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Promising stroke report does not tell full story

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News of a 43 per cent fall in stroke incidents since 2000 made headlines in October. A report from King’s College London suggested that the number of people affected by stroke is falling, but people are having strokes at a younger age.

It also reported that there has only been a small relative decrease in stroke rates in the black population. It said this may be due to higher average levels in black patients of high blood pressure and diabetes, both of which can increase the risk of stroke.

Researchers analysed data from the South London Stroke Register, looking particularly at patients who had an ischaemic stroke, which is caused by a blood clot, between 2000 and 2015.

The study also found that, across the population, patients who had strokes tended to have them younger, with a decrease in the average age at first stroke from 72.3 in 2000- 2003, to 69.3 in 2012-2015.

The team attributes the overall reduced rate to a range of factors including improved prevention measures such as medication like statins.

Reduced rates of smoking and drinking are also thought to be an important factor as making these lifestyle changes can significantly lower people’s risk of stroke.

Experienced stroke consultant Liz Iveson, based at Woodlands Neurological Centre in York, warns that headlines announcing a 43 per cent plummet in stroke numbers may be misleading.

However, she also believes the South London Stroke register from which the data was compiled, is fairly representative of the wider population.

“The lesser reduction in the black population is well known. The black population statistically has a higher incidence of hypertension and small vessel stroke and an increase in obesity.

“Overall, the incidence of ischaemic stroke has fallen but the number of people hospitalised for stroke aged between 15-44 years has risen significantly in recent years. The rates for hospitalisation for stroke in older adults have fallen. This may be in part due to increased awareness and detection of stroke in younger people too.

“There are many hypotheses and pieces of evidence around why the average age of people with stroke has fallen overall. There is an increase in stroke risk factors in the young – the number of women under 45 years old who have three to five risk factors for stroke has doubled recently.

“Rates of all the ‘traditional’ risk factors one used to associate with older age are also all increasing.

“High blood pressure and smoking are the main factors associated with the increased risk but the increase in diabetes, obesity, high cholesterol and binge drinking all contribute.”

Iveson also sees flaws in the UK’s screening system which may be contributing to a lowering of the average stroke age.

She says: “Adults under 45 don’t tend to go to screening programmes or get their blood pressure or cholesterol checked. Also, if high blood pressure is detected it is often left untreated for longer compared to older patients. The ‘go away, do some exercise, reduce stress, eat more fruit and come back approach’ is sometimes not followed up in busy individuals.

“Also, anecdotally, there is a sense that borderline high blood pressure is not acted on. Many patients I see after a stroke or mini stroke have been told for years their blood pressure is a ‘little high’ but not too bad.

“The big push is to try and emphasise that there’s no such thing as ‘borderline blood pressure’. It is either high or it isn’t. The guidelines are clear enough numbers-wise.”

Iveson also points to other risk factors such as lack of sleep and stress, which are increasingly being researched.

“People under 50 tend to work longer hours, have more perceived stress and poor sleep hygiene compared to the older population. The increase in shift working patterns and use of electronic gadgets are thought not to help with this either.

“The FAST campaign is still valid however there is some evidence that young people are less familiar with stroke symptoms and the need for urgent attention to ‘act fast’.”

The well-publicised World Stroke Day initiative on 29th October went some way to raising stroke awareness in younger people. Charities, care providers and even national governments marked the day by turning the spotlight on the issue.

From Luxembourg – where the health ministry reported the worrying fact that a quarter of all strokes there are in the under 65s – to Hyderabad, where doctors warned that one in seven stroke victims are under 45, stroke dominated headlines around the world for one day at least.

As well as greater awareness, developing better treatments is clearly key to managing stroke in all age groups.

Certainly, improved preventative measures are playing their part in lowering overall stroke numbers, says Iveson.

“There is an increased uptake in statin use and in prescribing statins. They have so much evidence behind them and the newer ones are well tolerated. Simvastatin was the main original statin but about one in five people got muscle aches and stopped the statin hence the bad press they used to have.

“But generally, I do think GPs are more aware about actively lowering cholesterol now. Statins are used so much in cardiology, diabetes, vascular and renal medicine as well as stroke, that the prescribing of them doesn’t have the same negative connotations as it used to have.”

In the longer term, inter-generational changes in drinking habits may help to limit stroke risk in younger people.

A study published in October involving nearly 10,000 young people in the UK found that the proportion of 16- to 24-year-olds who say they never drink alcohol rose from 18 per cent in 2005 to 29 per cent in 2015. The study also found that young people who did drink alcohol were drinking less nowadays and that binge drinking rates were falling.

The researchers said the drop in numbers of young people drinking suggested a shift in attitudes towards alcohol. They say this could be due to increased awareness of the health risks of alcohol, as well as changes in the way young people spend their leisure time.

The research was carried out by University College London. Iveson says: “It is really interesting thinking about the future as there is an increased trend in people aged 45-65 years drinking every day and therefore increasing their risk of stroke but there is a significant difference coming through in behaviour in the younger millennial generation.

“They are less likely to smoke, drink and take drugs and also their lifestyle choices are different. They are much more aware of healthy eating, appearance and exercise – and put it into practice. Meditation and mindfulness have been shown to reduce stroke risk and blood pressure too.

“I do think this change in lifestyle choices will have a significant impact on stroke incidence in the future. The only caution with this is again related to perceived stress and the increase in mental health issues in the younger generation. It is unclear how much this will impact.”

Meanwhile, in terms of emerging findings on stroke risk, a new study suggests that iron levels may be a factor.

Imperial College London found that people with higher iron levels may be at greater risk of certain types of stroke.

The researchers analysed genetic data from more than 48,000 people and found that higher levels of iron are associated with an elevated risk of a cardioembolic type of stroke.

A statistical method was used to calculate the impact of genetics on people’s iron status, focusing on three points in the genome where a single ‘letter’ difference in the DNA can slightly increase or reduce a person’s iron status.

These findings follow previous research which suggested that iron may protect against stroke and coronary artery disease. “This result was unexpected. It was previously thought higher iron levels might protect against stroke, but this study investigates this further to find that iron may actually increase the risk of some types of stroke,” said Dr Dipender Gill, lead author of the study.

The researchers have cautioned that this is an early stage finding and stated that they don’t recommend that patients at risk of stroke reduce their iron intake, as it has many crucial roles in the body.

Dr Gill said that further research is needed to investigate why iron may lead to increased risk of stroke. “Iron is a vital nutrient, essential for a number of biological processes in the body, including transporting oxygen.

“However, previous research has suggested that in some cases iron can actually trigger blood to form a clot. This now needs further investigation.”

In another recent stroke study, Swedish researchers have evidenced a correlation between general fitness and reduced risk of severe stroke.

The study of more than 900 stroke survivors found that fitter people were twice as likely as sedentary people to have a mild stroke rather than a severe one.

The benefit was seen among older adults who walked for an average of 35 minutes a day. “Stay physically active. Keep on walking,” advised senior researcher Dr Katharina Sunnerhagen.

The findings do not prove that exercise, itself, was responsible, said Sunnerhagen, a professor at the University of Gothenburg, in Sweden.

But she said it is clear that regular activity has a range of health benefits – and less severe strokes may be one of them.

The findings are based on data from 925 older adults treated for a stroke at the same hospital. When the patients started post- stroke rehab, they were asked about their usual exercise habits before the stroke.

Overall, 48 per cent said they’d been active. Most of the patients had suffered a mild stroke, based on tests of their movement, speech and other abilities when they were hospitalised.

But physically active people were particularly likely to have a mild stroke: 85 to 89 per cent did, versus 73 per cent of sedentary people, the findings showed.

There could, of course, be other differences between physically active and inactive seniors, Sunnerhagen said.

MND

£1m dedicated to MND research through 7 in 7 Challenge

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A £1million fund has been created to lead new research into potential treatments for Motor Neurone Disease (MND) through the efforts of an iconic challenge by Kevin Sinfeld. 

Kevin, director of rugby at Leeds Rhinos, raised over £2million through his 7 in 7 Challenge, inspired by his former team-mate and close friend Rob Burrow. 

Rhinos legend Rob was diagnosed with MND in December 2019, and Kevin completed seven marathons in as many days to help boost badly-needed research into the condition. 

Now, with £500,000 of the money raised through the 7 in 7 Challenge ring fenced for research, that sum has been matched by medical research charity LifeArc. 

The move has created a £1million joint fund established by the MND Association and LifeArc, which will support research projects focused on developing new therapies or repurposing drugs already approved for use for other conditions.

“This is fantastic news and an amazing contribution from LifeArc,” says Kevin. 

“When we set out to complete the 7 in 7 Challenge we hoped to raise awareness and funds to support the MND community but it is so wonderful to see the inspiration it has given people and organisations, like LifeArc, so they too can support the need for more research.

“Our hope, like that of everyone affected by this brutal disease including Rob, is that this money will make a real difference and help find the breakthrough we all desperately want.”

Researchers are now able to apply for a share of the funding, with the criteria that they will be expected to conclude their project within three years and be target driving with set milestones and a credible delivery plan – including a clear route to reach MND patients.

Dr Brian Dickie, director of research development at the MND Association says: “We are so grateful to LifeArc for this generous contribution and are looking forward to working with them to identify projects which have a real chance of making a difference to our community in the coming years.”

Melanie Lee, LifeArc’s chief executive, emphasised that the focus of the new funding is on boosting research around potential treatment options based on the latest understanding of the disease.

“The ambition around stimulating the search for new treatments fits with LifeArc’s approach over the last 25 years to translate early science into health care treatments or diagnostics that can transform patients’ lives,” she says. 

“Our partnership with the MND Association is the latest in a series of strategic partnerships that maximise LifeArc’s expertise in translating strong discoveries from the lab into benefitting patients with conditions with few or no effective treatment options.”

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What causes a stroke?

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Ischemic and hemorrhagic are the two main types of stroke

Over 100,000 people in the UK suffer a stroke each year, with there currently being around 1.2 million survivors living in the country.

Many people note that despite how common strokes are they remain unaware of what the actual causes of a stroke are.

Depending on which of the two types develops, causes and outcomes can differ.

What both have in common is they restrict blood flow to the brain. This leads to a reduction in the brain’s oxygen levels, which can cause tissue damage.

Here, NR Times breaks down why a stroke may occur and what risk factors there are behind each different type.

What are the different types of stroke?

There are two main types of strokes: ischaemic and hemorrhagic.

Ischemic strokes make up nearly 90 percent of all cases and they materialise when an artery which provides blood and oxygen to the brain becomes blocked. 

A hemorrhagic stroke is much less common, but happens when an artery leading to the brain bursts and starts to leak blood around or in the brain.

Causes of an ischaemic stroke

The brain is only able to function properly when its arteries supply it with oxygen-rich blood, meaning any blockages can cause lasting damage.

With a lack of blood flow, the brain is unable to make enough energy to work. If this consists for more than a few minutes, brain cells will begin to die.

This is exactly what happens in an ischaemic stroke, but there are a range of reasons as to why these blockages develop.

One of the main causes is when the arteries around the head narrow, which makes it harder for the blood to pass through.

This can also lead to something called atherosclerosis, which is where substances in the blood (such as fat or cholesterol) stick to the sides of the arteries.

Blood can build up on these deposits, causing a further increase in pressure and a reduction to the brain’s oxygen supply.

There are a number of reasons for these blockages, with the most common ones being around a person’s lifestyle.

For example, smoking can increase the risk of a stroke by up to 50 percent.

This is because nicotine not only narrows the arteries, but it also makes the heart beat faster, causing an increase in blood pressure.

Excessive alcohol intake, obesity and high cholesterol levels are also all listed as major risk factors when it comes to ischaemic strokes.

Problems with the arteries around the heart can also lead to an ischaemic stroke.

Irregular heartbeats, heart attacks and other irregularities around this area can again limit the blood’s oxygen levels.

Causes of a hemorrhagic stroke

Hemorrhagic strokes are most common in people ages 45 to 70, but they affect a lot more younger people than an ischaemic stroke.

These are caused after the arteries around the brain burst and cause bleeding.

Depending on where the artery is can affect the outcome of the hemorrhagic stroke.

If the bleeding occurs within the brain, blood shooting out at high pressure can kill some cells.

Bleeding on the surface increases the pressure in the protective layer between the brain and the skull, potentially causing more cell loss.

This bleeding is normally caused by chronically high blood pressure. In many cases, the increased pressure can cause the arteries to expand and weaken, meaning a split in them is more likely to take place.

A rarer cause of hemorrhagic stroke is where the blood vessels around the brain are connected abnormally, causing further stress on the brain. These are congenital (present at birth) but the reason for their occurrence is currently unknown.

Again, the best way to reduce the risk of an hemorrhagic stroke is to make healthy lifestyle choices.

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NHS pilots video service for epilepsy diagnoses

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A new clinical video service which supports epilepsy diagnoses and management in the era of coronavirus and beyond has been launched in the UK.

vCreate Neuro allows registered patients and carers to share smartphone-recorded videos of potential seizures or unknown movements with their clinical team via a secure, NHS-trusted system.

The data and footage act as a visual aid to assist clinical teams with rapid precision diagnostics, creating a digitised clinical pathway that minimises the need for face-to-face clinic appointments and invasive tests.

The system is currently being piloted across Scotland and, following its initial success, across England including Great Ormond Street Hospital, Evelina London and Sheffield Children’s Hospital.

The system is available to families who are concerned that they, their child or loved one may be experiencing seizures or unexplained episodes including epilepsy.

Since May 2020, more than 2,000 families have shared over 5,000 videos with their clinical teams across the platform.

Dean MacLeod was referred to the service when her seven-year-old daughter, Olivia, began having unknown movements in May 2020.

Dean uploaded videos of Olivia during these episodes as Olivia’s seizures grew more frequent.

The videos were reviewed by Paediatric Neurology professionals at the Royal Hospital for Children, Glasgow, and, supported with telephone appointments, Olivia was diagnosed with a form of epilepsy and quickly started on treatment.

Speaking about her experience, Dean said: “I’ve found vCreate to be invaluable in Olivia’s journey since she started having seizures last summer.

“We live in a remote location on the Isle of Lewis, Scotland, and we have a very limited paediatric service on the Island. The service has made it easy to access the specialist clinical knowledge needed by sending recordings of various seizure events to the Paediatric Neurology team at Glasgow.

“Since the diagnosis, I have kept in regular contact with the clinical team through the platform, sending videos and typically receiving advice from a Consultant within 24 hours which is fantastic. Between the vCreate service and telephone discussions, our family have not needed to have face-to-face consultations which has been hugely beneficial during the pandemic.”

Professor. Sameer Zuberi, consultant paediatric neurologist at the Royal Hospital for Children, Glasgow, said: “vCreate Neuro has transformed how we use carer-recorded video in our service. We are diagnosing epilepsy more rapidly, preventing misdiagnosis and saving unnecessary investigations. Families feel in more control and better connected to the service.

During the Covid-19 pandemic, many people experiencing seizures and seizure-like episodes, including children, have been unable to see a clinician.

Create Neuro aims to help by empowering patients to use asynchronous video technology for self-management, reducing the need for physical appointments. 

Founder Ben Moore said: “We’re passionate about family-forward care, and worked closely with clinical teams, patients and carers to develop the vCreate Neuro service.

“The system aims to improve patient care, reduce the number of clinic investigations – and resulting costs to the NHS – and digitise the patient pathway. We want families to be in control of their healthcare journey and have a direct link to their clinical team despite the pandemic restrictions.”

The vCreate platform has been independently assessed and approved by Information Governance teams in over 100 UK NHS Trusts.

 Within the platform, a clinical database is available as a learning resource for clinicians to study seizure types, events, and other symptoms.

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