MESOTHERAPY

INTRODUCTION

Mesotherapy is an art of injecting small quantities of various medicinal preparations such as vitamins, minerals and other conventional drugs directly into the mesoderm to treat pathological conditions locally. It involves the administration of intradermal or subcutaneous injections of compounds to treat a variety of medical conditions and avoiding systemic adverse effects due to drugs. It appears to be a novel technique to administer medicines local to the pathology while the skin serves as a natural time- release system.

BACKGROUND OF MESOTHERAPY

The term mesotherapy (derived from Greek mesos. “Middle” and therapeia to treat medically) denotes injection of substances into middle layer of skin ( mesoderm) for medical purposes.

Historical aspects

[1]

Mesotherapy was originally used to treat painful conditions using local procaine injections. Michael Pistor who coined the term mesotherapy is considered the father of mesotherapy. In his original article,he described treating deafness, tinnitus, vertigo and headaches using local injections of procaine. Earlier to this in 1884, Koller an ophthalmologist used local cocaine to relieve pain. In 1925 Lerich used intradermal injections in the intercostal spaces. In 1937 Aron studied the use of intradermal injections to have an analgesic effect. Albert Lemaire, a Belgian physician used procaine injections to treat trigeminal neuralgia. In 1952, Michel Pistor a French physician popularized mesotherapy to treat various conditions in dermatology,sports,traumatology and vascular disease chiefly as a pain-relieving therapy. He defined mesotherapyas a techniquethat was used to treat mesoderm,(primary germ layer that develops into connective tissue, muscle and the circulatory system). In 1953, Dr.Mario Lebel invented a 3mm length needle that could be used precisely for injection of substances into the dermis. In 1964, the French society of Mesotherapy was founded by Michel Pistor and use of mesotherapy was extended to treat cosmetic conditions.

The American influence was evident after Dr. Lionel Bissoon popularized the technique in North America. Despite the fact that mesotherapy is gaining popularity in aesthetic medicine especially for localized cellulite reduction, it continues to be a controversial topic and therefore requires cautious approach. The safety and efficacy of these mesotherapy remain ambiguous to patients and physicians alike. [2]

Applied basic science

[1, 3]

The concept that led to discovery of mesotherapy is quite interesting. Pistor saw recovery of chronic hearing loss while treating a patient with procaineinjections for an asthma attack. Subsequent intradermal injections of this product into the mastoid region proved this effect to be true. However the depth of injection was considered important. This led the researchers to the fact that at a depth of 1.5 to 2mm the local activity of the product would last longer due to a persistent reservoir with weak local diffusion in the dermis whereas products injected into dermis would dissipate to greater distances.A product when injected intradermally acts in two ways. Firstly, by stimulating dermal receptors in situ and secondly, over long distances by reaching other organs via circulation. A concept of meso-interface exists which is the surface of contact established between the injected products and the tissue injected. The more the multiple punctures are made and the more fragmented products are delivered in small quantities, the greater the meso-interface and proportionately greater numbers of dermal receptors get activated.Pistor has always described this technique as follows. “A little volume, a few times and in the right place”. The idea was that by placing these products in the dermis, the skin acts as a reservoir for drugs to diffuse slowly via microcirculation to activate dermal receptors.

A general mechanism of action (based on the target site, dermis) and a specific mechanism of action (based on the ingredients used) has been proposed to explain the concept of mesotherapy. The dermis is considered to be common denominator for circulatory, neurological and immunological functions; and the general mode of action is believed to occur by correction of these altered functions. Individual drugs or agents target the specific indication of mesotherapy.

EQUIPMENTS

The various equipments used in mesotherapy are

1. Mesogun
   
   (Fig 1)
   
2. Mircromesotherapy device
3. Needleless Mesotherapy

Mesogun

Mesogun is a syringe infusion pump that is capable of injecting the desired substance at a required amount, speed and depth using the injector and needle. Syringes varying from 2cc-10cc and needle lengthsvarying in size from 4mm to 13mm can be used based on the indication, and desired depth of injection. A device known as guide is used to keep the needle at a constant depth. Once the parameters are chosen, the product can be injected by one of the following modes.

1. Continuous – Min 3cc/min Max 10cc/min.
2. Mircrodose – Max0.1cc/trigger.
3. Standard dose – Max 0.3cc/trigger.
4. Mesoperfusion – Max 0.3cc/trigger.
5. Nappage – 0.1cc/trigger.

Advantages of Mesogun

1. Good comfort level for patient and physician
2. Procedure is faster and relatively painless
3. Accurate delivery system
4. Versatality – Ability to perform various modes such as nappage, continuous, mesoperfusion in dosimetry.

Syringes used in Mesogun:


Generally 1ml, 5ml, 10ml and 20ml syringes with luer lock system is used based on the indication.

MesoNeedles (Fig2 a):


Mesoneedles or “Lebel needles” are commonly used in mesotherapy.The John Screw needles have an adjustable length.The recommended parameters for needles are based on the site of injection:

Face and neck – 4mm 30G mesoneedles

Fat and cellulite – 6mm 30G mesoneedles, ½ inch 30G needles.

Multi-injectors and plates (Fig2 b):


These accessories help to cover larger areas in a short time facilitating faster and easier procedure for the injector. There are sterile circular and linear multi-injectors with needles ready to be used for any body part.

Micromesotherapy Device

Micromesotherapy is an evolution of conventional mesotherapy. Usually mesotherapy uses needles to deliver drugs in deep dermal layer. Here a reverse cone shaped device has ultrafine needle 32Gx2mm by which drugs are injected into the superficial layer of dermis therebyminimizing incidence of bruising, pain and scarring.

Needle-Less Mesotherapy or


No Needle Mesotherapy

This is a needle free device that pushes mesotherapy products painlessly through the skin using electrical waves known as isophoresis. The main features of needle less mesotherapy are:

1. Less painful and less traumatic
2. Uses ultrasound/electroporation technology.
3. Probably around 20% efficiency compared to traditional mesotherapy as there is no neocollagenesis or neo angiogenesis reactions that occur with needle micro injury.
4. This may be an option if mesotherapy is not allowed in the country.

It has been discussed in details in Chapter 12.

MESO SOLUTIONS (




Fig6


[VG1]

The basic requirements of meso products is that it should be approved and skin-compatible.Systemic administration (intravenous, intramuscular, subcutaneous or intradermal) should be safe and known pharmacological actions to be effective. The ingredients used in mesotherapy products should be water soluble, isotonic and non-allergenic.

The mesoproducts vary with the indications chosen for treatment


^.


[4] [ Figure 3]Products used for mesotherapy involves combination of products some of which are main ingredients known as principals as they have high grade of evidence in the treatment of each indications and complementary agents that have been approved for treatment of each indications. For a mixture to be effective it should contain 2 – 3 principals for any given indication. Therefore the ingredients in mesosolutions are broadly classified into main categories:

• Principal (P) / Major
• Complementary (C) / Minor.

The main targets for mesotherapy are skin, hair, fat and cellulite. (Table 11.1).

Table 11.1 Principal and Complementary ingredients in meso solutions in various indications

INDICATION	PRINCIPAL/MAJOR	COMPLEMENTARY/MINOR
SKIN REJUVENATION
Mesolift	Hyaluronic Acid 5 DMAE Organic silicum Fibronectin + Vegetal Proteins	Vitamin C Glycolic Acid Xadenal Vitamin A Growth Factors Stem Cells
Mesoglow	Hyaluronic Acid Siloag	Vitamin C Xadenal Taurine
Meso lightening	Kojic Acid Azalaic Acid Vitamin C Glutathione	Tretinoin Glycolic Acid
Striae or stretch marks
Stretch Marks	Organic silicum Centella Asiatica Vegetal Proteins + Fibronectin	DMAE Vitamin C Idebenone
Hair Loss
Androgenetic Alopecia	Minoxidil Finasteride Dutasteride Dexenol Biotin	Amino acids Peptides Zinc Azelaic Acid Stem Cells
Telogen effluvium	Biotin Dexapanthenol	Pyridoxine Multi Vitamins Trace Elements
Cellulite and Fat
Meso Cellulite	Caffeine Carnitine Aminophylline DMAE Rutin	Artichoke Yohimbine Procaine Vitamin C
Fat deposits Body Sculpting, localized fat, Cellulite	PPC Deoxy cholate	L – Carnitine Aminophylline Pentoxifylline

DMAE -Dimethylaminoethanol ; PPC – Phosphatidylcholine

TECHNIQUES FOR MESOTHERAPY INJECTIONS

The mesoproducts can be injected into the skin by various injection techniques to reach desired depth.The commonly used techniques and the desired depth reached are summarized in Table 11.2and Illustration 11.1

Table 11.2: Techniques and depth in mesotherapy injections

Technique	Depth
Intraepidermal	1mm
Papular	2mm
Nappage	2-4mm
Point by point	4mm
Mesoperfusion	> 4mm

The salient features of various techniques are outlined below:

Intra-epidermal

This is one of the most superficial of the techniques described by Perrin.

1. Depth: 1mm within the epidermis
2. Painless, no bleeding
3. Simple and large surface covered
4. Ideal for patients with low pain threshold
5. Ideal for facial rejuvenation, mesoglow

Papular

1. Depth:2mm dermoepidermal junction
2. Painful
3. Useful in mesobotox
4. Ideal treatment of wrinkles

Nappage(French for ‘covering’)

Also known as picotage is the classic injection technique in mesotherapy. (Illustration 11.2) It is the most widely used technique in aesthetic dermatology. The syringe is held obliquely and the physician applies constant pressure on the plunger flicks the wrist to infuse a drop of the solutioninto the dermis

(Fig 4)


.

The injections are 2-2.5mm deep and 1cm apart. This technique can also be used for injections using a mesogun

.


(Fig 5)

1. Depth 2-4mm
2. Less pain and less bleeding
3. Ideal for rejuvenation and scalp treatments

Point by Point


(Fig 6)

1. Depth 4mm
2. Perpendicular injection
3. Ideal for fat reduction

Mesoperfusion

1. Depth > 4 mm
2. Mesosolution is injected slowly over a priod of 10 minutes
3. Not commonly used in dermatology

PRACTICAL ASPECTS OF MESOTHERAPY

Indications and contraindications for mesotherapy are listed in box 11.1 and box11.2.

Box 11.1 Indications for mesotherapy

Box 11.2 : Contraindications for mesotherapy

Related to patient Unrealistic expectations Body mass index greater than 30 Pregnancy / Lactation H/O strokes, recent cancer. H/o multiple meds for heart disease H/o allergy to ingredients e.g. Soy proteins, lignocaine. Autoimmune disorders Epilepsy Insulin dependent diabetes

Related to product Aminophylline – Known hypersensitivity to drug, active peptic ulcer, Pentoxiphylline, aminophylline- recent cerebral retinal bleed L. carnitine – history of seizure disorder Phosphatidyl – choline relative contraindications with antiphospholipid antibody syndrome Caffeine – arrhythmias, anxiety, insomnia hypotension Mannitol – pulmonary edema, renal disease.

Patient selection

Selecting the patient with a valid indication for mesotherapy is the key to success. Care should be taken to avoid patients with active skin diseases, too elderly and patients with history of sensitive skin. For androgenetic alopecia better results are seen in patient with Grades 1 – 3.

Counseling and preparing the patient

A proper counseling is essential before starting mesotherapy. Patients with body dysmorphic disorders and those with unrealistic expectations should not be treated. Alternate procedures should be discussed sufficiently as mesotherapy is still in the controversial stage. A written informed consentis mandatory in the present medical scenario. A good before and after clinical photograph is needed to evaluate results following the procedure.

Procedural aspects

The area to be treated is marked and thoroughly cleaned with an antiseptic solution. For anesthesia, a local anesthetic cream may be applied or ice-anesthesia can be used to numb the treatment area. Patients are preferably injected in a lying down position. The required quantity of ingredients is drawn into the syringe using an 18Gx11/2needle. The injection is given either manually or using a device to deliver by the papular, nappage or point by point technique. A gentle massage is given after the treatments. Fresh normal saline and a mositurising cream can be applied to the treated area and massaged gently. [9]. The procedure takes about 20 – 30 minutes depending on the indication and area to be treated. There is no downtime after the procedure and the patient will be able to return to normal activities immediately.

Good results are seen with mesotherapy done for skin rejuvenation, cellulite and double chin. [Fig 7, 8, 9]

Post procedure care and counseling for follow up

There may be mild pain, pinpoint bleeding, itching, burning or erythema after the injection which will subside spontaneously. Bruising and hematoma can appear occasionally and can be managed symptomatically. Mild swelling at site of injection may require anti-inflammatory agents for few days.

The patients need to be counseled on the following aspects:

1. Avoid sun exposure and smoking for next 48 hours
2. Loose fitting clothes to be worn especially after lipolytic injections.
3. The area to be treated is generally massaged after 72 hours and continued daily till disappearance of nodules if any.

Follow up

: Generally treatments are given once every 1-2weeks for 6 sessions, then once a month for 5months. Maintenance sessions are to be done once or twice a year. This protocol may be altered depending on the indication, patient’s lifestyle, financial position and response to

previous treatments.

Complications

Though there are few evidence based studies on the efficacy of mesotherapy, there are documented reports on various complications. [10-17] The complications can be classified as local and systemic complications. (Box 11. 3)

Box 11.3: Complications

Local Bruising Burning or itching Pain, Tenderness, swelling Urticaria [10] Skin necrosis, Ulcers [11] Abscess [12] Hyper pigmentation Atypical mycobacterial infection [13] Rare – granulomatous panniculitis [14,15], koebnerisation, granuloma annulare, Oleoma [16]

Systemic Anaphylaxis Nausea Vasovagal shock Hepatic toxicity Nerve demyelination Allergy to specific ingredients Thyrotoxicosis Ischaemic colitis [17]

Management of Complications:

Bruising:

It is a common but preventable complication. Always advice patient to stop aspirin or NSAIDs at least 2 weeks prior to the day of procedure. While injecting be slow and gentle. It is advisable to avoid mesotherapy during menstruation.

Burning/Itching:

Burning can be overcome by adding lignocaine to the products if compatible. A mesomask applied immediately following procedure can also minimize burning and itching as it has a soothing effect.

Pain/Tenderness:


P

rocedural pain can be minimized by using adequate topical anaesthesia. Immediate post treatment pain can be alleviated by cold compresses with ice. Other methods that help to minimize pain are by pinching the skin for point by point injections or by stretching it when giving a nappage. Change needles after every few pricks to reduce the pain caused by blunt injecting needles

Urticaria:

Urticaria can be avoided by a careful history to avoid products that would provoke an allergic reaction. E.g. phosphatidyl choline in individuals with history of allergy to soy proteins.

Skin necrosis:

Skin necrosis occurs usually with phosphatidyl choline when the injections are given superficially <1cm below the epidermal surface, excessive injection volume at each point, or in appropriately small distances between the points.

Ulcers:

Ulcers can due to infection or irritant nature of the drugs. Irritant induced ulcers can be prevented by minimizing the number of drugs used in the cocktail to 4 or 5. Infective ulcers can be avoided by disinfecting the treatment area thoroughly and by wearing sterile gloves and using sterile equipment and materials.

Hyper pigmentation:

This can be avoided by advising the patient photo protection for 48 hours after the procedure and by addition of topical skin lightening agents in patients with a history of post inflammatory hyper pigmentation.

COMBINING MESOTHERAPY WITH OTHER TECHNIQUES

Mesotherapy can be combined with other techniques to enhance results.Soon after injection of mesotherapy products, ultrasound, radiofrequency or electroporation may be applied to help in better diffusion of the injected products. The techniques are discussed in chapter 12. Mesomasks can be applied immediately after the injections to minimize bleeding points and to overcome the discomfort that follows injections.It is a 150 g of powder to be mixed with water to form a paste which is applied for 15minutes as a mask over gauze. This allows all products to penetrate deeper in the skin to give a better effect. These masks contain a mixture of calcium sulfate, talc and orange oil. Other procedures such as chemical peels, fillers and neurotoxins can be carried out between the mesotherapy sessions.

In countries where mesotherapy is not practiced, mesotherapy products can be used following cosmetic skin needling. By using a dermaroller in the area to be treated, it is possible to create micro perforations that will be used as channels to deliver a product deeply into the skin.

CLINICAL STUDIES

Mesotherapy has been in history for a long time and there are proponents who have been successfully using it in practice for the benefits of their patients. However there are few indexed studies about the safety and efficacy of mesotherapy but many about its complications, hence it only natural to distrust proponents in relation to this technique Hence adequate controlled studies are needed to establish the value of mesotherapy in aesthetic dermatology. [18] Mesotherapy for skin rejuvenation, treatment of local fat deposits, body sculpting have been assigned Evidence Level C, whereas cellulite treatment has been assigned Evidence Level D [18].

Few recent studies have shown promising results for mesotherapy in various aesthetic indications. A study by Larruba et al showed good results with hyaluronic acid mesotherapy on photoaging and assessed by ultrasound techniques. [5] A study by Savoia etal showed promising

---

[VG1]
An excellent compilation with evidence for few of them are given in these two articles from IJDVL

1. Sarkar R, Garg VK, Mysore V. Position paper on mesotherapy. Indian J Dermatol Venereol Leprol 2011;77:232-7
2. Konda D, Thappa DM. Mesotherapy: What is new?. Indian J Dermatol Venereol Leprol 2013;79:127-34

Another review of various indication s of mesotherapy is in this article by Dr. premlatha

3.Latha P. and Vandana K.R. / International Journal of Advanced Pharmaceutics / 1 (1), 2011, 19-29

( full text available of all three)

The meso solutions can be tabulated in the format below

1. Indication
2. Product
3. Mechanism of action ( should include original intention versus intention in mesotherapy e.g. aminophylline was originally used for brochodilation. In mesotherapy it is used for vasodilatation etc
4. Evidence grade ( wherever available)

Written by: Yung Bing Yong

Introduction

The brain is the primary organ of the centre nervous system that controls our body and houses our mind. It is metabolically active and dependent on a continuous supply of oxygenated blood. If the blood supply is interrupted, the brain could not function normally, resulting a rapid appearance of focal or global disturbance of cerebral functions and its consequent neurological symptoms. If deprived of oxygen for 20s, the brain falls into unconsciousness as the electrical activity cease due to energy depletion. This can become irreversible if it extends beyond 5 min when permanent damage has been made

[1]
.

In this PBL scenario, a 67-year-old Caucasian woman who has a 15 pack-year smoking history arrived in A&E with ipsilateral weakness of both her right upper and lower limb, difficulty speaking and is known with atrial fibrillation and hypertension. Her current medication is warfarin and amlodipine. Clinical presentation and further investigation suggests that she had a stroke.

To further understand the cases in more details,

four

learning objectives below are proposed in attempt to cover the knowledge necessary to explain the scenario in this PBL:

1. 
   Describe the blood supply of the brain.
   
2. 
   Explore the epidemiology of strokes.
   
3. 
   Explain the value of CT with and without contrast in this PBL scenario.
   
4. 
   Consider the treatment and prognosis of the patient.
   

Term to be clarified:

(a)

Warfarin

: An anticoagulant to reduce the risk of blood clotting by inhibiting vitamin K epoxide reductase. It

decrease the levels of active vitamin K and thus lowered the efficiency of blood coagulation cascade.

2. 
   Amlodipine
   
   : A calcium channel blocker. It works by blocking calcium influx into smooth muscles cells of the wall

of blood vessels. As a result, vasoconstriction is inhibited and thus reducing the blood pressure.

3. 
   Aphasia
   
   
   [2]
   : Difficulty in using language. It is categorised into four main types:

• Expressive aphasia – patients know what to say, but are having trouble saying what they mean.
• Receptive aphasia – patients are having difficulty making sense of the words or diagrams.
• Anomic aphasia – patients are facing problems recalling words, names or numbers. (“speaking in a

roundabout way”)

• Global aphasia – patients cannot speak, understand speech, read, or write. It is the combination of

expressive and receptive aphasia.

4. 
   Pack year
   
   : unit for measuring the smoking history of a person as to be used in risk factor estimation.

1 pack year= 20 cigarettes per day.

Formula:


No. of pack year =

5. 
   Equivocal plantar response
   
   : normal and consistent plantar reflex of both legs. Plantar reflex is a reflex elicited

when the sole of the foot is stimulated with a blunt instrument. The toes flex as a

result. This is to disregard the Babinski sign (the toes extend and fans out), which

indicating the presence of spinal cord injury.

1. 
   
   Describe the blood supply of the brain.
   
   

The brain constitutes just about 2% of the body weight but demands 20% of the available oxygen and 15% of the cardiac output

[3]
. Blood is supplied to the brain via two sets of branches from the dorsal aorta, which forms the

anterior

and

posterior circulations

. The anterior circulation supplies the forebrain and the deep structures such as the basal ganglia, thalamus, and internal capsule entering through the carotid canal and foramen lacerum by making a stepwise turn; whereas the posterior circulation supplies the structures of the posterior fossa (posterior cortex, midbrain, cerebellum and brainstem) entering the skull cavity through the foramen magnum.

The anterior circulation carries 80% of the blood supply of the brain. Once entering the brain, the

internal carotid artery

(

ICA

) passes through the cavernous sinus and branches off as the

middle cerebral artery

(

MCA

) and

anterior cerebral artery

(

ACA

). The two anterior cerebral arteries are anastomosed by the

anterior communicating artery

. The remaining 20 % of the arterial supply of the brain derived from the posterior circulation comprises the

vertebral

,

basilar

and

posterior cerebral arteries

(

PCAs

).

The two circulations are united at the base of the midbrain around the optic chiasm by a network of arteries called the Circle of Willis

(Fig. 2).

Looking at the anterior circulation of the Circle of Willis, which arises from the ICA, the

ophthalmic artery

can be observed. It supplies the orbit, the eye muscles and the retina, and eventually connects to the external carotid arteries.

The MCA is the largest and thus the most important branch of the ICA due to its clinical relevance as the common site of stroke. It receives 80% of the carotid blood flow and its proximal part gives off deep branches- lateral and medial striate arteries supply corpus striatum and the internal capsule regions of the brain. Occlusion of these deep arteries is the chief cause of classic stroke, and the most common location is the putamen and internal capsule.

The disability experienced by the stroke patient depends on the area of brain tissues damaged due to cerebrovascular accident in one particular or more blood supply of the brain. Figure 4 illustrated the functional areas supplied by individual cerebral vasculature.

Figure 5, on the other hand gives a few examples of possible symptoms caused by damage from strokes in different areas. In the interest of this PBL scenario, damage in Broca’s area lead to expressive aphasia; damage in Wernicke’s area provokes receptive aphasia; damage in both respective area will then prompt to global aphasia.

Having compared the homunculus of the somatosensory and motor cortex as shown above (Fig. 6) to the functional area supplied by cerebral arteries (Fig. 4), the legs to the hips is on the medial surface of the cerebral cortex that is supplied by the ACA. Therefore, even though, the MCA is occluded in this scenario, there is not complete paralysis in the legs.

2. 
   
   Explore the epidemiology of strokes.
   
   

Stroke occurs approximately 152,000 times a year in the UK in which men are at a 25% higher risk of having a stroke and at a younger age compared to women.

[4]

It is defined as the temporary or permanent loss of function of brain tissues caused by interruption of the vascular supply. It is subdivided into:

• 
  Haemorrhagic stroke
  
  : Aneurism of blood vessels in the brain that burst.
• 
  Ischemic stroke
  
  : Blood vessels in the brain are either clog by local atherosclerosis or thromboembolism.
• 
  Transient ischemic attack (TIA)
  
  : Same pathophysiology as ischemic stroke, but occurrence last less than 24 hours. Therefore, it is always a retrospective diagnosis.

Risk factors

of stroke can be classified into:

Modifiable risk factors	Non-modifiable risk factors
Smoking	Age > 75
Diabetes	Men
Being overweight/obese	Family history
Alcohol Use	Genetic predisposition

Direct or indirect causes:

Ischemic stroke

– Atheroscelerosis, hypertension, atrial fibrillation, valve disorder, sickle cells, thrombocytosis

Haemorrhagic stroke

– Aneurysm, head trauma, arteriovenous malformation, chronic hypertension, drug

3. 
   
   Explain the basic principle of CT with and without contrast in this PBL scenario.
   
   

Ideally, when stroke is suspected, a brain CT scan is arranged immediately to differentiate the type of stroke: Haemorrhagic or ischemic stroke, which determine the treatment option that are significantly different.

In practice,

non-contrast CT

is usually

not sensitive

in diagnosing ischaemic stroke or cerebral infarction in an emergency situation but is a quick method to identify acute haemorrhage in the brain, as a pool of blood will show up in white and disqualify the use of thrombolytic or clot-buster. As the time passes (first 24 hours) loss of grey-white differentiation would be shown on the CT that could suggest signs of infarction.

[5]

[6]
This is the why the patient in this case did not present any sign of stroke at 7:05am on the head CT.

To better diagnosing ischaemic stroke, recent advances in CT technology, be it the contrast CT called CT angiography provide additional data to visualise the cerebral vasculature shortly after an intravenous contrast bolus.

If an ischaemic stroke is diagnosed as in the case of this PBL, and it has been less than four and a half hours since symptoms started, Alteplase will be given intravenously, while haemorrhagic stroke can be managed with surgical repair.

[7]

4. 
   
   Consider the treatment and prognosis of the patient.
   
   

Treatment for ischaemic stroke

(1)

Immediate Care

• Thrombolytic (within golden 3-4.5 hours): Tissues plasminogen activator (tPA); Alteplase; Urokinase
• Intravenous fibrinolytic therapy
• Surgery: carotid endoterectomy/ angioplasty
• Ultrasound-enhanced thrombolysis
• Aspirin

(2)

Rehabilitation

Life after stroke can be very difficult and challenging. Rehabilitation is necessary to improve quality of life and the eventual outcome, if not full function of the body.

• Speech & language therapy helps people who have problems producing or understanding speech.
• Physiotherapy helps with relearning movement and co-ordination of muscles.
• Psychological care helps with common mental health problems such as depression.
• Occupational therapy helps with assessing patients’ home and improving their abilities to carry out daily activities such as dressing and eating.

(3)

Secondary Prevention

3 in 10 stroke survivors will suffer another stroke or TIA.

[8]
That is why secondary prevention is much importance. Seeing the fact that the patient as illustrated in this case has atrial fibrillation and is on warfarin but still encountered a stroke attack, a close monitor of warfarin INR should be done afterwards and possible increase in doses or change of medication. Healthy lifestyle that covers the diet and exercise should be recommended and implemented.

Prognosis

How well a patient does after acute ischaemic stroke depend on numerous factors, such as the area of brain tissues is damaged, the affected body function, and the time of appropriate treatment is received.

Generally, patient often improves in moving, talking and thinking in the weeks to months after a stroke and undergoes rehabilitation. However, they do suffer some sort of morbidity. Only roughly 30% of patients are neurologically normal or near normal. Fortunately, about 50% of patients are completely or almost completely independent in daily living.

[9]

(1855 words)

References

1. Adams HP Jr, et al. Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association.
   
   Stroke
   
   1994; 25: 1901-1914.
2. Brierley JB. Experimental hypoxic brain damage.
   
   Journal of Clinical Pathology
   
   1977s3-11: 181-187.
3. Bryan RN, et al. Diagnosis of acute cerebral infarction: Comparison of CT and MR imaging.
   
   AJNR Am J Neuroradiol
   
   1991; 12: 611-620.
4. Clarke DD, Sokoloff L. Regulation of Cerebral Metabolic Rate.
   
   Basic Neurochemistry: Molecular, Cellular and Medical Aspects
   
   , 6
   
   ^th
   
   edition. Philadelphia: Lippincott-Raven; 1999.
5. Lee JM, Grabb MC, Zipfel GJ, Choi DW. Brain tissue responses to ischemia.
   
   J Clin Invest
   
   . 2000;106(6):723-731.
6. MedlinePlus.
   
   Aphasia
   
   . Available at:
   
   http://www.nlm.nih.gov/medlineplus/aphasia.html
   
   . [Accessed 24
   
   ^th
   
   March 2015].
7. Michael-Titus A, Revest P, Shortland P. STROKE AND HEAD INJURY.
   
   The Nervous System
   
   , 2
   
   ^nd
   
   edition: Elsevier Limited; 2010. pp. 200-209.
8. NICE.
   
   Alteplase for treating acute ischaemic stroke (review of technology appraisal guidance 122)
   
   . Available at: http://www. nice.org.uk/guidance/ta264/chapter/1-guidance. [Accessed 11 April 2015].
9. Rull G.
   
   Thrombolytic Treatment of Acute Ischaemic Stroke
   
   . Available at
   
   http://www.patient.co.uk/doctor/thrombolytic-treatment-of-acute-ischaemic-stroke
   
   . [Accessed 11 April 2015].
10. Stoke Association.
    
    State of the Nation Stroke Statistics-January 2015
    
    . Available at:
    
    http://www.stroke.org.uk/resource-sheet/state-nation-stroke-statistics
    
    . [Accessed 11 April 2015].
11. Townsend N, et al.
    
    Coronary heart disease statistics 2012 edition
    
    . British Heart Foundation: London
12. Xavier AR, et al. Neuroimaging of Stroke: A Review.
    
    South Med J
    
    . 2003;96(4). Available at:
    
    http://www.medscape.com/viewarticle/452843_2
    
    . [Accessed 11 April 2015]

Images

Figure 1:

http://www.mayfieldclinic.com/Images/PE-AneurUnruptured_Figure1.jpg

Figure 2:

http://upload.wikimedia.org/wikipedia/commons/thumb/2/2e/Circle_of_Willis_en.svg/1000px-Circle_of_Willis_en.svg.png

Figure 3:

http://www.meddean.luc.edu/lumen/MedEd/neuro/neurovasc/ImageFiles/mca.jpg

Figure 4:

http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case3/Case3Images/CerArtDistBlum1.jpg

Figure 5:

http://www.patient.co.uk/health/stroke-leaflet

Figure 6:

http://harmonicresolution.com/homunculus1.jpeg

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Introduction

The purpose of the Bridge Project under the National Heart Failure training Program (NHeFT) (It Takes a Community: Creating a Bridge to Improved Healthcare Outcomes for Heart Failure) is to stimulate quality improvement for patients with heart failure, including quality of life, and to disseminate this model to various care settings through collaborative efforts. Our short term plan is to reduce the 30 day readmission rate at your institution. Our long term plan is to facilitate the development of interdisciplinary disease management programs along the continuum of care which will improve the health of older adults with heart failure and empower the staff that cares for them with education tailored to each care setting.

We believe that the devastating downward trend of heart failure can be reversed through collaboration and education. By improving care in individual settings and working together to create standards of care and improve communication, we believe we can reverse the downward spiral. Before implementing an improvement plan, it is critical that a process map be constructed to target the areas where the rate limiting step/s exist that are affecting the desired outcome. In addition, these rate limiting steps may be the very ones that need intervention in the plan, do, see, and act cycle of quality improvement.

Although some of these questions pertain to the hospital setting, it is nonetheless important to understand the “patient’s journey” from hospitalizations to home or skilled nursing facility to home and finally to your group. The seamless transition is one of the keys to success in caring for this population. Therefore, although this program is intended to set up a heart failure program within your outpatient cardiology group, obtaining hospital information is important. The hospital would be wherever your population of patients is being admitted. It may be not just one hospital but 2 or 3. Much of this information can be obtained from public websites. Once you have identified those for us, we will obtain as much data as we can. Coupled to your answers, we will process map your system/s.

This survey aims to identify efforts that have been or are currently being implemented and to assess the needs of each hospital/practice system who do or do not have a structured heart failure program to assist in developing and implementing the heart failure disease management plan. Admissions process:

What information do you get for patients admitted to the hospital in a non-heart failure service when they are discharged? How do you know that you will be seeing these patients?

Who has access to the information concerning patients that you will be responsible for?

How are patients admitted (i.e. by phone, in person, by paperwork) to the hospitals where you practice?

What is the process and structure of admissions?

Who admits patients, i.e., where do the patients come from? Consider PCP, Cardiologists, nurses, ED or transfers.

Cardiologists that participate in this program will:

Use optimal medical therapy processes to keep patients out of the hospital, thereby improving morbidity.

Medication uptitration to goal levels as Guideline, evidenced-based care.

Actively participate and support the multi-disciplinary team in the care of the heart failure patients.

To use a hospitalization to actively uptitrate medical therapy beyond simply diuretic treatment.

Support actively the patient educational efforts of the heart failure team members directly to the patient

Reinforce the educational objectives of the total health care team including sodium dietary restriction, fluid restriction when necessary, increased activity and medication compliance.

Consideration and discussion of ICD implantation when, in spite of 3 months of optimal medical therapy including optimally titrated doses of beta blockade, the patient’s ventricular function has not improved >35%.

Consideration of biV pacing if patient remains symptomatic in spite of optimal medical therapy and has a wide QRS.

To support the outpatient performance measures in the entirety of the practice and team effort.

Protocol:

A managed care program dedicated for heart failure patients to improve symptoms, functional capacity, and reduce hospitalizations. A second objective of the program is to practice using Guideline evidenced-based care with a combination of optimal medical therapy, patient education, close followup and pro-active interventional care to keep patients at home. Protocols will be individualized according to patient diagnosis and prognosis.

Inclusion Criteria:

Patients with a diagnosis of heart failure (ICD code 402, 404 and 428) who have been admitted to the hospital for decompensated heart failure in the past year.

Patients with frequent admissions for decompensated heart failure

Patients with the diagnosis of heart failure who have been requiring escalating doses of diuretics.

Patients with heart failure who have not been tolerating uptitration of evidenced-based care, e.g., ACE inhibitors or beta blockers

Patients with heart failure who have had compliance issues with diet or medication

Exclusion criteria

Patients with end-stage renal disease and dialysis

Patients with a history of drug abuse as an etiology of heart failure

Patients with stable heart failure who have never been hospitalized, NYHA Class I and II.