Seven Minutes in Stroke - Luciano Sposato

Luciano Sposato

London Health Sciences Centre, London Schulich School of Medicine & Dentistry, Western University, Clinical Neurological Sciences, London, Ontario, Canada

1. What inspired you towards neuroscience?

The brain intrigued me since I was a medical student. With the exception of neurology and cardiology, I actually found medical school quite boring. Because of how medicine was taught in Argentina, I wasn’t able to understand the use of what I was studying.  The only topics that were really straightforward to me were those related to the brain. 

2. Why stroke? 

When I was in my second year of Internal Medicine residency, one of my first teaching assignments was to prepare a stroke lecture for first year residents and students. Since that single day in which I lectured during about 90 very boring minutes, I devoted all my passion to stroke. I will always be grateful to my former Internal Medicine chief resident Dr. Marichu Arriola, who encouraged me do it.

3. What have been the highs so far?

There have been many highs. Perhaps one of the most meaningful ones was moving from Argentina to Canada to practice stroke neurology and to continue pursuing my research career in 2013.  Recently, I had the fascinating experience of delivering a Ted Talk about the Heart and Brain Connection in Argentina (https://www.youtube.com/watch?v=c1iMoel2LxA). It was a totally different experience, in a stadium with 10.000 attendees and other 40.000 people watching the talk through online live streaming.

4. What have been the lows?

Perhaps the lows are related to the difficulties that researchers face in Argentina and other South American countries because of very limited resources. 

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

I have two young children, Augusto (4 years old) and Emma (2 years old), and a wonderful fully supportive wife, Patricia, who is also a neurologist. I try to be at home with my kids as much as possible and so far I think I have managed to be with them a lot more than I suspected before they were born.

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

Real mentorship is a complex matter. My greatest mentor was Prof. Jorge L. Ferreiro in Argentina. He was the Head of Neurology at the Hospital de Clínicas “José de San Martín”, Buenos Aires University, Argentina, where I completed my residencies in Internal Medicine and Neurology. He was the first who believed in my potential as a young physician.

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

Within the last few years I have had the chance and pleasure of collaborating with amazing researchers in the field of cerebrovascular disease and epidemiology. I was able to develop and conduct ReNACer, the Argentinean Stroke Registry, and PrEViSTA, a population-based study of stroke incidence, risk factors, recurrence and mortality in Argentina. We invited recognized experts in the field to join the team. I was also very lucky to be able to work with already existing datasets from very important studies, trials, and cohorts. I am very grateful to many top researchers who have kindly allowed me to work with them and shared their data: Peter Rothwell and Sarah Pendlebury (Oxford Vascular Study); Joanna Wardlaw, Peter Sandercock, Richard Lindley, and Martin Dennis (IST-3 Trial); Bud Kukull and John Trojanovsky (National Alzheimer’s Coordinating Centre), Moira Kapral (Registry of the Canadian Stroke Network and the Institute o Clinical Evaluative Sciences), among others. Vladimir Hachinksi was who initiated the collaborations. 

Seven Minutes in Stroke - Thalia Field

Thalia Field MD FRCPC MHSc

Assistant Professor, Faculty of Medicine, University of British Columbia

Stroke Neurologist, Vancouver Stroke Program

1 - I don’t know if I was so much inspired towards neuroscience as I was running away from geology! I did my undergraduate program in geology because I though mountains were pretty to look at and I could go on field trips instead of sitting in class. I quickly realized that I did not have the appropriate temperament - on fieldwork trips, my classmates were much more interested in filling their backpacks with shiny, interesting (and very heavy!) rocks while I was more interested in eating and drinking anything heavy as quickly as I could, finding the warmest spot possible, and waiting for the day to be over. I applied for summer research jobs to be close to my family in Calgary, and by luck a young Michael Hill was finishing his fellowship and was looking for an Earth Sciences-inclined student to look at weather data to define Chinooks, a warm wind phenomenon that can trigger migraines and, as he wondered, possibly strokes. My alternative gig was searching for meteorites on my own in Northern Alberta (my interviewer took one look at me and said, “we work in all sorts of weather, even the pouring rain…you don’t want to work in the pouring rain, do you?” I didn’t!) and the rest is history.

2 - Stroke seemed to me the diametric opposite of geology - instead of looking at change over millions and billions of years, the Calgary Stroke Program was focusing on that critical moment where one minute you are independent and enjoying your life and the next you are hemiplegic and unable to speak. tPA had recently been introduced and the Calgary Stroke Program had a dynamic group of young, enthusiastic clinician-researchers who were changing clinical practice and making people better. I wanted to be a part of that.

3- The highs are always patients with excellent outcomes and students working with me who achieve successes like grants, abstracts, and manuscripts - the future of stroke depends on training more young talent and I want to continue that tradition.

4 - The lows are having to give bad news to patients and families, and being excessively tired after a week of service - I once tried to brush my teeth with lipstick.

5- It’s tricky- you’ll have to ask my partner and my friends whether I really pull off this balance - but on a weekly basis I work out, try to read one novel and month and get sucked into Podcasts and Netflix - my current favourites, respectively, are “Grownups Read Things they Wrote as Kids” and “Fargo.” And I am committed to taking vacations twice a year- I find the time off allows my brain to work in different ways and actually helps me to consolidate ideas with regards to my research.

6 - I have been incredibly lucky to have the support of a number of key mentors. My most important mentors during my training have been Michael Hill, who inspired me to go into stroke neurology and who I still rely on for honest advice and clarity of thought; Gord Gubitz and Steve Phillips in Halifax, who were models of clinical excellence and patient rapport while I was a medical student; Oscar Benavente, who inspired my interest in clinical research and clinical trials, developed and supported my interest in secondary prevention and lacunar stroke, and never fails to make me laugh; and Eric Smith and Joanna Wardlaw, who have led me to ask new questions about the natural history of cerebral small vessel disease and how we can develop new treatments, and have generously integrated me into the international network of small vessel disease researchers. The stroke community is small, and I’ve found my mentors through the support and generosity of my other mentors.

7 - I’m currently trying to forge connections outside of stroke, as I feel that we might learn valuable lessons and strategies by looking outwards: big data and machine learning may give important tools for risk prediction and selection of optimal patients to enrich future clinical trials; other systemic conditions that advance brain aging may teach us about the mechanisms of cerebral small vessel disease; cardiology remains a model for how stroke can expand research funding and instrastructure. But my most important collaboration is with my partner, Glenn, who ensures that I close my laptop from time to time and tries to keep my feet just a millimetre off the ground. 

CALL FOR APPLICATIONS WSO Young Stroke Professionals Brief Clinical Exchange Scholarship Program

CALL FOR APPLICATIONS

WSO Young Stroke Professionals Brief Clinical Exchange Scholarship Program

Purpose:

To support young stroke professionals from any discipline to spend a 1-2 week observership at an international center of excellence in order to foster best clinical practice benchmarking and collaborative research.

Nature of support:

Up to 5 scholarships will be awarded each year to cover travel and accommodation up to US$2000 per scholarship, to be reimbursed by WSO on presentation of receipts and short travel reports from both observer and host. The host institution is expected to waive any observership fees.

Application and selection process:

Applications are restricted to current WSO members. Applications will be judged by the WSO Young Stroke Professionals Committee based on merit with 2 of the 5 positions weighted towards young stroke professionals from low-middle income countries. The applicants should generally be below 40 years of age.

The application should include:

• curriculum vitae 
• provisional budget for travel and accommodation to the proposed institution 
• written confirmation from the proposed institution agreeing to the visit 
• a 500 word statement explaining how this visit will aid the young stroke professional’s career

Closing Date:

Applications for the 2016 round (for travel by end of 2016) must be lodged with the WSO via email (admin@world-stroke.org) by 5th February 2016

For further information contact Dr Bruce Campbell, WSO Young Stroke Professionals Committee (bruce.campbell@mh.org.au)

Seven Minutes in Stroke - Liam Johnson

Seven minutes in stroke 

1. What inspired you towards neuroscience?

During my undergraduate studies in Exercise and Sports Science, I completed a motor control and development unit where I studied the link between movement and the central nervous system (CNS), and what happens when the CNS, and in particular the brain, is injured or diseased. This ignited a passion in me to try to understand as much as I could about this link between the brain and movement, and in particular, how exercise can be used to help people recover from, or deal with, neurological or neuromuscular conditions.

2. Why stroke? 

One in 6 Australians will experience a stroke in their lifetime, and many of them will be left with long-lasting disability and at an increased risk of suffering a recurrent stroke. So few patients get the rehabilitation they need, and what they do get does little to improve their fitness, muscle strength and endurance, or reduce vascular risk factors. There is an urgent need for evidence-based rehabilitation interventions that promote recovery and reduce the risk of recurrent stroke. Exercise and physical activity is recommended after stroke, but unfortunately, it remains unclear what should be prescribed and when. Given my expertise in exercise physiology, I have a significant opportunity to make important contributions to the knowledge about exercise prescription and establishing a pathway from acute care to long-term health and well-being after stroke. This is a critical need for stroke survivors and will potentially transform the current rehabilitation landscape.

3. What have been the highs so far?

Stroke survivors want answers to questions such as what exercise they should be doing, how much and how hard they should exercise, and when should they begin exercise training. The fact that I am leading research that will hopefully answer these questions gives me enormous satisfaction. I also very much enjoy engaging with the participants in my studies – their support of my research is very humbling.

I also feel incredibly privileged to be working in a Research Institute that is the foremost stroke research centre in Australia. I am surrounded by amazing researchers and scientists that are passionate about finding ways of helping people with neurological and mental health conditions – every day is inspiring.

4. What have been the lows?

Navigating the challenges of being in research is a persistent battle. It has never been tougher to win grants to support your research, particularly for early career researchers. Knowing that your livelihood is dependent on that next grant is something I find very stressful.

I also struggle to deal with rejections from scientific publishers and near-misses from grant funders. The feeling of failure and not being good enough is pervasive in this line of work and can at times be overwhelming.

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

With difficulty actually! Firstly, I should say that I have tremendous support from my wife to do what I do, but I think, like many, I find this to be one of the most challenging aspects of research. I think just being mindful of trying to maintain a balance is important – and then putting in place some strategies to keep work and home life separate works reasonably well for me. I try to maintain pretty rigid routines with what I dedicate my time to and when, and I exercise every day which I find is super important for my physical and mental health. Weekends are primarily time for me and my family, and I make sure I take at least one-week away from work a couple of times a year, not only for me to refresh and recharge, but also to dedicate time to my marriage and fur-babies.

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

I have been very fortunate to be mentored by a number of people, though mainly in informal arrangements, whereby I have come to them, as leaders in research I am interested in, for guidance. It is really only in hindsight that I consider people like Professors Frank Mastaglia, Gary Thickbroom and Dylan Edwards to have been fantastic mentors. Since moving to The Florey Institute, I have been incredibly fortunate to be supervised by Professor Julie Bernhardt, who I consider to be a mentor as much as my supervisor. Julie has been tremendously influential of me – her care, guidance and support drives me every single day to give the very best of myself to my work. Via the Florey Institute’s formal mentoring program, I have also been lucky to be mentored by Dr Lachlan Thompson more recently, which I am finding to be very helpful also.

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

Building on the hard work and leadership of people like Professor Bernhardt, I have been privileged to access an extensive network of collaborators, in particular within the Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery. I also collaborate with a number of other groups, including a group based in New York, USA, focussing on telemedicine and virtual rehabilitation, and a group researching exercise training for people with Parkinson’s disease at Deakin University. I believe that having a strong reputation for excellence and integrity in your research, being willing to work with others and open to opportunities, and being generous in the collaboration are some of the more important ingredients for initiating and establishing healthy collaborations.

Seven Minutes in Stroke: Valeria Caso

The International Journal of Stroke has incredible author and reviewer support from stroke experts around the world. Over the years I've interviewed, met with, emailed, conversed and conferenced with so many amazing people who's career path and study interest are so interesting these wonderful stories must be shared! So we have started a new blog series entitled Seven Minutes in Stroke'.

Our first 'Seven Minutes in Stroke' series kicks off with the inspiring Valeria Caso, President elect of the European Stroke Organisation.

Seven minutes in stroke

1. What inspired you towards neuroscience?

My interest for neuroscience was sparked by a conference on Childhood Neuropsychiatry that I attended during my last year of high school; listening to the speaker, showing the developmental phases of the brain and its pathologies, I knew that this was my calling.

2. Why stroke?

During my 2nd year of Neurological specialization my Director sent me to Germany,  my home country, to learn how to set up what would be the future Perugia Stroke Unit. During those 6 months, my passion for stroke care began.

3. What have been the highs so far?

Well, the Perugia Stroke Unit was established in 1998, so over the last 17 years the satisfying moments have been many. We adopted the stroke pathways that resulted in one of the lowest mortality rates in Italy. We have seen great advances in treatment which have saved, undoubtedly, hundreds of lives, as well as reducing significantly disability.

4. What have been the lows?

Still, people have not gotten the message that when they have symptoms of stroke they need to get to the hospital. In fact, because of this we see unnecessary victims of stroke.

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

I am very lucky because my family members are very supportive, especially my well-chosen husband.

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

The first and most important is my friend and colleague Maurizio Paciaroni who was the first person I met at Clinica Neurologica. Over the last twenty years, we have been working side by side building up the Stroke Unit and carrying out research. Our dedication has produced many accomplishments in the field of stroke. The remaining three mentors have been Didier Leys, Werner Hacke and Michael Brainin who have provided me with professional opportunities that were important steps in my career. I am grateful for their genuine support and their trust.  

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

Currently, my most important collaborations include those with healthcare professionals interested in nurturing the field of Women’s Medicine. This is because, we share the understanding  that there are inherent  differences between the sexes regarding responses to treatment, time of disease and outcome.  Building these collaborations has been possible through mutual integrity and passion for the patients. 

World Stroke Organization Proclamation

SAGE to begin publishing the International Journal of Stroke January 2016

Taken from the SAGE website!

http://www.uk.sagepub.com/aboutus/press/2015/apr/9.htm

London (April 9 2015)- SAGE, one of the world’s leading independent and academic publishers, has today announced that it is to publish the International Journal of Stroke,the official journal of the World Stroke Organization (WSO) incorporating the International Stroke Society (ISS) and the World Stroke Federation (WSF).

Focused on the clinical aspects of stroke, the International Journal of Stroke reviews not only current topics and recent advances of global interest, but also those which may be more prevalent to certain regions to help facilitate the international debate and awareness around stroke. The journal accepts leading opinion pieces, topical reviews and original contributions from clinical or basic science researchers, alongside pieces focused on the associated structures to manage protocols within the field. The journal is edited by the internationally recognised stroke expert Professor Geoffrey Donnan, who was awarded the prestigious Bethlehem Griffiths Research Foundation (BGRF) medal in 2008.

Speaking about the new partnership, Karen Phillips, Editorial Director, SAGE, remarked that:

“SAGE has developed a strong medical portfolio over the past decade and to have been selected to publish the International Journal of Stroke is a testament to the dynamic nature and breadth of our titles and an indication of our growing strength across these disciplines. We are delighted to be working closely with the leading editorial board and WSO to continue to support access to cutting edge research on stroke awareness, further developing the reach of the journal and making it an excellent platform for sharing international stroke research.”

The International Journal of Stroke Editor- in- Chief Geoffrey Donnan, further stated:

“We are thrilled to now be publishing with SAGE, a publisher whom we feel not only is closely aligned with both our editorial goals but who has proven itself a leader within the field, now being ranked in the top 4 for publication of medical journals. Their growing medical background and clear vision for our future development is what we are most looking forward to when we begin working together. With SAGE behind us we are confident in the continuation of our key aim: reducing the global burden of stroke through prevention, treatment and long term care.”

WSO President Professor Stephen Davis added:

“SAGE offered everything that we were looking for when finding a new home including: the opportunity for international development and a great understanding of the field in which the journal is situated. We are all excited at WSO about this new partnership with SAGE and delighted with the upward trajectory of our Journal as the truly global medium for stroke research and education.”

The first SAGE issue will publish in January 2016. Please click here for more information on the journal.

# # #

SAGE Founded 50 years ago by Sara Miller McCune to support the dissemination of usable knowledge and educate a global community, SAGE publishes more than 800 journals and over 800 new books each year, spanning a wide range of subject areas. A growing selection of library products includes archives, data, case studies, conference highlights and video. SAGE remains majority owned by our founder and after her lifetime will become owned by a charitable trust that secures the company’s continued independence. Principal offices are located in Los Angeles, London, New Delhi, Singapore, Washington DC and Boston.www.sagepub.com

The International Journal of Stroke is the flagship publication of the World Stroke Organization and publishes high quality research articles, reviews and clinical trial protocols from around the world. IJS is dedicated to building a global stroke community, making it a global voice for stroke research and an excellent platform for sharing international stroke research.

The World Stroke Organization (WSO) is the world’s leading organization in the fight against stroke. It was established in October 2006 through the merger of the International Stroke Society and the World Stroke Federation with the purpose of creating one world voice for stroke. Today, WSO has more than 2000 individual members and over 60 society members from 85 different countries. www.world-stroke.org

What do Emilio Botin (Spanish banker), James Gandolfini (american actor) and my grandpa (argentine journalist) had in common? None should have died when they did….

They all suffered “heart attacks”. No details have been provided on Mr. Botin’s (79) death but according to a media source “it was totally unexpected” and “…it occurred a few hours before he would present a painting by Velázquez that he helped restore…”. Mr Gandolfini (51), well known for his role in the Soprano’s, was on vacation in Rome and planning to attend the closing of the Taormina Film festival in Sicily when his 13 year old son found him unconscious at their hotel’s bathroom. Resuscitation efforts at a hospital were unsuccessful. My grandfather (68) died of acute pulmonary oedema (i.e. acute heart failure) the day after he was planning to join a sports club…

Despite medical supervision (a cardiologist was “seeing” my grandfather), it is an epidemiologic fact common to most people above 40 years of age to have at least an untreated or undertreated vascular risk factor. Among the most common modifiable risk factors are inappropriate nutrition with or without excess weight, a sedentary life, current or recent smoking, high blood pressure (undiagnosed in 1 out of 3 people and uncontrolled in 80% of diagnosed patients in developed countries), abnormal lipid levels or diabetes. Also, Botín, Gandolfini and my grandfather shared a load of un-modifiable risk factors such as male sex, age and, potentially, a spectrum of unfavorable genetic traits. All these factors alter the normal arterial wall structure generating plaques that progressively narrow the vessel’s lumen leading to a decrease in blood flow to the heart, brain and other organs. 

The vascular problem is complex and dynamic. It is definitely not just a matter of clogged pipes. In fact, 80% of myocardial infarctions (MI’s) -with a high mortality rate- occur due to arteries that are not previously “stenotic” (i.e. narrowed). These patients will not be detected with a coronary “stress” test which only identifies arteries that have advanced narrowing and thus cannot supply enough blood to the heart muscle. Only 20% of MI’s occur in patients with previously narrowed arteries and these are the ones that can be detected by warning symptoms or a positive stress test. The concern, then, is that the vast majority of people have “plaques” covering the arterial wall (as dirt may accumulate in the walls of a plumbing system) which do not decrease the vessel’s diameter and are thus difficult to detect with conventional studies. The danger is that the so called “plaque accident” can unexpectedly occur leading to a sudden plaque disruption that generates a clogging cascade ending within minutes with a blocked artery… and an infarcted or dead person. A similar mechanism underlies many strokes. We have all heard people saying: “… how could this happen?… he/she was so healthy….”. In the case of James Gandolfini, the New York Times quoted that, after receiving results of the autopsy, a family member stated that he “…died… of natural causes”. Wrong! These people are sick and the essential -the status of their arteries- was invisible to the eye…

What Botín, Gandolfini and my grandpa did not know is that almost 80% of vascular events occur in people with few risk factors. This is the reason why most people feel that a heart attack or stroke is something that will happen “to others”. Yet, some people get health check-ups with the hope that if “approved” they get a few years’ survival guaranteed. Disappointingly, a Danish study on 180.000 people published recently in the British Medical Journal showed that conventional health check-ups (including a chest Xray, EKG, ultrasounds and blood tests among others) did not decrease total mortality or death secondary to cardiovascular disease or cancer, the very reasons for promoting and performing these evaluations (pap smear, mammogram, colonoscopy and prostate exams were excluded). So, what are we missing?

Could an eye doctor give you the right glass prescription without examining your eyes? The exact same rationale applies to disease of the arteries irrespective of whether they are in the heart, brain, legs or kidneys. Different methods can reliably evaluate arteries but most are expensive and some are invasive such as catheterization and others, like multi slice CT, use high doses of radiation precluding the repeated testing needed for disease follow-up. Ultrasound is fast, reliable, non invasive and affordable. There are ultrasound tests available that allow to objectively measure the atherosclerosis load in the vessel’s wall. Atherosclerotic plaque quantification was originally developed by David Spence in the 90’s and further studied by Valentin Fuster and others more recently. A quantification of arterial “plaque” burden (expressed in square or cubic millimeters depending on the technique) allows to accurately measuring the individual’s risk of having a vascular event. Knowing a person’s vascular risk factor profile (smoker, excess weight, hypertensive, etc) does not provide accurate data on that individual person’s risk of suffering a heart attack, stroke or other vascular event. In concordance with this notion, the latest lipid therapy guidelines recommend treatment according to the person’s vascular risk and not according to a specific cholesterol level. It is impossible to accurately define the best medical treatment based only on a person’s risk factor profile (or using “risk scores” which are derived from risk factor data) without measuring the load of atherosclerosis that affects the arteries. Vascular prevention should be based on a tailor made treatment. Or, again, could the eye doctor give you the right glass prescription just knowing you can’t see well (i.e. that you have vascular risk factors) without examining your eyes (i.e. your arteries)?

From Galileo Galilei to the software metrics guru Tom de Marco, many have stressed that one can only control what is measured. And everything is measurable. We should not only be measuring the conventional risk factors such as blood pressure, cholesterol, glucose, exercise and calories, but also the amount of atherosclerosis in the arteries. Only then we will be able to adjust the treatment of vascular risk factors “individually” according to all findings. The World Health Organization and different research authorities have shown that cardiovascular deaths could decrease by 80% if what we know about vascular disease was applied effectively. Botín, Gandolfini and my grandfather, no matter their wealth, social status or popularity were probably not receiving the medications and other measures (exercise, nutrition) that could have prevented their deadly vascular event. It is also unlikely that they had their “atherosclerosis” burden measured to adjust treatment according to their individual atherosclerosis load. There are millions more like them that every year have fatal MI’s and strokes. Of the approximately 150,000 people that die every day worldwide, almost one third dies of vascular related disease. Most of these deaths are preventable. It is due time to declare “tolerance zero” to unexpected vascular death.   

Conrado J. Estol, M.D., Ph.D.