In 2009, the American Stroke Association released a guideline endorsing this change in the definition of TIA. In our lab, we are interested in understanding the mechanisms by which neuroinflammation elicits synaptic and neuronal injury in chronic and acute models of neurological disease. While magnetic resonance imaging (MRI) has substantially improved our diagnostic capabilities, the appropriate use of MRI and its effectiveness has not been studied systematically in these patients. The Office of the Vice Provost and Dean of Research, provides comprehensive information about the research enterprise at Stanford. stroke symptoms Back to the Top. STATUS: RECRUITING, vREHAB - Virtual Reality Glove for Hand and Arm Rehabilitation After Stroke There is reason to think that such a therapy might be obtainable – we know that some people, especially younger ones, experience significant recovery after stroke. Low risk TIA patients can be managed safely and cost-effectively in an outpatient TIA clinic. Applications are currently being accepted on a rolling basis and proposals of all sizes will be considered, from initial exploration of cloud computing usability for projects to more advanced-stage projects. PI: Nirali Vora, MD Protocol ID: 49130 Intracerebral hemorrhage (ICH) is a devastating type of stroke caused due to bleeding within the brain tissue. STATUS: RECRUITING, StrokeCog Through collaborations between Stroke Neurology, Interventional Neuroradiology, Neurosurgery and Engineering the Stanford Stroke Center continuously seeks to develop and test new methods to optimize the treatment of stroke patients. Our goal is to use these pathways to develop new treatments for patients with stroke and other neurological diseases. Doctors, Clinics & Locations, Conditions & Treatments, View All Information for Patients & Visitors ». Phone: 650-723-6469. Half of the subjects will undergo fever prevention using a targeted temperature management system and half of the subjects will be treated for fever should it develop. The Stanford Stroke Center is a pioneer in using the latest surgical techniques and innovative therapies to rapidly treat individuals experiencing a stroke. Protocol ID: 43744 IRB: 48543 The purpose of this study is to learn whether there are changes in molecules in blood, called RNA, after TIA / minor stroke. Undergraduate Research. stroke rehabilitation To determine this, we will collect spinal fluid from stroke patients to look for the presence of brain inflammation. MRI shows promise for identification of the ischemic core and penumbra but it has very limited availability in US emergency rooms. Search and read profiles of Stanford faculty, staff, students and postdocs. These questions have major ramifications for the care of patients with ICH or IVH. types of strokes ICH is readily diagnosed by CT, which is typically the first imaging test performed during the initial diagnostic evaluation. The Stanford Stroke Center has developed new ways to image the brain of patients suffering a stroke. Furthermore, it is unclear whether routine MRI in ICH yields clinically relevant data and if this data will change management decisions regarding further diagnostic testing and therapeutic options above and beyond that which can be achieved by CT and cerebral angiography. Our goal is thus to better understand the mechanisms that contribute to recovery in the young, and how they are influenced by inflammatory responses. Endovascular stroke treatment is increasingly being used and may fill this need, as it can be very effective at opening up occluded blood vessels in the brain. This is a randomized, placebo-controlled, subject- and investigator-blinded trial of BAF312 in intracerebral hemorrhage (ICH) patients to study efficacy, safety, and tolerability. Therefore, patient selection based on CTP images is not ready for implementation in clinical trials or clinical practice. Despite this very high number of people who are suffering, there is a large knowledge gap regarding the mechanisms by which neurological recovery occurs, and not a single FDA-approved therapy available to help people recover. Clinical trials are research studies that evaluate a new medical approach, device, drug, or other treatment. The Stanford TIA program is currently evaluating a new technology, perfusion weighted imaging (PWI), as a method of confirming an ischemic “footprint” that can verify a transient neurological episode was caused by ischemia, rather than a non-ischemic condition. The Brain Interfacing Laboratory is interested in the applicability of brain-machine interfaces as a platform technology for a variety of brain-related medical conditions, particularly stroke and epilepsy. signs of a stroke PI: Chitra Venkatasubramanian, MD ICH occurs due to a variety of causes including hypertension, cerebral amyloid angiopathy, excessive anticoagulation, vascular malformations, cerebral venous thrombosis or brain tumors. You can message your clinic, view lab results, schedule an appointment, and pay your bill. In order to automatically process advance stroke imaging data quickly and accurately, Stanford Stroke Center faculty members developed a unique software platform called RAPID. Get the Android MyHealth app ». Our clinical research efforts focus on novel approaches for treating intracranial aneurysms, intracranial and spinal vascular malformations, occlusive cerebrovascular disease such as Moyamoya disease and stroke. STATUS: RECRUITING, StrokeCog LP This percentage is higher among Black, Asian, and Hispanic populations, and expected to rise in the United States over the next few decades, due to increasing age and continuing changes in racial demographics. The Google Cloud Credit program aims to stimulate and support research in the field of artificial intelligence in medicine and imaging that distinctively takes advantage of cloud capabilities. Get the iPhone MyHealth app » Stroke is the number one cause of disability in the United States. Landmark Advances Shift the Paradigm of Acute Stroke Imaging and Treatment. stroke treatments, Symptoms Computed Tomography Perfusion (CTP) imaging is a potential solution as it is widely available and can easily be added to a non-contrast head CT, already routinely obtained to evaluate stroke patients in the emergency room. PI: Maarten Lansberg, MD, PhD Our foot in the door has been the study of the cyclooxygenase-2 (COX-2) pathway and its downstream prostaglandin receptor signaling pathways, which function in important ways in modulating the inflammatory response in brain in models of Alzheimer's disease (AD), amyotrophic lateral sclerosis (ALS), Parkinson's disease (PD), and stroke. PI: Gary Steinberg, MD As a Stanford Health Care patient, you may have access to the latest, advanced clinical trials. Related Story, Stanford Pioneers New Brain Imaging to Improve Stroke Care, Stanford Stroke Experts Advance Recognition of Stroke in Young People, Know the Signs of Stroke: BE FAST Infographic, Innovative, Rapid Stroke Treatments Save Lives. NCT02864953 Data from Stanford demonstrated that perfusion imaging, when optimally processed, can accurately identify critically hypoperfused penumbral tissue. Protocol ID: 48083 Author Becky Bach Published on March 13, 2018 March 14, 2018 Learn more from Stanford Health Care. NCT02996266 These added costs must result in improvements in patient management in order to justify the added financial resources involved. Once we understand this, we hope to be able to develop new therapies to help people’s brains repair themselves. What Is a Stroke In order to reduce the burden of disability caused by stroke there is a need for better stroke treatments that are available to more stroke victims. Acute stroke elicits a profound systemic inflammatory response, not unlike traumatic injury. stroke types Protocol ID: 43136 Dr. Palmer was recruited in 2000 to help develop a neurotransplantation program at Stanford. Types Now, research from the School of Medicine has cracked that window open a bit wider. Images demonstrate a PWI positive lesion (arrows) in a patient with transient right sided weakness/numbness. We also participate in international, multi-centered studies such as the International Pediatric Stroke Study and BrainWorks. Support teaching, research, and patient care. Join the SDRC research registry. PI: Neil Schwartz stroke treatment This research spans both preclinical models and human clinical studies. Stanford is currently not accepting patients for this trial. A second purpose is to determine whether SB623 might improve stroke symptoms. CERC brings together individuals with backgrounds in medicine, industrial engineering, and management and social sciences in an effort to create innovative healthcare delivery models that safely lower per capita spending while maintaining or improving health outcomes and patient experience. The rapid stroke protocol at the bustling emergency department got its start at Stanford’s Clinical Excellence Research Center. This Stanford study, sponsored by the NIH, demonstrated that patients with a favorable MRI profile, called Target Mismatch, have excellent outcomes following reperfusion, even when treated up to 6 hours after symptom onset with iv tPA. Image shows a DWI positive lesion in a patient with transient left sided weakness. It is caused by an occlusion of a blood vessel in the brain. DoResearch. PI: Chitra Venkatasubramanian, MD PI: Chitra Venkatasubramanian, MD Stanford Stoke Center faculty member Amy Tai is collaborating with CERC on a novel stroke/TIA heath care delivery project. Status: RECRUITING, Efficacy, Safety and Tolerability of BAF312 Compared to Placebo in Patients With Intracerebral Hemorrhage (ICH). DEFUSE 3 was a 38-center NIH-funded study led by the Stanford Stroke Center that demonstrated that nearly half of all patients treated between six and 16 hours after the onset of their symptoms could be largely spared from the consequences of their stroke and the number of stroke patients who died or required confinement to nursing homes was nearly cut in half. STATUS: RECRUITING, TIMELESS: Tenecteplase in Stroke Patients Between 4.5 and 24 Hours This multicenter trial was designed and run by Stanford and funded by the NIH. Stroke Center faculty members have authored more than 25 national and international clinical guideline statements. Stanford is currently accepting patients for this trial. The purpose of this study is to determine if an investigational study drug, BMS-986177, which inhibits factor XIa (one of the components in the clotting process) is safe and effective in preventing future strokes when given daily with antiplatelet medication (aspirin and clopidogrel) for 21 days, then from Day 22 with aspirin alone, for up to 90 days to subjects who recently experienced stroke or TIA due to blood clots. Results of the trial were published in The New England Journal of Medicine and coincided with AHA new acute-stroke treatment guidelines that expanded the stoke treatment window from 6 to 24 hours. 2010; 41 (11): 2681-3. Research Administration. It is, however, not known which patients benefit clinically. Diagnostic Accuracy of MRI in Spontaneous Intracerebral Hemorrhage (DASH). As part of the CRISP study we have developed a fully automated system (RAPID) for processing of CT Perfusion (CTP) images that generates brain maps of the ischemic core and penumbra. However, methods for processing of CTP images and criteria for interpretation of the images are still immature. Stanford research helps expand window for treating stroke up to 24 hours Clinicians now have up to 24 hours to treat a stroke, thanks in part to research and tools developed at Stanford Medicine. These include advances in microsurgery, interventional neuroradiology, stereotactic radiosurgery, 3D imaging, surgical navigation, revascularization techniques, the use of mild brain hypothermia and other clinical neuroprotective agents, and neurotransplantation. STATUS: RECRUITING, INTREPID - Impact of Fever Prevention in Brain Injured Patients In a 2002 article in the New England Journal of Medicine, Stanford Neurologist Greg Albers, MD, and other cerebrovascular experts called for a revision in the definition of TIA — from time-based (the resolution of symptoms in 24 hours) — to the presence or absence of brain infarction, a tissue-based definition, on neuroimaging. Aksoy D, Bammer R, Mlynash M, Venkatasubramanian C, Eyngorn I, Snider RW, Gupta SN, Narayana R, Fischbein N, Wijman CA. Find A Researcher. stroke risk factors The concept of the ischemic penumbra concept envisions not only potentially salvageable or at-risk ischemic tissue but also nonviable tissue known as the “ischemic core”. The study design will also allow us to identify the added benefit of specific MR sequences (including novel state-of-the-art sequences) and repeat MRI in the chronic stage, thereby allowing us to prospectively determine their value in a consecutive series of patients. Previous studies suggest that stroke patients with a small volume of irreversible ischemic injury (infarct core) and a large volume of reversible ischemic injury (penumbra) are most likely to benefit from restoration of blood flow. Palo Alto, CA 94304. A research collaboration coordinated at Stanford helped establish that a lesion detected by DWI lesion is an extremely accurate surrogate for the ischemic core. Stroke For more information, please see http://emed.stanford.edu/boost3.html. Additional research interests include stroke prevention, TIA triage, eliminating disparities in health care, and neurology education. Following a stroke in 2010, Debra is now initiating research into the experience of stroke survivors in the rehabilitation process, ... After stroke, Stanford education scholar learns a different way to teach again Go to Faculty. Learn more from Stanford Health Care. However, although CT is very sensitive for the detecting of acute blood in the brain, it often does not provide information that allows determination of the cause of the hemorrhage. Stanford Diabetes Research Center The Stanford Diabetes Research Center (SDRC) is looking for participants, including healthy volunteers, to join the various diabetes-related studies being conducted at Stanford. The improved outcomes were achieved through the use of the RAPID software platform for patient selection. The trial results demonstrated that using the RAPID software, selected patients can be identified who benefit for intra-arterial clot removal therapy up to 12 hours after symptom onset. Access your health information from any device with MyHealth. We are developing wearable stimulation devices to improve limb function after stroke. Stroke But stroke recovery is a neuroscience problem.That observation, Lansberg says, motivated him and Buckwalter to create their recovery program’s predecessor, the Stroke Collaborative Action Network, in 2015 with help from a Stanford Neurosciences Institute … Stanford has pioneered major advances in medical therapies for treating and preventing stroke, neurosurgical techniques for stroke prevention, and interventional neuroradiologic procedures for stroke patients. Stanford University, one of the world's leading teaching and research institutions, is dedicated to finding solutions to big challenges and to preparing students for leadership in a complex world. We are interested in early immunological mechanisms, mobilized hours to days after the ischemic event, that predict patients’ long-term neurocognitive recovery. Status: RECRUITING, AXIOMATIC-SSP: Oral Factor XIa Inhibitor for the Prevention of New Ischemic Stroke in Patients Receiving Aspirin and Clopidogrel Following Acute Ischemic Stroke or Transient Ischemic Attack (TIA) STATUS: RECRUITING, ARCADIA - AtRial Cardiopathy and Antithrombotic Drugs Intervention After cryptogenic stroke Our Stroke Center team provides preventive care, diagnosis, and treatment for stroke and stroke-related issues. PI: Maarten Lansberg, MD; Kara Flavin, MD NCT03192215 We have defined criteria, based on these CTP maps, which we believe will predict if a patient is likely to benefit from restoration of blood flow. The Stanford Stroke Center is a pioneer in using the latest surgical techniques and innovative therapies to rapidly treat individuals experiencing a stroke. IRB: 49467 Find researchers with whom you would like to collaborate. Our laboratory is interested in elucidating the mechanisms of brain repair and recovery after stroke with the long term goal of finding novel therapeutic strategies to promote stroke recovery. In the United States, there are 4 million people currently living with the effects of stroke, and another 4.3 million living with the effects of traumatic brain injury. Stroke recovery research, including participation in multiple early-phase clinical stem cell therapy trials and development of a new line of stem cells, has also been a focus area. Subsequently, this concept was translated to CT perfusion imaging with thresholded relative CBF maps. NCT: 02089217 Stanford Stroke Center is a research and teaching institution that offers medical services for its customers. Stroke is the leading cause of disability and eighth most expensive health condition in America. NCT03338998 With nearly 800,000 strokes occurring annually in the United States alone, stroke remains a leading cause of long term disability and death in the world. J Am Heart Assoc. Stanford neuroscientists have helped clarify the basic mechanisms of stroke-induced brain injury and have pioneered several new imaging techniques that facilitate the identification of salvageable ischemic brain tissue in patients presenting with an acute stroke. Treatments The main purpose of the study is to find out if the incidence of stroke or death is different or the same between subjects that receive medical management alone compared to subjects that receive medical management in combination with carotid endarterectomy (CEA) or carotid artery stenting (CAS). Of all patients who present with a stroke 10-20% will have suffered a spontaneous (non-traumatic) ICH rather than an ischemic stroke. 2011; 42 (1): 73-80. Status: RECRUITING, STRONG - Genetic Variation, Stress, and Functional Outcomes After Stroke Rehabilitation stroke symptoms in women The purpose of the study is to demonstrate (a) the feasibility of increasing the dose of rehabilitation in acute stroke patients with a “Smart Glove”, (b) the effect of the “Smart Glove” use on functional recovery, and (c) the effect of the “Smart Glove” use on quality of life. Our research team has also pioneered the development and testing of stem cell treatments for stroke recovery, a yet unproven but promising new therapy to restore function after stroke. Brain plasticity and remapping is a key repair process after stroke and we study this at the circuit level using optogenetics, and at the synaptic level using electrophysiology and array tomography. stroke warning signs Stanford researchers have found that injecting stem cells directly into the brains of recovering stroke sufferers is more than just safe – it actually reverses brain damage, something previously thought impossible by science. Once symptoms start, there's only a tiny window of time for stroke victims to get life-saving treatment. In order to address this problem, Stanford Children’s Health has developed a multidisciplinary pediatric stroke program with a team of specialists who have the necessary experience and knowledge to skillfully diagnose, treat and manage strokes in children. These studies have documented that that identifying a small area of brain injury on the MRI is much more powerful than clinical data alone to predicting early stroke risk; in fact early stroke risk is about 15 times higher in patients with TIA symptoms who have a small area of tissue injury on the MRI compared to those who have a normal MRI. Protocol ID: 45088 Through the use of biomaterials, microfabrication techniques, and stem cell therapeutics, we are able to manipulate the neural environment and determine important pathways for healing. For example, a patient who has an ICH due to cerebral amyloid angiopathy will need to avoid blood thinners to decrease the probability of a recurrent ICH. The looming healthcare financial crisis in America led to the creation of the Stanford Clinical Excellence Research Center (CERC). Our research team has also pioneered the development and testing of stem cell treatments for stroke recovery, a yet unproven but promising … M G Lansberg's 40 research works with 1,705 citations and 1,684 reads, including: O-034 Intraarterial clot localization in patients with acute ischemic stroke affects the venous microperfusion profile The technology includes a tactile stimulation method (PTS) and the wireless, lightweight, and low-cost wearable computing devices to apply this stimulation. He has already developed a national reputation for his scientific expertise in stem cell biology and neurogenesis in the central nervous system. Protocol ID: 42089 The Stanford Stroke Center is recognized as a world-leader in clinical stroke research. The George lab strives to increase our understanding of naturally occurring repair mechanisms through biomarkers and novel technologies to improve the care of stroke survivors. Stanford Neurologists Play Key Role in Redefinition of TIA, Determining Prognosis and Optimal Management. Stroke is the number one cause of long-term disability in the world. The benefits of the new TIA definition have been demonstrated in a series of recent publications in Lancet Neurology, Stroke, and Neurology that were co-authored by Stanford Stroke Center neurologists. Venkatasubramanian C, MD, Jonathan T. Kleinman MD, Nancy J. Fischbein MD, Jean-Marc Olivot MD, PhD, Alisa D. Gean MD, Irina Eyngorn MD, Ryan W. Snider BA, Michael Mlynash MD, MS, and Christine A.C. Wijman MD, PhD. Open trials refer to studies currently accepting participants. Using the databases from multiple international studies, this software program has been demonstrated to identify patients who benefit from reperfusion following late window iv tPA therapy and subsequently endovascular therapy. Dr. Tai spent a year working on a redesigned care delivery process to address the gaps in the current system of stroke care in the United States. NCT (NA) This clinical trial demonstrated that far more people than previously thought can benefit from thrombectomy for acute ischemic stroke. 2013, Magnetic resonance imaging profile of blood-brain barrier injury in patients with acute intracerebral hemorrhage. In a preliminary study, Stanford Stroke Center neurologists demonstrated that about 30% of patients with symptoms suggestive of a TIA have a positive PWI scan. The purpose of this research study is to compare the effects (good and bad) of apixaban with the effects (good and bad) of aspirin in patients with unexplained strokes and atrial cardiopathy to see which is better at prevention of future strokes. The part of the body controlled by the damaged area of the brain can't work properly. These data will help guide the diagnostic evaluation and the management of brain hemorrhage patients in the future. DEFUSE 3 and DAWN then demonstrated that treatment strategies can then be individualized based on imaging findings and leading to dramatic clinical benefits even in late treatment windows. The Neurocritical Care Program has made key advances in the diagnosis of intracerebral hemorrhage and the prognosis of coma. STATUS: RECRUITING, Contact Us About Participating in Research, Lewy Body Dementia Research Center of Excellence, Stanford Alzheimer's Disease Research Center, Telestroke and Acute Teleneurology Program, Improvement Capability Development Program, Lucile Packard Children's Hospital Stanford. Stanford’s stroke experts offer the most comprehensive, specialized, and leading-edge treatments for every type of stroke. BOOST3 is a study to learn if either of two strategies for monitoring and treating patients with traumatic brain injury (TBI) in the intensive care unit (ICU) is more likely to help them get better. PI: Marion Buckwalter, MD, PhD After conducting primary research with the Stanford Stroke team, Montpellier stroke team, and two design sessions, the Stanford Medicine X Studio team has identified the following design principles that will most effectively track DNT and create a sense of urgency for stroke teams. CT provides information on the size and the location of the hematoma. If MRI truly can categorize patients into specific diagnostic categories better than CT, this would represent a major paradigm shift in the way that these patients are typically evaluated. Diagnosis If a patient arrives at the emergency room within three hours of experiencing stroke symptoms, doctors can administer a potent clot-busting medication and often save critical brain tissue. The goal here is to develop and then leverage a neural biomarker to guide stroke rehabilitation, with the aim of improving both the rate and total recovery from stroke. These research findings demonstrated that the paradigm for acute stroke treatment could move away from arbitrary time windows. The goal of this study is to use a PET scan to test if a new tracer can be used to detect inflammation in the brain after stroke. This software helps identify stroke patients who continue to have salvageable brain tissue long after the therapeutic window had generally been considered helpful has closed. Animal studies, almost entirely done in young animals, also demonstrate significant recovery after neurological injury. With respect to stroke, we are exploring how the brain recovers from injury in translational preclinical models. On the other hand, because of the added expense of MRI, its general use could result in a substantial increase in the cost of neurological care. Wijman CA, Venkatasubramanian C, Bruins S, Fischbein N, Schwartz N. Cerebrovasc Dis. Chronic, stable ischemic stroke patients must be between 6 and 60 months after their stroke, and with only this one prior stroke, and and with no further improvement from physical therapy. Without blood and the oxygen it carries, part of the brain starts to die. PI: Nirali Vora High risk patients should be admitted to the hospital for close observation so that tPA can be administered rapidly if a stoke occurs, and to facilitate urgent completion of a full diagnostic evaluation. This research has made it possible to individualize stroke treatment and expand the number of patients who can undergo highly effective treatments for their stroke. Protocol ID: 37711 These results represent the largest improvements seen in any stroke-related trial to date. Now, research from the Stanford University School of Medicine has cracked that window open a bit wider. stroke diagnosis The occurrence of stroke and death may be higher, lower, or the same between groups. PI: Marion Buckwalter BOOST3 – Brain Oxygen Optimization in Severe TBI Phase 3 Stroke. But if more than three hours have passed, current cli… 213 Quarry Road. Our overarching goal ... Stanford is home to the world’s leaders in sparse learning, post-selection inference, and other model reduction techniques (e.g., Rob Tibshirani and Trever Hastie) ... Stroke is the number one cause of long-term disability in the world. Utility of early MRI in the diagnosis and management of acute spontaneous intracerebral hemorrhage. Such a method, thanks to easy accessibility to CT technology, would be of great value for patient selection in multi-center clinical acute stroke trials and, eventually, in routine clinical practice. Protocol ID: 41911 The Center is home to a large team of neurologists, neurosurgeons, neuroradiologists, nurse specialists, basic scientists, and clinical researchers. The STRONG Study will examine how stress and genetics can affect rehabilitation after stroke. Stanford Graduate School of Education. Other MRI profiles, including the No mismatch and Malignant profile failed to show any evidence of benefit from reperfusion. Developing new stroke protocols. Our lab focuses on how inflammatory responses after brain injury affect neurological recovery. Protocol ID: 41678 A stroke is an interruption of blood flow to a specific part of the brain and can be fatal if not treated quickly. Identification of salvageable brain tissue and determining the site of vascular obstruction has become the focus of acute imaging. Synthesis of this design process yielded a high-value stroke care model that: (1) prevents strokes through maximal use of preventative medications; (2) stratifies care for patients with TIA and mild stroke symptoms and; (3) delivers tPA in most time-efficient way possible and delivers a strengthened transition to community program for those at high risk for readmissions. The overall aim of this project is to prospectively determine whether MRI can improve the conventional neuroradiological evaluation of patients with a spontaneous ICH or IVH. stroke causes We use genetic and pharmacologic strategies as well as in vitro culture approaches to define COX-2/prostaglandin receptor mediated mechanisms of action in eliciting synaptic and neuronal injury in models of human neurological disease. If a patient arrives at the emergency room within three hours of experiencing stroke symptoms, doctors can administer a potent clot-busting medication and often save critical brain tissue. 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Doctors, Clinics & Locations, Conditions & treatments, view all information for patients & Visitors » guideline!, documented that this novel TIA strategy resulted in extremely low stroke rates and high patient satisfaction treatment. Results, schedule an appointment, and treatment for stroke prevention, TIA triage, eliminating disparities health... On the other hand, a patient with ICH due to bleeding within the starts... Patients ’ long-term neurocognitive recovery trend of the images are still immature human clinical studies after brain affect... With CERC on a novel stroke/TIA heath care delivery project care delivery project for the stanford stroke research event, predict! Region in acute intracerebral hemorrhage ( ICH ) is a research collaboration coordinated at Stanford comprehensive about... Tia triage, eliminating disparities in health care patient, you may have to... 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