Abstract WP148: Functional Independence Score of Acute Stroke Patients Can Predict Favorable Clinical Outcome at 3 Months After Stroke Onset

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Takashi Johno ◽  
Hiroyuki Kawano ◽  
Masataka Torii ◽  
Hiroshi Kamiyama ◽  
Tatsuo Amano ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Functional Independence ◽  
Stroke Onset ◽  
Stroke Patients ◽  
Favorable Clinical Outcome

Abstract P186: New Prehospital Triage for Stroke Patients Significantly Reduces Transport Time of EVT Patients Without Delaying IVT

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Michal Bar ◽  
Martin Cabal ◽  
Ondrej Volny ◽  
Petr Jaššo ◽  
David Holeš ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Stroke Onset ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Transport Time ◽  
Vessel Occlusion ◽  
Mortality And Morbidity ◽  
Prehospital Triage ◽  
Favorable Clinical Outcome ◽  
Suspected Stroke

Background and Purpose: Ischemic stroke is a leading cause of mortality and morbidity worldwide. The time from stroke onset to treatment impacts clinical outcome. Here we examined whether changing a triage model from “drip and ship” to “mothership” yielded significant reductions of onset-to-groin time (OGT) in patients receiving EVT, and onset-to-needle time (ONT) in IVT-treated patients, compared to before FAST-PLUS test implementation. We also investigated whether the new triage improved clinical outcomes. Methods: In a prospective interventional multicenter study, we evaluated the effects of changing the prehospital triage system for suspected stroke patients in the Moravian-Silesian region, Czech Republic. In the new system, the validated FAST PLUS test is used to differentiate patients with suspected large vessel occlusion, and triage-positive patients are transported directly to the CSC. Time metrics and patient data were obtained from the regional EMS database and SITS database. Results: For EVT patients, the median OGT was 213 min in 2015, and 142 min in 2018; and median TT was 118 min in 2015, and 47 min in 2018. For tPA patients, the median ONT was 110 min in 2015, and 109 min in 2018; and median TT was 41 min in 2015, and 48 min in 2018. Clinical outcome did not significantly change. The median mRS at 3 months after stroke onset in both 2015 and 2018 was 2 among tPA patients, and 3 among EVT patients. The percentages of patients with favorable clinical outcome (mRS 0-2) were comparable between 2015 and 2018: 60% vs 59% in tPA patients, and 40% vs 44% in EVT patients. Conclusions: The new prehospital triage has yielded shorter onset-to-groin times for EVT patients. No changes were found in the onset-to-needle time for IVT-treated patients, or in the clinical outcome at 3 months after stroke onset.

scholarly journals New Prehospital Triage for Stroke Patients Significantly Reduces Transport Time of EVT Patients Without Delaying IVT

2021 ◽  
Vol 12 ◽  
Author(s):  
Martin Cabal ◽  
Linda Machova ◽  
Daniel Vaclavik ◽  
Petr Jasso ◽  
David Holes ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Stroke Onset ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Transport Time ◽  
Vessel Occlusion ◽  
Mortality And Morbidity ◽  
Prehospital Triage ◽  
Favorable Clinical Outcome ◽  
Suspected Stroke

Background and Purpose: Ischemic stroke is a leading cause of mortality and morbidity worldwide. The time from stroke onset to treatment impacts clinical outcome. Here, we examined whether changing a triage model from “drip and ship” to “mothership” yielded significant reductions of onset-to-groin time (OGT) in patients receiving EVT and onset-to-needle time (ONT) in IVT-treated patients, compared to before FAST-PLUS test implementation. We also investigated whether the new triage improved clinical outcomes.Methods: In a before/after multicenter study, we evaluated the effects of changing the prehospital triage system for suspected stroke patients in the Moravian–Silesian region, Czech Republic. In the new system, the validated FAST PLUS test is used to differentiate patients with suspected large vessel occlusion and triage-positive patients are transported directly to the CSC. Time metrics and patient data were obtained from the regional EMS database and SITS database.Results: For EVT patients, the median OGT was 213 min in 2015 and 142 min in 2018, and the median TT was 142 min in 2015 and 47 min in 2018. For tPA patients, the median ONT was 110 min in 2015 and 109 min in 2018, and the median TT was 41 min in 2015 and 48 min in 2018. Clinical outcome did not significantly change. The percentages of patients with favorable clinical outcome (mRS 0–2) were comparable between 2015 and 2018: 60 vs. 59% in tPA patients and 40 vs. 44% in EVT patients.Conclusions: The new prehospital triage has yielded shorter OGTs for EVT patients. No changes were found in the onset-to-needle time for IVT-treated patients, or in the clinical outcome at 3 months after stroke onset.

scholarly journals In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

2020 ◽  
Author(s):  
Juha-Pekka Pienimäki ◽  
Jyrki Ollikainen ◽  
Niko Sillanpää ◽  
Sara Protto
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Mechanical Thrombectomy ◽  
Clinical Laboratory ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Ordinal Logistic Regression Analysis ◽  
Stroke Center

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

Abstract WP68: Tissue Type Plasminogen Activator (t-PA) and Edaravone Combination Therapy Study (YAMATO Study)

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Junya Aoki ◽  
Kazumi Kimura ◽  
Norifumi Metoki ◽  
Yohei Tateishi ◽  
Kenichi Todo ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Arterial Occlusion ◽  
Artery Occlusion ◽  
Free Radical Scavenger ◽  
Favorable Outcome ◽  
Tissue Type ◽  
Radical Scavenger ◽  
Stroke Patients ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Favorable Clinical Outcome

Introduction&Hypothesis: The aim of the present study was to investigate whether administration of edaravone, a free radical scavenger, before or during t-PA administration can increase the rate of early recanalization and improve the clinical outcome in stroke patients with major arterial occlusion. Methods: YAMATO study is an investigator initiated, multicenter (17 hospitals in Japan), prospective, randomized, open labeled study. Acute stroke patients with horizontal (M1) or vertical (M2) portion of the middle cerebral artery occlusion within 4.5 h of onset were studied. The subjects were randomly allocated to the early edaravone (early-E) group (intravenous edaravone [30 mg] was started before or during t-PA administration) and the late edaravone (late-E) group (edaravone was started after t-PA administration). Primary outcome, defined as any early recanalization 1h after t-PA therapy. Secondary outcomes included the rate of the significant recanalization, defined as ≥50% of the territory of the occluded artery on magnetic resonance angiography, or the thrombolysis in cerebral infarction score ≥2b on digital subtraction angiography as well as the incidence of symptomatic intracerebral hemorrhage (sICH), and the favorable clinical outcome (modified Rankin scale [mRS] of 0-2) at 3 months after onset. Results: One-hundred and sixty-six patients (96 men; median age [interquartile range], 78 [69-85] years) were randomized 1:1 to either the early-E group or the late-E group. Twenty-three (13.9%) had proximal M1 occlusion; 60 (36.1%), distal M1 occlusion; 83 (50%), M2 occlusion. Early recanalization was similarly observed in the early-E group and in the late-E group (53.1% vs. 53.0%, P=1.000). The rate of significant recanalization was also similar between the 2 groups (27.2% vs. 33.7%, p=0.399). sICH was occurred in 4 (4.8%) patients in the early-E group and in 2 (2.4%) in the late-E group (p=0.682). Among the 144 patients who were pre-morbid mRS of 0-2 and eligible for 3 months assessment, favorable outcome was seen in 53.9% in the early-E group and 57.4% in the late-E group (p=0.738) Conclusions: The timing of the edaravone infusion should not affect the rate of early recanalization, sICH, or favorable outcome after t-PA therapy.

Abstract WP471: Significant Factors for Early Independent Toilet Activities in Acute Stroke Patients

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Yuki Sawada ◽  
Takahisa Mori ◽  
Yuna Hosaka
Keyword(s):  
Cognitive Function ◽  
Acute Stroke ◽  
Mmse Score ◽  
Multiple Logistic Regression Analysis ◽  
Early Discharge ◽  
Functional Independence ◽  
Lower Limbs ◽  
Stroke Patients ◽  
Trunk Control ◽  
Significant Factors

Introduction: Acute stroke patients have problems with toilet activities. Independent toilet activity in hospitalized patients is important for dischargee to home. Hypothesis: Lower limbs function, trunk control and cognitive function are important factors of early independent toilet activities and discharge to home within 7 days. Methods: We included acute ischemic stroke patients who 1) were admitted from June 2017 to May 2018 and 2) received early rehabilitation treatment. Patients with disturbed level of consciousness were excluded. Functional independence measure (FIM) scale of 6 or 7 was defined as independence and FIM scale of 5 or less as dependence. We evaluated Brunnstrom Recovery Stage (BRS) of arms, fingers and lower limbs, trunk control test (TCT), Mini-Mental State Examination (MMSE) and investigated significant factors of early independent toilet activities and discharge to home within 7 days. Results: One-hundred twenty-four patients met our inclusive criteria. Their average age was 75.8 years, male gender of 63.7%, median BRS of arms, fingers and lower limbs was 5, 5 and 5, median TCT score and MMSE score were 94 and 24.7, respectively. Fifty-three patients were independent in toilet activity and 73 patients were dependent. All patients with independent toilet activity discharged to home within 7 days. In independent and dependent toilet activity patients, an average age was 73.6 and 77.4 (p<0.05), median BRS of arms was 5 and 5 (p<0.01), median BRS of fingers was 6and 5 (p<0.01), median BRS of lower limbs was 5 and 5 (p<0.01), median TCT score was 100 and 61 (p<0.01), and median MMSE score was 27.8 and 22.5 (p<0.01), respectively. Multiple logistic regression analysis showed that MMSE score (p<0.01), TCT score (p<0.01), and BRS of lower limbs (p<0.05) were independent factors for independent toilet activity and discharge to home. Receiver operating characteristic (ROC) curve for early discharge to home demonstrated that cut-off values of MMSE score, TCT score and MRS of lower limbs were 27 or more, 87 or more and 5 or more, respectively. Conclusion: BRS as lower limbs function, TCT as trunk control and MMSE as cognitive function were important factors of early independent toilet activities and early discharge to home.

Abstract W P211: Clinical Characteristics of Pseudo Negative Cases in Prehospital Triage for Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Shuichi Tonomura
Keyword(s):  
Acute Stroke ◽  
Clinical Characteristics ◽  
Stroke Onset ◽  
The Other ◽  
Small Vessel ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Stroke Subtypes ◽  
Prehospital Triage ◽  
Prehospital Diagnosis

Objective: The accuracy of prehospital diagnosis for stroke by emergency medical services (EMS) is improved using instruments for symptom recognition. On the other hand, prehospital misdiagnosis for stroke and subsequent delay in presentation to a hospital with stroke expertise play a critical role in the exclusion of potential therapeutic candidates. Our study aims to investigate the clinical characteristics of pseudo-negative cases in prehospital triage for stroke/TIA by EMS. Methods: From April 2013 to April 2014, consecutive 644 acute stroke patients were transferred by EMS to our hospital. We investigated prehospital diagnosis, Cincinnati prehospital stroke scale (CPSS) by EMS, neurological symptoms and complaints of patients themselves at stroke onset. We also examined activity of daily life (ADL) and cognitive impairments before stroke onset, and stroke subtypes in final diagnoses. Results: Among 644 acute stroke patients, 36 patients (22 men, mean 72.5±4.4 years old) were pseudo-negative cases in prehospital triage for stroke and had no abnormalities in CPSS by EMS. When EMS arrived at emergency site, 12 patients (33%) had loss of consciousness. Before stroke onset, 6 patients (17%) had impaired ADL (modified Rankin Scale >2), and 5 (14%) cognitive impairment. Among the stroke subtypes, the proportion of small vessel occlusion (22.4%, p=0.0025) and transient ischemic attack (TIA) (25%, p=0.0021) was significant higher in pseudo negative cases in prehospital triage; on the other hand, intracranial hemorrage (11%, p=0.0028) was lower. In complaint of patients themselves at stroke onset, weakness in one or two extremities was reported in 20 patients (56%), abnormal speech/language in 13 (36%), however all of them were not clarified by EMS. Conclusion: This study showed that small vessel occlusion and TIA tend to be misdiagnosed in a prehospital triage by EMS. The complaint of patients themselves at stroke onset is important to prehospital diagnoses by EMS.

scholarly journals Adherence to Post-Acute Rehabilitation Guidelines Improves Functional Recovery in Stroke

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 333-333
Author(s):  
Pamela W Duncan ◽  
Ronnie D Horner ◽  
Dean M Reker ◽  
VA Medical Ctr ◽  
Kansas City ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Acute Stroke ◽  
Functional Recovery ◽  
Stroke Rehabilitation ◽  
Functional Independence ◽  
Case Mix ◽  
Stroke Patients ◽  
Sf 36 ◽  
Acute Rehabilitation

97 Purpose & Methods: To assess if compliance with post-stroke rehabilitation guidelines improves functional recovery. The design of the study was an inception cohort of stroke patients followed prospectively for 6 months. The setting was eleven Department of Veteran Affairs Medical Centers providing care to stroke patients. The subjects included 288 selected patients with stroke admitted between January 1998 - March 1999. Data were abstracted from medical records and telephone interviews. Primary outcome was the Functional Independence Motor Score (FIM). Secondary outcomes included Instrumental Activities of Daily Living (IADL), SF-36 physical functioning, and the Stroke Impact Scale (SIS). Acute and post-acute rehabilitation composite compliance scores (range 0–100) were derived from an algorithm. All outcomes were adjusted for case mix. Results: Average compliance scores in acute and post acute care settings were 68.2% (+ 14) and 69.5% (+ 14.4), respectively. After case-mix adjustment, level of compliance with post-acute rehabilitation guidelines was significantly associated with FIM motor, IADL, and the SIS physical domain scores. SF-36 physical function scores and mortality were not affected by compliance with post-acute rehabilitation guidelines. Level of compliance with rehabilitation guidelines in acute settings was unrelated to any of the outcome measures. Conclusion: Process of care in post-acute stroke rehabilitation affects 6-month functional recovery. Our findings support the use of guidelines as means of assessing quality of care and improving outcomes. These quality indicators are needed to ensure that quality of care is not comprised with new organizational and funding changes involving post-acute stroke care.

Abstract W P48: Flair Vessel Hyper-intensities Could Predict Target Mismatch Signs in Acute Stroke Patients

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Manabu Inoue ◽  
Michael Mlynash ◽  
Carlo W Cerada ◽  
Nishant K Mishra ◽  
Soren Christensen ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Clinical Outcomes ◽  
Pooled Analysis ◽  
Stroke Patients ◽  
Good Clinical Outcome ◽  
Kappa Score ◽  
Early Reperfusion ◽  
Diffusion Weighted Images ◽  
Fluid Attenuated Inversion Recovery

Background and purpose: Fluid-attenuated inversion recovery (FLAIR) vessel hyper-intensities (FVH) have been hypothesized to have a positive correlation with good collaterals and more favorable clinical outcomes in acute stroke patients. We assessed if FVH predict the Target mismatch profile (TMM) and clinical outcomes in the DEFUSE studies. Methods: Patients with technically adequate baseline diffusion weighted images (DWI), perfusion images (PWI), and FLAIR images were included in this pooled analysis of the DEFUSE 1 and 2 studies. The FVH sign was defined as visible hyper-intense vessels on FLAIR images and assessed at basal ganglia levels by two independent raters. Clinical outcomes were assessed using modified Rankin Scale (mRS) at 90 days. The Target mismatch profile was based on baseline DWI and PWI volumes using automated software (RAPID). Results: Seventy seven patients met the inclusion criteria. Median time (IQR) from symptom onset to baseline MRI was 4.6 hours (3.9 - 5.4) and median (IQR) DWI lesion was 13.1 (5.0 - 32.0) ml. Of these, 66 patients (86%) had the FVH sign. Kappa score for inter-rater agreement was 0.621 (95CI: 0.33 - 0.91). Seventy (74%) cases with FVH had TMM profile vs. 33% of No FVH patients (p=0.023). Good clinical outcome (mRS 0-2) did not differ (50% with FVH vs. 73% without FVH, p=0.203). Only 38% of the patients with FVH had good angiographic collaterals and the rate of early reperfusion did not differ (45% with FVH vs. 25% without FVH, p=0.45). Conclusions: FVH is common in acute stroke patients (86%) and is associated with the Target Mismatch profile. However, FVH was not associated with favorable angiographic collaterals, good clinical outcome or early reperfusion in the DEFUSE 1 and 2 cohorts.

Abstract TP205: Clinical Aspects Of First-ever Stroke In Patients With Permanent Pacemaker

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Jiro Kitayama ◽  
Hiroshi Nakane ◽  
Hiromi Ishikawa ◽  
Masahiro Shijo ◽  
Masahiro Kamouchi ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Pacemaker Implantation ◽  
The United States ◽  
Permanent Pacemaker ◽  
Stroke Onset ◽  
Clinical Aspects ◽  
Stroke Patients ◽  
Stroke Treatment ◽  
Stroke Registry ◽  
History Of

OBJECTIVES: Recently, increasing numbers of patients take pacemaker implantation: almost sixty thousands in Japan, and no less than two hundreds of thousands in the United States per year. Previous reports have indicated that prevalence of atrial fibrillation (Af) is high, and several coagulation markers are elevated in those with pacemaker. However, the precise features of stroke with implanted device are not clear. We, thus, examined the clinical aspects of stroke in pacemaker patients. METHODS: For the present study, we analyzed data from the Fukuoka Stroke Registry that is a multicenter epidemiological study database on acute stroke. From June 1999 to May 2011, 11376 ischemic stroke patients (72±12 years of age, female/male=4613/6763) who admitted to the hospital within seven days after onset were enrolled in the registry. Stroke subtypes were classified according to the diagnostic criteria of TOAST (Trial of Org 10172 in Acute Stroke Treatment). RESULTS: A total of 207 patients (1.8% of registered stroke patients) were with pacemaker. Among them, 130 patients had no history of any stroke. They appeared to be a mean age of 81±9 (range 42 to 97) years, and female/male ratio of 77/53. Mean duration from pacemaker implantation to stroke onset was 8±7 (median 6, quartile 3-11) years. 32 patients (25%) were given oral anticoagulant prior to stroke onset; 60 (46%) were on antiplatelet. Prevalence of Af in pacemaker patients was 48% (n=63). In those with Af, 48 patients (76%) were diagnosed as cardioembolic stroke, but only 22 (35%) were on anticoagulation before onset. Even in those without Af, 33 cases (49%) were also diagnosed as cardioembolic. The percentage of subjects with increased plasma D-dimer (≥1.5 μg/ml) was significantly higher in pacemaker group than no-pacemaker group, regardless of the presence or absence of Af (75% vs. 45% with Af; p<0.0001, 74% vs. 25% without Af; p<0.0001). CONCLUSIONS: In our current study, stroke in pacemaker patients revealed to have higher incidence of cardiogenic embolism, with or without Af. In addition, the majority was elderly, and failed to receive anticoagulant prior to stroke. It is needed to re-consider therapeutic strategy, including anticoagulation, for prevention of stroke in those with permanent pacemaker.

Abstract TMP12: Does Prehospital Magnesium Sulfate Differentially Improve Outcome in Hyperacute Stroke Patients With Higher Pretreatment Blood Pressure?

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Phoebe H Johnson-Black ◽  
Sidney Starkman ◽  
Nerses Sanossian ◽  
David Liebeskind ◽  
Samuel Stratton ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Cerebrovascular Disease ◽  
Acute Stroke ◽  
Magnesium Sulfate ◽  
Controlled Trial ◽  
Functional Independence ◽  
Forest Plot ◽  
Stroke Patients ◽  
Improve Outcome ◽  
Acute Cerebral Ischemia

Introduction: Magnesium sulfate (Mg) has blood pressure (BP) lowering, cerebral blood flow enhancing, and neuroprotective effects in preclinical and clinical studies. In the IMAGES phase 3 trial, Mg up to 12h after onset showed no benefit in acute stroke, but was associated with improved outcome in patients with higher blood pressure at entry. Hypothesis: We tested the hypothesis that ultra-early Mg improves functional outcome in acute stroke patients with higher baseline BP. Methods: FAST-MAG is a multicenter, double-blind, randomized, placebo-controlled trial of paramedic-initiated Mg, administered to patients with suspected stroke within 2h of symptom onset. The primary analysis showed neutral effect of Mg. This secondary analysis examines rates of functional independence (mRS 0-2) at 3m for Mg and placebo for different field BP groups. Results: Among 1622 patients with acute cerebrovascular disease, age was 69.6 (±13.4), 42% female, entry deficit severity in the field was LAMS 3.8 (±1.2), and first post-enrollment NIHSS in the ED was 11.5 (±9.9). Systolic blood pressure prior to enrollment was higher among patients with intracerebral hemorrhage (ICH) than acute cerebral ischemia (ACI), 175 (±25) vs 155 (±27), p < .001. The Figure shows the Forest plot for Mg vs placebo and functional independence among blood pressure groups. Heterogeneity of treatment effect was noted in the all-cerebrovascular patients population (p < .01), with fewer independent outcomes with Mg than placebo among patients with higher entry BPs. Analysis of Functional Independence (mRS 0-2) at 90 Days in Prespecified Subgroups Conclusion: This analysis did not confirm the prior finding of magnesium sulfate benefit among acute stroke patients with elevated blood pressure (and actually provided a signal in the opposing direction). Mg was not demonstrated to improve outcome when started in the first 2h of onset among patients with acute cerebrovascular disease and higher blood pressures.

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