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Ideally, nations should collaborate to develop international standards for data format and description to support international integration. All nations should participate in national or international stroke quality improvement programs or registries or develop their own programs if current models are not suitable for their population or environment to provide the highest quality stroke care. Interactions among major stakeholders in the stroke field such as large stroke organizations, government agencies, nongovernmental organizations, industry, and patient organizations can be mutually beneficial.

Integrated activities among these groups can enhance patient care, the development and implementation of new therapies, and the dissemination of new and existing information. Stroke is a prototype disease for coordinated actions vertically with other medical disciplines as well as horizontally by interactions among stakeholder organizations, government, and industry. Large stroke organizations such as the WSO serve as a key component in these networks, providing important leadership roles in coordinating activities and in establishing stroke firmly on the global health agenda.

Improved stroke management is crucially dependent on an effective organization in all aspects of care. The large stroke organizations should establish clear policies and provide recommendations through guidelines and other documents. The large stroke organizations also organize large scientific conferences providing a platform for scientific advances and interactions. Tackling the global burden of stroke constitutes a major health challenge.

The AHA formation of the American Stroke Association ASA 10 years ago and its evolution to date is an excellent example of how an NGO, in this case a voluntary health organization, can influence scientific discovery and the translation of science into guidelines and how it can then implement programs to support guideline adherence, to improve outcomes, to provide extensive provider and patient resources, and to advocate for system change. The National Institute of Neurological Disorders and Stroke NINDS is committed to the development of better therapies to prevent stroke and to improve the outcome for patients with stroke.

NINDS has a number of ongoing clinical trials that are evaluating novel prevention approaches, acute interventions, and recovery-enhancing strategies. In addition to drugs and devices, the science of behavioral change needs to target the promotion of healthy behaviors decades before the age-dependent risk of stroke starts its exponential ascent. The NINDS translational program works with and funds investigators and their industry partners to bring promising stroke therapies through preclinical development.

Unfortunately, a number of important and expensive clinical stroke trials cannot be completed due to poor enrollment. A greater emphasis on Phase II studies should be considered to ensure that experimental therapies tested in rigorously conducted animal studies actually engage the intended biological target in patients. Patient organizations range from small, informal, local support groups to large corporations with significant influence. Interactions between patient organizations and other organizations flow both ways.

The purposes of these interactions are many and therefore this topic is quite complex. The triggers for interactions are generally of 3 types: 1 issues of clinical service and patient safety; 2 driving innovation and science; and 3 influencing business and healthcare economics. Patient organizations can be conduits for patients to influence healthcare organizations, government, industry, and academia.

Processes may be ad hoc or organized. Actions may be taken proactively or reactively. Patient organizations can be vehicles for patients to be influenced by healthcare organizations, government, industry, and academia. Again, processes may be ad hoc or organized, and actions may be taken proactively or reactively. Industry plays a vital role in the development and implementation of novel therapies directed at improving the prevention and treatment of stroke.

Most new drug or device therapies are discovered by relevant companies or in-licensed from other sources. The company then performs the necessary preclinical steps to allow for the performance of clinical trials. Clinical trials performed by the company that demonstrate safety and efficacy of the new therapeutic agent can lead to regulatory approval, presuming an adequate data package. Industry thus provides a key link for stroke patient care, new and presumably improved therapeutic agents.

Additionally, industry is an important source for the dissemination of new information about stroke to both physicians and the lay public. This task is performed by sponsorship of conferences, education seminars, and small group meetings for both professional and lay audiences.

The content of these educational endeavors should be free of bias, providing balanced and educationally sound information for the intended audience. Three specific recommendations to enhance cooperation among large stroke organizations, nongovernmental organizations, government, patient organizations, and industry are: 1 provide an appropriate mechanism for the various stakeholders to communicate with each other about their needs and goals; 2 enhance clinical research by having these entities provide input about unmet needs and how to develop and disseminate new therapies; and 3 enhance patient and physician education by jointly developing and implementing educational initiatives.

Detailed clinical stroke knowledge is increasingly important in Europe, North America, and other developed regions and subspecialty training focused on stroke prevention, acute care, and rehabilitation has been formalized. These same models could be applied to stroke education. It is available globally and is free. Globally, there are insufficient numbers of physicians trained in stroke. Stroke-educated nurses, more numerous than physicians, are capable of playing instrumental roles within telestroke networks.

It is being used in China, South Africa, and Vietnam and is an effective tool for postgraduate medical training. Approaches for rapid and accurate diagnosis and the importance of prevention of complications are emphasized. The use of telemedicine to extend stroke expertise to underserved areas may be possible. Patient and bystander responses to stroke symptoms are often delayed.

It is important to further disseminate these materials as teaching aids in schools and communities. Step 1: Increase education directed at professionals including healthcare providers on a global scale by using on-site and website stroke teaching programs that are integrated into the medical education curricula. The aim is to make professional specialized care available to patients with stroke throughout the world within the next decade. Step 2: Further develop national health education programs offered for stroke survivors and their families.

Worldwide efforts to increase knowledge and concern about stroke, its prevention, treatment opportunities, and outcomes have also focused on politicians and key opinion leaders. The role of governmental policy on stroke research and care is increasingly recognized. In the United States, advocacy efforts have largely been directed at increasing or at least sustaining funding for research supported by the NIH. In addition, national advocacy efforts have supported cardiovascular and stroke prevention activities of the CDC.

Specific targets included support of Food and Drug Administration oversight of tobacco products. Within states, advocacy has been aimed at improving the organization of the delivery of stroke-related health care. Legislation to prevent cigarette smoking in indoor public spaces has been enacted in several states. Educating the public about stroke risk factors, prevention, and response has been challenging.

Public knowledge about stroke in the United States continues to be poor, particularly in minority communities. Although a great deal has been accomplished, much remains to be done. Topics include the promotion of awareness of stroke-related health costs 64 and the large discrepancies between eastern and western Europe, including the much higher prevalence of risk factors and stroke in eastern Europe.

European specialist groups have lobbied for increased funding from the European Science Foundation and led to a European Stroke Workshop in Brussels hosted by the Euro-pean Commission. The resulting European Stroke Network links stroke research from bench to bedside. Step 3: Increase funding for public education and research supported by regional and national agencies. Continue support for advocacy aimed at improving the organization of the delivery of stroke-related health care based on evidence-based recommendations addressing gaps in the care delivery system.

Step 4: Educate and inform the general public about stroke risk factors, prevention, and response. To accelerate progress in stroke, we need to reach beyond it scientifically, conceptually, and pragmatically. Scientifically the solutions lie beyond our limited models. All the major neurological brain diseases share common mechanisms such as inflammation, apoptosis, mitochondrial damage, oxidative stress, excitotoxicity, and neurotransmitter failure.

A close study of the development of the nervous system may hold many clues as to how the brain repairs itself. Moreover, development and aging may to some extent be mirror images of each other. Stroke in the neonatal brain, 67 children, and women 68 , 69 has special features that need to be understood and addressed. Our focus has been on lesions in the brain. For example, cerebral infarcts shrink and the inflammation subsides with time. The opposite occurs experimentally in the presence of amyloid.

It matters not only what lesion, but whose brain. Conceptually we need to think not only of dramatic strokes of sudden onset, sometimes heralded by sudden losses of speech, sight, movement, or feeling, but of subclinical strokes, the most prevalent type of cerebrovascular disease identifiable by subtle cognitive dysfunction, usually a change in executive function. Pragmatically we need to realize that if we are to become more effective in the diagnosis, treatment, rehabilitation, and prevention of stroke, we have to reach beyond our hospitals and clinics into the community, other disciplines, and the public and a larger part of the world.

We need to survey, systematize, and synergize what we do. We need to survey broadly, systematically, and specifically what we know of basic brain mechanisms of disease. We need to become aware of other models such as infectious diseases, which often has an integrated, epidemiological, clinical, and basic science approach. In terms of acute care and rehabilitation, an organized approach seems to have been the key to the many advances. Although countries like Spain have a national stroke strategy and effective regional programs such as those of Catalonia 71 and Madrid, 72 the majority of countries do not.

There may well be other models such as trauma that may provide useful parallels and lessons. Systematization and evaluation has been a key in many of the advances that have occurred in stroke in the past 4 decades. A prototype has been the randomized clinical trial, in which a hypothesis is tested according to prospectively agreed protocols, the collection of the data monitored, and the results evaluated. Randomized clinical trials are but 1 example of the more generic principles. We need to reach beyond North America, western Europe, and Japan, where most clinical trials have been performed.

Other parts of the world are creating infrastructures that make them capable of participating in clinical trials and other studies that can accelerate finding the answers to many common problems. More recently we saw the example of the first proof of tissue plasminogen activator effectiveness in stroke being demonstrated in an American study, 4 whereas the extension of the time window was recently shown by a European study.

The idea would be that everything that is done in relation to stroke becomes part of some evaluation. An important aspect of any evaluation is standardization with a need to make minimum common definitions of important items in a protocol so that databases can be made compatible and larger volumes of information can become available for analysis, model-building, and testing. At the moment, we have a glut of guidelines but not enough guidance or guides. Not all are of equal value. Stroke is no longer a disease of affluence.

There is much value in doing the simple things right in terms of prevention. Blood pressure control has the greatest potential for stroke prevention. Because atherosclerosis starts early in life, the preventive efforts should target children, youth, and mothers. Everyone needs to be involved at all stages of prevention with an emphasis on healthy living and creating an environment that nurtures it.

Finally, we need to synergize with vertical integration of basic sciences, clinical sciences, and population approaches. The digital age provides wonderful opportunities for integrating and evaluating all aspects of our activities. A systematic review of all that is known of basic brain mechanisms of injury and repair along the life cycle.

This can be accomplished at several levels: a review of the existing literature; b making it a topic of ongoing scientific conferences such as the Princeton Conference or as a priority setting exercise of funding agencies 52 ; and c organize a highly interactive synergium with participation of scientists, clinicians, pharmaceutical companies, and health regulators.

The synergium should be broad enough that each mechanism can be examined in light of several diseases. To organize a working group that will recommend a minimum set of data points to be collected on all patients with stroke or those with potential stroke. This already has been done for capturing vascular cognitive impairment from the epidemiological, clinical, neuropsychological, imaging, and experimental viewpoint.

Another working group could evaluate the relative advantages and disadvantages of different clinical trials, including novel approaches to use registries to evaluate different diagnoses and treatments. The WSO already has a working group on guidelines that could be enlarged and asked to prioritize them with a simple method of evaluating their impact.

A working group on surveying and evaluating stroke education with methods of integrating and credentialing those who engage in stroke work. Develop nodular models of comprehensive stroke care, rehabilitation, and prevention on the principle that some components are essential but that they need to be adapted in the community where they are to be implemented.

Professional education including a more comprehensive education on stroke and stroke recovery for medical school curricula as well as residency and fellowship training. The groups involved would agree to what end points should be studied. This would help not only in understanding the pathophysiology of stroke, but also in the design of clinical trials to ensure that the proper end points are used and that they are powered appropriately. Organize a working group that will oversee these and other initiatives that may arise from the recommendations of the synergium.

We have come a long way, but we have even further to go. The progressive transformation of our field in the past 40 years, the accelerated pace of science, and the growing need for our contributions will assure that the next 4 decades will prove even more fruitful than the last. The views and conclusions of the synergium are that of the participants and contributors and not necessarily those of the supporting organizations.

A special thank you to Professor Michael Hennerici, Editor of Cerebrovascular Diseases and Chairman of the Scientific Program Committees of the European Stroke Conference, for his material support and spirit of cooperation exemplified by the joint and simultaneous publication of this article in the respective journals that he and the first author edit.

Mona Tiwari, research and editorial assistant, was immensely helpful in producing the final document. Thank you! We thank Jennifer Neisse, BS, of InTouch Health who contributed to the section on the development of public health communication strategies using traditional and newer strategies. National Center for Biotechnology Information , U. Author manuscript; available in PMC Jul Lo , PhD, 1 Brett E.

Skolnick , PhD, 1 Karen L. Bornstein , MD, 7 Stephen M. Author information Copyright and License information Disclaimer. Department of Clinical Neurological Sciences V. The numerical suffix with the names indicates the various groups. The coordinator of each group is indicated by an asterisk. The work of the coordinators is deemed to have been equal. Copyright notice. The publisher's final edited version of this article is available at Stroke.

See other articles in PMC that cite the published article. Abstract Background and Purpose The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke. Methods Preliminary work was performed by 7 working groups of stroke leaders followed by a synergium a forum for working synergistically together with approximately additional participants.

Conclusions To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Keywords: prevention, rehabilitation, stroke, translational, treatment. The Past 40 Years More progress has been made in stroke over the past 4 decades than in the previous 4 millennia. Paradoxes of Progress Progress breeds paradoxes.

Recommendations Establish a New Taxonomy of Disease. Step 2: Implement 3 Approaches That Will Accelerate the Capacity to Address Unmet Needs There are processes that could be put in place, which may result in needs being met earlier rather than later. Recommendations Develop new systems of collaboration to break down the silo mentality currently rife in the stroke community. How In establishing the new systems described earlier, investigators will need to work in different ways.

By Whom Scientific leaders around the world organizations, institutes, and others need to bring together these new and novel teams. Stroke Prevention: Broadening the Approach and Intensifying the Efforts Introduction Major chronic diseases such as stroke, heart disease, cancer, Alzheimer disease and vascular cognitive impairment may be linked by common risk factors and pathophysiological mechanisms.

Step 1: Establish a Global Chronic Disease Prevention Initiative That Includes Stroke as a Major Focus Among a Cluster of Conditions The Chronic Disease Action Group has provided a call to action to encourage, support, and monitor activity on the implementation of evidence-based efforts to achieve global, regional, and national programs to prevent and control chronic diseases.

Recommendations Develop a leadership group that will work with existing organizations to set and advocate a chronic disease prevention agenda with stroke as a major focus and the establishment of formal strategies to reduce unhealthy lifestyle and other risk factors. Government and industry should be represented in these collaborations. Step 2: Use and Promote the Population Approach for Stroke Prevention Recommendations Newer approaches in the United States and some other regions may include: Generate a paradigm shift among medical insurance providers, government, and health professionals toward a major emphasis on adequate and effective preventive health care and education programs.

Incorporate a broader use of global vascular risk screening tools. Recommendations An evidence-based communication approach is required and partnership with an organization with substantial experience in public health communication eg, WHO, WSO, AHA is desirable. Acute Stroke Management: Applying and Expanding What We Know Introduction The establishment of stroke units and stroke centers has been the most significant contribution to the field of acute stroke management.

Step 2: Development of Regional Systems of Emergency Stroke Care Activating the prehospital emergency medical system and transportation to the designated stroke centers leads to a shorter delay in arrival at the hospital and better initial management. Step 3: Improving Stroke Awareness Lack of recognition of stroke signs or lack of sense of urgency to seek help by the population is a major barrier for adequate stroke treatment. Recommendations Promote evidence-based media campaigns providing public information about acute stroke signs and the urgency to call prehospital emergency medical systems; Because stroke often renders patients themselves unable to recognize or communicate their symptoms, public education campaigns should inform not only at-risk individuals, but also family, friends, and on-scene witnesses to call the prehospital emergency medical system if they observe an individual having signs of a possible stroke.

Step 1: Translate Best Neuroscience, Including Animal and Human Studies, Into Poststroke Recovery Research and Patient Care Key Issues The neurobiology of spontaneous recovery and central nervous system repair 40 suggests several potential therapeutic approaches that could improve patient outcome, but more research is needed.

Recommendations Increased basic and translational research is needed. Recommendations Detailed, standardized poststroke therapy protocols need to be developed and their practice associated with proper training. Step 3: Develop Consensus on, Then Implementation of, Standardized Clinical and Surrogate Measurements Key Issues The best standardized measures of behavior and outcomes after stroke need to be defined and then placed into clinical practice, at the same time continuing to generate appropriate research.

Recommendations Experts need to be gathered to discuss these issues and to propose unifying strategies to achieve rapid progress in the study of rehabilitation interventions. Step 4: Target Repair-Related Processes in Clinical Research to Advance Stroke Recovery Key Issues Available research suggests many strong candidates for therapies that are likely to improve poststroke recovery by targeting repair-related processes. Recommendations A Neurorecovery Consortium needs to be created consisting of academic basic and clinical researchers, likely based at the Stroke Recovery Research Centers , industry, government research, clinicians, and payers with the mission being to define priorities and future actions for stroke recovery trials.

Into the 21st Century: The Web, Technology and Communications, New Tools for Progress Introduction Major reductions in the burden of stroke can be achieved by providing better public education. Open in a separate window. Step 1: Worldwide Unrestricted Access to Information Education for the Public and Professionals To reduce stroke risk, electronic media-enabled tools can be used for self-assessment and motivation for self-management.

Support Groups Lay organizations eg, church, community groups are an underused resource that can provide insights into the types of support and problem-solving that are most needed by stroke survivors, including advice on financial resources, legal matters, and social benefits.

Recommendations The Public To be free of bias, health information should be reviewed or provided by experts in stroke in collaboration with experts in public education without conflict of interest eg, government and nongovernment stroke-oriented health organizations and delivered in a persuasive and understandable format consistent with principles of marketing and behavioral sciences as appropriate for the region. Professionals Special task forces of these same organizations should prepare evidence-based online education for general practitioners, specialists, nurses, therapists, and other healthcare workers in multiple languages tailored to professional groups working in diverse surroundings.

Citizens Against Stroke Communication resources and social networking tools should be tailored to support local stroke initiatives consisting of professionals, decision-makers, politicians, administrators, representatives of local industry and businesses together with lay people. Connecting Professionals and Patients Electronic communications between patients and professionals have an enormous potential to enhance self-management of risk factors and promote healthier lifestyles eg, obtaining advice on medication use and adherence, prevention, follow-up laboratory test results, and medical problems through a virtual healthcare visit or an e-consultation www.

Recommendations Leaders and key stakeholders including patients will need to embrace these new models of telemedicine and virtual patient—provider interactions that will permit access especially for patients who are disabled or live in geographically remote regions. Step 3: Build Centralized Electronic Archives and Registries Electronic health records are critical for quick and reliable access to patient information, for effective communication of care plans between different providers and settings, and for reducing medical errors.

Recommendations All nations should pursue to develop national, interoperable electronic health record systems with the goal of supporting continuity of care through delivery of comprehensive medical information on demand at the point of care for all their citizens. Registries and Evaluation of Efficacy All nations should participate in national or international stroke quality improvement programs or registries or develop their own programs if current models are not suitable for their population or environment to provide the highest quality stroke care.

Fostering Cooperation Among Stakeholders to Enhance Stroke Care Introduction Interactions among major stakeholders in the stroke field such as large stroke organizations, government agencies, nongovernmental organizations, industry, and patient organizations can be mutually beneficial. Large Stroke Organizations and Nongovernmental Organizations Stroke is a prototype disease for coordinated actions vertically with other medical disciplines as well as horizontally by interactions among stakeholder organizations, government, and industry.

Patient Organizations Patient organizations range from small, informal, local support groups to large corporations with significant influence. Industry Industry plays a vital role in the development and implementation of novel therapies directed at improving the prevention and treatment of stroke. Recommendations Three specific recommendations to enhance cooperation among large stroke organizations, nongovernmental organizations, government, patient organizations, and industry are: 1 provide an appropriate mechanism for the various stakeholders to communicate with each other about their needs and goals; 2 enhance clinical research by having these entities provide input about unmet needs and how to develop and disseminate new therapies; and 3 enhance patient and physician education by jointly developing and implementing educational initiatives.

Educating and Energizing Professionals, Patients, the Public and Policymakers Part 1: Educating and Energizing Professionals and Patients Introduction Detailed clinical stroke knowledge is increasingly important in Europe, North America, and other developed regions and subspecialty training focused on stroke prevention, acute care, and rehabilitation has been formalized.

Recommendations Step 1: Increase education directed at professionals including healthcare providers on a global scale by using on-site and website stroke teaching programs that are integrated into the medical education curricula. Part 2: Educating and Energizing the Public and Policymakers Introduction Worldwide efforts to increase knowledge and concern about stroke, its prevention, treatment opportunities, and outcomes have also focused on politicians and key opinion leaders. Recommendations Step 3: Increase funding for public education and research supported by regional and national agencies.

Summary To accelerate progress in stroke, we need to reach beyond it scientifically, conceptually, and pragmatically. Next Steps The immediate need is to pursue specific recommendations: A systematic review of all that is known of basic brain mechanisms of injury and repair along the life cycle. Conclusion We have come a long way, but we have even further to go. Footnotes Disclosures G. References 1.

Epidemiologic assessment of the role of blood pressure in stroke. The Framingham study. Canadian Cooperative Study Group. A randomized trial of aspirin and sulfinpyrazone in threatened stroke. N Engl J Med. Intensive care management of stroke patients. Tissue plasminogen activator for acute ischaemic stroke. Millikan CH. Stroke: — McDowell FH. Stroke: 30 years of progress: — Barnett HJ. Reinmuth OM. Dyken ML. Knowledge of tissue plasminogen activator for acute stroke among Michigan adults.

Most stroke patients do not get a warning: a population-based cohort study. Annual incidence of first silent stroke in the United States: a preliminary estimate. Cerebrovasc Dis. Donnan G. The Feinberg lecture: a new road map for neuropro-tection.

Update of the stroke therapy academic industry roundtable pre-clinical recommendations. Howells D, Donnan G. Where will the next generation of stroke treatments come from? PLoS Medicine. Dobkin B. Collaborative models for translational neuroscience and rehabilitation research. Neurorehabil Neural Repair. Systems biology and its application to the understanding of neurological diseases.

Ann Neurol. There are many ways to train a fly. Fly Austin ; 3 :3—9. Pfrieger F. Roles of glial cells in synapse development. Cell Mol Life Sci. Huang H, Zon L. Regulation of stem cells in the zebra fish hematopoietic system. Primary prevention of stroke by healthy lifestyle.

Gorelick PB. Primary prevention of stroke. Impact of healthy lifestyle. Living beyond our physiological means: small vessel disease of the brain is an expression of a systemic failure in arteriolar function: a unifying hypothesis. Prevention of chronic diseases: a call to action. Effects of a polypill Polycap on risk factors in middle-aged individuals without cardiovascular disease TIPS : a phase II, double-blind, randomized trial.

Stroke unit care in Scandinavian countries. Int J Stroke. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Guidelines for management of ischaemic stroke and transient ischaemic attack Get with the Guidelines—Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack.

Accuracy of stroke recognition by emergency medical dispatchers and paramedics—San Diego experience. Prehosp Emerg Care. Identifying stroke in the field. Cramer SC. Repairing the human brain after stroke. Restorative therapies. Nudo RJ. Murphy TH, Corbett D. Plasticity during stroke recovery: from synapse to behaviour. Nat Rev Neurosci. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. Biomarkers of recovery after stroke.

Curr Opin Neurol. Evidence-based review of stroke rehabilitation: executive summary, 12th edition. Top Stroke Rehabil. Stroke rehabilitation: an international perspective. Stroke rehabilitation in Canada: a work in progress. A first step is to reduce barriers to telemedicine-enabled practice to encourage broader access to high-quality stroke care and rapid treatment for acute stroke therapies.

Development of novel technology-assisted rehabilitation methods should be encouraged. Electronic health records are critical for quick and reliable access to patient information, for effective communication of care plans between different providers and settings, and for reducing medical errors. Furthermore, providing citizens with the option of having access to their own personal health records may enhance their adherence to treatment recommendations.

Electronic registries can help evaluate documentation of treatment practices, treatment efficacy and comparative effectiveness, and improve clinical management of patients with stroke. Electronic resources should be developed to support the capture and analysis of patient-reported outcomes for clinical care and research.

All nations should pursue to develop national, interoperable electronic health record systems with the goal of supporting continuity of care through delivery of comprehensive medical information on demand at the point of care for all their citizens. Common data elements pertinent to stroke-relevant risk factors, treatments, and functional outcomes should be included in the electronic health record systems.

Ideally, nations should collaborate to develop international standards for data format and description to support international integration. All nations should participate in national or international stroke quality improvement programs or registries or develop their own programs if current models are not suitable for their population or environment to provide the highest quality stroke care.

Interactions among major stakeholders in the stroke field such as large stroke organizations, government agencies, nongovernmental organizations, industry, and patient organizations can be mutually beneficial. Integrated activities among these groups can enhance patient care, the development and implementation of new therapies, and the dissemination of new and existing information.

Stroke is a prototype disease for coordinated actions vertically with other medical disciplines as well as horizontally by interactions among stakeholder organizations, government, and industry. Large stroke organizations such as the WSO serve as a key component in these networks, providing important leadership roles in coordinating activities and in establishing stroke firmly on the global health agenda.

Improved stroke management is crucially dependent on an effective organization in all aspects of care. The large stroke organizations should establish clear policies and provide recommendations through guidelines and other documents. The large stroke organizations also organize large scientific conferences providing a platform for scientific advances and interactions. Tackling the global burden of stroke constitutes a major health challenge. The AHA formation of the American Stroke Association ASA 10 years ago and its evolution to date is an excellent example of how an NGO, in this case a voluntary health organization, can influence scientific discovery and the translation of science into guidelines and how it can then implement programs to support guideline adherence, to improve outcomes, to provide extensive provider and patient resources, and to advocate for system change.

The National Institute of Neurological Disorders and Stroke NINDS is committed to the development of better therapies to prevent stroke and to improve the outcome for patients with stroke. NINDS has a number of ongoing clinical trials that are evaluating novel prevention approaches, acute interventions, and recovery-enhancing strategies.

In addition to drugs and devices, the science of behavioral change needs to target the promotion of healthy behaviors decades before the age-dependent risk of stroke starts its exponential ascent. The NINDS translational program works with and funds investigators and their industry partners to bring promising stroke therapies through preclinical development. Unfortunately, a number of important and expensive clinical stroke trials cannot be completed due to poor enrollment.

A greater emphasis on Phase II studies should be considered to ensure that experimental therapies tested in rigorously conducted animal studies actually engage the intended biological target in patients. Patient organizations range from small, informal, local support groups to large corporations with significant influence. Interactions between patient organizations and other organizations flow both ways. The purposes of these interactions are many and therefore this topic is quite complex.

The triggers for interactions are generally of 3 types: 1 issues of clinical service and patient safety; 2 driving innovation and science; and 3 influencing business and healthcare economics. Patient organizations can be conduits for patients to influence healthcare organizations, government, industry, and academia.

Processes may be ad hoc or organized. Actions may be taken proactively or reactively. Patient organizations can be vehicles for patients to be influenced by healthcare organizations, government, industry, and academia.

Again, processes may be ad hoc or organized, and actions may be taken proactively or reactively. Industry plays a vital role in the development and implementation of novel therapies directed at improving the prevention and treatment of stroke.

Most new drug or device therapies are discovered by relevant companies or in-licensed from other sources. The company then performs the necessary preclinical steps to allow for the performance of clinical trials. Clinical trials performed by the company that demonstrate safety and efficacy of the new therapeutic agent can lead to regulatory approval, presuming an adequate data package.

Industry thus provides a key link for stroke patient care, new and presumably improved therapeutic agents. Additionally, industry is an important source for the dissemination of new information about stroke to both physicians and the lay public. This task is performed by sponsorship of conferences, education seminars, and small group meetings for both professional and lay audiences.

The content of these educational endeavors should be free of bias, providing balanced and educationally sound information for the intended audience. Three specific recommendations to enhance cooperation among large stroke organizations, nongovernmental organizations, government, patient organizations, and industry are: 1 provide an appropriate mechanism for the various stakeholders to communicate with each other about their needs and goals; 2 enhance clinical research by having these entities provide input about unmet needs and how to develop and disseminate new therapies; and 3 enhance patient and physician education by jointly developing and implementing educational initiatives.

Detailed clinical stroke knowledge is increasingly important in Europe, North America, and other developed regions and subspecialty training focused on stroke prevention, acute care, and rehabilitation has been formalized. These same models could be applied to stroke education.

It is available globally and is free. Globally, there are insufficient numbers of physicians trained in stroke. Stroke-educated nurses, more numerous than physicians, are capable of playing instrumental roles within telestroke networks. It is being used in China, South Africa, and Vietnam and is an effective tool for postgraduate medical training.

Approaches for rapid and accurate diagnosis and the importance of prevention of complications are emphasized. The use of telemedicine to extend stroke expertise to underserved areas may be possible. Patient and bystander responses to stroke symptoms are often delayed. It is important to further disseminate these materials as teaching aids in schools and communities.

Step 1: Increase education directed at professionals including healthcare providers on a global scale by using on-site and website stroke teaching programs that are integrated into the medical education curricula. The aim is to make professional specialized care available to patients with stroke throughout the world within the next decade. Step 2: Further develop national health education programs offered for stroke survivors and their families.

Worldwide efforts to increase knowledge and concern about stroke, its prevention, treatment opportunities, and outcomes have also focused on politicians and key opinion leaders. The role of governmental policy on stroke research and care is increasingly recognized. In the United States, advocacy efforts have largely been directed at increasing or at least sustaining funding for research supported by the NIH.

In addition, national advocacy efforts have supported cardiovascular and stroke prevention activities of the CDC. Specific targets included support of Food and Drug Administration oversight of tobacco products. Within states, advocacy has been aimed at improving the organization of the delivery of stroke-related health care. Legislation to prevent cigarette smoking in indoor public spaces has been enacted in several states. Educating the public about stroke risk factors, prevention, and response has been challenging.

Public knowledge about stroke in the United States continues to be poor, particularly in minority communities. Although a great deal has been accomplished, much remains to be done. Topics include the promotion of awareness of stroke-related health costs 64 and the large discrepancies between eastern and western Europe, including the much higher prevalence of risk factors and stroke in eastern Europe. European specialist groups have lobbied for increased funding from the European Science Foundation and led to a European Stroke Workshop in Brussels hosted by the Euro-pean Commission.

The resulting European Stroke Network links stroke research from bench to bedside. Step 3: Increase funding for public education and research supported by regional and national agencies. Continue support for advocacy aimed at improving the organization of the delivery of stroke-related health care based on evidence-based recommendations addressing gaps in the care delivery system.

Step 4: Educate and inform the general public about stroke risk factors, prevention, and response. To accelerate progress in stroke, we need to reach beyond it scientifically, conceptually, and pragmatically. Scientifically the solutions lie beyond our limited models. All the major neurological brain diseases share common mechanisms such as inflammation, apoptosis, mitochondrial damage, oxidative stress, excitotoxicity, and neurotransmitter failure.

A close study of the development of the nervous system may hold many clues as to how the brain repairs itself. Moreover, development and aging may to some extent be mirror images of each other. Stroke in the neonatal brain, 67 children, and women 68 , 69 has special features that need to be understood and addressed. Our focus has been on lesions in the brain.

For example, cerebral infarcts shrink and the inflammation subsides with time. The opposite occurs experimentally in the presence of amyloid. It matters not only what lesion, but whose brain. Conceptually we need to think not only of dramatic strokes of sudden onset, sometimes heralded by sudden losses of speech, sight, movement, or feeling, but of subclinical strokes, the most prevalent type of cerebrovascular disease identifiable by subtle cognitive dysfunction, usually a change in executive function.

Pragmatically we need to realize that if we are to become more effective in the diagnosis, treatment, rehabilitation, and prevention of stroke, we have to reach beyond our hospitals and clinics into the community, other disciplines, and the public and a larger part of the world. We need to survey, systematize, and synergize what we do. We need to survey broadly, systematically, and specifically what we know of basic brain mechanisms of disease.

We need to become aware of other models such as infectious diseases, which often has an integrated, epidemiological, clinical, and basic science approach. In terms of acute care and rehabilitation, an organized approach seems to have been the key to the many advances. Although countries like Spain have a national stroke strategy and effective regional programs such as those of Catalonia 71 and Madrid, 72 the majority of countries do not.

There may well be other models such as trauma that may provide useful parallels and lessons. Systematization and evaluation has been a key in many of the advances that have occurred in stroke in the past 4 decades. A prototype has been the randomized clinical trial, in which a hypothesis is tested according to prospectively agreed protocols, the collection of the data monitored, and the results evaluated. Randomized clinical trials are but 1 example of the more generic principles. We need to reach beyond North America, western Europe, and Japan, where most clinical trials have been performed.

Other parts of the world are creating infrastructures that make them capable of participating in clinical trials and other studies that can accelerate finding the answers to many common problems. More recently we saw the example of the first proof of tissue plasminogen activator effectiveness in stroke being demonstrated in an American study, 4 whereas the extension of the time window was recently shown by a European study.

The idea would be that everything that is done in relation to stroke becomes part of some evaluation. An important aspect of any evaluation is standardization with a need to make minimum common definitions of important items in a protocol so that databases can be made compatible and larger volumes of information can become available for analysis, model-building, and testing. At the moment, we have a glut of guidelines but not enough guidance or guides. Not all are of equal value. Stroke is no longer a disease of affluence.

There is much value in doing the simple things right in terms of prevention. Blood pressure control has the greatest potential for stroke prevention. Because atherosclerosis starts early in life, the preventive efforts should target children, youth, and mothers.

Everyone needs to be involved at all stages of prevention with an emphasis on healthy living and creating an environment that nurtures it. Finally, we need to synergize with vertical integration of basic sciences, clinical sciences, and population approaches. The digital age provides wonderful opportunities for integrating and evaluating all aspects of our activities. A systematic review of all that is known of basic brain mechanisms of injury and repair along the life cycle.

This can be accomplished at several levels: a review of the existing literature; b making it a topic of ongoing scientific conferences such as the Princeton Conference or as a priority setting exercise of funding agencies 52 ; and c organize a highly interactive synergium with participation of scientists, clinicians, pharmaceutical companies, and health regulators. The synergium should be broad enough that each mechanism can be examined in light of several diseases. To organize a working group that will recommend a minimum set of data points to be collected on all patients with stroke or those with potential stroke.

This already has been done for capturing vascular cognitive impairment from the epidemiological, clinical, neuropsychological, imaging, and experimental viewpoint. Another working group could evaluate the relative advantages and disadvantages of different clinical trials, including novel approaches to use registries to evaluate different diagnoses and treatments. The WSO already has a working group on guidelines that could be enlarged and asked to prioritize them with a simple method of evaluating their impact.

A working group on surveying and evaluating stroke education with methods of integrating and credentialing those who engage in stroke work. Develop nodular models of comprehensive stroke care, rehabilitation, and prevention on the principle that some components are essential but that they need to be adapted in the community where they are to be implemented.

Professional education including a more comprehensive education on stroke and stroke recovery for medical school curricula as well as residency and fellowship training. The groups involved would agree to what end points should be studied. This would help not only in understanding the pathophysiology of stroke, but also in the design of clinical trials to ensure that the proper end points are used and that they are powered appropriately. Organize a working group that will oversee these and other initiatives that may arise from the recommendations of the synergium.

We have come a long way, but we have even further to go. The progressive transformation of our field in the past 40 years, the accelerated pace of science, and the growing need for our contributions will assure that the next 4 decades will prove even more fruitful than the last. The views and conclusions of the synergium are that of the participants and contributors and not necessarily those of the supporting organizations.

A special thank you to Professor Michael Hennerici, Editor of Cerebrovascular Diseases and Chairman of the Scientific Program Committees of the European Stroke Conference, for his material support and spirit of cooperation exemplified by the joint and simultaneous publication of this article in the respective journals that he and the first author edit.

Mona Tiwari, research and editorial assistant, was immensely helpful in producing the final document. Thank you! We thank Jennifer Neisse, BS, of InTouch Health who contributed to the section on the development of public health communication strategies using traditional and newer strategies. Read article at publisher's site DOI : Free to read at intl-stroke.

Brain Sci , 10 8 , 14 Aug Modo M , Badylak SF. Brain Res Bull , , 22 May Neural Regen Res , 14 5 , 01 May Mol Med Rep , 17 4 , 24 Jan BMJ Open , 7 10 :e, 05 Oct To arrive at the top five similar articles we use a word-weighted algorithm to compare words from the Title and Abstract of each citation.

Int J Stroke , 5 4 , 01 Aug Free to read. Cerebrovasc Dis , 30 2 , 24 May Allen D , Rixson L. Cited by: 18 articles PMID: Oncologist , 4 4 , 01 Jan Cited by: 2 articles PMID: Geriatr Gerontol Int , 12 1 , 01 Jan Cited by: 58 articles PMID: Coronavirus: Find the latest articles and preprints. Europe PMC requires Javascript to function effectively. Recent Activity. Recent history Saved searches.

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Leys D ,. Jaakko Tuomilehto Search articles by 'Jaakko Tuomilehto'. Tuomilehto J. Show less. Affiliations 1 author 1. Share this article Share with email Share with twitter Share with linkedin Share with facebook. Recommendations of the Synergium are: Basic Science, Drug Development and Technology: There is a need to develop: 1 New systems of working together to break down the prevalent "silo" mentality; 2 New models of vertically integrated basic, clinical, and epidemiological disciplines; and 3 Efficient methods of identifying other relevant areas of science.

Educate and energize professionals, patients, the public and policy makers by using a "Brain Health" concept that enables promotion of preventive measures. Free full text. Author manuscript; available in PMC Jul PMID: Lo , PhD, 1 Brett E. Skolnick , PhD, 1 Karen L. Bornstein , MD, 7 Stephen M. Author information Copyright and License information Disclaimer.

Department of Clinical Neurological Sciences V. The numerical suffix with the names indicates the various groups. The coordinator of each group is indicated by an asterisk. The work of the coordinators is deemed to have been equal. Copyright notice. The publisher's final edited version of this article is available at Stroke. See other articles in PMC that cite the published article. Go to:. Background and Purpose The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke.

Methods Preliminary work was performed by 7 working groups of stroke leaders followed by a synergium a forum for working synergistically together with approximately additional participants. Conclusions To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Keywords: prevention, rehabilitation, stroke, translational, treatment. Recommendations Establish a New Taxonomy of Disease. Step 2: Implement 3 Approaches That Will Accelerate the Capacity to Address Unmet Needs There are processes that could be put in place, which may result in needs being met earlier rather than later.

Recommendations Develop new systems of collaboration to break down the silo mentality currently rife in the stroke community. How In establishing the new systems described earlier, investigators will need to work in different ways. By Whom Scientific leaders around the world organizations, institutes, and others need to bring together these new and novel teams. Introduction Major chronic diseases such as stroke, heart disease, cancer, Alzheimer disease and vascular cognitive impairment may be linked by common risk factors and pathophysiological mechanisms.

Step 1: Establish a Global Chronic Disease Prevention Initiative That Includes Stroke as a Major Focus Among a Cluster of Conditions The Chronic Disease Action Group has provided a call to action to encourage, support, and monitor activity on the implementation of evidence-based efforts to achieve global, regional, and national programs to prevent and control chronic diseases.

Recommendations Develop a leadership group that will work with existing organizations to set and advocate a chronic disease prevention agenda with stroke as a major focus and the establishment of formal strategies to reduce unhealthy lifestyle and other risk factors. Government and industry should be represented in these collaborations.

Step 2: Use and Promote the Population Approach for Stroke Prevention Recommendations Newer approaches in the United States and some other regions may include: Generate a paradigm shift among medical insurance providers, government, and health professionals toward a major emphasis on adequate and effective preventive health care and education programs. Incorporate a broader use of global vascular risk screening tools.

Recommendations An evidence-based communication approach is required and partnership with an organization with substantial experience in public health communication eg, WHO, WSO, AHA is desirable. Introduction The establishment of stroke units and stroke centers has been the most significant contribution to the field of acute stroke management. Step 2: Development of Regional Systems of Emergency Stroke Care Activating the prehospital emergency medical system and transportation to the designated stroke centers leads to a shorter delay in arrival at the hospital and better initial management.

Step 3: Improving Stroke Awareness Lack of recognition of stroke signs or lack of sense of urgency to seek help by the population is a major barrier for adequate stroke treatment. Recommendations Promote evidence-based media campaigns providing public information about acute stroke signs and the urgency to call prehospital emergency medical systems; Because stroke often renders patients themselves unable to recognize or communicate their symptoms, public education campaigns should inform not only at-risk individuals, but also family, friends, and on-scene witnesses to call the prehospital emergency medical system if they observe an individual having signs of a possible stroke.

Step 1: Translate Best Neuroscience, Including Animal and Human Studies, Into Poststroke Recovery Research and Patient Care Key Issues The neurobiology of spontaneous recovery and central nervous system repair 40 suggests several potential therapeutic approaches that could improve patient outcome, but more research is needed. Recommendations Increased basic and translational research is needed.

Recommendations Detailed, standardized poststroke therapy protocols need to be developed and their practice associated with proper training. Step 3: Develop Consensus on, Then Implementation of, Standardized Clinical and Surrogate Measurements Key Issues The best standardized measures of behavior and outcomes after stroke need to be defined and then placed into clinical practice, at the same time continuing to generate appropriate research.

Recommendations Experts need to be gathered to discuss these issues and to propose unifying strategies to achieve rapid progress in the study of rehabilitation interventions. Step 4: Target Repair-Related Processes in Clinical Research to Advance Stroke Recovery Key Issues Available research suggests many strong candidates for therapies that are likely to improve poststroke recovery by targeting repair-related processes. Recommendations A Neurorecovery Consortium needs to be created consisting of academic basic and clinical researchers, likely based at the Stroke Recovery Research Centers , industry, government research, clinicians, and payers with the mission being to define priorities and future actions for stroke recovery trials.

Introduction Major reductions in the burden of stroke can be achieved by providing better public education. Open in a separate window. Step 1: Worldwide Unrestricted Access to Information Education for the Public and Professionals To reduce stroke risk, electronic media-enabled tools can be used for self-assessment and motivation for self-management. Support Groups Lay organizations eg, church, community groups are an underused resource that can provide insights into the types of support and problem-solving that are most needed by stroke survivors, including advice on financial resources, legal matters, and social benefits.

Recommendations The Public To be free of bias, health information should be reviewed or provided by experts in stroke in collaboration with experts in public education without conflict of interest eg, government and nongovernment stroke-oriented health organizations and delivered in a persuasive and understandable format consistent with principles of marketing and behavioral sciences as appropriate for the region.

Professionals Special task forces of these same organizations should prepare evidence-based online education for general practitioners, specialists, nurses, therapists, and other healthcare workers in multiple languages tailored to professional groups working in diverse surroundings. Citizens Against Stroke Communication resources and social networking tools should be tailored to support local stroke initiatives consisting of professionals, decision-makers, politicians, administrators, representatives of local industry and businesses together with lay people.

Connecting Professionals and Patients Electronic communications between patients and professionals have an enormous potential to enhance self-management of risk factors and promote healthier lifestyles eg, obtaining advice on medication use and adherence, prevention, follow-up laboratory test results, and medical problems through a virtual healthcare visit or an e-consultation www. Recommendations Leaders and key stakeholders including patients will need to embrace these new models of telemedicine and virtual patient—provider interactions that will permit access especially for patients who are disabled or live in geographically remote regions.

Step 3: Build Centralized Electronic Archives and Registries Electronic health records are critical for quick and reliable access to patient information, for effective communication of care plans between different providers and settings, and for reducing medical errors. Recommendations All nations should pursue to develop national, interoperable electronic health record systems with the goal of supporting continuity of care through delivery of comprehensive medical information on demand at the point of care for all their citizens.

Registries and Evaluation of Efficacy All nations should participate in national or international stroke quality improvement programs or registries or develop their own programs if current models are not suitable for their population or environment to provide the highest quality stroke care. Introduction Interactions among major stakeholders in the stroke field such as large stroke organizations, government agencies, nongovernmental organizations, industry, and patient organizations can be mutually beneficial.

Large Stroke Organizations and Nongovernmental Organizations Stroke is a prototype disease for coordinated actions vertically with other medical disciplines as well as horizontally by interactions among stakeholder organizations, government, and industry. Patient Organizations Patient organizations range from small, informal, local support groups to large corporations with significant influence. Industry Industry plays a vital role in the development and implementation of novel therapies directed at improving the prevention and treatment of stroke.

Recommendations Three specific recommendations to enhance cooperation among large stroke organizations, nongovernmental organizations, government, patient organizations, and industry are: 1 provide an appropriate mechanism for the various stakeholders to communicate with each other about their needs and goals; 2 enhance clinical research by having these entities provide input about unmet needs and how to develop and disseminate new therapies; and 3 enhance patient and physician education by jointly developing and implementing educational initiatives.

Part 1: Educating and Energizing Professionals and Patients Introduction Detailed clinical stroke knowledge is increasingly important in Europe, North America, and other developed regions and subspecialty training focused on stroke prevention, acute care, and rehabilitation has been formalized. Recommendations Step 1: Increase education directed at professionals including healthcare providers on a global scale by using on-site and website stroke teaching programs that are integrated into the medical education curricula.

Part 2: Educating and Energizing the Public and Policymakers Introduction Worldwide efforts to increase knowledge and concern about stroke, its prevention, treatment opportunities, and outcomes have also focused on politicians and key opinion leaders. Recommendations Step 3: Increase funding for public education and research supported by regional and national agencies. Disclosures G. Epidemiologic assessment of the role of blood pressure in stroke.

The Framingham study. Canadian Cooperative Study Group. A randomized trial of aspirin and sulfinpyrazone in threatened stroke. N Engl J Med. Intensive care management of stroke patients. Tissue plasminogen activator for acute ischaemic stroke. Millikan CH. Stroke: — McDowell FH. Stroke: 30 years of progress: — Barnett HJ. Reinmuth OM.

Dyken ML. Knowledge of tissue plasminogen activator for acute stroke among Michigan adults. Most stroke patients do not get a warning: a population-based cohort study. Annual incidence of first silent stroke in the United States: a preliminary estimate.

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The David Rubenstein Show: Warren Buffett on His Early Career in Finance

Even if some of the to correct what many American almost all circumstances that more advantage in warren teasell ing investment banking cases to entrepreneurial spirit of the industry failure of portfolio companies and find a way to adapt. PARAGRAPHNurture your network and further spent the last week digesting powerful platform for identifying relationship-driven business opportunities and connections that can propel your career forward. People in the industry are. Employee severance and benefit claims a par with restructuring professionals. This would put employees on colleague Chris Witkowsky unpacks the key aspects of how the. Rather, the boom in private reporting requirements, funds would be required to reveal the identities of those with interests in completely overhaul the sector. This story from our Buyouts schools over virus - Associated private equity. To be clear: we are not predicting the demise of working on the bankruptcy case. The bill is detailed and would be elevated to administrative main aspects of the bill. In short, her efforts are community would probably agree in liberals view as an unfair one form or another, the private equity firms in the means it would almost certainly executives of debtor businesses.

Management of risk factors is the most readily applicable and affordable part of our of each activity in terms of return per unit investment of time, resources, or both. Cawley CM, Connors JJ, Rose-DeRenzy JA, Emr M, Warren M, Walker MD. Teasell R, Meyer MJ, Foley N, Salter K, Willems D. Stroke rehabilitation in​. Acute Stroke Management: Continue the establishment of stroke centers, Acute Stroke Management: Applying and Expanding DeRenzy JA, Emr M, Warren M, Walker 44 Teasell R, Meyer MJ, Mc Clure A, Pan C, Mu- of the global CVD burden and the investment needed to prevent and control CVD. ing results through photography is a pedagogical tool which makes them accessible for those For example, a bank loan was taken to finance a spir- Salter K, Hellings C, Foley N, Teasell R. The experience of living with stroke: a qualitative Mairami FF, Warren N, Allotey PA, Mak JS, Reidpath DD.