Patients' age as a determinant of care received following acute stroke: a systematic review

Weight-control compensatory behaviors patterns and correlates: a scoping review

Objective

Weight-control compensatory behaviors appear to be a commonly utilized strategy for health management. Individuals engaging in such behaviors believe that the negative consequences from unhealthy behaviors will be neutralized by the positive consequences of healthy behaviors. Existing research has not reached a consensus on whether such behaviors are beneficial to health. This review aims to (1) summarize the patterns of weight-control compensatory health behaviors in different populations, (2) highlight correlates, predictors, and consequences of compensatory health behaviors, and (3) identify gaps for future research.

Method

This review identified existing literature using online databases, CINAHL and PubMed. Primary research articles published after 2000 with non-clinical participants of 12 years or older who engaged in compensatory behaviors for weight control purposes were selected. Descriptive statistics were extracted from 35 studies.

Results

Different patterns for weight-control compensatory behaviors emerged between the female and male sexes. Meanwhile, no clear association of such behaviors was found across weight status. Studies reviewed also highlighted three main areas of compensatory behaviors for weight management, namely dietary behaviors, physical activity, and alcohol consumption. Weight-control compensatory behaviors had significant negative correlations with mental health indicators, such as psychosocial functioning, emotional differentiation ability, and body esteem.

Conclusion

Weight-control compensatory behaviors may be a widely used weight management strategy and can be presented in diverse ways. Although believed to be promoting health, such behaviors appear to be associated with poor psychological well-being. This emerging topic warrants more in-depth investigation to establish the direction of causation. Future research may investigate the relationship between weight-control compensatory behaviors and various aspects of health over longer time periods, examine the engagement of multiple weight-control compensatory behaviors, and focus on high-risk populations.

Predictors of functional outcome after stroke: Sex differences in older individuals

BACKGROUND

Sex differences in stroke are well documented, with females being older at onset, with more severe strokes and worse outcomes than males. Females receive less comprehensive stroke unit treatment. Similarly, older individuals receive poorer quality care than younger ones. There is limited research on sex differences in factors that impact 3-month poststroke functional outcome in people older than 80 years.

METHODS

This register-based and cross-sectional study analyzed data from two stroke quality registers in Sweden from 2014 through 2019. The study included patients aged ≥80 with a diagnosis of ischemic or hemorrhagic stroke. Sociodemographic features, prestroke condition, stroke severity on admission (National Institutes of Health Stroke Scale [NIHSS]), stroke unit care, rehabilitation plans, and 3-month poststroke functional outcome measured with the modified Rankin Scale were analyzed. Ordinal regression analyses stratified by sex were conducted to assess sex differences in factors that impact poststroke functional outcome 3 months after the stroke.

RESULTS

A total of 2245 patients were studied with the majority (59.2%) being females. Females experienced more severe strokes (NIHSS median 4 vs. 3, p = 0.01) and were older at stroke onset than males (87.0 vs. 85.4, p < 0.001). Females were also less independent prestroke (69.9% vs. 77.4%, p < 0.001) and a higher proportion of females lived alone (78.2% vs. 44.2%, p < 0.001). Males received intravenous thrombolysis more often than females (16.3% vs. 12.0%, p = 0.005). Regarding 3-month functional outcome, males benefited more from thrombolysis (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.30-0.83), whereas females benefited more from thrombectomy (OR 0.40, 95% CI 0.20-0.71).

CONCLUSION

Stroke care should be adapted to sex disparities in older individuals, while clinicians should be aware of these sex disparities. Further research could clarify the mechanisms behind these disparities and lead to a more personalized approach to stroke care of the older population.

Intensive Rehabilitation Program in Older Adults with Stroke: Therapy Content and Feasibility-Preliminary Results from the BRAIN-CONNECTS Study

The main objective was to assess the feasibility of an intensive rehabilitation program (IRP) for stroke patients; and secondly, to detect eventual age-related differences in content, duration, tolerability, and safety in a prospective observational cohort of patients diagnosed with subacute stroke, admitted to inpatient rehabilitation (BRAIN-CONNECTS project). Activities during physical, occupational and speech therapy, and time dedicated to each one were recorded. Forty-five subjects (63.0 years, 77.8% men) were included. The mean time of therapy was 173.8 (SD 31.5) minutes per day. The only age-related differences when comparing patients ≥65 and <65 years were a shorter time allocated for occupational therapy (-7.5 min (95% CI -12.5 to -2.6), p = 0.004) and a greater need of speech therapy (90% vs. 44%) in the older adults. Gait training, movement patterns of upper limbs, and lingual praxis were the most commonly performed activities. Regarding tolerability and safety, there were no losses to follow-up, and the attendance ratio was above 95%. No adverse events occurred during any session in all patients. Conclusion: IRP is a feasible intervention in patients with subacute stroke, regardless of age, and there are no relevant differences on content or duration of therapy.

Factors Associated with Receiving a Discharge Care Plan After Stroke in Australia: A Linked Registry Study

Background

Discharge planning is recommended to optimise the transition from acute care to home for patients admitted with stroke. Despite this guideline recommendation, many patients do not receive a discharge care plan. Also, there is limited evidence on factors influencing the provision of discharge care plan post-stroke. We evaluated patient, clinical and system factors associated with receiving a care plan on discharge from hospital back to the community after stroke.

Methods

This was an observational cohort study of patients with acute stroke who were discharged to the community between 2009-2013, using data from the Australian Stroke Clinical Registry linked to hospital administrative data. For this analysis, we used merged dataset containing information on patient demographics, clinical characteristics, and receipt of acute care processes. Multivariable logistic regression models were used to determine factors associated with receiving a discharge care plan.

Results

Among 7812 eligible patients (39 hospitals, median age 73 years, 44.7% female, 56.9% ischaemic stroke), 47% received a care plan at discharge. The odds of receiving a discharge care plan increased over time (odds ratio [OR] 1.39 per year, 95% CI 1.37-1.48), and varied between hospitals. Factors associated with receiving a discharge care plan included greater socioeconomic position (OR 1.18, 95% CI 1.02-1.38), diagnosis of ischaemic stroke (OR 1.18, 95% CI 1.05-1.33), greater stroke severity (OR 1.15, 95% CI 1.01-1.31), or being discharged on antihypertensive medication (OR 3.07, 95% CI 2.69-3.50). In contrast, factors associated with a reduced odds of receiving a discharge care plan included being aged 85+ years (vs < 85 years; OR 0.79, 95% CI 0.64-0.96), discharged on a weekend (OR 0.56, 95% CI 0.46-0.67), discharged to residential aged care (OR 0.48, 95% CI 0.39-0.60), or being treated in a large hospital ( > 300 beds; OR 0.30, 95% CI 0.10-0.92).

Conclusions

Implementing practices to target people who are older, discharged to residential aged care, or discharged on a weekend may improve discharge planning and post-discharge care after stroke.

Factors Associated With Emergency Department Length of Stay and In-hospital Mortality in Intracerebral Hemorrhage Patients

ABSTRACT

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is a medical emergency that requires rapid identification and focused assessment early to ensure the best possible outcomes. The purpose of this study is to evaluate the associations between system and patient factors and emergency department (ED) length of stay and in-hospital mortality in patients given a diagnosis of ICH. METHODS: A sample of 3108 ICH patients was selected from a statewide administrative database for cross-sectional retrospective analysis. System characteristic (hospital stroke certification), patient characteristics (age, sex, and race), and covariate conditions (stroke severity and comorbidities) were analyzed using descriptive statistics and hierarchical logistic regression models to address the study questions. RESULTS: The mean ED length of stay is 2.9 ± 3 hours (range, 0-42 hours) before admission to an inpatient unit. Inpatient mortality is 14.9%. Stroke center certification (P < .000) and stroke severity (P ≤ .000) are significant predictors of ED length of stay, whereas age (P < .000), stroke severity (P < .000), comorbidities (P = .047), and ED length of stay (P = .04) are significant predictors of in-hospital mortality. Most notably, an ED length of stay of 3 hours or longer has a 37% increase in the odds of in-hospital mortality. CONCLUSION: Our findings support age, stroke severity, and ED length of stay as predictors of in-hospital mortality for ICH patients. The importance of timely admission to an inpatient unit is emphasized. Optimal systems of care and expedited inpatient admission are vital to reduce morbidity and mortality for ICH stroke patients.

Gender- and age-related differences in the quality of mental health care among inpatients with unipolar depression: a nationwide study

Objective: The relationship between gender, age and the quality of mental health care among inpatients with depression is unclear. This study examined gender- and age-related differences in the quality of care as reflected by the fulfilment of process performance measures of care among inpatients with unipolar depression in Denmark.Methods: In a nationwide cohort study, 16,858 patients admitted to psychiatric hospital wards for depression between 2011 and 2016 were identified from the Danish Depression Database. Patients were divided according to age (18-39, 40-65, 66-79 and ≥80 years) and stratified by gender. Quality of care was defined as having fulfilled process performance measures of care, reflecting national clinical guideline recommendations. High overall quality of care was defined as having received ≥80% of the processes. The associations were assessed using binomial regressions.Results: With men in the age group 18-39 years serving as the reference, men and women in the age category ≥80 years were more likely to receive higher quality of care with an adjusted relative risk (aRR) of 1.43 [95% confidence interval (CI) = 0.98; 2.10] and 1.30 (95% CI = 0.90; 1.90), respectively. Likewise, for men and women aged 66-79 years, the aRRs as 1.34 (95% CI = 1.07; 1.67) and 1.47 (95% CI = 1.14; 1.90). For men and women aged 40-65, the aRRs was 1.15 (95% CI = 1.00; 1.33) and 1.07 (95% CI = 0.93; 1.24), respectively.Conclusion: Older patients received higher quality of inpatient care for depression, as reflected by a higher proportion of fulfilled guideline supported process measures. In contrast, we found no gender-related differences.

Evaluation of determinants for age disparities in the survival improvement of colon cancer: results from a cohort of more than 486,000 patients in the United States

Over the past two decades, elderly colon cancer patients experienced less improvement in survival than their younger counterparts, yet the contributing factors remain unknown. We aimed to evaluate factors that may contribute to the age disparity of survival improvement among patients with colon cancer. Using data from the National Cancer Database, we identified patients diagnosed with colon cancer between 2004 and 2012 with follow-up data up to 2017. The hazard ratios (HR) and 95% confidence intervals (CI) for 5-year OS associated with study variables were estimated using multivariable Cox regression. Among 486,284 patients included in this study, elderly patients (aged ≥75) had a lower adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines (% of non-adherence: 45.3%) than younger patients (aged <50, 19.3%; P<0.001). After adjusting for demographics, access to care and clinical characteristics, compared with patients diagnosed between 2004 and 2006, younger and older patients diagnosed between 2010 and 2012 experienced 16% (HR: 0.84, 95% CI: 0.81-0.88) and 6% (HR: 0.94, 95% CI: 0.93-0.95) reductions in mortality (P for interaction=1.42×10-5), respectively. After an additional adjustment for guideline adherence status, no significant difference in the improvement of survival was noted (P for interaction=0.17). The association patterns were similar regardless of tumor stage, race, and high comorbidity scores (all P for interaction>0.05). Several patient-related factors were identified in association with noncompliance to NCCN guidelines, including comorbidity status. However, over 60% of noncompliance elderly patients had a Charlson comorbidity score of 0. The observed age disparity in survival improvement among colon cancer patients was primarily explained by a slower improvement in adherence to NCCN treatment guidelines in elderly than younger patients. Many older adults were not receiving recommended therapies despite minimal comorbidities. Our findings call for measures to increase adherence to treatment guidelines among elderly patients to improve survival.

Mild cognitive impairment and receipt of procedures for acute ischemic stroke in older adults

BACKGROUND AND PURPOSE

Older patients with pre-existing mild cognitive impairment (MCI) receive less evidence-based care after acute myocardial infarction, however, whether they receive less care after acute ischemic stroke (AIS) is unknown. We compared receipt of guideline-concordant procedures after AIS between older adults with pre-existing MCI and normal cognition.

METHODS

Prospective study of 591 adults ≥65 hospitalized for AIS between 2000 and 2014, and followed through 2015 using data from the nationally representative Health and Retirement Study, Medicare and American Hospital Association. We assessed pre-existing MCI (modified Telephone Interview for Cognitive Status score of 7-11) and normal cognition (score of 12-27). Primary outcome was a composite quality measure representing the number of 4 procedures (carotid imaging, cardiac monitoring, echocardiogram, and rehabilitation assessment) received within 30 days after AIS (ordinal scale with values of 0, 1, 2, 3-4).

RESULTS

Among survivors of AIS, 26.9% had pre-existing MCI (62.9% were women, with a mean [SD] age of 82.4 [7.7] years), and 73.1% had normal cognition (51.4% were women, with a mean age of 78.4 [7.2] years). Patients with pre-existing MCI, compared to cognitively normal patients, had 39% lower cumulative odds of receiving the composite quality measure (unadjusted cumulative odds ratio, OR, 0.61 [95% CI, 0.43-0.87]; P=0.006). However, this association became non-significant after adjusting for patient and hospital factors (adjusted cumulative OR, 0.83 [95% CI, 0.56-1.24]; P=0.37). Lower cumulative odds of receiving the composite quality measure were associated with older patient age (adjusted cumulative OR per 1-year older age, 0.97 [95% CI, 0.95-0.99]; P=0.01) and Southern hospitals (adjusted cumulative OR for South vs North, 0.54 [95% CI, 0.31-0.94]; P=0.03).

CONCLUSIONS

Differences in receipt of guideline-concordant procedures after AIS exist between patients with pre-existing MCI and normal cognition. These differences were largely explained by patient and regional factors associated with receiving less AIS care.

Effectiveness of telerehabilitation in the management of adults with stroke: A systematic review

Background

Stroke is a leading cause of mortality and morbidity and access to timely rehabilitation can reduce morbidity and help patients to return to normal life. Telerehabilitation can deliver rehabilitation services with the use of technology to increase patient options, deliver services more efficiently and overcome geographical barriers to healthcare access. Despite its popularity, there is conflicting evidence for its effectiveness. Therefore, the aim of this systematic review was to update the current evidence base on the effectiveness of telerehabilitation for stroke.

Methods

A systematic search of databases (Medline Ovid; Embase; Emcare; Scopus; The Cochrane Library; PEDro; OTSeeker) was conducted in April 2018 (updated in October 2018). This review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and methodology registered with PROSPERO (CRD42018090445). A modified McMaster critical appraisal tool for quantitative studies was used to assess the methodological quality of the included studies. Given the heterogeneity of the included studies, a descriptive synthesis was conducted.

Results

Out of 1868 studies, 13 randomised controlled trials met the inclusion criteria. A diverse range of interventions were delivered through a variety of telerehabilitation systems and the effectiveness measured through a myriad of outcome measures. Summarised findings from the heterogeneous evidence base indicate that telerehabilitation may have a positive impact on a range of primary and secondary outcomes. However, despite these positive findings, the current evidence lacks clarity and uniformity in terms of intervention parameters and measurement of outcomes, which limits broader application of these results.

Discussion

Telerehabilitation, as an alternate form of rehabilitation for people with stroke, shows potential. However, due to methodological and practical concerns, an unequivocal recommendation cannot be made. Findings from this review may inform future policies and practices regarding the use of telerehabilitation for stroke patients.

Prevention and Treatment of Acute Stroke in the Nonagenarians and Beyond: Medical and Ethical Issues

PURPOSE OF REVIEW

As one of the fastest growing portions of the population, nonagenarians will constitute a significant percentage of the stroke patient population in the near future. Nonagenarians are nevertheless not specifically targeted by most clinical guidelines. In this review, we aimed to summarise the available evidence guiding stroke prevention and treatment in this age group.

RECENT FINDINGS

Several recent observational studies have shown that the benefits of anticoagulation for the oldest old patients with atrial fibrillation may outweigh the bleeding risk. A sub-analysis of the IST-3 trial has shown for the first time that thrombolysis treatment in acute ischaemic stroke may be beneficial and safe even in octogenarian patients and older. Several recent observational studies have assessed thrombolysis in nonagenarians. The latest of these has shown better disability outcomes without increased rates of symptomatic intracerebral haemorrhage with thrombolysis. Nonagenarian stroke patients may benefit from similar preventative and therapeutic strategies as their younger counterparts. A few important exceptions include primary prevention using aspirin or statins. Patient selection is nevertheless essential given the increased adverse event rates. Patient preference should play a key role in the decision-making process. Clinical trials including more nonagenarian patients are required to yield more robust evidence.

Sex Differences in Care and Long-Term Mortality After Stroke: Australian Stroke Clinical Registry

Introduction: There is some evidence that women receive evidence-based care less often than men, but how this influences long-term mortality after stroke is unclear. We explored this issue using data from a national stroke registry. Materials and Methods: Data are first-ever hospitalized strokes (2010-2014) in the Australian Stroke Clinical Registry from 39 hospitals linked to the national death registrations. Multilevel Poisson regression was used to estimate the women:men mortality rate ratio (MRR), with adjustment for sociodemographics, stroke severity, and processes of care (stroke unit care, intravenous thrombolysis, antihypertensive agent[s], and discharge care plan). Results: Among 14,118 events (46% females), women were 7 years older and had greater baseline severity compared to men (29% vs. 37%; p < 0.001), but there were no differences in the four processes of care available across hospitals. In the whole cohort, 1-year mortality was greater in women than men (MRR_unadjusted 1.44, 95% confidence interval [CI] 1.34-1.54). However, there were no differences after adjusting for age and stroke severity (MRR_adjusted 1.03, 95% CI 0.95-1.10). In analyses of additional processes from Queensland hospitals (n = 5224), women were less often administered aspirin ≤48 hours (61% vs. men 69%, p < 0.015). In Queensland hospitals, there were no statistically significant sex differences in 1-year mortality after adjusting for age, stroke severity, and early administration of aspirin. Conclusion: Greater mortality in women can be explained by differences in age and stroke severity. This highlights the importance of better management of risk factors in the elderly and, potentially, the need for greater access to early aspirin for women with stroke.

Understanding delays in acute stroke care: a systematic review of reviews

Background

Stroke is the leading cause of adult long-term disability in Western countries. Intravenous thrombolytic therapy with recombinant tissue plasminogen activator is safe and effective within the first 4.5 h after the onset of stroke. Various factors delaying acute stroke care have been identified in the literature. This review aimed to provide an overview of factors delaying acute stroke care and attempted to show how they interact in a synthetic framework.

Methods

We conducted a systematic review of literature reviews published in Medline and DORIS until 2016 on factors influencing acute stroke pathway timeframe.

Results

We analyzed 31 reviews that cover all factors of delays from stroke onset to treatment. We identified 27 factors that had a significant impact on acute stroke care and can be categorized into four distinct categories: patient-related factors, training, resources and lack of coordination. We also reported associations between factors observed in both between categories (mainly between patients and organizational/logistical factors) and within categories.

Conclusion

This review provides a wide overview of factors influencing acute stroke pathway. Since it was observed that the identified factors were interrelated, they needed to be analyzed in a systematic way. We hence created a synthetic framework that combines several categories of factors while assuming that factor weight varies from a study context to another. Better knowledge on underlying mechanisms between factors would provide crucial improvement of the interventions aiming at reducing delays in both pre-hospital and inhospital stages. For future research, we recommend adopting a systemic perspective on factors influencing acute stroke pathway.

What factors affect clinical decision-making about access to stroke rehabilitation? A systematic review

Objectives:

To determine the factors affecting clinical decision-making about which patients should receive stroke rehabilitation.

Methods:

Data sources (MEDLINE, CINAHL, AMED and PsycINFO) were searched systematically from database inception to August 2018. Full-text English-language studies of data from stroke clinicians were included. Studies of patients were excluded. The included studies were any design focussed on clinical decision-making for referral or admission into stroke rehabilitation. Summary factors were compiled from each included study. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool.

Results:

After removing duplicates, 1915 papers were identified, of which 13 met the inclusion criteria. Eight included studies were qualitative and one used mixed methods. A total of 292 clinicians were included in the studies. Quality of the included studies was mixed. Patient-level and organizational factors as well as characteristics of individual clinicians contributed to decisions about rehabilitation. The most often described factors were patients’ pre- and poststroke function (n = 6 studies), presence of dementia (n = 6), patients’ social/family support (n = 6), organizational service pressures (n = 7) and the decision-making clinician’s own knowledge (n = 5) and emotions (n = 5).

Conclusion:

The results highlight a lack of clinical guidance to aid decision-making and reveal that a subjective approach to rehabilitation decision-making influenced by patient-level and organizational factors alongside clinicians’ characteristics occurs across services and countries.

Clinical Outcome of Ischemic Stroke in Old Patients Versus Oldest-Old

BACKGROUND

It is unclear whether very old patients benefit from stroke unit. The aim of our work was to compare the clinical outcome of patients with ischemic stroke aged either 70 or 80 (G 1) versus oldest-old greater than or equal to 81 years (G 2).

METHODS

Of 1187 patients admitted with stroke during 5 years in our stroke unit, we included 252 patients with independent functional status (modified Rankin scale, [mRS] ≤ 2) before the stroke. All patients underwent clinical examination, blood test, electrocardiography, brain imaging, and cerebrovascular ultrasound. Clinical outcome was assessed with the mRS and National Institutes of Health Stroke Scale (NIHSS) at discharge. We considered favorable outcome mRS 0-2 at discharge.

RESULTS

Of 252 patients included, 55% were male, 150 (59.5%) patients belonged to G1 and 102 (40.5%) G2. We detected a significant increase of atrial fibrillation, bronchoaspiration, mortality, higher NIHSS at admission, and worse functional status at discharge in G2. No significant differences in other demographic, vascular risk factors, hospital stay, NIHSS at discharge or subtype of stroke were found. NIHSS at discharge was the only independent predictor of good functional status (odds ratio 0.4; 95% confidence interval, 0.3-0.6; P < .001).

CONCLUSIONS

Oldest-old patients showed similar NIHSS at discharge than younger patients despite having higher neurological severity at admission. Our results support the hypothesis that oldest-old patients have good recovery potential, and should not be excluded from the stroke unit. The worse functional status detected at discharge in these patients could be attributed to others factors and not to neurological severity.

The potential dual role of transcallosal inhibition in post-stroke motor recovery

Up to now, the mechanism of motor impairment and recovery after stroke has been thought to be based on the interhemispheric competition model. According to this model, which assumes that suppressing the excitability of contralesional hemisphere will enhance recovery by reducing transcallosal inhibition (TCI) of the stroke hemisphere, many clinical trials used non-invasive brain stimulation to improve motor function. Despite some positive findings, meta-analysis shows an important source of variability in the results, questioning whether the interhemispheric competition model would be exhaustive enough to explain the positive results or whether other mechanisms could explain the motor effects of inhibitory stimulation in the contralesional hemisphere. The goal of this study was to review the relationship between increased TCI and motor impairment after stroke.A systematic review of clinical studies investigating TCI through transcranial magnetic stimulation (TMS) in stroke patients and the relationship of this metric with motor recovery was then performed. After a literary search in PubMed eleven articles were included. The potential role of several covariates was examined and discussed.Overall, the importance of TCI as a putative mechanism for stimulation of the contralesional hemisphere seems to depend on the baseline motor function. In other words, from evidence coming mostly from chronic patients, modulation of abnormal TCI seems to be useful for patients with good motor function and less important in patients with poor motor function. TCI seems to be negatively correlated with mirror movements of the paretic hand. It can be inferred that suppressing the activity of the contralesional hemisphere could be beneficial for patients with good residual motor function and strong TCI, but not for those with poor motor function and weak TCI. Baseline motor function and measure of TCI should be taken into account for stratification of patients in clinical trials and for the design of customized treatment.

Intravenous Recombinant Tissue Plasminogen Activator and Ischemic Stroke: Focused Update of 2010 Clinical Practice Advisory From the American Academy of Emergency Medicine

BACKGROUND

Stroke treatment is a continuum that begins with the rapid identification of symptoms and treatment with transition to successful rehabilitation. Therapies for acute ischemic stroke (AIS) may vary based on anatomic location, interval from symptom onset, and coexisting health conditions. Successful therapy requires a seamless systematic approach with coordination from prehospital environment through acute management at medical facilities to disposition and long-term care of the patient. The emergency physician must balance the benefits and risks of alteplase recombinant tissue plasminogen activator (rtPA) for AIS management.

OBJECTIVE

We review the recent medical literature on the topic of AIS and assess intravenous rtPA for the following questions: 1) is there any applicable, new, high-quality evidence that the benefits of intravenous rtPA are justified in light of the harms associated with it, and 2) if so, does the evidence clarify which patients, if any, are most likely to benefit from the treatment.

METHODS

A MEDLINE literature search from January 2010 to October 2016 and limited to human studies written in English for articles with keywords of cerebrovascular accident and (thromboly* OR alteplase). Guideline statements and nonsystematic reviews were excluded. Studies targeting differences between specific populations (males vs. females) were excluded. Studies identified then underwent a structured review from which results could be evaluated.

RESULTS

Three hundred twenty-two papers on thrombolytic use were screened and nine appropriate articles were rigorously reviewed and recommendations given.

CONCLUSIONS

No new studies published between 2010 and 2016 meaningfully reduced uncertainty regarding our understanding of the benefits and harms of intravenous rtPA for AIS. Discussions regarding benefit and harm should occur for patients, and risk prediction scores may facilitate the conversation.

Sex Differences in Long-Term Mortality After Stroke in the INSTRUCT (INternational STRoke oUtComes sTudy)

Background—

Women are reported to have greater mortality after stroke than men, but the reasons are uncertain. We examined sex differences in mortality at 1 and 5 years after stroke and identified factors contributing to these differences.

Methods and Results—

Individual participant data for incident strokes were obtained from 13 population-based incidence studies conducted in Europe, Australasia, South America, and the Caribbean between 1987 and 2013. Data on sociodemographics, stroke-related factors, prestroke health, and 1- and 5-year survival were obtained. Poisson modeling was used to estimate the mortality rate ratio (MRR) for women compared with men at 1 year (13 studies) and 5 years (8 studies) after stroke. Study-specific adjusted MRRs were pooled to create a summary estimate using random-effects meta-analysis. Overall, 16 957 participants with first-ever stroke followed up at 1 year and 13 216 followed up to 5 years were included. Crude pooled mortality was greater for women than men at 1 year (MRR 1.35; 95% confidence interval, 1.24–1.47) and 5 years (MRR 1.24; 95% confidence interval, 1.12–1.38). However, these pooled sex differences were reversed after adjustment for confounding factors (1 year MRR, 0.81; 95% confidence interval, 0.72–0.92 and 5-year MRR, 0.76; 95% confidence interval, 0.65–0.89). Confounding factors included age, prestroke functional limitations, stroke severity, and history of atrial fibrillation.

Conclusions—

Greater mortality in women is mostly because of age but also stroke severity, atrial fibrillation, and prestroke functional limitations. Lower survival after stroke among the elderly is inevitable, but there may be opportunities for intervention, including better access to evidence-based care for cardiovascular and general health.

How Patient Demographics, Imaging, and Beliefs Influence Tissue-Type Plasminogen Activator Use: A Survey of North American Neurologists

BACKGROUND AND PURPOSE

Understanding physician decision making is increasingly recognized as an important topic of study, especially in stroke care. We sought to characterize the process of acute stroke decision making among neurologists in the United States and Canada from clinical and epistemological perspectives.

METHODS

Using a factorial design online survey, respondents were presented with clinical data to mimic an acute stroke encounter. The history, examination, computed tomographic (CT) scan, CT angiogram, and CT perfusion were presented in sequence, and respondents rated their diagnostic confidence and likelihood of treatment with tissue-type plasminogen activator after each element. Patient age, race, sex, and CT perfusion imaging results were randomized, whereas the rest of the clinical presentation was held constant.

RESULTS

We collected 715 responses, of which 473 (66%) were complete. Diagnostic certainty and likelihood of treatment with tissue-type plasminogen activator rose incrementally as additional clinical data were provided. Diagnostic certainty and treatment likelihood were strongly influenced by the clinical history and the CT scan. Other factors such as physicians' personal beliefs or biases were not influential. Respondents' accuracy in interpreting CT angiographic and CT perfusion images was variable and generally low.

CONCLUSIONS

Diagnostic certainty and likelihood of treatment with tissue-type plasminogen activator increase with additional clinical data, with the history being the most important factor for diagnostic and treatment decisions. Respondents had difficulty in interpreting the results of CT perfusion scans although they had little impact on treatment decisions. We did not identify treatment bias based on patient age, race, or sex.

The burden of disease in older people and implications for health policy and practice

23% of the total global burden of disease is attributable to disorders in people aged 60 years and older. Although the proportion of the burden arising from older people (≥60 years) is highest in high-income regions, disability-adjusted life years (DALYs) per head are 40% higher in low-income and middle-income regions, accounted for by the increased burden per head of population arising from cardiovascular diseases, and sensory, respiratory, and infectious disorders. The leading contributors to disease burden in older people are cardiovascular diseases (30·3% of the total burden in people aged 60 years and older), malignant neoplasms (15·1%), chronic respiratory diseases (9·5%), musculoskeletal diseases (7·5%), and neurological and mental disorders (6·6%). A substantial and increased proportion of morbidity and mortality due to chronic disease occurs in older people. Primary prevention in adults aged younger than 60 years will improve health in successive cohorts of older people, but much of the potential to reduce disease burden will come from more effective primary, secondary, and tertiary prevention targeting older people. Obstacles include misplaced global health priorities, ageism, the poor preparedness of health systems to deliver age-appropriate care for chronic diseases, and the complexity of integrating care for complex multimorbidities. Although population ageing is driving the worldwide epidemic of chronic diseases, substantial untapped potential exists to modify the relation between chronological age and health. This objective is especially important for the most age-dependent disorders (ie, dementia, stroke, chronic obstructive pulmonary disease, and vision impairment), for which the burden of disease arises more from disability than from mortality, and for which long-term care costs outweigh health expenditure. The societal cost of these disorders is enormous.

[Stroke rehabilitation in nursing homes: intensity of and motivation for physiotherapy]

INTRODUCTION

Stroke is a frequent and potential invalidating disease, of which recovery can be improved by rehabilitation. In The Netherlands old and frail stroke patients are rehabilitated in nursing homes. Probably, the intensity of and motivation for physiotherapy are important for successful discharge. The aim was to determine (1) therapy intensity of and motivation for physical therapy of geriatric stroke patients (2) its correlates and (3) the effect on discharge destination.

METHODS

Data were obtained from the 'GRAMPS'-study, a longitudinal observational study of stroke rehabilitation in 15 Dutch nursing homes. Direct time spent on physiotherapy was registered during admission. Motivation was measured by the Pittsburgh Rehabilitation Participation Scale (PRPS). Data of 84 patients were analysed using uni- and multivariate regression analysis.

RESULTS

Patients received an average 109 min of physiotherapy per week. 69 patients (82%) were good motivated for physiotherapy (had all PRPS scores 4 or higher). Therapy intensity was positively associated with the presence of a partner and good motivation. No significant independent variables of motivation were found. Therapy-intensity was positively related to discharge to prior living situation.

CONCLUSION

Intensity of physiotherapy of stroke rehabilitation is an independent variable of successful discharge and is higher when the patient has a partner or is better motivated. These findings stress the importance of high motivation and therapy intensity in geriatric stroke rehabilitation.

Outcome and risk factors presented in old patients above 80 years of age versus younger patients after ischemic stroke

BACKGROUND

Older patients are associated with increased stroke prevalence, worse outcome, and risk of undertreatment in comparison with younger patients. The aim of the present study was to compare risk factor distribution and functional outcome in stroke survivors older and younger than 80 years.

METHODS

The analysis was based on consecutive patients admitted within 6 hours after stroke onset and discharged with ischemic stroke, surviving at least 3 months after ictus. To prevent bias, the analysis was based on a registry from before implementation of tissue plasminogen activator treatment; all patients received stroke unit care in accordance with the guidelines. The population was dichotomized into patients aged less than 80 years and 80 years of age or older. Modified Rankin Scale (mRS) score and Barthel Index (BI) were used to assess 3-month and 1-year outcome.

RESULTS

Patients 80 years of age or older presented with significantly more severe strokes than younger patients, median Scandinavian Stroke Scale score 39 vs 42 (P = .003). Median mRS score before stroke was significantly higher in patients aged 80 years or older (P < .001) and remained high 3 months and 1 year after ictus (P < .001); the BI was equivalently lower (P < .001). The decline in function was comparable between groups. Patients 80 years of age or older of whom the majority were women (P < .001) presented with atrial fibrillation (P < .001), and hypertension (P = .005).

CONCLUSIONS

Risk factors vary significantly with age, suggesting different stroke mechanisms. Patients older than 80 years experience more severe strokes and frequently have minor impairments before stroke. The increase in impairment after stroke is comparable with what is observed in younger patients, suggesting that good recovery after stroke may also be expected in older patients.

A qualitative exploration of discharge destination as an outcome or a driver of acute stroke care

Background

Many patients with acute stroke do not receive recommended care in tertiary hospital settings. Allied health professionals have important roles within multidisciplinary stroke teams and influence the quality of care patients receive. Studies examining the role of allied health professionals in acute stroke management are scarce, and very little is known about the clinical decision making of these stroke clinicians. In this study we aimed to describe factors that influence the complex clinical decision making of these professionals as they prioritise acute stroke patients for recommended care. This qualitative study was part of a larger mixed methods study.

Methods

The qualitative methodology applied was a constructivist grounded theory approach.

Fifteen allied health professionals working with acute stroke patients at three metropolitan tertiary care hospitals in South Australia were purposively sampled.

Semi-structured interviews were conducted face to face using a question guide, and digital recording. Interviews were transcribed and analysed by two researchers using rigorous grounded theory processes.

Results

Our analysis highlighted ‘predicted discharge destination’ as a powerful driver of care decisions and clinical prioritisation for this professional group. We found that complex clinical decision making to predict discharge destination required professionals to concurrently consider patient’s pre-stroke status, the nature and severity of their stroke, the course of their recovery and multiple factors from within the healthcare system. The consequences of these decisions had potentially profound consequences for patients and sometimes led to professionals experiencing considerable uncertainty and stress.

Conclusions

Our qualitative enquiry provided new insights into the way allied health professionals make important clinical decisions for patients with acute stroke. This is the first known study to demonstrate that the subjective prediction of discharge destination made early in an acute admission by allied health professionals, has a powerful influence over the care and rehabilitation provided, and the ultimate outcomes for stroke patients.

Age-related disparities in use of completion lymphadenectomy for melanoma sentinel lymph node metastasis

BACKGROUND

Guidelines recommend that patients with melanoma metastatic to the sentinel lymph node (SLN) undergo a completion lymphadenectomy (CLND) of the affected lymph node basin. We have previously reported on decreased use of SLN biopsy among elderly patients. We hypothesized that elderly patients with SLN metastases would have lower rates of CLND relative to their younger counterparts.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for patients who underwent SLN biopsy for intermediate thickness cutaneous melanoma (Breslow thickness 1.01 mm-4.00 mm) from 2004 to 2008 and were found to have SLN metastasis. Patients were categorized according to age by decade. We then used multivariate logistic regression models to predict receipt of CLND. Additional covariates included sex, race/ethnicity, T stage, tumor histology, tumor location, and ulceration. The likelihood of receiving a CLND was reported as OR with 95% CI; significance was set at P ≤ 0.05.

RESULTS

Entry criteria were met by 765 patients. Of these, 548 (71.6%) patients underwent CLND. On multivariate analysis, patients in the age groups 70-79 y old (OR 0.39, CI 0.20-0.78; P = 0.007) and ≥ 80 y old (OR 0.27, CI 0.12-0.61; P = 0.001) were less likely to undergo CLND than the youngest age group (1-39 y old).

CONCLUSIONS

Elderly patients with SLN metastasis are less likely to receive CLND than their younger counterparts. A multi-center randomized clinical trial evaluating the potential survival benefit of CLND is ongoing. Further research to assess reasons why the elderly are less likely to receive CLND are needed.

Assessing rural-urban disparities in the use of sentinel lymph node biopsy for melanoma

BACKGROUND

We hypothesized that patients in urban areas with intermediate thickness cutaneous melanoma would have higher rates of sentinel lymph node biopsy (SLNB) relative to their rural-dwelling counterparts.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for patients who underwent surgery for intermediate thickness cutaneous melanoma from 2004-2008. Patients were categorized as coming from urban or rural counties based on a nine-point scale. We used multivariate logistic regression models to predict use of SLNB. Covariates examined included sex, race/ethnicity, age, T stage, tumor histology, tumor location, and ulceration. The likelihood of undergoing SLNB was reported as OR with 95% CI.

RESULTS

Of 8441 patients, 8382 (99.3%) had complete information regarding use of SLNB. On multivariate analysis, patients from rural counties had a decreased likelihood of receiving a SLNB (OR 0.87, CI 0.78-0.97; P = 0.014). Additional factors associated with a decreased likelihood of receiving a SLNB included increasing age, Asian/Hispanic/Unknown race, and head and neck or overlapping primary tumor site.

CONCLUSIONS

Patients in rural areas are less likely to receive a SLNB for intermediate thickness cutaneous melanoma than their urban-dwelling counterparts.

High environmental temperature and preterm birth: a review of the evidence

OBJECTIVE

to examine the evidence in relation to preterm birth and high environmental temperature.

BACKGROUND

this review was conducted against a background of global warming and an escalation in the frequency and severity of hot weather together with a rising preterm birth rate.

METHODS

electronic health databases such as: SCOPUS, MEDLINE, CINAHL, EMBASE and Maternity and Infant Care were searched for research articles, that examined preterm birth and high environmental temperature. Further searches were based on the reference lists of located articles. Keywords included a search term for preterm birth (preterm birth, preterm, premature, <37 weeks, gestation) and a search term for hot weather (heatwaves, heat-waves, global warming, climate change, extreme heat, hot weather, high temperature, ambient temperature). A total of 159 papers were retrieved in this way. Of these publications, eight met inclusion criteria.

DATA EXTRACTION

data were extracted and organised under the following headings: study design; dataset and sample; gestational age and effect of environmental heat on preterm birth. Critical Appraisal Skills Programme (CASP) guidelines were used to appraise study quality.

FINDINGS

in this review, the weight of evidence supported an association between high environmental temperature and preterm birth. However, the degree of association varied considerably, and it is not clear what factors influence this relationship. Differing definitions of preterm birth may also add to lack of clarity.

KEY CONCLUSIONS

preterm birth is an increasingly common and debilitating condition that affects a substantial portion of infants. Rates appear to be linked to high environmental temperature, and more especially heat stress, which may be experienced during extreme heat or following a sudden rise in temperature. When this happens, the body may be unable to adapt quickly to the change. As global warming continues, the incidence of high environmental temperature and dramatic temperature changes are also increasing. This situation makes it important that research effort is directed to understanding the degree of association and the mechanism by which high temperature and temperature increases impact on preterm birth. Research is also warranted into the development of more effective cooling practices to ameliorate the effects of heat stress. In the meantime, it is important that pregnant women are advised to take special precautions to avoid heat stress and to keep cool when there are sudden increases in temperature.

Gestational diabetes mellitus among women born in South East Asia: a review of the evidence

OBJECTIVE

The aim of this paper was to examine rates of gestational diabetes mellitus (GDM) among women born in South East Asia, now residing in a developed country

DATA SOURCES

Established health databases including: SCOPUS, MEDLINE, CINAHL, EMBASE and Maternity and Infant Care were searched for journal papers, published 2001-2011.

STUDY SELECTION

Studies that examined GDM among women born in South East Asia (SEA) were sought. Keywords included gestational diabetes and a search term for Asian ethnicity (Asian, Asia, race, ethnic, and ethnicity). Further searches were based on citations and references found in located articles. Of 53 retrieved publications, five met inclusion criteria.

DATA EXTRACTION

Data were extracted and organised under the following headings: GDM rates among women born in SEA; screening for GDM; and characteristics of GDM risk for SEA born women. Study quality was assessed by using the CASP (Critical Appraisal Skills Programme) guidelines.

DATA SYNTHESIS

This review produced three main findings: (1) compared to combined Asian groups, GDM rates were lower among SEA women; (2) compared to other Asian sub-groups, GDM rates among SEA women were in the intermediate range; and (3) SEA born women demonstrated consistently higher rates of GDM than women from the same ethnic background who were born in countries such as the US, UK or Australia.

CONCLUSIONS

From this review, it was clear that a 'one size fits all' approach to Asian ethnicity was not useful for estimating GDM rates among SEA women. There was also considerable difference among women of SEA ethnicity born in South East Asia, compared to women of the same ethnic background born in developed countries. Future research should explore the unique characteristics of GDM risk for these women. Such information is necessary for the development of strategies for the prevention and treatment of GDM among SEA women.

Geographic variation in utilization of sentinel lymph node biopsy for intermediate thickness cutaneous melanoma

BACKGROUND AND OBJECTIVES

Sentinel lymph node biopsy (SLNB) is the standard for evaluation of the draining lymphatic basin for intermediate thickness melanoma. Despite this, SLNB has not been uniformly adopted. We hypothesized that there are geographic areas of the United States where patients are less likely to receive SLNB.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for patients who underwent surgery for intermediate thickness cutaneous melanoma (Breslow thickness 1.00-4.00 mm) from 2004 to 2008. Patients were categorized according to geographic area based on the reporting registry. Multivariate logistic regression models predicted use of SLNB.

RESULTS

Entry criteria were met by 8957 patients. On multivariate analysis, patients from the South were less likely (OR 0.54, CI 0.48-0.62; P < 0.001) to receive a SLNB. Additional factors associated with a decreased likelihood of receiving a SLNB included head and neck primary tumor site, high or unknown serum LDH, Asian, Hispanic, Native American or unknown race, and increasing age.

CONCLUSIONS

Patients from the South were less likely to receive a SLNB for an intermediate thickness cutaneous melanoma. This report of geographic disparities on a national level should be confirmed locally to better guide interventions aimed at eliminating these disparities.

Systematic review of parameters of stimulation, clinical trial design characteristics, and motor outcomes in non-invasive brain stimulation in stroke

INTRODUCTION/OBJECTIVES

Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation are two powerful non-invasive neuromodulatory therapies that have the potential to alter and evaluate the integrity of the corticospinal tract. Moreover, recent evidence has shown that brain stimulation might be beneficial in stroke recovery. Therefore, investigating and investing in innovative therapies that may improve neurorehabilitative stroke recovery are next steps in research and development. Participants/Materials and Methods: This article presents an up-to-date systematic review of the treatment effects of rTMS and tDCS on motor function. A literary search was conducted, utilizing search terms "stroke" and "transcranial stimulation." Items were excluded if they failed to: (1) include stroke patients, (2) study motor outcomes, or (3) include rTMS/tDCS as treatments. Other exclusions included: (1) reviews, editorials, and letters, (2) animal or pediatric populations, (3) case reports or sample sizes ≤2 patients, and (4) primary outcomes of dysphagia, dysarthria, neglect, or swallowing.

RESULTS

Investigation of PubMed English Database prior to 01/01/2012 produced 695 applicable results. Studies were excluded based on the aforementioned criteria, resulting in 50 remaining studies. They included 1314 participants (1282 stroke patients and 32 healthy subjects) evaluated by motor function pre- and post-tDCS or rTMS. Heterogeneity among studies' motor assessments was high and could not be accounted for by individual comparison. Pooled effect sizes for the impact of post-treatment improvement revealed consistently demonstrable improvements after tDCS and rTMS therapeutic stimulation. Most studies provided limited follow-up for long-term effects.

CONCLUSION

It is apparent from the available studies that non-invasive stimulation may enhance motor recovery and may lead to clinically meaningful functional improvements in the stroke population. Only mild to no adverse events have been reported. Though results have been positive results, the large heterogeneity across articles precludes firm conclusions.