Variations in Health-Related Quality of Life (HRQoL) and survival 1 year after stroke: five European population-based registers

Health-Related Quality of Life Among Patients With Stroke: A Cross-Sectional Study

PURPOSE

To assess levels and predictive factors of health-related quality of life (HRQOL) among stroke patients.

METHODS

The study employed a cross-sectional predictive correlational design. Levels of HRQOL were assessed using the Stroke-Specific Quality of Life (SS-QOL) scale, and the Hospital Anxiety and Depression Scale was employed to assess psychological aspects among 209 Saudi stroke patients. The analysis included demographic and medical variables to comprehensively explore influencing factors.

RESULTS

A two-step hierarchical multiple regression analysis was performed. The overall SS-QOL summary score (49 items) showed a mean score of 94.4 (SD = 8.1), indicating poor functioning. Nine predictor variables were found to significantly predict HRQOL levels, including age (β = -0.212, p ≤ .001), female (β = -5.33, p ≤ .001), unmarried (β = 2.48, p ≤ .001), low gross monthly income (GMI) (β = -9.02, p ≤ .001), medium GMI (β = -8.36, p ≤ .001), having a medical history of hypertension (β = 2.7, p ≤ .01), time since stroke (β = 3.26 p ≤ .001), and being a probable case of anxiety (β = -4.29, p ≤ .001) and/or depression (β = -2.75, p ≤ .001). These variables collectively explained ~76% of the variance in HRQOL scores (adjusted R2 = .762, F (16,192) = 42.6, p ≤ .001).

CONCLUSIONS

Stroke patients exhibited poor HRQOL levels influenced by various factors. Clinicians should consider these predictors and intervene early to enhance HRQOL among patients at risk, emphasizing the importance of optimizing patient outcomes.

Modelling anticoagulation and health-related quality of life in those with atrial fibrillation: a secondary analysis of AFFIRM

Associations of anticoagulation with primary endpoints in longitudinal studies are impacted by selection bias and time-varying covariates (e.g. comorbidities). We demonstrate how time-varying covariates and selection bias influence association estimates between anticoagulation and health-related quality of life (HRQoL) in patients with atrial fibrillation. We performed a secondary analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management trial quality of life substudy. Dichotomized warfarin use was ascertained at the study baseline, 2 months later, and annually for up to 6 years. HRQoL was measured at every time point using a self-reported ordinal 5-point Likert-scale (lower score and lower odds ratio represents better health-related quality of life). Static and time-varying covariates were ascertained throughout the study period. Confounder-adjusted generalized mixed model and generalized estimating equation regressions were used to demonstrate traditional association estimates between anticoagulation and HRQoL. Inverse probability of treatment and censorship weights were used to ascertain the influence of time-varying confounding and selection bias. Age-stratified analysis (age ≥ 70 years) evaluated for effect modification. 656 individuals were included in the analysis, 601 on warfarin at baseline. The association of warfarin use with better HRQoL over time strengthened when accounting for time-varying confounding and selection bias (OR 0.30, 95% CI 0.14-0.55) compared to traditional analyses (OR 0.61, 95% CI 0.38-0.97), and was most pronounced in those ≥ 70 years upon stratified analysis. Anticoagulation is associated with higher HRQoL in patients with atrial fibrillation, with time-varying confounding and selection bias likely influencing longitudinal estimates in anticoagulation-HRQoL research.

Ethnic disparities in long-term outcomes and health care usage after stroke in the Netherlands

BACKGROUND

Poststroke health-related quality of life (HRQOL) is an important outcome that may be influenced by ethnicity.

OBJECTIVE

To compare long-term HRQOL, mental health and healthcare utilization between stroke survivors with a European (EUB) and non-European background (NEUB) in a hospital population.

METHODS

In this retrospective cohort study patients completed questionnaires 2-5 years after stroke. Assessments included the EuroQol-5D-3L (EQ-5D), Short Form (SF-36, with physical and mental component summary scales, PCS and MCS), Hospital Anxiety and Depression Scale (HADS; scores ≥8 indicate clinically relevant complaints) and a questionnaire on the usage of services from physicians and/or healthcare professionals (HCP) in the past 6 months. Linear and logistic regression analysis was used, adjusted for age, sex, level of education and functional outcome.

RESULTS

We included 207 patients (169 EUB, 38 NEUB); mean age 63.8 years (SD 14.4); 60.4 % male; mean follow up 36.3 months (SD 9.9). The EQ-5D and the PCS were higher in EUB versus NEUB patients (42.9 vs 35.4, p < 0.01; 0.76 vs 0.60, p < 0.01). The MCS showed a comparable, non-significant trend. The percentage of patients with HADS depression ≥8 was higher in NEUB patients versus EUB patients (54.3 % vs 29.8 %; p > 0.01). Significantly more NEUB patients had visited two or more physicians in the past six months compared to EUB patients (52.0 % vs 26.0 %; p = 0.01) whereas the use of services from HCP was similar.

CONCLUSIONS

NEUB stroke patients had worse outcomes regarding HRQOL and depressive symptoms compared to EUB patients. NEUB patients visited more physicians.

Associations of effort-reward imbalance at work and quality of life among workers after stroke: a one-year longitudinal study in Thailand

Stroke incidence is increasing among working-age population, but the role of psychosocial stress in the workplace in predicting quality of life (QoL) after stroke onset is understudied. This longitudinal study aimed to investigate the relationship between work stress, measured by the effort-reward imbalance (ERI) model, and QoL over one-year period among 103 Thai workers who had experienced a stroke. The study evaluated the effort (E)-reward (R) ratio and over-commitment, the extrinsic and intrinsic components of the ERI model, before discharge; QoL was repeatedly measured at baseline, six months, and 12 months after discharge, respectively, using the Short Form Version 2 (SF-12v2) indicators of physical and mental health composite scores. Generalized estimating equations were used to examine longitudinal relationships between work stress at baseline and QoL over one year by testing the hypotheses that E-R ratio and over-commitment would have direct effects on QoL, and potential moderating effects of over-commitment on E-R ratio and QoL. The results supported the ERI model partially, as over-commitment was significantly associated with poor mental health (coefficient - 8.50; 95% CI: -13.79, -3.20) after adjusting baseline sociodemographic, behavioral, and clinical characteristics, while the E-R ratio was not significantly associated with physical or mental health; the interaction between the E-R ratio and over-commitment was also not significant. These findings suggest that more attention should be paid to workers' personal coping skills and ability to handle work-related problems and prioritize interventions that address over-commitment to promote long-term mental health among workers with stroke.

Trajectories of post-stroke quality of life and long-term prognosis: Results from an eleven-year prospective study

PURPOSE

The relationship between quality of life (QoL) and long-term prognosis in stroke patients is still unclear. We explored physical and mental QoL trajectories during the first six months after stroke and determined the associations between trajectories and long-term prognosis in patients with first-ever ischemic stroke.

METHODS

Included were 733 participants from a prospective study. QoL was assessed with the 12-item Short Form Survey (SF-12) at baseline, 3 and 6 months. Patients' prognoses (stroke recurrence and death) were identified from 2010 to 2021. The latent class growth model (LCGM) was used to identify distinct trajectories of physical and mental QoL measured over the first 6 months. We employed the Cox model or Fine-Gray model for prognoses to examine the associations between QoL trajectories and prognosis.

RESULTS

Five trajectories of physical QoL and five trajectories of mental QoL were identified. For physical QoL of the Poor-Improved, and Moderate-Impaired trajectory versus Moderate-Improved trajectory, the hazard ratio (HR) for death was 2.39 (1.14 to 5.02), and 2.03(0.93 to 4.44); the HR for recurrence was 1.56 (0.83 to 2.94) and 2.33 (1.28 to 4.24). For mental QoL of the Moderate-Impaired trajectory versus the Moderate-Improved trajectory, the HR for death was 2.48 (1.21 to 5.07). The results were robust in the sensitivity analysis.

CONCLUSION

QoL during the first six months after ischemic stroke can be categorized into distinct groups. Change in QoL was associated with long-term survival. Secondary prevention of recurrent strokes might rely more on improving patients' physical QoL.

Health-related quality of life in stroke survivors: a 5-year follow-up of The Fall Study of Gothenburg (FallsGOT)

BACKGROUND

There are limited data on long-term prevalence and predictors of health-related quality of life (HRQoL) in stroke survivors. Therefore, the aim was to describe the prevalence of impaired HRQoL, and to identify factors in acute stroke that are associated with impaired HRQoL, 5 years after stroke.

METHODS

The 305 (60.5%) stroke survivors of the original 504 participants from The Fall Study of Gothenburg were invited to participate in a 5-year follow-up including assessment of HRQoL using the EuroQol 5 Dimensions 3 Levels questionnaire (EQ-5D-3L). To identify baseline predictors of impaired HRQoL, based on the EQ-5D-3L's five dimensions, univariate and multivariate logistic regression analyses were performed.

RESULTS

A total of 129 participants (42.3% of the survivors) completed the questionnaire at a median follow-up time of 58 months. At baseline, their mean age was 70.6 years, and they had a median NIHSS score of 1. The median (interquartile range [IQR]) EQ-5D-3L index score was 0.87 (0.71-0.93) and the median (IQR) EQ-visual analogue scale was 70 (49.8-88). In total, 102 (79%) participants were classified as having impaired HRQoL, stated primarily (among 68.5%) related to Pain/Discomfort. Higher age was identified as a predictor of impaired HRQoL related to Mobility (Odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01-1.10) and Self-Care (OR 1.09, 95% CI 1.02-1.17), and longer hospital stay at baseline was identified as a predictor related to Mobility (OR 1.09, 95% CI 1.01-1.18), Self-Care (OR 1.10, 95% CI 1.02-1.18)) and Usual Activities. (OR 1.10, 95% CI 1.03-1.18).

CONCLUSION

At 5 years after stroke, four out of five participants (79%) reported impaired HRQoL related to any of the five dimensions assessed by using the EQ-5D-3L. Most reported, impaired HRQoL was related to Pain/Discomfort. Higher age and longer hospital care period at index stroke were associated with impaired HRQoL. The findings could assist to identify individuals at high risk of low HRQoL, who might benefit from special attention and psychological support.

Contribution of participation and resilience to quality of life among persons living with stroke in Sweden: a qualitative study

PURPOSE

Resilience contributes to positive adaptation after many health conditions, but little is known about its contribution to long-term recovery after stroke. This study investigated the lived experience of resilience and participation and their relationship to quality of life after stroke in Sweden.

MATERIAL AND METHOD

Semi-structured telephone interviews were conducted with 19 informants (10 male, 9 female), aged from 44-89 years and between 1 and 19 years post-stroke. Stroke severity ranged from mild (n = 8), moderate (n = 9) to severe (n = 2). Interviews were analysed using content analysis.

RESULTS

The analysis resulted in an overarching theme; Life with stroke has been adapted to but not accepted, built on five subthemes: 1) Adapting and adjusting life, 2) Meaningful values in life, 3) Inner resources, 4) Support and treatment from social relations, and 5) Support and treatment from external resources.

CONCLUSION

Participants described a tension between adapting and accepting life after stroke. Resilience was a useful framework, highlighting the contribution of inner, social and societal resources to recovery and quality of life, both directly and as enhanced through increased participation. Important factors for adaptation are meaningful values in life, individual strategies for adaptation and support from both social relationship and the society.

Restoring After Central Nervous System Injuries: Neural Mechanisms and Translational Applications of Motor Recovery

Central nervous system (CNS) injuries, including stroke, traumatic brain injury, and spinal cord injury, are leading causes of long-term disability. It is estimated that more than half of the survivors of severe unilateral injury are unable to use the denervated limb. Previous studies have focused on neuroprotective interventions in the affected hemisphere to limit brain lesions and neurorepair measures to promote recovery. However, the ability to increase plasticity in the injured brain is restricted and difficult to improve. Therefore, over several decades, researchers have been prompted to enhance the compensation by the unaffected hemisphere. Animal experiments have revealed that regrowth of ipsilateral descending fibers from the unaffected hemisphere to denervated motor neurons plays a significant role in the restoration of motor function. In addition, several clinical treatments have been designed to restore ipsilateral motor control, including brain stimulation, nerve transfer surgery, and brain–computer interface systems. Here, we comprehensively review the neural mechanisms as well as translational applications of ipsilateral motor control upon rehabilitation after CNS injuries.

Persisting consequences of ischemic stroke after three months, assessed with the Stroke Impact Scale Version 3.0

INTRODUCTION

Acute ischemic stroke (AIS) has a significant impact on different aspects of the patient's life resulting in loss of independence and poor Health-related Quality of life (HR-QoL).

AIMS

This study aimed to evaluate the impact of AIS on HR-QoL during the first three months post-stroke in a defined Bulgarian population.

METHODS

A total of 150 patients with AIS - 50 with thrombolytic and 100 with non-thrombolytic therapy, were enrolled in a hospital-based study at a tertiary care referral center for neurological disorders in Bulgaria. The HR-QoL of stroke survivors was assessed with the Stroke Impact Scale 3.0 on discharge, in the first and the third-month post-stroke.

RESULTS

The overall HR-QoL remained significantly reduced during the observation period. The most affected domains in the third-month were Participation, Hand function, Mobility, Strenght, and Activities of daily living (ADL). Improvement in all HR-QoL domains was found, most pronounced up to the first-month post-stroke. The higher age, NIHSS and mRS scores were associated with worse SIS 3.0 scores. Left-hemispheric AIS was associated with worse Memory and Communication outcomes, while Right-hemispheric lesions had a higher impact on the Emotions. Large-artery occlusion determined diminished Strenght scores, whereas cardioembolism impacted Communication and ADL domains. Contrarily, lacunar stroke showed more favourable outcomes in all domains.

CONCLUSION

There is the utmost need to focus on the long-term effects of ischemic stroke, due to the rising number of patients who live with the consequences of stroke. Stroke treatment should not be directed exclusively to acute stroke care or prevention, but also to optimizing the post-stroke functioning and Quality of life.

Effects of Virtual Reality-Based Therapy on Quality of Life of Patients with Subacute Stroke: A Three-Month Follow-Up Randomized Controlled Trial

Objective: To evaluate the influence of conventional rehabilitation combined with virtual reality on improving quality of life related to post-stroke health. Design: Randomized controlled trial. Setting: Rehabilitation and neurology departments of a general hospital (Talavera de la Reina, Spain). Subjects: A total of 43 participants with subacute stroke. Intervention: Participants were randomized into experimental group (conventional treatment + virtual reality) and control (conventional treatment). Main measures: Health-related quality of life as measured by the EuroQoL-5 dimensions instrument (EQ-5D-5L) and EuroQoL visual analog scale (EQ-VAS). Results: A total of 23 patients in the experimental group (62.6 ± 13.5 years) and 20 in the control (63.6 ± 12.2 years) completed the study. In the experimental group, EQ-VAS score was 29.1 ± 12.8 at baseline, 86.5 ± 7.1 post-intervention, and 78.3 ± 10.3 at the three-month follow-up. The control group obtained scores of 25.5 ± 5.1, 57.0 ± 4.7, and 58.5 ± 5.9, respectively. We identified significant differences at the post-intervention and follow-up timepoints (p = 0.000) and a partial η² of 0.647. In EQ-5D-5L, the severity of issues decreased after intervention in the experimental group, while pain and anxiety dimensions increased between post-intervention and follow-up. Conclusions: The conventional rehabilitative approach combined with virtual reality appears to be more effective for improving the perceived health-related quality of life in stroke survivors.

Health-related quality of life after ischemic stroke: impact of sociodemographic and clinical factors

BACKGROUND AND AIMS

Ischemic stroke (IS) is one of the leading causes of death and long-term disability in Bulgaria. IS affects different aspects of the patient's life and results in loss of independence and poor health-related quality of life (HR-QoL). We aimed to analyze the impact of IS on HR-QoL and to identify possible associations with sociodemographic, clinical features, and vascular risk factors (RF).

METHODS

A prospective, hospital-based study was undertaken from 1 July 2019 to 31 June 2020, at a tertiary care referral center for neurological disorders in Bulgaria. A total of 150 patients with acute IS - 50 with thrombolytic and 100 with non-thrombolytic therapy - were included. Thorough clinical and sociodemographic data were collected. The NIHSS scale determined stroke severity, and HR-QoL was assessed with the Stroke Impact Scale Version 3.0 (SIS 3.0) during the first 3 months.

RESULTS

The overall HR-QoL improved during the observation period, but still, it remained significantly worse. The major predictors of a marked reduction in HR-QoL were age, female sex, lower education level, and actively working at stroke onset, high NIHSS score, anterior circulation stroke, and more extended hospital. Atrial fibrillation and heart failure were significantly associated with poor HR-QoL. The other investigated vascular risk factors were associated with different extends with poorer HR-QoL, except for dyslipidemia.

CONCLUSION

Stroke survivors have significantly reduced HR-QoL. Multiple interacting factors are associated with an unfavorable outcome after IS. Early detection of these factors would help to improve the care for IS patients, to reduce disabilities and improve HR-QoL.

Different Stroke Scales; Which Scale or Scales Should Be Used?

BACKGROUND

There has been a considerable development in the clinometric of stroke. But researchers are concerned that some scales are too generic, inherently and the insight may not be provided. The current study was conducted to determine which scale or scales should be used in stroke survivors.

METHODS

We selected 67 studies which were published between January 2010 and December 2018 from Up to date, CINAHL, ProQuest, Scopus, PubMed, Embase, Medline, Elsevier and Web of Science with MeSH terms. Inclusion criteria were: clinical trials, prospective studies, retrospective cohort studies, or cross-sectional studies; original research in adult human stroke survivors. We excluded the following articles: non-adult population; highly selected studies or treatment studies without incidence data; commentaries, single case reports, review article, editorials and non-English articles or articles without full text available.

RESULTS

Face Arm Speech Test and Cincinnati Pre-Hospital Stroke Scale scales because it was easy to learn and rapidly administer the recommended dose to use in pre-hospital, but there are not gold standard in stroke diagnosis in Pre-Hospital. National Institutes of Health Stroke Scale valuable in the acute stage for middle cerebral artery, not chronic or long term post stroke outcome. The Barthel Index scores for approximately three weeks could predict activities of daily living disabilities in 6 months.

CONCLUSION

Every scale has an advantage and a disadvantage and we were not able to introduce the gold standard for each item, but some special scales were used more in the studies, preferred for comparing with other studies to match the research results.

Association of Health Utility Score with Physical Activity Outcomes in Stroke Survivors

Health-related quality of life (HRQoL) after stroke tends to vary across studies or across stages of stroke. It is useful to use the health utility score to compare HRQoL across studies. Physical activity after stroke also tends to vary similarly. The purpose of the present study was to determine associations between the health utility score and physical activity outcomes in stroke survivors. This cross-sectional study recruited stroke survivors who could ambulate outside, free of assistance. We assessed the health utility score with the EuroQoL 5-Dimension 3-Level questionnaire. The physical activity outcomes were the number of steps taken and duration of moderate-to-vigorous physical activity (MVPA) as measured with an accelerometer. Multiple linear regression analyses were used to determine whether the physical activity outcomes were independently associated with the health utility score. Fifty patients (age: 68.0 years; 40 men, 10 women) were included. Multiple linear regression analysis showed the health utility score to be significantly associated with the number of steps taken (β = 0.304, p = 0.035) but not with MVPA. This is the first study to examine the association between the health utility score and objectively measured physical activity in stroke survivors. Promoting physical activity especially by increasing the number of steps taken might be a priority goal in improving a patient's health utility score after stroke.

Determinants of Long-Term Health-Related Quality of Life in Young Ischemic Stroke Patients

OBJECTIVES

This study aimed to assess long-term, health-related quality of life (HRQOL) in a young ischemic stroke cohort, and to identify factors associated with poor HRQOL.

MATERIALS AND METHODS

We conducted a survey with ischemic stroke survivors in Estonia aged 18-54 years at the time of stroke, measuring HRQOL with the three-level version of the five-dimension EuroQol (EQ-5D-3L). The control group comprised the participants of the Health Behavior among Estonian Adult Population study. A tobit regression model with a backward stepwise analysis was used to identify factors associated with low EQ-5D-3L utility scores.

RESULTS

In total, 352 patients with a mean follow-up time from the qualifying event of 5.7 years and 2304 controls were included. The mean EQ-5D-3L utility score in stroke survivors was significantly lower compared with that in the general population (0.71 vs. 0.87, respectively, p<0.001). However, the subgroup with excellent functional outcome had a significantly higher mean EQ-5D-3L utility score compared with non-stroke counterparts (0.91 v 0.87, respectively, p<0.001). The largest differences between stroke survivors and the general population were in the physical domains. Coronary heart disease at the index event, and higher follow-up duration, functional disability, depressive symptoms, recurrent stroke, and not being fully employed at follow-up, were independently associated with lower HRQOL.

CONCLUSION

Young ischemic stroke survivors have long-term decreased HRQOL, except for those with excellent functional recovery. Our results prioritize motor rehabilitation and highlight the importance of secondary prevention, treatment of depression, and career counselling as potential ways of increasing HRQOL.

Stroke-Specific Quality of Life one-year post-stroke in two Scandinavian country-regions with different organisation of rehabilitation services: a prospective study

Purpose: To compare stroke-specific health related quality of life in two country-regions with organisational differences in subacute rehabilitation services, and to reveal whether organisational factors or individual factors impact outcome.Materials and methods: A prospective multicentre study with one-year follow-up of 369 first-ever stroke survivors with ischaemic or haemorrhagic stroke, recruited from stroke units in North Norway (n = 208) and Central Denmark (n = 161). The 12-domain Stroke-Specific Quality of Life scale was the primary outcome-measure.Results: The Norwegian participants were older than the Danish (M_age= 69.8 vs. 66.7 years, respectively), had higher initial stroke severity, and longer stroke unit stays. Both cohorts reported more problems with cognitive, social, and emotional functioning compared to physical functioning. Two scale components were revealed. Between-country differences in the cognitive-social-mental component showed slightly better function in the Norwegian participants. Depression, anxiety, pre-stroke dependency, initial stroke severity, and older age were substantially associated to scale scores.Conclusions: Successful improvements in one-year functioning in both country-regions may result from optimising long-term rehabilitation services to address cognitive, emotional, and social functioning. Stroke-Specific Quality of Life one-year post-stroke could be explained by individual factors, such as pre-stroke dependency and mental health, rather than differences in the organisation of subacute rehabilitation services.IMPLICATIONS FOR REHABILITATIONThe stroke-specific health related quality of life (SS-QOL) assessment tool captures multidimensional effects of a stroke from the perspective of the patient, which is clinically important information for the rehabilitation services.The cognitive-social-mental component and the physical health component, indicate specific functional problems which may vary across and within countries and regions with different organisation of rehabilitation services.For persons with mild to moderate stroke, longer-term functional improvements may be better optimised if the rehabilitation services particularly address cognitive, emotional, and social functioning.

Experiences of quality of life the first year after stroke in Denmark and Norway. A qualitative analysis

Purpose: This study aims to explore quality of life (QOL) during the first year of recovery after stroke in North Norway and Central Denmark. Method: Individual in-depth interviews with 11 stroke survivors were performed twelve months after stroke onset. An interpretative, inductive approach shaped the interview process and the processing of data. Results: We found that QOL reflected the individuals' reconstruction of the embodied self, which was identified by three intertwined and negotiating processes: a familiar self, an unfamiliar self, and a recovery of self. Further, we found that reconstruction of the embodied self and QOL could be framed as an ongoing and interrelated process of "being, doing, belonging and becoming". Enriching social relations, successful return to work, and continuity and presence in professional support during recovery enhanced the experience of QOL. Fatigue and sustained reduced function hindered participation in meaningful activities and influenced the perceived QOL negatively. Conclusions: The two countries differed in descriptions of continuity and support in the professional follow-up during the recovery process, influencing the degree of encouragement in reconstructing the embodied self. Reconstruction of the embodied self is a means of understanding stroke survivors' QOL during the first year of recovery, supporting an individualized and tailored rehabilitation practice.

Using frailty and quality of life measures in clinical care of the elderly in Canada to predict death, nursing home transfer and hospitalisation - the frailty and ageing cohort study

OBJECTIVE

To assess the value of using frailty measures in primary care for predicting death, nursing home transfer (NHT) and hospital admission.

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

All 380 people, mean age 88.4, living in the community and receiving home-based primary geriatric care from one practice in Victoria, Canada.

INTERVENTIONS/MEASUREMENTS

A 60 min baseline assessment which included: Clinical Frailty Scale (CFS), EuroQol EQ-5D-5L (EQ-5D), EuroQol Visual Analogue Scale (EQ-VAS) and Gait Speed (Gaitspeed).

OUTCOMES

Death, NHT and hospital admission.

RESULTS

During 18 months of follow-up, there were 39 (10.3%) deaths, 48 (12.6%) NHTs and 93 (24.5%) individuals admitted to hospital. All three outcomes were predicted by: CFS Level 6+7/4+5 (HR death 5.92, 95% CI 3.12 to 11.22, NHT 6.00, 95% CI 3.37 to 10.66 and hospital admission 2.92, 95% CI 1.93 to 4.40); EQ-5D Quintile 1/Quintile 5 (death 6.26, 95% CI 2.11 to 18.62; NHT 3.18, 95% CI 1.29 to 7.82 and hospital admission 2.94, 95% CI 1.47 to 5.87); EQ-VAS Q1/Q5 (death 7.0, 95% CI 2.34 to 20.93; NHT 3.38, 95% CI 1.22 to 9.35 and hospital admission 6.69, 95% CI 3.20 to 13.99) and Gaitspeed (death 5.87, 95% CI 1.78 to 19.34; NHT 8.51, 95% CI 3.18 to 22.79 and hospital admission 11.05, 95% CI 5.45 to 22.40). Medical diagnoses, multiple comorbidities and polypharmacy were weaker predictors of these outcomes. Cox regression analyses showed CFS (adjusted HR 2.88, 95% CI 1.23 to 6.68), EQ-VAS (0.96, 95% CI 0.93 to 0.98), estimated glomerular filtration rate (0.97, 95% CI 0.95 to 1.00) and haemoglobin (0.97, 95% CI 0.94 to 0.99) were independently associated with death. Gaitspeed (0.13, 95% CI 0.03 to 0.57), Geriatric Depression Scale (1.39, 95% CI 1.07 to 1.82) and dementia diagnosis (4.61, 95% CI 1.86 to 11.44) were associated with NHT. Only CFS (1.75, 95% CI 1.21 to 2.51) and EQ-VAS (0.98, 95% CI 0.96 to 0.99) were associated with hospital admission. No other diagnoses, polypharmacy nor multiple comorbidities predicted these outcomes.

CONCLUSIONS

For elderly people, standardised simple measures of frailty and health status were stronger predictors of death, NHT and hospital admission than medical diagnoses. Consideration should be given to adding these measures into usual medical care for this age group.

Quality of life and functional limitations after pulmonary embolism and its prognostic relevance

BACKGROUND

While the importance of patients' quality of life (QoL) in chronic cardiac or pulmonary disease is uncontroversial, the burden of an acute pulmonary embolism (PE) on QoL has received little attention thus far.

OBJECTIVES

We aimed to validate the German PEmb-QoL questionnaire, identify associations between QoL and clinical/functional parameters, and investigate the prognostic relevance of QoL for long-term survival in survivors of an acute PE episode.

PATIENTS/METHODS

Patients were invited for a clinical follow-up visit including assessment of QoL using the German PEmb-QoL questionnaire 6 months after an objectively confirmed PE at a single center. Internal consistency reliability, construct-related validity, and regressions between PEmb-QoL and clinical patient-characteristics were assessed using standard scale construction techniques.

RESULTS

Overall, 101 patients [median age, 69 ([interquartile range] IQR 57-75) years; women, 48.5%] were examined 208 (IQR 185-242) days after PE. Internal consistency reliability and construct-related validity of the PEmb-QoL questionnaire were acceptable. As many as 47.0% of patients reported dyspnea, 27.5% had right ventricular (RV) dysfunction on transthoracic echocardiography (TTE), and 25.3% were diagnosed with post-PE impairment (PPEI) at 6-month follow-up. Furthermore, 15.9% of patients were diagnosed with depression 6 months after an acute PE. The QoL was affected by dyspnea, preexisting pulmonary disease, and PPEI, and a reduced QoL was associated with an increased risk for long-term mortality after an observation period of 3.6 years.

CONCLUSIONS

The German PEmb-QoL questionnaire is a reliable instrument for assessing QoL 6 months after PE. The QoL was affected by dyspnea, preexisting pulmonary disease, and PPEI and was associated with long-term mortality.

Biomarkers of immune capacity, infection and inflammation are associated with poor outcome and mortality after stroke - the PREDICT study

Background

Almost 40% of stroke patients have a poor outcome at 3 months after the index event. Predictors for stroke outcome in the early acute phase may help to tailor stroke treatment. Infection and inflammation are considered to influence stroke outcome.

Methods

In a prospective multicenter study in Germany and Spain, including 486 patients with acute ischemic stroke, we used multivariable regression analysis to investigate the association of poor outcome with monocytic HLA-DR (mHLA-DR) expression, interleukin 6 (IL-6), interleukin 10 (IL-10), tumor necrosis factor alpha (TNF-alpha) and lipopolysaccharide-binding protein (LBP) as markers for immunodepression, inflammation and infection. Outcome was assessed at 3 months after stroke via a structured telephone interview using the modified Rankin Scale (mRS). Poor outcome was defined as a mRS score of 3 or higher which included death. Furthermore, a time-to-event analysis for death within 3 months was performed.

Results

Three-month outcome data was available for 391 patients. Female sex, older age, diabetes mellitus, atrial fibrillation, stroke-associated pneumonia (SAP) and higher National Institute of Health Stroke Scale (NIHSS) score as well as lower mHLA-DR levels, higher IL-6 and LBP-levels at day 1 were associated with poor outcome at 3 months in bivariate analysis. Furthermore, multivariable analysis revealed that lower mHLA-DR expression was associated with poor outcome.

Female sex, older age, atrial fibrillation, SAP, higher NIHSS score, lower mHLA-DR expression and higher IL-6 levels were associated with shorter survival time in bivariate analysis. In multivariable analysis, SAP and higher IL-6 levels on day 1 were associated with shorter survival time.

Conclusions

SAP, lower mHLA-DR-expression and higher IL-6 levels on day one are associated with poor outcome and shorter survival time at 3 months after stroke onset.

Trial registration

www.clinicaltrials.gov, NCT01079728, March 3, 2010.

The combined impact of dependency on caregivers, disability, and coping strategy on quality of life after ischemic stroke

BACKGROUND

To estimate the additional impact of coping and of being dependent on caregivers, over and above the large effects of disability on utility after ischemic stroke.

METHODS

A total of 539 patients were recruited into an observational, retrospective study when returning for a check-up between 3 and 36 months after an ischemic stroke. Patients' modified Rankin Scale (mRS), dependency on caregivers, the Brandtstädter and Renner Coping questionnaire (with summary scores: Tenacity of Goal Pursuit (TGP) and Flexible Goal Adjustment (FGA) coping styles), EQ-5D-3 L and co-morbidities were evaluated.

RESULTS

In multivariable regression, greater disability (mRS) resulted in large utility losses, between 0.06 for mRS 1 to 0.65 for mRS 5 (p < 0.0001). Dependency on caregivers caused an additional dis-utility of 0.104 (p = 0.0006) which varied by mRS (0.044, 0.060, 0.083, 0.115, 0.150 and 0.173 for mRS 0-5). The effect of coping on utility varied by coping style, by the disability level of the patient and by his or her dependency on caregivers. FGA coping was associated with additional increases in utility (p < 0.0001) over and above the effect of disability and dependency, whereas TGA had no significant impact. FGA coping was associated with larger utility changes among more disabled patients (0.018 to 0.105 additional utility, for mRS 0 to mRS 5 respectively). Dependent patients had more to gain from FGA coping than patients who function independently of caregivers: utility gains were between 0.049 and 0.072 for moderate to high levels of FGA coping. In contrast, the same positive evolution in FGA coping resulted in 0.039 and 0.057 utility gain among independent patients. Finally, we found that important stroke risk factors and co-morbidities, such as diabetes and atrial fibrillation, were not predictors of EQ-5D utility in a multivariable setting.

CONCLUSIONS

This study suggests that treatment strategies targeting flexible coping styles and decreasing dependency on caregivers may lead to significant gains in quality of life above and beyond treatment strategies that solely target disability.

Diffusion tensor imaging as a prognostic biomarker for motor recovery and rehabilitation after stroke

PURPOSE

Despite improved acute treatment and new tools to facilitate recovery, most patients have motor deficits after stroke, often causing disability. However, motor impairment varies considerably among patients, and recovery in the acute/subacute phase is difficult to predict using clinical measures alone, particularly in severely impaired patients. Accurate early prediction of recovery would help rationalize rehabilitation goals and improve the design of trials testing strategies to facilitate recovery.

METHODS

We review the role of diffusion tensor imaging (DTI) in predicting motor recovery after stroke, in monitoring treatment response, and in evaluating white matter remodeling. We critically appraise DTI studies and discuss their limitations, and we explore directions for future study.

RESULTS

Growing evidence suggests that combining clinical scores with information about corticospinal tract (CST) integrity can improve predictions about motor outcome. The extent of CST damage on DTI and/or the overlap between the CST and a lesion are key prognostic factor that determines motor performance and outcome. Three main strategies to quantify stroke-related CST damage have been proposed: (i) measuring FA distal to the stroke area, (ii) measuring the number of fibers that go through the stroke with tractography, and (iii) measuring the overlap between the stroke and a CST map derived from healthy age- and gender-matched controls.

CONCLUSION

Recovery of motor function probably involves remodeling of the CST proper and/or a greater reliance on alternative motor tracts through spontaneous and treatment-induced plasticity. DTI-metrics represent promising clinical biomarkers to predict motor recovery and to monitor and predict the response to neurorehabilitative interventions.

Life satisfaction in persons with severe stroke - A longitudinal report from the Sunnaas International Network (SIN) stroke study

Introduction

The overall aim of the present study was to explore perceived life satisfaction in persons with stroke, from admission to specialised rehabilitation until follow up 1 year post-discharge. The secondary aim was to evaluate possible external and internal explanatory factors for perceived life satisfaction.

Patients and methods

A prospective, descriptive study of specialised rehabilitation of persons with stroke. Persons with a primary diagnosis of stroke were enrolled in the study.

Results

Overall, total score on LiSat-11 showed that life was perceived as satisfying by 11% on admission, 21% at discharge, 25% at 6 and 31% at 12 months after discharge from rehabilitation, reported by 230 participating persons with stroke. Repeated measurement indicated significant differences of total life satisfaction between clinics, also when controlled for disability and severity. The items "sexual life," "health," and "vocational life"/"financial" were most dissatisfying at the various reported time points. The linear regression analysis revealed an equal amount of internal and external explanatory factors at the different time points, explaining between 16% and 41% of the variations.

Discussion and conclusion

The perceived life satisfaction was reported as low/dissatisfying at the four stated time points in all the participating clinics. Four items were especially vulnerable post-stroke: vocational situation, sexual life, physical health and mental health. Both internal and external factors contributed to life satisfaction, such as gender, severity of stroke, marital status, country, models of rehabilitation, occupational status, length of stay (LOS), number of therapies and hours in therapy. However, there were significant differences between clinics, indicating that unidentified factors may also influence life satisfaction.

Analysis of consistency between temporospatial gait parameters and gait assessment with the use of Wisconsin Gait Scale in post-stroke patients

INTRODUCTION

Due to the increasing incidence and social effects of stroke there is a growing interest in finding methods enabling gait analysis in this group of patients. Observational techniques are predominantly applied in clinical practice; on the other hand advanced quantitative methods allow in-depth multidimensional gait assessment. The present study was designed to assess the consistency between temporospatial gait parameters acquired through 3-dimensional gait analysis and the results of gait assessment with the use of observational WGS in post stroke hemiparetic patients.

MATERIAL AND METHOD

The study was performed in a group of 30 post-stroke patients, over 6 months from the onset of ischaemic stroke, who were able to walk unassisted. Gait assessment based on WGS was performed by an experienced physiotherapist, with the use of video recordings. Assessment of temporospatial parameters was based on gait analysis performed with BTS Smart system.

RESULTS

The findings show moderate correlation between WGS based gait assessment and gait velocity (r=-0.39; p=0.0316). Similar relationship was identified between gait cycle duration and score in WGS for both unaffected (r=-0.36; p=0.0477) and affected side (r=-0.37; p=0.0426). Higher correlation level was demonstrated for stance phase on the unaffected side and gait assessment based on WGS (r=0.58; p=0.0009).

CONCLUSIONS

Gait assessments with the use of temporospatial parameters and with observational WGS were found to produce moderate and good consistent results. WSG is a useful, simple tool for assessing gait in post stroke hemiparetic patients.

Prevalence and impact of disability and sexual dysfunction on Health-Related Quality of Life of Nigerian stroke survivors

PURPOSE

To investigate the impact of disability and sexual dysfunction on Health-Related Quality of Life (HRQoL) among Nigerian stroke survivors (SSv) and to determine their association using sexual functioning (SF), Global Disability Measure and Function (GDMF), and demographic profiles.

METHODS

This study involved 121 consecutive SSv attending healthcare services in two tertiary health facilities in Nigeria. Demographic details were obtained through interview while HRQoL, SF, and Global Disability (GD) were assessed using Stroke-Specific Quality of Life (SS-QoL-12), Changes in Sexual Functioning Questionnaire (CSFQ-14), and World Health Organization Disability Assessment Schedule (WHODAS-2.0), respectively. Determinants of HRQoL were explored using the Poisson regression analysis.

RESULTS

Most of the SSv had moderate/severe GD (95%) and low SF (86.8%). Their HRQoL decreased with increase in their age (p = 0.005) and with increase in GD (p = 0.001). This association remained unchanged even when adjusted for SF (p = 0.001). Those with low SF but with mild GD had relatively better HRQoL than those with moderate/severe GD even when they had higher SF. Their HRQoL was negatively impacted by their GD but not by their SF despite direct correlation between SF and HRQoL. With a unit increase in level of GD, there was 8% decrease in HRQoL scores in psychosocial and 17% decrease in physical domains.

CONCLUSION

Although sexual dysfunction and global disability are prevalent among Nigerian SSv, their low HRQoL is determined by their disability and not by SF. Hence, effort at reducing global disability should be the focus of rehabilitation after stroke. Implication for Rehabilitation Global functional and sexual deficiencies abound in stroke survivors and they impact negatively on their overall quality of life. Sexual dysfunction correlates negatively on physical and psychosocial wellbeing of stroke survivors. Rehabilitation goal(s) should focus disability reduction and improvement of sexual functioning to enhance quality of life. Rehabilitation professionals should equip themselves with tools to counsel stroke survivors on sex issue since sexual dysfunction is common post stroke.

A decision analytic model to investigate the cost-effectiveness of poisoning prevention practices in households with young children

BACKGROUND

Systematic reviews and a network meta-analysis show home safety education with or without the provision of safety equipment is effective in promoting poison prevention behaviours in households with children. This paper compares the cost-effectiveness of home safety interventions to promote poison prevention practices.

METHODS

A probabilistic decision-analytic model simulates healthcare costs and benefits for a hypothetical cohort of under 5 year olds. The model compares the cost-effectiveness of home safety education, home safety inspections, provision of free or low cost safety equipment and fitting of equipment. Analyses are conducted from a UK National Health Service and Personal Social Services perspective and expressed in 2012 prices.

RESULTS

Education without safety inspection, provision or fitting of equipment was the most cost-effective strategy for promoting safe storage of medicines with an incremental cost-effectiveness ratio of £2888 (95 % credible interval (CrI) £1990-£5774) per poison case avoided or £41,330 (95%CrI £20,007-£91,534) per QALY gained compared with usual care. Compared to usual care, home safety interventions were not cost-effective in promoting safe storage of other household products.

CONCLUSION

Education offers better value for money than more intensive but expensive strategies for preventing medicinal poisonings, but is only likely to be cost-effective at £30,000 per QALY gained for families in disadvantaged areas and for those with more than one child. There was considerable uncertainty in cost-effectiveness estimates due to paucity of evidence on model parameters. Policy makers should consider both costs and effectiveness of competing interventions to ensure efficient use of resources.

Health-related quality of life is inversely correlated with C-reactive protein and age in Mycobacterium avium complex lung disease: a cross-sectional analysis of 235 patients

Background

Mycobacterium avium complex (MAC) lung diseases generally cause chronic disease in immunocompetent hosts. Although a few studies have examined health-related quality of life (HRQL) in patients with MAC lung disease, there have been no large studies. This study aimed to evaluate HRQL and its correlation with clinical outcomes in MAC lung disease.

Methods

A cross-sectional study was conducted at Keio University Hospital to investigate the factors associated with HRQL in pulmonary nontuberculous mycobacterial diseases. MAC lung diseases were diagnosed according to the 2007 ATS/IDSA guidelines for nontuberculous mycobacterial diseases. The 36-item short form health survey (SF-36) was administered to assess clinical outcomes. Clinical variables included treatment status, latest haematological data, and bacterial smear and culture results.

Results

The SF-36 scores for the 235 patients (median age, 69 years; 45 men and 190 women) with MAC lung disease, except for the bodily pain and mental health subscale scores, were significantly lower than the Japanese population norms. In the multivariable analyses, current treatment for MAC and a positive sputum smear or culture within the past year were significantly associated with lower SF-36 scores. C-reactive protein (CRP) and age showed stronger inverse correlations with SF-36 scores.

Conclusions

HRQL, especially the physical component, was impaired in patients with MAC lung diseases; this appears to be related with current treatment status, positive sputum smear or culture within the previous year, and particularly CRP and age. Further studies including qualitative assessments are needed to investigate the efficacy of CRP as a marker for progression or treatment response in MAC lung disease.

Trial registration

Clinical trial registered with UMIN (UMIN000007964).