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Background: Early reperfusion has the best likelihood for a favorable outcome in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Our experience with mobile stroke unit (MSU) for direct to angiosuite (DTAS) transfer in AIS patients with suspected LVO is presented. Methods: Retrospective review of prospectively collected data from November 2019 to August 2022, of patients evaluated and transferred by the University of Alberta Hospital MSU and moved to angiosuite for endovascular thrombectomy (EVT). Result: A total of 41 cases were included. Nine were chosen for DTAS and 32 were shifted to angiosuite after stopping for computed tomography (CT) angiography of the head and neck (no-DTAS). Stroke severity measured by NIHSS (median with interquartile range (IQR)) was higher in patients of DTAS, 22 (14–24) vs 14.5 (5–25) in no-DTAS (p = 0.001). The non-contrast CT head in MSU showed hyperdense vessels in 8 (88.88%) DTAS vs 11 (34.35%) no-DTAS patients (p = 0.003). The EVT timelines (median with IQR, 90th percentile) including “door to artery puncture time” were 31 (23–50, 49.2) vs 79 (39–264, 112.8) minutes, and “door to recanalization time” was 69 (49–110, 93.2) vs 105.5 (52–178, 159.5) minutes in DTAS vs no-DTAS group, respectively. The workflow times were significantly shorter in the DTAS group (p < 0.001). Eight (88.88%) out of 9 DTAS patients had LVO and underwent thrombectomy. Conclusions: MSU for DTAS in patients with high NIHSS scores, cortical signs, and CT showing hyperdense vessel is an effective strategy to reduce the EVT workflow time.

Background: Hyperacute treatment of acute stroke may lead to thrombolysis in stroke mimics (SM). Our aim was to determine the frequency of thrombolysis in SM in primary stroke centers (PSC) dependent on telestroke versus comprehensive stroke centers (CSC). Method: Retrospective review of prospectively collected data from the Quality improvement and Clinical Research (QuICR) registry, the Discharge Abstract Database (DAD), and The National Ambulatory Care Reporting System (NACRS) of consecutive patients treated with intravenous thrombolysis for acute ischemic stroke in Alberta (Canada) from April 2016 to March 2021. Result: A total of 2471 patients who received thrombolysis were included. Linking the QuICR registry to DAD 169 (6.83%) patients were identified as SM; however, on our review of the records, only 112 (4.53%) were actual SM. SMs were younger with a mean age of 61.66 (±16.15) vs 71.08 (±14.55) in stroke. National Institute of Health Stroke Scale was higher in stroke with a median (IQR) of 10 (5–17) vs 7 (5–10) in SM. Only one patient (0.89 %) in SM groups had a small parenchymal hemorrhage versus 155 (6.57%) stroke patients had a parenchymal hemorrhage. There was no death among patients of thrombolysed SM during hospitalization versus 276 (11.69%) in stroke. There was no significant difference in the rate of SM among thrombolysed patients between PSC 27 (5.36%) versus CSC 85 (4.3%) (P = 0.312). The most responsible diagnosis of SM was migraine/migraine equivalent, functional disorder, seizure, and delirium. Conclusion: The diagnosis of SM may not always be correct when the information is extracted from databases. The rate of thrombolysis in SM via telestroke is similar to treatment in person at CSC.

Today, one of the most widely debated topics in the world is disparity in global wealth and access to social services. Within the new economy, microfinance is becoming a more powerful tool for poverty alleviation. The bulk of microfinance programs were established with the explicit objective of alleviating poverty and empowering individuals of the country. Furthermore, a rising number of microfinance institutions (MFIs) prefer to work with promising entrepreneurs with unique business ideas because they believe they are more responsible and trustworthy. Programs such as the Self Help Bank Linkage Program in India have been steadily gaining popularity due to their beneficial economic impact and the assumption that they help women to become more self-sufficient. So far, the SHG Program has delivered microfinance to its mostly female participants using a new form of group saving and lending. According to the research, investing in women has been proved to be the most effective way to increase family health, nutrition, hygiene, and educational levels, and hence the entire society. Thus, it is vital to provide additional support for women in both financial and non-financial services. A large number of top public and private sector banks are launching programs specifically aimed to assist women in starting their own businesses. In recent years, even the unorganized sector has begun to participate in the microfinance movement. The purpose of this study is to determine the effectiveness of microfinance as a tool for boosting women entrepreneurship in India.

The Early Chishti Sufi Shaikhs from thirteenth and fourteenth century Delhi made critical interventions in the religious lives of the Muslims in South Asia. They cultivated in their adherents the much-needed ethical vision and sensitivity towards the socially marginalized. Yet hardly any attention is paid to the pedagogy of these Sufis on religion and spirituality. Their discourses on their community are documented in their literary works like malfūzāt. Of late, malfūzāt have been studied as a literary genre for the unique processes of their making. But their didactic contents on Islam and their instructions to Sufi initiates have barely been examined. This lacuna stems on account of the usage of these religious texts as fillers for information lacking in court chronicles. The essay studies the pedagogy of the Early Chishtī Shaikhs and as they related to charity in medieval South Asia. It also examines the mechanisms deployed by them to cultivate a philanthropic vision in Muslims in the praxis of faith.

Mimics account for almost half of hospital admissions for suspected stroke. Stroke mimics may present as a functional (conversion) disorder or may be part of the symptomatology of a neurological or medical disorder. While many underlying conditions can be recognized rapidly by careful assessment, a significant proportion of patients unfortunately still receive thrombolysis and admission to a high-intensity stroke unit with inherent risks and unnecessary costs. Accurate diagnosis is important as recurrent presentations may be common in many disorders. A non-contrast CT is not sufficient to make a diagnosis of acute stroke as the test may be normal very early following an acute stroke. Multi-modal CT or magnetic resonance imaging (MRI) may be helpful to confirm an acute ischaemic stroke and are necessary if stroke mimics are suspected. Treatment in neurological and medical mimics results in prompt resolution of the symptoms. Treatment of functional disorders can be challenging and is often incomplete and requires early psychiatric intervention.

The rostral mesencephalon may influence ocular motility in the vertical, horizontal, and torsional trajectories through intricate supranuclear, internuclear, and infranuclear neural networks. Strategic unilateral midbrain lesions may result in contralateral horizontal gaze palsy with saccadic failure due to combined interruption of supranuclear corticofugal fibers from the frontal eye field and colliculofugal fibers from the superior colliculus. In this article, we report a patient who sustained combined vertical and horizontal gaze deficits after a single infarct involving the mesodiencephalic junction. The neural substrate for each deficit is briefly discussed in light of clinical findings. This case presented a triad of three distinct syndromes of horizontal gaze paresis, vertical one-and-a-half syndrome, and pseudoabducens palsy due to damage of nuclear and supranuclear projections within the rostral mesencephalon. This combination was due to a single embolic infarct in the territory of the posterior thalamosubthalamic artery (artery of Percheron) that arises at the basilar bifurcation. Coexistence of these phenomena exemplified how rostral midbrain lesions may affect ocular motility in the vertical, horizontal, and torsional planes, along with disruption of normal vergence control.

Background Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a multisystem disease that primarily involves the respiratory tract. The first case of COVID-19 was identified in late 2019 in the province of Wuhan, China, which was followed by the rapid spread of the disease globally, becoming a present-day pandemic. Objectives The aim of this study is to describe the clinical characteristics, comorbidities, and outcomes of critically sick patients with COVID-19 pneumonia admitted to the intensive care unit (ICU) of Fatima Memorial Hospital, Lahore, from March 2021 to August 2021. A total of 133 patients were chosen for this retrospective cohort study. Results There was a total of 133 patients, out of which 65 (48.9%) were male and 68 (51.1%) were female. Of these 133 patients, 70 (52.6%) were discharged home after recovery and 63 (47.4%) died; 96 (72.2%) patients had diabetes mellitus and of these, 53 (55.2%) patients died and 43 (44.8%) were discharged, 94 (70.7%) patients had hypertension, out of which 53 (56.4%) died and 41 (43.6%) were discharged home, 40 (30.1%) patients had ischemic heart disease (IHD), out of which 28 (70%) died and 12 (30%) were discharged. A total of 48 (36.1%) patients needed invasive positive pressure ventilation (IPPV) and 78 (58.6%) patients required noninvasive positive pressure ventilation (NIPPV). Conclusion Patients with one or more underlying co-morbidities had poor clinical outcomes compared to those with no co-morbidities, with the most vulnerable group being patients with Ischemic heart disease, chronic kidney disease, hypertension, and diabetes mellitus in descending order.

Intravenous thrombolysis with alteplase bolus followed by infusion is a global standard of care for patients with acute ischaemic stroke. We aimed to determine whether tenecteplase given as a single bolus might increase reperfusion compared with this standard of care.In this multicentre, open-label, parallel-group, registry-linked, randomised, controlled trial (AcT), patients were enrolled from 22 primary and comprehensive stroke centres across Canada. Patients were eligible for inclusion if they were aged 18 years or older, with a diagnosis of ischaemic stroke causing disabling neurological deficit, presenting within 4·5 h of symptom onset, and eligible for thrombolysis per Canadian guidelines. Eligible patients were randomly assigned (1:1), using a previously validated minimal sufficient balance algorithm to balance allocation by site and a secure real-time web-based server, to either intravenous tenecteplase (0·25 mg/kg to a maximum of 25 mg) or alteplase (0·9 mg/kg to a maximum of 90mg; 0·09 mg/kg as a bolus and then a 60 min infusion of the remaining 0·81 mg/kg). The primary outcome was the proportion of patients who had a modified Rankin Scale (mRS) score of 0-1 at 90-120 days after treatment, assessed via blinded review in the intention-to-treat (ITT) population (ie, all patients randomly assigned to treatment who did not withdraw consent). Non-inferiority was met if the lower 95% CI of the difference in the proportion of patients who met the primary outcome between the tenecteplase and alteplase groups was more than -5%. Safety was assessed in all patients who received any of either thrombolytic agent and who were reported as treated. The trial is registered with ClinicalTrials.gov, NCT03889249, and is closed to accrual.Between Dec 10, 2019, and Jan 25, 2022, 1600 patients were enrolled and randomly assigned to tenecteplase (n=816) or alteplase (n=784), of whom 1577 were included in the ITT population (n=806 tenecteplase; n=771 alteplase). The median age was 74 years (IQR 63-83), 755 (47·9%) of 1577 patients were female and 822 (52·1%) were male. As of data cutoff (Jan 21, 2022), 296 (36·9%) of 802 patients in the tenecteplase group and 266 (34·8%) of 765 in the alteplase group had an mRS score of 0-1 at 90-120 days (unadjusted risk difference 2·1% [95% CI - 2·6 to 6·9], meeting the prespecified non-inferiority threshold). In safety analyses, 27 (3·4%) of 800 patients in the tenecteplase group and 24 (3·2%) of 763 in the alteplase group had 24 h symptomatic intracerebral haemorrhage and 122 (15·3%) of 796 and 117 (15·4%) of 763 died within 90 days of starting treatment INTERPRETATION: Intravenous tenecteplase (0·25 mg/kg) is a reasonable alternative to alteplase for all patients presenting with acute ischaemic stroke who meet standard criteria for thrombolysis.Canadian Institutes of Health Research, Alberta Strategy for Patient Oriented Research Support Unit.

BACKGROUND Focal seizure with impaired awareness, post-seizure Todd's phenomenon, and post-stroke recrudescence can all present with focal neurological deficits, mimicking stroke. As acute ischemic stroke mimics, they are distractors in the emergency setting where management is time-sensitive both for seizure and stroke. Nevertheless, a timely diagnosis can be made with exploration of the clinical features supported by investigation such as computerized tomographic perfusion. CASE REPORT Our patient was a 65-year-old woman who was known hypertensive, with type 2 diabetes mellitus, and previous intracerebral hemorrhage with minimal right-sided residual deficits, but still able to ambulate independently. She was brought to the Emergency Department because 1 hour prior to presentation, she had sudden worsening of weakness of the right limbs, aphasia, aggression, and confusion. An initial impression of repeat acute stroke, focal seizure with impaired awareness, Todd's phenomenon, and post-stroke recrudescence was considered. While CT angiography was suggestive of left middle cerebral artery occlusion, CT perfusion revealed extensive hypoperfusion patterns beyond the region of the occlusion, thus suggesting a different etiology from acute ischemic stroke. In view of her previous left hemispheric lesion coupled with the presentation, our working diagnosis was seizure with Todd's phenomenon, and she was started on an anti-epileptic drug. Her condition returned to baseline within 24 h of admission and was subsequently discharged. CONCLUSIONS Our case demonstrates that adequate elucidation of clinical features in conjunction with CT perfusion, as a dual-purpose tool, can aid the diagnosis of both stroke mimics and acute ischemic stroke in the Emergency Department where rapid treatment is essential.

Effective English language teaching has been a great challenge in Pakistan and particularly in Azad Jammu and Kashmir district at middle level schools. This research explored teachers’ perception of using appropriate teaching strategies in public sector schools of Azad Jammu and Kashmir, Pakistan. The population of the study included male- female teachers of public sector schools of the Bagh district of Pakistan. A sample of 50 schools and 150 teachers of English Language were selected. The findings reveal an insignificant difference between the perception of male and female teachers about the use of different teaching methods. The p-value was greater than alpha that confirms this there is insignificant difference of insights among male and female teachers. It was also discovered that classroom instructions at middle school level were not aligned with National Curriculum 2006. The teachers in AJK were not aware about the spirit of curriculum 2006 as well as National Professional Standards of Teachers. A majority of respondents used grammar translation method for teaching while a very low percentage used other teaching methods. It is recommended that teachers need to be trained in using other useful and effectives strategies In-service training programs for teacher should be arranged, specifically focusing on ELT. There is a need draw a perfect alignment between curriculum instructions and assessment in general and more specifically in subject of English.

To evaluate the oncological and functional outcomes of bone tumour patients who underwent reconstruction with mega prosthesis.A retrospective study was conducted in the department of Orthopaedics Aga Khan University Hospital, Karachi. All the paediatric and adult age group patients diagnosed with malignant, benign and metastatic bone tumours and meeting the inclusion criteria were selected and analysed. Retrospective data was collected from January 2008-January 2018.Sixty-two patients, 30 (48.4%) females and 32 (51.6%) males. were included in the study. Of these 57 (92%) cases had involvement of the lower limb. The mean age was 36.95±19.1 years with a range of 9-81 years. The duration of patients follow up was from 1-124 months (mean 32.7±36.43 months). There were 29 (47%) malignant cases. The most commonly occurring tumour site was distal femur and proximal femur. There were 53 (85%) primary surgeries (first time conducted surgeries) while 9(15%) revision surgeries were done. Major complications were encountered in 19 (30.6%) patients and 13 (20.9%) had minor complications. Post-surgery local recurrence occurred in 2 (3.2%) patients while 7 (11.2%) had distant metastasis. In functional outcomes the mean MSTS score of our patients was 72.09±26.43. The survival rate was 69.8% with 45 patients recovered.With a good patient selection, adherence to the principles of tumour surgery and an adequate applied knowledge of mega prosthesis insertion, a good functional outcome was achieved.

Many oil and gas companies have suffered major production losses, and higher cost of maintenance due to the total shutdown of their plants to conduct TAM event during a certain period and according to scope of work. Therefore, TAM is considered the biggest maintenance activity in oil and gas plant in terms of manpower, material, time and cost. These plants usually undergo other maintenance strategies during normal operation of plants such as preventive, corrective and predictive maintenance. However, some components or units cannot be inspected or maintained during normal operation of plant unless plant facilities are a totally shut downed due to operating risks. These risks differ from a company to another due to many factors such as fluctuated temperatures and pressures, corrosion, erosion, cracks and fatigue caused by operating conditions, geographical conditions and economic aspects. The aim of this paper is to develop a TAM model to optimize the TAM scheduling associated with decreasing duration and increasing interval of the TAM of the gas plant. The methodology that this paper presents has three stages based on the critical and non-critical pieces of equipment. At the first stage, identifying and removing Non-critical Equipment pieces (NEs) from TAM activity to proactive maintenance types. During the second stage, the higher risk of each selected equipment is assessed in order to prioritize critical pieces of equipment based on Risk Based Inspection (RBI). At the third stage, failure probability and reliability function for those selected critical pieces of equipment are assessed. The results of development of the TAM model is led to the real optimization of TAM scheduling of gas plants that operated continuously around the clock in order to achieve a desired performance of reliability and availability of the gas plant, and reduce cost of TAM resulting from the production shutdown and cost of inspection and maintenance.

Failure modes and effect analysis (FMEA) is a proactive, highly structured and systematic approach for failure analysis. It has been also applied as a risk assessment tool, by ranking potential risks based on the estimation of risk priority numbers (RPNs). This article develops an improved FMEA methodology for strategic risk analysis. The proposed approach combines the analytic hierarchy process (AHP) technique with the exponential and weighted geometric mean method (EWGM) to support risk analysis. AHP is applied to estimate the weights of three risk factors: Severity (S), Occurrence (O) and Detection (D), which integrate the RPN for each risk. The EWGM method is applied for ranking RPNs. Combining AHP with EWGM allows avoiding repetition of FMEA results. The results of the developed methodology reveal that duplication of RPNs has been decreased, facilitating an effective risk ranking by offering a unique value for each risk. The proposed methodology not only focuses on high severity values for risk ranking but it also considers other risk factors (O and D), resulting in an enhanced risk assessment process. Furthermore, the weights of the three risk factors are considered. In this way, the developed methodology offers unique value for each risk in a simple way which makes the risk assessment results more accurate. This methodology provides a practical and systematic approach to support decision makers in assessing and ranking risks that could affect long-term strategy implementation. The methodology was validated through the case study of a power plant in the Middle East, assessing 84 risks within 9 risk categories. The case study revealed that top management should pay more attention to key risks associated with electricity price, gas emissions, lost-time injuries, bad odour and production.

Construction projects have encountered poor performance due to the insecure environment caused by insurgency and terrorism in the world. The real cause includes lack of desired resource and reluctance of stakeholders/project teams to work in such areas. The project suffers a massive loss of finances, time overrun and poor quality which ends up the project in the midway. In the current research, various risks which affect the productivity of the project due to an insecure environment will be identified. Multiple factors are affecting the objectives of the project; time and cost will be extracted from the literature review and structured interviews from stakeholders who have already work experience in these areas. A model incorporating these factors will be developed. The model will further be validated and verified from the project which has been implemented in such areas. This study will help not only help in increasing the performance of the project but also set a yardstick for development projects implemented in insurgency-hit areas of the world. Key words: Poor performance, time overrun, cost overrun, man-made disaster areas, terrorism, infrastructure development projects.

PurposeThis paper aims to present the development of a knowledge-based system (KBS) to support the implementation of Lean Six Sigma (L6s) principles applied to enhance quality management (QM) performance within a health-care environment. Design/methodology/approachThe process of KBS building has been started by acquiring knowledge from experts in field of L6σ and QM in health care. The acquired knowledge has been represented in a rule-based approach for capturing L6σ practices. These rules are produced in IF […].THEN way where IF is the premise and THEN is the action. The produced rules have been integrated with gauging absence pre-requisites (GAP) technique to facilitate benchmarking of best practice in a health-care environment. A comprehensive review of the structure of the system is given, detailing a typical output of the KBS. FindingsImplementation of L6s principles to enhance QM performance in a health-care environment requires a pre-assessment of the organisation’s competences. The KBS provides an enhanced strategic and operational decision-making hierarchy for achieving a performance benchmark. Research limitations/implicationsThe KBS needs validation in real health-care environment, which will be done in Oman’s hospitals. Practical implicationsThe paper is intended to benefit QM practitioners in the health-care sector during decision-making to achieve performance improvement against a best practice benchmark. Originality/valueThis research presents a novel application of a hybrid KBS with GAP methodology to support the implementation of L6s principles to enhance QM performance in a health-care environment.

Background and ObjectivesThe rate of infarct core progression in patients with acute ischemic stroke is variable and affects outcome of reperfusion therapy. We evaluated the hypoperfusion index (HI) to estimate the initial rate of core progression in patients with medium vessel occlusion (MeVO) compared to large vessel occlusion (LVO) stroke and within a larger time frame since stroke onset.MethodsCore progression was assessed in 106 patients with acute stroke and CT perfusion. Using reperfusion trial core time criteria, fast progressors had core >70 mL within 6 hours of stroke onset and slow progressors had core ≤70 mL, mismatch ≥15 mL, and mismatch to core ratio ≥1.8 within 6 to 24 hours. The relationship between HI and infarct core progression (core/time) was examined using receiver operating characteristics to determine optimal HI cutoff. The HI cutoff was then tested in the overall cohort, compared between MeVO and LVO, and evaluated in patients up to 24 hours from stroke onset to differentiate fast from slow rate of core progression. HI threshold was assessed in a second independent cohort of 110 patients with acute ischemic stroke.ResultsIn 106 patients with acute stroke, 6.6% were fast progressors, 27.4% were slow progressors, and 66% were not classified as fast or slow progressor by reperfusion trial core time criteria. HI >0.5 was associated with fast progression and able to distinguish fast from slow progressors (area under the curve [AUC] 0.94; 95% confidence interval [CI] 0.80–0.99). In MeVO (n = 26) HI >0.5 had a core progression of 0.30 mL/min compared to 0.03 mL/min for HI ≤0.5 (p < 0.001). In LVO (n = 80), HI >0.5 had a core progression of 0.26 mL/min compared to 0.02 mL/min for HI ≤0.5 (p < 0.001). In patients not classified as fast or slow progressor by reperfusion trial criteria, those with HI >0.5 had progression rate of 0.21 mL/min compared to 0.03 mL/min for those with HI ≤0.5 (p < 0.001). Validation in a second cohort of patients with acute ischemic stroke (n = 110; MeVO = 42, LVO = 68) yielded similar results for HI >0.5 to distinguish fast and slow core progression with an AUC of 0.84 (95% CI 0.72–0.97).DiscussionHI can differentiate fast from slow core progression in MeVO and LVO within the first 24 hours of acute ischemic stroke. Consideration of core progression rate at time of stroke evaluation may have implications in the selection of patients with MeVO and LVO stroke for reperfusion therapy that warrant further study.

Introduction Mechanisms driving neurodegeneration in Parkinson's disease (PD) are unclear and neurovascular dysfunction may be a contributing factor. White matter hyperintensities (WMH) are commonly found on brain MRI in patients with PD. It is controversial if they are more prevalent or more severe in PD compared with controls. This systematic review aims to answer this question. Methods A systematic search of electronic databases was conducted for studies of WMH in patients with PD. A qualitative synthesis was done for studies reporting WMH prevalence or WMH scores on a visual rating scale (VRS). In studies reporting total WMH volume, the difference between patients with PD and controls was pooled using random effects meta-analysis. Results Among 3860 subjects from 24 studies, 2360 were cases and 1500 controls. Fifteen studies reported WMH scores and four studies reported the prevalence of WMH. On VRS, five studies reported no difference in WMH scores, three found higher WMH scores in PD compared to controls, three reported increased WMH scores either in periventricular or deep white matter, and four reported higher scores only in PD with dementia. In studies reporting WMH volume, there was no difference between patients with PD and controls (pooled standardized mean difference = 0.1, 95%CI: −0.1–0.4, I2 = 81%). Conclusion WMH are not more prevalent or severe in patients with PD than in age-matched controls. PD dementia may have more severe WMH compared to controls and PD with normal cognition. Prospective studies using standardized methods of WMH assessment are needed.

IntroductionThe COVID-19 pandemic has resulted in a dramatic unexplained decline in hospital admissions due to acute coronary syndromes and stroke. Several theories have emerged aiming to explain this decline, mostly revolving around the fear of contracting the disease and thus avoiding hospital visits.AimsIn this study, we aim to examine the impact of the COVID-19 pandemic on stroke admissions to a tertiary care centre in Qatar.MethodsThe Hamad General Hospital stroke database was interrogated for stroke admissions between September 2019 and May 2020. The number of stroke admissions, stroke subtypes and short-term outcomes was compared between the ‘pre-COVID-19’ period (September 2019 to February 2020) and the COVID-19 pandemic period (March to May 2020).ResultsWe observed a significant decline in monthly admissions in March (157), April (128) and May (135) compared with the pre-COVID-19 6-month average (229) (p=0.024). The reduction in admissions was most evident in functional stroke mimics. The average admissions decreased from 87 to 34 per month (p=0.0001). Although there were no significant differences in admissions due to ischaemic stroke (IS), intracranial haemorrhage or transient ischaemic attacks between the two periods, we noted a relative decrease in IS due to small vessel disease and an increase in those due to large vessel atherosclerosis in March to May 2020.ConclusionsThe decline in overall stroke admissions during the COVID-19 pandemic is most likely related to concerns of contracting the infection, evidenced mainly by a decline in admissions of stroke mimics. However, a relative increase in large vessel occlusions raises suspicion of pathophysiological effects of the virus, and requires further investigation.

Guidelines are lacking for management of acute ischemic stroke and stroke prevention in patients with immune thrombocytopenia (ITP). Our aim is to highlight the dilemma inherent in managing patients with both significant bleeding and thrombotic risk factors. In this review, we present two patients with history of ITP who presented with acute ischemic stroke and received tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT), a rare management strategy in this patient population. In addition, we identified 27 case reports of ischemic stroke in patients with ITP; none of them received tPA or EVT. Furthermore, there are 92 patients with significant thrombocytopenia with no available data regarding the cause of thrombocytopenia, who were acutely treated with tPA or EVT. Conclusive evidence cannot be determined based on these limited number of cases. Future multicenter prospective cohort studies in patients with ITP are needed to provide better evidence-based treatment plans. At present, treatment of acute ischemic stroke in patients with ITP requires close collaboration between hematology and vascular neurology experts to find a balance between the benefit and risk of hemorrhagic complications.

Mobile Stroke Unit (MSU) expedites the delivery of intravenous thrombolysis in acute stroke patients. We further evaluated the functional outcome of patients shipped to a tertiary care centre or repatriated to local hospitals after triage by MSU in acute stroke syndrome in rural northern Alberta. Consecutive patients with suspected acute stroke syndrome were included. On the basis of neurology consultation and, Computed Tomography findings, patients, who were thrombolysed or needed advanced care were transported to the Comprehensive stroke center (CSC) (Triage to CSC group). Other patients were repatriated to local hospital care (Triage to LHC group). A total of 156 patients were assessed in MSU, 73 (46.8%) were female and the mean age was 66.6 ± 15 years. One hundred and eight (69.2%) patients, including 41 (26.3%) treated with thrombolysis were transported to the CSC (Triage to CSC group) and 48 (30.8%) were repatriated to local hospital care. The diagnosis made in MSU and final diagnosis were matching in 88% (95) and 91.7% (44, p = 0.39) in Triage to CSC and Triage to LHC groups respectively. Prehospital triage by MSU of acute stroke syndrome can reliably repatriate patients to the home hospital. The proposed model has the potential to triage patients according to their medical needs by enabling treatment in home hospitals whenever reasonable.

© 2020 Elsevier Ltd Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p

In an acute stroke setting, transcranial Doppler (TCD) and transcranial color-coded duplex (TCCD) have an important diagnostic utility in the monitoring of an arterial occlusion and microemboli detection. In addition, TCD has proven to be a very useful tool in the detection and progression of cerebral vasospasm in patients with subarachnoid hemorrhage. TCD/TCCD may have an important role in defining collateral blood flow (CF) in stroke patients. It is a noninvasive technique and can be utilized repeatedly allowing for changes in the blood flow dynamics as treatment is delivered. In this review, we outlined the evolving role of TCD/TCCD in defining CF in patients with an acute ischemic stroke, predicting clinical outcome and monitoring the treatment's efficacy of the CF augmentation.

BACKGROUND AND PURPOSE The purpose of this study was to compare Doppler ultrasound (DUS) to other angiographic modalities: computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA). METHODS All DUS studies performed at Stroke Prevention Clinic (SPC) from 2011 to 2013 and referred for further angiographic modalities were included. Patients were excluded if the corresponding angiographic modality was not performed within 6 months of DUS. Patients were also excluded if they underwent interventions before DUS or between the time of DUS and the corresponding angiographic modality. The degree of stenosis was classified as mild (

BackgroundEvaluation of patients with a suspected stroke is one of the most common neurological emergencies requiring rapid, comprehensive assessment by the stroke service to determine patient eligibility for timely reperfusion therapies. Prehospital evaluation may help to improve patient selection and reduce avoidable admissions to overcapacity emergency departments.Methods and resultsWe report on our early experience of prehospital triage of patients with a suspected stroke using a mobile stroke unit (MSU) equipped with CT scanner in rural Alberta. During the initial 4 months of operation, 28 patients were evaluated by the team in the MSU. Eight patients were within the time window of thrombolysis and were treated with intravenous tissue plasminogen activator in the MSU. No patients suffered haemorrhage or any other complications. Fourteen patients with multiple aetiologies (stroke mimics 6, transient ischaemic attacks 2, subacute stroke outside thrombolysis window 2, intracranial haemorrhage 3 and cerebral contusion 1) were assessed in the field and transferred to the tertiary hospital. Six patients after assessment and imaging were repatriated back to the local hospital as they were deemed stroke mimics or were outside of the reperfusion window.ConclusionsThe MSU offers a novel approach to performing timely evaluation and treatment of patients with a suspected stroke in rural settings and may help reduce admissions to overcapacity tertiary care facilities.

Importance The relative rates of detection of atrial fibrillation (AF) or atrial flutter from evaluating patients with prolonged electrocardiographic monitoring with an external loop recorder or implantable loop recorder after an ischemic stroke are unknown. Objective To determine, in patients with a recent ischemic stroke, whether 12 months of implantable loop recorder monitoring detects more occurrences of AF compared with conventional external loop recorder monitoring for 30 days. Design, setting, and participants Investigator-initiated, open-label, randomized clinical trial conducted at 2 university hospitals and 1 community hospital in Alberta, Canada, including 300 patients within 6 months of ischemic stroke and without known AF from May 2015 through November 2017; final follow-up was in December 2018. Interventions Participants were randomly assigned 1:1 to prolonged electrocardiographic monitoring with either an implantable loop recorder (n = 150) or an external loop recorder (n = 150) with follow-up visits at 30 days, 6 months, and 12 months. Main outcomes and measures The primary outcome was the development of definite AF or highly probable AF (adjudicated new AF lasting ≥2 minutes within 12 months of randomization). There were 8 prespecified secondary outcomes including time to event analysis of new AF, recurrent ischemic stroke, intracerebral hemorrhage, death, and device-related serious adverse events within 12 months. Results Among the 300 patients who were randomized (median age, 64.1 years [interquartile range, 56.1 to 73.7 years]; 121 were women [40.3%]; and 66.3% had a stroke of undetermined etiology with a median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score of 4 [interquartile range, 3 to 5]), 273 (91.0%) completed cardiac monitoring lasting 24 hours or longer and 259 (86.3%) completed both the assigned monitoring and 12-month follow-up visit. The primary outcome was observed in 15.3% (23/150) of patients in the implantable loop recorder group and 4.7% (7/150) of patients in the external loop recorder group (between-group difference, 10.7% [95% CI, 4.0% to 17.3%]; risk ratio, 3.29 [95% CI, 1.45 to 7.42]; P = .003). Of the 8 specified secondary outcomes, 6 were not significantly different. There were 5 patients (3.3%) in the implantable loop recorder group who had recurrent ischemic stroke vs 8 patients (5.3%) in the external loop recorder group (between-group difference, -2.0% [95% CI, -6.6% to 2.6%]), 1 (0.7%) vs 1 (0.7%), respectively, who had intracerebral hemorrhage (between-group difference, 0% [95% CI, -1.8% to 1.8%]), 3 (2.0%) vs 3 (2.0%) who died (between-group difference, 0% [95% CI, -3.2% to 3.2%]), and 1 (0.7%) vs 0 (0%) who had device-related serious adverse events. Conclusions and relevance Among patients with ischemic stroke and no prior evidence of AF, implantable electrocardiographic monitoring for 12 months, compared with prolonged external monitoring for 30 days, resulted in a significantly greater proportion of patients with AF detected over 12 months. Further research is needed to compare clinical outcomes associated with these monitoring strategies and relative cost-effectiveness. Trial registration ClinicalTrials.gov Identifier: NCT02428140.

India’s decision to pursue an aggressive foreign policy to subdue Pakistan and its tactic to implement such policy entails a perilous course of action. The dangerous brinksmanship between the states since the last two years along the Line of Control (LoC) and the Working Boundary could lead to disastrous consequences. The US’s ever increasing cooperation with India and its lukewarm response to Islamabad’s call, is yet another factor, which encourages New Delhi to adopt an offensive behaviour towards Pakistan. Modi’s Kashmir policy has resulted in failure, causing despondency among the people of the Indian Occupied Kashmir (IOK). Modi’s rigid approach towards Pakistan and the people of IOK continues to irk the Indo-Pak relations. India’s absurd policy towards Pakistan has rather compelled Islamabad to resist, which faded the flexibility and goodwill towards New Delhi shown by it during the past ten years. An unresolved Kashmir issue is a historical fact, which cannot be sidelined and ignored for too long. Even a minor miscalculation by India, in pursuit of its foreign policy objectives for undermining Islamabad’s will to resist, could put the entire region in trouble. India and the international community should, therefore, realise that none of the strategies other than ‘dialogue’ involving all the stakeholders would succeed in resolving the long pending issues including the core issue of Jammu and Kashmir (J&K).

Background and purposeFlow diversion is a relatively new strategy used to treat complex cerebral aneurysms. The optimal method for radiographic follow-up of patients treated with flow diverters has not been established. The rate and clinical implications of in-stent stenosis for these devices is unclear. We evaluate the use of transcranial Doppler ultrasound (TCD) for follow-up of in-stent stenosis.Materials and methodsWe analyzed 28 patients treated with the Pipeline embolization device (PED) over the course of 42 months from January 2009 to June 2012. Standard conventional cerebral angiograms were performed in all patients. TCD studies were available in 23 patients.ResultsAngiographic and TCD results were compared and found to correlate well.ConclusionsTCD is a potentially useful adjunct for evaluating in-stent stenosis after flow diversion.

Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. The 2016 update of the Canadian Stroke Best Practice Recommendations Telestroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. These recommendations focus on the use of telemedicine technologies to rapidly identify and treat appropriate patients with acute thrombolytic therapies in hospitals without stroke specialized expertise; select patients who require to immediate transfer to stroke centers for Endovascular Therapy; and for the patients who remain in community hospitals to facilitate their care on a stroke unit and provide remote access to stroke prevention and rehabilitation services. While these latter areas of Telestroke application are newer, they are rapidly developing, with new opportunities that are yet unrealized. Virtual rehabilitation therapies offer patients the opportunity to participate in rehabilitation therapies, supervised by physical and occupational therapists. While not without its limitations (e.g., access to telecommunications in remote areas, fragmentation of care), the evidence-to-date sets the foundation for improving access to care and management for patients during both the acute phase and now through post stroke recovery.

Purpose This paper aims to develop a knowledge-based (KB) system for Lean Six Sigma (LSS) maintenance in environmentally sustainable buildings (Lean6-SBM). Design/methodology/approach The Lean6-SBM conceptual framework has been developed using the rule base approach of KB system and joint integration with gauge absence prerequisites (GAP) technique. A comprehensive literature review is given for the main pillars of the framework with a typical output of GAP analysis. Findings Implementation of LSS in the sustainable building maintenance context requires a pre-assessment of the organisation’s capabilities. A conceptual framework with a design structure is proposed to tackle this issue with the provision of an enhancing strategic and operational decision-making hierarchy. Research limitations/implications Future research work might consider validating this framework in other type of industries. Practical implications Maintenance activities in environmentally sustainable buildings must take prodigious standards into consideration, and, therefore, a robust quality assurance measure has to be integrated. Originality/value The significance of this research is to present a novel use of hybrid KB/GAP methodologies to develop a Lean6-SBM system. The originality and novelty of this approach will assist in identifying quality perspectives while implementing different maintenance strategies in the sustainable building context.

Objective: To assess the glycemic response of metformin in patients with Type-2 Diabetes Mellitus (T2DM) as well as to see its association with reductions in BMI and GIT intolerance. Methods: This Quasi, Experimental study was conducted at Jinnah-Allama Iqbal Institute of Diabetes and Endocrinology (JAIDE) Jinnah Hospital, Lahore from 1st March 2016 to 30th September 2016. Newly diagnosed T2DM patients were given metformin for duration of three months and later on they were categorized into Responders and Non-Responders on the basis of HbA1c (A1C) reductions, which were estimated by Hemoglobin (A1C) analyzer (TD4611A TAIDoc Tech. Taiwan) through photometry. Similarly, baseline BMI and BMI after three months therapy with metformin was also recorded. Results: Among total of 200 patients, 40.5% of the patients were classified as Non-Responders whereas; 59.5% of the patients as Responders. The baseline BMI (26.09 kg/m2) was also decreased significantly after metformin therapy (25.40 kg/m2). It was found that metformin reduced the A1C in all the patients. However, the glycemic control was much better in patients with higher baseline A1C (1.13% ± 0.08) as compared to lower baseline levels (0.61% ± 0.07). Regarding GIT intolerance, 140 patients lacked the symptoms, out of which 60.7% were responders and 39.3% were non-responders. Conclusions: Metformin lead to improvement in glycemic control in 59.5% of newly diagnosed T2DM patients after taking metformin for three months but in 40.5% it did not which may be because of combined effects of various gene polymorphisms and their interaction with non-genetic factors. Metformin reduced the BMI in all the patients; however, BMI lowering activity of metformin was same regardless of its effect on HbA1C. Moreover, the signs and symptoms of GIT intolerance did not differ between the two groups.

Governance perspective plays a vital role in the success of Quality Management in Healthcare Environment (QMHE). In fact, QMHE has adopted and applied different quality tools and models in recent times, with some even developing their own quality-based initiatives. This paper will present an original approach of using Knowledge Based (KB) system integrated with Gauge Absence Perquisite (GAP) analysis. This approach will help to measure the effectiveness of governance body as part of the QMHE. In fact, the GAP method has been used for benchmarking the present performance with the standardized ones. The results will help healthcare practitioners to improve the governance boy’s gaps and take the correct decisions. The KB System has been validated in order to prove its ability to assess the impact of Governance on the QMHE by capturing data related to the organization’s performance. It has also shown how the rules are embedded in each module to establish relationships, and convert this data into information. The system has proven to be capable in assessing and comparing the organization’s level of performance with the QM benchmark.

The importance of maintenance has escalated significantly by the increase in automation in manufacturing processes. This condition changed the perspective of maintenance from being considered as an inevitable cost to being seen as a key business function to drive competitiveness. Consequently, maintenance decisions need to be aligned with the business competitive strategy as well as the requirements of manufacturing/quality functions in order to support manufacturing equipment performance. Therefore, it is required to synchronise the maintenance strategy and operations with business and manufacturing/quality aspects. This article presents the design and development of a Knowledge Based System for Integrated Maintenance Strategy and Operations. The developed framework of the Knowledge Based System for Integrated Maintenance Strategy and Operations is elaborated to show how the Knowledge Based System for Integrated Maintenance Strategy and Operations can be applied to support maintenance decisions. The knowledge-based system integrates the Gauging Absences of Prerequisites methodology in order to deal with different decision-making priorities and to facilitate benchmarking with a target performance state. This is a new contribution to this area. The Knowledge Based System for Integrated Maintenance Strategy and Operations is useful in reviewing the existing maintenance system and provides reasonable recommendations for maintenance decisions with respect to business and manufacturing perspectives. In addition, it indicates the roadmap from the current state to the benchmark goals for the maintenance system.