A systematic review and critical appraisal of quality measures for the emergency care of acute ischemic stroke

Seventh Cervical Nerve (C7) Transection for Spastic Arm Paralysis After Cerebral Injury

BACKGROUND

Spastic limb paralysis because of cerebral injury can cause long-term disability. Its treatment varies from conservative to operative; however, the optimum treatment is yet to be found.

OBJECTIVE

To test the hypothesis that patients with spastic arm paralysis who receive C7 nerve transection to their paralyzed side might have reduction in spasticity, pain, and improvement in arm function.

METHODS

Four patients with spastic hemiparesis that had ceased to improve after 1 year of rehabilitation, having pain and poor function, were included. All 4 patients underwent C7 nerve transection plus rehabilitation. The outcome was assessed at 1, 3, and 6 months by the Fugl-Meyer upper extremity scale for motor recovery, by the Modified Ashworth Scale score for spasticity, and by the visual analogue score for pain. Functional use of the limb was also assessed by performance of activities such as dressing, tying shoe laces, wringing a towel, and operating a mobile phone.

RESULTS

At the end of 6 months, there was a significant improvement in mean Fugl Meyer score, reduction in Modified Ashworth score, and Visual Analogue scale for pain. At the beginning of the study, none of the patients could perform any day-to-day activities; however, at the end of 6 months, 3/4 of the patients could perform at least 1 activity.

CONCLUSION

C7 neurectomy leads to improved motor function, reduction of spasticity and pain, and improvement in function in patients with spastic arm paralysis because of cerebral injury.

A Quality Measurement Framework for Emergency Department Care of Psychiatric Emergencies

As a primary access point for crisis psychiatric care, the emergency department (ED) is uniquely positioned to improve the quality of care and outcomes for patients with psychiatric emergencies. Quality measurement is the first key step in understanding the gaps and variations in emergency psychiatric care to guide quality improvement initiatives. Our objective was to develop a quality measurement framework informed by a comprehensive review and gap analysis of quality measures for ED psychiatric care. We conducted a systematic literature review and convened an expert panel in emergency medicine, psychiatry, and quality improvement to consider if and how existing quality measures evaluate the delivery of emergency psychiatric care in the ED setting. The expert panel reviewed 48 measures, of which 5 were standardized, and 3 had active National Quality Forum endorsement. Drawing from the measure appraisal, we developed a quality measurement framework with specific structural, process, and outcome measures across the ED care continuum. This framework can help shape an emergency medicine roadmap for future clinical quality improvement initiatives, research, and advocacy work designed to improve outcomes for patients presenting with psychiatric emergencies.

Reconstruction of paralyzed arm function in patients with hemiplegia through contralateral seventh cervical nerve cross transfer: a multicenter study and real-world practice guidance

BACKGROUND

A previous randomized controlled trial showed contralateral seventh cervical nerve (CC7) cross transfer to be safe and effective in restoring the arm function of spastic arm paralysis patients in a specified population. Guidance on indications, safety and expected long-term improvements of the surgery are needed for clinical practice.

METHODS

This is a retrospective, multicenter, propensity score-matched cohort study. All patients registered between 2013 and 2019 with unilateral spastic arm paralysis over 1 year who were registered at one of five centers in China and South Korea were included. Patients received CC7 cross transfer or rehabilitation treatment in each center. Primary outcome was the change in the upper-extremity Fugl-Meyer (UEFM) score from baseline to 2-year follow-up; larger increase indicated better functional improvements.

FINDINGS

The analysis included 425 eligible patients. After propensity score matching, 336 patients who were 1:1 matched into surgery and rehabilitation groups. Compared to previous trial, patient population was expanded on age (< 12 and > 45 years old), duration of disease (< 5 years) and severity of paralysis (severe disabled patients with UEFM < 20 points). In matched patients, the overall increases of UEFM score from preoperative evaluation to 2-year follow-up were 15.14 in the surgery group and 2.35 in the rehabilitation group (difference, 12.79; 95% CI: 12.02-13.56, p < 0.001). This increase was 16.58 at 3-year and 18.42 at 5-year follow-up compared with the surgery group baseline. Subgroup analysis revealed substantial increase on UEFM score in each subgroup of age, duration of disease, severity of paralysis and cause of injury. No severe complication or disabling sequela were reported in the surgery group.

INTERPRETATION

This study showed that CC7 cross transfer can provide effective, safe and stable functional improvements in long-term follow-up, and provided evidences for expanding the indications of the surgery to a wider population of patients with hemiplegia.

Combination of pregabalin and transcutaneous electrical nerve stimulation for neuropathic pain in a stroke patient after contralateral C7 nerve transfer: a case report

BACKGROUND

Contralateral C7 nerve transfer is a new surgical treatment for stroke patients with unilateral upper extremity paralysis, but neuropathic pain in the nonparalyzed side is the common complication after surgery. We report a stroke patient with neuropathic pain after C7 nerve transfer who received combination treatment of transcutaneous electrical nerve stimulation(TENS) and pregabalin.

CASE SUMMARY

A 53-year old, 6 months post-stroke patient with right hemiplegia after contralateral C7 nerve transfer was admitted in our department with a significant neuropathic pain in his left upper extremity. The treatment of pregabalin and TENS were used for patient. The visual analogue scale(VAS), medical outcomes study sleep scale(MOS-SS) and hospital anxiety and depression scale(HADS) were assessed after 1 months treatment. After treatment, the pain of his nonparalyzed upper extremity was relieved, the sleeping quality and the anxiety and depression were improved in patient.

CONCLUSION

This report suggests that the combination of pregabalin and TENS have prominent clinical effects on neuropathic pain of nonparalyzed side in stroke patients after contralateral C7 nerve transfer.

Contralateral cervical seventh nerve transfer for spastic arm paralysis via a modified prespinal route: a cadaveric study

BACKGROUND

We proposed contralateral cervical seventh nerve transfer for spastic arm paralysis after central neurological injury in the New England Journal of Medicine (NEJM) in 2018. In this surgery, we applied a new surgical route for nerve transfer, the Huashan prespinal route. The objective of this study was to elaborate our new surgical technique, clarify its relationship to the vertebral artery, and provide anatomical data on this novel method.

METHODS

The effectiveness and safety of the Huashan prespinal route in contralateral C7 nerve transfer were evaluated anatomically. Nine cadavers (4 males, 5 females) were available for this study. Among these, anatomical parameters of the vertebral artery were obtained from 6 cadavers, and the anastomosis of the bilateral cervical seventh nerve was observed on 3 cadavers undergoing contralateral C7 nerve transfer via the Huashan prespinal route.

RESULTS

Tension-free anastomosis of the bilateral cervical seventh nerve was achieved through the Huashan prespinal route. The tilt angle of the vertebral artery to the sagittal plane (with thyroid cartilage as the origin) was 25.5 ± 4.5°, at 22.5 ± 1.6° and 28.7 ± 4.3° on the left and right side, respectively. The safe drilling angle to penetrate through the longus colli muscles for the creation of a longus colli muscle tunnel to avoid injury to the vertebral artery in our surgical technique was above 33.2°.

CONCLUSIONS

The cadaveric study confirms that the presented technique allowed simple, effective, and safe contralateral C7 nerve transfer. This technique can be used in the treatment of hemiplegia and brachial plexus injury. There is a safe scope of drilling angle for creating the longus colli muscle tunnel required for this surgical route. The anatomical parameters obtained in this study will be helpful for the performance of this operation.

Simple Grading for Motor Function in Spastic Arm Paralysis: Hua-Shan Grading of Upper Extremity

OBJECTIVE

Spastic arm paralysis after central neurological injury has a long-term effect on the patient's quality of life. Effective neurosurgical treatment for this dysfunction has been described in our previous studies. It is of great significance to determine a set of unified and concise clinical standards for motor function grading in the neurosurgical treatment and management.

METHODS

We first conducted a retrospective study that included 51 hemiplegic patients from the Neurosurgery and Microsurgery outpatient database of Huashan Hospital. The neurosurgeons cooperated with rehabilitation experts to design and administer the new rating system (Hua-Shan Grading of Upper Extremity, H-S grading) after analyzing the scale scores and video records of these patients. We then randomly enrolled 64 patients with unilateral spastic arm paralysis after stroke or brain trauma. The Fugl-Meyer Assessment, the Ashworth scale and the new grading system were applied and analyzed to evaluate the participants' motor function.

RESULTS

Based on rehabilitation medicine scales and long-term follow-up, a feasible and concise grading system was applied that was based on the patients' characteristics and the examination experiences of neurosurgeons and rehabilitation experts in clinical practice. This method could effectively grade upper extremity motor function, usually in 3-5 minutes. A significant correlation was found between H-S grading and the Fugl-Meyer score by the Spearman test (r = .937, P < .01). The mean difference between any two levels of the new grading system was significant (P < .05). And good test-retest reliability, the Cronbach's alpha coefficient and the validity indices were presented. In addition, it was more sensitive to motor function compared with the Ashworth scale.

CONCLUSION

As a supplement to the classic scales, H-S grading was developed in the area of spastic hemiplegia treatment. It is standardized and simplified for patients in the chronic stage after central neurological injury.

Quality Measures in Foot and Ankle Care

BACKGROUND

Quality measures may be operationalized in payment models or quality reporting programs to assess foot and ankle surgeons, but if existing measures allow accurate representation of a foot and ankle surgeon's practice is unclear.

METHODS

National quality measures databases, clinical guidelines, and MEDLINE/PubMed were systematically reviewed for quality measures relevant to foot and ankle care. Measures meeting internal criteria were categorized by clinical diagnosis, National Quality Strategy priority, and Donabedian domain.

RESULTS

Of 12 quality measures and 16 candidate measures, National Quality Strategy priorities most commonly addressed "Effective Clinical Care" (n = 19) and "Communication and Coordination of Care" (n = 6). Donabedian classifications addressed were process (n = 25) and outcome (n = 3). Diabetic foot care was most commonly addressed (n = 18).

CONCLUSIONS

Available foot and ankle quality measures are limited in number and scope, which may hinder appropriate assessment of care, analysis of trends, and quality improvement. Additional measures are needed to support the transition to a value-based system.

LEVEL OF EVIDENCE

Level I.

What Is the State of Quality Measurement in Spine Surgery?

BACKGROUND

Value-based healthcare models rely on quality measures to evaluate the efficacy of healthcare delivery and to identify areas for improvement. Quality measure research in other areas of health care has generally shown that there is a limited number of available quality measures and that those that exist disproportionately focus on processes as opposed to outcomes. The purpose of this study was to assess the current state of quality measures and candidate quality measures in spine surgery.

QUESTIONS/PURPOSES

(1) How many quality measures and candidate quality measures are currently available? (2) According to Donabedian domains and National Quality Strategy (NQS) priorities, what aspects or domains of care do the present quality measures and candidate quality measures represent?

METHODS

We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures relevant to spine surgery. A systematic search for candidate quality measures was also performed using MEDLINE/PubMed and Embase as well as publications from the American Academy of Orthopaedic Surgeons, Congress of Neurological Surgeons, and the North American Spine Society. Clinical practice guidelines were included as candidate quality measures if their development was in accordance with Institute of Medicine criteria for the development of clinical practice guidelines, they were based on consistent clinical evidence including at least one Level I study, and they carried the strongest possible recommendation by the developing body. Quality measures and candidate quality measures were then pooled for analysis and categorized by clinical focus, NQS priority, and Donabedian domain. Our initial search yielded a total of 3940 articles, clinical practice guidelines, and quality measures, 74 of which met criteria for inclusion in this study.

RESULTS

Of the 74 measures studied, 29 (39%) were quality measures and 45 (61%) were candidate quality measures. Fifty of 74 (68%) were specific to the care of the spine, and 24 of 74 (32%) were related to the general care of spine patients. The majority of the spine-specific measures were process measures (45 [90%]) and focused on the NQS priority of "Effective Clinical Care" (44 [88%]). The majority of the general care measures were also process measures (14 [58%]), the highest portion of which focused on the NQS priority of "Patient Safety" (10 [42%]).

CONCLUSIONS

Given the large number of pathologies treated by spine surgeons, the limited number of available quality measures and candidate quality measures in spine surgery is inadequate to support the transition to a value-based care model. Additionally, current measures disproportionately focus on certain aspects or domains of care, which may hinder the ability to appropriately judge an episode of care, extract usable data, and improve quality. Physicians can steward the creation of meaningful quality measures by participating in clinical practice guideline development, assisting with the creation and submission of formal quality measures, and conducting the high-quality research on which effective guidelines and quality measures depend.

Trial of Contralateral Seventh Cervical Nerve Transfer for Spastic Arm Paralysis

BACKGROUND

Spastic limb paralysis due to injury to a cerebral hemisphere can cause long-term disability. We investigated the effect of grafting the contralateral C7 nerve from the nonparalyzed side to the paralyzed side in patients with spastic arm paralysis due to chronic cerebral injury.

METHODS

We randomly assigned 36 patients who had had unilateral arm paralysis for more than 5 years to undergo C7 nerve transfer plus rehabilitation (18 patients) or to undergo rehabilitation alone (18 patients). The primary outcome was the change from baseline to month 12 in the total score on the Fugl-Meyer upper-extremity scale (scores range from 0 to 66, with higher scores indicating better function). Results The mean increase in Fugl-Meyer score in the paralyzed arm was 17.7 in the surgery group and 2.6 in the control group (difference, 15.1; 95% confidence interval, 12.2 to 17.9; P<0.001). With regard to improvements in spasticity as measured on the Modified Ashworth Scale (an assessment of five joints, each scored from 0 to 5, with higher scores indicating more spasticity), the smallest between-group difference was in the thumb, with 6, 9, and 3 patients in the surgery group having a 2-unit improvement, a 1-unit improvement, or no change, respectively, as compared with 1, 6, and 7 patients in the control group (P=0.02). Transcranial magnetic stimulation and functional imaging showed connectivity between the ipsilateral hemisphere and the paralyzed arm. There were no significant differences from baseline to month 12 in power, tactile threshold, or two-point discrimination in the hand on the side of the donor graft.

RESULTS

The mean increase in Fugl-Meyer score in the paralyzed arm was 17.7 in the surgery group and 2.6 in the control group (difference, 15.1; 95% confidence interval, 12.2 to 17.9; P<0.001). With regard to improvements in spasticity as measured on the Modified Ashworth Scale (an assessment of five joints, each scored from 0 to 5, with higher scores indicating more spasticity), the smallest between-group difference was in the thumb, with 6, 9, and 3 patients in the surgery group having a 2-unit improvement, a 1-unit improvement, or no change, respectively, as compared with 1, 6, and 7 patients in the control group (P=0.02). Transcranial magnetic stimulation and functional imaging showed connectivity between the ipsilateral hemisphere and the paralyzed arm. There were no significant differences from baseline to month 12 in power, tactile threshold, or two-point discrimination in the hand on the side of the donor graft.

CONCLUSIONS

In this single-center trial involving patients who had had unilateral arm paralysis due to chronic cerebral injury for more than 5 years, transfer of the C7 nerve from the nonparalyzed side to the side of the arm that was paralyzed was associated with a greater improvement in function and reduction of spasticity than rehabilitation alone over a period of 12 months. Physiological connectivity developed between the ipsilateral cerebral hemisphere and the paralyzed hand. (Funded by the National Natural Science Foundation of China and others; Chinese Clinical Trial Registry number, 13004466 .).

Role of Interleukin-10 in Acute Brain Injuries

Interleukin-10 (IL-10) is an important anti-inflammatory cytokine expressed in response to brain injury, where it facilitates the resolution of inflammatory cascades, which if prolonged causes secondary brain damage. Here, we comprehensively review the current knowledge regarding the role of IL-10 in modulating outcomes following acute brain injury, including traumatic brain injury (TBI) and the various stroke subtypes. The vascular endothelium is closely tied to the pathophysiology of these neurological disorders and research has demonstrated clear vascular endothelial protective properties for IL-10. In vitro and in vivo models of ischemic stroke have convincingly directly and indirectly shown IL-10-mediated neuroprotection; although clinically, the role of IL-10 in predicting risk and outcomes is less clear. Comparatively, conclusive studies investigating the contribution of IL-10 in subarachnoid hemorrhage are lacking. Weak indirect evidence supporting the protective role of IL-10 in preclinical models of intracerebral hemorrhage exists; however, in the limited number of clinical studies, higher IL-10 levels seen post-ictus have been associated with worse outcomes. Similarly, preclinical TBI models have suggested a neuroprotective role for IL-10; although, controversy exists among the several clinical studies. In summary, while IL-10 is consistently elevated following acute brain injury, the effect of IL-10 appears to be pathology dependent, and preclinical and clinical studies often paradoxically yield opposite results. The pronounced and potent effects of IL-10 in the resolution of inflammation and inconsistency in the literature regarding the contribution of IL-10 in the setting of acute brain injury warrant further rigorously controlled and targeted investigation.

[Potential for the survey of quality indicators based on a national emergency department registry : A systematic literature search]

BACKGROUND

Emergency department processes are often key for successful treatment. Therefore, collection of quality indicators is demanded. A basis for the collection is systematic, electronic documentation. The development of paper-based documentation into an electronic and interoperable national emergency registry is-besides the establishment of quality management for emergency departments-a target of the AKTIN project. The objective of this research is identification of internationally applied quality indicators.

METHODS

For the investigation of the current status of quality management in emergency departments based on quality indicators, a systematic literature search of the database PubMed, the Cochrane Library and the internet was performed.

RESULTS

Of the 170 internationally applied quality indicators, 25 with at least two references are identified. A total of 10 quality indicators are ascertainable by the data set. An enlargement of the data set will enable the collection of seven further quality indicators. The implementation of data of care behind the emergency processes will provide eight additional quality indicators.

CONCLUSION

This work was able to show that the potential of a national emergency registry for the establishment of quality indicators corresponds with the international systems taken into consideration and could provide a comparable collection of quality indicators.

Implementation of Computerized Physician Order Entry Is Associated With Increased Thrombolytic Administration for Emergency Department Patients With Acute Ischemic Stroke

STUDY OBJECTIVE

Electronic health record systems with computerized physician order entry and condition-specific order sets are intended to standardize patient management and minimize errors of omission. However, the effect of these systems on disease-specific process measures and patient outcomes is not well established. We seek to evaluate the effect of computerized physician order entry electronic health record implementation on process measures and short-term health outcomes for patients hospitalized with acute ischemic stroke.

METHODS

We conducted a quasi-experimental cohort study of patients hospitalized for acute ischemic stroke with concurrent controls that took advantage of the staggered implementation of a comprehensive computerized physician order entry electronic health record across 16 medical centers within an integrated health care delivery system from 2007 to 2012. The study population included all patients admitted to the hospital from the emergency department (ED) for acute ischemic stroke, with an initial neuroimaging study within 2.5 hours of ED arrival. We evaluated the association between the availability of a computerized physician order entry electronic health record and the rates of ED intravenous tissue plasminogen activator administration, hospital-acquired pneumonia, and inhospital and 90-day mortality, using doubly robust estimation models to adjust for demographics, comorbidities, secular trends, and concurrent primary stroke center certification status at each center.

RESULTS

Of 10,081 eligible patients, 6,686 (66.3%) were treated in centers after the computerized physician order entry electronic health record had been implemented. Computerized physician order entry was associated with significantly higher rates of intravenous tissue plasminogen activator administration (rate difference 3.4%; 95% confidence interval 0.8% to 6.0%) but not with significant rate differences in pneumonia or mortality.

CONCLUSION

For patients hospitalized for acute ischemic stroke, computerized physician order entry use was associated with increased use of intravenous tissue plasminogen activator.

A National Evaluation of Door-to-Imaging Times among Acute Ischemic Stroke Patients within the Veterans Health Administration

BACKGROUND

Rapid brain imaging for ischemic stroke is important for patient outcomes. We sought to determine the proportion of ischemic stroke patients receiving brain imaging within the guideline-recommended 24 hours, and predictors of faster imaging among patients with acute symptoms.

METHODS

Retrospective analysis of Veterans Health Administration (VHA) Office of Performance Measurement Stroke Special Project data. Of 3000 ischemic stroke patients, secondary samples included 649 presenting within 6 hours of onset, and 217 potentially tissue plasminogen activator (tPA)-eligible patients (onset-to-arrival time <3 hours, National Institutes of Health Stroke Scale >2). Two linear regression models examined the association between door-to-imaging time and predictors among secondary samples, accounting for clustering within hospital.

RESULTS

Of the 3000 ischemic stroke patients, 97.1% had brain imaging within 24 hours. Among patients presenting within 6 hours of onset, median door-to-imaging time was 59 minutes (interquartile range [IQR], 33-109). Predictors of faster door-to-imaging time included elevated arrival blood pressure and stroke center presentation. Among the potentially tPA-eligible patients, median door-to-imaging time was 52 minutes (IQR, 31-105); no significant predictors were identified.

CONCLUSIONS

Nearly all ischemic stroke patients at VHA hospitals have door-to-imaging time within 24 hours. There remains room for improvement for timely brain imaging among patients with acute symptom onset.

Neuroprotective effects of SMADs in a rat model of cerebral ischemia/reperfusion

Previous studies have shown that up-regulation of transforming growth factor β1 results in neuroprotective effects. However, the role of the transforming growth factor β1 downstream molecule, SMAD2/3, following ischemia/reperfusion remains unclear. Here, we investigated the neuroprotective effects of SMAD2/3 by analyzing the relationships between SMAD2/3 expression and cell apoptosis and inflammation in the brain of a rat model of cerebral ischemia/reperfusion. Levels of SMAD2/3 mRNA were up-regulated in the ischemic penumbra 6 hours after cerebral ischemia/reperfusion, reached a peak after 72 hours and were then decreased at 7 days. Phosphorylated SMAD2/3 protein levels at the aforementioned time points were consistent with the mRNA levels. Over-expression of SMAD3 in the brains of the ischemia/reperfusion model rats via delivery of an adeno-associated virus containing the SMAD3 gene could reduce tumor necrosis factor-α and interleukin-1β mRNA levels, down-regulate expression of the pro-apoptotic gene, capase-3, and up-regulate expression of the anti-apoptotic protein, Bcl-2. The SMAD3 protein level was negatively correlated with cell apoptosis. These findings indicate that SMAD3 exhibits neuroprotective effects on the brain after ischemia/reperfusion through anti-inflammatory and anti-apoptotic pathways.