A 2 year multidomain intervention of diet, exercise, cognitive training, and ...Nutricia
A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial
A 2 year multidomain intervention of diet, exercise, cognitive training, and ...Nutricia
A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial
A less-invasive-approach-of-medial-meniscectomy-in-rat-a-model-to-target-earl...science journals
In order for insulin to exert its biological actions on target cells in peripheral tissues like muscle and adipose tissues, Insulin must pass through the endothelial barrier into the interstitium.
PRA Insights Report: Alzheimer's Disease ResearchEmma Whieldon
This PRA Insights report focusing on Alzheimer’s disease research was compiled from survey data gathered at the 2017 Alzheimer’s Association International Conference (AAIC). The aim of the survey was to gather insight on clinical development and the future of research in Alzheimer’s disease from pharma and biotech, academic researchers, next generation investigators, clinicians and the care research community involved in the prevention and treatment of Alzheimer’s disease and other dementias.
Background: Cardiac catheterization is considered as the gold standard practice for the recognition and diagnosis coronary heart disease. The hazard physically and emotionally occurs from this procedure can disturb the patient’s perception of their health. Nursing care is vital in survival and avoids the patients from post cardiac catheterization problems. So the competence of nurses about knowledge and practice regarding patient care after cardiac catheterization is very crucial. Aims: the aim of this study to investigate the effect of creating learning guideline for nurses caring for patients safety undergoing cardiac catheterization. Methods: A quasi experimental research design was conducted. The study was conducted at the Cardiac Catheterization intensive care, cardiac care and emergency units at general Port Said hospital in Port Said city – Egypt. Subjects: A purposive sample of 51 nurses was working in those departments. Tools: two tools were utilized. Tool I: consisted of the following: Part 1: Socio-demographic data of the nurses. Part II: nurses’ knowledge about cardiac catheterization. Tool II: Nursing care after cardiac catheterization to providing patient safety. Results: The study revealed that the majority of nurses have a highly satisfactory level of knowledge and performance regarding patient safety on cardiac catheterization post implementation the learning guideline than pre learning guideline. It was reflected positive correlation between nurses qualification, experience and knowledge regarding patient’s safety at post learning guideline with significant difference regarding experience. While, there was a strong positive correlation between the performance of studied nurses and their qualification regarding the post learning guideline implementation with significant. Finally, positive correlation between performance and knowledge regarding patient safety at post learning guideline implementation. Conclusion: it can be concluded that learning guideline considerably improved the nurses’ level of knowledge and performance regarding Caring For Patients Safety Undergoing Cardiac Catheterization. Overall knowledge score between pre learning guideline and post learning guideline was found to be significant. While, total performance score between pre learning guideline and post learning guideline was found to be not significant. Therefore, the learning guidelines are recommended for educating these nurses to promote knowledge and performance regarding patient safety to decrease hazards following cardiac catheterization.
Study of Neonatal Outcome with Low Apgar Score in Term Neonatesiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Palliative care could help improve the quality of life for Parkinson’s diseas...Δρ. Γιώργος K. Κασάπης
A small study of individuals with Parkinson’s disease finds that adding palliative care to standard care may help raise their quality of life. Half the patients in a 210-person trial were assigned to visit physicians as usual, while the others also received palliative care — a team of a social worker, nurse, palliative medicine specialist, and chaplain visited the patient at home or via telemedicine to discuss symptoms and difficult emotions and offer support to caregivers. Patients in the combination care group had more improvement in their quality of life score (as measured by a survey that assesses physical and mental health).
These patients also scored higher on quality of life measures when their caregivers were surveyed in their stead.
Geriatric Oncology
1. Relationship between aging and cancer
2. Constructs of frailty and multimorbidity
3. Evidence for geriatric assessment in older adults living with cancer
A less-invasive-approach-of-medial-meniscectomy-in-rat-a-model-to-target-earl...science journals
In order for insulin to exert its biological actions on target cells in peripheral tissues like muscle and adipose tissues, Insulin must pass through the endothelial barrier into the interstitium.
PRA Insights Report: Alzheimer's Disease ResearchEmma Whieldon
This PRA Insights report focusing on Alzheimer’s disease research was compiled from survey data gathered at the 2017 Alzheimer’s Association International Conference (AAIC). The aim of the survey was to gather insight on clinical development and the future of research in Alzheimer’s disease from pharma and biotech, academic researchers, next generation investigators, clinicians and the care research community involved in the prevention and treatment of Alzheimer’s disease and other dementias.
Background: Cardiac catheterization is considered as the gold standard practice for the recognition and diagnosis coronary heart disease. The hazard physically and emotionally occurs from this procedure can disturb the patient’s perception of their health. Nursing care is vital in survival and avoids the patients from post cardiac catheterization problems. So the competence of nurses about knowledge and practice regarding patient care after cardiac catheterization is very crucial. Aims: the aim of this study to investigate the effect of creating learning guideline for nurses caring for patients safety undergoing cardiac catheterization. Methods: A quasi experimental research design was conducted. The study was conducted at the Cardiac Catheterization intensive care, cardiac care and emergency units at general Port Said hospital in Port Said city – Egypt. Subjects: A purposive sample of 51 nurses was working in those departments. Tools: two tools were utilized. Tool I: consisted of the following: Part 1: Socio-demographic data of the nurses. Part II: nurses’ knowledge about cardiac catheterization. Tool II: Nursing care after cardiac catheterization to providing patient safety. Results: The study revealed that the majority of nurses have a highly satisfactory level of knowledge and performance regarding patient safety on cardiac catheterization post implementation the learning guideline than pre learning guideline. It was reflected positive correlation between nurses qualification, experience and knowledge regarding patient’s safety at post learning guideline with significant difference regarding experience. While, there was a strong positive correlation between the performance of studied nurses and their qualification regarding the post learning guideline implementation with significant. Finally, positive correlation between performance and knowledge regarding patient safety at post learning guideline implementation. Conclusion: it can be concluded that learning guideline considerably improved the nurses’ level of knowledge and performance regarding Caring For Patients Safety Undergoing Cardiac Catheterization. Overall knowledge score between pre learning guideline and post learning guideline was found to be significant. While, total performance score between pre learning guideline and post learning guideline was found to be not significant. Therefore, the learning guidelines are recommended for educating these nurses to promote knowledge and performance regarding patient safety to decrease hazards following cardiac catheterization.
Study of Neonatal Outcome with Low Apgar Score in Term Neonatesiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Palliative care could help improve the quality of life for Parkinson’s diseas...Δρ. Γιώργος K. Κασάπης
A small study of individuals with Parkinson’s disease finds that adding palliative care to standard care may help raise their quality of life. Half the patients in a 210-person trial were assigned to visit physicians as usual, while the others also received palliative care — a team of a social worker, nurse, palliative medicine specialist, and chaplain visited the patient at home or via telemedicine to discuss symptoms and difficult emotions and offer support to caregivers. Patients in the combination care group had more improvement in their quality of life score (as measured by a survey that assesses physical and mental health).
These patients also scored higher on quality of life measures when their caregivers were surveyed in their stead.
Geriatric Oncology
1. Relationship between aging and cancer
2. Constructs of frailty and multimorbidity
3. Evidence for geriatric assessment in older adults living with cancer
Factors influencing the receipt of diabetic retinopathy screening in a high r...TÀI LIỆU NGÀNH MAY
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Perioperative Management of the Pediatric Organ Donorasclepiuspdfs
Introduction: For bereaved families, organ donation does not take away from the pain and loss of death, but it does give some meaning at the time and a great deal of comfort later. Each and every family whose child has suffered brain stem death should be offered the chance to donate. When a diagnosis of brain death has been made in a child, it may be possible for organ donation to occur, but it requires optimization of the donor and meticulous planning. There are a number of medical, nursing, ethical, psychological, and administrative issues which must be addressed in the perioperative period to facilitate the procurement of organs in good condition. Aim: This review aims to provide up to date information and provides the clinical pathway used in our tertiary level, university-affiliated children’s hospital for the management of the child in the critical care unit before organ donation, and intraoperative anaesthetic management. Method: This review was prepared using literature and clinical guidelines which were obtained from Medline and EMBASE databases, using the following search terms: Organ donation; intensive care management of organ donor; paediatric; neonatal; transplant outcome; and graft outcome. The focused literature search was carried out in 2017 by the five authors involved in the project. Results: The Society of Critical Care Medicine published consensus based guidelines for donor management in adult patients in 2015. Many of the core critical care principles in this document are similar in infants and children; although there are different considerations with respect to the diagnosis of brain death, consent, and pharmacological management. Full-text papers were employed by the project group to update our clinical pathway for the perioperative management of the infant or child who is a potential organ donor. Providing critical care medical and nursing staff with a pathway may improve communication, confidence, and delivery of care to the deceased child, their family and the graft recipients in this challenging situation.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
Patient summaries defined as the minimal set of health information that needs to be conveyed for patient safety in the context of emergency or unplanned care were initially introduced in a European context in the cross-border setting across member states of the European Union. Quite complex and high impact emergency situations involve young children and their parents. Then, shifting to a patient-centric perspective, patient summaries make sense in the hands of active and empowered parents and carers. This workshop builds on the work of the Trillium-II project that aims to scale-up use of patient summaries and the work of the MOCHA project which is analyzing health policies for children in 30 European states. The expected outcome of the workshop is to identify challenges and propose recommendations for further coordinated action where digital health policies interface with standards, with clear objectives, actions and intended benefits.
The opportunity and waste of human potential: Managing the mental health of t...Studiosity.com
At Studiosity's "Students First 2019" Symposium:
The renowned youth mental health advocate, Australian of the Year, and this year's keynote, Professor Pat McGorry, addressed the critical need for early intervention for tertiary students.
This year's Studiosity 'Students First' Symposium was hosted at La Trobe University City Campus, 25 and 26 July 2019.
EVIDENCE BASED 2
1
EVIDENCE BASED 4
Evidence Based RUA
The purpose of this assignment is to identify individual assessment trends to determine the highest priority concept, conduct a research study of the topic outline in relation to the NCLEX-RN test plan and provide evidence-based research regarding nursing practice. Based upon the category of physiological integrity, the topic of greatest opportunity is “physiological adaptation” which focuses on the client needs category. According the NCLEX-RN test plan (2019), Physiological adaption the nurses manage and provide care for the clients with acute, chronic, or life-threatening physical health conditions. The primary goal of “physiological adaptation” category is to interpret clinical findings, analyze nursing actions as it correlates with the client’s care and take immediate action when needed and evaluate client’s outcomes based on the priority decisions (NSCBN, 2019). This category requires entry level nurses to demonstrate their knowledge, skills, and abilities for the successful completion of the NCLEX-RN test plan into the nursing practice.
Importance
It is crucial for entry level nurses to apply normal physiological changes across the life span and understand the disease alterations and the negative effects across the lifespan. The nursing process and Maslow of hierarchy of needs guides nurses through the care with a systemized approach to meet the client needs. (Macedo at el, 2016). Erikson’s stages of development allow for analysis of developmental considerations when planning care and nursing (Orenstein & Lewis, 2020). The nurse should use clinical judgment to process data and interpret data which identifies safe nursing interventions. If a nurse fails to take in life-span considerations amongst her clients when implementing client care can cause life-threatening problems. Electrolyte imbalances fall under the clients need category of physiological adaptations (NCSBN, 2019). Nurses must understand the pathophysiology and the difference in lifespan considerations as caring for older adult clients and knowing when to intervene to provide effective care. In older adults’ clients, total water content decreases which causes a higher risk for dehydration and fluid and electrolyte imbalances in this population (Kear, 2017). Nurses must identify clinical findings and apply knowledge of the unresolved issue as clients are prone to prolonged readmission and increase hospital stays (Yilmaz at el, 2016).
Healthcare Disparities, Inequalities, and Interventions
This population targets clients with sepsis, diuresis from AKI, respiratory acidosis, burns, and excessive gastrointestinal or wound loses (Kear, 2017). Older Clients with chronic conditions are susceptible to pressure ulcers due to their decrease sensation, cardio output, perfusion, activity, mental status, and fluid and electrolyte imbalances (Macedo at el, 2016). As a client ages their kidney functi ...
The management of pediatric polytrauma -a simple reviewEmergency Live
This Clinical review, published by Libertas Academica, is an interesting commentary about the management of pediatric polytrauma.
This research was realized by
H. Mevius, M. van Dijk, A. Numanogluand A.B. van As between the MC-Sophia Childen's Hospital, Rotterdam, and the Red Cross War memorial Children's Hospital in Cape Town, South Africa.
H. Mevius1, M. van Dijk2–4, A. Numanoglu2,3 and A.B. van As2,3
1Medical Student, Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands. 2Department
of Paediatric Surgery, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa. 3University of Cape Town, Cape Town,
South Africa. 4Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands.
1Medical Student, Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands. 2Department
of Paediatric Surgery, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa. 3University of Cape Town, Cape Town,
South Africa. 4Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands.
ABSTRACT: Polytrauma is a major cause of mortality and morbidity in both developed and developing countries. The primary goal of this review is to provide a comprehensive overview on current knowledge in the management of pediatric polytrauma patients (PPPs). A database review was conducted based on a search in the Embase, Medline OVID-SP, Web of Science, Cochrane central, and Pubmed databases. Only studies with “paediatric population” and “polytrauma” as criteria were included. A total of 3310 citations were retrieved. Of these, 3271 were excluded after screening, based on title and abstract. The full texts of 39 articles were assessed; further selection left 25 articles to be included in this review. The most crucial point in the
management of PPPs is preparedness of the staff and an emergency room furnished with age-appropriate drugs and equipment combined with a systemic
approach.
KEY WORDS: pediatric population, polytrauma, multiple injuries, current management, review
Introduction
Polytrauma is a medical term that describes the condition of a patient subjected to multiple traumatic injuries and can be a life-threatening condition. These (life threatening) injuries typically affect two or more body regions and present a challenge for diagnosis and treatment.1,2 However, there is no consensus yet about the term polytrauma in both literature and practice.3
Polytrauma is a major cause of mortality and morbidity in both developed and developing countries. Despite its preventability, trauma remains the most common cause of death and disability in children.2 In fact, all over the world, more than 700,000 children under the age of 15 years die each year due to accidental injury.4 Leading causes of polytrauma are road traffic crashes, falls from heights, and
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Australian Clinical Consensus Guideline: The diagnosis and acute management of childhood stroke
1. Guidelines
Australian Clinical Consensus Guideline:
The diagnosis and acute management of
childhood stroke
Tanya L Medley1,2
, Christina Miteff3
, Ian Andrews4
,
Tyson Ware5
, Michael Cheung1,2,6
, Paul Monagle1,2,7
,
Simone Mandelstam1,2,7
, Alison Wray2,7
, Clair Pridmore8
,
Christopher Troedson9
, Russell C Dale10
, Michael Fahey11
,
Adriane Sinclair12
, Peter Walsh13
, Belinda Stojanovski1,7
and
Mark T Mackay1,2,14
Abstract
Stroke is among the top 10 causes of death in children and survivors carry resulting disabilities for decades, at substantial
cost to themselves and their families. Children are not currently able to access reperfusion therapies, due to limited
evidence supporting safety and efficacy and long diagnostic delays. The Australian Clinical Consensus Guideline for the
Diagnosis and Acute Management of Childhood Stroke was developed to minimize unwarranted variations in care and
document best evidence on the risk factors, etiologies, and conditions mimicking stroke that differ from adults. Clinical
questions were formulated to inform systematic database searches from 2007 to 2017, limited to English and pediatric
studies. SIGN methodology and the National Health and Medical Research Council system were used to screen and
classify the evidence. The Grades of Recommendation, Assessment, Development, and Evaluation system (GRADE) was
used to grade evidence as strong or weak. The Guideline provides more than 60 evidence-based recommendations to
assist prehospital and acute care clinicians in the rapid identification of childhood stroke, choice of initial investigation, to
confirm diagnosis, determine etiology, selection of the most appropriate interventions to salvage brain at risk, and
prevent recurrence. Recommendations include advice regarding the management of intracranial pressure and congenital
heart disease. Implementation of the Guideline will require reorganization of prehospital and emergency care systems,
including the development of regional stroke networks, pediatric Code Stroke, rapid magnetic resonance imaging and
accreditation of primary pediatric stroke centers with the capacity to offer reperfusion therapies. The Guideline will
allow auditing to benchmark timelines of care, access to acute interventions, and outcomes. It will also facilitate the
development of an Australian childhood stroke registry, with data linkage to international registries, to allow for accurate
data collection on stroke incidence, treatment, and outcomes.
Keywords
Acute, childhood stroke, clinical guidelines, management, pediatrics, protocols
Received: 5 April 2018; accepted: 13 June 2018
1
Murdoch Children’s Research Institute, University of Melbourne,
Melbourne, Australia
2
Department of Paediatrics University of Melbourne, Melbourne,
Australia
3
John Hunter Children’s Hospital, Sydney, Australia
4
Sydney Children’s Hospital, School of Women’s and Children’s Health,
University of New South Wales, Sydney, Australia
5
Royal Hobart Hospital, Hobart, Australia
6
Department of Cardiology Royal Children’s Hospital, Melbourne,
Australia
7
Royal Children’s Hospital, Melbourne, Australia
8
Women’s and Children’s Hospital. Adelaide, Australia
9
Children’s Hospital at Westmead, Discipline of Child and Adolescent
Health, University of Sydney, Sydney, Australia
10
Children’s Hospital at Westmead and University of Sydney, Sydney
Australia
11
Department of Paediatrics Monash University, Department of Medicine
Melbourne University, and Monash Children’s Hospital, Melbourne,
Australia
12
Lady Cilento Children’s Hospital, University of Queensland, Brisbane,
Australia
13
Perth Children’s Hospital, Perth, Australia
14
Department of Neurology Royal Children’s Hospital, Melbourne
Australia
Corresponding author:
Mark MacKay, Royal Children’s Hospital Melbourne, Victoria, Australia.
Email: mark.mackay@rch.org.au
International Journal of Stroke, 14(1)
International Journal of Stroke
2019, Vol. 14(1) 94–106
! 2018 World Stroke Organization
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1747493018799958
journals.sagepub.com/home/wso
2. Introduction
Stroke is a major cause of morbidity and mortality in
children across the world. The Global Burden of
Disease study has reported a 35% increase in the num-
bers of childhood strokes from 1990 to 2013.
Childhood arterial ischemic stroke (AIS) has incidence
of 1.2–2.1 per 100,000 children per year1–3
and hemor-
rhagic stroke (HS) an incidence of 0.7–5.1/100,000 chil-
dren per year.3–5
Mortality ranges from 3.6–14% for
AIS6–9
and 6–54% for HS3–5
with death due to the
stroke or the underlying disease. In Australia, the inci-
dence of childhood stroke remains unknown.
More than half of survivors have long-term neuro-
logical impairment and 10–20% suffer recurrent
strokes. Stroke places significant demands on families,
the community, and health system. Studies from the
US have estimated average costs of US$20,972 per
child for acute hospital care10
and a five-year direct
cost of US$130,000 per patient.11
These costs are diffi-
cult to translate to the Australian healthcare system
and a comprehensive economic analysis should be a
research priority for Australia. Childhood stroke differs
from adult stroke in terms of risk factors, etiologies,
and pathophysiology.1,12
Data, predominantly from
uncontrolled case series, suggest that nonatherosclero-
tic arteriopathies and cardiac disorders are the most
commonly identified causes of childhood AIS,1,2,12
and arteriovenous malformations are the most
common cause of HS.13,14
One-third of children with AIS are less than 1-year
old and one-half less than 5 years.15
The catch-cry ‘‘Time
is Brain’’ is, therefore, very applicable to children,
because failure to salvage brain with reperfusion thera-
pies means worse functional outcomes, and survivors
face living with disability for decades. Outcomes follow-
ing stroke in the immature brain are likely to be different
to those in adults, with failure of achieving normal devel-
opmental milestones being as important as loss of func-
tion. The higher frequency of stroke mimics, age-related
variability in clinical presentation, diversity of causes
and comorbidities are important challenges to early
diagnosis and, collectively, necessitate child-specific
approaches. It is unknown whether children have differ-
ent pharmacologic responses to reperfusion and second-
ary preventative therapies, due to developmental
differences in hemostatic systems.
Thus, while some care principles are relevant, direct
application of adult guidelines to the investigation and
management of childhood stroke is not appropriate.
This Guideline addresses the diagnosis and acute
management of childhood ischemic stroke and non-
traumatic intracranial hemorrhagic stroke in (i) chil-
dren beyond the neonatal period (ages 29 days to 18
years) and (ii) neonates and children with congenital
heart disease who are at increased risk of stroke. It is
not inclusive of cerebral sinovenous thrombosis,
Moyamoya or sickle cell disease, noncardiac perinatal,
or spinal cord stroke.
Guideline development methodology
The Australian Childhood Stroke Advisory
Committee, representing a panel of Australia’s’ leading
clinical experts and guideline developers from all ter-
tiary pediatric centers, agreed on questions of clinical
importance, to inform the scope and priority areas for
the Guideline. Literature was systematically identified
from Pubmed and EMBASE databases, limited to
English, the last 10 years and pediatric studies key rele-
vant studies older than 10 years were however included.
Final search strings for each question can be found in
The Diagnosis and Acute Management of Childhood
Stroke—Technical Document.16
The literature was inde-
pendently screened for inclusion and assessed for quality
using SIGN methodology17
by two committee members,
and conflicting assessments resolved by a third reviewer.
Existing guidelines, where available, were independently
assessed using AGREE II methodology.18
Evidence sum-
mary tables for each question were created to provide an
overview of relevant literature, which was then graded by
the quantity, quality, consistency, clinical impact, gener-
alizability, and applicability (using the National Health
and Medical Research Council) system. Drafted recom-
mendations were graded strong or weak, based on their
benefit over harm to the patient, in alignment with the
Grades of Recommendation, Assessment, Development
and Evaluation (GRADE) system.19
All evidence sum-
maries and resulting recommendations were approved by
the full committee. The drafted guideline underwent a
period of targeted external consultation, suggestions
reviewed in a blinded fashion, and a consensus process
used to modify recommendations.
Australian Childhood Stroke Clinical
Guideline recommendations
The following sections provide an overview of recom-
mendations for the diagnosis and acute management of
childhood stroke. The PICO (Population, Intervention
or exposure, Comparison and Outcome) framework
was used formulate questions deemed to be clinical
importance. These questions informed areas of focus
which included (i) clinical identification of stroke in
the emergency department, (ii) neuroimaging to con-
firm diagnosis, (iii) investigations to determine under-
lying etiology, (iv) stabilization of modifiable factors
(such as seizures) to minimize further injury, (iv) treat-
ments including intravenous and endovascular reperfu-
sion therapies, secondary preventative antiplatelet and
International Journal of Stroke, 14(1)
Medley et al. 95
3. anticoagulant therapies, corticosteroids agents, and
management interventions for suspected raised intra-
cranial pressure, and (vi) specific recommendations
for children with congenital heart disease (not pre-
sented here, but found online at www.mcri.edu.au).
Section 1: Clinical identification of stroke in the
emergency department
Significant delays in the diagnosis of childhood stroke
limit access to reperfusion therapies. Factors contribut-
ing to the delays include the low incidence, varying clin-
ical presentations, limited access to urgent diagnostic
neuroimaging, and poor awareness of childhood stroke
among physicians and carers.20–27
Implementation of
immediate response protocols in pediatric emergency
departments have been shown to reduce delays in diag-
nosis.25–28
Developed here is a Quick Reference Guide to
the diagnosis and acute management of childhood stroke
(Figure 1).
Diagnosis of childhood stroke begins with know-
ledge of the signs and symptoms and of presenting fea-
tures that differentiate stroke from mimics29
(Figure 1).
Clinical presentation varies depending on stroke
type, vessels involved, and the child’s age. Focal
neurological deficits and seizures are more common
presenting features of AIS, whereas headache, vomit-
ing, and altered mental status are more common and
focal neurological deficits less common in HS.29–31
Conditions mimicking childhood stroke differ from
adult stroke32,33
where migraine is a common non-
stroke diagnosis.32
Stroke recognition tools, which are widely used by
emergency responders to differentiate stroke from its
mimics in adults, have been shown to improve diagnos-
tic accuracy, decrease time to diagnosis, and increase
access to reperfusion therapies. In children, currently
available tools do not accurately distinguish strokes
from mimics.34,35
Further work is, therefore, required
to develop, validate, and implement pediatric specific
recognition tools to reduce the diagnostic delay in child-
hood stroke. In contrast, the pediatric modification of
the National Institutes of Health Stroke Scale
(PedNIHSS) has good to excellent interrater reliability
to determine severity of stroke symptoms.36
Section 2: Neuroimaging
Neuroimaging is essential to confirm a stroke diagnosis.
Here we present recommendations (Section 2) and a
rapid and full diagnostic protocol (Figure 2) for neu-
roimaging with the goal of standardizing neuroimaging
protocols across Australian pediatric institutions.
Diagnosis must be confirmed on brain imaging in chil-
dren before considering reperfusion therapies (Figures
1 and 2) as stroke is an uncommon cause of focal
neurological symptoms, accounting for less than one-
third of cases.26,28,32
There are arguments for and
against computed tomography (CT) and magnetic res-
onance imaging modalities in suspected childhood
stroke. The advantages of CT are that most children
will not require sedation and it is readily available in
most emergency departments. However, these benefits
are largely outweighed by the evidence showing that CT
has poor sensitivity for early detection of ischemic
infarction resulting in a delayed diagnosis.22,24,27,37
Thus, magnetic resonance imaging (MRI), with diffu-
sion-weighted imaging (DWI) and apparent diffusion
coefficient (ADC) sequences, is recommended as the
imaging modality of choice for suspected AIS (Figure
2). In contrast, CT imaging and MRI gradient echo
sequences (such as susceptibility-weighted imaging)
are equally sensitive for the detection of intraparench-
ymal blood. Therefore, where signs and symptoms sug-
gest hemorrhagic stroke, and access to sedation or MRI
is delayed, a CT can be performed.
Accessing urgent MRI is a major challenge in
the pediatric emergency department, particularly with
the added requirement for sedation in younger children.
As the use of reperfusion therapies are highly time-
Section 1: Recommendations for the clinical identification of stroke
Children presenting with sudden onset of the following symptoms are at high risk of stroke and should undergo immediate neurological
assessment and consideration of urgent neuroimaging: (i) focal weakness, (ii) visual or speech disturbances, (iii) limb incoordination or
ataxia, (iv) altered mental status, (v) headache, (vi) signs of raised intracranial pressure, or (vii) seizures with additional neurological
symptoms. Level of evidence (III).
In children presenting with neurological symptoms or signs relevant for stroke, the use of adult stroke recognition tools to differentiate
childhood stroke from its mimics are not recommended in their current form. Level of evidence (III-2).
In all children between the ages of 2 and 18 years, stroke severity should be assessed upon arrival to the hospital using the Pediatric National
Institute of Health Stroke Scale to facilitate ongoing management. Level of evidence (III, CBR)
International Journal of Stroke, 14(1)
96 International Journal of Stroke 14(1)
4. dependent, rapid MRI protocols to accurately diagno-
sis stroke are imperative. Therefore, a rapid protocol
(of approximately 10–15 min, depending on MRI cap-
abilities) is proposed, based on a review of literature
and expert opinion, for children presenting within the
windows for reperfusion therapies, and a full diagnostic
protocol for those presenting beyond these times
(Figure 2).
Figure 1. Quick Reference Guide for the diagnosis and acute management of childhood stroke.
MRI: magnetic resonance imaging; CT: computed tomography; CTA, CT angiography; PPSC: primary pediatric stroke center; MMCAI: malignant middle cerebral artery
infarction; ICH: intracranial hemorrhage; ICP: intracranial pressure.
International Journal of Stroke, 14(1)
Medley et al. 97
5. Section 3: Investigations to determine underlying
stroke etiology
Investigations to determine underlying etiology guide
prognostication and treatments to reduce risk of
stroke recurrence. While the level of evidence is low,
studies are consistent in demonstrating an association
between arteriopathies and initial AIS1,2,12,38–48
and
recurrent events.7,13,49,50
Unilateral focal cerebral arter-
iopathy, dissection, and Moyamoya disease are the
Section 2: Neuroimaging recommendations for diagnosing arterial ischemic and hemorrhagic stroke
In children with suspected AIS, urgent brain MRI should be performed as the diagnostic imaging modality of choice. Level of evidence (I (adult),
III-2–IV pediatric).
In children undergoing MRI for suspected AIS within time frames for reperfusion therapies, a rapid imaging protocol including (i) axial DWI/
ADC, (ii) axial gradient echo (such as SWI) for detection of hemorrhage, (iii) axial fast spin echo or turbo spin T2, (iv) consideration of
fluid-attenuated inversion recovery if greater than 1 year of age, (v) axial T1, and (vi) time of flight MRA, to inform ongoing management,
is recommended. Level of evidence (III-2, VI).
In children with suspected AIS where urgent MRI is not possible, CT imaging, including CTA and CT perfusion, can be considered as an
alternative, particularly in older teenagers. Level of evidence (CBR).
In children with suspected hemorrhagic stroke, urgent brain MRI or CT should be performed. Level of evidence (III-3).
Figure 2. Imaging pathway for suspected childhood stroke (29 days to 18 years of age).
MRI: magnetic resonance imaging; DWI: diffusion-weighted images; ADC: apparent diffusion coefficient; SWI: susceptibility-weighted images; FSE: fast spin echo; TSE:
turbo spin echo; FLAIR: fluid-attenuated inversion recovery; TOF: time of flight; MRA: magnetic resonance angiography; PPSC: primary pediatric stroke center; CT:
computed tomography; CTA: computed tomography angiography.
*Time may vary between scanners.
yIn children with alternative diagnoses, if attaining subsequent imaging will be difficult/traumatic (e.g. young children or those with intellectual disability) consideration
should be given to complete a full diagnostic scan to elucidate etiology.
z
E.g. investigations for specific arteriopathies may include (i) intracranial arteriopathy using vessel wall imaging (axial/coronal pre and postcontrast T1 weighted imaging) or
(ii) cervical dissection via contrast MRA and axial/coronal fat saturated pre and postcontrast T1.
§
There are substantial difficulties associated with delivering contrast in young children, particularly using pump injection in the absence of general anaesthetic, and the skill
required to attain images without movement error, teenagers 13–18 years of age. Note: Sequences are a guide and should be at discretion of the neuroradiologist.
International Journal of Stroke, 14(1)
98 International Journal of Stroke 14(1)
6. most commonly identified subtypes of arteriopa-
thies.51,52
Vascular imaging, which is essential to diag-
nosis, should preferably be performed as part of the
initial diagnostic imaging study.
Cardiac disorders also account for a significant pro-
portion of childhood strokes.12,53
This cohort is an
important target for primary prevention, as diagnosis
is usually known prior to the stroke event. Congenital
heart defects, particularly complex cyanotic lesions,
account for the majority of clinically recognized
strokes.39,40
A case–control study of 412 children
reported a 19-fold increased stroke risk in children
aged >28 days with congenital heart disease. The risk
was even greater for children with a history of cardiac
surgery although many events were unrelated to or
occurred more than five years from surgery.41
In mixed
congenital heart disease cohort studies, the incidence of
preoperative stroke ranges from 10 to 31%.1,2,12,38
Case–control and cohort studies indicate that infec-
tion is associated with an increased risk of childhood
stroke. Varicella infection was first implicated as a risk
factor for childhood stroke almost 20 years ago.54,55
The multinational VIPS study found that infection in
the week prior to stroke was associated with a 6.3-fold
increased risk of AIS.56
Serological investigations of the
same cohort demonstrated higher rates of acute herpes
simplex and varicella infection in children with stroke,
compared to controls.57
An association between iron deficiency and child-
hood stroke has been demonstrated in two case–control
studies.58,59
Meta analyses suggest that prothrombotic
factors including Factor V Leiden, prothrombin
G20210A, methyl tetrahydrofolate reductase, lipopro-
tein (a), protein C deficiency, antiphospholipid antibo-
dies, and lupus anticoagulant may also be associated
with childhood stroke. However, the evidence is incon-
sistent and inconclusive. Interpretations of findings are
influenced by methodological limitations including lack
of concurrent controls, highly selected patient popula-
tions, the use of adult reference ranges, which do not
consider developmental differences in hemostatic fac-
tors, and failure to confirm abnormalities on follow-
up testing. The evidence for serum biomarkers, such
as D-dimer and C-reactive protein, serum amyloid A,
myeloperoxidase, and tumor necrosis factor alpha, is
also limited by small sample sizes, lack of data on
reproducibility, and limited follow up data.
Section 4: Code Stroke protocols and primary
pediatric stroke center care
Two studies26,27
have demonstrated the benefit of an
Emergency Department acute Code Stroke protocols
with (i) reduced time to secondary preventative treat-
ment, (ii) increased usage of, and shorter time to MRI
as first imaging modality, and (iii) improved access to
reperfusion therapies. Developed here is a Quick
Reference guide to the diagnosis and acute manage-
ment of childhood stroke that can be implemented to
reduce time to diagnosis (Figure 1). There are, however,
no data to directly demonstrate the benefit of pediatric
stroke units. Australian adult stroke units are defined
Section 3: Investigations for suspected or confirmed childhood stroke
Upon presentation, all children should undergo the following pathology: full blood count with differential, basic biochemistry (urea, creatinine,
electrolytes, glucose), and a coagulation screen (international normalized ratio/prothrombin time, activated partial thromboplastin time,
fibrinogen). Level of evidence (CBR).
Vascular imaging (MR or CT angiography) of the intracranial and neck vessels is recommended in all children with confirmed AIS. Level of
evidence (II–IV).
Ongoing radiological surveillance is recommended in children with cervical or cranial arteriopathies, due to the association with increased risk
of recurrent events. Level of evidence (II–IV).
Conventional angiography may be considered in cases where diagnostic uncertainties persist following MR or CT angiography. Level of
evidence (III).
Echocardiography and ECG should be performed in all children with AIS. Level of evidence (III–IV).
A full blood count and iron studies should be performed in all children with suspected stroke at presentation. Level of evidence (III–IV).
Investigation of prothrombotic makers (anticardiolipin Ab(ACLA), lupus anticoagulant, antithrombin, protein C, protein S, activated protein C
resistance, Factor V Leiden, prothrombin G20210A, and MTHFR TT677 mutations) and serum homocysteine is reasonable in children
with radiologically confirmed stroke, where etiology remains to be fully elucidated. Level of evidence (I–IV).
A history of recent infection (within the preceding six months), particularly varicella infection should be sought in children with suspected or
confirmed stroke. Level of evidence (II–III3).
In children with AIS measurement of biomarkers CRP, D-dimer and serum amyloid, and myeloperoxidase are unlikely to influence manage-
ment directly. There is insufficient evidence to support testing for more specific serum biomarkers for inflammation, systemic vasculitides,
or genetic polymorphisms. Level of evidence (II–III-3).
International Journal of Stroke, 14(1)
Medley et al. 99
7. by a minimum set of criteria and services and are cate-
gorized into comprehensive stroke centers and primary
stroke centers.60
Presented here are consensus-based
recommendations for the required service elements to
facilitate certification of a hospital as a Primary
Pediatric Stroke Center (PPSC, Table 1), drawing on
key components of adult primary and comprehensive
stroke centers. The development of PPSC’s across
Table 1. Elements of service for pediatric stroke care centers
Element of service
Primary pediatric
stroke centera
Organized prehospital services 7
Coordinated emergency department systems (e.g. code stroke) 3b
Coordinated regional stroke systems (includes protocols for hospital bypass, transfer to stroke centers) 3b
Onsite CT brain imaging (24/7) 3
Advanced imaging capability (e.g. MRI/MRA, catheter angiography) 3 (24/7)
On-site neurosurgical services (e.g. for hemicraniectomy due to large middle cerebral artery infarcts) 3c
Delivery of intravenous tissue plasminogen activator (tPA) Optional
Ability to provide acute monitoring up to 72 h 3
Dedicated stroke coordinator position 3d
Dedicated medical lead 3
Access to ICU 3
Provision of telehealth services for acute assessment and treatment Optional
Coordination with rehabilitation service providers 3
Routine involvement of carers in rehabilitation process 3
Routine use of guidelines, care plans and protocols 3b
Access and collaboration with other services (cardiology, palliative care, vascular) Optional
Regional responsibility Commonly
Parent/carer and children provided with appropriate level of literature 3
Table adapted from National Acute Stroke Services Framework 2015.60
a
Consensus based recommendations on the elements of service relevant to childhood stroke to qualify as a primary pediatric stroke center.
b
Upon successful implementation of guideline recommendations.
c
If neurosurgical services are not available, the institution should have developed transfer protocols.
d
If a stroke coordinator not available, institution should have a dedicated medical lead who has a primary focus on stroke (stroke center director).
Section 4: Recommendations for primary pediatric stroke center care
All children with stroke should be admitted to pediatric centers meeting criteria for a primary pediatric stroke center. Level of evidence
(Adult I).
Parents/carers and children should be provided with the appropriate level of stroke literature. Level of evidence (CBR, IV).
International Journal of Stroke, 14(1)
100 International Journal of Stroke 14(1)
8. Australia will help determine whether children obtain
similar benefits from dedicated stroke units as adults.
The variations between adult primary centers criteria,
and those recommended for children, are explained by
differences in pathophysiology, presentation, fre-
quency, staffing constraints, and international recom-
mendations from leading pediatric stroke institutions.
Section 5: Reperfusion interventions,
antithrombotic, immunotherapies, and
management of raised intracranial pressure
Reperfusion therapies. Intravenous and endovascular
thrombolytic therapies have revolutionized the manage-
ment of ischemic stroke in adults, reducing the severity
of disability and mortality rates. For adults, the recom-
mendations for eligibility and efficacy of interventions
are based on multiple large randomized controlled
trials. There are no such trials in children, and thrombo-
lytic agents are not approved by the Therapeutic Goods
Administration for use in Australian children. Despite
this lack of evidence, there are growing numbers of inter-
national publications reporting use of these interven-
tions. Thus, there is a strong impetus for development
of primary pediatric stroke centers, and formulation
of pediatric protocols with clear guidelines around eligi-
bility and exclusion criteria, to allow some children to
access off-label treatment, whilst minimizing risk of
complications.
A total of 67 studies reporting intravenous thrombo-
lytic or endovascular therapy in children were reviewed
for the Guideline, including one case–control study and
case reports for 82 children. Treatments administered
included (i) IV–tPA alone in 28 children, (ii) IA–tPA
alone in 13 children, (iii) IA–urokinase alone in 8 or
IA–streptokinase alone in 1 child, (iv) endovascular
therapy with mechanical clot retrieval alone in 22 chil-
dren, or in combination with (v) IV–tPA (n ¼ 5), (vi)
IA–tPA (n ¼ 3), or (vii) IA–urokinase (n ¼ 2) children.
The median age of treated children was 10 years; the
youngest patient was 2.5 months and only 13% were
less than five years. The anterior circulation was
affected in the majority of cases. Cardiac embolism
was the most commonly identified stroke mechanism,
in 42% of children, followed by dissection in 12%,
other/nonspecified arteriopathies 5%; no etiology was
identified in 29% of cases. The effect of interventions is
difficult to interpret due to variations in reporting of
baseline data, outcomes at follow-up, and description
or severity of deficits. Twenty percent of children were
neurologically normal at discharge but 4% died.
The evidence for use of IA–tPA and endovascular
therapy in childhood AIS is inconsistent largely due to
heterogeneity in stroke etiology, age, time to treatment,
stroke severity, imaging findings, and reporting of out-
comes and adverse events.
Anticoagulation and antiplatelet therapy. The American
College of Chest Physicians Clinical Guideline on
Antithrombotic Therapy in Neonates and Children, pub-
lished in 2012, presents specific recommendations for
AIS. New evidence published since 2012 was reviewed
for the Australian Childhood Stroke Guideline, and rec-
ommendations are provided for the timing and use of
anticoagulation, antiplatelet, and steroid therapy in chil-
dren with radiologically confirmed ischemic stroke.
Despite the absence of controlled trials, there is a
body of literature supporting the safety of using antic-
oagulation and antiplatelet therapy in children with
stroke61–70
and suggested eligibility and protocol when
considering use of IV–tPA in children with stroke as a
part of the thrombolysis in pediatric stroke study.71
In
review of the literature, eight studies were identified
describing the use of anticoagulation or antiplatelet ther-
apy in children with AIS, of varying etiologies, including
a systematic review,63
five cohort studies,64,66–70
and a
case series.65
Three of these studies compared treated
and untreated cases.65–67
While there are limited data, it is reasonable to
assume safety of anticoagulation and antiplatelet ther-
apy, based on current findings unable to find an
increased risk of bleeding. Evidence regarding the role
of antithrombotic therapy in recurrent stroke is varied,
but may suggest benefit of treating with unfractionated
heparin, compared to aspirin or no treatment.69
In the
absence of consistent high-quality evidence, one
approach is to administer anticoagulation upon exclu-
sion of hemorrhage until the exclusion of dissection or
embolism as a cause of stroke.72
The rationale is to
reduce the risk of recurrent stroke while investigating
for etiology. An alternative argument suggests initial
use of Aspirin, because the potentially increased risk
of bleeding should be considered and that formal antic-
oagulation should only be administered after embolism
or dissection as proven.73
The biological rationale in
favor of initial heparinization is that recurrent strokes
are most likely to occur within the first 48–72 hours if
there is dissection or embolus.
Steroid therapy. Current or past infection or inflamma-
tory disease may be associated with increased risk of
stroke. Two papers that addressed the use of steroids in
childhood AIS were identified.74,75
A systematic review
of 32 observational studies and two trials involving 152
children provided weak evidence for the benefits of ster-
oid treatment in childhood AIS, in the context of tuber-
culous or bacterial meningitis, and some subtypes of
arteriopathy. It was noted, however, that the studies
reviewed had no internal controls or comparison
International Journal of Stroke, 14(1)
Medley et al. 101
9. groups. The authors concluded that there was little
robust evidence either in favor or against the use of
immunotherapy in childhood AIS.
Intracranial pressure and decompressive craniectomy for
acute arterial stroke. In the pediatric population data
suggests that 1–12% of children with AIS develop
malignant middle cerebral artery infraction (MMCAI)
and raised intracranial pressure.76–78
The most import-
ant indicators for raised intracranial pressure with both
supra and infratentorial infarcts are deteriorating level
of consciousness and the worsening of neurologic
dysfunction. Seizures longer than 5 minutes and more
severe neurologic dysfunction—measured as higher ini-
tial PedNIHSS scores (>7.5) are independent pre-
dictors of developing MMCAI syndrome.79
Adult data are high-quality, extensive, and support-
ive of decompressive craniectomy for MMCAI with
four systematic reviews80–83
reporting marked reduc-
tion in mortality compared to medical treatment
alone and overall improved disability measured by
Modified Rankin Scale. There are no controlled trials
of decompressive craniectomy in pediatric stroke
patients, with data confined to retrospective series or
Recommendations for reperfusion interventions, antithrombotic, immunotherapies, and
management of raised intracranial pressure
Reperfusion therapies.
IV–tPA may be appropriate in specific children. Consensus on potential eligibility criteria include (i) 2 to 17 years of age, (ii) radiologically
confirmed arterial stroke with absence of hemorrhage, (iii) pediatric stroke severity score 4 and 24, and (iv) treatment can be
administrated within 4.5 h from known symptom onset. However, the absence of high-quality evidence means that benefit over harm to
these children cannot be accurately assessed. Level of evidence (III, IV).
Administration of IV–tPA in children with confirmed stroke should not be considered where the time from symptom onset is unknown or
greater than 4.5 h. Level of evidence (I–III).
Where administration of IV–tPA is being considered for children with stroke, eligibility and protocols should align with previously developed
international consensus-based standards and adult protocols where appropriate (e.g. in teenagers 13–18 years). Level of evidence (CBR).
Endovascular therapies may be appropriate in some children meeting adult eligibility criteria, defined as radiologically diagnosed ischemic
stroke caused by large vessel occlusion and where treatment can be initiated within 6 h since onset of stroke symptoms. The absence of
high quality pediatric evidence, together with differences in underlying pathophysiology, means that benefit over harm for children cannot
be accurately assessed. Level of evidence (III-2, IV).
In children with stroke where time of onset of symptoms is unknown or greater than 6 h, adult evidence suggests that endovascular therapy
inclusive of IA–tPA and mechanical clot retrieval should not be considered. Level of evidence (Adult II).
Anticoagulation and antiplatelet therapy are safe in children with AIS after the exclusion of hemorrhage. Level evidence (III, IV).
In children with AIS, anticoagulation should not be administered within 24 h of receiving neurovascular intervention. Level evidence (adult I).
For all children with AIS, after exclusion of hemorrhage, unfractionated heparin, low molecular weight heparin, or Aspirin is recommended as
an initial therapy until the exclusion of dissection and embolic causes. Adapted from72
In children where an AIS is NOT caused by cardioembolism or dissection, daily aspirin is recommended for a minimum of 2 years. Adapted from72
In children with AIS, secondary to cardioembolism treatment with low molecular weight heparin or Vitamin K antagonist is recommended for a
minimum of three months. Adapted from72
In children with AIS secondary to dissection, treatment with low molecular weight heparin or Vitamin K antagonist is recommended for a
minimum of 6 weeks. Ongoing treatment should be dependent on neuroradiological assessment of stenosis severity and recurrent
ischemic episodes. Adapted from72
Steroids.
In children where the cause of AIS is NOT cardioembolic or dissection, the addition of steroids to antiplatelet therapy may be considered in
some subgroups of children with infection and arteriopathy related etiologies. Level of evidence (I–IV). Adapted from72
Intracranial pressure.
Early recognition of the minority of pediatric patients with acute stroke who may develop raised intracranial pressure should prompt initial
supportive care and early neurosurgical referral for consideration of decompressive craniectomy. Level of evidence (IV).
Decompressive craniectomy should be considered for children with malignant ischemic MCA (or ICA) territory infarction. Level of evidence (III, IV).
Suboccipital decompressive craniectomy should be considered for children with posterior circulation ischemic strokes and raised intracranial
pressure or decreasing level of consciousness. Level of evidence (IV).
Decompressive craniectomy may be considered 24 h after treatment with intravenous thrombolytic therapy (e.g. tPA). Level of evidence (IV).
Placement of an intracranial pressure monitor and subsequent time to assess pressure should not delay decompressive craniectomy. Level of
evidence (CBR).
Placement of an intracranial pressure measuring device at the time of decompressive craniectomy should be considered for pediatric patients.
Level of evidence (CBR, IV).
Elevation of the head of the bed to 30–45
is recommended after decompressive craniectomy. Level of evidence (Adult, I).
International Journal of Stroke, 14(1)
102 International Journal of Stroke 14(1)
10. case studies.76,78,79,84–88
Collectively, low quality evi-
dence suggests that morbidity and mortality outcomes
after decompressive craniectomy for MMCAI and
raised intracranial pressure may be better for children
than adults, recognizing the issue of publication bias
toward positive outcomes. Only one relevant pediatric
paper was identified reporting outcomes following pos-
terior fossa decompression for posterior circulation
stroke.89
Clinical considerations
The most important issue faced by the Guideline writ-
ing group was the low quality of evidence in pediatric
stroke, with few case–control or cohort studies to guide
recommendations for clinical recognition, neuroima-
ging, and investigation of underlying etiologies, and
no randomized controlled trials to guide recommenda-
tions for acute and secondary prevention therapies.
It will not be possible to improve outcomes for chil-
dren affected by stroke without minimizing extent of
brain injury. This requires better clinical recognition of
stroke symptoms among carers, emergency medical ser-
vices and pediatric physicians, more rapid radiological
confirmation or diagnosis, and initiating interventions to
restore perfusion and to minimize secondary injury. The
guideline committee felt that implementation of a stan-
dardized approach to diagnosis and management of
childhood stroke would be unattainable if recommenda-
tions were largely based on consensus statements.
Despite limited evidence, the guideline writing group
decided, prior to reviewing the evidence, that it was
appropriate to assign strong GRADE recommendations
for questions where there was potential benefit (based on
clear evidence from adults and lower quality evidence in
children) and almost no harm in children, and that weak
recommendations were appropriate where it was less
clear that benefit outweighed harm.
Summary
The purpose of the Guideline is to provide recommenda-
tions for the diagnosis and acute management of child-
hood stroke in order to reduce variation in care across
pediatric centers, to reduce time to diagnosis and treat-
ment, and to facilitate the development of a national
collaborative research network and stroke registry. The
Guideline is aimed at pediatric health professionals
working in secondary and tertiary level acute pediatric
centers. It is anticipated that administrators, funders, and
policy makers who manage and deliver care for children
with stroke will also End the Guideline useful.
Effective implementation requires engagement of
clinicians, hospital administrators, government,
research funding organizations, and stroke advocacy
groups. Priorities include (i) coordinated regional
stroke systems of care with predefined protocols for
hospital bypass to accredited primary stroke centers
with the capability to offer reperfusion therapies, (ii)
multidisciplinary pediatric stroke teams, and (iii) devel-
opment of institutional pediatric Stroke Code protocols
which include rapid imaging protocols, validated clin-
ical decision support tools, and parallel work practices
to increase efficiencies.
Narrowing the gaps in knowledge between adults
and children is of vital importance. Improving the evi-
dence for key interventions which have transformed
outcomes for adults, such as stroke units, intravenous
thrombolysis, and reperfusion therapies, is particularly
important. Audits that capture data on timelines of
care, access to acute interventions, adherence to recom-
mended inclusion and exclusion criteria, treatment
complications of treatment, and functional outcomes
using validated outcome measures will allow for bench-
marking of practice across centers. Appointment of a
key worker (ideally a stroke nurse/coordinator) will
ensure data collection for national auditing as well as
providing appropriate information and support to chil-
dren and their families affected by stroke.
It is also clear there is a need for high-quality multi-
center research across many areas of childhood stroke.
Developing a national pediatric registry with common
data elements and centralized data collection will be
required to elucidate incidence, standardize reporting,
and measure implementation of the guideline. Other
research priorities include an economic analysis of life-
time cost of pediatric stroke in Australian children and
determination of the accuracy of diagnosing arterial
ischemic and hemorrhagic stroke using standardized
diagnostic protocols.
Acknowledgements
The Murdoch Children’s Research Institute gratefully
acknowledges funding support from the Ian Potter
Foundation, and as part of the external consultation process,
reviews by Associate Professors Franz Babl and Richard
Leventer and Professor Stacy Goergen. The endorsement
from the Stroke Foundation of Australia, and the
Australian and New Zealand Childhood Stroke Society is
also acknowledged.
Declaration of conflicting interests
The author(s) declared the following potential conflicts of inter-
est with respect to the research, authorship, and/or publication
of this article: TM and MM contributed to all aspects of the
guideline development, including conducting the evidence
searches, data analysis, completing the evidence summaries sup-
porting the recommendations, drafting and editing the guide-
line, coordinating the external consultation process, and final
approval of the guideline. All other members contributed by
reviewing and grading evidence, discussions by meetings,
International Journal of Stroke, 14(1)
Medley et al. 103
11. writing and collectively finalizing the wording of all
recommendations.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: The Murdoch Children’s Research Institute gratefully
acknowledges funding support from the Ian Potter
Foundation.
ORCID iD
Tanya L Medley http://orcid.org/0000-0002-9505-6634
Ian Andrews http://orcid.org/0000-0002-9852-4755
Russell C Dale http://orcid.org/0000-0002-0109-8877
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