Seven minutes in stroke - Dr A Antonio Arauz

Dr A Antonio Aruz

Stroke Clinic

Instituto Nacional de Neurologia y Neurocirugía Manuel Velasco Suárez

Mexico City

1. What inspired you towards neuroscience?

Honestly, my first option was cardiology, but I was accepted into a great Mexican Neuroscience Institution (Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez) and there I began to deepen in Neurosciences. It has been a great adventure. The challenge of neurological diagnosis, the exact location of brain lesions, based on clinical findings. The breakthrough in diagnostic and treatment methods are fascinating. 

2. Why stroke?

Stroke is one of the leading causes of death in Mexico, but mainly it is the leading cause of disability. In the 80s the study of patients with stroke was completely different, but it was a major clinical diagnostic challenge. That’s why I decided cerebrovascular field.  I’am lucky to have witnessed the great changes in the diagnosis and treatment of stroke. At the beginning (20 years ago) that I began the study of cerebral vascular diseases, there was little that could be done in the acute treatment of ischemic stroke. Things are now, totally different. 

3. What have been the highs so far?

To be able to work in a multidisciplinary team, including neurosurgeons, interventionists and rehabilitation specialists, and with colleagues from other countries, in multinational groups, but mainly participate in the training of medical doctors, neurologists, and stroke neurologists.

I still feel excited that our manuscripts are accepted and see them published. And of course, seeing the recovery of a patient after stroke is always a great achievement. 

4. What have been the lows?

It has always been frustrating to have nothing to offer to our patients and this is frequent in many cases. Although there are great advances in acute ischemic stroke, there is little we can do in intracerebral hemorrhages, in some vascular malformations, etc. 

Driving change in the national/local stroke care system it is often frustrating. The public policies in my country are almost impossible to modify and try to have an acute stroke treatment system, is still a pending issue in Mexico. 

5. How do you balance work life with the needs of home life?

It is always a challenge. In my case, it has been changing over time, with the different stages of growth of my sons. However, family is always the priority. Thankfully my wife Alma, and my son’s Eduardo and Fernando have been very supportive.

6. Who are your most important mentors and how did you find them?

I am very grateful to Fernando Barinagarrementeria for introducing me to the field of vascular Neurology. Over the time Fernando has been not only an academic mentor. He has been a friend and I have had the privilege of sharing with him many projects, meetings, trips, as well as discussions about stroke, politics and life itself.

During my time as a Neurology resident, in addition to Fernando, there were some other professors who undoubtedly influenced my training. 

7. What are your most important collaborations and how have you built them?

I am also fortunate to have been able to have very important collaborations. For example with Peter Sandercook and the IST3 group, or in the SPS3 project with Oscar Benavente and Bob Hart. 

Other important collaborations have arisen from my interest in arterial dissections and cerebral venous thrombosis in our population, which has allowed us to participate in collaborative work groups. 

More recently in the ESUS working group and NAVIGATE ESUS trial. Although this was a negative trial, it has generated many manuscripts published in high impact journals. A good example is the sub-analysis of the regional, sex and age differences in Diagnostic testing published in International Journal of Stroke. 

These collaborations have been built by the publication on specific topics, by reference of other colleagues or by previous collaborations. 

Seven Minutes in Stroke - Benjamn T. King

Dr Benjamin King from  the Department of Neurology, Dell Medical School and the University of Texas submitting author of the manuscript 'Optimal Delay Time to Initiate Anticoagulation after Ischemic Stroke in Atrial Fibrillation (START): methodology of a pragmatic, response-adaptive, prospective randomized clinical trial.' published in the International Journal of Stroke. 

1.      What inspired you towards neuroscience?

Unsurprisingly, I came to the field of neuro-epidemiology in a roundabout way, but the neurosciences were always a focus. My undergraduate program at Bard College provided the opportunity to partner with a team building a zebrafish neuroscience lab from the ground up. I was thrilled by my time studying the mechanism of addiction in this model, but I was also determined to move on to human subjects research. From there I went to work at inpatient psychiatric care facilities for a while, but never left the mind/brain question behind.

2. Why stroke?
As we all know, stroke results in a massive amount of disability and death. Public health training recognizes the benefits of addressing the largest drivers of disease burden such as this. Moving the needle even slightly in the prevention, care, or recovery from stroke can lead to inflated population health benefits. I was developing and managing research in emergency medicine when our first acute ischemic stroke trial came along.  It didn’t take long before that became our focus.

I'm lucky to really love the work I do

3.      What have been the highs so far?

I’m lucky to really love the work I do. There is something special that happens when a completely new research question gets introduced – usually when one of my clinician partners kicks down my door out of the blue – and we get to start solving a design question from scratch. There is also a great feeling when you get to see the work you do as an epidemiologist lead to changes in service delivery.  Add to that any and every time I get to take a crack at a clean dataset …and there are too many highs to count.

4. What have been the lows?
Peer-reviewed rejections of grant proposals never seem to get easier.  I’m proud of our wins, but I’m still learning to shake off the losses.

5. How do you balance work life with the needs of home life?
My wife and I both work long hours. She has a background in social work, from before her law career, and does a good job of reminding both of us about the importance of self-care. Setting aside time for ourselves is key. It requires hard work at both ends of the spectrum.

6. Who are your most important mentors and how did you find them?
Dr. Truman Milling hired me to build the Emergency Medicine research program in Austin and we have been working and writing together ever since. It is a truly rare thing to find a clinician with his gift for writing and the technical aspects of research design. When Dr. Steven Warach relocated to Austin from his position as the head of intramural research at NINDS our team leapt at the chance to manage his research program. I have been benefiting from his leadership ever since.  His perspective and insights have literally helped to shape the modern era of vascular neurology practice.

Finally, my epidemiologic training was mentored by some of the greatest methodologists in both epidemiology and biostatistics. My doctoral advisor, Dr. Steven Kelder, has shown me over and over that the field of epidemiology can be used to enact real, systemic changes by studying and testing solutions to complex problems. I first met Dr. Kelder during the master’s program, when I walked into his office unannounced and asked for a job… over a decade before asking him to be my advisor.

7. What are your most important collaborations and how have you built them?

As an epidemiologist I get to work in and around a lot of different specialties. One of my favorite endeavors is the collaboration built to connect our work in the tertiary care setting with housing and homelessness service agencies in our local community. In fact, my dissertation was a deep dive into the psychometric and validation testing of a popular vulnerability score measure used for housing resource prioritization. Honorable mentions go to our collaborators in the Lone Star Stroke Consortium, my partners in the Dell Medical School’s Department of Population Health and the Division of Psychology.

Seven Minutes in Stroke - Dr James Siegler

Dr James Siegler is the submitting author for the paper ‘CT perfusion in stroke mimics’ to the International Journal of Stroke which has been published online and allocated to the April edition of the journal for 2020. 

We asked Dr Siegler to tell us a little bit about himself in our Seven Minutes in Stroke professional series.

1. What inspired you towards neuroscience?

In high school, I was drawn to biology. At the time, my whole family began to seriously address the dementia symptoms of my great grandmother (who lived to be 106!), and I had wondered why this was. How could such a presumably healthy and active woman spend the remaining few years of her life in a memory fog? In college, my interest in neuroscience solidified as my questions were answered--and yet, even more questions emerged. So began my lifelong quest to understand the brain and the mind.

2. Why stroke?

In medical school, the most accomplished and supportive neurology mentor I could find was a stroke specialist. Dr. Sheryl Martin-Schild who was a recent addition to the Tulane faculty and soon after her appointment as the Stroke Director she led the team to swift approval as a Comprehensive Stroke Center. I initially found stroke interesting on a research level (only later came to enjoy it clinically). At the time, we were exploring the effects of combination antiplatelet therapy for secondary stroke prevention, extending the window for intravenous thrombolysis, and investigating unique tools for endovascular thrombectomy. It would be an understatement to say that stroke was witnessing a revolution in diagnosis and treatment.

3. What have been the highs so far?

Since my initial foray into stroke, as everyone knows, we are closing PFOs, expanding our knowledge of how to manage strokes due to unknown mechanisms, optimizing antiplatelet therapy for secondary stroke prevention, and we can now safely and effectively treat large vessel occlusions up to 24 hours after onset. With the exception of development of the head CT or the testing of alteplase, I can't think of any better "highs" in stroke research or clinical practice.

As far as my personal highs, I have been honored to participate in a number of these pivotal stroke trials (POINT, DEFUSE-3, NAVIGATE-ESUS, ARCADIA) and collaborate with some of these investigators in my own research. Learning from them has been instrumental to my career as a junior researcher.

4. What have been the lows?

Nothing out of the ordinary to say here; difficulties with a rigorous internship, challenges inherent to inflexible mentors. However, some of these are vital to our personal growth and they are informative of our roles as medical educators and leaders.

5. How do you balance work life with the needs of home life?

My wife and I have been fortunate enough to have recently given birth to our first daughter, Sofia, on June 29. My wife, Erika, has been BEYOND phenomenal in caring for our baby girl, and has always supported my academic interests. As a junior clinician, I can't say I've figured it out just yet. But from my early days as a Hopkins undergraduate, where I double majored in neuroscience and history of medicine, worked every semester in some sort of research lab, and still made time to find employment to pay for my room and board, I was forced into a life of efficiency and pragmatism. Taking these things with me through medical school and residency, and building on them, has helped me balance home life with work requirements and academic productivity.

‘If there is ever a choice to be made between life and work, 9 times out of 10 I will choose life.’

6. Who are your most important mentors and how did you find them?

Without a doubt the most instrumental mentor in my early career was Dr. Sheryl Martin-Schild. She took me on as a research assistant as a first-year medical student, where I worked with 3 other medical students developing a local stroke registry at Tulane University School of Medicine. Four years later, our team had grown to nearly 30 students and neurology residents, and we had published more than 20 original research papers. 

I have to admit that none of my grades or test scores have ever attracted anyone's attention. I've always considered myself a hard worker, but somehow I could never get past some sort of ceiling created by multiple choice tests. Clinical research provided me with an opportunity to cultivate new skills, and I am so grateful for every mentor who has helped me along the way. No doubt because of our productivity at Tulane, I was able to match at the Hospital of the University of Pennsylvania and collaborate with internationally renown stroke researchers like Scott Kasner, Steve Messe, and Brett Cucchiara, as well as junior faculty Mike Mullen and Chris Favilla. Not to mention the unparalleled research support team of our stroke division!

7. What are your most important collaborations and how have you built them?

While I have been lucky to collaborate with many clinicians, scientists, statisticians, and other researchers, I believe my most important contribution to neurology and my most important collaborations have involved online medical education. As a senior neurology resident at the Hospital of the University of Pennsylvania, and an avid cyclist (spending hours and hours on my bike listening to a variety of music and podcasts) I thought it would be more useful to spend that time listening to clinical content. The state of podcasting in neurology back in 2015 was far less developed than podcasting in other medical disciplines (e.g., emergency medicine and internal medicine). I wanted to create something better.

So I recruited some amazing teachers and friends in neurology to help me produce my own neurology podcast, BrainWaves. Michael Rubenstein, Ali Hamedani, and my wife Erika Mejia, have all been HUGE collaborators and supporters in this regard. Without their help, we would not have been able to produce more than 170 episodes of this podcast with more than 300,000+ downloads. By the summer of 2019, we have collaborated with more than 70 unique clinicians and scientists across the US and internationally to generate this impressive body of work that targets trainees in neurology and medicine.

How have I built these collaborations? I ask nicely. :-) A carrot works better than a stick. It also helps to say "Your episode will be listened to by more than 2,000 people." For better or worse, I find this far more impactful than the majority of my research publications...

Dr Inna Lutsenko World Conference on Research Integrity 2019 at Hong Kong University

Report from the ‘Brain diseases - from bench to bedside’ conference, Moscow April 12-13, 2018.

The meeting, organized by Professors Eugene Gusev and Alla Guekht, focused on the recent developments in translational research and treatment innovations in cerebrovascular diseases, epilepsy, cognitive impairment and dementia, depression, demyelinating diseases and others. It was held at the Buyanov City Clinical hospital, and was organised in partnership with the following institutions: Ministry of Health of The Russian Federation, Russian Academy of Sciences, Moscow Healthcare Department, Pirogov Russian National Research Medical University, World Stroke Organization, European Stroke  Organization, World Federation of Neurology, International League Against Epilepsy, European Federation of Neurorehabilitation, All-Russian Society of Neurologists, Moscow Research and Clinical Center for Neuropsychiatry. 

The Conference Faculty had a high-level meeting with Professor V. Skvortsova, Minister of Health for the Russian Federation, to discuss the management of stroke and brain disorders and highlight the priority this should be given both internationally and within the Russian Federation.  An action plan on collaborative strategy in brain diseases has been discussed.

The conference proved very popular and over 700 delegates from 42 cities of the Russian Federation attended with additional registrants from Belarus, Georgia, Kazakhstan, Tajikistan, Ukraine and Uzbekistan. The conference attracted a high level of media coverage and both Professors P. Sandercock & V. Caso gave video interviews for local media organisations. 

The stroke session began with an update on ‘Controversies in thrombolysis’ by P.Sandercock, who highlighted the importance of not withholding thrombolysis to patients with ischaemic stroke purely on the basis of age over 80.  V. Caso gave a powerful talk on ‘Life after stroke in women’. She highlighted the particularities of stroke management during pregnancy and demonstrated how gender inequality results in adverse effects in women’s healthcare in general and in stroke outcome in particular. M. Hilz gave a detailed overview of autonomic dysfunction in diseases requiring neurological intensive medicine. V. Parfenov covered management of patients after stroke, highlighting the value of lifestyle changes (quitting smoking, increasing physical activity and fresh fruit and vegetable consumption) and antithrombotic therapy with aspirin after ischaemic events. I. Koltunov, N.Pechatnikova and V. Kakaulina presented their work on Cerebrovascular diseases associated with genetic metabolic disorders and demonstrated the program of genetic screening for rare diseases, supported by the Moscow government. A. Pryamikov, A.Mironkov and O. Sazhina, doctors from the Regional Stroke Center in the host hospital, closed the session with an interesting talk on their experience on carotid endarterectomy and internal carotid artery stenting in acute stroke. 

The clinical stroke-focused session was followed by a translational science session, which covered a broader range of topics.  I. Blumke reported work from The European Epilepsy Brain Bank Consortium: 25 years of interdisciplinary experience with epilepsy surgery in 9579 children and adults, L. Østergaard presented novel data on the role of capillary pathways in stroke and cognitive decline, N. Gulyaeva highlighted how distant hippocampal damage in brain disorders may be related to corticoid-mediated mechanisms. A. Shpak spoke on neurotrophic factors in neuro-ophthalmology, showing their important role in glaucoma as the model of neurodegenerative diseases.  D. Muresanu gave a talk titled ‘From neurobiology to evidence based medicine: concepts in neurorehabilitation after stroke’.  

The session on cognitive and affective disorders was opened by the lecture by M.Feedman focusing on the diagnostic and treatment challenges of frontotemporal dementia. R. Akzhigitov and co-authors gave an overview on depression in neurological diseases, presenting the huge experience of the Moscow Research and Clinical Center for Neuropsychiatry with the very effective programs of multidisciplinary management of depressions and cognitive impairment, including post-stroke.

The session on the following day was dedicated to epilepsy. V.Krylov and I.Trifonov presented the results of the epilepsy surgery program, which is successfully developing in Moscow and other cities of the Russian Federation. S. Wiebe gave a thorough overview of the outcomes of epilepsy surgery. He emphasized that the novel way of conceptualizing surgical outcomes highlights the importance of longitudinal data. N.Specchio described special issues of epilepsy surgery in children. A.Hauser demonstrate how TBI and post-traumatic epilepsy represent a substantial societal burden. He reviewed the major risk factors and stated that studying the predictors of epilepsy after TBI should become one of the priorities. The successes and challenges in the implementation of the 68th WHA resolution on epilepsy have been presented by E.Gusev and A.Guekht. They demonstrated that epilepsy is comorbid to stroke and other major noncommunicable diseases, dramatically increasing their severity and mortality. The last session was opened by E.Beghi with the talk describing the mechanisms and predictors of falls in neurological diseases, including stroke, Parkinson’s disease, multiple sclerosis and others. He stressed that stroke can be the cause of balance disorders due to impaired ability to produce fast, accurate and coordinated muscular patterns. Several interesting talks were presented by Russian colleagues on multiple sclerosis, including the burden of multiple sclerosis (V. Mkrtchyan, N. Pavlov) and therapeutic approaches (N. Khachanova and N. Arzymanian). The novel techniques and experience of neurostimulation in gait disorders in multiple sclerosis patients were presented by the neurosurgery team of the Buyanov City Clinical hospital (S.Asratyan). The significant part of the session was dedicated to management of ALS, presented by members of the Russian and foreign faculty. 

The interactive video session concluded the conference with presentation of interesting cases in different aspects of neurology and with a lot of discussion.

On the next day, the international faculty and the leading Russian specialists on brain diseases visited the Moscow Research and Clinical Centre for Neuropsychiatry of the Healthcare Department of Moscow, one of the leading institutions for management of patients with post-stroke cognitive impairment, depression and anxiety, suicidal ideations, epilepsy and other brain diseases. It was the second meeting of the international scientific advisory board of the Research and Clinical Centre, formed in October 2017 during the World Stroke Day Congress in Moscow. 

The meeting started with an overview of the >100 year history of the center, presented by its director A. Guekht. The scientific achievements, patient management and educational activity of the center, as well as the state of the art facilities for diagnostics and research were quite impressive. 

Professor N. Gulyaeva (Institute of Higher Nervous Activity, RAS) presented the results of studies in translational neuroscience. Then, completed and ongoing research projects in post-stroke cognitive impairment, epilepsy, depression and suicide, and autonomic disorders were presented by the specialists of the Center and of collaborative institutions (Pirogov Russian National Research Medical University, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Serbsky State Scientific Center for Social and Forensic Psychiatry, Institute of Higher Nervous Activity and Neurophysiology of RAS, N.V.Sklifosovsky Research Institute of Emergency Medicine and Buyanov City Clinical Hospital). The projects were extensively discussed by the faculty, and plans for international publications and new projects had been developed. The true highlights of the meeting was a series of seminars in stroke and other brain diseases led by the eminent members of the international faculty. These seminars were of high educational value for the doctors and researchers from Moscow clinics.

The conference closed with warm thanks from the organising committee to the supporting organisations, the conference faculty and conference participants for their efforts in improving the outcomes for people with stroke and brain disorders. The conference strengthens the international collaborative efforts to tackle these disorders, which place such a burden on patients, society and health systems.

Peter Sandercock

LATEST PODCAST The Brain Health Index: Towards a combined measure of neurovascular and neurodegenerative structural brain injury with David Dickie

The Brain Health Index: Towards a combined measure of neurovascular and neurodegenerative structural brain injury with David Dickie

Report on Tianfu Stroke Research Methodology Training Workshop, Chengdu, China 25th May 2018

The Tianfu Stroke Research Methodology Training Workshops held in Chengdu, China on the 25^thMay 2018was organised by Professors Ming Liu and Shihong Zhang and their team from the West China Hospital Chengdu.  

It took place the day before the Tianfu Stroke Conference and attracted over 100 clinicians (all in the early stage of their research careers) who were interested in clinical stroke research. The WSO Faculty members were Professor Ming Liu, Professor Craig Anderson, and the other Faculty were Dr Fergus Doubal, Professor Shihong Zhang, and Jie Yang.  

The focus of the workshop was on epidemiological and clinical (bedside) research and the topics were: 

• First steps in research: what training do you need
• Raising a good research question, and choosing the correct research design
• A checklist for setting up your research study
• Cluster RCT/RCT based on stroke registry
• Introduction of common scales in clinical research of stroke
• Imaging of cerebral small vessel diseases
• Techniques of cerebral perfusion imaging in assessing collateral circulation
• Introduction of imaging technology in study white matter diseases
• How to write a scientific paper and get it published
• How to critique a scientific paper: perspective from reviewers
• How to write a funding application.

The workshop involved interactive tasks and there was very active discussion of each topic, with Faculty members being asked supplementary questions during the breaks.   Feedback on the course was very positive.

The faculty L to R, Prof Wu Bo, Prof Wei Manlin, Prof Zhang Shihong, Prof Peter Sandercock, Prof Liu Ming, Prof Craig Anderson.

Professor Peter Sandercock attended the workshop as faculty, he is the Chair of the World Stroke Organisation, Education committee. 

YSP career tips for success 10. Knowing when to say no

We continue our theme of balance and finding space for family, friendships and leisure time. Professor Bruce Campbell from the Department of Medicine  of the Royal Melbourne Hospital, in Melbourne, Australia. We know one very well known Professor who informs on their out of office that all emails sent during their out of office time will be deleted and emails of importance will need to be sent again after a certain time. If you are in a senior position, this could definitely be a consideration!

YSP career tips for success 9. Balance, Organizational skills/balancing family and work

Associate Professor Coralie English, who works in physiotherapy at the University of Newcastle  knows what it's like to balance a successful work life and a busy little family.  Assoc. Professor English explores this important point in career management, and as we come in to the Northern hemisphere summer this is an incredibly timely tip! 

YSP career tips for success 8. meeting potential Collaborators

As we all know, face to face contact can be incredibly helpful, and is a quick way to integrate into a global scientific career! Dr. Shoichiro Sato Consultant Stroke Neurologist, Chief of Cerebrovascular Clinic at the National Cerebral and Cardiovascular Center, Osaka, Japan talks about meeting with potential collaborators. You can use these tips below at the coming ESOC next week in Sweden! If your anywhere near the World Stroke Organization blog, do drop by and say hello!

8. Meeting potential collaborators

Collaborations with other researchers can make your research excellent. You can attend events in your institution or join domestic/international conferences, not only to watch or make presentations, but also to network with potential collaborators.  

YSP career tips for success 7. Collaborating and networking, starting collaborative studies

In this weeks iteration of the Young Stroke Professionals top 10 career tips for success, Nils Henninger, Associate Professor of Neurology and Psychiatry, University of Massachusetts Medical School, explores collaborations, one of the key strategies for development in any career!  

YSP career tips for success 6. Applying to grants and publishing

Grants season can be a really difficult career point to navigate, especially as this repetitive and time consuming process can often have disheartening results. In this weeks Young Stroke Professional career tips we look at applying for grants and publishing papers, this time with Rufus Olusola Akinyemi who is the Senior Research Fellow at the Neuroscience and Ageing Research Unit, at the 

Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan,  and is a Consultant Neurologist at the Department of Medicine, University College Hospital, Ibadan, Nigeria.

YSP Career tips for success 5. Academic protection and institutional commitment -

Continuing with our Young Stroke Professional series we have tip 5, a short but important insight for those embarking on a career in stroke research delivered by Professor Bo Wu, Professor of neurology at the West China hospital, Sichuan University on

The early days:

5. Academic protection and institutional commitment 

Academic protection is essential to the mission of the academy as well as the principles of academia, researchers should have freedom and right to choose the research field and communicate these ideas with others. 

Announcing our World Stroke Day Campaign Stars

World Stroke Award Winners 2017

The World Stroke Organization is proud to announce the winners of our World Stroke Awards. World Stroke Award winners are selected based on their impact, innovation and alignment with the World Stroke Day campaign theme. World Stroke Day 2017 was focused on stroke prevention, with messaging that aimed to raise public awareness of key risks and the steps we can all take to prevent stroke.

The ‘What’s your reason?’ campaign was the most successful yet, with 218 activities registered in 62 countries. The Campaign Committee received 35 Award submissions which were reviewed against criteria for High Income, Low to Middle Income and Individual Achievement. Here are the winners in each category:

YSP career tips for success 4. The science part II

It’s week four of our YSP career tips for success series and we are now looking at projects, and which ones we should do , this time with Atte Meretoja from Helsinki University Hospital, Helsinki, Finland.

4. What projects should you do?

Choosing your first research project is not the most critical decision you make, but choosing the next few will be. Successful researchers always have multiple projects going on simultaneously. Many, if not most projects will fail, some will became moderate successes, and some will make your career. As there is no certain way of telling which project will go bust, you need to throughout your career 1) diversify the risk, 2) consider cost-effectiveness, and 3) seek mutually beneficial collaborations.

Diversifying risk relates to combining high risk and low risk research. High risk projects, typically interventional trials or long-term prospective observational cohorts of rare cases, will take years of full time work to complete, will test a single novel hypothesis which if proven will change clinical practice globally, but if negative will be of little interest to anyone. Low risk projects, typically retrospective observational studies, will collect over a few months or a year a dataset of consecutive patients in routine clinical practice and then report numerous hypothesis generating observations of associations in that dataset. Earlier in one’s career, with less opportunity to bear failed projects, it might be wiser to emphasize low risk.

Cost-effectiveness relates to the ratio of time invested per scientific output. Output can be measured with quantity and quality, but in reality measuring the former is easier. Therefore early in one’s career one has to emphasize quantity. Getting a few papers out will prove that you can write and publish, which will then get you a little funding to buy you time to do a few more projects, with an aim of getting on to the first solid ground of a few years of secure funding. For this reason, you need to think quick returns initially. Start off with multiple projects that can be completed in a year. Congress abstracts and articles in stroke journals will give you hints on topics others find worthwhile just now, then find your own twist to these.

As quantity is not everything and we need to compete in an increasingly competitive funding environment, it is crucial to include in your first half-a-dozen or dozen papers some that will be clearly novel and original. Systematic literature reviews may be helpful in identifying areas with little or no previous observational work. Over time it might be wise to increase the number of high-risk projects, as these when successful will get you to faculty positions.

The most cost-effective studies are those done in collaboration. Once you have collected a dataset, be that observational or trial data, make sure you reach out to others working in the same field. Most people will be happy to share their data for a chance of publishing a research project together, especially if you will do the analyses and write the first draft. You might find it much easier to publish research that comes from multiple sites due to external validity. Inviting others into your projects will often result in counter-invitations.

In summary, do not put all of your eggs in one basket but rather diversify by taking many projects early on, emphasizing first those with likely quick returns and then making sure you have some with totally novel outputs. In the long run collaboration will be most cost-effective approach.

Atte.Meretoja@hus.fi