rate among perioperative stroke victims was 14.4% versus 2.3% for nonstroke patients. Together, these data suggest an association between stroke and mortality in the perioperative period in patients undergoing CABG, demonstrating a need for improved monitoring, screening, and treatment of stroke before, during, and shortly after surgery.

Sexuality after stroke with hemiplegia. II. With special regard to partnership adjustment and to fulfilment

Aspects of sexual function, partnership responsiveness and fulfilment after stroke were, together with sexually performance orientated and stigmatic attitudes, investigated in 51 subjects. Erectile and orgastic spectatoring were frequent after stroke and were in the males significantly associated. Retarded ejaculation occurred for no males before but for 15% after the stroke. Marked decreases in different kinds of caressive behaviour were followed by discontentment and up to and about half the subjects felt that sexual partnership responsiveness had deteriorated. After the stroke the commonly occurring reduction in general sexual satisfaction was significantly associated with symptoms of increased sexual dysfunction, disturbed partnership responsiveness and reduced sexual fulfilment. The high prevalence of sexual maladjustment in stroke victims appears mostly to be psychogenic. Important precipitating factors are performance orientation and sexual stigmatism. Moreover, lack of sexual information and counselling may contribute to deterioration of partnership sexuality.

The effects of sunlight exposure therapy on the improvement of depression and quality of life in post-stroke patients: A RCT study

Previous studies have suggested that nearly 30% of the stroke victims present with signs of depression within the first 5 years of illness. Since post-stroke depression significantly affects the patient both physically and psychologically, the emotional disturbances impede the progress and effectiveness of rehabilitation. To utilize sunlight therapy in post-stroke patients in order to improve the depression and daily activity function. This study was a single-blind design randomized controlled intervention with sunlight exposure design. The population were stroke patients with tendency to depression. Exposed to sunlight for at least 30 min per day, at least 14 days of exposure duration of 4 weeks. A total of 46 patients were 23 patients in the experimental group and the control group. The research tools include: depression status (Taiwanese depression scale, TDS), physical activity function (Barthel Index), and cognitive status (MMSE). The CONSORT guideline was used in this study. After the data was analyzed with the generalized estimating equation (GEE), significant improvement was noted among the experimental ground in 2nd post-test depression score, daily function in the first and second post-test Barthel Index score. There was no significant improvement in cognitive function. This study confirms that sunlight therapy improves the mental health of post-stroke patients with depressed mood. It also enhances daily activity and facilitates the recovery to a health state.

Leaving No Large Vessel Occlusion Stroke Behind: Reorganizing Stroke Systems of Care to Improve Timely Access to Endovascular Therapy.

Leaving No Large Vessel Occlusion Stroke Behind: Reorganizing Stroke Systems of Care to Improve Timely Access to Endovascular Therapy.

Essential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in India.

Essential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in India.

Prehospital oxygen for stroke victims

Prehospital oxygen for stroke victims

Teaching the National Institutes of Health Stroke Scale to Paramedics (E-Learning vs Video): Randomized Controlled Trial.

BackgroundPrompt and accurate identification of stroke victims is essential to reduce time from symptom onset to adequate treatment and to improve neurological outcomes. Most neurologists evaluate the extent of neurological deficit according to the National Institutes of Health Stroke Scale (NIHSS), but the use of this scale by paramedics, the first healthcare providers to usually take care of stroke victims, has proven unreliable. This might be, at least in part, due to the teaching method. The video used to teach NIHSS lacks interactivity, while more engaging electronic learning (e-learning) methods might improve knowledge acquisition.ObjectiveThis study was designed to evaluate whether a highly interactive e-learning module could enhance NIHSS knowledge acquisition in paramedics.MethodsA randomized controlled trial comparing a specially designed e-learning module with the original NIHSS video was performed with paramedics working in Geneva, Switzerland. A registration number was not required as our study does not come into the scope of the Swiss federal law on human research. The protocol was nevertheless submitted to the local ethics committee (Project ID 2017-00847), which issued a “Declaration of no objection.” Paramedics were excluded if they had prior knowledge of or previous training in the NIHSS, or if they had worked in a neurology or neurosurgery ward. The primary outcome was overall performance in the study quiz, which contained 50 questions. Secondary outcomes were performance by NIHSS item, time to course and quiz completion, user satisfaction regarding the learning method, user perception of the course duration, and probability the user would recommend the course to a colleague.ResultsThe study was completed by 39 paramedics. There was a better overall median score (36/50 vs 33/50, P=.04) and a higher degree of satisfaction regarding the learning method in the e-learning group (90% vs 37%, P=.002). Users who had followed the e-learning module were more likely to recommend the course to a colleague (95% vs 63%, P=.02). Paramedics in the e-learning group took more time to complete the course (93 vs 59 minutes, P<.001), but considered the duration to be more adequate (75% vs 32%, P=.01). Time to quiz completion was similar between groups (25 vs 38 minutes, P=.12).ConclusionsUse of an e-learning module shows promising results in teaching the NIHSS to paramedics.

Serum-Based Proteomics Reveals Lipid Metabolic and Immunoregulatory Dysregulation in Cervical Artery Dissection With Stroke.

Cervical artery dissection (CAD) is an important causal factor for stroke in young and middle-aged individuals and presents a great burden to the individual stroke victim. However, the pathophysiological mechanisms underlying CAD remain unknown. Here, an iTRAQ (isobaric tagging for relative and absolute quantitation)–based quantitative proteomic approach was performed, to identify differentially expressed proteins in serum samples obtained from spontaneous CAD and non-CAD ischemic stroke subjects. Differential protein expression was analyzed for Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway overrepresentation, and six differential proteins were selected for enzyme-linked immunosorbent assay validation. Through KEGG analysis, the significantly differentiated proteins were primarily involved in immunoregulation, blood coagulation, and lipid metabolism. For the first time, differential expressions of apolipoprotein B, apolipoprotein C-I, lipopolysaccharide-binding protein, vascular cell adhesion molecule 1, fibulin-1, and ficolin-2 were confirmed as being significantly upregulated in CAD as compared to non-CAD ischemic stroke subjects. In conclusion, proteomic analysis reveals that early perturbation of immunoregulation and lipid metabolism may be involved in the pathophysiology of CAD. Specifically, the panel of six proteins identified is promising as serum-based biomarkers for the detection of increased CAD risk in stroke subjects.

O viver de idosos após o acidente vascular cerebral

Objetivo: compreender o viver de idosos após a ocorrência de um Acidente Vascular Cerebral (AVC). Método: investigação qualitativa e descritiva. Dados coletados entre janeiro e março de 2018 em três Estratégias de Saúde da Família (ESF), por meio de entrevista semiestruturada com idosos, vítimas de AVC, cujas informações foram analisadas conforme análise temática. Resultados: os dados permitiram construir três categorias: modificações funcionais e sociais na vida de idosos após a ocorrência do AVC; o (des)cuidado após o AVC no entendimento da pessoa idosa; e perspectivas de futuro da pessoa idosa após a ocorrência do AVC. A assistência imediata e resolutiva na instituição hospitalar, o acompanhamento da ESF e o envolvimento familiar são fundamentais para a reabilitação da pessoa idosa. Considerações finais: os resultados permitiram compreender o viver de idosos, que apresentaram mudanças em seu cotidiano após a ocorrência do AVC, com diferentes graus de comprometimentos físicos e psíquicos.