301
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Abstract
Disruption of cerebral blood flow may influence brain energy metabolism to produce reversible or irreversible neurologic deficits. The emergency physician is in a unique position to provide timely treatment during the first few hours of an acute stroke. He or she must be facile with unique pharmacologic and non-pharmacologic treatment designed for the stroke patient concerning ventilation, blood pressure, and circulation.
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Affiliation(s)
- J F Naradzay
- Emergency Department, Park Ridge Hospital, Rochester, New York, USA
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302
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Davenport RJ, Dennis MS. Assessing the quality of care. Measuring the process of care is not always straightforward. BMJ (CLINICAL RESEARCH ED.) 1996; 312:185. [PMID: 8563562 PMCID: PMC2349855 DOI: 10.1136/bmj.312.7024.185a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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303
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Langhorne P, Wagenaar R, Partridge C. Physiotherapy after stroke: more is better? PHYSIOTHERAPY RESEARCH INTERNATIONAL 1996; 1:75-88. [PMID: 9238725 DOI: 10.1002/pri.6120010204] [Citation(s) in RCA: 175] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Physiotherapy is an established component of stroke rehabilitation but uncertainties remain about the most appropriate intensity of therapy input. We conducted a systematic review of the randomised trials of physiotherapy after stroke where qualitatively similar therapy regimens were provided at different levels of intensity. A heterogeneous group of seven randomised trials (597 patients) was identified. Dichotomous outcomes (death or the combined poor outcome of death or deterioration) were analysed by use of the odds ratio and 95% confidence interval. Patients subjected to more intensive physiotherapy input showed a non-significant reduction in case fatality (odds ratio 0.60; 95% CI 0.33-1.09) and a significant reduction (OR 0.54; 95% CI 0.34-0.85; p < 0.01) in the combined poor outcome of death or deterioration by the end of follow-up. Two statistical techniques were used to identify patterns within the continuous data. Firstly, impairment and disability scores were converted to a standardised measure of 0-100 and the weighted mean difference (WMD) between the scores in the intensive and conventional physiotherapy groups were then calculated. Modest improvements were observed in both the impairment (WMD+5; 95% CI-1-11) and disability scores (WMD+5; 95% CI 0-10) recorded at the initial review (median 3 months post-stroke), but not at the final review (median 1 year post-stroke). Secondly, Fisher's inverse chi-squared test was used to combine the p values from individual trials; this confirmed the above findings (p < 0.05 at initial review; p > 0.05 at final review). More intensive physiotherapy input was associated with a reduction in the combined poor outcome of death or deterioration and may enhance the rate of recovery. These observations warrant further investigation.
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Affiliation(s)
- P Langhorne
- Academic Section of Geriatric Medicine, Royal Infirmary, Glasgow, UK
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304
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Lincoln NB, Willis D, Philips SA, Juby LC, Berman P. Comparison of rehabilitation practice on hospital wards for stroke patients. Stroke 1996; 27:18-23. [PMID: 8553397 DOI: 10.1161/01.str.27.1.18] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE The aim of the study was to observe patients on a stroke unit and to compare their activity with that of patients on conventional hospital wards to identify aspects of rehabilitation practice that might account for differences in outcome. METHODS Stroke patients admitted to the hospital were observed on three 8-hour shifts over 3 consecutive days. An observer recorded, at 10-minute intervals, where patients were, what they were doing, and whether their positioning was as recommended by rehabilitation therapists. Patients on a stroke unit were compared with those on conventional wards. RESULTS Stroke unit patients spent less time by their beds and more time in other locations on the ward (P < .001). There were significant differences in the frequency of behaviors observed in the two types of ward (P < .001). Stroke unit patients had significantly more interaction with nurses and therapists (P < .001). They were also more often in the recommended position (P < .001). CONCLUSIONS The proportion of time in therapeutic activity was low in all locations, with patients spending many hours sitting and doing nothing. Despite this, stroke unit patients had more therapeutic contact with staff and were more often in the recommended position. These two features may account for some of the differences in outcome.
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Affiliation(s)
- N B Lincoln
- Stroke Research Unit, City Hospital, Nottingham, UK
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305
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Partridge C, Edwards S. The bases of practice--neurological physiotherapy. PHYSIOTHERAPY RESEARCH INTERNATIONAL 1996; 1:205-8. [PMID: 9238735 DOI: 10.1002/pri.59] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- C Partridge
- National Hospital for Neurology and Neurosurgery, London, UK
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306
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Abstract
The recent interest in the development of services for stroke patients reflects an increasing optimism about stroke management and the recognition that properly organised care can improve outcomes after stroke. A comprehensive stroke service should provide early assessment and investigation of stroke disease in both in-patient and out-patient settings, acute care for stroke in-patients to manage their medical and surgical problems, and rehabilitation for patients with persisting functional problems. Other components may include out-patient, day hospital or domiciliary rehabilitation facilities and continuing care and support facilities for patients discharged from hospital. This article discusses the evidence to support different components of a comprehensive stroke service and emphasises the need for flexible approaches to different local conditions.
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Affiliation(s)
- P Langhorne
- Academic Section of Geriatric Medicine, Royal Infirmary, Glasgow, UK
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307
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Dávalos A, Castillo J, Martinez-Vila E. Delay in neurological attention and stroke outcome. Cerebrovascular Diseases Study Group of the Spanish Society of Neurology. Stroke 1995; 26:2233-7. [PMID: 7491642 DOI: 10.1161/01.str.26.12.2233] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Despite efforts to reduce the delay between stroke onset and new interventional treatments, no studies have analyzed the repercussions of early neurological attention on the clinical outcome of stroke patients. METHODS Data were obtained from 721 patients admitted consecutively for a transient ischemic attack or stroke to the neurology departments of 18 Spanish hospitals that followed the same diagnostic and therapeutic guidelines in the acute phase. Factors assessed were age, sex, Canadian Stroke Scale score on admission, previous Barthel Index, and delay before attention by the first physician, by emergency services, by a neurologist, and before hospitalization. Patients' outcomes were classified as good (Barthel Index > 60) or poor (Barthel Index < or = 60 or in-hospital death) depending on patient's functional capacity on discharge. The individual contribution of each of these variables on clinical outcome was estimated with logistic regression analysis. RESULTS Patients in worse neurological condition on admission presented earlier to the first physician, emergency department, and neurologist. The mortality rate was not significantly modified by early or late presentation at the different medical stages. Logistic regression analysis revealed that the relative risk of poor outcome in patients seen by the neurologist after the first 6 hours from symptom onset was 5.6 (95% confidence interval, 3.4 to 9.2) (P < .0001). Multiple linear regression analysis showed that the delay before the patient received neurological attention correlated positively with the duration of hospitalization (P < .0001). The delays before the patient was seen by the first physician or the emergency department and before hospitalization were not independently related to clinical outcome or length of hospitalization. CONCLUSIONS Early neurological attention in acute stroke is related to better functional outcome and shorter hospitalization.
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Affiliation(s)
- A Dávalos
- Section of Neurology, Hospital Dr Josep Trueta, Girona, Spain
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308
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Abstract
BACKGROUND AND PURPOSE Stroke unit rehabilitation tends to be directed toward stroke patients with moderately severe disabilities ("the middle group"). Data collected on a stroke rehabilitation unit, however, showed improving outcome over 3 years in patients with a poor prognosis (discharge home: 48% versus 16%, P < .02; discharge Barthel Index score: 9 versus 6, P < .05). The hypothesis that stroke rehabilitation units may improve outcome in severely disabled stroke patients was tested in this study. METHODS A randomized controlled study was undertaken in 71 patients with a poor prognosis who were treated either on a stroke rehabilitation unit (n = 34) or on general wards (n = 37) to compare outcome between the two groups. Data collected were also compared with those from a methodologically similar study undertaken 3 years ago. RESULTS Severe stroke patients treated on the stroke rehabilitation unit had a significantly better outcome compared with general wards (mortality: 21% versus 46%, P < .05; discharge home 47% versus 19%, P < .01; median length of hospital stay: 43 versus 59 days, P < .02). The number of stroke unit patients being discharged home had increased significantly from the previous study, with a trend toward improvement in median discharge Barthel Index score. CONCLUSIONS Stroke rehabilitation units may improve outcome in severe stroke patients. This improvement appears to be due to the development of innovative management strategies that reduce mortality and institutionalization and enable caregivers to support more disabled stroke patients at home.
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Affiliation(s)
- L Kalra
- Orpington Stroke Unit, King's College School of Medicine and Dentistry, London, UK
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309
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Donnan GA, Davis SM. Stroke: progress at last? Med J Aust 1995; 163:343-4. [PMID: 7565256 DOI: 10.5694/j.1326-5377.1995.tb124624.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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310
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Webb DJ, Fayad PB, Wilbur C, Thomas A, Brass LM. Effects of a specialized team on stroke care. The first two years of the Yale Stroke Program. Stroke 1995; 26:1353-7. [PMID: 7631336 DOI: 10.1161/01.str.26.8.1353] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Strategies have been proposed for stroke care to improve quality or reduce cost. We sought to document the effects of a new program of specialized stroke care. METHODS In a programmatic review using historical and concurrent control subjects, we evaluated patients discharged with a stroke diagnosis (diagnosis-related group 14) over a 6-year period between January 1987 and December 1992. Patients were from an academic medical center. The intervention was consultation (on university neurology patients) by a specialized multidisciplinary team during the last 2 years of the review period. The main outcome measures were median length of stay and rate of common complications before and after implementation compared with other hospital services (private neurology and medicine). RESULTS Stroke team involvement was associated with a shortened median length of stay from 10 to 8 days (P < .0001). There was no significant change in the median length of stay for the private neurology or medicine services. After stroke team involvement, there were fewer urinary tract infections (P = .056), and those patients who developed infection had a shorter length of stay (P = .0007). There was no change in the rate of aspiration pneumonia or in length of stay for patients with aspiration pneumonia. Mortality did not change. CONCLUSIONS A coordinated, multidisciplinary approach to stroke care may reduce length of stay and morbidity in patients hospitalized because of stroke.
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Affiliation(s)
- D J Webb
- Yale Stroke Program, Department of Neurology, Yale University School of Medicine, New Haven, CT 06510-8018, USA
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311
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Jørgensen HS, Nakayama H, Raaschou HO, Olsen TS. The authors reply. Arch Phys Med Rehabil 1995. [DOI: 10.1016/s0003-9993(95)80539-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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312
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Jørgensen HS, Nakayama H, Raaschou HO, Larsen K, Hübbe P, Olsen TS. The effect of a stroke unit: reductions in mortality, discharge rate to nursing home, length of hospital stay, and cost. A community-based study. Stroke 1995; 26:1178-82. [PMID: 7604410 DOI: 10.1161/01.str.26.7.1178] [Citation(s) in RCA: 159] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Treatment of stroke patients in specialized stroke units has become more frequent, yet the effect of this treatment has not been determined. METHODS In a community-based, prospective, and consecutive study of 1241 unselected acute stroke patients, we compared outcome of stroke treatment between two neighboring communities within Greater Copenhagen: the Bispebjerg community, where all acute stroke patients are treated and rehabilitated on a stroke unit, and Frederiksberg community, where all acute stroke patients are treated and rehabilitated on general neurological and medical wards. Except for the different organization of stroke treatment, the two communities and the two patient groups were comparable. Specifically, age, sex, marital status, prestroke residence, and stroke severity were not statistically different between patients treated on the stroke unit and those treated on the general neurological and medical wards. Multivariate regression analyses were used to estimate the independent influence of stroke unit treatment on outcome. RESULTS Stroke unit treatment significantly reduced in-hospital mortality (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.34 to 0.74; P < .001), case-fatality rate (OR, 0.45; CI, 0.28 to 0.71; P < .001), 6-month mortality (OR, 0.57; CI, 0.39 to 0.82; P = .002), 1-year mortality (OR, 0.59; CI, 0.42 to 0.84; P = .003), and discharge rate to a nursing home (OR, 0.61; CI, 0.38 to 0.98; P = .04). Discharge rate to the patient's own home was significantly increased (OR, 1.90; CI, 1.30 to 2.70; P < .001). The length of hospital stay (including rehabilitation) was reduced significantly by 30% in patients treated on the stroke unit despite their lower mortality (P < .001). The savings due to stroke unit treatment were estimated at 1313 bed-days and three places at a nursing home per 100 stroke patients. CONCLUSIONS Treatment of unselected acute stroke patients on a stroke care unit saved lives, reduced the length of hospital stay, reduced the frequency of discharge to a nursing home, and potentially reduced cost.
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Affiliation(s)
- H S Jørgensen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
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313
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Abstract
BACKGROUND AND PURPOSE We sought to evaluate the effect of setting on the rate of medical complications during stroke rehabilitation. METHODS A study of the frequency and nature of medical complications in stroke rehabilitation was undertaken in 245 patients managed either on a stroke rehabilitation unit (n = 124) or on general medical wards (n = 121). The stroke unit setting was characterized by established protocols for prevention, early diagnosis, and management of complications (eg, aspiration, infections, thromboembolism, pressure sores, depression, stroke progression). Similar protocols did not exist on general medical wards except for thromboembolism, pressure sores, and secondary stroke prevention. RESULTS Medical complications were documented in 147 patients (60%) and were more common in patients with severe strokes (97%). The frequency of reported complications was similar in both settings. Aspiration (33% versus 20%; P < .01) and musculoskeletal pain (38% versus 23%; P < .05) were more commonly documented on the stroke unit, whereas urinary problems (18% versus 7%; P < .01) and infections (49% versus 25%; P < .01) were more commonly seen on general medical wards. The reported frequency of deep vein thrombi, pressure sores, and stroke progression was similar in both settings. Although depression was reported equally in both settings (34% on the stroke unit versus 27% on general wards), patients on the stroke unit were more likely to be treated compared with general wards (67% versus 36%; P < .05). CONCLUSIONS The study shows that inpatient stroke rehabilitation is a medically active service. Management on specialist units is associated with earlier detection and management of stroke-related problems and prevention of potentially life-threatening complications.
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Affiliation(s)
- L Kalra
- Orpington Stroke Unit, Bromley Hospitals NHS Trust, UK
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314
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Evans RL, Connis RT, Hendricks RD, Haselkorn JK. Multidisciplinary rehabilitation versus medical care: a meta-analysis. Soc Sci Med 1995; 40:1699-706. [PMID: 7660183 DOI: 10.1016/0277-9536(94)00286-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Research studies in physical medicine have not demonstrated the effectiveness of inpatient rehabilitation services, primarily due to differences in methodological approaches which have led to inconsistent findings. Because of differing inclusion and outcome criteria, even meta-analyses have been inconclusive. To address this problem, research literature comparing the clinical effectiveness of rehabilitation programs with medical care was evaluated for three uniformly available outcome criteria: survival; functional ability; and discharge location. Published trials were obtained from citations in Index Medicus (Medicine) and Nursing and Allied Health Abstracts covering the recent 20 year period from 1974 to 1994. We used meta-analyses to test the hypotheses that specialized rehabilitative care (vs conventional medical care) improves health outcomes. Results of our meta-analyses indicated that rehabilitation services were significantly associated with better rates of survival and improved function during hospital stay (P < 0.01), but significance was not observed at follow-up. Also, rehabilitation patients returned to their homes and remained there more frequently than controls (P < 0.001). We concluded that patients who participate in inpatient rehabilitation programs function better at hospital discharge, have a better chance of short term survival, and return home more frequently than non-participants. However, long term survival and function were the same for experimental and control subjects. The sustaining benefit of returning home may suffice to justify the provision of inpatient rehabilitation. However, the lack of other long term benefits suggests that services may need to be continued at home or in subacute care settings to optimize their effectiveness.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R L Evans
- Department of Veterans Affairs Medical Center, Seattle, WA, USA
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315
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Wolfe C, Beech R, Ratcliffe M, Rudd AG. Stroke care in Europe. Can we learn lessons from the different ways stroke is managed in different countries? JOURNAL OF THE ROYAL SOCIETY OF HEALTH 1995; 115:143-7. [PMID: 7643337 DOI: 10.1177/146642409511500303] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Stroke is a major health care problem in the European Union and consumes significant resources. The mortality rates from stroke and treatment strategies vary significantly between member states. Only by comparison between centres in different member states with differing health care delivery can the effect of these varying approaches to the management of stroke on outcome be assessed. Conducting a study on a European wide basis in centres which are known to differ in terms of treatment strategies and outcomes allows an immediate analysis of the effectiveness, resource requirements and cost of different methods of managing stroke patients. This paper addresses the current burden of stroke and strategies for its management. An outline of a European Union project, assessing how stroke is managed in different countries, is provided with the aim of indicating a strategy for discovering and promoting more cost-effective services for stroke care in the future.
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Affiliation(s)
- C Wolfe
- Department of Public Health Medicine, United Medical School of Guy's Hospital, London
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316
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Lázaro M, Cruz-Jentoft AJ, Ribera JM. The role of geriatric consultation in elderly urologic patients. AGING (MILAN, ITALY) 1995; 7:240-1. [PMID: 8547385 DOI: 10.1007/bf03324323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- M Lázaro
- Servicio de Geriatría, Hospital Universitario San Carlos, Madrid, Spain
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317
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Jørgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J, Støier M, Olsen TS. Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995; 76:406-12. [PMID: 7741609 DOI: 10.1016/s0003-9993(95)80568-0] [Citation(s) in RCA: 580] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To determine the time course of both neurological and functional recovery from stroke. DESIGN Prospective, consecutive, and community based. SETTING The stroke unit of a hospital in Copenhagen, Denmark. This setting receives all acute stroke patients admitted from a well-defined catchment area of 239,886 inhabitants within the city of Copenhagen. Acute treatment as well as all stages of rehabilitation are cared for within the stroke unit regardless of age, stroke severity, and premorbid condition. PATIENTS 1,197 patients with acute stroke. MAIN OUTCOME MEASURES Weekly examinations of neurological deficits (using the Scandinavian Neurological Stroke Scale) and functional disabilities (Activity of Daily Living (ADL) measured by the Barthel Index) were performed from the time of acute admission to the end of rehabilitation. These evaluations were repeated 6 months poststroke. Time course of recovery was stratified according to initial stroke severity and disability. RESULTS Functional recovery was completed within 12.5 weeks (95% confidence interval (CI) 11.6 to 13.4) from stroke onset in 95% of the patients. However, 80% of the patients had reached their best ADL function within 6 weeks (CI 5.3 to 6.7) from onset. The time course of functional recovery was strongly related to initial stroke severity. Best ADL function was reached within 8.5 weeks (CI 8 to 9) in patients with initially mild strokes, within 13 weeks (CI 12 to 14) in patients with moderate strokes, within 17 weeks (CI 15 to 19) in patients with severe strokes, and within 20 weeks (CI 16 to 24) in patients with very severe strokes. After these time-points, no significant changes occurred. However, a valid prognosis of functional outcome can be made much earlier. Best ADL function was reached by 80% of the patients with initially mild strokes within 3 weeks (CI 2.6 to 3.4), within 7 weeks (CI 6 to 8) of the patients with moderate strokes, and within 11.5 weeks (CI 10 to 13) of the patients with severe and very severe strokes. The time course of neurological recovery followed a pattern similar to that of functional recovery, but preceeded functional recovery by 2 weeks on average. CONCLUSIONS A reliable prognosis can in all stroke patients be made within 12 weeks from stroke onset. Even in patients with severe and very severe strokes, neurological and functional recovery should not be expected after the first 5 months.
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Affiliation(s)
- H S Jørgensen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
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318
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Jørgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J, Støier M, Olsen TS. Outcome and time course of recovery in stroke. Part I: Outcome. The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995; 76:399-405. [PMID: 7741608 DOI: 10.1016/s0003-9993(95)80567-2] [Citation(s) in RCA: 334] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate the outcome of stroke stratified according to both initial stroke severity and initial level of disability. DESIGN Prospective, consecutive, and community based. SETTING A stroke unit of a hospital in Denmark. This setting receives all acute stroke patients admitted from a well-defined catchment area of 239,886 inhabitants within the City of Copenhagen. Acute treatment as well as all stages of rehabilitation are cared for within the stroke unit regardless of age, stroke severity, and premorbid condition. PATIENTS 1197 patients with acute stroke. MAIN OUTCOME MEASURES Primary outcome was measured as death, discharge to nursing home, or to own home. Secondary outcome was measured as neurological deficits and functional disabilities after completed rehabilitation and again 6 months after stroke onset, using the Scandinavian Neurological Stroke Scale and the Barthel Index. RESULTS Stroke was initially very severe in 223 (19%) of the patients, severe in 171 (14%), moderate in 316 (26%), and mild in 487 (41%) patients. Two hundred and fifty (21%) patients died during hospital stay, 177 (15%) were discharged to nursing home, and 770 (64%) patients were discharged to their own home. After completed rehabilitation, 11% of survivors still had severe or very severe neurological deficits, 11% had moderate deficits, and 78% had no or only mild deficits; 20% were severely or very severely disabled, 8% were moderately disabled, 26% were mildly disabled, and 46% had no disability in activities of daily living. Detailed information on outcome stratified according to initial stroke severity/disability also is presented. CONCLUSIONS This study provides a thorough description of the needs for stroke rehabilitation in the community and the amount of postrehabilitation disability in stroke survivors. For outcome prediction, the results can be used as a reliable tool for prognostication of the chances (or risks) of various outcomes in patients characterized by initial degree of stroke severity and/or functional disability using simple, reliable scores in the acute phase of stroke. However, the results should not be used as a guideline for selecting patients for rehabilitation in the acute phase because even the most severe cases regularly experience meaningful improvement during rehabilitation.
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Affiliation(s)
- H S Jørgensen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
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319
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Counsell C, Warlow C, Sandercock P, Fraser H, van Gijn J. The Cochrane Collaboration Stroke Review Group. Stroke 1995. [DOI: 10.1161/01.str.26.3.498] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
There is a pressing need to identify which interventions are definitely effective in the prevention of stroke and in the treatment and rehabilitation of stroke patients, which interventions are definitely ineffective, and which interventions require further research. This information is most reliably obtained from reviewing all the available evidence from randomized controlled trials in a systematic way.
Summary of Comment
There have been many (at least 800) randomized controlled trials relevant to stroke. It would be difficult for any one individual to keep track of all these trials, and therefore most clinicians, therapists, and researchers are dependent, to some degree, on reviews of this literature. However, most current reviews are unsystematic and tend to be either incomplete or biased, so that their recommendations can be seriously flawed. Until now there has been no attempt to systematically identify all randomized controlled trials relevant to stroke (including subarachnoid hemorrhage), to review the data they contain, and to keep these reviews up-to-date in the light of new evidence. The Stroke Review Group has now been established within the Cochrane Collaboration to try to perform these tasks. There are presently 40 collaborators from 13 countries working on approximately 25 reviews.
Conclusions
Identifying and reviewing all randomized controlled trials relevant to stroke should bring important benefits to patients and all those involved in purchasing or providing care for patients with stroke. The Cochrane Collaboration Stroke Review Group has started this process and would welcome help from anyone interested in collaborating in this enormous task.
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Affiliation(s)
- Carl Counsell
- From the Department of Clinical Neurosciences, Western General Hospital, Edinburgh, United Kingdom (C.C., C.W., P.S., H.F.), and the Department of Neurology, University of Utrecht (Netherlands) (J. van G.)
| | - Charles Warlow
- From the Department of Clinical Neurosciences, Western General Hospital, Edinburgh, United Kingdom (C.C., C.W., P.S., H.F.), and the Department of Neurology, University of Utrecht (Netherlands) (J. van G.)
| | - Peter Sandercock
- From the Department of Clinical Neurosciences, Western General Hospital, Edinburgh, United Kingdom (C.C., C.W., P.S., H.F.), and the Department of Neurology, University of Utrecht (Netherlands) (J. van G.)
| | - Hazel Fraser
- From the Department of Clinical Neurosciences, Western General Hospital, Edinburgh, United Kingdom (C.C., C.W., P.S., H.F.), and the Department of Neurology, University of Utrecht (Netherlands) (J. van G.)
| | - Jan van Gijn
- From the Department of Clinical Neurosciences, Western General Hospital, Edinburgh, United Kingdom (C.C., C.W., P.S., H.F.), and the Department of Neurology, University of Utrecht (Netherlands) (J. van G.)
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320
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Kaste M, Palomäki H, Sarna S. Where and how should elderly stroke patients be treated? A randomized trial. Stroke 1995; 26:249-53. [PMID: 7831697 DOI: 10.1161/01.str.26.2.249] [Citation(s) in RCA: 107] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE Elderly stroke patients in particular are at risk of receiving less than optimal care. We studied the effects of the department care (medicine versus neurology) on the outcome of elderly stroke patients in a randomized controlled trial with 1-year follow-up. METHODS A total of 243 consecutive patients aged 65 years or older with acute stroke were randomized to receive care in the Departments of Medicine or the Department of Neurology of a university teaching hospital with a referral area of 1.1 million. The outcome was assessed by mortality, length of hospital stay, ability to live at home on discharge, Barthel Index, and Rankin grades at 1 year. RESULTS There were no differences in sex and age, severity or type of stroke, other diseases, or social factors between the two groups. One-year mortality was 21% in both patients treated by the Departments of Medicine and those treated by the Department of Neurology. Patients treated by the Department of Neurology were discharged an average of 16 days earlier (24 versus 40 days). The length of hospital stay of patients aged younger than 75 years differed significantly (P = .02). Patients randomized to neurological wards more often went directly home (75% versus 62%; P = .03), and their functional status was better as assessed with Barthel Index and Rankin grades at 1 year (P = .02 and P = .03, respectively). Independent predictors of a better functional outcome and shorter hospital stay by stepwise multivariate analysis included management by the Department of Neurology. CONCLUSIONS Well-organized management of elderly stroke patients was associated with a better outcome. It was also the more economical alternative.
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Affiliation(s)
- M Kaste
- Department of Neurology, University of Helsinki, Finland
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321
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Shahar E, McGovern PG, Sprafka JM, Pankow JS, Doliszny KM, Luepker RV, Blackburn H. Improved survival of stroke patients during the 1980s. The Minnesota Stroke Survey. Stroke 1995; 26:1-6. [PMID: 7839376 DOI: 10.1161/01.str.26.1.1] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE The underlying reasons for the decline in stroke mortality in the United States are not well understood and have been the subject of ongoing debate. This study was undertaken to determine whether survival of hospitalized stroke patients has changed during the 1980s, thereby contributing to the decline in stroke mortality during that period. METHODS For the years 1980, 1985, and 1990, we obtained listings of discharge diagnoses from hospitals in the Minneapolis-St Paul metropolitan area and identified all hospitalizations with a discharge diagnosis code of acute cerebrovascular disease according to the International Classification of Diseases, 9th Revision. A 50% random sample of men and women aged 30 to 74 years was selected in each survey for detailed medical record abstraction. Standardized sets of criteria for stroke were then used to validate acute stroke events throughout the 1980s. Each of the three period cohorts of hospitalized stroke patients (1980, 1985, and 1990) was followed for at least 2 years for all-cause mortality end point. RESULTS A total of 1853 patients met minimal criteria for acute stroke: 564 patients in 1980, 598 patients in 1985, and 691 patients in 1990. Controlling for age, the odds of death within 2 years after stroke were approximately 40% lower in 1990 than in 1980. The relative odds of 2-year death in 1990 (versus 1980) were 0.65 (95% confidence interval, 0.47 to 0.89) and 0.60 (95% confidence interval, 0.42 to 0.85) for men and women, respectively. The improved survival was evident in the short term (28 days) as well as for stroke patients who survived that period. Analysis according to stroke subtype revealed that improved survival of ischemic stroke and specifically of stroke with no apparent cardioembolic source largely accounted for the overall trend. The prognosis of stroke patients who were admitted in a comatose state has not changed during that decade. CONCLUSIONS Despite the absence of any clear major advances in acute stroke therapy, survival of stroke patients substantially improved during the 1980s. The underlying reasons for this unexpected yet remarkable trend remain uncertain but may include improved supportive and rehabilitative care of stroke victims as well as a change in the natural history of the disease.
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Affiliation(s)
- E Shahar
- Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis 55454-1015
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323
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Davis SM. Tissue rescue therapy for acute ischaemic stroke. J Clin Neurosci 1995; 2:7-15. [DOI: 10.1016/0967-5868(95)90023-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/1994] [Accepted: 08/05/1994] [Indexed: 11/15/2022]
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324
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Abstract
Medical treatments which presumably alter cerebral blood flow (CBF) have been quite unimpressive in their effect on stroke outcome. In considering experimental and clinical data from the use of haemodilution and of the antiplatelet agent prostacyclin in focal cerebral ischaemia, and the current work with fibrinolytic agents in acute stroke, several lessons are apparent. Often agents hypothesized to affect CBF receive an underserved reputation based on sparse experimental evidence. Significant even unsuspected differences between species limit application to the clinical setting. Limitations of CBF measurements in experimental models and in humans raise questions about apparent responses to those agents. The failure to confirm a relationship between CBF enhancement and reduction in infarct development experimentally has plagued these approaches. The need for early application of agents which may modulate CBF during cerebral ischaemia is critical. Attention to these general issues and careful application of appropriate models are necessary so that a potentially useful therapeutic intervention is not overlooked.
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Affiliation(s)
- G J Del Zoppo
- Department of Molecular and Experimental Medicine, Scripps Research Institute, La Jolla, CA
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325
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Allison SP. Is routine computed tomography in strokes unnecessary? Costs outweigh benefits. BMJ (CLINICAL RESEARCH ED.) 1994; 309:1499-500. [PMID: 7804061 PMCID: PMC2541599 DOI: 10.1136/bmj.309.6967.1499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Until the results of early intervention trials are known, computed tomography should be used selectively rather than routinely in all patients with stroke. Scanning may be advised in young patients (under 65 years) or in those with an atypical course where there is diagnostic doubt and computed tomography would influence management. The cost and medicolegal implications of routine scanning are enormous and should be considered carefully in relation to other and possibly more effective strategies.
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326
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Lincoln NB. Is stroke better managed in the community? Only hospitals can provide the required skills. BMJ (CLINICAL RESEARCH ED.) 1994; 309:1357-8. [PMID: 7866087 PMCID: PMC2541842 DOI: 10.1136/bmj.309.6965.1357] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- N B Lincoln
- Stroke Research Unit, City Hospital, Nottingham
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327
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Dennis M, Langhorne P. So stroke units save lives: where do we go from here? BMJ (CLINICAL RESEARCH ED.) 1994; 309:1273-7. [PMID: 7888851 PMCID: PMC2541829 DOI: 10.1136/bmj.309.6964.1273] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- M Dennis
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh
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328
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Young GB, Thrasher D. Planning care for neurology and neurosurgery patients with critical illnesses. Neurol Sci 1994; 21:295-8. [PMID: 7874612 DOI: 10.1017/s0317167100040853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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329
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Evans RL, Connis RT, Haselkorn JK, Hendricks RD. Can meta-analysis help determine whether rehabilitation medicine improves outcome? Psychol Rep 1994; 75:849-50. [PMID: 7862795 DOI: 10.2466/pr0.1994.75.2.849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Critical assessment of current meta-analyses of research evaluating outcomes of programs in rehabilitation is presented as are recommendations for use of appropriate selection criteria and data in future meta-analyses.
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Affiliation(s)
- R L Evans
- Department of Veterans Affairs Medical Center, Seattle, WA 98108
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330
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Adams HP, Brott TG, Crowell RM, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Marler JR, Woolson RF, Zivin JA. Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 1994; 90:1588-601. [PMID: 8087974 DOI: 10.1161/01.cir.90.3.1588] [Citation(s) in RCA: 83] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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331
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Adams HP, Brott TG, Crowell RM, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Marler JR, Woolson RF, Zivin JA. Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994; 25:1901-14. [PMID: 8073477 DOI: 10.1161/01.str.25.9.1901] [Citation(s) in RCA: 225] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
BACKGROUND AND PURPOSE Most strokes occur among people aged 65 years and older. The increasing proportion of persons who are in this age group underlines the importance for health-care providers to be aware of trends in poststroke survival. We investigated poststroke survival trends from 1985 to 1989 among Medicare beneficiaries. METHODS Medicare hospital claim records and enrollment data were obtained on 1 901 439 Medicare patients with a principal diagnosis of stroke occurring during the years 1985 through 1989. Cox proportional hazard techniques were used to compare the 2-year poststroke survival for strokes occurring in 1986, 1987, 1988, and 1989 relative to strokes occurring in 1985. Poststroke survival trends were examined among groups defined by age, race, region, type of stroke, and, for a 20% subset, history of stroke. RESULTS We observed a modest improvement in poststroke survival from 1985 to 1989 (1989:1985 hazard ratio, 0.96; P < .05). Trends for persons with hemorrhagic stroke showed more improvement (hazard ratio, 0.88; P < .05) than those for persons with ischemic stroke (hazard ratio, 0.98; P < .05). Improvement was also greater among persons without known prior hospitalization for stroke (hazard ratio, 0.94; P < .05) and during periods of follow-up shorter than 2 years. CONCLUSIONS The variations in poststroke survival among subgroups of the population have important implications for the quality of life of stroke survivors and for the future medical and nursing needs of these populations.
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Affiliation(s)
- D S May
- Office of Surveillance and Analysis, Centers for Disease Control and Prevention, Atlanta, Ga
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333
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Affiliation(s)
- M Peckham
- Department of Health, Richmond House, Whitehall, London, UK
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Leys D, Hommel M, Woimant F, Pruvo JP. [Treatment of cerebral ischemia in its acute phase and prospectives]. Rev Med Interne 1994; 15:350-6. [PMID: 8059163 DOI: 10.1016/s0248-8663(05)81444-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
At the acute stage of cerebral ischemia, the "therapeutic window" probably does not last more than 6-12 hours. Despite similar treatments, patients admitted in stroke specialist units are more likely to survive and to have a good functional outcome than patients treated in general wards. In most cases acute arterial hypertension should not be treated. Thrombolytic agents given within 6 hours after onset, are now under evaluation in several clinical trials. There is no scientific evidence to support the use of anti-coagulation as a curative treatment of acute cerebral ischemia; however, clinical trials remain necessary, especially in progressing stroke. Neuroprotective drugs protect neurons against the consequences of hypoxia in animals: most clinical trials with oral nimodipine led to negative results but the meta-analysis suggests that patients receiving nimodipine within 12 hours after stroke onset might have a lower mortality rate and a better functional outcome. Other clinical trials with neuroprotective drugs are currently running: anti-NMDA drugs, chlomethiazol, tirilazad, ganglioside GM 1, etc Most therapeutic agents are now under evaluation. An early admission of patients with acute stroke is required to evaluate therapeutics agents which probably cannot be effective if started more than 6-12 hours after stroke onset.
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Affiliation(s)
- D Leys
- Groupe neurovasculaire lillois, CHU de Lille, hôpital B, France
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335
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Affiliation(s)
- P Humphrey
- Walton Centre for Neurology and Neurosurgery, Liverpool, UK
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336
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Counsell CE, Fraser H, Sandercock PA. Archie Cochrane's challenge: can periodically updated reviews of all randomised controlled trials relevant to neurology and neurosurgery be produced? J Neurol Neurosurg Psychiatry 1994; 57:529-33. [PMID: 8201319 PMCID: PMC1072909 DOI: 10.1136/jnnp.57.5.529] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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337
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Abstract
BACKGROUND AND PURPOSE Shorter lengths of hospital stay in stroke units could be due to quicker functional recovery or mechanisms of expediting hospital discharge. METHODS Stroke survivors with an intermediate prognosis at 2 weeks after stroke (n = 146) were randomized for management in a stroke rehabilitation unit or in general wards. Barthel scores were monitored at weekly intervals until hospital discharge. The duration and type of physiotherapy and occupational therapy received by patients in either setting were also recorded. The rate of change of Barthel scores, therapy input, and the duration of hospital stay were compared between the two settings. RESULTS Neurological deficits and median initial Barthel scores were comparable between patients in the stroke unit (n = 73) and general wards (n = 68). Median discharge Barthel score of patients managed in the stroke unit was significantly higher than that of patients managed in general wards (15 versus 12). Median Barthel scores in the stroke unit group rose rapidly after 2 weeks, reaching a plateau at 6 weeks. The change in median Barthel score in patients in general wards was significantly slower, reaching a plateau at 12 weeks despite similar therapy input. There was a significant delay in discharging stroke patients in general wards (20 weeks) compared with those in the stroke unit (6 weeks). CONCLUSIONS Functional recovery is significantly greater and more rapid in a stroke rehabilitation unit compared with general wards despite similar therapy input. These units also shorten hospital lengths of stay by expediting appropriate discharges.
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Affiliation(s)
- L Kalra
- Orpington Stroke Unit, Bromley Hospitals, UK
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338
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Hankey GJ. What's New? Med J Aust 1994. [DOI: 10.5694/j.1326-5377.1994.tb125837.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Graeme J Hankey
- Department of NeurologyRoyal Perth Hospital Wellington Street Perth WA 6001
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339
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Affiliation(s)
- C F Bladin
- Stroke Research Unit, University of Toronto, Canada
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340
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Affiliation(s)
- D T Wade
- Rivermead Rehabilitation Centre, Oxford
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341
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