"Eye" Don't See: An Analysis of Visual Symptom Reporting by Stroke Survivors from a Large Epidemiology Study

Individualized goals expressed by patients undergoing stroke rehabilitation: an observational study

OBJECTIVES

To explore the rehabilitation goals measured with the Patient-Specific Functional Scale (PSFS) in patients undergoing acute and subacute stroke rehabilitation. In addition, to assess whether PSFS goals corresponded to impairments and activity limitations, as identified by standardized measures.

DESIGN

Observational study.

PARTICIPANTS

A total of 71 participants undergoing inpatient stroke rehabilitation.

METHODS

The PSFS goals were linked to second-level categories in the International Classification of Functioning, Disability and Health (ICF), using established linking rules. Frequencies of the linked ICF categories were calculated. Frequencies of participants with limitations in walking, activities of daily living (ADL), vision, language, and cognition, were calculated, along with goals in corresponding areas of functioning.

RESULTS

The participants' goals were linked to 50 second-level ICF categories, comprising areas such as walking and moving, ADL, language, vision, and cognition. The most frequent ICF categories were "Moving around in different locations" (n = 24), "Walking" (n = 23), "Toileting" (n = 16), "Hand and arm use (n = 12) and "Fine hand use (n = 12)". Of participants with limitations in walking, cognition, and vision, 85%, 10%, and 16%, respectively, had goals in these areas.

CONCLUSION

Participants' goals included walking, ADL, language, vision, and cognition. Few with impairments in cognition or vision had goals in these corresponding areas on the PSFS.

Barriers to Care for Poststroke Visual Deficits in Alberta, Canada

Poststroke visual impairment (VI) negatively affects rehabilitation potential and quality of life for stroke survivors. In this cross-sectional observational study, stroke survivors and providers were surveyed to quantify perspectives regarding care for poststroke VI in Alberta, Canada (n = 46 survivors; n = 87 providers). Few patients (35%) felt prepared to cope with VI at the time of discharge from acute stroke and inpatient rehabilitation settings. Less than 25% of stroke survivors, and <16% of providers, felt referral processes were adequate. 95.2% of providers and 82% of stroke survivors advocated for a provincial clinical pathway to improve care quality for poststroke VI.

Mid-range visual deficits after stroke: Prevalence and co-occurrence

Visual deficits are common after stroke and are powerful predictors for the chronic functional outcome. However, while basic visual field and recognition deficits are relatively easy to assess with standardized methods, selective deficits in visual primitives, such as shape or motion, are harder to identify, as they often require a symmetrical bilateral posterior lesion in order to provoke full field deficits. Therefore, we do not know how often they occur. Nevertheless, they can have severe repercussions for daily-life functioning. We aimed to investigate the prevalence and co-occurrence of hemifield “mid-range” visual deficits (i.e. color, shape, location, orientation, correlated motion, contrast, texture and glossiness), using a novel experimental set-up with a gaze-contingent presentation of the stimuli. To this end, a prospective cohort of 220 ischemic (sub)cortical stroke patients and a healthy control group was assessed with this set-up. When comparing performance of patients with controls, the results showed that deficits in motion-perception were most prevalent (26%), followed by color (22%), texture (22%), location (21%), orientation (18%), contrast (14%), shape (14%) and glossiness (13%). 63% of the stroke patients showed one or more mid-range visual deficits. Overlap of deficits was small; they mostly occurred in isolation or co-occurred with only one or two other deficits. To conclude, it was found that deficits in “mid-range” visual functions were very prevalent. These deficits are likely to affect the chronic post-stroke condition. Since we found no strong patterns of co-occurrences, we suggest that an assessment of deficits at this level of visual processing requires screening the full range of visual functions.

'If we don't assess the patient's vision, we risk starting at the wrong end': a qualitative evaluation of a stroke service knowledge translation project

Background

Visual impairments (VIs) affect 60% of stroke survivors and have negative consequences for rehabilitation and quality of life poststroke. Symptoms of VIs post stroke are difficult to identify for stroke survivors and health care professionals without using a structured vision assessment. In this study, we qualitatively evaluate the implementation outcomes after implementing a structured visual assessment with the Competence, Rehabilitation of Sight after Stroke Vision (KROSS) assessment tool in stroke care services.

Methods

This is a qualitative study comprising four focus group interviews. The health care personnel (HCP) involved in the implementation or with experience using the KROSS assessment tool in practice were invited to participate. We used Proctor et al.’s definitions of implementation outcomes as a framework, which informed the interview guide and analysis. We used a deductive - inductive content analysis, as described by Elo and Kyngäs.

Results

The participants found the structured vision assessment with the KROSS tool as being acceptable; they expressed a motivation and intention to use the new routine in practice. They believed it was important to assess their patient’s visual function because it influenced other rehabilitation activities and activities of daily living. Most of the participants reported having adopted the vision assessment in their practice, except for those participants from the home care services who experienced that they have few stroke survivors to follow up on. The assessment was believed to be more appropriate to perform within the rehabilitation services where there is more of a focus on functional assessments. Although vision assessment was new to all the participants, they felt that they improved their vision assessment skills by regularly using the assessment tool. Together with sufficient instructions and supervision, they believed that vison assessment was feasible for their practise. Including the vison assessment in the existing routines and systems was important to promote sustainable implementation.

Conclusion

Implementing a structured vision assessment with the KROSS tool in health care services was experienced as acceptable and feasible. The new routine led to increased attention towards poststroke VIs and increased collaboration with vision experts. Tailoring the routine to each practice and how they organise their work can support the integration of a vision assessment in their routines. To promote better vision care poststroke vision assessment and follow up should be included in the stroke care pathways.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07732-w.

Macular Microvasculature Is Associated With Total Cerebral Small Vessel Disease Burden in Recent Single Subcortical Infarction

Purpose

To assess the retinal microvasculature, choriocapillaris, and choroidal thickness in recent single subcortical infarction (RSSI) patients compared with healthy controls. We also assessed the correlation between the macular microvascular changes and choroidal changes with their clinical implications in RSSI patients.

Methods

Forty-six RSSI patients and 39 healthy controls (HC) were enrolled in our study. Magnetic resonance imaging (MRI) was done for all RSSI patients, and a total cerebral small vessel disease (CSVD) score was assessed for all patients. Swept-source optical coherence tomography (SS-OCT) was used to image and assess the choroidal thickness and SS-OCT angiography (SS-OCTA) was used to image and assess the macular microvasculature and choriocapillaris in all participants. Clinical information was collected for all participants.

Results

RSSI patients showed significantly sparser inner retinal microvasculature (P = 0.003) when compared with healthy controls. RSSI patients showed significantly thinner choroidal thickness (P < 0.001) when compared with HC. No significant difference (P = 0.247) was seen when the choriocapillaris was compared between the two groups. CSVD burden (P = 0.014) and NIHSS score (P = 0.010) showed significant correlation with the inner retinal microvasculature of RSSI patients. The inner retinal microvasculature (P = 0.016) and choroidal thickness (P = 0.018) showed a significant correlation with the MoCA scores in RSSI patients.

Conclusions

Our report suggests that retinal and choroidal imaging may serve as useful indicators to expand our understanding of RSSI and its clinical validity.

Impact of the COVID-19 pandemic on cardiovascular heart disease medication use: time-series analysis of England's prescription data during the COVID-19 pandemic (January 2019 to October 2020)

BACKGROUND

Management of high blood pressure (BP) typically requires adherence to medication regimes. However, it is known that the COVID-19 pandemic both interrupted access to some routine prescriptions and changed some patient health behaviours.

AIM

This study, therefore, retrospectively investigated prescription reimbursement of cardiovascular (CVD) medicines as a proxy measure for patient adherence and access to medicines during the pandemic.

METHODS

A cohort study of all primary care patients in England prescribed CVD medicines. The exposure was to the global pandemic. Prescriptions were compared before and after the pandemic's onset. Statistical variation was the outcome of interest.

RESULTS

Descriptive statistics show changes to monthly prescriptions, with wide confidence intervals indicating varying underlying practice. Analysis of variance reveals statistically significant differences for bendroflumethiazide, potassium-sparing diuretics, nicorandil, ezetimibe, ivabradine, ranolazine, colesevelam and midodrine. After the pandemic began (March-October 2020), negative parameters are observed for ACE inhibitors, beta-blockers, calcium channel blockers, statins, antiplatelet, antithrombotics, ARBs, loop diuretics, doxazosin, bendroflumethiazide, nitrates and indapamide, indicating decelerating monthly prescription items (statistically significant declines of calcium channel blockers, antithrombotic, adrenoreceptor blockers and diuretics) of CVD medicines within the general population. Many data points are not statistically significant, but fluctuations remain clinically important for the large population of patients taking these medications.

CONCLUSION

A concerning decline in uptake of CVD therapies for chronic heart disease was observed. Accessible screening and treatment alongside financial relief on prescription levies are needed. A video abstract is (4 min 51 s) available: https://bit.ly/39gvEHi.