Analysis of 30-day stroke mortality in a community-based registry in Warsaw, Poland

Early symptom measurement of Post-Stroke Depression (PSD)

BACKGROUND

We reported the factor structure and psychometric properties of a new measure of early symptoms of Post-Stroke Depression (PSD).

METHODS

Cross-sectional survey methods were used to administer the measure to hospitalized post-stroke patients (N=410) in southeast China, 7-30 days after mild to moderate stroke. Factor structure of the measure was evaluated using exploratory factor analysis (EFA) with first and second order confirmatory factor analysis (CFA). Measurement reliability of each factor and the total measure was assessed using Cronbach alpha coefficient, item-total correlation, item-subscale correlation and the composite coefficient. Discriminant validity was tested using the estimated correlation matrix and average variance extracted (AVE).

RESULTS

The EFA extracted a theoretically consistent, clinically interpretable, 29-item, 6-factor model for early symptoms of PSD (dull, guilt, low, wakefulness, emotional, and nervous). A first order CFA retained the 6-factors but deleted 3 underperforming items. The results of a second-order CFA for a 6-factor, 26-item model showed acceptable model fit (χ(2)/df=2.25, CFI=0.973, TLI=0.970, RMSEA=0.055 and WRMR=1.168) with acceptable reliability and discriminant validity.

LIMITATIONS

The study survey methods and purposive sampling procedures resulted in a clinically less homogenous final sample. Separate evaluation of predictive validity, criteria validity, test-retest reliability, and invariance to patient psychosocial characteristics of the measure is planned.

CONCLUSIONS

Our measure detected early symptoms of PSD in primarily first-ever stroke patients, an average of 11.07 days post stroke, well within the 14 day peak benchmark.

Anticoagulants for preventing recurrence following presumed non-cardioembolic ischaemic stroke or transient ischaemic attack

BACKGROUND

After a first ischaemic stroke, further vascular events due to thromboembolism are common and often fatal. Anticoagulants could potentially reduce the risk of such events, but any benefits could be offset by an increased risk of fatal or disabling haemorrhages.

OBJECTIVES

To assess the effect of prolonged anticoagulant therapy compared with placebo or open control following presumed non-cardioembolic ischaemic stroke or transient ischaemic attack.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register in May 2008. In June 2008 we searched three online trial registers, used Web of Science Cited Reference Search to identify new citations of previously included studies, contacted a pharmaceutical company, and also contacted authors for additional information on included trials.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing at least one month of anticoagulant therapy with control in people with previous, presumed non-cardioembolic, ischaemic stroke or transient ischaemic attack.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data.

MAIN RESULTS

Eleven trials involving 2487 participants were included. The quality of the nine trials which predated routine computerised tomography (CT) scanning and the use of the International Normalised Ratio to monitor anticoagulation was poor. There was no evidence of an effect of anticoagulant therapy on either the odds of death or dependency (two trials, odds ratio (OR) 0.83, 95% confidence interval (CI) 0.52 to 1.34) or of 'non-fatal stroke, myocardial infarction, or vascular death' (four trials, OR 0.96, 95% CI 0.68 to 1.37). Death from any cause (OR 0.95, 95% CI 0.73 to 1.24) and death from vascular causes (OR 0.86, 95% CI 0.66 to 1.13) were not significantly different between treatment and control. The inclusion of two recently completed trials did not alter these conclusions. There was no evidence of an effect of anticoagulant therapy on the risk of recurrent ischaemic stroke (OR 0.85, 95% CI 0.66 to 1.09). However, anticoagulants increased fatal intracranial haemorrhage (OR 2.54, 95% CI 1.19 to 5.45), and major extracranial haemorrhage (OR 3.43, 95% CI 1.94 to 6.08). This is equivalent to anticoagulant therapy causing about 11 additional fatal intracranial haemorrhages and 25 additional major extracranial haemorrhages per year for every 1000 patients given anticoagulant therapy.

AUTHORS' CONCLUSIONS

Compared with control, there was no evidence of benefit from long-term anticoagulant therapy in people with presumed non-cardioembolic ischaemic stroke or transient ischaemic attack, but there was a significant bleeding risk.

Eligibility of stroke units in Poland for administration of intravenous thrombolysis

Systemic thrombolysis treatment was approved in Poland in 2003 and should be performed in specialist stroke units (SU). We performed a survey to determine stroke service preparedness for thrombolysis treatment in Poland. We sent a questionnaire evaluating the neurological departments in Poland, where stroke patients are treated. We divided them into four categories: (i) class A SU (fulfilling criteria of the National Program for Stroke Prevention and Therapy and European Stroke Initiative guidelines), (ii) class B (conditionally fulfilling criteria), (iii) class C (not fulfilling criteria), and (iv) departments without SU. Only class A units are eligible for implementing thrombolysis. We obtained response from 194 of 222 (87.4%) departments; 90 (46.4%) declared having an SU. According to criteria, 20 class A, 56 class B, 14 class C. During one year, 71 208 patients were admitted to hospitals; 69,982 (98.2%) to neurological departments. A total of 10,959 (15.4%) were treated in class A SU, 23,650 (33.2%) in class B, 5153 (7.2%) in class C, whereas 30,220 (42.4%) in neurological departments without SU. Our survey showed that only 15.4% stroke patients in Poland are admitted to high-quality SU, where thrombolysis may potentially be administered. Improvement of SU quality in Poland is necessary for wide implementation of new methods of stroke therapy.

Anticoagulants for preventing recurrence following presumed non-cardioembolic ischaemic stroke or transient ischaemic attack

BACKGROUND

After a first ischaemic stroke, further vascular events due to thromboembolism (especially myocardial infarction and recurrent stroke) are common and often fatal. Anticoagulants could potentially reduce the risk of such events, but any benefits could be offset by an increased risk of fatal or disabling haemorrhages.

OBJECTIVES

The objective of this review was to assess the effect of prolonged anticoagulant therapy (compared with placebo or open control) following presumed non-cardioembolic ischaemic stroke or transient ischaemic attack.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register. We contacted companies marketing anticoagulant agents. The most recent search for this review was carried out in August 2002.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing at least one month of anticoagulant therapy with control in people with previous presumed non-cardioembolic ischaemic stroke or transient ischaemic attack.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data.

MAIN RESULTS

Eleven trials involving 2487 patients were included. The quality of the 9 trials which predated routine computerised tomography scanning and the use of the International Normalised Ratio to monitor anticoagulation was poor. There was no evidence of an effect of anticoagulant therapy on either the odds of death or dependency (two trials, odds ratio 0.83, 95% confidence interval [CI] 0.52 to 1.34) or of 'non-fatal stroke, myocardial infarction, or vascular death' (four trials, odds ratio 0.96, 95% CI 0.68-1.37). Death from any cause (odds ratio 0.95, 95% CI 0.73 to 1.24) and death from vascular causes (odds ratio 0.86, 95% CI 0.66 to 1.13) were not significantly different between treatment and control. The inclusion of two recent completed trials did not alter these conclusions. There was no evidence of an effect of anticoagulant therapy on the risk of recurrent ischaemic stroke (odds ratio 0.85, 95% CI 0.66 to 1.09). However, anticoagulants increased fatal intracranial haemorrhage (odds ratio 2.54, 95% CI 1.19 to 5.45), and major extracranial haemorrhage (odds ratio 3.43, 95% CI 1.94 to 6.08). This is equivalent to anticoagulant therapy causing about 11 additional fatal intracranial haemorrhages and 25 additional major extracranial haemorrhages per year for every 1000 patients given anticoagulant therapy.

REVIEWER'S CONCLUSIONS

Compared with control, there was no evidence of benefit from long-term anticoagulant therapy in people with presumed non-cardioembolic ischaemic stroke or transient ischaemic attack, but there was a significant bleeding risk.

High case-fatality rates in the Warsaw stroke registry

We studied 1-year survival in 297 patients with first-even-in-lifetime ischemic stroke (FEL-IS) selected from a population-based study of stroke in the Mokotow district of Warsaw. Case fatality rates were 29% at 30 days and 51% at 1 year. These case fatality rates are significantly higher than in other industrialized countries. Early deaths were primarily caused by neurological sequelae of stroke or complications of immobility, whereas late deaths (>30 days) were primarily caused by stroke recurrence or complications of immobility. Predictors of survival were analyzed by life table methods. Adverse predictors of 1-year survival included greater age, low activities of daily living scores, atrial fibrillation, greater weakness, congestive heart failure, and untreated hypertension. Patients with stroke recurrence were more likely to die in the first year. We hypothesize that stroke severity contributes to high case-fatality rates by increasing death caused by both direct neurological sequelae and complications of immobility. Medical comorbidity probably contributes to high case-fatality rates in Poland by increasing stroke recurrence rates and by increasing deaths caused by immobility. We hypothesize that high case-fatality rates in Poland could be reduced by improved rehabilitation of stroke patients to avoid deaths caused by immobility and by better control of medical comorbidity in stroke patients.