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- Ratajczak-Tretel, B., et al.
(författare)
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Atrial fibrillation in cryptogenic stroke and TIA patients in the nordic atrial fibrillation and stroke The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study : Main results
- 2023
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Ingår i: European Stroke Journal. - : SAGE Publications. - 2396-9873 .- 2396-9881. ; 8:1, s. 148-156
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: Secondary stroke prevention depends on proper identification of the underlying etiology and initiation of optimal treatment after the index event. The aim of the NOR-FIB study was to detect and quantify underlying atrial fibrillation (AF) in patients with cryptogenic stroke (CS) or transient ischaemic attack (TIA) using insertable cardiac monitor (ICM), to optimise secondary prevention, and to test the feasibility of ICM usage for stroke physicians. Patients and methods: Prospective observational international multicenter real-life study of CS and TIA patients monitored for 12 months with ICM (Reveal LINQ) for AF detection. Results: ICM insertion was performed in 91.5% by stroke physicians, within median 9 days after index event. Paroxysmal AF was diagnosed in 74 out of 259 patients (28.6%), detected early after ICM insertion (mean 48 ± 52 days) in 86.5% of patients. AF patients were older (72.6 vs 62.2; p < 0.001), had higher pre-stroke CHA₂DS₂-VASc score (median 3 vs 2; p < 0.001) and admission NIHSS (median 2 vs 1; p = 0.001); and more often hypertension (p = 0.045) and dyslipidaemia (p = 0.005) than non-AF patients. The arrhythmia was recurrent in 91.9% and asymptomatic in 93.2%. At 12-month follow-up anticoagulants usage was 97.3%. Discussion and conclusions: ICM was an effective tool for diagnosing underlying AF, capturing AF in 29% of the CS and TIA patients. AF was asymptomatic in most cases and would mainly have gone undiagnosed without ICM. The insertion and use of ICM was feasible for stroke physicians in stroke units.
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| 2. |
- Ratajczak-Tretel, B, et al.
(författare)
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Prediction of underlying atrial fibrillation in patients with a cryptogenic stroke : results from the NOR-FIB Study
- 2023
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Ingår i: Journal of Neurology. - 1432-1459. ; 270:8, s. 4049-4059
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Atrial fibrillation (AF) detection and treatment are key elements to reduce recurrence risk in cryptogenic stroke (CS) with underlying arrhythmia. The purpose of the present study was to assess the predictors of AF in CS and the utility of existing AF-predicting scores in The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study.METHOD: The NOR-FIB study was an international prospective observational multicenter study designed to detect and quantify AF in CS and cryptogenic transient ischaemic attack (TIA) patients monitored by the insertable cardiac monitor (ICM), and to identify AF-predicting biomarkers. The utility of the following AF-predicting scores was tested: AS5F, Brown ESUS-AF, CHA 2DS 2-VASc, CHASE-LESS, HATCH, HAVOC, STAF and SURF. RESULTS: In univariate analyses increasing age, hypertension, left ventricle hypertrophy, dyslipidaemia, antiarrhythmic drugs usage, valvular heart disease, and neuroimaging findings of stroke due to intracranial vessel occlusions and previous ischemic lesions were associated with a higher likelihood of detected AF. In multivariate analysis, age was the only independent predictor of AF. All the AF-predicting scores showed significantly higher score levels for AF than non-AF patients. The STAF and the SURF scores provided the highest sensitivity and negative predictive values, while the AS5F and SURF reached an area under the receiver operating curve (AUC) > 0.7.CONCLUSION: Clinical risk scores may guide a personalized evaluation approach in CS patients. Increasing awareness of the usage of available AF-predicting scores may optimize the arrhythmia detection pathway in stroke units.
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| 3. |
- Ratajczak-Tretel, B, et al.
(författare)
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Underlying causes of cryptogenic stroke and TIA in the nordic atrial fibrillation and stroke (NOR-FIB) study : the importance of comprehensive clinical evaluation
- 2023
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Ingår i: BMC Neurology. - : Springer Science and Business Media LLC. - 1471-2377. ; 23:1
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Cryptogenic stroke is a heterogeneous condition, with a wide spectrum of possible underlying causes for which the optimal secondary prevention may differ substantially. Attempting a correct etiological diagnosis to reduce the stroke recurrence should be the fundamental goal of modern stroke management.METHODS: Prospective observational international multicenter study of cryptogenic stroke and cryptogenic transient ischemic attack (TIA) patients clinically monitored for 12 months to assign the underlying etiology. For atrial fibrillation (AF) detection continuous cardiac rhythm monitoring with insertable cardiac monitor (Reveal LINQ, Medtronic) was performed. The 12-month follow-up data for 250 of 259 initially included NOR-FIB patients were available for analysis.RESULTS: After 12 months follow-up probable stroke causes were revealed in 43% patients, while 57% still remained cryptogenic. AF and atrial flutter was most prevalent (29%). In 14% patients other possible causes were revealed (small vessel disease, large-artery atherosclerosis, hypercoagulable states, other cardioembolism). Patients remaining cryptogenic were younger (p < 0.001), had lower CHA 2DS 2-VASc score (p < 0.001) on admission, and lower NIHSS score (p = 0.031) and mRS (p = 0.016) at discharge. Smoking was more prevalent in patients that were still cryptogenic (p = 0.014), while dyslipidaemia was less prevalent (p = 0.044). Stroke recurrence rate was higher in the cryptogenic group compared to the group where the etiology was revealed, 7.7% vs. 2.8%, (p = 0.091). CONCLUSION: Cryptogenic stroke often indicates the inability to identify the cause in the acute phase and should be considered as a working diagnosis until efforts of diagnostic work up succeed in identifying a specific underlying etiology. Timeframe of 6-12-month follow-up may be considered as optimal.TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02937077, EudraCT 2018-002298-23.
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| 4. |
- van Dishoeck, E. F., et al.
(författare)
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Water in star-forming regions: Physics and chemistry from clouds to disks as probed by Herschel spectroscopy
- 2021
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Ingår i: Astronomy and Astrophysics. - : EDP Sciences. - 0004-6361 .- 1432-0746. ; 648
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Tidskriftsartikel (refereegranskat)abstract
- Context. Water is a key molecule in the physics and chemistry of star and planet formation, but it is difficult to observe from Earth. The Herschel Space Observatory provided unprecedented sensitivity as well as spatial and spectral resolution to study water. The Water In Star-forming regions with Herschel (WISH) key program was designed to observe water in a wide range of environments and provide a legacy data set to address its physics and chemistry. Aims. The aim of WISH is to determine which physical components are traced by the gas-phase water lines observed with Herschel and to quantify the excitation conditions and water abundances in each of these components. This then provides insight into how and where the bulk of the water is formed in space and how it is transported from clouds to disks, and ultimately comets and planets. Methods. Data and results from WISH are summarized together with those from related open time programs. WISH targeted ∼80 sources along the two axes of luminosity and evolutionary stage: from low- to high-mass protostars (luminosities from <1 to > 10Lpdbl) and from pre-stellar cores to protoplanetary disks. Lines of H2O and its isotopologs, HDO, OH, CO, and [O I], were observed with the HIFI and PACS instruments, complemented by other chemically-related molecules that are probes of ultraviolet, X-ray, or grain chemistry. The analysis consists of coupling the physical structure of the sources with simple chemical networks and using non-LTE radiative transfer calculations to directly compare models and observations. Results. Most of the far-infrared water emission observed with Herschel in star-forming regions originates from warm outflowing and shocked gas at a high density and temperature (> 10cm-3, 300-1000 K, v ∼ 25 km s-1), heated by kinetic energy dissipation. This gas is not probed by single-dish low-J CO lines, but only by CO lines with Jup > 14. The emission is compact, with at least two different types of velocity components seen. Water is a significant, but not dominant, coolant of warm gas in the earliest protostellar stages. The warm gas water abundance is universally low: orders of magnitude below the H2O/H2 abundance of 4 × 10-4 expected if all volatile oxygen is locked in water. In cold pre-stellar cores and outer protostellar envelopes, the water abundance structure is uniquely probed on scales much smaller than the beam through velocity-resolved line profiles. The inferred gaseous water abundance decreases with depth into the cloud with an enhanced layer at the edge due to photodesorption of water ice. All of these conclusions hold irrespective of protostellar luminosity. For low-mass protostars, a constant gaseous HDO/H2O ratio of ∼0.025 with position into the cold envelope is found. This value is representative of the outermost photodesorbed ice layers and cold gas-phase chemistry, and much higher than that of bulk ice. In contrast, the gas-phase NH3 abundance stays constant as a function of position in low-mass pre- and protostellar cores. Water abundances in the inner hot cores are high, but with variations from 5 × 10-6 to a few × 10-4 for low- and high-mass sources. Water vapor emission from both young and mature disks is weak. Conclusions. The main chemical pathways of water at each of the star-formation stages have been identified and quantified. Low warm water abundances can be explained with shock models that include UV radiation to dissociate water and modify the shock structure. UV fields up to 102-10times the general interstellar radiation field are inferred in the outflow cavity walls on scales of the Herschel beam from various hydrides. Both high temperature chemistry and ice sputtering contribute to the gaseous water abundance at low velocities, with only gas-phase (re-)formation producing water at high velocities. Combined analyses of water gas and ice show that up to 50% of the oxygen budget may be missing. In cold clouds, an elegant solution is that this apparently missing oxygen is locked up in larger μm-sized grains that do not contribute to infrared ice absorption. The fact that even warm outflows and hot cores do not show H2O at full oxygen abundance points to an unidentified refractory component, which is also found in diffuse clouds. The weak water vapor emission from disks indicates that water ice is locked up in larger pebbles early on in the embedded Class I stage and that these pebbles have settled and drifted inward by the Class II stage. Water is transported from clouds to disks mostly as ice, with no evidence for strong accretion shocks. Even at abundances that are somewhat lower than expected, many oceans of water are likely present in planet-forming regions. Based on the lessons for galactic protostars, the low-J H2O line emission (Eup < 300 K) observed in extragalactic sources is inferred to be predominantly collisionally excited and to originate mostly from compact regions of current star formation activity. Recommendations for future mid- to far-infrared missions are made.
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