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Adeniji O, Adeleye O, Akinyemi J, Otubogun F, Ogunde G, Ogunrombi M, Adesina D, Wahab A, Ogunlana M, Alimi T, Akinyemi R. Organized multi-disciplinary stroke team care improves acute stroke outcomes in resource limited settings; Results of a retrospective study from a Nigerian tertiary hospital. J Stroke Cerebrovasc Dis 2023; 32:107307. [PMID: 37633206 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND Evidence for the impact of organized stroke multidisciplinary teams (MDTs) on outcomes in Africa is sparse. AIM To compare stroke outcomes, before and after the establishment (September 16, 2016) of a pioneer MDT at a tertiary hospital in southern Nigeria. METHODS Using a retrospective, observational study design, the in-patient record of all stroke patients admitted between September 2014 to September 2018 was retrieved and rigorously reviewed. 155 patients seen 2 years before the MDT were compared with 169 stroke patients seen 2 years after the MDT. Stroke severity at admission and functioning at discharge were assessed using the Stroke Levity Scale (SLS) and the modified Rankin scale (mRS). RESULTS Mean ages (in years) were 60 pre-MDT vs 59.57 post MDT (p = 0.754). There were more males, 51% pre-MDT vs 54.2% post MDT (p = 0.565). SLS and mRS were not significantly different; severe SLS and mRS pre-MDT, 52.9% vs post-MDT, 49.4% (p = 0.727) and pre-MDT 19.4% vs post-MDT 19.5% (p = 0.685) respectively. More post-MDT patients were discharged alive, pre-MDT,56.8% vs 79.2% post MDT (p < 0.001); had swallow tests, pre-MDT 9.23% vs post-MDT 33.5% (p < 0.001); on secondary prevention, pre-MDT 67.7% vs post-MDT 78.9% (p = 0.023); had more clinic visits, pre-MDT,0.7% vs post-MDT 38.3% (p < 0.001). MDT was independently associated with lower in-hospital mortality on multivariable regression, adjusted odds ratio (OR) (95% Confidence interval CI) 0.17 (0.09-0.32). CONCLUSION Our results suggest that an organized MDT may improve acute outcomes and reduce mortality in resource constrained settings where there may be no stroke units. These findings need further prospective validation.
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Affiliation(s)
- Olaleye Adeniji
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria.
| | - Osi Adeleye
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Joshua Akinyemi
- Department of Medical Statistics and Epidemiology, College of Medicine, University College hospital Ibadan, Oyo State, Nigeria
| | - Folajimi Otubogun
- Neurology unit, Federal Medical center, Ebute Meta, Lagos State, Nigeria
| | - Gabriel Ogunde
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Postal Address: PMB 017 GPO, General Post Office, Ibadan, Oyo State, Nigeria
| | - Mayowa Ogunrombi
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Deborah Adesina
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Ahmed Wahab
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Michael Ogunlana
- Department of Physiotherapy, Federal Medical Center, Abeokuta, Ogun State, Nigeria
| | - Talayo Alimi
- Department of Physiotherapy, Federal Medical Center, Abeokuta, Ogun State, Nigeria
| | - Rufus Akinyemi
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Postal Address: PMB 017 GPO, General Post Office, Ibadan, Oyo State, Nigeria
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Egan M, Laliberte Rudman D, Lanoix M, Meyer M, Linkewich E, Montgomery P, Fearn J, Donnelly B, Collver M, Daly S. Exemplary post-discharge stroke rehabilitation programs: A multiple case study. Clin Rehabil 2022; 37:851-863. [PMID: 36542091 PMCID: PMC10126453 DOI: 10.1177/02692155221144891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective The objective of this study was to identify essential aspects of exemplary post-discharge stroke rehabilitation as perceived by patients, care partners, rehabilitation providers, and administrators. Design We carried out an exploratory qualitative, multiple case study. Stroke network representatives from four regions of the province of Ontario, Canada each nominated one post-discharge rehabilitation program they felt was exemplary. Setting The programs included: a mixed home- and clinic-based service; a home-based service; a clinic-based service with a stroke community navigator and; an out-patient clinic-based service. Participants Participants included 32 patients, 16 of their care partners, 23 providers, and 5 administrators. Methods We carried out semi-structured qualitative interviews with patients and care partners, focus groups with providers, and semi-structured interviews with administrators. Health records of patient participants were reviewed. Using an interpretivist-informed inductive content analysis, we developed overarching categories and subcategories first for each program and then across programs. Results Across four regions with differing types of programs, exemplary care was characterized by three essential components: stroke and stroke rehabilitation knowledge, relationship built through personalized respectful care, and a commitment to high quality, person-centered care. Conclusion Exemplary post-discharge care included knowledge regarding identification and treatment of stroke-related impairment, that is, information found in best practice guidelines. However, expertise related to building relationship through providing personalized respectful care, within a mutually supportive, improvement-oriented team was also essential. Additionally, administrators played a crucial role in ensuring continued ability to deliver exemplary care.
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Affiliation(s)
- Mary Egan
- School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Debbie Laliberte Rudman
- School of Occupational Therapy, Western University Faculty of Health Sciences, London, Ontario, Canada
| | - Monique Lanoix
- Faculty of Philosophy, Saint Paul University, Ottawa, Ontario, Canada
| | - Matthew Meyer
- Senior Leadership, London Health Sciences Centre, London, Ontario, Canada
| | - Elizabeth Linkewich
- Regional Stroke Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Phyllis Montgomery
- School of Nursing and Allied Health Professions, Laurentian University, Sudbury, Ontario, Canada
| | - Jenn Fearn
- Northeastern Stroke Network, Health Sciences North, Sudbury, Ontario, Canada
| | - Beth Donnelly
- Champlain Regional Stroke Network, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Margo Collver
- Regional Stroke Centre, London Health Sciences Centre, London, Ontario, Canada
| | - Shauna Daly
- Rehabilitation, Bruyere Continuing Care, Ottawa, Ontario, Canada
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Yadav RS, Chaudhary D, Avula V, Shahjouei S, Azarpazhooh MR, Abedi V, Li J, Zand R. Social Determinants of Stroke Hospitalization and Mortality in United States' Counties. J Clin Med 2022; 11:jcm11144101. [PMID: 35887865 PMCID: PMC9320068 DOI: 10.3390/jcm11144101] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/29/2022] [Accepted: 06/28/2022] [Indexed: 12/10/2022] Open
Abstract
(1) Background: Stroke incidence and outcomes are influenced by socioeconomic status. There is a paucity of reported population-level studies regarding these determinants. The goal of this ecological analysis was to determine the county-level associations of social determinants of stroke hospitalization and death rates in the United States. (2) Methods: Publicly available data as of 9 April 2021, for the socioeconomic factors and outcomes, was extracted from the Centers for Disease Control and Prevention. The outcomes of interest were “all stroke hospitalization rates per 1000 Medicare beneficiaries” (SHR) and “all stroke death rates per 100,000 population” (SDR). We used a multivariate binomial generalized linear mixed model after converting the outcomes to binary based on their median values. (3) Results: A total of 3226 counties/county-equivalents of the states and territories in the US were analyzed. Heart disease prevalence (odds ratio, OR = 2.03, p < 0.001), blood pressure medication nonadherence (OR = 2.02, p < 0.001), age-adjusted obesity (OR = 1.24, p = 0.006), presence of hospitals with neurological services (OR = 1.9, p < 0.001), and female head of household (OR = 1.32, p = 0.021) were associated with high SHR while cost of care per capita for Medicare patients with heart disease (OR = 0.5, p < 0.01) and presence of hospitals (OR = 0.69, p < 0.025) were associated with low SHR. Median household income (OR = 0.6, p < 0.001) and park access (OR = 0.84, p = 0.016) were associated with low SDR while no college degree (OR = 1.21, p = 0.049) was associated with high SDR. (4) Conclusions: Several socioeconomic factors (e.g., education, income, female head of household) were found to be associated with stroke outcomes. Additional research is needed to investigate intermediate and potentially modifiable factors that can serve as targeted interventions.
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Affiliation(s)
- Randhir Sagar Yadav
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA; (R.S.Y.); (D.C.); (S.S.)
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL 32207, USA
| | - Durgesh Chaudhary
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA; (R.S.Y.); (D.C.); (S.S.)
- Department of Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Venkatesh Avula
- Department of Molecular and Functional Genomics, Weis Center for Research, Geisinger Health System, Danville, PA 17822, USA; (V.A.); (J.L.)
| | - Shima Shahjouei
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA; (R.S.Y.); (D.C.); (S.S.)
| | - Mahmoud Reza Azarpazhooh
- Departments of Clinical Neurological Sciences and Epidemiology, University of Western Ontario, London, ON N6A 3K7, Canada;
| | - Vida Abedi
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA 17033, USA;
| | - Jiang Li
- Department of Molecular and Functional Genomics, Weis Center for Research, Geisinger Health System, Danville, PA 17822, USA; (V.A.); (J.L.)
| | - Ramin Zand
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA; (R.S.Y.); (D.C.); (S.S.)
- Department of Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
- Neuroscience Institute, The Pennsylvania State University, Hershey, PA 17033, USA
- Correspondence:
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Lau SCL, Drake BF, Sanders-Thompson VL, Baum CM. Racial Variation in the Association Between Domains of Depressive Symptomatology and Functional Recovery in Stroke Survivors. J Racial Ethn Health Disparities 2022; 10:1058-1066. [PMID: 35378721 DOI: 10.1007/s40615-022-01293-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of the study was to investigate the relationships between various domains of depressive symptomatology and functional recovery in Black and White stroke survivors. METHODS Black (n = 181) and White (n = 797) stroke survivors from the Stroke Recovery in Underserved Population database were included. Four domains of depressive symptomatology (depressed affect, positive affect, somatic symptoms, interpersonal difficulties) were measured by the Center for Epidemiologic Studies Depression Scale at discharge; functional recovery was measured by the Functional Independence Measure at discharge and 3-month follow-up. Multivariable linear regression analyses examined the relation between race and functional recovery, and the association between depressive symptomatology and functional recovery by race. RESULTS Three-month functional recovery was greater among White stroke survivors than Black survivors. Affective symptoms of depression predicted poorer functional recovery of White survivors; whereas somatic symptoms predicted poorer functional recovery of Black survivors. CONCLUSIONS Domains of depressive symptomatology were differentially associated with poorer functional recovery in Black and White stroke survivors. Psychosocial interventions aimed at alleviating depressive symptomatology have the potential to improve functional recovery in Black and White stroke survivors and should be addressed in planning rehabilitation post-stroke.
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Affiliation(s)
- Stephen C L Lau
- Program in Occupational Therapy, Washington University School of Medicine, 600 S. Taylor Ave 00163, St. Louis, MO, 63110, USA
| | - Bettina F Drake
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Carolyn M Baum
- Program in Occupational Therapy, Washington University School of Medicine, 600 S. Taylor Ave 00163, St. Louis, MO, 63110, USA.
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA.
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.
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Barra M, Faiz KW, Dahl FA, Næss H. Stroke Mimics on the Stroke Unit - Temporal trends 2008-2017 at a large Norwegian university hospital. Acta Neurol Scand 2021; 144:695-705. [PMID: 34498731 DOI: 10.1111/ane.13527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/11/2021] [Accepted: 08/19/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective was to quantify temporal trends in stroke mimics (SM) admissions relative to cerebrovascular accidents (CVA), incidence of hospitalized SMs and characterize the SM case-mix at a general hospital's stroke unit (SU). MATERIALS & METHODS All SU admissions (n = 11240) of patients aged 15 or older to Haukeland University Hospital between 2008-2017 were prospectively included and categorized as CVA or SM. Logistic regression was used to estimate time trends in the proportion of SMs among the admissions. Poisson regression was used to estimate time trends in age- and sex-dependent SM incidence. RESULTS SMs were on average younger thaan CVA patients (68.3 vs. 71.4 years) and had a higher proportion of females (53.6% vs. 44.5%). The total proportion of SM admissions was 51.0%. There was an increasing time trend in the proportion of SM admissions, odds ratio 1.150 per year (p < 0.001), but this trend appears flattening, represented by a significant quadratic time-term, odds ratio 1.009 (p < 0.001). A higher SM proportion was also associated with the time period of a Mass Media Intervention (FAST campaign) in 2014. There was also an increasing trend in SM incidence, that remains after adjusting for age, sex, and population; also, for incidence the trend appears to be flattening. CONCLUSIONS SMs account for approximately half of the SU admissions, and the proportion has been increasing. A FAST campaign appears to have temporarily increased the SM proportion. The age- and sex-dependent incidence of SM has been increasing but appears to flatten out.
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Affiliation(s)
- Mathias Barra
- The Health Services Research Unit (HØKH) Akershus University Hospital HF Lørenskog Norway
- Institute for Global Health BCEPSUniversity of Bergen Bergen Norway
| | - Kashif Waqar Faiz
- The Health Services Research Unit (HØKH) Akershus University Hospital HF Lørenskog Norway
- Department of Neurology Akershus University Hospital HF Lørenskog Norway
| | - Fredrik Andreas Dahl
- The Health Services Research Unit (HØKH) Akershus University Hospital HF Lørenskog Norway
| | - Halvor Næss
- Department of Neurology Haukeland University Hospital HF Bergen Norway
- Centre for age‐related medicine Stavanger University Hospital Stavanger Norway
- Institute of clinical medicine University of Bergen Bergen Norway
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Wei L, Cao Y, Zhang K, Xu Y, Zhou X, Meng J, Shen A, Ni J, Yao J, Shi L, Zhang Q, Wang P. Prediction of Progression to Severe Stroke in Initially Diagnosed Anterior Circulation Ischemic Cerebral Infarction. Front Neurol 2021; 12:652757. [PMID: 34220671 PMCID: PMC8249916 DOI: 10.3389/fneur.2021.652757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/10/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose: Accurate prediction of the progression to severe stroke in initially diagnosed nonsevere patients with acute-subacute anterior circulation nonlacuna ischemic infarction (ASACNLII) is important in making clinical decision. This study aimed to apply a machine learning method to predict if the initially diagnosed nonsevere patients with ASACNLII would progress to severe stroke by using diffusion-weighted images and clinical information on admission. Methods: This retrospective study enrolled 344 patients with ASACNLII from June 2017 to August 2020 on admission, and 108 cases progressed to severe stroke during hospitalization within 3-21 days. The entire data were randomized into a training set (n = 271) and an independent test set (n = 73). A U-Net neural network was employed for automatic segmentation and volume measurement of the ischemic lesions. Predictive models were developed and used for evaluating the progression to severe stroke using different feature sets (the volume data, the clinical data, and the combination) and machine learning methods (random forest, support vector machine, and logistic regression). Results: The U-Net showed high correlation with manual segmentation in terms of Dice coefficient of 0.806 and R 2 value of the volume measurements of 0.960 in the test set. The random forest classifier of the volume + clinical combination achieved the best area under the receiver operating characteristic curve of 0.8358 (95% CI 0.7321-0.9269), and the accuracy, sensitivity, and specificity were 0.7780 (0.7397-0.7945), 0.7695 (0.6102-0.9074), and 0.8686 (0.6923-1.0), respectively. The Shapley additive explanation diagram showed the volume variable as the most important predictor. Conclusion: The U-Net was fully automatic and showed a high correlation with manual segmentation. An integrated approach combining clinical variables and stroke lesion volumes that were derived from the advanced machine learning algorithms had high accuracy in predicting the progression to severe stroke in ASACNLII patients.
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Affiliation(s)
- Lai Wei
- Department of Radiology, Tongji Hospital, Tongji University, Shanghai, China
| | - Yidi Cao
- Shanghai Key Laboratory of Artificial Intelligence for Medical Image and Knowledge Graph, Shanghai, China
- Institute of Healthcare Research, Shanghai, China
| | - Kangwei Zhang
- Department of Radiology, Tongji Hospital, Tongji University, Shanghai, China
| | - Yun Xu
- Department of Radiology, Tongji Hospital, Tongji University, Shanghai, China
| | - Xiang Zhou
- Department of Radiology, Tongji Hospital, Tongji University, Shanghai, China
| | - Jinxi Meng
- Department of Radiology, Tongji Hospital, Tongji University, Shanghai, China
| | - Aijun Shen
- Department of Radiology, Tongji Hospital, Tongji University, Shanghai, China
| | - Jiong Ni
- Department of Radiology, Tongji Hospital, Tongji University, Shanghai, China
| | - Jing Yao
- Department of Radiology, Tongji Hospital, Tongji University, Shanghai, China
| | - Lei Shi
- Shanghai Key Laboratory of Artificial Intelligence for Medical Image and Knowledge Graph, Shanghai, China
- Institute of Healthcare Research, Shanghai, China
| | - Qi Zhang
- Shanghai Key Laboratory of Artificial Intelligence for Medical Image and Knowledge Graph, Shanghai, China
- Institute of Healthcare Research, Shanghai, China
- Shanghai Institute for Advanced Communication and Data Science/School of Communication and Information Engineering, Shanghai University, Shanghai, China
| | - Peijun Wang
- Department of Radiology, Tongji Hospital, Tongji University, Shanghai, China
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PREDICTORS OF INDEPENDENT WALKING RECOVERY AFTER STROKE IN PATIENTS ADMITTED TO AN INTEGRATED STROKE UNIT. WORLD OF MEDICINE AND BIOLOGY 2021. [DOI: 10.26724/2079-8334-2021-4-78-172-176] [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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Abstract
BACKGROUND Organised inpatient (stroke unit) care is provided by multi-disciplinary teams that manage stroke patients. This can been provided in a ward dedicated to stroke patients (stroke ward), with a peripatetic stroke team (mobile stroke team), or within a generic disability service (mixed rehabilitation ward). Team members aim to provide co-ordinated multi-disciplinary care using standard approaches to manage common post-stroke problems. OBJECTIVES • To assess the effects of organised inpatient (stroke unit) care compared with an alternative service. • To use a network meta-analysis (NMA) approach to assess different types of organised inpatient (stroke unit) care for people admitted to hospital after a stroke (the standard comparator was care in a general ward). Originally, we conducted this systematic review to clarify: • The characteristic features of organised inpatient (stroke unit) care? • Whether organised inpatient (stroke unit) care provide better patient outcomes than alternative forms of care? • If benefits are apparent across a range of patient groups and across different approaches to delivering organised stroke unit care? Within the current version, we wished to establish whether previous conclusions were altered by the inclusion of new outcome data from recent trials and further analysis via NMA. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (2 April 2019); the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 4), in the Cochrane Library (searched 2 April 2019); MEDLINE Ovid (1946 to 1 April 2019); Embase Ovid (1974 to 1 April 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 2 April 2019). In an effort to identify further published, unpublished, and ongoing trials, we searched seven trial registries (2 April 2019). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists. SELECTION CRITERIA Randomised controlled clinical trials comparing organised inpatient stroke unit care with an alternative service (typically contemporary conventional care), including comparing different types of organised inpatient (stroke unit) care for people with stroke who are admitted to hospital. DATA COLLECTION AND ANALYSIS Two review authors assessed eligibility and trial quality. We checked descriptive details and trial data with co-ordinators of the original trials, assessed risk of bias, and applied GRADE. The primary outcome was poor outcome (death or dependency (Rankin score 3 to 5) or requiring institutional care) at the end of scheduled follow-up. Secondary outcomes included death, institutional care, dependency, subjective health status, satisfaction, and length of stay. We used direct (pairwise) comparisons to compare organised inpatient (stroke unit) care with an alternative service. We used an NMA to confirm the relative effects of different approaches. MAIN RESULTS We included 29 trials (5902 participants) that compared organised inpatient (stroke unit) care with an alternative service: 20 trials (4127 participants) compared organised (stroke unit) care with a general ward, six trials (982 participants) compared different forms of organised (stroke unit) care, and three trials (793 participants) incorporated more than one comparison. Compared with the alternative service, organised inpatient (stroke unit) care was associated with improved outcomes at the end of scheduled follow-up (median one year): poor outcome (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.69 to 0.87; moderate-quality evidence), death (OR 0.76, 95% CI 0.66 to 0.88; moderate-quality evidence), death or institutional care (OR 0.76, 95% CI 0.67 to 0.85; moderate-quality evidence), and death or dependency (OR 0.75, 95% CI 0.66 to 0.85; moderate-quality evidence). Evidence was of very low quality for subjective health status and was not available for patient satisfaction. Analysis of length of stay was complicated by variations in definition and measurement plus substantial statistical heterogeneity (I² = 85%). There was no indication that organised stroke unit care resulted in a longer hospital stay. Sensitivity analyses indicated that observed benefits remained when the analysis was restricted to securely randomised trials that used unequivocally blinded outcome assessment with a fixed period of follow-up. Outcomes appeared to be independent of patient age, sex, initial stroke severity, stroke type, and duration of follow-up. When calculated as the absolute risk difference for every 100 participants receiving stroke unit care, this equates to two extra survivors, six more living at home, and six more living independently. The analysis of different types of organised (stroke unit) care used both direct pairwise comparisons and NMA. Direct comparison of stroke ward versus general ward: 15 trials (3523 participants) compared care in a stroke ward with care in general wards. Stroke ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.78, 95% CI 0.68 to 0.91; moderate-quality evidence). Direct comparison of mobile stroke team versus general ward: two trials (438 participants) compared care from a mobile stroke team with care in general wards. Stroke team care may result in little difference in the odds of a poor outcome at the end of follow-up (OR 0.80, 95% CI 0.52 to 1.22; low-quality evidence). Direct comparison of mixed rehabilitation ward versus general ward: six trials (630 participants) compared care in a mixed rehabilitation ward with care in general wards. Mixed rehabilitation ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.65, 95% CI 0.47 to 0.90; moderate-quality evidence). In a NMA using care in a general ward as the comparator, the odds of a poor outcome were as follows: stroke ward - OR 0.74, 95% CI 0.62 to 0.89, moderate-quality evidence; mobile stroke team - OR 0.88, 95% CI 0.58 to 1.34, low-quality evidence; mixed rehabilitation ward - OR 0.70, 95% CI 0.52 to 0.95, low-quality evidence. AUTHORS' CONCLUSIONS We found moderate-quality evidence that stroke patients who receive organised inpatient (stroke unit) care are more likely to be alive, independent, and living at home one year after the stroke. The apparent benefits were independent of patient age, sex, initial stroke severity, or stroke type, and were most obvious in units based in a discrete stroke ward. We observed no systematic increase in the length of inpatient stay, but these findings had considerable uncertainty.
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Affiliation(s)
- Peter Langhorne
- Academic Section of Geriatric Medicine, ICAMS, University of Glasgow, Glasgow, UK
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Vratsistas-Curto A, Sherrington C, McCluskey A. Dosage and predictors of arm practice during inpatient stroke rehabilitation: an inception cohort study. Disabil Rehabil 2019; 43:640-647. [PMID: 31311348 DOI: 10.1080/09638288.2019.1635215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe the amount/type of arm practice completed by stroke survivors during inpatient rehabilitation; and establish predictors of arm practice dose achieved. MATERIALS AND METHODS Inception cohort study including 99 consecutively admitted stroke survivors. Amount (repetitions) and type of arm practice completed during inpatient rehabilitation and possible predictors of dose were recorded. RESULTS Average length-of-stay was 36.9 days (standard deviation (SD) = 30.0, median = 28.0, interquartile range = 39.5) and days of therapy provided was 11.1 days (SD = 13.3, median = 6.0, IQR = 12.0). Mean number of arm practice sessions completed overall was 12.8 (SD = 15.3, median = 7.0, interquartile range = 15.0), or 2.0 sessions per week (SD = 1.5, median = 1.5, interquartile range = 1.7). Mean repetitions of practice completed per therapy day was 86.1 (SD = 76.5, median = 68.5, interquartile range = 88.2). Variation in practice dose was best explained by age (-1.3 repetitions per year of age, p = 0.04) and cognitive impairment (-34.9 repetitions, p = 0.03). In participants without cognitive impairment (n = 73) variation in dose was best explained by stroke severity (modified Rankin Sale = 5, -48.4 repetitions, p = 0.01), and the inability to grasp/release (Box and Block Test = 0, +48.3 repetitions, p = 0.03). CONCLUSIONS The amount of arm practice completed was low. Daily sessions were often not provided as recommended in clinical guidelines. Clinicians should focus on strategies to increase intensity and opportunities for arm practice.Implications for RehabilitationDose (repetitions) of arm practice varied greatly during inpatient rehabilitation.Number of arm rehabilitation sessions provided was lower than levels recommended in clinical guidelines.Therapists and researchers should focus on strategies to increase amount of therapy and opportunities for arm practice.
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Affiliation(s)
- Angela Vratsistas-Curto
- School of Public Health, Institute of Musculoskeletal Health, The University of Sydney, Sydney, Australia
| | - Catherine Sherrington
- School of Public Health, Institute of Musculoskeletal Health, The University of Sydney, Sydney, Australia
| | - Annie McCluskey
- Discipline of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
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de la Fuente J, García-Torrecillas JM, Solinas G, Iglesias-Espinosa MM, Garzón-Umerenkova A, Fiz-Pérez J. Structural Equation Model (SEM) of Stroke Mortality in Spanish Inpatient Hospital Settings: The Role of Individual and Contextual Factors. Front Neurol 2019; 10:498. [PMID: 31156536 PMCID: PMC6533919 DOI: 10.3389/fneur.2019.00498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 04/24/2019] [Indexed: 01/15/2023] Open
Abstract
Introduction: Traditionally, predictive models of in-hospital mortality in ischemic stroke have focused on individual patient variables, to the neglect of in-hospital contextual variables. In addition, frequently used scores are betters predictors of risk of sequelae than mortality, and, to date, the use of structural equations in elaborating such measures has only been anecdotal. Aims: The aim of this paper was to analyze the joint predictive weight of the following: (1) individual factors (age, gender, obesity, and epilepsy) on the mediating factors (arrhythmias, dyslipidemia, hypertension), and ultimately death (exitus); (2) contextual in-hospital factors (year and existence of a stroke unit) on the mediating factors (number of diagnoses, procedures and length of stay, and re-admission), as determinants of death; and (3) certain factors in predicting others. Material and Methods: Retrospective cohort study through observational analysis of all hospital stays of Diagnosis Related Group (DRG) 14, non-lysed ischemic stroke, during the time period 2008–2012. The sample consisted of a total of 186,245 hospital stays, taken from the Minimum Basic Data Set (MBDS) upon discharge from Spanish hospitals. MANOVAs were carried out to establish the linear effect of certain variables on others. These formed the basis for building the Structural Equation Model (SEM), with the corresponding parameters and restrictive indicators. Results: A consistent model of causal predictive relationships between the postulated variables was obtained. One of the most interesting effects was the predictive value of contextual variables on individual variables, especially the indirect effect of the existence of stroke units on reducing number of procedures, readmission and in-hospital mortality. Conclusion: Contextual variables, and specifically the availability of stroke units, made a positive impact on individual variables that affect prognosis and mortality in ischemic stroke. Moreover, it is feasible to determine this impact through the use of structural equation methodology. We analyze the methodological and clinical implications of this type of study for hospital policies.
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Affiliation(s)
- Jesús de la Fuente
- Educational Psychology, School of Education and Psychology, University of Navarra, Pamplona, Spain.,Educational Psychology, School of Psychology, University of Almería, Almería, Spain
| | - Juan Manuel García-Torrecillas
- Emergency and Research Unit, University Hospital Torrecárdenas, Almería, Spain.,CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Giulliana Solinas
- Biotechnology, Department of Medicine, University of Sassari, Sassari, Italy
| | | | | | - Javier Fiz-Pérez
- Organizational and Developmental Psychology, Università Europea di Roma, Rome, Italy
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Tørnes M, McLernon D, Bachmann M, Musgrave S, Warburton EA, Potter JF, Myint PK. Does service heterogeneity have an impact on acute hospital length of stay in stroke? A UK-based multicentre prospective cohort study. BMJ Open 2019; 9:e024506. [PMID: 30948571 PMCID: PMC6500188 DOI: 10.1136/bmjopen-2018-024506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To determine whether stroke patients' acute hospital length of stay (AHLOS) varies between hospitals, over and above case mix differences and to investigate the hospital-level explanatory factors. DESIGN A multicentre prospective cohort study. SETTING Eight National Health Service acute hospital trusts within the Anglia Stroke & Heart Clinical Network in the East of England, UK. PARTICIPANTS The study sample was systematically selected to include all consecutive patients admitted within a month to any of the eight hospitals, diagnosed with stroke by an accredited stroke physician every third month between October 2009 and September 2011. PRIMARY AND SECONDARY OUTCOME MEASURES AHLOS was defined as the number of days between date of hospital admission and discharge or death, whichever came first. We used a multiple linear regression model to investigate the association between hospital (as a fixed-effect) and AHLOS, adjusting for several important patient covariates, such as age, sex, stroke type, modified Rankin Scale score (mRS), comorbidities and inpatient complications. Exploratory data analysis was used to examine the hospital-level characteristics which may contribute to variance between hospitals. These included hospital type, stroke monthly case volume, service provisions (ie, onsite rehabilitation) and staffing levels. RESULTS A total of 2233 stroke admissions (52% female, median age (IQR) 79 (70 to 86) years, 83% ischaemic stroke) were included. The overall median AHLOS (IQR) was 9 (4 to 21) days. After adjusting for patient covariates, AHLOS still differed significantly between hospitals (p<0.001). Furthermore, hospitals with the longest adjusted AHLOS's had predominantly smaller stroke volumes. CONCLUSIONS We have clearly demonstrated that AHLOS varies between different hospitals, and that the most important patient-level explanatory variables are discharge mRS, dementia and inpatient complications. We highlight the potential importance of stroke volume in influencing these differences but cannot discount the potential effect of unmeasured confounders.
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Affiliation(s)
- Michelle Tørnes
- Ageing Clinical and Experimental Research Group, College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, UK
| | - David McLernon
- Medical Statistics Team, College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, UK
| | - Max Bachmann
- Norwich Medical School, Univeristy of East Anglia, Norwich, UK
| | | | | | - John F Potter
- Norwich Medical School, Univeristy of East Anglia, Norwich, UK
- Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, UK
| | - Phyo Kyaw Myint
- Ageing Clinical and Experimental Research Group, College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, UK
- Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, UK
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12
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Zhang H, Zhang Q, Liao Z. Microarray Data Analysis of Molecular Mechanism Associated with Stroke Progression. J Mol Neurosci 2019; 67:424-433. [PMID: 30610589 DOI: 10.1007/s12031-018-1247-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 12/18/2018] [Indexed: 12/13/2022]
Abstract
This study aimed to explore the molecular mechanism of stroke and provide a new target in the clinical management. The miRNA dataset GSE97532 (3 blood samples from middle cerebral artery occlusion (MCAO) and 3 from sham operation) and mRNA dataset GSE97533 (3 blood samples from MCAO and 3 from sham operation) were obtained from GEO database. Differentially expressed mRNA (DEGs) and miRNAs (DEMIRs) were screened out between MCAO and sham operation groups. Then, DEMIR-DEG interactions were explored and visualized using Cytoscape software. Moreover, the enrichment analysis was performed on these DEMIRs and DEGs. Furthermore, protein-protein interaction (PPI) network was constructed. Finally, the DEG-target transcription factors (TFs) were investigated using the WebGestal software. The current bioinformatics analysis revealed 38 DEMIRs and 546 DEGs between MCAO and sham operation groups. The DEMIR-DEG analysis revealed 370 relations, such as miR-107-5p-Furin. The top 10 up- and downregulated DEMIRs were mainly enriched in pathways like cAMP signaling pathway. The PPI network analysis revealed 2 modules. The target DEGs of the 10 up- and downregulated DEMIRs in 2 modules were mainly assembled in functions like ATP binding and pathway including ABC transporters. Furthermore, the DEG-TF network analysis identified 5 outstanding TFs including androgen receptor (AR). miR107-5p might take part in the progression of stroke via inhibiting the expression of Furin. TFs like AR might be used as a novel gene therapy target for stroke. Furthermore, cAMP signaling pathway and ATP binding function might be a novel breakthrough for stroke treatment.
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Affiliation(s)
- Hongmei Zhang
- Department of Neurology, Fourth People's Hospital of Jinan, No. 50 Shifan Road, Tianqiao District, Jinan, 250031, Shandong Province, China
| | - Qiying Zhang
- Department of Internal Medicine, Second People's Hospital of Jinan, No. 148 Jingyi Road, Huaiyin District, Jinan, 250001, Shandong Province, China
| | - Zuning Liao
- Department of Neurology, Fourth People's Hospital of Jinan, No. 50 Shifan Road, Tianqiao District, Jinan, 250031, Shandong Province, China.
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13
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Soelberg Sorensen P, Giovannoni G, Montalban X, Thalheim C, Zaratin P, Comi G. The Multiple Sclerosis Care Unit. Mult Scler 2018; 25:627-636. [PMID: 30351211 PMCID: PMC6439947 DOI: 10.1177/1352458518807082] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Treatment of multiple sclerosis (MS) has become increasingly multifaceted and comprises not only a variety of disease-modifying drugs with different mechanism of action but also a wide range of symptomatic therapies. Today, it is not possible for the family physician or even many general neurologists to master the current treatment algorithm, and this calls for the establishment of multidisciplinary MS Care Units. The core of the MS Care Unit would, in addition to MS neurologists and nurses, typically comprise neuropsychologists, clinical psychologists, physiotherapists, occupational therapists and secretaries, and will work together with a group of different specialists on formalized diagnostic workup procedures, protocols for initiation and follow-up of disease-modifying therapies. It is obvious that the terms of performance of different MS Care Units will vary across regions and need to be balanced with clinical practice according to local conditions. Although the main objective for establishment of MS Care Units will be to offer the single MS patient seamless and correct management of the disease to increase patient satisfaction and quality of life, it may even be cost-effective for the society by maintaining the working ability and reducing the costs of home help and custodial care by keeping people with MS resourceful.
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Affiliation(s)
- Per Soelberg Sorensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gavin Giovannoni
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | | | - Paola Zaratin
- Italian Multiple Sclerosis Foundation, Genoa, Italy/Multiple Sclerosis International Federation (MSIF), London, UK
| | - Giancarlo Comi
- Department of Neurology and Institute of Experimental Neurology, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
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Zheng C, Lee Y, Bin H, Jiong W. A randomized controlled trial comparing electroacupuncture with manual acupuncture for motor function recovery after ischemic stroke. Eur J Integr Med 2018. [DOI: 10.1016/j.eujim.2018.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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He J, Gao Y, Wu G, Lei X, Zhang Y, Pan W, Yu H. Molecular mechanism of estrogen-mediated neuroprotection in the relief of brain ischemic injury. BMC Genet 2018; 19:46. [PMID: 30029590 PMCID: PMC6053825 DOI: 10.1186/s12863-018-0630-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 06/20/2018] [Indexed: 12/23/2022] Open
Abstract
Background This study aimed to explore the molecular mechanism of estrogen-mediated neuroprotection in the relief of cerebral ischemic injury. The gene expression profiles were downloaded from Gene Expression Omnibus database, and differentially expressed genes (DEGs) were identified using limma package in R software. Further, DEGs were subjected to Gene Ontology (GO) cluster analysis using online Gene Ontology Enrichment Analysis Software Toolkit and to GO functional enrichment analysis using DAVID software. Using the Gene Set Analysis Toolkit V2, enrichment analysis of Kyoto Encyclopedia of Genes and Genomes pathways was performed. In addition, protein-protein interaction (PPI) network was constructed using STRING database, and submodule analysis of PPI network. Lastly, the significant potential target sites of microRNAs (miRNAs) were predicted using Molecular Signatures Database, and the function analysis of targets of predicted miRNA was also performed using DAVID software. Results In total, 321 DEGs were screened in the estrogen-treated sample. The DEGs were mainly associated with intracellular signaling and metabolic pathways, such as calcium channel, calcineurin complex, insulin secretion, low-density lipoprotein reconstruction, and starch or sugar metabolism. In addition, GO enrichment analysis indicated an altered expression of the genes related to starch and sucrose metabolism, retinol metabolism, anti-apoptosis (eg., BDNF and ADAM17) and response to endogenous stimulus. The constructed PPI network comprised of 243 nodes and 590 interaction pairs, and four submodules were obtained from PPI network. Among the module d, four glutamate receptors as Gria4, Gria3, Grin3a and Grik4 were highlighted. Further, 5 novel potential regulatory miRNAs were also predicted. MIR-338 and MIR520D were closely associated with cell cycle, while the targets of MIR-376A and MIR-376B were only involved in cell soma. Conclusions The DEGs in estrogen-treated samples are closely associated with calcium channel, glutamate induced excitotoxicity and anti-apoptotic activity. In addition, some functionally significant DEGs such as BDNF, ADAM17, Gria4, Gria3, Grin3a, Grik4, Gys2 and Ugtla2, and new miRNAs like MIR-338 and MIR-376A were identified, which may serve as potential therapeutic targets for the effective treatment of cerebral ischemic injury. Electronic supplementary material The online version of this article (10.1186/s12863-018-0630-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jiaxuan He
- Department of Anesthesia, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Ya Gao
- Department of Pediatric surgery, Second Affiliated Hospital of Xi'an Jiaotong University, No.157, XiWu Road, Xi'an, 710004, China.
| | - Gang Wu
- Department of Anesthesia, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Xiaoming Lei
- Department of Anesthesia, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Yong Zhang
- Department of Anesthesia, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Weikang Pan
- Department of Pediatric surgery, Second Affiliated Hospital of Xi'an Jiaotong University, No.157, XiWu Road, Xi'an, 710004, China
| | - Hui Yu
- Department of Pediatric surgery, Second Affiliated Hospital of Xi'an Jiaotong University, No.157, XiWu Road, Xi'an, 710004, China
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Infections Diagnosed after Admission to a Stroke Unit and Their Impact on Hospital Mortality in Poland from 1995 to 2015. J Stroke Cerebrovasc Dis 2018. [PMID: 29526387 DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Implementation of modern stroke unit care might have attenuated the negative effect of infections on stroke outcome. Our aim was to investigate changes in the occurrence of pneumonia and urinary infections diagnosed after admission to experienced Polish stroke center between 1995 and 2015, and their association with hospital mortality. MATERIALS AND METHODS This is a retrospective registry-based analysis of consecutive patients with acute stroke from highly urbanized area (Warsaw, Poland) in years 1995-2015. A total of 5174 patients were divided to 4 time periods: 1995-2000 (n = 883), 2001-2006 (n = 1567), 2006-2010 (n = 1539), and 2011-2015 (n = 1183). Odds ratios (ORs) for hospital death were calculated after adjustment for age, congestive heart failure, preexisting disability, stroke type, and baseline neurological deficit, separately in years 1995-2015, 1995-2000, and 2011-2015. RESULTS Over time there was a significant decrease in the proportion of patients diagnosed with pneumonia (20%, 19%, 9%, and 15%, respectively) or urinary tract infection (29%, 21%, 24%, and 18%, respectively) and in the proportion of patients having body temperature of 38.0°C or higher at least once within first 7 days of hospital stay (20%, 20%, 13%, and 13%, respectively), without significant change in the use of antibiotics (range 35%-37%). Hospital mortality was strongly predicted by pneumonia (OR 3.6-4.2) and fever (OR 2.7-4.7) but not urinary infections. CONCLUSIONS Over the last 2 decades there was a decrease in the proportion of patients with acute stroke diagnosed with pneumonia or urinary tract infection during stroke unit stay. Hospital death was strongly predicted by pneumonia and fever but no by urinary infections.
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17
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Vratsistas-Curto A, McCluskey A, Schurr K. Use of audit, feedback and education increased guideline implementation in a multidisciplinary stroke unit. BMJ Open Qual 2017; 6:e000212. [PMID: 29450304 PMCID: PMC5699124 DOI: 10.1136/bmjoq-2017-000212] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/04/2017] [Accepted: 10/04/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The audit-feedback cycle is a behaviour change intervention used to reduce evidence-practice gaps. In this study, repeat audits, feedback, education and training were used to change practice and increase compliance with Australian guideline recommendations for stroke rehabilitation. OBJECTIVE To increase the proportion of patients with stroke receiving best practice screening, assessment and treatment. METHODS A before-and-after study design was used. Data were collected from medical records (n=15 files per audit). Four audits were conducted between 2009 and 2013. Consecutive files of patients with stroke admitted to the stroke unit were selected and audited retrospectively. Staff behaviour change interventions included four cycles of audit feedback, and education to assist staff with change. The primary outcome measure was the proportion of eligible patients receiving best practice against target behaviours, based on audit data. RESULTS Between the first and fourth audit (2009 and 2013), 20 of the 27 areas targeted (74%) met or exceeded the minimum target of 10% change. Practice areas that showed the most change included sensation screening (+75%) and rehabilitation (+100%); neglect screening (+92%) and assessment (100%). Some target behaviours showed a drop in compliance such as anxiety and depression screening (-27%) or little or no overall improvement such as patient education about stroke (6% change). CONCLUSIONS Audit feedback and education increased the proportion of inpatients with stroke receiving best practice rehabilitation in some, but not all practice areas. An ongoing process of quality improvement is needed to help sustain these improvements.
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Affiliation(s)
- Angela Vratsistas-Curto
- Musculoskeletal Health Sydney, School of Public Health, The University of Sydney, New South Wales, Australia
| | - Annie McCluskey
- Discipline of Occupational Therapy, Faculty of Health Sciences, University of Sydney, Lidcome, New South Wales, Australia
- The StrokeEd Collaboration, Regents Park, New South Wales, Australia
| | - Karl Schurr
- The StrokeEd Collaboration, Regents Park, New South Wales, Australia
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Meyer MJ, Teasell R, Kelloway L, Meyer SB, Willems D, O'Callaghan C. Timely access to inpatient rehabilitation after stroke: a qualitative study of perceived barriers and potential solutions in Ontario, Canada. Disabil Rehabil 2017; 40:3120-3126. [PMID: 28922947 DOI: 10.1080/09638288.2017.1377296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Stroke units have been established as best practice care, in part because they offer timely initiation of rehabilitation. Experts in Ontario, Canada recommend that eligible patients be transferred to inpatient rehabilitation (on average) by day 5 after ischemic stroke and day 7 after a hemorrhagic stroke. This study explores perceived barriers to implementation of these recommendations and potential solutions. METHOD Exploratory focus groups were held with stakeholders from five geographically diverse regions across Ontario between September 2011 and January 2012. Participants were asked to consider the recommendations, list perceived barriers and to collectively discuss potential solutions. Data analysis included coding of transcribed data, sorting material to identify themes and confronting themes with a formalized body of knowledge. RESULTS Barriers identified by participants fell into three categories: patient-centered, clinician-focused and resource or system based, within these, specific challenges included managing patients' medical and emotional readiness for rehabilitation, timely completion of medical tests, staff comfort in discharging patients, dedicated transportation and funding-related concerns. CONCLUSIONS The structure of Ontario's health care system presents challenges to early transfer of stroke patients to inpatient rehabilitation, yet the stakeholders consulted in this study felt that these could be addressed with proper planning, improved coordination and targeted investment. Implications for rehabilitation Stroke units are a well-established best practice in stroke care and timely access to rehabilitation is a key component of their effectiveness. Stroke experts in Ontario, Canada recommend transfer of suitable patients to inpatient rehabilitation on day 5 and day 7, on average, after ischemic and hemorrhagic stroke, respectively. Stakeholders report that meeting these targets may require some adjustments to local processes of care, many of which can be achieved with little to no financial investment.
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Affiliation(s)
- Matthew J Meyer
- a Lawson Health Research Institute, Parkwood Institute , London , ON , Canada.,b London Health Sciences Centre , London , ON , Canada.,c Ontario Stroke Network , Toronto , ON , Canada.,d Department of Epidemiology and Biostatistics , Western University , London , ON , Canada
| | - Robert Teasell
- a Lawson Health Research Institute, Parkwood Institute , London , ON , Canada.,e St. Joseph's Health Care, Parkwood Institute , London , ON , Canada.,f Physical Medicine and Rehabilitation , Schulich School of Medicine and Dentistry, University of Western Ontario , London , ON , Canada
| | | | - Samantha B Meyer
- g School of Public Health and Health Systems , University of Waterloo , Waterloo , ON , Canada
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Leong DP, Joseph PG, McKee M, Anand SS, Teo KK, Schwalm JD, Yusuf S. Reducing the Global Burden of Cardiovascular Disease, Part 2: Prevention and Treatment of Cardiovascular Disease. Circ Res 2017; 121:695-710. [PMID: 28860319 DOI: 10.1161/circresaha.117.311849] [Citation(s) in RCA: 210] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In this second part of a 2-part series on the global burden of cardiovascular disease, we review the proven, effective approaches to the prevention and treatment of cardiovascular disease. We specifically review the management of acute cardiovascular diseases, including acute coronary syndromes and stroke; the care of cardiovascular disease in the ambulatory setting, including medical strategies for vascular disease, atrial fibrillation, and heart failure; surgical strategies for arterial revascularization, rheumatic and other valvular heart disease, and symptomatic bradyarrhythmia; and approaches to the prevention of cardiovascular disease, including lifestyle factors, blood pressure control, cholesterol-lowering, antithrombotic therapy, and fixed-dose combination therapy. We also discuss cardiovascular disease prevention in diabetes mellitus; digital health interventions; the importance of socioeconomic status and universal health coverage. We review building capacity for conduction cardiovascular intervention through strengthening healthcare systems, priority setting, and the role of cost effectiveness.
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Affiliation(s)
- Darryl P Leong
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.).
| | - Philip G Joseph
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Martin McKee
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Sonia S Anand
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Koon K Teo
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Jon-David Schwalm
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Salim Yusuf
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
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Mitchell AJ, Sheth B, Gill J, Yadegarfar M, Stubbs B, Yadegarfar M, Meader N. Prevalence and predictors of post-stroke mood disorders: A meta-analysis and meta-regression of depression, anxiety and adjustment disorder. Gen Hosp Psychiatry 2017; 47:48-60. [PMID: 28807138 DOI: 10.1016/j.genhosppsych.2017.04.001] [Citation(s) in RCA: 204] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 03/09/2017] [Accepted: 04/02/2017] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To ascertain the prevalence and predictors of mood disorders, determined by structured clinical interviews (ICD or DSM criteria) in people after stroke. METHODS Major electronic databases were searched from inception to June 2016 for studies involving major depression (MDD), minor depression (MnD), dysthymia, adjustment disorder, any depressive disorder (any depressive disorder) and anxiety disorders. Studies were combined using both random and fixed effects meta-analysis and results were stratified as appropriate. RESULTS Depression was examined on 147 occasions from 2days to 7years after stroke (mean 6.87months, N=33 in acute, N=43 in rehabilitation and N=69 in the community/outpatients). Across 128 analyses involving 15,573 patients assessed for major depressive disorder (MDD), the point prevalence of depression was 17.7% (95% CI=15.6% to 20.0%) 0.65 analyses involving 9720 patients determined MnD was present in 13.1% in all settings (95% CI=10.9% to 15.8%). Dysthymia was present in 3.1% (95% CI=2.1% to 5.3%), adjustment disorder in 6.9% (95% CI=4.6 to 9.7%) and anxiety in 9.8% (95% CI=5.9% to 14.8%). Any depressive disorder was present in 33.5% (95% CI=30.3% to 36.8%). The relative risk of any depressive disorder was higher following left (dominant) hemisphere stroke, aphasia, and among people with a family history and past history of mood disorders. CONCLUSION Depression, adjustment disorder and anxiety are common after stroke. Risk factors are aphasia, dominant hemispheric lesions and past personal/family history of depression but not time since stroke.
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Affiliation(s)
- Alex J Mitchell
- Department of Cancer Studies & Molecular Medicine, Leicester Royal Infirmary, LE1 5WW, UK.
| | | | - John Gill
- Leicestershire Partnership NHS Trust, UK.
| | | | - Brendon Stubbs
- South London and Maudsley NHS Foundation Trust, Denmark Hill, London, UK.
| | - Mohammad Yadegarfar
- Faculty of Health, Social care and Education, Anglia Ruskin University, Chelmsford, UK.
| | - Nick Meader
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK.
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Kim DY, Kim YH, Lee J, Chang WH, Kim MW, Pyun SB, Yoo WK, Ohn SH, Park KD, Oh BM, Lim SH, Jung KJ, Ryu BJ, Im S, Jee SJ, Seo HG, Rah UW, Park JH, Sohn MK, Chun MH, Shin HS, Lee SJ, Lee YS, Park SW, Park YG, Paik NJ, Lee SG, Lee JK, Koh SE, Kim DK, Park GY, Shin YI, Ko MH, Kim YW, Yoo SD, Kim EJ, Oh MK, Chang JH, Jung SH, Kim TW, Kim WS, Kim DH, Park TH, Lee KS, Hwang BY, Song YJ. Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016. BRAIN & NEUROREHABILITATION 2017. [DOI: 10.12786/bn.2017.10.e11] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Deog Young Kim
- Department of Rehabilitation Medicine, Yonsei University College of Medicine, Korea
| | - Yun-Hee Kim
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea
| | - Jongmin Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea
| | - Min-Wook Kim
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Sung-Bom Pyun
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Korea
| | - Woo-Kyoung Yoo
- Department of Physical Medicine and Rehabilitation, Hallym University College of Medicine, Korea
| | - Suk Hoon Ohn
- Department of Physical Medicine and Rehabilitation, Hallym University College of Medicine, Korea
| | - Ki Deok Park
- Department of Rehabilitation Medicine, Gachon University College of Medicine, Korea
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Seong Hoon Lim
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Kang Jae Jung
- Department of Physical Medicine and Rehabilitation, Eulji University Hospital & Eulji University School of Medicine, Korea
| | - Byung-Ju Ryu
- Department of Physical Medicine and Rehabilitation, Sahmyook Medical Center, Korea
| | - Sun Im
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Sung Ju Jee
- Department of Rehabilitation Medicine, Chungnam National University College of Medicine, Korea
| | - Han Gil Seo
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Ueon Woo Rah
- Department of Physical Medicine and Rehabilitation, Ajou University School of Medicine, Korea
| | - Joo Hyun Park
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Min Kyun Sohn
- Department of Rehabilitation Medicine, Chungnam National University College of Medicine, Korea
| | - Min Ho Chun
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Hee Suk Shin
- Department of Rehabilitation Medicine and Institute of Health Sciences, Gyeongsang National University College of Medicine, Korea
| | - Seong Jae Lee
- Department of Rehabilitation Medicine, College of Medicine Dankook University, Korea
| | - Yang-Soo Lee
- Department of Rehabilitation Medicine, Kyungpook National University School of Medicine, Korea
| | - Si-Woon Park
- Department of Rehabilitation Medicine, Catholic Kwandong University International St Mary's Hospital, Korea
| | - Yoon Ghil Park
- Department of Rehabilitation Medicine, Yonsei University College of Medicine, Korea
| | - Nam Jong Paik
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Sam-Gyu Lee
- Department of Physical and Rehabilitation Medicine, Chonnam National University Medical School, Korea
| | - Ju Kang Lee
- Department of Rehabilitation Medicine, Gachon University College of Medicine, Korea
| | - Seong-Eun Koh
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Korea
| | - Don-Kyu Kim
- Department of Physical Medicine and Rehabilitation, College of Medicine, Chung-Ang University, Korea
| | - Geun-Young Park
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Yong Il Shin
- Department of Rehabilitation Medicine, Pusan National University Hospital, Korea
| | - Myoung-Hwan Ko
- Department of Physical Medicine and Rehabilitation, Chonbuk National University Medical School, Korea
| | - Yong Wook Kim
- Department of Rehabilitation Medicine, Yonsei University College of Medicine, Korea
| | - Seung Don Yoo
- Department of Physical Medicine and Rehabilitation, Kyung Hee University College of Medicine, Korea
| | - Eun Joo Kim
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Hospital, Korea
| | - Min-Kyun Oh
- Department of Rehabilitation Medicine and Institute of Health Sciences, Gyeongsang National University College of Medicine, Korea
| | - Jae Hyeok Chang
- Department of Rehabilitation Medicine, Pusan National University Hospital, Korea
| | - Se Hee Jung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Tae-Woo Kim
- TBI rehabilitation center, National Traffic Injury Rehabilitation Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Dae Hyun Kim
- Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Korea
| | - Kwan-Sung Lee
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Byong-Yong Hwang
- Department of Physical Therapy, Yong-In University College of Health & Welfare, Korea
| | - Young Jin Song
- Department of Rehabilitation Medicine, Asan Medical Center, Korea
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Yoo SD, Jeong YS, Kim TW. Medical rehabilitation system for patients in acute rehabilitation units. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2017. [DOI: 10.5124/jkma.2017.60.11.864] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Seung Don Yoo
- Department of Physical Medicine and Rehabilitation, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | | | - Tae-Woo Kim
- National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea
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Abstract
Intracerebral hemorrhage (ICH) is a potentially devastating neurologic injury representing 10-15% of stroke cases in the USA each year. Numerous risk factors, including age, hypertension, male gender, coagulopathy, genetic susceptibility, and ethnic descent, have been identified. Timely identification, workup, and management of this condition remain a challenge for clinicians as numerous factors can present obstacles to achieving good functional outcomes. Several large clinical trials have been conducted over the prior decade regarding medical and surgical interventions. However, no specific treatment has shown a major impact on clinical outcome. Current management guidelines do exist based on medical evidence and consensus and these provide a framework for care. While management of hypertension and coagulopathy are generally considered basic tenets of ICH management, a variety of measures for surgical hematoma evacuation, intracranial pressure control, and intraventricular hemorrhage can be further pursued in the emergent setting for selected patients. The complexity of management in parenchymal cerebral hemorrhage remains challenging and offers many areas for further investigation. A systematic approach to the background, pathology, and early management of spontaneous parenchymal hemorrhage is provided.
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Chen L, Fang J, Ma R, Gu X, Chen L, Li J, Xu S. Additional effects of acupuncture on early comprehensive rehabilitation in patients with mild to moderate acute ischemic stroke: a multicenter randomized controlled trial. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2016; 16:226. [PMID: 27430340 PMCID: PMC4950630 DOI: 10.1186/s12906-016-1193-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 07/07/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Acupuncture is not considered a conventional therapy for post-stroke sequelae but it might have some additional positive effects on early rehabilitation. We conducted this trial to determine whether acupuncture has additional effects in early comprehensive rehabilitation for acute ischemic stroke and dysfunctions secondary to stroke. METHODS Two hundred fifty patients were randomized into two groups: acupuncture (AG) or no acupuncture (NAG). Eighteen acupuncture treatment sessions were performed over a 3-week period. The primary outcome was blindly measured with National Institutes of Health Stroke Scale (NIHSS) at week 1, week 3, and week 7. Secondary outcomes included: Fugl-Meyer Assessment (FMA) for motor function, bedside swallowing assessment (BSA) and videofluoroscopic swallowing study (VFSS) for swallowing function, the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) for cognitive function, and the adverse reaction of acupuncture for safety assessment. RESULTS Significant improvements from acupuncture treatment were observed in NIHSS (p < 0.001), VFSS (p < 0.001), MMSE (p < 0.001), MoCA (p = 0.001), but not obtained from FMA (p = 0.228). Changes from baseline of all above variables (except FMA) also had the same favorable results. A significant improvement in FMA lower extremity subscale appeared in AG (p = 0.020), but no significant difference was found for the upper extremity subscale (p = 0.707). More patients with swallowing disorder recovered in AG (p = 0.037). Low incidence of mild reaction of acupuncture indicated its safety. CONCLUSIONS This trial showed acupuncture is safe and has additional multi-effect in improving neurologic deficits, swallowing disorder, cognitive impairment, and lower extremity function, but has no significant improvement for upper extremity function during this short-term study period. TRIAL REGISTRATION Chictr.org ChiCTR-TRC -12001971 (March 2012).
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Affiliation(s)
- Lifang Chen
- />Department of Acupuncture, The Third Affiliated Hospital of Zhejiang Chinese Medical University, 219 Moganshan Road, Xihu District, Hangzhou City, Zhejiang Province 310005 China
| | - Jianqiao Fang
- />Department of Acupuncture, The Third Affiliated Hospital of Zhejiang Chinese Medical University, 219 Moganshan Road, Xihu District, Hangzhou City, Zhejiang Province 310005 China
- />The Third Clinical Medical College, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou City, Zhejiang Province 310053 China
| | - Ruijie Ma
- />Department of Acupuncture, The Third Affiliated Hospital of Zhejiang Chinese Medical University, 219 Moganshan Road, Xihu District, Hangzhou City, Zhejiang Province 310005 China
| | - Xudong Gu
- />Department of Rehabilitation, The Second Hospital of Jiaxing, 1518 North Huancheng Road, Jiaxing, Zhejiang Province 314000 China
| | - Lina Chen
- />Department of Rehabilitation, Hangzhou First People’s Hospital, 261 Huansha Road, Hangzhou, Zhejiang Province 310006 China
| | - Jianhua Li
- />Department of Rehabilitation, Sir Run Run Shaw Hospital College of Medicine Zhejiang University, No. 3 East Qingchun Road, Hangzhou, Zhejiang Province 310016 China
| | - Shouyu Xu
- />The Third Clinical Medical College, Zhejiang Chinese Medical University, 548 Binwen Road, Binjiang District, Hangzhou City, Zhejiang Province 310053 China
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Enderby P, Pandyan A, Bowen A, Hearnden D, Ashburn A, Conroy P, Logan P, Thompson C, Winter J. Accessing rehabilitation after stroke – a guessing game? Disabil Rehabil 2016; 39:709-713. [DOI: 10.3109/09638288.2016.1160448] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Pam Enderby
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anand Pandyan
- Institute for Science and Technology in Medicine & School of Health and Rehabilitation, Keele University, Keele, UK
| | - Audrey Bowen
- Stroke Research, MAHSC, University of Manchester, Salford, UK
| | - David Hearnden
- Dudley MBC Adult Care, Dudley Social Services, Dudley, UK
| | - Ann Ashburn
- Faculty of Health Science, University of Southampton, Southampton, UK
| | - Paul Conroy
- Stroke Research, MAHSC, University of Manchester, Salford, UK
| | - Pip Logan
- Division of Rehabilitation and Ageing, School of Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Carl Thompson
- School of Healthcare, University of Leeds, Leeds, UK
| | - Jacqueline Winter
- Institute for Science and Technology in Medicine & School of Health and Rehabilitation, Keele University, Keele, UK
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López-Espuela F, Pedrera-Zamorano JD, Jiménez-Caballero PE, Ramírez-Moreno JM, Portilla-Cuenca JC, Lavado-García JM, Casado-Naranjo I. Functional Status and Disability in Patients After Acute Stroke: A Longitudinal Study. Am J Crit Care 2016; 25:144-51. [PMID: 26932916 DOI: 10.4037/ajcc2016215] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Stroke is a major public health problem. OBJECTIVE To use the Barthel Index to evaluate basic activities of daily living in stroke survivors and detect any predictors of functional outcome at 6 months after stroke. METHODS In an observational longitudinal study, data were gathered on consecutive patients admitted to the comprehensive stroke unit at Hospital San Pedro de Alcantara, Cáceres, Spain. Sociodemographic and clinical data were obtained prospectively at hospital admission and during follow-up 6 months later. Information on type of stroke, score on the Barthel Index, findings from the neurological evaluation, and other relevant data were collected. RESULTS Of 236 patients admitted, 175 participated in the study. Mean age was 69.60 (SD, 12.52) years, 64.6% were men, and mortality was 12.8%. Six months after experiencing a stroke, 84.8% of patients had returned to their own homes, 8.0% were institutionalized, and the others were residing at a family member's home. Scores on the Barthel Index 6 months after stroke correlated with baseline scores on the National Institute of Health Stroke Scale (r = -0.424; P < .001) and with depressive mood 6 months after stroke (r = -0.318; P < .001). Age was negatively associated with Barthel Index scores at the time of hospital discharge and 6 months after stroke. CONCLUSIONS Functional status 6 months after stroke was influenced by age, sex, stroke severity, type of stroke, baseline status, mood, and social risk. Comorbid conditions, socioeconomic level, and area of residence did not affect patients' functional status.
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Affiliation(s)
- Fidel López-Espuela
- Fidel López-Espuela is research nurse, Juan Diego Pedrera-Zamorano is head of the nursing department, Pedro Enrique Jiménez-Caballero, José María Ramírez-Moreno, and Juan Carlos Portilla-Cuenca are neurologists, Jesús María Lavado-García is vice dean of the nursing school, and Ignacio Casado-Naranjo is head of the department of neurology, Stroke Unit, Hospital San Pedro de Alcantara, Cáceres, Spain
| | - Juan Diego Pedrera-Zamorano
- Fidel López-Espuela is research nurse, Juan Diego Pedrera-Zamorano is head of the nursing department, Pedro Enrique Jiménez-Caballero, José María Ramírez-Moreno, and Juan Carlos Portilla-Cuenca are neurologists, Jesús María Lavado-García is vice dean of the nursing school, and Ignacio Casado-Naranjo is head of the department of neurology, Stroke Unit, Hospital San Pedro de Alcantara, Cáceres, Spain
| | - Pedro Enrique Jiménez-Caballero
- Fidel López-Espuela is research nurse, Juan Diego Pedrera-Zamorano is head of the nursing department, Pedro Enrique Jiménez-Caballero, José María Ramírez-Moreno, and Juan Carlos Portilla-Cuenca are neurologists, Jesús María Lavado-García is vice dean of the nursing school, and Ignacio Casado-Naranjo is head of the department of neurology, Stroke Unit, Hospital San Pedro de Alcantara, Cáceres, Spain
| | - José María Ramírez-Moreno
- Fidel López-Espuela is research nurse, Juan Diego Pedrera-Zamorano is head of the nursing department, Pedro Enrique Jiménez-Caballero, José María Ramírez-Moreno, and Juan Carlos Portilla-Cuenca are neurologists, Jesús María Lavado-García is vice dean of the nursing school, and Ignacio Casado-Naranjo is head of the department of neurology, Stroke Unit, Hospital San Pedro de Alcantara, Cáceres, Spain
| | - Juan Carlos Portilla-Cuenca
- Fidel López-Espuela is research nurse, Juan Diego Pedrera-Zamorano is head of the nursing department, Pedro Enrique Jiménez-Caballero, José María Ramírez-Moreno, and Juan Carlos Portilla-Cuenca are neurologists, Jesús María Lavado-García is vice dean of the nursing school, and Ignacio Casado-Naranjo is head of the department of neurology, Stroke Unit, Hospital San Pedro de Alcantara, Cáceres, Spain
| | - Jesús María Lavado-García
- Fidel López-Espuela is research nurse, Juan Diego Pedrera-Zamorano is head of the nursing department, Pedro Enrique Jiménez-Caballero, José María Ramírez-Moreno, and Juan Carlos Portilla-Cuenca are neurologists, Jesús María Lavado-García is vice dean of the nursing school, and Ignacio Casado-Naranjo is head of the department of neurology, Stroke Unit, Hospital San Pedro de Alcantara, Cáceres, Spain
| | - Ignacio Casado-Naranjo
- Fidel López-Espuela is research nurse, Juan Diego Pedrera-Zamorano is head of the nursing department, Pedro Enrique Jiménez-Caballero, José María Ramírez-Moreno, and Juan Carlos Portilla-Cuenca are neurologists, Jesús María Lavado-García is vice dean of the nursing school, and Ignacio Casado-Naranjo is head of the department of neurology, Stroke Unit, Hospital San Pedro de Alcantara, Cáceres, Spain
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Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2032-60. [PMID: 26022637 DOI: 10.1161/str.0000000000000069] [Citation(s) in RCA: 1980] [Impact Index Per Article: 220.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. METHODS A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. RESULTS Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. CONCLUSIONS Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
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Kutlubaev MA, Akhmadeeva LR. [The early post-stroke mobilization]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOĬ FIZICHESKOĬ KULTURY 2015; 92:46-50. [PMID: 25876435 DOI: 10.17116/kurort2015146-50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Early mobilization is an important prerequisite for the successful recovery after stroke. However, it is unclear at present how early mobilization should be started after stroke. Three randomized controlled trials were devoted to the comparison of the effectiveness and safety of very early (within the first day after stroke) and early (within two days after stroke) mobilization. The meta-analysis of the results of these studies did not reveal any advantages of very early mobilization over early mobilization. One randomized control study was designed to compare the consequences of mobilization within 3 and 7 days after stroke. It has demonstrated that earlier mobilization is associated with fewer complications and does not exert negative effect on cerebral haemodynamics. A number of observational studies confirmed the positive effect of early mobilization on the outcome of stroke. It is concluded that it may be justified to start mobilization on the second day after stroke provided there are no contraindications to such modality. The practicability of very early mobilization remains to be elucidated.
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Affiliation(s)
- M A Kutlubaev
- GBUZ 'Respublikanskaja klinicheskaja bol'nitsa im. G.G. Kuvatova', ul. Dostoevskogo, 132, Ufa, Rossijskaja Federatsija, 450005
| | - L R Akhmadeeva
- GBOU VPO 'Bashkirskij gosudarstvennyj meditsinskij universitet' Minzdrava Rossii, Ufa
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Jung S, Stapf C, Arnold M. Stroke unit management and revascularisation in acute ischemic stroke. Eur Neurol 2014; 73:98-105. [PMID: 25413619 DOI: 10.1159/000365210] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 06/10/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Stroke affects one in six people throughout their lifetimes and is the most frequent cause of disability in adults. Several recanalization therapies have emerged and the management of patients in stroke units has improved over the last decades. SUMMARY This article examines the current treatment options for stroke patients, summarizing the key clinical evidence, as well as listing the complications and practical issues related to each of these main treatment options. KEY MESSAGES Recent advances in the treatment of acute stroke include developments in intravenous thrombolysis (IVT), intra-arterial treatment and bridging therapies. CLINICAL IMPLICATIONS Treatment within a stroke unit reduces mortality and disability regardless of age, sex and stroke severity. IVT is widely available and reduces disability when initiated within 4.5 h after the onset of symptoms. The major limitations of IVT are the low recanalization rates and the narrow time frame. Intra-arterial treatment, especially when using newly developed stent-retrievers, achieves very high recanalization rates. It is restricted by its limited availability and by the longer time span required to initiate therapy. Bridging both therapies is a promising approach that combines the advantages of both therapies, but the superiority of this approach remains to be proven. Future strategies to reduce the burden of acute stroke in Europe should focus on immediate access to acute stroke care and dedicated stroke units for all patients.
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Affiliation(s)
- Simon Jung
- Departments of Neurology, University Hospital Bern and University of Bern, Bern, Switzerland
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Ueba T, Hamada O, Ogata T, Inoue T, Shiota E, Sankai Y. Feasibility and safety of acute phase rehabilitation after stroke using the hybrid assistive limb robot suit. Neurol Med Chir (Tokyo) 2014; 53:287-90. [PMID: 23708218 DOI: 10.2176/nmc.53.287] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Acute phase rehabilitation is an important treatment for improving the functional outcome of patients after stroke. The present cohort study analyzed the feasibility and safety of acute phase rehabilitation using the hybrid assistive limb robot suit in 22 patients, 7 males and 15 females (mean age 66.6 ± 17.7 years). Neurological deterioration, mortality, or other accidents were recorded as adverse events. Baseline characteristics of each patient were recorded at the first hybrid assistive limb rehabilitation. Hybrid assistive limb rehabilitation was conducted for 12.1 ± 7.0 days with the patients in stable condition. Acute phase hybrid assistive limb rehabilitation was performed a total of 84 times with no adverse events recorded except for orthostatic hypotension. Good functional outcomes were obtained in 14 patients. Orthostatic hypotension was observed during the first hybrid assistive limb rehabilitation in four patients, and was significantly associated with intracerebral hemorrhage (p = 0.007) and lower Brunnstrom stage (p = 0.033). Acute phase rehabilitation using the hybrid assistive limb suit is feasible and safe. Patients with intracerebral hemorrhage and lower Brunnstrom stage should be carefully monitored for orthostatic hypotension.
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Affiliation(s)
- Tetsuya Ueba
- Department of Neurosurgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
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Gache K, Leleu H, Nitenberg G, Woimant F, Ferrua M, Minvielle E. Main barriers to effective implementation of stroke care pathways in France: a qualitative study. BMC Health Serv Res 2014; 14:95. [PMID: 24575955 PMCID: PMC3943407 DOI: 10.1186/1472-6963-14-95] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 02/21/2014] [Indexed: 01/19/2023] Open
Abstract
Background Stroke Care Pathways (SCPs) aim to improve quality of care by providing better access to stroke units, rehabilitation centres, and home care for dependent patients. The objective of this study was to identify the main barriers to effective implementation of SCPs in France. Methods We selected 4 types of SCPs currently implemented in France that differed in terms of geographical location, population size, socio-economic conditions, and available health care facilities. We carried out 51 semi-structured interviews of 44 key health professionals involved in these SCPs and used the interview data to (i) create a typology of the organisational barriers to effective SCP implementation by axial coding, (ii) define barrier contents by vertical coding. The typology was validated by a panel of 15 stroke care professionals. Results Four main barriers to effective SCP implementation were identified: lack of resources (31/44 interviewees), coordination problems among staff (14/44) and among facilities (27/44), suboptimal professional and organisational practices (16/44), and inadequate public education about stroke (13/44). Transposition of the findings onto a generic SCP highlighted alternative care options and identified 10 to 17 barriers that could disrupt continuity of care. Conclusion Lack of resources was considered to be the chief obstacle to effective SCP implementation. However, the main weakness of existing SCPs was poor communication and cooperation among health professionals and among facilities. We intend to use this knowledge to construct a robust set of quality indicators for use in SCP quality improvement initiatives, in comparisons between SCPs, and in the assessment of the effective implementation of clinical practice guidelines.
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Affiliation(s)
| | | | - Gérard Nitenberg
- Compaq-HPST, Institut de Cancérologie Gustave Roussy, 114 rue Edouard Vaillant, Villejuif 94805, France.
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Physical activity early after stroke and its association to functional outcome 3 months later. J Stroke Cerebrovasc Dis 2014; 23:e305-12. [PMID: 24529353 DOI: 10.1016/j.jstrokecerebrovasdis.2013.12.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/29/2013] [Accepted: 12/09/2013] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Early rehabilitation that includes early mobilization and increased amount of motor activity is hypothesized to be one of the most important factors contributing to the beneficial effect of comprehensive stroke unit treatment, whereas too much bed rest is hypothesized to be harmful. The purpose of the present study was to assess the association between early activity/bed rest and functional outcome 3 months later. METHODS This was a prospective cohort study including patients with the diagnosis of stroke admitted to Trondheim University Hospital, Norway. Patients were eligible if they were less than 14 days poststroke and did not receive palliative care. Motor activity/bed rest was recorded in the acute phase using a standard method of observation, and the outcome was assessed by the modified Rankin Scale (mRS) score 3 months later. A proportional odds model was used to analyze the association between motor activity/bed rest and outcome. All analyses were adjusted for age, gender, stroke severity, time from stroke to observation, and prestroke function. RESULTS A total of 106 patients (mean age 79.0 years, 56.6% men) were included. The odds ratio for a higher mRS score (poor outcome) was 1.04 (95% confidence interval [CI] 1.02-1.07, P = .001) as time in bed increased and .97 (95% CI .93-1.02, P = .283) as time in motor activity increased. CONCLUSIONS This study confirms that time in bed in the early phase is associated with poor functional outcome 3 months later, indicating that too much bed rest should be avoided in the early phase after stroke.
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Chan DKY, Levi C, Cordato D, O'Rourke F, Chen J, Redmond H, Xu YH, Middleton S, Pollack M, Hankey GJ. Health service management study for stroke: a randomized controlled trial to evaluate two models of stroke care. Int J Stroke 2014; 9:400-5. [PMID: 24393220 DOI: 10.1111/ijs.12240] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 11/07/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND The most effective and efficient model for providing organized stroke care remains uncertain. This study aimed to compare the effect of two models in a randomized controlled trial. METHODS Patients with acute stroke were randomized on day one of admission to combined, co-located acute/rehabilitation stroke care or traditionally separated acute/rehabilitation stroke care. Outcomes measured at baseline and 90 days postdischarge included functional independence measure, length of hospital stay, and functional independence measure efficiency (change in functional independence measure score ÷ total length of hospital stay). RESULTS Among 41 patients randomized, 20 were allocated co-located acute/rehabilitation stroke care and 21 traditionally separated acute/rehabilitation stroke care. Baseline measurements showed no significant difference. There was no significant difference in functional independence measure scores between the two groups at discharge and again at 90 days postdischarge (co-located acute/rehabilitation stroke care: 103.6 ± 22.2 vs. traditionally separated acute/rehabilitation stroke care: 99.5 ± 27.7; P = 0.77 at discharge; co-located acute/rehabilitation stroke care: 109.5 ± 21.7 vs. traditionally separated acute/rehabilitation stroke care: 104.4 ± 27.9; P = 0.8875 at 90 days post-discharge). Total length of hospital stay was 5.28 days less in co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (24.15 ± 3.18 vs. 29.42 ± 4.5, P = 0.35). There was significant improvement in functional independence measure efficiency score among participants assigned to co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (co-located acute/rehabilitation stroke care: median 1.60, interquartile range: 0.87-2.81; traditionally separated acute/rehabilitation stroke care: median 0.82, interquartile range: 0.27-1.57, P = 0.0393). Linear regression analysis revealed a high inverse correlation (R(2) = 0.89) between functional independence measure efficiency and time spent in the acute stroke unit. CONCLUSION This proof-of-concept study has shown that co-located acute/rehabilitation stroke care was just as effective as traditionally separated acute/rehabilitation stroke care as reflected in functional independence measure scores, but significantly more efficient as shown in greater functional independence measure efficiency. Co-located acute/rehabilitation stroke care has potential for significantly improved hospital bed utilization with no patient disadvantage.
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Affiliation(s)
- Daniel K Y Chan
- Department of Aged Care and Rehabilitation, Bankstown-Lidcombe Hospital, Sydney, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
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Affiliation(s)
- Larry B. Goldstein
- From the Department of Neurology, Duke Stroke Center, Duke University Medical Center and Durham VAMC, Durham, NC
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